Left-sided Heart Catheterization Research Articles

Noninvasive Evaluation of Cardiac Chamber Pressures Using Subharmonic-Aided Pressure Estimation With Definity Microbubbles

BackgroundNoninvasive and accurate assessment of intracardiac pressures has remained an elusive goal of noninvasive cardiac imaging. ObjectivesThe purpose of this study was to investigate if errors in intracardiac pressures obtained noninvasively using contrast microbubbles and the subharmonic-aided pressure estimation (SHAPE) technique are <5 mm Hg. MethodsIn a nonrandomized institutional review board–approved clinical trial (NCT03243942), patients scheduled for a left-sided and/or right-sided heart catheterization procedure and providing written informed consent were included. A standard-of-care catheterization procedure was performed advancing clinically used pressure catheters into the left and/or right ventricles and/or the aorta. After pressure catheter placement, patients received an infusion of Definity microbubbles (n = 56; 2 vials diluted in 50 mL of saline; infusion rate: 4-10 mL/min) (Lantheus Medical Imaging). Then SHAPE data was acquired using a validated interface developed on a SonixTablet scanner (BK Medical Systems) synchronously with the pressure catheter data. A conversion factor (mm Hg/dB) was derived from SHAPE data and measurements with a SphygmoCor XCEL PWA device (ATCOR Medical) and was combined with SHAPE data from the left and/or the right ventricles to obtain clinically relevant systolic and diastolic ventricular pressures. ResultsThe mean value of absolute errors for left ventricular minimum and end diastolic pressures were 2.9 ± 2.0 and 1.7 ± 1.2 mm Hg (n = 26), respectively, and for right ventricular systolic pressures was 2.2 ± 1.5 mm Hg (n = 11). Two adverse events occurred during Definity infusion; both were resolved. ConclusionsThese results indicate that the SHAPE technique with Definity microbubbles is encouragingly efficacious for obtaining intracardiac pressures noninvasively and accurately. (Noninvasive, Subharmonic Intra-Cardiac Pressure Measurement; NCT03243942)

Prognostic Value of Right Ventricular Cardiac Power Output at Rest in Patients with Advanced Heart Failure.

There is supporting evidence that normal right heart function is crucial for the maintenance of normal overall hemodynamics. The heart can be described as a hydraulic pump, and cardiac power reflects the hydraulic function of the heart. The present analysis aimed to evaluate the prognostic value of right ventricular cardiac power output (RV-CPO) at rest in patients with advanced heart failure (HF). Between September 2010 and July 2013, 172 patients with advanced HF referred to our hospital were included in this study. Performing right-sided and left-sided heart catheterization simultaneously for each patient at baseline, we evaluated the hemodynamics with longitudinal follow-up of adverse outcomes such as cardiac mortality, ventricular assist device placement, and cardiac transplant (HTx). The threshold RV-CPO at rest value was 0.15 Watts. Increased RV-CPO (> 0.15 Watts) was correlated with an increase in adverse outcomes. Over 52 months, we observed 50 cardiac deaths, 10 HTx, and 12 ventricular assist device placements. The prognostic value of RV-CPO remained significant after adjustment for age, gender, ejection fraction, cardiac output, mean arterial pressure, valvular heart disease, diabetes, body surface area and mineralocorticoid receptor antagonist medication dummy (hazard ratio 0.052, 95% confidence interval 0.006 to 0.406, p = 0.005). Higher RV-CPO at rest was an independent predictor of adverse outcomes. Therefore, RV-CPO could be integrated into the clinical evaluation used for individual risk stratification of patients with advanced HF in order to consider earlier HTx listing and/or earlier consideration for mechanical circulatory support device therapy.

Inadequate left ventricular unloading during ramp is associated with hospitalization or death during left ventricular assist device support.

A combined right and left-sided heart catheterization (RHC/LHC) protocol was recently reported to optimize patients supported by left ventricular assist device (LVAD). Using this platform, we sought to evaluate the prognostic significance of several hemodynamic indices, including left ventricular end-diastolic pressure (LVEDP) and transaortic gradient (peak aortic pressure - peak left ventricular pressure in systole, TAG). We evaluated all patients undergoing RHC/LHC at our institution from 2015 through 2018, and comprehensive clinical data were obtained. Primary end points were (1) a composite outcome that included hospitalization or death and (2) 1-year overall survival after catheterization. Forty-two patients were included in the analysis. Optimization resulted in normalization of hemodynamic parameters; all variables were significantly improved from baseline (P≤.05). On univariate modeling, final LVEDP was associated with the primary end point (hazard ratio [HR], 1.2 per 1-mm Hg increase; 95% CI, 1.1-1.3; P=.002). After adjusting for LVAD speed, TAG, and cardiac index in a multivariate model, the association between LVEDP and the composite end point remained significant (HR, 1.2 per 1-mm Hg increase; 95% CI, 1.1-1.4; P=.001). In the setting of LVAD support, inadequate LV unloading was a significant marker of poor outcomes with time, suggesting that LVEDP is a central prognostic marker in this population.

75-Year-Old Man With Chest Pain and Dyspnea

75-Year-Old Man With Chest Pain and Dyspnea

Correlation of Invasively Estimated Left Ventricular End Diastolic Pressure with Acceleration of E’ Wave by Tissue Doppler Imaging of Mitral Annulus

Background: There is no single noninvasive index that provides a direct measure of LV filling pressure. However, invasive measuring of LV end diastolic pressure (LVEDP) provides reliable assessment of LV diastolic dysfunction, but its invasive nature limits its use in daily practice. Accurate noninvasive assessment of LV diastolic dysfunction is highly desirable, and the relationship between the degree of LVEDP and acceleration of E’ wave obtained by tissue Doppler imaging (TDI) of mitral annulus is not clearly assessed; here in our study we aimed to assess the relation between the degree of LVEDP and the acceleration rate of E’ wave of mitral annular Doppler tissue. Patients and Methods: The study included 60 patients divided equally into 3 groups according to the degree of LVEDP, group I (Normal): ’ ratio and E’ wave acceleration rate. Coronary angiography and left sided heart catheterization and measuring LVEDP were performed for correlating E’ wave acceleration rate with invasively estimated LVEDP. Results: There was significant progressive decrease in E’ acceleration rate (E’ Acc rate) with progressive increase in LVEDP from I to III (P 0.001), while there was significant progressive increase in E/E’ ratio with progressive increase in LVEDP from I to III (P 0.003). Peak E’ acceleration rate had a significant negative correlation with LVEDP in all three groups, with p value of 0.003, 0.044 and 0.021 respectively in group I, II & III. Regarding E/E’ ratio there was a significant positive correlation in predicting normal and elevated LVEDP with p value (0.001 and 0.006) respectively while there was a non-significant correlation between E/E’ and LVEDP within grey zone group. Conclusion: E’ acceleration rate could be used as a reliable index to assess LVEDP.

57-Year-Old Man With Atypical Chest Pain

57-Year-Old Man With Atypical Chest Pain

Aortic Stenosis: Then and Now.

During the late 1950s and most of the 1960s, Dr John Ross and I led the busy clinical cardiology program then existing at the Clinical Center of the National Institutes of Health. During this period, the assessment and surgical treatment of severe aortic stenosis (AS) in adults, predominantly rheumatic in origin, were both undergoing rapid changes. In the 1950s, before open heart surgery and left-sided heart catheterization were available, after thoracotomy dilators were inserted through a ventriculotomy, and severely obstructed aortic valves were blindly opened. 1 The selection of patients for this operation was difficult. Dr Paul Wood, Director of the National Heart Institute in London, who was considered by many to be the world9s leading clinical cardiologist of the era, wrote: At the present time aortic valvotomy is too hazardous and too crude an operation to advise when it is most desirable (just before the onset of symptoms) and frequently too late when impending disaster makes it imperative. 2

Ventricular Diastolic Pressure Ratio as a Marker of Treatment Response in Pulmonary Hypertension

Pulmonary hypertension (PH) is diagnosed and classified through right-sided heart catheterization, with a number of hemodynamic markers used to help guide treatment decisions. These markers may not reflect the complex remodeling of the right ventricle or the interplay between ventricles and struggle to predict treatment response. This study investigates the use of a novel marker: the ratio of left ventricular end-diastolic pressure to right ventricular end-diastolic pressure (LVEDP/RVEDP) in predicting treatment outcomes in a cohort of patients with PH. We performed a retrospective analysis of patients with PH at INOVA Fairfax Hospital's advanced lung disease program with simultaneous left-sided and right-sided heart catheterization. The primary end point was the time to clinical improvement, defined by an improvement in distance walked on the 6-min walk test (6MWT) of > 35m in a year without interceding hospitalization for worsening PH or the need for additional PH therapy. A total of 51 patients were included in the final analysis, 21 of whom (41.2%) had a salutary treatment effect with a mean improvement in the 6MWT of 75 m. Treatment responders were more likely to have a lower LVEDP/RVEDP ratio (1.08 vs1.62; P= .051). This association persisted in the final multivariate regression model after adjustment for age and sex and controlling for severity of PH (OR, 0.17; 95%CI, 0.03-0.65; P= .024). The LVEDP/RVEDP ratio is a novel marker for therapeutic response in patients with PH treated with pulmonary vasodilator medications and may offer robust predictive value independent of existing markers of disease severity.

40-Year-Old Woman With Breathlessness and Fatigue

40-Year-Old Woman With Breathlessness and Fatigue

Early diastolic driving force as a new Doppler index for prediction of left ventricular end diastolic pressure

BackgroundWe thought that the early diastolic driving force (DF) can offer a clinically reliable method to determine left ventricular end diastolic pressure (LVEDP). Material and methodsOne hundred patients were scheduled for estimation of LVEDP by left-sided heart catheterization (LVEDPcath) and Echocardiography, via estimation of the mitral E wave velocity and its deceleration time (DT), to calculate the DF=density×volume×acceleration=1.055×(mitral valve area×velocity time integral)×peak E/acceleration time (AT) =1.055×{(220/P1/2)×(E×AT)/2}×E/AT, if P1/2=0.29 DT, and hence DF=400 E2/DT=0.004 E2/DT Newton. Tissue Doppler estimation of the mitral annular E′ for the E/E′ ratio and septal (E/E′-S) and lateral (E/E′-L) was done. ResultsDF had a negative correlation (r=−0.63, P<0.001), but E/E′-L and E/E′-S had positive correlations (r=0.87 and 0.85 respectively, P<0.001) with LVEDP. At a cutoff value of 0.1N, DF had a sensitivity of 94.1%, specificity of 86.7%, to determine LVEDP>16. E/E′-L is more sensitive and more specific than E/E′-S (72.9% and 93.3% vs. 58.8% and 86.7%) in prediction of LVEDPcath. DF is the almost powerful independent predictor of LVEDPcath (P=0.002). DF had a coefficient=0.619 (P<0.001) for estimation of the LVEDP in the gray zone. ConclusionEarly diastolic DF could be used as a reliable index for elevated LVEDP, especially in the gray zone.

Right- and Left-Sided Heart Catheterization as a Quality Marker for Catheterization Laboratories (from the National Veterans Affairs Clinical Assessment Reporting and Tracking Program)

The rate of concurrent right-heart catheterization (RHC) in patients undergoing left-heart catheterization (LHC) for coronary artery disease (CAD) indications or bilateral heart catheterization (BHC) is recommended as a measure of hospital quality, with higher rates suggesting over utilization. Our aim was to describe the prevalence of BHC and abnormal RHC findings in patients undergoing BHC with a primary indication for LHC. A retrospective analysis was performed for patients undergoing cardiac catheterization for CAD indications using the Department of Veterans Affairs Clinical Assessment Reporting and Tracking Program. Patients undergoing catheterization from October 2007 to September 2011 in 76 Veterans Affairs hospitals were included. Among 95,656 patients undergoing catheterization for CAD, 6,611 (6.9%) underwent BHC and 88,929 (93.0%) LHC. Among the patients undergoing BHC, 61.3% had at least 1 of the following abnormal RHC values: mean pulmonary artery (PA) pressure >25 mm Hg, pulmonary capillary wedge pressure (PCWP) >15 mm Hg, or pulmonary vascular resistance (PVR) >3 Woods units. A total of 37.5% of patients had mean PA pressures of 26 to 40 mm Hg and 11.1% had mean PA pressures >40 mm Hg. A total of 34.4% of patients had mean PCWP of 16 to 25 mm Hg and 13.6% had mean PAWP >25 mm Hg. A total of 16.5% of patients had PVR between 3 and 6 WU and 2.9% had PVR >6 WU. A total of 4.3% of patients met formal criteria for pulmonary arterial hypertension (defined as the combination of PA mean >25 mm Hg, PCWP ≤15 mm Hg, and PVR >3). In conclusion, these findings suggest that most BHC were performed for appropriate clinical reasons. Future studies should further explore BHC rate as an effective quality indicator.

Coronary Anatomy in the Newborn: What Do We Need to Know and When?

Coronary Anatomy in the Newborn: What Do We Need to Know and When?

Usefulness of International Normalized Ratio to Predict Bleeding Complications in Patients With End-Stage Liver Disease Who Undergo Cardiac Catheterization

Patients with end-stage liver disease frequently require invasive cardiac procedures in preparation for liver transplantation. Because of the impaired hepatic function, these patients often have a prolonged prothrombin time and elevated international normalized ratio (INR). To determine whether an abnormal prothrombin time/INR is predictive of bleeding complications from invasive cardiac procedures, we retrospectively reviewed, for bleeding complications, the databases and case records of our series of patients with advanced cirrhosis who underwent cardiac catheterization. A total of 157 patients underwent isolated right-sided heart catheterization, and 83 underwent left-sided heart catheterization or combined left- and right-sided heart catheterization. The INR ranged from 0.93 to 2.35. No major procedure-related complications occurred. Several patients in each group required a blood transfusion for gastrointestinal bleeding but not for procedure-related bleeding. No significant change was found in the hemoglobin after right-sided or left-sided heart catheterization, and no correlation was found between the preprocedure INR and the change in postprocedure hemoglobin. When comparing patients with a normal (≤1.5) and elevated (>1.5) INR, no significant difference in hemoglobin after the procedure was found in either group. In conclusion, despite an elevated INR, patients with end-stage liver disease can safely undergo invasive cardiac procedures. An elevated INR does not predict catheterization-related bleeding complications in this patient population.

Monozygotic Twins with Identical Cardiac Conditions

A 53-year-old white man with prior hypertension and hyperlipidemia was sent to the hospital from his physician's office with chest pain and atrial fibrillation. His rapid heart rate was slowed with a diltiazem drip. Echocardiography demonstrated an ejection fraction of approximately 20%. Cardiac catheterization showed severe global left ventricular hypokinesis but no significant coronary narrowing. He had a “left dominant” circulation. An identical twin brother had also presented to another hospital 1 year earlier with atrial fibrillation and depressed cardiac function. The patient's twin had also undergone left-sided heart catheterization, which had revealed a depressed left ventricular ejection fraction, no coronary narrowing, and a “left dominant” circulation (Figure). Figure Invasive angiogram of monozygotic twins: (a) the index case and (b) his brother. There is no appreciable coronary artery disease in the left anterior descending artery (LAD), left circumflex artery (LCx), or obtuse marginals (OM). The twins are both noted ...

Computerized Acoustic Cardiographic Electromechanical Activation Time Correlates With Invasive and Echocardiographic Parameters of Left Ventricular Contractility

Background Electromechanical activation time (EMAT) is a systolic time interval defined as the time from Q-wave onset to the peak first heart sound. We assessed the correlation between systolic dysfunction and EMAT calculated using computerized acoustic cardiography. Methods A total of 25 patients with heart failure contemporaneously underwent echocardiography, left-sided heart catheterization, and acoustic cardiography. Invasive pressure–volume hemodynamics included peak isovolumetric left ventricular (LV) pressure at the end-diastolic volume, end-diastolic pressure, dyssynchrony, and maximal +dP/dT. An EMAT/(R to R interval) (%EMAT) interval ≥ 0.15 was prospectively defined as abnormal. Results An abnormal %EMAT correlated with a lower LV ejection fraction (50.9% ± 18.6% with normal EMAT vs 32.0% ± 10.9% with abnormal EMAT, P = .015), end-systolic elastance (3.07 ± 1.56 mm Hg/mL vs 1.43 ± 0.83 mm Hg/mL, P = .018), and peak isovolumetric LV pressure at the end-diastolic volume (317 ± 90 mm Hg vs 222 ± 67 mm Hg, P = .015). An abnormal %EMAT was associated with a higher end-systolic volume index (33.6 ± 29.3 mL/m 2 vs 71.0 ± 35.8 mL/m 2, P = .011), end-diastolic volume index (61.2 ± 29.8 mL/m 2 vs 100.3 ± 40.8 mL/m 2, P = .012), and dyssynchrony (26.1% ± 6.0% vs 31.5% ± 3.5%, P = .028). There was no difference in end-diastolic pressure (20.3 ± 7.9 mm Hg vs 21.4 ± 12.3 mm Hg, P = .78). Conclusions An abnormal %EMAT was strongly associated with impaired LV contractility but had no association with LV filling pressures. This noninvasive, simple, point-of-care diagnostic test has potential applications when echocardiography cannot be obtained in a timely fashion to assess systolic function.

First-in-Man Implantation of Left Ventricular Partitioning Device in a Patient With Chronic Heart Failure: Twelve-Month Follow-up

Background The ventricular partitioning device (VPD) (Cardiokinetix Inc., Redwood City, Calif) is a novel device that is deployed percutaneously in the left ventricle in patients with anteroapical regional wall motion abnormalities after a myocardial infarction (MI) to partition the ventricle and segregate the dysfunctional region. In this case report we present the first implantation of the VPD in a human, with a 12-month efficacy and safety follow-up. Methods and Results A 48-year-old man had an anterior MI in 2004. A coronary angiogram showed an occlusion of the proximal segment of the left anterior descending artery with no stenosis on other major epicardial vessels. Echocardiography revealed a dilated left ventricle (62 mm) with anteroapical wall motion abnormalities, no apical thrombus, a calculated ejection fraction of 26.8% (by Simpson biplane formula), and an end-systolic volume index (ESVi) of 76.8 mL/m 2. The VPD implant was delivered percutaneously from the femoral artery by the standard techniques for left-sided heart catheterization. The postimplantation course was uneventful. Echocardiography on discharge showed the VPD implanted at the apex, with a left ventricular ejection fraction of 30.9% and an ESVi of 57.2 mL/m 2. Left ventricular ejection fraction and ESVi remained improved during the 12-month follow-up. Conclusion This case report demonstrates that VPD implantation in this particular patient was feasible and that it may provide a nonsurgical approach to prevent or reverse left ventricle remodeling.

Relationship Between Accurate Auscultation of a Clinically Useful Third Heart Sound and Level of Experience

Poor performance by physicians-in-training and interobserver variability between physicians have diminished clinicians' confidence in the value of the third heart sound (S3). To determine whether auscultation of a clinically useful S3 improves with advancing levels of experience, we performed a prospective, blinded, observational study of 100 patients undergoing left-sided heart catheterization. Patients underwent blinded auscultation by 4 physicians (each from 1 of 4 different levels of experience), phonocardiography, measurement of blood B-type natriuretic peptide levels, echocardiography for measurement of left ventricular ejection fraction, and cardiac catheterization for measurement of left ventricular end-diastolic pressure. Whereas residents' and interns' auscultatory findings demonstrated no significant agreement with phonocardiographic findings, an S3 auscultated by cardiology fellows (kappa = 0.37; P<.001) and cardiology attendings (kappa = 0.29; P = .003) agreed with phonocardiographic findings. Although the sensitivities of the S3 were low (13%-52%) for identifying patients with abnormal measures of left ventricular function, the specificities were high (85%-95%), with the best test characteristics exhibited by phonocardiography and more experienced physicians. The S3 detected by attendings and fellows was superior in distinguishing an elevated B-type natriuretic peptide level, a depressed left ventricular ejection fraction, or an elevated left ventricular end-diastolic pressure (P = .002-.02 for attendings and .02-.03 for fellows) compared with residents (P = .02-.47) or interns (P = .09-.64). The S3 auscultated by more experienced physicians demonstrated fair agreement with phonocardiographic findings. Although correlations were superior for phonocardiography, the associations between the S3 and abnormal markers of left ventricular function improved with each level of auscultator experience.

Immediate and late outcomes of patients undergoing transseptal left-sided heart catheterization for symptomatic valvular and arrhythmic diseases

The transseptal technique has been widely used for diagnostic and therapeutic left-sided heart catheterization. However, its differential immediate and late outcomes among patients with various valvular and arrhythmic diseases are not yet determined. Beginning from 1993, all patients undergoing transseptal procedures were screened and categorized into diagnosis, arrhythmia, and valvuloplasty groups according to the purposes of the catheterization. Incidences of transseptum-related acute major events (cardiac perforation, embolic stroke, and bradyarrhythmia during the procedure) and late complications (residual atrial septal defect [ASD], embolic stroke, bradyarrhythmia, and death up to 18 months) were analyzed and compared between groups. From January 1993 to May 2003, a total of 176 patients underwent 184 transseptal procedures for diagnosis of valvular heart diseases (n = 8), catheter ablation of arrhythmogenic foci (n = 29), and mitral valvuloplasty (n = 147). The immediate outcome was similar among the 3 groups, with an overall acute complication incidence of 3.8%. At follow-up, the incidences of bradyarrhythmia, embolic stroke, and death were not different among the 3 groups. Patients undergoing valvuloplasty had a significantly higher prevalence of residual ASD, especially for those with more severe mitral stenosis and less valvuloplasty success. However, presence of ASD did not impose disadvantage over the 1.5-year prognosis. Transseptal left-sided heart catheterization can be safely applied to patients with different categories of cardiac diseases with comparably good immediate and late outcomes. Although patients undergoing percutaneous valvuloplasty have a higher chance of permanent ASD creation, their prognosis is not influenced.

Ross Procedure in a Quadricuspid Aortic Valve

A quadricuspid aortic valve is a rare congenital cardiovascular abnormality, and when present, it is associated with aortic valve regurgitation. If aortic valve replacement is required, mechanical or biological prostheses are used. We report the case of a patient with a severely regurgitant quadricuspid aortic valve in whom a Ross procedure was performed.

Association Between Phonocardiographic Third and Fourth Heart Sounds and Objective Measures of Left Ventricular Function

The third (S3) and fourth (S4) heart sounds detected by phonocardiography are considered to represent the criterion standards of the gallop sounds, but their test characteristics have not been explored. To determine the diagnostic test characteristics of the S3 and S4 for prediction of left ventricular dysfunction using a computerized heart sound detection algorithm. Prospective study of 90 adult patients undergoing elective left-sided heart catheterization at a single US teaching hospital between August 2003 and June 2004. The mean age was 62 (SD, 13) years (range, 24-90 years) and 61 (68%) were male. Within a 4-hour period, participants underwent computerized heart sound phonocardiographic analysis, cardiac catheterization, transthoracic echocardiography, and blood sampling for assessment of an S3/S4, left ventricular end-diastolic pressure (LVEDP), left ventricular ejection fraction (LVEF), and B-type natriuretic peptide (BNP), respectively. Diagnostic test characteristics of the computerized phonocardiographic S3 and S4 using markers of left ventricular function as criterion standards. Mean (SD) LVEDP was significantly elevated (18.4 [6.9] mm Hg vs 12.1 [7.3] mm Hg; P<.001), mean (SD) LVEF was reduced (49.4% [20.2%] vs 63.6% [14.8%]; P<.001), and median (interquartile range) BNP was elevated (330 [98-1155] pg/mL vs 86 [41-192] pg/mL; P<.001) in those with an S3, S4, or both compared with patients without a diastolic heart sound. The sensitivities of these heart sounds to detect an elevated LVEDP, reduced LVEF, or elevated BNP were 41%, 52%, and 32% for an S3, and 46%, 43%, and 40% for an S4, respectively. For abnormal levels of the same markers of ventricular function, the specificities of the S3 were 92%, 87%, and 92%, while the specificities of the S4 were 80%, 72%, and 78%, respectively. Neither the phonocardiographic S3 nor the S4 is a sensitive marker of left ventricular dysfunction. The phonocardiographic S3 is specific for left ventricular dysfunction and appears to be superior to the moderate specificity of the phonocardiographic S4.