Mean Pulmonary Pressure Research Articles

Single-Ventricle Outcomes After Neonatal Palliation of Severe Ebstein Anomaly With Modified Starnes Procedure.

We have previously shown that neonates in profound cardiogenic shock caused by a severe Ebstein anomaly can be successfully salvaged with fenestrated right ventricular exclusion and systemic to pulmonary shunt (modified Starnes procedure). The long-term outcome of single-ventricle management in these patients is not known. We retrospectively reviewed the records of patients who underwent neonatal Starnes procedure between 1989 and 2015. Patient demographics, clinical variables, and outcome data were collected. Twenty-seven patients (13, 48% boys) underwent the Starnes procedure at 7 (5-9) days of life. All were intubated and on prostaglandin, 24 (89%) were inotrope dependent, and 22 (81%) had no antegrade flow from the right ventricle. Three patients underwent nonfenestrated right ventricular exclusion, 2 (67%) of whom died. Of the remaining 24, 3 (13%) died during the same hospitalization. The 22 neonatal survivors have been followed for 7 (6-8) years: 1 patient is awaiting a Glenn procedure; 1 died after undergoing a Glenn procedure; and the remaining 20 patients have successfully undergone Fontan completion. Their indexed pulmonary vascular resistance was 1.8 (1.2-2.3) W/m2, and mean pulmonary pressure was 12 (9-18) mm Hg. At last follow-up, 1 patient had died, and the remaining patients had normal left ventricular function, and all but 1 have New York Heart Association class I symptoms. Two patients have required pacemaker implantation, whereas the rest are in sinus rhythm. Survival for the entire cohort at 1, 5, and 10 years is 81±4%, 81±5%, and 76±3%, respectively, whereas for those with fenestrated right ventricular exclusion, survival at 1, 5, and 10 years is 87±2%, 87±2%, and 81±4%, respectively. Long-term single-ventricle outcomes among neonatal survivors of the modified Starnes procedure are excellent. There is reliable remodeling of the excluded right ventricle and good function of the left ventricle.

Isolated Unilateral Absence of Pulmonary Artery: Adult Manifestations of a Congenital Disease

SESSION TITLE: Student/Resident Case Report Poster - Pulmonary Vascular Disease I SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Unilateral absence of pulmonary artery (UAPA) is a rare congenital disorder. In the absence of other lesions, is survivable into adulthood. Adult patients can present with chest pain (CP), dyspnea on exertion (DOE), recurrent infections, or hemoptysis. Clinical diagnosis is difficult without radiographic support. CASE PRESENTATION: 56 year-old female former smoker with moderate obstructive lung disease presented for second opinion after multiple hospital admissions for CP, DOE and recurrent bronchitis. Hyper-inflated left lung, right mediastinal shift, and absent right hilar shadow noted on chest x-ray (CXR). CT angiogram revealed hypoplastic right lung with right greater left centrilobular emphysema, right nodularity, ground glass, and abrupt cessation right pulmonary artery. Right and left heart catheterization revealed mean pulmonary pressure of 27, and large arterial fistula between the left circumflex coronary artery and several branches of the right pulmonary vasculature. CT coronaries showed proximal interruption of the right pulmonary artery with collateral vasculature recruited from SA nodal branch of the left circumflex, bronchial, internal mammary, intercostal, and phrenic arteries. DISCUSSION: Adult patients with isolated UAPA are often asymptomatic. Common presentations are pulmonary infections, CP, DOE, hemoptysis or pulmonary hypertension (PAH). CXR shows ipsilateral contracted lung with mediastinal, tracheal shift toward the affected side, absent hilar shadow, and contralateral lung hyperinflation. Diagnosis is confirmed with contrast-enhanced CT. Recurrent infections can be secondary to poor blood flow to the affected lung, reduced delivery of inflammatory cells and impaired ciliary function. Decreased blood flow can also result in alveolar hypocapnia causing secondary bronchoconstriction and mucus trapping. PAH results from increased blood flow to the contralateral pulmonary artery, increased shear endothelial stress, and release of vasoconstrictors. Our patient's chest pain was felt not due to coronary steal as cardiac stress testing was negative. There is no clear consensus on treatment for UAPA other than symptom management. CONCLUSIONS: Although isolated UAPA is a congenital abnormality, it can remain undetected until adulthood. Clinicians need to be aware of characteristic CXR findings that may suggest UAPA. . Reference #1: Harke, A et al. Isolated Unilateral Absence of a Pulmonary Artery: A Case Report and Review of the Literature.” CHEST 2002; (122.4) 1471-477. Reference #2: Yiu MWC et al. Radiological features of isolated unilateral absence of the pulmonary artery. J HK Coll Radiol. 2001;4:277-280. Reference #3: Kruzliak, P et al. Unilateral Absence of Pulmonary Artery: Pathophysiology, Symptoms, Diagnosis and Current Treatment. Archives of Cardiovascular Diseases 2013; 106.8-9: 448-54 DISCLOSURE: The following authors have nothing to disclose: Santosh Reddy, Kimberly Cao No Product/Research Disclosure Information

Transcatheter Edge-to-Edge Treatment of Functional Tricuspid Regurgitation in an Ex Vivo Pulsatile Heart Model

BackgroundAlthough associated with left heart pathologies, functional tricuspid regurgitation (FTR) is often left untreated during left heart surgery. Hence, owing to its degenerative character, reoperation is often needed, encompassing an impressive (25% to 35%) mortality rate. Thus transcatheter approaches to FTR are raising great interest. ObjectivesThe authors evaluated the post-treatment effectiveness of the edge-to-edge technique using the percutaneous mitral valve repair device in an ex vivo pulsatile model of FTR. MethodsThe devices were implanted in 11 porcine hearts simulating FTR. In each heart, single-clip treatments involved grasping leaflet pairs in the medial or commissural position (6 combinations). Two-clip treatments were then performed considering all possible 15 combinations of leaflet pairs and medial/commissural grasping. Cardiac output, mean pulmonary pressure, and mean diastolic valve pressure gradient were evaluated in physiological and simulated pathological conditions (FTR), and post-treatments. ResultsGrasping the septal and anterior leaflets allowed for the best post-procedural outcome, ensuring a complete re-establishment of physiological-like hemodynamics. Septal and posterior grasping induced a significant recovery from FTR, although less marked. Conversely, grasping the anterior and posterior leaflets did not reduce FTR, and was detrimental in some specific cases. ConclusionsThis experimental work demonstrated that the transcatheter edge-to-edge repair technique is a feasible approach for FTR. The study investigated this approach to develop a selective, specific structural intervention methodology for treating FTR, considering the several biomechanical factors that alter proper functionality of valvular substructures. These results can be used to guide the development of edge-to-edge repair techniques in treatment of FTR.

Preoperative Echocardiography Examination of Right Ventricle Function in Patients Scheduled for LVAD Implantation Correlates with Postoperative Hemodynamic Examinations

BACKGROUND Left ventricular assist devices (LVAD) are used to treat heart failure. Preoperative prediction of RV function after LVAD implantation is crucial. Correlations were found between preoperative echo and RV function after LVAD implantation. MATERIAL AND METHODS We retrospectively reviewed 23 male patients (8 ischemic, 15 nonischemic cardiomyopathy) with LVAD implantation (17 HeartWare, 6 HeartMate II) at the Silesian Center for Heart Diseases from 1 January 2013 to 28 October 2014. Preoperative TTE data of RV function included RVFAC (fractional area change), TAPSE (tricuspid annulus plane systolic excursion), RV diameter (RV4), and RV/LV (right/left ventricle) ratio. Postoperative hemodynamic mean pulmonary pressure (mPAP), central venous pressure (CVP), cardiac output (CO), and cardiac index (CI) were measured and recorded every 2 h up to 10 days (1, 2, …120) and correlated. Study endpoints were mortality, discharge from ICU, and RV dysfunction. RESULTS There were no RV dysfunctions. Correlations of CO and CI with RV4 and RV/LV ratio were significantly positive at many time points, with TAPSE and FAC positive or negative. Correlations mPAP with RV4 were significantly positive: 1, 2, 3, 7, 8, 57, 58, 59. With RV/LV ratio positive: 44, 47, with TAPSE in 36. With FAC positive 11, 13-15, 22 and negative 57. Correlations CVP with RV4 were negative, with positive significance in 1, 52. With RV/LV ratio positively 52, 54, 56 and negative 71, 72, 73. With TAPSE were negative significantly: 30, 68. With FAC positive 11, 12, 13, 14 and negative: 68. CONCLUSIONS RV4 and RV/LV ratio before LVAD implantation are more predictive for postoperative RV function than RVFAC and TAPSE, probably because RVFAC and TAPSE are load-dependent.

Abstract 262: A Rat Model of Heart Failure With Preserved Ejection Fraction Induced by Pressure Overload

The absence of animal models displaying clinical phenotypes of HFpEF represents a challenge to the pharmaceutical industry in the hope of identifying novel treatments that would benefit patients with this syndrome. We, at Merck, examined the supracoronary aortic banding (SAB) in rats as a potential model and set out to characterize its phenotypes. Juvenile Sprague-Dawley rats were used; a hemostatic clip with an opening of 0.7 mm was placed around the ascending aorta to elicit a pressure overload to the LV. Echocardiography was performed every 3 weeks and invasive hemodynamics was measured at week 9 to evaluate cardiac structural and functional effects; heart and lungs were harvested at the end for morphological and histological analysis. Nine weeks after SAB, LV hypertrophy and dysfunction were apparent, as manifested by increases in LVEDP, left atrial pressure, plasma BNP, LV and lung weights; LV relaxation time constant (Tau) and mitral early to late inflow ratio (E/A) were also increased; while EF and FS were preserved (see table, mean ± SEM). In addition, SAB rats had elevated mean pulmonary pressure (sham 14 ± 1.7 vs. SAB 37 ± 4.4 mm Hg, p<0.05) with an abnormal transpulmonary gradient (sham 12 ± 2.5 vs. SAB 23 ± 0.1 mm Hg, p<0.05), indicating comorbidity of pulmonary hypertension. Finally, piloerection, dyspnea and loss of muscle mass were evident and exercise tolerance measured by treadmill test was decreased in SAB rats. In summary, rats undergoing SAB exhibit many of the clinical phenotypes of HFpEF. Further work includes examining the effects of novel therapies in SAB rats on improving these clinical phenotypes of HFpEF and expanding the model to study morbidity and mortality.

Prevalence, Predictors and Clinical Outcome of Residual Pulmonary Hypertension Following Tricuspid Annuloplasty.

BackgroundTricuspid annuloplasty is increasingly performed during left heart valve surgery, but the long‐term clinical outcome postoperatively is not satisfactory. The aim of this study was to determine whether residual pulmonary hypertension (PHT) contributes to the adverse outcome.Methods and ResultsOne‐hundred thirty‐seven patients (age 61±11 years; men, 30%) who underwent tricuspid annuloplasty during left‐side valve surgery were enrolled. The mean pulmonary artery systolic pressure before surgery was 49±13 mm Hg and 32±15 mm Hg following surgery. Patients were divided into 3 groups according to postoperative pulmonary artery systolic pressure: no residual PHT (n=78, 57%), mild residual PHT (n=43, 31%), or significant residual PHT (n=16, 12%). A preoperative larger right ventricular (RV) geometry and tricuspid valve tethering area were associated with mild or significant residual PHT. A total of 24 adverse events (20 heart failures and 4 cardiovascular deaths) occurred during a median follow‐up of 25 months. Kaplan–Meier survival curve demonstrated that patients with significant residual PHT had the highest percentage of adverse events followed by those with mild residual PHT. Patients with no residual PHT had a very low risk of adverse events. Multivariable Cox regression analysis revealed that both mild (hazard ratio=4.94; 95% CI =1.34–18.16; P=0.02) and significant residual PHT (hazard ratio=8.67; 95% CI =2.43–30.98; P<0.01) were independent factors associated with adverse events.ConclusionsThe present study demonstrated that 43% of patients who underwent tricuspid annuloplasty had residual PHT. The presence of mild or significant residual PHT was associated with adverse events in these patients.

Similar hemodynamic decongestion with vasodilators and inotropes: systematic review, meta-analysis, and meta-regression of 35 studies on acute heart failure.

Acute heart failure (AHF) with reduced left-ventricular ejection fraction (LVEF) is often a biventricular congested state. The comparative effect of vasodilators and inotropes on the right- and/or left-sided congestion is unknown. A systematic review, meta-analysis, and meta-regression of AHF studies using pulmonary artery catheter were performed using PubMed, Embase, and Cochrane library. Data from 35 studies, including 3016 patients, were studied. Included patients had a weighted mean age of 60years, left-ventricular ejection fraction (LVEF) of 24%, and plasma B-type natriuretic peptide (BNP) of 892pg/ml. Both the left- and right-ventricular filling pressures were elevated: weighted mean pulmonary artery wedge pressure (PAWP) was 25mmHg (range 17-31mmHg) and right atrial pressure (RAP) 12mmHg (range 7-18mmHg). Vasodilators and inotropes had similar beneficial effects on PAWP [-6.3mmHg (95% CI -7.4 to -5.2mmHg) and -5.8mmHg (95% CI -7.6 to -4.0mmHg), respectively] and RAP [-2.9mmHg (95% CI -3.8 to -2.1mmHg) and -2.8mmHg (95% CI -3.8 to -1.7mmHg), respectively]. Among inotropes, inodilators, such as levosimendan, have greater beneficial effect on the left-ventricular filling pressure than dobutamine. Drug-induced improvement of PAWP tightly paralleled that of RAP with all studied drugs (r 2=0.90, p<0.001). Vasodilators and inotropes had no short-term effect of renal function. The left- and right-sided filling pressures are similarly improved by vasodilators or inotropes, in AHF with reduced LVEF.

Transcatheter Aortic Valve Replacement with the CoreValve in High- Risk, Extra-High-Risk, or Inoperable Patients: Midterm Follow-Up, the St. Luke’s Global City Heart Institute Experience

Background: Symptomatic, severe aortic stenosis (AS) is a potentially life-threatening and functionally limiting disease that typically affects the elderly. Such patients often have multiple comorbidities, which adversely influence outcomes of surgical aortic valve replacement (SAVR). As an effective minimally invasive valve replacement technique for high-risk patients with severe symptomatic AS, transcatheter aortic valve replacement (TAVR) is comparable to SAVR. This study reports the authors’ TAVR experience with the CoreValve THV (Medtronic) in 51 high-risk, extra-high-risk, or inoperable patients with severe aortic valve disease. Methods: All patients were assessed and risk stratified by a multidisciplinary team of cardiologists, surgeons, and cardiac anesthetists using the Society of Thoracic Surgeons (STS) score and logistic EuroSCORE (LE), computed tomography angiography (CTA), 2D echocardiography and coronary angiography. Coronary artery revascularization was done when indicated. Echocardiography and clinical follow-up was done at 1, 3, 6 and 12 months; and then every year thereafter or whenever clinically indicated. TAVR was done at the cardiac catheterization laboratory with transesophageal echocardiography (TEE) guidance and mostly under general anesthesia. The femoral approach was used whenever possible. Those with unsuitable femoral anatomy underwent subclavian or direct aortic implantation. Results: A total of 51 patients underwent TAVR. Twenty-seven (53%) were males; mean age was 77.8 years. Forty-nine had severe, symptomatic, calcific AS; two had severe aortic regurgitation (AR). Forty-nine (96%) had congestive heart failure, 34 of which were in New York Heart Association (NYHA) classes III–IV. Two (4%) had recurrent syncope. Fifty-one (100%) had hypertension; 32 (63%) had chronic obstructive pulmonary disorder; and 40 (78%) had coronary artery disease. The mean STS and LE scores were 10.71 and 15.31, respectively. The mean left ventricular ejection fraction (LVEF) was 55%; mean aortic valve area (AVA), 0.65 cm2; peak and mean gradients, 80.19 mmHg and 49.17 mmHg, respectively; and mean pulmonary artery pressure, 45.2 mmHg. Procedural success was 98%, with 30-day all-cause mortality of 8%. Mean hospital stay was 10.13 days. Twelve (23.5%) had permanent pacemaker implantation for high-grade atrioventricular block. Mean follow-up was 446.2 days. On follow-up, 5 (10%) had died of noncardiac causes, 1 (2%) of sudden cardiac death 16 months after implantation. Serial echocardiograms demonstrated no AR in 25 (51%); trivial to mild, 14 (29%); moderate to severe periventricular leucomalacia, 1(2%). Mean and peak follow-up gradients were 17.947 (p≤0.0001) and 9.417 mmHg (p≤0.0001), respectively; mean AVA, 1.84 cm2 (p≤0.0001); mean LVEF, 59.39% (p=0.003); mean pulmonary artery systolic pressure, 43.47 mmHg (p=0.599). Thirty-eight surviving patients remain in NYHA Class I, while 4 are Class II (p=0.002). Conclusion: TAVR in high-risk, extra-high-risk, or inoperable patients can be performed with high procedural success and acceptable 30-day mortality. Valve performance, valve gradients and AVA remain stable and significantly improve on follow-up. Most patients remain in functional Class I. Follow-up noncardiac mortality appears to be a function of multiple complex comorbidities among extra-high risk or inoperable patients.

Investigation of prognostic effect of red cell distribution width on chronic thromboembolic pulmonary hypertension in patients with acute pulmonary embolism

Objective To investigate the clinical characteristics of acute pulmonary embolism in the elderly and its differences between the elderly and non-elderly patients, and explore the predictive effect of red blood cell distribution width(RDW)on chronic thromboembolic pulmonary hypertension(CTEPH)in patients with acute pulmonary embolism. Methods A total of 129 consecutive patients with acute pulmonary embolism admitted into Affiliated Hospital of Binzhou Medical College were selected from Jan.2009 to Dec.2013.Clinical data including the basic data, blood routine test, blood gas analysis, Doppler echocardiography during admission were retrospectively analyzed.All the patients were followed-up.Ancillary findings and changes of the disease were recorded in detail during the follow-up period.SPSS 19.0 was used to analyze the results. Results The incidences of CEPPH and venous thromboembolism(VTE)in APE patients were higher in the elderly than in non-elderly.The mean RDW and pulmonary arterial systolic pressure on admission in APE patients were higher in the elderly than in non-elderly [(14.22±2.11)% vs.(13.48±1.69)%, P=0.033, for mean RDW] and [(54.82±21.77)mmHg vs.(42.20±19.36)mmHg, P=0.010 for pulmonary arterial systolic pressure]. The mean RDW was higher in CTEPH patients than in patients without CTEPH [(16.79±3.08)% vs.(13.68±1.68)%, P=0.016]. Multivariate Logistic analyses showed that the increased RDW level was an independent risk factors for CTEPH in APE patients(OR=1.535, 95% CI: 1.094-2.155, P=0.013). The area under receiver operating characteristics curve(AUC)of RDW level for predicting CTEPH in APE patients was 0.856(95% CI: 0.706-0.987, P<0.001), the corresponding cut-off point was 14.85%, and the sensitivity and specificity were 88.9% and 87.5% respectively. Conclusions The increased RDW level could predict the risk of CTEPH to a certain extent in APE patients. Key words: Pulmonary embolism; Hypertension, pulmonary; Erythrocytes

Right Ventricular Function in Patients With Left Ventricular Assist Device Support by Pulsatile Polvad MEV and Continuous-Flow Pumps Heartware and Heartmate II

BackgroundLeft ventricular assist device (LVAD) support is increasingly used in patients with heart failure. The right ventricle (RV) plays a main role in LVAD support. Little is known about the effects of pulsatile Polvad MEV devices or continuouseconds flow pumps on RV function. We compared hemodynamic parameters of RV in patients after implantation of Polvad MEV (PM) and Heartware (HW) or Heartmate II (HMII) LVADs. MethodsForty-four patients were retrospectively reviewed after implantation of PM (group P; n = 24 [21 M, 3 F]) or HW or HMII (group C; n = 20 [20 M, 0 F]) LVADs from April 2007 to February 2014. Hemodynamic data—mean pulmonary pressure (mPAP), central venous pressure (CVP), cardiac output (CO), and cardiac index (CI)—were collected before surgery, after surgery, and every 2 hours in the intensive care unit, with the time points numbered from 1 to 120. Right ventricular work (RVW) was calculated according to the equation: RCW = CO × (mPAP − CVP) × 0.0144 (g·m). ResultsBaseline characteristic of the patients were similar. mPAP values were similar between groups. CVP values were higher in group P, significantly at time points 5 and 7–33. CO values were higher in group C, significantly from point 3 and almost all the time to point 43. CI reached significance at point 9, 12–14, 16–19, and 30–41. RCW was higher in group P before implantation. Post-implantation RCW values were higher in group C, significantly at time points 19, 20, 32–34, 51–53, and 55–57. ConclusionsContinuous-flow pumps more effectively optimize RV function than pulsatile LVADs, which can result in more effective prevention of RV failure or insuffiency in that group.

Effect of Exercise on Pulmonary Arterial Capacitance in Heart Failure

PURPOSE: Heart failure is often associated with abnormal pulmonary hemodynamics. Pulmonary arterial capacitance (PAC) is a measure of the distensibility of the pulmonary vasculature and is a determinant of right ventricular afterload. Previously it has been shown that, at rest, PAC demonstrates a hyperbolic relationship with pulmonary vascular resistance (PVR) in heart failure (HF) patients and is an independent predictor of mortality. Our aim was to determine how exercise affects PAC and its relationship with exercise capacity and indices of respiratory gas exchange. METHODS: 39 HF patients undergoing right heart catheterization performed incremental exercise to exhaustion. Pulmonary arterial systolic pressure (PAPs), pulmonary arterial diastolic pressure (PAPd), mean pulmonary artery pressure (PAPm), and mean pulmonary wedge pressure (PWPm) were measured invasively at rest and at peak exercise. Ventilation (VE), oxygen consumption (VO2), carbon dioxide production (VCO2), and heart rate (HR) were continuously collected at rest and during exercise. Arterial and mixed venous blood samples were collected for determination of cardiac output (Q) via direct Fick. The following variables were then calculated: stroke volume (SV)=Q/HR; PAC=SV/(PAPs-PAPd); PVR=(PAPm-PWPm)/Q. RESULTS: PAC significantly decreased from rest to peak exercise (2.6 vs. 1.6 ml/mmHg, p<0.01). At peak exercise, PAC was correlated with VO2max (PAC=0.29*VO2max-0.87, R=0.74). PAC was negatively correlated to PVR at rest (R=0.85) and during exercise (R=0.82) according to a hyperbolic fit. PAC was negatively correlated to VE/VCO2 at rest (R=0.53) and during exercise (R=0.52) according to a hyperbolic fit. CONCLUSIONS: In patients with classic systolic HF, PAC is reduced and falls further with exercise. In addition, subjects with the greatest capacitance to accept increases in pulmonary blood volume have a better exercise capacity. This increased pulmonary vascular distensibility during exercise yields lower resistance to forward flow. The gas exchange measure ventilatory efficiency, a marker of disease severity and prognosis in HF patients, is also related to reduced PAC. Supported by NIH grant HL71478.

0036 : Prognostic value of concomitant aortic regurgitation in patients operated for severe aortic stenosis

The aim of this study was to evaluate the prognostic value of concomitant aortic regurgitation (AR) in patients operated for severe aortic stenosis (AS) by examining the impact of presence and severity of concomitant AR in patients operated for severe AS on short-term outcome. Retrospective study including 37 consecutive patients operated due to severe AS. Patients were divided in two groups, G1: AS group (n=15) and G2: AS + AR (n=22). All patients had a transthoracic echography a week and 6 months after cardiac surgery. Patients mean age was 59,08 with older patients in group 66,16±6,4 vs 54,27±16,3 (p=0,012). 59,5% of the patients were males. Dyspnoea was the predominating symptom (74%) with 40% in stage II and 26% in stage III of NYHA. Coronary artery disease was more frequent in G1 (33% vs 14%; p=0,079, NS). Pre-operative echocardiography showed no difference between the two groups for left ventricular ejection, LV hypertrophy, mean aortic gradients, aortic area and pulmonary pressure. However mean LV diameters were greater in G2 with a mean LV end diastolic diameter (LVEDD) à 58,95±8,4 mm vs 51,2±8,19 mm (p=0,018) and LV end systolic diameter (LVESD) à 39,6±10,5 mm vs 33,2±8,79 mm (p=0,049). Immediate and short-term echocardiographic follow-up showed no difference between the 2 groups. Only LV diameters were greater in G2 avec un LVEDD 59,1 mm vs 51 mm (p=0,03) et LVESD 40,3 mm vs 33,2 mm (p=0,02) à 1 week and LVEDD at 58, 8±9,9 mm vs 50,7±8,19 mm (p=0,032) and LVESD à 40,1±9,7 mm vs 32,8±12 mm (p=0,024) at 6 months. Our data indicate that the preoperative presence of concomitant AR was associated with greater LV diameters. The author hereby declares no conflict of interest

(1051) - Performance of Continuous Flow Left Ventricular Assist Devices for the Smaller Size Patient Population

Since continuous flow left ventricular assist devices (CF-LVAD) became a standard care for end-stage heart failure patients, it is still a challenge to implant CF-LVAD for smaller size patients. We analyzed mid-term outcomes of these patients. CF-LVADs were implanted in 73 patients (15 female, 40±13 year-old, 51 dilated cardiomyopathy) for the purpose of bridge to heart transplantation (HTx) (BTT) and implanted devices were HeartMateII in 36, EVAHEART in 17, Jarvik2000 in 10, DuraHeart in 9 and HeartWare in 1.The average body surface are (BSA) was 1.65±0.19 m2 (1.22-2.07). These patients were divided into two groups, standard group (BSA>1.6m2, n=43) and small group (BSA≤1.6m2, n=30). Mid-term clinical outcomes and data collected from post-implant echocardiography and catheter examination (obtained from 63 patients) were compared between two groups. Optimal LVAD pump speed was set by clinical parameters including echocardiography. The average support period was 1.7±1.1 years (0.1-4.3). Post-implant catheter data showed no significant difference between two groups in cardiac index (2.9±0.6L/m2 in small group, 2.8±0.5L/m2 in standard group, p=0.27) and mean pulmonary pressure 14±4 mmHg, 16±6 mmHg, p=0.10). Echocardiography at 1 month showed left ventricular dimension was significantly reduced in both group and there were no significant difference between two groups (18±15%, 14±17%, p=0.29). There were no operative deaths and 4 late deaths due to cerebrovascular accident (CVA) in 3 and right heart failure in 1. One- and 2-year survival rate (censored by HTx and recovery) for overall patients were 97% and 95%, respectively, and there were no significant difference between two groups (Log-rank test, p=0.59). CVA were recorded in 24 patients and 1- and 2-year freedom from CVA were 68% and 62%, respectively, and there were no significant difference between two groups (p=0.49). Serial echocardiography showed that 1- and 2-year freedom from mild or greater aortic regurgitation were 84% and 63% and there were no significant difference between two groups (p=0.60). CF-LVAD provided excellent clinical outcomes for small size patients in terms of survival and hemodynamics. There were no significant difference between small size patients and standard size patients.

Midterm benefits of surgical pulmonary embolectomy for acute pulmonary embolus on right ventricular function

ObjectiveSurgical pulmonary embolectomy has been used for the successful treatment of massive and submassive pulmonary emboli. The purpose of this study is to document the short- and midterm echocardiographic follow-up of right ventricular function after surgical pulmonary embolectomy for acute pulmonary embolus. MethodsA retrospective review of the local Society of Thoracic Surgeons database of patients who underwent surgical pulmonary embolectomy for acute pulmonary embolectomy was conducted from 1998 to 2014 at a US academic center. Patients with chronic thrombus were excluded. The institutional echocardiographic database was searched for follow-up studies to compare markers of right ventricular function. Unadjusted outcomes were described, and quantitative comparisons were made of short- and long-term echocardiographic data. ResultsA total of 44 patients were included for analysis; 35 patients (79.5%) had a submassive pulmonary embolectomy, and 9 patients (20.5%) had a massive pulmonary embolectomy and required preoperative inotropy. Mean cardiopulmonary bypass time was 68.0 ± 40.2 minutes, and 30 patients (68.2%) underwent procedures without aortic crossclamping. There was 1 in-hospital mortality (2.3%), and there were no permanent neurologic deficits. A total of 21 patients had echocardiography results available for follow-up. Perioperative echocardiographic data showed an immediate decrease in tricuspid regurgitant velocity and right ventricular pressure (P < .05). Mean midterm echocardiographic follow-up was 30 months in 12 patients. At midterm follow-up, improvements in right ventricular function observed postoperatively persisted. Only 1 patient had moderate right ventricular dysfunction, and no patient had worse than mild tricuspid regurgitation. Mean tricuspid valve regurgitant velocity was 2.4 ± 0.7 m/s, and mean pulmonary artery systolic pressure was 37.2 ± 14.2 mm Hg. ConclusionsSurgical pulmonary embolectomy may represent optimal therapy in selected patients for massive and submassive acute pulmonary emboli given the low morbidity and mortality rates. Echocardiographic follow-up shows preserved improvement in right ventricular function in the majority of patients.

Main pulmonary arterial wall shear stress correlates with invasive hemodynamics and stiffness in pulmonary hypertension.

Pulmonary hypertension (PH) is associated with proximal pulmonary arterial remodeling characterized by increased vessel diameter, wall thickening, and stiffness. In vivo assessment of wall shear stress (WSS) may provide insights into the relationships between pulmonary hemodynamics and vascular remodeling. We investigated the relationship between main pulmonary artery (MPA) WSS and pulmonary hemodynamics as well as markers of stiffness. As part of a prospective study, 17 PH patients and 5 controls underwent same-day four-dimensional flow cardiac magnetic resonance imaging (4-D CMR) and right heart catheterization. Streamwise velocity profiles were generated in the cross-sectional MPA in 45° increments from velocity vector fields determined by 4-D CMR. WSS was calculated as the product of hematocrit-dependent viscosity and shear rate generated from the spatial gradient of the velocity profiles. In-plane average MPA WSS was significantly decreased in the PH cohort compared with that in controls (0.18 ± 0.07 vs. 0.32 ± 0.08 N/m(2); P = 0.01). In-plane MPA WSS showed strong inverse correlations with multiple hemodynamic indices, including pulmonary resistance (ρ = -0.74, P < 0.001), mean pulmonary pressure (ρ = -0.64, P = 0.006), and elastance (ρ = -0.70, P < 0.001). In addition, MPA WSS had significant associations with markers of stiffness, including capacitance (ρ = 0.67, P < 0.001), distensibility (ρ = 0.52, P = 0.013), and elastic modulus (ρ = -0.54, P = 0.01). In conclusion, MPA WSS is decreased in PH and is significantly associated with invasive hemodynamic indices and markers of stiffness. 4-D CMR-based assessment of WSS may represent a novel methodology to study blood-vessel wall interactions in PH.

0386: Prevalence, characteristics and prognosis of moderate to severe tricuspid regurgitation in patients with precapillary pulmonary hypertension

Our study aim to characterize clinical, biological, echocardio-graphic and hemodynamic parameters related with severity of TR and if TR is associated with higher risk of acute right ventricular heart failure (ARVHF) or death in PPH patiens. We reviewed data from 116 stable patients referred to the French pulmonary hypertension referral center. All patients had right heart catheterization with mean pulmonary pressure (mPAP) >25mmHg, with pulmonary wedge pressure <15mmHg and pulmonary vascular resistance (PVR) >3 WU. On echo-cardiography, severity of TR was determined from 2-dimensional and Doppler color flow image in the apical 4-chamber view. Patients were divided in two groups according to the severity of TR (TR <grade 3 and TR ≥grade 3). 37 (32%) patients have TR grade ≥3. Compared with patients TR <grade 3, no difference were observed in gender, NYHA class, and 6-minute walk distance. On RCH, both groups had similar mPAP, cardiac index, right atrial mean pressure and pulmonary vascular resistance. On echocardiography, Patients with TR grade ≥3 have higher right atrial volume (57 (45-70) vs 36 (32-40)mL/m 2 , p<0.001), higher end-diastolic right ventricular area (16 (14-17) vs 14 (13-15)cm 2 /m 2 , p=0.04), higher end-systolic right ventricular area (12 (10-14) vs 10 (9-11)cm 2 /m 2 , p=0.01), and higher BNP level (248 (141-355) vs 102 (59-144)pg/mL, p=0.003). There were no difference in tricuspid annular plane systolic excursion nor in tricuspid S’ velocity. During a median follow up of 17 months, death or ARVHF was observed in 14% of patients with TR grade ≥3 and 7% of patients with TR grade <3 with no statistical difference. PPH patients with TR grade ≥3 have higher right atrial volume, end-diastolic and end-systolic right ventricular area and BNP level compared with patients with TR <grade 3. There was more numerous major events in follow up in this group, without statistical difference.

Abstract 14156: Airway Gene Delivery of Serca2a Ameliorates Chronic Pulmonary Hypertension in a Large Animal Preclinical Model

Downregulation of sarcoplasmic reticulum Ca2+-ATPase 2a (SERCA2a) in the pulmonary vasculature leads to perturbations in Ca2+ homeostasis, endothelial dysfunction, and transition of pulmonary artery smooth muscle cells from a contractile to a proliferative phenotype. To assess the feasibility and benefits of sustained pulmonary vascular SERCA2a gene transfer, we created a model of chronic post-capillary PH in Yorkshire swine by partial pulmonary vein banding. Development of chronic PH was hemodynamically confirmed, and animals were randomized to intratracheal administration of adeno-associated virus type 1 (AAV1) carrying the human SERCA2a gene (n=10, AAV1.SERCA2a group) or Saline (n=10). Transduction efficacy after intratracheal delivery of AAV1 was confirmed by β-galactosidase detection in the distal pulmonary vasculature and significant overexpression of SERCA2a protein at the distal airway and small pulmonary arteries. Two months after gene delivery, disease progression was prevented in AAV1.SERCA2a treated animals as assessed by mean pulmonary pressure (29[5] vs 54[20] mmHg, p=0.027, Figure) and pulmonary vascular resistance index (3.2[2.2] vs 10.3[7.1] Wood units*m2, p=0.020) along with decreased small vessel remodeling in the AAV1.SERCA2a group (p&lt;0.05). RV ejection fraction (61[7] vs 50[7] % units, p=0.014) was preserved and improvement of RV end-diastolic pressure-volume relationship (0.12[0.08] vs 0.28[0.07] mmHg/ml, p=0.08) in AAV1.SERCA2a treated pigs versus Saline. In conclusion, airway-based delivery of AAV vectors to the pulmonary arteries is feasible, efficient, and safe in a clinically relevant chronic PH model. Selective vascular SERCA2a overexpression results in beneficial effects on pulmonary hemodynamics and RV performance, and may offer therapeutic benefit by modifying fundamental pathophysiology in pulmonary vascular diseases.

Abstract 13111: Cardiac Determinants of Right Ventricular Pressure-Flow Response to Exercise in Heart Failure: A Non-Invasive Approach Combining Cardiopulmonary Exercise Testing and Exercise-Echocardiography

Background: The pulmonary pressure (PAP) over cardiac output (CO) exercise response has been proposed as expression of right ventricular (RV) to pulmonary circulation (PC) coupling. The functional implications and cardiac phenotype of PAP/CO slope in heart failure (HF) have never been investigated. Aim: To define the functional and cardiac characteristics related to an unfavorable RV-PC coupling in HFrEF. Methods: 87 HFrEF patients (mean age 65±11 y, male 70%, mean LVEF 33±9%) underwent a maximal CPET (incremental ramp protocol) combined with exercise-echo. MeanPAP/CO slope is calculated as the slope between the exercise increase in mean PAP and CO. Results: Population was divided into 2 groups according to mPAP/CO slope: Group A (n=27) slope &lt;3.5 mmHg/L*min and B (n= 60) slope≥3.5 mmHg/L*min. Patients with abnormal response (Group B) exhibited a worse functional capacity (lower maximal workload and peak oxygen consumption) and ventilatory efficiency (steeper VE/VCO2). Group B had also worse LV remodeling and higher prevalence of dynamic severe mitral regurgitation (MR), associated with elevated pulmonary arterial pressure (systolic PAP) and an impaired rest and peak CO. The best linear regression model identified age, gender, LV EDVi and rest and peak severe MR as main cardiac determinants of mPAP/CO slope. Conclusions: In HFrEF population, an unfavorable pulmonary pressure to cardiac output exercise response, or steeper mPAP/CO slope, is associated with advanced eccentric LV remodeling and dynamic severe MR, overall resembling the most unfavorable functional phenotype.

Abstract 17885: Pulmonary Vascular Compliance Predicts Mortality in the Acute Respiratory Distress Syndrome

Introduction: Novel markers of prognosis in the acute respiratory distress syndrome (ARDS) are needed. Hypothesis: We hypothesized that pulmonary vascular compliance would predict outcome in ARDS, and that higher left heart filling pressure would be associated with increased pulsatile loading of the right ventricle manifested as reduced RC time. Methods: We performed a retrospective analysis of 392 subjects with a complete hemodynamic data set on trial day 0 in the ARDS Network Fluid and Catheter Treatment Trial of PA catheter use in ARDS. Pulmonary vascular compliance (Cpa) was calculated as stroke volume divided by PA pulse pressure. Pulmonary vascular resistance (PVR) was calculated as mean PA pressure minus pulmonary artery wedge pressure (PAWP) divided by cardiac output. The RC time was calculated as the product of PVR and Cpa. Cox proportional hazard modeling and Kaplan-Meier survival analysis were performed with primary outcome of death. Results: The mean age was 50 ± 16 years. Mean PA pressure and PAWP were both elevated (29 ± 8 mmHg and 15 ± 5 mmHg, respectively) as was cardiac output (7.7 ± 2.7 L/m). The mean PVR was 2.1 ± 1.2 Wood units and Cpa 4.6 ± 2.5 ml/mmHg. Mean RC time was 0.47 ± 0.24 seconds (s). With each 5 mmHg increase in PAWP, RC time decreased by 0.06 s (p&lt;0.0001 for slope). There was increased hazard of death per quartile decrease in Cp (HR 1.28, 95% CI 1.08-1.52; p = 0.004) and per quartile increase in PVR (HR 1.23, 95% CI 1.04-1.46; p = 0.02). Adjusted for APACHE III score, there remained a trend towards increased hazard of death per quartile increase in PVR (HR 1.2 95% CI 1.03-1.4, p = 0.02) and per quartile decrease in Cp (HR 1.18 95% CI 1.0-1.4, p = 0.055). Kaplan-Meier survival curves per quartile of Cp are shown in the Figure. Conclusion: Pulmonary vascular compliance predicts mortality in ARDS. Higher wedge pressure is associated with lower RC time in ARDS consistent with increased RV pulsatile loading.

Abstract 15388: Persistent Pulmonary Hypertension After Transcatheter Aortic Valve Implantation: Impact on Mortality

Objective: Severe aortic stenosis leads to increased pulmonary arterial systolic pressure. A controversy still remains regarding the impact of persistent pulmonary hypertension (PHT) on prognosis of patients undergoing transcatheter aortic valve implantation (TAVI). We sought to investigate the impact of persistent PHT on 2-year all-cause mortality of patients with severe aortic stenosis following TAVI. Methods: Patients with severe and symptomatic aortic stenosis (effective orifice area [EOA]≤1 cm 2 ) who were scheduled for TAVI with a self-expanding valve at our institution were prospectively enrolled. Prospectively collected echocardiographic data before and after TAVI were retrospectively analyzed in all patients. Pulmonary artery systolic pressure was estimated as the sum of the right ventricular to the right atrial gradient during systole and the right atrial pressure. PHT following TAVI was classified as absent if &lt;35 mmHg and persistent if ≥35 mmHg. Primary clinical end-point was 2-year all-cause mortality defined according to the criteria proposed by the Valve Academic Research Consortium-2. Results: Hundred and forty patients (mean age: 82±9 years) were included in the study. The primary clinical end point occurred in 17 patients (12%) during a median follow-up period of 2 years. Mean pulmonary artery systolic pressure was reduced in all patients following TAVI (45±9 versus 41±6 mmHg, p&lt;0.01). Mortality rate was higher in patients with persistent PHT compared to patients with normal pulmonary artery systolic pressure following TAVI (26% versus 14 %, p&lt;0.01). Patients that reached the primary clinical end point had a higher post procedural mean systolic pulmonary pressure (43±9 versus 39±6 mmHg, p=0.02). In multivariate regression analysis, persistence of PHT (OR: 2.51, 95% CI: 1.109-7.224, p=0.01) was an independent predictor of long-term mortality. Conclusions: The persistence of pulmonary hypertension after TAVI is associated with long term mortality. Identifying the population that will clearly benefit from TAVI is still need to be validated by larger trials.