455 Haemodynamic prediction of primary graft dysfunction in lung transplant recipients

Abstract Aims Primary graft dysfunction (PGD) is a form of acute lung injury, that occurs after lung transplantation (LTx), characterized by pulmonary oedema and diffuse alveolar damage. Pulmonary hypertension is a well-known risk factor for PGD and some invasive and non-invasive studies showed an association between PGD and altered left heart filling pressure. Despite the cardiopulmonary haemodynamic seems to be mainly involved in the pathogenesis of PGD, no reliable predictive parameter has been demonstrated. The aim of our study is to test whether pulmonary arterial pressure and left diastolic function may be considered in the risk PGD stratification. Methods and results we retrospectively analyzed the results of right heart catheterization (RHC) performed in occasion of the assessment for the LTx eligibility. All patients have been assessed at the Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico of Milan (Italy) from 2006 to 2018. We included all form of respiratory diseases except for cystic fibrosis. PGD was defined as PaO2/FIO2 < 300, with infiltrates at 72 h after reperfusion. We grouped patients in two groups according to the PGD development or absence (PGD+ and PGD−). Ninety patients were analyzed (mean age 55 ± 10; 53 male). Bilateral LTx was performed in 57 cases (63%). The most frequent indications for LTx were Interstitial Lung Disease (38%), Idiopathic Pulmonary Fibrosis (32%) an COPD (16%). Mean pulmonary arterial pressure (mPAP 29.4 ± 11.5 mmHg vs. 24.2 ± 9.7 mmHg, P = 0.016) and PAWP (12.9 ± 4.3 mmHg vs. 10.4 ±.,8 mmHg, P = 0.012) values were significantly higher in the PGD+ than in the PGD− group as well as PAWP values. At the multivariate analysis, both mPAP and PAWP were independent risk factors for PGD development even adjusted for BMI, age, or indication for LTx (mPAP non-adjusted OR: 1.05, 95% CI: 1.01–1.10, P = 0.027; mPAP adjusted OR: 1.06, 95% CI: 1.00–1.12, P = 0.046; PAWP non-adjusted OR: 1.13, 95% CI: 1.02–1.25, P = 0.016; PAWP adjusted OR: 1.14, 95% CI: 1.01–1.29, P = 0.036). No difference was observed between pulmonary vascular resistance (PVR) values. After a sub analysis of the patients with PAWP ≥15 mmHg, we observed that the ratio between PVR and PAWP was significantly higher in the PGD + group (0.18 ± 0.11 vs. 0.09 ± 0.05, P = 0.036). Conclusion s our data confirmed that pulmonary circulation plays a crucial role in the prediction of PGD and elevated mPAP is the one of the main risk factors. Of note, despite in both group PAWP in was within normal values (<15 mmHg), it was determinant in the risk stratification for PGD development. We suppose that the increased PVR due to pulmonary parenchymal diseases may “mask” and “underestimate” the role of the left ventricular diastolic dysfunction creating a sort of vascular barrage witch is overcome after lung transplantation hesitating in pulmonary oedema. This hypothesis is corroborated by the significative difference of PVR/PAWP ratio that can select patients at risk for PGD.

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MO746CARDIAC REMODELING AND PULMONARY HYPERTENSION IN HEMODIALYSIS PATIENTS

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfab097.0026 ◽

2021 ◽

Vol 36 (Supplement_1) ◽

Author(s):

Ekaterina Borodulina ◽

Alexander M Shutov

Keyword(s):

Pulmonary Hypertension ◽

Left Ventricular Hypertrophy ◽

Arterial Pressure ◽

Ventricular Hypertrophy ◽

Pulmonary Arterial Pressure ◽

Hemodialysis Patients ◽

Left Ventricular ◽

Hemodialysis Treatment ◽

Systolic Pulmonary Arterial Pressure ◽

Pulmonary Arterial

Abstract Background and Aims An important predictor of cardiovascular mortality and morbidity in hemodialysis patients is left ventricular hypertrophy. Also, pulmonary hypertension is a risk factor for mortality and cardiovascular events in hemodialysis patients. The aim of this study was to investigate cardiac remodeling and the dynamics of pulmonary arterial pressure during a year-long hemodialysis treatment and to evaluate relationship between pulmonary arterial pressure and blood flow in arteriovenous fistula. Method Hemodialysis patients (n=88; 42 males, 46 females, mean age was 51.7±13.0 years) were studied. Echocardiography and Doppler echocardiography were performed in the beginning of hemodialysis treatment and after a year. Echocardiographic evaluation was carried out on the day after dialysis. Left ventricular mass index (LVMI) was calculated. Left ventricular ejection fraction (LVEF) was measured by the echocardiographic Simpson method. Arteriovenous fistula flow was determined by Doppler echocardiography. Pulmonary hypertension was diagnosed according to criteria of Guidelines for the diagnosis and treatment of pulmonary hypertension of the European Society of Cardiology. Results Pulmonary hypertension was diagnosed in 47 (53.4%) patients. Left ventricular hypertrophy was revealed in 71 (80.7%) patients. Only 2 (2.3%) patients had LVEF<50%. At the beginning of hemodialysis correlation was detected between systolic pulmonary arterial pressure and LVMI (r=0.52; P<0.001). Systolic pulmonary arterial pressure negatively correlated with left ventricular ejection fraction (r=-0.20; P=0.04). After a year of hemodialysis treatment LVMI decreased from 140.49±42.95 to 123.25±39.27 g/m2 (р=0.006) mainly due to a decrease in left ventricular end-diastolic dimension (from 50.23±6.48 to 45.13±5.24 mm, p=0.04) and systolic pulmonary arterial pressure decreased from 44.83±14.53 to 39.14±10.29 mmHg (р=0.002). Correlation wasn’t found between systolic pulmonary arterial pressure and arteriovenous fistula flow (r=0.17; p=0.4). Conclusion Pulmonary hypertension was diagnosed in half of patients at the beginning of hemodialysis treatment. Pulmonary hypertension in hemodialysis patients was associated with left ventricular hypertrophy, systolic left ventricular dysfunction. After a year-long hemodialysis treatment, a regress in left ventricular hypertrophy and a partial decrease in pulmonary arterial pressure were observed. There wasn’t correlation between arteriovenous fistula flow and systolic pulmonary arterial pressure.

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THE NATURAL HISTORY OF PULMONARY HYPERTENSION IN CHILDREN WITH VENTRICULAR SEPTAL DEFECTS ASSESSED BY SERIAL RIGHT-HEART CATHETERIZATION

PEDIATRICS ◽

10.1542/peds.27.4.621 ◽

1961 ◽

Vol 27 (4) ◽

pp. 621-626

Author(s):

Robert E. Stanton ◽

Donald C. Fyler

Keyword(s):

Natural History ◽

Arterial Pressure ◽

Pulmonary Arterial Pressure ◽

Clinical Status ◽

Right Heart Catheterization ◽

Heart Catheterization ◽

Ventricular Septal Defects ◽

Septal Defects ◽

History Of ◽

Pulmonary Arterial

The natural history of the pulmonary arterial pressure in 23 children with isolated ventricular septal defects has been evaluated by serial night heart catheterization. In none of the 23 patients was there a significant increase in pulmonary arterial pressure. Eight patients showed a significant decrease. The direction of shunts did not change between procedures, and the clinical status was stable. Our experience correlated well with the majority of institutions. It would appear that the natural course of pulmonary arterial pressure in ventricular septal defect is not commonly one of progressive rise.

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Primary Graft Dysfunction

Seminars in Respiratory and Critical Care Medicine ◽

10.1055/s-0041-1728794 ◽

2021 ◽

Vol 42 (03) ◽

pp. 368-379

Author(s):

Jake G. Natalini ◽

Joshua M. Diamond

Keyword(s):

Risk Factors ◽

Lung Transplantation ◽

Ex Vivo ◽

Significant Risk ◽

Subsequent Development ◽

Primary Graft Dysfunction ◽

Graft Dysfunction ◽

Donor Pool ◽

Ex Vivo Lung Perfusion ◽

Increased Risk

AbstractPrimary graft dysfunction (PGD) is a form of acute lung injury after transplantation characterized by hypoxemia and the development of alveolar infiltrates on chest radiograph that occurs within 72 hours of reperfusion. PGD is among the most common early complications following lung transplantation and significantly contributes to increased short-term morbidity and mortality. In addition, severe PGD has been associated with higher 90-day and 1-year mortality rates compared with absent or less severe PGD and is a significant risk factor for the subsequent development of chronic lung allograft dysfunction. The International Society for Heart and Lung Transplantation released updated consensus guidelines in 2017, defining grade 3 PGD, the most severe form, by the presence of alveolar infiltrates and a ratio of PaO2:FiO2 less than 200. Multiple donor-related, recipient-related, and perioperative risk factors for PGD have been identified, many of which are potentially modifiable. Consistently identified risk factors include donor tobacco and alcohol use; increased recipient body mass index; recipient history of pulmonary hypertension, sarcoidosis, or pulmonary fibrosis; single lung transplantation; and use of cardiopulmonary bypass, among others. Several cellular pathways have been implicated in the pathogenesis of PGD, thus presenting several possible therapeutic targets for preventing and treating PGD. Notably, use of ex vivo lung perfusion (EVLP) has become more widespread and offers a potential platform to safely investigate novel PGD treatments while expanding the lung donor pool. Even in the presence of significantly prolonged ischemic times, EVLP has not been associated with an increased risk for PGD.

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EFFECTS OF SUBLINGUAL NITROGLYCERIN ON PULMONARY ARTERIAL PRESSURE IN PATIENTS WITH LEFT VENTRICULAR FAILURE

Annals of Internal Medicine ◽

10.7326/0003-4819-50-1-34 ◽

1959 ◽

Vol 50 (1) ◽

pp. 34 ◽

Cited By ~ 40

Keyword(s):

Arterial Pressure ◽

Pulmonary Arterial Pressure ◽

Left Ventricular ◽

Left Ventricular Failure ◽

Sublingual Nitroglycerin ◽

Ventricular Failure ◽

Pulmonary Arterial

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Right ventricle performances with echocardiography and 99mTc myocardial perfusion imaging in pulmonary arterial hypertension patients

Experimental Biology and Medicine ◽

10.1177/1535370218775321 ◽

2018 ◽

Vol 243 (9) ◽

pp. 754-761

Author(s):

Jie Liu ◽

Lei Fei ◽

Guang-Qing Huang ◽

Xiao-Ke Shang ◽

Mei Liu ◽

...

Keyword(s):

Pulmonary Arterial Hypertension ◽

Myocardial Perfusion ◽

Arterial Pressure ◽

Right Ventricle ◽

Arterial Hypertension ◽

Pulmonary Arterial Pressure ◽

Right Heart Catheterization ◽

Heart Catheterization ◽

Mean Pulmonary Arterial Pressure ◽

Pulmonary Arterial

Right heart catheterization is commonly used to measure right ventricle hemodynamic parameters and is the gold standard for pulmonary arterial hypertension diagnosis; however, it is not suitable for patients’ long-term follow-up. Non-invasive echocardiography and nuclear medicine have been applied to measure right ventricle anatomy and function, but the guidelines for the usefulness of clinical parameters remain to be established. The goal of this study is to identify reliable clinical parameters of right ventricle function in pulmonary arterial hypertension patients and analyze the relationship of these clinical parameters with the disease severity of pulmonary arterial hypertension. In this study, 23 normal subjects and 23 pulmonary arterial hypertension patients were recruited from January 2015 to March 2016. Pulmonary arterial hypertension patients were classified into moderate and severe pulmonary arterial hypertension groups according to their mean pulmonary arterial pressure levels. All the subjects were subjected to physical examination, chest X-ray, 12-lead electrocardiogram, right heart catheterization, two-dimensional echocardiography, and technetium 99m (99mTc) myocardial perfusion imaging. Compared to normal subjects, the right heart catheterization indexes including right ventricle systolic pressure, right ventricle end diastolic pressure, pulmonary artery systolic pressure, pulmonary artery diastolic pressure, pulmonary vascular resistance, and right ventricle end systolic pressure increased in pulmonary arterial hypertension patients and were correlated with mean pulmonary arterial pressure levels. Echocardiography parameters, including tricuspid regurgitation peak velocity, tricuspid regurgitation pressure gradient, tricuspid annular plane systolic excursion and fractional area, right ventricle-myocardial performance index, were significantly associated with the mean pulmonary arterial pressure levels in pulmonary arterial hypertension patients. Furthermore, myocardial perfusion imaging was not observed in the normal subjects but in pulmonary arterial hypertension patients, especially severe pulmonary arterial hypertension subgroup, and showed potential diagnostic properties for pulmonary arterial hypertension. In conclusion, mean pulmonary arterial pressure levels are correlated with several right heart catheterization and echocardiography markers in pulmonary arterial hypertension patients; echocardiography and 99mTc myocardial perfusion can be used to evaluate right ventricle performance in pulmonary arterial hypertension patients. Impact statement In this study, we analyzed the clinical parameters for evaluating RV function, including right ventricle catheterization (RHC), echocardiography, and technetium 99m (99mTc) myocardial perfusion imaging (MPI) in normal Asian subjects and PAH patients ( n = 23 for each group). Our results demonstrated that six RHC indexes, four echocardiography indexes and MPI index were significantly altered in PAH patients and correlated with the levels of mean pulmonary arterial pressure. Importantly, we evaluated the diagnostic performance of MPI and found that MPI has a strong diagnostic accuracy in PAH patients. The findings from this study will be of interest to clinical investigators who make diagnosis and therapeutic strategies for PAH patients.

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Impact of the updated hemodynamic definitions on diagnosis rates of pulmonary hypertension

Pulmonary Circulation ◽

10.1177/2045894020931299 ◽

2020 ◽

Vol 10 (3) ◽

pp. 204589402093129

Author(s):

Seda Tanyeri ◽

Ozgur Y. Akbal ◽

Berhan Keskin ◽

Aykun Hakgor ◽

Ali Karagoz ◽

...

Keyword(s):

Pulmonary Hypertension ◽

Arterial Pressure ◽

European Society ◽

Pulmonary Arterial Pressure ◽

Heart Catheterization ◽

Mean Pulmonary Arterial Pressure ◽

Pressure Threshold ◽

Normal Mean ◽

Pulmonary Arterial ◽

European Society Of Cardiology

We evaluated whether updated pulmonary hypertension definitive criteria proposed in sixth World Symposium on Pulmonary Hypertension had an impact on diagnosis of overall pulmonary hypertension and pre-capillary and combined pre- and post-capillary phenotypes as compared to those in European Society of Cardiology/European Respiratory Society 2015 pulmonary hypertension Guidelines. Study group comprised the retrospectively evaluated 1300 patients (age 53.1 ± 18.8 years, female 807, 62.1%) who underwent right heart catheterization with different indications between 2006 and 2018. Mean pulmonary arterial pressure ≥25 mmHg (European Society of Cardiology) and PAMP (mean pulmonary arterial pressure) >20 mmHg (World Symposium on Pulmonary Hypertension) right heart catheterization definitions criteria were used, respectively. For pre-capillary pulmonary hypertension, pulmonary artery wedge pressure ≤15 mmHg and pulmonary vascular resistance ≥3 Wood units criteria were included in the both definitions. Normal mean pulmonary arterial pressure (<21 mmHg), borderline mean pulmonary arterial pressure elevation (21–24 mmHg), and overt pulmonary hypertension (≥25 mmHg) were documented in 21.1, 9.8, and 69.1% of the patients, respectively. The pre-capillary and combined pre- and post-capillary pulmonary hypertension were noted in 2.9 and 1.1%, 8.7 and 2.5%, and 34.6 and 36.6% of the patients with normal mean pulmonary arterial pressure, borderline, and overt pulmonary hypertension subgroups, respectively. The World Symposium on Pulmonary Hypertension versus European Society of Cardiology/European Respiratory Society definitions resulted in a net 9.8% increase in the diagnosis of overall pulmonary hypertension whereas increases in the pre-capillary pulmonary hypertension and combined pre- and post-capillary pulmonary hypertension diagnosis were only 0.8 and 0.3%, respectively. The re-definition of mean pulmonary arterial pressure threshold seems to increase the frequency of the overall pulmonary hypertension diagnosis. However, this increase was mainly originated from those in post-capillary pulmonary hypertension subgroup whereas its impact on pre-capillary and combined pre- and post-capillary pulmonary hypertension was negligible. Moreover, criteria of pre-capillary pulmonary vascular disease and combined pre- and post-capillary phenotypes were still detectable even in the presence of normal mean pulmonary arterial pressure. The obligatory criteria of pulmonary vascular resistance ≥3 Wood units seems to keep specificity for discrimination between pre-capillary versus post-C pulmonary hypertension after lowering the definitive mean pulmonary arterial pressure threshold to 20 mmHg.

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Clinical Risk Factors for Primary Graft Dysfunction after Lung Transplantation

American Journal of Respiratory and Critical Care Medicine ◽

10.1164/rccm.201210-1865oc ◽

2013 ◽

Vol 187 (5) ◽

pp. 527-534 ◽

Cited By ~ 297

Author(s):

Joshua M. Diamond ◽

James C. Lee ◽

Steven M. Kawut ◽

Rupal J. Shah ◽

A. Russell Localio ◽

...

Keyword(s):

Risk Factors ◽

Lung Transplantation ◽

Clinical Risk Factors ◽

Primary Graft Dysfunction ◽

Graft Dysfunction ◽

Clinical Risk

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A canine model of neurogenic pulmonary edema

Journal of Applied Physiology ◽

10.1152/jappl.1985.59.3.1019 ◽

1985 ◽

Vol 59 (3) ◽

pp. 1019-1025 ◽

Cited By ~ 18

Author(s):

M. B. Maron

Keyword(s):

Arterial Pressure ◽

Pulmonary Edema ◽

Pulmonary Arterial Pressure ◽

Canine Model ◽

Systemic Arterial Pressure ◽

Left Ventricular ◽

Neurogenic Pulmonary Edema ◽

Lung Water ◽

Pulmonary Arterial ◽

Alpha Chloralose

The purpose of this study was to evaluate the usefulness of the intracisternal administration of veratrine as a model of neurogenic pulmonary edema (NPE) in the alpha-chloralose-anesthetized dog. Veratrine (40–60 micrograms/kg) was injected into the cisterna magna of 17 animals, and systemic arterial, pulmonary arterial, and left ventricular end-diastolic (LVEDP) pressures were followed for 1 h. Eleven animals developed alveolar edema. In these animals, systemic arterial pressure increased to 273 +/- 9 (SE) Torr, pulmonary arterial pressure to 74.5 +/- 4.9 Torr, and LVEDP to 42.8 +/- 4.5 Torr, and large amounts of pink frothy fluid, with protein concentrations ranging from 48 to 93% of plasma, appeared in the airways. Postmortem extravascular lung water content (Qwl/dQl) averaged 7.30 +/- 0.46 g H2O/g dry lung wt. Six animals escaped developing this massive degree of edema after veratrine (Qwl/dQl = 4.45 +/- 0.24). These animals exhibited similar elevated systemic arterial pressures (268 +/- 15 Torr), but did not develop the degree of pulmonary hypertension (pulmonary arterial pressure = 52.5 +/- 6.7 Torr, LVEDP = 24.8 +/- 4.0 Torr) observed in the other group. These results suggest that both hemodynamic and permeability mechanisms may play a role in the development of this form of edema and that veratrine administration may provide a useful model of NPE.

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