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Bajwa EK, Cislak D, Kumar A, Li D, Messina EJ, Reynders T, Denef JF, Corcea V, Buch KP, Lai E, Stoch SA. Phase 1 Study of MK-5475, an Inhaled Soluble Guanylate Cyclase Stimulator, in Participants with Pulmonary Hypertension Associated with Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2024; 19:1105-1121. [PMID: 38803412 PMCID: PMC11129706 DOI: 10.2147/copd.s454905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 05/14/2024] [Indexed: 05/29/2024] Open
Abstract
Purpose This phase 1 study (NCT04370873) evaluated safety and pharmacokinetics/pharmacodynamics (PK/PD) of MK-5475 in participants with pulmonary hypertension associated with COPD (PH-COPD). Methods Eligible participants were 40-80 years old with COPD (FEV1/FVC <0.7; FEV1 >30% predicted) and PH (mean pulmonary arterial pressure ≥25 mmHg). Participants were randomized 2:1 to MK-5475 or placebo via dry-powder inhaler once daily for 7 days in Part 1 (360 µg) or 28 days in Part 2 (380 µg). Safety was assessed by adverse events (AEs) and arterial blood oxygenation. Part-2 participants had pulmonary vascular resistance (PVR; primary PD endpoint) and pulmonary blood volume (PBV; secondary PD endpoint) measured at baseline and Day 28. A non-informative prior was used to calculate posterior probability (PP) that the between-group difference (MK-5475 - placebo) in mean percent reduction from baseline in PVR was less than -15%. Results Nine participants were randomized in Part 1, and 14 participants in Part 2. Median age of participants (86.4% male) was 68.5 years (41-77 years); 95.5% had moderate-to-severe COPD. Incidences of AEs were comparable between MK-5475 and placebo: overall (5/14 [36%] versus 5/8 [63%]), drug-related (1/14 [7%] versus 2/8 [25%]), and serious (1/14 [7%] versus 1/8 [13%]). MK-5475 caused no meaningful changes in arterial blood oxygenation or PBV. MK-5475 versus placebo led to numerical improvements from baseline in PVR (-21.2% [95% CI: -35.4, -7.0] versus -5.4% [95% CI: -83.7, 72.9]), with between-group difference in PVR less than -15% and calculated PP of 51%. Conclusion The favorable safety profile and numerical reductions in PVR observed support further clinical development of inhaled MK-5475 for PH-COPD treatment.
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Affiliation(s)
| | | | | | - Dan Li
- MRL, Merck & Co., Inc., Rahway, NJ, USA
| | | | - Tom Reynders
- Translational Medicine, MSD Belgium, Brussels, Belgium
| | | | - Vasile Corcea
- PMSI Republican Clinical Hospital “T. Mosneaga”, ARENSIA EM Unit, Chisinau, Republic of Moldova
| | - Ketan P Buch
- Department of Internal Medicine, Pulmonary and Critical Care Medicine, Lexington VA Healthcare, Lexington, KY, USA
| | - Eseng Lai
- MRL, Merck & Co., Inc., Rahway, NJ, USA
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Gifford JR, Blackmon C, Hales K, Hinkle LJ, Richards S. Overdot and overline annotation must be understood to accurately interpret V.O 2MAX physiology with the Fick formula. Front Physiol 2024; 15:1359119. [PMID: 38444762 PMCID: PMC10912163 DOI: 10.3389/fphys.2024.1359119] [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: 12/20/2023] [Accepted: 01/26/2024] [Indexed: 03/07/2024] Open
Abstract
Few formulas have been used in exercise physiology as extensively as the Fick formula, which calculates the rate of oxygen consumption (i.e., V.O2) as the product of cardiac output (Q.) and the difference in oxygen content in arterial and mixed venous blood (Δav ¯ O2). Unfortunately, the physiology of maximum V.O2 (V.O2MAX) is often misinterpreted due to a lack of appreciation for the limitations represented by the oft-ignored superscript annotations in the Fick formula. The purpose of this perspective is to explain the meaning of the superscript annotations and highlight how such annotations influence proper interpretation of V.O2MAX physiology with the Fick formula. First, we explain the significance of the overdots above V.O2 and Q., which indicate a measure per unit of time. As we will show, the presence of an overdot above Q. and lack of one above Δav ¯ O2 denotes they are different types of ratios and should be interpreted in the context of one another-not in contrast to each other as is commonplace. Second, we discuss the significance of the overline above the "v ¯ " in Δav ¯ O2, which indicates the venous sample is an average of blood that comes from mixed sources. The mixed nature of the venous sample has major implications for interpreting the influence of oxygen diffusion and blood flow heterogeneity on V.O2MAX. Ultimately, we give recommendations and insights for using the Fick formula to calculate V.O2 and interpret V.O2MAX physiology.
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Affiliation(s)
- Jayson R. Gifford
- Department of Exercise Sciences, Brigham Young University, Provo, UT, United States
- Program of Gerontology, Brigham Young University, Provo, UT, United States
| | - Christina Blackmon
- Department of Exercise Sciences, Brigham Young University, Provo, UT, United States
| | - Katelynn Hales
- Department of Exercise Sciences, Brigham Young University, Provo, UT, United States
| | - Lee J. Hinkle
- Department of Exercise Sciences, Brigham Young University, Provo, UT, United States
| | - Shay Richards
- Department of Exercise Sciences, Brigham Young University, Provo, UT, United States
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3
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Oh C, Lee HC, Lee S, Shim MS, Yoon SB, Jung J, Yoon SH, Kim YH, Ko Y, Hong B, Ku Y. Continuous cardiac output estimation using a new modified Fick method during off-pump coronary artery bypass graft surgery: a retrospective observational study. J Anesth 2024; 38:1-9. [PMID: 37740733 DOI: 10.1007/s00540-023-03260-x] [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: 06/07/2023] [Accepted: 09/07/2023] [Indexed: 09/25/2023]
Abstract
PURPOSE Several technical aspects of the Fick method limit its use intraoperatively. A data-driven modification of the Fick method may enable its use in intraoperative settings. METHODS This two-center retrospective observational study included 57 (28 and 29 in each center) patients who underwent off-pump coronary artery bypass graft (OPCAB) surgery. Intraoperative recordings of physiological data were obtained and divided into training and test datasets. The Fick equation was used to calculate cardiac output (CO-Fick) using ventilator-determined variables, intraoperative hemoglobin level, and SvO2, with continuous thermodilution cardiac output (CCO) used as a reference. A modification CO-Fick was derived and validated: CO-Fick-AD, which adjusts the denominator of the original equation. RESULTS Increased deviation between CO-Fick and CCO was observed when oxygen extraction was low. The root mean square error of CO-Fick was decreased from 6.07 L/min to 0.70 L/min after the modification. CO-Fick-AD showed a mean bias of 0.17 (95% CI 0.00-0.34) L/min, with a 36.4% (95% CI 30.6-44.4%) error. The concordance rates of CO-Fick-AD ranged from 73.3 to 87.1% depending on the time interval and exclusion zone. CONCLUSIONS The original Fick method is not reliable when oxygen extraction is low, but a modification using data-driven approach could enable continuous estimation of cardiac output during the dynamic intraoperative period with minimal bias. However, further improvements in precision and trending ability are needed.
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Affiliation(s)
- Chahyun Oh
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Soomin Lee
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Man-Shik Shim
- Department of Thoracic & Cardiovascular Surgery, Chungnam National University Hospital, Daejeon, Korea
| | - Soo Bin Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jinsik Jung
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Seok-Hwa Yoon
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Yoon-Hee Kim
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Youngkwon Ko
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Boohwi Hong
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
- Big Data Center, Biomedical Research Institute, Chungnam National University Hospital, Daejeon, Korea
| | - Yunseo Ku
- Department of Biomedical Engineering, Chungnam National University College of Medicine, 266 Munhwa-Ro(St), Jung-Gu, Daejeon, 35015, Korea.
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Kelly NJ, Newhouse D, Chapagain H, Patel A, Tang Y, Howard A, Kirillova A, Kim HJ, Rahman H, El Khoury W, Nouraie SM, Hickey G, Sade LE, Jain S, Chan SY. Omics and Extreme Phenotyping Reveal Longitudinal Association Between Left Atrial Size and Pulmonary Vascular Resistance in Group 2 Pulmonary Hypertension. J Am Heart Assoc 2023; 12:e031746. [PMID: 38014658 PMCID: PMC10727316 DOI: 10.1161/jaha.123.031746] [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: 07/11/2023] [Accepted: 11/02/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Left heart disease is the most common cause of pulmonary hypertension (PH) and is frequently accompanied by increases in pulmonary vascular resistance. However, the distinction between phenotypes of PH due to left heart disease with a normal or elevated pulmonary vascular resistance-isolated postcapillary PH (IpcPH) and combined pre- and postcapillary PH (CpcPH), respectively-has been incompletely defined using unbiased methods. METHODS AND RESULTS Patients with extremes of IpcPH versus CpcPH were identified from a single-center record of those who underwent right heart catheterization. Individuals with left ventricular ejection fraction <40% or with potential causes of PH beyond left heart disease were excluded. Medication usage in IpcPH and CpcPH was compared across Anatomical Therapeutic Chemical classes and identified vitamin K antagonists as the only medication with pharmacome-wide significance, being more commonly used in CpcPH and for an indication of atrial fibrillation in ≈90% of instances. Accordingly, atrial fibrillation prevalence was significantly higher in CpcPH in a phenome-wide analysis. Review of echocardiographic data most proximal to right heart catheterization revealed that left atrial diameter indexed to body surface area-known to be associated with atrial fibrillation-was increased in CpcPH regardless of the presence of atrial fibrillation. An independent cohort with serial right heart catheterizations and PH-left heart disease showed a significant positive correlation between change in left atrial diameter indexed to body surface area and change in pulmonary vascular resistance. CONCLUSIONS Guided by pharmacomic and phenomic screens in a rigorously phenotyped cohort, we identify a longitudinal association between left atrial diameter indexed to body surface area and pulmonary vascular resistance with implications for the future development of diagnostic, prognostic, and therapeutic tools.
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Affiliation(s)
- Neil J. Kelly
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, and Blood Vascular Medicine InstitutePittsburghPA
- Heart and Vascular InstitutePittsburghPA
- Pittsburgh VA Medical CenterPittsburghPA
| | - David Newhouse
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, and Blood Vascular Medicine InstitutePittsburghPA
| | | | | | - Yicheng Tang
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, and Blood Vascular Medicine InstitutePittsburghPA
| | - Ato Howard
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of MedicineUniversity of Pittsburgh School of Medicine and University of Pittsburgh Medical CenterPittsburghPA
| | - Anna Kirillova
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, and Blood Vascular Medicine InstitutePittsburghPA
| | - Hee‐Jung J. Kim
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, and Blood Vascular Medicine InstitutePittsburghPA
| | - Haris Rahman
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, and Blood Vascular Medicine InstitutePittsburghPA
| | - Wadih El Khoury
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, and Blood Vascular Medicine InstitutePittsburghPA
- Heart and Vascular InstitutePittsburghPA
| | - Seyed Mehdi Nouraie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of MedicineUniversity of Pittsburgh School of Medicine and University of Pittsburgh Medical CenterPittsburghPA
| | - Gavin Hickey
- Heart and Vascular InstitutePittsburghPA
- Pittsburgh VA Medical CenterPittsburghPA
| | | | | | - Stephen Y. Chan
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, and Blood Vascular Medicine InstitutePittsburghPA
- Heart and Vascular InstitutePittsburghPA
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Jenkins DP, Martinez G, Salaunkey K, Reddy SA, Pepke-Zaba J. Perioperative Management in Pulmonary Endarterectomy. Semin Respir Crit Care Med 2023; 44:851-865. [PMID: 37487525 DOI: 10.1055/s-0043-1770123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (PH), provided lesions are proximal enough in the pulmonary vasculature to be surgically accessible and the patient is well enough to benefit from the operation in the longer term. It is a major cardiothoracic operation, requiring specialized techniques and instruments developed over several decades to access and dissect out the intra-arterial fibrotic material. While in-hospital operative mortality is low (<5%), particularly in high-volume centers, careful perioperative management in the operating theater and intensive care is mandatory to balance ventricular performance, fluid balance, ventilation, and coagulation to avoid or treat complications. Reperfusion pulmonary edema, airway hemorrhage, and right ventricular failure are the most problematic complications, often requiring the use of extracorporeal membrane oxygenation to bridge to recovery. Successful PEA has been shown to improve both morbidity and mortality in large registries, with survival >70% at 10 years. For patients not suitable for PEA or with residual PH after PEA, balloon pulmonary angioplasty and/or PH medical therapy may prove beneficial. Here, we describe the indications for PEA, specific surgical and perioperative strategies, postoperative monitoring and management, and approaches for managing residual PH in the long term.
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Affiliation(s)
- David P Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Guillermo Martinez
- Department of Anaesthesiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Kiran Salaunkey
- Department of Anaesthesiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - S Ashwin Reddy
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
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6
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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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7
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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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8
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Aslam MI, Gruslova AB, Almomani A, Nolen D, Elliott JJ, Jani VP, Kottam A, Porterfield J, Heighten C, Anderson AS, Valvano JW, Feldman MD. Modification of a Transvalvular Microaxial Flow Pump for Instantaneous Determination of Native Cardiac Output and Volume. J Card Fail 2023; 29:1369-1379. [PMID: 37105397 DOI: 10.1016/j.cardfail.2023.04.007] [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: 11/21/2022] [Revised: 04/10/2023] [Accepted: 04/10/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND The current Impella cardiopulmonary (CP) pump, used for mechanical circulatory support in patients with cardiogenic shock (CS), cannot assess native cardiac output (CO) and left ventricular (LV) volumes. These data are valuable in facilitating device management and weaning. Admittance technology allows for accurate assessment of cardiac chamber volumes. OBJECTIVES This study tested the ability to engineer admittance electrodes onto an existing Impella CP pump to assess total and native CO as well as LV chamber volumes in an instantaneous manner. METHODS Impella CP pumps were fitted with 4 admittance electrodes and were placed in the LVs of adult swine (n = 9) that were subjected to 3 different hemodynamic conditions, including Impella CP speed adjustments, administration of escalating doses of dobutamine and microsphere injections into the left main artery to result in cardiac injury. CO, according to admittance electrodes, was calculated from LV volumes and heart rate. In addition, CO was calculated in each instance via thermodilution, continuous CO measurement, the Fick principle, and aortic velocity-time integral by means of echocardiography. RESULTS Modified Impella CP pumps were placed in swine LVs successfully. CO, as determined by admittance electrodes, was similar by trend to other methods of CO assessment. It was corrected for pump speed to calculate native CO, and calculated LV chamber volumes trended as expected in each experimental protocol. CONCLUSIONS We report, for the first time, that an Impella CP pump can be fitted with admittance electrodes and used to determine total and native CO in various hemodynamic situations. CONDENSED ABSTRACT Transvalvular mechanical circulatory support devices such as the Impella CP do not have the ability to provide real-time information on native cardiac output (CO) and left ventricular (LV) volumes. This information is critical in device management and in weaning in patients with cardiogenic shock. We demonstrate, for the first time, that Impella CP pumps coupled with admittance electrodes are able to determine native CO and LV chamber volumes in multiple hemodynamic situations such as Impella pump speed adjustments, escalating dobutamine administration and cardiac injury from microsphere injection.
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Affiliation(s)
- M Imran Aslam
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Aleksandra B Gruslova
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Ahmed Almomani
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Drew Nolen
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - James J Elliott
- Department of Laboratory Animal Resources, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Vivek P Jani
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Anil Kottam
- BridgeSource Medical Corporation, Austin, Texas
| | | | | | - Allen S Anderson
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Jonathan W Valvano
- Department of Electrical Engineering, University of Texas at Austin, Austin, Texas
| | - Marc D Feldman
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas.
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Hameed A, Condliffe R, Swift AJ, Alabed S, Kiely DG, Charalampopoulos A. Assessment of Right Ventricular Function-a State of the Art. Curr Heart Fail Rep 2023; 20:194-207. [PMID: 37271771 PMCID: PMC10256637 DOI: 10.1007/s11897-023-00600-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2023] [Indexed: 06/06/2023]
Abstract
PURPOSE OF REVIEW The right ventricle (RV) has a complex geometry and physiology which is distinct from the left. RV dysfunction and failure can be the aftermath of volume- and/or pressure-loading conditions, as well as myocardial and pericardial diseases. RECENT FINDINGS Echocardiography, magnetic resonance imaging and right heart catheterisation can assess RV function by using several qualitative and quantitative parameters. In pulmonary hypertension (PH) in particular, RV function can be impaired and is related to survival. An accurate assessment of RV function is crucial for the early diagnosis and management of these patients. This review focuses on the different modalities and indices used for the evaluation of RV function with an emphasis on PH.
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Affiliation(s)
- Abdul Hameed
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Andrew J Swift
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- INSIGNEO, Institute for in silico Medicine, University of Sheffield, Sheffield, UK
| | - Samer Alabed
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- INSIGNEO, Institute for in silico Medicine, University of Sheffield, Sheffield, UK
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- NIHR Sheffield Biomedical Research Centre, Sheffield, UK
| | - Athanasios Charalampopoulos
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK.
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.
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10
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Chiba Y, Iwano H, Aoyagi H, Tamaki Y, Motoi K, Ishizaka S, Murayama M, Yokoyama S, Nakabachi M, Nishino H, Kaga S, Kamiya K, Nagai T, Anzai T. Associations of right ventricular pulsatile load and cardiac power output to clinical outcomes in heart failure: Difference from systemic circulation. J Cardiol 2023; 81:404-412. [PMID: 36503065 DOI: 10.1016/j.jjcc.2022.12.003] [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] [Received: 08/03/2022] [Revised: 10/21/2022] [Accepted: 11/20/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although left ventricular (LV) cardiac power output (CPO) is a powerful prognostic indicator in heart failure (HF), the significance of right ventricular (RV) CPO is unknown. In contrast, RV pulsatile load is a key prognostic marker in HF. We investigated the impact of RV-CPO and pulsatile load on cardiac outcome and the prognostic performance of the combined systemic and pulmonary circulation parameters in HF. METHODS Right heart catheterization and echocardiography were performed in 231 HF patients (62 ± 16 years, LV ejection fraction 42 ± 18 %). Invasive and noninvasive CPOs were calculated from mean systemic or pulmonary arterial pressure and cardiac output. LV-CPO was then normalized to LV mass (LV-P/M). Pulmonary arterial capacitance and the ratio of acceleration time to ejection time (AcT/ET) of RV outflow were used as parameters of RV pulsatile load. The primary endpoints, defined as a composite of cardiac death, HF hospitalization, ventricular arrythmia, and LVAD implantation after the examination, were recorded. RESULTS Noninvasive CPOs were moderately correlated with invasive ones (LV: ρ = 0.787, RV: ρ = 0.568, and p < 0.001 for both). During a median follow-up period of 441 days, 57 cardiovascular events occurred. Lower LV-P/M and higher RV pulsatile load were associated with cardiovascular events; however, RV-CPO was not associated with the outcome. Echocardiographic LV-P/M and AcT/ET showed significant incremental prognostic value over the clinical parameters. CONCLUSIONS RV pulsatile load assessed by AcT/ET may be a predictor of clinical events in HF patients. The combination of echocardiographic LV-P/M and AcT/ET could be a novel noninvasive prognostic indicator in HF patients.
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Affiliation(s)
- Yasuyuki Chiba
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroyuki Iwano
- Division of Cardiology, Teine Keijinkai Hospital, Sapporo, Japan; Diagnostic Center for Sonography, Hokkaido University Hospital, Sapporo, Japan.
| | - Hiroyuki Aoyagi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yoji Tamaki
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Ko Motoi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Suguru Ishizaka
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Michito Murayama
- Diagnostic Center for Sonography, Hokkaido University Hospital, Sapporo, Japan
| | - Shinobu Yokoyama
- Division of Clinical Laboratory and Transfusion Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Masahiro Nakabachi
- Division of Clinical Laboratory and Transfusion Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Hisao Nishino
- Division of Clinical Laboratory and Transfusion Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Sanae Kaga
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Kiwamu Kamiya
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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11
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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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12
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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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13
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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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14
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Desole S, Obst A, Habedank D, Opitz CF, Knaack C, Hortien F, Heine A, Stubbe B, Ewert R. Comparison between thermodilution and Fick methods for resting and exercise‐induced cardiac output measurement in patients with chronic dyspnea. Pulm Circ 2022; 12:e12128. [PMID: 36051350 PMCID: PMC9425001 DOI: 10.1002/pul2.12128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 06/07/2022] [Accepted: 08/08/2022] [Indexed: 11/10/2022] Open
Abstract
Studies comparing thermodilution (TD) and the direct Fick method (dFM) for cardiac output (CO) measurement are rare. We compared CO measurements between TD (2–5 cold water injections), the dFM, and indirect Fick method (iFM) at rest and during exercise, and assessed the effect of averaging different numbers of TD measurements during exercise. This retrospective study included 300 patients (52.3% women, mean age 66 ± 11 years) having pulmonary hypertension (76.0%) or unexplained dyspnea. Invasive hemodynamic and gas exchange parameters were measured at rest (supine; n = 300) and during unloaded cycling (semi‐supine; n = 275) and 25‐W exercise (semi‐supine; n = 240). All three methods showed significant differences in CO measurement (ΔCO) at rest (p ≤ 0.001; ΔCO > 1 L/min: 45.0% [iFM vs. dFM], 42.0% [iFM vs. TD], and 45.7% [TD vs. dFM]). ΔCO (TD vs. dFM) was significant during unloaded cycling (p < 0.001; ΔCO > 1 L/min: 56.6%) but not during 25‐W exercise (p = 0.137; ΔCO > 1 L/min: 52.8%). ΔCO (TD vs. dFM) during 25‐W exercise was significant when using one or two (p ≤ 0.01) but not three (p = 0.06) TD measurements. Mean ΔCO (TD [≥3 measurements] vs. dFM) was −0.43 ± 1.98 and −0.06 ± 2.29 L/min during unloaded and 25‐W exercise, respectively. Thus, TD and dFM CO measurements are comparable during 25‐W exercise (averaging ≥3 TD measurements), but not during unloaded cycling or at rest. Individual ΔCOs vary substantially and require critical interpretation to avoid CO misclassification.
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Affiliation(s)
- Susanna Desole
- Division of Pneumology, Department of Internal Medicine BUniversity Hospital GreifswaldGreifswaldGermany
| | - Anne Obst
- Division of Pneumology, Department of Internal Medicine BUniversity Hospital GreifswaldGreifswaldGermany
| | - Dirk Habedank
- Division of Pneumology, Department of Internal Medicine BUniversity Hospital GreifswaldGreifswaldGermany
- Division of Cardiology, Department of Internal MedicineDRK‐HospitalBerlinGermany
| | - Christian F. Opitz
- Division of Cardiology, Department of Internal MedicineDRK‐HospitalBerlinGermany
| | - Christine Knaack
- Division of Pneumology, Department of Internal Medicine BUniversity Hospital GreifswaldGreifswaldGermany
| | - Franziska Hortien
- Division of Pneumology, Department of Internal Medicine BUniversity Hospital GreifswaldGreifswaldGermany
| | - Alexander Heine
- Division of Pneumology, Department of Internal Medicine BUniversity Hospital GreifswaldGreifswaldGermany
| | - Beate Stubbe
- Division of Pneumology, Department of Internal Medicine BUniversity Hospital GreifswaldGreifswaldGermany
| | - Ralf Ewert
- Division of Pneumology, Department of Internal Medicine BUniversity Hospital GreifswaldGreifswaldGermany
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15
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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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16
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Suzuki S, Asano R, Aoki T, Nakayama S, Ueda J, Tsuji A, Noguchi T, Ogo T. Prognostic impact of follow-up pulmonary vascular resistance in pulmonary arterial hypertension. Open Heart 2022; 9:openhrt-2022-002054. [PMID: 35675988 PMCID: PMC9185661 DOI: 10.1136/openhrt-2022-002054] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 05/18/2022] [Indexed: 11/30/2022] Open
Abstract
Objective Pulmonary arterial hypertension (PAH), caused by pulmonary artery remodelling and increased pulmonary vascular resistance (PVR) due to an unknown mechanism, is an intractable disease with a poor prognosis. The recent development of PAH-specific treatment medications may allow for higher PVR reduction than previously achieved. This study aimed to identify the prognostic significance of follow-up PVR levels achieved shortly after the initiation of targeted treatment in patients with idiopathic/heritable pulmonary arterial hypertension (I/H-PAH). Methods We analysed the data of all patients with I/H-PAH admitted to our hospital between 1998 and 2019. We collected data at baseline and during the first invasive haemodynamic evaluation. The primary outcome was death or lung transplantation. Results Of the 133 treatment-naïve patients enrolled in this study, 47 experienced adverse events during a median follow-up period of 6.4 (IQR 3.5–11.5) years. The median time interval to first follow-up from diagnosis was 162 (IQR 117–253) days. Incidence of the primary outcome was significantly lower in patients who achieved low PVR at follow-up. Of risk factors evaluated at follow-up, the multivariate Cox regression analysis revealed PVR as an independent predictor of the primary outcome (HR 1.103, 95% CI 1.029 to 1.183; p=0.006). The results were consistent across risk profiles according to the simplified risk stratification recommended by the European Society of Cardiology and European Respiratory Society guidelines. Conclusion Follow-up PVR was an independent predictor of transplant-free survival in patients with I/H-PAH. Evaluation of haemodynamic status shortly after initiating treatment may help predict long-term prognosis.
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Affiliation(s)
- Sho Suzuki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Ryotaro Asano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tatsuo Aoki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sayuri Nakayama
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Jin Ueda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akihiro Tsuji
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takeshi Ogo
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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17
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Boehm PM, Schwarz S, Thanner J, Veraar C, Gerges M, Gerges C, Lang I, Apfaltrer P, Prosch H, Taghavi S, Klepetko W, Ankersmit HJ, Moser B. Larger pulmonary artery to ascending aorta ratios are associated with decreased survival of patients undergoing pulmonary endarterectomy. JTCVS OPEN 2022; 10:62-72. [PMID: 36004247 PMCID: PMC9390379 DOI: 10.1016/j.xjon.2022.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 02/17/2022] [Indexed: 11/25/2022]
Abstract
Objectives The ratio of pulmonary artery (PA) and ascending aorta (AA) diameters has recently been shown to be a useful indicator for disease severity and predictor of outcome in patients with pulmonary hypertension and heart failure. This study aimed at evaluating the applicability of this ratio for perioperative risk assessment of patients with chronic thromboembolic pulmonary hypertension undergoing pulmonary endarterectomy. Methods In this retrospective cohort study on 149 patients undergoing pulmonary endarterectomy between 2013 and 2020, the preoperative PA to AA ratio was analyzed on axial computed tomography. Variables of pulmonary hemodynamic status were assessed during preoperative right heart catheterization and postoperative Swan-Ganz catheter measurements. Perioperative survival was analyzed by Kaplan-Meier method and log-rank tests. Results Preoperative computed tomography measurements showed a median AA diameter of 31 mm (range, 19-47 mm), and a median PA diameter of 36 mm (range, 25-55 mm). The calculated median PA to AA ratio was 1.13 (range, 0.79-1.80). PA to AA ratio correlated positively with PA pressure (systolic, r = 0.352 [P < .001]; diastolic, r = 0.406 [P < .001]; mean, r = 0.318 [P < .001]) and inversely with age (r = −0.484 [P < .001]). Univariable Cox regression analysis identified PA diameter (P = .008) as a preoperative parameter predictive of survival. There was a significant difference (log-rank P = .037) in 30-day survival probability for patients with lower PA to AA ratios (<1.136; survival probability, 97.4%) compared with patients with higher ratios (>1.136; survival probability, 88.9%). Conclusions PA to AA ratio shows a correlation with other variables associated with pulmonary hypertension. In addition, patients with higher PA to AA ratios have lower survival probabilities after PEA. Further analysis of PA to AA ratio on the selection of chronic thromboembolic pulmonary hypertension for different treatment modalities—pulmonary endarterectomy, medical therapy, and or balloon pulmonary angioplasty—is warranted.
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Affiliation(s)
- Panja M. Boehm
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Stefan Schwarz
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Jürgen Thanner
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Cecilia Veraar
- Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Mario Gerges
- Division of Cardiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria
| | - Christian Gerges
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Irene Lang
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Paul Apfaltrer
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Helmut Prosch
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Shahrokh Taghavi
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Walter Klepetko
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Bernhard Moser
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
- Address for reprints: Bernhard Moser, MD, PhD, MBA, Department of Thoracic Surgery, Medical University of Vienna, Austria, Waehringer Guertel 18-20, 1090 Vienna, Austria.
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18
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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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19
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Ugawa S, Akagi S, Ejiri K, Nakamura K, Ito H. Quantification of Lung Perfusion Blood Volume in Dual-Energy Computed Tomography in Patients with Pulmonary Hypertension. Life (Basel) 2022; 12:684. [PMID: 35629352 PMCID: PMC9143856 DOI: 10.3390/life12050684] [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: 03/30/2022] [Revised: 04/28/2022] [Accepted: 05/03/2022] [Indexed: 11/17/2022] Open
Abstract
Dual-energy computed tomography (DECT) is a promising technique for the assessment of the lung perfused blood volume (LPBV) in the lung parenchyma. This study was performed to compare the LPBV by DECT of patients with pulmonary hypertension (PH) and controls and to evaluate the association between the LPBV and the perfusion ratio derived by lung perfusion scintigraphy. This study involved 45 patients who underwent DECT (25 patients with PH and 20 controls). We measured the total LPBV and distribution of the LPBV in each lung. The total LPBV was significantly lower in the PH group than the control group (38 ± 9 vs. 45 ± 8 HU, p = 0.024). Significant differences were observed between the LPBV of the upper lung of the PH and control groups (34 ± 10 vs. 47 ± 10, p = 0.021 and 37 ± 10 vs. 47 ± 8, p < 0.001). A significant correlation was observed between the LPBV and the lung perfusion scintigraphy. A lower total LPBV and lower LPBV of the upper lung as detected by DECT might be specific findings of PH.
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Affiliation(s)
- Satoko Ugawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan; (S.U.); (K.E.); (K.N.); (H.I.)
- Department of Cardiology, Kagawa Prefectural Central Hospital, Takamatsu 760-8557, Japan
| | - Satoshi Akagi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan; (S.U.); (K.E.); (K.N.); (H.I.)
| | - Kentaro Ejiri
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan; (S.U.); (K.E.); (K.N.); (H.I.)
| | - Kazufumi Nakamura
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan; (S.U.); (K.E.); (K.N.); (H.I.)
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan; (S.U.); (K.E.); (K.N.); (H.I.)
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20
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Rali AS, Butcher A, Tedford RJ, Sinha SS, Mekki P, Van Spall HGC, Sauer AJ. Contemporary Review of Hemodynamic Monitoring in the Critical Care Setting. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2021.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Hemodynamic assessment remains the most valuable adjunct to physical examination and laboratory assessment in the diagnosis and management of shock. Through the years, multiple modalities to measure and trend hemodynamic indices have evolved with varying degrees of invasiveness. Pulmonary artery catheter (PAC) has long been considered the gold standard of hemodynamic assessment in critically ill patients and in recent years has been shown to improve clinical outcomes among patients in cardiogenic shock. The invasive nature of PAC is often cited as its major limitation and has encouraged development of less invasive technologies. In this review, the authors summarize the literature on the mechanism and validation of several minimally invasive and noninvasive modalities available in the contemporary intensive care unit. They also provide an update on the use of focused bedside echocardiography.
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Affiliation(s)
- Aniket S Rali
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Amy Butcher
- Department of Cardiovascular Anesthesia and Critical Care, Baylor College of Medicine, Houston, TX
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Shashank S Sinha
- Division of Cardiology, Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA
| | - Pakinam Mekki
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Harriette GC Van Spall
- Department of Medicine, Department of Health Research Methods, Evidence, and Impact, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Andrew J Sauer
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, KS
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21
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Badagliacca R, Rischard F, Giudice FL, Howard L, Papa S, Valli G, Manzi G, Sciomer S, Palange P, Garcia JG, Vanderpool R, Rinaldo R, Vigo B, Insel M, Fedele F, Vizza CD. INCREMENTAL VALUE OF CARDIOPULMONARY EXERCISE TESTING IN INTERMEDIATE-RISK PULMONARY ARTERIAL HYPERTENSION. J Heart Lung Transplant 2022; 41:780-790. [DOI: 10.1016/j.healun.2022.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 02/02/2022] [Accepted: 02/28/2022] [Indexed: 01/29/2023] Open
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22
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Robertson L, Bunclark K, Ross RM, Cannon J, Sheares K, Taboada D, Pepke-Zaba J, Toshner M. The prognostic ability of cardiac output determined by inert gas rebreathing technique in pulmonary hypertension. Chron Respir Dis 2022; 19:14799731221078473. [PMID: 35184583 PMCID: PMC8864257 DOI: 10.1177/14799731221078473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
This investigation validated the inert gas rebreathing (IGR) technique and
determined IGR prognostic ability compared to invasive cardiac output
measurements in patients with pulmonary hypertension. IGR compared with
thermodilution cardiac output demonstrated a moderate bias. IGR technique
demonstrated long-term prognostic value comparable to invasive cardiac output in
pulmonary hypertension patients
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Affiliation(s)
- Lucy Robertson
- Department of Medicine, University
of Cambridge, Cambridge, UK
- Lucy Robertson, Pulmonary Vascular Disease
Unit, Royal Papworth Hospital, Papworth Road, Cambridge CB2 0AY, UK.
| | | | | | - John Cannon
- Department of Medicine, University
of Cambridge, Cambridge, UK
| | - Karen Sheares
- Department of Medicine, University
of Cambridge, Cambridge, UK
| | - Dolores Taboada
- Department of Medicine, University
of Cambridge, Cambridge, UK
| | | | - Mark Toshner
- Department of Medicine, University
of Cambridge, Cambridge, UK
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23
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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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24
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Kumai Y, Seguchi O, Mochizuki H, Kimura Y, Iwasaki K, Kuroda K, Nakajima S, Matsumoto Y, Watanabe T, Yanase M, Sata M, Fukushima S, Fujita T, Chikamori T, Kobayashi J, Fukushima N. Impact of sleep-disordered breathing on ventricular tachyarrhythmias after left ventricular assist device implantation. J Artif Organs 2022; 25:223-230. [PMID: 35022936 DOI: 10.1007/s10047-021-01307-y] [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: 08/03/2021] [Accepted: 11/30/2021] [Indexed: 10/19/2022]
Abstract
Sleep-disordered breathing (SDB) is associated with an increased risk of adverse events in patients with heart failure (HF); however, its impact in patients implanted with a left ventricular assist device (LVAD) remains unclear. We aimed to investigate the prevalence of SDB in patients with LVAD and its impact on their clinical outcomes. Fifty consecutive patients with LVAD who underwent portable sleep monitoring between September 2017 and April 2018 were prospectively enrolled, and they were followed up for 170 ± 36 days. According to their respiratory disturbance indexes (RDIs), they were categorized into the SDB group (RDI ≥ 15, n = 12) and the non-SDB group (RDI < 15, n = 38). The incidence of adverse events during the follow-up period was investigated after enrollment. Multivariate logistic regression analysis revealed significant differences in SDB in LVAD-implanted patients in terms of the logarithmic transformation brain natriuretic peptide (BNP) values (p = 0.005). The optimal BNP cut-off value for SDB prediction in LVAD-implanted patients was 300 pg/mL (sensitivity: 58.3%, specificity: 94.7%). During follow-up, ventricular tachyarrhythmias (VTas) occurred significantly more frequently in the SDB group (4 [33%] vs. 2 [5%] patients, p = 0.02); Atrial tachyarrhythmia (ATa) also tended to occur more frequently in the SDB group (2 [25%] vs. 2 [2%] patients, p = 0.07). SBD was prevalent in 24% of the LVAD-implanted patients with advanced HF. Furthermore, SDB was significantly associated with high BNP levels and was also potentially associated with subsequent incidence of VTa in patients with LVAD.
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Affiliation(s)
- Yuto Kumai
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Osamu Seguchi
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan.
| | - Hiroki Mochizuki
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Yuki Kimura
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Keiichiro Iwasaki
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Kensuke Kuroda
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Seiko Nakajima
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Yorihiko Matsumoto
- Department of Pulmonology and Infection Control, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Takuya Watanabe
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Masanobu Yanase
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Makoto Sata
- Department of Pulmonology and Infection Control, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Satsuki Fukushima
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | | | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Norihide Fukushima
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan.
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25
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Hsu S, Fang JC, Borlaug BA. Hemodynamics for the Heart Failure Clinician: A State-of-the-Art Review. J Card Fail 2022; 28:133-148. [PMID: 34389460 PMCID: PMC8748277 DOI: 10.1016/j.cardfail.2021.07.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/19/2021] [Accepted: 07/21/2021] [Indexed: 01/03/2023]
Abstract
Heart failure (HF) fundamentally reflects an inability of the heart to provide adequate blood flow to the body without incurring the cost of increased cardiac filling pressures. This failure occurs first during the stressed state, but progresses until hemodynamic derangements become apparent at rest. As such, the measurement and interpretation of both resting and stressed hemodynamics serve an integral role in the practice of the HF clinician. In this review, we discuss conceptual and technical best practices in the performance and interpretation of both resting and invasive exercise hemodynamic catheterization, relate important pathophysiologic concepts to clinical care, and discuss updated, evidence-based applications of hemodynamics as they pertain to the full spectrum of HF conditions.
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Affiliation(s)
- Steven Hsu
- Division of Cardiology, Dept. of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - James C Fang
- Division of Cardiology, Department of Medicine, University of Utah, Salt Lake City, Utah.
| | - Barry A Borlaug
- Division of Cardiology, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
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26
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Duknic M, Lichtblau M, Saxer S, Berlier C, Schneider SR, Schwarz EI, Carta AF, Furian M, Bloch KE, Ulrich S. Comparison of Repetitive Cardiac Output Measurements at Rest and End-Exercise by Direct Fick Using Pulse Oximetry vs. Blood Gases in Patients With Pulmonary Hypertension. Front Med (Lausanne) 2021; 8:776956. [PMID: 34888330 PMCID: PMC8649780 DOI: 10.3389/fmed.2021.776956] [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] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 10/25/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Exact and simultaneous measurements of mean pulmonary artery pressure (mPAP) and cardiac output (CO) are crucial to calculate pulmonary vascular resistance (PVR), which is essential to define pulmonary hypertension (PH). Simultaneous measurements of mPAP and CO are not feasible using the direct Fick (DF) method, due to the necessity to sample blood from the catheter-tip. We evaluated a modified DF method, which allows simultaneous measurement of mPAP and CO without needing repetitive blood samples. Methods: Twenty-four patients with pulmonary arterial or chronic thromboembolic PH had repetitive measurements of CO at rest and end-exercise during three phases of a crossover trial. CO was assessed by the original DF method using oxygen uptake, measured by a metabolic unit, and arterial and mixed venous oxygen saturations from co-oximetry of respective blood gases served as reference. These CO measurements were then compared with a modified DF method using pulse oximetry at the catheter- and fingertip. Results: The bias among CO measurements by the two DF methods at rest was −0.26 L/min with limits of agreement of ±1.66 L/min. The percentage error was 28.6%. At the end-exercise, the bias between methods was 0.29 L/min with limits of agreement of ±1.54 L/min and percentage error of 16.1%. Conclusion: Direct Fick using a catheter- and fingertip pulse oximetry (DFp) is a practicable and reliable method for assessing CO in patients with PH. This method has the advantage of allowing simultaneous measurement of PAP and CO, and frequent repetitive measurements are needed during exercise. Clinical Trial Registration:https://clinicaltrials.gov/ct2/show/NCT02755259, identifier: NCT02755259.
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Affiliation(s)
- Milos Duknic
- Department of Pulmonology, University Hospital Zürich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Mona Lichtblau
- Department of Pulmonology, University Hospital Zürich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Stéphanie Saxer
- Department of Pulmonology, University Hospital Zürich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Charlotte Berlier
- Department of Pulmonology, University Hospital Zürich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Simon R Schneider
- Department of Pulmonology, University Hospital Zürich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Esther I Schwarz
- Department of Pulmonology, University Hospital Zürich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Arcangelo F Carta
- Department of Pulmonology, University Hospital Zürich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Michael Furian
- Department of Pulmonology, University Hospital Zürich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Konrad E Bloch
- Department of Pulmonology, University Hospital Zürich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Silvia Ulrich
- Department of Pulmonology, University Hospital Zürich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
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27
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Kittleson MM, Prestinenzi P, Potena L. Right Heart Catheterization in Patients with Advanced Heart Failure: When to Perform? How to Interpret? Heart Fail Clin 2021; 17:647-660. [PMID: 34511212 DOI: 10.1016/j.hfc.2021.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Right heart catheterization is an established cornerstone of advanced heart failure management, as a clear understanding of the patient's hemodynamic status offers insight into diagnosis, prognosis, and management. In this review, the authors will describe the role of right heart catheterization in the diagnosis and management of shock, in the context of left ventricular assist devices, in the assessment of heart transplant candidacy, and also explore future directions of implantable monitoring devices for pulmonary artery and left atrial pressure monitoring.
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Affiliation(s)
- Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai, Los Angeles, CA, USA
| | - Paola Prestinenzi
- Heart Failure and Heart Transplant Program, IRCCS Policlinico di Sant'Orsola, Building 25 via Massarenti, 9, 40138 Bologna, Italy
| | - Luciano Potena
- Heart Failure and Heart Transplant Program, IRCCS Policlinico di Sant'Orsola, Building 25 via Massarenti, 9, 40138 Bologna, Italy.
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28
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Lin SY, Chang FC, Lin JR, Chou AH, Tsai YF, Liao CC, Tsai HI, Chen CY. Increased FIO2 influences SvO2 interpretation and accuracy of Fick-based cardiac output assessment in cardiac surgery patients: A prospective randomized study. Medicine (Baltimore) 2021; 100:e27020. [PMID: 34516492 PMCID: PMC8428708 DOI: 10.1097/md.0000000000027020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 08/03/2021] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION The study aimed to reveal how the fraction of inspired oxygen (FIO2) affected the value of mixed venous oxygen saturation (SvO2) and the accuracy of Fick-equation-based cardiac output (Fick-CO). METHODS Forty two adult patients who underwent elective cardiac surgery were enrolled and randomly divided into 2 groups: FIO2 < 0.7 or >0.85. Under stable general anesthesia, thermodilution-derived cardiac output (TD-CO), SvO2, venous partial pressure of oxygen, hemoglobin, arterial oxygen saturation, arterial partial pressure of oxygen, and blood pH levels were recorded before surgical incision. RESULTS Significant differences in FIO2 values were observed between the 2 groups (0.56 ± 0.08 in the <70% group and 0.92 ± 0.03 in the >0.85 group; P < .001). The increasing FIO2 values lead to increases in SvO2, venous partial pressure of oxygen, and arterial partial pressure of oxygen, with little effects on cardiac output and hemoglobin levels. When comparing to TD-CO, the calculated Fick-CO in both groups had moderate Pearson correlations and similar linear regression results. Although the FIO2 <0.7 group presented a less mean bias and a smaller limits of agreement, neither group met the percentage error criteria of <30% in Bland-Altman analysis. CONCLUSION Increased FIO2 may influence the interpretation of SvO2 and the exacerbation of Fick-CO estimation, which could affect clinical management. TRIAL REGISTRATION ClinicalTrials.gov ID number: NCT04265924, retrospectively registered (Date of registration: February 9, 2020).
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Affiliation(s)
- Sheng-Yi Lin
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Feng-Cheng Chang
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- College of Medicine, Fu Jen Catholic University, Taipei, Taiwan
| | - Jr-Rung Lin
- Clinical Informatics and Medical Statistics Research Center and Graduate Institute of Clinical Medicine, Chang Gung University, Taoyuan, Taiwan
- Biostatistics, National Taiwan University, Taipei, Taiwan
| | - An-Hsun Chou
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yung-Fong Tsai
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chia-Chih Liao
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsin-I. Tsai
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Yu Chen
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
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29
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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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Sarah B, Ashrith G, Sandeep S. Evaluation, Diagnosis, and Classification of Pulmonary Hypertension. Methodist Debakey Cardiovasc J 2021; 17:86-91. [PMID: 34326927 PMCID: PMC8298121 DOI: 10.14797/ocdf4453] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 11/13/2022] Open
Abstract
Pulmonary hypertension (PH) is a rare heterogenous disease characterized by
elevated blood pressure in the lungs. Patients with PH require careful
evaluation and management at an expert center. Understanding of the mechanisms
underlying the development of PH has increased over the past two decades, and
several treatment options for pulmonary arterial hypertension have emerged.
Despite this progress, PH continues to carry high morbidity and mortality. The
6th World Symposium on Pulmonary Hypertension that occurred in late 2018
modified the clinical classification of PH into five groups. In this review, we
focus on the evaluation and diagnosis of PH and discuss the updated clinical
classification.
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Affiliation(s)
| | - Guha Ashrith
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
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Cardiopulmonary Hemodynamics in Pulmonary Hypertension and Heart Failure: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 76:2671-2681. [PMID: 33243385 DOI: 10.1016/j.jacc.2020.10.007] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/21/2020] [Accepted: 10/09/2020] [Indexed: 02/02/2023]
Abstract
Pulmonary hypertension (PH) is an independent risk factor for adverse clinical outcome, particularly in left heart disease (LHD) patients. Recent advances have clarified the mean pulmonary artery pressure (mPAP) range that is above normal and is associated with clinical events, including mortality. This progress has for the first time resulted in a new clinical definition of PH that is evidenced-based, is inclusive of mPAP >20 mm Hg, and emphasizes early diagnosis. Additionally, pulmonary vascular resistance (PVR) 2.2 to 3.0 WU, considered previously to be normal, appears to associate with elevated clinical risk. A revised approach to classifying PH patients as pre-capillary, isolated post-capillary, or combined pre-/post-capillary PH now guides point-of-care diagnosis, risk stratification, and treatment. Exercise hemodynamic or confrontational fluid challenge studies may also aid decision-making for patients with PH-LHD or otherwise unexplained dyspnea. This collective progress in pulmonary vascular and heart failure medicine reinforces the critical importance of accurate hemodynamic assessment.
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The contemporary pulmonary artery catheter. Part 2: measurements, limitations, and clinical applications. J Clin Monit Comput 2021; 36:17-31. [PMID: 33646499 PMCID: PMC7917533 DOI: 10.1007/s10877-021-00673-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 02/08/2021] [Indexed: 12/25/2022]
Abstract
Nowadays, the classical pulmonary artery catheter (PAC) has an almost 50-year-old history of its clinical use for hemodynamic monitoring. In recent years, the PAC evolved from a device that enabled intermittent cardiac output measurements in combination with static pressures to a monitoring tool that provides continuous data on cardiac output, oxygen supply and-demand balance, as well as right ventricular performance. In this review, which consists of two parts, we will introduce the difference between intermittent pulmonary artery thermodilution using bolus injections, and the contemporary PAC enabling continuous measurements by using a thermal filament which heats up the blood. In this second part, we will discuss in detail the measurements of the contemporary PAC, including continuous cardiac output measurement, right ventricular ejection fraction, end-diastolic volume index, and mixed venous oxygen saturation. Limitations of all of these measurements are highlighted as well. We conclude that thorough understanding of measurements obtained from the PAC is the first step in successful application of the PAC in daily clinical practice.
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Abstract
The aim of this review is to present the current options for cardiac output (CO) monitoring in children undergoing cardiac surgery. Current technologies for monitoring identified were a range of invasive, minimally invasive, and non-invasive technologies. These include pulmonary artery catheter, transoesophageal echocardiography, pulse contour analysis, electrical cardiography, and thoracic bioreactance. A literature search was conducted using evidence databases which identified two current guidelines; the NHS Greater Glasgow and Clyde guideline and Royal College of Anaesthetics Guideline. These were appraised using the AGREE II tool and the evidence identified was used to create an overview summary of each technological option for CO monitoring. There is limited evidence regarding the accuracy of modalities available for CO monitoring in paediatric patients during cardiac surgery. Each technology has advantages and disadvantages; however, none could be championed as the most beneficial. Furthermore, a gold standard for CO monitoring has not yet been identified for paediatric populations, nor is it apparent whether one modality is preferable based on the available evidence. Additional evidence using a standardised method for comparing CO measurements should be conducted in order to determine the best option for CO monitoring in paediatrics. Furthermore, cost-effectiveness assessment of each modality should be conducted. Only then will it be possible for clear, evidence-based guidance to be written.
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Lange TJ, Borst M, Ewert R, Halank M, Klose H, Leuchte H, Meyer FJ, Seyfarth HJ, Skowasch D, Wilkens H, Held M. [Current Aspects of Definition and Diagnosis of Pulmonary Hypertension]. Pneumologie 2020; 74:847-863. [PMID: 32663892 DOI: 10.1055/a-1199-1548] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
At the 6th World Symposium on Pulmonary Hypertension (WSPH), which took place from February 27 until March 1, 2018 in Nice, scientific progress over the past 5 years in the field of pulmonary hypertension (PH) was presented by 13 working groups. The results of the discussion were published as proceedings towards the end of 2018. One of the major changes suggested by the WSPH was the lowering of the diagnostic threshold for PH from ≥ 25 to > 20 mmHg mean pulmonary arterial pressure, measured by right heart catheterization at rest. In addition, the pulmonary vascular resistance was introduced into the definition of PH, which underlines the importance of cardiac output determination at the diagnostic right heart catheterization.In this article, we discuss the rationale and possible consequences of a changed PH definition in the context of the current literature. Further, we provide a current overview on non-invasive and invasive methods for diagnosis, differential diagnosis, and prognosis of PH, including exercise tests.
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Affiliation(s)
- T J Lange
- Uniklinik Regensburg, Klinik für Innere Medizin II, Bereich Pneumologie, Regensburg
| | - M Borst
- Medizinische Klinik I, Caritas-Krankenhaus, Bad Mergentheim
| | - R Ewert
- Pneumologie, Uniklinik Greifswald, Greifwald
| | - M Halank
- Universitätsklinikum Carl Gustav Carus, Medizinische Klinik 1, Bereich Pneumologie, Dresden
| | - H Klose
- Universitätsklinikum Hamburg-Eppendorf, Abteilung für Pneumologie, Hamburg
| | - H Leuchte
- Klinik der Barmherzigen Schwestern, Krankenhaus Neuwittelsbach, Lehrkrankenhaus der LMU München, München
| | - F J Meyer
- Lungenzentrum München (Bogenhausen-Harlaching), München Klinik gGmbH, München
| | - H-J Seyfarth
- Bereich Pneumologie, Universitätsklinikum Leipzig, Leipzig
| | - D Skowasch
- Universitätsklinikum Bonn, Medizinische Klinik II, Sektion Pneumologie, Bonn
| | - H Wilkens
- Klinik für Innere Medizin V, Universitätsklinikum des Saarlandes, Homburg
| | - M Held
- Medizinische Klinik mit Schwerpunkt Pneumologie und Beatmungsmedizin, Klinikum Würzburg Mitte, Standort Missioklinik, Würzburg
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Methods to improve the yield of right heart catheterization in pulmonary hypertension. RESPIRATORY MEDICINE: X 2020. [DOI: 10.1016/j.yrmex.2020.100015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
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Exercise Pulmonary Resistances Predict Long-Term Survival in Systemic Sclerosis. Chest 2020; 159:781-790. [PMID: 32931822 DOI: 10.1016/j.chest.2020.08.2110] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/19/2020] [Accepted: 08/22/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Pulmonary hemodynamics during exercise may reveal early pulmonary vascular disease and may be of clinical and prognostic relevance in systemic sclerosis (SSc). We aimed to assess the prognostic relevance of exercise pulmonary resistances in patients with SSc with no or mildly increased mean pulmonary arterial pressure (mPAP). RESEARCH QUESTION Are pulmonary resistances at peak exercise independent predictors of mortality in systemic sclerosis? STUDY DESIGN AND METHODS All SSc patients with resting mPAP < 25 mm Hg and at least one year of follow-up data who underwent symptom-limited exercise right heart catheterization between April 2005 and December 2018 were analyzed retrospectively. Age-adjusted Cox regression analysis was used to evaluate the association between pulmonary resistances and all-cause mortality. RESULTS The cohort consisted of 80 patients: 73 women and 7 men with a mean age of 57 years (interquartile range [IQR], 47-67 years) and a mean follow-up time of 10.4 years (IQR, 8.5-11.8 years). At baseline, resting mPAP of ≤ 20 mm Hg and 21 to 24 mm Hg was found in 68 and 12 patients, respectively. Pulmonary vascular resistance (PVR) and total pulmonary resistance (TPR) at peak exercise were associated significantly with mortality (P = .006 [hazard ratio (HR), 2.20; 95% CI, 1.26-3.87] and P = .026 [HR, 1.56; 95% CI, 1.06-2.29]), whereas resting PVR and TPR were not (P = .087 [HR, 2.27; 95% CI, 0.89-5.83] and P = .079 [HR, 1.88; 95% CI, 0.93-3.80]). The mPAP per cardiac output (CO) and transpulmonary gradient (TPG) per CO slopes were associated significantly with mortality (P = .047 [HR, 1.14; 95% CI, 1.002-1.286] and P = .034 [HR, 1.34; 95% CI, 1.02-1.76]) as well. The area under the receiver operating characteristic curve for exercise PVR to predict 10-year mortality was 0.917 (95% CI, 0.797-1.000). INTERPRETATION PVR and TPR at peak exercise, mPAP/CO slope, and TPG/CO slope are predictors of age-adjusted long-term mortality in SSc patients with no or mildly increased pulmonary arterial pressure.
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Bavry AA, Hess E, W Waldo S, Barón AE, Kumbhani DJ, Bhatt DL, Pandey A. Long-term predictive value of stroke volume index obtained from right heart catheterization: Insights from the veterans affairs clinical assessment, reporting, and tracking program. Clin Cardiol 2020; 43:1126-1132. [PMID: 32897582 PMCID: PMC7533971 DOI: 10.1002/clc.23418] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 06/24/2020] [Accepted: 06/26/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Right heart catheterization-derived hemodynamic parameters have been associated with short-term prognosis. HYPOTHESIS Hemodynamic parameters will be associated with long-term prognosis. METHODS Retrospective cohort study from the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program included patients who underwent an index right heart catheterization between 2008 and 2016. Cox proportional hazard models were used to examine the association between stroke volume index and all-cause mortality. RESULTS For the final cohort of 37 209 patients, mean follow-up was 3.7 ± 2.5 years. All-cause mortality was 42.0% in the low (<35 cc/beat/m2 ) compared with 33.2% in the normal stroke volume index group (≥35 cc/beat/m2 ). In adjusted analysis, low stroke volume was significantly associated with higher mortality risk (HR (95% CI) 1.14 (1.10-1.18); P < .001) independent of clinical parameters. The area under the curve (AUC) for continuous measures of stroke volume index at predicting mortality in a Cox proportional hazard model was 0.56 at 3 years. When stroke volume index was combined with 14 clinical covariates, the AUC was 0.70 at 3 years. The addition of stroke volume index to these clinical covariates did not increase the discriminatory ability of the model at 1 year in a clinically meaningful way (integrated discrimination improvement index = 0.0021, 95% CI: 0.0010-0.0034). CONCLUSIONS The long-term prognostic value of right heart catheterization-derived stroke volume index appears to be marginal. While there was a weak association of low stroke volume index and excess mortality, inclusion of this parameter to a set of clinical covariates did not improve prognostic discrimination.
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Affiliation(s)
- Anthony A Bavry
- Department of Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Edward Hess
- Rocky Mountain Regional VA Medical Center, Denver, Colorado, USA
| | - Stephen W Waldo
- Rocky Mountain Regional VA Medical Center, Denver, Colorado, USA.,University of Colorado School of Medicine, Denver, Colorado, USA
| | - Anna E Barón
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Dharam J Kumbhani
- Department of Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ambarish Pandey
- Department of Medicine, University of Texas Southwestern, Dallas, Texas, USA
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Hardin EA, Stoller D, Lawley J, Howden EJ, Hieda M, Pawelczyk J, Jarvis S, Prisk K, Sarma S, Levine BD. Noninvasive Assessment of Cardiac Output: Accuracy and Precision of the Closed-Circuit Acetylene Rebreathing Technique for Cardiac Output Measurement. J Am Heart Assoc 2020; 9:e015794. [PMID: 32851906 PMCID: PMC7660774 DOI: 10.1161/jaha.120.015794] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Background Accurate assessment of cardiac output is critical to the diagnosis and management of various cardiac disease states; however, clinical standards of direct Fick and thermodilution are invasive. Noninvasive alternatives, such as closed‐circuit acetylene (C2H2) rebreathing, warrant validation. Methods and Results We analyzed 10 clinical studies and all available cardiopulmonary stress tests performed in our laboratory that included a rebreathing method and direct Fick or thermodilution. Studies included healthy individuals and patients with clinical disease. Simultaneous cardiac output measurements were obtained under normovolemic, hypovolemic, and hypervolemic conditions, along with submaximal and maximal exercise. A total of 3198 measurements in 519 patients were analyzed (mean age, 59 years; 48% women). The C2H2 method was more precise than thermodilution in healthy individuals with half the typical error (TE; 0.34 L/min [r=0.92] and coefficient of variation, 7.2%) versus thermodilution (TE=0.67 [r=0.70] and coefficient of variation, 13.2%). In healthy individuals during supine rest and upright exercise, C2H2 correlated well with thermodilution (supine: r=0.84, TE=1.02; exercise: r=0.82, TE=2.36). In patients with clinical disease during supine rest, C2H2 correlated with thermodilution (r=0.85, TE=1.43). C2H2 was similar to thermodilution and nitrous oxide (N2O) rebreathing technique compared with Fick in healthy adults (C2H2 rest: r=0.85, TE=0.84; C2H2 exercise: r=0.87, TE=2.39; thermodilution rest: r=0.72, TE=1.11; thermodilution exercise: r=0.73, TE=2.87; N2O rest: r=0.82, TE=0.94; N2O exercise: r=0.84, TE=2.18). The accuracy of the C2H2 and N2O methods was excellent (r=0.99, TE=0.58). Conclusions The C2H2 rebreathing method is more precise than, and as accurate as, the thermodilution method in a variety of patients, with accuracy similar to an N2O rebreathing method approved by the US Food and Drug Administration.
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Affiliation(s)
- E Ashley Hardin
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX.,Institute for Exercise and Environmental Medicine Texas Health Presbyterian Hospital Dallas TX
| | - Douglas Stoller
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX.,Institute for Exercise and Environmental Medicine Texas Health Presbyterian Hospital Dallas TX
| | - Justin Lawley
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX.,Institute for Exercise and Environmental Medicine Texas Health Presbyterian Hospital Dallas TX
| | - Erin J Howden
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX.,Institute for Exercise and Environmental Medicine Texas Health Presbyterian Hospital Dallas TX
| | - Michinari Hieda
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX.,Institute for Exercise and Environmental Medicine Texas Health Presbyterian Hospital Dallas TX
| | - James Pawelczyk
- Department of Physiology Pennsylvania State University University Park and Hershey PA
| | - Sara Jarvis
- Department of Biological Sciences Northern Arizona University Flagstaff AZ
| | - Kim Prisk
- Department of Medicine University of California at San Diego La Jolla CA
| | - Satyam Sarma
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX.,Institute for Exercise and Environmental Medicine Texas Health Presbyterian Hospital Dallas TX
| | - Benjamin D Levine
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX.,Institute for Exercise and Environmental Medicine Texas Health Presbyterian Hospital Dallas TX
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Khirfan G, Almoushref A, Naal T, Abuhalimeh B, Dweik RA, Heresi GA, Tonelli AR. Mixed Venous Oxygen Saturation Is a Better Prognosticator Than Cardiac Index in Pulmonary Arterial Hypertension. Chest 2020; 158:2546-2555. [PMID: 32629034 DOI: 10.1016/j.chest.2020.06.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 06/10/2020] [Accepted: 06/27/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND European Society of Cardiology (ESC) and European Respiratory Society (ERS) guidelines include thermodilution cardiac index (TDCI) and mixed venous oxygen saturation (SvO2) as two of the three hemodynamic determinations used in risk assessment of patients with pulmonary arterial hypertension (PAH). SvO2 may be a better measurement than TDCI to assess prognosis in patients with either idiopathic or heritable PAH. RESEARCH QUESTION What is the concordance between TDCI and SvO2 ESC/ERS risk group allocation and their prognostic value in patients with PAH? STUDY DESIGN AND METHODS In this retrospective study, we assessed the correlation between SvO2 and TDCI in patients with idiopathic and heritable PAH. We determined concordance in the ESC/ERS risk group allocation and association with survival, both at baseline and follow-up. RESULTS A total of 158 patients (mean age, 58 ± 17 years; 72% women) with idiopathic (91%) and heritable (9%) PAH were included. There was moderate association between TDCI and SvO2 (r = 0.50; 95% CI, 0.37-0.62). Weighted kappa revealed a fair agreement between TDCI and SvO2 (κ = 0.30; 95% CI, 0.18-0.42), with concordance in risk group allocation in 49% of patients. During a median follow-up of 45 months (interquartile range, 23-105), 62 patients (39%) died. Using Kaplan-Meier analysis, survival was impacted by the SvO2 (log rank = 0.002) but not by the TDCI risk group allocation (log-rank = 0.51). Using the Cox proportional hazard model, adjusted for age and sex, SvO2 (but not TDCI) was associated with mortality (hazard ratio per 1% change, 0.94; 95% CI, 0.91-0.97; P < .001). INTERPRETATION When using the cutoffs proposed by the ESC/ERS guidelines, we noted poor concordance in risk score allocation between TDCI and SvO2. In patients with idiopathic or heritable PAH, SvO2 measurements are superior to TDCI in predicting long-term mortality.
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Affiliation(s)
- Ghaleb Khirfan
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | | | - Tawfeq Naal
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC
| | | | - Raed A Dweik
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Gustavo A Heresi
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Adriano R Tonelli
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH.
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Bonno EL, Viray MC, Jackson GR, Houston BA, Tedford RJ. Modern Right Heart Catheterization: Beyond Simple Hemodynamics. ACTA ACUST UNITED AC 2020. [DOI: 10.21693/1933-088x-19.1.6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Eric L. Bonno
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Michael C. Viray
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Gregory R. Jackson
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Brian A. Houston
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Ryan J. Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
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Po JR, Tong M, Meeran T, Potluri A, Raina A, Doyle M, Biederman R. Quantification of Cardiac Output with Phase Contrast Magnetic Resonance Imaging in Patients with Pulmonary Hypertension. J Clin Imaging Sci 2020; 10:26. [PMID: 32363088 PMCID: PMC7193209 DOI: 10.25259/jcis_36_2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 04/13/2020] [Indexed: 11/04/2022] Open
Abstract
Objective The purpose of the study is to compare phase contrast (PC) imaging with invasive measurements of cardiac output (CO) in patients with pulmonary hypertension (PH). Materials and Methods We analyzed 81 cases with PH who underwent cardiac magnetic resonance imaging and right heart catheterization (RHC). Measurement of CO and stroke volume (SV) by cardiac magnetic resonance (CMR) was performed by PC imaging of the proximal aorta (Ao) and pulmonary artery (Pa) and by RHC using the Fick and thermodilution (TD) methods. Results There was good correlation in CO measurements between PC and RHC; however, there was better correlation with SV measurements; Fick-TD (r=0.85), PC-TD (Ao r=0.77, Pa r=0.79), and PC-Fick (Ao r = 0.73, Pa r = 0.78). Bland-Altman analysis of SV showed that Pa PC had slightly lower standard deviation than Ao PC; PC-Fick (Pa SD = 15.11 vs. Ao SD = 16.4 ml) and PC-TD (Pa SD = 16.99 ml vs. Ao SD = 17.4 ml) while Fick-TD had the lowest (SD = 14.4 ml). Compared to Fick, measurement of SV with Ao PC (‒4.12 ml) and Pa PC (0.22 ml) both had lower mean difference than TD (‒11.1 ml). Conclusion Non-invasive measurement of CO and SV using PC-CMR correlates well with invasive measurement using RHC. Our study showed that PC-CMR had high accuracy and precision when compared to Fick. Among all the modalities, PC-CMR contributed the least amount of variation in measurements.
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Affiliation(s)
- Jose Ricardo Po
- Borgess Heart Institute, Ascension Borgess Hospital, 1722 Shaffer St., Kalamazoo, Michigan, United States
| | - Matthew Tong
- Department of Cardiovascular Medicine, Wexner Medical Center, 410 W 10th Ave, Columbus, Ohio, United States
| | - Talha Meeran
- Department of Cardiology, Fortis Hospital Mulund, Mumbai, Maharashtra, India
| | - Alekhya Potluri
- Department of Cardiology, Einstein Medical Center, 5401 Old York Road, Philadelphia, United States
| | - Amresh Raina
- Cardiovascular Institute, Allegheny General Hospital, 320 E North Ave., Pittsburgh, Pennsylvania, United States
| | - Mark Doyle
- Cardiovascular Institute, Allegheny General Hospital, 320 E North Ave., Pittsburgh, Pennsylvania, United States
| | - Robert Biederman
- Cardiovascular Institute, Allegheny General Hospital, 320 E North Ave., Pittsburgh, Pennsylvania, United States
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Stadler S, Mergenthaler N, Lange TJ. The prognostic value of DLCO and pulmonary blood flow in patients with pulmonary hypertension. Pulm Circ 2019; 9:2045894019894531. [PMID: 31908765 PMCID: PMC6935895 DOI: 10.1177/2045894019894531] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 11/19/2019] [Indexed: 12/12/2022] Open
Abstract
Background Cardiac output is a prognostic marker in patients with pulmonary hypertension. Pulmonary blood flow as a surrogate for cardiac output can be measured non-invasively by inert gas rebreathing. We hypothesized that pulmonary blood flow can predict outcome in patients with pulmonary hypertension. Methods From January 2009 to January 2012, we measured pulmonary blood flow by inert gas rebreathing in outpatients with pulmonary hypertension. Patients with pulmonary hypertension confirmed by right heart catheterization and a valid inert gas rebreathing maneuver were followed until January 2016. The investigated outcome was all-cause mortality. Results We included 259 patients (mean age 65 ± 13 years, 53% female) with pulmonary hypertension and classified into groups 1 (n = 103), 2 (n = 26), 3 (n = 80), and 4 (n = 50) according to the current pulmonary hypertension classification system. The median time between pulmonary hypertension diagnosis and inert gas rebreathing was 9 (IQR 0; 36) months. During a median follow-up time of 51 (IQR 20; 68) months, 109 patients (42%) died. Parameters significantly associated with survival (in order of decreasing statistical strength) were diffusion capacity of the lung for carbon monoxide (DLCO), 6-minute walk distance (6-MWD), age, NTpro-BNP, WHO functional class, group 3 pulmonary hypertension, and tricuspid annular plane systolic excursion (TAPSE), while baseline hemodynamics and pulmonary blood flow were not. In multivariable Cox regression analysis, DLCO, age, 6-MWD, and TAPSE remained significant and independent predictors of the outcome. DLCO as the strongest parameter also significantly predicted survival in aetiological subgroups except for group 4. Conclusions DLCO is a strong and independent predictor for survival in patients with pulmonary hypertension of different aetiologies, while pulmonary blood flow measured by inert gas rebreathing is not.
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Affiliation(s)
- Stefan Stadler
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Nicoletta Mergenthaler
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Tobias J Lange
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
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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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Abstract
In early 2019, the 6th World Symposium on Pulmonary Hypertension (WSPH) released an updated document highlighting the advances in the last five years. During the quinquennial event many experts worked together to suggest new changes in the disease diagnosis and management. Since inception of the WSPH in 1973, this is the first time when the hemodynamic definition of pulmonary hypertension (PH) has been updated. These proceedings have re-defined the different hemodynamic types of PH that occur with the left heart disease along with introduction to the genetic testing as part of pulmonary arterial hypertension (PAH) evaluation. Objective of this review is to highlight the evaluation and diagnosis of PAH based on the proceedings of the 6th WSPH. Accurate early diagnosis and subsequent management of PH is necessary, as despite of treatment advances, survival remains suboptimal.
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Affiliation(s)
- Sandeep Sahay
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, Institute of Academic Medicine, Houston Methodist Hospital, Houston, TX, USA
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46
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Jaafar S, Visovatti S, Young A, Huang S, Cronin P, Vummidi D, McLaughlin V, Khanna D. Impact of the revised haemodynamic definition on the diagnosis of pulmonary hypertension in patients with systemic sclerosis. Eur Respir J 2019; 54:13993003.00586-2019. [PMID: 31196948 DOI: 10.1183/13993003.00586-2019] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 05/24/2019] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Pulmonary arterial hypertension (PAH) is one of the leading causes of mortality in systemic sclerosis (SSc). We explored the impact of the updated haemodynamic definition of pulmonary hypertension (PH), as proposed by the 6th World Symposium on Pulmonary Hypertension. METHODS In this single-centre retrospective analysis, patients with SSc who had right heart catheterisation (RHC) were included. We compared the prior PH definition to the updated PH definition. The prior definition classified PH as mean pulmonary arterial pressure (mPAP) ≥25 mmHg and further divided into pre-capillary PH (PAH and PH due to lung disease and/or hypoxia), post-capillary PH, and combined pre- and post-capillary PH groups. For the updated definition, PH was classified as mPAP >20 mmHg and further divided into the different groups. We validated our findings in the DETECT cohort. RESULTS Between 2005 and March 2019, 268 RHCs were performed in this single-centre cohort. Using the prior definition, 137 (51%) were diagnosed with PH, with 89 classified as pre-capillary PH (56 with PAH and 33 with PH due to lung disease and/or hypoxia), 29 as post-capillary PH, and 19 as combined pre- and post-capillary PH. When the updated definition was applied to the cohort, seven out of 131 (5%) with no PH were reclassified to pre-capillary PH (PAH (n=1), PH due to lung disease (n=3) and post-capillary PH (n=3)). In those with mPAP 21-24 mmHg, with no left heart or significant lung disease, one out of 28 (4%) in our cohort and four out of 36 (11%) in the DETECT cohort were reclassified as PAH. CONCLUSION The updated PH definition does not appear to have a significant impact on the diagnosis of PH in two different screening cohorts.
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Affiliation(s)
- Sara Jaafar
- Division of Rheumatology and Scleroderma Program, Dept of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Scott Visovatti
- Division of Cardiovascular Disease, Dept of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Amber Young
- Division of Rheumatology and Scleroderma Program, Dept of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Suiyuan Huang
- Division of Rheumatology and Scleroderma Program, Dept of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Paul Cronin
- Division of Cardiothoracic Radiology, Dept of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Dharshan Vummidi
- Division of Cardiothoracic Radiology, Dept of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Vallerie McLaughlin
- Division of Cardiovascular Disease, Dept of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Dinesh Khanna
- Division of Rheumatology and Scleroderma Program, Dept of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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47
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Smith JR, Johnson BD, Olson TP. Impaired central hemodynamics in chronic obstructive pulmonary disease during submaximal exercise. J Appl Physiol (1985) 2019; 127:691-697. [PMID: 31295068 DOI: 10.1152/japplphysiol.00877.2018] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
It is unknown whether central hemodynamics are impaired during exercise in chronic obstructive pulmonary disease (COPD) patients. We hypothesized that, at a similar absolute V̇o2 during exercise, COPD patients would have a lower stroke volume and cardiac output compared with healthy controls. Furthermore, we hypothesized that greater static hyperinflation [ratio of inspiratory capacity to total lung capacity (IC/TLC)] and expiratory intrathoracic pressure would be significantly related to the lower cardiac output and stroke volume responses in COPD patients. Clinically stable COPD (n = 13; FEV1/FVC: 52 ± 13%) and controls (n = 10) performed constant workload submaximal exercise at an absolute V̇o2 of ~1.3 L/min. During exercise, inspiratory capacity maneuvers were performed to determine operating lung volumes and cardiac output (via open-circuit acetylene rebreathe technique) and esophageal pressure were measured. At similar absolute V̇o2 during exercise (P = 0.81), COPD had lower cardiac output than controls (COPD: 11.0 ± 1.6 vs. control: 12.2 ± 1.2 L/min, P = 0.03) due to a lower stroke volume (COPD: 107 ± 13 vs. control: 119 ± 19 mL, P = 0.04). The heart rate response during exercise was not different between groups (P = 0.66). FEV1 (%predicted) and IC/TLC were positively related to stroke volume (r = 0.68, P = 0.01 and r = 0.77, P < 0.01). Last, esophageal pressure-time integral during inspiration was positively related to cardiac output (r = 0.56, P = 0.047). These data demonstrate that COPD patients have attenuated cardiac output and stroke volume responses during exercise compared with control. Furthermore, these data suggest that the COPD patients with the most severe hyperinflation and more negative inspiratory intrathoracic pressures have the most impaired central hemodynamic responses.NEW & NOTEWORTHY Chronic obstructive pulmonary disease leads to cardiac structural changes and pulmonary derangements that impact the integrative response to exercise. However, it is unknown whether these pathophysiological alterations influence the cardiac response during exercise. Herein, we demonstrate that COPD patients exhibit impaired central hemodynamics during exercise that are worsened with greater hyperinflation.
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Affiliation(s)
- Joshua R Smith
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Bruce D Johnson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Thomas P Olson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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48
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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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49
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Fukuda K, Date H, Doi S, Fukumoto Y, Fukushima N, Hatano M, Ito H, Kuwana M, Matsubara H, Momomura SI, Nishimura M, Ogino H, Satoh T, Shimokawa H, Yamauchi-Takihara K, Tatsumi K, Ishibashi-Ueda H, Yamada N, Yoshida S, Abe K, Ogawa A, Ogo T, Kasai T, Kataoka M, Kawakami T, Kogaki S, Nakamura M, Nakayama T, Nishizaki M, Sugimura K, Tanabe N, Tsujino I, Yao A, Akasaka T, Ando M, Kimura T, Kuriyama T, Nakanishi N, Nakanishi T, Tsutsui H. Guidelines for the Treatment of Pulmonary Hypertension (JCS 2017/JPCPHS 2017). Circ J 2019; 83:842-945. [PMID: 30853682 DOI: 10.1253/circj.cj-66-0158] [Citation(s) in RCA: 120] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine
| | - Hiroshi Date
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University
| | - Shozaburo Doi
- Department of Pediatrics, Perinatal and Maternal Medicine, Graduate School, Tokyo Medical and Dental University
| | - Yoshihiro Fukumoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine
| | - Norihide Fukushima
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Masaru Hatano
- Department of Cardiovascular Medicine/Therapeutic Strategy for Heart Failure, The University of Tokyo Hospital
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Field of Functional Physiology, Okayama University Graduate School of Medicine
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School
| | - Hiromi Matsubara
- Department of Clinical Science, National Hospital Organization Okayama Medical Center
| | - Shin-Ichi Momomura
- Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University
| | - Masaharu Nishimura
- Department of Respiratory Medicine, Hokkaido University Graduate School of Medicine
| | - Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Toru Satoh
- Internal Medicine II, Kyorin University School of Medicine
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Keiko Yamauchi-Takihara
- Health and Counseling Center and Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Koichiro Tatsumi
- Department of Respirology, Graduate School of Medicine, Chiba University
| | | | | | - Shunji Yoshida
- Department of Rheumatology and Infectious Diseases, Fujita Health University Hospital
| | - Kohtaro Abe
- Department of Cardiovascular Medicine, Kyushu University Hospital
| | - Aiko Ogawa
- Department of Clinical Science, National Hospital Organization Okayama Medical Center
| | - Takeshi Ogo
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine/Department of Advanced Medicine for Pulmonary Hypertension, National Cerebral and Cardiovascular Center
| | - Takatoshi Kasai
- Department of Cardiovascular Medicine, Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine
| | | | | | - Shigetoyo Kogaki
- Department of Pediatrics and Neonatology, Osaka General Medical Center
| | | | - Tomotaka Nakayama
- Department of Pediatrics, Toho University Medical Center Omori Hospital
| | - Mari Nishizaki
- Department of Rehabilitation, National Hospital Organization, Okayama Medical Center
| | - Koichiro Sugimura
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Nobuhiro Tanabe
- Department of Advanced Medicine in Pulmonary Hypertension, Graduate School of Medicine, Chiba University
| | - Ichizo Tsujino
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Atsushi Yao
- Division for Health Service Promotion, The University of Tokyo
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Motomi Ando
- Daiyukai General Hospital Cardiovascular Center
| | - Takeshi Kimura
- Department Cardiovascular Medicine, Graduate School of Medicine and Faculty of Medicine, Kyoto University
| | | | | | - Toshio Nakanishi
- Department of Pediatric Cardiology, Tokyo Women's Medical University
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
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50
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Badagliacca R, Papa S, Poscia R, Valli G, Pezzuto B, Manzi G, Torre R, Gianfrilli D, Sciomer S, Palange P, Naeije R, Fedele F, Vizza CD. The added value of cardiopulmonary exercise testing in the follow-up of pulmonary arterial hypertension. J Heart Lung Transplant 2018; 38:306-314. [PMID: 30581051 DOI: 10.1016/j.healun.2018.11.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 11/25/2018] [Accepted: 11/30/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The added value of cardiopulmonary exercise testing (CPET) in the follow-up of patients with stable pulmonary arterial hypertension (PAH) remains undefined. METHODS Idiopathic, heritable, and drug-induced PAH patients free from clinical worsening (CW) after 1 year of treatment were enrolled in derivation (n = 80) and validation (n = 80) cohorts at an interval of 6 years and followed for 3 years. Prognostic models were constructed and validated in low-risk patients in World Health Organization (WHO) Functional Class I or II with cardiac index (CI) ≥2.5 liters/min/m2 and right atrial pressure (RAP) <8 mm Hg. Discrimination and calibration were assessed. RESULTS Forty-one derivation cohort patients had CW (51.2%) during 722 ± 349 days. Changes (∆) in WHO classification and CI and absolute value of RAP were independent predictors of CW. With addition of CPET variables, peak oxygen uptake (VO2 peak) and ∆CI independently improved the power of the prognostic model. Receiver operating characteristic (ROC)-derived cut-off values for ∆CI and VO2 peak were 0.40 liter/min/m2 and 15.7 ml/kg/min (≥60% predicted value), respectively. Twenty-nine validation cohort patients had CW (36.2%) during 710 ± 282 days. Different combinations of cut-off values of VO2 peak and ∆CI defined 4 groups. The event-free survival rates at 1, 2, and 3 years were 100%, 100%, and 100%, respectively, for the high ∆CI with high VO2 peak combination; 100%, 88%, and 71% for low ∆CI/high VO2 peak; 80%, 54%, and 40% for high ∆CI/low VO2 peak; and 72%, 54%, and 33% for low ∆CI/low VO2 peak. CONCLUSIONS The combinations of baseline VO2 peak and change in CI during follow-up is important in prognostication of low-risk patients with idiopathic, heritable, and drug-induced PAH.
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Affiliation(s)
- Roberto Badagliacca
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy.
| | - Silvia Papa
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Roberto Poscia
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Gabriele Valli
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Beatrice Pezzuto
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Giovanna Manzi
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Roberto Torre
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Susanna Sciomer
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Paolo Palange
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Robert Naeije
- Department of Cardiology, Erasme University Hospital, Brussels, Belgium
| | - Francesco Fedele
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Carmine Dario Vizza
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
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