Inferior Vena Cava Diameter Research Articles

Accuracy of right atrial pressure estimation by transthoracic echocardiography

Abstract Background/Introduction Transthoracic echocardiography provides an estimate of right atrial pressure (RAP) using the guideline-recommend method of measuring inferior vena cava (IVC) diameter and collapsibility. Despite being ubiquitously reported and necessary for the estimation pulmonary artery systolic pressure, the accuracy of this method for RAP estimation has not been rigorously validated. Purpose To evaluate the accuracy of the guideline-recommended method for the estimation of RAP by TTE. Methods A single center, retrospective chart review of patients who had a TTE and right heart catheterization (RHC) within 48 hours of each other from January 2018 to December 2020. Maximum and minimum IVC diameter were measured by trained study personnel. Accuracy was then stratified by the presence/absence of a history of two variables that could modify IVC diameter independent of RAP—syncope, which is associated with more dilated IVC in some studies and liver disease, which could result in compression (from parenchymal fibrosis surrounding the IVC) or dilation (from diversion of portal blood flow through the IVC among other mechanisms) of the IVC. Results The 117 patients who met inclusion criteria had a median age of 67 years old (interquartile range [IQR] 58 – 75) and median RAP of 13 mmHg (IQR 8 – 18) on RHC. The median time between TTE and RHC was 9.6 hours (IQR 3.8 – 24.5 hours) during which 24 (20.5%) patients received intravenous fluids (median 220 mL administered; IQR 145 – 320). Forty-three (35.9%) received diuretics between the studies with most patients receiving either 1 (26 patients, 61.9% of those who received diuretics) or 2 (13 patients, 31.0%) diuretic doses. In evaluating accuracy, only 26 patient’s (20.5%) RAP by RHC fell within estimated RAP range by TTE (Figure 1). After excluding the 60 patients who received fluids and/or diuretics between the TTE and RHC, the TTE estimate was still only accurate in 13 (22.8%) patients. When analyzing how each subcomponent of the TTE guidelines for RAP estimation correlated with RAP via RHC, maximum IVC diameter and percent collapsibility had Pearson’s correlation coefficients of 0.47 and 0.24 respectfully (Figure 2A and 2B). Past medical history was significant for syncope in 16 patients (13.7%) and liver disease in 8 patients (6.8%). Compared to those without each factor, the absolute accuracy of the TTE estimate was lower when stratified by a history of syncope (12.5% accurate vs 21.8%, p = 0.60) and liver disease (12.5% vs 21.2%, p = 0.90) though neither were statistically significant. Conclusion In this retrospective chart review, RAP estimation by TTE using the guideline-recommended method had limited accuracy. Prospective evaluation with minimal time between RHC and TTE is needed to validate the accuracy of the TTE guidelines.Accuracy of TTE for RAP estimationCorrelation between RAP & TTE Variables

Effect of renal dialysis session on novel echocardiographic parameters of left and right ventricle in patients with end-stage renal disease

Abstract Introduction Chronic heart disease is among the leading causes of end-stage renal disease (ESR). On the other hand, patients with ESR undergoing dialysis demonstrate often subclinically impaired left and/or right ventricular function according to small studies, and higher prevalence of chronic heart disease. However, data regarding the effect of renal dialysis on novel echocardiographic parameters among renal dialysis patients remain limited.The purpose of our study, was to study the effect of renal dialysis on novel echocardiographic parameters of left and right ventricle. Methods All 50 patients (14 females) of mean age 62.9 years undergoing renal dialysis in our kidney unit regularly were included in our study. Blood pressure, heart rate and weight measurements and heart echocardiogram with measurement of LV GLS, RV GLS, RV FWS, LA ResS, E/e’ ratio, Right Ventricular Systolic pressure (PASP) and inferior vena cava (IVC) diameter, before and after renal dialysis session, were carried out. Results Mean values of body weight (79,9 vs 77,6 kg), heart rate (74,2 vs 73,5 bpm) and blood pressure (131,5/80,6 vs 123,5/76,9 mmHg) were as expected statistically significant reduced after renal dialysis (p<0,001). Values of PASP (36,1 vs 27,8 mmHg), E/e’ ratio (14 vs 12,5) and IVC diameter (1,6 vs 1,3 cm), were statistically significant reduced after renal dialysis (p<0,001). Furthermore, values of RV GLS (-19,3 vs -20,3 %), RV FWS (-21,2 vs -22,6 %) and LA ResS (29,6 vs 30,7%), were statistically significant improved after renal dialysis session (p <0,001), while LV GLS depicted a minor improvement (-17,9% vs 18,2%) not statistically significant. Conclusion In conclusion, renal dialysis session had a beneficial effect on novel echocardiographic parameters of left and right ventricle (RV GLS, RV FWS, LA ResS) due to improvement of hemodynamic parameters (blood pressure, heart rate, PASP and IVC diameter) and intravascular volume reduction. Larger clinical studies should be organized to further investigate the effect of renal dialysis on those parameters and the underlying mechanisms in the chronic setting of hemodialysis.

Clinical utility of fibrosis-4 index in predicting increased right atrial pressure

Abstract Introduction Fibrosis-4 (FIB-4) index, derived from serum aspartate transaminase, alanine aminotransferase, platelet count and age, is an easily measurable marker reflecting hepatic fibrosis. Recently, FIB-4 index has been reported to be associated with cardiac events in heart failure (HF) patients. We examined whether FIB-4 index was useful in predicting elevated right atrial pressure (RAP) in comparison with directly measured RAP. Methods We studied consecutive 293 HF patients who underwent right heart catheter (RHC) examinations at our institution between Sep 2021 and May 2023. The exclusion criteria were as follows: viral or metabolic chronic hepatic diseases, thrombocytopenia. The subjects received RHC examination and blood test on the same day, and echocardiography within 3 days from the RHC examination. On top of FIB-4 index, diameter of inferior vena cava (IVC) and its respiratory changes were measured as a conventional method to estimate RAP. Results A total of 252 patients (mean 64.7 years of age, 52.8% men) were eligible for this study. FIB-4 index was significantly correlated with mean RAP (r = 0.39, p < 0.001). ROC curve analysis revealed that 1.80 was the optimal cutoff value of FIB-4 index to predict increased RAP > 10mmHg (AUC 0.74, p < 0.001, sensitivity 76.1%, specificity 74.0%). As shown in Figure, the diagnostic accuracy increased when FIB-4 index was combined with IVC diameter (AUC 0.77), which was significantly higher than the combination (AUC 0.71) of IVC diameter alone (AUC 0.71, p < 0.001, cutoff 17mm, sensitivity 67.6%, specificity 71.8%) and IVC respiratory changes alone (AUC 0.61, p = 0.005, cutoff 53%, sensitivity 77.5%, specificity 44.2%). Conclusions FIB-4 index was clinically useful in predicting increased RAP, especially when it was combined with IVC diameter.

Frailty and MECKI score in predicting mortality in advanced heart failure

Abstract Background Physical frailty (PF), characterized by decreased physiological reserves and increased vulnerability to stressors, has emerged as a significant predictor of adverse outcomes in heart failure (HF). The MECKI (Metabolic Exercise Cardiac Kidney Index) score, a composite index derived from cardiopulmonary exercise testing parameters and renal function, has shown promise in predicting outcomes in HF patients. Purpose The aim of the study is to evaluate the independent prognostic role of the MECKI score and PF on mortality in patients with advanced heart failure (AHF). Methods Ninety-one patients with AHF were enrolled, including 42 on the heart transplant waiting list, 10 undergoing evaluation for listing, and 49 removed from the list due to transplant contraindications or reaching age limits. All patients included in the study were on medically optimized therapy. MECKI score assessment was conducted upon enrollment, along with hematological and biochemical evaluations including creatinine, hemoglobin, Na+, and NT-pro-BNP levels. Patients also underwent echocardiography assessing ejection fraction (EF), TAPSE, Inferior Vena Cava (IVC) diameters, and PASP. Additionally, all patients performed the 6-minute walk test (6MWT) and cardiopulmonary exercise testing with assessment of VO2max and VE/VCO2. Frailty was assessed based on modified Fried criteria. Results The mean age was 56.5±11.2 years. Mean NYHA class was 2.7±0.6, EF was 28.8±7.6, TAPSE was 17.5±4.2, and NT-proBNP was 2912.2±3249.0. Mean VO2max was 12.0±3.5 ml/kg/min, and mean distance walked during 6MWT was 278.8±137.2 meters. Mean frailty score was 3.2±1.2 while mean MECKI score was 15.2±14,2. During a mean follow-up of 32.0±15.3 months, there were 21 deaths, 15 patients received heart transplants, and 1 patient underwent LVAD implantation. Stratified data for mortality showed statistically significant differences in deceased patients compared to survivors regarding NYHA class (3.2±0.3 vs 2.6±0.7; p<0.001), Frailty Index (4.4±0.7 vs 2.7±1.13; p<0.001), NT-proBNP (5425.0±2863.0 vs 1731.0±1618.0; p<0.001), VE/VCO2 (42.7±12.3 vs 35.0±9.1; p<0.003), and MECKI score (29.4±15.2 vs 11.2±11.2; p<0.001). Linear regression analysis demonstrated a significant positive correlation for Frailty Index and MECKI score with age, NYHA class, VE/VCO2, IVC, and NT-proBNP, while showing a negative correlation with TAPSE, VO2max, and 6-minute walk test. Cox regression analysis on mortality demonstrated the predictive role of Frailty (HR=2.121; 95%CI=1.017-4.421; p=0.045) and MECKI score (HR=1.043; 95%CI=1.009-1.079; p=0.014) independently from age, sex, NYHA class, NT-proBNP, EF, TAPSE, VO2max, 6MWT, and IVC diameter. ROC curves demonstrated an AUC of 0.896 for MECKI score and mortality, and 0.884 for Frailty Index and mortality. Conclusions The MECKI score and physical frailty are both valid independent predictors of mortality in patients with advanced heart failure.

Multiorgan congestion assessment by venous excess ultrasound score in acute heart failure

Abstract Purpose Congestion assessment in patients with heart failure (HF) remains challenging and currently relies on clinical judgment, while validated methods to quantify congestion are lacking. Aim This study sought to explore the prevalence and clinical utility of different patterns of multi-organ venous congestion as assessed by the Venous Excess Ultrasound (VExUS) score in hospitalized patients with HF. Methods Consecutive patients admitted for acute HF were prospectively enrolled. Inferior vena cava (IVC) diameter, hepatic vein, portal vein and renal vein Doppler waveforms were assessed at admission and patients were stratified based on VExUS score from 0 to 3, with higher values indicating worse congestion (Picture 1). The clinical score Get With The Guidelines (GWTG)-HF for predicting in-hospital mortality in HF was evaluated. In-hospital mortality was recorded. Results Two-hundred-ninety patients admitted with acute HF were included and 114 (39%) of them were classified as VExUS score 3 which was the most prevalent group. Patients with VExUS score 3 suffered more frequently from chronic atrial fibrillation, chronic kidney disease and anemia. Parameters independently associated with VExUS score 3 were higher mean E/e’ ratio, larger right ventricular size, severe tricuspid regurgitation and impaired right atrial function. VExUS score 3 was associated with in-hospital mortality [OR 8.03, 95% CI (2.25–28.61), p=0.001]. The addition of VExUS score on top of the GWTG-HF score improved the predictability of the model (Δx2=+8.44, p=0.03) for in-hospital mortality, whereas other indices of venous congestion (right atrial function, IVC size) did not (Picture 2). Conclusion Patients admitted with acute HF commonly had severe venous congestion based on VExUS score. VExUS score improved the prediction of in-hospital mortality as compared to other indices of venous congestion.VExUS and adverse cardiac remodelingModels for in-hospital mortality

Association of pulsatile venous waveform pattern in the venous studies of lower extremities to 2d-echocardiographic parameters for right heart function and right atrial pressure

Abstract Introduction To date, the detection of pulsatile venous waveform (PVW) pattern in venous duplex scans are read as suggestive of increased central venous pressure (CVP) and/or right-sided heart failure. In the advent of point of care ultrasound, non-invasive measures can be used to determine systemic hemodynamics in emergent clinical settings. Purpose This study aims to determine the association of PVW pattern to echocardiographic parameters of right ventricular (RV) function and right atrial pressure (RAP). Methods A single center retrospective study of adult patients with venous studies of the lower extremities and 2d-echocardiogram done from January 2019 to October 2023. Logistic regression analyses were performed to determine the association of PVW pattern with RV dysfunction based on TAPSE, S’ and FAC, as well as with increased RAP. Results A total of 2086 adult patients were included with median for age of 67 years of which 1141 (55%) were females, and 728 (35%) were hypertensive. PVW pattern was noted from 163 participants (7.8%) of which a higher proportion had heart failure, kidney disease, COVID-19, pneumonia and valvular heart disease. Patients with PVW pattern had a significantly lower median TAPSE [18 (IQR 15-20) vs 20 (IQR 18-22)] and median S’ [11.1 (IQR 8.6-13.20) vs 12.3 (IQR 10.6-14.40)] with FAC 27.1 + 11.9%. Increased RAP was noted in 7% of the study population. Patients with PVW pattern had a higher median inferior vena cava (IVC) diameter [1.9 ( IQR 1.5-2.3) vs 1.5 (IQR 1.3-1.8)] and lower median IVC collapsibility [39.9 (IQR 23.5-51.4) vs 50 (IQR 38.9-58.80]. PVW pattern is significantly associated with TAPSE (crude OR 3.89; CI 2.67-5.66, p<0.0001), S’ (crude OR 3.26, CI 2.30-4.62, p<0.0001) and increased RAP (adjusted OR 6.06, CI 4.02-9.14, p<0.0001). Conclusion Patients with PVW pattern had about 4 times and 3 times higher odds of developing RV systolic dysfunction based on TAPSE and S’, respectively. Its presence confers about 6 times higher odds of developing increased RAP. These parameters can direct further diagnostic work-up and guide assessment of response to decongestive therapy in critical units and other areas where 2d-echocardiogram is not readily accessible.

Symptomatic orthostatic hypotension due to standing mid-left ventricular obstruction: a case report

Abstract Background Orthostatic hypotension (OH) is a common cardiovascular disorder typically associated with autonomic dysfunction. However, various other mechanisms can contribute to its occurrence. Case Summary An 88-year-old woman was referred to the cardiology unit due to recurrent syncope episodes while standing. Echocardiography revealed a normally contracting left ventricle with severe hypertrophy, a restrictive filling pattern, reduced stroke volume, and a decreased inferior vena cava diameter (4 mm/m²). In the standing position, she experienced syncope, and invasive blood pressure monitoring confirmed OH, alongside a normal increase in heart rate and evidence of mid-left ventricular obstruction (MVO) on echocardiogram. Discontinuation of diuretics and administration of fluids and beta-blockers effectively resolved the OH. Discussion This case underscores the importance of considering mechanisms beyond autonomic dysfunction and volume depletion in the etiology of OH in elderly patients. Notably, this is the first documented case of OH associated with MVO occurring in an upright posture, resulting in a significant decrease in cardiac output and subsequent syncope. Preventing volume depletion and using non-vasodilating beta-blockers may represent optimal therapeutic strategies in such cases.

Echocardiographic Assessment of Central Venous Pressure using Inferior Vena Cava Indices: An Estimate Guide for Right Atrial Pressure

Purpose: To assess the correlation between inferior vena cava echocardiographic indices and central venous pressure, right atrial pressure and thus to practice, assessment of inferior vena cava, as a guide for the status of right side of the heart. Materials and Methods: In this descriptive cross-sectional study, a total of (60) patients (males and females) with their age ranging between (18–80) years were admitted to the respiratory care unit. Echocardiographic assessment of inferior vena cava hemodynamics (IVC expiratory, IVC inspiratory diameters and IVC collapsibility index) were carried out. In addition to the standard echocardiography examination, right heart function measurements (Tricuspid Annular Plane Systolic Excursion and right atrial area), in spontaneously and mechanically ventilated, patients were done. Findings: Both IVCe and IVCi diameters showed strong negative correlation with collapsibility index, (r= -0.920 for IVCe and r= -0.964 for IVCi) (P<0.001). There was a positive correlation between TAPSE and IVC-CI (r=0.857, P<0.001). Moreover, RA area was negatively correlated with collapsibility index (r = -0.892, P <0.001). IVC-CI in mechanically ventilated patients (40.11± 1.782) compared to spontaneous breathing (48.91± 1.811) (P <0.001) Implications to Theory, Practice and Policy: There was a linear relationship of IVC collapsibility index with TAPSE but an inverse relation with RA area. Evaluation of IVC diameter and its collapsibility index was an easy and non-invasive method to estimate CVP and RAP and so evaluate right heart performance of critically ill patients. Its use is more helpful in patients who are spontaneously breathing than those who are mechanically ventilated. The study tried to find an estimate predictor of right atrial pressure.

Evaluation of lateral sagittal infraclavicular block according to inferior vena cava collapsibility index (VCI-CI): An observational study.

Depending on the total amount of fluid, changes occur in the amount of fluid in the peripheral area. The aim of this study was to observe the differences caused by hemodynamic changes after lateral sagittal infraclavicular block (LS-ICB) according to the inferior vena cava collapsibility index (VCI-CI). In this prospective, observational study (Clinical Trial Number: NCT05968105), patients undergoing elective hand and wrist surgery with LS-ICB were classified according to VCI-CI, with Group 1 defined as inferior vena cava (VCI) diameter < 1.5 cm and VCI-CI > 50% and Group 2 defined as VCI diameter > 1.5 cm and VCI-CI < 50%. Groups were compared for demographic characteristics, defined durations, rescue analgesics, and complications. Continuous hemodynamic parameters and pulsed wave Doppler were evaluated within groups. Demographic characteristics and time periods were comparable between the groups. Hemodynamic parameters and pulsed wave Doppler measurements showed no significant differences. However, while Group 1 remained consistent, Group 2 exhibited differences in axillary artery diastolic diameter and axillary artery contractility index. A significant statistical difference was observed in Group 1 for the perfusion index at 30 minutes and postoperatively, whereas Group 2 remained consistent. The dosage and number of patients requiring rescue analgesics were similar across both groups, and no complications were reported. Blood flow increased after LS-ICB without a corresponding increase in axillary artery diameter. Group 1 showed a tendency toward a lower perfusion index in the postoperative period.

Diagnostic accuracy of subclavian vein versus inferior vena cava collapsibility index for predicting postinduction hypotension: An observational study

Background: Hypotension following induction of general anesthesia (GA) is commonly observed. Ultrasound (US) measurement of collapsibility index (CI) of the inferior vena cava (IVC) for predicting postinduction hypotension has been studied. As there is limited data available comparing the diagnostic accuracy of subclavian vein (SCV) versus IVC-CI, we performed this observational study. Methods: A total of 132 adult patients scheduled for elective surgery under GA were enrolled. US measurements of three readings of maximum and minimum diameters of SCV and IVC were recorded during both quiet and deep breathing, and the mean of three values was calculated. CI was derived using the formula: (dmax – dmin) × 100/dmax. Subsequently, GA was administered using standard technique, irrespective of the findings of SCV and IVC measurements. The administered drugs and dosage were recorded. Hemodynamic parameters were collected at baseline and then at every minute for the first 20 min. The primary objective was to compare the diagnostic accuracies of SCV-CI and IVC-CI for prediction of postinduction hypotension during quiet breathing. The secondary objectives were to compare the diagnostic accuracies during deep breathing and find the correlation between IVC-CI and SC-CI during quiet and deep breathing, incidence of hypotension, and time required to acquire US images. Results: Fifty-seven patients developed postinduction hypotension. During quiet breathing, SCV-CI ≥10% had a sensitivity of 68% and specificity of 56% (area under curve [AUC] [95% confidence interval {CI}] of 0.659 [0.56–0.75]; P = 0.002), while IVC-CI ≥34% had a sensitivity of 70% and specificity of 59% (AUC [95% CI] of 0.672 [0.58–0.76]; P = 0.001) for prediction of postinduction hypotension. During deep breathing, both SCV-CI and IVC-CI had moderate accuracy (P = 0.001 for both). Pearson’s correlation showed a significant positive correlation between SCV-CI and IVC-CI with a correlation coefficient (r) of 0.313 during quiet breathing and 0.379 during deep breathing (P &lt; 0.001). The time required for acquiring US images was significantly less for SCV compared to IVC during both quiet and deep breathing (P &lt; 0.001 for both). Conclusion: Both SCV-CI and IVC-CI were found to have good and comparable diagnostic accuracy for the prediction of postinduction hypotension. We also found a significant positive correlation between SCV-CI and IVC-CI. In comparison to IVC, US scanning of SCV took lesser time to acquire the images.

Cardio-ocular syndrome: Retinal microvascular changes in acutely decompensated heart failure.

To investigate the changes in retinal microvasculature by contemporary imaging techniques during episodes of acute decompensated heart failure (ADHF) and following recompensation compared to age-matched controls without known cardiac or retinal disease. Adult patients hospitalized with a primary diagnosis of ADHF, regardless of left ventricular ejection fraction (LVEF) and treated with a minimum dose of 40 mg of intravenous furosemide or equivalent were included. Transthoracic echocardiography was conducted in all patients. Eye examinations were performed out within the initial 24 h after admission and after recompensation before discharge. All eyes underwent a general examination, including a best corrected visual acuity test, dilated fundoscopy, spectral-domain optical coherence tomography (OCT) as well as OCT angiography (OCT-A). In addition, 40 participants without documented cardiac or retinal diseases served as controls. Forty patients with ADHF (mean age 78.9 ± 8.8 years; 32% female) with a mean LVEF of 43 ± 12.8% were included. All patients were treated with intravenous diuretics for a median of 4.3 ± 2.8 days. There was a significant reduction in N-terminal pro-B-type natriuretic peptide from baseline up to discharge (10 396 [interquartile range 6410] vs. 6380 [interquartile range 3933] pg/ml, p ≤ 0.001) and inferior vena cava diameters (2.13 ± 0.4 vs. 1.63 ± 0.3 cm, p = 0.003). Compared to the control group, patients with ADHF showed on admission impaired visual acuity (0.15 ± 0.1 vs. 0.35 ± 0.1 logMAR, p < 0.001), reduced macular vessel density (18.0 ± 1.9 vs. 14.3 ± 3.6 mm/mm2, p < 0.001) and perfusion density (42.6 ± 3.2 vs. 35.2 ± 9.7%, p < 0.001). After recompensation, the mean overall vessel density and mean overall perfusion density were markedly increased at discharge (14.3 ± 3.6 vs. 19.7 ± 2.6 mm/mm2, p = 0.001, and 35.2 ± 9.7 vs. 39.2 ± 6.5%, p = 0.005, respectively). The mean diameter of the superior temporal retinal vein at admission was significantly larger compared to the control group (136 ± 19 vs. 124 ± 22 μm, p = 0.008) and decreased significantly to 122 ± 15 μm at discharge (p < 0.001). This analysis revealed a remarkable reversible change in retinal microvasculature after ADHF. This could provide a valuable evidence for use of OCT-A in the assessment of overall microperfusion and haemodynamic status in patients with acute heart failure.

Portal Vein Pulsatility: A Valuable Approach for Monitoring Venous Congestion and Prognostic Evaluation in Acute Decompensated Heart Failure.

The severity of systemic congestion is associated with increased portal vein flow pulsatility (PVP). To determine the usefulness of PVP as a marker of decongestion and prognosis in acute decompensated heart failure (ADHF) patients. 105 patients, 60% of whom were men, were hospitalized with ADHF, and their PVP index (PVPI) was calculated (maximum velocity-minimum velocity/maximum velocity) × 100 on admission and before discharge, along with their EVEREST score, inferior vena cava diameter (IVC), NT-proBNP, serum sodium, and glomerular filtration rate. A PVPI ≥ 50% was defined as a marker of systemic congestion. After treatment with loop diuretics, a decrease in PVPI of >50% before discharge was considered a marker of decongestion The patients were classified into two groups (G): G1-PVPI decrease ≥ 50% (54 patients) and G2-PVPI decrease < 50% (51 patients). At discharge, compared to G2, G1 patients had lower mean PVPI (14.2 vs. 38.9; p < 0.001), higher serum Na (138 vs. 132 mmol/L, p = 0.03), and a higher number of patients with a significant (>30%) NT-proBNP decrease (42 vs. 27, p = 0.007). PVPI correlated with IVC (r = 0.55, p < 0.001), NT-proBNP (r = 0.21, p = 0.04), and serum Na (r = -0.202, p = 0.04). A total of 55% of patients had worsening renal failure (G1 63% vs. G2 48%, p = 0.17). After 90 days, G2 patients had higher mortality (27.45% vs. 3.7 p = 0.001) and rehospitalization (49.01% vs. 33.33%, p < 0.001). In multivariate regression analysis, PVPI was an independent predictor of rehospitalization (OR 1.05, 95% CI 1.00-1.10, p = 0.048). Portal vein flow pulsatility, a meaningful marker of persistent subclinical congestion, is related to short-term prognosis in ADHF patients.

Usefulness of Antigen Carbohydrate 125 and N-Terminal Pro-B-Type Natriuretic Peptide for Assessing Congestion in Chronic Heart Failure: Insights from the CARDIOREN Registry

Introduction: A comprehensive assessment of congestion, including circulating biomarkers, is recommended in patients with acute heart failure. The circulating biomarkers natriuretic peptides (NPs) and carbohydrate antigen-125 (CA125) could be useful for congestion assessment in ambulatory chronic heart failure (CHF), but there is only limited information about their applicability in this context. Therefore, this study aimed to examine the association of plasma CA125 and NP levels with clinical and ultrasound congestion parameters in CHF. Methods: This is a cross-sectional substudy of the Cardioren Spanish Registry, which enrolled 1,107 patients with CHF from 13 tertiary hospitals in Spain between October 2021 and February 2022. Through ambulatory visits, we performed a comprehensive assessment of congestion-related parameters, including clinical variables (orthopnea, peripheral edema, and jugular engorgement, represented by the composite congestion score [CCS]), echocardiography variables (lung B-lines and inferior vena cava [IVC] diameter), and circulating biomarkers (CA125 and NPs). The association of the NP and CA125 levels with the clinical and echocardiographic congestion parameters was examined by multiple linear and logistic regression analyses. Results: This substudy included 802 patients for whom all the biomarker parameters were available {median age, 74 (interquartile range [IQR], 63–81) years; 65% male}. The proportion of patients with left ventricular ejection fraction ≥50% and estimated glomerular filtration rate <60 was 34% and 58%, respectively. The median CCS was 0 (IQR: 0–1), with 45% of the sample exhibiting a median CCS of ≥1. The jugular engorgement, peripheral edema, and orthopnea rates were 32%, 21%, and 21%, respectively. A total of 35% of patients who underwent ultrasound examination showed lung B-lines, and the median IVC diameter was 16 mm. The median CA125 and NTproBNP levels were 14 U/mL (IQR: 9–28) and 1,382 pg/mL (IQR: 563–3,219), respectively. Multivariate analysis showed that higher CA125 levels were independently associated with higher odds of peripheral edema (p = 0.023) and lung B-lines (p < 0.001). Further, NTproBNP was positively associated with jugular engorgement (p < 0.001), orthopnea (p = 0.034), and enlarged IVC diameter (p = 0.031). Conclusions: Clinical signs of congestion are frequent in CHF. In the ambulatory setting, NTproBNP was associated with parameters linked to intravascular congestion such as orthopnea, jugular engorgement, and IVC diameter, whereas CA125 was associated with extravascular volume overload parameters (peripheral edema and lung B-lines).

Primerjava ultrazvočnega merjenja premera spodnje votle vene in merjenja sestave telesa z metodo bioelektrične impedance za oceno tekočinskega stanja pri novorojenčkih

Background: Neonatal medical conditions often disrupt the physiological processes that regulate fluid balance, so assessing fluid status in sick neonates is important for clinical management. In clinical practice we use clinical signs, which, however, on their own, do not provide a reliable assessment of fluid status. We aimed to compare two methods: i) diameters and collapsibility index of vena cava inferior (VCI) measured by ultrasonography and ii) analysis of body composition by bioelectrical impedance (BIA) and to evaluate their relation to changes in body mass. Methods: In a cohort-prospective clinical trial we included 27 neonates aged 1–7 days with various pathologies. Ultrasound measurements of VCI transversely and longitudinally, measurements of body composition by BIA and measurements of body mass were performed in each subject at least three times with an interval of 24–72 hours. Simultaneous measurements of the same subject were then analysed and evaluated. Results: The average proportion of total body water (TBW) decreased in the first days after birth, from 80.3% (Day 1) to 73.1% (Day 8) (p = 0.006). The decrease in the average proportion of extracellular water (ECW) in the first days after birth was not statistically significant. The association between ECW and body mass over time was statistically significant (p &lt; 0.001). The association between transversely measured large VCI diameter during inspiration, body mass, and ECW was statistically significant (p = 0.024). No statistically significant association with ECW or body mass was proven for the other ultrasound-measured variables. Conclusions: By measuring body composition with BIA, we confirmed the reduction of the average proportions of TBW after birth and the association between body mass, ECW, and transversely measured maximal diameter of VCI during inspiration. BIA is an appropriate method for monitoring fluid status in a newborn. Additional research on a larger number of subjects is needed to define the significance of VCI measurements for assessing fluid status.

Comparative assessment of venous congestion severity and hospitalization outcomes in patients with acute decompensated heart failure with preserved ejection fraction

Aim. To characterize the potental of additional paraclinical research methods (ultrasound, determination of body composition) for assessing the congestion severity in patients with acute decompensated heart failure with preserved ejection fraction (ADHFpEF) in the intensive care unit.Material and methods. We examined 82 patients with ADHFpEF aged from 50 to 85 years, who were hospitalized in the intensive care unit of the Veresaev City Clinical Hospital (Moscow). All patients underwent a standard clinical and laboratory examination, including determination of NT-proBNP, as well as echocardiography, chest radiography, bioimpedance analysis, Venous Excess Ultrasound (VExUS), lung ultrasound. Depending on the congestion degree visualized by VExUS, patients were divided into three groups.Results. The median levels of NT-proBNP, E/A and E/e', number of B-lines in one lung segment, ECW and TBW, and the diuretics' dose used in the hospital in pa tients with ADHFpEF and severe congestion were significantly higher. Signs of congestion obtained as a result of X-ray examination did not differ significantly between groups. In-hospital death was associated with higher values of NT-proBNP, E/A ratio, IVC diameter, number of B-lines in one lung segment, ECW and TBW. The odds of death in patients with VExUS Grade 3 increased 20,9 times compared to Grade 1 (95% CI: 1,125-387,688).Conclusion. Higher levels of NT-proBNP, the dose of diuretics used in the hospital, and ECW and TBW were associated with congestion severity. The severity of congestion assessed by VExUS and ECW/TBW are positively associated with inhospital mortality

Pulmonary hypertension in ischemic heart failure: a pilot study

Aim. To evaluate the role of cardiopulmonary system assessment in a group of patients with pulmonary hypertension (PH) associated with ischemic heart failure (HF) with the right ventricular-pulmonary arterial (RV-PA) coupling.Material and methods. Forty stable patients were examined. The patients were divided into 3 groups depending on the left ventricle ejection fraction (LVEF). PH was established by using expert transthoracic echocardiography. RV-PA coupling was calculated by 2 following ways: as tricuspid annular plane systolic excursion (TAPSE)/pulmonary artery systolic pressure (PASP) ratio and as TAPSE´Pulmonary Artery Aceleration Time (pACT) multiplication.Results. The patients included in the study were mainly men (73,8%), functional class PH II-III (95,2%), stage IIB CHF (62%). The highest values of TAPSE (18,6±3 mm) and RV-PA coupling (0,64±0,42 mm/mm Hg) were found in the patients with preserved LVEF. In the general cohort, high level of NT-proBNP corresponds to reduced values of RVPA coupling (rs=-0,563) and TAPSE (rs=-0,666; p&lt;0,01). The severity of PH directly affects the level of NT-proBNP (p&lt;0,01). As the stage of HF and PH functional class increases, the indicators of PASP, inferior vena cava diameter and NT-proBNP level significantly increase, as well as TAPSE and RV-PA coupling decrease (p&lt;0,05). Different calculating methods of RV-PA coupling has a strong correlation (rs=0,832; p&lt;0,01).Conclusion. The right heart and RV-PA coupling assessment in patients with ischemic HF of origin is of significant value for the early diagnosis of PH and timely clinical decision-making.

Inferior vena CAVA and lung ultraSound-guided therapy in acute heart failure: A randomized pilot study (CAVAL US-AHF study)

The optimal assessment of systemic and lung decongestion during acute heart failure is not clearly defined. We evaluated whether inferior vena cava (IVC) and pulmonary ultrasound (CAVAL US) guided therapy is superior to standard care in reducing subclinical congestion at discharge in patients with AHF. CAVAL US-AHF was an investigator-initiated, single-center, single-blind, randomized controlled trial. A daily quantitative ultrasound protocol using the 8-zone method was used and treatment was adjusted according to an algorithm. The primary endpoint was the presence of more than 5 B-lines and/or an increase in IVC diameter and collapsibility at discharge. And secondary endpoint exploratory outcome was the composite of readmission for HF, unplanned visit for worsening HF or death at 90 days RESULTS: Sixty patients were randomized to CAVAL US (n = 30) or control (n = 30). The primary endpoint was achieved in 4 patients (13.3%) in the CAVAL US group and 20 patients (66.6%) in the control group (P < .001). A significant reduction in HF readmission, unplanned visit for worsening HF or death at 90 days was seen in the CAVAL US group (13.3% vs 36.7%; log rank P = .038). Other endpoints such as NT-proBNP reduction at discharge showed a nonstatistically significant reduction in the CAVAL US group (48% IQR 27-67 vs 37% -3-59; P = .09). Safety outcomes were similar in both groups. IVC and lung ultrasound-guided therapy in AHF patients significantly reduced subclinical congestion at discharge. CAVAL US-AHF provides preliminary evidence for the potential use of a simple technique to guide decongestive therapy during hospitalization for AHF, which may reduce the composite outcome at 90 days.

IVC collapsibility indices in assessment of volume overload in neonatal cardiac patients

BackgroundFluid overload is associated with increased morbidity and mortality in critically ill patients. An accurate assessment of fluid status in neonatal cardiac pediatric patients is required for assessment of fluid overload. Estimation of fluid status using different Doppler parameters may be helpful in determination of fluid status.PurposeTo evaluate difference in fluid status in neonates with and without congenital heart diseases. To detect sensitivity of Doppler Ultrasound in early determination of fluid status. To compare between different parameters (IVC diameter, IVCCI, and IVC/AO ratio) between cardiac and healthy neonates.MethodsTransabdominal Doppler parameters of 25 full-term newborns with congenital heart diseases and congestive heart failure were compared to 25 post-natal age and sex-matched normal healthy neonates serving as controls. Aortic as well as inspiratory and expiratory inferior vena cava diameters were measured. Subsequently, inferior vena cava collapsibility index (IVCCI) and inferior vena cava-to-aortic ratio (IVC/AO) were calculated.ResultsFluid overload detected by increased IVC diameter (decreased IVCCI and increased IVC/AO ratio) was observed in the cardiac compared to the control group. There was positive correlation between the fluid volume and the IVC diameter and IVC/AO ratio and negative correlation with the IVC collapsibility indices.ConclusionsFluid overload with increased IVC diameter and lack of IVC collapsibility were observed in neonates with congenital heart diseases and congestive heart failure compared with those hemodynamically stable controls. We recommend the use of IVC diameter, IVCCI, and IVC/AO ratio as rapid, easy and sensitive parameters in assessing volume status.

Efficacy and safety of hypertonic saline therapy in ambulatory patients with heart failure: The SALT-HF trial.

Combination of hypertonic saline solution (HSS) with intravenous loop diuretics has been suggested to improve diuretic response in patients hospitalized for heart failure (HF). The efficacy and safety of this approach in the ambulatory setting remain unexplored. In this multicentre, double-blind, randomized study, we allocated ambulatory patients with worsening heart failure (WHF) to a 1-h infusion of intravenous furosemide (ivFurosemide)-HSS versus ivFurosemide. The primary endpoint was the volume of diuresis at 3 h. Secondary endpoints included 3-h natriuresis and weight variation, 7-day congestion data, kidney function and electrolytes, and 30-day clinical events. Overall, 167 participants (median age: 81 years, 30.5% female) were randomized across 13 sites between December 2020 and March 2023. There were no differences in 3-h diuresis between treatments (ivFurosemide-HSS: 1099 ml vs. ivFurosemide: 1103 ml, p = 0.963), 3-h natriuresis (∆ +2.642 mEq/L, p = 0.559), or 3-h weight (∆ +0.012 kg, p = 0.920). Patients in the ivFurosemide-HSS arm experienced significant weight decrease at 7 days (Δ -0.586 kg, p = 0.048). There were no between-treatment differences in clinical congestion score, biomarkers, inferior vena cava diameter, or the presence of lung ultrasound B-lines. At 30 days, 26.5% of the patients in the ivFurosemide-HSS group versus 33.3% in the ivFurosemide group experienced WHF (hazard ratio 0.76, p = 0.330). The incidence of death from any cause or HF hospitalization was 6% of patients in the ivFurosemide-HSS group and 8.3% of patients in the ivFurosemide group (hazard ratio 0.69, p = 0.521). The incidence of worsening kidney function or metabolic derangements was not significantly different in the two arms. A single infusion of ivFurosemide-HSS did not improve 3-h diuresis or congestion parameters in patients with ambulatory WHF. This therapy showed an appropriate safety profile.

The Inferior Vena Cava Filter Placement Parameters May Predict Filter Retrieval Outcomes

ObjectiveWe aimed to investigate the potential correlation between the placement factors of various retrievable inferior vena cava filters and retrieval outcomes. Additionally, we aimed to identify the factors affecting the placement tilt of the filter. Materials and methodsThis retrospective study was conducted at a tertiary care center to investigate patients who had previously undergone retrievable filter placement at our center and who subsequently had their filters removed between January 2020 and December 2021. Patient characteristics and filter-related factors were recorded. Complex filter retrieval was defined as cases that required a minimum of 8 minutes of fluoroscopy or that involved advanced techniques. Regression models were used to explore patient- and placement procedure-related factors that could influence retrieval outcomes and the placement tilt angle. ResultsThe study included 163 patients, and all filters were successfully retrieved. Thirty-seven (22.7%) retrievals were classified as complex retrievals. The mean diameter of the inferior vena cava in the preplacement position for the entire cohort was 16 ± 1.8 mm. The median filter tilt angles at placement and retrieval were 5.0° (IQR, 1.8°- 9°) and 4.6° (IQR, 2.1°-8.0°), respectively. The placement tilt angle was not significantly associated with complex retrieval (p=0.59). The filter hook abutment to the vena cava wall (OR, 10.76, p = 0.003), dwell time (OR, 1.02, p =0.029), and diameter of the vena cava (OR, 10.21, p < 0.001) were associated with complex retrieval. The diameter (p=0.049), age (p=0.049), and filter brand (p=0.001) were found to be significantly associated with placement tilt. ConclusionsThe inferior vena cava diameter at the time of placement predicts difficulty in filter retrieval. In addition, the filter hook abutting the IVC wall and long indwelling time may complicate retrieval. The vena cava diameter is also closely related to the degree of filter tilt.