Cardiac Power Index Research Articles

Abstract 14498: Cardiogenic Shock Intravascular Cooling Trial (CHILL-SHOCK)

Introduction: Despite advances in revascularization and mechanical support, cardiogenic shock (CS) remains a highly morbid clinical state with 30-day mortality approaching 50%. Therapeutic hypothermia (TH) has been demonstrated to improve hemodynamics and reduce inflammation in small studies, but prospective randomized data is limited. We aimed to assess the safety and hemodynamic effects of TH (33 °C for 24 hours) in patients with CS. Methods: A total of 20 patients in CS were randomized to either TH plus standard therapy or standard therapy alone in this pilot study. Patients randomized to TH were cooled and rewarmed via intravenous cooling catheter. The primary safety endpoint was a composite of bradycardia requiring treatment, bleeding requiring transfusion as a result of catheter placement or secondary to resulting coagulopathy, shivering, hyperglycemia requiring insulin for non-diabetic patients, electrolyte derangement unexplained by other therapies, and complications from cooling catheter insertion. Secondary endpoints included hemodynamic parameters (cardiac output, pulmonary artery pressure, systemic vascular resistance, and cardiac power index). Results: There were no statistically significant differences in the composite analysis of prespecified safety outcomes (3 events in TH group vs 0 events in control group, p = 0.24). Patients randomized to TH demonstrated a statistically significant increase in cardiac index (3.6 [3.1, 3.9] L/min/m 2 vs 2.6 [2.5, 3.2] L/min/m 2 , p = 0.03) and cardiac power index (0.61 [0.55, 0.70] W/m 2 vs 0.53 [0.44, 0.57] W/m 2 , p = 0.03) compared to the control group at 48-96 hours after randomization. There were no statistically significant differences between the two groups for other collected hemodynamic variables. Conclusions: TH is a safe adjunct therapy for patients presenting with CS and may yield improvement in specific hemodynamic parameters. Larger studies are necessary to better understand the clinical benefits of TH in patients presenting with CS.

The Cardiac Power Index during Abdominal Open Aortic Surgery: Intraoperative Insights into the Cardiac Performance-A Retrospective Observational Analysis.

Background: The Cardiac Power Index (CPI) measures the rate of energy output generated by the heart and correlates this with in-hospital mortality due to cardiogenic shock. In open aortic surgery, both aortic clamping and unclamping expose the heart to abrupt variations of the left ventricle afterload, preload, and contractility, with possible hemodynamic impairment. We investigated how aortic-cross clamping (Ao-XC) and unclamping (Ao-UC) procedures affect the CPI during open aortic surgery. Methods: We retrospectively analyzed our surgical database of 67 patients submitted to open surgical aortic repair at Humanitas Research Hospital, Milan. Patients were monitored by an EV1000-FloTrac SystemTM (Edwards Lifescience, Irvine, CA, USA) beyond the standard intra-operative hemodynamic monitoring. The primary outcome was the variation of basal CPI after aortic clamping and unclamping. Secondary outcomes were variations of the cardiac index (CI), mean arterial pressure (MAP), heart rate, and lactate during aortic clamping and after unclamping. The CPI was computed as: (CI × MAP)/451. Results: The CPI changed significantly after aortic unclamping. CPI: basal = 0.39 ± 0.1 W/m2, after Ao-XC = 0.39 ± 0.1 W/m2, and after Ao-UC = 0.44 ± 0.2 W/m2, p < 0.05. The CI changed during both cross-clamping and unclamping (p < 0.0001), whilst the MAP and heart rate did not during any phase of the surgery. Five subjects (8.3%) needed inotropic support after cross-clamping. Their basal CPI was lower than the general population: 0.31 ± 0.11 W/m2 vs. 0.39 ± 0.1 W/m2. Conclusions: The CPI describes the adaptation of the cardiac function to the changes in preload, contractility, and afterload occurring during aortic cross-clamping and unclamping. It may be used to explore the cardiac performance in real-time and predict cardiac impairment in the intraoperative period in a minimally invasive way, similar to ventriculo-arterial coupling parameters.

The first study to evaluate non-invasive haemodynamic profile changes in reaction to nitroglycerin in patients with HFmrEF in comparison to HFpEF and HFrEF

Abstract Introduction According to 2021 guidelines for management of heart failure (HF) there are 3 types of HF – with reduced (HFrEF; ≤40%), mildly reduced (HFmrEF; 41–49%) and preserved (HFpEF; ≥50%) left ventricle ejection fraction (LVEF). The middle group – HFmrEF – is the least known and requires further research. The aim of the study was to assess clinical and hemodynamic profile of patients with HFmrEF at rest and after sublingual administration of 0.4 mg of nitroglycerin (NTG). Material and methods The hemodynamic profile was assessed on the last day of hospitalization due to acute decompensated heart failure. The control groups for patients with HFmrEF were groups of HFpEF and HFrEF, while there was no control group on healthy subjects. The clinical profile of patients was assessed by data from medical interview, results of laboratory tests and measured echocardiographic parameters, while the hemodynamic profile – at rest and after administration of 0.4mg of NTG – was assessed by electrical cardiometry (EC) using the ICON® device. Results Overall, 15 consecutive patients from each type of HF were included into the study and most of them were men (N=32; 71%). Diabetes was significantly more frequent in the HFpEF group. The HFrEF group had significantly higher left ventricle end-diastolic dimension (LVDD; p=0.0003) and lower right ventricle systolic function (TAPSE; p=0.0026). The analysis of the hemodynamic profile at rest showed significant differences between HFmrEF and HFrEF in systolic time ratio (STR; p=0.0202) and pre-ejection period (PEP; p=0.0487). In comparison to HFrEF group, patients with HFmrEF were significantly different in the change of stroke volume and stroke volume index (SV/SI; p=0.0134/0.0223), cardiac output and cardiac index (CO/CI; p=0.005/0.0079), systemic vascular resistance and its' indexed values (SVR/SVRI; p=0.0339/0.0294), the cardiac power index (CPI; p=0.0489) and corrected flow time (FTC; p=0.0369). The change in the following parameters: SV, SI, CO, CI, FTC, SVR, SVRI and CPI after NTG administration, in the HFmrEF group had and an opposite direction in comparison to patients with HFpEF (p=NS) and HFrEF (p&amp;lt;0.05) (Fig. 1). The principal component analysis showed that the HFmrEF group is less heterogenetic and located within the two others (Fig. 2). Conclusions Clinical profile of patients with HFmrEF based on medical interview, laboratory and echographic findings showed that they are a mid-filed group. Patients with HFmrEF significantly differs from HFrEF in the changes of hemodynamic profile after sublingual NTG administration, considering EC parameters of the blood flow (SV, SI, CO, CI, SVR, SVRI) and heart muscle contractility (CPI, FTC). The reaction to NTG showed that HFmrEF is the intermediate and more homogeneous group that is comprised in the other two groups. The median reaction to NTG in the HFmrEF group was opposite to the reaction in HFpEF and HFrEF patients. Funding Acknowledgement Type of funding sources: None.

Heart rate control and hemodynamic improvement with Ivabradine in cardiogenic shock patients on mechanical circulatory support

Abstract Background Cardiogenic shock (CS) is a life threatening condition due to primary cardiac dysfunction. First line therapy involves drug administration (including inotropes and/or vasopressors) up to mechanical circulatory support. Tachycardia is a compensatory mechanism in response to hypotension and low cardiac output or a side effect related to inotropic drugs. Ivabradine selectively acts on IKf channel in the sinoatrial node to reduce sinus heart rate without affecting inotropism. Its use in small non-randomized series of patients with CS was safe and well tolerated [1]. Methods We present the use of ivabradine in six patients with CS undertaking veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Data regarding haemodynamic and echocardiographic monitoring were collected before, at 12, 24 and 48 hours after ivabradine administration. Results Ivabradine was administered through naso-gastric tube with a median time of 23 hours [IQR 18–28] since VA-ECMO implantation at the starting dose of 2.5 mg twice a day. Haemodynamic and echocardiographic parameters are shown in table. Ivabradine was well tolerated and led to a significant reduction of heart rate after first administration (p&amp;lt;0.01) (Fig. 1, panel A). Echo-derived stroke volume increased significantly (p&amp;lt;0.001) (Fig. 1, panel B); so did cardiac index (p&amp;lt;0.001) and left ventricular cardiac power index (p 0.005) (Fig. 1, panel C). VA-ECMO rate pump and blood flow significantly decreased (respectively p 0.002, p 0.001). No significant changes were observed in arterial blood pressure (p&amp;gt;0.05). Norepinephrine was down-titrated in all patients (p 0.01). Patients presented with cardiac arrest died due to neurological injury whereas the others were weaned off VA-ECMO and discharged alive. Conclusions Ivabradine administration resulted in an effective reduction of heart rate leading to ventricular stroke volume allowing the reduction of extracorporeal flow support and vasopressors administration. Funding Acknowledgement Type of funding sources: None.

Immediate reduction in left ventricular ejection time following TAVI is associated with improved quality of life.

BackgroundTAVI has shown to result in immediate and sustained hemodynamic alterations and improvement in health-related quality of life (HRQoL), but previous studies have been suboptimal to predict who might benefit from TAVI. The relationship between immediate hemodynamic changes and outcome has not been studied before. This study sought to assess whether an immediate hemodynamic change, reflecting myocardial contractile reserve, following TAVI is associated with improved HRQoL. Furthermore, it assessed whether pre-procedural cardiac power index (CPI) and left ventricular ejection fraction (LVEF) could predict these changes.MethodsDuring the TAVI procedure, blood pressure and systemic hemodynamics were prospectively collected with a Nexfin® non-invasive monitor. HRQoL was evaluated pre-procedurally and 12 weeks after the procedure, using the EQ-5D-5L classification tool.ResultsOverall, 97/114 (85%) of the included patients were eligible for analyses. Systolic, diastolic and mean arterial pressure, heart rate, and stroke volume increased immediately after TAVI (all p < 0.005), and left ventricular ejection time (LVET) immediately decreased with 10 ms (95%CI = −4 to −16, p < 0.001). Overall HRQoLindex increased from 0.810 [0.662–0.914] before to 0.887 [0.718–0.953] after TAVI (p = 0.016). An immediate decrease in LVET was associated with an increase in HRQoLindex (0.02 index points per 10 ms LVET decrease, p = 0.041). Pre-procedural CPI and LVEF did not predict hemodynamic changes or change in HRQoL.ConclusionTAVI resulted in an immediate hemodynamic response and increase in HRQoL. Immediate reduction in LVET, suggesting unloading of the ventricle, was associated with an increase in HRQoL, but neither pre-procedural CPI nor LVEF predicted these changes.Clinical trial registration https://clinicaltrials.gov/ct2/show/NCT03088787

Prognostic value of right atrial pressure-corrected cardiac power index in cardiogenic shock.

The pulmonary artery catheter (PAC)-derived cardiac power index (CPI) has been found of prognostic value in cardiogenic shock (CS) patients. The original CPI equation included the right atrial pressure (RAP), accounting for heart filling pressure as a determinant of systolic myocardial work, but this term was subsequently omitted. We hypothesized that the original CPI formula (CPIRAP ) is superior to current CPI for risk stratification in CS. A single-centre cohort of 80 consecutive Society for Cardiovascular Angiography and Interventions (SCAI) B-D CS patients with available PAC records was included. Overall in-hospital mortality was 21.3%. Results showed CPIRAP to be the strongest haemodynamic predictor of in-hospital death (padj =0.038), outperforming CPI [area under the receiver operating characteristic (ROC) curves: 0.726 and 0.673, P-for-difference=0.025]. When the population was stratified according to the identified CPIRAP (0.28W/m2 ) and accepted CPI (0.32W/m2 ) thresholds, the cohort with discordant indexes (low CPIRAP and high CPI) comprised a group of 13 patients featuring a congested phenotype with frequent right ventricle or biventricular involvement. In this group, in-hospital mortality was high (30.8%) similar to those with concordant low CPI and CPIRAP . Incorporating RAP in CPI calculation (CPIRAP ) improves the prognostic yield in patients with CS SCAI B-D. A cut-off of 0.28W/m2 identifies patients at higher risk of in-hospital mortality. The improved prognostic value of CPIRAP may derive from identification of patients with more intravascular congestion who may experience substantial in-hospital mortality, uncaptured by the commonly used CPI equation.

Predictive Accuracy of Hemodynamic Surrogate Indices in Patients with Advanced Heart Failure

<h3>Purpose</h3> Right heart catheterization (RHC) is an essential tool in the evaluation advanced heart failure (AHF) patients. It is unclear which of the established hemodynamic surrogate indices are most predictive of poor outcomes. We aimed to compare the predictive accuracy of published hemodynamic surrogates in AHF patients. <h3>Methods</h3> In a pooled registry of patients undergoing RHC for evaluation of decompensated heart failure, we analyzed several hemodynamic indices with cut-off values taken from previously published studies, including: systolic blood pressure / pulmonary capillary wedge pressure (SBP/PCWP) ratio < 4; cardiac power index (CPI=MAP x CI/451) <0.44; cardiac power efficiency (CPE= CPI/PCWP) <0.018; aortic pulsatility index (API=SBP-DBP/PCWP) <1.45; pulmonary artery pulsatility index (PAPi=PASP-PADP/CVP) <2.0; CVP + PCWP >30; CVP/PCWP >0.6. The primary composite outcome was defined as freedom from advanced heart failure therapies, inotropes, or death. <h3>Results</h3> A total of 182 patients (median age 59, 71% male) were included and were on oral medical therapy at the time of RHC. The median (mmHg) SBP was 113 (101, 122), MAP 86 (76.3, 94), RA 15 (10, 18), mean PA 39.5 (32, 47.6), PCWP 26 (20, 32), cardiac index 1.8 (L/m/m2) (1.5, 2.1). At 30 days, 122 patients met the primary composite outcome including 5 deaths. At end of study follow up (up to 365 days) 15 additional patients (n=137) met the primary outcome. All hemodynamic surrogates at their designated cut-off values were associated with an increased risk of the primary outcome at 30 days (<i>P</i><0.05), and at follow-up up to one year with the exception of API (Figure). The receiver operator characteristic analyses for all indices at their pre-designated cut-off values had a comparable range of risk discrimination of 0.58 to 0.64 (Figure) at one-year. <h3>Conclusion</h3> Novel hemodynamic surrogates may be additive in risk prognostication of AHF patients, but can vary in diagnostic accuracy at their pre-specified cut-off values when applied to external clinical cohorts.

The β 1 -Adrenergic Receptor Contributes to Sepsis-Induced Immunosuppression Through Modulation of Regulatory T-Cell Inhibitory Function.

Although cardiovascular benefits of β 1 -adrenergic receptor blockade have been described in sepsis, little is known about its impact on the adaptive immune response, specifically CD4 T cells. Herein, we study the effects of β 1 -adrenergic receptor modulation on CD4 T-cell function in a murine model of sepsis. Experimental study. University laboratory. C57BL/6 mice. High-grade sepsis was induced by cecal ligation and puncture in wild-type mice (β 1+/+ ) with or without esmolol (a selective β 1 -adrenergic receptor blocker) or in β 1 -adrenergic receptor knockout mice (β 1-/- ). At 18 hours after surgery, echocardiography was performed with blood and spleen collected to analyze lymphocyte function. At 18 hours, β 1+/+ cecal ligation and puncture mice exhibited characteristics of high-grade sepsis and three surrogate markers of immunosuppression, namely decreased splenic CD4 T cells, reduced CD4 T-cell proliferation, and increased regulatory T lymphocyte cell proportions. Pharmacologic and genetic β 1 -adrenergic receptor blockade reversed the impact of sepsis on CD4 T and regulatory T lymphocyte proportions and maintained CD4 T-cell proliferative capacity. β 1 -adrenergic receptor blocked cecal ligation and puncture mice also exhibited a global decrease in both pro- and anti-inflammatory mediators and improved in vivo cardiovascular efficiency with maintained cardiac power index despite the expected decrease in heart rate. β 1 -adrenergic receptor activation enhances regulatory T lymphocyte inhibitory function and thus contributes to sepsis-induced immunosuppression. This can be attenuated by β 1 -adrenergic receptor blockade, suggesting a potential immunoregulatory role for this therapy in the management of sepsis.

A Novel Hypertension Management Algorithm Guided by Hemodynamic Data

A Novel Hypertension Management Algorithm Guided by Hemodynamic Data

Hemodynamic Effects of Levosimendan in Outpatients With Advanced Heart Failure: An Echocardiographic Pilot Study.

Infusions of levosimendan delivered in ambulatory/outpatient settings have been shown to improve quality of life and reduce hospitalizations in patients with advanced heart failure (HF). The aim of this pilot study was to evaluate the effects of ambulatory infusion of levosimendan on echocardiographic markers of perfusion, congestion, and cardiovascular efficiency. Thirty patients with diagnosed advanced HF underwent ambulatorial infusion of levosimendan at a total dose of 6.25 mg as a part of a repetitive biweekly treatment strategy with the inotrope. Standardized transthoracic echocardiography and Doppler examinations, were performed 1 hour before and 48 hours after completion of ambulatory infusion. At 48 hours after ambulatory infusion of levosimendan, a significant increase in the stroke volume (37.47 ± 12.38 mL/beat vs. 45.47 ± 14.48 mL/beat; P < 0.05) and cardiac output (2.64 ± 0.66 L/min vs. 3.26 ± 0.57 L/min; P < 0.05) occurred. Significant postreductions versus prereductions were also recorded in left atrial pressure (27.37 ± 6.62 mm Hg vs. 22.82 ± 4.17 mm Hg; P < 0.01), mean pulmonary artery pressure (27.69 ± 4.64 mm Hg vs. 23.24 ± 5.32; P < 0.01), and inferior vena cava diameter (23.81 ± 7.63 mm vs. 18.53 ± 4.82 mm; P < 0.01). Significant improvements were noted in the resting cardiac power output (0.46 ± 0.15 watt vs. 0.53 ± 0.22 watt; P < 0.01) and the resting cardiac power index (0.24 ± 0.08 watt/m2 vs. 0.28 ± 0.11 watt/m2; P < 0.01). In outpatients with advanced HF, infusion of levosimendan was associated with hemodynamic responses that may contribute to the clinical benefit previously reported in such patients.

Afterload-related cardiac performance predicts prognosis in critical ill patients with sepsis: A prospective observational pilot study.

To investigate the usefulness of afterload-related cardiac performance (ACP) for assessing cardiac impairment and predicting prognosis in septic patients.Adult patients with sepsis in the intensive care unit were included. Cardiac output, cardiac index, cardiac power index, and ACP were calculated at the time of admission (D0) and 48-72 h after admission (D3). They were correlated with Acute Physiology and Chronic Health Evaluation II and sequential organ failure assessment scores, then the prognostic values were analyzed.A total of 41 patients with sepsis were selected. ACP showed a stronger negative correlation with Acute Physiology and Chronic Health Evaluation II and sequential organ failure assessment scores than cardiac output, cardiac index, and cardiac power index. ACP predicted 28-day mortality with an area under the curve of 0.775 and 0.976 on D0 and D3, respectively. In addition, most non-survivors had emergent cardiac impairment (ACP ≤ 80%) on D0, and cardiac function was deteriorated on D3. Survival analysis showed that the patients with a decreased ACP from D0 to D3 had the highest mortality. The decrease of ACP on D3 was an independent risk factor for mortality (hazard ratio, 11.89; P = .0028).ACP can be used to assess the severity of cardiac impairment in sepsis. Continued decline of ACP during the first 3 days strongly suggests a poor prognosis.

An Analysis of Frequency of Continuous Blood Pressure Variation and Haemodynamic Responses during Haemodialysis

Background: Higher beat-to-beat blood pressure (BP) variation during haemodialysis (HD) has been shown to be associated with elevated cardiac damage markers and white matter ischaemic changes in the brain suggesting relevance to end-organ perfusion. We aimed to characterize individual patterns of BP variation and associated haemodynamic responses to HD. Methods: Fifty participants underwent continuous non-invasive haemodynamic monitoring during HD and BP variation were assessed using extrema point (EP) frequency analysis. Participants were divided into those with a greater proportion of low frequency (LF, n = 21) and high frequency (HF, n = 22) of BP variation. Clinical and haemodynamic data were compared between groups. Results: Median EP frequencies for mean arterial pressure (MAP) of mid-week HD sessions were 0.54 Hz (interquartile range 0.18) and correlated with dialysis vintage (r = 0.32, p = 0.039), NT pro-BNP levels (r = 0.32, p = 0.038), and average real variability (ARV) of systolic BP (r = 0.33, p = 0.029), ARV of diastolic BP (r = 0.46, p = 0.002), and ARV of MAP (r = 0.57, p < 0.001). In the LF group, MAP positively correlated with cardiac power index (CPI) in each hour of dialysis, but not with total peripheral resistance index (TPRI). In contrast, in the HF group, MAP correlated with TPRI in each hour of dialysis but only with CPI in the first hour. Conclusions: EP frequency analysis of continuous BP monitoring during dialysis allows assessment of BP variation and categorization of individuals into low- or high-frequency groups, which were characterized by different haemodynamic responses to dialysis. This may assist in improved individualization of dialysis therapy.

Prognostic value of resting cardiac power index depends on mean arterial pressure in dilated cardiomyopathy.

AimsIn recent decades, haemodynamic parameters have been estimated for risk stratification and determining treatment strategies for patients with non‐ischaemic dilated cardiomyopathy (DCM). In various invasive procedures, the cardiac pumping capability is defined as cardiac power output (CPO), which is calculated by multiplying cardiac output by the mean arterial pressure. Lower CPO values in advanced heart failure predict adverse outcomes. However, few studies discuss the prognostic value of CPO in mild‐to‐moderate phase patients. This study aimed to determine the value of the cardiac power index (CPI) obtained from the resting CPO for predicting the prognosis of patients with New York Heart Association Functional Class II or III DCM.Methods and resultsFrom March 2000 to January 2020, a total of 623 cardiomyopathy patients were evaluated for haemodynamic parameters. Patients with secondary cardiomyopathy, ischaemic cardiomyopathy, valvular heart disease, and Class IV cardiomyopathy were excluded. A total of 176 DCM patients fulfilled the criteria for inclusion. Patients were 51.7 ± 12.5 years old (mean ± standard deviation) with a mean left ventricular ejection fraction of 32.1 ± 9.2%. The patients were divided into two groups by their median CPI (CPI < 0.52, low‐CPI; CPI ≥ 0.52, high‐CPI). No significant differences were found in the left ventricular end‐diastolic diameter, left ventricular ejection fraction, or pulmonary arterial wedge pressure between the groups. The probability of cardiac event‐free survival was significantly lower for low‐CPI than for high‐CPI groups by Kaplan–Meier analysis (P = 0.012), even with no significant difference between the high and low cardiac index groups (P = 0.069). Furthermore, Cox proportional hazards regression analysis revealed that, in addition to the CPI, the systolic and mean arterial pressure involved in CPI calculation were independent predictors of cardiac events. Indeed, among these factors, mean arterial pressure had the strongest prognostic ability.ConclusionsAlthough CPI is effective for stratifying DCM and predicting cardiac events in patients with Class II/III DCM, this prognostic value depends on mean arterial pressure.

Afterload-related cardiac performance identifies cardiac impairment and associates with outcome in patients with septic shock: a retrospective cohort study

BackgroundSeptic patients with cardiac impairment are with high mortality. Afterload-related cardiac performance (ACP), as a new tool for diagnosing septic cardiomyopathy (SCM), still needs to be evaluated for its impact on the prognosis for patients with septic shock.MethodsIn this retrospective study, 100 patients with septic shock undertaken PiCCO monitoring were included. The ability of ACP, cardiac index (CI), and cardiac power index (CPI) to discriminate between survivors and non-survivors was tested by comparing the area under the receiver operating characteristic curve (AUROC) analysis. Cox proportional hazards regression analyses were performed to assess the associations of ACP with day-28 mortality. Curve estimation was used to describe the relationship between the hazard ratio (HR) of death and ACP.ResultsACP had a strong linear correlation with CI and CPI (P < 0.001). ACP demonstrated significantly greater discrimination for day-28 mortality than CI before adjusted [AUROC 0.723 (95% CI 0.625 to 0.822) vs. 0.580 (95% CI 0.468 to 0.692), P = 0.007] and CPI after adjusted [AUROC 0.693 (95% CI 0.590 to 0.797) vs. 0.448 (0.332 to 0.565), P < 0.001]. Compared with ACP > 68.78%, HR for ACP ≤ 68.78% was 3.55 (1.93 to 6.54) (P < 0.001). When adjusted with age, APACHE-II score, Vasoactive Inotropic Score, Lactate, CRRT, day-1 volume, fibrinogen and total bilirubin as possible confounders, and decrease ACP are still associated with increasing day-28 mortality (P < 0.05). An exponential relationship was observed between ACP12h and HR of day-28 death.ConclusionsOur results suggested thatACP could improve mortality predictions when compared to CI and CPI. Decreased ACP was still an independent risk factor for increased day-28 mortality.

Cardiac Power Output and Cardiac Power Efficiency Show Prognostic Value in LVAD Patients

<h3>Purpose</h3> Hemocompatibility-related clinical adverse events (HRAE) are thought to be driven by the pump-patient interaction. We hypothesized that the hemodynamic variables cardiac power output (CPO) and cardiac power efficiency (CPE), which reflect underlying ventricular contribution, have prognostic value in patients with left ventricular assist devices (LVADs). <h3>Methods</h3> Prospectively collected hemodynamic data from patients with LVADs who had undergone invasive hemodynamic ramp study at our institution between 4/2014-7/2018 were analyzed. CPO [(mean arterial pressure x cardiac output)/451], cardiac power index (CPI) (CPO/body surface area), and CPE (CPI/ pulmonary capillary wedge pressure) were calculated. Patients were divided into groups of high and low CPO and CPE using ROC-derived cutoff values of 0.847W and 0.0552 WmmHg/m² respectively. Hemocompatibility scores (HCS) were also calculated for each patient based on their HRAE. Univariate and multivariate logistic regression analyses were performed to determine the association between CPO and CPE with primary endpoints of HRAE, HCS, heart failure readmissions, and mortality. <h3>Results</h3> 91 patients (average age 61 ± 11 years, 34% women, 40% Black, 38% ischemic cardiomyopathy) were included in the analysis. Low CPO was significantly associated with higher rates of HRAE, HR 2.02 (95% CI 1.12-3.66, p=0.02, Figure 1A). CPO was not significantly associated with mortality or heart failure readmission, HR 1.84 (95% CI 0.68-3.32, p=0.31) and HR 1.84 (95% CI 0.92-3.68, p=0.083), respectively. Low CPE was significantly associated with higher rates of HRAE, heart failure readmission (Figure 1B), and mortality (Figure 1C) when adjusted for LVAD type: HR 1.97 (95% CI 1.02-3.81, p=0.043), HR 3.11 (95% CI 1.28-7.58, p=0.012), and HR 3.41 (95% CI 1.18-9.88, p=0.024), respectively. <h3>Conclusion</h3> CPO and CPE demonstrate prognostic value in patients with LVADs, showing significant associations with HRAE, heart failure readmissions, and mortality.

Comparison of levosimendan, NO, and inhaled iloprost for pulmonary hypertension reversibility assessment in heart transplant candidates.

AimsAssessing reversibility of pulmonary vascular changes through vasoreactivity testing (VRT) optimizes end‐stage heart failure patient selection for heart transplant. All efforts should be made to unload the left ventricle and reduce pulmonary vascular resistance to effectively exclude irreversible pulmonary hypertension.Methods and resultsWe reviewed our centre's cardiac transplant registry database (2009–2017) for VRT and compared haemodynamic responses with 40 ppm inhaled NO (n = 14), 14–17 μg inhaled iloprost (n = 7), and 24 h 0.1 μg/kg/min intravenous levosimendan (n = 14). Response to levosimendan was assessed by repeat right heart catheterization within 72 h. Baseline clinical and haemodynamic features were similar between groups. VRT was well tolerated in all patients. All drugs effectively reduced pulmonary artery pressures and transpulmonary gradient while increasing cardiac index, although levosimendan had a greater impact on cardiac index increase (P = 0.036). Levosimendan was the only drug that reduced pulmonary artery wedge pressure (P = 0.004) and central venous pressures (P < 0.001) and increased both left and right ventricular stroke work indexes (P = 0.020 and P = 0.042, respectively) and cardiac power index (P < 0.001) compared with NO and iloprost. Right ventricular end‐diastolic pressures and central venous pressure were only decreased by levosimendan. The rate of positive responses (≥10 mmHg decrease or final mean pulmonary artery pressure ≤40 mmHg with increased/unaltered cardiac index) was lower with inhaled iloprost (14%) than with either levosimendan or NO (71% and 64%, respectively; P < 0.05).ConclusionsLevosimendan may be a safe and effective alternative for pulmonary hypertension reversibility assessment or a valuable pre‐test medical optimization tool in end‐stage heart failure patient assessment for heart transplantation offering extended haemodynamic benefits. Whether it increases the rate of positive responses or allows a better selection of candidates to heart transplantation remains to be established.

Non-Invasive Hemodynamic Monitoring in TAVI-Patients Reveals More Pronounced Early in-Hospital Circulatory Recovery for Low-Gradient Aortic Stenosis

Background: Little is known about differences and changes in hemodynamic in patients with Low-gradient (LG) and Non-Low-Gradient (NLG-) Aortic valve Stenosis (AS). Our current observation reveals such specific changes using the non-invasive NICaS® electrical bio-impedance monitoring system. Aim: Primary goal was to illustrate possible differences in subgroups of LG-AS and NLG-AS patients and to discriminate post-procedural adaptive mechanisms for the two subgroups. Methods and findings: In 99 unselected patients subjected to TAVI, NICaS® measurements were performed at baseline, 6 to 8 hours after TAVI and before discharge. 46 patients had a mean pressure gradient <40 mmHg corresponding to a LG-AS. Primary endpoint was defined as the change in cardiac index between the LG-AS and NLG-AS group at discharge. Cardiac index increased in both groups as compared with baseline [from 2.52 ± 0.75 to 3.45 ± 1.15 L/min/m2 (P=0.00014) in LG-AS and form 2.70 ± 0.97 to 3.08 ± 0.94 L/min/m2 (P=0.0198) in NLG-AS]. Increase in cardiac index was more pronounced in LG-AS with a difference between the groups of 0.52 ± 0.32 L/min/m2 (P=0.041) at discharge. Additionally, LG-AS patients showed higher increase in stroke volume index, cardiac power index, and Granov-Goor index and decrease of total peripheral resistance and total peripheral resistance index as secondary parameters. One limitation of our study is the observational design in a small cohort of patients. Therefore, larger trials are warranted to confirm our findings and to show whether there is prognostic relevance for long term outcomes of the different subgroups. Conclusion: NICaS® monitoring represents an accurate non-invasive bedsidetool to discriminate adaptive circulatory changes in subgroups of aortic stenosis patients subjected to TAVI. Hemodynamic parameters recovered more effectively in LG-AS patients after procedure. Whether a measurement-guided approach might be used for tailored peri-procedural management and could have long-term prognostic influence for AS subgroups remains to be elucidated.

P.851Differences in healthcare resource utilization across oral atypical antipsychotic treatments in patients with schizophrenia

The echocardiographic indices have not been validated in critically ill population. The authors investigated the correlation between some echocardiographic and hemodynamic parameters.Prospective, spontaneous, noninterventional observational study.Adult cardiothoracic intensive care unit, single center (Royal Brompton Hospital, London, United Kingdom).Consecutive adult patients admitted to the cardiothoracic intensive care unit for severe respiratory failure, primary cardiocirculatory failure, and post-aortic surgery.Clinical hemodynamic parameters (stroke volume [SV], cardiac output [CO], mean arterial pressure [MAP], and cardiac power index [CPI]) and echocardiographic indices of ventricular function (left ventricular total isovolumic time [t-IVT], mitral annular plane systolic excursion [MAPSE], and left ventricular fraction [LVEF]) were evaluated offline.The study comprised 117 patients (age 57.2 ± 19; 60.6% male). The t-IVT showed an inverse correlation with SV, CO, MAP, and CPI (r –67%; –38%; –45%; –51%, respectively). MAPSE exhibited a positive correlation with SV, CO, MAP, and CPI (r 43%; 44%; 34%; 31%, respectively). LVEF did not show any correlation. In the multivariate analysis the association between t-IVT and hemodynamics was confirmed for SV, CO, MAP, and CPI, with the highest partial correlation between t-IVT and MAP (R = –58%).MAPSE and t-IVT are 2 reproducible and reliable echocardiographic indices of systolic function and ventricular efficacy associated with hemodynamic variables in cardiothoracic critically ill patients, whereas LVEF did not show any correlation.

Hemodynamic Profiles of Cardiogenic Shock Depending on Their Etiology.

The pathophysiology of cardiogenic shock (CS) varies depending on its etiology, which may lead to different hemodynamic profiles (HP) and may help tailor therapy. We aimed to assess the HP of CS patients according to their etiologies of acute myocardial infarction (AMI) and acute decompensated chronic heart failure (ADCHF). We included patients admitted for CS secondary to ADCHF and AMI. HP were measured before the administration of any inotrope or vasopressor. Systemic Vascular Resistances index (SVRi), Cardiac Index (CI), and Cardiac Power Index (CPI) were measured by trans-thoracic Doppler echocardiography on admission. Among 37 CS patients, 28 had CS secondary to ADCHF or AMI and were prospectively included. The two groups were similar in terms of demographic data and shock severity criteria. AMI CS was associated with lower SVRi compared to CS related to ADCHF: 2010 (interquartile range (IQR): 1895–2277) vs. 2622 (2264–2993) dynes-s·cm−5·m−2 (p = 0.002). A trend toward a higher CI was observed: respectively 2.13 (1.88–2.18) vs. 1.78 (1.65–1.96) L·min−1·m−2 (p = 0.067) in AMICS compared to ADCHF. CS patients had different HP according to their etiologies. AMICS had lower SVR and tended to have a higher CI compared to ADHF CS. These differences should be taken into account for patient selection in future research.

Pronounced haemodynamic changes during and after robotic-assisted laparoscopic prostatectomy: a prospective observational study

ObjectivesRobotic-assisted laparoscopic prostatectomy (RALP) is typically conducted in steep Trendelenburg position (STP). This study investigated the influence of permanent 45° STP and capnoperitoneum on haemodynamic parameters during and after RALP.DesignProspective...