Pulmonary arterial hypertension confirmed by right heart catheterization following COVID-19 pneumonia: A case report and review of literature

BACKGROUND Pulmonary arterial hypertension(PAH)is a disease of the arterioles resulting in an increased resistance in pulmonary circulation with associated high pressures in the pulmonary arteries,causing irreversible remodeling of the pulmonary arterial walls.Coronavirus disease 2019(COVID-19)has been associated with development of new onset PAH in the literature leading to symptoms of dyspnea,cough and fatigue that persist in spite of resolution of acute COVID-19 infection.However,the majority of these cases of COVID related PAH were diagnosed using echocardiographic data or via right heart catheterization in mechanically ventilated patients.CASE SUMMARY Our case is the first reported case of COVID related PAH diagnosed by right heart catheterization in a non-mechanically ventilated patient.Right heart catheterization has been the gold standard for diagnosis of pulmonary hypertension.Our patient had right heart catheterization four months after her initial COVID-19 infection due to persistent dyspnea.CONCLUSION This revealed new onset PAH that developed following her infection with COVID-19,an emerging sequela of the infection.

Simultaneous ramp right heart catheterization and echocardiography in a Reliant Heart left ventricular assist device

Many clinicians caring for patients with continuous flow left ventricular assist devices(CF-LVAD) use ramp right heart catheterization(RHC) studies to optimize pump speed and also to troubleshoot CF-LVAD malfunction. An investigational device,the Reliant Heart Heart Assist 5(Houston,TX),provides the added benefit of an ultrasonic flow probe on the outflow graft that directly measures flow through the CF-LVAD. We performed a simultaneous ramp RHC and echocardiogram on a patient who received the above CF-LVAD to optimize pump parameters and investigate elevated flow through the CF-LVAD as measured by the flow probe. We found that the patient's hemodynamics were optimized at their baseline pump speed,and that the measured cardiac output via the Fick principle was lower than that measured by the flow probe. Right heart catheterization may be useful to investigate discrepancies between flow measured by a CF-LVAD and a patient's clinical presentation,particularly in investigational devices where little clinical experience exists. More data is needed to elucidate the correlation between the flow measured by an ultrasonic probe and cardiac output as measured by RHC.

Congenital heart“Challenges”in Down syndrome

In this editorial,we comment on the article by Kong et al published in the recent issue of the World Journal of Cardiology.In this interesting case,the authors present the challenges faced in managing a 13-year-old patient with Down syndrome(DS)and congenital heart disease(CHD)associated with pulmonary arterial hypertension.In this distinct population,the Authors underscore the need for early diagnosis and management as well as the need of a multidisciplinary approach for decision making.It seems that the occurrence of CHD in patients with DS adds layers of complexity to their clinical management.This editorial aims to provide a comprehensive overview of the intricate interplay between DS and congenital heart disorders,offering insights into the nuanced diagnostic and therapeutic considerations for physicians.

Hemodynamic parameters obtained by transthoracic echocardiography and right heart catheterization： a comparative study in patients with pulmonary hypertension

Background Hemodynamic evaluation is crucial for the management of patients with pulmonary hypertention. Clinicians often prefer a rapid and non-invasive method. This study aimed to examine the feasibility of transthoracic echocardiography for the measurements of hemodynamic parameters in patients with pulmonary hypertension. Methods A prospective single-center study was conducted among 42 patients with pulmonary hypertension caused by different diseases. Transthoracic echocardiography and right-heart catheterization were performed within 24 hours. Pulmonary artery systolic, diastolic and mean pressure （PASP, PADP and PAMP）, cardiac output （CO）, and pulmonary capillary wedge pressure （PCWP） were measured by both methods. A linear correlation and a Bland-Altman analysis were performed to compare the two groups of hemodynamic parameters. Results A good correlation was found between invasive and non-invasive measurements for PASP （r=0.96）, PADP （r=0.85）, PAMP （r=0.88）, CO （r=0.82）, and PCWP （r=0.81）. Further agreement analysis done by the Bland-Altman method showed that bias and a 95% confidence interval for PASP, PADP, and CO were clinically acceptable while great discrepancies existed for PAMP and PCWP. Conclusions The non-invasive measurements by PASP, PADP, and CO in patients with pulmonary hypertension correlate well with the invasive determinations. Transthoracic echocardiography （TTE） was inappropriate for estimating PCWP and PAMP.

Treatment with neurohormonal inhibitors and prognostic outcome in pulmonary arterial hypertension with risk factors for left heart disease

BACKGROUND Despite major advances in pharmacologic treatment,patients with pulmonary arterial hypertension(PAH)still have a considerably reduced life expectancy.In this context,chronic hyperactivity of the neurohormonal axis has been shown to be detrimental in PAH,thus providing novel insights on the role of neurohormonal blockade as a potential therapeutic target.AIM To evaluate the application and prognostic effect of neurohormonal inhibitors(NEUi)in a single-center sample of patients with idiopathic PAH and risk factors for left heart disease.METHODS We analyzed data retrospectively collected from our register of right heart catheterizations performed consecutively from January 1,2005 to October 31,2018.Patients on beta-blocker,angiotensin-converting enzyme inhibitor,angiotensin receptor blocker or mineralocorticoid receptor antagonist at the time of right heart catheterization were classified as NEUi users and compared to NEUi nonrecipients.RESULTS Complete data were available for 57 PAH subjects:27 of those(47.4%)were taking at least one NEUi at the time of right heart catheterization and were compared with the remaining 36 NEUi non-recipients.NEUi users were older and had a higher cardiovascular risk profile compared to non-recipients.Additionally,NEUi non-users had a higher probability of dying during the course of follow-up than NEUi recipients(56.7%vs 25.9%,log-rank P=0.020).CONCLUSION The above data highlighted a subgroup of patients with PAH and comorbidities for left heart disease in which NEUi use has shown to be associated with improved survival.Future prospective studies are needed to identify the most appropriate therapeutic strategies in this subset population.

Exercise Catheterization for Hemodynamic Evaluation of Adults with Coarctation of the Aorta

Background: Coarctation of the aorta (CoA) is associated with a generalized arteriopathy and long-term complicationsdespite repair. Data on invasive exercise hemodynamics in this population are lacking. Accordingly, wereviewed adults with CoA undergoing exercise catheterization to assess 1. hemodynamic profile;2. feasibilityfor assessment of CoA severity. Methods: Twenty patients undergoing exercise cardiac catheterization (12 armadduction and 8 supine cycle ergometry) at a quaternary care center between 2004 and 2021 were identified. Restingand exercise hemodynamic data were abstracted from the procedure logs. Results: Mean age was 43.6 ±12.0 years. Eleven patients (55%) had resting pulmonary arterial wedge pressure (PAWP) >15 mmHg;amongthose undergoing arterial catheterization, left ventricular end-diastolic pressure was >15 mmHg in 63%. Elevenpatients (55%) had pulmonary hypertension: 7 (35%) combined and 4 (20%) isolated post-capillary. At peak exercise,ΔPAWP/Δcardiac output (CO) ≥2 and Δmean pulmonary artery pressure/ΔCO ≥3 mmHg/l/min were foundin 7 (78%) and 6 (67%) patients, respectively;the composite of exercise PAWP ≥25 mmHg or ΔPAWP/ΔCO>2 was seen in 12 (86%). CoA peak-to-peak gradients at baseline (n = 14) and during exercise (n = 9) were 12(3–16) and 16 mmHg (9–28), respectively. Only 2 patients had an increase in CoA gradient to >20 mmHg withexercise. Conclusions: Diastolic dysfunction and pulmonary hypertension were highly prevalent, with exerciseunmasking abnormal diastolic and pulmonary vascular reserve in some individuals. Most patients failed to showsignificant increases in CoA peak-to-peak gradients with exercise. Further studies are warranted to establish thebest diagnostic method for CoA severity assessment.

Catheter ablation for atrial fibrillation in heart failure:untying the Gordian knot

Atrial fibrillation(AF) and heart failure(HF) are complex clinical entities that occur concomitantly in a significant population of patients, and their prevalence is rising in epidemic proportions. Traditionally, both rate and rhythm control strategies have been regarded as equivalent in the management of dysrhythmia in this AF-HF cohort with escalation of treatment largely guided by symptoms. Both disorders are involved in an elaborate pathophysiological interplay with shared cardiovascular risk factors that contribute to the development and sustenance of both AF and HF. Recent studies and continued development of evidence to support catheter ablation for AF has brought into question the traditional belief in equivalence between rate and rhythm control. Indeed, recent trials, in particular the CASTLE-AF(Catheter Ablation versus Standard Conventional Therapy in Patients with Left Ventricular Dysfunction and Atrial Fibrillation) study, suggest that catheter ablation for AF improves survival and rates of hospitalisation in patients with concomitant HF and AF, threatening a paradigm shift in the management of this patient cohort. The evident mortality benefit from clinical trials suggests that catheter ablation for AF should be considered as a therapeutic intervention in all suitable patients with the AF-HF syndrome as these patients may derive the greatest benefit from restoration of sinus rhythm. Further research is needed to refine the evidence base, especially to determine which subgroup of HF patients benefit most from catheter ablation and what is the optimal timing.

Migration of distal catheter of ventriculoperitoneal shunt into heart:report of 2 cases and review of literature

Objective To discuss the mechanism,clinical features,complications,diagnosis criteria and treatment of intracardiac migration of the distal catheter of ventriculoperitoneal shunt. Methods The diagnosis criteria and treatment of 2 cases of intracardiac migration of the distal catheter of

Prognostic value of coronary artery calcium score in patients with stable an-gina pectoris after percutaneous coronary intervention

Objectives To evaluate the prognostic value of the coronary artery calcium （CAC） score in patients with stable angina pectoris （SAP） who underwent percutaneous coronary intervention （PCI）. Methods A total of 334 consecutive patients with SAP who underwent first PCI following multi-slice computer tomography （MSCT） were enrolled from our institution between January 2007 and June 2012. The CAC score was calculated according to the standard Agatston calcium scoring algorithm. Complex PCI was defined as use of high pressure bal-loon, kissing balloon and/or rotablator. Procedure-related complications included dissection, occlusion, perforation, no/slow flow and emer-gency coronary artery bypass grafting. Main adverse cardiac events （MACE） were defined as a combined end point of death, non-fatal myo-cardial infarction, target lesion revascularization and rehospitalization for cardiac ischemic events. Results Patients with a CAC score〉300 （n=145） had significantly higher PCI complexity （13.1%vs. 5.8%, P=0.017） and rate of procedure-related complications （17.2%vs. 7.4%, P=0.005） than patients with a CAC score≤300 （n=189）. After a median follow-up of 22.5 months （4-72 months）, patients with a CAC score≤300 differ greatly than those patients with CAC score＆gt;300 in cumulative non-events survival rates （88.9 vs. 79.0%, Log rank 4.577, P=0.032）. After adjusted for other factors, the risk of MACE was significantly higher [hazard ratio （HR）：4.3, 95%confidence inter-val （95%CI）：2.4-8.2, P=0.038] in patients with a CAC score〉300 compared to patients with a lower CAC score. Conclusions The CAC score is an independent predictor for MACE in SAP patients who underwent PCI and indicates complexity of PCI and proce-dure-related complications.

Role of 2-dimensional Doppler echo-cardiography in screening portopulmonary hypertension in portal hypertension patients

BACKGROUND: Portopulmonary hypertension (PPH) is difficult to recognize in the early and middle stages because it is frequently asymptomatic. As right ventricular function is impaired in patients with moderate and severe PPH, any dramatic hemodynamic changes in liver transplantation or other procedures may result in death from pulmonary and cardiac events. In this study, we investigated the prevalence of PPH in patients with portal hypertension (PHT) mainly caused by hepatitis B virus, and evaluated the effect of 2-dimensional Doppler echocardiography (2D-ECHO) in screening for PPH. METHODS: One hundred and five PHT patients received transthoracic 2D-ECHO preoperatively, systolic pulmonary arterial pressure (SPAP, normal range <30 mmHg) and pulmonary acceleration time (PAT, normal range >= 120 msec) were measured to screen for PPH (positive result: SPAP >= 30 mmHg and/or PAT <100 msec). Subsequently, pulmonary hemodynamic parameters were measured by right heart catheterization (RHC) for definitive diagnosis of PPH. The results of the two methods were compared to assess the screening effect of 2D-ECHO. RESULTS: The prevalence of PPH in this study was 3.8% (4/105). About 90% (95/105) of patients had a detectable tricuspid regurgitation by 2D-ECHO and the mean SPAP was 27.7 +/- 5.9 mmHg. Twenty-two of these 95 patients had an SPAP >30 mmHg. The mean PAT of all patients was 140 23 msec and 5 were <100 msec. Twenty-two patients were screened out by 2D-ECHO and 4 were diagnosed by RHC. A positive significant correlation (r=0.55, P<0.01) was found between SPAP measured by 2D-ECHO and mean pulmonary artery pressure (MPAP) measured by RHC, and a weak but significant negative correlation (r=-0.27, P=0.005) existed between PAT and pulmonary vascular resistance (PVR). The sensitivity, specificity, agreement rate, positive predictive value and negative predictive value of the screening test were 100%, 82%, 83%, 18% and 100%, respectively. CONCLUSIONS: The prevalence of PPH in this study is lower than in Western countries. As a screening test, 2D-ECHO has very high sensitivity and negative predictive value. A negative test result can directly be used to exclude PPH, while a positive result should be confirmed by RHC.

The Changes of Left Ventricular Form and Function After Closure of Moderate-to Large-sized Patent Ductus Arteriosus Using Domestic-made Occluder

Objectives To evaluate the changes of the left ventricular form and function after closure of moderate- to large-sized patent ductus arteriosus （PDA） using domestic-made occluder. Methods 22 patients with PDA underwent procedure successfuly using the domestic-made occluder. The mean PDA minimal （pulmonary end） diameter by aortography was 8.01±2.47 mm （range 4 to 15.5mm）. All patients underwent transthoracic echocardiography （TTE） study before the procedure and the following 48 hours, 3 months after procedure. Results All patients had been implanted the domestic-made occluders successfully with no haematolysis, infective endocarditis, recanalization and other complications. At 3 months, mean LVED was decreased to 50.05±6.55 mm, compared to the pre-procedure （55.67 ±8.48 mm）, P 〈 0.01. After 48 hours of the procedure, mean LVEDD and LVESD decreased significantly （156.22± 51.40 mL vs. 121.28±35.73ml, 57.16±32.07 mL vs. 45.88±15.97 mL）, P〈 0.05. At 3 months, LVEDD decreased to 110.93 ±15.08ml, LVSV reached 73.50± 9.19 mL, compared to the pre-procedure, P 〈 0.01. LVESD decreased to 37.43±10.44 mL at 3 months, P〈 0.05. Conclusions Closuring of moderate- to largesized PDA using domestic-made occluder is effective and safe. After procedure, left ventricular form and function improved.

Comparative study of catheter-mediated gene transfer into heart

OBJECTIVE: To investigate the feasibility and features of 3 catheter-mediated approaches of gene transfer into heart, including direct myocardial injection (DMI), coronary artery perfusion (CAP), and intrapericardial cavity injection (ICI). METHODS: Fifteen dogs were used, and 0.3 ml (1 x 10(9) pfu) of an adenovirus (Adex1SR LacZ) was injected into the heart by 3 methods. The dogs were killed 5 days following injection, and gene expressions in heart and liver were evaluated by histochemical analysis. RESULTS: The results showed that (1) the CAP method was relatively less damaging and induced sparse LacZ expression in the myocardium, and the gene expression was also found in both vessels within the myocardium and liver; (2) gene transfer by DMI resulted in intense LacZ expression around the injection accompanied by a local inflammatory response; (3) LacZ expression elicited by ICI was detected in either the inner surface of the parietal pericardium or epicardial surface of the heart, and also in the myocardium underlying the visceral pericardium. CONCLUSION: Three catheter-mediated methods of gene transfer into the heart may be used and a reasonable approach should be chosen according to purpose.

Impact of Tricuspid Regurgitation Severity on Accuracy of Echocardiographic Estimation of Systolic Pulmonary Artery Pressure in Patients With Pulmonary Arterial Hypertension

Objective:This study aims to investigate the impact of tricuspid regurgitation(TR)severity on the accuracy of echocardiographic estimation of systolic pulmonary arterial pressure(sPAP)in patients with pulmonary arterial hypertension(PAH).Methods:Patients who were diagnosed with PAH and had a right heart catheterization(RHC)and echocardiography examination were selected retrospectively from May 2018 to December 2021.sPAP measured by RHC is used as the gold standard.A difference in sPAP of less than 10 mmHg between echocardiographic estimation by peak TR velocity and RHC measurement was defined as accurate,with a difference≥10 mmHg considered inaccurate.The factors affecting the accuracy of echocardiographic sPAP estimation were analyzed by univariate and multivariate analysis.Results:A total of 138 patients aged(45.57±15.97)years with PAH were enrolled.sPAP measured by echocardiography and RHC were(80.83±23.46)and(81.62±30.05)mmHg,respectively.The values of the 2 methods were highly correlated(r=0.809,P<0.01)and Bland-Altman plots showed good consistency.The accuracy rate of sPAP estimation by echocardiography was 42.03%(58/138).In the 57.97%(80/138)of patients where echocardiography was inaccurate,sPAP was overestimated in 28.26%(39/138)and underestimated in 29.71%(41/138).Univariate analysis showed that there was a statistically significant difference between the accurate and inaccurate groups in World Health Organization-Function Class,N-terminal pro-B-type natriuretic peptide,severity of TR,tricuspid annular plane systolic excursion(TAPSE),sPAP-RHC,mean pulmonary artery pressure,pulmonary vascular resistance(P<0.05).Multivariate logistic regression analyses identified the TR severity(odds ratio=2.292,95%confidence interval:1.126–4.667,P=0.022)and TAPSE(odds ratio=0.733,95%confidence interval:0.621–0.865,P<0.001)as independent predictors for the accuracy of echocardiographic sPAP estimation.Conclusion:Higher TR severity and lower TAPSE values reduce the accuracy of sPAP estimated by echocardiography.Therefore,TR severity and right heart function should be considered when echocardiography is used to estimate sPAP by the TR velocity.

Endocardial mapping and ablation of tachycardia guided by noncontact balloon catheter mapping system

Objective To describe a new noncontact balloon catheter mapping system and to assess the clinical utility of this system for guiding endocardial mapping and ablation of tachycardia.Methods Five patients with tachycardia underwent endocardial mapping and radiofrequency ablation using the noncontact balloon catheter mapping system. A 9 French, 64-electrode balloon catheter and a conventional 7 French electrode catheter for mapping and ablation were positioned in the same ventricular chamber. Ventricular three-dimensional geometry was established by the computerized mapping system. Using a boundary element inverse solution, 3360 virtual endocardial electrograms were computerized and used to derive isopotential maps. The earliest endocardial activation site, the exit site and the activation sequence of tachycardia or the critical isthmus of the reentry circuit were identified. Radiofrequency ablation with circular or linear lesion was performed at the target sites guided by the locator system.Results Six clinical types of tachycardia, 5 of which were ventricular tachycardia and one was concealed fasciculoventricular fiber mediated tachycardia, were induced by programmed stimulation. The mean cycle length of these tachycardias was 336.6±42.69 msec. The earliest activation site and the exit site of 5 mapped tachycardias were all identified using the system. One type of ventricular tachycardia was hemodynamically unstable and difficult to terminate, and could not be mapped. Among the 6 types of tachycardias, radiofrequency ablation was successful in 4. There was no complication during and after the procedure. During the mean follow-up of 6 months, no tachycardia recurred in the patients with a successful ablation.Conclusions The noncontact mapping system described in this study has advantage over conventional mapping techniques for refractory tachycardia. It is not only helpful for understanding the electrophysiologic mechanism of a complex case, but also suitable for mapping hemodynamically-intolerated and nonsustained ventricular tachycardia.

Initial experience of occluding special type patent ductus arterioses using the Amplatzer vascular plug

Background Occluders licensed for clinical use are not fit for some special Krichenko E patent ductus arterioses. The Amplatzer vascular plug I （AVP1） has not been licensed for use for closure of patent ductus arteriose. We report our initial experience to occluding special type patent ductus arterioses with the AVPI-a single lobe device of single layer Nitinol mesh for short vessel landing zones. Methods Patients referred with small and long Krichenko E patent ductus arterioses 1 mm to 3 mm in diameter underwent occlusion using AVPI. All cases underwent pre-, intra- and post-procedural echocardiography and chest X-ray at the completion of the procedure, the next day and at a 30-day, 3-month and 6-month follow-up visits. Device sizing for device waist diameter and length was based on aortography. Results From April 2008 to June 2012, 26 patients with a mean age of （7.6±8.0） years （range 6 months-32 years） and a mean weight of （23.8±14.8） kg （range 7-67 kg） underwent successful patent ductus arteriose closure. The mean ductus diameter was （2.1±0.7） mm （range 1-3 mm）. Transpulmonary （22/26） and transaortic approaches （4/26） were used. No persistent patency was observed after 24 hours and after one month. No device displacement, residual flow and iatrogenic coarctation of the aorta were observed after three months and six months. Conclusions The AVP1 makes it easy to close some Krichenko E patent ductus arterioses. Smaller delivery catheter profile and symmetric cylindrical device shape allow for use for small and long Krichenko E patent ductus arterioses 1 mm to 3 mm in diameter and small patients through transaortic approaches. Broader experience is required to further delineate device and patient selection as well as to document its long-term efficacy and safety.

Effect of prolonging interval time between coronary angiography and percutaneous coronary intervention on X-ray-induced DNA double-strand breaks in blood lymphocytes

Background It is desirable to minimize the risk of adverse radiation effects associated with percutaneous coronary intervention.The aim of this study was to determine the impact of prolonging the interval between coronary angiography and percutaneous coronary intervention on X-ray-induced DNA double-strand breaks in blood lymphocytes using γ-H2AX immunofluorescence microscopy.Methods Blood samples of eight patients were taken before the first exposure to ionizing radiation,10 minutes,20 minutes,30 minutes,1 hour,and 24 hours after the last exposure to determine the γ-H2AX foci repair kinetics.Fifty-eight patients undergoing percutaneous coronary intervention were randomized to an intermittent radiation exposure group and a continuous radiation exposure group.Blood samples were taken before coronary angiography and 15 minutes after the last exposure.By enumerating γ-H2AX foci,the impact of prolonging the interval on DNA double-strand breaks was investigated.Student t-test was used to compare the difference in DNA double-strand breaks between the two groups.Results An increase in foci was found in all patients received percutaneous coronary intervention.The maximum number of γ-H2AX foci was found 10-20 minutes after the end of the last exposure.There was no statistically significant difference between the two groups in γ-H2AX foci at baseline.On average there were （0.79±0.15） γ-H2AX foci induced by interventional X-rays per lymphocyte in the continuous radiation exposure group and （0.66±0.21） in the intermittent radiation exposure group after exposure （P〈0.05）.Conclusions A significant number of γ-H2AX foci develop following the percutaneous coronary intervention procedures.The number of X-ray-induced DNA double-strand breaks may be decreased by prolonging the interval time between coronary angiography and percutaneous coronary intervention to 30 minutes.