Cardiac Catheterization Research Articles

Reduced Pulmonary Artery Compliance in a Conscious State Predicts Cardiac Event After Transcatheter Edge-to-Edge Repair in Patients With Ventricular Secondary Mitral Regurgitation.

Right ventricular (RV) dysfunction negatively affects mitral valve transcatheter edge-to-edge repair (M-TEER) outcomes in patients with ventricular secondary mitral regurgitation (vSMR). However, RV dysfunction occurs in the late phase of heart failure, when it may not respond to interventions. The pulsatile component of RV afterload, pulmonary artery (PA) compliance, is a sensitive parameter that decreases before RV dysfunction occurs. We explored the utility of PA compliance in predicting cardiac events after M-TEER. We analyzed 107 patients with vSMR who underwent M-TEER and in whom right heart catheter parameters were measured in a conscious state. Twenty-four patients had a cardiac event. There were no differences in patient characteristics or echocardiographic parameters between groups with and without cardiac events. PA compliance was significantly reduced in the event group, but other RV function parameters did not differ between the 2 groups. Receiver operating characteristic curve analysis revealed an optimal prognostic cut-off value for PA compliance of 2.7 mL/mmHg. In multivariate Cox regression, reduced PA compliance (<2.7 mL/mmHg) was strongly associated with cardiac events. Kaplan-Meier analysis revealed PA compliance had significant prognostic power for the composite outcome of cardiac events (log-rank P<0.01). Reduced PA compliance (hemodynamically derived in the conscious state) was a strong prognostic indicator in patients with vSMR who underwent M-TEER.

Efficacy and Safety of Distal Radial Artery Access versus Proximal Radial Artery Access for Cardiac Procedures: A Systematic Review and Meta-analysis.

Cardiac catheterization using the distal radial artery access (DRA), at the level of the anatomical snuff box post radial artery bifurcation, may be linked to a lower rate of arterial occlusion and better hemostasis. In this meta-analysis, we compare DRA versus proximal radial artery access (PRA) in cardiac catheterization or angiography. A detailed literature search was performed on PubMed, Cochrane, Embase and Clinicaltrials.gov from inception till June 2024. Risk ratios (RR) and mean differences (MD) were pooled for categorical and continuous outcomes, respectively. Random effects meta-analysis was undertaken on Revman. Our meta-analyses include 21 randomized controlled trials with 9,539 patients (DRA 4,761, PRA 4,778). DRA significantly reduced 24-hour radial artery occlusion (RAO) rates (RR 0.30, 95% CI 0.23 to 0.40, p ≤ 0.00001), and time to hemostasis (minutes) (MD -44.46, 95% CI -50.64 to -38.92, p < 0.00001), whereas PRA was significantly superior in terms of the puncture success rate (RR 0.96, 95% CI 0.93 to 0.99, p < 0.01), the crossover rate (RR 2.89, 95% CI 2.02 to 4.15, p < 0.00001, and puncture attempts (MD 0.69, 95% CI 0.37 to 1.00, p = 0.00001). DRA was associated with a lower risk of occlusion and lower time to hemostasis, but required a greater number of puncture attempts and had lower success rate. Further research is required to elucidate the most optimal approach.

One-stage relief of bilateral outflow tract obstruction and left main coronary ostial stenosis in an infant with Williams syndrome: the technique

A 3-month-old, 5.2-kg infant with Williams syndrome presented with failure to thrive and a systolic murmur. He was taken to the cardiac catheterization laboratory for a planned pulmonary valvotomy based on findings of severe pulmonary stenosis on the transthoracic echocardiogram. However, he suffered cardiac arrest and had to be resuscitated; the procedure was aborted. Cardiac catheterization revealed suprasystemic right ventricular pressure and severe bilateral branch pulmonary artery stenosis with bilateral branch hypoplasia. The decision was made to proceed with surgical relief of the obstruction.

Insights from serial cardiovascular magnetic resonance imaging show early progress in diastolic dysfunction relates to impaired right ventricular deformation

Latent pulmonary vascular disease is a distinct feature already in the early pathophysiology of masked heart failure with preserved ejection fraction (HFpEF) and associated with reduced right ventricular (RV) functional reserve. We hypothesized that serial real-time cardiovascular magnetic resonance (CMR) imaging at rest and during exercise-stress may detect early progress in pathophysiological alterations in HFpEF. Patients presenting with exertional dyspnoea and signs of diastolic dysfunction (E/e’>8, left ventricular (LV) ejection fraction > 50%) were prospectively enrolled in the HFpEF Stress Trial (NCT03260621). Rest and exercise-stress echocardiography, CMR and right heart catheterisation were performed at baseline. Pulmonary capillary wedge pressure (PCWP) was used for classification of HFpEF (≥ 15/25mmHg at rest/during exercise-stress) and non-cardiac dyspnoea (NCD). Repeat rest and exercise-stress CMR was performed in median 2.94 years after recruitment during which timeframe some HFpEF patients had undergone interatrial shunt device (IASD) implantation. Cardiovascular events were assessed after 4 years.Serial CMR scans were available for NCD n = 10, HFpEF n = 10 and HFpEF with IASD implantation following baseline diagnosis n = 6. RV long axis strain at rest and during exercise-stress decreased in HFpEF (p = 0.007 for both) but neither in NCD nor HFpEF with IASD. In contrast, in NCD, an improvement in LA LAS during exercise-stress (p = 0.028) was noted. There were no functional alterations in HFpEF patients who had undergone IASD implantation. RV functional deterioration may be a pathophysiological feature during early-stage disease progress in HFpEF. In this observational study RV functional deterioration was detected in HFpEF patients only but not patients with NCD and patients with HFpEF that were treated with IASD placement. These findings should next be explored in adequately powered future research trials. Clinicaltrials.gov: NCT03260621 (First posted date 24/08/2017).

A Scoring System for Diagnosing Heart Failure with Preserved Ejection Fraction Based on Exercise Echocardiography.

Exercise stress echocardiography (ESE) is often used to identify heart failure with preserved ejection fraction (HFpEF) in patients presenting dyspnea. However, diagnostic criteria have not been standardized. Here, we sought to develop ESE-based criteria to diagnose HFpEF in dyspneic patients. A total of 81 consecutive patients with dyspnea who underwent exercise right heart catheterization and ESE were evaluated. Diagnosis of HFpEF was ascertained by directly-measured hemodynamics (61 HFpEF and 20 controls). Logistic regression analysis was applied to develop an ESE-based scoring system to diagnose HFpEF. Multivariable logistic regression analysis identified resting left atrial reservoir strain <20%, exercise septal E/e' ratio >13, and increases in ultrasound B-lines as independent predictors of HFpEF. A weighted score was created with these variables (the ESE score) ranging from 0 to 5. The ESE score accurately discriminated HFpEF from controls (area under the curve [AUC] 0.90, p<0.0001), with a superior diagnostic ability to the ASE/ESCVI criteria (AUC comparison p<0.0001). The ESE score classified the HFpEF probability into three categories (probabilities: low risk 28%, intermediate risk 59-83%, and high risk 95-99%). In a cohort of 620 dyspneic patients, the predictive ability of the derived score was assessed. A higher ESE score was associated with an increased risk of all-cause mortality or worsening HF events even after adjusting for confounders (hazard ratio; 1.17 per 1-point increase, 95% confidence intervals; 1.00-1.37, p=0.04). The ESE score, which is based on three echocardiographic variables, may be an effective tool for diagnosing HFpEF on exercise echocardiography.

Clinical and angiographic profile of left main coronary artery disease in patients with chronic coronary syndrome: a retrospective study

BackgroundObstructive left main disease (LMD) is a challenging entity of coronary artery disease with variable patterns among different studies. We aimed to evaluate the prevalence, demographic, clinical, and angiographic profiles of LMD. We conducted a single-center retrospective study over a period of 10 years to screen all patients who underwent elective cardiac catheterization for chronic coronary syndrome. Of the 19,336 screened cases, 944 obstructive LMD patients were included as the patients' group. Age and sex-matched control groups included patients with normal coronary angiography and non-LMD.ResultsObstructive LMD had a prevalence of 4.9%, a mean age of around 60 years, and a male to female ratio of approximately 3:1. About 9.8% of LMD patients were < 50 years. Compared to males, females with LMD had significantly older age and increasing prevalence with age from 9.7% in patients < 50 years to 27.4% in patients > 70 years. LMD versus non-LMD patients had a significantly higher prevalence of diabetes mellitus, dyslipidemia, and number of stenotic coronary segments and arteries, and nonsignificant differences regarding smoking, hypertension, previous myocardial infarction, and ejection fraction. Ostial LMD had a prevalence of 2%, a mean age of around 58 years and 21% were females. In LMD patients, the most affected sites were the ostial/proximal left anterior descending artery and distal left main bifurcation. Bypass grafting surgery was the standard angiographic decision in LMD in 75.8% of cases, which was significantly higher than non-LMD. LMD patients revascularized surgically versus percutaneous treatment had significantly lower ejection fraction, significantly higher multivessel disease, and no significant differences regarding age, sex, hypertension, and diabetes mellitus.ConclusionObstructive LMD is a relatively common angiographic finding, with a higher prevalence among males around 60 years. In LMD, bypass grafting was the main revascularization strategy. We recommend integrating clinical characteristics, and noninvasive investigations as a predictive model of LMD.

Predictive utility of cardiac index-systemic vascular resistance plot and perfusion pressure in late post-Fontan patients.

Cases of Fontan failure with normal Fontan pressure have been reported. This study aimed to identify catheterisation-derived haemodynamic predictors of heart transplantation/death, other than Fontan pressure, in late post-Fontan patients. This retrospective study evaluated post-Fontan patients who underwent cardiac catheterisation at age ≥10 years between 1993 and 2018. The predictive effect of cardiac index-systemic vascular resistance index plot and perfusion pressure on freedom from the primary outcome (heart transplantation/death) was evaluated. Patients were categorised into haemodynamic categories A (cardiac index ≥ 3, systemic vascular resistance index ≥ 13), B (cardiac index < 3, systemic vascular resistance index ≥ 13), C (cardiac index ≥ 3, systemic vascular resistance index < 13), and D (cardiac index < 3, systemic vascular resistance index < 13). In total, 79 patients (median age: 15.7 [range: 10.1-50.2] years) were included; of them, the primary endpoint occurred in 10 (13%; median follow-up: 1.9 [range: 0.1-18.8] years). Category C patients had significantly shorter freedom from the endpoint than categories A and B patients. Univariate analysis identified significant haemodynamic predictors, including Fontan pressure, pulmonary/systemic vascular resistance index, pulmonary/systemic flow, systemic arterial oxygen saturation, systemic venous oxygen saturation, systemic vascular resistance index, perfusion pressure, perfusion pressure < 53 mmHg, and category C. In multivariable analysis, perfusion pressure < 53 mmHg and category C emerged as predictors of heart transplantation/death alongside Fontan pressure. Haemodynamic profiling of late post-Fontan patients using the cardiac index-systemic vascular resistance index plot can aid to comprehend the post-Fontan status and predict clinical prognosis.

Transcatheter closure of atrial and ventricular septal defects in patients with dextrocardia: a clinical analysis.

To assess the feasibility of transcatheter closure in patients with dextrocardia and isolated atrial septal defect or ventricular septal defect. A retrospective analysis was performed on the clinical data of 10 patients with dextrocardia and atrial septal defect or ventricular septal defect from June 2013 to January 2023 and successfully underwent transcatheter closure. Patient data were meticulously collected. The study cohort comprised 10 patients, with three males, aged between 3 and 38 years. Intraoperative right heart catheterisation revealed the following measurements: the mean pulmonary arterial pressure of 20.5(18,24,3) mmHg, and a pulmonary-to-systemic flow ratio of 1.80(1.58,2.15). There were five atrial septal defects, with defect diameters of 26(20,30) mm, comprising three dextroversion and two mirror-image dextrocardia. Intraoperative echocardiography confirmed the absence of any residual shunt. Among them, a patient with mirror-image dextrocardia, atrial septal defects, and interrupted inferior vena cava required an alternative approach due to femoral vein limitations. The right internal jugular vein was punctured, and a 22 mm atrial septal occluder was successfully deployed via this route. The study identified five ventricular septal defects, with defect diameters of 4(3.5,5.5) mm, including two dextroversion and three mirror-image dextrocardia. Upon post-operative repeat left ventriculography, no residual shunt was detected in all but one case, which exhibited a minimal residual shunt. Throughout the perioperative period and subsequent post-operative follow-up, no severe complications were observed. For patients with dextrocardia accompanied by simple CHD, transcatheter closure is a viable option when interventional treatment is indicated. Although transcatheter closure of atrial septal defects or ventricular septal defect in patients with dextrocardia presents unique challenges, it is safe and effective when the anatomical nuances of dextrocardia are thoroughly understood.

Inhalation of the Novel Tryptophan Hydroxylase 1 Inhibitor TPT-004 Alleviates Pulmonary Arterial Hypertension.

Inhaled pharmacotherapies are promising treatment options for patients with pulmonary arterial hypertension (PAH) as they minimize extrapulmonary adverse effects. Recently, we developed a highly specific inhibitor (TPHi) of the serotonin synthesizing enzyme tryptophan hydroxylase 1, TPT-004. We hypothesized that repetitive nose-only inhalation of TPT-004 alleviates PAH and pulmonary vascular remodeling in the Sugen-hypoxia (SuHx) rat model. Male Sprague-Dawley rats were divided into 3 groups: (i) ConNx, control animals kept in room air during the study; (ii) SuHx [rats subcutaneously injected with the VEGFR2-inhibitor SU5416, then exposed to chronic hypoxia (3 weeks), followed by 5.5 weeks of room air]; (iii) SuHx + TPHi [SuHx animals treated with TPHi by inhalation for 4 weeks]. Closed-chest right-left heart catheterization and cardiac MRI were performed in spontaneously breathing rats. Lungs underwent histological and mRNA-seq analysis. SuHx-exposed rats had severe PAH, RV hypertrophy, and RV dilation. In comparison with SuHx-exposed rats, TPHi-treated SuHx rats had significantly lower RV systolic pressure (67.25 vs.51.47mmHg; p<0.0001), normalized RV end-systolic volume (182.6 vs. 105.1µL; p<0.0001) and improved RV ejection fraction by cardiac MRI (47.9 vs. 66.8%; p<0.0001). Inhaled TPT-004 did not affect LV end-diastolic or systemic blood pressure. TPT-004 therapy reversed pulmonary vascular remodeling and alveolar macrophage infiltration. RNA-sequencing unraveled TPHi-induced changes in pulmonary gene expression: 1) increased cell adhesion and reduced cell motility/migration; 2) suppressed extracellular matrix remodeling; 3) modulated immune response; 4) suppressed pulmonary vascular remodeling via modulating proliferation, apoptosis, and homeostasis. Taken together, TPT-004 is an effective therapeutic PAH agent, does not cause any hemodynamic adverse effects in rodents, and thus, should be tested further towards a clinical phase 1b/phase 2 study in PAH patients.

CLINICAL EXERCISE PHYSIOLOGISTS IN THE INPATIENT SETTING – A CASE STUDY

https://youtu.be/i0pv5V6NKxM INTRODUCTION Preservation of functional capacity for patients admitted to the cardiovascular intensive care unit (CVICU) relies heavily on interventions prescribed by physical therapy. Traditional interventions are bed/chair exercises utilizing only body weight and ambulation around the unit. In this case, the clinical exercise physiologist (CEP) sought to push this standard of care to prepare a subject implanted with a BiVACOR total artificial heart (TAH) for orthotopic heart transplantation (OHT). This serves to present the methods in doing so and the need to further implement the role of clinical exercise physiologists in the inpatient setting. CASE PRESENTATION A 51-year-old male with history of chronic nonischemic cardiomyopathy, hypertension, diabetes mellitus, hyperlipidemia, and obesity presented to the hospital for right heart catheterization (RHC) in the setting of increased heart failure symptoms. Results of RHC led to admission and listing as UNOS status 4 for OHT. Hospital course was complicated by hypotension, ventricular tachycardia, and chronic kidney disease. Cardiothoracic surgery determined the need for mechanical circulatory support, a TAH as bridge to transplant. The patient elected to undergo implantation of BiVACOR, a TAH geared towards individuals with biventricular or univentricular heart failure where left ventricular assist device is not recommended. The patient is part of the BiVACOR Early Feasibility Trial in humans, approved by the FDA – he was the third human implant and would remain in hospital until OHT. The goal of the multi-disciplinary team was to preserve functional capacity during admission. MANAGEMENT Before implant, the patient’s 6-minute walk test (6MWT) distance was 320 meters, 2.52 METs. Post-implant in the ICU, the patient walked 1,800 feet 4 times per day. His 6MWT distance 13 days post-implant was 411 meters, 2.95 METs. By day 22 post-implant the patient progressed to recumbent bike cycling intervals. He was able to tolerate one 3-minutes interval and two 4-minutes intervals, split by 6-minutes rest intervals. His prescription was to cycle at 55-65 RPMs for 10-15 minutes three days per week with progression to 30 minutes continuously, 5-6 days per week. The patient was transplanted prior to completing any further sessions. During the cycling session, his blood lactate was measured at 5.2 mmol and hemoglobin 5.7 g/dL. His blood pressures remained stable, with normal responses to exercise, and pump flow increased from 8.9 L/min at rest to 12.5 L/min at peak exercise. Reported quadriceps muscle fatigue was the reason for session discontinuation. DISCUSSION Inpatient rehab goals of care should evolve to include various modalities of exercise that allow for more physiological adaptations, decreasing the impact of frailty and improving quality of life during admission. This patient’s case is an attestation to the growing need for exercise intervention prescribed by the CEP at all levels of care.

Donor pulmonary hemodynamics does not impact recipient outcomes in adult heart transplantation.

PurposeThe impact of donor pulmonary hemodynamics as assessed by mean pulmonary artery pressure (mPAP) and transpulmonary gradients (TPG) on the clinical outcome of heart transplant (HT) recipients is unknown. We compared outcomes of adult HT recipients as stratified by donor pulmonary hemodynamics in the contemporary era in the United States. MethodsWe reviewed adult donor hearts (age ≥ 18 years) which were offered for transplantation between January 2010 and March 2023 in the UNOS database with available right heart catheterization (RHC) data. Adjusted Cox regression was performed to evaluate the relationship between 30-day and 1-year mortality after HT and donor mPAP, TPG, and mean arterial pressure (MAP). Each hemodynamic parameter was modeled as a quadratic polynomial to not assume a linear relationship with mortality. Results2038 HT recipients with complete donor RHC were included: 58 % were on inotrope support. Elevated mPAP (≥25 mmHg), TPG (≥15), and PVR (≥1.5) were present in 416 (20.4 %), 179 (8.8 %), and 2038 (100 %), respectively. No significant association was found between donor mean PAP (HR 1.47, 95 % CI 0.80–2.67), donor TPG (HR 0.47, 95 % CI 0.20–1.08), and donor PVR (HR 1.69, 95 % CI 0.77–3.72) and 30-day mortality. Similarly, no significant association was found between donor mPAP (HR 1.33, 95 % CI 0.90–1.95), donor TPG (HR 0.65, 95 % CI 0.37–1.12), and donor PVR (HR 1.38, 95 % CI 0.83–2.32) and 1-year mortality. ConclusionsDonor pulmonary pressures did not impact post-heart transplant survival in adult recipients. Donors with abnormal pulmonary hemodynamics remain viable donor hearts for transplantation.

Interventricular septal dissection in a patient with atrial septal defect and pulmonary hypertension

Background: Interventricular septal dissection (IVSD) is a sporadic disorder. Previous literature has reported cases of IVSD caused by sinus valsalva aneurysms, post-myocardial infarction patients, congenital abnormalities, or post-thoracic trauma. However, no prior literature has reported IVSD cases caused by an atrial septal defect (ASD) accompanied by pulmonary hypertension. This case report aims to initiate the discussion of recognizing the association between ASD-PH and IVSD. Case presentation: A 48-year-old female with ASD was brought to Dr. Sardjito General Hospital with complaints of fatigue. In 2013, the patient experienced attacks of hemoptysis, which was then revealed to be caused by an increase in pulmonary pressure. Transthoracic echocardiography (TTE) examination results concluded that the patient had a high probability of pulmonary hypertension (PH), secundum atrial septal defect (ASD), which was 22-25 mm in diameter, a bidirectional shunt, and mid-apical interventricular septum dissection with flow. The patient underwent a right heart catheterization examination on September 3rd, 2015, at Dr. Sardjito General Hospital and was confirmed with pulmonary hypertension. The patient underwent computed topography (CT) scan with contrast on March, 2024, for evaluation, where we found a rupture of the interventricular septal muscle. Conclusion: The incidence of interventricular septal dissection is rare. Various causes are suspected, such as sinus of Valsalva rupture, post-myocardial infarction events, or associated congenital abnormalities. From this report, we present an IVSD case that is concurrent with ASD-PH. ASD and pulmonary hypertension, through combination of myocardial injury and hypertension, can cause interventricular septal dissection. Keywords: interventricular septal dissection, atrial septal defect, pulmonary hypertension, case report

Decreased Homeostasis Model Assessment of β-Cell Function in Patients Without Diabetes Can Predict Future Events in Patients With Cardiovascular Disease

Reduced insulin secretion is linked to diabetes and cardiovascular disease (CVD), but its role in non-diabetic CVD patients is unclear. The homeostasis model assessment of β-cell function (HOMA-β) measures pancreatic β-cell function. This study investigated the association between HOMA-β and adverse cardiovascular events in non-diabetic CVD patients. This study included 1301 non-diabetic CVD patients who underwent cardiac catheterization at the University of Yamanashi Hospital. HOMA-β was calculated based on fasting blood glucose and insulin levels. Patients were followed for 3 years to track adverse events, such as all-cause death, myocardial infarction, angina pectoris requiring percutaneous coronary intervention, and heart failure. Receiver operating characteristic curve analysis established a HOMA-β cut-off value of ≤49.3%. Kaplan-Meier analysis indicated that patients with HOMA-β ≤49.3% had a significantly higher risk of adverse events (P <0.001), with a 2.65-fold increased risk (hazard ratio 2.65; 95% confidence interval 1.97-3.57). Adding HOMA-β to traditional risk factors such as age, sex, estimated glomerular filtration rate, and left ventricular ejection fraction significantly improved risk prediction, as demonstrated by net reclassification improvement and integrated discrimination improvement. Decreased HOMA-β is a significant predictor of adverse cardiovascular events in CVD patients without diabetes. These findings suggest reduced insulin secretion contributes to worse outcomes, underscoring the importance of monitoring HOMA-β in this population.

Diagnosis: Pulmonary Hypertension. Next Steps.

Pulmonary hypertension (PH) is a disease that is generally first encountered by primary care physicians. Usually, patients present with dyspnea on exertion and a loss of exercise tolerance, although they can have symptoms of chest discomfort, syncope, or edema. Most patients are diagnosed with 2 dimensional doppler echocardiography although echo is not 100% sensitive nor specific in making this diagnosis. Note that the diagnostic criteria for this disease have changed recently. Most patients develop pulmonary hypertension secondary to left heart failure, or to pulmonary disease with or without hypoxemia. Ultimately, many patients require right heart catheterization for diagnosis and for proper treatment. This is best performed by those that specialize in management of this disease. It is important to diagnose patients who have pulmonary hypertension due to pulmonary artery hypertension and patients with chronic thromboembolic pulmonary hypertension as these patients require specialized treatment that is most effective if started early in the disease course. This review discusses issues related to diagnosis and appropriate referral of patients with pulmonary hypertension.

Correlation of right heart catheterization with simultaneous echocardiography for the assessment of pulmonary hypertension in patients with severe tricuspid regurgitation

Abstract Background In severe tricuspid regurgitation (TR), it is important to accurately measure pulmonary artery pressure because pulmonary hypertension is a poor prognostic factor in severe TR. Therefore, we sought to investigate the correlation between PASP using simultaneously measured echocardiography and right heart catheterization (RHC). Method In this observational prospective study, a total of 33 patients with severe TR were enrolled between September 2021 and May 2024. Data was obtained by simultaneously measuring echocardiography and RHC. The correlation between the PASP by echocardiography and RHC was analyzed using Pearson correlation and Bland-Altman analysis. To properly evaluate right atrial pressure (RAP), additional parameters, including systolic flow reversal of the hepatic vein and the V wave cut-off sign, were incorporated. Result PASP by RHC was strongly correlated with PASP by simultaneous measured echocardiography, with a correlation coefficient (r) of 0.87. The bias was 1.5 mmHg, and the limits of agreement (LoA) ranged from -12.5 to 15.5 mmHg. Recategorizations with systolic flow reversal on hepatic vein Doppler and V wave cut-off sign as well as the size and respiratory collapsibility of inferior vena cava provide a more accurate estimate of RAP (eRAP) by echocardiography (p = 0.004). Using this approach for eRAP, a correlation between PASP by RHC and PASP by echocardiography was more prominent (r = 0.91, LoA -9.9 ~ 13.0 mmHg). Conclusion PASP simultaneously measured by echocardiography with systolic flow reversal on hepatic vein Doppler and V wave cut-off sign was highly correlated with PASP by RHC in patients with severe TR.

Echocardiographic estimate of pulmonary capillary wedge pressure improves outcome prediction in chronic heart failure

Abstract Background An echocardiographic algorithm to estimate pulmonary capillary wedge pressure (ePCWP) and pulmonary vascular resistance (ePVR) has been recently validated versus right heart catheterization (1). Purpose The aim of this study was to assess the prognostic significance of these measures in heart failure (HF) patients. Methods Consecutive outpatients with HF and left ventricular ejection fraction (LVEF) &amp;lt;50% undergoing echocardiography were selected and followed-up for the composite endpoint of cardiac death or HF hospitalization. Results Out of 2,214 patients (71±12 years, 76% males, LVEF 35±9%), ePCWP (16±6 mmHg) was elevated (&amp;gt;15 mmHg) in 52% of cases and ePVR (1.7±0.7 WU) was elevated (&amp;gt;2 WU) in 25% of cases. Patients with increased ePCWP were older, had a higher NYHA class, more pronounced cardiac remodeling, systo/diastolic dysfunction, and neurohormonal activation, particularly when ePVR was also elevated (p&amp;lt;0.001). Over a median follow-up of 33 (17-48) months, both measures stratified patients for the risk of the primary endpoint (Log-Rank 152 for PCWP, and 44 for ePVR, p&amp;lt;0.001). At adjusted regression analysis, ePCWP (hazard ratio for 1 mmHg increase 1.03 [95%CI 1-01-1-05], p&amp;lt;0.001) but not ePVR (p=0.584) predicted the primary endpoint, even in the subpopulation of patients with atrial fibrillation (p=0.003). ePCWP outperformed current diastolic dysfunction grading (Δ C-statistics 0.068 [95% CI 0.045-0.093], p&amp;lt;0.001), and stratified patients’ risk across each diastolic dysfunction grade at univariate analysis (Grade I: p=0.002; Grade II-III: p&amp;lt;0.001; Indeterminate cases: p=0.010). The addition of ePCWP to a multivariable prognostic model, including patients’ age, NYHA class III-IV, chronic obstructive pulmonary disease, estimated glomerular filtration rate, NT-proBNP, and LVEF, improved the accuracy of risk prediction (Δ C-statistics 0.008 [95% CI 0.002-0.014], p=0.007). Conclusion The echocardiographic estimates of PCWP retained clinical and prognostic significance in a large contemporary cohort of patients with chronic HF and LVEF &amp;lt;50%. This algorithm could facilitate early identification of high-risk patients, possibly reducing the need of right heart catheterisation, and allowing a tailored therapeutic approach. Graphical abstract KM curves for the primary endpoint - AF

Correlation of left ventricular global longitudinal strain by speckle-tracking echocardiography with invasive LV filling pressure

Abstract Introduction The left ventricular (LV) systolic function can affect diastolic relaxation. The interaction of systolic and diastolic myocardial function resembles the mechanism of "coil compression and relaxation." This concept has gained significant attention in recent years, challenging the notion of "isolated diastolic dysfunction." Speckle tracking echocardiography (STE) is a sensitive and innovative method for evaluating global myocardial function beyond LVEF. This study examined the possible correlation between left ventricular longitudinal strain (GLS) and different LV filling pressures. Method Patients scheduled for diagnostic coronary angiography and left heart catheterization were included. The exclusion criteria were any degree of mitral stenosis, more than moderate mitral regurgitation or aortic stenosis, left bundle branch block, or atrial fibrillation. Measurements of LV end-diastolic pressure (LVEDP), LV min diastolic pressure (LVMDP), and LV pre-A diastolic pressure (LV pre-A) were taken via cardiac catheterization. On the same day, LV global longitudinal strain (LV GLS) was assessed using the EPIQ 7 Philips vendor. Results A total of seventy patients were studied (mean age: 50.24 ± 12.6 years; 60% male). The mean LVEF was 46.8% (SD:10.3), and the mean E/e’= 11.1 (SD:4.1). Pearson’s correlation coefficient showed a moderate negative relationship between LV GLS and LVEDP (R=-0.45, p&amp;lt;0.001), LVMDP (R=-0.44, p&amp;lt;0.001), and LV pre-A (R=-0.43, p&amp;lt;0.001). Conclusion The correlation of multiple invasive LV filling pressure parameters (LVEDP, LVMDP, and LV pre-A pressure) with LV GLS signifies the possible role of systolic parameters in predicting diastolic dysfunction. Integrating LV GLS with conventional algorithms may improve the non-invasive assessment of diastolic dysfunction.

Correlation of pulmonary artery systolic pressures derived from echocardiography and hemodynamic catheterization in patients with tricuspid regurgitation: a large single-center study

Abstract Introduction Echocardiography is the recommended modality for non-invasive assessment of pulmonary pressures. However, in patients with severe tricuspid regurgitation (TR), the reliability of echocardiographically derived systolic pulmonary artery pressure (sPAP) is questioned. Limited data exists on the correlation between echocardiography and right heart catheterization (RHC) in selected group of patients with severe TR. Purpose To evaluate the correlation between echocardiographic and RHC measurements for sPAP in patients with varying TR severity. Method Patients who underwent echocardiography and RHC within three days at a large single referral center were retrospectively included. Exclusion criteria included incomplete echocardiographic and RHC data, ≥moderate pulmonary stenosis, low-quality images, and pregnancy. Echocardiographic sPAP was calculated using simplified Bernoulli equation. Echocardiographic right atrial pressure (RAP) was assessed by evaluating inferior vena cava (IVC) dimension and collapsibility. A difference of ≥10 mmHg between the two modalities for sPAP was considered clinically significant. Results Of 3696 patients included, mean age was 64±14 years, 1689 (46%) were females, 1659 (45%) had systemic hypertension, and 582 (16%) had atrial fibrillation. TR was &amp;lt;moderate in 2475 (67%) patients, moderate in 499 (14%), moderate-severe in 277 (7%), and severe in 445 (12%). Pulmonary hypertension (PH) was diagnosed in 3079 subjects (83%). A good correlation was found between sPAP derived by echocardiographic and RHC in the whole cohort (correlation coefficient (LCC) 0.79, CI 0.78-0.80), in severe TR subgroup (LCC 0.78, CI 0.75-0.82), and in severe TR with PH subgroup (LCC 0.76, CI 0.71-0.79). The mean echocardiographic misestimation for sPAP in severe TR was 3.97 mmHg (CI -5.24 to -2.71). The correlation between the two modalities for RAP was moderate in the whole cohort (LCC 0.59, CI 0.57-0.61) and fair in severe TR (LCC 0.35, CI 0.27-0.42). A clinically significant difference between the two modalities for sPAP was found in 1504 patients (41%), predominantly due to the right ventricle-right atrium gradient misestimation, rather than RAP misestimation, in patients with no PH (67% vs 33%), patients with mild-moderate PH (mean Pulmonary Artery Pressure (mPAP) 21-34 mmHg) (67% vs 33%) and severe PH (mPAP ≥35 mmHg) (76% vs 24%). Conclusion The correlation between echocardiographic and RHC measurements is good for sPAP, even in severe TR patients, while it is only fair to moderate for RAP. A clinically significant difference between echocardiographic and RHC sPAP is more commonly observed in patients with PH, with right ventricle-right atrium gradient misestimation being the most common cause.

Catheter-directed thrombolysis of massive pulmonary embolism in high risk bleeding patients (local experience in kenya, single centre study)

Abstract Background Pulmonary Embolism (PE) is the third most common cause of death after myocardial infarction (MI), and cerebrovascular accidents (CVA) (1). For patients who are at risk of major bleeding such as advanced age, recent operation or delivery or major trauma, strategies to minimise bleeding risk should be considered, including catheter directed thrombolysis therapy (2) in reduced dose. Death from massive PE often occurs within the first two hours, and the risk remains elevated for up to 72 hours after presentation (3,4). Thirty-day survival following the diagnosis of a PE is only estimated to be 59.1%, and despite advances in medical care, in-hospital mortality from acute PE has remained stable over the past decade (5). Catheter directed thrombolysis (CDT) is a novel treatment option for massive/sub massive pulmonary embolism as systemic thrombolysis for acute PE carries up to 20% risk of major bleeding, including 2-5% risk of hemorrhagic stroke (6). Purpose To determine the clinical outcomes of catheter directed thrombolysis in patients with massive/ sub massive pulmonary embolism. Methods We conducted a retrospective quantitative study of 15 patients who presented with massive pulmonary embolism. A systematic random sampling was done to select the patients at advanced age, recent operation or first 2 weeks post labour with high bleeding risk, clinical data was recorded. All patients were taken to Cath lab with right heart catheterization, RA, RV and PA pressure were measured. Swan-Ganz catheter were placed in the main pulmonary trunk in case of bilateral PE, or sub-selective in the culprit branch. Alteplase infusion was given for 24-72 hours until proof for significant lysis of the clot. Clinical success defined as: 1. Stabilization of hemodynamics 2. Improvement in pulmonary systolic pressures, D-Dimer, TAPSE, RV/LV ratio and repeat CT findings 3. Survival to hospital discharge 4. Improvement in 30-day morbidity and mortality. Results There were no death on the trial group at discharge or at 30 days follow up. There were significant improvement of RV size and function elucidated by improvement of RV/LV ratio which were reduced from 1.06±0.18 to 0.89±0.2, TAPSE increased from 14.07±1.6 to 17.6±2.2, p &amp;lt; 0.01. There was significant drop in systolic pulmonary pressure(sPA) 67±14.5 mmHg to 38±14.5mmHg, p&amp;lt;0.001. The improvement of RV function and reduced sPA pressure were associated with increase in D-Dimer by at least 35% post thrombolysis, p&amp;lt;0.001. Conclusion Catheter directed thrombolysis (CDT) improves clinical outcomes in patients with acute pulmonary embolism with minimal risk of minor bleeding, and rapid recovery of right ventricular dysfunction. There were no major bleeding or death noticed in the treatment group and at one month follow up. In experienced centres, CDT is a safe and an effective treatment for both massive and/ or submassive PE. Echocardiography findings before CDT Echocardiography findings after CDT

Pressure-strain-volume analysis-derived wasted work predicts clinical outcomes after transcatheter tricuspid valve intervention

Abstract Background The pressure-strain loop is a non-invasive alternative to the traditional pressure-volume analysis for calculating myocardial work. Incorporating volume into work calculations may be particularly beneficial in evaluating patients with tricuspid regurgitation (TR) undergoing transcatheter tricuspid valve intervention (TTVI), who often present with highly varied load conditions. Purpose The study aimed to test the hypothesis that pressure-strain-volume analysis-derived right ventricular (RV) work will predict the composite clinical outcome of heart failure hospitalization (HFH) and death within 12 months after the TTVI. Methods Patients undergoing TTVI at two tertiary centers were included between June 2021 and November 2023. The pre-procedural three-dimensional echocardiographic acquisitions of the RV (to obtain RV volumes and global longitudinal strain) and RV pressures obtained from same day, pre-procedural right heart catheterization or calculated from TR maximal velocity and right atrial pressure were integrated into pressure-strain-volume loops using dedicated software (ReVISION, Argus Cognitive, USA). The pressure-strain-volume derived myocardial work was quantified as the volume under the three-dimensional curve and characterized by the following metrics: global work index (GWIV), global constructive work (GCWV), global wasted work (GWWV), and global work efficiency (GWEV). Conventional pressure-strain analysis-derived metrics were also calculated as previously described (1). The composite outcome was HFH or death within 12 months after TTVI. Cox regression analysis was performed to investigate the possible associations with the composite outcome and included all baseline clinical, echocardiographic, hemodynamic and RV work parameters. Variables were considered for multivariate analysis when they were related to composite endpoint on univariate analysis with a p value &amp;lt;0.05. Results Of 76 patients included, 52.6% were female. The mean age was 79.3 ± 7.5 years and median TRI-Score 5 [4-7] points. Transcatheter interventions included transcatheter tricuspid valve repair (61.8%) and tricuspid valve replacement (38.2%). TR at discharge was trace/mild, moderate, severe or massive in 60.6%, 26.3%, 13.2% and 0% cases respectively. At 12-month follow-up, 26 (34.2%) patients met the composite endpoint. After adjustment for number of HFH 12 months prior to TTVI, atrial fibrillation, glomerular filtration rate and NT-proBNP, GWWV remained the only baseline parameter significantly associated with increased risk of HFH and death at 12-month follow-up in the multivariate analysis with an adjusted OR of 1.079 (95% confidence interval 1.020 - 1.143; p = 0.009). Conclusion Results of this analysis show that baseline pressure-strain-volume analysis-derived wasted work identifies patients at higher risk for HFH or death following TTVI. Thus, the GWWV calculation may help identify individuals who are more likely to benefit from TTVI.