Diastolic Pressure Gradient Research Articles

Calculation of intraprocedural hemodynamics with computational functional dynamic in mitral valve edge-to-edge repair

Abstract Background Hemodynamic outcomes in patients undergoing transcatheter edge-to-edge-repair of the mitral valve (M-TEER) are difficult to predict. Computational functional dynamic (CFD) is frequently used in biomedical engineering to simulate blood flow patterns under various conditions. The authors developed a standardized workflow for individualized analyses and investigated the hemodynamic of mitral regurgitation volumes and gradients by using CFD. Methods 20 patients from two high volume centers who suffered from severe mitral regurgitation (MR) and underwent full cycle cardiac computed tomography (CT) prior procedure were enrolled. Baseline computed tomography and intraprocedural data were analyzed. Based on the specific valve morphology, individualized CFD-simulations were performed to calculate MR volumes prior to intervention and estimate hemodynamics after M-TEER. Results CFD-analyses of 20 patients (mean age 80±4 years, 60% male) showed excellent correlation between baseline PISA method-based MR volumes (45±23ml) measured in transesophageal echocardiography (TEE) and CFD-based calculation (45±26ml; R=0.917; P<0.001) as well as between TEE-measured mean baseline effective regurgitant orifice area (EROA; 27±16mm²) and CFD-measured EROA (24±18mm²; R=0.869; P<0.001)). After device implantation, correlation between intraprocedural TEE-measured and CFD-estimated correlation for residual MR volumes (R=0.949; P<0.001) and EROA (R=0.841; P<0.001) remained robust. Post-interventional mean diastolic pressure gradient (TEE) was 3.6±2.8mmHg which was in close correlation with the CFD estimated gradient (3.0±1.8mmHg, R=0.905; P<0.001). Conclusions This is the first study to use a CFD-standardized workflow for predicting hemodynamic changes in patients undergoing M-TEER using data from two different centers. In the future, CFD-based analyses might serve as a key-diagnostic tool for predicting residual MR volumes and gradients for M-TEER-procedures.Comparison of TEE and CFD flow patternBland-Altman-Blots

Sex differences in the long-term outcomes of moderate rheumatic mitral stenosis

Abstract Background There are limited data on the sex differences in the long-term outcomes of moderate mitral stenosis (MS). Purpose This study aimed to investigate sex differences in long-term outcomes of moderate AS. Methods From the Multicenter mitrAl STEnosis with Rheumatic etiology (MASTER) registry of 3,140 patients, we included patients with moderate MS (1.5 < mitral valve area ≤ 2.0 cm2) between January 2000 and December 2021 who had not undergone previous percutaneous of surgical treatment of MS. Primary outcomes were a composite of all-cause death, heart failure (HF) hospitalization, ischemic stroke, and mitral valve intervention. We analyzed clinical and echocardiographic variables based on sex. Results A total of 788 patients (mean 62.2 ± 12.9 years, women 74.5%) were followed over a mean duration of 7.0 ± 6.0 years. During follow-up, 287 patients (36.4%) experienced primary outcomes. Women (n=587) had more atrial fibrillation (AF) (p=0.022), higher left ventricular (LV) ejection fraction (EF) (p<0.001), and smaller LV chamber (LV mass index; p<0.001) compared to men. Primary outcomes did not differ for both sexes (p=0.285). However, on the analysis of both sexes according to right ventricular systolic pressure (RVSP), men with elevated RVSP had poorer outcomes (p<0.001) but women did not differ (p=0.238) (Figure 1). On the multivariate Cox regression analysis, elevated RVSP was the only factor that was independently associated with poorer outcomes (hazard ratio [HR], 1.30 [95% CI, 1.10-1.05], p=0.005) in men. However, in women, several factors including older age (HR 1.02, 95% CI 1.00-1.03, p=0.012), presence of AF (HR 2.40, 95% CI 1.66-3.48, p<0.001), decreased LV EF (HR 0.98, 95% CI 0.97-1.00, p=0.007), and higher mean diastolic pressure gradient (HR 1.09, 95% CI 1.01-1.17, p=0.027) showed the independent association with poorer outcome, but not in RVSP (Figure 2). Conclusions In moderate MS, RVSP showed a significant prognostic role in men, but in women, various comorbidities other than that were associated with prognosis. Therefore, different follow-up strategy using specific parameters for each gender would be needed.

Prognosis of different hemodynamic classifications in patients with pulmonary hypertension due to left heart disease

Objective: To compare the prognostic values of different classification by using transpulmonary pressure gradient (TPG), diastolic pressure gradient (DPG) and pulmonary vascular resistance (PVR) in patients with pulmonary hypertension due to left heart disease (PH-LHD), and investigated hemodynamic and clinical factors associated with mortality in patients with PH-LHD. Methods: This was a single-center prospective cohort study. In-hospital patients diagnosed with PH-LHD via right heart catheterization at the Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, from September 2013 to December 2019 were enrolled. Patients were divided according to TPG (cutoff value 12 mmHg; 1 mmHg=0.133 kPa), DPG (cutoff value 7 mmHg), PVR (cutoff value 3 Wood Units), and the combination of TPG and PVR. Baseline characteristic was recorded. All patients were followed up until the occurrence of endpoint event, defined as all-cause death that occurred during the follow-up period, or until April 18, 2022. Receiver operating characteristic curves were used to compare the predictive value of 3 classification methods for all-cause death in PH-LHD patients. The optimal cutoff values were calculated using Jorden index. Survival analysis was performed using Kaplan-Meier analysis, and log-rank test was used to compare the predictive efficacy of classification methods based on optimal cutoff values or guidance-recommended thresholds for the survival of PH-LHD patients. Variables showing statistical significance in the univariate analysis were incorporated into multivariate Cox regression model to analyze the independent risk factors for all-cause mortality. Results: A total of 243 patients were enrolled, aged (54.9±12.7) years old, including 169 (69.5%) males. During a median follow-up of 57 months, there were 101 (41.6%) deaths occurred. Grouping results were as follows: (1) TPG: TPG≤12 mmHg group 115 patients, TPG>12 mmHg group 128 patients; (2) DPG: DPG<7 mmHg group 193 patients, DPG≥7 mmHg group 50 patients; (3) PVR: PVR≤3 Wood Units group 108 patients, PVR>3 Wood Units group 135 patients; (4) TPG and PVR: TPG≤12 mmHg and PVR≤3 Wood Units group 89 patients, TPG>12 mmHg and PVR>3 Wood Units group 109 patients. PVR (AUC=0. 698,95%CI:0.631-0.766) had better predictive value for all-cause mortality than TPG (AUC=0.596, 95%CI: 0.523-0.669) and DPG (AUC=0.526, 95%CI: 0.452-0.601) (all P<0.05). The optimal cutoff values for TPG, DPG, and PVR were13.9 mmHg, 2.8 mmHg, and 3.8 Wood Units, respectively. Kaplan-Meier analysis based on the optimal cutoff values or guidance-recommended thresholds showed that PVR and TPG were the predictors of survival (P<0.05), while DPG did not showed significance (P>0.05). Multivariate Cox regression analysis showed that age, PVR and log2N-terminal pro-B-type natriuretic peptide were independent risk factors for all-cause mortality in PH-LHD patients (all P<0.05). Conclusion: Classification according to PVR was most valuable in predicting all-cause death in PH-LHD patients, while TPG showed moderate predictive ability and DPG had no predictive value.

Computational haemodynamics for pulmonary valve replacement by means of a reduced fluid-structure interaction model.

Pulmonary valve replacement (PVR) consists of substituting a patient's original valve with a prosthetic one, primarily addressing pulmonary valve insufficiency, which is crucially relevant in Tetralogy of Fallot repairment. While extensive clinical and computational literature on aortic and mitral valve replacements is available, PVR's post-procedural haemodynamics in the pulmonary artery and the impact of prosthetic valve dynamics remain significantly understudied. Addressing this gap, we introduce a reduced Fluid-Structure Interaction (rFSI) model, applied for the first time to the pulmonary valve. This model couples a three-dimensional computational representation of pulmonary artery haemodynamics with a one-degree-of-freedom model to account for valve structural mechanics. Through this approach, we analyse patient-specific haemodynamics pre and post PVR. Patient-specific geometries, reconstructed from CT scans, are virtually equipped with a template valve geometry. Boundary conditions for the model are established using a lumped-parameter model, fine-tuned based on clinical patient data. Our model accurately reproduces patient-specific haemodynamic changes across different scenarios: pre-PVR, six months post-PVR, and a follow-up condition after a decade. It effectively demonstrates the impact of valve implantation on sustaining the diastolic pressure gradient across the valve. The numerical results indicate that our valve model is able to reproduce overall physiological and/or pathological conditions, as preliminary assessed on two different patients. This promising approach provides insights into post-PVR haemodynamics and prosthetic valve effects, shedding light on potential implications for patient-specific outcomes.

Continuous Right Ventricular Pressure Monitoring in Cardiac Surgery

Right ventricular (RV) dysfunction in cardiac surgery can lead to RV failure, which is associated with increased morbidity and mortality. Abnormal RV function can be identified using RV pressure monitoring. The primary objective of the study is to determine the proportion of patients with abnormal RV early to end-diastole diastolic pressure gradient (RVDPG) and abnormal RV end-diastolic pressure (RVEDP) before initiation and after cardiopulmonary bypass (CPB) separation. The secondary objective is to evaluate if RVDPG before CPB initiation is associated with difficult and complex separation from CPB, RV dysfunction, and failure at the end of cardiac surgery. Prospective study. Tertiary care cardiac institute. Cardiac surgical patients. Cardiac surgery. Automated electronic quantification of RVDPG and RVEDP were obtained. Hemodynamic measurements were correlated with cardiac and extracardiac parameters from transesophageal echocardiography and postoperative complications. Abnormal RVDPG was present in 80% of the patients (n = 105) at baseline, with a mean RVEDP of 14.2 ± 3.9 mmHg. Patients experienced an RVDPG > 4 mmHg for a median duration of 50.2% of the intraoperative period before CPB initiation and 60.6% after CPB separation. A total of 46 (43.8%) patients had difficult/complex separation from CPB, 18 (38.3%) patients had RV dysfunction, and 8 (17%) had RV failure. Abnormal RVDPG before CPB was not associated with postoperative outcome. Elevated RVDPG and RVEDP are common in cardiac surgery. RVDPG and RVEDP before CPB initiation are not associated with RV dysfunction and failure but can be used to diagnose them.

Invasive haemodynamics predict outcomes in paediatric pulmonary artery hypertension.

Invasive haemodynamics are often performed for initiating and guiding pulmonary artery hypertension therapy. Little is known about the predictive value of invasive haemodynamic indices for long-term outcomes in children with pulmonary artery hypertension. We aimed to evaluate invasive haemodynamic data to help predict outcomes in paediatric pulmonary artery hypertension. Patients with pulmonary artery hypertension who underwent cardiac catheterisation (2006-2019) at a single centre were included. Invasive haemodynamic data from the first cardiac catheterisation and clinical outcomes were reviewed. The combined adverse outcome was defined as pericardial effusion (due to right ventricle failure), creation of a shunt for pulmonary artery hypertension (atrial septal defect or reverse Pott's shunt), lung transplant, or death. Among 46 patients with a median [interquartile range (IQR)] age of 13.2 [4.1-44.7] months, 76% had CHD. Median mean pulmonary artery pressure was 37 [28-52] mmHg and indexed pulmonary vascular resistance was 6.2 [3.6-10] Woods units × m2. Median pulmonary artery pulsatility index was 4.0 [3.0-4.7] and right ventricular stroke work index was 915 [715-1734] mmHg mL/m2. After a median follow-up of 2.4 years, nine patients had a combined adverse outcome (two had a pericardial effusion, one underwent atrial level shunt, one underwent reverse Pott's shunt, and six died). Patients with an adverse outcome had higher systolic and mean pulmonary artery pressures, higher diastolic and transpulmonary pressure gradients, higher indexed pulmonary vascular resistance, higher pulmonary artery elastance, and higher right ventricular stroke work index (p < 0.05 each). Invasive haemodynamics (especially mean pulmonary artery pressure and diastolic pressure gradient) obtained at first cardiac catheterisation in children with pulmonary artery hypertension predicts outcomes.

Abstract 15170: Prognostic Implication of Left Atrial Reservoir Strain in Severe Mitral Stenosis With Low Transmitral Diastolic Pressure Gradient: Result From Long-Term Follow-Up Registry

Background: Prognosis of severe mitral stenosis (MS) with low transmitral mean diastolic pressure gradient (MDPG) has not been fully understood with lack of long-term follow-up study. Aims: We investigated the prognostic implication in severe MS with low MDPG. Methods: We included patients with severe rheumatic MS (mitral valve area [MVA] &lt; 1.5 cm 2 ) from the Multicenter mitrAl STEnosis with Rheumatic etiology (MASTER) registry. Patients with severe MS were categorized into high (≥ 5 mmHg) or low (&lt; 5 mmHg) MDPG groups. The primary outcome was a composite of all-cause mortality and stroke. Among 1,248 patients with severe MS, 322 (25.8%) had low and 926 (74.2%) had high MDPG. Results: Their mean age was 59±13 years, 25% were men, and 74% had atrial fibrillation. Patients with low MDPG were older and had a higher prevalence of atrial fibrillation. During a mean follow-up of 6.8±5.9 years, 194 patients (15.5%) experienced composite events. Patients with severe MS and low MDPG had a higher risk of experiencing composite events compared to those with high MDPG (hazard ratio [HR]: 1.56, 95% CI: 1.15-2.12; p=0.004). Subgroup analysis with low MDPG revealed that decreased left atrial reservoir strain (LARs) was independently associated with poorer outcome (HR, 2.58, 95% CI: 1.08-6.20; p=0.034). Conclusion: Severe MS patients with low MDPG are at higher risk of adverse events compared to those with high MDPG. The assessment of LARs can be useful in identifying subgroups of low MDPG severe MS patients with poor prognosis.

Risk Factors and Outcomes With Progressive Mitral Annular Calcification.

Background Mitral annular calcification (MAC) is a chronic degenerative process that may progress. This study aimed to investigate associating factors and clinical implications of MAC progression. Methods and Results Among 560 patients with MAC identified by transthoracic echocardiography between January 2012 and June 2016, 138 patients (mean±SD age 72.7±10.2 years, 73 women) with mild or moderate MAC who received follow-up examination within 18 to 36 months were retrospectively analyzed. Progressive MAC was defined as hemodynamic or structural profiles that had worsened by more than 1 grade. Hemodynamic features were assessed by the transmitral mean diastolic pressure gradient (MDPG), and structural features were assessed by the MAC angle in the parasternal short-axis view. The clinical outcome was defined as a composite of all-cause mortality, hospitalization for heart failure, and occurrence of ischemic stroke. Forty-three patients (31.2%) showed progressive MAC. Patients with progressive MAC had higher systolic blood pressure, pulse pressure, MAC angle, and MDPG than those with stable MAC. Patients with progressive MAC had smaller left ventricular (LV) end-systolic dimensions and higher LV ejection fractions compared with those with stable MAC. In multivariate analysis, pulse pressure, LV ejection fraction, MAC angle, and MDPG at baseline were significantly associated with MAC progression. During a median of 39.2 months' follow-up, patients with progressive MAC showed poorer clinical outcomes than those with stable MAC (log-rank P=0.015). Conclusions MAC progression is not rare and is associated with structural substrate and hemodynamic loads that result in mechanical stress. Patients with progressive MAC have poor outcomes.

Mitral and tricuspid valve repair using interannular bridging in children.

In children, it is difficult to control mitral (MV) or tricuspid valve (TV) regurgitation with conventional procedures alone because complex factors hamper easy improvement of valve coaptation. We investigated interannular bridging in children with MV/TV regurgitation. The subjects were 9 patients who underwent interannular bridging to control TV or MV regurgitation between January 2014 and December 2021. We analyzed reintervention for the valve, progression of stenosis/regurgitation, and valve growth. The TV and MV groups included four and five patients, respectively. At operation, the median age was 5.8 (1.4 to 14) years in TV and 3.6 (0.3 to 7.0) years in MV. The median weight was 13.0 (8.4 to 41.2) kg in TV and 11.0 (4.8 to 18.3) kg in MV. The median follow-up periods were 78 (11 to 94) months for TV and 30 (4 to 34) months for MV. None of the patients in either group underwent reintervention. Moderate or greater regurgitation recurred in one TV patient but subsequently improved to mild regurgitation. Valve stenosis (mean diastolic pressure gradient >10 mmHg) was not detected. Median valve diameter (Z-score) ranged from -1.17 (-3.7 to 0.85) at discharge to -0.59 (-1.2 to 2.01) at the latest follow-up in TV patients. In MV patients, valve diameter changed from 1.14 (-1.68 to 1.46) to 0.72 (-0.23 to 1.36). After bridging, the coaptation height (CH) was maintained at the same value over time. Interannular bridging could be a useful approach for complicated TV/MV regurgitation in children.

Left Atrioventricular Transvalvular Pressure Gradients Derived from Intraoperative and Postoperative Echocardiograms following Atrioventricular Septal Defect Repair.

Left atrioventricular valve (LAVV) stenosis following an atrioventricular septal defect (AVSD) repair is a rare but potentially life-threatening complication. While echocardiographic quantification of diastolic transvalvular pressure gradients is paramount in the evaluation of a newly corrected valve function, it is hypothesized that these measured gradients are overestimated immediately following a cardiopulmonary bypass (CPB) due to the altered hemodynamics when compared to postoperative valve assessments using awake transthoracic echocardiography (TTE) upon recovery after surgery. Out of the 72 patients screened for inclusion at a tertiary center, 39 patients undergoing an AVSD repair with both intraoperative transesophageal echocardiograms (TEE, performed immediately after a CPB) and an awake TTE (performed prior to hospital discharge) were retrospectively selected. The mean (MPGs) and peak pressure gradients (PPGs) were quantified using a Doppler echocardiography and other measures of interest were recorded (e.g., a non-invasive surrogate of the cardiac output and index (CI), left ventricular ejection fraction, blood pressures and airway pressures). The variables were analyzed using the paired Student's t-tests and Spearman's correlation coefficients. The MPGs were significantly higher in the intraoperative measurements when compared to the awake TTE (3.0 ± 1.2 vs. 2.3 ± 1.1 mmHg; p < 0.01); however, the PPGs did not significantly differ (6.6 ± 2.7 vs. 5.7 ± 2.8 mmHg; p = 0.06). Although the assessed intraoperative heart rates (HRs) were also higher (132 ± 17 vs. 114 ± 21 bpm; p < 0.001), there was no correlation found between the MPG and the HR, or any other parameter of interest, at either time-point. In a further analysis, a moderate to strong correlation was observed in the linear relationship between the CI and the MPG (r = 0.60; p < 0.001). During the in-hospital follow-up period, no patients died or required an intervention due to LAVV stenosis. The Doppler-based quantification of diastolic transvalvular LAVV mean pressure gradients using intraoperative transesophageal echocardiography seems to be prone to overestimation due to altered hemodynamics immediately after an AVSD repair. Thus, the current hemodynamic state should be taken into consideration during the intraoperative interpretation of these gradients.

Alterations of pulmonary vascular afterload in exercise‐induced pre‐ and post‐capillary pulmonary hypertension

Exercise imposes increased pulmonary vascular afterload based on rises in pulmonary artery (PA) wedge pressure, declines in PA compliance, and resistance-compliance time. In health, afterload stress stabilizes during steady-state exercise. Our objective was to examine alterations of these exercise-associated stresses in states of pre- and post-capillary pulmonary hypertension (PH). PA hemodynamics were evaluated at rest, 2 and 7min of steady-state exercise at moderate intensity in patients who exhibited Pre-capillary (n=22) and post-capillary PH (n=22). Patients with normal exercise hemodynamics (NOR-HD) (n=32) were also studied. During exercise in all groups, PA wedge pressure increased at 2min, with no further change at 7min. In post-capillary PH and NOR-HD, increases in PA diastolic pressure and diastolic pressure gradient remained stable at 2 and 7min of exercise, while in pre-capillary PH, both continued to increase at 7 min. The behavior of the diastolic pressure gradient was linearly related to the duration of resistance-compliance time at rest (r2 =0.843) and exercise (r2 =0.760). Exercise resistance-compliance time was longer in pre-capillary PH associated with larger increases in diastolic pressure gradient. Conversely, resistance-compliance time was shortest in post-capillary PH compared to pre-capillary PH and NOR-HD and associated with limited increases in exercise diastolic pressure gradient. During steady-state, modest-intensity exercise-specific patterns of pulmonary vascular afterload responses were observed in pre- and post-capillary PH relative to NOR-HD. Longer resistance-compliance time related to greater increases in PA diastolic pressure and diastolic pressure gradients in pre-capillary PH, while shorter resistance-compliance time appeared to limit these increases in post-capillary PH.

Impact of diastolic pulmonary gradient and pulmonary artery pulse index on outcomes in heart transplant patients-Results from the Eurotransplant database.

Predicting complications associated with pulmonary hypertension (PH) after cardiac transplantation is an important factor when considering cardiac transplantation. The transpulmonary gradient (TPG) is recommended to quantify PH in transplant candidates. Nonetheless, PH remains a common driver of mortality. The diastolic pressure gradient (DPG) and pulmonary vascular resistance (PVR) can differentiate post- from combined pre- and post-capillary PH and may improve estimation of PH-associated risks. We used a large European cohort of transplant candidates to assess whether the pulmonary pulsatility index (PAPi), improves prediction of graft failure and mortality compared to DPG and PVR. Out of all patients undergoing heart transplantation between 2009 and 2019 in Eurotransplant member states (n = 10,465), we analyzed the impact of PH (mPAP > 25 mmHg) and right heart catheter hemodynamic data on graft failure and mortality within 1-5 years. In 1,407 heart transplant patients with PH (79% male, median age 54 years, IQR 39-69 years), the median PVR was 2.5 WU (IQR 1.6 WU) with a median mPAP (pulmonary arterial pressure) of 32 mmHg (IQR 9 mmHg). Patients with low (< 3 mmHg) DPG had a better 5 year survival than those with higher DPG (log rank p = 0.023). TPG, mPAP, PAPi, and PVR did not improve prediction of survival. Low PAPi (OR = 2.24, p < 0.001) and high PVR (OR = 2.12, p = 0.005) were associated with graft failure. PAPI and PVR are associated with graft failure in patients with PH undergoing cardiac transplantation. DPG is associated with survival in this cohort.

Inhaled Epoprostenol and Milrinone Effect on Right Ventricular Pressure Waveform Monitoring

BackgroundPulmonary hypertension (PH) and right ventricular (RV) dysfunction are major complications in cardiac surgery. This study aimed to evaluate the change in RV pressure waveform in patients receiving a combination of inhaled epoprostenol and inhaled milrinone (iE&iM) before cardiopulmonary bypass (CPB) and to assess the safety of this approach with a matched case-control group. MethodsA prospective single-centre cohort study of adult patients undergoing cardiac surgery administered iE&iM through an ultrasonic mesh nebulizer. RV pressure waveform monitoring was obtained by continuously transducing the RV port of the pulmonary artery (PA) catheter. ResultsThe final analysis included 26 patients receiving iE&iM. There was a significant drop in mean PA pressure (MPAP) (–4.8 ± 8.7, P = 0.010), systolic PA pressure (SPAP) (–8.2 ± 12.8, P = 0.003), RV end-diastolic pressure (RVEDP) (–2.1 ± 2.8, P < 0.001) and RV diastolic pressure gradient (RVDPG) (–1.7 ± 1.4, P < 0.001) after 17 ± 9 minutes of iE&iM administration. Patients also had a significant increase in RV outflow tract (RVOT) gradient (3.7 ± 4.7, P < 0.001), RV maximal rate of pressure rise during early systole (dP/dt max) (68.3 ± 144.7, P = 0.024), and left ventricular (LV) dP/dt max (66.4 ± 90.1, P < 0.001). Change in RVOT gradient was only observed in those with a positive pulmonary vasodilator response to treatment. Treatment with iE&iM did not present adverse effects when compared with a matched case-control group. ConclusionsCoadministration of iE&iM in cardiac surgery patients presenting with PH or signs of RV dysfunction is a safe and effective treatment approach in improving RV function. Appearance of a transient increase in RVOT gradient after iE&iM could be useful to predict response to treatment.

Abstract 13710: Acute Beneficial Effects of a Rho-Kinase Inhibitor, Fasudil in Patients With Pulmonary Hypertension Due to Left Heart Disease

Introduction: The prognosis of reactive pulmonary hypertension (PH) due to left heart disease is poor, and the pathogenesis of the disease is not well understood. Rho-Kinase inhibitor, fasudil dilates vascular smooth muscle and may improve pulmonary hypertension. We evaluated the acute effects of fasudil on hemodynamic parameters in patients with pulmonary hypertension due to left heart disease prospectively. Methods: From 2016 June to 2022 May, 100 consecutive patients requiring hospitalization for worsening chronic heart failure were enrolled. All patients underwent invasive hemodynamic measurement though right heart catheterization.In patients with mean pulmonary arterial pressure greater than 25 mmHg at baseline, 30 mg of fasudil was administered intravenously for 30 minutes. The hemodynamic measurements were performed at baseline and after 30 minutes of fasudil. PH due to left heart disease is defined as mean pulmonary arterial pressure (mPAP) ≥25mmHg and mean pulmonary capillary wedge pressure (mPCWP) &gt;15mmHg. Patients with PH were classified into 2 types, depending on the elevation of pulmonary vascular resistance (PVR) or the diastolic pressure gradient (DPG): Reactive-PH with elevated PVR (&gt;3.0 Wood units: WU) and/or DPG (&gt;7mmHg), and Passive-PH with normal PVR (≤3.0 WU) and DPG (≤7mmHg). Results: Fifty patients (mean age 70 years; 14 women and 36 men) received administration of fasudil. 30 patients had Passive-PH, and 20 patients had Reactive-PH. PVR significantly decreased after administration of fasudil in both Passive-PH and Reactive-PH group (1.7 to 1.4 WU, 3.5 to 2.7 WU, P&lt;0.001). The rate of change in PVR after administration of fasudil was significantly higher in the Reactive-PH group compared to the Passive-PH group (33% vs 21 %, P&lt;0.05). mPAP and cardiac index significantly improved in both Passive-PH (34±8.5 vs. 28±8.2 mmHg, 2.7±0.7 vs. 2.9±0.8 l/min/m 2 , p&lt;0.05) and Reactive-PH group (41±7.9 vs. 33±9.0 mmHg, 2.2±0.6 vs. 2.4±0.6 l/min/m 2 , p&lt;0.05). Mean blood pressure and arterial oxygen saturation were unaffected by fasudil (87 to 84 mmHg, 99 to 90 mmHg, 98 to 97%, 97 to 97%, not significant). Conclusions: Fasudil improves pulmonary hypertension due to left heart disease without any detrimental effects on hemodynamics.

Abstract 12459: Hemodynamic Progression of Mitral Annular Calcification: Prevalence, Characteristics, and Clinical Implications

Background: A recent study demonstrated that transmitral mean diastolic pressure gradient (MDPG) in patients with mitral annular calcification (MAC) is associated with increased mortality, however, the longitudinal hemodynamic progression over time in patients with MAC and its characteristics are unclear. In this study, the clinical and echocardiographic characteristics of MAC correlated with hemodynamic progression and its clinical implications were investigated. Methods: In total, 161 patients (mean age 74.7±10.5 yeas, 63 men) with MAC were identified by index transthoracic echocardiography (TTE) between January 2012 and June 2016 and performed follow-up TTE after 3 years. Stable MAC (n=146, 90.7%) was defined as a difference of transmitral mean pressure gradient (MDPG) less than 2 mmHg between initial and follow-up TTE, and progressive MAC (n=15. 9.5%) was defined as MDPG increased above 2mmHg. Results: There was no significant difference of baseline characteristics between the group with stable MAC and progressive MAC. In the group of progressive MAC compared to that of stable MAC, a proportion of moderate-to-severe MAC (66.7 vs. 28.1%, p =0.002), significant MS (26.7 vs. 8.2%, p =0.046), maximal thickness of MAC (0.7±0.5 vs. 0.5±0.3, p =0.023), and MDPG (2.8±1.7 vs. 2.2±1.5, p =0.048) were significantly higher at the index TTE ( Figure ). In the group with progressive MAC, increase in left atrial (LA) volume index and pulmonary artery systolic pressure were significant. In-5-year mortality and newly developed atrial fibrillation tended to be more common in progressive MAC group, but there was no statistical significance. Conclusions: Hemodynamic progression occurs in about 10% of patients over 3 years. Patients with progressive MAC have larger baseline MAC thickness and calcification extent, even if MDPG is less than 3 mmHg. Patients with progressive MAC are more likely to develop LA enlargement and pulmonary hypertension, which are prone to poor outcome.

Abstract 10214: Invasive versus Echocardiographic Hemodynamics in the First Genetically Modified Porcine to Human Xenotransplant

Introduction: Our medical center performed the first genetically modified cardiac xenotransplant in human and performed longitudinal invasive and noninvasive hemodynamic measurements throughout the recipient’s hospitalization. We hypothesized that echocardiographic derived hemodynamic assessments would correlate with invasive measurements within the cardiac xenotransplant. Methods: Transthoracic echocardiography (TTE) and right heart catheterizations were performed in the cardiac xenotransplant. Retrospective analysis of TTE and invasive hemodynamics were analyzed to assess correlation between various parameters. The following invasive hemodynamics were measured or calculated: right atrial pressure (RAP), pulmonary artery systolic and diastolic pressures (PASP, PADP), pulmonary vascular resistance (PVR), pulmonary artery pulsatility index (PAPi), cardiac output (CO), cardiac index (CI), right ventricular stroke work index (RVSWI) and cardiac power output (CPO). TTE measurements and calculations included: RAP based on inferior vena cava size and collapsibility, PASP calculated via tricuspid regurgitation velocity (TRV), PADP based on end diastolic pressure gradient, right ventricular outflow time-velocity integral (TVI RVOT), PVR (TRV/TVI RVOT x 10 +0.16) PAPi, CO (using left ventricular outflow tract (LVOT) velocity-time integral and LVOT area), CI (from TTE-derived CO), CPO and RVCPI {4x(TRV) 2 } x TAPSE as a surrogate of RVSWI. Results: Pearson correlation for RVSWI and RVCPI using invasive measurements obtained at the time of TTE was -0.095 and at time of mixed venous blood gas (mVBG) was 0.963. Mean absolute difference in time between mVBG and TTE was 4h 59 min. Pearson correlation for catheter-based continuous CO (CCO) monitoring with TTE was 0.965. Conclusions: In a retrospective analysis of porcine cardiac xenotransplant function, there was a strong correlation between directly measured hemodynamics with TTE, particularly when mVBG was obtained.

Prognostic value of pulmonary hemodynamic parameters for predicting survival in acute coronary syndrome

Objective: To explore the characteristics and prognostic value of pulmonary hemodynamics in patients with acute coronary syndrome (ACS). Methods: From a prospective multicenter registry study of pulmonary hypertension due to left heart disease, consecutive ACS patients who underwent coronary angiography in combination with left and right heart catheterization during hospitalization between January 2013 and November 2016 were involved. The primary endpoint was all-cause mortality. The prognostic variables identified by the Lasso analysis were included in the Global Registry of Acute Coronary Events (GRACE) score. Model performance was evaluated before and after the addition of hemodynamic parameters. Results: A total of 251 patients were enrolled, with age of (63.7±11.5) years. A total of 198 males (78.9%) and 53 females (21.1%) were recruited, and the median follow-up time was 34.7 months. Right heart catheterization-assessed mean pulmonary arterial pressure (mPAP), systolic pulmonary arterial pressure (sPAP) and diastolic pressure gradient (DPG) were found to be significant predictors for survival in ACS. Adjusted for age and sex, the adjusted HR (95%CI) of mPAP, sPAP and DPG were 1.068 (1.015-1.123), 1.033 (1.002-1.065) and 1.094 (1.008-1.187), respectively (P<0.05). Applied to the present cohort of 251 patients, the median of the GRACE score was 123 points, with a C-index of 0.703 (95%CI: 0.615-0.791) for predicting mortality. After the addition of mPAP or DPG to the GRACE score, the C-index increased to 0.715 (95%CI: 0.629-0.801) or 0.711 (95%CI: 0.625-0.797), respectively. When comparing two models before and after the addition of mPAP or DPG, the integrated discriminatory index (IDI) was 4.3% (95%CI: 0.2%-13.5%, P=0.030) and 3.0% (95%CI: 0.2%-11.1%, P=0.020), respectively. Conclusion: Pulmonary hemodynamics can be predictive for survival in ACS patients, providing incremental prognostic value to risk assessment in ACS.

Left atrial strain and clinical outcome in patients with significant mitral regurgitation after surgical mitral valve repair.

BackgroundThis study aimed to investigate the prognostic value of left atrial (LA) strain in patients with significant mitral regurgitation (MR) after surgical mitral valve (MV) repair.MethodsA total of 169 patients (age 55 ± 15 years, 88 men) with moderate or severe MR on echocardiogram at least 6 months after surgical MV repair for primary MR were studied. Two-dimensional, Doppler, and speckle tracking echocardiography including MR quantitative measures, chamber size, and LA strain were comprehensively analyzed. The primary outcome was a composite of cardiovascular death, heart failure hospitalization, and MV reoperation.ResultsDuring a median of 44.4 months [interquartile range (IQR): 18.7–70.3 months] of follow-up, 44 patients (26%) experienced clinical events; these patients had greater MR volume, elevated mean diastolic pressure gradient and pulmonary artery systolic pressure, and enlarged chamber size compared with patients who did not experience events. Patients with events showed significantly lower LA strain [13.3% (IQR: 9.3–23.8%) vs. 24.0% (IQR: 13.1–31.4%), p = 0.003] and higher MR volume/LA strain [3.09 ml/% (IQR: 2.06–5.80 ml/%) vs. 1.57 ml/% (IQR: 1.04–2.72 ml/%), p < 0.001] than those without events. MR volume/LA strain was a good predictor of clinical outcomes (cut-off 1.57 ml/%, area under the curve 0.754, p < 0.001). On multivariable Cox proportional analysis, MR volume/LA strain was independently associated with clinical outcomes (hazard ratio: 1.269, 95% confidence interval: 1.109–1.452, p < 0.001) along with pulmonary artery systolic pressure.ConclusionA measure of LA mechanical function relative to MR volume is associated with clinical outcomes in patients with significant MR after surgical MV repair.

An updated meta-analysis of hemodynamics markers of prognosis in patients with pulmonary hypertension due to left heart disease

Abstract Background Pulmonary hypertension (PH) is associated with a poor prognosis in patients with left heart disease (LHD). Several hemodynamic variables have been shown to predict outcome, including pulmonary vascular resistance (PVR), pulmonary artery compliance (PAC), and the diastolic pressure gradient (DPG). We sought to provide an updated analysis on the association of these variables with prognosis in PH-LHD. Methods We performed a systematic literature review including studies reporting association measurements between DPG and/or PVR and/or PAC and death in PH-LHD patients. These hemodynamic variables were extracted to estimate the pooled hazard ratio (HR) of adverse outcome for each one, and cumulative meta-analysis was performed to investigate temporal trends in the effects reported in the literature as well as the impact of sample size. Results 17 articles were identified, including 9716 patients with LHD, heterogeneous in terms of age, sex, and etiology of cardiac disease. In this large population, we found that PVR (HR, 1.09; 95% CI: 1.06–1.12), DPG (HR, 1.02; 95% CI: 1.01–1.02) and PAC (HR, 0.73; 95% CI: 0.76–0.81) were associated with an increased risk of adverse outcome, albeit with a less solid performance of DPG (Figure 1). Similar results were found when hemodynamic variables were analyzed according to the thresholds commonly applied in clinical practice, or subdividing cohorts according to the underlying LHD (either heart failure with preserved or reduced left ventricular ejection fraction, or valvular heart disease). Furthermore, cumulative metanalysis indicated that these results are consistently stable since 2018 (Figure 2). Conclusions Despite the heterogeneity of PH-LHD group and the intrinsic limitations of each variable, PVR, DPG, and PAC have an established prognostic value in PH-LHD. The strongest correlation with PVR and PAC supports their use in defining disease severity and identifying a subgroup of patients at higher risk of adverse outcome. We believe that these results are consistent through the years and unlikely to change with the addition of further studies. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship.

Identification of distinct subgroups in moderately severe rheumatic mitral stenosis using data-driven phenotyping of longitudinal hemodynamic progression

Abstract Background Rheumatic mitral stenosis (MS) is a significant cause of valvular heart disease. Pulmonary artery systolic pressure (PASP) reflects the hemodynamic consequences of MS and is used to determine treatment strategies. However, PASP progression and expected outcomes in patients with moderately severe MS remain unclear. Purpose We aimed to examine the impact of progression rate of PASP in moderately severe MS. Methods A cohort of 866 consecutive patients with moderately severe rheumatic MS (1.0 cm2. Results Data-driven phenotyping identified two distinct trajectories based on PASP progression: a rapid progression group (N=38, 8.7%) and a slow progression group (N=398, 91.3%). Patients in the rapid progression group were older and had more comorbidities than patients in the slow progression group, including diabetes, and atrial fibrillation (all P&amp;lt;0.05). The initial mean diastolic pressure gradient and PASP were higher in the rapid progression group than in the slow progression group (6.2±2.4 mmHg vs. 5.1±2.0 mmHg, P=0.001, and 42.3±13.3 mmHg vs. 33.0±9.2 mmHg, P&amp;lt;0.001, respectively). During a mean follow-up of 7.0±3.0 years, the event-free survival rate was significantly lower in the rapid progression group than in the slow progression group (log-rank P&amp;lt;0.001). Rapid PASP progression was a significant risk factor for composite outcomes even after adjusting for comorbidities (hazard ratio: 3.08, 95% confidence interval (CI): 1.68–5.64, P&amp;lt;0.001). Multivariate regression analysis revealed that PASP&amp;gt;40 mmHg was independently associated with the probability of rapid progression group allocation (odds ratio: 4.95, 95% CI: 2.08–11.99, P&amp;lt;0.001). Conclusions Two groups with distinct patterns of PASP progression were identified. Rapid PASP progression was associated with a significantly higher risk of the composite outcomes. The main independent echocardiographic predictor for rapid progression group allocation was initial PASP&amp;gt;40 mmHg. Funding Acknowledgement Type of funding sources: Private hospital(s). Main funding source(s): This study was supported by a Severance Hospital Research fund for Clinical excellence (SHRC) (C-2020-0041) and a faculty research grant of Yonsei University College of Medicine (6-2020-0156).