Intrarenal Venous Flow Patterns Research Articles

Impact of Renal Congestion in Patients With Secondary Mitral Regurgitation After Mitral Transcatheter Edge-to-Edge Repair.

Renal congestion is a potential prognostic factor in patients with heart failure and recently, assessment has become possible with intrarenal Doppler ultrasonography (IRD). The association between renal congestion assessed by IRD and outcomes after mitral transcatheter edge-to-edge repair (TEER) is unknown, so we aimed to clarify renal congestion and its prognostic implications in patients with mitral regurgitation (MR) who underwent TEER using MitraClip system.Methods and Results: Patients with secondary MR who underwent TEER and were assessed for intrarenal venous flow (IRVF) by IRD were classified according to their IRVF pattern as continuous or discontinuous. Of the 105 patients included, 78 patients (74%) formed the continuous group and 27 (26%) were the discontinuous group. Kaplan-Meier analysis revealed significant prognostic power of the IRVF pattern for predicting the composite outcome of all-cause death and heart failure rehospitalization (log-rank P=0.0257). On multivariate Cox regression analysis, the composite endpoint was independently associated with the discontinuous IRVF pattern (hazard ratio, 3.240; 95% confidence interval, 1.300-8.076; P=0.012) adjusted using inverse probability of treatment weighting. IRVF patterns strongly correlated with clinical outcomes without changes in renal function. Thus, they may be useful for risk stratification after mitral TEER for patients with secondary MR.

Hemodynamic evaluation of right-sided congestion with doppler ultrasonography in pulmonary hypertension: portal vs intra-renal venous flow patterns

Abstract Introduction Renal congestion is a key pathophysiological mechanism mediating adverse outcomes in patients with heart failure. Novel approaches to evaluate renal congestion like renal Doppler ultrasonography show promise as a noninvasive hemodynamic monitoring tool. Portal Doppler ultrasound is a less challenging exam and could potentially provide similar information than intra-renal Doppler. Methods and Results We enrolled 95 patients with suspected or diagnosed pulmonary hypertension (PH) presenting to the emergency department or to a scheduled ambulatory clinic. Patients underwent renal and portal Doppler ultrasonography. Renal congestion was graded using the validated renal venous stasis index (RVSI) or renal venous patterns. The portal vein pulsatility fraction (PVPF) was used to quantify portal congestion. We found high degree of correlation (R = 0.93) between portal and renal congestion, with excellent agreement (κ = 0.92 [0.86-0.98]). Both RVSI and PVPF showed excellent interclass correlation and agreement amongst operators (ICC 0.93). 90-day mortality or need for renal replacement therapy was significantly more frequent in patients with high PVPF (p=0.001) HR: 5.3 (1.9-17.0). Conclusions Altered portal venous flow accurately predicts the presence of renal congestion and is technically easier to obtain. Portal vein Doppler may identify patients with pulmonary hypertension at risk for renal deterioration secondary to venous congestion.Portal-renal patterns and their outcomes

Comparison of various surrogate markers for venous congestion in predicting acute kidney injury following cardiac surgery: A cohort study

BackgroundVenous congestion has been demonstrated to increase the risk of acute kidney injury (AKI) after cardiac surgery. Although many surrogate markers for venous congestion are currently used in clinical settings, there is no consensus on which marker is most effective in predicting AKI. MethodsWe evaluated various markers of venous congestion, including central venous pressure (CVP), inferior vena cava (IVC) diameter, portal pulsatility fraction (PPF), hepatic vein flow pattern (HVF), intra-renal venous flow pattern (IRVF), and venous excess ultrasound grading score (VExUS) in adult patients undergoing cardiac surgery to compare their ability in predicting AKI. ResultsAmong the 230 patients enrolled in our study, 53 (23.0%) developed AKI, and 11 (4.8%) required continuous renal replacement therapy (CRRT). Our multivariate logistic analysis revealed that IRVF, PPF, HVF, and CVP were significantly associated with AKI, with IRVF being the strongest predictor (odds ratio [OR] 2.27; 95% confidence interval [CI], 1.38–3.73). However, we did not observe any association between these markers and CRRT. ConclusionVenous congestion is associated with AKI after cardiac surgery, but not necessarily with CRRT. Among the markers tested, IRVF exhibits the strongest correlation with AKI.

Phenotyping congestion in acute heart failure by renal flow and right heart to pulmonary circulation coupling.

In acute heart failure (AHF), kidney congestion is basic to treatment and prognosis. Its aetiology is manifold and quite unexplored in details mainly regarding the right heart to pulmonary circulation (Pc) coupling. We investigated the right heart to kidney interrelationship by Doppler renal flow pattern, right atrial dynamics, and right ventricular (RV) function to Pc coupling in AHF. In 119 AHF patients, echocardiographic and renal Doppler data were analysed. Univariate and multivariate regression models were performed to define the determinants of a quantitative parameter of renal congestion, the renal venous stasis index (RVSI). When grouped according to different intra-renal venous flow patterns, no differences were observed in haemodynamics and baseline renal function. Nonetheless, patients with renal Doppler evidence of congestion showed a reduced RV function [tricuspid annular plane systolic excursion (TAPSE), S'-wave velocity, and fractional area change], impaired RV to Pc coupling [TAPSE/pulmonary artery systolic pressure (PASP) ratio], and right atrial peak longitudinal strain (RAPLS), along with signs of volume overload [increased inferior vena cava (IVC) diameters and estimated right atrial pressure]. Univariate and multivariate regression analyses confirmed TAPSE/PASP, RAPLS, and IVC diameter as independent determinants of the RVSI. RVSI was the only variable predicting the composite outcome (cardiac death, heart failure hospitalization, and haemodialysis). An easy-to-use echo-derived right heart score of four variables provided good accuracy in identifying kidney congestion. In AHF, the renal venous flow pattern combined with a right heart study phenotypes congestion and clinical evolution. Keys to renal flow disruption are an impaired right atrial dynamics and RV-Pc uncoupling. Integration of four right heart echocardiographic variables may be an effective tool for scoring the renal congestive phenotype in AHF.

Intrarenal Venous Flow Pattern Changes Do Relate With Renal Function Alterations in Acute Heart Failure

BackgroundThere is scarce evidence supporting the clinical utility of congestive intrarenal venous flow (IRVF) patterns in patients with acute heart failure. ObjectivesThis study aims to: 1) investigate the association between IRVF patterns and the odds of worsening renal function (WRF); 2) track the longitudinal changes of serum creatinine (sCr) across IRVF at predetermined points and its association with decongestion; and 3) explore the relationship between IRVF/WRF categories and patient outcomes. MethodsIRVF was assessed at baseline (pre–decongestive therapy), 72 hours, and 30 and 90 days postdischarge. Changes in sCr trajectories across dynamic IRVF variations and parameters of decongestion were assessed using linear mixed effect models. The association between IRVF/WRF categories and outcomes was evaluated using univariable/multivariable models. ResultsIn this prospective, multicenter study with 188 participants, discontinuous IRVF patterns indicated higher odds of WRF (OR: 3.90 [95% CI: 1.24-12.20]; P = 0.020 at 72 hours; and OR: 5.76 [95% CI: 1.67-19.86]; P = 0.006 at 30 days) and an increase in sCr (Δ-72 hours 0.14 mg/dL [95% CI: 0.06-0.22]; P = 0.001; Δ-discharge 0.13 mg/dL [95% CI: 0.03-0.23]; P = 0.007). However, the diuretic response and decongestion significantly influenced the magnitude of these changes. Patients exhibiting both WRF and discontinuous IRVF at 30 days experienced an increased hazard of adverse events (HR: 5.96 [95% CI: 2.63-13.52]; P < 0.001). ConclusionsDiscontinuous IRVF identifies patients with higher odds of WRF during admission and postdischarge periods. Nonetheless, adequate diuretic response and decongestion could modify this association. Patients showing both WRF and discontinuous IRVF at 30 days had increased rates of adverse events.

Impaired Renal Vein Flow in Atrial Fibrillation: A Potential Risk for Renal Dysfunction.

BACKGROUND Atrial fibrillation (AF) is one of the most common heart rhythm disorders. Identification and early treatment of AF risk factors can improve mortality and morbidity rates. This study aimed to compare the renal venous stasis index (RVSI) and intra-renal venous flow (IRVF) patterns evaluated by intra-renal Doppler ultrasonography in patients with AF and sinus rhythm (SR). MATERIAL AND METHODS A total of 68 patients, 34 with AF (lasting >12 months AF) and 34 with SR (no previous diagnosis of AF and no AF attack in 24-h Holter monitoring) were included in the study. The RVSI was calculated, and the IRVF patterns were determined using intra-renal Doppler ultrasonography. High RVSI was defined as >0.12 RVSI. In addition, echocardiography and a 6-min walk test were performed. A model including diabetes mellitus, hypertension, creatine, Pro-BNP, left ventricular ejection fraction, presence of AF, and systolic pulmonary artery pressure was created to evaluate the effects of variables on high RVSI. RESULTS The RVSI value was significantly higher in patients with AF than in those with SR (P=0.004). The SR group exhibited a higher prevalence of the continuous flow pattern, which is one of the IRVF patterns (P=0.015). In contrast, the biphasic flow pattern was observed more frequently in patients with AF (P=0.003). The presence of AF was found to predict the high RVSI (P=0.002, OR=14.134, 95% CI 2.083-71.277). CONCLUSIONS The presence of AF may affect the IRVF and cause an increase in RVSI.

Intrarenal Doppler ultrasonography in patients with HFrEF and acute decompensated heart failure undergoing recompensation

ObjectivesRenal venous congestion due to backward heart failure leads to disturbance of renal function in acute decompensated heart failure (ADHF). Whether decongestion strategies have an impact on renal venous congestion is unknown. Objective was to evaluate changes in intrarenal hemodynamics using intrarenal Doppler ultrasonography (IRD) in patients with heart failure with reduced ejection fraction (HFrEF) and ADHF undergoing recompensation.MethodsProspective observational study in patients with left ventricular ejection fraction (LV-EF) ≤ 35% hospitalized due to ADHF. IRD measurement was performed within the first 48 h of hospitalisation and before discharge. Decongestion strategies were based on clinical judgement according to heart failure guidelines. IRD was used to assess intrarenal venous flow (IRVF) pattern, venous impedance index (VII) and resistance index (RI). Laboratory analyses included plasma creatinine, eGFR and albuminuria.ResultsA number of 35 patients with ADHF and LV-EF ≤ 35% were included into the study. IRD could be performed in 30 patients at inclusion and discharge. At discharge, there was a significant reduction of VII from a median of 1.0 (0.86–1.0) to 0.59 (0.26–1.0) (p < 0.01) as well as improvement of IRVF pattern categories (p < 0.05) compared to inclusion. Albuminuria was significantly reduced from a median of 78 mg/g creatinine (39–238) to 29 mg/g creatinine (16–127) (p = 0.02) and proportion of patients with normoalbuminuria increased (p = 0.01). Plasma creatinine and RI remained unchanged (p = 0.73; p = 0.43).DiscussionThis is the first study showing an effect of standard ADHF therapy on parameters of renal venous congestion in patients with HFrEF and ADHF. Doppler sonographic evaluation of renal venous congestion might provide additional information to guide decongestion strategies in patients with ADHF.Graphical abstract

Clinical role of intrarenal venous flow patterns in decompensated heart failure with worsening renal function.

The clinical implication of intrarenal venous flow patterns in decompensated heart failure with worsening renal function is unknown. We aimed to study the relationship between intrarenal venous flow patterns, inferior vena cava volume status, caval index, clinical degree of congestion and the renal outcome in patients with decompensated heart failure and worsening renal function. Secondary objectives were to study the combined endpoint of readmission and mortality rate within 30 days (after the last scan) among intrarenal venous flow patterns and the effect of congestion status on the renal outcome. Twenty-three patients admitted for decompensated heart failure (ejection fraction ⩽40%) with worsening renal function (absolute increase in serum creatinine of 26.5 µmol/L or ⩾1.5-fold increment from baseline) were enrolled in this study. A total of 64 scans were performed. Patients were visited on day 0, 2, 4 and 7 (or earlier if discharged). Patients were called 30 days after discharge to evaluate readmission or mortality. Intrarenal venous flow patterns were ranked from continuous, interrupted, biphasic, to monophasic. Clinical congestion was scored from 0 to 7. Intrarenal venous flow patterns had statistically significant positive correlations with inferior vena cava volume status (Spearman's ρ, 0.51; p < 0.01) and congestion score (ρ, 0.65; p < 0.01) and a significant negative correlation with caval index (ρ, -0.53; p < 0.01). Intrarenal venous flow patterns were not significant in predicting estimated glomerular filtration rate improvement or the combined endpoint. Reduced congestion significantly predicted an estimated glomerular filtration rate improvement on the following scan day (p = 0.04, odds ratio = 4.3, 95% confidence interval = 1.1-17.2). Although intrarenal venous flow patterns correlate with other congestive parameters, clinical congestion status rather than intrarenal venous flow patterns predicted the renal outcome.

CA125 but not NT-proBNP predicts the presence of a congestive intrarenal venous flow in patients with acute heart failure.

Intrarenal venous flow (IRVF) measured by Doppler ultrasound has gained interest as a potential surrogate marker of renal congestion and adverse outcomes in heart failure. In this work, we aimed to determine if antigen carbohydrate 125 (CA125) and plasma amino-terminal pro-B-type natriuretic peptide (NT-proBNP) are associated with congestive IRVF patterns (i.e., biphasic and monophasic) in acute heart failure (AHF). We prospectively enrolled a consecutive cohort of 70 patients hospitalized for AHF. Renal Doppler ultrasound was assessed within the first 24-h of hospital admission. The mean age of the sample was 73.5 ± 12.3 years; 47.1% were female, and 42.9% exhibited heart failure with preserved ejection fraction. The median (interquartile range) for NT-proBNP and CA125 were 6149 (3604-12330) pg/mL and 64 (37-122) U/mL, respectively. The diagnostic performance of both exposures for identifying congestive IRVF patterns was tested using the receiving operating curve (ROC). The cut-off for CA125 of 63.5 U/mL showed a sensibility and specificity of 67% and 74% and an area under the ROC curve of 0.71. After multivariate adjustment, CA125 remained non-linearly and positively associated with congestive IRVF (P-value = 0.008) and emerged as the most important covariate explaining the variability of the model (R2: 47.5%). Under the same multivariate setting, NT-proBNP did not show to be associated with congestive IRVF patterns (P-value = 0.847). CA125 and not NT-proBNP is a useful marker for identifying patients with AHF and congestive IRVF patterns.

Intrarenal Doppler ultrasonography reflects hemodynamics and predicts prognosis in patients with heart failure

We aimed to clarify clinical implications of intrarenal hemodynamics assessed by intrarenal Doppler ultrasonography (IRD) and their prognostic impacts in heart failure (HF). We performed a prospective observational study, and examined IRD and measured interlobar renal artery velocity time integral (VTI) and intrarenal venous flow (IRVF) patterns (monophasic or non-monophasic pattern) to assess intrarenal hypoperfusion and congestion in HF patients (n = 341). Seven patients were excluded in VTI analysis due to unclear imaging. The patients were divided into groups based on (A) VTI: high VTI (VTI ≥ 14.0 cm, n = 231) or low VTI (VTI < 14.0 cm, n = 103); and (B) IRVF patterns: monophasic (n = 36) or non-monophasic (n = 305). We compared post-discharge cardiac event rate between the groups, and right-heart catheterization was performed in 166 patients. Cardiac index was lower in low VTI than in high VTI (P = 0.04), and right atrial pressure was higher in monophasic than in non-monophasic (P = 0.03). In the Kaplan–Meier analysis, cardiac event rate was higher in low VTI and monophasic groups (P < 0.01, respectively). In the Cox proportional hazard analysis, the combination of low VTI and a monophasic IRVF pattern was a predictor of cardiac events (P < 0.01). IRD imaging might be associated with cardiac output and right atrial pressure, and prognosis.

Abstract 14468: Right Heart: Renal Venous Stasis Determinant in Acute Heart Failure

Introduction: The heart-kidney interaction in heart failure (HF) is a matter of special interest, especially due to its strong prognostic significance. The search for a reliable, non-invasive parameter with high pathophysiological and prognostic impact to evaluate HF-related renal congestion remains attractive. Doppler evaluation of intra-renal venous flow (IRVF) has been recently employed in HF patients, with a spectrum of findings ranging from a normal continuous flow to a monophasic discontinuous one, indicative of low and high degrees of renal congestion, respectively. Hypothesis: We postulated a role for right atrial dynamics in the renal congestion pathophysiology. The impairment in atrial deformation and pump function may play a primary role increasing the pulsatile backward load in the venous system, especially in acute heart failure (AHF) patients. Methods: 119 consecutive AHF patients were prospectively investigated within 48 hours from admission. Doppler-derived descriptors of renal hemodynamics included the renal arterial resistive index, IRVF pattern, venous impedance index and renal venous stasis index (RVSI). Results: Right atrial peak longitudinal strain (RAPLS) showed a strong correlation with IRVF pattern (Fig A) and various indices of RV function (TAPSE, S’, FAC) and RV coupling as represented by the TAPSE/PASP ratio (Fig B). At multivariate regression analysis, TAPSE/PASP ratio emerged as the main determinant of RVSI. On the other hand, considering only patients with a clearly impaired RV coupling (TAPSE/PASP &lt;0.30), RAPLS emerged as the best determinant of RVSI (Fig C-D). Conclusions: Our data confirms the main role of the right heart in determining renal stasis in HF patients. When RV to pulmonary circulation uncoupling is severe, the right atrium becomes the key balancing factor in the venous renal flow response. Studies on the mechanistic contribution of the RA dysfunction and the recovery potential of interventions are warranted.

Abstract 13330: Intrarenal Doppler Ultrasonography Reflects Hemodynamics and Predicts Prognosis in Patients With Heart Failure

Introduction: We aimed to clarify clinical implications of intrarenal hemodynamics (congestion and hypoperfusion) assessed by intrarenal Doppler ultrasonography (IRD) and their prognostic impacts in patients with heart failure (HF). Methods and Results: We performed IRD and measured interlobar renal artery velocity time integral (VTI) and intrarenal venous flow (IRVF) patterns (monophasic or non-monophasic pattern) to assess intrarenal hypoperfusion and congestion in HF patients (n=341). These patients were categorized based on 1) VTI: high VTI (VTI ≥ 14.0 cm, n=231) or low VTI (VTI &lt; 14.0 cm, n=103); and 2) IRVF: monophasic (n=36) or non-monophasic (n=305) pattern. We performed right-heart catheterization, and examined post-discharge cardiac event rate such as cardiac death and rehospitalization due to worsening HF. Regarding renal perfusion, cardiac index was positively correlated with VTI (R=0.270, P=0.040). Concerning renal congestion, levels of right atrial pressure were higher in monophasic pattern than in non-monophasic pattern (9.0 vs. 7.2 mmHg, P=0.029). Importantly, HF patients with low VTI and a monophasic IRVF pattern (subset 4) had the highest cardiac event rate ( Figure ). In the Cox proportional hazard analysis, the combination of low VTI and a monophasic IRVF pattern was found to be a strong predictor of cardiac events (HR 8.357, 95% CI 3.365-20.752). Conclusion: Intrarenal hypoperfusion and congestion assessed by IRD imaging reflected cardiac output and right atrial pressure, and was useful to risk-stratify HF patients.

The Effect of Decongestion on Intrarenal Venous Flow Patterns in Patients With Acute Heart Failure

BackgroundDiscontinuous intrarenal venous flow patterns, as assessed by renal Doppler ultrasound examination, are associated with changes in hemodynamics such as volume expansion and poorer diuretic response in patients with heart failure (HF). We aimed to study intrarenal venous and arterial flow patterns after decongestive treatment in patients with acute HF. Methods and ResultsFifteen patients with acute HF were enrolled. Intrarenal venous and arterial flow patterns were assessed at baseline, 1 hour after administration of loop diuretics, at day 2 and day 3. Among patients hospitalized for acute HF, 13 (87%) had a discontinuous venous flow pattern at admission. After decongestive treatment, a significant improvement of the venous impedance index (P = .021) and venous discontinuity index (P = .004) was observed at day 3 compared with baseline. There was no effect on the intrarenal arterial flow patterns. ConclusionsIn patients who exhibit discontinuous renal venous flow patterns hospitalized for decongestive treatment owing to acute HF led to a normalization of intrarenal venous flow to a continuous pattern.

Prognostic Impact of Changes in Intrarenal Venous Flow Pattern in Patients With Heart Failure

BackgroundIt remains unclear whether intrarenal venous flow (IRVF) patterns in patients with heart failure (HF) could change over the clinical course, and whether the changes could have a clinical impact. Thus, this study aimed to clarify these characteristics as well as to identify the relation between changes in the IRVF pattern and renal impairment progression. Methods and ResultsPatients with HF with repetitive IRVF evaluations were enrolled. Doppler waveforms of IRVF were classified into the following 3 flow patterns: continuous, biphasic discontinuous, and monophasic discontinuous. Primary end points included death from cardiovascular diseases and unplanned hospitalization for HF. Finally, 108 patients with adequate images were enrolled. The IRVF in 35 patients (32.4%) shifted to another pattern at the follow-up examinations. The median brain natriuretic peptide level in the continuous flow pattern at follow-up was significantly decreased (183 to 60 pg/mL, P < .001), whereas that of the discontinuous flow pattern at follow-up was increased (from 339 to 366 pg/mL, P = .042) and the estimated glomerular filtration rate was decreased (from 55 to 50 mL/min/1.73 m2, P = .013). A multivariable Cox proportional hazard model analysis revealed that the discontinuous pattern at follow-up (P < .001) and brain natriuretic peptide (P = .021) were significantly associated with the end points, independent of age, estimated glomerular filtration rate, and serum sodium level. ConclusionsThe IRVF pattern could be changed depending on the status of congestion. Persistent or worsened renal congestion, represented by discontinuous flow patterns, during the clinical courses indicated a poor prognosis accompanied by renal impairment in patients with HF.

P0201ASSOCIATION OF INTRARENAL VEIN FLOW PATTERNS WITH CARDIAC FUNCTION IN OUTPATIENTS WITH CHRONIC KIDNEY DISEASE AND HEART FAILURE

Abstract Background and Aims In patients with chronic kidney disease (CKD) and heart failure (HF), renal venous congestion plays a key role in determining renal dysfunction and a worse prognosis. Αim of this ongoing study is to identify Doppler intrarenal venous flow patterns reflecting renal congestion in patients with CKD and HF and to detect possible associations with cardiac function parameters. Prognostic implications will be evaluated at a next stge. Method We prospectively enroll outpatients affected by CKD stages 3-4 and HF, in stable clinical conditions and in conventional therapy. All patients undergo clinical evaluation, routine biochemistry, transthoracic echocardiogram and renal echo-Doppler. Pulsed Doppler flow recording is performed at the level of the right interlobular renal veins at the end-expiratory phase. The intrarenal venous flow patterns are divided into five types according to the waveforms of the flow. Type A and B are characterized by a continuous flow and considered normal waveforms. Type C is characterized by a short interruption and/or reversal flow during the end-diastolic or protosystolic phase. Type D and E are characterized by a wide interruption and/or reversal flow, respectively. Types C, D and E are considered abnormal and reflect increasing venous pressure within the kidneys. Results Until now, 36 patients (27males / 9 females), 13 (36%) diabetics, aged 69.4±10.6 years old, have been included, and baseline characteristics are presented. Twenty patients (55%) have CKD stage 3, and 16 patients CKD stage 4 (45%). Fifteen (40%) of these patients have HF New York Heart Association (ΝΥΗA) class II, 18 (50%) ΝΥΗΑ class ΙΙΙ and 3 (10%) ΝΥΗΑ class IV. Mean ejection fraction (EF) is 34.5±7.8%, moderately reduced in 9 (25%) and severely reduced in 27 (75%) of these patients. By analyzing the waveforms, we noticed that 27 patients (75%) had venous patterns of continuous flow (type A 18% and type B 57%) and 9 (25%) had venous patterns with not continuous flows (21% type C and 4% type D). The patients with renal venous patterns A and B had higher EF than those with renal venous patterns C and D (36±8% vs. 30±5%, p=0.045). We have also observed that worsening HF according to NYHA classification was significantly associated to more pathological renal venous patterns (rho=0.402, p=0.034) Conclusion In patients with CKD and HF we may observe abnormal intrarenal vein flow patterns, in the context of renal congestion, related to the functional state of the heart. Further studies will indicate the clinical and prognostic significance of these measurements to better characterize patients with cardio-renal syndrome.

Doppler-Derived Renal Venous Stasis Index in the Prognosis of Right Heart Failure.

BackgroundPersistent congestion with deteriorating renal function is an important cause of adverse outcomes in heart failure. We aimed to characterize new approaches to evaluate renal congestion using Doppler ultrasonography.Methods and ResultsWe enrolled 205 patients with suspected or prediagnosed pulmonary hypertension (PH) undergoing right heart catheterization. Patients underwent renal Doppler ultrasonography and assessment of invasive cardiopulmonary hemodynamics, echocardiography, renal function, intra‐abdominal pressure, and neurohormones and hydration status. Four spectral Doppler intrarenal venous flow patterns and a novel renal venous stasis index (RVSI) were defined. We evaluated PH‐related morbidity using the Cox proportional hazards model for the composite end point of PH progression (hospitalization for worsening PH, lung transplantation, or PH‐specific therapy escalation) and all‐cause mortality for 1‐year after discharge. The prognostic utility of RVSI and intrarenal venous flow patterns was compared using receiver operating characteristic curves. RVSI increased in a graded fashion across increasing severity of intrarenal venous flow patterns (P<0.0001) and was significantly associated with right heart and renal function, intra‐abdominal pressure, and neurohormonal and hydration status. During follow‐up, the morbidity/mortality end point occurred in 91 patients and was independently predicted by RVSI (RVSI in the third tertile versus referent: hazard ratio: 4.72 [95% CI, 2.10–10.59; P<0.0001]). Receiver operating characteristic curves suggested superiority of RVSI to individual intrarenal venous flow patterns in predicting outcome (areas under the curve: 0.789 and 0.761, respectively; P=0.038).ConclusionsWe propose RVSI as a conceptually new and integrative Doppler index of renal congestion. RVSI provides additional prognostic information to stratify PH for the propensity to develop right heart failure.Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT03039959.

O38-2 - The Association between Renal Congestion on Admission and Clinical Course in Acute Decompensated Heart Failure

Objectives: To investigate the relationship between renal congestion, body weight loss, and worsening renal function (WRF) in patients with acute decompensated heart failure (ADHF). Methods: We studied 110 patients (mean age, 78 ± 10 yrs; 72 [65%] men) with ADHF who underwent intrarenal Doppler ultrasonography (IRD) to evaluate intrarenal venous flow (IRVF) within 24 h after admission. Doppler waveforms of IRVF were divided into 3 patterns: continuous, biphasic discontinuous, and monophasic discontinuous. We defined the discontinuous (biphasic and monophasic) IRVF patterns as the surrogate of renal congestion. WRF was defined as a >0.3 mg/dl increase in creatinine from baseline to discharge. Results: IRVF patterns were continuous (n = 21), biphasic (n = 50), and monophasic pattern (n = 39). Baseline creatinine level was highest in the monophasic pattern (1.2 ± 0.5 vs 1.2 ± 0.4 vs 1.6 ± 0.6 mg/dl, P < .05), while baseline body mass index was lowest in the continuous pattern (22.1 ± 2.8 vs 24.1 ± 3.4 vs 25.1 ± 4.5 kg/m2, P < .05) among the 3 patterns. Patients with continuous pattern had milder BW loss during hospital stay (−3.0plusmn;3.0 kg vs −5.0 ± 3.0 kg vs −6.4 ± 4.3 kg, P < .05) and higher frequency of WRF (33% vs 6% vs 13%, P = .02) than the other patterns during the hospitalization. Conclusions: Renal congestion evaluated by IRD on admission could predict the extent of body weight loss and WRF in ADHF.

Intrarenal Flow Alterations During Transition From Euvolemia to Intravascular Volume Expansion in Heart Failure Patients

ObjectivesThe goal of this study was to assess: 1) the intrarenal flow in heart failure (HF) patients during the transition from euvolemia to intravascular volume overload; and 2) the relationship between intrarenal flow and diuretic efficiency. BackgroundIntrarenal blood flow alterations may help to better understand impaired volume handling in HF. MethodsResistance index (RI) and venous impedance index (VII) were assessed in 6 healthy subjects, 40 euvolemic HF patients with reduced ejection fraction (HFrEF), and 10 HF patients with preserved ejection fraction (HFpEF). Assessments were performed by using Doppler ultrasonography at baseline, during 3 h of intravascular volume expansion with 1 l of hydroxyethyl starch 6%, and 1 h after the administration of a loop diuretic. Clinical parameters, echocardiography, and biochemistry were assessed. Urine output was collected after 3 and 24 h. ResultsIn response to volume expansion, VII increased significantly in HFrEF patients (0.4 ± 0.3 to 0.7 ± 0.2; p < 0.001) and in HFpEF patients (0.4 ± 0.3 to 0.7 ± 0.2; p = 0.002) but not in healthy subjects (0.2 ± 0.2 to 0.3 ± 0.1; p = 0.622). This outcome was reversed after loop diuretic administration. In contrast, RI did not change significantly after volume expansion. Echocardiographic-estimated filling pressures did not change significantly. VII during volume expansion was significantly correlated with diuretic response in HF patients independent of baseline renal function (R2 = 0.35; p < 0.001). ConclusionsIn HF patients, intravascular volume expansion resulted in significant blunting of venous flow before a significant increase in cardiac filling pressures could be demonstrated. The observed impaired renal venous flow is correlated with less diuretic efficiency. Intrarenal venous flow patterns may be of interest for evaluating renal congestion.

Maternal bradycardia occurring prior to onset of HELLP syndrome in a woman with pre-eclampsia

A 36-year-old nulliparous woman developed pre-eclampsia at gestational week (GW) 28–6/7. Cardiac status was checked regularly. Heart rate of 93 beats per minute (bpm) with left atrial diameter (LAD) of...

Clinical Implications of Intrarenal Hemodynamic Evaluation by Doppler Ultrasonography in Heart Failure

ObjectivesThis study clarified the characteristics of intrarenal Doppler ultrasonography (IRD) profiles and their prognostic implications in heart failure (HF). BackgroundIRD can assess intrarenal hemodynamics. MethodsInitially, 224 patients with HF were prospectively enrolled; 151 inpatients were enrolled during hospitalization for HF, and 73 were outpatients in our institution. In IRD profiles of interlobar vessels, the arterial resistance index (RI), venous impedance index (VII), and intrarenal venous flow (IRVF) pattern were assessed. Patients were followed to evaluate the associations with 1-year prognosis. Primary endpoints included death from cardiovascular disease and unplanned hospitalization for HF. ResultsFinally, 217 patients with adequate IRD images were enrolled. IRD profiles were associated with conventional risk factors for HF. In particular, IRVF was associated with mean right atrial pressure (RAP); 3 IRVF patterns were stratified by RAP (in a continuous pattern: 5.4 ± 2.5; in a biphasic pattern: 9.5 ± 3.5; and in a monophasic pattern: 14.9 ± 4.3 mm Hg; p < 0.001). In addition, the monophasic IRVF pattern had a poorer prognosis than the other patterns (log rank p < 0.001), and prognosis was poorer for the biphasic pattern than for the continuous flow pattern (log rank p = 0.01). Multivariate Cox proportional hazard model analysis revealed that IRVF patterns were associated with the endpoints, independent of other HF risk factors. ConclusionsIRVF patterns, rather than RI, depended on RAP, suggesting a correlation with renal congestion. In addition, IRVF patterns strongly correlated with clinical outcomes independent of RAP and other risk factors and might provide additional information to stratify vulnerable HF patients.