Differentiating pre-capillary and post-capillary pulmonary hypertension by Doppler echocardiography in a large realworld database

Background: Pulmonary hypertension (PH) is common, dangerous and has multiple causes. Vasodilator therapy has significantly improved the prognosis of patients with pulmonary arterial hypertension (PAH), but the diagnosis can be challenging, requiring right heart catheterisation (RHC). Differentiating pre-capillary PH (prePH) and postcapillary PH (postPH) and measuring pulmonary vascular resistance (PVR) are key steps for diagnosing PAH. A novel echocardiographic parameter, the pulmonary to left atrial ratio (ePLAR), which is derived from the tricuspid regurgitation velocity (TRV) divided by the ratio between the early diastolic filling velocity and the early mitral annulus velocity (E/e’), i.e., ePLAR=TRV/E/e’, has been described as a surrogate for RHC. This retrospective cohort study tests the ability of ePLAR to differentiate prePH and postPH, in a large real world database. Methods: The data from all RHC performed within a 5-year period (January 2010 to February 2015) were extracted from the hospital database. The closest corresponding echocardiograms (echos) were searched in the national echo database Australia (NEDA) using the identifiers from RHC data. The performance of ePLAR in differentiating two PH physiologies was compared against the gold standard RHC using various statistical methods. Results: 887 pairs of echos and RHCs were merged and analysed in our study. The median time difference between RHC and echocardiography was 7 (IQR 1-62) days. The ePLAR was calculable in 184 cases (21%). Median (IQR) ePLAR values were significantly different between prePH and postPH groups: 0.35 (0.13-0.50) m/s vs 0.17 (0.12-0.23) m/s (P=0.003), despite both groups having similar mean pulmonary artery pressures. The optimal ePLAR cut-off of 0.28m/s had a positive predictive value of 94% for postPH, with sensitivity of 83% and specificity of 67%. Conclusions: ePLAR helps to discriminate postPH from prePH and may be useful in evaluating these patients

Applications of minimally invasive cardiac output monitors

Because of the increasing age of the population, critical care and emergency medicine physicians have seen an increased number of critically ill patients over the last decade. Moreover, the trend of hospital closures in the United States t imposes a burden of increased efficiency. Hence, the identification of devices that facilitate accurate but rapid assessments of hemodynamic parameters without the added burden of invasiveness becomes tantamount. The purpose of this review is to understand the applications and limitations of these new technologies

Assessment of RV stiffness and relaxation

Right ventricle (RV) has frequently been described as the forgotten ventricle in the circulation. However, its importance in various cardiac diseases is now unquestioned. This recognition has led to improved risk stratification and development of algorithms for intervention, which incorporate measurements of RV function as key components of the assessment of many conditions. The diastolic function plays an important role in determining ventricular filling and stroke volume. Abnormal left ventricular (LV) diastolic function has been recognized in many cardiovascular diseases and is associated with worse outcomes, including total mortality and hospitalizations due to heart failure. In this review, we define what global RV diastolic function is, and how to measure it. This article indicates the validation of kinematic model parameters for assessing RV diastolic function

Contribution of Ventricular Diastolic Dysfunction to Pulmonary Hypertension Complicating Chronic Systolic Heart Failure

ObjectivesThe aim of the study is to clarify the clinical role of Doppler-echocardiographic parameters of left ventricular diastolic dysfunction (LVDD) as determinants of pulmonary hypertension in patients experiencing left ventricular systolic dysfunction (LVSD) with and without the presence of functional mitral valve regurgitation (FMR).BackgroundPulmonary hypertension (pulmonary venous or mixed pulmonary venous-arterial hypertension) complicating LVSD is associated with poor outcomes beyond that of LVSD alone. The view of the contribution of LVDD as a determinant of pulmonary hypertension is controversial and not well defined as a tool in clinical practice.MethodsData from patients with LVEF ≤40% undergoing Doppler-echocardiography evaluations during the period from August 2001 to December 2004 were analyzed. Pulmonary systolic pressure (PSP), parameters of diastolic function (mitral valve [MV] transmitral flow velocity [E]/mitral annular diastolic velocity [e′] ratio, MV deceleration time [DT]), quantitated effective regurgitant orifice area (EROA) of FMR, and clinical characteristics were evaluated. Pulmonary hypertension was defined as an estimated PSP ≥45 mm Hg.ResultsCriteria were met in 1,541 patients; one-third (n = 533) demonstrating PSP ≥45 mm Hg (58 ± 10 mm Hg, range 45 to 102 mm Hg). Patients with pulmonary hypertension were older with higher E/e′ ratio, EROA, and lower DT and LVEF. In multivariate analysis, pulmonary hypertension was independently predicted not only by severity of FMR (EROA ≥20 mm2, odds ratio: 3.8, p < 0.001) but also by parameters of LVDD (E/e′ ratio ≥15, odds ratio: 3.31, p < 0.001; DT ≤150 ms, odds ratio: 3.8, p < 0.001). Receiver-operating characteristics curve analysis showed that EROA, E/e′ ratio, and DT provided significant incremental value in predicting pulmonary hypertension (c-statistic 0.830, p < 0.001).ConclusionsPatients with LVSD commonly have secondary pulmonary hypertension, which is largely determined by the severity of LVDD even with adjustment for FMR and low LVEF. Thus, measures of LVDD in routine clinical practice where PSP may not be estimated are important physiologic descriptors of hemodynamic status and are cumulatively linked in the prediction of pulmonary hypertension

Accuracy of invasive arterial pressure monitoring in cardiovascular patients: An observational study

INTRODUCTION: Critically ill patients and patients undergoing high-risk and major surgery, are instrumented with intra-arterial catheters and invasive blood pressure is considered the “gold standard” for arterial pressure monitoring. Nonetheless, artifacts due to inappropriate dynamic response of the fluid-filled monitoring systems may lead to clinically relevant differences between actual and displayed pressure values. We sought to analyze the incidence and causes of resonance/underdamping phenomena in patients undergoing major vascular and cardiac surgery. METHODS: Arterial pressures were measured invasively and, according to the fast-flush Gardner’s test, each patient was attributed to one of two groups depending on the presence (R-group) or absence (NR-group) of resonance/underdamping. Invasive pressure values were then compared with the non-invasive ones. RESULTS: A total of 11,610 pulses and 1,200 non-invasive blood pressure measurements were analyzed in 300 patients. Ninety-two out of 300 (30.7%) underdamping/resonance arterial signals were found. In these cases (R-group) systolic invasive blood pressure (IBP) average overestimation of non-invasive blood pressure (NIBP) was 28.5 (15.9) mmHg (P <0.0001) while in the NR-group the overestimation was 4.1(5.3) mmHg (P <0.0001). The mean IBP-NIBP difference in diastolic pressure in the R-group was −2.2 (10.6) mmHg and, in the NR-group −1.1 (5.8) mmHg. The mean arterial pressure difference was 7.4 (11.2) mmHg in the R-group and 2.3 (6.4) mmHg in the NR-group. A multivariate logistic regression identified five parameters independently associated with underdamping/resonance: polydistrectual arteriopathy (P =0.0023; OR = 2.82), history of arterial hypertension (P =0.0214; OR = 2.09), chronic obstructive pulmonary disease (P =0.198; OR = 2.61), arterial catheter diameter (20 vs. 18 gauge) (P <0.0001; OR = 0.35) and sedation (P =0.0131; OR = 0.5). The ROC curve for the maximal pressure–time ratio, showed an optimum selected cut-off point of 1.67 mmHg/msec with a specificity of 97% (95% CI: 95.13 to 99.47%) and a sensitivity of 77% (95% CI: 67.25 to 85.28%) and an area under the ROC curve by extended trapezoidal rule of 0.88. CONCLUSION: Physicians should be aware of the possibility that IBP can be inaccurate in a consistent number of patients due to underdamping/resonance phenomena. NIBP measurement may help to confirm/exclude the presence of this artifact avoiding inappropriate treatments

Cardiopulmonary Predicators of Dysfunctional Ventilator Weaning Response after Coronary Artery Bypass Graft

Although the majority of coronary artery bypass graft (CABG) surgery patients are extubated within 6 to 8 hours following surgery, 20% to 40% of patients remain intubated 12 hours after surgery due to dysfunctional ventilator weaning response (DVWR). DVWR associated with increased morbidity and mortality (30% to 43%) following CABG surgery. Finding significant antecedence to predict DVWR could help to identify and prevent the complications from DVWR after CABG surgery. Literature review revealed that there is an association between cardiopulmonary indicators (CPI) and DVWR after CABG surgery. Cardiopulmonary indicators are the selected hemodynamic parameters that have an association with DVWR. The association of CPI with DVWR may be used to predict DVWR. Therefore, this study set out to find a predictive model for DVWR using CPI and significant antecedence. The purposes of this research study were to describe the characteristics of CPI among patients with normal ventilator weaning response (NVWR) and dysfunctional ventilator weaning response (DVWR) after coronary artery bypass graft (CABG) surgery, to find the differences in characteristics of cardiopulmonary indicators between patients with NVWR and DVWR after CABG surgery, and to build a prediction model for DVWR with significant antecedence. A retrospective case control study with time series design was utilized. An inclusion criteria guided purposive sampling technique was used to recruit 300 subjects from a retrospective audit of electronic medical records of patients who underwent CABG surgery between May 2003 and February 2006. Among the 300 subjects, 100 subjects constituted the case group and 200 constituted the control group. This study utilized descriptive and inferential statistical analysis, which was performed through SAS programs including PROC UNIVARIATE, PROC FREQ, PROC GLM, PROC REG, PROC MIXED REPEATED MEASURE ANOVA, and PROC LOGISTIC. The study included such demographic variables as age and sex and clinical variables COPD, CHF, renal failure, number of grafts, and BSA, which were used for the description of the study sample as well as included in the analysis as covariates. The outcome variables of this study were DVWR and NVWR. The independent variable of the study was CPI, which included heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP), cardiac output (CO), respiratory rate (RR), mixed venous oxygen saturation (SVO2), oxygen saturation (SPO2), pulmonary artery diastolic pressure (PAD) and pulmonary artery systolic pressure (PASP). An hourly time series measurement of selected CPI for 12 consecutive hours after CABG surgery was used to predict DVWR. Findings revealed that several antecedence including COPD, CHF, MAP, RR, CO, PAD, and PASP were significantly associated with DVWR. In addition, findings revealed that the odds in favor of DVWR for patients with COPD were 5.466 times higher as compared to patients without COPD, holding all other variables constant. The odds in favor of DVWR for patients with CHF were 3.930 times higher than for patients without CHF, holding all other variables constant. The odds in favor of DVWR for patients with decrease 10mm/Hg mean MAP were 1.915 times the probability of NVWR, holding all other variables constant. This implies that hypotension increases risk of developing DVWR after CABG surgery. The odds in favor of DVWR for patients with decrease 5 points of mean RR were 2.978 times the probability of NVWR, holding all other variables constant. This implies that patients with lower RR are at risk of developing DVWR after CABG surgery. The odds in favor of DVWR for patients with decrease in mean CO by 2 points were 1.943 times the probability of NVWR, holding all other variables constant. This implies that patients with low CO are at the risk of developing DVWR after CABG surgery. The odds in favor of DVWR for patients with increase in mean PAD by 5mm/hg were 3.640 times the probability of NVWR, holding all other variables constant. This implies that patients with high PAD pressure are at risk of developing DVWR after CABG surgery. The odds in favor of DVWR for patients with decrease in mean PASP by 10mm/hg were 3.053 times the probability of NVWR, holding all other variables constant. This implies that the patients with low PASP are at risk of developing DVWR after CABG surgery. In conclusion, the results of this study revealed significant antecedence to predict DVWR after CABG surgery, including COPD, CHF, MAP, RR, CO, PAD, and PASP. Therefore, this study concluded that the above-mentioned significant antecedence may be used to predict DVWR after CABG surgery in critical care. The implications from the conclusion are that the weaning protocols after CABG surgery may be tailored using these significant predictors. In addition, the study findings imply that patients with a history of COPD and CHF have significant risk of developing DVWR after CABG surgery. Therefore, this researcher recommends that weaning criteria be developed considering the above risk factors for high risk patients

Predictors of Increased Left Ventricular Filling Pressure in Dialysis Patients with Preserved Left Ventricular Ejection Fraction

Aim To study the left and right ventricular function and to assess the predictors of increased left ventricular (LV) filling pressure in dialysis patients with preserved LV ejection fraction. Methods This study included 63 consecutive patients (age 57 ± 14 years, 57% women) with end-stage renal failure. Echocardiography, including tissue Doppler measurements, was performed in all patients. Based on the median value of the ratio of transmitral early diastolic velocity to early myocardial velocity (E/E’ ratio), patients were divided into 2 groups: the group with high filling pressure (E/E’>10.16) and the group with low filling pressure (E/ E’≤10.16). Results Compared with patients with low filling pressure, the group of patients with high filling pressure included a higher proportion of diabetic patients (41% vs 13%, P = 0.022) and had greater LV mass index (211 ± 77 vs 172 ± 71 g/m3, P = 0.04), lower LV lateral long axis amplitude (1.4 ± 0.3 vs 1.6 ± 0.3 cm, P = 0.01), lower E wave (84 ± 19 vs 64 ± 18cm/s, P < 0.001), lower systolic myocardial velocity (S’: 8.6 ± 1. 5 vs 7.0 ± 1.3 cm/s, P < 0.001), and lower diastolic myocardial velocities (E’: 6.3 ± 1.9 vs 9.5 ± 2.9 cm/s, P < 0.001; A’: 8.4 ± 1.9 vs 9.7 ± 2.5 cm/s, P = 0.018). Multivariate analysis identified LV systolic myocardial velocity – S’ wave (adjusted odds ratio, 1.909; 95% confidence interval, 1.060-3.439; P = 0.031) and age (1.053; 1.001-1.108; P = 0.048) as the only independent predictors of high LV filling pressure in dialysis patients. Conclusions In dialysis patients with preserved left ventricular ejection fraction, reduced systolic myocardial velocity and elderly age are independent predictors of increased left ventricular filling pressure

Exercise pulmonary hypertension in asymptomatic degenerative mitral regurgitation

BACKGROUND: Current guidelines recommend mitral valve surgery for asymptomatic patients with severe degenerative mitral regurgitation and preserved left ventricular systolic function when exercise pulmonary hypertension (PHT) is present. However, the determinants of exercise PHT have not been evaluated. The aim of this study was to identify the echocardiographic predictors of exercise PHT and the impact on symptoms. METHODS AND RESULTS: Comprehensive resting and exercise transthoracic echocardiography was performed in 78 consecutive patients (age, 61+/-13 years; 56% men) with at least moderate degenerative mitral regurgitation (effective regurgitant orifice area =43+/-20 mm(2); regurgitant volume =71+/-27 mL). Exercise PHT was defined as a systolic pulmonary arterial pressure (SPAP) >60 mm Hg. Exercise PHT was present in 46% patients. In multivariable analysis, exercise effective regurgitant orifice was an independent determinant of exercise SPAP (P56 mm Hg) was more accurate than resting PHT (SPAP >36 mm Hg) in predicting the occurrence of symptoms during follow-up (P=0.032). CONCLUSIONS: Exercise PHT is frequent in patients with asymptomatic degenerative mitral regurgitation. Exercise mitral regurgitation severity is a strong independent predictor of both exercise SPAP and exercise PHT. Exercise PHT is associated with markedly low 2-year symptom-free survival, emphasizing the use of exercise echocardiography. An exercise SPAP >56 mm Hg accurately predicts the occurrence of symptoms.Peer reviewe

Left ventricular diastolic function in relation to the urinary proteome: a proof-of-concept study in a general population

Background: In previous studies, we identified two urinary proteomic classifiers, termed HF1 and HF2, which discriminated subclinical diastolic left ventricular (LV) dysfunction from normal. HF1 and HF2 combine information from 85 and 671 urinary peptides, mainly up- or down-regulated collagen fragments. We sought to validate these classifiers in a population study. Methods: In 745 people randomly recruited from a Flemish population (49.8 years; 51.3% women), we measured early and late diastolic peak velocities of mitral inflow (E and A) and mitral annular velocities (e' and a') by conventional and tissue Doppler echocardiography, and the urinary proteome by capillary electrophoresis coupled with mass spectrometry. Results: In the analyses adjusted for sex, age, body mass index, blood pressure, heart rate, LV mass index and intake of medications, we expressed effect sizes per 1-SD increment in the classifiers. HF1 was associated with 0.204 cm/s lower e' peak velocity (95% confidence interval, 0.057–0.351; p = 0.007) and 0.145 higher E/e' ratio (0.023–0.268; p = 0.020), while HF2 was associated with a 0.174 higher E/e' ratio (0.046–0.302; p = 0.008). According to published definitions, 67 (9.0%) participants had impaired LV relaxation and 96 (12.9%) had elevated LV filling pressure. The odds of impaired relaxation associated with HF1 was 1.38 (1.01–1.88; p = 0.043) and that of increased LV filling pressure associated with HF2 was 1.38 (1.00–1.90; p = 0.052). Conclusions: In a general population, the urinary proteome correlated with diastolic LV dysfunction, proving its utility for early diagnosis of this condition

Three-dimensional echocardiography and 2D-3D speckle tracking imaging in chronic pulmonary hypertension. diagnostic accuracy in detecting hemodynamic signs of RV failure

Background and objective. Our aim was to compare three-dimensional (3D) and 2D and 3D speckle tracking (2D-STE, 3D-STE) echocardiographic parameters with conventional right ventricular (RV) indexes in patients with chronic pulmonary hypertension (PH), and investigate whether these techniques could result in better correlation with hemodynamic variables indicative of heart failure. Methods. Seventy-three adult patients (mean age, 53±13 years; 44% male) with chronic PH of different etiologies were studied by echocardiography and cardiac catheterization (25 precapillary PH from pulmonary arterial hypertension, 23 obstructive pulmonary heart disease, and 23 postcapillary PH from mitral regurgitation). Thirty healthy subjects (mean age, 54±15 years; 43% male) served as controls. Standard 2D measurements (RV-FAC -fractional area change-, TAPSE -tricuspid annular plane systolic excursion-) and mitral and tricuspid tissue Doppler annular velocities were obtained. RV 3D volumes, and global and regional ejection fraction (3D-RVEF) were determined. RV strains were calculated by 2D-STE and 3D-STE. Results. RV 3D global-free-wall longitudinal strain (3DGFW-RVLS), 2D global-free-wall longitudinal strain (GFW-RVLS), apical-free-wall longitudinal strain (AFW-RVLS), basal-free-wall longitudinal strain (BFW-RVLS), and 3D-RVEF were lower in patients with pre-capillary PH (p<0.0001) and post-capillary PH (p<0.01) compared to controls. 3DGFW-RVLS (HR 4.6, 95% CI 2.79-8.38, p=0.004) and 3D-RVEF (HR 5.3, 95% CI 2.85-9.89, p=0.002) were independent predictors of mortality. ROC curves showed that the thresholds offering an adequate compromise between sensitivity and specificity for detecting hemodynamic signs of RV failure were 39% for 3D-RVEF (AUC 0.89), -17% for 3DGFW-RVLS (AUC 0.88), -18% for GFW-RVLS (AUC 0.88), -16% for AFW-RVLS (AUC 0.85), 16mm for TAPSE (AUC 0.67), and 38% for RV-FAC (AUC 0.62). Conclusions. In chronic PH, 3D, 2D-STE and 3D-STE parameters indicate global and regional RV dysfunction that is associated with RV failure hemodynamics better than conventional echo indices