Ambulatory Hemodynamic Monitoring in the Management of Pulmonary Arterial Hypertension

Abstract

Background: Pulmonary arterial hypertension (PAH) is characterized by pulmonary vascular remodeling, rise in pulmonary arterial pressures, and if left untreated, right heart failure. Invasive hemodynamic assessment with right heart catheterization (RHC) has been the gold standard for the diagnosis and serial assessment of patients with PAH. However, RHC has important limitations and might be supplemented by newer technologies in the management of PAH patients. Implications for Clinicians: Implantable hemodynamic monitors (IHM) hold the promise of being able to provide accurate pulmonary artery pressure measurements, with frequent or continuous remote monitoring in the home or ambulatory setting. As such, IHMs may provide a more complete understanding of a patient's hemodynamic profile and burden of disease. IHM data may also help to provide ongoing feedback in terms of a PAH patient's response to medical therapy and other interventions and might be valuable in specific subsets of patients with borderline or exercise-induced PAH. Conclusions: Though clinical studies using IHMs in PAH patients have been limited to small series and case reports, these devices hold a great deal of promise to supplement RHC in the management of PAH patients and warrant further investigation and clinical experience.

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“…Its invasive nature precludes its regular use in clinical practice. Newer technologies could overcome this limitation providing periodical measurement of pulmonary arterial systolic, diastolic and mean pressures and of cardiac output assessed through a validated algorithm [ 54 ]. In this regard, Benza et al recently evaluated the feasibility and early safety of monitoring PAH patients using an IHM implanted in a distal branch of the pulmonary artery, previously tested in patients with heart failure [ 55 ].…”

Computational Simulator Models and Invasive Hemodynamic Monitoring as Tools for Precision Medicine in Pulmonary Arterial Hypertension

“…Conversely, right heart catherization allows for a comprehensive hemodynamic assessment, but it is an invasive procedure with technical challenges, and it must be performed in a clinic, providing a snapshot of patient’s hemodynamics at a single time point. Ambulatory IHMs, such as CardioMEMS TM (Abbott, Sylmar, CA, USA), providing frequent remote hemodynamic measurements in the home setting and recording the variability of pulmonary pressure during the day, provide additional information for PAH patients’ management, potentially overcoming the above limitations [ 22 ].…”

“…Conversely, the experience of IHMs in the management of patients with PAH is still limited to small series. CardioMEMS system implantation in 26 PAH patients with NYHA class III or IV has recently shown that IHMs may represent a promising tool to early identify decompensation or noncompliance, to reassess response to therapy and to allow rapid drug titration, reducing in-person visits and invasive hemodynamic assessments [ 22 , 26 ]. Importantly, while clinical experience with IHMs in PAH is increasing, providing a huge amount of data, IHMs represent a unique opportunity to improve and validate computational cardiovascular simulators in this setting.…”

Ask the Expert: Are Newer Management Approaches Increasing the Economic Burden of Treating Pulmonary Arterial Hypertension?

“…As described in the main articles of this issue of Advances, 3 new oral medications were approved in 2013, 2,3 and implantable hemodynamic monitoring and implantable pump delivery systems are poised to change our understanding of disease severity, response to treatment, as well as delivery of intravenous prostacyclin. 3,4 There is also news regarding additional treatments in the therapeutic pipeline and recent data supporting firstline double 5 and triple combination 6 medication therapy. These developments are raising the question: is the economic burden of treating PAH continually increasing, and if so, is it worth the additional cost?…”