围心脏手术期被动肺动脉高压:从基础到临床
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摘要
由于左心房压力的升高而导致肺动脉压力升高称为被动肺高压(passive pulmonary hypertension,pPH),多由左心疾病导致,其实质是肺血容量增多,在PH分类中pPH属第二类。最近,我们小组鉴定出另一类pPH,它由血管收缩药物引起,与左心疾病导致的pPH有相似的病理生理表现,二者可以叠加而加重pPH。围心脏手术期,手术创伤导致的心脏功能不全时常使用血管收缩药物,因此临床中pPH的叠加现象可能极为普遍。然而,此类肺高压诊断困难而临床上对此认识不足而常被忽视。为增加对pPH的了解,减轻其临床危害,本文对两类pPH的病理生理及其叠加效应进行综述。
In left heart disease, pulmonary artery pressure would increase due to the elevated left atrial pressure.This type of pulmonary hypertension(PH) is belonged to type Ⅱ as a passive PH(pPH) in its classification. The essential cause of pPH is excessive blood volume. Recently, we have identified another type of pPH, which is induced by vasopressors. Vasopressor-induced pPH shares similar pathophysiological manifestations with left heart disease-induced pPH. pPH would, therefore, be aggressive if vasopressors were applied in patients with left heart disease, which may be common after cardiac surgery, because heart undergoing surgical trauma may require support of vasopressors.Unfortunately, pPH after cardiac surgery is often ignored because of the difficulty in diagnosis. To improve the understanding of pPH and its effect on outcomes, here we highlight the mechanisms of interaction between vasopressorinduced and left heart failure-induced pPH, and provide insights into its therapeutic options.
In left heart disease, pulmonary artery pressure would increase due to the elevated left atrial pressure.This type of pulmonary hypertension(PH) is belonged to type Ⅱ as a passive PH(pPH) in its classification. The essential cause of pPH is excessive blood volume. Recently, we have identified another type of pPH, which is induced by vasopressors. Vasopressor-induced pPH shares similar pathophysiological manifestations with left heart disease-induced pPH. pPH would, therefore, be aggressive if vasopressors were applied in patients with left heart disease, which may be common after cardiac surgery, because heart undergoing surgical trauma may require support of vasopressors.Unfortunately, pPH after cardiac surgery is often ignored because of the difficulty in diagnosis. To improve the understanding of pPH and its effect on outcomes, here we highlight the mechanisms of interaction between vasopressorinduced and left heart failure-induced pPH, and provide insights into its therapeutic options.
引文
1 Simonneau G, Gatzoulis MA, Adatia I, et al. Updated clinical classification of pulmonary hypertension. J Am Coll Cardiol, 2013,62(25Suppl):D34-D41.
2 Galie N, Hoeper MM, Humbert M, et al. Guidelines for the diagnosis and treatment of pulmonary hypertension:the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology(ESC)and the European Respiratory Society(ERS), endorsed by the International Society of Heart and Lung Transplantation(ISHLT). Eur Heart J,2009, 30(20):2493-2537.
3 Rosenkranz S, Gibbs JS, Wachter R, et al. Left ventricular heart failure and pulmonary hypertension. Eur Heart J, 2016, 37(12):942-954.
4 Hoeper MM, Bogaard HJ, Condliffe R, et al. Definitions and diagnosis of pulmonary hypertension. J Am Coll Cardiol, 2013,62(25 Suppl):D42-D50.
5 Jiang C, Qian H, Luo S, et al. Vasopressors induce passive pulmonary hypertension by blood redistribution from systemic to pulmonary circulation. Basic Res Cardiol, 2017,112(3):21.
6 Vachiery JL, Adir Y, Barbera JA, et al. Pulmonary hypertension due to left heart diseases. J Am Coll Cardiol, 2013, 62(25 Suppl):D100-D108.
7 Arrigo M, Huber LC. Passive pulmonary hypertension:more than hydrostatics. Chest, 2014, 145(2):413.
8 Lemos-Filho, Luciano B, Mikkelsen, et al. Sex, race, and the development of acute lung injury. Chest, 2013,143(4):901-909.
9 Borlaug BA. Discerning pulmonary venous from pulmonary arterial hypertension without the help of a catheter. Circ Heart fail,2011, 4(3):235-237.
10 Robbins IM, Hemnes AR, Pugh ME, et al. High prevalence of occult pulmonary venous hypertension revealed by fluid challenge in pulmonary hypertension. Circ Heart Fail, 2014, 7(1):116-122.
11 Oudiz RJ. Pulmonary hypertension associated with left-sided heart disease. Clin Chest Med, 2007, 28(1):233-241.
12 Melenovsky V, Borlaug BA, Rosen B, et al. Cardiovascular features of heart failure with preserved ejection fraction versus nonfailing hypertensive left ventricular hypertrophy in the urban Baltimore community:the role of atrial remodeling/dysfunction. J Am Coll Cardiol, 2007, 49(2):198-207.
13 Melenovsky V, Hwang SJ, Lin G, et al. Right heart dysfunction in heart failure with preserved ejection fraction. Eur Heart J, 2014,35(48):3452-3462.
14 Zakeri R,Chamberlain, AM, Roger, VL, et al. Temporal relationship and prognostic significance of atrial fibrillation in heart failure patients with preserved ejection fraction:a community-based study. Circulation, 2013,128(10):1085-1093.
15 Georgiopoulou VV, Kalogeropoulos AP, Borlaug BA, et al. Left ventricular dysfunction with pulmonary hypertension:part 1:epidemiology, pathophysiology, and definitions. Circ Heart Fail,2013,6(2):344-354.
16 Dupuis J, Guaazi M. Pathophysiology and clinical relevance of pulmonary remodelling in pulmonary hypertension due to left heart diseases. Can J Cardiol, 2015, 31:416-429.
17 Mikkelsen ME, Christie JD, Lanken PN, et al. The adult respiratory distress syndrome cognitive outcomes study:long-term neuropsychological function in survivors of acute lung injury. Am J Resp Crit Care Med, 2012, 185:1307-1315.
18 Agarwal R, Shah SJ, Foreman AJ, et al. Risk assessment in pulmonary hypertension associated with heart failure and preserved ejection fraction. J Heart Lung Transpl, 2012, 31(5):467-477.
19 Ten Freyhaus H, Dagnell M, Leuchs M, et al. Hypoxia enhances platelet-derived growth factor signaling in the pulmonary vasculature by down-regulation of protein tyrosine PHosPHatases.Am J Resp Crit Care Med, 2011,183(8):1092-1102.
20 Harvey RM, Enson Y, Ferrer MI. A reconsideration of the origins of pulmonary hypertension. Chest, 1971, 59(1):82-94.
21 Naeije R, Vachiery JL, Yerly P, et al. The transpulmonary pressure gradient for the diagnosis of pulmonary vascular disease. Eur Respir J, 2013, 41(1):217-223.
22 Gerges C, Gerges M, Lang MB, et al. Diastolic pulmonary vascular pressure gradient:a predictor of prognosis in"out-of-proportion"pulmonary hypertension. Chest, 2013, 143(3):758-766.
23 Chen Y, Guo H, Xu D, et al. Left ventricular failure produces profound lung remodeling and pulmonary hypertension in mice:heart failure causes severe lung disease. Hypertension, 2012, 59(6):1170-1178.
24 Guazzi M, Borlaug BA. Pulmonary hypertension due to left heart disease. Circulation, 2012,126(8):975-990.
25 Fujimoto N, Borlaug BA, Lewis GD, et al. Hemodynamic responses to rapid saline loading:the impact of age, sex, and heart failure.Circulation, 2013, 127(1):55-62.
26 Andersen MJ, Olson TP, Melenovsky V, et al. Differential hemodynamic effects of exercise and volume expansion in people with and without heart failure. Circ Heart Fail, 2015, 8:41-48.
27 Omar S, Zedan A, Nugent K. Cardiac vasoplegia syndrome:pathophysiology, risk factors and treatment. Am J Med Sci, 2015,349(1):80-88.
28 Hochman JS, Buller CE, Sleeper LA, et al. Cardiogenic shock complicating acute myocardial infarction--etiologies, management and outcome:a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries for cardiogenic shock? J Am Coll Cardiol, 2000, 36(3 Suppl A):1063-1070.
29 Aung K, Htay T. Vasopressin for cardiac arrest:a systematic review and meta-analysis.. Arch Intern Med, 2005, 165(1):17-24.
30 Mentz RJ, Metra M, Cotter G, et al. Early vs. late worsening heart failure during acute heart failure hospitalization:insights from the PROTECT trial. Eur J Heart Fail, 2015,17(7):697-706.
31 Rieg AD, Rossaint R, Uhlig S, et al. Cardiovascular agents affect the tone of pulmonary arteries and veins in precision-cut lung slices.PloS one, 2011, 6(12):e29698.
32 Sarkar J, Golden PJ, Kajiura LN, et al. Vasopressin decreases pulmonary-to-systemic vascular resistance ratio in a porcine model of severe hemorrhagic shock. Shock, 2015, 43(5):475-482.
33 Leather HA, Segers P, Berends N, et al. Effects of vasopressin on right ventricular function in an experimental model of acute pulmonary hypertension. Crit Care Med, 2002, 30(11):2548-2552.
34 Hussain MB, Marshall I. Characterization of alpha 1-adrenoceptor subtypes mediating contractions to phenylephrine in rat thoracic aorta, mesenteric artery and pulmonary artery. Br J Pharmacol,1997,122(5):849-858.
35 Morimatsu H, Ishikawa K, May CN, et al. The systemic and regional hemodynamic effects of PHenylePHrine in sheep under normal conditions and during early hyperdynamic sepsis. Anesth Analg, 2012,115(2):330-342.
36 Lamy A, Devereaux PJ, Prabhakaran D, et al. Five-year outcomes after off-pump or on-pump coronary-artery bypass grafting. N Engl J Med, 2016, 375(24):2359-2368.
37 Koch CG, Li L, Sessler DI, et al. Duration of red-cell storage and complications after cardiac surgery. N Engl J Med, 2008, 358(12):1229-1239.
38 Fergusson DA, Hebert PC, Mazer CD, et al. A comparison of aprotinin and lysine analogues in high-risk cardiac surgery. N Engl J Med, 2008, 358(22):2319-2331.
39 Qiu Y, Lin J, Yang Y, et al. Lack of efficacy of ulinastatin therapy during cardiopulmonary bypass surgery. Chin Med J(Engl), 2015,128:3138-3142.
40 Hein OV, Birnbaum J, Wernecke KD, et al. Three-year survival after four major post-cardiac operative complications. Crit Care Med, 2006, 34(11):2729-2737.
41 Du B, An Y, Kang Y, et al. Characteristics of critically ill patients in ICUs in mainland China. Crit Care Med, 2013, 41(1):84-92.
42 Packer M, McMurray J, Massie BM, et al. Clinical effects of endothelin receptor antagonism with bosentan in patients with severe chronic heart failure:results of a pilot study. J Card Fail,2005,11(1):12-20.
43 Califf RM, Adams KF, McKenna WJ, et al. A randomized controlled trial of epoprostenol therapy for severe congestive heart failure:the Flolan International Randomized Survival Trial(FIRST). Am Heart J, 1997,134(1):44-54.
44 Redfield MM, Chen HH, Borlaug BA, et al. Effect of phosphodiesterase-5 inhibition on exercise capacity and clinical status in heart failure with preserved ejection fraction:a randomized clinical trial. JAMA, 2013, 309:1268-1277.
45 HasenfuβG, Hayward C, Burkhoff D, et al. A transcatheter intracardiac shunt device for heart failure with preserved ejection fraction(REDUCE LAP-HF):a multicentre, open-label, singlearm, phase 1 trial. Lancet, 2016, 387:1298-1304.
46 Del Trigo M, Bergeron S, Bernier M, et al. Unidirectional Left-toright interatrial shunting for treatment of patients with heart failure with reduced ejection fraction:a safety and proof-ofprinciple cohort study. Lancet, 2016, 387:1290-1297.
47 Abraham WT, Adamson PB, Bourge RC, et al. Wireless pulmonary artery haemodynamic monitoring in chronic heart failure:a randomised controlled trial. Lancet, 2011, 377(9766):658-666.
48 Patel ND, Weiss ES, Schaffer J, et al. Right heart dysfunction after left ventricular assist device implantation:a comparison of the pulsatile HeartMate I and axial-flow HeartMate II devices. Ann Thorac Surg, 2008, 86(3):832-840.
49 Torre-Amione G, Southard RE, Loebe MM, et al. Reversal of secondary pulmonary hypertension by axial and pulsatile mechanical circulatory support. J Heart Lung Transplant, 2010,29(2):195-200.
2 Galie N, Hoeper MM, Humbert M, et al. Guidelines for the diagnosis and treatment of pulmonary hypertension:the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology(ESC)and the European Respiratory Society(ERS), endorsed by the International Society of Heart and Lung Transplantation(ISHLT). Eur Heart J,2009, 30(20):2493-2537.
3 Rosenkranz S, Gibbs JS, Wachter R, et al. Left ventricular heart failure and pulmonary hypertension. Eur Heart J, 2016, 37(12):942-954.
4 Hoeper MM, Bogaard HJ, Condliffe R, et al. Definitions and diagnosis of pulmonary hypertension. J Am Coll Cardiol, 2013,62(25 Suppl):D42-D50.
5 Jiang C, Qian H, Luo S, et al. Vasopressors induce passive pulmonary hypertension by blood redistribution from systemic to pulmonary circulation. Basic Res Cardiol, 2017,112(3):21.
6 Vachiery JL, Adir Y, Barbera JA, et al. Pulmonary hypertension due to left heart diseases. J Am Coll Cardiol, 2013, 62(25 Suppl):D100-D108.
7 Arrigo M, Huber LC. Passive pulmonary hypertension:more than hydrostatics. Chest, 2014, 145(2):413.
8 Lemos-Filho, Luciano B, Mikkelsen, et al. Sex, race, and the development of acute lung injury. Chest, 2013,143(4):901-909.
9 Borlaug BA. Discerning pulmonary venous from pulmonary arterial hypertension without the help of a catheter. Circ Heart fail,2011, 4(3):235-237.
10 Robbins IM, Hemnes AR, Pugh ME, et al. High prevalence of occult pulmonary venous hypertension revealed by fluid challenge in pulmonary hypertension. Circ Heart Fail, 2014, 7(1):116-122.
11 Oudiz RJ. Pulmonary hypertension associated with left-sided heart disease. Clin Chest Med, 2007, 28(1):233-241.
12 Melenovsky V, Borlaug BA, Rosen B, et al. Cardiovascular features of heart failure with preserved ejection fraction versus nonfailing hypertensive left ventricular hypertrophy in the urban Baltimore community:the role of atrial remodeling/dysfunction. J Am Coll Cardiol, 2007, 49(2):198-207.
13 Melenovsky V, Hwang SJ, Lin G, et al. Right heart dysfunction in heart failure with preserved ejection fraction. Eur Heart J, 2014,35(48):3452-3462.
14 Zakeri R,Chamberlain, AM, Roger, VL, et al. Temporal relationship and prognostic significance of atrial fibrillation in heart failure patients with preserved ejection fraction:a community-based study. Circulation, 2013,128(10):1085-1093.
15 Georgiopoulou VV, Kalogeropoulos AP, Borlaug BA, et al. Left ventricular dysfunction with pulmonary hypertension:part 1:epidemiology, pathophysiology, and definitions. Circ Heart Fail,2013,6(2):344-354.
16 Dupuis J, Guaazi M. Pathophysiology and clinical relevance of pulmonary remodelling in pulmonary hypertension due to left heart diseases. Can J Cardiol, 2015, 31:416-429.
17 Mikkelsen ME, Christie JD, Lanken PN, et al. The adult respiratory distress syndrome cognitive outcomes study:long-term neuropsychological function in survivors of acute lung injury. Am J Resp Crit Care Med, 2012, 185:1307-1315.
18 Agarwal R, Shah SJ, Foreman AJ, et al. Risk assessment in pulmonary hypertension associated with heart failure and preserved ejection fraction. J Heart Lung Transpl, 2012, 31(5):467-477.
19 Ten Freyhaus H, Dagnell M, Leuchs M, et al. Hypoxia enhances platelet-derived growth factor signaling in the pulmonary vasculature by down-regulation of protein tyrosine PHosPHatases.Am J Resp Crit Care Med, 2011,183(8):1092-1102.
20 Harvey RM, Enson Y, Ferrer MI. A reconsideration of the origins of pulmonary hypertension. Chest, 1971, 59(1):82-94.
21 Naeije R, Vachiery JL, Yerly P, et al. The transpulmonary pressure gradient for the diagnosis of pulmonary vascular disease. Eur Respir J, 2013, 41(1):217-223.
22 Gerges C, Gerges M, Lang MB, et al. Diastolic pulmonary vascular pressure gradient:a predictor of prognosis in"out-of-proportion"pulmonary hypertension. Chest, 2013, 143(3):758-766.
23 Chen Y, Guo H, Xu D, et al. Left ventricular failure produces profound lung remodeling and pulmonary hypertension in mice:heart failure causes severe lung disease. Hypertension, 2012, 59(6):1170-1178.
24 Guazzi M, Borlaug BA. Pulmonary hypertension due to left heart disease. Circulation, 2012,126(8):975-990.
25 Fujimoto N, Borlaug BA, Lewis GD, et al. Hemodynamic responses to rapid saline loading:the impact of age, sex, and heart failure.Circulation, 2013, 127(1):55-62.
26 Andersen MJ, Olson TP, Melenovsky V, et al. Differential hemodynamic effects of exercise and volume expansion in people with and without heart failure. Circ Heart Fail, 2015, 8:41-48.
27 Omar S, Zedan A, Nugent K. Cardiac vasoplegia syndrome:pathophysiology, risk factors and treatment. Am J Med Sci, 2015,349(1):80-88.
28 Hochman JS, Buller CE, Sleeper LA, et al. Cardiogenic shock complicating acute myocardial infarction--etiologies, management and outcome:a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries for cardiogenic shock? J Am Coll Cardiol, 2000, 36(3 Suppl A):1063-1070.
29 Aung K, Htay T. Vasopressin for cardiac arrest:a systematic review and meta-analysis.. Arch Intern Med, 2005, 165(1):17-24.
30 Mentz RJ, Metra M, Cotter G, et al. Early vs. late worsening heart failure during acute heart failure hospitalization:insights from the PROTECT trial. Eur J Heart Fail, 2015,17(7):697-706.
31 Rieg AD, Rossaint R, Uhlig S, et al. Cardiovascular agents affect the tone of pulmonary arteries and veins in precision-cut lung slices.PloS one, 2011, 6(12):e29698.
32 Sarkar J, Golden PJ, Kajiura LN, et al. Vasopressin decreases pulmonary-to-systemic vascular resistance ratio in a porcine model of severe hemorrhagic shock. Shock, 2015, 43(5):475-482.
33 Leather HA, Segers P, Berends N, et al. Effects of vasopressin on right ventricular function in an experimental model of acute pulmonary hypertension. Crit Care Med, 2002, 30(11):2548-2552.
34 Hussain MB, Marshall I. Characterization of alpha 1-adrenoceptor subtypes mediating contractions to phenylephrine in rat thoracic aorta, mesenteric artery and pulmonary artery. Br J Pharmacol,1997,122(5):849-858.
35 Morimatsu H, Ishikawa K, May CN, et al. The systemic and regional hemodynamic effects of PHenylePHrine in sheep under normal conditions and during early hyperdynamic sepsis. Anesth Analg, 2012,115(2):330-342.
36 Lamy A, Devereaux PJ, Prabhakaran D, et al. Five-year outcomes after off-pump or on-pump coronary-artery bypass grafting. N Engl J Med, 2016, 375(24):2359-2368.
37 Koch CG, Li L, Sessler DI, et al. Duration of red-cell storage and complications after cardiac surgery. N Engl J Med, 2008, 358(12):1229-1239.
38 Fergusson DA, Hebert PC, Mazer CD, et al. A comparison of aprotinin and lysine analogues in high-risk cardiac surgery. N Engl J Med, 2008, 358(22):2319-2331.
39 Qiu Y, Lin J, Yang Y, et al. Lack of efficacy of ulinastatin therapy during cardiopulmonary bypass surgery. Chin Med J(Engl), 2015,128:3138-3142.
40 Hein OV, Birnbaum J, Wernecke KD, et al. Three-year survival after four major post-cardiac operative complications. Crit Care Med, 2006, 34(11):2729-2737.
41 Du B, An Y, Kang Y, et al. Characteristics of critically ill patients in ICUs in mainland China. Crit Care Med, 2013, 41(1):84-92.
42 Packer M, McMurray J, Massie BM, et al. Clinical effects of endothelin receptor antagonism with bosentan in patients with severe chronic heart failure:results of a pilot study. J Card Fail,2005,11(1):12-20.
43 Califf RM, Adams KF, McKenna WJ, et al. A randomized controlled trial of epoprostenol therapy for severe congestive heart failure:the Flolan International Randomized Survival Trial(FIRST). Am Heart J, 1997,134(1):44-54.
44 Redfield MM, Chen HH, Borlaug BA, et al. Effect of phosphodiesterase-5 inhibition on exercise capacity and clinical status in heart failure with preserved ejection fraction:a randomized clinical trial. JAMA, 2013, 309:1268-1277.
45 HasenfuβG, Hayward C, Burkhoff D, et al. A transcatheter intracardiac shunt device for heart failure with preserved ejection fraction(REDUCE LAP-HF):a multicentre, open-label, singlearm, phase 1 trial. Lancet, 2016, 387:1298-1304.
46 Del Trigo M, Bergeron S, Bernier M, et al. Unidirectional Left-toright interatrial shunting for treatment of patients with heart failure with reduced ejection fraction:a safety and proof-ofprinciple cohort study. Lancet, 2016, 387:1290-1297.
47 Abraham WT, Adamson PB, Bourge RC, et al. Wireless pulmonary artery haemodynamic monitoring in chronic heart failure:a randomised controlled trial. Lancet, 2011, 377(9766):658-666.
48 Patel ND, Weiss ES, Schaffer J, et al. Right heart dysfunction after left ventricular assist device implantation:a comparison of the pulsatile HeartMate I and axial-flow HeartMate II devices. Ann Thorac Surg, 2008, 86(3):832-840.
49 Torre-Amione G, Southard RE, Loebe MM, et al. Reversal of secondary pulmonary hypertension by axial and pulsatile mechanical circulatory support. J Heart Lung Transplant, 2010,29(2):195-200.