Low Output State Research Articles

Functional and imaging outcomes of the Fontan circulation following pregnancy

IntroductionThe Fontan circulation palliates single-ventricle congenital heart disease by separating the systemic and pulmonary circulations. An increasing number of women with a Fontan circulation are wishing to become pregnant, however the ability to increase cardiac output during pregnancy is limited in many due to the chronic low output state. We describe pregnancy outcomes in these women at a large tertiary centre, including functional and imaging outcomes. MethodsWe retrospectively investigated women with a Fontan circulation giving birth after 24 weeks' gestation between 1995 and 2023. Data collected included obstetric and neonatal complications, changes in cardiac volumes and ejection fraction (EF), and functional outcomes including change in NYHA class and exercise capacity pre- and post-pregnancy, compared to matched male controls. ResultsTwenty-six pregnancies occurred among 23 women. Almost half experienced obstetric complications, primarily bleeding, which was the commonest indication for emergency C-section. Worsening cardiac symptoms complicated 50 % of pregnancies, with 4 requiring hospital admission for decompensation. Arrhythmias were not uncommon. Mean VO2max declined post-pregnancy (p = 0.03), though not significantly compared to controls. Worsening of NYHA class was uncommon (15.4 %), suggesting that cardiovascular complications during pregnancy do not correlate with longer-term functional limitation. EF worsened post-pregnancy, declining significantly more so than in matched controls (p = 0.03), however there were no changes in cardiac volumes. ConclusionsPregnancy in women with a Fontan circulation is associated with high rates of obstetric complications and worsening cardiac symptoms. However, successful pregnancies are possible, with little evidence of medium-term functional impairment. This data informs pre-pregnancy counselling of Fontan women of child-bearing age.

Prognostic relevance of baseline right ventricular echocardiographic evaluation in patients undergoing valvular surgery with tricuspid intervention

Abstract Background Tricuspid valve (TV) intervention is frequently performed both as part of multivalvular surgery and as an isolated procedure. Tricuspid regurgitation (TR) significantly worsen right ventricular (RV) function, which is a prognostic determinant in many clinical scenarios. Purpose Our aim was to evaluate the relevance of baseline right ventricular (RV) baseline echocardiographic in the prognosis after tricuspid valve surgery (TVS). Methods Retrospective observational study of patients undergoing TVS between 2009 and 2022 in our tertiary centre. Baseline right chambers echocardiographic parameters were evaluated: RV diameters (basal, mid and longitudinal), TAPSE, fractional area change (FAC), Doppler tissue velocity of the tricuspid annulus (RVS´) and free wall- (FW-) and 4 chambers- (4C-) global longitudinal strain (GLS). Likewise, systolic pulmonary artery pressure (sPAP) and left ventricular ejection fraction (LVEF) were collected among other variables. Association of echocardiographic parameters with major clinical events at year was explored. Results Finally 273 consecutive patients (71 ± 10.5 years old, 66.7% female) that underwent valvular surgery with tricuspid intervention were included. Multivalvular procedure was performed in 81.3% (50.6% mitral and tricuspid, 25.6% mitral, aortic and tricuspid and 5.1% aortic and tricuspid) and EuroScore was 5 [3-9]. The most common TV lesion was TR (97.8%), functional in 84.2%. The main surgical technique was tricuspid annuloplasty with prosthetic ring (57.9%). Preoperative echocardiographic parameters are presented in Table. Baseline LVEF was 59 [53-65]%. The most frequent postoperative complication was low output (23.4%) and there was an overall mortality rate of 8.3% during the first year of follow-up. Postsurgical low output state was associated with vena contracta TR (0,78 vs 0,66 cm; p <0.001) and 4C-GLS ((-15.7 vs -17.3%; p= 0.03). None of the baseline echocardiographic variables was associated with early mortality. Conclusions Baseline RV echocardiographic parameters were associated with postoperative low output but not mortality. The relatively preserved RV dimensions and function in our series may explain these findings. Table. Baseline RV echocardiographic variablesTable

Comprehensive non-invasive haemodynamic assessment in acute decompensated heart failure-related cardiogenic shock: a step towards echodynamics.

Haemodynamic assessment can be determinant in phenotyping cardiogenic shock (CS) and guiding patient management. Aim of this study was to evaluate the correlation between echocardiographic and invasive assessment of haemodynamics in acute decompensated heart failure-related CS (ADHF-CS). All consecutive ADHF-CS patients (SCAI shock stage ≥B) undergoing right heart catheterization (RHC) between 2020 and 2022 were prospectively enrolled. Patients underwent echocardiography 30 min before RHC. The evaluated haemodynamic parameters and their echocardiographic estimates ('e') comprised cardiac index (CI), wedge pressure (WP), pulmonary artery pressures (PAP), cardiac power output (CPO) and pulmonary artery pulsatility index (PAPi). Hundred and one ADHF-CS patients (56 ± 11 years, 64% SCAI shock stage C, left ventricular ejection fraction 29 ± 5%) were included. Good correlation was found for CI, systolic PAP, RAP, and CPO (Pearson r > 0.8 for all), moderate correlation for ePAPi (r = 0.67) and PVR (r = 0.51), while estimation of WP was weak. The sensitivity and specificity of eCI to identify low output state (CI ≤2.2 L/min/m2) were 0.97 and 0.73, respectively, those of eWP for elevated filling pressures (WP >15 mmHg) were 0.84 and 0.55, those of ePAPs for PAPs ≥35 mmHg were 0.87 and 0.63, those of eCPO for CPO <0.6 W were 0.76 and 0.85, those of ePAPi for PAPi <1.85 were 0.89 and 0.92. Echocardiographic phenotyping of CS showed a good agreement with invasive classification (K value 0.457, P < 0.001). Echocardiographic estimation of haemodynamics and subsequent phenotypization of CS is feasible with good agreement with invasive evaluation.

Multi-Task neural network model considering low power output risk for short-term photovoltaic forecasting

As the proportion of installed photovoltaic power generation continues to increase, low output under the influence of large-scale weather systems has an increasingly significant influence on the power grid. There is an urgent need to improve photovoltaic power generation forecasting accuracy and reduce the risk of insufficient output in forecast results. To this end, a multi-task neural network model considering low power output risk (LPOMTN) for short-term photovoltaic forecasting is proposed. First, a numerical weather forecast encoder based on multi-scale CNN-Attention is established, which can extract multi-time scale photovoltaic output characteristics. Then a low-output day prediction module based on parallel CNN decoding and a photovoltaic low-output process prediction module based on the clear-sky model and LSTM were established. The latter uses the prediction results of the former as input, and the two modules perform training modeling in a multi-task learning manner to strengthen the model’s sensitivity to low-output states and improve the accuracy of low-output process predictions. The calculation example results show that LPOMTN has higher average forecasting accuracy for power output processes compared to methods such as XGBoost.

Symmetrical peripheral gangrene: A rare case with unpredictable presentation and tragic outcome

Symmetrical peripheral gangrene (SPG) is a rare condition characterized by acute ischemic damage in multiple extremities without any obstruction or vasculitis in the supplying vessels. It commonly affects the toes, hands, scrotum, and earlobes, increasing the risk of limb amputation and significantly impacting the patient’s quality of life. The underlying vascular injury mechanism is disseminated intravascular coagulation, and SPG can manifest unpredictably in conditions associated with septic shock, low output states, vasospastic conditions, myeloproliferative disorders, or hyper viscosity syndrome. In this case study, a 19-year-old woman presented with bluish-black blisters on her feet and legs, accompanied by pain. The blisters gradually increased in size and burst, resulting in a watery discharge tinged with blood. Despite various investigations and treatments involving multiple departments, the patient ultimately succumbed to septic shock and passed away on June 13, 2023, as confirmed by a house officer and a senior resident.

Is There A Structural Basis For Vasovagal Syncope? Cardiac Functions In Patients With Vasovagal Syncope

Aim: The pathophysiology of vasovagal syncope (VVS) is not completely understood. Some echocardiographic parameters have been defined to contribute to its pathophysiology. However. whether right atrial (RA) and right ventricular (RV) functions have any impact on development of VVS is not well known. In this study we aimed to evaluate the baseline echocardiographic parameters in patients with VVS with special focus on right ventricle and atrium functions.&#x0D; Material and methods: We evaluated the medical records of 42 patients with VVS and 41 age and sex matched healthy subjects. Patients with at least two syncopal attack and positive head-up-tilt test were enrolled in the study. All medical records of echocardiography and head-up-tilt test were obtained.&#x0D; Results: Among left ventricular function parameters, there were no significant difference between the groups. Right ventricle myocardial performance index (p= 0.003) and maximal pulmoner systolic flow velocity (PVmax) (p=0.03) were significantly differ between the groups. RAA was significantly larger (p=0.04) and the ratio of tricuspid filling velocities (E/A), (p=0.01) was significantly lower in VVS group. &#x0D; Conclusions: The findings of the present study indicate a subtle right atrial diastolic dysfunction in patients with VVS. Decreased right atrial contribution to RV filling may cause a lower RV stroke volüme which explains the lower PVmax values in our VVS group. All together, those findings may serve for a tendency to low output states and hypotension as in VVS.

Periprocedural acute hemodynamic decompensation associated with substrate-based ablation of ventricular tachycardia in patients with structural heart disease - rare and nonpredictable event

Abstract Funding Acknowledgements Type of funding sources: None. Background Radiofrequency (RF) catheter ablation is an established treatment method in patients with structural heart disease (SHD) and recurrent ventricular tachycardia (VT). Due to underlying SHD, concomitant heart failure and a high burden of comorbidities, these patients are at considerable risk of periprocedural complications including acute hemodynamic decompensation (AHD) with a reported rate of up to 11%. The PAINESD score [sum of 5, 3, 6, 6, 3, 5, and 3 points for chronic obstructive pulmonary disease (COPD), age &amp;gt;60 years, ischemic cardiomyopathy (ICM), NYHA Class &amp;gt;2, LV ejection fraction (LVEF) &amp;lt;25%, electrical storm (ES), and diabetes mellitus (DM), respectively] was proposed to predict the risk of AHD, and identify the patients who may benefit from pre-emptive use of percutaneous left ventricular assist device (pVAD). Purpose The single-centre, retrospective study investigated the incidence of AHD in large-volume, tertiary referral EP centre and the predictive power of the PAINESD score. Methods We included patients who had their first ablation for SHD-related VT between August 2006 and December 2020. The procedure was performed under conscious sedation except for patients who were on mechanical ventilation because of hemodynamical or electrical instability before the ablation. Substrate mapping/ablation was performed primarily during spontaneous rhythm or right-ventricular pacing. Induced VTs were terminated by overdrive pacing or cardioverted. Activation and entrainment mapping were used rarely – only in well-tolerated VTs. The goal of ablation was to abolish all inducible VTs. A purposely established institutional registry for complications of invasive procedures was used to collect all periprocedural complications that were subsequently adjudicated using the source medical records. AHD triggered by ablation procedure was defined as intraprocedural or early post-procedural (&amp;lt;12 h) development of acute pulmonary oedema or refractory hypotension, requiring urgent intervention including (but not limited to) inotropic agents and/or artificial ventilation and/or pVAD implant. Results The study cohort consisted of 1143 patients (age: 63±13 years, males: 87%, ICM: 67%, ES: 25%, NYHA Class: 2.1±1.0, LVEF: 34±13%, DM: 32%, COPD: 12%). Their PAINESD score was 11.4±6.6 (median: 12, interquartile range: 6–17). The ablation procedure (total duration 187±78 min, RF time: 23±15 min) was complicated by AHD in 13/1143 = 1.1% patients and these adverse events were not predicted by PAINESD score (Figure). Conclusions We observed a substantially lower rate (1.1%) of AHD than previously reported (up to 11%). These events did not accumulate in patients with upper-tertile PAINESD score in whom the highest AHD risk was reported (up to 24%). This observation may be explained by careful substrate-based ablation under conscious sedation that prevents prolonged low-output state related to repeated VT induction and mapping in general anaesthesia.

PO-05-039 PERIPROCEDURAL ACUTE HEMODYNAMIC DECOMPENSATION ASSOCIATED WITH SUBSTRATE-BASED ABLATION OF VENTRICULAR TACHYCARDIA IN PATIENTS WITH STRUCTURAL HEART DISEASE – RARE AND NONPREDICTABLE EVENT

Patients with structural heart disease (SHD) and recurrent ventricular tachycardia (VT) are at considerable risk of periprocedural complications of radiofrequency (RF) catheter ablation including acute hemodynamic decompensation (AHD). The PAINESD score [sum of 5, 3, 6, 6, 3, 5, and 3 points for chronic obstructive pulmonary disease (COPD), age >60 years, ischemic cardiomyopathy (ICM), NYHA Class >2, LV ejection fraction (LVEF) <25%, electrical storm (ES), and diabetes mellitus (DM), respectively] was proposed to predict the risk of AHD, and identify the patients who may benefit from pre-emptive use of percutaneous left ventricular assist device (pVAD). The single-center, retrospective study investigated the incidence of AHD in large-volume, tertiary referral EP center and the predictive power of the PAINESD score. We included patients who had their first ablation for SHD-related VT between August 2006 and December 2020. The procedure was performed under conscious sedation except for patients who were on mechanical ventilation because of hemodynamical or electrical instability before the ablation. Substrate mapping/ablation was performed primarily during spontaneous rhythm or right-ventricular pacing. Activation and entrainment mapping were used rarely, only in well-tolerated VTs. The goal of ablation was to abolish all inducible VTs. AHD triggered by ablation procedure was defined as intra- or early post-procedural (<12 h) development of acute pulmonary oedema or refractory hypotension, requiring urgent intervention like inotropic agents and/or artificial ventilation and/or pVAD implant. The study cohort consisted of 1143 patients (age: 63±13 years, males: 87%, ICM: 67%, ES: 25%, NYHA Class: 2.1±1.0, LVEF: 34±13%, DM: 32%, COPD: 12%). Their PAINESD score was 11.4 ± 6.6 (median: 12, interquartile range: 6–17). The ablation procedure (total duration 187±78 min, RF time: 23±15 min) was complicated by AHD in 13/1143 = 1.1% patients and these adverse events were not predicted by PAINESD score (Figure). We observed a substantially lower rate (1.1%) of AHD than previously reported (up to 11%). These events did not accumulate in patients with upper-tercile PAINESD score in whom the highest AHD risk was reported (up to 24%). This observation may be explained by careful substrate-based ablation under conscious sedation that prevents prolonged low-output state related to repeated VT induction and mapping in general anesthesia.

Abstract 15767: Association of Invasive Hemodynamic Evaluation With 3- and 6-Months Survival in Patients Treated for Cardiogenic Shock

Introduction: Cardiogenic shock (CS) is a complex spectrum of low output states which can occur in the setting of Acute Coronary Syndrome (ACS) or Acute Decompensated Heart Failure (ADHF). Its management is guided by frequent hemodynamic assessment and prompt treatment without which the mortality rate ranges from 27% to 51%. Contemporary data suggests that the use of right heart catheterization (RHC) improves in-hospital mortality and survival of patients. Our study aims to compare the difference in survival at 3 and 6 months based on RHC. Methods: A single center retrospective analysis was performed on patients admitted with CS secondary to ACS or ADHF from 7/01/2018 till 6/30/2020 at the University of Iowa. Patients were identified by the International Classification of Diseases 10th Revision Clinical Modification (ICD-10 CM) codes and were risk-stratified using the Society of Cardiovascular Angiography &amp; Interventions (SCAI) Shock Classification. 3 and 6 months survival analysis was done with the help of Log Rank test and Kaplan Meier survival curves. RHC was also evaluated as a predictor by Cox Regression analysis among all SCAI groups. Results: 647 patients admitted with CS, 249 patients underwent RHC during their admission. 51 had ACS and 198 had isolated ADHF as the precipitating cause of CS in patients who underwent invasive assessment. Evaluation by RHC showed improved 3 months survival in patients with SCAI 2 (p&lt;0.01), SCAI3 (p=0.01) and SCAI 5 CS (&lt;0.01). The association was significant at 6 months in SCAI 2 (p&lt;0.01), and SCAI 5 CS (&lt;0.01). RHC was a significant predictor of improved survival in SCAI 2 (HR 0.23; p=0.03; 95% CI 0.06 - 0.9), SCAI 3 (HR 0.26; p=0.01; 95% CI 0.08 - 0.8) and SCAI 5 CS (HR 0.20; p=0.04; 95% CI 0.04 - 0.97) at 3 months and SCAI 5 CS at 6 months(HR 0.20; p=0.04; 95% CI 0.46 - 0.9). Conclusion: Our study indicates that invasive hemodynamic evaluation during the treatment of CS favors survival in specially in the SCAI 2, SCAI 3 and SCAI 5 classification groups. In addition, RHC predicts better survival in these patients over 3 and 6 months. We assume that patients in SCAI 4 group may also gain same benefit however, due to limited number of patients our analysis couldn’t reach statistical significance in the SCAI 4 category.

Interpretation of Hemodynamic Catheterization Data by Years of Experience: An International Survey of Cardiologists

<h3>Purpose</h3> Right heart catheterization (RHC) is a core skill of cardiologists, however, data interpretation may be influenced by prior clinician experience. We sought to assess parameters felt to offer prognostic information during RHC between early- and late-career cardiologists. <h3>Methods</h3> A survey assessing the utilization and interpretation of RHC data was distributed to two large international professional societies. Early career (EC and late career (LC) groups were demarcated at 10 years of practice. We sought to assess differences in practice patterns and interpretation of RHC data for prognosis and management. <h3>Results</h3> A total of 261 responses were received, with similar numbers of EC (142, 54%) and LC (119, 46%). EC cardiologists were more likely than LC to be heart failure specialists (64% vs 39%, p<.001) with similar practice settings. Less EC than LC respondents considered low cardiac index to be the most important factor for prognosis (43% vs 53%, p=.005), whereas EC more often considered elevated filling pressures as most prognostic (Table). More EC than LC utilize cardiac power output for prognosis (67% vs 50%, p<.001). With regards to the medical management of a low output state patients with elevated systemic resistance, 59% of EC respondents favored nitroprusside compared to 44% of LC respondents who favored milrinone (p<.001). EC and LC both agreed that inotrope therapy should be started on the floor/ICU (50% vs 45%, p=.745). <h3>Conclusion</h3> Our survey data demonstrates a difference between EC and LC cardiologists in both the utilization of RHC parameters for prognosis as well as preferred initial approach to managing patients with low cardiac output. Further research comparing long term prognostic outcomes of RHC parameters may provide insight into practice variation and should be further explored.

Four Limb Gangrene - A Rare Presentation

We report a case of a 73-year-old male, who presented with acute gangrene of the left thumb which then progressed to symmetrical peripheral gangrene of digits of all four limbs, with no comorbid diseases. On investigation, there was high D-dimer, normal lipid profile, and two-dimensional Echo. Computed tomography and magnetic resonance angiogram of all limbs revealed atherosclerotic changes. The patient underwent disarticulation of digits under the wrist block. Symmetrical peripheral gangrene, seen in a wide variety of medical conditions presents as symmetrical gangrene of two or more extremities without large vessel obstruction or vasculitis. The fingers and toes (rarely nose, ear lobes, or genitalia) are affected. It may manifest unpredictably in conditions associated with sepsis, diabetes mellitus, low-output states, vasospastic conditions, myeloproliferative disorders, or hyperviscosity syndrome. It carries a high mortality rate with a very high frequency of multiple limb amputations in survivors.

Hyperkalemia: Major but still understudied complication among heart transplant recipients.

Hyperkalemia is a recognized and potentially life-threatening complication of heart transplantation. In the complex biosystem created by transplantation, recipients are susceptible to multiple mechanisms for hyperkalemia which are discussed in detail in this manuscript. Hyperkalemia in heart transplantation could occur pre-transplant, during the transplant period, or post-transplant. Pre-transplant causes of hyperkalemia include hypothermia, donor heart preservation solutions, conventional cardioplegia, normokalemic cardioplegia, continuous warm reperfusion technique, and ex-vivo heart perfusion. Intra-transplant causes of hyperkalemia include anesthetic medications used during the procedure, heparinization, blood transfusions, and a low output state. Finally, post-transplant causes of hyperkalemia include hemostasis and drug-induced hyperkalemia. Hyperkalemia has been studied in kidney and liver transplant recipients, but there is limited data on the incidence, causes, management, and prevention in heart transplant recipients. Hyperkalemia is associated with an increased risk of hospital mortality and readmission in these patients. This review describes the current literature pertaining to the causes, pathophysiology, and treatment of hyperkalemia in patients undergoing heart transplantation and focuses primarily on post-heart transplantation.

Bolus-free low-dose levosimendan infusion for acute decompensated hypoperfused heart failure

Abstract Funding Acknowledgements Type of funding sources: None. Aims and Methods Aim of this study was to assess the feasibility of a bolus-free, low-dose levosimendan infusion for acute decompensated heart failure (ADHF) with hypoperfusion. All consecutive patients who received levosimendan without intravenous bolus at our Department for ADHF in the last 6 months were included in this is a single-center retrospective study. To avoid abrupt drop in blood pressure, all patients started infusion at 0.01 mcg/kg/min, and gradual titration was achieved, up to 0.1 mcg/kg/min. Continuous variables are reported as medians (IQR), categorical as proportions. Paired measures were compared with the Wilcoxon signed-rank test. p-value was set at 5%. Analyses were performed using RStudio v1.3. Results We included 26 patients [males 84.6%; age 72 (59-76) years]. Patients had severe LV dysfunction [LVEF of 20 (20-25)%] and moderate/severe RV dysfunction in 46.2%. Most patients were admitted for cardiogenic shock (26.9%) or low-output state (61.5%); baseline serum lactate was 1.6 (1.2-3.2) mmol/L. Etiology was ACS in 26.9% patients, worsening HF in 53.8%, and valvular disease in 26.9%. All patients required inotropes: 73.1% required adrenaline [max dose 0.10 (0.05-0.15) mcg/kg/min]; 50.0% required noradrenaline [max dose 0.10 (0.05-0.18) mcg/kg/min]; 26.9% received levosimendan alone [max dose 0.05 (0.03-0.10) mcg/kg/min]. Levosimendan was used in combination with adrenaline in 69.2%, after 3 (0-4) days of adrenaline initiation. Duration of levosimendan infusion was 3 (1-4) days. MCS was pursued in 69.2% [57.7% IABP, 15.4% Impella CP, and 3.8% VA-ECMO]. Oro-tracheal intubation was required in 50.0%, CVVHDF was required in 11.5% patients. No patient required levosimendan interruption for hypotension/arrhythmia. In-hospital mortality was 7.7%. One patients underwent successful LVAD implantation, and one patient was referred for HTx. Invasive hemodynamic data, before and during levosimendan, was available for 7 patients. Initiation of levosimendan led to a non-significant drop in SVR [14.8 (13.3-16.9) vs 19.5 (14.6-25.4) WU; p = 0.093], but SBP was unchanged (p = 0.470). Left ventricular systolic performance was improved: CI [2.6 (2.4-2.7) vs 2.2 (2.0-2.3) Lt/min/m²; p = 0.016]; CPO [0.9 (0.8-1.0) vs 0.8 (0.8-0.9) W; p = 0.031]. Mean PAP (p = 0.297), and PCWP (p = 0.149) remained unchanged. Notably, no significant adjustments in diuretic (p = 0.422) or adrenaline (p = 0.999) doses, IABP counterpulsation ratio (p = 0.999), or Impella flow (p = 0.999) were recorded between these longitudinal assessments. As a result of improved myocardial function, LVEF increased from admission to discharge [20 (20-25) vs 25 (20-32)%; p = 0.024]. Discussion This preliminary study reports on a bolus-free, low-intensity levosimendan regimen for ADHF with hypoperfusion. Levosimendan improved indexes of myocardial performance. In this cohort, levosimendan often required concomitant inopressor and was started at a very low dose to avoid abrupt drop in blood pressure. Abstract Figure 1

Thermodilution Cardiac Index Has Poor Agreement with That Measured by the Direct Fick Method in Low-Output States

<h3>Purpose</h3> The thermodilution (Td) method is routinely used for measurement of cardiac output although its accuracy in low-output states remains uncertain. Criteria for designating heart transplant listing status in the contemporary allocation system is incumbent on meeting strict cardiac index (CI) cutoffs. We aimed to assess the agreement between Td and direct Fick (dFick) CI in patients with low CI. <h3>Methods</h3> In this retrospective analysis of 535 patients who underwent right heart catheterization with dFick CI measurement as part of clinically indicated hemodynamic evaluation using the gold-standard Douglas bag technique, 253 patients had both Td/dFick CI measurements. Three saline injections were typically used and averaged in Td CI measurements. We included 118 patients who specifically had a CI of </= 2.2 L/min/m² by dFick method. Agreement between Td and dFick method was assessed by median absolute percentage difference, Spearman's rank correlation, and Bland-Altman Method. <h3>Results</h3> Among the 118 patients included (Mean [SD] age 60 [12.2] years, 42.3% female), Median (interquartile range, IQR) overall dFick and Td CI values differed significantly (1.86 [1.65, 2.1] and 2.03 [1.78, 2.31] L/min/m², respectively; P<0.001). The two measurements weakly correlated (r_s=0.31, P<0.001), with a systematic error introduced by Td CI expressed a mean difference of 0.21 (-0.61, 1.03) L/min/m² (Figure). Median (IQR) absolute percentage difference between Td and dFick was 16.9 (7.9, 27.9)%. Td and dFick CI's differed by >25% in 33.1% of patients. <h3>Conclusion</h3> The agreement of Td with the gold-standard dFick CI measurements in patients with low CI was suboptimal. These data are important consider in in clinical scenarios such as heart transplant listing status where strict hemodynamic cutoffs guide urgency.

Temporary mechanical circulatory support prevents the occurrence of a low-output state in high-risk coronary artery bypass grafting: A case series.

Coronary artery bypass grafting (CABG) is a durable treatment for coronary artery disease. Left ventricular dysfunction (LVD) (a division of cardiothoracic surgery) (ejection fraction < 35%) significantly elevates perioperative risk for patients pursuing surgical revascularization. Periprocedural support with temporary mechanical circulatory support (tMCS) has shown benefit in this patient population. Four patients with ischemic cardiomyopathy and LVD underwent CABG at our institution between 2017 and 2018. Each patient received perioperative ventricular support using a microaxial tMCS device (Impella 5.0®). The occurrence of a postoperative low-output state (LOS) was assessed for as well as postoperative morbidity and mortality, device-specific complications, and tMCS support duration. All patients survived to device explant without device-related complications. Two patients required reoperation for nondevice-related bleeding. All patients were without an LOS at 24 hpostoperatively with cardiac indices of 2.9-3.6 L/min/m2 , normalized serum lactate, and vasoactive-inotrope scores of 0-12.0. There was a notably high incidence of acute renal failure (50%), which was observed in patients with preoperative cardiogenic shock. One patient died 10 days after the device explant. Of the three patients that survived to discharge, two were alive at the most recent follow-up. Postoperative device support varied widely (0-500 h). Perioperative tMCS may be a viable strategy for preventing postoperative LOS in high-risk CABG patients with a low complication rate and acceptable morbidity. The application of microaxial tMCS devices in CABG is an area that warrants further investigation to delineate its impact on perioperative outcomes and potentially expand the indications for such devices.

Mechanical circulatory support in the management of life-threatening arrhythmia

Life-threatening refractory unstable ventricular arrhythmias in presence of advanced heart failure (HF) may determine haemodynamic impairment. Haemodynamic mechanical support (HMS) in this setting has a relevant role to restore end-organ perfusion. Catheter ablation (CA) of ventricular tachycardia (VT) is effective at achieving rhythm stabilization, allowing patient's weaning from HMS, or bridging to permanent HF treatments. Acute heart decompensation during CA at anaesthesia induction in presence of advanced heart disease, in selected cases requires a preemptive HMS to prevent periprocedure adverse outcomes. Substrate ablation during sinus rhythm (SR) might be an effective strategy of ablation in presence of unstable VTs; however, in a minority of patients, it might have some limitations and might be unfeasible in some settings, including the case of the mechanical induction of several unstable VTs and the absence of ablation targets. In case of the persistent induction of unstable VTs after a previous failure of a substrate-based ablation in SR, a feasible alternative strategy of ablation might be VT activation/entrainment mapping supported by HMS. Multiple devices are available for HMS in the low-output states related to electrical storm and during CA of VT. The choice of the device is not standardized and it is based on the centres' expertise. The aim of this article is to provide an up-to-date review on HMS for the management of life-threatening arrhythmias, in the context of catheter ablation and discussing our approach to manage critical VT patients.

Pericardial Left Ventricular Assist Device (PALVAD) development via large animal and cadaveric models

Abstract Background Cardiogenic shock complicates around 8% of acute myocardial infarctions with a significant short term mortality of 35–50%. Traditional mechanical circulatory support can improve cardiac output (CO) however they have significant adverse event profiles related to their position within the circulation, including but not limited to infection, stroke and embolism. PALVAD is an extra circulatory left ventricular assist device, designed to be implanted percutaneously., It provides cardiac support whilst sitting outside the circulatory system in the space between the pericardium and left ventricular (LV) free wall. The dual balloon system connects to an external pumping system via a drive line. The actuator balloon augments CO through ECG gated LV systolic compression and the positioning balloon sits against the pericardial surface dissipating this force across a large surface. Purpose Assess device efficacy in a low CO state in a non-recovery porcine model. Understand device interactions with the left ventricle and pericardium in a cadaveric model. Methodology Non-recovery porcine model experiments were conducted in three 40k-50g pigs at a large animal catheterisation facility. An Esmolol infusion was titrated to create a low output state. A Millar catheter was placed in the LV for simultaneous pressure and volume measurements and a Transonic flow probe was placed around the internal carotid for flow measurements. The device was inserted percutaneously and operated for a total of 4.7 hrs. For cadaveric experiments the device was inserted into a Thiel embalmed saline perfused cadaver following which detailed CT and MRI imaging was undertaken. Results When target reduction in cardiac output was met PALVAD increased systolic pressure by 34%, stroke volume by 54%, CO by 53% and flow by 53%. There was no macroscopic evidence of epicardial or pericardial damage. Cadaveric imaging further informed optimal positioning of the device in relation to the LV free wall. Conclusions PALVAD performance during low CO state in non-recovery porcine experiments is promising. Further recovery experiments, including histology assessment, are planed to evaluate safety and efficacy with longer term use to guide optimisation towards the eventual aim of a first-in-man trial. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): British Heart Foundation Translational Research Grant

Arterial elastance modulation by intra-aortic balloon counterpulsation in patients with acute decompensated heart failure and low-output state

: Heart failure is characterized by ventriculo-arterial decoupling which decreases myocardial efficiency and is exacerbated by tachycardia and by increased total peripheral resistance that worsen static arterial elastance; unlike aortic pressure by itself, this measure is independent of the function of the ventricle. Therefore, it is an index which describes arterial properties.We investigated the effect of intra-aortic balloon counterpulsation on arterial elastance, a variable which can be obtained non-invasively, in patients with acute decompensated heart failure deteriorated in low output state.17 out of 24 patients admitted for acute decompensated heart failure underwent intra-aortic balloon counterpulsation insertion for hemodynamic worsening condition despite medical therapy.Hemodynamic variables were obtained with a pulmonary artery catheter; arterial elastance and cardiac power index were calculated.Intra-aortic balloon counterpulsation was associated with a decrease of the arterial elastance median value (1.64 vs. 1.28 mmHg/ml- P = 0.04) along withan increase in cardiac power index (0.29, vs 0.40, W/m; P = 0.02 ). Mixed venous saturation (53 mmHg, vs 70 mmHg; P = 0.007) and pulmonary mean arterial pressure (41 vs 30 mmHg; P = 0.005) significantly changed after intraortic balloon counterpulsation insertion. No significant changes in heart rate (median 80, vs 80, bpm; P = 0.809) were observed.Intraortic balloon counterpulsation may effectively improve arterial elastance on top of a conservative use of inotropes/vasopressors, with a significant improvement in hemodynamics.

Home Therapies in Advanced Heart Failure: Inotropes and Diuretics.

Heart failure (HF) is a significant cause of morbidity, mortality, and decreased quality of life (QOL). Symptoms, including reduced activity tolerance, fatigue, palpitations, and dyspnea, result from volume overload or low output states. Herein, we review the best available literature supporting diuretic and inotropic therapies in advanced HF and how these improve QOL. While diuretics and inotropes reduce symptoms and hospitalizations in advanced HF, there is an increased risk of harms with both modalities. While diuretic complications include electrolyte and renal function abnormalities, adverse event data with inotropes is more complex and includes possible arrhythmias and death. Further, inotrope utilization is complicated by required intravenous access, infusion costs, and limited outpatient support. Ambulatory use of diuretics and inotropes may improve patients' QOL through symptom management and reduced hospitalizations. However, risks and limitations of both modalities must be considered as treatment decisions are made.

52-Year-Old Woman With Fever, Diaphoresis, and Abdominal Pain

52-Year-Old Woman With Fever, Diaphoresis, and Abdominal Pain