Non-invasive measurement of right atrial pressure by near-infrared spectroscopy: preliminary experience. A report from the SICA-HF study

To assess the clinical value of measuring right atrial pressure (RAP) using near-infrared spectroscopy (NIRS) in patients with chronic heart failure (CHF). Methods and results RAP was measured non-invasively using NIRS over the external jugular vein (Venus 1000, Mespere LifeSciences, Canada) in ambulatory patients with CHF enrolled in the Studies Investigating Co-morbidities Aggravating Heart Failure (SICA-HF) programme. Comparing 243 patients with CHF (mean age 71 years; mean left ventricular ejection fraction (LVEF) 45%, median NT-proBNP 788 ng/L) to 49 controls (NT-proBNP ≤125 ng/L), RAP was 7 [interquartile range (IQR) 4–11] mmHg vs. 4 (IQR 3–8) mmHg (P < 0.001). Those with RAP ≥10 mmHg (n = 75) were older, had more severe clinical congestion and renal dysfunction, higher plasma NT-proBNP, larger left atrial volume, higher systolic pulmonary pressure and were more often in atrial fibrillation but their LVEF was similar to patients with lower RAP. During a median follow-up of 595 (IQR: 492–714) days, 49 patients (20%) died or were hospitalized for worsening CHF. Compared with patients with RAP ≤5 mmHg, those with RAP ≥10 mmHg had a greater risk of an event (hazard ratio 2.38, 95% confidence interval 1.19–4.75, P = 0.014). RAP measured by NIRS predicted outcome, competing with NT-proBNP in multivariable models. Conclusions Measuring RAP using NIRS identifies ambulatory patients with CHF who have more severe congestion and a worse outcome. The device might be a useful objective method of monitoring RAP, especially for those inexperienced in eliciting physical signs or when measurement of natriuretic peptides is not immediately available

Optical bonding agents for severe environments

Test results and applications of elastors (General Electric RTV 665, Dow Corning (DC) XR-63-488, DC 93-500, DC 182, and DC 184) considered for use as optical bonding agents in aerospace environments are presented

Newer imaging modalities to identify high-risk ambulatory patients with heart failure

The lack of widely accepted objective measures of cardiac dysfunction other than left ventricular ejection fraction (LVEF) has hampered, and continues to hamper, clinical research in patients with heart failure (HF). Identifying patients at higher risk of adverse outcome would allow better targeting of therapy to those with most to gain.The thesis is divided in three parts.In the first part, I report the results of studies of the association between echocardiographic measures of right atrial pressure (by measuring the inferior vena cava (IVC) diameter) and outcome in ambulatory patients with HF. I also studied the associations with prognosis of a newer echocardiographic method (global longitudinal strain, GLS) to assess left ventricular systolic function in patients with normal LVEF on conventional imaging. In the second part, I report the results of studies of the associations of left atrial function by cardiac magnetic resonance (cMRI) with outcome in ambulatory patients with HF. I also studied the relationship between QRS morphology on ECG with cardiac structure and function measured by cMRI in ambulatory patients with HF.In the third part, I report the results of developing and prospectively evaluating an ultrasound method to measure the internal jugular vein diameter (as an objective estimate of the right atrial pressure) and its changes with respiratory manoeuvres.I studied the association between the jugular vein diameter, clinical and echocardiographic variables, and its relations with outcome in ambulatory patients with HF and controls.My results showed that upstream consequences of a dysfunctional left ventricle, such as impaired left atrial function measured by cMRI, a distended IVC or internal jugular vein by ultrasound, provide powerful prognostic information, similar to that obtained by measuring N-terminal pro-B-type natriuretic peptide plasma levels, in individuals with HF regardless of whether they have a reduced or normal LVEF.As residual congestion (dilated IVC or jugular vein) and impaired left atrial function appear strongly related to an adverse outcome, tailoring treatment to minimise congestion or improving left atrial function is an attractive concept worth testing.Published articles:1) Pellicori P, Carubelli V, Zhang J, Castiello T, Sherwi N, Clark AL, Cleland JG. IVC diameter in patients with chronic heart failure: relationships and prognostic significance. JACC Cardiovasc Imaging. 2013;6:16-28.http://doi.org/10.1016/j.jcmg.2012.08.012http://www.sciencedirect.com/science/article/pii/S1936878X120087902) Pellicori P, Kallvikbacka-Bennett A, Khaleva O, Carubelli V, Costanzo P, Castiello T, Wong K, Zhang J, Cleland JG, Clark AL. Global longitudinal strain in patients with suspected heart failure and a normal ejection fraction: does it improve diagnosis and risk stratification? Int J Cardiovasc Imaging. 2014;30:69-79.http://doi.org/10.1007/s10554-013-0310-yhttps://link.springer.com/article/10.1007/s10554-013-0310-y3) Pellicori P, Zhang J, Lukaschuk E, Joseph AC, Bourantas CV, Loh H, Bragadeesh T, Clark AL, Cleland JG. Left atrial function measured by cardiac magnetic resonance imaging in patients with heart failure: clinical associations and prognostic value. Eur Heart J. 2015;36:733-42.https://doi.org/10.1093/eurheartj/ehu405https://academic.oup.com/eurheartj/article/36/12/733/2293211/Left-atrial-function-measured-by-cardiac-magnetic?searchresult=14) Pellicori P, Joseph AC, Zhang J, Lukaschuk E, Sherwi N, Bourantas CV, Loh H, Clark AL, Cleland JG. The relationship of QRS morphology with cardiac structure and function in patients with heart failure. Clin Res Cardiol. 2015;104:935-45.http://doi.org/10.1007/s00392-015-0861-0https://link.springer.com/article/10.1007/s00392-015-0861-05) Pellicori P, Kallvikbacka-Bennett A, Zhang J, Khaleva O, Warden J, Clark AL, Cleland JG. Revisiting a classical clinical sign: jugular venous ultrasound. Int J Cardiol. 2014;170:364-70.http://doi.org/10.1016/j.ijcard.2013.11.015http://www.sciencedirect.com/science/article/pii/S01675273130198766) Pellicori P, Kallvikbacka-Bennett A, Dierckx R, Zhang J, Putzu P, Cuthbert J, Boyalla V, Shoaib A, Clark AL, Cleland JG. Prognostic significance of ultrasound-assessed jugular vein distensibility in heart failure. Heart. 2015;101:1149-58.http://dx.doi.org/10.1136/heartjnl-2015-307558http://heart.bmj.com/content/101/14/114

Interatrial shunt devices for heart failure with normal ejection fraction: a technology update

Heart failure with normal ejection fraction (HeFNEF) accounts for ~50% of heart failure admissions. Its pathophysiology and diagnostic criteria are yet to be defined clearly which may hinder the search for effective treatments. The clinical hallmark of HeFNEF is exertional breathlessness, often due to an abnormal increase in left atrial pressure during exercise. Creation of an interatrial communication to offload the left atrium is a possible therapeutic approach. There are two percutaneously delivered devices currently under investigation which are discussed in this review

Terapia diuretica nell’insufficienza cardiaca cronica: evidenze, esperienze, prospettive = Diuretic treatment in patients with chronic heart failure: evidences, experiences, and current perspectives

Congestion is a fundamental clinical sign in patients with chronic heart failure (CHF). Diuretics are the mainstay treatment for congestion but, so far, no randomized trial has ever shown any beneficial effect of diuretics on mortality in patients with CHF. It is also unclear how and when diuretics should be up, or down titrated, or when their use can be safely stopped. In this review, we discuss current evidence regarding the clinical use of diuretics. We also highlight the need for more clinical trials to explore the short- and long-term safety, efficacy and clinical benefits of different classes of diuretics, used alone or in combination, in patients with CHF

New ways to visualize and combat congestion in heart failure = Nuevos modos de visualizar y combatir la congestión en la insuficiencia cardiaca

No abstract available

Myocardial dysfunction and coronary artery disease as therapeutic targets in heart failure

No abstract available

Structural heart disease, cardiac dysfunction and heart failure: the ambiguity of a definition

No abstract available

The effects of short-term omission of daily medication on the pathophysiology of heart failure

Aims Pharmacological therapies for heart failure (HF) aim to improve congestion, symptoms, and prognosis. Failing to take medication is a potential cause of worsening HF. Characterizing the effects of short-term medication omission could inform the development of better technologies and strategies to detect and interpret the reasons for worsening HF. We examined the effect of planned HF medication omission for 48 h on weight, echocardiograms, transthoracic bio-impedance, and plasma concentrations of NT-proBNP. Methods and results Outpatients with stable HF and an LVEF &lt;45% were assigned to take or omit their HF medication for 48 h in a randomized, crossover trial. Twenty patients (16 men, LVEF 32 ± 9%, median NT-proBNP 962 ng/L) were included. Compared with regular medication, omission led to an increase in NT-proBNP by 99% (from 962 to 1883 ng/L, P &lt; 0.001), systolic blood pressure by 16% (from 131 to 152 mmHg, P &lt; 0.001), and left atrial volume by 21% (from 69 to 80 mL, P = 0.001), and reductions in transthoracic bio-impedance by 10% (from 33 to 30 Σ, P = 0.001) and serum creatinine by 8% (from 135 to 118 µmol/L, P = 0.012). No significant changes in body weight, heart rate, or LVEF were observed. Conclusions The characteristic pattern of response to short-term medication omission is of increasing congestion but, in contrast to the pattern reported for disease progression, with a rise in blood pressure and improved renal function. In stable HF, weight is not a sensitive marker of short-term diuretic omission

Clinical and prognostic relationships of pulmonary artery to aorta diameter ratio in patients with heart failure: a cardiac magnetic resonance imaging study

Background: The pulmonary artery (PA) distends as pressure increases. Hypothesis: The ratio of PA to aortic (Ao) diameter may be an indicator of pulmonary hypertension and consequently carry prognostic information in patients with chronic heart failure (HF). Methods: Patients with chronic HF and control subjects undergoing cardiac magnetic resonance imaging were evaluated. The main PA diameter and the transverse axial Ao diameter at the level of bifurcation of the main PA were measured. The maximum diameter of both vessels was measured throughout the cardiac cycle and the PA/Ao ratio was calculated. Results: A total of 384 patients (mean age, 69 years; mean left ventricular ejection fraction, 40%; median NT-proBNP, 1010 ng/L [interquartile range, 448–2262 ng/L]) and 38 controls were included. Controls and patients with chronic HF had similar maximum Ao and PA diameters and PA/Ao ratio. During a median follow-up of 1759 days (interquartile range, 998–2269 days), 181 patients with HF were hospitalized for HF or died. Neither PA diameter nor PA/Ao ratio predicted outcome in univariable analysis. In a multivariable model, only age and NT-proBNP were independent predictors of adverse events. Conclusions: The PA/Ao ratio is not a useful method to stratify prognosis in patients with HF