Diagnostic Right Heart Catheterization Research Articles

Integrating Right Ventricular Pressure Waveform Analysis With Two-Point Volume Measurement for Quantification of Systolic and Diastolic Function: Experimental Validation and Clinical Application

To define in an experimental model the variance, accuracy, precision, and concordance of single-beat measures of right ventricular (RV) contractility and diastolic capacitance relative to conventional reference standards, and apply the methods to a clinical data set. A retrospective, observational analysis of recorded pressure waveforms and RV volume measurements. At a university laboratory. Archived data from previous studies of anesthetized swine and awake patients undergoing clinically-indicated right-heart catheterization. Recording of RV pressure with simultaneous measurement of RV volume by conductance (swine) or 3-dimensional (3D) echocardiography (humans) during changes in contractility and/or loading conditions. Using experimental data, single-beat measures of RV contractility quantified as end-systolic elastance, and diastolic capacitance quantified as the predicted volume at an end-diastolic pressure of 15 mmHg (V15), were compared to multi-beat, preload- variant, reference standards using correlation, Bland-Altman analysis, and 4-quadrant concordance testing. This analysis indicated that the methods were not directly interchangeable with reference standards, but were sufficiently robust to suggest potential clinical utility. Clinical application supported this potential by demonstrating enhanced assessment of the response to inhaled nitric oxide in patients undergoing diagnostic right-heart catheterization. Study results supported the possibility of integrating automated RV pressure analysis with RV volume measured by 3D echocardiography to create a comprehensive assessment of RV systolic and diastolic function at the bedside.

Risks of Right Heart Catheterization and Right Ventricular Biopsy: A 12-year, Single-Center Experience

ObjectiveTo study the incidence of complications when undergoing right heart catheterization (RHC) and right ventricular biopsy (RVB). MethodsComplications following RHC and RVB are not well reported. We studied the incidence of death, myocardial infarction, stroke, unplanned bypass, pneumothorax, hemorrhage, hemoptysis, heart valve repair/replacement, pulmonary artery perforation, ventricular arrhythmias, pericardiocentesis, complete heart block, and deep vein thrombosis (primary endpoint) following these procedures. We also adjudicated the severity of tricuspid regurgitation and causes of in-hospital death following RHC. Diagnostic RHC procedures, RVB, multiple right heart procedures alone or combined with left heart catheterization, and complications from January 1, 2002, through December 31, 2013, were identified using the clinical scheduling system and electronic records at Mayo Clinic, Rochester, Minnesota. International Classification of Diseases, Ninth Revision billing codes were used. Registration was queried to identify all-cause mortality. All clinical events and echocardiograms for worsening tricuspid regurgitation were reviewed and adjudicated. ResultsA total of 17,696 procedures were identified. Procedures were categorized into those undergoing RHC (n=5556), RVB (n=3846), multiple right heart catheterization (n=776), and combined right and left heart catheterization procedures (n=7518). Primary endpoint was seen in 21.6 and 20.8 of 10,000 procedures for RHC and RVB, respectively. There were 190 (1.1%) deaths during hospital admission and none was related to the procedure. ConclusionComplications following diagnostic RHC and RVB are seen in 21.6 and 20.8 procedures, respectively, of 10,000 procedures and all deaths were secondary to acute illness.

Right Heart Catheterization in Pediatric Pulmonary Arterial Hypertension: Insights and Outcome from a Large Tertiary Center.

Aim: To define the clinical characteristics, hemodynamics, and adverse events for pediatric patients with pulmonary arterial hypertension (PAH) undergoing right heart catheterization (RHC). Methods: The large referral single center data of 591 diagnostic RHC procedures performed between 2005 and 2020 on pediatric PAH patients was retrospectively collected and analyzed. Results: A total of 591 RHC procedures performed on 469 patients with congenital heart disease (CHD)-PAH (median age 8.8 years, 7.9% New York Heart Association (NYHA) class > II, 1.5% with syncope) and 122 patients with idiopathic PAH (median age of 9.0 years, 27.0% NYHA class > II, 27.0% with syncope) were included. Of those, 373 (63.1%) procedures were performed under general anesthesia. Eighteen patients (18/591, 3.0%) suffered adverse events (mainly pulmonary hypertensive crisis, PHC, n = 17) during the RHC procedure, including 14 idiopathic pulmonary arterial hypertension (IPAH) patients and 4 CHD-PAH patients, and one IPAH patient died in hospital 63 hours after RHC. The risk of developing PHC was significantly increased in patients with IPAH (OR = 14.02, 95%CI: 4.49–43.85, p < 0.001), atrial blood gas pH < 7.35 (OR = 12.504, 95%CI: 3.545–44.102, p < 0.001) and RAP > 14 mmHg (OR = 10.636, 95%CI: 3.668–30.847, p < 0.001). Conclusions: RHC is generally a low-risk procedure in pediatric patients with PAH. However, PHC occur in approximately 3% of patients. Therefore, RHC should be performed in a large, experienced referral pediatric cardiology center, especially in pediatric patients with IPAH requiring general anesthesia.

Pulmonary hypertensive crisis in children with pulmonary arterial hypertension undergoing cardiac catheterization.

Pediatric patients with pulmonary arterial hypertension (PAH) are considered to be at risk for pulmonary hypertensive crisis (PHC) or even death during right heart catheterization (RHC). This retrospective study was designed to identify the risks and clinical characteristics associated with PHC in pediatric PAH patients. We included 163 consecutive procedures from 147 pediatric patients diagnosed with PAH who underwent diagnostic RHC in Beijing Anzhen Hospital between January 2007 and December 2020. The average patient age was 9.0 ± 4.7 years and 84 (51.5%) were females. Before RHC, over 20% of patients were in New York Heart Association (NYHA) class III–IV. Sedation or general intravenous anesthesia was used in 103 procedures (63.2%), with spontaneous breathing in 93.2%. PHC occurred in 19 patients (11.7%), 5 (3.1%) required cardiac compression, and 1 died (0.6%). Compared to patients without PHC, those who experienced PHC were more likely to be in NYHA class III–IV (p = 0.012) before RHC, require sedation (p = 0.011), had echocardiographic indices of higher peak tricuspid regurgitation velocity (p = 0.018), and right ventricle (RV) to left ventricle (LV) ratio (p < 0.001). Multivariate logistic regression for PHC identified the need for sedation and a higher RV/LV ratio as independent predictors. In conclusion, the risk of RHC remains significant in children with PAH, particularly in those with severe RV dilation who require sedation during cardiac catheterization. Comprehensive evaluation, close monitoring, and appropriate treatment before and during the procedure are essential for reducing mortality.

Cardiac Catheterization and Hemodynamics in a Multicenter Cohort of Children with Pulmonary Hypertension.

Rationale: Hemodynamic assessments direct care among children with pulmonary hypertension, yet the use of cardiac catheterization is highly variable, which could impact patient care and research. Objectives: We analyzed hemodynamic findings from right heart catheterization (RHC) and left heart catheterization and acute vasodilator testing (AVT) and the safety of catheterization in children with World Symposium on Pulmonary Hypertension (WSPH) group 1 and 3 subtypes in a large multicenter North American cohort. Methods: Of 1,475 children enrolled in the Pediatric Pulmonary Hypertension Network Registry (2014-2020), there were 1,383 group 1 and 3 patients, of whom 671 (48.5%) underwent RHC at diagnosis and were included for analysis. Results: Compared with those without diagnostic RHC, these children were older, less likely to be an infant or preterm, more often female, treated with targeted pulmonary hypertension medications at diagnosis, and had advanced World Health Organization functional class. Catheterization was performed without a difference in complication rates between WSPH groups. Pulmonary capillary wedge pressure was well correlated with left ventricular end-diastolic pressure and left atrial pressures. Results of AVT using three different methods were comparable; positive AVT results were observed in 8.0-11.8% of subjects, did not differ between WSPH groups 1 and 3, and were not associated with freedom from the composite endpoint of lung transplantation or death during follow-up. Conclusions: In a large pediatric pulmonary hypertension cohort, diagnostic RHC with or without left heart catheterization in WSPH group 1 and 3 patients was performed safely at experienced pediatric pulmonary hypertension centers. Hemodynamic differences were noted between group 1 and 3 subjects. Higher mean pulmonary arterial pressure and mean pulmonary arterial pressure/mean systemic arterial pressure ratio were associated with a higher risk of death/transplantation. Findings suggest overall safety and potential value of RHC as a standard diagnostic approach to guide pulmonary hypertension management in children.

Abstract 12480: Establishing Safety and Risk Profile of Right Heart Catheterization

Introduction: We aim to elucidate the incidence of major complications related to right heart catheterization (RHC) and ascertain if there are unique risks with right ventricular biopsy. Methods: Diagnostic RHC procedures from 1/1/2002 through 12/31/2013 were identified using the clinical scheduling system at Mayo Clinic, Rochester. Major complications were identified through electronic records using International Classification of Diseases, Ninth Revision billing codes. All events were recorded and adjudicated. Analysis was performed on four separate patient categories (RHC/RV angiography alone, RV biopsy alone, multiple RHC procedures, and concurrent RHC/LHC procedures) and the overall group. Primary outcomes are described in Table 1. Outcomes were measured within 7 days of the procedure, except for death (same day events) and tricuspid regurgitation (variable time endpoints). Results: There were 17,696 RHC procedures (5,556 RHC/RV angiography, 3,846 RV biopsy alone, 776 multiple RHC procedures, and 7,518 combined RHC/LHC). Patient population had a mean age of 56.5 years (15.3) and was predominantly male (58.5%). Same-day death related to RHC procedure occurred in 1 procedure or 0.6 of 10,000 RHCs. There was no significant difference in the risk of complications across RHC procedure categories except for worsening tricuspid regurgitation, which was significantly (p&lt;0.001) more prevalent with RV biopsy (392 cases, 6.0%) than without (136 cases, 1.2%). Conclusion: The incidence of major complications related to right heart catheterization is rare. Worsening tricuspid regurgitation is the most frequently identified change with a significantly higher prevalence with biopsies.

Nitric Oxide Stroke Volume Index as a New Hemodynamic Prognostic Parameter for Patients with Pulmonary Arterial Hypertension.

The aim of the study was to determine the prognostic value of hemodynamic parameters measured during initial diagnostic right heart catheterization (RHC) in standard conditions and using a nitric oxide reversibility test. A retrospective observational study of 62 patients with pulmonary arterial hypertension (PAH) was performed. Clinical, biochemical, echocardiographic, and hemodynamic data obtained at the time of the PAH diagnosis were precisely analyzed. Patients were followed for five years. Death or lung transplantation was considered as a primary endpoint. The mean follow-up period was 1090 ± 703 days and the median age was 46.84 years. In the studied group, 25 patients survived, 36 patients died, and one underwent a lung transplantation. From all the examined parameters, only stroke volume index during reversibility test with iNO (SVI(NO test)) (HR = 0.910; 95% confidence interval 0.878–0.944; p < 0.001) and initial arterial oxygen saturation (SaO2) (HR = 0.910; 95% confidence interval 0.843–0.982; p = 0.015) have been established as independent predictors of death or lung transplantation in the five-year follow–up. An SVI(NO test) value above 39.86 mL/m2 was associated with 100% five-year survival rate (AUC = 0.956; 95% confidence interval 0.899–1.000; p < 0.001; specificity/sensitivity: 100/84%). The results of the analysis suggest that the SVI(NO test) measured during the initial diagnostic RHC could be a very valuable prognostic factor in the PAH patients.

P167 Pulmonary hypertension in patients with systemic sclerosis: an audit of screening practices, incidence and cost over 10 years

Abstract Background Patients with systemic sclerosis (SSc) are at risk of developing pulmonary arterial hypertension (PAH), a subtype of pulmonary hypertension (PH) which is not due to left-heart disease, chronic hypoxia or pulmonary arterial thrombus. The European Society of Cardiology recommends annual screening of patients with SSc due to the insidious presentation of PAH, poor outcomes, and the availability of effective treatments. Transthoracic echocardiography is the standard screening investigation, but NT pro-BNP, a biochemical marker of ventricular stretch, may be a cost-effective initial test with echocardiography reserved for patients with new or worsening symptoms or increasing NT pro-BNP. Our centre introduced NT pro-BNP as an adjunct to echocardiography in 2014. Methods We audited our SSc-PAH screening programme from 2009-2018 against the standard that every SSc patient should be screened annually with echocardiography or NT pro-BNP. Patients seen by the regional PH service prior to the first rheumatology clinic were excluded. We used our centre’s database of SSc patients and electronic patient records to determine if a patient had undergone PH screening. We calculated cost estimates from our hospital’s biochemistry and echocardiography departments. Results From 2009 to 2018, the number of SSc patients requiring annual screening rose from 81 to 215. In 2009, 65% of patients were screened - all with echocardiography. In 2018, 88% of patients were screened - 25% had an echocardiogram and 83% had a NT pro-BNP. 63% of patients were screened only through NT pro-BNP. Across the 1476 patient-years studied, only 6 new cases of PH were identified. PH was secondary to ILD in two cases, and true PAH in three cases (one patient refused diagnostic right-heart catheterisation). All three PAH diagnoses came from echocardiograms requested for worsening dyspnoea, so are not attributable to the screening programme. On 31 December 2018, 55% of these patients were taking phosphodiesterase 5 inhibitors (PDE-5i) for severe Raynaud’s phenomenon (50% on sildenafil and 5% on tadalafil). 4% of patients were prescribed bosentan and 3% of patients were prescribed dual therapy with a PDE5i and bosentan. This may explain our centre’s low incidence of PAH. The annual cost of screening per patient has dropped from £82 in 2014 to £59 in 2018, and the total annual cost has plateaued since 2014, despite rising patient numbers and improved screening rates. Conclusion Since introducing NT pro-BNP alongside echocardiography as a screening tool for PAH in SSc patients, we spend less on our screening programme per patient and achieve higher screening rates. However, in 10 years, our screening programme has not detected any asymptomatic cases of PAH, raising questions about the necessity of screening asymptomatic SSc patients. Widespread PDE-5i use may contribute to the low incidence of PAH in our cohort. Disclosures L. Spray None. J. Vila None. B. Griffiths None.

Effect of Trans-catheter closure of the Ductus Arteriosus in Preterm Infants

Purpose: Patent ductus arteriosus (PDA) is a common clinical condition in preterm infants with hemodynamic consequences of systemic hypo-perfusion and later pulmonary hypertension. Management of pulmonary hypertension in the presence of a large PDA with left to right shunting is challenging. We sought to assess the effect of the PDA and its trans-catheter device closure on the pulmonary vascular bed in preterm infants. Methods: A review of 100 consecutive children who underwent trans-catheter device closure of PDA was performed. Preterm infants who had a diagnostic right heart catheterization …

Feasibility of Exercise Hemodynamic Evaluation in the Clinical Cardiac Catheterization Laboratory

Purpose Provocative testing during right heart catheterization (RHC) is gaining increasing acceptance to evaluate cardiac and pulmonary vascular contributions to dyspnea . For this purpose, the use of cycle ergometry at measured work rates has been recommended as a physiologically relevant and sensitive stressor. Methods The program was initiated in 07/2016. After standard diagnostic RHC, patients were transferred to a cycle ergometer and hemodynamics were assessed in up to 2 exercise stages if tolerated. Hemodynamic diagnoses at rest were assigned based on guideline recommendations and exercise hemodynamic diagnoses were assigned based on sex-specific reference ranges developed by our laboratory. Results Between 07/2016 and 09/2018, 77 patients (60 ± 14 years, 48% female) were referred. Resting hemodynamic assessment was performed in all patients and the exercise protocol was initiated in 74. Figure 1 illustrates the hemodynamic classification at rest and after the exercise protocol. At rest, 47 patients (61%) had normal hemodynamics; after the exercise protocol, the number of patients with normal hemodynamics declined to 26 (34%). Exercise induced pulmonary hypertension related to left heart disease (PH-LHD) was disclosed in 18 (38%) of 47 patients with normal resting hemodynamics. One year follow-up (FUP) assessment has been completed in 19 patients and death or hospitalization was observed in 4 (21%) patients that had 1 year FUP assessment completed and all these adverse outcomes occurred amongst patients with abnormal hemodynamic findings during exercise. Conclusion In this prospective series, a submaximal, cycle ergometry protocol performed during RHC was possible in 96% of the cohort referred. The intervention revealed hemodynamic abnormalities in 45% of patients with normal resting hemodynamics. Amongst patients with normal hemodynamic findings during exercise that had 1 year FUP assessment completed, none had an adverse composite outcome of death or hospitalization.

ABNORMAL RIGHT VENTRICULAR - PULMONARY VASCULAR COUPLING AT REST AND EXERCISE IN PATIENTS WITH DYSPNEA OF UNKNOWN ORIGIN AND/OR SUSPECTED PULMONARY HYPERTENSION

Exercise during right heart catheterization (RHC) is employed in select centers to demonstrate the extent to which pulmonary artery (PA) hemodynamics and/or left heart filling pressures may be abnormal. Both lesions may increase the effective PA elastance (Ea), which is a measure of afterload to the right ventricle (RV) as it ejects during systole. RV contractile performance can be expressed as the RV end-systolic elastance (Ees), and the ratio of Ees:Ea reflects ventricular-vascular coupling. We examined the Ees:Ea ratio at rest and during exercise in patients with dyspnea and/or suspected pulmonary hypertension, grouped by their exercise hemodynamic classification. Patients referred for an exercise hemodynamic study underwent a submaximal cycle-ergometry challenge during diagnostic RHC. RV and PA pressures were simultaneously transduced, and thermodilution cardiac output was determined. The RV and PA pressure waveforms were analyzed offline to determine Ees using the single-beat method and calculate Ea as [mean PA pressure/stroke volume]. Exercise hemodynamic classifications have been defined a priori by our laboratory from previous prospective studies of exercise hemodynamics in healthy volunteers. Exercise hemodynamic classifications include: 1) left heart disease (Ex-LHD) based on an increased slope of the PA wedge pressure/cardiac output relationship; 2) pulmonary vascular disease (Ex-PVD) based on an elevated end-diastolic pulmonary pressure gradient; 3) combined (Ex-CPH) if both criteria are met; 4) hemodynamically Ex-Normal if neither criteria are met. Preliminary data and descriptive statistics were available for 42 consecutive patients (17M/25F; Age = 58±15); exercise hemodynamic classifications comprised 14 Ex-Normal, 15 Ex-LHD, 8 Ex-PVD, and 5 Ex-CPH. At baseline, mPAP ≥25 mmHg was present in 0/14 Ex-Normal, 5/15 Ex-LHD, 5/8 Ex-PVD, and 5/5 Ex-CPH (Table 1). Ex-LHD had similar Ees and modestly higher Ea compared to Ex-Normal. Ex-PVD had substantially higher Ees and Ea compared to Ex-Normal. Ex-PVD also had substantially higher Ees and Ea compared to Ex-LHD. However, Ees:Ea appeared similarly depressed in both Ex-LHD and Ex-PVD compared to Normal. This was despite normal pulmonary pressures at baseline in Ex-LHD. During exercise, Ees:Ea appeared to augment modestly in Ex-Normal, but remained stable in other groups (Figure 1). Systolic RV performance augmented in proportion with increased load during exercise; however, less favorable ventricular-vascular coupling in patients with pulmonary vascular and/or left heart disease persisted during exercise. Despite mostly normal at rest hemodynamics, ventricular-vascular coupling appears abnormal in patients with left heart disease exposed by exercise.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

FEASIBILITY OF EXERCISE HEMODYNAMIC EVALUATION IN THE CLINICAL CARDIAC CATHETERIZATION LABORATORY

Provocative testing during right heart catheterization (RHC) is gaining increasing acceptance to evaluate cardiac and pulmonary vascular contributions to dyspnea. For this purpose, the use of cycle ergometry at measured work rates has been recommended as a physiologically relevant and sensitive stressor, but also increases the complexity of the investigation. A pilot experience was undertaken to examine the feasibility and diagnostic utility of a submaximal cycle ergometry protocol performed during RHC. The program was initiated in July, 2016. Patients referred for invasive evaluation of dyspnea of unclear etiology or suspected pulmonary hypertension underwent standard diagnostic RHC. Patients were then transferred to a cycle ergometer in a semi-upright position, and hemodynamics were assessed at rest, then at Light Intensity and Moderate Intensity submaximal exercise stages if tolerated. Hemodynamic diagnoses at rest were assigned based on guideline recommendations and exercise hemodynamic diagnoses were assigned based on sex-specific reference ranges developed by our laboratory. Between July 2016 and March 2018, 59 patients (61 ± 15 years, 53% female) were referred for invasive exercise hemodynamic evaluation. The clinical indications were dyspnea of unclear etiology in 32 (54%) and suspected pulmonary hypertension in 27 (46%). Resting hemodynamic assessment was performed in all patients and the exercise protocol was initiated in 56. In three (5%) cases, exercise hemodynamic evaluation was not performed based on concerns regarding safety. Ultrasound guided vascular access was obtained from antecubital veins in 52 (88%) and internal jugular veins in seven patients (12%). Table 1 details fluoroscopic exposures and procedure duration. The Light Intensity exercise stage (25 ± 9 Watts) was completed in 56 (95%), while Moderate Intensity exercise stage (56 ± 20 Watts)was completed in 29 (49%) patients. Figure 1 illustrates the hemodynamic classification at rest and after the exercise protocol. At rest, 35 patients (59%) had normal hemodynamics; however after the exercise protocol, the number of patients with normal hemodynamics declined to 20 (34%). Exercise induced pulmonary hypertension related to left heart disease (PH-LHD) was disclosed in 13 (37%) of 35 patients with normal resting hemodynamics. In this prospective series, a submaximal, cycle ergometry protocol performed during RHC was possible in 95% of the cohort referred. The intervention revealed hemodynamic abnormalities in over one-third of patients with normal resting hemodynamics. Exercise induced PH-LHD was the most frequently disclosed hemodynamic abnormality. This study also included prospective assessments of patient reported outcomes of breathlessness.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Is it possible to apply the treat-to-target strategy in primary Sj\xf6gren\u2019s syndrome-associated pulmonary arterial hypertension?

The treat-to-target (T2T) strategy improved long-term survival of patients with pulmonary arterial hypertension (PAH). Little was known about applying the T2T strategy in primary Sjogren’s syndrome-associated PAH (pSS-PAH). We investigated how to identify patients who are more likely to reach the treatment goals in a cohort of pSS-PAH. In this way, we explored the possibility of implementing T2T in pSS-PAH. Data were retrospectively collected from patients visiting our center between 2007 and 2017. PAH was confirmed by right heart catheterization (RHC). Patients were treated following the T2T strategy. PAH treatment goals were defined by the 5th World Symposium on Pulmonary Hypertension. The primary end point was reaching the PAH treatment goals. Of the 62 patients enrolled, 98.4% were female, with a mean age of 38.9 ± 9.1 years at the diagnostic RHC. The median disease duration of pSS was 46 months (0–365), while the median disease duration of PAH was 12 months (0–149). Following the T2T strategy, 32 (50%) patients achieved the treatment goals. The 1-, 3-, and 5- year cumulative rates of reaching the goals were 40.6, 67.4, and 73.9%, respectively. Predictive factors included using immunosuppressants (HR 4.715, 95% CI 1.101–20.192, p = 0.037) and right ventricular anterior-posterior diameter (RV-APD) > 30 mm at baseline (HR 0.426, 95% CI 0.188–0.968, p = 0.042). The results provide strong evidence that patients who received immunosuppressants are more likely to reach the treatment goals. In contrast, impaired RV structure correlates to worse treatment response. The T2T strategy is effective in pSS-PAH.

The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update

Mandeep R. Mehra, MD (Chair), Charles E. Canter, MD, Margaret M. Hannan, MD, Marc J. Semigran, MD, Patricia A. Uber, PharmD, David A. Baran, MD, Lara Danziger-Isakov, MD, MPH, James K. Kirklin, MD, Richard Kirk, MD, Sudhir S. Kushwaha, MD, Lars H. Lund, MD, PhD, Luciano Potena, MD, PhD, Heather J. Ross, MD, David O. Taylor, MD, Erik A.M. Verschuuren, MD, PhD, Andreas Zuckermann, MD and on behalf of the International Society for Heart Lung Transplantation (ISHLT) Infectious Diseases, Pediatric and Heart Failure and Transplantation Councils

Improved survival in limited scleroderma-related pulmonary artery hypertension

Reportedly, patients with scleroderma-related pulmonary hypertension (SSc-PAH) respond poorly to new vasoactive drugs (NVD). Forty-nine SSc-PAH patients underwent right heart catheterization (RHC) and, according to NVD availability, divided as follows: Group 1 (n=23, from 1999 to 2004, poor availability), and Group 2 (n=26, from 2005 to 2010, good availability). Before diagnostic RHC, NVD had been given to 30% of the patients in Group 1, and 58% of those in Group 2 (p=0.049). At diagnosis, patients in Group 1 had greater heart dilatation (p<0.01), higher mean pulmonary artery pressure (p<0.05), lower pulmonary artery capacitance (p<0.05), and lower carbon monoxide lung diffusing capacity (DLco, p<0.05) than those in Group 2. At a median follow-up time of 15.5months, DLco further decreased in Group 1 (p<0.05), whereas cardiac index increased in Group 2 (p<0.05). At 36months of follow-up, 72.4% of the patients in Group 2 were still alive as opposed to 30.4% in Group 1 (p=0.02). In multivariate analysis, DLco and mixed venous oxygen saturation (SvO2) were independent predictors of survival. A value of DLco <7.2mL/mmHg/min was associated with a hazard ratio (HR) of 5.3 (p<0.001); for SvO2 <63.8%, the HR was 3.7 (p<0.01).NVD have beneficial effects in patients with SSc-PAH. Both DLco and SvO2 are predictors of survival and may assist in planning treatment.

Otto Klein--the forgotten founder of diagnostic cardiac catheterization

Otto Klein's pioneering work . Werner Forsmann introduced a catheter into his own heart in 1928 to show the feasibility of this technique for injection of drugs directly into the heart. However, Otto Klein has to be credited for the first diagnostic right-heart catheterization. In 1929, he performed, as the first in the world, 11 successful right-heart catheterizations including passage of the catheter into the right atrium and right ventricle and estimated the cardiac output using the Fick principle. Cardiac output in three patients without heart disease was 4.5, 5.6, and 6.67 L/min. Klein presented his data during lectures in Prague (November 1929) and at the Congress of the German Society for Internal Medicine held in Wiesbaden (April 1930) and published his work in Munchener Medizinische Wochenschrift …