Pulmonary Index Research Articles

Fully automatic quantification of pulmonary fat attenuation volume by CT: an exploratory pilot study

BackgroundNon-malignant chronic diseases remain a major public health concern. Given the alterations in lipid metabolism and deposition in the lung and its association with fibrotic interstitial lung disease (fILD) and chronic obstructive pulmonary disease (COPD), this study aimed to detect those alterations using computed tomography (CT)-based analysis of pulmonary fat attenuation volume (CTpfav).MethodsThis observational retrospective single-center study involved 716 chest CT scans from three subcohorts: control (n = 279), COPD (n = 283), and fILD (n = 154). Fully automated quantification of CTpfav based on lung segmentation and HU-thresholding. The pulmonary fat index (PFI) was derived by normalizing CTpfav to the CT lung volume. Statistical analyses were conducted using Kruskal–Wallis with Dunn’s post hoc tests.ResultsPatients with fILDs demonstrated a significant increase in CTpfav (median 71.0 mL, interquartile range [IQR] 59.7 mL, p < 0.001) and PFI (median 1.9%, IQR 2.4%, p < 0.001) when compared to the control group (CTpfav median 43.6 mL, IQR 16.94 mL; PFI median 0.9%, IQR 0.5%). In contrast, individuals with COPD exhibited significantly reduced CTpfav (median 36.2 mL, IQR 11.4 mL, p < 0.001) and PFI (median 0.5%, IQR 0.2%, p < 0.001).ConclusionThe study underscores the potential of CTpfav and PFI as imaging biomarkers for detecting changes in lung lipid metabolism and deposition and demonstrates a possibility of tracking these alterations in patients with COPD and ILDs. Further research is needed to validate these findings and explore the clinical relevance of CTpfav and PFI in lung disease management.Relevance statementThis study introduces a fully automated method for quantifying CTpfav, potentially establishing it as a new imaging biomarker for chronic lung diseases.Key PointsThis retrospective observational study employed an open-source, automated algorithm for the quantification of CT pulmonary fat attenuation volume (CTpfav).Patients with fibrotic interstitial lung disease (fILD) showed a significantly higher CTpfav and pulmonary fat index (PFI), i.e., CTpfav/CT lung volume, compared to a control group.Patients with chronic obstructive pulmonary disease (COPD) showed significantly lower CTpfav and PFI compared to the control group.CTpfav and PFI may each serve as imaging biomarkers for various lung diseases and warrant further investigation.Graphical

Role of integrated pulmonary index in respiratory monitoring of spontaneously breathing COVID-19 patients with moderate to severe respiratory symptoms

Role of integrated pulmonary index in respiratory monitoring of spontaneously breathing COVID-19 patients with moderate to severe respiratory symptoms

Prenatal Prediction of Fetal Lung Maturity Using 3D Lung Volume, Lung-to-Liver Intensity Ratio Tissue Histogram and Pulmonary Artery Doppler Indices

Prenatal Prediction of Fetal Lung Maturity Using 3D Lung Volume, Lung-to-Liver Intensity Ratio Tissue Histogram and Pulmonary Artery Doppler Indices

Evaluation of pulmonary artery pressure, blood indices, and myocardial microcirculation in rats returning from high altitude to moderate altitude

BackgroundTo investigate changes in pulmonary artery pressure (PAP), blood indices, and myocardial microcirculation in rats returning from high altitude (HA) to moderate altitude (MA).MethodsForty 4-week-old male Sprague-Dawley rats were randomly divided into four groups with ten rats in each group. One group was transported to the MA area (MA-group), and the other three groups were transported to HA (HA-group-A, HA-group-B, and HA-group-C). After 28 weeks of age, the rats from the HA area were transported to the MA area for 0 days, 10 days, and 20 days, respectively. PAP, routine blood tests, and computed tomography myocardial perfusion indices were measured.ResultsCompared with the MA-group, the body weight of HA-groups decreased (p < 0.05), and PAP in HA-group-A and HA-group-B increased (p < 0.05). In the HA groups, PAP initially increased and then decreased. Compared with the MA-group, red blood cells (RBC), hemoglobin (HGB), and hematocrit (HCT) of rats in HA-group-A increased (p < 0.05). Compared with the HA-group-A, RBC, HGB, and HCT of HA-group-B gradually decreased (p < 0.05) while MCV decreased (p < 0.05), and PLT of HA-group-C increased (p < 0.05). Compared with the MA group, blood flow (BF) and blood volume (BV) of the HA-group-A decreased (p < 0.05). Compared with the HA-group-A, TTP increased first and then decreased (p < 0.05), and BF and BV increased gradually (p < 0.05). Pathological results showed that myocardial fiber arrangement was disordered, and cell space widened in the HA group.ConclusionPAP, blood parameters, and myocardial microcirculation in rats returning from high to MA exhibited significant changes.Relevance statementThis study provides an experimental basis for understanding the physiological and pathological mechanisms during the process of deacclimatization to HA and offers new insights for the prevention and treatment of deacclimatization to HA syndrome.Key PointsForty rats were raised in a real plateau environment.Myocardial microcirculation was detected by CT myocardial perfusion imaging.The PAP of the unacclimated rats increased first and then decreased.The myocardial microcirculation of the deacclimated rats showed hyperperfusion changes.Graphical

Impact of inhaled nitric oxide therapy in patients with cardiogenic shock treated with veno-arterial extracorporeal membrane oxygenation combined with Impella: a retrospective cohort study

BackgroundThe mortality rate of patients with cardiogenic shock (CS) requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO) combined with Impella (ECPELLA) support remains high. Inhaled nitric oxide (iNO) improves right ventricular (RV) function, resulting in increased Impella flow, which may facilitate early withdrawal of VA-ECMO and improve survival. This study investigated the prognostic impact of iNO therapy in ECPELLA patients.MethodsWe retrospectively analyzed the data of consecutive patients with CS supported by ECPELLA from September 2019 to March 2024 at our hospital. Changes in pulmonary artery pulsatility index (PAPi) and Impella flow over time were evaluated, and VA-ECMO withdrawal rate, time to withdrawal, and 30-day survival were compared between ECPELLA patients with and without iNO therapy.ResultsOf the 48 ECPELLA patients, 25 were treated with iNO. There were no significant differences between the groups in baseline characteristics or lactate levels at mechanical circulatory support induction. Patients with iNO therapy demonstrated significant improvements in the PAPi over time and a trend toward increased Impella flow, as well as a significantly higher VA-ECMO withdrawal rate (88% vs. 48%, P = 0.002) and a shorter time to VA-ECMO withdrawal (5 [3–6] days vs. 7 [6–13] days, P = 0.0008) than those without iNO therapy. Kaplan–Meier analysis demonstrated that the 30-day survival rate was significantly higher in patients with iNO than in those without (76% vs. 26%, P = 0.0002).ConclusionsiNO therapy in patients with CS requiring ECPELLA was associated with short-term prognosis by improving RV function and facilitating weaning from VA-ECMO.Trial registration Retrospectively registered in UMIN-CTR (Reference No. R00006352).

Abstract 4124267: Comparison of Right Ventricular Failure Prediction Models to Predict Right Ventricular Assist Device (RVAD) After HeartMate3 Implantation

Introduction: The requirement for right ventricular-assisted device (RVAD) implantation portends poor outcomes after left ventricular-assisted device (LVAD) implantation. We investigate RVF prediction models to help prediction of RV failure requiring RVAD implantation after centrifugal-flow LVAD HeartMate3 (HM3) placement. Methods: A total of 124 patients who underwent HM3 implantation at our institution from 2015-2023 were included in our analysis. We collected clinical variables used in EUROMACS RVF Risk Score (Circulation 2018), Utah Model (Am J Cardiology 2010), Michigan RVF Risk Score (JACC 2008), and CRITT (ATS 2013). Baseline scoring systems were compared with our cohort of patients with and without RVAD implantation after HM3 placement with ROC Area Under the Curve (AUC) statistical analysis. In addition, we investigated the pulmonary artery pulsatility index (PAPi) as a predictor for RV failure requiring RVAD. Results: There were 17 patients (13.7%) who underwent RVAD implantation after HM3 placement. Patients who required RVAD implant had worse survival (p = 0.037). The EUROMACS score differentiated those patients who required RVAD from those who did not (AUC: 0.66; 95% C.I: 0.51-0.81). In contrast, CRITT (AUC: 0.64; 95% C.I: 0.49-0.78), Michigan score (AUC: 0.37; 95% C.I: 0.25-0.51), and Utah (AUC: 0.53; 95% C.I: 0.40-0.68) scores did not differentiate those who required RVAD. PAPi was significantly lower in patients requiring RVAD (2.5±1.2 vs 3.9±3.0, p=0.001). Also, even as a single parameter, PAPi had an AUC of 0.63 (95% C.I: 0.50-0.76). Conclusion: RVAD implantation is associated with high early mortality. Existing RVF prediction models were not able to predict future RVAD requirements with high AUC, with the EUROMACS system having the only statistical significance. There is a lack of a strong predictive model for RV failure in HM3. Future efforts are needed to establish predictors for RV failure requiring RVAD implants in the HM3 population, especially utilizing novel hemodynamic markers such as PAPi.

Abstract 4132909: Hemodynamic Indices of Right Ventricular Function Differentially Predict Adverse Clinical Outcomes in Heart Failure with Preserved vs Reduced Ejection Fraction

Background: While the critical role of right ventricular dysfunction (RVD) in heart failure (HF) is increasingly recognized, the prevalence and prognostic impact of RVD across HF subtypes is poorly understood. Research Questions/Aims: We aimed to characterize differences in hemodynamic indices of RV function among patients with HF with preserved vs reduced ejection fraction (HFpEF, EF≥50% vs HFrEF, EF&lt;50%) and to examine associations of RVD with longitudinal clinical outcomes by HF subtype. Methods: We identified patients with prevalent HF undergoing clinically indicated right heart catheterization at Massachusetts General Hospital (2005-2016). We examined three RV hemodynamic indices: right atrial to wedge pressure ratio (RA/PCWP), RV stroke work index (RVSWI), and pulmonary artery pulsatility index (PAPi). We used multivariable linear regression to assess differences in RV indices in HFpEF vs HFrEF. We then used Cox models to examine the association of each index with HF hospitalizations (HFH), major adverse cardiac events (MACE), and death, stratified by HF subtype. Models were adjusted for age, sex, BMI, hypertension, diabetes, lung disease, sleep apnea, and prior MI. Results: Of 2,062 patients (age 66 years, 33% women), 1,242 (60%) had HFrEF and 820 (40%) had HFpEF. RVD (RVSWI &lt;450 mm Hg*ml/m 2 ) was present in 27% of HFrEF vs 21% of HFpEF patients. Those with HFpEF had higher RA/PCWP (β 0.12, SE 0.05, p=0.012) and RVSWI (β 0.22, SE 0.05, p&lt;0.001) relative to HFrEF. Over 4.1 median years follow-up, 915 HFH, 1,066 MACE, and 1,116 death events occurred. Among those with HFrEF, lower PAPi was associated with greater risk of HFH (HR 0.84 (0.77, 0.92); p&lt;0.001) and MACE (HR 0.88 (0.81, 0.96); p=0.003), and higher RVSWI was associated with greater risk of death (HR 1.17, (1.07, 1.27); p&lt;0.001, Figure ). In contrast, in those with HFpEF, only higher RA/PCWP was associated with greater risk of death (HR 1.11 (1.00, 1.23); p=0.042). Conclusion: RVD occurs frequently in both HFrEF and HFpEF, and hemodynamic measures of RV function are associated with greater risk of MACE, death, and HFH. Importantly, the prognostic value of RV indices varied by HF subtype, highlighting key differences in the role of RVD in HFrEF vs HFpEF.

Is There a Correlation Between the Location of the Clot in the Pulmonary Arterial Tree with the Location of the Mucus Plug in the Pulmonary Bronchial Tree in Patients with chronic obstructive pulmonary disease Experiencing Pulmonary Embolism? Novel Findings.

The study aimed to investigate the impact of mucus plugs on the localization of clots in pulmonary embolisms among chronic obstructive pulmonary disease (COPD) patients. The retrospective study examined 200 participants diagnosed with both COPD and pulmonary embolism. Of these, 100 patients exhibited mucus plugs in the segmental and subsegmental branches of the pulmonary bronchial tree, while the remaining 100 did not, using computed tomography images for diagnosis. Data collection encompassed a comprehensive review of patient records, including medical history and imaging reports, to determine the presence of mucus plugs and the localization of clots in pulmonary embolism cases. Patients with mucus plugs exhibited a notably longer duration of COPD (P = .021) and a higher mean pulmonary arterial occlusion index (23 vs. 12, P = .001). Moreover, the prevalence of clots in major pulmonary arteries was significantly elevated in the mucus plug group compared to the non-mucus plug group (P < .05). Conversely, patients without mucus plugs displayed a higher incidence of clots in segmental and subsegmental arteries (P < .001). Strong positive correlations existed between mucus plugs in segmental branches and clots in major pulmonary arteries, with moderate to strong correlation coefficients (0.51 to 0.62, P < .05). Additionally, strong negative correlations were observed between mucus plugs in segmental branches and clots in segmental and subsegmental arteries, with correlation coefficients (CC) ranging from -0.74 to -0.76 (P < .05). Similarly, a significant negative correlation was noted between mucus plugs in subsegmental branches and clots in subsegmental arteries (CC: -0.68 and -0.71, P < .05). The results suggest that mucus plugs may be associated with increased severity of COPD, higher pulmonary arterial occlusion index, and altered clot distribution within the pulmonary artery tree. These findings emphasize the importance of recognizing mucus plugs as a key consideration in COPD assessment and management, potentially influencing disease severity, vascular remodeling, and thrombotic risk management.

Association Between Pulmonary Artery Pulsatility Index and Radial Artery Pulse Pressure and Successful Separation from Peripheral Veno-Arterial Extracorporeal Membrane Oxygenation: A French Single-Center Retrospective Study From 2017 to 2021

ObjectiveFew reliable tools exist to predict outcome of weaning patients from veno-arterial ECMO (VA-ECMO). Pulmonary artery pulse pressure indexed on right atrial pressure (PAPi) reflects the ventricular-pulmonary coupling and may be representative of right ventricle recovery. Radial artery pulse pressure (rPP) may be representative of left ventricular recovery. We intended to explore the usefulness of these indices in the weaning from VA-ECMO DesignRetrospective cohort study SettingSingle center in a tertiary university hospital ParticipantsPatients benefiting from a VA-ECMO for all-cause refractory cardiogenic shock between 2017 and 2021. Non-inclusion criteria were minor/pregnant patients, ECMO < 48 hours. Univariate and multivariate logistic regression analyses explored the relationship between PAPi and rPP with weaning success. InterventionsWe explored the association between the pulmonary artery pulse pressure indexed on right atrial pressure (PAPi), the radial artery pulse pressure (rPP) and the success of weaning from VA-ECMO. Measurements and Main Results124 patients were included for rPP analysis and 82 patients for PAPi analysis. Higher rPP and PAPi (50.43 vs 26.3 mmHg, p<0.001: 1.78 vs 0.88, p<0.001, respectively) and shorter ECMO duration were associated with weaning success. Areas under ROC for rPP and PAPi were 0.85 and 0.88. The combination of rPP ≥ 40 mmHg and PAPi ≥ 1.09 predicted weaning with a sensitivity of 0.94, specificity of 1.00, positive predictive value of 1.00 and negative predictive value of 0.84. ConclusionsHigher pulmonary arterial pulsatility index and radial artery pulse pressure were predictors of successful weaning from VA-ECMO in this retrospective study.

The pulmonary artery obstruction index (PAOI) score is correlated with right ventricular systolic pressure, tricuspid regurgitation and D-dimer values in patients with pulmonary embolism

The pulmonary artery obstruction index (PAOI) score is correlated with right ventricular systolic pressure, tricuspid regurgitation and D-dimer values in patients with pulmonary embolism

The clinical value of integrated pulmonary index monitoring during an endobronchial ultrasound-guided transbronchial needle aspiration procedure under sedoanalgesia: A prospective study.

To evaluate the clinical relevance of Integrated Pulmonary Index (IPI) monitoring during transbronchial needle aspiration (EBUS-TBNA) under sedation and determine whether it reduces hypoxic events compared to standard monitoring. This prospective observational research was carried out at Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey, between July 2022 and July 2023. A total of 50 patients, aged 18-80 years with American Society of Anesthesiologists scores of I-III, undergoing EBUS-TBNA with deep sedation for diagnostic purposes were included. The IPI values were measured at 6 time points: baseline, induction, 3, 5, 10 minutes, and at the end of the procedure. Patients were categorized based on whether their IPI scores were above 7 (group 1) or below 7 (group 2). A total of 43 patients completed the study. Group 1 had higher end-tidal carbon dioxide and respiratory rate at multiple time points, including induction and at 3, 5, and 10 minutes post-induction (p<0.05). Group 2 experienced a higher rate of apnea at these times (p<0.05). Those with lower IPI scores (namely, IPI=3 and IPI=4) showed significantly higher apnea rates, while those with higher scores (namely, IPI=7 and IPI=8) were less likely to have apneic episodes. The IPI monitoring during EBUS-TBNA under sedation demonstrated improved detection of apnea episodes and enhanced respiratory safety compared to standard monitoring techniques. Additional research involving more varied populations is necessary to confirm these results.

Factors affecting the use of salbutamol before hospital admission in children with asthma exacerbation.

Early home intervention for asthma exacerbation (AE) in children is associated with more favorable outcomes. Inhaled short-acting beta2 agonists (SABA) are the cornerstones of AE treatment. We aimed to determine what proportion of parents administered salbutamol to their children to treat asthma exacerbation at home, and the factors affecting the decision to administer the medication. Additionally, we also aimed to examine the parents' level of knowledge regarding salbutamol use. Asthma patients who were admitted to pediatric allergy outpatient clinics due to AE were included in the study. Parents' knowledge related to home salbutamol use was evaluated using a questionnaire. Modified Pulmonary Index Score was used to evaluate AE severity. The study included 177 children (64.4% males) with a median age of 6.16 years. Of these, 86 patients (48.6%) had not administered salbutamol before hospital admission, and parents of 69 (80%) patients stated that they knew salbutamol should be administered but they did not want to administer it without consulting a doctor. Of the 91 patients who had used salbutamol before hospital admission, 28 (30.7%) had administered the incorrect dose, 2 (2.2%) used the incorrect technique, and 9 (9.9%) had the incorrect dose and incorrect technique. In multivariate logistic regression analysis, history of hospitalizations (odds ratio [OR]: 6.35; 95% confidence interval [CI]: 3.07-13.9; P < 0.001), history of more than five exacerbations (OR: 4.51, 95%CI: 1.94-10.48; P < 0.001 ), and presence of sputum (OR: 2.54; 95%CI: 1.10-5.87; P = 0.028) were the main predictors of salbutamol use. Asthma patients and their parents should be better educated and actively encouraged on the use of SABA at home during an AE.

The effects of targeting mild hypercapnia on right ventricular function after out-of-hospital cardiac arrest. A sub-study of the TAME trial.

Abstract Background The Targeted Therapeutic Mild Hypercapnia After Resuscitated Cardiac Arrest (TAME) trial found similar neurological outcomes between mild hypercapnia and normocapnia in resuscitated out-of- hospital cardiac arrest (OHCA) patients. Hypercapnic acidosis can cause pulmonary vasoconstriction and aggravate right ventricular dysfunction, which is common and associated with worsened outcomes after OHCA. Purpose We investigated the effects of targeting mild hypercapnia on right ventricular function. Methods Single-centre, pre-planned and prospective sub-study. Comatose OHCA patients were randomised to targeted mild hypercapnia (PaCO2 =6.7–7.3 kPa) or targeted normocapnia (PaCO 2 =4.7- 6.0 kPa) for 24 hours. Transthoracic echocardiography was performed at baseline, during intervention and 48 hours after randomisation. Serial right heart catherisation (RHC) was performed if available. Results A total of 137 patients were randomised, 111 were evaluated with echocardiography and 52 and 59 randomised to mild hypercapnia and normocapnia, respectively. 84 patients received RHC; 41 and 43 in the hypercapnia and normocapnia-group, respectively. Overall, the median age was 64 years, 80 % were male and median time to ROSC was 22 minutes. Baseline characteristics did not differ significantly between treatments groups (p &amp;gt;0.05). Targeting mild hypercapnia was associated with lower tidal volumes, respiratory frequencies and respiratory acidosis (P-group &amp;lt; 0.05). Positive end-expiratory pressure, right atrial pressure, pulmonary vascular resistance index and pulmonary capillary wedge pressure were similar between groups (P-group &amp;gt; 0.05). Median time to echocardiography after randomisation was 21 (IQR 14-23) and 17 (IQR 9-22) hours in the hypercapnia and normocapnia-group, respectively. Tricuspid annular plane systolic excursion (TAPSE) was similar between treatment-groups at baseline and higher in the hypercapnia-group during the intervention with a median of 21 mm (IQR 18-23) versus 16 mm (IQR 13-21), p = 0.002. S', fractional area change (FAC) and the ratio of TAPSE to the pulmonary artery systolic pressure (PASP) were all higher in the hypercapnia-group during the intervention. Overall, median left ventricular ejection fraction was 45 % (IQR 38-55) without treatment group differences (p=0.2). Both invasive and echocardiographic assessment found increased cardiac index and stroke volumes in the hypercapnia-group (p &amp;lt;0.05). Right ventricular stroke work index (RVSWI) was consistently higher in the hypercapnia-group throughout the intervention (P-group &amp;lt; 0.001), while the pulmonary artery pulsatility index did not differ (P-group &amp;gt;0.05). Conclusions In patients resuscitated from OHCA, targeting mild hypercapnia compared to normocapnia was associated with increased TAPSE, S', FAC, TAPSE:PASP, RVSWI and cardiac index. Contrary to our prior concern these results indicate improved right ventricular function while targeting mild hypercapnia.

Pulmonary artery pulsatility index evaluation in intermediate-to-high and high-risk pulmonary embolism patients underwent transcatheter intervention

Abstract Background The clinical impact of pulmonary embolism (PE) transcatheter intervention on the right ventricular function and its potential role as procedural outcomes has to be defined. Methods Consecutive patients who underwent pulmonary transcatheter intervention between 2021 and 2023 were included in an observational fashion. Data about clinical characteristics, PE risk stratification, pre and post-interventional pulmonary artery pressure (PAP) and Pulmonary Artery Pulsatility Index (PAPi) were collected. The primary endpoint was a composite of in-hospital death or repeated intervention. Results 49 patients were included, mostly female gender (61.2%), with a mean age of 67±12,9 years old, 79.6% with &amp;gt; 1 PE risk factor, and 55% of them stratified as high-risk (HR) PE. 34.6% of the patients were treated with transcatheter thrombolysis (all in the intermediate-to-high-risk cohort), 20% with FlowTriever device, 53.4% with Indigo Cath8 or Lightning 12 device, 8.1% of the procedure was performed under ECMO support. All patients classified in intermediate-to-high risk (IHR) survived, and the mean PAP was reduced (33.4±10.9 to 24.3±7.1 mmHg p&amp;lt;0.01), as well as PAPi (2,3±0.35 to 1.68±0.26 p&amp;lt;0.01). 22% of the patients In IHR experienced the primary endpoint, in these populations, the mean PAP (pre 33±4.1 vs post 30.5±4.6 p=0.58) and PAPi (pre 1.35±.0.6 vs post 1.4±0.6 p=0.39) did not change significantly. On the other side, those who survived without events had a slight significative reduction in mean PAP (pre 32±6.7 vs post 24.6±4.3 p&amp;lt;0.02) while the PAPi significantly increased (1.2±0.6 vs 1.8±0.2 p&amp;lt;0.01). In the HR population, a delta PAPi &amp;gt; 0.45 demonstrated a 65.7% sensitivity and 75% Specificity for the primary outcome AUC 0.83 at ROC curve analysis. Conclusion Pulmonary Thrombus aspiration significantly changes the PAP and PAPi in patients with acute PE. While in IHR patients the overperforming PAPi seems to normalize, in HR patients it increases and may be a marker of procedural success and right ventricle recovery.

The hemodynamic classification system for hemodynamic-related adverse events in left ventricular assist device patients

Abstract Background Durable left ventricular assist device (LVAD) physiology predisposes to right heart failure (RHF) and aortic insufficiency (AI), recently labelled hemodynamic-related adverse events (HDREs). However, the pathophysiology, incidence, and associated morbidity of HDREs remains largely unsettled due to heterogeneity in data reporting. Purpose We sought to validate the recently proposed LVAD Hemodynamic Classification System (HCS) for HDREs. Methods RHF and AI HDREs were retrospectively adjudicated, staged (mild to severe) and phenotyped (isolated or combined RHF/AI-HDREs) based on the HCS assessed at 6-month post-LVAD implant among 183 consecutive patients undergoing LVAD implant at a quaternary heart failure center, and either alive at 6-month on support (n=175) or deceased due to late HDREs 1 to 6 months post-LVAD implant (n=8). The primary outcome was a composite of first HF hospitalization or cardiovascular death between 6 and 24 months after LVAD-implant. Results At 6-month assessment, RHF-HDRE was adjudicated in all patients, while AI-HDRE could not be adjudicated in 22 (12.0%) patients. Overall, 53 (29.0%) patients developed an RHF-HDRE, and 26 (16.0%) an AI-HDRE (phenotypes: 39 isolated RHF, 15 isolated AI, 11 combined RHF-AI, 3 not-adjudicated). During pre-LVAD assessment, age and pulmonary artery pulsatility index were independently associated with RHF-HDRE; and pre-LVAD AI and systolic pulmonary artery pressure with AI-HDRE. Patients developing the combined RHF-AI phenotype required the most intensive bundle of critical care pre-LVAD implantation, had more frequent pre-LVAD RV dysfunction, the highest rate of early post-LVAD RHF, and the most prominent features of suboptimal left ventricular unloading, RV dysfunction, peripheral congestion, renal damage and impaired functional capacity at 6-month assessment. RHF-HDRE (adj-HR 2.69, 95%CI 1.14-6.34, p=0.024), AI-HDRE (adj-HR 4.21, 95%CI 1.70-10.40, p=0.002) and HDRE phenotype (isolated RHF or AI HDRE vs. no HDRE: adj-HR 2.80, 95%CI 1.03-7.62, p=0.044; combined RHF and AI HDRE vs. no HDRE: adj-HR 4.53, 95%CI 1.33-15.35, p=0.015) were associated with the primary outcome. A graded increase in primary outcome was observed with rising RHF and AI stages. Conclusions The LVAD Hemodynamic Classification System for HDREs identifies pathophysiological and clinical clusters of patients with significant prognostic implications. It may help the development of targeted strategies to mitigate HDREs and improve the success of long-term LVAD support.

Glutathione s-transferase pi is a marker of loop diuretic resistance in patients with congestive heart failure exacerbation

Abstract Background Loop diuretic resistance (LDR) in patients with heart failure (HF) exacerbation is associated with worse clinical outcomes, greater symptom burden and mortality. Diagnosis and treatment of LDR remains a significant clinical dilemma. Purpose To assess the ability of different urine biomarkers to predict LDR in patients with HF exacerbation. Methods Consecutive patients with congestive HF exacerbation were prospectively included in the study. HF was diagnosed according to ESC 2021 HF Guidelines definition. Congestion was defined as a presence of one or more of the following signs: edema, ascites, pleural effusion. LDR was defined as persistent congestion on the 4th day of hospital stay despite high i.v. loop diuretic dose. Urine biomarkers released from different parts of the nephron (Kidney Injury Molecule-1 - KIM-1, N-acetyl-β-D-glucosaminidase - NAG, uromodulin, glutathione S-transferase Pi - pi-GST, aquaporin-2), transthoracic echo, clinical and biochemical parameters were evaluated on the 1st and 4th day of hospital stay. Results are presented as mean ±standard deviation or median (interquartile range). Results 40 patients were included in the study with median age 84 (72,8; 86) years, median left ventricle ejection fraction (EF) 35.3 (26,5; 49) %, median NT-proBNP 8967.5 (3024; 15241) pg/ml. LDR was found in 14 (35%) patients. Univariate analysis identified the following risk factors for LDR: urine pi-GST concentration on admission and on the 4th day, right ventricle to pulmonary circulation coupling index (TAPSE/PASP ratio), presence of mitral regurgitation, serum creatine concentration, serum urea concentration, serum LDL concentration. Logistic regression analysis identified pi-GST concentration as a significant independent risk factor for LDR in this population: odds ratio (OR) 5.75 [95% confidence interval (CI) 1.271–25.990]. Conclusions Urine pi-GST on admission and after 4 days of treatment might be a marker for a development of LDR in patients with congestive HF exacerbation.

Hemodynamic profiles and survival in chronic advanced heart failure patients evaluated for heart replacement therapy

Abstract Background Advanced heart failure (HF) is associated with dismal prognosis despite optimal medical therapy. Invasive assessment with right heart catheterization (RHC) is a valuable tool to assess transplant candidates and hemodynamic profiling is crucial to stratify prognosis and select patients for advanced therapies. Purpose This study aims to examine the relationship between hemodynamic profiles based on cardiac index (CI) and filling pressures and survival in ambulatory patients with advanced HF evaluated for heart replacement therapy (HRT) such as heart transplantation (HT) and left ventricular assist device (LVAD) implant. Methods We analyzed adult ambulatory advanced HF patients evaluated for HRT with an available baseline RHC from 2003 to 2022. Hemodynamic data were classified using a CI &amp;lt; 2.2 l/min/m2 as marker of reduced cardiac output ("cold" profile opposed to the "warm" profile) and increased filling pressure, defined as right atrial pressure ≥ 10 mmHg and/or pulmonary capillary wedge pressure (PCWP) ≥ 15 mmHg as a marker for congestion ("wet" profile opposed to the "dry" profile). Study endpoint was death or urgent HT or LVAD implant at 5 years. Results Study population included 610 patients (mean age 53±10 years, 79% males). According to hemodynamic criteria, 332 patients (55%) exhibited a "wet cold" hemodynamic profile, 117 (19%) a "cold dry", 91 (15%) a "warm wet" and 66 (11%) a "warm dry" phenotype. The "wet" patients showed a significantly higher prevalence of pulmonary hypertension (96% wet cold, 94% wet warm vs 21% dry warm, 19% dry cold; p&amp;lt;0,001), a lower pulmonary artery pulsatility index (4,0 wet cold, 4,1 wet warm vs 7,4 dry warm, 6,9 dry cold; p&amp;lt;0,001). No differences were found in etiology of HF. Both reduced CI [OR 1,6 (1-2,4), p=0.003] and increased filling pressures [OR 1,9, (1,2-2,8) p=0.007] were associated with worse outcomes. Survival differed significantly among hemodynamic profiles, with a survival rate of 48% in the "cold wet" profile compared to 68% in the "cold dry" [OR 1,9 (1,2-3,1) p=0,007] and 65% in the "warm dry" [OR 2,2 (1,1-4,2), p=0.01]. The difference between "cold wet" and "warm wet" was borderline significant (p=0.07). Further stratification between right and left ventricular filling pressures showed that isolated right ventricular congestion was rare and associated with low event rate, while in patients with preserved CI, biventricular congestion was associated with borderline worse survival as compared to isolated left ventricular increased filling pressures (p=0.06). Conclusions Hemodynamic profiles assessed with RHC stratify prognosis in ambulatory patients with advanced HF referred for HRT. Evaluation of hemodynamic phenotype may help identify subgroups of patients at high risk and guide therapeutic decisions. Further studies are needed to confirm these findings and develop personalized management strategies to improve clinical outcomes in this population.Survival-hemodynamic phenotypeSurvival-filling pressures

Deep Phenotyping of Pulmonary Edema and Pulmonary Vascular Permeability in COVID-19 ARDS.

Background Clinical monitoring of pulmonary edema due to vascular hyperpermeability in ARDS poses significant clinical challenges. Presently, no biological or radiological markers are available for quantifying pulmonary edema. Our aim was to phenotype pulmonary edema and pulmonary vascular permeability in patients with COVID-19 ARDS. Methods Transpulmonary thermodilution measurements were conducted in 65 COVID-19 ARDS patients on the day of intubation to determine extravascular lung water index (EVLWi) and pulmonary vascular permeability index (PVPi). In parallel, ventilatory parameters, clinical outcomes, the volume of lung opacity measured by chest CT, and plasma proteomics (358 unique proteins) were compared between tertiles based on the EVLWi and PVPi. Regression models were used to associate EVLWi and PVPi with plasma, radiological, and clinical parameters. Computational pathway analysis was performed on significant plasma proteins in the regression models. Results Patients with the highest EVLWi values at intubation exhibited poorer oxygenation parameters and more days on the ventilator. Extravascular lung water strongly correlated with the total volume of opacity observed on CT(r=0.72), while the PVPi had weaker associations with clinical and radiological parameters. Plasma protein concentrations demonstrated a stronger correlation with PVPi than with EVLWi. The highest tertile of PVPi was associated with proteins linked to the acute phase response (cytokine and chemokine signaling) and extracellular matrix turnover. Conclusions In the clinical setting of COVID-19 ARDS, pulmonary edema (EVLWi) can be accurately quantified through chest CT and parallels deterioration in ventilatory parameters and clinical outcomes. Vascular permeability (PVPi) is strongly reflected by inflammatory plasma proteins.

Hemodynamic Support With the Impella 5.5 Acute Mechanical Circulatory Support Device.

The Impella 5.5 is increasingly used as a bridge to recovery or heart replacement therapies despite lack of clinical trial evidence. We report real-world outcomes and hemodynamic effects of 150 consecutive patients from a single, high-volume center. Primary outcome was incidence of recovery, durable left ventricular assist device (LVAD), or heart transplant compared with incidence of death at 90 days. Secondary outcomes included hemodynamic trends and upgrade to veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. The composite endpoint occurred in 59.3% and death in 18.8% of patients (incidence rate ratio: 8.1 [95% confidence interval {CI}: 5.4-12.2], p < 0.001). Decreases in pulmonary artery diastolic pressure (PADP) (p = 0.026), estimated pulmonary effective arterial elastance (Ea) (p < 0.001), and vasoactive-inotropic score (VIS) (p < 0.001) occurred during Impella 5.5 support. Pulmonary artery diastolic pressure correlated with estimated Ea (p < 0.001), suggesting improved right ventricle (RV) afterload with left ventricle (LV) unloading. Veno-arterial extracorporeal membrane oxygenation upgrade occurred in 11.3% of patients who had higher baseline right atrial pressure (RAP) (16.0 [9.0-20.5] vs. 9.0 [7.0-12.0], p = 0.022), PADP (28.5 [25.0-31.0] vs. 23.0 [18.0-28.0], p = 0.011), and lower pulmonary artery pulsatility index (PAPi) (1.45 [0.82-3.45] vs. 2.5 [1.65-3.86], p = 0.029). Upgrade patients had higher repeated measures trends in RAP (p < 0.001) and PADP (p = 0.015). The Impella 5.5 improved hemodynamics and effectively bridged to recovery or heart replacement therapies. Co-existing RV dysfunction can be supported on Impella 5.5 with careful hemodynamic trend monitoring.

CT-based body composition analysis and pulmonary fat attenuation volume as biomarkers to predict overall survival in patients with non-specific interstitial pneumonia

BackgroundNon-specific interstitial pneumonia (NSIP) is an interstitial lung disease that can result in end-stage fibrosis. We investigated the influence of body composition and pulmonary fat attenuation volume (CTpfav) on overall survival (OS) in NSIP patients.MethodsIn this retrospective single-center study, 71 NSIP patients with a median age of 65 years (interquartile range 21.5), 39 females (55%), who had a computed tomography from August 2009 to February 2018, were included, of whom 38 (54%) died during follow-up. Body composition analysis was performed using an open-source nnU-Net-based framework. Features were combined into: Sarcopenia (muscle/bone); Fat (total adipose tissue/bone); Myosteatosis (inter-/intra-muscular adipose tissue/total adipose tissue); Mediastinal (mediastinal adipose tissue/bone); and Pulmonary fat index (CTpfav/lung volume). Kaplan–Meier analysis with a log-rank test and multivariate Cox regression were used for survival analyses.ResultsPatients with a higher (> median) Sarcopenia and lower (< median) Mediastinal Fat index had a significantly better survival probability (2-year survival rate: 83% versus 71% for high versus low Sarcopenia index, p = 0.023; 83% versus 72% for low versus high Mediastinal fat index, p = 0.006). In univariate analysis, individuals with a higher Pulmonary fat index exhibited significantly worse survival probability (2-year survival rate: 61% versus 94% for high versus low, p = 0.003). Additionally, it was an independent risk predictor for death (hazard ratio 2.37, 95% confidence interval 1.03–5.48, p = 0.043).ConclusionFully automated body composition analysis offers interesting perspectives in patients with NSIP. Pulmonary fat index was an independent predictor of OS.Relevance statementThe Pulmonary fat index is an independent predictor of OS in patients with NSIP and demonstrates the potential of fully automated, deep-learning-driven body composition analysis as a biomarker for prognosis estimation.Key PointsThis is the first study assessing the potential of CT-based body composition analysis in patients with non-specific interstitial pneumonia (NSIP).A single-center analysis of 71 patients with board-certified diagnosis of NSIP is presentedIndices related to muscle, mediastinal fat, and pulmonary fat attenuation volume were significantly associated with survival at univariate analysis.CT pulmonary fat attenuation volume, normalized by lung volume, resulted as an independent predictor for death.Graphical