Publications by authors named "Laith Alkukhun"

15 Publications

  • Page 1 of 1

Outcomes of Direct Oral Anticoagulants in Atrial Fibrillation Patients Across Different Body Mass Index Categories.

JACC Clin Electrophysiol 2021 05 31;7(5):649-658. Epub 2021 Mar 31.

University of Pittsburgh Medical Center Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA. Electronic address:

Objectives: This study sought to evaluate direct oral anticoagulant (DOAC) outcomes (vs. warfarin) in patients with atrial fibrillation (AF) across body mass index (BMI) categories, including ≥40 and <18.5 kg/m.

Background: Clinical trials have not systematically tested the fixed DOAC dosing in underweight and morbidly obese patients.

Methods: We retrospectively included consecutive patients with nonvalvular AF with CHADS-VASc (Congestive heart failure, Hypertension, Age ≥75, Diabetes, Stroke/transient ischemic attack/systemic thromboembolism, Vascular disease, Age 65-74, Sex) of ≥1 receiving OACs at our hospital system (2010-2018). Patients were categorized into groups 1 (underweight: BMI of <18.5 kg/m), 2 (normal/overweight: BMI of 18.5 to <30 kg/m), 3 (grade 1/2 obesity: BMI of 30 to <40 kg/m), and 4 (grade 3 obesity: BMI of ≥40 kg/m). We further classified patients by DOAC versus warfarin use. Outcomes were ischemic stroke, significant bleeding events (i.e., resulting in hospitalization), and mortality.

Results: We included 36,094 patients with a mean age of 74 ± 11 years and CHADS-VASc of 3.4 ± 1.5. Groups 1 through 4 included 455 (1.3%), 18,339 (50.8%), 13,376 (37.1%), and 3,924 (10.9%) patients, respectively. DOAC use ranged from 49% to 56%. At 3.8 follow-up years, with multivariable Cox regression, DOACs (vs. warfarin) were associated with lower risk of ischemic stroke, bleeding, and mortality across all BMI groups, with hazard ratios (HRs) of 0.73 (95% confidence interval [CI]: 0.63 to 0.85), 0.75 (95% CI: 0.64 to 0.87), 0.75 (95% CI: 0.65 to 0.88), and 0.75 (95% CI: 0.64 to 0.87) (p < 0.001 for all) for ischemic stroke; 0.42 (95% CI: 0.19 to 0.92), 0.41 (95% CI: 0.19 to 0.89), 0.45 (95% CI: 0.20 to 1.00), and 0.43 (95% CI: 0.20 to 0.94) (p < 0.05 for all) for bleeding; and 0.90 (95% CI: 0.68 to 1.19; p = 0.5), 0.70 (95% CI: 0.66 to 0.75; p < 0.0001), 0.65 (95% CI: 0.60 to 0.71; p < 0.0001), and 0.66 (95% CI: 0.56 to 0.77; p < 0.0001) for mortality, in groups 1 to 4, respectively.

Conclusions: In patients with nonvalvular AF, DOACs compared to warfarin were associated with better safety and effectiveness across all BMI categories, including underweight and morbidly obese patients.
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http://dx.doi.org/10.1016/j.jacep.2021.02.002DOI Listing
May 2021

Use Trends and Adverse Reports of SelectSecure 3830 Lead Implantations in the United States: Implications for His Bundle Pacing.

Circ Arrhythm Electrophysiol 2020 07 15;13(7):e008577. Epub 2020 Jun 15.

UPMC Heart and Vascular Institute, University of Pittsburgh, PA (A.F.B., L.A., N.C.W., A.B., D.W., M.G., J.S., S.J., A.V., R.B., N.A.M.E., S.S., K.K.).

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http://dx.doi.org/10.1161/CIRCEP.120.008577DOI Listing
July 2020

Wearable Cardioverter-Defibrillator Therapy for the Prevention of Sudden Cardiac Death: A Systematic Review and Meta-Analysis.

JACC Clin Electrophysiol 2019 02 30;5(2):152-161. Epub 2019 Jan 30.

Division of Cardiology, Albany Medical College, Albany, New York.

Objectives: This study sought to synthesize the available evidence on the use of the wearable cardioverter-defibrillator (WCD).

Background: Observational WCD studies for the prevention of sudden cardiac death have provided conflicting data. The VEST (Vest Prevention of Early Sudden Death) trial was the first randomized controlled trial (RCT) showing no reduction in sudden cardiac death as compared to medical therapy only.

Methods: We searched PubMed, EMBASE, and Google Scholar for studies reporting on the outcomes of patients wearing WCDs from January 1, 2001, through March 20, 2018. Rates of appropriate and inappropriate WCD therapies were pooled. Estimates were derived using DerSimonian and Laird's method.

Results: Twenty-eight studies were included (N = 33,242; 27 observational, 1 RCT-WCD arm). The incidence of appropriate WCD therapy was 5 per 100 persons over 3 months (95% confidence interval [CI]: 3.0 to 6.0, I = 93%). In studies on ischemic cardiomyopathy, the appropriate WCD therapy incidence was lower in the VEST trial (1 per 100 persons over 3 months; 95% CI: 1.0 to 2.0) as compared with observational studies (11 per 100 persons over 3 months; 95% CI: 11.0 to 20.0; I = 93%). The incidence of inappropriate therapy was 2 per 100 persons over 3 months (95% CI: 1.0 to 3.0; I = 93%). Mortality while wearing WCD was rare at 0.7 per 100 persons over 3 months (95% CI: 0.3 to 1.7; I = 94%).

Conclusions: The rate of appropriately treated WCD patients over 3 months of follow-up was substantial; higher in-observational studies as compared with the VEST trial. There was significant heterogeneity. More RCTs are needed to justify continued use of WCD in primary prevention.
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http://dx.doi.org/10.1016/j.jacep.2018.11.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6383782PMC
February 2019

Changes in main pulmonary artery diameter during follow-up have prognostic implications in pulmonary arterial hypertension.

Respirology 2017 11 17;22(8):1649-1655. Epub 2017 May 17.

Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA.

Background And Objective: A dilated pulmonary artery (PA) is a common finding in patients with pulmonary arterial hypertension (PAH). Little is known on the variations in PA size over time and whether these changes track with disease severity and/or predict long-term survival.

Methods: We included patients with PAH who had at least two computed tomography (CT) scans of the chest done on different visits. Both scans matched the use of i.v. contrast.

Results: Pairs of CT scans were compared in 113 PAH patients. During a median (interquartile range (IQR)) time difference between scans of 8 (IQR: 3.5-20.0) months, we noted an increase in main PA diameter of 0.5 ± 1.8 mm (mean ± SD) (P = 0.008). When CT scans were performed >12 months apart (n = 47), the main PA diameter increased or decreased by >1 mm in 40% and 13% of the patients, respectively. An increase in main PA diameter was associated with lower PA compliance, higher right ventricular (RV) systolic pressure, worse RV function and a decline in 6-min walk distance. During a median (IQR) follow-up of 33 (IQR: 4.5-47) months, 53 (46.9%) patients died. The change in PA diameter was a significant predictor of mortality (hazard ratio (HR) per mm increase: 1.33 (95% CI: 1.11-1.61), P = 0.002) when adjusted for difference in time and slice thickness between CT scans, age, gender, PAH aetiology and pulmonary vascular resistance.

Conclusion: In PAH patients, an increase in CT-derived main PA diameter over time is associated with progression in pulmonary pressures, RV dysfunction, a decline in functional capacity and higher mortality.
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http://dx.doi.org/10.1111/resp.13073DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5884162PMC
November 2017

Non-invasive screening for pulmonary hypertension in idiopathic pulmonary fibrosis.

Respir Med 2016 08 2;117:65-72. Epub 2016 Jun 2.

Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA. Electronic address:

Background: Pulmonary hypertension (PH) is a common complication of idiopathic pulmonary fibrosis (IPF) that is associated with poor prognosis. Noninvasive screening for PH in IPF patients is challenging and a combination of several noninvasive determinations can improve discrimination.

Methods: We included 235 IPF patients who underwent right heart catheterization (RHC) as part of the lung transplant evaluation. We measured electrocardiographic (ECG) and echocardiographic variables as well as the pulmonary artery (PA) and ascending aorta (AA) diameters on chest CT. We recorded results of arterial blood gases (ABG), pulmonary function (PFT) and 6-min walk tests (6MWT).

Results: Several variables were predictors of PH in IPF patients in univariable models including a lower arterial oxygenation and 6MWT distance; worse right ventricular (RV) function, rightward deviation of the QRS axis and a higher FVC/DLCOc ratio, PA/AA diameter ratio, and estimated RV systolic pressure. In multivariable analysis, a worse RV function and higher PA/AA ratio remained predictors of PH (c-index 0.75 (0.65-0.84)). Similarly, a worse RV function, a higher PA/AA ratio and a rightward QRS axis deviation were independent predictors of precapillary PH (c-index 0.86 (0.76-0.92)). A combination of PA/AA diameter ratio <1.1, a QRS axis <90° and normal RV function showed a negative predictive value of 85% for precapillary PH.

Conclusions: There are significant differences in ECG, echocardiographic, chest CT, PFT and ABG parameters between IPF patients with and without PH. However, these noninvasive tests alone or combination have limited discrimination ability for PH screening in IPF.
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http://dx.doi.org/10.1016/j.rmed.2016.06.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4976395PMC
August 2016

Predictors of mortality after transjugular portosystemic shunt.

World J Hepatol 2016 Apr;8(11):520-9

Mona Ascha, Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH 44195, United States.

Aim: To investigate if echocardiographic and hemodynamic determinations obtained at the time of transjugular intrahepatic portosystemic shunt (TIPS) can provide prognostic information that will enhance risk stratification of patients.

Methods: We reviewed medical records of 467 patients who underwent TIPS between July 2003 and December 2011 at our institution. We recorded information regarding patient demographics, underlying liver disease, indication for TIPS, baseline laboratory values, hemodynamic determinations at the time of TIPS, and echocardiographic measurements both before and after TIPS. We recorded patient comorbidities that may affect hemodynamic and echocardiographic determinations. We also calculated Model for End-stage Liver Disease (MELD) score and Child Turcotte Pugh (CTP) class. The following pre- and post-TIPS echocardiographic determinations were recorded: Left ventricular ejection fraction, right ventricular (RV) systolic pressure, subjective RV dilation, and subjective RV function. We recorded the following hemodynamic measurements: Right atrial (RA) pressure before and after TIPS, inferior vena cava pressure before and after TIPS, free hepatic vein pressure, portal vein pressure before and after TIPS, and hepatic venous pressure gradient (HVPG).

Results: We reviewed 418 patients with portal hypertension undergoing TIPS. RA pressure increased by a mean ± SD of 4.8 ± 3.9 mmHg (P < 0.001), HVPG decreased by 6.8 ± 3.5 mmHg (P < 0.001). In multivariate linear regression analysis, a higher MELD score, lower platelet count, splenectomy and a higher portal vein pressure were independent predictors of higher RA pressure (R = 0.55). Three variables predicted 3-mo mortality after TIPS in a multivariate analysis: Age, MELD score, and CTP grade C. Change in the RA pressure after TIPS predicted long-term mortality (per 1 mmHg change, HR = 1.03, 95%CI: 1.01-1.06, P < 0.012).

Conclusion: RA pressure increased immediately after TIPS particularly in patients with worse liver function, portal hypertension, emergent TIPS placement and history of splenectomy. The increase in RA pressure after TIPS was associated with increased mortality. Age, splenectomy, MELD score and CTP grade were independent predictors of long-term mortality after TIPS.
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http://dx.doi.org/10.4254/wjh.v8.i11.520DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4832094PMC
April 2016

Are transcutaneous oxygen and carbon dioxide determinations of value in pulmonary arterial hypertension?

Microcirculation 2015 May;22(4):249-56

Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA.

Background: We hypothesized that transcutaneous gas determinations of O2 and CO2 (TcPO2 and TcPCO2 ) are associated with the severity of PAH.

Methods: In this cross-sectional study, we included consecutive patients with PAH (group 1 PH; n = 34). Transcutaneous gas determinations were compared to those of age- and gender-matched healthy controls (n = 14), nongroup 1 PH (n = 19) or patients with high estimated RVSP on echocardiography but without hemodynamic evidence of PH (n = 12).

Results: In patients with PAH, TcPO2 , and TcPCO2 were significantly associated with PaO2 (R = 0.44, p = 0.03) and PaCO2 (R = 0.77, p < 0.001), respectively. TcPO2 /FiO2 (mean difference: -65.0 [95% CI: -121.3, -8.7]) and TcPCO2 (mean difference: -7.4 [95% CI: -11.6, -3.1]) were significantly lower in patients with PAH than healthy controls. TcPCO2 was useful in discriminating PAH patients from other individuals (AUC: 0.74 [95% CI: 0.62, 0.83]). TcPO2 /FiO2 ratio was significantly associated with mean PAP, TPG, PVR, CI, SVI, DLCO, six-minute walk distance and components of the CAMPHOR questionnaire.

Conclusions: Transcutaneous pressure of CO2 was lower in patients with PAH. Transcutaneous pressure of O2 over inspired fraction of O2 ratio was inversely associated with severity of disease in patients with PAH.
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http://dx.doi.org/10.1111/micc.12191DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4411192PMC
May 2015

Electrocardiographic differences between COPD patients evaluated for lung transplantation with and without pulmonary hypertension.

COPD 2014 Dec 1;11(6):670-80. Epub 2014 Jul 1.

Department of Pulmonary, Allergy and Critical Care Medicine. Respiratory Institute , Cleveland Clinic, Cleveland, OH , USA.

Introduction: Pulmonary hypertension (PH) is an indicator of poor prognosis in COPD patients; particularly in those with mean pulmonary artery pressure ≥ 40 mm Hg. Electrocardiography (ECG) might be useful for screening of this condition.

Methods: Retrospective study of COPD patients evaluated for lung transplantation in whom we analyzed the 12-lead ECG performed closest to the time of right heart catheterization.

Results: We included 142 patients. PH was present in 90 patients (63%) and 16 (11%) had a mean PAP ≥ 40 mmHg. The PR interval was longer in PH patients (151 (29) versus 139 (22) ms, p = 0.01) and T wave axis had a left shift (56.9 (32) versus 68.7 (19) degrees, p = 0.006). PR interval was longer (178.5 (35) versus 142.2 (23) ms, p = 0.001), T wave axis had a leftward deflection (63.6 (24) versus 42.8 (46) degrees, p = 0.005) and S wave in lead I was larger (0.19 (0.13) versus 0.12 (0.12) mV, p = 0.03) in patients with mean PAP ≥ 40 mmHg. A PR interval > 137 ms and S wave in DI > 0.02 mV had a sensitivity of 100% and a specificity of 59.5% to identify COPD patients with a mean PAP ≥ 40 mmHg.

Conclusion: There are significant ECG differences between advanced COPD patients with and without PH; however the ECG is an inadequate tool to differentiate between the groups. A prolonged PR interval suggests the presence of severe PH.
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http://dx.doi.org/10.3109/15412555.2014.898047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4634884PMC
December 2014

Heart rate slopes during 6-min walk test in pulmonary arterial hypertension, other lung diseases, and healthy controls.

Physiol Rep 2014 Jun 11;2(6). Epub 2014 Jun 11.

Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio.

Six-minute walk test (6MWT) continues to be a useful tool to determine the functional capacity in patients with vascular and other lung diseases; nevertheless, it has a limited ability to predict prognosis in this context. We tested whether the heart rate (HR) acceleration and decay slopes during the 6-m walk test are different in patients with pulmonary arterial hypertension (PAH), other lung diseases, and healthy controls. In addition, we assessed whether the HR slopes are associated with clinical worsening. Using a portable, signal-morphology-based, impedance cardiograph (PhysioFlow Enduro, Paris, France) with real-time wireless monitoring via a Bluetooth USB adapter we determined beat-by-beat HR. We included 50 subjects in this pilot study, 20 with PAH (all on PAH-specific treatment), 17 with other lung diseases (obstructive [n = 12, 71%] or restrictive lung diseases [5, 29%]), and 13 healthy controls. The beat-by-beat HR curves were significantly different among all three groups of subjects either during the activity or recovery of the 6MWT. HR curves were less steep in PAH than the other two groups (P < 0.001). HR acceleration rates were slower in patients with PAH or other lung diseases with progression of their disease (P < 0.001). In conclusion, the acceleration and decay slopes during 6MWT are different among patients with PAH, other lung diseases, and healthy controls. The HR slopes during 6MWT were steeper in patients without clinical worsening.
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http://dx.doi.org/10.14814/phy2.12038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4208645PMC
June 2014

Sublingual microcirculation in pulmonary arterial hypertension.

Ann Am Thorac Soc 2014 May;11(4):504-12

Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio.

Rationale: Pulmonary arterial hypertension (PAH) is a pulmonary vasculopathy that leads to failure of the right ventricle and premature death.

Objectives: To determine whether the sublingual microcirculation is affected in patients with PAH compared with healthy age- and sex-matched control subjects.

Methods: Using the CapiScope Handheld Video Capillaroscope we measured the sublingual microvasculature density, flow index, tortuosity, and curvature. Videos were acquired immediately after right heart catheterization, and determinations were made off-line by investigators blinded to the group assignment or hemodynamics.

Measurements And Main Results: In this cross-sectional pilot study, we included 26 patients with PAH (age, mean ± SD, 56.7 ± 10 yr; 77% women) and 14 healthy control subjects (age, 53.1 ± 12 yr; 71% women). Sublingual microvasculature flow index was lower (2 ± 0.66 vs. 2.7 ± 0.37, P < 0.001) with higher heterogeneity index (0.63 ± 0.63 vs. 0.25 ± 0.25, P = 0.04) in patients with PAH than control subjects. Microvasculature density was similar between the groups, but tortuosity was more pronounced in patients than control subjects (tort 0: 45 ± 19 vs. 23.6 ± 12, P = 0.001 and tort 1: 0.2 ± 0.16 vs. 0.06 ± 0.04, P < 0.001).

Conclusions: Patients with PAH showed lower sublingual microvasculature flow index and higher tortuosity compared with healthy age- and sex-matched control subjects. Further investigations are needed to assess whether this methodology can provide information on disease prognosis and/or response to therapy in this condition.
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http://dx.doi.org/10.1513/AnnalsATS.201308-277OCDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4225801PMC
May 2014

Electrocardiography at diagnosis and close to the time of death in pulmonary arterial hypertension.

Ann Noninvasive Electrocardiol 2014 May 30;19(3):258-65. Epub 2013 Dec 30.

Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, Cleveland, OH.

Background: Scarce information exits on the electrocardiographic (ECG) characteristics of pulmonary arterial hypertension (PAH) patients close to their death and whether observed abnormalities progress from the time of PAH diagnosis.

Methods: We analyzed the characteristics of the ECG performed at initial diagnosis, during the course of the disease and close to the time of death on consecutive PAH patients followed at our institution between June 2008 and December 2010.

Results: We included 50 patients with PAH (76% women) with mean (SD) age of 58 (14) years. Median heart rate (83 vs 89 bpm, P = 0.001), PR interval (167 vs 176 ms, P = 0.03), QRS duration (88 vs 90 ms, P = 0.02), R/S ratio in lead V1 (1 vs 2, P = 0.01), and QTc duration (431 vs 444 ms, P = 0.02) significantly increased from the initial to the last ECG. In addition, the frontal QRS axis rotated to the right (97 vs 112 degrees, P = 0.003) and we more commonly observed right bundle branch block (5% vs 8%, P = 0.03) and negative T waves in inferior leads (31% vs 60%, P = 0.004). No patient had normal ECG at the time of death.

Conclusions: Significant changes progressively occur in a variety of ECG parameters between the time of the initial PAH diagnosis and close to death.
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http://dx.doi.org/10.1111/anec.12125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4004655PMC
May 2014

Value of impedance cardiography during 6-minute walk test in pulmonary hypertension.

Clin Transl Sci 2013 Dec 6;6(6):474-80. Epub 2013 Sep 6.

Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA.

Background: Methods that predict prognosis and response to therapy in pulmonary hypertension (PH) are lacking. We tested whether the noninvasive estimation of hemodynamic parameters during 6-minute walk test (6MWT) in PH patients provides information that can improve the value of the test.

Methods: We estimated hemodynamic parameters during the 6MWT using a portable, signal-morphology-based, impedance cardiograph (PhysioFlow Enduro) with real-time wireless monitoring via a bluetooth USB adapter.

Results: We recruited 48 subjects in the study (30 with PH and 18 healthy controls). PH patients had significantly lower maximum stroke volume (SV) and CI and slower cardiac output (CO) acceleration and decelerations slopes during the test when compared with healthy controls. In PH patients, CI change was associated with total distance walked (R = 0.62; P < 0.001) and percentage of predicted (R = 0.4, P = 0.03), HR recovery at 1 minute (0.57, P < 0.001), 2 minutes (0.65, P < 0.001), and 3 minutes (0.66, P < 0.001). Interestingly, in PH patients CO change during the test was predominantly related to an increase in SV instead of HR.

Conclusions: Estimation of hemodynamic parameters such as cardiac index during 6-minute walk test is feasible and may provide useful information in patients with PH. Clin Trans Sci 2013; Volume #: 1-7.
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http://dx.doi.org/10.1111/cts.12090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4286797PMC
December 2013

Subcutaneous to intravenous prostacyclin analog transition in pulmonary hypertension.

J Cardiovasc Pharmacol 2014 Jan;63(1):4-8

Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH.

Introduction: Prostacyclin analogs are Food and Drug Administration-approved therapies for the treatment of pulmonary arterial hypertension and can be administered by inhalational, intravenous (IV), or subcutaneous (SQ) routes. Because there are limited data to guide the transition between SQ to IV prostacyclin analogs, we describe our experience.

Methods: We performed a retrospective review of patients with pulmonary hypertension diagnosed by right heart catheterization, who underwent transition from SQ to IV prostacyclin analogs.

Results: We included 7 patients with pulmonary arterial hypertension and 2 with chronic thromboembolic pulmonary hypertension in this retrospective study. Median (interquartile range) age was 54 (39-63) years, and 67% were women. The reasons for the SQ to IV switch were site pain (n = 6, 67%), major surgery (n = 2, 22%), and septic shock (n = 1, 11%). SQ treprostinil was converted to IV treprostinil (n = 5, 56%) or IV epoprostenol (n = 4, 44%). When SQ treprostinil was converted to IV treprostinil, the initial mean (range) dose decreased from 84.9 (36.5-167) to 70.8 (24-114) ng·kg⁻¹·min⁻¹. When SQ treprostinil was converted to IV epoprostenol, the dose decreased from 24.5 (17.5-30) to 13.3 (9-20) ng·kg⁻¹·min⁻¹. The patient transitioned from SQ to IV treprostinil in the context of septic shock died a month after hospitalization. No deteriorations were observed in the remaining patients during the first year.

Conclusions: Under careful monitoring, SQ treprostinil was transitioned to IV treprostinil or epoprostenol without complications. Dosing downadjustment was needed in some patients who were switched over from SQ to IV prostacyclin analogs.
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http://dx.doi.org/10.1097/FJC.0000000000000018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4662283PMC
January 2014