Atrial Pressure Research Articles

Correlation between right atrial pressure measured via right heart catheterization and venous excess ultrasound, inferior vena cava diameter, and ultrasound-measured jugular venous pressure: a prospective observational study

BackgroundVenous congestion is associated with adverse cardiovascular outcomes, necessitating accurate venous pressure assessment. Current methods, such as right heart catheterization (RHC), have limitations. Non-invasive techniques, including venous excess ultrasound (VExUS), inferior vena cava (IVC) assessment, and ultrasound-measured jugular venous pressure (uJVP), show promise but require validation in diverse populations.AimsWe aimed to assess the correlation between right atrial pressure (RAP) via RHC and non-invasive methods, including VExUS, IVC diameter with collapsibility index (CI) by American Society of Echocardiography (ASE) classification, and uJVP.MethodsIn a prospective study involving 73 patients undergoing RHC, we evaluated the correlation between RAP and VExUS, IVC CI by ASE classification, and uJVP. We introduced and compared a modified VExUS grading system.ResultsVExUS significantly correlated with RAP (p < 0.001), especially between VExUS grade 0 and grade 3. RAP significantly differed across IVC classifications by ASE (P < 0.001). VExUS grade 0 correlated with IVC class 1, and VExUS grade 3 correlated with IVC class 3. The modified VExUS grading system improved low and high RAP differentiation. uJVP exhibited a robust, highly significant positive correlation with invasively measured RAP (ρ = 0.67, P < 0.001).ConclusionThis study establishes a strong correlation between non-invasive ultrasound measurements (VExUS, IVC diameter with CI, and uJVP) and invasively measured RAP. These findings underscore the clinical potential of these non-invasive techniques in venous congestion assessment and patient risk stratification.

Accelerated atrial pacing reduces left-heart filling pressure: a combined clinical-computational study.

Accelerated atrial pacing offers potential benefits for patients with heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF), compared with standard lower-rate pacing. The study investigates the relationship between atrial pacing rate and left-heart filling pressure. Seventy-five consecutive patients undergoing catheter ablation for AF underwent assessment of mean left atrial pressure (mLAP) and atrioventricular (AV) conduction delay (PR interval) in sinus rhythm and accelerated atrial pacing with 10 bpm increments up to Wenckebach block. Computer simulations (CircAdapt) of a virtual HFpEF cohort complemented clinical observations and hypothesized the modulating effects of AV coupling and atrial (dys)function. In the study cohort, 49(65%) patients had a high HFpEF likelihood (H2FPEF ≥ 5.0), and 28(37%) an elevated mLAP ≥ 15 mmHg at sinus rhythm. Optimal pacing rates of 100 [70-110]bpm (median [IQR]) significantly reduced mLAP from 12.8 [10.0-17.4]mmHg in sinus rhythm (55 [52-61]bpm) to 10.4 [7.8-14.8]mmHg (P < .001). Conversely, higher pacing rates (130 [110-140]bpm) significantly increased mLAP to 14.7 [11.0-17.8]mmHg (P < .05). PR interval and, hence, AV conduction delay prolonged incrementally with increasing pacing rates. Simulations corroborated these clinical findings, showing mLAP reduction at a moderately increased pacing rate and a subsequent increase at higher rates. Moreover, simulations suggested that mLAP reduction is optimized when AV conduction delay shortens with increasing rate. Accelerated pacing acutely reduces left-heart filling pressure in patients undergoing AF catheter ablation and computer simulations with HFpEF features, suggesting it as a potential therapeutic strategy to alleviate congestion symptoms. Virtual HFpEF patient cohorts hypothesize that AV sequential pacing may further optimize this therapy's beneficial effects.

Phosphodiesterase 9 Inhibition Combined With Valsartan and With Sacubitril/Valsartan in Experimental Ovine Heart Failure.

LCZ696 (sacubitril/valsartan) antagonizes the renin-angiotensin system while simultaneously augmenting the natriuretic peptides (NPs). Inhibition of phosphodiesterase 9 inhibition (PDE9i), which hydrolyses NP-generated cGMP may be a more specific means of enhancing NP bioactivity. The objective of the present study was to compare for the first time effects of LCZ696 and PDE9i+valsartan in experimental heart failure (HF) and investigate combination PDE9i+LCZ696. Seven sheep received, on separate days, intravenous boli of (1) LCZ696, (2) PDE9i+valsartan, (3) PDE9i+LCZ696, and (4) vehicle control, during mild HF and severe HF. Compared with control, LCZ696 and PDE9i+LCZ696 induced similar increases in plasma NPs (greater increments in severe HF), whereas PDE9i+valsartan reduced NP levels. Circulating cGMP was elevated following LCZ696 and PDE9i+valsartan, and further increased with combination PDE9i+LCZ696. All active treatments increased plasma renin and angiotensin II (greater increments in severe HF). Plasma aldosterone was unchanged. Plasma endothelin-1 was elevated by LCZ696 and PDE9i+LCZ696, but not PDE9i+valsartan. Active treatments reduced arterial and left atrial pressure and peripheral resistance and increased cardiac output (more pronounced in severe-HF). PDE9i+LCZ696 induced greater hemodynamic changes relative to LCZ696 and PDE9i+valsartan. Treatments had minimal renal effect in mild HF. In severe HF, treatments elevated urine cGMP in association with significant increases in creatinine clearance and diuresis and natriuresis, effects especially prominent with PDE9i+LCZ696. LCZ696 and PDE9i+valsartan have similar beneficial hemodynamic and renal effects in HF, with combined PDE9i+LCZ696 producing additional improvements. Overall, effects were significantly greater in severe HF. Findings suggest PDE9i might serve as a replacement for neprilysin inhibition or as an adjunct therapy to LCZ696.

Differences in the Impact of Left Ventricular Outflow Tract Obstruction on Intraventricular Pressure Gradient in Feline Hypertrophic Cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is a common form of cardiomyopathy in cats, and heart failure occurs as diastolic dysfunction progresses. HCM in cats is broadly classified as non-obstructive and obstructive hypertrophic cardiomyopathy, depending on the presence or absence of outflow tract obstruction. Measurement of the intraventricular pressure differences (IVPD) using color M-mode (CMM) has attracted attention as a reliable diastolic index as it correlates with catheterization, the gold standard for the assessment of diastolic performance. Because IVPD is affected by the size of the heart, the intraventricular pressure gradient (IVPG) index, which is unaffected by heart size, is by calculated by dividing IVPD by LV length. In the present study, CMM IVPG was used to non-invasively assess diastolic impairment in cats with obstructive hypertrophic cardiomyopathy. This study was conducted on 10 control cats and 18 cats in the HCM group. Although no severe left atrial enlargement was observed in the HCM group, the basal IVPG was significantly increased in the HOCM group compared to the control group. Although IVPD typically suggests impaired diastolic function and reduced ventricular compliance, the significant increase observed in the HOCM group compared to controls may suggest an indirect elevation in left atrial pressure, likely secondary to left ventricular outflow tract obstruction. The increase in IVPG in HOCM, as shown in this study, is a pathological effect of left ventricular outflow tract obstruction that cannot be detected by conventional echocardiographic indices, and evaluating IVPG is useful to evaluate cardiac function from a perspective that differs from conventional methods.

Electrophysiological characteristics of pulmonary vein conduction recovery after radiofrequency ablation of atrial fibrillation

This study aimed to identify the specific site of pulmonary vein conduction recovery after radiofrequency ablation (RFA) of atrial fibrillation (AF) for improved outcomes and reduced recurrence. Patients who underwent RFA for AF at our institution were included. The ablation procedure was guided by the ablation index (AI) and left, and right atrial pressures were monitored before and after ablation. Additionally, the recovery time of the sinoatrial node under Burst 400/300 ms stimulation was examined. Among 60 repeat procedure patients, 48 had paroxysmal and 12 had persistent AF. The recovery sites were 36.6% in the left anterior superior, 35% in the right anterior superior, 20% in the left anterior inferior, 20% in the right anterior inferior, 13.3% in the right top, and 11.6% in the left top. Preoperative and postoperative left and right atrial pressures were significantly higher in the persistent AF group compared with the paroxysmal AF group (P < 0.01). Postoperative left atrial pressures were significantly elevated compared to the preoperative levels in both groups (P < 0.01). Sinoatrial node recovery time in the persistent AF group was significantly longer compared with the paroxysmal AF group (P < 0.01). Under the guidance of AI, the recurrence of atrial fibrillation after radiofrequency surgery and the recovery of pulmonary vein potential are mostly concentrated in the upper anterior, lower anterior, and upper left and right pulmonary veins. As the duration of atrial fibrillation prolongs, the left and right atrial pressure increases year by year, while the recovery time of the sinus node gradually prolongs.

Post-TIPS Right Atrial Pressure and Left Atrial Volume Index Predict Heart Failure and Mortality: Dual Center Experience

Background: Heart failure (HF) after Transjugular Intrahepatic Portosystemic Shunt (TIPS) placement affects up to 20% of patients. Understanding factors associated with post-TIPS HF is critical. Cirrhotic Cardiomyopathy (CCM) is associated with adverse clinical outcomes. Aims: We aim to evaluate whether hemodynamic measurements and echocardiographic markers of CCM pre- and post-TIPS can predict post-TIPS HF and death. Methods: We performed a retrospective study of cirrhotic patients who underwent TIPS between 2010 and 2015 at two centers. Patients with cardiomyopathies other than CCM were excluded. A multivariable-adjusted time-to-event analysis assessed associations of clinical, hemodynamic, and echocardiographic parameters with post-TIPS HF and death during 2 years of follow-up. 180-day landmark analysis was used to assess association of echocardiographic changes with outcomes. Results: 360 patients met study criteria. 32 developed HF post-TIPS (8.8%). Right atrial pressure (RAP) measured intraprocedurally post-TIPS insertion was associated with increased risk for HF (adjusted HR 1.10 [1.04-1.17]), with a cut off of 22mm Hg associated with highest risk (multivariable HR 2.71, [1.22-6.02]. 92 patients died (25.5%). An increase in left atrial volume index (LAVI) within 180 days post-TIPS was associated with increased mortality (HR 1.08 [1.01-1.15]). Other echocardiographic CCM markers were not associated with HF or death. Conclusion: Increases in RAP and LAVI post-TIPS, but not CCM status, predict post-TIPS HF and death, respectively. Surveillance echocardiography may play a role in identifying those at highest risk of decompensation post-TIPS. Further prospective study of CCM and its markers in relation to TIPS outcomes is warranted.

Hemodynamic Effects and Clinical Outcomes of Left Atrial Veno-Arterial Extracorporeal Membrane Oxygenation (LAVA-ECMO) in Cardiogenic Shock

Left atrial veno-arterial extracorporeal membrane oxygenation (LAVA-ECMO) in cardiogenic shock (CS) is a novel mechanical cardiocirculatory support strategy that provides robust cardiocirculatory support and simultaneous left and right atrial venting by way of a multifenestrated transeptal catheter. We performed a single-center retrospective analysis of all patients aged ≥18 years with CS who underwent LAVA-ECMO at a quaternary care institution from 2018 to 2023. Clinical outcomes and prehemodynamics and posthemodynamics were evaluated. A total of 68 patients were analyzed (75% were men, 72% were white, median age of 63 years). The indications for LAVA-ECMO were CS because of myocardial infarction (29.4%), biventricular failure (26.5%), and/or valvular heart disease (26.5%). Trans-septal puncture was guided by intracardiac echocardiography (86.8%) or transesophageal echocardiography (13.2%). Arterial cannulation was performed by way of transcaval access in 25% of the cases. Post-LAVA-ECMO cannulation was associated with substantial improvement in the hemodynamics within 24 hours after cannulation, including reduction in right atrial pressure (absolute mean difference: -5.0 mm Hg, p <0.001), mean pulmonary artery pressure (-9.0 mm Hg, p <0.001), pulmonary capillary wedge pressure (-10.0 mm Hg, p <0.001), and left ventricular end-diastolic pressure (-14.0 mm Hg, p <0.001). Survival to decannulation occurred in 69.1%, whereas the 30-day survival from cannulation was 51.5%. The in-hospital all-cause mortality was 51.5%. Only 5 patients (7.4%) required additional mechanical circulatory support (MCS) (4 Impella, 1 veno-arterio-venous extracorporeal membrane oxygenation). There were no complications related to transeptal placement of the venous ECMO cannula. In conclusion, LAVA-ECMO, an MCS strategy providing biatrial drainage, appears to also provide simultaneous left ventricular venting, as demonstrated by improved invasive hemodynamics. Although the procedure appears safe, with no direct complications to interatrial septal cannulation, postcannulation complications remain high, and further studies are needed to evaluate the full safety profile of LAVA-ECMO compared with alternative MCS strategies.

Abstract 4136316: BMP10 as novel marker for right atrial dilatation and pressure in precapillary pulmonary hypertension

Introduction: Precapillary pulmonary hypertension (precPH) leads to increased right atrial (RA) stretch and pressure. The right atrium is the major source of bone morphogenetic protein 10 (BMP10) in adults. Aim: This study aims to investigate BMP10 in relation to RA dilatation and pressure overload. Methods: We studied BMP10 mRNA in fresh RA tissue of N=5 Chronic Thromboembolic Pulmonary Hypertension (CTEPH) patients and N=9 controls and protein expression in paraffin-embedded RA tissue of N=4 Pulmonary Arterial Hypertension (PAH) patients and N=6 controls. We prospectively included 48 precPH patients (N=22 idiopathic PAH, N=14 hereditary PAH and N=12 CTEPH, and N=16 controls. To study BMP10-induced transcriptional activity, we assayed serum samples in human microvascular endothelial cells (HMEC) with a BMP-responsive transcriptional luciferase assay. BMP10 activity was calculated by subtracting BMP activity after incubation with antibodies for Alk1Fc and bone morphogenetic protein 9 (BMP9). We assessed correlations between BMP10 activity and RA dilatation (RA max volume&gt;79 ml/m 2 for male or &gt;69 ml/m 2 for female) and right ventricular (RV) dilatation (RV end-diastolic volume&gt;108 ml/m 2 for male and &gt;96 ml/m 2 for female). In a cohort of CTEPH patients that underwent pulmonary endarterectomy (PEA) we assessed the effect of pressure unloading on BMP10 activity. Normality of data was checked and statistical differences between groups were tested using an independent sample t-test or Wilcoxon rank-sum test. Results: BMP10 mRNA, protein and downstream activity were higher in the precPH RA tissue (Figure 1A-F). High systemic BMP10 activity was associated with RA dilatation and high RA pressure, but not RV dilatation in precPH (Figure 2A-C). Finally, pressure unloading after PEA in CTEPH patients results in a reduction in BMP10 activity (figure 2D). Conclusions: Local RA BMP10 expression and activity is increased in precPH. Increased systemic BMP10 activity was related to RA dilatation and pressure. Pressure unloading of the right heart leads to a reduction of systemic BMP10 activity. Future studies are needed to determine whether increased BMP10 release is an adaptative mechanism or can be used as therapeutic target.

Abstract 4120749: GPR39 Orchestrates the Myogenic Response in Coronary Autoregulation

Background: Coronary autoregulation is the ability of a normal heart to maintain constant coronary blood flow (CBF) over a wide range of coronary driving pressures (CDPs) provided cardiac work remains constant. It is based on the myogenic response, the molecular mechanism of which is unknown. We recently described the presence of a G-protein coupled receptor (GPR39) in the vascular smooth muscle cells (VSMCs) of coronary arterioles in the mouse heart. We showed that endogenous eicosanoids, the vasoconstrictor 15-hydroxyeicosatetraenoic acid (15-HETE) and the vasodilator 14,15-epoxyeicosatrienoic acid (14,15 EET). act through this receptor to maintain coronary vascular tone. Hypothesis: We, therefore, hypothesized that GPR39 is the molecular switch responsible for the coronary myogenic response and autoregulation. Methods: We studied 6 anesthetized dogs at baseline and after administration of VC-108, a specific, potent GPR39 antagonist. Both during baseline and drug administration multiple coronary stenoses were created on the left anterior descending coronary artery (LAD). At each stage, heart rate, mean aortic pressure, distal LAD pressure, and right atrial pressure (RAP) were measured, as was CBF. Stenosis severity was defined by the CDP (LAD pressure minus RAP). Results: Mean basal coronary hyperemic response was 3.0 in all anesthetized animals indicating normal vasomotor function. Systemic hemodynamics did not differ between baseline and drug stages. Figure 1 is an example from a single dog where, at baseline, CBF remained constant over a CDP of 40-90 mm Hg indicating intact autoregulation. As expected, CBF declined when CDP fell below the autoregulatory range. After VC-108 administration CBF correlated linearly with CDP, indicating abolishment of the myogenic response. Baseline CDP vs. CBF data from all 6 animals within the autoregulatory range is depicted in Figure 2. No relation is noted between the two indicating intact autoregulation. In contrast, CDP vs. CBF relation is linear in all animals after VC108 is administered over the entire range of CDP’s measured, indicating abolishment of autoregulation (Figure 3). Conclusions: Our results indicate that GPR39 is a potential molecular switch for the regulation of the myogenic response underlying coronary autoregulation. Pharmacological blockage of GPR39 abolishes the myogenic tone. These novel findings set the stage for development of novel pharmacological agents for treatment of coronary artery disease.

Abstract 4130072: Prognostic Impact of Renal Microcirculatory Dysfunction in Heart Failure Assessed by the Advanced Doppler technique, Superb Microvascular Imaging

Aims: The significance of cardio-renal interactions in heart failure (HF) prognosis has become increasingly evident, yet there are no established methods to assess them. To address this issue, we propose a novel approach using Superb Microvascular Imaging (SMI), an ultrasound method that that enables detailed visualization of microvascular flow, to assess renal microcirculation. Methods: We retrospectively analyzed 78 patients who underwent renal ultrasonography using SMI from October 2020 to May 2023. We measured changes over time of Vascular Index (VI), which quantifies the blood flow signal area in the region of interest on the SMI image (Figure 1). Key measurements included Maximum VI (Max.VI), Minimum VI (Min.VI), and the cyclic variation of VI, calculated as the intrarenal perfusion index (IRPI) = (Max.VI - Min.VI) / Max.VI within one cardiac cycle. The primary endpoint of this study was a composite event (CE), defined as a composite of all-cause death and unplanned hospitalization for worsening HF. Results: During a mean follow-up period of 1.6±0.8 years, 13 of 78 patients (17%) experienced a CE. Compared with patients without CE, those with CE had significantly lower Max.VI (0.28±0.15 vs 0.46±0.18, p=0.002) and Min.VI (0.10±0.12 vs 0.22±0.14, p=0.007), and IRPI was significantly higher in the event group (0.68±0.19 vs 0.55±0.17, p=0.018). In univariable Cox regression analyses, Max.VI (HR 0.35, 95%CI 0.17-0.71, p=0.004), Min.VI (HR 0.28, 95%CI 0.10-0.75, p=0.012), IRPI (HR 1.97, 95%CI 1.11-3.51, p=0.021), creatinine (Cr) (HR 1.67, 95%CI 1.26-2.21, p&lt;0.001) and estimated right atrial pressure by echocardiography (eRAP) (HR 4.22, 95%CI 1.42-12.5, p&lt;0.001) were significantly associated with CE. In multivariable Cox regression analyses, Min.VI remained significantly associated with CE in the model adjusted for Cr (HR 0.35, 95%CI: 0.13-0.92, p=0.033), and in the model adjusted for eRAP (HR 0.11, 95%CI: 0.11-0.82, p=0.019). ROC curve analysis showed that, although not statistically significant, the predictive power of Min.VI was superior to that of Cr and eRAP (Figure 2). Stratifying patients by a Min.VI cut-off value of 0.08, determined through ROC analysis, showed that those with Min.VI &lt; 0.08 had a significantly poorer prognosis (log-rank p&lt;0.001) (Figure 3). Conclusion: The use of Superb Microvascular Imaging to assess renal circulation provides new insights into the prognosis of HF and allows risk stratification beyond conventional markers.

Abstract 4138252: Association between Pressure-Adjusted Heart Rate and Mortality in Cardiogenic Shock

Introduction: Among patients with cardiogenic shock (CS), high right atrial pressure (RAP) and low mean arterial pressure (MAP) are associated with in-hospital mortality. Pressure-adjusted heart rate (PAHR), defined as heart rate * RAP-to-MAP ratio (HR * [RAP/MAP]), integrates these parameters and has been used to identify cardiovascular dysfunction in critical illness. Higher PAHR values associate with higher surgical ICU mortality, but the prognostic significance of PAHR has not been assessed in cardiac intensive care unit (CICU) patients with CS. Hypothesis: We hypothesized that higher PAHR values are associated with higher risk of in-hospital mortality in patients with CS. Methods: The Critical Care Cardiology Trials Network (CCCTN) is a multinational registry of CICUs coordinated by the TIMI Study Group. Among CS admissions (2018-2023) undergoing invasive hemodynamic assessment within 24h of CICU admission, we calculated PAHR (in bpm) and assessed its relationship with in-hospital mortality. Patients on temporary mechanical circulatory support were excluded. Odds ratios were adjusted for age, sex, vasoactive-inotropic score (VIS), SCAI stage, and preceding cardiac arrest. Subgroup analyses stratifying by CS subtype were performed. Results: Among the 1411 CS admissions in the analysis cohort (mean age 61 years, 31% women), 18% had AMI-CS, 75% had HF-CS, and 7% had secondary CS. At the time of assessment (median 1.4h after CICU admission), 75% were on vasoactive support (median VIS 3.8). Median HR was 92 (Q1-Q3 77-109) bpm, RAP 15 (Q1-Q3 10-19) mmHg, MAP 75 (Q1-Q3 67-87) mmHg, and PAHR 17 (Q1-Q3 11-24) bpm. A stepwise gradient of higher in-hospital mortality with increasing PAHR values (p-trend &lt;0.001; Fig ) was observed. In adjusted models, a higher PAHR was associated with higher in-hospital mortality (aOR per 10-bpm, 1.35 [95% CI, 1.15-1.58]), and had stronger prognostic associations with mortality than its individual hemodynamic components (Fig) . Conclusion: Higher PAHR is strongly associated with in-hospital mortality in CS patients. PAHR, a simple parameter which is readily calculable without needing a pulmonary artery catheter, may aid in identifying CS patients at higher risk of death.

Abstract 4127071: Pulmonary Artery Catheter Utilization in Cardiogenic Shock: Clinical Characteristics and Outcomes

Background: The pulmonary artery catheter (PAC) is used for hemodynamic monitoring, but its impact on patient outcomes, especially in cardiogenic shock (CS), is controversial. Several studies have shown no significant benefits and noted complications, leading to a decline in PAC use. However, PAC use appears to have increased recently in guiding management decisions in CS. Our study aims to assess the clinical characteristics and outcomes of CS patients receiving PACs versus not. Methods: We included patients with CS admitted to a tertiary academic medical center between May 2015 and December 2023. Variables were compared using Kruskal-Wallis, chi-squared, and Fisher's exact tests. Hemodynamic parameters were collected from either right heart catheterization or from a PAC. Endpoints included native heart survival to discharge, durable left ventricular assist device (LVAD) implantation, heart transplant (HTx), and 30-day and 1-year survival from discharge. Results: The study group consisted of 742 patients with CS. Of these, 385 (52%) received a PAC and 357 (48%) did not. The baseline characteristics of the two groups are shown in Table 1A . PAC patients had more severe shock, worse hemodynamics, and higher rates of temporary mechanical circulatory support (MCS) use. Hemodynamic measurements at shock onset differed, with PAC patients having higher right atrial pressures and lower cardiac index by Fick. Clinical outcomes and MCS related complications are shown in Table 1B. There was no significant difference in native heart survival at discharge, but HTx and durable LVAD implantation was higher in the PAC group. PAC placement was associated with longer hospital stays and more MCS related complications, including bleeding and hemolysis. The 30-day survival rate was similar between groups, and 1-year survival was marginally higher in the PAC group. Conclusion: PAC patients exhibited more severe clinical characteristics, longer hospital stays, higher rates of temporary MCS use and complications, durable LVAD implantation, and HTx. Short-term survival rates were similar, but 1-year survival was slightly better for PAC patients. Further studies are needed to provide clearer insights into PAC use in CS.

The mechanistic interaction between mechanical dyssynchrony and filling pressure in cardiac resynchronization therapy candidates.

Both left ventricular (LV) mechanical dyssynchrony and filling pressure have been shown to be associated with outcome in heart failure patient treated with cardiac resynchronization therapy (CRT). To investigate the mechanistic link between mechanical dyssynchrony and filling pressure and to assess their combined prognostic value in CRT candidates. Left atrial pressure (LAP) estimation and quantification of mechanical dyssynchrony were retrospectively performed in 219 CRT patients using echocardiography. LAP was elevated (eLAP) in 49% of the population, normal (nLAP) in 40%, and indeterminate (iLAP) in 11%. CRT response was defined as %-decrease in LV end-systolic volume after 12±6 months CRT. Clinical endpoint was all-cause mortality during 4.8 years (interquartile range: 2.7-6.0 years). To investigate the mechanistic link between mechanical dyssynchrony and filling pressure, the CircAdapt computer model was used to simulate cardiac mechanics and hemodynamics in virtual hearts with LBBB and various causes of increased filling pressure. Patients with nLAP had more significant mechanical dyssynchrony than those with eLAP. The combined assessment of both parameters before CRT was significantly associated with reverse LV remodeling and post-CRT survival. Simulations revealed that mechanical dyssynchrony is attenuated by increased LV operational chamber stiffness, regardless of whether it is caused by passive or active factors, explaining the link between mechanical dyssynchrony and filling pressure. Our combined clinical-computational data demonstrate that in patients with LBBB, the presence of mechanical dyssynchrony indicates relatively normal LV compliance and low filling pressure, which may explain their strong association with positive outcomes after CRT.

Left ventricular diastolic dysfunction worsens prognosis in patients with heart failure due to dilated cardiomyopathy.

The prognostic significance of left ventricular (LV) diastolic dysfunction (LVDD) severity in patients with dilated cardiomyopathy (DCM) remains uncertain. This study aimed to evaluate the association of LVDD severity and elevated left atrial pressure (eLAP) with patient outcomes in stable, non-acutely decompensated patients with DCM. This single-centre, retrospective, observational study involved 740 DCM patients (either inpatients or outpatients) managed at our tertiary cardiac centre between 2010 and 2021. Due to incomplete data, 96 patients were excluded. LVDD and eLAP were assessed using echocardiography according to the 2016 guidelines of the European Association of Cardiovascular Imaging (EACVI). The primary outcomes were all-cause mortality and heart failure (HF)-related mortality. The final cohort comprised of 644 DCM patients [mean age: 52±12years, LV ejection fraction (LVEF): 26±10%]. Over a median follow-up period of 41 (18.5-66.7) months, 105 (16.3%) patients died: 8 (5.3%) patients in the normal left atrial pressure (nLAP) group and 97 (19.6%) patients in the eLAP group. eLAP was identified as an independent prognostic factor for both all-cause mortality [hazard ratio (HR) 2.0; 95% confidence interval (CI) 1.1-3.7; P=0.01] and HF-related mortality (HR 2.5; 95% CI 1.01-6.5; P=0.04), even after adjusting for LVEF and atrial fibrillation (AF) presence. Additionally, HF-related mortality rates were significantly higher in patients with moderate to severe LVDD compared with those with mild LVDD [5 (3.3%) vs. 67 (13.6%), P<0.05]. This study's findings highlight the importance of assessing the severity of LVDD in patients with DCM, which provides incremental prognostic information over LVEF.

Association Between Pulmonary Artery Pulsatility Index and Radial Artery Pulse Pressure and Successful Separation from Peripheral Veno-Arterial Extracorporeal Membrane Oxygenation: A French Single-Center Retrospective Study From 2017 to 2021

ObjectiveFew reliable tools exist to predict outcome of weaning patients from veno-arterial ECMO (VA-ECMO). Pulmonary artery pulse pressure indexed on right atrial pressure (PAPi) reflects the ventricular-pulmonary coupling and may be representative of right ventricle recovery. Radial artery pulse pressure (rPP) may be representative of left ventricular recovery. We intended to explore the usefulness of these indices in the weaning from VA-ECMO DesignRetrospective cohort study SettingSingle center in a tertiary university hospital ParticipantsPatients benefiting from a VA-ECMO for all-cause refractory cardiogenic shock between 2017 and 2021. Non-inclusion criteria were minor/pregnant patients, ECMO < 48 hours. Univariate and multivariate logistic regression analyses explored the relationship between PAPi and rPP with weaning success. InterventionsWe explored the association between the pulmonary artery pulse pressure indexed on right atrial pressure (PAPi), the radial artery pulse pressure (rPP) and the success of weaning from VA-ECMO. Measurements and Main Results124 patients were included for rPP analysis and 82 patients for PAPi analysis. Higher rPP and PAPi (50.43 vs 26.3 mmHg, p<0.001: 1.78 vs 0.88, p<0.001, respectively) and shorter ECMO duration were associated with weaning success. Areas under ROC for rPP and PAPi were 0.85 and 0.88. The combination of rPP ≥ 40 mmHg and PAPi ≥ 1.09 predicted weaning with a sensitivity of 0.94, specificity of 1.00, positive predictive value of 1.00 and negative predictive value of 0.84. ConclusionsHigher pulmonary arterial pulsatility index and radial artery pulse pressure were predictors of successful weaning from VA-ECMO in this retrospective study.

Invasive hemodynamic characteristics in patients with mitral annular calcification related mitral stenosis and chest radiation.

Quantification of invasive hemodynamics and mitral annular calcification-related mitral stenosis remains underexplored in patients exposed to chest radiation. We sought to explore invasive hemodynamic parameters via transseptal catheterization in patients with and without chest radiation who had a diagnosis of mitral annular calcification-related mitral stenosis. After excluding patients with more than moderate mitral regurgitation, we found that there was no difference in mitral valve area on hemodynamic testing in patients with and without radiation with an elevated baseline transmitral gradient on transthoracic echocardiography in the setting of mitral annular calcification-related mitral stenosis. There was a higher transmitral gradient and left atrial pressure in patients with prior radiation consistent with left atrial noncompliance, suggesting that treatment mitral valve stenosis may not relieve symptoms in this cohort of patients.

The hemodynamic effects of protamine in pediatric patients undergoing pulmonary artery reconstruction and unifocalization surgery: A Pilot Study.: Hemodynamic effects of protamine in children.

ObjectivesTo determine protamine administration increases pulmonary artery pressures in patients undergoing unifocalization or pulmonary artery reconstruction surgeries. Design: Retrospective database study. SettingA large pediatric heart center within an academic quaternary care facility. ParticipantsAll patients undergoing pulmonary artery reconstruction or unifocalization procedure identifiable within the data warehouse. InterventionsWe collected data from Stanford University's data repository, formatted it, and analyzed it using RStudio (v 2023.06.1+524). Measurements and Main ResultsOur primary outcome is the change in pulmonary artery pressure (PAP) after an administration of protamine. Secondary outcomes include changes in the mean arterial pressure, the ratio of systolic pulmonary artery to systemic artery pressure, right sided filling pressure, and left atrial pressure. After a protamine bolus, we found a difference in PAP (Friedman X2 = 49.46, p <0.001). When compared to two minutes before its administration, the PAP was higher at two minutes (29.00 mmHg versus 25.00 mmHg, p <0.001), five minutes (30.00 mmHg versus 25.00 mmHg, p <0.001) and ten minutes (31 mmHg versus 25 mmHg, p < 0.001). When co-administered with calcium, there was also a significant increase in PAP (Friedman X2 = 28.11, p < 0.001), with a higher PAP ten minutes after calcium administration when compared to two minutes before (32 mmHg versus 26 mmHg, p < 0.001) Conclusions: Protamine administration led to a small increase in PAP after separation from cardiopulmonary bypass in patients undergoing pulmonary artery reconstruction or unifocalization surgeries. Calcium co-administration did not lead to a greater increase in PAP.

Echocardiographic predictors of mortality in cardiac intensive care unit patients with pulmonary hypertension

Abstract Background Pulmonary Hypertension (PH) is a diverse condition associated with elevated mortality. We sought to determine the association of Transthoracic Echocardiography (TTE) parameters with in-hospital mortality in patients with PH admitted to Cardiac Intensive Care Unit (CICU). Methods We included 1 Clinic CICU admissions from 2007 to 2018, with available TTE parameters within the first day of CICU admission who had PH defined as an estimated right ventricular systolic pressure (RVSP) ≥36 mmHg. The primary outcome was in-hospital mortality, evaluated using logistic regression. Results We included 3085 unique CICU patients with PH, predominantly WHO group 2 and 3. Median age was 73.7 (63.8, 82.4) years, and 1343 (43.5%) were females. Heart failure (65.6%) and respiratory failure (34.0%) were the most common admission diagnoses. The median RVSP was 47 (41, 56) mmHg, and 1314 (42.6%) had RVSP ≥50 mmHg. A total of 337 (10.9%) patients died during hospitalization. In-hospital deaths had higher RVSP (51 versus 47 mmHg, p &amp;lt;0.001), reflecting higher right atrial (RA) pressure (14 versus 10 mmHg, p &amp;lt;0.001) (Figure). In-hospital mortality increased with worse TTE parameters reflecting Right Ventricle-Pulmonary Artery (RV-PA) coupling, such as Tricuspid Annular Plane Systolic Excursion/ Right Ventricular Systolic Pressure (RVSP), Tricuspid Annular Systolic Velocity (TASV)/RVSP and TASV/ Tricuspid Regurgitation velocity ratios. Conclusion In CICU patients with PH, we have identified the specific Doppler TTE parameters with strong associations with outcomes. Specifically, RA pressure and parameters of RV-PA coupling had the highest discrimination for in-hospital mortality. Comprehensive Doppler TTE is valuable for identification of high-risk PH patients to facilitate further investigation plans, management, and prognostication. Figure: In-hospital mortality in association with right ventricular (RV) function and right atrial pressure (RAP).In-hospital mortality in association wit

Right ventricular myocardial work predicts heart failure hospitalizations irrespective of ejection fraction

Abstract Hospitalization for heart failure worsening (HFW) associates with increased subsequent rehospitalization rate and mortality irrespective of left ventricular ejection fraction (EF). However there’s little evidence regarding predictors of HFW to timely apply preventive measurements. Since right ventricular (RV) dysfunction often associates with more advanced stages of HF we assumed that RV myocardial work (MW) assessment might be used in prediction of HFW. Methods 158 patients with HF (48% female) 58±7 years on guideline directed medical therapy in sinus rhythm and with at least one hospitalization in the last 6 months were enrolled in the study. Patients with HFrEF, HFmrEF and HFpEF were evenly represented. All patients were appropriately decongested prior to the study. The primary outcome was rehospitalization, HFW or cardiovascular death. RVMW was derived from RV global strain, including interventricular septum, and noninvasively estimated pulmonary arterial pressure (PAP). Systolic PAP (sPAP) was measured as the sum of maximum RV and right atrial (RA) pressure gradient (PGmax) from tricuspid regurgitation (TR) jet peak velocity and mean right atrial pressure (RAP) estimated from diameter and collapsing of inferior vena cava. Mean PAP (mPAP) was measured as the sum of PGmean RV-RA by tracing TR jet and RAP. Diastolic PAP was estimated as dPAP = 1.5 × [mPAP − (sPAP/3)]. Then RV global work index (RVGWI), constructive (RVGCW), and efficient work (RVGWE) were derived by the software dedicated for left ventricular MW. Left ventricular global longitudinal strain, left atrial (LA) reservoir strain (LAS), LA pump strain, LA volume index (LAVi), B lines, inferior vena cava, NT-pro-BNP, TAPSE/sPAP and RVMW were also measured. Patients followed up for 12 months. Results 53 events were registered at 12 months of which 42 rehospitalizations due to HFW and 11 CV deaths. Among all parameters in the multivariate analysis lower RVGCW was associated with HFW (HR 0.978, 95% CI 0.973–0.998, p = 0.014). RVGCW was the most powerful predictor of CV events (AUC 0.91) with cut off value of 148 mmHg% that had 96% sensitivity and 88% specificity. Number of patients who died with RVGCW &amp;lt; 148 mmHg% was 8 of 11 (73%) total deaths (HR 0.421, 95% CI 0.083–0.986, p = 0.028). Conclusion RVGCW was a predictor of HFW and 1 year mortality in patients with HF irrespective of EF.

Residual congestion in acute decompensated heart failure: A novel approach through microvascular imaging of renal circulation

Abstract Background In patients admitted for acute decompensated heart failure (ADHF), residual congestion at discharge is associated with adverse clinical outcomes. Traditionally, the extent of congestion has been inferred from central venous pressure, but it has also been highlighted that this is insufficient for a comprehensive evaluation of residual congestion. On the other hand, renal congestion is an important finding of organ congestion, and Superb Microvascular Imaging (SMI), a technique that reveals minute flow details, is promising for assessing renal circulation. We hypothesized that in patients with ADHF, assessment of renal circulation using SMI may be superior to conventional methods in assessing residual congestion. Methods In this prospective study, we enrolled 45 consecutive patients admitted with ADHF. We performed comprehensive evaluations including blood tests, echocardiography, and renal ultrasonography using SMI. The vascular index (VI), as measured by SMI, was calculated as the percentage of blood flow signal area in the region of interest. Subsequently, we calculated the intra-renal perfusion index (IRPI), representing cyclic variation in VI, as (maximum VI - minimum VI) within one cardiac cycle, divided by the maximum VI (Figure). Brain Natriuretic Peptide (BNP) levels were utilized to evaluate the state of decongestion. Results At discharge, the mean IRPI was 0.61±0.04, while the median BNP levels were 204.9 pg/ml (interquartile range: 102.7, 428.2). Patients exhibiting elevated log BNP levels at discharge (&amp;gt;2.31, based on median value) displayed significantly higher IRPI values [0.61(0.49, 0.86) vs 0.53(0.35, 0.59), p=0.02] and were older (80.8±8.5 vs 70.3±14.9 years, p=0.010). However, no significant differences were observed regarding laboratory parameters including hematocrit and creatinine levels, as well as echocardiographic parameters such as ejection fraction, E/e' ratio, and estimated right atrial pressure (RAP). Moreover, at discharge, creatinine levels (p=0.56) and estimated RAP (p=0.06) exhibited no significant correlation with IRPI. Conclusion Renal circulation evaluated by SMI may serve as a useful indicator of the extent of residual congestion at discharge compared to blood tests and echocardiographic estimates of right atrial pressure in patients admitted for ADHF.