Pulmonary Hypertension With Left-Sided HF: Searching for Appropriate Treatment, Management - Pulmonology Advisor

Pulmonary Hypertension With Left-Sided HF: Searching for Appropriate Treatment, Management - Pulmonology Advisor

Pulmonary Hypertension With Left-Sided HF: Searching for Appropriate Treatment, Management - Pulmonology Advisor

Posted: 07 Feb 2020 12:00 AM PST

Pulmonary hypertension (PH) can be a severe and potentially debilitating complication in patients with chronic left-sided heart failure (HF). In a review published in Heart Failure Clinics, researchers from Germany and Italy provided recommendations on assessment and an overview of targeted management strategies that may be helpful for these patients.

The presence of PH in patients with left-sided HF can confer poor prognosis and survival, making appropriate assessment of the condition crucial for optimizing outcomes. According to the researchers, right heart catheterization or a fluid challenge may be indicated in some patients at intermediate risk in an effort to obtain a correct diagnosis. A pulmonary arterial wedge pressure (PAWP) of ≥15 mm Hg is a mandatory criterion for establishing PH associated with left-sided HF.

Guidelines recommend that PAWP should be assessed at end-expiration at rest using a proper "zero" point at the mid-chest. A provocative test should be used to confirm PAWP findings in patients with borderline PAWP values (ie, 13-15 mm Hg) or in patients with lower PAWP but who present with echocardiographic signs of left ventricular hypertrophy.

There are currently no approved targeted therapies for patients with PH and right HF with preserved ejection fraction (EF) or HF with reduced EF. Clinical trials are currently ongoing to test drugs that either activate guanylate cyclase or inhibit phosphodiesterase type 5 in patients with PH and HF with preserved EF. These studies include the DYNAMIC trial (Pharmacodynamic Effects of Riociguat in Pulmonary Hypertension and Heart Failure With Ejection Fraction; ClinicalTrials.gov Identifier: NCT02744339) and the PASSION Study (Phosphodiesterase-5 Inhibition in Patients With HF With Preserved Ejection Fraction and Combined Post- and Pre-Capillary PH; European Union Clinical Trials Register No.: 2017-003688-37).

The investigators suggested exercise training, a guideline-recommended treatment, may be beneficial in some individuals. In the context of PH with left-sided HF, exercise training may be associated with improvements in exercise capacity. In patients with right ventricular failure whose prognoses do not improve despite use of vasopressors and inotropes, mechanical circulatory is often necessary.

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"A profound understanding of the mechanisms that may lead to the development of PH [caused by chronic left-sided HF] might be helpful to improve the management of these patients," the researchers wrote.

Reference

Marra A-M, Benjamin N, Cittadini A, Bossone E, Grünig E. When pulmonary hypertension complicates heart failure. Heart Fail Clin. 2020;16(1):53-60.

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Pulmonary Hypertension

Case 3: A Newborn with a Mass on the Right Ventricle - AAP News

Posted: 02 Mar 2020 01:13 AM PST

Presentation

A male neonate is born at 36 2/7 weeks via vaginal delivery at a level 2 nursery. The mother is a 34-year-old, gravida 8, para 4, aborta 3 woman.

The maternal history is remarkable for chronic hypertension that was treated with labetalol and amlodipine; hypothyroidism that was treated with levothyroxine; and obesity and gestational diabetes that were controlled with diet. Maternal laboratory findings are as follows: human immunodeficiency virus, negative; rapid plasma reagin, nonreactive; hepatitis B, negative; group B Streptococcus, negative; blood type, O positive; and antibodies, negative. The mother has not received any medication at the time of delivery. The neonate is born via cesarean section for nonreassuring fetal heart tracing and clear amniotic fluids.

Anthropometric measurements at birth are as follows: weight, 2,740 g (45th percentile); head circumference, 34 cm (77th percentile); length, 45.5 cm (20th percentile); growth status: appropriate for gestational age; Apgar scores, 7 and 8 at 1 and 5 minutes, respectively. The neonate requires positive pressure ventilation for 1 minute after delivery.

On admission to the nursery, the neonate exhibits signs of mild respiratory distress and tachypnea, and is placed on continuous positive airway pressure (CPAP) of 6 cm H2O with a fraction of inspired oxygen (Fio2) of 50%; chest radiograph (Fig 1) shows mild ground glass appearance. Because of his worsening respiratory status, the neonate undergoes intubation and is administered surfactant. A few minutes after surfactant administration, the infant's condition suddenly deteriorates, requiring an increase in Fio2 to 100%. Although the neonate receives maximal ventilator and oxygen support, his oxygen saturation remains under 80%. The presence of a pneumothorax prompts the placement of a left chest tube. He is transferred to a …

Inhaled Nitric Oxide in Emergency Medical Transport of the Newborn - AAP News

Posted: 02 Mar 2020 01:13 AM PST

Abstract

Randomized controlled trials in the 1990s confirmed the safety and efficacy of inhaled nitric oxide (iNO) in near-term and term newborns with hypoxemic respiratory failure and pulmonary hypertension, demonstrating improved oxygenation and reduced need for extracorporeal membrane oxygenation (ECMO) therapy. However, in about 30% to 40% of sick newborns, these improvements in oxygenation and hemodynamics are not sustained and affected infants often require rapid transfer to an ECMO center despite the initiation of iNO. Abrupt discontinuation of iNO therapy before transport in patients who have had little apparent clinical benefit can be harmful because of acute deterioration with severe hypoxemia. Thus, continued use of iNO therapy during hospital transfer of infants with pulmonary hypertension is important. In this review, we describe: 1) the history of iNO use during transport; 2) a practical approach to iNO during transport; and 3) guidelines for the initiation of iNO before or during transport.

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