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Kalapurakal G, Chau VQ, Imamura T, Tolia S, Sciamanna C, Macaluso GP, Joshi A, Pillarella J, Pauwaa S, Dia M, Kabbany T, Monaco J, Dela Cruz M, Cotts WG, Pappas P, Tatooles AJ, Narang N. Haemodynamic effects of intra-aortic balloon pumps stratified by baseline pulmonary artery pulsatility index. ESC Heart Fail 2024. [PMID: 39294848 DOI: 10.1002/ehf2.15083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 08/26/2024] [Accepted: 09/04/2024] [Indexed: 09/21/2024] Open
Abstract
AIMS Intra-aortic balloon pump (IABP) devices are commonly used in patients with heart failure related cardiogenic shock (HF-CS), including those with out-of-proportion right ventricular (RV) dysfunction. Pulmonary artery pulsatility index (PAPi) is a haemodynamic surrogate for RV performance. We aimed to assess short-term haemodynamic changes in patients with HF-CS following IABP support stratified by baseline PAPi. METHODS AND RESULTS This is a single-centre study of 67 consecutive patients with HF-CS who underwent IABP placement between 2020 and 2022. The primary aim was haemodynamic changes of specific variables on pulmonary artery catheter monitoring over 72 h following IABP placement. Secondary aims were clinically significant changes in diuretic regimens, changes in inotropes or vasopressors at 72 h following IABP, along with clinical outcomes. Prior to IABP placement, 57% of the total cohort (median age 59 years [48, 69], 31% female) had Society of Cardiovascular Angiography and Interventions Stage C HF-CS. Thirty-eight (56%) patients had a PAPi <2.0. Following 72 h of IABP support, the PAPi <2.0 group had an observed significant decrease in central venous pressure (CVP; 20 to 12 mmHg, P < 0.001) and mean pulmonary artery pressure (mPAP; 37.5 to 28.5 mmHg, P = 0.001), and an increase in PAPi (1 to 1.6, P = 0.001). No significant change in cardiac index (CI; 2 to 2.1 L/min/m2, P = 0.31) was observed. The PAPi ≥2.0 group (N = 29) had no observed significant change in CVP (10 to 8 mmHg, P = 0.47), or PAPi (2.6 to 2.8, P = 0.92), but there was a significant improvement in CI (1.9 to 2.5 L/min/m2, P = 0.004) along with reduction in mPA (37 to 29 mmHg, P = 0.03). The PAPi <2.0 group had a significant increase in diuretic requirement (52.6% vs. 20.7%, P = 0.01) and numerically greater addition of inotropes/vasopressors (47.3% vs. 34.4%, P = 0.07) compared with the PAPi ≥2.0 group at 72 h following IABP placement. Significantly more patients in the PAPi ≥2.0 group underwent left ventricular assist device (55.2% vs. 26.3%, P = 0.02), with no overall significant differences observed in escalation to veno-arterial extracorporeal membrane oxygenation, 30-day mortality, renal replacement therapy post-IABP, or rates of heart transplantation. CONCLUSIONS IABP devices in those with HF-CS and low or abnormal PAPi may provide modest short-term haemodynamic benefits without significant improvement in CI, along with greater need for adjustment in medical therapeutics to achieve haemodynamic optimization.
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Affiliation(s)
- George Kalapurakal
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Vinh Q Chau
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Sanika Tolia
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Chris Sciamanna
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Gregory P Macaluso
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Anjali Joshi
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Jessica Pillarella
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Sunil Pauwaa
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Muhyaldeen Dia
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Tarek Kabbany
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - James Monaco
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Mark Dela Cruz
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - William G Cotts
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Patroklos Pappas
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Antone J Tatooles
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Nikhil Narang
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
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Aldweib N, Deghani P, Broberg CS, van Dissel A, Altibi A, Wong J, Baker D, Gindi S, Khairy P, Opotowsky AR, Shah S, Magalski A, Cramer J, Kauling RM, Dellborg M, Krieger EV, Yeung E, Roos-Hesselink J, Aboulhosn J, Nicolarsen J, Masha L, Gallego P, Celermajer DS, Kay J, Muhll IV, Jameson SM, O’Donnell C, Fusco F, John AS, Macon C, Antonova P, Cotts T, Sarubbi B, Rodriguez F, DeZorzi C, Jayadeva PS, Kuo M, Kutty S, Gupta T, Burchill LJ, Monserrate CPR, Lubert AM, Grewal J, Pylypchuk S, Belkin M, Wilson WM. Prognostic Significance of Hemodynamics in Patients With Transposition of the Great Arteries and Systemic Right Ventricle. Circ Heart Fail 2024; 17:e011882. [PMID: 39206568 PMCID: PMC11408092 DOI: 10.1161/circheartfailure.124.011882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 07/24/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Patients with transposition of the great arteries (TGA) and systemic right ventricle often confront significant adverse cardiac events. The prognostic significance of invasive hemodynamic parameters in this context remains uncertain. Our hypothesis is that the aortic pulsatility index and hemodynamic profiling utilizing invasive measures provide prognostic insights for patients with TGA and a systemic right ventricle. METHODS This retrospective multicenter cohort study encompasses adults with TGA and a systemic right ventricle who underwent cardiac catheterization. Data collection, spanning from 1994 to 2020, encompasses clinical and hemodynamic parameters, including measured and calculated values such as pulmonary capillary wedge pressure, aortic pulsatility index, and cardiac index. Pulmonary capillary wedge pressure and cardiac index values were used to establish 4 distinct hemodynamic profiles. A pulmonary capillary wedge pressure of ≥15 mm Hg indicated congestion, termed wet, while a cardiac index <2.2 L/min per m2 signified inadequate perfusion, labeled cold. The primary outcome comprised a composite of all-cause death, heart transplantation, or the requirement for mechanical circulatory support. RESULTS Of 1721 patients with TGA, 242 individuals with available invasive hemodynamic data were included. The median follow-up duration after cardiac catheterization was 11.4 (interquartile range, 7.5-15.9) years, with a mean age of 38.5±10.8 years at the time of cardiac catheterization. Among hemodynamic parameters, an aortic pulsatility index <1.5 emerged as a robust predictor of the primary outcome, with adjusted hazard ratios of 5.90 (95% CI, 3.01-11.62; P<0.001). Among the identified 4 hemodynamic profiles, the cold/wet profile was associated with the highest risk for the primary outcome, with an adjusted hazard ratio of 3.83 (95% CI, 1.63-9.02; P<0.001). CONCLUSIONS A low aortic pulsatility index (<1.5) and the cold/wet hemodynamic profile are linked with an elevated risk of adverse long-term cardiac outcomes in patients with TGA and systemic right ventricle.
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Affiliation(s)
- Nael Aldweib
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR
| | | | - Craig S. Broberg
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR
| | | | - Ahmad Altibi
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR
| | - Joshua Wong
- Royal Melbourne Hospital, Department of Medicine, Melbourne, Australia
| | - David Baker
- University of Sydney and Royal Prince Alfred Hospital, Sydney, Australia
| | - Salil Gindi
- Children’s Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Paul Khairy
- Montreal Heart Institute, Montreal, Quebec, Canada
| | - Alexander R. Opotowsky
- Cincinnati Children’s Hospital Medical Center, Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | | | - Anthony Magalski
- University of Missouri- Kansas City and Saint Luke’s Hospital, Kansas City, MO
| | - Jonathan Cramer
- Children’s Hospital, Omaha & University of Nebraska Medical Center, Omaha, NE
| | | | - Mikael Dellborg
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eric V. Krieger
- University of Washington Medical Center and Seattle Children’s Hospital, Seattle, WA
| | | | | | | | | | - Luke Masha
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR
| | | | - David S. Celermajer
- University of Sydney and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Joseph Kay
- Colorado University School of Medicine, Denver, CO
| | | | - Susan M. Jameson
- Stanford University, School of Medicine, Departments of Pediatrics and Medicine, Palo Alto, CA
| | - Clare O’Donnell
- Green Lane Paediatric and Congenital Cardiac Service, Auckland City Hospital, Auckland, New Zealand
| | | | | | - Condrad Macon
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR
| | | | - Timothy Cotts
- University of Michigan Medical Center, Ann Arbor, MI
| | | | | | - Christopher DeZorzi
- Boston Children’s Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Medicine, Division of Cardiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | | | - Marissa Kuo
- Ochsner Medical Center, New Orleans, Louisiana, USA
| | | | - Tripti Gupta
- Ochsner Medical Center, New Orleans, Louisiana, USA
| | - Luke J. Burchill
- Royal Melbourne Hospital, Department of Medicine, Melbourne, Australia
| | - Carla P. Rodriguez Monserrate
- Boston Children’s Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Medicine, Division of Cardiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Adam M. Lubert
- Cincinnati Children’s Hospital Medical Center, Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jasmine Grewal
- St.Paul’s Hospital, Division of Cardiology, University of British Columbia, Vancouver, BC, Canada
| | | | | | - William M. Wilson
- Royal Melbourne Hospital, Department of Medicine, Melbourne, Australia
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Leung C, Wong IMH, Ho CB, Chiang MCS, Fong YH, Lee PH, So TC, Yeung YK, Leung CY, Cheng YW, Chui SF, Chan AKC, Wong CY, Chan KT, Lee MKY. Cardiac power output ratio: Novel survival predictor after percutaneous ventricular assist device in cardiogenic shock. ESC Heart Fail 2024. [PMID: 38982624 DOI: 10.1002/ehf2.14949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 06/19/2024] [Accepted: 06/21/2024] [Indexed: 07/11/2024] Open
Abstract
AIMS Currently, there is limited data on prognostic indicators after insertion of percutaneous ventricular assist device (PVAD) in the treatment of cardiogenic shock (CS). This study evaluated the prognostic role of cardiac power output (CPO) ratio, defined as CPO at 24 h divided by early CPO (30 min to 2 h), in CS patients after PVAD. METHODS AND RESULTS Consecutive CS patients from the QEH-PVAD Registry were followed up for survival at 90 days after PVAD. Among 121 consecutive patients, 98 underwent right heart catheterization after PVAD, with CPO ratio available in 68 patients. The CPO ratio and 24-h CPO, but not the early CPO post PVAD, were significantly associated with 90-day survival, with corresponding area under curve in ROC analysis of 0.816, 0.740, and 0.469, respectively. In multivariate analysis, only the CPO ratio and lactate level at 24 h remained as independent survival predictors. The CPO ratio was not associated with age, sex, and body size. Patients with lower CPO ratio had significantly lower coronary perfusion pressure, worse right heart indices, and higher pulmonary vascular resistance. A lower CPO ratio was also significantly associated with mechanical ventilation and higher creatine kinase levels in myocardial infarction patients. CONCLUSION In post-PVAD patients, the CPO ratio outperformed the absolute CPO values and other haemodynamic metrics in predicting survival at 90 days. Such a proportional change of CPO over time, likely reflecting native heart function recovery, may help to guide management of CS patients post-PVAD.
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Affiliation(s)
- Calvin Leung
- Department of Medicine, Division of Cardiology, Queen Elizabeth Hospital, Hong Kong SAR
| | - Ivan Man Ho Wong
- Department of Medicine, Division of Cardiology, Queen Elizabeth Hospital, Hong Kong SAR
| | - Cheuk Bong Ho
- Department of Medicine, Division of Cardiology, Queen Elizabeth Hospital, Hong Kong SAR
| | | | - Yan Hang Fong
- Department of Medicine, Division of Cardiology, Queen Elizabeth Hospital, Hong Kong SAR
| | - Pok Him Lee
- Department of Medicine, Division of Cardiology, Queen Elizabeth Hospital, Hong Kong SAR
| | - Tai Chung So
- Department of Medicine, Division of Cardiology, Queen Elizabeth Hospital, Hong Kong SAR
| | - Yin Kei Yeung
- Department of Medicine, Division of Cardiology, Queen Elizabeth Hospital, Hong Kong SAR
| | - Chung Yin Leung
- Department of Medicine, Division of Cardiology, Queen Elizabeth Hospital, Hong Kong SAR
| | - Yuet Wong Cheng
- Department of Medicine, Division of Cardiology, Queen Elizabeth Hospital, Hong Kong SAR
| | - Shing Fung Chui
- Department of Medicine, Division of Cardiology, Queen Elizabeth Hospital, Hong Kong SAR
| | - Alan Ka Chun Chan
- Department of Medicine, Division of Cardiology, Queen Elizabeth Hospital, Hong Kong SAR
| | - Chi Yuen Wong
- Department of Medicine, Division of Cardiology, Queen Elizabeth Hospital, Hong Kong SAR
| | - Kam Tim Chan
- Department of Medicine, Division of Cardiology, Queen Elizabeth Hospital, Hong Kong SAR
| | - Michael Kang Yin Lee
- Department of Medicine, Division of Cardiology, Queen Elizabeth Hospital, Hong Kong SAR
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Reiter T, Kerzner J, Fette G, Frantz S, Voelker W, Ertl G, Bauer W, Morbach C, Störk S, Güder G. Accuracy of VO 2 estimation according to the widely used Krakau formula for the prediction of cardiac output. Herz 2024; 49:50-59. [PMID: 37439804 PMCID: PMC10830659 DOI: 10.1007/s00059-023-05196-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/21/2023] [Accepted: 06/01/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND Invasive cardiac output (CO) is measured with the thermodilution (TD) or the indirect Fick method (iFM) in right heart catheterization (RHC). The iFM estimates CO using approximation formulas for oxygen consumption ([Formula: see text]O2), but there are significant discrepancies (> 20%) between both methods. Although regularly applied, the formula proposed by Krakau has not been validated. We compared the CO discrepancies between the Krakau formula with the reference (TD) and three established formulas and investigated whether alterations assessed in cardiac magnetic resonance imaging (CMR) determined the extent of the deviations. METHODS This retrospective study included 188 patients aged 63 ± 14 years (30% women) receiving both CMR and RHC. The CO was measured with TD or with the iFM using the formulas by Krakau, LaFarge, Dehmer, and Bergstra for [Formula: see text]O2 estimation (iFM-K/-L/-D/-B). Percentage errors were calculated as twice the standard deviation of the difference between two CO methods divided by their means; a cut-off of < 30% was regarded as acceptable. The iFM and TD-derived CO ratio was built, and deviations > 20% were counted. Logistic regression analyses were performed to identify determinants of a deviation of > 20%. RESULTS The TD-derived CO (5.5 ± 1.7 L/min) was significantly different from all iFM (K: 4.8 ± 1.6, L: 4.3 ± 1.6; D: 4.8 ± 1.5 L/min; B: 5.4 ± 1.8 L/min all p < 0.05). The iFM-K-CO differed from all methods (p < 0.001) except iFM‑D (p = 0.19). Percentage errors between TD-CO and iFM-K/-L/-D/-B were all beyond the acceptance limit (44/45/44/43%), while percentage errors between iFM‑K and other iFM were all < 16%. None of the parameters measured in CMR was predictive of a discrepancy of > 20% between both methods. CONCLUSION The Krakau formula was comparable to other iFM in estimating CO levels, but none showed satisfactory agreement with the TD method. Improved derivation cohorts for [Formula: see text]O2 estimation are needed that better reflect today's patients undergoing RHC.
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Affiliation(s)
- Theresa Reiter
- Department of Internal Medicine I, Cardiology Division, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
| | - Julia Kerzner
- Department of Internal Medicine I, Cardiology Division, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
| | - Georg Fette
- Department of Clinical Research & Epidemiology, Comprehensive Heart Failure Center, University Hospital Würzburg, Am Schwarzen Berg 26, 97078, Würzburg, Germany
- Chair of Computer Science VI, University of Würzburg, 97074, Würzburg, Germany
| | - Stefan Frantz
- Department of Internal Medicine I, Cardiology Division, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
- Department of Clinical Research & Epidemiology, Comprehensive Heart Failure Center, University Hospital Würzburg, Am Schwarzen Berg 26, 97078, Würzburg, Germany
| | - Wolfram Voelker
- Department of Internal Medicine I, Cardiology Division, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
| | - Georg Ertl
- Department of Clinical Research & Epidemiology, Comprehensive Heart Failure Center, University Hospital Würzburg, Am Schwarzen Berg 26, 97078, Würzburg, Germany
| | - Wolfgang Bauer
- Department of Internal Medicine I, Cardiology Division, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
| | - Caroline Morbach
- Department of Internal Medicine I, Cardiology Division, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
- Department of Clinical Research & Epidemiology, Comprehensive Heart Failure Center, University Hospital Würzburg, Am Schwarzen Berg 26, 97078, Würzburg, Germany
| | - Stefan Störk
- Department of Internal Medicine I, Cardiology Division, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
- Department of Clinical Research & Epidemiology, Comprehensive Heart Failure Center, University Hospital Würzburg, Am Schwarzen Berg 26, 97078, Würzburg, Germany
| | - Gülmisal Güder
- Department of Internal Medicine I, Cardiology Division, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany.
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Aslanger E, Akaslan D, Ataş H, Yıldırımtürk Ö, Öz M, Kocakaya D, Yıldızeli B, Mutlu B. Is Pulmonary Capillary Wedge Pressure a Reliable Indicator of Postcapillary Pulmonary Hypertension? Am J Cardiol 2024; 211:307-315. [PMID: 37984643 DOI: 10.1016/j.amjcard.2023.11.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 10/30/2023] [Accepted: 11/11/2023] [Indexed: 11/22/2023]
Abstract
Although current pulmonary hypertension (PH) guidelines recommend a pulmonary capillary wedge pressure (PCWP) >15 mm Hg for the detection of a postcapillary component, the rationale of this recommendation may not be quite compatible with the peculiar hemodynamics of PH. We hypothesize that a high PCWP alone does not necessarily indicate left-sided disease, and this diagnosis can be improved using left ventricle transmural pressure difference (∆ PTM). In this 2-center, retrospective, observational study, we enrolled 1,070 patients with PH who underwent heart catheterization, with the final study population comprising 961 cases. ∆ PTM was calculated as PCWP minus right atrial pressure. The patients with group II PH had significantly higher ∆ PTM values (12.6 ± 6.6 mm Hg) compared with the other groups (1.1 ± 4.8 in group I, 12.4 ± 6.6 in group II, 2.5 ± 6.4 in group III, and 0.8 ± 8.0 in group IV, p <0.001) despite overlapping PCWP values. A ∆ PTM cutoff of 7 mm Hg identifies left heart disease when PCWP is >15 (area under curve 0.825, 95% confidence interval 0.784 to 0.866, p <0.001). Five-year mortality was significantly higher in patients with high ∆ PTM and PCWP subgroups compared with low ∆ PTM plus high PCWP (26.1% vs 18.5%, p = 0.027) and low ∆ PTM and PCWP subgroups (26.1% vs 15.6%, p <0.001). ∆ PTM has supplementary discriminatory power in distinguishing patients with and without postcapillary PH. In conclusion, a new approach utilizing ∆ PTM may improve our understanding of PH pathophysiology and may identify a subpopulation that may potentially benefit from PH-specific treatments.
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Affiliation(s)
- Emre Aslanger
- Department of Cardiology, Başakşehir Pine and Sakura City Hospital, Istanbul, Turkey.
| | - Dursun Akaslan
- Department of Cardiology, Pendik Training and Research Hospital, Marmara University, Istanbul, Turkey
| | - Halil Ataş
- Department of Cardiology, Pendik Training and Research Hospital, Marmara University, Istanbul, Turkey
| | - Özlem Yıldırımtürk
- Department of Cardiology, Health Sciences University, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Melih Öz
- Department of Cardiology, Health Sciences University, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Derya Kocakaya
- Department of Pulmonology, Pendik Training and Research Hospital, Marmara University, Istanbul, Turkey
| | - Bedrettin Yıldızeli
- Department of Thoracic Surgery, Pendik Training and Research Hospital, Marmara University, Istanbul, Turkey
| | - Bülent Mutlu
- Department of Cardiology, Pendik Training and Research Hospital, Marmara University, Istanbul, Turkey
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Volodarsky I, Kerzhner K, Haberman D, Cuciuc V, Poles L, Blatt A, Kirzhner E, George J, Gandelman G. Comparison between Cardiac Output and Pulmonary Vascular Pressure Measured by Indirect Fick and Thermodilution Methods. J Pers Med 2023; 13:jpm13030559. [PMID: 36983740 PMCID: PMC10054496 DOI: 10.3390/jpm13030559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/04/2023] [Accepted: 03/13/2023] [Indexed: 03/30/2023] Open
Abstract
INTRODUCTION Right heart catheterization (RHC) is a diagnostic procedure, the main purpose of which is to diagnose pulmonary hypertension and investigate its etiology and treatability. In addition to measuring blood pressure in heart chambers, it includes estimating cardiac output (CO) and calculation of pulmonary vascular resistance (PVR) derived from the CO. There are two common methods to evaluate the CO-the indirect Fick method and the thermodilution method. Depending on the clinical conditions, either of the two may be considered better. Several studies have showed that, in most cases, there is no difference between measurements rendered by the two methods. Other studies have raised suspicion of a discrepancy between the two methods in a substantial number of patients. A clear opinion on this matter is missing. AIM To evaluate the agreement between the values of the CO and PVR found by the thermodilution and indirect Fick methods. METHODS We retrospectively included patients that underwent RHC in Kaplan Medical Center during the last two years with a measurement of the CO using both the thermodilution and the indirect Fick methods. The measurements obtained upon RHC and the clinical data of the patients were collected. The values of the CO and PVR measured or calculated using the two methods were compared for each patient. RESULTS We included 55 patients that met the inclusion criteria in this study. The mean CO measured by the thermodilution method was 4.94 ± 1.17 L/min and the mean CO measured by the indirect Fick method was 5.82 ± 1.97 L/min. The mean PVR calculated using the thermodilution method was 3.33 ± 3.04 Woods' units (WU) and the mean PVR calculated using the indirect Fick method was 2.71 ± 2.76 WU. Among the patients with normal mPAP, there was a strong and statistically significant correlation between the PVR values calculated by the two methods (Peasron's R2 = 0.78, p-value = 0.004), while among the patients with elevated mPAP, the correlation between the PVR values calculated by the two methods was not statistically significant. CONCLUSION The findings of this small study demonstrate that, in a proportion of patients, the indirect Fick method and thermodilution method classify the PVR value differently. In our experience, it seems that, in these patients, the indirect Fick method misclassified patients with a pathological finding as normal. We, therefore, recommend that upon performing RHC, at least in patients with mPAP > 25 mmHg, both the thermodilution and indirect Fick methods be performed and, whenever they disagree, the values obtained from the thermodilution method should be preferred.
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Affiliation(s)
- Igor Volodarsky
- Heart Center, Kaplan Medical Center, The Hebrew University of Jerusalem, Pasternak St., 1, Rehovot 76100, Israel
| | - Katerina Kerzhner
- Internal Medicine Department A, Kaplan Medical Center, Pasternak St., 1, Rehovot 76100, Israel
| | - Dan Haberman
- Heart Center, Kaplan Medical Center, The Hebrew University of Jerusalem, Pasternak St., 1, Rehovot 76100, Israel
| | - Valeri Cuciuc
- Heart Center, Kaplan Medical Center, The Hebrew University of Jerusalem, Pasternak St., 1, Rehovot 76100, Israel
| | - Lion Poles
- Heart Center, Kaplan Medical Center, The Hebrew University of Jerusalem, Pasternak St., 1, Rehovot 76100, Israel
| | - Alex Blatt
- Heart Center, Kaplan Medical Center, The Hebrew University of Jerusalem, Pasternak St., 1, Rehovot 76100, Israel
| | - Elena Kirzhner
- Internal Medicine Department A, Kaplan Medical Center, Pasternak St., 1, Rehovot 76100, Israel
| | - Jacob George
- Heart Center, Kaplan Medical Center, The Hebrew University of Jerusalem, Pasternak St., 1, Rehovot 76100, Israel
| | - Gera Gandelman
- Heart Center, Kaplan Medical Center, The Hebrew University of Jerusalem, Pasternak St., 1, Rehovot 76100, Israel
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Schmücker G, Burgdorf C, Blohm JH, Bugno M, Meyer K, Remppis BA. Modern gold standard of cardiac output measurement - A simplified bedside measurement of individual oxygen uptake in the cath lab. J Basic Clin Physiol Pharmacol 2022; 33:639-644. [PMID: 34995436 DOI: 10.1515/jbcpp-2021-0293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/20/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Cardiac output (CO) measurements employing the direct Fick principle represent the gold standard in right-sided heart catheterization (RHC). The current widespread approach in hemodynamic workup however uses the indirect Fick principle with assumed values for oxygen uptake (VO2) leading to incorrect CO values in up to 25% of patients. We have tested a contemporary breath-by-breath gas analyzer that allows precise real-time measurements of VO2 with appropriate time and effort to serve the direct Fick principle. METHODS By means of a small and mobile metabolic cart assembled with widely used components of a standard spiroergometer, we performed bedside measurements of individual VO2. In 33 unselected, consecutive patients with various indications for RHC we compared CO values derived from indirect vs. direct Fick calculations. RESULTS In 28 of the 33 patients, VO2 measurements were completed with a plausible dataset within a median of 3.2 (interquartile range 2.8-6.2) min. In nine of the 28 patients, CO values based on measured VO2 values differed by more than 20% from CO calculations based on assumed VO2 values with value deviations scattering over a broad range in both directions (maximally +52% to minimally -46%). CONCLUSIONS The bedside measurement of VO2 for gold standard CO determination is technically feasible within a few min and can thus be easily included in any RHC protocol. As modern therapy for numerus indications demand a precise upfront measurement of hemodynamics, our method might help to correctly identify patients for costly therapies.
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Affiliation(s)
- Georg Schmücker
- Klinik für Kardiologie, Herz- und Gefäßzentrum Bad Bevensen, Bad Bevensen, Germany
| | - Christof Burgdorf
- Klinik für Kardiologie, Herz- und Gefäßzentrum Bad Bevensen, Bad Bevensen, Germany
| | - Jan-Henrik Blohm
- Klinik für Kardiologie, Herz- und Gefäßzentrum Bad Bevensen, Bad Bevensen, Germany
| | - Mathias Bugno
- Klinik für Kardiologie, Herz- und Gefäßzentrum Bad Bevensen, Bad Bevensen, Germany
| | - Kathrin Meyer
- Klinik für Kardiologie, Herz- und Gefäßzentrum Bad Bevensen, Bad Bevensen, Germany
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Narang N, Thibodeau JT, Parker WF, Grodin JL, Garg S, Tedford RJ, Levine BD, McGuire DK, Drazner MH. Comparison of Accuracy of Estimation of Cardiac Output by Thermodilution Versus the Fick Method Using Measured Oxygen Uptake. Am J Cardiol 2022; 176:58-65. [PMID: 35613956 PMCID: PMC9648100 DOI: 10.1016/j.amjcard.2022.04.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/24/2022] [Accepted: 04/08/2022] [Indexed: 11/18/2022]
Abstract
The thermodilution (TD) method is routinely used for the estimation of cardiac output (Q̇C). However, its accuracy, compared with the gold-standard Fick method, where systemic oxygen uptake (V̇O2) is directly measured, and Q̇C calculated from V̇O2 and the arterio-venous oxygen difference ("direct" Fick), has not been well validated. The present study determined the agreement between TD and Fick methods in consecutive patients who underwent pulmonary artery catheterization for a broad range of clinical conditions. This is a subanalysis of a previous study comparing the indirect versus Fick method based on a prospective, consecutive patient registry of 253 patients who underwent pulmonary artery catheterization for clinical indications at a single center between 1999 and 2005. We included patients that had an estimation of Q̇C both by the Fick method using measured V̇O2 by exhaled gas analyses from timed Douglas bag collections and by TD. Cardiac index was classified as low when ≤2.2 L/min/m2 or normal when >2.2 L/min/m2. The median (25th, 75th percentile) age of the cohort was 59 (50,67) years, and 50% were female. A total of 43.5% had normal left ventricular function by ventriculography, and 25.7% had ischemic heart disease. Median overall Fick and TD Q̇C were 4.4 (3.5, 5.5) and 4.3 (3.7, 5.2) L/min, respectively (p = 0.04). The median absolute percent error between Fick and TD Q̇C was 17.5 (7.7, 28.4)%, with a typical error of 0.88 L/min (95% confidence interval [CI] 0.82 to 0.95). Median absolute percent error was comparable in the low (n = 118) and normal Q̇CI (n = 135) groups (16.9% vs 18.9%, respectively, p = 0.88). typical error was 0.3 (95% CI 0.27 to 0.33) and 0.49 (95% CI 0.45 to 0.55) L/min/m2 in that comparison. Percent error >25% between Fick and TD Q̇C was observed in over 30% of patients. Overall, Fick and TD Q̇C modestly correlated (Rs = 0.64, p <0.001), with a nondirectional error introduced by TD Q̇C [mean bias of 0.21 (-2.2, 2.7) L/min]. There was poor agreement between TD and the gold-standard Fick method, highlighting the limitations of making clinical decisions based on TD.
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Affiliation(s)
- Nikhil Narang
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois; Division of Cardiology, Department of Medicine, University of Illinois-Chicago, Chicago, Illinois.
| | - Jennifer T Thibodeau
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - William F Parker
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Justin L Grodin
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sonia Garg
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Benjamin D Levine
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, Texas
| | - Darren K McGuire
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Parkland Health and Hospital System, Dallas, Texas
| | - Mark H Drazner
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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9
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Hillerson D, Charnigo R, Moon Kim S, Iyengar A, Lane M, Misumida N, Kolodziej AR, Ogunbayo GO, Abdel-Latif A, Gurley JC, Booth DC. Ratio of Mixed Venous Oxygen Saturation-to-Pulmonary Capillary Wedge Pressure: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. Circ Heart Fail 2022; 15:e008838. [PMID: 35026961 DOI: 10.1161/circheartfailure.121.008838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hemodynamic values from right heart catheterization aid diagnosis and clinical decision-making but may not predict outcomes. Mixed venous oxygen saturation percentage and pulmonary capillary wedge pressure relate to cardiac output and congestion, respectively. We theorized that a novel, simple ratio of these measurements could estimate cardiovascular prognosis. METHODS We queried Veterans Affairs' databases for clinical, hemodynamic, and outcome data. Using the index right heart catheterization between 2010 and 2016, we calculated the ratio of mixed venous oxygen saturation-to-pulmonary capillary wedge pressure, termed ratio of saturation-to-wedge (RSW). The primary outcome was time to all-cause mortality; secondary outcome was 1-year urgent heart failure presentation. Patients were stratified into quartiles of RSW, Fick cardiac index (CI), thermodilution CI, and pulmonary capillary wedge pressure alone. Kaplan-Meier curves and Cox proportional hazards models related comparators with outcomes. RESULTS Of 12 019 patients meeting inclusion criteria, 9826 had values to calculate RSW (median 4.00, interquartile range, 2.67-6.05). Kaplan-Meier curves showed early, sustained separation by RSW strata. Cox modeling estimated that increasing RSW by 50% decreases mortality hazard by 19% (estimated hazard ratio, 0.81 [95% CI, 0.79-0.83], P<0.001) and secondary outcome hazard by 28% (hazard ratio, 0.72 [95% CI, 0.70-0.74], P<0.001). Among the 3793 patients with data for all comparators, Cox models showed RSW best associated with outcomes (by both C statistics and Bayes factors). Furthermore, pulmonary capillary wedge pressure was superior to thermodilution CI and Fick CI. Multivariable adjustment attenuated without eliminating the association of RSW with outcomes. CONCLUSIONS In a large national database, RSW was superior to conventional right heart catheterization indices at assessing risk of mortality and urgent heart failure presentation. This simple calculation with routine data may contribute to clinical decision-making in this population.
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Affiliation(s)
- Dustin Hillerson
- Lexington Veterans Affairs Health Care System, University of Kentucky, Lexington. (596), KY (D.H., M.L., N.M., A.A.-L., D.C.B.).,Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.)
| | - Richard Charnigo
- Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.).,Department of Biostatistics, University of Kentucky, Lexington. (R.C.)
| | - Sun Moon Kim
- Reid Heart Center, FirstHealth of the Carolinas, Pinehurst, NC (S.M.K.).,Department of Medicine, University of North Carolina at Chapel Hill (S.M.K.)
| | - Amrita Iyengar
- Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.).,College of Medicine, University of Kentucky, Lexington. (A.I.)
| | - Matthew Lane
- Lexington Veterans Affairs Health Care System, University of Kentucky, Lexington. (596), KY (D.H., M.L., N.M., A.A.-L., D.C.B.).,College of Pharmacy, University of Kentucky, Lexington. (M.L.)
| | - Naoki Misumida
- Lexington Veterans Affairs Health Care System, University of Kentucky, Lexington. (596), KY (D.H., M.L., N.M., A.A.-L., D.C.B.).,Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.)
| | - Andrew R Kolodziej
- Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.)
| | - Gbolahan O Ogunbayo
- Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.)
| | - Ahmed Abdel-Latif
- Lexington Veterans Affairs Health Care System, University of Kentucky, Lexington. (596), KY (D.H., M.L., N.M., A.A.-L., D.C.B.).,Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.)
| | - John C Gurley
- Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.)
| | - David C Booth
- Lexington Veterans Affairs Health Care System, University of Kentucky, Lexington. (596), KY (D.H., M.L., N.M., A.A.-L., D.C.B.).,Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.)
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10
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Khirfan G, Li M, Wang X, Dweik RA, Heresi GA, Tonelli AR. Is pulmonary vascular resistance index better than pulmonary vascular resistance in predicting outcomes in pulmonary arterial hypertension? J Heart Lung Transplant 2021; 40:614-622. [PMID: 33962868 DOI: 10.1016/j.healun.2021.03.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 03/09/2021] [Accepted: 03/29/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In contrast to pulmonary vascular resistance (PVR), PVR index (PVRI) accounts for variations in body habitus. We tested the association of PVRI compared to PVR with clinical outcomes in lean and obese (BMI ≥30 kg/m2) patients with pulmonary arterial hypertension (PAH). METHODS This retrospective study included adult patients with PAH who underwent right heart catheterization at Cleveland Clinic between February 1992 and November 2019. RESULTS We included 644 patients (mean age, 53 ± 16 years, and 74 % females). PAH was idiopathic or heritable in 44% of patients. Cardiac output increased (p <0.0001), while PVR decreased (p <0.0001) with increasing body weight. Both PVR and PVRI were associated with markers of disease severity, with more pronounced association for PVRI. Both PVR and PVRI were risk factors for first PAH hospitalization, mortality and mortality or lung transplant in the whole cohort and the group of patients with BMI < 30 kg/m2. However, PVRI (HR (95% CI): 1.06 (1.02 -1.11)), but not PVR (HR (95% CI): 1.03 (0.99-1.07)), was a risk factor for first PAH hospitalization in obese patients. In the obese group, neither PVR nor PVRI were risk factors for mortality. CONCLUSIONS PVRI appears to have a stronger association than PVR with disease severity markers in PAH; however, both PVR and PVRI were similarly associated with hospitalizations and survival in the overall cohort. We found no strong evidence to recommend a change from PVR to PVRI in the definition of PAH.
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Affiliation(s)
- Ghaleb Khirfan
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Manshi Li
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Xiaofeng Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Raed A Dweik
- Department of Pulmonary, Allergy and Critical Care Medicine. Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gustavo A Heresi
- Department of Pulmonary and Critical Care Medicine. Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Adriano R Tonelli
- Staff, Department of Pulmonary and Critical Care Medicine. Respiratory Institute, Cleveland Clinic, Cleveland, Ohio.
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11
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Jacobs RA, Lundby C. Contextualizing the biological relevance of standardized high-resolution respirometry to assess mitochondrial function in permeabilized human skeletal muscle. Acta Physiol (Oxf) 2021; 231:e13625. [PMID: 33570804 PMCID: PMC8047922 DOI: 10.1111/apha.13625] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 12/16/2022]
Abstract
Aim This study sought to provide a statistically robust reference for measures of mitochondrial function from standardized high‐resolution respirometry with permeabilized human skeletal muscle (ex vivo), compare analogous values obtained via indirect calorimetry, arterial‐venous O2 differences and 31P magnetic resonance spectroscopy (in vivo) and attempt to resolve differences across complementary methodologies as necessary. Methods Data derived from 831 study participants across research published throughout March 2009 to November 2019 were amassed to examine the biological relevance of ex vivo assessments under standard conditions, ie physiological temperatures of 37°C and respiratory chamber oxygen concentrations of ~250 to 500 μmol/L. Results Standard ex vivo‐derived measures are lower (Z ≥ 3.01, P ≤ .0258) en masse than corresponding in vivo‐derived values. Correcting respiratory values to account for mitochondrial temperatures 10°C higher than skeletal muscle temperatures at maximal exercise (~50°C): (i) transforms data to resemble (Z ≤ 0.8, P > .9999) analogous yet context‐specific in vivo measures, eg data collected during maximal 1‐leg knee extension exercise; and (ii) supports the position that maximal skeletal muscle respiratory rates exceed (Z ≥ 13.2, P < .0001) those achieved during maximal whole‐body exercise, e.g. maximal cycling efforts. Conclusion This study outlines and demonstrates necessary considerations when actualizing the biological relevance of human skeletal muscle respiratory control, metabolic flexibility and bioenergetics from standard ex vivo‐derived assessments using permeabilized human muscle. These findings detail how cross‐procedural comparisons of human skeletal muscle mitochondrial function may be collectively scrutinized in their relationship to human health and lifespan.
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Affiliation(s)
- Robert A. Jacobs
- Department of Human Physiology & Nutrition University of Colorado Colorado Springs (UCCS) Colorado Springs CO USA
| | - Carsten Lundby
- Innland University of Applied Sciences Lillehammer Norway
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12
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Abstract
Purpose of review Heart failure with preserved ejection fraction (HFpEF) is a complex and heterogeneous condition of multiple causes, characterized by a clinical syndrome resulting from elevated left ventricular filling pressures, with an apparently unimpaired left ventricular systolic function. Although HFpEF has been long recognized as a distinct entity with significant morbidity for patients, its diagnosis remains challenging to this day. In recent years, few diagnostic algorithms have been postulated to aid in the identification of this condition. Invasive hemodynamic and metabolic evaluation is often warranted for the conclusive diagnosis and risk stratification of HFpEF, in patients presenting with undifferentiated DOE. Recent findings Rest and provoked hemodynamics remain the golden-standard diagnostic tool to unequivocally confirm the diagnosis of both established and incipient HFpEF, respectively. Cycle exercise hemodynamics is the paramount provocative maneuver to unveil this condition. Rapid saline loading does not offer a significant benefit over that of cycle exercise. Vasoactive agents can also uncover and confirm incipient HFpEF disease. The role of metabolic evaluation in patients presenting with idiopathic dyspnea on exertion (DOE) is of unparalleled value for those who have expertise in cardiopulmonary exercise test (CPET) interpretation; however, the average clinician who focuses solely on oxygen consumption will find it underwhelming. Invasive CPET stands alone as the ultimate diagnostic tool to discriminate between pulmonary, cardiovascular, and skeletal muscle disorders, and their respective contribution to DOE and exercise intolerance. Summary Several hemodynamic and metabolic parameters have demonstrated not only strong diagnostic value, but also predictive power in HFpEF. Additionally, these diagnostic methods have given rise to several therapeutic interventions that are now part of our clinical armamentarium. Regrettably, due to the heterogeneity and multicausality of HFpEF, none of the targeted interventions have been so far successful in decreasing the mortality burden of this prevalent condition.
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13
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Narang N, Dela Cruz M, Imamura T, Chung B, Nguyen AB, Holzhauser L, Smith BA, Kalantari S, Raikhelkar J, Sarswat N, Kim GH, Jeevanandam V, Burkhoff D, Sayer G, Uriel N. Discordance between lactic acidemia and hemodynamics in patients with advanced heart failure. Clin Cardiol 2021; 44:636-645. [PMID: 33734459 PMCID: PMC8119805 DOI: 10.1002/clc.23584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 02/16/2021] [Accepted: 02/18/2021] [Indexed: 01/22/2023] Open
Abstract
Background Elevated lactic acid (LA) levels carry a poor prognosis in patients with shock. Data are lacking on the significance of LA levels in patients with acute decompensated heart failure (ADHF). Hypothesis This study assessed the relationship between LA levels, hemodynamics and clinical outcomes. Methods This was a retrospective analysis of registry data of 100 advanced heart failure patients presenting for right heart catheterization (RHC) for concern of ADHF. LA levels (normal ≤2.1 mmol/L) were obtained prior to RHC; no significant changes in therapy were made between LA collection and RHC. Results Median age was 58 (47.3, 64.8) years; 57% were receiving inotropes prior to RHC. Median pulmonary capillary wedge pressure (PCWP) and cardiac index (CI) were 28 (21, 35) mmHg and 2.0 (1.7, 2.5) L/min/m2, respectively. Eighty patients had normal LA prior to RHC. There was no correlation between LA levels and PCWP (R = 0.09, p = .38); 63% of the normal LA group had a PCWP >24 mmHg. There was a moderate inverse correlation between LA and CI (R = − 0.40; p < .001); 58% of the normal LA group had a CI <2.2 L/min/m2. Thirty‐day survival free of death/hospice, inotrope dependence, progression to heart transplant/left‐ventricular assist device implant was comparable between the normal and elevated LA groups (28% vs. 20%; p = .17). Conclusion In patients presenting with ADHF, normal LA levels do not exclude the presence of depressed CI (a hemodynamic criteria for cardiogenic shock) and may not offer accurate risk stratification. Invasive hemodynamics should not be delayed based on normal LA levels alone.
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Affiliation(s)
- Nikhil Narang
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Mark Dela Cruz
- Division of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Teruhiko Imamura
- Second Department of Medicine, University of Toyama, Toyama, Japan
| | - Ben Chung
- Division of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Ann B Nguyen
- Division of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Luise Holzhauser
- Division of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Bryan A Smith
- Division of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Sara Kalantari
- Division of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Jayant Raikhelkar
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Nitasha Sarswat
- Division of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Gene H Kim
- Division of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Valluvan Jeevanandam
- Section of Cardiac Surgery, Department of Surgery, University of Chicago Medical Center, Chicago, Illinois, USA
| | | | - Gabriel Sayer
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Nir Uriel
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
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14
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Momoi M, Hiraide T, Shinya Y, Momota H, Fukui S, Kawakami M, Itabashi Y, Fukuda K, Kataoka M. Triple oral combination therapy with macitentan, riociguat, and selexipag for pulmonary arterial hypertension. Ther Adv Respir Dis 2021; 15:1753466621995048. [PMID: 33627044 PMCID: PMC7919213 DOI: 10.1177/1753466621995048] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: The evidence regarding triple oral combination therapy for patients with
pulmonary arterial hypertension (PAH) is scarce. This study was performed to
investigate the effectiveness and safety of triple oral combination therapy
with macitentan, riociguat, and selexipag. Methods: Among consecutive patients with PAH who were referred to our hospital from
2009 to 2020, those who underwent triple oral combination therapy using
macitentan, riociguat, and selexipag were retrospectively analyzed.
Hemodynamic and echocardiographic assessments and Kaplan–Meier analyses of
all-cause death and initiation of prostacyclin infusion were conducted. Results: Twenty-six patients underwent this combination therapy. These patients were
predominantly female (73.1%) with a median age of 38 years at baseline and
nine patients were taking some PAH medications at baseline. The median time
from initiation of the first PAH drug to the third PAH drug in treatment
naïve patients was 24 days (interquartile range, 12–47 days). Four patients
(15.0%) discontinued taking any of the three vasodilators because of adverse
events, and 17 patients (65.4%) reached the maximum dose of all three drugs.
The mean pulmonary arterial pressure, pulmonary vascular resistance, and
cardiac output improved by 29%, 65%, and 82%, respectively (median
observation period: 441 days) and similar improvements were observed in
treatment-naïve patients at baseline. The survival rate and prostacyclin
infusion-free rate since administration of all three vasodilators was 93.3%
and 74.6% at 3 years, respectively. When patients were divided by risk
stratification, the prostacyclin-free rate at 3 years was 92.9% in
low-/intermediate-risk patients and 55.0% in high-risk patients. Conclusion: Triple oral combination therapy with macitentan, riociguat, and selexipag
sufficiently improved clinical parameters and was well tolerated in patients
with PAH. This combination could be a particularly promising strategy in
patients with low/intermediate risk and possibly even in half of patients
with high risk. Further studies are needed to validate these findings. The reviews of this paper are available via the supplemental
material section.
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Affiliation(s)
- Mizuki Momoi
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Takahiro Hiraide
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiki Shinya
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Hiromi Momota
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Shogo Fukui
- Department of Rehabilitation, Keio University Hospital, Tokyo, Japan
| | - Michiyuki Kawakami
- Department of Rehabilitation Medicine, Keio University Hospital, Tokyo, Japan
| | - Yuji Itabashi
- Department of Laboratory Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Masaharu Kataoka
- Department of Cardiology, Keio University School of Medicine, Shinanomachi 35, Shinjuku-ku, Tokyo 160-8582, Japan.,Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
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15
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Kresoja KP, Faragli A, Abawi D, Paul O, Pieske B, Post H, Alogna A. Thermodilution vs estimated Fick cardiac output measurement in an elderly cohort of patients: A single-centre experience. PLoS One 2019; 14:e0226561. [PMID: 31860679 PMCID: PMC6924680 DOI: 10.1371/journal.pone.0226561] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 11/28/2019] [Indexed: 11/19/2022] Open
Abstract
Aims Patients referred to the cath-lab are an increasingly elderly population. Thermodilution (TD, gold standard) and the estimated Fick method (eFM) are interchangeably used in the clinical routine to measure cardiac output (CO). However, their correlation in an elderly cohort of cardiac patients has not been tested so far. Methods A single, clinically-indicated right heart catheterization was performed on each patient with CO estimated by eFM and TD in 155 consecutive patients (75.1±6.8 years, 57.7% male) between April 2015 and August 2017. Whole Body Oxygen Consumption (VO2) was assumed by applying the formulas of LaFarge (LaF), Dehmer (De) and Bergstra (Be). CO was indexed to body surface area (Cardiac Index, CI). Results CI-TD showed an overall moderate correlation to CI-eFM as assessed by LaF, De or Be (r2 = 0.53, r2 = 0.54, r2 = 0.57, all p < .001, respectively) with large limits of agreement (-0.64 to 1.09, -1.07 to 0.77, -1.38 to 0.53 l/m2/min, respectively). The mean difference of CI between methods was 0.22, -0.15 and -0.42 (all p<0.001 for difference to TD), respectively. A rate of error ≥20% occurred with the equations by LaF, De or Be in 40.6%, 26.5% and 36.1% of patients, respectively. A CI <2.2 l/m2min was present in 42.6% of patients according to TD and in 60.0%, 31.0% and in 16.1% of patients according to eFM by the formulas of LaF, De or Be. Conclusion Although CI-eFM shows an overall reasonable correlation with CI-TD, the predictive value in a single patient is low. CI-eFM cannot replace CI-TD in elderly patients.
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Affiliation(s)
- Karl-Patrik Kresoja
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité–University Medicine, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- German Cardiovascular Research Centre (DZHK), partner site Berlin, Germany
| | - Alessandro Faragli
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité–University Medicine, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- German Cardiovascular Research Centre (DZHK), partner site Berlin, Germany
| | - Dawud Abawi
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité–University Medicine, Berlin, Germany
| | - Oliver Paul
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité–University Medicine, Berlin, Germany
| | - Burkert Pieske
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité–University Medicine, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- German Cardiovascular Research Centre (DZHK), partner site Berlin, Germany
- German Heart Center Berlin, Berlin, Germany
| | - Heiner Post
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité–University Medicine, Berlin, Germany
- German Cardiovascular Research Centre (DZHK), partner site Berlin, Germany
- Department of cardiology and angiology, St. Marien-Hospital Mülheim, Mülheim, Germany
| | - Alessio Alogna
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité–University Medicine, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- German Cardiovascular Research Centre (DZHK), partner site Berlin, Germany
- * E-mail:
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Narang N, Chung B, Nguyen A, Kalathiya RJ, Laffin LJ, Holzhauser L, Ebong IA, Besser SA, Imamura T, Smith BA, Kalantari S, Raikhelkar J, Sarswat N, Kim GH, Jeevanandam V, Burkhoff D, Sayer G, Uriel N. Discordance Between Clinical Assessment and Invasive Hemodynamics in Patients With Advanced Heart Failure. J Card Fail 2019; 26:128-135. [PMID: 31442494 DOI: 10.1016/j.cardfail.2019.08.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/04/2019] [Accepted: 08/07/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Historically, invasive hemodynamic guidance was not superior compared to clinical assessment in patients admitted with acute decompensated heart failure (ADHF). This study assessed the accuracy of clinical assessment vs invasive hemodynamics in patients with ADHF. METHODS AND RESULTS We conducted a prospective cohort study of patients admitted with ADHF. Prior to right-heart catheterization (RHC), physicians categorically predicted right atrial pressure, pulmonary capillary wedge pressure, cardiac index and hemodynamic profile (wet/dry, warm/cold) based on physical examination and clinical data evaluation (warm = cardiac index > 2.2 L/min/m2; wet = pulmonary capillary wedge pressure > 18 mmHg). We collected 218 surveys (of 83 cardiology fellows, 55 attending cardiologists, 45 residents, 35 interns) evaluating 97 patients. Of those patients, 46% were receiving inotropes prior to RHC. The positive and negative predictive values of clinical assessment compared to RHC for the cold and wet subgroups were 74.7% and 50.4%. The accuracy of categorical prediction was 43.6% for right atrial pressure, 34.4% for pulmonary capillary wedge pressure and 49.1% for cardiac index, and accuracy did not differ by clinician (P > 0.05 for all). Interprovider agreement was 44.4%. Therapeutic changes following RHC occurred in 71.1% overall (P < 0.001). CONCLUSIONS Clinical assessment of patients with advanced heart failure presenting with ADHF has low accuracy across all training levels, with exaggerated rates of misrecognition of the most high-risk patients.
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Affiliation(s)
- Nikhil Narang
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637
| | - Ben Chung
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637
| | - Ann Nguyen
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637
| | - Rohan J Kalathiya
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637
| | - Luke J Laffin
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Mail Code JB1, Cleveland, Ohio 44195
| | - Luise Holzhauser
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637
| | - Imo A Ebong
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637
| | - Stephanie A Besser
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637
| | - Teruhiko Imamura
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637
| | - Bryan A Smith
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637
| | - Sara Kalantari
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637
| | - Jayant Raikhelkar
- Department of Medicine, Section of Cardiology, Columbia University Medical Center, 622 W. 168th St PH10-203A New York, NY 10032
| | - Nitasha Sarswat
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637
| | - Gene H Kim
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637
| | - Valluvan Jeevanandam
- Department of Surgery, Section of Cadiac Surgery, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637
| | - Daniel Burkhoff
- Columbia University Medical Center and Cardiovascular Research Foundation, 1700 Broadway, 9th floor, New York, NY 10019
| | - Gabriel Sayer
- Department of Medicine, Section of Cardiology, Columbia University Medical Center, 622 W. 168th St PH10-203A New York, NY 10032
| | - Nir Uriel
- Department of Medicine, Section of Cardiology, Columbia University Medical Center, 622 W. 168th St PH10-203A New York, NY 10032.
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17
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Khirfan G, Ahmed MK, Almaaitah S, Almoushref A, Agmy GM, Dweik RA, Tonelli AR. Comparison of Different Methods to Estimate Cardiac Index in Pulmonary Arterial Hypertension. Circulation 2019; 140:705-707. [PMID: 31424987 DOI: 10.1161/circulationaha.119.041614] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ghaleb Khirfan
- Department of Pulmonary, Allergy, and Critical Care Medicine (G.K., R.A.D., A.R.T.), Respiratory Institute
| | - Mostafa K Ahmed
- Department of Pulmonary and Critical Care Medicine (M.K.A.), Respiratory Institute.,Department of Chest Diseases, Faculty of Medicine, Assiut University, Egypt (M.K.A., G.M.A.)
| | - Saja Almaaitah
- Department of Internal Medicine (S.A.), Medicine Institute
| | | | - Gamal M Agmy
- Department of Chest Diseases, Faculty of Medicine, Assiut University, Egypt (M.K.A., G.M.A.)
| | - Raed A Dweik
- Department of Pulmonary, Allergy, and Critical Care Medicine (G.K., R.A.D., A.R.T.), Respiratory Institute
| | - Adriano R Tonelli
- Department of Pulmonary, Allergy, and Critical Care Medicine (G.K., R.A.D., A.R.T.), Respiratory Institute
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18
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Opotowsky AR, Hess E, Maron BA, Brittain EL, Barón AE, Maddox TM, Alshawabkeh LI, Wertheim BM, Xu M, Assad TR, Rich JD, Choudhary G, Tedford RJ. Thermodilution vs Estimated Fick Cardiac Output Measurement in Clinical Practice: An Analysis of Mortality From the Veterans Affairs Clinical Assessment, Reporting, and Tracking (VA CART) Program and Vanderbilt University. JAMA Cardiol 2019; 2:1090-1099. [PMID: 28877293 DOI: 10.1001/jamacardio.2017.2945] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Thermodilution (Td) and estimated oxygen uptake Fick (eFick) methods are widely used to measure cardiac output (CO). They are often used interchangeably to make critical clinical decisions, yet few studies have compared these approaches as applied in medical practice. Objectives To assess agreement between Td and eFick CO and to compare how well these methods predict mortality. Design, Setting, and Participants This investigation was a retrospective cohort study with up to 1 year of follow-up. The study used data from the Veterans Affairs Clinical Assessment, Reporting, and Tracking (VA CART) program. The findings were corroborated in a cohort of patients cared for at Vanderbilt University, an academic referral center. Participants were more than 15 000 adults who underwent right heart catheterization, including 12 232 in the Veterans Affairs cohort between October 1, 2007, and September 30, 2013, and 3391 in the Vanderbilt cohort between January 1, 1998, and December 31, 2014. Exposures A single cardiac catheterization was performed on each patient with CO estimated by both Td and eFick methods. Cardiac output was indexed to body surface area (cardiac index [CI]) for all analyses. Main Outcomes and Measures All-cause mortality over 90 days and 1 year after catheterization. Results Among 12 232 VA patients (mean [SD] age, 66.4 [9.9] years; 3.3% female) who underwent right heart catheterization in this cohort study, Td and eFick CI estimates correlated modestly (r = 0.65). There was minimal mean difference (eFick minus Td = -0.02 L/min/m2, or -0.4%) but wide 95% limits of agreement between methods (-1.3 to 1.3 L/min/m2, or -50.1% to 49.4%). Estimates differed by greater than 20% for 38.1% of patients. Low Td CI (<2.2 L/min/m2 compared with normal CI of 2.2-4.0 L/min/m2) more strongly predicted mortality than low eFick CI at 90 days (Td hazard ratio [HR], 1.71; 95% CI, 1.47-1.99; χ2 = 49.5 vs eFick HR, 1.42; 95% CI, 1.22-1.64; χ2 = 20.7) and 1 year (Td HR, 1.53; 95% CI, 1.39-1.69; χ2 = 71.5 vs eFick HR, 1.35; 1.22-1.49; χ2 = 35.2). Patients with a normal CI by both methods had 12.3% 1-year mortality. There was no significant additional risk for patients with a normal Td CI but a low eFick CI (12.9%, P = .51), whereas a low Td CI but normal eFick CI was associated with higher mortality (15.4%, P = .001). The results from the Vanderbilt cohort were similar in the context of a more balanced sex distribution (46.6% female). Conclusions and Relevance There is only modest agreement between Td and eFick CI estimates. Thermodilution CI better predicts mortality and should be favored over eFick in clinical practice.
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Affiliation(s)
- Alexander R Opotowsky
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Edward Hess
- Veterans Affairs Eastern Colorado Health Care System, Denver
| | - Bradley A Maron
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Evan L Brittain
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.,Vanderbilt Translational and Clinical Cardiovascular Research Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anna E Barón
- Veterans Affairs Eastern Colorado Health Care System, Denver
| | - Thomas M Maddox
- Veterans Affairs Eastern Colorado Health Care System, Denver.,University of Colorado School of Medicine, Denver
| | - Laith I Alshawabkeh
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Bradley M Wertheim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Meng Xu
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee
| | - Tufik R Assad
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jonathan D Rich
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Gaurav Choudhary
- Providence Veterans Affairs Medical Center, Providence, Rhode Island.,Alpert Medical School of Brown University, Providence, Rhode Island
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston
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19
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Grafton G, Cascino TM, Perry D, Ashur C, Koelling TM. Resting Oxygen Consumption and Heart Failure: Importance of Measurement for Determination of Cardiac Output With the Use of the Fick Principle. J Card Fail 2019; 26:664-672. [PMID: 30753933 DOI: 10.1016/j.cardfail.2019.02.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 02/01/2019] [Accepted: 02/03/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Resting oxygen consumption (VO2) is often estimated and frequently used to guide therapeutic decisions in symptomatic heart failure (HF) patients. The relationship between resting VO2 and symptomatic HF and the accuracy of estimations of VO2 in this population are unknown. METHODS AND RESULTS We performed a cross-sectional study of HF patients (n = 691) and healthy control subjects (n = 77). VO2 was measured with the use of a metabolic cart, and estimated VO2 was calculated with the use of the Dehmer, LaFarge, and Bergstra formulas and the thermodilution method. The measured and estimated VO2 were compared and the potential impact of estimations determined. In the multivariable model, resting VO2 decreased with increasing New York Heart Association (NYHA) functional class in a stepwise fashion (β NYHA functional class IV vs control = -36 mL O2/min; P < .001). Estimations of VO2 with the use of derived equations diverged from measured values, particularly for patients with NYHA functional class IV limitations. The percentage difference of measured VO2 versus estimated VO2 was >25% in 39% (n = 271), 25% (n = 170), 82% (n = 566), and 39% (n = 271) of HF patients when using the Dehmer, LaFarge, Bergstra, and thermodilution-derived estimations of VO2 respectively. CONCLUSIONS Resting VO2 decreases with increasing NYHA functional class and is lower than in control subjects. Using estimations of VO2 to calculate CO may introduce clinically important error.
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Affiliation(s)
- Gillian Grafton
- Division of Cardiovascular Medicine, Henry Ford, Detroit, Michigan
| | - Thomas M Cascino
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan.
| | - Daniel Perry
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
| | - Carmel Ashur
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
| | - Todd M Koelling
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
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20
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Abstract
Diagnostic and interventional cardiac catheterization is routinely used in the diagnosis and treatment of congenital heart disease. There are well-established concerns regarding the risk of radiation exposure to patients and staff, particularly in children given the cumulative effects of repeat exposure. Magnetic resonance imaging (MRI) offers the advantage of being able to provide better soft tissue visualization, tissue characterization, and quantification of ventricular volumes and vascular flow. Initial work using MRI catheterization employed fusion of x-ray and MRI techniques, with x-ray fluoroscopy to guide catheter placement and subsequent MRI assessment for anatomical and hemodynamic assessment. Image overlay of 3D previously acquired MRI datasets with live fluoroscopic imaging has also been used to guide catheter procedures.Hybrid x-ray and MRI-guided catheterization paved the way for clinical application and validation of this technique in the assessment of pulmonary vascular resistance and pharmacological stress studies. Purely MRI-guided catheterization also proved possible with passive catheter tracking. First-in-man MRI-guided cardiac catheter interventions were possible due to the development of MRI-compatible guidewires, but halted due to guidewire limitations.More recent developments in passive and active catheter tracking have led to improved visualization of catheters for MRI-guided catheterization. Improvements in hardware and software have also increased image quality and scanning times with better interactive tools for the operator in the MRI catheter suite to navigate through the anatomy as required in real time. This has expanded to MRI-guided electrophysiology studies and radiofrequency ablation in humans. Animal studies show promise for the utility of MRI-guided interventional catheterization. Ongoing investment and development of MRI-compatible guidewires will pave the way for MRI-guided diagnostic and interventional catheterization coming into the mainstream.
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21
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Rogers T, Ratnayaka K, Khan JM, Stine A, Schenke WH, Grant LP, Mazal JR, Grant EK, Campbell-Washburn A, Hansen MS, Ramasawmy R, Herzka DA, Xue H, Kellman P, Faranesh AZ, Lederman RJ. CMR fluoroscopy right heart catheterization for cardiac output and pulmonary vascular resistance: results in 102 patients. J Cardiovasc Magn Reson 2017; 19:54. [PMID: 28750642 PMCID: PMC5530573 DOI: 10.1186/s12968-017-0366-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 06/21/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Quantification of cardiac output and pulmonary vascular resistance (PVR) are critical components of invasive hemodynamic assessment, and can be measured concurrently with pressures using phase contrast CMR flow during real-time CMR guided cardiac catheterization. METHODS One hundred two consecutive patients underwent CMR fluoroscopy guided right heart catheterization (RHC) with simultaneous measurement of pressure, cardiac output and pulmonary vascular resistance using CMR flow and the Fick principle for comparison. Procedural success, catheterization time and adverse events were prospectively collected. RESULTS RHC was successfully completed in 97/102 (95.1%) patients without complication. Catheterization time was 20 ± 11 min. In patients with and without pulmonary hypertension, baseline mean pulmonary artery pressure was 39 ± 12 mmHg vs. 18 ± 4 mmHg (p < 0.001), right ventricular (RV) end diastolic volume was 104 ± 64 vs. 74 ± 24 (p = 0.02), and RV end-systolic volume was 49 ± 30 vs. 31 ± 13 (p = 0.004) respectively. 103 paired cardiac output and 99 paired PVR calculations across multiple conditions were analyzed. At baseline, the bias between cardiac output by CMR and Fick was 5.9% with limits of agreement -38.3% and 50.2% with r = 0.81 (p < 0.001). The bias between PVR by CMR and Fick was -0.02 WU.m2 with limits of agreement -2.6 and 2.5 WU.m2 with r = 0.98 (p < 0.001). Correlation coefficients were lower and limits of agreement wider during physiological provocation with inhaled 100% oxygen and 40 ppm nitric oxide. CONCLUSIONS CMR fluoroscopy guided cardiac catheterization is safe, with acceptable procedure times and high procedural success rate. Cardiac output and PVR measurements using CMR flow correlated well with the Fick at baseline and are likely more accurate during physiological provocation with supplemental high-concentration inhaled oxygen. TRIAL REGISTRATION Clinicaltrials.gov NCT01287026 , registered January 25, 2011.
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Affiliation(s)
- Toby Rogers
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD USA
| | - Kanishka Ratnayaka
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD USA
- Department of Cardiology, Rady Children’s Hospital, San Diego, CA USA
| | - Jaffar M. Khan
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD USA
| | - Annette Stine
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD USA
| | - William H. Schenke
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD USA
| | - Laurie P. Grant
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD USA
| | - Jonathan R. Mazal
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD USA
| | - Elena K. Grant
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD USA
- Department of Cardiology, Children’s National Medical Center, Washington, DC USA
| | - Adrienne Campbell-Washburn
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD USA
| | - Michael S. Hansen
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD USA
| | - Rajiv Ramasawmy
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD USA
| | - Daniel A. Herzka
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD USA
| | - Hui Xue
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD USA
| | - Peter Kellman
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD USA
| | - Anthony Z. Faranesh
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD USA
| | - Robert J. Lederman
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD USA
- Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Building 10, Room 2c713, Bethesda, MD 20892-1538 USA
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22
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Domingo E, Grignola JC, Aguilar R, Messeguer ML, Roman A. Pulmonary arterial wall disease in COPD and interstitial lung diseases candidates for lung transplantation. Respir Res 2017; 18:85. [PMID: 28477618 PMCID: PMC5420403 DOI: 10.1186/s12931-017-0568-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 04/27/2017] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) associated with lung disease has the worst prognosis of all types of PH. Pulmonary arterial vasculopathy is an early event in the natural history of chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD). The present study characterized the alterations in the structure and function of the pulmonary arterial (PA) wall of COPD and ILD candidates for lung transplantation (LTx). METHODS A cohort of 73 patients, 63 pre-LTx (30 COPD, 33 ILD), and ten controls underwent simultaneous right heart catheterisation and intravascular ultrasound (IVUS). Total pulmonary resistance (TPR), capacitance (Cp), and the TPR-Cp relationship were assessed. PA stiffness and the relative area of wall thickness were estimated as pulse PA pressure/IVUS pulsatility and as [(external sectional area-intimal area)/external sectional area] × 100, respectively. RESULTS Twenty-seven percent of patients had pulmonary arterial wedge pressure > 15 mmHg and were not analyzed. PA stiffness and the area of wall thickness were increased in comparison with controls, even in patients without PH (p < 0.05). ILD patients showed a significant higher PA stiffness, and lower Cp beyond mean PA pressure (mPAP) and lower area of wall thickness than COPD patients (p < 0.05). TPR-Cp relationship was shifted downward left for ILD patients. CONCLUSIONS Significant increase of PA stiffness and area of wall thickness were present even in patients without PH and can make the diagnosis of pulmonary vasculopathy at a preclinical stage in PH-lung disease candidates for LTx. ILD patients showed the worst PA stiffness and Cp with respect to COPD.
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Affiliation(s)
- Enric Domingo
- Area del Cor, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Physiology Department, School of Medicine, Universitat Autonoma, Barcelona, Spain
| | - Juan C Grignola
- Pathophysiology Department, School of Medicine, Hospital de Clínicas, Universidad de la República, Avda Italia 2870, PC 11600, Montevideo, Uruguay.
| | - Rio Aguilar
- Cardiology Department, Hospital Universitario de la Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | | | - Antonio Roman
- Department of Neumology, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Ciberes, Instituto de Salud Carlos III, Madrid, Spain
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23
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Fanari Z, Grove M, Rajamanickam A, Hammami S, Walls C, Kolm P, Saltzberg M, Weintraub WS, Doorey AJ. Cardiac output determination using a widely available direct continuous oxygen consumption measuring device: a practical way to get back to the gold standard. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2016; 17:256-61. [PMID: 26976237 DOI: 10.1016/j.carrev.2016.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Revised: 02/15/2016] [Accepted: 02/24/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Accurate assessment of cardiac output (CO) is essential for the hemodynamic assessment of valvular heart disease. Estimation of oxygen consumption (VO2) and thermodilution (TD) are employed in many cardiac catheterization laboratories (CCL) given the historically cumbersome nature of direct continuous VO2 measurement, the "gold standard" for this technique. A portable facemask device simplifies the direct continuous measurement of VO2, allowing for relatively rapid and continuous assessment of CO. METHODS AND MATERIALS Thirty consecutive patients undergoing right heart catheterization had simultaneous determination of CO by both direct continuous and assumed VO2 and TD. Assessments were only made when a plateau of VO2 had occurred. All measurements of direct continuous and assumed VO2, as well as, TD CO were obtained in triplicate. RESULTS Direct continuous VO2 CO and assumed VO2 CO correlated poorly (R=0.57; ICC=0.59). Direct continuous VO2 CO and TD CO also correlated poorly (R=0.51; ICC=0.60). Repeated direct continuous VO2 CO measurements were extremely correlated and reproducible [(R=0.93; ICC=0.96) suggesting that this was the most reliable measurement of CO. CONCLUSIONS CO calculated from direct continuous VO2 measurement varies substantially from both assumed VO2 and TD based CO, which are widely used in most CCL. These differences may significantly impact the CO measurements. Furthermore, continuous, rather than average, measurement of VO2 appears to give highly reproducible results.
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Affiliation(s)
- Zaher Fanari
- Division of Cardiology, University of Kansas School of Medicine, Kansas City, KS, USA.
| | - Matthew Grove
- Section of Cardiology, Carolina East Medical Center, New Bern, NC, USA
| | | | - Sumaya Hammami
- Division of Cardiology, University of Kansas School of Medicine, Kansas City, KS, USA; Section of Cardiology, Christiana Care Health System, Newark, DE, USA
| | - Cassie Walls
- Section of Cardiology, Christiana Care Health System, Newark, DE, USA
| | - Paul Kolm
- Value Institute, Christiana Care Health System, Newark, DE, USA
| | | | - William S Weintraub
- Section of Cardiology, Christiana Care Health System, Newark, DE, USA; Value Institute, Christiana Care Health System, Newark, DE, USA
| | - Andrew J Doorey
- Section of Cardiology, Christiana Care Health System, Newark, DE, USA; Value Institute, Christiana Care Health System, Newark, DE, USA
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24
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Chase PJ, Davis PG, Wideman L, Starnes JW, Schulz MR, Bensimhon DR. Comparison of Estimations Versus Measured Oxygen Consumption at Rest in Patients With Heart Failure and Reduced Ejection Fraction Who Underwent Right-Sided Heart Catheterization. Am J Cardiol 2015; 116:1724-30. [PMID: 26443561 DOI: 10.1016/j.amjcard.2015.08.051] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 08/29/2015] [Accepted: 08/29/2015] [Indexed: 10/23/2022]
Abstract
Cardiac output during right-sided heart catheterization is an important variable for patient selection of advanced therapies (cardiac transplantation and left ventricular assist device implantation). The Fick method to determine cardiac output is commonly used and typically uses estimated oxygen consumption (VO2) from 1 of 3 published empirical formulas. However, these estimation equations have not been validated in patients with heart failure and reduced ejection fraction (HFrEF). The objectives of the present study were to determine the accuracy of 3 equations for estimating VO2 compared with direct measurement of VO2 and determine the extent clinically significant error occurred in calculating cardiac output of patients with HFrEF. Breath-by-breath measurements of VO2 from 44 patients who underwent cardiac catheterization (66% men; age, 65 ± 11 years, left ventricular ejection fraction, 22 ± 6%) were compared with the derived estimations of LaFarge and Miettinen, Dehmer et al, and Bergstra et al. Single-sample t tests found only the mean difference between the estimation of LaFarge and Miettinen and the measured VO2 to be nonsignificant (-10.3 ml/min ± 6.2 SE, p = 0.053). Bland-Altman plots demonstrated unacceptably large limits of agreement for all equations. The rate of ≥25% error in the equations by LaFarge and Miettinen, Dehmer et al, and Bergstra et al occurred in 11%, 23%, and 45% of patients, respectively. Misclassification of cardiac index derived from each equation for 2 clinically important classifications: cardiogenic shock-21%, 23%, and 32% and hypoperfusion-16%, 16%, and 25%; respectively. In conclusion, these findings do not support the use of these empiric formulas to estimate the VO2 at rest in patients with HFrEF who underwent right-sided heart catheterization.
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25
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Maeder MT, Karapanagiotidis S, Dewar EM, Kaye DM. Accuracy of Echocardiographic Cardiac Index Assessment in Subjects with Preserved Left Ventricular Ejection Fraction. Echocardiography 2015; 32:1628-38. [PMID: 25728504 DOI: 10.1111/echo.12928] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION We aimed to determine the accuracy of the echocardiographic assessment of cardiac index (CI) in subjects with preserved left ventricular ejection fraction (LVEF). METHODS Thirty-three subjects with LVEF >50%, normal sinus rhythm, and a broad spectrum of hemodynamic profiles underwent echocardiography immediately followed by right heart catheterization. As gold standards, CI was assessed using thermodilution [CI (TD)] and the Fick method [CI (F)]. Echocardiographic CI was assessed by four methods: from the left ventricular outflow tract (LVOT) velocity time integral and the LVOT diameter as measured [CI (LVOTm)] as well as estimated from body surface area [CI (LVOTe)], and from stroke volume indices assessed using the biplane [CI (BP)] and monoplane [CI (MP)] methods. RESULTS The mean CI (TD), CI (F), CI (LVOTm), CI (LVOTe), CI (BP), and CI (MP) were 3.0 ± 0.9, 3.1 ± 0.7, 2.8 ± 0.6, 3.3 ± 0.6, 2.0 ± 0.6, and 2.2 ± 0.7 L/min/m(2) . There were modest correlations between CI (TD) and CI (F) and all four noninvasive measures of CI with r(2) values ranging from 0.09 to 0.30. CI (LVOTm) underestimated CI (TD) and CI (F) by 0.3 and 0.3 L/min/m(2) , CI (LVOTe) overestimated CI (TD) and CI (F) by 0.3 and 0.2 L/min/m(2) , and CI (BP) and CI (MP) underestimated CI (TD) and CI (F) by 1.1 and 1.1 L/min/m(2) and 0.9 and 0.9 L/min/m(2) , respectively, with large limits of agreement for all comparisons. CONCLUSIONS In subjects with nondilated left ventricles with preserved LVEF, flow- or volume-based measures of CI by 2D echocardiography may not accurately reflect CI (TD) and CI (F). Further larger studies are required to verify our findings and to evaluate the accuracy of contrast and 3D echocardiography in this setting.
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Affiliation(s)
- Micha T Maeder
- Heart Failure Research Group, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Heart Center, Alfred Hospital, Melbourne, Victoria, Australia.,Cardiology Division, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Sofie Karapanagiotidis
- Heart Failure Research Group, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Heart Center, Alfred Hospital, Melbourne, Victoria, Australia
| | - Elizabeth M Dewar
- Heart Failure Research Group, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Heart Center, Alfred Hospital, Melbourne, Victoria, Australia
| | - David M Kaye
- Heart Failure Research Group, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Heart Center, Alfred Hospital, Melbourne, Victoria, Australia
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26
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Tonelli AR, Wang XF, Abbay A, Zhang Q, Ramos J, McCarthy K. Can we better estimate resting oxygen consumption by incorporating arterial blood gases and spirometric determinations? Respir Care 2014; 60:517-25. [PMID: 25516992 DOI: 10.4187/respcare.03555] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND We hypothesize that oxygen consumption (V̇o2) estimation in patients with respiratory symptoms is inaccurate and can be improved by considering arterial blood gases or spirometric variables. METHODS For this retrospective study, we included consecutive subjects who underwent cardiopulmonary exercise testing. Resting V̇o2 was determined using breath-by-breath testing methodology. Using a training cohort (n = 336), we developed 3 models to predict V̇o2. In a validation group (n = 114), we compared our models with 7 available formulae. RESULTS Our first model (V̇o2 = -184.99 + 189.64 × body surface area [BSA, m(2)] + 1.49 × heart rate [beats/min] + 51.51 × FIO2 [21% = 0; 30% = 1] + 30.62 × gender [male = 1; female = 0]) showed an R(2) of 0.5. Our second model (V̇o2 = -208.06 + 188.67 × BSA + 1.38 × heart rate + 35.6 × gender + 2.06 × breathing frequency [breaths/min]) showed an R(2) of 0.49. The best R(2) (0.68) was obtained with our last model, which included minute ventilation (V̇o2 = -142.92 + 0.52 × heart rate + 126.84 × BSA + 14.68 × minute ventilation [L]). In the validation cohort, these 3 models performed better than other available equations, but had wide limits of agreement, particularly in older individuals with shorter stature, higher heart rate, and lower maximum voluntary ventilation. CONCLUSIONS We developed more accurate formulae to predict resting V̇o2 in subjects with respiratory symptoms; however, equations had wide limits of agreement, particularly in certain groups of subjects. Arterial blood gases and spirometric variables did not significantly improve the predictive equations.
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Affiliation(s)
- Adriano R Tonelli
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic
| | - Xiao-Feng Wang
- Respiratory Institute Biostatistics Core, Quantitative Health Sciences, Cleveland Clinic
| | - Anara Abbay
- Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Qi Zhang
- Respiratory Institute Biostatistics Core, Quantitative Health Sciences, Cleveland Clinic
| | - José Ramos
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic
| | - Kevin McCarthy
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic
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27
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Tonelli AR, Conci D, Tamarappoo B, Newman J, Dweik RA. Prognostic value of echocardiographic changes in patients with pulmonary arterial hypertension receiving parenteral prostacyclin therapy. J Am Soc Echocardiogr 2014; 27:733-741.e2. [PMID: 24780356 PMCID: PMC4065815 DOI: 10.1016/j.echo.2014.03.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND It is unknown whether the echocardiographic changes observed after treatment of patients with pulmonary arterial hypertension have prognostic value. METHODS Subjects with pulmonary arterial hypertension, confirmed by right heart catheterization, who underwent Doppler echocardiography before (baseline) and after 1 year of treatment (follow-up) with parenteral prostacyclin analogues were retrospectively identified. Echocardiographic parameters were measured offline by two investigators. RESULTS A total of 48 patients were included (mean age, 45 ± 14 years; 83% women). Compared with baseline, follow-up echocardiography showed reductions in right atrial area (mean percentage change, 12 ± 25%; P < .001), right ventricular (RV) basal and middle cavity dimensions (mean percentage change, 8.5 ± 14% [P < .001] and 6.8 ± 17% [P = .005], respectively), and peak tricuspid regurgitant velocity (mean percentage change, 10 ± 14%; P < .001). Tricuspid annular plane systolic excursion (mean percentage change, 36 ± 43%; P < .001) and RV outflow tract time-velocity integral (mean percentage change, 48 ± 66%; P < .001) increased. During a median follow-up period of 52.5 months (interquartile range, 20.5-80 months), 18 patients (37.5%) died, mostly (n = 15 [83%]) from progression of pulmonary arterial hypertension. The changes in RV end-diastolic area (hazard ratio [HR per 10% decrease, 0.73; 95% confidence interval [CI], 0.57-0.93), tricuspid valve regurgitation velocity (HR per 10 cm/sec decrease, 0.58; 95% CI, 0.37-0.89), RV outflow tract velocity-time integral (HR per 10% increase, 0.90; 95% CI, 0.83-0.98), and subjective RV function (HR per 1 unit of improvement [e.g., from moderate to mild], 0.55; 95% CI, 0.31-0.96) were associated with overall mortality. CONCLUSIONS Echocardiographic parameters that estimate RV systolic pressure and assess RV morphology and function improve after 1 year of prostacyclin analogue treatment, and the degree of change has prognostic implications.
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Affiliation(s)
- Adriano R. Tonelli
- Staff, Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Diego Conci
- Fellow, Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Balaji Tamarappoo
- Staff, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jennie Newman
- Nurse, Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Raed A Dweik
- Director of Pulmonary Vascular Diseases Program, Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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28
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Narang N, Thibodeau JT, Levine BD, Gore MO, Ayers CR, Lange RA, Cigarroa JE, Turer AT, de Lemos JA, McGuire DK. Inaccuracy of Estimated Resting Oxygen Uptake in the Clinical Setting. Circulation 2014; 129:203-10. [DOI: 10.1161/circulationaha.113.003334] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Nikhil Narang
- From the Department of Medicine, University of Chicago, Chicago, IL (N.N.); Department of Internal Medicine (J.T.T., B.D.L., M.O.G., A.T.T., J.A.d.L.,D.K.M.) and Cardiovascular Division (J.T.T., B.D.L., M.O.G., A.T.T., J.A.d.L., D.K.M.), the University of Texas Southwestern Medical Center, Dallas, TX; Institute of Exercise and Environmental Medicine at the Texas Health Presbyterian Hospital, Dallas, TX (B.D.L.); the Department of Clinical Sciences at the University of Texas Southwestern Medical
| | - Jennifer T. Thibodeau
- From the Department of Medicine, University of Chicago, Chicago, IL (N.N.); Department of Internal Medicine (J.T.T., B.D.L., M.O.G., A.T.T., J.A.d.L.,D.K.M.) and Cardiovascular Division (J.T.T., B.D.L., M.O.G., A.T.T., J.A.d.L., D.K.M.), the University of Texas Southwestern Medical Center, Dallas, TX; Institute of Exercise and Environmental Medicine at the Texas Health Presbyterian Hospital, Dallas, TX (B.D.L.); the Department of Clinical Sciences at the University of Texas Southwestern Medical
| | - Benjamin D. Levine
- From the Department of Medicine, University of Chicago, Chicago, IL (N.N.); Department of Internal Medicine (J.T.T., B.D.L., M.O.G., A.T.T., J.A.d.L.,D.K.M.) and Cardiovascular Division (J.T.T., B.D.L., M.O.G., A.T.T., J.A.d.L., D.K.M.), the University of Texas Southwestern Medical Center, Dallas, TX; Institute of Exercise and Environmental Medicine at the Texas Health Presbyterian Hospital, Dallas, TX (B.D.L.); the Department of Clinical Sciences at the University of Texas Southwestern Medical
| | - M. Odette Gore
- From the Department of Medicine, University of Chicago, Chicago, IL (N.N.); Department of Internal Medicine (J.T.T., B.D.L., M.O.G., A.T.T., J.A.d.L.,D.K.M.) and Cardiovascular Division (J.T.T., B.D.L., M.O.G., A.T.T., J.A.d.L., D.K.M.), the University of Texas Southwestern Medical Center, Dallas, TX; Institute of Exercise and Environmental Medicine at the Texas Health Presbyterian Hospital, Dallas, TX (B.D.L.); the Department of Clinical Sciences at the University of Texas Southwestern Medical
| | - Colby R. Ayers
- From the Department of Medicine, University of Chicago, Chicago, IL (N.N.); Department of Internal Medicine (J.T.T., B.D.L., M.O.G., A.T.T., J.A.d.L.,D.K.M.) and Cardiovascular Division (J.T.T., B.D.L., M.O.G., A.T.T., J.A.d.L., D.K.M.), the University of Texas Southwestern Medical Center, Dallas, TX; Institute of Exercise and Environmental Medicine at the Texas Health Presbyterian Hospital, Dallas, TX (B.D.L.); the Department of Clinical Sciences at the University of Texas Southwestern Medical
| | - Richard A. Lange
- From the Department of Medicine, University of Chicago, Chicago, IL (N.N.); Department of Internal Medicine (J.T.T., B.D.L., M.O.G., A.T.T., J.A.d.L.,D.K.M.) and Cardiovascular Division (J.T.T., B.D.L., M.O.G., A.T.T., J.A.d.L., D.K.M.), the University of Texas Southwestern Medical Center, Dallas, TX; Institute of Exercise and Environmental Medicine at the Texas Health Presbyterian Hospital, Dallas, TX (B.D.L.); the Department of Clinical Sciences at the University of Texas Southwestern Medical
| | - Joaquin E. Cigarroa
- From the Department of Medicine, University of Chicago, Chicago, IL (N.N.); Department of Internal Medicine (J.T.T., B.D.L., M.O.G., A.T.T., J.A.d.L.,D.K.M.) and Cardiovascular Division (J.T.T., B.D.L., M.O.G., A.T.T., J.A.d.L., D.K.M.), the University of Texas Southwestern Medical Center, Dallas, TX; Institute of Exercise and Environmental Medicine at the Texas Health Presbyterian Hospital, Dallas, TX (B.D.L.); the Department of Clinical Sciences at the University of Texas Southwestern Medical
| | - Aslan T. Turer
- From the Department of Medicine, University of Chicago, Chicago, IL (N.N.); Department of Internal Medicine (J.T.T., B.D.L., M.O.G., A.T.T., J.A.d.L.,D.K.M.) and Cardiovascular Division (J.T.T., B.D.L., M.O.G., A.T.T., J.A.d.L., D.K.M.), the University of Texas Southwestern Medical Center, Dallas, TX; Institute of Exercise and Environmental Medicine at the Texas Health Presbyterian Hospital, Dallas, TX (B.D.L.); the Department of Clinical Sciences at the University of Texas Southwestern Medical
| | - James A. de Lemos
- From the Department of Medicine, University of Chicago, Chicago, IL (N.N.); Department of Internal Medicine (J.T.T., B.D.L., M.O.G., A.T.T., J.A.d.L.,D.K.M.) and Cardiovascular Division (J.T.T., B.D.L., M.O.G., A.T.T., J.A.d.L., D.K.M.), the University of Texas Southwestern Medical Center, Dallas, TX; Institute of Exercise and Environmental Medicine at the Texas Health Presbyterian Hospital, Dallas, TX (B.D.L.); the Department of Clinical Sciences at the University of Texas Southwestern Medical
| | - Darren K. McGuire
- From the Department of Medicine, University of Chicago, Chicago, IL (N.N.); Department of Internal Medicine (J.T.T., B.D.L., M.O.G., A.T.T., J.A.d.L.,D.K.M.) and Cardiovascular Division (J.T.T., B.D.L., M.O.G., A.T.T., J.A.d.L., D.K.M.), the University of Texas Southwestern Medical Center, Dallas, TX; Institute of Exercise and Environmental Medicine at the Texas Health Presbyterian Hospital, Dallas, TX (B.D.L.); the Department of Clinical Sciences at the University of Texas Southwestern Medical
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29
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Gertz ZM, McCauley BD, Raina A, O'Donnell W, Shellenberger C, Willhide J, Forfia PR, Herrmann HC. Estimation of oxygen consumption in elderly patients with aortic stenosis. Catheter Cardiovasc Interv 2013; 83:E128-33. [DOI: 10.1002/ccd.25018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 05/12/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Zachary M. Gertz
- Pauley Heart Center; Virginia Commonwealth University Medical Center; Richmond Virginia
| | | | - Amresh Raina
- Section of Heart Failure/Transplant & Pulmonary Hypertension; Allegheny General Hospital; Pittsburgh Pennsylvania
| | - William O'Donnell
- Division of Cardiology; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
| | - Charlene Shellenberger
- Division of Cardiology; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
| | - Judi Willhide
- Division of Cardiology; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
| | - Paul R. Forfia
- Division of Cardiology; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
| | - Howard C. Herrmann
- Division of Cardiology; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
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30
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Gertz ZM, Raina A, O'Donnell W, McCauley BD, Shellenberger C, Kolansky DM, Wilensky RL, Forfia PR, Herrmann HC. Comparison of Invasive and Noninvasive Assessment of Aortic Stenosis Severity in the Elderly. Circ Cardiovasc Interv 2012; 5:406-14. [DOI: 10.1161/circinterventions.111.967836] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Background—
Aortic valve area (AVA) in aortic stenosis (AS) can be assessed noninvasively or invasively, typically with similar results. These techniques have not been validated in elderly patients, where common assumptions make them most prone to error. Accurate assessment of AVA is crucial to determine which patients are appropriate candidates for aortic valve replacement.
Methods and Results—
Fifty elderly patients (mean 86 years, 46% female) referred for cardiac catheterization to evaluate AS also underwent transthoracic echocardiography within 24 hours. To minimize assumptions all patients had 3-dimensional echocardiography (Echo-3D), and at catheterization using directly measured oxygen consumption (Cath-mVo
2
) and thermodilution cardiac output (Cath-TD). Correlation between Cath-mVo
2
and Echo-3D AVA was poor (
r
=0.41). Cath-TD AVA had a moderate correlation with Echo-3D AVA (
r
=0.59). Cath-mVo
2
(AVA=0.69 cm
2
) and Cath-TD (AVA=0.66 cm
2
) underestimated AVA compared with Echo-3D (AVA=0.76 cm
2;
P
=0.08 for comparison with Cath-mVo
2
;
P
=0.001 for Cath-TD). Compared with Echo-3D, the sensitivity and specificity for determining critical disease (AVA <0.8 cm
2
) were 81% and 42% for Cath-mVo
2
, and 97% and 53% for Cath-TD. The only independent predictor of the difference between noninvasive and invasive AVA was stroke volume index (
P
<0.01). Resistance, a less flow-dependent measure, showed a stronger correlation between Echo-3D and Cath-mVo
2
(
r
=0.69), and Echo-3D and Cath-TD (
r
=0.77).
Conclusions—
Standard techniques of AVA assessment for AS show poor correlation in elderly patients, with frequent misclassification of critical AS. Less flow-dependent measures, such as resistance, should be considered to ensure that only appropriate patients are treated with aortic valve replacement.
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Affiliation(s)
- Zachary M. Gertz
- From the Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA (Z.M.G., W.O., B.D.M., C.S., D.M.K., R.L.W., P.R.F., H.C.H.); Section of Heart Failure/Transplant and Pulmonary Hypertension, Allegheny General Hospital, Pittsburgh, PA (A.R.)
| | - Amresh Raina
- From the Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA (Z.M.G., W.O., B.D.M., C.S., D.M.K., R.L.W., P.R.F., H.C.H.); Section of Heart Failure/Transplant and Pulmonary Hypertension, Allegheny General Hospital, Pittsburgh, PA (A.R.)
| | - William O'Donnell
- From the Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA (Z.M.G., W.O., B.D.M., C.S., D.M.K., R.L.W., P.R.F., H.C.H.); Section of Heart Failure/Transplant and Pulmonary Hypertension, Allegheny General Hospital, Pittsburgh, PA (A.R.)
| | - Brian D. McCauley
- From the Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA (Z.M.G., W.O., B.D.M., C.S., D.M.K., R.L.W., P.R.F., H.C.H.); Section of Heart Failure/Transplant and Pulmonary Hypertension, Allegheny General Hospital, Pittsburgh, PA (A.R.)
| | - Charlene Shellenberger
- From the Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA (Z.M.G., W.O., B.D.M., C.S., D.M.K., R.L.W., P.R.F., H.C.H.); Section of Heart Failure/Transplant and Pulmonary Hypertension, Allegheny General Hospital, Pittsburgh, PA (A.R.)
| | - Daniel M. Kolansky
- From the Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA (Z.M.G., W.O., B.D.M., C.S., D.M.K., R.L.W., P.R.F., H.C.H.); Section of Heart Failure/Transplant and Pulmonary Hypertension, Allegheny General Hospital, Pittsburgh, PA (A.R.)
| | - Robert L. Wilensky
- From the Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA (Z.M.G., W.O., B.D.M., C.S., D.M.K., R.L.W., P.R.F., H.C.H.); Section of Heart Failure/Transplant and Pulmonary Hypertension, Allegheny General Hospital, Pittsburgh, PA (A.R.)
| | - Paul R. Forfia
- From the Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA (Z.M.G., W.O., B.D.M., C.S., D.M.K., R.L.W., P.R.F., H.C.H.); Section of Heart Failure/Transplant and Pulmonary Hypertension, Allegheny General Hospital, Pittsburgh, PA (A.R.)
| | - Howard C. Herrmann
- From the Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA (Z.M.G., W.O., B.D.M., C.S., D.M.K., R.L.W., P.R.F., H.C.H.); Section of Heart Failure/Transplant and Pulmonary Hypertension, Allegheny General Hospital, Pittsburgh, PA (A.R.)
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31
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Tzifa A, Schaeffter T, Razavi R. MR imaging-guided cardiovascular interventions in young children. Magn Reson Imaging Clin N Am 2012; 20:117-28. [PMID: 22118596 DOI: 10.1016/j.mric.2011.08.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Diagnostic cardiac catheterization procedures in children have been largely replaced by magnetic resonance (MR) imaging studies. However, when invasive catheterization is required, MR imaging has a significant role to play, when combined with invasive pressure measurements. Beyond the established reduction to the radiation dose involved, solely MR image-guided or MR image-assisted catheterization procedures can accurately address clinical questions, such as estimation of pulmonary vascular resistance and cardiac output response to stress, without needing to perform laborious measurements that are prone to errors. This article describes MR image-guided or MR image-assisted cardiac catheterization procedures for diagnosis and intervention in children.
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Affiliation(s)
- Aphrodite Tzifa
- Division of Imaging Sciences, King's College London BHF Centre, NIHR Biomedical Research Centre at Guy's & St Thomas' Hospital NHS Foundation Trust, UK.
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32
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Hemnes AR, Forfia PR, Champion HC. Assessment of pulmonary vasculature and right heart by invasive haemodynamics and echocardiography. Int J Clin Pract 2010:4-19. [PMID: 19624796 DOI: 10.1111/j.1742-1241.2009.02110.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Understanding the haemodynamical profile of the right ventricle and pulmonary circulation is critical to not only the initial evaluation of, but also the continued management of pulmonary hypertension. Despite advances in non-invasive imaging techniques, right heart catheterisation (RHC) remains the gold standard for diagnosis of pulmonary hypertension and its various causes. Even so, integration of invasive haemodynamical data with the echo-Doppler exam provides the most comprehensive assessment of the pathophysiology of pulmonary hypertension in the individual patient. Here, we review technical aspects of basic RHC as well as specialised procedures including exercise and fluid challenge in the evaluation of pulmonary hypertension. Interpretation of data in the context of pulmonary vascular disease is discussed. Echocardiographical assessment of the right ventricular structure and function in pulmonary vascular disease are discussed along with the integration of haemodynamical and echocardiographical data in the clinical context.
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Affiliation(s)
- A R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, TN, USA
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33
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Schmitz A, Kretschmar O, Knirsch W, Woitzek K, Balmer C, Tomaske M, Bauersfeld U, Weiss M. Comparison of calculated with measured oxygen consumption in children undergoing cardiac catheterization. Pediatr Cardiol 2008; 29:1054-8. [PMID: 18592299 DOI: 10.1007/s00246-008-9248-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2008] [Revised: 04/25/2008] [Accepted: 05/19/2008] [Indexed: 10/21/2022]
Abstract
Our objective was to compare calculated (LaFarge) with measured oxygen consumption (VO(2)) using the AS/3 TM Compact Airway Module M-CAiOVX (Datex-Ohmeda, Helsinki, Finland; AS/3 TM) in children without cardiac shunts in a prospective, observational study. VO(2) was determined at the end of the routine diagnostic and/or interventional catheterization. VO(2 )was calculated according to the formula of LaFarge and Miettinen for each child and compared with the measured VO(2). Data were compared using simple regression and Bland Altman analysis. Fifty-two children aged from 0.5 to 16 years (median, 6.9 years) and weighing 3.4 to 59.4 kg (median, 22.9 kg) were investigated. Calculated VO(2 )values ranged from 59.0 to 230.8 ml/min, and measured VO(2) values from 62.7 to 282.2 ml/min. Comparison of calculated versus measured VO(2) values revealed a significant correlation (r = 0.90, p < 0.0001). Bias and precision were 8.9 and 48.3 ml/min, respectively (95% limits of agreement: -39.4 to 57.2 ml/min). Comparison of calculated VO(2) in children older than 3 years (n = 41), as restricted to the formula, with measured VO(2), revealed a slightly reduced correlation (r = 0.86, p < 0.0001). Bias and precision were 10.0 and 52.5 ml/min, respectively (95% limits of agreement: -42.4 to 62.5 ml/min). We conclude that calculation of VO(2) by the LaFarge formula does not provide reliable values compared to measured values. In clinical routine, measured rather than calculated VO(2) values should be used for the estimation of cardiac output and related variables.
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Affiliation(s)
- Achim Schmitz
- Department of Anesthesia, University Children's Hospital Zurich, Steinwiesstrasse, Switzerland.
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34
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Fakler U, Pauli C, Hennig M, Sebening W, Hess J. Assumed oxygen consumption frequently results in large errors in the determination of cardiac output. J Thorac Cardiovasc Surg 2005; 130:272-6. [PMID: 16077386 DOI: 10.1016/j.jtcvs.2005.02.048] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE We sought to investigate the differences in assumed and measured oxygen consumption values for the determination of cardiac output by using the Fick principle in a pediatric population with congenital heart disease. METHODS The patient population consisted of 143 patients with a mean age of 11.3 years (age range, 2 days to 23.8 years) undergoing cardiac catheterization during general anesthesia and with mechanical ventilation. Oxygen consumption was measured with a standard commercial analyzing system (Deltatrac II; Datex, Engström, Helsinki, Finland). Assumed oxygen consumption values were calculated according to the formulas of Krovetz and Goldbloom and LaFarge and Miettinen. Comparisons between measurements and assumptions were performed by Bland-Altman plots. Two-sided paired t tests were used to assess a difference of the assumed and measured values. RESULTS The range of measured oxygen consumption values was between 55.2 and 249 mL . min -1 . m -2 . The Krovetz-Goldbloom formula led to systematically larger values compared with the measured values (P = .0001; mean difference of -53.3 mL . min -1 . m -2 ; 95% confidence interval, -56.7 to -49.8 mL . min -1 . m -2 ). The use of the LaFarge-Miettinen formula tends to overestimate oxygen consumption (P = .0037; mean difference of -15.9 mL . min -1 . m -2 ; 95% confidence interval, -26.5 to -5.4 mL . min -1 . m -2 ). A similarly poor agreement was found when analyzing a subgroup of 25 patients with Fontan-type circulation. CONCLUSION The use of assumed instead of measured oxygen consumption values introduces large errors in the determination of cardiac output.
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Affiliation(s)
- Ullrich Fakler
- Department of Pediatric Cardiology and Congenital Heart Disease, Technische Universität München, Germany.
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Greci LS, Rashkow A. High-output cardiac failure in a patient with prostate cancer. CONGESTIVE HEART FAILURE (GREENWICH, CONN.) 2001; 7:220-222. [PMID: 11828171 DOI: 10.1111/j.1527-5299.2001.01010.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The authors describe a case of high-output cardiac failure in a patient with rapidly progressing prostate cancer for which no previously described cause could be found. His new onset and increasingly worsening heart failure corresponded to the rapid spread of his prostate cancer. The authors hypothesize that a cytokine released from the neoplastic cells or the bone was responsible for the high-output cardiac failure observed in this patient. (c)2001 CHF, Inc.
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Affiliation(s)
- L S Greci
- The Departments of Internal and Preventive Medicine, Griffin Hospital, Yale University School of Medicine, Derby, CT 06418
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Abstract
OBJECTIVE To compare measured and predicted oxygen consumption (VO2) in children with congenital heart disease. DESIGN Retrospective study. SETTING The cardiac catheterisation laboratory in a university hospital. PATIENTS 125 children undergoing preoperative cardiac catheterisation. INTERVENTIONS VO2 was measured using indirect calorimetry; the predicted values were calculated from regression equations published by Lindahl, Wessel et al, and Lundell et al. Stepwise linear regression and analysis of variance were used to evaluate the influence of age, sex, weight, height, cardiac malformation, and heart failure on the bias and precision of predicted VO2. An artificial neural network was trained and used to produce an estimate of VO2 employing the same variables. The various estimates for VO2 were evaluated by calculating their bias and precision values. RESULTS Lindahl's equation produced the highest precision (+/- 42%) of the regression based estimates. The corresponding average bias of the predicted VO2 was 3% (range -66% to 43%). When VO2 was predicted according to regression equations by Wessel and Lundell, the bias and precision were 0% and +/- 44%, and -16% and +/- 51%, respectively. The neural network predicted VO2 from variables included in the regression equations with a bias of 6% and precision +/- 29%; addition of further variables failed to improve this estimate. CONCLUSIONS Both regression based and artificial intelligence based techniques were inaccurate for predicting preoperative VO2 in patients with congenital heart disease. Measurement of VO2 is necessary in the preoperative evaluation of these patients.
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Affiliation(s)
- P O Laitinen
- Department of Anaesthesiology, Hospital for Children and Adolescents, University of Helsinki, Finland
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Wolf A, Pollman MJ, Trindade PT, Fowler MB, Alderman EL. Use of assumed versus measured oxygen consumption for the determination of cardiac output using the Fick principle. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1998; 43:372-80. [PMID: 9554760 DOI: 10.1002/(sici)1097-0304(199804)43:4<372::aid-ccd3>3.0.co;2-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Assumed oxygen consumption (VO2) is increasingly used as a convenient surrogate for measured VO2 for calculation of cardiac output. This substitution is often based on empirical formulae, previously validated only in relatively young patients. To assess the inaccuracy introduced by extrapolating these formulae to older patients, we compared measured VO2 with assumed VO2 in 57 patients. VO2 was measured using an open circuit analyzer. Assumed VO2 was calculated according to the LaFarge or Bergstra formulae. Agreement between both methods was assessed according to the method of Bland and Altman. The mean difference of measured VO2 minus assumed VO2 was 7.9 ml/min/m2 (P < 0.02) using the LaFarge formula, and -15.6 ml/min/m2 (P < 0.0002) using the Bergstra formula across a range of measured VO2 from 70 to 176 ml/min/m2. A systematic error was introduced by assumed VO2 from both formulae of underestimating higher and overestimating lower values of VO2, resulting in poor overall agreement with measured VO2. The same error and poor agreement was found when analyzing subgroups of patients > or =60 or <70 years of age. In summary, use of assumed VO2 introduces large, unpredictable errors in adult patients, suggesting requirement for measurement of VO2 when calculating cardiac output.
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Affiliation(s)
- A Wolf
- Division of Cardiovascular Medicine, Stanford University Medical Center, California 94305, USA
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Hundley WG, Meshack BM, Willett DL, Sayad DE, Lange RA, Willard JE, Landau C, Hillis LD, Peshock RM. Comparison of quantitation of left ventricular volume, ejection fraction, and cardiac output in patients with atrial fibrillation by cine magnetic resonance imaging versus invasive measurements. Am J Cardiol 1996; 78:1119-23. [PMID: 8914874 DOI: 10.1016/s0002-9149(96)90063-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Currently available invasive and noninvasive techniques for the determination of left ventricular end-diastolic and end-systolic volumes, ejection fraction, and cardiac output are more time-consuming and potentially less accurate in patients with atrial fibrillation (AF) than in those with sinus rhythm. Although magnetic resonance imaging (MRI) can rapidly and accurately measure these variables in patients with sinus rhythm, its ability to do so in subjects with AF is not known. To determine if left ventricular volumes, ejection fraction, and cardiac output can be measured accurately in patients with AF using MRI, 26 subjects (13 women and 13 men, aged 15 to 76 years) in sinus rhythm (n = 13) or AF (n = 13) underwent MRI followed immediately by invasive measurements of these indexes. For those in AF, MRI measurements of left ventricular end-diastolic volume, end-systolic volume, stroke volume, ejection fraction, and cardiac output correlated well with catheterization measurements (r = 0.90, 0.90, 0.95, 0.85, and 0.90, respectively). In addition, the mean difference between MRI and catheterization measurements was similar in subjects with AF and in those with sinus rhythm. Compared with standard invasive measurements, MRI provides an accurate noninvasive determination of left ventricular volumes, ejection fraction, and cardiac output in patients with AF.
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Affiliation(s)
- W G Hundley
- Department of Internal Medicine (Cardiovascular Division), University of Texas Southwestern Medical Center, Dallas, USA
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Hundley WG, Li HF, Willard JE, Landau C, Lange RA, Meshack BM, Hillis LD, Peshock RM. Magnetic resonance imaging assessment of the severity of mitral regurgitation. Comparison with invasive techniques. Circulation 1995; 92:1151-8. [PMID: 7648660 DOI: 10.1161/01.cir.92.5.1151] [Citation(s) in RCA: 178] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND In the patient with mitral regurgitation who is being considered for valvular surgery, cardiac catheterization is usually performed to quantify the severity of regurgitation and to determine its influence on left ventricular volumes and systolic function. Magnetic resonance imaging (MRI) potentially provides a rapid, noninvasive method of acquiring these data. Thus, this study was done to determine whether MRI can reliably measure the magnitude of mitral regurgitation and evaluate the effect of regurgitation on left ventricular volumes and systolic function. METHODS AND RESULTS Twenty-three subjects (14 women and 9 men 15 to 72 years of age) with (n = 17) or without (n = 6) mitral regurgitation underwent MRI scanning followed immediately by cardiac catheterization. The presence (or absence) of valvular regurgitation was determined, and left ventricular volumes and regurgitant fraction were quantified during each procedure. There was excellent correlation between invasive and MRI assessments of left ventricular end-diastolic (r = .95) and end-systolic (r = .95) volumes and regurgitant fraction (r = .96). All MRI examinations were completed in < 28 minutes. CONCLUSIONS In the patient with mitral regurgitation, MRI compares favorably with cardiac catheterization for assessment of the magnitude of regurgitation and its influence on left ventricular volumes and systolic function.
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Affiliation(s)
- W G Hundley
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas 75235-9085, USA
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Hundley WG, Li HF, Hillis LD, Meshack BM, Lange RA, Willard JE, Landau C, Peshock RM. Quantitation of cardiac output with velocity-encoded, phase-difference magnetic resonance imaging. Am J Cardiol 1995; 75:1250-5. [PMID: 7778549 DOI: 10.1016/s0002-9149(99)80772-3] [Citation(s) in RCA: 114] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Velocity-encoded, phase-difference magnetic resonance imaging (MRI) previously has been used to measure flow in the aorta, as well as in the pulmonary, carotid, and renal arteries, but these measurements have not been validated against currently accepted invasive techniques. To determine the accuracy of velocity-encoded, phase-difference MRI measurements of cardiac output, 23 subjects (11 men and 12 women, aged 15 to 72 years) underwent velocity-encoded, phase-difference MRI measurements of cardiac output in the proximal aorta, followed immediately by cardiac catheterization, with measurement of cardiac output by the Fick principle and by thermodilution. For MRI, Fick, and thermodilution measurements, stroke volume was calculated by dividing cardiac output by heart rate. The magnetic resonance images were acquired in 1 to 3 minutes. For all patients, the agreement between measurements of stroke volume was 3 +/- 9 ml for MRI and Fick, -3 +/- 11 ml for MRI and thermodilution, and 0 +/- 8 ml for MRI and the average of Fick and thermodilution. Compared with standard invasive measurements, velocity-encoded, phase-difference MRI can accurately and rapidly determine cardiac output.
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Affiliation(s)
- W G Hundley
- Department of Internal Medicine (Cardiovascular Division), University of Texas Southwestern Medical Center, Dallas 75235-9085, USA
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Determination of cardiac output by invasive methods. DEVELOPMENTS IN CARDIOVASCULAR MEDICINE 1993. [DOI: 10.1007/978-94-011-1848-4_1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Flores ED, Lange RA, Bedotto JB, Danziger RS, Hillis LD. Assessment of the sensitivity of hydrogen inhalation in the detection of left-to-right shunting. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1990; 20:94-8. [PMID: 2191785 DOI: 10.1002/ccd.1810200206] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
For the detection of left-to-right intracardiac shunting, the oximetric and standard indocyanine green techniques are relatively insensitive, in that neither can reliably detect a shunt with a ratio of pulmonary to systemic flow (Qp/Qs) less than 1.3 (percentage shunt, 23%). Although the hydrogen inhalation method is said to be much more sensitive in this regard, no previous study has measured its sensitivity. Accordingly, in 15 patients (4 men, 11 women, aged 38 to 67 years) without intracardiac shunting, hydrogen inhalation was performed 1) without and 2) with an artificially created femoral arteriovenous shunt of known size, and cardiac output was measured by thermodilution. For the 15 subjects with cardiac outputs of 3.64 to 8.10 liters/min, shunts of 22 to 248 ml/min were created, so that the shunts ranged from 0.5% to 3.3%. Hydrogen inhalation detected all shunts greater than or equal to 1.3% (Qp/Qs greater than or equal to 1.01). Of the 10 shunts less than 1.3%, it detected 5, with the smallest being 0.7%. Thus, the hydrogen inhalation technique is extremely sensitive in identifying the presence of left-to-right shunting, far more sensitive than the oximetric and standard indocyanine green methods.
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Affiliation(s)
- E D Flores
- Department of Internal Medicine (Cardiovascular Division), University of Texas Southwestern Medical Center, Dallas 75235
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Lange RA, Dehmer GJ, Wells PJ, Tate DA, Jain A, Flores ED, Nichols TC, Hillis LD. Limitations of the metabolic rate meter for measuring oxygen consumption and cardiac output. Am J Cardiol 1989; 64:783-6. [PMID: 2801530 DOI: 10.1016/0002-9149(89)90765-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Over the past few years, a metabolic rate meter has been introduced for easy measurement of oxygen consumption. However, its accuracy is unproved. In 40 patients (26 men, 14 women, ages 34 to 73 years), cardiac output was measured simultaneously by thermodilution and the Fick method using the metabolic rate meter to quantitate oxygen consumption. In comparison with thermodilution, the results using the Fick method were low (5.26 +/- 1.18 vs 4.14 +/- 0.99 liters/min, respectively, p less than 0.01). In 18 patients cardiac output also was measured by the Fick method using a Douglas bag to quantitate oxygen consumption. In these patients, oxygen consumption measured with the metabolic rate meter was lower than that obtained using the Douglas bag (168 +/- 25 vs 216 +/- 42 ml/min, respectively, p less than 0.01). With the Douglas bag, the Fick and thermodilution cardiac output measurements were similar (4.68 +/- 1.08 vs 4.87 +/- 0.86 liters/min, respectively, difference not significant), and they differed by less than or equal to 10% in 15 patients. In contrast, with the metabolic rate meter, the results of thermodilution were higher than those with the Fick method (4.84 +/- 0.95 vs 3.60 +/- 0.71 liters/min, respectively, p less than 0.01), and differed by less than or equal to 10% in only 1 patient (p less than 0.01). Thus, the values for oxygen consumption and cardiac output obtained with the metabolic rate meter are lower than actual values. This device is less accurate than the Douglas bag.
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Affiliation(s)
- R A Lange
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas 75235
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Cigarroa RG, Lange RA, Williams RH, Bedotto JB, Hillis LD. Underestimation of cardiac output by thermodilution in patients with tricuspid regurgitation. Am J Med 1989; 86:417-20. [PMID: 2648822 DOI: 10.1016/0002-9343(89)90339-2] [Citation(s) in RCA: 132] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
INTRODUCTION This study was done to assess the accuracy and reliability of the thermodilution technique in measuring cardiac output in patients with tricuspid regurgitation. PATIENTS AND METHODS In 30 subjects (17 men, 13 women, aged 50 +/- 14 [mean +/- SD] years), cardiac output was measured in close temporal proximity by thermodilution as well as Fick or indocyanine green dye, after which the presence and severity of tricuspid regurgitation were assessed by contrast right ventriculography or pulsed Doppler echocardiography. RESULTS In the 13 patients without tricuspid regurgitation, there was excellent agreement between the results of thermodilution and Fick or indocyanine green dye cardiac output determinations (4.95 +/- 1.19 liters/minute by thermodilution, 4.90 +/- 1.11 liters/minute by Fick or indocyanine green dye; NS). In contrast, in the 17 patients with tricuspid regurgitation, the results of thermodilution were consistently lower than those of Fick or indocyanine green dye (4.22 +/- 1.45 liters/minute by thermodilution, 4.99 +/- 1.67 liters/minute by Fick or indocyanine green dye; p less than 0.001). CONCLUSION Thus, the thermodilution technique of measuring cardiac output is inaccurate in patients with tricuspid regurgitation, yielding results that are consistently lower than the actual outputs.
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Affiliation(s)
- R G Cigarroa
- Department of Internal Medicine (Cardiovascular Division), University of Texas Southwestern Medical Center, Dallas 75235
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Hillis LD, Firth BG, Winniford MD. Comparison of thermodilution and indocyanine green dye in low cardiac output or left-sided regurgitation. Am J Cardiol 1986; 57:1201-2. [PMID: 3706179 DOI: 10.1016/0002-9149(86)90704-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Hillis LD, Firth BG, Winniford MD. Analysis of factors affecting the variability of Fick versus indicator dilution measurements of cardiac output. Am J Cardiol 1985; 56:764-8. [PMID: 3904383 DOI: 10.1016/0002-9149(85)91132-4] [Citation(s) in RCA: 121] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
This study was performed to assess the relation between Fick and indicator dilution measurements of cardiac output (CO) in a large number of subjects and to evaluate this relation in patients with a low CO, a high CO, and left-sided cardiac regurgitation. In 808 patients (428 men, 380 women, mean age 50 +/- 11), CO was measured by Fick and either thermodilution (right atrium to pulmonary artery)(n = 252) or indocyanine green dye ("dye")(pulmonary artery to systemic artery)(n = 556) within 10 minutes of each other. There was excellent agreement between Fick and both thermodilution and dye. The difference between Fick and indicator dilution measurements was 9 +/- 9%; it was 10% or less in 67% and 20% or less in 91% of patients. The disparity between Fick and indicator dilution measurements was increased in patients with a low CO (less than 2 liters/min/m2)(n = 152) (difference 14 +/- 11%, p less than 0.001) and those with aortic or mitral regurgitation (n = 83) (difference 13 +/- 11%, p less than 0.001). In these groups, the disparity between Fick and thermodilution measurements was not exaggerated, but the disparity between Fick and dye measurements was greater. Thus, although there is excellent agreement between Fick and both thermodilution and dye measurements of CO, thermodilution is preferable to dye in patients with a low CO and those with aortic or mitral regurgitation.
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Hillis LD, Winniford MD, Dehmer GJ, Firth BG. Left ventricular volumes by single-plane cineangiography: in vivo validation of the Kennedy regression equation. Am J Cardiol 1984; 53:1159-63. [PMID: 6702696 DOI: 10.1016/0002-9149(84)90654-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
This study was performed to assess the accuracy and reliability of the regression equations of Kennedy et al and Wynne et al in the quantitation of single plane left ventricular (LV) volumes. In 15 patients with normal LV function and without intracardiac shunting or valvular insufficiency, gated equilibrium blood pool scintigraphy was performed simultaneously with the measurement of cardiac output (by thermodilution), after which left ventriculography was performed in the 30 degrees right anterior oblique (RAO) projection. From the scintigraphically determined LV ejection fraction (EF) and the thermodilution-measured stroke volume (SV), absolute LV volumes were calculated. The cineangiographic LV volumes obtained with the regression equation of Kennedy et al closely approximated those calculated by scintigraphy/thermodilution, whereas the volumes determined using the regression equation of Wynne et al were larger (p less than 0.05) than the calculated volumes. In 204 patients without intracardiac shunting or valvular insufficiency, SV was measured by the Fick or indicator dilution methods, after which single-plane left ventriculography was performed in the 30 degrees RAO projection. In the 83 patients without coronary artery disease with normal (n = 69) or depressed (n = 14) LVEF, cineangiographic SV (obtained using the regression equation of Kennedy et al) closely approximated forward SV. Similarly, this relation was excellent in the 142 patients whose LVEFs were greater than or equal to 0.50.(ABSTRACT TRUNCATED AT 250 WORDS)
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