[Right heart adaptation to pulmonary arterial hypertension: physiology and pathobiology].

Survival in patients with pulmonary arterial hypertension (PAH) is closely related to right ventricular (RV) function. Although pulmonary load is an important determinant of RV systolic function in PAH, there remains a significant variability in RV adaptation to pulmonary hypertension. In this report, the authors discuss the emerging concepts of right heart pathobiology in PAH. More specifically, the discussion focuses on the following questions. 1) How is right heart failure syndrome best defined? 2) What are the uderlying molecular mechanisms of the failing right ventricle in PAH? 3) How are RV contractility and function and their prognostic implications best assessed? 4) What is the role of targeted RV therapy? Throughout the report, the authors highlight differences between right and left heart failure and outline key areas of future investigation. (J Am Coll Cardiol 2013;62:D22-33) a 2013 by the American College of Cardiology Foundation).

[1]  Ami A. Shah,et al.  Right Ventricular Dysfunction in Systemic Sclerosis–Associated Pulmonary Arterial Hypertension , 2013, Circulation. Heart failure.

[2]  D. Bernstein,et al.  Dynamic microRNA expression during the transition from right ventricular hypertrophy to failure. , 2012, Physiological genomics.

[3]  G. Koch,et al.  Echocardiographic predictors of adverse outcomes in primary pulmonary hypertension. , 2002, Journal of the American College of Cardiology.

[4]  H. Tan,et al.  Electrophysiologic remodeling of the left ventricle in pressure overload-induced right ventricular failure. , 2012, Journal of the American College of Cardiology.

[5]  A. Denault,et al.  Characteristics and Outcome After Hospitalization for Acute Right Heart Failure in Patients With Pulmonary Arterial Hypertension , 2011, Circulation. Heart failure.

[6]  M. Maitland,et al.  Mitochondrial metabolism, redox signaling, and fusion: a mitochondria-ROS-HIF-1alpha-Kv1.5 O2-sensing pathway at the intersection of pulmonary hypertension and cancer. , 2008, American journal of physiology. Heart and circulatory physiology.

[7]  Bernard Lambermont,et al.  The role of right ventricular-pulmonary arterial coupling to differentiate between effects of inotropic agents in experimental right heart failure. , 2006, Critical care medicine.

[8]  N. Fowler.  The normal pulmonary arterial pressure-flow relationships during exercise. , 1969, The American journal of medicine.

[9]  P. Light,et al.  Phosphodiesterase Type 5 Is Highly Expressed in the Hypertrophied Human Right Ventricle, and Acute Inhibition of Phosphodiesterase Type 5 Improves Contractility , 2007, Circulation.

[10]  H. Valantine,et al.  Recovery of the right ventricle after single-lung transplantation in pulmonary hypertension. , 1994, The American journal of cardiology.

[11]  A. Torbicki,et al.  Characteristics and prognosis of patients with decompensated right ventricular failure during the course of pulmonary hypertension. , 2008, Kardiologia polska.

[12]  S. Xavier,et al.  Pulmonary Arterial Hypertension: Use of Delayed Contrast-Enhanced Cardiovascular Magnetic Resonance in Risk Assessment , 2013, Arquivos brasileiros de cardiologia.

[13]  C. Lorenz,et al.  MRI complements standard assessment of right ventricular function after lung transplantation. , 1995, The Annals of thoracic surgery.

[14]  N. Westerhof,et al.  Right ventricular oxygen supply parameters are decreased in human and experimental pulmonary hypertension. , 2013, The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation.

[15]  W. Paulus,et al.  Right Ventricular Diastolic Impairment in Patients With Pulmonary Arterial Hypertension , 2013, Circulation.

[16]  G. Lip,et al.  The role of monocytes and inflammation in the pathophysiology of heart failure , 2011, European journal of heart failure.

[17]  A. Zaiman,et al.  Hemodynamic predictors of survival in scleroderma-related pulmonary arterial hypertension. , 2010, American journal of respiratory and critical care medicine.

[18]  A. Noordegraaf,et al.  The role of the right ventricle in pulmonary arterial hypertension , 2011, European Respiratory Review.

[19]  N. Westerhof,et al.  The arterial load in pulmonary hypertension , 2010, European Respiratory Review.

[20]  Kohtaro Abe,et al.  The right ventricle under pressure: cellular and molecular mechanisms of right-heart failure in pulmonary hypertension. , 2009, Chest.

[21]  J B Seward,et al.  Value of a Doppler-derived index combining systolic and diastolic time intervals in predicting outcome in primary pulmonary hypertension. , 1998, The American journal of cardiology.

[22]  H. Ghofrani,et al.  Imatinib in pulmonary arterial hypertension patients with inadequate response to established therapy. , 2010, American journal of respiratory and critical care medicine.

[23]  J. Kline,et al.  Right ventricular heart failure from pulmonary embolism: key distinctions from chronic pulmonary hypertension. , 2010, Journal of cardiac failure.

[24]  E. Fadel,et al.  Experimental Models of Right Heart Failure: A Window for Translational Research in Pulmonary Hypertension , 2013, Seminars in Respiratory and Critical Care Medicine.

[25]  W. Paulus,et al.  Bisoprolol Delays Progression Towards Right Heart Failure in Experimental Pulmonary Hypertension , 2012, Circulation. Heart failure.

[26]  S. Ghio,et al.  Prognostic relevance of the echocardiographic assessment of right ventricular function in patients with idiopathic pulmonary arterial hypertension. , 2010, International journal of cardiology.

[27]  Jeroen J. Bax,et al.  Prognostic Value of Right Ventricular Longitudinal Peak Systolic Strain in Patients With Pulmonary Hypertension , 2012, Circulation. Cardiovascular imaging.

[28]  W. Winkelmayer,et al.  Incidence, correlates, and consequences of acute kidney injury in patients with pulmonary arterial hypertension hospitalized with acute right-side heart failure. , 2011, Journal of cardiac failure.

[29]  C. Long,et al.  Chronic Pulmonary Artery Pressure Elevation Is Insufficient to Explain Right Heart Failure , 2009, Circulation.

[30]  M. Fujita,et al.  Clinical correlates and prognostic significance of six-minute walk test in patients with primary pulmonary hypertension. Comparison with cardiopulmonary exercise testing. , 2000, American journal of respiratory and critical care medicine.

[31]  Nico Westerhof,et al.  Progressive right ventricular dysfunction in patients with pulmonary arterial hypertension responding to therapy. , 2011, Journal of the American College of Cardiology.

[32]  G. Lewis,et al.  Pulmonary Vascular Response Patterns During Exercise in Left Ventricular Systolic Dysfunction Predict Exercise Capacity and Outcomes , 2011, Circulation. Heart failure.

[33]  R. Walsh,et al.  Application of a time varying elastance model to right ventricular performance in man. , 1988, Cardiovascular research.

[34]  J. Zwanenburg,et al.  Interventricular mechanical asynchrony in pulmonary arterial hypertension: left-to-right delay in peak shortening is related to right ventricular overload and left ventricular underfilling. , 2008, Journal of the American College of Cardiology.

[35]  Paul Sorajja,et al.  Relationship of pulmonary arterial capacitance and mortality in idiopathic pulmonary arterial hypertension. , 2006, Journal of the American College of Cardiology.

[36]  A. Zaiman,et al.  Outcomes of hospitalisation for right heart failure in pulmonary arterial hypertension , 2011, European Respiratory Journal.

[37]  H. Katus,et al.  High-sensitive troponin T: a novel biomarker for prognosis and disease severity in patients with pulmonary arterial hypertension. , 2010, Clinical science.

[38]  J. Sandoval,et al.  Survival in primary pulmonary hypertension. Validation of a prognostic equation. , 1994, Circulation.

[39]  D. Bernstein,et al.  Molecular and physiological characterization of RV remodeling in a murine model of pulmonary stenosis. , 2008, American journal of physiology. Heart and circulatory physiology.

[40]  H. Ghofrani,et al.  Imatinib Mesylate as Add-on Therapy for Pulmonary Arterial Hypertension: Results of the Randomized IMPRES Study , 2013, Circulation.

[41]  M. Humbert,et al.  The association between resting and mild-to-moderate exercise pulmonary artery pressure , 2011, European Respiratory Journal.

[42]  B. Westerhof,et al.  RC time constant of single lung equals that of both lungs together: a study in chronic thromboembolic pulmonary hypertension. , 2009, American journal of physiology. Heart and circulatory physiology.

[43]  M. Hoeper,et al.  Incidence and clinical relevance of supraventricular tachyarrhythmias in pulmonary hypertension. , 2007, American heart journal.

[44]  M. Humbert,et al.  Non-invasive indices of right ventricular function are markers of ventricular-arterial coupling rather than ventricular contractility: insights from a porcine model of chronic pressure overload. , 2013, European heart journal cardiovascular Imaging.

[45]  J. E. Hansen,et al.  Usefulness of right-to-left shunting and poor exercise gas exchange for predicting prognosis in patients with pulmonary arterial hypertension. , 2010, The American journal of cardiology.

[46]  M. Humbert,et al.  Survival in Patients With Idiopathic, Familial, and Anorexigen-Associated Pulmonary Arterial Hypertension in the Modern Management Era , 2010, Circulation.

[47]  E. Michelakis,et al.  Mitochondrial NOS is upregulated in the hypoxic heart: implications for the function of the hypertrophied right ventricle. , 2009, American journal of physiology. Heart and circulatory physiology.

[48]  J. Linehan,et al.  Distensibility of the normal human lung circulation during exercise. , 2005, American journal of physiology. Lung cellular and molecular physiology.

[49]  M. Gomberg-Maitland,et al.  Validation of the pulmonary hypertension connection equation for survival prediction in pulmonary arterial hypertension. , 2012, Chest.

[50]  Tammo Delhaas,et al.  Cardiovascular modeling in pulmonary arterial hypertension: focus on mechanisms and treatment of right heart failure using the CircAdapt model. , 2012, The American journal of cardiology.

[51]  A. Torbicki,et al.  Detectable Serum Cardiac Troponin T as a Marker of Poor Prognosis Among Patients With Chronic Precapillary Pulmonary Hypertension , 2003, Circulation.

[52]  W. Paulus,et al.  Right ventricular pacing improves right heart function in experimental pulmonary arterial hypertension: a study in the isolated heart. , 2009, American journal of physiology. Heart and circulatory physiology.

[53]  Jeffrey A Feinstein,et al.  Electrical Resynchronization: A Novel Therapy for the Failing Right Ventricle , 2003, Circulation.

[54]  G. Di Salvo,et al.  Range in pulmonary artery systolic pressure among highly trained athletes. , 2011, Chest.

[55]  K. Chatterjee,et al.  Effects of intravenous nesiritide on pulmonary vascular hemodynamics in pulmonary hypertension. , 2005, Journal of cardiac failure.

[56]  W. Graninger,et al.  Borderline pulmonary arterial pressure is associated with decreased exercise capacity in scleroderma. , 2009, American journal of respiratory and critical care medicine.

[57]  M. Humbert,et al.  Changes in exercise haemodynamics during treatment in pulmonary arterial hypertension , 2008, European Respiratory Journal.

[58]  A. Torbicki,et al.  Serum N-terminal brain natriuretic peptide as a prognostic parameter in patients with pulmonary hypertension. , 2006, Chest.

[59]  M. Wilkins,et al.  Emerging concepts and translational priorities in pulmonary arterial hypertension. , 2008, Circulation.

[60]  Titus Kuehne,et al.  Magnetic Resonance Imaging Analysis of Right Ventricular Pressure-Volume Loops: In Vivo Validation and Clinical Application in Patients With Pulmonary Hypertension , 2004, Circulation.

[61]  Paolo Pelosi,et al.  Clinical review: Positive end-expiratory pressure and cardiac output , 2005, Critical care.

[62]  P. Fawcett,et al.  Molecular signature of a right heart failure program in chronic severe pulmonary hypertension. , 2011, American journal of respiratory cell and molecular biology.

[63]  I. Belenkie,et al.  Ventricular interaction: from bench to bedside , 2001, Annals of medicine.

[64]  S. Rich,et al.  The short-term effects of digoxin in patients with right ventricular dysfunction from pulmonary hypertension. , 1998, Chest.

[65]  E H Bergofsky,et al.  Survival in Patients with Primary Pulmonary Hypertension: Results from a National Prospective Registry , 1991 .

[66]  S. Hunt,et al.  Right Ventricular Function in Cardiovascular Disease, Part II: Pathophysiology, Clinical Importance, and Management of Right Ventricular Failure , 2008, Circulation.

[67]  P. Postmus,et al.  Exercise testing to estimate survival in pulmonary hypertension. , 2008, Medicine and science in sports and exercise.

[68]  Sanjiv J. Shah,et al.  Association of Serum Creatinine With Abnormal Hemodynamics and Mortality in Pulmonary Arterial Hypertension , 2008, Circulation.

[69]  N. Voelkel,et al.  Pathobiology of pulmonary arterial hypertension and right ventricular failure , 2012, European Respiratory Journal.

[70]  James O. Mudd,et al.  Pulmonary Capillary Wedge Pressure Augments Right Ventricular Pulsatile Loading , 2012, Circulation.

[71]  R. Kronmal,et al.  Sex and Race Differences in Right Ventricular Structure and Function: The Multi-Ethnic Study of Atherosclerosis–Right Ventricle Study , 2011, Circulation.

[72]  S. Ghio,et al.  Clinical and prognostic relevance of echocardiographic evaluation of right ventricular geometry in patients with idiopathic pulmonary arterial hypertension. , 2011, The American journal of cardiology.

[73]  Nico Westerhof,et al.  Pulmonary endarterectomy normalizes interventricular dyssynchrony and right ventricular systolic wall stress , 2012, Journal of Cardiovascular Magnetic Resonance.

[74]  Anton Vonk-Noordegraaf,et al.  Early onset of retrograde flow in the main pulmonary artery is a characteristic of pulmonary arterial hypertension , 2011, Journal of magnetic resonance imaging : JMRI.

[75]  P. Hassoun,et al.  Comprehensive invasive and noninvasive approach to the right ventricle-pulmonary circulation unit: state of the art and clinical and research implications. , 2009, Circulation.

[76]  J. Orens,et al.  Lung transplantation for primary and secondary pulmonary hypertension. , 2001, The Annals of thoracic surgery.

[77]  S. Solomon,et al.  GUIDELINES AND STANDARDS , 2010 .

[78]  J. Dyck,et al.  A dynamic and chamber-specific mitochondrial remodeling in right ventricular hypertrophy can be therapeutically targeted. , 2008, The Journal of thoracic and cardiovascular surgery.

[79]  N. Chesler,et al.  How to measure peripheral pulmonary vascular mechanics , 2009, 2009 Annual International Conference of the IEEE Engineering in Medicine and Biology Society.

[80]  I. Belenkie,et al.  Volume loading reduces pulmonary vascular resistance in ventilated animals with acute lung injury: evaluation of RV afterload. , 2011, American journal of physiology. Regulatory, integrative and comparative physiology.

[81]  A. van Rossum,et al.  Delayed contrast-enhanced magnetic resonance imaging in pulmonary arterial hypertension. , 2005, Circulation.

[82]  P. Jaksch,et al.  Reverse cardiac remodelling in patients with primary pulmonary hypertension after isolated lung transplantation. , 2004, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[83]  S. Hunt,et al.  Right Ventricular Function in Cardiovascular Disease, Part I: Anatomy, Physiology, Aging, and Functional Assessment of the Right Ventricle , 2008, Circulation.

[84]  Javier Sanz,et al.  Imaging of the right ventricle. , 2012, Cardiology clinics.

[85]  Dave P. Miller,et al.  Characterization of connective tissue disease-associated pulmonary arterial hypertension from REVEAL: identifying systemic sclerosis as a unique phenotype. , 2010, Chest.

[86]  J. Bronzwaer,et al.  Prognostic value of right ventricular mass, volume, and function in idiopathic pulmonary arterial hypertension. , 2007, European heart journal.

[87]  N. Voelkel,et al.  Right ventricle in pulmonary hypertension. , 2011, Comprehensive Physiology.

[88]  N. Chesler,et al.  How to measure pulmonary vascular and right ventricular function , 2009, 2009 Annual International Conference of the IEEE Engineering in Medicine and Biology Society.

[89]  B. Groves,et al.  Changes in gene expression in the intact human heart. Downregulation of alpha-myosin heavy chain in hypertrophied, failing ventricular myocardium. , 1997, The Journal of clinical investigation.

[90]  N. Westerhof,et al.  Right ventricular oscillatory power is a constant fraction of total power irrespective of pulmonary artery pressure. , 2010, American journal of respiratory and critical care medicine.

[91]  Theo Arts,et al.  Control of Whole Heart Geometry by Intramyocardial Mechano-Feedback: A Model Study , 2012, PLoS Comput. Biol..

[92]  K. Kangawa,et al.  Plasma brain natriuretic peptide as a prognostic indicator in patients with primary pulmonary hypertension. , 2000, Circulation.

[93]  J. Kline,et al.  Cardiac inflammation contributes to right ventricular dysfunction following experimental pulmonary embolism in rats. , 2006, Journal of molecular and cellular cardiology.

[94]  J. Marcus,et al.  Interventricular mechanical asynchrony due to right ventricular pressure overload in pulmonary hypertension plays an important role in impaired left ventricular filling. , 2005, Chest.

[95]  H. Niessen,et al.  Extent of MRI delayed enhancement of myocardial mass is related to right ventricular dysfunction in pulmonary artery hypertension. , 2007, AJR. American journal of roentgenology.

[96]  A. Berghold,et al.  Pulmonary vascular resistances during exercise in normal subjects: a systematic review , 2011, European Respiratory Journal.

[97]  P. Pellikka,et al.  Right ventricular strain for prediction of survival in patients with pulmonary arterial hypertension. , 2011, Chest.

[98]  J M Norton,et al.  Toward consistent definitions for preload and afterload. , 2001, Advances in physiology education.

[99]  R. Riley,et al.  Studies of the pulmonary circulation at rest and during exercise in normal individuals and in patients with chronic pulmonary disease. , 1948, The American journal of physiology.

[100]  M. Rubenfire,et al.  Outcome after cardiopulmonary resuscitation in patients with pulmonary arterial hypertension. , 2002, American journal of respiratory and critical care medicine.

[101]  E. Ashley,et al.  New insights for the diagnosis and management of right ventricular failure, from molecular imaging to targeted right ventricular therapy , 2010, Current opinion in cardiology.

[102]  P. Hassoun,et al.  Hyponatremia predicts right heart failure and poor survival in pulmonary arterial hypertension. , 2008, American journal of respiratory and critical care medicine.

[103]  Jeroen J. Bax,et al.  Right ventricular longitudinal peak systolic strain measurements from the subcostal view in patients with suspected pulmonary hypertension: a feasibility study. , 2012, Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography.

[104]  M. Humbert,et al.  Deleterious effects of beta-blockers on exercise capacity and hemodynamics in patients with portopulmonary hypertension. , 2006, Gastroenterology.

[105]  R. Naeije,et al.  Effects of norepinephrine and dobutamine on pressure load-induced right ventricular failure* , 2004, Critical care medicine.

[106]  J. Loscalzo,et al.  Pulmonary arterial hypertension , 2006, The New England journal of medicine.

[107]  R. Naeije,et al.  Effects of levosimendan versus dobutamine on pressure load-induced right ventricular failure* , 2006 .

[108]  Nico Westerhof,et al.  Noninvasively assessed pulmonary artery stiffness predicts mortality in pulmonary arterial hypertension. , 2007, Chest.

[109]  M. Ishihara,et al.  Right ventricular electrical remodeling and arrhythmogenic substrate in rat pulmonary hypertension. , 2013, American journal of respiratory cell and molecular biology.

[110]  S. Hazen,et al.  Sensitive cardiac troponin I predicts poor outcomes in pulmonary arterial hypertension , 2011, European Respiratory Journal.

[111]  Sanjiv J. Shah,et al.  Survival in pulmonary arterial hypertension: a reappraisal of the NIH risk stratification equation , 2009, European Respiratory Journal.

[112]  C. Ayers,et al.  Association of cardiac troponin I with disease severity and outcomes in patients with pulmonary hypertension. , 2013, The American journal of cardiology.

[113]  Gloria Tamborini,et al.  Is right ventricular systolic function reduced after cardiac surgery? A two- and three-dimensional echocardiographic study. , 2009, European journal of echocardiography : the journal of the Working Group on Echocardiography of the European Society of Cardiology.

[114]  Nico Westerhof,et al.  Pulmonary vascular resistance and compliance stay inversely related during treatment of pulmonary hypertension. , 2008, European heart journal.

[115]  David A Bluemke,et al.  Myocardial delayed enhancement in pulmonary hypertension: pulmonary hemodynamics, right ventricular function, and remodeling. , 2011, AJR. American journal of roentgenology.

[116]  P. McGuire,et al.  Cardiac chamber-specific alterations of ANP and BNP expression with advancing age and with systemic hypertension , 2004, Molecular and Cellular Biochemistry.

[117]  M. Gladwin,et al.  Right ventricular function and failure: report of a National Heart, Lung, and Blood Institute working group on cellular and molecular mechanisms of right heart failure. , 2006, Circulation.

[118]  J. Marcus,et al.  Early-diastolic left ventricular lengthening implies pulmonary hypertension-induced right ventricular decompensation. , 2012, Cardiovascular research.

[119]  M. Raza.  Adrenergic Receptor Blockade Reverses Right Heart Remodeling and Dysfunction in Pulmonary Hypertensive Rats , 2011 .

[120]  H. Farber,et al.  Pulmonary hemodynamic responses to brain natriuretic peptide and sildenafil in patients with pulmonary arterial hypertension. , 2006, Chest.

[121]  S. Ghio,et al.  Inappropriate exercise-induced increase in pulmonary artery pressure in patients with systemic sclerosis , 2010, Heart.

[122]  M. Buckingham,et al.  Building the mammalian heart from two sources of myocardial cells , 2005, Nature Reviews Genetics.

[123]  J. Wild,et al.  Ventricular mass index correlates with pulmonary artery pressure and predicts survival in suspected systemic sclerosis-associated pulmonary arterial hypertension. , 2009, Rheumatology.

[124]  L. Dell’Italia.  Anatomy and physiology of the right ventricle. , 2012, Cardiology clinics.

[125]  T. Abraham,et al.  Tricuspid annular displacement predicts survival in pulmonary hypertension. , 2006, American journal of respiratory and critical care medicine.

[126]  Horst Olschewski,et al.  Assessment of pulmonary arterial pressure during exercise in collagen vascular disease: echocardiography vs right-sided heart catheterization. , 2010, Chest.

[127]  R. Naeije,et al.  Pulmonary vascular responses to exercise: a haemodynamic observation , 2012, European Respiratory Journal.

[128]  M. Arzt,et al.  Impact of right ventricular reserve on exercise capacity and survival in patients with pulmonary hypertension , 2013, European journal of heart failure.

[129]  P. V. van Riel,et al.  Right ventricle Tei-index: a tool to increase the accuracy of non-invasive detection of pulmonary arterial hypertension in connective tissue diseases. , 2007, European journal of echocardiography : the journal of the Working Group on Echocardiography of the European Society of Cardiology.

[130]  R. Naeije,et al.  How prostacyclin improves cardiac output in right heart failure in conjunction with pulmonary hypertension. , 2007, American journal of respiratory and critical care medicine.

[131]  J. Bronzwaer,et al.  Clinically significant change in stroke volume in pulmonary hypertension. , 2011, Chest.

[132]  G. Lopaschuk,et al.  Fatty Acid Oxidation and Malonyl-CoA Decarboxylase in the Vascular Remodeling of Pulmonary Hypertension , 2010, Science Translational Medicine.

[133]  N. Westerhof,et al.  Progressive changes in right ventricular geometric shortening and long-term survival in pulmonary arterial hypertension. , 2012, Chest.

[134]  Christopher S Coffey,et al.  Predicting Survival in Pulmonary Arterial Hypertension: Insights From the Registry to Evaluate Early and Long-Term Pulmonary Arterial Hypertension Disease Management (REVEAL) , 2010, Circulation.

[135]  A. Chapelier,et al.  Long-term outcome of double-lung and heart-lung transplantation for pulmonary hypertension: a comparative retrospective study of 219 patients. , 2010, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[136]  R. Tuder,et al.  Targeting energetic metabolism: a new frontier in the pathogenesis and treatment of pulmonary hypertension. , 2012, American journal of respiratory and critical care medicine.

[137]  R. Dellinger.  Inflammation in right ventricular dysfunction due to thromboembolic pulmonary hypertension , 2011 .

[138]  V. Fuster,et al.  Prevalence and correlates of septal delayed contrast enhancement in patients with pulmonary hypertension. , 2007, The American journal of cardiology.

[139]  W. Paulus,et al.  Perspectives on novel therapeutic strategies for right heart failure in pulmonary arterial hypertension: lessons from the left heart , 2010, European Respiratory Review.

[140]  M. Humbert,et al.  Prognostic factors of acute heart failure in patients with pulmonary arterial hypertension , 2009, European Respiratory Journal.