The hemodynamic and prognostic impact of systolic pressure change during right ventricular ejection in patients with HFREF

Background and purpose

The gold-standard method to evaluate right ventricular (RV) function in pulmonary hypertension (PH) relies on invasive pressure-volume loop (PV-loop) measurement of RV-pulmonary artery (PA) coupling defined as the ratio of end-systolic RV elastance to pulmonary arterial elastance (Ees/Ea). The normal RV PV-loop has a triangular shape with a peaking early systolic pressure (early-SP). With progression of PH the PV-loop changes from trapezoid to a rectangular and ultimately to a trapezoid shape. Along with these geometric changes, the ratio between early-SP and end-systolic pressure (ESP) decreases from >1 to <1 with a late systolic peaking of RV pressure. How all these changes relate to RV afterload, RV-PA coupling, non-invasive RV function, and prognosis in PH due to left heart disease is incomplete understood.

Methods

We analyzed and categorized the conductance catheter-derived single-beat RV PV-loops in 133 patients with HFREF (110 patients: a post-hoc analysis of the Magdeburg CRT Responder Trial, 23 from a local PV-L-derived CRT-optimization trial) according their shape (triangular, rectangular, trapezoid), and determined the early-SP/ESP ratio.

Results

Using multivariate linear regression analysis (adjusted for afterload parameter PVR, PA-compliance, PCWP, PAmean), only PCWP (beta=−0.17) and PA-compliance (beta=0.61) remained significant determinants of the early-SP/ESP ratio and PV-loop shape. In turn, early-SP/ESP ratio seems to be an important determinant of RV-PA coupling efficiency (Ees/Ea) of the RV to afterload (r=0.8, p<0.001). The association between early-SP/ESP ratio and Ees/Ea ratio was closer than Ees/Ea ratio to the other afterload parameters Ea (r=−0.7), PVR (r=−0.41), and PA-compliance (r=0.62). Furthermore, the early-SP/ESP ratio was significantly associated with parameters of non-invasive RV function such as TAPSE (r=0.67), FAC (r=0.76), RVEF (r=0.7), and the non-invasive RV-PA coupling parameter TAPSE/PASP (r=0.8) (all p<0.001). In cox regression analysis, the early-SP/ESP ratio was a strong indicator for long-term survival (median FU 4.2 years) (OR 0.025, CI 95% 0.007–0.09). Simple categorization of the RV PV-loop shapes into “triangular” (early-SP/ESP ratio >1.1, mean survival 7.7 years), “rectangular” (0.9–1.1, 6.4 years) and “trapezoid” (<0.9, 3.2 years) clearly differentiated long-term survival of HFREF patients (log rank, Chi square 50.1, p<0.001).

Conclusion

The early-SP/ESP ratio determines the shape of RV-PV-loops and is closely associated with predominately pulsatile PA load, RV-PA coupling capacity, RV function, and long-term prognosis of patients with HFREF.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Boston Scientific

Predictors and prognosis of RV function in pulmonary hypertension due to heart failure with reduced ejection fraction

Background and aims

Failure of right ventricular (RV) function worsens outcome in pulmonary hypertension (PH). The adaptation of RV contractility to afterload, the RV-pulmonary artery (PA) coupling, is defined by the ratio of RV end-systolic to PA elastances (Ees/Ea). Using pressure volume loop (PV-L) technique we aimed to identify an Ees/Ea cutoff predictive for overall survival and to assess hemodynamic and morphologic conditions for adapted RV function in secondary PH due to Heart Failure with Reduced Ejection Fraction (HFREF).

Methods

This post hoc analysis is based on 112 patients of the prospective Magdeburger Resynchronization Responder Trial. All patients underwent right and left heart echocardiography, and a baseline PV-L and RV catheter measurement. A subgroup of patients (n=50) without a pre-implanted cardiac device underwent MRI at baseline.

Results

The analysis revealed that 0.68 is an optimal Ees/Ea cutoff (area under the curve: 0.697, p<0.001) predictive for overall survival (median follow up = 4.7 years, Ees/Ea ≥0.68 vs. <0.68, log-rank 8.9, p=0.003. In patients with PH (n=76, 68%) Multivariate Cox-regression demonstrated the independent prognostic value of RV-Ees/Ea in PH patients (HR 0.2, p<0.038). Patients without PH (n=36, 32%) and those with PH but RV-Ees/Ea ≥0.68 showed comparable RV-Ees/Ea ratios (0.88 vs. 0.9, p=0.39), RV size/function, and survival. In contrast, secondary PH with RV-PA coupling ratio Ees/Ea <0.68 corresponded extremely close to cut-off values that define RV dilatation/remodeling (RVEDV >160ml, RV-mass/volume-ratio <0.37 g/ml) and dysfunction (RVEF <38%, TAPSE <16mm, FAC <42%, and stroke-volume/end-systolic volume ratio <0.59) and is associated with a dramatically increased short and medium-term all-cause mortality. Independent predictors of prognostically unfavorable RV-PA coupling (Ees/Ea <0.68) in secondary PH were a preexistent dilated RV (end-diastolic volume >171ml, odds ratio, OR 0.96, p=0.021), high pulsatile load (PA compliance <2.3 ml/mmHg, OR 8.6, p=0.003), and advanced systolic left heart failure (left ventricular (LV) ejection fraction <30%, OR 1.23, p=0.028).

Conclusions

The RV-PA coupling ratio Ees/Ea predicts overall survival in PH due to HFREF and is mainly affected by pulsatile load, RV remodeling and LV dysfunction. Prognostically favorable coupling (RV-Ees/Ea ≥0.68) in PH was associated with preserved RV size/function and mid-term survival, comparable to HFREF without PH.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Boston Scientific

Right ventricular pulmonary vascular coupling in secondary tricuspid regurgitation: a pressure volume loop study

Introduction

The severity of secondary tricuspid regurgitation (sTR) predicts outcome of patients with left heart failure with reduced ejection fraction (HFrEF). In these patients sTR predominantly occurs as a result of secondary pulmonary hypertension (PH). However, more than 46% of patients with severe PH have only mild or none sTR. In this study we tested the hypothesis that intrinsic right ventricular (RV) contractility adaptation to the pulmonary arterial (PA) vascular load (RV-PA-coupling) is associated with the presence and severity of sTR.

Methods

In 110 patients with HFrEF (a post-hoc analysis of the Magdeburger CRT Responder Trial, DRKS00011133) we quantified the RV intrinsic contractility response (end-systolic elastance, Ees) to pulmonary vascular afterload (arterial elastance, Ea) and its coupling ratio (RV-PA coupling ratio: Ees/Ea) by the RV pressure-volume loop catheter technique at baseline, and combined it with echocardiography-derived parameter of sTR presence and severity and RV function.

Results

Echocardiography at baseline demonstrated no or trace TR (TR0) in 67 patients (61%), mild TR (TR1) in 23 (21%), moderate TR (TR2) in 11 (10%), and severe TR (TR3) in 9 (8%). The transition from TR0 to TR1 was characterized by a pronounced drop of the RV-PA coupling ratio (TR0: Ees/Ea= 0.88, 0.67–1.1 vs. TR1: Ees/Ea= 0.48, 0.3–0.83, p<0.001), caused by a non-adaptive, non-rising Ees (0.24 mmHg/ml, 0.34–0.44 vs. 0.3 mmHg/ml, 0.21–0.46, p=0.8, respectively, p<0.001). We observed a further but only marginal drop of Ees/Ea from TR1 to TR3 (p=0.008) caused by an additional small non-significant decrease of Ees and increase of Ea. Interestingly, other afterload parameter, such as PA-pressure, wedge pressure (PCWP), PA compliance, and PA resistance (PVR), and parameters of RV function, such as tricuspid annular plane systolic excursion (TAPSE) and fractional area shortening (FAC) followed the same course of a pronounced drop from TR0 to TR1, succeeded by an only marginal change from TR1 to TR3. In contrast, the progressive RV-PA un-coupling from TR0 to TR3 was accompanied by a more or less continuously increase of RV size and volume load (end-diastolic (ED) area in 4 chamber view, ED-RV outflow tract diameter, size of tricuspid annulus). In the binary logistic regression analysis, the decrease of RV-PA coupling ratio Ees/Ea (OR 0.14, CI 0.001–0.165) and PA compliance (OR 0.44, CI 0.25–0.79) were independently associated with the transition from TR0 to TR1–3.

Conclusion

The presence and severity of secondary TR in patients with HFREF is independently associated with a progressive RV-PA uncoupling. Most importantly, already the transition from none TR to mild TR is characterized by a significant and pronounced increase of pulmonary vascular afterload, a non-adaptive RV contractility response, and resulting RV-PA un-coupling.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Boston Scientific

P4687Relevance of TAPSE and FAC, and their relationship to PASP as echo-derived measures for RV-PA coupling in heart failure: a comparative analysis with invasive RV-pressure volume loop data

Background

Right ventricular (RV) to pulmonary artery (PA) coupling (C), quantified by pressure volume (PV) loop analysis, predicts RV function, and is independently associated with long term survival in systolic heart failure (HFrEF). However, the PV loop technique is invasive and complex to carry out, especially when used to do RV functional analyses. Different echo-surrogate parameters are proposed to measure RV-PA-C, such as the tricuspid annular plane systolic excursion, TAPSE/PAsystolic pressure (SP) and FAC (fractional area change)/PASP as the most promising parameters. However, up to now, no validation of these non-invasive coupling indices with the invasive gold standard method of RV-PV-loops has been done.

Methods

In 111 patients with advanced HFrEF (Post-hoc analysis of Magdeburger CRT Responder Trial, DRKS00011133), echo-derived TAPSE and FAC, and their relationship to PASP were related to the RV PV-loop-derived parameters of intrinsic RV contractility (Ees), pulmonary load (Ea), and the RV-PA-C efficiency (Ees/Ea) by linear regression analysis. Within a MRI substudy (n=49 patients) we examined the relationship of pure longitudinal contraction (MRI-TAPSE) and radial free wall to septum contraction (area change of 5 RV segments from tricuspid valve to apex in the short axis view) to the invasive RV-PA-C.

Results

The MRI analysis demonstrated that radial RV contraction (R2=0.77, p<0.001) correlated better to invasive RV-PA-C than pure longitudinal shortening (R2=0.37, p<0.001) (radial vs. longitudinal: p<0.00). Echo data for the entire patient cohort confirmed the MRI data. The FAC (R2=0.8, p<0.001) was significantly better associated with RV-PA-C than TAPSE (R2=0.57, p<0.001) (TAPSE vs FAC, p<0.001). Placing TAPSE or FAC into a quotient with PASP did not at all (TAPSE vs. TAPSE/PASP, p=0.1) or significantly attenuated (FAC vs. FAC/PASP R2=0.8 vs 0.58, p<0.001) their association to RV-PA-C. However, FAC/PASP and TAPSE/PASP correlated significantly better with global afterload (Eea), PA compliance, and pressure volume area (PVA), (p<0.001). In ROC analysis for all-cause mortality, all 4 tested parameters were prognostic relevant, however, with higher AUC values for FAC/PASP (AUC=0.74, p<0.001) and TAPSE/PASP (AUC=0.74, p<0.001) than for single TAPSE (AUC= 0.71, p=0.001) or FAC (AUC=0.7, p=0.001). Within a multivariate Cox regression analysis, only the FAC/PASP remained an independent predictor for long term survival.

Conclusion

FAC, an echo parameter that includes a predominant radial with a smaller part of longitudinal contraction, correlated significantly better to the invasively derived RV-PA-C-ratio than pure longitudinal RV shortening (TAPSE). Combining FAC or TAPSE with PASP did not improve the non-invasive RV-PA coupling information. However, it provided more comprehensive information on pulmonary vascular load and RV oxygen consumption, which seems to be translated into a higher prognostic power.

Acknowledgement/Funding

scientific grant from Boston Scientific

[Vomiting and collapse of a 28-year-old male long distance runner in middle European Summer]

BACKGROUND

Hyperthermia often ends fatally and must therefore be promptly recognized and adequately treated.

CASE

A 28-year-old man participated in a long-distance race (3 km) on a hot summer day (28 °C). The runner collapsed, had to vomit but continued the run and reached the finish. Neurologically, the patient presented with intermittent cerebral seizures. External cooling batteries were immediately applied and cold infusions were started. The patient was admitted to the intensive care unit of the university hospital (body temperature 40.2 °C). After a few hours, a manifest disseminated intravascular coagulopathy developed with multiple organ failure. It took 12 l of volume replacement, 8 units of fresh frozen plasma and 2 units of erythrocyte concentrates in the first 12 h to stabilize the patient. Although with the help of forced external cooling and application of cold infusions, the body temperature could be lowered to 38 °C by the next morning, the overall situation of the patient continued to deteriorate. Despite dialysis and massive substitution of coagulation factors, the patient could not be sufficiently stabilized and died of brain edema.

CONCLUSION

Not only the old or young children are subject to the potential danger of a fatal heat stroke but also young athletic persons after normal sports activities (3 km run). Cooling must be started immediately and the patient must be hospitalized as a vital emergency. If hemostasis fails due to the heat-related loss of hepatogenic protein synthesis, a viscious circle begins, which, as in the reported case, is irreversible despite maximum therapy and substitution.

[Correlation between changes in the nerve fiber layer and examination of the visual field using automatic perimetry in diagnosing primary open angle glaucoma]

PURPOSE

To analyse the correlation between changes in the nerve fiber layer and the appearance of defects in the visual field in primary open angle glaucoma (POAG).

MATERIAL

and methods: Digital image processing of the nerve fiber layer and examination of the visual field (30-2 Humphrey) was performed in 450 patients. The conditions for obtaining the digital images are presented.

RESULTS

Defects of the nerve fiber layer were evaluated qualitatively and quantitatively using automatic perimetry and the correlation was estimated. The results are discussed.

CONCLUSION

Examination of patients suspected of having POAG is much more precise when using both techniques performed the same day. Thus it will be possible to save time for: early diagnosis, monitoring the treatment, limiting the progression of glaucoma.

Development of model aqueous ophthalmic solution of indomethacin

A new model aqueous solution of indomethacin was developed on the basis of Pluronic F68 (15%) and F127 (10%). They showed some practical advantages over the models prepared with polyols and polysorbate 80, which were used for comparison. It was found that both Pluronics acted very similarly and were more effective as solubilizers, created an appropriate viscosity, and formed reversible gels at higher temperatures, ensured the indomethacin chemical stability and prolonged in vitro drug diffusion, and showed high physiological tolerance on rabbit eyes. Moreover, indomethacin stability and solution viscosity in the presence of Pluronics did not change after heat sterilization (i.e., the samples can bear heat sterilization).