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Mathavan A, Mathavan A, Reddy R, Jones K, Eagan C, Alnuaimat H, Ataya A. Pulmonary hypertension in hereditary hemorrhagic telangiectasia: A clinical review. Pulm Circ 2023; 13:e12301. [PMID: 37868718 PMCID: PMC10585978 DOI: 10.1002/pul2.12301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/24/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant hereditary disorder characterized by recurrent spontaneous epistaxis, mucocutaneous telangiectasias, and solid organ arteriovenous malformations (AVMs). Pulmonary hypertension (PH) is an increasingly recognized complication in patients with HHT, most often precipitated by high-output heart failure in the presence of hepatic AVMs as well as pulmonary arterial hypertension in the form of a proliferative vasculopathy. The presence of PH in patients with HHT is associated with significant elevations in rates of morbidity and mortality. Additionally, there is growing recognition of a thromboembolic propensity in this population that increases the risk of chronic thromboembolic PH, posing unique clinical considerations regarding the use of anticoagulation. Patients with HHT are also at risk of PH due to disorders commonly seen in the general population, including left-sided heart and lung disease. The etiology of PH in HHT is multifaceted and complex; the diagnostic approach and treatment strategies must consider the underlying pathophysiology of HHT. This comprehensive review summarizes current knowledge of PH in HHT, detailing the pathogenesis of known etiologies, diagnostic evaluation, and suggested treatment modalities as well as emerging therapies that may be of future interest.
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Affiliation(s)
- Akash Mathavan
- Department of Internal MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Akshay Mathavan
- Department of Internal MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Renuka Reddy
- Division of Pulmonary, Critical Care, and Sleep MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Kirk Jones
- Department of Internal MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Christina Eagan
- Division of Pulmonary, Critical Care, and Sleep MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Hassan Alnuaimat
- Respiratory Institute Pulmonary, Critical Care, and Sleep MedicineCleveland Clinic Abu DhabiAbu DhabiUnited Arab Emirates
| | - Ali Ataya
- Division of Pulmonary, Critical Care, and Sleep MedicineUniversity of FloridaGainesvilleFloridaUSA
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Correlation of Impedance Cardiography-Derived and Cardiac Magnetic Resonance-Derived Stroke Volumes. Curr Probl Cardiol 2023; 48:101457. [PMID: 36273652 DOI: 10.1016/j.cpcardiol.2022.101457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 10/13/2022] [Indexed: 01/04/2023]
Abstract
Cardiac output (CO) and other hemodynamic parameter measurements play an important role in the management of cardiovascular conditions; however, due to limitations of current day technologies, such measurements are either not routinely performed or incorporated into clinical practice. Moreover, measurement of these hemodynamic parameters in the outpatient setting at different time points to assess interval change is currently not feasible. We attempted to validate total-body impedance cardiography-based Non-Invasive Cardiac System (NICaS) derived stroke volume (SV) with that from cardiac magnetic resonance (CMR), a current day gold standard method of assessment. We compared SV, as it is the primary unit of measurement utilized by both technologies. Forty-one consecutive patients undergoing CMR were also investigated by NICaS following CMR. The consistency of non-invasive technology-derived SV measurement was validated by NICaS measurement in 10 subjects, both before and after CMR. Of the 41 enrolled patients; data from 38 patients was adequate for comparison (motion artifact prevented CMR measures in 3 patients). Fourteen patients (37%) were female; mean age was 55 ± 15 years (28-87 years) and body-mass index was 28.7 ± 5.5 kg/m2 (20.5-41.9 kg/m2). Hypertrophic cardiomyopathy (9/41) was the most common study indication for CMR. NICaS-derived SV strongly correlated with CMR [NICaS 77 ± 20 ml (31-123 ml) and CMR 84 ± 23 ml (47-132 ml); P < 0.001; r = 0.77; ICC = 0.73]. The Bland-Altman limits of agreement between NICaS and CMR were -26.7% and 39.9%. NICaS-derived SV collected before and after MRI did not differ [80 ± 18 ml (51-102 ml) pre and 76 ± 17 ml (50-99 ml) post; P = 0.0007, Kappa = 1]. Agreement between NICaS-derived and CMR-derived SV was within the acceptable range of boundaries set by the US Food and the Drug Administration. Consistency in SV measurement at different time-points may allow use of this technology to identify interval hemodynamic changes noninvasively.
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The Influence of Methods for Cardiac Output Determination on the Diagnosis of Precapillary Pulmonary Hypertension: A Mathematical Model. J Clin Med 2023; 12:jcm12020410. [PMID: 36675338 PMCID: PMC9864355 DOI: 10.3390/jcm12020410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 12/26/2022] [Accepted: 12/29/2022] [Indexed: 01/06/2023] Open
Abstract
Background: precapillary pulmonary hypertension (PH, PcPH) is now defined as a mean pulmonary artery pressure (mPAP) > 20 mmHg, a pulmonary artery wedge pressure (PAWP) ≤ 15 mmHg and a pulmonary vascular resistance (PVR) > 2 WU. For PVR calculation, the measurement of cardiac output (CO) is necessary. It is generally measured using thermodilution. However, recent data showed that the agreement with direct Fick method, historically the gold standard, is less than previously reported. We aimed to create a mathematical model that calculated the probability of being classified differently (PcPH or unclassified PH) if CO measured by direct Fick was used instead of thermodilution for any individual patients with a mPAP > 20 mmHg and a PAWP ≤ 15 mmHg. Methods: The model is based on Bland and Altman analysis with a normally distributed difference of cardiac output, fixed 1.96 standard deviation of bias, bias and physiological cardiac output limits. Results: Following a literature review of the studies comparing CO measured with direct Fick and thermodilution, we fixed the 1.96 standard deviation of bias at 2 L/min, bias at 0 L/min and physiological resting CO limits between 1.3 L/min and 10.2 L/min. Conclusions: This model can help the clinician to evaluate the potential benefit of measuring CO using direct Fick during the diagnostic work-up and its utility in confirming or ruling out a diagnosis of PcPH in any given patient with a mPAP > 20 mmHg and a PAWP ≤ 15 mmHg.
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Non-Invasive Cardiac Output Determination Using Magnetic Resonance Imaging and Thermodilution in Pulmonary Hypertension. J Clin Med 2022; 11:jcm11102717. [PMID: 35628843 PMCID: PMC9143884 DOI: 10.3390/jcm11102717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 04/30/2022] [Accepted: 05/09/2022] [Indexed: 12/10/2022] Open
Abstract
Magnetic resonance imaging (MRI) can be used to measure cardiac output (CO) non-invasively, which is a paramount parameter in pulmonary hypertension (PH) patients. We retrospectively compared stroke volume (SV) obtained with MRI (SVMRI) in six localisations against SV measured with thermodilution (TD) (SVTD) and against each other in 24 patients evaluated in our PH centre using Bland and Altman (BA) agreement analyses, linear correlation, and intraclass correlation (ICC). None of the six tested localisations for SVMRI reached the predetermined criteria for interchangeability with SVTD, with two standard deviations (2SD) of bias between 24.1 mL/beat and 31.1 mL/beat. The SVMRI methods yielded better agreement when compared against each other than the comparison between SVMRI and SVTD, with the best 2SD of bias being 13.8 mL/beat. The inter-observer and intra-observer ICCs for COMRI were excellent (inter-observer ICC between 0.889 and 0.983 and intra-observer ICC between 0.991 and 0.999). We could not confirm the interchangeability of SVMRI with SVTD based on the predetermined interchangeability criteria. The lack of agreement between MRI and TD might be explained because TD is less precise than previously thought. We evaluated a new method to estimate CO through the pulmonary circulation (COp) in PH patients that may be more precise than the previously tested methods.
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Troger F, Lechner I, Reindl M, Tiller C, Holzknecht M, Pamminger M, Kremser C, Schwaiger J, Reinstadler SJ, Bauer A, Metzler B, Mayr A, Klug G. A novel approach to determine aortic valve area with phase-contrast cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2022; 24:7. [PMID: 34986847 PMCID: PMC8734220 DOI: 10.1186/s12968-021-00838-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 12/15/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Transthoracic echocardiography (TTE) is the diagnostic routine standard for assessing aortic stenosis (AS). However, its inaccuracies in determining stroke volume (SV) and aortic valve area (AVA) call for a more precise and dependable method. Phase-contrast cardiovascular magnetic resonance imaging (PC-CMR) is a promising tool to push these boundaries. Thus, the aim of this study was to validate a novel approach based on PC-CMR against the gold-standard of invasive determination of AVA in AS compared to TTE. METHODS A total of 50 patients with moderate or severe AS underwent TTE, cardiac catheterization and CMR. AVA via PC-CMR was determined by plotting momentary flow across the valve against flow-velocity. SV by CMR was measured directly via PC-CMR and volumetrically using cine-images. Invasive SV and AVA were determined via Fick-principle and Gorlin-formula, respectively. TTE yielded SV and AVA using continuity equation. Gradients were calculated via the modified Bernoulli-equation. RESULTS SV by PC-CMR (85 ± 31 ml) correlated strongly (r: 0.73, p < 0.001) with cine-CMR (85 ± 19 ml) without significant bias (lower and upper limits of agreement (LLoA and ULoA): - 41 ml and 44 ml, p = 0.83). In PC-CMR, mean pressure gradient correlated significantly with invasive determination (r: 0.36, p = 0.011). Mean AVA, as determined by PC-CMR during systole (0.78 ± 0.25 cm2), correlated moderately (r: 0.54, p < 0.001) with invasive AVA (0.70 ± 0.23 cm2), resulting in a small bias of 0.08 cm2 (LLoA and ULoA: - 0.36 cm2 and 0.55 cm2, p = 0.017). Inter-methodically, AVA by TTE (0.81 ± 0.23 cm2) compared to invasive determination showed similar correlations (r: 0.58, p < 0.001 with a bias of 0.11 cm2, LLoA and ULoA: - 0.30 and 0.52, p < 0.001) to PC-CMR. Intra- and interobserver reproducibility were excellent for AVA (intraclass-correlation-coefficients of 0.939 and 0.827, respectively). CONCLUSIONS Our novel approach using continuous determination of flow-volumes and velocities with PC-CMR enables simple AVA measurement with no bias to invasive assessment. This approach highlights non-invasive AS grading through CMR, especially when TTE findings are inconclusive.
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Affiliation(s)
- Felix Troger
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Christina Tiller
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Magdalena Holzknecht
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Mathias Pamminger
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Christian Kremser
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Johannes Schwaiger
- Department of Internal Medicine, Academic Teaching Hospital Hall in Tirol, Hall in Tirol, Austria
| | - Sebastian J Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Axel Bauer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Agnes Mayr
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Gert Klug
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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Girdharry NR, Bentley RF, Valle FH, Karvasarski E, Osman S, Gurtu V, Kolker S, Mak S. Body Habitus Considerations During Right Heart Catheterization. CJC Open 2021; 3:1108-1116. [PMID: 34712937 PMCID: PMC8531193 DOI: 10.1016/j.cjco.2021.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 04/26/2021] [Indexed: 11/17/2022] Open
Abstract
Background Obese and overweight body habitus are common among patients undergoing right heart catheterization for suspected pulmonary hypertension, but previous studies have described only patients with severe obesity. This study examined the effect of body habitus on intracardiac pressures, thermodilution cardiac output (TDCO), indirect Fick (iFick) cardiac output (CO), and pulmonary vascular resistance (PVR) in subjects with normal cardiopulmonary hemodynamics. Methods A retrospective analysis was conducted on healthy volunteers and patients referred for right heart catheterization for dyspnea of unknown origin with normal hemodynamics. Of the 65 subjects (53 ± 14 years; 51% female), 31% were normal weight, 49% were overweight, and 20% had obesity, as defined by a body mass index of 30-39.9 kg/m2. Mixed venous oxygen saturations and intracardiac pressures were compared across body mass index categories. Agreement between iFick CO calculated by 3 formulae, and TDCO and PVR was examined. Results No differences in intracardiac pressures were observed, but mixed venous oxygen saturations were lower in the obese group. iFick CO underestimated TDCO, particularly with the LaFarge formula, with a systematic difference of 0.33 L/min for every 1 L/min increase in CO. This difference was largest in the obese group—on average by 23% ± 10%, translating to an overestimation of PVR by 34% ± 16% on average. Conclusions In individuals without severe obesity, intracardiac pressures are not different, but mixed venous oxygen saturations are lower. Obesity confounds estimations of CO and PVR by iFick methods, which could result in inappropriate hemodynamic classification. These data can inform best practices in hemodynamic assessment of populations with obesity.
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Affiliation(s)
- Natasha R Girdharry
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Cardiology, Mount Sinai Hospital/University Health Network, Toronto, Ontario, Canada
| | - Robert F Bentley
- Division of Cardiology, Mount Sinai Hospital/University Health Network, Toronto, Ontario, Canada.,Department of Exercise Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Felipe H Valle
- Division of Cardiology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Elizabeth Karvasarski
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Cardiology, Mount Sinai Hospital/University Health Network, Toronto, Ontario, Canada
| | - Sinan Osman
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Cardiology, Mount Sinai Hospital/University Health Network, Toronto, Ontario, Canada
| | - Vikram Gurtu
- Division of Cardiology, Mount Sinai Hospital/University Health Network, Toronto, Ontario, Canada
| | - Shimon Kolker
- Division of Cardiology, Mount Sinai Hospital/University Health Network, Toronto, Ontario, Canada
| | - Susanna Mak
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Cardiology, Mount Sinai Hospital/University Health Network, Toronto, Ontario, Canada
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Genecand L, Adler D, Beghetti M, Lador F. Cardiac Output Determination in Precapillary Pulmonary Hypertension: A Systematic Review. Respiration 2021; 100:1243-1250. [PMID: 34256370 DOI: 10.1159/000517084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 05/06/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cardiac output determination is essential in precapillary pulmonary hypertension. While direct Fick is the gold standard, thermodilution is commonly used as the reference method. Moving to noninvasive methods would be highly beneficial for patients, avoiding repetitive invasive assessments. This systematic review followed 3 objectives: (1) assessing the validity of indirect Fick and thermodilution in precapillary pulmonary hypertension, (2) assessing the interchangeability of noninvasive cardiac output measurement methods against reference methods in precapillary pulmonary hypertension, and (3) detecting methodological heterogeneity in the included studies. METHODS We systematically reviewed the literature using medical databases and following PRISMA guidelines. We included articles comparing an invasive or noninvasive cardiac output measurement method with thermodilution or direct Fick in precapillary pulmonary hypertension patients. Cutoffs of limits of agreement and percentage error derived from the Bland and Altman graph were used to accept interchangeability. To study methodological heterogeneity, we extracted 9 quality criteria from all studies. RESULTS Eleven studies were included. None reached the suggested interchangeability criteria. The median number of the 9 assessed quality criteria was 2 with interquartile range (0-4). CONCLUSIONS Further studies evaluating the reliability of thermodilution and the consequences of its use in precapillary pulmonary hypertension patients are necessary. No evidence supports the use of indirect Fick in precapillary pulmonary hypertension. The studied noninvasive methods could not be considered interchangeable with invasive methods. A robust methodology should be used to draw sensible conclusions.
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Affiliation(s)
- Léon Genecand
- Geneva Medical University, Geneva University Hospitals, Geneva, Switzerland, .,Internal Medicine Department, Riviera Chablais Hospital, Rennaz, Switzerland, .,Pulmonary Hypertension Program, Geneva University Hospitals, Geneva, Switzerland,
| | - Dan Adler
- Division of Pulmonary Diseases, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Maurice Beghetti
- Pulmonary Hypertension Program, Geneva University Hospitals, Geneva, Switzerland.,Paediatric Cardiology Unit, Geneva University Hospitals, Switzerland, Centre Universitaire Romand de Cardiologie et Chirurgie Cardiaque Pédiatrique, University of Geneva and Lausanne, Geneva, Switzerland
| | - Frédéric Lador
- Pulmonary Hypertension Program, Geneva University Hospitals, Geneva, Switzerland.,Division of Pulmonary Diseases, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
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Moghaddam N, Swiston JR, Tsang MYC, Levy R, Lee L, Brunner NW. Impact of targeted pulmonary arterial hypertension therapy in patients with combined post- and precapillary pulmonary hypertension. Am Heart J 2021; 235:74-81. [PMID: 33422519 DOI: 10.1016/j.ahj.2021.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/05/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Combined post- and precapillary pulmonary hypertension (CpcPH) portends poor outcomes in pulmonary hypertension related to left heart disease (PH-LHD). While recent evidence does not support the use of targeted pulmonary arterial hypertension (PAH) therapy in PH-LHD, there is a lack of clinical data on their use in CpcPH. We evaluated the outcomes in patients with CpcPH treated with PAH therapies. METHODS Retrospectively, 50 patients meeting hemodynamic criteria of CpcPH and started on PAH-targeted drugs were identified. Fifty age- and gender-matched PAH patients were chosen as controls. We evaluated the change in 6-minute walk distance, World Health Organization functional class (FC), tricuspid annular plane systolic excursion, BNP or NT-proBNP, and pulmonary artery systolic pressure at 3, 6, 12, and 24 months of follow-up. RESULTS After adjusting for age and gender, there was no improvement in World Health Organization FC in CpcPH over 2 years (odds ratio of change to FC I/II 1.01, 95% CI: 0.98-1.04). There was no significant improvement in 6-minute walk distance (β coefficient 0.21, 95% CI: -0.98 to 1.4), reduction in BNP/NT-proBNP (β coefficient -12.16, 95% CI: -30.68 to 6.37), increase in tricuspid annular plane systolic excursion (β coefficient 0.074, 95% CI: 0.010-0.139), or decrease in pulmonary artery systolic pressure (0.996, 95% CI: 0.991-1.011) in CpcPH with therapy. There was higher mortality in CpcPH compared to PAH on treatment (24% vs 4%, P = .003). CONCLUSIONS There were no improvements in symptoms, exercise capacity, or echocardiographic parameters with PAH-targeted therapy in CpcPH. Further studies into potential treatments benefiting this population are needed.
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Affiliation(s)
- Nima Moghaddam
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - John R Swiston
- Division of Respirology, University of British Columbia, Vancouver, British Columbia, Canada; Vancouver General Hospital Pulmonary Hypertension Program, Vancouver, British Columbia, Canada
| | - Michael Y C Tsang
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert Levy
- Division of Respirology, University of British Columbia, Vancouver, British Columbia, Canada; Vancouver General Hospital Pulmonary Hypertension Program, Vancouver, British Columbia, Canada
| | - Lisa Lee
- Vancouver General Hospital Pulmonary Hypertension Program, Vancouver, British Columbia, Canada
| | - Nathan W Brunner
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada; Vancouver General Hospital Pulmonary Hypertension Program, Vancouver, British Columbia, Canada.
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Hirani N, Brunner NW, Kapasi A, Chandy G, Rudski L, Paterson I, Langleben D, Mehta S, Mielniczuk L. Canadian Cardiovascular Society/Canadian Thoracic Society Position Statement on Pulmonary Hypertension. Can J Cardiol 2020; 36:977-992. [DOI: 10.1016/j.cjca.2019.11.041] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 11/20/2019] [Accepted: 11/21/2019] [Indexed: 11/15/2022] Open
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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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Papaioannou TG, Xanthis D, Argyris A, Vernikos P, Mastakoura G, Samara S, Floros IT, Protogerou AD, Tousoulis D. Accuracy and precision of cardiac output estimation by an automated, brachial cuff-based oscillometric device in patients with shock. Proc Inst Mech Eng H 2019; 234:1330-1336. [DOI: 10.1177/0954411919888321] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Non-invasive monitoring of cardiac output is a technological and clinical challenge, especially for critically ill, surgically operated, or intensive care unit patients. A brachial cuff-based, automated, oscillometric device used for blood pressure and arterial stiffness ambulatory monitoring (Mobil-O-Graph) provides a non-invasive estimation of cardiac output values simultaneously with regular blood pressure measurement. The aim of the study was to evaluate the feasibility of this apparatus to estimate cardiac output in intensive care unit patients and to compare the non-invasive estimated cardiac output values with the respective gold standard method of thermodilution during pulmonary artery catheterization. Repeated sequential measurements of cardiac output were performed, in random order, by thermodilution (reference) and Mobil-O-Graph (test), in 24 patients hospitalized at intensive care unit. Reproducibility and accuracy of the test device were evaluated by Bland–Altman analysis, intraclass correlation coefficient, and percentage error. Mobil-O-Graph underestimated significantly the cardiac output by −1.12 ± 1.38 L/min ( p < 0.01) compared to thermodilution. However, intraclass correlation coefficient was >0.7 indicating a fair agreement between the test and the reference methods, while percentage error was approximately 39% which is considered to be within the acceptable limits. Cardiac output measurements were reproducible by both Mobil-O-Graph (intraclass correlation coefficient = 0.73 and percentage error = 27.9%) and thermodilution (intraclass correlation coefficient = 0.91 and percentage error = 26.7%). We showed for the first time that cardiac output estimation in intensive care unit patients using a non-invasive, automated, oscillometric, cuff-based apparatus is reproducible (by analyzing two repeated cardiac output measurements), exhibiting similar precision to thermodilution. However, the accuracy of Mobil-O-Graph (error compared to thermodilution) could be considered fairly acceptable. Future studies remain to further examine the reliability of this technology in monitoring cardiac output or stroke volume acute changes which is a more clinically relevant objective.
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Affiliation(s)
- Theodore G Papaioannou
- Biomedical Engineering Unit, First Department of Cardiology, Medical School, Hippokration Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Antonis Argyris
- Cardiovascular Prevention and Research Unit, Department of Pathophysiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Stamatia Samara
- Cardiovascular Prevention and Research Unit, Department of Pathophysiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Athanase D Protogerou
- Cardiovascular Prevention and Research Unit, Department of Pathophysiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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