Abstract
Aims
Pulmonary hypertension (PH) and pulmonary vascular disease (PVD) are common and associated with adverse outcomes in heart failure with preserved ejection fraction (HFpEF). Little is ...known about the impact of PVD on the pathophysiology of exercise intolerance.
Methods and results
Heart failure with preserved ejection fraction patients (n = 161) with elevated pulmonary capillary wedge pressure (≥15 mmHg) at rest were classified into three groups: non-PH-HFpEF (n = 21); PH but no PVD (isolated post-capillary PH, IpcPH; n = 95); and PH with PVD (combined post- and pre-capillary PH, CpcPH; n = 45). At rest, CpcPH-HFpEF patients had more right ventricular (RV) dysfunction and lower pulmonary arterial (PA) compliance compared to all other groups. While right atrial pressure (RAP) and left ventricular transmural pressure (LVTMP) were similar in HFpEF with and without PH or PVD at rest, CpcPH-HFpEF patients demonstrated greater increase in RAP, enhanced ventricular interdependence, and paradoxical reduction in LVTMP during exercise, differing from all other groups (P < 0.05). Lower PA compliance was correlated with greater increase in RAP with exercise. During exercise, CpcPH-HFpEF patients displayed an inability to enhance cardiac output, reduction in forward stroke volume, and blunted augmentation in RV systolic performance, changes that were coupled with marked limitation in aerobic capacity.
Conclusion
Heart failure with preserved ejection fraction patients with PVD demonstrate unique haemodynamic limitations during exercise that constrain aerobic capacity, including impaired recruitment of LV preload due to excessive right heart congestion and blunted RV systolic reserve. Interventions targeted to this distinct pathophysiology require testing in patients with HFpEF and PVD.
Background Experimental studies support a link between obesity and pulmonary hypertension (PH), yet clinical studies have been limited. This study sought to determine the association of obesity and ...pulmonary hemodynamic measures and mortality in PH. Methods and Results We examined patients undergoing right-sided heart catherization (2005-2016) in a hospital-based cohort. Multivariable regression models tested associations of body mass index and pulmonary vascular hemodynamics, with PH defined as mean pulmonary artery pressure >20 mm Hg, and further subclassified into precapillary, postcapillary, and mixed PH. Multivariable Cox models were used to examine the effect of PH and obesity on mortality. Among 8940 patients (mean age, 62 years; 40% women), 52% of nonobese and 69% of obese individuals had evidence of PH. Higher body mass index was independently associated with greater odds of overall PH (odds ratio, 1.34; 95% CI, 1.29-1.40;
<0.001 per 5-unit increase in body mass index) as well as each PH subtype (
<0.001 for all). Patients with PH had greater risk of mortality compared with individuals without PH regardless of subgroup (
<0.001 for all). We found that obesity was associated with 23% lower hazard of mortality among patients with PH (hazard ratio, 0.77; 95% CI, 0.69-0.85;
<0.001). The effect of obesity was greatest among those with precapillary PH (hazard ratio, 0.57; 95% CI, 0.46-0.70;
<0.001), where obesity modified the effect of PH on mortality (
for interaction=0.02). Conclusions Obesity is independently associated with PH. PH is associated with greater mortality; this is modified by obesity such that obese patients with precapillary PH have lower mortality compared with nonobese counterparts. Further studies are needed to elucidate mechanisms underlying obesity-related PH.
Pulmonary hypertension (PH) is a common complication of interstitial lung disease (ILD) and is associated with worse outcomes and increased mortality. Evaluation of PH is recommended in lung ...transplant candidates, but there are currently no standardized screening approaches. Trials have identified therapies that are effective in this setting, providing another rationale to routinely screen patients with ILD for PH.
What screening strategies for identifying PH in patients with ILD are supported by expert consensus?
The study convened a panel of 16 pulmonologists with expertise in PH and ILD, and used a modified Delphi consensus process with three surveys to identify PH screening strategies. Survey 1 consisted primarily of open-ended questions. Surveys 2 and 3 were developed from responses to survey 1 and contained statements about PH screening that panelists rated from −5 (strongly disagree) to 5 (strongly agree).
Panelists reached consensus on several triggers for suspicion of PH including the following: symptoms, clinical signs, findings on chest CT scan or other imaging, abnormalities in pulse oximetry, elevations in brain natriuretic peptide (BNP) or N-terminal pro-brain natriuretic peptide (NT-proBNP), and unexplained worsening in pulmonary function tests or 6-min walk distance. Echocardiography and BNP/NT-proBNP were identified as screening tools for PH. Right heart catheterization was deemed essential for confirming PH.
Many patients with ILD may benefit from early evaluation of PH now that an approved therapy is available. Protocols to evaluate patients with ILD often overlap with evaluations for pulmonary hypertension-interstitial lung disease and can be used to assess the risk of PH. Because standardized approaches are lacking, this consensus statement is intended to aid physicians in the identification of patients with ILD and possible PH, and provide guidance for timely right heart catheterization.
Abnormal hemodynamics are associated with poor clinical outcomes in patients with heart failure. Given the invasiveness and unfeasibility of routine right heart catheterization, non-invasive ...methodologies to monitor hemodynamics are needed. The CardioMEMS™ device is a recently developed technology that enables remote monitoring of pulmonary artery pressures via an implanted sensor located in the distal left pulmonary artery. Along with the CardioMEMS™, a remote dielectric system might be another promising device that reports indirect intra-thoracic filling pressures associated with pulmonary congestion. In patients with advanced heart failure who require left ventricular assist devices, non-invasive hemodynamic monitoring is particularly necessary, given the increased procedural risks of invasive assessments. The HeartWare ventricular assist device flow waveform is a variable under active investigation that might also provide an estimation of filling pressures. This methodology is expected to lead to the development of a smart pump that can adjust its own settings, including the pump speed, automatically by monitoring the hemodynamics.
The aim of this study was to enumerate and categorize quality metrics relevant to the pediatric/congenital cardiac catheterization laboratory (PCCL).
Diagnostic and interventional catheterization ...procedures are an increasingly important part of the care of young patients with cardiac disease. Measurement of the performance of PCCL programs in a stringent and consistent fashion is a crucial step toward improving outcomes. To the best of our knowledge, a systematic evaluation of current quality metrics in PCCL has not been performed previously.
Potential metrics were evaluated by: 1) a systematic review of peer-reviewed research; 2) a review of metrics from organizations interested in quality improvement, patient safety, and/or PCCL programs; and 3) a survey of U.S. PCCL cardiologists. Collected metrics were grouped on 2 dimensions: 1) Institute of Medicine domains; and 2) the Donabedian structure/process/outcome framework. Survey responses were dichotomized between favorable and unfavorable responses and then compared within and between categories.
In the systematic review, 6 metrics were identified (from 9 publications), all focused on safety either as an outcome (adverse events AEs, mortality, and failure to rescue along with radiation exposure) or as a structure (procedure volume or operator experience). Four organizations measure quality metrics of PCCL programs, of which only 1 publicly reports data. For the survey, 229 cardiologists from 118 hospital programs responded (66% of individuals and 72% of hospital programs). The highest favorable ratings were for safety metrics (p < 0.001), of which major AEs, failure to rescue, and procedure-specific AEs had the highest ratings. Of respondents, 67% stated that current risk adjustment were not effective. Favorability ratings for hospital characteristics, PCCL characteristics, and quality improvement processes were significantly lower than for safety and less consistent within categories.
There is a limited number of PCCL quality metrics, primarily focused on safety. Confidence in current risk adjustment methodology is low. The knowledge gaps identified should guide future research in the development of new quality metrics.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Pulmonary hypertension (PH) is a heterogeneous and highly morbid disease, diagnosed with mean pulmonary artery pressure (PAP) measured by invasive right heart catheterization (RHC). However, RHC ...risks complications and cannot provide continuous PAP monitoring over long durations. Non-invasive assessment of PAP has gained interest for its low risk and convenience compared to invasive measurement. Recently, seismocardiogram (SCG), which unobtrusively records chest vibrations from cardiovascular motions, has demonstrated feasibility for PAP estimation. In this paper, we propose an attentive conditional adversarial generative network (CGAN) framework for the purpose of continuous PAP assessment using SCG. This is the first time that the PAP waveforms morphology has been accurately reconstructed from SCG. The proposed framework involves a U-net generator with a soft attention module to focus on salient SCG features, along with a PatchGAN discriminator for localized assessment. It uses Wasserstein distance in the loss function to improve training stability, which is compared with existing generative models using the same SCG-RHC dataset. Results show that our model yields superior PAP waveform reconstruction performance with Pearson correlation coefficient (PCC) of 0.982. The reconstructed waveforms exhibit high correlation with invasive RHC measurement, with quantitative statistics and physiological indices validating strong agreement. This work represents a novel approach for continuous, non-invasive PAP estimation, offering valuable improvements in the management of PH.
The accurate assessment of hemodynamics is paramount to providing timely and efficacious care for patients presenting in cardiogenic shock. Recently, the regular use of the pulmonary artery catheter ...in cardiogenic shock has had a resurgence with emerging data indicating improved survival in the modern era. Optimal multidisciplinary management of advanced heart failure and cardiogenic shock relies on our ability to effectively communicate and understand the complete hemodynamic assessment. Standardization of data acquisition and a renewed focus on the physiological processes, and thresholds driving disease progression, including the coupling ratio and myocardial reserve, are needed to fully understand and interpret the hemodynamic assessment. This State-of-the-Art review discusses best practices in the cardiac catheterization laboratory as well as emerging data on the prognostic role of emerging advanced hemodynamic parameters.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Cardiac catheterization Shoaib, Ahmad; Sana Ullah, Mohsin Zia; Ul Haq, Muhammad Ayyaz ...
Medicine (Abingdon. 1995, UK ed.),
June 2022, 2022-06-00, Volume:
50, Issue:
6
Journal Article
Peer reviewed
Cardiac catheterization involves the insertion of fine-bore tubes (catheters) into the heart through cannulae inserted into a peripheral artery or vein. Previously, transfemoral access was ...predominantly used, but the safer radial artery approach is now the preferred access route for most UK operators. Left heart catheterization is used to evaluate coronary arteries, left-sided valvular function, left ventricular function and aortic root anatomy. Haemodynamic and oxygen saturation data obtained from right and left heart catheterization provide information on cardiac chamber function, valvular function, pericardial constraint and pulmonary and systemic circulation haemodynamics. A comprehensive evaluation is especially invaluable in the diagnostic work-up and/or monitoring of individuals with complex cardiac conditions, particularly those with ischaemic heart disease, valvular disease, pulmonary arterial hypertension, intracardiac shunts, pericardial disease or heart failure.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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