Elevated PVR Research Articles

BMP10 reflects pre-capillary pulmonary hemodynamics: association of biomarkers and hemodynamic parameters in pulmonary hypertension

Abstract Background and aims The role of biomarkers in diagnosing pulmonary hypertension (PH) and distinguishing between pre- and post-capillary PH remains poorly understood. We aimed to identify biomarkers with a strong association with mean pulmonary arterial pressure, mPAP (PH diagnosis) and pulmonary vascular resistance, PVR (pre-capillary component), but not with pulmonary arterial wedge pressure, PAWP (post-capillary component). Methods Blood samples were collected in patients undergoing right heart catheterization within a prospective cross-sectional study. Biomarkers measured included BMP10, NT-proBNP, ANG2, ESM1/endocan, FGF23, GDF15, IGFBP7, IL6, MyBPC3, proC3, and proC6/endotrophin. Primary outcomes were mPAP, PVR, and PAWP, while secondary outcomes included PH diagnosis (mPAP > 20 mmHg) and elevated PVR (> 2 Wood units). Multivariable linear and logistic regression models were used to assess the relationship between biomarkers and outcomes. Results Of the 127 patients included (age 66 ± 13 years, 54% female), 73% were diagnosed with PH. BMP10, NT-proBNP, ANG2, MyBPC3, and FGF23 showed a strong association with mPAP (p < 0.001). BMP10 and NT-proBNP were strongly associated with PVR (p < 0.001), while NT-proBNP and ANG2 were strongly associated with PAWP (p < 0.001). NT-proBNP had the strongest association with the diagnosis of PH (area under the curve = 0.76). BMP10 was the only biomarker associated with elevated PVR (OR 1.60, 95%CI 1.01–2.54, p = 0.04) but not with PAWP (p = 0.86). Conclusions Several biomarkers were strongly associated with mPAP, PAWP, and PVR. BMP10 was the only biomarker strongly associated with mPAP and PVR, but not with PAWP, thus reflecting the pre-capillary PH component. Measurement of BMP10 along with NT-proBNP may aid in diagnosing PH. Graphical abstract

Importance of heart failure duration for development of pulmonary hypertension in advanced heart failure

Background and objectivesPulmonary vascular resistance (PVR) is critical when evaluating candidacy for advanced heart failure (HF) therapies, but risk factors for elevated PVR are not well studied. We hypothesized that HF duration would be associated with elevated PVR. MethodsDanish single-center registry of consecutive in- and outpatients undergoing right heart catheterization as part of advanced HF work up. The relation between HF duration and PVR was estimated by regression analysis. Finally, the relation between PVR and long-term mortality was assessed by Cox proportional hazards regression and Kaplan-Meier analyses. ResultsA total of 549 patients (77% men, median age 54 (43–61) years, median HF duration 1.6 years (0.1–7.1)) were included. Univariate linear regression displayed an association between longer HF duration and increasing PVR (p = 0.014). PVR > 3 WU was present in 92 patients (17%) who were older (median p < 0.001) and had longer HF duration (p = 0.03). HF duration (per 1 year increase) did not predict PVR > 3 WU after adjustment for covariables (OR 1.00; p = 0.99). During a mean follow-up time of 4.5 years, there were 240 (44%) deaths. Increasing PVR was associated with elevated all-cause mortality risk (adjusted HR 1.24; p < 0.001). PVR > 3 WU was associated with higher mortality (adjusted HR 1.49; p = 0.027). ConclusionLonger duration of HF was associated with higher PVR in patients with advanced HF, but this association disappeared in multivariate analyses. Longer HF duration per se likely does not cause elevated PVR and should not discourage evaluation for heart transplantation.

Echocardiographic estimation of pulmonary vascular resistance in advanced lung disease.

Noninvasive assessment of pulmonary hemodynamics is often performed by echocardiographic estimation of the pulmonary artery systolic pressure (ePASP), despite limitations in the advanced lung disease population. Other noninvasive hemodynamic variables, such as echocardiographic pulmonary vascular resistance (ePVR), have not been studied in this population. We performed a retrospective analysis of 147 advanced lung disease patients who received both echocardiography and right heart catheterization for lung transplant evaluation. The ePVR was estimated by four previously described equations. Noninvasive and invasive hemodynamic parameters were compared in terms of correlation, agreement, and accuracy. The ePVR models strongly correlated with invasively determined PVR and had good accuracy with biases of <1 Wood units (WU), although with moderate precision and wide 95% limits of agreement varying from 5.9 to 7.8 Wood units. The ePVR models were accurate to within 1.9 WU in over 75% of patients. In comparison to the ePASP, ePVR models performed similarly in terms of correlation, accuracy, and precision when estimating invasive hemodynamics. In screening for pulmonary hypertension, ePVR models had equivalent testing characteristics to the ePASP. Mid-systolic notching of the right ventricular outflow tract Doppler signal identified a subgroup of 11 patients (7%) with significantly elevated PVR and mean pulmonary artery pressures without relying on the acquisition of a tricuspid regurgitation signal. Analysis of ePVR and determination of the notching pattern of the right ventricular outflow tract Doppler flow velocity envelope provide reliable insights into hemodynamics in advanced lung disease patients, although limitations in precision exist.

The Correlation of Diabetes Mellitus and Urinary Retention From Intravesical OnabotulinumtoxinA Injection for Overactive Bladder.

The objective was to determine whether patients with diabetes mellitus (DM) treated with intravesical onabotulinumtoxinA (BoNT) injection for overactive bladder (OAB) had increased urinary retention requiring clean intermittent catheterization (CIC), as well as the impact of disease duration and severity. We hypothesize that patients with DM will have higher rates of retention after BoNT injection. We performed a retrospective cohort analysis of women in the Kaiser Permanente Southern California Health System who underwent BoNT injection for OAB, excluding women with a history of urinary retention or neurogenic bladder. We identified 565 patients, 410 in the control group and 155 in the DM group. No significant difference was found in the rate of CIC (9% in the control group versus 5.8% in the DM group, P = 0.2), voiding dysfunction, and peak postprocedure postvoid residual volume (PVR). Patients with diabetes had a significantly increased rate of postprocedure urinary tract infection (UTI; 27.6% versus 38.1%, P = 0.02). Urinary tract infection was significantly associated with urinary retention (adjusted odds ratio [OR], 2.26; 95% confidence interval [CI], 1.02-4.99; P = 0.045) and peak PVR ≥200 mL (adjusted OR, 2.42; 95% CI, 1.15-5.06; P = 0.019). Diabetic disease duration and severity were not a predictor of urinary retention, elevated PVR, or voiding dysfunction; however, the presence of ≥1 disease-related complication was a predictor of UTI (adjusted OR, 2.81; 95% CI, 1.34-5.91; P = 0.006). Diabetic patients had a similar rate of urinary retention requiring CIC after BoNT injection for OAB compared with nondiabetic patients. Diabetic patients had an increased risk of UTI based on disease severity.

Neuromuscular Paralysis is not a Barrier to Same Day Catheter Removal After HoLEP

To determine if same day catheter removal is feasible in a population of holmium laser enucleation of the prostate patients who received paralysis and if bladder pressure monitoring could predict successful catheter removal. From February 2021 to February 2022, we evaluated same day catheter removal for patients undergoing holmium laser enucleation of the prostate. Criteria for proceeding with same day catheter removal included: an uncomplicated procedure, continuous bladder irrigation weaned within 120 minutes of arrival to PACU, minimal postoperative hematuria and a bladder pressure over 30 cmH20 as measured using the VP Test device (SRS Medical). One hundred and eight patients were enrolled, with a median age of 68 years (IQR: 62.0-73.0) and prostate volume 80.8cc (IQR: 64.8-112.3). Criteria for catheter removal was met by 83/108 (76.9%) patients. Of those that attempted a trial of void, 69/83 passed for an effective pass rate of 83.1%. Median maximum detrusor pressure for those that passed and failed were 51.0 cmH20 (IQR: 40.5 -68.0) and 48.0 cmH20 (IQR: 38.8-61.8) [P=.53], respectively. Intraoperative Lasix administration was associated with a higher rate of trial of void (TOV) success and preoperative PVR was associated with lower TOV success, with OR (95%CI) of 5.8 (1.4, 29.5) [P=.02] and 0.6 (0.4, 0.9) [P=.01], respectively. Same day catheter removal is feasible in those who receive neuromuscular paralysis, with a success rate >80%. Bladder pressure monitoring did not assist with differentiating which patients will pass or fail a trial of void. Intraoperative Lasix administration may be helpful in increasing success for same day catheter removal while elevated preoperative PVR was associated with TOV failure.

Pre-Operative Urodynamic Assessment Has Poor Predictive Value for Developing Post-Operative Urinary Retention

BackgroundPost-operative urinary retention (POUR) following primary total joint arthroplasty (TJA) has a reported prevalence up to 35%. Risk factors for POUR have included surrogate markers such as the presence or absence of urologic disease. Pre-operative dynamic measurement with post-void residual volumes (PVR) has not been investigated as a tool for assessing POUR risk. MethodsAll male TJA patients underwent an institutional pre-operative screen for POUR, including PVR measurements, patient-derived subjective urinary retention scores, and assessment of urologic disease. The prospectively collected data were retrospectively reviewed. Proportions were evaluated with the chi-squared test, while continuous variables were evaluated by logistic regression analysis. Receiver-operator characteristic curves were utilized to determine the efficacy of using urodynamic variables as a predictor of developing POUR. ResultsTwo hundred fifty-two male patients were reviewed who had a mean age of 64.9 years and mean body mass index of 30.8 kg/m2. The overall rate of POUR was 5.1%. Patient urinary retention scores were not associated with POUR. Elevated pre-operative PVR (>10 cc) alone and in combination with a history of urologic disease was significantly associated with POUR. However, both had low positive predictive values (10.5% and 18.2%), despite high negative predictive values (99.2% and 97.9%). Utilization of PVR resulted in moderate sensitivity (91.6%) and low specificity (72.1%) with an area under the curve of 0.69. ConclusionUrodynamic measurements and patient urinary retention scores, as part of an institutional pre-operative screening protocol, have limited value in determining which patients are at increased risk of POUR. The utility of obtaining these measurements pre-operatively is questionable.

Abstract 16534: Pulmonary Artery Tapering Pattern on Chest CT-Angiogram Predicts Phenotype of Pulmonary Hypertension

Introduction: Non-invasive methods to identify phenotype of pulmonary hypertension (PH) are essential to improve the diagnostic algorithm of PH. Hypothesis: Delayed tapering of pulmonary artery (PA) is a signature of pre-capillary PH, while in post-capillary PH, the PA tapers rapidly. This differential tapering pattern of PA can be detected on a chest CT-angiogram (CTA), and quantified as a ratio of main PA diameter to PA branch diameter (right or left) at 5.0 cm length after the PA bifurcation. Methods: We identified 30 subjects with chest CTA and PH confirmed with invasive right heart catheterization (RHC). We identified 3 PH phenotypes: 1. “PVD” (pulmonary vascular disease) = Pre-capillary PH (n=10, PVR&gt;3.0 WU, PAWP &lt;15mmHg), 2. “Mixed” = pre- and post-capillary PH (n=10, PVR&gt;3.0 WU, PAWP &gt;15mmHg), and 3. “PVH” (pulmonary venous hypertension) = post-capillary PH (n=10, PVR&lt;3.0 Woods units [WU], PAWP &gt;15mmHg). Results: The results are summarized in Table. Additional results are expressed as comparison among the three groups in order: PVD vs Mixed vs PVH (mean±SD, % or n, as appropriate). CTA-chest findings: RV basal diameter (mm)= 51.1±8.4 vs 51.0±5.4 vs 38.1±13.9, left ventricular (LV) basal diameter (mm)= 32.1±7.2 vs 31.6±13.3 vs 56.6±15.2*, PA:Ao ratio= 1.1±0.1 vs 1.1±0.2 vs 1.0±0.1. Echo findings: tricuspid annular plane systolic excursion (TAPSE, mm)= 16±3 vs 19±4 vs 22±10*. We performed ROC to identify predictive ability of PA:RPA-5 and PA:LPA-5 to predict PVR&gt;3 WU. The AUC for PA:RPA-5 = 0.859 (p=0.03) and for PA:LPA-5 = 0.812 (p=0.01); with optimal cut-off for both parameters (PA:RPA-5 and PA:LPA-5) was 1.85. Among the overall cohort, the patients with PA:RPA&lt;1.85, 15/16 had PVR&gt;3 and 11/16 were on PH meds. Conclusion: Pattern of PA tapering quantified with PA:RPA-5 or PA:LPA-5 can reliably identify elevated PVR (&gt;3.0 WU). Pre-capillary PH imprints a signature morphological mark on the pattern of PA dilation that can be identified with a CTA-thorax.

Validation of the best practice policy statement on urodynamic antibiotic prophylaxis for the high-risk patient in the era of antibiotic stewardship.

To validate the recommendations of the Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction (SUFU) 2017 Best Practice Policy Statement (BPPS) for Urodynamic Antimicrobial Prophylaxis in high-risk patients. After institutional review board approval, 489 patients who underwent urodynamics (UDS) in the absence of antibiotic prophylaxis were retrospectively reviewed. Patients were stratified according to the SUFU BPPS risk factors (neurogenic lower urinary tract dysfunction [NLUTD], elevated postvoid residual [PVR], immunosuppression, age over 70, catheter use, and orthopedic implants). χ2 , Fisher's exact test, Student t test, and univariate and multiple logistic regression analyses were used to assess the associations between these risk factors and postprocedural urinary tract infection (UTI). Twenty-two (4.5%) patients developed symptomatic postprocedural UTI. Univariate analysis revealed statistical differences in the incidence of UTI in patients with elevated PVR and NLUTD groups. The variables that were associated with UTI on multivariate analysis were elevated PVR (odds ratio [OR]: 4.91, 95% confidence interval [CI], 1.92-12.56, P = .001) and NLUTD (OR: 4.84, 95% CI, 1.75-3.37, P = .002). The data analysis for all other high-risk groups failed to show significant correlations with UTI on univariate or multivariate analysis. Patients with three risk factors were more likely to develop UTI than patients with 1 or 2 risk factors. No patient developed pyelonephritis, sepsis, or joint infection. Elevated PVR, NLUTD, and possessing three risk factors were significant predictors for post-UDS UTI. All other risk factors were not associated with postprocedural UTI. Morbidity associated with UTI was low. Antimicrobial prophylaxis for these conditions should be reconsidered.

Use of a symptom-based questionnaire to screen for the presence of significant voiding dysfunction in patients with multiple sclerosis and lower urinary tract symptoms: a pilot study

IntroductionLower urinary tract dysfunction is common in people with multiple sclerosis, leading to overactive bladder symptoms, voiding difficulties or a combination. First-line medications for overactive bladder symptoms are effective. Current guidelines recommend measuring post-void residual volume (PVR) before commencing these treatments, as they can potentially exacerbate voiding difficulties in those with significant underlying voiding dysfunction (pre-treatment PVR > 100 ml). However, facilities to do so are not readily available to all clinicians, potentially delaying effective therapy.AimsTo conduct a pilot study investigating the association between lower urinary tract symptoms and PVR volume in people with multiple sclerosis using a validated questionnaire and to determine if questionnaire scores can be used to exclude a significantly elevated (> 100 ml) PVR volume.MethodsPatients with multiple sclerosis referred to a tertiary hospital uro-neurology service completed the Urinary Symptom Profile questionnaire and underwent PVR measurement by bladder ultrasound. A ratio of the questionnaire low stream score/total score was calculated to standardise the relative degree of voiding symptoms compared to overall lower urinary tract symptoms.ResultsOf 40 patients (29 females, mean age 50 years), 30% had an elevated PVR volume. PVR volume was correlated with low stream score and ratio of low stream/total score. A cut-off of > 0.15 for low stream/total score ratio had 92% sensitivity and 71% specificity in predicting an elevated PVR volume.ConclusionA symptom-based questionnaire maybe a useful screening tool to distinguish patients in whom PVR measurement is required from those who could safely start on treatment for overactive bladder symptoms.

RIGHT VENTRICULAR SUPPORT IN FAT EMBOLISM SYNDROME: A ROLE FOR PULMONARY VASODILATORS AND EXTRACORPOREAL MEMBRANE OXYGENATION?

SESSION TITLE: Clinical Conundrums in ECMO SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/20/2019 01:00 pm - 02:00 pm INTRODUCTION: Pulmonary fat embolism (PFE) is a common phenomenon in the setting of orthopedic trauma. Of all patients with PFE, only a minority go on to develop the more catastrophic fat embolism syndrome (FES) that is characterized primarily by hypoxemia, altered mentation, fever, and petechiae. Thought to occur as a result of mechanical embolization of fat from the bone marrow coupled with a dysregulated inflammatory response, FES has a mortality of up to 20% with clinical decompensation primarily driven by acute cor pulmonale and RV failure [1]. CASE PRESENTATION: A 39-year old male with a history of GERD presented to the ED after suffering a traumatic femur fracture and went for operative fixation on the same day. The next day, he decompensated with fever (100.9F), tachycardia (140-150 bpm) and hypoxemia (SpO2 85% on RA). Exam was notable for moderate respiratory distress, an S3 gallop, cool extremities, and bilateral lower extremity edema. Labs were notable for leukocytosis (17,000 /mm3), hemoglobin 11.3 gm/dL, normal renal and liver function, and an A-a gradient of 192mmHg (45% FiO2) with an increased pulmonary shunt fraction. Troponin and BNP were mildly elevated. CTA demonstrated an enlarged RV, dilated PA, and bilateral interstitial infiltrates with no pulmonary embolus. Lower extremity US was negative for DVT. TTE showed a hyperdynamic and under-filled LV as well as a markedly dilated RV with severely depressed systolic function and an estimated RVSP 75 mmHg. His condition worsened, with RHC demonstrating severely elevated mPAP (60mmHg) and PVR (7.4 Wood units). He continued to deteriorate requiring increasing high flow oxygen support. The decision was made to cannulate for VA-ECMO and initiate on inotropes as well as pulmonary vasodilators. After 7 days, he was decannulated and continued on vasodilator therapy. At 1-month follow-up, RV function had normalized, and vasodilator therapy was discontinued. DISCUSSION: Management of FES in this patient was extrapolated from treatment algorithms for massive thrombotic PE with cor pulmonale, including use of extracorporeal support and pulmonary vasodilators. Treatment of FES remains relatively under-investigated and is based on data from case reports and case series. Interventions may include heparin, aspirin, corticosteroids, and albumin, but the quality of evidence supporting these therapies is low [2]. At present, there are no published descriptions of pulmonary vasodilator use in patients with FES. CONCLUSIONS: ECMO and pulmonary vasodilator therapy may help support patients with severe respiratory failure due to FES [3]. Further research into these modalities is warranted. Reference #1: Fabian TC, Hoots AV, Stanford DS, Patterson CR, Mangiante EC. Fat embolism syndrome: prospective evaluation in 92 fracture patients. Crit Care Med. 1990;18(1):42-46. Reference #2: Bederman SS, Bhandari M, McKee MD, Schemitsch EH. Do corticosteroids reduce the risk of fat embolism syndrome in patients with long-bone fractures? A meta-analysis. Can J Surg J Can Chir. 2009;52(5):386-393. Reference #3: Webb DP, McKamie WA, Pietsch JB. Resuscitation of fat embolism syndrome with extracorporeal membrane oxygenation. J Extra Corpor Technol. 2004;36(4):368-370. DISCLOSURES: No relevant relationships by Samuel McElwee, source=Web Response No relevant relationships by Takudzwa Mkorombindo, source=Web Response No relevant relationships by Raymond Wade, source=Web Response No relevant relationships by Keith Wille, source=Web Response

Impact of preoperative urodynamics on women undergoing pelvic organ prolapse surgery.

Preoperative urodynamic studies (UDS) are frequently performed before pelvic organ prolapse (POP) surgery to assess urethral and bladder function. The primary goal of this study is to examine how preoperative UDS are utilized and what value these studies have in patient treatment and/or counseling. We retrospectively reviewed patients who underwent prolapse surgery and had preoperative UDS between June 2010 and February 2015. Indications for UDS were classified into four categories: (1) occult stress urinary incontinence only, (2) overactive bladder symptoms, (3) mixed or insensible urinary incontinence, and (4) voiding symptoms and/or elevated post-void residual. We identified changes in management or counseling that were directly attributable to UDS results prior to surgery. Three hundred ninety-two patients underwent urodynamic testing for indications 2-4 above, and 316 met the inclusion criteria. Fifty-seven percent (180/316) had OAB symptoms (34.4% wet, 65.6% dry), 40.2% (127/316) had mixed incontinence, and 17.1% (54/316) had voiding symptoms and/or elevated PVR. A total of 3.5% (11/316) patients had alteration in their management or counseling based on the results of the UDS; 29.4% (50/170) of the women evaluated for occult SUI alone or with other symptoms demonstrated it and 41 underwent sling placement. UDS did not have a significant impact on preoperative management or counseling in POP surgery if demonstration of occult SUI was not the indication for preoperative study in women committed to POP surgery. Major alterations in treatment were rare and occurred mostly in women with stress incontinence that also had concomitant voiding symptoms and/or elevated PVR.

Urodynamic factors associated with the large capacity bladder and incomplete emptying after prolapse repair (2009-2015).

To identify the clinical and urodynamic factors associated with the large capacity bladder and incomplete bladder emptying after prolapse repair. We identified 592 women who underwent anterior and/or apical prolapse repair at our institution from 2009 to 2015. Women were stratified by urodynamic capacity. The primary outcome was incomplete emptying at the longest follow-up (postvoid residual [PVR] > 200 mL). Data were analyzed in the Statistical Analysis System software. Two hundred and sixty-six women (mean age, 61 years) had preoperative urodynamic tracings available for review. After surgery, there were 519 PVRs in 239 women recorded at up to 2949 days (mean, 396) and nine time points (median, 2; IQR, 1-3). The receiver operator curve for predicted probability of longest follow-up PVR greater than 200 mL (area under curve = 0.67) identified the 600 mL cutpoint which defined large capacity bladder. Large capacity bladders (capacity, >600 mL [n=79] vs ≤600 mL, [n=160]) had a mean: detrusor pressure at maximum flow (21 vs 22 cm H2 O; P = 0.717), maximum flow rate (19 vs 17 mL/s; P = 0.148), significantly elevated PVR (202 vs 73 mL; P < 0.001), and significantly lower voiding efficiency (VE) (74 vs 82%, P < 0.05). Following prolapse repair, elevated PVR was associated with large capacity (PVR 101 vs 49 mL, P < 0.05). Large bladders had a two- to three-fold risk of longest follow-up PVR greater than 200 mL (14.3%-20.3% [capacity, >600 mL] vs 4.1%-7.0% [capacity, ≤600 mL]). VE was similar after surgery regardless of the capacity (87% vs 88%, P = 0.772). The decision to pursue prolapse repair should be individualized and take into account, the bladder capacity and goals for PVR improvement after surgery.

Left Ventricular Assist Devices in Pulmonary Hypertension Group 2 With Significantly Elevated Pulmonary Vascular Resistance: A Bridge to Cure

Pulmonary hypertension secondary to left heart disease (WHO Group 2) is a known risk factor in patients with heart failure. The favourable effect of left ventricular assist devices (LVAD) on pulmonary hypertension has been demonstrated before, although this effect has not been well-studied in advanced pulmonary arterial bed disease with a significant elevation in pulmonary vascular resistance. We reviewed the records of 258 LVAD patients in our institution. Patients with elevated mean pulmonary artery pressure (mPAP>25mmHg) and elevated pulmonary vascular resistance (PVR ≥3 Wood units) were included in the study. Patients were divided into two groups based on their baseline PVR (PVR=3-5 Wood units (WU) vs. PVR>5WU). The groups were studied for the changes in their pulmonary haemodynamics after the placement of LVAD. Fifty-one (51) patients were included in the study. All patients showed a significant improvement in their pulmonary haemodynamic parameters post LVAD placement. In the group with the higher PVR, mPAP dropped from a baseline of 43±7mmHg to 22±6mmHg post LVAD placement (p<0.001), while PVR dropped from 6.3±1.2 Wood units to 2.2±1.1 Wood units (p<0.001). In a subgroup of patients who underwent cardiac transplantation post LVAD (n=14), all patients maintained a normalised PVR (<3WU) one year post cardiac transplantation. Left ventricular assist devices can reverse pulmonary hypertension WHO Group 2 with significantly elevated PVR; this effect is not dependent on the baseline PVR, and is maintained up to one year post cardiac transplantation.

Elevated post-void residual volume in a geriatric post-hip fracture assessment in women-associated factors and risk of mortality.

Multiple factors contribute to elevated post-void residual urine volumes (PVR), but they may indicate detrusor underactivity (DU), especially in older women. The aim here was to examine factors associated with and prognostic significance of elevated PVR in a geriatric post-hip fracture assessment in a female population. Consecutive female hip fracture patients (n = 409) aged 65years and older were included. PVR was measured by bladder scanner. PVR of 160ml or more was deemed elevated. Age-adjusted univariate logistic regression analyses were conducted to examine the association of the domains of the comprehensive geriatric assessment (CGA) with elevated PVR. Cox proportional hazards model was used to determine the age-adjusted association of an elevated PVR with 1-year mortality. Of the patients, 64 (15.6%) had elevated PVR. Having urinary or fecal incontinence, difficulties in physical activities of daily living, malnutrition, poor performance on Timed Up and Go and Elderly Mobility Scale were significantly associated with elevated PVR. Difficulties in instrumental activities of daily living, renal dysfunction, constipation, polypharmacy, nocturia, cognitive impairment and depressive mood were not associated with elevated PVR. Elevated PVR significantly increased the risk of mortality 1 year post hip fracture. Elevated PVR is relatively common in older female hip fracture patients and associated with physical functioning, malnutrition and risk of mortality. Even though a causal relationship cannot be confirmed, the findings may suggest a relationship between DU and physical frailty. PVR deserves to be included in the CGA of frail older patients including women.

135 - Elevated Post-Void Residual Urine Volume: Identifying Risk Factors and Predicting Resolution

Study Objective: Evaluate the resolution rate of elevated post-void residual urine volume (PVR) in patients undergoing reconstructive surgery for pelvic organ prolapse (POP), and identify risk factors for elevated preoperative PVR and persistently elevated postoperative PVR.

Loss of Small Vessel Volume Fraction as a Marker for Pulmonary Hypertension in COPD

SESSION TITLE: Pulmonary Hypertension SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: Pulmonary hypertension develops in a subset of subjects with COPD, and when present is accompanied by increasing morbidity and mortality. Early diagnosis, prognostication and selection of subjects that may benefit from pulmonary vasodilatory therapy remains challenging. In prior work it has been shown that smokers show evidence of pulmonary vascular pruning in 3D reconstruction of the pulmonary vasculature. In this study we examine changes to the pulmonary vascular tree in patients with COPD and pre-capillary pulmonary hypertension proven by right heart catheterization (PAH). METHODS: A retrospective database query of subjects with diagnosis of COPD and PH possessing ct angiograms yielded approximately 200 subjects. From these, 21 subjects with non-elevated PCWP (<15mmHg), PH (elevated PVR and mPAP) and FEV1/FVC of less than 70% by PFT were selected. Of these, seven had 1mm cuts appropriate for reconstruction. A cohort of 15 subjects having undergone right heart catheterization, imaging and exercise testing with no evidence of cardiopulmonary disease was used as control subjects. Vascular reconstruction was performed as previously described. Small vessel volume fraction, defined as the vascular volume in small vessels (less than 5mm2 in cross-sectional area) divided by total vascular volume, was used to measure pruning. Association was tested using a two-tailed t-test, assuming unequal variances. RESULTS: Seven patients (Age 65.7±10.5) with COPD (FEV1pp 61.7±6.8%) were identified with precapillary PAH (mPAP 45±14.3mmHg; PVR 8.6±6WU; mPCWP 10.8±2.2mmHg, max 14mmHg). Fifteen subjects (Age 46 ; mPAP 15mmHg; PVR 1.1 WU; mPCWP 9mmHg) were used as controls. Subjects with PAH and COPD had significant proximal dilation and distal loss of vasculature, which was quantified by dividing the volume in small vessels (defined as those with cross sectional area of less than 5mm2 ) by the total volume of the vasculature detected. Small vessel volume fraction in the COPD group was lower (0.37 ± 0.12) as compared to control subjects (0.55 ±0.11) with a p-value of 0.006 for the comparison. CONCLUSIONS: The vascular pruning previously described in smokers is quantifiable from CT angiography in subjects with precapillary pulmonary arterial hypertension in the context of significant COPD burden. CLINICAL IMPLICATIONS: Measurement of pulmonary vascular morphology in smokers may be useful in detecting and subtyping the extent of pulmonary vascular disease in smokers. DISCLOSURE: The following authors have nothing to disclose: Farbod Rahaghi, Viviana Paz, James Ross, Raúl San José Estépar, George Washko, Franck Rahaghi Image processing techniques for reconstruction of the vasculature used are currently in exploratory stage and appropriate only for research purposes.

Contralateral Pulmonary Hypertension Following Resuscitation of Unilateral Ductal Origin of a Pulmonary Artery: A Multi-institutional Review.

In isolated unilateral ductal origin of a pulmonary artery (DOPA), intervention to establish reperfusion of the affected lung without direct re-anastomosis may lead to pulmonary hypertension (PH) in the contralateral lung. Multicenter retrospective review of patients with unilateral DOPA, who underwent palliation with a ductal stent (DS) or Blalock-Taussig (BT) shunt with subsequent development of PH in the contralateral lung, was conducted. Ten patients (4 females; median weight 3.2kg, range 2.1-5.2) who underwent DS or BT shunt and developed contralateral PH were identified. Eight infants had right-sided DOPA. Stents/shunt used had a median diameter of 3.5mm (range 2.5-5.2). After DS in 9 patients, 7 patients were exclusively treated with medical therapies, whereas 2 patients received intermediate procedures: one received an additional contralateral DS and other underwent surgical banding of the DS prior to PA reimplantation. Seven patients who underwent DS and one patient with BT shunt underwent PA reimplantation at median of 3.3 (0.6-18) months. PA pressure was documented to be normal in 5 patients immediately following PA reimplantation, 1 year later in 2 patients, and 1 patient is on Tadalafil with elevated PVR of 5.5 indexed Wood units. One patient died and one patient is awaiting surgery with normal PA pressure. We describe the development of severe contralateral PH following DS or BT shunt as the initial intervention for unilateral DOPA. Pulmonary hypertension resolved in 7/8 patients who underwent surgical PA reimplantation. The cause of PH in the normally connected lung in these cases remains unclear.

Natural history of post-void residual urine volume over 5 years in community-dwelling older men: The Concord Health and Ageing in Men Project.

To describe the natural history of post-void residual urine volume (PVR) in community-dwelling older men. The Concord Health and Ageing in Men Project involves a representative sample of community-dwelling men aged 70 and older in a defined geographic area of Sydney, Australia. PVR were measured at baseline and 2-year and 5-year follow-up. The measurements were considered valid when the voided volumes were 150 mL and over. Three-hundred twenty-nine men without conditions that are likely to alter PVR (neurological disorders, prostate cancer, and a history of urological treatment) were included in the analyses. Baseline PVR were 0-49 mL in 183 men, 50-99 mL in 59 men, 100-199 mL in 72 men, 200-399 mL in 11 men, and 400 mL and over in 4 men. Thirteen out of 314 (4%) men with a baseline PVR of 0-199 mL and 2 out of 11 (18%) men with a baseline PVR of 200-399 mL had surgery for benign prostate enlargement (BPE) or indwelling catheterization over 5 years compared to three out of four men (75%) with a PVR of 400 mL and over. In all 101 men with a baseline PVR of less than 400 mL who did not receive urological treatment during follow-up and had valid PVR data for both 2-year and 5-year follow-up, PVR did not exceed 400 mL at either follow-up time point. Conservative management may be appropriate for most older men with incidentally found elevated PVR of up to 400 mL.

The Relationship of Anterior Vaginal and Apical Position to Postvoid Residual Urine.

The aim of the study was to investigate the association between severity of anterior vaginal or apical prolapse and postvoid residual volume (PVR). The charts of all women who presented to Urogynecology Clinic at Olive View-UCLA Medical Center for a 2-year period were reviewed. Demographic data, the degree of prolapse pelvic organ prolapse quantification points Aa, Ba, and C, and PVR were recorded. Patients with incomplete pelvic organ prolapse quantification assessment or improperly measured PVR were excluded. Three hundred fifty-two patients were included. Median age was 54 years (range, 26-80). Mean gravidity and parity were 4.4 and 3.7, respectively. Mean body mass index was 29.9 kg/m. One hundred forty-nine women had previous pelvic surgery. Median PVR was 25 mL, and 40 patients (11.4%) had a PVR of 100 mL or greater.Considering 15 potential PVR predictors, we found that the position of apex/cervix (point C) significantly correlated with an increase in PVR and also after controlling for the other significant covariates (rate of change b = 4.7% increase in PVR/cm, P = 0.0007). The other significant (P < 0.05) covariates were gravidity (5.7% per pregnancy), postmenopausal status (32.4%), and vaginal surgical history (61.4%). This was not true, however, for the anterior vaginal position (points Aa, Ba; P > 0.15). There was no difference in mean PVR in patients with versus without a hysterectomy (P = 0.236). Elevated PVR values have long been linked with prolapse of the anterior vaginal wall. We found that there is a linear association between PVR and the anatomic position of the apex. There was no association of PVR with the position of the anterior vaginal wall.

Best practice policy statement on urodynamic antibiotic prophylaxis in the non-index patient.

Antibiotic prophylaxis before urodynamic testing (UDS) is widely utilized to prevent urinary tract infection (UTI) with only limited guidance. The Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction (SUFU) convened a Best Practice Policy Panel to formulate recommendations on the urodynamic antibiotic prophylaxis in the non-index patient. Recommendations are based on a literature review and the Panel's expert opinion, with all recommendations graded using the Oxford grading system. All patients should be screened for symptoms of UTI and undergo dipstick urinalysis. If the clinician suspects a UTI, the UDS should be postponed until it has been treated. The first choice for prophylaxis is a single oral dose of trimethoprim-sulfamethoxazole before UDS, with alternative antibiotics chosen in case of allergy or intolerance. Individuals who do NOT require routine antibiotic prophylaxis include those without known relevant genitourinary anomalies, diabetics, those with prior genitourinary surgery, a history of recurrent UTI, post-menopausal women, recently hospitalized patients, patients with cardiac valvular disease, nutritional deficiencies or obesity. Identified risk factors that increase the potential for UTI following UDS and for which the panel recommends peri-procedure antibiotics include: known relevant neurogenic lower urinary tract dysfunction, elevated PVR, asymptomatic bacteriuria, immunosuppression, age over 70, and patients with any indwelling catheter, external urinary collection device, or performing intermittent catheterization. Patients with orthopedic implants have a separate risk stratification. These recommendations can assist urodynamic providers in the appropriate use of antibiotics for UDS testing. Clinical judgment of the provider must always be considered.