Hemodynamic Catheterization Research Articles

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

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

Use of Right Ventricular Free-Wall Strain in a Multivariable Estimate of Right Ventricular-Arterial Coupling in Pediatric Pulmonary Arterial Hypertension.

Right ventricular-arterial coupling (RVAC) describes the relationship between right ventricular contractility and pulmonary vascular afterload. Noninvasive surrogates for RVAC using echocardiographic estimates of right ventricular function, such as tricuspid annular plane systolic excursion (TAPSE), have been shown to correlate with invasively measured RVAC and predict clinical outcomes in pediatric pulmonary arterial hypertension. However, given the limitations of TAPSE at accurately estimating right ventricular function in children, we hypothesized that a multivariable estimate of RVAC using right ventricular free-wall longitudinal strain (RVFW-LS) may perform better than those utilizing TAPSE at predicting clinical outcomes. In all, 108 children from 2 institutions with pulmonary arterial hypertension underwent hemodynamic catheterization with simultaneous echocardiography. In a retrospective analysis, hybrid (echo and invasive) RVAC metrics included TAPSE/pulmonary vascular resistance (PVRi) and RVFW-LS/PVRi. Noninvasive echocardiographic metrics were TAPSE/echo-derived pulmonary artery systolic pressure (PASP) and RVFW-LS/PASP. RVFW-LS correlated with PVRi (r=0.315, P=0.01), though TAPSE did not (r=0.058, P=0.64). PVRi, PASP, and RVAC metrics declined in patients with worse World Health Organization Functional Class (n=108), while TAPSE and RVFW-LS did not. PVRi, PASP, RVFW-LS/PVRi, TAPSE/PVRi, and RVFW-LS/PASP predicted the outcome variable of transplant or death (area under the curve, 0.771 [P<0.001], 0.729 [P=0.004], 0.748 [P=0.002], 0.732 [P=0.009], and 0.714 [P=0.01], respectively), while TAPSE/PASP, RVFW-LS, and TAPSE did not (area under the curve, 0.671, 0.603, and 0.525, respectively). In patients without a history of repaired congenital heart disease (n=88), only RVFW-LS/PASP, PVRi, PASP, and RVFW-LS/PVRi predicted outcomes (area under the curve, 0.738 [P=0.002], 0.729 [P=0.01], 0.729 [P=0.01], and 0.729 [P=0.015], respectively). In the pediatric population, baseline PVRi and echo-estimated PASP were strongly associated with adverse clinical outcomes, but TAPSE and RVFW-LS were not. Estimates of RVAC utilizing RVFW-LS were superior to those utilizing TAPSE-however, only marginally additive to PASP and PVRi at predicting the adverse clinical outcome in patients without a history of repaired congenital heart disease.

Chronotropic Response to Exercise is Decreased in Patients With Congenital Heart Disease Compared to Cardiomyopathy Following Pediatric Heart Transplantation.

Two common indications for pediatric heart transplantation are congenital heart disease and cardiomyopathy. Prior studies suggest differences in chronotropy on cardiopulmonary exercise testing outcomes depending on indication for heart transplantation. We aimed to determine whether the number of pretransplant sternotomies is associated with differences in heart rate response during exercise testing. A retrospective analysis of our institutional pediatric heart transplant data between 2004 and 2022 was performed. Patients were categorized by indication for transplantation into a cardiomyopathy (CM) group if they had a congenital or acquired cardiomyopathy or a congenital heart disease (CHD) group including all other forms of congenital cardiac anatomic abnormalities. CHD patients (n = 40) differed from CM patients (n = 53) by mean number of sternotomies prior to transplant (2.4 ± 1.8 vs. 0.5 ± 0.9, p < 0.001). There were no significant differences in echocardiographic function or catheterization hemodynamics. In cardiopulmonary exercise testing performance, the congenital heart disease group had a significantly higher resting heart rate (91.8 ± 11.2 vs. 86.4 ± 10.2 bpm, p = 0.019), lower percent predicted age-predicted maximal heart rate achieved (78.3 ± 8.5% vs. 83.2 ± 11.4%, p = 0.032), and lower heart rate reserve (68.6 ± 19.8 vs. 84.4 ± 24.0 bpm, p = 0.001) despite a similar age and average time from transplantation. Regression analysis confirmed number of pretransplant sternotomies as a main predictor of heart rate metrics. There is greater chronotropic incompetence in patients who underwent transplantation due to congenital heart disease compared to cardiomyopathy. The groups differ significantly by number of sternotomies, potentially supporting the hypothesis that prior surgical disruption of cardiac innervation may cause decreased chronotropic response to exercise following transplantation.

Elevated pulmonary capillary wedge pressure, higher blood pressure, and lower cardiac index in infants with bronchopulmonary dysplasia

BackgroundLeft ventricular diastolic dysfunction indicated by elevated pulmonary capillary wedge pressure (ePCWP) may worsen cardiorespiratory status in bronchopulmonary dysplasia (BPD), but the scope of ePCWP by cardiac catheterization is not well described. MethodsThis single-center retrospective cohort study included infants with BPD without congenital heart disease, significant intracardiac shunts, or pulmonary vein stenosis who underwent cardiac catheterization from 2010 to 2021. ePCWP was defined as >10 mmHg. Quantitative measures of ventricular systolic and diastolic function were performed on existing echocardiograms. Patients with and without ePCWP were compared using the Chi-squared or Wilcoxon rank-sum tests. Associations between catheterization hemodynamics and echocardiographic parameters were assessed by simple linear regression. ResultsSeventy-one infants (93% Grade 2 or 3 BPD) met inclusion criteria, and 30 (42%) had ePCWP. Patients with ePCWP were older at catheterization (6.7 vs. 4.5 months, p < 0.001), more commonly underwent tracheostomy (66.7% vs. 29.3%, p = 0.003), and had higher mean systemic blood pressure [64.5 (56.0, 75.0) vs. 47.0 (43.0, 55.0) mm Hg, p < 0.001], higher systemic vascular resistance [11.9 (10.4, 15.6) vs. 8.7 (6.7, 11.2) WU*m2, p < 0.001), and lower cardiac index [3.9 (3.8, 4.9) vs. 4.7 (4.0, 6.3) L/min/m2, p = 0.03] at catheterization. Mean pulmonary artery pressure, pulmonary vascular resistance, and mortality were similar between the groups. Echocardiographic indices of left ventricular diastolic dysfunction did not correlate with PCWP. ConclusionsePCWP was common in infants with severe BPD who underwent cardiac catheterization in this cohort. The association between ePCWP and higher systemic blood pressure supports further study of afterload reduction in this population.

Hemodynamic features of chronic constrictive pericarditis and concomitant pleural disease: a case report

Chronic constrictive pericarditis (CP) is an uncommon form of heart failure in which a thickened and often calcified pericardium limits diastolic filling, ultimately reducing cardiac pump performance. Diagnosis can be challenging and may require integrating clinical data with meticulous echocardiographic assessment and cross-sectional cardiac imaging. If non-invasive testing is inconclusive, right heart catheterization remains the gold standard diagnostic test. Classic hemodynamic features of constrictive pericarditis may also be seen in restrictive cardiomyopathy and are often insufficient to establish the diagnosis. Therefore, the preferred hemodynamic criteria of CP include the finding of increased ventricular interdependence and intrathoracic and intracardiac pressure dissociation. However, the presence of concomitant pleural disease may interfere with the catheterization hemodynamics and decrease the accuracy of these criteria as we present in this case report.

Invasive Cardiac Hemodynamics in Apical Hypertrophic Cardiomyopathy.

Symptomatic limitations in apical hypertrophic cardiomyopathy may occur because of diastolic dysfunction with resultant elevated left ventricular filling pressures, cardiac output limitation to exercise, pulmonary hypertension (PH), valvular abnormalities, and/or arrhythmias. In this study, the authors aimed to describe invasive cardiac hemodynamics in a cohort of patients with apical hypertrophic cardiomyopathy. Patients presenting to a comprehensive hypertrophic cardiomyopathy center with apical hypertrophic cardiomyopathy were identified (n=542) and those who underwent invasive hemodynamic catheterization (n=47) were included in the study. Of these, 10 were excluded due to postmyectomy status or incomplete hemodynamic data. The mean age was 56±18 years, 16 (43%) were women, and ejection fraction was preserved (≥50%) in 32 (91%) patients. The most common indication for catheterization was dyspnea (48%) followed by suspected PH (13%), and preheart transplant evaluation (10%). Elevated left ventricular filling pressures at rest or exercise were present in 32 (86%) patients. PH was present in 30 (81%) patients, with 6 (20%) also having right-sided heart failure. Cardiac index was available in 25 (86%) patients with elevated resting filling pressures. Of these, 19 (76%) had reduced cardiac index and all 6 with right-sided heart failure had reduced cardiac index. Resting hemodynamics were normal in 8 of 37 (22%) patients, with 5 during exercise; 3 of 5 (60%) patients had exercise-induced elevation in left ventricular filling pressures. In patients with apical hypertrophic cardiomyopathy undergoing invasive hemodynamic cardiac catheterization, 86% had elevated left ventricular filling pressures at rest or with exercise, 81% had PH, and 20% of those with PH had concomitant right-sided heart failure.

Association of Cardiopulmonary Hemodynamics and Mortality in Veterans With Liver Cirrhosis: A Retrospective Cohort Study.

Portopulmonary hypertension (PoPH), associated with increased mortality, can limit treatment options for liver diseases. Data on the continuum of clinical risk related to cardiopulmonary hemodynamics in PoPH are lacking. As part of the United States national Veterans Affairs Clinical Assessment, Reporting, and Tracking database, we performed a retrospective cohort study of adults with cirrhosis undergoing right heart catheterization between October 1, 2017, and September 30, 2022. Pulmonary hypertension (mean pulmonary arterial pressure [mPAP] >20 mm Hg without PoPH) and PoPH (mPAP >20 mm Hg+pulmonary artery wedge pressure ≤15 mm Hg+pulmonary vascular resistance ≥3 WU) were defined by right heart catheterization hemodynamics. Multivariable Cox proportional hazards using natural splines for hemodynamic variables were used to evaluate the association between cardiopulmonary hemodynamics and mortality following right heart catheterization. A total of 4409 patients were included in the final analysis, predominantly men (96.3%), with a mean age of 68.5 years. Pulmonary hypertension and PoPH were observed in 71.6% and 10.2% of the cohort, respectively. Compared with a reference cardiac index of 2.5 L/min per m2, the hazard for mortality increased progressively with decreasing cardiac index, even after adjustment for mPAP and pulmonary vascular resistance. The minority of patients with PoPH (N=65, 14.5%) were prescribed pulmonary vasodilator therapy. These data suggest that pulmonary hypertension and PoPH are prevalent in veterans with chronic liver disease, but low use of targeted PoPH therapy persists. Cardiac function discriminated mortality risk across a wide range of mPAP and pulmonary vascular resistance values and may diagnose and clarify prognosis in this patient population.

“Fontan Conduit Stent-Angioplasty and Progression of Fontan-Associated Liver Disease”

Patients with Fontan circulation insidiously develop congestive hepatopathy related to chronically reduced cardiac output and central venous hypertension, also known as Fontan-associated liver disease (FALD). Fontan pathway obstruction is increasingly detected and may accelerate FALD. The impact of conduit stent angioplasty on FALD is unknown. Retrospective, single-center review of patients with Fontan circulation who underwent conduit stent angioplasty at cardiac catheterization over 5-year period. Demographics and cardiac histories were reviewed. Labs, liver ultrasound elastography, echocardiogram, hemodynamic and angiographic data at catheterization were recorded pre- and post-stent angioplasty. Primary outcome was change in hepatic function via MELD-XI scores and liver stiffness (kPa), with secondary outcomes of ventricular function, BNP, and repeat catheterization hemodynamics. 33 patients underwent Fontan conduit stent angioplasty, 19.3 ± 7.0 years from Fontan operation. Original conduit diameter was 19.1 ± 1.9 mm. Prior to angioplasty, conduit size was reduced to a cross-sectional area 132 (91, 173) mm2 and increased to 314 (255, 363) mm2 post-stent. Subjects’ baseline median MELD-XI of 11 (9, 12) increased to 12 (9, 13) at 19 ± 15.5 months post-angioplasty (n = 22, p = 0.053). There was no significant change in liver stiffness at 12.1 ± 8.9 months post-angioplasty (n = 15, p = 0.13). Median total bilirubin significantly increased (1.4 [0.9, 1.8]), from baseline 1.1 [0.7, 1.5], p = 0.04), as did median BNP (41 [0, 148] from baseline 34 [15, 79]; p = 0.02). There were no significant changes in ventricular function or repeat invasive hemodynamics (n = 8 subjects). Mid-term follow-up of Fontan subjects post-conduit stent angioplasty did not show improvements in non-invasive markers of FALD.

Abstract 14666: Prognostic Value of Artificial Intelligence-Enabled ECG for Increased Left Ventricular Filling Pressure

Introduction: Left ventricular diastolic function and filling pressure (FP) can be assessed by echocardiography and cardiac catheterization. Recently, a novel artificial intelligence (AI)-enabled ECG has proven to be effective in identifying increased FP determined by echocardiographic assessment of diastolic function. Aims: We aimed to compare a prognostic value of AI-ECG determination of FP compared to echocardiography and catheterization. Methods: This study included 4,213 patients who had a transthoracic echocardiogram and ECG within 30 days before hemodynamic cardiac catheterization. Increased FP was defined as pulmonary artery wedge pressure &gt;15 mmHg by catheterization and grade 2 or 3 diastolic dysfunction by echocardiography based on diastolic function guidelines. Increased FP by ECG was identified using previously developed AI-ECG. AI-ECG performance was evaluated using the area under the curve (AUC) of the receiver operating curve. We assessed the risk of all-cause mortality using Kaplan-Meier estimate and multivariable Cox proportional-hazards models. Results: AI-ECG had AUCs of 0.8 and 0.7 for predicting increased FP determined by echocardiography and catheterization, respectively. Death was observed in 2,776 (34%) patients over a median follow-up of 7.7 years (IQR 7.1, 8.3). Survival of patients with normal and increased FP by AI-ECG, Echocardiography, and catheterization are shown in Figure 1a. Concordant diagnoses of normal and increased FP by AI-ECG and catheterization or echocardiography had the highest and lowest survival rates, respectively. When FP by AI-ECG was discordant, survival was better predicted by AI-ECG compared to echocardiography and catheterization (Figure 1b). Conclusion: AI-ECG for FP has a potential to discriminate prognosis further compared to FP determined by echocardiography or catheterization.

Association between right heart catheterization hemodynamics and glycosylated hemoglobin levels in adults with heart failure with reduced ejection fraction.

Retrospective cohort study of adult patients with HFrEF and no prior diagnosis of diabetes who underwent RHC and had HbA1c levels measured 30 days before or after the RHC. This study excluded patients who had received blood transfusions within 90 days prior to HbA1c measurement and patients with known diabetes. Univariate and multivariate regression analyses adjusted for age, sex, and BMI were used to test for an association between RHC hemodynamic parameters and HbA1c levels. A total of 136 patients were included with a mean age of 55 ± 15 years and mean HbA1c was 5.99 ± 0.64%. Unadjusted univariate models showed that HbA1c is significantly associated with cardiac index (CI) by the Fick method and thermodilution, right atrial pressure (RAP), and mean pulmonary arterial pressure (MPAP). After multivariate analysis, for every one unit increase in HbA1c, there was a 0.19 and 0.26 L/min/m2 decrease in expected CI by thermodilution and by the Fick method (P = 0.03 and P < 0.01), respectively. For every one unit increase in HbA1c, there was a 2.39 mmHg increase in expected RAP (P = 0.01). Elevated HbA1c levels measured within 30 days before or after the index RHC in patients with a left ventricular ejection fraction <40% were associated with congestive hemodynamic parameters.

Hot septum and strain reversus: additional echocardiographic signs associated to constrictive pericarditis and pericardial involvement detected by CMR

Abstract Funding Acknowledgements Type of funding sources: None. Background A typical echocardiographic global longitudinal strain (GLS) pattern has been described in in patients with constrictive pericarditis (CP): a characteristic reduction in the regional longitudinal strain of the left ventricular free wall and relative sparing of the septal longitudinal strain value which creates the so-called "hot-septum (HSS)" at the bullseye plot, described by some authors as "strain reversus (SR)". Currently, there is no consensus about definition, prevalence and cut-off values of this GLS pattern. Purpose The aim of this study was to evaluate the prevalence of echocardiographic HSS or SR among pericardial diseases, their diagnostic role in constrictive pericarditis and their correlation with pericardial involvement assessed by cardiac magnetic resonance (CMR). Methods This is a retrospective, single centre cohort study. Consecutive patients admitted for pericardial diseases were enrolled if they underwent both to echocardiogram and CMR. Exams were reviewed and all signs of pericardial disease were systematically assessed, including echocardiographic GLS. Diagnosis of CP was confirmed at hemodynamic catheterization. HSS was visually assessed and defined as an area of septal sparing with reduced LS of the lateral wall at bullseye plot. SR was defined as the ratio between septal LS and lateral LS &amp;lt;1 and was assessed as anterolateral wall LS (ALWLS)/inferoseptal wall LS (ISWLS) and inferolateral wall LS (ILWLS)/anteroseptal wall LS(ASWLS) at basal, mid and apical level. Results After screening of 196 patients, a total of 53 were included. The study population was divided in CP (16 patients) and non-constrictive pericarditis (NCP, 37 patients). Left ventricular ejection fraction (LVEF) was similar between CP and NCP (59.5±10.0% vs 62±6.2%, p 0.190) while GLS was significantly reduced in CP (13.8±2.7% vs 17.6±3.8%). The prevalence of HSS was higher in CP than NCP (75% vs 10,8%, p &amp;lt;0.001) and it was strongly associated with the diagnosis of CP (OR: 3.20, CI: 1.67 – 4.74, p &amp;lt;0.001; c-statistic 0.82). SR was significantly lower in CP patients (0.68±0.43 vs 1.18±0.68, p 0.004). Logistic regression model showed an association between CP and a reduced basal ILWLS/ASWLS ratio (OR: 2.23, CI: 0.59 – 4.07; p 0.017; figure 1); the best cut-point for CP prediction was 0.96 (c-statistic: 0.71, sensitivity 0.54, specificity 0.88, figure 2). HSS was mainly associated to pericardial thickening (OR: 2,09, CI: 0.74–3.4; p 0.002) and less to pericardial LGE (OR: 1.78, CI: 0.16 – 3.39; p 0.031) and pericardial oedema (OR: 1.28, CI: 0.36 – 2.53; p 0.044). Conclusion Hot septum and strain reversus are echocardiographic signs associated to constrictive pericarditis and pericardial involvement detected by cardiac magnetic resonance. The use of strain echocardiography can help to distinguish between pericarditis with and without constriction.

Quantitative Measures of Right Ventricular Size and Function by Echocardiogram Correlate with Cardiac Catheterization Hemodynamics in Congenital Diaphragmatic Hernia

To evaluate associations between cardiac catheterization (cath) hemodynamics, quantitative measures of right ventricular (RV) function by echocardiogram, and survival in patients with congenital diaphragmatic hernia (CDH). This single-center retrospective cohort study enrolled patients with CDH who underwent index cath from 2003 to 2022. Tricuspid annular plane systolic excursion z score, RV fractional area change, RV free wall and global longitudinal strain, left ventricular (LV) eccentricity index, RV/LV ratio, and pulmonary artery acceleration time were measured from preprocedure echocardiograms. Associations between hemodynamic values, echocardiographic measures, and survival were evaluated by Spearman correlation and Wilcoxon rank sum test, respectively. Fifty-three patients (68% left-sided, 74% liver herniation, 57% extracorporeal membrane oxygenation, 93% survival) underwent cath (39 during index hospitalization, 14 later) including device closure of a patent ductus arteriosus in 5. Most patients (n=31, 58%) were on pulmonary hypertension treatment at cath, most commonly sildenafil (n=24, 45%) and/or intravenous treprostinil (n=16, 30%). Overall, hemodynamics were consistent with precapillary pulmonary hypertension. Pulmonary capillary wedge pressure was >15mm Hg in 2 patients (4%). Lower fractional area change and worse ventricular strain were associated with higher pulmonary artery pressure while higher LV eccentricity index and higher RV/LV ratio were associated with both higher pulmonary artery pressure and higher pulmonary vascular resistance. Hemodynamics did not differ based on survival status. Worse RV dilation and dysfunction by echocardiogram correlate with higher pulmonary artery pressure and pulmonary vascular resistance on cath in this CDH cohort. These measures may represent novel, noninvasive clinical trial targets in this population.

The role of cardiac catheterization in solving the issue of surgical treatment of symptomatic hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is an underdiagnosed genetic heart disease with a prevalence of 0.2–0.5 %. Although the prognosis of HCM is relatively favorable, the annual overall mortality is about 0.7 %. The most common complication of HCM is obstruction of the left ventricular outflow tract (LVOT). Careful diagnosis and timely identification of high-risk patients by confirming the presence and degree of obstruction of the left ventricular outflow tract may reduce morbidity and mortality due to timely and correctly selected treatment. One-third of patients with HCM have echocardiographically confirmed LVOT obstruction at rest, and another third may have LVOT obstruction with provocation. Our clinical case demonstrates the presence of a small group of patients with HCM, whose LVOT obstruction is underestimated by transthoracic echocardiography (TTE) neither at rest nor when using provocative tests (Valsalva tests, exercise), and its hemodynamic significance is revealed only with invasive hemodynamic catheterization of the heart. Below, we illustrate the utility of hemodynamic catheterization as an adjunctive tool to echocardiography to help establish the presence, magnitude, and location of obstruction in patients with HCM in the absence of such data on TTE. In case of a high degree of suspicion that LVOT obstruction is responsible for refractory symptoms, catheterization can establish the presence of a hemodynamically significant LVOT gradient and, accordingly, without deviating from clinical recommendations, to carry out optimal surgical treatment, in our case – septal alcohol ablation with subsequent elimination of symptoms and restoration of the patient’s endurance to physical exertion.

Abstract 14490: Relationship Between Right Heart Catheterization Hemodynamics and Glycosylated Hemoglobin Levels in Adults With Heart Failure With Reduced Ejection Fraction

Introduction: Elevated glycosylated hemoglobin (HbA1c) levels have been associated with adverse outcomes in heart failure (HF). However, the relationship between hemodynamics and glycemia has not been established. Hypothesis: Elevated HbA1c levels are associated with abnormal right heart catheterization (RHC) hemodynamic parameters in patients with HF with reduced ejection fraction and no prior diagnosis of diabetes mellitus (DM). Methods: We performed a retrospective study of adults patients (&gt;21 years) with a left ventricular ejection fraction &lt;40% who underwent a RHC between June 1, 2015 and June 1, 2021 and had HbA1c levels measured 30 days before or after the RHC. We excluded patients who had received blood transfusions within 90 days prior to HbA1c measurement and patients with known DM. We conducted univariate and multivariate regression analysis adjusted for age, gender, and body mass index (BMI) to test for an association between RHC hemodynamic parameters and HbA1c. Results: A total of 136 patients were included with a mean age of 55 ± 15 years; 75% were males. The mean BMI was 29.88 ± 8.08 kg/m2, and meanHbA1c was 5.99 ± 0.64%. Unadjusted univariate models showed that HbA1c is significantly associated with cardiac index (CI) by Fick and thermodilution, right atrial pressure (RAP), and mean pulmonary arterial pressure (mPAP). After multivariateanalysis, for every one unit increase in HbA1c, there was a 0.19 and 0.26 L/min/m2decrease in expected CI by thermodilution and by Fick, respectively ( P = 0.03 and P &lt;0.01). For every one unit increase in HbA1c, there was a 2.39 mmHg increase in expected RAP ( P = 0.01). There was no association between MPAP and HbA1c after adjustment (Table 1). Conclusions: Changes in HbA1c levels measured within 30 days before or after the index RHC in patients with a left ventricular ejection fraction &lt;40% were associated withchanges in hemodynamic parameters that correlate with congestive hemodynamics(reduced CI and elevated RAP).

Abstract 11899: Biomarker Profile Associated With Provider Assessed Frailty in Advanced Heart Failure Patients Undergoing Lvad: An Intermacs Analysis

Introduction: Frailty is a state of increased vulnerability and decline in multi-organ physiologic reserve. Among patients considered for left ventricular assist device (LVAD), frailty is associated with increased morbidity and mortality. However, a biomarker profile that is associated with the presence of frailty and reflects multiorgan dysfunction is unknown. Methods: We selected all patients from Interagency Registry for Mechanical Assisted Circulatory Support (INTERMACS) national database who underwent an LVAD between years 2006-2017 and had available data on provider-assessed frailty (n=21,977; 4,659 females). Then, using several pre-implant variables (n=32) such as vitals, right heart catheterization hemodynamics, echocardiographic and serum biomarkers we created a stepwise multivariable logistic regression model that allowed every variable to enter or leave the model at a significance of 0.05 to examine the odds of provider-assessed frailty prior to LVAD. Results Frailty was present in 968 patients (238 females; mean age 63.1yrs). Frail patients were more likely to be older, had higher levels of blood urea nitrogen (BUN), alanine transaminase, total bilirubin, lactate dehydrogenase, B-type natriuretic peptide (BNP), N-terminal proBNP, international normalized ratio (INR) and white blood cell counts but lower albumin, prealbumin, hemoglobin and platelet counts (p &lt;0.05 for all comparisons). In stepwise logistic regression model, advancing age, higher bilirubin, BUN, INR and a lower albumin, hemoglobin, creatinine and platelets levels were the remaining variables associated with higher odds of frailty (see table). Conclusion In our study, 7 commonly obtained serum biomarkers and age were associated with presence of frailty. Future studies will examine if treatment that ensures modifying these biomarkers can reduce the risk of post-LVAD morbidity and mortality. Table

Morphology and rheology of pulmonary arteries: A relationship with right ventricular function in patients with pulmonary arterial hypertension associated with atrial septal defect?

Qualitative and quantitative hemodynamic flow indexes have been related to right ventricular (RV) function in pulmonary arterial hypertension (PAH), using 4-dimensional flow cardiac magnetic resonance (4D-flow CMR). Little is known in PAH congenital heart disease population characterized by intracardiac shunting. A prospective bi-centric study was conducted in two French referral centers for PAH to assess RV function and anatomical and rheological parameters in the proximal pulmonary arteries (PA) in PAH associated with atrial septal defect (ASD). A multiparametric evaluation, including a complete hemodynamic catheterization and a 4D flow CMR, was performed in 24 patients (50 years [41–55]) with PAH-ASD, of whom 16 (66%) had a persistent left-to-right shunt. Patients were divided into two groups according to the presence ( n = 14) or absence ( n = 10) of RV dysfunction, defined as RV ejection fraction (RVEF) < 45%. Tricuspid annular excursion (TAPSE) was 21 mm [18–26] and RVEF was 37% [27–52]. Mean pulmonary artery pressure was 50 mmHg [39–59] and pulmonary vascular resistance was 8 Wood units [6–8] and 42% were in WHO/NYHA function class III or VI. RV function was correlated with RV-PA coupling (correlation coefficient = −0.91, P <0.0001), PA compliance (correlation coefficient = −0.40, P = 0.04), and PA stiffness index (correlation coefficient = 0.43, P = 0.03). Helicity and vorticity were correlated with PA area, but there was no significant relationship with RV function. Intrinsic parameters were more alterated in the group without RV dysfunction, characterized by a persistent left to right shunt, with a decreased tight PA compliance ( P = 0.01), decreased distensibility ( P = 0.01), decreased pulsatility index ( P = 0.06), increased β-stiffness index ( P = 0.01), and increased elastance ( P = 0.01). In patients with left-to-right shunt, barometric and volumetric overload aggravates proximal PA remodelling with increased PA dilatation and stiffness. Paradoxically, in patients with RV dysfunction, normally associated with end-stage of PAH and right-to-left shunt, this remodelling is significantly less considerable.

Standard volume infusion unmasked diastolic dysfunction in pediatric heart transplant recipients during surveillance cardiac catheterization, but without echocardiographic correlates.

Adult experience evaluating left ventricular diastolic function (LVDFx) includes volume administration during catheterization while obtaining pulmonary capillary wedge pressures (PCWP) or left ventricular end diastolic pressures (LVEDP). Catheterization is inherently challenging in pediatric patients, making echocardiographic assessment ideal. Pediatric echocardiographic studies predicting LVDFx have variable hemodynamic and hydration conditions and have produced inconsistent results. We evaluated the association between simultaneous echocardiographic and catheterization assessment of LVDFx, using a fluid bolus for optimal loading conditions. Prospective cohort study of pediatric heart transplant recipients receiving echocardiogram simultaneous with routine cardiac catheterization. Mitral valve inflow velocities, septal and lateral wall tissue Doppler indices, and PCWP and/or LVEDP were obtained and repeated following a 10ml/kg bolus. Echocardiographic parameters were evaluated for an association with changes in PCWP or LVEDP following the bolus. Abnormal LVDFx was defined as PCWP or LVEDP ≥12 mm Hg. Twenty-nine patients underwent catheterization. Median pre-bolus PCWP and LVEDP were 11.0 mm Hg and 10.0 mm Hg, respectively. After bolus, median PCWP and LVEDP increased to 14.0 mm Hg (p< .001) and 13 mm Hg (p< .001), respectively. Of 21 patients with normal pre-bolus catheterization hemodynamics, 14 (66.7%) increased to abnormal following fluid bolus. Using area under an ROC, no echocardiographic parameter of LVDFx, or their ratios, were associated with predetermined abnormal LVEDP and/or PCWP. After bolus, our cohort demonstrated significant increases in LVEDP and/or PCWP, unmasking diastolic dysfunction. Fluid challenges should be considered in pediatric patients undergoing cardiac catheterization with suspected diastolic dysfunction. Echocardiographic measurements were unable to discriminate between normal and abnormal LVEDP and/or PCWP.

Interpretation of Hemodynamic Catheterization Data by Years of Experience: An International Survey of Cardiologists

<h3>Purpose</h3> Right heart catheterization (RHC) is a core skill of cardiologists, however, data interpretation may be influenced by prior clinician experience. We sought to assess parameters felt to offer prognostic information during RHC between early- and late-career cardiologists. <h3>Methods</h3> A survey assessing the utilization and interpretation of RHC data was distributed to two large international professional societies. Early career (EC and late career (LC) groups were demarcated at 10 years of practice. We sought to assess differences in practice patterns and interpretation of RHC data for prognosis and management. <h3>Results</h3> A total of 261 responses were received, with similar numbers of EC (142, 54%) and LC (119, 46%). EC cardiologists were more likely than LC to be heart failure specialists (64% vs 39%, p<.001) with similar practice settings. Less EC than LC respondents considered low cardiac index to be the most important factor for prognosis (43% vs 53%, p=.005), whereas EC more often considered elevated filling pressures as most prognostic (Table). More EC than LC utilize cardiac power output for prognosis (67% vs 50%, p<.001). With regards to the medical management of a low output state patients with elevated systemic resistance, 59% of EC respondents favored nitroprusside compared to 44% of LC respondents who favored milrinone (p<.001). EC and LC both agreed that inotrope therapy should be started on the floor/ICU (50% vs 45%, p=.745). <h3>Conclusion</h3> Our survey data demonstrates a difference between EC and LC cardiologists in both the utilization of RHC parameters for prognosis as well as preferred initial approach to managing patients with low cardiac output. Further research comparing long term prognostic outcomes of RHC parameters may provide insight into practice variation and should be further explored.

The importance of right heart function in heart failure with preserved ejection fraction

Abstract Funding Acknowledgements Type of funding sources: None. Background Heart failure (HF) is a complex clinical syndrome that is a frequent cause of morbidity and mortality. Although half of patients with HF have a preserved ejection fraction (HFpEF), the majority of studies have examined the prognostic impact of left heart parameters instead of the right. We thus evaluated associations of right heart hemodynamics and echocardiographic measures with outcomes in HFpEF subjects. Purpose To perform long-term mortality analysis of patients with decompensated HFpEF using strain imaging and right heart catheterization hemodynamics. Methods This was a retrospective cross-sectional study which included patients hospitalized for acute heart failure exacerbation as the primary admitting diagnosis based on clinical and laboratory parameters as determined by the primary medical team. Patients included were only those with HFpEF and with available echocardiographic and right heart catheterization (RHC) hemodynamic data done during the index admission. 2D strain analysis software was used to automatically calculate right ventricular free wall strain (RVFWS), fractional area change (FAC), and left ventricular global longitudinal strain (LVGLS). Demographic and clinical parameters were obtained including RHC hemodynamics. The outcome of interest was long term 6-year all-cause mortality. Right and left ventricular echocardiographic strain and hemodynamic parameters were compared between patients with mortality and those who survived using independent T tests and non-parametric methods as appropriate. Multivariable logistic regression was used to identify echocardiographic and hemodynamic factors independently associated with all-cause mortality. Results From a total of 100 patients, 47% were Caucasian and 53% were female. The mean age was 67.4 ± 14.3. There was an 18% long term all cause mortality rate. Of the right sided echocardiographic strain parameters, only RVFWS was statistically significantly lower among those who died (12.0 vs 15.7 p = 0.038). Meanwhile, 4 chamber LVGLS was significantly lower (13.8 vs 15.1 p = 0.016) and mean right atrial (RA) pressure was higher (13.6 vs 10.7 p = 0.076) although this did not reach statistical significance. Looking at echocardiographic strain and hemodynamic parameters as predictors of mortality, after adjusting for age, gender and race accounting for the major differences in these parameters between the survival groups, only RVFWS (OR 1.90, 95% CI 1.12-3.28; p = 0.02) and RA pressure (OR 1.85, 95% CI 1.12-3.28; p = 0.016) remained independently associated with long term all-cause mortality with C statistic of 0.751 for the overall predictive model. Conclusion Among patients with HFpEF admitted for acute heart failure exacerbation, baseline RVFWS and RA hemodynamic pressure measurements were independently associated with long term all-cause mortality. This suggests that right heart diagnostic parameters may hold more prognostic utility in HFpEF. Abstract Figure. Abstract Figure.

Relation Between Pulmonary Artery Pressures Measured Intraoperatively and at One-Year Catheterization After Unifocalization and Repair of Tetralogy With Major Aortopulmonary Collateral Arteries

To assess the relationships between pulmonary artery (PA) pressure and the PA:aortic systolic pressure ratio measured intraoperatively and at surveillance catheterization in patients achieving complete unifocalization and repair for tetralogy of Fallot with major aortopulmonary collateral arteries (TOF/MAPCAs). This was a single-center retrospective cohort analysis of all patients who underwent complete repair of TOF/MAPCAs from 2002-2019 and received a postoperative surveillance catheterization at our center 6-24 months after surgery. Associations between intraoperative and catheter hemodynamic data were analyzed. 163 patients were included. Median systolic PA pressure was 30 (quartiles 26, 35) and 35 (28, 42) mmHg intraoperatively and at catherization respectively; systolic aortic pressure 90 (86, 100) and 84 (76, 92); and PA:aortic pressure ratio was 0.33 (0.28, 0.40) and 0.41 (0.34, 0.49). Moderate correlation was found between the intraoperative and catheter-based hemodynamics, with the majority of systolic PA pressures within 10mmHg and PA:Ao systolic ratios within 0.1. Changes in the ratio were influenced to a similar degree by differences in PA and aortic pressures. Surgical and/or catheter reinterventions were more common in patients with both higher intraoperative PA systolic pressure and PA:aortic systolic ratios and in those with greater discrepancy between intraoperative and catheterization values. PA systolic pressure and the PA:aortic systolic pressure ratio measured immediately after repair remain useful metrics for assessing the initial operative PA reconstruction, and as indicators of longer term hemodynamics. Initially elevated and subsequently discrepant PA systolic pressure and PA:aortic systolic pressure ratios were associated with higher rates of reintervention. (Figure 7).