Ventricular Stroke Work Index Research Articles

Elevated plasma WIF-1 levels are associated with worse prognosis in heart failure with pulmonary hypertension.

Heart failure (HF) is a progressive condition that is becoming more prevalent in the ageing population. Pulmonary hypertension is a common complicating factor in HF and negatively impacts survival. Plasma biomarkers are a potential method for determining the prognosis of patients with left heart failure with pulmonary hypertension (LHF-PH). We aimed to analyse the prognostic capability of 33 proteins related to, among other pathways, inflammation, coagulation, and Wnt signalling in LHF-PH. Plasma levels of 33 proteins were analysed using proximity extension assay from the plasma of 20 controls and 67 LHF-PH patients, whereof 19 underwent heart transplantation (HT). Haemodynamics in the patients were assessed using right heart catheterization. Eleven proteins had elevated plasma levels in LHF-PH compared with controls (P<0.01), which decreased towards the controls' levels after HT (P<0.01). Survival analysis of these proteins showed that elevated plasma levels of growth hormone, programmed cell death 1 ligand 2, tissue factor pathway inhibitor 2, and Wnt inhibitory factor 1 (WIF-1) were associated with worse transplantation-free survival in LHF-PH (P<0.05). When adjusted for age, sex and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels using multivariable cox regressions, only WIF-1 remained prognostic [hazard ratio (95% confidence interval)] [1.013 (1.001-1.024)]. WIF-1 levels in LHF-PH patients also correlated with the mean right atrial pressure (rs =0.42; P<0.01), stroke volume index (rs =0.41; P<0.01), cardiac index (rs =-0.42; P<0.01), left ventricular stroke work index (rs =-0.41; P<0.01), and NT-proBNP (rs =0.63; P<0.01). The present study demonstrated that LHF-PH patients have higher plasma WIF-1 levels than healthy controls, suggesting that plasma WIF-1 may be a potential future prognostic biomarker in LHF-PH. Its prognostic capability could be further refined by including it in a multi-marker panel. Further studies are needed to establish the potential role of WIF-1 in LHF-PH pathophysiology in larger cohorts to determine its clinical applicability.

High-dose adenosine versus saline-induced cardioplegic arrest in coronary artery bypass grafting: A randomized double-blind clinical feasibility trial.

In this clinical trial, we evaluated if a short-acting nucleoside, adenosine, as a high-dose bolus injection with blood cardioplegia induces faster arrest and provides better myocardial performance in patients after bypass surgery for coronary artery disease. Forty-three patients scheduled for elective or urgent coronary artery bypass grafting were prospectively recruited in two-arm 1:1 randomized parallel groups to either receive 20 mg of adenosine (in 21 patients) or saline (in 22 patients) into the aortic root during the first potassium-enriched blood cardioplegia infusion. The main outcomes of the study were ventricular myocardial performance measured with cardiac index, right ventricular stroke work index, and left ventricular stroke work index at predefined time points and time to asystole after a single bolus injection of adenosine. Conventional myocardial biomarkers were compared between the two groups at predefined time points as secondary endpoints. Electrocardiographic data and other ad hoc clinical outcomes were compared between the groups. Compared with saline, adenosine reduced the time to asystole (68 (95% confidence interval (95% CI) = 37-100) versus 150 (95% CI = 100-210) seconds, p = 0.005). With myocardial performance, the results were inconclusive, since right ventricular stroke work index recovered better in the adenosine group (p = 0.008), but there were no significant overall differences in cardiac index and left ventricular stroke work index between the groups. Only the post-cardiopulmonary bypass cardiac index was better in the adenosine group (2.3 (95% CI = 2.2-2.5) versus 2.1 (95% CI = 1.9-2.2) L/min/m2, p = 0.016). There were no significant differences between the groups in cardiac biomarker values. A high dose adenosine bolus at the beginning of the first cardioplegia infusion resulted in significantly faster asystole in coronary artery bypass grafting patients but enhanced only partially the ventricular performance.EudraCT number: 2014-001382-26. https://www.clinicaltrialsregister.eu/ctr-search/trial/2014-001382-26/FI.

Pulmonary artery pulsatility index as a predictor of right ventricular failure in left ventricular assist device recipients: A systematic review.

It is critical to identify patients at increased risk of right ventricular failure (RVF) before left ventricular assist device (LVAD) implantation. Pulmonary artery pulsatility index (PAPi) is a hemodynamic parameter that is a specific measure of right ventricular function and may better identify LVAD recipients at risk for RVF. This systematic review analyzes the predictive value of preoperative PAPi to RVF in the setting of LVAD implantation. Databases were searched for all studies reporting on PAPi and RVF after LVAD implantation. Data collected included: number of patients, patient characteristics, incidences of RVF, PAPi, central venous pressure (CVP), CVP/pulmonary capillary wedge pressure, tricuspid annular plane systolic excursion, and right ventricular stroke work index. Thirty-two studies (4,756 patients) were included in this review. The incidence of RVF was found to be 27.48% (1,307 patients). The weighted mean (standard deviation) of preoperative PAPi associated with RVF vs No RVF was 2.17 (2.36) and 2.87 (3.21), respectively. When comparing LVAD recipients with RVF and No RVF, patients who developed RVF had a significantly lower preoperative PAPi by a WMD (95% CI) of -0.74 [-1.00, -0.49] (p < .001). The remaining variables (CVP; CVP/pulmonary capillary wedge pressure; tricuspid annular plane systolic excursion; and right ventricular stroke work index) were also confirmed as predictors of RVF after LVAD implantation. This systematic review demonstrates the utility of PAPi as a clinical predictor of RVF after LVAD implantation. Based on our findings, we recommend that PAPi be used in conjunction with traditional hemodynamic parameters when risk stratifying LVAD recipients for RVF.

Oral milrinone for management of refractory right ventricular failure in patients with left ventricular assist devices.

We present a single-centre retrospective experience using oral milrinone in patients with a left ventricular assist device (LVAD) and concurrent refractory right ventricular failure. All patients implanted with LVAD between January 2013 and July 2021 from a high-volume advanced heart failure service were reviewed. Eight patients were initiated on oral milrinone during this period. Oral milrinone was started 1.5 [inter-quartile range (IQR) 1-2.3] years after LVAD implantation and continued for 1.2 (IQR 0.5-2.8) years. Therapeutic milrinone levels were achieved (232.2±153.4ng/mL) with 62.4±18% of time within the therapeutic range. Two patients had adverse events (non-sustained ventricular tachycardia and ventricular fibrillation effectively treated by internal cardioverter defibrillator) but did not require milrinone discontinuation. Four deaths occurred, one after transplant and three from disease progression determined to be unrelated to oral milrinone use. Three patients continue oral milrinone therapy in the community. There was no significant difference found after the initiation of oral milrinone on any of the physiological measures; however, there were trends in reduction of New York Heart Association class from 3.4±0.5 to 3.0±0.8 (P=0.08), reduction of right atrial/wedge pressure from 0.9±0.3 to 0.5±0.2 (P=0.08), and improvement of right ventricular stroke work index from 3.8±2 to 5.8±2.7 (P=0.16). Oral milrinone appears safe for long-term use in the outpatient setting when combined with therapeutic monitoring in this complex medical cohort with limited management options. Further study is needed to ascertain whether this treatment is effective in reducing heart failure symptoms and admissions.

Bedside Ultrasound of Internal Jugular Vein for Right Ventricular Function Assessment

<h3>Purpose</h3> Assessing right ventricular (RV) function is important in critically ill heart failure patients and candidacy for mechanical circulatory support options. In addition, diastolic heart failure and fluid overload are the earliest manifestations of rejection and coronary vasculopathy in heart transplant (HTx) recipients. Echocardiographic measurements can be difficult to obtain due to body habitus and poor ultrasound windows. Using ultrasound (POCUS) to assess dynamic changes in internal jugular vein (IJV) dimension could be a quick and reproducible method for bedside RV function assessment. <h3>Methods</h3> Patients scheduled to undergo right heart catheterization (RHC) as their standard of care were prospectively enrolled. While supine, the IJV was imaged at the apex of the sternocleidomastoid. Using M-mode on a portable ultrasound machine, maximum (Dmax) and minimum (Dmin) anteroposterior diameters were measured during normal breathing. Respiratory variation in diameter (RVD) was then calculated using the following equation [(Dmax - Dmin)/Dmax] and expressed as a percentage. RHC was then performed within one hour. <h3>Results</h3> A total of 92 heart failure patients were enrolled with mean age 58 and mean BMI 30.3. IJV dimensions could be assessed in all patients irrespective of BMI. Poor right ventricular (RV) function (right ventricular stroke work index -RVSWI) of <5 g/m/beat/m² was associated with low RVD (16% vs 34%, p = 0.001). An IJV RVD of < 15% had 82% specificity for RVSWI < 5 (ROC AUC 0.774). When using pulmonary artery pulsatility pressure (PAPi), an RVD of <15% had 79% specificity for a PAPi ≤ 2. When combined with a Dmin of 1cm, the specificity increased to 87% (Odds ratio 3.75, p=0.016). 21 of these assessments were in HTx patients, showing similar correlation. A Dmax >1.1cm or RVD <20% individually had specificity of 80% for RAP >=10 mmHg (both with ROC AUC > 0.800). Again, RVSWI <5 was associated with low RVD (19% vs 41%, p = 0.02). In the 14 biopsies performed in HTx patients, 4 were noted with >= 2R acute cellular rejection and all 4 of these had an RAP >=8mmHg, Dmax >1cm and RVD <20% (p<0.01). <h3>Conclusion</h3> Less dynamic IJV diameter variation on POCUS correlates with poor RV function and may be an early indicator of rejection in HTx patients. This assessment can be easily done at bedside regardless of body habitus, with great specificity and can be helpful in the diagnostic management of these patients.

A Novel Technique for Temporary Right Ventricular Support Using the Existing Cardiopulmonary Bypass Circuit During LVAD Implantation

<h3>Purpose</h3> Right heart failure following implantation of left ventricular assist devices (LVADs) occurs in 9-42% of patients. A variety of predictive models allow for selection of patients at high-risk for early RV failure. We sought to develop a technique to provide temporary right heart support using a centrally cannulated cardiopulmonary bypass (CPB) circuit during the LVAD implantation procedure. <h3>Methods</h3> Patients at high-risk for RV failure during LVAD implantation were supported by a modified CPB circuit. The objective was to separate from CPB without the need for a percutaneous or durable right ventricular assist device (RVAD). A standard CPB circuit was altered to include three bridges with the ability to exclude the venous reservoir, oxygenator, and arterial filter (Figure 1). Prior to weaning from CPB, a cannula was placed into the main pulmonary artery and connected to the arterial limb. This configuration enabled the circuit to easily transition between standard CPB, a RVAD, or both. Following wean from CPB and reversal of coagulopathy, the RVAD configuration allowed for delivery of blood while supporting the RV. <h3>Results</h3> From 2019 to 2021 four patients were identified at a single institution. Pre-operative mean clinical values included central venous pressure (CVP) of 16mmHg ± 3.9, pulmonary capillary wedge pressure (PCWP) of 25.3mmHg ± 2.8, tricuspid annular plane systolic excursion (TAPSE) of 1.2cm ± 0.28, right ventricular stroke work index (RVSWI) of 315 ± 41.2, and CVP/PCWP 0.63 ± 0.11. All patients were successfully weaned from CPB to LVAD support at the time of surgery. <h3>Conclusion</h3> We present a novel method of CPB weaning during LVAD implantation that allows for RV support. This configuration is easy to implement using a standard CPB circuit and serves as an immediate bridge for patients at high-risk for early RV failure. Furthermore, this technique avoids the RV strain that occurs with volume resuscitation while weaning from CPB and correcting coagulopathy.

İleri evre kalp yetmezliği olan hastalarda sol ventriküler atım iş indeksinin prognostik değeri

Aim: The impact of reduced myocardial contractility on patients’ outcomes with advanced heart failure (HF) and the correct measurement units for its measure is most important. The present work aims to evaluate the prognostic value of the left ventricular stroke work index (LVSWI), which is considered a measure of myocardial contractility, in patients with advanced HF.&#x0D; Material and Methods: Between September 2010 and July 2013, 172 patients with advanced HF admitted to the hospital to guide the specified therapies were included in this study. At baseline, patients were assessed with cardiac catheter-based hemodynamic measurements, ensued by the longitudinal follow-up (median of 52 months) for adverse outcomes (cardiac mortality, ventricular assist device (VAD) placement, and heart transplant (HTx)).&#x0D; Results: Median LVSWI was 16 cJ/m2. Decreased LVSWI (

Echocardiographic left ventricular stroke work index: An integrated noninvasive measure of shock severity.

Echocardiographic findings vary with shock severity, as defined by the Society for Cardiovascular Angiography and Intervention (SCAI) shock stage. Left ventricular stroke work index (LVSWI) measured by transthoracic echocardiography (TTE) can predict mortality in the cardiac intensive care unit (CICU). We sought to determine whether LVSWI could refine mortality risk stratification by the SCAI shock classification in the CICU. We included consecutive CICU patients from 2007 to 2015 with TTE data available to calculate the LVSWI, specifically the mean arterial pressure, stroke volume index and medial mitral E/e' ratio. In-hospital mortality as a function of LVSWI was evaluated across the SCAI shock stages using logistic regression, before and after multivariable adjustment. We included 3635 unique CICU patients, with a mean age of 68.1 ± 14.5 years (36.5% females); 61.1% of patients had an acute coronary syndrome. The LVSWI progressively decreased with increasing shock severity, as defined by increasing SCAI shock stage. A total of 203 (5.6%) patients died during hospitalization, with higher in-hospital mortality among patients with lower LVSWI (adjusted OR 0.66 per 10 J/m2 higher) or higher SCAI shock stage (adjusted OR 1.24 per each higher stage). A LVSWI <33 J/m2 was associated with higher adjusted in-hospital mortality, particularly among patients with shock (SCAI stages C, D and E). The LVSWI by TTE noninvasively characterizes the severity of shock, including both systolic and diastolic parameters, and can identify low-risk and high-risk patients at each level of clinical shock severity.

Combining Minimally Invasive Surgery With Ultra-Fast-Track Anesthesia in HeartMate 3 Patients: A Pilot Study

Minimally invasive surgery for left ventricular assist device implantation may have advantages over conventional sternotomy (CS). Additionally, ultra-fast-track anesthesia has been linked to better outcomes after cardiac surgery. This study summarizes our early experience of combining minimally invasive surgery with ultra-fast-track anesthesia (MIFTA) in patients receiving HeartMate 3 devices and compares the outcomes between MIFTA and CS. From October 2015 to January 2019, 18 of 49 patients with Interagency Registry for Mechanically Assisted Circulatory Support profiles >1 underwent MIFTA for HeartMate 3 implantation. For bias reduction, propensity scores were calculated and used as a covariate in a regression model to analyze outcomes. Weighted parametric survival analysis was performed. In the MIFTA group, intensive care unit stays were shorter (mean difference, 8 days [95% CI, 4-13]; P<0.001), and the incidences of pneumonia and right heart failure were lower than those in the CS group (odds ratio, 1.36 [95% CI, 1.01-1.75]; P=0.016, respectively). At 6 and 12 hours postoperatively, MIFTA patients had a better hemodynamic performance with lower pulmonary wedge pressure (mean difference, 2.23 mm Hg [95% CI, 0.41-4.06]; P=0.028) and a higher right ventricular stroke work index (mean difference, -1.49 g·m/m2 per beat [95% CI, -2.95 to -0.02]; P=0.031). CS patients had a worse right heart failure-free survival rate (hazard ratio, 2.35 [95% CI, 0.96-5.72]; P<0.01). Compared with CS, MIFTA is a beneficial approach for non-Interagency Registry for Mechanically Assisted Circulatory Support 1 HeartMate 3 patients with lower adverse event incidences, better hemodynamic performance, and preserved right heart function. Future large multicentric investigations are required to verify MIFTA's effects on outcomes.

Echocardiographic Biventricular Coupling Index to Predict Precapillary Pulmonary Hypertension

Pulmonary hypertension (PH) is a frequent and detrimental condition. Right heart catheterization (RHC) is the gold standard to identify PH subtype (pre-capillary from post-capillary PH) and is key for treatment allocation. In this study, the novel echocardiographic Biventricular Coupling Index (BCI), based on the ratio between Right Ventricular Stroke Work Index and left ventricular E/E' ratio, was tested for the discrimination of PH subtype using RHC as the comparator. BCI was derived in 334 consecutive patients who underwent transthoracic echocardiography and RHC for all indications. BCI was then tested in a validation cohort of 1349 patients. The accuracy of BCI to identify pre-capillary PH (pPH) was high in the derivation cohort (AUC 0.82, CI 0.78-0.88, p<0.001, optimal cut-point 1.9). BCI identified pPH patients with a high accuracy also in the validation cohort (AUC 0.87, 95% CI 0.85-0.89, p<0.001; subgroup with PH: AUC 0.91, 95%CI 0.89-0.93, p<0.001, cut-point 1.9, sensitivity 82%, specificity 89%, positive predictive value 77% and negative predictive value 92%). BCI outperformed both the D'Alto score (Z coefficient=3.56, difference between areas=0.05; 95%CI 0.02-0.07, p<0.001) and the echocardiographic Pulmonary to Left Atrial Ratio index (Z coefficient=2.88, difference between areas=0.02; 95%CI 0.01-0.04, p=0.004). BCI is a novel non-invasive index based on routinely available echocardiographic parameters that identifies with high accuracy patients with pPH. BCI may be of value in the screening work-up of PH.

Left ventricular myocardial work indices and invasive measurement of stroke work: a correlation study

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND A novel echocardiographic method allows to non-invasively assess myocardial work using pressure-strain loops. Even though left ventricular myocardial work has already emerged as a promising prognostic tool for various pathological conditions, its relationship with invasively-derived corresponding indices has not been assessed in humans yet. PURPOSE This study aimed to explore the correlation between left ventricular myocardial work (LVMW) indices and invasively-derived left ventricular stroke work index (LVSWI) in a cohort of patients with advanced heart failure (HF) considered for heart transplantation. METHODS All consecutive patients with advanced heart failure considered for heart transplantation from 2016 to 2021 that had already performed right heart catheterization (RHC) as part of the workup and with an available echocardiographic exam were included (n = 91). Myocardial work analysis was performed in 44 patients, according to exclusion criteria. Conventional LV functional parameters and LVMW indices, including LV global work index (LVGWI), LV global constructive work (LVGCW), LV global wasted work (LVGWW), LV global work efficiency (LVGWE) and other were calculated and compared with invasively measured LV stroke work index (LVSWI). RESULTS Median time between RHC and echocardiography was 0 months [interquartile range (IQR): 0 – 1]. Median age was 60 years (IQR: 54 – 63). For the most part, etiology of HF was non-ischemic (61.4%) and all patients were either on class NYHA II (61.4%) or III (27.3%). Median left ventricular ejection fraction was 25% (IQR: 22.3 – 32.3), median NT-proBNP 1377 pg/mL (IQR: 646 – 2570). Among conventional parameters of LV function, LV global longitudinal strain (LVGLS) significantly correlated with LVSWI (r = - 0.337; p = 0.031), whereas LVEF did not (r = 0.308; p = 0.050). With regard to LVMW indices, some of them demonstrated correlation with LVSWI, particularly LVGWI (r = 0.425; p = 0.006), LVGCW (r = 0.506; p = 0.001), LV global positive work (LVGPW; r = 0.464; p = 0.003) and LV global systolic constructive work (LVGSCW; r = 0.471; p = 0.002). CONCLUSIONS Among left ventricular myocardial work indices, LVGCW correlated better with invasively-derived stroke work, thus representing a powerful and reliable tool for a more comprehensive evaluation of myocardial function. Abstract Figure. Study flow chart Abstract Figure. Correlation results

Heart transplantation strategies in arrhythmogenic right ventricular cardiomyopathy: a tertiary ARVC centre experience.

AimsEnd‐stage heart failure necessitating evaluation for heart transplantation is increasingly recognized in arrhythmogenic right ventricular cardiomyopathy (ARVC). These patients present unique challenges in pre‐transplant and peri‐transplant management given their predominantly right ventricular (RV) failure and propensity for ventricular arrhythmias. We sought to utilize a tertiary ARVC referral and heart transplant centre experience to describe management of a series of patients with ARVC undergoing heart transplantation at our centre.Methods and resultsWe queried the Johns Hopkins ARVC Registry for all patients who underwent heart transplantation and further studied the subset undergoing transplantation at the Johns Hopkins Hospital. Patient demographics, clinical characteristics, and pre‐transplant clinical course were obtained from the registry and electronic medical records. Of the 532 patients in the ARVC Registry, 63 (12%) underwent heart transplantation. Nine (six male) of these patients both had known ARVC prior to transplant and were transplanted at Johns Hopkins Hospital between 2006 and 2020 at a mean age of 42 ± 14 years old. Pathogenic ARVC genetic variants were identified in six (67%) patients, all of whom had variants in the plakophilin‐2 (PKP2) gene. RV failure was universal with median right atrial to pulmonary capillary wedge pressure (RA/PCWP) ratio of 1.4 [interquartile range (IQR) 1.2–1.5] and median right ventricular stroke work index (RVSWI) of 0 g·m/m2/beat (IQR 0–0.3). Six had a history of catheter ablation for ventricular arrhythmia with five of the six having at least three ablations. Transplant evaluation was initiated an average of 344 ± 407 days after first developing heart failure symptoms. The most common bridge to transplant support included inotropes (n = 3) and extracorporeal membrane oxygenation (ECMO) (n = 2). Contraindication to inotropes or mechanical support was common due to ventricular arrhythmia and RV predominant cardiomyopathy.ConclusionsHeart transplantation is a curative treatment for ARVC, but due to frequent ventricular arrhythmias and RV predominant pathology, patients require unique considerations in regard to timing of evaluation, haemodynamic support options, and wait listing qualification.

297 Echocardiographic biventricular coupling index to predict pre-capillary pulmonary hypertension

Abstract Aims Pulmonary hypertension (PH) affects millions of people worldwide. Right heart catheterization (RHC) is the gold standard to correctly classify the subtype of PH. Biventricular coupling index (BCI) is a new echocardiographic index defined as the ratio between non-invasive right ventricular stroke work index (RVSWI) and E/E′ ratio. Due to his comprehensive functional characterization of the right heart physiology, we hypothesized it might correctly identify pre-capillary PH. Methods and results BCI was derived in a cohort of 334 patients from the University Hospital of Trieste (Italy) and Karolinska University Hospital (Sweden) who underwent transthoracic echocardiography and RHC for all indications (&amp;lt;6 h between the exams). The accuracy of BCI to identify pre-capillary PH was high in the derivation cohort (AUC: 0.82, P &amp;lt; 0.001, CI: 0.78–0.88). Subsequently BCI was tested in a large validation cohort of 1349 patients with available transthoracic echocardiography and RHC from the Fondazione Toscana G. Monasterio of Pisa (Italy). Among patients with PH, BCI showed a high accuracy to correctly identify pre-capillary PH (AUC = 0.91, 95% CI: 0.89–0.93, P &amp;lt; 0.001), with an optimal cut-off of 1.9 providing a sensitivity of 82% and a specificity of 89%, PPV 77%, and a NPV 92%. BCI outperformed previous indexes, such as the D’Alto score (Z coefficient 3.56, difference between areas 0.05 95% CI: 0.02–0.07, P &amp;lt; 0.001) and the echocardiographic Pulmonary to Left Atrial Ratio (ePLAR) index (Z coefficient 2.88, difference between areas 0.02 95% CI: 0.01–0.04, P &amp;lt; 0.004). Conclusions BCI is a new non-invasive index based on standard echocardiographic parameters that allows, with high accuracy, the identification of patients with pre-capillary PH, outperforming previously proposed indexes. Routine use of BCI index could be implemented in the screening work-up of pre-capillary PH.

48 Correlation of left ventricular myocardial work indices and invasive measurement of stroke work

Abstract Aims A novel echocardiographic method allows to non-invasively assess myocardial work using pressure–strain loops. Even though left ventricular myocardial work has already emerged as a promising prognostic tool for various pathological conditions, its relationship with invasively-derived corresponding indices has not been assessed in humans yet. This study aimed to explore the correlation between left ventricular myocardial work (LVMW) indices and invasively derived left ventricular stroke work index (LVSWI) in a cohort of patients with advanced heart failure (HF) considered for heart transplantation. Methods and results All consecutive patients with advanced heart failure considered for heart transplantation from 2016 to 2021 that had already performed right heart catheterization (RHC) as part of the workup and with an available echocardiographic exam were included (n = 91). Myocardial work analysis was performed in 44 patients, according to exclusion criteria. Conventional LV functional parameters and LVMW indices, including LV global work index (LVGWI), LV global constructive work (LVGCW), LV global wasted work (LVGWW), LV global work efficiency (LVGWE), and other were calculated and compared with invasively measured LV stroke work index (LVSWI). Median age was 60 years [interquartile range (IQR): 54–63]. Median time between RHC and echocardiography was 0 months (IQR: 0–1). For the most part, etiology of HF was non-ischaemic (61.4%) and all patients were either on class NYHA II (61.4%) or III (27.3%). Median left ventricular ejection fraction was 25% (IQR: 22.3–32.3), median NT-proBNP 1377 pg/ml (IQR: 646–2570). Among conventional parameters of LV function, LVEF did not significantly correlate with LVSWI (r = 0.308; P = 0.050) whereas LV global longitudinal strain (LVGLS) did (r = −0.337; P = 0.031). With regard to LVMW indices, some of them demonstrated correlation with LVSWI, particularly LVGWI (r = 0.425; P = 0.006), LVGCW (r = 0.506; P = 0.001), LV global positive work (LVGPW; r = 0.464; P = 0.003), and LV global systolic constructive work (LVGSCW; r = 0.471; P = 0.002). Conclusions Among left ventricular myocardial work indices, LVGCW correlated better with invasively derived stroke work, thus representing a powerful and reliable tool for a more comprehensive evaluation of myocardial function.

The Prognostic Utility of Invasive Right Heart Catheterization in Patients Prior to Transcatheter Aortic Valve Replacement.

Invasive right heart catheterization (RHC) provides valuable prognostic information in cases of severe aortic stenosis, but is not done routinely prior to transcatheter aortic valve replacement (TAVR). Therefore, we sought to investigate the prognostic utility of pre-TAVR RHC for assessing outcomes post TAVR. This is a single-center, retrospective study of patients who underwent RHC prior to TAVR between June 2011 and March 2019. We evaluated abnormalities in the following variables as predictors of poor outcomes post TAVR: pulmonary capillary wedge pressure (PCWP), systolic pulmonary artery pressure (PASP), mixed venous oxygen saturation (MVO2), right ventricular stroke work index (RVSWI), and right atrial pressure (RAP). Cox proportional hazard regression models were used to assess the primary composite outcome of all-cause mortality and hospitalization for heart failure. A total of 522 patients (mean age, 83.5 ± 4.5 years; 49.4% women) with complete invasive hemodynamic data were included. At a median follow-up of 529.5 days, there were 127 deaths and 59 heart failure hospitalizations. On multivariate analysis, PCWP ≥15 mm Hg (hazard ratio [HR], 1.48; 95% confidence interval [CI], 1.02-2.07), PASP ≥50 mm Hg (HR, 1.66; 95% CI, 1.17-2.36), MVO2 ≤60% (HR, 1.42; 95% CI, 1.01-1.98), RVSWI ≥12 g•m/m²/beat (HR, 1.40; 95% CI, 1.004-1.94), and RAP ≥10 mm Hg (HR, 1.66; 95% CI, 1.09-2.51) were independent predictors of death or heart failure hospitalization. Preprocedural invasive RHC provides useful prognostic information. A comprehensive invasive hemodynamic assessment should be considered for risk stratification in patients undergoing TAVR.

Effects of ischaemic postconditioning in aortic valve replacement: a multicenter randomized controlled trial.

The effect of ischaemic postconditioning (IPost) on postcardioplegic cardiac function is not known. We hypothesized that IPost was cardioprotective in adult patients undergoing elective aortic valve replacement. In a multicentre, prospective, randomized trial, patients (n = 209) were randomized to either a standard operation (controls) or postconditioning. Immediately before the cross-clamp was released, patients in the postconditioning group underwent 3 cycles of flow/non-flow (2 min each) of normothermic blood via the antegrade cardioplegia line. The primary end point was cardiac index. Secondary end points included additional haemodynamic measurements, biomarkers of cardiomyocyte injury, renal function parameters, intra- and postoperative arrhythmias and use of inotropic agents. There was no significant difference between the groups regarding cardiac index [mean between-group difference, 95% confidence interval (CI), 0.11 (-0.1 to 0.3), P = 0.27]. Postconditioning had no effect on other haemodynamic parametres. There was no between-group difference regarding troponin T or creatine kinase MB. Postconditioning reduced the relative risk for arrhythmias by 45% (P = 0.03) when postoperative atrial fibrillation and intraoperative ventricular fibrillation were combined. There were no differences in patients with/without diabetes, patients above/below 70 years of age or between the centres. However, after postconditioning, the cardiac index [95% CI, 0.46 (0.2-0.7), P = 0.001], cardiac output (P < 0.001), mean arterial pressure (P < 0.001) and left ventricular stroke work index (P < 0.001) were higher in males compared to females. IPost had no overall cardioprotective effects in patients undergoing aortic valve replacement but improved postoperative cardiac performance in men compared to women.

Abstract 12407: A Comparison of Hemodynamic and Cardiopulmonary Exercise Stress Variables for Advanced Heart Failure Prognosis

Introduction: Both invasive hemodynamics as measured by right heart catheterization (RHC) and cardiopulmonary exercise testing (CPET) are used for prognostication in advanced heart failure patients. We aimed to compare the prognostic performance of these variables in patients with advanced heart failure with a particular focus on defining the incremental prognostication of advanced hemodynamic metrics compared to CPET variables. Methods: We retrospectively analyzed patients who underwent both a RHC and CPET within one year of each other from January 2013 to January 2019 at our institution. The CPET variables of peak oxygen consumption (VO2), minute ventilation/carbon dioxide production (VE/VCO2), oxygen pulse (VO2/HR), and the RHC variables of left ventricular stroke work index (LVSWI), cardiac power output (CPO), and aortic pulsatility index (API) were used. The primary outcome was death, left ventricular assist device, or heart transplant at one year following the RHC. Results: A total of 55 patients were included in the analysis: 35% women, 51% Black, and 27% ischemic cardiomyopathy. Overall, using Spearman’s analysis, there were no significant correlations between the RHC and CPET variables. On Kaplan-Meier analysis, lower LVSWI was significantly associated with the primary outcome when compared to lower VO2/HR, HR 5.3 (95% CI 1.2-23, p = 0.02.), lower VE/VCO2, HR 3.7 (95% CI 1.3-10.4, p = 0.014), and lower peak VO2, HR 7.0 (95% CI 0.9-56, p = 0.06). Conclusion: LVSWI is more associated with one-year outcomes in patients with advanced heart failure than other prognostic hemodynamic or CPET variables. Furthermore, advanced hemodynamic metrics are more prognostic than CPET measurements when these values are discordant.

Implantation of ventricular assist devices in hypertrophic cardiomyopathy with left ventricular systolic dysfunction.

AimsThe outcomes of patients with hypertrophic cardiomyopathy with left ventricular systolic dysfunction (HCM‐LVSD) undergoing left ventricular assist device (LVAD) implantation remain unclear. We retrospectively evaluated the clinical impact of LVAD implantation on clinical outcomes, including haemodynamics and brain natriuretic peptide (BNP) levels, in patients with HCM‐LVSD, in comparison with those with dilated cardiomyopathy (DCM).Methods and resultsIn this retrospective, single‐centre, observational study conducted in Japan, the medical records of patients who underwent LVAD implantation in the National Cerebral and Cardiovascular Center between 2011 and 2020 were reviewed. We enrolled 96 patients with DCM (average age: 43.5 years; 73 men) and 24 patients with HCM‐LVSD (average age: 48.3 years; 16 men). The HCM‐LVSD group had smaller left ventricles with thicker ventricular walls than the DCM group, which became more prominent after LVAD implantation. Preoperatively, BNP values were comparable between both groups; however, 3 months post‐implantation, they were significantly higher in the HCM‐LVSD group. Pulmonary artery pulsatility index, right ventricular stroke work index, and cardiac index were lower, and right atrial pressure was higher, in the HCM‐LVSD group, suggesting subclinical impairment of right ventricular function. The HCM‐LVSD group demonstrated equivalent outcomes, including overall survival, cerebrovascular accidents, right ventricular failure, LVAD‐related infections, arrhythmia, and aortic insufficiency, post‐implantation.ConclusionsDespite a decreased right ventricular function with higher BNP values, patients with HCM‐LVSD and DCM showed comparable outcomes post‐LVAD implantation.

Right Ventricular Dysfunction Is Common and Identifies Patients at Risk of Dying in Cardiogenic Shock

BackgroundUnderstanding the prognostic impact of right ventricular dysfunction (RVD) in cardiogenic shock (CS) is a key step toward rational diagnostic and treatment algorithms and improved outcomes. Using a large multicenter registry, we assessed (1) the association between hemodynamic markers of RVD and in-hospital mortality, (2) the predictive value of invasive hemodynamic assessment incorporating RV evaluation, and (3) the impact of RVD severity on survival in CS. Methods and ResultsInpatients with CS owing to acute myocardial infarction (AMI) or heart failure (HF) between 2016 and 2019 were included. RV parameters (right atrial pressure, right atrial/pulmonary capillary wedge pressure [RA/PCWP], pulmonary artery pulsatility index [PAPI], and right ventricular stroke work index [RVSWI]) were assessed between survivors and nonsurvivors, and between etiology and SCAI stage subcohorts. Multivariable logistic regression analysis determined hemodynamic predictors of in-hospital mortality; the resulting models were compared with SCAI staging alone. Nonsurvivors had a significantly higher right atrial pressure and RA/PCWP and lower PAPI and RVSWI than survivors, consistent with more severe RVD. Compared with AMI, patients with HF had a significantly lower RA/PCWP (0.58 vs 0.66, P = .001) and a higher PAPI (2.71 vs 1.78, P < .001) and RVSWI (5.70 g-m/m2 vs 4.66 g-m/m2, P < .001), reflecting relatively preserved RV function. Paradoxically, multiple RVD parameters (PAPI, RVSWI) were associated with mortality in the HF but not the AMI cohort. RVD was more severe with advanced SCAI stage, although its prognostic value was progressively diluted in stages D and E. Multivariable modelling incorporating the RA/PCWP improved the predictive value of SCAI staging (area under the curve [AUC] 0.78 vs 0.73, P < .001), largely driven by patients with HF (AUC 0.82 vs 0.71, P < .001). ConclusionsRVD is associated with poor outcomes in CS, with key differences across etiology and shock severity. Further studies are needed to assess the usefulness of RVD assessment in guiding therapy.

The Prognostic Role of Right Ventricular Stroke Work Index during Liver Transplantation.

Right heart-associated hemodynamic parameters including intraoperative pulmonary vascular resistance (PVR) were reported to be associated with patient survival after liver transplantation. We investigated whether intraoperative stroke work indexes of both ventricles could have a better prognostic value than PVR. We reviewed 683 cases at a tertiary care academic medical center. We collected intraoperative variables of baseline central venous pressure, baseline right ventricle end-diastolic volume, mixed venous oxygen saturation, intraoperative PVR and right and left ventricular stroke work indexes. Time-weighted means or area under the curve of intraoperative right and left ventricular stroke work indexes were calculated as exposure variables. One-year all-cause mortality or graft failure was our primary outcome. Cox proportional hazard regression analysis was performed to evaluate the association between exposure variables and one-year all-cause mortality or graft failure. Kaplan–Meier survival curve analysis of our primary outcome was performed for different time-weighted mean ventricular stroke work index groups. Cubic spline curve analysis was performed to evaluate the linear relationship between our exposure variables and primary outcome. Time-weighted mean right ventricular stroke work index was significantly associated with one-year all-cause mortality or graft failure (hazard ratio 1.21, 95% confidence interval (CI) 1.12–1.36, p < 0.001). However, there was no significant association between time-weighted mean left ventricular stroke work index, time-weighted mean PVR, PVR at the end of surgery and one-year mortality. Area under the curve of right ventricular stroke work index was also significantly associated with one-year mortality or graft failure (hazard ratio 1.24, 95% CI 1.15–1.37, p < 0.001). Kaplan–Meier survival curve analysis showed a significant difference in the survival between different mean right ventricular stroke work index groups (Log-rank test: p = 0.002). Cubic spline function curve showed the gradual increase in the risk of mortality with a positive slope with time-weighted mean right ventricular stroke work index. In conclusion, intraoperative elevated right ventricular stroke work index was significantly associated with poor patient or graft survival after liver transplantation. Intraoperative right ventricular stroke work index could be an intraoperative hemodynamic goal and prognostic marker for mortality after liver transplantation.