Pulmonary Artery Pulsatility Index Research Articles

Pulmonary artery elastance as a predictor of hospital mortality in heart failure cardiogenic shock.

The initial bundle of cares strongly affects haemodynamics and outcomes in acute decompensated heart failure cardiogenic shock (ADHF-CS). We sought to characterize whether 24h haemodynamic profiling provides superior prognostic information as compared with admission assessment and which haemodynamic parameters best predict in-hospital death. All patients with ADHF-CS and with available admission and 24h invasive haemodynamic assessment from two academic institutions were considered for this study. The primary endpoint was in-hospital death. Regression analyses were run to identify relevant predictors of study outcome. We included 127 ADHF-CS patients [65 (inter-quartile range 52-72) years, 25.2% female]. Overall, in-hospital mortality occurred in 26.8%. Non-survivors were older, with greater CS severity. Among admission variables, age [odds ratio (OR)=1.06; 95% confidence interval (CI): 1.02-1.11; Padj=0.005] and CPIRAP (OR=0.62 for 0.1 increment; 95% CI: 0.39-0.95; Padj=0.034) were found significantly associated with in-hospital death. Among 24h haemodynamic univariate predictors of in-hospital death, pulmonary elastance (PaE) was the strongest (area under the curve of 0.77; 95% CI: 0.68-0.86). PaE (OR=5.98; 95% CI: 2.29-17.48; Padj<0.001), pulmonary artery pulsatility index (PAPi, OR=0.77; 95% CI: 0.62-0.92; Padj=0.013) and age (OR=1.06; 95% CI: 1.02-1.11; Padj=0.010) were independently associated with in-hospital death. Best cut-off for PaE was 0.85mmHg/mL and for PAPi was 2.95; cohort phenotyping based on these PaE and PAPi thresholds further increased in-hospital death risk stratification; patients with 24h high PaE and low PAPi exhibited the highest in-hospital mortality (56.2%). Pulmonary artery elastance has been found to be the most powerful 24h haemodynamic predictor of in-hospital death in patients with ADHF-CS. Age, 24h PaE, and PAPi are independently associated with hospital mortality. PaE captures right ventriclar (RV) afterload mismatch and PAPi provides a metric of RV adaptation, thus their combination generates four distinct haemodynamic phenotypes, enhancing in-hospital death risk stratification.

One Pump for Two Hearts: Using an Impella 5.5 Micro-Axial Pump in Peripartum Cardiogenic Shock.

Cardiogenic shock (CS) occurs infrequently in pregnancy and has a high mortality rate. Medical treatment options are few, with limited evidence of efficacy. Temporary mechanical circulatory supports (tMCS) may play a key role in addressing this therapeutic lacuna. We report successfully managing second-trimester CS using an Impella 5.5 micro-axial pump. Our patient presented in the second-trimester with CS. Hemodynamic parameters indicated biventricular dysfunction (low cardiac index, low pulmonary artery pulsatility index). She received diuresis and inotropic support to optimize her fluid status and cardiac function. However, failure to improve to the point where she would be able to tolerate the hemodynamic stresses of labor despite optimizing medical therapy prompted consideration of tMCS. The Impella 5.5 was chosen for its higher output (to maximize fetal perfusion), relative longevity, and lower hemolysis rates compared to other devices. It was used to support her from gestational weeks 28-30 and through the delivery. Support was continued for 4 weeks postpartum to allow for any potential cardiac recovery. Hope unrealized, a workup for destination therapy was initiated. Patient preference and high panel reactive antibodies informed the decision to pursue destination left ventricular assist device (LVAD) therapy. After a 3 month neonatal intensive care unit (NICU) stay, mother and baby were successfully discharged home.

Invasive haemodynamics predict outcomes in paediatric pulmonary artery hypertension.

Invasive haemodynamics are often performed for initiating and guiding pulmonary artery hypertension therapy. Little is known about the predictive value of invasive haemodynamic indices for long-term outcomes in children with pulmonary artery hypertension. We aimed to evaluate invasive haemodynamic data to help predict outcomes in paediatric pulmonary artery hypertension. Patients with pulmonary artery hypertension who underwent cardiac catheterisation (2006-2019) at a single centre were included. Invasive haemodynamic data from the first cardiac catheterisation and clinical outcomes were reviewed. The combined adverse outcome was defined as pericardial effusion (due to right ventricle failure), creation of a shunt for pulmonary artery hypertension (atrial septal defect or reverse Pott's shunt), lung transplant, or death. Among 46 patients with a median [interquartile range (IQR)] age of 13.2 [4.1-44.7] months, 76% had CHD. Median mean pulmonary artery pressure was 37 [28-52] mmHg and indexed pulmonary vascular resistance was 6.2 [3.6-10] Woods units × m2. Median pulmonary artery pulsatility index was 4.0 [3.0-4.7] and right ventricular stroke work index was 915 [715-1734] mmHg mL/m2. After a median follow-up of 2.4 years, nine patients had a combined adverse outcome (two had a pericardial effusion, one underwent atrial level shunt, one underwent reverse Pott's shunt, and six died). Patients with an adverse outcome had higher systolic and mean pulmonary artery pressures, higher diastolic and transpulmonary pressure gradients, higher indexed pulmonary vascular resistance, higher pulmonary artery elastance, and higher right ventricular stroke work index (p < 0.05 each). Invasive haemodynamics (especially mean pulmonary artery pressure and diastolic pressure gradient) obtained at first cardiac catheterisation in children with pulmonary artery hypertension predicts outcomes.

(814) - Pre-Implant Pulmonary Artery Pulsatility Index and Its Relationship with Early Right Ventricular Failure After Left Ventricular Assist Device Implantation: An INTERMACS Analysis

(814) - Pre-Implant Pulmonary Artery Pulsatility Index and Its Relationship with Early Right Ventricular Failure After Left Ventricular Assist Device Implantation: An INTERMACS Analysis

Monitoring a Mystery: The Unknown Right Ventricle during Left Ventricular Unloading with Impella in Patients with Cardiogenic Shock.

Background: Right ventricular (RV) dysfunction or failure occurs in more than 30% of patients in cardiogenic shock (CS). However, the importance of timely diagnosis of prognostically relevant impairment of RV function is often underestimated. Moreover, data regarding the impact of mechanical circulatory support like the Impella on RV function are rare. Here, we investigated the effects of the left ventricular (LV) Impella on RV function. Moreover, we aimed to identify the most optimal and the earliest applicable parameter for bedside monitoring of RV function by comparing the predictive abilities of three common RV function parameters: the pulmonary artery pulsatility index (PAPi), the ratio of right atrial pressure to pulmonary capillary wedge pressure (RA/PCWP), and the right ventricular stroke work index (RVSWI). Methods: The data of 50 patients with CS complicating myocardial infarction, supported with different flow levels of LV Impella, were retrospectively analyzed. Results: Enhancing Impella flow (1.5 to 2.5 L/min ± 0.4 L/min) did not lead to a significant variation in PAPi (p = 0.717), RA/PCWP (p = 0.601), or RVSWI (p = 0.608), indicating no additional burden for the RV. PAPi revealed the best ability to connect RV function with global hemodynamic parameters, i.e., cardiac index (CI; p < 0.001, 95% CI: 0.181-0.663), pulmonary capillary wedge pressure (PCWP; p = 0.005, 95% CI: -6.721--1.26), central venous pressure (CVP; p < 0.001, 95% CI: -7.89-5.575), and indicators of tissue perfusion (central venous oxygen saturation (SvO2); p = 0.008, 95% CI: 1.096-7.196). Conclusions: LV Impella does not impair RV function. Moreover, PAPi seems to be to the most effective and valid predictor for early bedside monitoring of RV function.

Right Ventricular Assist Device Placement During Left Ventricular Assist Device Implantation Is Associated With Improved Survival.

Right ventricular failure (RVF) is a significant cause of mortality in patients undergoing left ventricular assist device (LVAD) implantation. Although right ventricular assist devices (RVADs) can treat RVF in the perioperative LVAD period, liberal employment before RVF is not well established. We therefore compared the survival outcomes between proactive RVAD placement at the time of LVAD implantation with a bailout strategy in patients with RVF. Retrospectively, 75 adult patients who underwent durable LVAD implantation at our institution and had an RVAD placed proactively before LVAD implantation or as a bailout strategy postoperatively due to hemodynamically unstable RVF were evaluated. Patients treated with a proactive RVAD strategy had lower Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) and a higher proportion of these required temporary mechanical circulatory support (MCS) preoperatively. Preoperative hemodynamic profiling showed a low pulmonary artery pulsatility index (PAPi) score of 1.8 ± 1.4 and 1.6 ± 0.94 (p = 0.42) in the bailout RVAD and proactive RVAD groups, respectively. Survival at 3, 6, and 12 months post-LVAD implantation was statistically significantly higher in patients who received a proactive RVAD. Thus, proactive RVAD implantation is associated with short- and medium-term survival benefits compared to a bailout strategy in RVF patients undergoing LVAD placement.

The Association of the Pulmonary Artery Pulsatility Index and Right Ventricular Function after Cardiac Surgery.

The pulmonary artery pulsatility index (PAPi) has been shown to correlate with right ventricular (RV) failure in patients with cardiac disease. However, the association of PAPi with right ventricular function following cardiac surgery is not yet established. PAPi and other hemodynamic variables were obtained postoperatively for 959 adult patients undergoing cardiac surgery. The association of post-bypass right ventricular function and other clinical factors to PAPi was evaluated using linear regression. A propensity-score matched cohort for PAPi ≥ 2.00 was used to assess the association of PAPi with postoperative outcomes. 156 patients (16.3%) had post-bypass right ventricular dysfunction defined by visualization on transesophageal echocardiography. There was no difference in postoperative PAPi based on right ventricular function (2.12 vs. 2.00, p=0.21). In our matched cohort (n = 636), PAPi < 2.00 was associated with increased incidence of acute kidney injury (23.0% vs 13.2%, p < 0.01) and ventilator time (6.0 hours vs 5.6 hours, p=0.04) but not with 30-day mortality or intensive care unit length of stay. In a general cohort of patients undergoing cardiac surgery, postoperative PAPi was not associated with postcardiopulmonary bypass right ventricular dysfunction. A postoperative PAPi < 2 may be associated with acute kidney injury.

Right heart reserve function assessed with fluid loading predicts late right heart failure after left ventricular assist device implantation.

BackgroundA left ventricular assist device (LVAD) is an effective therapeutic option for advanced heart failure. Late right heart failure (LRHF) is a complication after LVAD implantation associated with increasing morbidity and mortality; however, the assessment of right heart function, including right heart reserve function after LVAD implantation, has not been established. We focused on a fluid loading test with right heart catheterization (RHC) to evaluate right heart pre-load reserve function and investigate its impact on LRHF. MethodsPatients aged > 18 who received continuous-flow LVAD between November 2007 and December 2022 at our institution and underwent RHC with saline loading (10ml/kg for 15 min) 1 month after LVAD implantation were included. ResultsOverall, 31 LRHF or deaths (RHF group) have occurred in 149 patients. Comparing the RHF and non-RHF groups, pulmonary artery pulsatility index (PAPi) at rest (1.8±0.89 vs. 2.5±1.4, p=0.02) and right ventricular stroke work index (RVSWi) change ratio with saline loading (0.96±0.32 vs. 1.1±0.20, p=0.03) was significantly different. The PAPi at rest and RVSWi change ratio with saline loading were identified as the postoperative risks for LRHF or death. The cohort was divided into three groups based on whether the PAPi at rest and RVSWi change ratio were low. The event-free curve significantly differed between the three groups (p<0.001). ConclusionsHemodynamic assessment with saline loading can evaluate the right ventricular pre-load reserve function of patients with LVAD. The low RVSWi change with saline loading was a risk factor for LRHF following LVAD implantation.

Sex Disparities in Left Ventricular Assist Device Implantation: Delayed Presentation and Worse Right Heart Failure.

We explored whether women undergo continuous-flow left ventricular assist device (CF-LVAD) implantation in later stages of heart failure (HF) than men, evidenced by worse preoperative right HF (RHF). We also compared two propensity models with and without preoperative RHF to assess its effect on outcomes. INTERMACS was queried from July 2008 to December 2017. Propensity model 1 matched men and women on age ≥50 years, HF etiology, body surface area, INTERMACS class, comorbidities, device strategy, temporary mechanical circulatory support, and device type. Model 2 included these variables plus LV end-diastolic diameter, right atrial pressure/pulmonary capillary wedge pressure, pulmonary artery pulsatility index, and right ventricular ejection fraction. The primary outcome was all-cause mortality. Secondary outcomes comprise RHF, rehospitalization, renal dysfunction, stroke, and device malfunction. In model 1, characteristics were comparable between 3,195 women and 3,195 men, except women more often had preoperative RHF and postoperative right VAD support and had worse 1 year and overall survival. In model 2, after propensity matching for additional risk factors for preoperative RHF, 1,119 women and 1,119 men had comparable post-LVAD implant RVAD use and survival. These findings suggest that women present more often with biventricular failure and after implantation have higher RHF and mortality rates.

Pulmonary Artery Pulsatility Index Is Associated With Mechanical Circulatory Support Device Selection In Patients With ST-elevation MI Complicated By Cardiogenic Shock

Pulmonary Artery Pulsatility Index Is Associated With Mechanical Circulatory Support Device Selection In Patients With ST-elevation MI Complicated By Cardiogenic Shock

Prognostic Implication of Intestinal Wall Edema in Patients with Aortic Stenosis Receiving Trans-Catheter Aortic Valve Replacement.

A recently proposed mechanism, the intestinal-cardiovascular relationship, serves as a framework to elucidate the interplay between these two systems. In our investigation, we assessed the prognostic implications of colon wall thickness, a marker correlated with intestinal congestion and dysfunction, in patients diagnosed with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). Patients diagnosed with severe aortic stenosis who underwent TAVR at our institution during the period spanning 2015 to 2022 were retrospectively enrolled. As part of the institutional protocol, patients underwent abdominal computed tomography upon admission, preceding TAVR. Our analysis aimed to assess the influence of colon wall thickness on the occurrence of either all-cause mortality or readmission due to heart failure within a two-year period. A total of 345 patients were included. The median age was 85 (82, 88) years, and 99 patients were male. Baseline colon wall thickness was distributed widely, with a median value of 2.2 (2.0, 2.5) mm. Patients with thicker colon walls tended to have lower pulmonary artery pulsatility index values, indicating more impaired right ventricular function and more advanced malnutrition. A thicker colon wall was independently associated with 2-year death or heart failure readmission with a hazard ratio of 2.02 (95% confidence interval 1.01-14.07), adjusted for hemoglobin, age, and plasma B-type natriuretic peptide levels (p = 0.049), and significantly stratified the primary endpoint at a cutoff of 2.7 mm (25% versus 10%, p = 0.005). Our initial observation revealed that a thicker baseline colon wall correlated with increased rates of mid-term mortality and readmission due to heart failure subsequent to TAVR. Developing a comprehensive understanding of the underlying causality necessitates further in-depth investigations through subsequent studies.

Pulmonary artery pulsatility index predicts mechanical circulatory support following heart transplantation

Pulmonary artery pulsatility index predicts mechanical circulatory support following heart transplantation

Occult right ventricular dysfunction and right ventricular-vascular uncoupling in left ventricular assist device recipients

BackgroundCurrent assessments remain insensitive for detecting right heart failure post left ventricular assist device (LVAD). Sensitive pressure-volume loop assessments of right ventricle (RV) contractility may improve our appreciation of post-LVAD RV dysfunction. MethodsThirteen LVAD patients and 20 reference (non-LVAD) subjects underwent comparison of echocardiographic, right heart cath hemodynamic, and pressure-volume loop-derived assessments of RV contractility using end-systolic elastance (Ees), RV afterload by effective arterial elastance (Ea), and RV-pulmonary arterial (RV-PA) coupling (ratio of Ees/Ea). ResultsLVAD patients had lower RV Ees (0.20±0.08 vs. 0.30±0.15 mmHg/ml, p=0.01) and lower RV Ees/Ea (0.37±0.14 vs 1.20±0.54, p<0.001) versus reference subjects. Low RV Ees correlated with reduced RV septal strain, an indicator of septal contractility, in both the entire cohort (r=0.68, p=0.004) as well as the LVAD cohort itself (r=0.78, p=0.02). LVAD recipients with low RV Ees/Ea (below the median value) demonstrated more clinical heart failure (71% vs 17%, p=0.048), driven by an inability to augment RV Ees (0.22±0.11 vs 0.19±0.02 mmHg/ml, p=0.95) to accommodate higher RV Ea (0.82±0.38 vs 0.39±0.08 mmHg/ml, p=0.002). Pulmonary artery pulsatility index (PAPi) best identified low baseline RV Ees/Ea (≤0.35) in LVAD patients (AUC=0.80); during ramp study, change in PAPi also correlated with change in RV Ees/Ea (r=0.58, p=0.04). ConclusionsLVAD patients demonstrate occult intrinsic RV dysfunction. In the setting of excess RV afterload, LVAD patients lack the RV contractile reserve to maintain ventriculo-vascular coupling. Depression in RV contractility may be related to LVAD LV unloading which reduces septal contractility.

Hemodynamic profile of obesity in cardiogenic shock

Abstract Background There is a growing understanding that cardiogenic shock (CS) is a hemodynamically heterogenous condition. Hemodynamic variants within this entity are not well studied but, if recognize, may help to optimize therapies. Purpose We explored hemodynamics in patients with CS based on their body mass index (BMI). Methods The Cardiogenic Shock Working Group (CSWG) registry includes patients with CS, regardless of etiology, from 17 clinical sites across the USA. We stratified the participants into BMI quartiles (BMI≤24.4 kg/m2, 24.433.1 kg/m2), and studied the hemodynamic variables in CS depending on body mass index (BMI). Results The total cohort consisted of 3,492 patients admitted with CS (mean age 62.1±14 years, 69% male), including 2,024 (58.0%) of CS related to advanced heart failure (HF-CS) and 969 (27.8%) acute myocardial infarction (AMI) related CS. IN HF-CS, more obese patients in higher BMI quartile had larger left ventricle, higher ejection fraction, and greater cardiac output (Table). Their systolic blood pressure was higher, and pulmonary artery pressure was lower than in lower BMI quartiles. Their pulmonary artery pulsatility index decreased from 2.2±1.4 in the second quartile to 1.6±1.3 in the forth (highest) quartile. Mortality in creased with the BMI increase, from 23.3% in the lowest BMI quartile to 30% in the highest BMI quartile, p=0.0128. In AMI-CS, there was no distinct hemodynamic profile related to obesity. Conclusions In cardiogenic shock related to heart failure, unlike in AMI-related cardiogenic shock, there is a distinct hemodynamic pattern of obesity, consistent with larger left ventricle, higher ejection fraction, higher cardiac output and systemic pressure, higher right atrial pressure, and lower pulmonary artery pulsatility index. In this subset, obesity is associated with the highest in-hospital mortality.

Echocardiographic assessment of right heart function in the presence of TR: Is right heart strain the answer?

Abstract Background Right heart function is challenging to assess with echocardiography due to the complex anatomy and load dependence. To complicate the assessment, significant tricuspid regurgitation flatters the right ventricle. These complexities have led to the need for other modalities and invasive measures of RV function to complement clinical decision-making and risk profiling. Speckle tracking can assess subtle anomalies and appears to be promising for right heart assessment. We assessed right heart strain against classic echocardiographic measures of RV function (TAPSE, RVS’ and fractional area change (FAC)) and invasive measures of RV function (right ventricular stroke work index (RVSWI) and Pulmonary Artery Pulsatility index (PAPi)), in patients with severe TR and without, to see strain reclassifies the assessment of RV function from "normal" to impaired and to assess the prognostic value of right heart strain. Methods A single-centre retrospective analysis of data from 262 consecutive patients (age 74 ±11.2 years old; male 53%) with both right heart catheterization (RHC) and TTE. Clinical data was gathered from patient files, and outcomes of heart failure hospitalisation or death were recorded. Echocardiographic evaluation was completed on commercially available GE ultrasounds and data was stored on a dedicated workstation for offline analysis (EchoPAC version 112.99). Statistical analysis was performed using SAS 15.1. Results Over a median follow up of 34 ±15 months 99 events occurred. 53% of patients had severe TR. RV free wall strain reclassified RV function as impaired in 73% of patients with "normal" RV function as determined by FAC (p value 0.005), and in 71% of patients with normal RVS’ (p value 0.03) with severe TR. Using invasive measures, RVSWI reclassified RV function as abnormal when compared to TAPSE in 53% of patients (p value 0.02). PAPi reclassified RV function as impaired compared to TAPSE in 53% of patients (p value of 0.009). In patients with TR 3+, right atrial strain reclassified presence of right heart dysfunction in 91% of patients compared to TAPSE &amp;gt;17 (p value 0.01) and in 95% of patients compared to RVS’ (p value 0.004). In patients with moderate or less TR, RV strain reclassified 66% as having RV dysfunction with normal FAC (p value 0.003) and reclassified 61% of patients with RV dysfunction in patients with a normal RVS (p value 0.03). Invasive measures did not reclassify RV function assessment in patients with moderate or less TR. In patients with and without TR, RV strain and invasive measures were in accordance. Abnormal RV strain (&amp;gt;-23%) was associated with an adverse prognosis HR 3.63 (1.43 – 9.22). Conclusion In the presence of severe TR, right heart strain helps to reclassify RV function, comparable to invasive measures. Abnormal right heart strain is strongly associated with prognosis and its utility should be confirmed in prospective studies.

Abstract 14220: Establishing Dosing Parameters for the Use of Maternal Hyperoxygenation to Affect Fetal Cardiovascular Physiology

Introduction: Maternal hyperoxygenation (MH) has been used to aid in the prognosis of fetal abnormalities. No data exist on the dose-response relationship or washout time of short-term MH administration related to fetal cardiovascular effects. Hypothesis: There may be a dose-response to MH with effect on pulmonary vascular resistance as measured by pulmonary artery pulsatility index (PAPI) and combined cardiac output (CCO). Aims: The aims of this study were: to determine the appropriate MH dose to obtain a physiologic response (i.e. decrease in PAPI), to evaluate the change in CCO, and to identify the washout period. Methods: Expectant mothers with normal fetal echocardiograms were prospectively recruited from 3/2019 to 6/2023. A research echocardiogram with MH was performed after 31 weeks gestation. Fetal cardiac abnormalities and other comorbidities were excluded. Patients were randomly assigned to either; 2 liters (L) nasal cannula (NC), 4L NC or 8L facemask, all at 100% Fi0 2 . Measurements of PAPI and CCO were performed at baseline, at 1 minute (min) and at 5 min intervals to 20 mins. The same time points were repeated off oxygen. Differences in PAPI were compared between doses and between time points using a mixed effects model. Results: We recruited 29 patients at a mean gestational age of 32.9 (± 0.9 weeks). On oxygen, there was a statistically significant decrease in the PAPI at 8L (-0.18 per min, 95% CI -0.32, -0.05), with the largest decrease occurring between baseline and 5 mins, and PAPI stabilizing after 10 mins (figure). During the washout period, starting at 1 min off oxygen, PAPI values normalized, with no statistically significant changes with 2L, 4L or 8L compared to baseline. No effect on CCO was seen from MH administration. Conclusions: An oxygen dose of 8L is needed for an appropriate PAPI response, with the largest effect occurring before 10 mins. After oxygen is removed, PAPI values normalize by one min. Changes in CCO were not seen with MH in this normal population.

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

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

Obesity Modifies Clinical Outcomes of Right Ventricular Dysfunction.

Right ventricular (RV) dysfunction is associated with increased mortality across a spectrum of cardiovascular diseases. The role of obesity in RV dysfunction and adverse outcomes is unclear. We examined patients undergoing right heart catheterization between 2005 and 2016 in a hospital-based cohort. Linear regression was used to examine the association of obesity with hemodynamic indices of RV dysfunction (pulmonary artery pulsatility index, right atrial pressure:pulmonary capillary wedge pressure ratio, RV stroke work index). Cox models were used to examine the association of RV function measures with clinical outcomes. Among 8285 patients (mean age, 63 years; 40% women), higher body mass index was associated with worse indices of RV dysfunction, including lower pulmonary artery pulsatility index (β, -0.23; SE, 0.01; P<0.001), higher right atrium:pulmonary capillary wedge pressure ratio (β, 0.25; SE, 0.01; P<0.001), and lower RV stroke work index (β, -0.05; SE, 0.01; P<0.001). Over median of 7.3 years of follow-up, we observed 3006 mortality and 2004 heart failure hospitalization events. RV dysfunction was associated with a greater risk of mortality (eg, pulmonary artery pulsatility index:hazard ratio, 1.11 per 1-SD increase [95% CI, 1.04-1.18]), with similar associations with risk of heart failure hospitalization. Body mass index modified the effect of RV dysfunction on all-cause mortality (Pinteraction≤0.005 for PAPi and RA:PCWP ratio), such that the effect of RV dysfunction was more pronounced at higher body mass index. Patients with obesity had worse hemodynamic measured indices of RV function across a broad hospital-based sample. While RV dysfunction was associated with worse clinical outcomes including mortality and heart failure hospitalization, this association was especially pronounced among individuals with higher body mass index.

Postoperative Pulmonary Artery Pulsatility Index Improves Prediction of Right Ventricular Failure After Left Ventricular Assist Device Implantation

This study evaluated whether the postoperative pulmonary artery pulsatility index (PAPi) is associated with postoperative right ventricular dysfunction after durable left ventricular assist device (LVAD) implantation. Single-center retrospective observational cohort study. The University of Kansas Medical Center, a tertiary-care academic medical center. Sixty-seven adult patients who underwent durable LVAD implantation between 2017 and 2019. All patients underwent open cardiac surgery with cardiopulmonary bypass under general anesthesia with pulmonary artery catheter insertion. Clinical and hemodynamic data were collected before and after surgery. The Michigan right ventricular failure risk score and the European Registry for Patients with Mechanical Circulatory Support score were calculated for each patient. The primary outcome was right ventricular failure, defined as a composite of right ventricular mechanical circulatory support, inhaled pulmonary vasodilator therapy for 48 hours or greater, or inotrope use for 14 days or greater or at discharge. Thirty percent of this cohort (n=20) met the primary outcome. Preoperative transpulmonary gradient (odds ratio [OR] 1.15, 95% CI 1.02-1.28), cardiac index (OR 0.83, 95% CI 0.71-0.98), and postoperative PAPi (OR 0.85, 95% CI 0.75-0.97) were the only hemodynamic variables associated with the primary outcome. The addition of postoperative PAPi was associated with improvement in the predictive model performance of the Michigan score (area under the receiver operating characteristic curve 0.73 v 0.56, p=0.03). An optimal cutoff point for postoperative PAPi of 1.56 was found. The inclusion of postoperative PAPi offers more robust predictive power for right ventricular failure in patients undergoing durable LVAD implantation, compared with the use of existing risk scores alone.

Persistence of pulmonary hypertension in patients undergoing ventricular assist devices and orthotopic heart transplantation.

Pulmonary hypertension (PH) is common in advanced heart failure and often improves quickly after left ventricular assist device (VAD) implantation or orthotopic heart transplantation (OHT), but long-term effects and outcomes are not well-described. This study evaluated PH persistence after VAD as destination therapy (VAD-DT), bridge to transplant (VAD-OHT), or OHT-alone. The study constituted a retrospective review of patients who underwent VAD-DT (n = 164), VAD-OHT (n = 111), or OHT-alone (n = 138) at a single tertiary-care center. Right heart catheterization (RHC) data was collected pre-, post-intervention (VAD and/or OHT), and 1-year from final intervention (latest-RHC) to evaluate the longitudinal hemodynamic course of right ventricularfunction and pulmonary vasculature. PH (GroupII and Group I) definitions were adapted from expert guidelines. All groups showed significant improvements in mean pulmonary artery pressure (mPAP), pulmonary artery wedge pressure (PAWP), cardiac output,and pulmonary vascular resistance (PVR) at each RHC with greatest improvement at post-intervention RHC (post-VAD or post-OHT). PH was reduced from 98% to 26% in VAD-OHT, 92%-49% in VAD-DT, and 76%-28% in OHT-alone from preintervention to latest-RHC. At latest-RHC mPAP remained elevated in all groups despite normalization of PAWP and PVR. VAD-supported patients exhibited suppressed pulmonary artery pulsatility index (PaPi < 3.7) with improvement only posttransplant at latest-RHC. Posttransplant patients with PH at latest-RHC (n = 60) exhibited lower survival (HR: 2.1 [95%CI: 1.3-3.4], p < 0.001). Despite an overall significant improvement in pulmonary pressures and PH proportion, a notable subset of patients exhibited PH post-intervention. Post-intervention PH was associated with lower posttransplant survival.