Recovery of RV Function Determines Outcomes of Extracorporeal Biventricular Support for Acute Biventricular Failure

One of the most challenging questions to answer in pulmonary arterial hypertension (PAH) is: “When is the optimal time to proceed with lung transplantation?” The current lung allocation scoring (LAS) system prioritizes donor organ resources based on severity of illness. Factors used to assign LAS do not account for known predictors of outcome for PAH patients—including determinants of right ventricular (RV) function. It has been recognized that the system places PAH patients at a distinct disadvantage, and concerted efforts are being made to correct this by considering variables that reflect RV function, specifically mean right atrial pressure (mRAP) and cardiac index (CI).

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Hemodynamic Support Using Percutaneous Transfemoral Impella 5.0 and Impella RP for Refractory Cardiogenic Shock

Case Reports in Cardiology ◽

10.1155/2019/4591250 ◽

2019 ◽

Vol 2019 ◽

pp. 1-6 ◽

Cited By ~ 1

Author(s):

Pratik K. Dalal ◽

Amy Mertens ◽

Dinesh Shah ◽

Ivan Hanson

Keyword(s):

Left Ventricle ◽

Pulmonary Artery ◽

Cardiogenic Shock ◽

Ventricular Function ◽

Standard Of Care ◽

Left Ventricular ◽

Biventricular Failure ◽

Ventricular Support ◽

The Right ◽

Flow Pump

Acute myocardial infarction (AMI) resulting in cardiogenic shock continues to be a substantial source of morbidity and mortality despite advances in recognition and treatment. Prior to the advent of percutaneous and more durable left ventricular support devices, prompt revascularization with the addition of vasopressors and inotropes were the standard of care in the management of this critical population. Recent published studies have shown that in addition to prompt revascularization, unloading of the left ventricle with the placement of the Impella percutaneous axillary flow pump can lead to improvement in mortality. Parameters such as the cardiac power output (CPO) and pulmonary artery pulsatility index (PAPi), obtained through pulmonary artery catheterization, can help ascertain the productivity of right and left ventricular function. Utilization of these parameters can provide the information necessary to escalate support to the right ventricle with the insertion of an Impella RP or the left ventricle with the insertion of larger devices, which provide more forward flow. Herein, we present a case of AMI complicated by cardiogenic shock resulting in biventricular failure treated with the percutaneous insertion of an Impella RP and Impella 5.0 utilizing invasive markers of left and right ventricular function to guide the management and escalation of care.

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Levosimendan, milrinone and dobutamine in acute experimental pulmonary embolism

European Heart Journal Acute Cardiovascular Care ◽

10.1093/ehjacc/zuab020.193 ◽

2021 ◽

Vol 10 (Supplement_1) ◽

Author(s):

MD Lyhne ◽

SJ Dragsbaek ◽

JV Hansen ◽

JG Schultz ◽

A Andersen ◽

...

Keyword(s):

Pulmonary Embolism ◽

Acute Pulmonary Embolism ◽

Cardiovascular Effects ◽

Right Heart Catheterization ◽

Mechanical Work ◽

Heart Catheterization ◽

Funding Sources ◽

Mean Pulmonary Arterial Pressure ◽

Acute Pe ◽

Rv Function

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Laerdal Foundation for Acute Medicine, Novo Nordisk Foundation Background/Introduction: Acute pulmonary embolism (PE) is a frequent condition in acute cardiac care and is potentially fatal. Cause of death is right ventricular (RV) failure due to increased RV afterload from both pulmonary vascular obstruction and vasoconstriction. Inodilators are interesting drugs of choice as they may improve RV function and lower its afterload. Purpose We aimed to investigate the cardiovascular effects of three clinically relevant inodilators: levosimendan, milrinone and dobutamine in acute PE. Methods We conducted a randomized, blinded, animal study using 18 female pigs. Animals received large autologous PE until doubling of baseline mean pulmonary arterial pressure and were randomized to four logarithmically increasing doses of each inodilator. Effects were evaluated with bi-ventricular pressure-volume loop recordings, right heart catheterization and blood gas analyses. Results Induction of PE increased RV afterload and pulmonary pressure (p < 0.05) causing RV dysfunction. Levosimendan and milrinone showed beneficial hemodynamic profiles by lowering RV pressures and volume (p < 0.001) and improved RV function and cardiac output (p < 0.05) without increasing RV mechanical work. Dobutamine increased RV pressure and function (p < 0.01) but at a cost of increased mechanical work at the highest doses, showing an adverse hemodynamic profile. See Figure. Conclusion(s): In a porcine model of acute PE, levosimendan and milrinone reduced RV afterload and improved RV function, whereas dobutamine at higher doses increased RV afterload and RV mechanical work. The study motivates clinical testing of inodilators in patients with acute PE and RV dysfunction. Abstract Figure. Inodilators in acute pulmonary embolism

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CMR markers for early right ventricular dysfunction in precapillary pulmonary hypertension

European Heart Journal ◽

10.1093/ehjci/ehaa946.0241 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

J Vos ◽

T Leiner ◽

A.P.J Van Dijk ◽

F.J Meijboom ◽

G.T Sieswerda ◽

...

Keyword(s):

Pulmonary Hypertension ◽

Right Ventricle ◽

Right Ventricular ◽

Circumferential Strain ◽

Peak Strain ◽

Healthy Controls ◽

Free Wall ◽

Global Circumferential Strain ◽

The Right ◽

Rv Function

Abstract Introduction Precapillary pulmonary hypertension (pPH) causes right ventricular (RV) pressure overload inducing RV remodeling, often resulting in dysfunction and dilatation, heart failure, and ultimately death. The ability of the right ventricle to adequately adapt to increased pressure loading is key for patients' prognosis. RV ejection fraction (RVEF) by cardiac magnetic resonance (CMR) is related to outcome in pPH patients, but this global measurement is not ideal for detecting early changes in RV function. Strain analysis on CMR using feature tracking (FT) software provides a more detailed assessment, and might therefore detect early changes in RV function. Aim 1) To compare RV strain parameters in pPH patients and healthy controls, and 2) to compare strain parameters in a subgroup of pPH patients with preserved RVEF (pRVEF) and healthy controls. Methods In this prospective study, a CMR was performed in pPH patients and healthy controls. Using FT-software on standard cine images, the following RV strain parameters were analyzed: global, septal, and free wall longitudinal strain (GLS, sept-LS, free wall-LS), time to peak strain (TTP, as a % of the whole cardiac cycle), the fractional area change (FAC), global circumferential strain (GCS), global longitudinal and global circumferential strain rate (GLSR and GCSR, respectively). A pRVEF is defined as a RVEF >50%. To compare RV strain parameters in pPH patients to healthy controls, the Mann-Whitney U test was used. Results 33 pPH-patients (55 [45–63] yrs; 10 (30%) male) and 22 healthy controls (40 [36–48] yrs; 15 (68%) male) were included. All RV strain parameters were significantly reduced in pPH patients compared to healthy controls (see table), except for GCS and GCSR. Most importantly, in pPH patients with pRVEF (n=8) GLS (−26.6% [−22.6 to −27.3] vs. −28.1% [−26.2 to −30.6], p=0.04), sept-LS (−21.2% [−19.8 to −23.2] vs. −26.0% [−24.0 to −27.9], p=0.005), and FAC (39% [35–44] vs. 44% [42–47], p=0.02) were still significantly impaired compared to healthy controls. The RV TTP was significantly increased in pPH patients compared to healthy controls (47% [44–57] vs. 40% [33–43], p≤0.001). Conclusions Several CMR-FT strain parameters of the right ventricle are impaired in pPH patients when compared to healthy controls. Moreover, even in pPH patients with a preserved RVEF multiple RV strain parameters (GLS, sept-LS, and FAC) remained significantly impaired, and TTP significantly prolonged, in comparison to healthy controls. This suggests that RV strain parameters may be used as an early marker of RV dysfunction in pPH patients. Funding Acknowledgement Type of funding source: None

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Chryseobacterium bacteraemia in a patient with heart failure: case report and literature review

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytaa338 ◽

2020 ◽

Author(s):

Taylor Wood ◽

Antonio Abbate ◽

Inna Tchoukina ◽

Michael P Stevens

Keyword(s):

Emergency Department ◽

Human Infection ◽

Blood Cultures ◽

Vasopressor Therapy ◽

Duration Of Treatment ◽

Chryseobacterium Indologenes ◽

Case Summary ◽

Biventricular Failure ◽

Heart Failure Case ◽

Antimicrobial Regimen

Abstract Background A 29-year-old male with recently diagnosed biventricular failure from myopericarditis and subsequent constrictive pericarditis on home milrinone presented to the Emergency Department with fevers/chills. Case summary On arrival to the Emergency Department, he was found to have septic shock and required vasopressor therapy. Chryseobacterium indologenes grew on his admission blood cultures, and he was treated with ciprofloxacin and piperacillin/tazobactam. He quickly improved, allowing for a successful pericardiectomy, was weaned off inotropes and discharged from the hospital. Discussion Chryseobacterium indologenes is an environmental Gram-negative rod found in groundwater. It is rarely associated with human infection, but is associated with indwelling lines and has been documented in immunocompromised patients. Treatment typically involves line removal and a fluoroquinolone or piperacillin/tazobactam; the most optimal antimicrobial regimen and duration of treatment are unknown.

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Circulation derived from 4D flow MRI correlates with right ventricular dysfunction in patients with tetralogy of Fallot

Scientific Reports ◽

10.1038/s41598-021-91125-2 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Nanae Tsuchiya ◽

Michinobu Nagao ◽

Yumi Shiina ◽

Shohei Miyazaki ◽

Kei Inai ◽

...

Keyword(s):

Right Ventricular ◽

Tetralogy Of Fallot ◽

Main Pulmonary Artery ◽

Vortex Formation ◽

Cine Mri ◽

Short Axis ◽

4D Flow Mri ◽

4D Flow ◽

Flow Mri ◽

Rv Function

AbstractWe used 4D-flow MRI to investigate circulation, an area integral of vorticity, in the main pulmonary artery (MPA) as a new hemodynamic parameter for assessing patients with a repaired Tetralogy of Fallot (TOF). We evaluated the relationship between circulation, right ventricular (RV) function and the pulmonary regurgitant fraction (PRF). Twenty patients with a repaired TOF underwent cardiac MRI. Flow-sensitive 3D-gradient sequences were used to obtain 4D-flow images. Vortex formation in the MPA was visualized, with short-axis and longitudinal vorticities calculated by software specialized for 4D flow. The RV indexed end-diastolic/end-systolic volumes (RVEDVi/RVESVi) and RV ejection fraction (RVEF) were measured by cine MRI. The PR fraction (PRF) and MPA area were measured by 2D phase-contrast MRI. Spearman ρ values were determined to assess the relationships between circulation, RV function, and PRF. Vortex formation in the MPA occurred in 15 of 20 patients (75%). The longitudinal circulation (11.7 ± 5.1 m2/s) was correlated with the RVEF (ρ = − 0.85, p = 0.0002), RVEDVi (ρ = 0.62, p = 0.03), and RVESVi (ρ = 0.76, p = 0.003) after adjusting for the MPA size. The short-axis circulation (9.4 ± 3.4 m2/s) in the proximal MPA was positively correlated with the MPA area (ρ = 0.61, p = 0.004). The relationships between the PRF and circulation or RV function were not significant. Increased longitudinal circulation in the MPA, as demonstrated by circulation analysis using 4D flow MRI, was related to RV dysfunction in patients with a repaired TOF.

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Right ventricular rather than left ventricular systolic dysfunction predicts outcome in patients undergoing transcatheter aortic valve implantation: insights from cardiac magnetic resonance imaging

European Heart Journal ◽

10.1093/ehjci/ehaa946.2583 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

M Koschutnik ◽

C Nitsche ◽

C Dona ◽

V Dannenberg ◽

A.A Kammerlander ◽

...

Keyword(s):

Heart Failure ◽

Cox Regression ◽

Systolic Dysfunction ◽

Left Ventricular ◽

Prognostic Information ◽

Transcatheter Aortic Valve ◽

Kaplan Meier ◽

Lv Volumes ◽

Valve Implantation ◽

Rv Function

Abstract Background Right ventricular (RV) function is strongly associated with outcome in heart failure. Whether it also adds important prognostic information in patients undergoing transcatheter aortic valve implantation (TAVI) is unknown. Methods We consecutively enrolled patients with severe aortic stenosis (AS) scheduled for TAVI and preprocedural cardiac magnetic resonance (CMR) imaging. Kaplan-Meier estimates and multivariate Cox regression analyses were used to identify factors associated with outcome. A composite of heart failure hospitalization and/or cardiovascular death was selected as primary study endpoint. Results 423 consecutive patients (80.7±7.3 years; 48% female) were prospectively included, 201 (48%) underwent CMR imaging. 55 (27%) patients presented with RV systolic dysfunction (RVSD) defined by RV ejection fraction (RVEF) <45%. RVSD was associated with male sex (69 vs. 40%; p<0.001), New York Heart Association (NYHA) functional status (NYHA ≥ III: 89 vs. 57%; p<0.001), NT-proBNP serum levels (9365 vs. 2715 pg/mL; p<0.001), and history of atrial fibrillation (AF: 51 vs. 30%; p=0.005). On CMR, RVSD was associated with left ventricular (LV) volumes (end-diastolic: 187 vs. 137 mL, end-systolic: 119 vs. 53 mL; p<0.001) and EF (39 vs. 64%; p<0.001). A total of 51 events (37 deaths, 14 hospitalizations for heart failure) occurred during follow-up (9.8±9 months). While LVSD (LVEF <50%) was not significantly associated with outcome (HR 0.83, 95% CI: 0.33 – 2.11; p=0.694), RVSD showed a strong and independent association with event-free survival by multivariate Cox regression analysis (HR 2.47, 95% CI: 1.07–5.73; p=0.035), which was adjusted for all relevant CMR parameters (LV volumes and EF), cardiovascular risk factors (sex, NYHA, AF, diabetes mellitus type II, use of diuretics), and routine biomarkers (NT-proBNP, creatinine). Conclusions RVSD rather than LVSD, as determined on CMR, is an important predictor of outcome in patients undergoing TAVI. RV function might thus add useful prognostic information on top of established risk factors. Figure 1. Kaplan-Meier survival curves Funding Acknowledgement Type of funding source: None

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Inhaled nitric oxide preserves ventricular function during resuscitation using a percutaneous mechanical circulatory support device in a porcine cardiac arrest model: an echocardiographic myocardial work analysis

BMC Cardiovascular Disorders ◽

10.1186/s12872-021-01992-w ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Christoph Nix ◽

Rashad Zayat ◽

Andreas Ebeling ◽

Andreas Goetzenich ◽

Uma Chandrasekaran ◽

...

Keyword(s):

Nitric Oxide ◽

Cardiac Arrest ◽

Mechanical Circulatory Support ◽

Left Ventricular ◽

Inhaled Nitric Oxide ◽

Circulatory Support ◽

Support Device ◽

Mechanical Circulatory Support Device ◽

Rv Function ◽

Circulatory Support Device

Abstract Background Resuscitation using a percutaneous mechanical circulatory support device (iCPR) improves survival after cardiac arrest (CA). We hypothesized that the addition of inhaled nitric oxide (iNO) during iCPR might prove synergistic, leading to improved myocardial performance due to lowering of right ventricular (RV) afterload, left ventricular (LV) preload, and myocardial energetics. This study aimed to characterize the changes in LV and RV function and global myocardial work indices (GWI) following iCPR, both with and without iNO, using 2-D transesophageal echocardiography (TEE) and GWI evaluation as a novel non-invasive measurement. Methods In 10 pigs, iCPR was initiated following electrically-induced CA and 10 min of untreated ventricular fibrillation (VF). Pigs were randomized to either 20 ppm (20 ppm, n = 5) or 0 ppm (0 ppm, n = 5) of iNO in addition to therapeutic hypothermia for 5 h following ROSC. All animals received TEE at five pre-specified time-points and invasive hemodynamic monitoring. Results LV end-diastolic volume (LVEDV) increased significantly in both groups following CA. iCPR alone led to significant LV unloading at 5 h post-ROSC with LVEDV values reaching baseline values in both groups (20 ppm: 68.2 ± 2.7 vs. 70.8 ± 6.1 mL, p = 0.486; 0 ppm: 70.8 ± 1.3 vs. 72.3 ± 4.2 mL, p = 0.813, respectively). LV global longitudinal strain (GLS) increased in both groups following CA. LV-GLS recovered significantly better in the 20 ppm group at 5 h post-ROSC (20 ppm: − 18 ± 3% vs. 0 ppm: − 13 ± 2%, p = 0.025). LV-GWI decreased in both groups after CA with no difference between the groups. Within 0 ppm group, LV-GWI decreased significantly at 5 h post-ROSC compared to baseline (1,125 ± 214 vs. 1,835 ± 305 mmHg%, p = 0.011). RV-GWI was higher in the 20 ppm group at 3 h and 5 h post-ROSC (20 ppm: 189 ± 43 vs. 0 ppm: 108 ± 22 mmHg%, p = 0.049 and 20 ppm: 261 ± 54 vs. 0 ppm: 152 ± 42 mmHg%, p = 0.041). The blood flow calculated by the Impella controller following iCPR initiation correlated well with the pulsed-wave Doppler (PWD) derived pulmonary flow (PWD vs. controller: 1.8 ± 0.2 vs. 1.9 ± 0.2L/min, r = 0.85, p = 0.012). Conclusions iCPR after CA provided sufficient unloading and preservation of the LV systolic function by improving LV-GWI recovery. The addition of iNO to iCPR enabled better preservation of the RV-function as determined by better RV-GWI. Additionally, Impella-derived flow provided an accurate measure of total flow during iCPR.

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Right ventricular ejection fraction as predictor of outcome in acute heart failure using RV ellipsoid model: A retrospective analysis of a prospective cross-sectional study

JRSM Cardiovascular Disease ◽

10.1177/20480040211002775 ◽

2021 ◽

Vol 10 ◽

pp. 204800402110027

Author(s):

Eshan Ashcroft ◽

Otar Lazariashvili ◽

Jonathan Belsey ◽

Max Berrill ◽

Pankaj Sharma ◽

...

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Right Ventricular ◽

Retrospective Analysis ◽

Cross Sectional Study ◽

Volume Estimation ◽

Sectional Study ◽

Cross Sectional ◽

Ventricular Ejection Fraction ◽

Rv Function

Objectives The right ventricular (RV) function is an important prognostic factor in acute and chronic heart failure (HF). Echocardiography is an essential imaging modality with established parameters for RV function which are useful and easy to perform. However, these fail to reflect global RV volumes due to reliability on one acoustic window. It is therefore attractive to calculate RV volumes and ejection fraction (RVEF/E) using an ellipsoid geometric model which has been validated against MRI in healthy adults but not in the HF patients. Design This is a retrospective analysis of a prospective cross-sectional study enrolling 418 consecutive patients with symptoms of HF according to a predefined study protocol. All patients underwent echocardiographic assessment of RV function using Tricuspid Annular Plane Systolic Excursion (TAPSE) and RV fractional area change (RVFAC) and RVEF/E. Setting Single centre study with multiple locations for acute in-patients including high dependency units. Participants Patients with acute or exacerbation of chronic HF older than 18 y.o. Main outcome measures Ability of RVEF/E to predict patient outcomes compared with two established parameters of RV function over two-year follow-up period. Primary outcome measure was all-cause mortality. Results RVEF/E is equal to TAPSE & RVFAC in predicting outcome (p ≤ 0.01 vs p ≤ 0.01) and provides additional benefit of RV volume estimation based on standard 2D echo measurements. Conclusions In this study we have shown that RVEF/E derived from ellipsoid model is not inferior to well established measures of RV function as a prognostic indicator of outcome in the acute HF.

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