Improvement In Pulmonary Hemodynamics Research Articles

Surgical Repair of Giant Dissecting Pulmonary Artery Aneurysm Associated with Atrial Septal Defect and Pulmonary Arterial Hypertension: A Case Report

Pulmonary artery aneurysm (PAA) and pulmonary artery dissection (PAD) are rare and potentially fatal conditions that may lead to pulmonary artery (PA) rupture and cardiac tamponade. PAA is often associated with other cardiac and congenital heart diseases, such as atrial septal defect (ASD). We report a case of a patient with ASD and a giant dissecting PAA who underwent surgical repair to prevent potentially fatal outcome and discuss the probable etiologies of this case. We present a rare case of a 50-year-old woman with a secundum ASD and severe pulmonary arterial hypertension (PAH) who developed a giant PAA of 114 mm with dissection. The PAA caused extrinsic compression of the left main coronary artery (LMCA), which was misdiagnosed as coronary artery disease (CAD) at local hospital. Right heart catheterization revealed PAH of 73 mmHg and she was referred to our center for further treatment. After 4 months of lowering PAH treatment, she underwent successful surgical repair of the PAA to release the compression of LMCA, as well as mechanical valve replacement, fenestrated ASD closure and tricuspid valvuloplasty. She had an uneventful recovery and showed significant improvement in pulmonary hemodynamics and clinical symptoms at one-year follow-up. PAA with dissection is a rare complication of ASD and PAH that can potentially be fatal. Patients with large or symptomatic PAA and PAD may require early surgical intervention, particularly if they experience compression of nearby structures or are at risk of rupture. It is crucial to promptly refer and consult with specialists and ensure optimal preoperative hemodynamic management to enhance patient outcomes.

Macitentan in Adults with Sickle Cell Disease and Pulmonary Hypertension: A Proof-of-Concept Study

Pulmonary hypertension (PH) in sickle cell disease (SCD) is associated with a mortality rate of 37%. There is an upregulation of adhesion molecules which leads to the expression of endothelin-1, a potent vasoconstrictor. A prospective, descriptive study was done to determine the safety and efficacy of macitentan in patients with SCD and PH. Continuous variables were reported as mean ± SEM or percentage where appropriate. We screened 13 patients and recruited five. All five patients were adults. Data were analyzed as appropriate by student t - test. Statistical significance was assumed at p < 0.05. Baseline pulmonary hemodynamics obtained by right heart catheterization and systemic hemodynamics were (± SEM): mean pulmonary artery pressure (MPAP) 32 ± 8 mmHg, right atrial pressure (RAP) 9 ± 4 mmHg, pulmonary vascular resistance (PVR) 257 dynes-sec/cm5 and CI 3·7 ± 0.39 l/m2. Of all parameters, only PVR and 6-min walk distance changed significantly. For the group, MPAP decreased by 15.6%, PVR by 22.5% and RAP by 25.5%. The 6-minute walk distance increased over sixteen weeks except in Patient 4 who had a 3% decrease. The mean walk distance increased in the total distance, from 464 ± 158 meters to 477 ± 190 meters (p .123). In four patients, the adverse events were mild to moderate and did not lead to study drug discontinuation. Significant improvement in pulmonary hemodynamics and exercise capacity in patients with SCD-related pulmonary arterial hypertension. We found that macitentan was safe and well tolerated.

Long-term effects of pulmonary endarterectomy on pulmonary hemodynamics, cardiac function, and exercise capacity in chronic thromboembolic pulmonary hypertension

Long-term changes in exercise capacity and cardiopulmonary hemodynamics after pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) have been poorly described. We analyzed the data from 2 prospective surgical CTEPH cohorts in Hammersmith Hospital, London, and Amsterdam UMC. A structured multimodal follow-up was adopted, consisting of right heart catheterization, cardiac magnetic resonance imaging, and cardiopulmonary exercise testing before and after PEA. Preoperative predictors of residual pulmonary hypertension (PH; mean pulmonary artery pressure >20mm Hg and pulmonary vascular resistance ≥2WU) and long-term exercise intolerance (VO2max <80%) at 18months were analyzed. A total of 118 patients (61 from London and 57 from Amsterdam) were included in the analysis. Both cohorts displayed a significant improvement of pulmonary hemodynamics, right ventricular (RV) function, and exercise capacity 6months after PEA. Between 6 and 18months after PEA, there were no further improvements in hemodynamics and RV function, but the proportion of patients with impaired exercise capacity was high and slightly increased over time (52%-59% from 6 to 18months). Long-term exercise intolerance was common and associated with preoperative diffusion capacity for carbon monoxide (DLCO), preoperative mixed venous oxygen saturation, and postoperative PH and right ventricular ejection fraction (RVEF). Clinically significant RV deterioration (RVEF decline >3%; 5 [9%] of 57 patients) and recurrent PH (5 [14%] of 36 patients) rarely occurred beyond 6months after PEA. Age and preoperative DLCO were predictors of residual PH post-PEA. Restoration in exercise tolerance, cardiopulmonary hemodynamics, and RV function occurs within 6months. No substantial changes occurred between 6 and 18months after PEA in the Amsterdam cohort. Nevertheless, long-term exercise intolerance is common and associated with postoperative RV function.

Changes in Pulmonary Hemodynamics Resulted From Long-Term Mechanical Heart Support

Aim To study the dynamics of right ventricular function and pulmonary hemodynamics in patients with pulmonary hypertension during mechanical circulatory support of the heart.Material and methods A retrospective analysis was performed for 25 implantations of left ventricular assist device performed in the Meshalkin National Medical Research Center from 2006 through 2021. Mechanical assist devices were implanted in 21 men and 4 women (median age, 37.5 [29; 48] years). All patients had severe, NYHA functional class III-IV chronic heart failure refractory to the optimal drug therapy. Invasive measurements showed that mean pulmonary arterial pressure (MPAP) was 50 [44.5; 60] mm Hg, transpulmonary pressure gradient (TPG) was 16 [14; 19] mm Hg, and calculated pulmonary vascular resistance was 5.4 [4.9; 9] Wood units, which is an absolute contraindication (TPG &gt;15 mm Hg or pulmonary vascular resistance &gt;5 Wood units) for heart transplantation (HT).Results Duration of left ventricular support was from 17 to 948 days. For 12 (48 %) patients, the HT was performed at 180-948 days following the implantation of left ventricular assist device; 3 patients are presently waiting for HT; 10 patients died from various complications, 6 of them died during the hospital stage. Already during the early stage after the implantation of the mechanical assist device, pulmonary hemodynamics significantly improved. Thus, in one week, MPAP decreased from 50 [44.5; 60] mm Hg to 36 [33; 38] mm Hg (р=0.012) whereas pulmonary vascular resistance decreased from 5.4 [4.9; 9] to 2.9 [2.4; 3.6] Wood units (р=0.008). Follow-up showed further improvement of pulmonary hemodynamics; at 1 month, MPAP was 29 [27; 30] mm Hg and by the time of HT, MPAP was 2.0 [24.8; 26.3] mm Hg (р=0.01), i.e., reached a normal level, which made it possible to perform HT. Similar dynamics was observed for other variables that reflected pulmonary hemodynamics.Conclusion Mechanical support of the heart is able to alleviate manifestations of pulmonary hypertension in most patients with end-stage heart failure. It is necessary to develop an algorithm for identifying the category of patients with a high risk of progression of right ventricular failure.

Refined Balloon Pulmonary Angioplasty in Chronic Thromboembolic Pulmonary Hypertension: Initial Results of U.S. Regional Program

BackgroundBalloon pulmonary angioplasty (BPA) is rapidly evolving therapeutic option for patients with nonsurgical chronic thromboembolic pulmonary hypertension (CTEPH). There are few U.S. studies that have reported on the outcomes of this novel therapeutic option. ObjectivesThe authors sought to evaluate the efficacy and safety of refined BPA in the treatment of patients with CTEPH. MethodsThis is a retrospective study of CTEPH patients that underwent BPA. The primary efficacy endpoint was the change in pulmonary vascular resistance after BPA as compared to baseline and the primary safety endpoint was the rate of hemoptysis within 24 hours. Secondary endpoints included death, World Health Organization functional class, and 6-minute walk distance. Logistic regression was used to evaluate factors associated with a hemodynamic and functional response. ResultsA total of 211 BPA sessions were performed on 77 patients (average 2.7 ± 1.7 sessions/patient). After BPA the mean pulmonary vascular resistance improved by 26% (6.5 ± 3.4 WU to 4.8 ± 2.9 WU, P < 0.001). The mean 6-minute walk distance improved by 71.7 m (P < 0.001), and WHO functional class improved by 1 functional class (P < 0.001). There was one death related to reperfusion lung injury. Ten sessions (4.7%) were complicated by hemoptysis. Independent factors associated with improved functional and hemodynamic response included preprocedural use of riociguat, reduce baseline PA compliance, and >3 BPA sessions/patient. ConclusionsThis single center study from the United States showed that BPA with refined techniques in patients with CTEPH was relatively safe and was associated with significant improvements in pulmonary hemodynamics and functional capacity.

Distal vessel pulmonary thromboendarterectomy: Results from a single institution

Chronic thromboembolic pulmonary hypertension (CTEPH) is primarily managed by pulmonary thromboendarterectomy (PTE). As advanced surgical techniques permit resection at the segmental and subsegmental level, PTE can now be curative for CTEPH mostly involving the distal pulmonary arteries. Between January 2017 and June 2021, consecutive patients undergoing PTE were categorized according to the most proximal level of chronic thrombus resection: Level I (main pulmonary artery), Level II (lobar), Level III (segmental) and Level IV (subsegmental). Proximal disease patients (any Level I or II) were compared to distal disease (Level III or IV bilaterally) patients. Demographics, medical history, preoperative pulmonary hemodynamics, and immediate postoperative outcomes were obtained for each group. During the study period, 794 patients underwent PTE, 563 with proximal disease and 231 with distal disease. Patients with distal disease more frequently had a history of an indwelling intravenous device, splenectomy, upper extremity thrombosis or use thyroid replacement and less often had prior lower extremity thrombosis or hypercoagulable state. Despite more use of PAH-targeted medications in the distal disease group (63.2% vs 50.1%, p < 0.001), preoperative hemodynamics were similar. Both patient groups exhibited significant improvements in pulmonary hemodynamics postoperatively with comparable in-hospital mortality rates. Compared to proximal disease, a lower percentage of patients with distal disease showed residual pulmonary hypertension (3.1% vs 6.9%, p=0.039) and airway hemorrhage (3.0% vs 6.6%, p=0.047) postoperatively. Thromboendarterectomy for distal (segmental and subsegmental) CTEPH is technically feasible and may result in favorable pulmonary hemodynamic outcomes, without increased mortality or morbidity.

Impact of Time to Intervention on Catheter-Directed Therapy for Pulmonary Embolism.

Retrospective cohort study. Single academic center. We identified patients for which the PE response team had been activated from January 2014 to October 2021. Patients were split into two cohorts depending on whether they went to CDT less than 24 hours from admission (early) versus greater than 24 hours (late). None. Data on demographics, timing of interventions, pulmonary hemodynamics, and outcomes were collected. Sixty-four patients were included in analysis. Thirty-nine (63.8%) underwent their procedure less than 24 hours from admission, whereas 25 (36.2%) underwent the procedure after 24 hours. The time from admission to CDT was 15.9 hours (9.1-20.3 hr) in the early group versus 33.4 (27.9-41) in the late group (p ≤ 0.001). There was a greater decrease in pulmonary artery systolic pressure after intervention in the early cohort (14 mm Hg [6-20 mm Hg] vs 6 mm Hg [1-10 mm Hg]; p = 0.022). Patients who received earlier intervention were found to have shorter hospital LOS (4 vs 7 d; p = 0.038) and ICU LOS (3 vs 5 d; p = 0.004). There was no difference in inhospital mortality between the groups (17.9% vs 12%; p = 0.523). Patients who underwent CDT within 24 hours of admission were more likely to have shorter hospital and ICU LOS. The magnitude of change in LOS between the two cohorts was not fully explained by the difference in time to CDT. There were modest improvements in pulmonary hemodynamics in the patients who underwent CDT earlier.

Impact of Rapid Weight Loss after Bariatric Surgery in Systemic Inflammatory Response and Pulmonary Hemodynamics in Severely Obese Subjects with Pulmonary Hypertension.

Pulmonary hypertension (PH) can be associated with obesity. The excessive production of proinflammatory mediators by dysfunctional adipocytes may enhance remodeling of the pulmonary vasculature and worsen pulmonary hemodynamics. This study aimed to describe the changes in pulmonary arterial pressures and systemic inflammation in patients with obesity with PH after bariatric surgery (BaS). In this retrospective cohort study, we compared patients with PH who underwent BaS from 2008 to 2018 at our institution (group 1) to a group of severely obese patients with PH (group 2). Echocardiographic right ventricular systolic pressure (RVSP) was used as an indirect measurement of pulmonary arterial pressures. Red blood cell distribution width (RDW) was used as a marker of systemic inflammation. A total of 40 patients were included, 20 per group. In group 1, the RVSP decreased from 44.69 ± 7.12 mmHg to 38.73 ± 12.81 mmHg (p = 0.041), and the RDW decreased from 15.22 ± 1.53 to 14.41 ± 1.31 (p = 0.020). In group 2, the RVSP decreased from 60.14 ± 18.08 to 59.15 ± 19.10 (0.828), and the RDW increased from 15.37 ± 1.99 to 15.38 ± 1.26 (0.983). For both groups, we found a positive correlation between RVSP and RDW changes, although the correlation was not statistically significant. Previous studies suggest BaS could be a safe and effective procedure to achieve weight loss in obese patients with PH, with an additional modest improvement in pulmonary hemodynamics. The results of this study reinforce this observation and suggest that such improvement could be related to a decrease in systemic inflammation. Further prospective studies with bigger samples are needed to better understand these findings.

INHALED IMATINIB FOR PULMONARY ARTERIAL HYPERTENSION CLINICAL TRIAL: DESIGN OF THE IMPACT PHASE 2B/3 STUDY DESIGN

INHALED IMATINIB FOR PULMONARY ARTERIAL HYPERTENSION CLINICAL TRIAL: DESIGN OF THE IMPACT PHASE 2B/3 STUDY DESIGN

Long-term outcomes of combined pulmonary endarterectomy and additional balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension.

The early and long-term outcomes after pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) have been established by several high-volume centers, but the impact of postoperative residual pulmonary hypertension affecting postoperative clinical parameters remains unclear. This study aims to investigate the institutional surgical results of PEA and to evaluate the efficacy of additional balloon pulmonary angioplasty (BPA) for residual pulmonary hypertension. We retrospectively reviewed 222 patients (57.7 ± 12.9years old, 141 female) who underwent PEA for CTEPH at the National Cerebral and Cardiovascular Center between 2000 and 2020. The preoperative mean pulmonary artery pressure (mPAP) was 45.6 ± 9.7mmHg and pulmonary vascular resistance (PVR) was 1062 ± 451 dyne*sec/cm-5. Postoperative mPAP (23.4 ± 11mmHg, 204 patients, P < 0.001) and PVR (419 ± 291 dyne*sec/cm-5, 199 patients, P < 0.001) significantly improved after PEA. Since 2011, 62 patients (28%) underwent BPA after PEA for "catecholamine dependent" residual PH 1month after PEA in 14, "scheduled" BPA with residual PH 1year after PEA in 32, and 16 "symptomatic" patients without residual PH. Their mPAP had significantly improved by PEA (48.1 ± 7.7 to 32.0 ± 10.2mmHg, P < 0.001), and further improved (33.8 ± 11.1 to 26.5 ± 9.1mmHg, P < 0.001) after BPA. PEA provided immediate and substantial improvements in pulmonary hemodynamics and favorable long-term survival. In addition, postoperative BPA improved postoperative clinical parameters for eligible patients regardless of the presence of residual PH.

Modification of pulmonary endarterectomy to prevent neurologic adverse events.

Neurologic adverse events (NAEs) are a major complication after pulmonary endarterectomy (PEA) performed under periods of deep hypothermic circulatory arrest (HCA) for chronic thromboembolic pulmonary hypertension. We modified the PEA strategy to prevent NAEs and evaluated the effectiveness of these modifications. We reviewed the surgical outcomes of 87 patients divided into the following three groups based on the surgical strategy used: group S (n = 49), periods of deep HCA with alpha-stat strategy; group M1 (n = 19), deep HCA with modifications of slower cooling and rewarming rates and the pH-stat strategy for cooling: and group M2 (n = 13), multiple short periods of moderate HCA. PEA provided significant improvement of pulmonary hemodynamics in each group. Sixteen (29%) of the 49 group S patients suffered NAEs, associated with total circulatory arrest time (cutoff, 57min) and Jamieson type I disease. The Group M1 and M2 patients did not suffer NAEs, although the group M1 patients had prolonged cardiopulmonary bypass (CPB) and more frequent respiratory failure. NAEs were common after PEA performed under periods of deep HCA. The modified surgical strategy could decrease the risk of NAEs but increase the risk of respiratory failure. Multiple short periods of moderate HCA may be useful for patients at risk of NAEs.

CXCL10 levels in diagnosis and improved hemodynamics in patients with chronic thromboembolic pulmonary hypertension undergoing balloon pulmonary angioplasty.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive pulmonary vascular disease characterized by pulmonary artery stenosis or obstructions resulting from insufficient thrombus resolution. Chemokine (C‐X‐C motif) ligand 10 (CXCL10) is a chemokine that contributes to the pathogenesis of many autoimmune diseases and cancers. The present study aims to investigate the levels of CXCL10 in patients with CTEPH throughout balloon pulmonary angioplasty (BPA) and its correlation with the improvement of pulmonary hemodynamics. Plasma CXCL10 levels were measured in 38 CTEPH patients with 100 BPA sessions and in 28 healthy controls. Correlations between CXCL10 and pulmonary hemodynamics were investigated. Receiver operating characteristic (ROC) curves were plotted to display the diagnostic value and the predictive ability for perioperative complications of CXCL10 and CXCL10‐related models. Nomograms were plotted to visualize the diagnostic value and the predictive ability for perioperative complications of CXCL10 and CXCL10‐related models. CXCL10 levels are higher in CTEPH patients compared with healthy controls (36.5 [95% confidence interval {CI}: 25.0–51.1] vs. 14.8 [95% CI: 11.1–30.9], p < 0.0001) and decreased significantly after BPA treatment (36.5 [95% CI: 25.0–51.1] vs. 24.7 [95% CI: 17.2–36.6], p < 0.0005). Preoperative CXCL10 levels positively correlated with mean right atrial pressure (r = 0.25), systolic pulmonary artery pressure (PAP; r = 0.28), diastolic PAP (r = 0.33), mean PAP (r = 0.36), pulmonary vascular resistance (r = 0.31), and N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP; r = 0.46). Furthermore, plasma CXCL10 levels adjusting for age and sex displayed a sensitivity of 86.0% and a specificity of 67.9% for discriminating CTEPH patients from healthy controls. Preoperative CXCL10 levels, in combination with NT‐proBNP, predicted perioperative complications with a sensitivity of 100.0% and a specificity of 46.9% as displayed in ROC analysis. In conclusion, circulating CXCL10 might contribute to the evaluation of disease severity in CTEPH patients and be useful to evaluate the treatment effect of BPA. Future studies are warranted to further study the relationship between pulmonary hemodynamics and circulating CXCL10.

Pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension: a systematic review.

Pulmonary thromboendarterectomy (PTE) is the gold standard treatment for patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, the results are poorly quantified outside a few registry reports and several individual centers. A systematic review was performed searching five electronic databases assessing the outcomes for adult patients undergoing PTE for CTEPH. All articles that reported mortality data were included. Primary outcome measures were early/inpatient mortality; secondary outcomes were survival, pulmonary haemodynamics, morbidity and functional status following PTE for CTEPH. Results were pooled via a meta-analysis of proportions and meta-regression. A total of 5,717 studies were identified, yielding sixty-one relevant papers. Thirty-day mortality ranged from 0.8% to 24.4%, and on meta-analysis was 8.4% [95% confidence interval (CI): 7.2-9.6%]. Mortality was noted to decrease with increasing center volume of PTE cases (P<0.01). Residual pulmonary hypertension was reported in 8.2% to 44.5% of patients. CTEPH is associated with acceptable short-term mortality and an improvement in pulmonary hemodynamics. With increasing volume of experience and ongoing developments over time peri-operative mortality continues to decrease.

Does Age Matter? Pulmonary Endarterectomy in the Elderly Patient with CTEPH.

The gold standard treatment of patients with chronic thromboembolic pulmonary hypertension (CTEPH) is pulmonary endarterectomy (PEA). Little is known about the influence of advanced age on surgical outcome. Therefore, the aim of this study was to investigate the impact of patient's age on postoperative morbidity, mortality, and quality of life in a German referral center. Prospectively collected data from 386 consecutive patients undergoing PEA between 01/2014 and 12/2016 were analyzed. Patients were divided into three groups according to their age: group 1: ≤ 50 years, group 2: > 50 ≤ 70 years, group 3: > 70 years. After PEA, distinct improvements in pulmonary hemodynamics, physical capacity (World Health Organization [WHO] functional class and 6-minute walking distance) and quality of life were found in all groups. There were more complications in elderly patients with longer time of invasive ventilation, intensive care, and in-hospital stay. However, the in-hospital mortality was comparable (0% in group 1, 2.6% in group 2, and 2.1% in group 3 [p = 0.326]). Furthermore, the all-cause mortality at 1 year was 1.1% in group 1, 3.2% in group 2, and 6.3% in group 3 (p = 0.122). PEA is an effective treatment for CTEPH patients of all ages accompanied by low perioperative and 1-year mortality. CTEPH patients in advanced age carefully selected by thorough preoperative evaluation should be offered PEA in expert centers to improve quality of life, symptoms, and pulmonary hemodynamics.

Effects of left ventricular assist device on pulmonary functions and pulmonary hemodynamics: A meta-analysis. waqasullah.dr@gmail.com.

BACKGROUNDGiven current evidence, the effect of left ventricular assist device (LVAD) implantation on pulmonary function tests remains controversial.AIMTo better understand the factors contributing to the changes seen on pulmonary function testing and the correlation with pulmonary hemodynamics after LVAD implantation.METHODSElectronic databases were queried to identify relevant articles. The summary effect size was estimated as a difference of overall means and standard deviation on a random-effects model.RESULTSA total of four studies comprising 219 patients were included. The overall mean forced expiratory volume in one second (FEV1), forced vital capacity (FVC) and diffusion lung capacity of carbon monoxide (DLCO) after LVAD implantation were significantly lower by 0.23 L (95%CI: 0.11-0.34, P = 00002), 0.18 L (95%CI: 0.03-0.34, P = 0.02), and 3.16 mmol/min (95%CI: 2.17-4.14, P < 0.00001), respectively. The net post-LVAD mean value of the cardiac index was significantly higher by 0.49 L/min/m2 (95%CI: 0.31-0.66, P < 0.00001) compared to pre-LVAD value. The pulmonary capillary wedge pressure and pulmonary vascular resistance were significantly reduced after LVAD implantation by 8.56 mmHg (95%CI: 3.78-13.35, P = 0.0004), and 0.83 Woods U (95%CI: 0.11-1.55, P = 0.02), respectively. There was no significant difference observed in the right atrial pressure after LVAD implantation (0.61 mmHg, 95%CI: -2.00 to 3.32, P = 0.65). Overall findings appear to be driven by studies using HeartMateII devices.CONCLUSIONLVAD implantation might be associated with a significant reduction of the spirometric measures, including FEV1, FVC, and DLCO, and an overall improvement of pulmonary hemodynamics.

Prostanoids in pediatric pulmonary hypertension: clinical response, time-to-effect, and dose-response.

For pediatric pulmonary arterial hypertension (PAH) patients treated with parenteral prostanoids, response predictors, and the dose-effect relationship are ill defined. We determined the following: (1) which pulmonary vascular hemodynamic variable, after initiating prostanoids, best correlates with a significant clinical response; (2) the time interval after treatment when if no pulmonary hemodynamic improvement has occurred, none is ever likely to; and (3) the relationship between the prostanoid dose and its hemodynamic effects. This is a retrospective cohort study of 31 pediatric patients with Group 1 PAH treated with parenteral prostanoids. We found the following: (1) A fall in mean pulmonary arterial pressure (mPAP) of ≥25% predicted freedom from adverse clinical events with 80.7% accuracy and was also associated with improved functional class. (2) Thirty-three percent of patients who avoided an adverse clinical event demonstrated a ≥25% reduction in mPAP after 1 year of treatment, and 65% by 2 years. (3) Lower mPAP was seldom seen with doses of epoprostenol >60 ng/kg/min (100 ng/kg/min for treprostinil). Cardiac index was positively correlated with the dose of epoprostenol but not treprostinil; cardiac index >4 l/min/m2 was seen at modest as well as high doses. We conclude that a ≥25% fall in mPAP on prostanoids indicates a positive clinical response which, if validated in other studies, may be useful for patient management or clinical trials. Some patients take more than 2 years for this change. Exceptionally high doses were generally not more effective than lower, although we could not determine whether lower doses would have been as effective.

Impact of Left Ventricular Assist Device on Pulmonary Functions and Pulmonary Hemodynamics: A Meta-analysis

Background Given current evidence, the effect of left ventricular assist device (LVAD) implantation on pulmonary function tests (PFT) remains controversial. Methods Electronic databases were queried to identify relevant articles. The summary effect size was estimated as a difference of overall means and standard deviation (SD) on a random-effects model. Results A total of four studies comprising 219 patients were included. The overall mean forced expiratory volume in one second (FEV1), forced vital capacity (FVC) and diffusion lung capacity of carbon monoxide (DLCO) after LVAD implantation were significantly lower by 0.23L (95% (confidence interval) CI 0.11-0.34, p=00002), 0.18L (95% CI 0.03-0.34, p=0.02), and 3.16 mmol/min (95% CI 2.17-4.14, p Conclusion LVAD implantation might be associated with a significant reduction of the spirometric measures, including FEV1, FVC, and DLCO, and an overall improvement of pulmonary hemodynamics.

Exercise right heart catheterization before and after balloon pulmonary angioplasty in inoperable patients with chronic thromboembolic pulmonary hypertension.

Background *These authors contributed equally as last authors.Balloon pulmonary angioplasty is an evolving, interventional treatment option for inoperable patients with chronic thromboembolic pulmonary hypertension (CTEPH). Pulmonary hypertension at rest as well as exercise capacity is considered to be relevant outcome parameters. The aim of the present study was to determine whether measurement of pulmonary hemodynamics during exercise before and six months after balloon pulmonary angioplasty have an added value.MethodsFrom March 2014 to July 2018, 172 consecutive patients underwent balloon pulmonary angioplasty. Of these, 64 consecutive patients with inoperable CTEPH underwent a comprehensive diagnostic workup that included right heart catheterization at rest and during exercise before balloon pulmonary angioplasty treatments and six months after the last intervention.ResultsImprovements in pulmonary hemodynamics at rest and during exercise, in quality of life, and in exercise capacity were observed six months after balloon pulmonary angioplasty: WHO functional class improved in 78% of patients. The mean pulmonary arterial pressure (mPAP) at rest was reduced from 41 ± 9 to 31 ± 9 mmHg (p < 0.0001). The mPAP/cardiac output slope decreased after balloon pulmonary angioplasty (11.2 ± 25.6 WU to 7.7 ± 4.1 WU; p < 0.0001), and correlated with N-terminal fragment of pro-brain natriuretic peptide (p = 0.035) and 6-minute walking distance (p = 0.01).ConclusionsExercise right heart catheterization provides valuable information on the changes of pulmonary hemodynamics after balloon pulmonary angioplasty in inoperable CTEPH patients that are not obtainable by measuring resting hemodynamics.

4283Exercise right heart catheterization before and after balloon pulmonary angioplasty in inoperable patients with chronic thromboembolic pulmonary hypertension

Abstract Background Balloon pulmonary angioplasty (BPA) is an evolving treatment option for inoperable patients with chronic thromboembolic pulmonary hypertension (CTEPH). The main indicator for success is improvement in pulmonary hemodynamics, but outcome data are heterogeneous. Purpose The aim of the present study was to evaluate pulmonary hemodynamics not only at rest, but also during exercise before and 6 months after BPA. Methods We report a prospective series of 64 consecutive patients with inoperable CTEPH who were treated interventionally with BPA. All patients underwent standardized assessment prior to the first BPA and 6 months after the last intervention. Assessment included WHO FC, Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR), 6-minute walking distance (6MWD), serum levels of the N-terminal fragment of pro-brain natriuretic peptide (NT-proBNP), and exercise RHC. Results The mean number of sessions per patient was 5.6 (± 1.3) and the mean number of pulmonary segments targeted in all interventions was 11 (± 3). BPA treatment led to improvements in pulmonary hemodynamics and exercise capacity (6MWD: 416±94 m vs. 463±96 m; p&lt;0.0001) except for CO and CI during RHC at rest; these parameters showed improvements only during exercise RHC. MPAP at rest showed a reduction from 41±9 to 31±9 mmHg (p&lt;0.0001) and PVR at rest decreased from 6.8±2.3 WU to 4.3±1.9 WU (p&lt;0.0001). Further decreases were observed for systolic pulmonary arterial pressure, TPG, PVR, and TPR. Cardiac output (7.0±2.0 L/min vs. 8.3±2.0 L/min; p&lt;0.0001) and cardiac index during exercise RHC (3.8±1.1 L/min/m2 vs. 4.4±1.1 L/min/m2; p&lt;0.0001) improved significantly. Median NT-proBNP concentrations decreased from 741 ng/L (IQR 192–1425 ng/L) to 139 ng/L (IQR 60–266 ng/L) during BPA treatment (p&lt;0.0001). Results from the CAMPHOR questionnaire showed significant improvements in symptoms (11±5.8 vs. 5.5±4.9, p&lt;0.0001), activity limitations (9.2±5.6 vs. 5.2±4.5, p&lt;0.0001), and quality of life (6.4±5.7 vs. 3.5±3.7, p&lt;0.0001). Conclusion Significant improvements in pulmonary hemodynamics at rest and during exercise were observed 6 months after BPA. Exercise right heart catheterization offers a more discriminating evaluation of the changes in pulmonary hemodynamics after BPA.

Reversibility of Fixed Pulmonary Hypertension with LVADs as a Bridge to Candidacy Strategy for Heart Transplantation: A Systematic Review and Meta-Analysis

Introduction Current guidelines recommend against listing for heart transplantation (HTx) if there is evidence of fixed pulmonary hypertension (fPH) given that these patients tend to have poor post-HTx outcomes. The purpose of this study is to investigate the feasibility of left ventricular assist device (LVAD) implantation as a bridge to candidacy (BTC) in patients with fPH through a systematic review and meta-analysis of published literature. Methods We systematically searched Medline, Embase & the Cochrane library through December 31, 2018 for studies reporting patients with fPH treated with LVADs as a BTC for HTx. The primary outcome analyzed percentage of patients within each cohort achieving reversibility of pulmonary hemodynamics and the secondary endpoint was the time necessary to improve hemodynamics. Studies meeting inclusion criteria were assessed with the Newcastle-Ottawa tool. We performed a random-effects meta-analysis using pooled proportions and heterogeneity was examined using I2 statistics. All statistical analyses were carried out using Stata/IC 14.2. Results A total of 8 studies (6 retrospective cohorts and 2 prospective cohorts) including 207 patients (89% male, mean age 49.46 years) formed part of our analysis. Continuous flow LVADs were used in 176 patients (79%). Our meta-analysis showed 97% reversal of fPH (95% CI, 88-100%) (Figure 1). The mean response time was of 5.33 months (95% CI: 3.67-7.00). Out of the initial 207 patients, 80% (95% CI:61-98%) were effectively bridged to receive a HTx. Conclusions Our findings show that in patients unable to be listed for HTx due to fPH, a BTC strategy with LVAD implantation is associated with improvement in pulmonary hemodynamics with a mean response time of approximately 5 months. Further studies evaluating long-term outcomes in these patients are warranted.