Right ventricular dyssynchrony in patients with pulmonary hypertension is associated with disease severity and functional class

BACKGROUND: Abnormalities in right ventricular function are known to occur in patients with pulmonary arterial hypertension. OBJECTIVE: Test the hypothesis that chronic elevation in pulmonary artery systolic pressure delays mechanical activation of the right ventricle, termed dyssynchrony, and is associated with both symptoms and right ventricular dysfunction. METHODS: Fifty-two patients (mean age 46 ± 15 years, 24 patients with chronic pulmonary hypertension) were prospectively evaluated using several echocardiographic parameters to assess right ventricular size and function. In addition, tissue Doppler imaging was also obtained to assess longitudinal strain of the right ventricular wall, interventricular septum, and lateral wall of the left ventricle and examined with regards to right ventricular size and function as well as clinical variables. RESULTS: In this study, patients with chronic pulmonary hypertension had statistically different right ventricular fractional area change (35 ± 13 percent), right ventricular end-systolic area (21 ± 10 cm(2)), right ventricular Myocardial Performance Index (0.72 ± 0.34), and Eccentricity Index (1.34 ± 0.37) than individuals without pulmonary hypertension (51 ± 5 percent, 9 ± 2 cm(2), 0.27 ± 0.09, and 0.97 ± 0.06, p < 0.005, respectively). Furthermore, peak longitudinal right ventricular wall strain in chronic pulmonary hypertension was also different -20.8 ± 9.0 percent versus -28.0 ± 4.1 percent, p < 0.01). Right ventricular dyssynchrony correlated very well with right ventricular end-systolic area (r = 0.79, p < 0.001) and Eccentricity Index (r = 0.83, p < 0.001). Furthermore, right ventricular dyssynchrony correlates with pulmonary hypertension severity index (p < 0.0001), World Health Organization class (p < 0.0001), and number of hospitalizations (p < 0.0001). CONCLUSION: Lower peak longitudinal right ventricular wall strain and significantly delayed time-to-peak strain values, consistent with right ventricular dyssynchrony, were found in a small heterogeneous group of patients with chronic pulmonary hypertension when compared to individuals without pulmonary hypertension. Furthermore, right ventricular dyssynchrony was associated with disease severity and compromised functional class

Attenuation of Salt-Induced Cardiac Remodeling and Diastolic Dysfunction by the GPER Agonist G-1 in Female mRen2.Lewis Rats

The G protein-coupled estrogen receptor (GPER) is expressed in various tissues including the heart. Since the mRen2.Lewis strain exhibits salt-dependent hypertension and early diastolic dysfunction, we assessed the effects of the GPER agonist (G-1, 40 nmol/kg/hr for 14 days) or vehicle (VEH, DMSO/EtOH) on cardiac function and structure.Intact female mRen2.Lewis rats were fed a normal salt (0.5% sodium; NS) diet or a high salt (4% sodium; HS) diet for 10 weeks beginning at 5 weeks of age.Prolonged intake of HS in mRen2.Lewis females resulted in significantly increased blood pressure, mildly reduced systolic function, and left ventricular (LV) diastolic compliance (as signified by a reduced E deceleration time and E deceleration slope), increased relative wall thickness, myocyte size, and mid-myocardial interstitial and perivascular fibrosis. G-1 administration attenuated wall thickness and myocyte hypertrophy, with nominal effects on blood pressure, LV systolic function, LV compliance and cardiac fibrosis in the HS group. G-1 treatment significantly increased LV lusitropy [early mitral annular descent (e')] independent of prevailing salt, and improved the e'/a' ratio in HS versus NS rats (P<0.05) as determined by tissue Doppler.Activation of GPER improved myocardial relaxation in the hypertensive female mRen2.Lewis rat and reduced cardiac myocyte hypertrophy and wall thickness in those rats fed a high salt diet. Moreover, these advantageous effects of the GPER agonist on ventricular lusitropy and remodeling do not appear to be associated with overt changes in blood pressure

Implementation of Patient-Centered Shared Decision Making for LVAD Candidates: Year 1 Results of a Multi-Site Study

A decision aid (DA) prior to left ventricular assist device (LVAD) placement significantly increased patient knowledge and satisfaction with life after LVAD implant in a multi-site RCT (VADDA). Little evidence exists regarding best practices for implementation of a DA in real-world cardiovascular care. This project aims to evaluate DA implementation at nine U.S. hospitals with a focus on optimizing shared decision-making (SDM). Sites received an implementation plan and participated in a training webinar about ways to use the DA during LVAD evaluation to promote SDM. LVAD coordinators completed a 10-item SDM Implementation Fidelity Checklist (score 0-10) describing optimal DA use and integration of SDM as part of the DA deployment for each patient. DA “reach” is calculated by dividing the number of checklists received by the total number of patients receiving pre-LVAD education during evaluation. DA “fidelity” is calculated using LVAD coordinator self-report of the patient encounter on the Fidelity Checklist. Sites received ongoing monitoring and support from a coordinating center to discuss barriers and facilitators of DA use. Physicians and coordinators (n=30) were surveyed about their attitudes towards use of the LVAD decision aid during the first year of implementation. 454 patients received a DA from September 2018-September 2019 with an average Fidelity Checklist score of 8.5 (range 6.2-10.0). Reach ranged from 14.7%-90.2% of patients across sites with an overall reach of 53.2%. At baseline, a majority (60%, SD=1.00) of cardiologist and coordinator stakeholders believed DAs are relevant to clinical practice, and agree they improve patients’ knowledge (63%, SD=0.87), satisfaction (57%, SD=0.95) and decrease anxiety (57%, SD=0.97). The most frequently cited barrier to using DAs was “not enough time to use the tool in its entirety” (50%, SD=1.34) and questioning that “the effectiveness of the aid was not well established” (40%, SD=1.42). These findings support the feasibility, high fidelity and usefulness of a LVAD DA into busy real-world cardiovascular care. The majority of clinical providers believe the aid is relevant to clinical practice