Effect of Oral Qing-Dai Medication on Pulmonary Arterial Pressure Levels in Patients With Ulcerative Colitis.

BACKGROUND: Qing-Dai (QD) treatment of patients with ulcerative colitis (UC) sometimes causes pulmonary arterial hypertension (PAH). However, the relationship of QD treatment to pulmonary arterial systolic pressure (PASP) in patients with UC has not been clarified.Methods and Results:The 27 patients with UC who were screened for PAH by transthoracic echocardiography (TTE) and underwent repeat TTE at 1 year were analyzed in this prospective observational study. Mean age was 44.0 years old, and median follow-up duration was 392. During the follow-up, 21 patients continued QD treatment (continuous group) and 6 patients discontinued the treatment (discontinuous group). In all patients, no significant difference in PASP levels between baseline and at follow-up was observed (21.4 vs. 21.3 mmHg, P=0.802). Furthermore, the mean PASP of patients in the continuous group did not differ from baseline to follow-up (21.4 mmHg to 22.6 mmHg, P=0.212); however, in the discontinuous group mean PASP was significantly decreased (21.5 mmHg to 16.8 mmHg, P=0.005). Moreover, changes in PASP from baseline to follow-up differed between the continuous and discontinuous groups (+1.1 mmHg vs. -4.7 mmHg, P=0.004). In addition, multivariable analyses revealed that only the duration of oral QD at baseline affected the increase of PASP. CONCLUSIONS: In patients with UC, QD treatment may have an undesirable association with an increase in PASP.

The Role of Echocardiography in the Diagnosis and Prognosis of Pulmonary Hypertension.

The right heart catheterisation constitutes the gold standard for pulmonary hypertension (PH) diagnosis. However, echocardiography remains a reliable, non-invasive, inexpensive, convenient, and easily reproducible modality not only for the preliminary screening of PH but also for PH prognosis. The aim of this review is to describe a cluster of echocardiographic parameters for the detection and prognosis of PH and analyse the challenges of echocardiography implementation in patients with suspected or established PH. The most important echocardiographic index is the calculation of pulmonary arterial systolic pressure (PASP) through the tricuspid regurgitation (TR). It has shown high correlation with invasive measurement of pulmonary pressure, but several drawbacks have questioned its accuracy. Besides this, the right ventricular outflow track acceleration time (RVOT-AT) has been proposed for PH diagnosis. A plethora of echocardiographic indices: right atrial area, pericardial effusion, the tricuspid annular plane systolic excursion (TAPSE), the TAPSE/PASP ratio, tricuspid annular systolic velocity (s'), can reflect the severity and prognosis of PH. Recent advances in echocardiography with 3-dimensional right ventricular (RV) ejection fraction, RV free wall strain and right atrial strain may further assist the prognosis of PH.

Correlation analysis between lung ultrasound scores and pulmonary arterial systolic pressure in patients with acute heart failure admitted to the emergency intensive care unit.

Background: No convenient, inexpensive, and non-invasive screening tools exist to identify pulmonary hypertension (PH) - left heart disease (LHD) patients during the early stages of the disease course. This study investigated whether different methods of lung ultrasound (LUS) could be used for the initial investigation of PH-LHD. Methods: This was a single-center prospective observational study which was performed in the Zigong Fourth People's Hospital. We consecutively enrolled patients with heart failure (HF) admitted to the emergency intensive care unit from January 2018 to May 2020. Transthoracic echocardiography and LUS were performed within 24 h before discharge. We used the Spearman coefficient for correlation analysis between ultrasound scores and pulmonary arterial systolic pressure (PASP). Bland-Altman plots were generated to inspect possible bias, and receiver operating characteristic (ROC) curves were calculated to assess the relationship between ultrasound scores and an intermediate and high echocardiographic probability of PH-LHD. Results: Seventy-one patients were enrolled in this study, with an overall median age of 79 (interquartile range: 71.5-84.0) years. Among the 71 patients, 36 (50.7%) cases were male, and 26 (36.6%) had an intermediate and high echocardiographic probability of PH. All four LUS scores in patients with an intermediate and high probability of PH were significantly higher than in patients with a low probability of PH (P <0.05). The correlation coefficient (r) between different LUS scoring methods and PASP was moderate for the 6-zone (r=0.455, P <0.001), 8-zone (r=0.385, P=0.001), 12-zone (r=0.587, P <0.001), and 28-zone (r=0.535, P <0.001) methods. In Bland-Altman plots, each of the four LUS scoring methods had a good agreement with PASP (P <0.001). The 8-zone and 12-zone methods showed moderately accurate discriminative values in differentiating patients with an intermediate and high echocardiographic probability of PH (P <0.05). Conclusions: LUS is a readily available, inexpensive, and risk-free method that moderately correlates with PASP. LUS is a potential screening tool used for the initial investigation of PH-LHD, especially in emergencies or critical care settings.

Tricuspid annular plane systolic excursion and pulmonary arterial systolic pressure relationship in heart failure: an index of right ventricular contractile function and prognosis.

Echo-derived pulmonary arterial systolic pressure (PASP) and right ventricular (RV) tricuspid annular plane systolic excursion (TAPSE; from the end of diastole to end-systole) are of basic relevance in the clinical follow-up of heart failure (HF) patients, carrying two- to threefold increase in cardiac risk when increased and reduced, respectively. We hypothesized that the relationship between TAPSE (longitudinal RV fiber shortening) and PASP (force generated by the RV) provides an index of in vivo RV length-force relationship, with their ratio better disclosing prognosis. Two hundred ninety-three HF patients with reduced (HFrEF, n = 247) or with preserved left ventricular (LV) ejection fraction (HFpEF, n = 46) underwent echo-Doppler studies and N-terminal pro-brain-type natriuretic peptide assessment and were tracked for adverse events. The median follow-up duration was 20.8 mo. TAPSE vs. PASP relationship showed a downward regression line shift in nonsurvivors who were more frequently presenting with higher PASP and lower TAPSE. HFrEF and HFpEF patients exhibited a similar distribution along the regression line. Given the TAPSE, PASP, and TAPSE-to-PASP ratio (TAPSE/PASP) collinearity, separate Cox regression and Kaplan-Meier analyses were performed: one with TAPSE and PASP as individual measures, and the other combining them in ratio form. Hazard ratios for variables retained in the multivariate regression were as follows: TAPSE/PASP

Association between the TAPSE to PASP ratio and short-term outcome in patients with light-chain cardiac amyloidosis.

BACKGROUND: Amyloid light-chain cardiac amyloidosis (AL-CA) patients experiencing RV failure have a poorer prognosis. The echocardiographic ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary arterial systolic pressure (PASP) serves as a non-invasive proxy for evaluating the coupling between the right ventricle (RV) and pulmonary circulation. The aim of this study was to assess the association between the TAPSE/PASP ratio and short-term outcome in patients with AL-CA. METHODS: Seventy-one patients diagnosed with AL-CA were enrolled in this retrospective cohort study.Short-term outcome was defined as 6-month all-cause mortality. Receiver operating characteristic (ROC), logistic regression, and Kaplan-Meier analysis were used in this study. RESULTS: Among seventy-one patients with AL-CA (mean age, 62 ± 8 years, 69% male), 17 (24%) died within the first 6 months (mean follow-up period 55 ± 48 days). Linear regression analysis indicated that the TAPSE/PASP ratio was correlated with RV global longitudinal strain (r = -0.655, p < 0.001), RV free wall thickness (r = -0.599, p < 0.001), and left atrial reservoir strain (r = 0.770, p < 0.001). The time-dependent ROC and the area under the curve (AUC) showed that the TAPSE/PASP ratio was a better predictor (AUC = 0.798; 95% confidence interval (CI): 0.677-0.929) of short-term outcome than TAPSE (AUC = 0.734; 95% CI: 0.585-0.882) and PASP (AUC: 0.730; 95% CI: 0.587-0.874). Multivariate logistic regression showed that patients with the worse TAPSE/PASP (< 0.47 mm/mmHg) and lower systolic blood pressure (< 100 mmHg) had the highest risk of dying. CONCLUSIONS: The TAPSE/PASP ratio is associated with the short-term outcome of patients with AL-CA. The combination of TAPSE/PASP ratio < 0.474 mmHg and SBP < 100 mmHg could identify the subgroup of patients with AL-CA at elevated risk of poor prognosis.

Surgical Treatment for Empyema Thoracis: Prognostic Role of Preoperative Transthoracic Echocardiography and Serum Calcium.

BACKGROUND: Empyema is a major cause of mortality and hospitalization. Symptoms include difficulty breathing and chest pain. Calcium plays an essential role in the physiology of the cardiovascular system. However, there is little evidence on the role of echocardiography and the serum calcium levels of patients undergoing video-assisted thoracoscopic surgery (VATS) for empyema. This study aimed to investigate the risk factors for postoperative mortality in patients with empyema who required surgery. METHODS: This single-institution retrospective study compared the outcomes of VATS for thoracic empyema (in terms of survival and mortality) in 122 patients enrolled between July 2015 and June 2019. RESULTS: This study examined patients with thoracic empyema. The majority of the patients were males (100/122, 81.9%). The in-hospital/30-day mortality rate was 10.6% (13 patients). The calcium levels were 7.82 ± 1.17 mg/dL in the survival group and 6.88 ± 1.88 mg/dL in the mortality group (p = 0.032). In the mortality group, the utilization of echocardiography and serum calcium levels independently contributed to the risk prediction more than clinical variables. Patients in our cohort exhibited elevated pulmonary artery systolic pressure (PASP) and hypocalcemia, which were associated with increased postoperative mortality. CONCLUSION: Elevated PASP and calcium levels at the low end of the normal range demonstrated significant prognostic value in predicting mortality in patients with thoracic empyema who required surgical intervention. Recognizing this potential is critical in order to obtain better outcomes.

Identification of Distinct Subgroups in Moderately Severe Rheumatic Mitral Stenosis Using Data-Driven Phenotyping of Longitudinal Hemodynamic Progression.

Background Rheumatic mitral stenosis is a significant cause of valvular heart disease. Pulmonary arterial systolic pressure (PASP) reflects the hemodynamic consequences of mitral stenosis and is used to determine treatment strategies. However, PASP progression and expected outcomes based on PASP changes in patients with moderately severe mitral stenosis remain unclear. Methods and Results A total of 436 patients with moderately severe rheumatic mitral stenosis (valve area 1.0-1.5 cm2) were enrolled. Composite outcomes included all-cause mortality and hospitalization for heart failure. Data-driven phenotyping identified 2 distinct trajectory groups based on PASP progression: rapid (8.7%) and slow (91.3%). Patients in the rapid progression group were older and had more diabetes and atrial fibrillation than those in the slow progression group (all P<0.05). The initial mean diastolic pressure gradient and PASP were higher in the rapid progression group than in the slow progression group (6.2±2.4 mm Hg versus 5.1±2.0 mm Hg [P=0.001] and 42.3±13.3 mm Hg versus 33.0±9.2 mm Hg [P<0.001], respectively). The rapid progression group had a poorer event-free survival rate than the slow progression group (log-rank P<0.001). Rapid PASP progression was a significant risk factor for composite outcomes even after adjusting for comorbidities (hazard ratio, 3.08 [95% CI, 1.68-5.64]; P<0.001). Multivariate regression analysis revealed that PASP >40 mm Hg was independently associated with allocation to the rapid progression group (odds ratio, 4.95 [95% CI, 2.08-11.99]; P<0.001). Conclusions Rapid PASP progression was associated with a higher risk of the composite outcomes. The main independent predictor for rapid progression group allocation was initial PASP >40 mm Hg.

Clinical and Predictive Value of Computed Tomography Angiography in High-Altitude Pulmonary Hypertension.

Background: High-altitude pulmonary hypertension (HAPH), as the group 3 pulmonary hypertension, has been less studied so far. The limited medical conditions in the high-altitude plateau are responsible for the delay of the clinical management of HAPH. Objectives: This study aims to identify the imaging characteristics of HAPH and explore noninvasive assessment of mean pulmonary arterial pressure (mPAP) based on computed tomography angiography (CTA). Methods: Twenty-five patients with suspected HAPH were enrolled. Right heart catheterization (RHC) and pulmonary angiography were performed. Echocardiography and CTA image data were collected for analysis. A multivariable linear regression model was fit to estimate mPAP (mPAPpredicted). A Bland-Altman plot and pathological analysis were performed to assess the diagnostic accuracy of this model. Results: Patients with HAPH showed slow blood flow and coral signs in lower lobe pulmonary artery in pulmonary arteriography, and presented trend for dilated pulmonary vessels, enlarged right atrium, and compressed left atrium in CTA (P for trend <0.05). The left lower pulmonary artery-bronchus ratio (odds ratio: 1.13) and the ratio of right to left atrial diameter (odds ratio: 1.09) were significantly associated with HAPH, and showed strong correlation with mPAPRHC, respectively (r = 0.821 and r = 0.649, respectively; all P < 0.0001). The mPAPpredicted model using left lower artery-bronchus ratio and ratio of right to left atrial diameter as covariates showed high correlation with mPAPRHC (r = 0.907; P < 0.0001). Patients with predicted HAPH also had the typical pathological changes of pulmonary hypertension. Conclusions: Noninvasive mPAP estimation model based on CTA image data can accurately fit mPAPRHC and is beneficial for the early diagnosis of HAPH.

Tricuspid annular plane systolic excursion (TAPSE) in pediatric pulmonary hypertension: Integrating right ventricular ejection efficiency (RVEe) into advanced multi-parametric imaging.

The tricuspid annular plane systolic excursion (TAPSE) has evolved into one of the major echocardiographic indicators of systolic right ventricular (RV) longitudinal function in pediatric pulmonary hypertension (PH). Current RV function research in children with PH focusses on multi-parametric approaches that include TAPSE. The RV ejection efficiency (RVEe) is one of the new variables that reflects the relationship of TAPSE divided by the indexed pulmonary vascular resistance (PVRi) measured by cardiac catheterization. Here, we investigated not only RVEe, but also the ratio of TAPSE divided by pulmonary systolic arterial pressure (PASP; TAPSE/PASP ratio), and a possible association of these indices with NYHA functional class (FC) or the modified ROSS score in 42 children with PH. Both, the RVEe (TAPSE/PVRi) and the TAPSE/PASP ratio were inversely related to NYHA FC and the modified ROSS score in the pediatric PH compared. Compared to TAPSE as single measure, in both multiparametric variables (RVEe, TAPSE/PASP) more pronounced differences in subjects with different NYHA FC/modified ROSS score values were observed. Taken together, the RVEe (TAPSE/PVRi) and TAPSE/PASP ratio distinguish between NYHA FC/modified ROSS score compared to the single echocardiographic variable TAPSE, highlighting the usefulness of a multiparametric approach.

Indications for Surgery for Tricuspid Regurgitation.

Despite the fact that tricuspid regurgitation (TR) can result in significant symptoms, patients are rarely referred for isolated surgical repair, or replacement, and most surgeries are performed in the context of other planned cardiac surgery. In this article, we review the different causes of TR, the natural history of untreated severe TR, indications and timing for isolated TR surgery, indications for TR surgery performed at the time of left-sided valve surgery, and surgical approaches for correction of TR.

Echocardiographic estimation of pulmonary arterial systolic pressure in acute heart failure. Prognostic implications.

BACKGROUND: Prognostic implications of echocardiographic assessment of pulmonary hypertension (PH) in non-selected patients hospitalized for acute heart failure (AHF) are not clearly defined. The aim of this study was to evaluate the association between echocardiography-derived PH in AHF and 1-year all-cause mortality. METHODS: We prospectively included 1210 consecutive patients admitted for AHF. Patients with significant heart valve disease were excluded. Pulmonary arterial systolic pressure (PASP) was estimated using transthoracic echocardiography during hospitalization (mean time after admission 96±24h). Patients were categorized as follows: non-measurable, normal PASP (PASP≤35mmHg), mild (PASP 36-45mmHg), moderate (PASP 46-60mmHg) and severe PH (PASP >60mmHg). The independent association between PASP and 1-year mortality was assessed with Cox regression analysis. RESULTS: At 1-year follow-up, 232 (19.2%) deaths were registered. PASP was measured in 502 (41.6%) patients with a median of 46 [38-55] mmHg. The distribution of population was: 708 (58.5%), 76 (6.3%), 147 (12.1%), 190 (15.7%) and 89 (7.4%) for non-measurable, normal PASP, mild, moderate and severe PH, respectively. One-year mortality was lower for patients with normal PASP (1.32 per 10 person-years), intermediate for patients with non-measurable, mild and moderate PH (2.48, 2.46 and 2.62 per 10 persons-year, respectively) and higher for those with severe PH (4.89 per 10 person-years). After multivariate adjustment, only patients with PASP >60mmHg displayed significant adjusted increase in the risk of 1-year all-cause mortality, compared to patients with normal PASP (HR=2.56; CI 95%: 1.05-6.22, p=0.038). CONCLUSIONS: In AHF, severe pulmonary hypertension derived by echocardiography is an independent predictor of 1-year-mortality.

Does the Society of Thoracic Surgeons risk score accurately predict operative mortality for patients with pulmonary hypertension?

OBJECTIVE: This study assessed the impact of pulmonary hypertension (PH) on morbidity and mortality after the most common cardiac operations and evaluated the accuracy of the Society of Thoracic Surgeons (STS) risk model for patients with PH. METHODS: At a single center between 1994 and 2010, all adult cardiac operations performed with recorded preoperative mean pulmonary arterial pressure (MPAP) and STS predicted mortality were reviewed. MPAP was defined as normal (<25 mm Hg) or as mild (25-34 mm Hg), moderate (35-44 mm Hg), or severe (≥ 45 mm Hg) PH. Multivariate analysis was performed to elucidate the contribution of PH to morbidity and mortality. RESULTS: In all, 3343 patient records were reviewed. Coronary artery bypass grafting (CABG) was the most common procedure (67.5%), followed by aortic valve replacement (24.9%) and mitral valve procedures (6.3%). Postoperative complications and mortality increased with increasing MPAP. Multivariable analysis found that both moderate (odds ratio, 7.17; P < .001) and severe (odds ratio, 13.73; P < .001) PH were significantly associated with increased mortality, even after accounting for STS risk. A subset analysis of isolated CABG cases revealed markedly increased mortality for all categories of PH (mild odds ratio, 1.99; moderate odds ratio, 11.5; severe odds ratio, 38.9; P < .001). CONCLUSIONS: Morbidity and mortality were independently associated with PH. Observed mortality was significantly higher than predicted by the STS model for patients with moderate and severe PH, particularly in isolated CABG. Addition of PH to the STS risk model should be considered, or alternative tools should be used to assess risk in these patients.

Original rat model of high kinetic unilateral pulmonary hypertension surgically induced by combined surgery.

OBJECTIVES: The characteristic morphologic lesions observed in the lungs of patients with congenital cardiac anomalies have not been closely modeled in rat shunt-related models, except for the reversible grade 1 changes. The present study reported an original rat model of unilateral pulmonary hypertension surgically induced by combined surgery to reproduce more advanced pulmonary vascular lesions. METHODS: The right pulmonary artery was ligated through a right posterolateral thoracotomy, and a cervical shunt was established 1 week later. The immediate and chronic effects on the pulmonary hemodynamics were evaluated through right heart catheterization immediately after and at 8 and 12 weeks postoperatively. The morphologic changes in pulmonary vasculature were analyzed after staining with hematoxylin-eosin and modified Weigert's method. The right ventricular hypertrophy index was calculated and artery blood gas analysis performed. RESULTS: A pulmonary hypertensive status was successfully induced immediately after cervical surgery and progressively aggravated into a borderline state with disease course advancing. Pulmonary vasculopathy demonstrated a transition from reversibility (muscularization, intimal proliferation of grade 1-2) at 8 weeks to irreversibility (intimal fibrosis, entirely luminal occlusion, grade 3) at 12 weeks postoperatively. Conspicuous right ventricular hypertrophy and decreasing partial arterial pressure of oxygen were also observed. CONCLUSIONS: The present shunt-related model successfully simulated a hypertensive status in pulmonary circulation and reproduced the characteristic transition of pulmonary vasculopathy from reversibility to irreversibility within a relatively short period. Thus, this model could offer an alternative with low mortality and high reproducibility for investigations on the underling mechanisms of shunt-related pulmonary hypertension.