The elephant in the room

The elephant in the room Downloaded from https://academic.oup.com/eurheartj/article-abstract/39/36/3396/4983961 by Ed 'DeepDyve' Gillespie user on 18 October 2018 DISCUSSION FORUM European Heart Journal (2018) 39, 3396 doi:10.1093/eurheartj/ehy239 1,2 Hayan Al Maluli * 1 2 Department of Internal Medicine, University of North Dakota School of Medicine and Health Sciences, 1301 N Columbia Rd, Grand Forks, ND 58203, USA; and Heart Failure and Pulmonary Hypertension Program, Sanford Medical Center-Fargo, 801 Broadway N, Fargo, ND 58102, USA Online publish-ahead-of-print 24 April 2018 I read with great interest the manuscript titled ‘Sildenafil for improving out- However, in my humble opinion, a different way of selecting comes in patients with corrected valvular heart disease and persistent pul- patients for SIOVAC may have provided a much-needed answer for 1 . monary hypertension (SIOVAC)’ by Drs Bermejo et al. which provided . those of us who have similar patients in whom we struggle to further important data on the role of pulmonary vasodilators in patients with pul- . reduce left-sided filling pressures, but who in fact have truly impaired monary hypertension (PH) and left-sided heart disease. The authors con- . RV-PC coupling. Such a trial would have likely had implications for a cluded that phosphodiesterase 5 inhibitors (PDE5i) can be harmful in such . wide variety of cardiac patients including advanced heart failure ones. 2 . patients, something the accompanying editorial emphasized. . Shifting attention from pulmonary arterial pressure to RV function Pulmonary vasodilators improve outcomes by recoupling the dys- (the elephant in the room) as the main predictor of response to pul- functional right ventricle (RV) with an unfavourable pulmonary circula- monary vasodilators (just as it is the main predictor of outcomes in tion (PC). In this study, the RV-PC units were clearly coupled as precapillary PH) may allow us to design similarly strong studies that evidenced by normal RV size and function (RV ejection fraction, nor- . may in fact change clinical guidelines and help us manage these com- mal cardiac index, and right atrial to pulmonary capillary wedge pres- . plex patients. sure ratio of 0.5) as well as borderline elevated pulmonary vascular Conflict of interest: none declared. resistance (PVR) of 3.4 WU, and a normal diastolic pressure gradient (DPG) of 2.0 mmHg. Yes, by definition this group represented ‘com- References bined’ pre- and post-capillary physiology, but PC involvement was only 1. Bermejo J, Yotti R, Garcı´a-Orta R, Sa ´nchez-Ferna ´ndez PL, Casta~ no M, Segovia- modest. More importantly, the RV has perfectly adapted to these mild Cubero J, Escribano-Subı´as P, San Roma ´n JA, Borra ´s X, Alonso-Go ´ mez A, Botas J. derangements. Sildenafil for improving outcomes in patients with corrected valvular heart disease and persistent pulmonary hypertension: a multicenter, double-blind, randomized Drs Galie `’ et al. eloquently stated that themainabnormality here clinical trial. Eur Heart J 2018;39:1255–1264. was elevated left-sided filling pressures, and it is true that this should be . 2. Galie ` N, Manes A, Dardi F, Palazzini M. Aiming at the appropriate target for the the main target of therapy, whenever possible. The caveat here is the treatment of pulmonary hypertension due to left heart disease. Eur Heart J 2018; 39:1265–1268. ‘whenever possible’. It is interesting that even with supposedly normally 3. Vonk-Noordegraaf A, Haddad F, Chin KM, Forfia PR, Kawut SM, Lumens J, Naeije functioning prosthesis, left atrial pressure remained so elevated (some- R, Newman J, Oudiz RJ, Provencher S, Torbicki A, Voelkel NF, Hassoun PM. Right timestoover40 mmHg).This, in itself,isatopic worthyoffurther in- heart adaptation to pulmonary arterial hypertension: physiology and pathobiology. vestigation since it is frequently encountered in clinical practice. . J Am Coll Cardiol 2013;62:D22–D33. * Corresponding author. Tel: 701-234-1557, Fax: 701-234-3813, Email: Hayan.almaluli@Sanfordhealth.org Published on behalf of the European Society of Cardiology. All rights reserved. V The Author(s) 2018. For permissions, please email: journals.permissions@oup.com. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Heart Journal Oxford University Press

The elephant in the room

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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: journals.permissions@oup.com.
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Abstract

Downloaded from https://academic.oup.com/eurheartj/article-abstract/39/36/3396/4983961 by Ed 'DeepDyve' Gillespie user on 18 October 2018 DISCUSSION FORUM European Heart Journal (2018) 39, 3396 doi:10.1093/eurheartj/ehy239 1,2 Hayan Al Maluli * 1 2 Department of Internal Medicine, University of North Dakota School of Medicine and Health Sciences, 1301 N Columbia Rd, Grand Forks, ND 58203, USA; and Heart Failure and Pulmonary Hypertension Program, Sanford Medical Center-Fargo, 801 Broadway N, Fargo, ND 58102, USA Online publish-ahead-of-print 24 April 2018 I read with great interest the manuscript titled ‘Sildenafil for improving out- However, in my humble opinion, a different way of selecting comes in patients with corrected valvular heart disease and persistent pul- patients for SIOVAC may have provided a much-needed answer for 1 . monary hypertension (SIOVAC)’ by Drs Bermejo et al. which provided . those of us who have similar patients in whom we struggle to further important data on the role of pulmonary vasodilators in patients with pul- . reduce left-sided filling pressures, but who in fact have truly impaired monary hypertension (PH) and left-sided heart disease. The authors con- . RV-PC coupling. Such a trial would have likely had implications for a cluded that phosphodiesterase 5 inhibitors (PDE5i) can be harmful in such . wide variety of cardiac patients including advanced heart failure ones. 2 . patients, something the accompanying editorial emphasized. . Shifting attention from pulmonary arterial pressure to RV function Pulmonary vasodilators improve outcomes by recoupling the dys- (the elephant in the room) as the main predictor of response to pul- functional right ventricle (RV) with an unfavourable pulmonary circula- monary vasodilators (just as it is the main predictor of outcomes in tion (PC). In this study, the RV-PC units were clearly coupled as precapillary PH) may allow us to design similarly strong studies that evidenced by normal RV size and function (RV ejection fraction, nor- . may in fact change clinical guidelines and help us manage these com- mal cardiac index, and right atrial to pulmonary capillary wedge pres- . plex patients. sure ratio of 0.5) as well as borderline elevated pulmonary vascular Conflict of interest: none declared. resistance (PVR) of 3.4 WU, and a normal diastolic pressure gradient (DPG) of 2.0 mmHg. Yes, by definition this group represented ‘com- References bined’ pre- and post-capillary physiology, but PC involvement was only 1. Bermejo J, Yotti R, Garcı´a-Orta R, Sa ´nchez-Ferna ´ndez PL, Casta~ no M, Segovia- modest. More importantly, the RV has perfectly adapted to these mild Cubero J, Escribano-Subı´as P, San Roma ´n JA, Borra ´s X, Alonso-Go ´ mez A, Botas J. derangements. Sildenafil for improving outcomes in patients with corrected valvular heart disease and persistent pulmonary hypertension: a multicenter, double-blind, randomized Drs Galie `’ et al. eloquently stated that themainabnormality here clinical trial. Eur Heart J 2018;39:1255–1264. was elevated left-sided filling pressures, and it is true that this should be . 2. Galie ` N, Manes A, Dardi F, Palazzini M. Aiming at the appropriate target for the the main target of therapy, whenever possible. The caveat here is the treatment of pulmonary hypertension due to left heart disease. Eur Heart J 2018; 39:1265–1268. ‘whenever possible’. It is interesting that even with supposedly normally 3. Vonk-Noordegraaf A, Haddad F, Chin KM, Forfia PR, Kawut SM, Lumens J, Naeije functioning prosthesis, left atrial pressure remained so elevated (some- R, Newman J, Oudiz RJ, Provencher S, Torbicki A, Voelkel NF, Hassoun PM. Right timestoover40 mmHg).This, in itself,isatopic worthyoffurther in- heart adaptation to pulmonary arterial hypertension: physiology and pathobiology. vestigation since it is frequently encountered in clinical practice. . J Am Coll Cardiol 2013;62:D22–D33. * Corresponding author. Tel: 701-234-1557, Fax: 701-234-3813, Email: Hayan.almaluli@Sanfordhealth.org Published on behalf of the European Society of Cardiology. All rights reserved. V The Author(s) 2018. For permissions, please email: journals.permissions@oup.com.

Journal

European Heart JournalOxford University Press

Published: Sep 21, 2018

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