Pulmonary Diastolic Pressure Research Articles

Impact of Age and of the Patent Ductus Arteriosus on Pulmonary Hemodynamics in Children with Complete Atrioventricular Septal Defect.

Complete atrioventricular septal defect (CAVSD) can lead to the development of pulmonary obstructive vascular disease due to high pulmonary blood flow and pressures. This study aimed to evaluate the changes in pulmonary hemodynamics with aging and with patent ductus arteriosus (PDA) in children with CAVSD. We retrospectively evaluated 137 children (94% with trisomy 21, median age of 195 (25-2963) days, 58.4% female) with CASVD referred to cardiac catheterization from January 2000 to December 2020. Those with associated congenital heart disease, except PDA, had been excluded. They were divided into three age terciles (T1, T2, and T3). Aging was directly associated with higher mean (T1: 34.2 ± 9.1; T2: 37.1 ± 5.8; T3: 42 ± 10.6 mmHg, p < 0.001) and diastolic (T1: 19.4 ± 5.3; T2 21.6 ± 5.0; T3: 26.0 ± 9.5 mmHg, P < 0.001) pulmonary arterial pressures, and with higher pulmonary vascular resistance (T1: 3.24 ± 1.69, T2: 3.47 ± 1.19; T3: 4.49 ± 3.91 Wu.m2, p = 0.023). This resulted in a loss of eligibility for anatomical correction, which became evident only after 300 days of age. PDA was associated with a higher mean (37.2 [35.9; 38.5] vs. 41.3 [37.5; 45.0] mmHg, p = 0.049) and diastolic (21.7 [20.7; 22.6] vs. 26.4 [24.1; 29.0] mmHg, p = 0.001) pulmonary pressure, and resistor-compliance time (0.28 [0.26; 0.29] vs. 0.36 [0.31; 0.40], p = 0.001) after adjusting for age and sex. In children with CAVSD, aging was associated with worsening of pulmonary vascular hemodynamics, particularly when PDA was associated, resulting in loss of eligibility for anatomical correction after 10 months of age as the first surgical option.

Myocardial Work Indices Predict Hospitalization in Patients with Advanced Heart Failure.

An increasing proportion of heart failure (HF) patients progress to the advanced stage (AdHF) with high event rates and limited treatment options. Echocardiography, particularly Speckle Tracking-derived myocardial work (MW), is useful for HF diagnosis and prognosis. We aimed to assess MW's feasibility in the prognostic stratification of AdHF. We retrospectively screened patients with AdHF who accessed our hospital in 2018-2022. We excluded subjects with inadequate acoustic windows; unavailable brachial artery cuff pressure at the time of the echocardiography; atrial fibrillation; and mitral or aortic regurgitation. We measured standard parameters and left ventricular (LV) strain (LS) and MW. The population was followed up to determine the composite outcomes of all-cause mortality, left ventricular assist device implantation and heart transplantation (primary endpoint), as well as unplanned HF hospitalization (secondary endpoint). We enrolled 138 patients, prevalently males (79.7%), with a median age of 58 years (IQR 50-62). AdHF etiology was predominantly non-ischemic (65.9%). Thirty-five patients developed a composite event during a median follow-up of 636 days (IQR 323-868). Diastolic function, pulmonary pressures, and LV GLS and LV MW indices were not associated with major events. Contrarily, for the secondary endpoint, the hazard ratio for each increase in global work index (GWI) by 50 mmHg% was 0.90 (p = 0.025) and for each increase in global constructive work (GCW) by 50 mmHg% was 0.90 (p = 0.022). Kaplan-Meier demonstrated better endpoint-free survival, with an LV GWI ≥ 369 mmHg%. GWI and GCW, with good feasibility, can help in the better characterization of patients with AdHF at higher risk of HF hospitalization and adverse events, identifying the need for closer follow-up or additional HF therapy.

Association of pulmonary hypertension with the outcome in patients undergoing edge-to-edge mitral valve repair

ObjectivesThe association of pulmonary hypertension (PH) with the outcome after mitral transcatheter edge-to-edge repair (M-TEER) focusing on the new ESC/ERS guidelines definition for PH.BackgroundPH is frequently found in patients with...

Increased Chamber Resting Tone Is a Key Determinant of Left Ventricular Diastolic Dysfunction.

Twitch-independent tension has been demonstrated in cardiomyocytes, but its role in heart failure (HF) is unclear. We aimed to address twitch-independent tension as a source of diastolic dysfunction by isolating the effects of chamber resting tone (RT) from impaired relaxation and stiffness. We invasively monitored pressure-volume data during cardiopulmonary exercise in 20 patients with hypertrophic cardiomyopathy, 17 control subjects, and 35 patients with HF with preserved ejection fraction. To measure RT, we developed a new method to fit continuous pressure-volume measurements, and first validated it in a computational model of loss of cMyBP-C (myosin binding protein-C). In hypertrophic cardiomyopathy, RT (estimated marginal mean [95% CI]) was 3.4 (0.4-6.4) mm Hg, increasing to 18.5 (15.5-21.5) mm Hg with exercise (P<0.001). At peak exercise, RT was responsible for 64% (53%-76%) of end-diastolic pressure, whereas incomplete relaxation and stiffness accounted for the rest. RT correlated with the levels of NT-proBNP (N-terminal pro-B-type natriuretic peptide; R=0.57; P=0.02) and with pulmonary wedge pressure but following different slopes at rest and during exercise (R2=0.49; P<0.001). In controls, RT was 0.0 mm Hg and 1.2 (0.3-2.8) mm Hg in HF with preserved ejection fraction patients and was also exacerbated by exercise. In silico, RT increased in parallel to the loss of cMyBP-C function and correlated with twitch-independent myofilament tension (R=0.997). Augmented RT is the major cause of LV diastolic chamber dysfunction in hypertrophic cardiomyopathy and HF with preserved ejection fraction. RT transients determine diastolic pressures, pulmonary pressures, and functional capacity to a greater extent than relaxation and stiffness abnormalities. These findings support antimyosin agents for treating HF.

Abstract 13293: Predicting Successful ECMO Decannulation - A Novel Machine Learning Approach

Introduction: Extra Corporeal Membrane Oxygenation (ECMO) has emerged as a crucial life support intervention, yet the decision-making process for safe decannulation remains challenging due to a paucity of data. Methods: 199 patients who underwent venoarterial ECMO for cardiogenic shock between 2015 and 2021 were identified. Demographic, hemodynamic, laboratory, and echocardiographic data obtained within 24 hours of decannulation were collected. Successful decannulation was defined as survival without relapse to mechanical circulatory support or heart transplant within 30 days. The dataset was randomly split into 80/20 train-validation splits, and four machine learning models were employed. 5-fold cross-validation and error analysis were performed. Feature importance was derived from the best performing model. Results: 103 patients were successfully weaned off ECMO. Table 1 provides patient characteristics, which were used as features in the models. Among the models tested, Random Forest (RF) exhibited the highest performance (accuracy 85.0%, precision 90.0%, recall 85.7%, AUROC 0.94). Figure 1 depicts the performance for each model as well as the ranked feature importance and Receiver Operating Curve for the RF model. The most important features were mixed venous oxygen saturation, systolic blood pressure, ECMO flow rate and pulmonary diastolic blood pressure. Conclusion: This study demonstrates the successful application of machine learning in predicting ECMO weaning outcomes. Future research will add features and patients to enhance model performance with the goal of developing a clinical tool to assist physicians caring for ECMO patients.

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

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

Pulmonary arterial hemodynamic in patients with or without pulmonary disease admitted after cardiac arrest - a sub study of the BOX trial

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Novo Nordisk Foundation Background Patients with pulmonary disease may have altered pulmonary hemodynamic compared to patients without pulmonary disease. We hypothesize that these patients with pre-existing pulmonary disease have significantly elevated pulmonary arterial pressure during the first 48 hours of ICU-stay. Methods The BOX-trial was an investigator-initiated, randomized, controlled study of targeted MAP (63 vs 77 mmHg) and PaO2 (9-10 vs 13-14 kPa) interventions in 789 comatose OHCA (of presumed cardiac origin) patients. Pre-existing, significant pulmonary disease was recorded at baseline. Patients underwent serial hemodynamic assessments with pulmonary artery catheter at time of insertion (0 h), 6 h, 12 h, 24 h, 36 h and 48 h. Among parameters recorded was cardiac output (CO). Pulmonary arterial pressures and central venous pressure were measured continuously. Patient characteristics included age, time to return of spontaneous circulation (ROSC) and initial rhythm. Results Hemodynamic parameters from 730 patients were analysed, of which 89 (12%) had pulmonary disease. Of these, 57 (8%) had COPD, 26 (4%) had asthma and 6 (1%) had non-obstructive pulmonary disease. Patients with pulmonary disease were older (66±12 vs 62±14 years) and had similar time to ROSC (20±14 vs 23±16 minutes). Initial shockable rhythm was present in 73/89 (82%) with pulmonary disease and in 580/641 (90%) without, p=0.015. At 12 hours, mean pulmonary artery pressure (27±5 vs 24±6 p&amp;lt;0.0001, see Figure 1), systolic pulmonary pressure (36±7 vs 33±8 p=0.0004), and diastolic pulmonary pressure (21±5 vs 18±5 p&amp;lt;0.0001) were all significantly higher for patients with pulmonary disease than patients without. This association remain statistically significant, when adjusting for primary rhythm, time to ROSC and age. Also, heart rate (72±21 vs 66±17 bpm, p&amp;lt;0.0056) was significantly higher in patients with pulmonary disease. Cardiac index (cardiac output adjusted for body surface), central mixed venous saturation and CVP was similar between groups. Conclusions Pre-existing pulmonary disease in resuscitated OHCA-patients is associated with significantly elevated pulmonary pressures.

The Effectiveness of Bax/Bcl-2 Gene Expression Ratio, Cardiac Function and Pulmonary Hemodynamics Indexes caused by Cardiopulmonary Rehabilitation Nursing.

This study aimed to observe the effects of cardiopulmonary rehabilitation nursing on gene expression, cardiac function and pulmonary hemodynamic indexes after percutaneous coronary intervention (PCI). A total of 104 coronary heart disease patients who received PCI treatment from January 2020 to January 2022 were selected by convenience sampling method. The patients were divided into control and observation groups by random number table method, with 52 cases in each group. The control group received routine nursing and the observation group received cardiopulmonary rehabilitation nursing. Cardiac function and pulmonary hemodynamics indexes were compared between the two groups. To evaluate gene expression, blood was taken from patients and healthy people after receiving complete information and obtaining consent. White blood cells were isolated by salting out. After RNA extraction and cDNA synthesis, the expression levels of Bcl2 and BAX genes were quantitatively measured by real-time PCR. Results showed that one month after discharge, the left ventricular end-diastolic diameter was decreased in the observation group compared with the control group and left ventricular ejection fraction and six minutes walk test grading were increased compared with the control group, showing a significant difference (P< 0.05). The pulmonary hemodynamic indexes were decreased in both groups compared with those at admission, but the pulmonary diastolic blood pressure, pulmonary systolic blood pressure, mean pulmonary artery pressure and pulmonary vascular resistance were lower in the observation group than in the control group of the same period, showing a difference (P< 0.05). The incidence of MACE was 1.92% (1/52) in the observation group, which was lower compared to the control group, showing a difference (P< 0.05). In this study, real-time PCR analysis showed that the expression ratio of Bcl2 to BAX genes in peripheral blood T cells in disease patients compared to healthy people was not different (P=0.07). In conclusion, Cardiopulmonary rehabilitation nursing for coronary heart disease after PCI can promote faster recovery of cardiac function, prolong exercise endurance and improve pulmonary hemodynamics indexes, demonstrating clinical reference value.

Left atrial strain and clinical outcome in patients with significant mitral regurgitation after surgical mitral valve repair.

BackgroundThis study aimed to investigate the prognostic value of left atrial (LA) strain in patients with significant mitral regurgitation (MR) after surgical mitral valve (MV) repair.MethodsA total of 169 patients (age 55 ± 15 years, 88 men) with moderate or severe MR on echocardiogram at least 6 months after surgical MV repair for primary MR were studied. Two-dimensional, Doppler, and speckle tracking echocardiography including MR quantitative measures, chamber size, and LA strain were comprehensively analyzed. The primary outcome was a composite of cardiovascular death, heart failure hospitalization, and MV reoperation.ResultsDuring a median of 44.4 months [interquartile range (IQR): 18.7–70.3 months] of follow-up, 44 patients (26%) experienced clinical events; these patients had greater MR volume, elevated mean diastolic pressure gradient and pulmonary artery systolic pressure, and enlarged chamber size compared with patients who did not experience events. Patients with events showed significantly lower LA strain [13.3% (IQR: 9.3–23.8%) vs. 24.0% (IQR: 13.1–31.4%), p = 0.003] and higher MR volume/LA strain [3.09 ml/% (IQR: 2.06–5.80 ml/%) vs. 1.57 ml/% (IQR: 1.04–2.72 ml/%), p < 0.001] than those without events. MR volume/LA strain was a good predictor of clinical outcomes (cut-off 1.57 ml/%, area under the curve 0.754, p < 0.001). On multivariable Cox proportional analysis, MR volume/LA strain was independently associated with clinical outcomes (hazard ratio: 1.269, 95% confidence interval: 1.109–1.452, p < 0.001) along with pulmonary artery systolic pressure.ConclusionA measure of LA mechanical function relative to MR volume is associated with clinical outcomes in patients with significant MR after surgical MV repair.

Coronary perfusion pressure is associated with adverse outcomes in advanced heart failure.

Myocardial perfusion is an important determinant of cardiac function. We hypothesized that low coronary perfusion pressure (CPP) would be associated with adverse outcomes in heart failure. Myocardial perfusion impacts the contractile efficiency thus a low CPP would signal low myocardial perfusion in the face of increased cardiac demand as a result of volume overload. We analyzed patients with complete hemodynamic data in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness trial using Cox Proportional Hazards regression for the primary outcome of the composite risk of death, heart transplantation, or left ventricular assist device [(LVAD). DT × LVAD] and the secondary outcome of the composite risk of DT × LVAD and heart failure hospitalization (DT × LVADHF). CPP was calculated as the difference between diastolic blood pressure and pulmonary artery wedge pressure. Heart failure categories (ischemic vs non-ischemic) were also stratified based on CPP strata. The 158 patients (56.7 ± 13.6years, 28.5% female) studied had a median CPP of 40mmHg (IQR 35-52mmHg). During 6months of follow-up, 35 (22.2%) had the composite primary outcome and 109 (69.0%) had the composite secondary outcome. When these outcomes were then stratified based on the median, CPP was associated with these outcomes. Increasing CPP was associated with lower risk of both the primary outcome of DT × LVAD (HR 0.96, 95% CI 0.94-0.99 p = .002) and as well as the secondary outcome of DT × LVADHF (p = .0008) There was significant interaction between CPP and ischemic etiology (p = .04). A low coronary artery perfusion pressure below (median) 40mmHg in patients with advanced heart failure undergoing invasive hemodynamic monitoring with a pulmonary artery catheter was associated with adverse outcomes. CPP could useful in guiding risk stratification of advanced heart failure patients and timely evaluation of advanced heart failure therapies.

Accuracy of Estimated versus Calculated Mean Pulmonary Arterial Pressure

<h3>Purpose</h3> Less than half of heart failure physicians calculate mean pulmonary arterial pressures (mPAP). Rather, they are reported from approximation between the systolic and diastolic pulmonary pressures. Imprecise assessment of mPAP will result in inaccurate calculation of the pulmonary vascular resistance (PVR), which can alter perceived eligibility for heart transplantation (HT). We sought to assess for differences between reported and calculated mPAP and associated PVR. <h3>Methods</h3> We retrospectively analyzed consecutive patients undergoing right heart catheterization with milrinone drug study at our institution (2/2013-11/2019). Hemodynamics were measured at baseline and again after a 50 mcg/kg milrinone load. We retrospectively calculated the mPAP as (2/3)*(diastolic PA) + (1/3)*(systolic PA), as well as the corresponding PVR. We compared the median reported and calculated mPAPs at baseline and following milrinone study. Finally, we assessed the number of patients in which calculation of mPAP reclassified the PVR across the cut-off of 3.5 WU, which is often used to determine eligibility for HT. <h3>Results</h3> A total of 224 patients were included - median age 57 (IQR 48-66) years, 34% women, and 31% ischemic cardiomyopathy. At baseline, median mPAP remained the same when comparing the calculated (40 mmHg, IQR 31-47) versus the reported mPAP (40 mmHg, IQR 32-48), though calculation resulted in significantly less variation in measurements (<i>p<</i>0.001). Calculated PVR, 3.5 WU (IQR 2.3-4.6), was significantly lower than reported PVR, 3.8 WU (IQR 2.5-5.1), <i>p<</i> 0.001. After milrinone study, final calculated mPAP, 33 mmHg (IQR 26-41), again had significantly less variability compared to reported, 33 mmHg (IQR 25-42), <i>p</i><0.001, and subsequent PVR was significantly lower with calculated mPAP, PVR 2.65 WU (IQR 1.88-3.70), compared to reported mPAP, PVR 2.78 WU (IQR 1.93-3.78), <i>p</i><0.001. There were 46 patients (21%) in which the PVR transitioned across the PVR cutoff of 3.5 WU after calculation of mPAP - 40 (18%) had PVR decrease to ≤ 3.5 from > 3.5, and 6 (3%) had PVR increase to > 3.5 from ≤ 3.5. <h3>Conclusion</h3> Calculation of mPAP resulted in less variation in measurement, affecting downstream calculation of PVR. More than one in five patients had PVR values transition across the cut-off of 3.5 WU following calculation of mPAP, which could alter subsequent eligibility for HT.

High prevalence of occult left ventricular diastolic dysfunction detected by exercise stress test in systemic sclerosis

Despite the poor prognosis of systemic sclerosis (SSc) due to the co-occurrence of left ventricular diastolic dysfunction (LVDD), presence of occult LVDD has not been sufficiently investigated. This retrospective study aimed to reveal the prevalence and determinants of occult LVDD in patients with SSc by exercise stress test. Forty-five SSc patients (age, 63 ± 13 years; men/women, 6/39) with normal pulmonary artery pressure and pulmonary artery wedge pressure (PAWP) at rest underwent a symptom-limited exercise test with right heart catheterization using a supine cycle ergometer; haemodynamic parameters at rest, leg raise and during exercise were evaluated. Occult LVDD defined PAWP ≥ 25 mmHg during exercise was seen in 13 patients (29%). Higher PAWP, lower pulmonary vascular resistance and diastolic pulmonary pressure gradient, larger left atrium at rest, and higher PAWP during leg raise (15 ± 4 vs 10 ± 4 mmHg in non-LVDD group, p < 0.001) were observed in the occult LVDD group. The area under the ROC curve for PAWP after leg raise was largest at 0.83 (95% CI: 0.70–0.95, p = 0.001). About one-third (29%) of SSc patients with normal haemodynamics at rest showed occult LVDD. A higher PAWP after leg raise could be useful for detecting occult LVDD.

Predictive Modeling of Secondary Pulmonary Hypertension in Left Ventricular Diastolic Dysfunction

Diastolic dysfunction is a common pathology occurring in about one third of patients affected by heart failure. This condition may not be associated with a marked decrease in cardiac output or systemic pressure and therefore is more difficult to diagnose than its systolic counterpart. Compromised relaxation or increased stiffness of the left ventricle induces an increase in the upstream pulmonary pressures, and is classified as secondary or group II pulmonary hypertension (2018 Nice classification). This may result in an increase in the right ventricular afterload leading to right ventricular failure. Elevated pulmonary pressures are therefore an important clinical indicator of diastolic heart failure (sometimes referred to as heart failure with preserved ejection fraction, HFpEF), showing significant correlation with associated mortality. However, accurate measurements of this quantity are typically obtained through invasive catheterization and after the onset of symptoms. In this study, we use the hemodynamic consistency of a differential-algebraic circulation model to predict pulmonary pressures in adult patients from other, possibly non-invasive, clinical data. We investigate several aspects of the problem, including the ability of model outputs to represent a sufficiently wide pathologic spectrum, the identifiability of the model's parameters, and the accuracy of the predicted pulmonary pressures. We also find that a classifier using the assimilated model parameters as features is free from the problem of missing data and is able to detect pulmonary hypertension with sufficiently high accuracy. For a cohort of 82 patients suffering from various degrees of heart failure severity, we show that systolic, diastolic, and wedge pulmonary pressures can be estimated on average within 8, 6, and 6 mmHg, respectively. We also show that, in general, increased data availability leads to improved predictions.

Estimating filling pressures in paediatric heart transplant recipients using echocardiographic parameters and B-type natriuretic peptide.

Longitudinal evaluation of allograft diastolic function in paediatric heart transplant recipients is important for early detection of acute rejection, cardiac allograft vasculopathy, and graft dysfunction. Mean diastolic right atrial and pulmonary capillary wedge pressures obtained at catheterisation are the reference standards for assessment. Echocardiography is non-invasive and more suitable for serial surveillance, but individual parameters have lacked accuracy. This study aimed to identify covariates of post-transplant mean right atrial and pulmonary capillary wedge pressures, including B-type natriuretic peptide and certain echocardiographic parameters. A retrospective review of 143 scheduled cardiac catheterisations and echocardiograms from 56 paediatric recipients transplanted from 2007 to 2011 was performed. Samples with rejection were excluded. Univariate and multivariate linear regression models using backward selection were applied to a database consisting of B-type natriuretic peptide, haemodynamic, and echocardiographic data. Ln B-type natriuretic peptide, heart rate z-score, left ventricular end-diastolic dimension z-score, mitral E/e', and percent interventricular septal thickening in systole were independently associated with mean right atrial pressure. Ln B-type natriuretic peptide, heart rate z-score, left ventricular end-diastolic dimension z-score, left ventricular mass (observed/predicted), and mitral E/e' were independently associated with mean pulmonary capillary wedge pressure. Covariates of B-type natriuretic peptide included mean pulmonary artery and pulmonary capillary wedge pressures, height, haemoglobin, fractional shortening, percent interventricular septal thickening in systole, and pulmonary vascular resistance index. B-type natriuretic peptide and echocardiographic indices of diastolic function were independently related to post-transplant mean right atrial and pulmonary capillary wedge pressures in paediatric heart transplant recipients without rejection.

Effective Diastolic Mechanical Support Using a New Implantable Cardiac Compression Device

<h3>Purpose</h3> Diastolic mechanical cardiac assist has been difficult to provide. We examined the hemodynamic effects of a new, implantable cardiac assist system on ovine cardiac performance. The device is inserted via the apex of the pericardium. It encompasses and encircles both left and right ventricles. The device self-expands to encompass the heart without suturing; it is held in place by the pericardium. There are 2 concentric chambers. An internal chamber is saline-filled and conforms to the heart. An external chamber is air-filled and provides external compression followed by negative pressure to aid with relaxation. (See figure). Device compression and relaxation is EKG-triggered. <h3>Methods</h3> The device was implanted in 7 sheep with heart failure induced by microsphere embolization. Cardiac performance was assessed for 6-8 hours. Invasive monitoring with a Swan-Ganz catheter, LV catheter, and flow probes provided data on cardiac function. <h3>Results</h3> Initiation of cardiac assist resulted in increased cardiac output of up to 0.7 L/min (21% increase). Systolic BP increased by 15 mmHg (22% increase). Mean pulmonary artery pressure decreased by 3 mmHg (10% decrease). Filling pressures declined indicating ventricular and pulmonary artery unloading. Diastolic pulmonary pressure declined by 7mmHg on average (from 23mmHg to 16 mmHg; -30%). LVEDP declined from 17 mmHg to 13 mmHg. Increased -dP/dt was dramatic after device activation (see figure) <h3>Conclusion</h3> Diastolic, and systolic, cardiac assistance can be achieved with a new implantable device that encompasses the heart compressing and relaxing sequentially in an ovine model of heart failure.

Pulmonary Vascular Reverse Remodeling in Combined Post and Pre Capillary Pulmonary Hypertension Occurs Over Time after Left Ventricular Assist Device Implantation

Purpose Left ventricular assist device (LVAD) has been reported to improve pulmonary hypertension (PH) due to left heart disease (PH-LHD). However, prevalence of combined post- and pre-capillary PH (Cpc-PH) in patients with PH-LHD and the impact of LVAD implantation on Cpc-PH has not been fully elucidated. This study aimed to investigate hemodynamic changes following LVAD implantation in patients with PH-LHD to assess pulmonary vascular reverse remodeling. Methods Eighty-nine patients with advanced heart failure complicated by PH-LHD undergoing LVAD implantation who received serial right heart catheterizations at least 3 time points (before, early after, and 1-year after implantation) were retrospectively reviewed. Patients were divided into 2 groups as Cpc-PH group (n=50): pulmonary vascular resistance (PVR) > 3 Wood unit (WU) or diastolic pulmonary pressure gradient (DPG) ≥ 7 mmHg, and isolated post-capillary PH (Ipc-PH) group (n=39). Results Values of brain natriuretic peptide and transaminase in Cpc-PH group were higher than those in Ipc-PH group. Cpc-PH patients were consisted of 41 with PVR > 3 WU, 8 with PVR > 3 WU and DPG ≥ 7 mmHg, and 1 with DPG ≥ 7 mmHg preoperatively. Median values of PVR in both groups significantly decreased early after LVAD implantation [from 4.1 to 2.7 WU (p 3 WU (n=14) or DPG ≥ 7 mmHg (n=1) at that point. Among these 15 patients, 4 patients still remained on their PVR > 3 WU (n=3) or DPG ≥ 7 mmHg (n=1) even 1-year after LVAD implantation. PVR and DPG in these 4 patients turned to normal values at 3-year after implantation. Conclusion Over half of patients with PH-LHD were complicated by Cpc-PH in our study cohort. LVAD implantation readily improved hemodynamics regardless of complication of Cpc-PH, whereas 15 patients were still found to be PVR > 3 WU or DPG ≥ 7 mmHg which should be considered as persistent Cpc-PH. We speculate that most of Cpc-PH in patients with PH-LHD might be caused by alteration of vascular tone which will be promptly relieved by substantial left ventricular unload, however a certain number of patients with Cpc-PH might develop structural remodeling of pulmonary vasculature which requires months or years to achieve pulmonary vascular reverse remodeling.

Clinical and Hemodynamic Efficacy of Left Ventricular Unloading during Venoarterial Extracorporeal Membrane Oxygenation

<h3>Purpose</h3> Left ventricular (LV) distention is a feared complication in patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock. LV unloading could be achieved with concomitant intra-aortic balloon pump (IABP) or Impella. We sought to assess the clinical and hemodynamic effects of IABP and Impella on patients supported with VA-ECMO <h3>Methods</h3> We conducted a retrospective review of patients who received VA-ECMO at our institution between January 2015 and June 2020. Patients with post-cardiotomy shock were excluded. Patients were categorized as having received either ECMO alone or ECMO+LV unloading. LV unloading was further characterized as either ECMO+IABP, or ECMO+Impella. We recorded baseline characteristics, post-operative complications, and hemodynamic changes associated with device initiation. <h3>Results</h3> During the study period, 142 patients received ECMO alone, 76 received ECMO+IABP, and 76 received ECMO+Impella. The ECMO+LV unloading group had more male patients compared to ECMO alone (70.4% vs 57.5%, p=0.026). 39.4% of ECMO alone patients survived to discharge, compared to 44.4% of ECMO+LV unloading patients (p=0.12). The ECMO+LV unloading group showed a greater decrease in mean pulmonary diastolic pressures compared to ECMO alone after 24 hours of support (-6.0 ± 8.4 mmHg vs -0.1 ± 10.8 mmHg, p = 0.032). ECMO+Impella patients had a higher incidence of bleeding events compared to ECMO alone or ECMO+IABP (52.6% vs 37.3% vs 20.8%, p = 0.0003). Kaplan Meier analysis revealed that ECMO+IABP had better survival compared to ECMO alone and ECMO+Impella (Figure 1). In a multivariable Cox-hazard analysis, age (HR= 1.02), male sex (HR=0.57), baseline lactate (HR =1.05), baseline creatinine (HR=1.06), need for ECPR (HR=2.21) and presence of IABP (HR=0.48) were independent predictors for mortality. <h3>Conclusion</h3> Concomitant support with IABP may help to reduce morbidity in patients on VA-ECMO for cardiogenic shock.

Abstract 12812: The Use of Hemodynamics Does Not Aide in Correctly Identifying the Etiology of Cardiomyopathy in Patients Receiving Advanced Therapy

Introduction: There is limited evidence demonstrating the benefit of hemodynamics in diagnosing the etiology of cardiomyopathy in patients referred for advanced therapies such as left ventricular assist device (LVAD) or orthotropic heart transplantation (OHT). Hypothesis: In patients with end stage heart failure, invasive hemodynamic measures differ between patients with different etiologies of cardiomyopathy. Methods: Hemodynamic and echocardiography data from 119 patients undergoing LVAD (n=85, Male 76%, Age 63 ± 12 years) or OHT (n=34, Male 70%, Age 60 ± 11 years) at a single center was reviewed. The follow invasive hemodynamic measurements were recorded and compared (central venous pressure (CVP), Pulmonary Artery Pulsatility Index (PAPI), peripheral vascular resistance (PVR), transpulmonary gradient, mean pulmonary artery pressure, cardiac index, and pulmonary diastolic pressure decoupling) were compared between groups. Results: Between patients with dilated cardiomyopathy (DCM), ischemic cardiomyopathy (ICM), and those with missed diagnosis, there were no significant differences between CVP, PAPI, PVR, transpulmonary gradient, mean PA pressure, cardiac index, or decoupling (Table 1). Left ventricular end diastolic diameter (LVEDD) on echocardiography was significantly larger in patients with DCM when compared to those with ischemic cardiomyopathy as well as infiltrative cardiomyopathies (6.65±1.04mm, 6.24±0.77mm, and 5.14±1.25mm, respectively p&lt;0.0001). Conclusions: Hemodynamic measures in patients with stage D cardiomyopathy did not differ according to the etiology of the underlying cardiomyopathy. . The similarity in hemodynamic profiles amongst different cardiomyopathy subtypes likely reflects end stage disease. LVEDD performed better than hemodynamics to help differentiate cardiomyopathy etiologies, and in addition were helpful in identifying cases where the diagnosis was incorrect.

Role of Nitroglycerin administration through inhalation route as Nitric oxide donor in decreasing pulmonary hypertension as consequence of non-cyanotic congenital heart defects in children candidate for diagnostic cardiac catheterization

ABSTRACT Background: This work aimed to study nitroglycerin effect through inhalation route on pulmonary hemodynamics in children complaining from pulmonary hypertension associated withs noncyanotic congenital heart defects candidate for diagnostic cardiac catheterization. Methods: This prospective study had been carried out in Cardiac Catheterization Centre at El-Shatby Pediatric Alexandria University Hospital after approval of the medical ethical committee. Each parent had received verbal and plain language written explanation of the research protocol and informed consent had been taken from their parents. Eighteen children below twelve years old complaining noncyanotic congenital heart defects and left to right shunt with pulmonary hypertension who required diagnostic cardiac catheterization had participated prospectively in this research. After induction of anaesthesa, systemic and pulmonary pressures had been recorded for all patients invasively. Where pulmonary vascular resistance index and systemic vascular resistance index had been determined using standard formula based on Fick's principle through computerized program. Then patients received 2.5 µg/kg/min nitroglycerin through inhalation for 30 min. After that all measurements had been recorded again. Results: After nitroglycerin inhalational, mean, diastolic and systolic pulmonary pressures reduced significantly in comparison with their baseline data. Also, the PVRI had diminished from baseline data. No significate changes were recorded for systemic pressures and SVRI. Conclusion: Nitroglycerin inhalation decreased pulmonary pressures as well as pulmonary vascular resistance index, with no effect on systemic haemodynamics nor systemic vascular resistance index in kids with pulmonary hypertension as a consequence of noncyanotic congenital heart defects.

Evaluation of Real-Time Three-Dimensional Echocardiography in Right Ventricular Function and Hemodynamics in Patients with Idiopathic Pulmonary Hypertension

Objective: Oriented with the assessment on real-time echocardiography based upon three dimensions (RT-3DE) in estimating right ventricular function and hemodynamics in the patients undergoing idiopathic pulmonary hypertension. Methods: Sixty patients living with idiopathic pulmonary hypertension admitted to our hospital from September 2018 to June 2019 were enrolled. Another 20 healthy examiners were selected as healthy controls. According to pulmonary systolic blood pressure, 60 patients were divided into 20 mild patients, 20 moderate ones as well as 20 severe ones. RT-3DE was used to measure right heart structure related parameters in all subjects, including left ventricular transverse diameter (LVTD), right ventricular transverse diameter (RVTD), right ventricular global end diastolic volume (EDV), right ventricular ejection fraction (RVEF). End-systolic volume (ESV), stroke volume (SV), as well as hemodynamic parameters, including pulmonary systolic pressure (SPAP), right heart output (RCO), pulmonary diastolic blood pressure (DPAP), pulmonary arterial pressure (MPAP). The differences in right heart structure parameters and hemodynamic parameters betwixt the PH Group and the healthy control Group were compared. In addition, conventional two-dimensional echocardiography (2DE) and RT-3DE were used to compare the images of the patients who had serious pulmonary hypertension and those of the Control Group to analyze the tricuspid annulus systolic displacement (TAPSE), the Tei index, and the tricuspid annulus systolic peak velocity (S’) value. The Result is that SPAP, DPAP, and MPAP achieved higher level in the PH Group compared to those in the Healthy Group, and P &lt; 0005, the difference took on statistical significance. Those data of SPAP, DPAP and MPAP in the moderate and severe PH Group were higher than those in the mild PH Group, and P &lt; 0005, the difference was of statistical significance. The RCO of the patients from the PH Group as well as the Healthy Group got under comparison, and P &lt; 0005. They presented statistics-based dramatic difference. In addition, RCO showed a gradual decline in the patients who came down with mild, moderate, and serious PH, and the results were statistically significant. In addition, the comparison between RT-3DE and conventional echocardiography shows that RT-3DE has higher accuracy and diagnostic value.