We aimed at describing the different hemodynamic phenotypes of patients with pulmonary hypertension due to left heart disease before mitral valve replacement and/or concomitant aortic valve replacement and characterizing the impact of pulmonary hemodynamics on RV function. Subjects and method: 67 patients with pulmonary hypertension related to left heart diseases who underwent elective mitral valve replacement and/or aortic valve replacement enrolled in this prospective study from April, 2017 to April, 2018 at Hue Heart Center. Results and conclusions: Prevalence of three subgroups of patients pulmonary hemodynamics: isolated post-capillary pulmonary hemodynamics (Ipc - pulmonary hypertension); combined post- and pre-capillary pulmonary hypertension (Cpc - pulmonary hypertension); intermediate pulmonary hemodynamics were 43.2%, 28.4% and 28.4%, respectively. Cpc pulmonary hemodynamics presented with slightly higher weight and body mass index than intermediate patients (p < 0.05).
Trang 1THE STUDY ON CLINICAL PHENOTYPES OF PULMONARY
HYPERTENSION DUE TO LEFT HEART DISEASE AT PRE-OPERATION TIME IN PATIENTS WITH ISOLATED MITRAL VALVE REPLACEMENT OR DOUBLE VALVE REPLACEMENT
Kieu Van Khuong 1 ; Pham Thi Hong Thi 2
SUMMARY
Objectives: We aimed at describing the different hemodynamic phenotypes of patients with
pulmonary hypertension due to left heart disease before mitral valve replacement and/or concomitant aortic valve replacement and characterizing the impact of pulmonary
hemodynamics on RV function Subjects and method: 67 patients with pulmonary hypertension
related to left heart diseases who underwent elective mitral valve replacement and/or aortic valve replacement enrolled in this prospective study from April, 2017 to April, 2018 at Hue
Heart Center Results and conclusions: Prevalence of three subgroups of patients pulmonary
hemodynamics: isolated post-capillary pulmonary hemodynamics (Ipc - pulmonary hypertension); combined post- and pre-capillary pulmonary hypertension (Cpc - pulmonary hypertension); intermediate pulmonary hemodynamics were 43.2%, 28.4% and 28.4%, respectively Cpc pulmonary hemodynamics presented with slightly higher weight and body mass index than intermediate patients (p < 0.05) There was a significant difference in PAPs, PAPd, PAPm, TPG, DPG, PVR,
SV, CI parameters across the three subgroups of pulmonary hypertension left heart disease TAPSE showed a significantly difference between groups, while the ratio between TAPSE and systolic pulmonary artery pressures progressively decreased from Ipc pulmonary hemodynamics to
“intermediate” pulmonary hypertension - left heart diseases to Cpc pulmonary hypertension (p < 0.0001)
* Keywords: Pulmonary hypertension due to left heart disease; Mitral valve replacement
INTRODUCTION
Pulmonary hypertension (PH) is the
underlying physiological consequence of
left heart disease (LHD) In PH, both
pulmonary arterial occlusion pressure
(PAOP) and pre-capillary components
may affect the right ventricular (RV) after
load These changes contributed to RV
failure and patient prognosis This study
aimed: To characterize the different
preoperative hemodynamics between the different PH phenotypes and impact of pulmonary hemodynamics on RV function
SUBJECTS AND METHODS
1 Subjects
67 patients with isolated mitral valve replacement or double valve replacement from April, 2017 to April in 2018 in the Centre of Cardiology of Hue Central Hospital
1 103 Military Hospital
2 Vietnam National Heart Hospital
Corresponding author: Kieu Van Khuong (icudoctor103@gmail.com)
Date received: 20/12/2018
Date accepted: 20/01/2019
Trang 2* Exclusion criteria: Patients with coronary
diseases, systolic arterial hypertension
(systolic blood pressure was higher than
140 mmHg), primary pulmonary hypertension,
chronic obstructive pulmonary disease
(FEV1/FVC < 0.7), central nerve disorder,
and reoperation Surgeries combine with
repair congenital malformation, atrial
heart septal defect, ventricular septal
defect, patients refuse to join the study
Contraindication of pulmonary artery
catheter, infectious dermatitis, severe
disorder of coagulant system
2 Methods
A descriptive case series study
Examination and investigation: Biochemistry,
blood count, coagulant function, ECG, chest
X-ray, and transthoracic echocardiography
were performed as routine before cardiac surgery In operating room, peripheral vein, catheter pulmonary artery follow internal carotid artery pathway before pre-induction (measure base parameters) Pulmonary hypertension patients were divided into 3 subgroups: Isolated post-capillary pulmonary hypertension (DPG <
7 mmHg, PVR < 3WU), pre-post capillary mixed pulmonary hypertension (DPG ≥ 7 or PRV > 3WU), intermediate pulmonary hypertension (DPG < 7 or PVR ≤ 3) DPG: Diastolic pressure gradient (PAPd-PAOP) PVR: Pulmonary venous resistance All pulmonary and system, direct or indirect hemodynamic parameters were collected through Swan - Ganz catheter and Phillip MP70 monitor Data were processed by SPSS 21.0 edition software
RESULTS
Table 1: Characteristics of patients in subgroups of PH
(n = 67)
Isolated PH (n = 29)
Intermediate PH (n = 19)
Mixed PH
(BMI: Body mass index; BSA: Body surface area; NYHA: New York Heart Association;
AF: Atrial fibrillation)
Trang 3BSA and BMI among subgroups of pulmonary hypertension was significantly different (p < 0.05) There were no meaningful differences in other characteristics, such
as gender (female), age, height, severity of heart failure (NYHA score) and atrial fibrillation proportion
Table 2: Hemodynamic characteristics of subgroups PH
(n = 29)
Intermediate
PH (n = 19)
Mixed PH
(HR: Heart rate; ABPs: Systolic artery blood pressure; ABPd: Diastolic artery blood pressure; MAP: Mean artery pressure; PAPs: Systolic pulmonary artery pressure; PAPd: Diastolic pulmonary artery pressure; PAPm: Mean pulmonary artery pressure; PAOP: Pulmonary artery occlusion pressure; TPG: Transpulmonary gradient; DPG: Diastole pressure gradient; PVR: Pulmonary venous resistance; CVP: Central venous pressure, CVP/PAOP; SV: Stroke volume; CI: Cardiac index)
There was a significant difference in PAPs, PADd, PAPm, TPG, DPG, PVR, SV and
CI between subgroups of PH (p < 0.0001)
Trang 4Table 3: Change in right ventricle function in subgroups of PH
(n = 67)
Isolated PH (n = 29)
Intermediate
TAPSE/PAPs ≤ 0.27
(TAPSE: Tricuspid annular plane systolic excursion; TAPSE/PAPs ratio; RVSWI: Right ventricular stroke work Index)
TAPSE and TAPSE/PAPs decreased significantly in isolated post-capillary PH, intermediate PH and mixed PH subgroup, respectively (p < 0.001)
DISCUSSION
1 Characteristics of patients
Table 1 indicated that the characteristics
of patients such as female, age, height,
NYHA severity of heart failure and
proportion of AF were not significantly
different among subgroups of PH However,
they were different in weight and BMI,
highest in isolated post-capillary pulmonary
hypertension (50.5 kg and 20.07 ± 2.4 kg/m2),
followed by mixed pulmonary hypertension
and the lowest one was subgroup
intermediate PH (p < 0.05) The difference
corresponded with the study by Caravita
[1], but the subgroup which had got the
highest weight and BMI was mixed
post-pre-capillary PH Because his study
subjects were patients with left heart
disease due to degenerated valve, old
age with 64 ± 13 years old, proportion of
NYHA III, IV heart failure was around
69% While our subjects were almost
post-rheumatic fever valve disease with a
long time history of disease
2 Hemodynamic of patients among subgroups of PH
Post-capillary PH is a common complication of left heart disease However, a few number of patients have got PH which can not be explained with the increase of PAOP In these cases, the complex interactions among disorder of endothelial function, vasoconstriction and reformat pulmonary vessels can develop the precapillary factors in addition to post-capillary PH Recently, guidelines of
PH of ESC/ERS proposes definition of hemodynamic in order to classify post-capillary PH based on DPG and PVR [1]
In our study, when classifying PH hemodynamic, we had got the proportion
of isolated post capillary PH, intermediate
PH and mixed PH as 43.2%, 28.4%, and 28.4%, respectively For Dixon, the proportion of Mixed PH to preserve
EF heart failure patients was 7.5% [2] This rate was lower than our study because only 75.4% of 293 patients had
Trang 5got PH due to various reasons Otherwise,
the proportion of patients whose PVR
increased in his study was 18%
According to Naeije, the proportion of
mixed PH due to left heart disease was
from 12 to 13%, these had got severe PH
with higher TPG, DPG and PVR Besides,
the subgroup of mixed PH showed the
significant responding with ventilation, a
lower elasticity of pulmonary artery,
reduction of right ventricle and predicted
life expectancy compared to isolated PH
In our study, value of hemodynamic
parameters such as PAPs, PAPd, PAPm,
TPG, DPG, and PVR, respectively
increased from isolated PH and reached
the highest value in mixed PH This
difference was statistically significant with
p < 0.0001 The parameter which access
the efficiency of heart function such as
stroke volume and cardiac index reduce
respectively in isolated PH (SV: 48.9 ±
2.9 mL, CI 2.82 ± 0.64 L/min/m2),
intermediate PH (33.0 ±15.5 mL and
2.16 ± 0.72 L/min/m2), and mixed PH
(31.9 ± 13.2 mL and 2.12 ± 0.77 L/min/m2)
(p < 0.0001) (table 2)
Our result was similar to Caravita’s
study, in which PAPs, PAPd, PAPm, PAOP,
PDG, and TPG increased gradually
statistically from isolated PH, intermediate
PH to mixed PH And SV reduced
gradually from isolated PH (64 ± 20 mL),
mixed PH (58 ± 21 mL), intermediate PH
(54 ± 14 mL) [1] Therefore, pulmonary
and systemic hemodynamic in subgroup
mixed PH is usually worse than isolated
PH The study by Palazzini performed on
276 patients also demonstrates that the
patients with isolated PH have got better
prognosis than the 2 other subgroups (increase of PVR and DPG only)
3 Impact of RV function in subgroups
of PH
Post-capillary PH is a frequent pathophysiological complication of left heart disease In PH patients, both PAOP and pre-capillary PH affect afterload of RV These changes lead to RV dysfunction and a worse prognosis RV dysfunction, include reduction of RV systolic function and RV overload, for example: reduction
of RV leads to the increase of afterload Characteristics of impact of hemodynamic
on RV function in this study were shown
in table 3 We used TAPSE index and ratio TAPSE/PAPs, RVSWI, CVP/PAOP
as the alternative hemodynamic index to assess the disorder of RV function
According to Gerges M et al, in their prospective cohort study with 664 systolic heart failure patients and 339 diastolic heart failure cases, who were assessed pulmonary hemodynamic with intra-cardiac catheter, there were 12% mixed PH and the ratio TAPSE/PAPs can predict mixed
PH Younger age (p = 0.004), valvular heart disease (p = 0.046) and echo-derived tricuspid annular plane systolic excursion
to systolic pulmonary artery pressure ratio predicted mixed PH in DHF (p = 0.016) Right ventricular-pulmonary vascular coupling was worse in mixed PH than in those with isolated PH [5]
CONCLUSION
The average age was 46.7 ± 10.7 in isolated mitral valve replacement or simultaneous aortic and mitral valve
Trang 6replacement patients, proportion of
isolated PH, intermediate PH and mixed
PH were 43.2%, 28.4%, 28.4%, respectively
BMI and weight of subgroups was
significantly different (p < 0.05) PAPs,
PAPd, PAPm, TPG, DPG, and PVR got
the highest value in subgroup mixed PH,
followed by intermediate PH and lowest in
isolated PH patients (p < 0.001) Mixed
TAP subgroup has got lowest TAPSE
(17.4 ± 2.9 mm), and lower TAPSE/PAPs
ratio (0.33 ± 0.16d mm/mmHg) with
p < 0.001
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