Measurement Of Left Atrial Pressure Research Articles

A Novel Non-invasive Predictor Measure of Left Atrial Pressure and Practical Implicates in High Frequency Ventilation: Theory

A Novel Non-invasive Predictor Measure of Left Atrial Pressure and Practical Implicates in High Frequency Ventilation: Theory

Agreement of left atrial pressure with clinical risk scores and echocardiographic features in patients with atrial fibrillation referred for catheter ablation

Abstract Background Heart failure with preserved ejection fraction (HFpEF) frequently coexists with atrial fibrillation (AF). The diagnosis of HFpEF in AF is difficult because some diagnostic criteria for HFpEF may be associated with AF instead of HFpEF per se. Left atrial pressure (LAP) ≥15 mmHg has been used to confirm the diagnosis of HFpEF. Purpose We aimed to 1) determine LAP measurements in patients with AF undergoing catheter ablation; 2) assess the agreement between LAP measurement HFpEF risk scores and 3) determine the association between LAP measurement and clinical and echocardiographic features. Methods Consecutive patients with paroxysmal or persistent AF scheduled for catheter ablation were included. Participants were considered to have HFpEF if the mean LAP was ≥15 mm Hg. The LAP was measured only in sedated patients with spontaneous breathing. Participants had high probability of HFpEF if scored >5points in H2FPEF and/or ≥5 points in HFA-PEFF score. Results Of 107 participants, 29 (27%) had HFpEF according to mean LAP and 32 (30%) had high probability of HFpEF according to HFpEF scores. The highest agreement of HFpEF risk scores relative to elevated LAP was observed for H2FPEF score; among patients with mean LAP ≥15 mm Hg, 38% [n=11/29] of them had also high risk of HFpEF based on H2FPEF score, whereas only 10% [n=3/29] had high risk of HFpEF based on HFA-PEFF score. In multivariable analysis, the independent predictors of HFpEF were left ventricular ejection fraction (LVEF; OR 0.77, 95%CI 0,.64-0.91), intraventricular septum diameter (IVSd; OR 1.75, 95%CI 1.11-2.74), global longitudinal strain (GLS; OR 1.24, 9%CI 1.05-1.48). Conclusions More than one-fourth of patients scheduled for catheter ablation had HFpEF according to elevated LAP. The highest agreement to elevated LAP was observed for the H2FPEF score. Predictors of HFpEF diagnosis were lower LVEF, higher IVSd and GLS.

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.

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 15926: Left Atrial Pressure and H 2 FPEF Score in Patients With Atrial Fibrillation Who Underwent Catheter Ablation

Introduction: Heart failure with preserved ejection fraction (HFpEF) is a common comorbidity in atrial fibrillation (AF) patients and contributes to AF progression and stroke risk. Hypothesis: We explore the hemodynamic effects of left atrial pressure (LAP), which was directly measured during AF catheter ablation (AFCA), on HFpEF based on the H 2 FPEF score. Methods: We included 1,426 patients (73.3% male, median age, 61.0 [54.0-68.0] years; 45.7% persistent AF) who underwent AFCA, LAP measurements at both AF and sinus rhythm (SR), echocardiogram, and H 2 FPEF score, and excluded the patients with EF &lt;50%. We divided patients into low-risk (&lt; 6 points) and high-risk ( ≥ 6 points) HFpEF groups and measured LAP-mean depending on heart rates 90, 100, 110, and 120 bpm during right atrial pacing (Pace-HR) and isoproterenol (ISO-HR) infusion in all patients. Results: The LAP-mean was sequentially and significantly higher according to the H 2 FPEF score (p&lt;0.001) and had an independent association with the high-risk HFpEF group (OR 1.37 per 10mmHg increase [1.13-1.67], p=0.001). LAP-mean increased significantly with increasing Pace-HR (90-120 bpm, 10.4 to 11.6 mmHg, p&lt;0.001) but decreased with ISO-HR (90-120 bpm, 10.2 to 8.1 mmHg, p&lt;0.001). In patients with paroxysmal AF, LAP-mean[AF] was significantly higher than LAP-mean[SR] (p&lt;0.001), but not in those with non-paroxysmal AF (p=0.557). In patients with paroxysmal AF, ΔLAP-mean[Pace-HR, 120-90bpm] was significantly higher than that of non-paroxysmal AF (p&lt;0.001). Conclusions: LAP is independently associated with H 2 FPEF score and has inverse rate-dependent response depending on pacing or ISO infusion. Higher increase of LAP during AF or higher Pace-HR contributes to more severe symptoms in patients with paroxysmal AF than in non-paroxysmal AF.

Acute Effect of Atrial Fibrillation on Circulating Natriuretic Peptides: The Influence of Heart Rate, Rhythm Irregularity, and Left Atrial Pressure Overload

Plasma natriuretic peptides (NPs) are increased in patients with atrial fibrillation (AF) compared with the patients with sinus rhythm. This study investigated whether this phenomenon is intrinsic to heart rhythm irregularity and independent of the heart rate and left atrial pressure (LAP) overload. We investigated 46 patients (age: 59 ± 10years, male gender: 77%) with non-valvular paroxysmal AF who were scheduled for catheter ablation and had documented stable sinus rhythm for at least 18hours before the procedure. All patients underwent direct measurement of right atrial pressure and LAP, simultaneously with assessment of plasma B-type NP, N-terminal pro-brain NP, and mid-regional pro-atrial NP. The baseline measurement was followed by induction of AF by rapid atrial pacing in the first 24 patients and by regular pacing from the coronary sinus at 100/min (corresponding to the mean heart rate during induced AF) in the latter 22 patients. Hemodynamic assessment and blood sampling were repeated after 20min of the ongoing AF or fast regular paging. The baseline characteristics and hemodynamic measurements were comparable between study groups; however, patients in the regular atrial pacing group had a higher body mass index and a larger left atrial diameter compared with the induced AF group. Plasma levels of all 3 NPs increased significantly during induced AF but not during fast regular pacing, and the increase of NPs was independent of right atrial pressure and LAP. Baseline concentrations of NPs and heart rhythm irregularity were the only independent predictors of increased NPs.

Validation of E/e′ Using the Index-Beat Method as an Estimate of Left Atrial Pressure in Patients with Atrial Fibrillation

Introduction: Echocardiographic assessment of diastolic function during atrial fibrillation (AF) remains challenging due to the irregular cardiac cycle length. We sought to assess whether the index-beat method, the beat following two preceding cardiac cycles of equal duration, could provide a more reliable measurement of E/e′ (mitral E wave/diastolic tissue Doppler velocity) than the conventional averaging of consecutive beats and hence facilitate the noninvasive estimation of elevated left atrial pressure (LAP) in patients with AF. Methods: We prospectively studied 35 patients with persistent AF who had preserved left ventricular ejection fraction and underwent radiofrequency ablation. LAP was measured in conjunction with transseptal puncture during catheter ablation. Echocardiography was performed 24 h before ablation and E/e′ was determined using the recommended averaging of 10 beats and the index-beat method, with the observers blinded to the clinical details and LAP measurements. Results: Correlation analysis showed a strong positive correlation between two methods in terms of both septal E/e′ (r = 0.841, p < 0.001) and lateral E/e′ (r = 0.930, p < 0.001). Bland-Altman analysis also showed a good agreement between the two measurement methods in terms of E/e′. E/e′ determined using both conventional averaging and the index-beat method was significantly correlated with LAP (p < 0.05). After Fisher Z transformation, we found that the index-beat septal E/e′ had a better correlation with LAP than did the conventional averaging E/e′ (r = 0.736 vs. r = 0.392, Zr = −2.110, p = 0.035). Furthermore, the index-beat method took significantly less time to measure E/e′ (mean 33.6 s; 95% confidence intervals [CIs]: 32.1 s–36.2 s) than did conventional averaging method (mean 96.2 s; 95% CI: 90.2 s–102.3 s; p < 0.001). Receiver operating characteristic curve analysis revealed that the optimal cut-off for predicting mean LAP >12 mm Hg was 11 (sensitivity 100%; specificity 77.3%) for index-beat septal E/e′ and 16 (sensitivity 61.5%; specificity 95.5%) for index-beat lateral E/e′. Conclusions: Good correlations were found between E/e′ and LAP in patients with AF, particularly with the index-beat method. Moreover, the index-beat method can easily measure E/e′ at an accuracy similar to that for the conventional averaging of consecutive beats, which can therefore be applied to assess the diastolic dysfunction and potentially improve the diagnosis of heart failure in patients with AF.

Telemedicine in cardiology - what is new?

There is robust evidence for the clinical efficacy of telemedicine in heart failure (HF) patients to reduce mortality and morbidity. For the first time, the Federal Joint Committee (G-BA) has approved telemedicine for HF patients as a digital method of care for a well-defined heart failure population. Patients with HF and a reduced left ventricular ejection fraction (LVEF ) < 40 % are now eligible for telemonitoring in a real-world settings of out-patient care in Germany. The implementation of telemedicine in the German health care system is a complex process including the introduction of telemedical technologies, educational programs for the patients as well as the implementation of standard operating procedures (SOPs) for the staff of telemedical centers. The ongoing research in telemedicine in HF patients is focusing on three issues: a) research to extend the suitable HF-population for telemonitoring; b) research on new telemedical sensor technologies, e.g. a new pulmonary pressure measurement system (Cordella) and a system for wireless measurement of left atrial pressure (V-LAP); c) the introduction of methods of artifical intelligence (AI), e.g. the AI-based speech analysis using a smart phone to characterize the pulmonary fluid status.

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.

Society of thoracic surgeons risk score and left atrial pressure for predicting clinical outcomes among transcatheter mitral edge-to-edge repair patients.

Limited data exist regarding the performance of the Society of Thoracic Surgeons (STS) risk score among transcatheter mitral edge-to-edge repair (TEER) patients. Evaluate STS score accuracy, and the incremental value of post-procedural left atrial pressure (LAP). A retrospective analysis of TEER patients between 2013 and 2020. Patients were allocated into 3 groups: high (≥8% [n = 298, 31%]), intermediate (4%-8% [n = 318, 33%]), and low (<4% [n = 344, 36%]). Primary outcomes included 1-year mortality or cardiovascular hospitalizations. Cox proportional hazards regression modeling was used to determine the hazard ratio of the primary outcome, and STS score accuracy was assessed by receiver operating characteristic. A spline curve was used to display the relationship between LAP and the primary endpoint. Continuous net reclassification improvement (NRI) was used to determine the incremental value of LAP. We included 960 patients, primarily elderly (79 [70-85]), with a median STS risk of 5.6 (3-9). High-risk patients were older (83 [75-89], 81 [74-87], 72 [64-79], p < 0.001), and had more comorbidities compared to intermediate and low-risk groups. Upon Cox regression, STS score (high vs. low: HR 2.5 [1.7-3.8]; Intermediate vs. low: HR 1.8 [1.2-2.7] and LAP HR 1.03 [1.01-1.06], p = 0.007) were associated with the outcome. C statistics analysis revealed low accuracy of the STS score (AUC-0.61 [0.58-0.65, p < 0.001]). Continuous NRI analysis indicated an improvement in risk prediction of 17% (6.9-26.2), p < 0.001. STS risk score has low accuracy in predicting clinical outcomes after TEER. Adding LAP measurements can improve reclassification and identify those prone to adverse outcomes.

Left atrial appendage dimension predicts elevated brain natriuretic peptide in nonvalvular atrial fibrillation.

BNP elevation in patients with AF is observed in the absence of heart failure; however, prior mechanistic studies have not included direct left atrial pressure measurements. This study sought to understand how emptying function of the left atrial appendage (LAA) and LAA dimension contributes to brain-natriuretic peptide elevations (BNP) in atrial fibrillation (AF) accounting for left atrial pressure (LAP). 132 patients referredfor left atrial appendage occlusion (LAAO) were prospectively enrolled in this study. BNP levels and LAP were measured just before LAAO. Statistical analysis considered BNP, rhythm at time of procedure, LAP, LAA morphology, LAA size (ostial diameter, depth, volume), LAA emptying velocity, CHADS2-VASc score, body mass index (BMI), left ventricular ejection fraction (LVEF), estimated glomerular filtration rate (eGFR), and obstructive sleep apnea (OSA) diagnosis as covariates. Bivariate statistical analysis demonstrated positive associations with age, LAA ostial diameter, depth, and volume, LAP, AF status at time of measurement, OSA, and CHADS2-VASc score. BNP was negatively associated with LVEF, eGFR, LAA emptying velocity and BMI. With multivariate logistic regression including LAP as covariate, significant relationships between BNP and AF/AFL(OR 1.99 [1.03, 3.85]), LAP (OR 1.13 [1.06, 1.20]), LAA diameter (OR 1.14 [1.03, 1.27]), LAA depth (OR 1.14 [1.07, 1.22]), and LAA emptying velocity (OR 0.97 [0.96,0.99]) were observed; however, no significant associations were seen with LAA morphology or CHADS2-VASc score. BNP elevations in AF are associated with LAA size and function, but not CHADS2-VASc score or appendage morphology after accounting for changes in LAP.

Automatic quantitative measurement of left atrial pressure using mitral regurgitation spectrum: clinical study on comparison with floating catheter

IntroductionTo explore how to measure LAPEq accurately and quantitatively, that is, the left atrial pressure (LAP) measured and calculated by equation method using mitral regurgitation spectrum.MethodsThe mitral regurgitation spectrum, pulmonary arteriolar wedge pressure (PAWP) and invasive arterial systolic pressure of radial artery of 28 patients were collected simultaneously, including 3 patients with rheumatic heart disease, 15 patients with mitral valve prolapse and 10 patients with coronary artery bypass grafting, patients with moderate or above aortic stenosis were excluded. LAPBp (Doppler sphygmomanometer method), LAPEq (Equation method) and LAPC (Catheter method) were measured synchronously, and the measurement results of the three methods were compared and analyzed. A special intelligent Doppler spectrum analysis software was self-designed to accurately measure LAPEq. This study had been approved by the ethics committee of the Northern Theater General Hospital (K-2019-17), and applied for clinical trial (No. Chictr 190023812).ResultsIt was found that there was no significant statistical difference between the measurement results of LAPC and LAPEq (t = 0.954, P = 0.348), and significant correlation between the two methods [r = 0.908(0.844, 0.964), P < 0.001]. Although the measurement results of LAPC and LAPBP are consistent in the condition of non-severe eccentric mitral regurgitation, there are significant differences in the overall case and weak correlation between the two methods [r = 0.210, (−0.101, 0.510), P = 0.090]. In MVP patients with P1 or P3 prolapse, the peak pressure difference of MR was underestimated due to the serious eccentricity of MR, which affected the accuracy of LAPBP measurement.ConclusionsIt was shown that there is a good correlation between LAPEq and LAPC, which verifies that the non-invasive and direct quantitative measurement of left atrial pressure based on mitral regurgitation spectrum is feasible and has a good application prospect.

A STUDY OF FOSSA OVALIS : HOW THE MORPHOMETRY AND LOCATION AFFECTS TRANSSEPTAL APPROACH TO LEFT ATRIUM.

Background- Fossa Ovalis (FO) surrounded by limbus are embryological remnants in inter atrial septum of heart. By Trans-septal approach, towards the left heart chambers, floor of FO is punctured to perform various types of diagnostic and therapeutic procedures. Variable position and morphometry of FO remains main challenge. Materials and Methods– 30 heart specimens were procured from properly embalmed cadavers. FO was Inspected in interior of the right atrium. Shapes, diameters, position of FO were determined by Vernier callipers. Probe patency test was performed in cases of Patent Foramen Ovale (PFO). occurrence of PFO is 23.3% (7 out of 30 hearts). The average Result- transverse diameter of FO was 11.68 mm and average vertical diameter was 13.70 mm. Most of the FOs ware oval with longer vertical diameter. In 26 cases (86.6%) limbus is raised and in 4 it is totally flat with the surface of IAS. In 22 hearts, wall of FO were thinner than rest of inter atrial septum (IAS). In one case Chiari strands are found in the floor of FO. Conclusion– Raised limbus of FO prevents slipping of needle while puncturing. Small FO, Chiari strands or multiple cardiac anomalies are unfavourable for TS puncture. To perform Left atrial pressure measurement, and in different cardiac surgeries proper visualization and knowledge of FO is very important.

Transesophageal Echocardiography For The Assessment of Left Atrial Pressure After Trans-Septal Mitral Valve Interventions

The measure of left atrial pressure (LAP) is an ideal marker for the clinical efficacy of transcatheter mitral valve intervention. Currently, only the invasive measurement of LAP (i-LAP) is available and no echocardiographic methods are reliable in the setting of transcatheter mitral valve intervention. This study sought to validate a new echocardiographic method for the estimation of LAP (e-LAP) by comparing it with i-LAP. During percutaneous edge-to-edge procedure with MitraClip, the i-LAP was routinely monitored. Across the iatrogenic interatrial septum defect, the flow was sampled with continuous-wave Doppler echocardiography for deriving the mean pressure gradient between the left atrium and the right atrium, and the central venous pressure was added to obtain the e-LAP. The correlation between the measures derived from these 2 methods was explored. A total of 34 consecutive patients were included. Intraclass correlation coefficient between e-LAP and i-LAP was high (intraclass correlation coefficient [95% confidence interval] 0.809 [0.625 to 0.902], R Pearson 0.6, p <0.001); a bias of -1.3 mm Hg for e-LAP versus i-LAP was found (p=0.32). The median follow-up was 108 days (interquartile range 40 to 264). No death occurred and 6 patients were rehospitalized for heart failure. Postimplant e-LAP was correlated with rehospitalization at follow-up (hazard ratio 1.46, 95% confidence interval 1.022 to 2.1, p=0.038). A cut-off value of 9.5 mm Hg for the e-LAP was identified as predictor of rehospitalization for heart failure. The evaluation of e-LAP has optimal reliability compared with i-LAP; a value more than 9.5 mm Hg was found to be related to higher risk of events at short follow-up.

Left atrial appendage (LAA) flow profile of its different waves and its correlation with direct left atrial pressure measurement: Can LAA flow profile be a surrogate to estimate left atrial pressure.

Background:Left Atril Appendage(LAA) is one of the most contractile structure of the heart. Elevated Left atrial pressure (LAP) can change the flow profile in and out of LAA. There is little data on the effect of LAP on LAA flow velocities for patients in sinus rhythm, and it's not properly known that by evaluation of LAA flow spectra and its velocities, the LAP can be predicted. We tried to find the relationship between LAA flow velocities and LAP, with the premise that LAA flow velocities can be used as a surrogate for measuring LAP, by obtaining a regression equation in this prospective observational study.Methods:In forty patients with normal systolic and diastolic heart function undergoing elective off pump coronary artery bypass (OPCAB) under general anaesthesia, TEE based LAA flow velocities were measured and simultaneous direct measurements of LAP was done by the surgeon. We also studied the relation between the ratio of early mitral inflow velocity (E) and mitral lateral annular early diastolic velocity (E'), that is, (E/E') in all patients.Results:We found significant correlation between E/E' and LAP (r = 0.424, p = 0.024) however there was no significant correlation between LAA flow velocities and LAP.Conclusion:LAA flow profile can not be used under anaesthesia to evaluate LAP however E/E' shows a strong correlation with directly measured LAP.

Abstract 12994: Invasive Left Atrial Pressure Monitoring and Survival on Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock

Introduction: Elevated left atrial pressures (LAP) are associated with worse outcomes among patients with cardiogenic shock (CS), yet there are limited data on the utility of continuous invasive monitoring of LAPs on outcomes for CS. This is additionally true among refractory CS patients on peripheral VA ECMO, which itself can increase arterial afterload. Hypothesis: Our objective was to determine whether invasive LAP monitoring impacts survival for patients with refractory CS after 24 hours of VA ECMO support. Methods: We performed a cohort analysis among 10,906 patients ≥18yrs of age from the Extracorporeal Life Support Organization (ELSO) Registry from 2015 - 2020, with refractory CS treated with VA ECMO. The presence of invasive LAP monitoring was defined as either pulmonary capillary wedge pressure (PCWP) or pulmonary arterial diastolic pressure (PAD) values at 24 hours on VA ECMO. The exposure was measurement of LAPs at 24 hours on VA ECMO support, and the primary outcome was 30 day survival. We performed Kaplan Meier survival analysis, adjusting for age, PaO2/FiO2, pH, SCAI classification stage prior to ECMO, presence of a pre-ECMO cardiac arrest, mean arterial blood pressure on ECMO and year. Results: Median age of patients was 57 [IQR,46; 65] years with 31% females. Thirty two percent (n=3,465) presented with acute myocardial infarction, 29% (n=3,112) with acute heart failure and 1% (n=965) with both etiologies. Invasive LAP monitoring at 24 hours was performed in 33% (n=3608) of patients. The use of invasive LAP was associated with lower mortality (adjusted Hazard Ratio 0.88 [95% CI 0.81 to 0.95]; p=0.002). Conclusions: Implementation of invasive LAP monitoring may be associated with higher adjusted hospital survival in patients with refractory CS requiring VA-ECMO support. These findings merit further investigation and prospective validation to assess the relationship between invasive hemodynamic monitoring and outcomes in this patient population.

Experience of remote cardiac care during the COVID‐19 pandemic: the V‐LAP™ device in advanced heart failure

The outbreak of coronavirus disease 2019 (COVID-19) has imposed disruptive changes in cardiovascular care worldwide.1 During the pandemic, allocating resources and mitigating risks have been puzzling processes, requiring extensive adaptations of inpatient and outpatient services. While a dramatic rise of cases has led to overwhelming hospital admissions, heart failure (HF) remained a challenging scenario because clinical presentation may overlap with COVID-19 infection. Therefore, the usual modalities of care delivery for HF patients have been implemented, favouring preventive measures, minimizing in-person contacts, reducing patients' and health care providers' risk of exposure. This unprecedented scenario has accelerated the transition towards telemedicine as a way to provide safe, accountable, and effective care in HF. It is worth mentioning that HF is highly prevalent, especially among the elderly population, the most at risk for the worst outcomes with COVID-19: hospital readmissions negatively impact on patient prognosis and have been shown to predict mortality.2, 3 The present context offers the framework for discussing a paradigmatic example of chronic HF management through remote telemonitoring of left atrial pressure (LAP) using the V-LAP™ device (Vectorious Medical Technologies, Ltd, Tel Aviv, Israel), currently tested at our Institution under the V-LAP™ Left Atrium Monitoring systEm for Patients With Chronic sysTOlic & Diastolic Congestive heaRt Failure (VECTOR-HF) first-in-man clinical study (ClinicalTrials.gov NCT03775161). Given that Italy ranks among the highly affected territories, this approach might show most of his usefulness over the unexpected COVID-19 outbreak. The study population consists of patients in New York Heart Association (NYHA) functional class III, with left ventricular ejection fraction (LVEF) >15%, who have a history of hospitalization for worsening HF or elevated ambulatory levels of brain natriuretic peptide (BNP)/N-terminal pro BNP. The device is implanted under fluoroscopy and transoesophageal echo-guidance in a trans-septal fashion. Once implanted, the battery-free interatrial device captures the LAP. LAP measurements are daily collected by means of an external belt, sending data to the cardiologist via a cloud-based system. In our centre, two patients have been enrolled so far. Here we present the first case with the longer follow-up. The V-LAP system was implanted in a 75-year-old patient with HF with severely reduced LVEF (25%), NYHA class III, and repeat HF hospitalizations (two in the previous 6 months). After 90 days, right heart catheterization confirmed the accuracy of LAP measurements as compared to pulmonary capillary wedge pressure. Once the reliability was confirmed, LAP trends have been monitored and used to guide optimization of medical therapy (Figure 1). During the course of the COVID-19 pandemic, the V-LAP system showed remarkable reliability and easiness of use, encouraging patients to adhere with a high compliance rate (>99%) to the protocol. Remote analysis of LAP curves led to earlier detection of underlying disease progression preventing clinically relevant decompensation: when a rise in mean LAP was observed, diuretic therapy was modified accordingly. No hospital readmissions occurred over 6 months, avoiding medical contacts and in-hospital exposure. NYHA functional class improved (from III to II) and was coupled with an amelioration of the perceived quality of life, evaluated with the Kansas City Cardiomyopathy Questionnaire. In the first-in-human cases, the V-LAP™ implant was feasible, safe, and showed good accuracy and precision. Although further data are needed, HF patient management guided by the V-LAP system has the potential to significantly improve patient outcomes and also to decrease direct and indirect costs: the paucity of healthcare resources under the pandemic has highlighted the importance of safer and clinically appropriate solutions of remote telemonitoring, paving the way for a wider use of similar means. The COVID-19 pandemic has fostered the virtuous cycle of pre-clinical and clinical research, providing effective answers to the pressure of highly demanding therapeutic needs. Enduring advancements have been stimulated, and the benefits will last beyond the course of the outbreak. As telemedicine continues to flourish and to be applied even in ordinary settings, the words attributed to the late Albert Einstein seem appropriate: ‘All crises bring progress. Creativity is born from anguish, just like the day is born form the dark night. It is in crisis that inventiveness is born, as well as discoveries made and big strategies.’ Conflict of interest: none declared.

Characteristics and outcomes of patients with normal left atrial pressure undergoing transcatheter mitral valve repair.

A subset of patients at the time of transcatheter mitral valve repair (TMVR) will have normal left atrial pressure (LAP) (<13 mm Hg) despite having severe mitral regurgitation (MR). The goal of this study was to determine clinical characteristics and outcomes in patients with normal LAP undergoing TMVR. A single-centre retrospective cohort of consecutive patients who underwent transcatheter edge-to-edge mitral valve clip and continuous LAP monitoring between 5/1/2014 and 5/1/2018 was analysed. One-year mortality was compared by Kaplan-Meier survival curves. Multivariable analysis was performed to identify predictors of normal LAP and 1 year mortality. Of the 204 patients undergoing TMVR, 65% were men and the mean age was 81. Of these patients, 31 (15%) had normal LAP (mean LAP 10.5 mm Hg, mean V wave 16.5 mm Hg) and 173 had elevated LAP (mean LAP 19 mm Hg, mean V wave 32.5 mm Hg). The prevalence of severe MR was not different between groups, although the normal LAP group had significantly lower effective regurgitant orifice area and regurgitant volume. Other notable baseline characteristics including prior cardiac surgery, atrial fibrillation, hypertension, diabetes, congestive heart failure, body mass index, mechanism of MR and ejection fraction were similar between groups. However, there was an increased prevalence of chronic lung disease (CLD) (45.2% vs 17.3%, p<0.001) in the normal LAP group. On multivariate analysis, the only significant predictor of normal LAP was the presence of CLD (OR 4.79 (1.83-12.36), p=0.001) and 1-year mortality was significantly higher in the normal LAP group (32.3% vs 12.7%, p=0.006). After adjustment for comorbidities, normal LAP was no longer a predictor of 1-year mortality (RR 1.62 (0.64-4.06), p=0.32); however, CLD (RR 3.44 (1.37-8.67), p=0.01) remained a statistically significant predictor. Normal LAP at the time of TMVR is associated with a higher incidence of CLD which independently predicts increased 1-year mortality. In patients with CLD and apparently severe MR, measurement of LAP may help identify those with lower likelihood of benefit from TMVR.

A052 Investigation of Exhaled Nitric Oxide as a Measure of Left Atrial Pressure

During left-sided heart failure, left atrial pressure (LAP) increases, producing pulmonary congestion. Previous studies examining patients with symptomatic heart failure or rheumatic heart disease suggest a relationship between increased left atrial pressure (LAP) and fractional exhaled nitric oxide (FeNO), which can be measured by a reliable portable hand-held analyzer. If such a relationship existed, a portable diagnostic test could be used to supplement current assessments. This observational study examined a subset of the OxVALVE cohort, a UK population-based cohort aged 65 years and older. Participants were eligible for inclusion if they did not have a previous diagnosis of valvular heart disease, and could provide informed consent. Each participant had echocardiography performed at their local general practice. The E/e' ratio, measured via transthoracic echocardiography, was used as a surrogate of LAP. A consecutive subset of 277 participants had FeNO measurement attempted using a NIOX VERO electrochemical analyzer. Mean age of participants was 73.5±6.3 years, with 45% female. Only 10 participants had an NYHA class of III or more. FeNO was successfully measured in 227 participants, with a mean FeNO of 24.2 + 15.6ppb. Mean E/e' was 11.5±3.5. There were 58 participants with high E/e' (>14), and these were older than those with normal E/e' (<8) (76.8±7.4years vs 72.0±5.5 years, p<0.001). No relationship between FeNO and E/e' was seen on regression analysis. FeNO is not an accurate predictor of elevated E/e' in predominantly asymptomatic patients in a general practice setting.

Assessment of the Left Ventricular Diastolic Function and Its Association with the Left Atrial Pressure in Patients with Atrial Fibrillation.

Background and ObjectivesThe evaluation of left ventricular (LV) diastolic function in patients with atrial fibrillation (AF) is challenging. This study aimed to investigate the efficacy of the diagnostic algorithm for LV diastolic dysfunction (LVDD) in the current guidelines and to evaluate the association between increased left atrial pressure (LAP) and LV diastolic parameters.MethodsOne hundred and twenty-four patients with non-valvular AF and a preserved LV ejection fraction who had the same rhythm status on echocardiography and LAP measurements during catheter ablation were included. LV diastolic function was classified as normal, indeterminate, or LVDD according to the recent guidelines. Increased LAP was defined as mean LAP (mLAP) ≥15 mmHg.ResultsThe mLAP was not different among the normal, indeterminate, and LVDD groups. However, the prevalence of increased LAP was higher in the LVDD group. Among the LV diastolic parameters, only medial E/e′ was independently associated with mLAP in the whole study population. In patients with persistent AF (PeAF), E/e′ and e′ were significantly associated with mLAP, whereas in paroxysmal AF (PAF), mLAP was not associated with the LV diastolic parameters but with left atrial conduit function.ConclusionsIn general, increased LAP is known to be closely related with LVDD. However, the algorithm for LVDD from recent guidelines does not reflect well the increased LAP in AF patients. The diastolic parameters may aid in estimating the increased LAP in PeAF but may only have limited value for assessing increased LAP in PAF.