Improvement after bariatric surgery in chronic thromboembolic pulmonary hypertension: a novel treatment target

A 66-year-old man with a medical history significant for multiple pulmonary embolism and morbid obesity was evaluated for chronic thromboembolic pulmonary hypertension. Echocardiogram and right heart catheterisation were significant for severe pulmonary hypertension. Therefore, he was started on pulmonary hypertension medical therapy with riociguat and ambrisentan, in addition to anticoagulation. He experienced a dramatic clinical response to medical therapy. Despite haemodynamic improvement, the patient remained symptomatic with significant fatigue, exertional dyspnea and poor functional status as highlighted by a 6 min walk distance of only 128 m. Patient was referred for bariatric surgery with a gastric sleeve, after which he successfully lost 95 lbs in 6 months. Postoperative right heart catheterisation demonstrated normal pulmonary vascular resistance and cardiac output. His echocardiogram revealed normal right ventricular size and function. His 6 min walk distance also nearly quadrupled from 128 to 512 m, consistent with WHO Functional Class I.

Exercise Right Heart Catheterisation in Cardiovascular Diseases: A Guide to Interpretation and Considerations in the Management of Valvular Heart Disease

The use of exercise right heart catheterisation for the assessment of cardiovascular diseases has regained attention recently. Understanding physiologic haemodynamic exercise responses is key for the identification of abnormal haemodynamic patterns. Exercise total pulmonary resistance >3 Wood units identifies a deranged haemodynamic response and when total pulmonary resistance exceeds 3 Wood units, an exercise pulmonary artery wedge pressures/cardiac output slope >2 mmHg/l/min indicates the presence of underlying exercise-induced pulmonary hypertension related to left heart disease. In the evolving field of transcatheter interventions for valvular heart disease, exercise right heart catheterisation may objectively unmask symptoms and underlying haemodynamic abnormalities. Further studies are needed on the use of the procedure to inform the selection of patients who might receive the most benefit from transcatheter interventions for valvular heart diseases.

Chronisch-thromboembolische pulmonale Hypertonie: Strukturiertes körperliches Training nach pulmonaler Endarteriektomie

<b>Background:</b> Data on exercise training in chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary endarterectomy (PEA) as well as data on clinical and haemodynamic changes shortly after PEA are lacking. <b>Objective:</b> The objective of this prospective study was to analyse the safety, feasibility, and the effectiveness of combined supervised inpatient rehabilitation in patients with CTEPH directly after PEA. <b>Methods:</b> CTEPH patients started a 19-week rehabilitation program (3 weeks as inpatients and continued at home for another 16 weeks) with supervised exercise training as follow-up treatment shortly after PEA. Haemodynamics were assessed by right heart catheterisation before PEA and 22 weeks after PEA. Non-invasive assessments as transthoracic echocardiography and 6-min walking distance (6MWD) were performed before PEA and after 3 (that is, beginning of rehabilitation), 6, and 22 weeks following PEA. Adverse events were recorded throughout the study. <b>Results:</b> Forty-five CTEPH patients were included (49% female, 57.6 ± 12.4 years old, 60% WHO functional class III). Rehabilitation was started 3.3 ± 0.9 weeks after PEA. Exercise training was well tolerated in all patients without severe side effects. Haemodynamics measured by right heart catheterisation significantly improved from pre-PEA to 22 weeks post-PEA in cardiac output (+1.2 ± 1.5 L/min, 33.4%, <i>p</i> = 0.001) and mean pulmonary arterial pressure (-19 ± 13 mm Hg, –39.6%, <i>p</i> &#x3c; 0.0001). Right heart size measured by echocardiography, 6MWD, quality of life, and oxygen saturation significantly improved not only within the first 3 weeks after PEA but also during the following 19 weeks of exercise training. <b>Conclusions:</b> Supervised exercise training was feasible as early follow-up treatment after PEA. Further controlled studies are needed to discriminate the effects of PEA and early follow-up rehabilitation. <b>Trial Registration:</b> The study was registered at clinicaltrials.gov (NCT01393327) on July 13, 2011. The study start date was January 2010, and completion date was December 2013.

Abstract 14268: Responses to Exercise During Right Heart Catheterisation in Pulmonary Hypertension

Background: Hemodynamic changes during exercise at right heart catheterisation (RHC) may be a diagnostic and prognostic tool in pulmonary arterial hypertension (PAH). Method and Results: We retrospectively assessed the hemodynamic response to exercise during RHC of 138 patients with PAH secondary to idiopathic PAH (IPAH), connective tissue disease (CTD) or congenital heart disease (CHD). RHCs were performed at a single centre between 2007 and 2018. A submaximal comfort-based protocol on a reclined bicycle or straight leg raise test (SLRT) was employed. IPAH demonstrated the highest mean pulmonary artery pressure (mPAP) at rest, rising 47% with exercise, but a 66% rise in CO allowed pulmonary vascular resistance (PVR) to fall. Those with CTD demonstrated a 56% rise in mPAP, 70% rise in CO and PVR remained unchanged. In CHD, there was a 46% rise in mPAP, 49% rise in CO and a rise in PVR. Notably, there was a rise in pulmonary artery wedge pressure (PAWP) in all groups, most marked in those with IPAH. Total peripheral resistance (TPR), pulmonary artery compliance (PAC) and pulmonary artery elastance (Ea) changes were variable. TPR marginally decreased in IPAH patients, remained unchanged in those with CTD and increased in CHD. PAC decreased in all groups, with the lowest values observed in those with IPAH. Ea increased in all groups but was most notably higher in those with IPAH. Right ventricular stroke work index (RVSWI) increased in all patients, the lowest values before and after exercise were observed in the CTD cohort. Mean pulmonary artery pulsatility index (PaPi) increased in all groups, although was subtle and didn’t meet statistical significance for those with CTD and CHD. Conclusions: The hemodynamic response to exercise in patients with PAH differs between aetiologies. A rise in PAWP occurred in all groups, with ventricular interdependence a possible explanation. Whether there is a relationship between exercise hemodynamic changes and prognosis remains undetermined.