[The role of nursing in right heart catheterization. Advantages from peripheral venous access]. / Papel de enfermería en el cateterismo cardiaco derecho. Ventajas del acceso venoso periférico.

INTRODUCTION: Pulmonary hypertension (PH) is a serious disease that requires early diagnosis to achieve a better patient prognosis. Right heart catheterization (RHC) has become the main diagnostic test for this disease, measuring the pressures from the right heart chambers invasively, using a catheter placed through venous access. Nursing performance has an important role in RHC through peripheral venous access due to its well-done skills for canalization and knowledge about the management and care of these accesses. RHC performed through peripheral venous access provide advantages over those performed through central venous access. OBJECTIVE: To analyze the benefits from RHC through peripheral venous access compared to those performed through central venous access, as well as highlighting the role of nursing during this type of procedures. METHOD: A retrospective, descriptive, and observational study was performed for patients who underwent RHC in our center between January 2019 to January 2023. We analyzed clinical characteristics, access, fluoroscopy parameters, periprocedural complications, and hospital admissions. RESULT: A total of 115 patients were included. The average age was 65±12 years, with 58.1% of females. Risk stratification of PH was the reason for conducting RHC in 82.9%. The anterocubital veins became the main approach (72.2%), performed by hemodynamics nurses, while the central venous ones composed the rest (27.8%), which were done by cardiology specialized doctors. We observed a significant reduction in radiation dose in RHC via anterocubital route compared to central venous access (4.4Gycm2 vs 12.5Gycm2 [IQR: 4.5]; P<.001), and it does also in fluoroscopy times (2.3minutes vs 4.6minutes [IQR: 2.6]; P<.001). No complications were recorded, independently of the approach. Patients who underwent a scheduled catheterization were discharged more frequently on the same day of the procedure whether a peripheral approach was performed (77.2%, 44 of 57 patients), in comparison with the central one (28.6%) (P=.001). CONCLUSIONS: The RHC is an essential tool for the diagnosis of PH, achieving nursing such an important role for those performed by peripheral venous access. Peripheral venous access provides benefits and advantages like the reduction of radiation exposure and scan times, reduced hospital stay. All this could bring greater comfort, safety and better quality of care to the patient.

Hipertensión pulmonar y leiomiomas uterinos, ¿existe relación causal? Serie de casos y revisión fisiopatológica / Pulmonary Hypertension and Uterine Leiomyomas, Is there a Causal Relationship? Case Series and Pathophysiological Review

Introducción: Los leiomiomas uterinos son un tipo de neoplasia benigna de frecuente aparición en mujeres de edad reproductiva, relacionados con enfermedad tromboem- bólica venosa. Este vínculo surge del efecto producido por la compresión de fibromas que genera estasis venosa en la región pelviana. Sin embargo, este pareciera no ser el único factor que lo relaciona con el desarrollo posterior de hipertensión pulmonar, sino que su presencia es gatillo de una serie de fenómenos que influyen sobre la vasculatu - ra pulmonar y también a nivel sistémico. Método: Revisión de una serie de casos (seis) atendidos en nuestra unidad, seguido de una revisión sobre la relación entre leiomio- mas y distintas formas de hipertensión pulmonar con una revisión desde la fisiopatología. Resultado y conclusiones: Encontramos sustento bibliográfico en los múltiples caminos fisiopatológicos que relacionan los mediadores vasculares comunes, que parecieran ser el punto clave en la relación entre estas dos patologías.

Introduction: Uterine leiomyomas are a type of benign neoplasm that frequently appears in women of reproductive age, related to venous thromboembolic disease. This link arises from the effect produced by the compression of fibroids, which generates venous stasis in the pelvic region. However, this seems not to be the only factor that re- lates it to the subsequent development of pulmonary hypertension, but rather its presence is a trigger for a series of phenomena that influence the pulmonary vasculature and also at a systemic level. Method: Review of a series of cases (six) cared for in our unit, followed by a review on the relationship between leiomyomas and different forms of pulmonary hypertension with a review from the pathophysiology. Result and conclusions: We found bibliographic support in the multiple pathophysiological paths that relate the common vascular mediators, which appear to be the key point in the relationship between these two pathologies.

Actualización del abordaje de la hipertensión pulmonar tromboembólica crónica / Update in the management of chronic thrombo-embolic pulmonary hypertension

La hipertensión pulmonar tromboembólica crónica (HPTEC) es una forma potencialmente curable de hipertensión pulmonar (HP) que aparece hasta en 3% de los pacientes tras una embolia pulmonar (EP). En estos pacientes, la EP no se resuelve, dando paso a coágulos fibróticos organizados, con el desarrollo de HP precapilar debido a la obstrucción proximal de las arterias pulmonares. También puede desarrollarse una microvasculopatía distal que contribuye al aumento de la resistencia vascular pulmonar (RVP). La ecocardiografía transtorácica (ETT) es la exploración que permite establecer la sospecha de HP. La gammagrafía pulmonar de ventilación-perfusión (V/Q) es la herramienta fundamental en el estudio de los pacientes con sospecha de HPTEC; si es normal, prácticamente la descarta. El cateterismo cardiaco derecho es obligatorio para el diagnóstico. La HPTEC se define como la existencia de síntomas, defectos de perfusión residuales e HP precapilar tras un periodo mínimo de tres meses de anticoagulación. La angiografía pulmonar ayuda a determinar la extensión y la accesibilidad quirúrgica de las lesiones tromboembólicas. Las personas con HPTEC son candidatas a anticoagulación indefinida. La endarterectomía pulmonar es el tratamiento de elección, resultando en una mejoría clínica y hemodinámica significativa. Aproximadamente un 25% de los pacientes presentan HP residual postendarterectomía. La angioplastia pulmonar con balón (APB) es una técnica endovascular dirigida a lesiones más distales, de utilidad para sujetos con HPTEC inoperable o HP persistente/recidivante postendarterectomía. Ambos tipos de pacientes también se pueden beneficiar de tratamiento farmacológico para la HP. Las tres terapias constituyen los pilares de la terapia, que ha evolucionado hacia un enfoque multimodal.(AU)

Chronic thrombo-embolic pulmonary hypertension (CTEPH) is a potentially curable form of pulmonary hypertension (PH) that develops in up to 3% of patients after pulmonary embolism (PE). In these patients, PE does not resolve, leading to organized fibrotic clots, with the development of precapillary PH as a result of the proximal obstruction of the pulmonary arteries. In addition, a distal microvasculopathy may also develop, contributing to the increase of pulmonary vascular resistance. Transthoracic echocardiography is the diagnostic tool that allows to establish the suspicion of PH. Ventilation-perfusion lung scintigraphy is the fundamental tool in the study of patients with suspected CTEPH; if it is normal, virtually rules out the diagnosis. Right heart catheterization is mandatory for the diagnosis of these patients. CTEPH is defined as the existence of symptoms, residual perfusion defects and precapillary PH after a minimum period of three months of anticoagulation. Pulmonary angiography helps determine the extent and surgical accessibility of thromboembolic lesions. CTEPH patients are candidates for long-term anticoagulation. Pulmonary endarterectomy is the treatment of choice, resulting in significant clinical and hemodynamic improvement. About 25% of patients have residual PH post-endarterectomy. Balloon pulmonary angioplasty is an endovascular technique that targets more distal lesions, being potentially useful for patients with inoperable CTEPH or persistent/recurrent PH post-endarterectomy. Both types of patients may also benefit from pharmacological treatment for PH. These three therapies are the cornerstone of CTEPH treatment, which has evolved towards a multimodal approach.(AU)

Impacto del cateterismo derecho de ejercicio en el diagnóstico diferencial de la enfermedad tromboembólica pulmonar crónica / Value of exercise right heart catheterization in the differential diagnosis of chronic thromboembolic pulmonary disease

Introduction and objectives Chronic thromboembolic disease refers to the presence of chronic thrombotic pulmonary vascular thrombosis without pulmonary hypertension (PH) at rest but with exercise limitation after pulmonary embolism (PE). Our aim was to evaluate the hemodynamic response to exercise in these patients and its correlation with the values reached in cardiopulmonary exercise testing. Methods We included symptomatic patients with persistent pulmonary thrombosis after PE. We excluded patients with left heart disease or significant PH (mean pulmonary arterial pressure [mPAP] >25mmHg, pulmonary vascular resistance >3 WU, and pulmonary capillary wedge pressure [PCWP] >15mmHg). Cardiopulmonary exercise testing and exercise right heart catheterization were performed. Exercise-induced precapillary PH was defined as mPAP/CO slope >3 and PCWP/CO slope <2mmHg/l/min. The hemodynamic response and the values obtained in cardiopulmonary exercise testing were compared between patients with and without exercise-induced precapillary PH. Results We studied 36 patients; 4 were excluded due to incomplete hemodynamic data. Out of the 32 patients analyzed; 3 developed a pathological increase in PCWP. Among the remaining 29 patients (mean age, 49.4±13.7 years, 34.5% women), 13 showed exercise-induced PH. Resting mPAP was higher in those who developed exercise-induced PH (23.3±5.4 vs 19.0±3.8mmHg; P=.012), although CO was similar in the 2 groups. Patients with exercise-induced PH exhibited data of ventilatory inefficiency with reduced values of end-tidal CO2 pressure at the anaerobic threshold (32.8±3.0 vs 36.2±3.3mmHg; P=.021) and a higher Ve/VCO2 slope (34.2±4.8 vs 30.7±5.0; P=.049). Conclusions Exercise limitation and ventilatory inefficiency could be attributable to exercise-induced precapillary PH in a subgroup of patients with persistent pulmonary thrombosis and dyspnea (AU)

Introdución y objetivos La enfermedad tromboembólica crónica se define como la trombosis crónica de la vasculatura pulmonar y disnea, sin hipertensión pulmonar (HP) en reposo tras una embolia de pulmón. El estudio evaluó la hemodinámica al esfuerzo en estos pacientes y su relación con la ergoespirometría. Métodos Se incluyó a pacientes sintomáticos con trombosis pulmonar crónica tras una embolia de pulmón. Se excluyó a los pacientes con cardiopatía izquierda o HP significativa en reposo (presión arterial pulmonar media [PAPm] >25mmHg, resistencia vascular pulmonar >3 UW y presión capilar pulmonar [PCP] >15mmHg). Se realizó una ergoespirometría y un cateterismo derecho de ejercicio. La HP precapilar al ejercicio se definió como las pendientes PAPm/gasto cardiaco >3 y PCP/gasto cardiaco <2mmHg/l/min. Se comparó la respuesta hemodinámica y ergoespirométrica entre pacientes con y sin HP precapilar al ejercicio. Resultados Se estudió a 36 pacientes, excluyéndose 4 por calidad subóptima en el registro hemodinámico. Tres pacientes presentaron una elevación patológica de la PCP. De los 29 restantes (edad, 49,4±13,7 años; el 34,5% mujeres), en 13 se halló HP precapilar al ejercicio. La PAPm basal fue mayor en aquellos con HP al ejercicio (23,3±5,4 frente a 19,0±3,8mmHg; p=0,012), con similar gasto cardiaco. Aquellos con HP al ejercicio exhibieron valores reducidos de la presión de CO2 exahalada en el umbral anaeróbico (32,8±3,0 frente a 36,2±3,3mmHg; p=0,021) y mayor pendiente Ve/VCO2 (34,2±4,8 frente a 30,7±5,0; p=0,049). Conclusiones La HP precapilar al ejercicio se asocia con limitación funcional e ineficiencia ventilatoria en un subgrupo de pacientes con trombosis arterial pulmonar crónica y disnea persistente (AU)

The importance of data in Pulmonary Arterial Hypertension: from international registries to Machine Learning. / La importancia de los datos en la hipertensión arterial pulmonar: de los registros internacionales al machine learning.

Real-world registries have been critical to building the scientific knowledge of rare diseases, including Pulmonary Arterial Hypertension (PAH). In the past 4 decades, a considerable number of registries on this condition have allowed to improve the pathology and its subgroups definition, to advance in the understanding of its pathophysiology, to elaborate prognostic scales and to check the transferability of the results from clinical trials to clinical practice. However, in a moment where a huge amount of data from multiple sources is available, they are not always taken into account by the registries. For that reason, Machine Learning (ML) offer a unique opportunity to manage all these data and, finally, to obtain tools that may help to get an earlier diagnose, to help to deduce the prognosis and, in the end, to advance in Personalized Medicine. Thus, we present a narrative revision with the aims of, in one hand, summing up the aspects in which data extraction is important in rare diseases -focusing on the knowledge gained from PAH real-world registries- and, on the other hand, describing some of the achievements and the potential use of the ML techniques on PAH.

Update in the management of chronic thrombo-embolic pulmonary hypertension. / Actualización del abordaje de la hipertensión pulmonar tromboembólica crónica.

Chronic thrombo-embolic pulmonary hypertension (CTEPH) is a potentially curable form of pulmonary hypertension (PH) that develops in up to 3% of patients after pulmonary embolism (PE). In these patients, PE does not resolve, leading to organized fibrotic clots, with the development of precapillary PH as a result of the proximal obstruction of the pulmonary arteries. In addition, a distal microvasculopathy may also develop, contributing to the increase of pulmonary vascular resistance. Transthoracic echocardiography is the diagnostic tool that allows to establish the suspicion of PH. Ventilation-perfusion lung scintigraphy is the fundamental tool in the study of patients with suspected CTEPH; if it is normal, virtually rules out the diagnosis. Right heart catheterization is mandatory for the diagnosis of these patients. CTEPH is defined as the existence of symptoms, residual perfusion defects and precapillary PH after a minimum period of three months of anticoagulation. Pulmonary angiography helps determine the extent and surgical accessibility of thromboembolic lesions. CTEPH patients are candidates for long-term anticoagulation. Pulmonary endarterectomy is the treatment of choice, resulting in significant clinical and hemodynamic improvement. About 25% of patients have residual PH post-endarterectomy. Balloon pulmonary angioplasty is an endovascular technique that targets more distal lesions, being potentially useful for patients with inoperable CTEPH or persistent/recurrent PH post-endarterectomy. Both types of patients may also benefit from pharmacological treatment for PH. These three therapies are the cornerstone of CTEPH treatment, which has evolved towards a multimodal approach.

Value of exercise right heart catheterization in the differential diagnosis of chronic thromboembolic pulmonary disease.

INTRODUCTION AND OBJECTIVES: Chronic thromboembolic disease refers to the presence of chronic thrombotic pulmonary vascular thrombosis without pulmonary hypertension (PH) at rest but with exercise limitation after pulmonary embolism (PE). Our aim was to evaluate the hemodynamic response to exercise in these patients and its correlation with the values reached in cardiopulmonary exercise testing. METHODS: We included symptomatic patients with persistent pulmonary thrombosis after PE. We excluded patients with left heart disease or significant PH (mean pulmonary arterial pressure [mPAP] >25mmHg, pulmonary vascular resistance >3 WU, and pulmonary capillary wedge pressure [PCWP] >15mmHg). Cardiopulmonary exercise testing and exercise right heart catheterization were performed. Exercise-induced precapillary PH was defined as mPAP/CO slope >3 and PCWP/CO slope <2mmHg/l/min. The hemodynamic response and the values obtained in cardiopulmonary exercise testing were compared between patients with and without exercise-induced precapillary PH. RESULTS: We studied 36 patients; 4 were excluded due to incomplete hemodynamic data. Out of the 32 patients analyzed; 3 developed a pathological increase in PCWP. Among the remaining 29 patients (mean age, 49.4±13.7 years, 34.5% women), 13 showed exercise-induced PH. Resting mPAP was higher in those who developed exercise-induced PH (23.3±5.4 vs 19.0±3.8mmHg; P=.012), although CO was similar in the 2 groups. Patients with exercise-induced PH exhibited data of ventilatory inefficiency with reduced values of end-tidal CO2 pressure at the anaerobic threshold (32.8±3.0 vs 36.2±3.3mmHg; P=.021) and a higher Ve/VCO2 slope (34.2±4.8 vs 30.7±5.0; P=.049). CONCLUSIONS: Exercise limitation and ventilatory inefficiency could be attributable to exercise-induced precapillary PH in a subgroup of patients with persistent pulmonary thrombosis and dyspnea.

Validación externa del algoritmo InShape II para la exclusión de la enfermedad tromboembólica crónica en los pacientes con tromboembolismo pulmonar / External validation of the InShape II study algorithm for exclusion of chronic thromboembolic pulmonary hypertension in patients with pulmonary thromboembolism

Antecedentes y objetivo La complicación a largo plazo más grave del embolismo pulmonar (EP) es la hipertensión pulmonar tromboembólica crónica (HPTEC), cuyo diagnóstico precoz implica la realización de un gran número pruebas. El estudio InShape II propone un algoritmo de cribado precoz que pretende disminuir el número de estudios ecocardiográficos. El objetivo de nuestro estudio es validar este algoritmo en nuestra cohorte de pacientes. Material y métodos Se analizaron retrospectivamente los pacientes ingresados con diagnóstico de EP por angio-TC, en el Hospital Rey Juan Carlos entre noviembre del 2017 y febrero del 2020, seguidos durante al menos un año. Se recogieron datos clínicos, analíticos, y pruebas complementarias a los 3 meses y al año. Se aplicó a estos pacientes el algoritmo del estudio InShape II para validar sus resultados. Resultados En el periodo de estudio fueron diagnosticados de EP 236 pacientes, de los cuales 137 fueron excluidos. Se validó el algoritmo en 99 pacientes. Aplicando el score del InShape II hubiéramos realizado 19 ecocardiogramas (3 de ellos con probabilidad intermedia/alta de HPTEC) y no se hubieran hecho en 80 (2 de ellos con probabilidad intermedia/alta), por lo que se estableció una sensibilidad del score de un 60%, con una especificidad de un 83%, y un área bajo la curva (AUC) de 0,715 (IC 95%: 0,472-0,958). Conclusiones Nuestros resultados apoyan que el algoritmo del estudio InShape II podría ser una herramienta útil en el cribado inicial del estudio de HPTEC en entornos de baja incidencia, ya que evitaría la realización de ecocardiogramas que no aportan valor (AU)

Background and aim The most severe long-term complication of pulmonary embolism (PE) is chronic thromboembolic pulmonary hypertension (CTEPH), and its early diagnosis often requires numerous diagnostic tests. The InShape II study proposes an early screening algorithm that aims to reduce the number of echocardiographic studies. The objective of our study is to validate this algorithm in our patient cohort. Materials and methods We retrospectively analyzed patients admitted to Hospital Rey Juan Carlos between November 2017 and February 2020, who were diagnosed with PE based on computed tomography angiography (CTA). Patients were followed for at least one year, and clinical, laboratory, and complementary test data were collected at three months and one year. The InShape II algorithm was applied to these patients to validate its results. Results During the study period, 236 patients were diagnosed with PE, of which 137 were excluded. The algorithm was validated in 99 patients. Applying the InShape II score, 19 echocardiograms would have been performed (three of them with intermediate-high probability of CTEPH), while 80 echocardiograms would have been avoided (two of them with intermediate-high probability). This yielded a sensitivity of 60% and a specificity of 83% for the score, with an area under the curve (AUC) of 0.715 (95% CI: 0.472-0.958). Conclusions Our results support the notion that the InShape II algorithm could be a useful tool for initial screening of CTEPH in low-incidence settings, as it would avoid unnecessary echocardiograms that do not provide additional value (AU)

Study of left ventricular systolic dysfunction, left ventricular diastolic dysfunction and pulmonary hypertension in CKD 3b-5ND patients—A single centre cross-sectional study / Estudio de la disfunción sistólica ventricular izquierda, disfunción diastólica ventricular izquierda e hipertensión pulmonar en pacientes con ERC 3b-5ND – un estudio transversal en un solo centro

Introduction: Cardiovascular diseases are associated with increased morbidity and mortality among CKD (chronic kidney disease) population. Recent studies have found increasing prevalence of PH (pulmonary hypertension) in CKD population. Present study was done to determine prevalence and predictors of LV (left ventricular) systolic dysfunction, LVDD (left ventricular diastolic dysfunction) and PH in CKD 3b-5ND (non-dialysis) patients. Methods: A cross sectional observational study was done from Jan/2020 to April/2021. CKD 3b-5ND patients aged ≥15 yrs were included. Transthoracic 2D (2 dimensional) echocardiography was done in all patients. PH was defined as if PASP (pulmonary artery systolic pressure) value above 35mm Hg, LV systolic dysfunction was defined as LVEF (left ventricular ejection fraction)≤50% and LVDD as E/e′ ratio >14 respectively. Multivariate logistic regression model was done to determine the predictors. Results: A total of 378 patients were included in the study with 103 in stage 3b, 175 in stage 4 and 100 patients in stage 5ND. Prevalence of PH was 12.2%, LV systolic dysfunction was 15.6% and LVDD was 43.65%. Predictors of PH were duration of CKD, haemoglobin, serum 25-OH vitamin D, serum iPTH (intact parathyroid hormone) and serum albumin. Predictors of LVDD were duration of CKD and presence of arterial hypertension. Predictors of LV systolic dysfunction were eGFR (estimated glomerular filtration rate), duration of CKD, serum albumin and urine protein. Conclusion: In our study of 378 CKD 3b-5ND patients prevalence of PH was 12.2%, LV systolic dysfunction was 15.6% and LVDD was 43.65%. (AU)

Introducción: Las enfermedades cardiovasculares se asocian a un aumento de la morbilidad y la mortalidad entre la población con enfermedad renal crónica (ERC). Estudios recientes han encontrado un aumento de la prevalencia de la hipertensión pulmonar (HP) en la población con ERC. El presente estudio se llevó a cabo para determinar la prevalencia y los predictores de la disfunción sistólica del ventrículo izquierdo (VI), la disfunción diastólica del VI y la hipertensión pulmonar en pacientes con ERC 3b -5ND (sin diálisis). Métodos: Se realizó un estudio observacional transversal desde enero/2020 hasta abril/2021. Se incluyeron pacientes con ERC 3b -5ND de edad ≥15 años. Se realizó una ecocardiografía transtorácica 2D (bidimensional) a todos los pacientes. La HP se definió como un valor de presión sistólica de la arteria pulmonar superior a 35mm Hg, la disfunción sistólica del VI se definió como una fracción de eyección del ventrículo izquierdo ≤ 50% y la DVL como una relación E/e′>14 respectivamente. Se realizó un modelo de regresión logística multivariante para determinar los predictores. Resultados: Un total de 378 pacientes fueron incluidos en el estudio con 103 en estadio 3b, 175 en estadio 4 y 100 pacientes en estadio 5ND. La prevalencia de la HP fue del 12,2%, la disfunción sistólica del VI fue del 15,6% y la DVL fue del 43,65%. Los predictores de la HP fueron la duración de la ERC, la hemoglobina, la vitamina D 25-OH en suero, la iPTH en suero (hormona paratiroidea intacta) y la albúmina en suero. Los predictores de la EVL fueron la duración de la ERC y la presencia de hipertensión arterial. Los predictores de la disfunción sistólica del VI fueron la tasa de filtración glomerular estimada, la duración de la ERC, la albúmina sérica y las proteínas en orina. Conclusión: En nuestro estudio de 378 pacientes con ERC 3b-5ND la prevalencia de la HP fue del 12,2%, la disfunción sistólica del VI fue del 15,6% y la DVL fue del 43,65%. (AU)

Evolución y pronóstico de la insuficiencia tricuspídea moderada-grave tras tromboendarterectomía pulmonar o angioplastia de arterias pulmonares / Outcome of moderate-severe tricuspid regurgitation after pulmonary endarterectomy or balloon pulmonary angioplasty

Introducción y objetivos: No está definido el abordaje de la insuficiencia tricuspídea (IT) funcional moderada-grave en los pacientes con hipertensión pulmonar tromboembólica crónica tras la tromboendarterectomía pulmonar (TEA) o angioplastia con balón de las arterias pulmonares (ABAP). El objetivo de este estudio es analizar la evolución y los predictores de IT residual tras el procedimiento, así como su impacto pronóstico. Métodos: Estudio observacional unicéntrico. Se incluyó a 72 pacientes sometidos a TEA y 20 que completaron el programa de ABAP con diagnóstico de hipertensión pulmonar tromboembólica crónica y presentaban IT moderada-grave antes del procedimiento intervencionista. Resultados: La prevalencia de IT moderada-grave tras el procedimiento fue del 29%, sin diferencias entre los tratados con TEA o ABAP (el 30,6 frente al 25%; p=0,78). En el grupo con IT persistente se hallaron mayores presión arterial pulmonar media (40,2± 1,9 frente a 28,5±1,3mmHg; p<0,001), resistencia vascular pulmonar (472 [347-710] frente a 282 [196-408] dyn·s/cm5; p <0,001) y área de la aurícula derecha (23,0 [21-31] frente a 16,0 [14,0-20,0]; p <0,001) tras el procedimiento comparado con el de pacientes con IT ausente-ligera. La resistencia vascular pulmonar> 400dyn.s/cm5 y el área de la aurícula derecha> 22 cm2 tras el procedimiento se asociaron de manera independiente con la persistencia de la IT, pero no se identificaron predictores antes de la intervención. La IT moderada-grave residual y la presión pulmonar media> 30mmHg se asociaron con mayor mortalidad en 3 años de seguimiento. Conclusiones: La IT moderada-grave residual posterior a TEA o ABAP se asoció con la persistencia de una mayor poscarga y un persistente remodelado desfavorable de las cámaras cardiacas derechas tras el procedimiento. La IT moderada-grave y la hipertensión pulmonar residual se asociaron con un peor pronóstico a 3 años. (AU)

Introduction and objectives: The management of persistent moderate-severe tricuspid regurgitation (TR) in patients with chronic thromboembolic pulmonary hypertension after treatment with pulmonary endarterectomy (PEA) or balloon pulmonary angioplasty (BPA) is not well defined. This study aimed to analyze the progression and predictors of significant persistent postintervention TR and its prognostic impact. Methods: This single-center observational study included 72 patients undergoing PEA and 20 who completed a BPA program with a previous diagnosis of chronic thromboembolic pulmonary hypertension and moderate-to-severe TR. Results: The postintervention prevalence of moderate-to-severe TR was 29%, with no difference between the PEA- or BPA-treated groups (30.6% vs 25% P=.78). Compared with patients with absent-mild postprocedure TR, those with persistent TR had higher mean pulmonary arterial pressure (40.2±1.9 vs 28.5±1.3mmHg P <.001), pulmonary vascular resistance (472 [347-710] vs 282 [196-408] dyn.s/cm5; P <.001), and right atrial area (23.0 [21-31] vs 16.0 [14.0-20.0] P <.001). The variables independently associated with persistent TR were pulmonary vascular resistance> 400 dyn.s/cm5 and postprocedure right atrial area> 22cm2. No preintervention predictors were identified. The variables associated with increased 3-year mortality were residual TR and mean pulmonary arterial pressure> 30mmHg. Conclusions: Residual moderate-to-severe TR following PEA-PBA was associated with persistently high afterload and unfavorable postintervention right chamber remodeling. Moderate-to-severe TR and residual pulmonary hypertension were associated with a worse 3-year prognosis. (AU)

External validation of the InShape II study algorithm for exclusion of chronic thromboembolic pulmonary hypertension in patients with pulmonary thromboembolism.

BACKGROUND AND AIM: The most severe long-term complication of pulmonary embolism (PE) is chronic thromboembolic pulmonary hypertension (CTEPH), and its early diagnosis often requires numerous diagnostic tests. The InShape II study proposes an early screening algorithm that aims to reduce the number of echocardiographic studies. The objective of our study is to validate this algorithm in our patient cohort. MATERIALS AND METHODS: We retrospectively analyzed patients admitted to Hospital Rey Juan Carlos between November 2017 and February 2020, who were diagnosed with PE based on computed tomography angiography (CTA). Patients were followed for at least one year, and clinical, laboratory, and complementary test data were collected at three months and one year. The InShape II algorithm was applied to these patients to validate its results. RESULTS: During the study period, 236 patients were diagnosed with PE, of which 137 were excluded. The algorithm was validated in 99 patients. Applying the InShape II score, 19 echocardiograms would have been performed (three of them with intermediate-high probability of CTEPH), while 80 echocardiograms would have been avoided (two of them with intermediate-high probability). This yielded a sensitivity of 60% and a specificity of 83% for the score, with an area under the curve (AUC) of 0.715 (95% CI: 0.472-0.958). CONCLUSIONS: Our results support the notion that the InShape II algorithm could be a useful tool for initial screening of CTEPH in low-incidence settings, as it would avoid unnecessary echocardiograms that do not provide additional value.

An unusual cardiac involvement in mixed connective tissue disease / Una afección cardíaca poco común en la enfermedad mixta del tejido conjuntivo

Mixed connective tissue disease is an autoimmune disorder with overlapping features of systemic lupus erythematosus, systemic sclerosis and polymyositis. Cardiac involvement is common, being pericarditis the most frequent manifestation, as also pulmonary hypertension. The authors present a case of a woman with one year of symptoms of polyarthritis and myalgia with gradual muscle weakness and weight loss, with severe impaired mobility in the last months. The initial evaluation showed an inflammatory systemic condition with an infiltrative pattern in echocardiogram, with pulmonary hypertension, that was confirmed by cardiac magnetic resonance. After an extensive study, where infiltrative cardiomyopathies were a differential diagnosis, the patient meet criteria to mixed connective disease with signs of pulmonary hypertension and an atypical cardiac involvement. Immunosuppressive treatment and rehabilitation were initiated and one year after the patient remains asymptomatic without any limitations. (AU)

La enfermedad mixta del tejido conectivo es un trastorno autoinmune con características superpuestas de lupus eritematoso sistémico, esclerosis sistémica y polimiositis. La afectación cardiaca es común, siendo la pericarditis la manifestación más frecuente, al igual que la hipertensión pulmonar. Los autores presentan el caso de una mujer con un año de síntomas de poliartritis y mialgia con debilidad muscular gradual y pérdida de peso, con grave deterioro de la movilidad en los últimos meses. La evaluación inicial mostró un cuadro inflamatorio sistémico con patrón infiltrativo en ecocardiograma, con hipertensión pulmonar, que se confirmó por resonancia magnética cardiaca. Tras un amplio estudio, en el que las miocardiopatías infiltrativas constituyeron un diagnóstico diferencial, la paciente cumplía criterios de conectivopatía mixta con signos de hipertensión pulmonar y una afectación cardiaca atípica. Se inició tratamiento inmunosupresor y rehabilitación y un año después la paciente permanece asintomática sin limitaciones. (AU)

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.

Echocardiographic analysis of pulmonary arterial systolic pressure in pulmonary hypertension.

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.

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.

Papel del Doppler de la vena femoral en pacientes con insuficiencia cardiaca aguda: resultados de un estudio multicéntrico prospectivo / Role of the femoral vein doppler in acute heart failure patients: results from a prospective multicentric study

Antecedentes y objetivo El objetivo de nuestro estudio es definir el papel de la ecografía Doppler pulsada (PW-Doppler) de la vena femoral común en la evaluación de la dilatación de la vena cava inferior (VCI), la probabilidad de hipertensión pulmonar, la insuficiencia tricuspídea y la excursión sistólica del plano anular tricuspídeo (TAPSE). Métodos Se trata de un estudio prospectivo en dos hospitales en 74 pacientes ingresados con insuficiencia cardiaca aguda. Se realizó ecografía PW-Doppler de vena femoral común, ecocardiografía y evaluación de la VCI en el momento del ingreso, así como PW-Doppler y ecografía de VCI al alta hospitalaria. Resultados La detección de un flujo pulsátil (138 exploraciones) tuvo una curva ROC excelente para la detección de VCI mayor de 2cm (AUC 0,931, Sn95%, Sp 90%, VPP 93%, VPN 94%) con una odds ratio (OR) de 211,2 (intervalo de confianza del 95% 48,13-926,72). La pulsatilidad del flujo también tuvo el mayor rendimiento en la detección de la hipertensión pulmonar (AUC 0,8, Sn 95%, Sp 64%, VPP 84%, VPN 84%) y en la detección de la insuficiencia tricuspídea moderada-grave (AUC 0,79, Sn 95%, Sp 67%, VPP 88%, VPN 78%). Si el flujo es continuo, podemos descartar razonablemente una disminución del TAPSE (VPN 89%). Conclusión La detección del flujo PW-Doppler de vena femoral común puede ser una ventana alternativa para la detección de una dilatación de la VCI de 2cm, TR significativa y la probabilidad de hipertensión pulmonar elevada en la insuficiencia cardiaca aguda. También permite descartar razonablemente la disfunción del ventrículo derecho en casos de normalidad en estos pacientes (AU)

Background and objective The aim of our study is to define the role of Pulsed-Doppler (PW-Doppler) Ultrasound of the common femoral vein in the assessment of dilatation Inferior Vena Cava (IVC), probability of Pulmonary Hypertension (PH), Tricuspid Regurgitation (TR), and Tricuspid annular plane systolic excursion (TAPSE). Methods This is a prospective two-hospital study in 74 patients admitted with acute heart failure (AHF). We performed PW-Doppler ultrasound of the common femoral vein, Point of Care cardiac ultrasonography and assessment of the IVC at the time of admission, as well as PW-Doppler and ultrasound of the IVC at hospital discharge. Results The detection of a pulsatile flow (138 scans) had an excellent ROC curve for the detection of IVC greater than 2cm (AUC 0.931, Sn 95%, Sp 90%, PPV 93%, NPV 94%) with an Odds Ratio (OR) of 211.2 (95% confidence interval 48.13-926.72). The pulsatility of the flow also had the highest performance in the detection of PH (AUC 0.8, Sn 95%, Sp 64%, PPV 84%, NPV 84%) and in the detection of moderate-severe TR (AUC 0.79, Sn 95%, Sp 67%, PPV 88%, NPV 78%). If the flow is continuous, we can reasonably rule out diminished TAPSE (NPV 89%). Conclussion Detection of PW-Doppler flow of the common femoral vein may be an alternative window for the detection of an IVC dilation of 2cm, significant TR, and the likelihood of high PH in acute heart failure. It also allows us to reasonably rule out dysfunction of the right ventricle in cases of normality in these patients (AU)

Pulmonary artery obstruction index, pulmonary artery diameter and right ventricle strain as prognostic CT findings in patient with acute pulmonary embolism.

OBJECTIVE: This study was designed to determine predictors of pulmonary hypertension and signs of right heart dysfunction caused by pulmonary embolism (PE) that may lead to early detection of high-risk patients. So the predictive value of pulmonary artery obstruction index (PAOI), measured by pulmonary CT angiography (PCTA) in the acute setting, in predicting the patients susceptible to PE cardiac complications was evaluated. Also two other PCTA indices, pulmonary artery diameter (PAD), and right ventricle (RV) strain, in these patients were investigated and their predictive value for cardiac complications on follow up echocardiography were demonstrated. MATERIALS AND METHODS: In the study 120 patients with a definite diagnosis of PE were included. The PAOI, PAD and RV strain were measured using PCTA at the time of the initial diagnosis. Transthoracic echocardiography was done 6 months after the diagnosis of PE and RV echocardiographic indices were measured. Pearson correlation was used to investigate correlation between PAOI, PAD, RV strain and signs of right heart dysfunction. RESULTS: PAOI was strongly correlated with systolic pulmonary artery pressure (SPAP) (r=0.83), RV systolic pressure (r=0.78) and RV wall thickness (r=0.61) in long-term follow up echocardiography. A higher rate of RV dysfunction and RV dilation was detected among the patients with higher PAOI (P<0.001). PAOI≥18 was strongly predictive for development of RV dysfunction. Also developments of pulmonary hypertension, RV systolic hypertension, RV dilation, RV dysfunction, and RV hypertrophy were significantly more common among patients with higher PAD and RV strain (P<0.001). CONCLUSIONS: PAOI, PAD and RV strain are sensitive and specific PCTA indices that can predict the development of long-term complications such as pulmonary hypertension and right heart dysfunction, at the time of initial PE diagnosis.

La prueba cardiopulmonar de ejercicio contribuye a determinar con precisión el riesgo en pacientes con hipertensión pulmonar de bajo riesgo / Cardiopulmonary Exercise Testing Contributes to Accurate Risk Assessment in Patients with Low-risk Pulmonary Hypertension

RESUMEN Introducción : Las guías europeas de hipertensión arterial pulmonar (HAP) estratifican el riesgo valiéndose de características clínicas y estudios complementarios entre los cuales está la prueba cardiopulmonar de ejercicio (PCPE), de la cual toma en cuenta 3 parámetros: el consumo de O2 (VO2) pico, su porcentaje respecto del predicho y la pendiente ventilación minuto/ producción de dióxido de carbono (VE/VCO2). Sin embargo, ninguno de los modelos que validaron esta forma de estratificar el riesgo incluyeron la PCPE entre sus variables. Objetivos : Determinar qué proporción de pacientes con HAP del grupo I considerados de bajo riesgo y que caminan >440 metros en la prueba de caminata de 6 minutos (PC6M) tienen en la PCPE parámetros considerados de riesgo moderado o alto. Material y métodos : Se incluyeron pacientes >18 años con diagnóstico de HAP del grupo I considerados de bajo riesgo con una PC6M >400 metros a los que se les realizó una PCPE en la que se registró el VO2 pico, su porcentaje respecto del VO2 predicho y la pendiente VE/VCO2. Se determinó qué proporción de pacientes presentaban estos parámetros en un estrato de riesgo mayor a bajo riesgo (VO2 pico <15 ml/kg/min, su porcentaje respecto del predicho <65% y la pendiente VE/VCO2 >36). Resultados : Se incluyeron 18 pacientes. A pesar de ser pacientes de bajo riesgo y con buena clase funcional todos presentaron un VO2 pico menor al 85% del predicho, lo cual determina un deterioro al menos leve de la capacidad funcional. Un único paciente (6%) presentó los tres parámetros evaluados en bajo riesgo, 8 pacientes (44%) tuvieron al menos un parámetro alterado, 7 pacientes (39%) presentaron 2 parámetros alterados y en 2 pacientes (11%) todos los parámetros estuvieron alterados. Los parámetros que más frecuentemente se vieron alterados fueron el porcentaje respecto del VO2 predicho y la pendiente VE/VCO2, en el 67% de los casos. Solo 4 pacientes presentaron un VO2 pico <15 ml/k/m. Ningún paciente presentó valores de VO2 pico o porcentaje respecto del predicho en la categoría de alto riesgo. Sin embargo, 6 pacientes (33%) presentaron una pendiente VE/VCO2 considerada de alto riesgo. Conclusión : El 94% de los pacientes considerados de bajo riesgo presentaron al menos una variable en la PCPE que no corresponde a un perfil de riesgo bajo. La pendiente VE/VCO2 y el porcentaje de VO2 pico respecto del predicho fueron las variables más frecuentemente alteradas. La pendiente VE/VCO2 fue la única que mostró valores considerados de alto riesgo. La PCPE podría tener un lugar en la estratificación de precisión de pacientes de bajo riesgo. El valor de este hallazgo deberá ser evaluado en estudios prospectivos, al tiempo que genera las bases para el planteo de hipótesis respecto de la estratificación de riesgo y la intensidad del tratamiento en pacientes que aparentan estar en bajo riesgo.

ABSTRACT Background : European guidelines for pulmonary arterial hypertension (PAH) stratify the risk using clinical characteristics and complementary studies, including the cardiopulmonary exercise test (CPET). This takes into account 3 parameters: peak O2 consumption (peak VO2), its percentage with respect to the predicted VO2, and the minute ventilation/carbon dioxide production (VE/VCO2) slope. However, none of the models that validated this way of stratifying risk included PCPE among their variables. Objectives : To determine what proportion of patients with group I PAH considered to be at low risk and who walk >440 meters in the 6-minute walk test (6MWT) have parameters considered to be of moderate or high risk in the PCPE. Methods : Patients >18 years of age, diagnosed with group I PAH at low risk of events, who walked >440 meters in the 6MWT and had NT-proBNP value <300 pg/dL were included. A CPET was performed in which the peak VO2, its percentage with respect to the predicted VO2, and the VE/VCO2 slope were recorded. It was determined what proportion of patients presented these parameters in a higher than low risk stratum (peak VO2 consumption ≤15 ml/min/Kg, its percentage with respect to the predicted VO2 ≤65% and the VE/VCO2 slope ≥36). Results : Eighteen patients were included. Despite being low-risk patients with a good functional class, all patients presented a peak VO2 less than 85% of predicted, which determines a deterioration of functional capacity. A single patient (6%) presented the three parameters evaluated at low risk, 8 patients (44%) had at least one altered parameter, 7 patients (39%) presented 2 altered parameters and in 2 patients (11%) all parameters were altered. The parameters that were most frequently altered were the percentage of predicted peak VO2 and the VE/VCO2 slope in 67% of the cases. Only 4 patients presented a peak VO2 <15 ml/kg/m. No patient presented peak VO2 values or percentage of predicted VO2 in the high-risk category. However, 6 patients (33%) presented a high-risk VE/VCO2 slope. Conclusion : Majority (92%) of the patients considered low risk and who walk more than 440 meters in 6 minutes presented at least one altered variable in the CPET. The VE/VCO2 slope and the percentage of predicted peak VO2 consumption were the most frequently altered variables. The VE/VCO2 slope was the only one that showed values considered high risk. CPET could have a place in the precision stratification of low-risk patients. The value of this finding should be evaluated in prospective studies.

Índice de obstrucción de la arteria pulmonar, diámetro de la arteria pulmonar y strain del ventrículo derecho como hallazgos pronósticos de la tomografía computarizada en el paciente con embolia pulmonar aguda / Pulmonary artery obstruction index, pulmonary artery diameter and right ventricle strain as prognostic CT findings in patient with acute pulmonary embolism

Objetivo: Este estudio fue diseñado para determinar los predictores de la hipertensión pulmonar y los signos de disfunción cardíaca derecha causados por la embolia pulmonar (EP) que pueden conducir a la detección temprana de los pacientes de alto riesgo. Por lo tanto, se evaluó el valor predictivo del índice de obstrucción de la arteria pulmonar (IOAP), medido mediante angiografía pulmonar por TC (APTC) en el contexto agudo, para predecir los pacientes susceptibles de sufrir complicaciones cardíacas por EP. También se investigaron otros dos índices de APTC, el diámetro de la arteria pulmonar (DAP) y el strain del ventrículo derecho (VD), en estos pacientes y se demostró su valor predictivo de las complicaciones cardíacas en la ecocardiografía de seguimiento. Materiales y métodos: En el estudio fueron incluidos 120 pacientes con diagnóstico definitivo de EP. El IOAP, el DAP y el strain del VD se midieron mediante APTC en el momento del diagnóstico inicial. Se realizó una ecocardiografía transtorácica 6 meses después del diagnóstico de EP y se midieron los índices ecocardiográficos del VD. Se utilizó la correlación de Pearson para investigar la correlación entre IOAP, DAP, strain del VD y los signos de disfunción del hemicardio derecho. Resultados: El IOAP estaba fuertemente correlacionado con la presión arterial pulmonar sistólica (PAPS) (r=0,83), la presión sistólica del VD (r=0,78) y el grosor de la pared del VD (r=0,61) en la ecocardiografía de seguimiento a largo plazo. Se detectó una mayor tasa de disfunción del VD y de dilatación del VD entre los pacientes con mayor IOAP (p<0,001). Un IOAP≥18 fue claramente predictivo del desarrollo de la disfunción del VD. También la evolución de la hipertensión pulmonar, la hipertensión sistólica del VD, la dilatación del VD, la disfunción del VD y la hipertrofia del VD fueron significativamente más frecuentes entre los pacientes con mayor DAP y strain del VD (p<0,001)...(AU)

Objective: This study was designed to determine predictors of pulmonary hypertension and signs of right heart dysfunction caused by pulmonary embolism (PE) that may lead to early detection of high-risk patients. So the predictive value of pulmonary artery obstruction index (PAOI), measured by pulmonary CT angiography (PCTA) in the acute setting, in predicting the patients susceptible to PE cardiac complications was evaluated. Also two other PCTA indices, pulmonary artery diameter (PAD), and right ventricle (RV) strain, in these patients were investigated and their predictive value for cardiac complications on follow up echocardiography were demonstrated. Materials and methods: In the study 120 patients with a definite diagnosis of PE were included. The PAOI, PAD and RV strain were measured using PCTA at the time of the initial diagnosis. Transthoracic echocardiography was done 6 months after the diagnosis of PE and RV echocardiographic indices were measured. Pearson correlation was used to investigate correlation between PAOI, PAD, RV strain and signs of right heart dysfunction. Results: PAOI was strongly correlated with systolic pulmonary artery pressure (SPAP) (r=0.83), RV systolic pressure (r=0.78) and RV wall thickness (r=0.61) in long-term follow up echocardiography. A higher rate of RV dysfunction and RV dilation was detected among the patients with higher PAOI (P<0.001). PAOI≥18 was strongly predictive for development of RV dysfunction. Also developments of pulmonary hypertension, RV systolic hypertension, RV dilation, RV dysfunction, and RV hypertrophy were significantly more common among patients with higher PAD and RV strain (P<0.001). Conclusions: PAOI, PAD and RV strain are sensitive and specific PCTA indices that can predict the development of long-term complications such as pulmonary hypertension and right heart dysfunction, at the time of initial PE diagnosis.(AU)

Outcome of moderate-severe tricuspid regurgitation after pulmonary endarterectomy or balloon pulmonary angioplasty.

INTRODUCTION AND OBJECTIVES: The management of persistent moderate-severe tricuspid regurgitation (TR) in patients with chronic thromboembolic pulmonary hypertension after treatment with pulmonary endarterectomy (PEA) or balloon pulmonary angioplasty (BPA) is not well defined. This study aimed to analyze the progression and predictors of significant persistent postintervention TR and its prognostic impact. METHODS: This single-center observational study included 72 patients undergoing PEA and 20 who completed a BPA program with a previous diagnosis of chronic thromboembolic pulmonary hypertension and moderate-to-severe TR. RESULTS: The postintervention prevalence of moderate-to-severe TR was 29%, with no difference between the PEA- or BPA-treated groups (30.6% vs 25% P=.78). Compared with patients with absent-mild postprocedure TR, those with persistent TR had higher mean pulmonary arterial pressure (40.2±1.9 vs 28.5±1.3mmHg P <.001), pulmonary vascular resistance (472 [347-710] vs 282 [196-408] dyn.s/cm5; P <.001), and right atrial area (23.0 [21-31] vs 16.0 [14.0-20.0] P <.001). The variables independently associated with persistent TR were pulmonary vascular resistance> 400 dyn.s/cm5 and postprocedure right atrial area> 22cm2. No preintervention predictors were identified. The variables associated with increased 3-year mortality were residual TR and mean pulmonary arterial pressure> 30mmHg. CONCLUSIONS: Residual moderate-to-severe TR following PEA-PBA was associated with persistently high afterload and unfavorable postintervention right chamber remodeling. Moderate-to-severe TR and residual pulmonary hypertension were associated with a worse 3-year prognosis.

Evaluación mediante OCT del remodelado vascular pulmonar en insuficiencia cardiaca avanzada. Estudio OCTOPUS-CHF / Optical coherence tomography assessment of pulmonary vascular remodeling in advanced heart failure. The OCTOPUS-CHF study

Introducción y objetivos El remodelado vascular pulmonar es prevalente en la insuficiencia cardiaca avanzada. El cateterismo derecho es la prueba de elección, pero está limitado por la asunción de medidas indirectas, un enfoque de flujo no pulsátil, su dependencia de la carga o la variabilidad en la interpretación. Nuestro objetivo es evaluar la vasculopatía pulmonar mediante tomografía de coherencia óptica (OCT) intravascular y correlacionarla con los parámetros hemodinámicos. Métodos Estudio observacional, prospectivo y multicéntrico que incluyó a 100 pacientes en estudio previo al trasplante cardiaco. Todos se sometieron a un cateterismo derecho con OCT de la arteria pulmonar. Resultados La OCT se pudo analizar en 90 casos. La mediana de edad fue 57,50 [intervalo intercuartílico, 48,75-63,25] años y 71 eran varones (78,88%). La cardiopatía subyacente más frecuente fue la miocardiopatía dilatada no isquémica (33 pacientes [36,66%]). El grosor intimal se correlacionó con la presión arterial pulmonar media, las resistencias vasculares y el gradiente transpulmonar (coeficiente R de 0,42, 0,27 y 0,32 respectivamente). La estimación no invasiva de la presión sistólica pulmonar, el tiempo de aceleración y el acoplamiento ventriculoarterial también se correlacionaron con el grosor intimal (coeficiente R de 0,42, 0,27 y 0,49 respectivamente). Los pacientes con un grosor intimal > 0,25mm presentaron mayores presión pulmonar media (37,00 frente a 25,00mmHg; p=0,004) y resistencias vasculares (3,44 frente a 2,08 UW; p=0,017). Conclusiones La OCT pulmonar es factible y está significativamente asociada con los datos hemodinámicos. La correlación débil indica que el remodelado vascular no explica por completo la hipertensión pulmonar (AU)

Introduction and objectives Pulmonary vascular remodeling is common among patients with advanced heart failure. Right heart catheterization is the gold standard to assess pulmonary hypertension, but is limited by indirect measurement assumptions, a steady-flow view, load-dependency, and interpretation variability. We aimed to assess pulmonary vascular remodeling with intravascular optical coherence tomography (OCT) and to study its correlation with hemodynamic data. Methods This observational, prospective, multicenter study recruited 100 patients with advanced heart failure referred for heart transplant evaluation. All patients underwent right heart catheterization together with OCT evaluation of a subsegmentary pulmonary artery. Results OCT could be performed and properly analyzed in 90 patients. Median age was 57.50 [interquartile range, 48.75-63.25] years and 71 (78.88%) were men. The most frequent underlying heart condition was nonischemic dilated cardiomyopathy (33 patients [36.66%]). Vascular wall thickness significantly correlated with mean pulmonary artery pressure, pulmonary vascular resistance, and transpulmonary gradient (R coefficient=0.42, 0.27 and 0.32 respectively). Noninvasive estimation of pulmonary artery systolic pressure, acceleration time, and right ventricle-pulmonary artery coupling also correlated with wall thickness (R coefficient of 0.42, 0.27 and 0.49, respectively). Patients with a wall thickness over 0.25mm had significantly higher mean pulmonary pressures (37.00 vs 25.00mmHg; P=.004) and pulmonary vascular resistance (3.44 vs 2.08 WU; P=.017). Conclusions Direct morphological assessment of pulmonary vascular remodeling with OCT is feasible and is significantly associated with classic hemodynamic parameters. This weak association suggests that structural remodeling does not fully explain pulmonary hypertension (AU)