Reduction In Systolic Pulmonary Artery Pressure Research Articles

Right ventricular to pulmonary artery coupling change after catheter ablation of atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Background Right ventricular (RV) to pulmonary artery (PA) coupling can be assessed using the ratio between tricuspid annular plane systolic excursion (TAPSE) and pulmonary arterial systolic pressure (PASP). Although its use has been widely adopted in clinical practice, less is known about its role in patients with atrial fibrillation (AF) and its change after catheter ablation. Purpose The aim of this study is to assess the changes and the clinical impact of RV-PA coupling in patients with AF who underwent catheter ablation. Methods This is a prospective study that enrolled patients undergoing catheter ablation for AF between March 2021 and September 2022 in three tertiary centers in Italy. We evaluated the changes in RV structure and function and TAPSE/PASP between baseline and the 3-month follow-up and their relation with AF relapse after procedure. Results A total of 135 patients were included (mean age 65.2 ± 9.1 years; 68% males, mean left ventricular ejection fraction [LVEF] 56.9 ± 7.9%). Patients in the lowest tertile (TAPSE/PASP < 0.67 mm/mmHg) were older, with and LVEF and LV global longitudinal strain (LVGLS). They also showed lower TAPSE, S’ wave at Tissue Doppler and RV global strain and higher PASP. In the overall population, after 3 months from the ablation procedure, we observed a significant increase of TAPSE (from 22.4 ± 4.1 to 24.0 ± 3.8, p < 0.001), a reduction of PASP (from 29.5 ± 6.6 to 27.9 ± 7.7, p = 0.030) and an increase in TAPSE/PASP from 0.81 ± 0.27 to 0.93 ± 0.29 (p < 0.001). The latter improved both in the patients who were in sinus rhythm (p = 0.031) and with AF (p = 0.003) at baseline. Compared to patients in the highest TAPSE/PASP tertile, those in the lowest one (TAPSE/PASP < 0.67 mm/mmHg) showed an increased risk of AF relapse after catheter ablation (OR 4.33, 95% confidence interval 1.25 – 14.96, p = 0.020). Moreover, the increase of TAPSE/PASP ratio during the follow-up period was associated with a reduced probability of AF relapse, after adjustment for covariates (OR 0.70, 95% confidence interval 0.49 – 0.99, p = 0.046). Conclusion In a multicenter cohort of patients with AF undergoing catheter ablation, a significant improvement of RV-PA coupling, assessed by the TAPSE/PASP ratio, has been observed, regardless of rhythm at admission. Moreover, TAPSE/PASP at baseline, and its change, may represent a useful parameter to predict AF relapse after the procedure.

P267 ASSOCIATION BETWEEN EARLY MODIFICATION OF LEFT ATRIAL VOLUME AND RIGHT VENTRICULAR FUNCTION AFTER TRANSCATHETER EDGE–TO–EDGE REPAIR FOR MITRAL REGURGITATION

Abstract Background Transcatheter edge–to–edge repair (TEER) for severe mitral regurgitation (MR) is a therapeutic option in patients at high surgical risk. Post procedural reverse remodeling of the left ventricle, the left atrium (LA) and the right ventricle (RV) was shown to be associated with reduced symptoms and mortality. Methods In this retrospective study we have assessed consecutive patients with functional severe MR from February 2015 to July 2022. LA and RV structure and function have been evaluated before the procedure and at the discharge and they were correlated with symptoms. Results In the present study, 52 patients (69% males, mean age 65.2±10.2 years and mean left ventricular ejection fraction 28.8±5.7%) were included. No differences about baseline clinical and echocardiographic characteristics were reported in the group of patients who had LA volume reduction (n=31) and those who did not (n=21). In the overall population we have detected a significant increase of tricuspid annular plane systolic excursion (TAPSE), S‘ wave at Tissue Doppler and the ratio between TAPSE and systolic pulmonary artery pressure (SPAP), together with a significant reduction of SPAP (respectively, p=0.034, p=0.003, p<0.001 and p<0.001). Compared to patients who did not have LA volume reduction, the other group showed a significant increase of TAPSE/SPAP (from 0.40±0.17 to 0.52±0.21 mm/mmHg, p=0.002) and S’ wave (from 8.7±1.6 to 9.4±1.7 cm/s, p=0.005) and a reduction of SPAP (from 50.3±14.3 to 38.9±11.5 mmHg, p<0.001). LA volume modification from baseline to the discharge was associated with the modifications of SPAP (B coefficient 0.55, 95% confidence interval 0.09, 1.02, p=0.022) and TAPSE/SPAP (B coefficient –4.06, 95% confidence interval –7.78, –0.33, p=0.033), even at the multivariable analysis (respectively, B coefficient 0.61, 95% confidence interval 0.07, 1.14, p = 0.027 e B coefficient –4.82, 95% confidence interval –9.43, –0.23, p=0.040). Lastly, NYHA class improved in the group of patients who had LA volume reduction (p=0.011). Conclusion In this retrospective study an association between early modification of LA volume and RV functional parameters has been described. After TEER, RV function improved, particularly in the group of patients who had LA volume reduction. The latter have shown an improvement of symptoms at the discharge.

Effects of Cardiac Contractility Modulation Therapy on Right Ventricular Function: An Echocardiographic Study

Background. Cardiac contractility modulation (CCM) is a novel device-based therapy for patients with heart failure with reduced and mild reduced ejection fraction (HFrEF/HFmrEF). CCM increases cardiac performance and produces reverse left ventricular remodeling, with improved symptoms, functional capacity, quality of life, and reduced HF-related hospitalizations. However, to date, little evidence is available on the effects of CCM on right ventricle (RV) function. Therefore, we analyzed the effects of CCM on RV systolic function and RV–pulmonary artery (PA) coupling. Methods. Twenty-one (65 ± 12.5 years) patients with NYHA class III, ejection fraction < 40% and QRS < 120 ms were assessed at baseline. During follow up, two patients had died, and so nineteen patients were evaluated six months after CCM therapy. Using echocardiography, tricuspid annular systolic excursion (TAPSE), myocardial systolic excursion velocity (RVs), and RV free-wall strain was measured. PA systolic pressure (PASP) was estimated from tricuspid regurgitation, adding the right atrial pressure estimation. The RV-PA coupling was calculated as TAPSE/PASP ratio. Results. After six months, patients who underwent CCM therapy showed a reduction in RV diameters and improved RV systolic function, as evidenced by the increase in both TAPSE (16.6 ± 4.2 mm vs. 18.5 ± 3.6 mm; p < 0.05), RVs (10.1 ± 1.8 cm/s vs. 11.3 ± 11.4 cm/s; p < 0.05), and RV strain (−13.7 ± 1.8% vs. −15.6 ± 2.3%; p < 0.05). CCM also determined a reduction in PASP (34.2 ± 9.8 mmHg vs. 28 ± 6.2 mmHg; p < 0.05) and an increase in the TAPSE/PASP ratio (0.52 ± 0.14 mm/mmHg vs. 0.66 ± 0.23 mm/mmHg; p < 0.05). Conclusions. At six months, CCM increases RV reverse remodeling and performance, reducing RV size and improving RV systolic function, PASP, and RV-PA coupling.

Comparison of Efficacy between Sildenafil Alone and Sildenafil with Milrinone for Treatment of Persistent Pulmonary Hypertension of the Newborn

Introduction: In persistent pulmonary hypertension of the newborn (PPHN), some neonates do not response to single pulmonary vasodilator drug, so recently combination therapy is being tried to decrease pulmonary artery systolic pressure (PASP). The aim of the study was to compare the efficacy of oral sildenafil alone with combination of oral sildenafil and milrinone in neonates suffering from PPHN. Methods: This RCT study was conducted in Dhaka Shishu (Children) Hospital, from July 2018 to June 2020. Sixty eight (68) term and near term neonates aged <10 days (34 cases in each group) with moderate to severe PPHN were taken. Monotherapy with oral sildenafil was given in group-A and combined therapy with oral sildenafil and i/v milrinone in Group-B. Serial echocardiography was done at before starting the therapy, at 3 days and at 5 days of treatment. Data regarding baseline characteristics, clinical features, PASP, PO2, Spo2, hospital stay, mortality and others investigations were recorded and analyzed with SPSS version-26. Results: Post treatment PASP was significantly reduced in group A (sildenafil) and group-B (sildenafil plus milrinone) (p<0.05). But in combination group PASP was more reduced than monotherapy group (p<0.05). Within the group, the oxygen saturation and PO2 significantly improved in both groups (p<0.05) but no significant difference was found in between two groups (p>0.05). Adrenaline infusion, hypotension and less hospital stay were significantly seen (P<0.05) in combination group. Conclusion: Combined therapy with oral sildenafil and milrinone are more effective than monotherapy with oral sildenafil in reduction of PASP. Both therapies are effective in improvement of oxygenation.

Computed tomography angiographic parameters of pulmonary artery as prognostic factors of residual pulmonary hypertension after pulmonary endarterectomy.

ObjectivesThis study aimed to retrospectively assess using computed tomography pulmonary angiography (CTPA) for predicting residual pulmonary hypertension (RPH) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary endarterectomy (PEA).MethodsWe retrospectively analyzed data of 131 patients with CTEPH who underwent PEA in our center (2008–2015). We measured several diameters of the pulmonary artery and thoracic aorta preoperatively. We evaluated the relationship between these measurements (and their indices) and signs of RPH represented by pulmonary artery systolic pressure (PASP) estimated by echocardiography.ResultsSignificant correlations were observed between the aortopulmonary index and prediction of any residual hypertension and moderate/severe hypertension 1 year after PEA, and any residual hypertension and severe hypertension 2 years after PEA. The aortopulmonary index was significantly related to a reduction in PASP 1 year after the operation. A lower aortopulmonary index (≤0.88 for the ascending aorta and ≤0.64 for the descending aorta) predicted lower RPH.ConclusionsPreoperative CTPA parameters can be used to assess the risk of RPH after PEA. The aortopulmonary index has significant predictive value for RPH and a reduction in PASP after PEA. Lower values of the aortopulmonary index suggest a better outcome after PEA.

Transcatheter pulmonary denervation in patients with left heart failure with reduced ejection fraction and combined precapillary and postcapillary pulmonary hypertension: A prospective single center experience.

The present study was a prospective, single-center, single-arm study to investigate the efficacy of transcatheter pulmonary artery denervation (TPADN) in patients with combined postcapillary and precapillary PH (Cpc-PH) associated with left heart failure with reduced ejection fraction (HF-rEF). Pulmonary hypertension (PH) in patients with left ventricular systolic dysfunction has a negative impact on outcome. The combination of pulmonary artery systolic pressure (PAPs) ≥60 mmHg, transpulmonary pressure gradient (TPG) ≥12 mmHg, nonreversible mean PAP, and pulmonary vascular resistance (PVR) ≥3.5 Wood Units was considered as too high risk for heart transplantation (HTx). The clinical efficacy endpoint was an improvement in 6-min walking test and the hemodynamic endpoints were changes in PAPs, PVR, and TPG between baseline and 6months. Circumferential radiofrequency applications were delivered around distal main, left and right pulmonary arteries. At each ablation point temperature was 45°C and energy 10W. TPADN was performed in 10 patients. At 6-month in 5 patients we observed reduction in PAP, PVR, TPG, and DPG and then 1 had successful HTx, 2 are on HTx waiting list, 2 received LVADs, 2 patients did not improve, and 3 patients died. TPADN may be beneficial in selected patients with HF-rEF and Cpc-PH.

Right ventricular function and its coupling with the pulmonary circulation in acute heart failure

Abstract Background The right ventricle (RV) is extremely sensitive to hemodynamic changes and increased impedance. In acute heart failure (AHF), the development of pulmonary venous congestion and the increase of left ventricular (LV) filling pressures favors pulmonary vascular adverse remodeling and ultimately RV dysfunction, leading to the onset of symptoms and to a further decay of cardiac dynamics. Purpose The aim of the study was to evaluate RV morphology and functional dynamics at admission and discharge in patients hospitalized for AHF, analyzing the role and the response to treatment of the RV and its coupling with pulmonary circulation (PC). Methods Eighty-one AHF patients (mean age 75.75±10.6 years, 59% males) were prospectively enrolled within 24–48 hours from admission to the emergency department (ED). In either the acute phase and at pre-discharge all patients underwent M-Mode, 2-Dimensional and Doppler transthoracic echocardiography (TTE), as well as lung ultrasonography (LUS), to detect an increase of extravascular lung water (EVLW) and development of pleural effusion. Laboratory tests were performed in the acute phase and at pre-discharge including the evaluation of NT-proBNP. Results At baseline we observed a high prevalence of RV dysfunction as documented by a reduced RV systolic longitudinal function [mean tricuspid annular plane systolic excursion (TAPSE) at admission of 16.47±3.86 mm with 50% of the patients exhibiting a TAPSE<16mm], a decreased DTI-derived tricuspid lateral annular systolic velocity (50% of the subjects showed a tricuspid s' wave<10 cm/s) and a reduced RV fractional area change (mean FAC at admission of 36.4±14.6%). Furthermore, an increased pulmonary arterial systolic pressure (PASP) and a severe impairment in terms of RV coupling to PC was detected at initial evaluation (mean PASP at admission: 38.8±10.8 mmHg; average TAPSE/PASP at admission: 0.45±0.17 mm/mmHg). At pre-discharge a significant increment of TAPSE (16.47±3.86 mm vs. 17.45±3.88; p=0.05) and a reduction of PASP (38.8±10.8 mmHg vs. 30.5±9.6mmHg, p<0.001) was observed. Furthermore, in the whole population we assisted to a significant improvement in terms of RV function and its coupling with PC as demonstrated by the significant increase of TAPSE/PASP ratio (TAPSE/PASP: 0.45±0.17 mm/mmHg vs 0.62±0.20 mm/mmHg; p<0.001). Patients significantly reduced from admission to discharge the number of B-lines and NT-proBNP (B-lines: 22.2±17.1 vs. 6.5±5 p<0.001; NT-proBNP: 8738±948 ng/l vs 4227±659 ng/l p<0.001) (Figure 1). Nonetheless, no significant changes of left atrial and left ventricular dimensions and function were noted. Conclusions In AHF, development of congestion and EVLW significantly impact on the right heart function. Decongestion therapy is effective for restoring acute reversal of RV dysfunction, but the question remains on how to impact on the biological properties of the RV. Funding Acknowledgement Type of funding source: None

Evaluation of the Benefit of Extended Catheter-Directed Thrombolysis with Serial Angiography for Acute Pulmonary Embolism

PurposeTo evaluate whether extended catheter-directed thrombolysis (CDT) with repeat visits to the angiography suite provide added benefit in treatment of acute pulmonary embolism (PE). Materials and MethodsThis was a retrospective review of CDT procedures performed for acute PE in 156 patients (age 56.1 y ± 15.3, 46.2% women) between 2009 and 2019. All patients underwent at least 1 follow-up visit to the angiography suite for evaluation of pulmonary artery pressure (PAP) and thrombus burden (Miller score) before termination (111/156, 71.2%) or continuation of CDT (45/156, 28.8%). ResultsPatients who had CDT extended beyond the first follow-up visit required a higher total dose of tissue plasminogen activator (40.7 mg ± 14.3 vs 22.6 mg ± 9.9, P < .001) to achieve a similar final Miller score (6.4 ± 3.8 vs 7.6 ± 3.9, P = .1) and a similar reduction in systolic PAP (−14.4 mm Hg ± 10.2 vs −12.6 mm Hg ± 11.9, P = .6). The initial Miller scores were similar in both groups (19.7 ± 5.8 vs 19 ± 4, P = .4) but were significantly higher during the first follow-up visit (after 18 hours ± 5.5 vs 20 hours ± 4.8, P = .06) in patients requiring multiple follow-up visits (12.2 ± 5 vs 7.6 ± 3.9, P < .001). Multiple regression analyses identified heart rate > 100 beats/min and systolic PAP > 55 mm Hg as associated with the need for extended CDT. Extended CDT did not result in a higher hemorrhagic complication rate (1/45 vs 6/111, P = .7). ConclusionsPatients presenting with higher heart rates and systolic PAP may benefit from extended CDT to achieve similar reductions in PAP and thrombus burden, without clear added risk of hemorrhage.

P1710 Reverse right ventricular remodeling using right ventricular strain and strain rate after mitral clip implantation in functional mitral regurgitation, an echocardiographic study

Abstract Funding Acknowledgements none OnBehalf none Background Chronic mitral regurgitation (MR) leads to right ventricular dysfunction because of volume and pressure overload over a long time. Mitral valve repair with a mitral clip will reduce the (MR) but how much its effect on the right ventricle. Aim The aim of the present study is to assess the impact of Mitral Valve Clipping on right ventricular (RV) remodeling (RV strain and strain rate) at med term after Mitral Clip implantation in high-risk surgical patients with severe functional mitral regurgitation (MR). Methods Study population included 62 patients with severe functional MR. All the patients underwent full echocardiographic evaluation before MV clip, and at 12-month follow-up. RV systolic function was assessed using tissue Doppler and TAPSE. Using Tom-Tec software the RV endocardium is traced in the apical 4 chamber view to get the RV strain and strain rate. RV after load was evaluated using systolic pulmonary artery pressure. Results In our cohort, 62 patients had percutaneous mitral valve clip and completed at least 12 months of follow-up. The average age was 60.56 years, 24.19 were females, 50% were diabetic, 46.77 were hypertensive, 12.90 had ESRD and 11.29 % had anemia. Coronary artery disease (CAD) was present in 59.41 %, prior CABG in 11.67% and prior PCI in 35.48%. All parameters value was compared pre MV clip and 12 ± 4.6 months after MV clip. The RV longitudinal strain was -12.4 ± 2.6% and improved to -14.6 ± 3.1% (P 0.005) (Figure A and B). The RV strain rate was -1.1 ± 0.41 and improved to -1.3 ± 0.57 (P 0.004) (Figure C and D). The tricuspid annulus plane systolic excursion (TAPSE) was 1.76 ±0.57 mm, and improved to 1.82 ±0.63 mm (P 0.4). The systolic velocity at the tricuspid annulus was 9.50 ±2.33cm/sec and improved to 9.64 ±2.72 cm/sec (P 0.269). The systolic pulmonary artery pressure (SPAP) was 50.49 ±13.92 and improved to 42.33 (P 0.036). Conclusion Mitral Clip implantation induces a significant reverse remodeling of RV. It produces significant improvement in the hemodynamics of the right side indicated by the significant reduction in SPAP and a significant increase in longitudinal RV strain and strain rate. Those changes could be a direct reflection of the concomitant reduction in LV filling pressure produced by the significant reverse remodeling of the LV caused by Mitral Clipping. Abstract P1710 Figure.

Effectiveness of sildenafil in pulmonary hypertension secondary to mitral valve disease

Background and Aim: Pulmonary arterial hypertension almost always accompanies long-standing mitral valvular heart disease. The objective of this study is to study the effectiveness of sildenafil in reducing pulmonary hypertension in the peroperative and perioperative period. Materials and Methods: Fourteen patients were randomized into two groups test and control. Patients with mitral valvular disease with Pulmonary Artery Systolic Pressure (PASP) >50 were selected from the outpatient department and echo was done before the admission. Patients in the test group and control group were administered oral sildenafil 25 mg and placebo, respectively, three times a day in the preoperative period in the same fashion for 2 weeks. Preoperative echo was repeated thereafter. After induction of anesthesia and with all aseptic and antiseptic precautions, pulmonary artery catheter was inserted in the right internal jugular vein. PASP was calculated ½ hour after the induction of anesthesia. After operation, patients were monitored by transthoracic echo after 1 week. After discharge, patients were monitored by transthoracic echo at 1 month and at 3 months. Patients' data were analyzed using the statistical tools such as mean, Chi-square test for independence, and paired t-test. Results: There was a statistically significant reduction in PASP in the sildenafil group in the preoperative period (P

Conduction Abnormalities after Transcatheter Aortic Valve Implantation and Diastolic Dysfunction

Objectives: Transcatheter aortic valve implantation (TAVI) is frequently associated with the development of conduction abnormalities. We assessed the effect of conduction abnormalities on diastolic function following TAVI. Methods: In total, 101 consecutive post-TAVI patients were included, each with echocardiographic follow-up at 1 and 6 months. Diastolic properties were correlated with the occurrence of a long PR interval and wide QRS, and their change from baseline. The measured diastolic parameters included E/A ratio, E wave deceleration time, E wave to e′ ratio, left atrial (LA) volume, and systolic pulmonary artery pressure (SPAP). The clinical outcome was all-cause mortality. Results: Overall, TAVI was associated with a consistent decrease in SPAP at the 1- and 6-month follow-up. LA volumes were increased at 1 month post-TAVI in patients with a wide compared to normal QRS (p = 0.03) and at 6 months in patients with a normal compared to prolonged PR (p = 0.03). PR prolongation above 40 ms was associated with lower SPAP at the 1- but not 6-month follow-up. Survival was not influenced by conduction abnormalities. Conclusions: TAVI is associated with a reduction in SPAP. A postprocedural wide QRS and normal PR interval may unfavorably influence the left-sided filling performance, resulting in an increased LA volume. Other diastolic parameters, as well as survival, are not significantly affected by postprocedural conduction abnormalities.

A multicentre randomized-controlled trial of inhaled milrinone in high-risk cardiac surgical patients

Inhaled milrinone (iMil) has been used for the treatment of pulmonary hypertension (PH) but its efficacy, safety, and prophylactic effects in facilitating separation from cardiopulmonary bypass (CPB) and preventing right ventricular (RV) dysfunction have not yet been evaluated in a clinical trial. The purpose of this study was to investigate if iMil administered before CPB would be superior to placebo in facilitating separation from CPB. High-risk cardiac surgical patients with PH were randomized to receive iMil or placebo after the induction of anesthesia and before CPB. Hemodynamic parameters and RV function were evaluated by means of pulmonary artery catheterization and transesophageal echocardiography. The groups were compared for the primary outcome of the level of difficulty in weaning from CPB. Among the secondary outcomes examined were the reduction in the severity of PH, the incidence of RV failure, and mortality. Of the 124 patients randomized, the mean (standard deviation [SD]) EuroSCORE II was 8.0 (2.6), and the baseline mean (SD) systolic pulmonary artery pressure (SPAP) was 53 (9) mmHg. The use of iMil was associated with increases in cardiac output (P = 0.03) and a reduction in SPAP (P = 0.04) with no systemic hypotension. Nevertheless, there was no difference in the combined incidence of difficult or complex separation from CPB between the iMil and control groups (30% vs 28%, respectively; absolute difference, 2%; 95% confidence interval [CI], -14 to 18; P = 0.78). There was also no difference in RV failure between the iMil and control groups (15% vs 14%, respectively; difference, 1%; 95% CI, -13 to 12; P = 0.94). Mortality was increased in patients with RV failure vs those without (22% vs 2%, respectively; P < 0.001). In high-risk cardiac surgery patients with PH, the prophylactic use of iMil was associated with favourable hemodynamic effects that did not translate into improvement of clinically relevant endpoints. This trial was registered at ClinicalTrials.gov; identifier: NCT00819377.

Retrospective Study to Compare Ring Annuloplasty and Suture Annuloplasty in Tricuspid Valve Diseases

The Tricuspid regurgitation may be primary or secondary to left sided heart disease Residual tricuspid regurgitation is seen after tricuspid valve annuloplasty(TVA) - both ring and suture anuloplasty. A study was conducted in KEM Hospital as to validate the benefits of ring annuloplasty over suture anoloplasty. 80 patients undergoing MVR and TVA were studied. Of these 50 patients underwent MVR with ring annuloplasty and 30 underwent MVR with DeVegas annuloplasty. 2DECHO was done pre and postoperatively to determine pulmonary artery systolic pressure(PASP), grade of tricuspid regurgitation (TR), LV ejection fraction(LVEF) and tricuspid annulus. 82% of patients of ring annuloplasty group had reduction in PASP postoperatively compared to 56% in DeVegas annuloplasty . Grade of TR improved from moderately severe TR to mild TR in 86% in the ring annuloplasty group compared to53% in DeVegas annuloplasty group. 58% of patients of ring annuloplasty had maintained LV function postoperatively compared to 46% of patients in DeVegas annuloplasty.The mean tricuspid annulus showed reduction from preoperative annulus size of 37.72 to 27.5 in ring annuloplasty group and from 37.9to 27.13 in DeVegas annuloplasty group. Tricuspid ring annuloplasty is a better and durable repaire compared to suture annuloplasty for secondary TR. Aggressive management of secondary TR such as this could hopefully decreas the occurence of late TR following previous left sided valve surgery

Positive Airway Pressure Therapy for Sleep Disordered Breathing in Congestive Heart Failure is Associated with Reduction in Pulmonary Artery Systolic Pressure

Background: Sleep disordered breathing and pulmonary hypertension are both highly prevalent in patients with congestive heart failure (CHF). Since (SDB) has been shown to increase pulmonary pressures, we hypothesized that initiation of positive airway pressure (PAP) may reduce pulmonary artery systolic pressure (PASP) in compliant patients. Methods: A total of 125 consecutive CHF patients admitted for decompensation were screened. Of these patients, 18 met inclusion criteria for the study which included a PASP ≥ 36 and polysomnogram-proven SDB. A repeat echocardiogram performed at mean 8 weeks post intervention was reviewed to compare PASP. Results: There was no statistically significant difference in mean age, BMI, AHI, baseline PASP, and ejection fraction between the PAP-compliant group and PAP non-compliant group. A statistically significant mean reduction in PASP of 13.8 ± 7.0 mmHg (range: -25, -1) was observed in CHF patients with SDB who were compliant with PAP therapy, versus a mean increase of 0.9 ± 8.7 mmHg (range: -8, 15) in heart failure patients with SDB who were noncompliant with PAP therapy. Conclusions: The findings suggest that PAP therapy is associated with improvement in pulmonary hypertension with congestive heart failure and sleep disordered breathing.

Catheter-based therapy for acute pulmonary embolism: Lifesaving in a clinical dilemma!

Sir, 22-year-male, (body mass index 34) with Guillain-Barre Syndrome was on treatment with plasmapheresis. He suddenly became hemodynamically unstable on the 5th day of hospitalization. Arterial blood gas (ABG) showed hypercapnia and later hypoxia. Electrocardiograph showed sinus tachycardia. Echocardiography revealed hypokinesia of the right ventricle and moderate tricuspid regurgitation with pulmonary artery systolic pressure (PASP) of 45 mmHg. The patient continued to be hypoxemic, hypotensive, and suffered a cardiac arrest. In view of deteriorating status, the patient was taken for pulmonary angiography with the intention to diagnose as well treat pulmonary embolism in the same setting. After confirming the diagnosis, mechanical fragmentation was initiated in the embolus followed by intralesional urokinase [Figure 1]. Over the next 24 hrs, hemodynamic parameters gradually improved with the resolution of shock and reduction in pulmonary artery pressure to 27 mmHg. Figure 1 Pulmonary angiography (a) total cut-off of right pulmonary artery (RPA) and clot in left PA (b) mechanical breakdown and intrapulmonary urokinase administration (c) postprocedural pulmonary angiography revealing restoration of pulmonary flow in PA and ... The true incidence of Pulmonary embolism (PE) is unknown because the diagnosis of PE is more often missed than confirmed due of varying clinical presentations. Provisional diagnosis of pulmonary embolism is usually based on the clinical setting and the pretest probability guides the choice of confirmatory tests. This case was at high risk for pulmonary embolism as he was obese with quadriplegia and had been immobilized for almost 1-week. ABG showed respiratory acidosis which in not a common finding in patients of PE, but our patient had neuromuscular paralysis of respiratory and accessory muscles which precluded him from hyperventilation and resulted in respiratory acidosis as the first change in ABG. Thus, the presence of respiratory acidosis on ABG does not exclude the possibility of PE as quoted in one of the recent articles rather blood gas must never be analyzed alone but should be correlated to the clinical scenario.[1] Acute pulmonary embolism is pulmonary embolism resulting in hypotension, shock or need for cardiopulmonary resuscitation (CPR) and is recognized as the third major cause of death among the hospitalized patients. Hence, immediate attention and treatment is crucial. The American college of chest physicians consensus statement have laid down recommendations for management of PE but not more than two-thirds of the patients receive systemic thrombolysis because it is contraindicated (absolute or relative) in a large number of clinical conditions.[2] Since the first description of embolectomy catheter in 1971, the clinical application of catheter-based interventions in the management of acute PE are still very infrequent. There are no randomized controlled trials to compare its efficacy with systemic thrombolysis, with or without anticoagulation. In a recently published meta-analysis, only 594 cases of acute massive PE were treated with catheter-directed therapy (CDT), with a success rate reported to be about 86%.[3] Although our patient was a candidate for systemic thrombolysis, but refractory arterial hypotension and the need for CPR led to the selection of CDT as the modality of choice. Two hour period required for infusion of full dose of tPA and about 20% risk of major hemorrhage following its infusion also led to the selection of CDT as the first line therapy. The catheter-based fragmentation leads to mechanical debulking which can be clinically seen as an immediate improvement in hemodynamics, resolution of shock, and reduction in PASP. However, breakdown of the clot provides a large exposed area for subsequent thrombolysis. The thrombolytic infusion following debulking results in decreasing the incidence of chronic PE and pulmonary hypertension. FDA has approved urokinase (4400 IU/kg intravenous over 10 min, followed by 4400 IU/kg/h for 12 h) and streptokinase (250,000 IU intravenous over 30 min, followed by 100,000 IU/h for 24 h). It is a plasminogen activator with the additional quality of a catalytic agent that renders fibrinogen less clottable by thrombin. Furthermore, in terms of cost and availability it was chosen as the preferred agent. This case highlights that clinicians should have a low threshold for diagnosing PE in acutely bed ridden patients. In a selected group of patients with neurological disorders where systemic thrombolysis is contraindicated, combination of mechanical fragmentation and local thrombolysis may be a promising option for reduction in mortality.

Hypoxia, not pulmonary vascular pressure, induces blood flow through intrapulmonary arteriovenous anastomoses.

Blood flow through intrapulmonary arteriovenous anastomoses (IPAVA) is increased by acute hypoxia during rest by unknown mechanisms. Oral administration of acetazolamide blunts the pulmonary vascular pressure response to acute hypoxia, thus permitting the observation of IPAVA blood flow with minimal pulmonary pressure change. Hypoxic pulmonary vasoconstriction was attenuated in humans following acetazolamide administration and partially restored with bicarbonate infusion, indicating that the effects of acetazolamide on hypoxic pulmonary vasoconstriction may involve an interaction between arterial pH and PCO2. We observed that IPAVA blood flow during hypoxia was similar before and after acetazolamide administration, even after acid-base status correction, indicating that pulmonary pressure, pH and PCO2 are unlikely regulators of IPAVA blood flow. Blood flow through intrapulmonary arteriovenous anastomoses (IPAVA) is increased with exposure to acute hypoxia and has been associated with pulmonary artery systolic pressure (PASP). We aimed to determine the direct relationship between blood flow through IPAVA and PASP in 10 participants with no detectable intracardiac shunt by comparing: (1) isocapnic hypoxia (control); (2) isocapnic hypoxia with oral administration of acetazolamide (AZ; 250 mg, three times a day for 48 h) to prevent increases in PASP; and (3) isocapnic hypoxia with AZ and 8.4% NaHCO3 infusion (AZ + HCO3 (-) ) to control for AZ-induced acidosis. Isocapnic hypoxia (20 min) was maintained by end-tidal forcing, blood flow through IPAVA was determined by agitated saline contrast echocardiography and PASP was estimated by Doppler ultrasound. Arterial blood samples were collected at rest before each isocapnic-hypoxia condition to determine pH, [HCO3(-)] and Pa,CO2. AZ decreased pH (-0.08 ± 0.01), [HCO3(-)] (-7.1 ± 0.7 mmol l(-1)) and Pa,CO2 (-4.5 ± 1.4 mmHg; P < 0.01), while intravenous NaHCO3 restored arterial blood gas parameters to control levels. Although PASP increased from baseline in all three hypoxic conditions (P < 0.05), a main effect of condition expressed an 11 ± 2% reduction in PASP from control (P < 0.001) following AZ administration while intravenous NaHCO3 partially restored the PASP response to isocapnic hypoxia. Blood flow through IPAVA increased during exposure to isocapnic hypoxia (P < 0.01) and was unrelated to PASP, cardiac output and pulmonary vascular resistance for all conditions. In conclusion, isocapnic hypoxia induces blood flow through IPAVA independent of changes in PASP and the influence of AZ on the PASP response to isocapnic hypoxia is dependent upon the H(+) concentration or Pa,CO2.

Benefits of chronic blood transfusion in hemoglobin E/β thalassemia with pulmonary arterial hypertension.

ObjectiveThe aim of the research reported here was to compare pulmonary artery systolic pressure (PASP) and 6-minute walk distance after 1 year of follow-up in hemoglobin E/β thalassemia (E/β-Thal) with pulmonary arterial hypertension (PAH) patients who received chronic blood transfusions versus those who received occasional transfusions.MethodsA nonrandomized clinical trial was conducted at the Hematological Outpatient Clinic of Chiang Rai Hospital, Thailand. All adult cases of E/β-Thal with PAH (defined as PASP >35 mmHg by Doppler echocardiography) were evaluated and followed for the next 12 months. The patients were classified into two groups by patient preference. Group 1 patients received chronic blood transfusions – one to two units of leukocyte-poor packed red cells every 2–4 weeks – over 1 year to maintain pre-transfusion hemoglobin levels of ≥7.0 g/dL. Group 2 patients received occasional transfusions over the course of 1 year, with more than 4 weeks between transfusions. All patients were treated with iron chelation when serum ferritin levels were ≥1,000 μg/dL. PASP and the 6-minute walk distance were evaluated at baseline and at 6 and 12 months. Propensity score adjustment was used to control for confounding by indication and contraindication. Multivariable regression analysis was used to evaluate the effects of chronic blood transfusion.ResultsThere were 16 (53.3%) patients in Group 1 and 14 (46.7%) in Group 2. At 12 months, patients in Group 1 had a greater reduction in PASP than those in Group 1 (adjusted mean difference, −16.83; 95% confidence interval, −26.35 to −7.32; P=0.001). The 6-minute walk distance at 12 months in Group 1 patients was greater than that in Group 2 patients (adjusted mean difference, 46.55; 95% confidence interval, 18.08 to 75.02; P=0.001).ConclusionThis study found evidence that chronic blood transfusions may have beneficial effects in PAH in thalassemia patients over 1 year.

Abstract 19093: Paradoxical Improvement of Tricuspid Valve Incompetence Severity Following Implantation of Ventricular Leads

Background: Cardiac rhythm management devices (CRMD) require an endocardial ventricular lead to be placed across the tricuspid valve. Worsening tricuspid regurgitation (TR) with implantation of CRMD has been described. We report the incidence of improvement in TR after CRMD placement, which is an unexpected finding. Methods: We retrospectively reviewed 148 patients (age 68±15) that received a CRMD. TR, ejection fraction (EF) and pulmonary artery systolic pressure (PASP) measured by Doppler echocardiography before and after CRMD implantation were analyzed. The TR was graded according to the degree of severity as mild, moderate and severe. A scale of 0-4 according to the grade of severity was used. Improvement in the severity of TR was classified corresponding with the reduction in grades of severity of TR as follows: minimal (&lt;1grade), slight (1), and significant reduction (≥2). Results: Mean follow-up time was 30±12 months. Thirty-nine (26%) patients experienced improvement in the severity of TR (from 1.7±0.8 to 0.9±0.7; p=0.0001-5) after placement of a CRMD. The remaining 109 patients had an increase in the severity of TR (from 0.1±0.5 to 1.4±0.9; p=0.0005-10). Reduction in TR was associated with improvement in EF (from 41±19 to 47±14%; p=0.01) and PASP (from 45±15 to 36±14mmHg; p=0.002-2). Patients that had increase in TR did not have a significant change in their EF (from 40±17 to 42±15%; p=0.07) and had worsening of their PASP (from 38±14 to 42±16mmHg; p=0.002). Evaluation of improvement in TR per type of device implanted revealed no difference between patients who received pacemakers (PPM), defibrillators (ICD) or cardiac resynchronization therapy devices (CRT) (ICD/CRT vs PPM p=0.12; ICD vs PPM p=0.22; ICD vs CRT p=0.29 and CRT vs PPM p=0.07). Conclusion: Severity of TR may improve in some patients after CRMD placement. This could be attributed to diuresis and optimization of medical therapy at the time of CRM implant or restoration of AV synchrony with pacing, as evidenced by the reduction in PASP and improved EF among those patients.

Dynamic Nature of Pulmonary Artery Systolic Pressure in Decompensated Heart Failure With Preserved Ejection Fraction: Role of Functional Mitral Regurgitation

BackgroundPulmonary hypertension (PH) is prevalent in decompensated heart failure with preserved ejection fraction (HFpEF). We investigated the effect of a return to a compensated state on pulmonary artery systolic pressure (PASP) and functional mitral regurgitation (FMR). Methods and ResultsTwo-dimensional Doppler echocardiography was prospectively performed before initiation of standard therapy and 48 hours later in 37 patients hospitalized for HFpEF-related dyspnea and in 26 patients hospitalized for non-HFpEF–related dyspnea. Left atrial volume index, and E/e′ ratio, and PASP were significantly greater and E-wave deceleration time significantly shorter in HFpEF than in non-HFpEF patients. Thirty-two of the 37 HFpEF had FMR on admission whereas none of the non-HFpEF patients had FMR. After 48 hours of therapy, the reduction in PASP was significantly greater in the 26 HFpEF patients who improved than in the 11 HFpEF patients who did not (−24 vs −9 mm Hg, respectively; P < .0001), whereas PASP remained unchanged in non-HFpEF patients. The decrease in PASP correlated in HFpEF patients with reductions in blood pressure, heart rate, left ventricular end-diastolic volume, inferior vena cava diameter, E/A ratio, E/e′ ratio, mitral effective regurgitant orifice area (EROA), and E-wave deceleration time. The correlation between PASP and mitral EROA was the only one that remained significant by multivariate analysis. ConclusionsNoninvasive monitoring of PASP and FMR during an episode of HFpEF decompensation reveals that the return to a compensated state is associated with a significant reduction in PASP and FMR.

Hemodynamic Impact and Outcome of Permanent Pacemaker Implantation Following Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) frequently requires postprocedural permanent pacemaker (PPM) implantation. We evaluated clinical and hemodynamic impact of PPM after TAVI. Clinical and echocardiographic data were retrospectively analyzed in 230 consecutive patients who underwent TAVI and echocardiography at baseline and after 6 months. Echocardiographic parameters included left ventricular ejection fraction (LVEF), left ventricular (LV) stroke volume, early mitral velocity/annulus velocity ratio (E/e'), right ventricular index of myocardial performance, systolic pulmonary artery pressure (SPAP), and aortic, mitral, and tricuspid regurgitation grades. Clinical outcomes included 2-year survival and cardiovascular and PPM-related event-free survival. The Medtronic CoreValve and Edwards Sapien prosthesis were used in 201 and 29 patients, respectively. PPM was required in 58 patients (25.4%). Two-year and event-free survival rates were similar between patients with and without PPM. At 6 months, patients with PPM demonstrated attenuated improvement in LVEF (-0.9 ± 8.7% vs 2.3 ± 10.8%, respectively, p = 0.03) and LV stroke volume (-2 ± 16 vs 4 ± 10 ml/m(2), respectively, p = 0.015), a trend toward smaller reduction in systolic pulmonary artery pressure (-1 ± 12 vs -6 ± 10 mm Hg, respectively, p = 0.09), and deterioration of right ventricular index of myocardial performance (-3 ± 17% vs 5 ± 26%, respectively, p = 0.05). The differences in post-TAVI aortic, mitral, and tricuspid regurgitation grades were insignificant. In conclusion, PPM implantation after TAVI is associated with reduced LVEF and impaired LV unloading. However, this unfavorable hemodynamic response does not affect the 2-year clinical outcome. The maintenance of clinical benefit appears to be driven by TAVI-related recovery of LV and right ventricular performance that mitigates unfavorable impact of PPM.