Reduced pulmonary vascular reserve during stress echocardiography in confirmed pulmonary hypertension and patients at risk of overt pulmonary hypertension.
- 作者列表："Wierzbowska-Drabik K","Kasprzak JD","D Alto M","Ágoston G","Varga A","Ferrara F","Amor M","Ciampi Q","Bossone E","Picano E
:Noninvasive estimation of systolic pulmonary artery pressure (SPAP) during exercise stress echocardiography (ESE) is recommended for pulmonary hemodynamics evaluation but remains flow-dependent. Our aim was to assess the feasibility of pulmonary vascular reserve index (PVRI) estimation during ESE combining SPAP with cardiac output (CO) or exercise-time and compare its value in three group of patients: with invasively confirmed pulmonary hypertension (PH), at risk of PH development (PH risk) mainly with systemic sclerosis and in controls (C) without clinical risk factors for PH, age-matched with PH risk patients. We performed semisupine ESE in 171 subjects: 31 PH, 61 PH at risk and 50 controls as well as in 29 young, healthy normals. Rest and stress assessment included: tricuspid regurgitant flow velocity (TRV), pulmonary acceleration time (ACT), CO (Doppler-estimated). SPAP was calculated from TRV or ACT when TRV was not available. We estimated PVRI based on CO (peak CO/SPAP*0.1) or exercise-time (ESE time/SPAP*0.1). During stress, TRV was measurable in 44% patients ACT in 77%, either one in 95%. PVRI was feasible in 65% subjects with CO and 95% with exercise-time (p < 0.0001). PVRI was lower in PH compared to controls both for CO-based PVRI (group 1 = 1.0 ± 0.95 vs group 3 = 4.28 ± 2.3, p < 0.0001) or time-based PVRI estimation (0.66 ± 0.39 vs 3.95 ± 2.26, p < 0.0001). The proposed criteria for PH detection were for CO-based PVRI ≤ 1.29 and ESE-time based PVRI ≤ 1.0 and for PH risk ≤ 1.9 and ≤ 1.7 respectively. Noninvasive estimation of PVRI can be obtained in near all patients during ESE, without contrast administration, integrating TRV with ACT for SPAP assessment and using exercise time as a proxy of CO. These indices allow for comparison of pulmonary vascular dynamics in patients with varied exercise tolerance and clinical status.
: 运动负荷超声心动图 (ESE) 期间肺动脉收缩压 (SPAP) 的无创估计被推荐用于肺血流动力学评估，但仍然依赖于血流。我们的目的是评估在将SPAP和心输出量 (CO) 或运动时间相结合期间评估肺血管储备指数 (PVRI) 的可行性，并比较其在三组患者中的价值: 具有侵入性证实的肺动脉高压 (PH)，处于PH发展风险 (PH风险)主要与系统性硬化症和对照 (C) 没有PH的临床风险因素，与PH风险患者年龄匹配。我们在171名受试者中进行了半卧位ESE: 31名PH，61名PH风险和50名对照以及29名年轻健康的正常人。休息和压力评估包括: 三尖瓣反流血流速度 (TRV)，肺加速时间 (ACT)，CO (多普勒估计)。当TRV不可用时，根据TRV或ACT计算SPAP。我们基于CO (峰值CO/SPAP * 0.1) 或运动时间 (ESE时间/SPAP * 0.1) 估计PVRI。在应激期间，TRV在44% 例患者中是可测量的，在77% 例患者中是可测量的，在95% 例患者中是可测量的。PVRI在65% 例CO受试者和95% 例运动时间受试者中是可行的 (p <0.0001)。与对照组相比，PVRI的PH均较低，均基于CO的PVRI (组1 = 1.0 0.95 ± 4.28 2.3 vs组3 = 0.0001 ±，p < ) 或基于时间的PVRI估计 (0.66 ± 0.39 vs 3.95 ± 2.26，p <0.0001)。提出的PH检测标准分别为基于CO的pvri ≤ 1.29和基于ESE时间的pvri ≤ 1.0，PH风险 ≤ 1.9和 ≤ 1.7。在ESE期间，几乎所有患者都可以获得PVRI的无创估计，无需造影剂给药，将TRV与ACT整合用于SPAP评估，并使用运动时间作为CO的代表。这些指标允许比较具有不同运动耐量和临床状态的患者的肺血管动力学。
METHODS::We present the case of a 61-year-old woman with a large tumoral infiltration extending from the pelvis throughout the inferior vena cava inferior to the right atrium, protruding into the right ventricle and right ventricular outflow tract. She had been treated 10 years before for low-grade endometrial stromal sarcoma by hysterectomy and adnexectomy followed by hormone- and radio-therapy. Due to cancer recurrence, she underwent peritonectomy, appendectomy, and resection of terminal ileum.
METHODS:AIMS:Significant platelet activation after long stented coronary segments has been associated with periprocedural microvascular impairment and myonecrosis. In long lesions treated either with an everolimus-eluting bioresorbable vascular scaffold (BVS) or an everolimus-eluting stent (EES), we aimed to investigate (a) procedure-related microvascular impairment, and (b) the relationship of platelet activation with microvascular function and related myonecrosis. METHODS AND RESULTS:Patients (n=66) undergoing elective percutaneous coronary intervention (PCI) in long lesions were randomised 1:1 to either BVS or EES. The primary endpoint was the difference between groups in changes of pressure-derived corrected index of microvascular resistance (cIMR) after PCI. Periprocedural myonecrosis was assessed by high-sensitivity cardiac troponin T (hs-cTnT), platelet reactivity by high-sensitivity adenosine diphosphate (hs-ADP)-induced platelet reactivity with the Multiplate Analyzer. Post-dilatation was more frequent in the BVS group, with consequent longer procedure time. A significant difference was observed between the two groups in the primary endpoint of ΔcIMR (p=0.04). hs-ADP was not different between the groups at different time points. hs-cTnT significantly increased after PCI, without difference between the groups. CONCLUSIONS:In long lesions, BVS implantation is associated with significant acute reduction in IMR as compared with EES, with no significant interaction with platelet reactivity or periprocedural myonecrosis.
METHODS:BACKGROUND:Aortopulmonary window is an uncommon congenital heart disease, with untreated cases not surviving beyond childhood. However, very rarely it can present in adult patients with features of pulmonary hypertension. Clinically these patients cannot be differentiated from other more common conditions with left to right shunt. Transthoracic echocardiography if performed meticulously, can depict the defect in aortopulmonary septum. RESULTS:We report a case of large unrepaired aortopulmonary window in a 23 years old patient, diagnosed on transthoracic echocardiography.