Elevated Right Atrial Pressure Research Articles

Functional status is associated with mean right atrial pressure derived from cardiac MRI

Abstract Background Right atrial pressure (RAP) is a key metric in haemodynamic assessment. Elevated RAP is associated with poor prognosis in heart failure and pulmonary hypertension and physiologically with fluid overload. RAP can be measured invasively or non-invasively, but Cardiac MRI (CMR) currently cannot estimate RAP. Purpose To develop a model to estimate RAP from CMR from paired right heart catheter (RHC) and CMR assessments. Assess correlation to WHO functional status prior to prospective clinical validation studies. Methods Patients were recruited to a registry of those referred for assessment of dyspnoea between 2012 and 2020. Inclusion criteria were age >18 years, signs and symptoms of heart failure and adequate CMR image quality. Patients diagnosed with pulmonary arterial hypertension were excluded. RHC and CMR were performed on the same day. CMR 2- and 4- chamber cines were used to measure chamber dimensions, strain, ejection fraction and stroke volume with operator reviewed AI contours in MASS research software. Pearson’s product-moment correlation coefficient (r ) was used to assess relationships between CMR metrics and invasive mRAP. Variables were then included in stepwise multiple linear regression models to predict mRAP. These were compared with receiver-operator curve analysis and DeLong’s test. Kruskal-Wallis test compared median mRAP between WHO functional class groups. Results The cohort of 672 patients was divided based upon invasive mRAP ≤ 8mmHg (44%) and mRAP > 8mmHg (56%). Higher mRAP was associated with increased age, male sex and a higher diastolic blood pressure but there was no difference in rates of heart failure types although the majority had preserved ejection fraction (51% vs 52%) with few having reduced ejection fraction (4.1% vs 8%). Right atrial (RA) dimensions, strain and ejection fraction had the strongest correlation with mRAP with moderate correlation to right ventricular (RV) measurements. Multivariable models contained simple RA dimensions (model 1), RA dimensions and strain (model 2), RA and RV dimensions (model 3) and RA end systolic volume corrected for body mass index and sex (model 4). All models had similar predictive capability (Figure 1 Panel A). RA end systolic volume was isolated in model 1 as the only variable required for mRAP prediction (coefficient = 0.06, p < 0.001). Using a threshold of mRAP >8mmHg ROC analysis demonstrated an area under the curve of 0.78 (95% Confidence interval 0.75 to 0.81) (Figure 1 Panel B). Worse WHO functional Class at time of assessment was significantly associated with increased CMR derived mRAP (P<0.001) (Figure 2). Conclusions mRAP can be estimated with moderate confidence from CMR RA end systolic volume. Limited available clinical data suggest functional status may be predicted by CMR derived mRAP. Further studies on wider populations are required to validate this model externally, refine it and determine its prognostic clinical significance.

Prognostic Implication of Right Ventricular Free Wall Longitudinal Strain and Right Atrial Pressure Estimated By Echocardiography in Patients With Severe Functional Tricuspid Regurgitation.

The interaction between right ventricular (RV) function and pulmonary hypertension is crucial for prognosis of patients with severe functional tricuspid regurgitation. RV free wall longitudinal strain (RVFWLS) has been reported to detect RV systolic dysfunction earlier than other conventional parameters. Although pulmonary artery systolic pressure measured by Doppler echocardiography is often underestimated in severe functional tricuspid regurgitation, right atrial pressure (RAP) estimated by echocardiography may be viewed as a prognostic factor. Impact of RAP and RVFWLS on outcome in patients with severe functional tricuspid regurgitation remains unclear. The aim of the present study was to investigate prognostic implication of RAP, RVFWLS, and their combination in this population. We retrospectively examined 377 patients with severe functional tricuspid regurgitation. RAP, pulmonary artery systolic pressure, RV fractional area change, and RVFWLS were analyzed. RAP of 15 mm Hg was classified as elevated RAP. All-cause death at 2-year follow-up was defined as the primary end point. RVFWLS provided better prognostic information than RV fractional area change by receiver operating characteristic curve analysis. In the multivariable Cox regression analysis, elevated RAP and RVFWLS of ≤18% were independent predictors of clinical outcome. Patients with RVFWLS of ≤18% had higher risk of all-cause death than those without by Kaplan-Meier curve analysis. Furthermore, when patients were stratified into 4 groups by RAP and RVFWLS, the group with elevated RAP and RVFWLS of ≤18% had the worst outcome. Elevated RAP and RVFWLS of ≤18% were independent predictors of all-cause death. The combination of elevated RAP and RVFWLS effectively stratified the all-cause death.

Abstract 12544: Point-of-Care Ultrasound Estimation of Right Atrial Pressure Predicts Early Readmission in Patients With Acute Decompensated Heart Failure

Introduction: We previously developed and validated a highly accurate non-invasive, point-of-care ultrasound (POCUS) technique that uses right internal jugular vein (RIJV) compliance to predict elevated right atrial pressure (RAP). We sought to determine whether this POCUS technique would predict 30-day readmission in acute decompensated heart failure (ADHF) patients. Hypothesis: POCUS-based estimation of RAP at the time of discharge can predict 30-day readmission in patients with ADHF. Methods: In this prospective cohort study, consecutive patients admitted with ADHF were screened for eligibility. POCUS images of the RIJV at end-expiration and at maximal expansion during Valsalva were collected daily during the patient’s stay. To assess compliance, the change in cross-sectional area (CSA) of the RIJV induced by Valsalva was calculated using ImageJ and referred to as the distensibility index (DI). From ROC analysis, a DI≥66% was considered negative for elevated RAP while a DI<66% was considered positive (PPV 87%). 30 days post-discharge, readmission data were collected from patients’ EMR and a follow-up phone call. Sensitivity/specificity and predictive value analyses were conducted based on readmission data for those discharged with positive and negative tests. Results: A total of 237 admitted patients were eligible for this analysis. Patients discharged with a POCUS-estimated elevated RAP had a 30 day readmission rate 3.5 times greater than those discharged with normal POCUS-estimated RAP (26.7% vs 7.6%). POCUS-based normal RAP at discharge had a 92.4% negative predictive value (NPV) for avoiding 30-day readmission (P<.001). A subset of patients in this cohort (n=81) were admitted to a local community hospital. In this setting, POCUS estimation of RAP at discharge had a 95.7% NPV (P<.001) for avoiding 30-day readmission, and patients discharged with a POCUS-based elevated RAP had a 30-day readmission rate 9.6 times greater than those discharged with a normal POCUS test (41.2% vs 4.3%) . Conclusions: POCUS estimation of RAP strongly predicts avoidance of 30-day readmission for ADHF. Using this technique to guide discharge planning, potentially to reduce readmission for ADHF, deserves further investigation in a prospective randomized trial.

Evaluation of Right-Side Filling Pressure in Patients With Obesity With Heart Failure Using Handheld Ultrasound Score

The goal of this investigation is to evaluate the accuracy of handheld ultrasound score in assessing right atrial (RA) pressure in patients with obesity with heart failure. We prospectively studied 123 patients with heart failure referred for right-sided cardiac catheterization. Handheld ultrasound was performed before catheterization to evaluate volume status by estimating RA pressure using end-expiratory inferior vena cava (IVC) dimension, IVC respiratory collapsibility, and right internal jugular (RIJ) vein respiratory collapsibility. A 3-point simple score was created using multiple logistic regression. The patients were divided into 2 groups based on body mass index. The performance of this score was assessed using the receiver operating characteristics curve in each subgroup and was compared with the performance of the 2-point score (expiratory IVC dimension, IVC respiratory collapsibility). Median age was 58years (interquartile range 48 to 65), and 37% were women. The 3-point score including RIJ performed better than did the 2-point score in patients with obesity (area under the curve 0.84 [0.74 to 0.95]vs 0.69 [0.58 to 0.81], p=0.001). The performance of the scores did not differ in patients without obesity (area under the curve 0.85 [0.74 to 0.95]vs 0.82 [0.71 to 0.93], p=0.49). In patients with obesity, the 3-point score had a specificity of 100% and sensitivity of 21% (11% to 31%) for elevated RA pressure ≥10mm Hg. In conclusion, a 3-point score including both RIJ and IVC assessment performed better in patients with obesity with heart failure and highlights the importance of comprehensive evaluation in patients with obesity to achieve an accurate, noninvasive assessment of volume status.

Prognostic role of inferior vena collapsibility index in congenital heart disease: A validation study

BackgroundA recent study showed that inferior vena cava collapsibility index (IVCCI) <60% had better prognostic performance as compared to the American Society of Echocardiogram (ASE) criteria for estimating right atrial pressure (RAP). However, this study was based on a selected cohort of adults with congenital heart disease (CHD) that underwent right heart catheterization and limiting the generalizability of the results. The purpose of this study was, therefore, to validate the prognostic performance of IVCCI in a more representative sample of adults with CHD, which would in turn, improve generalizability of the results. MethodsRetrospective cohort study of adults with CHD that underwent echocardiogram at Mayo Clinic (2003−2021). Elevated RAP was defined as RAP >10 mmHg, and was estimated using IVCCI <60% or the ASE criteria (maximum IVC diameter < 2.1 cm and IVCCI <50%). Cardiovascular event was defined as heart failure hospitalization, heart transplant or cardiovascular death. ResultsOf the 4029 patients, 754 (19%) and 601 (15%) had elevated RAP (RAP >10 mmHg) based on IVCCI <60%, and the ASE criteria, respectively. Of the 4029 patients, 374 (9%) had cardiovascular events during 7.6 (4.4–10.5) years of follow-up. IVCCI <60% was independently associated with cardiovascular events (adjusted HR 2.08, 95% CI 1.75–2.42; C-statistic 0.708, 95%CI 0.688–0.728), and provided improved prognostic performance as compared to the ASE criteria (C-statistic difference 0.036, 95%CI 0.017–0.055, P = 0.008). ConclusionsIVCCI had superior prognostic performance as compared to the ASE criteria.

Abstract 13758: Distension of the Upright Ultrasound Jugular Venous Pulse is Predictive of All-Cause Mortality in Patients Referred for Right Heart Catheterization

Introduction: Bedside central venous pressure assessment is integral to diagnosing and managing heart failure (HF). A noninvasive point of care ultrasound (POCUS) assessment of the jugular venous pressure (uJVP) was validated as accurate in predicting elevated right atrial pressure (RAP) on right heart catheterization (RHC) in HF patients. A qualitative assessment of uJVP in the upright position (uuJVP) was found to be highly specific for detecting elevated RAP. We compared the prognostic value of the distended uuJVP and elevated RAP in predicting one-year mortality. Hypothesis: We hypothesized that a distended uuJVP was predictive of all-cause mortality. Methods: Adult patients undergoing RHC underwent uuJVP assessment with POCUS. A distended uuJVP was defined as internal jugular venous distention to at least the same size as the adjacent common carotid artery during resting inspiration and expiration (Figure 1c). Patients were examined upright at 90 degrees with their back/neck supported, and followed for one year after undergoing same day uuJVP assessment and RHC. Elevated RAP was defined as ≥10 mmHg on RHC. Kaplan Maier analysis of all-cause mortality was performed. Results: 100 patients had a uuJVP assessment prior to RHC. The distended uuJVP correlated with a mean RAP of 15 mmhg (8.3-17.1 mmHg) (Figure 1d) with a specificity of 94.6% for predicting RAP of ≥10 mmHg. Multivariate cox regression analysis showed that patients with a distended uuJVP had an increased one-year mortality (HR 3.20, 95% [CI 1.24- 8.20], p=.02) similar to those with RAP ≥10 mmHg by RHC (HR 3.21, 95% CI [1.20-8.64], p=.02) (Figure 1a/1b). Of 27 deaths, 11 (40.7%) had positive uuJVP with a specificity of 79.7%, 95% CI (69.2%-88%). Conclusions: The bedside distended uuJVP was similarly predictive of all-cause one-year mortality as elevated RAP by RHC. The clinical application of this simple, qualitative ultrasound estimate of RAP warrants further investigation.

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

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

Abstract 15585: Myocardial Reserve After Milrinone to Predict Right Ventricular Failure After LVAD Implantation

Introduction: Right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation is a common complication associated with increased morbidity and mortality. Identifying patients at risk for RVF remains challenging. We sought to assess pre-operative right ventricular myocardial reserve after milrinone loading as a risk predictor for post-LVAD RVF. Methods: Adult patients implanted with LVADs from 2013-2019 at a single center who had right heart catherization with milrinone drug study within 30-days preoperatively were included. In addition to standard hemodynamic variables, pulmonary artery pulsatility index (PAPI), right atrial to pulmonary capillary wedge pressure ratio (RA/PCWP), right ventricular stroke work index (RVSWI), pulmonary vascular resistance index (PVRi), and stroke volume index (SVI) were recorded before and after milrinone bolus (50 mcg/kg over ten minutes). Incidence of RVF defined by MCS-ARC criteria within one-year post LVAD were recorded. Student’s unpaired t-tests were used to compare mean of hemodynamic markers to RVF outcome. Results: A total 34 patients were included; 38% women, 50% African American, 68% had non-ischemic cardiomyopathy, 47% implanted with HeartMate 3 LVAD, 20.5% with HeartMate 2, and 32% with HeartWare HVAD. Final right atrial pressure (RAP) after milrinone was higher in those with post-LVAD RVF (15.5 + 7.8mmHg vs 9.2 + 3.9mmHg, p=0.005), as was final diastolic PA pressure (34.3 + 9.2mmHg vs 25.6 + 7.7mmHg, p=0.006). SVI post-milrinone was numerically higher in those without post-LVAD RVF (32.3 + 9.2 vs 26.0 + 7.9mL/m 2 , p=0.06). Percent change in PAPI (p=0.26), RA/PCWP (p=0.35), RVSWI (p=0.10), or PVRi (p=0.92) after milrinone were not associated with RVF. Conclusions: Persistently elevated RAP and diastolic PA pressure, despite milrinone infusion, are associated with RVF after LVAD implantation. Continued reduction in SVI post milrinone may also identify patients at risk for post-LVAD RVF.

Role of Inferior Vena Cava Dynamics for Estimating Right Atrial Pressure in Congenital Heart Disease.

Inferior vena cava (IVC) size and collapsibility (IVC dynamics) are used for estimating right atrial pressure (RAP). However, the diagnostic performance of the American Society of Echocardiography IVC criteria for estimating RAP in patients with congenital heart disease are unknown. The purpose of this study was to assess the role of IVC dynamics for estimating RAP in adults with congenital heart disease. We conducted a retrospective study of adults with congenital heart disease that underwent cardiac catheterization and echocardiogram at Mayo Clinic (2003-2019). IVC diameter was measured at inspiration (IVCmin) and end-expiration (IVCmax), and IVC collapsibility index (IVCCI) was calculated. Based on 918 patients, we observed a good correlation between IVCmax and invasive RAP (r=0.56, P<0.001); IVCmin and RAP (r=0.58, P<0.001); and IVCCI (r=-0.72, P<0.001). There was excellent correlation between invasive RAP and estimated RAP using IVCCI (r=0.80, P<0.001). We observed that IVCCI <60% had superior diagnostic performance as compared with American Society of Echocardiography criteria (IVCmax >2.1 cm, area under the curve difference 0.15, P<0.001; IVCCI <50%, area under the curve difference 0.09, P=0.008; combination of IVCmax >2.1 cm; and IVCCI <50%, area under the curve difference 0.06, P=0.02). Estimated RAP >10 mm Hg based on IVCCI had comparable prognostic performance as invasive RAP but superior prognostic performance as the American Society of Echocardiography criteria. IVCCI <60% was the best criterion to identify patients with elevated RAP. IVCCI was comparable to invasively measured RAP in its relation to prognosis. Further studies are required to determine whether the use of IVCCI in clinical decision-making will improve clinical outcomes in this population.

Diagnostic Performance of Pulsed Doppler Ultrasound of the Common Femoral Vein to Detect Elevated Right Atrial Pressure in Pulmonary Hypertension.

Right atrial pressure (RAP) is an important prognostic criterion in pulmonary hypertension (PH). The main goals were to evaluate the following: (i) the accuracy of Doppler assessment of common femoral vein flow waveform to detect elevated RAP and (ii) the diagnostic accuracy of RAP assessed by echocardiography (eRAP). Fifty-seven patients, addressed for right heart catheterization, were included in a retrospective cross-sectional study during a 6-month period. Forty-five patients (78.9%) had PH confirmed by RHC. Elevated RAP was defined by RAP ≥ 10mmHg. Femoral venous stasis index (FVSI) was highly correlated to RAP on both univariate (p < 0.001) and multivariate analysis (p = 0.003), and showed good diagnostic performances to detect elevated RAP (specificity: 92.3% [80.0-99.3], diagnosis accuracy: 90.4 [77.4-97.3], positive likelihood ratio: 12.5 [3.01-51.97]). Diagnosis accuracy of eRAP was only 51.2% (36.2-66.1). FVSI is independently correlated to RAP and a useful tool to predict elevated RAP in PH patients.

Calculation Of Cardiac Power Output With Right Atrial Pressure

<h3>Background</h3> The initial derivation of cardiac power output (CPO) included the difference between mean arterial pressure (MAP) and right atrial pressure (RAP) in the numerator, before multiplying by cardiac output (CO). In common use, CPO is calculated without RAP. Whereas the omission of RAP from the CPO calculation may be inconsequential for those with normal right-sided pressures, we hypothesized that the inclusion of RAP will enhance the prognostic performance of this parameter in those with elevated RAP. <h3>Methods</h3> We retrospectively analyzed consecutive patients undergoing right heart catheterization with milrinone drug study at our institution (2/2013-11/2019). CPO was calculated as [(MAP-RAP)xCO)]/451 Watts (W), and was then analyzed with RAP above or below the median. Univariable analysis was done for the primary outcome of freedom from advanced therapies, defined as need for inotropes, temporary mechanical circulatory support, left ventricular assist device, orthotopic heart transplant, or death at 30 days. Receiver operator characteristic analyses were completed to determine the optimal cutpoints, and Kaplan-Meier (KM) analyses were implemented. <h3>Results</h3> The cohort included 224 patients, median age 57 (IQR 48-66) years, 34% women, and 31% ischemic cardiomyopathy. Median RAP was 13 mmHg. CPO with RAP < 13 were older (61 vs 56 years-old, <i>p=</i>0.001) and had a lower ejection fraction (19% vs 23%, <i>p</i>=0.02) than CPO with RAP ≥ 13. Median CPO with RAP ≤ 13 (n=120) was 0.60 W (IQR 0.49-0.73) and CPO with RAP > 13 (n=104) was 0.52 W (IQR 0.40-0.65). In univariable analysis CPO with RAP ≤ 13 (OR 0.003, 95%CI 0.00-0.05, <i>p</i><0.001) and CPO with RAP > 13 (OR 0.004, 95%CI 0.00-0.08, <i>p</i><0.001) were both significantly associated with the primary outcome. In KM analysis, CPO with RAP ≤ 13 had no significant difference in the primary outcome (54% CPO < 0.67 W vs 73% CPO ≥ 0.67 W, <i>p=</i>0.10), while CPO with RAP > 13 had a significant difference in the primary outcome (55% CPO < 0.67 W vs 87% CPO ≥ 0.67 W, <i>p=</i>0.01). <h3>Conclusion</h3> In the setting of elevated, compared to normal, RAP, there is a significant difference in 30-day clinical outcomes when assessing heart failure patients using the original CPO calculation.

Unsupervised Machine Learning to Identify and Target Myofilament Mechanisms of Clinical RV Dysfunction in HFrEF

<h3>Purpose</h3> Treatments for right heart failure are supportive, with no direct therapies for right ventricular (RV) contractility. Using machine learning (ML), we sought to identify whether clinical RV dysfunction is reflected by impaired contractility in myocytes. Using this model, we then characterized the properties of an ideal sarcomere enhancing drug to restore RV contractility. <h3>Methods</h3> In a cohort of 20 patients with heart failure with reduced ejection fraction (HFrEF), we performed unsupervised ML on right heart catheterization data to obtain phenotypes of RV function. We next collected indices of myofilament mechanical function using a force-length control apparatus to assess permeabilized RV myocytes from hearts explanted from those same patients. We compared indices of myofilament function using a Mann-Whitney Test to identify a corresponding myofilament phenotype concordant with clinical RV dysfunction. <h3>Results</h3> We performed Gaussian Mixture Modeling, a form of unsupervised ML, on four clinical indices of RV function, namely right atrial pressure (RAP), RAP-to-pulmonary capillary wedge pressure ratio (RA/PCWP), pulmonary artery pulsatility index (PAPi), and pulmonary vascular resistance (PVR). Mixture modeling revealed one group of patients with good RV function (n=6) and another with poor RV function (n=14), specifically elevated RAP (p=0.0028) and RAP/PCWP (p=0.0005) and depressed PAPi (p=0.0005). In the group with poor RV function, we found altered myofilament mechanics, namely depressed calcium-activated maximum stress (T_max, p=0.048) and depressed actin-myosin cross-bridge detachment (p=0.050) but no alterations in other myofilament measures. We hypothesized that the optimal sarcomere enhancer to augment RV contractility would be one that augmented RV T_max without altering actin-myosin kinetics. One such drug is EMD57033. We tested EMD57033 in permeabilized RV myocytes in a subset of 10 patients and found that it improved myofilament contractility selectively in patients with depressed RV T_max (group-drug interaction p=0.006). <h3>Conclusion</h3> We used unsupervised machine learning solely on clinical indices of RV function to identify specific myofilament abnormalities indicative of RV dysfunction. EMD57033 selectively remedied the myofilament abnormalities observed in this RV dysfunctional group.

Fontan-associated liver disease.

Fontan-associated liver disease.

Accurate Estimation of Right-Filling Pressure Using Handheld Ultrasound Score in Patients with Heart Failure

IntroductionThis study aims to evaluate the accuracy of bedside assessment of inferior vena cava (IVC) and right internal jugular (RIJ) vein in predicting right atrial (RA) pressure in heart failure patients. MethodsWe prospectively studied 124 heart failure patients who were referred to our catheterization laboratory for right heart catheterizations to assess hemodynamics and to guide heart failure management. Just prior to the procedure, a handheld ultrasound examination was performed in each patient. The volume status was assessed by estimating RA pressure using end-expiratory IVC dimension, IVC respiratory collapsibility, and RIJ respiratory collapsibility. Patients were divided into 2 groups based on invasive RA pressure value. Multiple logistic regression models were used to identify factors associated with RA ≥10 mm Hg; a 3-point simple score was then created. The performance of this score was assessed using the receiver operating characteristics curve. ResultsIn this study 124 heart failure patients were included; median age was 59 years (interquartile range 48-65), and 40% were female. RIJ respiratory collapsibility <50%, end-expiratory IVC dimension ≥21 mm, and respiratory collapsibility <50% were significantly associated with elevated RA pressure, and were used to build the score. The area under the receiver operating characteristics curve (AUC) for the 3-point score was 0.84 (0.77-0.92), and it performed better than 2-point score using IVC characteristics alone (AUC 0.84 [0.77-0.92] vs 0.75 [0.67-0.83]; P = .003). Of 124 patients, 90 patients (72.5%) had concordant RA pressure and pulmonary capillary wedge pressure. ConclusionConcomitant ultrasound assessment of RIJ and IVC correlated better with RA pressure than IVC alone. A simple 3-point score can provide a useful and easily accessible tool to estimate volume status, and further guide management of heart failure patients.

Accuracy of Ultrasound Jugular Venous Pressure Height in Predicting Central Venous Congestion.

Assessment of volume status through the estimation of central venous pressure (CVP) is integral in the care of heart failure (HF). Bedside assessment is limited by obesity, variation in physical examination skills, and expertise in ultrasonography. To validate the accuracy of quantitative and qualitative point-of-care ultrasonography assessment of jugular venous pressure (JVP) in predicting elevated CVP. Prospective observational study using convenience sampling. 2 U.S. academic hospitals. Adult patients undergoing right heart catheterization between 5 February 2019 and 1 March 2021. Estimation of the JVP height by handheld ultrasound device (uJVP), JVP by traditional physical examination, and qualitative presence of a distended uJVP in the upright position (upright-uJVP) was done before invasive measurements. Receiver-operating characteristic analysis of the uJVP was compared with invasive hemodynamics. In 100 participants undergoing right heart catheterization for HF indications (mean age, 59.6 years; 44% with preserved ejection fraction), the uJVP in a reclined position accurately predicted elevated right atrial pressure (RAP) (>10 mm Hg), with an area under the curve of 0.84. A positive uJVP in the upright position was 94.6% specific for predicting elevated RAP. Limited examiners, only 2 centers, and convenience sampling. Point-of-care ultrasonography assessment of the uJVP is feasible, reproducible, and accurately predictive of elevated CVPs in patients undergoing right heart catheterization. Further investigation of clinical application of ultrasound-measured JVP seems warranted. None.

Factors influencing inferior vena cava diameter and its respiratory variation: Simultaneous comparison with hemodynamic data

BackgroundUltrasound assessment of inferior vena cava (IVC) diameter and its respiratory variation is widely used to estimate right atrial pressure (RAP). Generally, the IVC distends as the RAP rises; however, there may be discrepancies between the values. Therefore, it is critical to recognize clinical factors other than RAP that may influence IVC measurements. MethodsWe obtained the IVC maximum diameter and IVC collapsibility index (IVCCI) simultaneously during right-heart catheterization in 71 consecutive patients. Then, we assessed various clinical and hemodynamic factors to elucidate the independent determinants of IVC measurements. Moreover, we tried to generate the regression equation to estimate mean RAP from the IVC maximum diameter and IVCCI. ResultsThe mean IVC maximum diameter and IVCCI were 15 ± 4 mm and 51 ± 15%, respectively. In stepwise multivariate analysis, the higher mean RAP (β = 0.52; p < 0.0001), the presence of significant tricuspid regurgitation (β = 0.31; p = 0.0005), a larger body surface area (β = 0.22; p = 0.0017), and younger age (β = -0.18; p = 0.049) were independently associated with the IVC maximum diameter. Only the mean RAP was independently associated with the IVCCI (β = -0.45; p < 0.0001). The regression equation (R2 = 0.43, p < 0.0001) was as follows: estimated mean RAP = 3.7 + 0.62 × maximum IVC diameter / BSA - 0.07 × IVCCI. ConclusionDistension of the IVC mainly occurs with elevated RAP. However, the presence of significant tricuspid regurgitation, a larger body surface area, and younger age are associated with the IVC maximum diameter, independently of RAP. Interestingly, IVCCI is influenced only by RAP.

Abstract 10952: Increased Hepatic T1 Mapping Prediction of Elevated Right Atrial Pressure in Patients with Dilated Cardiomyopathy

Introduction: Elevated right atrial pressure (RAP) exhibits residual congestion and poor clinical outcomes in patients with heart failure (HF). In HF patients, persistent high RAP causes liver damage, which leads to liver fibrosis. Recent advances in T1 mapping of the liver using MRI allow the quantification of liver fibrosis. Hypothesis: Hepatic T1 mapping value may predicts high RAP in patients with chronic HF. Methods: We examined the data from the consecutive 40 patients with DCM ( 60 ± 13 years, 27 men) who underwent 3 Tesla cardiac and liver MRI, which were conducted within seven days of right heart catheterization. RV end-diastolic volume (RVEDV), end-systolic volume (RVESV), RV ejection fraction (RVEF), right atrial (RA) and left atrial (LA) volume, left ventricular end-diastolic volume (LVEDV), end-systolic volume (LVESV), LV ejection fraction (LVEF) and LV mass index (LVMI) were calculated from cine cardiac MRI. Native T1 mapping image (T1 short modified look locker inversion recovery-ShMOLLI- sequence) was acquired the heart and the liver (Figure A). Patients were divided into two groups according to RAP; high ( ≥ 8 mmHg; n=10) and low ( &lt;8 mmHg; n=30). Results: Ten patients had high RAP. There were no significant differences in LVEDV,LVESV, LVEF, LVMI, RVEDV, RVESV and RVEF between patients with high RAP group and those without ( 192 ± 54 ml vs 212 ± 57 ml; 136 ± 49 ml vs 154 ± 51 ml; 30 ± 9 % vs 28 ± 8 %; 79 ± 21 g/m 2 vs 81 ± 22 g/m 2 ; 45 ± 27 ml vs 46 ± 19 ml; 27 ± 18 ml vs 25 ± 15 ml; 42 ± 19% vs 46 ± 18%, respectively). The hepatic T1 mapping value was higher in the high RAP group ( 845 ± 47 ms vs 759 ± 90 ms, p &lt; 0.01) and exhibited a positive correlation with RAP ( R = 0.34, P &lt; 0.05). The hepatic T1 mapping value of ≥ 820ms was the optimal cutoff values for identifying high RAP ( T1: sensitivity, 89%; specificity, 72%; AUC, 0.80, Figure B). Conclusion: Increased native T1 mapping value of the liver may be helpful in non-invasively estimating elevated RAP.

Improved Prognostic Performance of Cardiac Power Output With Right Atrial Pressure: A Subanalysis of the ESCAPE Trial

BackgroundThe initial derivation of cardiac power output (CPO) included the difference between mean arterial pressure (MAP) and right atrial pressure (RAP) in the numerator, before multiplying by cardiac output (CO). We hypothesized that the inclusion of RAP (CPO–RAP) would enhance the prognostic performance of this parameter in those with an elevated RAP. Methods and ResultsWe obtained patient-level data from the ESCAPE trial via the Biolincc database. Participants with full final hemodynamics were included in the analysis. The CPO–RAP was calculated as [(MAP – RAP) × CO)]/451 Watts (W), and the CPO was calculated as (MAP × CO)/451. The primary outcome was freedom from left ventricular assist device, heart transplant, or death at 6 months. Included participants (n = 157) were a median of 58 years of age (interquartile range [IQR] 49–67 years), 27% were women, and 59% had ischemic cardiomyopathy. The median CPO was 0.70 W (IQR 0.50–0.90 W), and the median CPO–RAP was 0.62 W (IQR 0.47-0.79 W). In univariable logistic regressions, the CPO was not associated with the primary outcome (odds ratio 0.32, 95% confidence interval 0.08–1.29, P = .11), but the CPO-RAP was (odds ratio 0.10, 95% confidence interval 0.02–0.54, P < .01). In Kaplan-Meier analyses, there were no significant difference in outcomes with CPO (76% vs 64%, P = .08), but for CPO–RAP, there were significant differences in outcomes (81% vs 63%, P = .01). When further delineating CPO–RAP by RAP above or below the median, there was no significant difference in the outcome for participants with a RAP 8 or less (94% vs 79%, P = .07), but a significant difference in participants with a RAP of more than 8 mm Hg (66% vs 45%, P < .05). ConclusionsThe inclusion of RAP resulted in a significant association with the primary outcome; CPO alone was not.

Internal jugular vein ultrasound in patients with chronic congestive heart failure

Abstract Background Bedside assessment of intravascular volume in patients with chronic congestive heart failure (CHF) is often difficult. Under- and over-diuresis are common causes of morbidity and readmissions in these patients. Purpose We hypothesized that ultrasound assessment of the internal jugular vein would be easier and more reproducible than clinically assessing jugular venous pressure (JVP). Our goal was to create a bedside test that would be simpler to learn than inferior vena cava (IVC) assessment and easier to perform in obese patients. Methods Adults with HF (n=53, 52% men, mean age 65 years, mean BMI 29.6 kg/m2, mean LVEF 44%) scheduled for right heart catheterization (RHC) had an ultrasound of their right internal jugular (RIJ) vein performed immediately prior. Cross-sectional area of RIJ was measured during normal breathing with patients at 90 and 45 degrees recumbency and was indexed by height (RIJI). JVP was also assessed clinically. Results were compared to right atrial pressure (RAP) measured by RHC. Operators were blinded to RHC results and vice versa. Results JVP was correctly assessed clinically in only 43%. RIJI at 90 and 45 degrees were significantly larger in patients with elevated RAP compared to euvolemic patients (Table). At 90 degrees, RIJI of &amp;gt;15 predicted a RAP of &amp;gt;10 mmHg with 68% sensitivity and 72% specificity. At 45 degrees, RIJI of &amp;gt;10 predicted a RAP of &amp;gt;10 mmHg with 94% sensitivity and a negative predictive value of 80% (Table). Simply being able to see the RIJ at 90 degrees (n=34) had an 82.4% positive predictive value for elevated RAP. IVC data could not be obtained on 23% of patients due to body habitus or inability to lay flat. Conclusion Ultrasonographic RIJI is more accurate than clinical assessment in patients with CHF and can be accurately performed even in obese patients. It requires only a basic linear ultrasound probe and was easily performed by clinicians at various stages of training with reproducible results. With the increased availability of bedside ultrasound in clinical practice, it is a feasible method of evaluating chronic CHF patients. Funding Acknowledgement Type of funding sources: None.

Prognostic implications of echocardiographic measures of left and right atrial pressures on survival in patients with end stage renal disease

Background Volume excess is common in patients with end stage renal disease (ESRD). We examined the prognostic value of clinical and echocardiographic measures of left (LA) and right atrial (RA) hypertension in this population. Method We prospectively collected demographic, clinical, pharmacological, echocardiographic data on 575 consecutive ESRD patients on hemodialysis undergoing cardiac evaluation before renal transplantation in a dedicated cardiac clinic. Survival was analyzed as a function of clinical and echocardiographic measures of LA and (RA) hypertension. Result Elevated LA pressure was seen in 48% of the patients based on E/e’ velocity ratio of ≥ 15, and 28% had elevated RA pressure based on inferior vena caval size. Physical examination grossly underestimated the prevalence of both LA and RA hypertension. Atrial pressures were normal in 46% and both atrial pressures were elevated in 20% of the patients. Elevated LA pressure in the presence of normal RA pressure was found in 30%. Over a period of 20 ± 8 months, there were 43 deaths. There was a graded increase in mortality with increases in LA and bi-atrial hypertension (p = .009). The 2-year mortality rate was 6% in those with normal atrial pressures, 13% in those with isolated LA hypertension and 28% in those with bi-atrial hypertension. Conclusion Mitral E/e’ ratio and inferior vena caval size are vastly more sensitive than physical examination for recognition of elevated atrial pressures and are strong predictors of survival in ESRD patients. Limited echocardiographic examination may have a role in ESRD patients undergoing dialysis to help achieve euvolemic status.