Pulmonary Artery End-diastolic Pressure Research Articles

Study of Right Ventricular Function in Post COVID Syndrome in Recovered Mild Severity COVID-19 Patients Using Conventional and Speckle Tracking Echocardiography

Abstract Background Many patients seek medical help for COVID-19’s longer term physical and mental effects. The term post COVID syndrome is used by the World Health Organization (WHO) to identify individuals with a history of probable or confirmed COVID-19 infection, usually 3 months from the onset of infection with symptoms that last for at least 2 months and cannot be explained by an alternative diagnosis. Symptoms may be due to persistent chronic inflammation, sequelae of organ damage, and hospitalization and social isolation. These symptoms may persist from the initial infection, or appear after a period of recovery. RV dimensions (RVD) and RV function (RVF) are closely correlated to symptom occurrence and to exercise capacity in many clinical conditions. Consequently, a comprehensive and accurate evaluation of the RV is essential. Echocardiography is the modality of choice for the assessment of RVD and RVF in clinical practice owing to its numerous advantages. It is widely available, relatively cheaper than other modalities, non-invasive, and doesn’t require radiation or contrast injection. Nevertheless, the RV special anatomy, its retrosternal position and its complex architecture pose a challenge to conventional echocardiographic imaging. Novel modalities of echocardiography, such as myocardial deformation imaging by speckle tracking echocardiography (STE), provide the solution to overcome most of these challenges owing to the fact that it is independent of cardiac translation, angle-independent and load-independent. Aim and Objectives The aim was to study RV function in post COVID syndrome in recovered mild severity COVID-19 patients using 2D RV STE and correlate these findings with the patients’ symptomatology. Patients and Methods This study included 96 subjects divided into 3 age and gender matched groups; the first group consisted of 32 mild severity COVID-19 patients 3-6 months after recovery and not complaining of post COVID-19 syndrome, the second group consisted of 32 mild severity COVID-19 patients 3-6 months after recovery and complaining of post COVID-19 syndrome and the third group consisted of 32 healthy controls who didn’t get COVID-19. This study was conducted at Ain Shams University Hospitals. The patients were recruited from the outpatient ECHO clinic in the cardiology department during the period from March 2022 to August 2022. The entire study population was evaluated via 2D conventional echocardiography and STE imaging. Results Our study assessed RV functions at 3-6 months after recovery from mild severity COVID-19 disease. At the follow-up, TAPSE, RV-FAC, RV S’, RV-GLS and RV-FWLS parameters were significantly lower in patients with mild severity COVID-19 disease than healthy controls. They also showed lower values in patients with post COVID syndrome than those without post COVID syndrome with P-value = 0.032, 0.034, 0.003, 0.010 and 0.029 respectively. In addition, RV diameters (longitudinal, mid and basal RVEDD), RV MPI and sPAP values were significantly higher in patients with mild severity COVID-19 disease than healthy controls. They also showed higher values in patients with post COVID syndrome than those without post COVID syndrome with P-value = 0.043, 0.026, 0.014, 0.000 and 0.025 respectively. LV-GLS showed lower value in patients with post COVID syndrome than control group with P-value = 0.002. It also showed lower value in patients with post COVID syndrome than those without post COVID syndrome with P-value = 0.018. We also found that the most common symptom in post COVID syndrome was fatigue, with a percentage of 65.6%, followed by palpitations (40.6%) and chest pain (31%). These three symptoms showed a significant negative relation with RV 2D STE parameters. Additionally, a negative correlation between inflammatory markers including CRP, TLC, PLT, ferritin and D-dimer levels during active infection and long term echocardiographic parameters such as RV-GLS, RV-FWLS and LV-GLS was detected in our study. Conclusion We concluded that RV-GLS and RV-FWLS decreased at 3-6 month follow-up of patients with history of mild severity COVID-19 disease especially those complaining of post COVID syndrome. Additionally, it is demonstrated that increased CRP, TLC, PLT, ferritin and D-dimer levels during acute infection is related to RV-GLS, RV-FWLS and LV-GLS values. 2D STE may be used for both detection and follow-up for possible long term right ventricular dysfunction after mild severity COVID-19 disease. Key words: Post-COVID Syndrome, Speckle Tracking Echocardiography, RV-GLS, RV-FWLS, LV-GLS Abbreviations. Abbreviations: RV Right Ventricle STE Speckle Tracking Echocardiography 2D 2-Dimensional TAPSE Tricuspid Annular Plane Systolic Excursion RV-FAC Right Ventricular Fractional Area Change RV-GLS Right Ventricular Global Longitudinal Strain RV-FWLS Right Ventricular Free Wall Longitudinal Strain LV-GLS Left Ventricular Global Longitudinal Strain RVEDD Right Ventricular End Diastolic Dimension RV MPI Right Ventricular Myocardial Performance Index sPAP Systolic Pulmonary Artery Pressure CRP C – Reactive Protein TLC Total Leucocytic Count PLT Platelets WHO World Health Organization LVEDD Left Ventricular End Diastolic Dimension LVESD Left Ventricular End Systolic Dimension FS Fractional Shortening EF Ejection Fraction

MO746CARDIAC REMODELING AND PULMONARY HYPERTENSION IN HEMODIALYSIS PATIENTS

Abstract Background and Aims An important predictor of cardiovascular mortality and morbidity in hemodialysis patients is left ventricular hypertrophy. Also, pulmonary hypertension is a risk factor for mortality and cardiovascular events in hemodialysis patients. The aim of this study was to investigate cardiac remodeling and the dynamics of pulmonary arterial pressure during a year-long hemodialysis treatment and to evaluate relationship between pulmonary arterial pressure and blood flow in arteriovenous fistula. Method Hemodialysis patients (n=88; 42 males, 46 females, mean age was 51.7±13.0 years) were studied. Echocardiography and Doppler echocardiography were performed in the beginning of hemodialysis treatment and after a year. Echocardiographic evaluation was carried out on the day after dialysis. Left ventricular mass index (LVMI) was calculated. Left ventricular ejection fraction (LVEF) was measured by the echocardiographic Simpson method. Arteriovenous fistula flow was determined by Doppler echocardiography. Pulmonary hypertension was diagnosed according to criteria of Guidelines for the diagnosis and treatment of pulmonary hypertension of the European Society of Cardiology. Results Pulmonary hypertension was diagnosed in 47 (53.4%) patients. Left ventricular hypertrophy was revealed in 71 (80.7%) patients. Only 2 (2.3%) patients had LVEF<50%. At the beginning of hemodialysis correlation was detected between systolic pulmonary arterial pressure and LVMI (r=0.52; P<0.001). Systolic pulmonary arterial pressure negatively correlated with left ventricular ejection fraction (r=-0.20; P=0.04). After a year of hemodialysis treatment LVMI decreased from 140.49±42.95 to 123.25±39.27 g/m2 (р=0.006) mainly due to a decrease in left ventricular end-diastolic dimension (from 50.23±6.48 to 45.13±5.24 mm, p=0.04) and systolic pulmonary arterial pressure decreased from 44.83±14.53 to 39.14±10.29 mmHg (р=0.002). Correlation wasn’t found between systolic pulmonary arterial pressure and arteriovenous fistula flow (r=0.17; p=0.4). Conclusion Pulmonary hypertension was diagnosed in half of patients at the beginning of hemodialysis treatment. Pulmonary hypertension in hemodialysis patients was associated with left ventricular hypertrophy, systolic left ventricular dysfunction. After a year-long hemodialysis treatment, a regress in left ventricular hypertrophy and a partial decrease in pulmonary arterial pressure were observed. There wasn’t correlation between arteriovenous fistula flow and systolic pulmonary arterial pressure.

P5996HDAC inhibition improves myofibrillar relaxation and metabolism in a feline model of HFpEF

Abstract Background Heart failure (HF) with preserved ejection fraction (HFpEF) accounts for about 50% of all cases of HF and there are currently no effective therapies. Purpose To assess the effects of histone deacetylase (HDAC) inhibition on cardiac and mitochondrial function and the plasma metabolome in a large mammalian model of slow-progressive pressure overload with features of HFpEF. Methods Male domestic short hair cats (n=26, aged 2mo), underwent either sham (S) procedures (n=5) or aortic constriction with a customized pre-shaped band (n=21), resulting in slow progressive pressure overload during growth. 2 months post-banding, animals were treated daily with either 10mg/kg suberoylanilide hydroxamic acid (b+SAHA) (n=8), a pan-HDAC inhibitor, or vehicle (b+veh) (n=8) for 2 months. Serial in-vivo cardiopulmonary phenotyping was performed monthly, and invasive hemodynamic and gas exchange parameters were evaluated 4 months post-banding. Ex-vivo myofibril mechanical studies and blood-based metabolomic profiling were performed. Data is presented as mean±SEM. Results Echocardiography at 4-months post-banding revealed that b+SAHA animals had a significant reduction in left ventricular hypertrophy (LVH) and LA size vs. b+veh animals. Left ventricular end-diastolic pressure (LVEDP) and mean pulmonary arterial pressure (mPAP) were significantly lower in b+SAHA vs. b+veh. SAHA treatment also improved ex-vivo myofibril relaxation independent of LVH and this effect correlated with in-vivo improvements of LV relaxation. Furthermore, SAHA treatment preserved lung structure, and improved lung compliance and oxygenation, reflected by a decrease in alveolar-capillary wall thickness and intrapulmonary shunt. SAHA treatment also reduced perivascular fluid cuffs around extra-alveolar vessels, suggesting attenuated alveolar-capillary stress failure. Treatment with SAHA caused an increase in both oxygen consumption in-vivo and the percentage of type 1 skeletal muscle fibers (higher oxidative capacity). SAHA also increased mRNA levels of coactivators that regulate mitochondrial function and induced metabolic reprogramming towards mitochondrial oxidation preferentially utilizing fatty acids. SAHA treated HeLa cells showed a significant increase in oxidative phosphorylation and ATP production. Effects of SAHA Conclusion These results show that slow-progressive pressure overload mimics critical features of HFpEF. SAHA can improve cardiac, pulmonary, and metabolic derangements caused by chronic pressure overload. Therefore, HDAC inhibition may be an interesting therapeutic strategy to treat the ever growing HFpEF population. Acknowledgement/Funding NIH [HL33921 to S.R.H, HL116848, HL127240 to T.A.M]; AHA [16SFRN31400013 to T.A.M.]; Medical University of Graz [M.W.], Stadt Graz [M.W.]

Hemodynamic Improvement with Application of Mechanical Circulatory Support in Heart Failure with Preserved Ejection Fraction in a Mock Circulation Loop

Purpose Mechanical circulatory support (MCS) is a non-obvious therapy for heart failure with preserved ejection fraction (HFpEF) because ventricular systolic function is not reduced. We hypothesize MCS of the left ventricle (LV) or left atrium (LA) can improve the hemodynamics in HFpEF including when pulmonary arterial hypertension (PH) is present. Methods Hemodynamic conditions of HFpEF ± PH were recreated on a mock circulation loop (MCL) with a tunable resistance, arterial compliance, peripheral resistance, inertance, venous compliance, and replication of the Frank-Starling mechanism. Hemodynamic parameters were recorded, including atrial and ventricular pressures, ventricular volumes, ejection fraction, and cardiac output. A HeartWare HVAD™ (Medtronic, MN) was used in two different support configurations: 1) LV to aorta (Ao) and 2) LA to Ao. The pump speed was titrated to achieve systemic flow (Qs) of 4.0 L/min and 4.5 L/min. Results Conditions typically seen in patients with HFpEF ± PH were created in the MCL with complete hemodynamic profiles including HVAD support seen in Table1. In both configurations and regardless of PH status, further Qs augmentation was associated with a reduction in LV end-diastolic pressure, LA pressure and mean pulmonary artery pressure. In the LV to Ao configuration, LV volumes decreased, and ejection fraction improved. In the LA to Ao configuration, LV volumes increased. In the LV to Ao configuration, pressure-volume loop (PVL) data show a reduction in pressure-volume area including a decrease in both stroke work and potential energy. In LA to Ao configuration, PVL data show a decrease in stroke work but an increase in potential energy. This study was not designed to evaluate for suction events. Conclusion In HFpEF ± PH, MCS can increase Qs and reduce LA pressure. As compared to LV decompression, LA decompression does not volume unload the LV. This study shows potential for MCS as a therapeutic alternative for HFpEF.

Impact of right ventricular dysfunction and end-diastolic pulmonary artery pressure estimated from analysis of tricuspid regurgitant velocity spectrum in patients with preserved ejection fraction.

We aimed to analyse the association between right haemodynamic parameters, right ventricular (RV) dysfunction parameters, and outcomes in patients with preserved ejection fraction (EF). Retrospective analysis of right haemodynamic (systolic pulmonary pressure and end-diastolic pulmonary pressure based on tricuspid regurgitation (TR) velocity at pulmonary valve opening time), and RV parameters including size (end-diastolic and end-systolic area), function (RV fractional area change, Tei index, Tricuspid Annular Plane Systolic Excursion, and speckle tracking derived free wall strain), from 557 consecutive patients with preserved EF [EF ≥ 50%; age 64.9 + 20; 52% female; co-morbidity Charlson index 4.7 (2.9, 6.4)]. All cause and cardiac mortality were retrospectively analysed and correlated to echo haemodynamic and co-morbid parameters. TR velocity at pulmonary valve opening time and calculated end-diastolic pulmonary artery pressure were obtainable in 71% of patients. The best haemodynamic univariate predictor of mortality was calculated end-diastolic pulmonary artery pressure [hazard ratio 1.06 (1.04-1.07); P < 0.0001], superior to TR peak velocity and systolic pulmonary artery pressure. Elevated end-diastolic pulmonary artery pressure was associated with all cause and cardiac mortality even when adjusted for all significant clinical (age, gender, and Charlson index), and echo (stroke volume index, left atrial volume index, systolic pulmonary pressure, E/e', and Tei index) parameters. Tei index was superior to all other RV functional parameters (P < 0.05 for all parameters). TR velocity at pulmonary valve opening time and calculated end-diastolic pulmonary artery pressure are obtainable in most patients, and add prognostic information on top of clinical and routine haemodynamic and diastolic parameters.

Predictors for Left Ventricular Systolic Dysfunction and its Outcome after Patent Ductus Arteriosus (Pda) Closure by Device

Objective: To evaluate the predictors of left ventricle (LV) systolic dysfunction after PDA closure by device. Back ground: LV dysfunction is very common in patients after PDA closure by device. There are certain predictors leading to it. Methods: 63 patients of isolated PDA. Patients were admitted in paediatric cardiology department of National Institute of Cardiovascular Disease Karachi, Pakistan. Baseline echocardiography was performed. Hemodynamics were done during cardiac catheterization, pulmonary blood flow/systemic blood flow (QP/QS) and pulmonary vascular resistance calculated. After successful device closure echocardiography was repeated on day 1, after one, three and six months. All subjects were divided into two groups on the basis of post closure LV ejection fraction. All the parameters which include age, gender, weight, LVEDD z-score, QP, PDA size, left ventricle end diastolic pressure and pulmonary artery pressure compared in both groups. Results: 41 patients (65.1%) developed LV systolic dysfunction. Coil was used in only 3(4.8%) patients and two of them developed dysfunction. All patients recovered within six months except two had dysfunction beyond six months. 30 patients (47.6%) patients had weight Z-score <-3 SD and 29 of them developed dysfunction. Weight, base line LVEDD Z –score, QP, LVEDP and PDA size has significant impact on LV function with p-value <0.05. Conclusion: Hemodynamic effects of PDA, changes in LV dimensions and function caused by it are reversible after transcatheter closure of PDA. Large PDA size, high QP/QS are potential risk factors leading to LV dysfunction after device closure.

Using Cardiac Magnetic Resonance Imaging to Evaluate Cardiac Function and Predict Outcomes in Patients with Valvular Heart Disease

In valvular heart disease, elevated left atrial and pulmonary pressures contribute to right ventricular strain and, ultimately, right ventricle failure. Elevated pulmonary artery (PAP) and left ventricular end diastolic pressures are used as markers of right ventricle dysfunction and correlate with poor outcomes. Using cardiac magnetic resonance imaging (CMR), it is possible to directly quantify both left and right ventricular ejection function (LVEF and RVEF), and here, we compare CMR with traditional markers as outcome predictors. A retrospective review of prospectively collected data was performed for patients from January 2004 to February 2008 at a single center (n = 103). Patients were divided into those receiving CMR (n = 56) and those receiving only catheterization (n = 47). Univariate and multivariate logistic regression models were applied to determine predictors of mortality. Finally, predictive models for mortality using PAP, mean PAP, and left ventricular end diastolic pressure were compared to models using LVEF and RVEF obtained from CMR. Preoperative average CMR LVEF and RVEF were 57% and 46%, respectively. Only age emerged as an isolated predictor of mortality (P = 0.01) within the univariate models. Stepwise regression models were created using the catheterization or CMR data. When compared, the CMR model has a slightly better R, c (prediction accuracy), and sensitivity/specificity (0.22 vs 0.28, 0.77 vs 0.82, and 0.63/0.62 vs 0.69/0.64, respectively). Within our population, LVEF and RVEF predict mortality as least as well as traditional catheterization values. Additionally, CMR may identify of elevated PAPs caused by right ventricle dysfunction and those due to other causes, allowing these other causes to be addressed preoperatively.

Serial evaluation of hepatic function profile after Fontan operation

Moderate persistent elevation of the γ-glutamyltransferase (γGT) level is a frequent finding during long-term follow-up of patients with total cavopulmonary connection (TCPC) for palliation of functionally univentricular hearts. Serial intraindividual data revealed a significant increase in the γGT level within a minimum 4-year interval in more than 80 % of cases. The level of γGT elevation showed a significant correlation to hemodynamic parameters such as systemic ventricular end diastolic pressure and mean pulmonary artery pressure, but did not strongly correlate with duration of follow-up or other liver function parameters, which were less frequent and less impressively deranged. None of the patients had signs of synthetic dysfunction. With increasing postoperative follow-up, abnormalities of sonographic hepatic texture including increased echogenicity, inhomogeneity, or liver surface nodularity were found. All 17 patients with liver surface nodularity had a follow-up period of over 10years. Structural abnormalities did not correlate with biochemical or hemodynamic parameters. Doppler evaluation revealed inspiratory dependence of hepatic vein flow in more than 90 % as a relevant finding after TCPC; a decrease in portal vein flow velocity was observed in many patients. Since long-term survivors after Fontan procedure are at an increased risk of cardiac hepatopathy and cirrhosis, detailed routine investigation and monitoring of hepatic morphology are needed.

BNP levels in patients with long-term exposure to biomass fuel and its relation to right ventricular function

Abstract Previous studies have demonstrated a consistent increased risk for cardiovascular events and pulmonary disease in patients with biomass fuel exposure (BFE). However right ventricular (RV) function have not been investigated yet in these patients. In this study, pulmonary function, right ventricular function and their relations with Brain Natriuretic Peptide (BNP) were investigated in non-smoking female patients with BFE. Methods Our study population consisted of 39 female patients with BFE (group 1) and, 31 control subjects (group 2). Pulmonary function tests and transthoracic echocardiographic examination were performed. Right ventricular volumes, diameters and tissue velocities were obtained by tissue Doppler echocardiography. BNP levels were measured and correlated to right ventricular measurements and pulmonary artery pressure. Results In BFE group, obstructive and restrictive spirometric findings were found. RV diameters, volumes and pulmonary artery pressure were higher in group 1 than group 2. BNP levels were well correlated with right ventricular end diastolic diameter and pulmonary artery pressure. A suspicion is also arised that toxic chemicals in biomass fuel may play a role in RV dysfunction. Conclusion Biomass fuel exposure not only cause obstructive and/or restrictive lung disease but also leads to systolic and diastolic right ventricular dysfunction. BNP levels may be used to monitor pulmonary artery pressure and right ventricular enlargement in these patients.

Contrast-Induced Nephropathy in Patients Undergoing Emergency Percutaneous Coronary Intervention for Acute Coronary Syndrome

Contrast-induced nephropathy (CIN) is associated with significantly increased morbidity and mortality after coronary angiography and percutaneous coronary intervention (PCI). The aim of the present study was to assess the clinical features and in-hospital outcomes of CIN after emergency PCI. The serum creatinine (SCr) concentration was measured from days 0 to 30 in 338 consecutive patients with acute coronary syndrome undergoing emergency PCI. CIN was defined as an increase in SCr of >25% or >0.5 mg/dl within 2 days after PCI. Overall, 94 patients (28%) developed CIN. The mean SCr on admission was not significantly different between patients with CIN and those without CIN. The CIN group had significantly greater SCr at days 1, 2, and 30 than did the no CIN group. Multivariate analysis showed female gender (odds ratio [OR] 2.38, 95% confidence interval [CI] 1.12 to 5.07, p = 0.025), a culprit lesion in the left anterior descending artery (OR 2.37, 95% CI 1.31 to 4.27, p = 0.0042), contrast agent volume >200 ml (OR 3.60, 95% CI 1.96 to 6.62, p <0.001) and end-diastolic pulmonary arterial pressure >15 mm Hg (OR 2.03, 95% CI 1.02 to 4.04, p <0.01) to all correlate independently with CIN. The in-hospital mortality rate was greater in the CIN group than in the no CIN group (9.6% vs 3.3%, respectively; p = 0.025). In conclusion, CIN is a frequent complication of emergency PCI for acute coronary syndrome and is associated with a greater mortality rate and persistent renal dysfunction.

Doppler Echocardiography Can Provide a Comprehensive Assessment of Right Ventricular Afterload

The purpose of this study was to evaluate novel Doppler echocardiographic methods for a comprehensive assessment of right ventricular afterload, including pulmonary artery (PA) mean pressure (PAMP) and the PA pressure waveform. The study comprised 109 patients who underwent right-heart catheterization simultaneously (group A, n = 31) with Doppler echocardiography on 35 occasions or nonsimultaneously (group B, n = 78) within 24 hours of Doppler echocardiography. Right ventricular afterload variables were obtained using pulsed Doppler in the PA and continuous Doppler of tricuspid regurgitation. The intervals from QRS to the opening and closing of the pulmonary valve and to the peak velocity of tricuspid regurgitation were measured. PA end-diastolic pressure, PA systolic pressure, and PA notch pressure were calculated. The Doppler-derived pressure curve was separated into 3 parts with fitted second-order curves. Catheter PAMP and Doppler PA systolic pressure in group A were strongly related (R = 0.85). The regression equation from group A (PAMP = 0.65 x Doppler PA systolic pressure - 1.2 mm Hg) was used to calculate PAMP in group B. There was no difference between catheter PAMP (mean, 39 +/- 18 mm Hg; range, 8-95 mm Hg) and Doppler PAMP (mean, 39 +/- 15 mm Hg; range, 12-83 mm Hg) (P = .85). The systolic areas under the curves for catheter and Doppler PAMP in group A were 20 +/- 4.7 and 20 +/- 4.0 mm Hg s, respectively (P = .52), and the diastolic areas were 21 +/- 5.7 and 22 +/- 6.3 mm Hg s, respectively (P = .21). A comprehensive assessment of right ventricular afterload that includes PAMP and the PA pressure waveform can be provided by Doppler echocardiography in patients with a wide range of PA pressures and different diagnoses.

Right heart failure after infarction of the right ventricle (author's transl)

The right ventricular filling pressure was raised above 10 mm Hg in 20 cases (12%) out of 175 patients haemodynamically monitored in the acute phase after cardiac infarction. The end-diastolic pulmonary arterial pressure was not above 18 mm Hg so that in these cases an extensive necrosis of the right ventricle must be assumed to be the cause of right heart failure. In 75% of these patients with predominantly right sided infarction there was a posterior wall infarct whereas in patients with left heart failure the anterior wall was significantly more often affected. Patients with posterior wall infarction and right heart failure had more commonly infarct signs in the right precordial chest leads Vr3 to Vr6 and an increased diameter of the right ventricle in the echocardiogram than patients with posterior wall infarction but without right heart failure. However, a definite separation of the two groups was not possible with these non-invasive techniques. Haemodynamic changes should thus be decisive for the diagnosis of predominantly right heart infarction as these dictate the treatment.

Early prognostic implications of haemodynamic findings in acute myocardial infarction (author's transl)

Investigation of 226 patients with acute myocardial infarction showed that simultaneous assessment of end-diastolic pressure in the pulmonary artery as well as minute volume and arterial blood pressure enable a mostly reliable prognosis to be made. End-diastolic pulmonary artery pressure below 18 mm Hg, remaining so during the first two days of illness, is associated with mortality of around 7%. Initially increased values falling to below 18 mm Hg during the measurements are also linked with a good prognosis. An increase within the first 72 hours, as a consequence of progression of infarction or recurrence, increases mortality to around 23%. In cases where the initially increased end-diastolic pulmonary pressure cannot be lowered constantly, prognosis is also unfavourable due to chronic left heart failure in extensive cardiac infarction. The most certain prediction can be derived from the product of stroke volume and pressure, related to body surface. This stroke-work index does not only reflect pre- and after-loading of the left ventricle values mortality was 4%, rising to 88% with values below 25 g . m/m2. Haemodynamic monitoring is indicated for treatment surveillance particularly with vasodilators. Our results show that in addition a useful prognosis may be derived from the individual haemodynamic situation.

Fenestrated Occluders for Treatment of ASD in Elderly Patients with Pulmonary Hypertension and/or Right Heart Failure

Atrial septal defect (ASD) occlusion in adult patients with advanced age and left or right heart diastolic or systolic heart failure and in patients with pulmonary arterial hypertension bears a considerable risk of deterioration of heart failure. Therefore, we conducted this feasibility trial in 15 ASD patients with pulmonary hypertension and/or right heart failure using a fenestrated Amplatzer septal occluder (AGA Medical Corporation, Golden Valley, MN), allowing an overflow of blood in both directions in case of univentricular diastolic or systolic heart failure. In all patients, the device could be implanted without complications. All symptomatic patients showed an improvement in the New York Heart Association (NYHA) class, and no right or left heart decompensation occurred. On echocardiography, right ventricular end diastolic dimension (RVEDD) and pulmonary artery pressure (PAP) decreased significantly, whereas left ventricular end diastolic dimension (LVEDD) increased. Our series of 15 patients with fenestrated ASD occlusion shows that high-risk ASD occlusion can safely be accomplished with excellent clinical results and without complications by a fenestrated occluder.

Right ventricle Tei-index: A tool to increase the accuracy of non-invasive detection of pulmonary arterial hypertension in connective tissue diseases

To assess the accuracy of echocardiography for predicting pulmonary arterial hypertension (PAH) in a cohort of patients with systemic sclerosis and other connective tissue diseases, and to evaluate whether addition of the right ventricular (RV) Tei-index contributes to the non-invasive diagnosis of PAH in this patient group. Ninety-eight patients with systemic sclerosis and other connective tissue diseases in whom an echocardiography was performed in the period from January 1st 2004 to July 1st 2005 were included. Echocardiographic systolic pulmonary arterial pressure (PAP), end-diastolic PAP and RV Tei-index were calculated. In cases with a high suspicion of PAH right heart catheterization was performed and systolic, diastolic and mean PAP as well as pulmonary wedge pressure, cardiac output and pulmonary vascular resistance were obtained. These results were compared to the echocardiographic measurements. The average RV Tei-index of our patients was substantially above normal values. In 35 (36%) patients a right heart catheterization was performed and PAH was confirmed in 28 patients. In 6 of 7 patients without PAH, the RV Tei-index was below the upper limit of normal. A significant correlation was found between the RV Tei-index and the catheterization parameters such as systolic PAP, diastolic PAP and mean PAP. The accuracy of echocardiography for the detection of PAH increases when the echocardiographic systolic PAP is combined with an elevated RV Tei-index. As a result, by applying the Tei-index, the number of negative catheterizations can be minimized.

Ventricular septal rupture following myocardial infarction. Long-term survival of patients who did not undergo surgery. Single-centre experience.

Long-term survival is rare in patients not undergoing surgery after post-myocardial infarction ventricular septal rupture.We report our experience of seven patients out of 27, who did not undergo surgery and were followed up for a mean period of 2.8 years.They were evaluated after a mean period of 2.2 months after infarction in our centre. The septal defects measured 9.8 mms on average and the mean left-to-right shunt ratio was 1.98:1. The mean pulmonary artery, right atrial and left ventricular end diastolic pressures were 28.3 ± 10.6, 4 ± 3 and 15.8 ± 4.8 mm Hg, respectively. Only three out of seven patients had LV aneurysm and all patients had single-vessel disease. Smaller defect size, minimal left-to-right shunt and preserved right ventricular function may be the factors responsible for long-term survival.

Relation of pulmonary arterial diastolic and mean pulmonary arterial wedge pressures in patients with and without pulmonary hypertension

Management of the critically ill or postoperative patient in the intensive care unit may be facilitated by the measurement of right-sided and certain left-sided intracardiac filling pressures with a balloon-tipped, flow-directed catheter. Although previous studies have shown that properly obtained and oximetrically confirmed pulmonary arterial wedge pressure provides an accurate estimate of left atrial pressure, 1 Werko L. Varnauskas E. Eliasch H. Lagerlof H. Senning A. Thommasson B. Further evidence that the pulmonary capillary venous pressure pulse in man reflects cyclic pressure changes in the left atrium. Circ Res. 1953; 1: 337-344 Crossref PubMed Scopus (28) Google Scholar , 2 Connolly D.C. Kirklin J.W. Wood E.H. The relationship between pulmonary artery wedge pressure and left atrial pressure in man. Circ Res. 1953; 2: 434-440 Crossref Scopus (75) Google Scholar , 3 Lange R.A. Moore D.M. Cigarroa R.G. Hillis L.D. Use of pulmonary capillary wedge pressure to assess severity of mitral stenosis Is true left atrial pressure needed in this condition?. J Am Coll Cardiol. 1953; 13: 825-829 Abstract Full Text PDF Scopus (55) Google Scholar the procurement of an oximetrically confirmed wedge pressure may be difficult or impossible in some subjects. As a result, some investigators 4 Lipp-Ziff E.L. Kawanishi D.T. A technique for improving the accuracy of pulmonary artery diastolic pressure as an estimate of left ventricular end-diastolic pressure. Heart Lung. 1953; 20: 107-115 Google Scholar have suggested that pulmonary arterial diastolic pressure can be used as a surrogate for mean pulmonary arterial wedge pressure and, in turn, mean left atrial pressure. In 28 patients with varied pulmonary vascular resistances, Jenkins et al 5 Jenkins B.S. Bradley R.D. Branthwaite M.A. Evaluation of pulmonary arterial end-diastolic pressure as an indirect estimate of left atrial mean pressure. Circulation. 1953; 152: 75-78 Google Scholar demonstrated an excellent correlation between pulmonary arterial diastolic and mean left atrial pressures. Despite these reports, no previously published study has assessed the relation of pulmonary arterial diastolic to mean pulmonary arterial wedge pressures in a large number of patients in whom the catheter’s wedge position was confirmed oximetrically. Accordingly, this study was performed to assess this relation and to determine if it is influenced by pulmonary hypertension.

Hemodynamics derived from Transesophageal Echocardiography (TEE)

Table 1 lists the parameters that are sought routinely in developing a complete hemodynamic profile by TEE. The arterial blood pressure is an essential starting point. Knowledge of the cardiac output (flow velocity integral) allows placement of the other parameters in context by providing a notion of the status of the general circulation and of the level of pulmonary and systemic vascular resistance. The mitral inflow allows segregation of the diastolic function of the left ventricle into one of three categories: (1) normal, (2) restrictive, or (3) delayed relaxation. Pulmonary vein inflow is complementary to mitral inflow and further confirms the status of the filling pressure. The MR jet is another means of gauging the systemic blood pressure and the filling pressure but is more technically demanding than recording mitral valve and pulmonary valve inflows. Tricuspid regurgitation, also technically demanding, reliably provides peak pulmonary systolic pressure, and PR provides the end-diastolic pulmonary artery pressure. Doppler [table: see text] flow in the great veins is useful in estimating right atrial pressure; this information must be integrated with TR and PR velocities to estimate pulmonary artery pressure. Finally, the motion and curvature direction of the IAS allows identification of the atrium with the higher pressure. Using the dynamic behavior of this structure enables reconstructing of the pressure in one atrium from knowledge of pressure in the other. As the case example shows, using these techniques in a routine fashion enables an accurate, comprehensive, and reliable qualitative assay of hemodynamic status.

Late-diastolic forward flow in the aorta induced by left atrial contraction

Late-diastolic forward flow is a well-described phenomenon detectable by Doppler echocardiography in the pulmonary trunk. It is supported by a restrictive right ventricular diastolic function and by a low end-diastolic pulmonary artery pressure. A similar phenomenon for the left ventricle and the aorta has not been described. We report a case of a preterm infant with aortic stenosis and endocardial fibroelastosis, who underwent balloon valvuloplasty. Restrictive left ventricular diastolic filling led to high left atrial pressure (27 mm Hg) and a very pathologic ratio of early-to-late peak velocities (2.6) for an infant of 29 weeks' gestation. In combination with a low diastolic aortic pressure (24 mm Hg) caused by moderate aortic regurgitation after intervention, a late-diastolic forward flow was detectable in the aorta during left atrial contraction with pulsed Doppler echocardiography. (J Am Soc Echocardiogr 2000;13:866-8.)

Structural and functional characteristics of rat hearts with and without myocardial infarct. Initial experience with doppler echocardiography

To assess by Doppler echocardiography the structural and functional alterations of rat heart with surgical induced extensive myocardial infarction. Five weeks after surgical ligature of the left coronary artery, 38 Wistar-EPM rats of both sexes, 10 of them with extensive infarction, undergone anatomical and functional evaluation by Doppler echocardiography and then euthanized for anatomopathological analysis. Echocardiography was 100% sensible and specific to anatomopathological confirmed extensive miocardial infarction. Extensive infarction lead to dilatation of left ventricle (diastolic diameter: 0.89 cm vs.0.64 cm; systolic: 0. 72 cm vs. 0.33 cm) and left atrium (0.55 cm vs. 0.33 cm); thinning of left ventricular anterior wall (systolic: 0.14 cm vs. 0.23 cm, diastolic: 0.11 cm vs. 0.14 cm); increased mitral E/ A wave relation (6.45 vs. 1.95). Signals of increased end diastolic ventricle pressure, B point in mitral valve tracing in 62.5% and signs of pulmonary hypertension straightening of pulmonary valve (90%) and notching of pulmonary systolic flow (60%) were observed in animals with extensive infarction. Doppler echocardiography has a high sensitivity and specificity for detection of chronic extensive infarction. Extensive infarction caused dilatation of left cardiac chambers and showed in Doppler signals of increased end diastolic left ventricular pressure and pulmonary artery pressure.