Right-sided Heart Research Articles

Real-world evidence on pulmonary arterial hypertension: interim analysis from the Italian observational study INSPECTIO

Abstract Background Pulmonary arterial hypertension (PAH) is a rare, progressive disease leading to right-sided heart failure. The interest in risk assessment based on non-invasive parameters is growing, and insights from clinical practice are needed in this regard. INSPECTIO is an Italian observational study aimed at filling this knowledge gap. The results of an interim analysis at month 12 are presented below. Purpose The primary objective was to assess the change from baseline to month 12 in the number of the non-invasive low-risk parameters among World Health Organization functional class, 6-minutes walking distance, Brain Natriuretic Peptide (BNP) or N-terminal proBNP. Secondary objectives are the evaluation of echocardiographic and haemodynamic parameters, and the proportion of patients in which the therapy was optimized according to the guidelines. Methods Prospective, multicentre study on PAH patients at low/intermediate mortality risk treated with macitentan and/or selexipag as part of the oral combination therapy. Results Among 177 patients who were enrolled in 29 centres, 148 patients [median age 63.0 years (Q1/Q3: 53.5/73.0), 76.4% females] completed the 12-month follow up and were considered for this analysis. The median time from PAH diagnosis was 22.6 months (4.9/60.1). Sixty-four (43.2%) patients had idiopathic PAH; 4 (2.7%) heritable; 80 (54.1%) associated with other diseases [58 (72.5%) connective tissue disease, 11 (13.8%) congenital heart disease corrected for at least one year, 5 (6.3%) portal hypertension, 5 (6.3%) human immunodeficiency virus infection, 1 (1.3%) drug and toxins]. At baseline, 45.9% patients and 28.4% were in double and triple oral combination therapy, respectively. Primary objective: at month 12, the number of noninvasive low-risk parameters increased in 43 (29.1%) patients and remained stable in 80 (54.1%) patients [mean change 0.16 (p=0.017)]. The values at baseline, at month 12 and the change from baseline for each noninvasive parameter are shown in Table 1. Mean right atrial (RA) area (end-systole) and tricuspid annular plane systolic excursion (TAPSE) remained unchanged while a reduction of systolic pulmonary artery pressure (sPAP) was observed. Regarding the haemodynamic parameters, the mean pulmonary arterial pressure decreased [median change -4.5, (p=0.0346)], while cardiac index, pulmonary vascular resistance, and RA pressure remained stable (Table 2). The number of patients on triple therapy increased from 42 to 51 (+21.4%). Conclusions This study confirms that a noninvasive low-risk profile can be achieved with current combination PAH therapy. The modest or absent changes in echocardiographic and hemodynamic parameters suggest that treatment of PAH in real world is yet to be improved; on the other hand, the optimization of therapy in a significant portion of patients can possibly account for the improvement or stabilization observed.Noninvasive parametersEcho and hemodynamic parameters

Association of pulsatile venous waveform pattern in the venous studies of lower extremities to 2d-echocardiographic parameters for right heart function and right atrial pressure

Abstract Introduction To date, the detection of pulsatile venous waveform (PVW) pattern in venous duplex scans are read as suggestive of increased central venous pressure (CVP) and/or right-sided heart failure. In the advent of point of care ultrasound, non-invasive measures can be used to determine systemic hemodynamics in emergent clinical settings. Purpose This study aims to determine the association of PVW pattern to echocardiographic parameters of right ventricular (RV) function and right atrial pressure (RAP). Methods A single center retrospective study of adult patients with venous studies of the lower extremities and 2d-echocardiogram done from January 2019 to October 2023. Logistic regression analyses were performed to determine the association of PVW pattern with RV dysfunction based on TAPSE, S’ and FAC, as well as with increased RAP. Results A total of 2086 adult patients were included with median for age of 67 years of which 1141 (55%) were females, and 728 (35%) were hypertensive. PVW pattern was noted from 163 participants (7.8%) of which a higher proportion had heart failure, kidney disease, COVID-19, pneumonia and valvular heart disease. Patients with PVW pattern had a significantly lower median TAPSE [18 (IQR 15-20) vs 20 (IQR 18-22)] and median S’ [11.1 (IQR 8.6-13.20) vs 12.3 (IQR 10.6-14.40)] with FAC 27.1 + 11.9%. Increased RAP was noted in 7% of the study population. Patients with PVW pattern had a higher median inferior vena cava (IVC) diameter [1.9 ( IQR 1.5-2.3) vs 1.5 (IQR 1.3-1.8)] and lower median IVC collapsibility [39.9 (IQR 23.5-51.4) vs 50 (IQR 38.9-58.80]. PVW pattern is significantly associated with TAPSE (crude OR 3.89; CI 2.67-5.66, p<0.0001), S’ (crude OR 3.26, CI 2.30-4.62, p<0.0001) and increased RAP (adjusted OR 6.06, CI 4.02-9.14, p<0.0001). Conclusion Patients with PVW pattern had about 4 times and 3 times higher odds of developing RV systolic dysfunction based on TAPSE and S’, respectively. Its presence confers about 6 times higher odds of developing increased RAP. These parameters can direct further diagnostic work-up and guide assessment of response to decongestive therapy in critical units and other areas where 2d-echocardiogram is not readily accessible.

A patient with unexplained hypoxemia after a fall diagnosed with platypnea orthodeoxia syndrome: approaches to resolving discrepancies between level of hypoxemia and clinical presentation.

Platypnea orthodeoxia syndrome (POS) is a rare cause of hypoxemia. Diagnosis of POS is challenging, requiring a high index of clinical suspicion, special investigations, and collaboration with multiple specialists. We describe an 86-yr-old male who presented to the emergency department with hip pain after a witnessed fall. He was noted to be hypoxemic at presentation with a peripheral oxygen saturation (SpO2) of 84% on room air, with an inadequate increase in oxygenation after administration of a fractional concentration of inspired oxygen (FIO2) of 1.00. A chest radiograph, computed tomography pulmonary angiogram, and Doppler ultrasound of the liver were unremarkable. In the supine position with an FIO2 of 0.65, his SpO2 and arterial partial pressure of oxygen (PaO2) (96% and 74mm Hg, respectively) increased significantly relative to the seated position (84% and 50mm Hg, respectively). Contrast transthoracic echocardiography (TTE) showed a large patent foramen ovale (PFO) with right-to-left shunt. Transthoracic echocardiography showed rotation of the patient's heart, enabling direct alignment of the inferior vena cava with the PFO, creating a large anatomical right-to-left shunt in the seated position. Right heart catheterization confirmed a large PFO with normal right-sided heart pressures. He was treated with a septal occlusion and his SpO2 in the seated position improved immediately. The patient was discharged home without requiring supplemental oxygen. Platypnea orthodeoxia syndrome is a rare presentation of hypoxemia. Positional changes in oxygenation are the cardinal feature of POS. Discordance between lung imaging and the severity of hypoxemia should prompt investigation for an intracardiac shunt, which can occur in POS even in the absence of increased right-sided heart pressures. Either contrast TTE or transesophageal echocardiography is necessary to make this diagnosis.

Pulmonary Hypertension: Pharmacological and Non-Pharmacological Therapies.

Pulmonary hypertension (PH) is a severe and chronic disease characterized by increased pulmonary vascular resistance and remodeling, often precipitating right-sided heart dysfunction and death. Although the condition is progressive and incurable, current therapies for the disease focus on multiple different drugs and general supportive therapies to manage symptoms and prolong survival, ranging from medications more specific to pulmonary arterial hypertension (PAH) to exercise training. Moreover, there are multiple studies exploring novel experimental drugs and therapies including unique neurostimulation, to help better manage the disease. Here, we provide a narrative review focusing on current PH treatments that target multiple underlying biochemical mechanisms, including imbalances in vasoconstrictor-vasodilator and autonomic nervous system function, inflammation, and bone morphogenic protein (BMP) signaling. We also focus on the potential of novel therapies for managing PH, focusing on multiple types of neurostimulation including acupuncture. Lastly, we also touch upon the disease's different subgroups, clinical presentations and prognosis, diagnostics, demographics, and cost.

Transcatheter vacuum-assisted aspiration of large intracardiac and intravascular masses.

Intravascular and intracardiac masses are usually represented by thrombi, tumours, and vegetations. They can affect both the right and left chambers of the heart and the venous and arterial circulation. Traditionally, their treatment is surgical or, in some circumstances, based on systemic anticoagulation/fibrinolysis. However, the complexity and frailty of patients who sometimes present with these conditions have pushed surgeons to find alternative minimally invasive effective treatments. While small masses can be removed with multiple devices, large masses are a more challenging problem. Vacuum-assisted aspiration systems such as the AngioVac System were developed to treat intravenous and right-sided heart thrombi. The application of the AngioVac System was widened to right-sided endocarditis and, later, to left-sided thrombi and vegetations. This review summarises the clinical results of different uses of the vacuum-assisted aspiration system to treat intravenous and intracardiac masses.

Infective Endocarditis Among Women Who Inject Drugs

In the US and Canada, women comprise approximately one-third of people who inject drugs (PWID); however, clinical characteristics and outcomes of injection drug use complications in women are poorly described. To identify clinical characteristics and outcomes of infective endocarditis (IE) among women who inject drugs (WWID). This is a retrospective cohort study of PWID with definite IE (per 2023 Duke-International Society for Cardiovascular Infectious Diseases criteria) admitted from April 5, 2007, to March 15, 2018, at 5 tertiary-care hospitals in London, Ontario, and Regina, Saskatchewan, Canada. Data were analyzed from June 1, 2023, to August 2, 2024. Descriptive analyses were conducted for baseline characteristics at index hospitalization and stratified by sex. The primary outcome was the difference in 5-year survival between female and male PWID with IE. The secondary outcome was 1-year survival. Multivariable time-dependent Cox proportional hazards regression analyses were conducted for variables of clinical importance to evaluate 5-year mortality. Of 430 PWID with IE, 220 (51.2%) were women; of 332 non-PWID with IE, 101 (30.4%) were women. WWID with IE were younger than men (median [IQR] age, 31.5 [27.0-38.5] vs 38.5 [31.0-49.0] years), and 11 of 220 (5.0%) were pregnant at index hospitalization, although only 12 of 220 (5.5%) had contraceptive use documented. Women had a larger proportion of right-sided IE than men (158 of 220 women [71.8%] vs 113 of 210 men [53.8%]). WWID living in urban areas had higher mortality than WWID in rural areas (adjusted hazard ratio [aHR], 2.70; 95% CI, 1.15-6.34; P = .02). Overall mortality was lower among PWID referred for substance use disorder counseling in centers with inpatient services compared with centers with only outpatient referrals (aHR, 0.29; 95% CI, 0.17-0.51; P < .001). Overall mortality was lower with right-sided heart disease for both women (aHR, 0.44; 95% CI, 0.27-0.71; P < .001) and men (aHR, 0.22; 95% CI, 0.10-0.50; P < .001) and was higher with congestive heart failure for both women (aHR, 2.32; 95% CI, 1.29-4.18; P = .005) and men (aHR, 1.73; 95% CI, 1.07-2.79; P = .02). In this cohort of PWID with IE, women were overrepresented. Reasons for women's disproportionately high IE incidence need further study. Inpatient substance use disorder services, contraception counseling, and enhanced social support for WWID living in urban areas need to be prioritized.

Metabolic gene therapy in a canine with pulmonary hypertension secondary to degenerative mitral valve disease.

Myxomatous mitral valve disease (MMVD) stands out as the most prevalent acquired canine heart disease. Its occurrence can reach up to 40% in small breed dogs and escalates in geriatric canine populations. MMVD leads to thickening and incomplete coaptation of valve leaflets during systole, resulting in secondary mitral valve regurgitation. Serious complications may arise concurrently with the worsening of mitral valve regurgitation, including left-and right-sided congestive heart failure, and pulmonary hypertension (PH). Ultimately, the PH progression might contribute to the patient's demise or to the owner's decision of euthanasia. Most currently available FDA-approved therapies for PH are costly and aim to address the imbalance between vasoconstriction and vasodilation to restore endothelial cell function. However, none of these medications impact the molecular dysfunction of cells or impede the advancement of pulmonary vascular and right ventricular remodeling. Recent evidence has showcased successful gene therapy approaches in laboratory animal models of PH. In this manuscript, we summarize the latest advancements in gene therapy for the treatment of PH in animals. The manuscript incorporates original data showcasing sample presentations, along with non-invasive hemodynamic assessments. Our findings demonstrate that the use of metabolic gene therapy, combining synthetic adeno-associated virus with acid ceramidase, has the potential to significantly reduce the need for drug treatment and improve spontaneously occurring PH in dogs.

275 Frequency of chronic passive congestive livers at harvest in the Texas Panhandle and the association with carcass outcomes

Abstract Chronic passive congestive (CPC) livers are reported as one of the most common clinical signs of right-sided Bovine Congestive Heart Failure (BCHF). Frequency of CPC livers at harvest and the associated loss of offal and carcass value does not appear in the literature. Our objectives were to 1) quantify the frequency of CPC livers at harvest within the Texas Panhandle, and 2) evaluate the association with offal and carcass outcomes. Audits were performed over the duration of a production week (both harvest shifts) per each large commercial beef processing facility (4 total) in the Texas Panhandle. West Texas A&amp;M University trained personnel identified CPC (large blue) livers at evisceration and documented heart score (HS; scale 1 = normal to 5 = extreme structural changes), liver weight, USDA-FSIS inspection fate (U.S. Inspected &amp; Passed; U.S. Condemned) of the liver, remaining viscera, and carcass. Other visual observations (sex, predominant black hair coat color, carcass/visceral edema, liver abscesses) were noted. 1) Frequency data were documented among cattle-type populations: sex (steers, heifers, cows, bulls), and phenotype [native, dairy-cross, dairy, category-B (Mexico-origin)]. 2) Carcass and lot identification were collected for the purpose of tracking and obtaining carcass grading data. Of carcasses deemed wholesome-U.S. Inspected &amp; Passed, USDA yield and quality metrics [hot carcass weight (HCW), 12th-rib fat thickness (FT), ribeye area (REA), marbling score (MS)] of those identified with CPC, as well as data for the balance of respective lots were collected. Carcass outcomes of those exhibiting a CPC liver were compared with the outcomes of remaining lot. Frequency data were analyzed via chi-square. Carcass data were analyzed using mixed models, where occurrence of CPC liver was the fixed effect; facility, cattle type, and sex were random effects. A total of 83,527 animals were audited, with a CPC liver frequency of 0.17% (n = 144). Frequencies among sex (steer = 0.16%; heifer = 0.17%; cow = 0.33%; P &amp;lt; 0.01) and phenotypes (native = 0.15%; category-B = 0.04%; dairy cross = 0.14%; P = 0.01) were documented. Heart scores ranged from 1 to 4, with HS 3 occurring most frequently [HS 1 (n = 2); HS 2 (n = 39); HS 3 (n = 62); HS 4 (n = 17)]. Weights of CPC livers ranged from 7.3 kg to 34.4 kg; the heaviest CPC livers were recorded in cows (mean = 17.2 kg; P &amp;lt; 0.01). Despite USDA-FSIS guidelines, 2.08% of CPC livers were U.S. Inspected &amp; Passed, along with 16.90% of viscera and 84.03% of carcasses. Cow carcasses encountered the greatest U.S. Condemn-rates (38.24%) among the sex categories. Within the fed-beef population, natives were the only category resulting in U.S. Condemned carcasses (10.64%). All carcass outcomes were decreased (P ≤ 0.01) by CPC livers.

345 Breed differences within heart scores of fattening feedlot cattle

Abstract Feedlot heart disease (FHD) is a condition in fattening beef cattle that arises from right-side heart remodeling resulting from alveolar hypoxia. This hypoxic environment is hypothesized to result from the large body mass of fattened cattle. Sensitive cattle have increased incidence of pulmonary hypertension resulting from compensation mechanisms of the individual. The severity of this remodeling is quantified at harvest by gross examination of the heart utilizing a visual grading system of 1-5, where a score of 1 is a normal heart and a score of 5 is a severely remodeled heart. Previously, heart score was found to contain sire differences and to be moderately heritable. This led to more questions regarding other potential factors influencing heart scores, one of which was breed differences. Therefore, the objective of this study was to examine the prevalence of heart remodeling in beef and dairy cattle breeds and to investigate whether some breeds had a greater prevalence of heart remodeling. Heart scores were collected on Angus-influenced animals raised in the panhandle of Texas (1,103 m) and a Beef x Dairy group raised in western Kansas (846 m). The total number of animal observations was 2,069. Twenty-four percent of the individuals exhibited moderate to severe remodeling (score 3 and greater). Of this cohort, 1,307 animals had breed composition data (i.e., Angus, Simmental, Jersey, and Holstein) suitable for use in the analysis. Breed proportions ranged from 0% to 100% for Angus, 0 to 93.25% for Simmental, 0% to 69.22% for Jersey, and 0% to 78.06% for Holstein. Utilizing a linear regression model with heart score as the response and breed percentages and heart scorers as fixed effects, the importance of breed composition (covariate) was determined. The percentages of Angus influence tended to be associated with heart score (P = 0.0506), with a regression coefficient of -0.005. The percentage of Simmental had an association with the variation in heart score (P &amp;lt; 0.05) and had a regression coefficient of -0.008. Additionally, the percentages of Jersey and Holstein were found to reduce the incidence of heart score by a factor of -0.014 and -0.018 (P &amp;lt; 0.05), respectively. In summary, an increased percentage of either Jersey or Holstein breed resulted in reduced heart scores, while the incidence of beef breeds was found to be associated with some to little difference in the improvement of heart scores, alluding to potential breed advantages in mitigating right sided heart remodeling.

349 The relationship of heart score with hot carcass weight and fat depth in Angus cattle

Abstract Congestive Heart Failure (CHF) is a cardiopulmonary condition observed in cattle raised in feedlots situated at elevations above 800 m. This condition leads to right-sided heart failure caused by increased pulmonary vessel pressures and cardiopulmonary remodeling, known as pulmonary hypertension (PH). In cattle experiencing PH, pulmonary arterial pressure (PAP) becomes abnormally high, increasing heart muscle load. This load stretches muscle fibers and enlarges the right side of the heart which can lead to heart failure and death. To assess the severity of PH, animals are assigned a heart score (HS) on a scale ranging from 1 to 5 at harvest. A score of 1 represents a normal heart, while a score of 5 indicates extreme heart remodeling. Understanding the relationship between hot carcass weight (HCW), fat depth (FD), and HS in Angus cattle will provide useful information on the impacts of this condition on feedlot performance and profitability. The objective of this study was to determine if a phenotypic relationship between HCW and FD with HS in Angus-influenced cattle. For this experiment, a total of 798 black, Angus-influenced cattle were used (245 steers, 553 heifers) that were fed near Greeley, CO. The HCW, FD, and HS data from each animal were recorded at harvest. Three general linear models were used to estimate the effects of HS on HCW and FD. Mean HCW and FD were 393.1 kg, (SD = 90.9) and 0.66 mm, (SD = 0.18), respectively, with an average HS of 2.08 (SD = 0.77). For all models, HCW and FD were fit as dependent variables, while lot and HS were included as fixed effects. Model 1 included all HS categories independently. Model 2 divided HS into 2 groups of normal (HS = 1 or 2) or remodeled (HS = 3+). For model 3 HS 3 was removed leaving only HS of 4 or 5 in the remodeled group. For both HCW and FD in Model 1, the overall effect of HS was not significant (P = 0.82 and P = 0.40, respectively). However, when comparing individual scores, animals with a HS = 4 were 15.0 kg lighter for HCW than individuals with a HS = 1 (P &amp;lt; 0.05). Conversely for FD, a non-significant difference (P = 0.74) of -0.33 mm was observed between animals with a HS = 4 versus a HS = 1. Grouping HS into 2 categories in Model 2 did change the outcome, yielding non-significant HCW and FD differences. However, when eliminating the HS = 3 data, a significant reduction in HCW of 16.9 kg (P = 0.05) was observed between the 2 HS groups, whereas non-significant effects on FD remained. These data suggest that at extreme levels of heart remodeling HCW may be extremely impacted negatively.

343 The relationship between pulmonary arterial pressure phenotypes and oxygen consumption in beef cattle

Abstract The objective of this study was to determine if a phenotypic relationship between pulmonary arterial pressure (PAP) and oxygen consumption exists in beef cattle. Pulmonary arterial pressure is used as an indicator of pulmonary hypertension in cattle which is indicative of the susceptibility to both high-altitude disease and feedlot heart failure of an individual. Cattle with greater PAP are typically hypoxic and have initiated expression of compensatory mechanisms their cardio-pulmonary systems employ to combat this alveolar hypoxia. In turn, this causes an increase in PAP and, ultimately, right-sided heart failure. If hypoxic individuals consume more oxygen as a compensation mechanism, oxygen consumption as a trait could be used as an indicator of the prediction of PAP and feedlot heart failure and would be especially useful for cattle in deep phenotyping systems. Data used in the study included cattle with PAP measures on a total of 132 individuals. The data consisted of both steers (n = 99) and heifers (n = 33) from a ranch located in southern Wyoming at an elevation of approximately 2,195 m. After weaning on the ranch, cattle were transported to Colorado State University’s Agriculture Research, Development and Education Center located in Fort Collins, CO (elevation: 1,558 m). Oxygen consumption was measured using a Greenfeed system (C-Lock, Rapid City, South Dakota). To determine if a relationship exists between oxygen consumption and PAP, a simple linear regression model was used to regress PAP on average daily oxygen consumption. Effects included in the model were sex and phenotypic PAP. Average daily oxygen consumption was measured in kilograms per day and averaged 6.6 ± 1.66 kg with a range of 2.3 to 10.45 kg. Pulmonary arterial pressure averaged 42.6 ± 7.96 mm Hg and ranged from 33 to 81 mm Hg. In this data, sex did not account for a significant amount of variability in phenotypic PAP (P &amp;gt; 0.05). Oxygen consumption did account for a significant amount of variability in PAP (P &amp;lt; 0.05), and it was found that with every 1 kg increase of oxygen consumption, PAP is estimated to increase 1.02 mm Hg. These results indicate that a statistical relationship between oxygen consumption and PAP exists. Although these findings suggest that greater oxygen consumption leads to greater PAP, further research is required to fully comprehend the relationship between beef cattle PAP and oxygen consumption.

The Use of Pulmonary Arterial Pressure (PAP) for Improved Beef Cattle Management.

Pulmonary arterial pressure (PAP) determines cattle's susceptibility to High Altitude Disease (HAD), also known as Brisket Disease, High Mountain Disease, and right-sided heart failure (RHF). This non-infectious disease causes pulmonary hypertension due to hypoxia. PAP measures the resistance of blood flow through the lungs. It is estimated that 1.5 million head of cattle are raised in high-altitude environments (above 1500 m), and HAD accounts for 3-5% of calf death loss yearly. In addition, there have been increasing concerns about feedlot cattle succumbing to RHF at moderate elevations. This review focuses on the historical background, explanation of PAP measurement and scores, genetic implications, and the relationship between PAP and economically relevant traits. Specifically, traits such as gestation length, birth weight, weaning weight, and yearling weight may impact PAP scores. In addition, environmental effects and other factors impacting PAP score variations are discussed. Information gaps and research needs are addressed to determine where missing information could improve the understanding of PAP while also benefiting beef cattle producers in high-elevation production systems.

Redo isolated tricuspid valve replacement in a patient with isolated persistent left superior vena cava: a case report

BackgroundRedo isolated tricuspid valve surgery has high in-hospital mortality and morbidity and is a challenging procedure. We report a successful case of redo isolated tricuspid valve replacement for structural valve deterioration of a bioprosthesis in a patient with isolated persistent left superior vena cava (PLSVC).Case presentationAn 81-year-old man with a history of tricuspid valve replacement using a porcine bioprosthetic valve 9 years previously presented with dyspnea on exertion. Right heart failure due to worsening transvalvular leakage in the bioprosthetic tricuspid valve was considered to be the cause of his symptoms, and the decision was made to replace the tricuspid valve. An isolated PLSVC is considered to be an obstacle in right-sided heart valve surgery. The PLSVC was located deep to the left of the pulmonary artery and, after some effort, was cannulated by obtaining an excellent surgical view using retraction sutures on the left side of the pericardium. Cardiopulmonary bypass was initiated after cannulation of the ascending aorta, PLSVC, and femoral vein. After cross-clamping of the ascending aorta, cold blood cardioplegic arrest was induced under moderate hypothermia, and the PLSVC and inferior vena cava were snared. The right atrium was opened and the prosthetic tricuspid valve was examined. One of the leaflets was shortened, which appeared to cause the transvalvular leak. The prosthetic valve was explanted, the annulus was trimmed, and a new bioprosthetic valve was implanted. The postoperative course was uneventful.ConclusionsIt is important to treat structural valve deterioration of a prosthetic tricuspid valve in a timely manner. We hope that our intervention timing and surgical strategy can help surgeons to consider early intervention in similar cases, even if there are surgical obstacles such as isolated PLSVC.

Burden of Heart Failure in Patients With Tricuspid Regurgitation and Effect of Transcatheter Repair on Different Subdimensions of Quality of Life.

Right-sided heart failure (HF) due to severe tricuspid regurgitation (TR) is associated with reduced quality of life (QoL). Here, we analyzed the impact of TR on specific QoL dimensions and the effect of transcatheter tricuspid valve intervention (TTVI) on individual QoL items. In this study, we included 174 patients with HF (49% women; median age, 79 years; 97% New York Heart Association ≥3) with baseline QoL assessment undergoing TTVI by transcatheter edge-to-edge-repair at our center between April 2016 and March 2022. QoL was assessed by the standardized Minnesota Living With HF Questionnaire. QoL change after TTVI and correlation to functional end points were analyzed. In addition, all QoL domains and the 21 individual items of the Minnesota Living With HF Questionnaire were analyzed. TTVI significantly reduced TR (TR ≥3: baseline 95%, 1-year-follow-up 7%; P<0.001). Total Minnesota Living with HF Questionnaire score improved from 37 (interquartile range, 26-50) points to 31 (interquartile range, 17-42) points (median follow-up-interval, 355 days; P<0.001). QoL improvement was associated with positive New York Heart Association class, 6-minute walking distance, and actigraphy changes (all P<0.05). The detailed analysis revealed that all items of the physical-related QoL dimension were impaired at baseline and strongly improved after TTVI. In contrast, the emotional and "social" Minnesota Living With HF Questionnaire dimensions were largely unaffected at baseline, yet specific items improved with TTVI. In this single-center study, we delineate the QoL-associated disease burden of TR and identify specific QoL items that improved after TTVI. Our findings support TTVI in patients with reduced QoL and may add to the development of specific tools assessing the functional status of an increasing patient population undergoing TTVI.

Prognostic Indicators of Morbidity and Mortality in Children with Congestive Hepatopathy Presenting with Ascites.

Objectives: Congestive hepatopathy is a significant complication for children suffering from right-sided heart disease (RHD). We hypothesize that hospitalized pediatric patients with ascites will have congestive hepatopathy leading to advanced liver disease if their cardiac condition is RHD versus non-right-sided heart disease (NRHD). Methods: This is a retrospective cohort study of pediatric patients who presented with an ascites diagnosis (ICD-10 R18) and at least one cardiac diagnosis. Patient demographics, past medical history, laboratory values, imaging results, calculated clinical scores (e.g., APRI, FIB-4), treatment, length of stay (LOS), and death at hospital discharge were analyzed. Results: Of the 136 patients with ascites, 21 patients presented with a primary cardiac disease (12 in RHD and 9 in NRHD). Of these patients, eight (38%) were female, and nine (43%) were White, seven (33%) were Black, and five (24%) were unknown. The RHD group had a mean age of 5.1 Y (vs. 9.5 Y in NRHD). The mean APRI score in RHD patients was 2.87, and it was 0.85 in NRDH. Treatments were similar, with most patients requiring diuretics (11 RHD (92%) vs. 8 NRDH (89%)); 5 RHD (42%) vs. 4 NRDH (44%) required inotropic support. RHD patients had a longer LOS, with an average of 92 days vs. 52 days for NRDH patients. Overall, each group had one death at discharge (8% RHD vs. 11% NRDH). Conclusions: In the realm of children with ascites, the subset grappling with congestive heart disease paints a unique picture. In this context, ascites stands as an elusive predictor of liver decompensation, defying conventional diagnostic pathways.

Lymphatic morphology and function in chronic right heart failure due to secondary tricuspid valve regurgitation

BackgroundIn heart failure, the capacity of the lymphatic system dictates symptoms of circulatory congestion. This study aimed at describing structural and functional changes of the lymphatic system in patients with chronic right-sided heart failure. MethodsIndividuals with long-standing severe tricuspid valve regurgitation and symptoms of heart failure were compared with age- gender- and weight-matched controls. Lymphatic structure and function were examined using non-contrast MR lymphangiography and near-infrared fluorescence imaging. Microvascular fluid dynamics and distribution were evaluated using strain gauge plethysmography and bio-impedance. ResultsIn total nine patients and nine controls were included. Lymphatic morphology was unchanged in cases compared to controls with similar thoracic duct diameters 3.1(2.1–3.5) mm vs. 2.0(1.8–2.4) mm (p-value = 0.11), similar lymphatic classifications (p-value 0.34), and an identical number of lymphatic vessels in the legs 6 ± 1 vs. 6 ± 3 vessels/field (p-value = 0.72). Lymphatic function was comparable with contraction frequencies of 0.5 ± 0.2 and 0.5 ± 0.3 /min (p-value = 0.52) and a maximal lymphatic pumping pressure of 60 ± 13 and 57 ± 12 mmHg (p-value = 0.59) for cases and controls respectively. Finally, microvascular capillary filtration, isovolumetric threshold, and fluid distribution were similar between groups (p-value≥0.16 for all comparisons). ConclusionIn this small exploratory study, individuals with severe secondary tricuspid valve regurgitation and right-sided heart failure displayed a largely similar lymphatic anatomy and function. Thoracic duct diameter displayed a trend towards increased size in the patient group. We speculate that cases were indeed stable and optimally treated at the time of examination, and with a lymphatic system largely unaffected by any of the current or prior hemodynamic changes.

Exploring the inflammation-related mechanisms of Lingguizhugan decoction on right ventricular remodeling secondary to pulmonary arterial hypertension based on integrated strategy using UPLC-HRMS, systems biology approach, and experimental validation

BackgroundPulmonary arterial hypertension (PAH) and the consequent right heart dysfunction persist with high morbidity and mortality, and the mechanisms and pharmacologic interventions for chronic right-sided heart failure (RHF) have not been adequately investigated. Research has shown that prolonged inflammation is critical in precipitating the progression of PAH-associated right heart pathology. Some research demonstrated that Lingguizhugan decoction (LGZGD), as a classical Chinese medicine formula, had beneficial effects in alleviating PAH and RHF, while its underlying mechanisms involved are not fully elucidated. PurposeBased on that, this study aims to investigate the effects and underlying mechanisms of LGZGD on PAH-induced RHF. Study DesignIn this study, we identified the serum constituents and deciphered the potential anti-inflammatory mechanism and crucial components of LGZGD using combined approaches of UPLC-HRMS, transcriptomic analysis, and molecular docking techniques. Finally, we used in vivo experiments to verify the expression of key targets in the monocrotaline (MCT)-induced RHF model and the intervene effect of LGZGD. ResultsIntegrated strategies based on UPLC-HRMS and systems biology approach combined with in vivo experimental validation showed that LGZGD could improve right heart fibrosis and dysfunction via regulating diverse inflammatory signaling pathways and the activity of immune cells, including chemokine family CCL2, CXCR4, leukocyte integrins family ITGAL, ITGB2, and M2 macrophage infiltration, as well as lipid peroxidation-associated HMOX1, NOX4, and 4-HNE. ConclusionThe present research demonstrated for the first time that LGZGD might improve PAH-induced RHF through multiple anti-inflammatory signaling and inhibition of ferroptosis, which could provide certain directions for future research in related fields.

Clinical outcome of patients with rheumatic tricuspid valve disease: matched cohort study.

Rheumatic heart disease (RHD) is still a major health problem, especially in low- to mid-income countries, leading premature deaths owing to valvular disease. Although left-sided valvular involvement is most commonly seen in RHD, the tricuspid valve can also be affected. However, there is a lack of information about the prognostic value of primary tricuspid valve (TV) disease in RHD. This study aimed to determine the impact of TV disease on clinical outcome in RHD. This prospective study enrolled patients with rheumatic mitral valve disease (MVD) referred to a tertiary center for management of heart valve disease. Primary rheumatic TV disease was defined by echocardiographic features including thickening of leaflets associated with some degree of restricted mobility. Patients with rheumatic TV disease were matched to patients with MVD using 1:1 genetic matching algorithm that maximized balance of baseline covariates prior to exploring outcome differences. The main outcome was either need for MV replacement or death. Among 694 patients eligible for the study, age of 47 ± 13 years, 84% female, 39 patients (5.6%) had rheumatic TV disease. After excluding patients with incomplete data, 33 patients with TV disease were matched to 33 controls based on age, right-sided heart failure, atrial fibrillation, and MV area. During a mean follow-up of 42 months (median 28, IQR 8 to 71 months), 32 patients (48.5%) experienced adverse events, including 6 cardiovascular deaths and 26 patients who underwent surgery for mitral valve replacement. The adjusted analysis demonstrated a significant association between TV disease and the outcome, with a hazard ratio (HR) of 3.386 (95% CI 1.559-7.353; P = 0.002) in the genetic matched cohort with balance on baseline covariates of interest. The model exhibited good discriminative ability, as indicated by a C-statistic of 0.837. In patients with rheumatic mitral valve disease, rheumatic TV disease significantly increased risk of adverse events compared with matched controls. The involvement of TV may express overall disease severity that adversely affects clinical outcome.

Carcinoid Heart Disease.

Carcinoid heart disease (CHD) is a rare but potentially life-threatening sequela of advanced neuroendocrine neoplasm with carcinoid syndrome. These tumors can secrete vasoactive substances of which serotonin is the most prevalent. Carcinoid heart disease typically involves the right-sided heart valves and eventually leads to right heart failure. Monitoring N-terminal pro-B-type natriuretic peptide and 5-hydroxyindoleacetic acid at diagnosis and during treatment, as well as cardiac echocardiogram, helps to screen for CHD. Many patients are not screened for this appropriately. Multidisciplinary care for patients with CHD is ideal and involves medical oncology, cardiology, and cardiothoracic surgery.

Acute kidney injury in acute heart failure–when to worry and when not to worry?

ABSTRACT Acute kidney injury is common in patients with acute decompensated heart failure. It is more common in patients with acute heart failure who suffer from chronic kidney disease. Worsening renal function is often defined as a rise in serum creatinine of more than 0.3 mg/dL (26.5 µmol/L) which, by definition, is acute kidney injury (AKI) stage 1. Perhaps the term AKI is more appropriate than worsening renal function as it is used universally by nephrologists, internists and other medical practitioners. In health, the heart and the kidney support each other to maintain the body's homeostasis. In disease, the heart and the kidney can adversely affect each other's function, causing further clinical deterioration. In patients presenting with acute heart failure and fluid overload, therapy with diuretics for decongestion often causes a rise in serum creatinine and AKI. However, in the longer term the decongestion improves survival and prevents hospital admissions despite rising serum creatinine and AKI. It is important to realize that renal venous congestion due to increased right-sided heart pressures in acute heart failure is a major cause of kidney dysfunction and hence decongestion therapy improves kidney function in the longer term. This review provides a perspective on the acceptable AKI with decongestion therapy, which is associated with improved survival, as opposed to AKI due to tubular injury related to sepsis or nephrotoxic drugs, which is associated with poor survival.