- Email: [email protected]
Pulmonary Hypertension, 10:30 am — 11:20 am
Wednesday, November 1 HIV PCP, continued
UTILITY OF CHEST ROENTGENOGRAPY IN THE DIAGNOSIS OF PNEUMOCYSTIS CARINII PNEUMONIA (PCP) IN HIV-INFECTED INDIVIDUALS. hndrew Mcivor* MD. M Towers MB. P Webster MD. Sunnybrook Health Science Centre, U of Toronto. Introduction: Many investigators suggest empiric therapy against PCP for HIV infected individuals presenting with a typical chest x-ray, without bronchoscopy confirmation. Methods: We performed a retrospective assessment of the utility of chest X-rays, either alone or in combination with clinical and laboratory data to aid in the diagnosis of PCP. A chest physician and radiologist blinded to the outcomes reported a series of X-rays, using a visual analog scle to assess the likelihood of PCP (0 no PCP) before and after the clinical and laboratory data. Results: Of 38 consecutive HIV infected patients 92% male, mean age 40 yrs, 37% were positive for PCP on bronchoscopy, mean CD4 47 ± 37 cellsfmm3 and LDH 321 ± 190. The mean visual analog scale score for individuals PCP positive was 62 ± 32 which increased to 67 ± 33, with the addition of clinical information (p=0.04) compared to 34 ± 28 to 34 ± 33 (p=0.88) for PCP negative. Over all examination of the chest x-ray alone discriminated well between those with and without PCP (p=O.Ol4). Conclusion: Due to the high incidence of toxicity from anti-PCP medications and the potential for superimposed bacterial or viral infections not covered by some anti-PCP medications we still encourage bronchoscopic confirmation.
SIMILAR PULMONARY VASOACTIVE EFFECTS OF TOLAZQLINE AND CLONIDINE Tai-Shion Lee, X. Hou, Department of Anesthesiology Harbor-UCLA Medical Center, Torrance, CA, USA Six rings of isolated rabbit pulmonary artery (PA) with or without intact endothelium (E) were immersed in a 5 ml tissue bath containing a continuously oxygenated (95% 02/C02) Krebs solution at 370C and pH 7.4. After stabilization, the ring was either nonprecontracted or precontracted with norepinephrine (NE; 3x1Q-6M) or KCl (3x1Q-2M) alternately and the peak developed tension was recorded as the control. Then cumulative concentration response curves of tolazoline (TLZ) and clonidine (CND) were obtained. The changes were expressed as %of the control in mean + 5EM. Statistical analysis was perfonned using paired t-test. CI.ONII)!Ni: ANO 1 OIAZOIJNi: ON
~= =~~::;~~i
I~ ;•
.! I
CDIU:~~CUI-I
ON KCI PRECONTRACTED PULNONARY ARTEHY
I: -· _.- ~=~~ ~·=[U'I
LOG (Ill)
CJIICIZ.Cl.OiflDtNI:
'IJIWIGLE:'ftii.\ZOUNC
ON HE PRECOl'ITRACT£0 PULliOHARY ARTER't
i .: ·-,~~t
~ :: ~: : :
_.
~:
aatu:.~I.OG(~'I'OUZIIWI.I
With a tissue bath preparation, our study on isolated rabbit pulmonary artery has shown that CND and TLZ have similar dual vasoactive effects. Both produce dose-related vasoconstriction on non-pretreated and KCl pretreated PA rings, and vasodilation on NEprecontracted ones.
Pulmonary Hypertension 1 0:30 am - 11 :20 am fllllr 11\MEI\k: A!:H::S9'ENT IF 1-E"UDYJ\R'IIC EFFFI:TS £F l..fN:i TERM OXYff:N ~V I.EII\6 PI..LJ:£: ()(J·H.. ER ~~~
Ch.Ja,Jerl'"y Q. M.D., tiJaclarrama, ft'N M.D., O:ln..nia, R M.D., Galang, JC M.D., De &Jia, T M.D. Philippine Heart Center, IA!ezen City, Philippines TI"E!re has been renewed 1nterest 1n the dia:J"l051S of p.JlllDHiry arterial hyper"t.ensien in ct..unic Obstructive F\.al1101ary Disease (a:PD) with the use of a 2-D Echo doppler. l'Z-1 patients met t.he criteria set by the Pmeru::an College of ctEst Physicians-Naticnal l-le.3rt, LLng and Blo::x1 Institute Natunal U:nfer-ence en Oxygen Therapy. SpironEtric and arterial blood go£. st.udies, CCillplete blood ccunt and 2D-EIHJ doppler were dcrlE! en admissien, 3, 6 and 12 months. Serial 11Jl11Dldry funcha1 test sto.ed no chanqe fran baseline. The time to peak velcx:ity and the right ventricular pre-ejecticr~ period en 2D ECHJ doppler impn:l\IE'd with Oxygen therapy (p<.OOl). The right ventricular ejectial pe..>rilld and mean p.Jlmonary pressure shewed a trend toward impruvement with lcn::J b..>rm oxygen therapy (LTITf). I he herrDglubin and hematocrit decreased significantly. F\.alsed doppler echcx:ard1ography may be used to predict the presence of p.JlllDlary hypel'"tensim and assess tro hE..'IIlOdynamic respmse t.u L mr.
180S
PULMONARY HYPERTENSION IN PATIENTS WITH SEVERE RESTRICTIVE LUNG DISEASE: INCIDENCE AND CLINICAL CHARACTERISTICS Jason M. Lazar, KA Johnson, J Start, EJ Lazar, FCCP. Winthrop University Hospital, Mineola, NY, University of Pittsburgh Medical Center, Pittsburgh, PA. Pulmonary hypertension (PH) occurs in number of pulmonary and cardiac disorders. Although studied in chronic obstructive pulmonary disease, PH has not been well characterized in patients with restrictive lung disease (RLD). Accordingly, the objective of this study was to determine the incidence and clinical features of PH in severe RLD. We studied 24 consecutive patients who were markedly symptomatic from idiopathic pulmonary fibrosis with a FVC<80% predicted and normal FEV1/FVC ratio. Patients with primary cardiac disease were excluded.. There were 14 males and 10 females, age 53±7 years.. Pulmonary artery systolic pressures (PASP) were assessed in 22 patients by right heart catheterization and by Doppler echocardiography in 2 others.. Resting left ventricular (LV) and right ventricular (RV) ejection fraction (EF) were assessed by radionuclide ventriculography . 12 patients had SPAP240mmHg (Group 1) and 12 others had SPAP<40mmHg (Group 2) . Clinical features, pulmonary function, LVEF and RV EF were compared between the 2 groups. The % predicted FVC, FEV1, and DLCO did not correlate with PASP.. Data are shown below: *p
Abstracts, CHEST 1995
Wednesday, November 1 BRONCHIAL HYPERREACTIVITY (BR) IN YOUNG PATIENTS NITH PULMONARY HYPERTENSION (PH) ADRIAN 0 1 Hl\GAN 1 STILLWELL PC 1 ARROLIGA AC 1 S''~ERBA R, MEHTA A, KIRBY T, PERL M, CCF Lung Transplant ream, Cleveland Clinic Foundation, Cleveland, :Jhio, USA. I?URPOSE: with PH.
To document BR in young patients (pts)
~ETHODS: The records of all pts (<30 yr) ref~rred for lung transplantation were reviewed; the charts of pts with PH, either Eisenmenger's or primary, were abstracted. Pts with other causes of PH were excluded. Reactivity was defined as a change in FEV1>15% or FEF25-75>25%. RESULTS: Of 637 pts referred from 1991 to 1994, 20 had PH: 14 had PPH and 6 had Eisenmenger's. The baseline PFT's showed restriction in 3, obstruction in 4, mixed pattern in 7, and 4 were normal. Pre/post bronchodilator values were available in 14: 7 had BR. Three pts required hospitalization for wheezing and dyspnea that responded to bronchodilators. One pt had a primary diagnosis of asthma for 10 years before Eisenmenger 1 s was found. There \'/as no correlation with PA pressures or Ca channel blocker response. CONCLUSION: Half of the young pts with PH had BR by pft 1 s; it was clinically significant in at jleast 3.
PERCliTANEOUS PULMONARY ENOOARTERIAL BIOPSY IN A HYPERTENSIVE CANINE MODEL USING A NEW CATHETER Abraham Rothman, *D. M. Mann, H. Movahed, P. Wolf, R. G. Konopka, P. G. Chiles, C. A. Pedersen, K. M. Moser. University of California and *Vascular BioSciences Co., San Diego, CA. Introduction. The study of pulmonary vascular diseases has been limited in part by the lack of a simple nonsurgical method to obtain arterial tissue samples. Methods. We tested a new biopsy catheter to obtain pulmonary endoarterial samples percutaneously in 20-30 kg dogs. Pulmonary hypertension was induced by repeated delivery of 0.6 to 0.9 mm ceramic microspheres in the superior vena cava. Biopsy samples were obtained at pulmonary artery systolic pressures ranging from normal to 100 mm Hg. The 7.9 F catheter consists of two sliding tubes; the inner one has a window that accomodates endoarterial tissue by means of a vacuum, the outer tube cuts the tissue when activated. Results. The catheter successfully retrieved endoarterial biopsy samples in > 90% of attempts. There were no significant complications from the procedure. Histologically, compared to normal endoarterial tissue, samples obtained from dogs with pulmonary hypertension showed neointimal and smooth muscle cellular proliferation, thick nuclei, lipid-laden macrophages, mucoid degeneration, and disorganized elastic laminae. Conclusions. The endoarterial biopsy catheter was safe and effective in obtaining pulmonary arterial tissue in normal and hypertensive dogs. The quality of the biopsy samples allowed histologic discrimination between normal and hypertensive .tissue. This catheter could be of aid in the study, diagnosis and management of pulmonary vascular diseases.
VARIABILITY IN THE RESPONSES TO CARDIOPULMONARY EXERCISE IN PRIMARY PULMONARY HYPERTENSION. Jonathan B Ore~s •. ~D, WC Moore, MD, FJ Martinez, MD (FCCP)*, LJ Rubin, MD (FCCP). D~v.ls!on of ;"'nlmonary & Critical Care, University of Maryland School of Med1cme, Ball!more, Maryland and *The University of Michigan School of Medicine, Ann Arbor, Michigan, USA. lntroduc~ion: Previous studie~ have suggested that patients with pulmonary ?ypert~ns1on (PH) have a spec1fic pattern of abnormal responses to exercise mcludmg a lo.w V02ma.:, low anaerobic threshold, low 02 pulse, high Vd/Vt, ~levated v~ntllator:r eqmvale!lts and normal breathing reserve. Most reports mclude palients w1th both pnmary and secondary PH of varying severity and many lack a measurement of concurrent right heart catheterization parameters. Methods: To better define the cardiopulmonary responses to exercise in severe ~NYHA. class 1~1 and IV) primary PH, we performed cardiopulmonary exercise tests With severe ~rimary PH with measurement of arterial blood gases at m 6 pa~ents rest, m1d, and peak exerc1se and arterial lactate each minute of exercise. Resting heart catheterization was performed within 24 hours of the exercise test. Results: Variable Mean+SE Range PA systolic (mm Hg) 83 ± 7.6 59-99 PA diastolic (mm Hg) 31 ± 3.6 20-38 PA mean (mm Hg) 49 ± 4.9 33-58 CO(mmHg) 4 ± 0.58 2.8-6 PVR (mm Hg/Umin) 12 ± 2.2 9-16 V02max (% pred) 55 ± 4.8 40-69 Watts max(% pred) 68 ± 14.2 29-110 AT(% pred V02max) 37 ± 4.5 24-52 02 pulse max(% pred) 67 ± 7.7 40-86 Breathing reserve(%) 26 ± 8.3 7-57 Vd/Vt max 0.3 ± 0.03 0.22-0.41 P(A-a)02 max (mm Hg) 67 ± 15.6 14-95 There was a significant correlation between Vd/Vt max and resting PA mean pressure (r=0.99, p=0.002) and between maximal work rate (Watts) and resting PA systolic pressure (r=0.82, p=0.03). Conclusion: I) Cardiopulmonary responses to exercise are variable in patients with ~rimary PH. 2) The classic findings of a low AT, high Vd/Vt and normal breathmg reserve are not present in all patients. 3) The absence of these findings does not exclude the presence of hemodynamically severe primary PH.
PSEUDONORMALIZATION OF RIGHT VENTRICULAR INFLOW IN PATIENTS WITH PULMONARY VASCULAR HYPERTENSION
Takeo Naito, H. lkawa, Y. Hirano, T. Sasaki, E. Enya, H. Uehara, Klshikawa, K.Takada*, N. Kawai* Y. Nagasaka, FCCP, R. Katori. Kinki University and Seikeikai Hospital*, Osaka, Japan
Introduction: Pseudonormalization(PN) pattern of RV inflow in patients with pulmonary vascular hypertension(PVH) is seen rarely, thus its clinical significance is unknown. Methods: The transthoratic echocardiography was performed in 19 patients(pts) with PVH. RV inflow parameters were measured using pulsed Doppler echocardiography from the four- chamber view. The sampling point was placed at the center of the RV inflow tract immediately below the tricuspid annulus. RA fractional area shortening (RAFAS) was calculated using two-dimentional echocardiography. Results: PN pattern(A/E<1.0) of RV inflow was observed in 3 pts out of 19 pts. Early _, E ....., A A/E .,, RAFAS filling(E)was increased " ~ " and atrial filling(A) was ~ decreased as ., • normal shown in the figure. ~ range In 2 pts, PN(-) • changed to PN(+) as indicated by arrows. RAFAS was decreased in patients with 0 PN group. (-l (+) '<-l (+) (-l (+) Conclusions: PN pattern was observed in 3 pts of PVH . A possible mechanism of PN of RV inflow may be due to a depressed RA contraction. CHEST I 108 I 3 I SEPTEMBER, 1995 I Supplement
181 S
Wednesday, November 1 Pulmonary Hypertension,
continued
PULMONARY HYPERTENSION AS A RISK FACTOR FOR HEMORRHAGE FROM TRANSBRONCHIAL BIOPSY Morris MJ, Peacock MD and Mego OM Brooke Army Medical Center, Ft Sam Houston, TX Pulmonary hypertension (PH) has been widely stated to be a contraindication to transbronchial biopsy (TBBX) due to the risk of uncontrolled hemorrhage. A prospective double-blinded analysis was performed to determine this risk in patients with latent PH undergoing TBBX . Patients with interstitial lung disease who were undergoing TBBX were included in the study if there was no clinical or radiographic evidence of PH. Prior to bronchoscopy, patients underwent an echocardiogram with Doppler flow imaging to determine pulmonary artery pressures and RAIRV chamber size. PH was defined as a systolic pulmonary artery pressure (PAP) of 30 mm Hg or greater or evidence of right-sided chamber enlargement if no PAP could be determined. Bleeding during TBBX was measured and blood loss was quantitated by comparison with the patient's known hematocrit. Blood loss was defined as 1) Minimal 0-10 ml; 2) Mild 11-25 ml; 3) Moderate 26-100 ml; and 4) Severe> 100 mi. 41 patients have been enrolled in the study. Results of echocardiograms and blood losses are as follows: Ayq Blood Loss Moderate MikJ. Minimal 2.15 ml 1 0 18 PH 2.01 ml 0 1 No PH 21 These data reveal latent PH was present in 46% of our patients undergoing TBBX for interstitial lung disease. There was no increase in bleeding complications in this group.
1825
Abstracts, CHEST 1995
UTILITY OF CHEST ROENTGENOGRAPY IN THE DIAGNOSIS OF PNEUMOCYSTIS CARINII PNEUMONIA (PCP) IN HIV-INFECTED INDIVIDUALS. hndrew Mcivor* MD. M Towers MB. P Webster MD. Sunnybrook Health Science Centre, U of Toronto. Introduction: Many investigators suggest empiric therapy against PCP for HIV infected individuals presenting with a typical chest x-ray, without bronchoscopy confirmation. Methods: We performed a retrospective assessment of the utility of chest X-rays, either alone or in combination with clinical and laboratory data to aid in the diagnosis of PCP. A chest physician and radiologist blinded to the outcomes reported a series of X-rays, using a visual analog scle to assess the likelihood of PCP (0 no PCP) before and after the clinical and laboratory data. Results: Of 38 consecutive HIV infected patients 92% male, mean age 40 yrs, 37% were positive for PCP on bronchoscopy, mean CD4 47 ± 37 cellsfmm3 and LDH 321 ± 190. The mean visual analog scale score for individuals PCP positive was 62 ± 32 which increased to 67 ± 33, with the addition of clinical information (p=0.04) compared to 34 ± 28 to 34 ± 33 (p=0.88) for PCP negative. Over all examination of the chest x-ray alone discriminated well between those with and without PCP (p=O.Ol4). Conclusion: Due to the high incidence of toxicity from anti-PCP medications and the potential for superimposed bacterial or viral infections not covered by some anti-PCP medications we still encourage bronchoscopic confirmation.
SIMILAR PULMONARY VASOACTIVE EFFECTS OF TOLAZQLINE AND CLONIDINE Tai-Shion Lee, X. Hou, Department of Anesthesiology Harbor-UCLA Medical Center, Torrance, CA, USA Six rings of isolated rabbit pulmonary artery (PA) with or without intact endothelium (E) were immersed in a 5 ml tissue bath containing a continuously oxygenated (95% 02/C02) Krebs solution at 370C and pH 7.4. After stabilization, the ring was either nonprecontracted or precontracted with norepinephrine (NE; 3x1Q-6M) or KCl (3x1Q-2M) alternately and the peak developed tension was recorded as the control. Then cumulative concentration response curves of tolazoline (TLZ) and clonidine (CND) were obtained. The changes were expressed as %of the control in mean + 5EM. Statistical analysis was perfonned using paired t-test. CI.ONII)!Ni: ANO 1 OIAZOIJNi: ON
~= =~~::;~~i
I~ ;•
.! I
CDIU:~~CUI-I
ON KCI PRECONTRACTED PULNONARY ARTEHY
I: -· _.- ~=~~ ~·=[U'I
LOG (Ill)
CJIICIZ.Cl.OiflDtNI:
'IJIWIGLE:'ftii.\ZOUNC
ON HE PRECOl'ITRACT£0 PULliOHARY ARTER't
i .: ·-,~~t
~ :: ~: : :
_.
~:
aatu:.~I.OG(~'I'OUZIIWI.I
With a tissue bath preparation, our study on isolated rabbit pulmonary artery has shown that CND and TLZ have similar dual vasoactive effects. Both produce dose-related vasoconstriction on non-pretreated and KCl pretreated PA rings, and vasodilation on NEprecontracted ones.
Pulmonary Hypertension 1 0:30 am - 11 :20 am fllllr 11\MEI\k: A!:H::S9'ENT IF 1-E"UDYJ\R'IIC EFFFI:TS £F l..fN:i TERM OXYff:N ~V I.EII\6 PI..LJ:£: ()(J·H.. ER ~~~
Ch.Ja,Jerl'"y Q. M.D., tiJaclarrama, ft'N M.D., O:ln..nia, R M.D., Galang, JC M.D., De &Jia, T M.D. Philippine Heart Center, IA!ezen City, Philippines TI"E!re has been renewed 1nterest 1n the dia:J"l051S of p.JlllDHiry arterial hyper"t.ensien in ct..unic Obstructive F\.al1101ary Disease (a:PD) with the use of a 2-D Echo doppler. l'Z-1 patients met t.he criteria set by the Pmeru::an College of ctEst Physicians-Naticnal l-le.3rt, LLng and Blo::x1 Institute Natunal U:nfer-ence en Oxygen Therapy. SpironEtric and arterial blood go£. st.udies, CCillplete blood ccunt and 2D-EIHJ doppler were dcrlE! en admissien, 3, 6 and 12 months. Serial 11Jl11Dldry funcha1 test sto.ed no chanqe fran baseline. The time to peak velcx:ity and the right ventricular pre-ejecticr~ period en 2D ECHJ doppler impn:l\IE'd with Oxygen therapy (p<.OOl). The right ventricular ejectial pe..>rilld and mean p.Jlmonary pressure shewed a trend toward impruvement with lcn::J b..>rm oxygen therapy (LTITf). I he herrDglubin and hematocrit decreased significantly. F\.alsed doppler echcx:ard1ography may be used to predict the presence of p.JlllDlary hypel'"tensim and assess tro hE..'IIlOdynamic respmse t.u L mr.
180S
PULMONARY HYPERTENSION IN PATIENTS WITH SEVERE RESTRICTIVE LUNG DISEASE: INCIDENCE AND CLINICAL CHARACTERISTICS Jason M. Lazar, KA Johnson, J Start, EJ Lazar, FCCP. Winthrop University Hospital, Mineola, NY, University of Pittsburgh Medical Center, Pittsburgh, PA. Pulmonary hypertension (PH) occurs in number of pulmonary and cardiac disorders. Although studied in chronic obstructive pulmonary disease, PH has not been well characterized in patients with restrictive lung disease (RLD). Accordingly, the objective of this study was to determine the incidence and clinical features of PH in severe RLD. We studied 24 consecutive patients who were markedly symptomatic from idiopathic pulmonary fibrosis with a FVC<80% predicted and normal FEV1/FVC ratio. Patients with primary cardiac disease were excluded.. There were 14 males and 10 females, age 53±7 years.. Pulmonary artery systolic pressures (PASP) were assessed in 22 patients by right heart catheterization and by Doppler echocardiography in 2 others.. Resting left ventricular (LV) and right ventricular (RV) ejection fraction (EF) were assessed by radionuclide ventriculography . 12 patients had SPAP240mmHg (Group 1) and 12 others had SPAP<40mmHg (Group 2) . Clinical features, pulmonary function, LVEF and RV EF were compared between the 2 groups. The % predicted FVC, FEV1, and DLCO did not correlate with PASP.. Data are shown below: *p
Abstracts, CHEST 1995
Wednesday, November 1 BRONCHIAL HYPERREACTIVITY (BR) IN YOUNG PATIENTS NITH PULMONARY HYPERTENSION (PH) ADRIAN 0 1 Hl\GAN 1 STILLWELL PC 1 ARROLIGA AC 1 S''~ERBA R, MEHTA A, KIRBY T, PERL M, CCF Lung Transplant ream, Cleveland Clinic Foundation, Cleveland, :Jhio, USA. I?URPOSE: with PH.
To document BR in young patients (pts)
~ETHODS: The records of all pts (<30 yr) ref~rred for lung transplantation were reviewed; the charts of pts with PH, either Eisenmenger's or primary, were abstracted. Pts with other causes of PH were excluded. Reactivity was defined as a change in FEV1>15% or FEF25-75>25%. RESULTS: Of 637 pts referred from 1991 to 1994, 20 had PH: 14 had PPH and 6 had Eisenmenger's. The baseline PFT's showed restriction in 3, obstruction in 4, mixed pattern in 7, and 4 were normal. Pre/post bronchodilator values were available in 14: 7 had BR. Three pts required hospitalization for wheezing and dyspnea that responded to bronchodilators. One pt had a primary diagnosis of asthma for 10 years before Eisenmenger 1 s was found. There \'/as no correlation with PA pressures or Ca channel blocker response. CONCLUSION: Half of the young pts with PH had BR by pft 1 s; it was clinically significant in at jleast 3.
PERCliTANEOUS PULMONARY ENOOARTERIAL BIOPSY IN A HYPERTENSIVE CANINE MODEL USING A NEW CATHETER Abraham Rothman, *D. M. Mann, H. Movahed, P. Wolf, R. G. Konopka, P. G. Chiles, C. A. Pedersen, K. M. Moser. University of California and *Vascular BioSciences Co., San Diego, CA. Introduction. The study of pulmonary vascular diseases has been limited in part by the lack of a simple nonsurgical method to obtain arterial tissue samples. Methods. We tested a new biopsy catheter to obtain pulmonary endoarterial samples percutaneously in 20-30 kg dogs. Pulmonary hypertension was induced by repeated delivery of 0.6 to 0.9 mm ceramic microspheres in the superior vena cava. Biopsy samples were obtained at pulmonary artery systolic pressures ranging from normal to 100 mm Hg. The 7.9 F catheter consists of two sliding tubes; the inner one has a window that accomodates endoarterial tissue by means of a vacuum, the outer tube cuts the tissue when activated. Results. The catheter successfully retrieved endoarterial biopsy samples in > 90% of attempts. There were no significant complications from the procedure. Histologically, compared to normal endoarterial tissue, samples obtained from dogs with pulmonary hypertension showed neointimal and smooth muscle cellular proliferation, thick nuclei, lipid-laden macrophages, mucoid degeneration, and disorganized elastic laminae. Conclusions. The endoarterial biopsy catheter was safe and effective in obtaining pulmonary arterial tissue in normal and hypertensive dogs. The quality of the biopsy samples allowed histologic discrimination between normal and hypertensive .tissue. This catheter could be of aid in the study, diagnosis and management of pulmonary vascular diseases.
VARIABILITY IN THE RESPONSES TO CARDIOPULMONARY EXERCISE IN PRIMARY PULMONARY HYPERTENSION. Jonathan B Ore~s •. ~D, WC Moore, MD, FJ Martinez, MD (FCCP)*, LJ Rubin, MD (FCCP). D~v.ls!on of ;"'nlmonary & Critical Care, University of Maryland School of Med1cme, Ball!more, Maryland and *The University of Michigan School of Medicine, Ann Arbor, Michigan, USA. lntroduc~ion: Previous studie~ have suggested that patients with pulmonary ?ypert~ns1on (PH) have a spec1fic pattern of abnormal responses to exercise mcludmg a lo.w V02ma.:, low anaerobic threshold, low 02 pulse, high Vd/Vt, ~levated v~ntllator:r eqmvale!lts and normal breathing reserve. Most reports mclude palients w1th both pnmary and secondary PH of varying severity and many lack a measurement of concurrent right heart catheterization parameters. Methods: To better define the cardiopulmonary responses to exercise in severe ~NYHA. class 1~1 and IV) primary PH, we performed cardiopulmonary exercise tests With severe ~rimary PH with measurement of arterial blood gases at m 6 pa~ents rest, m1d, and peak exerc1se and arterial lactate each minute of exercise. Resting heart catheterization was performed within 24 hours of the exercise test. Results: Variable Mean+SE Range PA systolic (mm Hg) 83 ± 7.6 59-99 PA diastolic (mm Hg) 31 ± 3.6 20-38 PA mean (mm Hg) 49 ± 4.9 33-58 CO(mmHg) 4 ± 0.58 2.8-6 PVR (mm Hg/Umin) 12 ± 2.2 9-16 V02max (% pred) 55 ± 4.8 40-69 Watts max(% pred) 68 ± 14.2 29-110 AT(% pred V02max) 37 ± 4.5 24-52 02 pulse max(% pred) 67 ± 7.7 40-86 Breathing reserve(%) 26 ± 8.3 7-57 Vd/Vt max 0.3 ± 0.03 0.22-0.41 P(A-a)02 max (mm Hg) 67 ± 15.6 14-95 There was a significant correlation between Vd/Vt max and resting PA mean pressure (r=0.99, p=0.002) and between maximal work rate (Watts) and resting PA systolic pressure (r=0.82, p=0.03). Conclusion: I) Cardiopulmonary responses to exercise are variable in patients with ~rimary PH. 2) The classic findings of a low AT, high Vd/Vt and normal breathmg reserve are not present in all patients. 3) The absence of these findings does not exclude the presence of hemodynamically severe primary PH.
PSEUDONORMALIZATION OF RIGHT VENTRICULAR INFLOW IN PATIENTS WITH PULMONARY VASCULAR HYPERTENSION
Takeo Naito, H. lkawa, Y. Hirano, T. Sasaki, E. Enya, H. Uehara, Klshikawa, K.Takada*, N. Kawai* Y. Nagasaka, FCCP, R. Katori. Kinki University and Seikeikai Hospital*, Osaka, Japan
Introduction: Pseudonormalization(PN) pattern of RV inflow in patients with pulmonary vascular hypertension(PVH) is seen rarely, thus its clinical significance is unknown. Methods: The transthoratic echocardiography was performed in 19 patients(pts) with PVH. RV inflow parameters were measured using pulsed Doppler echocardiography from the four- chamber view. The sampling point was placed at the center of the RV inflow tract immediately below the tricuspid annulus. RA fractional area shortening (RAFAS) was calculated using two-dimentional echocardiography. Results: PN pattern(A/E<1.0) of RV inflow was observed in 3 pts out of 19 pts. Early _, E ....., A A/E .,, RAFAS filling(E)was increased " ~ " and atrial filling(A) was ~ decreased as ., • normal shown in the figure. ~ range In 2 pts, PN(-) • changed to PN(+) as indicated by arrows. RAFAS was decreased in patients with 0 PN group. (-l (+) '<-l (+) (-l (+) Conclusions: PN pattern was observed in 3 pts of PVH . A possible mechanism of PN of RV inflow may be due to a depressed RA contraction. CHEST I 108 I 3 I SEPTEMBER, 1995 I Supplement
181 S
Wednesday, November 1 Pulmonary Hypertension,
continued
PULMONARY HYPERTENSION AS A RISK FACTOR FOR HEMORRHAGE FROM TRANSBRONCHIAL BIOPSY Morris MJ, Peacock MD and Mego OM Brooke Army Medical Center, Ft Sam Houston, TX Pulmonary hypertension (PH) has been widely stated to be a contraindication to transbronchial biopsy (TBBX) due to the risk of uncontrolled hemorrhage. A prospective double-blinded analysis was performed to determine this risk in patients with latent PH undergoing TBBX . Patients with interstitial lung disease who were undergoing TBBX were included in the study if there was no clinical or radiographic evidence of PH. Prior to bronchoscopy, patients underwent an echocardiogram with Doppler flow imaging to determine pulmonary artery pressures and RAIRV chamber size. PH was defined as a systolic pulmonary artery pressure (PAP) of 30 mm Hg or greater or evidence of right-sided chamber enlargement if no PAP could be determined. Bleeding during TBBX was measured and blood loss was quantitated by comparison with the patient's known hematocrit. Blood loss was defined as 1) Minimal 0-10 ml; 2) Mild 11-25 ml; 3) Moderate 26-100 ml; and 4) Severe> 100 mi. 41 patients have been enrolled in the study. Results of echocardiograms and blood losses are as follows: Ayq Blood Loss Moderate MikJ. Minimal 2.15 ml 1 0 18 PH 2.01 ml 0 1 No PH 21 These data reveal latent PH was present in 46% of our patients undergoing TBBX for interstitial lung disease. There was no increase in bleeding complications in this group.
1825
Abstracts, CHEST 1995