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Evaluation of Right Ventricular Diastolic Function and Prognosis in Patients with Pulmonary Artery Hypertension
The 16th Annual Scientific Meeting
JHFS
S131
Symposium 5 S5-1
RV-Ea assessed by 3D echo imaging may be a promising index to assess afterload of RV in patients with refractory left-sided heart failure noninvasively.
Right-sided Heart Failure Accompanied by Pulmonary Arterial Hypertension KATSUMASA MIYAJI1, AIKO OGAWA2, HIROMI MATSUBARA1 Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan, 2Department of Clinical Laboratory, National Hospital Organization Okayama Medical Center, Okayama, Japan
S5-4
1
Right-sided heart failure (RHF) is one of the most crucial causes of death in patients with pulmonary hypertension (PH). Devastating increase in pulmonary vascular resistance and longstanding pressure overload of right ventricle (RV) induces RHF. The most important management of RHF in PH patients is to relieve high pulmonary arterial pressure as soon as possible. Recently, several medical treatments using prostanoids, endothelin receptor antagonists, and phosphodiesterase-5 inhibitors have been approved and available for pulmonary arterial hypertension (PAH), what is called PAH-specific therapy. Therefore, appropriate PAH-specific therapy should be introduced in PAH patients, which could lead rapid decrease in pressure overload of RV and would prevent from aggravation of RHF. However, RHF occasionally aggravates during introduction of PAH-specific therapy in PAH patients. Especially, the introduction of intravenous epoprostenol therapy often causes RHF because of its strong systemic vasodilation which causes the increase of venous return to right-side heart. Increased venous return often causes congestive symptoms such as peripheral edema, dilation of cardiac shadow and cardiogenic ascites. Cautious induction of PAH-specific therapy should be required such as gradual increase of the dosage of drugs, additional administration of diuretics and monitoring of hemodynamics.
S5-2 Evaluation of Right Ventricular Diastolic Function and Prognosis in Patients with Pulmonary Artery Hypertension KONOMI SAKATA, KAZUYA TAKEMOTO, YOUICHIRO UESUGI, GOU KIMURA, HANAKO KIKUCHI, JYUNSUKE SUEOKA, TOSHINORI MINAMISHIMA, KENICHI MATSUSHITA, TOURU SATO, HIDEAKI YOSHINO The Second Department of Internal Medicine, Kyorin University School of Medicine, Tokyo, Japan Objective: In patients with pulmonary artery hypertension (PAH), right ventricular (RV) pressure overload causes right heart failure. We sought to investigate the severity of RV systolic and diastolic dysfunction and prognosis using tissue Doppler (TDI) and speckle-tracking imaging (STI). Methods: We performed TDI and STI in 55 PAH patents. We measured early diastolic peak velocities of tricuspid inflow (TE), peak systolic (Ts’) and early diastolic tricuspid annular velocities (Te’) by TDI. RV peak systolic strain (PS), RV peak systolic strain rate (SSR), and RV peak early diastolic strain rate (DSR) were analyzed by STI in the longitudinal direction. Right atrial pressure (RAP) and cardiac index (CI) by right heart catheterization, and serum brain natriuretic peptide (BNP) were measured. Results: There were significant correlations between CI and Ts’ (r50.57, p!0.01), TE/Te’ (r50.72, p!0.01), PS (r50.63, p!0.01), and SSR (r50.45, p!0.01). There was significant correlation between RAP and TE/Te’ (r50.72, p!0.01), and PS (r50.40, p!0.01). BNP level was correlated with TE/Te’ (r50.72, p!0.01), PS (r50.67, p!0.01), SSR (r50.64, p!0.01), Ts’ (r50.55, p!0.01). Six patients died within one year. TE/Te’O7 (odds ratio 3.10, p50.01) was the most independent predictor to evaluate the prognosis. Conclusions: TDI and STI were useful for noninvasive evaluation of RV dysfunction and prognosis in patients with PAH.
S5-3 Worsening Role of Pulmonary Hypertension in Patients with Severe Left-sided Heart Failure YASUSHI SAKATA, YASUHARU TAKEDA, TOMOHITO OHTANI, ISAMU MIZOTE, ISSEI KOMURO Department of Cardiovascular Medicine, Graduate School of Medicine, Osaka University, Suita, Japan Pulmonary hypertension (PH) is one of key determinants in mortality and morbidity of patients with refractory left-sided heart failure. However, there still remain some problems to be solved in clinical settings. First is the reason why PH is a critical factor for these patients. We examined serial patients with refractory heart failure and severe functional mitral regurgitation (fMR) undergoing mitral valve surgery to elucidate factors associated with poor outcome of mitral valve surgery. We found RV diastolic diameter showed the difference between patients with successful and unsuccessful result in the operation, suggesting RV function might affect outcome of mitral repair for fMR. In these patients, RV diastolic diameter was significantly correlated to pulmonary vascular resistance. Therefore, PH may affect RV function as afterload. Then, next question is what type of procedures is suitable for evaluation of afterload of RV function. We evaluated RV systolic and diastolic volume, RV systolic pressure using 3D, Doppler and conventional echo imaging in a non-invasive manner and calculated the equation mimicking “RV effective arterial elastance (RV-Ea)” in seven patients with refractory heart failure. RV-Ea was higher in the patients with poor prognosis (1.0260.07) than those without (0.5560.24 mmHg/ml). Therefore,
Percutaneous Transluminal Pulmonary Angioplasty Markedly Ameliorates Severe Right Heart Failure in Patients with Distal-type Chromic Thromboembolic Pulmonary Hypertension KOICHIRO SUGIMURA, YOSHIHIRO FUKUMOTO, KIMIO SATOH, YUTAKA MIURA, KOTARO NOCHIOKA, TATSUO AOKI, SHUNSUKE TATEBE, SAORI YAMAMOTO, HIROAKI SHIMOKAWA Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan Background: Distal-type chronic thromboembolic pulmonary hypertension (d-CTEPH) still remains a fatal disease. We aimed to develop percutaneous transluminal pulmonary angioplasty (PTPA) as a new therapeutic strategy for the disorder. Case: Our first case was 74-year-old female with d-CTEPH without surgical indication, in whom medical treatment with vasodilators had been started at 70. She was transferred to our hospital due to progressive dyspnea. We started intravenous furosemide and dobutamine, and continuous infusion therapy with epoprostenol; however, we were unable to discontinue these intravenous drugs because of recurrent severe right heart failure. Eighteen months after the admission, we performed PTPA in this patient in a stepwise manner, and after a total of 8 sessions of the procedure, pulmonary hemodynamics was improved and we were finally able to discontinue all intravenous therapies. The latest cardiac catheterization showed improvement in mean pulmonary arterial pressure (mPAP) from 56 to 35 mmHg and brain natriuretic peptide from 1408 to 26 pg/ml. Clinical study: From July 2009 to May 2012, we prospectively enrolled 22 patients with d-CTEPH in our institute. We have performed PTPA, which resulted in significant improvement in pulmonary hemodynamics (PAP, 40.469.7 to 27.568.2 mmHg, P!0.0001) and the long-term prognosis as compared with the historical controls (n539, P!0.05). Conclusion: PTPA is an effective and safe new therapeutic option for d-CTEPH.
S5-5 Right and Left Ventricular Function, Dyssynchrony, and Interdependence in Patients with Acute and Chronic Pulmonary Artery Hypertension KAORU DOHI1, KAZUHIDE ICHIKAWA2, EMIYO SUGIURA2, TAKESHI TAKAMURA3, KATSUYA ONISHI2, NORIKAZU YAMADA2, MASHIO NAKAMURA4, MASAAKI ITO2 1 Department of Molecular and Laboratory Medicine, Mie University Graduate School of Medicine, Tsu, Japan, 2Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan, 3Department of Cardiology, Ise Red Cross Hospital, Ise, Japan, 4Department of Clinical Cardiovascular Research, Mie University Graduate School of Medicine, Tsu, Japan Objective: We investigated right and left ventricular (RV and LV) function, dyssynchrony, and interdependence in acute and chronic RV pressure overload (RVPO). Methods: RV and LV functions was analyzed using speckle-tracking strain and displacement imaging echocardiography in 37 patients with acute pulmonary thromboembolism (APTE), 36 patients with chronic pulmonary artery hypertension (CPAH), and 33 controls. The standard deviation of the heart rate-corrected timeto-peak regional systolic strain (PSS-dyssynchrony) and displacement (PSD-dyssynchrony) in the 6 segments was used to quantify RV and LV systolic dyssynchrony. Results: The APTE and CPAH groups had impaired RV and LV myocardial strain and large dysyncrhony compared with the Control group. RV and LV myocardial performance indices (MPI) were also abnormally high and correlated both in the APTE and CPAH groups. Multiple regression analysis indicated that pulmonary vascular resistance in the APTE group and RV global PSS in the CPAH group were independently associated with RV MPI, and LV longitudinal PSD-dyssynchrony in the APTE group and eccentricity index and heart rate in the CPAH group were independently associated with LV MPI. Conclusion: Both acute and chronic RVPO reduced ventricular strain, generate mechanical dyssynchronies, and impair myocardial performance in the right and left ventricles. Furthermore, pathophysiological mechanisms that regulate RV and LV interdependence are different depending on whether the ventricles are exposed to acute or chronic RVPO.
JHFS
S131
Symposium 5 S5-1
RV-Ea assessed by 3D echo imaging may be a promising index to assess afterload of RV in patients with refractory left-sided heart failure noninvasively.
Right-sided Heart Failure Accompanied by Pulmonary Arterial Hypertension KATSUMASA MIYAJI1, AIKO OGAWA2, HIROMI MATSUBARA1 Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan, 2Department of Clinical Laboratory, National Hospital Organization Okayama Medical Center, Okayama, Japan
S5-4
1
Right-sided heart failure (RHF) is one of the most crucial causes of death in patients with pulmonary hypertension (PH). Devastating increase in pulmonary vascular resistance and longstanding pressure overload of right ventricle (RV) induces RHF. The most important management of RHF in PH patients is to relieve high pulmonary arterial pressure as soon as possible. Recently, several medical treatments using prostanoids, endothelin receptor antagonists, and phosphodiesterase-5 inhibitors have been approved and available for pulmonary arterial hypertension (PAH), what is called PAH-specific therapy. Therefore, appropriate PAH-specific therapy should be introduced in PAH patients, which could lead rapid decrease in pressure overload of RV and would prevent from aggravation of RHF. However, RHF occasionally aggravates during introduction of PAH-specific therapy in PAH patients. Especially, the introduction of intravenous epoprostenol therapy often causes RHF because of its strong systemic vasodilation which causes the increase of venous return to right-side heart. Increased venous return often causes congestive symptoms such as peripheral edema, dilation of cardiac shadow and cardiogenic ascites. Cautious induction of PAH-specific therapy should be required such as gradual increase of the dosage of drugs, additional administration of diuretics and monitoring of hemodynamics.
S5-2 Evaluation of Right Ventricular Diastolic Function and Prognosis in Patients with Pulmonary Artery Hypertension KONOMI SAKATA, KAZUYA TAKEMOTO, YOUICHIRO UESUGI, GOU KIMURA, HANAKO KIKUCHI, JYUNSUKE SUEOKA, TOSHINORI MINAMISHIMA, KENICHI MATSUSHITA, TOURU SATO, HIDEAKI YOSHINO The Second Department of Internal Medicine, Kyorin University School of Medicine, Tokyo, Japan Objective: In patients with pulmonary artery hypertension (PAH), right ventricular (RV) pressure overload causes right heart failure. We sought to investigate the severity of RV systolic and diastolic dysfunction and prognosis using tissue Doppler (TDI) and speckle-tracking imaging (STI). Methods: We performed TDI and STI in 55 PAH patents. We measured early diastolic peak velocities of tricuspid inflow (TE), peak systolic (Ts’) and early diastolic tricuspid annular velocities (Te’) by TDI. RV peak systolic strain (PS), RV peak systolic strain rate (SSR), and RV peak early diastolic strain rate (DSR) were analyzed by STI in the longitudinal direction. Right atrial pressure (RAP) and cardiac index (CI) by right heart catheterization, and serum brain natriuretic peptide (BNP) were measured. Results: There were significant correlations between CI and Ts’ (r50.57, p!0.01), TE/Te’ (r50.72, p!0.01), PS (r50.63, p!0.01), and SSR (r50.45, p!0.01). There was significant correlation between RAP and TE/Te’ (r50.72, p!0.01), and PS (r50.40, p!0.01). BNP level was correlated with TE/Te’ (r50.72, p!0.01), PS (r50.67, p!0.01), SSR (r50.64, p!0.01), Ts’ (r50.55, p!0.01). Six patients died within one year. TE/Te’O7 (odds ratio 3.10, p50.01) was the most independent predictor to evaluate the prognosis. Conclusions: TDI and STI were useful for noninvasive evaluation of RV dysfunction and prognosis in patients with PAH.
S5-3 Worsening Role of Pulmonary Hypertension in Patients with Severe Left-sided Heart Failure YASUSHI SAKATA, YASUHARU TAKEDA, TOMOHITO OHTANI, ISAMU MIZOTE, ISSEI KOMURO Department of Cardiovascular Medicine, Graduate School of Medicine, Osaka University, Suita, Japan Pulmonary hypertension (PH) is one of key determinants in mortality and morbidity of patients with refractory left-sided heart failure. However, there still remain some problems to be solved in clinical settings. First is the reason why PH is a critical factor for these patients. We examined serial patients with refractory heart failure and severe functional mitral regurgitation (fMR) undergoing mitral valve surgery to elucidate factors associated with poor outcome of mitral valve surgery. We found RV diastolic diameter showed the difference between patients with successful and unsuccessful result in the operation, suggesting RV function might affect outcome of mitral repair for fMR. In these patients, RV diastolic diameter was significantly correlated to pulmonary vascular resistance. Therefore, PH may affect RV function as afterload. Then, next question is what type of procedures is suitable for evaluation of afterload of RV function. We evaluated RV systolic and diastolic volume, RV systolic pressure using 3D, Doppler and conventional echo imaging in a non-invasive manner and calculated the equation mimicking “RV effective arterial elastance (RV-Ea)” in seven patients with refractory heart failure. RV-Ea was higher in the patients with poor prognosis (1.0260.07) than those without (0.5560.24 mmHg/ml). Therefore,
Percutaneous Transluminal Pulmonary Angioplasty Markedly Ameliorates Severe Right Heart Failure in Patients with Distal-type Chromic Thromboembolic Pulmonary Hypertension KOICHIRO SUGIMURA, YOSHIHIRO FUKUMOTO, KIMIO SATOH, YUTAKA MIURA, KOTARO NOCHIOKA, TATSUO AOKI, SHUNSUKE TATEBE, SAORI YAMAMOTO, HIROAKI SHIMOKAWA Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan Background: Distal-type chronic thromboembolic pulmonary hypertension (d-CTEPH) still remains a fatal disease. We aimed to develop percutaneous transluminal pulmonary angioplasty (PTPA) as a new therapeutic strategy for the disorder. Case: Our first case was 74-year-old female with d-CTEPH without surgical indication, in whom medical treatment with vasodilators had been started at 70. She was transferred to our hospital due to progressive dyspnea. We started intravenous furosemide and dobutamine, and continuous infusion therapy with epoprostenol; however, we were unable to discontinue these intravenous drugs because of recurrent severe right heart failure. Eighteen months after the admission, we performed PTPA in this patient in a stepwise manner, and after a total of 8 sessions of the procedure, pulmonary hemodynamics was improved and we were finally able to discontinue all intravenous therapies. The latest cardiac catheterization showed improvement in mean pulmonary arterial pressure (mPAP) from 56 to 35 mmHg and brain natriuretic peptide from 1408 to 26 pg/ml. Clinical study: From July 2009 to May 2012, we prospectively enrolled 22 patients with d-CTEPH in our institute. We have performed PTPA, which resulted in significant improvement in pulmonary hemodynamics (PAP, 40.469.7 to 27.568.2 mmHg, P!0.0001) and the long-term prognosis as compared with the historical controls (n539, P!0.05). Conclusion: PTPA is an effective and safe new therapeutic option for d-CTEPH.
S5-5 Right and Left Ventricular Function, Dyssynchrony, and Interdependence in Patients with Acute and Chronic Pulmonary Artery Hypertension KAORU DOHI1, KAZUHIDE ICHIKAWA2, EMIYO SUGIURA2, TAKESHI TAKAMURA3, KATSUYA ONISHI2, NORIKAZU YAMADA2, MASHIO NAKAMURA4, MASAAKI ITO2 1 Department of Molecular and Laboratory Medicine, Mie University Graduate School of Medicine, Tsu, Japan, 2Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan, 3Department of Cardiology, Ise Red Cross Hospital, Ise, Japan, 4Department of Clinical Cardiovascular Research, Mie University Graduate School of Medicine, Tsu, Japan Objective: We investigated right and left ventricular (RV and LV) function, dyssynchrony, and interdependence in acute and chronic RV pressure overload (RVPO). Methods: RV and LV functions was analyzed using speckle-tracking strain and displacement imaging echocardiography in 37 patients with acute pulmonary thromboembolism (APTE), 36 patients with chronic pulmonary artery hypertension (CPAH), and 33 controls. The standard deviation of the heart rate-corrected timeto-peak regional systolic strain (PSS-dyssynchrony) and displacement (PSD-dyssynchrony) in the 6 segments was used to quantify RV and LV systolic dyssynchrony. Results: The APTE and CPAH groups had impaired RV and LV myocardial strain and large dysyncrhony compared with the Control group. RV and LV myocardial performance indices (MPI) were also abnormally high and correlated both in the APTE and CPAH groups. Multiple regression analysis indicated that pulmonary vascular resistance in the APTE group and RV global PSS in the CPAH group were independently associated with RV MPI, and LV longitudinal PSD-dyssynchrony in the APTE group and eccentricity index and heart rate in the CPAH group were independently associated with LV MPI. Conclusion: Both acute and chronic RVPO reduced ventricular strain, generate mechanical dyssynchronies, and impair myocardial performance in the right and left ventricles. Furthermore, pathophysiological mechanisms that regulate RV and LV interdependence are different depending on whether the ventricles are exposed to acute or chronic RVPO.