Mean Right Atrial Pressure Research Articles

Doppler-Derived Intrarenal Venous Flow Mirrors Right-Sided Heart Hemodynamics in Patients With Cardiovascular Disease.

Interruption in Doppler intrarenal venous flow (IRVF) has been used in assessing renal congestion and in the prediction of prognosis of cardiovascular diseases. However, there is a paucity of pathophysiological knowledge, so we aimed to clarify the determinants of IRVF interruption. Intrarenal Doppler studies were performed within 24 h before right-side catheterization studies. The interruption in IRVF in 73 patients was divided into a continuous pattern, and 4 discontinuous types based on the timing of interruption. Type 1, with an interruption in early systole, was associated with a-wave elevation of right atrial pressure (RAP). Type 2, with an interruption in early diastole, was associated with v-wave elevation, tricuspid regurgitation (TR), and right ventricular dysfunction. Both Type 1 and 2 were observed even in the normal range of mean RAP. Type 3, with an interruption throughout systole, was observed in advanced right heart failure patients with markedly elevated RAP, particularly elevated x-descend and atrial fibrillation. Finally, Type 4, with limited flow at systole, was observed in 2 of the patients with pulmonary arterial hypertension. IRVF interruption was closely related to RAP elevation at each specific point of the cardiac cycle rather than to mean RAP levels, suggesting that the characteristics of IRVF mirror right-sided heart hemodynamics, not mean RAP.

Relationship between Right Atrial Pressure and Inferior Vena Cava Dimensions in Pediatric Post Heart Transplant Patients

The correlation between a low right atrial pressure (RAP) and increased respiratory collapsibility of the inferior vena cava (IVC) is well studied in adults. There is limited data in the pediatric population, especially in the pediatric heart transplant population. This study aims to assess the relationship between non invasive imaging of both IVC dimensions and collapsibility to invasive RAP measurement. A retrospective review of the pediatric transplant patient data between 2015-2017 was performed. Seventy-six patients had cardiac catheterization and echocardiogram within a maximum two weeks of each other. Clinical data, including mean RAP during cath and N-terminal pro b-type natriuretic peptide (NTproBNP) were collected. Echos were reviewed on two separate occasions by a single reviewer for intra-observer variability. IVC diameter in long axis in inspiration and expiration, IVC collapsibility index, left ventricular remodeling index (LVRI) and tricuspid regurgitant (TR) velocity were reviewed. A higher IVC collapsibility index correlated with a lower RAP (r = -0.25, p = 0.03) and a larger IVC diameter in expiration (indexed to body surface area (BSA)) correlated with a higher RAP (r = +0.24, p = 0.04) (Figure 1A, 1B). There was a correlation between elevated NTproBNP and IVC collapsibility (r = -0.39, p = 0.0007), IVC expiratory diameter/BSA (r = 0.34, p = 0.0003), and RAP (r = 0.7, p = 0.0001)(Figure 1C, 1D, 1E). Secondary outcomes of TR velocity and LVRI had no correlation with RAP. Our study showed a correlation between both IVC collapsibility and IVC expiratory diameter (indexed to BSA) to mean RAP in pediatric heart transplant patients. Non invasive imaging of the IVC offers indirect data on right sided cardiac filling and intravascular volume status.

Right Atrial Pacing to Improve Acute Hemodynamics in Pulmonary Arterial Hypertension

Pacing to increase resting heart rate (HR) is commonly employed in order to improve hemodynamics and cardiac output (CO), particularly in post-operative setting when right ventricle (RV) dysfunction is present. We tested if right atrial (RA) pacing improves RV hemodynamics acutely, and if the degree of baseline RV dysfunction modifies this relationship. We prospectively enrolled adult subjects with known or suspected pulmonary arterial hypertension (PAH) who underwent elective right heart catheterization between January 2013 and April 2016. RV pressure-volume (PV) analysis was performed with conductance catheters. RV volumes were calibrated by cardiac MRI same day. After measuring baseline PV data, a bipolar pacing wire was positioned in the RA and rate set to 80 to 90 beats per minute (bpm). Rate was increased in steps of 20 bpm. PV loops were recorded at end-expiration after 1 minute in each group: 80-99, 100-119, and 120-139 bpm. Parametric data were analyzed by Repeated Measures ANOVA, and non-parametric data were analyzed by Friedman Test. Baseline hemodynamic predictors of CO were analyzed by Repeated Measures simple linear regression. Twenty-three subjects were included in this analysis. Baseline mean RA pressure was 7 ± 3 mmHg with pulmonary vascular resistance of 5.2 ± 4.1 wood units. As HR increased with RA pacing, stroke volume (SV) declined in each pacing group (68±22, 61±19, 54±21 mL, respectively; p<0.001) with increase in CO (5.5±1.9, 6.2±1.9, 6.6±2.5 L/min; p<0.001). The dP/dt maximum increased (429, 490, 549 mmHg/s; p<0.001); however, RV-pulmonary arterial coupling (Ees/Ea) fell with pacing (0.97 vs 0.84 vs 0.78, p=0.009). No baseline hemodynamic parameter or measure of RV function modified the relationship between CO and RA pacing. Between-subject data had large variation; exclusion of non-PAH subjects (n=6) did not alter results. As heart rate increases with RA pacing, RV contractility and CO increase modestly at the expense of cardiac efficiency.

1231 Left atrial septal and lateral wall strains contain different pressure information: Utility in pulmonary hypertension

Abstract Funding Acknowledgements South-Eastern Norway Regional Health Authority Background Reduced left atrial (LA) reservoir strain is a marker of elevated LA pressure. Thus it could be a potential non-invasive marker to differentiate pre- and post-capillary pulmonary hypertension (PH) as the latter is defined by elevated pulmonary capillary wedge pressure (PCWP) &amp;gt; 15 mmHg. However, in pre-capillary PH patients with elevated right atrial pressure (RAP), the atrial septal geometry may be abnormal. This could lead to lower regional LA septal strain, making LA lateral wall strain more accurately reflect PCWP. Purpose We investigated if LA lateral wall strain can differentiate between pre- and post-capillary PH, and how LA lateral wall strain and LA septal strain are both affected by elevated RAP in pre-capillary PH. Furthermore we investigated if LA septal strain can be used in pre-capillary PH patients to identify those with elevated RAP. Methods We analysed 63 patients with PH, 28 pre-capillary and 35 post-capillary, who underwent right heart catheterisation. Echocardiography was performed simultaneously with or within 24 hours of the invasive pressure measurements. Regional LA septal strain and lateral wall strain were measured from the apical four chamber view. Results Pulmonary artery pressure was 39.5 ± 11.1 mmHg (mean ± SD) in the pre-capillary PH patients and 37.0 ± 10.1 mmHg in the post-capillary PH patients (p = ns). Mean PCWP was 9.9 ± 2.5 mmHg and 24.5 ± 6.0 mmHg (p &amp;lt; 0.001), respectively. LA lateral wall strain was significantly lower in patients with post-capillary PH compared to pre-capillary PH (11.9 ± 7.7% vs 26.6 ± 9.9%, p &amp;lt; 0.001) (Fig. a,b). At a cut-off value of 18.0%, LA lateral wall strain could predict elevated PCWP &amp;gt; 15 mmHg with AUC = 0.88, sensitivity = 85.7% and specificity = 76.3%. In the 28 patients with pre-capillary PH, we classified mean RAP ≥ 10 mmHg as elevated and &amp;lt; 10 mmHg as normal. Seven of these patients had elevated RAP and showed significantly reduced LA septal strain compared to the 21 patients with normal RAP (13.0 ± 6.2% vs 22.1 ± 7.6%, p &amp;lt; 0.01). LA lateral wall strain showed no difference in these groups of pre-capillary PH patients (25.8 ± 10.1% vs 28.9 ± 9.4%) (Fig. c). Conclusions LA lateral wall strain can be used for differentiating between pre- and post-capillary PH. In addition, LA septal strain may be used in pre-capillary PH patients to identify those with elevated RAP. Abstract 1231 Figure

Right atrial pressure is under estimated by echocardiography in HFpEF patients

The estimation of right atrial pressure (RAP) is important for pulmonary pressure and right ventricular filling pressure estimation. The accuracy of the inferior vena cava study to evaluate RAP has been tested in a few studies, and never in patients with heart failure with preserved ejection fraction (HFpEF) Our study investigated whether the study of inferior vena cava (IVC) size and collapsibility was accurate in a cohort of patients with heart failure with preserved ejection fraction (HFpEF). Between January 2014 and December 2018, 142 patients with suspected HFpEF and pulmonary hypertension (PH), underwent right heart catheterization (RHC) and transthoracic echocardiography within 5 days in our referral centre. The estimating RAP according to IVC size and collapsibility were retrospectively determined. Patients were classified in 3 groups according to the current guidelines: ≤ 2.1 cm that collapses > 50% with a sniff suggested a normal RAP of 3 mm Hg, an IVC diameter > 2.1 cm that collapses < 50% with a sniff suggested a high RAP of 15 mm Hg. A RAP of 8 mmHg was suggested for the other patients. A total of 118 patients (83%) had a possible and complete IVC analysis. Mean RAP estimation by right heart catheterism was 13 ± 5 mmHg. Inferior vena cava at end expiration was 19 ± 7 mm. Thirty-eight patients had an echo estimate RAP of 3 mmHg, whereas hemodynamic RAP in this group was 10 ± 5 mmHg. Forty patients had an echo estimate RAP of 8 mmHg, whereas hemodynamic RAP in this group was 14 ± 5 mmHg. 37 patients had an echo estimate RAP of 15 mmHg, whereas hemodynamic RAP in this group was 17 ± 5 mmHg. The RAP difference estimation of echo and hemodynamics was > 5 mmHg in respectively 66%, 40% and 39% of the patients in each group ( Fig. 1 ). In HFpEF patients, RAP is high. The study of the IVC is feasible in most cases but the estimation of the RAP is hazardous. This could have consequence in the evaluation of pulmonary pressure.

P1652Limited correlation of calculated plasma volume status with invasive right heart pressures in patients with heart failure

Abstract Background Estimated plasma volume (ePV) can be calculated from haematocrit and body weight, and has been shown to correlate with PV measured using 125Iodine labelled human serum albumin. Comparing a patient's ePV to ideal PV (iPV), an estimate of a patient's relative congestion, called PV status (PVS), is possible. Higher PVS is associated with increased mortality in patients with heart failure (HF), and has been proposed as a simple, cheap, and non-invasive way of assessing congestion. Purpose Whether PVS is associated with invasively measured markers of congestion is unknown. We calculated PVS in patients with HF who had right heart catheterisation (RHC), and assessed any correlation between PVS and invasive measures of congestion. Methods We calculated PVS in consecutive patients who had RHC performed as part of transplant assessment. iPV was calculated as: iPV = c × weight (kg) where c=39 in males and c=40 in females. ePV was calculated using subjects' haematocrit and weight as follows: ePV = (1 − haematocrit) × [a + (b × weight in kg)], where haematocrit is a fraction, a=1530 in males and a=864 in females, and b=41 in males and b=47.9 in females. PVS was calculated as: PVS = PVS = (ePV − iPV) /iPV × 100%. Correlation between PVS and invasive wedge pressure, mean right atrial (RA) pressure, and NTproBNP were made using Pearson correlation. Results PV indices and RHC data were available for 61 patients, 43 (71%) were male. Median age was 55 [IQR 48, 58] years. 20 (33%), 24 (39%), and 15 (25%) were NYHA association class II, III, and IV respectively. The median NTproBNP was 1390 [IQR 512, 3612] pg/ml and median ejection fraction was 29 [IQR 20, 35] %. The median PVS was −5.9% (IQR −12.5, −1.6]. Median wedge and mean-RA pressures were 14 [7, 21] and 4 [1, 8] mmHg, respectively. Correlation between mean RA pressure and PVS is shown in the figure. There was no correlation between PVS and mean RA pressure (r=0.12, p=0.34) or wedge pressure (r=0.01, p=0.92). There was a weak correlation between NTproBNP and PVS (r=0.31, p=0.01) Correlation mean RA pressure and PVS Conclusion PVS did not correlate with the invasive measures of congestion, mean RA and wedge pressure, but was weakly correlated with NTproBNP. Although there were limited number of patients in this study, we question the conclusion that PVS is a marker of congestion, and whether it can be used clinically for this purpose.

P4368Estimation of pulmonary artery pressure from right atrial strain and tricuspid regurgitation velocity

Abstract Background Systolic pulmonary artery pressure (SPAP) can be estimated non-invasively as the sum of indices for right atrial (RA) pressure and tricuspid regurgitation (TR) pressure gradient. Although echocardiographic evaluation of inferior vena cava diameter and collapsibility is currently being used to estimate RA pressure (IVC method), RA strain may be an alternative since atrial strain is related to atrial pressure. Objective We tested if RA strain by speckle tracking echocardiography can be used as a surrogate of mean RA pressure (RA strain method), and by adding the TR pressure gradient, be used to estimate SPAP. Methods We retrospectively analyzed 91 patients (mean age, 58 years) referred to right heart catheterization due to unexplained dyspnea or suspected pulmonary hypertension. Echocardiography was performed within 24 hours of the invasive procedure. RA reservoir strain was calculated from apical four-chamber view. SPAP was calculated as the sum of peak TR pressure gradient and estimated RA pressure by the IVC or RA strain methods. Results Right heart catheterization showed SPAP and mean RA pressures of 51±20 mmHg and 9±6 mmHg, respectively. RA reservoir strain was inversely correlated with mean RA pressure (r=−0.61, p&lt;0.01). Thus, we set mean RA pressure as 5, 10 and 15 mmHg depending on high (≥25%), middle (10–25%) and low (≤10%) values of RA reservoir strain. As shown in the figure, both the RA strain and IVC methods when combined with peak TR velocity, provided good estimates of invasively measured SPAP. Conclusions RA strain provides a semiquantitative measure of RA pressure, which can be used in combination with peak TR velocity to estimate SPAP. This approach can be used as an alternative when the IVC method is not available in cases with poor subcostal window.

P5417Splenic volume changes as a hemodynamic parameter in advanced heart failure with left ventricular assist device

Abstract Background The spleen has been recognized as an important organ to reserve 20–30% of the total blood volume. Generally, splenomegaly has been thought to be related to congestion. However, in the setting of hypovolemic shock or hypoxemia, it has been reported that spleen contracted and splenic volume decreased. On the other hand, in advanced heart failure (HF), the hemodynamics is characterized by both low cardiac output (LO) and systemic congestion, and patients sometimes need support of left ventricular assist device (LVAD). However, it remains unclear about the association between spleen size and hemodynamic parameters in patients with LO who need LVAD support. Purpose The purpose of this study was to investigate the relationship between spleen size and hemodynamic parameters in advanced HF before and after LVAD implantation. Methods We enrolled 12 advanced HF patients with LVAD (11 males, 45±10 years). All patients underwent blood test, echocardiography, right heart catheterization, and computed tomography (CT) before and after LVAD implantation. Spleen size was measured by CT volumetry. We excluded patients with splenic infarction, or any infections, or mean right atrial pressure (RAP) &lt;5mmHg because of a possibility of hypovolemic status. LO was defined as CI less than 2.2L/min/m2. Results At pre- and post-LVAD implantation, cardiac output, cardiac index (CI), mean RAP, and mean pulmonary capillary wedge pressure were 3.1±0.6 vs. 4.9±0.9L/min, p=0.002; 1.7±0.3 vs. 2.8±0.3L/min/m2, p=0.002; 14±5 vs. 9±3mmHg, p=0.059; and 30±7 vs. 10±3mmHg, p=0.002, respectively. The serum brain natriuretic peptide level had significantly decreased (1101 [517–1446] vs 74 [35–216] pg/mL, p=0.002). In all patients, CI had increased to over 2.2L/min/m2. The splenic volume significantly increased from pre- to post-LVAD implantation (172±48 vs. 233±78mL, p=0.002) (Figure). Furthermore, all patients were divided into two groups; elevated RAP group (n=4) and non-elevated RAP group (n=8) after LVAD support. In elevated RAP group, there were no significant changes in the spleen size between pre- and post-LVAD implantation (167±45 vs. 223±111mL, p=0.068). On the other hand, in non-elevated RAP group, the spleen volume had significantly increased from pre- to post-LVAD support (172±53 vs. 231±62mL, p=0.011). In addition, there was one patient whose hemodynamic state had changed to LO again because of LVAD failure due to pump thrombosis. In this case, the splenic volume was 212mL before LVAD implantation with LO, and increased to 418mL after LVAD implantation with non-LO, although decreased to 227mL after LVAD pump failure with LO again. Splenic volume changes Conclusions The spleen may change its size in order to keep cardiac output by regulating cardiac preload depending on the systemic perfusion in advanced HF with LVAD. Acknowledgement/Funding None

Association between left ventricular diastolic function and right ventricular function and morphology in asymptomatic aortic stenosis

BackgroundAortic stenosis (AS) is a progressive disease in which left ventricular (LV) diastolic dysfunction is common. However, the association between diastolic dysfunction and right ventricular (RV) loading conditions and function has not been investigated in asymptomatic AS patients.Methods and findingsA total of 41 patients underwent right heart catheterization and simultaneous echocardiography at rest and during maximal supine exercise, stratified according to resting diastolic function. Cardiac chamber size and morphology was assessed using cardiac magnetic resonance imaging (cMRI). RV stroke work index, pulmonary artery (PA) compliance, PA elastance, PA pulsatility index, and right atrial pressure (RAP) were calculated at rest and maximal exercise. Ten patients (24%) had normal LV filling pattern, 20 patients (49%) had grade 1, and 11 patients (27%) had grade 2 diastolic dysfunction. Compared to patients with normal diastolic filling pattern, patients with diastolic dysfunction had lower RV end-diastolic volume (66 ± 11 ml/m2 vs. 79 ± 15 ml/m2, p = 0.02) and end-systolic volume (25 ± 7 ml/m2 vs. 32 ± 9 ml/m2, p = 0.04). An increase in mean RAP to ≥15 mmHg following exercise was not seen in patients with normal LV filling, compared to 4 patients (20%) with mild and 7 patients (63%) with moderate diastolic dysfunction (p = 0.003). PA pressure and PA elastance was increased in grade 2 diastolic dysfunction and correlated with RV volume and maximal oxygen consumption (r = -0.71, p < 0.001).ConclusionsModerate diastolic dysfunction is associated with increased RV afterload (elastance), which is compensated at rest, but is associated with increased RAP and inversely related to maximal oxygen consumption during maximal exercise.

Liver stiffness obtained by ElastPQ ultrasound shear wave elastography independently determines mean right atrial pressure.

We aimed to investigate the relationship between right atrial pressure (RAP) and liver stiffness (LS) determined by liver elastography (LE) during cardiac resynchronization therapy (CRT) in patients with heart failure (HF) and conventional pacemaker (PM) implantation in patients without HF. 60 patients with HF who underwent CRT and 60 patients without HF who underwent PM were enrolled. Routine echocardiography and laboratory examinations were performed. Systolic, diastolic, and mean RAP measurements were performed inversely during PM implantation and LS measurement with ElastPQ technique. Systolic, diastolic, and mean RAP, left ventricular (LV) systolic-diastolic, right ventricular (RV) diastolic and left atrial diameters, tricuspid regurgitation pressure gradient, and RV-myocardial performance index (MPI) values were significantly higher in patients with HF (p < 0.05 each-one). LV ejection fraction and tricuspid annular plane systolic excursion values were significantly lower in patients with HF group (p < 0.05 each-one). LS values and inspiratory (Ins) and expiratory inferior vena cava (IVC) diameters were significantly higher in the patients with HF (p < 0.05 each-one). Mean RAP was found to be closely related to LS value, Ins-IVC diameter, RV-MPI, and NT-proBNP levels. LS value and Ins-IVC diameter were found to determine patients with mean RAP > 5mmHg and > 10mmHg. When the cut-off value of LS was taken as 7kPa, it was found that the mean RAP > 10mmHg with 89.6% sensitivity and 87.5% specificity. The non-invasive LS value determined by LE independently determines the mean RAP in patients with and without HF. According to our study results, > 7kPa value for LS determined in liver US may be predictive for increased mean RAP.

Risk assessment and survival of patients with pulmonary hypertension: Multicenter experience in Turkey.

Objective:Risk stratification continues to evolve in pulmonary arterial hypertension (PAH). Our aim was to further confirm the risk assessment strategy in our cohort and to determine the most reliable model.Methods:We enrolled incident patients with idiopathic PAH (IPAH), heritable, drug-induced, congenital heart disease (CHD), connective tissue diseases (CTD) subsets, and chronic thromboembolic pulmonary hypertension (CTEPH) from January 2008 to February 2018. Data from the baseline and subsequent follow-ups within 1 year of diagnosis were included. An abbreviated risk assessment strategy was applied using the following variables: functional class (FC), 6-minute walk distance (6 MWD), N-terminal pro–brain natriuretic peptide (NT-proBNP) or BNP, right atrial (RA) area, pericardial effusion, the mean RA pressure, cardiac index, and mixed venous oxygen saturation. Three different methods were applied to categorize patients.Results:A total of 189 subjects (46±17 years, 23% male) were included. Sixty-one patients had died. The survival differed significantly between the risk groups both at diagnosis and during the follow-up. Patients with a low-risk profile had a better survival rate. An abbreviated risk assessment tool predicted mortality at early follow-up in the entire group and CHD, CTD subsets, and CTEPH, separately. An overall mortality among risk categories was significantly different according to each categorization method. The most reliable model comprised FC, 6 MWD, NT pro-BNP/BNP, and the RA area at the follow-up.Conclusion:The abbreviated risk assessment tool may be valid for the PAH subsets and CTEPH. Echocardiographic variables do matter. A model comprising FC, 6 MWD, NT pro-BNP/BNP, and the RA area at the follow-up could be useful for better prognostication.

Exercise desaturation as a marker of disease severity in pulmonary arterial hypertension

Introduction Pulmonary hypertension patients develop hemodynamic changes that contribute to the symptoms, especially during exertion. The inability of the heart to increase cardiac output and the ventilation/perfusion mismatch, may explain the presence of exercise oxygen desaturation. Rationale The rational is to study the relation of exercise oxygen desaturation with the severity of pulmonary arterial hypertension (PAH) group I. Patients and methods Thirty-nine patients diagnosed as having PAH group I were included in the study; 30 (76.9%) female patients and nine (23.1%) male patients. Six-minute walk distance (6MWD) was performed as a marker for the risk of mortality. The degree of desaturation was calculated. The disease severity is assessed in terms of right atrial pressure (RAP), oxygen saturation of the mixed venous blood, cardiac output, mean pulmonary artery pressure, and peripheral vascular resistance. Results The mean age was 37.74±10.58; the patients were presented within functional classes II and III. The mean 6MWD (264.95±87.32), RAP (10.87±6.22), and oxygen saturation of the mixed venous blood (58.67±8.13) denote moderate risk of mortality in 1 year of 5–10%. The mean degree of desaturation is 3.72%, and the basal oxygen saturation is 94.44%. There was a statistically significant negative correlation between the 6MWD and RAP, and positive correlation between 6MWD and arterial oxygen saturation, as well as between the mean pulmonary artery pressure and degree of desaturation. Conclusion Exercise desaturation is an important factor in the development and deterioration of PAH, yet it has no significant correlation with the parameters of the disease severity used.

Mean Right Atrial Pressure for Estimation of Left Ventricular Filling Pressure in Patients with Normal Left Ventricular Ejection Fraction: Invasive and Noninvasive Validation

There is a paucity of data on the utility of right atrial pressure (RAP) for estimating pulmonary capillary wedge pressure (PCWP) in patients with normal ejection fraction (EF), including patients with heart failure with preserved EF. Mean RAP was compared with PCWP in 129 patients (mean age, 61±11years; 45% men) with exertional dyspnea enrolled in a multicenter study. Measurements included left ventricular volumes, EF, and mitral inflow velocities. Mean PCWP was 14±7mmHg, and mean RAP was 8±5mmHg. A significant relation was presentbetween mean RAP and mean PCWP (r2=0.5, P<.001). RAP > 8mm Hg had 76% sensitivity and 86% specificity in detecting mean PCWP > 12mm Hg. In 101 patients with inconclusive mitral filling pattern (defined according to American Society of Echocardiography/European Association of Cardiovascular Imaging 2016 diastolic function recommendations), RAP by catheterization had sensitivity of 73% and specificity of 91%. In a subset of 59 patients with echocardiographic assessment of mean RAP, RAP by echocardiography had sensitivity of 76% and specificity of 89%. Mean RAP provides useful information about mean PCWP in many patients with normal left ventricular EF. There is good sensitivity and excellent specificity when combining invasive or noninvasive RAP and mitral velocities to determine if PCWP is elevated.

The prognostic value of the relationship between right atrial and pulmonary capillary wedge pressure in diverse cardiovascular conditions

BackgroundPhysical examination of jugular venous pressure is used to estimate right atrial (RA) pressure and infer left-sided filling pressure to assist volume management. Previous studies in advanced heart failure patients showed about 75% concordance between RA and pulmonary capillary wedge (PCW) pressures. We sought to determine the relationship between mean RA and mean PCW pressure and assess the clinical significance in a broad population of patients undergoing invasive right heart catheterization (RHC). MethodsWe examined 4135 RHC cases at a single academic medical center from February 2007 to December 2014, analyzing baseline variables, hemodynamic data, and in-hospital mortality. ResultsThe overall Pearson correlation for mean RA and PCW pressures was 0.68 with 70% concordance between dichotomized pressures (RA ≥10 and PCW ≥22 mmHg). Results were similar in subgroups with heart failure (r=0.67, 72%), STEMI/NSTEMI (r=0.60, 69%), unstable angina (r=0.78, 69%), stable/no angina (r=0.72, 67%), and valvular disease (r=0.61, 72%; Chi-square P=.15). Mean RA pressure was independently associated with in-hospital mortality in multivariate analysis (OR 1.12 [95% CI 1.081-1.157] per 1 mmHg increase, P<.001). The RA/PCW ratio was not independently associated with in-hospital mortality. Mean RA pressure was also weakly associated with worse renal function (rho=−0.16, P<.001). ConclusionIn patients undergoing right catheterization for diverse indications, the mean RA and PCW pressures correlated moderately well, but there was discordance in a sizable minority, in whom assessment of left-sided filling pressures using estimated jugular venous pressure may be misleading. Elevated right atrial pressure is a marker for in-hospital mortality.

Association of Cardiac Hemodynamic Factors With Severity of White Matter Hyperintensities in Chronic Valvular Heart Disease

The cerebral white matter hyperintensity (WMH) is frequently noted in patients with chronic heart disease. Long-term alteration of cardiac hemodynamics might have an influence on the mechanism of cerebral WMH. To investigate the association between chronically altered cardiac hemodynamics and severity of cerebral WMH in patients with chronic valvular heart disease. This cross-sectional analysis identified 303 consecutive patients at a tertiary referral center between 2008 and 2016 who were 50 years or older, and diagnosed with severe chronic valvular heart disease and underwent cardiac catherization, echocardiography, and received brain magnetic resonance imaging. Among these patients, 71 with other demonstrated cardiac disease, central nervous system disease, and/or without sufficient catheterization data were excluded, and the remaining 232 patients were included in further analyses. The site and mechanism of valve diseases, as well as clinical and medication profiles, were reviewed. Cardiac catheterization parameters such as right atrial (RA) mean pressure, right ventricular pressure, and aortic mean pressure were obtained. Comprehensive echocardiographic hemodynamic markers such as left ventricular (LV) ejection fraction, LV mass index, LV end diastolic volume, cardiac index, and E/e' ratio were also obtained. White matter hyperintensity volume was quantitatively evaluated using volumetric analysis. This study included 232 patients (103 men [44.4%] and 129 women [55.6%]; mean [SD] (range) age, 65.6 [8.8] (51-88) years) in the final analysis. The mean (SD) WMH volume was 5.93 (7.14) mL (median [interquartile range], 4.33 [1.33-8.62] mL), and mean (SD) RA pressure was 10.0 (4.7) mm Hg. From the catheterization data, 147 patients (63.4%) were classified as having a disease involving the mitral valve; 93 (40.1%), aortic valve; 37 (15.9%), tricuspid valve; and 4 (1.7%), pulmonary valve. In multivariate linear regression analysis, adjusting the type and mechanism of valve disease and clinical, echocardiographic, and/or other catheterization parameters, WMH volume was linearly associated with mean RA pressure (B coefficient, 0.702; 95% CI, 0.373-1.031; P = .001), along with age (B coefficient, 0.145; 95% CI, 0.029-0.261; P = .01) and mean aortic pressure (B coefficient, 0.112; 95% CI, 0.034-0.190; P = .005). Mean RA pressure was independently associated with the WMH volume in chronic valvular heart disease. Chronically altered RA hemodynamics might have a distinct influence on the pathomechanism underlying the development of WMH.

Right atrial emptying fraction non-invasively predicts mortality in pulmonary hypertension.

Right-sided heart failure is the most common cause of death in pulmonary hypertension (PH). Echocardiographic measurements of right atrial (RA) size are associated with worse outcome in PH, however the association between RA function and death in PH has not been well-described. 160 PH patients (World Health Organization groups 1-5) underwent cardiac magnetic resonance imaging (cMRI) and right heart catheterization (RHC) within 6 weeks of each other at a tertiary care academic medical center in the United States. We measured cMRI RA maximum and minimum volumes indexed to body surface area and calculated RA emptying fraction (RAEF). We evaluated the relationship between RAEF and clinical variables with death using Cox proportional hazard models. 57 deaths occurred during a median follow-up of 3.5 years (36 % died overall, 10 % per year). RAEF was directly correlated in univariate analyses with right ventricular (RV) ejection fraction, left ventricular (LV) ejection fraction, LV size, cardiac index, absence of tricuspid and pulmonic regurgitation, absence of pericardial effusion, estimated glomerular filtration rate, 6-minute walk distance, and pulmonary arterial oxygen saturation, whereas it was inversely correlated with death, BNP, heart rate, mean RA pressure, mean PA pressure, pulmonary and systemic vascular resistance, RV size, and RA size. Using multivariate analyses, RAEF had a robust inverse association with death after adjusting for measured risk factors (HR per 5 % change in RAEF: 0.83 [95 % CI 0.73-0.94], p = 0.003). In PH patients, decreased RAEF by cMRI is independently associated with worse survival after adjustment for other risk factors.

Correlation Between Doppler Echocardiography and Right Heart Catheterization Derived Pulmonary Artery Pressures: Impact of Right Atrial Pressures.

To evaluate the correlation between Doppler echocardiography (DE) and right heart catheterization (RHC) derived pulmonary artery pressures and to assess the impact of right atrial (RA) pressures on this correlation. Cross-sectional analytical study. Cardiology Department, Tahir Heart Institute, Chenab Nagar, from June 2013 to December 2014. All patients undergoing RHC were included. Relevant data were collected from hospital database. Continuous variables were expressed as the mean and SD or as the median and interquartile range where the distributions were skewed. Pearson correlation coefficient and Bland-Altman method were used to correlate DE derived right ventricular systolic pressure (RVSP) and RHC derived systolic pulmonary artery pressures (sPAP). Adjusted RVSP was calculated by replacing default value of RA pressure (10 mmHg) with RHC derived mean RA pressure. Receiver operating characteristic curve (ROC) was used to identify the best cut-off value of RVSP in predicting pulmonary hypertension. Fifty-one patients completed the study protocol. Mean age of study population was 45.22 &amp;plusmn;15.25 years with male to female ratio of 1.47:1. Median error was 13 mmHg (7 to 20). Pearson correlation coefficient (r) between RVSP and sPAP was 0.72. Bland-Altman method of correlation showed bias of +4.43 mmHg with 95% limits of agreement ranging from -34.61 to +43.47. Using ROC curve, the best cut-off value of RVSP was greater than 52 mmHg with accuracy of 75% (sensitivity: 81%, specificity: 69%) in predicting pulmonary hypertension. Adjusted RVSP showed only little improvement in correlation (r = 0.75), adjusted error (13.65 &amp;plusmn;13.05) and diagnostic accuracy (79%). Doppler echocardiography can frequently overestimate pulmonary artery pressures. Though correctly estimated RA pressure may improve this correlation, yet its contribution is only minimal.

Prognostic Factors for Survival in Pulmonary Hypertension Due to Left Heart Disease.

The epidemiological data of pulmonary hypertension (PH) due to left heart disease (LHD) are limited. This study investigated hemodynamic and clinical factors associated with mortality in patients with PH due to LHD. We conducted a retrospective review in 243 patients with PH due to LHD, defined as mean pulmonary arterial pressure ≥25 mmHg and pulmonary wedge pressure >15 mmHg at rest in right heart catheterization. Kaplan-Meier and Cox proportional hazard regression analyses were performed. Seventy-five patients died during an average follow-up of 52 months (range, 20-73 months). On multivariate analysis, only diastolic pulmonary vascular pressure gradient (DPG) ≥7 mmHg among hemodynamic measurements was a predictor of mortality. Elevated N-terminal pro-brain natriuretic peptide (NT-pro BNP), more severe New York Heart Association (NYHA) class, anemia, and renal dysfunction were more strongly associated with mortality. Mean right atrial pressure (RAP) and currently available markers of pulmonary vascular remodeling including transpulmonary pressure gradient (TPG) and pulmonary vascular resistance (PVR) had no effect on survival. DPG is weakly associated with mortality in PH due to LHD. Clinical factors such as NT-pro BNP, NYHA class, anemia and renal dysfunction are superior predictors. The prognostic ability of hemodynamic factors such as mean RAP, TPG, PVR and DPG is limited.

Echocardiographic Assessment of Right Atrial Pressure in a Pediatric and Young Adult Population.

Right atrial pressure (RAP) reflects right-sided cardiac hemodynamics and is useful in management of patients with cardiac and systemic disease. Studies in older adults demonstrated that inferior vena cava (IVC) diameter, IVC collapsibility index, hepatic vein systolic filling fraction (SFF), and right atrial volume (RAV) correlated with mean RAP at catheterization. This study aimed to assess the utility of echocardiographic parameters for assessment of RAP in children and young adults. Patients with pulmonary hypertension or heart transplantation undergoing right heart catheterization were recruited for this prospective observational pilot study. Transthoracic echocardiographic assessment of RAP was performed simultaneously with catheterization. For each parameter, three consecutive cardiac cycles were recorded. Long- and short-axis images of the IVC were obtained. RAV was assessed by area-length and biplane methods. IVC diameters and RAV were indexed to body surface area (BSA)(0.5) and (BSA)(1.4), respectively. Relationships between echocardiographic parameters and mean RAP were correlated using "Pearson's r." Fifty subjects aged 0.3-23 years (median 13, mean 12.3 ± 7 years) were enrolled. Mean RAP correlated modestly with RAV (r = 0.51, p < 0.001). Long-axis IVCmax (r = 0.30, p < 0.05) and tricuspid E wave velocity (r = 0.36, p < 0.01) also correlated with mean RAP. RV free wall tissue Doppler velocities, IVC collapsibility index, and hepatic vein SFF had no relation to mean RAP. In a pediatric and young adult population with pulmonary hypertension or heart transplantation, echocardiographic assessment of RAV and long-axis IVCmax provided a reasonable estimate of mean RAP. IVC collapsibility index and hepatic vein SFF demonstrated no association with mean RAP.

Abstract 12966: Combination of Urine Sodium Concentration and Plasma Brain Natriuretic Peptide Level Best Predicted the Clinical and Hemodynamic Effects of Tolvaptan Therapy in Patients With Heart Failure

Purpose: We identified the best predictors of clinical response to simple add-on tolvaptan (TLV) therapy in patients with heart failure (HF). Methods: We retrospectively enrolled 60 HF patients with excess fluid retention despite receiving adequate medical therapy including oral diuretics. All patients received simple add-on TLV (median of 7.5mg/day). They underwent right heart catheterization at baseline and after 7-day treatment. Results: Although the majority of patients were successfully treated with simple add-on TLV therapy (Group 1), but 22% (Group 2) were defined as being unsuccessfully treated because 1) HF symptom score worsened or 2) HF symptom score &gt;6, and mean pulmonary capillary wedge pressure (PCWP) &gt;18 mmHg and mean right atrial pressure (RAP) &gt;10 mmHg after TLV therapy. Although the degrees of body weight reduction and increment of urine volume were similar between the two groups, HF symptom score and mean PCWP and RAP improved, and plasma BNP level decreased only in the group 1 after TLV therapy. The group 2 had lower urine sodium/creatinine ratio (UNa/UCr) and higher plasma BNP level than responders at baseline, and they were identified as the independent predictors of unsuccessful TLV therapy by multivariate logistic regression analysis. Receiver operating characteristic curve analysis showed that UNa/UCr was the strongest predictor of unsuccessful TLV therapy with cut-off point of 46.5 mEq/gCr (AUC 0.847, 95% CI; 0.718-0.976, sensitivity 77%, specificity 81%, P&lt;0.001). Furthermore, combination with UNa/UCr 778 pg/ml best predicted unsuccessful TLV therapy with sensitivity of 54%, specificity of 100%, positive predictive value of 100%, negative predictive value of 89%, and accuracy of 90%. Conclusion: Simple add-on tolvaptan therapy ameliorated HF symptoms and provided hemodynamic improvement in majority of patients with HF, and the measurements of UNa/UCr and BNP level can help clinicians tailor HF treatment.