Pulmonary Artery Systolic Pressure In Patients Research Articles

Sacubitril/valsartan on right ventricular-pulmonary artery coupling and albumin-bilirubin score in heart failure in Chinese patients with reduced ejection fraction

ObjectiveImpaired right ventricular (RV)-pulmonary arterial (PA) coupling, calculated by measuring the tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP), can be used as an early indicator of right ventricular dysfunction (RVD) in patients with heart failure with a reduced ejection fraction (HFrEF). Patients suffering from HFrEF experience improvements in left ventricular (LV) function through the administration of sacubitril/valsartan therapy. In addition, the albumin-bilirubin (ALBI) score was associated with the fluid overload status and adverse clinical outcomes in patients with heart failure. This study aimed to assess whether angiotensin receptor-neprilysin inhibitor (ARNI) affects the TAPSE /PASP in patients with HFrEF, and whether there is a correlation between changes in the ALBI score and ARNI treatment.MethodsA retrospective observational study was conducted on 305 patients with HFrEF and RVD who were hospitalized between June 2020 and December 2021. One year after treatment, laboratory test results, ALBI score, transthoracic echocardiography (TTE), New York Heart Association classification, Minnesota Living with Heart Failure Questionnaire scores and changes in relevant variables were reevaluated.ResultsCompared to before sacubitril/valsartan treatment, the ALBI was found to be significantly reduced after one year of follow-up (-2.42 ± 0.37 vs. -2.51 ± 0.32, p < 0.001). Additionally, A significant improvement was demonstrated in the following echocardiography parameters assessing RV function after 1 year of treatment with sacubitril/valsartan: TAPSE (15 ± 1 vs. 18 ± 2 mm, p < 0.001), PASP (45 ± 8 vs. 40 ± 9 mmHg, p < 0.001), pulmonary artery diastolic pressure (PADP) (22 ± 4 vs. 19 ± 4 mmHg, p < 0.001), RV-PA coupling (0.35 ± 0.08 vs. 0.48 ± 0.12, p < 0.001), and RV s’(8.7 ± 2.2 vs. 9.5 ± 2.6 cm/s, p < 0.001). Multivariate analysis showed that the improvement of RV-PA coupling was associated with baseline PASP (r: -0.45, p < 0.001) and PADP (r: -0.45, p < 0.001).ConclusionsSacubitril/valsartan improves RV-PA conjugation in patients with RVD and HFrEF, and has a positive impact on the ALBI score by improving liver function in patients with HFrEF.

Clinical and echocardiographic predictors of outcome in liver transplant patients.

Liver transplant (LT) candidates undergo transthoracic echocardiography (TTE) before surgery to assess cardiac function and evaluate the echocardiographic probability of pulmonary hypertension (PHT). The improvement of pulmonary artery systolic pressure (PAPS) after transplant is associated with higher survival rates in patients with mild or moderate PHT. Although studies analyze the outcomes of LT in patients treated for PHT, the prognostic value of PAPS in patients without PHT in the follow-up is unknown. The aim of our study is to evaluate pre- and post-LT cardiac function, right ventricular function, pulmonary artery pressure, and their association with long-term mortality. 102 patients who underwent LT between 2011 and 2018 were compared for echocardiographic and hemodynamic parameters pre- and post-LT. After LT, systolic blood pressure, heart rate (HR), and PASP significantly increased, while tricuspid annular plane systolic excursion/PAPS decreased. Moreover, the higher difference in HR and PASP between pre- and post-LT was highlighted in those patients who died during the follow-up period after LT. Among all the parameters tested, in the multi-variable Cox regression for mortality, left ventricular ejection fraction and PASP difference were predictors of mortality. This study highlights the importance of TTE in LT screening as a tool to stratify patients at higher risk of death due to advanced cirrhotic cardiomyopathy and the importance of the change of echocardiographic parameters, in particular right and left ventricular hemodynamics, during the follow-up period. These parameters could be used to guide a more aggressive therapy.

IMPLICATION OF PULMONARY ARTERY SYSTOLIC PRESSURE FOR PROLONGED CARDIOPULMONARY BYPASS DURATION IN PATIENTS UNDERGOING RE-REPAIR FOR DEGENERATIVE MITRAL REGURGITATION

Objective: Emerging evidence revealed that the longer duration of cardiopulmonary bypass (CPB) during cardiac surgery renders patients at higher risk of adverse outcomes. However, little is known regarding the risk factor of prolonged CPB in patients undergoing re-repair of degenerative mitral regurgitation (DMR). We aimed to explore the prognostic significance of pulmonary artery systolic pressure (PASP) on CPB duration in patients undergoing re-repair of DMR. Design and method: Patients with DMR undergoing re-repair in our center were consecutively enrolled from Jan 2009 to Dec 2021. Patients were stratified into the prolonged CPB group (CPB time &lt; 132 min, n = 61) and the shorter CPB (CPB time &lt; 132, n = 59). Preoperative Univariable and multivariable logistic regression analyses were used to evaluate the impact of PASP on the risk of prolonged CPB duration. Results: Of the 120 patients enrolled, 61 had prolonged CPB time (50.8%). The mean preoperative PASP was higher in the prolonged CPB group compared with the shorter CPB group (45.2±21.9 vs. 37.7±15.1, P &lt; 0.05). CPB time increased with higher preoperative PASP (P &lt; 0.05). For per 10 units of pre-PASP value increase in patients undergoing re-repair for DMR, there were 1.25 times more likely to be associated with a prolonged CPB time (adjusted odds ratio [OR] 1.25, 95% confidence interval [CI] 1.01-1.56, P &lt; 0.05). Patients with preoperative PASP &gt; 50mmHg had an adjusted OR of 3.66 (95% CI 1.36-9.84, P &lt; 0.05) for a prolonged CPB period compared with those with preoperative PASP &lt; 50mmHg. Conclusions: Preoperative PASP in patients requiring re-repair for DMR was associated with a higher likelihood of an extended time of CPB. Regular screening of pulmonary hypertension may aid in perioperative risk-stratification in patients prior to re-repair for DMR.

The Effect of L-Arginine Oral Supplementation on the Improvement of Cardiovascular Function and Pulmonary Artery Pressure in Patients with Major and Intermedia β-Thalassemia.

Thalassemia is the most common inherited anemia in worldwide. Heart failure is the most common cause of mortality and morbidity in patients with major and intermedia β-thalassemia. This study aimed to evaluate the effect of oral administration of L-arginine on the improvement of systolic Pulmonary Artery Pressure (PAP) and cardiac function in patients with major and intermedia β-thalassemia. This randomized clinical trial was done on 88 patients with β-thalassemia admitted to Ali Asghar Hospital, Tehran, Iran between 2020 and 2021. Echocardiography was performed for all the patients before the intervention. Afterwards, the patients were randomly divided into two groups of placebo and L-arginine. The patients underwent echocardiography after eight weeks and were compared with respect to the results. The mean blood transfusion interval was 20.21 d in the placebo group and 17.14 d in the L-arginine group (P=0.082). The results revealed no significant difference between the two groups regarding the mean levels of Hemoglobin (Hb) and ferritin, frequency of splenectomy. However, the mean PAP significantly decreased from 32.88 to 26.02 in the L-arginine group (P=0.009), but did not change in the placebo group. Nonetheless, no significant change was observed in the mean Ejection Fraction (EF) before and after L-arginine administration. L-arginine administration prevented the increase of PAP and was effective in preventing cardiovascular disorders including increased systolic PAP in patients with major and intermedia B-thalassemia. However, the results have to be confirmed in further studies with larger sample sizes.

The impact of vascular access location on pulmonary arterial pressure in chronic kidney disease patients undergoing hemodialysis.

It is feared that among chronic kidney disease patients undergoing hemodialysis, arteriovenous fistula (AVF) itself could contribute to pulmonary hypertension (PH). The impact of AVF location on PH is yet to be assessed. We hypothesize that patients with proximal AVF have higher access blood flow and hence higher pulmonary arterial systolic pressure (PASP) than those with distal AVF. We aimed to compare the PASP between patients with proximal and distal AVF. In this cross-sectional study, PASP was estimated using Doppler echocardiography and blood flow in the AVF was assessed by Doppler ultrasound. PASP was modeled by multivariate linear regression. AVF location was the primary exposure of interest. Out of 89 patients undergoing hemodialysis, 72 (81%) had PH defined as PASP >35 mmHg. The mean blood flow in proximal and distal AVF was, respectively, 1240 and 783 mL/min (mean difference 457 mL/min, p < 0.001). Mean PASP in patients with proximal AVF was 16.6mmHg higher than those with distal AVF (p < 0.001, 95% CI 8.3-24.9). There was a positive correlation between access blood flow and PASP (r = 0.28, p = 0.007). If access blood flow was included as a covariate in the multivariate model, the association between AVF location and PASP ceased to exist. Patients with proximal AVF have a significantly higher PASP than those with distal AVF, and this could be attributed to the higher blood flow in proximal AVF compared to distal AVF.

Echocardiographic and clinical outcomes of MitraClip therapy in patients with severe mitral regurgitation

Abstract Background MitraClip implantation improves mitral regurgitation (MR), however its impact on pulmonary hypertension (PHT) is not fully elucidated. Our hypothesis was that changes in pulmonary pressure after MitraClip implantation might predict outcomes. Methods We studied a cohort of 149 consecutive patients who underwent MitraClip implantation between August 2015 and September 2019. We compared echocardiographic and clinical variables between a group with not-severe PHT and a group with severe PHT according to Pulmonary artery systolic pressure (PASP) &amp;gt;55 mmHg. Results Mean age of the cohort was 73±10 years, 75% were men, and 80% had functional MR. There are no differences in baseline characteristics between the two groups. There was a significant reduction of 13.6 mmHg in PASP at the severe PHT group from 68.2±10.9 mmHg before the procedure to 54.6±14.9 after (P=0.001) compared to the absence of a significant change in the second group. This reduction was maintained in the 6 months follow-up. Although PHT is considered a poor prognostic measure, and the severe PHT group had a baseline PASP higher than the not-severe group (P&amp;lt;0.001), however the Kaplan Meier curve did not show any significant difference in overall survival (p=0.468), and there is also no difference in one-year survival. Conclusions MitraClip therapy improves PASP in patients with severe MR and severe PHT. These patients showed the same survival as patients with not-severe PHT. MitraClip is a safety and effective procedure even for patients with severe PHT, that should not be excluded. Funding Acknowledgement Type of funding source: None

P293 Assessment of right ventricle parameters during stress in patients with asymptomatic primary mitral regurgitation

Abstract Background Evaluation of right ventricle (RV) function and pulmonary artery pressure (PAP) during stress, plays an important role in identifying worse prognosis for patients with chronic mitral regurgitation (MR) and may help to optimise the time of surgical interventions. Purpose The aim of the study was to evaluate changes of RV function and systolic PAP in patients with asymptomatic primary MR during stress echocardiography. Methods Resting and stress (veloergometry as per protocol 25 + 25 W every 3 minutes) echocardiography were performed in 63 asymptomatic patients (age 56.12 ± 13.97 years) with preserved left ventricle (LV) ejection fraction (EF) (&amp;gt;50%) at rest. 39 (61.9%) patients with moderate (grade 2-3) MR (MR group) and 24 (38.1%) patients without significant heart valves disease (control group) were included in the study. Statistical analyses were performed using the SPSS 20.0 software. The value of p &amp;lt; 0.05 was considered as statistically significant. Results Anthropometric and clinical characteristics, LV EF (64.96 ± 9.14% vs. 64.87 ± 6.46%, p = 0.97) and LV global longitudinal strain (GLS) (-19.24± 3.12% vs. -19.28 ± 3.36%, p = 0.055) at rest were not significantly different between MR and control groups. Diameter of RV was larger in MR group (36.07 ± 5.34 mm vs. 33.13 ± 3.48 mm) however difference was not significant (p = 0.971). Parameters of RV function (longitudinal myocardial velocity - S’, fractional area change (FAC) and tricuspid annular plane systolic excursion (TAPSE)) were similar in both groups at rest, during stress and at recovery phase (Picture 1). However TAPSE and S’ at rest (p = 0.037 and p = 0.205, respectively) and minimal stress (p = 0.006 and p = 0.035, respectively) were significantly lower in patients with MR who had highly increased (&amp;gt;60 mmHg) systolic PAP during stress. Also TAPSE (p = 0.002) and S’ (p = 0.017) during recovery phase were significantly lower in subjects with reduced LV contractile reserve (whom LV EF increased &amp;lt;4% or GLS &amp;lt;1.9% during stress). Systolic PAP during stress was growing much faster in patients with MR (Picture 1). Conclusions Patients with asymptomatic moderate primary mitral regurgitation had higher systolic PAP during stress even though at rest it was similar as in controls. Prominent severe pulmonary hypertension during stress was related to worsening parameters of RV function. Abstract P293 Figure. Parameters of RV during stress

Global longitudinal strain is a hallmark of cardiac damage in mitral regurgitation: the Italian arm of the European Registry of mitral regurgitation (EuMiClip)

BackgroundThe search for reliable cardiac functional parameters is crucial in patients with mitral regurgitation (MR). In the Italian arm of the European Registry of MR, we compared the ability of global longitudinal strain (GLS) and left ventricular (LV) ejection fraction (LVEF) to detect cardiac damage in MR.MethodsFive hundred four consecutive patients with MR underwent a complete echo-Doppler exam. A total of 431, 53 and 20 patients had degenerative, secondary and mixed MR, respectively. The main echocardiographic parameters, including LV and left atrial (LA) size measurements, pulmonary artery systolic pressure (PASP) and GLS were compared between patients with mild MR (n = 392) vs. moderate to severe MR (n = 112).ResultsLVEF and GLS were related one another in the pooled population, and separately in patients with mild and moderate/severe MR (all p < 0.0001). However, a certain number of patients were above the upper or below the lower limits of the 95% confidence interval (CI) of the normal relation in the pooled population and in patients with mild MR. Only 2 patients were below the 95% CI in moderate to severe MR. After adjusting for confounders by separate multivariate models, LVEF and GLS were independently associated with LV and left atrial size in the pooled population and in mild and moderate/severe MR. GLS, but not LVEF, was also independently associated with PASP in patients with mild and moderate to severe MR.ConclusionsBoth LVEF and GLS are independently associated with LV and LA size, but only GLS is related to pulmonary arterial pressure. GLS is a powerful hallmark of cardiac damage in MR.

P2453Value of pre-operative left atrial minimum volume as a surrogate for post-operative symptoms in patients with aortic stenosis who underwent aortic valve replacement

Abstract Background Previous reports have shown that symptoms after aortic valve replacement (AVR) are not uncommon depending on severity of myocardial fibrosis in patients with severe aortic stenosis (AS). Pre-operative minimum left atrial volume (LAVmin) at end-diastole determined by direct exposure of left ventricular end-diastolic pressure may be used as a surrogate for post-operative symptoms in patients with severe AS undergoing AVR. Purpose The purpose of this study was to examine the value of pre-operative echocardiographic LAVmin index (LAVImin) to predict post-operative symptomatic status after AVR in patients with severe AS. Methods The study population consisted of 219 patients with severe AS who underwent AVR and were followed up for 1000 days after AVR. Pre-operative maximum LAV index (LAVImax), LAVImin, LA emptying fraction (LAEF), LV volume indexes, LV ejection fraction (LVEF) by biplane Simpson's method, aortic valve area index (AVAI), mean aortic valve pressure gradient (mAV-PG), E/A, mean E/e' from LV inflow and mitral annular velocity, and pulmonary artery systolic pressure (PASP) were evaluated by Doppler echocardiography. Results After exclusion of 136 patients who met the exclusion criteria (atrial fibrillation, significant coronary artery disease, significant mitral valve diseases, pacemaker rhythm, and inadequate echocardiographic images), the final study population consisted of 75 patients (75±7 years old, 46 female). During a follow-up, 19 patients (25%) complained post-operative symptoms. There were no significant differences in pre-operative serum hemoglobin, creatinine, BNP, chronic obstructive pulmonary disease, hypertension, diabetes, LV volume indexes, LVEF, AVA, mAV-PG between patients with and without post-operative symptoms. There were significant differences in pre-operative LAVImax, LAVImin, and LAEF between patients with and without post-operative symptoms. (60±15 vs 47±15 ml/m2, 45±15 vs 28±1 ml/m2, and 29±12 vs 42±11 ml/m2, respectively). E/A, mean E/e', and PASP in patients with symptoms were significantly greater compared with patients without symptoms (1.0±0.3 vs 0.7±0.2, 25±3 vs 18±2, 44±17 vs 32±9 mmHg, respectively). In the multivariate analysis, pre-operative LAVImin was the independent predictor of the post-operative symptomatic status after AVR (odds ratio: 1.11, 95% confidence interval: 1.04 - 1.18). Receiver operating characteristic analysis revealed that area under the curve (AUC) of LAVImin (cutoff: 30ml/m2) for post-operative symptoms was the largest (0.84) among the other echocardiographic parameters, and significantly larger than that of mean E/e' (0.67, *p&lt;0.01) and LVEF (0.53, **p&lt;0.05) (figure). Figure 1. ROC analysis Conclusions The present results suggest that pre-operative echocardiographic LAVImin may be used as a surrogate for post-operative symptomatic status after AVR in patients with severe AS.

PH Grand Rounds: A Case of Pulmonary Hypertension Associated With High Cardiac Output State from Arteriovenous Fistula–Or Is It?

PH Grand Rounds: A Case of Pulmonary Hypertension Associated With High Cardiac Output State from Arteriovenous Fistula–Or Is It?

Time course of changes in left ventricular twist in the presence of idiopathic left bundle branch block during exercise testing

To investigate left ventricular (LV) deformation properties, rotation, and twist during a bicycle ergometer exercise test among patients with idiopathic left bundle branch block (LBBB). Thirty-four patients with idiopathic LBBB having a mean QRS duration of 153±24 msec were examined. A control group included 18 apparently healthy volunteers. All the patients and apparently healthy individuals underwent echocardiography to determine LV hemodynamic parameters, deformity, rotation and twist at rest and after exercise test. As compared with the control, the idiopathic LBBB group at rest showed decreases in LV global longitudinal deformity (-15.6±4.7 and -18.4±3.1%, respectively; p=0.037), apical rotation (4.59±4.2° and 8.99±3.68°; p=0.0067) and twist (9.08±4.59° and 13.96±4.61°; p=0.0156), whereas there were no differences in LV ejection fraction and end-systolic and end-diastolic volumes. After exercise testing there were no augmentations in basal and apical rotation and resulting ΔTwist in the idiopathic LBBB group compared with the control (-2.05±8.35 and 4.66±8.49%; p=0.0463). The described changes in LV rotation and twist during exercise testing occurred in the presence of elevated pulmonary artery systolic pressure (PASP) in the LBBB group compared with the control (41.6±3.81 and 32.4±3.81 mm Hg, respectively; p=0.0201). Decreases in LV basal, apical and resulting twist may lead to elevated PASP in patients with idiopathic LBBB during exercise.

Differential Impact of Net Atrioventricular Compliance on Clinical Outcomes in Patients with Mitral Stenosis According to Cardiac Rhythm

Net atrioventricular compliance (Cn), a parameter for the net compliance of the left atrium and left ventricle, is known to be a useful predictor of outcomes in patients with mitral stenosis (MS). The present study aimed to evaluate whether the impact of Cn on symptom status and clinical outcomes, as well as its contribution toward systolic pulmonary artery pressure (SPAP), differed according to cardiac rhythm. We retrospectively reviewed patients (N=308) with rheumatic pure MS. Doppler-derived Cn was calculated using planimetered mitral valve area and E-wave downslope of transmitral flow. The primary endpoint was defined as a composite of all-cause death, percutaneous mitral valvotomy, surgical mitral valve replacement, admission for heart failure, and stroke. Overall, there were 178 patients (58%) with sinus rhythm (SR) and 130 patients (42%) with atrial fibrillation (AF). In multivariable linear regression analysis, there was a significant independent association between Cn and SPAP in patients with SR (P=.014), but not in those with AF (P=.112). During a median follow-up of 38months, 130 patients (27%) experienced the study endpoint. In multivariable Cox regression, high Cn was associated with a more favorable prognosis in patients with SR (hazard ratio=0.83; 95% CI, 0.69-0.99; P=.038). Conversely, high Cn was not found to offset the burden of adverse clinical outcomes in those with AF (hazard ratio=1.18; 95% CI, 0.99-1.40; P=.071). Cn appears to be associated with SPAP and clinical outcomes in MS patients with SR. The predictive role of Cn in patients with AF requires further clarification.

Abstract 17584: Pulmonary Artery Systolic Pressure Independently Predicts All-Cause Mortality in Patients with Coronary Artery Disease Irrespective of a Diagnosis of Heart Failure

Background: Elevated pulmonary artery systolic pressure (PASP) is associated with a worse outcome in heart failure (HF), but the prognostic role of PASP in patients with coronary artery disease (CAD) remains unknown. Methods: 863 patients with known or suspected CAD (age: 64±13 years, 62% male) enrolled in the Emory Cardiovascular Biobank were followed for a median 455 days for all-cause death. Transthoracic echocardiographic parameters included measurement of left ventricular ejection fraction (LVEF, range: 5-80%) and diastolic function parameters. Youden’s index from the receiver operating curve analysis was used to determine the best discriminatory cutoff for PASP (cutoff=43 mmHg). Cox regression was performed to determine independent predictors of mortality. Results: 88 (10%) subjects died during follow-up. PASP correlated with left ventricular ejection fraction (LVEF, N=644, r=-0.20, p&lt;0.0001), C-reactive protein (CRP, N=539, r=0.12, p=0.004), and mitral valve inflow E/A ratio (N=359, r=0.32, p&lt;0.0001), mitral valve deceleration time (N=260, r=-0.16, p=0.007),and left atrial size (LAs, N=694, r=0.25, p&lt;0.0001). High PASP predicted incident mortality in a model adjusted for age, gender, diabetes, hypertension, dyslipidemia, smoking, glomerular filtration rate, CRP, heart failure, Gensini angiographic severity score, as well as aspirin, statin, beta-blocker, and angiotensin converting enzyme-inhibitor use (HR: 3.3, p=0.000001). The association of PASP with death was independent of LVEF (HR=3.2, p=0.00002). Thus, high PASP also predicted mortality in subjects with LVEF&gt;50% and no history of HF (HR: 4.7, p=0.004). In separate models, this association was also independent of LAs and E/A. Conclusion: High PASP &gt;43 mmHg is an independent predictor of mortality in patients with CAD even in those with preserved LVEF without HF. Whether high PASP predicts future development of HF and hospitalization for HF exacerbation needs to be investigated.

Novel Putative Polymorphism in SERPINC1 Encoding Antithrombin III Is Implicated in Elevated Estimated Systolic Pulmonary Pressure in Patients with Chuvash Polycythemia.

AbstractAbstract 2869Chuvash polycythemia (CP) is characterized by homozygosity for the R200W mutation in the von Hippel Lindau gene (VHL). This rare genetic disorder causes elevated levels of hypoxia inducible factor (HIF)-1 and HIF-2 that trigger constitutive hypoxia responses at normoxia. Hypoxia is a recognized cause of pulmonary hypertension. We recently reported that systolic pulmonary artery pressure (SPAP) estimated by echocardiography-determined tricuspid regurgitation velocity (TRV) was elevated in 120 CP patients compared to 31 Chuvash controls (P = 0.005), and that increasing age (P = 0.001), increasing systemic pulse pressure (P = 0.003) and lower serum ferritin concentration (P = 0.009) were independent predictors of higher estimated SPAP in CP patients [Sable et al., 2012]. In this study, we profiled gene expression for 16,642 genes in peripheral blood mononuclear cells (PBMCs) derived from a cohort of 43 CP patients, and measured the TRV for these individuals. Based on a prospectively chosen criterion of TRV ≥2.5 m/sec, 20 patients were classified as having elevated level of estimated SPAP and 23 were normal. Gene expression level between these two SPAP groups appeared to be homogenous. However, we identified 4777 genes at false discovery rate (FDR) <0.05 that exhibit pulse pressure by SPAP group interaction, suggesting a profound difference in pulse pressure regulation between the two SPAP groups.Further analysis of probe level data revealed a potential genetic polymorphism located within exon 7 of SERPINC1, encoding antithrombin III, at a site where a disease-associated SNP has not been reported. The minor allele of this polymorphism, which we designated “B”, was highly enriched in the elevated estimated SPAP group (P=0.0009), and classification based on the putative SERPINC1 genotypes strengthens the interaction effect with pulse pressure. Analysis of the gene expression data for the 43 CP patients with an additive genetic model of SERPINC1 identified 1902 differential genes at FDR <0.05. The 1120 genes up-regulated by the B allele were highly enriched in the Reactome G-protein coupled receptor pathway (Padjusted < 8×10−10). Several genes involved in smooth muscle contraction, regulation of blood pressure, and angiogenesis were up-regulated by the putative B allele, for example, HTR5A (serotonin receptor 5A), TAC3 (tachykinin 3), ADRA1D (adrenergic alpha-1D- receptor), BDKRB1 (bradykinin receptor B1), BDKRB2 (bradykinin receptor B1), EDN2 (endothelin 2), PTGER1 (prostaglandin E receptor 1), PTGIR (prostaglandin I2 receptor), APLNR (apelin receptor), RAMP2 (receptor activity modifying protein 2), MYH6 (myosin heavy chain 6), MYH7 (myosin heavy chain 7), MYL2 (myosin light chain 2), MYLK2 (myosin light chain kinase 2), MYLK3 (myosin light chain kinase 3), ACE (angiotensin I converting enzyme 1), ATP2A1 (ATPase cardiac muscle fast twitch 1), ADCY4 (adenylate cyclase 4), and PRKAA2 (protein kinase AMP-activated alpha 2 catalytic subunit). On the other hand, genes whose malfunction has been associated with familial pulmonary hypertension, including BMPR2 (bone morphogenetic protein receptor, type II), SMAD5 (SMAD family member 5), and ACVR2A (activin A receptor, type IIA), were among the 782 genes down regulated by the B allele.These results suggest that alterations in SERPINC1 may be implicated in the development of elevated SPAP in patients with CP. Antithrombin III deficiency is a potential factor in chronic thromboembolic pulmonary hypertension, but our results suggest that the putative B polymorphism may have effects beyond the coagulation cascade. Whether this is due to the SERPINC1 polymorphism itself or to another locus in linkage disequilibrium will require our future planned studies, beginning with sequencing of SERPINC1 exon 7 and identification of the polymorphism. Disclosures:No relevant conflicts of interest to declare.

Systolic pulmonary artery pressure and echocardiographic measurements in patients with euthyroid Hashimoto’s thyroiditis

The aim of this study was to investigate systolic pulmonary artery pressure (SPAP) and echocardiographic findings in patients with euthyroid Hashimoto's thyroiditis (HT). Thirty (8 male, 22 female, mean age 47.4+/-10.5 yr) consecutive patients with euthyroid HT and 30 (9 male, 21 female, mean age 46.4+/-10.7 yr) healthy controls were included in the study. Transthoracic echocardiography was performed for all patients and levels of thyroid hormones, thyroid autoantibodies, glucose, insulin, urea, and creatinine were compared. There were no significant differences in sex, age, body mass index, serum free T4, serum TSH, lipid profiles between patients and controls. Mean SPAP in patients with euthyroid HT were significantly higher than in controls (31.6+/-5.0 vs 25.6+/-4.5 mmHg, p=0.005). Late diastolic transmitral velocity and isovolumic relaxation time were also significantly higher in patients in comparison to controls. In addition, euthyroid HT patients with tricuspid or mitral regurgitation had a higher grade. Correlation between SPAP and antithyroid antibodies and TSH, however, was not significant in this population. Pulmonary arterial pressure is higher in patients with euthyroid HT. There may be a relationship between elevated pulmonary arterial pressure and autoimmune thyroid disease independent from thyroid function status. However, further investigations are needed to determine the exact mechanism of association between autoimmune thyroid diseases and pulmonary hypertension.

Accuracy of Doppler-Estimated Pulmonary Vascular Resistance in Patients Before Liver Transplantation

The hyperdynamic circulation associated with cirrhosis is typically characterized by high cardiac output and low systemic and pulmonary vascular resistance (PVR). Approximately 4% of cirrhotic patients develop portopulmonary hypertension, which is an important predictor of hemodynamic instability after orthotopic liver transplantation. Doppler estimation of pulmonary artery systolic pressure (PASP) is used as a screening test for the presence of portopulmonary hypertension. We tested the accuracy of a noninvasive measurement of PVR (ratio of peak tricuspid regurgitant velocity [TRV] to right ventricular outflow tract velocity time integral [VTI RVOT]) to detect increased PVR in a population before liver transplantation. We compared test characteristics of the TRV/VTI RVOT ratio to echocardiographically derived PASP for detection of invasively measured PVR >1.5 Wood units. There was no significant correlation between Doppler-derived PASP and invasively measured PVR. There was a moderate and significant correlation between TRV/VTI RVOT ratio and invasively measured PVR. Compared with Doppler-derived PASP, the TRV/VTI RVOT ratio was a more accurate test for PVR >1.5 Wood units. Using a cut-off value of TRV/VTI RVOT >0.12, the sensitivity and negative predictive value for PVR >1.5 Wood units were 100%. In conclusion, the TRV/VTI RVOT ratio is a more accurate screening test for the presence of portopulmonary hypertension than PASP in patients undergoing orthotopic liver transplantation. Routine use of this ratio may decrease the need for invasive hemodynamic assessment in this patient population.

Pulmonary Dead Space Fraction and Pulmonary Artery Systolic Pressure as Early Predictors of Clinical Outcome in Acute Lung Injury

The primary objective of this study was to test whether an elevated systolic pulmonary artery (PA) pressure or an elevated pulmonary dead space fraction (Vd/Vt) in early acute lung injury (ALI) is associated with poor clinical outcomes in the era of lung-protective ventilation. Prospective observational cohort study. ICUs of a university hospital. Forty-two patients with ALI receiving mechanical ventilation. PA pressure was measured noninvasively using transthoracic echocardiography. Vd/Vt was measured by volumetric capnography (NICO Cardiopulmonary Management System; Novametrix; Wallingford, CT). There was no difference in the mean systolic PA pressure in patients who died compared to those who survived (43 +/- 9 mm Hg vs 41 +/- 9 mm Hg, p = 0.54) [mean +/- SD]. In contrast to the PA systolic pressure, Vd/Vt was significantly higher in patients who died compared to those who survived (0.61 +/- 0.09 vs 0.53 +/- 0.10, p = 0.02). Similarly, Vd/Vt was higher in patients with < 7 ventilator-free days during the first 28 days after enrollment compared to those with > 7 ventilator-free days (0.61 +/- 0.08 vs 0.52 +/- 0.11, p = 0.008). In the era of lung-protective ventilation, systolic PA pressure early in the course of ALI is elevated but not predictive of outcome. However, elevated Vd/Vt in early ALI is associated with increased mortality and with fewer ventilator-free days.

Tissue Doppler Evaluation of Tricuspid Annulus for Estimation of Pulmonary Artery Pressure in Patients with COPD

Because transthoracic echocardiography is an inexpensive, easy, and reproducible method, it is the most commonly used noninvasive diagnostic tool to determine pulmonary artery pressure (PAP). Tissue Doppler imaging (TDI) emerged as a new echocardiographic method that can be applied in various clinical conditions. In our study we aimed to evaluate the relationship between tricuspid lateral annulus TDI parameters and pulmonary artery systolic pressure (PASP) as estimated by continuous wave Doppler in patients with chronic obstructive pulmonary disease (COPD). A total of 51 (42 men, mean age: 62.3 +/- 8.2 years) patients with clinically stable COPD were included in the study. The tricuspid annular systolic myocardial velocity (Sm), velocity time integral of Sm (SmVTI), early (Em) and late (Am) peak diastolic myocardial velocities, and myocardial isovolumic relaxation time (IVRTm) were acquired as well as two-dimensional (2-D) and conventional Doppler data. When compared with values of patients without pulmonary hypertension (PHT), Sm, SmVTI, Em, and Em/Am values were found to be lower and IVRTm values higher in patients with PHT. When all the patients were analyzed, there was a significant negative correlation between PASP and Sm and SmVTI (r = -0.82, p < 0.001 and r = -0.84, p < 0.001, respectively). Sm velocity < or = 12 cm/s had a sensitivity of 85% and a specificity of 93.3% for predicting PASP > 40 mmHg. SmVTI < or = 2.5 cm had a sensitivity of 85.7% and a specificity of 90% for detecting PHT. In our study, there was significant negative correlation between tricuspid lateral annular Sm and SmVTI values and PASP in patients with stable COPD irrespective of the presence of PHT. Tricuspid annular Sm and SmVTI had very good level sensitivity and specificity for predicting PHT. In conclusion, it might be suggested that in cases where noninvasive PASP measurement is not possible, TDI can be used as an alternative and reliable method to assess PAP.

The usefulness of a 10% air-10% blood-80% saline mixture for contrast echocardiography: Doppler measurement of pulmonary artery systolic pressure

ObjectivesWe assessed an air-blood-saline mixture for Doppler measurement of pulmonary artery systolic pressure (PASP) and the mechanism of enhancement of the Doppler signal by this mixture. BackgroundUnderestimation of PASP by Doppler echocardiography occurs with inadequate continuous wave (CW) signals of tricuspid regurgitation (TR). MethodsWe assessed in vitro the diameter and concentration of microbubbles of agitated air-saline mixture, air-blood-saline mixture and 10% air-10% plasma-80% saline mixture immediately, 5, 10 and 20 s after agitation. In 20 patients, PASP was estimated by Swan-Ganz catheter and CW Doppler of TR: 1) without contrast injection; 2) with intravenous injection of 10% air-90% saline; and 3) 10% blood-10% air-80% saline mixture. ResultsCompared to air-saline, addition of blood or plasma to the air-saline solution significantly increased the concentration of microbubbles (p < 0.001). The air-blood-saline (26.7 ± 7.2 μ) and air-plasma-saline mixture (25.3 ± 7.4 μ) had smaller microbubbles than air-saline mixture (31.6 ± 8.2 μ) (p < 0.001). The correlation between Doppler- and catheter-measured PASP at baseline (r = 0.64) improved with agitated air-saline (r = 0.86). With the air-blood-saline mixture, the correlation further improved (r = 0.92) and the best limits of agreement were obtained. ConclusionsThe combination of the patient’s own blood is a method of making a sterile solution of numerous small microbubbles for injection into the right-sided cardiac chambers. Clinically, the air-blood-saline mixture is easily prepared at bedside and is superior to the air-saline mixture in assessing PASP in patients with inadequate CW Doppler signals.