Percutaneous aspiration of a right atrial thrombus with the AngioVac system.

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Corrigendum to "ECG Markers of Hemodynamic Improvement in Patients with Pulmonary Hypertension".

[This corrects the article DOI: 10.1155/2018/4606053.].

ECG Markers of Hemodynamic Improvement in Patients with Pulmonary Hypertension.

INTRODUCTION: Several diagnostic tests have been recommended for risk assessment in pulmonary hypertension (PH), but the role of electrocardiography (ECG) in monitoring of PH patients has not been yet established. Therefore the aim of the study was to evaluate which ECG patterns characteristic for pulmonary hypertension can predict hemodynamic improvement in patients treated with targeted therapies. METHODS: Consecutive patients with pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH) were eligible to be included if they had had performed two consecutive right heart catheterization (RHC) procedures before and after starting of targeted therapies. Patients were followed up from June 2009 to July 2017. ECG patterns of right ventricular hypertrophy according to American College of Cardiology Foundation were assessed. RESULTS: We enrolled 80 patients with PAH and 11 patients with inoperable CTEPH. The follow-up RHC was performed within 12.6 ± 10.0 months after starting therapy. Based on median change of pulmonary vascular resistance, we divided our patients into two subgroups: with and without significant hemodynamic improvement. RV1, max⁡RV1,2 + max⁡SI,aVL - SV1, and PII improved along with the improvement of hemodynamic parameters including PVR. They predicted hemodynamic improvement with similarly good accuracy as shown in ROC analysis: RV1 (AUC: 0.75; 95% CI: 0.63-0.84), PII (AUC: 0.67, 95% CI: 0.56-0.77), and max⁡RV1,2 + max⁡SI,aVL - SV1 (0.73; 95% CI: 0.63-0.82). In Cox regression only change in RV1 remained significant mortality predictor (HR: 1.12, 95% CI: 1.01-1.24). CONCLUSION: Electrocardiogram may be useful in predicting hemodynamic effects of targeted therapy in precapillary pulmonary hypertension. Decrease of RV1, max⁡RV1,2 + max⁡SI,aVL - SV1, and PII corresponds with hemodynamic improvement after treatment. Of these changes a decrease of R wave amplitude in V1 is associated with better survival.

Right atrium enlargement predicts clinically significant supraventricular arrhythmia in patients with pulmonary arterial hypertension.

BACKGROUND: Right atrial (RA) enlargement is a common finding in patients with pulmonary arterial hypertension (PAH) and an important predictor of mortality, however its relation to the risk of atrial arrhythmias has not been assessed. OBJECTIVES: To assess whether RA enlargement is associated with supraventricular arrhythmias (SVA) and whether it predicts new clinically significant SVA (csSVA). METHODS: Patients with PAH were recruited between January 2010 and December 2014 and followed until January 2017. csSVA was diagnosed if it resulted in hospitalization. To assess predictors of new csSVA, only patients without a history of SVA at baseline were analyzed. RESULTS: Among 97 patients, any SVA was observed in 45 (46.4%) and included permanent atrial fibrillation(AF, n = 8), paroxysmal AF (n = 10), permanent atrial flutter (AFl, n = 1), paroxysmal AFl (n = 2) or other types of supraventricular tachycardia (n = 24). Patients with SVA as compared to patients without SVA were characterized by older age, lower distance in a 6-minute test, higher NT-proBNP, higher RA area index (RAai), left atrial area index, mean right atrial pressure (mRAP) and were more commonly treated with ß-blocker. Eighty five patients who were in sinus rhythm at baseline assessment and had no history of significant SVA were observed for 37 ± 19.9 months. During that time csSVA occurred in 15.3%. In univariate models, the occurrence of csSVA were predicted by age, right ventricular ejection fraction, right ventricular end diastolic index, RAai and mRAP, but in multivariate model only RAai remained significant predictor for csSVA (HR of 1.23, 95%CI: 1.11-1.36, p < 0.001). The optimal threshold for RA enlargement as discriminator of csSVA was 21.7 cm2/m2. CONCLUSIONS: In PAH patients RA enlargement is associated with increased prevalence of SVA. RAai is an independent predictor of hospitalization due to csSVA.

Mechanism and prognostic role of qR in V1 in patients with pulmonary arterial hypertension.

BACKGROUND: The presence of qR pattern in lead V1 of the 12-lead surface ECG has been proposed as a risk marker of death in patients with pulmonary arterial hypertension (PAH). We aimed to validate these findings in the modern era of PAH treatment and additionally to assess the relation of qR in V1 to PAH severity. We also investigated the possible mechanisms underlying this ECG sign. METHODS: Consecutive patients with PAH excluding patients with congenital heart defect were recruited between February 2008 and January 2016. A 12-lead standard ECG was acquired and analyzed for the presence of qR in V1 and other potential prognostic patterns. Cardiac magnetic resonance and echocardiography were used for structural (masses and volumes) and functional (ejection fraction, eccentricity index) characterization of left (LV) and right (RV) ventricles. Standard markers of PAH severity were also assessed. RESULTS: We enrolled 66 patients (19 males), aged 50.0±15.7years with idiopathic PAH (n=52) and PAH associated with connective tissue disease (n=14). qR in V1 was present in 26(39.4%) patients and was associated with worse functional capacity, hemodynamics and RV function. The main structural determinants of qR in V1 were RV to LV volume ratio (OR: 3.99; 95% CI: 1.47-10.8, p=0.007) and diastolic eccentricity index (OR: 15.0; 95% CI: 1.29-175.5, p=0.03). During observation time of 30.5±19.4months, 20 (30.3%) patient died, 13 (50%) patients with qR and 7 (17.5%) patients without qR pattern. Electrocardiographic determinants of survival were qR (HR: 3.06, 95% CI: 1.21-7.4; p=0.02) and QRS duration (HR: 1.02, 95% CI: 1.01-1.04; p=0.01). CONCLUSIONS: Presence of qR in V1 reflects RV dilation and diastolic interventricular septum flattening. It is a sign of advanced PAH and predicts the risk of death in this population.

Low-density lipoprotein cholesterol and survival in pulmonary arterial hypertension.

Low-density lipoprotein cholesterol(LDL-C) is a well established metabolic marker of cardiovascular risk, however, its role in pulmonary arterial hypertension (PAH) has not been determined. Therefore we assessed whether LDL-C levels are altered in PAH patients, if they are associated with survival in this group and whether pulmonary hypertension (PH) reversal can influence LDL-C levels. Consecutive 46 PAH males and 94 females were age matched with a representative sample of 1168 males and 1245 females, respectively. Cox regression models were used to assess the association between LDL-C and mortality. The effect of PH reversal on LDL-C levels was assessed in 34 patients with chronic thromboembolic pulmonary hypertension (CTEPH) undergoing invasive treatment. LDL-C was lower in both PAH (2.6 ± 0.8 mmol/l) and CTEPH (2.7 ± 0.7 mmol/l) patients when compared to controls (3.2 ± 1.1 mmol/l, p < 0.001). In PAH patients lower LDL-C significantly predicted death (HR:0.44/1 mmol/l, 95%CI:0.26-0.74, p = 0.002) after a median follow-up time of 33(21-36) months. In the CTEPH group, LDL-C increased (from 2.6[2.1-3.2] to 4.0[2.8-4.9]mmol/l, p = 0.01) in patients with PH reversal but remained unchanged in other patients (2.4[2.2-2.7] vs 2.3[2.1-2.5]mmol/l, p = 0.51). We concluded that LDL-C level is low in patients with PAH and is associated with an increased risk of death. Reversal of PH increases LDL-C levels.

Left ventricular mass is preserved in patients with idiopathic pulmonary arterial hypertension and Eisenmenger's syndrome.

BACKGROUND: Left ventricular (LV) atrophic remodelling was described for chronic thromboembolic pulmonary hypertension (PH) but not in other forms of PH. We aimed to assess LV morphometric changes in idiopathic pulmonary arterial hypertension (IPAH) and Eisenmenger's syndrome(ES). METHODS: Fifteen patients with IPAH, 15 patients with ES and 15 healthy volunteers were included. Magnetic resonance was used to measure masses of LV, interventricular septum (IVS), LV free wall (LVFW), and LV end diastolic volume (LVEDV) indexed for body surface area. RESULTS: Between patients with IPAH, ES and controls no differences in LVmassindex (54.4[45.2-63.3] vs 58.7[41.5-106.1] vs 52.8[46.5-59.3], p=0.50), IVSmassindex (21.6[18.2-21.9)] vs 27.4[18.0-32.9] vs 20.7[18.2-23.2], p=0.18), and LVFWmassindex ([32.4[27.1-40.0] vs 36.7[30.9-62.1] vs 32.5[26.9-36.1], p=0.29) were found. LVEDVindex was lower in IPAH patients than in controls and in ES patients (54.9[46.9-58.5] vs 75.2[62.4-88.9] vs 73.5[62.1-77.5], p<0.001). In IPAH LVEDV but not LV mass correlated with pulmonary vascular resistance (r=-0.56, p=0.03) and cardiac output (r=0.59, p=0.02). CONCLUSIONS: LV mass is not reduced in patients with IPAH and with ES and is not affected by haemodynamic severity of PH. LVEDV is reduced in IPAH patients in proportion to reduced pulmonary flow but preserved in patients with ES, where reduced pulmonary flow to LV is compensated by right-to left shunt.

Pulmonary artery pulse wave velocity in idiopathic pulmonary arterial hypertension.

BACKGROUND: Idiopathic pulmonary artery (PA) hypertension (IPAH) is associated with severe PA remodelling. Although the resulting increase in pulse wave velocity (PWV) might be of major pathophysiological relevance, little is known about PA-PWV in IPAH. The aim of this study was to characterize PA-PWV and its predictors in patients with IPAH. METHODS: We studied 26 consecutive patients with incident IPAH aged 55.0 (45.0-66.0) years (62% female) and 10 control subjects without pulmonary hypertension. PA-PWV was measured invasively; PA wall thickness and diameter were assessed using intravascular and transthoracic ultrasonography. RESULTS: PA-PWV was higher in IPAH than in control subjects (10.0 [7.5-14.0] m/s vs 3.5 [1.9-4.0] m/s; P < 0.001) as was also PA diameter and PA wall thickness. In IPAH patients, in univariate analysis PA-PWV was greater in men than in women and in patients with body mass index (BMI) < 25 kg/m(2) than with BMI ≥ 25 kg/m(2) and correlated positively with symptomatic disease duration, mean PA pressure, pulmonary vascular resistance, creatinine level, and negatively with low-density lipoprotein (LDL) cholesterol and triglyceride level but not with PA diameter or PA wall thickness. In multiple regression analysis mean PA pressure, LDL cholesterol level and BMI < 25 kg/m(2) were the main predictors of PA-PWV in IPAH patients (R(2) = 77%; P < 0.001). CONCLUSIONS: PA-PWV is increased in IPAH patients. High PA pressure, low LDL cholesterol level, and BMI < 25 kg/m(2) explain most of its variability in this group.

Changes in exercise capacity and cardiac performance in a series of patients with Eisenmenger's syndrome transitioned from selective to dual endothelin receptor antagonist.

BACKGROUND: Differences in clinical effects between selective and dual endothelin (ET) receptor antagonists (ERA) in patients with pulmonary arterial hypertension (PAH) are currently unknown. We aimed to assess prospectively how transition from selective (sitaxsentan) to dual (bosentan) ERA affected exercise capacity and cardiocirculatory performance in patients with Eisenmenger's syndrome. METHODS: A series of seven stable patients with Eisenmenger's syndrome aged 40.0 (30.0-56.0) years old treated with sitaxsentan were assessed before and three months after transition to bosentan. Six minute walk test and magnetic resonance to assess LV and RV mass, volume and ejection fraction, and pulmonary flow, and laboratory tests were performed. RESULTS: We observed an increase in LV mass [96.5 (66.0-116.0) vs. 123.0 (93.0-146.0)g; p=0.03], LV ejection fraction [55.0 (44.0-63.0) vs. 65.0 (58.0-70.0)%; p=0.02)], and pulmonary flow [64 (53.0-71.0) vs. 69.0 (55.0-84.0)ml/beat; p=0.046]. This was accompanied by an increase of oxygen saturation, elongation of 6MWD [435.0 (378.0-482.3) vs. 474 (405.0-534.7); p=0.02], decrease of NTproBNP level and increase of ET-1 level. CONCLUSIONS: Three month follow-up of stable patients with Eisenmenger's syndrome transitioned from sitaxsentan to bosentan revealed improvement of exercise capacity despite significant elevation of ET-1 level. Concurrent increase of LV ejection fraction and pulmonary flow might have contributed to these favourable effects.

Electrocardiogram for the diagnosis of right ventricular hypertrophy and dilation in idiopathic pulmonary arterial hypertension.

BACKGROUND: Currently, there are no data on the association between right ventricular (RV) structure and ECG changes specific for idiopathic pulmonary arterial hypertension (IPAH). Therefore, we aimed to assess the accuracy of the recommended ECG criteria for predicting RV hypertrophy (RVH) and dilation in patients with IPAH. METHODS AND RESULTS: Twelve-lead ECG and cardiovascular magnetic resonance imaging (CMR) were performed in 23 consecutive patients with IPAH aged 49.8±16.3 years. ECG criteria were referred to RV mass index and RV end-diastolic volume index as measured by CMR. Only the ECG voltage criteria based on R wave amplitude in lead V1, R wave amplitude in aVR, P wave amplitude in II and ventricular activation time in V1 were useful for differentiating between patients with and without RVH. A ventricular activation time in lead V1 of <0.01 s excluded RVH, whereas R in V1 >6 mm, R:S in V1 >1, R in aVR >4 mm, R:S in V5 to R:S in V1 <0.04 and P in II >2.5 mm confirmed the diagnosis. Only the ventricular activation time in V1 correlated with RV dilation and when >0.045s confirmed its diagnosis. CONCLUSIONS: Only a few of the recommended ECG criteria proved to be useful in the diagnosis of RVH or RV dilation in patients with IPAH. Changes in the cut-off values improved their accuracy.

Repolarization parameters in patients with acute ST segment elevation myocardial infarction treated with primary percutaneous coronary intervention with respect to predischarge ST-T pattern: a preliminary study.

BACKGROUND: Negative T wave and lack of ST segment elevation in predischarge ECG in ST-segment elevation myocardial infraction (STEMI) patients are given as markers of good prognosis. Repolarization duration, especially its late part (TpeakTend - TpTe), likewise ST-T patterns, is related to local post-myocardial infarction myocardial attributes. We analyzed the differences in QT parameters in STEMI patients with negative or not-negative T wave pattern in predischarge ECG. METHODS: The data from 83 STEMI patients (LVEF > 45%, first MI, one-vessel disease) who underwent successful percutaneous coronary intervention of infarct-related coronary artery (TIMI 3 flow) were collected. According to ST-T patterns in predischarge ECG, the cohort was divided into two groups: 38 patients with persistent ST elevation and/or non-negative T wave pattern (STT+), and 45 patients with negative T wave, without ST elevation (STT-). QT, QTpeak, and TpTe intervals were obtained from 5 consecutive beats of sinus rhythm 60-70 bpm between 6 a.m. and 8 a.m. from Holter recording, corrected to the heart rate (HR) with Bazett's formula. RESULTS: The study groups did not differ in gender, age, or treatment. No true antiarrhythmics were given. Both QTc and TpTec were longer in STT+ patients: 459 +/- 26 ms vs. 440 +/- 25 ms, p = 0.01 and 108 +/- 10 ms vs. 96 +/- 11 ms, p = 0.000015, respectively. Prolongation of late repolarization was found both in anterior and inferior infarction. CONCLUSIONS: STEMI patients who underwent successful percutaneous coronary intervention of infarct-related coronary arteries and demonstrated persistent ST elevation, without negative T wave at hospital discharge, had a longer repolarization duration, especially the late phase of it. Further studies are necessary to assess the prognostic value of this finding.