Right-sided Congestion Research Articles

Congestion patterns in severe tricuspid regurgitation and transcatheter treatment: Insights from a multicentre registry.

While invasively determined congestion holds mechanistic and prognostic significance in acute heart failure (HF), its role in patients with tricuspid regurgitation (TR)-related right- heart failure (HF) undergoing transcatheter tricuspid valve intervention (TTVI) is less well established. A comprehensive understanding of congestion patterns might aid in procedural planning, risk stratification, and the identification of patients who may benefit from adjunctive therapies before undergoing TTVI. The aim of this study was to investigate the role of congestion patterns in patients with severe TR and its implications for TTVI. Within a multicentre, international TTVI registry, 813 patients underwent right heart catheterization (RHC) prior to TTVI and were followed up to 24 months. The median age was 80 (interquartile range 76-83) years and 54% were women. Both mean right atrial pressure (RAP) and pulmonary capillary wedge pressure (PCWP) were associated with 2-year mortality on Cox regression analyses with Youden index-derived cut-offs of 17 mmHg and 19 mmHg, respectively (p < 0.01 for all). However, RAP emerged as an independent predictor of outcomes following multivariable adjustments. Pre-interventionally, 42% of patients were classified as euvolaemic (RAP <17 mmHg, PCWP <19 mmHg), 23% as having left-sided congestion (RAP <17 mmHg, PCWP ≥19 mmHg), 8% as right-sided congestion (RAP ≥17 mmHg, PCWP <19 mmHg), and 27% as bilateral congestion (RAP ≥17 mmHg, PCWP ≥19 mmHg). Patients with right-sided or bilateral congestion had the lowest procedural success rates and shortest survival times. Congestion patterns allowed for discerning specific patient's physiology and specifying prognostic implications of right ventricular to pulmonary artery coupling surrogates. In this large cohort of invasively characterized patients undergoing TTVI, congestion patterns involving right-sided congestion were associated with low procedural success and higher mortality rates after TTVI. Whether pre-interventional reduction of right-sided congestion can improve outcomes after TTVI should be established in dedicated studies.

Hemodynamic evaluation of right-sided congestion with doppler ultrasonography in pulmonary hypertension: portal vs intra-renal venous flow patterns

Abstract Introduction Renal congestion is a key pathophysiological mechanism mediating adverse outcomes in patients with heart failure. Novel approaches to evaluate renal congestion like renal Doppler ultrasonography show promise as a noninvasive hemodynamic monitoring tool. Portal Doppler ultrasound is a less challenging exam and could potentially provide similar information than intra-renal Doppler. Methods and Results We enrolled 95 patients with suspected or diagnosed pulmonary hypertension (PH) presenting to the emergency department or to a scheduled ambulatory clinic. Patients underwent renal and portal Doppler ultrasonography. Renal congestion was graded using the validated renal venous stasis index (RVSI) or renal venous patterns. The portal vein pulsatility fraction (PVPF) was used to quantify portal congestion. We found high degree of correlation (R = 0.93) between portal and renal congestion, with excellent agreement (κ = 0.92 [0.86-0.98]). Both RVSI and PVPF showed excellent interclass correlation and agreement amongst operators (ICC 0.93). 90-day mortality or need for renal replacement therapy was significantly more frequent in patients with high PVPF (p=0.001) HR: 5.3 (1.9-17.0). Conclusions Altered portal venous flow accurately predicts the presence of renal congestion and is technically easier to obtain. Portal vein Doppler may identify patients with pulmonary hypertension at risk for renal deterioration secondary to venous congestion.Portal-renal patterns and their outcomes

Hemodynamic Evaluation of Right-Sided Congestion With Doppler Ultrasonography in Pulmonary Hypertension

Hemodynamic Evaluation of Right-Sided Congestion With Doppler Ultrasonography in Pulmonary Hypertension

Disproportionate exercise-induced pulmonary hypertension in relation to cardiac output in heart failure with preserved ejection fraction: a non-invasive echocardiographic study.

Pulmonary hypertension (PH) and pulmonary vascular remodelling are common in patients with heart failure with preserved ejection fraction (HFpEF). Many patients with HFpEF demonstrate an abnormal pulmonary haemodynamic response to exercise that is not identifiable at rest. This can be estimated non-invasively by the mean pulmonary artery pressure-cardiac output relationship (mPAP/CO slope). We sought to characterize the pathophysiology of disproportionate exercise-induced PH in relation to CO (DEi-PH) and its prognostic impact in patients with HFpEF. A total of 345 patients (166 HFpEF and 179 controls) underwent ergometry exercise stress echocardiography with simultaneous expired gas analysis. DEi-PH was defined as the mPAP/CO slope >5.2 mmHg/L/min (median value). At rest, there were no differences in right ventricular (RV) function and severity of PH between HFpEF patients with and without DEi-PH. Compared with controls (n=179) and HFpEF without DEi-PH (n=83), HFpEF with DEi-PH (n=83) demonstrated worse exercise capacity (lower peak oxygen consumption), depressed RV systolic function, impaired RV-pulmonary artery coupling, limitation in CO augmentation, more right-sided congestion, and worse ventilatory efficiency (higher minute ventilation vs. carbon dioxide volume) during peak exercise. Kaplan-Meier analyses showed that HFpEF patients with DEi-PH had higher rates of composite outcomes of all-cause mortality or heart failure events than those without (log-rank p=0.0002). Patients with HFpEF and DEi-PH demonstrated distinct pathophysiologic features that become apparent only during exercise. These data suggest that DEi-PH is a pathophysiologic phenotype of HFpEF and reinforce the importance of exercise stress echocardiography for detailed characterization of HFpEF.

Pulmonary artery banding in sheep: a novel large animal model for congestive hepatopathy.

Congestive hepatopathy is becoming increasingly recognized among Fontan-palliated patients. Elevated central venous pressure is thought to drive the pathologic progression, characterized by sinusoidal dilatation, congestion, and fibrosis. A clinically relevant large animal model for congestive hepatopathy would provide a valuable platform for researching novel biomarkers, treatment, and prevention. Here, we report on a titratable, sheep pulmonary artery banding model for this disease application. Pulmonary artery banding was achieved by progressively inflating the implanted pulmonary artery cuff. Right ventricular catheter was implanted to draw venous blood samples and measure pressure. The pulmonary artery cuff pressure served as a surrogate for the intensity of pulmonary artery banding and was measured weekly. After about 9 wk, animals were euthanized, and the liver was harvested for histopathological assessment. Nine animal subjects received pulmonary artery banding for 64 ± 8 days. Four of the nine subjects exhibited moderate to severe liver injury, and three of those four exhibited bridging fibrosis. Increasing pulmonary artery cuff pressure significantly correlated with declining mixed venous oxygen saturation (P = 3.29 × 10-5), and higher congestive hepatic fibrosis score (P = 0.0238), suggesting that pulmonary artery banding strategy can be titrated to achieve right-sided congestion and liver fibrosis. Blood analyses demonstrated an increase in plasma bile acids, aspartate aminotransferase, and γ-glutamyltransferase among subjects with moderate to severe injury, further corroborating liver tissue findings. Our large animal pulmonary artery banding model recapitulates congestive hepatopathy and provides a basis to bridge the current gaps in scientific and clinical understanding about the disease.NEW & NOTEWORTHY We present here a large animal platform for congestive hepatopathy, a disease growing in clinical prevalence due to the increasing number of Fontan-palliated patients. Further data are needed to develop a better clinical management strategy for this poorly characterized patient population. Previous reports of animal models to study this disease have mostly been in small animals with limited fidelity. We show that congestive hepatopathy can be replicated in a chronic, progressive pulmonary artery banding model in sheep. We also show that the banding strategy can be controlled to titrate the level of liver injury. To date, we do not know of any other large animal model that can achieve this level of control over disease phenotype and clinical relevance.

Mitra-clip in Transthyretin Amyloidosis Cardiomyopathy A Case Series

IntroductionNon-invasive valvular interventions have dramatically changed the management of patients with multiple complex comorbidities. Patients with cardiac amyloidosis (CA) are often considered high-risk for surgical intervention. Trans-catheter aortic valve replacement (TAVR) is tolerated in this population, however, little is known about the safety and efficacy of per-cutaneous mitral valve interventions, such as the MitraClip procedure. We present three patients with CA and mitral regurgitation (MR) who have undergone this procedure.CasesA 75-year-old man with wild-type transthyretin cardiac amyloidosis (wtATTR), atrial fibrillation with prior ablations, a Watchman device in the left atrial appendage, resection of a malignant lung nodule presented with recurrent right pleural effusions. On exam, he had a loud MR murmur, which had been present for many years. Transthoracic echocardiogram (TTE) showed moderate MR. A transesophageal echocardiogram (TEE) revealed a partial flail of the posterior leaflet of the mitral valve resulting in moderate to severe eccentric anteriorly directed MR, amenable to the placement of a MitraClip. Two MitraClips were places, which led to marked improvement in his dyspnea and a decrease in the frequency of thoracenteses for recurrent pleural effusions. A 71-year-old man with wtATTR and a permanent pacemaker was seen in follow-up with marked dyspnea on exertion and fatigue, despite being euvolemic on exam; jugular venous pressure was not elevated but there was a Kussmaul's sign. First and second heart sounds normal and no MR murmur was heard, even in the left lateral position. TTE revealed moderate MR. His symptoms appeared disproportionate to the severity of his amyloid heart disease by exam as he had no evidence of right-sided congestion. It was suspected that the degree of MR was underestimated by TTE. TEE reveled mild diffuse thickening of the mitral valve leaflets with severe, functional MR that was directed centrally. The valve anatomy was suitable for MitraClip, and he underwent successful placement of 2 MitraClips. A 88-year-old man with MR and aortic insufficiency (AI) was seen with a new diagnosis of wtATTR. He had dyspnea on minimal exertion, marked fatigue, 3 pillow orthopnea and paroxysmal nocturnal dyspnea, he was euvolemic on examination, with a Kussmaul's sign, pansystolic and diastolic murmurs. TTE showed severe MR and moderate to severe AI, confirmed with TEE, which also showed the mitral valve was suitable for MitraClip. A single MitraClip was put in situ, with trace residual MR. He noted improvement in his energy and level of dyspnea following.DiscussionIt is important to consider other cardiac pathologies that co-exist in wtATTR, which can contribute to patients’ symptoms and are amenable to intervention. These cases demonstrate that MitraClip is feasible in MR in CA with careful patient selection.

The Worst Symptom as Defined By Patients During Heart Failure Hospitalization: Implications for Response to Therapy

BackgroundPatients perceive different symptoms of heart failure decompensation. It is not known whether the nature of the worst symptom relates to hemodynamic profile, response to therapy, or improvement in clinical trials. Methods and ResultsPatients in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness trial were hospitalized with advanced heart failure, ejection fraction ≤30%, and at least 1 sign and 1 symptom of elevated filling pressures. Visual analog scales (VAS) for symptoms were completed by 371 patients, who selected their worst symptom as difficulty breathing, fatigue, abdominal discomfort, or body swelling and also scored breathing and global condition at baseline and discharge. The dominant symptom identified was difficulty breathing by 193 (52%) patients, fatigue by 118 (32%), and abdominal discomfort and swelling each by 30 (8%) patients, combined as right-sided congestion for analysis. Clinical and hemodynamic assessments were not different between groups except that right-sided congestion was associated with more hepatomegaly, ascites, third heart sounds, and jugular venous distention. This group also had greater reduction in jugular venous distention and trend toward higher blood urea nitrogen after therapy. By discharge, average improvements in worst symptom and global score were 28 points and 24 points. For those with ≥10 points in improvement in worst symptom, 84% also improved global assessment ≥10 points. Initial fatigue was associated with less improvement (P = .002) during and after hospitalization, but improvements in symptom scores were sustained when re-measured during 6 months after discharge. ConclusionIn most patients hospitalized with clinical congestion, therapy will improve symptoms regardless of the worst symptom perceived, with more evidence of baseline fluid retention and reduction during therapy for worst symptoms of abdominal discomfort or edema. Improvement in trials should be similar when tracking worst symptom, dyspnea, or global assessment.

A surgical approach for S,L,L single ventricle incorporating total right atrium-pulmonary artery diversion

Patients with single ventricle and unfavorable anatomy for partitioning procedures have been considered inoperable. Such was the case in two patients with single ventricle and subaortic inverted (hypoplastic) infundibulum associated with subaortic obstruction and levo-transposition of the great vessels (S,L,L). Both had undergone pulmonary artery banding in infancy and presented 11 and 14 years later, cyanotic and severely incapacitated. Both patients were treated surgically by resection of the subaortic obstruction, patch closure of the right artrioventricular valve, closure of the proximal pulmonary artery, and diversion of systemic venous flow through a xenograft valved conduit from the right atrium to the distal pulmonary artery. Early postoperative complications included atrial dysrhythmias and right-sided congestion. The first patient, who had massive cardiomegaly and complete heart block preoperatively, developed congestive failure 20 months postoperatively. The second patient has an excellent functional result and is leading a normal life 1 years after operation. This procedure may be of value for patients with single ventricle in whom corrective ventricular septation is considered too risky or technically unfeasible.