Pulmonary – ABC CARDIOL

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Editorial

Electrocardiogram as a Predictor of Mortality in Individuals with Pulmonary Hypertension

Pulmonary hypertension (PH) is defined as mean pulmonary artery pressure greater than 20 mmHg in invasive assessment by right heart catheterization.^,

Guidelines suggest that patients with PH should be stratified according to their prognosis both at the time of diagnosis and throughout follow-up, with emphasis on clinical assessment by functional class, 6-minute walk test, and natriuretic peptide levels.

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Editorial

Transthoracic Echocardiography in Pulmonary Hypertension: Easy Tool, but Caution is Needed!

Hugo Hyung Bok Yoo

Screening high-risk individuals for pulmonary hypertension (PH) usually begins with transthoracic echocardiography (TTE) as the first-choice test for noninvasive pulmonary vascular hemodynamic status evaluation. Therefore, echocardiography can provide comprehensive information on heart morphology, ventricular function, and valve abnormalities.

Echocardiography is also a useful tool for estimating the systolic pulmonary arterial pressure (sPAP), right ventricular (RV), and right atrial (RA) pressures to assign an echocardiographic parameter of the probability of PH. Most often, the tricuspid regurgitation jet velocity (TRJV) is measured by TTE and, together with an estimate of the right atrial pressure (RAP) based on the inspiratory collapse and the size of the inferior vena cava, the TRJV jet is used to estimate the systolic pulmonary artery pressure (sPAP).

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Original Article

Correlation Between Echocardiographic and Hemodynamic Measurements in Right Atrium and Right Ventricle Assessments of Patients with Pulmonary Hypertension

Ana Tereza Azeredo Bastos Brito et al. João Batista Masson Silva Daniela do Carmo Rassi Daniela Graner Schuwartz Tannus Silva … Sandra Araújo Costa Diogo Sampaio de Oliveira Flavio de Souza Veiga Jardim Leandro Zacarias F. de Freitas Aguinaldo F. de Freitas Júnior Salvador Rassi

Abstract

Introduction

Pulmonary hypertension (PH), a serious clinical condition, can lead to right ventricular systolic dysfunction (RVSD) with prognostic implications. Patients with suspected PH should undergo transthoracic echocardiography (TTE) for diagnosis and evaluation as the main screening and follow-up exam.

Objective

To verify the associations of and agreement between measurements of mean pressure in the right atrium (RA) and RVSD with TTE

Method

Individuals diagnosed with PH were included. All patients underwent TTE and RCC. The following were evaluated by TTE: right atrial area (RAA), mean right atrial pressure through the diameter and collapsibility of the inferior vena cava (RMAPTTE), RA strain (RAS), tricuspid annular plane systolic excursion, fractional area change, RV free wall strain, and tricuspid s’ wave. Mean RA pressure (RMAPRCC) and cardiac index (CI) were evaluated through the RCC.

Results

Of the 16 patients, 13 were female. The mean patient age was 44.4 (±14.9) years. An association was found between RMAPRCC and AAD, RMAPTTE, and RAS (r=0.845, r=0.621, and r=-0.523, respectively; p<0.05). There was an association between the mortality risk categories measured by the RAA and RMAPRCC measures (X2=10.42; p=0.003), with moderate agreement (k=0.44; p=0.012). RVSDJ was present in 10 patients. There was an association between RVSD (present or absent) and CI (r=0.522; p=0.04) with moderate agreement (k=0.43; p=0.037).

Conclusion

The TTE and RCC measurements showed an association in the assessment of mean right atrial pressure, especially between RAA and RMAPRCC. An association with RVSD and moderate agreement between methods were also noted.

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My Approach To

My Approach To Echocardiographic Assessment In Pulmonary Hypertension

João Batista Masson-Silva et al. Cloves Geraldino da Silva Júnior

Echocardiographic assessment of PH probability

Echocardiographic PH probability can be classified as low, intermediate, or high. This categorization is based on the assessment of peak tricuspid regurgitation (TR) velocity and the presence of indirect signs suggestive of increased pulmonary vascular bed pressure ( ).^,

Peak TR velocity is the key criterion and should be measured by continuous-wave Doppler during smooth respiration according to the following recommendations:^{, –} ( ).

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Anatomopathological Session

Case 5/2017 – A 28-Year-Old Woman with Cor Pulmonale Due to Pulmonary Hypertension Secondary to Chronic Pulmonary Thromboembolism

Jussara de Almeida Bruno et al. Rafael Amorim Belo Nunes Paulo Sampaio Gutierrez Vera Demarchi Aiello

Clinical aspects

We report the case of a 28-year female patient denying any previous morbidity, who had acute PTE and progressively developed significant functional impairment and signs suggestive of chronic PTE during follow-up until death.

Venous thromboembolism (VTE) is the third most frequent cause of cardiovascular disease in the general population, with an annual incidence of 100 to 200 cases per 100000 inhabitants, acute PTE being its most severe clinical presentation. The prevalence and incidence of spontaneous VTE in young adults are low, but increase significantly in the presence of risk factors, such as oral contraception use, obesity and thrombophilia, especially in associations. The use of oral contraceptives, such as estrogens/progestogens, increases by 2 to 4 times the risk of venous thromboembolic events. Activated protein C resistance is attributed to a mechanism related to higher risk for VTE in patients on oral contraceptives. In our case, the patient had been on regular use of oral contraceptives until the first event, but there is no information on their formulation. Obesity is considered a risk factor, increasing by 2.4 times the risk for VTE in obese individuals as compared to non-obese individuals. When associating obesity and oral contraceptive use simultaneously, the risk for VTE increases by 10 times. Significant thrombophilias, such as deficiencies in protein C, protein S and antithrombin, homozygosity for factor V Leiden and prothrombin gene mutation increase in up to 7 times the risk for venous thromboembolic events in patients on oral contraceptives. During the patient’s follow-up, certain thrombophilias, such as prothrombin gene mutation, hyperhomocysteinemia and antiphospholipid syndrome, were excluded, but neither factor V Leiden nor deficiency in natural anticoagulants were investigated.

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Original Article

Hemodynamic Effects of Noninvasive Ventilation in Patients with Venocapillary Pulmonary Hypertension

André Moreira Bento et al. Luiz Francisco Cardoso Flávio Tarasoutchi Roney Orismar Sampaio … Luiz Junya Kajita Pedro Alves Lemos Neto

Background:

The hemodynamic effects of noninvasive ventilation with positive pressure in patients with pulmonary hypertension without left ventricular dysfunction are not clearly established.

Objectives:

Analyze the impact of increasing airway pressure with continuous positive airway pressure on hemodynamic parameters and, in particular, on cardiac output in patients with variable degrees of pulmonary hypertension.

Methods:

The study included 38 patients with pulmonary hypertension caused by mitral stenosis without left ventricular dysfunction or other significant valvulopathy. The hemodynamic state of these patients was analyzed in three conditions: baseline, after continuous positive pressure of 7 cmH₂O and, finally, after pressure of 14 cmH₂O.

Results:

The population was composed of predominantly young and female individuals with significant elevation in pulmonary arterial pressure (mean systolic pressure of 57 mmHg). Of all variables analyzed, only the right atrial pressure changed across the analyzed moments (from the baseline condition to the pressure of 14 cmH₂O there was a change from 8 ± 4 mmHg to 11 ± 3 mmHg, respectively, p = 0.031). Even though there was no variation in mean cardiac output, increased values in pulmonary artery pressure were associated with increased cardiac output. There was no harmful effect or other clinical instability associated with use application of airway pressure.

Conclusion:

In patients with venocapillary pulmonary hypertension without left ventricular dysfunction, cardiac output response was directly associated with the degree of pulmonary hypertension. The application of noninvasive ventilation did not cause complications directly related to the ventilation systems.

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Artigo Original

Experience with heterotopic heart transplantation in patients with elevated pulmonary vascular resistance: late follow-up

Jose Henrique Andrade Vila et al. José Pedro da Silva Luciana da Fonseca José Francisco Baumgratz … Américo Tangari Jr Weverton Ferreira Leite Claudia Jesus Guilhen Egas Armelin

BACKGROUND: Along the past few years the number of papers on heterotopic cardiac transplant has been very scarce in the medical literature, including at the international level; this is particularly true in reference to the long term follow-up of these patients and the reason which led to the presentation of our report. OBJECTIVE: To report the initial clinical experience and late evolution of 4 patients undergoing heterotopic heart transplantation, indications for this procedure and its major complications. METHODS: The surgeries were performed between 1992 and 2001, and all had as indication for heterotopic transplantation the PVR, which ranged from 4.8 WU to 6.5WU, with a transpulmonary gradient above 15mmHg. In the 3rd patient, a direct anastomosis between the pulmonary arteries was performed without the use of a prostetic tube, and a mitral valvuloplasty and a LV aneurysmectomy were performed in the native heart. The immediate immunosuppressive regimens were double, with cyclosporine and azathioprine in the first 3 patients, and cyclosporine and mycophenolate mofetil in the 4th patient. RESULTS: One immediate death occurred from graft failure, one death occurred after 2 ½ years, from endocarditis in an intraventricular thrombus in the native heart, and a third death occurred 6 years after transplantation, from post-operative complications of the aortic valve surgery in the native heart. The remaining patient is well, 15 years after the transplantation. This patient is in functional class II (NYHA), 6 years after a surgical occlusion of the native heart aortic valve. CONCLUSION: Heterotopic heart transplantation results are inferior to those of orthotopic heart transplantation because they present higher RVP. The intraventricular thrombi, in the native heart, which require prolonged anticoagulation, and aortic valve complications, also in the native heart, may require surgical treatment. However, a patient’s 15-year survival has demonstrated a long-term effectiveness of this option for selected patients.

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