Higher Systemic Vascular Resistance Research Articles

The “Preeclampsia and Hypertension Target Treatment” study: a multicenter prospective study to evaluate the effectiveness of the antihypertensive therapy based on maternal hemodynamic findings

Despite major advances in the pharmacological treatment of hypertension in the non-pregnant population, treatments for hypertension in pregnancy have remained largely unchanged over the years. There is recent evidence that a more adequate control of maternal blood pressure is achieved when the first given antihypertensive drug is able to correct the underlying hemodynamic disorder of the mother beside normalizing the blood pressure values. to compare the blood pressure control in women receiving an appropriate or inappropriate antihypertensive therapy in accordance with the baseline hemodynamic findings STUDY DESIGN: prospective multicenter study including a population of women with de novo diagnosis of HDP. A noninvasive assessment of the following maternal parameters was done upon the hospital admission by means of USCOM (Ultrasound Cardiac Output Monitor) before any antihypertensive therapy was given: Cardiac Output (CO), Heart Rate (HR), Systemic Vascular Resistance (SVR), Stroke Volume (SV). The clinician who prescribed the antihypertensive therapy was blinded to the hemodynamic evaluation and based on his preferences or on the local protocols used as 1st line a vasodilator (nifedipine or alpha methyldopa) or a beta-blocker (labetalol). The 1st line pharmacological treatment was retrospectively considered hemodynamically appropriate in either of the following circumstances: 1) Women with a hypodynamic profile (defined as low cardiac output [CO≤5L/min] and/or high systemic vascular resistance [SVR≥1300 dynes*s*cm]) who were administered oral nifedipine or alpha methyldopa. 2) Women with a hyperdynamic profile (defined as normal or high cardiac output [CO >5 L/min] and/or low systemic vascular resistances [SVR<1300 dynes*s*cm-]) who were administered oral labetalol. The primary outcome of the study was to compare the occurrence of severe hypertension between the women who were found to be treated with a hemodynamically appropriate or inappropriate therapy. A total of 152 women with HDP were included in the final analysis. Of these the majority displayed a hypodynamic profile (114 or 75.0%) and received a hemodynamically appropriate treatment (116 or 76.3%). The occurrence of severe hypertension prior to delivery was significantly lower in the group receiving an appropriate therapy compared with those inappropriately treated (6.0% vs. 19.4%; p= 0.02). Moreover, the number of women who achieved target values of BP within 48-72h from the treatment start was higher in the group who received an appropriate treatment (70.7% vs. 50.0%; p=0.02). In pregnant individuals with de novo HDP, a lower occurrence of severe hypertension is observed when the first line antihypertensive agent is tailored to the correct maternal hemodynamic profile.

Systemic Vascular Resistance and Myocardial Work Analysis in Hypertrophic Cardiomyopathy and Transthyretin Cardiac Amyloidosis with Preserved Left Ventricular Ejection Fraction.

Background: The pathophysiological impact of systemic vascular resistance (SVR) and pressure-strain loop-derived global myocardial work index (GWI) in hypertrophic cardiomyopathy (HCM) and transthyretin cardiac amyloidosis (ATTR) has been randomly investigated. Methods: Both SVR and GWI were assessed in outpatients consecutively referred at two Italian cardiology departments for heart failure with preserved left ventricular ejection fraction (LVEF), affected by either nonobstructive HCM or wild-type ATTR. Based on relevant cross-tabulations, the patients were gathered into 4 functional classes according to cut-off values of 1440 dyne/s/cm-5 for SVR, and 1576 mm Hg% for GWI, as suggested by previous studies. Results: A total of 60 patients, 30 in each group, aged 61 ± 16 years, with 78% males, were studied. HCM patients were younger than those with ATTR and in a better clinical condition (23% HCM vs. 77% ATTR were NYHA class II-III, p < 0.001). Overall, 51 patients (85%) showed a high SVR, 21/30 HCM (70%), and 30 ATTR (100%) (p < 0.005). Both SVR and GWI (expressions of ventricular-arterial coupling) were impaired in 43% of HCM patients (showing greater LV concentric hypertrophy) and 93% of ATTR patients (in advanced NYHA functional class) (p < 0.001). Conclusions: A substantial percentage of present study population showed impaired SVR and/or GWI, despite preserved LVEF. The proposed classification may shed further light on the pathophysiological and clinical characteristics of such hypertrophic phenotypes.

Effect of Maternal Preeclampsia on Cardiac Structure and Function in Very Low Birth Weight Infants.

We aimed to determine whether exposure to severe maternal preeclampsia (PE) in very low birth weight (VLBW) infants is associated with hypertrophic cardiac changes and altered hemodynamics. Case-control study of VLBW infants born at Los Angeles General Medical Center from May 2015 to August 2023, who had an echocardiogram within the first 7 days of life. Cases were infants exposed to maternal PE and controls were infants not exposed to maternal PE matched by birth weight (BW) 1:1. Laboratory, placental pathology results, hemodynamic data and clinical outcomes were collected and compared between cases and control infants. A total of 43 cases matched by BW with control infants were studied. There were no significant anatomical cardiac changes by echocardiography between cases and control infants. Cases had significantly higher blood pressure within the first 72 hours of life and lower ejection fraction (EF), fractional shortening, and peak systolic flow velocity through their patent ductus arteriosus (PDA) within the first week of life. Cases were more likely to be smaller despite being born at a later gestational age (GA), as well as small for GA with placental weight less than 10th percentile compared to control infants. Our findings indicate that infants born to mothers with PE have higher systemic vascular resistance as evidenced by elevated blood pressure, and lower EF and shortening fraction and higher pulmonary vascular resistance as evidenced by lower peak flow velocity through the PDA. We did not observe hypertrophic cardiac changes in exposed infants. These findings should be considered in clinical decision-making during management of these infants. · VLBW infants exposed to severe PE have higher rate of Small for gestational age and smaller placentas.. · VLBW infants exposed to severe PE have higher systemic vascular resistance during transitional period and lower EF and fractional shortening.. · VLBW infants exposed to severe PE have higher pulmonary vascular resistance..

Determinants of Urine Output Using Advanced Hemodynamic Monitoring in Critically Ill Patients Undergoing Continuous Renal Replacement Therapy

Introduction: Low cardiac output and hypovolemia are candidate macrocirculatory mechanisms explanatory of de novo anuria in intensive care unit (ICU) patients undergoing continuous renal replacement therapy (CRRT). We aimed to determine the hemodynamic parameters and CRRT settings associated with the longitudinal course of UO during CRRT. Methods: This is an ancillary analysis of the PRELOAD CRRT observational, single-center study (NCT03139123). Enrolled adult patients had severe acute kidney injury treated with CRRT for less than 24 h and were monitored with a calibrated continuous cardiac output monitoring device. Hemodynamics (including stroke volume index [SVI] and preload-dependence, identified by continuous cardiac index variation during postural maneuvers), net ultrafiltration (UF_NET), and UO were reported 4-hourly, over 7 days. Two study groups were defined at inclusion: non-anuric participants if the cumulative 24 h UO at inclusion was ≥0.05 mL kg⁻¹ h⁻¹, and anuric otherwise. Quantitative data were reported by its median [interquartile range]. Results: Forty-two patients (age 68 [58–76] years) were enrolled. At inclusion, 32 patients (76%) were not anuric. During follow-up, UO decreased significantly in non-anuric patients, with 25/32 (78%) progressing to anuria within 19 [10–50] hours. Mean arterial pressure (MAP) and UF_NET did not significantly differ between study groups during follow-up, while SVI and preload-dependence were significantly associated with the interaction of study group and time since inclusion. Higher UF_NET flow rates were significantly associated with higher systemic vascular resistances and lower cardiac output during follow-up. Multivariate analyses showed that (1) lower UO was significantly associated with lower SVI, lower MAP, and preload-independence; and (2) higher UF_NET was significantly associated with lower UO. Conclusions: In ICU patients treated with CRRT, those without anuria showed a rapid loss of diuresis after CRRT initiation. Hemodynamic indicators of renal perfusion and effective volemia were the principal determinants of UO during follow-up, in relation with the hemodynamic impact of UF_NET setting.

Temporary Mechanical Circulatory Support in Sepsis-Associated Cardiogenic Shock With and Without Acute Myocardial Infarction

To describe the current use and outcomes of temporary mechanical circulatory support (MCS) in patients with sepsis-associated cardiogenic shocks with and without acute myocardial infarction (AMI) in the United States. Retrospective cohort study. The National Inpatient Sample database from 2017 to 2019. Adult patients with sepsis-associated cardiogenic shock with and without AMI. Temporary MCSs, including intra-aortic balloon pump (IABP), percutaneous left ventricular assist device (pLVAD), and extracorporeal membrane oxygenation (ECMO). Multivariate logistic regression analyses adjusting for patient characteristics, organ failures, and socioeconomic status. Although the uses of IABP and pLVAD were associated with significantly lower odds of in-hospital mortality in patients with sepsis-associated cardiogenic shock (IABP: adjusted odds ratio [aOR] 0.57, 95% CI 0.44-0.73, p < .001; pLVAD: aOR 0.66, 95% CI 0.45-0.98, p=.037), ECMO was not (aOR 1.51, 95% CI 0.93-2.45, p=0.096). In the subgroup with AMI, temporary MCSs were not associated with significantly lower or higher odds of in-hospital mortality. In the subgroup without AMI, IABP was associated with significantly lower odds of in-hospital mortality (aOR 0.43, 95% CI 0.28-0.65, p < 0.001). Although temporary MCS is deemed to be a feasible option in sepsis-associated cardiogenic shock, the selection of the right patients whose shock is driven mainly by cardiogenic shock rather than septic shock, as represented by low cardiac output and high systemic vascular resistance, plays a critical role in the feasibility of this approach in the absence of clinical trials.

Hemodynamic Determinants of Elevated Blood Pressure and Hypertension in the Middle to Older-Age UK Population: A UK Biobank Imaging Study.

Increased systemic vascular resistance and, in older people, reduced aortic distensibility, are thought to be the hemodynamic determinants of primary hypertension but cardiac output could also be important. We examined the hemodynamics of elevated blood pressure and hypertension in the middle to older-aged UK population participating in the UK Biobank imaging studies. Cardiac output, systemic vascular resistance, and aortic distensibility were measured from cardiac magnetic resonance imaging in 31 112 (distensibility in 21 178) participants (46.3% male, mean age±SD 63±7 years). Body composition including visceral adipose tissue volume and abdominal subcutaneous adipose tissue volume were measured in 19 645 participants. Participants with higher blood pressure had higher cardiac output (higher by 17.9±26.6% in hypertensive compared with those with optimal blood pressure) and higher systemic vascular resistance (higher by 11.4±27.9% in hypertensive compared with those with optimal blood pressure). These differences were little changed after adjustment for body size and adiposity. The contribution of cardiac output relative to systemic vascular resistance was more marked in younger compared with older subjects. Aortic distensibility decreased with age and was lower in participants with higher compared with lower blood pressure but with a greater difference in younger compared with older subjects. In the middle to older-aged UK population, cardiac output plays an important role in contributing to elevated mean arterial blood pressure, particularly in younger compared with older subjects. Reduced aortic distensibility contributes to a rise in pulse pressure and systolic blood pressure at all ages.

Subclinical cardiac dysfunction may impact on fluid and vasopressor administration during early resuscitation of septic shock

BackgroundAccording to the Surviving Sepsis Campaign (SSC) fluids and vasopressors are the mainstays of early resuscitation of septic shock while inotropes are indicated in case of tissue hypoperfusion refractory to fluids and vasopressors, suggesting severe cardiac dysfunction. However, septic cardiac disfunction encompasses a large spectrum of severities and may remain “subclinical” during early resuscitation. We hypothesized that “subclinical” cardiac dysfunction may nevertheless influence fluid and vasopressor administration during early resuscitation. We retrospectively reviewed prospectically collected data on fluids and vasoconstrictors administered outside the ICU in patients with septic shock resuscitated according to the SSC guidelines that had reached hemodynamic stability without the use of inotropes. All the patients were submitted to transpulmonary thermodilution (TPTD) hemodynamic monitoring at ICU entry. Subclinical cardiac dysfunction was defined as a TPTD-derived cardiac function index (CFI) ≤ 4.5 min−1.ResultsAt ICU admission, subclinical cardiac dysfunction was present in 17/40 patients (42%; CFI 3.6 ± 0.7 min−1 vs 6.6 ± 1.9 min−1; p < 0.01). Compared with patients with normal CFI, these patients had been resuscitate with more fluids (crystalloids 57 ± 10 vs 47 ± 9 ml/kg PBW; p < 0.01) and vasopressors (norepinephrine 0.65 ± 0.25 vs 0.43 ± 0.29 mcg/kg/min; p < 0.05). At ICU admission these patients had lower cardiac index (2.2 ± 0.6 vs 3.6 ± 0.9 L/min/m2, p < 0.01) and higher systemic vascular resistances (2721 ± 860 vs 1532 ± 480 dyn*s*cm−5/m2, p < 0.01).ConclusionsIn patients with septic shock resuscitated according to the SSC, we found that subclinical cardiac dysfunction may influence the approach to fluids and vasopressor administration during early resuscitation. Our data support the implementation of early, bedside assessment of cardiac function during early resuscitation of septic shock.

Using omics to breathe new life into our understanding of the ductus arteriosus oxygen response

The ductus arteriosus (DA) connects the aorta to the pulmonary artery (PA), directing placentally oxygenated blood away from the developing lungs. High pulmonary vascular resistance and low systemic vascular resistance facilitate shunting of blood in utero from the pulmonary to the systemic circulation through the widely patent DA, thereby optimizing fetal oxygen (O2) delivery. With the transition from fetal (hypoxia) to neonatal (normoxia) oxygen conditions, the DA constricts while the PA dilates. This process often fails in prematurity, promoting congenital heart disease. Impaired O2-responsivness in the DA promotes persistent ductus arteriosus (PDA), the most common form of congenital heart disease. Knowledge of DA oxygen sensing has greatly advanced in the past few decades, however we still lack a complete understanding of the sensing mechanism. The genomic revolution of the past two decades has facilitated unprecedented discovery in every biological system. This review will demonstrate how multiomic integration of data generated from the DA can breathe new life into our understanding of the DA's oxygen response.

Effects of oxycodone hydrochloride and dezocine on hemodynamics and levels of inflammatory factors in patients receiving gynecological laparoscopic surgery under general anesthesia

We aimed to compare the effects of oxycodone hydrochloride and dezocine on hemodynamics and inflammatory factors in patients receiving gynecological laparoscopic surgery under general anesthesia. A total of 246 patients were divided into group A and B (n=123). Hemorheology indices were recorded 5 min after anesthesia (T0), 1 min after pneumoperitoneum (T1), when position was changed 5 min after pneumoperitoneum (T2), 15 min after pneumoperitoneum (T3), 1 min (T4) and 5 min (T5) after position was restored. Visual analogue scale scores 1, 2, 6, 12, 24 and 48 h after operation were recorded. Postoperative adverse reactions and visceral pain were observed. The expression levels of inflammatory factors were detected by enzyme-linked immunosorbent assay 12 h after operation. Compared with group A, group B had higher heart rate and mean arterial pressure at T2, lower central venous pressure and cardiac output at T1-T3, and higher systemic vascular resistance at T1-T5 (P<0.05). The incidence rate of pain syndrome in group A was lower (P<0.05). Group A had lower tumor necrosis factor-alpha and interleukin-6 expression levels and higher interleukin-10 level than those of group B (P<0.05). For gynecological laparoscopic surgery, oxycodone preemptive analgesia has superior outcomes to those of dezocine.

PS-BPC05-7: HEMODYNAMIC MANAGEMENT OF RESISTANT HYPERTENSION

Background: Hypertension is the most prevalent chronic disease worldwide and is related to a high probability of cardiac disease, kidney disease and cerebrovascular events. Blood pressure measurement was used in the last decades to diagnose and guide antihypertensive therapy; however blood pressure is the result of the interaction of more complex hemodynamic parameters previously reserved for experimental studies or critical care patients management using invasive methods. Since 1996 few studies have proposed the use of hemodynamic parameters to classify and guide hypertension therapy with good results. Purpose: The present study's purpose was to measure hemodynamic parameters in patients with non-controlled resistant hypertension and use it to guide pharmacologic treatment to archive control blood pressure values according to the European Society of Cardiology guidelines. Methods: A total of 84 patients between 32 and 95 years old diagnosed with non-controlled primary resistant hypertension were recruited and after previous therapy washout hemodynamic parameters were measured using noninvasive Methods: preload by central venous pressure (CVP) using inferior vena cava diameter, cardiac index and systemic vascular resistance using Lyljestrand &amp; Zander modified formula. Patients were classified into 3 basic groups depending on which parameter was above normal value: hyperdynamic (HD) for high cardiac index &gt; 3.5 L/min/m2, fluid overload (FO) for CVP &gt; 8cmH2O and high systemic vascular resistance index (HSVRi) &gt; 2500 dynes/sec/m2/cm5, also 3 combined groups were a patient had 2 simultaneous hemodynamic alterations (HD+FO, HD+HSVRi and FO+HSRVi), according to this classification pharmacotherapy was guided indicating Bisoprolol in HD group, Amlodipine to HSVR patients and Hydrochlorothiazide to FO patients, in combined groups, combined therapy was given. Patients were observed for 6 months period taking as primary endpoint blood pressure control, acute cardiovascular events and hypotension. Results: A significant reduction of hemodynamic parameters and blood pressure was observed in the first month of treatment obtaining a 100% hemodynamic and blood pressure goals in all patients in the third month of therapy without hypotension or acute cardiovascular event during this period, the HD+FO group reach goals at the 6th month of treatment without reported complications. Conclusions: In this preliminary study we observed that hemodynamic guided high blood pressure control may be a valuable tool for a better understanding, classification and treatment in patients with resistant hypertension; however larger outcome studies confirm this hypothesis.

Is Maternal Cardiovascular Performance Impaired in Altitude-Associated Fetal Growth Restriction?

Mundo, William, Lilian Toledo-Jaldin, Alexandrea Heath-Freudenthal, Jaime Huayacho, Litzi Lazo-Vega, Alison Larrea-Alvarado, Valquiria Miranda-Garrido, Rodrigo Mizutani, Lorna G. Moore, Any Moreno-Aramayo, Richard Gomez, Patricio Gutierrez, and Colleen G. Julian. Is maternal cardiovascular performance impaired in altitude-associated fetal growth restriction? High Alt Med Biol 00:000-000, 2022. Introduction: The incidence of fetal growth restriction (FGR) is elevated in high-altitude resident populations. This study aims to determine whether maternal central hemodynamics during the last trimester of pregnancy are altered in high-altitude FGR. Methods: In this cross-sectional study of maternal-infant pairs (FGR, n = 27; controls, n = 26) residing in La Paz, Bolivia, maternal heart rate, cardiac output (CO), stroke volume, and systemic vascular resistance (SVR) were assessed using continuous-wave Doppler ultrasound. Transabdominal Doppler ultrasound was used for uterine artery (UtA) resistance indices and fetal measures. Maternal venous soluble fms-like tyrosine kinase-1 (sFlt1) levels were measured. Results: FGR pregnancies had reduced CO, elevated SVR and UtA resistance, fetal brain sparing, and increased maternal sFlt1 versus controls. Maternal SVR was positively associated with UtA resistance and inversely associated with middle cerebral artery resistance and birth weight. Maternal sFlt1 was greater in FGR than controls and positively associated with UtA pulsatility index. Women with elevated sFlt1 levels also tended to have lower CO and higher SVR. Conclusion: Noninvasive assessment of maternal cardiovascular function may be an additional method for detecting high-risk pregnancies at high altitudes, thereby informing the need for increased surveillance and appropriate allocation of resources to minimize adverse outcomes.

Association of Immediate Postoperative Hemodynamic and Laboratory Values in Predicting Norwood Admission Outcomes.

The primary objective of this study was to determine whether or not hemodynamic parameters and laboratory values at the time of admission to the pediatric cardiac intensive care unit after the Norwood operation were associated with a composite outcome of either need for extracorporeal membrane oxygenation or inpatient mortality. This was a single-center retrospective study of infants with functionally univentricular hearts admitted to intensive care after the Norwood procedure from January 2011 to January 2020. Data were obtained at a single point (after a Norwood procedure) and then compared between two subsets of patients based on the presence or not of the composite outcome of interest. In univariate and multiple regression analyses, a series of receiver operator curves were generated to assess the relationship between the variables of interest and the composite outcome. Eight (7.6%) experienced the composite outcome out of a total of 104 patients. Those who experienced the composite endpoint had significantly higher oxygen extraction ratio (0.43 vs. 0.31, p = 0.01), lower systemic blood flow (2.5L/min versus 3.1L/min, p = 0.01), and higher systemic vascular resistance (20.2 indexed woods units versus 14.8 indexed woods units, p = 0.01). Those with systemic blood flow of less than 2.5L/min/m2 had a 17% risk of experiencing the composite endpoint AUC = 0.79. Those with systemic vascular resistance of greater than 19 indexed woods units had a 22% risk of experiencing the composite endpoint AUC 0.80. Systemic blood flow and systemic vascular resistance are independently associated with this composite outcome.

Evaluation of the definition of hyperdynamic circulation in patients with cirrhosis and ascites.

The aim of this study was to evaluate potential criteria for defining hyperdynamic circulation in patients with cirrhosis according to the severity of ascites and its association with the activation of vasoactive systems and markers of systemic inflammation. Cross-sectional studyof patients with cirrhosis and right heart catheter measurement from two different academic centers. We evaluated systemic vascular resistance (SVR)/cardiac output (CO) according to ascites severity. The first substudy evaluated the possible definition, the second validated the findings, and the third evaluated the possible mechanisms. Comparisons were performed by means of t test, Mann-Whitney U test, and analysis of variance. Finally, linear regression curves were adjusted to evaluate the relationship between CO and SVR according to the severity of ascites and compensated or decompensated stage of cirrhosis. The study included 721 patients (substudy 1, n=437; substudy 2, n=197; substudy 3, n=87). Hyperdynamic circulation (HC), defined by absolute cutoffs, had no association with the presence or severity of ascites in the first two cohorts. No association was observed between HC with renin, aldosterone, or markers of bacterial translocation. Comparison of linear regression curves showed a shift of the CO-SVR relationship to the left in patients with refractory ascites (p < 0.001) compared to patients without ascites as well as to patients with decompensated cirrhosis (p=0.002). Conclusion: HC according to the traditional concept of high CO and low SVR is not always present in ascites. Evaluation of the CO-SVR relationship according to the severity of ascites shows a shift to the left, suggesting that the presence of HC would be defined by this shift, independent of absolute values.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Cardiac function and exercise capacity in patients with metabolic syndrome: A cross-sectional study.

BackgroundMetabolic syndrome is a pre-diabetes condition that is associated with increased cardiovascular morbidity and mortality. We aimed to explore how exercise capacity, cardiac structure, and function were affected in patients with metabolic syndrome.MethodsOutpatients with echocardiography and exercise stress test combined with impedance cardiography (ETT + ICGG) results available from Nov 2018 to Oct 2020 were retrospectively enrolled. Echocardiographic, ETT + ICG profiles, and exercise performance were compared between patients with metabolic syndrome and the ones without. Sensitivity analyses were performed excluding patients without established coronary heart disease and further 1:1 paired for age and gender, respectively. Multiple linear regression was used to find out related predictors for maximal metabolic equivalents (METs).ResultsThree hundred and twenty-third patients were included, among whom 97 were diagnosed as metabolic syndrome. Compared to patients without metabolic syndrome, echocardiography showed that patients with metabolic syndrome had a significantly lower E/A ratio (p < 0.001). Besides, they have larger left atrium, larger right ventricle, and thicker interventricular septum (all p < 0.001), but similar left ventricular ejection fraction (P = 0.443). ICG showed that patients with metabolic syndrome had significantly higher stroke volume at rest and maximum (p < 0.001), higher left cardiac work index at rest and maximum (p = 0.005), higher systemic vascular resistance (SVR) at rest (p < 0.001), but similar SVI (p = 0.888). During exercise, patients with metabolic syndrome had lower maximal METs (p < 0.001), and a higher proportion suffering from ST-segment depression during exercise (p = 0.009). Sensitivity analyses yielded similar results. As for the linear regression model, 6 independent variables (systolic blood pressure, BMI, E/A ratio, the height of O wave, the peak value of LCWi, and the baseline of SVR) had statistically significant effects on the maximal METs tested in exercise (R = 0.525, R2 = 0.246, P < 0.001).ConclusionPatients with metabolic syndrome had significant structural alteration, apparent overburden of left ventricular work index, pre-and afterload, which may be the main cause of impaired exercise tolerance.

The cardiac-fetal-placental unit: fetal umbilical vein flow rate is linked to the maternal cardiac profile in fetal growth restriction

The functional maternal-fetal hemodynamic unit includes fetal umbilical vein flow and maternal peripheral vascular resistance. This study investigated the relationships between maternal and fetal hemodynamics in a population with suspected fetal growth restriction. This was a prospective study of normotensive pregnancies referred to our outpatient clinic for a suspected fetal growth restriction. Maternal hemodynamics measurement was performed, using a noninvasive device (USCOM-1A) and a fetal ultrasound evaluation to assess fetal biometry and velocimetry Doppler parameters. Comparisons among groups were performed with 1-way analysis of variance with Student-Newman-Keuls correction for multiple comparisons and with Kruskal-Wallis test where appropriate. The Spearman rank coefficient was used to assess the correlation between maternal and fetal hemodynamics. Pregnancies were observed until delivery. A total of 182 normotensive pregnancies were included. After the evaluation, 54 fetuses were classified as growth restricted, 42 as small for gestational age, and 86 as adequate for gestational age. The fetus with fetal growth restriction had significantly lower umbilical vein diameter (P<.0001), umbilical vein velocity (P=.02), umbilical vein flow (P<.0001), and umbilical vein flow corrected for fetal weight (P<.01) than adequate-for-gestational-age and small-for-gestational-age fetuses. The maternal hemodynamic profile in fetal growth restriction was characterized by elevated systemic vascular resistance and reduced cardiac output. The umbilical vein diameter was positively correlated to maternal cardiac output (rs=0.261), whereas there was a negative correlation between maternal systemic vascular resistance (rs=-0.338) and maternal potential energy-to-kinetic energy ratio (rs=-0267). The fetal umbilical vein time averaged max velocity was positively correlated to maternal cardiac output (rs=0.189) and maternal inotropy index (rs=0.162), whereas there was a negative correlation with maternal systemic vascular resistance (rs=-0.264) and maternal potential energy-to-kinetic energy ratio (rs=-0.171). The fetal umbilical vein flow and the flow corrected for estimated fetal weight were positively correlated with maternal cardiac output (rs=0.339 and rs=0.297) and maternal inotropy index (rs=0.217 and r=0.336), whereas there was a negative correlation between maternal systemic vascular resistance (rs=-0.461 and rs=-0.409) and maternal potential energy-to-kinetic energy ratio (rs=-0.336 and rs=-0.408). Maternal and fetal hemodynamic parameters were different in the 3 groups of fetuses: fetal growth restriction, small for gestational age, and adequate for gestational age. Maternal hemodynamic parameters were closely and continuously correlated with fetal hemodynamic features. In particular, a maternal hemodynamic profile with high systemic vascular resistance, low cardiac output, reduced inotropism, and hypodynamic circulation was correlated with a reduced umbilical vein flow and increased umbilical artery pulsatility index. The mother, placenta, and fetus should be considered as a single cardiac-fetal-placental unit. The correlations of systemic vascular resistance, cardiac output, and inotropy index with umbilical artery impedance indicate the key role of these 3 parameters in placental vascular tree development. The umbilical vein flow rate and, therefore, the placental perfusion seems to be influenced not only by these three parameters but also by the maternal cardiovascular kinetic energy.

C75 PHEOCHROMOCYTOMA–INDUCED CARDIOGENIC SHOCK: A MULTICENTER ANALYSIS OF CLINICAL PROFILES, MANAGEMENT AND OUTCOMES

Abstract Background Pheochromocytoma is a rare neuroendocrine tumor that arises from the adrenal gland and overproduces catecholamines; it is an infrequent cause of cardiogenic shock (CS). Several case reports have investigated pheochromocytoma–induced CS, but larger studies have not yet been carried out. Objectives Our work aims to describe a multicenter experience in the diagnosis and management of patients with pheochromocytoma–induced CS, and to raise awareness around this rare condition. Methods: We enrolled all patients with a diagnosis of pheochromocytoma–induced CS admitted to the intensive care units of 8 European referral Hospitals. Results Among the 17 patients (47% males, mean age 49,5 years), we found that pulmonary congestion was the mostly represented clinical feature (82%). The most represented echocardiographic left ventricle (LV) pattern was the reverse Takotsubo (TTS) pattern with apical hyperkinesis associated with basal– to mid–ventricular hypokinesis (47%). Elevated systemic vascular resistances (SVR) were observed. Endomyocardial biopsy of the LV was performed in one patient showing contraction band necrosis, oedema and inflammatory reaction. 76% of patients were treated with dobutamine, 70% needed noradrenaline, 29% adrenaline, 23.5% were treated with levosimendan and 17% with milrinone. Mechanical circulatory support devices (MCS) were necessary for 65% of patients. All patients benefited from pheochromocytoma’s surgical excision, with 4 patients operated on while under ECLS. All patients recovered, excepted one (presenting a severe left ventricular dilatation at admission) who required cardiac transplantation. Conclusion Pheochromocytoma is an infrequent cause of CS, with most often a TTS–like presentation. It should be suspected in case of a CS with high initial SVR and rapid deterioration. MCS must be considered in the most severe cases. The main challenge is to stabilize the patient, mostly with MCS, since it remains a reversible cause of CS with a low mortality rate. Adrenalectomy can safely be performed even when the patient is under MCS.

Vitamin C supplementation attenuates oxidative stress and improves erythrocyte deformability in cardiac surgery with cardiopulmonary bypass.

Cardiopulmonary bypass (CPB) depletes endogenous Vitamin C and generates oxidative stress in cardiac surgery. This study aimed to clarify whether Vitamin C supplementation reduces oxidant production and improves erythrocyte deformability in cardiac surgery with CPB. In a randomized and controlled design, 30 eligible patients undergoing cardiac surgery with hypothermic CPB were equally assigned to the Vitamin C group and control group. Subjects of the Vitamin C group and control group received an intravenous infusion of Vitamin C 20 mg·kg-1 and a placebo during rewarming period of CPB, respectively. We measured the plasma level of reactive oxygen species (ROS) and phosphorylation levels of non-muscle myosin IIA (NMIIA) in erythrocyte membrane, as an index of erythrocyte deformability, before and after CPB. Vitamin C supplementation attenuated the surge in plasma ROS after CPB, mean 1.661 ± standard deviation 0.801 folds in the Vitamin C group and 2.743 ± 1.802 in the control group. The tyrosine phosphorylation level of NMIIA after CPB was upregulated in the Vitamin C group compared to the control group, 2.159 ± 0.887 folds and 1.384 ± 0.445 (P = 0.0237). In addition, the phosphorylation of vasodilator-stimulated phosphoprotein (VASP) and focal adhesion kinase (FAK) in erythrocytes was concurrently enhanced in the Vitamin C group after CPB. The phosphorylation level of endothelial nitric oxide synthase in erythrocytes was significantly increased in the Vitamin C group (1.734 ± 0.371 folds) compared to control group (1.102 ± 0.249; P = 0.0061). Patients receiving Vitamin C had lower intraoperative blood loss and higher systemic vascular resistance after CPB compared to controls. Vitamin C supplementation attenuates oxidative stress and improves erythrocyte deformability via VASP/FAK signaling pathway in erythrocytes during CPB.

Hypotension associated with high cardiac output and low systemic vascular resistance in a patient with hyperparathyroidism and hypercalcemia.

Hypotension associated with high cardiac output and low systemic vascular resistance in a patient with hyperparathyroidism and hypercalcemia.

Maternal haemodynamic profile in pregnancy after assisted reproductive technology: A pilot study.

Singleton pregnancies obtained by assisted reproductive technology (ART) are at increased risk of adverse pregnancy outcome. Aim of this pilot study was to compare maternal hemodynamic profile in ART and spontaneous singleton pregnancies. Patients were enrollered during a third trimester routine obstetric examination. Maternal haemodynamic assessment was carried out by a single trained operator using an UltraSonic Cardiac Output Monitor in standardized conditions. Our pilot data suggests that women conceived after ART may have significantly lower Cardiac Output and significantly higher Systemic Vascular Resistance when compared to those conceiving spontaneously. These differences, if confirmed in larger studies, might explain the increased prevalence of adverse outcome, especially hypertensive disorders of pregnancy, in singleton ART pregnancies.