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Patient characteristics and catheterization data
Source publication
The aim of this study was to investigate the contribution of direct right-to-left ventricular interaction to left ventricular filling and stroke volume in 46 patients with pulmonary arterial hypertension (PAH) and 18 control subjects. Stroke volume, right and left ventricular volumes, left ventricular filling rate, and interventricular septum curva...
Contexts in source publication
Context 1
... regression analyses were performed to assess the correlations between catheterization, MR imaging, and TEE data. Table 1. With respect to cardiac catheterization and MR imaging measurements, there were no statistically signif- icant differences between patients diagnosed as idiopathic PAH and PAH related to systemic sclerosis. ...
Context 2
... five patients, the ECG could not be analyzed. The PAH group had a mean pulmonary arterial pressure of 55 16 mmHg, a normal pulmonary capillary wedge pressure (7 5 mmHg), and elevated right atrial pressure (10 5 mmHg; Table 1). There was no significant difference in heart rate during cardiac catheterization (81 16 beats/min), MR image acquisition (82 15 beats/min), and TEE (88 16 beats/min). ...
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Citations
... Nevertheless, because they share an IVS and pericardial sac, the RV and LV do not operate independently (25). Since the IVS is shared by both ventricles within the same pericardial sac, increasing RV pressure load causes the septum to bow toward the left ventricle, which alters LV geometry and reduces LV filling (26). The majority of patients with PAH have right-sided disease, while in later stages of the condition reduced left-sided function may also become apparent (6). ...
... A study by Gan et al. (26) aimed to investigate the contribution of direct right-to-left ventricular interaction to LV filling and SV in 46 patients with PAH by using cardiac magnetic resonance (CMR). When comparing patients with PAH to control subjects, there was a decrease in SV, left ventricular end-diastolic volume (LVEDV), and LV peak filling rate (26). Their findings indicate that, in patients with PAH, ventricular interaction mediated by IVS compromises LV filling. ...
... As already stated, due to the continuous circulatory system and shared septum, the RV-LV interdependence is a great matter of concern. Researchers have claimed that through ventricular dependence there is LV dysfunction in PH (26). A study by Burkett et al. (54) found that LVGLS was found significantly reduced in patients with PH in comparison with matched controls. ...
Pulmonary arterial hypertension (PAH) is a chronic and progressive disease that eventually leads to heart failure (HF) and subsequent fatality if left untreated. Right ventricular (RV) function has proven prognostic values in patients with a variety of heart diseases including PAH. PAH is predominantly a right heart disease; however, given the nature of the continuous circulatory system and the presence of shared septum and pericardial constraints, the interdependence of the right and left ventricles is a factor that requires consideration. Accurate and timely assessment of ventricular function is very important in the management of patients with PAH for disease outcomes and prognosis. Non-invasive modalities such as cardiac magnetic resonance (CMR) and echocardiography (two-dimensional and three-dimensional), and nuclear medicine, positron emission tomography (PET) play a crucial role in the assessment of ventricular function and disease prognosis. Each modality has its own strengths and limitations, hence this review article sheds light on (i) ventricular dysfunction in patients with PAH and RV–LV interdependence in such patients, (ii) the strengths and limitations of all available modalities and parameters for the early assessment of ventricular function, as well as their prognostic value, and (iii) lastly, the challenges faced and the potential future advancement in these modalities for accurate and early diagnosis of ventricular function in PAH.
... Because of the ventricular interdependence, the RV hypertrophy and dilation and the interventricular septum flattening occurring in PAH negatively affect the left ventricle (LV) structure and function. Individuals with PAH exhibit altered LV geometry (i.e., D-shaped) [4] and consequent impaired filling and reduced enddiastolic volume [16][17][18]. These changes weaken their LV function as it influences LV segmental function and torsion and decreases the systolic volume and thus their capacity to tolerate physical effort [3,4]. ...
... Moreover, combined exercise restrained increases in the percentage of extracellular matrix and collagen content, that were enhanced in nonexercised hypertensive rats. Such LV remodeling is in line with the preserved function as it directly influences ventricular filling rate, enddiastolic and systolic volumes, and then stroke volume [17,18]. Therefore, combined exercise training protected the LV against dysfunction and adverse remodeling which softens the progression of the disease. ...
Background
Under the adverse remodeling of the right ventricle and interventricular septum in pulmonary arterial hypertension (PAH) the left ventricle (LV) dynamics is impaired. Despite the benefits of combined aerobic and resistance physical trainings to individuals with PAH, its impact on the LV is not fully understood.
Objective
To test whether moderate-intensity combined physical training performed during the development of PAH induced by MCT in rats is beneficial to the LV’s structure and function.
Methods
Male Wistar rats were divided into two groups: Sedentary Hypertensive Survival (SHS, n = 7); and Exercise Hypertensive Survival (EHS, n = 7) to test survival. To investigate the effects of combined physical training, another group of rats were divided into three groups: Sedentary Control (SC, n = 7); Sedentary Hypertensive (SH, n = 7); and Exercise Hypertensive (EH, n = 7). PAH was induced through an intraperitoneal injection of MCT (60 mg/kg). Echocardiographic evaluations were conducted on the 22nd day after MCT administration. Animals in the EHS and EH groups participated in a combined physical training program, alternating aerobic (treadmill running: 50 min, 60% maximum running speed) and resistance (ladder climbing: 15 climbs with 1 min interval, 60% maximum carrying load) exercises, one session/day, 5 days/week for approximately 4 weeks.
Results
The physical training increased survival and tolerance to aerobic (i.e., maximum running speed) and resistance (i.e., maximum carrying load) exertions and prevented reductions in ejection fraction and fractional shortening. In addition, the physical training mitigated oxidative stress (i.e., CAT, SOD and MDA) and inhibited adverse LV remodeling (i.e., Collagen, extracellular matrix, and cell dimensions). Moreover, the physical training preserved the amplitude and velocity of contraction and hindered the reductions in the amplitude and velocity of the intracellular Ca2+ transient in LV single myocytes.
Conclusion
Moderate-intensity combined physical training performed during the development of MCT-induced PAH in rats protects their LV from damages to its structure and function and hence increases their tolerance to physical exertion and prolongs their survival.
... RV mechanical dyssynchrony comprises an important pathophysiological feature in PCPH [6]. Delayed timeto-peak contraction of the RV is evident in PAH [24,25], causing mechanically inefficient post-systolic isovolumetric contraction (i.e., wasted contractile work) [26]. In agreement with the literature, we discovered an increase in RV wasted work in both patient categories of RV hemodynamic overload. ...
Evaluating right ventricular (RV) function remains a challenge. Recently, novel echocardiographic assessment of RV myocardial work (RVMW) by non-invasive pressure-strain loops was proposed. This enables evaluation of right ventriculoarterial coupling and quantifies RV dyssynchrony and post-systolic shortening. We aimed to assess RVMW in patients with different etiologies of RV dysfunction and healthy controls. We investigated healthy controls (n=17), patients with severe functional tricuspid regurgitation (FTR; n=22), and patients with precapillary pulmonary hypertension (PCPH; n=20). Echocardiography and right heart catheterization were performed to assess 1) RV global constructive work (RVGCW; work needed for systolic myocardial shortening and isovolumic relaxation), 2) RV global wasted work (RVGWW; myocardial shortening following pulmonic valve closure), and 3) RV global work efficiency (RVGWE; describes the relation between RV constructive and wasted work). RVGCW correlated with invasive RV stroke work index (r=0.66, P<0.001) and increased in tandem with higher afterload, i.e., was low in healthy controls (454±73 mmHg%), moderate in patients with FTR (687±203 mmHg%), and highest among patients with PCPH (881±255 mmHg%). RVGWE was lower and RVGWW was higher in patients with FTR (86±8% and 91 mmHg% [53-140]) or PCPH (86±10% and 110 mmHg% [66-159]) as compared with healthy controls (96±3% and 10 mmHg%). RVMW by echocardiography provides a promising index of RV function to discriminate between patients with RV volume or pressure overload. The prognostic value of this measure needs to be settled in future studies.
Graphical abstract
Combining right heart catheterization and echocardiography, right ventricular (RV) pressure-strain loops were evaluated in healthy controls and in patients with severe functional tricuspid regurgitation (FTR) or precapillary pulmonary hypertension (PCPH). RV global constructive work (RVGCW) entails the work needed for systolic myocardial shortening and isovolumic relaxation; it increased in tandem with higher afterload. RV global wasted work (RVGWW) describes myocardial shortening following pulmonic valve closure and RV global work efficiency (RVGWE) is the ratio between RVGCW and RVGWW. RVGWW was higher and RVGWE was lower in both patient groups with RV hemodynamic overload.
... Moreover, a distinct observation was the preferential ductus venosus streaming toward the right heart, noted in 14 out of the 15 fetuses with left diaphragmatic hernia and intrathoracic liver herniation, whereas none of the examined fetuses with right diaphragmatic hernia exhibited this phenomenon [41]. Crucially, left ventricular hypoplasia may be exacerbated postnatally by an elevation in right ventricular afterload and volume, stemming from pulmonary hypoplasia accompanied by persistent pulmonary hypertension [43]. Recent literature data suggest that an imbalance in right-to-left ventricular volume exacerbates the prognosis, elevates the requirement for ECMO therapy, and markedly increases the mortality rate among infants with CDH [44]. ...
... 1,2 In PAH patients, elevated pulmonary artery (PA) pressure leads to chronic right ventricular (RV) pressure overload, and RV adaption is considered one of the key determinants of short-term and long-term outcomes. 3,4 Reduced right ventricular ejection fraction (RVEF) and enlargement are recognized as significant indicators of RV maladaptation. However, it's still difficult to recognize the transition from adaption to maladaptation in PAH patients and better imaging biomarkers are needed. ...
... RV concentric hypertrophy is generally considered an early adaptive response to PAH. [5][6][7][8] However, recent evidence indicates that not all instances of RV concentric hypertrophy in PAH patients are adaptive 9 and the adaptive nature of these changes should be interpreted in the context of ventricular interdependence. 3 Moreover, prolonged pressure overload can cause inadequate filling of the left ventricle (LV), 4,9,10 potentially leading to LV atrophic remodeling. 9 But in recent reports, higher LV end-diastolic volume correlated with better prognosis, indicating that a comprehensive consideration of both LV metrics and RV function may bring additive value in adaption-to-maladaptation evaluation in PAH patients. ...
Pulmonary arterial hypertension (PAH) still remains a life‐threatening disorder with poor prognosis. The right ventricle (RV) adapts to the increased afterload by a series of prognostically significant morphological and functional changes, the adaptive nature should also be understood in the context of ventricular interdependence. We hypothesized that left ventricle (LV) underfilling could serve as an important imaging marker for identifying maladaptive changes and predicting clinical outcomes in PAH patients. We prospectively enrolled patients with PAH who underwent both cardiac magnetic resonance and right heart catheterization between October 2013 and December 2020. Patients were categorized into four groups based on their LV and RV mass/volume ratio (M/V). LV M/V was stratified using the normal value (0.7 g/mL for males and 0.6 g/mL for females) to identify patients with LV underfilling (M/V ≥ normal value), while RV M/V was stratified based on the median value. The primary endpoint was all‐cause mortality, and the composite endpoints included all‐cause mortality and heart failure‐related readmissions. A total of 190 PAH patients (53 male, mean age 37 years) were included in this study. Patients with LV underfilling exhibited higher NT‐proBNP levels, increased RV mass, larger RV but smaller LV, lower right ventricular ejection fraction, and shorter 6‐min walking distance. Patients with LV underfilling had a 2.7‐fold higher risk of mortality than those without and LV M/V (hazard ratio [per 0.1 g/mL increase]: 1.271, 95% confidence interval: 1.082–1.494, p = 0.004) was also independent predictors of all‐cause mortality. Moreover, patients with low LV M/V had a better prognosis regardless of the level of RV M/V. Thus, LV underfilling is an independent predictor of adverse clinical outcomes in patients with PAH, and it could be an important imaging marker for identifying maladaptive changes in these patients.
... The higher rates of cardiogenic shock are likely due to the RV dysfunction. RV dilation and an increase in RV size cause a mechanical septal leftward shift, leading to compression of the left ventricle (LV) [18]. As a result, the LV displays a "D-shape," and there is an increased LV eccentricity index [17]. ...
Objective: To study the impact of group II pulmonary hypertension (PH) on the outcomes of patients admitted with ST-elevation Myocardial Infarction (STEMI), we conducted a nationwide retrospective cohort study.
Patients and Methods: Using the National Inpatient Sample (NIS) Database from 2017 to 2020, a retrospective study of adult patients with a principal diagnosis of STEMI with a secondary diagnosis with or without group II PH according to ICD-10 codes. Several demographics, including age, race, and gender, were analyzed. The primary endpoint was mortality, while the secondary endpoints included cardiogenic shock, mechanical intubation, length of stay in days, and patient charge in dollars. Multivariate logistic regression model analysis was used to adjust for confounders, with a p-value less than 0.05 considered statistically significant.
Results: The study included 27,020 patients admitted with a STEMI, 95 of whom had group II PH. The mean age for patients with and without PH was 66 and 67, respectively. In the PH group, 37% were females compared to 34% in the non-PH group. The in-hospital mortality rate was higher in the PH group (31.5% vs. 9.5%, P <.001, aOR 3.25, P <.023). The rates and adjusted odds of cardiogenic shock and mechanical ventilation were higher in the PH groups (aOR 1.12 aOR 2.16, respectively) but not statistically significant. Patients with PH had a longer length of stay and a higher total charge.
Conclusion: Group II PH was associated with worse clinical and economic outcomes in heart failure patients admitted with STEMI.
... Chronic RV pressure overload leads to RV hypertrophy, RV dilatation, RV dysfunction, and right heart failure [2,6,7,10,31]. Closely related to RV remodeling in PH, alterations in LV geometry and function have been documented [15,18,19,32]. In the present study, all RV but none of the LV volumetric function parameters differed between the PH and non-PH subjects; alterations in LV and RV strain parameters in PH have been found compared to both, non-PH and healthy controls.Impairments of LV and RV global peak strains and strain rates in PH have been observed previously [16,18,27,28,[33][34][35] and have been associated with severity of disease [16], clinical deterioration of patients [16,19] and outcome [16,19,34]. ...
... This causes a mechanical septal leftward shift, leading to LV underfilling and low cardiac output [64]. Indeed, the LV filling rate is well predicted by the leftward interventricular septal curvature, and in turn, stroke volume is much better correlated with LV end-diastolic volume than with RV end-diastolic volume in PAH [69]. ...
Right ventricular failure (RVF) is often caused by increased afterload and disrupted coupling between the right ventricle (RV) and the pulmonary arteries (PAs). After a phase of adaptive hypertrophy, pressure-overloaded RVs evolve towards maladaptive hypertrophy and finally ven-tricular dilatation, with reduced stroke volume and systemic congestion. In this article, we review the concept of RV-PA coupling, which depicts the interaction between RV contractility and afterload, as well as the invasive and non-invasive techniques for its assessment. The current principles of RVF management based on pathophysiology and underlying etiology are subsequently discussed. Treatment strategies remain a challenge and range from fluid management and afterload reduction in moderate RVF to vasopressor therapy, inotropic support and, occasionally, mechanical circulatory support in severe RVF.
... 8,20,21 The pathophysiology of RV-LV interaction in patients with PH emphasizes two major concepts: first, an increase in RV afterload contributes to the limitation of RV output, which facilitates right-sided filling pressures and underfilling of the LV; 22 second, PH-mediated ventricular interdependence leads to bowing of the septum towards the left ventricle and impairment of LV filling. 23,24 Consequently, LV preload and a decrease in stroke volume shorten LVET. In our study, all of the patients had preserved LV function, and LVET could indirectly but consistently reflect RV hemodynamics as well as NT-proBNP levels. ...
Background:
We tested the hypothesis that non-invasive pulse wave analysis (PWA)-derived systemic circulation variables can predict invasive hemodynamics of pulmonary circulation and the indicator of right heart function, N-terminal pro-brain natriuretic peptide (NT-proBNP), in patients with precapillary pulmonary hypertension (PH).
Methods:
This prospective study enrolled patients with group 1 and 4 PH who had complete PWA, NT-proBNP, and hemodynamics data. Risk assessment-based "hemodynamic score (HS)" and principal component analysis-based PWA variable grouping were determined/performed. Models of hierarchical multiple linear regression (HMLR) and receiver operating characteristic (ROC) curves were used to determine the relationships of PWA variables with HS and NT-proBNP and to predict the latter parameters.
Results:
Fifty-three PWAs were included. PWA variables were classified into 4 eigenvalue principal components (representing 90% configuration). Univariate analysis showed that left ventricular ejection time (LVET) was significantly negatively associated with HS and NT-proBNP levels. HMLR analysis showed that LVET was still significantly, negatively, and independently associated with HS (B = -0.006 [-0.010~-0.001]) and NT-proBNP (B = -13.47 [-21.20~-5.73]). ROC curve analysis showed that LVET > 306.9 msec and > 313.2 msec predicted the low-risk group of HS (AUC: 0.802; p = 0.001; sensitivity: 100%; and specificity: 59%) and low-to-intermediate risk levels of NT-proBNP (AUC: 0.831; p < 0.001; sensitivity: 100%; and specificity: 59%).
Conclusions:
The non-invasive PWA parameter, LVET, is an independent predictor of invasive right heart HS and NT-proBNP levels; it may serve as a novel biomarker of right ventricular function in patients with pre-capillary PH.
... The RV dilation and hypertrophy alter the myocardial contractility as ventricular inter-dependence is compromised due to septal displacement. With inadequate RV contractility and increased RV afterload, a vicious cycle of decreased pulmonary blood flow, with further reduction in pulmonary venous return, and thus lower LV preload with resultant systemic and coronary hypoperfusion and worsening myocardial contractility ensues (15,17,23). In our study, we observed a significant correlation between IS/ VIS at 12-, 24-and 48-HOL with septal bowing seen in the first postnatal echocardiogram-with higher scores associated with septal bowing. ...
Background
Neonates with congenital diaphragmatic hernia (CDH) have varying degrees of pulmonary hypoplasia, pulmonary hypertension (PH) and cardiac dysfunction. These neonates frequently require vasoactive support and are at high risk for mortality and morbidity, including prolonged ventilator support, need for extracorporeal membrane oxygenation (ECMO), prolonged length of stay, and need for tracheostomy. However, identifying which infants are at increased risk can be challenging. In this study, we sought to investigate the utility of the inotropic score (IS) and vasoactive inotropic score (VIS) as tools to predict significant clinical outcomes and overall survival in patients with CDH. Additionally, we evaluated the correlation between IS/VIS and postnatal echocardiographic variables.Methods
This was a retrospective chart review of 57 patients with CDH whose postnatal care was based on a standardized institutional protocol. We calculated the IS/VIS at 6-, 12-, 24-, 48 hours of life (HOL), on the day of CDH repair and 24- and 48 hours after surgical repair. The association of these scores with postnatal echocardiographic markers was analyzed using Pearson's correlation and linear regression, while logistic regression was used for binary outcomes, and Cox proportional hazards regression was used to assess associations with survival.ResultsWe found that every one-unit increase in IS/VIS at 6 HOL was associated with 13% increase in the odds of ECMO (p = 0.034) and 10.1% increase in risk of death (p = 0.021). An increase in IS/VIS at 12-, 24- and 48-HOL was associated with posterior septal bowing in the first postnatal echocardiogram (p < 0.05 for all). Additionally, we noted an inverse relationship between IS (r = −0.281, p = 0.036) and VIS (r = −0.288, p = 0.031) on the day of repair and left ventricle (LV) systolic function in first postnatal echocardiogram. Increase in IS (r = −0.307, p = 0.024) and VIS (r = −0.285, p = 0.037) on the day of repair was associated with decreased LV function on the post-repair echocardiogram.Conclusion
This retrospective study showed a significant association between IS/VIS obtained at various time points with clinical outcomes and echocardiographic findings in CDH, which could be used to guide prognosis and management in this patient population.
