Chest
Original Research Pulmonary Vascular DiseaseExaggerated Pulmonary Hypertension and Right Ventricular Dysfunction in High-Altitude Dwellers With Patent Foramen Ovale
Section snippets
Study Design and Participants
The study population consisted of 35 male patients with CMS and 22 healthy male HA dwellers living permanently in the city of La Paz or its surroundings (3,600-4,000 m altitude), enrolled consecutively in the study. All participants had typical Aymara surnames and self-identified themselves as Aymaras (the major indigenous population living in this region).
The patients with CMS were recruited at the Instituto Boliviano de Biologia de Altura, where the diagnosis of CMS was established based on
Baseline Characteristics
A PFO was found in 18 of the 57 participants (32%), of whom four had a PFO grade I, four had grade II, and 10 had grade III. Age, proportion of patients with CMS, and other baseline characteristics were similar between participants with and without a PFO (Table 1). A PFO grade I or II was found in four of 35 patients with CMS (11%) and in four of 22 healthy HA dwellers (18%), whereas a PFO grade III was found in six of 35 patients with CMS (17%) and four of 22 healthy subjects (18%) (P= .96).
Arterial Oxygen Saturation, Pulmonary Hemodynamic, and RV Variables at Rest
Discussion
In disease states associated with hypoxemia at low altitude, a PFO is associated with increased pulmonary artery pressure.6, 7 Surprisingly, in HA dwellers there is no information on the prevalence of PFO and its potential consequences on pulmonary artery pressure and RV function. Here, we believe for the first time, we show that although the prevalence of PFO in HA dwellers (32%) was similar to the one reported in low-altitude populations,24 its presence was associated with important
Conclusions
In conclusion, we show, for the first time to our knowledge, that in HA dwellers, the presence and the size of a PFO appear to have important hemodynamic consequences. At rest it's presence was associated with RV enlargement and, even more importantly, during mild exercise expected to be frequently associated with daily activity, a PFO in HA dwellers was related to exaggerated pulmonary hypertension and pulmonary vasoconstriction that was associated with RV enlargement and dysfunction.
Acknowledgments
Author contributions:R. B. had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. S. F. R., E. R., Y. A., and U. S. contributed to the study concept and design; R. B., L. P., S. F. R., E. R., and Y. A. contributed to the acquisition of the data; R. B., L. P., S. F. R., and U. S. contributed to the analysis and interpretation of data; R. B. and U. S. contributed to the drafting of the manuscript; L. P., S. F. R.,
References (32)
- et al.
Pulmonary hypertension in healthy men born and living at high altitudes
Am J Cardiol
(1963) - et al.
Circulatory adaptation to long-term high altitude exposure in Aymaras and Caucasians
Prog Cardiovasc Dis
(2010) - et al.
Prevalence of patent foramen ovale and its contribution to hypoxemia in patients with obstructive sleep apnea
Chest
(1998) - et al.
Increased prevalence of patent foramen ovale in patients with severe chronic obstructive pulmonary disease
J Am Soc Echocardiogr
(1999) - et al.
Exaggerated pulmonary hypertension during mild exercise in chronic mountain sickness
Chest
(2010) - et al.
Patent foramen ovale: a review of associated conditions and the impact of physiological size
J Am Coll Cardiol
(2001) - et al.
Effect on migraine of closure of cardiac right-to-left shunts to prevent recurrence of decompression illness or stroke or for haemodynamic reasons
Lancet
(2000) - et al.
Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography. Recommendations for quantification of Doppler echocardiography: a report from the Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography
J Am Soc Echocardiogr
(2002) - et al.
Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography
J Am Soc Echocardiogr
(2010) - et al.
RV contractility and exercise-induced pulmonary hypertension in chronic mountain sickness: a stress echocardiographic and tissue Doppler imaging study
JACC Cardiovasc Imaging
(2013)
Exercise induces rapid interstitial lung water accumulation in patients with chronic mountain sickness
Chest
Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts
Mayo Clin Proc
Patent foramen ovale in severe obstructive sleep apnea: clinical features and effects of closure
Chest
Patent foramen ovale-obstructive sleep apnea relationships: pro and cons
Cardiovasc Revasc Med
Systemic vascular dysfunction in patients with chronic mountain sickness
Chest
Oxidative-nitrosative stress and systemic vascular function in highlanders with and without exaggerated hypoxemia
Chest
Cited by (17)
High prevalence of patent foramen ovale in recreational to elite breath hold divers
2022, Journal of Science and Medicine in SportCitation Excerpt :The PFO may also act as a pressure relief pathway during conditions of high pulmonary arterial and/or right heart pressures whereby pressures may still be higher than normal, yet lower than they would be in the absence of a PFO.6 Interestingly, there are known pathophysiological associations of PFO with conditions of high pulmonary arterial pressure such as high altitude pulmonary edema (HAPE)2,7 and exaggerated pulmonary pressures with exercise in those with chronic mountain sickness.8 The presence of a PFO is also associated with impaired ventilatory acclimatization to altitude,2 impaired hypercapnic ventilatory responses,2 impaired pulmonary gas exchange efficiency at rest,2,4 and a higher core body temperature at rest and during exercise.2,9
Newborn screening for congenital heart disease using echocardiography and follow-up at high altitude in China
2019, International Journal of CardiologyCitation Excerpt :Those with PFO may be more susceptible to have reversal of flow across the defect at strenuous exercise and pneumonia [20]. It has been reported that the presence of PFO in high altitude residents is was associated with right ventricular enlargement and an exaggerated increase in PAP and right ventricular dysfunction at mild exercises [32]. First, our hospital is located in area where the main habitats are Hui and Han, with considerably less Tibetans.
The Right Heart International Network (RIGHT-NET): Rationale, Objectives, Methodology, and Clinical Implications
2018, Heart Failure ClinicsCitation Excerpt :However, the exact clinical relevance of abnormal responses in healthy patients with a known increased risk of developing PH and right heart failure remains unclear. The current state of knowledge based on reported exercise TTE studies of the pulmonary circulation and the RV in different populations are presented in Tables 1–3.19–64 Thus, the available literature shows great disparities in sample sizes (from n = 8 to n = 113), exercise protocols (leg press, cycle, or treadmill ergometry), timing of measurements, selection of variables of interest, and different work rates (ranging from 23 ± 7 WU up to 175 ± 50 WU).
Transcatheter closure of a small atrial septal defect with an Amplatzer™ patent foramen ovale occluder in a working dog with cyanosis and exercise intolerance at high altitude
2017, Journal of Veterinary CardiologyCitation Excerpt :Cardiovascular changes in individuals living at high altitudes include PH, right ventricular hypertrophy, and polycythemia [12,14,15]. In addition, the presence of a PFO in humans living at high altitude has been associated with increased pulmonary vasoconstriction and right ventricular systolic dysfunction compared with those without PFO [16]. It has also been reported that in mountaineers susceptible to high altitude pulmonary edema, there is a 4-fold increase in the frequency of PFO compared with those resistant to this condition, with more substantial hypoxemia appreciated in those with PFO [17].
Sleep-disordered breathing and vascular function in patients with chronic mountain sickness and healthy high-altitude dwellers
2016, ChestCitation Excerpt :For technical reasons, echocardiography could not be performed in three patients with CMS and three control subjects. To evaluate the presence of a PFO, in 11 patients with CMS and 4 control subjects, transesophageal echocardiography was performed as previously described,24 in combination with injection of echocardiographic contrast medium.34,35 The diagnosis of PFO required the crossing of bubbles from the right to the left atrium within four heart beats after the release of the strain.
Changes in cerebral autoregulation, stroke-related blood biomarkers, and autonomic regulation after patent foramen ovale closure in severe migraine patients
2023, CNS Neuroscience and Therapeutics
Funding/Support:The authors have reported toCHESTthat no funding was received for this study. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.