Vasodilator Testing Research Articles

Clinical and pathogenetic features of the development of endothelial dysfunction in patients with chronic kidney disease and its contribution to the development of cognitive impairments

THE AIM: to study the clinical and pathogenetic features of the development of endothelial dysfunction (ED) in patients with chronic kidney disease stages 3A-5D and its contribution to the development of cognitive impairment.PATIENTS AND METHODS: The study included 80 patients with CKD stages 3A-5D aged from 26 to 79 years (average age 58.9 ± 1.4 years): 43 women (average age 60.1 ± 1.9 years) and 37 men (average age 57.4±2.3 years). The patients were divided into 2 groups: group 1 included 40 patients with CKD 3A-5 (average age 59.9 ± 2.1 years), group 2 included 40 patients with CKD 5D (average age 58.1 ± 2 years). All patients underwent common and biochemical blood tests, the levels of endothelial nitric oxide synthase 3 (eNOS-3) and endothelin-1 (END-1) were determined, an endothelium-dependent vasodilation test (EDVD) was performed, testing for the presence and severity of cognitive disorders using the Montreal Cognitive Assessment Scale (MoCA) and the Mini Mental State Examination (MMSE).RESULTS: The prevalence of ED in the overall cohort of patients based on the results of a positive test with EDVD was 55 % of cases. ED was statistically significantly more often detected in the group of patients receiving hemodialysis treatment compared to patients in group 1: 70 % versus 40 %, respectively (p=0.007). The level of eNOS-3 in group 1 was higher compared to group 2 and amounted to 1.01±0.5 ng/ml versus 0.76±0.3 ng/ml (p=0.008). While the level of END-1 was statistically significantly lower in patients of group 1 compared to group 2 and amounted to 45.4±9.1 pg/ml versus 54.9±4.7 pg/ml (p<0.001). Cognitive impairments were identified in the general cohort: according to MMSE – in 67.5 % of cases, according to MoCA – in 71.3 %, and were more common in group 2. There were no statistically significant relationships between the results of the EDVD test and testing on the MoCA and MMSE scales. The level of eNOS-3 was lower in the subgroup of patients with cognitive impairment according to MoCA compared to the subgroup without it: 0.73±0.1 ng/ ml versus 0.94±0.2 ng/ml (p=0.127). The content of END-1 was statistically significantly higher in the subgroup of patients with cognitive impairment according to MoCA – 52.98±1.2 pg/ml compared to the subgroup without it – 47.67±1.5 pg/ml (p=0.043). When assessing the relationship between the levels of eNOS-3 and END-1 and the results of the EDVD test, it was found that in patients with a positive test in group 1, the level of eNOS-3 was statistically significantly higher compared to group 2 (p=0.01). An inverse relationship was observed for END-1; its level was lower in patients of group 1 compared to group 2 (p<0.01).CONCLUSION. Thus, the study revealed a high prevalence of endothelial dysfunction in patients with CKD stages 3A-5D. Progressive loss of renal function leads to dysregulation of the molecular mechanisms controlling vascular tone and the development of ED. eNOS-3 and END-1 have demonstrated high sensitivity for ED verification, and their detection improves the quality of the EDVD test. The development and progression of ED in patients with CKD is a multifactorial process that leads to hemodynamic disturbances in various organs and tissues, their damage and has a negative impact on the patient’s quality of life, his cognitive status and life expectancy.

The effects of oxygenation on acute vasodilator challenge in pulmonary arterial hypertension.

Identification of long-term calcium channel blocker (CCB) responders with acute vasodilator challenge is critical in the evaluation of patients with pulmonary arterial hypertension. Currently there is no standardized approach for use of supplemental oxygen during acute vasodilator challenge. In this retrospective analysis of patients identified as acute vasoresponders, treated with CCBs, all patients had hemodynamic measurements in three steps: (1) at baseline; (2) with 100% fractional inspired oxygen; and (3) with 100% fractional inspired oxygen plus inhaled nitric oxide (iNO). Those meeting the definition of acute vasoresponsiveness only after first normalizing for the effects of oxygen in step 2 were labeled "iNO Responders." Those who met the definition of acute vasoresponsiveness from a combination of the effects of 100% FiO2 and iNO were labeled "oxygen responders." Survival, hospitalization for decompensated right heart failure, duration of CCB monotherapy, and functional data were collected. iNO responders, when compared to oxygen responders, had superior survival (100% vs. 50.1% 5-year survival, respectively), fewer hospitalizations for acute decompensated right heart failure (0% vs. 30.4% at 1 year, respectively), longer duration of CCB monotherapy (80% vs. 52% at 1 year, respectively), and superior 6-min walk distance. Current guidelines for acute vasodilator testing do not standardize oxygen coadministration with iNO. This study demonstrates that adjusting for the effects of supplemental oxygen before assessing for acute vasoresponsiveness identifies a cohort with superior functional status, tolerance of CCB monotherapy, and survival while on long-term CCB therapy.

The oxidized phospholipid PGPC impairs endothelial function by promoting endothelial cell ferroptosis via FABP3

Ferroptosis is a novel cell death mechanism that is mediated by iron-dependent lipid peroxidation. It may be involved in atherosclerosis development. Products of phospholipid oxidation play a key role in atherosclerosis. 1-palmitoyl-2-glutaroyl-sn-glycero-3-phosphocholine (PGPC) is a phospholipid oxidation product present in atherosclerotic lesions. It remains unclear whether PGPC causes atherosclerosis by inducing endothelial cell ferroptosis. In this study, human umbilical vein endothelial cells (HUVECs) were treated with PGPC. Intracellular levels of ferrous iron, lipid peroxidation, superoxide anions (O2•−), and glutathione were detected, and expression of fatty acid binding protein-3 (FABP3), glutathione peroxidase 4 (GPX4), and CD36 were measured. Additionally, the mitochondrial membrane potential (MMP) was determined. Aortas from C57BL6 mice were isolated for vasodilation testing. Results showed that PGPC increased ferrous iron levels, the production of lipid peroxidation and O2•−, and FABP3 expression. However, PGPC inhibited the expression of GPX4 and glutathione production and destroyed normal MMP. These effects were also blocked by ferrostatin-1, an inhibitor of ferroptosis. FABP3 silencing significantly reversed the effect of PGPC. Furthermore, PGPC stimulated CD36 expression. Conversely, CD36 silencing reversed the effects of PGPC, including PGPC-induced FABP3 expression. Importantly, E06, a direct inhibitor of the oxidized 1-palmitoyl-2-arachidonoyl-phosphatidylcholine IgM natural antibody, inhibited the effects of PGPC. Finally, PGPC impaired endothelium-dependent vasodilation, ferrostatin-1 or FABP3 inhibitors inhibited this impairment. Our data demonstrate that PGPC impairs endothelial function by inducing endothelial cell ferroptosis through the CD36 receptor to increase FABP3 expression. Our findings provide new insights into the mechanisms of atherosclerosis and a therapeutic target for atherosclerosis.

Effect of Acute Vasodilator Testing Using Oxygen in Pulmonary Hypertension Due to Left Heart Disease.

Pulmonary vasodilators, including oxygen, have not shown consistent beneficial effects on pulmonary hypertension due to valvular heart disease (PH-VHD). Therefore, the study aimed to assess the effect of 100% fractional inspiration of oxygen (FiO2) on pulmonary and systemic hemodynamics in patients with combined pre- and post-capillary pulmonary hypertension (CpcPH) and isolated post-capillary pulmonary hypertension (IpcPH) due to PH-VHD. This prospective study was conducted among patients with PH-VHD undergoing mitral or aortic valve replacement or repair. The study was conducted after induction of anesthesia and pulmonary artery catheterization. Cardiac output was obtained using thermodilution and all direct, and derived hemodynamic variables were obtained at 30% and 100% FiO2. The patients were stratified a priori into responders {(≥10mmHg fall in mean pulmonary artery pressure (MPAP)} and non-responders. Fifty-seven patients completed the acute vasodilator test. The mean age and body mass index of the study population was 41.8 ± 14.1years and 21.4 ± 4.6kg/m2, respectively. There was a significant decrease in MPAP (40.77 ± 12.07mmHg vs 36.74 ± 13.3mmHg; P < .001) and pulmonary vascular resistance (PVR) {(median; Interquartile range (IQR); 388; 371 vs 323; 362dynes sec.cm-5; P < .001) at 100% FiO2. Transpulmonary gradient (TPG) and diastolic pulmonary gradient (DPG) also decreased significantly (P < .001 and P < .001). Cardiac output did not change significantly. The magnitude of decrease in MPAP, PVR, TPG, DPG, and pulmonary artery compliance (PAC) between CpcPH and IpcPH was comparable. Responders did not show a significantly greater fall in MPAP, PVR, TPG, DPG, and PAC after surgery. Hyperoxia may lead to reduction in MPAP and PVR in both hemodynamic phenotypes of PH-VHD. A larger sample size is required to support or refute the findings of this study.

Evaluation of endothelial dysfunction and inflammation in recovered COVID-19 patients

Aim: In our study, we aimed to evaluate the endothelial functions and hemogram parameters, which are considered as inflammation markers, in young people with a history of COVID-19 infection.&#x0D; Methods: This prospective study included 109 recovered COVID-19 patients and 50 healthy controls. Demographic characteristics, laboratory values and flow-mediated vasodilation test (FMD) results of the groups were compared.&#x0D; Results: Demographic and biochemistry parameters of the groups were similar. The calculated FMD values were significantly lower in the recovered COVID-19 patient group compared to the control group (8.66±3.31 vs 11.69±3.01; p= 0.001). While there was no difference between the groups in terms of neutrophil/lymphocyte ratio (NLR) and Platelet/Lymphocyte ratio (PLR), systemic immune-inflammation index (SII) was found to be higher in the patient group with recovered COVID-19 patients (p = 0.02). In correlation analysis, there was a low moderate negative correlation between FMD and SII (r = -0.35, p=0.002).&#x0D; Conclusion: FMD measurement and SII are simple, easily accessible parameters that can be useful in the early period to evaluate cardiovascular risks in the long term after COVID-19. There is a need for larger and multicenter studies on this subject.

Thermoregulation of Tuvan pastoralists and Western Europeans during cold exposure.

This study compared the metabolic and vascular responses, to whole-body and finger cold exposure, of a traditional population lifelong exposed to extreme cold winters with Western Europeans. Thirteen cold acclimatized Tuvan pastoralist adults (45 ± 9 years; 24.1 ± 3.2 kg/m2 ) and 13 matched Western European controls (43 ± 15 years; 22.6 ± 1.4 kg/m2 ) completed a whole-body cold (10°C) air exposure test and a cold-induced vasodilation (CIVD) test, which involved the immersion of the middle finger into ice-water for 30 min. During the whole-body cold exposure, the durations until the onset of shivering for three monitored skeletal muscles were similar for both groups. Cold exposure increased the Tuvans' energy expenditure by (mean ± SD) 0.9 ± 0.7 kJ min-1 and the Europeans' by 1.3 ± 1.54 kJ min-1 ; these changes were not significantly different. The forearm-fingertip skin temperature gradient of the Tuvans was lower, indicating less vasoconstriction, than the Europeans during the cold exposure (0 ± 4.5°C vs. 8.8 ± 2.7°C). A CIVD response occurred in 92% of the Tuvans and 36% of the Europeans. In line, finger temperature during the CIVD test was higher in the Tuvans than the Europeans (13.4 ± 3.4°C vs. 3.9 ± 2.3°C). Cold-induced thermogenesis and the onset of shivering were similar in both populations. However, vasoconstriction at the extremities was reduced in the Tuvans compared to the Europeans. The enhanced blood flow to the extremities could be beneficial for living in an extreme cold environment by improving dexterity, comfort, and reducing the risk of cold-injuries.

(357) Nocturnal Penile Tumescence Test in Patients with Erectile Dysfunction Associates With Penile and Systemic Vascular Disease

Abstract Introduction Erectile dysfunction (ED) is the most frequent male sexual dysfunction along with premature ejaculation. Moreover, its prevalence is increasing worldwide due to ageing of the population and spreading of risk factors like obesity, diabetes, hypercholesterolemia, hypertension, etc. Also, it represents an important cardiovascular risk marker because of its demonstrated tight association with cardiovascular disease (CVD). We dispose of many diagnostic tools to assess ED and a proper workup includes the anamnesis, a physical exploration, blood tests for hormonal and metabolic evaluation, and ED grading through validated questionnaires such as the International Index of Erectile Function (IIEF). One of the instrumental tests we may indicate is the nocturnal penile tumescence (NPT) test or “Rigiscan”. This test measures the spontaneous erections overnight and helps discriminating between organic and psychological ED. However, this is a highly specific but low sensitive test since a positive (normal) result can roll out an organic ED and suggest a psychological etiology while a negative result cannot confirm or exclude an organic condition. Objectives In this context the aim of this study is to investigate the predictive role of Rigiscan in discriminating patients with an organic ED and the presence of vascular disease in patients with ED. Methods We conducted a prospective study in patient 25 patient who underwent a Rigiscan test as part of ED assessment. Each patient had blood tests for hormonal and metabolic analysis, a measurement of the carotid intima-media thickness (cIMT), a brachial flow-mediated vasodilation test (FMD), and a penile color doppler ultrasound (PCDU) to assess penile hemodynamics. Results Our patients had a mean age of 47.9 ± 13.7 years, with a mean IIEF score of 9.0 ± 6.5. Among them 13 (54.2%) were active smokers, 5 (20.8%) were diabetics, 8 (32%) had dyslipidemia, and 4 (16.7%) had hypertension. Eleven patients (44%) had a normal Rigiscan while 14(56%) had a pathological result. We found that patient with a pathological Rigiscan presented with a cluster of impaired vascular function at different levels. In particular, they had statistically lower peak systolic velocity (PSV) in the PCDU (52.5 vs 80.2 cm/s p=0.014) and a higher prevalence of arterial insufficiency (42.9% vs 0.0% p=0.020). Moreover, in patients with negative Rigiscan, there was a higher cIMT (0.9 vs 0.7 mm) and lower response to FMD (7.7% vs 9.6%) with a more frequent diagnose of impaired FMD (63.6% vs 46.2%) but without reaching a statistically significance. Conclusion We can conclude that a negative Rigiscan is indicative of altered penile hemodynamics and may suggests the presence of systemic vascular disease. Therefore, while a positive Rigiscan excludes organic ED, a negative Rigiscan should be considered a cardiovascular risk marker and induce the clinician to address the cardiovascular risk in that patient. More studies with larger population are warranted to confirm and further investigated these findings. Disclosure No

Acute vasoreactivity testing during right heart catheterization in chronic thromboembolic pulmonary hypertension: Results from the pulmonary vascular disease phenomics study.

Chronic thromboembolic pulmonary hypertension (CTEPH) is believed to involve both vascular obstruction and vasoconstriction; hence, pulmonary vasodilators such as riociguat may be beneficial. Acute vasoreactivity testing (AVT) is seldom performed routinely in CTEPH patients, so there is limited understanding of the frequency and significance of an acute vasodilator response. Systematic vasodilator testing with oxygen (O2) and oxygen plus inhaled nitric oxide (O2 + iNO) was performed as part of the Pulmonary Vascular Disease Omics (PVDOMICS) NHLBI project, providing an opportunity to examine AVT responses in CTEPH. Patients with CTEPH enrolled in PVDOMICS (n = 49, 40 with prevalent CTEPH[82%])underwent right heart catheterization including AVT with O2 and O2 + iNO. Hemodynamics were obtained at baseline and with each challenge. Fourteen of 49 patients (29%) had >20% drop in pulmonary vascular resistance (PVR) with O2. With O2 + iNO, 30/49 (61%) had >20% drop in PVR, 20% had >20% drop in mean pulmonary artery pressure(mPAP) and PVR, and 8% had >10 mmHg decline in mPAP to mPAP < 40 with normal cardiac output. Patients on riociguat had less response to O2 + iNO than patients on phosphodiesterase-5inhibitors. Our findings shed light on the significant variability in vascular tone that is present in CTEPH, confirming that CTEPH represents a combination of mechanical obstruction and vasoconstriction that appears similar to that observed with Group 1 PAH. Additional study regarding whether results of acute vasodilator testing predict response to therapy and relate to prognosis is warranted.

1021 VASODILATOR CHALLENGE TEST WITH ISOSORBIDE DINITRATE DURING RIGHT HEART CATHETERIZATION: ANY ROLE IN POST-CAPILLARY PULMONARY HYPERTENSION PHENOTYPING?

Abstract Background and aims Despite recent advances in the diagnosis and treatment of pulmonary arterial hypertension (PAH), pulmonary hypertension associated with heart failure with preserved ejection fraction (HFpEF-PH) still represents a diagnostic and therapeutic dilemma. Among HFpEF-PH patients, discriminating between isolated post-capillary (IpcPH) from combined post-/pre-capillary (CpcPH) PH, and especially a better understanding of the latter, is still challenging. Such a distinction can have an important therapeutic impact, as new evidence suggests that therapy with PDE5i might be beneficial in specific CpcPH patients [Humbert M, Kovacs G, Hoeper M et al. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J, 2022]. Our study sought to comprehensively assess and explore the role of Isosorbide Dinitrate (ISDN) testing in HFpEF-PH phenotyping. Methods From November 2019, all patients referred to our service to investigate PH and elevated pulmonary artery wedge pressures (PAWP) at rest or after fluid challenge at the time of the right heart catheterization, had a vasodilator test with a slow IV bolus of ISDN (with a specific protocol). Clinical, echocardiographic and hemodynamic data were collected. Results 38 patients (25 CpcPH, 13 IpcPH) were included in the analysis. Baseline characteristics are shown in table 1. Based on ISDN response, patients were stratified into three groups (Table 2). Group 1 showed a lack of significant pressures reduction after ISDN (“vasodilator negative Cpc-PH”). Group 2 displayed a significant reduction of PAWP &amp;lt; 15 mmHg, but persistent PH and high Pulmonary Vascular Resistance (PVR) (“vasodilator positive Cpc-PH”). Group 3 were patients whose pulmonary pressures normalized after ISDN (Ipc-PH). Conclusions albeit on a small group of patients, our preliminary results warrant further studies on the potential role of ISDN in better phenotyping HFpEF-PH and identify subgroups of patients who might benefit from PH specific therapies (“vasodilator positive Cpc-PH”) after treatment of the underling left heart disease.

AVOIDING THYROID TESTING FATIGUE: PULMONARY ARTERIAL HYPERTENSION (PAH) IN A PATIENT WITH HASHIMOTO DISEASE

AVOIDING THYROID TESTING FATIGUE: PULMONARY ARTERIAL HYPERTENSION (PAH) IN A PATIENT WITH HASHIMOTO DISEASE

Comparison of intravenous sildenafil with inhaled nitric oxide for acute vasodilator testing in pulmonary arterial hypertension.

Acute vasodilator testing (AVT) identifies acute responders for initiation of calcium channel blockers in pulmonary arterial hypertension (PAH) and operability in congenital heart disease (CHD). We sought to determine the feasibility of intravenous sildenafil (ivS) as an alternative to inhaled nitric oxide (iNO) in AVT. All patients with PAH undergoing cardiac catheterization for AVT (November 2015 to December 2020) were prospectively enrolled. Hemodynamic data were obtained at baseline, with iNO 20 ppm and ivS (0.25 mg/kg for children and 10 mg for adults). We studied 44 patients with a mean age of 20.5 ± 14.4 years (27 [61%] females and 20 [45%]children). There were 17 (38.6%) patients in theCHD group for operability assessment and 27 patients in non-CHD group (idiopathic pulmonary arterial hypertension-16 [36.3%], residual PAH after shunt closure-7 [15.9%], and 2 cases [4.5%] each of familial PAH and portopulmonary hypertension). There was an excellent intraclass correlation for mean pulmonary artery pressures (0.903, 95% confidence interval,CI: 0.809-0.949, p < 0.001), mean aortic pressures (0.745, 95% CI: 0.552-0.858, p < 0.001), pulmonary vascular resistance index (0.920, 95% CI: 0.858-0.956, p < 0.001), systemic vascular resistance (SVR) index (0.828, 95% CI: 0.706-0.902, p < 0.001), and the ratio of pulmonary and SVR indices (0.857, 95% CI: 0.752-0.919, p < 0.001) between the two agents. There were two responders, both in non-CHD group, and were identified by iNO and ivS. The hemodynamic effects of ivS show excellent correlation with iNO and could be a potential alternative agent for identifying acute responders during AVT.

Long-term prognostic value of cardiac catheterization and acute vasodilator testing with inhaled iloprost in pediatric idiopathic pulmonary arterial hypertension.

To assess the long-term prognostic value of cardiac catheterization and acute vasodilator testing (AVT) with inhaled iloprost in children with idiopathic pulmonary arterial hypertension (IPAH).Data on 81 consecutive children with IPAH referred to our center who underwent cardiac catheterization and AVT between June 2008 and August 2019 were collected. The correlation between the invasive hemodynamic data and transplant-free survival was analyzed. Twenty-four patients died and 1 underwent lung transplantation during a median follow-up of 3.8 years, with a 5-year transplant-free survival rate of 64.9%. Univariate analysis showed that predictors associated with improved survival included a lower pulmonary vascular resistance index (PVRI), PVRI/systemic vascular resistance index (SVRI), mean pulmonary arterial pressure (mPAP)/mean systemic arterial pressure, mean right atrial pressure, and a higher cardiac index (CI), mixed systemic venous oxygen saturations (SvO2), and acute vasodilator response (AVR) according to the Barst criteria (decrease in mPAP and PVRI/SVRI ratio of >20% without a decrease in CI). In multivariate Cox regression analysis, Barst AVR and SvO2 were independently related to transplant-free survival. Multiple hemodynamic variables from cardiac catheterization and AVT with inhaled iloprost have important prognostic value for long-term survival in children with IPAH, of which pulmonary vasoreactivity defined by the Barst criteria and SvO2 are independent prognostic factors.

The state of platelet and plasma hemostasis as a predictor of coronary blood flow in patients with acute myocardial infarction.

Aim To study the relationship of the platelet function and plasma homeostasis with the blood flow in the infarct-related artery (IRA) and with the course of acute myocardial infarction (AMI).Material and methods This study included 93 patients with AMI (75 patients with ST-elevation AMI and 18 patients without ST segment elevation). 63 patients had TIMI 0-1 blood flow in the IRA and 30 patients had TIMI 2-3. Rotational thromboelastometry, impedance aggregometry, the endothelium-dependent vasodilation (EDVD) test, and the thrombodynamics test were performed for all patients. The primary clinical endpoint included the totality of in-hospital complications of AMI, and the secondary endpoint included the totality of out-of-hospital complications of AMI. Major bleedings (BARC 3-5) and minor bleedings (BARC 1-2) were evaluated separately.Results Patients with IRA TIMI 0-1 flow were characterized by a shorter blood clotting time (BCT), larger thrombus size and density, more intense platelet aggregation induced by arachidonic acid and ADP, and lower values of the EDVD test. It was found that the parameters of platelet aggregation induced by arachidonic acid (AUC Asa) in combination with BCT allowed assessment of the severity of IRA blood flow disorder (sensitivity 76 %, specificity 71 %) in patients with AMI, regardless of the presence of ST segment elevation on the ECG. In addition, the incidence of the primary endpoint was greater in patients with IRA TIMI 0-1 flow (41.3% and 16.7%, respectively; p=0.015). In patients with TIMI 2-3 flow in the long-term period of the disease, the incidence of minor bleedings was significantly higher (8.5% and 30.4 %, respectively; p=0.045).Conclusion Compared to patients with preserved blood flow, patients with AMI and IRA TIMI 0-1 flow are characterized by endothelial dysfunction and more intense processes of thrombogenesis and platelet aggregation. It has been shown for the first time that the combination of two simple criteria for assessing hemostasis (AUC Asa; BCT) allows assessment of the degree of IRA blood flow disorder in patients with AMI.

TGF-β receptor mutations and clinical prognosis in Chinese pediatric patients with idiopathic/hereditary pulmonary arterial hypertension.

The relationship between clinical prognosis and transforming growth factor‐β (TGF‐β) receptor mutations in Chinese pediatric patients with idiopathic/hereditary pulmonary arterial hypertension (IPAH/HPAH) remains unclear. We retrospectively studied the clinical characteristics and outcomes of pediatric patients with IPAH/HPAH who visited our Hospital from September 2008 to December 2020. One hundred and five pediatric patients with IPAH/HPAH were included, 46 of whom carried TGF‐β receptor mutations with a mean age at diagnosis of 82.8 ± 52.7 months, and 67 of them underwent right cardiac catheterization examinations and acute vasodilator testing. The result showed that mutation carriers demonstrated higher pulmonary vascular resistance (p = 0.012), higher right atrial pressure (p = 0.026), and lower cardiac index (p = 0.003). The 1‐, 2‐, and 3‐year survival rates of mutation carriers were 79.4%, 61.5% and 55.6%, respectively, compared with 96.6%, 91.1%, and 85.4% for nonmutation carriers (p = 0.0001). The prognosis of mutation carriers was significantly worse than that of nonmutation carriers. TGF‐β receptor gene mutation is an independent risk factor for death (p = 0.049, odd raito = 3.809, 95% confidence interval 1.006−14.429). In conclusion, TGF‐β receptor mutation is an important genetic factor for the onset of IPAH/PAH in Chinese pediatric patients. Those who carrying TGF‐β receptor mutations have a poor clinical prognosis. Therefore, TGF‐β receptor gene screening for pediatric patients with PAH and more aggressive treatment for mutation carriers are recommended.

A case report of a 37-year-old woman with pulmonary arterial hypertension first presented during her 3rd pregnancy and favourable long-term vasoreactive response

BackgroundPulmonary arterial hypertension is a rare disease associated with high rates of mortality and can significantly complicate pregnancy posing health risks for the mother and child alike.Case summaryWe present the case of a 37-year-old female patient with World Health Organisation functional Class IV symptoms during the 34th week of her 3rd pregnancy. Initial echocardiography showed a significantly elevated estimated systolic pulmonary artery pressure of 86 mmHg + central vein pressure as well as signs of chronic pulmonary hypertension. After a successful emergent caesarean section, pulmonary hypertension was confirmed via right heart catheterization. After exclusion of secondary aetiologies of pulmonary hypertension, the diagnosis of Class 1 pulmonary artery hypertension was made. We initially treated the patient with the phosphodiesterase-5 inhibitor sildenafil (20 mg oral bid trice daily) and later extended the medication with the dual endothelin receptor antagonist Macicentan (10 mg daily). Since the patient remained symptomatic vasodilator testing was performed and showed a significant response to intravenous Epoprostenol. We initiated a high-dose calcium channel blocker (CCB) therapy with amlodipine (20 mg daily) which led to symptomatic relief, increased exercise capacity as well as reduction in mean pulmonary artery pressure and pulmonary vascular resistance as confirmed by another right heart catheterization after therapy initiation.DiscussionSince the presentation is usually non-specific, the diagnosis of pulmonary artery hypertension can be challenging and cause a delay in treatment initiation. Even though rare vasodilator testing and invasive haemodynamic measurements should be performed to identify patients with favourable long-term response to high-dose CCB.

Cardiac Catheterization and Hemodynamics in a Multicenter Cohort of Children with Pulmonary Hypertension.

Rationale: Hemodynamic assessments direct care among children with pulmonary hypertension, yet the use of cardiac catheterization is highly variable, which could impact patient care and research. Objectives: We analyzed hemodynamic findings from right heart catheterization (RHC) and left heart catheterization and acute vasodilator testing (AVT) and the safety of catheterization in children with World Symposium on Pulmonary Hypertension (WSPH) group 1 and 3 subtypes in a large multicenter North American cohort. Methods: Of 1,475 children enrolled in the Pediatric Pulmonary Hypertension Network Registry (2014-2020), there were 1,383 group 1 and 3 patients, of whom 671 (48.5%) underwent RHC at diagnosis and were included for analysis. Results: Compared with those without diagnostic RHC, these children were older, less likely to be an infant or preterm, more often female, treated with targeted pulmonary hypertension medications at diagnosis, and had advanced World Health Organization functional class. Catheterization was performed without a difference in complication rates between WSPH groups. Pulmonary capillary wedge pressure was well correlated with left ventricular end-diastolic pressure and left atrial pressures. Results of AVT using three different methods were comparable; positive AVT results were observed in 8.0-11.8% of subjects, did not differ between WSPH groups 1 and 3, and were not associated with freedom from the composite endpoint of lung transplantation or death during follow-up. Conclusions: In a large pediatric pulmonary hypertension cohort, diagnostic RHC with or without left heart catheterization in WSPH group 1 and 3 patients was performed safely at experienced pediatric pulmonary hypertension centers. Hemodynamic differences were noted between group 1 and 3 subjects. Higher mean pulmonary arterial pressure and mean pulmonary arterial pressure/mean systemic arterial pressure ratio were associated with a higher risk of death/transplantation. Findings suggest overall safety and potential value of RHC as a standard diagnostic approach to guide pulmonary hypertension management in children.

THE RELATIONSHIP BETWEEN INFLAMMATION MARKERS AND MAGNESIUM/PHOSPHATE RATIO WITH ENDOTEL FUNCTION IN PERIPHERAL ARTERY DISEASE

Objective: In our study, it was aimed to evaluate the relationship between neutrophil/lymphocyte, monocyte/high-density lipoprotein and magnesium/phosphate ratios with endothelial functions in patients with peripheral artery disease. Methods: Sixty patients followed up with peripheral arterial disease were included in this study. Endothelial functions of the patients were evaluated by flow-mediated vasodilation test. Pearson correlation analysis was used to evaluate the relationship between magnesium/phosphate, neutrophil/lymphocyte, monocyte/high-density lipoprotein ratios with percent change in flow-mediated vasodilation. Results: 48.3% of the participants are male and 51.7% are female. The mean age of the patients were 66.85±11.08 years. The mean radial artery basal diameter was 0.24±0.02 cm in the flow-mediated vasodilatation test and after the test the mean radial artery diameter was 0.27±0.02 cm(p&lt;0.001). In the flow-mediated dilatation test predicting endothelial functions, the percentage change in arterial diameter was positively correlated with the Magnesium/phosphate ratio (r=-0.326, p=0.011), and negatively correlated with the Neutrophil/lymphocyte ratio and monocyte/high-density lipoprotein ratio (respectively r= -0.411, p=0.001; r=-0.530, p=0.001). Conclusion: Magnesium/phosphate ratio, neutrophil/lymphocyte ratio and monocyte/high-density lipoprotein ratio can be used to predict endothelial dysfunction in patients with peripheral artery disease.

Clinical characteristics and prognosis analysis of idiopathic and hereditary pulmonary hypertension patients with ACVRL1 gene mutations.

Pulmonary arterial hypertension is a kind of heart and lung vascular disease with low incidence and poor prognosis. Genetic variants are the important factors of pulmonary arterial hypertension. The mutations of activin receptor-like kinase-1 (ACVRL1) could cause pulmonary arteriole obstruction and occlusion in pulmonary arterial hypertension patients. The ACVRL1 gene mutation and clinical characteristics of Chinese idiopathic or hereditary pulmonary hypertension (IPAH/HPAH) patients are still unclear. This study aimed to retrospectively study the mutation characteristics of ACVRL1 gene in Chinese IPAH/HPAH patients and its effect on clinical prognosis. We analyzed the clinical, functional, hemodynamic and mutation characteristics of 12 IPAH/HPAH patients with ACVRL1 mutations and compared with 94 IPAH/HPAH patients (27 patients carried bone morphogenetic protein receptor type 2 (BMPR2) mutations and 67 without mutations). All ACVRL1 mutations of 12 patients were single nucleotide missense mutations. The ratio of male to female in 12 patients was 1:1. The diagnosis age of ACVRL1 mutation patients was younger than that of BMPR2 mutation patients (13.6 ± 11.3 years vs. 16.0 ± 12.9 years) but higher than that of patients without mutations (13.6 ± 11.3 years vs. 8.8 ± 8.5 years, p = 0.006). IPAH/HPAH patients with ACVRL1 mutation have rapid disease progresses, high overall mortality rate (approximately 50%) and no response to the acute pulmonary vasodilation test. In conclusion, this is the first study to analyze the ACVRL1 gene mutation and clinical characteristics of Chinese IPAH/HPAH patients. It is beneficial to screen ACVRL1 gene mutation for IPAH/HPAH patients to facilitate genetic counseling and early prevention and treatment.

PeakPETCO2 combined with FEV1/FVC predicts vasodilator-responsive patients with idiopathic pulmonary arterial hypertension.

Cardiopulmonary exercise testing and pulmonary function test are important methods for detecting human cardio-pulmonary function. Whether they could screen vasoresponsiveness in idiopathic pulmonary artery hypertension (IPAH) patients remains undefined. One hundred thirty-two IPAH patients with complete data were retrospectively enrolled. Patients were classified as vasodilator-responsive (VR) group and vasodilator-nonresponsive (VNR) group on the basis of the acute vasodilator test. Pulmonary function test and cardiopulmonary exercise testing were assessed subsequently and all patients were confirmed by right heart catheterization. We analyzed cardiopulmonary exercise testing and pulmonary function test data and derived a prediction rule to screen vasodilator-responsive patients in IPAH. Nineteen of VR-IPAH and 113 of VNR-IPAH patients were retrospectively enrolled. Compared with VNR-IPAH patients, VR-IPAH patients had less severe hemodynamic effects (lower RAP, m PAP, PAWP, and PVR). And VR-IPAH patients had higher anaerobic threshold (AT), peak partial pressure of end-tidal carbon dioxide (PETCO2), oxygen uptake efficiency (OUEP), and FEV1/FVC (P all <0.05), while lower peak partial pressure of end-tidal oxygen (PETO2) and minute ventilation (VE)/carbon dioxide output (VCO2) slope (P all <0.05). FEV1/FVC (Odds Ratio [OR]: 1.14, 95% confidence interval [CI]: 1.02–1.26, P = 0.02) and PeakPETCO2 (OR: 1.13, 95% CI: 1.01–1.26, P = 0.04) were independent predictors of VR adjusted for age, sex, and body mass index. A novel formula (=−16.17 + 0.123 × PeakPETCO2 + 0.127×FEV1/FVC) reached a high area under the curve value of 0.8 (P = 0.003). Combined with these parameters, the optimal cutoff value of this model for detection of VR is −1.06, with a specificity of 91% and sensitivity of 67%. Compared with VNR-IPAH patients, VR-IPAH patients had less severe hemodynamic effects. Higher FEV1/FVC and higher peak PETCO2 were associated with increased odds for vasoresponsiveness. A novel score combining PeakPETCO2 and FEV1/FVC provides high specificity to predict VR patients among IPAH.

MILD PULMONARY HYPERTENSION IN ADVANCED HEART FAILURE PATIENTS IS ASSOCIATED WITH BOTH ABNORMAL RESISTIVE AND PULSATILE LOAD AND LOWER 3-YEAR SURVIVAL

<h3>BACKGROUND</h3> Current guidelines require patients with heart failure (HF) being evaluated for advanced therapies such as heart transplantation or left ventricular assist device (LVAD) implantation to undergo right heart catheterization to identify the presence of pulmonary hypertension (PH). PH that is irreversible is a relative contraindication to heart transplantation and associated with poor prognosis. Based on the International Society for Heart and Lung Transplantation guidelines, reversibility is assessed with a vasodilator challenge if pulmonary artery systolic pressure (PASP) is > 50 mmHg, and either transpulmonary gradient (TPG) is > 15 mmHg or pulmonary vascular resistance (PVR) is > 3 WU. However, the most updated 6th World Symposium on Pulmonary Hypertension defined PH more broadly as to mean pulmonary artery pressure (mPAP) > 20 mmHg. As such, there is an intermediate group of patients with mild PH not meeting the threshold to receive a vasodilator challenge to determine whether mild PH is reversible. Our aim was to assess the hemodynamic characteristics of this group and determine whether they are at risk of worse clinical outcomes. <h3>METHODS AND RESULTS</h3> A retrospective analysis was performed of 175 patients with heart failure who were referred to our centre for right heart catheterization as part of evaluation for candidacy for advanced heart failure therapies. Patients were divided into three groups based on initial hemodynamics: patients with mPAP < 20 mmHg (No-PH, n=57), patients with significant PH meeting current guideline criteria for a vasodilator challenge (PH+V, n=41) and patients with mPAP > 20 mmHg that did not meet the threshold for vasodilator challenge (PH-V, n=77). Compared to the No-PH group, the PH-V group did not have a significantly different stroke volume index or cardiac index, however, they had a significantly higher PVR, indicating greater resistive load, and lower pulmonary artery compliance (PAC), indicating higher pulsatile load (Table). The PH-V group also had significantly higher mean right atrial pressure (mRAP) compared to the No-PH group, suggesting right ventricular decompensation. Composite pre-and post-intervention three-year survival after catheterization appeared lower in both PH+V and PH-V patients compared to the No-PH group (Figure). <h3>CONCLUSION</h3> HF patients assessed for advanced therapies identified as having mild PH have increased pulmonary pulsatile and resistive load, along with elevated right-sided filling pressures, and have increased mortality. Currently, this group does not undergo vasodilator testing to determine PH reversibility. Whether mild PH is modifiable, and its relationship to outcomes after heart transplantation or LVAD implant requires further study.