Right-heart contrast echocardiography reveals missed patent ductus arteriosus in a postpartum woman with pulmonary embolism: A case report

BACKGROUND As an established,simple,inexpensive,and surprisingly effective diagnostic tool,right-heart contrast echocardiography(RHCE)might help in solving a vexing diagnostic problem.If performed appropriately and interpreted logically,RHCE allows for differentiation of various usual and unusual right-to-left shunts based on the site of injection and the sequence of microbubble appearance in the heart.CASE SUMMARY A 31-year-old woman was readmitted to hospital with a 2-mo history of worsening palpitation and chest distress.Two years prior,she had been diagnosed with postpartum pulmonary embolism by conventional echocardiography and computed tomography angiography.While the latter showed no sign of pulmonary artery embolism,the former showed pulmonary artery hypertension,moderate insufficiency,and mild stenosis of the aortic valve.RHCE showed microbubbles appearing in the left ventricle,slightly delayed after rightheart filling with microbubbles;no microbubbles appeared in the left atrium and microbubbles’appearance in the descending aorta occurred nearly simultaneous to right pulmonary artery filling with microbubbles.Conventional echocardiography was re-performed,and an arterial horizontal bidirectional shunt was found according to Doppler enhancement effects caused by microbubbles.The original computed tomography angiography findings were reviewed and found to show a patent ductus arteriosus.CONCLUSION RHCE shows a special imaging sequence for unexplained pulmonary artery hypertension with aortic valve insufficiency and simultaneous patent ductus arteriosus.

Transthoracic echocardiography assists appropriate pulmonary artery catheter placement: An observational study

AIM: To investigate the utility of transthoracic echocardiography in confirming appropriate pulmonary artery catheter(PAC) placement. METHODS: Three commonly used transthoracic echocardiography(TTE) views were used to confirm PAC position in 103 patients undergoing elective cardiac surgery- the parasternal short axis right ventricular inflow-outflow view; the subcostal short axis right ventricular inflow-outflow view; and the parasternal short axis ascending aortic view. All PACs were inserted by the managing anesthesiologist under pressure waveform guidance alone, who was blinded to all sonographic information. A sonographer blinded to all pressure waveform information confirmed visualisation of an "empty" PA before PAC insertion, and visualisation of the PAC balloon in the main PA(MPA) or right PA(RPA) after attempts at placement were complete. Agreement, sensitivity and specificity of TTE in confirming appropriate PAC placement was compared against pressure waveformguidance as the "gold standard". The successful view used was compared against patients' anthropomorphic indices, presence of lung hyperinflation, and insertion of PAC during positive pressure ventilation. Agreement between TTE and pressure waveform guidance was analysed using Cohen's Kappa statistic. The relative proportion of total RPA seen by subcostal vs parasternal TTE views was also compared with a further 20 patients' computed tomography(CT) pulmonary angiograms(CTPA), to determine efficacy in detection of distal RPA PAC placement. RESULTS: Appropriate positioning of the PAC balloon, and its to-and-fro movement consistent with a nonwedged state, within the MPA or RPA was confirmed by TTE in 98 of the 103 patients [sensitivity 95%(95%CI: 89%-98%)], and absence of the PAC balloon before insertion correctly established in 100 patients [specificity 97%(92%-99%)]. This was in very good agreement with pressure waveform guidance [Cohen's Kappa 0.92,(0.87-0.98)]. The subcostal view was the best view to visualise the PAC tip when it was placed in the right pulmonary artery(OR 70, P < 0.0001), was more successful in patients with COAD(OR 9.5, P = 0.001), and visualized 61%(vs 44% by parasternal views, P < 0.001) of mean RPA lengths compared with CTPA; however the parasternal views were more successful in patients with higher body mass indexs(OR 0.78 for success with subcostal views, P < 0.001). There was a trend towards insertion during intermittent positive pressure ventilation favoring visualisation by subcostal views(OR 3.9, P = 0.08). The subcostal view visualized a greater length of the RPA than parasternal views(3.9 cm vs 2.9 cm, P < 0.0001). PACs were more often placed in the MPA than RPA(80 vs 18 patients). Three patient's pulmonary arteries were not visible by any TTE view; in a further 2 patients, despite preinsertion visualisation of their pulmonary arteries, the PAC balloon was not visible by any view with TTE where correct placement by pressure waveform was unequivocal.

Aorta-pulmonary septal defect and aortic origin of the right pulmonary artery with interruption of the aortic arch:a clinical analysis of 5 cases

Objective Reviewing the experience in diagnosis and treatment of cases with aorta-pulmonary septal defect and aortic origin of right pulmonary artery complicated with interruption of aortic arch. Methods Clinical data from medical records for 5 patients (4 boys and 1 girl,age from 1 to 18 years on admission) who had been treated in Wuhan Asia Heart Hospital between 2005 and 2009

Open Surgery for Retrieval of Patent Foramen Ovale Closure Device Embolized into Right Pulmonary Artery

Percutaneous Patent Foramen Ovate PFO/Atrial Septal Defect (ASD) closure has become an increasingly simplified procedure over the past decade. The main advantages of a percutaneous approach include avoidance of surgery, short procedure time and hospital stay. Device embolization is seen rarely but it can be fatal. We report this complication following a percutaneous PFO closure in a 44-year-old man. The device was embolized into the distal part of the right pulmonary artery. We removed the device surgically and closed the PFO/ASD.

Real-time Three-dimensional Echocardiography:A Feasible and Accurate Method for Measuring Right Ventricular Function in Pulmonary Hypertension

Right ventricular function is independently associated with poor clinical outcomes in patients with various cardiovascular diseases including pulmonary hypertension(PH).The complex geometry and mode of contractility means the right ventricle(RV)inlet and outlet are not in line;hence,2-dimensional echocardiography fails to accurately quantify RV volumes and function in such patients.Three-dimensional echocardiography(3DE)allows for reliable and reproducible quantification of RV volumes and function by overcoming these limitations of conventional echocardiography.This review focuses on the 3DE assessment of RV function in patients with PH and discusses the following points:(1)acquiring an RV data set for 3DE imaging,including details of all available 3DE systems and software utilized in daily practice;(2)the reliability and feasibility of RV remodeling measured with 3DE with different modalities in patients with PH;and(3)the prognostic value of 3DE-derived RV function in such patients.

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.

Surgical Outcomes of Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery in Children： An Echocardiography Follow？up

Background：Anomalous origin of the left coronary artery from the pulmonary artery （ALCAPA） is a rare but potentially life-threatening congenital heart defect. A retrospective analysis was carried out to elucidate the surgical outcomes of ALCAPA in infants and children using follow-up echocardiography. Methods： From September 2008 to March 2017, 26 children diagnosed with ALCAPA underwent left coronary re-implantation. All surviving patients received echocardiography during follow-up. Results： The mortality rate after the operation was 11.5%. Before repair, twenty patients （76.9%） presented with left ventricular （LV） dysfunction. The mean Z-score of the preoperative LV end-diastolic diameter was 4.42 ± 2.09. Mitral regurgitation （MR） was present in all patients. Two patients （7.7%）, both with mitral valve prolapse, underwent mitral valve repair at the time of ALCAPA repair. Two children required postoperative extracorporeal membrane oxygenation. LV function normalized at a median time of 5.3 months （range：0.5–36.0 months）. The Z-score of the LV end-diastolic diameter decreased simultaneously. The degree of MR gradually decreased in all surviving patients.All patients had patency of the proximal left coronary artery confirmed by echocardiography at the most recent follow-up. Six patients （26.1%） showed supravalvar pulmonary stenosis and seven patients （30.4%） showed right pulmonary stenosis during follow-up. Conclusions： Coronary re-implantation was effective for rebuilding a dual coronary system in patients with ALCAPA and resulted in progressive improved LV function and reduced functional MR. Echocardiography was valuable for evaluating the outcomes. LV function, the degree of MR, and possible complications could be detected with follow-up echocardiography.

Occult anomalous origin of the left coronary artery from the pulmonary artery with atrial septal defect initially visualized by transthoracic echocardiography

Anomalous origin of left coronary artery from the pulmonary artery （ALCAPA） is a rare congenitalcardiac malformation. Here we report a case of ALCAPA with atrial septal defect （ASD） initially visualized by transthoracic echocardiography, subsequently confirmed by the coronary angiography.

Echocardiography evaluation of right ventricular structure and function in patients with chronic obstructive pulmonary disease

Background Early and accurate assessment of right ventricular changes in patients with Chronic obstructive pulmonary disease(COPD)is of great value,because these changes are important factors affecting the prognosis of patients with COPD. This study aimed to investigate the changes of right ventricular structure and function by electrocardiography in COPD patients,and to evaluate the correlations of pulmonary function,COPD assessment test(CAT)score with the changes. Methods According to the"ABCD"2016 Global initiative for chronic obstructive pulmonary disease(GOLD)update,stable COPD patients were divided into four groups:GOLD A group,GOLD B group,GOLD C group,and GOLD D group. There were 30 patients of each group enrolled from December 2016 to December 2017 in Guangdong General Hospital. During the same period,30 physical examination volunteers were enrolled as the healthy control group. Pulmonary function and echocardiography were performed in all subjects. All COPD patients completed CAT test. One-way ANOVA and SNK-q test were used to analyze the differences in parameters of right ventricular structure and function between different GOLD groups and healthy controls. Pearson correlation analysis was used to analyze the relation between CAT score,forced expiratory volume in one second(FEV1)and echocardiographic parameters. Results Compared with control group,right ventricular wall thickness(RVWT)was significantly thicker in patients of GOLD A,B and C groups(P<0.001),but not for GOLD D group. In sharp contrast,only in the patients of GOLD D group,right ventricular basal diameter(RV basal diameter)and right ventricular outflow tract(RVOT)(2.84±0.56 cm and 4.63±0.54 cm)were significantly longer than those in healthy controls and other GOLD groups(P<0.001).The patients of GOLD C and D groups had higher E/A ratio and E/e′ ratio compared with control group,GOLD A and B groups(P<0.001). But only in GOLD D group,the fractional area change(FAC)and tricuspid annular plane systolic excursion(TAPSE)were decreased significantly,compared with control group and other GOLD groups(P<0.001). The right ventricular index of myocardial performance(RIMP)in GOLD B,C and D groups was increased significantly compared with healthy control and GOLD A group(P<0.001). Moreover,correlation analysis showed that no correlations were found between FEV1 and all parameters of right ventricular structure and function,but CAT was positively correlated with RIMP(r=0.696,P=0.019). Conclusions Echocardiography could be a good assessment for right ventricular structure and function in COPD patients. Right ventricular wall thickening and diastolic dysfunction occur in the early stage of COPD,followed by right ventricular volume enlargement and systolic dysfunction.

Early Intervention of Tongxinluo(通心络) on Right Ventricular Function Assessed by Echocardiography in Rats with Pulmonary Arterial Hypertension Induced by Monocrotaline

Objective:To investigate the effect of early intervention of Tongxinluo(通心络,TXL)on right ventricular function(RVF)of rats with pulmonary arterial hypertension(PAH)induced by monocrotaline(MCT).Methods:A total of 30 adult male Sprague-Dawley rats were assigned to 5 groups with complete random experiment design:Sham group(Sham),MCT group,TXL group,sildenafil(SIL)group and combination group(TXL+SIL),6 rats in each group.Rats were injected with 50 mg/kg MCT solution for inducing PAH model except for those in the sham group.From the day of modeling,rats of TXL,SIL and TXL+SIL groups were given TXL(1.2 g/kg),SIL(10 mg/kg)and combination solution(TXL:1.2 g/kg,SIL:10 mg/kg)respectively,and rats in Sham and MCT groups were given normal saline(5 m L/kg).The samples were collected and tested after 21 consecutive days of intragastric administration.Echocardiography was used to measure the related indices of RVF,including pulmonary arterial flow spectrum,pulmonary artery diameter(PAD),right ventricular wall thickness(RVWT),right ventricular diameter(RVD),tricuspidannular plane systolic excursion(TAPSE),right atrium transverse diameter(RAT),and inferior vena cava diameter(IVCD).Elastic Verhoeff-Van Gieson staining was adopted to measure the percentage of wall thickness(WT%)of pulmonary arteriols.Hematoxylin-eosin staining was used to measure the cross-sectional area(CSA)of right ventricular cardiomyocytes.Results:MCT-induced PAH rat model was successfully established.In MCT group the wall of pulmonary arterioles exhibited a prominent-increase thickness,PAD,RVWT,RVD,RAT,IVCD,WT%,right ventricular hypertrophy index(RVHI)as well as CSA of RV cardiomyocyte significantly increased(all P<0.01),and TAPSE markedly decreased(P<0.01).At the same time,TXL prominently improved all of the above indices(all P<0.01).In comparison with SIL,TXL significantly reduced RVD(P<0.05)and decreased CAS of RV cardiomyocytes(P<0.01),but TAPSE in SIL group was much larger than in TXL group(P<0.01).Moreover,TAPSE in TXL+SIL group was larger than that in TXL group(P<0.01),while the two groups performed equally well in terms of the other indices.Conclusion:Early intervention of TXL could inhibit pulmonary arterioles remodeling,and improve RVF by attenuating right ventricular hypertrophy,and TXL has a stronger effect on inhibiting right ventricular remodeling than SIL.

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.

Establishment of adult right ventricle failure in ovine using a graded, animal-specific pulmonary artery constriction model

Background: Right ventricle failure(RVF) is associated with serious cardiac and pulmonary diseases that contribute significantly to the morbidity and mortality of patients. Currently, the mechanisms of RVF are not fully understood and it is partly due to the lack of large animal models in adult RVF. In this study, we aim to establish a model of RVF in adult ovine and examine the structure and function relations in the RV.Methods: RV pressure overload was induced in adult male sheep by revised pulmonary artery constriction(PAC). Briefly, an adjustable hydraulic occluder was placed around the main pulmonary artery trunk. Then, repeated saline injection was performed at weeks 0, 1, and 4, where the amount of saline was determined in an animal-specific manner. Healthy, age-matched male sheep were used as additional controls. Echocardiography was performed bi-weekly and on week 11 post-PAC, hemodynamic and biological measurements were obtained.Results: This PAC methodology resulted in a marked increase in RV systolic pressure and decreases in stroke volume and tricuspid annular plane systolic excursion, indicating signs of RVF. Significant increases in RV chamber size, wall thickness, and Fulton's index were observed. Cardiomyocyte hypertrophy and collagen accumulation(particularly type III collagen) were evident, and these structural changes were correlated with RV dysfunction.Conclusion: In summary, the animal-specific, repeated PAC provided a robust approach to induce adult RVF, and this ovine model will offer a useful tool to study the progression and treatment of adult RVF that is translatable to human diseases.

Value of transthoracic echocardiography combined with cardiac troponin I in risk stratification in acute pulmonary thromboembolism

Background Acute pulmonary thromboembolism （APE） causes right ventricular dysfunction （RVD） and cardiac troponin I （cTnl） elevation. Patients with RVD and cTnl elevation have a worse prognosis. Thus, early detection of RVD and cTnl elevation is beneficial for risk stratification. In this study, we assessed 14-day adverse clinical events and combined RVD on transthoracic echocardiography （TTE） with cTnl in risk stratification among a broad spectrum of APE patients. Methods The prospective multi-centre trial included 90 patients with confirmed APE from 12 collaborating hospitals. Acute RVD on TTE was diagnosed in the presence of at least 2 of the following： right ventricular dilatation （without hypertrophy）, loss of inspiratory collapse of inferior vena cava （IVC）, right ventricular （RV） hypokinesis, tricuspid regurgitant jet velocity 〉2.8 m/s. The study patients were divided into two groups according to clinical and echocardiographic findings at presentation： Group Ⅰ： 50 patients with RVD; Group Ⅱ：40 patients without RVD. Results More than half of the patients （50/90, 55.6%） had RVD. Nearly one third （26/90, 28.9%） of patients had elevated cTnl at presentation and only 4.2% on the fourth day after initial therapy. A multiple Logistic regression model implied RVD, right and left ventricular end-diastolic diameter ratio （RVED/LVED）, and cTnl independently predict an adverse 14-day clinical outcome （P〈0.01）. Receiver operating characteristics （ROC） curves revealed that the cut-off values of RVED/LVED and cTnl yielding the highest discriminating power were 0.65 and 0.11 ng/ml, respectively. Furthermore, the incidence of an adverse 14-day clinical event in patients with RVD and elevated cTnl was greater （40.7%） than in patients with elevated cTnl or positive RVD alone （0% and 8.3%, respectively） （P〈0.001）. Conclusions RVD, RVED/LVED, and cTnl are independent predictors of 14-day clinical outcomes. The patients with RVED/LVED greater than 0.65 and cTnl higher than 0.11 ng/ml at presentation possibly have adverse 14-day events. RVD combined with cTnl can identify a subgroup of APE patients with a much more guarded prognosis.

Noninvasive model including right ventricular speckle tracking for the evaluation of pulmonary hypertension

AIM To find parameters from transthorathic echocardiography(TTE) including speckle-tracking(ST) analysis of the right ventricle(RV) to identify precapillary pulmonary hypertension(PH).METHODS Forty-four patients with suspected PH undergoing right heart catheterization(RHC) were consecutively included(mean age 63.1 ± 14 years, 61% male gender). All patients underwent standardized TTE including ST analysis of the RV. Based on the subsequent TTE-derived measurements, the presence of PH was assessed: Left ventricular ejection fraction(LVEF) was calculated by Simpsons rule from 4Ch. Systolic pulmonary artery pressure(s PAP) was assessed with continuous wave Doppler of systolic tricuspid regurgitant velocity and regarded raised with values ≥ 30 mmH g as a surrogate parameter for RA pressure. A concomitantly elevated PCWP was considered a means to discriminate between the precapillary and postcapillary form of PH. PCWP was considered elevated when the E/e' ratio was > 12 as a surrogate for LV diastolic pressure. E/e' ratio was measured by gauging systolic and diastolic velocities of the lateral and septal mitral valve annulus using TDI mode. The results were then averaged with conventional measurement of mitral valve inflow. Furthermore, functional testing with six minutes walking distance(6MWD), ECG-RV stress signs, NT pro-BNP and other laboratory values were assessed.RESULTS PH was confirmed in 34 patients(precapillary PH, n = 15, postcapillary PH, n = 19). TTE showed significant differences in E/e' ratio(precapillary PH: 12.3 ± 4.4, postcapillary PH: 17.3 ± 10.3, no PH: 12.1 ± 4.5, P = 0.02), LV volumes(ESV: 25.0 ± 15.0 mL, 49.9 ± 29.5 m L, 32.2 ± 13.6 m L, P = 0.027; EDV: 73.6 ± 24.0 mL, 110.6 ± 31.8 mL, 87.8 ± 33.0 mL, P = 0.021) and systolic pulmonary arterial pressure(sP AP: 61.2 ± 22.3 mm Hg, 53.6 ± 20.1 mm Hg, 31.2 ± 24.6 mm Hg, P = 0.001). STRV analysis showed significant differences for apical RV longitudinal strain(RVAS: -7.5% ± 5.6%, -13.3% ± 4.3%, -14.3% ± 6.3%, P = 0.03). NT pro-BNP was higher in patients with postcapillary PH(4677.0 ± 7764.1 pg/m L, precapillary PH: 1980.3 ± 3432.1 pg/mL, no PH: 367.5 ± 420.4 pg/mL, P = 0.03). Patients with precapillary PH presented significantly more often with ECG RV-stress signs(P = 0.001). Receiver operating characteristics curve analyses displayed the most significant area under the curve(AUC) for RVAS(cut-off < -6.5%, AUC 0.91, P < 0.001), sPAP(cut-off > 33 mmH g, AUC 0.86, P < 0.001) and ECG RV stress signs(AUC 0.83, P < 0.001). The combination of these parameters had a sensitivity of 82.8% and a specificity of 17.2% to detect precapillary PH. CONCLUSION The combination of non-invasive measurements allows feasible assessment of PH and seems beneficial for the differentiation between the pre- and postcapillary form of this disease.

Undifferentiated intimal sarcoma of the pulmonary artery:A case report

BACKGROUND Since 1923,only a few hundred cases of pulmonary arterial sarcoma(PAS)have been reported.It is easy for PAS to be misdiagnosed as pulmonary thromboembolism,which makes treatment difficult.The median survival time without surgical treatment for PAS is only 1.5-3 mo.Echocardiography is widely used in screening for pulmonary artery space-occupying lesions in patients with chest pain,dyspnea,and cough;furthermore,it is typically considered the first imaging examination for patients with PAS.CASE SUMMARY In May 2017,a 39-year-old male patient experienced chest pain with no particular obvious cause.At that time,the cause was thought to be pulmonary embolism.In July 2017,positron emission tomography–computed tomography revealed spaceoccupying lesions in the right lung and multiple metastases in both lungs.The lesions of the right lung were biopsied,and pathology revealed undifferentiated sarcoma.Chemotherapy had been performed since July 2017 in another hospital.In December 2019,the patient was admitted to our hospital for the sake of CyberKnife treatment.Echocardiography suggested:(1)A right ventricular outflow tract(RVOT)solid mass of the main pulmonary artery;and(2)mild pulmonary valve regurgitation.Ultrasonography showed the absence of a thrombus in the deep veins of either lower limb.CONCLUSION PAS is a single,central space-occupying lesion involving the RVOT and pulmonary valve.Echocardiography of PAS has its own characteristics.

Study the effect of exercise on systolic pulmonary artery pressure in healthy subjects

Introduction: As no data is available concerning the cut-off value defining abnormal pulmonary artery systolic pressure (PASP) response in subjects of various ages, the aim of this study is to assess physiological PASP response to exercise in healthy individuals of various ages. Material and methods: One hundred and twenty three healthy volunteers, aged 30 to 70 years, underwent Doppler echocardiographic measurements at rest and after treadmill exercise test. Pulmonary artery systolic pressure was estimated at rest, and immediately after peak exercise using Bernoulli formula (four times tricuspid valve regurgitation velocity squared adding an estimated right atrial pressure). Results: Lower and upper limits of PASP during rest was 7 and 28 mmHg and after peak exercise was 14 and 48 mmHg respectively. After exercise, PASP increased from rest (14 ± 4 mmHg) to peak (25 ± 7 mmHg). Pulmonary artery systolic pressure during rest and peak exercise, increased with age, but has no correlation with body mass index or gender. Conclusion: Pulmonary artery systolic pressure at peak exercise can frequently reach values ≥ 30 mmHg in healthy individuals with good exercise capacity, especially in elderly individuals, which goes beyond pathologic definitions of pulmonary hypertension.

Double Compression of Left Atrium and Pulmonary Artery by a Huge Descending Aortic Aneurysm with Intramural Hematoma Mimicking Pulmonary Embolism: A Case Report

Hemodynamic instability secondary to left atrial (LA) compression by an aortic aneurysm is a rare entity. We report?the case of a 43-year old woman with no previous diagnosis of congestive heart failure who was admitted for an initial diagnosis of pulmonary embolism (PE) based on shortness of breath, hypotension and D-Dimers?elevation. The electrocardiogram and blood counts were within normal limits. The chest X-ray revealed widening of the mediastinum. Transthoracic echocardiography demonstrated LA compression by a large descending thoracic aortic aneurysm. Left and right ventricle systolic functions were preserved. Chest angiography showed LA and left pulmonary artery (LPA) compression by a descending aortic aneurysm and an intramural hematoma with no evidence of PE evidence. Emergency surgery could not be done because of her financial status. She was treated medically and was discharged 1?week later with significant improvement. However she remained hypotensive.

Stress doppler echocardiography in connective tissue disease patients without overt pulmonary arterial hypertension

Background Pulmonary arterial hypertension(PAH) is a common complication of connective tissue disease(CTD) and confers a worse prognosis. Stress doppler echocardiography(SDE) can detect early pulmonary vasculopathy and assess right heart function in patients with pulmonary arterial hypertension. In this study, the SDE was applied to analyze the degree of pulmonary vascular lesion and the function of right heart in CTD patients without overt PAH. Methods CTD patients without overt PAH were divided into exercised-induced pulmonary hypertension(EIPH) group and non-EIPH group depending on whether tricuspid regurgitation(TR) exceeded 3.1 m/s during exercise and assessed by echocardiography at rest and during exercise. The data of right ventricular function and the slope of the incremental of the mean pulmonary artery pressure and cardiac output(ΔmPAP/ΔCO) were analyzed. Results Forty-seven CTD patients without overt PAH(35 female, mean age 40.3±12.0 years) were enrolled and divided into EIPH group(n=21) and non-EIPH group(n=26). Patients with systemic sclerosis(SSc) were more likely to have EIPH(47.6% vs. 28.6%, P<0.05) than those with systemic lupus erythematosus(SLE). Patients in EIPH group had a higher value of ΔmPAP/ΔCO than that of the non-EIPH group(4.5±3.1 vs. 2.2±1.3, P<0.05). SSc was more prevalent in CTD patients and the symptoms of dyspnea occurred more often in EIPH group(52.4%), indicating a pressure-flow mismatch induced by exercise. However, the cardiac function demonstrated by left ventricular ejection fraction(LVEF), tricuspid annular plane systolic excursion(TAPSE),DTI-Derived S'-wave velocity(S') and right ventricular fractional area change(RVFAC), as well as functional reserve reflected by the changes of TAPSE, S', RVFAC before and after exercise, did not differ significantly between the two groups. Conclusions Although right ventricular(RV) reserve function does not change much before and after exercise, patients in EIPH group have a higher value of ΔmPAP/ΔCO than that of the non-EIPH group and more likely to have symptoms during exercise. Thus, to assess the potential for pulmonary vascular disease, echocardiography should be performed at rest and during exercise.[S Chin J Cardiol 2019;20(1):31-36]

Pulmonary Arterial Hypertension and the Failing Ventricle:Getting It Right

Right ventricular failure(RVF)remains the primary cause of death in patients with pulmonary arterial hypertension.We review the pathophysiology of RVF,including the remodeling and ventriculoarterial uncoupling that occurs when the failing right side of the heart is unable to compensate for a rising afterload.Secondly,the noninvasive imaging techniques used in the assessment of RVF are explored,including echocardiography,cardiac magnetic resonance imaging,computed tomography,and positron emission tomography.Third,we describe how these imaging techniques and a patient’s clinical characteristics may be used to determine prognosis.Lastly,we explore the medical and surgical/interventional treatment options for RVF.Despite these treatment options,morbidity and mortality remain high in this patient population.The discovery of new prognostic indicators,use of hybrid imaging for early detection of RVF,and strategies to prevent the development of RVF will be important if outcomes in this patient population are to improve.

Prognostic value of the echocardiographic right/left ventricular end-diastolic diameter ratio in patients with idiopathic pulmonary arterial hypertension

Background Previous studies have shown that an echocardiographic right/left ventricular end-diastolic diameter ratio(RV/LV ratio)≥0.9 is an independent predictor of poor prognosis in patients with acute pulmonary embolism. The prognostic value of the RV/LV ratio in patients with idiopathic pulmonary arterial hypertension(IPAH) is still unknown. Methods We retrospectively enrolled 95 consecutive patients with newly diagnosed IPAH and 16 of them were reevaluated by echocardiography at 3-12 months following targeted therapy.Follow-up data were obtained by telephone interviews and review of the patients’ records.Results The RV/LV ratio was in parallel with the severity of World Health Orgnization(WHO) functional class and mean right atrial pressure.The RV/LV ratio was positively correlated with total pulmonary resistance(P P P 2 saturation(P P = 0.001),weight and absence of targeted therapy were independent predictors of death.No significant changes in the RV/LV ratio before and after targeted therapy were observed. A baseline RV/LV ratio≥0.84 or a further increase in the RV/LV ratio during targeted therapy indicated a poor prognosis. Conclusions The RV/LV ratio helps to assess the severity of IPAH and serves as an independent predictor of prognosis in patients with IPAH.