Concomitant Pulmonary Hypertension Research Articles

Pulmonary hypertension-related deaths in patients with acute pulmonary embolism in the United States, 2003 to 2020.

Data regarding the mortality trends in pulmonary embolism (PE)-related mortality in patients with concomitant pulmonary hypertension (PH) are lacking. We assessed the trends in PE-related mortality in patients with concomitant PH in the United States (US) over the past 2 decades and during the first year of the COVID-19 pandemic using data from the Centers for Disease Control and Prevention's (CDC) Wide-ranging ONline Data for Epidemiologic Research (WONDER) dataset. Mortality data were retrieved from the publicly available CDC WONDER mortality dataset from 2003 to 2020. Age-adjusted mortality rates (AAMRs), per 100,000 population, were assessed using Joinpoint regression modelling and expressed as estimated average annual percentage change (AAPC) with relative 95% CIs and stratified by urbanicity, sex, age, and race/ethnicity. Over the study period, the AAMR for PE/PH-related mortality linearly increased (AAPC: +4.3% [95% CI: 3.7 to 4.9], p < 0.001) without sex differences. The AAMR increase was more pronounced in White individuals (AAPC: +4.8% [95% CI: 4.1 to 5.5], p < 0.001) and in subjects living in rural areas (AAPC: +5.1% [95% CI: 3.8 to 6.4], p < 0.001) compared to those living in urban areas. During the first year of the COVID-19 pandemic there was a significant excess in PE/PH-related mortality among women, older than 65 years and living in rural areas. The rate of PE/PH-related mortality in the US is increasing. Although the early diagnosis of PH in patients with acute PE has become easier with improved diagnostic modalities, the mortality rate of these patients remains high.

Tadalafil in Neonates and Infants With Pulmonary Hypertension Secondary to Bronchopulmonary Dysplasia.

The primary outcome of this study was to describe the dosing regimen of tadalafil in neonates and infants diagnosed with pulmonary hypertension (PH) secondary to bronchopulmonary dysplasia (BPD). Secondary outcomes included tolerability, efficacy, adverse events, discontinuation of therapy, and changes in echocardiography. This was a single-center, retrospective review of neonates and infants <1 year of age at initiation of tadalafil for PH secondary to BPD from January 2010 to November 2021. Data collected from the electronic medical record included patient demographics, tadalafil dosing, oxygen support, mechanical ventilation, concomitant PH medications, adverse events, and echocardiography information. Forty-two patients-4 neonates and 38 infants-met the inclusion criteria. The postnatal and post-menstrual age (median, IQR) at diagnosis were 121 (35.5-153.5) days and 42.6 (40.6-47.6) weeks, respectively. The initial and highest tadalafil doses (median, range) were 1 (0.25-2) and 1 (0.5-2) mg/kg/day. Only 1 patient experienced pulmonary overcirculation and required tadalafil to be discontinued. Over half (57.1%) of the patients in this study discontinued tadalafil therapy owing to improvements in pulmonary artery pressures. Tadalafil 1 mg/kg/day was the most commonly used dose regimen in neonates and infants. Tadalafil at this dose of 1 mg/kg/day appears well tolerated in neonates and infants with PH secondary to BPD and correlates with improvements in pulmonary artery pressures. Further studies evaluating tadalafil in comparison to other phosphodiesterase-5 inhibitors in neonates with PH secondary to BPD are warranted.

Updates in the Pharmacotherapy of Pulmonary Hypertension in Patients with Heart Failure with Preserved Ejection Fraction.

Pulmonary hypertension (PH) associated with left heart disease (LHD) is a complex cardiopulmonary condition where a variable degree of pulmonary congestion, arterial vasoconstriction and vascular remodeling can lead to PH and right heart strain. Right heart dysfunction has a significant prognostic impact on these patients. Therefore, preserving right ventricular (RV) function is an important treatment goal. However, the treatment of PH in patients with left heart disease has produced conflicting evidence. The transition from pure LHD to LHD with PH is a continuum and clinically challenging. The heart failure with preserved ejection fraction (HFpEF) patient population is heterogeneous when it comes to PH and RV function. Appropriate clinical and hemodynamic phenotyping of patients with HFpEF and concomitant PH is paramount to making the appropriate treatment decision. This manuscript will summarize the current evidence for the use of pulmonary arterial vasodilators in patients with HFpEF.

Derivation and validation of a noninvasive prediction tool to identify pulmonary hypertension in patients with IPF: Evolution of the model FORD

The administration of inhaled prostanoids to patients with pulmonary hypertension (PH) related to idiopathic pulmonary fibrosis (IPF) and other fibrotic lung diseases improves functional outcomes. Selection of patients with IPF at risk for concomitant PH to undergo right heart catheterization (RHC) remains challenging. We sought to develop a clinical prediction tool based on common noninvasive parameters to identify PH in patients with IPF. A prediction model based on noninvasive parameters was derived from patients enrolled in the ARTEMIS-IPF randomized, placebo-controlled clinical trial. Predictor variables were tested for association with the presence of PH diagnosed based on RHC. The derived multivariable logistic regression model and associated point-score index were then externally validated in a real-world cohort of patients with IPF. Of the 481 patients included in the ARTEMIS-IPF study, 9.8% (N = 47) were diagnosed with PH related to IPF. Four variables were associated with PH and were included in the final model: forced vital capacity/diffusing capacity for carbon monoxide ratio (F), oxygen saturation nadir during 6-minute walk test (6MWT) (O), race (R), and distance ambulated during 6MWT (D). A model containing continuous predictors (FORD calculator) and a simple point-score system (FORD index) performed similarly well in the derivation cohort (area under the curve [AUC]: 0.75 and 0.75, respectively) and validation cohort (AUC: 0.69 and 0.69, respectively). The FORD models are simple, validated tools incorporating noninvasive parameters that can be applied to identify patients at risk of PH related to IPF who may benefit from invasive testing.

Comparison of milrinone versus dobutamine on invasive haemodynamics in patients with advanced heart failure on home inotropes

Abstract Background Home inotropic support is an established bridge to cardiac transplantation in patients with advanced heart failure. Milrinone, a phosphodiesterase 3 inhibitor, preferentially vasodilates pulmonary vasculature, thus is often chosen over dobutamine in patients with concomitant pulmonary hypertension. However, there is a paucity of data on the haemodynamic effects of milrinone in the pre-cardiac transplant population. Purpose We sought to examine the haemodynamic effects of milrinone vs. dobutamine out to 3 months in patients with advanced heart failure awaiting cardiac transplantation. Methods Patients in the home inotrope program at a quaternary referral centre from January 2000 to May 2022 were included. Retrospective analysis of echocardiographic and invasive haemodynamic studies via right heart catheterisation were performed at baseline (prior to commencement of inotrope), at 30 days (30D) and 3 months (3m). Results From a total of 119 patients, 57 were on milrinone and 62 on dobutamine. Non-ischaemic cardiomyopathies of various aetiologies accounted for 67%, while ischaemic cardiomyopathies accounted for 33%. Majority of patients were male (79%) with a mean age of 52±13 years. There was a significant increase in LVEF from 21±7% at baseline to 27±14% at 3m in those on dobutamine, p = 0.02. Similar increase in LVEF from 22±8% to 26±13% in the milrinone group did not reach significance, p = 0.43. Comparably, CI increased from 2.0±0.6L/min/m2 at baseline to 2.5±0.9L/min/m2 at 3m in the dobutamine cohort, p = 0.05, and from 2.0±0.7L/min/m2 at baseline to 2.3±0.6L/min/m2 at 3m in the milrinone cohort, p = 0.27. In the dobutamine cohort LVEDD was static from 68±14mm at baseline to 66±21mm at 3m, p = 0.78. LVEDD reduced from 67±11mm to 60± 9mm at 3m in the milrinone group, p = 0.09. Classification of mild right ventricular dysfunction increased from 7% to 18% after 30 days on milrinone, p= 0.2, compared to an increase from 10% to 16% in the dobutamine group, p = 0.47. Mean pulmonary artery pressure (mPAP) reduced from 34±11mmHg to 29±11mmHg at 3m in the milrinone group, p = 0.15. mPAP was static in the dobutamine group from 34±9mmHg at baseline to 34±10mmHg at 3m, p = 0.96. TPG in the milrinone group was 11.9±6.0mmHg to 12.9±6.3mmHg at 30D, with reduction at 3m to 9.6±6.3mmHg, p = 0.26. In the dobutamine group TPG remained static from 10.9±5.7mmHg at baseline to 11.4±5.1mmHg at 30D and 10.9±5.2 at 3m, p = 0.97. Wedge pressure (PCWP) reduced from 22±7mmHg at baseline to 21±7mmHg at 30D to 18±8mmHg at 3m in the milrinone group, p = 0.11. PCWP in the dobutamine group was static at 23±8mmHg at baseline to 24±5mmHg at 30D and 23±6mmHg at 3m, p = 0.92. Conclusion(s) Dobutamine demonstrated a significant increase in LVEF and CI out to 3 months, however milrinone demonstrated a larger improvement in RV function and greater reduction in cardiac and pulmonary pressures as compared to dobutamine. Larger studies are required to confirm these trends.Figure 1

Atrial fibrillation and high-grade functional mitral regurgitation - what is the chicken, what is the egg?

Abstract Background Atrial fibrillation (AF) and mitral valve regurgitation (MR) represent highly prevalent and intimately linked comorbidities with shared and interacting pathophysiological mechanisms [1]. The first-time and simultaneous occurrence of high-grade functional MR (fMR) and AF therefore often poses a chicken-or-egg dilemma, rendering clinical decision making on which of the two conditions should prioritized challenging. To date, data regarding the rationale and the timing of MR therapy in this cohort are lacking. Purpose The aim of the present study was to identify predictors of persistence of de novo high-grade fMR after rhythm control of concomitant de novo AF in order to provide guidance for the early clinical management of this relevant cohort of patients. Methods In a single center observational cohort study, consecutive patients presenting with first diagnosed MR and AF undergoing acute rhythm control of AF were identified and patients with non-high-grade MR, primary MR, simultaneous cardiogenic shock, prior mitral valve repair or replacement, endocarditis, intracardiac thrombi and/or concomitant relevant pathology of the aortic valve were excluded. Clinical and echocardiographic parameters at baseline and follow-up (FU) were assessed and predictors of persistence of high-grade fMR at FU were identified via multivariable logistic regression analyses. Results A total of 780 consecutive patients were identified between 2016 and 2022, of whom 100 patients were enrolled in the study. Acute rhythm control of AF was achieved predominantly by electrocardioversion (90%, 90/100) and in a minority by pulmonary vein isolation (10%, 10/100). After a median FU period of 318 days (IQR 849 days), 59% (59/100) patients showed mild to moderate fMR and 41% (41/100) patients presented with persisting high-grade fMR, of whom 44% (18/41) and 39% (16/41) underwent surgical or percutaneous MR therapy, respectively. The remaining 17% (7/41) were conservatively treated. AF/AT recurrence was not associated with persistent high-grade MR (Odds ratio [OR] 2.4, 95% confidence interval [CI] 0.6-4.5, p = 0.2), whereas concomitant first degree AV block (OR 1.4, 95%-CI 1.1-1.7, p=0.005), pulmonary hypertension (OR 1.3, 95%-CI 1.1-1.6, p=0.004) and NYHA functional class IV (OR 1.4, 95%-CI 1.1-1.6, p=0.02) at the time of first presentation were found to be predictors of persistent high-grade MR during FU in multivariable logistic regression. Conclusion Patients with de novo high-grade MR and AF presenting with concomitant first degree AV block, NYHA functional class IV or pulmonary hypertension are more likely to have persistent high-grade MR after early rhythm control of AF regardless of sinus rhythm stability during FU. In this constellation, early definitive therapy for MR should be prioritized. Larger, prospective studies are needed to confirm the results and to investigate the impact of early interventional rhythm control strategies on MR reversibility.

Effects of High-Flow Nasal Cannula on Right Heart Dysfunction in Patients with Acute-on-Chronic Respiratory Failure and Pulmonary Hypertension.

High-flow nasal cannula (HFNC) has several benefits in patients affected by different forms of acute respiratory failure, based on its own mechanisms. We postulated that HFNC may have some advantages over conventional oxygen therapy (COT) on the heart function in patients with acute-on-chronic respiratory failure with concomitant pulmonary hypertension (PH). We therefore designed this retrospective observational study to assess if HFNC improves the right and left ventricle functions and morphologies, arterial blood gases (ABGs), and patients' dyspnea, compared to COT. We enrolled 17 hospitalized patients receiving HFNC, matched with 17 patients receiving COT. Echocardiographic evaluation was performed at the time of admission (baseline) and 10 days after (T10). HFNC showed significant improvements in right ventricular morphology and function, and a reduction in sPAP. However, there were no significant changes in the left heart measurements with HFNC application. Conversely, COT did not lead to any modifications in echocardiographic measurements. In both groups, oxygenation significantly improved from baseline to T10 (in the HFNC group, from 155 ± 47 to 204 ± 61 mmHg while in the COT group, from 157 ± 27 to 207 ± 27 mmHg; p < 0.0001 for both comparisons). In conclusion, these data suggest an improvement of oxygenation with both treatments; however, only HFNC was able to improve the right ventricular morphology and function after 10 days from the beginning of treatment in a small cohort of patients with acute-on-chronic respiratory failure with PH.

Percutaneous left ventricular assist device as a short-term mechanical circulatory support before heart transplantation in patients with high pre-transplant pulmonary hypertension (series of clinical cases)

Federation In certain categories of patients with end-stage heart failure (HF), short-term mechanical circulatory support (MSC) is successfully used as a mechanical «bridge» to heart transplantation (HTx). In predominantly left-ventricular (LV) dysfunction, the use of isolated coronary artery bypass, especially amidst high pulmonary hypertension (PH), seems to be a more physiological method of short-term MSC.Objective: to present the results of a series of clinical cases of the use of percutaneous left ventricular assist device (pLVAD) before HTx in potential recipients with predominantly LV dysfunction and concomitant high PH.Materials and methods. Three potential heart recipients with predominantly left-sided HF and high pre-transplant PH (pulmonary vascular resistance, PVR, 4.7–6.6 Wood units) who required MSC due to progression of hemodynamic disorders were included in the study. A standard venous extracorporeal membrane oxygenation (ECMO) cannula (26 F) was used for percutaneous left atrial-femoral artery (LA–FA) bypass. The cannula was passed from the transfemoral route through the interatrial septum into the left atrial cavity. A paracorporeal centrifugal pump provided blood injection through a standard arterial ECMO cannula (15 F).Results. pLVAD unloaded the left ventricle effectively (PCWP reduced from 27–32 to 15–20 mmHg), reduced pre-transplant PH (mean pulmonary artery pressure (mPAP) reduced from 45–53 to 28–33 mmHg) and improved systemic hemodynamics (cardiac index (CI) increased from 1.8–1.9 to 2.1–2.6 l/min/m2 and mean arterial pressure (mAP) from 56–59 to 70–75 mmHg). All these created the prerequisites for subsequent successful HTx. Against the background of pLVAD, transpulmonary pressure gradient (TPG) decreased from 15–25 to 13–15 mmHg, and PVR decreased from 4.7–6.6 to 2.7–3.4 Wood units. pLVAD flow rate was 2.9–3.8 L/min or 1.38–1.83 L/min/m2 at 4700–7100 rpm. pLVAD duration ranged from 4 (n = 1) to 7 (n = 2) days. All patients underwent successful HTx.Conclusion. pLVAD is a highly effective method of short-term MSC in potential recipients with predominantly LV dysfunction and concomitant high PH, leading to rapid regression of the dysfunction against the background of left ventricular unloading. This short-term MSC technique can be successfully realized using standard ECMO cannulas and centrifugal pumps of any modification, without requiring additional special equipment.

Pulmonary hypertension associated with lung disease

Pulmonary hypertension (PH) is amultifactorial pulmonary vascular disease. PH associated with pre-existing lung disease is common and classified as group3 in the clinical classification. Patients with chronic obstructive or interstitial lung disease are most likely to develop PH, with up to 20% of patients showing signs of PH. Distinguishing between the symptoms of the underlying lung disease and concomitant PH can be difficult. Clinical assessment, lung function tests, laboratory tests, and echocardiography can be helpful. The hemodynamic definition of PH has recently been changed. PH associated with lung disease is apre-capillary form by definition. A special sub-stratification in group3 is the differentiation of hemodynamic severity. Severe PH in group3 is defined as apulmonary vascular resistance (PVR) greater than 5Wood units (WU). This pulmonary vascular phenotype is characterized by rather mild to moderate impairment of lung function or lung parenchymal destruction but with severe pulmonary vascular disease or right heart strain. Currently, there are no specific PH medications approved for group3. However, the use of specific PH medications for the pulmonary vascular phenotype is being discussed in studies or on acase-by-case basis, while in patients with aPVR below 5WU treatment focuses on the underlying disease.

Prevalence of pulmonary hypertension in patients with COVID‐19 related lung disease listed for lung transplantation: A UNOS registry analysis

COVID-19 related lung disease (CRLD) has emerged as an indication for lung transplantation (LT) in highly select patients. The prevalence and prognostic implication of coexisting pulmonary hypertension (PH) in patients with CRLD listed for LT is not known. Adult patients in the United Network for Organ Sharing database listed for LT for COVID-19 related acute respiratory distress syndrome or fibrosis through March 2022 were identified. The prevalence and impact of precapillary PH on pre- and posttransplantation survival was determined. Time-to-event analysis was used to compare outcomes between those with and without precapillary PH. We identified 245 patients listed for LT for CRLD who had right heart catheterization data available at the time of registry listing. Median age of the cohort was 54 years (interquartile range [IQR]: 46, 60), 56 (22.9%) were female, and the median lung allocation score was 81.3 (IQR: 53.3, 89.4). The prevalence of precapillary PH at the time of transplant listing was 27.9%. There was no significant difference in pretransplant mortality in patients with and without precapillary PH (sHR: 0.5; 95% confidence interval [CI]: 0.1-1.7, p = 0.261). A total of 187 patients ultimately underwent LT; of those, 60 (31.0%) were identified as having precapillary PH during the waitlist period. Posttransplantation survival was similar between patients with and without pretransplant precapillary PH (hazard ratio: 0.96; 95% CI: 0.2-3.7, p = 0.953). We observed a high rate of concomitant precapillary PH in patients listed for LT for CRLD. Though common, coexisting precapillary PH was not associated with a significant difference in either pre- or post-transplantation outcomes.

IMPACT OF PULMONARY DENERVATION ON QUALITY OF LIFE AFTER COMPLEX MITRAL VALVE SURGERY

Relevance. In recent years, concepts for assessing the quality of life have been developed. According to the WHO definition, quality of life is a person's perception of his position in life, culture and value system, it is associated with his goals, expectations, standards and concerns. Approximately three people out of every thousand have pulmonary hypertension for various reasons. This can lead to decreased exercise tolerance, quality of life, increased hospital admissions, and early death. An objective assessment of the quality of life of such patients will help achieve better clinical outcomes for patients and develop new treatments. Purpose of the study is to assessment of changes in the quality of life of patients with mitral valve disease associated with atrial fibrillation and high pulmonary hypertension (systolic blood pressure over 40 mmHg) during the first 24 months after radiofrequency denervation of the pulmonary arteries according to the SF-36 and MLHFQ questionnaires. Materials and Methods. The general population of patients (n = 202) with mitral heart disease, concomitant atrial fibrillation and high pulmonary hypertension was divided into several groups according to the complexity of surgical treatment: patients of the 1st group (n = 62) underwent only surgical correction of the mitral valve pathology (repair or replacement); patients of the 2nd group (n = 89) – surgical correction of the mitral valve pathology, as well as the Maze IV procedure using the AtriCure© bipolar ablator; patients of the 3rd group (n = 51) received complex surgical treatment by correcting mitral valvular pathology, performing the Maze IV procedure, as well as using radiofrequency denervation of the pulmonary arteries. The quality of life was assessed over several periods: initially, 6 months later, 1 and 2 years after surgical treatment. The scores were also converted to physical health component scores and mental health component scores. Results. The initial data of patients from different subgroups according to the criteria of the SF-36 questionnaire were comparable with each other. The indicators of the physical component and the psychological component of SF-36 characterize the 3rd group of patients with a lower level of quality of life in terms of the physical component, although no significant intergroup differences were found. Quality of life indicators after 6 months show positive changes in patients of all study groups without significant intergroup differences. Based on the results of 12 months, the greatest dynamics of the parameters of the questionnaire in terms of physical and mental components was observed in the 3rd group of patients. After 24 months, there is a significant advantage in changes in the indicators of patients of the 3rd group for all categories of the questionnaire. The target level after 6 months in the 3rd group was 100%, in the 2nd and 1st – 85.3% and 40.7%, respectively, maintaining differences up to 24 months. Conclusions. The use of a circular radiofrequency pulmonary artery denervation procedure is associated with a significant improvement in health status in assessing the quality of life of patients who have not undergone correction of pulmonary hypertension.

Therapeutic Strategy for Patients with Concomitant Pulmonary Artery Hypertension and Hypertrophic Obstructive Cardiomyopathy: A Rare Case Report

Combined cases of hypertrophic obstructive cardiomyopathy (HOCM) and pulmonary arterial hypertension (PAH) are rare and have a management dilemma. Although preload is crucial in the management of HOCM, anti-PAH agents dramatically change the preload, leading to improving or worsening heart failure in patients with HOCM. We had a 74-year-old woman with Sjogren-syndrome-associated PAH. Her heart failure worsened following the initiation of anti-PAH agents due to an incremental preload on the left ventricle, whereas HOCM clinically developed following the termination of anti-PAH agents and progressing anorexia due to the progression of the left ventricular outflow obstruction. Careful monitoring of the left ventricular outflow obstruction during initiation/termination of anti-PAH agents and medical intervention to the HOCM are highly recommended.

DERIVATION AND VALIDATION OF A SIMPLE MULTIDIMENSIONAL MODEL FOR IDENTIFICATION OF COEXISTING PULMONARY HYPERTENSION IN IDIOPATHIC PULMONARY FIBROSIS

DERIVATION AND VALIDATION OF A SIMPLE MULTIDIMENSIONAL MODEL FOR IDENTIFICATION OF COEXISTING PULMONARY HYPERTENSION IN IDIOPATHIC PULMONARY FIBROSIS

Intraoperative changes and prognostic implications of pulmonary hypertension in patients with hypertrophic obstructive cardiomyopathy undergoing surgical septal myectomy

ObjectivesPatients with hypertrophic cardiomyopathy often have concomitant pulmonary hypertension, which has a negative prognostic effect in patients undergoing myectomy. Our objective was to investigate the effect of myectomy on pulmonary artery pressure obtained via Swan-Ganz catheter and characterize how changes in pulmonary artery systolic pressure may indicate outcomes in these patients. MethodsWe performed a single-center retrospective analysis of 271 patients with recordings of intraoperative pulmonary artery pressures during surgical myectomy. We analyzed primary composite outcomes as 30-day or in-hospital major cardiopulmonary adverse events. ResultsThere was a 5.17% adverse event rate. Patients with adverse events were older, were more likely to be female, had chronic obstructive pulmonary disease, and had longer cardiopulmonary bypass times. Some 35.7% of those with adverse events had moderate to severe pulmonary hypertension (pulmonary artery systolic pressure ≥50 mm Hg) on postbypass stress test, compared with 4.3% of those without adverse events (P < .001). Further, 21.4% of patients with adverse events had pulmonary artery systolic pressure 50 mm Hg or greater at the end of surgery, compared with 1.9% of patients without adverse events (P < .001). The pulmonary artery systolic pressure decrease after surgery in those without adverse events was on average 5 mm Hg more than in those with adverse events. ConclusionsPostoperative pulmonary hypertension was associated with a higher rate of adverse cardiopulmonary events. This may influence the decision to use Swan-Ganz catheters in patients undergoing septal myectomy in monitoring pulmonary artery pressures to better risk stratify and manage these patients postoperatively.

DEVELOPMENT OF A RISK-ASSESSMENT TOOL FOR PREDICTION OF PULMONARY HYPERTENSION AND MORTALITY IN PATIENTS WITH INTERSTITIAL LUNG DISEASE

DEVELOPMENT OF A RISK-ASSESSMENT TOOL FOR PREDICTION OF PULMONARY HYPERTENSION AND MORTALITY IN PATIENTS WITH INTERSTITIAL LUNG DISEASE

Comment on “Predictive factors for concomitant pulmonary arterial hypertension at diagnosis of systemic lupus erythematosus in a Chinese population”

Comment on “Predictive factors for concomitant pulmonary arterial hypertension at diagnosis of systemic lupus erythematosus in a Chinese population”

P227 DOES NITROPRUSSIDE TEST BEHAVE AD AN INCREMENTAL PROGNOSTIC FACTOR IN SELECTION OF PATIENTS CANDIDATE TO LVAD IMPLANTATION?

Abstract Background Left ventricular assist device in the last two decades has been used to improve survival and quality of life of patients suffering from heart failure, regardless presence of concomitant pulmonary hypertension. Most patients showed improvement in pulmonary pressure. Current clinical practice lacks a reliable method for prediction of reverse remodelling and prognosis. Aim of this study is to investigate the possible role of nitroprusside test as prognostic factor in candidates to LVAD implantation. Methods We conducted a monocentric prospective observational study analysing 31 consecutive patients implanted with LVAD between July 2013 and October 2021 that underwent right heart catheterization and nitroprusside test before implantation. Basal and nitroprusside–obtained hemodynamic parameters were subsequently correlated with the primary outcome, defined as the composite of death and episodes of right ventricular failure. Results Mean age of study population was 58,6 ± 7,97 years, 12,9% were female. Most prevalent INTERMACS class was 3 and mean EF was 18 ± 4,92 %. Mean follow–up was 31,3 ± 20,4 months, during which 11 death and 14 episodes of RVF occurred. At basal hemodynamic assessment, patients with pulmonary vascular resistance above 3 WU had a significant higher rate of events (50% vs 9%, Likelihood ratio 5.7, p = 0.029). No hemodynamic parameter measured after nitroprusside infusion was found to predict survival or episode of RVF. Conclusion In this exploratory study we have shown that nitroprusside infusion does not add further prognostic information when compared with basal hemodynamic parameters.

Severe Aortic Valve Stenosis and Pulmonary Hypertension: A Systematic Review of Non-Invasive Ways of Risk Stratification, Especially in Patients Undergoing Transcatheter Aortic Valve Replacement.

Patients with severe aortic valve stenosis and concomitant pulmonary hypertension show a significantly reduced survival prognosis. Right heart catheterization as a preoperative diagnostic tool to determine pulmonary hypertension has been largely abandoned in recent years in favor of echocardiographic criteria. Clinically, determination of echocardiographically estimated systolic pulmonary artery pressure falls far short of invasive right heart catheterization data in terms of accuracy. The aim of the present systematic review was to highlight noninvasive possibilities for the detection of pulmonary hypertension in patients with severe aortic valve stenosis, with a special focus on cardiovascular biomarkers. A total of 525 publications regarding echocardiography, cardiovascular imaging and biomarkers related to severe aortic valve stenosis and pulmonary hypertension were analyzed in a systematic database analysis using PubMed Central®. Finally, 39 publications were included in the following review. It was shown that the current scientific data situation, especially regarding cardiovascular biomarkers as non-invasive diagnostic tools for the determination of pulmonary hypertension in severe aortic valve stenosis patients, is poor. Thus, there is a great scientific potential to combine different biomarkers (biomarker scores) in a non-invasive way to determine the presence or absence of PH.

Prognostic Significance of Pulmonary Hypertension in Patients with Hypertrophic Obstructive Cardiomyopathy Undergoing Septal Myectomy

<h3>Purpose</h3> Patients with hypertrophic obstructive cardiomyopathy (HOCM) often have concomitant pulmonary hypertension (PH). We hypothesize that concomitant PH is associated with increased risk for short-term adverse outcomes after septal myectomy. <h3>Methods</h3> We retrospectively evaluated 758 patients who underwent septal myectomy for treatment of HOCM between 2010 and 2020 at our institution. There were 396 total patients who had pre-op right heart catheterization (RHC). After exclusion of patients without complete RHC data, there were 281 patients included in the final analysis. Adverse events (AE) were defined by a composite endpoint which included post-operative stroke, TIA, MI, cardiac arrest, prolonged ventilation, reintubation, pneumonia, multi-organ failure, and mortality. Comparison was made between patients with and without AE. Categorical variables were compared with chi-square or Fisher's exact test where appropriate. Continuous variables were compared with one-way ANOVA. Significance was defined as p<0.05. <h3>Results</h3> The overall incidence of AE in the study population was low (n=17, 6%). Prolonged ventilation was the most common AE (n=9, 3.2%). Patients with AE were older in age (64 vs 57, p=.015) and were more likely to have chronic lung disease (OR 4.42, 95% CI 1.5-12.8; p=.003). On pre-op RHC, patients with AE had significantly greater pulmonary artery (PA) systolic pressure (47 vs 38, p=.010), mean PA pressure (32 vs 26, p=.017), PA pulsatility index (5.9 vs 3.8, p=.004), PA pulse pressure (28 vs 22, p=.009), transpulmonary gradient (13 vs 10, p=.02), and pulmonary vascular resistance (3.4 vs 2.0, p <.001). <h3>Conclusion</h3> Increased severity of concomitant PH in patients with HOCM undergoing septal myectomy surgery is associated with increased risk for short-term adverse outcomes. Preoperative pulmonary artery pressure is of prognostic predictive value. Screening for and treating PH before septal myectomy may reduce the risk of complications.

Acute and chronic exercise training in patients with Class II pulmonary hypertension: effects on haemodynamics and symptoms.

More than half of heart failure (HF) patients have concomitant pulmonary hypertension, impacting symptoms and prognosis. The role of exercise in this category of patients is still unclear, probably because of the lack of a clear relationship between exercise and acute and chronic pulmonary artery pressure variations and related changes in symptoms. The limited evidence on this topic is contradictory and hardly comparable due to use of different exercise programmes and pulmonary artery pressure assessment techniques. This is further compounded by different functional and structural classes of HF making definite assessments and interpretations of exercise effect on outcomes difficult. Exercise training programmes were proven beneficial in HF patients; however, the lack of data about their pulmonary haemodynamic effects prevents clear indications on the best exercise types for patients presenting secondary pulmonary hypertension and different HF categories. Indeed, some data suggest that not all HF patients have similar responses to training, leading to either beneficial or detrimental effects, depending on the HF type. Future studies, involving modern technologies such as continuous pulmonary artery pressure monitoring implantable devices, may clarify the current gaps in this field, aiming at patient‐tailored exercise training rehabilitation programmes, in order to improve clinical outcomes, quality of life, and hopefully prognosis.