RESUMO
PURPOSE: Pulmonary thromboendarterectomy (PTE) is the treatment for patients with chronic thromboembolic disease. In the immediate postoperative period, some patients may still experience life-threatening complications such as reperfusion lung injury, airway bleeding, and persistent pulmonary hypertension with consequent right ventricular dysfunction. These issues may require support with extracorporeal membrane oxygenation (ECMO) as a bridge to recovery or lung transplantation. This study aims to analyze our series of PTEs that require ECMO. METHODS: A descriptive and retrospective analysis of all PTE performed at the Favaloro Foundation University Hospital was conducted between March 2013 and December 2023. RESULTS: A total of 42 patients underwent PTE with a median age of 47 years (interquartile range: 26-76). The incidence of patients with ECMO was 26.6%, of which 53.6% were veno-venous (VV) ECMO. Preoperatively, a low cardiac index (CI), high right and left filling pressures, and high total pulmonary vascular resistances (PVRs) were associated with ECMO with a statistically significant relationship. The hospital mortality was 11.9%, and the mortality in the ECMO group was 45.5%, with a statistically significant relationship. Veno-arterial ECMO has a worse prognosis than VV ECMO. CONCLUSIONS: Preoperatively, a low CI, high right and left filling pressures, and high total PVRs were associated with ECMO after PTE.
Assuntos
Endarterectomia , Oxigenação por Membrana Extracorpórea , Mortalidade Hospitalar , Embolia Pulmonar , Humanos , Oxigenação por Membrana Extracorpórea/mortalidade , Oxigenação por Membrana Extracorpórea/efeitos adversos , Pessoa de Meia-Idade , Endarterectomia/efeitos adversos , Endarterectomia/mortalidade , Masculino , Estudos Retrospectivos , Feminino , Resultado do Tratamento , Adulto , Idoso , Embolia Pulmonar/mortalidade , Embolia Pulmonar/cirurgia , Embolia Pulmonar/fisiopatologia , Fatores de Tempo , Fatores de Risco , Artéria Pulmonar/fisiopatologia , Artéria Pulmonar/cirurgia , Hipertensão Pulmonar/mortalidade , Hipertensão Pulmonar/fisiopatologia , Hipertensão Pulmonar/cirurgiaRESUMO
BACKGROUND: In pulmonary hypertension (PH), the identification of easily obtainable prognostic markers associated with right ventricular (RV) dysfunction and survival is needed. OBJECTIVE: To evaluate the association of red cell distribution width (RDW) with clinical, echocardiographic parameters and survival in patients with pre-capillary PH, with the development of a mortality prediction model. METHODS: Observational, longitudinal, and prospective study conducted from May 2019 to December 2022. Thirty-four patients with pre-capillary PH underwent two-dimensional echocardiography and complete blood count. A cutoff point of 14.5% was considered to define RDW as altered (≥14.5%) or normal (<14.5%). P values <0.05 were considered significant. RESULTS: The median RDW was 14.4%. There was a significant difference in peripheral arterial oxygen saturation (SpO2) (p=0.028), RV strain (p=0.047), and pericardial effusion (p=0.002) between the normal and elevated RDW groups. During a median follow-up of 15 months, 20.6% died. Patients with increased RDW had a shorter overall survival (44.7%, log-rank p=0.019), which was a predictor of mortality in univariate Cox regression (HR 8.55, p=0.048). The addition of RV strain <16% and SpO2 ≤93% to the model including RDW alone showed incremental value in predicting mortality (χ2=8.2, p=0.049; χ2=12.4, p=0.041), with increased area under the receiver operating characteristic curve (0.729 vs. 0.837 vs. 0.909) and decreased probability of survival (44.7% vs. 35.6% vs. 25%, log-rank p=0.019). CONCLUSIONS: RDW provides information on the severity of pre-capillary PH by correlating with echocardiographic parameters of RV dysfunction and mortality, which is best predicted by a model including RDW, RV strain and SpO2.
FUNDAMENTO: Na hipertensão pulmonar (HP), é necessária a identificação de marcadores prognósticos de fácil obtenção associados com disfunção do ventrículo direito (VD) e sobrevida. OBJETIVO: Avaliar a associação do índice de anisocitose eritrocitária (RDW, do inglês red cell distribution width) com parâmetros ecocardiográficos e sobrevida em pacientes com HP pré-capilar, com o desenvolvimento de um modelo de predição de mortalidade. MÉTODOS: Estudo observacional, longitudinal, prospectivo, conduzido entre maio de 2019 e dezembro de 2022. Trinta e quatro pacientes com HP pré-capilar submeteram-se à realização de ecocardiograma bidimensional e hemograma. Um ponto de corte de 14,5% foi adotado para definir o RDW como alterado (≥14,5%) ou normal (<14,5%). Valores de p<0,05 foram considerados significativos. RESULTADOS: O RDW médio foi 14,4%. Houve uma diferença significativa na saturação periférica de oxigênio (SpO2) (p=0,028), strain do VD (p=0,047) e derrame pericárdico (p=0,002) entre os grupos com RDW normal e elevado. Durante um período mediano de 15 meses, 20,6% dos pacientes foram a óbito. Os pacientes com RDW aumentado tiveram uma sobrevida global mais curta (44,7%, log-rank p=0,019), sendo um preditor de mortalidade na regressão univariada de Cox. A adição do strain do VD < 16% e da SpO2 ≤93% ao modelo incluindo somente RDW mostrou valor incremental na predição de mortalidade (χ2=8,2, p=0,049; χ2=12,4, p=0,041), com área sob a curva ROC (do inglês, Receiver Operating Characteristic) aumentada (0,729 vs. 0,837 vs. 0,909) e probabilidade de sobrevida diminuída (44.7% vs. 35.6% vs. 25%, log-rank p=0,019). CONCLUSÕES: O RDW fornece informações sobre a gravidade da HP pré-capilar pela sua correlação com parâmetros ecocardiográficos de disfunção do VD e mortalidade, a qual é melhor predita por um modelo incluindo RDW, strain do VD e SpO2.
Assuntos
Ecocardiografia , Índices de Eritrócitos , Hipertensão Pulmonar , Humanos , Hipertensão Pulmonar/mortalidade , Hipertensão Pulmonar/sangue , Masculino , Feminino , Pessoa de Meia-Idade , Estudos Prospectivos , Prognóstico , Idoso , Estudos Longitudinais , Disfunção Ventricular Direita/mortalidade , Disfunção Ventricular Direita/sangue , Disfunção Ventricular Direita/diagnóstico por imagem , Disfunção Ventricular Direita/fisiopatologia , Adulto , Curva ROC , Valor Preditivo dos TestesRESUMO
Introdução: Hipertensão Pulmonar (HP), uma condição clínica grave, pode levar à disfunção sistólica do ventrículo direto (DSVD), com implicações prognósticas. Pacientes com suspeita de HP devem ser submetidos ao ecocardiograma transtorácico (ECOTT) para diagnóstico e avaliação, colocando-o como o principal exame de triagem e acompanhamento. Objetivo: Verificar a associação e a concordância das medidas referentes à pressão média no átrio direito (AD) e à disfunção sistólica do ventrículo direto (DSVD) ao (ECOTT) e ao cateterismo de câmaras direitas (CCD) em pacientes com (HP). Métodos: Foram incluídos indivíduos com diagnóstico de (HP). Todos os pacientes foram submetidos ao ECOTT e CCD. Avaliou-se pelo ECOTT: área do átrio direito (AAD), pressão média do átrio direito (AD) através por meio do diâmetro e da colapsabilidade da veia cava inferior (PMADECOTT ), strain AD (SAD), TAPSE (excursão sistólica do plano anular tricúspide), MAF (mudança da área fracional), SPLVD (strain da parede livre do VD) e onda s´ tricuspídea. Pelo CCD avaliaram-se pressão média do (PMADCCD ) e índice cardíaco (IC). Resultados: Dos 16 pacientes, 13 eram do sexo feminino. A idade média foi de 44,4 anos (±14,9). Constataram-se associação entre pressão média do átrio direito PMADCCD com área do átrio direito, PMADECOTT pressão média do átrio direito e SAD strain do átrio direito (r=0,845, r=0,621 e r=-0,523, respectivamente; p< 0,05). Verificou-se associação entre as categorias de risco de mortalidade, mensuradas pelas medidas AAD da área do átrio direito e pressão média do átrio direito PMADCCD (X2=10,42; p=0,003), com concordância moderada (k=0,44; p=0,012). DSVD A disfunção sistólica do ventrículo direto estava presente em dez pacientes. Houve associação entre disfunção sistólica do ventrículo direto DSVD (presente ou ausente) e índice cardíaco IC (r=0,522; p=0,04), com concordância moderada (k=0,43; p=0,037). Conclusão: As medidas do ecocardiograma transtorácico (ECOTT) e cateterismo de câmara direita (CCD) demostraram associação na avaliação da pressão média do átrio direito com melhor associação entre área do átrio direito AAD e pressão média do átrio direito (PMADCCD) . Houve associação com concordância moderada quanto à disfunção sistólica do ventrículo direto (DSVD) entre métodos. (AU)
Introduction: Pulmonary hypertension (PH), a serious clinical condition, can lead to right ventricular systolic dysfunction (RVSD) with prognostic implications. Patients with suspected PH should undergo transthoracic echocardiography (TTE) for diagnosis and evaluation as the main screening and follow-up exam. Objective: To verify the associations of and agreement between measurements of mean pressure in the right atrium (RA) and RVSD with TTE Method: Individuals diagnosed with PH were included. All patients underwent TTE and RCC. The following were evaluated by TTE: right atrial area (RAA), mean right atrial pressure through the diameter and collapsibility of the inferior vena cava (RMAPTTE), RA strain (RAS), tricuspid annular plane systolic excursion, fractional area change, RV free wall strain, and tricuspid s' wave. Mean RA pressure (RMAPRCC) and cardiac index (CI) were evaluated through the RCC. Results: Of the 16 patients, 13 were female. The mean patient age was 44.4 (±14.9) years. An association was found between RMAPRCC and AAD, RMAPTTE, and RAS (r=0.845, r=0.621, and r=-0.523, respectively; p<0.05). There was an association between the mortality risk categories measured by the RAA and RMAPRCC measures (X2=10.42; p=0.003), with moderate agreement (k=0.44; p=0.012). RVSDJ was present in 10 patients. There was an association between RVSD (present or absent) and CI (r=0.522; p=0.04) with moderate agreement (k=0.43; p=0.037). Conclusion: The TTE and RCC measurements showed an association in the assessment of mean right atrial pressure, especially between RAA and RMAPRCC. An association with RVSD and moderate agreement between methods were also noted. (AU)
Assuntos
Humanos , Masculino , Feminino , Adulto , Disfunção Ventricular Direita/complicações , Átrios do Coração/fisiopatologia , Hipertensão Pulmonar/diagnóstico , Ecocardiografia/métodos , Fluoroscopia/métodos , Cateterismo Cardíaco/métodos , Hemodinâmica/efeitos da radiação , Hipertensão Pulmonar/mortalidadeAssuntos
Humanos , Ecocardiografia/métodos , Ventrículos do Coração/anormalidades , Hipertensão Pulmonar/mortalidade , Hipertensão Pulmonar/diagnóstico por imagem , Ecocardiografia/estatística & dados numéricos , Cateterismo Cardíaco , Ecocardiografia Doppler/métodos , Disfunção Ventricular Direita/complicações , Hipertensão Pulmonar/classificaçãoRESUMO
BACKGROUND: Patients with acute decompensation of pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) admitted to intensive care unit (ICU) have high in-hospital mortality. We hypothesized that pulmonary hypertension (PH) severity, measured by a simplified version of European Society of Cardiology/European Respiratory Society (ESC/ERS) risk assessment, and the severity of organ dysfunction upon ICU admission, measured by sequential organ failure assessment score (SOFA) were associated with in-hospital mortality in decompensated patients with PAH and CTEPH. We also described clinical and laboratory variables during ICU stay. METHODS: Observational study including adults with decompensated PAH or CTEPH with unplanned ICU admission between 2014 and 2019. Multivariate logistic regression models were used to evaluate the association of ESC/ERS risk assessment and SOFA score with in-hospital mortality. ESC/ERS risk assessment and SOFA score were included in a decision tree to predict in-hospital mortality. RESULTS: 73 patients were included. In-hospital mortality was 41.1%. ESC/ERS high-risk group (adjusted odds ratio = 95.52) and SOFA score (adjusted odds ratio = 1.80) were associated with in-hospital mortality. The decision tree identified four groups with in-hospital mortality between 8.1% and 100%. Nonsurvivors had a lower central venous oxygen saturation, higher arterial lactate and higher brain natriuretic peptide in the end of first week in the ICU. CONCLUSIONS: High-risk on a simplified version of ERS/ESC risk assessment and SOFA score upon ICU admission are associate with in-hospital mortality. A decision tree based on ESC/ERS risk assessment and SOFA score identifies four groups with in-hospital mortality between 8.1% and 100%.
Assuntos
Hipertensão Pulmonar/mortalidade , Unidades de Terapia Intensiva , Adulto , Brasil/epidemiologia , Estudos de Coortes , Feminino , Mortalidade Hospitalar , Humanos , Ácido Láctico/sangue , Masculino , Pessoa de Meia-Idade , Peptídeo Natriurético Encefálico/sangue , Escores de Disfunção Orgânica , Saturação de Oxigênio , Prognóstico , Estudos Retrospectivos , Índice de Gravidade de DoençaRESUMO
Resumen La hipertensión arterial pulmonar es una enfermedad multifactorial que incrementa la mortalidad en el neonato como consecuencia de falla cardiaca. Los vasodilatadores pulmonares son la piedra angular del tratamiento, de los cuales el sildenafil es el fármaco más empleado. A continuación, se resumen los resultados de una revisión sistemática Cochrane en la que se evaluaron la eficacia y la seguridad del sildenafil para el tratamiento de la hipertensión arterial pulmonar en neonatos.
Abstract Pulmonary arterial hypertension is a multifactorial nosological entity that increases neonatal mortality as a result of heart failure. Pulmonary vasodilators are the cornerstone of treatment, of which sildenafil is the most commonly used drug. Therefore, the results of a recently updated Cochrane systematic review are summarized, in which the efficacy and safety of sildenafil for the treatment of pulmonary hypertension in neonates was evaluated.
Assuntos
Humanos , Recém-Nascido , Vasodilatadores/uso terapêutico , Citrato de Sildenafila/uso terapêutico , Hipertensão Pulmonar/tratamento farmacológico , Ensaios Clínicos Controlados Aleatórios como Assunto , Hipertensão Pulmonar/mortalidadeRESUMO
Pulmonary arterial hypertension is a multifactorial nosological entity that increases neonatal mortality as a result of heart failure. Pulmonary vasodilators are the cornerstone of treatment, of which sildenafil is the most commonly used drug. Therefore, the results of a recently updated Cochrane systematic review are summarized, in which the efficacy and safety of sildenafil for the treatment of pulmonary hypertension in neonates was evaluated.
La hipertensión arterial pulmonar es una enfermedad multifactorial que incrementa la mortalidad en el neonato como consecuencia de falla cardiaca. Los vasodilatadores pulmonares son la piedra angular del tratamiento, de los cuales el sildenafil es el fármaco más empleado. A continuación, se resumen los resultados de una revisión sistemática Cochrane en la que se evaluaron la eficacia y la seguridad del sildenafil para el tratamiento de la hipertensión arterial pulmonar en neonatos.
Assuntos
Hipertensão Pulmonar/tratamento farmacológico , Citrato de Sildenafila/uso terapêutico , Vasodilatadores/uso terapêutico , Humanos , Hipertensão Pulmonar/mortalidade , Recém-Nascido , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
OBJECTIVE: The aim of this study was to establish the effects of treprostinil in congenital diaphragmatic hernia (CDH) patients with persistent pulmonary hypertension (PHT) after 1 week of treatment. Drug effects were assessed by oxygenation index (OI), clinical end points, serial biochemical markers, and pre- and posttreatment echocardiogram. Treatment complications were also described. STUDY DESIGN: This is a quasi-experimental study of neonates with PHT admitted to the NICU within 48 hours showing persistent clinical instability, receiving mechanical ventilation with FiO2 > 60%, milrinone therapy, and inhaled nitric oxide. Clinical data were compared before and after treprostinil treatment. RESULTS: Seventeen neonates met the inclusion criteria. Median age was 17 days. Before treatment, median OI was 20 (IQR: 12-27). Suprasystemic PHT was estimated by echocardiogram in 8/17 patients; the rest were systemic. After 1 week of treatment, 15/17 patients were alive and median OI was 8 (IQR: 5-12, p = 0.0089). There were no statistically significant changes in laboratory data. Echocardiogram still showed suprasystemic PHT in 20% of patients. Adverse effects included hypotension, hematoma at the infusion site, and surgical persistent ductus arteriosus (PDA) closure in 4/17 patients. Fourteen patients were discharged. The median treatment time was 61 days. CONCLUSION: Treprostinil was well tolerated with satisfactory clinical response. Further studies are required to identify early responder subgroups.
Assuntos
Epoprostenol/análogos & derivados , Hérnias Diafragmáticas Congênitas/complicações , Hipertensão Pulmonar/tratamento farmacológico , Anti-Hipertensivos , Ecocardiografia , Epoprostenol/efeitos adversos , Epoprostenol/uso terapêutico , Feminino , Hematoma/etiologia , Humanos , Hipertensão Pulmonar/etiologia , Hipertensão Pulmonar/mortalidade , Hipotensão/etiologia , Recém-Nascido , Masculino , Resultado do TratamentoRESUMO
A doença pulmonar hipertensiva pode ser definida como um conjunto de alterações fisiopatológicas pulmonares que resultam em uma patologia grave, progressiva e com alta morbimortalidade. O ecocardiograma transtorácico é um método de imagem de fácil acesso e essencial para avaliação desta doença, principalmente na faixa pediátrica, na qual há limitações para realização frequente e de rotina do cateterismo direito. Nesta revisão, abordaremos as principais técnicas ecocardiográficas para o diagnóstico e a avaliação hemodinâmica da hipertensão pulmonar na população pediátrica. O diagnóstico precoce e o adequado estadiamento no acompanhamento das intervenções clínicas são fundamentais para escolha assertiva da abordagem terapêutica e, consequentemente, melhora do desfecho clínico
Assuntos
Humanos , Masculino , Feminino , Pediatria , Ecocardiografia/métodos , Criança , Hipertensão Pulmonar/mortalidade , Artéria Pulmonar , Valva Tricúspide , Veia Cava Inferior , Cateterismo Cardíaco , Ecocardiografia Doppler/métodos , Disfunção Ventricular Direita , Disfunção Ventricular Esquerda , Átrios do Coração , Ventrículos do CoraçãoRESUMO
OBJECTIVE: To assess the demographics, treatment algorithm, and outcomes in a large cohort of children treated with sildenafil. STUDY DESIGN: A retrospective cohort study of children with pulmonary hypertension (PH) treated with sildenafil at a single institution between 2004 and 2015. Baseline and follow-up data collected by chart review. RESULTS: There were 269 children included in this study: 47 with idiopathic pulmonary arterial hypertension, 53 with congenital heart disease, 135 with bronchopulmonary dysplasia, 24 with congenital diaphragmatic hernia, and 7 with other causes. Sildenafil was initial monotherapy in 84.8% and add-on therapy in 15.2%. Median follow-up time was 3.1 years (2 weeks-12.4 years). On follow-up, 99 (37%) remained on sildenafil or transitioned to tadalafil, 93 (35%) stopped sildenafil for improvement in PH, 54 (20%) died, and 20 (7%) were lost to follow-up. PH was most likely to improve in those with bronchopulmonary dysplasia, allowing for the discontinuation of sildenafil in 45%. Eighteen deaths were related to PH and 36 from other systemic causes. Two patients stopped sildenafil owing to airway spasm with desaturation. Overall survival was significantly lower in World Health Organization group 3 PH (bronchopulmonary dysplasia and congenital diaphragmatic hernia) vs group 1 (idiopathic pulmonary arterial hypertension and congenital heart disease), P = .02. CONCLUSIONS: In this retrospective experience in children with mainly World Health Organization groups 1 and 3 PH, low-dose sildenafil was well-tolerated, safe, and had an acceptable side effect profile. Although patients with group 3 PH have high mortality, survivors have a high likelihood of PH improving.