Normal Pulmonary Artery Systolic Pressure Research Articles

Evaluation of Risk Factors for Development of Pulmonary Hypertension in Patients with End Stage Renal Disease Undergoing Hemodialysis

Background: Pulmonary arterial hypertension (PAH) has recently been identified as a common complication in patients with end-stage renal disease (ESRD) who are undergoing hemodialysis (HD) or peritoneal dialysis (PD). The risk factors for the development of PAH in those patients are not well understood. Objective: To investigate the risk factors for the development of PAH in patients with ESRD on HD. Patients and Methods: This is a hospital-based cross-sectional study of 50 ESRD patients undergoing HD. The pulmonary artery systolic pressure (PASP) was measured using echocardiography. PASP ˃ 25 mmHg at rest was defined as PAH. As a result, patients were divided into two groups: those who had PAH and those who did not. Each patient's demographic, biochemical, and echographic findings were documented. Results: Out of 50 patients, 19 (38%) had PAH, while the remaining 31 (62%) had normal PASP. In multivariate analysis, HD duration > 3.4 years (OR= 2.13, 95%CI=1.45-31.38, p= 0.025), hypertension as a cause of ESRD (OR=6.12, 95%CI=1.4-26.77, p=0.031), hemoglobin (Hb) ≤ 10.0 g/dl (OR= 4.35, 95%CI=1.88-9.84, p= 0.018), and left ventricular ejection fraction (LVEF)≤ 55% (OR= 6.75, 95%CI=1.87-23.74, p=0.021) were independent factors associated with PAH. PASP had a significant positive correlation with the rate of fistula flow (r= 0.295, p= 0.038) and E/A ratio (r= 0.368, p= 0.008), but a significant negative correlation with LVEF (r= -0.345, p= 0.014). PASP had a positive significant correlation with each of rate of fistula flow (r= 0.295, p= 0.038) and E/A ratio (r= 0.368, p= 0.008), while it has a negative significant correlation with LVEF (r= -0.345, p= 0.014). Conclusion: Longer duration of HD, hypertensive nephropathy as a cause of ESRD, Hb≤ 10 g/dl, and LVEF ≤55% are among the demographic, biochemical, and clinical factors associated with the development of PAH in patients with ESRD under HD. The PASP has a positive correlation with fistula flow rate and E/A ratio and a negative correlation with LVEF. Keywords: Pulmonary arterial hypertension, End stage renal disease, Hemodialysis.

Outcomes of patients with elevated pulmonary artery systolic pressure on echocardiography due to chronic lung diseases

BackgroundPulmonary hypertension is associated with increased mortality, and lung diseases are the second most common cause of pulmonary hypertension. We aimed to evaluate the prognostic value of echocardiography in low-middle income countries where right heart catheterization is difficult to perform. MethodsThis retrospective chart review study included adult patients hospitalized from June 2012 to May 2021, with a pulmonary artery systolic pressure (PASP) of ≥35 mmHg on echocardiography. The control arm consisted of patients with similar lung diseases who did not have an elevated PASP. ResultsThe study and control arm consisted of 128 patients each, with both groups having similar lung diseases. Obesity hypoventilation syndrome was the most common etiology of elevated PASP (28.1 %), followed by pulmonary embolism (20.3 %). The overall 1-year mortality of the study cohort, after diagnosis of elevated PASP, was 20.3 %. The control cohort with normal PASP had a 1-year mortality of 4.7 %. In the study cohort, patients with bronchiectasis had the highest cause-specific 1-year mortality (45.5 %). In the normal PASP cohort, the highest cause-specific 1-year mortality was observed in patients with interstitial lung disease (13.0 %). One-year hospital readmission was observed in 46.9 % and 33.6 % of patients in the study and control arms, respectively. On multivariate analysis, increased odds of 1-year mortality were observed in patients with elevated PASP, patients with 1-year hospital readmission, and in patients with interstitial lung disease or bronchiectasis. ConclusionElevated PASP on echocardiography may be a prognostic factor for mortality in patients with chronic lung diseases.

Impact of pulmonary arterial systolic pressure on patients with mitral valve disease combined with atrial fibrillation.

To determine whether different changes of pulmonary artery systolic pressure (PASP) after surgeries have an impact on the long-term outcomes in patients with rheumatic and degenerative mitral valve (MV) disease and atrial fibrillation. Between 2004 and 2016, 1,188 patients with rheumatic and degenerative MV disease undergoing MV and Cox-Maze procedure were identified. Clinic outcomes, as well as rhythm state and echocardiography indices in long-term follow-up were recorded. Patients were grouped by the changes of PASP (persistently normal, persistently increased, increased, and decreased) from preoperative estimation to follow-up. A complete echocardiography was performed at baseline and after 5 years. During follow-up, free of death and atrial fibrillation (AF) off antiarrhythmic drugs was 90 and 61%, 78 and 41% at 5 and 10 years, respectively. Survival rate was higher in patients with persistently normal and became worse in patients with persistently increased and increased PASP (log-rank 166.0, P < 0.0001). Moreover, the patients with persistently normal PASP had a lowest risk of recurrent AF (SHR: 0817; CI: 0.765-0.872; P < 0.0001) after considering death as a competing risk. A persistently normal PASP at follow-up and degenerative MV disease were associated with improved survival and sinus rhythm (SR) maintenance at multivariable Cox regression analysis (P < 0.05). Patients with degenerative MV disease or have persistently normal PASP during follow-up have better survival and SR maintenance rate than patients with either rheumatic MV disease or persistently abnormal PASP.

Abstract 14248: The Impact of Trastuzumab on the Pulmonary Artery Systolic Pressure in Patients With HER-2 Positive Breast Cancer

Introduction: Despite that trastuzumab (TZB) improves life expectancy and prognosis in patients with HER-2 positive breast cancer (BC), cardiotoxicity is a well-established complication. However, other potential cardiac complications of TZB such as pulmonary hypertension (PHTN) are poorly investigated. Aim: Evaluate the effect of TZB on pulmonary artery systolic pressure (PASP) and measure the predictors of developing elevated PASP. Methods: The medical records for all females who received TZB treatment for confirmed HER-2 positive BC at King Hussein Cancer Centre in Jordan between 2014 - 2019 who had a documented normal PASP of ≤35 mmHg before treatment were evaluated. Results: A total of 436 patients with a mean age of 53±11 years were included. The leading comorbidities were hypertension and diabetes mellitus affecting 26.2% and 15.4% of the patients, respectively. 15.6% of the study’s population were active smokers. Prior to initiating TZB, 22.3% had left ventricular hypertrophy (LVH), 14.3% had mild tricuspid valve regurgitation (TR), 11.5% had pericardial effusion, and 4.8% had mild aortic valve regurgitation (AR).Of alarming significance, 24.8% of the patients had their PASP increased after one year. Patients who developed elevated PASP tend to be older (56.9 vs 51.3, P&lt;0.001), had baseline mild TR (26.3% vs 10.3%, P&lt;0.001), LVH (39.4% vs 17.6%, P&lt;0.001), and mild AR (9.1% vs 3.7%, P=0.031).Multivariate analysis showed that the only predictors of elevated PASP are TR at baseline (OR 3.9; 95% CI 1.58-6.17, P=0.001), and age (OR 1.04; 95% CI 1.01-1.06, P=0.005). However, baseline LVH (OR 1.79; 95% CI 0.98-3.26, P=0.057), number of the TZB cycles (OR 0.93; 95% 0.85-1.02, P=0.152), and the total dose of TZB (OR 1; 95% CI 1-1, P=0.284) were non-significant predictors. At 1 year follow up, the mean total cumulative dose of TZB was 6.8±1.8 grams that were given at a mean of 15±3 cycles. Moreover, major events (heart failure exacerbation, pulmonary embolism, and acute coronary syndrome) were recorded in 3.9% of the patients and death occurred in 4.1%. Conclusions: Trastuzumab demonstrated an increase in the PASP in a considerable portion of the patients at 1-year interval with this elevation being substantially concerning due to being highly indicative of PHTN.

ACUTE PULMONARY HYPERTENSION AFTER BORTEZOMIB THERAPY

ACUTE PULMONARY HYPERTENSION AFTER BORTEZOMIB THERAPY

Tricuspid Annular Systolic Velocity to Left Ventricular Outflow Velocity Time Integral Ratio: Proof of Concept Utility Analysis.

BackgroundThe tricuspid annular plane systolic excursion (TAPSE) / pulmonary artery systolic pressure (PASP) ratio has been a useful marker of right ventricular (RV)-pulmonary artery coupling. However, given the intricate functional and mechanical interdependence of the right and left ventricles, we believe this ratio would be less useful when assessing reduced left ventricular (LV) systolic function. Instead, we proposed using the tricuspid annular tissue Doppler imaging systolic velocity to LV outflow tract velocity time integral ratio (TA TDI s’ / LVOT VTI r) for this purpose. MethodsFor this proof-of-concept study, a retrospective analysis was conducted on 60 patients with complete echocardiographic studies while in sinus rhythm. The population was divided as follows; Group 1 included 20 individuals with normal left ventricular ejection fraction (LVEF) as well as normal RV and PASP. Group 2 was composed of 20 patients known to have been evaluated or treated for pulmonary hypertension, while group 3 was comprised of 20 patients treated for heart failure (HF). ResultsTAPSE/PASP ratios were no different from any of the studied groups. However, the proposed TA TDI s' /LVOT VTI r was statistically different among all three groups (Group 1: 0.6 ± 0.1*; Group 2: 0.5 ± 0.1°; and Group 3: 0.8 ± 0.3#; p < 0.001).ConclusionsBased on these results, there is now a need for additional prospective studies to explore the overall utility of using this TA TDI s' / LVOT VTI r in day-to-day routine assessments not only for diagnostic purposes but also to determine how this ratio correlates with symptoms and changes with therapy.

A modified Dabestani-Mahan formula estimates a normal pulmonary artery systolic pressure: a single-center retrospective study

Abstract Background Pulmonary artery systolic pressure (PASP) is increasingly used as an important datapoint in clinical decision-making and prognostication even in specialties outside of cardiology. Estimation of PASP by Doppler quantification using tricuspid regurgitation (TR) peak velocity is commonly used and correlates well with invasive measurement by right heart catheterization. Further study of transthoracic echocardiogram (TTE) techniques to estimate PASP is needed to provide this datapoint in the absence of sufficient Doppler data for the TR peak velocity method. One technique using right ventricular outflow tract acceleration time (AT) to estimate mean pulmonary artery pressure (MPAP) has been proposed by Dabestani Et al. by the equation MPAP=90-(0.62x AT). Assuming a linear relationship between MPAP and PASP, as suggested by Chemla Et al. by MPAP=(0.61xPASP)+2, a modified formula PASP=145-AT could possibly estimate a normal PASP ≤25 mmHg. Purpose To examine if a modified Dabestani-Mahan formula PASP=145-AT can estimate a normal PASP ≤25 mmHg as calculated by the TR peak velocity method. Methods We queried the electronic medical record at our institution for a sample of 300 patients who had a TTE performed between 2017 and 2020. Each TTE was reviewed and PASP was estimated for each using the TR peak velocity method. A right atrial pressure of 3 mmHg, 8 mmHg, or 15 mmHg was used in the estimation based on inferior vena cava diameter and collapsibility in keeping with the 2015 American Society of Echocardiography guidelines. A short axis view of pulmonary flow using the pulse-waved Doppler sample volume over the transpulmonary valve jet was then reviewed. The time from onset of ejection to peak flow velocity was measured manually as AT in milliseconds using Change Healthcare Cardiology Web Software Package 14.1.1. The measured AT was averaged over three cardiac cycles. Patients with a heart rate between 60 and 100 beats per minute at time of TTE and with sufficient Doppler data to estimate PASP by TR peak velocity and to measure AT were included in a logistic regression analysis. Results 154 patients were included in the statistical analysis. Patients who had a right ventricular outflow tract acceleration time greater than 120 milliseconds, giving a PASP ≤25 mmHg by the modified formula PASP=145-AT, had a 36 times greater odds of having a PASP ≤25 mmHg by the TR peak velocity method (OR=36.0, 95% CI=10.36–125.12, p&amp;lt;0.001). Conclusion(s) Based on a single-center sample, a right ventricular outflow tract acceleration time greater than 120 milliseconds could be used to estimate a normal pulmonary artery systolic pressure less than or equal to 25 mmHg in the absence of sufficient Doppler data for the commonly used TR peak velocity method. Funding Acknowledgement Type of funding sources: None.

The right ventricular-pulmonary circulation coupling in ischaemic heart disease; a stress echocardiography study

Abstract Objectives This study sought to assess the right ventricular (RV) - pulmonary circulation coupling in patients with coronary artery disease (CAD), preserved echocardiographic indices of right ventricular systolic function and normal pulmonary artery systolic pressure (PASP). Background Patients with CAD are at increased risk for developing left, and ultimately right heart failure. The analysis of underlying mechanisms of worsening RV function has been limited to the hemodynamic sequelae of increased left ventricular (LV) filing pressure leading to pulmonary hypertension. It has been reported that evaluation of RV functional state by using the tricuspid annular plane systolic excursion (TAPSE)/PASP ratio as a surrogate for the RV length-force is of clinical prognostic relevance in patients with known pulmonary hypertension; its role has not been extensively explored in other cardiac conditions including myocardial ischaemia. We hypothesized that the TAPSE/PASP ratio may be able to identify early and subtle changes in RV function in patients with CAD, normal estimated resting PASP, and preserved TAPSE. Methods Data were obtained from a prospectively maintained database, and 223 consecutive patients with preserved right ventricular systolic function (TAPSE≥16mm), and normal resting PASP (≤35mmHg), undergoing stress echocardiography (SE) for suspected coronary artery disease were included. Exclusion criteria: non-ischaemia study, severe valvular disease, poor image quality, resting pulmonary hypertension, reduced right ventricular systolic function. Transthoracic 2-D Doppler echocardiogram was performed by an accredited sonographer at rest and during stress phase and reviewed by two cardiologists unaware of clinical data. Results Fifty-three (24%) SE studies were positive for ischaemia and 170 (76%) negative. Demographic characteristics of both groups are shown in Table 1. All patients had TAPSE≥16mm and a PASP≤35mmHg as per inclusion criteria. The mean TAPSE/PASP ratio was significantly lower in patients with a positive SE suggestive of CAD than controls (0.84±0.22 vs 0.93±0.24, P=0.024). The TAPSE/PASP ratio showed significant correlation with the maximum workload (Watts) achieved (r=0.17, P=0.015) and exercise time (min) (r=0.15, P=0.031), and an inverse correlation with age (r=−0.26, P&amp;lt;0.001) and the development of inducible exertional breathlessness (Exp(B) 0.11, 95% CI 0.028–0.457, P=0.002) on SE. Conclusion Resting TAPSE/PASP was reduced in patients with positive SE, compared to controls. Indexing RV function to RV load, with the use of the TAPSE/PASP ratio identified early changes in RV-pulmonary circulation coupling in CAD patients without resting pulmonary hypertension; this may denote the beginning of subclinical RV dysfunction. Funding Acknowledgement Type of funding sources: None. Table 1

Pulmonary Hypertension Independently Shortens Survival of Patients with Myeloproliferative Neoplasms

Introduction: Myeloproliferative neoplasms (MPN) are frequently associated with symptoms of fatigue, poor sleep, mood disorders, lightheadedness and shortness of breath. The cause of these symptoms is not well understood and is often attributed to blood count abnormalities or elevated inflammatory cytokines common in these disorders. There is a high degree of overlap between clinical manifestations of MPN and symptoms reported by pts with pulmonary hypertension (PH). Small studies have shown that pts with MPNs are at risk for PH but the extent to which PH contributes to clinical symptoms and prognosis in MPN pts is unknown.Methods: 300 sequential MPN pts undergoing transthoracic echocardiography (echo) between January, 2011 and April, 2017 were studied (Table 1). A second MPN cohort of 287 patients (NoEcho) was matched for age and diagnosis to the MPN Echo+ (Echo) cohort. Baseline demographics including age, gender, diagnosis, date of diagnosis, mutation profile, transformation, BMT, bleeding or thrombosis history, symptoms, cardiovascular risk factors, echo indication and survival were collected for all pts. To ensure accurate echo assessment of PH sequelae, RV assessment via both tricuspid annular plane systolic excursion (TAPSE) and peak tricuspid annular systolic velocity (S‘) were required for study inclusion. RV dysfunction (RVDYS) was defined by impairment of both TAPSE and S’. RV global longitudinal strain (GLS) was quantified as a secondary means of assessing RV function as a continuous variable. Pulmonary artery systolic pressure (PASP) was calculated based on tricuspid regurgitant velocity and inferior vena cava caliber; PH (PASP³35 mmHg) and advanced PH (PASP³50 mmHg) were defined via established criteria. LV systolic and diastolic function, geometry, and mass were quantified based on linear dimensions in parasternal long axis, consistent with quantitative methods previously validated. Echoes were interpreted in a high-volume laboratory, for which expertise and reproducibility have been documented. All cause mortality was assessed following echo.Results: PH was identified in the majority (56%; 135/239) of MPN pts who underwent echo (Table 2). PH was common among all MPN subtypes (46% CML, 58% ET, 57% PV, 63% MF, 100% CEL, 42% MPN/MDS and 79% MPN-NOS). Advanced PH was identified in 20% of all MPN pts and within each subtype (15% CML, 13% ET, 16% PV, 29% MF, 33% CEL, 25% MPN/MDS and 43% MPN-NOS). RVDYS was 8-fold more common (24% vs 3%; p=<0.001) among MPN pts with PH and the magnitude of RVDYS increased stepwise in relation to PASP (p<0.001), suggesting that PH was causally related to RV failure. Although impaired LV systolic function (LVEF<50%) was no more common in MPN pts with PH (17% vs 10%; p=0.10), LV hypertrophy (38% vs 14%, p=<0.001), LV mass (99 ± 31 vs 83 ± 23 g/m2, p<0.001), LV filling pressure (E/e': 14±6 vs 11±4; p<0.001), and frequency of LV diastolic dysfunction (any grade: 71 vs 52%; p=0.003) were all increased in pts with PH. Left atrium (LA) area was also increased in MPN pts with PH (24 vs 19 cm2; p=0.001), further suggesting a post-capillary cause for PH in this MPN population. Myocardial biopsy of an MPN patient with advanced PH demonstrated interstitial fibrosis in non-infarcted myocardium suggesting that fibrosis could play a role in LV diastolic dysfunction and PH in pts with MPNs.During median follow-up of 6.2 yrs (0.1 to 43 yrs), likelihood of death was higher for pts with advanced PH (odds ratio 3.1, p=0.004), or with RVDYS whether quantified by GLS (odds ratio 2.4, p=0.04) or TAPSE/S' (odds ratio 2.3, p=0.048). Cox Proportional Hazards model (parameterized for age, gender, MPN diagnosis, transformation and BMT) indicated that the Echo cohort was similar to the NoEcho control group. Pts with PH were more likely to experience fatigue than pts with a normal estimated PASP. Whereas dyspnea was no more common in pts with PH as a whole, pts with advanced PH were more likely to experience both fatigue and dyspnea compared to those with less severe PH or normal PASP. Cox proportional hazards modeling identified Advanced PH as an independent predictor of death in models that included Age, Gender, MPN Diagnosis, Transformation and BMT.Conclusions : PH with post-capillary hemodynamics is extremely common in pts with MPN and is associated with frequently reported symptoms such as fatigue. When advanced or when associated with RVDYS, PH independently confers increased mortality risk for MPN pts. [Display omitted] DisclosuresRitchie:Bristol-Myers Squibb: Other: Research funding to my institution; Astellas Pharma: Other: Research funding to my institution; Celgene: Consultancy, Other: Travel, Speakers Bureau; Pfizer: Consultancy, Other: Research funding to my institution; NS Pharma: Other: Research funding to my institution; Incyte: Consultancy, Speakers Bureau; Novartis: Consultancy, Other: Research funding to my institution, and travel, Speakers Bureau.

Pulmonary Hypertension in Apparently Healthy Children in Southern Nigeria.

To determine the severity and prevalence of pulmonary hypertension and its relationship with age and body mass index (BMI) in healthy children. Observational study. University of Nigeria Teaching Hospital Ituku-Ozalla Enugu, Lagos State University Teaching Hospital, Niger Delta University Teaching Hospital, Bayelsa and Blessed Children Hospital Enugu from January 2010 to December 2019. Four hundred and seventy (470) apparently healthy children aged 1 to 17 years underwent Doppler echocardiographic studies. Their tricuspid regurgitation velocity (TRV) was measured with continuous wave Doppler. Pulmonary artery systolic pressure (PASP) was estimated using the Bernoulli equation. Elevated PASP were determined at PASP ≥35/mmHg. Values were compared against age and BMI. The mean age was 7.9 ± 3.3 years. Four hundred and fifty-nine subjects (97.7%) had normal PASP while 11 (2.3%) had elevated PASP. Those with elevated PASP had a significantly higher mean TRV of 2.7 ± 0.22 cm/s (95% CI; 2.55-2.85) vs TRV of 1.56 ± 0.43cm/s (95% CI; 1.52-1.60) and higher mean PASP of 39.27±4.89 mmHg (95% CI; 35.99-42.56) vs 20.45 ± 5.34 mHg (95% CI; 19.96-20.94) (p=0.001). Though majority of the children had appropriate weight for ages, those with elevated PASP had a significantly greater weight than those with normal PASP (p<0.001). There was a weak positive correlation of PASP with age (r=0.16) and BMI in normal weight (r=0.08). Obese children had a negative correlation value(r=-0.13). A weak negative correlation of PASP with BMI was seen in underweight (r=-0.17 and overweight (r=-0.73) children (p>0.05). The mean pulmonary artery systolic pressure in the studied apparently healthy Nigerian children was 20.45± 5.34/ mmHg. The frequency of elevated PASP was 2.3%, commoner in children with higher BMI. Age and body mass index are not optimal predictors of PASP. Key Words: Pulmonary artery systolic pressure, Children, Pulmonary hypertension, Echocardiography.

P255 A fall from the tractor: a case report

Abstract Introduction Pulmonary artery aneurysms (PAAs) are rare and infrequently diagnosed clinical conditions. They can have congenital, acquired or idiopathic causes. PAAs can be asymptomatic or present with non-specific manifestations even at large diameters up to 70 mm. Rupture and dissection are the main life threating complications. The optimal treatment remains uncertain. There are no clear guidelines regarding the therapeutical approach. Case presentation A 78-year-old male presented at our medical facility to investigate further a pulmonary artery aneurysm discovered accidentally after a traumatic fall from a farmer tractor. He had no important chronic diseases, but in his medical history it was reported that he was excluded from the military service on top of a cardiac murmur, never investigated with an echocardiography exam. The fall from the tractor caused a fracture of the second and third costal ribs with hematoma and a commotional cranial trauma. At the thoraco-abdominal computed tomography (CT) scan conducted after the fall emerged an important fusiform dilatation of the principal pulmonary trunk and the left pulmonary artery (3.8 cm and 5 cm respectively). There was also a mild dilatation of the right pulmonary artery (3 cm), thickening of the pulmonary valve cusps and dilatation of the right cardiac chambers with flattening of the interventricular septum. Pulmonary embolism was excluded. Transthoracic and transesophageal echocardiography revealed a dysplastic pulmonary valve, with thickened cusps and moderate stenosis with insufficiency. The jet of the right ventricular outflow tract was eccentric with an anterolateral direction and a correlated dilatation of the common pulmonary trunk (3.8 cm) and the left pulmonary artery (5 cm). The right ventricle appeared not dilated and the tricuspid regurgitation was mild with a normal systolic pulmonary artery pressure. The dilated pulmonary artery did not interfere with the flow in the left main coronary artery. We concluded that the pulmonary artery aneurysm was mainly due to the congenital pulmonary valvulopathy. The patient underwent successful pulmonary trunk, left pulmonary artery and pulmonary valve replacement with a bioprosthetic valved conduit. Conclusion Congenital pulmonary valvulopathy can remain clinically silent lifelong and is commonly discovered during exams performed due to other clinical circumstances. The eccentric jet caused by the valvulopathy can be the reason for dilatation of the pulmonary trunk and pulmonary arteries. Transthoracic and transesophageal echocardiography are competent tools for clarifying the cause of the pulmonary artery aneurysm and therefore are essential in the decision making regarding the treatment strategy. Abstract P255 Figure. Transesophageal echocardiography images

A study of echo cardiographic abnormalities

Prospective observational study conducted in Department of Respiratory Medicine, Chennai. 65 stable COPD (In patients and out patients) were recruited in this study which was appropriate by Institutional Human Ethical Committee. The selected patients were subjected to Spirometry, ECG, Echocardiography.Data was analysed by using appropriate statistical methods. Our study, included a total of 55 stable COPD patients between the age group of 40 to 70 years with the mean age of 55.01. There was a Male predominance of 63.6% with M: F ratio of 1.7:1. Based on the GOLD severity grading, 18.2%, 30.9%, 50.9% belongs to Mild, Moderate &amp; Severe COPD respectively. 58.1% were smoker among which 14.5% had pack years of &lt; 20 pack year and 43.6% had &gt; 20 pack years of smoking. Majority of smokers with pack years of less than 20 had mild COPD. However majority of Smokers with &gt;20 pack year majority belonged to severe (32.7%) group followed by 10.9% in moderate group. Among Non smoker (9.09%), 7.27% and 1.81% were in mild and moderate group respectively. The prevalence of Cardiac abnormality in the study group was analysed with ECG and Echocardiography. ECG abnormalities observed were as follows: P Pulmonale (43.6%), Right Axis Deviation (41.8%), Right Ventricular Hypertrophy (40%), Low voltage QRS complex (36.3%), Poor R wave progression (30.9%), T wave inversion (27.3 %) and Right Bundle Branch Block(20%).Echocardiographic changes observed were as follows: RA &amp; RV dilatation (50.9%), Tricuspid regurgitation (47.3%), RWMA (10.9%) and LV dysfunction (7.3%). The normal pulmonary artery systolic pressure was observed in 21.8% patients. 16.3 %, 43.6% and 18.2 % were observed in Mild, Moderate and severe PAP respectively.

STUCK IN TRANSIT: LOOMING DISASTER IN A PATIENT WITH A PATENT FORAMEN OVALE-ADHERENT THROMBUS

SESSION TITLE: Pulmonary Vascular Disease SESSION TYPE: Med Student/Res Case Report PRESENTED ON: 10/23/2019 8:45 AM - 9:45 AM INTRODUCTION: The diagnosis of an impending paradoxical embolism, defined as a thrombus adherent to a patent foramen ovale (PFO), is very rare with the first reported case in 1985 [1]. This phenomenon is increasingly diagnosed due to improved availability of echocardiography and advances in imaging technology, although fewer than 200 cases to date have been reported [2,3]. Impending paradoxical embolism carries a high 30-day mortality rate of 18.4-29% [3,4]. CASE PRESENTATION: Our patient is a 64-year-old male with tobacco use, former alcohol and methamphetamine abuse, who presents with 1-month of progressive exertional dyspnea, lower extremity swelling, and 1-week of left-sided pleuritic chest pain. He was tachycardic and tachypneic on admission, with a blood pressure of 111/78 and SpO2 of 89% on room air. Significant laboratory values include a BNP of 1937 (5-99), troponin 0.03 (<0.03), and an EKG showing sinus tachycardia and right axis deviation. Admission transthoracic echocardiogram (TTE) revealed a reduced left ventricular ejection fraction of 20-25% with global hypokinesis, a moderately dilated right ventricle with severely reduced systolic function, elevated estimated pulmonary artery systolic pressure (PASP) of 63-73 mmHg, and a mobile mass in the right atrium (RA). A CT chest angiogram showed extensive chronic/subacute-appearing thrombi involving the main pulmonary arteries with extension into the right and left lower lobe segmental branches, and a 4.6 cm heterogeneous RA mass. A transesophageal echocardiogram showed a 4.1 x 4.5 cm RA mass traversing a newly noted PFO. Lower extremity dopplers showed bilateral deep venous thromboses extending from the iliac to popliteal veins. Coronary angiogram was without significant obstructive coronary artery disease. His treatment included a continuous heparin infusion, oxygen supplementation, and progressive diuresis. The patient was transferred to a tertiary referral center for pulmonary thromboendarterectomy with PFO closure. The removed mass from the pulmonary arteries was consistent with chronic clot and the final pathology of the atrial mass was organizing thrombus. DISCUSSION: Despite the increasing frequency of detection of an impending paradoxical embolism, the diagnosis is still rare and there are no established treatment guidelines. There is a trend towards improved outcomes with surgical endarterectomy over thrombolysis or anticoagulation alone [5]. CONCLUSIONS: Our patient underwent successful endarterectomy without evidence of systemic embolization. At 1-year follow up, he has normal cardiac function and normal PASP by TTE, with no perfusion abnormalities on VQ scan. His hypercoagulable work-up was non-diagnostic, although anticoagulation for life is recommended. Reference #1: 1. U. Nellessen, W. Daniel, G. Matheis, et al.Impending paradoxical embolism from atrial thrombus: correct diagnosis by transeosophageal echocardiography and prevention by surgery. J Am Coll Cardiol, 5 (1985), pp. 1002-1004. Reference #2: 2. Podroužková H, Horváth V, Hlinomaz O, et al. Embolus entrapped in patent foramen ovale: impending paradoxical embolism. The Annals Of Thoracic Surgery. 2014;98(6):e151-e152. https://doi.org/10.1016/j.athoracsur.2014.08.072. Reference #3: 3. Myers P. O., Bounameaux H., Panos A., Lerch R., Kalangos A. Impending paradoxical embolism: systematic review of prognostic factors and treatment. Chest. 2010;137(1):164–170. https://doi.org/10.1378/chest.09-0961. 4. Shepherd F, White-Stern A, Rahaman O, Kurian D, Simon K. Saddle Pulmonary Embolism with Thrombus in Transit across a Patent Foramen Ovale. Case Rep Cardiol. 2017;2017:6752709. 5. Fauveaua E., Cohen A., Bonnet N., Gacem K., Lardoux H. Surgical or medical treatment for thrombus straddling the patent foramen ovale: Impending paradoxical embolism? Report of four clinical cases and literature review. Archives of Cardiovascular Diseases. 2008;101(10):637–644. https://doi.org/10.1016/j.acvd.2008.08.011. DISCLOSURES: No relevant relationships by Jenifer Lentz, source=Web Response

Influence of mildly and moderately elevated pulmonary artery systolic pressure on post-renal transplantation survival and graft function.

Severe pulmonary hypertension (PH) has been associated with decreased post-kidney transplant survival and increased rate of long-term cardiovascular complications. Despite a high prevalence of PH in patients with end-stage renal disease, data on post-transplant renal allograft survival in recipients with pre-existing mild-to-moderate PH are limited. The single-center retrospective study cohort consisted of 192 consecutive (2008-2015) renal transplant recipients with documented pretransplantation transthoracic echocardiogram (TTE) pulmonary artery systolic pressure (PASP). Mean age was 50.9±12.4years, 36.5% were females, and 81.25% were Caucasians. Elevated PASP≥37mmHg was present in 51 patients. Elevated PASP was more common in patients with decreased <50% left ventricular ejection fraction (13.73% vs 3.55%, P=0.010); otherwise, there were no significant differences in baseline demographic (age, ethnicity, gender, and donor status) and clinical parameters between patients with normal and elevated PASP. Four-year mortality (5.7%) was not significantly affected by elevated PASP. However, elevated PASP was associated with significantly decreased estimated glomerular filtration rate (eGFR) at 1year (52.26 vs 60.13mL/min, P=0.019) and 2years (51.04 vs 60.28mL/min, P=0.006) post-transplant. Mild and moderately elevated pre-kidney transplant PASP does not affect 4-year post-transplant mortality or graft loss. However, elevated pretransplant PASP is significantly associated with decreased 1year and 2years post-transplant eGFR. Preoperative echocardiographic evaluation for PH may be useful in predicting the probability of short-term renal graft and long-term graft dysfunction in these patients.

Lung volume reduction surgery in selected patients with emphysema and pulmonary hypertension.

Pulmonary hypertension (PH) is considered a contraindication for lung volume reduction surgery (LVRS). Because, it has been reported that endobronchial lung volume reduction may have a beneficial effect without increased mortality in patients with emphysema and PH, we evaluated its effect on PH in patients undergoing LVRS. From January 2014 until June 2016, 119 LVRSs were performed at Zurich University Hospital. PH was a contraindication for patients with homogeneous emphysema but was acceptable for those with heterogeneous emphysema. Thirty patients underwent echocardiography before and after LVRS, 10 of whom had preoperative systolic pulmonary artery pressures >35 mmHg and 20 of whom had normal systolic pulmonary artery pressure. The effect of LVRS on pulmonary artery pressure, lung function and survival was analysed. Ninety-day mortality for all 30 patients was 0, and the postoperative course did not differ significantly between the 2 groups. In patients with PH, the median systolic pulmonary artery pressure decreased from 41 mmHg [interquartile range (IQR) 39-47] to 37 mmHg (IQR 36-38, P = 0.04). These patients had an improvement of forced expiratory volume in 1 s from the median 27% predicted (IQR 23-34) to 33% (IQR 28-40, P = 0.007) 3 months postoperatively. If further confirmed in other cohorts, mild to moderate PH may no longer be considered a contraindication for LVRS in patients with heterogeneous emphysema.

Clinical associations of vascular endothelial growth factor in patients with systemic sclerosis

Aim: To assess serum levels of vascular endothelial growth factor (VEGF) and its clinical correlates in patients with systemic sclerosis (SSc). Materials and methods: Forty six (46) patients with SSc aged from 19 to 77 years (median, 50 years), with duration of the disease from 0.5 to 24 years (median, 7 years) were recruited into the study. There were equal numbers of the patients with limited (LSSc) and diffuse (DSSc) types of the disease (23 patients in each group, or 50%). All patients underwent clinical examination, including measurement of the forced vital capacity (FVC), diffusing capacity of the lung for carbon monoxide (DLCO) and pulmonary artery systolic pressure (PASP). Serum VEGF-A levels were determined by immunoenzyme assay in the patients and in 20 healthy controls. Results: VEGF levels in the healthy individuals were in the range from 0.2 to 264 pg/mL (median, 90.2). In SSc patients they varied from 0.02 to 1034.2 pg/mL (median, 147.2), with mean VEGF levels being over 2-fold higher than that in the control group (212.35 ± 253.93 and 97.74 ± 71.46 pg/mL, respectively; p = 0.032). DSSc patients had VEGF levels of 0.02 to 599.8 pg/mL (median, 93.6), whereas in LSSc they were from 0.02 to 1034.2 pg/mL (median, 162.4). Mean VEGF level in LSSc was higher than in DSSc (267.11 ± 268.74 vs 120.4 ± 141.09 pg/mL, respectively; p = 0.012). Current or past digital ulcers were found in 19 (41%) of all patients. Mean VEGF level in the patients with digital ulcers was higher than in those without ulcers; however, the difference was not statistically significant. PASP exceeded 30 mm Hg in 19 (43%) of the patients. VEGF levels in the patients with PASP of less than 30 mm Hg and ≥ 31 mm Hg were in the range of 0.02 to 363.6 pg/mL (median, 79.6) and 0.2–1034.2 pg/mL (median, 222.3), respectively. Mean VEGF level in the patients with high PASP was significantly higher than that in the patients with normal PASP (р = 0.0042). In the patients with DLCO ≥ 50% and &lt; 50% serum VEGF levels were found to be 0.02 to 599.8 pg/mL (median, 59.75) and 0.02 to 1034.2 pg/mL (median, 195.9), respectively. Mean VEGF levels in the patients with DLCO of less than 50% was significantly higher than in the patients with DLCO of 50% and above (364.2 ± 381.95 and 128.55 ± 142.7, respectively, р = 0.034). FVC was decreased (&lt; 80% of predicted) in 11 (26%) of 43 patients. Mean VEGF levels in the patients with low FVC was higher than in those with normal FVC, although the difference was non-significant. There was a moderate direct association between VEGF levels and PASP values (R = 0.4; p = 0.007). Also, a trend towards an inverse correlation between DLCO and VEGF levels was observed, which was however non-significant (R = -0.28; р = 0.07). Conclusion: A significant proportion of SSc patients have high serum VEGF levels. A close association with some clinical correlates indicates a pathogenetic role of VEGF in SSc. Further studies are necessary to clarify the precise contribution of VEGF into SSc pathophysiology.

Prognostic Value of Exercise-Stress Echocardiography in Asymptomatic Patients With Aortic Valve Stenosis

ObjectivesThis study sought to evaluate the prognostic value of mean pressure gradient (MPG) increase and peak systolic pulmonary artery pressure (SPAP) measured during exercise stress echocardiography in asymptomatic patients with aortic stenosis (AS). BackgroundExercise testing is recommended in asymptomatic AS patients, but the additional value of exercise-stress echocardiography, especially the prognostic value of MPG increase and peak SPAP, is still debated. MethodsWe enrolled all consecutive patients with pure, isolated, asymptomatic AS and preserved ejection fraction ≥50% and normal SPAP (<50 mm Hg) who underwent symptom-limited exercise echocardiography at our institution. Occurrence of AS-related events (symptoms or congestive heart failure) or occurrence of aortic valve replacement was recorded. ResultsWe enrolled 148 patients (66 ± 15 years of age; 74% males; MPG: 47 ± 13 mm Hg; SPAP: 34 ± 6 mm Hg). No complications were observed. Thirty-six patients (24%) had an abnormal exercise test result (occurrence of symptoms, fall in blood pressure, and/or ST-segment depression) and were referred for surgery. Among the 112 patients with a normal exercise test result, 38 patients (34%) had abnormal exercise echocardiography scores (MPG increase >20 mm Hg and/or SPAP at peak exercise >60 mm Hg). These 112 patients were managed conservatively. During a mean follow-up of 14 ± 8 months, an AS-related event occurred in 30 patients, and 25 patients underwent surgery. Neither MPG increase >20 mm Hg nor peak SPAP >60 mm Hg was predictive of occurrence of AS-related events or aortic valve replacement (all p > 0.20). In contrast, baseline AS severity was an important prognostic factor (all p < 0.01). ConclusionsIn this observational study including 148 patients with asymptomatic AS, we confirmed and extended the importance of exercise testing for unveiling functional limitation. More importantly, neither the increase in MPG nor in SPAP at peak exercise was predictive of outcome. Our results do not support the use of these parameters in risk-stratification and clinical management of asymptomatic AS patients.

Abstract 15388: Persistent Pulmonary Hypertension After Transcatheter Aortic Valve Implantation: Impact on Mortality

Objective: Severe aortic stenosis leads to increased pulmonary arterial systolic pressure. A controversy still remains regarding the impact of persistent pulmonary hypertension (PHT) on prognosis of patients undergoing transcatheter aortic valve implantation (TAVI). We sought to investigate the impact of persistent PHT on 2-year all-cause mortality of patients with severe aortic stenosis following TAVI. Methods: Patients with severe and symptomatic aortic stenosis (effective orifice area [EOA]≤1 cm 2 ) who were scheduled for TAVI with a self-expanding valve at our institution were prospectively enrolled. Prospectively collected echocardiographic data before and after TAVI were retrospectively analyzed in all patients. Pulmonary artery systolic pressure was estimated as the sum of the right ventricular to the right atrial gradient during systole and the right atrial pressure. PHT following TAVI was classified as absent if &lt;35 mmHg and persistent if ≥35 mmHg. Primary clinical end-point was 2-year all-cause mortality defined according to the criteria proposed by the Valve Academic Research Consortium-2. Results: Hundred and forty patients (mean age: 82±9 years) were included in the study. The primary clinical end point occurred in 17 patients (12%) during a median follow-up period of 2 years. Mean pulmonary artery systolic pressure was reduced in all patients following TAVI (45±9 versus 41±6 mmHg, p&lt;0.01). Mortality rate was higher in patients with persistent PHT compared to patients with normal pulmonary artery systolic pressure following TAVI (26% versus 14 %, p&lt;0.01). Patients that reached the primary clinical end point had a higher post procedural mean systolic pulmonary pressure (43±9 versus 39±6 mmHg, p=0.02). In multivariate regression analysis, persistence of PHT (OR: 2.51, 95% CI: 1.109-7.224, p=0.01) was an independent predictor of long-term mortality. Conclusions: The persistence of pulmonary hypertension after TAVI is associated with long term mortality. Identifying the population that will clearly benefit from TAVI is still need to be validated by larger trials.

Levels of uric acid may predict the future development of pulmonary hypertension in systemic lupus erythematosus: a seven-year follow-up study.

The objective of this paper is to assess whether pulmonary hypertension (PH) may be detected at one point in time or longitudinally predicted by serum uric acid (sUA) levels in systemic lupus erythematosus (SLE). We conducted a post-hoc analysis of a long-term followed cohort of Mexican SLE patients. Echocardiography-based definitions of PH by the ESC/ERS/ISHLT and its associations with clinical and laboratory data on enrollment were studied. Especially, the impact that sUA levels at baseline may have on the future development of PH in patients with normal pulmonary artery systolic pressure (PASP) was explored. Out of the 156 SLE patients originally enrolled in the cohort, 44 met the inclusion criteria for the present study and were grouped as having (n =10) or not having (n = 34) PH. At baseline, sUA levels of 5.83 ± 1.79 and 5.82 ± 1.97 mg/dl (p = ns) were found in patients with and without PH, respectively. No association between PASP and other markers was found. In patients with normal PASP, the presence of sUA ≥ 7 mg/dl at baseline predicted future development of PH (relative risk 8.5, 1.0009 to 72; p = 0.04). In SLE, sUA levels at one point in time are useless to detect PH. However, steady hyperuricemia may predict the future development of PH in patients with normal PASP at baseline.

Echocardiography of Right Ventriculoarterial Coupling Combined With Cardiopulmonary Exercise Testing to Predict Outcome in Heart Failure

Pulmonary hypertension, which is related to right ventricular (RV) failure, indicates a poor prognosis in heart failure (HF). Increased ventilatory response and exercise oscillatory ventilation (EOV) also have a negative impact. We hypothesized that the severity classification of HF and risk prediction could be improved by combining functional capacity with cardiopulmonary exercise testing (CPET) and RV-pulmonary circulation coupling, as evaluated by the tricuspid annular plane systolic excursion (TAPSE)-pulmonary artery systolic pressure (PASP) relationship. Four hundred fifty-nine patients with HF were assessed with Doppler echocardiography and CPET and were tracked for outcome. The subjects were followed for major cardiac events (cardiac mortality, left ventricular assist device implant, or heart transplant). Cox regression and Kaplan-Meier analyses were performed with TAPSE and PASP as individual measures that were then combined into a ratio form. The TAPSE/PASP ratio (TAPSE/PASP) was the strongest predictor, whereas the New York Heart Association classification and EOV added predictive value. A four-quadrant group prediction risk was created based on TAPSE (< 16 mm or ≥ 16 mm) vs PASP (< 40 mm Hg or ≥ 40 mm Hg) thresholds and the CPET variables distribution as follows: group A (TAPSE > 16 mm and PASP < 40 mm Hg) presented the lowest risk (hazard ratio, 0.17) and best ventilation; group B exhibited a low risk (hazard ratio, 0.88) with depressed TAPSE (< 16 mm) and normal PASP, a preserved peak oxygen consumption (V.o2), but high ventilation. Group C had an increased risk (hazard ratio, 1.3; TAPSE ≥ 16 mm, PASP ≥ 40 mm Hg), a reduced peak V.o2, and a high EOV prevalence. Group D had the highest risk (hazard ratio, 5.6), the worse RV-pulmonary pressure coupling (TAPSE < 16 and PASP ≥ 40 mm Hg), the lowest peak V.o2, and the highest EOV rate. TAPSE/PASP, combined with exercise ventilation, provides relevant clinical and prognostic insights into HF. A low TAPSE/PASP with EOV identifies patients at a particularly high risk of cardiac events.