Significant Pulmonary Hypertension Research Articles

Prediction of chronic thromboembolic pulmonary hypertension with standardised evaluation of initial computed tomography pulmonary angiography performed for suspected acute pulmonary embolism

ObjectivesCloser reading of computed tomography pulmonary angiography (CTPA) scans of patients presenting with acute pulmonary embolism (PE) may identify those at high risk of developing chronic thromboembolic pulmonary hypertension (CTEPH). We aimed to validate the predictive value of six radiological predictors that were previously proposed.MethodsThree hundred forty-one patients with acute PE were prospectively followed for development of CTEPH in six European hospitals. Index CTPAs were analysed post hoc by expert chest radiologists blinded to the final diagnosis. The accuracy of the predictors using a predefined threshold for ‘high risk’ (≥ 3 predictors) and the expert overall judgment on the presence of CTEPH were assessed.ResultsCTEPH was confirmed in nine patients (2.6%) during 2-year follow-up. Any sign of chronic thrombi was already present in 74/341 patients (22%) on the index CTPA, which was associated with CTEPH (OR 7.8, 95%CI 1.9–32); 37 patients (11%) had ≥ 3 of 6 radiological predictors, of whom 4 (11%) were diagnosed with CTEPH (sensitivity 44%, 95%CI 14–79; specificity 90%, 95%CI 86–93). Expert judgment raised suspicion of CTEPH in 27 patients, which was confirmed in 8 (30%; sensitivity 89%, 95%CI 52–100; specificity 94%, 95%CI 91–97).ConclusionsThe presence of ≥ 3 of 6 predefined radiological predictors was highly specific for a future CTEPH diagnosis, comparable to overall expert judgment, while the latter was associated with higher sensitivity. Dedicated CTPA reading for signs of CTEPH may therefore help in early detection of CTEPH after PE, although in our cohort this strategy would not have detected all cases.Key Points• Three expert chest radiologists re-assessed CTPA scans performed at the moment of acute pulmonary embolism diagnosis and observed a high prevalence of chronic thrombi and signs of pulmonary hypertension.• On these index scans, the presence of ≥ 3 of 6 predefined radiological predictors was highly specific for a future diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH), comparable to overall expert judgment.• Dedicated CTPA reading for signs of CTEPH may help in early detection of CTEPH after acute pulmonary embolism.

Abstract 9220: Employing a Convolutional Neural Network Facilitates Unsupervised Clustering of Aortic Outflow Velocity Profiles from Patients With Severe Aortic Stenosis

Introduction: The aortic outflow velocity profile is key to diagnose severe aortic stenosis (AS), and its shape reflects both aortic valve obstruction and left ventricular contractility. Hypothesis: Hypothesizing that aortic outflow velocity profiles contain more valuable information than can be captured by the human eye, features of the complex geometry of Doppler tracings were extracted by a convolutional neural network (CNN) pre-trained on big data (transfer learning). Methods: After pre-training a CNN (VGG-16) on a large data set (ImageNet data set; 14 million images belonging to 1,000 classes), the convolutional part was employed to transform Doppler tracings to 1D arrays. Principal component analysis (PCA) and k-means clustering of those 1D arrays were performed, and association between cluster and 2-year all-cause mortality was hereinafter assessed. Among 366 eligible patients with pre-procedural echocardiography and right heart catheterization prior to transcatheter aortic valve replacement (TAVR) for severe AS, good quality Doppler tracings from 101 patients were analyzed. Results: Among 101 patients (mean age: 79.3 ± 6.78 years; 49 [48.5%] women), estimated 2-year survival was 83.0% (95% CI: 75.1-91.7%). The convolutional part of the pre-trained VGG-16 model in conjunction with PCA and k-means clustering distinguished 2 shapes of aortic outflow velocity profiles. Kaplan-Meier analysis revealed that mortality in patients from cluster 2 (n = 40 [39.6%]) was significantly increased (HR for 2-year mortality: 3 [95% CI: 1-8.9]). Apart from reduced cardiac output and mean aortic valve gradient (AVG mean ), patients from cluster 2 were also characterized by signs of pulmonary hypertension, impaired right ventricular function and right atrial enlargement. Conventional dichotomization according to AVG mean confirmed that patients with AVG mean < 40 mmHg (n = 54 [53.5%]) decease earlier, but no statistical significance was reached (HR for 2-year mortality: 1.8 [95% CI: 0.59-5.2]). Conclusions: This is a proof-of-principle that transfer learning aids in agnostic interpretation of aortic outflow velocity profiles, thereby holding the promise to refine prognostic resolution for survival after TAVR.

Prevalence of cardiac pathology and relation to mortality in a multiethnic population hospitalised with COVID-19

ObjectiveTo determine the prevalence of cardiac abnormalities and their relationship to markers of myocardial injury and mortality in patients admitted to hospital with COVID-19.MethodsA retrospective and prospective observational study of...

Changing of pulmonary artery diameter in accordance with severity of COVID-19 (assessment based on non-contrast computer tomography)

BACKGROUND: Computed tomography is the method of choice for assessing the volume of lung damage in viral pneumonia, including those associated with COVID-19. In addition, computed tomography can determine the main vessels size of the thorax. This allowed us to analyze the relationship between the severity of COVID-19 and the changes in the diameters of the pulmonary artery (PA) and ascending aorta (Ao). Dilation of the PA is a sign of pulmonary hypertension. The study of these patterns may be of clinical significance in determining the treatment tactics and prognosis of the course of COVID-19 disease.
 AIM: To evaluate the relationship between PA diameter and the severity of the COVID-19 course in patients of different ages.
 MATERIALS AND METHODS: This study is a single-centered, cross-section, continuous, uncontrolled study performed on a group of patients (n=511, 267 men, median 59 years, IQR 49.065.0, ages 3184 years) who were treated in a temporary hospital to treat patient with COVID-19. During hospitalization all patients were examined by CT scan of the chest. All studies were carried out using a mobile CT scan system Airo TruCT (Stryker, USA). The degree of damage to the lung tissue was assessed using the CT volume scale 14. Measurement of the LA and Ao diameters was carried out using standard instruments of the radiologists CT workstation perpendicular to the long axis of the vessel.
 RESULTS: The following statistically significant regularities were obtained: the detection of a dilated pulmonary artery (PA) and an increased PA/Ao ratio correlated to an increase in the degree of lung damage in COVID-19 (Kruskal-Wallis test, K-W p 0.001; median test, MT p 0.001), the diameter of the ascending aorta (Ao) significantly increases with the patients age (K-W p 0.001; MT p 0.001). An insignificant correlation between an increase in the diameter of the pulmonary artery (PA) and the patients age (K-W p=0.094; MT p=0.311) and an insignificant correlation between detection of a change in aortic (Ao) diameter and the degree of lung damage (K-W p=0.061; MT p=0.165) were shown. In groups with a severe course of the disease and a large volume of lung lesions (CT-3 and CT-4), a significantly greater number of patients with signs of pulmonary hypertension (detection of the dilated pulmonary artery: 29 mm and more) was shown for all age groups.
 CONCLUSION: The study showed that PA dilatation and increased PA/Ao diameter ratio were significantly associated with increased pulmonary lesion volume in COVID-19 in all age groups.

Predictive association of pulmonary hypertension with risks of adverse renal outcomes in type 2 diabetes

Abstract Background Diabetic kidney disease is a major diabetic complication which contributes to the end-stage renal disease and renal deaths in diabetic patients. The aim of our study was to investigate the role of pulmonary hypertension (PHT) in the development of adverse renal outcomes in patients with type 2 diabetes (T2DM). Methods A total of 1479 diabetic patients (mean age 67±13 years; women, 44.7%) were recruited. Pulmonary artery systolic pressure (PASP) was estimated by transthoracic echocardiography at baseline. Adverse renal outcomes were defined as a composite endpoint of a sustained 40% decline in eGFR, end-stage renal disease requiring renal replacement therapy, kidney transplantation or renal deaths. Cox regression hazard model was used to assess the association between PHT and incident adverse renal outcomes. Results Patients were divided into three groups based on their baseline PASP: no PHT (n=1204, 75.1%), mild PHT (321, 20.0%) and significant PHT (78, 4.9%). A total of 474 adverse renal outcomes occurred during a median follow-up of 53 months, Kaplan-Meier survival curve showed that patients with significant PHT had highest risk of adverse renal outcomes. Multivariate cox regression demonstrated both mild PHT (HR=1.66, 95% CI 1.33, 2.06, P<0.001) and significant PHT (HR=2.09, 95% CI 1.45, 3.02, P<0.001) were independently associated with the incident adverse renal outcomes. Conclusion The presence of PHT was associated with adverse renal outcomes in patients with T2DM. Funding Acknowledgement Type of funding sources: None.

Long term outcomes for adults with complete atrioventricular septal defects

Abstract Background/Introduction Complete Atrio-Ventricular septal defect (AVSD) is a complex congenital cardiac disease, characterised by malformation at the atrio-ventricular junction and AV valve abnormalities. Long- term outcome data is limited. Purpose We sought to describe the long-term outcomes of adults with repaired complete AVSD in a tertiary adult congenital heart centre. Methods We retrospectively recruited patients with complete AVSD who underwent surgical repair between 1973 and 2001 in our centre. All clinical and echocardiographic data were collected and analysed for evidence of atrio-ventricular valve (AVV) deterioration, or cardiac dysfunction. We also assessed for the requirement for further surgical intervention throughout the follow up period. Results A total of 345 patients with AVSD were identified, partial AVSD 211, unrepaired 82. Fifty-two with repaired complete AVSD formed study group, female 36 (69%) and male 16 (31%), Trisomy 21 (23, 44%). Mean age at initial repair was 44 months (median 12, IQR 31.5). Mean follow up was 25.3 years (Median 24, IQR 9.75). Clinical status: At the latest follow-up, most patient were asymptomatic with NYHA I-II (n=46) Majority (n=36, 69%) required only initial repair and no further intervention. Further surgeries were performed in 16 patients including AVV repair (n=9) and LVOTO relief (n=3). Permanent pacemaker insertion needed in 6 (12%), all for heart block following valve repair. 7 patients (14%) had documented arrythmia, 4 (8%) requiring ablations and only 1 had endocarditis. Echo findings: AV Valve dysfunction was more commonly regurgitant rather than stenotic. More than moderate AVV regurgitation was present in 83% of patients, Left AVV (n=25, 48%), Right AVV (n=18, 35%) compared to 4% stenosis (LAVV n=1, RAVV n=1). Ventricular outflow tract obstruction was present in 8% of patients, RVOT obstruction (2, one native, one secondary to prior banding), LVOT obstruction (2, both native, one requiring surgical intervention). Right ventricular systolic dysfunction was present in 6% of patients (n=3), with mean TAPSE 14.1mm (SD± 3.1mm). Left ventricular dysfunction was present in 4% (n=2), mean LVEF 58.9% (SD±7.1%) and mean LV EDVi 55.06mL/m2 (SD±13.2 mL/m2). Only one patient had significant pulmonary hypertension (Mean PAP 48 mmHg). Conclusion Long-term outcomes of surgically repaired AVSD are highly favourable. Left AVV regurgitation is the most common residual lesion requiring further surgical intervention. Ventricular outflow tract obstruction was much less common, as was ventricular systolic dysfunction. Complete heart block was associated with surgical repair and arrhythmias were potential late complications. Funding Acknowledgement Type of funding sources: None.

PH Roundtable: Conundrums and Controversies in PH-ILD: To Treat or Not to Treat—Identifying Optimal Treatment Candidates

PH Roundtable: Conundrums and Controversies in PH-ILD: To Treat or Not to Treat—Identifying Optimal Treatment Candidates

RATE VS RHYTHM CONTROL IN A PATIENT WITH PULMONARY ARTERIAL HYPERTENSION AND ATRIAL FLUTTER: USE OF DIRECT HEMODYNAMIC MEASUREMENTS

TOPIC: Pulmonary Vascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Atrial arrhythmias in patients with pulmonary arterial hypertension (PAH) are generally felt to be poorly tolerated hemodynamically [1]. Although this observation has driven expert recommendations to attempt rhythm control first, there is no high-quality evidence to support this approach in rate-controlled arrhythmias. We present a case in which management in a patient with PAH and rate-controlled atrial flutter was informed by invasive hemodynamic measurements performed before and after cardioversion. CASE PRESENTATION: A 45-year-old female with history of PAH, treated with subcutaneous treprostinil and macitentan, and atrial flutter, was admitted for decompensated right heart failure and rate-controlled atrial flutter. Atrial flutter was recurrent after prior cardioversion, prompting consideration of ablation.As the patient was rate-controlled and given the potential risk of anesthesia and an invasive procedure, we measured hemodynamics before and immediately after electrical cardioversion. Hemodynamics are summarized in Table 1. Initial hemodynamics showed significant pulmonary hypertension, with evidence of both pre-capillary and post-capillary components and a reduced cardiac index. Cardioversion to sinus rhythm did not result in a significant change in hemodynamics. Given no hemodynamic improvement with restoration of sinus rhythm, ablation was not pursued. DISCUSSION: Attempting rhythm control in patients with rate-controlled atrial arrhythmias and PAH is the currently accepted practice, although the evidence to support this approach is insufficient. Improvement in cardiac function in heart failure with reduced ejection fraction can be seen immediately after electrical cardioversion, with significant improvement in stroke volume, even in rate-controlled populations[2]. In our case, hemodynamic measurements showed no improvement in cardiac performance or pulmonary pressures after cardioversion. This suggests that some patients with PAH and rate-controlled atrial arrhythmias merit an assessment of the potential benefit of a rhythm control strategy. Understanding the benefit of rhythm-control is particularly important in patients with PAH given the high-risk nature of anti-arrhythmic medications and cardiac ablation. Patients with PAH more often have atypical ablative targets leading to longer procedures, time under anesthesia, and more detrimental consequences if an iatrogenic ASD occurs[1]. CONCLUSIONS: While a rhythm control strategy may be beneficial for some PAH patients, hemodynamic evaluation may help inform the management strategy for rate-controlled atrial arrhythmias in this population. REFERENCE #1: Wanamaker, B., et al., Atrial Arrhythmias in Pulmonary Hypertension: Pathogenesis, Prognosis and Management. Arrhythm Electrophysiol Rev, 2018. 7(1): p. 43-48. REFERENCE #2: Fumagalli, S., et al., External Cardioversion of Atrial Fibrillation Causes an Early Improvement of Cardiac Performance: A Longitudinal Strain Analysis Study. J Cardiovasc Echogr, 2014. 24(1): p. 10-17. DISCLOSURES: No relevant relationships by Hana Bakalli, source=Web Response No relevant relationships by Aron Bender, source=Web Response No relevant relationships by Jessica Channick, source=Web Response Advisory Committee Member relationship with Actelion Please note: $5001 - $20000 by Richard Channick, source=Web Response, value=Consulting fee Consultant relationship with Actelion Please note: $5001 - $20000 by Richard Channick, source=Web Response, value=Consulting fee Advisory Committee Member relationship with Arena Please note: $5001 - $20000 by Richard Channick, source=Web Response, value=Consulting fee Advisory Committee Member relationship with Bayer Please note: $5001 - $20000 by Richard Channick, source=Web Response, value=Consulting fee Advisory Committee Member relationship with United Therapeutics Please note: $5001 - $20000 by Richard Channick, source=Web Response, value=Consulting fee No relevant relationships by Sonia Jasuja, source=Web Response No relevant relationships by Rajan Saggar, source=Web Response No relevant relationships by Alexander Sherman, source=Web Response

Very large Atrial Septal Defect Device Closure: Feasibility and safety

Objectives: There is limited data regarding feasibility and safety of very large ASD devices deployment. Percutaneous closure of very large atrial septal defect (ASD) is a valid alternative to surgical approach. But complications like erosion, cardiac perforation, atrioventricular block, pericardial effusion, infective endocarditis, or cardiac arrhythmias may occur following ASD device closure.
 Methods: Forty four patients with very large ostium secundum ASD were studied in a tertiary medical centre. Adult patients with defect size of 38 mm or more and device size of 40 mm or more were selected for device closure. Patients having suitable anatomy, significant left to right shunt(>1.5:1) ,right ventricular volume overload and without significant pulmonary arterial hypertension were chosen for device closure.
 Results : There were thirty six female patients and eight male patients in our study. Majority of our patients (twenty four) were in forty to fifty years age group. Device could be deployed successfully in forty two (95.5%). Twelve patients had device size of 46 mm (27%). Eight patients had 44 mm devices(18%). Forty two millimeter devices were used in sixteen patients (36%). Eight patients had device size of 40 mm(18%).Device embolization occurred in two patients. There were two cases of pericardial effusion and pericardiocentesis was needed in one patients. Transient complete heart block was seen in one patient. Four patients had suffered from transient and self terminating atrial arrhythmias. There was no mortality or erosion in our study.
 Conclusion: Percutaneous closure of very large ASD is feasible and associated with low complication rate

NT-proBNP level and lesion of the right ventricle in patients with pulmonary embolism

The aim – to study the relationship between the level of NT-proBNP, clinical-anamnestic and echocardiographic parameters in patients with pulmonary embolism (PE).Materials and methods. The study was carried out on 45 patients with PE, which was confirmed by computed tomo­­graphy. An echocardiographic study was carried out during hospitalization of patients according to the standard protocol. The examination plan of patients, along with standard laboratory tests, included the determination of the level of highly sensitive troponin I, C-reactive peptide (CRP) and NT-proBNP.Results and discussion. The level of NT-proBNP is increased in patients with PE, even in the absence of heart failure (2932±266 pg/ml). There were no significant differences in the level of the indicator depending on the gender of patients (p=0.3), on the presence of arterial hypertension (p=0.92) and the concomitant oncological process (p=0.88). A correlation was found between NT-proBNP level and the size of the right and left atrium: right atrium (p=0.014), left atrium (p=0.025). The relationship between the level of NT-proBNP and the pressure in the pulmonary artery according to ultrasound data was proved (in patients with PE without signs of pulmonary hypertension, the level of NT-proBNP is 405 pg/ml, versus 4067 pg/ml in the group of patients with increased pressure in the pulmonary artery (p=0.0047). A correlation was found between the levels of NT-proBNP and CRP.Conclusions. There is a significant increase in the level of NT-proBNP in patients with PE, the degree of which correlates with an increase in the size of the right atrium and pressure in the pulmonary artery (p=0.0047).

Relationship between air pollution levels in Madrid and the natural history of idiopathic pulmonary fibrosis: severity and mortality

ObjectiveWe aimed to assess the relationship between major air pollutants and the natural history and mortality of idiopathic pulmonary fibrosis (IPF).MethodsWe conducted a retrospective cohort study from 2013 to 2019 among 52 patients with IPF from the pneumology department of a tertiary hospital. According to their geocoded residential address, each patient was assigned a mean concentration of carbon monoxide (CO), nitrogen dioxide, particulate matter 2.5 and 10, ozone, and sulfur dioxide, as measured at a single surveillance station in central Madrid, Spain. We analyzed forced vital capacity (FVC), CO diffusing capacity, 6-minute walking test, degree of dyspnea, radiologic pattern, and signs of pulmonary hypertension in all patients.ResultsPatients’ mean age was 66 ± 10 years, and 79% were men. The mean predicted FVC was 78.9 ± 0.5%. Forty-two patients met the criteria for severe disease, and 18 patients died. Mortality was significantly associated with increased CO exposure (for each 0.1 mg/m2 increase: odds ratio 2.45, 95% confidence interval 1.39–4.56). We observed no association between any of the other investigated contaminants and IPF mortality or severity.ConclusionsAir pollution, specifically that caused by carbon monoxide, can increase mortality in patients with IPF.

Tachycardia and Pre-existing Chronic Kidney Disease Are Predictors of the Worse Clinical Outcomes in Patients Recently Hospitalized With Acute Heart Failure.

Background: This study aimed to assess the factors contributing to the outcomes of recently hospitalized patients with heart failure (HF).Methods: A prospective data of 76 adults who were admitted due to acute HF between October 1, 2019 and June 30, 2020 at our center were analyzed. Endpoints included survival and rehospitalization within six months after discharge.Results: The mean age was 64.9 ± 13.8 years, with a male preponderance (68.4%). Approximately 60.5% of patients had the left ventricular ejection fraction (LVEF) <40%, whereas 26.3% of patients had LVEF ≥50%. Coronary artery disease (75%), arterial hypertension (72.4%), chronic kidney disease (46.1%), and diabetes mellitus (46.1%) were the most frequent comorbidities. Poor compliance (40.8%) and non-cardiac infection (21.1%) were the common precipitating factors for hospitalization. The majority of subjects had severe symptoms, indicated by the frequent need of intensive care unit (43%), high N-terminal prohormone brain natriuretic peptide levels [NT-proBNP; median, 4765 (1539.7-11782.2) pg/mL], and presence of either atrial fibrillation, severe mitral regurgitation, or significant pulmonary hypertension in approximately one-third of cases. Even though in-hospital mortality was relatively low (2.6%), the all-cause mortality and rehospitalization rates in the next six months after discharge were still high, reaching 22.54% and 19.72%, respectively. Further survival analysis showed that tachycardia on admission and pre-existing chronic kidney disease (CKD) resulted in low six-month survival rates among these patients.Conclusion: After hospital discharge, patients with HF were still exposed to higher risks of death and readmission albeit with the medication addressed. Tachycardia on admission and pre-existing CKD might predict worse outcomes.

A review of chest X-ray in pulmonary hypertension: correlation of right descending pulmonary artery diameter with mean pulmonary artery pressure

Background: Pulmonary hypertension is a condition which there is an increase in mean pulmonary artery pressure measured at ≥25 mmHg. The gold standard in diagnosing this condition is right heart catheterization. Enlargement of right descending pulmonary artery on chest radiographs is a sign of pulmonary hypertension. However, the value of radiographic measurements reported was diverse. The study analyzes the correlation between the right descending pulmonary artery (RDPA) diameter on chest radiographs and means pulmonary artery pressure on right heart catheterization to understand whether RDPA diameter on chest X-ray could be a predictor in determining the severity of pulmonary hypertension.Methods: Thirty-five subjects were reviewed to compare RDPA diameter from a chest X-ray on posteroanterior projection and mPAP value from the right heart catheterization. The correlation between them was analyzed using Pearson's correlation test. RDPA diameter cut-off point was defined using the ROC curve.Result: RDPA diameter and mPAP revealed a high positive correlation (p&lt;0.001; r=0.824). The cut-off value of the RDPA diameter was 21.8 mm (sensitivity 81% and specificity 85.7%; AUC =0.9)Conclusion: The measurement of right descending pulmonary artery diameter on chest x-ray positively correlates with mean pulmonary artery pressure. Therefore, the diameter of the right pulmonary artery on the chest x-ray can predict the severity of pulmonary hypertension.

COVID-19 in Children with Congenital Heart Diseases: A Multicenter Case Series from Iran

Background Promptly discovering and counteracting COVID-19 is critical as it could have catastrophic effects. As an asymptomatic group, children are highly susceptible to be misdiagnosed, especially those suffering from underlying diseases. Furthermore, discriminating the direct effects of the virus from those of the underlying diseases can pose a dilemma to physicians. This case series aims to determine the relationship between COVID-19 and various types of congenial heart disease among children. Patients and Methods. Seven patients from three different medical centers were enrolled. Their detailed demographic information, past medical history, symptoms, type of congenital heart diseases, imaging tests, laboratory tests, medications, and outcomes were analyzed. Results The patients included 4 infants, 1 child, and 2 adolescents, with a median age of 9 months and a majority of boys. All of them had either obstructive lesions (right or left ventricular outflow tracts) or significant pulmonary hypertension. The more common clinical symptoms were cough, dyspnea, and fever. Two patients did not survive the illness. Conclusion Prompt treatment of patients with a combination of COVID-19 and severe obstructive cardiac pathology or pulmonary hypertension is essential due to a risk for serious and/or fatal consequences.

Pericardiocentesis induced right ventricular changes in patients with and without pulmonary hypertension

Pericardial effusion drainage in patients with significant pulmonary hypertension (PH) has been questioned because of hemodynamic collapse concern, mainly because of right ventricular (RV) function challenging assessment. We aimed to assess RV function changes related to pericardiocentesis in patients with and without PH. Consecutive patients with symptomatic moderate-to-large pericardial effusion who had either echocardiographic or clinical signs of cardiac tamponade and who underwent pericardiocentesis from 2013 to 2018 were included. RV speckle-tracking echocardiography analysis was performed before and after pericardiocentesis. Patients were stratified by significant PH (pulmonary artery systolic pressure [PASP] ≥50mmHg). The study cohort consisted of 76 patients, 23 (30%) with PH. In patients with PH, both end-diastolic and end-systolic areas (EDA, ESA) increased significantly after pericardiocentesis (22.6±8.0cm2 -26.4±8.4cm2 , P=.01) and (15.9±6.3cm2 -18.7±6.5cm2 , P=.02), respectively. However, RV function indices including fractional area change (FAC: 30.6±13.7%-29.1±8.8%, P=.61) and free-wall longitudinal strain (FWLS: -16.7±6.7 to -15.9±5.0, P=.50) remained unchanged postpericardiocentesis. In contrast, in the non-PH group, after pericardiocentesis, EDA increased significantly (20.4±6.2-22.4±5.9 cm2 , P=.006) but ESA did not (14.9±5.7 vs 15.0±4.6cm2 , P=.89), and RV function indices improved (FAC 27.9±11.7%-33.1±8.5%, P=.003; FWLS -13.6±5.4 to -17.2±3.9%, P<.001). Quantification of RV size and function can improve understanding of echocardiographic and hemodynamic changes postpericardiocentesis, which has the potential to guide management of PH patients with large pericardial effusion.

Study design of a randomised, placebo-controlled trial of nintedanib in children and adolescents with fibrosing interstitial lung disease.

Childhood interstitial lung disease (chILD) comprises >200 rare respiratory disorders, with no currently approved therapies and variable prognosis. Nintedanib reduces the rate of forced vital capacity (FVC) decline in adults with progressive fibrosing interstitial lung diseases (ILDs). We present the design of a multicentre, prospective, double-blind, randomised, placebo-controlled clinical trial of nintedanib in patients with fibrosing chILD (1199-0337 or InPedILD; ClinicalTrials.gov: NCT04093024).Male or female children and adolescents aged 6–17 years (≥30; including ≥20 adolescents aged 12–17 years) with clinically significant fibrosing ILD will be randomised 2:1 to receive oral nintedanib or placebo on top of standard of care for 24 weeks (double-blind), followed by variable-duration nintedanib (open-label). Nintedanib dosing will be based on body weight-dependent allometric scaling, with single-step dose reductions permitted to manage adverse events. Eligible patients will have evidence of fibrosis on high-resolution computed tomography (within 12 months of their first screening visit), FVC ≥25% predicted, and clinically significant disease (Fan score of ≥3 or evidence of clinical progression over time). Patients with underlying chronic liver disease, significant pulmonary arterial hypertension, cardiovascular disease, or increased bleeding risk are ineligible. The primary endpoints are pharmacokinetics and the proportion of patients with treatment-emergent adverse events at week 24. Secondary endpoints include change in FVC% predicted from baseline, Pediatric Quality of Life Questionnaire, oxygen saturation, and 6-min walk distance at weeks 24 and 52. Additional efficacy and safety endpoints will be collected to explore long-term effects.

Echocardiographic Evaluation of Cardiac Status in Patients with Chronic Obstructive Pulmonary Disease

Background: Chronic Obstructive Pulmonary Disease (COPD) is a global health burden having systemic and extrapulmonary manifestations. Among them cardiovascular changes are the major comorbidity associated with COPD, responsible for significant morbidity and mortality. Echocardiography is one of the simplest and noninvasive tools in assessing these changes. Objective: To evaluate the echocardiographic changes in patients with chronic obstruction palmonary disease. Methods: A cross sectional observational study was carried out in Department of Cardiology and Department of Respiratory Medicine, Dhaka Medical College Hospital from July, 2018 to June, 2019. Total 98 COPD patients were included in the study. They underwent spirometry in Department of Respiratory Medicine and echocardiography in Department of Cardiology. Data was collected from the patients and recorded in a structured report form. Results: Significant echocardiographic abnormalities were present in 51.02% patients. Most common echocardiographic change was pulmonary hypertension (43.9%). Other echocardiographic findings were dilated RA &amp; RV (36.7%), RVH (35.7%), LV diastolic dysfunction (30.6%) and RV systolic dysfunction (9.2%). Echocardiographic signs of pulmonary hypertension, dilated RA &amp; RV, RVH, RV systolic dysfunction and LV diastolic dysfunction were correlated with the severity of the disease. Though echocardiographic change of pulmonary hypertension was uncommon in COPD stage 1 &amp; 2, but it was very common in stage 3(45.7%) &amp; stage 4(92.9%). Conclusion: This study showed that echocardiographic changes were very common among the COPD GOLD stage 3 &amp; 4 patients. Though these changes were infrequent among mild COPD patients but their severity increased with increasing stage of COPD. Bangladesh Med Res Counc Bull 2020; 46(3): 204-210

Evolution of cardiac function in COVID 19 patients in the intensive care unit: insights from machine learning

Funding AcknowledgementsType of funding sources: None.BackgroundRepeated echocardiographic assessment of cardiac function is integral in management of intensive care units (ICU) patients. Machine learning (ML) can assist by integrating whole-cardiac cycle echo data derived from flow assessment and deformation imaging, and grouping patients on the basis of patterns of cardiac dysfunction and its evolution over time. Cardiac involvement has been suggested to be important in COVID-19 outcome and echo evaluation can inform on cardiac status. We use unsupervised ML to investigate and integrate longitudinal data from the COVID-HO study (NCT04371679) to determine the potential of tracking changes in cardiac function during ICU hospitalization. MethodsIn a single-centre, COVID-19 patients (n = 38) were prospectively followed with echocardiography as part of ICU management. The endpoint was defined as death or ICU discharge. LV myocardial deformation, as well as aortic, mitral and pulmonary artery blood-pool Doppler velocity profiles were used as input for ML. Clinical data was used to validate the ML derived phenotypes. Echo data from the initial and final echo examination were used to create an output space where participants were positioned based on cardiac function blinded to outcome status. Regression was used to estimate the echo and clinical characteristics of different regions in the space. Patient trajectories in the output space were investigated for each patient.ResultsEndpoint was not reached in 24% (n = 9) at the time of analysis. The cohort was 68% male, aged 65 ± 12 years, and with an ICU mortality 21% (n = 8). The median spent in ICU was 10 (IQR 7-18) days. The ML analysis demonstrated a heterogeneous output space (Fig 1A) we could define a gradual change in the shape of the pulmonary outflow velocity profile, from a normal towards pulmonary hypertension (Fig 1A, x axis). Jointly with differences in diastolic function (mitral inflow fusion and A wave accentuation) defined two regions: with signs of pulmonary hypertension (gray); and with normal pulmonary pressures but LV diastolic dysfunction (yellow). Investigation of patient trajectories (Fig 1B) demonstrated the feasibility of tracking changes during ICU hospitalization, showing a shift of a patient that died in the ICU, from initial diastolic dysfunction towards pulmonary hypertension (red), and a patient shifting from a region with normal diastolic function towards pulmonary hypertension, but with a positive outcome (blue). Echo data concurs with observed dynamics (Fig 1C and 1D).ConclusionML can integrate complex, whole-cardiac cycle echo data to group heterogeneous patients based on similarity of cardiac function. Patient trajectories across the output space demonstrate the feasibility of ML for echo data-based follow-up of patients during ICU hospitalization. Further echo and clinical data integration can improve characterisation of the output space regions and better define changes in cardiac function during hospitalization. Figure 1

Con: General Anesthesia Is Not Superior to Regional Anesthesia for Patients With Pulmonary Hypertension Undergoing Noncardiac Surgery

PATIENTS with significant pulmonary hypertension (PH) are known high-risk surgical candidates because of an increased incidence of adverse cardiopulmonary outcomes. 1 Smilowitz NR Armanious A Bangalore S et al. Cardiovascular outcomes of patients with pulmonary hypertension undergoing noncardiac surgery. Am J Cardiol. 2019; 123: 1532-1537 Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar , 2 Lai H-C Lai H-C Wang K-Y et al. Severe pulmonary hypertension complicates postoperative outcome of non-cardiac surgery. Br J Anaesth. 2007; 99: 184-190 Abstract Full Text Full Text PDF PubMed Scopus (137) Google Scholar , 3 Fox C Kalarickal PL Yarborough MJ et al. Perioperative management including new pharmacological vistas for patients with pulmonary hypertension for noncardiac surgery. Curr Opin Anaesth. 2008; 21: 467-472 Crossref PubMed Scopus (26) Google Scholar , 4 Gille J Seyfarth H-J Gerlach S et al. Perioperative anesthesiological management of patients with pulmonary hypertension. Anesth Res Pract. 2012; 2012: 1-16 Crossref Scopus (42) Google Scholar Despite the significant morbidity and mortality risk and increasing frequency of PH among surgical candidates, 5 Sarkar MS Desai PM. Pulmonary hypertension and cardiac anesthesia: Anesthesiologist's perspective. Ann Card Anaesth. 2018; 21: 116-122 PubMed Google Scholar ,6 Pritts CD Pearl RG. Anesthesia for patients with pulmonary hypertension. Curr Opin Anaesth. 2010; 23: 411-416 Crossref PubMed Scopus (66) Google Scholar the optimal anesthetic approach to significant PH remains controversial. Caring for such patients requires continuous evaluation of the delicate balance between maximizing cardiopulmonary blood flow and minimizing factors known to worsen this condition. The authors of the present report believe that regional anesthesia (RA) affords a number of advantages over general anesthesia (GA) in providing safe, optimal, perioperative management of patients with PH undergoing noncardiac surgery.

Design-Based Stereology of the Lung in the Hyperoxic Preterm Rabbit Model of Bronchopulmonary Dysplasia.

Bronchopulmonary dysplasia (BPD) is a complex condition frequently occurring in preterm newborns, and different animal models are currently used to mimic the pathophysiology of BPD. The comparability of animal models depends on the availability of quantitative data obtained by minimally biased methods. Therefore, the aim of this study was to provide the first design-based stereological analysis of the lungs in the hyperoxia-based model of BPD in the preterm rabbit. Rabbit pups were obtained on gestation day 28 (three days before term) by cesarean section and exposed to normoxic (21% O2, n = 8) or hyperoxic (95% O2, n = 8) conditions. After seven days of exposure, lung function testing was performed, and lungs were taken for stereological analysis. In addition, the ratio between pulmonary arterial acceleration and ejection time (PAAT/PAET) was measured. Inspiratory capacity and static compliance were reduced whereas tissue elastance and resistance were increased in hyperoxic animals compared with normoxic controls. Hyperoxic animals showed signs of pulmonary hypertension indicated by the decreased PAAT/PAET ratio. In hyperoxic animals, the number of alveoli and the alveolar surface area were reduced by one-third or by approximately 50% of control values, respectively. However, neither the mean linear intercept length nor the mean alveolar volume was significantly different between both groups. Hyperoxic pups had thickened alveolar septa and intra-alveolar accumulation of edema fluid and inflammatory cells. Nonparenchymal blood vessels had thickened walls, enlarged perivascular space, and smaller lumen in hyperoxic rabbits in comparison with normoxic ones. In conclusion, the findings are in line with the pathological features of human BPD. The stereological data may serve as a reference to compare this model with BPD models in other species or future therapeutic interventions.