Cardiac Power Index Research Articles

Pharmacologic treatment of hypertension guided by non-invasive haemodynamics in primary care improves blood pressure control

Abstract Background Current guidelines on hypertension (HTN) provide blood pressure (BP) targets and therapeutic algorithms but ignore the potential to treat individual patients according to their haemodynamic profile. We have shown that use of non-invasive haemodynamic information obtained by impedance cardiography (ICG) can improve BP control in the primary care setting. Purpose To investigate whether improved rates of BP control by matching patients’ non-invasive haemodynamics to specific pharmacologic treatments and increasing patient engagement translates into improved clinical outcome measures. Methods Electronic medical records (EMR) were obtained for 14,698 patients from two US primary care groups between 2014 and 2023. ICG was done when BP exceeded 140/90 mmHg. Haemodynamic measurements included mean arterial pressure (MAP), cardiac index (CI), cardiac power index (CPI), total peripheral resistance index (TPRI), stroke index (SI) and heart rate (HR) (Figure 1). Haemodynamic ICG profiles were classified as: Vasoconstriction, Hyperdynamic, or Mixed pattern. Printed clinical decision support (CDS) tools and later an EMR integrated CDS application were used to communicate recommendations to physicians. Printed reports were shared with patients to increase their engagement. Pharmacological therapy was tailored based on haemodynamic information. Rates of successful BP treatment and the occurrence of myocardial infarction (MI) or stroke were tracked through the EMR. Results Of 14,698 patients, 50% were women, 17% were Black and 17% were aged 18-49 years, 45% aged 50-69 years, and 38% age ≥ 70 years. A total of 21,246 ICGs were performed classifying patients as Vasoconstriction 47%, Hyperdynamic with high heart rate (HR) or high stroke index (SI) 24%, and Mixed Haemodynamic (combination of Vasoconstriction and Hyperdynamic) 29% (Figure 1). Demographic features were not strongly associated with haemodynamic classification. Within 2-3 years of inclusion, >85% of patient achieved BP control (<140/90 mmHg), which was sustained during follow-up. Over a median (IQR) follow-up of 8 (2016-2023) years, there were 14 (5) MI and 34 (16) strokes. These event rates appear to be lower than those reported in other large cohorts of patients with HTN. Conclusions Treating patients with HTN according to their individual haemodynamic profile is associated with high rates of BP control. Further analysis will determine whether the rates of MI, stroke and death are lower than expected based on the patients baseline risk profile.Haemodynamic Status (ICG Test Results)

Mixed venous to arterial pCO2-gap is poorly correlated to cardiac index in 1526 pulmonary artery catheter monitored critically ill patients

Abstract Background The CO2 gap is the difference between mixed venous and arterial CO2, and can be estimated by the difference in partial pressure in CO2 (Pv-aCO2 or ∆PCO2). ∆PCO2 is affected by cardiac output (CO), CO2 production and solubility. The central venous-to-arterial CO2 gap has been proposed as a less invasive surrogate for P(v-a)CO2 and has been investigated as a measure of adequacy of resuscitation, and to guide sepsis management. Nevertheless, the CO2-gap as determinant of CO has never been thoroughly investigated in large cohort of critically ill ICU-patients. This study aims to investigate the relationship between ∆PCO2 and cardiac index (CI) in a retrospective cohort of critically ill patients in a large quaternary cardiothoracic intensive care unit. Methods Over 62 months, pulmonary artery catheter monitored critically ill patients were identified and their case files reviewed in retrospect. Extracorporeal membrane oxygenation (ECMO) patients were excluded. P(v-a)CO2 measurements were defined as mixed venous and arterial pCO2 measurements drawn simultaneously or within maximum 30 minutes together with PA-measurements. Correlation coefficients were calculated between P(v-a)CO2 and CI, serum lactate, mixed venous saturations (SvO2), cardiac power index (CPI), inotropic score (IS), central venous pressure (CVP) and minute expiratory volume (MV)(Table 1). We used receiver operator characteristic (ROC) curves to assess the diagnostic performance of P(v-a)CO2 as a surrogate for CI lower than 2,2L/min/m2. Multivariate linear regression analysis was performed with P(v-a)CO2 as an dependent variable. Results 4414 P(v-a)CO2 measurements were identified from 1526 patients. Median P(v-a)CO2 was 0,86 kPa (0,66-1,1) or 6.45 mmHg (4.95-8.25), and mean CI was 2.7l/min/m2 (2.2-3.2). Correlation coefficients of P(v-a)CO2 with the other variables remained poor (> 0,35). The area under the ROC curve for P(v-a)CO2 as a predictor of CI<2.2l/min/m2 was 0.65, p<0.0001 (Fig. 1B). A value of P(v-a)CO2 > 6.9 mmHg was found to have the highest sensitivity and specificity, with a poor performance of 61.21% sensitivity and 62.73% specificity. Conclusion This large retrospective study in 1526 critically ill cardiac ICU-patients did not demonstrate a strong relationship between P(v-a)CO2 and CI, nor with any other hemodynamic variable found in the ICU patient cohort studied (Table 1). This raises scepticism regarding the efficacy of P(v-a)CO2 as a physiological goal in guiding resuscitation and management of this precarious patient group. Therefore, we argue that the PA-catheter remains the cornerstone in assessing critically ill (cardiothoracic) ICU patients.

Use of the cardiac power index to predict fluid responsiveness in the prone position: a proof-of-concept study

BackgroundThe primary aim of this proof-of-concept study was to investigate whether the Cardiac Power Index (CPI) could be a novel alternative method to assess fluid responsiveness in the prone position. MethodsPatients undergoing scheduled elective lumbar spine surgery in the prone position under general anesthesia were enrolled in the criteria of patients aged 19–75 years with American Society of Anesthesiologists (ASA) physical status I–II. The hemodynamic variables were evaluated before and after changes in posture after administering a colloid bolus (5 mL.kg−1) in the prone position. Fluid responsiveness was defined as an increase in the Stroke Volume Index (SVI) ≥ 10%. ResultsA total of 28 patients were enrolled. In responders, the CPI (median [1/4Q–3/4Q]) decreased to 0.34 [0.28–0.39] W.m−2 (p = 0.035) after the prone position. After following fluid loading, CPI increased to 0.48 [0.37–0.52] W.m−2 (p < 0.008), and decreased SVI (median [1/4Q–3/4Q]) after prone increased from 26.0 [24.5–28.0] mL.m−2 to 33.0 [31.0–37.5] mL.m−2 (p = 0.014). Among non-responders, CPI decreased to 0.43 [0.28–0.53] W.m−2 (p = 0.011), and SVI decreased to 29.0 [23.5–34.8] mL.m−2 (p < 0.009). CPI exhibited predictive capabilities for fluid responsiveness as a receiver operating characteristic curve of 0.78 [95% Confidence Interval, 0.60–0.95; p = 0.025]. ConclusionThis study suggests the potential of CPI as an alternative method to existing preload indices in assessing fluid responsiveness in clinical scenarios, offering potential benefits for responders and non-responders.

A novel echocardiographic parameter considering left ventricular afterload during V-A ECMO support.

Left ventricular stroke work index (LVSWI) and cardiac power index (CPI) account for the haemodynamic load of the left ventricle and are promising prognostic values in cardiogenic shock. However, accurately and non-invasively measuring these parameters during veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is challenging and potentially biased by the extracorporeal circulation. This study aimed to investigate, in an ovine model of cardiogenic shock, whether Pressure-Strain Product (PSP), a novel speckle-tracking echocardiography parameter, (1) can correlate with pressure-volume catheter-based LVSWI and CPI, and (2) can be load-independent during the flow modification of V-A ECMO. Nine Dorset-cross ewes (51 ± 4 kg) were included. After cardiogenic shock was induced, full support V-A ECMO (X L/min based on 60 mL/kg/min) commenced. At seven time points during 24-h observation, echocardiographic parameters as well as pressure-volume catheter-based LVSWI and CPI were simultaneously measured with X and following X-1 L/min of ECMO flow. PSP was calculated by multiplying global circumferential strain or global radial strain, and mean arterial pressure, for PSPcirc or PSPrad, respectively. PSPcirc showed a stronger correlation with LVSWI (correlation coefficient, CC = .360, p < .001) and CPI (CC = .283, p < .001) than other echocardiographic parameters. The predictability of PSPcirc for pressure-volume catheter-based LVSWI (AUC .82) and CPI (AUC .80) was also higher than other echocardiographic parameters. No statistically significant differences were identified between the two ECMO flow variations in PSPcirc (p = .558). A novel echocardiographic parameter, PSP, may non-invasively predict pressure-volume catheter-based LVSWI and CPI in a load-independent manner in a cardiogenic shock supported by V-A ECMO.

Cardiogenic Shock Intravascular Cooling Trial (CHILL-SHOCK)

Cardiogenic shock (CS) is complicated by high mortality rates. Targeted temperature control (TTC) has been proposed as an adjunct therapy in CS. This study aims to examine the safety of TTC in patients presenting with CS. In this open-label, randomized controlled pilot trial, 20 patients with hemodynamic criteria for CS were assigned to standard of care plus TTC vs standard of care alone. The primary outcome was a composite safety outcome, including well-described complications of TTC. Secondary outcomes included mortality at 90 days, invasive hemodynamic and echocardiographic parameters, electrocardiographic measurements, and inotrope dosing. There were no significant differences in the composite analysis of prespecified safety outcomes (3 events in the TTC group vs 0 events in the control group; P = 0.24). Patients randomized to TTC demonstrated a statistically significant increase in cardiac index and cardiac power index compared to the control group at 48-96 hours after randomization (3.6 [3.1, 3.9] L/min/m2 vs 2.6 [2.5, 3.15] L/min/m2; P = 0.029 and 0.61 [0.55, 0.7] W/m2 vs 0.53 [0.435, 0.565] W/m2; P = 0.029, respectively). TTC may be a safe adjunct therapy for patients presenting with CS and may yield improvement in specific hemodynamic parameters.

Impact of vasodilators on diuretic response in patients with congestive heart failure: A mechanistic trial of cimlanod (BMS-986231).

To investigate the effects of Cimlanod, a nitroxyl donor with vasodilator properties, on water and salt excretion after an administration of an intravenos bolus of furosemide. In this randomized, double-blind, mechanistic, crossover trial, 21 patients with left ventricular ejection fraction <45%, increased plasma concentrations of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and receiving loop diuretics were given, on separate study days, either an 8 h intravenous (IV) infusion of cimlanod (12 μg/kg/min) or placebo. Furosemide was given as a 40 mg IV bolus four hours after the start of infusion. The primary endpoint was urine volume in the 4 h after the bolus of furosemide during infusion of cimlanod compared with placebo. Median NT-proBNP at baseline was 1487 (interquartile range: 847-2665) ng/L. Infusion of cimlanod increased cardiac output and reduced blood pressure without affecting cardiac power index consistent with its vasodilator effects. Urine volume in the 4 h post-furosemide was lower with cimlanod (1032 ± 393 ml) versus placebo (1481 ± 560 ml) (p = 0.002), as were total sodium excretion (p = 0.004), fractional sodium excretion (p = 0.016), systolic blood pressure (p < 0.001), estimated glomerular filtration rate (p = 0.012), and haemoglobin (p = 0.010), an index of plasma volume expansion. For patients with heart failure and congestion, vasodilatation with agents such as cimlanod reduces the response to diuretic agents, which may offset any benefit from acute reductions in cardiac preload and afterload.

Assessing cardiac power output values in a healthy adult population.

Cardiac power output (CPO), which combines pressure and flow capacities, directly measures the heart's pumping capability. It is proposed as a superior alternative to ejection fraction in assessing cardiac function. However, there is a lack of data on CPO in healthy individuals, prompting a study to determine the cardiac power output in healthy adults in the Iranian population.This cross-sectional descriptive study investigated cardiac power in a sample of healthy individuals. Participants were recruited from healthy individuals referred to the Echocardiography department using convenience sampling.In this study, we examined the echocardiographic parameters in 173 individuals, of which 52% were men. Men exhibited significantly higher values for stroke volume, cardiac output, and cardiac power output (CPO) in both ventricles, as well as larger body surface area (BSA) and systemic mean arterial pressure (MAP), compared to women. Individuals under the age of 40 had significantly higher BSA and right ventricular cardiac output compared to those aged 40 or above. Multivariate analysis revealed that MAP, left ventricular (LV) cardiac output, LVCPO, pulmonary MAP, right ventricular (RV) CPO, and RV cardiac power index (CPI) were significant predictors of LVCPI changes.Our findings emphasize the importance of cardiac power output as a comprehensive measure of cardiac function, complementing the traditional use of ejection fraction. Further research is warranted to validate these results, establish accurate reference ranges, and explore the clinical implications of cardiac power output in various patient populations.

Anthracycline therapy induces an early decline of cardiac contractility with transient edema in low risk patients with breast cancer

Abstract Background Cancer therapy-related cardiac dysfunction (CTRCD) is a dreaded complication of anthracycline therapy in the treatment of breast cancer. CTRCD most frequently appears in patients with cardiovascular risk factors or known cardiovascular disease. There is limited evidence of incidence and prospective course of anthracycline-induced CTRCD in young patients without common risk factors for CTRCD. Purpose To longitudinally investigate a cohort of young women on anthracycline treatment due to breast cancer without cardiovascular risk factors or known cardiovascular disease. Methods 59 women with first-diagnosed breast cancer and planned anthracycline regime-based therapy were enrolled. Exclusion criteria were cardiovascular risk factors or known cardiovascular disease. We conducted a longitudinal assessment before, immediately after- and 12 months after cancer therapy with general laboratory, electrocardiograms, echocardiography and cardiovascular magnetic resonance (CMR), including myocardial relaxometry with T1, T2 and extracellular volume mapping. Results Every single patient experienced a drop in CMR-measured left ventricular ejection fraction (LVEF) of 6 ± 3 % immediately after cancer therapy. According to the novel definition 32 patients (54.2%) developed CTRCD after 12 months defined by reduction in LVEF, global longitudinal strain (GLS) and/or biomarkers elevation (Figure 1). LVEF reduction was accompanied by a decrease in stroke volume and cardiac power index while enddiastolic volume index remained stable. Global myocardial T2 relaxation times as well as myocardial mass increased coincidently with a decline in wall-thickening. While T2 values and myocardial mass normalized after 12 months, LVEF and GLS remained impaired. Conclusion Among breast cancer patients without pre-existing risk factors for CTRCD anthracyclines induce a decline of myocardial contractility in every single patient, which may lead to an increased risk of future cardiovascular diseases in these patients. Figure 1: Patients with diagnosed CTRCD directly after CT and after 12 months follow up stratified by underlying CTRCD criteria. Boldness of arrows proportionally represents the number of patients changing between the criteria. Some patients fulfilled more than one criterium for CTRCD.Graphical Abstract Figure 1

A physiologic, precision-medicine approach to guided pharmacological treatment of hypertension substantially improves blood pressure in a large community-based cohort

Abstract Background Worldwide blood pressure (BP) control rates remain poor. Hypertension (HTN) guidelines provide BP targets and recommend drug treatment algorithms but ignore the potential to treat the underlying haemodynamic reason. Patient’s poor adherence to medication is often identified as a potential cause of poor HTN control. Purpose To improve rates of BP control by matching patients’ non-invasive haemodynamics to specific pharmacologic treatments and increasing patient engagement. Methods 13,715 hypertensive patients were identified via the electronic medical record (EMR) from two US primary care groups between 2014 and 2023. Impedance Cardiography (ICG) was done when BP was &amp;gt;140/90. Physiologic measurements included blood pressure, mean arterial pressure, cardiac index, cardiac power index, total peripheral resistance index, stroke index and heart rate (Figure 1). HTN etiology was classified as: Vasoconstriction, Hyperdynamic, or Mixed pattern based on the haemodynamic findings of the ICG. Printed clinical decision support (CDS) tools and later an EMR integrated CDS application were used to communicate recommendations to physicians. Printed reports were shared with patients to increase their engagement. Rates of successful blood pressure treatment were tracked by analysis of EMR data. Results The demographics of 13,715 patients were 14% black, 50% women, 17% age 18-49, 45% age 50-69, and 38% age ≥ 70 years. A total of 21,246 ICGs were performed classifying patients as Vasoconstriction 46%, Hyperdynamic with high heart rate (HR) or high stroke index (SI) 25%, and Mixed Haemodynamic (combination of Vasoconstriction and Hyperdynamic) 29% (Figure 1). No demographic features predicted the physiologic grouping. 7,892 patients in the first cohort were treated from 2014 thru 2023 and obtained &amp;gt;90% BP control rate in 2016. This high control rate has been sustained for 6 years. 5,823 patients in the second cohort were treated from 2019 thru 2023 and obtained &amp;gt;86% BP control rate. Conclusions Haemodynamic data may help personalize anti-hypertensive therapy and improve control of HTN to &amp;gt;86-90%. Providing patients with insights about why their BP is high and providing rationale for selecting treatment may motivate their adherence and persistence with therapy. Hypertension physiology is not predicted by demographic features among patients managed in a primary care setting.Haemodynamic Status (ICG Test Results)

Abstract 11627: Association of Cardiac Power Output Index With PET Glucose Metabolism and Prognosis in Pulmonary Arterial Hypertension Patients. Two-year Follow-Up

Introduction: In pulmonary arterial hypertension (PAH) there is still a need for new prognostic markers to precisely identify the patients before clinical deterioration. We investigated cardiac power index (CPi) as a tool to assess right ventricular (RV) function and overall prognosis. Hypothesis: Hemodynamic changes occurring in PAH assessed with CPi are related with cardiac metabolism alterations in PET imaging what affects prognosis. Methods: Twenty-eight stable (WHO class II or III) patients (49.9±15.9 yo) had hybrid PET/MRI scans and heart catheterization performed during baseline and after 24-months. SUV RV/LV ratio was used to estimate cardiac 18-fluorodeoxyglucose uptake. Clinical endpoints (CEP - death or clinical deterioration) were assessed between visits. CPi was defined as the cardiac index х mean pulmonary artery pressure x 2.22 х 10-3. Results: Baseline CPi was 0.28±0.09 W/m2 and it correlated significantly with PET-derived SUV RV/LV ratio (r=0.55, p=0.002), confirming relationship between RV hemodynamics and cardiac metabolism. After 24 months of PAH specific therapy, we observed significant improvement in follow-up CPi - 0.23±0.04 W/m2 (p=0.04). Interestingly, baseline CPi predicted follow-up SUV RV/LV ratio. During 2-year observation, 16 patients (57%) had experienced CEP (including 4 deaths). Patients with CEP had higher baseline CPi than stable patients (0.32±0.09 vs 0.21±0.05, p=0.0006), as well as increased SUV RV/LV. CPi cut-off value to predict worse prognosis was 0.24 W/m2 (log-rank test, p=0.003, Figure) and CPi was also a significant predictor of CEP in multivariate analysis (R2 = 0.69; p=0.001). Conclusions: Indexed cardiac power output parameter is related with RV metabolism alterations in PAH and may help to identify stable patients at higher risk of death or clinical deterioration.

Abstract 17527: Plasma Proteomic Representations of Central Hemodynamics Over Time in Heart Failure

Introduction: Perturbation of central hemodynamic parameters are defining features in heart failure (HF) and strong prognostic factors, including increased filling pressures, reduced cardiac output (CI), extended blood circulation times and increased peripheral oxygen extraction (ΔAVO2). Invasive catheterization is used for precise assessment of central hemodynamics. Hypothesis: We postulated that plasma proteins may serve as non-invasive representations of central hemodynamics in HF patients. Methods: Affinity-based plasma proteomic profiling of 1305 proteins was applied to a cohort of patients with advanced HF undergoing invasive cardiac catheterization before and 6 months after heart transplantation. A total of 30 central hemodynamic parameters were measured and calculated. Protein profiles associated with central hemodynamics over time were identified from repeated-measures models. Results: We identified 1304 associations for 201 unique proteins meeting our Bonferroni-adjusted significance threshold (p&lt;1x10-6) for at least one hemodynamic parameter. Most of the 201 proteins were associated with more than one parameter. Most proteins (70%) associated with parameters in more than one of five domains (filling pressures, left ventricular (LV) function, right ventricular (RV) function, systemic arterial function, pulmonary arterial function). No proteins were associated with 6 of the 30 hemodynamic parameters, which changed little after transplantation and related to arterial function or RV function. The largest number of protein associations were observed for RAP, cardiac power index, left ventricular stroke work index, and ΔAVO2 followed by systolic blood pressure, CI, and PAWP (&gt;80). These include expected associations of natriuretic peptides, ST2 with LV function, filling pressures and of angiotensinogen with vascular function parameters. We further describe the discriminatory ability of identified proteins for clinically relevant differences in key hemodynamic parameters. Conclusions: We have identified circulating biomarkers to non-invasively monitor central hemodynamics in HF over time. Our findings may also inform understanding of pathways involved in HF pathophysiology and circulatory regulation.

Novel parameters for predicting fluid responsiveness during the mini fluid challenge and ability of the cardiac power index: an observational cohort study.

The percentage change in the stroke volume index (SVI) due to the mini fluid challenge (MFC) (MFC-ΔSVI%) is used commonly in daily practice. However, up to 20% of patients remain in the gray zone of this variable. Thus, it was aimed to compare the MFC-ΔSVI% and the percentage change in the cardiac power index (CPI) due to the MFC (MFC-ΔCPI%) with the baseline values of the pulse pressure variation (PPV) and stroke volume variation (SVV) in terms of their abilities to predict fluid responsiveness. The SVI, CPI, SVV, and PPV were recorded before 100 mL of isotonic saline was infused (MFC), after MFC was completed, and after an additional 400 mL of isotonic saline was infused to complete 500 mL of fluid loading (FL). Patients whose SVI increased more than 15% after the FL were defined as fluid responders. Sixty-seven patients completed the study and 35 (52%) of them were responders.The areas under the receiver operating characteristics curves for the MFC-ΔSVI% and MFC-ΔCPI% (0.94; 95% CI: 0.86-0.99 and 0.89; 95% CI: 0.79-0.95, respectively) were significantly higher than those for the SVV and PPV (0.63; 95% CI: 0.50-0.75 and 0.55; 95% CI: 0.42-0.67, respectively) (p < 0.001 for all of the comparisons). The gray zone analysis revealed that the MFC-ΔSVI% values of 12 patients were in the gray zone. Of the 12, the MFC-ΔCPI% values of 7 patients were outside of the gray zone. Fluid responsiveness can be predicted more accurately using the MFC-ΔSVI% and MFC-ΔCPI% than using the SVV and PPV. Additionally, concomitant use of the MFC-ΔSVI% and MFC-ΔCPI% is recommended, as this approach diminishes the number of patients in the gray zone.

Periodontal health status and its association with cardiovascular risk score among the rural community in India: A community-based study

Abstract Objectives: Our primary purpose was to examine the association between cardiovascular risk scores and the state of periodontal health within a rural community in India. Additionally, we aimed to explore the potential for incorporating assessments of periodontal health as an indicator of coronary artery disease (CAD). Materials and Methods: In total, 2100 study participants aged 30 and older were included in our research. We developed a semistructured questionnaire to collect information on sociodemographic factors, and the Framingham risk score questionnaire was utilized to assess the risk of cardiovascular disease (CVD). Results: We discovered a significant Pearson’s correlation coefficient of 0.761 between the CAD risk score and the cardiac power index (CPI) among our study participants. Similarly, the Spearman correlation coefficient between CAD risk levels and CPI was 0.654, with both values demonstrating statistical significance (P &lt; 0.001). Conclusion: Our results strongly indicate that incorporating CPI as one of the risk assessment factors for CVD is highly recommended. Presently, community education on dental health is predominantly centered around school-based initiatives. However, we propose expanding this educational effort to encompass all community members. Educating individuals about the importance of periodontal health in CVD is vital since maintaining good periodontal health can prevent or alleviate morbidity associated with heart conditions.

Treatment of patients with multiple organ dysfunction syndrome (MODS) with an electromagnetic field coupled to biorhythmically defined impulse configuration: the MicrocircMODS study

BackgroundTo potentially improve impaired vasomotion of patients with multiple organ dysfunction syndrome (MODS), we tested whether an electromagnetic field of low flux density coupled with a biorhythmically defined impulse configuration (Physical Vascular Therapy BEMER®, PVT), in addition to standard care, is safe and feasible and might improve disturbed microcirculatory blood flow and thereby improve global haemodynamics.MethodsIn a prospective, monocentric, one-arm pilot study, 10 MODS patients (APACHE II score 20–35) were included. Patients were treated, in addition to standard care, for 4 days with PVT (3 treatment periods of 8 min each day; day 1: field intensity 10.5 μT; day 2:14 μT, day 3:17.5 μT; day 4:21.0 μT). Primary endpoint was the effect of PVT on sublingual microcirculatory perfusion, documented by microvascular flow index (MFI). Patient safety, adverse events, and outcomes were documented.ResultsAn increase in MFI by approximately 25% paralleled 4-day PVT, with the increase starting immediately after the first PVT and lasting over the total 4-day treatment period. Concerning global haemodynamics (secondary endpoints), halving vasopressor use within 24 h, and haemodynamic stabilisation paralleled 4-day PVT with an increase in cardiac index, stroke volume index, and cardiac power index by 30%–50%. No adverse events (AEs) or serious adverse events (SAEs) were classified as causally related to the medical product (PVT) or study. Three patients died within 28 days and one patient between 28 and 180 days.ConclusionPVT treatment was feasible and safe and could be performed without obstruction of standard patient care. An increase in microcirculatory blood flow, a rapid reduction in vasopressor use, and an improvement in global haemodynamics paralleled PVT treatment. Findings of this pilot study allowed forming a concept for a randomized trial for further proof.Graphical abstract

Invasive Phenoprofiling of Acute-Myocardial-Infarction-Related Cardiogenic Shock.

Studies had previously identified three cardiogenic shock (CS) phenotypes (cardiac-only, cardiorenal, and cardiometabolic). Therefore, we aimed to understand better the hemodynamic profiles of these phenotypes in acute myocardial infarction-CS (AMI-CS) using pulmonary artery catheter (PAC) data to better understand the AMI-CS heterogeneity. We analyzed the PAC data of 309 patients with AMI-CS. The patients were classified by SCAI shock stage, congestion profile, and phenotype. In addition, 24 h hemodynamic PAC data were obtained. We identified three AMI-CS phenotypes: cardiac-only (43.7%), cardiorenal (32.0%), and cardiometabolic (24.3%). The cardiometabolic phenotype had the highest mortality rate (70.7%), followed by the cardiorenal (52.5%) and cardiac-only (33.3%) phenotypes, with significant differences (p < 0.001). Right atrial pressure (p = 0.001) and pulmonary capillary wedge pressure (p = 0.01) were higher in the cardiometabolic and cardiorenal phenotypes. Cardiac output, index, power, power index, and cardiac power index normalized by right atrial pressure and left-ventricular stroke work index were lower in the cardiorenal and cardiometabolic than in the cardiac-only phenotypes. We found a hazard ratio (HR) of 2.1 for the cardiorenal and 3.3 for cardiometabolic versus the cardiac-only phenotypes (p < 0.001). Also, multi-organ failure, acute kidney injury, and ventricular tachycardia/fibrillation had a significant HR. Multivariate analysis revealed that CS phenotypes retained significance (p < 0.001) when adjusted for the Society for Cardiovascular Angiography & Interventions score (p = 0.011) and ∆congestion (p = 0.028). These scores independently predicted mortality. Accurate patient prognosis and treatment strategies are crucial, and phenotyping in AMI-CS can aid in this effort. PAC profiling can provide valuable prognostic information and help design new trials involving AMI-CS.

Right Ventricular Cardiac Power Index Predicts 1 Year Outcome After Transcatheter Edge-to-Edge-Repair for Severe Tricuspid Valve Regurgitation

Tricuspid transcatheter edge-to-edge repair (T-TEER) for severe tricuspid regurgitation (TR) emerged as a novel treatment option for patients not amenable to surgery. However, knowledge regarding independent risk factors for a worse prognosis is rarely available. The study sought to investigate the impact of right ventricular cardiac power index (RVCPi) on 1-year outcomes in patients with severe symptomatic TR who underwent T-TEER. Consecutive patients with severe TR who underwent T-TEER from August 2020 to March 2022 were included and followed prospectively. Baseline clinical and invasive hemodynamic variables, changes in echocardiographic parameters and New York Heart Association functional class, and periprocedural and in-hospital major adverse events were assessed. Primary end point was defined as a composite of all-cause mortality and heart failure hospitalization at 1 year after T-TEER. A multivariable Cox proportional-hazards regression analysis was performed to identify independent risk factors for combined primary end point. RVCPi was calculated as: (cardiac index×mean pulmonary pressure)×K (conversion factor 2.22×10-3)=W/m². Receiver operator characteristic analysis was used to determine discriminative capacity of RVCPi. The prognostic value of RVCPi threshold was tested using Kaplan-Meier analysis. In total, 102 patients (mean age 81±6years, 51% women) at high operative risk underwent T-TEER for severe TR. Primary end point occurred in 30 patients (32%). Receiver operator characteristic curve analysis demonstrated that RVCPi was associated with an area under the curve of 0.69 (95% confidence interval 0.56 to 0.82; p=0.003). With a RVCPi threshold of 0.17W/m² (maximally selected rank statistics), the event-free survival was significantly higher in the RVCPi <0.17W/m² group compared with those with RVCPi ≥0.17W/m² (71% vs 35%, log-rank p<0.001). In the multivariable Cox regression analysis, RVCPi was an independent predictor for the combined primary end point (hazard ratio 2.6, 95% confidence interval 1.4 to 5.1, p=0.003). In conclusion, RVCPi is associated with outcome in patients who underwent T-TEER for severe TR and this hemodynamic predictor is useful in risk stratification of T-TEER candidates.

Impact of invasively determined cardiac power index on survival in patients with advanced chronic heart failure

Impact of invasively determined cardiac power index on survival in patients with advanced chronic heart failure

Hemodynamic Predictors of Stabilization When Using Temporary Mechanical Support for Cardiogenic Shock from Acute on Chronic Heart Failure

Cardiogenic shock from acute on chronic heart failure is a lethal condition that frequently requires temporary mechanical circulatory support devices (tMCS) as a bridge to stabilization, durable support, or heart transplantation. However, there are limited data on methods to optimize use of tMCS in this population. We identified patients who received tMCS devices for cardiogenic shock from acute on chronic heart failure at a single center from August 2016 to July 2020. All the patients had invasive hemodynamic data before and immediately after tMCS placement. We classified patients according to whether they showed stabilization or decompensation with tMCS. We then evaluated hemodynamics pre-tMCS, post-tMCS, and the change in hemodynamics with tMCS (∆-tMCS) and assessed their relationship with clinical outcomes. Among 111 patients who received tMCS, 71 stabilized, and 40 decompensated. Post-tMCS hemodynamics were more likely than were pre-tMCS or ∆-tMCS to predict stabilization. Post-tMCS cardiac index >2.1 (area under the curve: 92.2) and cardiac power index >0.3 (area under the curve: 89.6) were the best predictors of stabilization. Patients who decompensated had increased in-hospital all-cause mortality (hazard ratio 3.06 [1.29 to 7.24], p=0.011), cardiovascular mortality, and increased hospital and intensive care unit length of stay and were less likely to receive left ventricular assist device or heart transplant (hazard ratio 0.56 [0.36 to 0.88], p=0.01). In conclusion, among patients with cardiogenic shock from acute on chronic heart failure who received tMCS, post-tMCS cardiac index and cardiac power index were highly predictive of stabilization. Those who decompensated had increased mortality, hospital length of stay, and intensive care unit length of stay and were less likely to receive heart replacement therapy.

Adjunctive Hydrocortisone Improves Hemodynamics in Critically Ill Patients with Septic Shock: An Observational Study Using Transpulmonary Thermodilution.

Introduction: Septic shock is associated with high mortality and hemodynamic impairment. The use of corticoids is a common therapeutic tool in critically ill patients. However, data on the mechanisms and prognostic ability of hemodynamic improvement by adjunctive steroids are rare. This study primarily aimed to evaluate short-term effects of hydrocortisone therapy on catecholamine requirement and hemodynamics derived from transpulmonary thermodilution (TPTD) in 30 critically ill patients with septic shock and a 28 days mortality rate of 50%. Methods: Hydrocortisone was administered with an intravenous bolus of 200 mg, followed by a continuous infusion of 200 mg per 24 h. Hemodynamic assessment was performed immediately before as well as 2, 8, 16, and 24 h after the initiation of corticoids. For primary endpoint analysis, we evaluated the impact of hydrocortisone on vasopressor dependency index (VDI) and cardiac power index (CPI). Results: Adjunctive hydrocortisone induced significant decreases of VDI from 0.41 (0.29-0.49) mmHg-1 at baseline to 0.35 (0.25-0.46) after 2 h (P < .001), 0.24 (0.12-0.35) after 8 h (P < .001), 0.18 (0.09-0.24) after 16 h (P < .001) and 0.11 (0.06-0.20) mmHg-1 after 24 h (P < .001). In parallel, we found an improvement in CPI from 0.63 (0.50-0.83) W/m2 at baseline to 0.68 (0.54-0.85) after 2 h (P = .208), 0.71 (0.60-0.90) after 8 h (P = .033), 0.82 (0.6-0.98) after 16 h (P = .004) and 0.90 (0.67-1.07) W/m2 after 24 h (P < .001). Our analyses revealed a significant reduction in noradrenaline requirement in parallel with a moderate increase in mean arterial pressure, systemic vascular resistance index, and cardiac index. As a secondary endpoint, our results showed a significant decrease in lung water parameters. Moreover, changes in CPI (ΔCPI) and VDI (ΔVDI) after 24 h of hydrocortisone therapy revealed accurate prognostic ability to predict 28 days mortality (AUC = 0.802 vs 0.769). Conclusion: Adjunctive hydrocortisone leads to a rapid decrease in catecholamine requirement and a substantial circulatory improvement in critically ill patients with septic shock.

Utility of Cardiac Power Hemodynamic Measurements in the Evaluation and Risk Stratification of Cardiovascular Conditions.

Despite numerous advancements in prevention, diagnosis and treatment, cardiovascular disease has remained the leading cause of mortality globally for the past 20 years. Part of the explanation for this trend is persistent difficulty in determining the severity of cardiac conditions in order to allow for the deployment of prompt therapies. This review seeks to determine the prognostic importance of cardiac power (CP) measurements, including cardiac power output (CPO) and cardiac power index (CPI), in various cardiac pathologies. CP was evaluated across respective disease-state categories which include cardiogenic shock (CS), septic shock, transcatheter aortic valve replacement (TAVR), heart failure (HF), post-myocardial infarction (MI), critical cardiac illness (CCI) and an "other" category. Literature review was undertaken of articles discussing CP in various conditions and this review found utility and prognostic significance in the evaluation of TAVR patients with a significant correlation between one-year mortality and CPI; in HF patients showing CPI and CPO as valuable tools to assess cardiac function in the acute setting; and, additionally, CPO was found to be an essential tool in patients with CCI, as the literature showed that CPO was statistically correlated with mortality. Cardiac power and the derived measures obtained from this relatively easily obtained variable can allow for essential estimations of prognostic outcomes in cardiac patients.