Severe Right Ventricular Dysfunction Research Articles

Venous Congestion Assessed by Venous Excess Ultrasound (VExUS) and Acute Kidney Injury in Children with Right Ventricular Dysfunction.

Right ventricular dysfunction (RVD) is a complication following congenital cardiac surgery in children and can lead to systemic venous congestion, low cardiac output, and organ dysfunction. Venous congestion can be transmitted backwards and adversely affect encapsulated organs such as the kidneys. To investigate the association between systemic venous congestion, as estimated by Venous Excess Ultrasound (VExUS), and the occurrence of acute kidney injury (AKI) in children with RVD following congenital heart surgery. Secondary objectives included comparing changes in VExUS scores after initiating treatment for RVD and venous congestion. This was a prospective observational study in children with RVD. The VExUS study was performed on day 1, day 2, and day 3 and categorized as VExUS-1, VExUS-2, and VExUS-3. Among 43 patients with RVD and dilated inferior vena cava, 19/43 (44%), 10/43 (23%), and 12/43 (28%) were VExUS-2 and VExUS-3, respectively. There was an association between severe RVD and elevated pulmonary artery systolic pressures and a VExUS score >2. A significant association was observed between central venous pressure (CVP) measurements and VExUS. Among 31 patients with a high VExUS score >2, 18 (58%) had AKI. Additionally, improvement in CVP and fluid balance was associated with improving VExUS scores following targeted treatment for RVD. VExUS serves as a valuable bedside tool for diagnosing and grading venous congestion through ultrasound Doppler. An elevated VExUS score was associated with the occurrence of AKI, and among the components of VExUS, portal vein pulsatility may be useful as a predictor of AKI. Natraj R, Bhaskaran AK, Rola P, Haycock K, Siuba MTT, Ranjit S. Venous Congestion Assessed by Venous Excess Ultrasound (VExUS) and Acute Kidney Injury in Children with Right Ventricular Dysfunction. Indian J Crit Care Med 2024;28(5):447-452.

Challenges in Grading the Severity of Right Ventricular Dysfunction via Point-of-Care Echocardiography

Challenges in Grading the Severity of Right Ventricular Dysfunction via Point-of-Care Echocardiography

Monitoring of the right ventricular responses to pressure overload: prognostic value and usefulness of echocardiography for clinical decision-making.

Regardless of whether pulmonary hypertension (PH) results from increased pulmonary venous pressure in left-sided heart diseases or from vascular remodeling and/or obstructions in pre-capillary pulmonary vessels, overload-induced right ventricular (RV) dysfunction and its final transition into right-sided heart failure is a major cause of death in PH patients. Being particularly suited for non-invasive monitoring of the right-sided heart, echocardiography has become a useful tool for optimizing the therapeutic decision-making and evaluation of therapy results in PH. The review provides an updated overview on the pathophysiological insights of heart-lung interactions in PH of different etiology, as well as on the diagnostic and prognostic value of echocardiography for monitoring RV responses to pressure overload. The article focuses particularly on the usefulness of echocardiography for predicting life-threatening aggravation of RV dysfunction in transplant candidates with precapillary PH, as well as for preoperative prediction of post-operative RV failure in patients with primary end-stage left ventricular (LV) failure necessitating heart transplantation or a LV assist device implantation. In transplant candidates with refractory pulmonary arterial hypertension, a timely prediction of impending RV decompensation can contribute to reduce both the mortality risk on the transplant list and the early post-transplant complications caused by severe RV dysfunction, and also to avoid combined heart-lung transplantation. The review also focuses on the usefulness of echocardiography for monitoring the right-sided heart in patients with acute respiratory distress syndrome, particularly in those with refractory respiratory failure requiring extracorporeal membrane oxygenation support. Given the pathophysiologic particularity of severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection to be associated with a high incidence of thrombotic microangiopathy-induced increase in the pulmonary resistance, echocardiography can improve the selection of temporary mechanical cardio-respiratory support strategies and can therefore contribute to the reduction of mortality rates. On the whole, the review aims to provide a theoretical and practical basis for those who are or intend in the future to be engaged in this highly demanding field.

The Sugen/Hypoxia Rat Model for Pulmonary Hypertension and Right Heart Failure.

Pulmonary hypertension (PH) is a devastating disease, characterized by complex remodeling of the pulmonary vasculature. PH is classified into five groups based on different etiology, pathology, as well as therapy and prognosis. Animal models are essential for the study of underlying mechanisms, pathophysiology, and preclinical testing of new therapies for PH. The complexity of the disease with different clinical entities dictates the necessity for more than one animal model to resemble PH, as a single model cannot imitate the broad spectrum of human PH.Here we describe a detailed protocol for creating a rat model of PH with right ventricular (RV) failure. Furthermore, we present how to characterize it hemodynamically by invasive measurements of RV and pulmonary arterial (PA) pressures. Animals subjected to this model display severe pulmonary vascular remodeling and RV dysfunction. In this model, rats undergo a single subcutaneous injection of Sugen (SU5416, a vascular endothelial growth factor inhibitor) and are immediately exposed to chronic hypoxia in a hypoxia chamber for 3-6weeks. This Sugen/Hypoxia rat model resembles Group 1 PH.

Rimeporide, a first in class Na/H exchanger-1 inhibitor, ameliorates right ventricular dysfunction and pulmonary arterial hypertension in a SuHx model

Abstract Background Pulmonary arterial hypertension (PAH) is characterized by pulmonary vasoconstriction and vascular remodeling leading to right ventricular (RV) failure. Although RV function is the major prognostic factor in PAH, no RV-specific therapies exist. The Na+/H+ exchanger type 1 (NHE1) regulates the intra- and extracellular pH balance mainly through the 1:1 exchange of intracellular H+ with extracellular Na+. Increased NHE-1 activity is involved in several diseases, including hypoxic PAH. Inhibition of NHE-1 activity attenuates pulmonary vascular remodeling in rodents exposed to hypoxia but its potential direct contribution in RV remodeling remains unclear. Aim In the current study, we aimed to investigate the effect of NHE-1 inhibition by Rimeporide a preclinical hypoxic models of PH: Sugen5416/hypoxia. Methods Sugen/hypoxia model: PAH was induced in adult Sprague-Dawley rats with a single injection of SU5416 (20 mg/kg) followed by 3 weeks of hypoxia (10% O2; Sugen/Hypoxia model: SuHx) and then return to normoxia. Control rats were injected with equal volume of vehicle. At week 5 post-injection, control and SuHx rats were treated with rimeporide (100 mg/Kg daily in drinking water, n=10/group) or placebo (n=11/group) for 3 weeks. Echocardiography and blood sampling were performed. RV phenotype was monitored by echocardiography and hemodynamic analysis. Lung and heart were collected for histological and protein expression analysis, such as NHE-1 (target of Rimeporide). Results SuHx caused severe PAH and RV dysfunction. RV dysfunction was accompanied by an increase in RV hypertrophy and RV fibrosis and PA remodeling (increase in the arteriolar wall thickness and fibrosis). A marked increase in macrophages was found in lung and RV tissues but not in LV. Moreover, Western blot analysis showed that RV protein levels of NHE-1 was higher in SuHx rats than Normoxia rats. Treatment with Rimeporide reversed SuHx-induced PAH as well as RV dysfunction and blunted pulmonary and RV inflammation, RV NHE-1 protein expression. Conclusion Our results indicate that NHE-1 levels are increased in RV tissues from SuHx-induced PAH rats. Rimeporide, through NHE-1 inhibition, might be a potential new target for treatment of RV dysfunction and PAH.

Unmet Needs in the Assessment of Right Ventricular Function for Severe Tricuspid Regurgitation.

Tricuspid regurgitation (TR) is a highly prevalent valvular heart disease that has been long overlooked, but lately its independent association with adverse cardiovascular outcomes was recognized. The time point to intervene and repair the tricuspid valve is defined by the right ventricular (RV) dilation and dysfunction that comes up at a later stage. While guidelines favor tricuspid valve repair before severe RV dysfunction ensues, the definition of RV dysfunction in a universal manner remains vague. As a result, the candidates for transcatheter or surgical TR procedures are often referred late, when advanced RV dysfunction is established, and any derived procedural survival benefit is attenuated. Thus, it is of paramount importance to establish a universal means of RV function assessment in patients with TR. Conventional echocardiographic indices of RV function routinely applied have fundamental flaws that limit the precise characterization of RV performance. More recently, novel echocardiographic indices such as strain via speckle-tracking have emerged, demonstrating promising results in the identification of early RV damage. Additionally, evidence of the role of alternative imaging modalities such as cardiac computed tomography and cardiac magnetic resonance, for RV functional assessment in TR, has recently arisen. This review provides a systematic appraisal of traditional and novel multimodality indices of RV function in severe TR and aims to refine RV function assessment, designate future directions, and ultimately, to improve the outcome of patients suffering from severe TR.

(19) Grading Severity of Right Ventricular Dysfunction in Pulmonary Hypertension, a Mechanical Analysis

(19) Grading Severity of Right Ventricular Dysfunction in Pulmonary Hypertension, a Mechanical Analysis

Right ventricular cardiac resynchronization therapy in patients with right ventricular conduction delay and heart failure

Right ventricular cardiac resynchronization therapy in patients with right ventricular conduction delay and heart failure

Different Causes of Functional Tricuspid Valve Regurgitation Are Linked to Differences in Tricuspid Valve and Right-Sided Heart Geometry and Function: 3D Echocardiography Study.

Background and Objectives: The aim of this study was to clarify the tricuspid valve (TV) and right ventricular (RV) geometry and function characteristics using 3D echocardiography-based analysis and to identify echocardiographic predictors for severe tricuspid regurgitation (TR) in different etiologies of functional TR (fTR). Methods and Results: The prospective study included 128 patients (median age 64 years, 57% females): 109 patients with moderate or severe fTR (69-caused by dominant left-sided valvular pathology (LSVP), 40 due to precapillary pulmonary hypertension (PH)), and 19 healthy controls. The 2D and 3D-transthoracic echocardiography analysis included TV, right atrium, RV geometry, and functional parameters. All the RV geometry parameters as well as 3D TV parameters were increased in both fTR groups when compared to controls. Higher RV diameters, length, areas, volumes, and more impaired RV function were in PH group compared to LSVP group. PH was associated with larger leaflet tenting height, volume, and more increased indices of septal-lateral and major axis tricuspid annulus (TA) diameters. LVSP etiology was associated with higher anterior-posterior TA diameter and sphericity index. Univariate and multivariate logistic regression and ROC analyses revealed that different fTR etiologies were associated with various 2D and 3D echocardiographic parameters to predict severe TR: major axis TA diameter and TA perimeter, the leaflet tenting volume had the highest predictive value in PH group, septal-lateral systolic TA diameter-in LSVP group. The 3D TA analysis provided more reliable prediction for severe fTR. Conclusions: TV and RV geometry vary in different etiologies of functional TR. Precapillary PH is related to more severe RV remodeling and dysfunction and changes of TV geometry, when compared to LSVP group. The 3D echocardiography helps to determine echocardiographic predictors of severe TR in different fTR etiologies.

Late outcomes in adults with atrial switch for transposition of the great arteries according to risk factor profile at 30 years of age

ObjectiveTo compare the late outcomes of adults who underwent atrial switch repair for dextro-transposition of the great arteries, based on their risk profile at age 30 years. MethodsWe performed a retrospective study of 67 participants who had undergone atrial switch repair. “Low risk” people were defined as those who reached age 30 years or beyond with normal or mildly impaired systemic right ventricular (RV) function with no or mild tricuspid regurgitation (TR). “High risk” people were defined as those who had moderate or severe systemic RV dysfunction, or moderate or severe tricuspid regurgitation by age 30. The primary outcome was transplant-free survival and the secondary outcome was a composite end-point including hospitalisations for heart failure, inotrope requirement, referral for transplantation and transplantation. Results52/67 (78%) were classified as “low risk” and 15/67 (22%) were classified as “high risk”. At 45 years, transplant-free survival was 31% for the “high risk” group compared to 87% for “low risk”. All “high risk” people met the composite endpoint at 45 years compared to only 18% of the “low risk” group (hazard ratio 6.3, p = 0.03). ConclusionTransplant-free survival is markedly reduced in “high risk” atrial switch patients. Risk stratification based on systemic right ventricular function and tricuspid regurgitation at age 30 may predict future health outcomes for atrial switch patients.

Abstract 15151: Identification of Novel Right Ventricular Function Phenotypes in Pulmonary Arterial Hypertension Using Unbiased K-Means Clustering

Introduction: Survival in pulmonary arterial hypertension (PAH) is associated with right ventricular (RV) function rather than pulmonary vascular resistance (PVR). At present, RV function is not incorporated in current risk assessment models and studies evaluating RV function are generally limited to single-center studies. The aim was to identify novel RV function phenotypes using unbiased k-means clustering in patients with PAH. Methods: Baseline clinical and hemodynamic data in patients with PAH were harmonized data from 5 PAH clinical trials (COMPASS3: n=98, EARLY: n=176, GRIPHON: n=720, MAESTRO: n=44, and SERAPHIN: n=728). Pearson correlation analysis was used to select variables that reduce the co-linearity (|r| < 0.7) between hemodynamic variables used in the models. K-means clustering methods were applied to advanced RV hemodynamics including end-systolic pressure (ESP), arterial elastance (Ea), single-beat end-diastolic elastance (Eed), Pulse pressure (PP), stroke volume (SV) and RV stroke work (RVSW). Survival analysis was used to compare all-cause mortality among each cluster group. Results: Participants in the harmonized dataset (n=1766) had a mean PAP of 53 ± 17 mmHg, a cardiac output of 4.3±1.4 L/min, a wedge pressure of 9±4 mmHg and a PVR of 11.8±7.4 WU. K-means clustering identified four distinct RV cluster phenotypes that range from mild to severe RV dysfunction (Fig. A). Participants in RV cluster 1 (RV C1) have severe RV dysfunction with increased pressure/afterload, decreased cardiac function, and increased diastolic stiffness compared to RV cluster 4 (RV C4). (Fig. A) RV C1 had decreased six-minute walk distance compared to other clusters. RVC1 and RVC2 had increased risk of mortality compared to RV C4 (Fig. B). Conclusion: Applying K-means clustering to harmonized hemodynamic data from PAH clinical trial data identified 4 unique RV function phenotypes with different clinical outcomes.

Right ventricular and left ventricular diameters are independent predictors of death or cardiopulmonary resuscitation in intermediate and high-risk pulmonary embolisms

Abstract Background Increased right ventricular (RV) dilation measured by the ratio of RV diameter (RVD) to left ventricular (LV) diameter (LVD) (RV:LV) is associated with pulmonary embolism (PE) severity and mortality. Data regarding the individual contributions of RVD and LVD are limited. Purpose To examine RVD and LVD as independent contributors to death or need for cardiopulmonary resuscitation (CPR) in intermediate- or high-risk PEs treated with surgical or catheter-based strategies Methods We measured basal RVD and LVD on presenting transthoracic echocardiograms (TTE) using the diastolic 4-chamber view on 127 PEs managed with surgical embolectomy (n=95, 75%), extracorporeal membrane oxygenation (n=23, 18%), or catheter-directed embolectomy (n=9, 7%) for intermediate- (64%) or high-risk (36%) PE (based on European Society of Cardiology criteria) between 2005 and 2022. The primary outcome was the composite of death (n=2) or survivors requiring CPR (n=10). Results A total of 127 patients were analyzed. Subjects were 57±14 years, 38% women, BMI 34±8. Mean RVD and LVD were 4.4±0.9 cm and 3.9±0.8 cm respectively. All presented with severe RV dysfunction on TTE and elevated cardiac biomarkers (Troponin-I or B-type natriuretic peptide). Mean RV:LV was 1.2±0.3 (range 0.7 to 2.8). Using logistic regression, higher RV:LV was associated with increased odds of death or CPR (odds ratio (OR) 15 [95% confidence interval (CI): 2.5, 82] per 1-unit increase, p=0.002. RV:LV >1.2 was the cutoff most associated with death or CPR, OR 7.2 [95% CI: 1.5, 34.5], p=0.01. Increasing RVD [OR 3.8 (95% CI: 1.1, 12.8), p=0.03] and decreasing LVD [OR 4.9 (95% CI: 1.3, 16.9), p=0.02] were independent predictors of death or CPR. RVD >5.0 cm (OR 5.9 [95% CI: 1,5, 23.2], p 0.01) and LVD <3.6 cm (OR 7.0 [95% CI: 1.7, 27.9], p=0.006) were the cutoff values most associated with the primary outcome. These cutoff values remained significant predictors even after adjustment for body surface area. Other parameters or RV size and function (diastolic area, systolic area and fractional area change) did not predict death or CPR. All of the subjects meeting the primary outcome had high-risk PE. Discussion In addition to RV:LV greater than 1.2, RVD and LVD were independently associated with death or CPR among high- or intermediate risk PEs. The independent contribution of declining LVD on PE mortality is a novel finding and highlights PE associatient LV pathophysiology (hyperdynamic and underfilled) antecedent to hemodynamic collapse. PE literature focuses on RV dilation as a predictor of PE mortality. LVD may represent a useful measure to risk stratify PE patients and predict hemodynamic decompensation. Funding Acknowledgement Type of funding sources: None.

Evolution and clinical implications of right ventricular dysfunction in ischemic cardiomyopathy with or without coronary artery bypass surgery

Abstract Background The Surgical Treatment of Ischemic Heart Failure (STICH) trial demonstrated that coronary artery bypass grafting (CABG) provides additional survival benefits to patients with ischemic cardiomyopathy. However, it remains unclear whether this benefit is affected by preoperative right ventricular (RV) function and how post-therapeutic evolution of RV function influences long-term outcomes. Purpose We sought to investigate the implications of baseline RV function on therapeutic decision-making in patients with ischemic cardiomyopathy, and to evaluate the prognostic implications of post-therapeutic evolution of RV function. Methods Patients with available baseline echocardiographic RV function assessed by experienced Echocardiography Core Laboratory physicians were included from the hypothesis 1 of the STICH trial. The primary outcome was long-term all-cause mortality. Results A total of 1042 patients were included, among them 757 (72.7%) had normal RV function, 143 (13.7%) mild right ventricular dysfunction (RVD), and 142 (13.6%) moderate to severe RVD. After a median follow-up of 9.8 years, patients with RVD had a higher risk of all-cause mortality compared with patients with normal RV function [mild RVD: adjusted hazard ratio (aHR) 1.32; 95% confidence interval (CI) 1.06–1.64; moderate to severe RVD: aHR, 1.74; 95% CI 1.39–2.18]. Although no significant interaction was detected between RVD degree and treatment allocation (P for interaction = 0.399), a gradually decreasing survival benefit associated with CABG was observed among patients with normal RV function (aHR: 0.79; 95% CI: 0.65–0.96), mild RVD (aHR: 0.85; 95% CI: 0.56–1.29), and moderate to severe RVD (aHR: 0.97; 95% CI: 0.67–1.43). Among 746 patients with available RV function assessed at baseline and post-therapeutic 4-month follow-up, there was a gradient of increasing risk for all-cause mortality across patients with consistent normal RV function, recovery of RVD (aHR: 1.20; 95% CI: 0.88–1.64), newly developed RVD (aHR: 1.59; 95% CI: 1.18–2.14), and consistent RVD (aHR: 2.06; 95% CI: 1.60–2.67). Independent predictors of RVD recovery included baseline left ventricular ejection fraction (per 1-percent increment, adjusted odds ratio: 1.04; 95% CI: 1.00–1.09) and mitral regurgitation ≥ grade 2 (adjusted odds ratio: 0.42; 95% CI: 0.21–0.84). Conclusions Baseline RVD was associated with an increased risk of long-term mortality in patients with ischemic cardiomyopathy, and adding CABG to medical therapy might provide limited survival benefits in patients with moderate to severe RVD. A gradient of increasing risk for mortality was observed across different categories of RV function evolution, which emphasizes the necessity of pre- and post-therapeutic RV assessment for prognostic evaluation. Funding Acknowledgement Type of funding sources: None.

A CASE OF PULMONARY HYPERTENSION AS A POSSIBLE EXTRACRANIAL MANIFESTATION OF MOYAMOYA DISEASE

A CASE OF PULMONARY HYPERTENSION AS A POSSIBLE EXTRACRANIAL MANIFESTATION OF MOYAMOYA DISEASE

Imaging of the right ventricle in predicting the development of chronic thromboembolic pulmonary hypertension (CTEPH)

There is increasing evidence in the literature emphasizing the importance of right ventricular (RV) imaging in the prognosis of pulmonary hypertension. We aimed to investigate the predictive role of RV dysfunction parameters assessed by echocardiography (ECHO) and thorax computed tomography (CT) in developing CTEPH. We included prospectively patients diagnosed with pulmonary embolism (PE). All patients underwent ECHO and CT within 24 hours after admission. We repeated CT and ECHO after six months and one year to assess the incidence of CTEPH and the predictive role of RV dysfunction factors in the development of CTEPH. We included twenty-two patients (seven male) with a mean age of 53.9±17.9 years; CTEPH developed in two patients during the follow-up. Baseline PO2 levels were significantly lower in patients with CTEPH (61.5±11.4 vs 77.8±25.2, p<0.05). The baseline RV diameter, RV EF, and systolic PAP levels evaluated by ECHO differed significantly in two patients who developed CTEPH. Two patients that developed CTEPH had the lowest RVS (-10.3% and -11.7%). This study claims that hypoxemia, decreased RV EF, RVS, increased systolic PAP values in ECHO, and increased RV/LV ratio evaluated in thorax CT indicate the severity of RV dysfunction in acute PE and may predict CTEPH development.

The role of serial right heart catheterization in risk stratification and management of pulmonary arterial hypertension

Introduction Pulmonary arterial hypertension (PAH) is characterized by elevated pulmonary arterial blood pressure secondary to increased pulmonary vascular resistance. Despite the advances in medical therapy, PAH continues to be a significant cause of morbidity and mortality. Areas covered Invasive hemodynamic assessment by performing a right heart catheterization (RHC) remains the gold standard to confirm the diagnosis and further management of PAH. The RHC also helps to determine the severity of RV dysfunction and can be used to test for pulmonary vasoreactivity. After diagnosis and initiation of therapy, many PAH centers continue to perform RHC at regular intervals to monitor for disease progression and alter management. In this review, we discuss the importance of risk stratification in PAH, the role of RHC in the evaluation and treatment of these patients and compare non-invasive risk assessment tools to that of RHC. Expert opinion RHC is useful for diagnosis of PAH, assessing the risk of mortality and morbidity, directing the escalation and de-escalation of therapy, and monitoring for disease progression. In the current era of improved non-invasive cardiac hemodynamic assessment, the role for routine follow-up serial RHC in patients with PAH needs to be reassessed in future studies. With the availability of non-invasive risk assessment tools such as REVEAL Lite 2, it may be reasonable to reconsider the role of annual or protocoled RHC, and instead, move to an “as needed” and individual basis.

COVID-19 Pnömonili Hastaların Taburculuk Sonrası Sağ Ventrikül Fonksiyonunun Sağ Ventriküler Erken Giriş-Çıkış İndeksi ile Değerlendirilmesi

Aim
 The coronavirus disease 2019 (COVID-19) causes many cardiovascular complications. In patients with comorbidities, COVID-19 infection has a more severe course. Although some patients who do not have comorbidities, severe infection and death may occur. In studies, many echocardiographic parameters were found to be impaired in patients with COVID-19 pneumonia. The right ventricular premature inflow-output flow (RVEIO) index is a possible and indirect predictor of the severity of right ventricular dysfunction. The aim of our study is to evaluate the RVEIO index after discharge in patients with moderate-to-severe COVID-19 pneumonia without comorbidities.
 Methods
 The study was conducted in a single center, prospectively. One month after discharge, echocardiography and biochemical tests were performed in 57 patients with moderate-to-severe COVID-19 pneumonia without comorbidities.
 Results
 Pulmonary artery diameter was found to be significantly larger in the severe group [1.9 (1.8-2) vs. 2 (1.9-2.1); p=0.014]. Pulmonary artery acceleration time [140.92±11.70 vs 114.58±12.03; p=0.001)] and RVOT VTI [23.48±1.96 vs 19.18±2.2; p

Temporary Right-Ventricular Assist Devices: A Systematic Review.

Acute right-sided heart failure (RHF) is a complex clinical syndrome, with a wide range of clinical presentations, associated with increased mortality and morbidity, but about which there is a scarcity of evidence-based literature. A temporary right-ventricular assist device (t-RVAD) is a potential treatment option for selected patients with severe right-ventricular dysfunction as a bridge-to-recovery or as a permanent solution. We sought to conduct a systematic review to determine the safety and efficacy of t-RVAD implantation. Thirty-one studies met the inclusion criteria, from which data were extracted. Successful t-RVAD weaning ranged between 23% and 100%. Moreover, 30-day survival post-temporary RAVD implantation ranged from 46% to 100%. Bleeding, acute kidney injury, stroke, and device malfunction were the most commonly reported complications. Notwithstanding this, t-RVAD is a lifesaving option for patients with severe RHF, but the evidence stems from small non-randomized heterogeneous studies utilizing a variety of devices. Both the etiology of RHF and time of intervention might play a major role in determining the t-RVAD outcome. Standardized endpoints definitions, design and methodology for t-RVAD trials is needed. Furthermore, efforts should continue in improving the technology as well as improving the timely provision of a t-RVAD.

A Clinical Approach to Multimodality Imaging in Pulmonary Hypertension.

Pulmonary hypertension (PH) is a clinical condition characterized by progressive elevations in mean pulmonary artery pressures and right ventricular dysfunction, associated with significant morbidity and mortality. For resting PH to develop, ~50–70% of the pulmonary vasculature must be affected, suggesting that even mild hemodynamic abnormalities are representative of advanced pulmonary vascular disease. The definitive diagnosis of PH is based upon hemodynamics measured by right heart catheterization; however this is an invasive and resource intense study. Early identification of pulmonary vascular disease offers the opportunity to improve outcomes by instituting therapies that slow, reverse, or potentially prevent this devastating disease. Multimodality imaging, including non-invasive modalities such as echocardiography, computed tomography, ventilation perfusion scans, and cardiac magnetic resonance imaging, has emerged as an integral tool for screening, classifying, prognosticating, and monitoring response to therapy in PH. Additionally, novel imaging modalities such as echocardiographic strain imaging, 3D echocardiography, dual energy CT, FDG-PET, and 4D flow MRI are actively being investigated to assess the severity of right ventricular dysfunction in PH. In this review, we will describe the utility and clinical application of multimodality imaging techniques across PH subtypes as it pertains to screening and monitoring of PH.

Percutaneous thrombectomy and right ventricular mechanical circulatory support for pulmonary embolism in a coronavirus disease 2019 patient: case report, 1-year update, and echocardiographic findings.

BackgroundWe previously described percutaneous thrombectomy and right ventricular (RV) mechanical support of a coronavirus disease 2019 (COVID-19) patient with a massive pulmonary embolism. Here, we present a detailed echocardiographic and clinical timeline with 1-year follow-up.Case summaryA 57-year-old female with COVID-19 went into shock from a massive pulmonary embolism. After percutaneous removal of a large thrombus burden (AngioVac system; AngioDynamics Inc., Latham, NY, USA), she became severely hypotensive, requiring cardiopulmonary resuscitation, and hemodynamic support with an Impella RP device (Abiomed, Danvers, MA, USA). A paediatric transoesophageal echocardiography (TOE) probe monitored the procedure because an adult probe would not pass (S7-3t—Philips Medical Systems, Andover, MA, USA). Post-thrombectomy, surface imaging documented gradual resolution of RV dysfunction, tricuspid regurgitation, and elevated pulmonary artery pressure. Her course was complicated by renal failure requiring temporary dialysis. She was discharged home on apixaban. Hypercoagulability work-up was negative. Two months later, vocal cord surgery was performed for persistent stridor. Esophagoscopy at that time was prevented by osteophyte obstruction. At 10 months, she received the Pfizer-BioNTech vaccine. At 1 year, the patient remains healthy on apixaban, and her echocardiogram is normal.DiscussionThis case illustrates the pivotal role of echocardiography in the diagnosis, percutaneous treatment, and near- and long-term follow-up and management of a patient with massive pulmonary embolism due to COVID-19 with documentation of complete recovery from severe RV dysfunction and haemodynamic collapse. A paediatric TOE probe was a crucial alternative to the adult probe because of possible osteophyte obstruction.