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The elephant in the room: reply

The elephant in the room: reply DISCUSSION FORUM European Heart Journal (2018) 39, 3397 doi:10.1093/eurheartj/ehy241 Javier Bermejo*, Raquel Yotti, and Francisco Ferna´ndez-Avile´s; on behalf of the SIOVAC Investigators Hospital General Universitario Gregorio Mara~ no´n, Instituto de Investigacio´n Sanitaria Gregorio Mara~ no´n, Facultad de Medicina, Universidad Complutense de Madrid, and CIBERCV, Dr Esquerdo 46, 28007 Madrid, Spain Online publish-ahead-of-print 24 April 2018 This commentary refers to ‘The elephant in the room’, by . or TAPSE. Thus, evidence from randomized clinical trials supports H. Al Maluli on page 3396. . avoiding pulmonary vasodilators in Group 2 PH, irrespective of the degree of RV dysfunction or RV-PA uncoupling. We read with interest the letter of Dr Al Maluli, and very much . In patients enrolled in the SIOVAC trial, despite normal prosthetic appreciate his interest on our work. We agree that right ventricular . valve function and diuretic optimization, pulmonary capillary wedge (RV) function has a central role in patients with pulmonary hyper- pressure was unexpectedly high. Elevated left atrial pressure arises as tension (PH) and should never been overlooked. In fact, the the major determinant of an abnormal pulmonary circulation and out- . 3 SIOVAC trial included a comprehensive assessment of RV structure . comesinthispopulation. Therefore, we believe our results call for and function using echocardiography and, in a small group of patients, . redirecting research efforts towards understanding, preventing, and magnetic resonance. . eventually treating residual post-capillary PH in patients with valvular Dr Al Maluli suggests that clinical trials with pulmonary vasodila- heart disease (VHD). tors for Group 2 PH should target exclusively patients with overt . Conflict of interest: none declared. signs of RV dysfunction. Although no clinical trial has been designed in such a way, ancillary data from randomized clinical trials do not an- . References ticipate a favourable effect of sildenafil in this subset of patients. 1. Bermejo J, Yotti R, Garcia-Orta R, Sanchez-Fernandez PL, Castano M, Segovia- The RELAX trial showed a neutral effect of sildenafil compared to Cubero J, Escribano-Subias P, San Roman JA, Borras X, Alonso-Gomez A, Botas J, placebo on peak oxygen consumption at 6 months. Importantly, a Crespo-Leiro MG, Velasco S, Bayes-Genis A, Lopez A, Munoz-Aguilera R, de Teresa specific interaction analysis failed to identify any benefit of sildenafil E, Gonzalez-Juanatey JR, Evangelista A, Mombiela T, Gonzalez-Mansilla A, Elizaga J, . Martin-Moreiras J, Gonzalez-Santos JM, Moreno-Escobar E, Fernandez-Aviles F; neither in patients with RV dysfunction nor with RV-pulmonary Sildenafil for Improving Outcomes after VAlvular Correction (SIOVAC) Investigators. artery (PA) uncoupling at enrolment. Sildenafil for improving outcomes in patients with corrected valvular heart disease Patients with RV dysfunction and combined pre and post-capillary . and persistent pulmonary hypertension: a multicenter, double-blind, randomized clin- ical trial. Eur Heart J 2018;39:1255–1264. PH were also represented in the SIOVAC trial. In fact, 57% of 2. Hussain I, Mohammed SF, Forfia PR, Lewis GD, Borlaug BA, Gallup DS, Redfield patients had PVR > 3 WU, 50% had tricuspid annular plane systolic . MM. Impaired right ventricular-pulmonary arterial coupling and effect of sildenafil excursion (TAPSE) < 15 mm, and 29% significant tricuspid regurgita- . in heart failure with preserved ejection fraction: an ancillary analysis from the 1 . Phosphodiesterase-5 Inhibition to Improve Clinical Status And Exercise Capacity tion. Although we pre-defined a searching strategy for drug res- . in Diastolic Heart Failure (RELAX) trial. Circ Heart Fail 2016;9:e002729. ponders, all interaction analyses were non-significant. Observed . 3. Galie N, Manes A, Dardi F, Palazzini M. Aiming at the appropriate target for the trends did not point towards a favourable effect of sildenafil in . treatment of pulmonary hypertension due to left heart disease. Eur Heart J 2018; patients with higher values of PVR, or lower values of cardiac index . 39:1265–1268. * Corresponding author. Tel: þ34 91 5868279, Fax: þ34 91 5866727, Email: javier.bermejo@salud.madrid.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: reply

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Publisher
Oxford University Press
Copyright
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: journals.permissions@oup.com.
ISSN
0195-668X
eISSN
1522-9645
DOI
10.1093/eurheartj/ehy241
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Abstract

DISCUSSION FORUM European Heart Journal (2018) 39, 3397 doi:10.1093/eurheartj/ehy241 Javier Bermejo*, Raquel Yotti, and Francisco Ferna´ndez-Avile´s; on behalf of the SIOVAC Investigators Hospital General Universitario Gregorio Mara~ no´n, Instituto de Investigacio´n Sanitaria Gregorio Mara~ no´n, Facultad de Medicina, Universidad Complutense de Madrid, and CIBERCV, Dr Esquerdo 46, 28007 Madrid, Spain Online publish-ahead-of-print 24 April 2018 This commentary refers to ‘The elephant in the room’, by . or TAPSE. Thus, evidence from randomized clinical trials supports H. Al Maluli on page 3396. . avoiding pulmonary vasodilators in Group 2 PH, irrespective of the degree of RV dysfunction or RV-PA uncoupling. We read with interest the letter of Dr Al Maluli, and very much . In patients enrolled in the SIOVAC trial, despite normal prosthetic appreciate his interest on our work. We agree that right ventricular . valve function and diuretic optimization, pulmonary capillary wedge (RV) function has a central role in patients with pulmonary hyper- pressure was unexpectedly high. Elevated left atrial pressure arises as tension (PH) and should never been overlooked. In fact, the the major determinant of an abnormal pulmonary circulation and out- . 3 SIOVAC trial included a comprehensive assessment of RV structure . comesinthispopulation. Therefore, we believe our results call for and function using echocardiography and, in a small group of patients, . redirecting research efforts towards understanding, preventing, and magnetic resonance. . eventually treating residual post-capillary PH in patients with valvular Dr Al Maluli suggests that clinical trials with pulmonary vasodila- heart disease (VHD). tors for Group 2 PH should target exclusively patients with overt . Conflict of interest: none declared. signs of RV dysfunction. Although no clinical trial has been designed in such a way, ancillary data from randomized clinical trials do not an- . References ticipate a favourable effect of sildenafil in this subset of patients. 1. Bermejo J, Yotti R, Garcia-Orta R, Sanchez-Fernandez PL, Castano M, Segovia- The RELAX trial showed a neutral effect of sildenafil compared to Cubero J, Escribano-Subias P, San Roman JA, Borras X, Alonso-Gomez A, Botas J, placebo on peak oxygen consumption at 6 months. Importantly, a Crespo-Leiro MG, Velasco S, Bayes-Genis A, Lopez A, Munoz-Aguilera R, de Teresa specific interaction analysis failed to identify any benefit of sildenafil E, Gonzalez-Juanatey JR, Evangelista A, Mombiela T, Gonzalez-Mansilla A, Elizaga J, . Martin-Moreiras J, Gonzalez-Santos JM, Moreno-Escobar E, Fernandez-Aviles F; neither in patients with RV dysfunction nor with RV-pulmonary Sildenafil for Improving Outcomes after VAlvular Correction (SIOVAC) Investigators. artery (PA) uncoupling at enrolment. Sildenafil for improving outcomes in patients with corrected valvular heart disease Patients with RV dysfunction and combined pre and post-capillary . and persistent pulmonary hypertension: a multicenter, double-blind, randomized clin- ical trial. Eur Heart J 2018;39:1255–1264. PH were also represented in the SIOVAC trial. In fact, 57% of 2. Hussain I, Mohammed SF, Forfia PR, Lewis GD, Borlaug BA, Gallup DS, Redfield patients had PVR > 3 WU, 50% had tricuspid annular plane systolic . MM. Impaired right ventricular-pulmonary arterial coupling and effect of sildenafil excursion (TAPSE) < 15 mm, and 29% significant tricuspid regurgita- . in heart failure with preserved ejection fraction: an ancillary analysis from the 1 . Phosphodiesterase-5 Inhibition to Improve Clinical Status And Exercise Capacity tion. Although we pre-defined a searching strategy for drug res- . in Diastolic Heart Failure (RELAX) trial. Circ Heart Fail 2016;9:e002729. ponders, all interaction analyses were non-significant. Observed . 3. Galie N, Manes A, Dardi F, Palazzini M. Aiming at the appropriate target for the trends did not point towards a favourable effect of sildenafil in . treatment of pulmonary hypertension due to left heart disease. Eur Heart J 2018; patients with higher values of PVR, or lower values of cardiac index . 39:1265–1268. * Corresponding author. Tel: þ34 91 5868279, Fax: þ34 91 5866727, Email: javier.bermejo@salud.madrid.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 Journal – Oxford University Press

Published: Apr 24, 2018

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