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Sahay S, Lane J, Sharpe MG, Toth D, Paul D, Siuba MT, Tonelli AR. Impact on Pulmonary Hypertension Hemodynamic Classification Based on the Methodology Used to Measure Pulmonary Artery Wedge Pressure and Cardiac Output. Ann Am Thorac Soc 2023; 20:1752-1759. [PMID: 37561068 DOI: 10.1513/annalsats.202303-216oc] [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: 03/12/2023] [Accepted: 08/09/2023] [Indexed: 08/11/2023] Open
Abstract
Rationale: Guidelines recommend using end-expiration pulmonary pressure measurements to determine the hemodynamic subgroups in pulmonary hypertension. Pulmonary artery wedge pressure (PAWP) determinations averaged across the respiratory cycle (PAWPav) instead of PAWP at end-expiration (PAWPee) and cardiac output (CO) measured by Fick (COFick) instead of thermodilution (COTD) may affect the hemodynamic classification of pulmonary hypertension. Objectives: To assess the impact on the pulmonary hypertension hemodynamic classification of the use of PAWPee versus PAWPav as well as COFick versus COTD. Methods: This was a single-center retrospective study of consecutive patients (n = 151) who underwent right heart catheterization with COTD, COFick, PAWPee, and PAWPav. A secondary cohort consisted of consecutive patients (n = 71) who had mean pulmonary artery pressure at end-expiration (mPAPee) and mPAP averaged across the respiratory cycle (mPAPav) measured, as well as PAWPee and PAWPav. Results: The PAWPee and PAWPav were 16.8 ± 6.4 and 15.1 ± 6.8 mm Hg, respectively, with a mean difference of 1.7 ± 2.1 mm Hg. The COTD and COFick determinations were 5.0 ± 2.4 and 5.3 ± 2.5 L/min, respectively, with a mean difference of -0.4 ± 1.3 L/min. The hemodynamic group distribution was significantly different when using PAWPee versus PAWPav, when using either COTD or COFick (P < 0.001 for both comparisons), and these results were consistent in our secondary cohort. The pulmonary hypertension hemodynamic group distribution was not significantly different between COTD and COFick when using either PAWPee or PAWPav. Conclusions: The methodology used to measure PAWP, either at end-expiration or averaged across the respiratory cycle, significantly impacts the hemodynamic classification of pulmonary hypertension.
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Affiliation(s)
- Sandeep Sahay
- Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Hospital, Houston, Texas; and
| | - James Lane
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, and
| | - Megan G Sharpe
- Case Western Reserve University School of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - David Toth
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, and
| | - Deborah Paul
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, and
| | - Matthew T Siuba
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, and
| | - Adriano R Tonelli
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, and
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Grinstein J, Houston BA, Nguyen AB, Smith BA, Chinco A, Pinney SP, Tedford RJ, Belkin MN. Standardization of the Right Heart Catheterization and the Emerging Role of Advanced Hemodynamics in Heart Failure. J Card Fail 2023; 29:1543-1555. [PMID: 37633442 DOI: 10.1016/j.cardfail.2023.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 08/28/2023]
Abstract
The accurate assessment of hemodynamics is paramount to providing timely and efficacious care for patients presenting in cardiogenic shock. Recently, the regular use of the pulmonary artery catheter in cardiogenic shock has had a resurgence with emerging data indicating improved survival in the modern era. Optimal multidisciplinary management of advanced heart failure and cardiogenic shock relies on our ability to effectively communicate and understand the complete hemodynamic assessment. Standardization of data acquisition and a renewed focus on the physiological processes, and thresholds driving disease progression, including the coupling ratio and myocardial reserve, are needed to fully understand and interpret the hemodynamic assessment. This State-of-the-Art review discusses best practices in the cardiac catheterization laboratory as well as emerging data on the prognostic role of emerging advanced hemodynamic parameters.
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Affiliation(s)
- Jonathan Grinstein
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, Illinois.
| | - Brian A Houston
- Medical University of South Carolina, Department of Medicine, Section of Heart Failure, Charleston, South Carolina
| | - Ann B Nguyen
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, Illinois
| | - Bryan A Smith
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, Illinois
| | - Annalyse Chinco
- University of Chicago, Department of Surgery, Chicago, Illinois
| | - Sean P Pinney
- Mount Sinai Hospital, Department of Medicine, Section of Cardiology, New York, New York
| | - Ryan J Tedford
- Medical University of South Carolina, Department of Medicine, Section of Heart Failure, Charleston, South Carolina
| | - Mark N Belkin
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, Illinois
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Carroll AM, Farr M, Russell SD, Schlendorf KH, Truby LK, Gilotra NA, Vader JM, Patel CB, DeVore AD. Beyond Stage C: Considerations in the Management of Patients with Heart Failure Progression and Gaps in Evidence. J Card Fail 2023; 29:818-831. [PMID: 36958390 DOI: 10.1016/j.cardfail.2023.02.015] [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: 09/09/2022] [Revised: 02/07/2023] [Accepted: 02/24/2023] [Indexed: 03/25/2023]
Abstract
Despite treatment with contemporary medical therapies for chronic heart failure (HF), there has been an increase in the prevalence of patients progressing to more advanced disease. Patients progressing to and living at the interface of severe Stage C and Stage D HF are underrepresented in clinical trials, and there is a lack of high-quality evidence to guide clinical decision making. For patients with a severe HF phenotype, the medical therapies used for patients with a less advanced stage of illness are often no longer tolerated nor provide adequate clinical stability. The limited data on these patients highlights the need to increase formal research characterizing this high-risk population. This review summarizes existing clinical trial data on and incorporates our considerations for approaches to the medical management of patients advanced "beyond Stage C" HF.
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Affiliation(s)
- Aubrie M Carroll
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Maryjane Farr
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Stuart D Russell
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Kelly H Schlendorf
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lauren K Truby
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Nisha A Gilotra
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Justin M Vader
- Department of Medicine, Division of Cardiology, Washington University, St Louis, MO, USA
| | - Chetan B Patel
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Adam D DeVore
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC, USA.
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Azih NI, Read JM, Jackson GR, Inampudi C, Witer L, Kilic A, Pope NH, Hajj J, Haddad F, Tedford RJ, Houston BA. Cardiac output assessment methods in left ventricular assist device patients: A problem of heteroscedasticity. J Heart Lung Transplant 2023; 42:145-149. [PMID: 36481112 DOI: 10.1016/j.healun.2022.10.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 10/06/2022] [Accepted: 10/27/2022] [Indexed: 11/19/2022] Open
Abstract
Equipoise remains about how best to measure cardiac output (CO) in patients with left ventricular assist devices (LVAD). In this study, direct Fick CO was compared with thermodilution (TD) and indirect Fick (iFick) CO in 61 LVAD patients. TD and LaFarge iFick showed moderate correlation with direct Fick (R2 = 0.49 and R2 = 0.38, p < 0.001 for both), while Dehmer and Bergstra iFick showed poor correlation with direct Fick (R2 = 0.29 and R2 = 0.31, p < 0.001 for both). Absolute bias between all CO estimation techniques and direct Fick CO was lowest for TD compared to iFick methods but significant for all methods. All methods tended to overestimate CO compared to direct Fick, with greatest overestimation present in those with the lowest measured direct Fick CO. Bias and frequency of significant discrepancy were least using TD and Lafarge iFick CO estimation methods in this study, with TD CO demonstrating modestly better correlation and less heteroscedasticity compared to Lafarge.
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Affiliation(s)
- Nnamdi I Azih
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Jacob M Read
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Gregory R Jackson
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Chak Inampudi
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Lucas Witer
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Nicholas H Pope
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Jennifer Hajj
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Francois Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Brian A Houston
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina.
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Siuba MT, Bhardwaj A, Kirincich J, Perez O, Flanagan P, Lane J, Toth D, Paul D, Lehr C, Duggal A, Tonelli AR. Does veno-arterial carbon dioxide gradient provide an adequate estimation of cardiac index in pulmonary hypertension? EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:38-47. [PMID: 36301185 DOI: 10.1093/ehjacc/zuac139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/08/2022] [Accepted: 10/25/2022] [Indexed: 11/23/2022]
Abstract
AIMS Pulmonary hypertension (PH) management is dependent on cardiac output (CO) assessment. The gold standard Fick method for CO and cardiac index (CI) measurement is not widely available. An accessible and reliable method for CO/CI estimation is needed not only in catheterization labs but also in other environments such as the intensive care unit, where pulmonary artery catheters are less likely to be used. We hypothesized that veno-arterial carbon dioxide gradient (PvaCO2) is a reliable surrogate for Fick CI in patients with PH. METHODS AND RESULTS A single-centre retrospective analysis of patients with PH who underwent direct Fick CI (DFCI) measurement during right heart catheterization. The primary outcome was correlation between PvaCO2 and DFCI. To assess the agreement between central and mixed venous CO2 values, a separate prospective cohort of patients was analysed. Data from 186 patients with all haemodynamic types of PH were analysed. PvaCO2 moderately correlated with Fick CI, R = -0.51 [95% confidence interval (CI): -0.61, -0.39]. A higher PvaCO2 was associated with an increased risk of CI < 2.5 L/min/m2 (odds ratio: 1.88, 95% CI: 1.55, 2.35). Low thermodilution CI with normal veno-arterial carbon dioxide gradient values was associated with a thermodilution underestimation of Fick CI. In the prospective analysis of 32 patients, central venous CO2 overestimated mixed venous values (mean difference 3.3, 95% CI: 2.5, 4.0) and there was poor agreement overall (limits of agreement -1.10, 7.59). CONCLUSION Veno-arterial carbon dioxide gradient moderately correlates with Fick CI and may be useful to identify patients with low CI. Central and mixed venous CO2 values should not be used interchangeably in PH.
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Affiliation(s)
- Matthew T Siuba
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Ave L2-330, Cleveland, OH 44195, USA
| | - Abhishek Bhardwaj
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Ave L2-330, Cleveland, OH 44195, USA
| | - Jason Kirincich
- Department of Internal Medicine, Community Care Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Oscar Perez
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Ave L2-330, Cleveland, OH 44195, USA
| | - Patrick Flanagan
- Department of Internal Medicine, Community Care Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - James Lane
- Nursing Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - David Toth
- Nursing Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Deborah Paul
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Carli Lehr
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Ave L2-330, Cleveland, OH 44195, USA
| | - Adriano R Tonelli
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Ave L2-330, Cleveland, OH 44195, USA.,Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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