Pulmonary Artery Diastolic Pressure Research Articles

Right ventricular global work efficiency provides the highest prediction for improvements in right ventricle to left ventricle diameter ratio with acute pulmonary embolism treatments

Abstract Introduction In addition to standard echocardiographic measures, global longitudinal strain (GLS) with speckle tracking (ST) and myocardial work (MW) evaluation have been used in the assessment of right ventricle (RV) function in patients with acute pulmonary embolism (PE). In this study we aimed to compare echocardiographic measures, ST and MW in prediction of change in right ventricle (RV) to left ventricle (LV) diameter ratio (r) with treatments. Methods Our study comprised 83 consecutive patients (female %54.6, age 59±14.9 years) who admitted to our hospital with diagnosis of acute PE and underwent evidence-based treatments. Echocardiographic evaluation including ST and MW were performed within first 24 hours of admission. NT-pro-brain natriuretic peptide (NT-proBNP), troponin, pulmonary embolism severity index (PESI) and Qanadli score, RV and LV global work index (GWI), global work efficiency (GWE), global constructive work (GCW) and global wasted work (GWW), and RV-GLS were evaluated. Primary end-point (PEP) of this study was the change in RV to LVr on computed tomography (CT), and generalized additive model (GAM) in addition to classical linear regression (LR) were utilized for prediction of change in RV/LVr with these measures. Results PESI score and RV/LVr at admission were 84.8±23.8 and 1.13±0.39, respectively. Unfractioned or low-molecular weight heparin were treatments of choice in patients. The change in RV/LVr after selected treatments were 0.356. Mean hospital stay and overall follow-up duration were 8.7±3.7 and 328.7±126.8 days, respectively. In-hospital and long-term mortality rates were 1.2% and 13.3% respectively. Correlation co-efficients for intra- and interobserver agreement of MW measures varied from 0.85 to 0.96. The LR revealed that pulmonary arterial systolic, diastolic and mean pressure estimates, fractional area change and RV annular tissue velocity were significantly related with changes in RV/LVr (p values; 0.02, 0.01, 0.004, 0.03 and 0.03, respectively). Moreover, RV-GWE compared with RV-GLS showed a higher prediction for improvements in the RV/LVr (p value were <0.001 and 0.049, respectively). Utilization of GAM increased R2 value (from 0.15 to 0.20), and decreased the complexity of model. RV-GWE showed a moderate correlation with RV-GLS (r=-0.56), RV-GWI (r = 0.42), RV-GCW (r=0.32), LV-GWW(r=-0.55), LV-GLS (r=-0.33), FAC (r=0.26), NT-proBNP (r=-0.38), troponin (r=-0.28) but not with other measures. Conclusions The RV GWE as a novel myocardial work parameter seems to provide a better prediction for improvements in the RV/LVr with acute PE treatments as compared to clinical, laboratory and other echocardiographic measures including GLS.Figure-1Figure-2

Abstract 14106: Predicting Persistently Elevated Pulmonary Artery Diastolic Pressure Despite Adequate Diuresis

Introduction: Patients with chronic HF can be challenging to manage via ambulatory hemodynamic monitoring due to persistent elevations in pulmonary artery diastolic pressure (PADP) despite appropriate diuresis. Knowing what factors predict persistently elevated PADP on CardioMEMS can help guide patient selection and management. Hypothesis: We propose that underlying heart failure phenotypes exist that are less likely to respond to hemodynamic guided management. Methods: This was a single-center, retrospective analysis of Scripps Clinic patients who underwent CardioMEMS implantation from June 2015 to September 2022. A total of 115 patients were included and divided into two cohorts based off their average PADP calculated using their last 4 transmissions. The normal PADP cohort included patients with an average PADP ≤ 20 mmHg while the persistently elevated PADP cohort included patients with a PADP > 20 mmHg. Results: Of the 115 patients analyzed, 62 patients were in the normal PADP cohort while 53 patients were in the persistently elevated PADP cohort. There was no significant difference between baseline demographic data, except for renal function, as shown in Table 1. There was a significant difference between the two groups when comparing pulmonary pressures and PVR via right heart catheterization prior to CardioMEMS implantation, but not when comparing pulmonary artery pressure obtained via echocardiogram (Table 1). The persistently elevated PADP cohort had a significantly lower GFR and were on higher doses of loop diuretics than the normal PADP cohort. Conclusions: Our analysis shows that renal function, baseline invasive hemodynamic data consistent with pulmonary vascular remodeling and decreased cardiac index can help predict patients with persistent elevations in their PADP on ambulatory hemodynamic monitoring and highlights the importance of early HF management before vascular remodeling complicates hemodynamic guided management.

Abstract 18693: Effect of Mechanical Unloading on Cardiogenic Shock Severity in Venoarterial Extracorporeal Membrane Oxygenation Patients

Introduction: Mechanical unloading (MU) with Intra-aortic balloon pump (IABP) or Impella is commonly used to prevent left ventricular (LV) distension in VA-ECMO patients, but its impact on shock severity is not well described. Methods: Patients treated with VA-ECMO in our hospital between 2016-2022 for cardiogenic shock (CS) due to LV failure not related to cardiac surgery were included if no MU was used or it was instituted within 24h of ECMO cannulation. Patients were grouped according to MU: ECMO alone, ECMO + IABP or ECMO + Impella. Linear mixed effects models adjusting for age, sex, hypertension, acute myocardial infarction (AMI) etiology of shock and pre-ECMO cardiac arrest (CA) were used to assess the impact of MU on hemodynamic and perfusion markers. R version 4 was used for analysis. Results: Among 68 patients included, 18 received ECMO alone, 17 ECMO + IABP, and 33 ECMO + Impella. Age and CA were similar across groups. The Impella group had a higher proportion of men and patients with AMI. Pulmonary artery diastolic pressure was unchanged in all groups. Compared to ECMO alone, MU did not enhance lactate clearance (interaction: IABP p=0.7, Impella p=0.22), but it did improve the vasopressor-inotropic score (IABP p=0.03, Impella p=0.01), serum creatinine (IABP p=0.03, Impella p=0.04), and alanine transaminase (IABP only p=0.02). Survival to decannulation was similar in patients with ECMO alone (50%), Impella (64%) and IABP (65%) (p=0.68). Conclusions: In adults treated with VA-ECMO for CS unrelated to cardiac surgery, LV MU can lead to improvements in CS severity.

Abstract 18495: Right and Left Ventricular Starling Function in Heart Failure With Preserved Ejection Fraction

Background: Efficient conversion of cardiac filling pressure to stroke volume (SV) is described by the Frank-Starling mechanism. Our group has previously characterized dynamic Starling mechanisms (DSM) in the frequency domain using respiratory mediated changes in beat-by-beat SV as a function of changes in pulmonary artery diastolic pressures (PAD) and shown this to be impaired in heart failure with preserved ejection fraction (HFpEF). Right ventricular (RV) dysfunction is common in HFpEF but efficiency of the RV Starling mechanism is unknown. The goal of this study was to characterize RV and LV DSM in patients with HFpEF. Methods: We studied 16 HFpEF patients (10 females; age: 68 ± 6 years) at seated rest following the placement of a radial arterial and right heart catheter. DSM was quantified by transfer function (input/output frequency) analyses of beat-by-beat changes in PAD (for LV) and A wave right atrial pressures (for RV) as input variables. Output variable was SV (Modelflow from radial arterial line waveform) and normalized for LV DSM using direct-Fick derived SV and for RV DSM using acetylene rebreathing derived SV as a measure of pulmonary blood flow. Results: The power spectral density (PSD) was higher for LV compared to RV filling pressure (521 ± 446 vs 125 ± 111 mmHg 2 , P = 0.001); there was no difference for adjusted SV PSD (819 ± 764 vs 808 ± 765 ml 2 , P = 0.232). DSM gain was higher for LV compared to RV for all but 1 subject (0.58 ± 0.29 vs 0.30 ± 0.16 ml/mmHg, P = 0.002; Figure). Conclusions: RV DSM gain was significantly worse than LV DSM gain suggesting decreased RV contractile and/or compliance reserve in patients with HFpEF. These results highlight the utility of RV DSM gain to characterize RV dysfunction in patients with HFpEF.

Abstract 15854: Pulmonary Arterial Waveform Analysis and Supervised Machine Learning Predicts Outcomes in Heart Failure: An Analysis of the CHAMPION Trial

Introduction: Pulmonary artery (PA) pressure monitors have been shown to prevent hospitalizations in heart failure patients using mean pressure values. PA waveform analysis offers an overall assessment of right ventricular load that combines resistance and compliance. Hypothesis: We hypothesised that clinical outcomes can be predicted from PA waveform analyses from patients with an implanted PA monitor. Methods: The CHAMPION trial database was analysed. Information about the demographics and data collection methods for this cohort have been published previously. All waveforms were analysed automatically using Python. Tau or RC time, respiratory rate, respiratory range, P asymptote, mean pulmonary arterial pressure (mPAP), diastolic pulmonary arterial pressure (dPAP) and systolic pulmonary arterial pressure (sPAP) were derived from the raw waveforms. Tau and P asymptote were calculated using phase plane analysis. Outcomes of hospitalization or mortality were adjudicated as part of the original trial. Statistics were performed in R. A decision tree statistical approach using the XGBoost algorithm was used. Contribution to the model was assessed using Shapley Additive Explanations (SHAP) values. The dataset was split into 70% train and 30% test sets. Results: 296,948 PA pressure traces from 547 patients were analysed. 3 patients had insufficient quality of trace to analyse. There were 1340 outcome events throughout the follow up period, median 664 days. The trained algorithm was able to predict clinical outcomes in the test dataset with 100% accuracy. The most significant contributors according the mean SHAP value were RC time (SHAP = 1.1), respiratory range (SHAP = 1.1) and heart rate (SHAP = 1.1). Conclusions: Detailed analysis of the PA waveform from PA pressure monitors is feasible and yields clinically relevant information. A supervised machine learning algorithm trained on this data can accurately predict hospitalization or mortality events in heart failure patients.

127 Genetic Correlations Between Systolic and Diastolic Pulmonary Arterial Pressure in Beef Cattle

Abstract Pulmonary hypertension is a historical issue in high elevation beef production and is increasingly occurring in moderate elevation beef finishing systems (i.e., feedlots). Pulmonary arterial pressure (PAP) is the mean pressure (mmHg) measure in the pulmonary artery and is an indicator of pulmonary hypertension. To measure PAP, a certified veterinarian threads a catheter through the jugular vein to the heart and into the pulmonary artery. A total of 3 measures are recorded, including mean pulmonary arterial pressure (mPAP), systolic pulmonary arterial pressure (sPAP), and diastolic pulmonary arterial pressure. Systolic pressure is the pressure in the pulmonary artery during the contraction of the heart, whereas diastolic pressure is the pressure in the pulmonary artery during relaxation of the heart. For cattle living in high elevations, the Beef Improvement Federation Guidelines outline the risk of an individual by accounting for the elevation of the test and range of elevations at which that animal is expected to survive based on mPAP. The objective of this study was to estimate the genetic correlations between systolic and diastolic PAP. The data consisted of 1,352 animals with a mPAP, sPAP, and dPAP measured from 2011 to 2015. The systolic pulmonary arterial pressure has a mean of 65.4 ± 15.95 mmHg. The diastolic pulmonary arterial pressure has a mean of 18.2 ± 11.22 mmHg. Data were analyzed using a multiple trait, mixed effect animal model using the statistical software package ASReml 3.0. Fixed effects in the model included sex, birth year, wean date, and yearling date. Individual animal was included as the random effect. The respective heritabilities from the model were mPAP at 0.13 ± 0.05, sPAP at 0.9 ± 0.05 and dPAP at 0.09 ± 0.05. The phenotypic correlation between systolic and diastolic PAP was 0.18 ± 0.03, and the genetic correlation was 0.46 ± 0.32. The phenotypic correlation between sPAP and mPAP was 0.49 ± 0.02, and the genetic correlation was 0.69 ± 0.21. The phenotypic correlation between dPAP and mPAP was 0.83 ± 0.01, and the genetic correlation was 0.93 ± 0.07. Previous research with sPAP and dPAP has been conducted in humans, investigating methods to predict the likelihood of a person of developing pulmonary hypertension. These results provide a foundation to focus on how sPAP and dPAP impact the mPAP and current selection tools for a PAP measure and if the additional information could be useful for selection.

246 Evaluation of Live Growth Performance and Carcass Characteristics of Late Finishing Phase Beef Cattle with Varying Degrees of Pulmonary Hypertension

Abstract Late feedlot death caused by congestive heart failure has been quantified extensively through epidemiological studies however, these models do not consider losses or gains associated live growth performance, carcass quality, and consumer rejection of meat products. To address these gaps in the literature, we conducted two studies to characterize effects of pulmonary hypertension on four populations of feedlot cattle. In study one, reproductively intact (INT, n = 19), and ovariectomized (OVX, n = 18) yearling Sim-Angus heifers were selected on heart failure risk according to their pulmonary arterial pressure. Heifers were gradually transitioned onto a feedlot ration and fed to an acceptable harvest body composition determined using both 12th rib subcutaneous fat and body weight. Cattle were weighed biweekly and ADG was calculated by regressing body weight by days on feed (DOF). Pulmonary arterial pressure (PAP) was measured approximately every 3 months by a qualified veterinarian. Cattle were harvested at a commercial harvesting facility where carcass data and muscle samples were collected. In study two, weaned sim-angus steers (n = 41) were selected on heart failure risk categories using the same methodology outline above. Twenty steers were administered a steroidal growth promoting implant upon receiving (IMP) and twenty were untreated (NAT). Steers were fed to an average of 610 kg and data were collected using the same methodology outlined above. Data were analyzed using ANOVA, linear model, and Pearson correlation functions in R statistical software where PAP was used as a fixed continuous variable. Data were analyzed by study with the exception of live growth performance regression and correlations where data were combined. Linear regression within the combined datasets showed that initial mean PAP (P < 0.001), diastolic pressure (P < 0.001), and sex (P < 0.001) positively influenced ADG throughout the duration of the finishing period. Furthermore, initial PAP was moderately correlated with ADG (R = 0.38, P < 0.001). Gain to feed (G:F) was positively correlated with initial diastolic PAP (R = 0.31, P < 0.006). Neither initial mean PAP nor diastolic pressures impacted dry matter intake (DMI; P > 0.90), but sex was associated with DMI where steers had significantly decreased DMI (P = 0.003). Within study two, longissimus muscle objective color values were influenced by PAP where a* (redness; P < 0.001) and b* (yellowness; P < 0.04) values were negatively correlated with final PAP. These data begin to demonstrate the close relationship between live growth performance and pulmonary hypertension. More research is needed to better understand how cellular energy metabolism is potentially contributing to increased growth performance but negatively influencing muscle health in the form of oxygen binding capacity and inflammation.

Treatment of Severe Pulmonary Regurgitation in Enlarged Native Right Ventricular Outflow Tracts: Transcatheter Pulmonary Valve Replacement with Three-Dimensional Printing Guidance.

Severe pulmonary regurgitation (PR) often occurs following a transannular patch repair of tetralogy of Fallot, resulting in an enlarged native right ventricular outflow tract (nRVOT) with varying shapes. We conducted a single-center study with eight patients having severe PR and enlarged nRVOT (diameters ≥ 29 mm). Transcatheter pulmonary valve replacement (TPVR) was performed using the self-expanding PT-Valve. Preoperative evaluation included echocardiography, computed tomography, and magnetic resonance imaging. A 3D-printed model of the nRVOT was used for preoperative assessment. Follow-up data were collected in 1-year follow-up. PT-Valve was successfully implanted in all patients, resulting in immediate improvement of severe PR. Pulmonary artery diastolic pressure increased significantly (p < 0.001). No deaths or coronary compression occurred during the procedure. Over a 1-year follow-up, no stent displacement or fracture occurred. Only two patients had trace paravalvular leaks. Magnetic resonance imaging revealed a reversal of right ventricular remodeling, with a significant reduction in right ventricular end-diastolic volume index (p < 0.001) and improved right ventricular ejection fraction (p < 0.001). All patients achieved primary endpoints. 3D printing-guided PT-Valve implantation in enlarged nRVOT for severe PR is safe and effective, expanding TPVR indications and offering potential treatment for a broader patient population.

Assessment of pulmonary artery stiffness by multiparametric cardiac magnetic resonance-surrogate for right heart catheterization.

Cardiac magnetic resonance (CMR) imaging allows for multiparametric assessment of healthy pulmonary artery (PA) hemodynamics. Gender- and aging-associated PA stiffness and pressure alterations have remained clinically unestablished, however may demonstrate epidemiological differences in disease development. The aim of this study is to evaluate the role of CMR as a surrogate for catheter examinations by providing a comprehensive CMR assessment of sex- and age-related reference values for PA stiffness, flow, and pressure. PA hemodynamics were studied between gender and age groups (>/<50 years) using phase-contrast CMR. Corresponding correlation analyses were performed. 179 healthy volunteers with a median age of 32.6 years (range 11.3-68.2) were examined. Males demonstrated increased PA compliance (median [interquartile range] or mean ± standard deviation) (20.8 mm2/mmHg [16.6; 25.8] vs. 19.2 ± 7.1 mm2/mmHg; P < 0.033), higher pulse wave velocity (2.00 m/s [1.35; 2.87] vs. 1.73 m/s [1.19; 2.34]; P = 0.018) and a reduced full width half maximum (FWHM) (219 ± 22 ms vs. 235 ± 23 ms; P < 0.001) than females. Mean, systolic, diastolic PA pressure and pulmonary proportional pulse pressure were significantly elevated for males compared to females (P < 0.001). Older subjects (>50 years) exhibited reduced PA elasticity (41.7% [31.0; 52.9] vs. 66.4% [47.7; 83.0]; P < 0.001), reduced PA compliance (15.4 mm2/mmHg [12.3; 20.7] vs. 21.3 ± 6.8 mm2/mmHg; P < 0.001), higher pulse wave velocity (2.59 m/s [1.57; 3.59] vs. 1.76 m/s [1.24; 2.34]; P < 0.001) and a reduced FWHM (218 ± 29 ms vs. 231 ± 21 ms; P < 0.001) than younger subjects. Velocity-time profiles are dependent on age and gender. PA stiffness indices deteriorate with age. CMR has potential to serve as a surrogate for right heart catheterization.

Clinical and Paraclinical Findings of Primary Pulmonary Hypertension in Children

Background: Given the significant morbidity and mortality of juvenile pulmonary arterial hypertension (PAH), understanding the clinical and paraclinical findings of this condition can aid in the early diagnosis and identification of helpful factors in its treatment. Objectives: This study aimed to evaluate the clinical and paraclinical findings of idiopathic pulmonary arterial hypertension (iPAH) in children. Methods: This cross-sectional study was carried out on 20 children with iPAH who were assessed in terms of pulmonary hypertension or hospitalized at the cardiac ward of Imam Reza hospital, Mashhad, Iran, during January 2018 to October 2001. The clinical data, chest X-ray (CXR), electrocardiographic, echocardiographic, cardiac catheterization findings, and mortality results were extracted from the medical records and recorded in a researcher-made questionnaire. Results: The current study’s findings revealed a higher prevalence of iPAH in females (70%) than men, as well as in term neonates compared to preterm newborns. The most common clinical findings were active dyspnea, heart murmur, and cyanosis. Prominent pulmonary conus, right atrial enlargement (RAE), and right ventricular hypertrophy (RVH) were the most common CXR findings. The right axis deviation, RVH, and RAE were the most common abnormal findings of electrocardiography, respectively. Based on echocardiographic findings, dilated right atrium and dilated right ventricle were reported in all subjects. The mean of tricuspid regurgitation pressure gradient (TRPG) and peak systolic pressure gradient (PSPG) were 76.33 ± 22.8 and 44.2 ± 13.18 mmHg, respectively. The mean ratios of systolic pulmonary artery pressure (PAP), diastolic PAP, and mean pulmonary artery pressure (mPAP) to aortic systolic pressure were estimated at 0.92, 0.78, and 0.88, respectively. The results confirmed a significant relationship between mPAP and consanguinity (P = 0.03). In addition, the findings demonstrated a correlation between echocardiographic findings (i.e., TRPG and PSPG) and systolic PAP, diastolic PAP, and mPAP (P &lt; 0.05). In total, 56.3% of the patients expired, most of whom (37.5%) were the younger children. Conclusions: The findings suggest that IPAH should be considered as a possible diagnosis in various clinical manifestations, including respiratory distress, hepatomegaly, ascites and even neurological symptoms. Since there are no specific symptoms, therefore a set of history, physical examination, laboratory findings, and clinical suspicion should be taken into consideration.

Association Between Change in Ambulatory Pulmonary Artery Pressures and Natriuretic Peptides in Patients with Heart Failure: Results From the EMBRACE-HF Trial

BackgroundRemote monitoring of pulmonary artery (PA) pressures and serial N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurements guide heart failure (HF) treatment, but their association has yet to be described. Methods and ResultsIn the Empagliflozin Evaluation by Measuring the Impact on Hemodynamics in Patients with Heart Failure (EMBRACE-HF) trial, patients with HF and a remote PA pressure monitoring device were randomized to empagliflozin vs placebo. PA diastolic pressures (PADP) and NT-proBNP levels were obtained at baseline and 6 and 12 weeks. We used linear mixed models to examine the association between change in PADP and change in NT-proBNP, adjusting for baseline covariates. Of 62 patients, the mean patient age was 66.2 years, and 63% were male. The mean baseline PADP was 21.8 ± 6.4 mm Hg, and the mean NT-proBNP was 1844.6 ± 2767.7 pg/mL. The mean change between baseline and averaged 6- and 12-week PADP was –0.4 ± 3.1 mm Hg, and the mean change between baseline and averaged 6- and 12-week NT-proBNP was –81.5 ± 878.6 pg/mL. In adjusted analyses, every 2-mm Hg decrease in PADP was associated with an NT-proBNP reduction of 108.9 pg/mL (95% confidence interval –4.3 to 222.0, P = .06). ConclusionsWe observed that short-term decreases in ambulatory PADP seem to be associated with decreases in NT-proBNP. This finding may provide additional clinical context when tailoring treatment for patients with HF.

How to initiate aspirational embolectomy program for pulmonary embolism: single centre initial experience

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Recent advances in percutaneous mechanical thrombectomy provide lytic-free methods for treatment of pulmonary embolism (PE). Although guidelines recommend aspirational embolectomy only for high-risk PE patients with contraindication to or failed fibrinolysis, the method is currently being used in treatment of intermediate-high risk PE patients. We present our initial experiences with large bore percutaneous aspirational embolectomy catheter. Methods Patients with intermediate-high risk PE and at least one clinical feature (persistent hypoxemia, tachycardia, hypotension without shock, or dyspnoea on minimal exertion) were considered eligible for the method. Positive high-sensitive troponin was obligatory. PE was diagnosed by computed tomography. Echocardiography and doppler ultrasound of lower limbs venous system were performed upon admission. All procedures were performed by interventional cardiologist in cardiology suite. Light sedation with dexmedetomidine and/or midazolam was used. Ultrasound guided right or left femoral approach was used in all patients. A 7F balloon tipped catheter was used to cross the tricuspid and pulmonary valves and engage pulmonary artery (PA). After exchanging for 6F pigtail catheter an angiography was performed. Then, via multipurpose 6F catheter an extra-stiff wire was introduced distal to the thrombus. Over the wire a 20F or 24F aspirational embolectomy catheter was placed in front of the thrombus followed by the aspiration with 60 ml syringe. Up to 10 aspirations were allowed. Unfractionated heparin was used for periprocedural anticoagulation followed by apixaban or rivaroxaban as soon as hemostasis was achieved. Patients outcomes were recorded prospectively. Results From March to October 2022 a total of 10 patients were treated with aspirational embolectomy (6 females, median age 68.5 years (interquartile range 53.25-74)). Only the first case was performed with 20F catheter. In 9 patients sheathless approach was used due to material unavailability. In one case switching to left-side access was required due to inability to introduce the catheter in common femoral vein. In two cases a "lollipop" phenomenon occurred, one of which was a thrombus-in-transit (TIT) case. This case was complicated with TIT fragmentation on exit and re-embolism with circulatory arrest requiring veno-arterial extracorporeal circulatory support. Procedural success was achieved in all cases (in TIT patient two procedures were needed). All patients reported improvements in dyspnea levels. One patient required oxygen supplementation beyond 24h (TIT patient). Average PA systolic and diastolic blood pressure drop was 24.3±11.0 and 12.3±4.9 mmHg. Nine patients were alive at discharge, while TIT patient was still requiring hospitalisation. Conclusion Aspirational embolectomy can provide sufficient drop in PA pressures and symptom relief. Randomised trials are needed to determine the long term outcomes of the procedure.

Pulmonary artery pulsatility index in patients with tricuspid valve regurgitation: a simple non-invasive tool for risk stratification.

Tricuspid valve regurgitation (TR) is a common valvular disease associated with increased mortality. There is a need for tools to assess the interaction between the pulmonary artery (PA) circulation and the right ventricle in patients with TR and to investigate their association with outcomes. The pulmonary artery pulsatility index (PAPi) has emerged as a haemodynamic risk predictor in left heart disease and pulmonary hypertension (PH). Whether PAPi discriminates risk in unselected patients with greater than or equal to moderate TR is unknown. In 5079 patients with greater than or equal to moderate TR (regardless of aetiology) and PA systolic and diastolic pressures measured on their first echocardiogram, we compared all-cause mortality at 5 years based on the presence or absence of PH and PAPi levels. A total of 2741 (54%) patients had PH. The median PAPi was 3.0 (IQR 1.9, 4.4). Both the presence of PH and decreasing levels of PAPi were associated with larger right ventricles, worse right ventricular systolic function, higher NT-pro BNP levels, greater degrees of right heart failure, and worse survival. In a subset of patients who had an echo and right heart catheterization within 24 h, the correlation of non-invasive to invasive PA pressures and PAPi levels was very good (r = 0.76). In patients with greater than or equal to moderate TR with and without PH, lower PAPi is associated with right ventricular dysfunction, right heart failure, and worse survival. Incorporating PA pressure and PAPi may help stratify disease severity in patients with greater than or equal to moderate TR regardless of aetiology.

Expert Consensus on the Use of Human Serum Albumin in Adult Cardiac Surgery.

Expert Consensus on the Use of Human Serum Albumin in Adult Cardiac Surgery.

Effects of the Oral Angiotensin II Type 2 Receptor Agonist C21 in Sugen-Hypoxia Induced Pulmonary Hypertension in Rats.

Substantial evidence supports the involvement of the renin-angiotensin system in pulmonary hypertension (PH), and the angiotensin II type 2 receptor (AT2R) is known to exert tissue protective actions. The effect of the selective AT2R agonist C21 (also known as Compound 21 or buloxibutid) was evaluated in the rat Sugen-hypoxia PH model. After a single injection of Sugen 5416 and hypoxia for 21 days, C21 (2 or 20 mg/kg) or vehicle was administered perorally twice daily from Day 21 to Day 55. On Day 56, hemodynamic assessments were performed, and lung and heart tissue were prepared for quantification of cardiac and vascular remodeling and fibrosis. Treatment with C21 20 mg/kg improved cardiac output and stroke volume and decreased right ventricular hypertrophy (all p < 0.05). Treatment with C21 2 mg/kg significantly decreased vessel wall and muscular layer thickness and increased the luminal opening in vessels >100 μm (all p < 0.05). There were no significant differences between the two C21 doses on any parameter, and post hoc analyses comparing the merged C21 groups with the vehicle group showed that C21 treatment reduced vascular remodeling (reduced endothelial proliferation and thickening of the vascular wall) in vessels of all sizes; moreover, the diastolic pulmonary artery pressure and right ventricular pressure were reduced along with reduction of right ventricular hypertrophy. Sugen 5416 and hypoxia increased pulmonary collagen deposition, which was counteracted by C21 20 mg/kg. In conclusion, the effects of C21 on vascular remodeling, hemodynamic alterations, and fibrosis suggest that AT2R agonists may have a role in Group 1 and 3 PH treatment.

Effects Of Sodium-glucose Cotransporter Inhibitors On Pulmonary Artery Diastolic Pressure In Congestive Heart Failure

Effects Of Sodium-glucose Cotransporter Inhibitors On Pulmonary Artery Diastolic Pressure In Congestive Heart Failure

Pre-operative pulmonary artery pulsatility index does not predict mortality post-cardiac transplantation.

The pulmonary artery pulsatility index (PAPi) is a novel haemodynamic marker that has previously been shown to predict right ventricular dysfunction and mortality in patients with pulmonary hypertension and advanced heart failure. Utility of the PAPi in predicting outcomes post-cardiac transplantation is unknown. The aim of this study was to compare the prognostic significance of PAPi against pulmonary vascular resistance (PVR) for the predication of morbidity and all-cause mortality post-transplantation. All patients who underwent cardiac transplantation over a 6year period were studied. Pre-operative right heart catheter data was obtained. The PAPi was calculated as follows: (systolic pulmonary artery pressure [sPAP]-diastolic pulmonary artery pressure [dPAP])/right atrial (RA) pressure. One hundred fifty-eight patients with a mean age of 49±14years were studied (43 with a pre-transplant left ventricular assist device [LVAD]). Three patients were excluded due to missing data. In the non-LVAD group, there was no significant difference in PAPi or PVR, nor was there any association with post-operative outcome (including stratification by natural history sub-type; all P>0.05). In the LVAD group, there was no association with PAPi and post-operative outcome; however, PVR was predictive of post-operative mortality (mortality: 2.8±1.3 WU vs. alive: 1.7±0.7 WU; P=0.005). The PAPi was not able to discriminate mortality outcomes for patients post-cardiac transplantation. Pulmonary vascular resistance remains a marker of mortality in an LVAD cohort bridged to transplant (central illustration).

Correlation between pulmonary vascular performance and hemodynamics in patients with pulmonary arterial hypertension

ABSTRACT Objective To explore the correlation between pulmonary vascular performance and hemodynamics in patients with pulmonary arterial hypertension (PAH), using right heart catheterization (RHC) and intravascular ultrasound (IVUS). Method A total of 60 patients underwent RHC and IVUS examinations. Of these, 27 patients were diagnosed with PAH associated with connective tissue diseases (PAH-CTD group), 18 patients were diagnosed with other types of PAH (other-types-PAH group), and 15 patients were without PAH (control group). The hemodynamics and morphological parameters of pulmonary vessels in PAH patients were assessed using RHC and IVUS. Results There were statistically significant differences in right atrial pressure (RAP), pulmonary artery systolic pressure (sPAP), pulmonary artery diastolic pressure (dPAP), mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR) values between the PAH-CTD group, other-types-PAH group, and the control group (P < .05). No statistically significant difference was noticed in pulmonary artery wedge pressure (PAWP) and cardiac output (CO) values between these three groups (P > .05). The mean wall thickness (MWT), wall thickness percentage (WTP), pulmonary vascular compliance, dilation, elasticity modulus, stiffness index β, and other indicators were significantly different between these three groups (P < .05). Pairwise comparison showed that the average levels of pulmonary vascular compliance and dilation in PAH-CTD group and other-types-PAH group were lower than those in control group, while the average levels of elastic modulus and stiffness index β were higher than those in control group. Conclusion Pulmonary vascular performance deteriorates in PAH patients, and the performance is better in PAH-CTD patients than in other types of PAH.

Assessing Correlation Between Thoracic Impedance and Remotely Monitored Pulmonary Artery Pressure in Chronic Systolic Heart Failure.

Heart failure (HF) readmission continues to be a major health problem. Monitoring pulmonary artery pressure (PAP) and thoracic impedance (TI) are the two modalities utilized for early identification of decompensation in HF patients. We aimed to assess the correlation between these two modalities in patients who simultaneously had both the devices. Patients with history of New York Heart Association class III systolic HF with a pre-implanted intracardiac defibrillator (ICD) capable of monitoring TI and pre-implanted CardioMEMs™ remote HF monitoring device were included. Hemodynamic data including TI and PAPs were measured at baseline and then weekly. Weekly percentage change was then calculated as: Weekly percentage change = (week 2 - week1)/week 1 × 100. Variability between the methods was expressed by Bland-Altman analysis. Significance was determined as a P-value < 0.05. Nine patients met the inclusion criteria. There was no significant correlation between the assessed weekly percentage changes in pulmonary artery diastolic pressure (PAdP) and TI measurements (r = -0.180, P = 0.065). Using Bland-Altman analytic methods, both methods had no significant difference in agreement (0.011±0.094%, P = 0.215). With the linear regression model applied for Bland-Altman analysis, the two methods appeared to have proportional bias without agreement (unstandardized beta-coefficient of 1.91, t 22.9, P ≤ 0.001). Our study demonstrated that variations exist between measurement of PAdP and TI; however, there is no significant correlation between weekly variations between them.

The effect of ras human orthologue kinase inhibitor on the treatment of pulmonary hypertension: a systematic review

Abstract Funding Acknowledgements Type of funding sources: None. Background Pulmonary hypertension (PH) is a high mortality and an uncrackable disease up to date. The complex pathophysiology is one of the reasons for only a view treatment that can be given to patients with PH. Recent studies have found that ras human orthologue–kinase (Rho-kinase) plays a role in the pathophysiology of pulmonary hypertension. Rho-kinase maintains vasoconstriction and increases vasoreactivity in vascular smooth muscle. Although the theory outlining the impact of rho-kinase on the pathophysiology of PH is well established, studies on the use of rho-kinase inhibitors as a treatment for this population are few. Purpose This study aims to evaluate the effect of rho-kinase inhibitors in the treatment of pulmonary hypertension patients. Methods A systematic review based on PRISMA guidelines was conducted. We searched PubMed, ScienceDirect, ProQuest, Cochrane Library, and Scopus Library for studies evaluating the effect of Rho-kinase inhibitor in pulmonary hypertension patients. All English articles that related to this topic were included with no time limit. The outcome of interest is pulmonary hemodynamic parameters changes pre-and post-treatment with only parameters included if described in two or more studies. We assessed the quality of the study using the Newcastle Ottawa scale for observational study and the Cochrane risk of bias tools for randomized control trials study. Results Seven studies met the criteria including 254 Patients. The mean age was 40.1 years old and 36.8% were male. All the studies included PH patients but differ in the type of PH. Fasudil 30 mg or 60 mg was the regimen of the Rho-kinase inhibitor that was used. Several pulmonary hemodynamic parameters were included in this review: pulmonary vascular resistance (PVR), systemic vascular resistance (SVR), mean pulmonary arterial pressure (mPAP), mean systemic arterial pressure (mSAP), cardiac index (CI), right arterial pressure (RAP), systolic pulmonary arterial pressure (sPAP), diastolic pulmonary arterial pressure (dPAP), pulmonary capillary wedge pressure (PCWP) and pulmonary/systemic blood flow ratio (Qp/Qs ratio). All studies that described PVR, sPAP, dPAP, and Qp/Qs ratio found that rho-kinase inhibitors significantly improve those parameters. Significant improvement of mPAP was found in 4 studies but one found it not significant.CI and SVR showed to be significantly improved in 3 studies, but 2 showed no significance. Overall, our findings suggest that Rho-kinase inhibitor can successfully improve several pulmonary hemodynamic parameters in pulmonary hypertension patients. Conclusion Rho-kinase plays a role in the pathophysiology of pulmonary hypertension and the use of Rho-kinase inhibitors has been shown to improve several pulmonary hemodynamic parameters in pulmonary hypertension patients. Future studies conducted clinical trials and meta-analysis is needed to confirm the findings of this study.