Although pulmonary thromboendarterectomy is an effective modality for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH), the mortality in patients with severe haemodynamic disease is still high. Recently it was reported that fractional pulse pressure (pulmonary arterial pulse pressure/mean pulmonary arterial pressure) was higher in CTEPH than in primary pulmonary hypertension (PPH). It was hypothesized that fractional pulse pressure might be low in CTEPH with inaccessible distal thrombi and/or secondary pulmonary hypertensive change, resulting to the high operative mortality.To determine the in¯uence of fractional pulse pressure to the outcome of surgery, 32 patients with CTEPH who had thromboendarterectomy between 1985 and 1998 were studied. Pulmonary haemodynamics and fractional pulse pressure were compared between survivors (n=26) and nonsurvivors (n=6) postoperatively. Those parameters in PPH (n=18) and large vessel pulmonary arteritis (n=6) were also analysed.Fractional pulse pressure in CTEPH (1.230.21) was signi®cantly higher than in PPH (0.930.22; p=0.0017) and lower than in pulmonary arteritis (1.690.32; p=0.03). Fractional pulse pressure in survivors (1.260.21) was signi®cantly higher than in nonsurvivors (1.060.16; p=0.03). Fractional pulse pressure is a signi®cant predictor for mortality in patients with high pulmonary vascular resistance >1100 dynes . sec . cm -5 . To conclude fractional pulse pressure in addition to pulmonary vascular resistance might be useful in predicting for the outcome of surgery, especially in patients with severe haemodynamic impairment. Eur Respir J 2001; 17: 653±659. Although pulmonary thromboendarterectomy is an effective modality for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH) [1±15], the mortality in patients with high pulmonary vascular resistance is still high [8,9]. The inability to reduce pulmonary vascular resistance is a major risk factor associated with high mortality [4,9].Chronic pulmonary hypertension of any origin frequently results in pathological change in the proximal (elastic) and distal (resistive) pulmonary vasculature. The obstruction or signi®cant stenosis of large pulmonary artery increased pulse pressure (systolic pressurediastolic pressure) as well as characteristic impedance, and reduced wave re¯ection [16,17]. Grant et al. [16] reported that the degree of the right ventricular hypertrophy was dependent on the increase in pulse pressure rather than the increase in mean pulmonary arterial pressure [16,18]. However, primary pulmonary hypertension (PPH) and CTEPH generally induce severe haemodynamic disturbances in accordance to the increase of pulmonary vascular resistance or mean pulmonary arterial pressure compared to unilateral pulmonary arterial occlusion. Consideration of both impedance (i.e. the opposition to the pulsatile components of¯ow) and pulmonary vascular resistance (i.e. the opposition to the mean components of¯ow) are required to evaluate the right ventricular afterload, and t...
SUMMARYSeveral reports have demonstrated a close correlation between plasma atrial natriuretic peptide (ANP) concentration and atrial pressure in stable heart diseases. However, few studies have investigated whether plasma ANP concentration is a noninvasive indicator of hemodynamic parameters during the treatment of heart failure. Thus, we have studied the relationship between peripheral plasma ANP concentration and concurrent hemodynamic variables during the treatment of heart failure, and, in order to determine whether secretion of ANP is stimulated in this disease condition, we compared the plasma ANP concentration in the pulmonary artery with that in the peripheral veins.Studies were performed in each of 9 patients with acute heart failure due to myocardial infarction (Group A) or chronic heart failure (Group B), who were matched as closely as possible for treatment, age, sex and cardiac output. In group A, no significant correlation was found between plasma ANP levels and any measured hemodynamic variables. In group B, peripheral plasma ANP concentrations were significantly correlated with left atrial pressure (r=0.82, p<0.01), but not with right atrial pressure (r=0.56, p>0.05). Furthermore, in group B ANP levels in pulmonary arterial plasma were consistently higher than those in peripheral venous plasma, whereas in group A the opposite was observed in expired cases.These results suggest that measurement of peripheral plasma ANP is a useful noninvasive method for estimating left atrial pressure during the treatment of chronic heart failure. However, plasma ANP concentration may not be a valid means of estimating hemodynamic parameters in acute heart failure due to myocardial infarction. In such cases, the increased secretion of ANP was not obvious, and there may be other factors , in addition to atrial pressure, that regulate cardiac secretion of ANP.
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