Pulmonary Capillary Wedge Pressure Values Research Articles

Photoplethysmography and intracardiac pressures: early insights from a pilot study.

Invasive haemodynamic monitoring of heart failure (HF) is used to detect deterioration in an early phase thereby preventing hospitalizations. However, this invasive approach is costly and presently lacks widespread accessibility. Hence, there is a pressing need to identify an alternative non-invasive method that is reliable and more readily available. In this pilot study, we investigated the relation between wrist-derived photoplethysmography (PPG) signals and the invasively measured pulmonary capillary wedge pressure (PCWP). Fourteen patients with aortic valve stenosis who underwent transcatheter aortic valve replacement with concomitant right heart catheterization and PPG measurements were included. Six unique features of the PPG signals [heart rate, heart rate variability, systolic amplitude (SA), diastolic amplitude, crest time (CT), and large artery stiffness index (LASI)] were extracted. These features were used to estimate the continuous PCWP values and the categorized PCWP (low < 12 mmHg vs. high ≥ 12 mmHg). All PPG features resulted in regression models that showed low correlations with the invasively measured PCWP. Classification models resulted in higher performances: the model based on the SA and the model based on the LASI both resulted in an area under the curve (AUC) of 0.86 and the model based on the CT resulted in an AUC of 0.72. These results demonstrate the capability to non-invasively classify patients into clinically meaningful categories of PCWP using PPG signals from a wrist-worn wearable device. To enhance and fully explore its potential, the relationship between PPG and PCWP should be further investigated in a larger cohort of HF patients.

Is Pulmonary Capillary Wedge Pressure a Reliable Indicator of Postcapillary Pulmonary Hypertension?

Although current pulmonary hypertension (PH) guidelines recommend a pulmonary capillary wedge pressure (PCWP) above 15 mmHg for the detection of a post-capillary component, the rational of this recommendation may not be quite compatible with the peculiar hemodynamics of PH. We hypothesize that a high PCWP alone does not necessarily indicate left-sided disease and this diagnosis can be improved using LV transmural pressure difference (∆PTM). In this two-center, retrospective, observational study; we enrolled 1070 patients with PH who had undergone heart catheterization with the final study population comprising of 961 cases. ∆PTM was calculated as PCWP minus right atrial pressure. The patients with group II PH had significantly higher ∆PTM values (12.6 ± 6.6 mmHg) compared to the other groups (1.1 ± 4.8 in group I, 12.4 ± 6.6 in group II, 2.5 ± 6.4 in group III and 0.8 ± 8.0 in group IV, P<0.001) despite overlapping PCWP values. A ∆PTM cut-off of 7 mmHg identifies left-heart disease when PCWP>15 (area under curve, 0.825; 95% confidence interval, 0.784 to. 0.866; P<0.001). Five-year mortality was significantly higher in patients with high ∆PTM and PCWP subgroup compared to low ∆PTM plus high PCWP (26.1% vs. 18.5%, P=0.027), and low ∆PTM and PCWP subgroups (26.1% vs. 15.6%, P<0.001). ∆PTM has supplementary discriminatory power in distinguishing patients with and without post-capillary PH. In conclusion, a new approach utilizing ∆PTM may improve our understanding of PH pathophysiology and may identify a subpopulation who may potentially benefit from PH-specific treatments.

The Effect of Fluid Pre-loading on Vital Signs and Hemodynamic Parameters in a Porcine Model of Lipopolysaccharide-Induced Endotoxemia.

Background Animal models of distributive hypotension and resuscitation allow the assessment of hemodynamic monitoring modalities and resuscitation strategies. The fluid-first paradigm for resuscitation is currently being challenged with clinical trials. In this investigation, venous return and perfusion are assessed, and full hemodynamics are characterized, in a porcine model of endotoxemic hypotension with and without fluid pre-loading. Methods Two groups of six pigs had the induction of standardized endotoxemic hypotension("critical hypotension"). Group 1 underwent four 10 cc/kg crystalloid boluses, and Group 2 was not fluid pre-resuscitated. Both groups underwent progressive norepinephrine (NE) up-titration to 0.25 mcg/kg/minute over 30 minutes. Vital signs, central parameters, and laboratory values were obtained at baseline, "critical hypotension,"after each bolus and during NE administration. Results Endotoxemia decreased the systemic vascular resistance (SVR) in Group 1 (1031±106 dyn/s/cm-5 versus738±258 dyn/s/cm-5; P=0.03) and Group 2 (1121±196 dyn/s/cm-5 versus759±342 dyn/s/cm-5; P=0.003). In Group 1, the four fluid boluses decreased heart rate (HR), pulmonary capillary wedge pressure (PCWP), and central venous pressure (CVP) (P<0.05). No changes were observed in blood pressure, cardiac output (CO), or lactate. NE up-titration increased HR in Group 1and decreased CVP in both groups. Higher final CVP (11 {3} versus4 {4} mmHg; P=0.01) and PCWP (5 {1} versus2 {2} mmHg; P=0.005) values were observed in Group 1 relative to Group 2, reflecting increased venous return. Conclusions Porcine endotoxemic hypotension and resuscitation were robustly characterized. In this model, fluid loading improved venous return with NE, though perfusion (CO) was preserved by increased NE-induced chronotropy.

Left atrial stiffness and strain are novel indices of left ventricular diastolic function in children: validation followed by application in multisystem inflammatory syndrome in children due to COVID-19.

We hypothesized left atrial (LA) stiffness may serve as a surrogate marker in children to differentiate elevated pulmonary capillary wedge pressure (PCWP) from normal and help detect diastolic dysfunction in myocardial injury due to multisystem inflammatory syndrome in children (MIS-C). We validated LA stiffness in 76 patients (median age 10.5 years), 33 had normal PCWP (<12 mmHg) and 43 had elevated PCWP (≥12 mmHg). LA stiffness was applied to 42 MIS-C patients [28 with myocardial injury (+) and 14 without myocardial injury (-)], defined by serum biomarkers. The validation group consisted of a group with and without cardiomyopathies, whose PCWP values ranged from normal to severely elevated. Peak LA strain was measured by speckle-tracking and E/e' from apical four chamber views. Noninvasive LA stiffness was calculated as: LAStiffness=E/e'LAPeakStrain (%-1). Patients with elevated PCWP showed significantly elevated LA stiffness [median 0.71%-1 vs. 0.17%-1, P < 0.001]. Elevated PCWP group showed significantly decreased LA strain (median: 15.0% vs. 38.2%, P < 0.001). Receiver operator characteristic (ROC) curve for LA stiffness yielded an area under the curve (AUC) of 0.88 and cutoff value of 0.27%-1. In MIS-C group, ROC curve yielded an AUC of 0.79 and cutoff value of 0.29%-1 for identifying myocardial injury. In children with elevated PCWP, LA stiffness was significantly increased. When applied to children with MIS-C, LA stiffness classified myocardial injury accurately. LA stiffness and strain may serve as noninvasive markers of diastolic function in the pediatric population.

Evaluation of common clinical and hemodynamic parameters to pulmonary capillary wedge pressures in patients undergoing right heart catheterization.

A cornerstone of heart failure assessment is the right heart catheterization and the pulmonary capillary wedge pressure measurement it can provide. Clinical and hemodynamic parameters such as weight and jugular venous distention are less invasive measures often used to diagnose, manage, and treat these patients. To date, there is little data looking at the association of these key parameters to measured pulmonary capillary wedge pressure (PCWP). This is a large, retrospective, secondary analysis of a right heart catheterization database comparing clinical and hemodynamic parameters against measured PCWP in heart failure patients. A total of 538 subjects were included in this secondary analysis. Spearman's Rho analysis of each clinical and hemodynamic variable was used to compare their association to the documented PCWP. Variables analyzed included weight, body mass index (BMI), jugular venous distention (JVD), creatinine, edema grade, right atrial pressure (RAP), pulmonary artery systolic pressure (PASP), systemic vascular resistance, pulmonary vascular resistance, cardiac output (thermal and Fick), systolic blood pressure, diastolic blood pressure, heart rate, respiratory rate, oxygen saturation (SpO2), and pulmonary artery diastolic pressure (PADP). Ten out of 17 selected parameters had a statistically significant association with measured PCWP values. PADP had the strongest association (0.73, p<0.0001), followed by RAP and PASP (0.69, p<0.0001 and 0.67, p<0.0001, respectively). Other significant parameters included weight (0.2, p<0.001), BMI (0.2, p<0.001), SpO2 (-0.17, p<0.0091), JVD (0.24, p<0.005) and edema grade (0.2, p<0.0001). This retrospective analysis clarifies the associations of commonly used clinical and hemodynamic parameters to the clinically used gold standard for volume assessment in heart failure patients, PCWP.

Relationship between ventricular pressure and coronary artery disease in asymptomatic adult heart transplant recipients.

The association between data of right heart catheterization and cardiac allograft vasculopathy (CAV) in adult heart transplant (HTx) recipients remains to be determined. This is an observational, retrospective study, including all consecutive asymptomatic HTx patients undergoing routine right and left catheterization. The independent predictive power of pulmonary capillary wedge pressure (PCWP) to predict CAV (classified according to working formulation of a standardized nomenclature for CAV-2010) was the primary end point. Seventy-one patients were included, with a mean time from HTx to procedure of 19 ± 25 months. At coronary angiography first degree of CAV was found in eight patients (11.2%), second degree of CAV in two patients (2.8%), and third in two (2.8%). PCWP values were significantly higher in patients with CAV compared with patients without CAV (17.5 ± 7.5 vs. 10.4 ± 5.6, P < 0.001) and values of 15 mmHg or greater had an AUC of 0.71 (0.48-0.92), with a sensitivity of 71% and a specificity of 73% in predicting CAV, with an independent relationship confirmed at logistic regression analysis (odds ratio 1.28, IC 1.06-1.53; P = 0.008). A significantly elevated PCWP at the time of the diagnosis of transplant coronary artery disease may be considered as an early marker of CAV, especially in asymptomatic HTx recipients.

Influence of the Hemodynamic Status of Multiorgan Donors on Long-Term Kidney Graft Survival—A Multivariable Analysis

BackgroundThe quality of transplanted organ and timing of the initiation of its effective function depends on many factors potentially causing graft dysfunction. The aim of this study was to evaluate the influence of the cardiovascular status of multiorgan donors on the long-term kidney graft survival over a 15-year observation period. MethodsIn 2007, the authors of this study published a multicenter prospective study evaluating the influence of the hemodynamic status of multiorgan donors on the early function of transplanted kidney. The results of that study showed that mean arterial pressure, central venous pressure, and pulmonary capillary wedge pressure values of the donor importantly influence the frequency of delayed graft function after renal transplantation. The present analysis covers the effect of the donor's hemodynamic status parameters on graft function time within the 15-year observation period. Univariate and multivariate analyses using the Cox regression proportional hazard model were performed to evaluate the prognostic parameters for overall survival and renal graft survival time. P < .05 was considered to be significant. ResultsThe univariate analysis showed a significantly shorter time of graft survival in the group of recipients who had a kidney retrieved from donors with lower pulmonary capillary wedge pressure values (P = .038) and lower cardiac index values (P = .039). The same results were obtained for the multifactorial Cox logistic regression analysis. ConclusionsThe filling of the intravascular bed of the donor as determined by pulmonary capillary wedge pressure and maintained donor tissue perfusion as determined by cardiac index, impose important factors influencing long-term kidney graft survival.

High prevalence of exercise-induced heart failure with normal ejection fraction in post-heart transplant patients

Post-heart transplant patients are at increased risk of diastolic dysfunction. The aim of this study was to assess the prevalence of isolated only exercise-induced heart failure with normal ejection fraction (HFNEF) in heart transplant recipients. To determine pulmonary capillary wedge pressure (PCWP) at rest and during exercise, 81 patients after orthotopic heart transplantation with normal left ventricular ejection fraction (LVEF) underwent exercise right heart catheterization with simultaneous exercise echocardiography. Based on PCWP values, the patients were divided into three groups. Twenty-one patients had no evidence of HFNEF (PCWP at rest < 15 mmHg, maximal PCWP during exercise < 25 mmHg, prevalence 26%). Forty-seven subjects were found to have only exercise-induced HFNEF (PCWP at rest < 15 mmHg, maximal PCWP during exercise ≥ 25 mmHg, prevalence 58%). Thirteen patients had HFNEF already at rest (PCWP ≥ 15 mmHg at rest, prevalence 16%). Of the noninvasive parameters obtained at rest, multivariate regression analysis identified LV mass index adjusted for allograft age to be an independent predictor of exercise-induced HFNEF. In heart transplant recipients with normal LVEF, there is a high prevalence of exercise-induced HFNEF. LV mass index adjusted for allograft age is predictive of exercise-induced HFNEF.

Hemodynamic Pressure Waveform Analysis in Predicting Fluid Responsiveness

To assess the usefulness of central venous pressure (CVP), diastolic right ventricular pressure, and pulmonary capillary wedge pressure (PCWP) waveform analysis in predicting fluid responsiveness. A prospective observational study. Tertiary care university hospital. Forty-four patients undergoing coronary artery bypass grafting. Analysis of the a/v wave ratio of the PCWP, CVP, and right ventricular dP/dt to predict an increase in stroke volume >15% after the administration of 500 mL of colloid. Forty-four patients were enrolled in this study and 7 were excluded. There were 24 responders and 13 nonresponders. No differences in mean CVP and PCWP values between the responders and the nonresponders were found. The only parameter associated with a significant response to volume infusion was the ratio of the a/v waves of the PCWP tracing (p = 0.0001). The performance of the a/v wave ratio>1 of the PCWP tracing in predicting fluid responsiveness was evaluated by constructing a receiver operating characteristic curve. The area under the receiver operating characteristic curve was 0.89 (95% confidence interval, 0.79-0.99; p<0.05). The a/v ratio measured on the PCWP tracing is a predictor of fluid responsiveness in patients with preserved left ventricular function undergoing coronary artery bypass grafting.

Circulation: Clinical Summaries

<i>Circulation:</i> Clinical Summaries

Combination of continuous pulse pressure variation monitoring and cardiac filling pressure to predict fluid responsiveness

To assess if combining central venous pressure (CVP) and/or pulmonary capillary wedge pressure (PCWP) information with arterial pulse pressure variation can increase the ability to predict fluid responsiveness in patients under general anesthesia. This study is a retrospective analysis of patients scheduled for coronary artery bypass surgery and monitored with a pulmonary artery catheter who underwent a volume expansion after induction of general anesthesia. Among the 46 patients studied, 31 were responders to volume expansion. CVP similar to PCWP, was a poor predictor of fluid responsiveness, as indicated by low values of areas under the receiver operating characteristic curves [0.585 (95 % CI 0.389-0.780) and 0.563 (95 % CI 0.373-0.753) respectively, p = 0.76]. The area obtained for PPV was 0.897 (95 % CI 0.801-0.992) with a threshold value of 12 %. The sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio was 83.9 %, 86.7 %, 6.29 and 0.19 respectively. Combining information on right and/or left cardiac filling pressures with PPV did not increase the ability to predict whether a patient will be a responder or a non-responder to volume expansion. The ability to identify a potentially fluid responsive patient was no better using PPV plus cardiac filling pressures when compared to using PPV alone. Therefore, if PPV values are being monitored in a patient, CVP and PCWP values do not provide additional information to predict fluid responsiveness.

Non-invasive tissue Doppler imaging pulmonary capillary wedge pressure measurement improves NT-proBNP prognostic value in heart failure

Objective — The aim of the present study was to investigate whether the improvement of pulmonary capillary wedge pressure (PCWP) non-invasively assessed with tissue Doppler imaging is able to predict prognosis and cardiac-related mortality in patients with heart failure (HF), as previously demonstrated for NT-proBNP.Methods — We prospectively studied 23 patients (74 ± 10 y; 17 M, 6 F) with acute HF. NT-proBNP and PCWP were measured at admission and discharge. NT-proBNP concentrations were determined by a chemiluminescent immunoassay kit. PCWP was assessed using the ratio of transmitral E velocity to the early diastolic mitral annulus velocity (E’), with the formula PCWP = 1.9 + 1.24 (E/E’). Patients were divided in two groups according to the clinical end-point based on cardiac death and hospital readmission for HF.Results — After a mean follow-up of 230 days, 10 patients reached the end-point (group A), while 13 patients resulted event-free (group B). In group B, NT-proBNP values significantly decreased (3816 ± 7424 vs. 6799 ± 10537 pg/mL, P < 0.01) and PCWP improved (17 ± 7 vs. 23 ± 12 mmHg, P < 0.01).The decrease in both NT-proBNP and PCWP values was able to identify the majority of patients (77%) with an event-free survival at follow-up, whereas 70% of patients who reached the end-point had discordant changes in NT-proBNP and PCWP (x2 = 5.06, P < 0.05).Conclusions — The combination of a biochemical marker such as NT-proBNP and a new indicator of LV filling pressure (E/E’) allows to estimate the prognostic impact of standard medical therapy even in a small group of HF patients.

Ventilatory Efficiency and Resting Hemodynamics in Hypertrophic Cardiomyopathy

In patients with systolic heart failure, the ability of cardiopulmonary exercise testing (CPX) variables to reflect pathophysiology is well established. The relationship between CPX and pathophysiology has, however, not been thoroughly investigated in patients with nonobstructive hypertrophic cardiomyopathy (NHCM). The objective of this study was to assess the ability of CPX variables to reflect resting hemodynamics in patients with nonobstructive hypertrophic cardiomyopathy NHCM. We performed CPX and right heart catheterization on 83 subjects with NHCM (51 male/32 female, mean age = 38 +/- 10 yr, NYHA I-III mean = 1.7). Peak oxygen consumption ( O2) and minute ventilation/carbon dioxide ratio (V E/VCO2) at peak exercise were compared to resting hemodynamics including pulmonary artery systolic, diastolic and mean pressures (PASP, PADP and MPAP), and pulmonary capillary wedge pressure (PCWP). Elevations in PCWP (> or = 15 mm Hg), PASP (> or =30 and > or = 40 mm Hg), PADP (> 15 mm Hg) and MPAP (> or = 20 mm Hg) were detected in 22, 33, 10, and 23% of subjects, respectively. Peak V E/VCO2 (positive correlation) and peak VO2 (negative correlation) correlated modestly with all pressure measurements (r = 0.33-0.51, P < 0.01 for all measurements). By receiver operating curve analysis, a V E/VCO2 >35.5 exhibited the best diagnostic accuracy with a curve areas of 0.81 for PAP > or = 30 mm Hg (sensitivity/specificity = 86%/67%), 0.87 for PAP > or = 40 mm Hg (77%/100%), 0.86 for MPAP > 20 mm Hg (83%/79%), and 0.84 for PCWP > or = 15 mm Hg (80%/76%). CPX can accurately identify abnormal resting hemodynamics in patients with NHCM. Further testing of this modality in other forms of diastolic dysfunction may be warranted.

Detection of anti-hsp70 immunoglobulin G antibodies indicates better outcome in coronary artery bypass grafting patients suffering from severe preoperative angina

Background Recent findings indicate that molecular chaperones actively participate in myocardial cytoprotection. Moreover, ischemic tolerance can be induced in humans by brief ischemic events. Therefore, we investigated patients with severe angina attacks before coronary artery bypass grafting. We focused on appearance of anti-hsp70 antibodies as an immunologic response to heat shock protein induction by ischemia followed up by hemodynamic measurements perioperatively. We correlated these clinical findings with the presence of antibodies against hsp70 and the antioxidative capacity of patients' sera. Methods Thirty-five consecutive patients with coronary artery disease scheduled for coronary artery bypass grafting were included. Seventeen patients had severe angina, and 18 patients suffered from chronic stable angina preoperatively. In the patients' sera, antibodies against hsp70 were detected by enzyme-linked immunosorbent assay, and antioxidative capacity was detected using the chromogen assay. Cardiac output and pulmonary capillary wedge pressure were measured using a thermodilution catheter. We also evaluated C-reactive protein and creatine kinase MB isoenzyme, and performed a conventional leukocyte count. Results The sera of the 17 patients with severe angina attacks before surgery contained antibodies against hsp70 and a low antioxidative capacity. The interval between a severe angina attack and anti-hsp70 antibody titer are inversely correlated. These patients had better cardiac output and lower pulmonary capillary wedge pressure values after surgery. Conclusions Severe angina before cardiac surgery coincided with an improved outcome as measured by hemodynamic variables as compared with chronic stable angina. This finding correlated significantly with a low antioxidative capacity and the presence of antibodies against hsp70. These pathophysiologic mechanisms might therefore play a role in myocardial protection.

Is the Ratio of Transmitral Peak E-Wave Velocity to Color Flow Propagation Velocity Useful for Evaluating the Severity of Heart Failure in Atrial Fibrillation?

Although analysis of the transmitral inflow (TMF) pattern is widely used for evaluating left ventricular diastolic function and provides valuable information for the management of heart failure (HF) in sinus rhythm, its utility in patients with atrial fibrillation (AF) has not been established. The aim of this study was to investigate the relationship between the ratio of transmitral peak E-wave velocity to flow propagation velocity (E/Vp) obtained by a newly developed dual Doppler system and the plasma B-type natriuretic peptide (BNP) concentration or pulmonary capillary wedge pressure (PCWP) for evaluating the severity of heart failure with AF. In 68 patients with AF, the E/Vp was compared with plasma BNP concentration and PCWP. A cutoff value of > or =1.7 for E/Vp predicted a plasma BNP concentrationl of > or =200 pg/ml, with 80% sensitivity and 84% specificity. Only E/Vp was found to be independently significant by stepwise multilinear regression analysis (r=0.40, p=0.01). PCWP values had good correlation with E/Vp (r=0.63, p<0.01) and were significantly higher in the group with E/Vp >/=1.7 (16+/-6 mmHg vs 11+/-4 mmHg, p<0.05). The Doppler-derived index of E/Vp correlated well with the neurohormonal and hemodynamic parameters, and was useful for evaluating the severity of heart failure with AF.

Echocardiographic Doppler assessment of pulmonary capillary wedge pressure in surgical patients with postoperative circulatory shock and acute lung injury.

In cardiac patients, pulmonary capillary wedge pressure (PCWP) is estimated using color M-mode Doppler study of left ventricular filling and Doppler tissue imaging. The goal of this study was to assess whether echocardiography accurately estimates PCWP in critically ill patients. Sixty ventilated patients admitted for septic shock and acute lung injury were prospectively studied using simultaneously transesophageal echocardiography and pulmonary artery catheterization. Initial PCWP values and their changes measured invasively were compared to initial values and corresponding changes of early diastolic velocity of mitral annulus displacement measured by Doppler tissue imaging (Ea), flow propagation velocity of early diastolic mitral inflow measured by color M-mode Doppler (Vp), and their respective ratio to early mitral inflow velocity (E) measured by conventional Doppler: E/Ea and E/Vp. Relations between E/Ea, E/Vp, and PCWP were prospectively tested in 20 additional patients. E/Ea and E/Vp gave a rough estimate of initial PCWP values with mean biases of 0.4 +/- 2.2 and 0.1 +/- 2.9 mmHg, respectively. Receiving operating characteristic curves demonstrated that an E/Ea of 6 or greater is an accurate predictor of a PCWP of 13 mmHg or greater and that an E/Ea of 5.4 is a good predictor of a PCWP of 8 mmHg or less. Changes in PCWP were significantly correlated to changes in E/Ea (Rho = 0.84, P < 0.0001). In patients with postoperative circulatory shock and acute lung injury, transesophageal echocardiography estimates noninvasively PCWP. However, echocardiographic estimation of PCWP may not be accurate enough for adjusting therapy.

Aprotinin and Reduced Epinephrine Requirements in Orthotopic Liver Transplantation

In Reply:—We thank Drs. Jankowski, Findlay, and Plevak for their interest in our work and the editor for giving us the opportunity to respond to their remarks and questions. In our response, we will follow the same order as in the letter by Jankowski et al .We fully agree that a reduction of 50 μg epinephrine alone is not the main indication for administering aprotinin to patients undergoing orthotopic liver transplantation (OLT). The main objective of using aprotinin during OLT is to reduce transfusion requirements. However, aprotinin may have additional benefits. It is beyond doubt that aprotinin is an inhibitor of kallikrein. As discussed in our article, there is substantial evidence that activation of the kallikrein–kinin system plays a role in the hemodynamic changes after graft reperfusion in OLT. In our study, we have shown that aprotinin improves hemodynamic stability. This indirectly adds clinical evidence to the current literature that activation of the kallikrein–kinin system is involved in the hemodynamic changes during OLT. As we have suggested, further evidence could come from the measurement of plasma kallikrein–aprotinin complexes.At this stage, we cannot completely rule out that differences in blood loss have also contributed to the observed differences in vasopressor requirement between the placebo and aprotinin groups. However, we have no arguments to believe that the correction of blood loss was less adequate in the placebo group and thus could entirely explain the use of more epinephrine to maintain adequate perfusion pressure. Jankowski et al. suggested that pulmonary capillary wedge pressure might be a more appropriate reflection of the fluid status. Therefore, we have performed a retrospective analysis of pulmonary capillary wedge pressure in our patients at 5 and 30 min after reperfusion. No significant differences in mean pulmonary capillary wedge pressure values were found at these time points, confirming our conclusions about fluid status. Our position is also supported by a recent abstract from Jankowski's own group, reporting similar findings in a placebo-controlled study in patients undergoing OLT. 1In this abstract, significantly more vasopressor and inotropic infusions were reported in the placebo group, compared with the aprotinin group. The authors concluded that aprotinin may result in more stable hemodynamics during OLT and that part of this effect could be independent of its effects on blood loss. 1Jankowski et al . asked about the criteria that were used to select the subgroup of patients included in our study. They are correct that these patients were part of a larger, multicenter project. The selected center was the largest center participating in the EMSALT study and therefore enrolled the largest subgroup. No preselection or subselection was performed. The reason why we performed the study in this center only is explained by a combination of factors. First, all patients in this center received pulmonary artery catheters, which, in some European centers, is not standard practice during OLT. Second, the limited number of anesthesiologists and the uniform practice with respect to control of hemodynamics, as described in the article, contributed to the decision to perform this study on intraoperative hemodynamics and vasopressor use in one center only.The following variables were found to be nonparametrically distributed and therefore log transformed to perform two-way analysis of variance with correction for repeated measures: cardiac index, systemic vascular resistance index, and mean pulmonary artery pressure. By definition, median values and the Kruskall-Wallis test are not influenced by outliers. Therefore, the skewness of our data on epinephrine requirement did not affect our analysis.Our conclusion that concentrations of approximately 100 KIU/ml may be sufficient was not based on differences in blood pressure after reperfusion, as was suggested by Jankowski et al. , but on the lack of difference in vasopressor requirement between the regular and high-dose groups. We disagree with Jankowski et al. that we have ignored other mechanisms of action that could be involved as well. In the Discussion of our article, we mentioned that aprotinin ameliorates the systemic inflammatory response and the release of proinflammatory cytokines in patients undergoing cardiopulmonary bypass. However, whether these or other effects are clinically relevant in liver transplantation and contribute to a reduction of ischemia–reperfusion injury is still unclear. Unlike the effect of aprotinin on the kallikrein system, a positive effect of aprotinin on ischemia–reperfusion injury in liver transplantation has been debated. 2Although graft survival may be improved, we have not been able to demonstrate a significant reduction in peak concentrations of aspartate aminotransferase and alanine aminotransferase after transplantation in patients who received aprotinin, compared with placebo. 3This subject deserves more research.

Computerized radiographic assessment of pulmonary blood flow in patients with and those without mitral stenosis.

The authors investigated whether a computerized analysis system can be used with chest radiography for estimating the redistribution of pulmonary blood flow in patients with and those without mitral stenosis (MS). Their system uses four-directional Laplacian-Gaussian filtering and binarization. As a physical measure, the radiographic index, which reflects the area of opacity in selected regions of interest (ROIs), was used. Fifteen men with MS and 15 men without MS were included in the study. ROIs were selected in the right upper and lower lung zones on radiographs, and the images were processed with the system. The radiographic indexes were determined in each ROI. As a measure of pulmonary blood flow redistribution, the upper-to-lower lung zone radiographic index ratio (U/L) was calculated. The U/L values correlated with pulmonary capillary wedge pressure values (r = .405, P = .025). The mean U/L value of the MS group was significantly higher than that of the non-MS group (1.16 +/- 0.14 vs 1.05 +/- 0.09, respectively; P = .016). These preliminary results indicate that this system can be used for quantitative estimation of the redistribution of pulmonary blood flow.

Clinical, radiographic, and hemodynamic correlations in chronic congestive heart failure: conflicting results may lead to inappropriate care

Clinical and radiographic examinations are commonly used for estimating severity and titrating therapy of chronic congestive heart failure. The purpose of this study was to establish the relationship between findings on history, physical examination, chest roentgenogram, and pulmonary capillary wedge pressure (PCWP). Fifty-two consecutive patients with chronic congestive heart failure, referred for evaluation for heart transplantation, were studied; all patients underwent history, physical examination, upright chest roentgenogram, and cardiac catheterization. The mean left ventricular ejection fraction was 0.19 +/- 0.06. Patients were divided into three groups according to their PCWP: Group 1, normal PCWP (less than or equal to 15 mm Hg, n = 19); Group 2, mild to moderately elevated PCWP (16 to 29 mm Hg, n = 15); Group 3, markedly elevated PCWP (greater than or equal to 30 mm Hg, n = 18). Physical and radiographic signs of congestion were more common in the groups with higher PCWP, but they could not be used to reliably separate patients with different filling pressures. Physical findings (orthopnea, edema, rales, third heart sound, elevated jugular venous pressure) or radiographic signs (cardiomegaly, vascular redistribution, and interstitial and alveolar edema) had poor predictive value for identifying patients with PCWP values greater than or equal to 30 mm Hg. These findings had poor negative predictive value to exclude significantly elevated PCWP (greater than 20 mm Hg). Radiographic pulmonary congestion was absent in eight (53%) patients in Group 2 and seven (39%) in Group 3. In patients in Group 2 and 3, those without radiographic congestion were in a better New York Heart Association functional class (3.5 +/- 0.5 versus 2.8 +/- 0.6, p less than 0.01). There was good correlation between right atrial pressure and PCWP (r = 0.64, p less than 0.001). A normal right atrial pressure had no predictive value, but a pressure greater than 10 mm Hg was seen in all but one patient with a PCWP value greater than 20 mm Hg. Clinical, radiographic, and hemodynamic evaluations of chronic congestive heart failure yield conflicting results. Absence of radiographic or physical signs of congestion does not ensure normal PCWP values and may lead to inaccurate diagnosis and inadequate therapy. It is not known whether therapy aimed at normalizing PCWP is superior to relieving clinical and radiographic signs of congestion.

Clinical, radiographic, and hemodynamic correlations in chronic congestive heart failure: Conflicting results may lead to inappropriate care

purpose: Clinical and radiographic examinations are commonly used for estimating severity and titrating therapy of chronic congestive heart failure. The purpose of this study was to establish the relationship between findings on history, physical examination, chest roentgenogram, and pulmonary capillary wedge pressure (PCWP). patients and methods: Fifty-two consecutive patients with chronic congestive heart failure, referred for evaluation for heart transplantation, were studied; all patients underwent history, physical examination, upright chest roentgenogram, and cardiac catheterization. The mean left ventricular ejection fraction was 0.19 ± 0.06. Patients were divided into three groups according to their PCWP: Group 1, normal PCWP (less than or equal to 15 mm Hg, n = 19); Group 2, mild to moderately elevated PCWP (16 to 29 mm Hg, n = 15); Group 3, markedly elevated PCWP (greater than or equal to 30 mm Hg, n = 18). results: Physical and radiographic signs of congestion were more common in the groups with higher PCWP, but they could not be used to reliably separate patients with different filling pressures. Physical findings (orthopnea, edema, rales, third heart sound, elevated jugular venous pressure) or radiographic signs (cardiomegaly, vascular redistribution, and interstitial and alveolar edema) had poor predictive value for identifying patients with PCWP values greater than or equal to 30 mm Hg. These findings had poor negative predictive value to exclude significantly elevated PCWP (greater than 20 mm Hg). Radiographic pulmonary congestion was absent in eight (53%) patients in Group 2 and seven (39%) in Group 3. In patients in Group 2 and 3, those without radiographic congestion were in a better New York Heart Association functional class (3.5 ± 0.5 versus 2.8 ± 0.6, p <0.01). There was good correlation between right atrial pressure and PCWP (r = 0.64, p <0.001). A normal right atrial pressure had no predictive value, but a pressure greater than 10 mm Hg was seen in all but one patient with a PCWP value greater than 20 mm Hg. conclusion: Clinical, radiographic, and hemodynamic evaluations of chronic congestive heart failure yield conflicting results. Absence of radiographic or physical signs of congestion does not ensure normal PCWP values and may lead to inaccurate diagnosis and inadequate therapy. It is not known whether therapy aimed at normalizing PCWP is superior to relieving clinical and radiographic signs of congestion.