Análisis ecocardiográfico de la variabilidad de la presión sistólica arterial pulmonar en la hipertensión pulmonar / Echocardiographic analysis of pulmonary arterial systolic pressure in pulmonary hypertension

Resumen Introducción: La confiabilidad de la presión sistólica arterial pulmonar por ecocardiografía transtorácica se encuentra limitada por su variabilidad para definir la hipertensión pulmonar. Objetivo: Conocer la variabilidad en la presión sistólica arterial pulmonar estimada por ecocardiografía en la hipertensión pulmonar. Métodos: En el periodo 2016-2020 se captaron sujetos con hipertensión pulmonar que tuvieron estimada la presión sistólica de la arteria pulmonar por ecocardiografía transtorácica y por cateterismo cardiaco derecho. Se obtuvieron sus variables demográficas. Los datos se analizaron con el estadístico descriptivo de Bland-Altman y el coeficiente de correlación intraclase (intervalo de confianza al 95%). Resultados: Se estudiaron 152 sujetos, edad 60 ± 12 años. Índice de masa corporal 27.64 ± 4.69 kg/m2. La presión sistólica de la arteria pulmonar por ecocardiografía transtorácica 58.99 ± 18.62 vs. cateterismo cardiaco 55.43 ± 16.79. Diferencia media (sesgo) -3.6 (29.1, -36.2) y coeficiente de correlación intraclase 0.717 (0.610, 0.794). Conclusiones: La variabilidad es amplia y el acuerdo es sustancial con la presión sistólica de la arteria pulmonar. Se aconseja estimarla solo como tamizaje de la hipertensión pulmonar.

Abstract Introduction: The reliability of pulmonary arterial systolic pressure by transthoracic echocardiography is limited by its variability to define pulmonary hypertension. Objective: To know the variability of pulmonary arterial systolic pressure estimated by echocardiography in pulmonary hypertension. Their demographic variables were obtained. Methods: From 2016-2020 subjects with pulmonary hypertension were recruited, with pulmonary artery systolic pressure estimated by transthoracic echocardiography and by right heart catheterization. Data were analyzed using the Bland-Altman descriptive statistic and the intraclass correlation coefficient (95% confidence interval). Results: 152 subjects, age 60 ± 12 years, were studied. Body mass index 27.64 ± 4.69 kg/m2. The pulmonary artery systolic pressure estimated by transthoracic echocardiography 58.99 ± 18.62 vs. cardiac catheterization 55.43 ± 16.79 mmHg. Mean difference (bias) -3.6 (29.1, -36.2) and intraclass correlation coefficient 0.717 (0.610, 0.794). Conclusions: Variability is wide, and agreement is substantial for pulmonary artery systolic pressure. It is recommended to estimate only as screening for pulmonary hypertension.

Prueba de caminata de 6 minutos: del sujeto normal a la obesidad mórbida / Six minute walk test: from normal to morbid obesity subject

Resumen Introducción: La obesidad mórbida se asocia a alteraciones de la capacidad de caminar, sin embargo se desconoce cómo es el comportamiento de la prueba de caminata de 6 minutos en sujetos con incrementos del índice de masa corporal (IMC). Objetivo: Describir el comportamiento de la prueba de caminata de 6 minutos en sujetos con IMC normal hasta la obesidad mórbida. Métodos: Mediante un diseño transversal analítico se estudiaron sujetos de ambos sexos de 18 a 60 años con IMC: normal (18.5-24.9 kg/m2), sobrepeso (25-29.9 kg/m2), obesidad (30-39.9 kg/m2), obesidad mórbida (> 40 kg/m2). Se les realizó prueba de caminata de 6 minutos, se acotaron variables demográficas y antecedentes personales patológicos. Se analizaron las categorías de IMC con ANOVA de una vía y ajuste de Bonferroni y los sexos con prueba t, ambos para grupos independientes y correlaciones de Pearson para las diversas variables. Una p < 0.05 fue considerada estadísticamente significativa. Resultados: Se estudiaron 480 sujetos de ambos sexos en cuatro grupos. Edad: hombres 43 ± 11 y mujeres 45 ± 10 años. Porcentaje diabetes mellitus (6.7%), hipertensión arterial (18.3%). Metros caminados hombres vs. mujeres por IMC (normal: 483 ± 56 vs. 449 ± 61; sobrepeso: 471 ± 55 vs. 441 ± 44; obesidad: 455 ± 70 vs. 421 ± 47; obesidad mórbida: 443 ± 49 vs. 403 ± 54; p < 0.05). Correlación IMC-metros caminados r: -0.446 (p < 0.0001). Conclusiones: Los metros caminados en la prueba de caminata de 6 minutos disminuyeron conforme incrementó el IMC. El sexo masculino caminó más metros en todas las categorías.

Abstract Introduction: Morbid obesity is associated with alterations in the ability to walk, however, the behavior of the 6-minute walk test in subjects with increases in body mass index is unknown. Objective: To describe the behavior of the 6-minute walk test in subjects with normal body mass index to morbid obesity. Methods: Through an analytical cross-sectional design, subjects of both genders from 18 to 60 years old with body mass index were studied: Normal (BMI: 18.5-24.9); overweight (BMI: 25-29.9); obesity (BMI: 30-39.9); morbid obesity (BMI: > 40) kg/m2. A 6-minute walk test was performed, demographic variables and pathological personal history were delimited. BMI categories were analyzed with one-way ANOVA and Bonferroni adjustment, and gender with t-test, both for independent groups, and Pearson's correlations for the various variables. Results: 480 subjects of both genders were studied in four groups. Age: men 43 ± 11 and women 45 ± 10 years old. Percentage diabetes mellitus (6.7%), arterial hypertension (18.3%). Meters walked men vs. women by body mass index (normal: 483 ± 56 vs. 449 ± 61; overweight: 471 ± 55 vs. 441 ± 44; obesity: 455 ± 70 vs. 421 ± 47; morbid obesity: 443 ± 49 vs. 403 ± 54, p < 0.05). Correlation body mass index-meters walked: r: -0.446 (p < 0.0001). Conclusions: Meters walked in the 6-minute walk test decreased as body mass index increased. The male gender walked more meters in all categories.

Application of pulmonary circulation single-blocking method in intersegmental plane identification during segmentectomy / 中国胸心血管外科临床杂志

@#Objective    To introduce a new method for identifying intersegmental planes during thoracoscopic segmentectomy using pulmonary circulation single-blocking in the target segment. Methods    To retrospectively analyze the clinical data of 83 patients who underwent thoracoscopic pulmonary segmentectomy from January 2019 to March 2020 using the pulmonary circulation single-blocking method. There were 33 males and 50 females, with a median age of 54 (46-65) years, and they were divided into a single vein group (SVG, n=31) and a single artery group (SAG, n=52), and the clinical data of two groups were compared. Results    The intersegmental planes were identified successfully in both groups and there were no statistically significant differences between the two groups in terms of intersegmental plane management (P=0.823), operating time (P=0.786), intraoperative blood loss (P=0.775), chest drainage time (P=0.659), postoperative hospital stay (P=0.824) or the incidence of postoperative complications (P=1.000). Conclusion    The use of pulmonary circulation single-blocking for intersegmental plane identification during thoracoscopic segmentectomy is safe and feasible, and the intersegmental plane can be satisfactorily identified by the single-blocking of arteries or veins.

Variabilidad intrasujeto de la prueba de caminata de seis minutos / Within-subject variability of the 6-minute walk test

Introducción: la prueba de caminata de seis minutos evalúa la capacidad para hacer ejercicio y es de amplio uso, bajo costo y variabilidad diversa. Objetivo: definir la utilidad de una segunda prueba de caminata de seis minutos realizada a 30 minutos de la primera. Material y métodos: se llevó a cabo un estudio observacional, longitudinal y analítico de sujetos nacidos y habitantes de la Ciudad de México, de ambos géneros, sin enfermedad cardiopulmonar. Se registraron sus variables demográficas. Las diferencias se calcularon con la prueba t para grupos independientes y la variabilidad con el estadístico de BlandAltman; su magnitud, con el coeficiente de correlación intraclase e intervalos de confianza del 95% (IC 95%). Una p < 0.05 se consideró significativa. Resultados: se estudiaron 200 pruebas de 100 sujetos. La edad promedio fue de 36 ± 11 años. La media del índice de masa corporal fue 24.71 ± 3.24 kg/m2. Fueron 43 hombres (43%). La actividad más frecuente fueron las artes y los oficios en 38 (38%). Solo en 55 (55%) incrementaron en 24 los metros caminados en la segunda prueba. Los metros caminados totales de la caminata 1 frente a la 2 fueron 437.65 ± 48.84 frente a 441.62 ± 11.49. La diferencia media (sesgo) fue de −4 (57.9, −65.9) y el coeficiente de correlación intraclase de 0.800 (IC 95% 0.717-0.861). Conclusiones: la prueba de caminata de seis minutos es reproducible con variabilidad amplia. Estos resultados sugieren realizar solo una prueba de caminata de seis minutos

Background: The 6-minute walk test assesses the ability to perform exercise and it is widely used, of low cost, and of diverse variability. Objective: To define the usefulness of a second 6-minute walk test performed 30 minutes from the first. Material and methods: An observational, longitudinal and analytical study was carried out in subjects born and inhabitants from Mexico City, both genders, without cardiopulmonary disease. Their demographic variables were recorded. Differences were calculated with the t test for independent groups and variability with the Bland-Altman statistic; its magnitude, with the intraclass correlation coefficient and 95% confidence intervals (95% CI). A p < 0.05 was considered significant. Results: 200 tests from 100 subjects were studied. Average age was 36 ± 11 years. Body mass index average was 24.71 ± 3.24 kg/m2. 43 subjects were male (43%). The most frequent activity was arts and crafts in 38 (38%). Only 55 subjects (55%) increased by 24 the number of meters walked in the second test. Total of meters walked on walk 1 vs. 2 were: 437.65 ± 48.84 vs. 441.62 ± 11.49. Mean difference (bias) was of −4 (57.9, −65.9) and intraclass correlation coefficient of 0.800 (95% CI, 0.717-0.861). Conclusions: The 6-minute walk test is reproducible with wide variability. These results suggest to do only one 6-minute walk test

Caracterización de parámetros del intercambio gaseoso en la Ciudad de México / Characterization of gas exchange parameters in Mexico City

Introducción: en las grandes altitudes, el intercambio gaseoso suele estar deteriorado; en la altitud moderada de la Ciudad de México esto no está aún plenamente definido. Objetivo: caracterizar el intercambio gaseoso en la altitud moderada de la Ciudad de México. Material y métodos: mediante un estudio transversal analítico se estudiaron sujetos nacidos y habitantes de la Ciudad de México, de ambos géneros, con edades de 20 a 59 años sin enfermedad cardiopulmonar. Se registraron sus variables demográficas, espirometría simple y de gasometría arterial. Las diferencias en las variables se calcularon con ANOVA de una vía para grupos independientes y ajuste de Bonferroni. Una p < 0.05 se aceptó como significativa. Resultados: se estudiaron 335 sujetos, de los cuales 168 (50.15%) fueron hombres, la edad grupal fue de 45 ± 11 años, con índice de masa corporal 22.97 ± 1.54 Kg/m2. La relación volumen espiratorio forzado en el primer segundo/Capacidad vital forzada (VEF1/CVF) de 91.58 ± 12.86%. La presión arterial de oxígeno fue de 66 ± 5.02 mmHg, el bióxido de carbono: 32.07 ± 2.66 mmHg, la saturación arterial de oxígeno: 93.03 ± 1.80% y la hemoglobina: 14.07 ± 1.52 gr/dL. Conclusiones: la presión arterial de oxígeno y del bióxido de carbono están disminuidos a la altura de la Ciudad de México.

Background: At high altitude the gas exchange is impaired, in the moderate altitude of Mexico City they are not yet defined. Objective: To characterize the gas exchange in the moderate altitude of Mexico City. Material and methods: Through an analytical cross-sectional study, subjects born and inhabitants of Mexico City, both genders, aged 20 to 59 years without cardiopulmonary disease, were studied. Their demographic variables, simple spirometry and arterial blood gas were recorded. Differences in variables were calculated with one-way ANOVA for independent groups and Bonferroni adjustment. p < 0.05 was accepted as significant. Results: 335 subjects were studied, 168 (50.15%) men. Group age 45 ± 11 years old, body mass index 22.97 ± 1.54 Kg/m2. Forced expiratory volume ratio in the first second / Forced vital capacity (FEV1/FVC) 91.58 ± 12.86%. The arterial oxygen pressure was: 66 ± 5.02 mmHg, carbon dioxide: 32.07 ± 2.66 mmHg, arterial oxygen saturation: 93.0 3 ± 1.80%, and hemoglobin: 14.07 ± 1.52 gr/dL. Conclusions: The arterial oxygen pressure and carbon dioxide are lowered at the Mexico City altitude.

Deterioro del intercambio gaseoso en sujetos con incremento del índice de masa corporal a una altitud de 2, 240 metros sobre el nivel del mar / Deterioration of gas exchange in subjects with an increase in body mass index at an altitude of 2, 240 meters above sea level

Resumen Introducción: Las alteraciones del intercambio gaseoso se han reconocido en la obesidad mórbida; sin embargo, no se conoce su comportamiento conforme se incrementa el índice de masa corporal. Objetivo: Conocer el comportamiento del intercambio gaseoso a la altura de la Ciudad de México en el desarrollo de obesidad mórbida. Métodos: Mediante un diseño transversal analítico se estudió a sujetos pareados por género y edad de cuatro grupos diferentes de índice de masa corporal (kg/m2): normal (18.5-24.9), sobrepeso (25-29.9), obesidad (30-39.9) y obesidad mórbida (≥ 40). Se obtuvieron sus antecedentes patológicos y demográficos, variables de gasometría arterial y espirometría simple. Las variables se determinaron de acuerdo con las características de la muestra; las diferencias entre grupos se realizaron mediante Anova de una vía con ajuste de Bonferroni, así como la correlación de Pearson para las variables relacionadas. Una p < 0.05 se consideró con significación estadística. Resultados: Se estudió a 560 pacientes en cuatro grupos. La edad promedio fue de 49 ± 11 años. La mayor frecuencia de diabetes mellitus (34.29%), hipertensión arterial (50%) e hiperlipidemia (36.43%) se registró en el grupo de obesidad, y la de roncador (73.57%) en la obesidad mórbida. Se identificaron diferencias desde el grupo normal respecto de la obesidad mórbida: PaCO2 31.37 ± 2.08 vs. 38.14 ± 5.10 mmHg; PaO2 68.28 ± 6.06 vs. 59.86 ± 9.28 mmHg y SaO2 93.51 ± 1.93 vs. 89.71 ± 5.37%, todas con p = 0.0001. Correlación IMC-PaCO2: 0.497, e IMC-PaO2: -0.365, p = 0.0001, respectivamente. Conclusiones: A la altitud de la Ciudad de México y con índice de masa corporal > 30 kg/m2, las variables relacionadas con el intercambio gaseoso y espirometría simple comienzan a deteriorarse; son evidentes con IMC > 40 kg/m2.

Abstract Introduction: Alterations of gas exchange have been recognized in morbid obesity, however, it is not known how their behavior would be as the body mass index increases. Objective: To know the behavior of gas exchange at the level of Mexico City in the development of morbid obesity. Methods: Through analytical design, subjects matched by gender and age were studied from four different groups of body mass index (kg/m2), normal (18.5-24.9), overweight (25-29.9), obesity (30-39.9) and morbid obesity (≥ 40). Their pathological and demographic antecedents, arterial blood gas and simple spirometry variables were obtained. The variables were shown according to their sample characteristic. The differences between groups were made using one way Anova with Bonferroni adjustment, as well as Pearson’s correlation for the related variables. Statistical significance was considered with p < 0.05. Results: 560 subjects were studied in 4 groups. The average age 49 ± 11 years old. The highest frequency of diabetes mellitus (34.29%), arterial hypertension (50%) and hiperlipidemia (36.43%) was in the obesity group, and being snoring (73.57%) in morbid obesity. There were differences from the normal group versus. morbid obesity: PaCO2 31.37 ± 2.08 versus. 38.14 ± 5.10 mmHg; PaO2 68.28 ± 6.06 versus. 59.86 ± 9.28 mmHg and SaO2 93.51 ± 1.93 versus. 89.71 ± 5.37%, all with p = 0.0001. The IMC-PaCO2 correlation: 0.497, and IMC-PaO2: −0.365, p = 0.0001 respectively. Conclusions: At the altitude of Mexico City and body mass index > 30 kg/m2 the variables related to gas exchange and simple spirometry begin to deteriorate; are evident with BMI > 40 kg/m2.

Volume Vascular Pulmonar Estimado por Software Automatizado é um Preditor de Mortalidade após Embolia Pulmonar Aguda / Pulmonary Vascular Volume Estimated by Automated Software is a Mortality Predictor after Acute Pulmonary Embolism

Resumo Fundamento: A embolia pulmonar aguda (EPA) tem desfecho clínico variável. A angiotomografia computadorizada (angio-CT) é considerada o padrão-ouro para o diagnóstico. Objetivo: Avaliar se o volume vascular pulmonar (VVP) quantificado por software automatizado é um preditor de mortalidade após EPA. Métodos: Estudo de coorte retrospectivo no qual a imagem da angio-CT de 61 pacientes com EPA foi reanalisada. O VVP e o volume pulmonar (VP) foram estimados automaticamente pelo software Yacta. Calculamos o VVP ajustado pela razão: VVP(cm3)/VP(litros). Parâmetros prognósticos clássicos da angio-CT (carga embólica; razão do diâmetro do ventrículo direito/ventrículo esquerdo; razão do diâmetro da artéria pulmonar/aorta; desvio do septo interventricular; infarto pulmonar e refluxo de contraste na veia hepática) foram avaliados. A mortalidade em 1 mês foi o desfecho analisado. Consideramos um valor de p <0,05 como estatisticamente significativo. Resultados: Sete mortes (11%) ocorreram entre os 61 pacientes durante 1 mês de seguimento. O VVP ajustado <23cm3/L foi um preditor independente de mortalidade na análise univariada (odds ratio [OR]: 26; intervalo de confiança de 95% [IC95%]: 3-244; p=0,004) e na análise multivariada (OR ajustado: 19 [IC95%: 1,3-270]; p=0,03). Os parâmetros clássicos da angio-CT não foram associados à mortalidade em 1 mês nesta amostra. O VVP ajustado <23cm3/L apresentou sensibilidade de 86%, especificidade de 82%, valor preditivo negativo de 94% e valor preditivo positivo de 64% para identificação dos pacientes que morreram. Conclusão: VVP ajustado <23cm3/L foi um preditor independente de mortalidade após EPA. Esse parâmetro mostrou melhor desempenho prognóstico do que os outros achados clássicos da angio-CT. (Arq Bras Cardiol. 2020; 115(5):809-818)

Abstract Background: Acute pulmonary embolism (APE) has a variable clinical outcome. Computed tomography pulmonary angiography (CTPA) is the gold standard for this diagnosis. Objective: To evaluate if the pulmonary vascular volume (PVV) quantified by automated software is a mortality predictor after APE. Methods: Retrospective cohort study where the CTPA imaging of 61 patients with APE was reanalyzed. Pulmonary vascular volume (PVV) and pulmonary volume (PV) were automatically estimated using the Yacta software. We calculated the adjusted PVV by the ratio: PVV(cm3)/PV(liters). Classical prognostic CTPA parameters (clot load index, right ventricle/left ventricle diameter ratio, pulmonary artery/aorta diameter ratio, ventricular septal bowing, pulmonary infarction and reflux of contrast into the hepatic vein) were assessed. The outcome assessed was one-month mortality. We considered a p-value <0.05 as statistically significant. Results: Seven deaths (11%) occurred at one month among these 61 patients. PVV<23cm3/L was an independent predictor of one-month mortality in the univariate [odds ratio (OR): 26; 95% confidence interval (CI): 3-244; p=0.004] and multivariate analyses [adjusted OR: 19; 95%CI: 1.3-270; p=0.03]. The classical CTPA parameters were not associated with one-month mortality in this sample. The PVV<23cm3/L showed a sensitivity of 86%, a specificity of 82%, a negative predictive value of 94% and a positive predictive value of 64% to identify the patients who died. Conclusion: PVV<23cm3/L was an independent predictor of one-month mortality after APE. This parameter showed better prognostic performance than other classical CTPA findings. (Arq Bras Cardiol. 2020; 115(5):809-818)

Underexpression of endothelial nitric oxide synthase leads to more severe pulmonary complex vascular lesions associated with HIV patients / La baja expresión de oxido nítrico sintetasa provoca mayor severidad en las lesiones vasculares complejas asociadas al VIH

Abstract Background: Despite increase in survival of human immunodeficiency virus (HIV) patients due to highly active antiretroviral therapy, non-infectious complications are still prevalent such as presentation of lung vasculopathy, even in asymptomatic patients. Endothelial nitric oxide synthase (eNOS) is necessary to produce nitric oxide that causes pulmonary endothelial vasodilation. Participation of this protein in the pulmonary circulation in HIV patients has not been elucidated. This work studied the presence and expression of eNOS in pulmonary complex vascular lesions associated with HIV (PCVL/HIV). Methods: In lung tissues from patients who died from complications of HIV, we used immunohistochemistry and immune chemiluminescence (imageJ) to determine the different degrees of expression of eNOS in PCVL-HIV in comparison with non-PCVL/HIV. Reagents used were anti-eNOS and an automated system. All data are presented as mean and standard deviation. Differences were analyzed with Wilcoxon; p < 0.05 was accepted as statistically significant. Results: In 57 tissues, the histological evidence of pulmonary vasculopathy was showed as different types (proliferative, obliterative, and plexiform) and severe presentation of vasculopathy than non-PCVL/HIV. A statistically significant decrease of eNOS was observed in all PCVL/HIV tissue samples. Conclusion: eNOS has a relevant role in the pathogenesis of pulmonary vasculopathy in acquired immunodeficiency syndrome patients. It is necessary to determine in the future the participation of eNOS and other mechanisms involved in PCVL/HIV.

Resumen Antecedentes: A pesar del incremento en la sobrevivencia del paciente con virus de inmunodeficiencia humana (VIH) debido al uso del tratamiento antiretroviral altamente efectivo, las complicaciones no infecciosas siguen ocasionando vasculopatía pulmonar, aun en pacientes asintomáticos. La óxido nítrico sintetasa (ONSe) es necesaria para la producción de óxido nítrico la cual provoca vasodilatación pulmonar. La participación de esta proteína en la circulación pulmonar en los pacientes con VIH aún no se ha dilucidado. Este trabajo estudia la presencia y la expresión de ONSe en las lesiones vasculares pulmonares complejas asociadas al VIH (LVPC/VIH). Métodos: En tejidos pulmonares de pacientes que fallecieron por complicaciones del VIH, se utilizó inmunohistoquímica e inmunoquimioluminescencia (imageJ) para determinar los diferentes grados de expresión de la ONSe en LVPC/VIH. Los reactivos utilizados son anti-ONSe en sistema automatizado. Todos los datos son presentados en media y desviación estándar. Las diferencias son analizadas con la prueba de Wilcoxon; se aceptó como estadísticamente significativa una p < 0.05. Resultados: En 57 pacientes, la histología de la vasculopatía pulmonar mostró diferentes tipos (proliferativo, obliterativo y plexiforme) además de varias presentaciones de vasculopatía en tejidos no-LVPC/VIH. Se observó diferencia estadística en la disminución de ONSe en todos los tejidos LVPC/VIH. Conclusiones: La ONSe tiene un papel relevante en la patogénesis de la vasculopatía pulmonar en el VIH. Es necesario determinar en el futuro la participación de ONSe y otros mecanismos involucrados en LVPC/VIH.

Association between serum levels of osteopontin and systolic pulmonary artery pressure among healthy adults post acute high altitude exposure / 中华心血管病杂志

Objective: To explore the association between serum levels of osteopontin (OPN) and systolic pulmonary artery pressure (sPAP) in healthy men following acute high altitude exposure. Methods: According to the inclusion and exclusion criteria, this observational study included 94 male subjects (aged from 18 to 30 years, dwelling in lowland<500 m) who ascended to Litang (4 100 m) from Chongqing (400 m) by bus with a stair-like journey within 7 days in June 2013. Data including basic information, OPN, superoxide dismutase (SOD), and malondialdehyde (MDA) and echocardiographic derived sPAP were collected within 48 hours before ascent and within 2-7 hours after arrival. Accordingly, subjects were divided into 3 groups based on the tertiles of sPAP after acute high altitude exposure: low sPAP group (26.8-32.3 mmHg (1 mmHg=0.133 kPa)) (n=31), middle sPAP group (32.4-37.4 mmHg) (n=32) and high sPAP group (37.5-55.6 mmHg) (n=31). Associations of serum OPN and SOD levels with sPAP were analysed by univariate and multivariate linear regression analysis. Results: After acute high altitude exposure, the levels of sPAP were significantly increased (P<0.001). There were no differences in age, height, weight, body mass index, percent of Han nationality and smoking among 3 subgroups. However, following acute high altitude exposure, the levels of heart rate, systolic and diastolic blood pressure elevated (all P<0.05), whereas the levels of oxygen saturation were reduced in the total subjects and all subgroups (all P<0.05). Moreover, systolic blood pressure of subjects in the high sPAP group was higher than that in low and middle sPAP groups (both P<0.05), and diastolic blood pressure of subjects in high sPAP group was higher than that in low sPAP group (P<0.05). The serum levels of OPN were increased in total cohort(27.9 (22.5,34.0) μg/L vs. 25.6 (18.4, 33.1) μg/L, P<0.05)， and high sPAP group (P<0.05), whereas no differences were found in serum SOD and MDA levels among groups. Furthermore, the serum level of OPN in high sPAP group was higher than that in low sPAP group at high altitude (P<0.05), and there was a trend for decline in SOD level with increasing sPAP (P>0.05). Results from univariable linear regression analysis showed that the serum levels of OPN (r=0.32, P=0.002) and SOD (r=-0.22，P=0.032) were linearly correlated with sPAP in total cohort after high altitude exposure. Multivariate regression analysis showed that the serum levels of OPN(β=0.310，P=0.002) and SOD (β=-0.199，P=0.043) were independently associated with the levels of sPAP at high altitude. Conclusion: After acute high altitude exposure, the serum level of OPN is positively associated with sPAP, suggesting that OPN may be a novel bio-marker for predicting the increase of pulmonary pressure in response to acute high altitude exposure.

Sequestro pulmonar e tratamento endovascular: um relato de caso / Pulmonary sequestration and endovascular treatment: a case report

O sequestro pulmonar refere-se à anomalia congênita definida por massa de parênquima pulmonar não funcionante. É dividido pela existência de envoltório pleural próprio em intralobar, representando cerca de 75% dos casos, ou extralobar, responsável pelos 25% restantes. O diagnóstico é feito através de radiografia e confirmado com tomografia computadorizada, ressonância nuclear magnética e arteriografia. Tradicionalmente, o tratamento proposto é cirúrgico, mas a técnica endovascular tem apresentado bons resultados. É relatado o caso de uma mulher, 29 anos, com quadro clínico de pneumonias de repetição desde os 5 anos. A tomografia de tórax revelou malformação vascular em região inferior de pulmão direito. O tratamento vascular foi realizado através de embolização do ramo anômalo

Pulmonary sequestration is a congenital anomaly defined as a nonfunctioning mass of lung parenchyma. Presence of an independent pleural envelope classifies it as intralobar, accounting for approximately 75% of the cases, while absence classifies cases as extralobar, accounting for the remaining 25%. Diagnosis is made through radiography and confirmed by computed tomography, magnetic resonance, or angiography. The traditional treatment is open surgical repair, but endovascular techniques have been used, with good results. We report the case of a 29-year-old-woman presenting with recurrent pneumonia for 5 years. A CT scan of the chest revealed poor vascular formation in the lower region of the right lung. The pulmonary sequestration was treated by embolization of the anomalous branch

Protective Effect of Right Ventricular Mitochondrial Damage by Cyclosporine A in Monocrotaline-induced Pulmonary Hypertension

BACKGROUND AND OBJECTIVES: Mitochondria play a key role in the pathophysiology of heart failure and mitochondrial permeability transition pore (MPTP) play a critical role in cell death and a critical target for cardioprotection. The aim of this study was to evaluate the protective effects of cyclosporine A (CsA), one of MPTP blockers, and morphological changes of mitochondria and MPTP related proteins in monocrotaline (MCT) induced pulmonary arterial hypertension (PAH). METHODS: Eight weeks old Sprague-Dawley rats were randomized to control, MCT (60 mg/kg) and MCT plus CsA (10 mg/kg/day) treatment groups. Four weeks later, right ventricular hypertrophy (RVH) and morphological changes of right ventricle (RV) were done. Western blot and reverse transcription polymerase chain reaction (RT-PCR) for MPTP related protein were performed. RESULTS: In electron microscopy, CsA treatment prevented MCT-induced mitochondrial disruption of RV. RVH was significantly increased in MCT group compared to that of the controls but RVH was more increased with CsA treatment. Thickened medial wall thickness of pulmonary arteriole in PAH was not changed after CsA treatment. In western blot, caspase-3 was significantly increased in MCT group, and was attenuated in CsA treatment. There were no significant differences in voltage-dependent anion channel, adenine nucleotide translocator 1 and cyclophilin D expression in western blot and RT-PCR between the 3 groups. CONCLUSIONS: CsA reduces MCT induced RV mitochondrial damage. Although, MPTP blocking does not reverse pulmonary pathology, it may reduce RV dysfunction in PAH. The results suggest that it could serve as an adjunctive therapy to PAH treatment.

Hipertensión arterial pulmonar asociada al virus de inmunodeficiencia humana. A 3 décadas de su descripción / Pulmonary arterial hypertension associated with human immunodeficiency virus: thirty years after its description

Resumen El desarrollo de hipertensión arterial pulmonar asociada al virus de inmunodeficiencia humana reduce la probabilidad de sobrevivencia en el paciente afectado en comparación con el que no presenta esta alteración cardiopulmonar. La fisiopatogenia aún es incierta. Existen varias líneas de investigación para asociar las diferentes proteínas del virus en la lesión endo- telial. Desde el punto de vista terapéutico, existen modalidades de tratamiento que permiten una expectativa de vida aceptable.

Abstract The development of pulmonary arterial hypertension associated with human immunodeficiency virus reduces the probability of survival in the patient affected compared to those without cardiopulmonary disease. The pathophysiology is uncertain. There are several lines of research to associate the different proteins of the virus in the endothelial lesion. From a therapeutic point of view there are treatment modalities that allow an acceptable life expectancy.

Mecanismos regulatorios del tono vascular pulmonar neonatal: una perspectiva molecular / Regulatory mechanisms of neonatal pulmonary vascular tone: a molecular perspective

La adaptación al medio extrauterino incluye un aumento considerable de la PaO2, que induce especialmente cambios estructurales y vasoactivos en la circulación pulmonar, que llevarán a una circulación previamente pobremente irrigada, a recibir ∼100% del gasto cardíaco del recién nacido, permitiendo el normal intercambio gaseoso. La regulación local de la circulación arterial pulmonar neonatal basal, es mantenida por un delicado equilibrio entre agentes vasoconstrictores y vasodilatadores. Este equilibrio, permite mantener la circulación pulmonar como un territorio de gran flujo sanguíneo y baja resistencia. La acción de los vasoconstrictores permite la formación de las interacciones entre actina y la cadena liviana de la miosina, esta es inducida en la célula muscular lisa principalmente por dos vías: a) dependiente de calcio, que consiste en aumentar el calcio intracelular, facilitando finalmente la unión de actina y miosina, y b) independiente de calcio, la cual a través de consecutivas fosforilaciones logra sensibilizar a las proteínas involucradas promoviendo la unión de actina y miosina. Estas acciones son mediadas por agonistas generados principalmente en el endotelio pulmonar, como endotelina-1 y tromboxano, o por agonistas provenientes de otros tipos celulares como la serotonina. Los agentes vasodilatadores regulan la respuesta vasoconstrictora, principalmente inhibiendo la señalización que induce la vasocontricción independiente de calcio, a través de la activación de proteínas quinasas que inhibirán la función de la ROCK quinasa, uno de los últimos efectores de la vasocontricción antes de la formación de la unión de actina y miosina. Esta revisión describe estos mecanismos de primordial importancia en las primeras horas de nuestra vida como individuos independientes.

The extrauterine-milieu adaptation includes a considerable increase in PaO2, that specifically induces structural and vasoactive changes at pulmonary circulation. Such changes transform a poor irrigated circulation into a circulation that receive ∼100% of neonatal cardiac output, supporting the normal alveolar-capillary gas exchange. Local regulation of basal neonatal pulmonary circulation is maintaining by a delicate equilibrium between vasoconstrictor and vasodilator agents. This equilibrium, allows to maintain the pulmonary circulation as an hemodynamic system with a high blood flow and a low vascular resistance. Vasocontrictors action allows actin and light-chain myosin interaction. Two main pathways induced this effect in smooth muscle cell: a) a calcium dependent pathway, that increases intracellular calcium, facilitating actin - myosin binding, and b) the independent calcium pathway, which achieves through consecutive phosphorylation reactions sensitize the proteins involved, promoting the binding of actin and light-chain myosin. These actions are mediated by agonists produced mainly in the pulmonary endothelium, such as endothelin-1 and thromboxane, or by agonists from other cell types such as serotonin. Vasodilator agents regulate the vasoconstrictor response, mainly by inhibiting signals that induce calcium-independent vasoconstriction, through activation of protein kinases, which in turn will inhibit the function of ROCK kinase, one of the last effectors of vasoconstriction before formation of the actin and light-chain myosin binding. This review will focus on describing these mechanisms of primal importance in the first hours of our lives as independent individuals.

Disfunción grave de ventrículo derecho por ecocardiografía en hipertensión arterial pulmonar:: prevalencia, predictores clínicos, ecocardiográficos y tratamiento / Severe right ventricular dysfunction by echocardiography in pulmonary arterial hypertension:: prevalence, clinical predictors, echocardiograph and treatment / Disfunção grave do ventrículo direito por ecocardiografia na hipertensão arterial pulmonar:: prevalência, preditores clínicos, ecocardiográficos e tratamento

Introducción. La disfunción del ventrículo derecho (VD) es un marcador de alto riesgo en pacientes con hipertensión arterial pulmonar (HAP). Objetivo. Evaluar la prevalencia, predictores independientes clínicos y ecocardiográficos, y el tratamiento de la disfunción grave del VD (DGVD) por ecocardiografía en la hipertensión arterial pulmonar. Material y método. Entre Enero de 2010 y Diciembre de 2011, se incluyeron prospectivamente 422 pacientes (31 centros de 13 provincias argentinas). De ellos, 124 (29,4%) con HAP fueron incluidos en este análisis. La DGVD se definió por la presencia de deterioro moderado a severo de la función del VD o un TAPSE <15 mm. Resultados. La edad media fue de 45 ± 17 años y el 78% fueron mujeres. La DGVD se identificó en 37 casos (29,8%). Los predictores clínicos independientes fueron fatiga (HR=5,2; IC95%=1,9-14,1; p=0,001), frecuencia cardíaca (HR=1,045; IC95%=1,003-1,088; p=0,033) y cardiomegalia (HR=2,9; IC95%=1,2-7,5; p=0,024). El ecocardiograma en DGVD mostró mayor dilatación de aurícula derecha (84 vs 61%; p=0,013) y presión sistólica pulmonar (89 ± 28 vs 77 ± 27 mm Hg; p=0,045), con menor fracción de eyección ventricular izquierda (59 ± 12 vs 67 ± 10%; p=0,002). El tratamiento fue diferente en la DGVD con diuréticos (87 vs 63%; p=0,010) y digoxina (38 vs 20%; p=0,031), con similar uso de sildenafil (87 vs 74%), iloprost (11 vs 10%), bosentán (19 vs 9%), treprostinil (5 vs 5%) y ambrisentán (5 vs 5%). Conclusiones. Uno de cada tres pacientes con HAP presenta DGVD. El examen físico y la Rx de tórax permiten identificarlos clínicamente. La tasa similar de prescripción de fármacos específicos sugiere la necesidad de optimizar el tratamiento en estos casos más graves.

Introduction. Severe right ventricular dysfunction (SRVD) is a high risk marker in patients with pulmonary arterial hypertension (PAH). However, its clinical characteristics in Latin-Americans are poorly known. Objective. We sought to assess the prevalence, clinical markers and treatment of SRVD in Argentinean patients with PAH. Material and methods. Between Jan-10/Dec-11, 422 patients with diagnosis of pulmonary hypertension were prospectively included in 31 centers from 13 provinces from Argentina. Of them, 124 (29.4%) with diagnosis of PAH were included in the present analysis. SRVD was defined by moderate to severe RV dysfunction or TAPSE <15 mm. Results. Mean age was 45±17 and 78% were female. In logistic regression analysis, independent clinical predictors were fatigue (HR=5.2, 95%CI=1.9-14.1, p=0.001), heart rate (HR=1.045, 95%CI=1.003-1.088, p=0.033), and cardiomegaly (HR=2.9, 95%CI=1.2-7.5, p=0,024). Echocardiogram in SRVD showed more frequently right atrial dilation (84 vs 61%, p=0.013), and higher systolic pulmonary artery pressure (89±28 vs 77±27 mmHg, p=0.045), with lower left ventricular ejection fraction (59±12 vs 67±10 %, p=0.002). Treatment in SRVD was different in the use of diuretics (87 vs 63%, p=0.010) and digoxin (38 vs 20%, p=0.031), and it was similar in the use of sildenafil (87 vs 74%); iloprost (11 vs 10%); bosentan (19 vs 9%); treprostinil (5 vs 5%), and ambrisentan (5 vs 5%). Conclusion. One out of three patients with PAH presented SRVD. Physical examination and chest x-ray permit clinical identification. These patients received similar rate of specific drugs, suggesting the need of optimization of therapy driven to PAH in these more severe cases.

Introdução. A disfunção grave do ventrículo direito (VD) é um marcador de alto risco em pacientes com hipertensão arterial pulmonar (HAP). Entretanto, suas características clínicas nos latino-americanos são mal conhecidas. Objetivo. Avaliar a prevalência, os marcadores clínicos e o tratamento da disfunção grave do VD em pacientes com HAP. Material e métodos. Entre janeiro de 2010 e dezembro de 2011, foram incluídos prospectivamente 422 pacientes com diagnóstico de hipertensão pulmonar em 31 centros de 13 províncias da Argentina. Destes, 124 (29,4%) com diagnóstico de HAP foram incluídos na presente análise. A disfunção grave do VD foi definida por disfunção do VD moderada a grave ou TAPSE <15 mm. Resultados. A idade média foi de 45 ± 17 e 78% eram do sexo feminino. Na análise de regressão logística, os preditores clínicos independentes foram fadiga (HR=5,2; IC 95% = 1,9-14,1; p=0,001), freqüência cardíaca (HR=1,045; IC95% = 1,003-1,088; p=0,033) e cardiomegalia (HR=2,9; IC 95% = 1,2-7,5; p=0,024). O ecocardiograma na disfunção grave do VD apresentou maior freqüência de dilatação atrial direita (84 vs 61%; p=0,013) e maior pressão arterial sistólica (89 ± 28 vs 77 ± 27 mm Hg; p=0,045), com fração de ejeção ventricular esquerda menor (59 ± 12 vs 67 ± 10%; p=0,002). O tratamento foi diferente na disfunção grave do VD com diuréticos (87 vs 63%; p=0,010) e digoxina (38 vs 20%; p=0,031), sendo semelhante no uso de sildenafilo (87 vs 74%), iloprost (11 vs 10%), bosentano (19 vs 9%), treprostinil (5 vs 5%) e ambrisentano (5 vs 5%). Conclusão. Um em cada três pacientes com HAP apresentou disfunção grave do VD. O exame físico e a radiografia de tórax permitem a identificação clínica. Esses pacientes receberam taxa similar de medicamentos específicos, sugerindo a necessidade de otimização da terapia dirigida à HAP nesses casos mais graves.

Efficacy comparison of different embolization agents in transcatheter embolization for treating massive hemoptysis caused systemic pulmonary circulation shunt shunt / 重庆医学

Objective To evaluate the efficacy difference of different embolization agents in transcatheter embolization for treating massive hemoptysis caused by systemic pulmonary circulation shunt(SPS). Methods The clinical and imaging data in 98 patients with hemoptysis complicating SPS,including bronchodilator in 72 cases,pulmonary tuberculosis in 18 cases and lung carcinoma in 8 cases. All cases were treated with bronchial arterial embolization (BAE). According to different used embolization agents, the cases were divided into the gelfoam group and polyvinyl alcohol(PVA)grains embolization group. All cases were followed up at postoperative 1 d,1,3,6 months as well as 1,2 years. The data were analyzed by using Ridit test. Results Ninety-eight cases of massive hemoptysis were confirmed by DSA,among them,84 cases were complicating pulmonary artery fistula, 18 cases were pulmonary venous fistula and 2 cases were mixed fistula; 32 cases were simple BPS, 62 cases were pulmonary circulation fistula existed in the bronchial arteries and non-bronchial artery and 4 cases were simple non-BPS. The two groups had no complications such as embolism,paraplegia,esophagus-trachea fistula and skin ischemic necrosis. The follow up on postoperative 1 d, at postoperative 1, 3,6 months and at postoperative 1,2 years indicated that among 48 cases in the gelfoam group, 20 cases were cured, 18 cases were significantly effective,6 cases were effective and 4 cases were ineffective,the effective rate was 91.7 % ;among 50 cases in the PVA grain embolization group, 38 cases were cured, 8 cases were significantly effective,4 cases were effective and O case was ineffective, the effective rate was 100%. Moreove no severe complications such as ectopic embolism, paraplegia, esophagus-trachea fistula and skin ischemic necrosis occurred. The difference between the two groups had statistical significance by Ridit analysis. Conclusion Transcatheter embolization for treating massive hemoptysis caused by SPS is safe and reliable,has small trauma, using PVA grains embolization can reduce the long term recurrence rate of hemoptysis.

The evaluation by pulmonary wedge angiography of children with pulmonary artery hypertension ;associated with congenital heart disease / 中国介入心脏病学杂志

Objective To study pulmonary wedge angiography ( PWA ) with hemodynamic the evaluation of children with congenital heart disease and pulmonary artery hypertension ( PAH) . Methods Hemodynamic measurement and pulmonary wedge angiography were performed in 50 children with congenital heart disease. Comparison and analysis were made from the data obtained from PWA and catheterization. Results After PWA, the patients were categorized into 3 groups according to the measured hemodynamics parameters:group A [ n=15, patients with normal mean pulmonary artery pressure ( mPAP≤25 mmHg) and normal pulmonary vessel resistance (PVR﹤300 dyne?s?cm5)], group B [n=24, patients with PAH (mPAP﹥25 mmHg) but normal PVR] and group C (n=11, patients with PAH and elevated PVR (PVR≥300 dyne?s?cm5). Rote of tapering (ROT) was significant lower in group C than in group A and B (F=42. 559,P﹤0. 05). Pulmonary circulation time (PCT) was higher in group C than in group A and B (F=6. 037,P﹤0. 05). ROT correlated negatively with PVR (r = -0. 606, P ﹤0. 05). PCT index correlated positively with PVR (r=0. 783,P=0. 01). There was no significant correlation between PCT and mean pulmonary artery hypertension (mPAP). Conclusions PWA may help to make quantitative analysis of the pulmonary vascular status in patients with congenital heart disease.

Effects of selective lobar ventilation on intrapulmonary shunt and inflammatory response in patients with pulmonary dysfunction during thoracotomy / 中华麻醉学杂志

Objective To investigate the effects of selective lobar ventilation on intrapulmonary shunt and inflammatory response in patients with pulmonary dysfunction during thoracotomy.Methods Thirty-four ASA Ⅱ or Ⅲ patients,aged 64-79 years,weighing 50-85 kg,with moderate or severe impaired pulmonary function,scheduled for esophageal cancer radical correction,were randomly divided into two groups (n =17 each):one-lung ventilation group (group A) and selective lobar ventilation group (group B).In group A,an endobronchial blocker tube was used to obstruct the bronchus principalis and practice one-lung ventilation.In group B,an endobronchial blocker tube was used to obstruct the bronchi Iobares and practice selective lobar ventilation.Blood samples were taken from the arteria radialis and the internal jugular vein for blood gas analysis and determination of plasma concentrations of tumor necrosis factor-alpha (TNF-α),interleukin-6 (IL-6) and IL-8 by enzyme linked immunosorbent assay (ELISA) before anesthesia induction (T0),30 minutes following two-lung ventilation at the lateral position (T1),60 minutes following one-lung ventilation or selective lobar ventilation (T2) and at the end of surgery (T3).Peak airway pressure (Ppeak) and plateau airway pressure (Pplat) were recorded at the same time.Results The incidence of hypoxemia was significantly lower in group B (0) than in group A (18％,P ＜ 0.05).Compared with group A,Pliat and Ppeak at T1-3,the intrapulmonary shunt rate (Qs/Qt) at T2,TNF-α,IL-6 and IL-8 concentrations at T2-3 were significantly decreased in group B (P ＜ 0.05).Conclusion Selective lobar ventilation can reduce intrapulmonary shunt and inhibit inflammatory responses to help lessen mechanical ventilation-related lung injuryduring thoracotomy in patients with pulmonary dysfunction.

Effects of Shenmai injection on intrapulmonary shunt during one-lung ventilation in patients undergoing thoracic surgery / 中华麻醉学杂志

Objective To evaluate the effects of Shenmai injection on intrapulmonary shunt during one-lung ventilation in patients undergoing thoracic surgery.Methods Sixty ASA physical status Ⅰ or Ⅱ patients of both sexes,aged 40-60 yr,with body mass index of 18-25 kg/m2,scheduled for elective thoracic surgery,were randomly divided into 2 groups (n =30 each) using a random number table:control group (group C) and Shenmai injection group (group SM).Anesthesia was induced with midazolam,sufentanil,rocuronium,and etomidate.Starting from the end of induction of anesthesia until the time point immediately before one-lung ventilation,Shenmai injection 0.6 ml/kg (in 250 ml normal saline) was infused intravenously in SM group,and the equal volume of normal saline was given instead in C group.Immediately before one-lung ventilation,at 10 and 60 min of one-lung ventilation and at 10 min of two-lung ventilation,arterial and venous blood samples were collected for blood gas analysis and PaO2 was recorded.Intrapulmonary shunt (Qs/Qt) and alveolar-arterial oxygen pressure difference (P(A-a)DO2) were calculated.Results Compared with group C,PaO2 was significantly increased at 10 and 60 min of one-lung ventilation,and Qs/Qt and P(A-a)DO2 were decreased in group SM.Conclusion Shenmai injection 0.6 ml/kg infused intravenously before one-lung ventilation can reduce the intrapulmonary shunt during one-lung ventilation in patients undergoing thoracic surgery.

Clinical application of multi-slice spiral CT angiography in diagnosing bronchial-pulmonary shunts / 介入放射学杂志

Objective To evaluate multi- slice spiral CT angiography (MSCTA) in diagnosing bronchial-pulmonary shunts (BPS). Methods The materials of MSCTA images in 31 patients with DSA-confirmed BPS were retrospectively analyzed. Taking DSA imaging as the reference standard, the consistency in diagnosing BPS at different levels between MSCTA and DSA was compared. Results On MSCTA using aorta-density trigger scanning technique BPS was manifested as wrong-time enhancement of pulmonary artery branches. Wilcoxon test indicated that MSCTA had a high concordance with DSA in detecting BPS occurring at sub-segmental (or above) pulmonary artery branches (Z = -1.854, P > 0.05), but MSCTA detection of BPS occurring at peripheral pulmonary arteries was obviously poorer than DSA (Z = -3.923, P < 0.05). MSCTA confirmed the diagnosis of BPS in 11 cases with a sensitive rate of 35.5% (11/31), and no differences in revealing the number and the shunt levels of BPS existed between DSA and MSCTA. The number of abnormal systemic arteries demonstrated by MSCTA was quite the same as the number detected by DSA. No false positive case was seen. Conclusion MSCTA is very effective in diagnosing high-flow BPS locating at sub-segmental (or above) pulmonary artery branches as well as in revealing abnormal bronchus-related systemic arteries, which is very helpful in preoperatively evaluating the severity of the BP shunting and the supplying arteries to be obstructed.