Mean Pulmonary Capillary Wedge Pressure Research Articles

Congestion patterns in severe tricuspid regurgitation and transcatheter treatment: Insights from a multicentre registry.

While invasively determined congestion holds mechanistic and prognostic significance in acute heart failure (HF), its role in patients with tricuspid regurgitation (TR)-related right- heart failure (HF) undergoing transcatheter tricuspid valve intervention (TTVI) is less well established. A comprehensive understanding of congestion patterns might aid in procedural planning, risk stratification, and the identification of patients who may benefit from adjunctive therapies before undergoing TTVI. The aim of this study was to investigate the role of congestion patterns in patients with severe TR and its implications for TTVI. Within a multicentre, international TTVI registry, 813 patients underwent right heart catheterization (RHC) prior to TTVI and were followed up to 24 months. The median age was 80 (interquartile range 76-83) years and 54% were women. Both mean right atrial pressure (RAP) and pulmonary capillary wedge pressure (PCWP) were associated with 2-year mortality on Cox regression analyses with Youden index-derived cut-offs of 17 mmHg and 19 mmHg, respectively (p < 0.01 for all). However, RAP emerged as an independent predictor of outcomes following multivariable adjustments. Pre-interventionally, 42% of patients were classified as euvolaemic (RAP <17 mmHg, PCWP <19 mmHg), 23% as having left-sided congestion (RAP <17 mmHg, PCWP ≥19 mmHg), 8% as right-sided congestion (RAP ≥17 mmHg, PCWP <19 mmHg), and 27% as bilateral congestion (RAP ≥17 mmHg, PCWP ≥19 mmHg). Patients with right-sided or bilateral congestion had the lowest procedural success rates and shortest survival times. Congestion patterns allowed for discerning specific patient's physiology and specifying prognostic implications of right ventricular to pulmonary artery coupling surrogates. In this large cohort of invasively characterized patients undergoing TTVI, congestion patterns involving right-sided congestion were associated with low procedural success and higher mortality rates after TTVI. Whether pre-interventional reduction of right-sided congestion can improve outcomes after TTVI should be established in dedicated studies.

Noninvasive Prediction of Pulmonary Capillary Wedge Pressure in Patients With Normal Left Ventricular Ejection Fraction: Comparison of Cardiac Magnetic Resonance With Comprehensive Echocardiography

Cardiac magnetic resonance (CMR) was recently reported to predict mean pulmonary capillary wedge pressure (PCWP). However, there is a paucity of data on its accuracy for estimation of PCWP in patients with normal left ventricular (LV) ejection fraction (EF). We sought to examine its accuracy against the invasive gold standard and to compare it with the accuracy of comprehensive echocardiography. Stable patients with EF of ≥50% who underwent right heart catheterization, CMR, and echocardiographic imaging within 1week were included. Pulmonary capillary wedge pressure was estimated by CMR using a previously validated equation where PCWP is estimated based on the left atrial maximum volume and LV mass. Echocardiographic estimation of PCWP was based on 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines, taking into account the presence of myocardial disease. The mean age of the 79 patients was 55±15years, and 58.2% were female. There were 33 patients with PCWP >15mm Hg by right heart catheterization. Cardiac magnetic resonance prediction of PCWP had an area under the curve (AUC)=0.72. In comparison, echocardiographic prediction of PCWP showed a higher accuracy (AUC=0.87 vs AUC=0.72; P=.008). In patients with normal LV EF, CMR estimation of mean PCWP based on LV mass and left atrial volume has modest accuracy for detecting patients with mean PCWP >15mm Hg. Comprehensive echocardiography predicts elevated PCWP with higher accuracy in comparison with CMR.

Left ventricular to left arial volume ratio in the assessment of filling pressure in patients with dyspnoea and preserved ejection fraction.

Assessing filling pressure (FP) remains a clinical challenge despite advancements in non-invasive imaging techniques. This study investigates the utility of echocardiographic left ventricular (LV) to left atrial (LA) volume ratio in estimating the resting FP in patients with dyspnoea and preserved ejection fraction (EF). This study is a prospective, single-centre analysis of 53 consecutive patients with dyspnoea (New York Heart Association grade 2 or 3) and LVEF of ≥50% (mean age 71 ± 10 years) who underwent cardiac catheterisation, including direct measurement of LA pressure at rest using retrograde technique. Echocardiographic data were obtained 1.5 ± 1.0 h after cardiac catheterisation. The patients were divided into two groups: Group 1 consisted of individuals with elevated FP, indicated by a mean LA pressure or mean pulmonary capillary wedge pressure of >12 mmHg, and Group 2 comprised of patients with normal FP. The LV and LA volumes were measured at three specific points: the minimum volume (LVES, LAmin), the volume during diastasis (LVdias, LAdias), and the maximum volume (LVED, LAmax). The corresponding LV/LA volume ratios were analysed: end-systole (LVES/LAmax), diastasis (LVdias/LAdias), and end-diastole (LVED/LAmin). The patients in Group 1 exhibited lower LV/LA volume ratios compared with those in Group 2 (LVES/LAmax 0.44 ± 0.12 vs. 0.60 ± 0.23, P = 0.0032; LVdias/LAdias 1.13 ± 0.30 vs. 1.56 ± 0.49, P = 0.0007; LVED/LAmin 2.71 ± 1.57 vs. 4.44 ± 1.70, P = 0.0004). The LV/LA volume ratios correlated inversely with an increased FP (LVES/LAmax, r = -0.40, P = 0.0033; LVdias/LAdias, r = -0.45, P = 0.0007; LVED/LAmin, r = -0.55, P < 0.0001). Among all the measurements, the LVdias/LAdias ratio demonstrated the highest discriminatory power to distinguish patients with elevated FP from normal FP, with a cut-off value of ≤1.24 [area under the curve (AUC) = 0.822] for the entire group, encompassing both sinus rhythm and atrial fibrillation. For patients in sinus rhythm specifically, the cut-off value was ≤1.28 (AUC = 0.799), with P < 0.0001 for both. The LVdias/LAdias index demonstrated non-inferiority to the E/e' ratio [ΔAUC = 0.159, confidence interval (CI) = -0.020-0.338; P = 0.0809], while surpassing the indices of LA reservoir function (ΔAUC = 0.249, CI = 0.044-0.454; P = 0.0176), LA reservoir strain (ΔAUC = 0.333, CI = 0.149-0.517; P = 0.0004), and LAmax index (ΔAUC = 0.224, CI = 0.043-0.406; P = 0.0152) in diagnosing patients with elevated FP. The study presents a straightforward and reproducible method for non-invasive estimation of FP using routine TTE in patients with dyspnoea and preserved EF. The LVdias/LAdias index emerges as a promising indicator for identifying elevated FP, demonstrating comparable or even superior performance to established parameters.

Left ventricular fibrosis as a main determinant of filling pressures and left atrial function in advanced heart failure.

Advanced heart failure (AdHF) is characterized by variable degrees of left ventricular (LV) dysfunction, myocardial fibrosis, and raised filling pressures which lead to left atrial (LA) dilatation and cavity dysfunction. This study investigated the relationship between LA peak atrial longitudinal strain (PALS), assessed by speckle-tracking echocardiography (STE), and invasive measures of LV filling pressures and fibrosis in a group of AdHF patients undergoing heart transplantation (HTX). We consecutively enrolled patients with AdHF who underwent HTX at our Department. Demographic and basic echocardiographic data were registered, then invasive intracardiac pressures were obtained from right heart catheterization, and STE was also performed. After HTX, biopsy specimens from explanted hearts were collected to quantify the degree of LV myocardial fibrosis. Sixty-four patients were included in the study (mean age 62.5 ± 11 years, 42% female). The mean LV ejection fraction (LVEF) was 26.7 ± 6.1%, global PALS was 9.65 ± 4.5%, and mean pulmonary capillary wedge pressure (PCWP) was 18.8 ± 4.8 mmHg. Seventy-three % of patients proved to have severe LV fibrosis. Global PALS was inversely correlated with PCWP (R = -0.83; P < 0.0001) and with LV fibrosis severity (R = -0.78; P < 0.0001) but did not correlate with LVEF (R = 0.15; P = 0.2). Among echocardiographic indices of LV filling pressures, global PALS proved the strongest [area under the curve 0.955 (95% confidence interval 0.87-0.99)] predictor of raised (>18 mmHg) PCWP. In patients with AdHF, reduced global PALS strongly correlated with the invasively assessed LV filling pressure and degree of LV fibrosis. Such relationship could be used as non-invasive indicator for optimum patient stratification for therapeutic strategies.

Contemporary Outcomes of Children With Acute Fulminant Myocarditis Supported With Peripheral Extracorporeal Membrane Oxygenation.

Despite extracorporeal membrane oxygenation (ECMO) utilization in nearly 20% of cases, there are limited data in children with acute fulminant myocarditis (AFM) requiring ECMO. Herein we identify risk factors for death or heart transplant (HT) in children with AFM supported with ECMO, describe our experience with left atrial (LA) decompression, and depict long-term outcomes of survivors. We performed a retrospective cohort of patients <18 years with AFM (≤14 days of symptoms, rapid cardiogenic shock, and normal left ventricular [LV] size on presentation) supported with ECMO admitted to a single intensive care unit from 1997 to 2021. Among 28 patients (median age 9 years), 21 (75%) survived to discharge without HT. Patients were supported on ECMO for a median of 6 days. Three patients were bridged to HT with durable ventricular assist devices (VAD). Four patients died, two of whom were supported with VAD. At presentation, seven (25%) patients had high grade or complete atrioventricular block and eight (29%) had ventricular tachycardia. Before ECMO cannulation, 21 (75%) patients received CPR. The death/HT group had higher peak troponin levels (12.5 vs . 1.0 ng/ml, p = 0.02) and initial mean LA or pulmonary capillary wedge pressure (27 vs . 18 mm Hg, p = 0.03). Left atrial decompression was performed in 22 patients (79%). Twenty-two (79%) had acute myocarditis on endomyocardial biopsy. Among transplant-free survivors, 18 (86%) had normalization in LV function (median 7 days); the remaining three patients had persistent mild LV dysfunction at last follow-up (median 842 days). Transplant-free survival of pediatric patients with AFM supported on ECMO was 75% and associated with lower initial LA pressure and lower peak troponin. Recovery in ventricular function among survivors was rapid and durable.

Safety, usability, and performance of a wireless left atrial pressure monitoring system in patients with heart failure: the VECTOR-HF trial (final results)

Abstract Background In heart failure (HF), implantable hemodynamic monitoring devices have been shown to optimize therapy, anticipating clinical decompensation and preventing hospitalization. Direct left-sided hemodynamic sensors offer theoretical benefits beyond pulmonary artery pressure (PAP) monitoring systems. Aims We evaluated the safety, usability, and performance of a novel left atrial pressure (LAP) monitoring system in HF patients (V-LAP). Methods and Results The VECTOR-HF study was a first-in-human, prospective, multicenter, single-arm, clinical trial enrolling 30 patients with HF. The device consisted of an interatrial positioned leadless sensor, able to transmit LAP data wirelessly. After three months, a right heart catheterization (RHC) was performed to correlate mean pulmonary capillary wedge pressure (PCWP) with simultaneous mean LAP obtained from the device. Remote LAP measurements were then used to guide patient management. The miniaturized device was successfully implanted in all 30 patients, without acute Major Adverse Cardiac and Neurological Events (MACNE). At 3 months, freedom from short-term MACNE was 97%. Agreement between sensor-calculated LAP and PCWP was consistent, with a mean difference of -0.22±4.92mmHg, the correlation coefficient and the Lin’s Concordance Correlation Coefficient values were equal to 0.79 (P&amp;lt;0.0001) and 0.776 (95%CI=0.582-0.886), respectively. Preliminary experience with VLAP-based HF management was associated with significant improvements in NYHA functional class (32% of patients reached NYHA II class at 6 months, P&amp;lt;0.005; 60% of patients at 12 months, P&amp;lt;0.005) and 6-minute walk-test distance (from 244.59±119.59m at baseline to 311.78±129.88m after 6 months, P&amp;lt;0.05, and 343.95±146.15m after 12 months, P&amp;lt;0.05). Conclusion The V-LAP™ monitoring system proved to be safe and provided a good correlation with invasive PCWP. Initial evidence also suggests possible improvement in HF clinical symptoms that could be associated to a better outcome. Further studies are needed to test the efficacy of the device in heart failure patients.

Abstract 14855: Noninvasive Prediction of Pulmonary Capillary Wedge Pressure in Patients With Normal LV EF: Comparison of CMR With Echocardiography

Background: Cardiac magnetic resonance (CMR) was recently reported to predict mean pulmonary capillary wedge pressure (PCWP) with the best accuracy in mid-rage or reduced left ventricular (LV) ejection fraction (EF). . There is a paucity of data on the accuracy of CMR estimation of PCWP in patients with normal left ventricular (LV) ejection fraction (EF) or on how CMR compares with echocardiography in these patients. Methods: Stable patients with EF of ≥50%, who underwent right heart catheterization (RHC), CMR, and echocardiographic imaging within one week were included. PCWP was estimated by CMR using a previously validated equation where PCWP is estimated based on the left atrial maximum volume (LAV) and left ventricular mass (LVM) as PCWP=6.1352+ (0.07204*LAV) + (0.02256*LVM). Echocardiographic estimation of PCWP was based on 2016 ASE/EACVI guidelines taking into account the presence of myocardial disease and pulmonary vein atrial velocity. Results: Mean age was (54.6 ± 15.2), 58.2% females. There were 33 patients with PCWP &gt; 15 mmHg by RHC and 46 with a normal PCWP by right heart catheterization. The table shows sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for the two imaging modalities. CMR prediction of PCWP had an AUC=0.72. In comparison, echocardiographic prediction of PCWP had significantly higher accuracy (AUC=0.87 vs. AUC=0.72; P- value=0.008). Conclusion: In patients with normal LV EF, CMR estimation of mean PCWP has an acceptable accuracy for detecting patients with mean PCWP&gt;15 mmHg. Echocardiography predicts elevated PCWP with a significantly higher sensitivity, specificity, and overall accuracy in comparison with CMR.

Cardiopulmonary Performance Among Heart Failure Patients Before and After Left Ventricular Assist Device Implantation

BackgroundPatients with heart failure with reduced ejection fraction (HFrEF) have persistent impairments in functional capacity after continuous-flow left ventricular assist device (CF-LVAD) implantation. ObjectivesThis study aims to characterize longitudinal changes in exercise hemodynamics and functional capacity among patients with HFrEF before and after CF-LVAD implantation. MethodsTen patients underwent 3 invasive cardiopulmonary exercise tests on upright cycle ergometry with pulmonary artery catheterization: 1) Visit 1 before CF-LVAD implantation; 2) Visit 2 after device implantation with CF-LVAD pump speed held constant at baseline speed; and 3) Visit 3 with increases in pump speed during exercise (median: 1,050 rpm [IQR: 750-1,150 rpm] and 220 rpm [IQR: 120-220 rpm] for HeartMate 3 and HeartWare VAD, respectively). Hemodynamics and direct Fick cardiac output were monitored using pulmonary artery catheterization. Gas exchange metrics were determined using indirect calorimetry. ResultsMaximal oxygen uptake (Visits 1, 2, and 3: 10.8 ± 2.5 mL/kg/min, 10.7 ± 2.2 mL/kg/min, and 11.5 ± 1.7 mL/kg/min; P = 0.92) did not improve after device implantation. Mean pulmonary arterial and pulmonary capillary wedge pressures increased significantly during submaximal and peak exercise on preimplantation testing (P < 0.01 for rest vs peak exercise) and remained elevated, with minimal change on Visits 2 and 3 regardless of whether pump speed was fixed or increased. ConclusionsAmong patients with HFrEF, cardiovascular hemodynamics and exercise capacity were similar after CF-LVAD implantation, regardless of whether patients exercised at fixed or adjusted pump speeds during exercise. Further research is needed to determine methods by which LVADs may alleviate the HFrEF syndrome after device implantation. (Effect of mechanIcal circulatoRy support ON exercise capacity aMong pAtieNts with heart failure [IRONMAN]; NCT03078972)

Right heart catheterization predictors of symptomatic improvement in patients undergoing transcatheter tricuspid valve edge‐to‐edge repair

AbstractBackgroundTranscatheter tricuspid valve edge‐to‐edge repair (TTEER) is associated with improvement in outcomes for symptomatic patients with severe tricuspid regurgitation (TR). However, reliable predictors for clinical success are not yet fully defined. This study aims to describe right heart catheterization (RHC) findings in patients referred for TTEER and identify hemodynamic characteristics of patients who experience immediate symptomatic improvement following successful TR intervention.MethodsPatients who underwent TTEER and had a separate RHC within the preceding 6 months were included. Hemodynamic tracings from the RHC and TTEER procedures were reviewed and recorded. Clinical success was defined as a successful device implant with at least 1‐grade of TR reduction and improvement in NYHA class by 1 or more grades on 30‐day echocardiogram and clinical follow‐up.ResultsThirteen patients underwent an RHC within 6 months of TTEER procedure (median age 76 years [IQR: 73–80]). All patients were on a stable dose of loop diuretics. Baseline right atrial pressure was severely elevated (mean 19 mmHg [IQR: 9–24 mmHg]) with prominent CV waves. Median pulmonary capillary wedge pressure (PCWP) was 20 mmHg (IQR: 14–22) and 70% of patients had a mean PCWP &gt; 15 mmHg at rest. Median PCWP CV‐wave was 34 mmHg (IQR: 23–42). Higher PCWP CV‐wave height (40 mmHg [IQR 33–43] versus 18 mmHg [IQR 17–31]) was associated with lower likelihood of clinical success (OR 0.83, 95% CI: 0.35–0.97,p = 0.04).ConclusionsInclusion of invasive hemodynamics as part of pre‐TTEER evaluation may allow for improved TR phenotyping and patient selection. Patients with a large left atrial CV wave on resting RHC were less likely to experience immediate symptomatic improvement despite procedural success with TTEER.

Can echocardiographic parameters effectively predict elevated pcwp in heart transplant patients?

Abstract Funding Acknowledgements Type of funding sources: None. PCWP measurement remains the gold standard for the diagnosis of Heart Failure with preserved ejection fraction. Nevertheless, right heart catheterization (RHC) is a last step procedure nowadays, with most of the patients diagnosed solely by transthoracic echocardiography (TTE) parameters, as it is widely available and not associated with the risks of the invasive procedures. Heart transplant (HT) patients, on the other hand, routinely perform RHC as follow-up for rejection surveillance, allowing frequent invasive hemodynamic assessment. Purpose Evaluate the association between TTE parameters and the invasively measured pulmonary capillary wedge pressure (PCWP) by RHC in HT patients. Methods A retrospective analysis of consecutive HT patients submitted to RHC between February 2016 and November 2021, who previously performed TTE, was made. The area under the curve (AUC) was performed to evaluate the association between several TTE parameters (left ventricular (LV) end-diastolic diameter (LV EDD), LV end-systolic diameter (LV ESD), LV ejection fraction (LV EF), interventricular septum wall thickness (ST), LV global longitudinal strain (GLS), left atrium volume index (LAVi), transmitral E/A ratio (E/A), LV E/e’ ratio (E/e’), E velocity deceleration time (DT), isovolumetric relaxation time (IV RT), tricuspid annular plane systolic excursion (TAPSE) and systolic pulmonary artery pressure (sPAP)) and elevated PCWP (defined as &amp;gt;15mmHg). Statistical differences with a p-value &amp;lt;0.05 were considered significant. Results A total of 127 RHC were performed during the study period. Mean age was 50 years, 79% (n=100) were male, mean LV EF 58 ± 10% and mean BNP 808 ± 984 pg/mL. Mean PCWP was 12 ± 6 mmHg, with 28% (n=35) with a value higher than 15mmHg. AUC results of several TTE parameters for the prediction of elevated PCWP are depicted in Table 1. LV EF (AUC 0.702, p = 0.001) and GLS (AUC 0.768, p = 0.07) were significantly correlated with elevated PCWP, while the remaining parameters failed to do so. Conclusion In this HT group, several TTE indices commonly employed for non-invasive estimation of increased intraventricular pressures, including E/e', E/A ratio, LAVi, and sPAP, showed a poor correlation with elevated PCWP. GLS, a TTE parameter widely used to assess subclinical dysfunction were the parameter with the most robust association with elevated PCWP in this population, demonstrating that it has the potential to be used in routine clinical practice.

0834 Association of Sleep Disordered Breathing and Hemodynamics of World Symposium on Pulmonary Hypertension Groups in PVDOMICS Cohort

Abstract Introduction As sleep disordered breathing(SDB)-related pathophysiology of intermittent hypoxia, autonomic dysfunction and intrathoracic pressure alterations, etc. likely exerts differential influences across World Symposium on Pulmonary Hypertension(WSPH) groups that have yet to be characterized , we postulate differing SDB-pulmonary hemodynamics relationships across these groups. Methods Pulmonary Vascular Disease Phenomics(PVDOMICS-NCT02980887), a multicenter cohort study, included patients with mean pulmonary artery pressure(mPAP) on right heart catheterization(RHC) ≥ 25mmHg and home sleep apnea testing(HSAT) within 6 weeks of RHC. SDB measures included apnea-hypopnea index(AHI, 3% desaturation hypopnea definition used) and % recording time&amp;lt; 90% SpO2(TRT&amp;lt; 90%). Pulmonary hemodynamic indices included:mPAP, mean pulmonary capillary wedge pressure(PCWP), right atrial mean pressure(RAP). Linear regression models(beta coefficients±standard error) were constructed to assess sleep indices and RHC measurements with adjustment for age, sex, race, body-mass index(BMI), PH medication and supplemental oxygen use; PH group interaction was analyzed. Results We included 424 participants with available data in the final analytic sample. Groups 2 and 3 were older(65.6±11.9, 64.2±10.8 years, respectively) and Group 5 had the highest % males(71.4%). Group 2 had highest BMI: 34.3±9.2kg/m2 and Group 5 lowest: 28.7±6.4k g/m2. SDB(AHI≥5), was most prevalent in Group 2(71.4%) and least in Group 4(42.9%). TRT&amp;lt; 90% was highest in Group 1(37.0%, [P25=2.2, P75=87.3]) followed by Group 4(35.7% [5.3,82.9]) and lowest in Group 2(6.4% [0.61,41.8]). AHI and RAP association differed across groups, p=0.027 and was strongest in Group 2; per 5-unit increase in AHI, RAP increased by 0.75mmHg (estimate=0.75, standard error[0.15,1.36],p=0.015). TRT&amp;lt; 90% and mPAP had significant cross-group differences, p=0.004. TRT&amp;lt; 90% was associated with mPAP in Groups 1 and 4:per 5-unit increase in TRT&amp;lt; 90%, mPAP increased by 2mmHg(2.10,[1.52,2.68],p&amp;lt; 0.001) and 1.4mmHg(1.40,[0.07,2.73],p=0.039) respectively. Other associations were not significant. Conclusion SDB prevalence differs across WSPH groups and was highest in Group 2 PH. Findings suggest that AHI and TRT&amp;lt; 90%SaO2 differentially contribute to the pathogenesis in PH groups; with AHI associating with RAP, especially in Group 2 PH, and TRT&amp;lt; 90%SaO2 with mPAP in Groups 1 and 4 PH, perhaps via hypoxia-induced pulmonary vasoconstriction and remodeling. Support (if any) Funding: U01 HL125218, U01 HL125205, U01 HL125212, U01 HL125208, U01 HL125175, U01 HL125215, and U01 HL125177 and the Pulmonary Hypertension Association.

Safety, usability, and performance of a wireless left atrial pressure monitoring system in patients with heart failure: the VECTOR-HF trial.

In heart failure (HF), implantable hemodynamic monitoring devices have been shown to optimize therapy, anticipating clinical decompensation and preventing hospitalization. Direct left-sided hemodynamic sensors offer theoretical benefits beyond pulmonary artery pressure (PAP) monitoring systems. We evaluated the safety, usability, and performance of a novel left atrial pressure (LAP) monitoring system in HF patients. The VECTOR-HF study(NCT03775161) was a first-in-human, prospective, multicenter, single-arm, clinical trial enrolling 30 patients with HF. The device consisted of an interatrial positioned leadless sensor, able to transmit LAP data wirelessly. After three months, a right heart catheterization (RHC) was performed to correlate mean pulmonary capillary wedge pressure (PCWP) with simultaneous mean LAP obtained from the device. Remote LAP measurements were then used to guide patient management. The miniaturized device was successfully implanted in all 30 patients, without acute Major Adverse Cardiac and Neurological Events (MACNE). At 3 months, freedom from short-term MACNE was 97%. Agreement between sensor-calculated LAP and PCWP was consistent, with a mean difference of -0.22±4.92mmHg, the correlation coefficient and the Lin's Concordance Correlation Coefficient values were equal to 0.79 (P<0.0001) and 0.776 (95%CI=0.582-0.886), respectively. Preliminary experience with VLAP-based HF management was associated with significant improvements in NYHA functional class (32% of patients reached NYHA II class at 6 months, P<0.005; 60% of patients at 12 months, P<0.005) and 6-minute walk-test distance (from 244.59±119.59m at baseline to 311.78±129.88m after 6 months, P<0.05, and 343.95±146.15m after 12 months, P<0.05). The V-LAP™ monitoring system proved to be generally safe and provided a good correlation with invasive PCWP. Initial evidence also suggests possible improvement in HF clinical symptoms. This article is protected by copyright. All rights reserved.

ECG-guided non-invasive estimation of pulmonary congestion in patients with heart failure

Quantifying hemodynamic severity in patients with heart failure (HF) is an integral part of clinical care. A key indicator of hemodynamic severity is the mean Pulmonary Capillary Wedge Pressure (mPCWP), which is ideally measured invasively. Accurate non-invasive estimates of the mPCWP in patients with heart failure would help identify individuals at the greatest risk of a HF exacerbation. We developed a deep learning model, HFNet, that uses the 12-lead electrocardiogram (ECG) together with age and sex to identify when the mPCWP > 18 mmHg in patients who have a prior diagnosis of HF. The model was developed using retrospective data from the Massachusetts General Hospital and evaluated on both an internal test set and an independent external validation set, from another institution. We developed an uncertainty score that identifies when model performance is likely to be poor, thereby helping clinicians gauge when to trust a given model prediction. HFNet AUROC for the task of estimating mPCWP > 18 mmHg was 0.8 2pm 0.01 and 0.81pm 0.01 on the internal and external datasets, respectively. The AUROC on predictions with the highest uncertainty are 0.50 pm 0.02 (internal) and 0.56pm 0.04 (external), while the AUROC on predictions with the lowest uncertainty were 0.86 ± 0.01 (internal) and 0.82 ± 0.01 (external). Using estimates of the prevalence of mPCWP > 18 mmHg in patients with reduced ventricular function, and a decision threshold corresponding to an 80% sensitivity, the calculated positive predictive value (PPV) is 0.89pm 0.01when the corresponding chest x-ray (CXR) is consistent with interstitial edema HF. When the CXR is not consistent with interstitial edema, the estimated PPV is 0.78pm 0.02, again at an 80% sensitivity threshold. HFNet can accurately predict elevated mPCWP in patients with HF using the 12-lead ECG and age/sex. The method also identifies cohorts in which the model is more/less likely to produce accurate outputs.

Temporary balloon occlusion test can overestimate the risk of acute pulmonary edema after transcatheter atrial septal defect closure.

Atrial septal defect (ASD) closure can cause acute pulmonary edema. Before transcatheter closure is performed, temporary balloon occlusion test (BOT) is recommended in patients with left ventricular dysfunction to predict the risk of pulmonary edema. However, the accuracy of BOT has not been verified. This study aimed to compare hemodynamic differences between BOT and transcatheter closure. A total of 42 patients with a single ASD over age 18 years who underwent BOT before transcatheter ASD closure between October 2010 and May 2020 were analyzed. Pulmonary capillary wedge pressure (PCWP) was measured using a Swan-Ganz catheter placed in the pulmonary artery at baseline, after 10 min of BOT, and after transcatheter closure. Amplatzer septal occluder was used for all transcatheter closures. Mean patient age was 64 ± 18 years (range, 18-78). Mean ASD diameter and pulmonary to systemic flow ratio were 18 ± 5and 2.8 ± 1.0 mm, respectively. Mean PCWP at baseline, during BOT, and after transcatheter closure was 8.9 ± 2.9, 13.5 ± 4.2, and 9.5 ± 2.6 mmHg, respectively. The difference between BOT and after transcatheter closure values was significant (p < 0.001). During BOT, PCWP increased ≥18 mmHg in 7patients, whereas after ASD closure, PCWP was <18 mmHg in all 7and none developed acute pulmonary edema. Temporary balloon occlusion of an ASD and transcatheter ASD closure result in different hemodynamic change. BOT overestimates increase of PCWP after transcatheter ASD closure and requires careful interpretation. Well-designed, larger studies in higher-risk patients are warranted to verify the clinical implications of BOT in more detail.

Abstract 13710: Acute Beneficial Effects of a Rho-Kinase Inhibitor, Fasudil in Patients With Pulmonary Hypertension Due to Left Heart Disease

Introduction: The prognosis of reactive pulmonary hypertension (PH) due to left heart disease is poor, and the pathogenesis of the disease is not well understood. Rho-Kinase inhibitor, fasudil dilates vascular smooth muscle and may improve pulmonary hypertension. We evaluated the acute effects of fasudil on hemodynamic parameters in patients with pulmonary hypertension due to left heart disease prospectively. Methods: From 2016 June to 2022 May, 100 consecutive patients requiring hospitalization for worsening chronic heart failure were enrolled. All patients underwent invasive hemodynamic measurement though right heart catheterization.In patients with mean pulmonary arterial pressure greater than 25 mmHg at baseline, 30 mg of fasudil was administered intravenously for 30 minutes. The hemodynamic measurements were performed at baseline and after 30 minutes of fasudil. PH due to left heart disease is defined as mean pulmonary arterial pressure (mPAP) ≥25mmHg and mean pulmonary capillary wedge pressure (mPCWP) &gt;15mmHg. Patients with PH were classified into 2 types, depending on the elevation of pulmonary vascular resistance (PVR) or the diastolic pressure gradient (DPG): Reactive-PH with elevated PVR (&gt;3.0 Wood units: WU) and/or DPG (&gt;7mmHg), and Passive-PH with normal PVR (≤3.0 WU) and DPG (≤7mmHg). Results: Fifty patients (mean age 70 years; 14 women and 36 men) received administration of fasudil. 30 patients had Passive-PH, and 20 patients had Reactive-PH. PVR significantly decreased after administration of fasudil in both Passive-PH and Reactive-PH group (1.7 to 1.4 WU, 3.5 to 2.7 WU, P&lt;0.001). The rate of change in PVR after administration of fasudil was significantly higher in the Reactive-PH group compared to the Passive-PH group (33% vs 21 %, P&lt;0.05). mPAP and cardiac index significantly improved in both Passive-PH (34±8.5 vs. 28±8.2 mmHg, 2.7±0.7 vs. 2.9±0.8 l/min/m 2 , p&lt;0.05) and Reactive-PH group (41±7.9 vs. 33±9.0 mmHg, 2.2±0.6 vs. 2.4±0.6 l/min/m 2 , p&lt;0.05). Mean blood pressure and arterial oxygen saturation were unaffected by fasudil (87 to 84 mmHg, 99 to 90 mmHg, 98 to 97%, 97 to 97%, not significant). Conclusions: Fasudil improves pulmonary hypertension due to left heart disease without any detrimental effects on hemodynamics.

Abstract 15217: Intrahepatic Gene Expression Profile Differences in Patients With Fontan Associated Liver Disease

Introduction: Fontan associated liver disease (FALD) develops shortly after the Fontan palliation as the long-term consequence of chronically elevated central venous pressures. The molecular pathways underlying FALD remain largely unknown. We aimed to assess intrahepatic gene expression profile differences among these patients with advanced vs early fibrosis. Hypothesis: Advanced fibrosis in patients with Fontan circulation shows a specific gene expression profile with specific enriched pathways. Methods: This retrospective cohort study included adults with the Fontan circulation who had tissue available from at least one liver biopsy at the UCLA Adult Congenital Heart Disease Center. Clinical, laboratory, imaging and hemodynamic data prior to the liver biopsy were extracted from medical records. Patients were classified into early (F1-F2) or advanced fibrosis (F3-F4). RNA was isolated from formalin-fixed paraffin embedded liver tissue, RNA libraries were constructed using ribosomal RNA depletion method and sequencing was performed on Illumina Novaseq 6000. Differential gene expression and gene ontology analyses were carried out using DESeq2 and Metascape. Results: Seventy-seven patients were included, 53% women, 50% White and 20% Hispanic. Most patients had either a lateral tunnel (40%) or atriopulmonary (24%) Fontan. Four patients had 2 liver biopsies and 1 had hepatocellular carcinoma. Early and advanced fibrosis were present in 43 (54%) and 37 (46%) samples, respectively. Both groups had similar age, comorbidities, NYHA class, liver function tests and liver ultrasound features. Patients with advanced fibrosis had higher BNP, Fontan, mean pulmonary artery and capillary wedge pressures. Samples with advanced fibrosis had 921 up-regulated genes compared to the ones with early fibrosis. The up-regulated genes were enriched in extracellular matrix organization, regulation of cell adhesion, response to wounding, TGF-beta signaling pathway and blood vessel morphogenesis. Conclusions: Advanced fibrosis in patients with Fontan circulation exhibits up-regulated genes compared to early fibrosis, including pathways related to inflammation, congestion and angiogenesis, adding further insight into FALD pathophysiology.

Markers of bone metabolism are associated in all-cause mortality in heart failure with reduced ejection fraction

Abstract Background In patients with heart failure an increased risk of fracture-related mortality has been reported. A growing body of evidence suggests that, heart failure (HF) itself may be related to disturbances in bone metabolism, but the exact mechanism remains unclear. In patients with HF previous studies indicated a loss of renal function and alterations in bone micro-architecture, but the clinical relevance remains unclear. Purpose We aimed to evaluate the association between markers of bone metabolism with mortality and pro-brain natriuretic peptide (proBNP) in patients with HF with reduced ejection fraction (HFrEF). Methods We analysed participants of a prospective cohort study of patients referred to coronary angiography (CA). The baseline examination was performed at a tertiary care centre in Germany. Indications for CA were based on clinical routine. For the current analysis only patients with HFrEF were included. Patients were selected based on echocardiographic left ventricular (LV)-EF≤40%, symptoms of heart failure and elevated proBNP concentrations, as recommended by current clinical guidelines. We estimated the risk associated with parathyroid hormone (PTH), osteocalcin (OC), beta-crosslaps (βCL) and alkaline phosphatase (AP) and all-cause mortality using Cox proportional hazard models. Adjustments for demographic and clinical characteristics from the index hospital presentation were used as covariates. We included all individuals who had complete data for all variables in the study in our primary analysis. Additionally, we used linear regression analysis to investigate the correlation between proBNP and its association with PTH, OC, βCL and AP. Results A total of 297 participants (63.9±9.9 years; 17.9% females) were included in the analysis. Median follow-up was 10 years. Median LV-EF was 35%, median New York Heart Association functional class was 2 (IQR=1–3), mean pulmonary capillary wedge pressure was 15.3±7.4 mmHg and median proBNP levels of 2282 (IQR 1875–3758) ng/ml. Participants had in 42.3% multi-vessel atherosclerotic CAD (with stenosis of ≥50% considered diagnostic) with 66.4% had a previous myocardial infarction. In multivariate cox proportionate hazard models OC, βCL and AP were statistically significant associated with an increased risk for all-cause mortality (hazard ratio (HR)=1.6 [95% CI 1.2–2.2], HR=1.8 [95% CI 1.1–2.9] and HR=2.1 [95% CI 1.5–2.9], respectively). In multivariate analysis proBNP was associated with PTH (β-coefficient = 0.076; P≤0.001), AP (β-coefficient = 0.125; P=0.001) and βCL (β-coefficient = 0.062; P=0.046), but not with osteocalcin (β-coefficient = −0.055; P=0.145). Conclusion In patients with HFrEF markers of bone metabolism were significantly associated with mortality and proBNP concentrations. Future studies should focus on different aspects of bone metabolism, fracture rates and fracture related mortality in patients with different stages of heart failure. Funding Acknowledgement Type of funding sources: None.

Echocardiographic assessment alone is inadequate for determining elevated left sided filling pressures in patients with cardiogenic shock

Abstract Background Left atrial (LA) filling pressure assessment is of paramount importance in tailoring treatments for patients with cardiogenic shock (CS). ESC guidelines advocate for the use of mitral inflow Doppler and mitral annulus tissue Doppler measurements to predict elevated left atrial pressure in clinical practice. Echocardiographic measurement of LA pressures could reduce the need for invasive monitoring in CS patients, but its utility remains unproven in this population. Purpose We assessed the validity of mitral inflow velocity and mitral annulus velocity indices to determine LA pressures, correlating them with invasive measurement of pulmonary capillary wedge pressure (PCWP) in CS patients admitted to the cardiac intensive care unit (CICU). Methods We prospectively evaluated consecutive patients who underwent pulmonary artery catheter insertion in the CICU, measuring their haemodynamic parameters, including PCWP. This was immediately followed by a transthoracic echocardiography (TTE) performed by a critical care cardiologist, blinded to the invasive measurements. The early (E) and late (A) mitral inflow velocities were measured using mitral inflow Doppler and septal and lateral mitral annulus velocities (e') were measured using tissue Doppler, all in the apical 4-chamber view. TTE images were later reported by a second cardiologist, blinded to the invasive measurements and the patient. Correlations between E; E/A ratio; E/e' ratio and PCWP were evaluated using Pearson's correlation. Results Sixty patients were recruited into the study, aged 58±14 years, 27% female, with 96 assessments undertaken. The majority (55%) of patients were SCAI stage C, with 14% having had a cardiac arrest prior to CICU admission and 27% required mechanical ventilation at the time of assessment. Mean PCWP was 16.0±6.5 mmHg. Full mitral valve Doppler and tissue Doppler profiles were measured in 67 (70%) assessments, limited due to E/A fusion, atrial fibrillation and limited acoustic windows. There was only weak correlation between PCWP and E/A ratio (R=0.33, p=0.01), with no correlation between PCWP and the other measured values (Table 1), including E/e'. The AUC for identifying patients with elevated PCWP (≥15 mmHg) using E/A ratio was 0.67 (p=0.02), although there was no suitable value to use as a cut off with adequate sensitivity and specificity (Figure 1). Conclusion Echocardiographic non-invasive assessment of left sided cardiac filling pressures is technically challenging in patients with CS. Even when possible, there is weak correlation between echocardiographic and invasive measurements, suggesting limited value in this technique. Alternative non-invasive modalities, such as lung ultrasound, should be investigated in this population to assist clinical assessment. Funding Acknowledgement Type of funding sources: None.

HYDROXYCHLOROQUINE CAN BREAK YOUR HEART

HYDROXYCHLOROQUINE CAN BREAK YOUR HEART

Estimation of Changes in Intracardiac Hemodynamics Using Wearable Seismocardiography and Machine Learning in Patients With Heart Failure: A Feasibility Study.

Tracking changes in hemodynamic congestion and the consequent proactive readjustment of treatment has shown efficacy in reducing hospitalizations for patients with heart failure (HF). However, the cost-prohibitive nature of these invasive sensing systems precludes their usage in the large patient population affected by HF. The objective of this research is to estimate the changes in pulmonary artery mean pressure (PAM) and pulmonary capillary wedge pressure (PCWP) following vasodilator infusion during right heart catheterization (RHC), using changes in simultaneously recorded wearable seismocardiogram (SCG) signals captured with a small wearable patch. A total of 20 patients with HF (20% women, median age 55 (interquartile range (IQR), 44-64) years, ejection fraction 24 (IQR, 16-43)) were fitted with a wearable sensing patch and underwent RHC with vasodilator challenge. We divided the dataset randomly into a training-testing set (n = 15) and a separate validation set (n = 5). We developed globalized (population) regression models to estimate changes in PAM and PCWP from the changes in simultaneously recorded SCG. The regression model estimated both pressures with good accuracies: root-mean-square-error (RMSE) of 2.5 mmHg and R2 of 0.83 for estimating changes in PAM, and RMSE of 1.9 mmHg and R2 of 0.93 for estimating changes in PCWP for the training-testing set, and RMSE of 2.7 mmHg and R2 of 0.81 for estimating changes in PAM, and RMSE of 2.9 mmHg and R2 of 0.95 for estimating changes in PCWP for the validation set respectively. Changes in wearable SCG signals may be used to track acute changes in intracardiac hemodynamics in patients with HF. This method holds promise in tracking longitudinal changes in hemodynamic congestion in hemodynamically-guided remote home monitoring and treatment for patients with HF.