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.

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.

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.

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.

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.

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.