Pulmonary Circulation In Patients Research Articles

Prognostic value of novel cardiovascular magnetic resonance transit times beyond the pulmonary circulation in patients with ventricular dysfunction.

To evaluate the prognostic value of transit time (TT) assessment in the systemic circulation and organ perfusion in patients with ventricular dysfunction (VD). The primary endpoint was defined as death, heart failure admission, or ventricular arrhythmias, and the secondary endpoint was worsening renal function. A retrospective study on 139 patients who underwent cardiac magnetic resonance for VD evaluation and 50 controls. TT was measured as peak-to-peak time in signal intensity over time curves obtained at different stages of circulation (right cavities, left cavities, aorta, and peripheral organs) from first-pass perfusion images. Outcomes were monitored over a median follow-up of 15 months. A total of 139 patients were included (84% male, age 63 [57-70] years). Patients exhibited significantly prolonged TT compared to controls, with in-patients showing longer times than outpatients. Among the 29 patients reaching the primary endpoint, both PTT and STT were significantly prolonged (PTT: 9.75 s vs 13.4 s, p < 0.01; STT: 4.77 s vs 7.00 s, p < 0.01). Concurrent prolongation of PTT (> 10 s) and STT (> 5 s) was associated with a higher event probability (42.3%), compared to isolated abnormalities (6.3% for PTT, 6.7% for STT). Multivariate analysis revealed that combined PTT and STT alteration independently predicted the combined endpoint (HR IC 95%: 8.685 (2.415-31.236), p = 0.001). Prolonged RPT was independently associated with renal function deterioration (OR IC 95%: 1.129 (1.015-1.256), p = 0.024). Evaluation of TT beyond pulmonary circulation provides prognostic insights into VD. Simultaneous assessment of PTT and STT enhances specificity compared to isolated PTT evaluation, predicting combined adverse events. RPT is independently associated with renal impairment. For the first time, it is described that transit time can be evaluated in systemic circulation and in peripheral organs and that this assessment can be easily made from conventional CMR perfusion images and holds significant prognostic value. Pulmonary transit time is a valuable hemodynamic parameter; systemic transit time may also be valuable. Transit time can be measured in the systemic circulation, and is longer in patients with ventricular dysfunction. Systemic transit time assessed by magnetic resonance imaging identifies patients with ventricular dysfunction who will experience events during follow-up.

Right Ventricular Function and Pulmonary Coupling in Patients With Heart Failure and Preserved Ejection Fraction

BackgroundLimited data exist to characterize novel measures of right ventricular (RV) function and the coupling to pulmonary circulation in patients with heart failure and preserved left ventricular ejection fraction (HFpEF). ObjectivesThis study sought to assess the clinical implications of RV function, the association with N-terminal pro–B-type natriuretic peptide, and the risk for adverse events among patients with HFpEF. MethodsThis study analyzed measures of RV function by assessing absolute RV free wall longitudinal strain (RVFWLS) and its ratio to estimated pulmonary artery systolic pressure (PASP) (RVFWLS/PASP ratio) in 528 patients (mean age 74 ± 8 years, 56% female) with adequate echocardiographic images quality enrolled in the PARAGON-HF trial. Associations with baseline N-terminal pro–B-type natriuretic peptide and with total HF hospitalizations and cardiovascular death were assessed, after accounting for confounders. ResultsOverall, 311 patients (58%) had evidence of RV dysfunction, defined as absolute RVFWLS <20%, and among the 388 patients (73%) with normal tricuspid annular planar systolic excursion and RV fractional area change, more than one-half showed impaired RV function. Lower values of RVFWLS and RVFWLS/PASP ratios were significantly associated with higher circulating N-terminal pro–B-type natriuretic peptide. With a median follow-up of 2.8 years, there were 277 total HF hospitalizations and cardiovascular deaths. Both absolute RVFWLS (HR: 1.39; 95% CI: 1.05-1.83; P = 0.018) and RVFWLS/PASP ratio (HR: 1.43; 95% CI: 1.13-1.80; P = 0.002) were significantly associated with the composite outcome. Treatment effect of sacubitril/valsartan was not modified by measures of RV function. ConclusionsWorsening RV function and its ratio to pulmonary pressure is common and significantly associated with an increased risk of HF hospitalizations and cardiovascular death in patients with HFpEF. (Efficacy and Safety of LCZ696 Compared to Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction [PARAGON-HF]; NCT01920711)

Coil embolization of a pulmonary artery-bronchial fistula associated with intra parenchymal pseudoaneurysm, endovascular approach, and bronchoscopy monitoring – A case report

A 62-year-old man with a heavy background of the right upper lobe squamous cell carcinoma was admitted with massive hemoptysis. Computerized tomography (CT) showed a large right upper lobe lesion with infiltration of mediastinum and airways. A right pulmonary artery pseudoaneurysm slightly bulging into the right main bronchus was seen, suspicious for a pulmonary artery bronchial fistula. A combined endotracheal and angiographic approach was done. The right pulmonary artery angiogram showed a now occluded neck to the pseudoaneurysm which was selectively cannulated. Framing and packing coils were deployed. Contrast was endoscopically noted without bronchial bleeding. As the coils were entering the lung parenchyma, packing back to the neck was done carefully. No new bleeding was noted. A bronchial stent was inserted 6 weeks later and one coil protruding into the bronchus was seen. A 3 month CT follow-up did not show any residual pseudoaneurysm. Patient died 3 months after initial procedure of his progressive illness. Only three cases of endovascular management of bronchial-pulmonary artery fistula reported with different techniques including pulmonary artery stenting. Our case is the only one reported treated with only coil embolization. Limited data are available regarding the risk of pulmonary embolism after stenting. Anticoagulation required after stenting increases the risk of bleeding in patients with severe hemoptysis. Management with coils only facilitates further management. This preserves pulmonary circulation in patients with already compromised respiratory function. Coil only embolization of uncommon pulmonary artery bronchial fistula is feasible and facilitates further management as it does not require anticoagulation in patient with recurrent bleeding.

Radiation diagnostics of the state of ventilation and pulmonary circulation in patients with COPD

COPD is one of the most common human diseases. WHO experts predict an increase in economic damage from COPD by 2020 and claim that they will rank first among respiratory diseases and third among all causes of death. In Ukraine, about 3 million people, or at least 7% of the population, suffer from COPD. The purpose of the study is to analyze the available literature sources to establish the current state of the problem of radiological diagnosis of COPD, to identify problematic issues. Based on the analysis of literature data, it can be concluded that for a comprehensive examination of patients with COPD or suspected COPD, and assessment of external respiration - clinical examination and spirometry, especially in the early stages of the disease - is not enough. It is believed that in the initial stages of COPD, when spirometry and clinical data do not reveal abnormalities, radiological diagnosis is more sensitive than functional tests. Among the modern methods of radiological diagnosis of lung diseases - the method of CT today is the most sensitive and specific method of detecting pathological changes in the lung parenchyma and respiratory tract, it is available and widely used in everyday practice. Also a promising area is the use of functional CT (inspiratory-expiratory CT) - which should improve the assessment of respiratory function, including early detection of patients with COPD, which will promote the in time start of specific treatment, reduce episodes of exacerbations during the disease, assess the dynamics of the pathological process and the effectiveness of treatment, as well as improving the prognosis of work and life expectancy of patients. However, given the lack of unifying works on the study of this method, further studies of the capabilities of computed tomography in the diagnosis of signs of dysfunction of external respiration in patients with COPD are required. First of all, further research is required on the distribution of air trap zones, especially in patients with emphysema, it is desirable that these future studies are not based only on the principle of visual assessment in the form of exclusion / confirmation of air trap zones.

Fontan Circulation Might be Associated with Peripartum Cardiomyopathy: A Review of Mechanistic and Clinical Aspects.

Fontan operation has been defined as a palliative surgery connecting systemic venous return and pulmonary circulation in patients with certain forms of complex congenital heart disease (CHD). Fortunately, it has improved overall survival and chance of successful pregnancies among these patients. However, Fontan circulation (FC), as a potential trade-off, might be associated with specific late or post-gestational complications, including peripartum cardiomyopathy (PPCM) largely through its adverse effects on the placenta and inflammation-oxidation stress. Importantly, diagnosis of superimposed PPCM in women with FC might be a diagnostic challenge, requiring a high index of suspicion. Accordingly, the present paper aims to highlight the potential association of FC with PPCM evolution largely based on certain mechanistic and clinical perspectives.

Noninvasive Assessment of Right Ventricle Function and Pulmonary Artery Pressure Using Transthoracic Echocardiography in Women With Pre-Eclampsia: An Exploratory Study.

Background and objectivePre-eclampsia (PEC) is associated with the release of anti-angiogenic factors that are incriminated in raising systemic and pulmonary vascular resistance (PVR). Compared to the left heart and systemic circulation, much less attention has been paid to the right heart and pulmonary circulation in patients with PEC. We used transthoracic echocardiography (TTE) to estimate pulmonary artery (PA) pressure and right ventricular (RV) function in women with PEC.Materials and methodsWe conducted a case-control study at a tertiary care academic center. Ten early PEC (<34-week gestation) and nine late PEC (≥34-week gestation) patients with 11 early and 10 late gestational age-matched controls were enrolled. Two-dimensional TTE was performed on all patients. The estimated mean PA pressure (eMPAP) was calculated based on PA acceleration time (PAAT). PVR was estimated from eMPAP and RV cardiac output (RV CO). RV myocardial performance index (RV MPI), tricuspid annular plane systolic excursion (TAPSE), tissue tricuspid annular displacement (TTAD), and lateral tricuspid annular tissue peak systolic velocity (S’) were measured.ResultsCompared to early controls, in early PEC, the eMPAP and estimated PVR (ePVR) were elevated, PAAT was reduced, RV MPI was increased, TTAD was reduced, and TAPSE and TV S’ were unchanged. Compared to late controls, in late PEC, the eMPAP and ePVR were elevated, PAAT was reduced, and RV MPI was increased, while TAPSE, TTAD, and TV S’ were unchanged.ConclusionsIn a sample of women with PEC, early PEC was found to be associated with increased eMPAP and ePVR and subclinical decrement of RV function as assessed by TTE. TTE may be a useful noninvasive screening tool for early detection of pulmonary hypertension and RV dysfunction in PEC. An adequately powered longitudinal study is needed to determine the implications of these findings on long-term outcomes.

Angiographic Anatomy of Major Aortopulmonary Collateral Arteries and Association With Early Surgical Outcomes in Tetralogy of Fallot.

BackgroundDue in part to the heterogeneity of the pulmonary circulation in patients with tetralogy of Fallot and major aortopulmonary collateral arteries (MAPCAs), research on this condition has focused on relatively basic anatomic characteristics. We aimed to detail pulmonary artery (PA) and MAPCA anatomy in a large group of infants, assess relationships between anatomy and early surgical outcomes, and consider systems for classifying MAPCAs.Methods and ResultsAll infants ( <1 year of age) undergoing first cardiac surgery for tetralogy of Fallot/MAPCAs from 2001 to 2019 at Stanford University were identified. Preoperative angiograms delineating supply to all 18 pulmonary segments were reviewed for details of each MAPCA and the arborization and size of central PAs. We studied 276 patients with 1068 MAPCAs and the following PA patterns: 152 (55%) incompletely arborizing PAs, 48 (17%) normally arborizing PAs, 45 (16%) absent PAs, and 31 (11%) unilateral MAPCAs. There was extensive anatomic variability, but no difference in early outcomes according to PA arborization or the predominance of PAs or MAPCAs. Patients with low total MAPCA and/or PA cross‐sectional area were less likely to undergo complete repair.ConclusionsMAPCA anatomy is highly variable and essentially unique for each patient. Though each pulmonary segment can be supplied by a MAPCA, central PA, or both, all anatomic combinations are similarly conducive to a good repair. Total cross‐sectional area of central PA and MAPCA material is an important driver of outcome. We elucidate a number of novel associations between anatomic features, but the extreme variability of the pulmonary circulation makes a granular tetralogy of Fallot/MAPCA classification system unrealistic.

Adult congenital heart disease with pulmonary arterial hypertension: mechanisms and management.

Adult congenital heart disease (ACHD) encompasses a range of structural cardiac abnormalities present before birth attributable to abnormal foetal cardiac development. The pulmonary circulation of patients with ACHD and intracardiac or extracardiac defects is often exposed to increased blood flow and occasionally to systemic pressures. Depending on the location and magnitude of the defect as well as the time of surgical correction, the patient with ACHD is at risk of developing pulmonary arterial hypertension (PAH), which dramatically increases morbidity and mortality. It is encouraging that therapies applied in idiopathic PAH and significantly improve outcome are also effective in ACHD-related PAH (ACHD-PAH). This review summarizes the challenges encountered in the diagnosis and management of ACHD-PAH.

Remodeling of the Pulmonary Circulation in Patients with Viral Liver Cirrhosis

Aim. To study some structural and functional indicators of the right heart, as well as the effect of antiviral therapy on these parameters in patients with viral liver cirrhosis (VLC). Material and methods . Patients with VLC (n=98; mean age 40.6 years, disease duration 3.9 years) were examined. The patients were divided into 2 groups: without ascites (1 st group; n=59) and with ascites (2nd group; n=39). The control group included 22 healthy volunteers. All participants had standard and tissue Doppler echocardiography. Results. The thickness of the anterior wall of the right ventricle (RV) was increased in the 1 st and 2nd groups compared with the control (by 20% and 27%, respectively), as well as the volume index of the left atrium. The decrease in the rate of early RV filling (E) and the E/A ratio was found: in the 1st group - 0.9 [0.8;1.31 ], in the 2nd group - 0.8 [0.78; 1.2] with a control value of 1.6 [1.2;1.94] (p<0.001). Patients of the 2nd group compared with the control group and patients of the 1st group showed an increase in myocardial productivity index (by 35% and 35%, respectively) and time of isovolumetric RV filling (by 32% and 29%, respectively). RV dilatation, an increase in the index of the volume of the left atrium, dilatation of the pulmonary artery and an increase in systolic pressure in the pulmonary artery (in 2nd group - 36 [26;39] mm Hg, in 1 st group - 28 [1 9;32] mm Hg, in control - 24 [11 ;26] mm Hg; p<0.001) were also found in the 2nd group. The decrease in the maximum systolic velocity of the fibrous ring of the mitral valve in comparison with the reference level was found in 21 (36%) VLC patients with ascites and in 6 (1 6%) without ascites. The use of antiviral therapy led to a decrease in the left atrial volume index and systolic pressure in the pulmonary artery. A correlation was found between pressure level in the pulmonary artery and the Tei index (r=0.74; p<0.001), the systolic velocity of movement of the fibrous ring of the mitral valve (r=0.54; p<0.001), the diastolic velocity Em (r=0.72; p<0.001), blood flow velocity in the own liver artery (r=0.63; p<0.001) as well as the maximum systolic velocity in the portal vein (r=0.61; p<0.001). Conclusion. Structural and functional changes in the right heart and left atrium were found in VLC patients. These disorders depend on the degree of decompensation of the hepatic process and are more pronounced in patients with ascites. Antiviral therapy had a positive effect on some morpho-functional parameters of the heart. The found correlations indicate the effect of hepatic-portal blood flow on cardiohemodynamic disorders.

Accuracy of Doppler echocardiography in the hemodynamic assessment of pulmonary circulation in patients with systemic sclerosis

PurposePulmonary hypertension (PH) is an ominous complication in systemic sclerosis patients (SSc) and echocardiography is a screening tool for its detection. The goal of this study was to assess the reliability of resting and exercise echo Doppler parameters with data obtained by right heart catheterization (RHC). Material and methodsWe included 91 patients (84 F, 53.3 ± 15.2 years) with SSc. Transthoracic echocardiography followed by exercise Doppler-echocardiography (EDE) were performed. A positive EDE was defined as a ≥20 mmHg increase in tricuspid regurgitation peak gradient (TRPG). RHC with exercise was performed in positive EDE patients and/or in subjects with resting TRPG > 31 mmHg. ResultsFinally, RHC was performed in 20 patients. The correlation for the echocardiography and invasive measurement of systolic (sPAP) and mean (mPAP) pulmonary artery pressure was r = 0.66 (p = 0.001) and r = 0.7 (p = 0.001), respectively. We also found significant correlation between echocardiography and invasive measurement of exercise sPAP r = 0.68 (p = 0.001) and exercise mPAP r = 0.67 (p = 0.002). There was a correlation between pulmonary vascular resistance (PVR) assessed by echocardiography and measured by RHC r = 0.49, p = 0.027. The equation derived within our population was: PVR by echocardiography = 9.6*TRV/TVIRVOT+0.068. We also performed ROC analysis to predict PVR > 2 WU. Our results highlight that sPAP has the highest AUC (0.802, 95% CI 0.585–1). ConclusionDoppler resting and exercise echocardiography may provide a reliable, noninvasive method for determining resting and exercise sPAP, mPAP, and PVR in SSc patients, although it may underestimate or overestimate these values in some individuals. Doppler echocardiography does not replace RHC for definite hemodynamic assessment of suspected PH.

CONDITION OF HEMODYNAMICS IN THE PULMONARY CIRCULATION OF PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) CONCURRENT WITH METABOLIC SYNDROME WITH HYPERTROPHY AND ATROPHY OF THE MYOCARDIUM

In recent years, COPD is observed as not an isolated, but an associated pathology, in particular, concurrent with metabolic syndrome. The aim of the research is to identify the differences in changes of the rheopulmonography parameters (RPG) depending on the presence of hypertrophy or atrophy of the right ventricular myocardium in patients with COPD concurrent with metabolic syndrome. We studied changes in rheopulmonography (RPG) in 145 patients with chronic obstructive pulmonary disease (COPD) concurrent with metabolic syndrome. We detected precapillary hypertension of the pulmonary circulation in patients with right ventricular myocardial hypertrophy: anacrotism serration; flattened peak of the systolic wave; decreased Vcp; high placement of incisura; horizontal course of catacrotism; decreased amplitude of the systolic wave (in this case, due to a greater increase in the resistance of the blood flow in the pulmonary vessels than the decreased impact volume of the right ventricle); prolonged Q-a (in this group of patients, it depends more on hypertension of the pulmonary circulation than on the reduction of contractile function of the myocardium). In atrophy of the right ventricular myocardium, the following changes in the RPG were revealed: decreased systolic wave at its dramatic rise; prolonged Q-a (in this case, due to the weakened heart contraction); Vmax reduction (it reflects the reduction of myocardial contractility); in hypertrophy of the myocardium, Vcp., unlike RPG, does not decrease, which is explained by the decrease in the pressure of the pulmonary circulation. We believe that these changes in RPG allow differentiating hypertrophy and right ventricular myocardial atrophy along with established diagnostic criteria, and can be used as markers for the diagnosis and treatment of COPD concurrent with metabolic syndrome.

Mechanisms for compensation of pulmonary hypertension in chronic obstructive pulmonary disease

Despite multiple risk factors of pulmonary hypertension (PH) are known, the true incidence of PH remains undefined in patients with severe bronchial obstruction. Objective. The aim of the study was to identify mechanisms of compensation of the increase in pulmonary artery pressure and to determine their prognostic role. Design and methods. The results of a complex clinical and radiological studies of 200 patients with COPD II (B), and 207 patients with COPD III (D), and COPD IV (D), (GOLD 2017) were analyzed. A comparative analysis of changesin pulmonary circulation in patients (n = 8) with primary PH was performed. Male subjects predominated among the examined patients with COPD (90,6 %), the average age of patients with COPD II was 54,0 ± 6,3 years, in patients with COPD III–IV stages — 63,9 ± 5,8 years. The average age of patients with primary PH was 38,7 ± 7,9 years. The following diagnostic methods were performed: single-photon emission computer tomography, multidetector computed tomography, external respiration function, echocardiography. Results. In patients with COPD II (B), both ventilation and perfusion disorders developed, the diffusion capacity of the lungs decreased and the intrapulmonary shunting of the blood occurred. Despite overall decrease in pulmonary perfusion, local zones of increased blood flow appeared in the unchanged pulmonary parenchyma. This compensation mechanism was observed in 54,6 % of patients and was accompanied by partial decrease of pressure in the pulmonary artery to values close to normal. In severe COPD, 44,4 % patients developed hyperperfusion zones, but without any compensatory effect. In such cases, pressure reduction in the pulmonary artery system was promoted by the development of blood bypass, which was observed only in 10 % cases. Conclusions. We can speculate that the mechanism of compensation of increased pressure in the pulmonary artery and reduction of PaO2 results from the development of local zones of increased blood flow in the unchanged pulmonary parenchyma, but in severe bronchial obstructive pathology it causes the formation of blood shunting.

Left atrial dilatation in systolic heart failure: a marker of poor prognosis, not just a buffer between the left ventricle and pulmonary circulation.

The relation between systolic pulmonary pressure (sPAP) and left atrium in patients with heart failure (HF) is unclear. Diastolic dysfunction, expressed as restrictive mitral filling pattern (RMP), and functional mitral regurgitation (FMR) are associated with both LA enlargement and increased sPAP. We aimed to evaluate whether atrial dilation might modulate the consequences of RMP and FMR on the pulmonary circulation of patients with HF with reduced ejection fraction (HFrEF). 1256 HFrEF patients were retrospectively recruited in four Italian centers. Left ventricular (LVD) and atrial (LAD) diameters were measure by m-mode, and EF were measured. RMP was defined as E-wave deceleration time lower than 140ms. FMR was quantitatively measured. sPAP was evaluated based on maximal tricuspid regurgitant velocity and estimated right atrial pressure. Final study population was formed by 1005 patients because of unavailability of sPAP in 252 patients. Mean EF was 33±3, 35% had RMP, 67% had mild, and 26% moderate-to-severe FMR. 69% of patients had increased sPAP. A significant association was observed between sPAP and EF, RMP, FMR, and LAD (p<0.0001 for all). At multivariate analysis, LAD was positively associated with sPAP (p<0.0001) independently of EF, RMP, and FMR. Analogously, LAD (p<0.05) was associated with more severe symptoms and worse prognosis after adjustment for LV function and FMR. LA dilation was positively associated with sPAP independently of EF, RMP, and FMR. This highlights that LA size should be considered a marker of the severity of the disease.

Effect of arginine vasopressin on systemic and pulmonary arterial pressure in a patient with pulmonary hypertension secondary to pulmonary emphysema: a case report

Although data from several studies support the use of arginine vasopressin (AVP) for the treatment of hypotension concomitant with pulmonary hypertension (PH) in the cardiac surgery setting, to our knowledge, no previous studies have reported the effect of AVP on the systemic and pulmonary circulation of patients with PH secondary to lung diseases. In this report, we present the hemodynamic responses to bolus administrations of AVP and noradrenaline in a patient with PH secondary to pulmonary emphysema. The patient showed low systemic vascular resistance hypotension during off-pump single-lung transplantation. The bolus administration of AVP (0.5 U) increased systemic arterial pressure by 35.2%, with a minimal change in pulmonary arterial pressure, resulting in a significant decrease in the pulmonary arterial pressure/systemic arterial pressure ratio. In contrast, the bolus administration of noradrenaline (10 or 20 μg) increased both systemic and pulmonary arterial pressures by 14.8 and 6.7%, respectively. In summary, the bolus administration of AVP effectively increased systemic arterial pressure with a minimal effect on pulmonary arterial pressure in a patient with PH secondary to pulmonary emphysema. This case highlights the potential utility of AVP to treat low systemic vascular resistance hypotension in patients with PH secondary to lung diseases.

Ранняя ультразвуковая диагностика венозного застоя в малом круге кровообращения у пациентов с хронической сердечной недостаточностью

Ранняя ультразвуковая диагностика венозного застоя в малом круге кровообращения у пациентов с хронической сердечной недостаточностью

Macrophage migration inhibitory factor as a novel biomarker of portopulmonary hypertension.

Portopulmonary hypertension (POPH) is a poorly understood complication of liver disease associated with significant morbidity and mortality. We sought to identify novel biomarkers of POPH disease presence and severity. We performed a prospective, multicenter, case-control study involving patients with liver disease undergoing right heart catheterization. POPH cases were defined as a mean pulmonary arterial pressure (mPAP) ≥25 mmHg and pulmonary vascular resistance (PVR) >240 dynes˙s˙cm-5. Plasma samples were collected from the systemic and pulmonary circulation, and antibody microarray was used to identify biomarkers. Characterization and validation of a candidate cytokine, macrophage migration inhibitory factor (MIF), was performed using enzyme-linked immunosorbent assay. Continuous variables were compared using a Mann-Whitney U test and correlated with disease severity using Spearman correlation. MIF levels were elevated in both the systemic and pulmonary circulation in patients with POPH compared with controls (median MIF level [interquartile range] in systemic circulation: 46.68 ng/mL [32.31-76.04] vs. 31.19 ng/mL [26.92-42.17], P = 0.009; in pulmonary circulation: 49.59 ng/mL [35.90-108.80] vs. 37.78 [21.78-45.53], P = 0.002). In patients with POPH, MIF levels were positively correlated with PVR (r = 0.58, P = 0.006) and inversely correlated with cardiac output (r = -0.57, P = 0.007). MIF >60 ng/mL or tricuspid regurgitation gradient >50 mmHg had a 92% sensitivity and specificity for the diagnosis of POPH, with a positive predictive value of 86% and a negative predictive value of 96%. MIF is a promising novel biomarker of POPH disease presence and severity in patients with liver disease and portal hypertension.

Pulmonary artery dilation indicates severe obstructive sleep apnea in patients with resistant hypertension: the Resist-POL Study.

INTRODUCTION The effect of obstructive sleep apnea (OSA) on right ventricular (RV) function and pulmonary circulation parameters is unclear. OBJECTIVES The aim of this study was to determine whether newly diagnosed OSA and its severity has any impact on RV performance and echocardiographic parameters of pulmonary circulation in patients with true resistant hypertension. PATIENTS AND METHODS The study included 155 patients (93 men and 62 women; mean age, 47.5 ±10 years). The apnea-hypopnea index (AHI), end-diastolic and end-systolic area of the right ventricle, main pulmonary artery diameter (MPAd) at diastole, acceleration time (AccT), tricuspid annular systolic velocity wave, and tricuspid annular plane systolic excursion were evaluated. RESULTS Patients were divided into 4 groups: without OSA (AHI <5; n = 43), with mild OSA (AHI = 5-15; n = 45), moderate OSA (AHI = 15-30; n = 27), and severe OSA (AHI >30; n = 40). There were no differences in RV systolic function between the groups. Patients with severe OSA had a wider MPAd (26.0 ±2.6 vs 23.1 ±3.7 mm; P <0.0001) and shorter AccT (114.2 ±15.7 vs 133.4 ±22.1 ms; P <0.001) in comparison with patients without OSA. The cut-off for the best predictive value of severe OSA was an MPAd of 25 mm or higher with a sensitivity of 63.6% and specificity of 78.9%. The area under the receiver operating characteristic curve for severe OSA in relation to an MPAd of 25 mm or higher was 0.766 (95% confidence interval, 0.673-0.859; P <0.0001). Factors independently associated with an MPAd of 25 mm or higher were severe OSA and nighttime diastolic blood pressure levels. CONCLUSIONS Our study showed a relationship between pulmonary artery dilation and the presence of newly diagnosed severe OSA. Among the parameters studied, an MPAd of 25 mm or higher turned out to be the most useful parameter in identifying patients with severe OSA.

The potential role and limitations of echocardiography in acute respiratory distress syndrome.

Bedside use of Doppler echocardiography is being featured as a promising, clinically useful tool in assessing the pulmonary circulation in patients with acute respiratory distress syndrome (ARDS). The present review is aimed at summarizing the available evidence obtained with echocardiography on right ventricle (RV) function and pulmonary circulation in ARDS and to highlight the potential of this technique in clinical practice (only articles in English language were considered). According to the available evidence on echocardiographic findings, the following conclusions can be drawn: (a) echocardiography (transthoracic and transesophageal) has a growing role in the management ARDS patients mainly because of the strict interactions between the lung (and ventilation) and the RV and pulmonary circulation; (b) there may be a continuum of alterations in RV size and function and pulmonary circulation which may end in the development of acute cor pulmonale, probably paralleling ARDS disease severity; and (c) the detection of acute cor pulmonale should prompt intensivists to tailor their ventilatory strategy to the individual patient depending on the echocardiography findings. Bearing in mind the clinical role and growing importance of echocardiography in ARDS and the available evidence on this topic, we present a flow chart including the parameters to be measured and the timing of echo exams in ARDS patients. Despite the important progress that echocardiography has gained in the evaluation of patients with ARDS, several open questions remain and echocardiography still appears to be underused in these patients. A more systematic use of echocardiography (mainly through shared protocols) in ARDS could help intensivists to tailor the optimal treatment in individual patients as well as highlighting the limits and potential of this methodology in patients with ALI.

Changes in pulmonary circulation of patients with chronic obstructive pulmonary disease and idiopathic pulmonary fibrosis complicated by chronic respiratory failure

The aim of this study was to describe particularities of pulmonary circulation in patients with obstructive (chronic obstructive pulmonary disease (COPD)) or restrictive (idiopathic pulmonary fibrosis (IPF)) diseases and to study tendencies of pulmonary blood flow disorders in different pathological mechanisms of chronic respiratory failure (CRF). Methods . Results of image examination (multislice computed tomography, computed angiography, singlephoton emission computed tomography) were analyzed in 150 patients with severe stage 3–4 COPD (phenotype of emphyse ma) complicated by CRF or right heart failure and in 45 patients with IPF and lung «honeycombing». Results. Significant pulmonary circulation disorders were seen in patients with both obstructive and interstitial diseases complicated by CRF. These changes were caused by parenchyma remodeling, concomitant vascular lesions (pulmonary embolism, thrombosis in situ), cancer and persistent infectious inflammation. Conclusions. Timely detection of changes in pulmonary parenchyma and vessels allows adequate treatment, slowing progression of the disease and improving outcomes. In patients with mild to moderate COPD, therapeutic interventions could improve the reduced blood flow in ischemic areas of the lungs significantly more often than in IPF patients. Early treatment could prevent irreversible change in ischemic lung parenchyma which usually results in CRF development. Virtually, treatment has no effect on pulmonary circulation both in patients with obstructive and restrictive diseases with irreversible changes in pulmonary vessels.

Acute Effects of Rho-Kinase Inhibitor Fasudil on Pulmonary Arterial Hypertension in Patients With Congenital Heart Defects

We investigated the acute vasodilator effects of i.v. fasudil, a specific Rho-kinase inhibitor, on pulmonary circulation in patients with congenital heart defects (CHD) and severe pulmonary arterial hypertension (PAH). Thirty-five patients (34.23±12.10 years old) with CHD and severe PAH were consecutively enrolled. All patients underwent heart catheterization. At baseline and 30 min after initiation of i.v. fasudil, the following hemodynamic parameters were measured and calculated: right atrial pressure, pulmonary and systemic artery pressure (PAP and SAP), pulmonary and systemic vascular resistance, pulmonary-to-systemic blood pressure ratio (Pp/Ps), pulmonary-to-systemic blood flow ratio (Qp/Qs), cardiac index (CI) and artery oxygen saturation (SaO2). After fasudil treatment, marked decrease in mean PAP (mPAP), pulmonary vascular resistance (PVR), total pulmonary resistance, pulmonary-to-systemic vascular resistance ratio (Rp/Rs) and mean Pp/Ps (mPp/Ps) was found, while Qp/Qs increased significantly without affecting CI and SAP. mPAP, PVR, Rp/Rs and Qp/Qs tended to be improved more significantly in the post-tricuspid shunt group compared with the pre-tricuspid shunt group. Fasudil was well tolerated in patients with CHD and severe PAH, and significantly reduced PAP and PVR without affecting CI, SAP or SaO2.