Zhang Wei-hua

GW24-e0509 Increased Serum Bilirubin Levels Coincident With Pulmonary Hypertension due to Dilated Cardiomyopathy Assessed by Echocardiograhpy

Objectives The number of heart failure patients has been increasing steadily and it is thought to be one of the major public health problems. Dilated cardiomyopathy (DCM) is one of the main diseases that cause heart failure. Liver function is often abnormal in heart failure as a result of the accompanying hepatomegaly caused by the right heart failure. In the patients of chronic heart failure with acute decompensation, serum bilirubin increases which indicates severe congestion and low tissue perfusion. Systolic heart failure is an important manifestation of dilated cardiomyopathy (DCM), which could cause Group 2 pulmonary hypertension (PH), also PH due to left heart failure. Some studies demonstrated that hyperbilirubinemia is associated with advanced right heart failure and markedly reduced survival in patients with pulmonary aterial hypertension (PAH). There is few academic papers about serum bilirubin in the patients of Group 2 PH. The aim of this study was to analyse the difference of serum bilirubin in DCM patients with or without PH. Methods The patients of DCM with or without PH continuously admitted during January 2007 to December 2009 were studied which included 61 cases of DCM with PH and 51 cases of DCM without PH. PH was estimated by echocardiography which was defined by pressure gradient of tricuspid regurgitation more then 2.8 m/s and dimension of right ventricle outflow tract more then 25 mm. The clinical characteristic, heart function, echocardiography and serum total bilirubin and creatinine of the DCM patients were analysed. Results Compared to DCM without PH, no significantly difference of the sex, age, vital signs, combined diseases and arrhythmias was found, while the heart function was significantly malignant (p < 0.01), the left ventricle end-diastolic dimension, dimension of left atrium and right ventricle outflow tract were significantly dilated[(71.0 ± 9.62) mm vs (65.5 ± 7.17)mm; (52.8 ± 8.93) vs (43.9 ± 6.34)mm; (29.1 ± 5.30) mm vs (22.1 ± 3.30)mm, respectively p < 0.01], left ventricle ejective fraction was decreased [(0.281 ± 0.096) vs (0.362 ± 0.096), p < 0.01)], the incidence of pericardial effusion was increased (29/61 vs 7/51, p < 0.01), the serum total bilirubin was significantly increased [(45.3 ± 31.8)μmol/L vs (19.5 ± 9.08)μmol/L, p < 0.01] in the patients of DCM with PH. Conclusions For the patients of DCM with PH, the serum bilirubin level was increased which might indicate severe congestion and low tissue perfusion due to low cardiac output whereas the heart dilated much more with more malignant heart function.

GW24-e0444 Distinguish PVOD from PAH: Case Report and Review of Literature

Objectives Pulmonary veno-occlusive disease (PVOD) is a rare type of pulmonary hypertension, with similar clinical presentation to pulmonary arterial hypertension (PAH) but poorer prognosis and higher possibility to develop sever pulmonary oedema after specific PAH therapy, which have manifest the significance to distinguish PVOD from PAH for proper diagnose and clinical management. Methods We reported a 40-year-old male patient with a history of progressive dyspnea, fatigue, try cough, with a diagnosis of PAH confirmed elsewhere, was ultimately diagnosed as PVOD via non-invasive approaches—pulmonary function test (PFT), high-resolution CT scan of chest and bronchoalveolar lavage. In this paper, we also reviewed some published literature and discussed the differences between PVOD and PAH in all kinds of clinical aspects and highlighted the cautious application of PAH specific therapy strategy. Results The arterial blood gas analysis revealed severe hypoxemia (pH 7.47, PaCO2 30mm Hg, PaO2 53 mmHg and SO2 89% in room air). The pulmonary function testing identified no restrictive ventilatory defects (FEV1/FVC was 79.55%, VC 61.9% of predicted value) but a marked reduction in CO diffusion (DLCO was 35.8% of predicted value). The plasma level of N-terminal pro-brain natriuretic peptide (NT-proBNP) was 3180 pg/mL. The transthoracic echocardiography showed an enlarged right ventricle and atrium, moderate tricuspid regurgitation, bilateral pulmonary artery dilated and a small pericardial effusion. High-resolution computed tomography (HRCT) scan of the chest revealed interstitial oedema, enlarged lymph nodes in the mediastinum, few inflammation lesions on the superior lobe of left lung and the both main bronchi were compressed by the dilated pulmonary artery. CT pulmonary angiography showed dilated pulmonary arteries without embolism. The right heart catherization revealed mean pulmonary artery pressure as 57 mm Hg, and mean pulmonary capillary wedge pressure 14 mm Hg, showed as the pre-capillary pulmonary hypertension. The bronchoalveolar lavage confirmed occult alveolar haemorrhage by detecting hemosiderin-laden macrophages. Considering the risk of pulmonary oedema, the patient declined the specific PAH therapy. After treatment with warfarin (kept INR 2.0–3.0), diuretics, digtoxin and oxygen therapy, his symptoms improved in 3 months follow-up while ultimately died of right heart failure 18 months later. Conclusions This case justifies that PVOD should be taken into consideration when a PAH patient demonstrate remarkably low diffusing capacity of the lung for carbon monoxide (DLCO). The lung biopsy is the gold diagnostic standard, but usually not feasible. High-resolution CT scan and bronchoalveolar lavage are valuable for non-invasive approaches of PVOD which reveal the interstitial edema of the lungs and occult alveolar hemorrhage respectively in the patients with diagnosis of PAH and low diffusing capacity of the lung. Lung transplantation remains a feasible option of treatment. The specific therapies for PAH is cautiously recommended with extra attention to the possibility of developing pulmonary edema. Anticoagulation, diuretics and oxygen therapy merit evaluation.

CLINICAL OUTCOME OF TRANSCATHETER INTERVENTION THERAPY FOR COMBINED CONGENITAL CARDIAC DEFORMITIES IN THE SAME SESSION

Objectives To probe the safety and clinical results of percutaneous transcatheter intervention therapy in patients with combined congenital heart deformities in the same session. Methods Thirty patients (14 males and 16 females) with combined congenital heart deformities underwent simultaneous transcatheter intervention therapy, including 7 patients with atrial septal defect (ASD) and patent ductus arteriosus (PDA), 10 patients with ASD and ventricular septal defect (VSD), six patients with ASD and pulmonary stenosis (PS), 5 patients with ASD and PDA, 1 patient with PDA and PS, 1 patient with VSD, PDA and ASD. Their mean age was (17.9±13.5) years. Their mean weight was (38.8±22.0) kg. They underwent transcatheter therapy simultaneously with the sequential algorithm as balloon pulmonary valvuloplasty at first, followed by the occlusion of VSD, then the occlusion of PDA, then ASD, which can be adjusted depending on the circumstances. Follow-up with electrocardiogram (ECG) and transthoracie echocardiography (TTE) was undertaken 2 d, l m, 3 m, 6 m and 12 m after the procedures. Results 30 patients were treated successfully. In the 7 patients complicated with PS, the systolic pressure gradient across the pulmonary valve decreased from (46.1±15.1) mm Hg(1 mm Hg=0.133 kPa) to (17.6±3.8) mm Hg and the difference was significant(p<0.01). 1 patient showed incomplete right bundle branch block, one patient showed complete right bundle branch block and 1 patient showed incomplete left bundle branch block after intervention therapy, and ECG showed normal after treatment with dexamethasone. one patient with VSD and ASD, preoperative and 10 days after the procedure whose ECG showed Bifascicular block. The patient was given a permanent implanted cardiac pacemaker. Among two patients with VSD, a slight crevice shunt was detected after the procedure by TTE, they were detected disappearance of the crevice shunt by TTE at 6 months after the procedure. No patient encountered complications during follow-up. Conclusions Simultaneous transcatheter therapy of combined congenital heart deformities can obtain satisfactory effect by strict indication control and procedure manipulations.

INTERVENTIONAL THERAPY OF MULTIPLE ATRIAL SEPTAL DEFECTS

Objectives To evaluate the safety and efficiency of transactheter closure of multiple atrial septal defects. Methods A total of 10 patients (5 males and 5 females) with multiple atrial septal defects underwent transcatheter intervention therapy from October 2004 to January 2010. All the patients received transactheter closure of multiple atrial septal defects guided by X ray fluoroscopy and echocardiography by using Amplatzer septal occluder. Their mean age was (57.0±35.6) years. Their mean weight was (52.0±16.9) kg. Follow-up with electrocardiogram (ECG) and transthoracie echocardiography(TTE) was undertaken 2 d, l m, 3 m, 6 m and 12 m after the procedures Results Ten patients were treated successfully. One patient detected slight crevice shunt after the procedure by TTE, they were detected disappearance of the crevice shunt by TTE at 6 months after the procedure. No patient encountered complications during follow-up. Conclusions Transcatheter closure of multiple atrial septal defects is safe, effective and feasible.

CLINICAL ANALYSIS OF 15 CASES WITH PORTOPULMONARY HYPERTENSION IN ELDERLY PATIENTS

Objectives The aim of this study is to summarise the clinical features of PPH of the elderly patients with portal hypertension. Methods 15 patients with PPH including nine males and six females were includes in the study. Clinical features about Symptoms, physical examination findings and laboratory test results were evaluated. Results Dyspnoea was seen in 15 patients (100%), accentuated P2 in 10 patients (66.7%), systolic murmur of tricuspid area in 12 patients (80%), PaO2 <70 mm Hg in 15 patients (100%), with an average of (58.6±9.3) mm Hg. X-ray showed prominent pulmonary artery segment in 11 patients (73%), ECG with leads V1 R/S>1 in 9 patients (60%), echocardiography showed tricuspid regurgitation in 15 patients (100%), increase in right ventricular diameter of 10 patients (66.7%), right ventricular anterior wall thickening in 6 patients (40%). Child-Pugh Classification A of five cases, with an average of (64.4±8.1) mm Hg in PaO2 and (53.6±8.4) mm Hg in pulmonary arterial systolic pressure. Child-Pugh Classification B of three cases, with an average of (60.7±8.4) mm Hg in PaO2 and (68.3±12.6) mm Hg in pulmonary arterial systolic pressure. Child-Pugh Classification C of seven cases, with an average of (53.6±8.6) mm Hg in PaO2 and (75.7±16.4) mm Hg in pulmonary arterial systolic pressure. Conclusions Dyspnoea is an important clinical manifestation in PPH patients. Accentuated pulmonary second heart sound is the common features of pulmonary hypertension. X-ray, electrocardiogram could also show the increase of pulmonary arterial pressure. Our results suggest that the severity of PPH increases with lower blood oxygen pressure, as the liver function (Child Pugh classification higher) gets worse in elderly patients with portal hypertension.