The elephant in the room

The elephant in the room DISCUSSION FORUM European Heart Journal (2018) 0, 1–1 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 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 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. patients, something the accompanying editorial emphasized. Shifting attention from pulmonary arterial pressure to RV function Pulmonary vasodilators improve outcomes by recoupling the dysfunc- (the elephant in the room) as the main predictor of response to pul- tional right ventricle (RV) with an unfavourable pulmonary circulation monary vasodilators (just as it is the main predictor of outcomes in (PC). In this study, the RV-PC units were clearly coupled as evidenced precapillary PH) may allow us to design similarly strong studies that by normal RV size and function (RV ejection fraction, normal cardiac may in fact change clinical guidelines and help us manage these com- index, and right atrial to pulmonary capillary wedge pressure ratio of 0.5) . plex patients. as well as borderline elevated pulmonary vascular resistance (PVR) of Conflict of interest: none declared. 3.4 WU, and a normal diastolic pressure gradient (DPG) of 2.0 mmHg. Yes, by definition this group represented ‘combined’ pre- and post-capil- References lary physiology, but PC involvement was only modest. More importantly, . 1. Bermejo J, Yotti R, Garcı´a-Orta R, Sa ´nchez-Ferna ´ndez PL, Casta~ no M, Segovia- the RV has perfectly adapted to these mild derangements. Cubero J, Escribano-Subı´as P, San Roma ´n JA, Borra ´s X, Alonso-Go ´ mez A, Botas J. 2 . Drs Galie `’ et al. eloquently stated that the main abnormality here . Sildenafil for improving outcomes in patients with corrected valvular heart disease and persistent pulmonary hypertension: a multicenter, double-blind, randomized was elevated left-sided filling pressures, and it is true that this should be . clinical trial. Eur Heart J 2017. the main target of therapy, whenever possible. The caveat here is the . 2. Galie ` N, Manes A, Dardi F, Palazzini M. Aiming at the appropriate target for the ‘whenever possible’. It is interesting that even with supposedly normally . treatment of pulmonary hypertension due to left heart disease. Eur Heart J 2017. 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 timesto over40 mmHg). This, in itself, isa topic worthy of further 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. Downloaded from https://academic.oup.com/eurheartj/advance-article-abstract/doi/10.1093/eurheartj/ehy239/4983961 by Ed 'DeepDyve' Gillespie user on 08 June 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Heart Journal Oxford University Press

The elephant in the room

European Heart Journal , Volume Advance Article – Apr 24, 2018
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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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0195-668X
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1522-9645
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10.1093/eurheartj/ehy239
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Abstract

DISCUSSION FORUM European Heart Journal (2018) 0, 1–1 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 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 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. patients, something the accompanying editorial emphasized. Shifting attention from pulmonary arterial pressure to RV function Pulmonary vasodilators improve outcomes by recoupling the dysfunc- (the elephant in the room) as the main predictor of response to pul- tional right ventricle (RV) with an unfavourable pulmonary circulation monary vasodilators (just as it is the main predictor of outcomes in (PC). In this study, the RV-PC units were clearly coupled as evidenced precapillary PH) may allow us to design similarly strong studies that by normal RV size and function (RV ejection fraction, normal cardiac may in fact change clinical guidelines and help us manage these com- index, and right atrial to pulmonary capillary wedge pressure ratio of 0.5) . plex patients. as well as borderline elevated pulmonary vascular resistance (PVR) of Conflict of interest: none declared. 3.4 WU, and a normal diastolic pressure gradient (DPG) of 2.0 mmHg. Yes, by definition this group represented ‘combined’ pre- and post-capil- References lary physiology, but PC involvement was only modest. More importantly, . 1. Bermejo J, Yotti R, Garcı´a-Orta R, Sa ´nchez-Ferna ´ndez PL, Casta~ no M, Segovia- the RV has perfectly adapted to these mild derangements. Cubero J, Escribano-Subı´as P, San Roma ´n JA, Borra ´s X, Alonso-Go ´ mez A, Botas J. 2 . Drs Galie `’ et al. eloquently stated that the main abnormality here . Sildenafil for improving outcomes in patients with corrected valvular heart disease and persistent pulmonary hypertension: a multicenter, double-blind, randomized was elevated left-sided filling pressures, and it is true that this should be . clinical trial. Eur Heart J 2017. the main target of therapy, whenever possible. The caveat here is the . 2. Galie ` N, Manes A, Dardi F, Palazzini M. Aiming at the appropriate target for the ‘whenever possible’. It is interesting that even with supposedly normally . treatment of pulmonary hypertension due to left heart disease. Eur Heart J 2017. 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 timesto over40 mmHg). This, in itself, isa topic worthy of further 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. Downloaded from https://academic.oup.com/eurheartj/advance-article-abstract/doi/10.1093/eurheartj/ehy239/4983961 by Ed 'DeepDyve' Gillespie user on 08 June 2018

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European Heart JournalOxford University Press

Published: Apr 24, 2018

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