Cardiac Index In Patients Research Articles

Novel Computed Tomography Angiography Parameter Is Associated with Low Cardiac Index in Patients with Chronic Thromboembolic Pulmonary Hypertension: A Retrospective Analysis.

We completed a retrospective analysis of CTEPH patients in which individuals with low CI (<2.2-L/min/m2) were identified. Both absolute and fractional HU-Δ were derived from pulmonary CTA by subtracting the HU value of the left atrium (LA) and left ventricle (LV) from the main pulmonary artery (MPA) (absolute) and expressing them as a percentage of MPA-HU (fractional) on static axial images. These were compared between low and normal CI. Of the 237 patients, 50.2% were female, 53.2% were White, 36.7% were Black. Hemodynamics were mean pulmonary artery (PA) pressure = 45.4 ± 11.2-mmHg, pulmonary vascular resistance = 9.2 ± 4.4-WU, CI = 2.05 ± 0.48-L/min/m2. There was a higher mean MPA-HU = 391.1 ± 113.6 than LA-HU = 251.6 ± 81. In patients with low CI, the HU-Δ was higher, HU-ΔMPA-LA was 148.9 ± 78.4 vs. 124.5 ± 77.2 (p = 0.02), and HU-ΔMPA-LV was 170.7 ± 87 vs. 140 ± 82 (p = 0.009). A HU-ΔMPA-LA = 118 had a sensitivity of 75.6% and specificity of 77% to detect low CI, AUC 0.61, p = 0.003. A HU-ΔPA-LV = 156 had a sensitivity of 77% and specificity of 53% to detect low CI, AUC = 0.62, p = 0.001. A fractional reduction HU-ΔMPA-LA of 35% had a sensitivity and specificity of 79% and 53%, respectively, to detect low CI (AUC 0.65, p < 0.001). A fractional reduction of the HU-ΔMPA-LV of 40% had a sensitivity and specificity of 80% and 55%, respectively, to detect low CI (AUC 0.65, p < 0.001). HU Δ were highly reproducible (Kappa = 0.9, p < 0.001, 95% CI 0.86-0.95). High HU Δ between MPA-LA and MPA-LV were associated with low CI in patients with CTEPH.

Studying Hemodynamics during Weaning from Mechanical Ventilation among Critically ill Pediatric Patients

Abstract Background Among the multiple causes of weaning failure from mechanical ventilation, cardiovascular dysfunction is increasingly recognized as a quite frequent cause that can be treated successfully. Knowledge of the changes in the cardiopulmonary pathophysiology occurring during mechanical ventilation and its withdrawal is a prerequisite for early recognition of weaning failure of cardiovascular origin and optimal patient management. Aim of the Work Identification of hemodynamic and biomarkers changes during weaning process from mechanical ventilation and how these changes predict weaning success Methodology This cross sectional study was conducted on 50 children who were admitted to Pediatric Intensive Care Units and were mechanically ventilated and ready to be weaned according to weaning criteria. assessment of hemodynamic changes during weaning was done by tracing and comparing vital data, echocardiography parameters and levels of serum BNP and troponin in all patients during pressure support ventilation and at the end of spontaneous breathing trial (SBT) for identification of changes during weaning and risk factors for weaning failure. Results There was statistically significant increase in heart rate, cardiac index and E/A ratio at the end of SBTin all studied patients with lower cardiac index in patients who failed weaning, significant increase in TAPSE at the end of SBT with lower TAPSE in patients who failed weaning. Levels of BNP1 during pressure support were significantly higher in patients who failed weaning however levels of troponin didn’t show significant changes. Conclusion Transthoracic echocardiography can accurately detect changes in central hemodynamics induced by the SBT. It helps the attending physician to identify patients at high risk of weaning failure, when documenting a lower cardiac index, low TAPSE values.

Deficiency of the Deubiquitinase UCHL1 Attenuates Pulmonary Arterial Hypertension.

The ubiquitin-proteasome system regulates protein degradation and the development of pulmonary arterial hypertension (PAH), but knowledge about the role of deubiquitinating enzymes in this process is limited. UCHL1 (ubiquitin carboxyl-terminal hydrolase 1), a deubiquitinase, has been shown to reduce AKT1 (AKT serine/threonine kinase 1) degradation, resulting in higher levels. Given that AKT1 is pathological in pulmonary hypertension, we hypothesized that UCHL1 deficiency attenuates PAH development by means of reductions in AKT1. Tissues from animal pulmonary hypertension models as well as human pulmonary artery endothelial cells from patients with PAH exhibited increased vascular UCHL1 staining and protein expression. Exposure to LDN57444, a UCHL1-specific inhibitor, reduced human pulmonary artery endothelial cell and smooth muscle cell proliferation. Across 3 preclinical PAH models, LDN57444-exposed animals, Uchl1 knockout rats (Uchl1-/-), and conditional Uchl1 knockout mice (Tie2Cre-Uchl1fl/fl) demonstrated reduced right ventricular hypertrophy, right ventricular systolic pressures, and obliterative vascular remodeling. Lungs and pulmonary artery endothelial cells isolated from Uchl1-/- animals exhibited reduced total and activated Akt with increased ubiquitinated Akt levels. UCHL1-silenced human pulmonary artery endothelial cells displayed reduced lysine(K)63-linked and increased K48-linked AKT1 levels. Supporting experimental data, we found that rs9321, a variant in a GC-enriched region of the UCHL1 gene, is associated with reduced methylation (n=5133), increased UCHL1 gene expression in lungs (n=815), and reduced cardiac index in patients (n=796). In addition, Gadd45α (an established demethylating gene) knockout mice (Gadd45α-/-) exhibited reduced lung vascular UCHL1 and AKT1 expression along with attenuated hypoxic pulmonary hypertension. Our findings suggest that UCHL1 deficiency results in PAH attenuation by means of reduced AKT1, highlighting a novel therapeutic pathway in PAH.

Abstract 15999: Proportional Pulse Pressure and Shock Index as Predictors of Cardiac Index in Patients With Intermediate-Risk Pulmonary Embolism

Background: Risk stratification in intermediate-risk pulmonary embolism (PE) plays an important role in appropriate selection of therapies, however this is often challenging given variable phenotype. Proportional pulse pressure (PPP) and shock index (SI) have demonstrated to accurately predict cardiac index (CI) in patients with cardiogenic shock. Nonetheless, their applicability to patients with acute PE remains uncertain. Our objective is to investigate whether PPP and SI correlate with invasive assessment of CI in intermediate-risk PE. Methods: We retrospectively analyzed patients included in the Pulmonary Embolism Response Team (PERT) registry at NYCH+H/Bellevue who underwent invasive hemodynamic assessment. PPP was calculated as systolic blood pressure - diastolic blood pressure/systolic blood pressure. SI was calculated as heart rate/systolic blood pressure. Linear regression and correlation coefficients were used to examine the relationship between PPP, SI and CI as well as other clinical variables. Results: A total of 45 intermediate-risk PE patients were included (mean age was 57 ± 13 years and 43% were female). The SI moderately correlated with the composite pulmonary embolism shock score (CPES) (r = 0.5, p=0.0002), sPESI (r = 0.37, p=0.007), cardiac index (-0.42, p=0.004) and poorly correlated with lactate levels (r=0.23, p=0.18). PPP correlated poorly with CPES (r = 0.01, p=0.96), sPESI (r = -0.04, p=0.73), CI (r = 0.1 p=0.51) and lactate (-0.18, p=0.2). There was poor correlation between SI and PPP (r = -0.17, p=0.23). For every 0.1 increase in the shock index, the cardiac index was lower by 0.17L/minute/m 2 (p=0.017). Conclusions: In patients with intermediate-risk PE, a higher SI was associated with a lower CI, while PPP was not associated with CI. SI may provide additional valuable information to risk-stratify patients with acute PE and can potentially assist clinicians in triaging monitoring level therapeutic decisions.

Benefits of Macitentan in Patients with Pulmonary Hypertension: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

This systematic review and meta-analysis aimed to determine the efficacy of macitentan in patients with pulmonary hypertension (PH). A systematic search was made of PubMed, Embase, Cochrane Library, and clinicaltrials.gov, without language restrictions. Randomized controlled trials (RCTs) on treatment of PH with macitentan, compared with placebo or blank, were reviewed. Studies were pooled to weighted mean differences (WMDs) and risk ratios (RRs), with 95% confidence intervals (CIs). Six RCTs (enrolling 1,003 participants) met the inclusion criteria. Macitentan showed significant effects on 6-min walk distance (6MWD) (WMD 12.06 m, 95% CI 2.12 to 21.99 m), pulmonary vascular resistance (PVR) (WMD -186.51 dyn·s/cm-5, 95% CI -232.72 to -140.29 dyn·s/cm-5), mean pulmonary artery pressure (mPAP) (WMD -3.20 mmHg, 95% CI -5.93 to -0.47 mmHg), N-terminal pro-brain natriuretic peptide (NT-proBNP) (WMD -232.47 ng/L, 95% wCI -318.22 to -146.72 ng/L), and cardiac index (WMD 0.39 L/min/m2, 95% CI 0.20 to 0.58 L/min/m2). Macitentan significantly improved 6MWD, PVR, mPAP, NT-proBNP, and cardiac index in patients with PH. Macitentan should be further validated in patients with PH.

Predictive Value of the Changes in Neutrophil-Lymphocyte Ratio for Outcomes After Off-Pump Coronary Surgery.

The neutrophil-to-lymphocyte ratio (NLR) is an extensively analyzed prognostic inflammatory index in cardiac patients. The degree of change in NLR values before and after surgery (delta-NLR) can represent the inflammatory response induced by surgery and serve as a meaningful prognostic biomarker in surgical patients; however, this has not been well investigated. We aimed to investigate the predictive value of the perioperative NLR and delta-NLR for outcomes of off-pump coronary artery bypass (OPCAB) surgery by evaluating "days alive and out of hospital (DAOH)", a novel patient-centered outcome. In this single-center retrospective study, perioperative data, including NLR data, from 1322 patients were analyzed. The primary endpoint was DOAH at 90 days postoperatively (DAOH 90), and the secondary endpoint was long-term mortality. Linear regression analysis and Cox regression analysis were performed to identify independent risk factors for the endpoints. In addition, Kaplan-Meier survival curves were plotted to assess long-term mortality. The median NLR values significantly increased from 2.2 (1.6-3.1) at baseline to 7.4 (5.4-10.3) postoperatively, with median delta-NLR values of 5.0 (3.2-7.6). Preoperative NLR and delta-NLR were independent risk factors for short DAOH 90 in the linear regression analysis. In Cox regression analysis, delta-NLR, but not preoperative NLR, was an independent risk factor for long-term mortality. When patients were divided into two groups according to delta-NLR, the high delta-NLR group had a shorter DAOH 90 than the low delta-NLR group. Kaplan-Meier curves showed higher long-term mortality in the high delta-NLR group than in the low delta-NLR group. In OPCAB patients, preoperative NLR and delta-NLR were significantly associated with DAOH 90, and delta-NLR was an independent risk factor for long-term mortality, indicating their role in risk assessment, which is essential for perioperative management.

Ratio of carbon dioxide veno-arterial difference to oxygen arterial-venous difference is not associated with lactate decrease after fluid bolus in critically ill patients with hyperlactatemia: results from a prospective observational study

BackgroundHigh ratio of the carbon dioxide veno-arterial difference to the oxygen arterial-venous difference (PvaCO2/CavO2) is associated with fluid bolus (FB) induced increase in oxygen consumption (VO2). This study investigated whether PvaCO2/CavO2 was associated with decreases in blood-lactate levels FB in critically ill patients with hyperlactatemia.MethodsThis prospective observational study examined adult patients in the intensive care unit (ICU) with lactate levels > 1.5 mmol/L who received FBs. Blood-lactate levels were measured before and after FB under unchanged metabolic, respiratory, and hemodynamic conditions. The primary outcome was blood-lactate levels after FB. Significant decreases in blood-lactate levels were considered as blood-lactate levels < 1.5 mmol/L or a decrease of more than 10% compared to baseline.ResultsThe study enrolled 40 critically ill patients, and their median concentration of blood lactate was 2.6 [IQR:1.9 − 3.8] mmol/L. There were 27 (68%) patients with PvaCO2/CavO2 ≥ 1.4 mmHg/ml, and 10 of them had an increase in oxygen consumption (dVO2) ≥ 15% after FB, while 13 (32%) patients had PvaCO2/CavO2 < 1.4 mmHg/ml before FB, and none of them had dVO2 ≥ 15% after FB. FB increased the cardiac index in patients with high and low preinfusion PvaCO2/CavO2 (13.4% [IQR: 8.3 − 20.2] vs. 8.8% [IQR: 2.9 − 17.4], p = 0.34). Baseline PvaCO2/CavO2 was not found to be associated with a decrease in blood lactate after FB (OR: 0.88 [95% CI: 0.39 − 1.98], p = 0.76). A positive correlation was observed between changes in blood lactate and baseline PvaCO2/CavO2 (r = 0.35, p = 0.02).ConclusionsIn critically ill patients with hyperlactatemia, PvaCO2/CavO2 before FB cannot be used to predict decreases in blood-lactate levels after FB. Increased PvaCO2/CavO2 is associated with less decrease in blood-lactate levels.

Effect of Phosphodiesterase-5 (PDE-5) Inhibitors on Clinical Outcomes in Patients With Pulmonary Hypertension: A Meta-Analysis of Randomized Control Trials.

We intended to summarize the most recent research pertaining to the use of phosphodiesterase-5(PDE5) inhibitors in pulmonary hypertension in light of recent developments in the knowledge of the pathophysiological mechanisms and treatments for pulmonary hypertension, with major contributions in the area in the last decade. The aim of this meta-analysis is to determine the efficacy of PDE5 inhibitors for pulmonary hypertension in adults. We followed the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines to carry out this meta-analysis. Online database searching to identify eligible trials was performed in MEDLINE, EMBASE, and the Cochrane Library by two authors independently. Outcomes assessed in the current meta-analysis included change in the cardiac index from baseline in liters per minute per square meter (L/min/m2), mean peripheral arterial pressure (PAP) in mm Hg, mortality, hospitalization, and six-minute walking distance (6MWD) in meters (m). Overall, 17 articles met the inclusion criteria and were included in the current meta-analysis. PDE5 inhibitors significantly improve cardiac index (mean difference: 0.18, 95% CI: 0.04, 0.32, p-value: 0.01), mean PAP (mean difference: -5.61, 95% CI: -7.60, -3.62, p-value: 0.01), and 6MWD (mean difference: 26.26, 95% CI: 16.95, 35.57, p-value: 0.001) as compared to the patients in the control group. No significant difference was found in terms of risk of mortality (risk ratio (RR):0.51, 95% CI: 0.17, 1.54) and risk of hospitalization (RR: 0.59, 95% CI: 0.23, 1.55) between the two groups. The current meta-analysis concluded that PDE5 inhibitors improve 6MWD, mean PAP, and cardiac index in patients with pulmonary hypertension. However, no significant difference was reported in terms of mortality and hospitalization between the two groups.

Validation of cardiac index measured by four‐dimensional cardiac magnetic resonance flow against the invasively measured cardiac index in patients with pulmonary hypertension

AbstractThe purpose of this study was to validate cardiac index (CI) measured noninvasively by four‐dimensional (4D) and two‐dimensional (2D) cardiovascular magnetic resonance (CMR) flows against the invasively measured CI by right heart catheterization (RHC) in patients with pulmonary hypertension (PH). Thirty patients with PH (mean age: 32 ± 10 years) were included. 4D and 2D flow measured CI within 24 h from RHC measured CI invasively. Qualitative analysis of 4D pulmonary flow (vortex presence and eccentricity of flow) was performed.All patients had helical right‐sided flow with vortex formation; the mean vortex diameter was 29 ± 7 mm, occupying 69% of the main pulmonary artery (MPA) lumen. MPA was dilated (42 ± 9 mm). Mean CI measured by 4D flow CMR was closer to mean CI measured invasively (indirect Fick method CI = 2.1 ± 0.8 L/min/m2 vs. PA 4D flow = 2.3 ± 0.7 L/min/m2 “bias 0.22 ± 0.25 L/min, p = 0.001,” and Ao 4D flow = 2.3 ± 0.7 L/min/m2 “bias 0.2 ± 0.28 L/min, p = 0.001”), while 2D flow had a higher mean CI (PA 2D flow = 2.5 ± 0.7 L/min/m2 “bias 0.45 ± 0.7 L/min, p = 0.001” and Ao 2D flow = 2.5 ± 0.8 L/min/m2 “bias 0.45 ± 0.67 L/min, p = 0.001”). The correlation coefficients among the different comparisons of CI showed: a low correlation between the 2D flow‐indirect Fick method (Ao r2 = 0.37, PA r2 = 0.32) and a high correlation between the 4D flow‐indirect Fick method (Ao r2 = 0.86, PA r2 = 0.89).There is an excellent agreement between CI measured by 4D flow and CI measured invasively. 4D flow, a noninvasive imaging technique, could accurately measure CI better than the conventional 2D flow in patients with PH.

Comparative prognostic value of parameters of right ventricular pulsatile afterload in patients with advanced heart failure awaiting heart transplantation

Abstract Background Right ventricular (RV) function demonstrated a strong impact on survival of patients with advanced heart failure with reduced ejection fraction (HFrEF). In particular, increased RV pulsatile afterload (RVPA) was associated with poor prognosis. Several right heart catheterization-derived parameters have been proposed to characterize RVPA, including pulmonary artery compliance (PAC), elastance (PAE) and pulsatile index (PAPi). However, among these indices, the best prognostic indicator is undetermined. Purpose To assess the prognostic relevance of RVPA parameters in patients with advanced HFrEF evaluated for heart transplantation. Methods 149 patients with end-stage HFrEF underwent right heart catheterization during the evaluation for heart transplantation. All patients were clinically followed up until death or any censoring events including heart transplantation, left ventricular assist device (LVAD) and hospitalization for acute heart failure. Cox regression and ROC-curve analysis were used to test the prognostic value of RVPA determinants. Multivariate regression models with C-statistics were used to test the independent predictive value of RVPA indices. Results The mean age of the study population was 56.6±10.1 years and 85.2% were male. The most frequent aetiology of HFrEF was ischemic cardiomyopathy (52.3%). Mean LV ejection fraction was 25.7±10.2%. During a mean follow up time of 17±15 months, 29 (19.5%) patients met the primary endpoint: 9 (6%) patients died, 4 (2.68%) patients underwent an urgent heart transplantation, 11 (7.3%) patients underwent urgent LVAD implantation (as bridge to transplantation therapy) and 5 (3.3%) were hospitalized for HF. Patients who met the primary endpoint were significantly older patients (61.2±7.8 vs 55.4±10.2, p=0.006) and with worse hemodynamic profile than event-free survivors (PAC [1.8±0.8 vs. 2.7±2.0, p=0.01], mPAP [33.5±11.3 vs. 29.3±11.0, p=0.05], PVR [3.0±1.6 vs. 2.6±2.0, p=0.09] and PAE [1.12±0.5 vs. 0.98±0.6, p=0.04]). Among the RVPA parameters PAC&amp;lt;1.9 mL/mmHg (HR 4.0, CI 1.3–6.0, p=0.007) and PAE&amp;gt;0.9 mmHg/mL (HR 2.5, 95% CI 1.1–5.2, p=0.02) were associated with the primary endpoint. On the contrary, PAPi was not significantly associated with the outcome. PAC demonstrated a superior predictive value for the composite adverse outcome compared with pulmonary vascular resistances (PVR) (AUC comparison p=0.019) and PAPi (p=0.03) but similar compared with PAE (p=0.19) and mPAP (p=0.51). In multivariable regression models, PAC, but not PAE showed incremental prognostic value compared with cardiac index (p=0.02). Conclusions Hemodynamic indices of RVPA are associated with worse survival in patients with end-stage heart failure. In particular, PAC and PAE demonstrated superior prognostic value compared with PAPi and steady-state PVR. Moreover, PAC showed incremental prognostic value compared with cardiac index in patients awaiting heart transplantation. Funding Acknowledgement Type of funding sources: None.

Comparative Prognostic Value of Parameters of Pulsatile Right Ventricular Afterload in Patients With Advanced Heart Failure Awaiting Heart Transplantation

Right ventricular pulsatile afterload (RVPA) demonstrated a strong impact on survival of patients with advanced heart failure (HF) with reduced ejection fraction. The best prognostic parameter of RVPA is unknown. The aim of this work was to examine the prognostic relevance of pulmonary artery compliance (PAC), pulmonary artery elastance (PAE), and pulmonary artery pulsatile index (PAPi) in a consecutive cohort of patients with advanced HF evaluated for heart transplantation (HT). A total of 149 patients with end-stage HF underwent right-sided cardiac catheterization and were clinically followed up until death or any censoring events, including HT, left ventricular assist device, and hospitalization for acute HF. The primary endpoint occurred in 29 patients (19.5%) during a median follow-up time of 12 (interquartile range 3 to 34) months. This cohort presented a worse hemodynamic profile than event-free survivors. PAC <1.9 mL/mm Hg (hazard ratio 3, 95% confidence interval 1.3 to 6.0, p=0.007) and PAE >0.9 mmHg/mL (hazard ratio 2.5, 95% confidence interval 1.1 to 5.2, p=0.02) were associated with the adverse outcome. On the contrary, PAPi was not associated with the outcome. PAC demonstrated a superior predictive value for the composite adverse outcome compared with pulmonary vascular resistance (area under the curve comparison p=0.019) and PAPi (p=0.03) but similar compared with PAE (p=0.19) and mean pulmonary arterial pressure (p=0.51). PAC, but not PAE, showed incremental prognostic value compared with cardiac index (p=0.02). In conclusion, hemodynamic indexes of RVPA are associated with worse survival in patients with end-stage HF. PAC and PAE demonstrated superior prognostic value compared with PAPi and pulmonary vascular resistance. Moreover, PAC showed incremental prognostic value compared with cardiac index in patients awaiting HT.

Blunted cardiovascular effects of beta-blockers in patients with cirrhosis: Relation to severity?

AimsPatients with cirrhosis and portal hypertension are at high risk of developing complications such as variceal hemorrhage, ascites, and cardiac dysfunction, the latter of which is known as cirrhotic cardiomyopathy. Since non-selective beta-blockers (NSBB) may aggravate hemodynamic complications we investigated the effect of real-time propranolol infusion on cardiac function in patients with varying degrees of cirrhosis.MethodsThirty-eight patients with Child-Pugh A (n = 17), B (n = 17) and C (n = 4) underwent liver vein catheterization and cardiac magnetic resonance imaging. We assessed the effect of real-time propranolol infusion on the hepatic venous pressure gradient, cardiac index, stroke volume, ejection fraction, heart rate, and contractility.ResultsNineteen patients were classified as responders to beta-blocker therapy. In pooling Child-Pugh B and C patients, the reduction in cardiac index by beta-blockade was weaker than in Child-Pugh A patients (-8.5% vs. -20.5%, p = 0.043). The effect of NSBB on portal pressure was inversely correlated to changes in the left atrium where the left atrial volume changed by 4 mL±18 in responders compared to 15 mL±11 in non-responders (p = 0.03). Finally, the baseline ejection fraction correlated inversely with the reduction in portal pressure (r = -0.39, p = 0.02).ConclusionWe found the effect of beta-blockade on cardiac index in patients with advanced cirrhosis to be less potent than in patients with early cirrhosis, indicating that underlying cirrhotic cardiomyopathy increases, and the cardiac compensatory reserve becomes more compromised, with disease progression. The differential effects of beta-blockade in the left atrium may be used to predict the effect of beta-blockers on portal pressure, but further studies are needed to investigate this possibility.

Cardio-protective effect of regular transfusion in children with non-transfusion dependent thalassemia (NTDT): A cohort study.

Background and aim of the work:Cardiac complications occur in patients with non-transfusion dependent thalassemia (NTDT). The study aimed to evaluate transfusion effect on systolic and diastolic cardiac function in young NTDT patients.Methods:Study design: Cohort study. Seventeen regularly-transfused patients with NTDT (12.5±5.3 years; group 1) and 15 none/minimally transfused patients (13.2±4.8 years; group 2) were followed up for 5 years and compared as regards their clinical parameters, echocardiographic and Tissue-Doppler-Imaging.Results:Group 2 patients had significantly higher peak late-diastolic velocity of the left-ventricular-inflow Doppler (Am). Mitral-valve A-wave duration/pulmonary-veins, A-wave duration-ratio and pulmonary-vein S/D velocities-ratio were larger in group 2 as well (p = ≤ 0.01). The diameters of right and left outflow-tract were larger with a higher cardiac-index in patients of group 2. Systolic-function was similar in the 2 studied groups.Conclusion:Diastolic function assessment revealed indicators of an abnormal relaxation of left-ventricle in non-transfused patients, which suggests a diastolic dysfunction. An increase in the diameter of the outflow-tract is likely attributed to high cardiac-output status in non-transfused NTDT patients as they have a higher cardiac index. Early start of regular transfusion for NTDT patients might prevent serious long-term cardiac complications. (www.actabiomedica.it)

Reliability of Bioreactance and Pulse-Power Analysis in Measuring Cardiac Index in Patients Undergoing Cardiac Surgery With Cardiopulmonary Bypass

Less-invasive and continuous cardiac output monitors recently have been developed to monitor patient hemodynamics. The aim of this study was to compare the accuracy, precision, and trending ability of noninvasive bioreactance-based Starling SV and miniinvasive pulse-power device LiDCOrapid to bolus thermodilution technique with a pulmonary artery catheter (TDCO) when measuring cardiac index in the setting of cardiac surgery with cardiopulmonary bypass (CPB). A prospective method-comparison study. Oulu University Hospital, Finland. Twenty patients undergoing cardiac surgery with CPB. Cardiac index measurements were obtained simultaneously with TDCO intraoperatively and postoperatively, resulting in 498 measurements with Starling SV and 444 with LiDCOrapid. The authors used the Bland-Altman method to investigate the agreement between the devices and four-quadrant plots with error grids to assess the trending ability. The agreement between TDCO and Starling SV was qualified with a bias of 0.43 L/min/m2 (95% confidence interval [CI], 0.37-0.50), wide limits of agreement (LOA, -1.07 to 1.94 L/min/m2), and a percentage error (PE) of 66.3%. The agreement between TDCO and LiDCOrapid was qualified, with a bias of 0.22 L/min/m2 (95% CI 0.16-0.27), wide LOA (-0.93 to 1.43), and a PE of 53.2%. With both devices, trending ability was insufficient. The reliability of bioreactance-based Starling SV and pulse-power analyzer LiDCOrapid was not interchangeable with TDCO, thus limiting their usefulness in cardiac surgery with CPB.

The Relation Between Mean Arterial Pressure and Cardiac Index in Major Abdominal Surgery Patients: A Prospective Observational Cohort Study.

Cardiac output is an important hemodynamic variable and determines oxygen delivery. In contrast to blood pressure, cardiac output is rarely measured even in high-risk surgical patients, suggesting that clinicians consider blood pressure to be a reasonable indicator of systemic blood flow. However, the relationship depends on constant vascular tone and volume, both of which routinely vary during anesthesia and surgery. We therefore tested the hypothesis that there is no clinically meaningful correlation between mean arterial pressure and cardiac index in major abdominal surgery patients. In this prospective observational study, we assessed the relationship between mean arterial pressure and cardiac index in 100 patients having major abdominal surgery under general anesthesia. The pooled within-patient correlation coefficient calculated using meta-analysis methods was r = 0.34 (95% confidence interval, 0.28-0.40). Linear regression using a linear mixed effects model of cardiac index on mean arterial pressure revealed that cardiac index increases by 0.014 L·min-1·m-2 for each 1 mm Hg increase in mean arterial pressure. The 95% Wald confidence interval of this slope was 0.011 to 0.018 L·min-1·m-2·mm Hg-1 and thus within predefined equivalence margins of -0.03 and 0.03 L·min-1·m-2·mm Hg-1, thereby demonstrating lack of clinically meaningful association between mean arterial pressure and cardiac index. There is no clinically meaningful correlation between mean arterial pressure and cardiac index in patients having major abdominal surgery. Intraoperative blood pressure is thus a poor surrogate for cardiac index.

Bioreactance and fourth-generation pulse contour methods in monitoring cardiac index during off-pump coronary artery bypass surgery

The pulmonary artery catheter (PAC) is considered the gold standard for cardiac index monitoring. Recently new and less invasive methods to assess cardiac performance have been developed. The aim of our study was to assess the reliability of a non-invasive monitor utilizing bioreactance (Starling SV) and a non-calibrated mini-invasive pulse contour device (FloTrac/EV1000, fourth-generation software) compared to bolus thermodilution technique with PAC (TDCO) during off-pump coronary artery bypass surgery (OPCAB). In this prospective study, 579 simultaneous intra- and postoperative cardiac index measurements obtained with Starling SV, FloTrac/EV1000 and TDCO were compared in 20 patients undergoing OPCAB. The agreement of data was investigated by Bland–Altman plots, while trending ability was assessed by four-quadrant plots with error grids. In comparison with TDCO, Starling SV was associated with a bias of 0.13 L min−1 m−2 (95% confidence interval, 95% CI, 0.07 to 0.18), wide limits of agreement (LOA, − 1.23 to 1.51 L min−1 m−2), a percentage error (PE) of 60.7%, and poor trending ability. In comparison with TDCO, FloTrac was associated with a bias of 0.01 L min−1 m−2 (95% CI − 0.05 to 0.06), wide LOA (− 1.27 to 1.29 L min−1 m−2), a PE of 56.8% and poor trending ability. Both Starling SV and fourth-generation FloTrac showed acceptable mean bias but imprecision due to wide LOA and high PE, and poor trending ability. These findings indicate limited reliability in monitoring cardiac index in patients undergoing OPCAB.

Hemodynamic effects of levosimendan in cardiac surgery patients: a systemic review and meta-analysis

Introduction Levosimendan is a potent inodilator agent. The net effect of haemodynamic changes may result in a hyperdynamic state with low systemic vascular resistance. To assess the haemodynamic effects in cardiac surgery patients treated with levosimendan we conducted a systemic review. Our hypothesis was that levosimendan improves cardiac function, but also triggers a systemic vasodilatation. Methods Systematic review with meta-analysis. English-language literature with access to full texts and supplements in US National Library of Medicine (PUBMED), MEDLINE, EMBASE, and CENTRAL was searched systematically from 2006 until July 2018. Included randomized controlled trials, case-matched or retrospective studies providing at least two sequentially measured haemodynamic variables in adult patients undergoing cardiac surgery with cardio pulmonary bypass and treated with levosimendan in comparison to alternative drugs or devices. Results Cardiac index significantly increased in the levosimendan group by 0.74 (0.24 to 1.23) [standardised mean difference (95% CI); p = 0.003] from baseline to postoperative day (POD) 1, and by 0.75 (0.25 to 1.25; p = 0.003) from baseline to POD 7, when corrected for the standardized mean difference (SMD) at baseline by a multivariate mixed effects meta-analysis model. With the correction for baseline differences, other haemodynamic variables, especially the systemic vascular resistance did not significantly differ until POD 1 [-0.17 (-0.64 to 0.30), p=0.48] and POD 7 [-0.13 (-0.61 to 0.34), p=0.58] between the levosimendan and the comparator group. Discussion Levosimendan increased cardiac index in patients undergoing cardiac surgery. Although levosimendan has inodilator properties, this meta-analysis finds no clinical evidence that levosimendan produces vasopressor-resistant vasoplegic syndrome. Hypotension seems not to be statistically relevant.

Predictors of reduced cardiac index in patients with acute submassive pulmonary embolism.

Determine the baseline clinical, laboratory, and echocardiographic values that predict reduced cardiac index (CI) among subjects with acute submassive pulmonary embolism (PE). Submassive PE represents a large portion of acute PE population and there is controversy regarding optimal treatment strategies for these patients. There is significant heterogeneity within the submassive PE population and further refinement of risk stratification may aid clinical decision-making. We identified subjects with normotensive acute PE who underwent echocardiogram and right heart catheterization (RHC) prior to catheter-directed thrombolysis (CDT). We sought to determine the predictors of reduced CI, defined as CI < 2.2 L min-1 m-2 . Thirty-two subjects met the inclusion criteria and 41% had reduced CI. Baseline variables did not distinguish subjects with reduced versus normal CI. Brain natriuretic peptide (BNP) was significantly different between the reduced versus normal CI groups (BNP 440 vs. 160 pg/ml, p = .004, respectively). Univariate logistic regression identified BNP, right ventricular (RV):left ventricular (LV) diameter ratio, tricuspid annular plane systolic excursion (TAPSE), and right ventricular systolic pressure as predictors of reduced CI. In a multivariate logistic regression model, only TAPSE was an independent predictor of reduced CI. ROC curve analysis identified the following optimal cut points for prediction of reduced CI: BNP > 216 pg/ml, RV:LV ratio > 1.41, or TAPSE <1.6 cm. Almost half of subjects with acute submassive PE have reduced CI, despite normal systemic blood pressure. Optimal cut points for BNP, RV:LV ratio, and TAPSE were identified to predict reduced CI among patients with acute PE. These findings may aid in clinical decision-making and risk stratification of patients with acute submassive PE.

Changes in perfusion can detect changes in the cardiac index in patients with septic shock.

ObjectiveThe perfusion index (PI) is usually used to assess peripheral perfusion, which can be influenced by the cardiac index (CI). CI monitoring is often needed during the treatment of patients with shock. We investigated the relationship between changes in the PI (ΔPI) and changes in the CI (ΔCI) in patients with septic shock.MethodsThis retrospective study included patients with septic shock who underwent pulse-induced continuous cardiac output monitoring. We measured the CI and PI before and after fluid loading during the first 6 hours of intensive care unit admission. Fluid responsiveness was defined as a ≥10% ΔCI after fluid loading. Other hemodynamic and oxygen-derived parameters were also collected at the exact time of each CI measurement.ResultsFifty-five patients were included in the study (29 fluid responders, 26 fluid non-responders). In the univariate analysis, ΔPI was positively correlated with ΔCI. In the multivariable analysis, ΔPI was independently associated with ΔCI. The receiver operating characteristic curve showed that ΔPI was an appropriate marker with which to discriminate a CI increase with an area under the curve of 0.776.ConclusionThis study showed a positive correlation between ΔPI and ΔCI during the early treatment phase of septic shock.

Levosimendan and systemic vascular resistance in cardiac surgery patients: a systematic review and meta-analysis

Levosimendan is a potent non-adrenergic inodilator agent. The net effect of hemodynamic changes may result in a hyperdynamic state with low systemic vascular resistance. We conducted a systematic review and meta-analysis assessing hemodynamics in cardiac surgery patients treated with levosimendan. English-language literature was searched systematically from 2006 until October 2018, including randomized controlled trials and case-matched or retrospective studies providing at least two sequentially measured hemodynamic variables in adult patients who underwent cardiac surgery with cardiopulmonary bypass and were treated with levosimendan in comparison to alternative drugs or devices. Cardiac index significantly increased in the levosimendan group by 0.74 (0.24 to 1.23) [standardized mean difference (95% CI); p = 0.003] from baseline to postoperative day (POD) 1, and by 0.75 (0.25 to 1.25; p = 0.003) from baseline to POD 7, when corrected for the standardized mean difference at baseline by a multivariate mixed effects meta-analysis model. With this correction for baseline differences, other hemodynamic variables including systemic vascular resistance did not significantly differ until POD 1 [−0.17 (−0.64 to 0.30), p = 0.48] and POD 7 [−0.13 (−0.61 to 0.34), p = 0.58] between the levosimendan and the comparator group. Levosimendan increases cardiac index in patients undergoing cardiac surgery. Although levosimendan has inodilator properties, this meta-analysis finds no clinical evidence that levosimendan produces vasopressor-resistant vasoplegic syndrome.