Reduction In PVR Research Articles

Effectiveness of Electroacupuncture for Managing Urinary Retention Post Lumbar Spine Surgery: a retrospective single-cohort study.

Post-operative urinary retention (POUR) is a frequent complication following surgical procedures, characterized by an acute inability to void, leading to additional complications and extended hospitalization. Acupuncture has been shown to be effective in facilitating spontaneous urination and alleviating anxiety in patients experiencing poor urination. The present study aims to evaluate the effectiveness of electroacupuncture in the management of POUR in patients who have undergone lumbar spine surgery. This retrospective study conducted at the National Hospital of Acupuncture in Vietnam and reviewed the medical records of patients over 18 years old who underwent lumbar spine surgery and were diagnosed with POUR between January to December 2019. Electroacupuncture was administered at five specific acupuncture points Qugu (CV2), Zhongji (CV3), Zhibian (BL54), Pangguanshu (BL28), and Kunlun (BL60). This study monitored key parameters related to the effectiveness of the acupuncture treatment, including the number of acupuncture treatment sessions required until a patient was successfully treated was recorded, with a maximum of three acupuncture treatment sessions per patient, the time elapsed until urination following the treatment (minutes), and urinary bladder volume before and after treatment (mL). The study demonstrated a 93.3% success rate in treating POUR with electroacupuncture. A significant reduction in post-void residual volume was noted, and patients could void within 30 minutes post-treatment. No significant differences in treatment effectiveness were observed across difference genders and age groups. Electroacupuncture proved to be a highly effective treatment for POUR in patients post-lumbar spine surgery, with a rapid response time and substantial reduction in PVR. However, the retrospective nature of the study and single-center focus limit its generalizability. Future research incorporating randomized controlled trials or multi-center observational studies are recommended to validate these findings and explore the potential of acupuncture in POUR management on a broader scale.

Comparison Of Ventral Inlay and Dorsal Onlay Urethroplasty For Female Urethral Stricture

ObjectiveTo compare the outcomes of Ventral inlay buccal mucosal graft urethroplasty (VIBMGU) with dorsal onlay buccal mucosal graft urethroplasty (DOBMGU) for the treatment of Female urethral stricture (FUS). Material and MethodsThis study included women who underwent either VIBMGU or DOBMGU between January 2016 and June 2023. The preoperative AUA symptom scores, maximal urinary flow rate (Qmax), post-void residual volume (PVR) on ultrasonography, and length and location of the stricture were obtained from a prospectively maintained electronic database. The data obtained from the patient’s last visit was compared with the preoperative values for this study. The primary outcome was the success rate. The secondary outcomes were changes in AUA score, PVR, and Qmax. The patient's last follow-up visit was considered for the duration of the follow-up. ResultsSeventy-three patients were treated for BMGU for FUS. Forty-six patients underwent VIBMGU, and 27 patients underwent DOBMGU. The median duration of follow-up was 27.5 11.00-55.00) versus 14 (7.00-17.00) months respectively. The success rates of VIBMGU and DOBMGU were 89.13% and 88.89% respectively. There was a reduction in AUA scores and PVR and an improvement in Qmax postoperatively in both groups. The difference in the reduction in AUA scores between the VIBMGU and DOBMGU groups was statistically significant. The difference was not statistically significant in terms of reduction in PVR and improvement in Qmax between the two groups. ConclusionThe ventral inlay technique can provide equal results to the dorsal technique with the added advantage of vaginal sparing. This is the single largest series in the literature on female urethral stricture with the largest follow-up period of 90 months.

Vasoreactivity and inhaled treprostinil response in interstitial lung disease pulmonary hypertension

IntroductionDespite shared features with pulmonary arterial hypertension, acute vasoreactivity in pulmonary hypertension with interstitial lung disease (PH-ILD) is not well characterized, including its potential ability to predict therapeutic outcomes. We sought to determine if acute vasoreactivity in PH-ILD to oxygen (O2) and inhaled nitric oxide (iNO) predicts inhaled treprostinil (iTre) outcomes.Materials and MethodsIn this retrospective cohort analysis, we identified treatment-naïve PH-ILD patients with vasoreactivity testing using O2 and O2+iNO. Six-month iTre outcome was assessed. “iTre improvement” required fulfillment of criteria on objective assessment without clinical worsening. “iTre failure” was defined by lack of objective improvement or a clinical worsening event.ResultsAmong 75 PH-ILD patients, mPAP decreased by −3 mmHg (−12.6%) and PVR by −1.3WU (−23.7%) with O2+iNO. With O2+iNO, mPAP decreased ≥10 mmHg to <40 mmHg in 4 patients (5.3%), and 23 (30.7%) had ≥20% reduction in mPAP and PVR. Among 33 iTre-treated patients, there were 13 improvements and 20 failures. The microvascular response, measured by distensibility, to O2 aloneversusO2+iNO correlated with 6-month iTre outcome. Patients with 6-month iTre improvement had large relative distensibility increases with O2+ iNO (versusfailure, 76.0%versus15.3%, p=0.004). Conversely, iTre failure was associated with increased distensibility with O2 alone (versusimprovement, 26.8%versus−3.9%, p=0.045).ConclusionsIn PH-ILD, the microvascular response to O2versusO2+iNO testing was associated with six-month iTre outcome, likely reflecting the differential contributions of hypoxic vasoconstriction and remodeling. Acute vasoreactivity may inform therapeutic decision-making in PH-ILD.

Randomized Controlled Trial Comparing Open Simple Prostatectomy or Prostate Artery Embolization in Large Prostates: Clinical and Urodynamic Assessment — PoPAE Study

ObjectiveTo evaluate the effects of PAE and Open Simple Prostatectomy (OP) on LUTS and urodynamic parameters in subjects with prostate size > 80 cc³. MethodsPoPAE study (open simple Prostatectomy or Prostate artery embolization) was a randomized, open-label controlled trial performed between January 2020 and May 2022.Subjects with large prostates (> 80cc³), urodynamic parameters meeting obstruction criteria (Bladder Outlet Obstruction Index - BOOI > 40), and good detrusor function (Bladder contractility index>100) were included. The primary and co-primary endpoints were the variation in peak flow rate on uroflowmetry (Qmax) and BOOI. The secondary endpoints were the IPSS and ultrasonographic changes. Results23 and 25 subjects underwent PAE and OP were evaluated, respectively. At baseline, the 2 groups have shown similar clinical, radiological, laboratory, and urodynamic parameters.After 6 months, Qmax improved 8,3 ± 4.17 ml/sec in PAE and 15.1 ± 8.04 ml/sec in OP(mean difference 6.78 in favor of PE; p=0.012 [CI -9.00 to -3.00]). After treatment, 88 % of those men underwent OP were classified as unobstructed or equivocal (BOOi<40). On the other hand, 70% of subjects underwent PAE remained obstructed (BOOI>40) and none of them shifted to unobstructed status (BOOI<20). It was observed a similar reduction in IPSS and PVR in both groups. ConclusionPAE was inferior to conventional surgery for releasing BOO and improving peak urinary flow in large prostates. Nevertheless, PAE was able to improve symptoms and PVR, and might be an alternative method in selected patients.

Hemodynamic changes with serial balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension

Objective: To monitor hemodynamic changes during serial balloon pulmonary angioplasty (BPA) for chronic thromboembolic pulmonary hypertension (CTEPH). Methods: General clinical data of CTEPH patients diagnosed from October 2017 to January 2022 in Beijing Chaoyang Hospital were collected, and 83 patients who underwent at least 1 BPA treatment were included to analyze their 6 min walking distance, WHO functional class, N-terminal B-type natriuretic peptide precursor (NT-proBNP), troponin I (cTnI) and haemodynamic indices. Baseline and follow-up after the final BPA clinical data and hemodynamics, functional status and serial hemodynamics before each series of BPA were collected to evaluate the efficacy of BPA for CTEPH patients. Complications and managements were documented to confirm the safety of BPA for CTEPH patients. Results: Three hundred and forty BPA procedures were performed in 83 CTEPH patients. The median number of BPA procedures was 4.0 and a total of 2104 vessels were dilated. In general, mPAP [from 50.0(42.0-55.25) mmHg(1 mmHg=0.133 kPa) to 32.0(27.0-42.0) mmHg, P<0.001], PVR[from (806.6±323.2) dyn·s·cm-5 to 420.0(295.0-613.5) dyn·s·cm-5, P<0.001] were significantly improved compared with baseline, but not CO and CI. Functional parameters including WHO functional class Ⅰ/Ⅱ/Ⅲ/Ⅳ (from 0/35/34/14 to 43/32/7/1, P<0.001), 6MWD [from 364.5(300.0-429.5)m to 461.0(409.0-501.0)m, P<0.001], NT-proBNP [from 1 357.0(232.0-2 715.0) ng/L to 141.0(57.0-627.8) ng/L,P<0.001] were significantly improved compared with baseline. A cumulative (compared to baseline) and serial (compared to preceding BPA session) analysis of the sequential BPA session confirmed that a major hemodynamic improvement in PVR and mPAP occurred in the first 3 serial BPA treatments. There was a dose-response relationship: the more segments that were treated, the greater were the subsequent reduction in PVR and mPAP. There were 32.0 complications (9.4%) associated with BPA procedures, and the most common complication was pulmonary hemorrhage caused by catheter-related vascular injury. Conclusions: BPA is an effective and safe alternative for technically non-operable CTEPH patients. The hemodynamic benefits of BPA in CTEPH patients were cumulative and correlated with the total number of vessels successfully dilated.

Impact of rapid sequential combination therapy on distinct haemodynamic measures in newly diagnosed pulmonary arterial hypertension.

In pulmonary arterial hypertension (PAH), upfront combination therapy with ERA and PDE5i is associated with a reduction in morbidity and mortality events and improves standard haemodynamics, but data remain limited. Aims of this study were (i) to capture detailed haemodynamic effects of rapid sequential dual combination therapy in patients with newly diagnosed PAH; (ii) to monitor the impact of treatment initiation on clinical variables and patients' risk status, and (iii) to compare the treatment effect in patients with 'classical PAH' and 'PAH with co-morbidities'. Fifty patients (median age 57 [42-71] years, 66% female) with newly diagnosed PAH (76% idiopathic) were treated with a PD5i/sGC-S or ERA, followed by addition of the respective other drug class within 4weeks. All patients underwent repeat right heart catheterization (RHC) during early follow-up. At early repeat RHC (7±2months), there were substantial reductions in mean pulmonary artery pressure (mPAP: 52.2±13.5 to 39.0±10.6mmHg; -25.3%), and pulmonary vascular resistance (PVR: 12.1±5.7 to 5.8±3.1 WU; -52.1%), and an increase in cardiac index (2.1±0.4 to 2.7±0.7mL/min/m2; +32.2%) (all P<0.05). Haemodynamic improvements correlated with improved clinical parameters including 6-min walking distance (336±315 to 389±120m), NTproBNP levels (1.712±2.024 to 506±550ng/L, both P<0.05) and WHO-FC at 12months, resulting in improved risk status, and were found in patients with few (n=37) or multiple cardiovascular co-morbidities (BMI>30kg/m2, hypertension, diabetes, coronary artery disease [≥3]; n=13), albeit baseline PVR in PAH patients with multiple co-morbidities was lower (9.3±4.4 vs. 13.1±5.9 WU) and PVR reduction less pronounced compared with those with few co-morbidities (-42.7% vs. -54.7%). However, comprehensive haemodynamic assessment considering further variables of prognostic relevance such as stroke volume index and pulmonary artery compliance showed similar improvements among the two groups (SVI: +50.0% vs. +49.2%; PAC: 91.7% vs. 100.0%). Finally, the 4-strata risk assessment approach was better able to capture treatment response as compared with other approaches, particularly in patients with co-morbidities. Rapid sequential combination therapy with PDE5i/sGC-S and ERA substantially ameliorates cardiopulmonary haemodynamics at early follow-up in patients without, and to a lesser extent, with cardiovascular co-morbidities. This occurs in line with improvements of clinical parameters and risk status.

Hemodynamic changes with pulmonary arterial hypertension targeted therapies: a meta-analysis of 3898 treatment-naive patients

Abstract Background Pulmonary arterial hypertension (PAH)-targeted therapies exert significant hemodynamic changes. We aimed to systematically synthesize these effects and explore the pulmonary pressure and flow changes in relation to the resistance changes. Methods We systematically searched PubMed, CENTRAL, and Web of Science for studies evaluating the hemodynamic effects (mean pulmonary artery pressure [mPAP], cardiac index/output [CI/CO], pulmonary vascular resistance [PVR]) of PAH-targeted therapies (comprising endothelin receptor antagonists [ERA], phosphodiesterase type 5 inhibitors [PDE5i], prostanoids [either i.v./s.c. or p.o./inh], riociguat, and selexipag) either in monotherapy or combinations as assessed by right heart catheterization (RHC) in treatment-naïve PAH patients. We performed a random-effects meta-analysis and used meta-regression to evaluate the contribution of mPAP % reduction and CI/CO % increase on the PVR % reduction across different treatment groups. Results We included 68 studies comprising 90 treatment groups and 4276 patients (age 47.3±13.2, 74% women). PVR reduction as a percentage of the pre-treatment value was more pronounced in the oral + prostanoid i.v./s.c. combination therapy (mean difference [MD] -50.0%, 95% confidence interval [CI] -60.8%; -39.2%), compared to oral combination therapy (MD -41.7%, 95% CI -47.6%; -35.8%), prostanoid i.v./s.c. monotherapy (MD -31.8%, 95% CI -37.6%; -25.9%), and oral monotherapy (MD -21.6%, 95% CI -25.4%; -17.8%) (Figure 1). The contribution of mPAP % reduction and of CI/CO % increase to the PVR % reduction was equally significant in all treatment groups (Figure 2). In the oral combination therapy group CI/CO % increase had superior contribution over mPAP % reduction (R2 90% vs R2 0%), but this difference was driven by an outlier study with n = 8 patients and after the exclusion of the outlier, the contribution of mPAP % reduction and of CI/CO % increase to the PVR % reduction was equally significant also in the oral combination group. The same results applied in a sensitivity analysis including only studies with idiopathic/heritable/drugs-induced/connective tissue disease-associated PAH patients. Conclusion Combination therapies, especially with the inclusion of parenteral prostanoids, lead to remarkable hemodynamic improvement in treatment-naïve PAH patients. The contribution of mPAP and CI/CO % changes to the overall PVR % reduction is equally significant.Figure 1Figure 2

Impact of Parenteral Prostanoids in Pulmonary Arterial Hypertension: The Relevance of Timing.

Parenteral prostanoids are being recommended in pulmonary arterial hypertension (PAH) treatment, but the prognostic relevance of delayed treatment initiation is still debated. This study assessed the impact of the timing of prostacyclin treatment initiation on reducing PVR and achieving a low-risk profile in PAH patients. The study enrolled 151 patients who started on parenteral prostanoids with different treatment strategies. All patients underwent right heart catheterization, clinical evaluation, and risk assessments at baseline and after 1-year follow-up. Patients with an upfront strategy including parenteral prostanoid plus one oral drug had -5.3 ± 6.2 WU (-50 ± 19%) reduction in PVR, patients with an upfront strategy including parenteral prostanoid plus double oral drug had -12.8 ± 5.9 WU (-68 ± 17%) reduction in PVR, while patients with an add-on strategy including parenteral prostanoid after oral drugs had -3.9 ± 3.5 WU (-23 ± 19%) reduction in PVR. An upfront strategy including parenteral prostanoids was independently associated with an increased likelihood of achieving the greater reduction of PVR compared with an add-on strategy. Additionally, the greater the severity of PH at the time of diagnosis, in terms of PVR and RV reverse remodeling, the higher the probability of treatment failure. An upfront strategy including a parenteral prostanoid is associated with the highest likelihood of achieving a low-risk profile and a greater reduction of PVR compared with parenteral prostanoid as an add-on to oral treatment.

Prostatic Artery Embolization Using Polyethylene Glycol Microspheres: A 1-Year Follow-up Prospective Study Including 30 Patients

PurposeTo evaluate safety and effectiveness of prostatic artery embolization (PAE) using polyethylene glycol (PEG) microspheres in patients with moderate-to-severe benign prostatic hyperplasia (BPH). Materials and MethodsA single-center, prospective study of 30 patients who underwent PAE from August 2020 to December 2021 using PEG 400-μm microspheres was conducted. Patient evaluation data using International Prostate Symptom Score (IPSS), quality of life (QoL) score, prostate-specific antigen (PSA), peak urinary flow rate (Qmax), postvoid residual volume (PVR), and prostate volume (PV) at baseline and 3 and 12 months after PAE were obtained. ResultsBilateral PAE was performed in all patients. One patient had early clinical failure (3.3%) and another presented with lower urinary tract symptoms (LUTSs) recurrence (3.3%) at the 12-month follow-up. Twenty-eight patients (93.3%) experienced significant and durable LUTS improvement. Mean absolute (and relative) improvement at 3 and 12 months were: IPSS, 14.6 points (−69%) for both; QoL, 3.3 points (−70%) and 3.5 points (−74%); Qmax, 6.3 mL/s (+78%) and 8.6 mL/s (+100%); PSA reduction, 1.2 ng/mL (−22%) and 1.0 ng/mL (−15%); PVR reduction, 48 mL (−56%) and 58.2 mL (−49%); PV reduction, 23.4 cm3 (−29%) and 19.6cm3 (−25%); (P < .05 for all). No major adverse events were observed. Minor adverse events included urinary tract infection (4/30, 13.3%), prostatic tissue elimination (3/30, 10%), penile punctiform ulcer (1/30, 3.3%), and urinary retention (1/30, 3.3%). ConclusionsPAE using PEG microspheres was observed to be effective with sustained LUTS improvement at the 12-month follow-up. The incidence of urinary infection and prostatic tissue elimination was higher than previously reported for other embolics.

P283 PROGRESSION OF PULMONARY ARTERIAL HYPERTENSION OR LEFT HEART DISEASE? DO EXERCISE!

Abstract An 80–year–old man, diagnosed with idiopathic pulmonary arterial hypertension (PAH) in 2012 and treated with sildenafil, experienced his first hospitalization for heart failure in June 2019. He had several cardiovascular risk factors (overweight, hypertension, diabetes) and comorbidities (ischemic heart disease, and mild chronic obstructive pulmonary disease), whose progression was excluded. Since this event, he complained a progressive deterioration of the exertional dyspnea (NYHA III), with overt signs of fluid overload, right chambers dilation and high NTproBNP (1366 ng/L). However, the center taking care of this patient neither decided to fully re–evaluate him nor to escalate PAH–treatment due to his clinical profile (high suspicion of left heart disease, LHD). He then came to our pulmonary hypertension (PH) center where we decided to perform a cardiac catheterization, which showed the persistence of precapillary PH with high pulmonary vascular resistance, PVR (7.6 WU), low cardiac output, CO (2.2 L/min/m2), high right atrial pressure, RAP (12 mmHg). Pulmonary artery wedge pressure (PAWP) and left ventricular end–diastolic pressure (LVEDP) were at the upper limits of normal (13 mmHg and 16 mmHg, respectively) (Figure 1). Based on these “borderline” PAWP values, with an intermediate–high pre–test probability of left heart disease, we performed an exercise test with concomitant gas–exchange analysis on a cycle ergometer in the cath lab (Figure 2). Exercise induced a steep increase in pulmonary pressure (TPR 9 WU), unrelated to an exaggerate increase in PAWP or LVEDP (whose peak values reached 20 mmHg, with a PAWP/CO slope &amp;lt;2 mmHg/L/min), but entirely dependent on the precapillary component. Transpulmonary gradient (TPG)/CO slope was high, leading to an absent reduction in PVR (6.4 WU at peak), associated to severe increase in RAP (27 mmHg at peak, RAP/PAWP 1.4) (Figure 3). CO reserve was reduced (at peak 3.4 L/min/m2), due to both reduced increase in stroke volume and chronotropic incompetence. Accordingly, functional capacity was moderately–severely reduced (peak oxygen consumption was 8 ml/kg/min, 39% of predicted), with exercise hyperventilation. Once excluded LHD as the responsible of clinical worsening, and in consideration of the high–intermediate risk profile of this patient, we upgraded the PAH–specific therapy by adding macitentan, obtaining a subjective clinical improvement and a 3–years period of clinical stability.

Management of Pulmonary Hypertension Secondary to Valvular Heart Disease with Angiotensin-Receptor Neprilysin Inhibitor

<h3>Introduction</h3> Pulmonary hypertension secondary to left-sided valvular disease (VHD-PH) is associated with high morbidity and mortality. Angiotensin-receptor neprilysin inhibitor (ARNI) is a novel pharmacotherapy, which reduces afterload with natriuresis and peripheral vasodilation. Whether ARNI can also reduce pulmonary vasculature resistance is unknown. We present two cases of VHD-PH that improved after treatment with ARNI. <h3>Case Report</h3> Case 1: Ms. M is a 63-year-old woman with past medical history of rheumatic mitral valve (MV) stenosis (mean gradient = 12 mm Hg at a heart rate = 69 beats/minute) who presented with New York Heart Association (NYHA) Class IIIB symptoms. The initial workup showed normal left ventricular function (LV) but severe combined pre- and post-capillary PH (Cpc-PH). She was deemed to be a high-risk surgical candidate given the severity of PH. Subsequently, she was treated with ARNI for three months, and repeat right heart catheterization showed significant improvement in Cpc-PH (see Table). Case 2: Mr. S is a 59-year-old man with past medical history of MV endocarditis s/p remote bovine MV replacement in 1984 complicated by paravalvular leak and redo replacements who presented with worsening shortness of breath. The workup demonstrated a well-functioning MV prosthesis and normal LV function, but elevated filling pressures. After two months of diuresis, Mr. S continued to have NYHA Class IIIB symptoms with persistent Cpc-PH. He was subsequently started on ARNI, and two months later had complete resolution of his symptoms. Repeat evaluation showed normalization of pulmonary vascular resistance (PVR, see Table). <h3>Summary</h3> This report is the first to describe treatment of VHD-PH with ARNI along with invasive hemodynamic data showing successful reduction in PVR. In these two cases, treatment with ARNI led to reduction in not only mean pulmonary arterial pressures but also PVR. Future prospective trials are needed to evaluate role of ARNIs in treatment of VHD-PH.

Emerging minimally invasive transurethral treatments for benign prostatic hyperplasia: a systematic review with meta-analysis of functional outcomes and description of complications.

Several minimally invasive surgical procedures have been proposed as alternative therapies for benign prostatic hyperplasia (BPH). The present systematic review aimed to describe the functional outcomes and complications of emerging minimally invasive transurethral treatments for BPH. A comprehensive bibliographic search on the Medline and Cochrane Library databases was conducted. No chronological restriction was applied. Retrospective and prospective primary studies were included. A meta-analysis of IPSS, IPSS-QoL, Q<inf>max</inf>, and PVR was performed. Data on adverse events were presented narratively. A total of 18 studies were included. Thirteen papers were eligible for the meta-analysis. iTIND (Medi-Tate Ltd., Or-Akiva, Israel), Rezūm (Rezūm System, Boston Scientific, Marlborough, MA), and Aquablation (AquaBeam System, PROCEPT BioRobotics Inc., Redwood City, CA, USA) were associated with a significant improvement in IPSS (P<0.001), IPSS-QoL (P<0.001), and Q<inf>max</inf> (P<0.001) compared to baseline. A significant reduction of PVR from baseline was found with Rezūm (P<0.001) and Aquablation (P<0.001) but not iTIND (P=0.22). A significant difference in IPSS, IPSS-QoL, and Q<inf>max</inf> was shown in favor of Aquablation compared to Rezūm and iTIND (P<0.001). Rezūm and iTIND were mainly associated with mild to moderate adverse effects. Hematuria or bleeding was reported in all studies regarding Aquablation (0.8-26%), the need for transfusion or intervention for bleeding varied between 1.8% and 9%. Aquablation, Rezūm, and iTIND significantly improve urinary functional outcomes compared to baseline; however, Aquablation would seem to lead to better functional results compared to the other procedures. Rezūm and iTIND appear to have an excellent safety profile, while Aquablation would seem to expose patients to a non-negligible risk of bleeding.

Influence of the median lobe on the results at 4 years of the prostate vaporization by GreenLight laser.

The aim of this study was to examine the influence of a median lobe (ML) on complications and functional results after 4 years of GreenLight photoselective vaporization of the prostate (PVP). All men undergoing GreenLight PVP for benign prostatic hyperplasia were included in the baseline analysis and followed prospectively. Two groups were formed according to the presence or absence of the prostatic ML. Complications classified according Clavien and Dindo and functional results (International Prostate Symptom Score [IPSS], quality of life, maximum urinary flow rate [Qmax], and postvoid residual [PVR]) were evaluated with 4 years of follow-up. The pre- and postoperative data were compared by a chi-square test (χ2 ) for the qualitative variables and by a Student t test for the quantitative variables. A total of 432 patients (172 with ML and 260 without ML) were included prospectively from September 2005 to October 2013. The initial populations were comparable. At 4 years of follow-up, the improvement in mean IPSS was significantly greater for patients with ML at 6, 12, 24, and 48 months. The improvement in Qmax was significantly greater for patients with ML at 1, 6, 24, and 48 months. There was no significant difference between the two groups concerning the PVR reduction, the occurrence of complications, the level of average prostate-specific antigen, and the average ultrasound volume at 4 years. There is a clearer and longer-lasting improvement in urinary symptoms in patients with prostatic ML. The indication of PVP in those patients seems to be excellent, with good results persisting at 4 years.

Preserving ejaculatory function in young patients with lower urinary tract symptoms: medium- to long-term follow-up of prostatic urethral lift at a single center.

Background and aims:Prostatic urethral lift (Urolift™) is a minimally invasive technique to treat male lower urinary tract symptoms (LUTSs) due to benign prostatic hyperplasia (BPH). The aim of the present study was to assess safety and medium- to long-term outcomes in the relief of urinary symptoms.Methods:We included 35 men, affected by severe symptomatic BPH evaluated by International Prostate Symptom Score (IPSS), with normal erectile function (EF) and ejaculatory function (EjF) evaluated by the International Index of Erectile Dysfunction (IIEF-5) and Male Sexual Health Questionnaire for Ejaculatory Dysfunction (MSHQ-EjD-SF). Exclusion criteria were prostate larger than 70 cm3, bladder neck sclerosis, concomitant third prostatic lobe, and/or other cervical urethral obstruction or cancer. All patients, preoperatively, performed uroflowmetry (UFM) with peak flow (Q-max) and post void residual volume (PVR), digital rectal exam, transrectal prostate ultrasound to measure prostate volume, PSA, and cystoscopy. Follow-up was scheduled at 1–3–6 months, then yearly, evaluating UFM, IPSS, IIEF-5, and MSHQ-EjD-SF.Results:All procedures were performed by a single senior surgeon and follow-up was 33.8 ± 12 months. Preoperative PSA was 0.82 ± 0.4 ng/ml and mean operative time was 19.6 ± 10 min and 3 (2–4) implants per patient were used. Parameters reported at last follow-up schedule were: Q-max increase of 68% (p = 0.001), PVR reduction 68% (p = 0.005), and IPSS reduction 55% (p < 0.0001). EF and EjF were similarly preserved, and no patients presented retrograde ejaculation. A total of 88.6% of patients were satisfied with LUTSs improvement and 100% satisfied with EjF.Conclusion:Urolift can improve urinary disorders secondary to BPH, preserving EjF and EF. It is a safe and easy method, reproducible, and with low incidence of complications. Careful selection of patients is mandatory. The main reason for dissatisfaction is the higher expectation of better BPH symptoms relief although patients with high bladder neck and/or prostate volume >45 cm3 were aware of the possible failure.

Determinants of pulmonary vascular resistance reduction with upfront oral therapy in idiopathic pulmonary arterial hypertension: relevance in risk assessment

Abstract Background In pulmonary arterial hypertension (PAH) upfront oral therapy represents the standard of care for naive patients at low and intermediate risk. However little is known about associated changes in risk assessment and prediction of low risk status achievement. Purpose To evaluate determinants of PVR reduction in patients treated with upfront oral therapy and to create a score to predict PVR reduction after upfront oral treatment and compared its additive value on top of the European and REVEAL scoring system in predicting treatment response. Methods One-hundred-eighty-one consecutive naive PAH patients treated with upfront therapy at 11 italian centers were retrospectively evaluated. Evaluation included clinical, hemodynamic and simple echocardiographic parameters, together with European and REVEAL 2.0 risk scores. Results At the time of diagnosis, the majority of the patients was idiopathic PAH (80.6%), female (66.3%), at intermediate risk, 71.8% and 55.2%, respectively, according to the European (average method) and the REVEAL 2.0 risk scores. Ambrisentan-Tadalafil was the most frequent combination used (62%). The median PVR reduction obtained after 180 days (IQR 79–394) was −40.4% (IQR −25.8; −45.3). Age ≥60 years, male-sex, baseline mPAP 48 mmHg associated with low CI (&amp;lt;2.5 l/min/m2), and RV/LV ratio &amp;gt;1 associated with low TAPSE (&amp;lt;18 mm) emerged as independent predictors of poor PVR reduction, defined as the lower tertile of PVR changes (−25.8%). A treatment response score was created deriving weighted integers from the beta coefficient. At second evaluation 78 (43.1%) patients achieved or remained at European-derived low risk status, while 63 (34.8%) considering the REVEAL 2.0 score. Multivariate analysis for the prediction of treatment failure, defined as the absence of low-risk status at follow-up, demonstrated the incremental prognostic power of the models incorporating the treatment response score (≥3) on top of the European and REVEAL 2.0 scores, improving risk discrimination by 63.2% (IDI index 0.056) and 36.8% (IDI index 0.080), respectively. Conclusions A significant proportion of PAH patients treated with upfront oral combination are not able to achieve a low-risk status. The treatment response score helps clinicians in predicting treatment failure at the time of diagnosis. Funding Acknowledgement Type of funding source: None

Adding Echocardiography of the Right Heart to Risk Assessment Scores in Prostanoid-Treated Pulmonary Arterial Hypertension

To evaluate the added value echocardiographic criteria of right heart reverse remodeling (RHRR) in advanced PAH. Risk assessment is important for prognostication and therapeutic adjustments in pulmonary arterial hypertension (PAH). However, currently used scores do not include direct assessments of the right ventricle (RV) and most patients are assigned the uncertainty of intermediate risk. 110 consecutive PAH patients started on parenteral prostanoids were followed with periodic clinical, hemodynamic, and echocardiographic assessments. RHRR at 1-year assessment was defined by the combined reductions in right atrial (RA) and RV dimensions and left ventricular eccentricity index. Thirty-six (32.7%) patients had a RHRR at 1-year follow-up. After a mean follow-up of 1375±1359 days, 48 (43.6%) patients died. The European Respiratory and Cardiology Societies guidelines-derived risk score based on WHO class, 6-min walk distance, RA pressure and cardiac index at 1-year predicted long-term survival. The combination of low-risk European score and RHRR was able to improve the prognostic power of the model (c-statistic: 0.83, C.I. 0.75-0.92, vs 0.75, C.I. 0.64-0.86, respectively; p<0.001). Similar results applied to the United States Registry to Evaluate Early and Long-Term PAH Disease Management risk score 2.0. A reduction of pulmonary vascular resistance (PVR) >50% was associated with higher probability of RHRR. Patients with RHRR had greater improvement in WHO class, 6min walk distance and hemodynamics. Echocardiographic RHRR improves risk assessment in advanced PAH under prostacyclin therapy. A reduction in PVR by more than 50 % is associated with a high probability RHRR and improved prognosis.

P6325Gas exchange improvements during exercise correlate with hemodynamic changes in heart failure patients with a left ventricular assist device

Abstract Background The implantation of left ventricular assist devices (LVAD) has established its role in therapy for patients with end stage heart failure. Benefits in survival as well as an improved quality of life, compared to optimized medical therapy (OMT) alone, has been proven. There are limited data in the literature on the metabolic changes during exercise in LVAD patients, and in most studies no increase in peak oxygen consumption on cardiopulmonary exercise test (CPET) could be shown early after surgery. However, recent data suggests an improvement in peak oxygen uptake (VO2) as a late effect after rehabilitation. To further investigate these findings we sought to analyse CPET data from patients before LVAD implantation as well as in the early and late follow up in correlation with hemodynamic changes at these times. Methods We collected and retrospectively analysed data of heart failure patients who had undergone LVAD implantation, and in whom a right heart catheterization, a cardiopulmonary exercise test and an echocardiography had been performed at time before, as well as 6 Months and 12 months after LVAD implantation, respectively. Results Data of 43 patients implanted with an LVAD between 2011 and 2017 were analysed. There was significant improvement in cardiac output (3,2 vs 4,3 L/min, p&lt;0,001) and VE/VCO2 slope (46 vs 38, p=0,001) 6 months after LVAD implant as well as a significant reduction in PCWP (26 vs 11 mmHg, p&lt;0,001), PAP mean (40 vs 22 mmHg, p&lt;0,001), RA mean (12 vs 8 mmHg, p=0,002) and PVR (4,2 vs 2,5 WU, p&lt;0,001). However, there was no significant increase in peak VO2 after 6 months. 12 months after LVAD implantation there were no further significant changes in cardiac output, intracardiac pressures or VE/VCO2 slope, which all remained similar to the 6 months follow up. However, at that point, a significant increase in peak VO2 was seen, compared to baseline (1060 vs 1410ml/min, p=0,001) and to 6 months after surgery (Figure 1). Conclusion Cardiac output increases in heart failure patients early after LVAD implantation. Consequently, permanent ventricular off loading results in the reduction of intracardiac pressures and improvement in the VE/VCO2 slope 6 months after surgery. However, a significant rise in peak oxygen consumption could only be noted 12 months after surgery, suggesting either a delayed long-term effect of improved hemodynamics or other causes such as enhanced mobility or training due to improved quality of life.

What's New in Rezum: a Transurethral Water Vapour Therapy for BPH.

Rezum is a new minimally invasive treatment for benign prostate enlargement using thermal transurethral water vapour therapy. We review the evidence with advantages and disadvantages of this technique. There are five studies reported including a randomised control trial looking at the outcomes of Rezum. The outcomes show an IPSS reduction by 45-60%, QoL improvement with a score reduction of 37-59%, the Qmax improvement by 44-72% and the PVR reduction by 20-38%. Convective water vapour therapy using the Rezum system has been shown to have successful outcomes in the treatment of LUTS resulting from BPH. The reported complications are infrequent and often minor, and it seems to be relatively cost-effective.

The value of contrast-enhanced ultrasonography in detection of prostatic infarction after prostatic artery embolization for the treatment of symptomatic benign prostatic hyperplasia.

We aimed to assess the clinical and predictive role of contrast-enhanced ultrasonography (CEUS) as the primary method for imaging evaluation of prostatic artery embolization (PAE) for the treatment of symptomatic benign prostatic hyperplasia (BPH). Thirty-one patients with symptomatic BPH, treated with PAE from October 2016 until February 2018, were enrolled in this prospective, single-center study. Microspheres (100-700 µm) were utilized for PAE. International prostate symptom score (IPSS), quality of life (QoL), maximum urinary flow (Qmax), prostatic volume (PV) and post void residual volume (PVR) were measured at baseline and at 1, 3, and 6 months post PAE. Unenhanced transabdominal US was utilized for PV and PVR measurements; prostatic enhancement was studied with transabdominal CEUS at baseline, during the procedure, 1 day and 1, 3, and 6 months post PAE. Technical success was defined as embolization of the PA of at least one pelvic side. Clinical success was based on the improvement of IPSS and QoL, with no need for any additional treatment. Follow-up time ranged from 6 to 18 months (mean, 9.7±4.3 months). Clinical success rates were calculated and changes in prostatic enhancement were correlated with the outcome parameters. Technical success rate was 90.3%. Clinical success rates at 3, 6, and 12 months post PAE were 85.7%, 85.7%, and 79.1% respectively. Improvement of outcome parameters (baseline vs. 6-month values) was statistically significant, with 12.4 points mean reduction of IPSS (50.4%, P = 0.003), 2.0 points mean reduction of QoL (45.4%, P < 0.001), 30.3 mL mean reduction of PV (30.2%, P < 0.001), 72.6 mL mean reduction of PVR (51.8%, P = 0.005) and 8.6 mL/s mean increase in Qmax (103%, P = 0.002). The most significant complications were bladder ischemia (n=1), and ischemic rectal ulcer (n=1), both attributable to nontarget embolization, with complete recovery. CEUS 1 day post PAE demonstrated prostatic infarcts in 26/28 (92.8%) patients. The percentage of prostatic infarction (pPI, defined as prostatic infarcted volume 1 day post PAE divided by baseline PV) was 1%-71%. There was a very strong positive correlation between pPI and prostate shrinkage (r=0.81, P < 0.001), but a weak correlation between pPI and the improvement of the other outcome parameters (r= 0.01-0.36; P = 0.093-0.965). However, in the subgroup of patients with indwelling bladder catheter (9/28 patients), successful removal of the catheter was achieved only in patients with pPI>10%. CEUS appears to be a practical method for the study of the local ischemic effect of PAE, with potential predictive value.

Acute Iloprost Inhalation Improves Right Ventricle Function in Pulmonary Artery Hypertension: A Cardiac Magnetic Resonance Study.

Background: Right ventricle (RV) function is among the most important prognostic factors for pulmonary arterial hypertension (PAH) patients. Inhaled iloprost, an inhaled member of the prostacyclin family, is effective for the treatment of severe PAH and acute RV failure. However, the acute effects of iloprost on RV physiology have not been thoroughly explored in the past.Materials and Methods: This prospective study involved 69 incident PAH patients, including 23 idiopathic PAH (IPAH) patients, 26 patients with PAH associated with connective tissue disease (CTD-PAH) and 20 with PAH associated with congenital heart disease (CHD-PAH). All patients underwent both right heart catheterization and cardiac magnetic resonance imaging at baseline and 20 min after 5 μg iloprost inhalation.Results: Acute iloprost inhalation reduced PVR from 13 ± 7 to 10 ± 6 Wood U (P < 0.001), increased RV ejection fraction (RVEF) from 31 ± 11 to 35 ± 12 % (P < 0.001), increased RV stroke volume from 53 ± 21 to 57 ± 22 ml (P < 0.001) and decreased RV end-diastolic volume from 179 ± 67 to 172 ± 69 ml (P < 0.001). Acute iloprost inhalation-induced RVEF improvement was correlated with the degree of PVR reduction (P < 0.001) in IPAH patients, but not in CTD-PAH or CHD-PAH patients.Conclusion: Acute iloprost inhalation improved RVEF, RV stroke volume and decreased RV volume in IPAH and CTD-PAH patients. Iloprost-induced RVEF increase was proportional to PVR reduction in IPAH patients, but not in CTD-PAH or CHD-PAH patients.