Pulmonary Artery Pulse Pressure Research Articles

Efficacy and safety of the Aria pulmonary endovascular device in pulmonary hypertension

Abstract Background and aims A common feature of various forms of pulmonary hypertension (PH) is progressive decline of pulmonary arterial compliance (CPA), which correlates with reduced survival. In this acute study, we evaluated feasibility, safety and hemodynamic performance of the Aria pulmonary endovascular device in patients with PH associated with left heart disease (PH-LHD) and chronic lung disease (PH-CLD). Methods 8 patients with PH-LHD and 10 patients with PH-CLD were included in this study. The device was placed in the main pulmonary artery via the right femoral vein and was connected by a catheter to a gas-filled reservoir outside the body. During systole, gas shifts from the balloon to the reservoir, leading to deflation of the balloon. In diastole, the gas returns from the reservoir to the balloon, leading to balloon inflation and enhancing diastolic blood flow to the distal pulmonary capillary bed. Hemodynamics were assessed at baseline, and again with device off, device on and device off. The primary safety endpoint was the incidence of serious adverse events through 30 days after the procedure. Results No complications or investigational device-related serious adverse events occurred. Device activation in PH-LHD and PH-CLD patients decreased pulmonary arterial pulse pressure by 5.6±4.2mmHg (-12%; p=0.003) and 4.2±2.2mmHg (-11%; p<0.001), increased CPA by 0.4±0.2mL/mmHg (+23%; p=0.004) and 0.4±0.3mL/mmHg (+25%; p=0.001), and increased RV-PV coupling by 0.24±0.18 (+40%; p=0.012) and 0.11±0.07 (+21%; p=0.001), respectively. Conclusions Temporary implantation of the Aria endovascular device was feasible and safe. Device activation resulted in acute improvement of CPA and RV-PV coupling.Figure

The Right Ventricular-Arterial Compliance Index: A Novel Hemodynamic Marker to Predict Right Heart Failure Following Left Ventricular Assist Device.

The development of right heart failure (RHF) in patients with advanced heart failure following left ventricular assist device (LVAD) implantation remains difficult to predict. We proposed a novel composite hemodynamic index-the right ventricular-arterial compliance index (RVACi), derived from pulmonary artery pulse pressure (PAPP), ejection time (ET), heart rate (HR), and cardiac output (CO), with and expressed as mm Hg·s/L. We then conducted a retrospective, single-center analysis comparing the predictive value of RVACi for the development of RHF or unplanned right ventricular (RV) mechanical circulatory support following LVAD implantation against existing hemodynamic indices. One hundred patients were enrolled after screening 232 patients over a 10 year period, with 74 patients having complete hemodynamic data for RVACi calculation. There was good correlation between pulmonary arterial capacitance (R² = 0.48) and pulmonary vascular resistance (R² = 0.63) with RVACi, but not RV stroke work index or pulmonary artery pulsatility index. Reduced baseline RVACi (52 ± 23 vs. 92 ± 55 mm Hg·s/L; p = 0.02) was the strongest hemodynamic predictor of unplanned RV mechanical circulatory support requirement in patients following LVAD insertion. Composite pulsatile hemodynamic indices including RVACi may provide additional insight over existing hemodynamic indices for the prediction of RHF and need for RV mechanical circulatory support.

Pulmonary Artery Pressures and Mortality During Venoarterial ECMO: An ELSO Registry Analysis.

Systemic hemodynamics and specific ventilator settings have been shown to predict survival during venoarterial extracorporeal membrane oxygenation (ECMO). How the right heart (the right ventricle and pulmonary artery) affect survival during venoarterial ECMO is unknown. We aimed to identify the relationship between right heart function with mortality and the duration of ECMO support. Cardiac ECMO runs in adults from the Extracorporeal Life Support Organization Registry between 2010 and 2022 were queried. Right heart function was quantified via pulmonary artery pulse pressure (PAPP) for pre-ECMO and on-ECMO periods. A multivariable model was adjusted for modified Society for Cardiovascular Angiography and Interventions stage, age, sex, and concurrent clinical data (ie, pulmonary vasodilators and systemic pulse pressure). The primary outcome was in-hospital mortality. A total of 4442 ECMO runs met inclusion criteria and had documentation of hemodynamic and illness severity variables. The mortality rate was 55%; nonsurvivors were more likely to be older, have a worse Society for Cardiovascular Angiography and Interventions stage, and have longer pre-ECMO endotracheal intubation times (P<0.05 for all) than survivors. Increasing PAPP from pre-ECMO to on-ECMO time (ΔPAPP) was associated with reduced mortality per 2 mm Hg increase (odds ratio, 0.98 [95% CI, 0.97-0.99]; P=0.002). Higher on-ECMO PAPP was associated with mortality reduction across quartiles with the greatest reduction in the third PAPP quartile (odds ratio, 0.75 [95% CI, 0.63-0.90]; P=0.002) and longer time on ECMO per 10 mm Hg (beta, 15 [95% CI, 7.7-21]; P<0.001). Early on-ECMO right heart function and interval improvement from pre-ECMO values were associated with mortality reduction during cardiac ECMO. Incorporation of right heart metrics into risk prediction models should be considered.

Efficacy and safety of the Aria pulmonary endovascular device in pulmonary hypertension.

A common feature of various forms of pulmonary hypertension (PH) is progressive decline of pulmonary arterial compliance (CPA), which correlates with reduced survival. In this acute study, we evaluated feasibility, safety and haemodynamic performance of the Aria pulmonary endovascular device in patients with PH associated with left heart disease (PH-LHD) and chronic lung disease (PH-CLD). Eight patients with PH-LHD and 10 patients with PH-CLD were included in this study. The device was placed in the main pulmonary artery via the right femoral vein and was connected by a catheter to a gas-filled reservoir outside the body. During systole, gas shifts from the balloon to the reservoir, leading to deflation of the balloon. In diastole, the gas returns from the reservoir to the balloon, leading to balloon inflation and enhancing diastolic blood flow to the distal pulmonary capillary bed. Haemodynamics were assessed at baseline, and again with device off, device on and device off. The primary safety endpoint was the incidence of serious adverse events through 30 days after the procedure. No complications or investigational device-related serious adverse events occurred. Device activation in PH-LHD and PH-CLD patients decreased pulmonary arterial pulse pressure by 5.6 ± 4.2 mmHg (-12%; p = 0.003) and 4.2 ± 2.2 mmHg (-11%; p < 0.001), increased CPA by 0.4 ± 0.2 ml/mmHg (+23%; p = 0.004) and 0.4 ± 0.3 ml/mmHg (+25%; p = 0.001), and increased right ventricular-to-pulmonary vascular (RV-PV) coupling by 0.24 ± 0.18 (+40%; p = 0.012) and 0.11 ± 0.07 (+21%; p = 0.001), respectively. Temporary implantation of the Aria endovascular device was feasible and safe. Device activation resulted in acute improvement of CPA and RV-PV coupling.

Abstract 17077: Pulmonary Artery Compliance: Resistance is (Not?) Futile

Introduction: Small studies have suggested that low pulmonary artery compliance (PAC) — quantified by dividing stroke volume by the pulmonary artery pulse pressure — is an early indicator of pulmonary hypertension (PH). However, the relationship between PAC and mortality, and the clinical utility of PAC in all-comers remains in question. Research Questions: How does the risk of mortality in all-comers change with PAC? Does the PAC provide prognostic information over established hemodynamics (i.e., pulmonary vascular resistance [PVR], mean pulmonary artery pressure [mPAP])? Methods: Analysis was conducted on adult patients undergoing right heart catheterization at the University of Pittsburgh Medical Center Presbyterian Hospital 2005 - 2020, excluding those with prior heart/lung transplant, ventricular assist devices, and missing/non-physiologic hemodynamics. A cubic spline model was constructed to describe the relationship between PAC and the predicted risk of death. Multivariable Cox models for mortality were compared by plotting the distribution of 100 Harrell’s Concordance indices derived from Monte Carlo cross-validation. The fully-adjusted model was compared to models with one variable removed, thereby assessing the relative contribution of the withdrawn variable to model performance. Results: The cohort included 12,948 patients (median age 64, 55% male, 84% White); 29% had combined post- and pre-capillary PH, 24% pre-capillary PH, and 17% isolated post-capillary PH. The predicted risk of mortality 1) increased linearly as PAC decreased below 3 mL/mmHg, 2) tapered for PACs between 3 - 5 mL/mmHg, and 3) remained constant at PACs above 5 mL/mmHg (Figure 1). Removal of PAC from Cox models predicting mortality did not substantially affect model performance (Figure 2). Conclusions: A PAC below 5 mL/mmHg, and especially below 3 mL/mmHg, is associated with increased mortality; however, PAC does not improve prognostic information over the mPAP and PVR.

Hemodynamic and Management Perspectives in Heart Failure Patients

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

Clinical significance of lung cross-sectional area measured by computed tomography in chronic thromboembolic pulmonary hypertension: The correlation with pulmonary hemodynamics and the limitations.

The percentage cross-sectional area of the lung under five (%CSA<5) is the percentage of pulmonary vessels with <5 mm2 area relative to the total lung area on computed tomography (CT). The extent that %CSA<5 is related to pulmonary hemodynamics in patients with chronic thromboembolic pulmonary hypertension (CTEPH) is unclear, as is the effect of pulmonary endarterectomy (PEA) on %CSA<5. Therefore, we aimed to evaluate the clinical significance of %CSA<5 in patients with CTEPH. We studied 98 patients (64 females, mean age 62.5 ± 11.9 years), who underwent CT with %CSA<5 measurement and right heart catheterization (RHC). Patients were classified into groups based on eligibility for PEA. We compared the %CSA<5 with pulmonary hemodynamics measured by RHC in various groups. In 38 patients who underwent PEA, the relationship between %CSA<5 and pulmonary hemodynamics was also evaluated before and after PEA. Significant correlations between %CSA<5 and pulmonary vascular resistance, and compliance, and pulmonary artery pulse pressure were observed in all patients. Pulmonary hemodynamics in the patients who underwent or were eligible for PEA showed a significant correlation with %CSA<5. Additionally, %CSA<5 was significantly lower in the postoperative than in the preoperative group. There was no correlation between changes in %CSA<5 and pulmonary hemodynamics before and after PEA. Furthermore, %CSA<5 did not correlate significantly with prognosis. %CSA<5 may reflect pulmonary hemodynamics in CTEPH with central thrombosis. Furthermore, %CSA<5 was reduced by PEA postoperatively. However, %CSA<5 is not a prognostic indicator, its clinical usefulness in CTEPH patients is limited, and further validation is required.

Association Between the Pulmonary Artery Pulsatility Index and Prognosis in Pulmonary Arterial Hypertension: A Multicentre Study

BackgroundRisk stratification is fundamental in the management of pulmonary arterial hypertension (PAH). Pulmonary artery pulsatility index (PAPi), defined as pulmonary arterial pulse pressure divided by right atrial pressure (RAP), is a hemodynamic index shown to predict acute right ventricular (RV) dysfunction in several settings. Our objective was to test the prognostic utility of PAPi in a diverse multicentre cohort of patients with PAH. MethodsA multicentre retrospective cohort study of consecutive adult patients with a new diagnosis of PAH on right heart catheterization between January 2016 and December 2020 was undertaken across 4 major centres in Canada. Hemodynamic data, clinical data, and outcomes were collected. The association of PAPi and other hemodynamic variables with mortality was assessed by receiver-operating characteristic curves and Cox proportional hazards modeling. ResultsWe identified 590 patients with a mean age of 61.4 ± 15.5 years, with 66.3% being female. A low PAPi (defined as < 5.3) was associated with higher mortality at 1 year: 10.2% vs 5.2% (P = 0.02). In a multivariable model including age, sex, body mass index, and functional class, a low PAPi was associated with mortality at 1 year (area under the curveof 0.64 (95% confidence interval 0.55-0.74). However, high RAP (> 8 mm Hg) was similarly predictive of mortality, with an area under the curve of 0.65. ConclusionPAPi was associated with mortality in a large incident PAH cohort. However, the discriminative value of PAPi was not higher than that of RAP alone.

Pulmonary artery compliance in different forms of pulmonary hypertension

ObjectivePulmonary artery compliance (PAC), estimated as stroke volume (SV) divided by pulmonary artery pulse pressure (PP), may be a predictor of survival in pulmonary arterial hypertension (PAH). Resistance–compliance (RC) time,...

Proportional pulmonary pulse pressure: A new index to assess response to veno-arterial extracorporeal membrane oxygenation.

Based on theoretical physiology, the ratio of pulmonary artery pulse pressure to mean pulmonary pressure (PP-MPAP), termed proportional pulmonary pulse pressure, provides a measure of coupling between the right ventricle and the pulmonary circulation. This study tested the hypothesis that lower PP-MPAP ratio was associated with left ventricular (LV) distension in patients with cardiogenic shock who underwent extracorporeal life support (ECLS). This is a retrospective observational single-centre study of 22 patients with cardiogenic shock who underwent ECLS as the primary support modality without and with LV distension and Impella unloading. The relationship between post-support PP-MPAP and 12-hour lactate clearance was also assessed. Of the 22 patients: 10 patients underwent additional Impella unloading due to LV distension (Group 1) and 12 patients on ECLS only without LV distension (Group 2). As predicted by the theoretical model, PP-MPAP on ECLS dropped in Group 1 (pre-Impella) from 0.473 ± 0.067 to 0.372 ± 0.087, p < 0.001; but increased in Group 2 patients without LV distension (0.518 ± 0.070 to 0.549 ± 0.072, p = 0.002). Impella support in Group 1 increased PP-MPAP (0.372 ± 0.087 to 0.615 ± 0.094, p < 0.001). On multiple regression analysis, post-support PP-MPAP was significantly associated with 12-hour lactate clearance. Changes in PP-MPAP is associated hemodynamic response to ECLS and 12-hour lactate clearance. This simple parameter may guide therapeutic optimization in cardiogenic shock and ECLS.

Abstract 9770: Pulmonary Artery Pulsatility Index After Pediatric Heart Transplant

Background: The Pulmonary Artery Pulsatility index (PAPi) is calculated by pulmonary artery pulse pressure divided by central venous pressure and is directly proportional to right ventricular contractility and stroke volume, and indirectly proportional to pulmonary artery afterload and filling pressures. We hypothesize that PAPi will correlate with known hemodynamic parameters and predict acute kidney injury (AKI) post heart transplant (HTx). Methods: Medical records and hemodynamic data were retrospectively reviewed for patients ≤18 years old undergoing HTx at a single center between 1/2007-9/2021. Subgroups by HTx indication were myopathy or congenital heart disease (CHD). PAPi was calculated at catheterizations up to 5 years post HTx, with normal ≥ 2.0. Results: Fifty-three children underwent HTx in myopathy (n=27) or CHD (n=26) subgroups. Mean age at HTx was 5.95 ± 6.13 years (range: 58 days-18 years) with no difference between myopathy and CHD subgroups. PAPi correlated with known cardiovascular measures including thermodilution cardiac index (TDCI) and right ventricular end-diastolic pressure (RVEDp), confirming PAPi as a predictor of cardiovascular hemodynamics (Table 1) . At 1 year, children with AKI (n=11/49) had a lower PAPi compared to those with no AKI (1.55 ± 0.43 vs. 2.50 ± 1.16; p=0.004). Comparing initial to 5-year PAPi, the myopathy subgroup (n=18) remained similar (2.10 ± 0.99 vs. 2.12 ± 1.55; p=0.48) and the CHD subgroup (n=12) declined significantly (2.12 ± 0.91 vs. 1.67 ± 0.55; p=0.04). Conclusions: The PAPi in children post HTx correlates with known hemodynamic parameters. PAPi serves as a marker predicting renal dysfunction 1 year post HTx. Between HTx and 5 years post HTx, PAPi did not improve for the myopathy subgroup and declined significantly for the CHD subgroup suggesting that incorporating PAPi into existing risk models may substantially improve earlier implementation for advanced therapies and thus improve clinical outcomes.

Comprehensive assessments of pulmonary circulation in children with pulmonary hypertension associated with congenital heart disease.

Pulmonary hypertension associated with congenital heart disease (CHD-PH) encompasses different conditions confounded by the left-to-right shunt, left heart obstruction, ventricular dysfunction, hypoxia due to airway obstruction, dysplasia/hypoplasia of the pulmonary vasculature, pulmonary vascular obstructive disease, and genetic variations of vasoactive mediators. Pulmonary input impedance consists of the pulmonary vascular resistance (Rp) and capacitance (Cp). Rp is calculated as the transpulmonary pressure divided by the pulmonary cardiac output, whereas Cp is calculated as the pulmonary stroke volume divided by the pulmonary arterial pulse pressure. The plots of Rp and Cp demonstrate a unique hyperbolic relationship, namely, the resistor–capacitor coupling curve, which represents the pulmonary vascular condition. The product of Rp and Cp is the exponential pressure decay, which refers to the time constant. Alterations in Cp are more considerable in CHD patients at an early stage of developing pulmonary hypertension or with excessive pulmonary blood flow due to a left-to-right shunt. The importance of Cp has gained attention because recent reports have shown that low Cp potentially reflects poor prognosis in patients with CHD-PH and idiopathic pulmonary hypertension. It is also known that Cp levels decrease in specific populations, such as preterm infants and trisomy 21. Therefore, both Rp and Cp should be individually evaluated in the management of children with CHD-PH who have different disease conditions.

Low Pulmonary Artery Pulsatility Index by Echocardiography Is Associated With Increased Mortality in Pulmonary Hypertension

Pulmonary hypertension (PH) is a progressive pulmonary vascular disorder with elevated mortality risk. The pulmonary artery (PA) pulsatility index (PAPi) based on invasively acquired parameters has emerged as a hemodynamic risk predictor. Whether noninvasively derived PAPi (PA pulse pressure divided by right atrial pressure) is valuable is unclear. Consecutive patients undergoing transthoracic echocardiography for known or suspected PH were included with conventional echocardiographic measures of PA systolic, PA diastolic, and estimated right atrial pressures. In those patients with PH (mean PA pressure > 20mm Hg), PAPi was divided into 3 groups: <1.5, 1.5 to 3, and >3. Mortality was assessed over 5years. Of 1,045 patients enrolled, 64% had PH. Patients with the lowest PAPi had higher N-terminal-pro hormone B-type natriuretic peptide levels, larger right ventricles (RVs), worse RV systolic function, and greater degrees of tricuspid regurgitation. In patients with PH, PAPi was inversely proportional to the risk of death, with PAPi <3 associated with a 1.96-fold increased risk of death (95% CI, 1.45-2.64, P<.0001). At multivariate analysis, RV longitudinal systolic strain (hazard ratio [HR]=1.45, 1.24-1.71; P<.0001), PAPi <3 (HR=1.76, 1.31-2.37; P=.0002), and the presence of a pericardial effusion (HR=1.64, 1.20-2.26 P=.003) were independently associated with increased mortality. In age- and sex-adjusted models, PAPi was incremental to PA compliance. In patients with PH, low PAPi derived noninvasively by transthoracic echocardiography is associated with markers of right heart failure, RV dysfunction, and worse survival. PAPi could be incorporated into the conventional echo parameters reported in patients with PH and may be a useful predictor of outcome.

Prognostic Significance of Pulmonary Hypertension in Patients with Hypertrophic Obstructive Cardiomyopathy Undergoing Septal Myectomy

<h3>Purpose</h3> Patients with hypertrophic obstructive cardiomyopathy (HOCM) often have concomitant pulmonary hypertension (PH). We hypothesize that concomitant PH is associated with increased risk for short-term adverse outcomes after septal myectomy. <h3>Methods</h3> We retrospectively evaluated 758 patients who underwent septal myectomy for treatment of HOCM between 2010 and 2020 at our institution. There were 396 total patients who had pre-op right heart catheterization (RHC). After exclusion of patients without complete RHC data, there were 281 patients included in the final analysis. Adverse events (AE) were defined by a composite endpoint which included post-operative stroke, TIA, MI, cardiac arrest, prolonged ventilation, reintubation, pneumonia, multi-organ failure, and mortality. Comparison was made between patients with and without AE. Categorical variables were compared with chi-square or Fisher's exact test where appropriate. Continuous variables were compared with one-way ANOVA. Significance was defined as p<0.05. <h3>Results</h3> The overall incidence of AE in the study population was low (n=17, 6%). Prolonged ventilation was the most common AE (n=9, 3.2%). Patients with AE were older in age (64 vs 57, p=.015) and were more likely to have chronic lung disease (OR 4.42, 95% CI 1.5-12.8; p=.003). On pre-op RHC, patients with AE had significantly greater pulmonary artery (PA) systolic pressure (47 vs 38, p=.010), mean PA pressure (32 vs 26, p=.017), PA pulsatility index (5.9 vs 3.8, p=.004), PA pulse pressure (28 vs 22, p=.009), transpulmonary gradient (13 vs 10, p=.02), and pulmonary vascular resistance (3.4 vs 2.0, p <.001). <h3>Conclusion</h3> Increased severity of concomitant PH in patients with HOCM undergoing septal myectomy surgery is associated with increased risk for short-term adverse outcomes. Preoperative pulmonary artery pressure is of prognostic predictive value. Screening for and treating PH before septal myectomy may reduce the risk of complications.

Proportional Pulmonary Artery Pulse Pressure Identifies Hemodynamic Response to Impella: Conceptualization and Clinical Validation

<h3>Purpose</h3> <b>1.</b> To describe the physiologic determinants of proportional pulmonary artery pulse pressure (= ratio of pulmonary pulse pressure to mean pulmonary pressure, PP-MPAP) <b>2.</b> clinical application of PP-MPAP in patients with cardiogenic shock (CS) who underwent left-sided Impella support. <h3>Methods</h3> <b>1.</b> Using established physiologic concepts and prior data, the change in PP-MPAP a was modelled over a range of hemodynamic parameters (Matlab, Mathworks). <b>2.</b> 16 patients with CS who underwent Impella support were included. Hemodynamic responder was defined as increase in cardiac power output index (CPOi)>20%. Clinical endpoint was lactate clearance 12 hours after Impella support. <h3>Results</h3> <b>1.</b> The relationship between stroke volume at different heart rates and PAWP was modelled [FIGURE]. <b>2.</b> 16 patients were included (age: 50±7 years; 13/16 males; 9/16 acute MI; 7/16 cardiomyopathy; LVEF: 17±4%). Impella reduced PAWP in all patients, but only 6/16 patients were responders. As predicted by the model, PP-MPAP increased in responders but dropped in non-responders. The increase in PP-MPAP correlated with increase in CPOi. The 10 non-responders were escalated to Ecpella (3(2-5)hours post-Impella), which increased PP-MPAP [TABLE]. 12-hour lactate clearance was greater in responders despite escalation to Ecpella in non-responders. Post-support PP-MPAP and the change in PP-MPAP were significantly associated with 12-hour lactate clearance. <h3>Conclusion</h3> PP-MPAP has a predictable relationship with stroke volume, and can identify hemodynamic responders to Impella, who had higher 12-hour lactate clearance.

A Novel Hemodynamic Index of Post-operative Right Heart Dysfunction Predicts Mortality in Cardiac Surgical Patients.

This study aimed to investigate whether mortality following cardiac surgery was associated with the pulmonary artery pulsatility index (PAPi): pulmonary artery pulse pressure divided by central venous pressure (CVP), and a novel index: mean pulmonary artery pressure (mPAP) minus CVP. This retrospective analysis investigated all cardiac surgery patients in the Society of Thoracic Surgeons registry at a single academic medical center from January 2017 through March 2020 (n = 1510). The primary and secondary outcomes were mortality at 1 year and serum creatinine increase during index surgical admission, respectively. CVP, mPAP, PAPi, mPAP-CVP gradient, mean arterial pressure (MAP), and cardiac index (CI) were sampled continually from invasive hemodynamic monitors post-operatively. Associations with mortality were tested with univariate and multivariate analyses. The relationship with serum creatinine was investigated with Pearson's correlation at alpha = .05. One-year mortality was observed in 44/1200 patients (3.7%). On univariate analysis, mortality was associated with minimums for mPAP, MAP, and CI and maximums for CVP, mPAP, PAPi, mPAP-CVP gradient, and CI (all P < .10). Model selection revealed that the only independently predictive parameters were minimum MAP (AOR = .880 [.819-.944]), maximum mPAP-CVP gradient (AOR = 1.082 [1.031-1.133]), and maximum CI (AOR = 1.421 [.928-2.068]), with model c-statistic = .770. A maximum mPAP-CVP gradient >20.5 predicted mortality with 54.5% sensitivity and 79.30% specificity, maintaining significance on survival analysis (P < .001). Peak increase in serum creatinine from baseline demonstrated a weak association with all parameters (max |r| = .33). Mortality was not predicted by the post-operative PAPi; rather, it was independently predicted by the mPAP-CVP gradient, MAP, and CI.

Right ventricular and pulmonary artery pulse pressure variation and systolic pressure variation for the prediction of fluid responsiveness: an interventional study in coronary artery bypass surgery patients.

Predicting fluid responsiveness is essential when treating surgical or critically ill patients. When using a pulmonary artery catheter, pulse pressure variation and systolic pressure variation can be calculated from right ventricular and pulmonary artery pressure waveforms. We conducted a prospective interventional study investigating the ability of right ventricular pulse pressure variation (PPVRV) and systolic pressure variation (SPVRV) as well as pulmonary artery pulse pressure variation (PPVPA) and systolic pressure variation (SPVPA) to predict fluid responsiveness in coronary artery bypass (CABG) surgery patients. Additionally, radial artery pulse pressure variation (PPVART) and systolic pressure variation (SPVART) were calculated. The area under the receiver operating characteristics (AUROC) curve with 95%-confidence interval (95%-CI) was used to assess the capability to predict fluid responsiveness (defined as an increase in cardiac index of > 15%) after a 500 mL crystalloid fluid challenge. Thirty-three patients were included in the final analysis. Thirteen patients (39%) were fluid-responders with a mean increase in cardiac index of 25.3%. The AUROC was 0.60 (95%-CI 0.38 to 0.81) for PPVRV, 0.63 (95%-CI 0.43 to 0.83) for SPVRV, 0.58 (95%-CI 0.38 to 0.78) for PPVPA, and 0.71 (95%-CI 0.52 to 0.89) for SPVPA. The AUROC for PPVART was 0.71 (95%-CI 0.53 to 0.89) and for SPVART 0.78 (95%-CI 0.62 to 0.94). The correlation between pulse pressure variation and systolic pressure variation measurements derived from the different waveforms was weak. Right ventricular and pulmonary artery pulse pressure variation and systolic pressure variation seem to be weak predictors of fluid responsiveness in CABG surgery patients.

Echocardiographic-derived Pulmonary Artery Pulsatility Index: towards non-invasive evaluation of right ventricular function

Abstract Funding Acknowledgements Type of funding sources: None. Background. Pulmonary artery pulsatility index (PAPi)(1) is a powerful predictor of right ventricular failure in patients with acute inferior myocardial infarction(2) and in patients with heart failure undergoing LVAD implantation(3). PAPi derivation requires invasive right heart catheterism (RHC), thus limiting availability and seriate assessment of right ventricular function. Purpose. Aim of the study was to evaluate accuracy and agreement of echocardiographic derived PAPi (ePAPi) compared to right heart catheterism derived PAPi in heart failure with reduced ejection fraction (HFrEF) patients. Methods. ePAPi was defined as the ratio of pulmonary artery pulse pressure (sPAP – dPAP) to right atrial pressure (RAP). Systolic pulmonary artery pressure (sPAP) was determined from tricuspid regurgitation (TR) velocity using the simplified Bernoulli equation(4): sPAP = 4 x (peak TR jet velocity)2 + RA pressure. Diastolic pulmonary artery pressure (dPAP) was calculated as: dPAP = 4 x (end-diastolic pulmonary regurgitant velocity)2 + RA pressure. Simplified ePAPi, defined as peak TR pressure to RA pressure ratio was also investigated. Pearson and Spearman correlation tests were performed. A Bland-Altman plot analysis was performed to assess agreement between ePAPi and invasive PAPi. ROC curves were made to assess ePAPi accuracy in identifying patients with low PAPi (defined as PAPi &amp;lt; 2 and PAPi &amp;lt; 3.65). Results. 66 HFrEF patients (age 59 ± 10 years, 63% males, mean EF: 35 ± 9%) underwent RHC and blinded echocardiogram in a single center Cardiology Departement. Mean invasive derived PAPi was 4.4 ± 3.6, while ePAPi was 3.9 ± 2.3. ePAPi showed an excellent correlation with invasive PAPi (Pearson r: 0.80, p &amp;lt; 0.001; Spearman rho: 0.83, p &amp;lt; 0.001) and good agreement as shown in Bland Altman plot (figure 1). In ROC analysis, ePAPi accurately identified patients with low hemodynamic PAPi &amp;lt; 2 (Sensibility: 100%; Specificity: 87.2%; AUC: 0.97; Youden criterion: ePAPi &amp;lt; 2.3) and PAPi &amp;lt; 3.65 (Sensibility: 81.8%; Specificity: 84%; AUC: 0.89; Youden criterion: ePAPi &amp;lt; 3.6)(figure 2). Simplified ePAPi also showed good correlation and agreement (Pearson r: 0.58, p &amp;lt; 0.001; Spearman rho: 0.81, p &amp;lt; 0.001). Conclusions. In patients with HFrEF, echocardiographic derived PAPi showed a good agreement and correlation with invasive derived PAPi. ePAPi was also accurate in identifying patients with low PAPi values associated with poor outcomes and may be of interest for non-invasive right ventricular function seriate assessment. Further studies are needed to investigate prognostic implications. Abstract Figure. Abstract Figure 2

Association of Pulmonary Artery Pulsatility Index With Adverse Cardiovascular Events Across a Hospital-Based Sample.

The pulmonary artery pulsatility index (PAPi), calculated from the ratio of the pulmonary artery pulse pressure to right atrial pressure, is a predictor of right ventricular failure after inferior myocardial infarction and left ventricular assist device implantation. Whether PAPi is associated with adverse outcomes across a heterogeneous population is unknown. We examined consecutive patients undergoing right heart catheterization between 2005 and 2016 in a hospital-based cohort. Multivariable Cox models were utilized to examine the association between PAPi and all-cause mortality, major adverse cardiac events, and heart failure hospitalizations. We studied 8285 individuals (mean age 63 years, 39% women) with median PAPi across quartiles 1.7, 2.8, 4.2, and 8.7, who were followed over a mean follow-up of 6.7±3.3 years. Patients in the lowest PAPi quartile had a 60% greater risk of death compared with the highest quartile (multivariable-adjusted hazard ratio, 1.60 [95% CI, 1.36-1.88], P<0.001) and a higher risk of major adverse cardiac events and heart failure hospitalizations (hazard ratio, 1.80 [95% CI, 1.56-2.07], P<0.001 and hazard ratio, 2.08 [95% CI, 1.76-2.47], P<0.001, respectively). Of note, patients in quartiles 2 and 3 also had increased risk of cardiovascular events compared with quartile 4 (multivariable P<0.05 for all). Compared with the highest PAPi quartile, patients in PAPi quartiles 1 to 3 had a greater risk of all-cause mortality, major adverse cardiac events, and heart failure hospitalizations, with greatest risk observed in the lowest quartile. A low PAPi, even at values higher than previously reported, may serve an important role in identifying high-risk individuals across a broad spectrum of cardiovascular disease.

Abstract 13169: Serum Calcium is Positively Associated With Right Ventricular Function as Assessed by Hemodynamics and Echocardiography

Introduction: The physiologic role of calcium for cardiomyocyte contractility is well established. Post cardiac surgery, maintaining normocalcemia is associated with improved right ventricular (RV) function as compared to hypocalcemia. Hypothesis: We hypothesize that lower serum ionized calcium (iCa) is associated with RV dysfunction in non-surgical subjects. Methods: From a de-identified electronic health record, we extracted demographic, laboratory, echocardiographic, and first right heart catheterization (RHC) data to perform a cross-sectional analysis. iCa, obtained within 2 days of RHC, was tested for association with hemodynamics and pulmonary artery pulsatility index (PAPI; pulmonary artery pulse pressure / right atrial pressure) as a measure of RV function. We tested the association of iCa with reader-assessed RV dysfunction by echocardiography. RV dysfunction was coded as 0=none, 1=mild, 2=moderate, and 3=severe. All analyses were performed using ordinal regression adjusted for age, sex, and self-declared race. Results: From the 1,658 participants identified: median age 61 years, 42% female, 76% white, 18% black, 82% with mean pulmonary artery pressure ≥20mmHg, and 28% with pulmonary vascular resistance ≥3 Wood units. We observed a positive association between iCa and PAPI (Figure 1A, P&lt;0.0001, n=1,658). Higher iCa was positively associated with systemic pressures and negatively associated with pulmonary pressures (P&lt;0.01). By echocardiography, lower iCa was associated with higher prevalence of RV dysfunction (Figure 1B, P&lt;0.0001, n=1,355). Conclusion: In a clinical population referred for RHC, we concluded that higher iCa was associated with better RV function assessed by invasive hemodynamics and echocardiography. Further studies are needed to assess whether there is an etiologic relationship between iCa and RV function.