Pulsatility Index Research Articles

To evaluate the usefulness of Doppler of the ophthalmic artery performed between 19 and 25 weeks of gestation to predict the occurrence of preeclampsia. This was a prospective longitudinal study conducted among pregnant women between the 19th and 25th weeks of gestation. The study was carried out from October 1, 2023, to May 31, 2024, in the Departments of Radiology and Medical Imaging and Obstetrics and Gynecology of the Sylvanus Olympio University Hospital in Lomé (Togo). The Doppler parameters were compared between pregnant women who developed preeclampsia and those who did not during follow-up. A total of 313 pregnant women were enrolled, including 80 cases of preeclampsia. Only the first systolic peak, the second systolic peak, the pulsatility index, and the ratio of systolic peaks were significantly associated with the occurrence of preeclampsia. The first peak of systolic velocity had a sensitivity of 78.75% and a specificity of 63.51% for a cut-off value of 40 cm/s, with an area under the curve of 0.769 (95% CI: 0.709-0.830). The second peak of systolic velocity had a sensitivity of 76.28% and a specificity of 84.97% for a cut-off value of 23.28 cm/s, with an area under the curve of 0.853 (95% CI: 0.801-0.905). The PSV ratio had a sensitivity of 72.50% and a specificity of 63.94% for a cut-off value of 0.80, with an area under the curve of 0.718 (95% CI: 0.587-0.718). Ophthalmic artery Doppler may play a crucial role in early screening of preeclampsia, allowing timely intervention and treatment.

This study investigates risk factors for the development of preeclampsia (PE) in women with twin pregnancies and constructs and validates a column-line diagram prediction model for clinical decision-making. Records of 70 women with PE and 70 women without PE were selected from twin pregnancies who underwent labor and delivery at Huzhou Maternity and Child Health Care Hospital between September 2021 and June 2023. The cohort was then divided into a training set (98 cases) and a validation set (42 cases) in the ratio of 7:3 using a simple random sampling method. Clinical risk factors, blood biochemical indexes, and uterine artery pulsatility index of all pregnant women were collected to assess the risk of PE. The results were presented as odds ratios (OR) with 90% confidence intervals (CI). Least absolute shrinkage and selection operator regression analysis was used to screen the predictors and establish an optimized, multifactorial logistic regression-based columnar graph model. Distinction, calibration, and clinical utility of the columnar plot model were evaluated by using the receiver operator characteristic curve, calibration plot, and decision curve analysis. Age (OR = 13.39, 95% CI = 2.152-157.0, P = .014), prepregnancy body mass index (OR = 5.979, 95% CI = 1.365-34.27, P = .027), mode of conception (OR = 3.498, 95% CI = 1.071-12.79, P = .045), serum homocysteine cysteine level (OR = 2.079, 95% CI = 1.193-4.005, P = .016), serum β-human chorionic gonadotropin level (Log10; OR = 9.984, 95% CI = 1.467-82.77, P = .024), uterine artery pulsatility index (per0.1; OR = 1.347, 95% CI = 1.11-1.7, P = .005) were independent risk factors for PE (P < .05), and the column-line graph prediction model based on the above 6 risk factors had a good discriminatory degree (area under curve value: 0.880, 95% CI = 0.817-0.944 for training set validation, and 0.831, 95% CI = 0.704-0.958 for validation set validation). The calibration curve showed good agreement between the predicted and actual probabilities of the model (P > .05), and the decision curve analysis showed that the model had a high net clinical benefit (threshold probability values: >2.5% for the training set, 18% to 75% for the validation set). The column-line diagram model developed in this study can more accurately predict the risk of developing PE in women with twin pregnancies.

Abnormal cerebrovascular pulsatility is associated with white-matter injury, blood-brain-barrier leakage, and impaired glymphatic clearance, yet its extent in the microvasculature and aging dynamics remained obscured due to experimental and technical limitations. A multi-modal approach for quantifying flow and diameter pulsatility in small cerebral vessels is developed and applied it longitudinally in male C57BL/6JRj mice from 18 to 81 weeks, both in awake and anesthetized conditions. In the awake state, mean perfusion and pulsatility indexes varied by <10%, indicating preserved hemodynamics until late life when arterial diameter pulsatility and venular caliber rose modestly. Anaesthesia radically changes the microvascular dynamics: isoflurane produces age-dependent hyperemia, and both isoflurane and ketamine-xylazine double flow pulsatility and reshape diameter oscillations in drug-specific ways. To complement the longitudinal data from males, a separate cross-sectional comparison between sexes at 50-51 weeks of age is performed, which reveal significantly lower microvascular flow pulsatility in females despite no difference in mean perfusion. The results suggest that microvascular pulsatility remains stable during healthy aging yet can shift dramatically depending on the animal's condition, even if average cerebral perfusion isunchanged.

This study aims to evaluate the clinical utility of the Middle Cerebral Artery Diastolic Deceleration Area (MCA DDA) as a novel Doppler parameter for predicting hypoxia and adverse perinatal outcomes in pregnancies complicated by Fetal Growth Restriction (FGR). A prospective observational study was conducted at the Perinatology Clinic of Ankara Bilkent City Hospital between November 2023 and November 2024. A total of 102 singleton pregnancies were enrolled, including 51 FGR cases and 51 gestational age-matched controls. All participants underwent comprehensive ultrasonographic and Doppler assessments at 34 weeks of gestation. Doppler parameters, including Umbilical Artery Pulsatility Index (UA PI), Middle Cerebral Artery Pulsatility Index (MCA PI), Cerebroplacental Ratio (CPR), Cerebroplacental-Uterine Ratio (CPUR), and the novel MCA DDA, were recorded. Receiver Operating Characteristic (ROC) analysis was performed to evaluate the predictive performance of these parameters for composite adverse perinatal outcomes (CAPO), which included NICU admission, 5-min Apgar score < 7, umbilical artery pH < 7.20, and perinatal mortality. MCA DDA was significantly higher in the FGR group (9.26 ± 2.31) compared to controls (7.49 ± 2.98, p < 0.001). ROC analysis revealed that MCA DDA had an area under the curve (AUC) of 0.63 (95% CI: 0.52-0.75, p = 0.023) with an optimal cut-off value of 8.43 (sensitivity 63.6%, specificity 61.0%). In comparison, CPR demonstrated superior predictive performance with an AUC of 0.71 (95% CI: 0.59-0.82, p = 0.001), while CPUR showed an AUC of 0.66 (95% CI: 0.55-0.78, p = 0.006). The FGR group had significantly higher rates of CAPO (80%) and NICU admissions (42.2%) compared to the control group (p < 0.001). While MCA DDA is significantly elevated in FGR cases and provides valuable insights into cerebral diastolic blood flow, its predictive ability for adverse perinatal outcomes is moderate compared to traditional Doppler indices like CPR and CPUR. Integrating MCA DDA with established parameters may enhance fetal surveillance and improve perinatal outcome prediction in pregnancies complicated by FGR.

Minimum test tradeoff applied to uterine artery pulsatility index for antepartum prediction of preeclampsia.

Background: Heavy menstrual bleeding (HMB) is a prevalent and distressing manifestation among women with ovarian endometrioma, significantly affecting daily life and reproductive health. Evaluating uterine blood flow through Doppler ultrasound provides a non-invasive means to understand the hemodynamic alterations underlying endometriosis-related menstrual dysfunction. This study aimed to assess uterine perfusion parameters and identify clinical predictors of severe HMB in affected women. Objective: To evaluate uterine perfusion indices and determine the key clinical predictors of severe heavy menstrual bleeding in women with ovarian endometrioma. Methods: A cross-sectional study was conducted on 139 women aged 18–45 years with ultrasonographically confirmed ovarian endometrioma and HMB. Demographic and clinical data, including menstrual characteristics, PBAC scores, and pain symptoms, were recorded. Transvaginal Doppler ultrasonography was used to measure the uterine arterial Resistance Index (RI), Pulsatility Index (PI), Peak Systolic Velocity (PSV), End-Diastolic Velocity (EDV), and vessel diameter bilaterally. Statistical analysis was performed using Chi-square, Pearson or Spearman correlation, and multivariable logistic regression to identify predictors of severe HMB (PBAC ≥300). A p-value &lt;0.05 was considered significant. Results: Severe HMB occurred in 61.9% of participants and was significantly associated with chronic pelvic pain (p&lt;0.001), dysmenorrhea (p&lt;0.001), and bilateral endometriomas (p=0.001). Multivariate analysis identified chronic pelvic pain, dysmenorrhea, and bilateral endometriomas as independent predictors of severe bleeding. Mean Doppler indices showed slightly higher RI (0.89±0.04) and PI (2.95±0.20) in the right uterine artery than the left (RI 0.87±0.05; PI 2.88±0.18), suggesting mild lateral variation. No significant associations were observed for age, residence, or BMI. Conclusion: Chronic pelvic pain, dysmenorrhea, and bilateral ovarian endometriomas emerged as strong clinical predictors of severe HMB, highlighting the need for early diagnosis and individualized management. Although Doppler parameters provided valuable insights into uterine hemodynamics, they were not directly correlated with bleeding severity. Integrating clinical and Doppler evaluations can enhance diagnostic precision and inform targeted therapeutic approaches in endometriosis-related HMB.

Background: Cardiovascular (CV) risk factors such as hypertension have been linked to accelerated cognitive decline with aging but underlying hemodynamic mechanisms are unclear. Aortic stiffening, quantified by pulse wave velocity (PWV), may contribute to microvascular injury by elevating transmitted pulsatility and triggering vascular adaptations that limit blood flow. Using a novel single-session 4D flow MRI protocol we assessed heart-brain hemodynamics in cognitively asymptomatic adults with and without hypertension. Hypotheses: Age, higher CV disease (CVD) risk, and aortic PWV are associated with amplified intracranial pulsatility and reduced flow/velocity. Methods: Data have been collected in 24 cognitively asymptomatic adults (62.3±7.4 years; 7 males; 8 hypertensive; Telephone-MoCA≥17). CVD risk was determined using the simplified Framingham model, and physical activity was assessed by self-report. CV and intracranial 4D flow research sequences were acquired at 3T (Prisma, Siemens). Preprocessing and segmentation of aorta and Circle of Willis (CoW) were applied. Mean and peak velocity (Vmean, Vmax; m/s), and time-to-peak (TTP; ms) were quantified voxel-wise. Flow (ml/s), pulsatility index (PI), and aortic PWV were quantified as detailed in Fig 1. PWV was inverse transformed (PWV.T; ms/m). Results: Hypertensive participants were older (69.1±7.4 vs 58.9±4.5 years, p&lt;0.01), had higher CoW PI (1.16±0.28 vs 0.99±0.09, p=0.04), and lower CoW Vmax (0.71±0.06 vs 0.79±0.09 m/s, p=0.03) than controls. CVD risk score was associated with higher PI and lower velocities in the CoW (Fig 2). Higher physical activity was associated with higher CoW Vmean, Vmax, and flow (rho=0.47-0.48; p=0.02-0.03) and lower PI (rho=-0.43, p=0.04). Inverse relationships were found for: CoW Vmax with aortic PWV.T (r=-0.46, p=0.03), and CoW PI with TTP in both regions (r aorta =-0.43, p=0.04; r CoW =-0.45; p=0.03). CoW and aortic TTP showed moderate correlation (r=0.41, p=0.04; Fig 3). Conclusion: Preliminary results show correlations between heart and brain hemodynamic measures. Hypertension and CVD risk were related to adverse CoW hemodynamics, while physical activity showed favorable associations. Aortic PWV was related to lower intracranial peak velocity, suggesting a possible downstream effect. Expected association between aortic PWV and CoW PI was not observed. Findings highlight the complexity of heart-brain hemodynamics and support ongoing recruitment for stratified age-matched analysis.

Introduction: Fetal ductus arteriosus constriction (DAC) can cause hydrops, pulmonary arterial (PA) hypertension and even death. Maternal drug/dietary factors can cause DAC and resolve with withdrawal. Data on DAC postnatal outcomes is limited. In the current study we sought to explore the pre- and postnatal evolution and outcomes of DAC. Methods: We identified all pregnancies with structurally normal hearts and DAC in our program from 2009-2024. Those with ductal systolic velocity &gt;1.4 m/s, diastolic velocity &gt;0.35 m/s, pulsatility index &lt;1.9 were included. Fetal and neonatal clinical/echo parameters were collected. Right ventricular systolic dysfunction (RVDys) was defined as fractional area change (FAC) &lt;35%. Results: Of 41 fetuses with DAC, 17(41%) were referred for suspected fetal heart disease. Only 7 (17%) had an identifiable cause (5 drug related, 2 dietary). See Table 1 for fetal echo data. At diagnosis 2 had hydrops (1 with a non-cardiac cause) and none developed hydrops at review. The majority (9/15, 60%) with tricuspid regurgitation had gradients &gt;1/2 estimated systemic pressure. Four of 13 (31%) with RVDys received prenatal treatment (3 digoxin, 1 oxygen). Four fetuses had complete ductal closure (DC), all idiopathic and diagnosed at &gt; 33 weeks gestational age (GA). Of 32 with serial fetal echo, 14(43%) had resolution of DAC, including 5 with known cause, and of 6 with RVDys, 3(50%) improved when the cause was discontinued and 4 had ongoing RVDys. The fetus with hydrops due to DAC was delivered urgently on presentation at 36 weeks GA. Two of the 4 with DC required urgent preterm delivery due to RVDys and abnormal venous Dopplers. Postnatal data were available for 32(78%), all were admitted to the neonatal intensive care unit. One died from noncardiac causes. Three(9%) required invasive ventilation (including 2 with DC) and 18(56%) required CPAP. Only 2 received pulmonary vasodilators (2 nitric oxide, 1 sildenafil for &lt;2 weeks). Of 26(81%) postnatal echoes, 21(81%) had &gt;1/2 systemic PA pressure at 1 st echo, of whom 7(33%) normalized prior to discharge and a further 8(38%) on follow-up, with no follow up in 6(29%). Of 12 with prenatal RVDys and neonatal followup, all normalised by discharge. Five had genetic abnormalities and 9 had significant extracardiac pathologies. Conclusions: Despite a worse trajectory in cases with idiopathic DAC, postnatal outcomes are favorable in both subsets with resolved RVDys and resolved PA hypertension in infancy.

The anatomical and physiological congruence of cynomolgus macaques ( Macaca fascicularis ) to humans make them valuable models for translational research into heart failure (HF), renal disease (RD), and cardio-renal syndrome (CRS). In this study, we characterized aged cynomolgus monkeys with atherogenic diet-induced heart failure with reduced ejection fraction (HFrEF), including those with albuminuric RD—with or without changes in glomerular filtration rate (GFR)—to determine CRS progression and to compare findings with age-matched healthy controls. Sixty cynomolgus monkeys with HFrEF (mean ejection fraction [EF] 55.3% ± 0.7%) were studied. Animals were stratified into two groups based on baseline albuminuria status: microalbuminuric (HFrEF+RD; n=30) and normoalbuminuric (HFrEF-only, n=30). Multimodal diagnostics included cardiac 2D echocardiography, renal ultrasound, and biochemical analyses of urine and blood samples. Parameters assessed were 24-hour urine albumin-creatinine ratio (UACR), blood urea nitrogen, serum creatinine, and estimated GFR. Renal hemodynamics were evaluated by renal artery volume flow, peak systolic velocity, resistive index (RI), and pulsatility index (PI). HFrEF+RD animals exhibited a significant 2.8-fold increase in UACR over 25 weeks from 47.9±16.6 mg/g to 134.6±50.6 mg/g (p&lt;0.001) while the UACR of the HFrEF-only animals remained stable. Baseline renal ultrasound revealed significantly lower renal artery volume flow (p&lt;0.01) and peak systolic velocity (p&lt;0.0001) in both HFrEF+RD and HFrEF-only groups compared to controls. GFR was moderately reduced in both groups implying mild to moderate renal functional impairment. Notably, RI and PI values remained within normal limits, consistent with early or less severe renal vascular injury. These findings reflected evolving CRS primarily characterized by progressive proteinuria and declining renal hemodynamics essentially in the HFrEF+RD cohort. These findings demonstrate that aged cynomolgus macaques with HFrEF develop CRS phenotypes closely resembling human disease, with HF contributing to progressive renal impairment through hemodynamic and molecular mechanisms. This NHP model offers significant translational potential to elucidate bidirectional heart-kidney interactions, and to enable the preclinical evaluation of novel therapeutic strategies targeting CRS.

Introduction: Left ventricular assist devices (LVAD), widely adopted internationally, have been increasingly implemented in China as a vital life-support strategy for patients with end-stage heart failure. Non-pulsatile blood flow is a defining physiological characteristic of LVAD support. Although an association between reduced pulsatility and adverse outcomes continues to be proposed, robust clinical evidence remains lacking. Methods: Retrospective study of adults (&gt;18 years) receiving LVADs at four Chinese cardiac medical centers (Jan 2019 - Jul 2024) was conducted. Systemic pulsatility index (PI, calculated as pulse pressure divided by the mean arterial pressure) was derived from blood pressure measurements pre-LVAD and serially post-LVAD (days 1, 7, 14, 21, 28). Latent Class Trajectory Modeling (LCTM) identified distinct population groups based on PI trajectories; optimal model selection used lowest Bayesian Information Criterion (BIC), posterior probability &gt;0.8, and group size &gt;2%. The primary outcome was 90-day major adverse events (MAE: mortality or complications). Association between PI trajectories and clinical outcomes were assessed using univariable and multivariable logistic regression (adjusted for age, sex, BSA, pre-MI and INTERMACS level). Results: Among 115 LVAD patients (mean age 49.4 years, 87.3% male, mean LVEF 24.8%), LCTM failed to identify distinct groups when including pre-LVAD PI. Overall, PI markedly declined post-implantation compared to baseline. However, LCTM using only post-LVAD data revealed four distinct PI trajectory classes. Patients with persistently higher PI post-LVAD had a significantly lower incidence of postoperative myocardial infarction/injury (MI) compared to those with persistently low PI (OR 0.21, 95% CI 0.06–0.78, p=0.020). Further logistic regression confirmed this association between post-LVAD PI trajectory and MI occurrence. No significant differences were observed in major adverse events, mortality, or other complications among trajectory groups. Conclusion: In China's largest LVAD cohort, PI trajectory analysis revealed that patients maintaining persistently higher PI post-LVAD had a significantly lower risk of postoperative MI compared to those with persistently low PI.

ABSTRACT Aim To determine the impact of a community‐oriented model integrating first‐trimester risk stratification, fetal Doppler and routine antenatal ultrasound on preeclampsia (PE) and perinatal mortality rates in a rural population of central India. Methods The program covered 168 public sector centres providing pregnancy care services to nearly 1500 pregnancies annually. First‐trimester assessments included measurement of mean arterial blood pressure, mean uterine artery pulsatility index, risk stratification for preterm PE, recommending low‐dose aspirin 150 mg for women at high risk for preterm PE, and health education for public sector community health workers, pregnant women and their families. Second and third trimester assessments included fetal biometry, growth, fetal Doppler studies of uterine, umbilical, middle cerebral arteries and estimation of the cerebroplacental ratio, staging and protocol‐based management of fetal growth restriction and individualised clinical management of PE. Results The analysis included 4808 pregnant women screened from September 2019 to May 2025. Childbirth outcomes were available for 4016 (83.5%) women. The first trimester screening protocol ( n = 2933) identified 4.2% ( n = 124) women only at high risk for preterm PE and 10.7% ( n = 313) women at high risk for both preterm PE and fetal growth restriction. PE was reported in 28 (0.7%) of the 4016 women with childbirth outcomes. The perinatal mortality rate was 16.4/1000 childbirths in 2025 compared to 37.0/1000 childbirths in 2016. Health education was provided to all screened pregnant women and healthcare staff of the healthcare centres. Conclusion The community‐oriented model reduced the magnitude of PE and perinatal mortality in this rural community.

Background: Right ventricular failure (RVF) is a significant and potentially fatal complication following left ventricular assist device (LVAD) implantation. Clinically, RVF post-LVAD is difficult to accurately predict. Machine learning (ML) offers a promising approach to predict RVF after LVAD. Objective: To develop and evaluate machine learning models for the prediction of RVF following LVAD implantation. Methods: A comprehensive set of clinical, laboratory, echocardiographic, and demographic variables was utilized to train six machine learning classification models: decision tree, logistic regression, random forest, k-nearest neighbors, support vector machine, and gradient boosting. Each model was trained over 20 iterations using a 9:1 train-test split. Model performance was assessed using the area under the receiver operating characteristic curve (AUROC). Logistic regression weight analysis was employed to identify clinically relevant predictive variables for early and total RVF. Results: We analyzed 246 patients who underwent left ventricular assist device (LVAD) implantation at our center between January 2004 and December 2017. All patients underwent right heart catheterization (RHC) within 30 days prior to implantation and transthoracic echocardiography (TTE) within 30 days post-implantation to assess for early or late right ventricular failure (RVF). Early RVF was defined as the need for an unplanned right ventricular assist device (RVAD) within 30 days after LVAD implantation or requirement for more than 14 days of continuous inotropic support. Late RVF was defined as patients requiring medical intervention following the index hospitalization. ML models robustly predicted early RVF (AUROC: 0.769–0.841) and total RVF (0.765–0.850), with the random forest algorithm demonstrating the best performance for both. Models predicting late RVF were not as robust (0.467–0.593). Logistic regression weight analysis identified pulmonary artery pulsatility index (PAPi), global longitudinal strain (GLS), right ventricular dP/dt, and alanine aminotransferase (ALT) as clinically relevant predictors of early and total RVF. Conclusions: ML models reliably predicted early and total RVF following LVAD implantation. These findings support the potential utility of ML models in improving risk stratification to guide clinical decision-making in this high-risk population.

Introduction: Right ventricular failure (RVF) is a major adverse event following left ventricular assist device (LVAD) implantation. The complex mechanisms involved make it challenging to accurately predict RVF. Although supervised machine learning is useful for predicting complex outcomes, it is often difficult to identify specific factors that increase a patient's risk. This study aimed to assess the risk of RVF in individual patients and identify their unique risk factors using supervised machine learning. Methods: Between June 2010 and January 2024, 482 consecutive patients underwent continuous-flow LVAD implantation at Osaka University Hospital or the National Cerebral and Cardiovascular Center. Of them, 326 who underwent preoperative right heart catheterization and echocardiography were included in the analysis. Important features for predicting the risk of RVF were selected using the χ2 or Mann-Whitney U test, the Gini index in a random forest algorithm, and a literature review. The optimal classification algorithm for this analysis was selected from among the random forest, eXtreme Gradient Boosting, support vector machine, logistic regression, and ensemble learning algorithms by comparison of the area under the curve, accuracy, F1 score, and sensitivity through five-fold cross-validation of the test data. The SHapley Additive exPlanations (SHAP) value was used to assess the individual risk factors for RVF. Results: Thirteen important features (sex, age, non-ischemic cardiomyopathy, body surface area, aspartate aminotransferase level, blood urea nitrogen level, left ventricular end-diastolic dimension, left ventricular ejection fraction, right ventricular stroke work index, central venous pressure, pulmonary capillary wedge pressure, pulmonary pulsatility index, and Interagency Registry for Mechanically Assisted Circulatory Support profile) were selected. Ensemble learning was the most reliable classification algorithm. The area under the curve, accuracy, F1 score, and sensitivity were 0.87, 0.89, 0.77, and 0.80, respectively. The SHAP analysis revealed that impaired right ventricular function assessed by right heart catheterization, poor preoperative condition, and a good ejection fraction were associated with an increased risk in most cases. Conclusions: Supervised machine learning enables the accurate prediction of RVF after LVAD implantation, while SHAP values visualize individual risk factors and may optimize preoperative conditions.

To identify preoperative risk factors associated with postlaser fetal death of the donor twin in a large cohort of pregnancies complicated by twin-twin transfusion syndrome (TTTS). This retrospective cohort study of prospectively collected data included monochorionic diamniotic pregnancies complicated by TTTS that underwent laser surgery between March 2006 and May 2024 at two specialized referral centers. Patients underwent a comprehensive ultrasound examination, including fetal Doppler evaluation, to assign a Quintero stage and to obtain the middle cerebral artery (MCA) peak systolic velocity (PSV) for each twin within 24 h before laser surgery. An isolated elevation of the donor MCA-PSV was defined as having an MCA-PSV > 1.5 multiples of the median (MoM) in the absence of twin anemia-polycythemia sequence (TAPS). TAPS was defined as donor MCA-PSV > 1.5 MoM and recipient MCA-PSV < 1.0 MoM or intertwin MCA-PSV difference of > 0.5 MoM. Patients underwent postoperative ultrasound the day after surgery to document cardiac activity in each twin. Univariate logistic and multivariable Poisson (Zou's method) regression models were used to estimate the odds ratio and adjusted relative risk (aRR) for donor twin demise, adjusted for TAPS, TTTS stage, selective fetal growth restriction (sFGR), donor MCA pulsatility index < 10th percentile, gestational age < 18 weeks at surgery and other risk factors. Fetal demise of the donor twin was noted in 14.3% (229/1602) of the study population. Preoperative isolated elevation of donor MCA-PSV conferred the highest aRR of any risk factor for postlaser donor fetal demise (aRR, 2.69 (95% CI, 1.91-3.81); P < 0.001) compared with Stage-III TTTS (aRR, 2.34 (95% CI, 1.36-4.02); P = 0.002), MCA pulsatility index < 10th percentile (aRR, 1.91 (95% CI, 1.48-2.46); P < 0.001), velamentous cord insertion in the donor twin (aRR, 1.86 (95% CI, 1.43-2.41); P < 0.001), TAPS (aRR, 1.63 (95% CI, 1.19-2.23); P = 0.001), gestational age < 18 weeks at laser surgery (aRR, 1.59 (95% CI, 1.21-2.08); P = 0.001) and sFGR (aRR, 1.58 (95% CI, 1.19-2.07); P = 0.001). The observed frequency of fetal demise of the donor twin increased with each additional concomitant risk factor included. Isolated elevation of donor MCA-PSV prior to laser surgery for TTTS conferred the highest aRR for donor fetal demise among risk factors including TAPS, TTTS staging, sFGR and other covariates. This risk increased progressively when more than one risk factor was present in pregnancies complicated by TTTS. © 2025 International Society of Ultrasound in Obstetrics and Gynecology.

Background: Combined support with a micro-axial flow pump (mAFP) and venoarterial extracorporeal membrane oxygenation (VA-ECMO) (ECPELLA) is effective for refractory biventricular failure after cardiac arrest. However, VA-ECMO weaning can be challenging in patients with right ventricular (RV) failure or pulmonary hypertension. Inhaled nitric oxide (iNO) selectively dilates the pulmonary arteries, reducing RV afterload and potentially facilitating ECPELLA weaning. We report a case in which iNO enabled successful VA-ECMO removal in a patient with precapillary pulmonary hypertension. Case Presentation: An 83-year-old woman with hypertension, diabetes mellitus, chronic kidney disease, and peripheral artery disease (PAD) was admitted for heart failure exacerbation. After stabilization with medical therapy, she was transferred to a rehabilitation hospital. However, during rehabilitation she developed ventricular tachycardia. After successful resuscitation, she was readmitted to our center. Electrocardiography and echocardiography diagnosed anteroseptal acute coronary syndrome with cardiogenic shock. Emergent coronary angiography revealed critical stenosis of the left anterior descending artery. Percutaneous coronary intervention under mAFP support was performed, but systemic hypoperfusion persisted, prompting initiation of VA-ECMO to establish ECPELLA. Treatment and Outcome: Right heart catheterization under ECPELLA support demonstrated a mean pulmonary artery pressure of 27 mmHg, a pulmonary capillary wedge pressure of 6 mmHg, a pulmonary vascular resistance of 11.7 Wood units, and a pulmonary artery pulsatility index (PAPi) of 3.0—findings consistent with precapillary pulmonary hypertension and markedly reduced native cardiac output (CO) that precluded VA-ECMO weaning. Concomitant limb ischemia from PAD prompted initiation of iNO at 20 ppm. Following iNO, pulmonary vascular resistance decreased and both PAPi and native CO improved, allowing stepwise VA-ECMO weaning. VA-ECMO was removed on hospital day 2 and mAFP on day 3. Despite initial hemodynamic stabilization, worsening limb ischemia led to uncontrollable renal dysfunction and acidosis, and the patient died on day 4. Teaching Point: Early iNO may lower pulmonary vascular resistance, improve PAPi and native CO, and enable VA-ECMO weaning in ECPELLA patients with precapillary pulmonary hypertension.

Background: Cox proportional hazards models are common statistical methods widely used in cardiovascular research that depend on several key assumptions of the data to ensure validity of results. The assumption of linearity (that is, proportional), or the linear relationship between predictor variables and the log of the hazard, is rarely tested but recently observed in our group’s research to be unreliable. This discovery may prevent biased risk estimates if true relationships are nonlinear. Research Question: To interrogate the assumed linearity between key hemodynamic variables used in heart transplant risk stratification and patient outcomes, understanding the methodological reliance on standard Cox modeling in research design. Methods: Using a population subgroup defined for another study of adult, heart-only transplant candidates (Status 1-3) without mechanical circulatory support (MCS) listed in the UNOS Registry from 10/18/2018 to 09/30/2024 with follow-up through 10/04/2024. Hemodynamic values at listing were assessed for association with the outcome of death/deterioration on the waitlist. To evaluate the potentially nonlinear relationship between hemodynamic variables and the log cause-specific hazard, we applied restricted cubic splines to the above hemodynamic variables prior to inclusion into the cause-specific Cox proportional hazards model. Results: In total, 2,718 non-MCS patients were included. There was a significant non-linear association between left ventricular cardiac power output (CPOLV) (p-nonlinear = 0.012) and pulmonary artery pulsatility index (PAPI) (p-nonlinear = 0.033) with the outcome of death/deterioration on the waitlist. Additionally, these findings display threshold effects, where these variables can be treated as continuous below certain cutoff values but plateau beyond them. For instance, risk of death/deterioration increased sharply below PAPI = 2.42 but plateaued beyond that, violating linearity assumptions. Conclusion: Our findings demonstrate that commonly used hemodynamic markers may not exhibit linear risk relationships. This implies that Cox regression may misestimate true risk at certain hemodynamic values when analyzing not only CPOLV and PAPI, but perhaps other physiologic estimates in cardiac research. Thus, our results highlight the need for more routine testing for nonlinearity in Cox models when employed in cardiovascular outcomes research.

Clinical Course: A 62-year-old male with a history of coronary artery disease presented with one month of intermittent chest pain which progressed to severe persistent chest pain. Initial vitals: blood pressure 78/50 mmHg, pulse rate 100 bpm, and oxygen saturation 94%. Examination revealed bilateral pulmonary crackles and grade 4/6 holosystolic murmur at the cardiac apex. The electrocardiogram suggested inferolateral STEMI, and the patient was taken for coronary catheterization, and intubated due to hypoxic respiratory failure from pulmonary edema. Impella CP was placed for hemodynamic support. Catheterization revealed 100% occlusion of the mid-left circumflex (LCx), 75% occlusion of the distal left anterior descending artery, and chronic total occlusion of the right coronary artery. Two drug eluting stents were deployed to the mid-LCx lesion, achieving TIMI 3 flow. Emergent transesophageal echocardiogram (TEE) revealed hyperdynamic LV systolic function, severe mitral regurgitation (MR) with severe MV flail involving the posterior leaflet (Figure 1a-c). The posterolateral papillary muscle head was ruptured (Figure 1d). Despite Impella CP and pressor support with norepinephrine at 4 mcg/min, cardiogenic shock persisted; mixed venous oxygen saturation (MVO2) was 47%, pulmonary artery pulsatility index (PAPi) was 1.4, cardiac power output (CPO) was 0.61 W. Upgrading to Impella 5.5 improved MVO2 to 68%, PAPi to 2.5, and CPO to 1.16 W. He underwent coronary artery bypass grafting (CABG) and surgical mitral valve replacement (MVR) with a bioprosthetic valve. Following surgical MVR, TTE revealed an appropriately functioning bioprosthetic valve, and LV ejection fraction of 35-40% with multiple areas of hypokinesis. Despite appropriate prosthetic valve function, the patient suffered pulmonary hemorrhage, septic shock, and expired on hospital day 10. Discussion: Papillary muscle rupture is an uncommon complication of acute myocardial infarction but is often fatal. In our patient, TTE was imperative in timely recognition and management of acute MR and preparation for MVR. Impella mechanical circulatory support was used as a bridge to surgical intervention with MVR and temporized the patient’s cardiogenic shock. Despite its importance, literature on Impella use in this condition is scarce. While the patient ultimately expired, prompt use of echocardiography and Impella were important to bridge the gap to MVR.

Background: While early reperfusion therapy via PCI has significantly reduced mortality in STEMI patients, outcomes remain poor for those presenting with cardiogenic shock (CS) or severe heart failure. With increasing use of mechanical circulatory support (MCS), hemodynamic parameters measured by pulmonary artery catheters (PAC), such as cardiac power output (CPO) and pulmonary artery pulsatility index (PAPi), are being re-evaluated for prognostic purposes. Pulmonary arterial elastance (PaE), reflecting right ventricular afterload, is one such parameter. In this study, we used a simplified form of PaE, defined as systolic pulmonary artery pressure (sPAP) divided by stroke volume (SV), to assess its prognostic utility in STEMI patients with CS or severe heart failure. Methods: From a cohort of 1,390 STEMI patients who underwent PCI between January 2014 and December 2023, we included 145 patients who presented with Killip class 3–4 heart failure, had no missing PAC data, and were not treated with V-A ECMO or IMPELLA. All patients underwent right heart catheterization immediately after PCI. Simplified PaE (sPAP/SV), CPO, and PAPi were calculated, and their associations with in-hospital mortality were assessed using ROC curves and multivariable logistic regression. Results: In-hospital mortality occurred in 18.6% of patients. Simplified PaE showed the highest prognostic value (AUC = 0.729), outperforming CPO (AUC = 0.707) and PAPi (AUC = 0.501). The optimal cutoff value for simplified PaE was 1.38 mmHg/mL , above which in-hospital mortality was 50.0% , compared to 10.4% below the cutoff ( p &lt; 0.001 ). In multivariable analysis, simplified PaE remained independently associated with in-hospital death (OR per 0.1 mmHg/mL increase: 1.15; 95% CI: 1.06–1.24; p = 0.0004). Conclusions: Among PAC-derived parameters, simplified pulmonary arterial elastance (sPAP/SV) was the strongest predictor of in-hospital mortality in STEMI patients with CS or severe heart failure. Its ease of calculation and immediate availability may make it a useful tool for early bedside risk stratification in this critically ill population.

Background: Risk stratification for patients undergoing urgent ventricular tachycardia (VT) ablation remains limited, especially regarding right heart dysfunction. We investigated whether the right atrial pressure (RAP) to pulmonary capillary wedge pressure (PCWP) ratio or pulmonary artery pulsatility index (PAPi) predicts in-hospital outcomes following urgent VT ablation. Methods: We retrospectively analyzed 102 consecutive patients who underwent unplanned (urgent or emergent) inpatient ventricular tachycardia (VT) ablation and had right heart catheterization (RHC) performed within the preceding 12 months. All patients were admitted with recurrent VT, of these 67 patients (66%) had VT storm. Patients were stratified by RAP: PCWP &gt;0.6 versus ≤0.6 and PAPi &lt;2 versus ≥2. Primary outcomes included post-procedural acute kidney injury (AKI, per kidney disease: Improving Global Outcomes [KDIGO] criteria) and intra-procedural hemodynamic instability. Multivariable logistic regression adjusted for age, sex, left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) class, ischemic cardiomyopathy, context of RHC (outpatient vs inpatient) and moderate-to-severe mitral and tricuspid regurgitation (MR, TR). Results: We analyzed 102 consecutive inpatients admitted for urgent inpatient VT ablation, all of whom had right heart catheterization within the prior year. The overall cohort was predominantly male (88%), with a mean age of 64 years, and a high burden of advanced heart failure, including LVEF &lt;25% in 47% and NYHA class III–IV symptoms in 58% (Table 1). After multivariable adjustment, RAP: PCWP &gt;0.6 independently predicted AKI (odds ratio [OR] 10.4, 95% confidence interval [CI] 2.4–14.1, p=0.002) and hemodynamic instability (OR 6.1, 95% CI 1.5–16.3, p=0.050). AKI was also significantly more frequent in patients over 60 (OR 12.8, 95% CI 1.3-21.3). Notably, LVEF&lt;25% and NYHA III-IV were not significantly associated with these outcomes (Figure 1). Furthermore, PAPi &lt;2 was not significantly associated with adverse outcomes. Conclusion: Among patients undergoing urgent inpatient VT ablation, an elevated RAP:PCWP ratio, but not PAPi, identifies individuals at heightened risk of AKI and intra-procedural hemodynamic instability. Incorporating RAP:PCWP into preprocedural assessment may improve risk stratification, perioperative planning, and patient selection.

Background: Right ventricular failure (RVF) is a leading source of morbidity following durable LVAD implantation. Some propose using Impella 5.5 support as a surrogate “RV stress test” to evaluate RV reserve preoperatively. However, the physiologic effects of Impella 5.5 on RV performance and the validity of this approach remain poorly defined. Objective: To characterize the trajectory of RV hemodynamics during Impella 5.5 support. Methods: We retrospectively identified 124 patients supported with Impella 5.5 for cardiogenic shock between 2020 and 2024. After excluding those on ECMO or lacking serial invasive hemodynamic data, 65 patients were included. Right heart catheterization metrics—including central venous pressure (CVP), pulmonary artery pulsatility index (PAPi), pulmonary vascular resistance (PVR), RV stroke work index (RVSWi), effective arterial elastance (Ea), and RA:PCWP ratio—were assessed at baseline and every 12 hours up to 96 hours. Vasoactive inotrope score (VIS) and total diuretic dosing (in IV furosemide equivalents) were also recorded. RVF was defined per 2015 INTERMACS criteria as requiring RVAD or persistent RV dysfunction post-LVAD, necessitating prolonged inotropic or mechanical support. Results: Baseline demographics and destination therapies are summarized in Table 1. Hemodynamic changes over the 96-hour window are shown in Table 2. RAP, PCWP, and mPAP decreased significantly, indicating effective biventricular unloading (Figure 1). PVR and Ea declined, while PAPi and RVSWi remained stable to modestly improved, reflecting reduced RV afterload and preserved contractility (Figure 2A). RA:PCWP remained consistently &lt;0.6 without significant change. These shifts occurred without escalation in pharmacologic therapy: both VIS and total diuretic dosing declined or remained stable over time (Figure 2B), supporting mechanical unloading as the primary driver. Among the 23 patients who underwent LVAD, 10 (43.5%) developed RVF. Five of these had a pre-Impella PAPi &lt;1.85; however, 7 of 13 patients without RVF also had PAPi &lt;1.85, limiting the discriminative value of this threshold. Group-level PAPi values are shown in Table 3. Conclusion: Impella 5.5 support preserved or improved RV hemodynamics without unmasking dysfunction. These findings challenge the use of Impella as a diagnostic stress test for RV reserve and suggest intraoperative factors—such as septal distortion or pericardiotomy—may better explain post-LVAD RVF.