Decrease In Systolic Pulmonary Artery Pressure Research Articles

Pulmonary vascular reactivity to supplemental oxygen in Sherpa and lowlanders during gradual ascent to high altitude.

What is the central question of this study? How does hypoxic pulmonary vasoconstriction and the response to supplemental oxygen change over time at high altitude? What is the main finding and its importance? Lowlanders and partially de-acclimatized Sherpa both demonstrated pulmonary vascular responsiveness to supplemental oxygen that was maintained for 12days' exposure to progressively increasing altitude. An additional 2 weeks' acclimatization at 5050m altitude rendered the pulmonary vasculature minimally responsive to oxygen similar to the fully acclimatized non-ascent Sherpa. Additional hypoxic exposure at that time point did not augment hypoxic pulmonary vasoconstriction. Prolonged alveolar hypoxia leads to pulmonary vascular remodelling. We examined the time course at altitude, over which hypoxic pulmonary vasoconstriction goes from being acutely reversible to potentially irreversible. Study subjects were lowlanders (n=20) and two Sherpa groups. All Sherpa were born and raised at altitude. One group (ascent Sherpa, n=11) left altitude and after de-acclimatization in Kathmandu for ∼7days re-ascended with the lowlanders over 8-10days to 5050m. The second Sherpa group (non-ascent Sherpa, n=12) remained continuously at altitude. Pulmonary artery systolic pressure (PASP) and pulmonary vascular resistance (PVR) were measured while breathing ambient air and following supplemental oxygen. During ascent PASP and PVR increased in lowlanders and ascent Sherpa; however, with supplemental oxygen, lowlanders had significantly greater decrease in PASP (P=0.02) and PVR (P=0.02). After ∼14days at 5050m, PASP decreased with supplemental oxygen (mean decrease: 3.9mmHg, 95% CI 2.1-5.7mmHg, P<0.001); however, PVR was unchanged (P=0.49). In conclusion, PASP and PVR increased with gradual ascent to altitude and decreased via oxygen supplementation in both lowlanders and ascent Sherpa. Following ∼14days at 5050m altitude, there was no change in PVR to hypoxia or O2 supplementation in lowlanders or either Sherpa group. These data show that both duration of exposure and residential altitude influence the pulmonary vascular responses to hypoxia.

IMPROVEMENT OF LUNG FUNCTION AND PULMONARY ARTERY SYSTOLIC PRESSURE IN PATIENTS WITH INTERSTITIAL LUNG DISEASE ASSOCIATED WITH SYSTEMIC SCLEROSIS ON RITUXIMAB TREATMENT

IMPROVEMENT OF LUNG FUNCTION AND PULMONARY ARTERY SYSTOLIC PRESSURE IN PATIENTS WITH INTERSTITIAL LUNG DISEASE ASSOCIATED WITH SYSTEMIC SCLEROSIS ON RITUXIMAB TREATMENT

Phosphodiesterase inhibitor for heart failure with preserved ejection fraction: A systematic review and meta-analysis

BackgroundAlthough heart failure with preserved ejection fraction (HFpEF) is a serious disease, only limited options are available for its treatment. Recent studies have analyzed the effects of phosphodiesterase (PDE) inhibitors, especially PDE5 and PDE3 inhibitors, in patients with HFpEF, with mixed outcomes. MethodsWe searched PUBMED and EMBASE databases up to August 2021. Randomized controlled trials (RCTs) and clinical trials that tested the effects of PDE inhibitors on patients with HFpEF were included as eligible studies. Indicators of left ventricular (LV) function, pulmonary arterial pressure (PAP), right ventricular (RV) function, exercise capacity, and quality of life (QOL) were used to evaluate the efficacy of PDE inhibitors in HFpEF. ResultsSix RCTs that reported in 7 studies were included to evaluate the efficiency of PDE inhibitors on HFpEF patients. In the pooled analysis, PDE inhibitors showed insignificant changes in the ratio of early diastolic mitral inflow to annular velocities, left atrial volume index, pulmonary artery systolic pressure (PASP), pulmonary vascular resistance (PVR), peak oxygen uptake, 6-minute walking test distance, as well as Kansas City Cardiomyopathy Questionnaire score. However, substantial improvement was observed in the tricuspid annular plane systolic excursion (TAPSE). Additionally, the regression analysis showed that PDE inhibitor administration time is a critical factor for the decrease in PASP. ConclusionsPDE inhibitors did not effectively improve LV function, PAP, exercise capacity, and QOL in patients with HFpEF. However, they improved RV function with significant difference, suggesting that PDE inhibitors might be a promising option for HFpEF patients with RV dysfunction.

Pulmonary hypertension in mitral stenosis patients submitted to percutaneous balloon mitral valvuloplasty: an innocent bystander?

Abstract Funding Acknowledgements Type of funding sources: None. Background Percutaneous balloon mitral valvuloplasty (PBMV) is the cornerstone of the treatment of rheumatic mitral stenosis (MS) in suitable patients. Pulmonary hypertension (PH) is a common coexisting finding and an indication for intervention. We sought to assess the influence of PH in PBMV immediate results and in very longterm outcome. Methods Between 1991 and June 2021, 202 consecutive patients underwent PBMV in a single tertiary centre. Clinical data, echocardiographic parameters, and MACE (cardiovascular mortality, need for percutaneous or surgical mitral reintervention) were analysed. Results Mean age was 47.3 ± 13.6 years and 89.6% were women. A previous commissurotomy or PBMV was found in 10.4% and mean Wilkins score was 7.6 ± 1.4. PH, defined as pulmonary artery systolic pressure (PASP) ≥45mmHg, was present in 32.7% of patients. A successful procedure was achieved in 89.1% of total population. Mean mitral valve (MV) gradient decreased from 13.1 to 5.0 mmHg (p &amp;lt; 0.001) and MV area increased from 1.1 to 1.8 cm2 (p &amp;lt; 0.001). A significant reduction also occurred in left atrium diameter (48.8 to 46.8 mm, p &amp;lt; 0.001) and PASP (50.5 to 38.5 mmHg, p &amp;lt; 0.001). During a mean follow-up of 12.0 ± 8.8 years, 7 cardiovascular deaths occurred (3.5%) and 33.2% of patients needed MV reintervention. Baseline PH did not impact immediate success and was not related with MACE in the follow-up. However, PH persistence after PBMV was correlated with unsuccessful procedure (p = 0.023) and with the occurrence of MACE during FU (HR 3.3, CI 95% 1.1-9.6, p = 0.028 and Kaplan-Meier analysis, log-rank 0.020). Conclusions PBMV in patients with MS and PH is a safe and effective intervention, achieving a significant decrease in PASP after procedure. Baseline PH was not associated with success or MACE. However, PH persistence after PBMV, correlated with worse prognosis in longterm follow up. Special attention and further investigation for this subgroup is needed. Abstract Figure.

Association of Echocardiographic Findings with in-Hospital Mortality of COVID-19 Patients and Their Changes in One-Month Follow-Up; a Cohort Study.

Evidence showed that cardiac complications may occur in coronavirus disease-19 (COVID-19) during the acute and post-infection phases. This study aimed to evaluate the association between the echocardiographic characteristics and in-hospital mortality of COVID-19 patients as well as the changes after one-month follow-up. All adult (≥18 years old) hospitalized COVID-19 patients in need of echocardiography based on the guideline of the Iranian Society of Echocardiography for performing various types of echocardiography during the COVID-19 pandemic were included in this study. An expert cardiologist performed the echocardiography on all patients and also on all available patients one month after discharge. 146 hospitalized cases of COVID-19 and 81 cases available for 1-month follow-up echocardiography were studied in this prospective study. Left ventricle wall hypokinesia, aorta valve stenosis, dilated Inferior Vena Cava (IVC), and Pulmonary Artery Systolic Pressure (PASP) of more than 35 were associated with 3.59 (95% CI: 1.19-10.79, p = 0.02), ‎11 (95% CI: 3.3 - 36.63, p = 0.001), ‎5.58 (95% CI: 1.04-29.41, p = 0.041)‎, and 2.91 (95% CI: 1.35 - 6.3, p = 0.001) times higher odds of mortality than healthy subjects. In 1-month follow-up of patients, deterioration in LVEF (p = 0.03) was detected in the not-fully vaccinated patients, and a significant decrease in PASP was observed in all cases (p = 0.04); but these changes were not clinically important. Left ventricle wall hypokinesia, aorta valve stenosis, dilated IVC, and PASP ≥ 35 were predictors of in-hospital mortality in our study. There were not any potential clinically significant differences in one-month echocardiographic follow-ups of the studied patients.

Efficacy and safety of hydro-mechanical defragmentation in intermediate- and high-risk pulmonary embolism

BackgroundPulmonary embolism (PE) is the third most common acute cardiovascular syndrome. Percutaneous catheter directed hydro-mechanical defragmentation (HMD) is one of the recommended treatment options for PE in patients with contraindications to thrombolytic therapy or failed systemic thrombolysis (ST). We aimed to identify the safety and outcomes of catheter directed HMD in patients with high-risk PE. This nonrandomized controlled trial enrolled all patients with confirmed diagnoses of high- and intermediate-high-risk PE from October 2019 till January 2021. Fifty patients were included and divided into two groups by the PE response team according to the presence or absence of a contraindication for ST. Group B (ST) consists of 25 patients and group A (HMD) of 25 patients who cannot receive ST.ResultsThe two groups were comparable regarding baseline clinical characteristics with mean age 51 ± 13 years. In group A, systolic blood pressure (BP) and oxygen saturation increased after 24 h (p = 0.002) and 48 h (p < 0.001) compared to pre-HMD procedure. Mean pulmonary artery systolic pressure (PASP) and respiratory rate (RR) decreased after 48 h and at 30 days (p < 0.001) compared to pre-HMD procedure. The increase in systolic BP and oxygen saturation were significantly higher in HMD group compared with ST group after 48 h and at 30 days (p < 0.007). The decrease in PASP and RR was significantly higher in HMD group compared to ST group after 48 h and at 30 days (p < 0.001). Mortality rate at 30 days was 20% in HMD group compared to 32% in ST group.ConclusionsCatheter directed HMD for high-risk and intermediate-high-risk PE is safe and effective with acceptable mortalityTrial registration Clinical trial ID: NCT04099186.

Transcatheter closure for patent ductus arteriosus in patients with Eisenmenger syndrome: to do or not?

BackgroundPatent ductus arteriosus (PDA) complicated by Eisenmenger syndrome (ES) remains to be a major cause of morbidity and mortality worldwide. Giving increasing evidences of benefit from targeted therapies, ES patients once thought to be inoperable may have increasing options for management. This study aims to explore whether PDA in patients with ES can be treated with transcatheter closure (TCC).MethodsBetween August 2014 and July 2016, four of fifteen PDA-ES patients whose Qp/Qs improved significantly and Qp/Qs > 1.5 after acute vasodilator testing with 100% oxygen were selected to receive TCC and pulmonary vasodilator therapy. PAH-targeted drugs were prescribed before and after occlusion for all. Trial occlusion was performed before permanent closure.ResultsThe first TCC failed after initiation of PAH-targeted drugs for 6 months in four patients. After the medication was adjusted and extended to 12 months, TCC was performed for all without hemodynamic intolerances during perioperative period. Pulmonary artery systolic pressure (PASP) was significantly decreased (≥ 40%) immediately after TCC. During a mean follow-up of 48 ± 14.70 months, there were a further decrease of PASPs in two patients, the other two showed improved pulmonary vascular resistance, WHO functional class and six-minute walking distance despite deteriorated PASP.ConclusionSome selected PDA-ES patients might benefit from TCC and combined PAH-targeted drugs play a crucial role.

Abstract 14264: The Impact of Bariatric Surgery on Echocardiographic Features of Cardiac Remodeling and Diastolic Function

Introduction: Candidates for bariatric surgery are at increased risk for cardiovascular disease and often develop adverse cardiac remodeling as a result of obesity. Bariatric surgery can alter cardiac structure and function in these patients; however, this has not been fully investigated. Hypothesis: We hypothesized that patients undergoing bariatric surgery would demonstrate favorable cardiac remodeling and improvement in diastolic parameters according to the American Society of Echocardiography (ASE) guidelines. Methods: All patients undergoing bariatric surgery at our institution from 2014-2018 were reviewed. In patients with pre- and post-operative echocardiograms, the following were measured: left ventricular (LV) size, pulmonary artery systolic pressure (PASP), LV mass, mitral E/A, LV ejection fraction (EF), medial and lateral E/e’, medial e’ and a’, lateral e’ and a’, tricuspid regurgitation (TR) velocity, left atrial volume index (LAVI), degree of LV hypertrophy, and relative wall thickness (RWT). The grade of diastolic dysfunction (DD) was calculated according to ASE guidelines. Results: A total of 69 patients met criteria for inclusion, with 77% (n=53) female, 87% (n=60) non-white, and mean age 49±10.7. Mean decrease in BMI one year post-operatively was 14.6±5.7 kg/m 2 . Median time between bariatric surgery and post-operative echocardiogram was 21.8 months. Post-operatively, there was a mean 17.8 cm/s decrease in TR velocity (p=0.0064) and 4.2 mmHg decrease in PASP (p=0.02). LAVI increased by 3.4 mL/m 2 (p=0.048). There was no significant change in LV size, LV mass, LVEF, LV hypertrophy, or RWT. Out of the 29 patients with pre-existing DD (grade 1, n=20; grade 2, n=8; grade 3, n=1), 45% (n=13) demonstrated improvement in grade of DD. When compared to pre-operative DD, post-operatively, 5 of 20 patients with G1DD had no DD, 2 of 8 patients with G2DD had no DD, 5 of 8 patients with G2DD had G1DD, and 1 patient with G3DD had G1DD. This was driven by a decrease in TR velocity and medial E/e’. Conclusions: In patients undergoing bariatric surgery, TR velocity and PASP improved while LAVI paradoxically increased. Patients with pre-existing DD demonstrated improvement in diastology, driven by changes in TR velocity and medial E/e’.

Effect of ambrisentan on echocardiographic and Doppler measures from patients in China with pulmonary arterial hypertension

ABSTRACT Background We retrospectively evaluated the echocardiographic data of ambrisentan-treated patients with pulmonary arterial hypertension (PAH) (NCT01808313). Methods Change from baseline in right ventricle (RV) systolic function, right heart structure, and pulmonary artery systolic pressure (PASP) prognosis to Weeks 12 and 24 was evaluated by echocardiography. Results In the overall population, the mean tissue Doppler-derived tricuspid lateral annular systolic velocity (S’) increased by 0.6 cm/s at both Weeks 12 (p < 0.001) and 24 (p = 0.004) and tricuspid annular plane systolic excursion increased by 0.13 cm at Week 12 and 0.15 cm at Week 24 (both p < 0.001). A marked decrease in transverse and longitudinal RV and RA diameter at Weeks 12 and 24 was observed. A significant decrease in diastolic eccentricity index at both Weeks 12 (−0.1; p = 0.02) and 24 (−0.1; p = 0.001). The decrease in PASP from baseline was significant at both Weeks 12 (−9.5 mmHg; p<0.001) and 24 (-7.6 mmHg; p<0.001), while a decrease in the estimated right atrium pressure was found to be significant at Week 24 (−0.8mmHg; p = 0.01). Conclusion Significant improvements in a number of RV echocardiographic parameters were observed at Weeks 12 and 24 after ambrisentan treatment in patients with PAH.

Dynamics of the clinical functional and hemodynamic profile of patients with pulmonary arterial hypertension with initial monotherapy with endothelin receptor antagonists: bosentan vs. macitentan

Aim To compare results of 24-h treatments with bosentan and macitentan by the clinical functional status and indexes of pulmonary hemodynamics in patients with pulmonary arterial hypertension (PAH).Materials and methods Based on the Russian National Registry (NCT03707561), 44 patients older than 18 years with PAH (34 patients with idiopathic pulmonary hypertension (IPH) and 10 patients with Eisenmenger syndrome) were retrospectively included into this study. Based on the statistical method of pairwise comparison, two groups were formed and matched by age, gender, WHO functional class (FC), and 6-min walk distance (6MWD). 22 patients of group 1 (17 with IPH and 5 with Eisenmenger syndrome) were treated with macitentan 10 mg/day, and 22 patients of group 2 (17 with IPH and 5 with Eisenmenger syndrome) were treated with bosentan 250 mg/day. Clinical instrumental data (6MWD, Borg dyspnea score, chest X-ray, transthoracic echocardiography (EchoCG), and right heart catheterization (RHC)) were evaluated at baseline and after 24 weeks of therapy.Results By week 24 of the treatment, FC and 6MWD improved in both groups. The macitentan treatment was associated with a significant decrease in Borg score. Significant intergroup differences in EchoCG data were not observed. The bosentan treatment was associated with a decrease in right ventricular (RV) dimension and a tendency towards a decrease in calculated pulmonary artery systolic pressure (PASP). By week 24, the macitentan treatment as compared to the bosentan treatment, was associated with a decrease in cardiothoracic ratio (CTR). In both groups, RHC showed decreases in PASP, mean pulmonary artery pressure and pulmonary vascular resistance, and improvements in cardiac output (CO), cardiac index, and stroke volume (SV) values. By week 24, the increase in SV was greater in the macitentan treatment group than in the bosentan treatment group (р=0.05).Conclusion The 24-week treatment with bosentan or macitentan provided significant and comparable improvement of the functional profile in PAH patients with FC II (WHO) at baseline. The decrease in CTR was significantly more pronounced in the macitental treatment group compared to the bosentan treatment group. The 24-week bosentan treatment resulted in a decrease in RV anterior-posterior dimension, a tendency towards a decrease in PASP according to EchoCG data. Macitentan provided more pronounced dynamics of dyspnea than bosentan according to the results of 6MWD test and the increase in SV according to RHC data.

Impact of adenotonsilectomy on nasal airflow and pulmonary blood pressure in mouth breathing children

IntroductionAdenotonsillar hyperplasia (ATH) causing upper airway obstruction (UAO) may increase pulmonary artery systolic pressure (PASP). Early diagnosis and mouth breathing (MB) management may help in cases of high PASP. Total inspiratory nasal airflow (TINAF) obtained by active anterior rhinomanometry (AARM) is a means to quantify nasal patency. This study aimed to correlate TINAF with high PASP. MethodsThis is a prospective study involving 30 children between two and twelve years of age, with indication for adenotonsillectomy due to ATH, evaluated before and six months after surgery; and 29 nasal breathing (NB) children in the same age group. We obtained the PASP, calculated for tricuspid regurgitation, by means of a transthoracic echocardiography. We assessed nasal patency using the AARM to estimate the TINAF. ResultsThe mean PASP among mouth breathing children was 25.99 mmHg, with a Standard Deviation of (±) 3.27, p = 0.01 in the preoperative period; and 21.79 mmHg (±2.48; p = 0.01) in the postoperative period. Among nasal breathers, this mean value was 21.64 mmHg (±3.87, p = 0.01). The mean pre-operative TINAF was 266.76 cm3/s (±112.21, p = 0.01); and 498.93 cm3/s (±137.80, p = 0.01) after surgery. Among nasal breathers it was 609.37 cm3/s (±109.16; p = 0.01). The mean nasal patency in the preoperative period was 42.85% (±17.83; p = 0.01); and 79.33% (±21.35; p = 0.01) in the post-op. Among nasal breathers it was 112.94% (±15.88, p = 0.01). There was a significant Spearman correlation value between TINAF and PASP (r = −0.459; p = 0.01) when we analyzed all the groups. ConclusionPASP and TINAF values improved postoperatively and had an inverse correlation. This study suggests that by improving TINAF there was a decrease in PASP.

Tissue plasminogen activator dose and pulmonary artery pressure reduction in catheter directed thrombolysis of submassive pulmonary embolism.

PurposeThe purpose of this study is to assess the incremental effect of tissue plasminogen activator (t-PA) dose on pulmonary artery pressure (PAP) and bleeding during catheter directed thrombolysis (CDT) of submassive pulmonary embolism (PE).Materials and methodsRecords of 46 consecutive patients (25 men, 21 women, mean age 55±14 y) who underwent CDT for submassive PE between September 2009 and February 2017 were retrospectively reviewed. Mean t-PA rate was 0.7±0.3 mg/h. PAP was measured at baseline and daily until CDT termination. Mixed-effects regression modeling was performed of repeated PAP measures in individual patients. Bleeding events were classified by Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) and t-PA dose at onset.ResultsMean t-PA dose was 43.0±30.0 mg over 61.9± 28.8 h. Mean systolic PAP decreased from 51.7±15.5 mmHg at baseline to 35.6±12.7 mmHg at CDT termination (p<0.001). Mixed-effects regression revealed a linear decrease in systolic PAP over time (β = -0.37 (SE = 0.05), p<0.001) with reduction in mean systolic PAP to 44.8±1.9 mmHg at 12 mg t-PA/20 h, 39.5±2.0 mmHg at 24 mg t-PA/40 h, and 34.9±2.1 mmHg at 36 mg/60 h. No severe, one moderate, and 8 mild bleeding events occurred; bleeding onset was more frequent at ≤24 mg t-PA (p <0.001). One patient expired from cardiopulmonary arrest after 16 h of CDT (15.4 mg t-PA); no additional intra-procedural fatalities occurred.ConclusionIncreased total t-PA dose and CDT duration were associated with greater PAP reduction without increased bleeding events.

Does Nasal Surgery Affect Right Ventricular Myocardial Functions at the Tissue Level in Patients with Nasal Septum Deviation?

Objective: One of the most common causes of upper airway obstruction in adults is nasal septum deviation (NSD). The chronic hypoxia caused by this obstruction gradually leads to increased pulmonary vascular resistance, pulmonary hypertension (PHT), and right ventricular (RV) failure. The purpose of this study was to determine changes in RV myocardial functions at the tissue level before, and after surgery in patients with NSD. Subjects and Methods: Fifty-eight patients with symptoms of nasal obstruction and snoring were included in this observational study. Preoperative and postoperative third-month peripheral arterial oxygen saturation (SpO2), and RV systolic and diastolic functions measured by pulmonary artery systolic pressure (PASP), tissue Doppler parameters, and speckle tracking echocardiography (STE) were studied in these patients. Results: We observed a very significant decrease in PASP in the postoperative period (32.54 ± 5.24 mmHg vs. 24.22 ± 4.55 mmHg, p = 0.001). Postoperative SpO2 values, measured at room temperature also increased significantly (93.5 ± 0.82% vs. 95.6 ± 0.79%, p = 0.001). There was a significant improvement after surgery in RV systolic functions, represented by global longitudinal strain (GLS) (21.12 ± 2.07 vs. 22.49 ± 1.89, p = 0.013) and systolic global longitudinal strain rate (GLSRs) (1.30 ± 0.12 vs. 1.38 ± 0.13, p = 0.015). No significant differences in terms of RV diastolic function parameters were detected, including the RV early diastolic global longitudinal strain rate (GLSRe) (1.56 ± 0.21 vs. 1.55 ± 0.26, p = 0.86) and RV late diastolic global longitudinal strain rate (GLSRa) (0.88 ± 0.19; 0.89 ± 0.18, p = 0.76). Conclusion: This study was performed with an advanced technique capable of tissue level examination. The findings demonstrated significant improvement in both chronic hypoxia and RV systolic myocardial functions, measured at the tissue level after nasal surgery.

THE EFFICACY OF SILDENAFIL THERAPY IN PATIENTS WITH PULMONARY HYPERTENSION OF DIFFERENT ETIOLOGY: INFLUENCE ON THE CLINICAL, FUNCTIONAL, HEMODYNAMIC STATUS, STRUCTURE AND FUNCTION OF THE RIGHT AND LEFT HEART, RIGHT VENTRICULAR-ARTERIAL COUPLING

Aim: to study the efficacy of sildenafil therapy in pulmonary hypertension of different etiology, its influence on the clinical, functional, hemodynamic status, structure and function of the right and left heart, right ventricular-arterial coupling (RVAC) in pts with idiopathic pulmonary hypertension (IPAH) and chronic thromboembolic pulmonary hypertension (CTEPH).Materials and methods: in the study we included 29 IPAH pts aged 42.8±10.6 yrs, 28 CTEPH pts aged 43.4±10.4 yrs II-IV functional class (FC) (WHO), receiving stable standard therapy (anticoagulants, diuretics, glycosides) and calcium channel blockers for at least 3 months. Sildenafil was started at the dose of 10 mg TID to assess the tolerability for further titration after 1 wk to 20 mg 3 times a day. The treatment duration was 16 wks. At baseline and at wk 16 FC (WHO), 6-minute walking test (6-MWT), transthoracic echocardiography (Echo) and right heart catheterization (RHC) were performed.Results: both groups were comparable in baseline functional parameters: FC, the distance in 6-MWT, Borg index. The analysis of baseline structural and functional cardiac parameters by Echo in IPAH and CTEPH pts revealed pronounced cardiac remodeling as compared to the control group. All pts had criteria precapillary PH by RHC with comparable systolic pulmonary artery pressure (SPAP), mean pulmonary artery pressure (PAPm), cardiac output (CO) and index (CI), pulmonary vascular resistance (PVR) except for diastolic PAP (DPAP), which was higher in IPAH group (38.3±13.7 mm Hg vs 31.5±8.9 mm Hg in CTEPH group (p&lt;0.05). Sildenafil therapy resulted in the marked improvement of functional and hemodynamic status, cardiac remodeling parameters in both groups. To wk 16 IPAH pts achieved the 114m increase in 6-MWT as compared with 108m in CTEPH group. IPAH pts demonstrated the significant decrease in SPAP, PAPm, reduce of right ventricular (RV) size and improvement of contractile function - FAC and TAPSE, increase of RVAC by reducing LV stiffness. Eccentricity index of LV improved significantly only in CTEPH pts. Positive dynamic in RHC data (significant decrease of SPAP, PAPm, DPAP, PVR, increase of CO,CI, stroke volume). CTEPH pts showed a greater reduction in PVR, SPAP and significant SvO2 improvement.Conclusion: 1. In pts with IPAH and CTEPH of comparable baseline clinical, functional and hemodynamic status we found no significant differences in the severity of cardiac remodeling, RV and LV systolic and diastolic function. Regardless of etiology RVAC was reduced due to the significant increase of LV stiffnessEs. 2. 16-wk sildenafil therapy in pts with IPAH and CTEPH resulted in the positive dynamic of 6-MWT distance, dyspnea index, Echo data including LV stiffness. 3. In CTEPH group as compared with IPAH pts we found the more marked reduction in PVR, PASP and significant improvement SvO2 by RHC. The significant decrease in Es was observed only in CTEPH pts.

The effect of perioperative use of dexmedetomidine on pediatric patients with pulmonary hypertension undergoing congenital cardiac surgery

Background Anesthetic management of a pediatric patient with pulmonary arterial hypertension (PAH) poses an enormous challenge. The objective of this study was to evaluate the ability of dexmedetomidine to reduce the pulmonary artery pressure in pediatric patients with PAH undergoing cardiac surgery. Patients and method Seventy patients diagnosed with PAH were enrolled in this study. The patients were randomized into two groups: group D received dexmedetomidine infusion of 1 μg/kg/h for one hour, which was reduced to 0.5 μg/kg/h throughout the surgery until extubation in the post anesthesia care unit (PACU), and group C received 0.9% normal saline in the same volume. Pulmonary artery systolic pressure (PASP) and systemic systolic blood pressure (SSBP) were recorded throughout surgery and postoperatively in the PACU. The need for vasodilator and sedative drugs and the time of extubation and ICU stay were recorded for all patients. Results The patients in the dexmedetomidine group showed a significant decrease in PASP and PASP/SSBP ratio during surgery and throughout the first 24 h in the PACU (P Conclusion We concluded that perioperative use of dexmedetomidine in pediatric patients with pulmonary hypertension reduces the PASP throughout the operative and postoperative period.

Conduction Abnormalities after Transcatheter Aortic Valve Implantation and Diastolic Dysfunction

Objectives: Transcatheter aortic valve implantation (TAVI) is frequently associated with the development of conduction abnormalities. We assessed the effect of conduction abnormalities on diastolic function following TAVI. Methods: In total, 101 consecutive post-TAVI patients were included, each with echocardiographic follow-up at 1 and 6 months. Diastolic properties were correlated with the occurrence of a long PR interval and wide QRS, and their change from baseline. The measured diastolic parameters included E/A ratio, E wave deceleration time, E wave to e′ ratio, left atrial (LA) volume, and systolic pulmonary artery pressure (SPAP). The clinical outcome was all-cause mortality. Results: Overall, TAVI was associated with a consistent decrease in SPAP at the 1- and 6-month follow-up. LA volumes were increased at 1 month post-TAVI in patients with a wide compared to normal QRS (p = 0.03) and at 6 months in patients with a normal compared to prolonged PR (p = 0.03). PR prolongation above 40 ms was associated with lower SPAP at the 1- but not 6-month follow-up. Survival was not influenced by conduction abnormalities. Conclusions: TAVI is associated with a reduction in SPAP. A postprocedural wide QRS and normal PR interval may unfavorably influence the left-sided filling performance, resulting in an increased LA volume. Other diastolic parameters, as well as survival, are not significantly affected by postprocedural conduction abnormalities.

Prognostic Impact of Pulmonary Artery Systolic Pressure in Patients Undergoing Transcatheter Aortic Valve Replacement for Aortic Stenosis

Baseline pulmonary hypertension (PH) is a predictor of poor outcomes in patients with severe aortic stenosis (AS). Surgical aortic valve replacement is thought to alleviate PH. The aim of this study was to determine the prognostic impact of PH in patients who underwent transcatheter aortic valve replacement (TAVR). An observational cohort study was conducted using prospectively collected data on 277 consecutive patients with severe AS who underwent TAVR at the Mayo Clinic (Rochester, Minnesota) from November 1, 2008, to June 31, 2013. Clinical and echocardiographic data, pulmonary function characteristics, and outcomes stratified by tertiles of pulmonary artery systolic pressure (PASP) were analyzed. From 277 patients who underwent TAVR, 251 patients had PASP assessment at baseline. Those in the highest PASP tertile (PASP ≥49 mm Hg) had more severe chronic lung disease and worse diastolic dysfunction. Being in the highest PASP tertile was an independent predictor of long-term mortality (hazard ratio 2.88, 95% confidence interval 1.15 to 7.23). Patients in the highest PASP tertile had longer lengths of hospital stay, while other short-term outcomes (30-day mortality and readmission, stroke, prolonged ventilation, and reoperation for bleeding) were similar across PASP tertiles. TAVR was associated with a decrease in PASP in the highest PASP tertile at 1 week after the procedure (-8 ± 14 mm Hg) and at 3 months (-7 ± 15 mm Hg) compared with baseline. In conclusion, among patients with severe AS who underwent TAVR, higher baseline PASP was strongly associated with diastolic dysfunction and chronic lung disease. Patients with higher baseline PASP tolerated TAVR relatively well in the early postprocedural phase, with diminished long-term survival. PH should not disqualify patients with severe AS from consideration for TAVR.

Dynamic Nature of Pulmonary Artery Systolic Pressure in Decompensated Heart Failure With Preserved Ejection Fraction: Role of Functional Mitral Regurgitation

BackgroundPulmonary hypertension (PH) is prevalent in decompensated heart failure with preserved ejection fraction (HFpEF). We investigated the effect of a return to a compensated state on pulmonary artery systolic pressure (PASP) and functional mitral regurgitation (FMR). Methods and ResultsTwo-dimensional Doppler echocardiography was prospectively performed before initiation of standard therapy and 48 hours later in 37 patients hospitalized for HFpEF-related dyspnea and in 26 patients hospitalized for non-HFpEF–related dyspnea. Left atrial volume index, and E/e′ ratio, and PASP were significantly greater and E-wave deceleration time significantly shorter in HFpEF than in non-HFpEF patients. Thirty-two of the 37 HFpEF had FMR on admission whereas none of the non-HFpEF patients had FMR. After 48 hours of therapy, the reduction in PASP was significantly greater in the 26 HFpEF patients who improved than in the 11 HFpEF patients who did not (−24 vs −9 mm Hg, respectively; P < .0001), whereas PASP remained unchanged in non-HFpEF patients. The decrease in PASP correlated in HFpEF patients with reductions in blood pressure, heart rate, left ventricular end-diastolic volume, inferior vena cava diameter, E/A ratio, E/e′ ratio, mitral effective regurgitant orifice area (EROA), and E-wave deceleration time. The correlation between PASP and mitral EROA was the only one that remained significant by multivariate analysis. ConclusionsNoninvasive monitoring of PASP and FMR during an episode of HFpEF decompensation reveals that the return to a compensated state is associated with a significant reduction in PASP and FMR.

Hemodynamic Impact and Outcome of Permanent Pacemaker Implantation Following Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) frequently requires postprocedural permanent pacemaker (PPM) implantation. We evaluated clinical and hemodynamic impact of PPM after TAVI. Clinical and echocardiographic data were retrospectively analyzed in 230 consecutive patients who underwent TAVI and echocardiography at baseline and after 6 months. Echocardiographic parameters included left ventricular ejection fraction (LVEF), left ventricular (LV) stroke volume, early mitral velocity/annulus velocity ratio (E/e'), right ventricular index of myocardial performance, systolic pulmonary artery pressure (SPAP), and aortic, mitral, and tricuspid regurgitation grades. Clinical outcomes included 2-year survival and cardiovascular and PPM-related event-free survival. The Medtronic CoreValve and Edwards Sapien prosthesis were used in 201 and 29 patients, respectively. PPM was required in 58 patients (25.4%). Two-year and event-free survival rates were similar between patients with and without PPM. At 6 months, patients with PPM demonstrated attenuated improvement in LVEF (-0.9 ± 8.7% vs 2.3 ± 10.8%, respectively, p = 0.03) and LV stroke volume (-2 ± 16 vs 4 ± 10 ml/m(2), respectively, p = 0.015), a trend toward smaller reduction in systolic pulmonary artery pressure (-1 ± 12 vs -6 ± 10 mm Hg, respectively, p = 0.09), and deterioration of right ventricular index of myocardial performance (-3 ± 17% vs 5 ± 26%, respectively, p = 0.05). The differences in post-TAVI aortic, mitral, and tricuspid regurgitation grades were insignificant. In conclusion, PPM implantation after TAVI is associated with reduced LVEF and impaired LV unloading. However, this unfavorable hemodynamic response does not affect the 2-year clinical outcome. The maintenance of clinical benefit appears to be driven by TAVI-related recovery of LV and right ventricular performance that mitigates unfavorable impact of PPM.

Comparison of Continuous‐Flow and Pulsatile‐Flow Blood Pumps on Reducing Pulmonary Artery Pressure in Patients With Fixed Pulmonary Hypertension

Pulmonary hypertension (PH) is considered as a risk factor for morbidity and mortality in patients undergoing heart transplantation. Recently, left ventricular assist device (LVAD) implantation has been increasingly used in reducing pulmonary artery pressure (PAP) in patients with PH unresponsive to medical therapy. Herein, we aimed to compare the efficacy of continuous-flow and pulsatile-flow blood pumps on the improvement of PH in mechanical circulatory support patients. Twenty-seven patients with end-stage heart failure who underwent LVAD implantation surgery were enrolled. Fifteen of them (55.6%) had continuous-flow pump (HeartWare Ventricular Assist System, HeartWare, Inc., Miramar, FL, USA), and 12 of them (44.4%) had pulsatile pump (Berlin Heart EXCOR ventricular assist device, Berlin Heart AG, Berlin, Germany). The efficacy of LVADs on the improvement of PH was compared between continuous-flow and pulsatile pumps by the evaluation of systolic PAP, tricuspid annular plane systolic excursion (TAPSE), right ventricular systolic motion (RVSM), right ventricular ejection fraction (RVEF), and grade of tricuspid insufficiency (TI) for each of the study participants. All of the 15 patients who underwent continuous-flow blood pump implantation surgery (Group 1) were male with a mean age of 46.9 ± 11.7 years, and in pulsatile-flow blood pump implanted participants (Group 2), the mean age was 40.6 ± 16.8 years, all of whom were also male (P=0.259). Mean follow-up was 313.7 ± 241.3 days in Group 1 and 448.7 ± 120.7 days in Group 2 (P=0.139). In Group 1, mean preoperative and postoperative systolic PAP were measured as 51.7 ± 12.2 mm Hg and 22.2 ± 3.4 mm Hg, respectively, while those in Group 2 were 54.5 ± 7.5 mm Hg and 33.9 ± 6.4 mm Hg, respectively. A significantly greater decrease in systolic PAP was noticed in patients with continuous-flow blood pumps (P=0.023); however, no statistically significant difference was found when we considered the change in TAPSE between study groups (P=0.112). A statistical significance in the alteration of RVEF, RVSM, and the grade of TI during study visits was not found between the study groups (P=0.472, P=0.887, and P=0.237, respectively). Although the two studied types of LVADs were found to be effective in reducing PAP in heart transplantation candidates with PH, lesser postoperative systolic PAP values were achieved in patients who underwent continuous-flow pump implantation surgery.