Pressure Gradient Measurement Research Articles

Assessment of clinically significant portal hypertension by two-dimensional shear wave elastography.

To evaluate two-dimensional shear wave elastography (2DSWE) in parallel with transient elastography (TE) for diagnosing clinically significant portal hypertension (CSPH) and high-risk varices (HRV) in patients with chronic liver disease. Consecutive patients with suspicion of compensated advanced chronic liver disease (cACLD) [liver stiffness measurement (LSM)≥10kPa by TE, or morphological signs suggestive of cACLD on imaging], with no history of liver decompensation, underwent hepatic venous pressure gradient (HVPG) measurement, transjugular liver biopsy and esophagogastroduodenoscopy, which served as the reference methods for diagnosing CSPH, cACLD and HRV. All patients underwent LSM and spleen stiffness measurements (SSM) by 2DSWE and TE. Seventy-six (76) patients were included (78% men, mean age 62years, body mass index 28.3kg/m2 , 36.8% alcoholic, 30.3% non-alcoholic fatty liver disease, 14.5% viral hepatitis). Of them, 80.3%, 69.7%, 52.6% and 22.4% had cACLD, cirrhosis, CSPH and HRV respectively. LSM performed better than SSM in diagnosing CSPH and HRV. For CSPH, AUROCs (0.926 vs. 0.866), optimal cut-offs (20.1 vs. 20.2kPa) and sensitivity/specificity (80.5%/94.3% vs. 77.5% /86.1%) were comparable for 2DSWE and TE. Ruling-out of CSPH by 2DSWE (LSM at cut-off with ≥90% sensitivity (13.5kPa) and platelets≥150x109 /L) performed comparably to TE, with 1/24 cases falsely classified as negative. For HRV, AUROCs were similar (0.875 2DSWE, 0.851TE) with similar optimal LSM cut-offs enabling 100% sensitivity and ruling-out HRV. Liver stiffness measurement by 2DSWE appears to perform equally well as TE for diagnosing CSPH and ruling-out HRV in compensated chronic liver disease.

Factor VIII/protein C ratio independently predicts liver-related events but does not indicate a hypercoagulable state in ACLD

It has been suggested that the ratio of procoagulant factor VIII to anticoagulant protein C (FVIII/PC) reflects the hemostatic equilibrium. Moreover, FVIII/PC predicted decompensation/death in a small study not accounting for portal hypertension severity. We investigated (i) the prognostic value of FVIII/PC (outcome-cohort) and (ii) whether FVIII/PC reflects the hypercoagulable state (assessed by thrombomodulin-modified thrombin generation assay [TM-TGA]) or the risk of bleeding/thrombotic events in patients undergoing hepatic venous pressure gradient (HVPG) measurement during follow-up. (i) The outcome-cohort comprised 576 patients with evidence of advanced chronic liver disease (liver stiffness measurement ≥10 kPa and/or HVPG ≥6 mmHg). (ii) TM-TGA-cohort patients (n= 142) were recruited from the prospective VIenna CIrrhosis Study (VICIS: NCT03267615). (i) FVIII/PC significantly increased across clinical stages (p <0.001) as well as HVPG (p <0.001) and MELD score (p <0.001) strata and remained independently associated with decompensation/liver-related death (adjusted hazard ratio 1.06; 95% CI 1.01-1.11; p= 0.013), even after multivariable adjustment. It was also associated with acute-on-chronic liver failure (ACLF) development (adjusted hazard ratio 1.10; 95% CI 1.02-1.19; p= 0.015) in patients with decompensated cirrhosis. (ii) FVIII/PC showed a weak positive correlation with endogenous thrombin potential (Spearman's ρ= 0.255; p= 0.002), but this association disappeared after adjusting for the severity of liver disease. FVIII/PC was not associated with the development of bleeding (p= 0.272) or thrombotic events (p= 0.269). However, FVIII/PC correlated with biomarkers of different pathophysiological mechanisms that promote liver disease progression. FVIII/PC provides prognostic information regarding hepatic decompensation/death and ACLF, independently of established prognostic indicators. However, this is not evidence that hypercoagulability drives disease progression, as the correlation between FVIII/PC and thrombin generation is confounded by liver disease severity and FVIII/PC was not associated with thrombosis. Therefore, FVIII/PC does not reflect coagulation and results from previous studies on FVIII/PC require re-interpretation. NCT03267615 (in part). A balanced coagulation system is essential for preventing bleeding episodes and blood clot formation (thrombosis). Blood of patients with advanced liver disease may have increased coagulation potential, possibly promoting the worsening of liver disease via thrombosis in the blood vessels of the liver. The ratio between the results of 2 blood tests (procoagulant factor VIII to anticoagulant protein C) has been suggested to reflect these increases in coagulation potential. Our study demonstrates, on the one hand, that this ratio is a versatile predictor of the development of complications of cirrhosis, yet on the other hand, that it is unrelated to coagulation.

Development an Experimental Method to Investigate Hydrodynamic Drag

Newcastle University [UNEW] has enhanced the test section of their existing water channel facility. The new measurement section is utilized to measure pressure drop (and hence frictional drag) across a standard flat test panel (length=0.6 m; width=0.22 m). The panel can be tested as cleanly coated as well as exposed to light biofilm growth. Based on measured pressure gradients, the skin friction coefficients of these surfaces are calculated and compared with other well-established methods (i.e., measuring the boundary layer of similar surfaces using a [LDV] system in UNEW’s Emerson Cavitation Tunnel [ECT], to evaluate the pressure drop methodology. This paper presents a design and calibration of a flow cell to investigate skin-friction of three different surfaces in a fully developed turbulent flow.

Endoscopic Ultrasound-guided Portal Pressure Gradient Measurement Is Technically Successful and Safe Without Deep Sedation: A Proof-of-Concept Case Series

The hepatic venous pressure gradient (HVPG), which is the difference between the wedged (WHVP) and free hepatic vein pressures (FHVP), is the gold standard to evaluate portal hypertension in patients with cirrhosis 1 Bosch J Abraldes JG Berzigotti A et al. The clinical use of HVPG measurements in chronic liver disease. Nat Rev Gastroenterol Hepatol. 2009; 6: 573-582 Crossref PubMed Scopus (436) Google Scholar . Unfortunately, there currently exists a gap in the evaluation of patients with pre-sinusoidal portal hypertension, where HVPG is known to underestimate portal pressure. Endoscopic ultrasound-guided portal pressure gradient measurement (EUS-PPG) has recently brought back the possibility of safely obtaining direct portal vein pressure (PVP) and represents a long-awaited less-invasive diagnostic tool for patients with suspected pre-sinusoidal portal hypertension.

Endoscopic Ultrasound-Guided Portal Pressure Gradient Measurement, Is It Ready for Prime Time?

Portal hypertension is a serious complication of advanced liver disease. Portal pressure gradient measurement accurately determines severity of portal hypertension, prognosis, and guides medical therapy. Conventionally, interventional radiology-guided hepatic venous portal gradient measures portal pressure gradient indirectly using specialized balloon catheter. Recent advances in endoscopy have paved the novel method of endoscopic ultrasound-guided direct portal pressure gradient measurement to evaluate portal hypertension with equivalent safety in both animal models and humans studies. With the expansion of Endo-Hepatology practice, a concept of “one stop shop” is becoming more popular which is a comprehensive endoscopic approach in the evaluation of chronic liver disease. During the same endoscopic procedure, patients could be evaluated for esophageal or gastric varices, portal hypertensive gastropathy, EUS-guided elastography, EUS-guided portal pressure measurement and EUS-guided liver biopsy when suspecting advanced liver disease or diagnosis remains uncertain. This article focuses on the overview of portal hypertension and EUS-guided interventions such as EUS-guided portal pressure measurement, EUS-guided elastography and EUS-guided liver biopsy in the evaluation of individuals with advanced liver disease.

Research progress of cirrhotic portal hypertension in diagnostic imaging methods

Hepatic venous pressure gradient measurement via jugular vein catheterization is still currently the gold standard for evaluating portal hypertension. However, how to accurately and reproducibly assess whether there is portal hypertension has always been a concern in patients with liver cirrhosis. In recent years, imaging methods have made significant progress in the non-invasive diagnosis of portal hypertension. This paper reviews the current different diagnostic value of imaging methods and related research progress in an attempt to evaluate patients with cirrhotic portal hypertension.

To treat or not to treat pulmonary arteries: epinephrine provocation to unmask right ventricular load

BackgroundPulmonary artery stenosis (PAS) is common in congenital heart disease (CHD). The indication for treatment of PAS is primarily based on invasively measured pressure gradients. Anesthetics used during cardiac catheterization cause systemic and pulmonary hypotension. We hypothesize that this leads to underestimation of right ventricular (RV) pressure load and under treatment of PAS. The aim of this study is to describe the use of epinephrine to unmask RV pressure load in patients with PAS. MethodsAll cardiac catheterizations in which epinephrine was administered to evaluate RV load were included. There was an indication for treatment in case of a right to left ventricular (RV:LV) pressure ratio >0.6. The indication for treatment before and after epinephrine was evaluated to determine its role in clinical decision making. ResultsA total of 74 procedures were included. In all procedures the invasively measured LV pressure was below the awake blood pressure. At baseline, 33 patients had a RV:LV ratio >0.6. In 41 patients the baseline RV:LV ratio was <0.6. After epinephrine bolus, the LV pressure was raised up to the awake blood pressure. In 19 of the 41 patients without baseline indication, this resulted in a RV:LV ratio >0.6 thereby revealing the indication for treatment. No epinephrine related complications were registered. ConclusionThe hypotensive properties of anesthetics during cardiac catheterization may lead to underestimation of RV pressure load. Invasive pressure measurements should be performed under conditions similar to awake conditions. Epinephrine provocation prevented under treatment in 25% of our patients.

The Value of Liver and Spleen Stiffness for Evaluation of Portal Hypertension in Compensated Cirrhosis.

Patients with compensated advanced chronic liver disease who develop clinically significant portal hypertension (CSPH) are at high risk for hepatic decompensation and mortality if left untreated. Liver biopsy and hepatic venous pressure gradient (HVPG) measurements are the current gold standard procedures for determining fibrosis severity and diagnosing CSPH, respectively; however, both are invasive, limiting their use in clinical practice and larger trials of novel agents. As such, there is an unmet clinical need for reliable, validated, noninvasive measures to detect CSPH and to further assess portal hypertension (PH) severity. Alterations in the biomechanical properties of the liver or spleen in patients with cirrhosis can be quantified by tissue elastography, which examines the elastic behavior of tissue after a force has been applied. A variety of methods are available, including magnetic resonance elastography, shear‐wave elastography, and the most thoroughly investigated measure, vibration‐controlled transient elastography. Liver stiffness (LS) and spleen stiffness (SS) measurements offer valuable alternatives to detect and monitor CSPH. Both LS and SS correlate well with HVPG, with thresholds of LS >20‐25 kPa and SS >40‐45 kPa indicating a high likelihood of CSPH. Because SS is a direct and dynamic surrogate of portal pressure, it has the potential to monitor PH severity and assess PH improvement as a surrogate marker for clinical outcomes. Importantly, SS seems to be superior to LS for monitoring treatment response in clinical trials focusing on reducing PH.

Simultaneous EUS-guided portosystemic pressure measurement and liver biopsy sampling correlate with clinically meaningful outcomes

The measurement of the portosystemic pressure gradient (PSG) in patients with advanced liver disease is helpful to assess the severity of portal hypertension (PH) and predict adverse clinical outcomes. EUS-guided PSG (EUS-PSG) measurement is a novel tool to assess PSG in all patients with advanced liver disease. We sought to assess the safety, feasibility, and technical success of simultaneous EUS-PSG measurement and EUS-guided liver biopsy sampling using a single-center experience. Patients with suspected liver disease or cirrhosis were enrolled prospectively from 2020 to 2021. EUS-PSG was measured by calculating the difference between the mean portal pressure and the mean hepatic vein pressure. PH was defined as PSG >5mm Hg and clinically significant PH as PSG≥10mm Hg. The primary outcomes were procedural technical success rate and correlation of EUS-PSG with fibrosis stage obtained from concurrent EUS-guided liver biopsy sampling and the correlation of EUS-PSG with patients' imaging, clinical, and laboratory findings. The secondary outcome was occurrence of procedural adverse events (AEs). Twenty-four patients were included in the study. PSG measurement and EUS-guided liver biopsy sampling were successful in 23 patients (technical success rate of 96%) and 24 patients (100% success), respectively. Analysis revealed a significant association between both PSG and liver stiffness measured on transient elastography (P= .011) and fibrosis-4 score (P= .026). No significant correlation was found between the fibrosis stage on histology and measured PSG (P= .559). One mild AE of abdominal pain was noted. Additionally, EUS-PSG was predictive of clinically evident PH. Simultaneous EUS-PSG measurement and EUS-guided liver biopsy sampling were both feasible and safe and correlated with clinically evident PH and noninvasive markers of fibrosis.

A wall slip pressure gradient model of unclassified tailings paste in pipe flow: Theoretical and loop test study

The unclassified tailings paste (UTP) is a typical non-Newtonian fluid with a mass fraction over 70%, and the UTP disposal technology is of great significance to solve the disaster of tailings ponds and underground voids. The widely used Buckingham equation for predicting the pressure gradient of UTP in pipe flow does not consider the effect of wall slip drag reduction and the prediction accuracy is relatively low. To this end, a theoretical derivation based on the apparent wall slip equations established by previous scholars, sedimentation tests, loop tests and rheological tests were carried out. When the UTP is a Bingham fluid, the proposed new pressure gradient model which considers the wall slip effect is composed of the Buckingham equation and a dimensionless wall slip correction coefficient. The correction coefficient decreases with increases in either slip layer thickness and plastic viscosity of UTP, and increases with increases in either pipe diameter and slip layer viscosity. In this study, the dimensionless correction coefficient is 0.83∼0.85. When using the new pressure gradient model, the ratio of solids volume fraction to the maximum packing volume fraction of UTP (the filling degree) is at least 0.76. Compared with the measured pressure gradient from the loop tests in this study and the literature, the average error of the new pressure gradient model is 11.3%, whereas the average error of the Buckingham equation is 29.8%. The advantages of the new pressure gradient model are that the required parameters are easy to obtain, the model is easy to solve, and the prediction accuracy is better than the Buckingham equation. When the UTP is a Herschel-Bulkley fluid, the reliability of the pipe pressure gradient model which considers the wall slip effect still needs to be verified.

Artificial intelligence in the diagnosis of cirrhosis and portal hypertension.

Clinically significant portal hypertension is associated with an increased risk of developing gastroesophageal varices and hepatic decompensation. Hepatic venous pressure gradient measurement and esophagogastroduodenoscopy are the gold-standard methods for assessing clinically significant portal hypertension and gastroesophageal varices, respectively. However, invasiveness, cost, and feasibility limit their widespread use, especially if repeated and serial evaluations are required to assess the efficacy of pharmacotherapy. Artificial intelligence describes a range of techniques that allow machines to perform tasks typically thought to require human reasoning and problem-solving skills. Artificial intelligence has made great strides in the field of medicine, and is also involved in portal hypertension diagnosis. Artificial intelligence tools will potentially transform our practice by leveraging massive amounts of data to personalize care to the right patient, in the right amount, at the right time. This review focuses on the recent advances in artificial intelligence for the noninvasive diagnosis of portal hypertension and gastroesophageal varices and monitoring of risk assessment of its complications in clinical practice.

Validation of the New Diagnostic Criteria for Clinically Significant Portal Hypertension by Platelets and Elastography.

Background and AimsWe aimed to validate newly proposed noninvasive criteria for diagnosing clinically significant portal hypertension (CSPH) using liver stiffness measurements (LSM) by transient elastography (TE) and platelet count.MethodsDiagnostic performance of these new criteria for CSPH (LSM ≥ 25 kPa to rule in and Plt ≥ 150 × 109/L + LSM ≤ 15 kPa to rule out CSPH) were retrospectively tested in an independent cohort of consecutive patients who underwent hepatic venous pressure gradient (HVPG) measurements and liver biopsy due to suspicion of compensated advanced chronic liver disease. Suspicion of cACLD was based on LSM ≥ 10 kPa by TE or results of liver imaging, without overt signs of CSPH. Patients with conditions known to affect results of LSM (ALT > 5 × ULN, liver congestion, extrahepatic biliary obstruction, infiltrative liver neoplasms) were excluded.ResultsSeventy six (76) patients were included: 78.9% males, mean age 62 years, 36.8% suffered from alcoholic, 30.3% nonalcoholic fatty liver disease, 14.5% chronic viral hepatitis, 30.3% were obese, 52.6% had HVPG ≥ 10 mmHg, 56.6% had platelet count ≥ 150 × 109/L. LSM ≥ 25 kPa had 88.9% specificity (95% CI 73.9–96.9) to rule in, whereas Plt ≥ 150 + LSM ≤ 15 kPa had 100% sensitivity (95% CI 91.1–100) to rule out CSPH.ConclusionBy using these simple noninvasive criteria 49/76 (64.5%) patients could be classified correctly for the presence/absence of CSPH, thus obviating the need for HVPG measurements.

Impact of propofol sedation on the diagnostic accuracy of hepatic venous pressure gradient measurements in patients with cirrhosis

BackgroundMeasurement of the hepatic venous pressure gradient (HVPG) is the gold standard to evaluate the presence and severity of portal hypertension. The procedure is generally safe and well tolerated, but nevertheless, some patients demand for sedation. However, it is unknown whether propofol sedation would impair the accuracy of portal pressure measurements.MethodsThis is a prospective observational cohort study including cirrhotic patients with suspected portal hypertension undergoing invasive measurement of HVPG. Measurements of HVPG were performed in awake condition as well as under sedation with propofol infusion.ResultsIn total, 37 patients were included. Mean HVPG in awake condition was 15.9 mmHg (IQR 13–19) and during sedation 14.1 mmHg (IQR 12–17). While measures of free hepatic vein pressure (FHVP) were not altered after propofol sedation (p = 0.34), wedged hepatic vein pressure values (WHVP) decreased in an average by 2.05 mmHg (95% CI − 2.46 to − 1.16; p < 0.001) which was proportional to the magnitude of HVPG. In 31 out of 37 patients (83.8%), portal hypertension with HVPG ≥ 12 mmHg was found. Under sedation with propofol, two patients (5.4%) with borderline values would have been incorrectly classified as < 12 mmHg. After adjustment for the average difference of − 10%, all patients were correctly classified. Intraclass correlation coefficient between HVPG measurement in awake condition and under propofol sedation was 0.927 (95% CI 0.594–0.975).ConclusionsPropofol sedation during HVPG measurements is generally safe, however it may lead to relevant alterations of HVPG readings.

Experimental investigation of flow and pressure drop characteristics of air-oil slug flow in a horizontal tube

This study examines two-phase flow and pressure drop characteristics associated with slug flow in a tube with an inner diameter of 4 cm. Experiments are conducted using air and low viscosity mineral oil as working fluids at atmospheric pressure and two different oil temperatures, 25 and 45°C. The superficial gas and liquid velocities are in the range of 0.33–2.43 m/s and 0.20–1.20 m/s, respectively. Flow visualization images and temporal records of pressure drop oscillation are presented for different gas and liquid superficial velocities. The relevant flow parameters associated with slug flow, such as the elongated bubble velocity, elongated bubble length, liquid slug length, and liquid film thickness, are measured, and the relationship between the slug flow parameters and the superficial gas and liquid velocities is investigated. The measured pressure gradient data are also compared to predictions of previous homogeneous equilibrium models and semi-empirical correlations for two-phase frictional pressure gradient. A theoretical slug flow model for predicting the total pressure gradient of slug unit is presented using empirical correlations for the slug flow parameters. The new model accurately predicts the experimental pressure gradient data, evidenced by an overall mean absolute error of 19.3%.

S2005 Effects of Endoscopic Gastric Plication on Portal Pressure Gradient in a Patient With Non-Alcoholic Steatohepatitis Cirrhosis

Introduction: Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease worldwide with the prevalence approaching 90% in patients with obesity. Nonalcoholic steatohepatitis (NASH) is an aggressive form of NAFLD with an increased risk of cirrhosis. The treatment for NASH is limited to lifestyle modification. Case Description/Methods: Our patient was a 68-year-old woman with obesity and compensated NASH cirrhosis. She underwent an attempted Roux-en-Y gastric bypass, which was aborted due to cirrhosis. Transient elastography suggested cirrhosis with liver stiffness of 17 kPa. This case represents the convergence of endobariatrics and endohepatology. Specifically, we demonstrate the use of endoscopic gastric plication (EGP) to treat obesity and NASH in a patient with cirrhosis, as well as the application of endoscopic ultrasound (EUS)-guided portal pressure gradient (PPG) measurement to monitor its changes following EGP. Prior to EGP, she underwent EUS-guided PPG measurement. Specifically, a transgastric transhepatic puncture with a 25-gauge fine needle aspiration needle into the hepatic vein was achieved. The manometer and needle were flushed with heparinized saline solution. The manometer reading rose and plateaued. The process was repeated at least two more times and the average manometer number represented hepatic venous pressure (HVP). The needle was slowly withdrawn under Doppler. Subsequently, the portal vein was punctured, and the same steps repeated to measure the portal vein pressure (PVP). In this case, the average HVP and PVP were 17 mmHg and 28.5 mmHg. Therefore, her PPG prior to EGP was 11.5 mmHg. The patient then underwent an EGP procedure. The first set of plications was placed in the distal gastric body perpendicular to the length of the stomach to reduce its width. The second and third sets of plications were placed longitudinally to shorten the gastric length. The last set of plications was then placed at the proximal gastric body to further reduce its width. At 9 months, her weight decreased from 279 to 255 pounds, representing an 8.6% weight loss. Her liver stiffness decreased from 17 to 7.6 kPa, suggesting regression from stage 4 to stage 2 fibrosis. A follow-up PPG showed a PPG of 8 mmHg, representing a 30% reduction. Discussion: This case demonstrates the safety and efficacy profile of EGP for the treatment of compensated NASH cirrhosis with improvement in liver fibrosis and PPG. Watch video at https://bit.ly/3i0axL1.

Indian College of Radiology and Imaging Evidence-Based Guidelines for Interventions in Portal Hypertension and Its Complications.

Portal hypertension is a complication of chronic liver disease. Various radiological interventions are being done to aid in the diagnosis of portal hypertension; further, an interventional radiologist can offer various treatments for the complications of portal hypertension. Diagnosis of portal hypertension in its early stage may require hepatic venous pressure gradient measurement. Measurement of gradient also guides in diagnosing the type of portal hypertension, measuring response to treatment and prognostication. This article attempts to provide evidence-based guidelines on the management of portal hypertension and treatment of its complications.

Noncontrast-enhanced MRI-based Noninvasive Score for Portal Hypertension (CHESS1802): An International Multicenter Study.

Background and AimsThis study aimed to determine the performance of the non-invasive score using noncontrast-enhanced MRI (CHESS-DIS score) for detecting portal hypertension in cirrhosis.MethodsIn this international multicenter, diagnostic study (ClinicalTrials.gov, NCT03766880), patients with cirrhosis who had hepatic venous pressure gradient (HVPG) measurement and noncontrast-enhanced MRI were prospectively recruited from four university hospitals in China (n=4) and Turkey (n=1) between December 2018 and April 2019. A cohort of patients was retrospectively recruited from a university hospital in Italy between March 2015 and November 2017. After segmentation of the liver on fat-suppressed T1-weighted MRI maps, CHESS-DIS score was calculated automatically by an in-house developed code based on the quantification of liver surface nodularity.ResultsA total of 149 patients were included, of which 124 were from four Chinese hospitals (training cohort) and 25 were from two international hospitals (validation cohort). A positive correlation between CHESS-DIS score and HVPG was found with the correlation coefficients of 0.36 (p<0.0001) and 0.55 (p<0.01) for the training and validation cohorts, respectively. The area under the receiver operating characteristic curve of CHESS-DIS score in detection of clinically significant portal hypertension (CSPH) was 0.81 and 0.9 in the training and validation cohorts, respectively. The intraclass correlation coefficients for assessing the inter- and intra-observer agreement were 0.846 and 0.841, respectively.ConclusionsA non-invasive score using noncontrast-enhanced MRI was developed and proved to be significantly correlated with invasive HVPG. Besides, this score could be used to detect CSPH in patients with cirrhosis.

Predictors of Procedural Success in Patients With Degenerated Surgical Valves Undergoing Transcatheter Aortic Valve-in-Valve Implantation

Background: Valve-in-Valve transcatheter aortic valve implantation (ViV-TAVI) is a growing alternative for redo-surgery in patients with degenerated surgical valves. To our knowledge, data are lacking on the determinants on ViV-TAVI procedural success in patients with degenerated surgical valves.Methods: All consecutive patients undergoing ViV-TAVI for degenerated surgical valves at the Cleveland Clinic were analyzed. Data were extracted from our patient registry on baseline patient characteristics, echocardiographic parameters, and procedural details. To identify possible predictors of ViV-TAVI procedural success, we employed a multivariate logistic regression model.Results: A total of 186 patients who underwent ViV-TAVI were analyzed, with procedural success (VARC-2 device success and absence of periprocedural MACCE) reported in 165 (88.7%) patients. Patients with successful ViV-TAVI were significantly younger and had more frequent utilization of the transfemoral access than those with failed procedure. Other baseline and procedural characteristics were comparable between both groups. In terms of echocardiographic parameters, the procedural success group had a significantly lower AV peak pressure gradient (62.1 ± 24.7 vs. 74.1 ± 34.6 mmHg; p = 0.04) and lower incidence of moderate-to-severe aortic regurgitation [AR] (30.4 vs. 55%; p = 0.04). However, no significant differences between both groups were noted in terms of AV mean pressure gradient and left ventricular measurements. In multivariate analysis, lower AV peak pressure gradient (OR = 0.97, 95% CI: 0.95–0.99) and absence of moderate-to-severe AR (OR = 0.65, 95% CI: 0.44–0.95) at baseline emerged as independent predictors of ViV-TAVI procedural success.Conclusion: Valve-in-Valve TAVI for degenerated surgical valves is a feasible approach with high success rates, especially in those with lower AV peak pressure gradient and absence of moderate-to-severe AR. Studies with larger sample size and longer follow-up are required to further characterize the predictors of ViV-TAVI success and other clinical outcomes.

A novel technique for invasive aortic valve pressure gradient measurement using a 6 Fr Swan-Ganz catheter: a case series

BackgroundSimultaneous left ventricular (LV) and aortic (Ao) pressure gradient assessment has been rendered challenging since the recall of the Langston catheter. Here we describe a simple method for simultaneous LV and Ao pressure gradient assessment using a Swan-Ganz catheter.Case summaryWe describe two cases where assessment of simultaneous left ventricle and Ao valve gradients was done using a Swan-Ganz catheter to assess the degree of Ao stenosis and dynamic LV outflow obstruction.DiscussionUsing Swan-Ganz catheter assessment of simultaneous left ventricle and Ao valve gradients can simplify the procedure with reduced cost and increased patient safety.

Portal Hypertension in Non-alcoholic Fatty Liver Disease in the Era of Non-invasive Assessment

Non-alcoholic fatty liver disease (NAFLD) is one of the emerging global health problems due to an increase of burden worldwide. It has been known that NAFLD is strongly associated with metabolic syndrome. The progression of NAFLD is a complex and multifactorial mechanism. Portal hypertension is still the main key in liver disease progression management. In NAFLD, portal hypertension might occur in the non-cirrhotic condition. Hepatic vein pressure gradient measurement has been considered as the gold standard for portal pressure assessment; however, due to its invasiveness and the need for a high-expertise centre, it is considered a non-practical measurement tool in clinical practice. Many other non-invasive parameters have been developed to replace the invasive measurement; however, there are still some limitations with regard to the technical issue, patient’s condition, and its accuracy in the different stages of the disease. Therefore, the authors review portal hypertension related to the clinical course of NAFLD, and the development of portal pressure evaluation in patients with NAFLD.