Lower Cardiac Index Research Articles

Prognostic Value of Respiratory Variation in Right Atrial Pressure in Patients With Precapillary Pulmonary Hypertension

Precapillary pulmonary hypertension (PH) is characterized by elevated mean pulmonary artery pressure from increased pulmonary vascular resistance (PVR). Lack of respiratory variation in right atrial pressure (RAP) can be viewed as a surrogate for severe PH and inability of the right ventricle (RV) to tolerate preload augmentation during inspiration. Is the lack of respiratory variation in RAP predictive of RV dysfunction and worse clinical outcomes in precapillary PH? We retrospectively reviewed RAP tracings of patients with precapillary PH who underwent right heart catheterization. Patients with respiratory variation in RAP (end expiratory - end inspiratory) ≤2 mmHg were considered to have effectively no meaningful variation in RAP. Lack of respiratory variation in RAP was associated with lower cardiac index by indirect Fick (2.34±0.09 vs. 2.76±0.1 L/min/m2, p=0.001), lower pulmonary artery saturation (60±1.02% vs 64±1.15%, p=0.007), higher PVR (8.9±0.44 vs 6.1±0.49 Wood units, p<0.0001), RV dysfunction on echocardiography (87.3% vs 38.8%, p<0.0001), higher proBNP (2163±2997 vs 633±402 ng/ml, p<0.0001), and more hospitalizations within 1 year for RV failure (65.4% vs 29.6%, p<0.0001). There was also a trend toward higher mortality at 1 year in patients with no respiratory variation in RAP (25.4% vs 11.1%, p=0.06). Lack of respiratory variation in RAP is associated with poor clinical outcomes, adverse hemodynamic parameters, and RV dysfunction in patients with precapillary PH. Larger studies are needed to further evaluate its utility in prognosis and potential risk stratification in patients with precapillary PH.

Albumin effect on hemorheological parameters in patients with liver transplant.

Liver transplantation is a life-saving treatment in end-stage liver failure. Hemorheological features as blood fluidity and red blood cell aggregation may alter effective tissue perfusion, graft function and hemodynamic variables. The aim of the study is to investigate effect of albumin infusion on red blood cell deformability and aggregation, blood viscosity and hemodynamics in liver transplant patients. Seventeen live or cadaveric donors were included in this prospective study. Hemorheological and hemodynamic measurements were performed in order to evaluate the effects of albumin infusion in perioperative period. Erythrocyte aggregation was significantly reduced 90 minutes after albumin infusion (p < 0.01). Mean blood viscosity revealed significant decrease at 20 rpm and 50 rpm after 90 minutes of albumin infusion (p < 0.05). Plasma viscosity decreased significantly compared to the value before albumin infusion at 20 rpm (p < 0.05). Albumin replacement improved hemodynamic variables in patients with low blood pressure and cardiac index measurements (p > 0.05). Human albumin infusion led to decrease in whole blood and plasma viscosities, red blood cell aggregation and induced blood pressure and cardiac index elevation in perioperative liver transplant patients. Determination of hemodynamic and hemorheological effects of human albumin replacement in various patient populations may serve beneficial clinical data.

Dynamic chest radiography as a novel minimally invasive hemodynamic imaging method in patients with heart failure

PurposeDynamic chest radiography allows for non-invasive cardiopulmonary blood flow assessment. However, data on its use for heart failure hemodynamic assessment are scarce. We utilized dynamic chest radiography to estimate heart failure hemodynamics. MethodTwenty heart failure patients (median age, 67 years; 17 men) underwent dynamic chest radiography and right heart catheterization. The analyzed images were 16-bit images (grayscale range: 0–65,535). Right atrial, right pulmonary artery, and left ventricular apex pixel values (average of the grayscale values of all pixels within a region of interest) were measured. The correlations of the minimum, maximum, mean, amount of change, and rate of change in pixel values with right atrial pressure, pulmonary artery pressure, pulmonary artery wedge pressure, and cardiac index were analyzed. ResultsThe mean right atrial pixel value and mean right atrial pressure (R = −0.576, P = 0.008), mean right pulmonary artery pixel value and mean pulmonary artery pressure (R = −0.546, P = 0.013), and left ventricular apex pixel value change rate and mean pulmonary artery wedge pressure (R = −0.664, P = 0.001) or cardiac index (R = 0.606, P = 0.005) were correlated. The left ventricular apex pixel value change rate identified low cardiac index (area under the curve, 0.792; 95% confidence interval, 0.590–0.993; P = 0.031) and low cardiac index with high pulmonary artery wedge pressure (area under the curve, 0.902; 95% confidence interval, 0.000–1.000; P = 0.030). ConclusionsDynamic chest radiography is a minimally invasive tool for heart failure hemodynamic assessment.

Cardiac positron emission tomography in prediction of the clinical course of chronic thromboembolic pulmonary hypertension: prospective cohort study

INTRODUCTION: During the development of CTEPH maladaptive mechanisms in the right ventricle are accompanied by disturbances in myocardial energy metabolism and perfusion. These changes can be assessed visually and quantitatively using the molecular imaging method — PET with [18F]-FDG and [13N]-NH3.OBJECTIVE: Using cardiac PET/CT investigate the relationship between perfusion and metabolism of the right ventricular myocardium and the results of other instrumental examination methods in patients with CTEPH of different severity, as well as to calculate the threshold PET values to determine the group of patients with an unfavorable clinical course of the disease.MATERIALS AND METHODS: The study included 36 patients with a verified diagnosis of CTEPH, who were examined using a standard diagnostic protocol. Patients underwent cardiac PET/CT examinations with two radiopharmaceuticals: with [18F]-FDG to study the metabolism of the ventricular myocardium and with [13N]-NH3 to assess cardiac perfusion. For each radiopharmaceutical semi-quantitative accumulation indices (SUV) and the ratio of the levels of radiopharmaceutical uptake in the right and left ventricles (SUV RV/SUV LV) were obtained. Statistics: Shapiro-Wilk test, Student’s t-test, and Mann-Whitney U-test, Pearson correlation analysis, linear regression analysis, ROC analysis.RESULTS: The level of [18F]-FDG accumulation in the right ventricular myocardium is higher in patients with a high functional class of PH than in groups I, II (p&lt;0.01). All indicators of SUV RV/SUV LV for [18F]-FDG demonstrate a direct linear relation-ship with the level of mean PAP (r=0.691, p&lt;0.0001), PVR (r=0.715, p&lt;0.0001), right ventricular size (r=0.658, p&lt;0.0001), PASP (r=0.581, p&lt;0.001) and inverse linear relationship with the functional parameters of the right ventricle CI (r=–0.555, p=0.001), CO (r=–0.488, p=0.005), TAPSE (r=–0.552, p&lt;0.001), TAVS (r=–0.537, p&lt;0.001), and SvO2 (r=–0.666, p&lt;0.0001). A correlation was found between the accumulation of [13N]-NH3 and the main hemodynamic parameters used to assess the severity of the disease (СI, SvO2). The threshold values of [18F]-FDG and [13N]-NH3 accumulation indices have been obtained, which with high sensitivity (69.2–83.3%), specificity (68.4–94.7%) and diagnostic accuracy (0.73–0.83) make it possible to identify patients with a low cardiac index and an unfavorable prognosis.DISCUSSION: The obtained results confirm the presence of glucose hypermetabolism in right ventricular cardiomyocytes in the development of pulmonary hypertension and the association of these metabolic changes with the severity of PH. A significant correlation was demonstrated between the accumulation of both radiopharmaceuticals in the heart and the results of other examination methods characterizing the severity of disease and the prognosis of patients with CTEPH. Using a non-invasive PET/CT procedure, threshold values of PET parameters were obtained, which in the future can be used to identify patients with an unfavorable clinical prognosis.CONCLUSION: Cardiac PET/CT with [18F]-FDG and [13N]-NH3 is a promising non-invasive imaging technique that can be used to study metabolic and perfusion changes in the right ventricular myocardium in CTEPH, as well as to identify patients with a high risk of adverse events.

Clinical and hemodynamic phenotype of BMPR2 variation carriers with pulmonary arterial hypertension: A systematic review and a call to action

Background: Carriers of variations in the gene encoding bone morphogenetic protein receptor type 2 (BMPR2∆) are at high risk for severe pulmonary arterial hypertension (PAH+). Aim: To define the clinical and hemodynamic phenotype of BMPR2∆/PAH+ patients. Methods: We performed a systematic review encompassing observational data until July 2019 about BMPR2∆ and confirmed PAH diagnosis. According to international clinical guidelines, we aimed to determine the clinical and hemodynamic phenotype of BMPR2D/PAH+ patients. We also explored functional assessment and risk stratification. PROSPERO ID CRD42019124324. Results: We included 54 reports with 6,668 PAH+ patients, 1,220 were BMPR2∆/PAH+ with an allele frequency within studies ranging from 8.8% to 24.9%. Female sex was predominant, and age at diagnosis ranged from 32.2 to 46.2 years. We observed the occurrence of BMPR2∆ across all PAH clinical classifications, except for schistosomiasis. BMPR2∆ correlated with severity signs and symptoms in PAH, poor functional class, severe pulmonary hypertension with elevated pulmonary vascular resistance, and low cardiac index and output. The clinical and hemodynamic missing data ranged between 28%-49% and 50%-65%, respectively. Conclusion: BMPR2∆/PAH+ patients present a phenotype with high mortality risk. The clinical triad of dyspnea, syncope, and hemoptysis could suggest BMPR2∆/PAH+. However, poor clinical and hemodynamic characterization hinders translating the benefits of genomic analyses to the clinical setting.

Adults with small, unrepaired atrial septal defects have reduced cardiac index during exercise.

Small, unrepaired atrial septal defects are considered a benign lesion with good prognosis. Recently, clinical and register-based studies discovered increased long-term mortality and morbidity. The nature of these findings is not fully understood. Therefore, MRI was performed to evaluate cardiac function at rest and during exercise. Adults with open or spontaneously closed atrial septal defects and healthy, matched controls underwent MRI for evaluation of cardiac chamber volume. Quantitative flow scans measured blood flow in the ascending aorta and the proximal pulmonary artery at rest and during increasing supine exercise. In total, 15 open defects (39 ± 11 years) and 15 matched controls (38 ± 12 years) were included, along with 20 spontaneously closed (36 ± 13 years) and 20 controls (36 ± 11 years). Cardiac chamber volumes and flow measurements at rest were comparable between groups, as were heart rates and workloads during exercise. At maximal exercise, open defects reached 31% lower cardiac index and had 38% higher retrograde flow in the pulmonary artery than their controls, p < 0.01. Shunt ratio remained unchanged during exercise, 1.2 ± 0.2. Closed defects reached 18% lower cardiac index, p = 0.02, with comparable pulmonary retrograde flow. Maximal cardiac index was inversely correlated with increasing age for patients only. Adults with a small, open or spontaneously closed atrial septal defects exhibit markedly lower exercise capacity compared with healthy peers. Moreover, open defects exhibit higher retrograde flows with increasing exercise. Finally, increasing age is related to poorer results in patients but not healthy controls. Longitudinal studies are necessary in order to determine potential accelerated worsening of physical capacity along with age-related changes in patients.

EFFECT OF POLYMORPHIC VARIANTS OF AGT2R1 GENE ON HEMODYNAMIC PARAMETERS IN PREMATURE CHILDREN

Relevance. Maintaining hemodynamic in premature infants who are being treated in intensive care units is one of the significant challenges in the practice of modern neonatologists and intensivists. The study of AGT2R1 gene polymorphism can help predict the course of organ dysfunction and prevent the development of adverse clinical consequences.&#x0D; The aim is to study the effect of AGT2R1 gene polymorphism on hemodynamic parameters in premature children with bacterial infections.&#x0D; Subjects and methods. A prospective cohort study included 143 prematurely born children with bacterial infections: main groups (n=40) had arterial hypotension, control group (n=103) had no arterial hypotension. All patients underwent a standard complex of clinical and laboratory research methods and PCR in order to investigate the A1166C polymorphism of the AGT2R1 gene.&#x0D; Results. The study has revealed that the CC genotype of AGT2R1 occur significantly more often in premature children with arterial hypotension than in the control group (OR 10.17, p=0.027). As a result of intragroup analysis among the infants with arterial hypotension, stratified according to polymorphic variants of the AGT2R1 gene, we did not find any significant differences in medico-demographic indicators, the frequency of resuscitation measures, hemodynamic indicators. However, prematurely born children with AC+CC genotype compared to carriers of the AA variant genotype had a lower cardiac index (4.5 vs. 3.5 ml/min*m2, p=0.04), which indicates the influence of myocardial dysfunction on the occurrence arterial hypotension&#x0D; Conclusion. A1168C polymorphism of the AGT2R1 gene affects the hemodynamic disorders in premature children with bacterial infections. Further multifaceted studies on a larger sample of patients are required to confirm this hypothesis.

Abstract 12085: Cardiac Structural and Functional Differences Between the Types of Sleep Apnea in Patients With Heart Failure With Reduced Ejection Fraction

Introduction: In patients with heart failure with reduced ejection fraction (HFrEF), sleep-disordered breathing (SDB) may affect, or be affected by cardiac structure and function. We hypothesized that patients with OSA would demonstrate left ventricular (LV) remodeling and impaired LV function intermediate between that of patients with CSA and patients with no SDB. Methods: ADVENT-HF is a multinational randomized trial investigating the effect of adaptive servo ventilation in patients with HFrEF and SDB. Inclusion required LV ejection fraction (LVEF) ≤45%, and a polysomnographic (PSG) apnea-hypopnea index (AHI) ≥15. Subjects with an AHI &lt;15 were excluded from randomization but comprised a no-SDB (NSDB) group. All transthoracic echocardiograms (TTE) and PSGs were analyzed in core laboratories at University Health Network in Toronto. Patients with SDB were subdivided into those with OSA and those with CSA. We then compared baseline demographic and TTE characteristics of the NSDB, OSA and CSA cohorts. Results: Among them, 665 with acceptable TTE were analyzed. As shown in the table, the CSA group was older, more predominantly male, and had a higher AHI than the other groups, and a higher prevalence of atrial fibrillation and a lower minimum arterial oxyhemoglobin saturation level than the NSDB group. The CSA group also had greater LV mass index than the other groups, greater LV volume indices and lower LVEF than the OSA group, and lower cardiac index than the NSDB group. Although the OSA group had no significant differences in TTE findings compared to the NSDB group, the OSA group was older, more predominantly male, and had a greater AHI than the NSDB group and a higher BMI than the CSA group and lower minSaO 2 than the other groups. Conclusion: In patients with HFrEF, the degree of LV remodeling and dysfunction did not differ between the OSA and NSDB groups, but those with CSA had more advanced LV remodeling and dysfunction than the other groups signaling more advanced HF.

Abstract 12304: Right Ventricular Hemodynamics in COVID Patients With Shock

Introduction: Patients with serious COVID infections frequently develop shock. Their right-sided hemodynamic profiles have not been well characterized. Methods: In a prospectively collected database including 1997 patients hospitalized for COVID pneumonia from March 2020 to March 2021, 368 had shock requiring vasopressors. 327 had echocardiography to assess ventricular function and stroke volume based on clinical indications. LVEF (LV ejection fraction) and RVFAC (RV fractional area change) were measured using Simpson’s rule, stroke volume (SV) by aortic Doppler, and RVSP (RV systolic pressure) from tricuspid regurgitation velocity; 187 had evaluable data on all parameters. Patients were divided into groups with low or preserved RVFAC ( RVFAC L or RVFAC P , cutoff &amp;lte35%), and low or normal cardiac index, (CI, CI L or CI N , cutoff &amp;lte2.2 L/min/m 2 ). Results: Mean age: 65±12, LVEF 59.5±12.8, RVFAC 35.3±10.6, CI 2.41±0.89. Overall hospital mortality in this cohort with shock was 80%. Mean RVSP was 38.8±12.2, PEEP 11.0±3.7. 43% of patients had low RVFAC (&amp;lt35%), and RVFAC correlated with other measures of RV function such as tricuspid annular peak systolic excursion (TAPSE) and lateral tricuspid annulus peak systolic velocity (S’). Higher RVSP correlated with lower CI (r=0.134, p= 0.016) but not with PEEP (r=0.03, p=0.70). Mortality did not differ significantly among groups, (p=0.19 by ANOVA) but was highest in the group with low RVFAC and low CI. ( Figure ) Conclusion: RV dysfunction is common in patients with severe COVID-19 and shock. Although RV dysfunction is probably associated with a worse prognosis, outcome in COVID may be tied to pulmonary recovery. Whether treatment targeted at RV dysfunction will improve outcome remains uncertain.

Predictors of low cardiac output after isolated pericardiectomy: an observational study

BackgroundLow cardiac output is the main cause of perioperative death after pericardiectomy for constrictive pericarditis. We investigated the associated risk factors and consequences.MethodsWe selected constrictive pericarditis patients undergoing isolated pericardiectomy from January 2013 to January 2021. Postoperative low cardiac output was defined as requiring mechanical circulatory support or more than one inotrope to maintain a cardiac index > 2.2 L •min−1 •m−2 without hypoperfusion, despite adequate filling status. Uni- and multivariable analysis were used to identify factors associated with low cardiac output. Cox regression was used to identify factors associated with length of hospital stay.ResultsAmong 212 patients with complete data, 55 (25.9%) developed low cardiac output within postoperative day 1 (quartiles 1 and 2), which caused seven of the nine perioperative deaths. The rates of atrial arrhythmia, renal dysfunction, hypoalbuminemia, modest-to-severe hyponatremia, and hyperbilirubinemia caused by constrictive pericarditis were 9.4%, 12.3%, 49.1%, 10.4%, and 81.6%. The mean preoperative central venous pressure and cardiac index were 18 ± 5 cmH2O and 1.87 ± 0.45 L•min−1•m−2. Univariable analysis showed that low cardiac output patients had higher rates of atrial arrhythmia (OR 3.32 [1.35, 8.17], P = 0.007), renal dysfunction (OR 4.24 [1.94, 9.25], P < 0.001), hypoalbuminemia (OR 1.99 [1.06, 3.73], P = 0.031) and hyponatremia (OR 6.36 [2.50, 16.20], P < 0.001), greater E peak velocity variation (difference 2.8 [0.7, 5.0], P = 0.011), higher central venous pressure (difference 3 [2,5] cmH2O, P < 0.001) and lower cardiac index (difference − 0.27 [− 0.41, − 0.14] L•min−1•m−2, P < 0.001) than patients without low cardiac output. Multivariable regression showed that atrial arrhythmia (OR 4.04 [1.36, 12.02], P = 0.012), renal dysfunction (OR 2.64 [1.07, 6.50], P = 0.035), hyponatremia (OR 3.49 [1.19, 10.24], P = 0.023), high central venous pressure (OR 1.17 [1.08, 1.27], P < 0.001), and low cardiac index (OR 0.36 [0.14, 0.92], P = 0.032) were associated with low cardiac output (AUC 0.79 [0.72–0.86], P < 0.001). Cox regression analysis showed that hyperbilirubinemia (HR 0.66 [0.46, 0.94], P = 0.022), renal dysfunction (HR 0.51 [0.33, 0.77], P = 0.002), and low cardiac output (HR 0.42 [0.29, 0.59], P < 0.001) were associated with length of hospital stay.ConclusionsEarly recognition and management of hyponatremia, renal dysfunction, fluid retention, and hyperbilirubinemia may benefit constrictive pericarditis patients after pericardiectomy.

Prediction of Postoperative Deterioration in Cardiac Surgery Patients Using Electronic Health Record and Physiologic Waveform Data.

Postoperative hemodynamic deterioration among cardiac surgical patients can indicate or lead to adverse outcomes. Whereas prediction models for such events using electronic health records or physiologic waveform data are previously described, their combined value remains incompletely defined. The authors hypothesized that models incorporating electronic health record and processed waveform signal data (electrocardiogram lead II, pulse plethysmography, arterial catheter tracing) would yield improved performance versus either modality alone. Intensive care unit data were reviewed after elective adult cardiac surgical procedures at an academic center between 2013 and 2020. Model features included electronic health record features and physiologic waveforms. Tensor decomposition was used for waveform feature reduction. Machine learning-based prediction models included a 2013 to 2017 training set and a 2017 to 2020 temporal holdout test set. The primary outcome was a postoperative deterioration event, defined as a composite of low cardiac index of less than 2.0 ml min-1 m-2, mean arterial pressure of less than 55 mmHg sustained for 120 min or longer, new or escalated inotrope/vasopressor infusion, epinephrine bolus of 1 mg or more, or intensive care unit mortality. Prediction models analyzed data 8 h before events. Among 1,555 cases, 185 (12%) experienced 276 deterioration events, most commonly including low cardiac index (7.0% of patients), new inotrope (1.9%), and sustained hypotension (1.4%). The best performing model on the 2013 to 2017 training set yielded a C-statistic of 0.803 (95% CI, 0.799 to 0.807), although performance was substantially lower in the 2017 to 2020 test set (0.709, 0.705 to 0.712). Test set performance of the combined model was greater than corresponding models limited to solely electronic health record features (0.641; 95% CI, 0.637 to 0.646) or waveform features (0.697; 95% CI, 0.693 to 0.701). Clinical deterioration prediction models combining electronic health record data and waveform data were superior to either modality alone, and performance of combined models was primarily driven by waveform data. Decreased performance of prediction models during temporal validation may be explained by data set shift, a core challenge of healthcare prediction modeling.

Natriuretic peptides, extracellular volume, and subclinical cardiovascular changes in chronic kidney disease stages 1–3: a pilot study

Natriuretic peptide levels are elevated in persons with chronic kidney disease (CKD) stages 1–3, but it remains unclear whether this is associated with extracellular volume excess or early cardiovascular changes....

Fluid bolus administration in children, who responds and how? A systematic review and meta-analysis.

Fluid boluses are frequently utilized in children. Despite their frequency of use, there is little objective data regarding the utility of fluid boluses, who they benefit the most, and what the effects are. This study aimed to conduct pooled analyses to identify those who may be more likely to respond to fluid boluses as well as characterize clinical changes associated with fluid boluses. A systematic review of the literature and meta-analysis was conducted to identify pediatric studies investigating the response to fluid boluses and clinical changes associated with fluid boluses. A total of 15 studies with 637 patients were included in the final analyses with a mean age of 650 days ± 821.01 (95% CI 586 to 714) and a mean weight of 10.5kg ± 7.19 (95% CI 9.94 to 11.1). The mean bolus volume was 12.14 ml/kg ± 4.09 (95% CI 11.8 to 12.5) given over a mean of 19.55 min ± 10.16 (95% CI 18.8 to 20.3). The following baseline characteristics were associated with increased likelihood of response [represented in mean difference (95% CI)]: greater age [207.2 days (140.8 to 273.2)], lower cardiac index [-0.5ml/min/m2 (-0.9 to -0.3)], and lower stroke volume [-5.1ml/m2 (-7.9 to -2.3)]. The following clinical parameters significantly changed after a fluid bolus: decreased HR [-5.6bpm (-9.8 to -1.3)], increased systolic blood pressure [7.7 mmHg (1.0 to 14.4)], increased mean arterial blood pressure [5.5 mmHg (3.1 to 7.8)], increased cardiac index [0.3ml/min/m2 (0.1 to 0.6)], increased stroke volume [4.3ml/m2 (3.5 to 5.2)], increased central venous pressure [2.2 mmHg (1.1 to 3.3)], and increased systemic vascular resistance [2.1 woods units/m2 (0.1 to 4.2)]. Fluid blouses increase arterial blood pressure or cardiac output by 10% in approximately 56% of pediatric patients. Fluid blouses lead to significant decrease in HR and significant increases in cardiac output, stroke volume, and systemic vascular resistance. Limited published data are available on the effects of fluid blouses on systemic oxygen delivery.

Mechanisms of Transcranial Doppler Ultrasound phenotypes in paediatric cerebral malaria remain elusive

BackgroundCerebral malaria (CM) results in significant paediatric death and neurodisability in sub-Saharan Africa. Several different alterations to typical Transcranial Doppler Ultrasound (TCD) flow velocities and waveforms in CM have been described, but mechanistic contributors to these abnormalities are unknown. If identified, targeted, TCD-guided adjunctive therapy in CM may improve outcomes.MethodsThis was a prospective, observational study of children 6 months to 12 years with CM in Blantyre, Malawi recruited between January 2018 and June 2021. Medical history, physical examination, laboratory analysis, electroencephalogram, and magnetic resonance imaging were undertaken on presentation. Admission TCD results determined phenotypic grouping following a priori definitions. Evaluation of the relationship between haemodynamic, metabolic, or intracranial perturbations that lead to these observed phenotypes in other diseases was undertaken. Neurological outcomes at hospital discharge were evaluated using the Paediatric Cerebral Performance Categorization (PCPC) score.ResultsOne hundred seventy-four patients were enrolled. Seven (4%) had a normal TCD examination, 57 (33%) met criteria for hyperaemia, 50 (29%) for low flow, 14 (8%) for microvascular obstruction, 11 (6%) for vasospasm, and 35 (20%) for isolated posterior circulation high flow. A lower cardiac index (CI) and higher systemic vascular resistive index (SVRI) were present in those with low flow than other groups (p < 0.003), though these values are normal for age (CI 4.4 [3.7,5] l/min/m2, SVRI 1552 [1197,1961] dscm-5m2). Other parameters were largely not significantly different between phenotypes. Overall, 118 children (68%) had a good neurological outcome. Twenty-three (13%) died, and 33 (19%) had neurological deficits. Outcomes were best for participants with hyperaemia and isolated posterior high flow (PCPC 1–2 in 77 and 89% respectively). Participants with low flow had the least likelihood of a good outcome (PCPC 1–2 in 42%) (p < 0.001). Cerebral autoregulation was significantly better in children with good outcome (transient hyperemic response ratio (THRR) 1.12 [1.04,1.2]) compared to a poor outcome (THRR 1.05 [0.98,1.02], p = 0.05).ConclusionsCommon pathophysiological mechanisms leading to TCD phenotypes in non-malarial illness are not causative in children with CM. Alternative mechanistic contributors, including mechanical factors of the cerebrovasculature and biologically active regulators of vascular tone should be explored.

Hemodynamic differences between women and men with elevated blood pressure in China: A non-invasive assessment of 45,082 adults using impedance cardiography.

Whether there are sex differences in hemodynamic profiles among people with elevated blood pressure is not well understood and could guide personalization of treatment. We described the clinical and hemodynamic characteristics of adults with elevated blood pressure in China using impedance cardiography. We included 45,082 individuals with elevated blood pressure (defined as systolic blood pressure of ≥130 mmHg or a diastolic blood pressure of ≥80 mmHg), of which 35.2% were women. Overall, women had a higher mean systolic blood pressure than men (139.0 [±15.7] mmHg vs 136.8 [±13.8] mmHg, P<0.001), but a lower mean diastolic blood pressure (82.6 [±9.0] mmHg vs 85.6 [±8.9] mmHg, P<0.001). After adjusting for age, region, and body mass index, women <50 years old had lower systemic vascular resistance index (beta-coefficient [β] -31.7; 95% CI: -51.2, -12.2) and higher cardiac index (β 0.07; 95% CI: 0.04, 0.09) than men of their same age group, whereas among those ≥50 years old women had higher systemic vascular resistance index (β 120.4; 95% CI: 102.4, 138.5) but lower cardiac index (β -0.15; 95% CI: -0.16, -0.13). Results were consistent with a propensity score matching sensitivity analysis, although the magnitude of the SVRI difference was lower and non-significant. However, there was substantial overlap between women and men in the distribution plots of these variables, with overlapping areas ranging from 78% to 88%. Our findings indicate that there are sex differences in hypertension phenotype, but that sex alone is insufficient to infer an individual's profile.

Echocardiographic Characteristics of Cardiogenic Shock Patients with and Without Cardiac Arrest.

Cardiac arrest (CA) is associated with worse outcomes in patients with cardiogenic shock (CS). To better understand the contribution of CA on CS, we evaluated transthoracic echocardiography (TTE) parameters in CS patients with and without CA. We retrospectively identified CS patients with a TTE performed near cardiac intensive care unit admission between 2007 to 2018. We compared TTE measurements of left ventricular (LV) and right ventricular (RV) function in patients with and without CA. The primary outcome was all-cause in-hospital mortality, as determined using multivariable logistic regression. We included 1085 patients, 35% of whom had CA. Median age was 70 years and 37% were females. CA patients had higher severity of illness, more invasive mechanical ventilation and greater vasopressor/inotrope use. In-hospital mortality was 31% and was higher in CA patients (45% vs. 23%, p <0.001). Although LV ejection fraction (LVEF) was similar (35% vs. 37%, p = 0.05), CA patients had lower cardiac index, mitral valve E wave peak velocity, E/A ratio and E/e' ratio. TTE variables that were associated with hospital mortality varied, among patients with CA, these included measures of RV pressure and function and among patients without CA, these included parameters reflecting LV systolic function. Doppler assessments of RV systolic dysfunction were the strongest TTE predictors of hospital mortality in CS patients with CA, unlike CS patients without CA in whom LV systolic function was more important. This emphasizes the importance of RV assessment for mortality risk stratification after CA.

Longitudinal Associations Between Fat-Derived Dietary Patterns and Early Markers of Cardiovascular Disease Risk in the UK Biobank Study.

BackgroundAlthough the impact of dietary fats on cardiovascular disease (CVD) risk is widely researched, longitudinal associations between dietary patterns (DPs) based on fat type and early markers of CVD risk remain unclear.Methods and ResultsUK Biobank participants (46.9% men, mean age 55 years) with data on early markers of CVD risk (n=12 706) were followed longitudinally (2014–2020; mean 8.4 years). Two DPs (DP1, DP2) were derived using reduced rank regression (response variables: monounsaturated fat, polyunsaturated fat, and saturated fat based on two 24‐hour dietary assessments. Multivariable logistic and linear regression were used to investigate associations between DPs and odds of elevated CVD risk (using the nonlaboratory Framingham Risk Score) and changes in early CVD markers, respectively. DP1 (characterized by higher nuts and seeds and lower fruit and legumes intake) was positively correlated with saturated fat, monounsaturated fat, and polyunsaturated fat; DP2 (characterized by higher butter and high‐fat cheese, lower nuts and seeds intake) was positively correlated with saturated fat and negatively with polyunsaturated fat and monounsaturated fat. DP2 was associated with slightly higher odds of elevated CVD risk (odds ratio, 1.04 [95% CI, 1.00–1.07]). DP1 was associated with higher diastolic blood pressure (β, 0.20 [95% CI, 0.01–0.37]) and lower cardiac index (β, −0.02 [95% CI, −0.04 to −0.01]); DP2 was associated with higher carotid intima medial thickness (β, 1.80 [95% CI, 0.01–3.59]) and lower left ventricular ejection fraction (β, −0.15 [95% CI, −0.24 to −0.07]) and cardiac index (β, −0.01 [95% CI, −0.02 to −0.01]).ConclusionsThis study suggests small but statistically significant associations between DPs based on fat type and some early markers of CVD risk. Further research is needed to confirm these associations.

QRS fragmentation and prolongation as predictors of exercise capacity in patients after Fontan palliation.

Patients with Fontan anatomy are at increased risk for exercise intolerance and early morbidity and mortality. QRS complex fragmentation (fQRS) and prolongation have been studied in multiple heart diseases, but their clinical importance is unknown in the Fontan population. A retrospective cross-sectional study was performed. ECGs were evaluated for QRS prolongation (>98 percentile for age) and fQRS (≥3 R-waves/notches in the R/S complex [more than two in RBBB] in ≥2 contiguous leads). The primary outcome measures were CPET performance. Total 90 patients (median age 18 years, 57% male, 59% RV dominant) were included; 13% had fQRS and 31% had prolonged QRS. Demographically, patients with fQRS or prolonged QRS were like those without. Peak VO2 (64% vs. 63%, p .45), VE/VCO2 slope (85% vs. 88%, p = .74), and O2 pulse (149% vs. 129%, p = .83) were similar in the fQRS group versus those without. Upon multi-variable regression, body mass index (β = -0.38, p < .01) and QRS duration (β = -0.29, p < .01) were independently associated with % predicted VO2; fQRS was not. Lower cardiac index (2.2 vs. 2.8 L/min/m2 , p = .03) and higher ventricular end-diastolic pressure (13 vs. 10 mmHg, p = .02) was seen with fQRS. QRS fragmentation is present in patients with Fontan physiology. fQRS showed no association with CPET performance but was related to invasive hemodynamic markers of ventricular performance. QRS duration may be a better predictor of exercise function following Fontan.

C-14 | Mechanical Thrombectomy in Intermediate-low-risk Pulmonary Embolism Patients: Acute and Long-term Outcomes from the FLASH Registry

C-14 | Mechanical Thrombectomy in Intermediate-low-risk Pulmonary Embolism Patients: Acute and Long-term Outcomes from the FLASH Registry

Candidacy For Transcatheter Edge-to-edge Mitral Valve Repair Despite Low Cardiac Index A Single Center Experience

<h3>Introduction</h3> Transcatheter edge to edge repair (TEER) of the mitral valve with the MitraClip system has been shown to improve outcomes in patients with moderate to severe mitral regurgitation (MR). There is a lack of outcome data regarding the impact of MitraClip in recipients who have low cardiac index (CI), defined as those with a CI < 2.0 L/min/m2. The aim of this study was to compare pre-procedural clinical variables and post-procedural outcomes in patients with low and normal CI pre-intervention who underwent TEER of the mitral valve. <h3>Methods</h3> A retrospective analysis was performed utilizing our institutional database of TEER patients which included 181 adults with 3+ or greater MR from 2014-2020. Patients without right heart catheterization (RHC) prior to TEER were excluded. Cardiac output was measured using the indirect Fick method. Analysis was performed with T-test and Fisher's exact test. <h3>Results</h3> 105 patients had a pre TEER RHC, of which 35 patients had low cardiac index (group 1) and 70 patients who had normal cardiac index (group 2). Group 1 had a higher incidence of diabetes mellitus although was similar to group 2 in incidence of prior myocardial infarction (Table 1). Left ventricular ejection fraction was not significantly different between the groups. Both pulmonary capillary wedge pressure and mean pulmonary artery pressures were significantly elevated in group 1 as compared to group 2. The two groups did not have statistically different ICU durations or length of stay (Table 2). Symptom burden difference from baseline as measured by the KCCQ 12 was similar at 30 days. The percentage of patients with moderate MR or better at 30 days was similar between groups. Death on index post procedural hospitalization and in follow up was not statistically different. <h3>Conclusion</h3> A cohort of patients with low cardiac index that underwent TEER of the mitral valve did not demonstrate worse short or intermediate-term outcomes when compared to those with a normal cardiac index pre-procedure. This study may suggest a role for mitral valve TEER in carefully selected patients with cardiogenic shock or on inotropic therapy, who are not optimal candidates for other advanced heart failure therapies. Additional prospective data is required to support these findings.