Elisabete Jorge

Optical coherence tomography of the pulmonary arteries: A systematic review.

Optical coherence tomography (OCT) is an imaging technique extensively used for visualizing the coronary circulation, where it assists clinical decision-making. Along with the new interventional procedures being introduced for pulmonary vascular disease, there is an increasing need for intravascular imaging of the pulmonary arteries. Additionally, measurements of the wall thickness of the pulmonary arteries of patients with various types of pulmonary hypertension (PH) may provide relevant diagnostic and prognostic information. The aim of this review is to summarize all the available evidence on the use of OCT for imaging the pulmonary bed and to describe a simple protocol for OCT image acquisition. We conducted a systematic review of the literature using electronic reference databases through February 2015 (MEDLINE, Cochrane Library, Web of Knowledge, and references cited in other studies) and the search terms optical coherence tomography, pulmonary hypertension, and pulmonary arteries. Studies in which OCT was used to image the pulmonary vessels were considered for inclusion. We identified 14 studies reporting OCT imaging data from the pulmonary arteries. OCT was able to identify intravascular thrombi in patients with chronic thromboembolic PH (CTEPH), and an increase in vessel wall thickness was found in most patients with PH, compared with the controls. OCT has also been reported to be useful for the selection of balloon size in the setting of balloon pulmonary angioplasty for CTEPH. The main limitations include lack of standardization, little data on outcomes, cost, and the technical limitations involved in visualizing small-diameter (<1mm) pulmonary vessels. OCT has become a potential tool for the in vivo study of vascular changes in the pulmonary arteries, and may provide additional information in the assessment of patients with PH. Prospective high-quality studies assessing the safety, validity, and clinical impact of OCT imaging for pulmonary vessels are warranted.

Prognostic implications of left ventricular end-diastolic pressure in acute coronary syndromes with left ventricular ejection fraction of 40% or over

Abstract Introduction There is still debate concerning the impact of left ventricular end-diastolic pressure (LVEDP) on long-term prognosis after an acute coronary syndrome (ACS). Objective To assess LVEDP and its prognostic implications in ACS patients with left ventricular ejection fraction (LVEF) ≥40%. Methods We performed a prospective, longitudinal study of 1329 ACS patients from a single center between 2004 and 2006. LVEDP was assessed at the beginning of the coronary angiogram. Patients with LVEF >40% were included (nxa0=xa0489). The population was divided into three groups: A — LVEDP ≤19xa0mmHg (nxa0=xa0186); B — LVEDP >19 and ≤27xa0mmHg (nxa0=xa0172); and C — LVEDP >27xa0mmHg (nxa0=xa0131). The primary endpoint of the analysis was readmission for congestive heart failure in the year following the index admission. Results Mean LVEDP was 22.8xa0±xa07.8xa0mmHg. The groups were similar age, gender, cardiovascular risk factors, cardiovascular history, and medication prior to admission. There was an association between higher LVEDP and: admission for ST-elevation acute myocardial infarction (35.4 vs. 45.9 vs. 56.7%, pxa0 Conclusion In selected population LVEDP was a significant prognostic marker of future admission for congestive heart failure.

Predictors of Very Late Events After Percutaneous Mitral Valvuloplasty in Patients With Mitral Stenosis

Data on long-term outcomes of percutaneous mitral valvuloplasty (PMV) are still scarce. In addition, the persistence of pulmonary hypertension (PH) after PMV is a complication for which mechanisms and prognostic implications are unclear. Our aims were (1) to report the long-term outcomes of patients with rheumatic mitral stenosis treated with PMV; (2) to determine the risk factors for long-term poor outcomes; and (3) to analyze the prevalence and predictors of persistent PH. We prospectively enrolled 532 patients who underwent PMV from 1987 to 2011 at 2 hospitals. The following end points were assessed after PMV: all-cause mortality, mitral reintervention, a composite end point of all-cause mortality and mitral reintervention, and PH persistence. Survival status was available for 97% patients; the median follow-up was 10xa0years (interquartile range 4 to 18xa0years). Procedural success was achieved in 85% patients. During the follow-up, 21% patients died and 27% required mitral reintervention. Before PMV, 74% patients had PH that persisted after PMV in 45% of patients (p <0.001). Unfavorable valve anatomy (Wilkins score >8) and post-PMV mean pulmonary arterial pressure (PAP) were independent predictors of all-cause mortality, mitral reintervention, and the composite end point. Post-PMV mean PAP was significantly correlated with a mitral valve area (MVA) <2.5xa0cm(2) (p <0.001); in addition, on the echocardiographic follow-up, MVA was an independent predictor of systolic PAP (p <0.001). In conclusion, PMV represents an advantageous therapeutic option for patients with mitral stenosis in terms of long-term outcomes. Unfavorable valve anatomy and persistent PH were the most important predictors of long-term outcomes. The persistence of PH is associated with the MVA obtained after PMV.

Pulmonary Hypertension in Mitral Stenosis: An Optical Coherence Tomography Study

A 65-year old woman with a prior history of surgical mitral comissurotomy 30 years ago presented with a 6-month history of worsening fatigue and exertional dyspnea. On physical examination, she had a mitral stenosis murmur, a loud P2, with an irregular pulse and mild peripheral edema. The electrocardiogram showed atrial fibrillation; the echocardiogram was notable for a fibro-calcified mitral valve, with severe restriction of leaflet mobility and an area of 1.1 cm. Biventricular function was normal. As the valve anatomy was considered suitable for percutaneous intervention, the patient was scheduled a balloon valvuloplasty. The pre-intervention right heart catheterization showed a pulmonary artery pressure of 45/17/29 mmHg. After successful mitral dilatation, optical coherence tomography (LightLab Imaging Inc., Westford, Massachusetts, United States) was performed on a distal segmental branch of the right pulmonary artery (Fig. 1). Optical coherence tomography images showed diffuse thickening of the distal pulmonary arterial wall (Figs. 2 and 3). We registered a pulmonary artery wall thickness between 0.28 mm and 0.31 mm, higher when compared to reports from subjects without pulmonary hypertension (0.16 [0.03] mm for vessels with 2.14 [0.33] mm of diameter). No complications arose during or after the procedure. Optical coherence tomography is a safe and potentially useful tool for characterize, with high resolution, the pulmonary vessels and may contribute to investigate the mechanisms of vascular remodeling in pulmonary hypertension.

Implicações prognósticas da pressão telediastólica do ventrículo esquerdo nas síndromes coronárias agudas com fracção de ejecção maior ou igual a 40

INTRODUCTIONnThere is still debate concerning the impact of left ventricular end-diastolic pressure (LVEDP) on long-term prognosis after an acute coronary syndrome (ACS).nnnOBJECTIVEnTo assess LVEDP and its prognostic implications in ACS patients with left ventricular ejection fraction (LVEF) ≥40%.nnnMETHODSnWe performed a prospective, longitudinal study of 1329 ACS patients from a single center between 2004 and 2006. LVEDP was assessed at the beginning of the coronary angiogram. Patients with LVEF >40% were excluded (n=489). The population was divided into three groups: A - LVEDP ≤19 mmHg (n=186); B - LVEDP >19 and ≤27 mmHg (n=172); and C - LVEDP >27 mmHg (n=131). The primary endpoint of the analysis was readmission for congestive heart failure in the year following the index admission.nnnRESULTSnMean LVEDP was 22.8±7.8 mmHg. The groups were similar age, gender, cardiovascular risk factors, cardiovascular history, and medication prior to admission. There was an association between higher LVEDP and: admission for ST-elevation acute myocardial infarction (35.4 vs. 45.9 vs. 56.7%, p<0.01), higher peak levels of cardiac biomarkers, and lower LVEF (56.5±7.0 vs. 55.3±7.6 vs. 53.0±7.5%, p<0.01). There were no significant differences between the groups in terms of coronary anatomy, medical therapy during hospital stay and at discharge, or in-hospital mortality. With regard to the primary endpoint, cumulative freedom from congestive heart failure was higher in group A patients (99.4 vs. 97.6 vs. 94.4%, log rank p=0.02). In a multivariate Cox regression model, a 5-mmHg increase in LVEDP (HR 1.97, 95% CI 1.10-3.54, p=0.02) remained an independent predictor of the primary endpoint when adjusted for age, systolic function, atrial fibrillation, peak troponin I, renal function, and prescription of diuretics and beta-blockers.nnnCONCLUSIONnIn selected population LVEDP was a significant prognostic marker of future admission for congestive heart failure.Resumo Introducao Permanecem duvidas sobre o impacto prognostico a longo prazo da pressao telediastolica do ventriculo esquerdo (PTDVE) no contexto de uma sindrome coronaria aguda (SCA). Objectivo Caracterizar a PTDVE e o seu impacto prognostico numa populacao de doentes com SCA e fraccao de ejeccao ventricular esquerda (FEVE) ≥ a 40%. Populacao e metodos Estudo prospectivo, longitudinal e continuo de 1329 doentes admitidos (nxa0=xa0489) numa unidade de cuidados intensivos coronarios entre 2004 e 2006. Foram seleccionados os doentes submetidos a uma estrategia invasiva, no qual foi determinada a PTDVE, com FEVE ≥ 40%. A populacao foi divida em tres grupos: A — PTDVE ≤ 19xa0mmHg (nxa0=xa0186); grupo B — PTDVE > 19 ≤ 27xa0mmHg (nxa0=xa0172) e; grupo C — PTDVE > 27xa0mmHg (nxa0=xa0131). O resultado primario desta analise foi a readmissao por insuficiencia cardiaca congestiva (ICC) no ano seguinte a SCA. Resultados A PTDVE media da populacao foi de 22,8xa0mmHgxa0±xa07,8 mmHg. Os grupos eram homogeneos entre si no que disse respeito ao genero, idade, factores de risco cardiovascular, historia cardiovascular e medicacao previa a admissao. Quanto maior a PTDVE maior a probabilidade de uma admissao por enfarte agudo do miocardio com supradesnivelamento do segmento ST (35,4 versus 45,9 versus 56,7%, pxa0 Conclusao Na populacao referida a PTDVE teve um impacto prognostico importante a longo prazo relativamente a readmissao, hospitalar por ICC.