1414Vasodilator challenge with levosimendan as alternative to nitric oxide in advanced heart failure heart transplant candidates

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
M Tavares Da Silva ◽  
A P Lourenco ◽  
R A Rodrigues ◽  
R Lopes ◽  
J C Silva ◽  
...  
Keyword(s):  
Nitric Oxide ◽  
Heart Failure ◽  
Heart Transplant ◽  
Left Ventricular ◽  
Advanced Heart Failure ◽  
Left Ventricular Ejection ◽  
Stroke Work ◽  
Continuous Variables ◽  
Arterial Blood ◽  
Wedge Pressure

Abstract Introduction Vasodilator challenge (VC) during right heart catheterization in heart transplant (HTx) candidates is warranted whenever pulmonary artery (PA) systolic pressure ≥50 mmHg and either transpulmonary gradient (TPG) ≥15 mmHg or pulmonary vascular resistance (PVR) >3 WU as long as systolic arterial blood pressure >85 mmHg. Nitric oxide (NO) remains the mainstay but in doubtful cases a 24–48h course of diuretics, inotropes and vasoactive agents may be required. Our aim is to report our centre's experience with levosimendan (LEVO) as alternative to NO in VC in HTx candidates due to advanced heart failure (HF). Methods VC records with either NO (20 ppm for 5–10 mins) or within 72h of LEVO infusion (12 mg/kg/min for 24–48h) carried out between 2009 and September 2018 were retrieved from the centre's database. Analysis was carried out with Fisher's exact test or Student's t-test for categorical and continuous variables, respectively, or the equivalent non-parametric test for non-normal distribution variables. Data are presented as counts and percentage, or mean ± standard deviation and median, percentile 25–75, for categorical and continuous variables, respectively. Results Baseline demographic and clinical characteristics from 26 patients (NO=13; LEVO=13) were similar between groups (12% female; 54±10 years of age; left ventricular ejection fraction 20±7%; BNP 1550±1090 pg/mL; 88% on NYHA III-IV). Although no differences were observed in baseline cardiac index (CI, 1.6±0.3 vs 1.4±0.4 L/min.m-2, in NO and LEVO, respectively), LEVO patients showed higher right ventricular systolic (70±10 vs 60±13 mmHg; p=0.036) and diastolic pressures (16±4 vs 11±5 mmHg; p=0.009) and lower PA compliance (0.9±0.2 vs 1.3±0.4 ml/mmHg; p=0.007) as well as a trend for increased PA wedge pressure (26±4 vs 21±4 mmHg; p=0.09), translating worse hemodynamics. Upon VC only LEVO decreased PA pressure and the increase in CI was higher compared with NO (2.5±0.8 vs 1.9±0.5 L/min.m-2, p=0.004) thus PVR reduction was comparable between groups (7.8±2.7 to 4.7±1.8 vs 6.3±2.3 to 3.6±2.1 WU, respectively). Also, only LEVO increased right (497, 387–837 to 791, 570–946 mmHg.mL.m-2; p=0.006) and left ventricular stroke work index (895, 807–1364 to 1257, 1107–2957 mmHg.mL.m-2; p=0.005) and cardiac power output (0.4±0.1 to 0.6±0.1 W; p<0.001). Increase in PA compliance was also higher in LEVO (89±98 vs 22±30 Δ%, p=0.04). On the other hand, NO increased wedge pressure whereas LEVO had no effect thus TPG reduction was higher with NO (42±24% vs 17±27% drops, respectively; p=0.022). After HTx (NO=4; LEVO=10) mortality was similar in both groups (25% vs 30%; p=1.00). Conclusion LEVO is a safe and effective alternative in PVR reduction for VC. Its positive inotropic effect and long-lasting hemodynamic improvement may improve clinical status before HTx and allow better scrutiny of suitable candidates.

scholarly journals 48 Correlation of left ventricular myocardial work indices and invasive measurement of stroke work

2021 ◽  
Vol 23 (Supplement_G) ◽  
Author(s):  
Federico Landra ◽  
Giulia Elena Mandoli ◽  
Benedetta Chiantini ◽  
Maria Barilli ◽  
Giacomo Merello ◽  
...  
Keyword(s):  
Heart Failure ◽  
Heart Transplantation ◽  
Left Ventricular ◽  
Advanced Heart Failure ◽  
Left Ventricular Ejection ◽  
Stroke Work ◽  
Work Index ◽  
Stroke Work Index ◽  
Constructive Work ◽  
Global Work

Abstract Aims A novel echocardiographic method allows to non-invasively assess myocardial work using pressure–strain loops. Even though left ventricular myocardial work has already emerged as a promising prognostic tool for various pathological conditions, its relationship with invasively-derived corresponding indices has not been assessed in humans yet. This study aimed to explore the correlation between left ventricular myocardial work (LVMW) indices and invasively derived left ventricular stroke work index (LVSWI) in a cohort of patients with advanced heart failure (HF) considered for heart transplantation. Methods and results All consecutive patients with advanced heart failure considered for heart transplantation from 2016 to 2021 that had already performed right heart catheterization (RHC) as part of the workup and with an available echocardiographic exam were included (n = 91). Myocardial work analysis was performed in 44 patients, according to exclusion criteria. Conventional LV functional parameters and LVMW indices, including LV global work index (LVGWI), LV global constructive work (LVGCW), LV global wasted work (LVGWW), LV global work efficiency (LVGWE), and other were calculated and compared with invasively measured LV stroke work index (LVSWI). Median age was 60 years [interquartile range (IQR): 54–63]. Median time between RHC and echocardiography was 0 months (IQR: 0–1). For the most part, etiology of HF was non-ischaemic (61.4%) and all patients were either on class NYHA II (61.4%) or III (27.3%). Median left ventricular ejection fraction was 25% (IQR: 22.3–32.3), median NT-proBNP 1377 pg/ml (IQR: 646–2570). Among conventional parameters of LV function, LVEF did not significantly correlate with LVSWI (r = 0.308; P = 0.050) whereas LV global longitudinal strain (LVGLS) did (r = −0.337; P = 0.031). With regard to LVMW indices, some of them demonstrated correlation with LVSWI, particularly LVGWI (r = 0.425; P = 0.006), LVGCW (r = 0.506; P = 0.001), LV global positive work (LVGPW; r = 0.464; P = 0.003), and LV global systolic constructive work (LVGSCW; r = 0.471; P = 0.002). Conclusions Among left ventricular myocardial work indices, LVGCW correlated better with invasively derived stroke work, thus representing a powerful and reliable tool for a more comprehensive evaluation of myocardial function.

scholarly journals Differences in the prognoses of patients referred to an advanced heart failure center from hospitals with different bed volumes

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Koichi Narita ◽  
Eisuke Amiya ◽  
Masaru Hatano ◽  
Junichi Ishida ◽  
Hisataka Maki ◽  
...  
Keyword(s):  
Heart Failure ◽  
Primary Outcome ◽  
Left Ventricular ◽  
Cox Proportional Hazards ◽  
Advanced Heart Failure ◽  
Ventricular Assist Devices ◽  
Left Ventricular Ejection ◽  
Left Ventricular Assist Devices ◽  
Ventricular Ejection Fraction

AbstractFew reports have discussed appropriate strategies for patient referrals to advanced heart failure (HF) centers with available left ventricular assist devices (LVADs). We examined the association between the characteristics and prognoses of referred patients with advanced HF and the bed volume of the referring hospitals. This retrospective analysis evaluated 186 patients with advanced HF referred to our center for consultation about the indication of LVAD between January 1, 2015, and August 31, 2018. We divided the patients into two groups according to the bed volume of their referring hospital (high bed volume hospitals (HBHs): ≥ 500 beds in the hospital; low bed volume hospitals (LBHs): < 500 beds). We compared the primary outcome measure, a composite of LVAD implantation and all-cause death, between the patients referred from HBHs and patients referred from LBHs. The 186 patients with advanced HF referred to our hospital, who were referred from 130 hospitals (87 from LBHs and 99 from HBHs), had a mean age of 43.0 ± 12.6 years and a median left ventricular ejection fraction of 22% [15–33%]. The median follow-up duration of the patients was 583 days (119–965 days), and the primary outcome occurred during follow-up in 42 patients (43%) in the HBH group and 20 patients (23%) in the LBH group. Patients referred from HBHs tended to require catecholamine infusion on transfer more often than those referred from LBLs (36.5% (HBH), 20.2% (LBL), P = 0.021). Kaplan–Meier analysis indicates that the occurrence of the primary outcome was significantly higher in the HBH patients than in the LBH patients (log-rank P = 0.0022). Multivariate Cox proportional hazards analysis revealed that catecholamine support on transfer and long disease duration were statistically significant predictors of the primary outcome. Patients from HBHs had a greater risk of the primary outcome. However, the multivariate analysis did not indicate an association between referral from an HBH and the primary outcome. In contrast, catecholamine support on transfer, long duration of disease, and low blood pressure were independent predictors of the primary outcome. Therefore, these should be considered when determining the timing of a referral to an advanced HF center, irrespective of the bed volume of the referring hospital.

scholarly journals Myocardial Work Assessment for the Prediction of Prognosis in Advanced Heart Failure

2021 ◽  
Vol 8 ◽  
Author(s):  
Felix Hedwig ◽  
Olena Nemchyna ◽  
Julia Stein ◽  
Christoph Knosalla ◽  
Nicolas Merke ◽  
...  
Keyword(s):  
Heart Failure ◽  
Left Ventricular Assist Device ◽  
Ventricular Assist Device ◽  
Left Ventricular ◽  
Advanced Heart Failure ◽  
Left Ventricular Ejection ◽  
Assist Device ◽  
Ventricular Assist ◽  
Left Ventricular Assist ◽  
The Mean

Objectives: The aim of this study was to investigate whether echocardiographic assessment of myocardial work is a predictor of outcome in advanced heart failure.Background: Global work index (GWI) and global constructive work (GCW) are calculated by means of speckle tracking, blood pressure measurement, and a normalized reference curve. Their prognostic value in advanced heart failure is unknown.Methods: Cardiopulmonary exercise testing and echocardiography with assessment of GWI and GCW was performed in patients with advanced heart failure caused by ischemic heart disease or dilated cardiomyopathy (n = 105). They were then followed up repeatedly. The combined endpoint was all-cause death, implantation of a left ventricular assist device, or heart transplantation.Results: The median patient age was 54 years (interquartile range [IQR]: 48–59.9). The mean left ventricular ejection fraction was 27.8 ± 8.2%, the median NT-proBNP was 1,210 pg/ml (IQR: 435–3,696). The mean GWI was 603 ± 329 mmHg% and the mean GCW was 742 ± 363 mmHg%. The correlation between peak oxygen uptake and GWI as well as GCW was strongest in patients with ischemic cardiomyopathy (r = 0.56, p = 0.001 and r = 0.53, p = 0.001, respectively). The median follow-up was 16 months (IQR: 12–18.5). Thirty one patients met the combined endpoint: Four patients died, eight underwent transplantation, and 19 underwent implantation of a left ventricular assist device. In the multivariate Cox regression analysis, only NYHA class, NT-proBNP and GWI (hazard ratio [HR] for every 50 mmHg%: 0.85; 95% CI: 0.77–0.94; p = 0.002) as well as GCW (HR for every 50 mmHg%: 0.86; 95% CI: 0.79–0.94; p = 0.001) were identified as independent predictors of the endpoint. The cut-off value for predicting the outcome was 455 mmHg% for GWI (AUC: 0.80; p &lt; 0.0001; sensitivity 77.4%; specificity 71.6%) and 530 mmHg% for GCW (AUC: 0.80; p &lt; 0.0001; sensitivity 74.2%; specificity 78.4%).Conclusions: GWI and GCW are powerful predictors of outcome in patients with advanced heart failure.

Abstract 4869: Pulmonary Vasoconstriction Occurs out of Proportion to Increases in Pulmonary Capillary Wedge Pressure During Exercise in Heart Failure

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Gregory D Lewis ◽  
Ravi V Shah ◽  
Maryann Martinovic ◽  
Kenneth D Bloch ◽  
Marc J Semigran
Keyword(s):  
Heart Failure ◽  
Pulmonary Capillary Wedge Pressure ◽  
Exercise Capacity ◽  
Exercise Testing ◽  
Left Ventricular ◽  
Work Rate ◽  
Left Ventricular Ejection ◽  
Pulmonary Vasoconstriction ◽  
Pulmonary Capillary ◽  
Wedge Pressure

Secondary pulmonary hypertension (PH) is an important prognostic indicator in patients with systolic heart failure (HF), but the pattern of increase in pulmonary arterial pressure (PAP) during exercise and its relationship to exercise capacity and pulmonary capillary wedge pressure (PCWP) have not been comprehensively investigated. We hypothesized that HF patients would develop an increase in PAP out of proportion to the increase in PCWP during exercise and that the rate of PAP increase during exercise would predict exercise capacity in HF. Thirty-three patients with systolic HF (mean±SD, age 58 ± 7 years, left ventricular ejection fraction 0.27 ± 0.05, peak oxygen uptake 11.2 ± 3.2 ml/kg/min) and 10 normal subjects (age 53±9, sex, VO2) underwent cardiopulmonary exercise testing with simultaneous hemodynamic monitoring. There was a linear relationship between PAP and work rate in watts (R>0.85 for all subjects) whereas no consistent relationship between PCWP and work rate was present (R=0.02– 0.93). HF patients had a 3-fold greater rate of increase in PAP per watt than normals (slope=0.23±0.02 vs. 0.07±0.002 mmHg/W respectively, p<0.0001). In HF patients, PAP increased out of proportion to PCWP, as indicated by the slope of the gradient between PAP and PCWP (0.11±0.005 mmHg/W in HF vs. 0.01±0.005 mmHg/W in normals, p<0.0001). In HF patients, PAP slope, but not PCWP slope, inversely correlated with exercise capacity as measured by peak VO 2 (R=−0.41, p=0.04 and R=−0.12, p=0.56, respectively). Fifteen of the HF subjects underwent repeated exercise testing after 12-weeks of treatment with the pulmonary vasodilator sildenafil, with a resultant decrease in slope of the PAP-PCWP gradient from 0.11±0.02 to 0.07±0.01 mmHg, P<0.05. In patients with systolic HF there is a linear increase in PAP/watt that is out of proportion to the increase in PCWP/watt and inversely correlated with exercise capacity. Abnormal pulmonary vasoconstriction in response to physical activity in HF may represent a target for therapeutic intervention in HF. This research has received full or partial funding support from the American Heart Association, AHA National Center.

CRT operator challenges during procedure… tips and tricks

2021 ◽  
Vol 1 (58) ◽  
pp. 21-27
Author(s):  
Tomasz Wcisło ◽  
Haval Dariusz Qawoq
Keyword(s):  
Heart Failure ◽  
Left Ventricular ◽  
Advanced Heart Failure ◽  
Cardiac Resynchronization ◽  
Left Ventricular Ejection ◽  
Left Ventricular Dyssynchrony ◽  
Tips And Tricks ◽  
Resynchronization Therapy ◽  
Ventricular Ejection Fraction ◽  
Ventricular Dyssynchrony

In addition to pharmacological treatment, cardiac resynchronization therapy is an important method of heart failure treating. It’s indicated for patients with advanced heart failure, decreased left ventricular ejection fraction, a wide QRS syndrome, and the presence of left ventricular dyssynchrony despite optimal pharmacotherapy. The procedure is technically difficult and laden with many possible complications. Based on our own experience, this paper presents management with one of the periprocedural complications – dissection of the coronary sinus.

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