Stroke Volume Index Research Articles

Trendelenburg position is a reasonable alternative to passive leg raising for predicting volume responsiveness in mechanically ventilated patients in the ICU

BackgroundPassive leg raising (PLR) is a well-recognized method for assessing volume responsiveness in the intensive care unit (ICU); however, it has some limitations. The physiology of the cardiac preload induced by the Trendelenburg position and PLR is similar. The Trendelenburg position can be initiated from the supine position and then tilted downward (TRENDSUPINE) or from the reverse Trendelenburg position and then tilted further downward (TRENDrTREND). Therefore, this study aimed to compare the predictive performance of the percentage change in stroke volume index (ΔSVI) induced by TRENDSUPINE, TRENDrTREND, and PLR for volume responsiveness in mechanically ventilated patients in the ICU.MethodsThe study was a prospective single-center cohort study conducted in a comprehensive ICU. The study consisted of the following sequential steps: (1) baseline-1: supine position with a 0° bed angulation; (2) Trendelenburg position: 15° downward bed angulation; (3) baseline-2: the same position as baseline-1; (4) reverse Trendelenburg position: 15° upward bed angulation; (5) Trendelenburg position: 15° downward bed angulation; (6) baseline-3: the same position as baseline-1; (7) semi-recumbent position: trunk elevated at 45°; (8) PLR: lower limbs elevated at 45° and trunk in the supine position; (9) baseline-4: the same position as baseline-1; (10) volume loading test: 250 ml of 4% albumin was infused over 10 min. At each time point, hemodynamic parameters were monitored using pulse contour analysis. A positive volume response was defined as an increase of at least 15% in SVI on pulse contour monitoring from baseline-4 after the volume loading test. The receiver operating characteristic curves were performed for ΔSVI.ResultsIn this study, 36 patients were included for analysis, and of these, 15 patients (42%) were volume-responsive. TRENDSUPINE-induced ΔSVI (ΔSVISUPINE-TREND), TRENDrTREND-induced ΔSVI (ΔSVIrTREND-TREND) and PLR-induced ΔSVI (ΔSVIPLR) were 6%, 16%, and 11%, respectively (ΔSVISUPINE-TREND vs. ΔSVIrSUPINE-TREND, p < 0.001; ΔSVISUPINE-TREND vs. ΔSVIPLR, p < 0.05). The R2 values of the linear regression between ΔSVISUPINE-TREND, ΔSVIrTREND-TREND, ΔSVIPLR and volume loading test-induced ΔSVI were 0.14, 0.32, and 0.43, respectively (all p < 0.001). Furthermore, the area under the receiver operating characteristic curve for predicting volume responsiveness was 0.78 [95% confidence interval (CI), 0.59–0.92], 0.88 (95%CI, 0.75–0.96), and 0.83 (95%CI, 0.61–0.95) for TRENDSUPINE, TRENDrTREND, and PLR-induced ΔSVI, respectively, with no statistically significant difference among them. The sensitivity and specificity for predicting volume responsiveness were 93% and 67% for ΔSVISUPINE-TREND at 4% cutoff, 87% and 76% for ΔSVIrTREND-TREND at 13% cutoff, and 73% and 86% for ΔSVIPLR at 11% cutoff.ConclusionsThe Trendelenburg position (TRENDSUPINE and TRENDrTREND)-induced and PLR-induced percentage changes in SVI were similar in their ability to predict volume responsiveness in mechanically ventilated patients in the ICU. Considering that TRENDrTREND induced greater percentage changes in SVI, it is preferentially recommended as a reasonable alternative to PLR for predicting volume responsiveness in certain clinical scenarios.Trial registration: ChiCTR2300067694. Registered on January 18, 2023.

Echocardiographic index of left ventricular performance for prognostication in transthyretin cardiac amyloidosis: the central role of stroke volume index.

Cardiac amyloidosis typically causes restrictive cardiomyopathy, in which the impairment of diastolic function is dominant. Echocardiography provides prognostic information through some important parameters: left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS). However, LVEF often remains preserved despite disease progression, and GLS is not routinely performed as it is limited by suboptimal image quality. The stroke volume index (SVi) has already been shown to correlate with mortality in heart failure patients; still, its prognostic role in transthyretin cardiac amyloidosis (TTR-CA) is poorly studied. This prospective study aimed to evaluate the role of SVi in predicting mortality and heart failure hospitalizations in patients with cardiac amyloidosis, comparing it to other parameters of left ventricular performance. Baseline clinical transthoracic echocardiogram and laboratory data were collected prospectively in 115 patients with diagnosed TTR-CA. The outcome was the occurrence of the composite of heart failure hospitalization and death and its association with SVi, LVEF, GLS and MCF was tested by Cox proportional hazard modelling. Over a mean follow-up of 16.1 months (interquartile range 7.4-24.9 months), 29 patients died, and 19 were hospitalized for heart failure. SVi was associated with the composite outcome of death and heart failure hospitalization [hazard ratio 0.96; 95% confidence interval (CI) 0.93-0.99] and remained an independent predictor of outcome after adjustment for NAC stage, mitral regurgitation degree, age and the use of disease-modifying treatment. The best cut-off of SVi to predict outcome was 35 ml/m2 (hazard ratio 2.30; 95% CI 1.03-5.17). SVi is superior to LVEF, MCF, and GLS for prognostication in patients with TTR amyloidosis.

Effects of Blood Pressure Management Based on Non-Invasive Heart Function Monitoring on Reducing Postoperative Hypotension in Elderly Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Trial.

Postoperative hypotension is a common symptom in elderly patients undergoing total knee arthroplasty (TKA), which is associated with intraoperative blood pressure (BP) management. The study aimed to explore the causes of perioperative hypotension in TKA elderly patients and analyze the effects of BP management strategies based on non-invasive heart function monitoring on reducing postoperative hypotension. A total of 176 elderly TKA patients were divided into four groups: the tourniquet group (Group T), the non-tourniquet group (Group N), the goal-oriented BP management tourniquet group (Group GT), and the goal-oriented BP management non-tourniquet group (Group GN). Patients in Groups T and GT received TKA with a tourniquet. The BP of patients in Groups GT and GN was maintained based on non-invasive heart function monitoring. The mean arterial pressure (MAP), index of cardiac contractility (ICON), stroke volume (SV), and other circulatory indicators were measured using the non-invasive cardiometer monitor at five time points, including before anesthesia (T1), after anesthesia (T2), after completion of the osteotomy (T3), after suturing (T4), and after leaving the post-anesthesia care unit (T5). The frequency of postoperative hypotension within 24 hours was recorded, and the incidence of hypotension was calculated. The ICON, SV, and MAP were lower in Groups N and GN than in Groups T and GT at T3 (P < 0.05). The ICON, SV, and MAP were lower in Group N than in Groups GN at T4 and T5 (P < 0.05), and no significant difference was observed between Groups T and GT (P > 0.05). The incidence of postoperative hypotension within 24 hours was higher in Group N (47.1%) (P = 0.007) than in Group GN (21.6%), Group T (19.4%), and Group GT (14.8%). Postoperative hypotension in elderly patients undergoing TKA with a non-tourniquet was associated with decreased myocardial contractility. Enhancing myocardial contractility based on non-invasive cardiac function monitoring reduced the incidence of postoperative hypotension.

Evaluation of cardiovascular remodeling parameters as FMD, Zva, GLS in patients with aortic stenosis

Abstract Introduction Aortic stenosis (AS) is one of the most common acquired valvular heart defects in adults. In recent years, there has been increasing interest in effects of AS on remodeling of cardiovascular system, especially on microcirculatory function (flow-mediated dilation (FMD) and left ventricle global longitudinal strain (GLS). Some studies indicate that increased valvuloarterial impedance (Zva) is a marker of excessive LV hemodynamic load and identifies aortic stenosis patients with poor outcome. Purpose The aim of the study was to assess an influence of AS and hemodynamic type of AS on FMD, Zva and LV GLS as markers of cardiovascular remodeling. Methods Overall of 153 (66 females, 87 males; mean age: 71,5 ± 11,5 years) patients were included in the study: 86 patients with severe and moderate AS (42 females, 44 males; mean age 74,8 ± 12,2 years), and 67 ( 24 females, 43 males; mean age: 67,2 ± 8,9 years) controls. Based on standard transthoracic and transesophageal echocardiography 77 patients with severe AS (39 females, 38 males; mean age: 75,9 ± 10,5 years) were divided into subtypes: (1) high-gradient AS, (2) low-flow low-gradient with preserved LVEF AS, (3) low-flow low-gradient with reduced LVEF AS, (4) normal-gradient low-flow AS. FMD was measured on the brachial artery at rest and 5 minutes after vessel occlusion in all patients. GLS and Zva were evaluated for all patients. Zva was calculated on the basis of the following equation: Zva = (SAP * MG)/SVi, where SAP is the systolic arterial pressure, MG is the mean transvalvular pressure gradient and SVi is stroke volume index. Results The mean FMD in patients with AS was significantly lower 5.84 ± 0,47 % compared to the control group 9.66 ± 0,064 (p&amp;lt;0.001). In terms of GLS, patients with aortic stenosis had a lower mean GLS 14.05 ± 3,09 % , compared to controls 15.76 ± 3,74% (p=0.0028), with a similar LVEF of 54.6% and 52.5%, respectively. Mean FMD in the high-gradient, low-flow low-gradient with preserved LVEF, low-flow low-gradient with reduced LVEF, normal-gradient low-flow subgroups were 5.17%,6.3%, 1.85% and 6.96%, respectively. The mean GLS in the high-gradient, low-flow low-gradient with preserved LVEF, low-flow low-gradient with reduced LVEF, normal-gradient low-flow subgroups were -13.54%, -15.54% -10.5%, -13.46%, respectively. In the aortic stenosis group, the mean Zva was significantly higher at 5.62 ± 1.75 mmHg*ml-1*m2 compared to the control group at 4.80 ± 1.33 mmHg*ml-1*m2 (p=0.001334). Conclusion Aortic stenosis and hemodynamic type of AS has a significant impact on cardiac and vascular function, as reflected by changes in FMD, Zva, GLS values. Assessment of these parameters is crucial in monitoring patients with AS, allowing early detection of deterioration in cardiac function and appropriate therapeutic interventions. Flow-mediated dilation (FMD) Global longitudinal strain

Discriminative power of dobutamine echocardiography in patients with discordant low gradient aortic stenosis and preserved left ventricular ejection fraction.

Abstract Aims to explore the value of dobutamine stress-echocardiography (DSE) to identify severe aortic stenosis (AS) in patients with discordant low-gradient AS and preserved left ventricular ejection fraction (LVEF&amp;gt;50%). Methods Among 52 patients (age 79±7 years; males 46%, mean aortic gradient: 31±5 mmHg) with low gradient AS stenosis and preserved LVEF prospectively enrolled in the ROTAS trial, 42 underwent both DSE and CT aortic calcium score. An aortic calcium score &amp;gt; 1200 AU in women and &amp;gt; 2000 AU in men was used as a referral limit to identify severe AS. The Youden method was used to identify the best cut-off rest and stress echocardiography aortic parameters able to predict AS severity. Results In the overall population, DSE-parameters such as aortic valve area (AVA), indexed AVA (AVAi), aortic maximal velocity (AVMax), mean aortic gradient (MAG) and projected AVA (AVAproj) were modest predictors of AS severity Limiting the analysis to patients with stroke volume index &amp;lt; 35 ml/m², a DSE AVMax&amp;gt; 4.5 m/sec was a fair predictor of AS severity (AUC 0.73, Se 60%, Sp 95%, PPV 86%, NPV 81%, accuracy 82%) (Table1). Conclusions in patients with discordant low-gradient AS and preserved LVEF, echo-derived parameters have a modest predictive value for the detection of severe AS. A slightly better performance is observed when limiting the analysis to patients with low-flow.

Immediately improved diastolic function as determined by pulmonic vein Doppler-intraoperative TEE in TAVR patients and the impact of valvulo-arterial impedance

Abstract Background A recent study demonstrates that most TAVR patients experience immediate improvement in diastolic function as determined by pulmonic vein Doppler (PvD) measurements. Valvulo-arterial impedance (Zva) is a marker of global LV load and represents both valvular and arterial load. Zva &amp;gt; 3.5 has been shown as a predictor of poor adverse outcomes. We hypothesize that Zva might have an effect on the change in pulmonic vein Doppler after TAVR. Purpose This study aims to demonstrate the impact of valvulo-arterial impedance and the immediate improvement of diastolic function in TAVR patients as assessed by pulmonic vein Doppler-intraoperative TEE. Materials and Methods Patients who underwent TAVR from January 2020 to September 2023 and were performed pulmonic vein Doppler by intraoperative TEE (right upper pulmonic vein from 90-110° mid-esophageal view) during TAVR and measured S-, D-, and A- wave velocity. We obtained the blood pressure and transthoracic echocardiographic parameters to calculate the Zva [(systolic blood pressure + mean pressure gradient across the aortic valve)/stroke volume index by LVOT doppler]. To compare the PvD change between Zva &amp;lt; 3.5 and Zva ≥ 3.5, use chi-square for categorical data and a paired t-test for continuous data. Results 79 patients (mean age was 80.6 ± 5.6 years, 43 female) were enrolled in this study. S-wave was the only parameter with significantly increased velocity from baseline (33.2 ± 13.8 cm/s vs. 49.1 ± 18.6 cm/s, p &amp;lt; 0.001), whereas D-wave and A-wave did not significantly change from baseline (33.1 ± 14.5 cm/s vs. 33.3 ± 12.0 cm/s, p = 0.88; and 12.7 ± 7.8 cm/s vs. 13.3 ± 7.3 cm/s, p = 0.52, respectively). Of the 37 patients who had an S/D ratio &amp;lt; 1 at baseline, 26 of them converted to an S/D ratio &amp;gt; 1 immediately post-TAVR (Figure 1). In the group of Zva &amp;lt; 3.5, the number of patients who had PvD changed significantly compared with the group of Zva ≥ 3.5 (Figure 2). Conclusion The majority of patients in this study demonstrated that diastolic function improved immediately following TAVR using a pulmonic vein Doppler. S/D &amp;gt; 1 has improved significantly in the group with normal valvulo-arterial impedance (Zva &amp;lt; 3.5). Figure 1 Figure 2

Sarcomere gene mutations leading to lower myocardial work values in hypertrophic cardiomyopathy

Abstract Background Sarcomere gene mutations is hypertrophic cardiomyopathy (HCM) can have prognostic value and role in risk assessment, according to numerous studies. In our previous investigations, we confirmed that echocardiographic parameters of left ventricular (LV) myocardial work (MW) derived from the non-invasive pressure-strain curve were reduced in patients with HCM, especially in the case of clinical features with advanced disease. The aim of our present work was to investigate the MW parameters in genotyped HCM patients. Patients and Methods We examined 75 genotyped HCM patients [48 men (64%), age 51±12 years], who underwent standard and 2D-speckle tracking echocardiography. The patients were divided into sarcomere mutation positive (P/LP+, n=32) and mutation negative (P/LP-, n=43) groups based on carrying a pathogenic/probably pathogenic (P/LP) sarcomere gene variant. Later we extended our examination to patients with variants of unknown significance (VUS). Results There was no significant difference between the demographic (age, gender, BMI, BSA) and laboratory (troponin T, NTproBNP) parameters of the P/LP+ and P/ LP- groups. Also, no significant difference was found in most echocardiographic parameters (LAV, LAVI, LVmax, EF, SV, SV index, TAPSE) between the two groups, except that the proportion of obstructive patients was higher in the P/LP group (p=0.026) and the resting (p= 0.004) and provoked (p=0.0082) LVOT gradients were higher. Despite of no difference in the GLS value in the two groups (p=0.850), the P/LP+ group had lower global work index [GWI: p=0.0035), global constructive work (GCW: p=0.0006), and global wasted work (GWW: p=0.0098), while global work efficiency (GWE: p=0.485) did not differ. The differences remained even when patients carrying variants of unknown significance (VUS+) were examined in a separate group (GWI: p=0.013; GCW: p=0.001; GWW: p=0.005). Summary These results indicate that the pathological gene mutation underlying HCM, leads to lower myocardial work values, even with a similar morphological or functional appearance. The latter observation further confirms the possible role of MW parameters in the prognosis of HCM.

Left ventricular force with resting volumetric transthoracic echocardiography identifies different phenotypes in heart failure with preserved ejection fraction

Abstract Background Heart failure and preserved ejection fraction (HFpEF) is a heterogeneous entity including patients with different phenotypes of reduced, normal, and supernormal left ventricular (LV) function. Objectives To assess the value of resting LV elastance with transthoracic echocardiography (TTE) to identify HFpEF phenotypes. Methods In a prospective, observational, multicenter study, 2380 HFpEF patients were recruited from July 2016 to May 2024 by 35 certified laboratories of 15 countries. HFpEF was diagnosed according to the European Society of Cardiology (ESC) guidelines. Systolic blood pressure (SBP) was measured. We assessed wall motion score index (WMSI), LV end-diastolic volume (EDV), end-systolic volume (ESV), EF, force (SBP/ESV), stroke volume (SV), arterial elastance (AE, SBP/SV), ventricular-arterial coupling (VAC, as SV/ESV), and left atrial volume index (LAVI). Global longitudinal strain (GLS) was available in 1164 (48.9%) patients. In 271 (11.4%) patients, N-terminal pro-brain natriuretic peptide (NT-proBNP) was assessed. Patients were divided into three groups based on rest force: low rest force group (&amp;lt; 25% percentile, Group 1), median rest force group (≥ 25% percentile &amp; ≤ 75% percentile, Group 2), and high rest force group (&amp;gt; 75% percentile, Group 3). Results 330 (13.9%) patients presented with ischemic RWMA. The 3 groups showed a gradient with descending values (Group 3&amp;gt;2&amp;gt;1) for SBP, EF, GLS, AE, and VAC, with the opposite gradient (Group 1&amp;gt; 2&amp;gt; 3) for EDV, EDVi, ESV, ESVi, SV, SVi, and LAVI values (all P&amp;lt;0.01). Patients in Group 3 have higher NTproBNP level and higher percentage of B-line compared to groups 1 and 2 (P&amp;lt;0.05). The 3 groups were similar for values of coronary flow velocity, systolic pulmonary artery pressure, and E/e’ (see table). Univariable linear regression analysis showed that NTproBNP was correlated with force (r = 0.271, p &amp;lt; 0.001), VAC (r = 0.194, p = 0.001), LAVI (r = 0.327, p &amp;lt; 0.001), LVEDV (r = -0.245, p &amp;lt; 0.001), LVEDVi (r = -0.261, p &amp;lt; 0.001), LVESVi (r = -0.190, p = 0.002) and LVESV (r = -0.187, p = 0.002) (see figure). However, multivariable linear regression analysis showed that NTproBNP was independently associated with LAVI (β= 0.211, p &amp;lt; 0.001) and force (β= 1.804, p = 0.002). Conclusions HFpEF patients present with different LV contractile phenotypes, easily identified with resting LV force and volumetric TTE. LV force is linearly correlated with cardiac natriuretic peptide levels. The dominant hemodynamic feature of hypocontractile phenotype is a preload recruitment with dilation of LV EDV and normal SV, while the hypercontractile phenotype is characterized by a small LV with reduced SV. heat map

Low forward stroke volume index after transcatheter edge-to-edge repair for secondary mitral regurgitation predicts a worse prognosis in a 2-year follow-up

Abstract Background Transcatheter edge-to-edge repair (TEER) is an established treatment for patients with heart failure (HF) and significant secondary mitral regurgitation (SMR). While TEER often reduces mitral regurgitation (MR) severity, alleviating symptoms and improving prognosis, some patients do not experience these benefits. The absence of improvement in forward stroke volume may underlie this lack of response. Aim To evaluate the prognostic significance of forward stroke volume index (FSVi) following TEER for SMR. Methods We retrospectively analysed data from consecutive patients referred for TEER in our academic hospital from October 2016 to June 2023. The inclusion criteria were: symptomatic moderate to severe and severe SMR, anatomical suitability for TEER, and optimal medical therapy. Transthoracic echocardiograms (TTE) were performed before (up to 3 months pre-TEER, TTE-0), within 48 hours (TTE-1), and 6 months post-procedure (TTE-2). The FSVi was calculated by multiplying the left ventricular outflow tract area by the left ventricular outflow tract velocity-time integral. Patients were followed for a mean of 2 years. The composite endpoint was all-cause mortality or hospitalisation due to HF. Results Out of 67 patients treated with TEER, we included 50 patients who had follow-up at our hospital, TEE-0, and at least one of TEE-1 or TEE-2. Six patients with primary MR were excluded. Thus, 44 patients (mean age 69.7±8.2 years, 77% male) were included in the study. These patients were in NYHA class II to IV, with a median EuroSCORE II of 13% (IQR 7, 23), and a median LVEF of 31% (IQR 26, 36), 77% had ischaemic cardiomyopathy. The mean follow-up was 1.6±0.7 years. No patients were lost to follow-up. There were 22 composite endpoints including 12 deaths. At baseline patients in the group with composite endpoint were most often diabetic, had higher NYHA class, and lower 6-minute walking test distance. Echocardiographic parameters were similar in both groups. Median FSVi in TTE – 0 was 29 mL/m2 (22, 34) vs 31 mL/m2 (25, 36), p=0.2 (in the group with and without composite endpoint). After TEER, FSVi was significantly lower in the group with versus without a composite endpoint in TTE -1 [32 mL/m2 (27, 34) vs 38 mL/m2 (33, 43), p=0.005] and TTE -2 [32 mL/m2 (22, 33) vs 40 mL/m2 (34, 48), p=0.001]. The group with composite endpoint had higher NYHA class, lower 6-minute walking test distance, lower LVEF, and higher resting heart rate 6 months after TEER. The optimal cut-off value for the FSVi in TTE – 1 after TEER for predicting the composite endpoint was 35 ml/m2 (AUC 0.76, 80% sensitivity, 70% specificity, PPV 0.73, NPV 0.78). A significant difference in the composite endpoint occurrence was observed between groups with FSVi &amp;gt; 35 ml/m2 and ≤ 35 ml/m2 (TTE – 1) during the follow-up (Figure). Conclusions FSVi in early postprocedural TTE predicts death or rehospitalisation for HF in patients treated with TEER for SMR. Kaplan-Meier curves

Myocardial strain and work parameter changes predict long term mortality and rehospitalization in an acute heart failure patient population after levosimendan use

Abstract Introduction Decompensated acute heart failure (HF) in patients with reduced ejection fraction (HFrEF) signifies a pivotal stage in the progression of chronic HF. This condition is closely linked to increased rates of rehospitalization and a higher risk of mortality and morbidity due to inadequate decongestion. Recently, the field of quantitative echocardiography has experienced significant advancements, particularly in myocardial work analysis (MWA), which measures the energy the heart uses during each cardiac cycle. Purpose This study aimed to investigate the immediate effects of levosimendan on myocardial mechanics and to determine if these effects can predict the composite endpoint of HF-related rehospitalization and cardiovascular mortality. Methods 60 patients with HFrEF have been enrolled in the present study (age: 63.8±14.1, 46 males, 25 ischemic HFrEF, 35 non-ischemic HFrEF). or all patients, detailed baseline echocardiography, including strain imaging and myocardial work analysis (MWA), was conducted. Follow-up echocardiography was performed an average of 13.1±12.5 days after levosimendan administration. The clinical follow-up period lasted 496±191 days. Results Before levosimendan administration there was no significant difference in baseline echocardiographic, strain imaging and MWA parameters between ischemic and non-ischemic HFrEF groups. After the drug administration, left ventricular global wasted work (179±89 Hgmm% vs. 319±220 Hgmm%, p &amp;lt;0.05) was higher in the ischemic HFrEF group compared to non-ischemic HFrEF group. Among advanced echocardiographic parameters, global longitudinal strain (GLS) showed no significant improvement, however out of the MWA parameters, global work index (376±215 Hgmm% vs. 460±272 Hgmm%, p &amp;lt;0.05) improved significantly. The prognostic role of hemodynamic and novel echocardiographic parameters has been also assessed. Kaplan-Meier analysis revealed that LV stroke volume index improvement of 0.145 ml/m2 (p=0.01), LVEF improvement of at least 10% or more (p=0.032), LV GLS improvement of 0.85% (p=0.018) and lastly global constructive work improvement of 100 Hgmm% or more (p=0.021) resulted in significantly better event-free survival during the follow up period. Conclusion Levosimendan administration produces substantial immediate effects on hemodynamic parameters, myocardial deformation, and MWA metrics. These alterations appear to hold significant long-term prognostic value for predicting the composite endpoint and event-free survival.

Left ventricular, left atrial dysfunction and BNP progression in asymptomatic moderate and severe aortic stenosis

Abstract Introduction and aim Aortic stenosis (AS) is the most common valve disease in industrialized countries. Its prevalence is set to increase considerably in the coming years as the population ages (1). Data regarding the natural evolution in patients with moderate and severe AS are derived from cohorts of patients from 30 years ago (2, 3). We have thought to analyze the evolution of clinical, echocardiographic parameters and blood brain natriuretic peptide (BNP) in a recent cohort of truly asymptomatic patients with moderate to severe AS followed in the Valve Clinic. We also wanted to determine which is the echocardiographic parameter who’s annualized change will influence all-cause mortality in these patients. Methods We have enrolled 63 patients with moderate or severe truly asymptomatic AS (negative exercise test in each patient) followed up in our Valve Clinic from 2010 to 2023 who had at least 2 or 3 transthoracic echocardiographic examination (TTE) of excellent quality while still asymptomatic. All patients had a complete TTE with images suitable for left ventricular (LV) and left atrial (LA) deformation analysis by 2D speckle tracking. All conventional TTE parameters were analyzed as well as BNP measurements at the time of the TTE. Patients were followed up (mean follow up of 401 days) and all-cause mortality was assessed. Results Our results show progression of AS severity, a decrease in LV systolic function (GLS decreased significantly but LVEF and SV index remained changed), progression of LV diastolic dysfunction (progressive increase in E /e' ratio, in LA index volume with a significant decrease in LA reservoir function (PALs)). A progressive increase in estimated systolic pulmonary arterial pressure (PAPs) and a higher probability of pulmonary hypertension during follow-up was observed, while RV function parameters, TAPSE and S’ remained unchanged. BNP levels increased significantly over time. No patient was lost to follow-up and 23 (36.5%) patients died, 3 of cardiovascular cause. After adjustment for sex, age, presence of type 2 diabetes and coronary artery disease, all-cause mortality seemed to be significantly higher in patients with a decrease in LA reservoir function during follow-up (OR 0.77, CI 0.59-0.99, p=0.046). Conclusion To our knowledge, this is the first longitudinal contemporary study to describe the progression of AS and of all parameters of LV, LA, RV function and PHT in moderate to severe truly asymptomatic AS patients followed in a Valve Clinic. A higher risk of all-cause mortality was seen in patients with a poorer LA reservoir function. Annualized changed in LV and LA functional parameters may become a tool to improve risk stratification and therapeutic decision-making in asymptomatic severe AS if larger studies were to confirm our findings.

Effect of ticagrelor combined with metoprolol extended-release tablets on cardiac function and clinical prognosis in elderly patients with acute coronary syndrome after percutaneous coronary intervention

BackgroundAcute coronary syndrome (ACS) poses significant risks to older individuals. This study sought to assess the impact of combining ticagrelor and metoprolol extended-release tablets on clinical prognosis and cardiac function in elderly ACS patients following percutaneous coronary intervention (PCI).MethodsFrom February 2022 to February 2023, 90 elderly ACS patients who underwent PCI at our institution were retrospectively enrolled and divided into two groups: an observation group (OG) and a control group (CG), with 45 patients in each group. The CG received oral metoprolol extended-release tablets, while the OG received both oral metoprolol extended-release tablets and ticagrelor. Prognostic indicators and cardiac function were evaluated before and after treatment.ResultsThe treatment effectiveness rate in the OG was 97.78%, significantly higher than the CG's rate of 77.78% (P &amp;lt; 0.05). Post-treatment, the OG displayed notable improvements in cardiac function, including significantly higher left ventricular ejection fraction (LVEF), stroke volume (SV), cardiac output (CO), and cardiac index (CI) compared to the CG (P &amp;lt; 0.05). Both groups experienced enhanced exercise capacity, as evidenced by longer exercise duration (ED) and improved 6-min walking test (6MWT) results, with the OG showing superior gains (P &amp;lt; 0.05). Additionally, the OG had significantly higher serum levels of cardiac troponin T (cTnT) and creatine kinase isoenzyme (CK-MB) than the CG (P &amp;lt; 0.05). Decreases in serum levels of sICAM-1, MMP-9, and hs-CRP were observed in both groups, with more pronounced improvements in the OG (P &amp;lt; 0.05). The incidence of adverse prognostic events in the OG was significantly lower at 8.89%, compared to 37.78% in the CG (P &amp;lt; 0.05).ConclusionTicagrelor combined with metoprolol extended-release tablets can significantly improve cardiac function, motor performance, and quality of life in ACS patients after PCI. Additionally, it effectively increases myocardial injury markers and reduces serum inflammatory factor levels.

Mode of Delivery and Neonatal Transition: Insights from Electrical Cardiometry

Background/Objectives: Examining hemodynamic changes during the early transition period aids in identifying variations in neonatal outcomes linked to ante- or intrapartum events. It facilitates the recognition of potential impacts stemming from common intrapartum management practices. The current literature provides scant insights into cardio-circulatory changes during the crucial first 10 min after birth. The application of Electrical Cardiometry (EC) emerges as a valuable noninvasive clinical tool for measuring neonatal hemodynamics. This prospective cohort study aimed to assess hemodynamic variables, including heart rate (HR), stroke volume index (SVI), index of contractility (ICON), and cardiac output index (COI) during the first hour of life in late preterm and full-term infants. Additionally, this study investigated the relationship between the mode of delivery and cardiovascular adaptation. Methods: Two hundred infants, encompassing both full-term and preterm, were enrolled, with categorization into four groups based on mode of delivery and gestational age. Hemodynamic variables were continuously evaluated using an EC device throughout the first hour of life. Findings: A significant decreasing trend was observed in HR, SVI, COI, and ICON over the first hour of life (p &lt; 0.001). Infants delivered vaginally exhibited significantly higher HR, COI, SVI, and ICON compared to those born via Cesarean section (CS) (p = 0.006 and &lt;0.001 and 0.035 and 0.001, respectively). Conclusions: This study highlights a consistent decreasing trend in HR, SVI, COI, and ICON over the first hour of life in both full-term and preterm infants. Notably, hemodynamic variables exhibited heightened levels in infants delivered vaginally compared to those born by CS.

Outcomes and Predictors of Different Flow-Gradient Patterns of Aortic Stenosis Following Transcatheter Aortic Valve Replacement.

This study sought to explore the clinical factors associated with classical low-flow low-gradient (C-LFLG) and normal-flow low-gradient (NFLG) aortic stenosis (AS) compared to high-gradient (HG) AS. We also compared clinical and echocardiographic outcomes after transcatheter aortic valve replacement (TAVR) across flow-gradient patterns. Patients with C-LFLG AS have a higher mortality rate after TAVR than those with HG AS. However, what leads to C-LFLG AS and the predictors of mortality in this population remain unclear. In this retrospective, single-center study involving 1415 patients with severe AS, patients were classified into: 1) HG: (aortic valve mean gradient [MG] >40 mmHg); 2) C-LFLG, MG <40 mmHg, stroke volume index (SVI) <35 ml/m2, left ventricular ejection fraction (LVEF) <50%; 3) NFLG: MG <40 mmHg, SVI ≥35 ml/m2, LVEF ≥50%. Logistic regression was used for predictors of C-LFLG AS. Cox regression was used for predictors of mortality in the C-LFLG AS population. Male sex, multiple comorbidities, and moderate to severe mitral and tricuspid regurgitation (MR, TR) correlated with the C-LFLG AS group. Patients with C-LFLG AS had a higher mortality risk compared to HG AS at 2-years post-TAVR. Patients with NFLG AS had similar mortality at 1-year, but higher mortality at 2 years post-TAVR compared to HG AS. End-stage renal disease, atrial fibrillation, and other comorbidities predicted 2-year mortality in patients with C-LFLG AS. In conclusion, mortality after TAVR was higher in C-LFLG patients compared to HG. Male sex and multiple comorbidities predicted C-LFLG AS. Multiple comorbidities predicted mortality in those patients.

Ketone monoester ingestion improves cardiac function in adults with type 2 diabetes: a double-blind, placebo controlled, randomised, crossover trial.

Type 2 diabetes (T2D) is a metabolic disease associated with cardiovascular dysfunction. The myocardium preferentially uses ketones over free fatty acids as a more energy efficient substrate. The primary aim was to assess the effects of ketone monoester (Kme) ingestion on cardiac output index (Q̇i). Secondary aims were to assess the effects of Kme ingestion on markers of cardiac haemodynamics, muscle oxygenation and vascular function at rest, during and following step-incremental cycling. We undertook a double-blind, randomised, crossover design study in 13 adults (age, 66±10 y; BMI, 31.3±7.0 kg·m-2) with T2D. Participants completed two conditions, where they ingested a Kme (0.115 g‧kg-1) or a placebo taste-mathced drink. Cardiac function was measured using thoracic impedance cardiography and muscle oxygenation of the calf was determined via near-infrared spectroscopy. Macrovascular endothelial function was measured by flow mediated dilation (FMD) and microvascular endothelial function was measured via transdermal delivery of acetylcholine (ACh) and insulin. Circulating β-hydroxybutyrate [β-Hb] was measured throughout. Kme ingestion raised circulating β-Hb throughout the protocol (peak 1.9 mM; P=0.001 vs. placebo). Kme ingestion increased Q̇i by 0.75±0.5 L∙min-1∙m-2 (P=0.003) stroke volume index by 7.2±4.5 mL∙m-2 (P=0.001), and peripheral muscle oxygenation by 9.9±7.1% (P=0.001) and reduced systemic vascular resistance index by-420±-225 dyn∙s-1∙cm-5∙m-2 (P=0.031) compared to placebo condition. There were no differences between Kme and placebo in heart rate (P=0.995), FMD (P=0.542), ACh max (P=0.800), insulin max (P=0.242). Ingestion of Kme improved Q̇i, stroke volume index and peripheral muscle oxygenation, but did not alter macro- or microvascular endothelial function in people with T2D.

Cardiac Hemodynamics, Tissue Oxygenation, and Functional Capacity in Post-COVID-19 Patients.

Background and Objectives: This study aimed to evaluate and compare the functional capacity of post-COVID-19 patients with a control group and analyze cardiac hemodynamics and muscle tissue oxygenation responses during assessment protocols in both groups. Materials and Methods: A cross-sectional study was conducted involving patients with COVID-19 and a control group who were all aged ≥18 years. Participants underwent two functional capacity tests: the one-minute sit-stand test (1-STS) and the six-minute walk test (6MWT). Cardiac hemodynamic responses were evaluated using impedance during the 1-STS, and tissue perfusion responses in the oxygenation were recorded during and after both tests. The Friedman test was used for within-group and the Mann-Whitney test was used for between-group comparisons. Results: Thirty-six post-COVID-19 patients (median age 36 years, BMI 26.51 kg/m2) and eleven control subjects (median age 25 years, BMI 23.71 kg/m2) were enrolled. The post-COVID-19 group showed a 20% decrease in 6MWT distance (p = 0.0001) and a 28% decrease in 1-STS repetitions (p = 0.01) versus the control group. Cardiac hemodynamic differences were observed in the post-COVID-19 group during the 1-STS, with reductions in the stroke volume index (18%, p = 0.004), cardiac index (21%, p = 0.0009), Contractility Index (78%, p = 0.0001), and Ejection Fraction (29%, p = 0.0003) and increases in Systemic Vascular Resistance (25%, p = 0.03) and the Systemic Vascular Resistance Index (27%, p = 0.0007). Tissue oxygenation during the 6MWT and 1-STS showed no significant differences between groups. Conclusions: The post-COVID-19 subjects exhibited a reduction in functional capacity, changes in hemodynamic responses related to cardiac and systemic vascular resistance, and a similar pattern of muscle oxygen delivery and consumption in both tests.

How to Reliably Measure Stroke Volume Index in Pulmonary Arterial Hypertension: A Comparison of Thermodilution, Direct and Indirect Fick, and Cardiac MRI.

Stroke volume index (SVI) is an important prognostic parameter in pulmonary arterial hypertension (PAH). The direct Fick (DF) method represents the gold standard for measuring it. Indirect Fick (IF) and thermodilution (TD) are simpler and widely used alternatives. However, data on the accuracy of these methods in estimating SVI in PAH are scant. We aimed to compare these different invasive methods, and in a subgroup of patients, to a non-invasive method using MRI. We enrolled 103 PAH patients undergoing a diagnostic or follow-up right heart catheterization at our centre (mean age 56 years, 56% female). The Bland-Altman analysis was used to assess agreement between methods. Potential demographic, clinical, and hemodynamic biases were explored. The accuracy of cardiac magnetic resonance (CMR)-derived SVI was assessed in a subset of patients. The mean bias for IF-SVI vs. DF-SVI was -5.53 mL/min/m2 with a median percentage error (PE) of 15%. The mean bias was lower, 0.09 mL/min/m2, for TD-SVI vs. DF-SVI with a median PE of 10%. Low cardiac index and severe tricuspid regurgitation (TR) were associated with a greater bias between TD and DF. CMR-SVI showed good accuracy and precision even in patients with severe TR, compared to DF. The indirect Fick is the less reliable method to assess SVI also in PAH patients. Thermodilution is a valid alternative to direct Fick, but it should be used with caution in patients with severe TR or low cardiac index. SVI measured by cardiac MRI is a promising non-invasive alternative, especially in patients with severe TR. Our observation needs to be confirmed by other series and larger studies.

Deep learning model to identify and validate hypotension endotypes in surgical and critically ill patients.

Hypotension is associated with organ injury and death in surgical and critically ill patients. In clinical practice, treating hypotension remains challenging because it can be caused by various underlying haemodynamic alterations. We aimed to identify and independently validate endotypes of hypotension in big datasets of surgical and critically ill patients using unsupervised deep learning. We developed an unsupervised deep learning algorithm, specifically a deep learning autoencoder model combined with a Gaussian mixture model, to identify endotypes of hypotension based on stroke volume index, heart rate, systemic vascular resistance index, and stroke volume variation observed during episodes of hypotension. The algorithm was developed with data from 871 surgical patients who had 6962 hypotensive events and validated in two independent datasets, one including 1000 surgical patients who had 7904 hypotensive events and another including 1000 critically ill patients who had 53 821 hypotensive events. We defined hypotension as a mean arterial pressure <65 mm Hg for at least 1 min. In the development dataset, we identified four hypotension endotypes. Based on their physiological and clinical characteristics, we labelled them as: vasodilation, hypovolaemia, myocardial depression, and bradycardia. The same four hypotension endotypes were identified in the two independent validation datasets of surgical and critically ill patients. Unsupervised deep learning identified four endotypes of hypotension in surgical and critically ill patients: vasodilation, hypovolaemia, myocardial depression, and bradycardia. The algorithm provides the probability of each endotype for each hypotensive data point. Identifying hypotensive endotypes could guide clinicians to causal treatments for hypotension.

Left ventricular elastance with resting volumetric transthoracic echocardiography identifies different phenotypes in heart failure with preserved ejection fraction: A retrospective analysis of a multicenter prospective observational study.

Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous entity including patients with different phenotypes of near normal, normal, and supernormal left ventricular (LV) function. To assess the value of resting LV elastance (also known as force) with transthoracic echocardiography (TTE) to identify HFpEF phenotypes. In a prospective, observational, multicenter study, 2380 HFpEF patients were recruited from July 2016 to May 2024. Systolic blood pressure (SBP) was measured. We assessed LV end-diastolic volume (EDV), end-systolic volume (ESV), EF, force (SBP/ESV), stroke volume (SV), arterial elastance (AE), ventricular-arterial coupling (VAC), and left atrial volume index (LAVI). Global longitudinal strain (GLS) was available in 1164 (48.9%) patients. 680 patients finished follow-up with a composite end-point of major adverse cardiac events (MACEs). Patients were divided into three groups: low force (< 25th percentile, Group 1, < 3.24 mmHg/ml), intermediate force (≥ 25th percentile and ≤ 75 th percentile, Group 2, 3.24-5.48 mmHg/ml), and high force (> 75 th percentile, Group 3, >5.48 mmHg/ml). The 3 groups showed a gradient with descending values (Group 3>2>1) for SBP, EF, GLS, AE, and VAC, with the opposite gradient (Group 1> 2> 3) for EDV, ESV, SV, and LAVI values (all P<0.01). After a median follow-up of 16 months, 205 MACEs occurred in 138 patients. Cumulative MACEs rate was lowest in group 2 (14.7% person-year), higher in group 1 (16.1% person-year) and 3 (22.9% person-year, log rank p = 0.036). HFpEF patients present with different LV contractile phenotypes, easily identified with resting LV force and volumetric TTE. The dominant hemodynamic feature of hypocontractile phenotype is a preload recruitment with larger LV EDV and normal SV, while the hypercontractile phenotype is characterized by a small LV with reduced SV. The hypercontractile and hypocontractile phenotypes are associated with a higher risk of subsequent events.

Optimizing Cardiovascular Health Monitoring with IoT-Enabled Sensors and AI: A Focus on Obesity-Induced Cardiovascular Risks in Young Adults

With shifts in lifestyle and dietary patterns, obesity has become an increasing health issue among younger demographics, particularly affecting young adults. This trend is strongly associated with a heightened risk of developing chronic diseases, especially cardiovascular conditions. However, conventional health monitoring systems are often limited to basic parameters such as heart rate, pulse pressure (PP), and systolic blood pressure (SBP), which may not provide a comprehensive assessment of cardiac health. This study introduces an intelligent heart health monitoring system that leverages the Internet of Things (IoT) and advanced sensor technologies. By incorporating IoT-based sensors, this system aims to improve the early detection and continuous monitoring of cardiac function in young obese women. The research employed a TERUMO ES-P2000 to measure blood pressure and a PhysioFlow device to assess noninvasive cardiac hemodynamic parameters. Through precise sensor data collection, the study identified key indicators for monitoring cardiovascular health. Machine learning models and big data analysis were utilized to predict cardiac index (CI) values based on the sensor-derived inputs. The findings indicated that young obese women showed significant deviations in blood pressure (SBP and PP) and cardiac hemodynamic metrics (SVI, EDV, and ESV) at an early stage. The implementation of signal processing techniques and IoT sensors enhanced the CI prediction accuracy from 33% (using basic parameters like heart rate, PP, and SBP) to 66%. Moreover, the integration of extra sensor-based parameters, such as Stroke Volume Index (SVI) and Cardiac Output (CO), along with the use of color space transformations, successfully improved the prediction accuracy of the original data by 36.68%, increasing from 53.33% to 90.01%. This represents a significant improvement of 30.01% compared to the existing technology’s accuracy of 60%. These results underscore the importance of utilizing sensor-derived parameters as critical early indicators of cardiac function in young obese women. This research advances smart healthcare through early cardiovascular risk assessment using AI and noninvasive sensors.