Neuro-hormonal activation may lead to or be associated with pulmonary arterial hypertension (PAH) and right ventricular dysfunction. Notwithstanding whether it is the cause or the consequence of PAH-related right ventricle (RV) dysfunction neurohormonal activation contributes to significant morbidity and mortality in patients with PAH and the progression of RV dysfunction. Experimental data regarding the use of beta adrenergic blockade and renin-angiotensin aldosterone system modulation are encouraging. However, clinical studies have largely been negative or neutral; and, neuro-hormonal modulation is discouraged in patients with PAH related RV dysfunction for fear of systemic hypotension. Herein, we summarize the pathophysiological background that supports the potential role of neuro-hormonal modulation in the management of PAH related RV dysfunction; also present current clinical experience; and, discuss the need for controlled studies to move forward. Lastly, we review potential non- pharmacological modalities for neuro-hormonal modulations in PAH patients with RV dysfunction.
In 1973 the results of heart valve surgery at the National Heart Hospital in patients over 60 years of age were reported (Oh et al., 1973). After these results an increased number of elderly patients have been referred for operation and in this report we have analysed the outcome of elective cardiopulmonary bypass surgery in patients over the age of 70. Clinical material and methodsBetween July 1970 and July 1975 29 patients over the age of 70 underwent open heart surgery at the National Heart Hospital and Harefield Hospital. The age range was 70 to 75 (mean 71) years. There were 20 men and 9 women. The NYHA classification of functional class (1964) was used to define effort tolerance. Before operation all except 1 patient were severely limited by cardiac symptoms to finctional classes 3 or 4 (see Fig. A). All 29 patients were biologically young and though 16 patients had other medical conditions (see Table 1), these were not considered to contraindicate surgery.Sixteen patients underwent preoperative left heart catheterisation, and in 4 this included selective coronary arteriography. Leftventricularend-diastolic pressures were recorded and ejection fractions were calculated by computerised analysis of enddiastolic and end-systolic frames of the left ventricu-
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