Novel interventions on the tricuspid valve: how to consider the pulmonary circulation?

Purpose Of Review: This review addresses treatment options for moderate to severe tricuspid valve regurgitation and the importance of right ventricular function and the pulmonary circulation.

Recent Findings: Several interventional treatment options for severe tricuspid regurgitation have been developed including transcatheter edge-to-edge repair, annuloplasty and valve replacement. So far, transcatheter edge-to-edge repair is most frequently used with procedural success rates of more than 95% and improvements in functional and quality of life parameters for up to 2 years.

Prognostic Relevance of Cardiopulmonary Exercise Testing for Patients with Chronic Thromboembolic Pulmonary Hypertension.

Background: Following acute pulmonary embolism (PE), a relevant number of patients experience decreased exercise capacity which can be associated with disturbed pulmonary perfusion. Cardiopulmonary exercise testing (CPET) shows several patterns typical for disturbed pulmonary perfusion. Research question: We aimed to examine whether CPET can also provide prognostic information in chronic thromboembolic pulmonary hypertension (CTEPH).

Cardiopulmonary exercise testing and efficacy of percutaneous coronary intervention: a substudy of the ORBITA trial.

Aims: Oxygen-pulse morphology and gas exchange analysis measured during cardiopulmonary exercise testing (CPET) has been associated with myocardial ischaemia. The aim of this analysis was to examine the relationship between CPET parameters, myocardial ischaemia and anginal symptoms in patients with chronic coronary syndrome and to determine the ability of these parameters to predict the placebo-controlled response to percutaneous coronary intervention (PCI).

Methods And Results: Patients with severe single-vessel coronary artery disease (CAD) were randomized 1:1 to PCI or placebo in the ORBITA trial.

Dobutamine Stress Echocardiography Ischemia as a Predictor of the Placebo-Controlled Efficacy of Percutaneous Coronary Intervention in Stable Coronary Artery Disease: The Stress Echocardiography-Stratified Analysis of ORBITA.

Background: Dobutamine stress echocardiography is widely used to test for ischemia in patients with stable coronary artery disease. In this analysis, we studied the ability of the prerandomization stress echocardiography score to predict the placebo-controlled efficacy of percutaneous coronary intervention (PCI) within the ORBITA trial (Objective Randomised Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina).

Methods: One hundred eighty-three patients underwent dobutamine stress echocardiography before randomization.

Fractional Flow Reserve and Instantaneous Wave-Free Ratio as Predictors of the Placebo-Controlled Response to Percutaneous Coronary Intervention in Stable Single-Vessel Coronary Artery Disease.

Background: There are no data on how fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are associated with the placebo-controlled efficacy of percutaneous coronary intervention (PCI) in stable single-vessel coronary artery disease.

Methods: We report the association between prerandomization invasive physiology within ORBITA (Objective Randomised Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina), a placebo-controlled trial of patients who have stable angina with angiographically severe single-vessel coronary disease clinically eligible for PCI. Patients underwent prerandomization research FFR and iFR assessment.

Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial.

Background: Symptomatic relief is the primary goal of percutaneous coronary intervention (PCI) in stable angina and is commonly observed clinically. However, there is no evidence from blinded, placebo-controlled randomised trials to show its efficacy.

Methods: ORBITA is a blinded, multicentre randomised trial of PCI versus a placebo procedure for angina relief that was done at five study sites in the UK.

Oxygen Uptake Efficiency Slope and Breathing Reserve, Not Anaerobic Threshold, Discriminate Between Patients With Cardiovascular Disease Over Chronic Obstructive Pulmonary Disease.

Objectives: The study sought to compare the relative discrimination of various cardiopulmonary exercise testing (CPX) variables between cardiac and respiratory disease.

Background: CPX testing is used in many cardiorespiratory diseases. However, discrimination of cardiac and respiratory dysfunction can be problematic.

Physiology of oxygen uptake kinetics: Insights from incremental cardiopulmonary exercise testing in the Study of Health in Pomerania.

Background: Cardiopulmonary exercise testing allows for assessment of cardiac and respiratory limitation, but is often affected by patient effort. Indices of oxygen kinetics, including the oxygen uptake efficiency slope (OUES), oxygen uptake-work-rate slope (VO-WR slope) and the heart rate-oxygen uptake slope (HR-VO slope) are relatively effort independent but may be affected by patient characteristics. The objective of this study is to identify the impact of factors, such as age, gender, body size, respiratory function, smoking and beta-blockade on these parameters, as well as generate predictive equations.

Test-retest repeatability of cardiopulmonary exercise test variables in patients with cardiac or respiratory disease.

Background: The test-retest reliability for multiple cardiopulmonary exercise test (CPX) variables has not been compared in a single study and the influence of different diseases on test-retest reliability has not been examined. We investigated different measures of test-retest reliability for multiple variables and compared them by category of cardiac or respiratory disease.

Methods: Patients with chronic obstructive airways disease (n = 24), heart failure (n = 43), or severe mitral valve disease (n = 26) were recruited into a prospective study.

Systematic review of genuine versus spurious side-effects of beta-blockers in heart failure using placebo control: recommendations for patient information.

Background: Patients trying life-preserving agents such as beta-blockers may be discouraged by listings of harmful effects provided in good faith by doctors, drug information sheets, and media. We systematically review the world experience of side-effect information in blinded, placebo-controlled beta-blockade in heart failure. We present information for a physician advising a patient experiencing an unwanted symptom and suspecting the drug.

Impact of right ventricular reserve on exercise capacity and survival in patients with pulmonary hypertension.

Aims: Pulmonary hypertension is a clinical syndrome characterized by a progressive increase in pulmonary vascular resistance leading to right ventricular failure and death. Pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) are key subgroups of this disorder with comparable clinical and pathological findings. Resting pulmonary haemodynamics correlate only moderately with functional parameters and do not predict prognosis in these patients sufficiently accurately.

Respiratory rate predicts outcome after acute myocardial infarction: a prospective cohort study.

Aims: Risk stratification after acute myocardial infarction (MI) remains imperfect and new indices are sought that might improve the post-MI risk assessment. In a contemporarily-treated cohort of acute MI patients, we tested whether the respiratory rate provides prognostic information and how this information compares to that of established risk assessment.

Methods And Results: A total of 941 consecutive patients (mean age 61 years, 19% female) presenting with acute MI were enrolled between May 2000 and March 2005.

Incremental prognostic value of cardiopulmonary exercise testing and resting haemodynamics in pulmonary arterial hypertension.

Background: Pulmonary arterial hypertension (PAH) is a fatal disease despite recent treatment advances. Individual risk stratification is important. Exercise capacity and invasive haemodynamic data are both relevant, but data on the combined prognostic power are lacking.

The role for cardiopulmonary exercise testing in patients with atrial septal defects: a review.

Secundum atrial septal defects (ASD) are the commonest congenital cardiac abnormality. They are often identified incidentally, or in conjunction with an acquired cardiac abnormality. Untreated they may lead to significant morbidity and mortality, with consequences including right ventricular overload and right heart failure, pulmonary arterial hypertension, shunt reversal and cyanosis, and arrhythmias.

Effects of dynamic bilevel positive airway pressure support on central sleep apnea in men with heart failure.

Background: Treatment with continuous positive airway pressure (CPAP) improves cardiac function in chronic heart failure (CHF) patients with central sleep apnea (CSA)-Cheyne-Stokes respiration (CSR) by stabilizing ventilation, but frequently central apneas and hypopneas persist. Our objective was to test the hypothesis that flow-targeted dynamic bilevel positive airway pressure (BPAP) support (BiPAP autoSV; Respironics; Murrysville, PA) effectively suppresses CSR-CSA in CHF patients.

Methods: We studied 14 CHF patients with CSR-CSA (and residual CSA on positive airway pressure therapy) during 3 consecutive nights: (1) diagnostic polysomnography, (2) CPAP (n=10) or BPAP (n=4) titration, and (3) dynamic flow-targeted dynamic BPAP support with an expiratory positive airway pressure (EPAP) set to suppress obstructive respiratory events, and an inspiratory positive airway pressure (IPAP) dynamically ranging between 0 and 15 cm H2O above the EPAP.

Continuous intravenous iloprost to revert treatment failure of first-line inhaled iloprost therapy in patients with idiopathic pulmonary arterial hypertension.

Aims: To describe the clinical and haemodynamic effects during the first 6 months of continuous intravenous iloprost treatment in patients with idiopathic pulmonary arterial hypertension (IPAH) and relevant disease progression despite continued mono therapy with aerosolized iloprost.

Methods And Results: Twenty-four IPAH patients with clinical decompensation to NYHA class IV despite therapy with aerosolized iloprost and optimized conservative treatment were assessed clinically, haemodynamically and by cardiopulmonary exercise testing for at least 6 months. Upon switching from inhaled to intravenous iloprost all patients improved clinically (NYHA III) while pulmonary vascular resistance (PVR) and right atrial pressure decreased from 2386 +/- 243 to 1381 +/- 124 dyne .

Changes in exercise capacity, ventilation, and body weight following heart transplantation.

Aims: Peak oxygen uptake adjusted to body weight (peak VO(2)) and ventilatory efficiency (VE/VCO(2)-slope) are important prognostic parameters in chronic heart failure. Our study prospectively examined changes in these parameters over 24 months following heart transplantation (HTx) and evaluated the potentially confounding effects of weight gain.

Methods And Results: One hundred patients with chronic heart failure (16 female, mean age at HTx 53.

Development of respiratory control instability in heart failure: a novel approach to dissect the pathophysiological mechanisms.

Observational data suggest that periodic breathing is more common in subjects with low F(ETCO(2)), high apnoeic thresholds or high chemoreflex sensitivity. It is, however, difficult to determine the individual effect of each variable because they are intrinsically related. To distinguish the effect of isolated changes in chemoreflex sensitivity, mean F(ETCO(2)) and apnoeic threshold, we employed a modelling approach to break their obligatory in vivo interrelationship.

Abnormal ventilatory response to exercise in adults with congenital heart disease relates to cyanosis and predicts survival.

Background: Limited data exist with which to stratify risk in adult congenital heart disease (ACHD). An increased ventilatory response to exercise, expressed as ventilation per unit of carbon dioxide production (V(E)/V(CO2) slope), is an established predictor of impaired survival in acquired heart disease. We sought to establish the distribution, relation to cyanosis, and prognostic value of the V(E)/V(CO2) slope across a wide spectrum of ACHD patients.

Enhanced prognostic value from cardiopulmonary exercise testing in chronic heart failure by non-linear analysis: oxygen uptake efficiency slope.

Aims: Predicting survival from peak exercise oxygen uptake (peak VO2) in chronic heart failure (CHF) is hindered by its reduction if exercise duration is submaximal. The oxygen uptake efficiency slope (OUES) is a non-linear description of the ventilatory response to exercise, which has the potential to describe abnormalities even early in exercise. We evaluated the physiology of OUES and assessed its potential for prognostic information in patients with CHF.

The anti-CD14 antibody IC14 suppresses ex vivo endotoxin stimulated tumor necrosis factor-alpha in patients with chronic heart failure.

Background: Activation of the endotoxin (LPS) receptor, CD14, leads to tumor necrosis factor-alpha (TNF) production. Plasma LPS activity is elevated in patients with severe chronic heart failure (CHF). An anti-CD14 antibody, IC14, blocks TNF production in healthy volunteers.

Exercise hyperventilation in chronic heart failure is not caused by systemic lactic acidosis.

Background: Patients with heart failure have an abnormally high ventilatory response to exercise associated with gas exchange defects and reduced arterial pCO(2).

Aims: We examined the possibility of lactic acidosis as the stimulus to this increased ventilation that abnormally depresses pCO(2) during exercise in heart failure.

Method And Results: We studied 18 patients with chronic heart failure.

[Assessment of cardiopulmonary function at rest and during exercise in patients with pulmonary hypertension].

Pulmonary hypertension is diagnosed by various investigations that are essential for making the diagnosis. Following a careful history and physical examination, an electrocardiogram, a chest X-ray, lung function studies, blood tests and an echocardiogram form the basis of the diagnostic algorithm. Following these studies, a right and sometimes additional left heart catheterization are carried out to establish the diagnosis and to perform acute vasodilator testing.