The elephant in the room: reply

The elephant in the room: reply DISCUSSION FORUM European Heart Journal (2018) 0, 1–1 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 We read with interest the letter of Dr Al Maluli, and very much ap- avoiding pulmonary vasodilators in Group 2 PH, irrespective of the preciate his interest on our work. We agree that right ventricular degree of RV dysfunction or RV-PA uncoupling. (RV) function has a central role in patients with pulmonary hyperten- In patients enrolled in the SIOVAC trial, despite normal prosthetic sion (PH) and should never been overlooked. In fact, the SIOVAC valve function and diuretic optimization, pulmonary capillary wedge trial included a comprehensive assessment of RV structure and func- pressure was unexpectedly high. Elevated left atrial pressure arises as tion using echocardiography and, in a small group of patients, magnet- the major determinant of an abnormal pulmonary circulation and out- ic resonance. comesin thispopulation. Therefore, we believe our results call for Dr Al Maluli suggests that clinical trials with pulmonary vasodila- redirecting research efforts towards understanding, preventing, and tors for Group 2 PH should target exclusively patients with overt eventually treating residual post-capillary PH in patients with valvular signs of RV dysfunction. Although no clinical trial has been heart disease (VHD). designed in such a way, ancillary data from randomized clinical tri- Conflict of interest: none declared. als do not anticipate a favourable effect of sildenafil in this subset . of patients. . References The RELAX trial showed a neutral effect of sildenafil compared to . . 1. Bermejo J, Yotti R, Garcia-Orta R, Sanchez-Fernandez PL, Castano M, Segovia- placebo on peak oxygen consumption at 6 months. Importantly, a . Cubero J, Escribano-Subias P, San Roman JA, Borras X, Alonso-Gomez A, Botas J, specific interaction analysis failed to identify any benefit of sildenafil . Crespo-Leiro MG, Velasco S, Bayes-Genis A, Lopez A, Munoz-Aguilera R, de Teresa neither in patients with RV dysfunction nor with RV-pulmonary 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; artery (PA) uncoupling at enrolment. Sildenafil for Improving Outcomes after VAlvular Correction (SIOVAC) Investigators. Patients with RV dysfunction and combined pre and post-capillary Sildenafil for improving outcomes in patients with corrected valvular heart disease PH were also represented in the SIOVAC trial. In fact, 57% of and persistent pulmonary hypertension: a multicenter, double-blind, randomized clin- ical trial. Eur Heart J 2018;39:1255–1264. doi: 10.1093/eurheartj/ehx700. patients had PVR > 3 WU, 50% had tricuspid annular plane systolic . 2. Hussain I, Mohammed SF, Forfia PR, Lewis GD, Borlaug BA, Gallup DS, Redfield excursion (TAPSE) < 15 mm, and 29% significant tricuspid regurgita- MM. Impaired right ventricular-pulmonary arterial coupling and effect of sildenafil tion. Although we pre-defined a searching strategy for drug res- . in heart failure with preserved ejection fraction: an ancillary analysis from the Phosphodiesterase-5 Inhibition to Improve Clinical Status And Exercise Capacity ponders, all interaction analyses were non-significant. Observed in Diastolic Heart Failure (RELAX) trial. Circ Heart Fail 2016;9:e002729. trends did not point towards a favourable effect of sildenafil in . 3. Galie N, Manes A, Dardi F, Palazzini M. Aiming at the appropriate target for the patients with higher values of PVR, or lower values of cardiac index treatment of pulmonary hypertension due to left heart disease. Eur Heart J 2018; or TAPSE. Thus, evidence from randomized clinical trials supports 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. Downloaded from https://academic.oup.com/eurheartj/advance-article-abstract/doi/10.1093/eurheartj/ehy241/4983962 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
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Abstract

DISCUSSION FORUM European Heart Journal (2018) 0, 1–1 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 We read with interest the letter of Dr Al Maluli, and very much ap- avoiding pulmonary vasodilators in Group 2 PH, irrespective of the preciate his interest on our work. We agree that right ventricular degree of RV dysfunction or RV-PA uncoupling. (RV) function has a central role in patients with pulmonary hyperten- In patients enrolled in the SIOVAC trial, despite normal prosthetic sion (PH) and should never been overlooked. In fact, the SIOVAC valve function and diuretic optimization, pulmonary capillary wedge trial included a comprehensive assessment of RV structure and func- pressure was unexpectedly high. Elevated left atrial pressure arises as tion using echocardiography and, in a small group of patients, magnet- the major determinant of an abnormal pulmonary circulation and out- ic resonance. comesin thispopulation. Therefore, we believe our results call for Dr Al Maluli suggests that clinical trials with pulmonary vasodila- redirecting research efforts towards understanding, preventing, and tors for Group 2 PH should target exclusively patients with overt eventually treating residual post-capillary PH in patients with valvular signs of RV dysfunction. Although no clinical trial has been heart disease (VHD). designed in such a way, ancillary data from randomized clinical tri- Conflict of interest: none declared. als do not anticipate a favourable effect of sildenafil in this subset . of patients. . References The RELAX trial showed a neutral effect of sildenafil compared to . . 1. Bermejo J, Yotti R, Garcia-Orta R, Sanchez-Fernandez PL, Castano M, Segovia- placebo on peak oxygen consumption at 6 months. Importantly, a . Cubero J, Escribano-Subias P, San Roman JA, Borras X, Alonso-Gomez A, Botas J, specific interaction analysis failed to identify any benefit of sildenafil . Crespo-Leiro MG, Velasco S, Bayes-Genis A, Lopez A, Munoz-Aguilera R, de Teresa neither in patients with RV dysfunction nor with RV-pulmonary 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; artery (PA) uncoupling at enrolment. Sildenafil for Improving Outcomes after VAlvular Correction (SIOVAC) Investigators. Patients with RV dysfunction and combined pre and post-capillary Sildenafil for improving outcomes in patients with corrected valvular heart disease PH were also represented in the SIOVAC trial. In fact, 57% of and persistent pulmonary hypertension: a multicenter, double-blind, randomized clin- ical trial. Eur Heart J 2018;39:1255–1264. doi: 10.1093/eurheartj/ehx700. patients had PVR > 3 WU, 50% had tricuspid annular plane systolic . 2. Hussain I, Mohammed SF, Forfia PR, Lewis GD, Borlaug BA, Gallup DS, Redfield excursion (TAPSE) < 15 mm, and 29% significant tricuspid regurgita- MM. Impaired right ventricular-pulmonary arterial coupling and effect of sildenafil tion. Although we pre-defined a searching strategy for drug res- . in heart failure with preserved ejection fraction: an ancillary analysis from the Phosphodiesterase-5 Inhibition to Improve Clinical Status And Exercise Capacity ponders, all interaction analyses were non-significant. Observed in Diastolic Heart Failure (RELAX) trial. Circ Heart Fail 2016;9:e002729. trends did not point towards a favourable effect of sildenafil in . 3. Galie N, Manes A, Dardi F, Palazzini M. Aiming at the appropriate target for the patients with higher values of PVR, or lower values of cardiac index treatment of pulmonary hypertension due to left heart disease. Eur Heart J 2018; or TAPSE. Thus, evidence from randomized clinical trials supports 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. Downloaded from https://academic.oup.com/eurheartj/advance-article-abstract/doi/10.1093/eurheartj/ehy241/4983962 by Ed 'DeepDyve' Gillespie user on 08 June 2018

Journal

European Heart JournalOxford University Press

Published: Apr 24, 2018

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