Presence Of Right Ventricular Dysfunction Research Articles

Multiparametric right ventricular assessment improves risk stratification in patients with new-onset acute heart failure.

Risk stratification of patients with new-onset acute heart failure (AHF) is important but remains challenging. In the present study, we evaluated the prognostic value of a new multiparameter right ventricular dysfunction (RVD) score. Patients (n=210) hospitalized due to new-onset AHF between 2015 and 2018 were retrospectively included. Mean age was 56±10years, 24% were female and median left ventricular ejection fraction was 28% (interquartile range 20; 34%). The RVD score, tricuspid annular plane systolic excursion (TAPSE), and fractional area change (FAC) were determined at index hospitalization and after therapy titration. The 4-point RVD score included reduced TAPSE, right ventricular enlargement, moderate or severe tricuspid regurgitation and increased central venous pressure. The study endpoint was a composite of all-cause mortality, left ventricular assist device implantation, and heart transplantation. After 60months median follow-up time, 53 (25%) patients met the endpoint. At index hospitalization, there were no significant differences in any echocardiographic parameter between patients with and without the endpoint. After therapy titration, there were differences in TAPSE (16 vs. 19mm, P=0.001), FAC (33 vs. 40%, P<0.001) and the proportion of patients with RVD score ≥2 (36 vs. 4%, P<0.001). The presence of RVD despite therapy titration had different impact on survival depending on the parameter considered: the proportion of patients free from events after 1year was 87% in patients with TAPSE <17mm, 89% in patients with FAC <35% and 65% in patients with RVD score ≥2. In a multivariable analysis, RVD score ≥2 after therapy titration, but not TAPSE <17mm or FAC<35%, remained associated with a higher risk of the composite endpoint (hazard ratio 3.11, 95% confidence interval 1.44-6.74). A novel multiparametric RVD score might improve prognostic stratification in patients with new-onset AHF. RVD after therapy titration, but not at index hospitalization is associated with a higher risk of the composite endpoint.

A novel method for the evaluation of right ventricular dysfunction in acute pulmonary embolism: Myocardial work indices.

The presence of right ventricular dysfunction indicates a higher risk status in patients with pulmonary embolism (PE). The RV strain evaluated by speckle-tracking echocardiography seems to be more reliable method in the evaluation of RV dysfunction as compared to standard echocardiographic measures. In this study, we aimed to determine the value of myocardial-work indices in evaluating serial changes of RV function in acute PE. Our study comprised 83 consecutive acute PE patients who admitted to our tertiary cardiovascular hospital. Echocardiography was performed within the first 24-hours of hospitalization, and RV and LV myocardial-work parameters were obtained along with standard echocardiographic parameters. The change in the RV/LVr detected on tomography was selected as the primary outcome measure, and its' predictors were analyzed with classical linear regression and a generalized additive model (GAM). Among the LV-RV strain and myocardial work parameters, the RV global longitudinal strain (GLS) has borderline statistical significance in predicting the RV/LVr change whereas the RV global work efficiency (RV-GWE) strongly predicted RV/LVr change (p: 0.049 and <0.001, respectively). In this study, classical linear regression and GAM analyses showed that RV-GWE seems to offer a better prediction of RV/LVr change in patients with acute PE.

Acute Myocardial Infarction in COVID-19 Patients-A Review of Literature Data and Two-Case Report Series.

Background/Objectives: The newly emergent COVID-19 pandemic involved primarily the respiratory system and had also major cardiovascular system (CVS) implications, revealed by acute myocardial infarction (AMI), arrhythmias, myocardial injury, and thromboembolism. CVS involvement is done through main mechanisms-direct and indirect heart muscle injury, with high mortality rates, worse short-term outcomes, and severe complications. AMI is the echo of myocardial injury (revealed by increases in CK, CK-MB, and troponin serum markers-which are taken into consideration as possible COVID-19 risk stratification markers). When studying myocardial injury, physicians can make use of imaging studies, such as cardiac MRI, transthoracic (or transesophageal) echocardiography, coronary angiography, cardiac computed tomography, and nuclear imaging (which have been used in cases where angiography was not possible), or even endomyocardial biopsy (which is not always available or feasible). Two-case-series presentations: We present the cases of two COVID-19 positive male patients who were admitted into the Clinical Department of Cardiology in "Sfântul Apostol Andrei" Emergency Clinical Hospital of Galați (Romania), who presented with acute cardiac distress symptoms and have been diagnosed with ST elevation AMI. The patients were 82 and 57 years old, respectively, with moderate and severe forms of COVID-19, and were diagnosed with anteroseptal left ventricular AMI and extensive anterior transmural left ventricular AMI (with ventricular fibrillation at presentation), respectively. The first patient was a non-smoker and non-drinker with no associated comorbidities, and was later discharged, while the second one died due to AMI complications. Conclusions: From this two-case series, we extract the following: old age alone is not a significant risk factor for adverse outcomes in COVID-19-related CVS events, and that the cumulative effects of several patient-associated risk factors (be it either for severe forms of COVID-19 and/or acute cardiac injury) will most probably lead to poor patient prognosis (death). At the same time, serum cardiac enzymes, dynamic ECG changes, along with newly developed echocardiographic modifications are indicators for poor prognosis in acute cardiac injury in COVID-19 patients with acute myocardial injury, regardless of the presence of right ventricular dysfunction (due to pulmonary hypertension).

C-reactive Protein and Risk of Right Ventricular Dysfunction and Mortality in Patients With Acute Symptomatic Pulmonary Embolism

BackgroundRight ventricle (RV) dysfunction increases the risk of death from pulmonary embolism (PE). C-reactive protein (CRP) might identify RV inflammation and dysfunction in patients with PE. MethodsThis cohort study enrolled consecutive stable patients with acute PE between 2017 and 2023. We stratified patients by quartiles of CRP. We evaluated the association between CRP quartiles and the presence of RV dysfunction, and used multivariable models to assess for an association between CRP and the outcomes of all-cause and PE-specific mortality during the 30 days of follow-up after PE diagnosis. ResultsThe study included 633 stable patients with PE. Patients without RV dysfunction had significantly lower median (IQR) CRP levels compared with patients with RV dysfunction (n=509, 31.7 [10.0–76.4]mg/L vs n=124, 45.4 [16.0–111.4]mg/L; P=0.018). CRP showed a statistically significant positive association with the presence of RV dysfunction (P<0.01). On multivariable analysis, CRP level was not significantly associated with 30-day all-cause mortality (adjusted odds ratio [OR] per mg/L increment, 1.00; 95% CI, 1.00–1.01; P=0.095), but higher CRP was associated with significantly higher PE-related mortality (adjusted OR, 1.01; 95% CI, 1.00–1.01; P=0.026). Compared with patients in CRP quartile 1, patients in quartiles 2, 3, and 4 had a stepwise increase in the adjusted odds of 30-day all-cause death of 2.41 (P=0.148), 3.04 (P=0.062), and 3.15 (P=0.052), respectively. ConclusionsAs an indicator of RV dysfunction, CRP may improve risk stratification algorithms for hemodynamically stable patients with acute symptomatic PE.

Association between left ventricular systolic function parameters and myocardial injury, organ failure and mortality in patients with septic shock

BackgroundLeft ventricular ejection fraction (LVEF) is inconsistently associated with poor outcomes in patients with sepsis. Newer parameters such as LV longitudinal strain (LVLS), mitral annular plane systolic excursion (MAPSE) and LV longitudinal wall fractional shortening (LV-LWFS) may be more sensitive indicators of LV dysfunction, but are sparsely investigated. Our objective was to evaluate the association between five traditional and novel echocardiographic parameters of LV systolic function (LVEF, peak tissue Doppler velocity at the mitral valve (s´), LVLS, MAPSE and LV-LWFS) and outcomes in patients admitted to the Intensive Care Unit (ICU) with septic shock.MethodsA total of 152 patients admitted to the ICU with septic shock from two data repositories were included. Transthoracic echocardiograms were performed within 24 h of ICU admission. The primary outcome was myocardial injury, defined as high-sensitivity troponin T ≥ 45 ng/L on ICU admission. Secondary outcomes were organ support-free days (OSFD) and 30-day mortality. We also tested for the prognostic value of the systolic function parameters using multivariable analysis.ResultsLVLS, MAPSE and LV-LWFS, but not LVEF and s´, differed between patients with and without myocardial injury. After adjustment for age, pre-existing cardiac disease, Simplified Acute Physiology (SAPS3) score, Sequential Organ Failure Assessment (SOFA) score, plasma creatinine and presence of right ventricular dysfunction, only MAPSE and LV-LWFS were independently associated with myocardial injury. None of the systolic function parameters were associated with OSFD or 30-day mortality.ConclusionsMAPSE and LV-LWFS are independently associated with myocardial injury and outperform LVEF, s´ and LVLS. Whether these parameters are associated with clinical outcomes such as the need for organ support and short-term mortality is still unclear.Trial registration NCT01747187 and NCT04695119.

Determinants of right ventricular systolic dysfunction among patients with left heart failure in a Ghanaian hospital.

The presence of right ventricular dysfunction affects outcomes in patients with left heart failure. We assessed the determinants of right ventricular systolic dysfunction (RVSD) among patients with left heart failure presenting to the Korle Bu Teaching Hospital of Ghana. Consecutive patients with left heart failure who were 18 years and above were prospectively enrolled and assessed for evidence of RVSD by measuring the tricuspid annular plane systolic excursion, the peak velocity of the tricuspid annulus in systole (RV S'), the two-dimensional right ventricular fractional area change (RV FAC) and the right ventricular myocardial performance index (RV MPI). Two hundred and seventy participants were enrolled, of whom 75.2% had at least one abnormal index of right ventricular systolic function. The prevalence of RVSD was significantly higher among those with non-hypertensive heart failure (85.3 vs 66.0%, p < 0.001). The left ventricular outflow tract velocity-time integral (LVOT VTI) was strongly correlated with the RV FAC and an LVOT VTI < 9.8 cm predicted the presence of an RV FAC < 35% with a sensitivity of 81.5% and specificity of 81.9% [area under the curve 0.882; 95% confidence interval (CI): 0.838-0.926, p < 0.001]. Independent predictors of the presence of RVSD included a transmitral E/A > 2 [odds ratio (OR) = 4.684, 95% CI: 1.521-14.428, p = 0.007), left ventricular ejection fraction < 40% (OR = 4.205, 95% CI: 1.643-10.760, p = 0.003), pulmonary artery systolic pressure (PASP) ≥ 35 mmHg (OR = 2.434, 95% CI: 1.012-5.852, p = 0.047) and systemic systolic blood pressure (SBP) < 140 mmHg (OR = 2.631, 95% CI: 1.152-6.011, p = 0.022). RVSD was common in these Ghanaian patients with left heart failure. Left ventricular function, SBP and PASP were independent predictors of the presence of RVSD. Pending further validation, the LVOT VTI may serve as a useful surrogate or screening tool for RVSD in these patients.

Abstract 14932: Prediction of Pulmonary Embolism Using Random Forest Algorithm: A Study on 917 Patients Over a Period of 1 Year in a New York City Public Hospital

Introduction: Pulmonary Embolism (PE) can be challenging to diagnose. Artificial intelligence (AI)-generated models can help improve the diagnostic accuracy of detecting PE. Aim: Establish the diagnostic accuracy of AI-generated models in predicting PE as compared to routinely used diagnostic predictive tools (Well’s score, YEARS score, and revised Geneva score). Methods: We conducted a single-center retrospective review of patients who underwent computed tomography pulmonary angiography (CTPA) for diagnosing PE over a one-year period. Twenty-five parameters including age, sex, race, BMI, history of deep vein thrombosis or PE, malignancy, hypertension, COPD, CKD, presenting symptoms like chest pain, dyspnea, cough, palpitations, dizziness, lightheadedness/syncope, hemoptysis, fever, pain on palpation of the lower extremity, vitals including heart rate, respiratory rate, oxygen saturation, findings of lower extremity venous duplex, presence of right ventricular dysfunction on echocardiogram, elevated troponin and pro-brain natriuretic peptide were utilized to train the AI model. Random forest algorithms were trained for predicting PE in 80% of the dataset, while the remaining 20% was used to test the AI model. Subsequently, the accuracy of the model was matched with the accuracy of four alternative modalities: clinical judgment of PE being equally or more likely, Well’s score &gt;4, YEARS score ≥1, and revised Geneva score ≥11. CTPA results were used as the gold standard. Analysis was performed using STATA BE/17 and Python 3.8. Results: 917 patients were included in the analysis (median age: 57 years (IQR: 41-68); female: 59%). The AI model correctly classified patients with 84.6% diagnostic accuracy, outperforming every other modality (Figure 1). Conclusion: AI-generated prediction models can be useful in predicting PE with considerable accuracy. Further, large-scale studies are required to validate these results externally.

Abstract 13181: Tricuspid Regurgitation Impact on Outcomes (TRIO) Score in Patients With Tricuspid Regurgitation and Severe Pulmonary Hypertension

Background: Clinically significant tricuspid regurgitation (TR) is an important contributor to morbidity and mortality. The Tricuspid Regurgitation Impact on Outcomes (TRIO) score based on 8 parameters (age, gender, chronic heart failure, chronic lung disease, heart rate, creatinine, aspartate transaminase level, and TR severity) is used for risk stratification. The performance of the TRIO score in patients with TR secondary to severe pulmonary hypertension (PH) is unknown. Research Questions: To evaluate whether the TRIO score can be applied in patients with TR and pulmonary hypertension (PH), and to identify other predictors of mortality. Methods: Retrospective study including patients with TR ≥ moderate. Severe PH was defined as right ventricular systolic pressure (RVSP) ≥50 mmHg. The impact of clinical, echocardiographic and laboratory variables on mortality was evaluated with the Cox proportional hazard method. Results: A total of 13,482 patients from the TRIO population were included; severe PH was present in 6,530 (48.4%); mean age 73.4 + 13.3, 55.7% females. TRIO score performance was modest (AUC 0.62) in risk stratification (Figure A). PH patients had significantly higher mortality than those without PH at all levels of TRIO score (Figure B); differences were progressively lower with increasing TRIO scores. At multivariate analysis, only TRIO score [HR = 1.54 (1.35-1.77) per unit change], presence of an elevated NT-proBNP [HR = 1.02 (1.02-1.03) per 1000 pg/ml change], RVSP (HR = 1.08 (1.02-1.16) per 10 mmHg change], presence of RV dysfunction [HR = 1.15, (1.05-1.26)] and pulmonary artery pulsatility index (PAPi) ≤ 4 [HR = 1.34 (1.07-1.67)] were significant predictors of mortality (model AUC 0.65). Conclusions: TRIO score allows risk stratification in PH patients, but performance is modest; incorporating additional factors marginally increased model performance. PH patients have higher mortality at all levels of TRIO score, more so at low scores.

Hemodynamic and Management Perspectives in Heart Failure Patients

Introduction Prevalence of heart failure (HF) is increasing, and right ventricular (RV) dysfunction is an independent predictor of mortality. Accurate echocardiographic evaluation of RV function is challenging and novel parameters which can aid in prediction RV function are required. Pulmonary artery Pulsatility index (PAPi) is one such parameter. Patients and Methods We conducted a prospective study in 33 patients admitted with symptoms of HF and severe LV dysfunction (EF &lt; 35) who underwent right heart catheterization and followed them for 6 months. Primary objective was to determine the association of PAPi with hospitalizations and mortality in short-term follow-up in HF patients. Clinical, demographic, echocardiographic, and catheterization data were recorded. PAPi was calculated as a ratio of pulmonary artery pulse pressure and right atrial pressure. Results The mean age of population was 47 years (±12). Males were 20(61%) and females were 13(39%). Median PAPi in the study population was 2.42 (IQR-1.83). The study population were stratified into 3 groups based on 10th, 50th, and 90th percentile PAPi and on comparisons between groups PAPi was significantly associated with hospitalization at 1 and 6 months in univariate ( P = .03 and P = .03 respectively) and in multivariate analysis ( P = .04). PAPi was not found to be associated with mortality at 1 month or 6 months. However, the absolute mortality was low in the study population (n = 4). Conclusion PAPi has been found to be a strong and an independent predictor of hospitalization at 1 month and 6 months. Comments Advanced HF is seen in 1 out of 5 patients with HF. It is characterized by refractory symptoms, multiple hospitalizations, fluid retention, elevated natriuretic peptides, and decreased cardiac output often requiring inotropes. The survival rate is poor. The presence of right ventricular dysfunction is an independent predictor of mortality in these patients. Hemodynamic assessment is of importance in these patients to guide regarding further management, ie, use of inotropes, left ventricular assist devices, etc. The PAPi is a marker derived from the formula (PASP-PADP/RAP). 1 The outcome worsens as the PAPi decreases. However, the stroke volume, pulmonary artery capacitance (PAC), and right atrial pressure all have an impact on PAPi. Patients with high PAC will have better PAPi compared to those with low PAC with the stroke volume being constant. 2 Different subsets of HF population have varying PAPI thresholds, with isolated RV infarction having the lowest (0.9) and severe HF having the highest (3.2). 2 Future research should examine the impact of exercise, inotropes, and vasodilators.

Acute heart failure: differential diagnosis and treatment.

Acute heart failure is a heterogeneous clinical syndrome and is the first cause of unplanned hospitalization in people >65 years. Patients with heart failure may have different clinical presentations according to clinical history, pre-existing heart disease, and pattern of intravascular congestion. A comprehensive assessment of clinical, echocardiographic, and laboratory data should aid in clinical decision-making and treatment. In some cases, a more accurate evaluation of patient haemodynamics via a pulmonary artery catheter may be necessary to undertake and guide escalation and de-escalation of therapy, especially when clinical, echo, and laboratory data are inconclusive or in the presence of right ventricular dysfunction. Similarly, a pulmonary artery catheter may be useful in patients with cardiogenic shock undergoing mechanical circulatory support. With the subsequent de-escalation of therapy and haemodynamic stabilization, the implementation of guideline-directed medical therapy should be pursued to reduce the risk of subsequent heart failure hospitalization and death, paying particular attention to the recognition and treatment of residual congestion.

Worse survival in patients with right ventricular dysfunction and COVID-19–associated acute respiratory distress requiring extracorporeal membrane oxygenation: A multicenter study from the ORACLE Group

ObjectiveWe sought to determine the impact of right ventricular dysfunction on the outcomes of mechanically ventilated patients with COVID-19 requiring veno-venous extracorporeal membrane oxygenation. MethodsSix academic centers conducted a retrospective analysis of mechanically ventilated patients with COVID-19 stratified by support with veno-venous extracorporeal membrane oxygenation during the first wave of the pandemic (March to August 2020). Echocardiograms performed for clinical indications were reviewed for right and left ventricular function. Baseline characteristics, hospitalization characteristics, and survival were compared. ResultsThe cohort included 424 mechanically ventilated patients with COVID-19, 126 of whom were cannulated for veno-venous extracorporeal membrane oxygenation. Right ventricular dysfunction was observed in 38.1% of patients who received extracorporeal membrane oxygenation and 27.4% of patients who did not receive extracorporeal membrane oxygenation with an echocardiogram. Biventricular dysfunction was observed in 5.5% of patients who received extracorporeal membrane oxygenation. Baseline patient characteristics were similar in both the extracorporeal membrane oxygenation and non–extracorporeal membrane oxygenation cohorts stratified by the presence of right ventricular dysfunction. In the extracorporeal membrane oxygenation cohort, right ventricular dysfunction was associated with increased inotrope use (66.7% vs 24.4%, P < .001), bleeding complications (77.1% vs 53.8%, P = .015), and worse survival independent of left ventricular dysfunction (39.6% vs 64.1%, P = .012). There was no significant difference in days ventilated before extracorporeal membrane oxygenation, length of hospital stay, hours on extracorporeal membrane oxygenation, duration of mechanical ventilation, vasopressor use, inhaled pulmonary vasodilator use, infectious complications, clotting complications, or stroke. The cohort without extracorporeal membrane oxygenation cohort demonstrated no statistically significant differences in in-hospital outcomes. ConclusionsThe presence of right ventricular dysfunction in patients with COVID-19–related acute respiratory distress syndrome supported with veno-venous extracorporeal membrane oxygenation was associated with increased in-hospital mortality. Additional studies are required to determine if mitigating right ventricular dysfunction in patients requiring veno-venous extracorporeal membrane oxygenation improves mortality.

Comparative Analysis of 4 Risk Stratification Models to Identify Patients with Acute Pulmonary Embolism at Risk of Short Term Mortality in a Canadian Health Region

BACKGROUND Acute pulmonary embolism (PE) is a common, potentially life-threatening disease. It is estimated that 5-15% of patients with acute PE are at high risk of death or hemodynamic collapse. Multiple risk stratification models have been developed to identify patients at risk of complications. Common examples include, simplified Pulmonary Embolism Severity Index (sPESI) and Hestia criteria scores. The sPESI has demonstrated the ability to discriminate between high (score ≥ 1) and low risk (score =0) for 30-day mortality. Hestia criteria (score ≥ 1 = high risk, score = 0 low risk) has shown ability to identify low risk patients eligible for outpatient treatment. However, neither scoring model takes into account the presence of right ventricular dysfunction (RVD), a predictor of early mortality. Our objective was to compare the ability of 4 different risk stratification models to identify outpatients at risk of mortality up to 90 days after acute PE METHODS We conducted a retrospective cohort study of adult outpatients aged ≥18 years with objectively confirmed PE from 2014-2019. PE was identified by positive diagnostic imaging from radiology reports obtained via search of the Picture Archiving and Communication System (PACS) database in Eastern Health Region in Newfoundland and Labrador, Canada. Patient data was collected via manual chart review. We calculated sPESI and Hestia scores for each patient with confirmed PE using methods from original derivation studies. Patients were stratified into 4 categories according to sPESI or Hestia criteria alone, as well as a combination of sPESI or Hestia criteria with or without (w/wo) RVD. High risk PE included those with sPESI or Hestia = 0 with RVD. Categorical data are presented as percentages and continuous data are shown as mean±SD. Students t-test and X2 test were used to compare continuous and nominal variables, respectively. The Cox regression analysis was used to analyse all-cause mortality up to 90 days in each category. Area under the receiver operator curve was used to measure the discrimination of each of the 4 risk stratification models to estimate 7, 30 and 90-day mortality (AUC). AUC: 50%, 50-69%, ≥70-80%, >80-90% and >90-100% suggest no, modest, acceptable, excellent and outstanding discrimination respectively. RESULTS A total of 785 outpatients were included in this study and had a mean [SD] age of 64.9 [16.2] years; weight, 91.1 [29.4] kg; and 331 were male [42.2%]). About 17.6-31.5% were classified as low risk by the 4 risk stratification models. Death rate at 7, 30 and 90 days ranged from 2.4-11.3%, 2.0 - 9.6%, 2.3 - 11.0%, 4.9 - 9.4% for patients categorized by sPESI, Hestia criteria, sPESI w/wo RVD and Hestia w/wo RVD respectively in the high risk groups. No death occurred in low risk groups. Of the 4 models, sPESI and Hestia showed acceptable discrimination for 30-day mortality with AUC: 72.8 (95%CI; 66.6-78.9) and 71.0 (95%CI; 64.0-77.9) respectively. This suggests sPESI score and Hestia criteria have a 72.8% and 71.0% chance of properly identifying low-risk and high-risk individuals based on 30-day mortality risk, respectively. Use of sPESI alone demonstrated modest discrimination for risk of 7 [AUC; 69.1 (95%CI; 58.2-80.0)] and 90-day [AUC; 66.4 (95%CI; 49.3-83.6)] mortality while Hestia criteria alone showed modest discrimination for risk of 7-day mortality [AUC: 64.4 (95%CI: 47.0-81.7)] but poor discrimination for 90-day risk of mortality [AUC; 38.5 (95%CI: 17.6-59.3)]. Each risk stratification model discriminated modestly for 7-day mortality (AUC range, 58.9-69.1), with sPESI showing the highest and Hestia w/wo RVD the least. In each model, discrimination for 90-day was lowest (AUC range, 38.5-66.4) compared to 7 and 30-day mortality. Hestia w/wo RVD exhibited the least discrimination for risk of mortality (AUC; 50.0-59.2). CONCLUSION: Compared to other risk models, sPESI alone showed acceptable discrimination at identifying acute PE patients at risk of 30-day death and modest discrimination at 7 and 90 days and performed better across the three time trajectories. Use of Hestia criteria alone showed acceptable and modest discrimination at identifying patients at risk of 30 and 7-day death respectively but least discrimination for 90-day mortality compared to sPESI w/wo RVD and Hestia w/wo RVD. The Hestia w/wo RVD model had the least discrimination at identifying risk of 7 and 30-day mortality compared with other models. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Impact of clinical profile at admission on the outcomes in patients hospitalized for acute pulmonary embolism: data from the IPER Registry.

Acute pulmonary embolism (PE) is characterized by a large heterogeneity of clinical presentation and disease course. We investigate whether different symptom PE phenotypes in hemodynamically stable PE could be associated with 30-day mortality risk. Hemodynamically stable patients from the multicentre, prospective Italian Pulmonary Embolism Registry (IPER) (September 2006-August 2010) presenting the most common four clinical phenotypes (< 24h onset dyspnoea, chest pain, pleuritic pain and phlebitis) at admission were included and compared to those who were asymptomatic at admission. Overall, 1365 (mean age 68.7 ± 15.3 years, 609 males) were evaluated. Recent onset dyspnoea (< 24h), chest pain, pleuritic pain and phlebitis were observed in 28.4%, 19.7%, 12.9% and 25.2%, respectively while asymptomatic patients represented the remaining 13.6% of cases. PE presenting with recent dyspnoea onset and chest pain had a lower 30-day overall survival (log-rank p = 0.01 and p < 0.001, respectively). By contrast, there were no significant differences when comparing patients with pleuritic pain or phlebitis (log-rank p = 0.2). Similar findings were confirmed at the Cox multivariate regression analysis which indicated a higher mortality risk in patients with chest pain [HR 3.21, 95% CI 2.16-4.78, p < 0.001] or recent dyspnoea [HR 2.12, 95% CI 1.22-3.87, p = 0.002] independent of age, heart rate, presence of right ventricular dysfunction, positive cardiac troponin and administration of systemic thrombolysis. Hemodynamically stable PE patients presenting with chest pain or recent onset dyspnoea had a lower 30-day survival compared to those asymptomatic or presenting pleuritic or phlebitis pain.Trial registryClinicalTrials.gov; No: NCT01604538).

Abstract 15632: Rv Dysfunction and the Risk of Mortality in Cardiomyopathy Patients Who Suffered a Cardiac Arrest

Background: Right ventricular (RV) dysfunction has been associated with higher mortality in patients who suffer a cardiac arrest. However, the role of RV dysfunction in patients with known cardiomyopathy (CM) (EF&lt;50%) who suffer cardiac arrest from a shockable rhythm is not well examined. Aim: To assess the relationship between RV dysfunction and mortality in patients with cardiac arrest from a shockable rhythm without an ICD. Methods: We included patients with CM of any etiology who were hospitalized for the first time with cardiac arrest at a tertiary care center between 2011 and 2017. We examined in-hospital as well as long-term mortality. RV dysfunction was defined based on standard echo parameters. Results: A total of 208 patients were admitted to the hospital with cardiac arrest from a shockable rhythm (VT/VfIb) and 139 of those had no ICD at the time of the cardiac arrest. Out of those 139 patients, 48 had RV dysfunction. Patients with RV dysfunction had higher in-hospital mortality (44.7% vs 15.1%, p&lt;.001). Over a mean follow-up of 2.9±3.2 years, patients with RV dysfunction had higher long-term mortality rates (72.9 vs 53.8%, p=.029) as well as shorter mean survival time (33.2, CI [20.6-45.8], vs 66.0 [53-78.9] months, p=0.005, Figure). In a Cox regression model, patients with RV dysfunction had higher long-term mortality rates when adjusting for EF, initiation of new AAD, electrolyte abnormalities and new ischemia (HR 1.68, 95% CI [1.05-2.69], p=.028). During hospitalization, patients with RV dysfunction needed advanced HF treatment options (inotropes, OHT) more frequently compared to patients without RV dysfunction (70.8 vs 46.2%, p=.005). Conclusions: RV dysfunction is an independent predictor of mortality in patients with cardiac arrest from a shockable rhythm who do not have an ICD. Further studies should investigate whether the presence of RV dysfunction alone should be taken into consideration for decisions on ICD implantation in patients with CM.

Echocardiography findings in amniotic fluid embolism: a systematic review of the literature.

Amniotic fluid embolism (AFE) is a leading cause of obstetrical cardiac arrest and maternal morbidity. The pathogenesis of hemodynamic collapse is thought to be from right ventricular (RV) failure; however, there is a paucity of data documenting echocardiography findings in this population. We undertook a systematic review of the literature to evaluate the echocardiography findings in patients with AFE. We retrieved all case reports and case series reporting AFE in Embase and MEDLINE from inception to 20 November 2021. Studies reporting AFE diagnosed by fulfilling at least one of three different proposed AFE criteria and echocardiography findings during hospitalization were included. Patient and echocardiographic data were retrieved, and univariate logistic regression analysis was performed for outcomes of interest. Bias was assessed using the Joanna Briggs Institute clinical appraisal tool for case series. Eighty publications reporting on 84 patients were included in the final review. Fifty-five out of 82 patients with data (67%) showed RV dysfunction, including 11/82 (13%) with biventricular dysfunction; 14/82 (17%) had normal systolic function. No data on RV or left ventricular function were reported for two patients. The presence of RV dysfunction on echocardiography was associated with cardiac arrest (odds ratio [OR], 3.66; 95% confidence interval [CI], 1.39 to 9.67; P = 0.009), and a composite risk of cardiac arrest, maternal death or use of extracorporeal membrane oxygenation (OR, 3.86; 95% CI, 1.43 to 10.4; P = 0.007). A low risk of bias was observed in 15/84 (18%) cases. Right ventricular dysfunction on echocardiography is a common finding in AFE and is associated with a high risk of cardiac arrest. The finding of RV dysfunction on echocardiography may help diagnose AFE and help triage the highest risk patients with AFE. PROSPERO (CRD42021271323); registered 1 September 2021.

Prognostic implications of biventricular and left radial strain in heart failure

Abstract Background Chronic heart failure (CHF) is associated with the high ventricular filling pressures with subsequent negative impact on the left (LV) and right ventricular (RV), and left atrium (LA) mechanics, and pulmonary vasculature. All these could lead to poor long-term outcome. Purpose Assess the prognostic implications of LA, LV and RV mechanical dysfunction, and pulmonary hypertension, in CHF based on advanced echocardiographic technology. Methods A total of 2110 CHF patients were retrospectively reviewed and enrolled for the analyses. The 2D-Speckle tracking echocardiographic analysis was used to measure the peak LV, RV and LA longitudinal strain. The long-term outcomes were evaluated for all-cause CVS outcomes and recurrent hospitalization. Results For the 941eligible patients [mean age: 61±4; 62% male sex], 244 reached the combined endpoint. Population was divided into three groups based on the mean pulmonary artery systolic pressure (mPASP): Group 1, 25&amp;lt;mPASP≤40 mmHg; Group 2, 40&amp;lt;mPASP≤55 mmHg and Group 3, &amp;gt;mPASP 55 mmHg. Mean follow-up was 2.5±0.6 years. The higher mPASP was demonstrated in those with higher left atrial volume ndex (LAVI), NYHA ≥II class, pulmonary diseases, presence of at least moderate mitral and/or tricuspid regurgitation (TR) grades, significantly lower LVEF, lower strain values (LA, LV, RV), and tricuspid annular plane systolic excursion (TAPSE), p&amp;lt;0.001). High mPASP, lower LVEF and RV dysfunction were independent predictors of survival after multiple adjustments using different models. Conclusions Multiple factors are associated with poor outcomes in CHF; particularly the presence of RV dysfunction, severe PH and severely impaired, which would guide further manage of CHF and to consider other treatment options including device therapy or even transplantation. All these factors could strongly influence the risk stratification of patients with CHF Funding Acknowledgement Type of funding sources: None.

Clinical significance of structural remodeling concerning substrate characteristics and outcomes in arrhythmogenic right ventricular cardiomyopathy.

BackgroundThe substrate and ablation outcome in arrhythmogenic right ventricular cardiomyopathy (ARVC) with or without right ventricular (RV) dysfunction is unclear.ObjectiveWe aimed to investigate ablation outcome and substrate in ARVC patients with or without RV dysfunction.MethodsWe retrospectively studied ARVC patients with (group 1) or without RV dysfunction (group 2) undergoing substrate mapping/ablation. Baseline characteristics and electrophysiological features were compared. The RV was divided into 7 prespecified segments. The scarred segment was defined as more than 50% of the area with bipolar scar. A multivariate regression analysis was performed to predict the risk of ventricular tachycardia (VT) recurrence.ResultsA total of 106 patients were enrolled (57 in group 1 and 49 in group 2). There were more men (73.7% vs 32.7%, P < .05) in group 1 than group 2. Group 1 patients demonstrated larger abnormal substrate in both the endocardium (13.4 ± 14.7 cm2 vs 7.8 ± 5.4 cm2, P = .014) and in the epicardium (40.3 ± 27.7 cm2 vs 14.2 ± 12.6 cm2, P = .002) and had more scar in the inferior portion/tricuspid valve (TV) than group 2 patients. Twenty-five patients had recurrences of VT/ventricular fibrillation. After multivariate analysis, the presence of a superior TV scar in the endocardium predicted the recurrence in patients with sustained VT.ConclusionThe presence of RV dysfunction was associated with a larger abnormal substrate in the endocardium and epicardium of the RV. A scar involving the inferior portion and TV is associated with RV dysfunction. Scarring in the superior TV of the endocardium can predict recurrence despite catheter ablation.

Impact of recurrent acute heart failure hospitalizations on prognosis of heart failure patients

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Hospitalizations for acute heart failure (AHF) are significant events for heart failure (HF) patients (pts) with each hospitalization portending a poor prognosis. Our aim was to compare pts with recurrent AHF admissions to those without and to study the impact of recurrent admissions on overall mortality. Methods Single centre retrospective study that included all pts followed at the HF Clinic of the Cardiology Department that had at least one visit during 2018. All data since their initial follow-up on HF Clinic was considered. Recurrent admissions were defined as 2 or more admissions for AHF in the same year, during the follow-up. Results A total of 138 pts were included (83% male, mean age 61±11years). Dilated cardiomyopathy (65;47%) and ischemic cardiomyopathy (62;45%) were the most frequent aetiologies and most pts had HF with reduced ejection fraction (131;95%). Mean left ventricular ejection fraction (LVEF) was 26±9% and right ventricular dysfunction was present in 27% of the cases. The majority of patients was on NYHA class II (80, 58%). A total of 84 (61%) pts was medicated with inhibitors of the renin-angiotensin system (iRAS), 45 (33%) with angiotensin receptor-neprilysin inhibitor (ARNI), 127 (92%) with beta-blockers (BB) and 116 (84%) with mineralocorticoid receptor antagonists (MRA). Ninety-seven (70%) pts had a cardiac electronic device implanted (47 CRT, 50 ICD). During a median follow-up of 40 months (IQR 32-58), 41 (30%) pts had hospitalizations for AHF and 21 (15%) had recurrent admissions. The median time to the first hospitalization was 16 months (IQR 6-29). Pts with recurrent admissions had a similar comorbidity profile and HF aetiology in comparison to pts with one or none admissions. Considering baseline echocardiographic parameters on first visit, they had a higher mean E/E’ ratio (22±8 vs 14±6, p= .012) and pulmonary systolic artery pressures (52±20 vs 38±14 mmHg, p= .026). No differences were found in LVEF, left ventricular volumes, presence of right ventricular dysfunction or mitral regurgitation. They were less frequently medicated with iRAS or ARNI (81% vs 96%, p=.012) and BB (81% vs 94%, p= .043) and had a higher mean diuretic dosage (87±47 vs 63±43 mg). During the follow-up a total of 31 (22%) pts died, 14 (10%) for cardiovascular reasons. Pts with recurrent AHF admissions were more likely to die from any cause (log rank =.01). On a multivariate analysis, recurrent AHF hospitalizations were an independent predictor of all-cause death (HR 2.4, IC95% 1.1-5.2, p=.03). Conclusion Recurrent AHF hospitalizations are associated with a worse long-term outcome of HF pts. Efforts should be made for an earlier identification of these pts. A higher baseline pulmonary systolic artery pressure and mean E/E’ ratio may identify a higher risk group who benefits from a closer follow-up.

Evaluating the role of transthoracic echocardiography in hospitalised patients with COVID-19 infection.

ObjectiveTo identify the most common transthoracic echocardiogram (TTE) parameters in patients hospitalised with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2/COVID-19) and their association with myocardial injury and outcomes.MethodsA retrospective, single-centre, observational, exploratory cohort study was performed at the height of the COVID-19 pandemic. All SARS-CoV-2 polymerase chain reaction (PCR) positive patients who underwent a TTE during their inpatient admission between 1 March 2020 and 31 October 2020 were analysed. The most frequent cardiovascular risk factor profile and echocardiographic features were investigated.ResultsA total of 87 patients met the eligibility criteria. A salient 41.4% (n=36) of our cohort succumbed to this devastating virus. More than half of our hospital population (58.6%) were admitted to the intensive care unit (ITU) and this was significantly associated with inpatient mortality (OR: 7.14, CI 2.53 to 20.19, p<0.001). Hypertension was the most common cardiovascular risk factor (51.7%) with no additional prominence in non-survivors (OR: 2.33, CI 0.97 to 5.61, p=0.059). Remarkably, 90.8% of our cohort demonstrated a preserved left ventricular ejection fraction, although 69.1% had elevated troponin levels. Only 1 patient (1.1%) was given a diagnostic label of myocarditis. A raised pulmonary artery systolic pressure (36.8%) andright ventricle (RV) dysfunction (26.4%) were the most common echocardiographic features. In particular, the presence of RV dysfunction was significantly related to adverse outcomes (OR: 2.97, CI 1.11 to 7.94, p<0.03).ConclusionsIn this cohort of extremely unwell patients hospitalised with COVID-19 pneumonitis, the presence of RV dysfunction or admission to ITU was significantly associated with inpatient case fatality ratio. Moreover, COVID-19-induced myocarditis remains extremely rare.

Age Does Not Matter: Utilization of Veno-Arterial Extracorporeal Membrane Oxygenation for Massive Pulmonary Embolism in the Elderly Population

<h3>Purpose</h3> Management of massive and submassive pulmonary embolism (PE) remains a challenge. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a useful strategy in select patients with pulmonary emboli (PE) to provide hemodynamic support; however, age remains a relative contraindication based on prior literature as safety is controversial. <h3>Methods</h3> We retrospectively reviewed all patients with pulmonary emboli who were placed on peripheral VA-ECMO from 2015- 2021 at a single institution. Patients were identified and stratified into two groups with an age cutoff of 65 years of age. Demographics, pre-cannulation data, ECMO data, and echocardiographic results were obtained. Primary endpoints included 30-day, 6-month, and one-year survival. <h3>Results</h3> Sixty-nine patients <65 years of age (median age 58) and twenty patients ≥65 of age (median age 69) received VA-ECMO for PE. Hypertension incidence was higher in the ≥65 group; there were no differences in sex, BMI, pre-cannulation arrest, or in pre-cannulation ejection fraction or presence of right ventricular dysfunction. The median duration on ECMO was 5 days in both groups (p=0.503). 14.5% (10/69) of patients <65 and 25.0% (5/20) of patients ≥65 required surgical embolectomy after 5-7 days of VA-ECMO support (p=0.313). There was no difference in 30-day survival (91.3% (63/69, A) in <65 vs 90.0% (18/20) in ≥65, p=<0.999), 6-month survival (92.3% (60/65) in <65 vs 85% (17/20) in ≥65, p=0.385), and one-year survival (92.1% (58/63, B) in <65 vs 83.3% (15/18) in ≥65, p=0.367). There was no difference in ICU or hospital length of stay, need for renal replacement therapy, and rate of stroke between the groups. <h3>Conclusion</h3> There is no difference in 30-day, 6-month, or one-year survival in patients with a PE who are supported with VA-ECMO as compared to younger patients in our experience. As such, age should not be a contraindication for VA-ECMO use for cardiopulmonary support in management of pulmonary embolism.