Parameters and algorithms to evaluate cardiac mechanics by conductance catheter

This work is structured as follows: In Section 1 we discuss the clinical problem of heart failure. In particular, we present the phenomenon known as ventricular mechanical dyssynchrony: its impact on cardiac function, the therapy for its treatment and the methods for its quantification. Specifically, we describe the conductance catheter and its use for the measurement of dyssynchrony. At the end of the Section 1, we propose a new set of indexes to quantify the dyssynchrony that are studied and validated thereafter. In Section 2 we describe the studies carried out in this work: we report the experimental protocols, we present and discuss the results obtained. Finally, we report the overall conclusions drawn from this work and we try to envisage future works and possible clinical applications of our results. Ancillary studies that were carried out during this work mainly to investigate several aspects of cardiac resynchronization therapy (CRT) are mentioned in Appendix. -------- Ventricular mechanical dyssynchrony plays a regulating role already in normal physiology but is especially important in pathological conditions, such as hypertrophy, ischemia, infarction, or heart failure (Chapter 1,2.). Several prospective randomized controlled trials supported the clinical efficacy and safety of cardiac resynchronization therapy (CRT) in patients with moderate or severe heart failure and ventricular dyssynchrony. CRT resynchronizes ventricular contraction by simultaneous pacing of both left and right ventricle (biventricular pacing) (Chapter 1.). Currently, the conductance catheter method has been used extensively to assess global systolic and diastolic ventricular function and, more recently, the ability of this instrument to pick-up multiple segmental volume signals has been used to quantify mechanical ventricular dyssynchrony. Specifically, novel indexes based on volume signals acquired with the conductance catheter were introduced to quantify dyssynchrony (Chapter 3,4.). Present work was aimed to describe the characteristics of the conductancevolume signals, to investigate the performance of the indexes of ventricular dyssynchrony described in literature and to introduce and validate improved dyssynchrony indexes. Morevoer, using the conductance catheter method and the new indexes, the clinical problem of the ventricular pacing site optimization was addressed and the measurement protocol to adopt for hemodynamic tests on cardiac pacing was investigated. In accordance to the aims of the work, in addition to the classical time-domain parameters, a new set of indexes has been extracted, based on coherent averaging procedure and on spectral and cross-spectral analysis (Chapter 4.). Our analyses were carried out on patients with indications for electrophysiologic study or device implantation (Chapter 5.). For the first time, besides patients with heart failure, indexes of mechanical dyssynchrony based on conductance catheter were extracted and studied in a population of patients with preserved ventricular function, providing information on the normal range of such a kind of values. By performing a frequency domain analysis and by applying an optimized coherent averaging procedure (Chapter 6.a.), we were able to describe some characteristics of the conductance-volume signals (Chapter 6.b.). We unmasked the presence of considerable beat-to-beat variations in dyssynchrony that seemed more frequent in patients with ventricular dysfunction and to play a role in discriminating patients. These non-recurrent mechanical ventricular non-uniformities are probably the expression of the substantial beat-to-beat hemodynamic variations, often associated with heart failure and due to cardiopulmonary interaction and conduction disturbances. We investigated how the coherent averaging procedure may affect or refine the conductance based indexes; in addition, we proposed and tested a new set of indexes which quantify the non-periodic components of the volume signals. Using the new set of indexes we studied the acute effects of the CRT and the right ventricular pacing, in patients with heart failure and patients with preserved ventricular function. In the overall population we observed a correlation between the hemodynamic changes induced by the pacing and the indexes of dyssynchrony, and this may have practical implications for hemodynamic-guided device implantation. The optimal ventricular pacing site for patients with conventional indications for pacing remains controversial. The majority of them do not meet current clinical indications for CRT pacing. Thus, we carried out an analysis to compare the impact of several ventricular pacing sites on global and regional ventricular function and dyssynchrony (Chapter 6.c.). We observed that right ventricular pacing worsens cardiac function in patients with and without ventricular dysfunction unless the pacing site is optimized. CRT preserves left ventricular function in patients with normal ejection fraction and improves function in patients with poor ejection fraction despite no clinical indication for CRT. Moreover, the analysis of the results obtained using new indexes of regional dyssynchrony, suggests that pacing site may influence overall global ventricular function depending on its relative effects on regional function and synchrony. Another clinical problem that has been investigated in this work is the optimal right ventricular lead location for CRT (Chapter 6.d.). Similarly to the previous analysis, using novel parameters describing local synchrony and efficiency, we tested the hypothesis and we demonstrated that biventricular pacing with alternative right ventricular pacing sites produces acute improvement of ventricular systolic function and improves mechanical synchrony when compared to standard right ventricular pacing. Although no specific right ventricular location was shown to be superior during CRT, the right ventricular pacing site that produced the optimal acute hemodynamic response varied between patients. Acute hemodynamic effects of cardiac pacing are conventionally evaluated after stabilization episodes. The applied duration of stabilization periods in most cardiac pacing studies varied considerably. With an ad hoc protocol (Chapter 6.e.) and indexes of mechanical dyssynchrony derived by conductance catheter we demonstrated that the usage of stabilization periods during evaluation of cardiac pacing may mask early changes in systolic and diastolic intra-ventricular dyssynchrony. In fact, at the onset of ventricular pacing, the main dyssynchrony and ventricular performance changes occur within a 10s time span, initiated by the changes in ventricular mechanical dyssynchrony induced by aberrant conduction and followed by a partial or even complete recovery. It was already demonstrated in normal animals that ventricular mechanical dyssynchrony may act as a physiologic modulator of cardiac performance together with heart rate, contractile state, preload and afterload. The present observation, which shows the compensatory mechanism of mechanical dyssynchrony, suggests that ventricular dyssynchrony may be regarded as an intrinsic cardiac property, with baseline dyssynchrony at increased level in heart failure patients. To make available an independent system for cardiac output estimation, in order to confirm the results obtained with conductance volume method, we developed and validated a novel technique to apply the Modelflow method (a method that derives an aortic flow waveform from arterial pressure by simulation of a non-linear three-element aortic input impedance model, Wesseling et al. 1993) to the left ventricular pressure signal, instead of the arterial pressure used in the classical approach (Chapter 7.). The results confirmed that in patients without valve abnormalities, undergoing conductance catheter evaluations, the continuous monitoring of cardiac output using the intra-ventricular pressure signal is reliable. Thus, cardiac output can be monitored quantitatively and continuously with a simple and low-cost method. During this work, additional studies were carried out to investigate several areas of uncertainty of CRT. The results of these studies are briefly presented in Appendix: the long-term survival in patients treated with CRT in clinical practice, the effects of CRT in patients with mild symptoms of heart failure and in very old patients, the limited thoracotomy as a second choice alternative to transvenous implant for CRT delivery, the evolution and prognostic significance of diastolic filling pattern in CRT, the selection of candidates to CRT with echocardiographic criteria and the prediction of response to the therapy.

Bioimaging of animal embryogenesis: mathematical methods and computational algorithms

Some fundamental biological processes such as embryonic development have been preserved during evolution and are common to species belonging to different phylogenetic positions, but are nowadays largely unknown. The understanding of cell morphodynamics leading to the formation of organized spatial distribution of cells such as tissues and organs can be achieved through the reconstruction of cells shape and position during the development of a live animal embryo. We design in this work a chain of image processing methods to automatically segment and track cells nuclei and membranes during the development of a zebrafish embryo, which has been largely validates as model organism to understand vertebrate development, gene function and healingrepair mechanisms in vertebrates. The embryo is previously labeled through the ubiquitous expression of fluorescent proteins addressed to cells nuclei and membranes, and temporal sequences of volumetric images are acquired with laser scanning microscopy. Cells position is detected by processing nuclei images either through the generalized form of the Hough transform or identifying nuclei position with local maxima after a smoothing preprocessing step. Membranes and nuclei shapes are reconstructed by using PDEs based variational techniques such as the Subjective Surfaces and the Chan Vese method. Cells tracking is performed by combining informations previously detected on cells shape and position with biological regularization constraints. Our results are manually validated and reconstruct the formation of zebrafish brain at 7-8 somite stage with all the cells tracked starting from late sphere stage with less than 2% error for at least 6 hours. Our reconstruction opens the way to a systematic investigation of cellular behaviors, of clonal origin and clonal complexity of brain organs, as well as the contribution of cell proliferation modes and cell movements to the formation of local patterns and morphogenetic fields.

Breakpoint analysis of human chromosome 3 inversions during hominoid evolution

Comparative fluorescence in situ hybridization (FISH) mapping revealed four large DNA segments which have been conserved in their entirety between human chromosome 3 and Bornean orangutan chromosome 2 as well as three evolutionary breakpoints which distinguish between the human and Bornean orangutan chromosome forms. Examination of the structural and functional features of evolutionary breakpoints provides new insights into the possible effects of evolutionary rearrangements on genome function and the relationship between human chromosome pathology and evolution. FISH of human BAC clones which were assesssed in human genomic sequence to primate chromosomes, combined with precise breakpoint localizations by polymerase chain reaction (PCR) analysis of flow-sorted chromosomes and in silico analysis, were used to characterize the evolutionary breakpoints. None of the three breakpoints studied disrupts a validated gene(s), however they are all associated with segmental duplications. At least eleven DNA segments (&a

Structural and functional analysis of centromeric chromatin

Animal neocentromeres are defined as ectopic centromeres that have formed in non-centromeric locations and avoid some of the features, like the DNA satellite sequence, that normally characterize canonical centromeres. Despite this, they are stable functional centromeres inherited through generations. The only existence of neocentromeres provide convincing evidence that centromere specification is determined by epigenetic rather than sequence-specific mechanisms. For all this reasons, we used them as simplified models to investigate the molecular mechanisms that underlay the formation and the maintenance of functional centromeres. We collected human cell lines carrying neocentromeres in different positions. To investigate the region involved in the process at the DNA sequence level we applied a recent technology that integrates Chromatin Immuno-Precipitation and DNA microarrays (ChIP-on-chip) using rabbit polyclonal antibodies directed against CENP-A or CENP-C human centromeric proteins. These DNA binding-proteins are required for kinetochore function and are exclusively targeted to functional centromeres. Thus, the immunoprecipitation of DNA bound by these proteins allows the isolation of centromeric sequences, including those of the neocentromeres. Neocentromeres arise even in protein-coding genes region. We further analyzed if the increased scaffold attachment sites and the corresponding tighter chromatin of the region involved in the neocentromerization process still were permissive or not to transcription of within encoded genes. Centromere repositioning is a phenomenon in which a neocentromere arisen without altering the gene order, followed by the inactivation of the canonical centromere, becomes fixed in population. It is a process of chromosome rearrangement fundamental in evolution, at the bases of speciation. The repeat-free region where the neocentromere initially forms, progressively acquires extended arrays of satellite tandem repeats that may contribute to its functional stability. In this view our attention focalized to the repositioned horse ECA11 centromere. ChIP-on-chip analysis was used to define the region involved and SNPs studies, mapping within the region involved into neocentromerization, were carried on. We have been able to describe the structural polymorphism of the chromosome 11 centromeric domain of Caballus population. That polymorphism was seen even between homologues chromosome of the same cells. That discovery was the first described ever. Genomic plasticity had a fundamental role in evolution. Centromeres are not static packaged region of genomes. The key question that fascinates biologists is to understand how that centromere plasticity could be combined to the stability and maintenance of centromeric function. Starting from the epigenetic point of view that underlies centromere formation, we decided to analyze the RNA content of centromeric chromatin. RNA, as well as secondary chemically modifications that involve both histones and DNA, represents a good candidate to guide somehow the centromere formation and maintenance. Many observations suggest that transcription of centromeric DNA or of other non-coding RNAs could affect centromere formation. To date has been no thorough investigation addressing the identity of the chromatin-associated RNAs (CARs) on a global scale. This prompted us to develop techniques to identify CARs in a genome-wide approach using high-throughput genomic platforms. The future goal of this study will be to focalize the attention on what strictly happens specifically inside centromere chromatin.

Evolution and historical biogeography of the Eastern Atlantic skates

In my thesis, I tested the hypothesis that the diversification of the Eastern Atlantic skate faunas arose through vicariance rather than dispersal, using combined approach of molecular phylogeny reconstruction and zoogeography (namely historical biogeography). This analyses have been carried out independently on four Rajidae genera belonging to two different tribes: Rajini (Raja and Dipturus) and Amblyrajini (Rajella and Leucoraja). These taxa were selected because they displayed high species diversity and richness of endemic species in the Eastern Atlantic and Mediterranean. The verification of this hypothesis was carried out by reconstructing the best phylogenetic relationships among four genera and 26 species (including several endemism) based on mtDNA and nuDNA gene variation and several statistical approaches. Divergence times of taxa have been estimated based on molecular clock and fossil calibration to explain evolutionary patterns in the context of geological framework. Main issues are (i) the evidence that Eastern Atlantic skate evolution and displacement of species diversity occurred from pulsed geographical speciation (i.e. repeated series of parallel and independent speciation events) started in the Late Eocene-Early Miocene and they have occurred prevalently during Miocene; (ii) such relatively ancient origin of diversification has been allowed the sympatric displacement and evolution of several congeneric taxa likely because they have accumulated huge differences in the genomic and physiological/behavioural phenotypic traits; (iii) recently diverged sister species and taxa showed allopatric or parapatric evolution by the presence of oceanographic or hydrogeographical barriers which likely prevent large mixing between parapatric sister species.

Neoproterozoic to middle Palaeozoic evolution of the Central Asian Orogenic Belt in south-central Mongolia: chronological and geochemical perspectives

Mongolia occupies a central position within the eastern branch of the large accretionary Central Asian Orogenic Belt (CAOB) or Altaids. The present work aims to outline the geodynamic environment and possible evolution of this part of the eastern CAOB, predominantly from the Cambrian to the middle Palaeozoic. The investigation primarily focussed on zircon geochronology as well as whole-rock geochemical and Sm–Nd isotopic analyses for a variety of metaigneous rocks from the southern Hangay and Gobi-Altai regions in south-central Mongolia. The southern slope of the Hangay Mountains in central Mongolia exposes a large NWSE-trending middle Neoproterozoic ophiolitic complex (c. 650 Ma), which is tectonically integrated within an accretionary complex developed between the Precambrian Baydrag and Hangay crustal blocks. Formation of the entire accretionary system along the north-eastern margin of the Baydrag block mainly occurred during the early Cambrian, but convergence within this orogenic zone continued until the early Ordovician, because of on-going southward subduction-accretion of the Baydrag block. An important discovery is the identification of a late Mesoproterozoic to early Neoproterozoic belt within the northern Gobi-Altai that was reworked during the late Cambrian and throughout the late Ordovician/Devonian. Early Silurian low-grade mafic and felsic metavolcanic rocks from the northern Gobi-Altai display subduction-related geochemical features and highly heterogeneous Nd isotopic compositions, which suggest an origin at a mature active continental margin. Early Devonian protoliths of granodioritic and mafic gneisses from the southern Gobi-Altai display geochemical and Nd isotopic compositions compatible with derivation and evolution from predominantly juvenile crustal and mantel sources and these rocks may have been emplaced within the outboard portion of the late Ordovician/early Silurian active continental margin. Moreover, middle Devonian low-grade metavolcanic rocks from the southwestern Gobi-Altai yielded geochemical and Nd isotopic data consistent with emplacement in a transitional arc-backarc setting. The combined U–Pb zircon ages and geochemical data obtained from the Gobi-Altai region suggest that magmatism across an active continental margin migrated oceanwards through time by way of subduction zone retreat throughout the Devonian. Progressive extension of the continental margin was associated with the opening of a backarc basin and culminated in the late Devonian with the formation of a Japan-type arc front facing a southward open oceanic realm (present-day coordinates).

The dynamics of early-type galaxies as a tool to understand their hot coronae and their IMF

Dynamical models of galaxies are a powerful tool to study and understand several astrophysical problems related to galaxy formation and evolution. This thesis is focussed on a particular type of dynamical models, that are widely used in literature, and are based on the solution of the Jeans equations. By means of a numerical Jeans solver code, developed on purpose and able to build state-of-the-art advanced axisymmetric galaxy models, two of the main currently investigated issues in the field of research of early-type galaxies (ETGs) are addressed. The first topic concerns the hot and X-ray emitting gaseous coronae that surround ETGs. The main goal is to explain why flat and rotating galaxies generally exhibit haloes with lower gas temperatures and luminosities with respect to rounder and velocity dispersion supported systems. The second astrophysical problem addressed concerns instead the stellar initial mass function (IMF) of ETGs. Nowadays, this is a very controversial issue due to a growing number of works on ETGs, based on different and independent techniques, that show evidences of a systematic variation of the IMF normalization as a function of galaxy velocity dispersion or mass. These studies are changing the previous opinion that the IMF of ETGs was the same as that of spiral galaxies, and hence universal throughout the whole large family of galaxies.

Residual function, spontaneous reorganisation and treatment plasticity in homonymous visual field defects

This thesis will focus on the residual function and visual and attentional deficits in human patients, which accompany damage to the visual cortex or its thalamic afferents, and plastic changes, which follow it. In particular, I will focus on homonymous visual field defects, which comprise a broad set of central disorders of vision. I will present experimental evidence that when the primary visual pathway is completely damaged, the only signal that can be implicitly processed via subcortical visual networks is fear. I will also present data showing that in a patient with relative deafferentation of visual cortex, changes in the spatial tuning and response gain of the contralesional and ipsilesional cortex are observed, which are accompanied by changes in functional connectivity with regions belonging to the dorsal attentional network and the default mode network. I will also discuss how cortical plasticity might be harnessed to improve recovery through novel treatments. Moreover, I will show how treatment interventions aimed at recruiting spared subcortical pathway supporting multisensory orienting can drive network level change.

Die Bedeutung von molekularem Sauerstoff für die Evolution des genetischen Codes

Die Entstehung und Evolution des genetischen Codes, der die Nukleotidsequenz der mRNA in die Aminosäuresequenz der Proteine übersetzt, zählen zu den größten Rätseln der Biologie. Die ersten Organismen, die vor etwa 3,8 Milliarden Jahren auf der Erde auftraten, nutzten einen ursprünglichen genetischen Code, der vermutlich ausschließlich abiotisch verfügbare Aminosäuren terrestrischer oder extraterrestrischer Herkunft umfasste. Neue Aminosäuren wurden sukzessive biosynthetisiert und selektiv in den Code aufgenommen, welcher in der modernen Form aus bis zu 22 Aminosäuren besteht. Die Ursachen für die Selektion und die Chronologie ihrer Aufnahme sind bis heute unbekannt und sollten im Rahmen der vorliegenden Arbeit erforscht werden. Auf Grundlage quanten-chemischer Berechnungen konnte in dieser Arbeit zunächst ein Zusammenhang zwischen der HOMO-LUMO-Energiedifferenz (H-L-Distanz), die ein inverses quanten-chemisches Korrelat für allgemeine chemische Reaktivität darstellt, und der chronologischen Aufnahme der Aminosäuren in den genetischen Code aufgezeigt werden. Demnach sind ursprüngliche Aminosäuren durch große H-L-Distanzen und neue Aminosäuren durch kleine H-L-Distanzen gekennzeichnet. Bei einer Analyse des Metabolismus von Tyrosin und Tryptophan, bei denen es sich um die beiden jüngsten Standard-Aminosäuren handelt, wurde ihre Bedeutung als Vorläufer von Strukturen ersichtlich, die sich durch eine hohe Redox-Aktivität auszeichnen und deren Synthese gleichzeitig molekularen Sauerstoff erfordert. Aus diesem Grund wurden die Redox-Aktivitäten der 20 Standard-Aminosäuren gegenüber Peroxylradikalen und weiteren Radikalen getestet. Die Untersuchungen ergaben eine Korrelation zwischen evolutionärem Auftreten und chemischer Reaktivität der jeweiligen Aminosäure, die sich insbesondere in der effizienten Reaktion zwischen Tryptophan bzw. Tyrosin und Peroxylradikalen widerspiegelte. Dies indizierte eine potentielle Bedeutung reaktiver Sauerstoffspezies (ROS) bei der Konstituierung des genetischen Codes. Signifikante Mengen an ROS wurden erst zu Beginn der Oxygenierung der Geobiosphäre, die als Great Oxidation Event (GOE) bezeichnet wird und vor circa 2,3 Milliarden Jahren begann, gebildet und müssen zur oxidativen Schädigung vulnerabler, zellulärer Strukturen geführt haben. Aus diesem Grund wurde das antioxidative Potential von Aminosäuren beim Prozess der Lipidperoxidation untersucht. Es konnte gezeigt werden, dass lipophile Derivate von Tryptophan und Tyrosin befähigt sind, die Peroxidation von Rattenhirnmembranen zu verhindern und humane Fibroblasten vor oxidativem Zelltod zu schützen. Daraus gründete sich das in dieser Arbeit aufgestellte Postulat eines Selektionsvorteils primordialer Organismen während des GOEs, die Tryptophan und Tyrosin als redox-aktive Aminosäuren in Membranproteine einbauen konnten und somit vor Oxidationsprozessen geschützt waren. Demzufolge wurde die biochemische Reaktivität als Selektionsparameter sowie oxidativer Stress als prägender Faktor der Evolution des genetischen Codes identifiziert.

Pretransplant pulmonary hypertension and long-term allograft right ventricular function

Graft right ventricular (RV) function is compromised directly posttransplant, especially in heart transplantation (HTx) recipients with pretransplant pulmonary hypertension (PH). Graft RV size and systolic function, and the effect of the recipient's pulmonary haemodynamics on the graft extracellular matrix are not well characterised in the patients long-term after HTx.

Sonographic Assessment of Fetal Cardiac Function: Indirect Measurements of Fetal Cardiac Function, Newer Techniques and Clinical Applications

Noninvasive blood flow measurements based on Doppler ultrasound studies are the main clinical tool for studying the cardiovascular status of fetuses at risk for circulatory compromise. Usually, qualitative analysis of peripheral arteries and in particular clinical situations such as severe growth restriction or volume overload also of venous vessels close to the heart or of flow patterns in the heart is being used to gauge the level of compensation in a fetus. However, quantitative assessment of the driving force of the fetal circulation, the cardiac output remains an elusive goal in fetal medicine. This article reviews the methods for direct and indirect assessment of cardiac function and explains new clinical applications. Part 1 of this review describes the concept of cardiac function and cardiac output and the techniques that have been used to quantify output. Part 2 summarizes the use of arterial and venous Doppler studies in the fetus and gives a detailed description of indirect measurements of cardiac function (like indices derived from the duration of segments of the cardiac cycle) with current examples of their application.

Sonographic Assessment of Fetal Cardiac Function: Introduction and Direct Measurement of Cardiac Function

Noninvasive blood flow measurements based on Doppler ultrasound studies are the main clinical tool for studying the cardiovascular status in fetuses at risk for circulatory compromise. Usually, qualitative analysis of peripheral arteries and, in particular clinical situations such as severe growth restriction or volume overload, also of venous vessels close to the heart or of flow patterns in the heart are being used to gauge the level of compensation in a fetus. Quantitative assessment of the driving force of the fetal circulation, the cardiac output, however, remains an elusive goal in fetal medicine. This article reviews the methods for direct and indirect assessment of cardiac function and explains new clinical applications. Part 1 of this review describes the concept of cardiac function and cardiac output and the techniques that have been used to quantify output. Part 2 summarizes the use of arterial and venous Doppler studies in the fetus and gives a detailed description of indirect measures of cardiac function (like indices derived from the duration of segments of the cardiac cycle) with current examples of their application.

Bacillus anthracis: Molecular taxonomy, population genetics, phylogeny and patho-evolution

Bacillus anthracis, the etiological agent of anthrax, manifests a particular bimodal lifestyle. This bacterial species alternates between short replication phases of 20-40 generations that strictly require infection of the host, normally causing death, interrupted by relatively long, mostly dormant phases as spores in the environment. Hence, the B. anthracis genome is highly homogeneous. This feature and the fact that strains from nearly all parts of the world have been analysed for canonical single nucleotide polymorphisms (canSNPs) and variable number tandem repeats (VNTRs) has allowed the development of molecular epidemiological and molecular clock models to estimate the age of major diversifications in the evolution of B. anthracis and to trace the global spread of this pathogen, which was mostly promoted by movement of domestic cattle with settlers and by international trade of contaminated animal products. From a taxonomic and phylogenetic point of view, B. anthracis is a member of the Bacillus cereus group. The differentiation of B. anthracis from B. cereus sensu strict, solely based on chromosomal markers, is difficult. However, differences in pathogenicity clearly differentiate B. anthracis from B. cereus and are marked by the strict presence of virulence genes located on the two virulence plasmids pXO1 and pXO2, which both are required by the bacterium to cause anthrax. Conversely, anthrax-like symptoms can also be caused by organisms with chromosomal features that are more closely related to B. cereus, but which carry these virulence genes on two plasmids that largely resemble the B. anthracis virulence plasmids. (C) 2011 Elsevier B.V. All rights reserved.

Pulmonary artery pressure and cardiac function in children and adolescents after rapid ascent to 3,450 m

High-altitude destinations are visited by increasing numbers of children and adolescents. High-altitude hypoxia triggers pulmonary hypertension that in turn may have adverse effects on cardiac function and may induce life-threatening high-altitude pulmonary edema (HAPE), but there are limited data in this young population. We, therefore, assessed in 118 nonacclimatized healthy children and adolescents (mean ± SD; age: 11 ± 2 yr) the effects of rapid ascent to high altitude on pulmonary artery pressure and right and left ventricular function by echocardiography. Pulmonary artery pressure was estimated by measuring the systolic right ventricular to right atrial pressure gradient. The echocardiography was performed at low altitude and 40 h after rapid ascent to 3,450 m. Pulmonary artery pressure was more than twofold higher at high than at low altitude (35 ± 11 vs. 16 ± 3 mmHg; P < 0.0001), and there existed a wide variability of pulmonary artery pressure at high altitude with an estimated upper 95% limit of 52 mmHg. Moreover, pulmonary artery pressure and its altitude-induced increase were inversely related to age, resulting in an almost twofold larger increase in the 6- to 9- than in the 14- to 16-yr-old participants (24 ± 12 vs. 13 ± 8 mmHg; P = 0.004). Even in children with the most severe altitude-induced pulmonary hypertension, right ventricular systolic function did not decrease, but increased, and none of the children developed HAPE. HAPE appears to be a rare event in this young population after rapid ascent to this altitude at which major tourist destinations are located.