Andrew D. Mihalek

Diastolic pulmonary gradient predicts outcomes in group 1 pulmonary hypertension (analysis of the NIH primary pulmonary hypertension registry).

BACKGROUNDnDiastolic pulmonary gradient (DPG), calculated as the difference between pulmonary artery diastolic pressure and mean pulmonary capillary wedge pressurexa0≥xa07xa0mmHg is associated with pulmonary vascular disease and portends poor prognosis in heart failure (HF). The prognostic relevance of DPG in group 1 pulmonary hypertension (PH) is uncertain.nnnMETHODSnUsing the Pulmonary Hypertension Connection (PHC) risk equation for 225 patients in the NIH-PPH, the 5-year probability of death was calculated, which was then compared with DPG using a Cox proportional hazards model. Kaplan-Meier survival curves were determined for two cohorts using the median DPG of 30xa0mmHg as cutoff, and significance was tested using the log-rank test.nnnRESULTSnThe mean age was 38.1xa0±xa016.0 years old, 63% female, and 72% were white. The mean DPG was 31.6xa0mmHgxa0±xa013.8xa0mm Hg and only 1.8% had a DPG <7xa0mm Hg. Increasing DPG was significantly associated with increased 5-year mortality even after adjustment for the PHC risk equation (HR 1.29 per 10xa0mm Hg increase). When DPG was dichotomized based on the median of 30xa0mm Hg, the HR for DPG >30xa0mm Hg with respect to 5-year mortality was 2.03. After adjustment for pulmonary artery systolic pressure (PASP), increasing DPG remained significantly associated with decreased 5 years survival (HR 1.99 for DPGxa0>xa030xa0mm Hg).nnnCONCLUSIONSnDPG is independently associated with survival in group 1xa0PH patients even after adjustment for the PHC risk equation or PASP. Patients with increased DPG had a 2-fold increased risk of mortality. The use of DPG for guiding treatment and prognosis in group 1xa0PH should be further investigated.

Haemodynamically Derived Pulmonary Artery Pulsatility Index Predicts Mortality in Pulmonary Arterial Hypertension

BACKGROUNDnPulmonary artery (PA) pulsitility index (PAPi) is a novel haemodynamic index shown to predict right ventricular failure in acute inferior myocardial infarction and post left ventricular assist device surgery. We hypothesised that PAPi calculated as [PA systolic pressure - PA diastolic pressure]/right atrial pressure (RAP) would be associated with mortality in the National Institutes of Health Registry for Primary Pulmonary Hypertension (NIH-RPPH).nnnMETHODSnThe impact of PAPi, the Pulmonary Hypertension Connection (PHC) risk score, right ventricular stroke work, pulmonary artery capacitance (PAC), other haemodynamic indices, and demographic characteristics was evaluated in 272 NIH-RPPH patients using multivariable Cox proportional hazards (CPH) regression and receiver operating characteristic (ROC) analysis.nnnRESULTSnIn the 272 patients (median age 37.7+/-15.9years, 63% female), the median PAPi was 5.8 (IQR 3.7-9.2). During 5years of follow-up, 51.8% of the patients died. Survival was markedly lower (32.8% during the first 3years) in PAPi quartile 1 compared with the remaining patients (58.5% over 3years in quartiles 2-4; p<0.0001). The best multivariable CPH survival model included PAPi, the PHC-Risk score, PAC, and body mass index (BMI). In this model, the adjusted hazard ratio for death with increasing PAPi was 0.946 (95% CI 0.905-0.989). The independent ROC areas for 5-year survival based on bivariable logistic regression for PAPi, BMI, PHC Risk, and PAC were 0.63, 0.62, 0.64, and 0.65, respectively (p<0.01). The ROC area for 5-year survival for the multivariable logistic model with all four covariates was 0.77 (p<0.0001).nnnCONCLUSIONSnPulmonary artery pulsatility index was independently associated with survival in PAH, highlighting the utility of PAPi in combination with other key measures for risk stratification in this population.

Increased Pulmonary-Systemic Pulse Pressure Ratio Is Associated With Increased Mortality in Group 1 Pulmonary Hypertension

BACKGROUNDnPulmonary arterial hypertension (PAH) is characterised by remodelling of the pulmonary vasculature leading to right ventricular (RV) failure. The failing RV, through interventricular uncoupling, deleteriously impacts the left ventricle and overall cardiac efficiency. We hypothesised that the ratio of the pulmonary artery pulse pressure to the systemic pulse pressure (pulmonary-systemic pulse pressure ratio, or PS-PPR) would be associated with mortality in PAH.nnnMETHODSnWe conducted a retrospective analysis of 262 patients in the National Institute of Health Primary Pulmonary Hypertension Registry (NIH-PPH). We evaluated the association between the PS-PPR and mortality after adjustment for the Pulmonary Hypertension Connection (PHC) risk equation.nnnRESULTSnAmong 262 patients (mean age 37.5±15.8years, 62.2% female), median PS-PPR was 1.04 (IQR 0.79-1.30). In the Cox proportional hazards regression model, each one unit increase in the PS-PPR was associated with more than a two-fold increase in mortality during follow-up (HR 2.06, 95% CI 1.40-3.02, p=0.0002), and this association of PS-PPR with mortality remained significant in the multivariable Cox model adjusted for the PHC risk equation, mean pulmonary artery pressure, and body mass index (BMI) (adjusted HR 1.81, 95% CI 1.13-2.88, p=0.01). Furthermore, PS-PPR in the upper quartile (>1.30) versus quartiles 1-3 was associated with a 68% increase in mortality after adjustment for these same covariates (adjusted HR 1.68, 95% CI 1.13-2.50, p=0.01).nnnCONCLUSIONSnPulmonary-systemic pulse pressure ratio, a marker of biventricular efficiency, is associated with survival in PAH even after adjustment for the PHC risk equation. Further studies are needed on the wider applications of PS-PPR in PAH patients.

Right atrial to left atrial volume index ratio is associated with increased mortality in patients with pulmonary hypertension

Pulmonary hypertension (PH) is characterized by increased pulmonary vascular resistance leading to right heart failure. Elevated right atrial (RA) pressure reflects right ventricular (RV) pressure overload and is an established risk factor for mortality in PH. We hypothesized that PH patients with an increased ratio of RA to LA volume index (RAVI/LAVI), would have increased mortality.

A case of massive hemoptysis following transesophageal echocardiogram

Introduction Tracheal intubation leading to injury of the airway is a rare complication of transesophageal echocardiography (TEE). Tracheal trauma is not a described complication of TEE, and safety literature for this procedure remains silent on the matter. We describe the case of a patient on systemic anticoagulation and antiplatelet therapy who underwent TEE and suffered massive hemoptysis requiring bronchial artery embolization (BAE). Case presentation An elderly patient was admitted to the hospital with recently diagnosed atrial fibrillation and shortness of breath. The patient underwent a TEE with successful synchronized cardioversion on hospital day #2. Later that day the patient experienced respiratory distress and hemoptysis and was intubated. Oropharyngeal and gastrointestinal sources of bleeding were excluded. A bronchoscopy revealed active bleeding from an ulceration in the bronchus intermedius (BI) of the right lung. A 7 French Arndt endobronchial blocker (Cook Medical, Bloomington, Indiana) was placed and anticoagulation reversed. Bleeding stopped for two days, but then returned on hospital day #5, requiring BAE to the right bronchial artery. The procedure was successful, the patient was successfully extubated, and was discharged over the next 10 days. Discussion Massive hemoptysis and respiratory compromise as a result of tracheal trauma is not described in the TEE literature. This patient proved to be a difficult esophageal intubation secondary to a newly discovered Zenkers diverticulum. The risk for bleeding in this patient was higher secondary to anticoagulation with warfarin and antiplatelet therapy with ticagrelor. As in all cases of massive hemoptysis, key aspects of care in this case involved localization of bleeding, reversal of anticoagulation, and definitive management such as BAE. Conclusions Tracheal trauma is not a described complication of TEE, but clinicians should be mindful of this possible complication in patients receiving anticoagulation. Typical management for massive hemoptysis was successful in this patient.

Decreased pulmonary arterial proportional pulse pressure is associated with increased mortality in group 1 pulmonary hypertension

This study evaluated the utility of a novel index, pulmonary arterial (PA) proportional pulse pressure (PAPP; range 0–1, defined as [PA systolic pressure – PA diastolic pressure] / PA systolic pressure), in predicting mortality in patients with World Health Organization group 1 pulmonary hypertension (PH).