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The coronavirus disease-2019 (COVID-19) pandemic has dramatically disrupted cardiovascular disease fellowship training. Significant reductions in cardiac volumes and simultaneous reassignment of physicians, including to COVID-19–centric services, have led to educational challenges in fellowship

Just as Hippocrates vowed his life to practicing the highest standards of medicine, cardiovascular disease fellowship program directors strive not only to provide comprehensive training for our fellows, but also to support them for long-term success in both professional and personal lives. Pregnancy

BACKGROUND Pulmonary hypertension (PH) is frequently reported in patients with advanced chronic kidney disease and is associated with early allograft failure and death. However, the causes of PH are heterogeneous, and patient prognosis may vary by etiologic subtype. METHODS Data from the University of North Carolina Cardiorenal Registry were examined to determine associations between PH, with or without elevated left atrial pressure (eLAP), and mortality in candidates for kidney transplantation. PH and eLAP were determined by Doppler echocardiography and by tissue Doppler imaging, respectively. RESULTS From 2006 to 2013, 778 registry patients were screened preoperatively by echocardiography. Most patients were black (64%) and men (56%); the mean age was 56 years. PH was identified in 97 (12%) patients; of these, eLAP was prevalent in half. During a median follow-up of 4.4 years, 179 (23%) received a kidney transplant, and 195 (25%) died. After adjustments for demographics, comorbidities, dialysis vintage, and kidney transplantation, PH was associated with twice the 5-year mortality (hazard ratio [HR] = 2.11; 95% confidence interval [CI]: 1.48-3.03), with stronger associations in the absence of eLAP (HR = 2.87; 95% CI: 1.83-4.49) than with eLAP (HR = 1.11; 95% CI: 0.57-2.17), P for interaction = 0.01. CONCLUSIONS The mortality risk associated with PH among patients with advanced chronic kidney disease appears to differ by etiology. Patients with PH in the absence of eLAP are at high risk of death and in need of focused attention. Future research efforts should investigate potential strategies to improve outcomes for these patients.

We show that spironolactone use was associated with an increased rate of all-cause hospitalizations, but no difference in hospitalizations for heart failure or pulmonary arterial hypertension, in patients with World Health Organization Group 1 pulmonary arterial hypertension. A possible reason for this finding is confounding from retrospective study design.

Background: Pulmonary hypertension (PH) is commonly reported in patients with end-stage renal disease (ESRD), and is associated with early graft failure and death in kidney transplant recipients. Calcifications of the lung, pulmonary vessels, heart, and kidney are frequently observed with ESRD, the consequence of secondary hyperparathyroidism. It follows that pulmonary artery vasculopathy, notably from extraosseous calcification, may contribute to PH. A popular, but unestablished, theory is that the stiffened pulmonary artery is unable to accommodate elevations in right ventricular stroke volume caused by arteriovenous (AV) hemodialysis shunts. We hypothesized that extraosseous calcification is related to PH in patients evaluated for kidney transplantation, and that the association is largely driven by AV shunts. Methods: Established in 2006, the UNC Cardiorenal Registry offers ongoing enrollment to all patients with stage 4 or 5 chronic kidney disease (CKD) referred for pretransplant cardiac evaluation. Pulmonary artery systolic pressure (PASP) was derived from routine echocardiograms within 6 months of the registry visit. All echocardiograms followed a standardized protocol, and were interpreted by the same cardiologist. PH was defined by a tricuspid regurgitant jet velocity >2.8 m/s, corresponding to a PASP >40 mmHg. Classification of grade 2 diastolic dysfunction (impaired left ventricular relaxation with elevated left atrial pressure) required a transmitral E/A ratio ≥ 0.8, and a transmitral to myocardial relaxation E/e’ ratio ≥ 15. Mitral annular calcification (MAC) was visually assessed, and considered evidence of extraosseous calcification. Associations between MAC and PH were analyzed with logistic regression, adjusted for age, sex, BMI, diastolic dysfunction, mitral regurgitation, left atrial dilation, and hematocrit. Results: From 2006-2013, 795 registry patients were screened preoperatively by echocardiography. Most were male (56%) and black (61%) with a mean age of 56 years. The majority (74%) received dialysis (13% peritoneal, 61% hemodialysis), for an average 2.8 years prior to the registry visit. PH, MAC, and AV shunts were present in 17%, 28%, and 62%; respectively. Relative to patients without MAC, those with MAC had higher odds of PH (OR adj =1.80; 95% CI: 1.17 – 2.78), which was not impacted by adjustment for AV shunts (OR adj = 1.78; 95% CI: 1.15 – 2.76). Further adjustment for years of dialysis modestly attenuated the association (OR adj = 1.55; 95% CI: 0.99 – 2.43). Conclusion: MAC is associated with higher odds of PH in severe CKD, irrespective of factors associated with PASP in the general population (age, sex, BMI), sources of pulmonary congestion (diastolic dysfunction, mitral regurgitation, and left atrial dilation), and causes of hyperdynamic circulation (hematocrit). The association is independent of hemodialysis shunts and dialysis vintage.

Pulmonary arterial hypertension (PAH) is a panvasculopathy that affects the distal pulmonary arteries and leads to restricted blood flow. This increased afterload leads to adaptive mechanisms of the right ventricle, with eventual failure once it can no longer compensate. Pulmonary hypertension from associated conditions, most importantly left heart disease, i.e. heart failure, can also lead to the same sequela. Patients often experience early vague symptoms of dyspnea and exercise intolerance, and thus PH can elude clinicians until right heart failure symptoms predominate. Evidence-based treatment options with pulmo-nary vasodilators are available for those with PAH and should be employed early. It is essential that patients be accurately categorized by their etiology of PH, as treatment strategies differ, and can potentially be dangerous if employed in the wrong clinical scenario.