PPV May Be a Starting Point to Achieve Circulatory Protective Mechanical Ventilation

Pulse pressure variation (PPV) is a mandatory index for hemodynamic monitoring during mechanical ventilation. The changes in pleural pressure (Ppl) and transpulmonary pressure (PL) caused by mechanical ventilation are the basis for PPV and lead to the effect of blood flow. If the state of hypovolemia exists, the effect of the increased Ppl during mechanical ventilation on the right ventricular preload will mainly affect the cardiac output, resulting in a positive PPV. However, PL is more influenced by the change in alveolar pressure, which produces an increase in right heart overload, resulting in high PPV. In particular, if spontaneous breathing is strong, the transvascular pressure will be extremely high, which may lead to the promotion of alveolar flooding and increased RV flow. Asynchronous breathing and mediastinal swing may damage the pulmonary circulation and right heart function. Therefore, according to the principle of PPV, a high PPV can be incorporated into the whole respiratory treatment process to monitor the mechanical ventilation cycle damage/protection regardless of the controlled ventilation or spontaneous breathing. Through the monitoring of PPV, the circulation-protective ventilation can be guided at bedside in real time by PPV.

The effect of levosimendan on right ventricular function in patients with heart dysfunction: a systematic review and meta-analysis

Levosimendan exerts positive inotropic and vasodilatory effects. Currently, its effects on right heart function remain uncertain. This systematic review and meta-analysis is intended to illustrate the impacts of levosimendan on systolic function of the right heart in patients with heart dysfunction. We systematically searched electronic databases (PubMed, the Cochrane Library, Embase and Web of Science) up to November 30, 2020, and filtered eligible studies that reported the impacts of levosimendan on right heart function. Of these, only studies whose patients suffered from heart dysfunction or pulmonary hypertension were included. Additionally, patients were divided into two groups (given levosimendan or not) in the initial research. Then, RevMan5.3 was used to conduct further analysis. A total of 8 studies comprising 390 patients were included. The results showed that after 24 h of levosimendan, patients’ right ventricular fractional area change [3.17, 95% CI (2.03, 4.32), P < 0.00001], tricuspid annular plane systolic excursion [1.26, 95% CI (0.35, 2.16), P = 0.007] and tricuspid annular peak systolic velocity [0.86, 95% CI (0.41, 1.32), P = 0.0002] were significantly increased compared to the control group. And there is an increasing trend of cardiac output in levosimendan group [1.06, 95% CI (− 0.16, 2.29), P = 0.09 ] .Furthermore, patients’ systolic pulmonary arterial pressure [− 5.57, 95% CI (− 7.60, − 3.54), P < 0.00001] and mean pulmonary arterial pressure [− 1.01, 95% CI (− 1.64, − 0.37), P = 0.002] were both significantly decreased, whereas changes in pulmonary vascular resistance [− 55.88, 95% CI (− 206.57, 94.82), P = 0.47] were not significant. Our study shows that in patients with heart dysfunction, levosimendan improves systolic function of the right heart and decreases the pressure of the pulmonary artery.

Risk stratification and survival in patients after liver transplantation: the role of right heart function and dimension

Background Liver transplantation (LTx) is often the only treatment strategy in patients with advanced liver disease. Since the donor pool is limited, careful preoperative examination of the cardiac functional status is crucial. Especially the presence of pulmonary hypertension (PH) either coincidental or as part of porto-pulmonary hypertension (PoPHT) is known to play a prognostic role in post-transplant survival and graft durability. However, right heart function itself may play a role even in the absence of PH. Purpose We retrospectively evaluated right heart function data acquired during transthoracic echocardiography (TTE) in the evaluation process for LTx listing to identify patient populations at risk for poor long-term prognosis. Methods We performed a single-center retrospective cohort study of patients that underwent LTx between 2011 and 2020. All patients ultimately underwent LTx; Survival data were assessed at 90 days, 1 year and 3 years. The waiting period from time of cardiac assessment to the actual operation was blinded. We evaluated right heart end-diastolic diameter (RVEDd), tricuspid annular plane systolic excursion (TAPSE), as well as right atrial area (RAA). We pre-specified cut-offs for abnormal values with RVEDd above 39 mm, TAPSE below 18 mm and RAA above 16 cm2. Results We evaluated 351 patients who underwent LTx. 247 data sets were complete and could be included in the primary analysis (mean age 56.3±10.3 years, 75.7% male). Patients had a median Lab-MELD-Score of 14 points (IQR: 10–21 points). 23.8% of patients received a living donor transplant. The left ventricular ejection fraction was not compromised in any of the subjects (mean LVEF: 68.6±9.0%). The median waiting time in days between TTE and LTx was 142 days (IQR: 37–434 days) The primary end-point of mortality occurred in 44 or 17.8% of patients over a Period of three years. In univariate Cox-regression the pre specified cut-offs for TAPSE and RAA were not associated with a statistically significant survival (HR 0.663, CI: 0.33–1.33, p: 0.25). However, univariate analysis revealed that increased RVEDd was associated with post-LTx survival (HR 1.98, CI: 1.09–3.58, p=0.025) as well as Log-Rank (Mantel-Cox) in the Kaplan-Meier-estimate (Chi2: 5.25, p:0.022). In multivariable analysis including several laboratory values as well as the Lab-Meld-Score (Figure 2), RVEDd group remained the only significant parameter predicting mortality (HR 2.12, CI: 1.02–4.41, p=0.04). The Kaplan Meier analysis showed a significant difference in survival at 3 years of follow-up. Combining right ventricle parameters in a secondary analysis did not provide any additional benefit in predicting survival Conclusion Analysis of right heart function and especially dilatation was able to provide additional information concerning long-term outcome post-LTx in this retrospective analysis even when taking into consideration that moderate to severe PH or PoPHT was ruled out beforehand. FUNDunding Acknowledgement Type of funding sources: None.

Sex Differences, Estrogen Metabolism and Signaling in the Development of Pulmonary Arterial Hypertension

Pulmonary arterial hypertension (PAH) is a complex and devastating disease with a poor long-term prognosis. While women are at increased risk for developing PAH, they exhibit superior right heart function and higher survival rates than men. Susceptibility to disease risk in PAH has been attributed, in part, to estrogen signaling. In contrast to potential pathological influences of estrogen in patients, studies of animal models reveal estrogen demonstrates protective effects in PAH. Consistent with this latter observation, an ovariectomy in female rats appears to aggravate the condition. This discrepancy between observations from patients and animal models is often called the “estrogen paradox.” Further, the tissue-specific interactions between estrogen, its metabolites and receptors in PAH and right heart function remain complex; nonetheless, these relationships are essential to characterize to better understand PAH pathophysiology and to potentially develop novel therapeutic and curative targets. In this review, we explore estrogen-mediated mechanisms that may further explain this paradox by summarizing published literature related to: (1) the synthesis and catabolism of estrogen; (2) activity and functions of the various estrogen receptors; (3) the multiple modalities of estrogen signaling in cells; and (4) the role of estrogen and its diverse metabolites on the susceptibility to, and progression of, PAH as well as their impact on right heart function.

Evaluation of the Therapeutic Effect of Pulmonary Embolism by CT Pulmonary Angiography Combined With Clinical Indexes

Background To evaluate the value of CT pulmonary angiography (CTPA) in evaluating the therapeutic efficacy of pulmonary embolism (PE) through the study of CT pulmonary artery obstruction index (PAOI),right ventricular function parameters and some clinical indexes related to coagulation function and cardiac function injury.Materials and methods Select 30 patients with pulmonary embolism who underwent CTPA examination before and after treatment in our hospital, sort out their CTPA images before and after treatment, and obtain PAOI and right heart function parameters, including ascending aorta diameter (AAd), main pulmonary artery diameter (MPAd), ratio of main pulmonary artery diameter to ascending aorta diameter (MPAd/AAd), right pulmonary artery trunk diameter (RPAd), left pulmonary artery trunk diameter (LPAd), the ratio of the maximum short axis diameter of the right ventricle to the maximum short axis diameter of the left ventricle (RVd/LVd), and calculate the pulmonary artery obstruction index (PAOI).At the same time obtain the required clinical indicators, including serum D-dimer, N-terminal B-type natriuretic peptide precursor (NT-proBNP), cardiac troponin I (cTnI), myocardial enzyme profile (aspartate aminotransferase (AST), lactate dehydrogenase (LDH), creatine kinase (CK)).Results MPAd, RPAd, LPAd, RVd / LVd, PAOI, D-dimer, cTnI, CK, LDH, AST had significant changes after treatment (P < 0.05), while the other parameters and indexes had no significant differences before and after treatment (P > 0.05). PAOI is positively correlated with RVd/LVd, MPAd, D-dimer. The correlation coefficient ranges from 0.281 to 0.423, among which, the correlation with D-dimer is the closest, with a correlation coefficient of 0.423. There was no significant correlation between other parameters and PAOI (P < 0.05).Conclusion CTPA is of great significance in evaluating the severity of pulmonary embolism, right heart function and therapeutic efficacy.

Evaluation of the Therapeutic Effect of Pulmonary Embolism by CT Pulmonary Angiography Combined With Clinical Indexes

BackgroundTo evaluate the value of CT pulmonary angiography (CTPA) in evaluating the therapeutic efficacy of pulmonary embolism (PE) through the study of CT pulmonary artery obstruction index (PAOI), right ventricular function parameters and some clinical indexes related to coagulation function and cardiac function injury.Materials and methodsSelect 30 patients with pulmonary embolism who underwent CTPA examination before and after treatment in our hospital, sort out their CTPA images before and after treatment, and obtain PAOI and right heart function parameters, including ascending aorta diameter (AAd), main pulmonary artery diameter (MPAd), ratio of main pulmonary artery diameter to ascending aorta diameter (MPAd/AAd), right pulmonary artery trunk diameter (RPAd), left pulmonary artery trunk diameter (LPAd), the ratio of the maximum short axis diameter of the right ventricle to the maximum short axis diameter of the left ventricle (RVd/LVd), and calculate the pulmonary artery obstruction index (PAOI).At the same time obtain the required clinical indicators, including serum D-dimer, N-terminal B-type natriuretic peptide precursor (NT-proBNP), cardiac troponin I (cTnI), myocardial enzyme profile (aspartate aminotransferase (AST), lactate dehydrogenase (LDH), creatine kinase (CK)).ResultsMPAd, RPAd,LPAd,RVd / LVd, PAOI, D-dimer, cTnI, CK, LDH, AST had significant changes after treatment (P < 0.05), while the other parameters and indexes had no significant differences before and after treatment (P > 0.05). PAOI is positively correlated with RVd/LVd, MPAd, D-dimer. The correlation coefficient ranges from 0.281 to 0.423, among which, the correlation with D-dimer is the closest, with a correlation coefficient of 0.423. There was no significant correlation between other parameters and PAOI (P < 0.05).ConclusionCTPA is of great significance in evaluating the severity of pulmonary embolism, right heart function and therapeutic efficacy.