Elevated Pulmonary Artery Systolic Pressure Research Articles

Integrative Cardiopulmonary Ultrasound for Interstitial Lung Disease Assessment: Correlation between Lung Ultrasound Performance and Cardiac Involvement

The aims of this study were to apply integrative cardiopulmonary ultrasound (thoracic ultrasound) to the evaluation of patients with interstitial lung disease (ILD) and to determine the relationship between lung ultrasound signs and echocardiographic parameters such as systolic pulmonary artery pressure (SPAP) and various right ventricular parameters. ILD patients and healthy controls underwent lung ultrasound (LUS) and echocardiographic tests. In addition to traditional echocardiographic parameters, right ventricular free wall longitudinal strain (RVLS_FW) was measured using 2-D speckle-tracking echocardiography. The degree of pulmonary fibrosis or the disease severity of each ILD patient was scored with a semiquantitative scoring method, taking into account multiple LUS signs. Statistical analyses were performed to compare various parameters between ILD patients with and those without pulmonary hypertension. Correlations between the different parameters were then evaluated, and the LUS scores were used to predict pulmonary hypertension using a receiver operating characteristic curve analysis. Among the 90 patients who qualified for entry into this study, 30% (n = 27) had pulmonary hypertension. The patients with pulmonary hypertension had larger right ventricular dimensions, lower RVLS_FW and higher LUS scores. An effective correlation was found between ILD LUS scores and echocardiographic parameters, especially SPAP (r = 0.735, p < 0.001). The groups were comparable with respect to most echocardiographic parameters, with mild, moderate and severe pulmonary fibrosis, whereas SPAP was significantly higher in the moderate and severe groups. RVLS_FW was obviously reduced in the group with severe pulmonary fibrosis. Although RVLS_FW in the mild pulmonary fibrosis group was in the normal range, it was slightly reduced compared with that of the controls. A cutoff of more than 16 LUS points had 85.2% sensitivity and 80.3% specificity in predicting elevated SPAP (>36 mm Hg). Thoracic ultrasound is useful in the assessment of ILD. As ILD progresses, the structure or function of the right ventricle gradually deteriorates. LUS not only detects lung conditions in ILD, but also indirectly reflects SPAP and right ventricular function. Integrated use of LUS and echocardiography will provide an invaluable point-of-care imaging modality to facilitate the diagnosis, management and treatment of patients with ILD.

Associates and Prognosis of Giant Left Atrium; Single Center Experience.

BackgroundLeft atrial (LA) remodeling develops as a result of longstanding pressure overload. However, determinants and clinical outcome of excessive remodeling, so called giant left atrium (GLA), are not clear.MethodsClinical characteristics of patients with GLA (antero-posterior diameter higher than 65 mm), including echo-Doppler parameters, and follow-up clinical outcomes from a tertiary referral hospital were investigated.ResultsAmong 68519 consecutive primary patients who underwent echocardiography over a period of 10 years, data from 163 GLA cases (0.24%) were analyzed. Main causes were significant rheumatic mitral stenosis (n = 58, 36%); other causes comprised significant rheumatic mitral regurgitation (MR; n = 10, 6%), mitral valve (MV) prolapse or congenital mitral valvular disease (MVD) (n = 20, 12%), and functional MR (n = 25, 15%). However, mild rheumatic MV disease (n = 4, 3%) or left ventricular (LV) systolic or diastolic dysfunction without significant MR (n = 46, 28%) were also causes of GLA. During median follow-up of 22 months, 42 cases (26%) underwent composite events. MV surgery was related to lower rate of composite events. In multivariate analysis, MV surgery, elevated pulmonary arterial systolic pressure, and increased LA volume index were independent predictors of future events (p < 0.05) regardless of underlying diseases or history of MV surgery.ConclusionAlthough rheumatic MVD with atrial fibrillation is the main contributor to GLA, longstanding atrial fibrillation with LV dysfunction but without MVD also could be related to GLA. Even in GLA state, accurate measurement of LA volume is crucial for risk stratification for future events, regardless of underlying disease.

Exercise Echocardiography Findings and Outcome in Patients with Right Ventricular Dilation not Related to Left-Sided Heart Disease

Objective: Symptoms may be similar in patients with heart or lung disease. Thus, patients with lung disease are occasionally referred for evaluation by exercise echocardiography (ExE). We aimed to study the clinical, ExE data and outcome of patients with right ventricular (RV) dilation not explained by left ventricular (LV) heart disease. Methods: Retrospective analysis of RV dysfunctional data in absence of LV heart disease in patients submitted to an ExE. Results: Data on RV dilation in absence of LV heart disease were found in 21 of 18,400 ExE studies (0.11%). In 4 of the 21 patients (19%) RV function and systolic pulmonary artery pressure were normal at rest. However, exercise induced RV dysfunction and/or elevated systolic pulmonary artery pressure in all of these 4 patients. During follow-up of 5.2 ± 5.7 years 11 patients died (52%), most of them of respiratory causes (73%), being pulmonary thromboembolism (PTE) (38%) the most frequent final diagnosis. Conclusion: RV dysfunction in absence of LV disease is rare among patients referred for ExE. ExE is of value as sometimes abnormalities on RV function arise only with exercise

Respiratory and cardiovascular complications in patients with liver cirrhosis due to hepatitis C virus and its impact on quality of life

ObjectiveTo assess the respiratory and cardiovascular complications in patients with liver cirrhosis due to hepatitis C virus and its impact on quality of life. Subjects and methodsThe study was carried out on 100 patients with liver cirrhosis and 50 healthy control volunteer without liver cirrhosis where respiratory and cardiovascular complications were assessed by arterial blood gas (ABG) analysis (PaO2, PaCO2 and pH), pulmonary function tests (PFTs) [forced vital capacity (FVC%), forced expiratory volume in one second (FEV1%), FEV1/FVC ratio and forced expiratory flow in 25% to 75% of FVC (FEF 25–75%)] and echocardiography [pulmonary artery systolic pressure (PASP), left atrial (LA) area, diastolic dysfunction (DD), and pulse rate]. ResultsThe pulmonary artery systolic pressure (PASP) measured by echo was significantly higher (48.23mmHg) in cirrhotic patients than that of the control non cirrhotic group (28.02mmHg) (P<0.001). By ABG analysis, PaO2 was significantly lower in cirrhotic patients (52.29mmHg) than in the control group (79.34mmHg) (P<0.001) with a significant negative correlation between PASP and PaO2. On the other hand, the differences between both groups regarding PaCO2 and pH were insignificant (P>0.05). There was a highly significant positive correlation between portal vein diameter and the level of PASP. High mortality rate 41% was reported among patients with high PASP. Regarding the PFTs, the differences between both groups regarding the FVC%, FEV%, FEV1/FVC and FEF 25–75% were insignificant (P>0.05). ConclusionRespiratory and cardiovascular complications (elevated PASP, hypoxemia, increased LA area DD and/or tachycardia) are common complications in hepatic patients and should be assessed for control of symptoms, quality of life and survival.

Reasearch on correlation between lung ultrasound findings of interstitial lung diseases and cardiac involvement

Objective To assess the relationship between lung ultrasonography and cardiac involvement (pulmonary artery systolic pressure, right ventricular function) in patients with interstitial lung diseases(ILD) by integrative cardiopulmonary ultrasound (also called thoracic ultrasound, TUS). Methods Seventy two patients with clinically diagnosed ILD were investigated at the Department of Respiratory Medicine in our hospital. The tranditional echocardiographic parameter included pulmonary arterial systolic pressure(PASP), tricuspid regurgitation area(ATR), main pulmonary artery diameter(DMPA), left pulmonary artery diameter (DLPA), right pulmonary artery diameter(DRPA), right ventricular outflow tract dimensions at the proximal or subvalvular level(DRVOT1), right ventricular outflow tract dimensions at the distal or pulmonic valve(DRVOT2), right ventricular basal diameter(RVTD), mid-right-ventricular diameter(RVDm), tricuspid annular plane systolic excursion(TAPSE), left ventricular ejection fraction (LVEF) and left ventricular end-diastolic diameter (LVEDd). Tissue Doppler parameters includpeak velocity of tricuspid annulus (S′, e′, a′) and myocardial performance index(MPI); Two-dimensional speckle tracking imaging(2D-STI) parameter was right ventricular global strain(RVGLS). The number of B lines and the performance of pleural line were evaluated by lung ultrasound.Statistical analysis was performed on the above TUS indexes. Results ①With the use of PASP higher than 36mmHg as the criterion for pulmonary hypertension(PH), all patients were divided into group ILDPH and group ILDNPH, comparison of TUS parameters in two groups, several parameters had statistical difference including ATR, RVD, RVDm, RPA, RVGLS, MPI, FAC, the number of B lines and the grade of pleural line. ②According to the degree of pleural involvement, all patients were divided into severe group and mild-moderate group, in the comparison of echocardiographic parameters, only ATR, RPA and RVGLS had statistic difference. ③A positive correlation was found between the number of B lines and PASP(r=0.547), a weak correlation was found between the grade of pleural line and PASP or RVGLS. ④A cut off more than 35 B lines had 95.8% sensitivity, 37.5% specificity in predicting elevated PASP(>36 mmHg), and the area under the ROC curve was 0.707. Conclusions TUS can effectively assess ILDs. With the disease progresess, the structure or function of right ventricular will gradually damaged.Lung ultrasound can not only evaluate the changes of lung in ILD, but also indirectly reflect PASP and the function of right ventricle, and it combined with echocardiography can provide more useful information for clinical diagnosis and management of ILDs. Key words: Integrative cardiopulmonary ultrasound; Interstitial lung diseases; Pulmonary hypertension; Ventricular function, right

Detection of elevated pulmonary pressures by the ECG-derived ventricular gradient: A comparison of conversion matrices in patients with suspected pulmonary hypertension

BackgroundThe aim was to assess the diagnostic value of the Inverse Dower (INVD)-derived vectorcardiogram (VCG) and the Kors-derived VCG to detect elevated systolic pulmonary artery pressure (SPAP) in suspected pulmonary hypertension (PH). MethodsIn 132 patients, morphologic variables were evaluated by comparing the VCG parameters synthesized by INVD and Kors matrix. Comparison of the diagnostic accuracy of detecting SPAP ≥50mmHg between the matrices was performed by ROC curve analysis and logistic regression analysis. ResultsMost VCG parameters differed significantly between INVD and Kors. ROC analysis for detection of SPAP ≥50mmHg by VG projected on the X-axis demonstrated no difference (p=0.99) between INVD (AUC=0.80) and Kors (AUC=0.80). Both the INVD- and Kors-derived VCG provided significant diagnostic information on the presence of SPAP ≥50mmHg (INVD, OR 1.05, 95%CI 1.03–1.07; P<0.001; Kors, OR 1.05, 95%CI 1.03–1.08; P<0.001). ConclusionAlthough there were significant differences in measures of vector morphology, both INVD- and Kors-derived VCG demonstrated equal clinical performance in case of elevated SPAP.

Safety of Bronchoscopy in Patients with Echocardiographic Evidence of Pulmonary Hypertension

Background: Bronchoscopy with transbronchial and endobronchial biopsy and transbronchial needle aspiration is an important diagnostic tool in the pulmonologist's armamentarium. Safety in patients with pulmonary hypertension is controversial and many bronchoscopists consider this as a contraindication for the procedure. Objectives: To evaluate safety of bronchoscopy in patients with echocardiographic pulmonary hypertension and to compare with patients without it. Methods: Retrospective analysis of patients who underwent bronchoscopic transbronchial biopsy, endobronchial biopsy and/or endobronchial ultrasound-guided transbronchial needle aspiration. Patients were divided into two groups based on echocardiographic results: control group with systolic pulmonary artery pressure <36 and a group with elevated systolic pulmonary artery pressure (eSPAP) ≥36. Results: One-hundred and ninety patients met the study criteria. Patients in the control group were younger with a lower incidence of chronic kidney disease. There was no difference in prevalence of congestive heart failure, obstructive airway disease, malignancy, liver disease, coagulopathy, use of antiplatelet agent or anticoagulant drugs. Incidence of minor bleeding due to bronchoscopic biopsies was 4.8% in both groups (p = 1.00). Incidence of major bleeding was similar in the groups (one patient in each group). In the control group, one patient had pneumothorax and another required prolonged mechanical ventilation (>4 h). In the eSPAP group, two patients required prolonged mechanical ventilation. There was no procedure-related mortality or sedation complications in the cohort. Conclusion: Our study provides additional support that in patients with echocardiographic evidence of pulmonary hypertension, transbronchial and endobronchial biopsies and endobronchial ultrasound-guided transbronchial needle aspiration are safe procedures.

Association of Elevated Plasma Endothelin-1 Levels With Pulmonary Hypertension, Mortality, and Heart Failure in African American Individuals: The Jackson Heart Study.

Despite pathophysiological links between endothelin-1 and pulmonary vascular remodeling, to our knowledge, the association between plasma endothelin-1 levels and pulmonary hypertension has not been studied in the general population. Also, whether endothelin-1 can predict future heart failure and mortality, outcomes that are associated with pulmonary hypertension, in a population cohort is unclear. To determine whether elevated plasma endothelin-1 levels are associated with pulmonary hypertension, mortality, and heart failure. Data from the Jackson Heart Study, a longitudinal, prospective observational cohort study of heart disease in African American individuals from Jackson, Mississippi, were analyzed. The community population sample was limited to participants with detectable tricuspid regurgitation on echocardiography. The study participants included self-identified African American individuals with plasma endothelin-1 levels and tricuspid regurgitation on echocardiogram (n = 3223) at the time of first examination (2000-2004). The analysis of the data began on April 14, 2014, and was completed on February 23, 2016. Log-transformed plasma endothelin-1 level. Cross-sectional analysis: presence of pulmonary hypertension (defined as an elevated pulmonary artery systolic pressure >40 mm Hg on echocardiogram). Longitudinal outcomes were all-cause mortality (median follow-up, 7.75 years) and heart failure admissions (median follow-up, 5.32 years). Of the 3223 participants enrolled in the study, 1051 were men (32.6%). Mean (SD) endothelin-1 levels were 1.36 (0.64) pg/mL; 217 of 3223 cohort members (6.7%) had pulmonary hypertension. After adjusting for potential confounders, log-transformed endothelin-1 levels were associated with increased odds of pulmonary hypertension (adjusted odds ratio per log increment in endothelin-1, 1.66; 95% CI, 1.16-2.37). Log-transformed endothelin-1 levels were associated with mortality (adjusted hazard ratio per log increment in endothelin-1, 1.69; 95% CI, 1.27-2.25; median follow-up, 7.75 years) and heart failure (adjusted hazard ratio per log increment in endothelin-1, 1.57, 95% CI, 1.05-2.37; median follow-up, 5.32 years) in the study cohort. Phenotyping by pulmonary hypertension and endothelin-1 level showed mortality decreasing in order from subgroup with pulmonary hypertension and high endothelin-1 (high endothelin-1: ≥1.7 pg/mL; upper quartile); pulmonary hypertension and low endothelin-1 <1.7 pg/mL; lower 3 quartiles); no pulmonary hypertension and high endothelin-1; and no pulmonary hypertension and low endothelin-1 (log-rank χ2 = 77.16; P < .01 ). Elevated plasma endothelin-1 levels, especially associated with an elevated pulmonary artery systolic pressure on echocardiogram, may identify an at-risk population that could be evaluated for targeted prevention and management strategies in future studies.

Prognostic Implications of Elevated Pulmonary Artery Pressure After ST-Segment Elevation Myocardial Infarction

Elevated systolic pulmonary artery pressure (SPAP) after ST-segment elevation myocardial infarction (STEMI) has been associated with adverse outcome. However, little is known about the development of increased SPAP after STEMI treated with primary percutaneous coronary intervention. The aims of this study were to investigate the incidence and determinants of elevated SPAP (SPAP ≥36mm Hg at 12months) after first STEMI and to analyze its prognostic implications. A total of 705 patients (60 ± 12years; 75% men; left ventricular ejection fraction [LVEF] 47 ± 9%) with first STEMI treated with primary percutaneous coronary intervention were evaluated. Two-dimensional echocardiography was available at baseline and 12-month follow-up. Data on all-cause mortality were collected at long-term follow-up. Incident elevated SPAP was present in 5% (n= 38) of patients. Patients with incident elevated SPAP were older (66 ± 12 vs 60 ± 11 years, p= 0.001), had more systemic hypertension (58% vs 30%, p <0.001) and lower LVEF (43 ± 9% vs 48 ± 8%, p <0.001) than their counterparts. Left atrial volume was larger (23 ± 11 vs 18 ± 6ml/m(2), p= 0.006), and moderate to severe mitral regurgitation was more prevalent in patients with incident elevated SPAP (16% vs 7%, p= 0.05). Independent correlates of incident elevated SPAP at 12-month follow-up were age (odds ratio [OR] 1.04, 95% CI 1.01 to 1.08, p= 0.01), hypertension (OR 2.52, 95% CI 1.23 to 5.14, p= 0.01), baseline LVEF (OR 0.94, 95% CI 0.90 to 0.98, p= 0.003), and baseline left atrial volume (OR 1.08, 95% CI 1.03 to 1.12, p= 0.001). Incident elevated SPAP was independently associated with all-cause mortality (hazard ratio 3.84, 95% CI 1.76 to 8.39, p= 0.001). In conclusion, although the incidence of elevated SPAP after STEMI is low, its presence is independently associated with increased risk of all-cause mortality at follow-up.

Right atrial morphology and function in patients with systemic sclerosis compared to healthy controls: a two-dimensional strain study.

Enlargement and dysfunction of the right atrium might be an early sign for pulmonary hypertension in systemic sclerosis (SSc). This is the first study to analyse right atrial morphology and function in SSc patients compared to healthy controls by speckle-tracking two-dimensional strain echocardiography (2DSE) at rest and during exercise. Furthermore, right atrial function was correlated with further clinical findings. Adult patients with SSc for >3years (n = 90) and 55 age- and gender-matched healthy controls underwent a panel of non-invasive assessments including transthoracic echocardiography, pulsed Doppler myocardial imaging and 2DSE at rest and during exercise. Furthermore, serological tests and high-resolution chest computed tomography were performed. SSc patients showed significant impairment of right atrial function and the right atrial enlargement, measured by 2DSE at rest and during exercise compared to controls (both p < 0.001). These findings were more evident in SSc patients with pulmonary fibrosis (p < 0.001) and in patients with high pulmonary artery systolic pressures (PAPs) during exercise. In the SSC patients, right atrial lateral strain was significantly associated with PAPs during effort, right atrial area, left ventricle stroke volume and inferior vena cava diameter using multivariable analysis. The findings of this study suggest that a high proportion of SSc patients reveal right atrial dysfunction even without manifest pulmonary hypertension. Impaired right atrial function occurred mostly in patients with pulmonary fibrosis and/or elevated PAPs during exercise, was independently associated with prognostic factors and may therefore be useful for risk stratification. Further studies are needed to analyse if right atrial dysfunction assessed by 2DSE may help to improve early diagnosis of pulmonary hypertension.

Relation of Pulmonary Artery Pressure and Renal Impairment in ST Segment Elevation Myocardial Infarction Patients.

Recent reports have demonstrated the adverse effects of venous congestion on renal function in patients having heart failure. None of the above trials, however, included patients with acute ischemia. Echocardiographic correlates of increased right ventricular afterload would be associated with an increased risk of acute kidney injury (AKI) in ST elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). We conducted a retrospective study of consecutive 930 STEMI patients who underwent primary PCI and had a full echocardiography study performed within 72 hours of hospital admission between June 2011 and December 2014. Echocardiography demonstrated that patients with AKI had significantly lower left ventricular (LV) ejection fraction, higher systolic pulmonary artery pressure (SPAP), and right atrial pressures (P < 0.001 for all). Following the performance of logistic multivariate analysis model, SPAP (HR 1.07, 95% CI 1.04-1.11; P < 0.001) and LV ejection fraction (HR 0.95, 95% CI 0.92-0.99; P = 0.03) emerged as independent predictors of AKI. On receiver operating characteristic (ROC) curve analysis, the optimal cutoff value of SPAP to predict AKI was measured as more than 32 mmHg, with 71% sensitivity and 62% specificity (AUC 0.739, 95% CI 0.671-0.806, P < 0.001). Among STEMI patients undergoing primary PCI, worse LV function and elevated SPAP were associated with increased risk of AKI.

Pioglitazone alleviates cardiac and vascular remodelling and improves survival in monocrotaline induced pulmonary arterial hypertension.

Pulmonary arterial hypertension (PAH) is a fatal disease with limited therapeutic options. Pathophysiological changes comprise obliterative vascular remodelling of small pulmonary arteries, elevated mean pulmonary arterial systolic pressure (PASP) due to elevated resistance of pulmonary vasculature, adverse right ventricular remodelling, and heart failure. Recent findings also indicate a role of increased inflammation and insulin resistance underlying the development of PAH. We hypothesized that treatment of this condition with the peroxisome proliferator-activated receptor-γ (PPARγ) activator pioglitazone, known to regulate the expression of different genes addressing insulin resistance, inflammatory changes, and vascular remodelling, could be a beneficial approach. PAH was induced in adult rats by a single subcutaneous injection of monocrotaline (MCT). Pioglitazone was administered for 2weeks starting 3weeks after MCT-injection. At day 35, hemodynamics, organ weights, and -indices were measured. We performed morphological and molecular characterization of the pulmonary vasculature, including analysis of the degree of muscularization, proliferation rates, and medial wall thickness of the small pulmonary arteries. Furthermore, markers of cardiac injury, collagen content, and cardiomyocyte size were analyzed. Survival rates were monitored throughout the experimental period. Pioglitazone treatment improved survival, reduced PASP, muscularization of small pulmonary arteries, and medial wall thickness. Further, MCT-induced right ventricular hypertrophy and fibrosis were attenuated. This was accompanied with reduced cardiac expression of brain natriuretic peptide, as well as decreased cardiomyocyte size. Finally, pulmonary macrophage content and osteopontin gene expression were attenuated. Based on the beneficial impact of pioglitazone, activation of PPARγ might be a promising treatment option in PAH.

Risk factors for pulmonary hypertension at the predialysis stage of chronic kidney disease

To investigate the incidence and risk factors of pulmonary hypertension (PH) in patients with chronic kidney disease (CKD). 86 patients (53% men, 47% women; mean age, 45±13 years) with nondiabetic CKD were examined. According to the magnitude of glomerular filtration rate (GFR) decrease, all the patients were divided into 3 groups: 1) 33 patients with a GFR of 89--45 ml/min; 2) 33 with a GFR of 44--15 ml/min; 3) 20 with a GFR of <15 ml/min who were treated with hemodialysis. A control group consisted of 20 individuals with preserved kidney function (a GFR of >90 ml/min). Physical examination and transthoracic echocardiography were performed in all the patients. The serum concentrations of N-terminal pro-B-type natriuretic peptide (NT-proBNT) and cystatin C were determined. PH was detected in 21 (24.4%) of the 86 patients with CKD. As CKD progressed, its prevalence in Groups 1, 2, and 3 increased, amounting to 18.2, 24.2, and 35%, respectively. The most predictably significant risk factors for PH were hypertension (ρ=0.35; р=0.001) and kidney dysfunction (creatinine (ρ=0.23; р=0.02). Elevated pulmonary artery systolic pressure (PASP) correlated with right ventricular (RV) dimension index (ρ=0.45; р<0.0001), right atrial volume index (ρ=0.3; р=0.02), left atrial volume index (ρ=0.3; р=0.009), and left ventricular mass index (ρ=0.35; р=0.03). In all the patients with CKD in the presence of PH, the NT-proBNP level was significantly higher than in its absence: 37.43 (5.83; 59.84) and 8.54 (5.1; 20.43) fmol/ml, respectively (р=0.01). Positive correlations were found between the level of cystatin C and the presence of PH (ρ=0.32; р=0.003). Analysis of the ROC curve (AUC=0.718; р=0.03) in the predialysis-stage CKD groups (n=66) revealed that the cystatin C level of > 1045 ng/ml with a sensitivity of 71% and a specificity of 60% suggested that PH was present. Multivariate analysis showed that the factors correlating with the presence of PH were NT-proBNP (β=0.34; р=0.008) and RV dimension index (β=0.3; р=0.002). EchoCG reveals PH in almost 25% of the patients with CKD, which occurs at its predialysis stage. Elevated PASP is associated with myocardial structural changes. Traditional risk factors (hypertension) and diminished kidney function affect the development of PH.

Elevated systolic pulmonary artery pressure for prediction of myocardial necrosis and right ventricular dysfunction in acute pulmonary embolism

BackgroundEchocardiography is currently the mainstay examination for assessment of right ventricular dysfunction (RVD) in acute pulmonary embolism (PE). RVD is associated with poorer prognosis, but there is still no generally accepted definition. Systolic pulmonary artery pressure (sPAP) is mostly not included in these RVD-criteria. We aimed to investigate sPAP for prediction of myocardial necrosis and RVD in acute PE. MethodsData of 182 patients with acute PE were analyzed retrospectively. PE patients with sPAP≤30mmHg were compared to those with sPAP>30mmHg. Logistic regression models were calculated to investigate associations between sPAP and myocardial necrosis as well as RVD. Moreover ROC curves and cut-off values for sPAP predicting myocardial necrosis and RVD were computed. Results134 patients (mean age 67.8±15.2 years, 59.7% female) with acute PE event were included in the study. Mean sPAP value was 33.96±18.14mmHg. PE patients with sPAP>30mmHg (59.7%) were significantly older (71.2±13.8 vs. 62.7±15.7 years, P=0.000489), more frequently female (66.3% vs. 50.0%, P=0.0609), showed higher heart rate (98.8±25.5 vs. 87.7±22.1 beats/min, P=0.00266), shock-index (0.76±0.42 vs. 0.63±0.26, P=0.00892), cardiac Troponin I (0.15±0.30 vs. 0.14±0.32ng/ml, P=0.00670) and higher percentage of RVD (80.0% vs. 29.6%, P<0.000001).In multivariant regression model, sPAP was associated with respectively myocardial necrosis (OR 1.021, 95% CI 0.998–1.045, P=0.0736) and RVD (OR 1.100, 95% CI 1.064–1.136, P<0.000001).ROC analysis for sPAP predicting myocardial necrosis revealed an AUC of 0.628 with sPAP cut-off value of 41.00mmHg. ROC analysis for sPAP predicting RVD showed an AUC of 0.829 with sPAP cut-off value of 31.00mmHg. ConclusionssPAP and respectively RVD and myocardial necrosis are both associated. sPAP is highly effective to predict RVD. sPAP values >31mmHg indicate for RVD.

Correlations between echocardiographic parameters of right ventricular dysfunction and Galectin-3 in patients with chronic obstructive pulmonary disease and pulmonary hypertension.

To evaluate the association between echocardiographic right ventricular (RV) structural and functional parameters and galectin-3 levels in patients with chronic obstructive pulmonary disease (COPD) and associated pulmonary hypertension presenting with acutely aggravated dyspnoea. We conducted a prospective study on forty patients with COPD and forty healthy volunteers matched for age and sex (mean age 59+/-6 years), measuring galectin-3 and NT-proBNP serum levels and specific echocardiographic parameters. Galectin-3 was significantly higher in patients with COPD and elevated systolic pulmonary artery pressure than in healthy volunteers and discriminated better between patients with likely and possible pulmonary hypertension when compared to NT-proBNP. In multivariate analysis, the global model was better related to galectin-3 than to NT-proBNP levels (R²=0.61 vs. 0.31, p<0.001). Moreover, in contrast to NT-proBNP levels, correlations between galectin-3 levels and RV dysfunction, as assessed by the E/E' ratio and RV ejection fraction, persisted after adjustment for cardiovascular risk factors and COPD-induced inflammation. In patients with COPD-associated pulmonary hypertension presenting with acutely aggravated dyspnoea, galectin-3 levels are predictive of RV dysfunction and correlate better with RV dysfunction parameters compared to NT-proBNP.

Acute respiratory distress syndrome (ARDS)-associated acute cor pulmonale and patent foramen ovale: a multicenter noninvasive hemodynamic study.

IntroductionAcute cor pulmonale (ACP) and patent foramen ovale (PFO) remain common in patients under protective ventilation for acute respiratory distress syndrome (ARDS). We sought to describe the hemodynamic profile associated with either ACP or PFO, or both, during the early course of moderate-to-severe ARDS using echocardiography.MethodsIn this 32-month prospective multicenter study, 195 patients with moderate-to-severe ARDS were assessed using echocardiography during the first 48 h of admission (age: 56 (SD: 15) years; Simplified Acute Physiology Score: 46 (17); PaO2/FiO2: 115 (39); VT: 6.5 (1.7) mL/kg; PEEP: 11 (3) cmH2O; driving pressure: 15 (5) cmH2O). ACP was defined by the association of right ventricular (RV) dilatation and systolic paradoxical ventricular septal motion. PFO was detected during a contrast study using agitated saline in the transesophageal bicaval view.ResultsACP was present in 36 patients, PFO in 21 patients, both PFO and ACP in 8 patients and the 130 remaining patients had neither PFO nor ACP. Patients with ACP exhibited a restricted left ventricle (LV) secondary to RV dilatation and had concomitant RV dysfunction, irrespective of associated PFO, but preserved LV systolic function. Despite elevated systolic pulmonary artery pressure (sPAP), patients with isolated PFO had a normal RV systolic function. sPAP and PaCO2 levels were significantly correlated.ConclusionsIn patients under protective mechanical ventilation with moderate-to-severe ARDS, ACP was associated with LV restriction and RV failure, whether PFO was present or not. Despite elevated sPAP, PFO shunting was associated with preserved RV systolic function.

Incidence and risk factors of chronic thromboembolic pulmonary hypertension in patients after acute pulmonary embolism.

Early identification and treatment of chronic thromboembolic pulmonary hypertension (CTEPH) are critical to prevent disease progression. We determined the incidence and risk factors for CTEPH in patients with a first episode of acute pulmonary embolism (PE). In this study, consecutive patients with first-episode acute PE were followed for ≤5 years. Pulmonary hypertension (PH) was screened for by echocardiography. Suspected cases were evaluated by right heart catheterization (RHC) and pulmonary angiography (PA). If invasive procedures were not permitted, PH was diagnosed by systolic pulmonary artery pressure (SPAP) >50 mmHg. Diagnosis of CTEPH was confirmed by PA, ventilation/perfusion (V/Q) lung scan, or computed tomography (CT) PA (CTPA). Overall, 614 patients with acute PE were included (median follow-up, 3.3 years). Ten patients were diagnosed with CTEPH: cumulative incidence 0.8% [95% confidence interval (CI), 0.0-1.6%] at 1 year, 1.3% (95% CI, 0.3-2.3%) at 2 years, and 1.7% (95% CI, 0.7-2.7%) at 3 years. No cases of CTEPH developed after 3 years. History of lower-limb varicose veins [hazard ratio (HR), 4.3; 95% CI, 1.2-15.4; P=0.024], SPAP >50 mmHg at initial PE episode (HR, 23.5; 95% CI, 2.7-207.6; P=0.005), intermediate-risk PE (HR, 1.2; 95% CI, 1.0-1.4; P=0.030), and CT obstruction index over 30% at 3 months after acute PE (HR, 42.5; 95% CI, 4.4-409.8; P=0.001) were associated with increased risk of CTEPH. CTEPH was not rare after acute PE in this Chinese population, especially within 3 years of diagnosis. Lower-limb varicose veins, intermediate-risk PE with elevated SPAP in the acute phase, and residual emboli during follow-up might increase the risk of CTEPH.

Does High Alveolar Fluid Reabsorption Prevent HAPE in Individuals with Exaggerated Pulmonary Hypertension in Hypoxia?

An exaggerated increase in pulmonary arterial systolic pressure (PAsP) is a highlight of high altitude pulmonary edema (HAPE). However, the incidence of HAPE at 4559 m was much lower in altitude-naïve individuals with exaggerated pulmonary vasoconstriction (HPV) in normobaric hypoxia than in known HAPE-susceptibles, indicating that elevated PAsP alone is insufficient to induce HAPE. A decreased nasal potential difference (NPD) has been found in HAPE-susceptibles, where, based on animal models, NPD serves as surrogate of alveolar epithelial ion transport. We hypothesize that those HAPE-resistant individuals with high HPV may be protected by elevated alveolar Na and fluid reabsorption, which might be detected as increased NPD. To test this hypothesis, we measured NPD in normoxia of subjects who were phenotyped in previous studies as high altitude tolerant (controls), known HAPE-susceptibles with high HPV (HP+HAPE), as well as individuals with high HPV but without HAPE (HP-no-HAPE) at 4559 m. NPD and amiloride-sensitive NPD were lower in HP+HAPE than in controls, whereas HP-no-HAPE were not different from either group. There were no differences in Cl-transport between groups. Our results show low nasal ion transport in HAPE but higher transport in those individuals with the highest HPV but without HAPE. This indicates that in some individuals with high PAsP at high altitude high alveolar fluid reabsorption might protect them from HAPE.

Right Ventricular Outflow Tract Doppler Envelope Notching Predicts Pulmonary Vascular Resistance in Patients with Advanced Liver Disease

Portopulmonary hypertension (POPH) affects 6% of liver transplant (LT) candidates and is associated with poor outcomes. Screening for POPH with a transthoracic echocardiogram (TTE) is the standard of care, but diagnosis requires right heart catheterization (RHC) which carries risks in pts with advanced liver disease (ALD). Systolic deceleration or “notching” of the right ventricular outflow tract Doppler flow velocity envelope (FVERVOT) correlates with high pulmonary vascular resistance (PVR) in mixed pulmonary hypertension (PH) but has not been validated in pts with ALD. The ratio of peak tricuspid regurgitant velocity (TRV, m/s) and time-velocity integral of the RVOT (TVIRVOT) per the formula PVR=TRV/TVIRVOT x 10 has been shown to reliably estimate PVR. We investigated whether PVR can be predicted by the shape of FVERVOT or estimated by the TRV/TVIRVOT ratio in pts undergoing evaluation for LT. We included 100 pts who underwent RHC and TTE as part of LT evaluation from 01/10 to 03/15. Median time between the two tests was 5 days. We categorized the shape of FVERVOT as no (NN), late-systolic (LSN) or mid-systolic (MSN) notching. Unpaired t-tests were used to compare sample means for continuous variables and linear regression analysis to test the correlation between invasive and non-invasive PVR. The mean patient age was 57±8.5 years; 50% were male with diverse etiologies of ALD (35% HCV, 21% alcoholic, 10% cryptogenic, 6% NASH, 4% autoimmune, 24% other) and 79% were transplanted. The prevalence of POPH as defined by PVR≥3 on RHC was 12%. Elevated systolic pulmonary artery pressure (PAPs≥40mmHg) on TTE was present in 54% and mean PAP≥25mmHg on RHC in 24%. The shape of the FVERVOT Doppler exhibited NN in 81%, LSN in 10% and MSN in 9%. Pts with either LSN or MSN had higher mean PAP than those with NN (28±9 vs 35±11mmHg, p=0.007) and higher transpulmonary gradient (TPG), diastolic pulmonary gradient (DPG) and PVR; the difference between LSN and MSN was not significant. TAPSE was lower in pts with LSN or MSN compared to NN (Fig 1), and non invasively estimated PVR was higher (1.8±0.5 vs 1.4±0.5 WU, p=0.003). Poor correlation was observed between noninvasive and invasive PVR (R2=0.10, p=0.001). RVOT notching and non-invasive PVR were poor predictors of mortality. Elevated PAPs on TTE was a sensitive but not specific screening tool for PVR≥3 (Sn=82%, Sp=48%). RVOT Doppler flow velocity notching reliably predicts POPH in pts with ALD.

Tissue Doppler Findings in Patients with Pulmonary Arterial Hypertension

: Background: Pulmonary hypertension is an untreatable condition with poor prognosis and factors such as more elevated pulmonary arterial systolic pressure and right ventricular dysfunction are associated with a worse outcome. Objectives: Considering the limitations of the current modalities, this study aimed to find the relationship between tissue Doppler-derived systolic and diastolic parameters and elevated pulmonary arterial pressure in order to assess the routine application of tissue Doppler imaging in evaluation of pulmonary arterial hypertension. Patients and Methods: This study was conducted on 100 inpatient and outpatient individuals referred to the Department of Echocardiography in Shahid Faghihi hospital, Shiraz, Iran from July 2012 to March 2013. The individuals who had preserved right ventricular function in the presence of pulmonary arterial hypertension were included in the case group. On the other hand, the patients who did not have echocardiographic signs of pulmonary arterial hypertension were enrolled into the control group. All the patients underwent a complete transthoracic echocardiogram including 2-dimensional, color flow, and spectral Doppler as well as tissue Doppler imaging using a vivid E9 system, and the desired systolic and diastolic parameters were recorded. The relationship among these parameters was evaluated by independent sample t-test using the SPSS statistical software, version 16. Besides, P Results: The mean time to peak strain was significantly longer in the case group (203.98 ± 47.54 milliseconds) compared to the controls (81.20 ± 25.76 milliseconds). The mean early diastolic tricuspid inflow velocity/early diastolic tricuspid annulus velocity (E/E’a) ratio was also significantly higher in the case group (10.24 ± 6.19) compared to the controls (4.70 ± 0.80). In contrast, Isovolumic Contraction (IVC) acceleration time/IVC time ratio was reduced in the case group (0.44 ± 0.09) in comparison to the control patients (0.56 ± 0.05). Conclusions: In conclusion, our results suggested that increasing degrees of pulmonary artery systolic pressure affected timing of some tissue Doppler-derived intervals within the cardiac cycle, including IVC time, time to peak systolic myocardial velocity (Sm), and time to peak strain. Therefore, tissue Doppler imaging could be used in assessment of patients with suspected pulmonary arterial hypertension.