Elevated Right Atrial Pressure Research Articles

Diagnostic utility of right atrial reservoir strain to identify elevated right atrial pressure in heart failure

Abstract Funding Acknowledgements Type of funding sources: None. Background. Accurate non-invasive estimation of right atrial pressure (RAP) is essential to assess volume status and optimize therapy in heart failure (HF). This study aimed to evaluate the utility of right atrial reservoir strain (RASr) assessed by speckle-tracking echocardiography to identify elevated RAP in HF and compare diagnostic performance with the recommendation-based estimate employing inferior vena cava size and collapsibility (RAPIVC). Methods. Association between RASr and invasive RAP (RAPInvasive) was examined in 103 HF subjects that underwent standard echocardiography with speckle-tracking strain analysis directly followed by right heart catheterization. The discriminatory ability of RASr to identify RAPInvasive > 7mmHg was evaluated and compared with RAPIVC. Results. RASr demonstrated a significant association with RAPInvasive (β = -0.41, p < 0.001) and strong discriminatory ability to identify subjects with RAPInvasive > 7mmHg (AUC = 0.78; 95% CI 0.68-0.87; p < 0.001). At a cut-off value of -15%, RASr demonstrated 78% sensitivity, 72% specificity, 72% positive predictive value and 77% negative predictive value to identify elevated RAPInvasive. In comparison, RAPIVC (AUC = 0.71) demonstrated 89% sensitivity, 32% specificity, 55% positive predictive value and 77% negative predictive value with high false positive rate. In subjects with intermediate RAPIVC (8mmHg), RASr maintained significant diagnostic ability to identify elevated RAPInvasive (AUC = 0.69; 95% CI 0.52 to 0.85, p = 0.03). Conclusions. RASr demonstrates strong ability to identify elevated RAP and may be useful as a novel noninvasive estimate of RAP in HF management.

Correlation of internal jugular and subclavian vein diameter variation on bedside ultrasound with invasive right heart catheterization

IntroductionAccurate estimation of fluid status is paramount in patients with heart failure. We hypothesized that bedside ultrasound assessment of the internal jugular vein (IJV) and subclavian vein (SCV) could reliably estimate right atrial pressure (RAP). MethodsProspectively enrolled patients were positioned supine. IJV was imaged at the apex of the right sternocleidomastoid muscle and SCV was imaged at the lateral third of the right clavicle. Using M-mode on a portable ultrasound machine, the maximum (Dmax) and minimum (Dmin) anteroposterior diameters were noted during normal breathing. Respiratory variation in diameter (RVD) was calculated as [(Dmax – Dmin)/Dmax] and expressed as percent. Collapsibility was assessed with sniff maneuver. Patients then underwent right heart catheterization and their findings were correlated with above. ResultsTotal of 72 patients were enrolled with mean age 61 years, mean BSA 1.9 m2, and left ventricular ejection fraction 45 ± 20%. Elevated RAP≥ 10 mmHg was associated with dilated IJV Dmax(1.0 vs. 0.7cm, p = 0.001), less RVD with resting respiration (14% vs. 40% for IJV, p = 0.001 and 24% vs. 45% for SCV, p = 0.001), and reduced likelihood of total collapsibility with sniff (16% vs. 66% patients for IJV, p = 0.001 and 25% vs. 57% patients for SCV, p = 0.01). For RAP ≥10 mmHg, lack of IJV complete collapsibility with sniff had a sensitivity of 84% while IJV Dmax > 1cm and RVD <50% had a specificity of 80%. ConclusionThe IJV and SCV diameters and their respiratory variation are reliable in estimating RA pressure.

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 16084: Relationship Between Diastolic Interventricular Septal Flattening and Prognosis in Patients With Severe Tricuspid Regurgitation

Introduction: Diastolic interventricular septal flattening is one of the major findings in patients with severe tricuspid regurgitation (TR). However, the relationship between diastolic interventricular septal flattening and outcome in patients with severe TR is not fully understood. This study aimed to investigate the impact of diastolic interventricular septal flattening on cardiac events in patients with severe TR. Methods: We retrospectively reviewed patients who underwent 2 dimensional echocardiography and were diagnosed as severe TR in 2014. Eccentricity index in end-diastole (EI-ED) was measured as septal wall configuration (Figure). Cardiac events investigated as endpoints were cardiac death and heart failure (HF) admission. Results: 376 patients were diagnosed as severe TR. We excluded 15 patients on mechanical respiratory support during echocardiography and 20 with missing data of clinical information. Remaining 341 severe TR patients (75 ± 16 years, 191 (56%) female) were investigated in this study.232 (68%) patients showed abnormal EI-ED (defined as over 1.0). During a follow-up period (median, 183 days; range. 40 to 983 days), 119 (34%) patients experienced cardiac events (29 cardiac death and 90 HF admission). By the Cox proportional hazard model, the presence of abnormal EI-ED and right atrial pressure (RAP) elevation on echocardiography (defined as more than 8mmHg) were independent predictors for cardiac events with a hazard ratio of 2.71 (95% Confidential interval (CI), 1.25 to 5.86; p=0.011) and of 3.02 (95%CI, 1.08 to 8,47; p=0.036) respectively. The Kaplan-Meier curves showed that severe TR patients with abnormal EI-ED and RAP elevation were at higher risk for cardiac event (Figure). Conclusions: The presence of abnormal EI-ED is an important predictor for cardiac events in patients with severe TR. The presence of abnormal EI-ED and RAP elevation can be a potential surrogate marker of advanced therapy for severe TR.

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.

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.

Venous Congestion, Not Cardiac Index is Associated with Diuretic Resistance

Background Diuretic resistance is associated with worse outcomes in acute decompensated heart failure (ADHF). Traditional dogma has held that low cardiac index (CI) is a driver of diuretic resistance by reducing renal perfusion. Recently, accumulating evidence has shown that venous congestion has a more potent effect on cardiorenal interactions than low CI. However, venous congestion also likely identifies patients with increased volume overload and the potential for a greater diuretic response. Hypothesis Right atrial pressure (RAP) will be associated with diuretic response while CI will have little to no association. Methods We analyzed a subset of patients from the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) dataset (n=190). Diuretic efficiency (DE) was defined as daily urine output (UOP) per doubling of loop diuretic dose, and compared with baseline, final (day of pulmonary artery catheter (PAC) removal) and change in PAC variables. Daily UOP was additionally examined with time-matched PAC measurements. Results DE was weakly positively correlated with baseline RAP (r=0.16, p=0.03) but negatively correlated with final RAP (r=-0.21, p=0.009) and change in RAP from baseline (r=-0.27, p=0.001). There was no correlation between DE and the remaining PAC variables, including CI. In high vs. low DE groups dichotomized by median value, the low DE group had significantly higher final RAPs (9.0, IQR 6.0-15.5 mmHg vs. 8.0, IQR 4.8-12.0 mmHg, p=0.04) and smaller reductions in RAP (-2.0 mmHg, IQR-5.0-2.0 mmHg vs. -5.0, IQR=-10.0-0.0 mmHg, p=0.03). There were no DE group differences for baseline CI (p=0.78), final CI (p=0.42), or change in CI (p=0.92). There were no significant differences in DE in subjects with CI 2.2 L/min/m2 (p=0.95). Time-matched PAC and UOP data showed a weak positive correlation between RAP and UOP adjusted for diuretic dose (r=0.13, p=0.03), but no correlation between UOP and CI (p=0.18). Conclusions We were unable to identify any association between CI and DE. Higher baseline RAP predicted better DE, but later in the hospital course higher RAP predicted worse DE, likely indicating that elevated RAP is a marker rather than a mediator of diuretic response. Overall, these results suggest that PACs provide limited value in the workup of diuretic resistance.

Diagnostic utility of right atrial reservoir strain to identify elevated right atrial pressure in heart failure

BackgroundAccurate non-invasive estimation of right atrial pressure (RAP) is essential to assess volume status and optimize therapy in heart failure (HF). This study aimed to evaluate the utility of right atrial reservoir strain (RASr) assessed by speckle-tracking echocardiography to identify elevated RAP in HF and compare diagnostic performance with estimated RAP employing inferior vena cava size and collapsibility (RAPIVC), in addition to RA area. MethodAssociation between RASr and invasive RAP (RAPInvasive) was examined in 103 HF subjects that underwent standard echocardiography with speckle-tracking strain analysis directly followed by right heart catheterization. The discriminatory ability of RASr to identify RAPInvasive > 7 mmHg was evaluated and compared with RAPIVC and RA area. ResultsRASr demonstrated association with RAPInvasive (β = −0.41, p < 0.001) and was an independent predictor when adjusted for potential confounders (β = −0.25, p < 0.001). Further, RASr showcased strong discriminatory ability to identify subjects with RAPInvasive > 7 mmHg (AUC = 0.78; 95% CI 0.68–0.87; p < 0.001). At a cut-off value of −15%, RASr displayed 78% sensitivity and 72% specificity to identify elevated RAPInvasive. In comparison, RAPIVC (AUC = 0.71; 95% CI 0.61–0.81; p < 0.001) demonstrated 89% sensitivity and 32% specificity with high false positive rate. RA area (AUC = 0.66; 95% CI 0.55–0.76, p = 0.005) displayed 64% sensitivity and 53% specificity. ConclusionsRASr demonstrates good ability to identify elevated RAP and relatively stronger diagnostic performance when compared with conventional non-invasive measures. RASr may be useful as a novel noninvasive estimate of RAP in HF management.

Doppler-Derived Intrarenal Venous Flow Mirrors Right-Sided Heart Hemodynamics in Patients With Cardiovascular Disease.

Interruption in Doppler intrarenal venous flow (IRVF) has been used in assessing renal congestion and in the prediction of prognosis of cardiovascular diseases. However, there is a paucity of pathophysiological knowledge, so we aimed to clarify the determinants of IRVF interruption. Intrarenal Doppler studies were performed within 24 h before right-side catheterization studies. The interruption in IRVF in 73 patients was divided into a continuous pattern, and 4 discontinuous types based on the timing of interruption. Type 1, with an interruption in early systole, was associated with a-wave elevation of right atrial pressure (RAP). Type 2, with an interruption in early diastole, was associated with v-wave elevation, tricuspid regurgitation (TR), and right ventricular dysfunction. Both Type 1 and 2 were observed even in the normal range of mean RAP. Type 3, with an interruption throughout systole, was observed in advanced right heart failure patients with markedly elevated RAP, particularly elevated x-descend and atrial fibrillation. Finally, Type 4, with limited flow at systole, was observed in 2 of the patients with pulmonary arterial hypertension. IRVF interruption was closely related to RAP elevation at each specific point of the cardiac cycle rather than to mean RAP levels, suggesting that the characteristics of IRVF mirror right-sided heart hemodynamics, not mean RAP.

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.

Timing and Trends of Right Atrial Pressure and Risk of Right Heart Failure After Left Ventricular Assist Device Implantation

Elevated right atrial pressure (RAP) is associated with poor outcomes after left ventricular assist device (LVAD) implantation. However, the optimal time for RAP measurement and the importance of resolution of right heart congestion prior to LVAD implantation remain unclear. We performed a retrospective cohort study of 134 consecutive LVAD recipients from our institution. Congestion was defined as RAP ≥ 14 mmHg and was assessed at hospital admission and implant. The primary outcome was death or right ventricular assist device (RVAD) implantation. When stratified by congestion status at admission, congested and non-congested patients had similar event-free survival rates (hazard ratio [HR]: 1.2, 95% confidence interval [CI]: 0.6-2.6). However, when stratified at implant, congested patients had a higher rate death or RVAD implantation (HR: 2.5, 95% CI: 1.1-5.6). Patients were then divided into 4 groups based on their trajectory of congestion status: no congestion, resolved congestion, new congestion, or persistent congestion. Patients with no congestion and resolved congestion had similar outcomes, whereas patients with persistent congestion had a markedly increased rate of death or RVAD implantation (HR: 3.1, 95% CI: 1.3-7.6). RAP at LVAD implantation is more strongly associated with postoperative outcomes than admission RAP. Patients not responsive to decongestive therapies, with persistently elevated RAP, represent a high-risk cohort for adverse outcomes following LVAD implantation.

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

"Silent" hypoxemia in COVID-19: Hunt for the shunt!

Dear Editor, We read with interest the exemplary description of the respiratory and cardiovascular effects of COVID-19 infection by Kapoor, featured recently in the journal.[1] While we appreciate the elaboration upon the multi-faceted spectrum of the novel SARS-Cov-2 pneumonia in the index article, the lack of dyspnea (”silent”or “happy” hypoxemia) and plummeting desaturation in this cohort of patients, continue to bewilder and baffle the fraternity at large. In this context, we wish to impress upon the very interesting hypothesis recently put forth by Fisher, regarding the role of the unanticipated opening of an underlying patent foramen ovale (PFO) in explaining this mysterious hypoxemia.[2] Nevertheless, a number of factors surrounding this hypothesis merit attention: (i) Considering the existing literature on the magnitude of intra-thoracic shunt in acute respiratory distress syndrome (ARDS)[2] and given the astonishingly high frequency of a probe-patent PFO (20-25%)[3]; the intra-cardiac right-to-left (R-L) shunt could add significantly to the intrapulmonary shunt in aggravating the systemic hypoxemia ahead of the deterioration in the respiratory mechanics. (ii) In addition, Gattinoni and colleagues have also adequately highlighted the importance of estimating the shunt fraction in the COVID-related ARDS (as they describe it as a not so “typical” ARDS).[4] (iii) Moreover, the accompanying pathological elevation of right atrial pressures (RAP) (in background of pulmonary artery hypertension owing to the ongoing inflammatory process) is expected to promote the intra-cardiac R-L shunting (precluded in health by the physiologically higher left atrial pressures compared to RAP) which is unlikely to respond well to oxygenation wherein positive pressure ventilation will only make the matter worse.[15] While the debate on the mechanisms of “silent” hypoxemia continues to snowball with every passing day of the pandemic, acknowledgement to the shunt patho-physiology and bedside echocardiographic exploration for PFO cannot only provide anatomico-physiological clues to the deteriorating oxygen saturation rather the degree of R-L shunt can also guide the monitoring of the concomitant pulmonary vasodilator therapy with the potential of benefitting a considerable number of critically ill COVID-19 patients. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Clinical significance of postoperative atrial arrhythmias in patients who underwent lung transplantation.

Background/AimsAtrial arrhythmia (AA) occasionally occurs after lung transplantation (LT); however, risk factors for AA and their impact on clinical outcomes are inconsistent. We aimed to investigate the incidence, predisposing factors, and clinical outcomes of AA after LT.MethodsWe retrospectively evaluated 153 consecutive patients who underwent LT between January 2010 and August 2016. An AA episode was defined as a documented atrial fibrillation (AF), atrial flutter, or atrial tachycardia on 12-lead electrocardiography or episodes lasting ≥ 30 seconds on telemetry monitoring.ResultsThe mean follow-up time was 22.0 ± 19.1 months. Postoperative AA occurred in 46 patients (30.1%) after LT. Patients with postoperative AA were older, had larger body surface area, and had an increased incidence of paroxysmal AF prior to transplantation, idiopathic pulmonary fibrosis, and postoperative tracheostomy than patients without AA. Preoperative right atrial pressure (RAP) (odds ratio [OR], 1.19; p = 0.005) and longer periods of mechanical ventilation (OR, 1.03; p = 0.008) were found to be independent risk factors for AA after surgery. Development of AA was a significant predictor of long-term overall mortality (hazard ratio, 2.75; p = 0.017).ConclusionsPatients with elevated preoperative RAP and long-term ventilator care had a higher risk of AA after LT. Further, AA after LT was associated with poor long-term survival.

HEMODYNAMICS IN HEART FAILURE – IS CLINICAL EXAMINATION RELEVANT?

Elucidating hemodynamic parameters remains the hallmark of management inpatients with acute or chronic heart failure. Demystification of assessment offilling pressures is a continual and vital pursuit for cardiologists. In the era ofhand-held imaging devices, extensive diastolic guidelines and readily availableemerging biomarkers ala, brain natriuretic peptide (BNP); is the role of clinicalexamination (CE) becoming obsolete? CE consists of carefully taken targetedhistory and meticulously conducted physical examination. The determination of 'wet' is based on the presence of any sign or symptom that is associated with elevated ventricular fillingpressures. Assessing volume status is critical in the management of HF, helpful in titrating the dosage of diuretic and agentsused to modulate preload and afterload. Clinical findings that help to assess volume status are distention of jugular veins (JVD),hepatojugular reflux (HJR). Orthopnea, bendopnea and square-wave response of blood pressure during Valsalva maneuver.7Volume depletion can be detected by the presence of signs of dehydration, changes in blood pressure and heart rate withchanges in posture.7 A new term has been introduced in the world of cardiology called 'bendopnea' observed in patients with advanced HF. Patientsdevelop dyspnea on bending forward at the waist and it is assessed in patients while sitting in a chair and bending forwardtouching their feet with hands. It is deemed to be present if a patient develops dyspnea within 30 seconds of bending forward. 25 25Bendopnea was seen in a minority of patients with elevated filling pressure with low cardiac output. Recent studies have 26documented the presence of bendopnea in one fifth to half the number of patients presenting for evaluation for heart failure andits presence has been seen to increase worse outcomes in six months.26-29. To conclude, meticulously conducted clinical examination is of immense importance in the management of patients with HF. Itoffers both diagnostic and prognostic information and is helpful in guiding the therapy. Clinical examination is more accurate inassessing elevated ventricular filling pressure inferred from signs of elevated right atrial pressure. Detection of low cardiacoutput remains challenging. In patients of HF with deteriorating renal function, low cardiac output and right-left equalizer of fillingpressure should be considered

P5417Splenic volume changes as a hemodynamic parameter in advanced heart failure with left ventricular assist device

Abstract Background The spleen has been recognized as an important organ to reserve 20–30% of the total blood volume. Generally, splenomegaly has been thought to be related to congestion. However, in the setting of hypovolemic shock or hypoxemia, it has been reported that spleen contracted and splenic volume decreased. On the other hand, in advanced heart failure (HF), the hemodynamics is characterized by both low cardiac output (LO) and systemic congestion, and patients sometimes need support of left ventricular assist device (LVAD). However, it remains unclear about the association between spleen size and hemodynamic parameters in patients with LO who need LVAD support. Purpose The purpose of this study was to investigate the relationship between spleen size and hemodynamic parameters in advanced HF before and after LVAD implantation. Methods We enrolled 12 advanced HF patients with LVAD (11 males, 45±10 years). All patients underwent blood test, echocardiography, right heart catheterization, and computed tomography (CT) before and after LVAD implantation. Spleen size was measured by CT volumetry. We excluded patients with splenic infarction, or any infections, or mean right atrial pressure (RAP) &lt;5mmHg because of a possibility of hypovolemic status. LO was defined as CI less than 2.2L/min/m2. Results At pre- and post-LVAD implantation, cardiac output, cardiac index (CI), mean RAP, and mean pulmonary capillary wedge pressure were 3.1±0.6 vs. 4.9±0.9L/min, p=0.002; 1.7±0.3 vs. 2.8±0.3L/min/m2, p=0.002; 14±5 vs. 9±3mmHg, p=0.059; and 30±7 vs. 10±3mmHg, p=0.002, respectively. The serum brain natriuretic peptide level had significantly decreased (1101 [517–1446] vs 74 [35–216] pg/mL, p=0.002). In all patients, CI had increased to over 2.2L/min/m2. The splenic volume significantly increased from pre- to post-LVAD implantation (172±48 vs. 233±78mL, p=0.002) (Figure). Furthermore, all patients were divided into two groups; elevated RAP group (n=4) and non-elevated RAP group (n=8) after LVAD support. In elevated RAP group, there were no significant changes in the spleen size between pre- and post-LVAD implantation (167±45 vs. 223±111mL, p=0.068). On the other hand, in non-elevated RAP group, the spleen volume had significantly increased from pre- to post-LVAD support (172±53 vs. 231±62mL, p=0.011). In addition, there was one patient whose hemodynamic state had changed to LO again because of LVAD failure due to pump thrombosis. In this case, the splenic volume was 212mL before LVAD implantation with LO, and increased to 418mL after LVAD implantation with non-LO, although decreased to 227mL after LVAD pump failure with LO again. Splenic volume changes Conclusions The spleen may change its size in order to keep cardiac output by regulating cardiac preload depending on the systemic perfusion in advanced HF with LVAD. Acknowledgement/Funding None

Performance of Noninvasive Assessment in the Diagnosis of Right Heart Failure After Left Ventricular Assist Device.

Right heart failure (RHF) after left ventricular assist device (LVAD) is associated with poor outcomes. Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) defines RHF as elevated right atrial pressure (RAP) plus venous congestion. The purpose of this study was to examine the diagnostic performance of the noninvasive Intermacs criteria using RAP as the gold standard. We analyzed 108 patients with LVAD who underwent 341 right heart catheterizations (RHC) between January 1, 2006, and December 31, 2013. Physical exam, echocardiography, and laboratory data at the time of RHC were collected. Conventional two-by-two tables were used and missing data were excluded. The noninvasive Intermacs definition of RHF is 32% sensitive (95% cardiac index (CI), 0.21-0.44) and 97% specific (95% CI, 0.95-0.99) for identifying elevated RAP. Clinical assessment failed to identify two-thirds of LVAD patients with RAP > 16 mm Hg. More than half of patients with elevated RAP did not have venous congestion, which may represent a physiologic opportunity to mitigate the progression of disease before end-organ damage occurs. One-quarter of patients who met the noninvasive definition of RHF did not actually have elevated RAP, potentially exposing patients to unnecessary therapies. In practice, if any component of the Intermacs definition is present or equivocal, our data suggest RHC is warranted to establish the diagnosis.

Elevated Right Atrial Pressure Associated with Alteration of Left Ventricular Contractility and Ventricular-Arterial Coupling in Pulmonary Artery Hypertension.

Pulmonary artery hypertension (PAH) is a progressive disorder which leads to heart failure and death. Development of dilated right ventricle (RV), progressive RV dysfunction and increased right atrial (RA) pressure make the RV transition from a compensated to a decompensated phase and eventually leads to heart failure. However, the relationship between elevated RA pressure and left ventricular contractility and ventricular arterial coupling (VAC) has not been well studied. 36 patients were recruited and underwent both right heart catheterization (RHC) and cardiac magnetic resonance (CMR). Left ventricular (LV) pressure-volume loops were reconstructed from RHC and CMR. LV contractility was assessed by end-systolic elastance (Ees) using single-beat method and arterial elastance (Ea) was estimated as the ratio of end-systolic pressure and stroke volume (SV). The VAC was calculated as the ratio of Ees and Ea (i.e. Ees/Ea). The results demonstrated a nonlinear relationship between RA pressure and Ees, RA pressure and VAC. Ees increased when RA pressure increased to 7 mmHg and then decreased when RA pressure exceeded 7 mmHg. Ees were 2.79 ± 1.61 mmHg/ml, 4.27 ±1 33 mmHg/ml, 2.69 ± 0.89 mmHg/ml and 2.36± 1.10 mmHg/ml at ascending quartiles of RA pressure, respectively (quartile 1: RAP≤5 mmHg; quartile 2: 5<; RAP≤7 mmHg; quartile 3: 7<; RAP 10 mmHg and quartile 4: RAP>10 mmHg). Similarly, VAC were 1.36 ± 0.61, 1.93±0.86, 1.16 ± 0.55 and 0.95± 0.27 the four quartiles (both ANOVA P <; 0.05). We found that there was a nonlinear relationship between RA pressure and LV contractility, and between RA pressure and ventricular-arterial coupling. A cut-off value of 7 mmHg of RAP may indicate a decompensated LV hemodynamics.

Doppler Recognition of Low or Normal Central Venous Pressure from Continuous Flow from Inferior Vena Cava Into Right Atrium

Estimation of right atrial (RA) or central venous pressure (CVP) is a critical component of a comprehensive transthoracic echocardiographic (TTE) examination. We hypothesize that continuous inflow from the inferior vena cava (IVC) into the RA is a surrogate for low/normal CVP and can be reliably imaged in standard echocardiographic parasternal short and right ventricular inflow views. We retrospectively studied 200 patients who underwent right heart catheterization (RHC) within 8 hours of TTE between 2012 and 2016, and selected 60 patients in whom the continuous wave Doppler beam incidentally interrogated IVC inflow into RA during evaluation of the tricuspid valve. From these studies, we sought an uninterrupted Doppler wave (DW) inflow signal. CVP on RHC were then compared in patients with continuous and interrupted DW. Other TTE and RHC parameters were also noted and compared in these 2 groups. The average time interval between TTE and RHC was 266 ± 151 minutes. Of 60 patients (males = 39 (65%); age 63 ± 14 years), 12 patients (20%) had continuous DW and 48 (80%) had interrupted DW inflow signal from IVC into the RA. Of the 12 patients with continuous flow, 11 had RA pressure of ≤7 mm Hg. Similarly, of 48 patients with interrupted flow, RA pressure was >7 mm Hg in 45, and less than ≤7 mm Hg in 3 patients (two-sided p value 0.0001). The continuous DW signal predicted RA of ≤7 mm Hg with a sensitivity and specificity of 98% and 78%, respectively. Additionally, when combined with IVC size and collapsibility (normal-sized collapsible IVC), the sensitivity and specificity of DW signal to predict RA of ≤ 7 mmHg were enhanced to 94% and 92%, respectively. In conclusion, IVC flow pattern can be reliably studied to estimate CVP in standard echocardiographic views. Continuous and interrupted IVC flow predicts normal and elevated RA pressure, respectively.

How Dynamic are Hemodynamics?: Short-Term Changes in Hemodynamic Measures and Indices among Heart Failure Patients

Purpose Pulmonary arterial catheters (PAC) are valuable tools for guiding heart failure management and evaluating patients for advanced therapies. Although several hemodynamically-derived indices have prognostic value in patients with advanced heart failure, the short-term variance that can be seen in these measurements has not been well described. This study aimed to determine short-term variations in hemodynamic measurements and associated indices among heart failure patients. Methods Patients undergoing clinically-indicated PAC placement at our institution from April 2018 with serial hemodynamic measurements were prospectively recruited. Hemodynamics and clinical variables were collected at the time 0 and again at 24 hours. Hemodynamic indices frequently used to assess the right ventricle, including pulmonary artery pulsatility index (PAPi), right atrial pressure (RAP) to pulmonary capillary wedge pressure (PCWP) ratio, and transpulmonary gradient were also calculated for both time points. Results Data was available for 57 patients with an average of age 58.3 years. Compared to baseline measurements, 24-hour data revealed a significant reduction in RAP (-1.6 mmHg; p= Conclusion Our single-center experience with short-term hemodynamic measurements revealed improvement in filling pressures over 24 hours. Notably, in patients with initially elevated RAP, PAPi significantly improved. Such findings demonstrate that PAPi's utility as a risk prediction index must be considered in the context of its variability based on loading conditions, rather than as a static value.