Pulmonary Hypertension

Pulmonary hypertension (PH) is defined by a mean pulmonary artery pressure (mPAP) >25 mmHg at rest or >30 mmHg with exer­cise [26]. A large case-control study, includ­ing 3,349 HIV-infected patients over a peri­od of 5.5 years found a cumulative incidence of PH of 0.57%, resulting in an annual inci­dence of 0.1%, whereas its incidence in the general population is only 1-2 per 1 million people [27].

Echocardiography is a reliable tool to screen PH, rule out secondary forms and refine prognostic stratification. Echocardio­graphy allows the estimation of pulmonary arterial systolic pressure (PASP) (Fig. 3) and provides additional information regard­ing the cause, consequences and prognosis of PH. A high correlation was found between transthoracic echocardiography findings and right heart catheterisation measurements [26]. Age, body mass index, systemic hypertension have been shown to increase PASP and should be taken into account when a PASP level is interpreted at an individual level [26].

Echocardiography also allows diagnosis of secondary causes of PH. It can easily rec­ognize left heart valvular and myocardial diseases responsible for pulmonary venous hypertension, and congenital heart diseases with systemic-pulmonary shunts. The exam­ination includes venous injection of agitat­ed saline contrast medium to rule out atrial septal defect or patent Foramen ovale.

In the pre-HAART era and among 131 cases, the most frequent echocardiographic findings were a dilatation of right heart chambers (98%), tricuspid regurgitation (64%), and paradoxical septal motion (40%) [32]. Zuber et al. [33] suggested an indirect link between HIV, HAART and the inci­dence of PH. They found, in a retrospective study, an improvement of hemodynamic parameters in patients treated with HAART. In a group of 35 patients who had serial Doppler echocardiography, RV sys­tolic pressure increased by a median of 25 mm Hg in nine patients who were not treat­ed with HAART, decreased by a median of 3 mm Hg in nine patients who were not treat­ed with NRTI and decreased by a median of 21 mm Hg in 14 patients who received HAART (ppatients with HIV infection, Kaposi sar­coma and lymphoma occur more commonly than in immunocompetent subjects. In the pre-HAART period, the cardiac Kaposi sar­coma prevalence varies from 12-8% in ret­rospective autopsies studies [44]. Echocar­diographic findings in this setting found pericardial tamponade or pericardial con­striction.

Malignant Lymphoma

Lymphomas are observed in 5-10% of pa­tients with AIDS, which is 25-60 times high­er than expected in the general population [45]. Primary cardiac lymphoma is rare [46]. Clinical presentation and echocardiographic findings include congestive heart failure, pericardial effusion or tamponade with nodu­lar or polypoid masses involving the peri­cardium with variable myocardial infiltration and of the right atria. Malignant lymphoma is infrequent in HIV patients; the lesions pre­dominantly involve the pericardium with my­ocardial infiltration [46].The introduction of HAART led to the reduction in the incidence of cardiac involvement by Kaposi sarcoma and non-Hodgkin’s lymphoma [8].