Elevated Pulmonary Capillary Wedge Pressure Research Articles

Hemodynamic Characteristics and Outcomes of Pulmonary Hypertension in Patients Undergoing Tricuspid Valve Repair or Replacement

BackgroundThe impact of pulmonary hypertension (PH) on outcomes after surgical tricuspid valve replacement (TVR) and repair (TVr) is unclear. We sought to characterize PH in patients undergoing TVR/TVr, based on invasive hemodynamics and evaluate the effect of PH on mortality. MethodsWe identified 86 consecutive patients who underwent TVR/TVr with invasive hemodynamic measurements within 3 months before surgery. We used Kaplan-Meier survival and restricted mean survival time (RMST) analyses to quantify the effects of PH on survival. ResultsThe mean age was 63 ± 13 years, 59% were female, 45% had TVR, 55% had TVr, 39.5% had isolated TVR/TVr, and 60.5% had TVR/TVr concomitant with other cardiac surgeries). Eighty-six percent of these patients had PH with a mean pulmonary artery pressure of 30 ± 10 mm Hg, pulmonary vascular resistance (PVR) of 2.5 (interquartile range: 1.5-3.9) Wood units (WU), pulmonary arterial compliance of 2.3 (1.6-3.6) mL/mm Hg, and pulmonary arterial elastance of 0.8 (0.6-1.2) mm Hg/mL. Cardiac output was mildly reduced at 4.0 ± 1.4 L/min, with elevated right-atrial pressure (14 ± 12 mm Hg) and pulmonary capillary wedge pressure (19 ± 7 mm Hg). Over a median follow-up of 6.3 years, 22% of patients died. Patients with PVR ≥ 2.5 WU had lower RMST over 5 years compared with patients with PVR < 2.5 WU. ConclusionPH is common in patients undergoing TVR/TVr, with combined pre- and postcapillary being the most common type. PVR ≥ 2.5 WU is associated with lower survival at 5-year follow-up.

Abstract 13180: Ultrasound Jugular Venous Pressure Collapse Point Predicts Elevated Right Atrial Pressure on Right Heart Catheterization in Obese and Nonobese Patients

Introduction: Accurate intravascular volume status assessment is central to heart failure management, but current non-invasive bedside techniques remain a challenge. Visual inspection of jugular venous pulsation (JVP) is used as a surrogate for central venous pressure (CVP). Studies have shown variability and inaccuracy of the JVP exam in estimating CVP or right atrial pressure (RAP). Published methods of RAP estimation through internal jugular vein (IJV) ultrasonography are either complex or require offline analysis. We validated a simplified approach to ultrasonography of the JVP (uJVP) as a method to predict RAP. Methods: Adult patients undergoing right heart catheterization (RHC) were enrolled prior for IJV imaging with point of care ultrasound (POCUS) device, Butterfly iQ™. The IJV was identified on ultrasound with the patient reclined (head of bed between 30-45°) and followed cranially until tapering smaller than the adjacent carotid artery throughout the entirety of the respiratory cycle. The height of this collapse point from the sternal angle added to 5 centimeters was defined as ultrasound JVP (uJVP). Results: 77 participants underwent uJVP assessment on the same day prior to RHC. Average BMI was 33 kg/m 2 . The area under the curve (AUC) of uJVP and RAP greater than 10mmHg on RHC was 0.879 (95% CI 0.759-0.931, p&lt;0.001), with AUC of 0.972 and 0.818 for non-obese and obese subgroups respectively, and AUC of 0.876 for elevated RAP and pulmonary capillary wedge pressure (PCWP). A uJVP cutoff of 9 or higher was 85% sensitive and 72% specific at identifying RAP greater than 10mmHg. Conclusion: We developed and validated a novel technique identifying the uJVP using POCUS which correlates with invasive RAP regardless of obesity. This technique predicted combined elevated left and right sided intracardiac pressures. The uJVP’s potential to enhance the diagnostic value of the bed-side examination in an increasingly obese heart failure population warrants further research.

Abstract 16244: Point of Care Ultrasound of the Jugular Venous Pulse in the Upright Position (u 2 Jvp) Predicts Elevated Right Atrial Pressure and Pulmonary Capillary Wedge Pressure on Right Heart Catheterization in Obese and Non-obese Patients

Introduction: Accurate intravascular volume status assessment is central to heart failure management, but current non-invasive bedside techniques remain a challenge. The visual inspection of jugular venous pulsation (JVP) in a reclined position and measuring its height from the sternal notch has been used as a surrogate for right atrial pressure (RAP). There are no studies on the predictive value of a visible internal jugular vein (IJV) in the upright position (U 2 JVP). Hypothesis: Point of care ultrasound (POCUS) for volume assessment in the upright position is predictive of clinically significant hypervolemia. Methods: Adult patients undergoing right heart catheterization (RHC) were enrolled prior for IJV imaging with point of care ultrasound (POCUS) device, Butterfly iQ™. The IJV and its size in comparison to the carotid artery was identified on ultrasound with the patient upright. Elevated RAP and PCWP was present if the IJV was still visible and not collapsed throughout the entirety of the respiratory cycle. Valsalva was used to confirm the position of a collapsed IJV. Results: 72 participants underwent U 2 JVP assessment on the same day prior to RHC. Average BMI was 31.9 kg/m2. The area under the curve (AUC) of U 2 JVP predicting RAP greater than 10 mmHg and PCWP of 15 mmhg or higher on RHC was 0.78 (95% CI 0.66-0.9, p&lt;0.001), with AUC of 0.86 and 0.74 for non-obese and obese subgroups respectively, p= 0.38. The finding of a visible U 2 JVP in the upright position was 70.6 % sensitive and 85.5 % specific with a negative predictive value of 90.4% for identifying both RAP greater than 10 mmHg and PCWP equal or greater than 15 mmHg. Conclusions: The U 2 JVP is novel and pragmatic bed-side approach to the assessment of clinically significant elevated intra-cardiac pressures in our increasingly obese heart failure population.

Left atrial deformation in estimating left atrial pressure

Abstract Background In the absence of mitral valve disease, elevated left atrial (LA) pressure reflects reduced left ventricular (LV) compliance and raised diastolic pressures, hence an important explanation for exertional breathlessness. Methods We studied 145 symptomatic patients, age 63±14 years, 55 males, using conventional transthoracic echocardiography guidelines protocol, including LA and LV myocardial deformation investigations along with simultaneous right heart catheterization using conventional techniques. From invasive measurements, pulmonary artery pressure (PAP), pulmonary capillary wedge pressure (PCWP) were measured and pulmonary vascular resistance (PVR) calculated. No patient had more than mild mitral or aortic valve disease. Results LA strain rate during atrial systole (LASRa) was the strongest correlate with PCWP (r2=−0.39, p&amp;lt;0.001), over and above LASR during LV systole (LASRs) and peak LA longitudinal strain (PALS) (r2=−0.21 and −0.19, respectively, p&amp;lt;0.001 for both). Both LASRa and PALS predicted elevated PCWP &amp;gt;15 mmHg but only modestly (AUC= 0.55 and 0.52). The relationship between LASRa and PCWP was stronger in patients with post-capillary pulmonary hypertension compared to those with pre-capillary pulmonary hypertension (r2=0.21 vs. r2=0.02). However, the strongest relationship between LASRa and PCWP was in patients with LA volume &amp;gt;34 ml/m2 (r2=0.59, p&amp;lt;0.001, see figure) but other strain relationships did not improve after only including patients with increased LA volume. Finally, LASRa correlated modestly with the respective LVSRa (r=0.53, P&amp;lt;0.01), and to lesser extent with other cavity interaction correlations (r=0.26–0.48, p&amp;lt;0.01). Conclusion Despite being somehow related to ventricular function, left atrial strain rate during atrial contraction is the closest correlate to PCWP, particularly in patients with dilated LA cavity. These data should be of significant clinical value in daily management of symptomatic patients. LASRaecho and PCWPrhc in patients with d Funding Acknowledgement Type of funding source: None

Assessing the Validity of Echocardiographic Criteria for Left Ventricular Diastolic Dysfunction in Patients with Pulmonary Hypertension

Background: In patients with pulmonary hypertension (PHT), the assessment of left ventricular (LV) diastolic function by echocardiography may not be reliable. PHT can affect Doppler parameters of LV diastolic function such as mitral inflow velocities and mitral annular velocities. The current guidelines for the assessment of LV diastolic function do not recommend specific adjustments for patients with PHT. Methods: We analyzed 36 patients from the PHT clinic that had an echocardiogram and right heart catheterization performed within 6 months of each other. Early mitral inflow velocity (E), lateral mitral annular velocity (lateral e’), septal mitral annular velocity (septal e’), tricuspid free wall annular velocity (RV e’) were measured and compared to the invasively measured intracardiac pressures including pulmonary capillary wedge pressure (PCWP), mean pulmonary artery pressure, and right ventricular end-diastolic pressure. Results: Among patients with PHT, the specificity of the septal e’ for LV diastolic dysfunction was 0.19, and the positive predictive value was 0.13 (lower than the lateral e’ or E/average e’). By receiver-operating characteristic curve analysis, the area under the curve (AUC) of lateral and septal e’ was just 0.64 (p = 0.9) and 0.53 (p = 0.6), respectively, while the AUC of average E/e’ was 0.94 (p < 0.001). The septal e’ was paradoxically lower at 6.5 ± 1.9 cm/s for normal PCWP compared to 6.9 ± 1.7 cm/s for elevated PCWP (p = 0.04). 81 versus 40% (p = 0.017) of patients with normal versus elevated PCWP had an abnormal septal e’ <7 cm/s. By linear regression, there was no correlation between the Doppler parameters of LV diastolic function and the PCWP. Conclusion: Our study suggests E/average e’ may be the only reliable tissue Doppler parameter of LV diastolic dysfunction in patients with PHT, and that septal e’ is paradoxically decreased in patients with PHT and normal left-sided filling pressures.

A Clinical Prediction Model for Normalization of Pulmonary Vascular Resistance After Left Ventricular Assist Device Implantation

Background Patients with heart failure with reduced ejection fraction (HFrEF) and elevated pulmonary vascular resistance (PVR) are at risk increased for poor outcomes and may be ineligible for heart transplantation (HT). Left ventricular assist device (LVAD) therapy can lower PVR for certain patients, but it is difficult to identify these patients preoperatively. Methods Using the INTERMACS registry, we developed a clinical prediction model to predict the likelihood of PVR normalization (≤ 3 WU) or HT within 1 year of LVAD implant among patients with baseline PVR > 3 WU. Backwards stepwise selection was used to select variables from 14 candidate predictors and logistic regression was used to estimate model coefficients. Model performance was summarized using measures of discrimination (c-statistic) and calibration (Harrel's EAVG). Internal validation was performed using bootstrap resampling over 200 iterations to generate an average calibration slope, which was used to uniformly shrink all model coefficients to generate the final model. Results There were 2209 patients available for analysis. Median preoperative PVR was 4.26 WU (IQR 3.54-5.54 WU) and the median time from LVAD implant to postoperative PVR assessment was 3 months. 1596 patients (72%) experienced PVR normalization or were transplanted within 1 year. 412 (19%) patients died and 201 (9%) were alive with persistently elevated PVR at 1 year. Final model coefficients are shown in the Table. Important predictors included older age (OR 0.72 per 10 years), severe baseline mitral regurgitation (MR) (OR 2.49 vs no MR), and increased baseline pulmonary capillary wedge pressure (PCWP) (OR 1.24 per 5 mmHg increase). The model c-statistic was 0.66 and EAVG was 0.004. Conclusion Among patients with elevated PVR, preoperative patient characteristics such as severe MR and elevated PCWP are able to predict the likelihood of PVR normalization or HT within 1 year of LVAD implantation. These findings can help to inform decision making and frame patient expectations regarding anticipated improvements in pulmonary vascular disease following LVAD surgery. Future studies are needed to investigate potential management strategies to increase the likelihood of PVR normalization with LVAD support.

Hypotensive Response on Cardiopulmonary Stress Test Predicts Elevated Pulmonary Capillary Wedge Pressure and Reduced Cardiac Output in Patients Undergoing Evaluation for Left Ventricular Assist Device

Purpose Cardiopulmonary stress test (CPX) and right heart catheterization (RHC) are integral part of the routine evaluation for ventricular assist device (LVAD) therapy. A hypotensive response, or failure to augment systolic blood pressure at peak stress above resting values might be a marker of high-risk physiology. We sought to evaluate the association between hypotensive response on CPX and invasive hemodynamics in patients undergoing LVAD evaluation. Methods This was a retrospective single center study of consecutive adult patients who underwent LVAD surgery at our center between 1/2011 and 1/2019. Only patients with both CPX and RHC performed within 12 months of implantation were included. Hypotensive response was defined as a peak exercise systolic blood pressure lower than the resting systolic blood pressure. Central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP) and cardiac index determined using the thermodilution method (CI) were collected from RHC data. Multivariable Cox regression analysis was performed to evaluate the association between CPX data and hemodynamics. Results A total of 313 patients were included in the study and 115 met inclusion criteria. The mean age was 60.1 years, 66% were designated bridge to transplant (BTT) and the majority (85%) were classified as INTERMACS 3-5. Forty seven percent (54/115) developed a hypotensive response during testing. The group had a mean PCWP of 23.7 mmHg and a mean CI of 1.7 L/min/m2. In contrast, patients with normal blood pressure response had a significantly lower PCWP (19.8 mmHg; P=0.011) and significantly higher CI (2.0 L/min/m2; p=0.030). There was no difference in CVP values between the groups. Mean exercise duration was 6 minutes and 1 seconds in the hypotensive group, and 7 minutes 8 seconds in the group with normal blood pressure response. Conclusion A hypotensive response on CPX performed prior to LVAD implantation is associated with more severely abnormal hemodynamics. Identification of this high risk feature earlier has the potential to improve outcomes by preventing late LVAD implantation.

Longitudinal Strain and Strain Rate for Estimating Left Ventricular Filling Pressure in Heart Transplant Recipients

Traditional parameters have limited value to estimate left ventricular filling pressure (LVFP) in orthotropic heart transplant (OHT) recipients. We hypothesized that global longitudinal strain (GLS), diastolic, and systolic strain rate (SR) would be depressed in OHT recipients with elevated LVFP and could overcome the limitations of traditional parameters. We studied consecutively OHT patients at the time of endomyocardial biopsies and retrospectively pretransplantation studies conforming to the same protocol. Comprehensive echocardiography with strain measurements was performed. Results were compared with pulmonary capillary wedge pressure (PCWP) obtained from right heart catheterization that was performed just after the echocardiography study. In all, 74 studies were performed in 50 OHT recipients. Mean PWCP was 11.8 ± 4.3 mm Hg (range: 4 to 25 mm Hg). Several parameters, but not left atrial volume index, mitral inflow velocities, annular velocities, and their ratio (E/e'), were different between studies with normal (n = 47) and elevated PCWP (n = 27). Area Under Curve for GLS (0.932*), E/e'SR (0.849*), and systolic SR (0.848*) (*p <0.0001) were more accurate than traditional parameters for predicting PCWP>12 mm Hg. GLS, systolic SR and E/e'SR remained accurate regardless of LV ejection fraction and allograft vasculopathy. Meanwhile, E/e' was accurate to predict PWCP in native failing hearts before transplantation. Changes in GLS and E/e'SR tracked accurately changes in PCWP. In conclusion, traditional indices of diastolic function perform poorly in OHT recipients, whereas GLS and E/e'SR provide reliable means of LVFP, irrespective of ejection fraction and allograft vasculopathy. These parameters also track reasonably well the changes in LVFP.

The Differential Impact of the Left Atrial Pressure Components on Pulmonary Arterial Compliance–Resistance Relationship in Heart Failure

An increase in the pulmonary capillary wedge pressure (PAWP) has been shown to impact on the inherent relationship between the pulmonary arterial compliance (PAC) and pulmonary vascular resistance (PVR), thus augmenting the pulsatile relative to the resistive load of the right ventricle. However, the PAWP comprises the integration of both the steady and the pulsatile pressure components. We sought to address the differential impact of the these distinct PAWP components on the PAC-PVR relationship in a cohort of patients with heart failure. The study population consisted of 192 patients with hemodynamic findings diagnostic for heart failure. Off-line analysis was performed using the MATLAB software. The steady and pulsatile PAWP components were calculated as mid-A pressure and mean pressure during the V-wave oscillation, respectively. The PAC and PVR were hyperbolically and inversely associated and the subgroup of patients with PAWP above the median (>18 mm Hg) displayed a significant left and downward shift of the curve fit (P < .001). The shift in the PAC-PVR fit between patients with higher versus low steady PAWP was not significant (P = .43). In contrast, there was a significant downward and leftward shift of the PVR-PAC curve fit for the subgroup with a higher pulsatile PAWP (P < .001). Furthermore, only the pulsatile PAWP was significantly associated with the time-constant of the pulmonary circulation, assessed as the PAC × PVR product (P < .001). In patients with heart failure, the pulsatile rather than the steady PAWP component stands for the previously documented shift of the PAC-PVR relationship occurring at an elevated PAWP.

Echocardiography to estimate high filling pressure in patients with heart failure and reduced ejection fraction.

AimsEchocardiographic assessment of left ventricular filling pressures is performed using a multi‐parametric algorithm. Unselected sample of patients with heart failure with reduced ejection fraction (HFrEF) patients may demonstrate an indeterminate status of diastolic indices making interpretation challenging. We sought to test improvement in the diagnostic accuracy of standard and strain echocardiography of the left ventricle and left atrium (LA) to estimate a pulmonary capillary wedge pressure (PCWP) > 15 mmHg in patients with HFrEF.Methods and resultsOut of 82 consecutive patients, 78 patients were included in the final analysis and right heat catheterization, and echocardiogram was performed simultaneously. According to the univariable analysis, E wave velocity, the ratio between E‐wave/A‐wave (E/A, area under the curve [AUC] = 0.81, respectively), isovolumic relaxation time (AUC = 0.83), pulmonary vein D wave (AUC = 0.84), pulmonary vein S/D Ratio (AUC = 0.85), early pulmonary regurgitation velocity (AUC = 0.80), and accelerationa time at right ventricular out‐flow tract (RVOT AT, AUC = 0.84) identified with the highest accuracy PCWP > 15 mmHg. They were all tested in multivariate analysis, and they were not independently correlated with PCWP. Tricuspid regurgitation (TR) velocity was measurement with the highest predictive value in identifying PCWP > 15 mmHg (AUC = 0.89), compared with other established parameters such as the ratio between e‐wave velocity divided by mitral annular e' velocity (E/e'), deceleration time, or LA indexed volume (LAVi), which all reached a lower accuracy level (AUC = 0.75; 0.78; 0.76). Among strain measures, global longitudinal strain in four chamber view (GLS 4ch), the ratio between e‐wave velocity divided by mitral annular e' strain rate (E/e'sr), and LA longitudinal strain at the reservoir phase were helpful in estimating elevated PCWP (AUC = 0.77; 0.76; 0.75). According to multivariable analysis, the following two models had the greatest accuracy in detecting PCWP > 15 mmHg: (i) TR velocity, LAVi, and E wave velocity (receiver operating characteristic [ROC]‐AUC = 0.98), (ii) AT RVOT, LAVi and GLS 4ch (ROC‐AUC = 0.96). Neither E/A (ROC‐AUC = 0.81) nor E/e' (ROC‐AUC = 0.75) was an independent predictor when included in the model. The two MODELS were applicable to the entire population and demonstrated better agreement with the invasive reference (91% and 88%) than the guidelines algorithm (77%) regardless of the type of rhythm.ConclusionsOur suggested echocardiographic approach could be used to potentially reduce the frequency of “doubtful” classification and increase the accuracy in predicting elevated left ventricular filling pressure leading to a decrease in the number of invasive assessment made by right heart catheterization.

Protek Duo Rapid Deployment cannulation utilized to bridge to durable heartware left ventricular assist device

A 43-year-old gentleman was transferred for management of acute on chronic cardiogenic shock (left ventricular ejection fraction < 10%). Upon arrival, we inserted a left axillary intra-aortic balloon pump for hemodynamic support. He underwent an emergent left and right-heart catheterization which showed patent stents and coronaries, in the setting of severely elevated pulmonary artery and pulmonary capillary wedge pressure. On hospital day 35, we escalated support to Centrimag in conjunction with a 31 French Protek Duo Rapid Deployment cannula. A centrimag cannula apical sewing cuff was sewn in continuous fashion along the left ventricular apex. Via modified seldinger technique, we tunneled the Protek Duo Rapid Deployment cannula through the silastic sewing cuff and the ventricular apex, traversing the aortic valve. On hospital day 50, he underwent left anterior thoracotomy and mini-sternotomy for implantation of durable Heartware left ventricular assist device. He was discharged home off inotropes and had resumed his normal activities. He is currently listed as status four for heart transplantation.

Efficacy of Left Ventricular Assist Device Therapy in Cold and Dry Chronic Heart Failure Patients

LVAD therapy has been primarily studied in patients with elevated pulmonary capillary wedge pressure (PCW) and low cardiac index (CI), "cold and wet". In daily practice, LVADs are often also offered to patients with low PCW and low CI, "cold and dry". The efficacy of LVAD therapy in this population is not well studied. Patients implanted with LVAD with a baseline CI <2.0 Lpm were categorized as "wet" (PCW>18mmHg) or "dry" (PCW<18mmHg). These values were derived from serial pre-LVAD right heart catheterization studies in order to reflect a sustainable hemodynamic profile. Variables of interest and 3-year survival were compared between groups. Independent predictors of mortality were identified using multivariate Cox regression analysis. Serial invasive hemodynamics data was available for 92 pts (cold-dry group, n=34 and cold-wet group, n=58) (Table). Diuretic and vasodilator use pre-LVAD was comparable in both groups. Cold-dry patients had no change in CVP or PCW with a smaller increase in CI after LVAD. Adjusted 3-year mortality was higher for cold-dry patients (Figure). Age (HR=1.09, 95%CI 1.02-1.2; p=006) and cold-dry profile (HR=5.4, 95%CI 1.4-21; p=0.016) were identified as independent predictors of mortality. "Cold and dry" patients with advanced heart failure may not derive equal benefit from LVAD therapy as those who are "cold and wet". This observation warrants further investigation.

Unplanned HM3 Heart Failure-Related Hospitalizations: Reclassifying Post-Discharge Right Ventricular Failure

Heart failure-related hospitalization (HFH) after continuous-flow left ventricular assist device (CF-LVAD) implant remains prevalent. Our primary aim was to better elucidate the extent of HFH in patients supported by HM3 resulting from predominant right (RHFS) versus left (LHFS) HF syndrome. We also re-classified INTERMACS-defined RHF by the underlying HFS phenotype. Retrospective data were extracted on patients with HFH post-HM3 implant at our institution (January 2017-May 2019) for demographics, hemodynamics by echocardiogram and/or right heart catheterization, and detailed physical exam findings. Data from each HFH were used to categorize the underlying HFS phenotypes (Table 1). HFH is defined as re-hospitalization post-index implant with a fluid overload syndrome and use of parenteral diuretics. INTERMACS RHF is defined by elevated right atrial pressure requiring the use of varying degrees of right ventricular support, including the sole use of parenteral diuretics. Statistical analyses used the Fisher exact t-test (SAS, version 9.4). One hundred forty-three patients defined the HM3 study cohort. Twenty-three patients (mean age 57.7 ± 11.2 years) had HFH (16.1% prevalence), with a median time to first HFH of 65.6 days post-implant. HFH was due to LHFS in 11 patients (47.8%; 2 LHFS and 9 BiV HFS) and predominant RHFS in 12 patients (52.2%). Twenty-one patients met criteria for INTERMACS-defined RHF (14.7% prevalence). By categorical phenotyping, an elevated pulmonary capillary wedge pressure (PCWP) >15 mm Hg was noted in 42.9% of these cases. BiV HFS and predominant RHFS account for most HFH post-HM3 implant. LHFS account for nearly half of the post-discharge INTERMACS-defined RHF re-hospitalizations. Further examination of the predictors and underlying causes of partial LV unloading, and the implications on long-term outcomes including survival and functional capacity is warranted.

Implications of Early Hemodynamic Profiling after Continuous-Flow Left Ventricular Assist Device Implantation

Optimal hemodynamics is associated with improved outcomes in patients with continuous-flow left ventricular assist device (CF-LVAD). Our primary aim was to define the hemodynamic profiles of patients on CF-LVADs, and explore the impact of partial LV unloading on the prevalence of elevated right atrial pressure (RAP) in these patients. Retrospective data on demographics and invasive hemodynamics (early post-implant during index hospitalization and late post-discharge at median 4.7 months) were extracted on patients at our institution with CF-LVAD implants from January 2017-July 2019. Hemodynamic profiles are categorized as optimal or non-optimal (Table 1), and partial LV unloading is defined as pulmonary capillary wedge pressure (PCWP) >15 mm Hg. Statistical analyses used the Fisher's exact test (SAS, version 9.4). Two hundred fifty-nine patients had CF-LVAD implants. Seventy-eight patients (mean age 57.1 ± 10.2 years) had invasive hemodynamics at both time-points early post-implant and late post-discharge (Table 1). Early post-implant, 15 patients (32.1%) had optimal hemodynamics and 71 patients (68%; 18 LHF, 28 BiV HF, and 7 RHF) had non-optimal hemodynamics. The majority of patients with RAP >12 mm Hg had a coexisting elevated PCWP [early post-implant (28 of 35 patients, 80%) or late post-discharge (22 of 28 patients, 78.6%)]. The absence (hazard ratio 2.99, p=0.01) versus presence (hazard ratio 0.72 p=0.34) of early partial LV unloading in the setting of an elevated RAP is associated with an increased risk of death and hospitalizations at 6-months post-implant. Partial LV unloading with concomitant elevated RAP early post-implant is associated with better event-free survival in comparison to patients with isolated elevated RAP. Future analysis of a validation cohort on these observations and their association with long-term outcomes is warranted.

Left Atrial Strain Correlates with Elevated Filling Pressures in Pediatric Heart Transplantation Recipients

Noninvasive assessment of diastolic function in pediatric heart transplantation (PHTx) patients is important for monitoring of rejection, cardiac allograft vasculopathy, and nonspecific graft failure. We hypothesized that left atrial strain (LAS) would correlate with pulmonary capillary wedge pressure (PCWP) and that cutoff values to identify elevated left ventricular (LV) filling pressure could be derived for clinical practice and future testing. This was a secondary analysis of a prospectively collected cohort of PHTx patients undergoing same-day cardiac catheterization with biopsy and transthoracic echo. There were 70 patients with 85 clinical encounters. Traditional mitral inflow Doppler, LAS, LV diastolic strain and strain rate, and ratios for mitral E to LV diastolic strain and strain rate were assessed. Correlation with PCWP was performed, and receiver operator characteristic curves were generated for an elevated mean PCWP, acute rejection, and cardiac allograft vasculopathy. Decreased LAS during the atrial reservoir phase (Ɛres) correlated with higher invasively measured PCWP (r=-0.40, P<.001). An Ɛres cutoff of 14.5% had good discriminatory ability for an elevated PCWP (sensitivity 75%, specificity 82%), and Ɛres>22.0% had 100% negative predictive value; Ɛres was superior to other measures of diastolic function. Subanalyses for recent acute rejection (n=9) showed good discriminatory ability for Ɛres of 14.5% (sensitivity 89%, specificity 74%). LAS correlates with invasively measured PCWP and can identify elevated pressures better than traditional and other advanced diastolic function parameters. Use of LAS in PHTx patients may aid in noninvasive monitoring for rejection and nonspecific graft dysfunction.

P820 Echocardiographic assessment of late-onset right ventricular dysfunction following continuous-flow left ventricular assist device

Abstract Early right ventricular failure (RVF) remains one of the main factors associated with early mortality following continuous-flow left ventricular assist device (LVAD) implantation. However, late-onset RVF (LoRVF) has emerged as an increasing concern, but little is known about its incidence rate and the value of transthoracic echocardiography (TTE) to predict this complication during the LVAD follow-up. Methods and results We retrospectively analyzed the 1-year hemodynamic and clinical data from patients (p) that, between 2016 and 2018, underwent a right heart catheterization (RHC) after LVAD as bridge to transplantation (BTT). 73 p (84% males, 52 ± 12 years, 49% Heart Ware LVAD, 51% Heart Mate 3 LVAD), out of 187 LVAD implants, were studied. According to the Intermacs definition, LoRVF was assigned if the RHC showed a central venous pressure (CVP)&amp;gt;18 mmHg with cardiac index&amp;lt; 2.3 L/min/m2. Isolated LoRVF was assigned if LoRVF was present in the absence of elevated pulmonary capillary wedge pressure (PCWP) ≤15 mmHg. TTE was performed at the time of the RHC and the following parameters were obtained: parasternal long-axis left ventricular end diastolic diameter (LVEDD), basal (RVED1) and mid-cavity (EDRV2) end diastolic RV linear dimension in 4 chamber view, severity of tricuspid regurgitation (TR) and of mitral regurgitation (MR), tricuspid annular plane systolic excursion (TAPSE), and the position of the LVAD inflow cannula (IC). LoRVF was present in 16 p (22% of the studied population): 12 p (75%) presented a PCWP &amp;gt; 15 mmHg and 4 p (25%) presented isolated LoRVF. Symptoms and signs of venous congestion were present in 2/3 of the p with LoRVF and elevated PCWP. On the other hand, all the p with isolated LoRVF presented severe signs of venous congestion, and 50% of them could be successfully transplanted in high urgent status. P with LoRVF showed more dilated RV (RVED1 43.8 ± 9.2 vs 37.7 ± 5.3 mm, p = 0.02) and lower TAPSE (11 ± 2 vs 14 ± 2 mm p &amp;lt; 0.01) than the no LoRVF group. RVED1 showed a weak significant correlation with CVP (R = 0.3, p = 0.02). On the other hand, the presence of an elevated PCWP was not related to etiology of the cardiomyopathy, type and speed of LVAD, position of the IC, LVEDD, nor the presence of MR &amp;gt; mild. Conclusion LoRVF is a frequent complication during LVAD support as BTT and most of the cases are associated with persistent elevated PCWP. Isolated LoRVF, which is not associated with high PCWP, has a bad prognosis. RV evaluation with TTE during the clinical follow-up can be useful to detect LoRVF. However a persistent elevated PCWP is not associated with echocardiographic signs of incomplete unloading of the LV by the LVAD.

1231 Left atrial septal and lateral wall strains contain different pressure information: Utility in pulmonary hypertension

Abstract Funding Acknowledgements South-Eastern Norway Regional Health Authority Background Reduced left atrial (LA) reservoir strain is a marker of elevated LA pressure. Thus it could be a potential non-invasive marker to differentiate pre- and post-capillary pulmonary hypertension (PH) as the latter is defined by elevated pulmonary capillary wedge pressure (PCWP) &amp;gt; 15 mmHg. However, in pre-capillary PH patients with elevated right atrial pressure (RAP), the atrial septal geometry may be abnormal. This could lead to lower regional LA septal strain, making LA lateral wall strain more accurately reflect PCWP. Purpose We investigated if LA lateral wall strain can differentiate between pre- and post-capillary PH, and how LA lateral wall strain and LA septal strain are both affected by elevated RAP in pre-capillary PH. Furthermore we investigated if LA septal strain can be used in pre-capillary PH patients to identify those with elevated RAP. Methods We analysed 63 patients with PH, 28 pre-capillary and 35 post-capillary, who underwent right heart catheterisation. Echocardiography was performed simultaneously with or within 24 hours of the invasive pressure measurements. Regional LA septal strain and lateral wall strain were measured from the apical four chamber view. Results Pulmonary artery pressure was 39.5 ± 11.1 mmHg (mean ± SD) in the pre-capillary PH patients and 37.0 ± 10.1 mmHg in the post-capillary PH patients (p = ns). Mean PCWP was 9.9 ± 2.5 mmHg and 24.5 ± 6.0 mmHg (p &amp;lt; 0.001), respectively. LA lateral wall strain was significantly lower in patients with post-capillary PH compared to pre-capillary PH (11.9 ± 7.7% vs 26.6 ± 9.9%, p &amp;lt; 0.001) (Fig. a,b). At a cut-off value of 18.0%, LA lateral wall strain could predict elevated PCWP &amp;gt; 15 mmHg with AUC = 0.88, sensitivity = 85.7% and specificity = 76.3%. In the 28 patients with pre-capillary PH, we classified mean RAP ≥ 10 mmHg as elevated and &amp;lt; 10 mmHg as normal. Seven of these patients had elevated RAP and showed significantly reduced LA septal strain compared to the 21 patients with normal RAP (13.0 ± 6.2% vs 22.1 ± 7.6%, p &amp;lt; 0.01). LA lateral wall strain showed no difference in these groups of pre-capillary PH patients (25.8 ± 10.1% vs 28.9 ± 9.4%) (Fig. c). Conclusions LA lateral wall strain can be used for differentiating between pre- and post-capillary PH. In addition, LA septal strain may be used in pre-capillary PH patients to identify those with elevated RAP. Abstract 1231 Figure

P2452Application of left atrial strain for differentiation between pre- and post-capillary pulmonary hypertension

Abstract Background Pulmonary hypertension (PH) is classified as pre- or post-capillary PH, and pulmonary capillary wedge pressure (PCWP) &gt;15 mmHg is used as criterion for post-capillary PH. Elevated left atrial (LA) pressure is associated with reduced LA reservoir strain. Thus, LA strain may potentially serve to differentiate between these diagnoses. Objectives This study tested the hypothesis that LA strain can be used as a noninvasive parameter to differentiate between pre- and post-capillary PH. Methods We analyzed 103 patients (mean age: 58 years, 51 female) referred to right heart catheterization due to unexplained dyspnea or suspected heart failure. Echocardiography was performed within 24 hours of the invasive procedure. Mean pulmonary artery pressure (PAP) was noninvasively estimated from tricuspid regurgitation (TR) velocity and inferior vena cava (IVC) diameter and collapsibility. LA reservoir strain was calculated from apical four-chamber view by speckle tracking echocardiography, and was feasible in 101 patients. Results Twenty-eight patients were invasively confirmed with pre-capillary PH and 43 patients with post-capillary PH. The remaining 32 patients had no PH. LA reservoir strain was significantly lower in patients with post-capillary PH than patients with pre-capillary PH (9.9±5.5% vs. 24.6±8.2%, p&lt;0.01). At a cut-off value of 15.4%, LA reservoir strain could predict elevated PCWP &gt;15 mmHg with AUC=0.88, sensitivity=84.8% and specificity=81.8%. As shown in the figure, echocardiography with LA reservoir strain correctly differentiated 82% of patients into pre- and post-capillary PH. Conclusions These results suggest that LA reservoir strain can be used to predict elevated PCWP, thus allowing discrimination between pre- and post-capillary PH.

Utility of Pacemaker With Sleep Apnea Monitor to Predict Left Ventricular Overload and Acute Decompensated Heart Failure

Pacemakers with sleep apnea monitor (SAM) provide an easy tool to assess obstructive sleep apnea over long periods of time. The link between respiratory disturbances at night and the incidence of acute decompensated heart failure (ADHF) is not well established. We aimed at (1) determining the ability of SAM pacemakers to evaluate the extent of left ventricular overload and (2) assess the impact of respiratory disturbances at night on the occurrence of ADHF over 1-year of follow-up. We conducted a single-center prospective study. Consecutive patients with SAM pacemakers were comprehensively assessed. SAM automatically computes a respiratory disturbance index (RDI, apneas/hypopneas per hour - AH/h) in the previous night and the percentage of nights with RDI >20 AH/h in the previous 6 months. Thirty-seven patients were included (79.3 ± 11.2 years, 46% males). A high RDI in the previous night and a higher %nights with increased RDI were associated with increased NT-proBNP values (p = 0.008 and p = 0.013, respectively) and were the sole predictors of increased noninvasive pulmonary capillary wedge pressures (PCWP) in the morning of assessment (p = 0.031 and p = 0.044, respectively). Receiver operating characteristic curve analysis revealed an area under the curve of 0.804 (95% confidence interval 0.656 to 0.953, p = 0.002) for %nights with RDI >20 AH/h in the prediction of high PCWP. Patients with >12.5% of nights with RDI >20AH/h tended to have more ADHF during follow-up (log-rank p = 0.067). In conclusion, a high burden of apneas/hypopneas at night is associated with elevated NT-proBNP and PCWP values and an increased risk of ADHF over 1 year. These patients might benefit from early tailored clinical management.

A Case Series of Biopsy-Proven Eosinophilic Myocarditis at a Tertiary Care Center

BackgroundThere is limited published literature on acute eosinophilic myocarditis (EM), a rare form of acute myocarditis, wherein eosinophils invade the myocardium with wide-ranging clinical sequalae. We aim to describe our experience in the largest contemporary case series of histologically-proven EM.MethodsTwo authors independently reviewed the surgical pathology and autopsy databases for acute EM (01/2009 to 12/2017). Only patients with endomyocardial biopsy/autopsy and clinical course consistent with acute EM were included. We abstracted demographic data, comorbidities, clinical diagnostics, and clinical outcomes.ResultsSeven patients had acute EM (Table). The average age was 53-years and five subjects were women. The most common etiology of EM was idiopathic. Five patients had peripheral eosinophilia. Three patients had elevated pulmonary capillary wedge pressure and three patients had reduced cardiac output. Six patients were treated with steroids, four of whom received IV pulse dosed steroids. Two patients required intra-aortic balloon pump support, one of whom subsequently underwent durable left ventricular assist device implantation. Two patients died during index hospitalization, one of septic shock and one of refractory ventricular tachycardia.ConclusionThe etiologies, clinical presentation, and course of acute EM varied widely. Prompt diagnosis, treatment with immunosuppression, and circulatory support may reduce cardiovascular mortality in this population. There is limited published literature on acute eosinophilic myocarditis (EM), a rare form of acute myocarditis, wherein eosinophils invade the myocardium with wide-ranging clinical sequalae. We aim to describe our experience in the largest contemporary case series of histologically-proven EM. Two authors independently reviewed the surgical pathology and autopsy databases for acute EM (01/2009 to 12/2017). Only patients with endomyocardial biopsy/autopsy and clinical course consistent with acute EM were included. We abstracted demographic data, comorbidities, clinical diagnostics, and clinical outcomes. Seven patients had acute EM (Table). The average age was 53-years and five subjects were women. The most common etiology of EM was idiopathic. Five patients had peripheral eosinophilia. Three patients had elevated pulmonary capillary wedge pressure and three patients had reduced cardiac output. Six patients were treated with steroids, four of whom received IV pulse dosed steroids. Two patients required intra-aortic balloon pump support, one of whom subsequently underwent durable left ventricular assist device implantation. Two patients died during index hospitalization, one of septic shock and one of refractory ventricular tachycardia. The etiologies, clinical presentation, and course of acute EM varied widely. Prompt diagnosis, treatment with immunosuppression, and circulatory support may reduce cardiovascular mortality in this population.