Ventricular-arterial Coupling Research Articles

Non-Invasive Evaluation of Right Ventricular Pulmonary Artery Coupling Ratio as a Risk Stratification Tool for Patients with HFpEF

Non-Invasive Evaluation of Right Ventricular Pulmonary Artery Coupling Ratio as a Risk Stratification Tool for Patients with HFpEF

Ventricular arterial coupling in patients with ischemia but no obstructive coronary artery disease: novel insight into heart failure progression

Abstract Background Ischemia with no obstructive coronary artery disease (INOCA) is prevalent in women and is associated with increased risk of developing heart failure with preserved ejection fraction (HFpEF). While the exact mechanism contributing to heart failure progression remains incompletely understood, we hypothesize that impaired ventricular-arterial coupling (VAC) plays a key role. Purpose To evaluate VAC across the INOCA-HFpEF continuum. Methods To accomplish our research objective, we leveraged cardiac magnetic resonance images from individuals with INOCA and HFpEF from the WISE Pre-HFpEF (NCT03876223) and WISE HFpEF (NCT02582021) studies, along with reference controls. Aortic pulse wave velocity (aPWV) was measured using velocity-encoded MRI, from the proximal ascending to distal descending aorta. Global longitudinal strain (GLS) was measured by feature tracking of horizontal and vertical long axis cine images. VAC was defined as the ratio between aPWV and GLS. To test for potential mediators, we assessed the relationship between VAC and age, risk factors, systolic blood pressure (SBP), diastolic blood pressure (DBP), myocardial perfusion reserve index (MPRI), LV end diastolic pressure (LVEDP), cardiac structure/function, and Kansas City Cardiomyopathy questionnaire (KCCQ). Results The baseline characteristics of the three study groups are described in the Table. Patients with INOCA had similar KCCQ scores as HFpEF patients, suggesting INOCA patients may have subclinical HFpEF. Consistent with our hypothesis, we observed a progressive impairment in VAC across the three groups (Controls vs INOCA vs HFpEF), being significantly worst in HFpEF(Figure). Importantly, VAC was inversely related with age, systolic/diastolic blood pressure, and LV mass index (R=-0.6, R=-0.4, R=-0.4, R=-0.3 respectively, all p <0.001). Conclusion The data herein support the hypothesis that VAC contributes to heart failure progression, with age, arterial blood pressure and LV mass being key determinants. That VAC was not yet significantly different between INOCA, and reference controls highlights an important opportunity for intervention to prevent heart failure progression.

TAPSE/sPAP at peak exercise as a surrogate of RV-PA uncoupling can predict exercise-induced pulmonary hypertension in symptomatic patients with chronic thromboembolic pulmonary disease

Abstract Background and aim Chronic thromboembolic disease (CTED) refers to the presence of chronic thrombotic pulmonary vascular occlusion in the absence of pulmonary hypertension (PH) at rest but with exercise limitation caused by established vasculopathy. Symptoms after an acute pulmonary embolism (PE) with persistent lung perfusion defects need a complete diagnostic approach. Exercise echocardiography (ex-echo), with surrogate parameters of ventricular-arterial (VA) coupling could be of interest to non-invasively assess a pathological hemodynamic response. The aim of this study is to analyze the role of ex-echo and non-invasive assessment of VA coupling by echocardiography in predicting an abnormal hemodynamic response in symptomatic patients with chronic thrombotic pulmonary vascular occlusion. Methods Symptomatic patients with confirmed perfusion defects in lung V/Q scintigraphy despite optimal anticoagulant therapy for at least 3 months after an acute PE were selected. Relevant PH at rest was ruled-out (mPAP <25 mmHg, PVR <3 Wu, PAWP <15 mmHg, according to available definition at the time). Right heart catheterization with incremental exercise protocol (adapted cycle ergometer), with simultaneous transthoracic echo were performed. Parameters were collected at each exercise level. A mPAP/CO slope >3 mmHg·L−1·min−1 measured invasively was considered an abnormal hemodynamic response to exercise. Right VA coupling was estimated as TAPSE/sPAP ratio. A non invasive echo mPAP/CO slope was obtained from Doppler measurements. Results 31 patients (32% women, mean age 51.8 ± 14.7 y.) were included. Fourteen patients (45%) developed ex-PH. Baseline and peak exercise characteristics and parameters according to hemodynamic response are shown in Table 1. Moderate significative correlations between invasive hemodynamics and echo derived parameters at peak exercise were observed: sPAP: r=0.793 (p <0.001), CO r=0.532 (p 0.003), mPAP/CO slope r=0.458 (p 0.012). Peak exercise TAPSE/sPAP showed an AUC=0.85 (CI95% 0.70-1.00, fig. 1), and a cutoff point of <0.52 mm/mmHg, showed a S 80% / E 93% PPV 92% and NPV 81%, to predict an abnormal response. The echo derived mPAP/CO slope showed an AUC=0.78 (CI95% 0.59-0.96), and a cutoff point of > 2.44 mmHg·L−1·min−1 showed a S and E of 85% and 67% PPV 71 % and NPV of 83% to predict ex-PH. Abnormal septal motion at peak exercise showed a S 90%, E 78%, PPV 71% and NPV of 93% to predict ex-PH. Conclusions In our study cohort, up to 45% of symptomatic patients with persistent pulmonary thrombosis after a PE, without relevant PH at rest, developed ex-PH. New echo-derived parameters such as TAPSE/sPAP, a surrogate RV-PA coupling parameter, and echo-mPAP/CO slope, showed a good performance to predict an abnormal hemodynamic response. Ex-echo, feasible, non invasive and widely available, might represent a useful tool for the selection of patients for invasive hemodynamic workup.Peak exercise TAPSE/sPAP ROC curveTable 1

Post-coronavirus disease-19: the impact of cardiopulmonary rehabilitation on arterial stiffness, left ventricular deformation, and ventricular-arterial coupling

Abstract Introduction Although coronavirus disease-19 (COVID-19) is a primarily a respiratory disease, impairment of cardiovascular function has been documented, even in the post-acute phase. Cardiopulmonary rehabilitation could represent an appealing approach in the management of cardiovascular sequelae of post-COVID-19, which may affect arterial and left ventricular function, ultimately influencing ventricular-arterial coupling (VAC). Purpose In this study, we assess the impact of a post-acute COVID-19 rehabilitation program on arterial stiffness, left ventricular deformation, and VAC. Methods We enrolled 60 convalescent patients from COVID-19 and one-month post-acute disease were randomized at 1:1 ratio in a 3-month cardiopulmonary rehabilitation program (study group) or not (control group). The levels of pro-inflammatory interleukin-1β (IL-1β) were determined. Arterial stiffness was evaluated by carotid-femoral Pulse wave velocity (cf-PWV) at 1 month and at 4 months post-acute disease. Transthoracic echocardiography was performed, and left ventricular global longitudinal strain (LV-GLS) was estimated. Finally, the ratio of cf-PWV/LV-GLS was calculated as an index of VAC. Results There were no significant differences in major risk factors across the studied groups (age, sex, body mass index, smoking, hypertension, diabetes mellitus, dyslipidemia). Moreover, patients across the study groups did not differ regarding the levels of IL-1β. Although cf-PWV was similar in the study and the control group at baseline, it was improved only in the study group (8.2±1.3m/sec vs. 6.6±1.0m/sec, p<0.001) but not in the control group (8.9±1.8m/sec vs. 8.8±1.9m/sec, p=0.74). Similarly, for GLS, no differences were noted at baseline. However, the study group exhibited a significant improvement during the study (-19.6±2.0% vs. -21.3±1.9%, p<0.001), while no changes were observed in the control group (-18.7±2.9% vs. -18.3±2.1%, p=0.15). Finally, VAC was significantly ameliorated only in patients receiving cardiopulmonary rehabilitation (-0.43±0.11m/s% vs. -0.31±0.06m/s%, p<0.001). When individuals undergoing cardiopulmonary rehabilitation were stratified according to median baseline IL-1β levels, those presenting with lower concentrations experienced a significant benefit in ΔVAC (IL-1β<8.4pg/ml: 0.14±0.08m/s% vs. IL-1β≥8.4pg/ml: 0.09±0.05m/s%, p=0.04). Conclusion A 3-month cardiopulmonary rehabilitation program following the acute phase of COVID-19 accelerates the recovering of arterial and ventricular function, especially in individuals with a lower baseline inflammatory burden.

Treatment with sacubitril/valsartan and improvement of ventricular-arterial coupling in heart failure with reduced ejection fraction

Abstract Background Treatment with the angiotensin receptor-neprilysin inhibitor sacubitril/valsartan (S/V) in patients with heart failure and reduced ejection fraction (HFrEF) reduces mortality and heart failure (HF) hospitalizations. The specific hemodynamic mechanisms underlying these beneficial effects are currently unclear. Purpose This study aimed to assess the effects of S/V treatment on left ventricular (LV) end-systolic elastance (Ees), effective arterial elastance (Ea), and the ventricular-arterial coupling ratio (Ea/Ees) in patients with HFrEF using non-invasive pressure-volume analysis. Methods 117 patients with symptomatic HF and LVEF <40% in whom treatment with S/V was initiated were enrolled in this multicenter German prospective study. We used transthoracic echocardiography with simultaneous arm-cuff blood pressure measurements for non-invasive pressure-volume loop analyses. Primary endpoints were changes in Ees, Ea, and Ea/Ees ratio after six months of S/V treatment. Results The mean age was 65 (±13) years and 30% were female. In 54.7% of the patients, the etiology of HF was ischemic, and 45.3% was non-ischemic. 58.4% had first HF diagnosis at baseline. 102 patients with complete clinical and echocardiographic data at baseline and after six months of follow-up were analyzed. Among those, 62% were on target dose of S/V. Six months of S/V treatment resulted in a significant increase of Ees (0.66 mmHg/ml, IQR [0.45;0.94] vs. 0.78 mmHg/ml [0.57;1.10], p=0.001) and decrease of Ea (1.76 mmHg/ml [1.48;2.13] vs. 1.62 mmHg/ml [1.36;1.96], p=0.014). Hence, the Ea/Ees ratio significantly improved (2.52 [1.88;4.05] vs. 1.93 [1.50;2.63], p<0.001). In addition, LV volumes and pressure improved significantly with a regression of the LV end-systolic volume (LVESV: 142 ml [115;180] vs. 96 ml [65;124]), end-diastolic volume (LVEDV: 216 ml [179;247] vs. 165 ml [132;200]) and LV end-diastolic pressure (LVEDP: 19.6 mmHg [18.2;22.4] vs. 17.8 mmHg [16.6;19.9]), p<0.001 respectively. The LVEF increased from a median of 33% (27;37) to 43% (36;49), p<0.001. NT-proBNP level decreased from (median) 1771 pg/ml [838;5211] to 724 pg/ml [300;1575] and mean 6-minute walking distance increased from 371m (±125) to 423 m (±122), p<0.001 respectively. The percentage of patients with NYHA class III changed from 25.6% to 5.9%. Conclusion In a 6-months treatment period, initiation of sacubitril/valsartan in patients with heart failure and reduced ejection fraction was associated with reduction of LV volumes, improved LV function, reduction in afterload and fewer heart failure symptoms. These new data indicate that beyond reverse LV remodeling, improvement of LV contractility and ventricular-arterial coupling may contribute to the favorable clinical outcomes on treatment with sacubitril/valsartan in chronic heart failure.

Right ventricular pulmonary arterial coupling in patients with implanted left ventricular assist devices

Abstract Background Both the right ventricular (RV) contractile function and pulmonary arterial (PA) pressure influence clinical outcomes in patients supported with left ventricular assist devices (LVADs), but the impact of RV-PA coupling is unknown. Purpose This study aimed to determine the prognostic impact of RV-PA coupling in patients with implanted LVADs. Methods Patients with implanted third-generation LVADs were retrospectively enrolled. The RV-PA coupling was assessed preoperatively by the ratio of RV free wall strain (RVFWS) and noninvasively measured peak RV systolic pressure (RVSP). The primary endpoint was a composite of all-cause mortality or right heart failure (RHF) hospitalization. Secondary endpoints consisted of all-cause mortality at a 12-month follow-up and RHF hospitalization. Results A total of 72 patients with good RV myocardial imaging were included. The median age was 57 years, 67 patients (93.1%) were men and 41 (56,9%) had dilated cardiomyopathy. A receiver-operating characteristic analysis (AUC 0.703, 51.5% sensitivity, 94.9% specificity) was used to identify the optimal cutoff point (0.28%/mmHg) for the RVFWS/TAPSE threshold. Event rates were estimated using the Kaplan-Meier method showing an association with an increased risk for the primary endpoint of death or RHF hospitalization (89.47% vs. 30.19%, p<0.001). A similar observation applied to all-cause mortality (47.37% vs. 13.21%, p=0.003) and RHF hospitalization (80.43% vs. 20%, p<0.001). Conclusion An advanced RV dysfunction assessed by RV-PA coupling may serve as a predictor of adverse outcomes in patients with implanted LVADs.

Abstract 109: Nitric Oxide Added to the ECMO Circuit Improves Neuroprotection and Cardiac Function After Cardiac Arrest

Background: Veno-arterial extracorporeal life support (ECLS) is increasingly used in patients during cardiac arrest. Nitric Oxide (NO) has shown potential for exerting a protective role in ischemia/reperfusion damage in different organs. Aim: This study aims to investigate the cardio and neuroprotective effects of NO administered in the extracorporeal membrane oxygenation (ECMO) circuit after cardiac arrest. Methods: Thirty male SD rats were subjected to 10 minutes of cardiac arrest. They were randomly assigned to receive ECMO or ECMO plus NO (20 ppm) administered in the oxygenator (ECMO+NO). After 1 hour, the animals were weaned from ECMO, hemodynamic analysis using pressure-volume miniaturized catheter, and cardiac and brain samples were collected after two hours. Results: Analysis of cardiac function showed improved systolic cardiac function in the ECMO+NO group compared to standard ECMO (stroke volume: 55 ± 8 vs. 26 ± 9 μl, cardiac index: 9.05 ± 1.41 vs. 4.70 ± 0.81 ml/min/100g, dP/dt max : 6870 ± 290 vs. 5124 ± 205 mmHg/s; p<0.01). The ECMO+NO group also exhibited reduced systemic resistance (total peripheral resistance: 2.14 ± 0.42 vs. 2.95 ± 0.35 mmHg/ml/min/100g; p<0.05) and improved ventricular-arterial coupling (Ees/Ea: 0.96 ± 0.15 vs. 0.53 ± 0.15; p<0.001). Neuroinflammation, assessed by the expression of Iba1, a microglia activation marker, was attenuated in the ECMO+NO group (8.37 ± 0.41% vs. 12.58 ± 0.48%; p < 0.001). The extent of hypoxic brain areas, analyzed by thiol oxidation, was lower in the ECMO+NO group (4.07 ± 0.45% vs. 11.72 ± 1.03%; p<0.01). Conclusions: NO administration in the oxygenator during ECMO after cardiac arrest improves cardiac function and ventricular-arterial coupling and enhances neuroprotection decreasing neuroinflammation and hypoxic areas. NO administration in the ECMO circuit might be a promising therapeutic adjunct during ECLS.

Abstract 13563: Long-Term Prognostic Value of Afterload Mismatch Index in Acute Decompensated Heart Failure With and Without Reduced Left Ventricular Ejection Fraction

Backgrounds: Ventricular-arterial coupling has been shown to have physiologic importance in heart failure. At the acute worsening of heart failure, increased ratio of pulmonary capillary wedge pressure to systemic systolic pressure (PCWP/SBP) might reflect the degree of afterload mismatch. However, there is no information available on the long-term prognostic value of PCWP/SBP in patients with acute decompensated heart failure (ADHF), relating to reduced left ventricular ejection fraction (LVEF). Methods: We studied 240 patients admitted for ADHF (with LVEF<40% [HFrEF, n=110] and without LVEF<40% [n=130]), who underwent right heart catheterization at the admission and were discharged with survival. PCWP/SBP was obtained at the admission. The study endpoint was cardiovascular death (CVD). Results: During a mean follow-up period of 5.2±4.4 yrs, 59 patients had CVD. PCWP/SBP was significantly higher in patients with than without CVD (0.216±0.078 vs 0.172±0.064, p<0.0001). Multivariate Cox regression analysis revealed that PCWP/SBP was significantly associated with CVD, independently of prior heart failure hospitalization, body mass index, estimated glomerular filtration rate, and serum sodium level. Patients with high PCWP/SBP (>0.206 determined by ROC analysis: AUC 0.668[0.586-0.749]) had a significantly greater CVD risk than those with low PCWP/SBP (≤0.206) in both groups with and without HFrEF(with: 36% vs 11%, p=0.016; without: 42% vs 18%, p=0.0057). Conclusions: PCWP/SBP, an index of afterload mismatch, could provide the long-term prognostic information in patients admitted with ADHF, regardless of reduced LVEF.

Abstract 16270: Pulse Pressure Amplification Contributes to the Exaggerated Peripheral Blood Pressure Response to Exercise in Patients With HFpEF

Background: Patients with suspected heart failure and preserved ejection fraction (HFpEF) undergo invasive (right heart catheterization) cardiopulmonary exercise testing (iCPET) to confirm diagnosis. During iCPET peripheral arterial blood pressure (BP) is measured using a brachial cuff or radial arterial catheter. Notably, peripheral BP is typically higher than central BP and this difference is assessed by measuring pulse pressure amplification (PPA; peripheral - central PP; PP = systolic BP [SBP] - diastolic BP). The effect of PPA on the assessment of (exaggerated) exercise BP in HFpEF is unknown. Methods: 20 patients with HFpEF (75% Female; age: 69±7 years, BMI: 38±7 kg/m 2 ) were studied at rest and during submaximal and maximal cycling exercise. We measured radial BP (arterial catheterization) and derived ascending aortic BP using a transfer function applied to radial arterial waveforms (SphygmoCor). Pulse pressure amplification was assessed as radial-aortic pulse pressure. Data were compared with one-way and two-way (Site*Exercise Stage) ANOVA. Results: The increase in radial PP with exercise was greater than aortic PP (Site*Stage P<0.001; Figure A); thus, PPA increased with exercise (ANOVA, P =0.001; Figure B). The increase in PPA was due to a greater increase in radial compared to aortic SBP (Site*Stage P=0.002; Figure C). The change in diastolic pressure was not different between sites (Figure D). Increases in PPA accounted for ~30% of the increase in radial SBP. The incidence of exaggerated exercise SBP (Male: >210 mmHg; Female: >190 mmHg) was higher in the radial artery compared to aorta (95 vs 40 %, χ2<0.001). Conclusion: Peak exercise SBP was ~50 mmHg greater in the radial artery compared to aorta. The marked overestimation of central BP during exercise when measuring peripheral BP leads to misguided interpretation of BP responses to exercise, the magnitude of afterload and has implications for the assessment of ventricular-arterial coupling.

Bio-Humoral and Non-Invasive Haemodynamic Correlates of Renal Venous Flow Patterns across the Heart Failure Spectrum.

Background: We evaluated the bio-humoral and non-invasive haemodynamic correlates of renal congestion evaluated by Doppler renal venous flow (RVF) across the heart failure (HF) spectrum, from asymptomatic subjects with cardiovascular risk factors (Stage A) and structural heart disease (Stage B) to patients with clinically overt HF (Stage C). Methods: Ultrasound evaluation, including echocardiography, lung ultrasound and RVF, along with blood and urine sampling, was performed in 304 patients. Results: Continuous RVF was observed in 230 patients (76%), while discontinuous RVF (dRVF) was observed in 74 (24%): 39 patients had pulsatile RVF, 18 had biphasic RVF and 17 had monophasic RVF. Stage C HF was significantly more common among patients with dRVF. Monophasic RVF was associated with worse renal function and a higher urinary albumin-to-creatinine ratio (uACR). After adjusting for hypertension, diabetes mellitus, the presence of Stage C HF and serum creatinine levels, worsening RVF patterns were associated with higher NT-proBNP levels, worse right ventricular-arterial coupling, larger inferior vena cava and higher echo-derived pulmonary artery wedge pressure. This trend was confirmed when only patients with HF Stage C were analysed after adjusting for the left ventricle ejection fraction (LVEF). Conclusion: Abnormal RVF is common across the HF spectrum. Worsening RVF patterns are independently associated with increased congestion, worse non-invasive haemodynamics and impaired RV-arterial coupling. RVF evaluation could refine prognostic stratification across the HF spectrum, irrespective of LVEF.

Relationship between cardiac mechanical properties and cardiac magnetic resonance imaging at rest in childhood acute lymphoblastic leukemia survivors.

The characterization of cardiac mechanical properties may contribute to better understanding of doxorubicin-induced cardiotoxicity. Our study aims to investigate the relationship between cardiac mechanical properties, T1 and T2 relaxation times and partition coefficient.Fifty childhood acute lymphoblastic leukemia survivors underwent a cardiac magnetic resonance (CMR) at rest on a 3T MRI system and included a standard ECG-gated 3(3)3(3)5 MOLLI sequence for T1 mapping and an ECG-gated T2-prepared TrueFISP sequence for T2 mapping. Partition coefficient, ejection fraction, end-diastolic volume (EDV) and end-systolic volume (ESV) were calculated. CircAdapt model was used to study cardiac mechanical performance (left ventricle stiffness (LVS), contractility (LVC) and pressure (Pmin and Pmax), cardiac work efficiency (CWE) and ventricular arterial coupling).In the whole cohort, our results showed that LVC (R2 = 69.2%, r = 0.83), Pmin (R2 = 62.9%, r = 0.79) and Pmax can be predicted by significant CMR parameters, while T1 (R2 = 23.2%, r = 0.48) and partition coefficient (R2 = 13.8%, r = 0.37) can be predicted by significant cardiac mechanical properties. In SR group LVS (R2 = 94.8%, r = 0.97), LVC (R2 = 93.7%, r = 0.96) and Pmin (R2 = 90.6%, r = 0.95) can be predicted by significant cardiac mechanical properties, while in HR + DEX group CWE (R2 = 49.8%, r = 0.70) can be predicted by significant cardiac mechanical properties. Partition coefficient (R2 = 72.6%, r = 0.85) can be predicted by significant CMR parameters in SR group.Early characterization of cardiac mechanical properties from CMR parameters has the potential to early detect doxorubicin-induced cardiotoxicity.

Tricuspid Regurgitation Velocity/Tricuspid Annular Plane Systolic Excursion (TRV/TAPSE) Ratio as a Novel Indicator of Disease Severity and Prognosis in Patients with Precapillary Pulmonary Hypertension.

Tricuspid annular plane systolic excursion (TAPSE) and tricuspid regurgitation velocity (TRV) are two echocardiographic parameters with prognostic value in patients with pulmonary hypertension (PH). When analyzed concurrently as the TRV/TAPSE ratio, they allow the ventricular-pulmonary artery coupling (RVPAC) to be assessed. This could better predict disease severity in patients with PH. Our study aimed to evaluate the prognostic value of the TRV/TAPSE ratio echocardiographic parameter in adults with precapillary PH. This study included 39 patients (74% women; average age, 63 years) with precapillary PH (pulmonary arterial hypertension and chronic thromboembolic PH) The mean follow-up period was 16.6 ± 13.3 months. Twelve patients (31%) died during the observation time. We measured TAPSE as a surrogate of RV contractility and TRV reflecting RV afterload, while ventricular-arterial coupling was evaluated by the ratio between these two parameters (TRV/TAPSE). To assess disease progression and the patient's functional capacity, the World Health Organization functional class (WHO FC) was determined. Patient physical capacity was also evaluated using the 6 min walk test (6MWT). The analysis included values of N-terminal prohormone brain natriuretic peptide (NT-proBNP), which were taken routinely during the follow-up visit. The mean calculated TRV/TAPSE ratio was 0.26 ± 0.08 m/s/mm. Upon comparison of the TRV/TAPSE ratio to the disease prognostic indicators, we observed a statistically significant correlation between TRV/TAPSE and the results of the WHO FC, 6MWT, and NT-proBNP. The TRV/TAPSE ratio is thus a good predictor of mortality in PH patients (AUC, 0.781). Patients with a TRV/TAPSE ratio > 0.30 m/s/mm had a shorter survival time, with log-rank test p < 0.0001. Additionally, ROC analysis revealed higher AUC for TRV/TAPSE than for TAPSE and TRV alone. TRV/TAPSE is a promising practicable echocardiographic parameter reflecting RVPAC. Moreover, TRV/TAPSE could be viable risk stratification parameter and could have prognostic value in patients with PH.

Pressure-Volume Loops for Reviewing Right Ventricular Physiology and Failure in the Context of Left Ventricular Assist Device Implantation.

Right ventricular (RV) function is complex as a number of determinants beyond preload, inotropy and afterload play a fundamental role. In particular, arterial elastance (Ea), ventriculo-arterial coupling (VAC), and (systolic) ventricular interdependence play a vital role for the right ventricle. Understanding and actively visualizing these interactions in the failing RV as well as in the altered hemodynamic and morphological situation of left ventricular assist device (LVAD) implantation may aid clinicians in their understanding of RV dysfunction and failure. While, admittedly, hard data is scarce and invasive pressure-volume loop measurements will not become routine in cardiac surgery, we hope that clinicians will benefit from the comprehensive, simulation-based review of RV pathology. In particular, the aim of this article is to first, address and clarify the pathophysiologic hemodynamic factors that lead to RV dysfunction and then, second, expand upon this basis examining the changes occurring by LVAD implantation. This is illustrated using Harvi software which shows elastance, ventricular arterial coupling, and ventricular interdependence by simultaneously showing pressure volume loops of the right and left ventricle.

Ventricular-arterial coupling and cardiovascular risk among young adults: The African-PREDICT study.

Ventricular-arterial coupling (VAC) has independent diagnostic and prognostic value for cardiovascular (CV) risk stratification, but studies on its association with anthropometric and CV factors are sparse in young individuals without overt CV disease. We aim to provide descriptive data regarding VAC and its associations with CV risk factors in young adults without overt CV disease. For 631 (mean age, 24 ± 3 yr; 51% female) individuals, VAC was determined by carotid-femoral pulse wave velocity (PWV)/global longitudinal strain (GLS). Multivariable logistic and linear regression models were performed to explore the association between PWV/GLS and CV risk factors. A P-value < 0.05 was considered statistically significant. The mean PWV/GLS was 0.33 ± 0.07 m/s%. Higher ratios of PWV/GLS associated with older age, male sex, and a higher prevalence of CV risk factors (i.e., higher blood pressure, prevalent hypertension, higher waist circumference, active smoking, higher plasma triglycerides, lower high-density lipoprotein cholesterol, and an adverse urine albumin/creatinine ratio). Furthermore, higher PWV/GLS was associated with echocardiographic measures such as lower ejection fraction and higher left ventricle mass index. In expanded logistic regression models, higher ratios of PWV/GLS were significantly associated with the prevalence of active smoking [odds ratio (OR), 1.88; confidence interval (CI) 1.36-2.58, P < 0.001] and hypertension (OR 1.98; CI 1.40-2.80, P < 0.001). We demonstrated that worse VAC reflected by higher values of PWV/GLS are significantly associated with CV risk factors in young adults. The results suggest that PWV/GLS might serve as a tool to improve the profiling of cardiovascular risk in young adults.NEW & NOTEWORTHY Assessing VAC is especially useful in heart failure and valvular heart disease, but less is known about VAC in the pathophysiology of CV disease risk in younger individuals. In young individuals without overt CV disease, we showed descriptive data regarding VAC, determined by PWV/GLS ratio, and explored the associations of VAC with clinical CV disease risk factors. Worse VAC, reflected by higher values of PWV/GLS, associated with high blood pressure and smoking in young adults.

A new simplified cardiac damage staging for aortic stenosis: the role of longitudinal global strain and right ventricular arterial coupling

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Transcatheter aortic valve replacement (TAVR) continues to evolve as a treatment for patients with severe aortic stenosis (AS) in different clinical scenarios. As aortic valve disease progresses, secondary cardiac damage sets in; this damage is not always reversible and determines the prognosis by itself. Concerning extra-valvular repercussions, different staging systems of cardiac damage have been published and proposed as a prognostic tool that may help to improve the selection of candidates to TAVR. Purpose The aims of our study were to identify independent risk factors for 1-year mortality in patients with severe AS undergoing TAVR and to develop a new cardiac damage staging system to stratify these patients. Methods patients undergoing TAVR from 2017 to 2021 were included in a single-center prospective registry. Transthoracic echocardiography was performed in all patients before TAVR. Logistic regression analysis and Cox’s regression were used to identify predictors of 1-year all-cause mortality. Applying variables from the regression analyses, a new staging model was proposed. The area under the ROC curve (AUC ROC) was used to measure the discriminatory capacity of different staging models to predict 1-year mortality risk. Results 496 patients (mean age 81.9±6.2 years, 67% men) were included. 1-year mortality in our population was 22.3% (n= 111). Left ventricle ejection fraction (LVEF), moderate mitral regurgitation (MR), severe tricuspid regurgitation (TR), and right ventricular-arterial coupling (RVAc) were found to be independent predictors of all-cause 1-year mortality. A new classification system with three different stages was developed: Stage 0) No cardiac damage: LVEF ≥ 60%; left ventricle global longitudinal strain (LV-GLS) &amp;lt; −15%, RVAc ≥ 0.35 and absence of MR. Stage 1) Left side subclinical damage: LVEF 50–59.9% or LV-GLS ≥ −15% or presence of moderate or severe MR. Stage 2) Left or right ventricular damage: LVEF &amp;lt; 50% or RVAc &amp;lt; 0.35. The area under the ROC curve for this model was 0.67 (95% confidence interval 0.60–0.73), and its predictive performance was superior compared to the previously published systems (p = 0.009). A stepwise increase in 1-year all-cause mortality for each category increment in this new cardiac staging system was found. Conclusion Cardiac damage staging might have an important role in patients’ selection and better timing for TAVR. A model that includes new parameters, such as LV GLS and RVAc, may help to both improve prognostic stratification and contribute to better selection and earlier programming of TAVR.

Transthoracic echocardiography parameters as predictors of 30-day readmission after admission for new-onset heart failure

Abstract Funding Acknowledgements Type of funding sources: None. Background In an aging population. heart failure (HF) is one of the biggest challenges facing healthcare systems in the coming years. Hospital readmissions after discharge continue to be one of the main problems for both patients and health systems as they represent costs and work overload for staff. The aim of this study is to re-visit the prognostic value of transthoracic echo parameters (TTE) in readmissions after a new-onset HF episode. Methods Consecutive patients admitted with a first episode of HF were prospectively included into a registry. All patients underwent transthoracic echocardiography based on current guidelines for chamber quantification within 24hrs after admission. Conventional systolic and diastolic function parameters were obtained. In addition. longitudinal strain and ventricular-arterial coupling of both ventricles were evaluated. Results 218 consecutive patients were included. Clinical and imaging characteristics are described in Table 1. 32 patients (14.7%) had readmission within 30-days. Mean age of the cohort was 73.4±13.4 years; mean LV ejection fraction (LVEF) was 42.3±14.2% and mean LV global longitudinal strain (LV-GLS) was −9.2±3.4%. Patients with 30-day readmissions had lower LVEF (37.8±3.1 vs 42.7±1.5%. p = 0.255) and significantly lower LV-GLS (−7.4±2.4 vs −9.5±3.4%. p = 0.042). Regarding diastolic function, patients with 30-day readmissions had a slightly higher E/e’ ratio (15.1±10.3 vs 14.3±7.2, p = 0.747) and a significantly larger left atrium volume index (57.2ml/m2 vs 45.5ml/m2). Right ventricular-arterial coupling (RVAc) was significantly lower in patients with readmissions (0.43±0.11 vs 0.69±0.9, p = 0.031). As for clinicals variables; only obesity was significantly associated with 30-day readmissions (Table 1). A model to predict 30-days readmissions that included LVEF, LV-GLS, LAVI and RVAc had an area under the ROC curve of 0.831. CI (0.72–0.95). Figure 1. Conclusions Several clinical scores have been proposed. however. cardiac function parameters are barely taken into account in most scores. Simple and feasible TTE parameters can accurately predict readmissions after a first episode of heart failure and might be included in clinical scores for better risk stratification of patients with new-onset HF.

Redefining cardiac damage staging in aortic stenosis: the value of GLS and RVAc.

Cardiac damage staging has been postulated as a prognostic tool in patients undergoing transcatheter aortic valve replacement (TAVR). The aims of our study are (i) to validate cardiac damage staging systems previously described to stratify patients with aortic stenosis (AS), (ii) to identify independent risk factors for 1-year mortality in patients with severe AS undergoing TAVR, and (iii) to develop a novel staging model and compare its predictive performance to that of the above mentioned. Patients undergoing TAVR from 2017 to 2021 were included in a single-centre prospective registry. Transthoracic echocardiography was performed in all patients before TAVR. Logistic and Cox's regression analysis were used to identify predictors of 1-year all-cause mortality. In addition, patients were classified based on previously published cardiac damage staging systems, and the predictive performance of the different scores was measured.Four hundred and ninety-six patients (mean age 82.1 ± 5.9 years, 53% female) were included. Mitral regurgitation (MR), left ventricle global longitudinal strain (LV-GLS) and right ventricular-arterial coupling (RVAc) were independent predictors of all-cause 1-year mortality. A new classification system with four different stages was developed using LV-GLS, MR, and RVAc. The area under the receiver operating characteristic curve was 0.66 (95% confidence interval 0.63-0.76), and its predictive performance was superior compared with the previously published systems (P < 0.001). Cardiac damage staging might have an important role in patients' selection and better timing for TAVR. A model that includes LV-GLS, MR, and RVAc may help to improve prognostic stratification and contribute to better selection of patients undergoing TAVR.

The Relationship of Renal Augmented Velocity Index With Ventricular-Arterial Coupling in Comparison to Renal Resistive Index: Analysis by Means of Arterial and Ventricular Elastances in Hypertensive Patients.

It's a well-known scientific statement that the heart and kidney functions are frequently tied together and the impairment of one directly alters the other. However, there exist knowledge gaps about this intricate pathophysiologic link and the exact unifying mechanism is not established. Herein, we aimed to investigate the presence of cardiorenal interaction at subclinical level while the conventional cardiac and renal clinical parameters are not disrupted yet in patients with hypertension. We chose a novel renal Doppler ultrasonographic parameter-augmented velocity index (Avi)-and an echocardiographic measure-ventriculoarterial coupling-which is complex to analyze but increasingly used after its acceptance about being a key determinant of cardiovascular efficiency. We recruited 137 patients without a previous history of antihypertensive medication use (47.4% women; median age, 49 years). Renal Avi, renal resistive index (RI), arterial elastance (Ea ), ventricular elastance (Ees ) and Ea /Ees (ventriculoarterial coupling) parameters were all examined. Renal Avi, Ea , and Ea /Ees values were higher in females. Correlation analysis revealed that renal Avi was correlated with many hemodynamic variables including Ea and Ea /Ees . On multiple linear regression analysis, Ea and Ea /Ees remained as significant independent predictors of renal Avi but not of renal RI after adjustments for co-variables (β = 0.488, P < .001 for Ea ; β = 0.380, P < .001 for Ea /Ees ). In comparison to renal RI, we suggest that renal Avi is a more reliable and promising index that can even measure subclinical changes in the cardiorenal circulation which needs to be elucidated.

A method for calculating left ventricular ejection fraction noninvasively from left ventricular arterial coupling (Ees/Ea)

BackgroundEjection fraction (EF), which is assessed using ultrasonography, is a standard parameter for evaluating cardiac function in clinical cardiology and for cardiovascular management during general anesthesia. However, it is impossible to continuously and non-invasively assess EF using ultrasonography. The aim of our study was to develop a method for estimating EF non-invasively using the left ventricular arterial coupling ratio (Ees/Ea).MethodsEes/Ea was estimated non-invasively using the parameters pre-ejection period (PEP), ejection time (ET), end-systolic pressure (Pes) and diastolic pressure (Pad), which were calculated from a vascular screening system, VeSera 1000/1500 (Fukuda Denshi Co., Ltd., Tokyo, Japan). Then, left ventricular efficiency (Eff) as a pump, defined as the ratio of external work (EW) to myocardial oxygen consumption, which strongly correlates with the pressure-volume area (PVA), was calculated by a new formula using Ees/Ea, and was used to approximate EF (EFeff). Simultaneously, we measured EF using transthoracic echocardiography (EFecho), and compared it with EFeff.ResultsThe study included 44 healthy adults (36 males, 8 females), in whom mean EFecho was 66 ± 5% and EFeff was 57 ± 9%. We found a positive correlation between EFecho and EFeff (R2 = 0.219, p < 0.05) on Bland-Altman analysis, with limits of agreement of – 7.5 to 24.4%, and percentage error of 24%.ConclusionThe results suggest that EF can be measured non-invasively using left ventricular arterial coupling.

Development and characterization of canine-specific computational models to predict pulsatile arterial hemodynamics and ventricular-arterial coupling.

Pulsatile hemodynamics analyses provide important information about the ventricular-arterial system which cannot be inferred by standard blood pressure measurements. Pulse wave analysis (PWA), wave separation analysis (WSA), and wave power analysis (WPA) characterize arterial hemodynamics with limited preclinical applications. Integrating these tools into preclinical testing may enhance understanding of disease or therapeutic effects on cardiovascular function. We used a canine rapid ventricular pacing (RVP) heart failure model to: (1) Characterize hemodynamics in response to RVP and (2) assess analyses from flow waveforms synthesized from pressure compared to those derived from measured flow. Female canines (n = 7) were instrumented with thoracic aortic pressure transducers, ventricular pacing leads, and an ascending aortic flow probe. Data were collected at baseline, 1 week, and 1 month after RVP onset. RVP progressively reduced stroke volume (SV), the PWA SV estimator, and WSA and WPA pulsatility and wave reflection indices. Indices derived from synthesized flow exhibited similar directional changes and high concordance with measured flow calculations. Our data demonstrate the value of analytical hemodynamic methods to gain deeper insight into cardiovascular function in preclinical models. These approaches can provide complementary value to standard endpoints in evaluating potential effects of pharmaceutical agents intended for human use.