Right Heart Catheterization In Patients Research Articles

Balloon venoplasty for right heart catheterization from the arm in patients with subclavian vein stenosis.

In the trans-radial era, arm venous access for right heart catheterization (RHC) is rising. Procedural success is affected by many factors, including subclavian/innominate vein stenosis (SVS) and pre-existing wires or catheters. In a study published previously by the same authors, 2% of cases had unsuccessful RHC through the arm, predominantly due to SVS. Since that study, techniques to improve RHC success rates have been developed, including crossing the stenosis with a coronary guidewire, followed by balloon dilatation. We aimed to determine whether subclavian/innominate venoplasty allows successful RHC in patients with SVS. Our retrospective study included patients who had RHC from the arm between November 1, 2019, and December 31, 2022 that was unsuccessful due to the inability to pass a catheter through the SVS, and then underwent balloon venoplasty. The success rate of completed RHC was then assessed. Out of 2506 RHCs via arm access, 2488 were successful with a catheter alone or over a guidewire. In 18 patients, venoplasty was needed for catheter passage over a guidewire. Post-dilatation, all 18 cases (100%) had successful RHC with a mean procedural time of 35.2 (SD = 15.5) minutes. The most common stenosis site was the subclavian vein in 13 patients (72.2%), and 12 patients (66.7%) had pacemaker/ implantable cardioverter defibrillator wires present. Balloon dilatation of SVS is an efficacious method to improve the success rate of RHC from the arm. It is a safe technique that may prevent cross-over to a different access site, thereby improving patient satisfaction and reducing the possibility of alternate site complications.

Characteristics and outcomes of gemcitabine-associated pulmonary hypertension.

Despite its known cardiac and lung toxicities, the chemotherapy drug gemcitabine has only rarely been associated with pulmonary hypertension (PH), and the underlying mechanism remains unclear. The objective of the present study was to assess the association between gemcitabine and PH. We identified incident cases of precapillary PH confirmed by right heart catheterisation in patients treated with gemcitabine from the French PH Registry between January 2007 and December 2022. The aetiology, clinical, functional, radiological and haemodynamic characteristics of PH were reviewed at baseline and during follow-up. A pharmacovigilance disproportionality analysis was conducted using the World Health Organization (WHO) pharmacovigilance database. We identified nine cases of pulmonary arterial hypertension, either induced (in eight patients) or exacerbated (in one patient) by gemcitabine. Patients exhibited severe precapillary PH, with a median mean pulmonary arterial pressure of 40 (range 26-47) mmHg, a cardiac index of 2.4 (1.6-3.9) L·min-1·m-2 and a pulmonary vascular resistance of 6.3 (3.1-12.6) Wood units. The median time from the initiation of gemcitabine to the onset of PH was 7 (4-50) months, with patients receiving a median of 16 (6-24) gemcitabine injections. Six patients showed clinical improvement upon discontinuation of gemcitabine. In the WHO pharmacovigilance database, we identified a significant signal with 109 cases reporting at least one adverse event related to PH with gemcitabine. Both clinical cases and pharmacovigilance data substantiate a significant association between gemcitabine use and the onset or worsening of precapillary PH. The observed improvement following the discontinuation of treatment underscores the importance of PH screening in gemcitabine-exposed patients experiencing unexplained dyspnoea.

Contemporary Evidence and Practice on Right Heart Catheterization in Patients with Acute or Chronic Heart Failure.

Heart failure (HF) has a global prevalence of 1-2%, and the incidence around the world is growing. The prevalence increases with age, from around 1% for those aged <55 years to >10% for those aged 70 years or over. Based on studies in hospitalized patients, about 50% of patients have heart failure with reduced ejection fraction (HFrEF), and 50% have heart failure with preserved ejection fraction (HFpEF). HF is associated with high morbidity and mortality, and HF-related hospitalizations are common, costly, and impact both quality of life and prognosis. More than 5-10% of patients deteriorate into advanced HF (AdHF) with worse outcomes, up to cardiogenic shock (CS) condition. Right heart catheterization (RHC) is essential to assess hemodynamics in the diagnosis and care of patients with HF. The aim of this article is to review the evidence on RHC in various clinical scenarios of patients with HF.

Hepatic venous stasis index reflects hepatic congestion and predicts adverse outcomes in patients with heart failure

Abstract Background It has been reported that the hepatic vein waveforms determined by abdominal ultrasonography can assess hepatic congestion in heart failure (HF) patients. However, the parameter which quantifies hepatic vein waveforms has not been established. We suggest hepatic venous stasis index (HVSI) as the novel indicator to evaluate hepatic congestion quantitatively. To examine the clinical significance of HVSI in HF patients, we aimed to clarify the associations of HVSI with parameters of cardiac function and right heart catheterization (RHC), as well as that with prognosis, in patients with HF. Methods We performed abdominal ultrasonography, echocardiography and RHC in patients with HF (N = 513). The patients were divided into three groups based on HVSI as follows; HVSI 0 (HVSI = 0, N = 253), low HVSI (HVSI 0.01–0.20, N = 132) and high HVSI (HVSI &amp;gt; 0.20, N = 128) as shown in Figure 1. We examined the associations of HVSI with parameters of cardiac function and RHC, and followed up for cardiac events defined as cardiac death or worsening HF. Results There were significant correlations between HVSI and mean right atrial pressure (R = 0.244, P &amp;lt; 0.001), right ventricular fractional area change (R = -0.195, P &amp;lt; 0.001) and inferior vena cava diameter (R = 0.318, P &amp;lt; 0.001). During the follow-up period, cardiac events occurred in 87 patients. In the Kaplan–Meier analysis, cardiac event rate increased across increasing HVSI (log-lank, P = 0.002, Figure 2). In the multivariate Cox proportional hazard analysis, high HVSI was independently associated with cardiac events (high HVSI group vs. HVSI 0 group: hazard ratio, 1.746; 95% confidence interval, 1.053–2.894, P = 0.031). Conclusions HVSI assessed by abdominal ultrasonography reflects hepatic congestion and right-sided HF, and is associated with adverse prognosis in HF patients.Figure 1Figure 2

Accuracy of Transthoracic Echocardiogram as a Screening Method in the Clinical Practice of Pulmonary Hypertension Investigation.

The transthoracic echocardiogram (TTE) plays a screening role in the diagnostic algorithm of pulmonary hypertension (PH). Studies have shown a significant disagreement between TTE measurements of the systolic pulmonary artery pressure (sPAP) and right atrial pressure (RAP) and those obtained by right heart catheterization (RHC). To compare TTE measurements of sPAP and RAP with those obtained by RHC in patients being investigated for PH. Patients referred to a PH reference center with a high or intermediate TTE probability of PH upon admission were submitted to RHC. The agreement between sPAP and RAP from both procedures was assessed through the Bland-Altman test. Differences of up to 10 mmHg for sPAP and 5 mmHg for RAP were considered within the variability of the test. Receiver Operating Characteristic (ROC) curve was constructed to determine the most accurate sPAP and Tricuspid regurgitation maximal velocity (TRV)values associated with the diagnosis of PH by RHC. The adopted level of statistical significance was 5%. Ninety-five patients were included. The Bland-Altman analysis showed a bias of 8.03 mmHg (95% CI:-34.9-50.9) for sPAP and -3.30 mmHg (95% CI:-15.9-9.3) for RAP. AUC for sPAP and TRV measured by TTE for discrimination of probable PH were 0.936 (95% CI: 0.836-1.0) and 0.919 (95% CI: 0.837-1.0), respectively. However, only 33.4% of the echocardiographic estimate of sPAP and 55.1% of RAP were accurate, as compared to the measurements obtained by RHC. TTE has a high discriminatory power as a screening diagnostic method for PH despite presenting disagreements between sPAP and RAP absolute values when compared to RHC measurements.

Hepatic Venous Stasis Index Reflects Hepatic Congestion and Predicts Adverse Outcomes in Patients With Heart Failure.

Background It has been reported that the hepatic vein waveforms determined by abdominal ultrasonography can assess hepatic congestion in patients with heart failure (HF). However, the parameter that quantifies hepatic vein waveforms has not been established. We suggest the hepatic venous stasis index (HVSI) as the novel indicator to evaluate hepatic congestion quantitatively. To examine the clinical significance of HVSI in patients with HF, we aimed to clarify the associations of HVSI with the parameters of cardiac function and right heart catheterization, as well as that with prognosis, in patients with HF. Methods and Results We performed abdominal ultrasonography, echocardiography, and right heart catheterization in patients with HF (n=513). The patients were divided into 3 groups based on HVSI as follows: HVSI 0 (HVSI=0, n=253), low HVSI (HVSI 0.01-0.20, n=132), and high HVSI (HVSI>0.20, n=128). We examined the associations of HVSI with parameters of cardiac function and right heart catheterization and followed up for cardiac events defined as cardiac death or worsening HF. There was a significant increase in level of B-type natriuretic peptide, inferior vena cava diameter, and mean right atrial pressure with increasing HVSI. During the follow-up period, cardiac events occurred in 87 patients. In the Kaplan-Meier analysis, cardiac event rate increased across increasing HVSI (log-rank, P=0.002). Conclusions HVSI assessed by abdominal ultrasonography reflects hepatic congestion and right-sided HF and is associated with adverse prognosis in patients with HF.

Evaluation of the diagnostic and prognostic potential of optical coherence tomography (OCT) of the pulmonary arteries during standardised right heart catheterisation in patients with pulmonary hypertension: a cross-sectional single-centre experience.

Pulmonary hypertension (PH) is diagnosed based on an invasive evaluation of the mean pulmonary artery (PA) pressure. The morphological assessment of the pulmonary arteries was only recently not feasible. With the advent of optical coherence tomography (OCT)-imaging, an accessible tool allows to study PA morphology longitudinally. The primary hypothesis was that OCT distincts the PA structure of PH patients from control subjects. The secondary hypothesis was that PA wall thickness (WT) correlates with the progression of PH. This is a retrospective monocentric study of 28 paediatric patients with (PH group) and without PH (control group) who had undergone cardiac catheterisation including OCT imaging of the PA branches. OCT parameters analysed were WT and the quotient of WT and diameter (WT/DM) and those were compared between the PH group and the control group. In addition, the OCT parameters were aligned with the haemodynamic parameters to evaluate the potential of OCT as a risk factor for patients with PH. WT and WT/DM in the PH group were significantly higher compared to the control group {WT: 0.150 [0.230, range (R): 0.100-0.330] vs. 0.100 [0.050, R: 0.080-0.130] mm, P<0.001; WT/DM: 0.06 [0.05] vs. 0.03 [0.01], P=0.006}. There were highly significant correlations between WT and WT/DM with the haemodynamic parameters mean pulmonary arterial pressure (mPAP) [Spearman correlation coefficient (rs) =0.702, P<0.001; rs=0.621, P<0.001], systolic pulmonary arterial pressure (sPAP) (rs=0.668, P<0.001; rs=0.658, P<0.001) and WT and pulmonary vascular resistance (PVR) (rs=0.590, P=0.02). Also, there was a significant correlation between WT and WT/DM and the risk factors quotient of mPAP and mean systemic arterial pressure (mSAP) (mPAP/mSAP) (rs=0.686, P<0.001; rs=0.644, P<0.001) and pulmonary vascular resistance index (PVRI) (rs=0.758, P=0.002; rs=0.594, P=0.02). OCT can detect significant differences in WT of the PA in patients with PH. Furthermore, the OCT parameters correlate significantly with haemodynamic parameters and risk factors for patients with PH. More investigations are required to evaluate to what extent the impact of OCT can contribute to the clinical care of children with PH.

P395 PULMONARY HYPERTENSION OUTPATIENT CLINIC IN CUNEO: SUMMARY OF THE FIRST TWO YEARS OF ACTIVITY

Abstract Backgroung: Pulmonary hypertension (PH) is a pathophysiological disorder that may involve multiple clinical conditions and may be associated with a variety of cardiovascular and respiratory diseases. PH is defined by a mean pulmonary arterial pressure (mPAP) ≥ 20 mmHg at rest,assessed by right heart catheterization (RHC). Methods The Cardiology Rare Disease Outpatient Clinic was opened in 2021 in the Cardiology Division of S. Croce and Carle Hospital, Cuneo. In this ambulatory setting, patients with suspected or confirmed PH diagnosis were screened and followed up. The outpatient evaluation included cardiological physical examination, electrocardiogram (ECG) and transthoracic echocardiogram. In case of echocardiographic PH suspicion (intermediate or high probability) a comprehensive work–up was performed with first level diagnostic tools (respiratory function tests with DLCO, high–resolution chest CT, arterial blood gases, blood tests and overnight oximetry or polysomnography). Eventually, lung scintigraphy was performed and work up was completed with RHC with vasoreactivity test with nitric oxide (NO) if indicated. Multidisciplinary team approach proved to be an essential requirement for good practice in this setting. Results Between January 2021 and December 2022, 95 patients were evaluated in the PH outpatient clinic; Sixty–one (63%) patients were female, mean age was 66 years. Forty–two (42%) patients were referred from Rheumatology, 9 (9%) from Pulmonologiy, 13 (14%) from Emergency Medicine or Internal Medicine, 20 (21%) from Cardiology, and the remaining 13 (14%) patients from other departments or from other hospitals. Following clinical and echocardiographic evaluation, patients were stratified into low, intermediate and high PH–risk levels. In 23 (24%) patients RHC was performed and in one case it was associated with vasoreactivity test with NO. Eight (8%) patients with chronic thromboembolic PH (CTEPH) suspicion were referred to the Hub Center in Pavia to evaluate pulmonary endarterectomy. Seven (7%) patients were treated with specific therapy for group 1 PH and 3 (3%) patients for CTEPH. Two (2%) patients died during follow–up. Conclusions The aim of the dedicated PH outpatient clinic is to screen patients and identify those who need a complete work–up for diagnosis and classification of PH subtypes, in order to select those patients who could benefit from specific PH therapies, and to monitor the response at FU.

Abstract 13869: Outcomes of Right Heart Catheterization in Patients With ST-Elevation Myocardial Infarction and Cardiogenic Shock: A Nationwide Analysis From the United States

Introduction: The role of continuous hemodynamic assessment with right heart catheterization (RHC) in the management of cardiogenic shock (CS) continues to be debated. There are limited data exploring the outcomes of RHC in patients with ST-elevation myocardial infarction (STEMI) and CS. This study aims to assess the outcomes of RHC in patients with CS secondary to STEMI. Methods: This is a retrospective study of the Nationwide Inpatients Sample database that identified patients hospitalized with STEMI and CS on mechanical circulatory support with percutaneous left ventricular assist device to compare outcomes in those treated with RHC versus no RHC. Our primary outcome was in-hospital mortality. Secondary outcomes included cardiac, renal, neurologic, and pulmonary complications, need for blood transfusion, hospital length of stay (LOS), and total cost. The trends of RHC utilization were also evaluated. Results: The total cohort included 11,235 patients hospitalized for STEMI and CS between 2016-2019, of which 4,180 (37.2%) underwent RHC. Despite the higher comorbidity burden in the RHC group, there was a trend towards improved in-hospital mortality with RHC compared to no RHC (42% vs. 46%, p=0.07). However, RHC was associated with significantly higher renal (61% vs. 55%, p=0.01) and pulmonary complications (67% vs. 59%, p&lt;0.001) and more blood transfusions (18% vs. 14%, p=0.005). There were no significant differences in cardiac (58% vs. 56%, p=0.19) and neurologic complications (6% vs. 5%, p=0.15) between both groups. The LOS was longer and the cost was higher with RHC. There was a trend towards increased RHC utilization from 2016-2019 (p&lt;0.001). Conclusions: Although non-significant, RHC in STEMI patients with CS is associated with reduced in-hospital mortality. Given the possible mortality benefit with RHC, further research is necessary to optimize utilization of RHC while reducing complications in STEMI patients with CS.

Abstract 14490: Relationship Between Right Heart Catheterization Hemodynamics and Glycosylated Hemoglobin Levels in Adults With Heart Failure With Reduced Ejection Fraction

Introduction: Elevated glycosylated hemoglobin (HbA1c) levels have been associated with adverse outcomes in heart failure (HF). However, the relationship between hemodynamics and glycemia has not been established. Hypothesis: Elevated HbA1c levels are associated with abnormal right heart catheterization (RHC) hemodynamic parameters in patients with HF with reduced ejection fraction and no prior diagnosis of diabetes mellitus (DM). Methods: We performed a retrospective study of adults patients (&gt;21 years) with a left ventricular ejection fraction &lt;40% who underwent a RHC between June 1, 2015 and June 1, 2021 and had HbA1c levels measured 30 days before or after the RHC. We excluded patients who had received blood transfusions within 90 days prior to HbA1c measurement and patients with known DM. We conducted univariate and multivariate regression analysis adjusted for age, gender, and body mass index (BMI) to test for an association between RHC hemodynamic parameters and HbA1c. Results: A total of 136 patients were included with a mean age of 55 ± 15 years; 75% were males. The mean BMI was 29.88 ± 8.08 kg/m2, and meanHbA1c was 5.99 ± 0.64%. Unadjusted univariate models showed that HbA1c is significantly associated with cardiac index (CI) by Fick and thermodilution, right atrial pressure (RAP), and mean pulmonary arterial pressure (mPAP). After multivariateanalysis, for every one unit increase in HbA1c, there was a 0.19 and 0.26 L/min/m2decrease in expected CI by thermodilution and by Fick, respectively ( P = 0.03 and P &lt;0.01). For every one unit increase in HbA1c, there was a 2.39 mmHg increase in expected RAP ( P = 0.01). There was no association between MPAP and HbA1c after adjustment (Table 1). Conclusions: Changes in HbA1c levels measured within 30 days before or after the index RHC in patients with a left ventricular ejection fraction &lt;40% were associated withchanges in hemodynamic parameters that correlate with congestive hemodynamics(reduced CI and elevated RAP).

Exercise hemodynamics by echocardiography and right heart catheterization in patients with chronic thromboembolic pulmonary disease

Abstract Background Chronic thromboembolic pulmonary hypertension (CTEPH) is an important cause of pulmonary hypertension (PH). A subclinical form of PH is referred to as exercise-induced pulmonary hypertension (EIPH), and its prevalence in patients with chronic thromboembolic pulmonary disease (CTEPD) without pulmonary hypertension at rest is unknown. Purpose To explore the occurrence of exercise-induced pulmonary hypertension (PH) in patients with CTEPD and compare exercise echocardiography with right heart catheterization (RHC). Methods In total, 16 patients with CTEPD, all diagnosed after pulmonary embolism, underwent exercise echocardiography and exercise RHC with dynamic supine leg exercise using a cycle ergometer. CTEPH at rest was defined as mean pulmonary artery pressure (mPAP) &amp;gt;20 mmHg and pulmonary vascular resistance (PVR) ≥3WU. EIPH by RHC was defined as mPAP &amp;gt;30 mmHg with total pulmonary resistance (TPR) ≥3 WU. Based on these criteria, our patients with CTEPD are presented by a flow chart (Figure 1). Systolic pulmonary artery pressure by echocardiography was calculated by tricuspid regurgitation peak velocity (TR V max) and the Bernoulli formula: 4 × (TR V)2. The RHC examination followed the exercise echocardiography within 2 hours. Groups were compared with independent sample t-test. Results Four patients (25%) were diagnosed with EIPH by exercise RHC. Patients with EIPH had a mean mPAP at peak exercise of 40.5 mmHg (range 38 to 43mmHg) and TPR of 3.7 WU (range 3.0 to 4.3 WU). The same patients also had a higher TR V max at peak exercise during exercise echocardiography compared to the patients without EIPH (Table 2). None of the patients had signs of elevated left-sided filling pressure during exercise by RHC, and none had left ventricular diastolic dysfunction during exercise by echocardiography. Conclusion In total, 4 of 16 patients with CTEPD were diagnosed with EIPH. The same four patients also had abnormal pulmonary artery pressure rise during exercise echocardiography and invasive RHC. These findings suggest that exercise echocardiography may be useful for screening patients with CTEPD and suspected EIPH. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Ostfold Hospital Trust

Clinical Characteristics of Patients Undergoing Right Heart Catheterizations in Community Hospitals.

BackgroundRecognition of precapillary pulmonary hypertension (PH) has significant implications for patient management. However, the low a priori chance to find this rare condition in community hospitals may create a barrier against performing a right heart catheterization (RHC). This could result in misclassification of PH and delayed diagnosis/treatment of precapillary PH. Therefore, we investigated patient characteristics and echocardiographic parameters associated with the decision whether to perform an RHC in patients with incident PH in 12 Dutch community hospitals.Methods and ResultsIn total, 275 patients were included from the OPTICS (Optimizing PH Diagnostic Network in Community Hospitals) registry, a prospective cohort study with patients with incident PH; 157 patients were diagnosed with RHC (34 chronic thromboembolic PH, 38 pulmonary arterial hypertension, 81 postcapillary PH, 4 miscellaneous PH), while 118 patients were labeled as probable postcapillary PH without hemodynamic confirmation. Multivariable analysis showed that older age (>60 years), left ventricular diastolic dysfunction grade 2–3, left atrial dilatation were independently associated with the decision to not perform an RHC, while presence of prior venous thromboembolic events or pulmonary arterial hypertension‐associated conditions, right atrial dilatation, and tricuspid regurgitation velocity ≥3.7 m/s favor an RHC performance.ConclusionsOlder age and echocardiographic parameters of left heart disease were independently associated with the decision to not perform an RHC, while presence of prior venous thromboembolic events or pulmonary arterial hypertension‐associated conditions, right atrial dilation, and severe PH on echocardiography favored an RHC performance. As such, especially elderly patients may be at an increased risk of diagnostic delays and missed diagnoses of treatable precapillary PH, which could lead to a worse prognosis.

Abstract 11182: Reliability of Systolic Pulmonary Artery Pressure by Doppler Echocardiography Compared to Right Heart Catheterization in Patients with Congenital Heart Disease: Analysis in a Large Patient Population

Introduction: Pulmonary arterial hypertension (PAH) in patients with congenital heart disease (CHD) is associated with increased morbidity and mortality. While Doppler echocardiography (DE) has been a useful screening test in PAH, the presence of structural cardiac defects may affect the ability to reliably predict systolic pulmonary arterial pressure (sPAP).Therefore, this study was to analyze the reliability of sPAP assessment by DE compared to right heart catheterization (RHC) in a large CHD patient population. Methods: We retrospectively analyzed simple atrial septal defect (ASD) , ventricular septal defect (VSD) and patent ductus arteriosus (PDA) patients older than 14 years with matched examinations (within 1 months) from 2015 to 2020. Relationships between RHC- and DE-derived sPAP were assessed using the Pearson correlation. Bland-Altman analyses were performed to evaluate the agreement between DE and RHC measurements of sPAP. Results: 1937 ASD patients,188 VSD patients, 294 PDA patients were included in this study. In ASD patients, sPAP was 47.06±14.33 mmHg by DE and 39.42±13.18 mmHg by RHC(P&lt;0.001). There was moderate correlation between DE and RHC measurements of PASP (r = 0.585, P&lt;0.05). Bland-Altman analysis showed a bias of 7.6 mmHg for sPAP (95% limits of agreement -17.0 to 32.3 mmHg). In VSD patients, sPAP was 60.89±26.36 mmHg by DE and 64.39±35.79 mmHg by RHC(P&lt;0.001). There was highly correlation between DE and RHC measurements of PASP (r = 0.866, P&lt;0.05). Bland-Altman analysis showed a bias of -3.5 mmHg for sPAP (95% limits of agreement -39.7 to 32.7 mmHg). In PDA patients, sPAP was 49.96±19.53 mmHg by DE and 53.10±29.36 mmHg by RHC(P&lt;0.001). There was highly correlation between DE and RHC measurements of PASP (r=0.813, P&lt;0.05). Bland-Altman analysis showed a bias of -3.1 mm Hg for sPAP (95% limits of agreement -37.7 to 31.5 mmHg). Conclusions: DE estimates of sPAP are inaccurate in patients with CHD, a significant overestimation of the sPAP in ASD patients, significant underestimate of the sPAP in VSD and PDA patients.

Isometric Handgrip Stress Test during Right Heart Catheterization in Patients with Mitral Regurgitation -A Case Series Study.

Objective The severity of mitral regurgitation (MR) dynamically changes during a stress test. Isometric handgrip is a readily-available stress test in daily practice; however, little is known regarding the response to isometric handgrip in MR patients during right heart catheterization. We aimed to evaluate this issue from our case-series study. Methods We retrospectively investigated consecutive MR patients using the isometric handgrip stress test during right heart catheterization at our institution between October 2019 and April 2021. After resting measurements were obtained, sustained maximum-effort hand dynamometer grasping was maintained for about 2-3 minutes. We investigated the differences in right heart catheterization data between at rest and during handgrip, and evaluated the individual response to the isometric handgrip stress test. Results We investigated a total of 15 patients (mean age: 75±6 years, moderate/severe MR: 7/8, primary/secondary MR: 8/7, mean left ventricular ejection fraction: 56±16%, exertional dyspnea: 10). During the handgrip test, the pulmonary capillary wedge pressure (PCWP) significantly increased [9 (8, 13) mmHg at rest to 20 (15, 27) mmHg during handgrip; p<0.001]. PCWP changes varied among individuals (range 2-22 mmHg) and were not correlated with patients' backgrounds including age, the natriuretic peptide levels, left ventricular ejection fraction, left atrial diameter or E/e' (all p>0.05). Patients with PCWP ≥25 mmHg during handgrip had a higher prevalence of exertional dyspnea than those without [6 (100%) vs. 4 (44%); p=0.04]. Conclusion We observed dynamic and varied hemodynamic changes during isometric handgrip in MR patients, suggesting that further research is needed to evaluate the clinical value of this maneuver.

The biventricular dysfunction evaluation in the different types of pulmonary hypertension

Abstract Background Right ventricular (RV) function is well-known prognostic factor in patients with pulmonary hypertension (PH). However, situation becomes critical when underfilling of left ventricle (LV) leads to systemic hypoperfusion and scenario worsening. Objective To evaluate the relationship of RV and LV dysfunction in patients with the different forms of PH. Methods We evaluated parameters of RV and LV function and their relationship during right heart catheterization (RHC) in 125 patients with different forms of pulmonary arterial hypertension (PAH) and 51 patients with chronic thromboembolic PH (CTEPH), 7 patients with PH associated with left heart disease (LHD) and 17 patients in whom PH was excluded after procedure. In all patients recommended echocardiography protocol (Echo) and NT-proBNP level evaluation were performed. Results In the group without PH the RV stroke work index (RVSWI) level and its ratio to the LV stroke work index (LVSWI) were lowest and in the normal range: 7,0±0,7 ml·mmHg/m2 and 0,13±0,02 respectively. In all patients with PH, we noted the significant elevation of RVSWI &amp;gt;20 ml·mmHg/m2. Patients with PAH and CTEPH had a smaller left atrium, LV volumes on Echo and decreased stroke volume and pulmonary artery wedge pressure. The underfilling of LV in IPAH and CTEPH groups accompanied by severe lowering of LWSWI to 35–45 ml·mmHg/m2 (p&amp;lt;0,05 compared with LHD group and patients without PH). In spite of the levels of cardiac index were similar in patients with LHD and without PH, the RVSWI (23,1±2,7 ml·mmHg/m2) and its RVSWI/LVSWI ratio (0,53±0,09) were significantly higher in LHD group and confirmed severe RV overload. Only in HIV infection group observed severe depression of the pumping function of both heart's sides and levels of RWSWI and LVSWI were lowest, but the ratio was elevated (0,53) and indicated RV overload. Similar data were observed when we compare pumping coefficients of RV and LV in different groups. We did not find any association between NT-proBNP level and the LV volume and function. Conclusion The simultaneous evaluation of parameters of RV and LV function and their ratio during RHC in patients with different types of PH allowed not just to estimate the degree of RV overload and dysfunction, but also LV underfilling and dysfunction. Funding Acknowledgement Type of funding sources: None.

Increased serum PCSK9 in patients with idiopathic pulmonary arterial hypertension: insights from inflammatory cytokines.

Proprotein convertase subtilisin/kexin type 9 (PCSK9) is an important and major player in the pathophysiology of hypercholesterolemia and atherosclerosis. Recently, PCSK9 has been implicated in the pathogenesis of inflammatory diseases. Whether PCSK9 is involved in idiopathic pulmonary arterial hypertension (IPAH) remains unclear. This study aimed to investigate the relationship between PCSK9 and IPAH. Serum PCSK9, interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), interleukin-1 β (IL-1β), and monocyte chemotactic protein-1 (MCP-1) were measured by enzyme linked immunosorbent assay. Transthoracic echocardiography was performed among 40 IPAH patients and 20 control subjects. Hemodynamic data were collected via right heart catheterization in patients with IPAH. Serum PCSK9, TNF-α, IL-6, IL-1β, and MCP-1 levels were significantly higher in IPAH patients than in control subjects (p < 0.001). Among enrolled IPAH patients, PCSK9 levels were higher in WHO-FC III/IV patients compared with those in WHO-FC I/II (p < 0.05), and were positively correlated with TNF-α, IL-6, MCP-1, N-Terminal pro-brain natriuretic peptide, pulmonary arterial systolic pressure (r = 0.653, p < 0.001), pulmonary arterial diastolic pressure (r = 0.466, p = 0.002), mean pulmonary arterial pressure (mPAP, r = 0.730, <0.001), pulmonary vascular resistance (r = 0.488, p = 0.001), and right ventricle diameter (r = 0.563, p < 0.001). In multiple regression analysis, mPAP was strongly associated with serum PCSK9 (β = 0.694, p < 0.001), independent of other variables. Receiver operating characteristic curve analysis showed the optimal cutoff value of serum PCSK9 concentration for predicting IPAH was 90.67 ng/ml, with a sensitivity of 90.0% and a specificity of 85.0%. In conclusion, IPAH patients had elevated serum PCSK9 levels which correlated the presence and severity of pulmonary hypertension. PCSK9 may be a novel potential therapeutic target.

Under Pressure: Right Heart Catheterization and Provocative Testing for Diagnosing Pulmonary Hypertension.

Pulmonary hypertension (PH) is a heterogenous disorder involving multiple pathophysiological processes that ultimately affect the vasculature within the lungs. Right heart catheterization (RHC) continues to be the benchmark for diagnosing PH. The use of provocation techniques during RHC can help sub-characterize the type of PH and thus assist in developing appropriate treatment strategies for the management of each PH subtype. This review examines proven and novel approaches for evaluating the pulmonary vasculature during RHC and aspires to provide an accurate, clinically relevant framework for using RHC to diagnose and manage PH. Further improvement in standardized protocols will help optimize the application of RHC in patients with PH.

Haemodynamic effects of PAH-targeted therapies in pulmonary hypertension due to lung disease: A systematic review and meta-analysis

BackgroundPulmonary hypertension (PH) is a negative predictor in patients with lung disease and/or hypoxia (group 3 PH). Current guidelines do not endorse the use of targeted therapies for pulmonary arterial hypertension (PAH) in patients with group 3 PH, due to lack of strong evidence. However, a variety of studies have examined the effect of PAH-targeted therapies in group 3 PH with mixed methods and conflicting results. ObjectiveTo evaluate the effect of PAH-targeted therapies on haemodynamic parameters as assessed by right heart catheterization in patients with group 3 PH. MethodsSearch strategy included PubMed and CENTRAL databases for randomized controlled trials from inception until Jan 30, 2020. We hand searched review articles, clinical trial registries and reference lists of retrieved articles. The primary outcome was the effect of PAH-targeted therapies on haemodynamic parameters [mean pulmonary arterial pressure (mPAP), pulmonary vascular resistance (PVR), cardiac index (CI) and right atrial pressure (RAP)] in patients with group 3 PH, while secondary outcomes were 6-min walking distance (6MWD), brain natriuretic peptide (BNP) and quality of life (QoL). ResultsFive studies with a total of 140 patients were included. PAH-targeted therapies improved significantly mPAP [mean difference (MD) −4.02 mmHg, 95% CI -7.95;-0.09], and PVR [standardized mean difference (SMD) −0.29, 95% CI -0.50;-0.07], but not CI (SMD 0.23, 95% CI -0.23; 0.70) or RAP (MD 0.26 mmHg, 95% CI -18.75; 19.27). PAH-targeted therapies significantly increased the 6MWD by 38.5 m (95% CI 17.6; 59.4), while they did not manage to improve QoL (SMD -3.42, 95% CI -14.74; 7.91) or BNP values. There was no effect of oxygenation by the PAH-targeted therapies compared to placebo. ConclusionPAH-targeted therapies slightly improved mPAP and PVR in group 3 PH, without affecting CI. Larger RCTs targeted in specific subpopulations are needed to extract more robust conclusions. Protocol registrationOpen Science Framework 10.17605/OSF.IO/56FDW.

Radiological and hemodynamic parameters in patients with suspected ventricular aneurysm and interventricular septal perforation after acute myocardial infarction: A comparison of non-invasive and invasive diagnostic modalities.

Transthoracic echocardiography is a rapid, sensitive and non-invasive technique for diagnosing ventricular septal perforation. Furthermore, left ventricular angiography is generally used for left ventricular aneurysm but right heart catheterization is the gold standard for septal perforation following myocardial infarction. The objectives of the present study were to compare radiological and hemodynamic diagnostic parameters of non-invasive methods with those of right heart catheterization in patients with suspected ventricular aneurysm and interventricular septal perforation after acute myocardial infarction. Data regarding demographics and clinical characteristics, as well as right heart catheterization, echocardiography and angiographic parameters of 199 patients examined within 21 days after myocardial infarction due to suspected ventricular septal defect indicated by persistent colic pain in the pre-cardiac region were collected and analyzed. Coronary angiography identified 149 (75%) patients with single-vessel disease, 42 (21%) patients with two-vessel disease and 8 (4%) patients with triple-vessel disease. Transthoracic color Doppler echocardiography strengthened the diagnostic performance of right heart catheterization regarding segmental motor abnormalities but underestimated the right atrial pressure, systolic pulmonary artery pressure, mean pulmonary artery pressure and pulmonary capillary wedge pressure compared with right heart catheterization (P<0.0001 for all). Overall, there was no procedural complication requiring emergency intervention, no major complications and no conditions resulting in death due to diagnostic modalities. Transthoracic color Doppler echocardiography may strengthen the diagnostic performance of right heart catheterization regarding radiological measurements but underestimated hemodynamic measurements (level of evidence: 3).

Feasibility and safety of the antecubital venous access for right heart catheterization in patients with pulmonary hypertension.

BackgroundThe diagnosis of pulmonary arterial hypertension requires right heart catheterization (RHC) which is typically performed via proximal venous access (PVA). Antecubital venous access (AVA) is an alternative approach for RHC that can minimize complications, decrease procedural duration and allow for immediate patient recovery. A direct comparison between the two procedures in patients with pulmonary hypertension (PH) is lacking.ObjectivesTo determine the feasibility, safety, and adoption rates of AVA-RHC as compared with ultrasound-guided PVA in a subpopulation of patients with PH.MethodsAll patients who underwent RHC for evaluation of PH between December 2014 and March 2017 at a single large academic medical center were included in this study. Demographic, procedural and outcomes data were retrieved from the medical records.ResultsIn total, 159 RHC were included (124 AVA, 35 PVA). The duration of RHC was significantly shorter in the AVA compared with PVA group (53 (IQR 38–70) vs. 80 (IQR 56–95) min, respectively, p < 0.001). 19% of AVA (24/124) procedures were switched to PVA. Failed attempts at AVA were more common in scleroderma (50% failure rate). Success rate of AVA increased from 81.2% to 93.3% from the first to last quartile. Fluoroscopy time was similar in both groups, the difference between the groups in the radiation dose are not statistically significant (54.5 (IQR 25–110) vs. 84.5 (IQR 30–134)).ConclusionAVA-RHC is a feasible and safe alternative to PVA in patients with PH who are evaluated for pulmonary arterial hypertension diagnosis. Our experience and rapid adoption rate support the use of AVA as the preferred access site for RHC in uncomplicated PH patients.