Lower Pulmonary Artery Pulsatility Index Research Articles

Prognostic Importance of Pulmonary Artery Pulsatility Index and Right Ventricular Stroke Work Index in End-Stage Heart Failure Patients

Background: Right ventricular (RV) failure is an important cause of morbidity and mortality in patients with left ventricular (LV) end-stage heart failure (ESHF). Pulmonary artery pulsatility index (PAPi) and RV stroke work index (RVSWI) are invasive parameters related to RV function. This study aimed to investigate the prognostic impact of PAPi and RVSWI in these patients. Methods and Results: In this study, 416 patients with ESHF were included. The adverse cardiac event (ACE) was defined as LV assist device implantation, urgent heart transplantation, or cardiac mortality. There were 218 ACE cases and 198 non-ACE cases over a median follow-up of 503.50 days. Patients with ACE had lower PAPi and similar RVSWI compared to those without ACE (3.1 ± 1.9 vs. 3.7 ± 2.3, p = 0.003 and 7.3 ± 4.9 vs. 6.9 ± 4.4, p = 0.422, respectively). According to the results of multivariate analysis, while PAPi (from 2 to 5.65) was associated with ACE, RVSWI (from 3.62 to 9.75) was not associated with ACE (hazard ratio [HR]: 0.75, 95% confidence interval [CI] [0.55–0.95], p = 0.031; HR: 0.79, 95% CI: [0.58–1.09], p = 0.081, respectively). Survival analysis revealed that PAPi ≤2.56 was associated with a higher ACE risk compared to PAPi >2.56 (HR: 1.46, 95% CI: 1.11–1.92, p = 0.006). PAPi ≤2.56 could predict ACE with 56.7% sensitivity and 51.3% specificity at 1 year. Furthermore, the association between RVSWI and ACE was nonlinear (J-curve pattern). Low and high values seem to be associated with higher ACE risk compared to intermediate values. Conclusion: The low PAPi was an independent risk for ACE and it had a linear association with it. However, RVSWI seems to be have a nonlinear association with ACE (J-curve pattern).

Pretransplant Right Ventricular Dysfunction Is Associated With Increased Mortality After Heart Transplantation: A Hard Inheritance to Overcome

BackgroundRight ventricular dysfunction (RVD) is a major issue in patients with advanced heart failure because it precludes the implantation of left ventricular assist device, usually leaving heart transplantation (HTx) as the only available treatment option. The pulmonary artery pulsatility index (PAPi) is a hemodynamic parameter integrating information of right ventricular function and of pulmonary circulation. Our aim is to evaluate the association of preoperative RVD, hemodynamically defined as a low PAPi, with post-HTx survival. Methods and ResultsConsecutive adult HTx recipient at 2 Italian transplant centers between 2000 and 2018 with available data on pre-HTx right heart catheterization were included retrospectively. RVD was defined as a value of PAPi lower than the 25th percentile of the study population. The association of RVD with the 1-year post-HTx mortality and other secondary end points were evaluated. Multivariate logistic regression was used to adjust for clinical and hemodynamic variables. Analyses stratified by pulmonary vascular resistance (PVR) status (≥3 Woods units vs <3 Woods units) were also performed. Among 657 HTx recipients (female 31.1%, age 53 ± 11 years), patients with pre-HTx RVD (PAPi of <1.68) had significantly lower 1-year survival rates (77.8% vs 87.1%, P = .005), also after adjusting for estimated glomerular filtration rate, total bilirubin, PVR, serum sodium, inotropes, and mechanical circulatory support at HTx (hazard ratio 2.0, 95% confidence interval, 1.3–3.1). RVD was also associated with post-HTx renal replacement therapy (hazard ratio 2.0, 95% confidence interval 1.05–3.30) and primary graft dysfunction (hazard ratio 1.7, , 95% confidence interval 1.02–3.30). When stratifying patients by estimated PVR status, RVD was associated with worse 1-year survival among patients with normal PVR (76.9% vs 88.3%, P = .003), but not in those with increased PVR (78.6% vs 83.2%, P = .49). ConclusionsPreoperative RVD, evaluated through PAPi, is associated with mortality and morbidity after HTx, providing incremental prognostic value over traditional clinical and hemodynamic parameters.

Abstract P505: Rv Sarcomeres From Lv-hfref Patients With Low Papi Have Abnormal Rv Thick Filament Structure

Patients with left heart failure and reduced ejection fraction (HFrEF) have variable RV failure that, if present, drastically worsens outcomes. In a cohort of 21 HFrEF patients from two hospital sites, we have previously shown (Aslam et al, Eur J HF; 2020: volume 23, pages 339-341) that like global function, RV myocyte maximum calcium-activated myocyte tension (T max ) is quite variable (COV 27%). To determine if a relationship between RV myocyte function and indices of RV chamber function exists, we trained a random forest classifier based on 41 clinical variables, including hemodynamic, laboratory, and echocardiographic data, and queried the importance of each. This revealed that the most predictive model for reduced T max was based on the pulmonary artery pulsatility index (PAPi), an established clinical index of RV failure. To gain insight into potential mechanisms for depressed T max in HFrEF patients with a low PAPi, we obtained small angle x-ray diffraction patterns in 5 HFrEF patients with depressed PAPi and T max and compared this to 5 non-failing (NF) controls. The equatorial intensity ratio I(1,1)/I(1,0) was reduced in low T max RV muscle fibers vs. controls (0.250.06 vs. 0.180.02, P&lt;0.0001), suggesting myosin heads are more associated with the thick filament backbone. In meridional reflections, we find a significant decrease in M3 band spacing (14.340.03 nm in NF vs. 14.300.01 nm in HFrEF; P=0.0013) suggesting more myosin heads are in the “OFF” configuration. The latter may underly tension reduction in RV myocytes from failing RV HFrEF patients. Ongoing studies will examine these structural changes in HFrEF patients with a broader range of PAPi and T max to test if this association applies. These findings focus attention on thick filament structural and configuration abnormalities as potential culprits underlying RV disease in HFrEF. Further studies using novel sarcomere enhancers will test if these changes can be remedied, and if so, in which patients.

Does pulmonary artery pulsatility index predict mortality in pulmonary arterial hypertension?

AimsPulmonary artery pulsatility index (PAPi), defined as [(pulmonary artery systolic pressure − diastolic pulmonary artery pressure)/mean right atrial pressure], is a novel haemodynamic index that predicts right ventricular failure after myocardial infarction and left ventricular assist device implantation. We analysed if a low PAPi is associated with death in our 14 ‐ ​year pulmonary arterial hypertension (PAH) registry.MethodsConsecutive patients with newly diagnosed PAH and complete haemodynamic data were prospectively enrolled into our standing registry between January 2003 and December 2016. PAPi was calculated from baseline invasive right heart catheterization data. A prognostic cut‐off value was determined with a decision tree. Baseline characteristics of ‘high’ and ‘low’ PAPi groups based on this cut‐off were compared, as well as odds of death and time‐to‐death.ResultsOne hundred and two patients were included. Mean age was 53 years, and 77% were women. Our multi‐ethnic cohort was 64% Chinese, 23% Malay, and 10% Indian. The aetiologies were idiopathic (33%), connective tissue disease (31%), congenital heart disease (24%), and others (12%). The low PAPi group (<5.3) had a greater age (56 years vs. 49 years), lower pulmonary artery systolic pressure (71 mmHg vs. 85 mmHg), and higher mean right atrial pressure (14 mmHg vs. 6 mmHg). Mortality risk was higher in the low PAPi group (adjusted odds ratio: 2.98 and adjusted hazard ratio: 2.23). Mean right atrial pressure was the strongest predictor (hazard ratio 1.114, P = 0.009) when components of PAPi were analysed.ConclusionsPulmonary artery pulsatility index was found to be predictive of mortality in PAH and may be a valuable marker for risk stratification. Its prognostic strength may be driven by mean right atrial pressure.

Combined Utility of Aortic Pulsatility Index and Pulmonary Artery Pulsatility Index for Risk Stratification in Advanced Heart Failure Patients

<h3>Purpose</h3> To assess the prognostic role of simultaneous biventricular function using hemodynamic parameters in advanced heart failure patients. <h3>Methods</h3> We retrospectively analyzed 184 patients undergoing a milrinone drug study at time of right heart catheterization (RHC) at our institution from January 2013 to January 2019. Aortic pulsatility index (API) was calculated as (systolic blood pressure - diastolic blood pressure)/pulmonary capillary wedge pressure, and pulmonary artery pulsatility index (PAPI) was calculated as (systolic pulmonary artery pressure - diastolic pulmonary artery pressure)/central venous pressure. Using our team's previous identification of cutpoint values for API and PAPI, 1.45 and 2.3, respectively, we stratified patients into the following groups: (1) High API, High PAPI; (2) High API, Low PAPI; (3) Low API, High PAPI; and (4) Low API, Low PAPI. Univariate and multivariate logistic regression analyses were performed to determine association with escalation of therapy, defined as left ventricular assist device implantation, heart transplantation, or death. <h3>Results</h3> Low API, Low PAPI was associated with escalation of therapy or death at 30-days (OR 3.2, 95% CI 1.23 - 9.49, p = 0.024). Low API, Low PAPI and Low API, High PAPI were also associated with the one-year endpoint of freedom from escalation of therapy or death (OR 3.63, 95% CI 1.55 - 8.75, p = 0.003; OR 4.13, 95% CI 1.5 - 12.45, p = 0.008; respectively). In multivariate analysis, both of these risk statuses remained significant predictors of the one-year endpoint when adjusting for Fick cardiac index (OR 3.72, 95% CI 1.5 - 9.48, p = 0.005; OR 4.18, 95% CI 1.49 - 12.82, p = 0.009; respectively). <h3>Conclusion</h3> The combined use of API and PAPI possesses utility for risk stratification regarding both short- and long-term freedom from escalation of therapy or death.

Patients with Severe Right Ventricular Dysfunction and Low Arterial Elastance Have Poor Prognosis Even after Heart Transplantation

<h3>Purpose</h3> To study the impact of severe right ventricular (RV) dysfunction on survival after heart transplantation <h3>Methods</h3> Data from 250 patients was analyzed for the effect of severe RV dysfunction , categorized by high right atrial pressure (RAP), low pulmonary artery pulsatility index (PAPi) and the presence of ascites, on 90 day and medium term survival . Systemic afterload was estimated by arterial elastance (<i>E_a</i>) (method given below) and systemic vascular resistance (SVR) . <i>Calculation of E_a: End systolic pressure E_sys) = (2* systolic blood pressure + diastolic pressure) / 3 . (1) Stroke volume (SV) = (CO / HR). (2) Arterial Elastance (E_a ) = E_sys / SV (3)</i> Organ perfusion pressure index (OPPI) ((Mean arterial pressure - RAP) / BSA) and modified MELD score was calculated . <h3>Results</h3> 90 day survival was worse with RAP > 15 (p = 0.014 ) , PAPi < 0.9 (p= 0.104) ,with ascites (p = 0.005) <i>,</i> higher MELD score ( odds ratio 1.07, p = 0.06 ) and lower OPPI (odds ratio 0.92,p = 0.004). The effect of RAP ,PAPi and MELD score on mortality was not seen if afterload was higher (<i>Ea > 2.7,SVR >1600 dynes/cm^-5/sec).</i> 5 years survival was worse for RAP > 15 ( p = 0.0059) , ascites (p = 0.009), PAPi < 0.9 (p= 0.1897) and MELD score > 20 ( p=0.022 ) This effect of RAP , PAPi and MELD score was absent if Ea > 2.7. Survival for OPPI < 40 was worse (p = 0.0124) but only if RAP was more than 15 mm hg. The relationship between RAP,Ea and OPPI and the effect on medium term survival is shown in a cox proportional hazard regression survival curve ( Fig 1). <h3>Conclusion</h3> 90 day and 5 year survival after heart transplantation are worse in patients with severe preoperative RV dysfunction but only <i>if the systemic arterial afterload</i> is low . Organ perfusion pressure index less than 40 appears to be deleterious in the short and medium term. Vasodilator drugs used to treat systolic left heart failure may adversely affect survival if RAP is high . Intra aortic balloon pump might be a more physiological alternative in patients awaiting transplantation.

Improving Prediction of Acute Right Ventricular Failure in Patients Undergoing Left Ventricular Assist Devices Using Novel Comprehensive Eighteen-Segment Echocardiographic Strain Analysis

<h3>Purpose</h3> The complex anatomy and different contraction patterns of the different right ventricular (RV) wall segments has made it challenging to predict acute RV failure (ARVF) in patients receiving a left ventricular assist device (LVAD). We sought to improve the prediction of ARVF after LVAD by performing a comprehensive 18-segment strain (ε) analysis of the RV. <h3>Methods</h3> Prospectively enrolled LVAD recipients had a right heart catheterization and echocardiogram prior to implant. From RV-focused views (Figure 1A), 18-segment ε was performed and indexed to pulmonary arterial elastance (Ea [PV]). ARVF was defined as need for RVAD, inotropes for >14 days or pulmonary vasodilator for >48 hours post-LVAD. Logistic regression was used to identify associations between specific parameters and ARVF. <h3>Results</h3> ARVF occurred in 15 of 30 patients enrolled. Lower pulmonary artery pulsatility index (PAPi), TAPSE and basal free wall (FW) (basal anterior, lateral and posterior FW) segmental ε/Ea (PV) were significantly associated with ARVF. Indexed basal FW segmental strain provided incremental predictive value over PAPi and TAPSE (Figure 1B). <h3>Conclusion</h3> Prediction of ARVF in LVAD candidates can be improved by adding comprehensive RV segmental strain analysis to traditional echocardiographic and hemodynamics parameters.

Abstract 16661: Fluid Challenge During Right Heart Catheterization for Evaluation of Pulmonary Hypertension Identifies Patients With Decreased Right Ventricular Function

Introduction: Fluid challenge during right heart catheterization (RHC) identifies occult left heart diastolic dysfunction (Occ-DD) in 10-20% of patients initially diagnosed with pre-capillary pulmonary hypertension (PH). The prognostic implications of the response to fluid challenge are not known. Abnormal right ventricular (RV) function is a poor prognostic indicator in all forms of PH. Hypothesis: We hypothesized that fluid challenge during RHC identifies patients with worse RV function and survival. Methods: Consecutive patients referred for RHC with fluid challenge from 2009-2016 were studied. Occ-DD was defined by a resting pulmonary arterial wedge pressure (PAWP) &lt; 15 mmHg, and a PAWP &gt; 18 mmHg after 500cc fluid challenge. Resting DD was defined by resting PAWP &gt; 15 mmHg. RV function was assessed by pulmonary artery pulsatility index (PAPi) or RV stroke work index (RVSWI). Statistical analysis was conducted using Kruskal Wallis test. Survival analysis was conducted by log rank test. Results: Of the 310 patients identified, 83% were female with a mean age of 54 + 14 years. The cohort consisted of 204 (66%) patients without DD, 30 (10%) with Occ-DD, and 76 (24%) with resting DD. Patients with Occ-DD were older (59 + 12 vs 51 + 14, p &lt; 0.0001) with greater BMI (31 + 6 vs 28 + 7, p &lt; 0.0001), but had similar prevalence of obesity, hypertension, diabetes mellitus, and coronary disease to all groups. Patients with Occ-DD had lower PAPi (7.8 + 0.4 vs 8.5 + 0.4, p &lt; 0.0001), lower RVSWI (9.9 + 0.8 vs 17.8 + 0.7 mmHg*ml/m2, p &lt; 0.0001) (Figure), and decreased survival (3.7 + 3.5 vs 4.9 + 3.5 years, p &lt; 0.0001) compared to those without DD. After adjustment for RV function, survival was no longer different between groups. Conclusions: Patients with Occ-DD after fluid challenge during RHC have decreased survival due to worse RV function compared to patients without DD. These findings suggest important prognostic implications for fluid challenge in the evaluation of patients with PH.

Abstract 17141: Pulmonary Artery Pulsatility Index is Associated With Greater Mortality Across a Broad Hospital-Based Cohort

Introduction: The pulmonary artery pulsatility index (PAPi), calculated from the ratio of pulmonary artery pulse pressure to right atrial pressure, was initially described as a novel predictor of right ventricular failure after inferior myocardial infarction or left ventricular assist device implantation. Whether PAPi is associated with adverse outcomes in broader samples is unknown. Hypothesis: A lower PAPi is associated with mortality in a broad population referred for right heart catheterization. Methods: We examined consecutive patients undergoing right heart catheterization between 2005-2016 in a hospital-based cohort. The following exclusion criteria were applied: shock or cardiac arrest within 24 hours of catheterization, presence of mechanical circulatory support, prior cardiac transplant, prior valvular surgery, or those with missing key clinical covariates. Multivariable Cox models were utilized to examine the association between PAPi and mortality. Analyses were adjusted for age, sex, BMI, hypertension, diabetes, prior myocardial infarction, and prior heart failure. Results: We studied 8559 patients with mean age 63 years and 40% women. We found that patients in the lowest quartile of PAPi were younger, with greater proportion of men, and higher BMI, yet similar NT-proBNP compared with other quartiles ( Table 1 ). Over 12.5 years of follow-up, there were 2441 death events. Patients in the lowest PAPi quartile had a 31% greater risk of death compared with the highest quartile (multivariable adjusted HR 1.31, 95% CI 1.15-1.48, p&lt;0.001), whereas no differences in survival were seen among individuals in quartile 2 or 3 (p&gt;0.05 vs quartile 4 for both). Conclusions: Patients in the lowest PAPi quartile had a 31% increased risk of all-cause mortality in a broad population referred for right heart catheterization. These findings highlight a potential role for PAPi in identifying high-risk individuals across a spectrum of disease.

Impact of the angle between aortic and mitral annulus on the occurrence of hemolysis during Impella support

Abstract Background Hemolysis of Impella is known as a major comorbidity and adequate device positioning and optimization of volume status are recommended. However, we have sometimes experienced hemolysis refractory to these adjustments and anatomical feature appears to be crucial in such cases. Methods We enrolled 26 patients (median 71 y; BSA 1.6 m2; LVEF 27%) with cardiogenic shock who received Impella insertion from March 2018 to November 2019. The angle of the aortic and mitral annulus which was drawn at the apical 3-chamber view on echocardiography, just before or after Impella insertion was measured (Figure). Hemolytic event was defined as follows; (1) Gross dark red urine and elevation of serum LDH level after initiation of Impella support were seen and subsequently required to lower the support level of Impella under P6. (2) Blood sample data indicating hemolysis (i.e. elevation of LDH level over 1.5 fold of normal range, anemia complicated with decreased haptoglobin, the elevation of total bilirubin level accompanied indirect bilirubin elevation) was found and subsequently required to initiate continuous hemodiafiltration. Results The freedom from hemolytic event was significantly lower in the narrow angle group (&amp;lt;126.5 degrees, Figure A) compared with the wide angle group (≥126.5 degrees, Figure B) (18% vs 83%, p&amp;lt;0.0001). The narrow angle was a significant risk factor of hemolytic event with an unadjusted hazard ratio 13.9 (95% confidence interval 2.88–67.2, p=0.0499) and a hazard ratio 15.5 (95% confidence interval 3.15–76.3, p=0.0008) adjusted for lower pulmonary artery pulsatility index, which was another risk factor significant in the univariate analyses. Furthermore, 30-day survival rate was significantly lower in the narrow angle group compared with the wide angle group (63% vs 100%, p=0.0116). Conclusions The narrow angle (&amp;lt;126.5 degrees) was an independent risk factor of hemolytic event and 30-day survival was lower compared with the wide angle group. Figure 1 Funding Acknowledgement Type of funding source: None

Prognostic Impact of the Pulmonary Artery Pulsatility Index in Patients with Chronic Heart Failure and Severe Mitral Regurgitation Undergoing Percutaneous Edge-to-Edge Repair

Background: Pulmonary artery (PA) pulsatility index (PAPi), calculated as (PA systolic pressure – PA diastolic pressure)/right atrial pressure, emerged as a novel predictor of right ventricular failure in patients with acute inferior myocardial infarction, advanced heart failure, and severe pulmonary hypertension. However, the prognostic utility of PAPi in transcatheter mitral valve repair (TMVR) using the MitraClip® system has never been tested. Objective: To assess the prognostic impact of PAPi in patients with severe functional mitral regurgitation (MR) and chronic heart failure (CHF) undergoing TMVR. Methods: Consecutive patients with severe functional MR (grade 3+ or 4+) and CHF who underwent successful TMVR (MR ≤2+ at discharge) were enrolled and divided into 3 groups according to PAPi (A: low PAPi ≤2.2; B: intermediate PAPi 2.21–3.99; C: high PAPi ≥4.0). The primary endpoint was a composite of all-cause mortality and rehospitalization due to CHF during a mean follow-up period of 16 ± 4 months. The impact of PAPi on prognosis was assessed by a receiver-operating characteristic (ROC) analysis and a multivariable Cox proportional hazard regression analysis investigating independent predictors for outcome. Results: 78 patients (A: n = 27, B: n = 28, C: n = 23) at high operative risk (logistic EuroSCORE [European System for Cardiac Operative Risk Evaluation] 18.8 vs. 21.5 vs. 20.6%; nonsignificant) were enrolled. Mean PAPi was 1.6 ± 0.41 vs. 2.9 ± 0.53 vs. 6.8 ± 3.5; p < 0.001). Patients with low PAPi showed significantly higher rates of early rehospitalization for heart failure at the 30-day follow-up (14.9 vs. 7.1 vs. 4.3%; p = 0.04). In the long term, a significantly lower event-free survival for the combined primary endpoint was observed in the low PAPi group (44.4 vs. 25.0 vs. 20.3%; log-rank p = 0.016). ROC curve analysis revealed that optimal sensitivity and specificity were achieved using a PAPi cutoff of 2.46 (sensitivity 83%, specificity 78.3%, area under the curve 0.82 [0.64–0.99]; p = 0.01). In Cox regression analysis, PAPi ≤2.46 was an independent predictor for the combined primary endpoint (hazard ratio 2.85; 95% confidence interval 1.15–7.04; p = 0.023). Conclusions: PAPi is strongly associated with clinical outcome among patients with CHF and functional MR undergoing TMVR. A PAPi value ≤2.46 predicts a worse prognosis independent of other important clinical, echocardiographic, and hemodynamic factors. Therefore, PAPi may serve as a new parameter to improve patient selection for TMVR.

HeartWare Ventricular Assist Device Cannula Position and Hemocompatibility-Related Adverse Events

HeartWare ventricular assist device (HVAD) cannula position is associated with hemodynamics and heart failure readmissions. However, its impact on hemocompatibility-related adverse events (HRAEs) remains uncertain. HVAD patients were followed for 1 year afterindex hospitalization, when cannula coronal angle was quantified from chest x-ray film. Invasive right heart catheterization and transthoracic echocardiography were performed. One-year occurrences of each HRAE were compared between those with and without a cannula coronal angle of greater than 65 degrees. Among 63 HVAD patients (median age 60 years, 63% male), 10 (16%) had a cannula coronal angle greater than 65 degrees. The wide-angle group had elevated intracardiac pressures and lower pulmonary artery pulsatility index (P < .05). They also had reduced right ventricular function by echocardiography. Freedom from HRAEs tended to be lower in the wide-angle group (24% vs 62%; P= .11). The rate of gastrointestinal bleeding was significantly higher in the greater than 65 degrees group (0.90 events/year vs 0.40 events/year; P= .013). The rates of stroke and pump thrombosis were statistically comparable irrespective of cannula angle (P > .05). HVAD cannula coronal angle was associated with reduced right ventricular function and HRAEs. Prospective studies evaluating surgical techniques to ensure optimal device positioning and its effects on HRAEs are warranted.

Low Pulmonary Artery Pulsatility Index Is Associated With Adverse Outcomes in Ambulatory Patients With Advanced Heart Failure

BackgroundThe pulmonary artery pulsatility index (PAPi) is a composite measure of right heart function, and low PAPi is associated with increased likelihood of mortality in patients hospitalized with cardiogenic shock. Our aim was to determine how PAPi correlates with other measures of right heart function and whether PAPi is associated with outcomes in ambulatory outpatients with advanced heart failure. MethodsWe assessed 673 consecutive ambulatory outpatients for heart transplantation over 10 years. The median age was 52 years, 72% were male, and dilated cardiomyopathy was the most common cause. All patients underwent detailed assessment, including right heart catheterization, and PAPi was calculated. The coprimary endpoints were death, urgent heart transplantation and mechanical circulatory support. ResultsMedian PAPi was 2.2 (interquartile range 1.42–3.62), and variation was predominantly due to variation in right atrial pressure. PAPi was well correlated with the right atrial pressure to pulmonary capillary wedge pressure ratio (rho –0.766) but less well correlated with the right ventricular stroke work index (rho 0.561) and tricuspid annular plane systolic excursion (rho 0.292). Patients in the lowest PAPi quartile (0.16–1.41) had lower event-free survival at 1 year (68.7%) and 3 years (45.6%) compared with all other PAPi quartiles (log rank P = 0.0286). ConclusionsPAPi offers a composite measure of right heart function that differs from other right heart catheter or echocardiographic measures. A PAPi of less than 1.41 is associated with adverse clinical outcomes in ambulatory outpatients with advanced heart failure.

Hemodynamics of concomitant tricuspid valve procedures at LVAD implantation.

Tricuspid regurgitation (TR) is common in patients receiving left ventricular assist device (LVAD) implantation. The current literature is conflicting regarding the effects of concomitant tricuspid valve repair (TVR) at LVAD implantation. We investigated the hemodynamic effects of concomitant TVR at LVAD implantation. Consecutive clinically stable LVAD outpatients who underwent hemodynamic ramp testings were enrolled in this study, and they were stratified by concomitant TVR. Results of hemodynamic ramp tests were compared between the TVR group and the non-TVR group. Among 65 LVAD patients undergoing ramp tests, 34 patients had received TVR, and 31 had not. There were no significant differences in baseline characteristics between two groups except for higher degree of TR and lower pulmonary artery pulsatility index in the TVR group (P < .05 for both). Following LVAD implantation, the degree of TR improved significantly in the TVR group down to the comparable level with the non-TVR group. During ramp tests, the TVR group had steeper cardiac index slope (0.14 ± 0.12 vs 0.07 ± 0.07 L/min/m2 /step, P = .002) and higher cardiac index at set LVAD speed (2.99 ± 0.84 vs 2.52 ± 0.42 L/min/m2 , P = .007). Concomitant TVR improves cardiac output and its response to LVAD speed change following LVAD implantation. Longitudinal clinical implications of such hemodynamic changes are unknown.

P6311Is the new PH classification useful to assess the need for heart transplantation? Looking for harder markers for hard patients

Abstract Background Pulmonary hypertension (PH) is an important prognostic marker among patients (pts) with heart failure. Recent ESC guidelines have introduced the concept of diastolic transpulmonary gradient (DPG) to differentiate combined (CpC) and isolated (IpC) post-capillary PH. However, its validation in a setting of patients evaluated for heart transplantation (HT) has been poorly explored; moreover, it doesn't incorporate right ventricular (RV) function. Purpose To analyze the prognostic role of current classification of PH and its interplay with RV function and diuretic therapy in pts with advanced heart failure referred for HT. Methods We included all pts evaluated for HT in our Center (2002–16) undergoing to a right heart cath (RHC), collecting data at first evaluation. Patients were divided into three groups: no PH (mPAP&lt;25 mmHg), IpC-PH (mean PAP &gt;25 mmHg, PVR&lt;3 WU), CpC-PH (mean PAP&gt;25 mmHg, PVR ≥3 WU and/or DPG ≥7 mmHg). Pulmonary artery pulsatility index (PAPi) was analyzed as a marker of RV function; oral furosemide&gt;125 mg/day (median value) or i.v. diuretics/dialysis were considered as high-dose diuretics (HDD). The study endpoint was the combined incidence of death or need for high urgent HT, expressed as 2-yrs survival rate. Results Among the overall cohort of 458 pts (53.1±10.9 yrs, 82,6% males, 40.3% CAD, 9.3% on IABP), 57.9% had PH: 30.8% IpC-PH, 27.1% CpC-PH. Only 8 pts (0.2%) had DPG≥7, one with PVR&lt;3. The use of HDD differed significantly according to PH classes (44.6% vs 56.3% vs 68.3%, no PH vs IpC vs CpC-PH respectively, p&lt;0.01) and was associated with a worse outcome (p&lt;0.01). The incidence of the primary endpoint in the overall cohort was 74.1±2.5%. While pts with CpC-PH had the worst prognosis, DPG≥7 did not predict the primary endpoint. At multivariate analysis, PVR ≥3 WU (HR: 16.7), PAPi &lt;3.8 (median value, HR: 4.1), HDD (HR: 5.6) were independent predictors of the primary endpoint, (p&lt;0.04 for all) as well as need for IABP (HR: 19.0, p&lt;0.01), even adjusting for clinical variables. Lower PAPi values carried an higher risk at 2 years both in IpC and CpC PH groups, thus allowing to better stratify the need for urgent HT (81.6±6.6% vs 78.6±5.7% vs 67.3±6.7% vs 49.1±7.9% respectively, p&lt;0.001) (Fig.1). Figure 1 Conclusion Our results suggest that, even if current definition of type 2 PH predicts the need of urgent HT, the incorporation of DPG ≥7 is epidemiologically irrelevant and doesn't increase accuracy, whereas combining an indirect marker of RV function (PAPi) with PVR assessment, even correcting for diuretic therapy, could help to better stratify the need of a rare resource like HT in patients with advanced heart failure and pulmonary hypertension.

Use of Pulmonary Artery Pulsatility Index in Cardiac Surgery

This study evaluated whether the pulmonary artery pulsatility index (PAPi) collected before and after cardiopulmonary bypass (CPB) is predictive and diagnostic of new onset right ventricular (RV) failure in the elective cardiac surgical population. This was a prospective observational study of patients who underwent cardiac surgery between 2017 and 2019. Weill Cornell Medicine, a single large academic medical center. The study comprised 119 patients undergoing elective cardiac surgery. Cardiopulmonary bypass, transesophageal echocardiography, pulmonary artery catheter, and elective cardiac surgery. Echocardiographic and hemodynamic data were collected at 2 time points: pre-CPB and post-chest closure/post-CPB. Patients with and without post-CPB RV dysfunction fractional area of change (<35%) were compared, and receiver operating characteristic curves were constructed. One hundred and nineteen patients undergoing elective surgery-coronary artery bypass grafting (23%), aortic valve replacement (21%), aortic surgery (19%), and combined surgery (37%)-were evaluated. Post-CPB RV dysfunction was associated with lower pre-CPB PAPi values (2.0 ± 1.0 v 2.5 ± 1.2; p = 0.001 and p = 0.03) and higher pre-CPB central venous pressure (8.3 ± 3.6 and 6.9 ± 2.7; p = 0.003 and p = 0.02, respectively). Pre-CPB PAPi (0.98 [95% confidence interval {CI} 0.96-0.99]), end systolic area (0.99 [95% CI 0.98-0.99]), and end diastolic area (1.01 [95% CI 1.001-1.02]) were independently associated with RV dysfunction in multivariable modeling, with a lower PAPi and end systolic area and higher end diastolic area demonstrating a greater risk of RV dysfunction post-CPB (post-CPB area under the curve for PAPi 0.80 [95% CI 0.71-0.88; sensitivity = 0.68, specificity = 0.93, optimal cutoff = 1.9]). PAPi measured pre-CPB is a potential predictor and marker of post-CPB RV dysfunction and may have diagnostic utility in cardiac surgery. Additional, large-scale studies are needed to confirm this finding.

Clinical Parameters of Right Ventricular Dysfunction Predict Depressed RV Myofilament Function

Purpose Right ventricular dysfunction (RVD) in heart failure with reduced ejection fraction (HFrEF) drives morbidity and mortality. Clinical hemodynamic parameters such as elevated right atrial pressure to pulmonary capillary wedge pressure ratio (RAP/PCWP) and low pulmonary artery pulsatility index (PAPi) are widely used to identify patients with significant RVD. However, their correspondence to intrinsic RVD is unknown. We therefore tested whether RAP/PCWP or PAPi are associated with sarcomere and molecular dysfunction. Methods Human RV tissue was obtained from explanted hearts of HFrEF patients and controls, along with corresponding demographic/hemodynamic data. Skinned myocytes were isolated and affixed to a force-length transducer to assess RV myofilament force-calcium curves. Protein was extracted from tissue and immunoblotting performed. Results Myofilament maximal calcium-activated force (Fmax) generation was significantly diminished in HFrEF patients with RVD (HFrEF-RVD, defined as RA:PCWP > 0.54 and PAPi Conclusion RAP/PCWP and PAPi, used to identify clinical RVD, predict true intrinsic RV sarcomeric dysfunction in human HFrEF, and are associated with a distinct molecular signature. Further work will uncover the RV sarcomeric defects underlying diminished RV hemodynamic performance.

Lower Pulmonary Artery Pulsatility Index after Left Ventricular Assist Device Implantation is Associated with Worse Heart Failure Free Survival

Purpose Pulmonary artery pulsatility index (PAPi) before left ventricular assist device (LVAD) implantation is associated with postoperative right ventricular failure . This study aimed to investigate the implication of post LVAD PAPi on clinical outcomes. Methods Following LVAD implantation, invasive hemodynamic tests were performed. PAPi was calculated as (systolic pulmonary artery pressure - diastolic pulmonary artery pressure)/mean right atrial pressure . One-year mortality, gastrointestinal bleeding (GIB), heart failure (HF), pump thrombosis (PT), and stroke event rates were compared between low PAPi group and high PAPi group based on the established ROC cut-off value. Results 97 LVAD patients received hemodynamic tests at 598 ± 668 days following LVAD implantation. The mean age was 60 years old and 60 (62%) were male. Mean PAPi was 2.9 ± 2.6. We divided the subjects into a low PAPi group (PAPi ventricular tachyarrhythmia prior to LVAD implantation (p 0.05 for all). Conclusion Lower PAPi post LVAD implantation is associated with reduced survival free from HF hospitalization. PAPi may serve as a marker of right ventricular failure in this population.

The Combination of Tricuspid Annular Plane Systolic Excursion and HeartMate Risk Score Predicts Right Ventricular Failure After Left Ventricular Assist Device Implantation.

Right ventricular (RV) failure is difficult to predict and is a major determinant of poor outcomes after left ventricular assist device (LVAD) implantation. We evaluated the associations of the following variables with severe RV failure in LVAD patients: tricuspid annular plane systolic excursion (TAPSE), pulmonary artery pulsatility index (PAPi), simplified RV contraction pressure index (sRVCPI), and HeartMate Risk Score (HMRS). We performed a retrospective case-control study on 216 patients who underwent continuous-flow LVAD implantation between 2008 and 2014. The primary analysis assessed the ability of HMRS, PAPi, sRVCPI, and TAPSE to predict severe RV failure. A secondary analysis evaluated the incremental benefit of combining predictive variables. Seventy-four patients developed severe RV failure (24%). Compared with the control group, the severe RV failure group had lower TAPSE (1.30 vs. 1.55; p < 0.001), lower PAPi (1.77 vs. 2.47; p = 0.001), lower sRVCPI (42.71 vs. 57.82; p < 0.001), and higher HMRS (2.12 vs. 1.65; p < 0.001). All four variables had similar receiver operating characteristic curves with modest area under the receiver operating characteristic curve (0.63-0.67, all p values < 0.001). In the evaluation of combined predictive variables, the combination of TAPSE with HMRS was found to be best for predicting severe RV failure. In summary, patients at risk for severe RV failure after LVAD implantation were successfully identified using TAPSE, PAPi, sRCPI, and HMRS. The combination of TAPSE and HMRS-incidentally, the least invasive and most readily available variables-proved to be superior to RV-centric metrics for predicting severe RV failure. The predictive and clinical use of these two variables should be tested prospectively.

Preoperative Ascites Predicts Right Ventricular Failure post-LVAD Implantation

Introduction Preoperative cardiac ascites has been shown to be a predictor of mortality in the latest INTERMACS report. However, it has not been shown to be an independent risk factor for the development of RVF after LVAD implantation. Hypothesis Pre-operative ascites on imaging during implant admission is associated with post-operative RVF. Methods We performed a single-center retrospective study of 153 patients who received a continuous-flow durable LVAD between 1/2006 and 12/2016 and who also had preoperative abdominal ultrasound or CT aduring implant admission. Severe RVF was defined as meeting criteria for clinical RVF and having inotropes > 14 days after implant, inotropes re-started 14 days after implant, RVAD implant, and death from RVF. The severity of ascites was extracted from the radiology reports and was graded as either none/trace, mild, moderate, or severe. A multivariate analysis of pre-operative ascites stratified by severity and post-implant RVF was performed. Results In our 153 patient cohort, 43 (28.1%) were found to have significant ascites, with 35 (22.9%) having mild ascites, 8 (5.6%) having moderate ascites, and 0 having severe ascites. Patients with ascites had higher preoperative total bilirubin, lower platelet count, higher mean RA pressure, higher mean PA pressure, lower pulmonary artery pulsatility index (PAPi), higher PCWP, and higher mortality rate, p Table 1 ). The multivariable model (which included age, INTERMACS level, creatinine, gender, and total bilirubin) found that preoperative ascites (OR 1.98, 95% CI [1.02 - 3.81], p = 0.04) and total bilirubin (OR 1.50, 95% CI [1.07 - 2.10], p = 0.018) were independent predictors of post-implant RVF. The ROC curve of ascites and post-operative RVF had a c-statistic of 0.72 ( Figure 1 ). Conclusion The preoperative presence of ascites correlates with post-operative RVF. Abdominal imaging could be useful in further risk stratifying patients for post-implant RVF.