Elevated Left Atrial Pressure Research Articles

Effectiveness of exhaled nitric oxide for the prediction of non-invasive left atrial pressure in older people: a cross-sectional cohort study.

During left-sided heart failure (HF), left atrial and pulmonary venous pressure increase, which may lead to pulmonary congestion. Previous cohort studies, examining participants with symptomatic HF or rheumatic heart disease, suggest a relationship between increased left atrial pressure (LAP) and fractional exhaled nitric oxide (FeNO). To examine the strength of association between FeNO and echocardiographic assessment of LAP by the E/e' ratio, to determine if FeNO could be used to identify those with elevated LAP. This cross-sectional cohort study examined a subset of the OxVALVE cohort aged ≥65 years. Data collection was undertaken in primary care practices in central England. Each participant underwent a focused cardiovascular history and clinical examination. Standard transthoracic echocardiographic (TTE) assessment was performed on all participants, with the E/e' ratio calculated to obtain a validated surrogate of LAP. FeNO was measured in 227 participants. FeNO was higher in males compared with females and no different in participants with asthma, chronic obstructive pulmonary disease (COPD), or those using inhaled steroids. Participants with a high E/e' (>14) were older, with a higher proportion of females than males. There was no relationship between E/e' and FeNO, either when measured as a continuous variable or in the group with high E/e'. FeNO was not found to be an accurate predictor of elevated LAP in a primary care setting.

Echocardiographic assessment alone is inadequate for determining elevated left sided filling pressures in patients with cardiogenic shock

Abstract Background Left atrial (LA) filling pressure assessment is of paramount importance in tailoring treatments for patients with cardiogenic shock (CS). ESC guidelines advocate for the use of mitral inflow Doppler and mitral annulus tissue Doppler measurements to predict elevated left atrial pressure in clinical practice. Echocardiographic measurement of LA pressures could reduce the need for invasive monitoring in CS patients, but its utility remains unproven in this population. Purpose We assessed the validity of mitral inflow velocity and mitral annulus velocity indices to determine LA pressures, correlating them with invasive measurement of pulmonary capillary wedge pressure (PCWP) in CS patients admitted to the cardiac intensive care unit (CICU). Methods We prospectively evaluated consecutive patients who underwent pulmonary artery catheter insertion in the CICU, measuring their haemodynamic parameters, including PCWP. This was immediately followed by a transthoracic echocardiography (TTE) performed by a critical care cardiologist, blinded to the invasive measurements. The early (E) and late (A) mitral inflow velocities were measured using mitral inflow Doppler and septal and lateral mitral annulus velocities (e') were measured using tissue Doppler, all in the apical 4-chamber view. TTE images were later reported by a second cardiologist, blinded to the invasive measurements and the patient. Correlations between E; E/A ratio; E/e' ratio and PCWP were evaluated using Pearson's correlation. Results Sixty patients were recruited into the study, aged 58±14 years, 27% female, with 96 assessments undertaken. The majority (55%) of patients were SCAI stage C, with 14% having had a cardiac arrest prior to CICU admission and 27% required mechanical ventilation at the time of assessment. Mean PCWP was 16.0±6.5 mmHg. Full mitral valve Doppler and tissue Doppler profiles were measured in 67 (70%) assessments, limited due to E/A fusion, atrial fibrillation and limited acoustic windows. There was only weak correlation between PCWP and E/A ratio (R=0.33, p=0.01), with no correlation between PCWP and the other measured values (Table 1), including E/e'. The AUC for identifying patients with elevated PCWP (≥15 mmHg) using E/A ratio was 0.67 (p=0.02), although there was no suitable value to use as a cut off with adequate sensitivity and specificity (Figure 1). Conclusion Echocardiographic non-invasive assessment of left sided cardiac filling pressures is technically challenging in patients with CS. Even when possible, there is weak correlation between echocardiographic and invasive measurements, suggesting limited value in this technique. Alternative non-invasive modalities, such as lung ultrasound, should be investigated in this population to assist clinical assessment. Funding Acknowledgement Type of funding sources: None.

TARGETING TUMOR NECROSIS FACTOR (TNF) IN ATRIAL STRETCH-DEPENDENT ADVERSE ATRIAL REMODELING AND VALVULAR ATRIAL FIBRILLATION IN A MOUSE MODEL OF AORTIC REGURGITATION

TARGETING TUMOR NECROSIS FACTOR (TNF) IN ATRIAL STRETCH-DEPENDENT ADVERSE ATRIAL REMODELING AND VALVULAR ATRIAL FIBRILLATION IN A MOUSE MODEL OF AORTIC REGURGITATION

How to diagnose and treat acute pulmonary hypertension when you have no cardiology support

Acute pulmonary hypertension (aPH) is a complex, physiology-driven disorder that causes critical illness in newborns, the hallmark of which is elevated pressure in the pulmonary vascular bed. Several underlying hemodynamic phenotypes exist, including classic arterial aPH with resistance-driven elevations in pulmonary arterial pressure (PAP), alongside flow-driven aPH from left-to-right shunt lesions, and primary left ventricular dysfunction with pulmonary venous hypertension and elevated left atrial pressure. Targeted neonatal echocardiography (TnECHO) is an important tool for evaluation of hemodynamics in aPH and is highly useful for evaluating modulators of disease and targeting cardiovascular therapy. The diagnostic approach to aPH includes confirmation of elevation of PAP, evaluation of the cause and exclusion of structural cardiac disease, assessment of the response of the myocardium to adverse loading conditions, and appraisal of the adequacy of systemic blood flow. Therapeutic goals include support of right ventricular (RV) function, RV afterload reduction, and selection of cardiotropic agents that support underlying pathophysiology without adverse effects on heart rate or pulmonary vascular resistance in addition to routine supportive intensive care. Training programs for TnECHO exist across multiple jurisdictions and strong correlation with pediatric cardiology assessment has been demonstrated. Future directions include adapting TnECHO training with a greater focus on achieving competency, and further research into the role of the modality in providing individualized cardiovascular care for patients with heterogenous underlying physiology, and its effect on key neonatal outcomes.

Potential role of bolus-tracking data of carotid CT angiography for atrial fibrillation prediction.

Atrial fibrillation (AF), a significant cause of ischemic stroke, often goes undetected because of its asymptomatic nature. This study investigated whether the total bolus-tracking time (TTT) and average slope (AS) of a bolus-tracking graph could be used to predict AF. This single-center, retrospective study included patients who underwent carotid CTA and a 24-h Holter test. TTT and the average degree of enhancement during bolus-tracking, derived from carotid CTA, were defined as variables of interest. All patients underwent transthoracic echocardiography. Left ventricular diastolic dysfunction and elevated left atrial pressure (LAP) were identified according to the guidelines of the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging. The final cohort comprised 716 patients, 80 of whom presented with AF. The TTT of the AF group was significantly longer (23.8 ± 5.2 s) than that of the non-AF group (18.7 ± 2.8 s); p < 0.001. The AS of the bolus-tracking graph of the AF group was 0.80 ± 0.24, which was significantly lower than that of the non-AF group 1.38 ± 0.21 (p < 0.001). TTT was associated with a significantly higher risk of AF (odds ratio [OR]: 1.36; p < 0.001) and elevated LAP (OR: 1.46; p < 0.001). In contrast, the AS of the bolus-tracking graph was not significantly associated with either AF or an elevated LAP. TTT derived from bolus-tracking carotid CTA is an effective adjuvant tool for detecting AF related to left ventricular diastolic dysfunction and elevated LAP, confirmed using echocardiography. • Atrial fibrillation is not only a significant cause of ischemic stroke but is also often masked because of its atypical and asymptomatic features. • The total tracking time, derived from bolus tracking of carotid computed tomography angiography, may be an effective adjuvant tool for detecting undiagnosed atrial fibrillation and elevated left atrial pressure in patients.

Left ventricular diastolic function and respiratory outcomes in preterm infants: a retrospective study.

The role of left ventricular (LV) diastolic pressure in the pathophysiology of bronchopulmonary dysplasia (BPD) is unclear. We evaluated the trajectory of echocardiographic parameters of LV diastolic function and the association with respiratory outcomes in preterm infants. We retrospectively analysed measurements of LV diastolic function (E, e', A, Ee' and E/A ratios) in infants below 32 weeks' gestation (GA). We compared infants with and without BPD by two-way RM ANOVA. We considered Ee' ratio as a proxy of LV filling pressure and identified a cut-off value using ROC analysis. We divided infants using such threshold and compared respiratory outcomes between groups by Mann-Whitney or Chi-square tests. We included 72 infants. Ee' ratio at 28 days was significantly associated with the duration of respiratory support (beta (std. error) = 5.32 (1.82), p = 0.005) and BPD (beta = 0.27 (0.10), p = 0.008). Infants with Ee' ratio > 12 at 28 days had longer respiratory support, oxygen requirement, and higher BPD rates than infants with Ee' ratio ≤ 12. LV diastolic function associated with elevated LV filling pressure may contribute to the pathophysiology of BPD. Serial echocardiographic measurements could identify infants at risk of worse respiratory outcomes. In very preterm infants, we assessed the trajectory of left ventricular diastolic function by serial echocardiographic evaluations and evaluated its association with respiratory outcomes. On average, infants who developed bronchopulmonary dysplasia had higher Ee' at 28 postnatal days and 36 weeks postmentrual age than infants who did not develop the disease. Infants with elevated Ee' at 28 postnatal days, suggestive of elevated left atrial pressure, required longer respiratory support.

Analysis of the relationship between the amplitude of aortic wall motion and heart function

PurposeBecause the posterior wall of the aorta and left atrium are interlocked, the amplitude of motion of the aortic wall (AMAW) may reflect cardiac and vessel functions. This study examined the relationship between cardiac and vessel functions and AMAW.MethodsPatients with cardiovascular diseases or patients undergoing health examinations who visited a participating hospital and underwent echocardiography and brachial–ankle pulse-wave velocity (baPWV) examinations were registered. The correlations between echocardiographic indices, ankle–brachial index, and baPWV and AMAW on M-mode echocardiography were analyzed.ResultsOverall, 184 patients were enrolled. Heart rate (r = − 0.1587), ejection fraction (EF; r = 0.3240), wall thickness (r = − 0.1598), peak early diastolic mitral annular velocity (E) to peak early diastolic mitral annular velocity ratio (e’; r = − 0.2463), and baPWV (r = − 0.1928) significantly correlated with AMAW. In the stratified multiple regression analysis, E/e’ (standardized partial regression coefficients = − 0.1863) and mean baPWV (standardized partial regression coefficients = − 0.1917) in patients with an EF of ≥ 60% (n = 114) significantly correlated with AMAW. In patients with an EF of < 60% (n = 70), E/e’ (standardized partial regression coefficients = − 0.2443) significantly correlated with AMAW.ConclusionBecause E/e’ correlated with AMAW in patients with an EF of < 60% or ≥ 60%, AMAW might be an indicator of left atrial pressure elevation. Moreover, because AMAW correlated with baPWV in patients with an EF of ≥ 60%, changes in the restricted left atrial volume might influence diastolic dysfunction. AMAW may be related to cardiac and vessel functions.

Relationship between left ventricular diastolic function and the risk of left atrial appendage thrombus in patients with nonvalvular atrial fibrillation.

In patients with nonvalvular atrial fibrillation (NVAF), the impact of left ventricular diastolic function on the risk of left atrial appendage (LAA) thrombus has rarely been studied. This prospective study aimed to investigate the relationship between diastolic function and the risk of LAA thrombus in patients with NVAF. Seventy-six patients with NVAF admitted to receive radiofrequency catheter ablation were prospectively enrolled. All the patients underwent transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) in 24h before ablation. Diastolic function was estimated by TTE including left atrial volume index (LAVI) and E/e', as well as invasive left atrial pressure (LAP) measured during the ablation procedure. LAA peak emptying velocity (LAA-PEV) and the intensity of spontaneous echo contrast (SEC) were determined by TEE. Average E/e', LAVI and mean LAP had a significant positive correlation with the intensity of SEC, the coefficient of correlation were 0.344 (p = 0.002), 0.416 (p < 0.001) and 0.402 (p < 0.001), respectively. After adjustment for CHA2DS2-VASc score and type of AF, multivariate regression analysis revealed that increased LAP (OR 1.144, 95% CI 1.012-1.293, p = 0.031) independently correlated with the risk of LAA thrombus (SEC ≥ Grade 2). LAA-PEV showed a significantly inverse relationship with mean LAP in patients with AF (r = - 0.525, p < 0.001), and in the assessment of elevated LAP with TEE, the LAA-PEV cut-off of 0.40m/s had a sensitivity of 80%, specificity of 81%. Left ventricular diastolic dysfunction may constitute a potential risk for LAA thrombus and stroke. Furthermore, evaluation of LAA emptying with use of TEE is helpful for assessing the LAP status of patients with AF.

Diagnostic Accuracy of the 2016 Guideline-Based Echocardiographic Algorithm to Estimate Invasively-Measured Left Atrial Pressure by Direct Atrial Cannulation

BackgroundAlthough estimation of left ventricular filling pressure (LVFP) using an integrated echocardiographic algorithm is recommended, the usefulness of this algorithm has not been fully validated. ObjectivesThe purpose of this study was to investigate the reliability of an algorithmic classification system using invasively measured left atrial pressure (LAP) in a large-scale cohort. MethodsThe authors enrolled 1,967 patients (age 68 ± 10 years) whose LAP was directly measured within the left atrium during catheter ablation for atrial fibrillation. Patients were classified into 3 groups based on the echocardiographic algorithm: normal (group N, n = 1,282), undetermined (group U, n = 160), and elevated (group E, n = 346) LAP groups. Invasively measured LAP and echocardiographic parameters estimating LVFP were compared among the groups. ResultsThe median LAP was 12.6 ± 5.7 mm Hg in the entire cohort. LAP was significantly higher in group E than that in the other groups (groups E vs U vs N, 14.2 ± 6.3 mm Hg vs 13.5 ± 5.9 mm Hg vs 12.0 ± 5.5 mm Hg; P < 0.001). Among group E patients, 43.1% had elevated LAP (≥15 mm Hg), whereas 56.9% had normal LAP (<15 mm Hg). Of the patients in group N, 69.0% had normal LAP, whereas 31% had elevated LAP. Although the correlation between invasively measured LAP and E/e′, peak tricuspid regurgitant velocity, and left atrial volume index was modest, the number of abnormal values correlated significantly with elevated LAP (P < 0.001). ConclusionsThe classification using combined echocardiographic parameters in the recommendations may be useful for detecting patients with normal LVFP but may be limited for detecting elevated LVFP.

CARD19: In vitro and In vivo Testing of the Pulsatile CorWave Membrane LVAD

Background: Lack of physiologic pulsatility with the use of continuous flow (CF) LVADs has been associated with serious adverse events including stroke, bleeding, and aortic insufficiency. CorWave is developing a unique LVAD employing an undulating membrane to generate a physiologic pulse while improving hemocompatibility. The present studies focused on in vitro and in vivo testing of the pump control algorithms for hemodynamic performance and hemocompatibility. Methods: The pump actuator, membrane, and blood flow path were designed using respectively electromagnetic simulations (MAGNET), Fluid-Structure Interaction (COMSOL), and Computational Fluid Dynamics. Algorithms were developed for actuator control, synchronization with the native left ventricle (LV), suction detection, and adaptive physiologic control. They were tested in a mock circulation loop (MCL) with INTERMACS 1-2, 3-4, and 5-6 heart failure (HF) profiles using LV pressure-volume loops to examine performance. The algorithms were then tested in chronic implants in healthy sheep for up to 3 months, and in acute implants in sheep with induced HF (ejection fraction < 40%). Results: During MCL tests, in synchronous pulsation (SynchPuls) mode, the membrane pump generated a more physiologic PV loop, with lower mean left atrial pressures (LAP), increased native LV stroke volume, and 1:1 opening of the aortic valve. CF pumps generated a characteristic, non-physiologic narrow PV loop with elevated mean LAP and aortic valve opening once per 3-5 beats. These results demonstrated the SynchPuls algorithm could respond to changes in pre-load to better unload the LV, restore more physiologic hemodynamics, and ensure aortic valve opening, so we proceeded to animal trials, which present more dynamic and challenging conditions. During acute implants in sheep with HF, using SynchPuls, the membrane pump increased cardiac output from ~2 to ~4 LPM. The physiologic control algorithm adjusted pump output to prevent LV suction and retrograde flow during hemodynamic manipulations, including epinephrine administration, and head up or down tilt. The algorithms switched to continuous mode, as intended, when arrhythmias or tachycardia were detected. In chronic implants, the SynchPuls algorithm successfully synchronized with the LV for > 97% of heartbeats and adapted to circadian cycles. Biomarkers of end-organ function returned to baseline within 2 weeks of implant, hemolysis was < 20 mg/dL, and VWF activity was preserved during the chronic implants. Conclusion: These studies showed that the membrane pump can provide physiologic pulsatility and restore cardiac output in HF models. The algorithms’ robustness was confirmed in chronic implants. Overall, these successful tests demonstrated that the CorWave membrane pump can deliver the hemocompatibility, pulsatility, and adaptability required to advance the LVAD field.

C-23 | Peri-Procedural Complications in Transcatheter Aortic Valve Replacement with Atrial Fibrillation: Insight from the National Inpatient Sample 2016-2019

Transcatheter aortic valve replacement (TAVR) is rapidly becoming commonplace for severe symptomatic aortic stenosis (AS). Elevated left ventricular and atrial pressures result in progressive left atrial dilation which in turn predisposes to the generation of atrial fibrillation (AF). Since many who undergo TAVR had increased risk of AF, we aimed to assess outcomes in these individuals.

Bidirectional Glenn shunt with tricuspid valve resection in patients with infective endocarditis.

Bidirectional Glenn shunt with tricuspid valve resection in patients with infective endocarditis.

First in Human Experience of a Novel No-implant Interatrial Shunt Device for Heart Failure with Preserved Ejection Fraction

<h3>Introduction</h3> Chronic heart failure withpreserved ejection fraction (HFpEF) comprises approximately 50% of all heartfailure diagnoses and currently has limited proven drug or device therapies. Symptomsof HFpEF, particularly dyspnea, are primarily mediated by elevated left atrialpressure. Creation of an interatrial shunt to permit left-to-right atrial flowmay improve dyspnea and other patient outcomes by mediating left atrialdecompression, thereby reducing diastolic filling pressures and improvingexercise tolerance and quality of life. Recently, implantable interatrial shuntdevices have demonstrated promise as a therapeutic option for HFpEF. Deliveringthe physiologic benefit of an interatrial shunt without a permanent cardiacimplant may have clinical advantages. We report the 6-month outcomes ofpatients treated with an implant-free interatrial shunt device. The purpose ofthis first in human study was to evaluate the safety, feasibility anddurability of the percutaneous atrial septectomy enabled by the AlleviantMedical device. <h3>Methods</h3> Key inclusion criteria were NYHAclass II (with history of greater than class II), III and ambulatory class IV,echocardiographic evidence of diastolic dysfunction, elevated peak PCWP andnormal right atrial pressure during supine ergometry. The procedure utilizedfemoral vein access and standard transseptal catheterization techniques. Thedevice was utilized to capture, excise, and remove a precisely sized section ofthe atrial septum to create a therapeutic shunt under fluoroscopic andechocardiographic guidance. <h3>Results</h3> 10 patients were enrolled inthe study. Mean age was 67 ± 8 years. Mean LVEF was 61.1 ± 10.1%. 4 patientswere NYHA class II; 6 were NYHA class III at baseline. The procedure wassuccessful with shunt creation confirmed in all patients (mean shunt size 6.8 ±1.0 mm) and no device or procedure-related adverse events. At 30 days, meanpeak exercise PCWP was reduced significantly (8 ± 10 mmHg, p=.026). At 6 months,NYHA status improved by one class in 7 patients, worsened by one class in 1 patientand did not change in 2 patients. All shunts were open at 6 months with left-to-rightflow and stable size confirmed via TEE (mean shunt size 6.8 ± 0.7 mm across ninepatients). At 6 months, mean 6MWT increased (146 ± 76 m, p<.001), ProBNPdecreased (687 ± 234 pg/ml, p<.001), and KCCQ score increased (24 ± 15,p<.001). No device or procedure-related serious adverse events occurredthrough 6 months. <h3>Conclusions</h3> This initial experiencedemonstrates that percutaneous creation of an implant-free interatrial shunt inpatients with HFpEF is safe and feasible with sustained clinical and hemodynamicimprovement and shunt patency through 6 months. Subsequent clinical studies tocontinue clinical evidence development are currently underway.

Latent Pulmonary Vascular Disease May Alter the Response to Therapeutic Atrial Shunt Device in Heart Failure.

In REDUCE LAP-HF II (A Study to Evaluate the Corvia Medical, Inc IASD System II to Reduce Elevated Left Atrial Pressure in Patients With Heart Failure), implantation of an atrial shunt device did not provide overall clinical benefit for patients with heart failure with preserved or mildly reduced ejection fraction. However, prespecified analyses identified differences in response in subgroups defined by pulmonary artery systolic pressure during submaximal exercise, right atrial volume, and sex. Shunt implantation reduces left atrial pressures but increases pulmonary blood flow, which may be poorly tolerated in patients with pulmonary vascular disease (PVD). On the basis of these results, we hypothesized that patients with latent PVD, defined as elevated pulmonary vascular resistance during exercise, might be harmed by shunt implantation, and conversely that patients without PVD might benefit. REDUCE LAP-HF II enrolled 626 patients with heart failure, ejection fraction ≥40%, exercise pulmonary capillary wedge pressure ≥25 mm Hg, and resting pulmonary vascular resistance <3.5 Wood units who were randomized 1:1 to atrial shunt device or sham control. The primary outcome-a hierarchical composite of cardiovascular death, nonfatal ischemic stroke, recurrent HF events, and change in health status-was analyzed using the win ratio. Latent PVD was defined as pulmonary vascular resistance ≥1.74 Wood units (highest tertile) at peak exercise, measured before randomization. Compared with patients without PVD (n=382), those with latent PVD (n=188) were older, had more atrial fibrillation and right heart dysfunction, and were more likely to have elevated left atrial pressure at rest. Shunt treatment was associated with worse outcomes in patients with PVD (win ratio, 0.60 [95% CI, 0.42, 0.86]; P=0.005) and signal of clinical benefit in patients without PVD (win ratio, 1.31 [95% CI, 1.02, 1.68]; P=0.038). Patients with larger right atrial volumes and men had worse outcomes with the device and both groups were more likely to have pacemakers, heart failure with mildly reduced ejection fraction, and increased left atrial volume. For patients without latent PVD or pacemaker (n=313; 50% of randomized patients), shunt treatment resulted in more robust signal of clinical benefit (win ratio, 1.51 [95% CI, 1.14, 2.00]; P=0.004). In patients with heart failure with preserved or mildly reduced ejection fraction, the presence of latent PVD uncovered by invasive hemodynamic exercise testing identifies patients who may worsen with atrial shunt therapy, whereas those without latent PVD may benefit.

The a’ velocity by tissue-Doppler echocardiography correlates to invasive mean left atrial pressure in patients with normal ejection fraction

Objectives To evaluate the correlation of a’ velocity by tissue-Doppler measurements with invasively measured mean left atrial pressure in patients with normal ejection fraction. Design In this retrospective study, we evaluated the septal a’, lateral a’ and average a’ velocity by tissue-Doppler echocardiography, in 125 in-hospital patients, 1–12 h before an elective pulmonary vein isolation due to intermittent atrial fibrillation, and compared to invasively measured mean left atrial pressure (LAP) during the invasive procedure. The patients, aged 35–81 years, had to be in sinus rhythm at both examinations, no atrial fibrillation during two procedures, no or mild valve disease and normal ejection fraction (>50%). Results Invasively measured mean LAP correlated well to septal a’ (r = −0.435), lateral a’ (r = −0.473) and average a’ velocity (r = −0.491). Normal mean LAP (≤12 mmHg) was found in 95 patients and elevated mean LAP (>12 mmHg) in 30 patients. The patients with elevated mean LAP had a lower septal a’ velocity (6.5 ± 2.7 vs 8.6 ± 2.3 cm/s; p < .01), lateral a’ velocity (5.9 ± 2.3 vs 8.6 ± 2.1 cm/s; p < .01) and average a’ velocity (6.2 ± 2.4 vs 8.8 ± 2.1 cm/s; p < .01) compared to patients with normal mean LAP. Septal a’, lateral a’ and average a’ velocity were good predictors of elevated mean LAP with AUC of 0.78, 0.83 and 0.82. Average a’ velocity with cut-off < 7.25 cm/s had a sensitivity of 83% and a specificity of 77% to predict elevated mean LAP. Conclusion The a’ velocity is a good indicator of mean LAP and might be considered in the evaluation of left ventricle filling pressure in patients with normal ejection fraction.

REDUCE LAP-HF II interatrial shunt trial: neutral, but necessary

Heart failure affects more than 26 million people worldwide, of whom nearly 50% will die within 5 years and over 30% routinely have symptoms with minimal exertion despite advances in pharmacological therapy.1 Elevated left atrial pressure is a well established target of therapy for patients with heart failure irrespective of their left ventricular ejection fraction (LVEF).2 Based on these observations, left atrial unloading via an interatrial shunt was proposed as an approach to deliver excess left atrial volume into the right atrium, thereby decreasing left atrial pressure and pulsatile load on the pulmonic circulation.

Left atrial appendage (LAA) flow profile of its different waves and its correlation with direct left atrial pressure measurement: Can LAA flow profile be a surrogate to estimate left atrial pressure.

Background:Left Atril Appendage(LAA) is one of the most contractile structure of the heart. Elevated Left atrial pressure (LAP) can change the flow profile in and out of LAA. There is little data on the effect of LAP on LAA flow velocities for patients in sinus rhythm, and it's not properly known that by evaluation of LAA flow spectra and its velocities, the LAP can be predicted. We tried to find the relationship between LAA flow velocities and LAP, with the premise that LAA flow velocities can be used as a surrogate for measuring LAP, by obtaining a regression equation in this prospective observational study.Methods:In forty patients with normal systolic and diastolic heart function undergoing elective off pump coronary artery bypass (OPCAB) under general anaesthesia, TEE based LAA flow velocities were measured and simultaneous direct measurements of LAP was done by the surgeon. We also studied the relation between the ratio of early mitral inflow velocity (E) and mitral lateral annular early diastolic velocity (E'), that is, (E/E') in all patients.Results:We found significant correlation between E/E' and LAP (r = 0.424, p = 0.024) however there was no significant correlation between LAA flow velocities and LAP.Conclusion:LAA flow profile can not be used under anaesthesia to evaluate LAP however E/E' shows a strong correlation with directly measured LAP.

Echocardiographic vs Invasive Estimation of Left Atrial Pressure – Ongoing Search for the Holy Grail

Elevated mean left atrial pressure (mLAP) is the key pathophysiological consequence of heart failure and the underlying cause of dyspnoea across the spectrum of left-sided valvular and pericardial diseases. Echocardiographic estimation of mLAP can be calculated by the equation mLAPECHO =1.24x(E/E’)+1.9. This formula was developed by correlation with mean pulmonary capillary wedge pressure at right heart catheterisation. Evidence of validation against direct mLAP measurements is lacking.

HbA1c and FIB-4 as serologic markers for the risk of progression of stage A heart failure.

The use of glycosylated hemoglobin as a diabetic glycemic control and cardiovascular risk marker is well documented. It has also been suggested as a marker for early diastolic hemodynamic changes leading to clinical heart failure, but is less well characterized. This study explored the association between elevated glycosylated hemoglobin and liver Fibrosis-4 values and worsening measures of diastolic cardiac function in order to assess their potential as early serologic markers in cardiovascular disease prevention.A retrospective cohort analysis was conducted in 102 patients presenting to the Parkview Medical Center health system who had received a full resting echo characterized by normal systolic ejection fraction and clinical risk factors associated with stage A heart failure in conjunction with glycosylated hemoglobin and Fibrosis-4 scores within a 3-month time window. Using regression analysis, measures of diastolic cardiac function were assessed in conjunction with rising glycosylated hemoglobin levels characterized as <6.5 and >6.5 and Fibrosis-4 scores after controlling for the presence of hypertension, coronary artery disease and valvular heart disease. Glycosylated hemoglobin levels >6.5 were significantly associated with a higher E/e’ ratio and closely associated with an elevated left atrial volume index both indicative of elevated left atrial pressure as a sensitive marker for diastolic cardiac dysfunction. Fibrosis-4 scores did not appear to be clinically associated with progression of diastolic dysfunction.Thus, glycosylated hemoglobin may act as an early marker for identifying patients at increased risk for the progression of stage A heart failure. Fibrosis-4 scores do not appear to be related.

HbA1c and FIB-4 as serologic markers for the risk of progression of stage A heart failure

The use of glycosylated hemoglobin as a diabetic glycemic control and cardiovascular risk marker is well documented. It has also been suggested as a marker for early diastolic hemodynamic changes leading to clinical heart failure, but is less well characterized. This study explored the association between elevated glycosylated hemoglobin and liver Fibrosis-4 values and worsening measures of diastolic cardiac function in order to assess their potential as early serologic markers in cardiovascular disease prevention.A retrospective cohort analysis was conducted in 102 patients presenting to the Parkview Medical Center health system who had received a full resting echo characterized by normal systolic ejection fraction and clinical risk factors associated with stage A heart failure in conjunction with glycosylated hemoglobin and Fibrosis-4 scores within a 3-month time window. Using regression analysis, measures of diastolic cardiac function were assessed in conjunction with rising glycosylated hemoglobin levels characterized as &lt;6.5 and &gt; 6.5 and Fibrosis-4 scores after controlling for the presence of hypertension, coronary artery disease and valvular heart disease. Glycosylated hemoglobin levels &gt; 6.5 were significantly associated with a higher E/e’ ratio and closely associated with an elevated left atrial volume index both indicative of elevated left atrial pressure as a sensitive marker for diastolic cardiac dysfunction. Fibrosis-4 scores did not appear to be clinically associated with progression of diastolic dysfunction.Thus, glycosylated hemoglobin may act as an early marker for identifying patients at increased risk for the progression of stage A heart failure. Fibrosis-4 scores do not appear to be related.