Efficacy and safety of endotracheal instillation of iloprost for persistent pulmonary hypertension of the newborn

Objective: To determine the efficacy and safety of endotracheal instillation of iloprost as a rescue therapy for persistent pulmonary hypertension of the newborn. Methods: Neonates diagnosed with persistent pulmonary hypertension who were unresponsive to standard treatment protocol applied for persistent pulmonary hypertension in our unit, and who were being followed up with mechanical ventilation, were included in the study. Iloprost was instilled endotracheally as a rescue treatment. Systolic pulmonary artery pressure, oxygen saturation index, mean airway pressure, fraction of inspired oxygen, preductal and postductal venous oxygen saturation, heart rate, and blood pressure were recorded before and after 30 minutes of endotracheal iloprost instillation. Adverse events after endotracheal iloprost were recorded. Results: Twenty neonates were included. The median gestational age and birth weight were found to be 37 (30.5-38) weeks and 2975 (2125-3437.5) grams, respectively. When compared to the period before endotracheal iloprost instillation, systolic pulmonary artery pressure, oxygen saturation index, mean airway pressure, and fraction of inspired oxygen values significantly decreased (p < 0.001, p < 0.001, p = 0.021, p = 0.001, respectively), whereas preductal and postductal oxygen saturation values significantly increased 30 minutes after the endotracheal iloprost instillation (p = 0.002, p < 0.001, respectively). There were no significant differences in heart rate and blood pressure values before and after the iloprost administration. No adverse events were observed. Conclusion: Endotracheal instillation of iloprost was found to be an effective and safe therapy for persistent pulmonary hypertension unresponsive to conventional treatment.

Evolution of Echocardiographic Abnormalities Identified in Previously Healthy Individuals Recovering from COVID-19

(1) Background: Although the infection with the SARS-CoV-2 virus affects primarily the lungs, it is well known that associated cardiovascular (CV) complications are important contributors to the increased morbidity and mortality of COVID-19. Thus, in some situations, their diagnosis is overlooked, and during recovery, some patients continue to have symptoms enclosed now in the post-acute COVID-19 syndrome. (2) Methods: In 102 patients, under 55 years old, and without a history of CV diseases, all diagnosed with post-acute COVID-19 syndrome, we assessed by transthoracic echocardiography (TTE) four patterns of abnormalities frequently overlapping each other. Their evolution was followed at 3 and 6 months. (3) Results: In 35 subjects, we assessed impaired left ventricular function (LVF), in 51 increased systolic pulmonary artery pressure, in 66 diastolic dysfunction (DD) with normal LVF, and in 23 pericardial effusion/thickening. All TTE alterations alleviated during the follow-up, the best evolution being observed in patients with pericarditis, and a considerably worse one in those with DD, thus with a reduction in severity (4) Conclusions: In patients with post-acute COVID-19 syndrome, several cardiac abnormalities may be assessed by TTE, most of them alleviating in time. Some of them, especially DD, may persist, raising the presumption of chronic alterations.

Normal Chest X-Ray in Patients with Pulmonary Embolism May Involve Increased Risk of Massive Pulmonary Embolism

Purpose: Chest radiography is normal in approximately 20-40% of acute pulmonary embolism (PE) patients without cardiopulmonary disease. The aim of this study was to determine whether there is any difference between the patients with normal chest X-ray and those with pathological findings in terms of clinical severity and prognosis. Methods: 178 of PE patients were included in the study. 110 patients had no parenchymal pathology, whereas group 1 (n = 110); group 2 (n = 68) had various pathological parenchymal findings in 68 patients. Clinical and radiological parameters were compared between these groups. Following the diagnosis of PE, the cases were recorded in the fifth year. Results: In 178 participants; those with normal chest X-ray (group 1), with parenchymal pathological findings on the chest X-ray (group 2); echocardiographic systolic pulmonary artery pressure (sPAP) (p = 0.68), gender (p = 0.9) and thrombus type (p = 0.41) were similar. The patients in group 1 were not different in terms of central thrombus detected in computed tomography pulmonary angiogram compared to the patients in group 2; however, the chest radiograph of the patients in group 1 had no parenchymal pathology. Central thrombus group 1, group 2, respectively; 97 (89.0%), 53 (77.9%), p = 0.07. There was no significant difference between the two groups in terms of mortality which was followed up in fifth year (p > 0.05). Conclusions: Normal chest X-ray in PE can determine mortality and may involve increased risk of massive PE.

Can Severity of Pulmonary Hypertension Affect Success Rate of Balloon Mitral Commissurotomy?

Introduction: Rheumatic heart disease is responsible for the most prevalent pathological causes of mitral stenosis and is closely coupled with pulmonary hypertension. Balloon mitral commissurotomy as an alternative method for mitral valve replacement leads to a reduction in pulmonary pressure. All grades of pulmonary hypertension usually regress after mitral commissurotomy; however, the insignificant changes of pulmonary artery hypertension following balloon mitral valvuloplasty are not uncommon. Methods: This retrospective observational study was carried out on 160 patients with significant symptomatic mitral stenosis (mitral valve area [MVA] <1.5 cm ) who underwent successful percutaneous transvenous mitral commissurotomy (PTMC) within 2016-2020 at Shaheed Rajaie Cardiovascular, Medical and Research Center, Tehran, Iran. Results: In this study, 89.4% of the patients were female, and the mean age of the participants was 47.2±12.4 years. Most (74%) patients presented with dyspnea on exertion functional class II. The mean basic MVA was 1±0.20 cm that increased to 1.43±0.23 cm , and the mean basic systolic pulmonary artery pressure (PAP) was 43.84±11.93 mmHg that decreased to 35.13±7.7 mmHg. Persistent PAP after successful PTMC was observed in 34% of the patients. This group of patients showed smaller MVA gain and PAP reduction after the procedure. Pulmonary vascular resistance (PVR) > 2 Wood units was correlated to 91.7% of the post-procedural success rate. Conclusion: The PTMC plays an important role in the reduction of PAP; nevertheless, the chronicity and severity of PAP can lead to persistent pulmonary hypertension. The assessment of initial PAP and basic PVR can help select patients with more likely intended results.

733 Evaluation of pulmonary pressures in patients underwent to MitraClip

Mitral regurgitation (MR) is the second most frequent valve heart disease in Europe and its underlying mechanism primary-organic (due to disease of the mitral leaflets), or secondary-functional (where valve leaflets and chordae are structurally normal and MR results from alterations in left ventricle and left atrium geometry), determines the therapeutic approach. Transcatheter Edge-to-Edge Repair (TEER) with MitraClip implantation is a minimal-invasive treatment that according to 2021 ESC Guidelines should be considered (class indication IIa) in selected symptomatic patients with severe MR despite optimal medical therapy, not eligible for surgery and fulfilling COAPT trial inclusion criteria, suggesting an increased chance of responding to treatment. Optimal valve morphology features for TEER are central pathology (second scallop), no leaflet calcifications, mitral valve area &gt;4 cm2, mobile length of posterior leaftel &gt;10 mm, coaptation depth &lt;11mm, normal leaflet strength and mobility, flail width &lt;15 mm, flail gap &lt;10 mm. TEER may be considered (class IIb) only in selected cases when the COAPT criteria are not fulfilled with the aim of improving symptoms and quality of life. MR occurs during systole, that at normal heart rates represents 30–50% of the cardiac cycle. As such, marked left atrial (LA) pressure elevation is present only transiently, representing less of a drive to development of secondary pulmonary hypertension compared to chronic LA pressure elevation seen in severe mitral stenosis. Anyway, in patients with severe MR echocardiography often reveals elevated systolic pulmonary artery pressure (PAPs) and MitraClip implantation usually is associated with a slight increase of the trans-mitral gradient with possible repercussions on pulmonary pressures. To better describe the effect of MitraClip implantation on pulmonary pressures and clinical outcomes we did a retrospective study enrolling in the period 2012–2021 25 patients with severe mitral regurgitation treated with TEER. We aimed to evaluate the clinical outcomes (symptoms, signs of heart failure, NYHA functional class) and the pulmonary pressures assessed by an echocardiographic examination before and after the intervention. At 6-month follow-up all patients with repaired mitral regurgitation showed an improvement in the NYHA class (from IV to II) and no need for re-hospitalization. We observed a trend in the reduction of the mean sistolic pulmonary arterial pressure of 2.68 mmHg ± 15 mmHg (P 0.39, 95% C.I. −9.03 to 3.67) with an unchanged left ventricle ejection fraction. Moreover, the echocardiographic exam showed a normalization of the S and D waves pattern in the pulmonary veins at the PW Doppler evaluation. We can assume that the clinical improvement and the reduction of dyspnoea in these patients underwent TEER is related to a reduction of pressures in the pulmonary circulation regardless of the ejection fraction. This finding could be used as a tool that the cardiologist has to evaluate in the echocardiography lab to reveal a new mitral valve disfunction. Considering the small sample, a greater number of patients will be enrolled to highlight the statistical significance.

264 Cardiac and pulmonary sequelae after COVID-19 pneumonia: a case series

Aims Although the new coronavirus (SARS-CoV-2) may cause an acute multiorgan syndrome (COVID-19), data are emerging on mid- and long-term sequelae of COVID-19 pneumonia. Since no study has hitherto investigated the role of both cardiac and pulmonary ultrasound techniques in detecting such sequelae, this study aimed at evaluating these simple diagnostic tools to appraise the cardiopulmonary involvement occurring after COVID-19 pneumonia. Methods and results Twenty-nine patients fully recovered from COVID-19 pneumonia were considered at our centre. On admission, all patients underwent 12-lead electrocardiogram (ECG) and transthoracic echocardiography (TTE) evaluation. Compression ultrasound (CUS) and lung ultrasound (LUS) were also performed. Finally, in each patient, pathological findings detected on LUS were correlated with the pulmonary involvement occurring after COVID-19 pneumonia as assessed on thoracic computed tomography (CT). Out of 29 patients (mean age 70 ± 10 years old; M 69%), prior cardiovascular and pulmonary comorbidities were recorded in 22 (76%). Twenty-seven patients (93%) were in sinus rhythm and two (7%) in atrial fibrillation. ECG repolarization abnormalities were extremely common (93%) and reflected the high prevalence of pericardial involvement on TTE (86%). Likewise, pleural abnormalities were frequently observed (66%). TTE signs of left and right ventricular dysfunction were reported in two patients only, but values of systolic pulmonary artery pressure were abnormal in 16 (55%) despite absence of prior comorbidities in 44% of them. Regarding LUS evaluation, most patients displayed abnormal values of diaphragmatic thickness and excursion (93%) which well correlated with the high prevalence (76%) of on pathological findings on CT scan. CUS ruled out deep vein thrombosis in all patients. Conclusions Data on cardiopulmonary sequelae after COVID-19 pneumonia are scarce. In our study, simple diagnostic tools (TTE and LUS) proved clinically useful for detection of cardiopulmonary involvement after COVID-19 pneumonia.

604 Echocardiographic assessment of right ventricular function and pulmonary pressures in hospitalized patients with COVID-19

Aims Pulmonary involvement in Coronavirus 19 disease (COVID-19) may affect right ventricular (RV) function and pulmonary pressures resulting in further deterioration of patient clinical status. However, the prognostic value of echocardiographic parameters including tricuspid annular plane systolic excursion (TAPSE), systolic pulmonary artery pressure (PASP), and TAPSE/PASP ratio has been poorly investigated in this clinical setting. Methods and results This is a multicentre Italian study including patients admitted for severe COVID-19 in seven Italian Hospitals. Transthoracic echocardiography (TTE) was performed within 48 h from admission in all cases. In-hospital mortality and pulmonary embolism (PE) were identified as the primary and secondary outcome measures, respectively. Of 1401 patients with severe COVID-19, 227 (16.1%) subjects underwent TTE within 48 h from admission and were included in this study. The mean age was 68 ± 13 years and 62.6% of patients were male. Intensive care unit (ICU) admission was reported in 73 patients (32.2%); ICU patients showed lower left ventricular ejection fraction (LVEF), lower TAPSE, and higher LV end systolic volume and PASP values than non-ICU patients. Also, ICU patients showed higher incidence of acute respiratory distress syndrome (82.2% vs. 30.5%; P &lt; 0.001), acute cardiac injury (46.6% vs. 22.7%; P &lt; 0.001), acute heart failure (34.2% vs. 9.1%; P &lt; 0.001), and death (63.9% vs. 14.3%; P &lt; 0.001) compared with non-ICU patients. By stratifying the study population into tertiles according to TAPSE, PASP, and TAPSE/PASP values, patients in the lower TAPSE and TAPSE/PASP ratio tertiles, and those in the higher PASP tertile, showed a significantly higher incidence of death during the hospitalization. At univariable logistic regression analysis, TAPSE, PASP, and TAPSE/PASP were significantly associated with a higher risk of death and PE, both in patients admitted or not to ICU. After propensity score weighting adjustment for multiple baseline potential confounders and further multivariable adjustment for LVEF value, the regression analysis showed that TAPSE, PASP and TAPSE/PASP were independently associated with risk of death (TAPSE: OR: 0.85, CI: 0.74–0.97, P = 0.017; PASP: OR: 1.08, CI: 1.03–1.13, P = 0.002; TAPSE/PASP: OR: 0.02, CI: 0.02 × 10−1—0.20, P &lt; 0.001) and with the risk of PE (TAPSE: OR: 0.70, CI: 0.60–0.82, P &lt; 0.001; PASP: OR: 1.10, CI: 1.05–1.14, P &lt; 0.001; TAPSE/PASP: OR: 0.02 × 10−1, CI: 0.01 × 10−2—0.04, P &lt; 0.001) during the hospitalization. The risk death according to TAPSE, PASP, and TAPSE/PASP ratio tertiles was estimated considering discharge alive as competing risk (Figure). The lowest TAPSE and TAPSE/PASP tertiles, and the highest PASP tertile, were significantly associated with poorer survival during the hosptialization (P &lt; 0.001). Conclusions Echocardiographic evidence of RV systolic dysfunction, increased PASP and a poor RV-arterial coupling assessed by TAPSE/PAPS ratio may help to identify COVID-19 patients at higher risk of mortality and PE during the hospitalization.

Application and Validation of the Tricuspid Annular Plane Systolic Excursion/Systolic Pulmonary Artery Pressure Ratio in Patients with Ischemic and Non-Ischemic Cardiomyopathy

The main aim of this study was to assess the prognostic utility of TAPSE/PASP as an echocardiographic parameter of maladaptive RV remodeling in cardiomyopathy patients using cardiac magnetic resonance (CMR) imaging. Furthermore, we sought to compare TAPSE/PASP to TAPSE. The association of the echocardiographic parameters TAPSE/PASP and TAPSE with CMR parameters of RV and LV remodeling was evaluated in 111 patients with ischemic and non-ischemic cardiomyopathy and cut-off values for maladaptive RV remodeling were defined. In a second step, the prognostic value of TAPSE/PASP and its cut-off value were analyzed regarding mortality in a validation cohort consisting of 221 patients with ischemic and non-ischemic cardiomyopathy. A low TAPSE/PASP (<0.38 mm/mmHg) and TAPSE (<16 mm) were associated with a lower RVEF and a long-axis RV global longitudinal strain (GLS) as well as higher RVESVI, RVEDVI and NT-proBNP. A low TAPSE/PASP, but not TAPSE, was associated with a lower LVEF and long-axis LV GLS, and a higher LVESVI, LVEDVI and T1 relaxation time at the interventricular septum and the RV insertion points. Furthermore, in the validation cohort, low TAPSE/PASP was associated with a higher mortality and TAPSE/PASP was an independent predictor of mortality. TAPSE/PASP is a predictor of maladaptive RV and LV remodeling associated with poor outcomes in cardiomyopathy patients.

Prognostic Implications of Right Ventricular Function and Pulmonary Pressures Assessed by Echocardiography in Hospitalized Patients with COVID-19

Aims: Pulmonary involvement in Coronavirus disease 2019 (COVID-19) may affect right ventricular (RV) function and pulmonary pressures. The prognostic value of tricuspid annular plane systolic excursion (TAPSE), systolic pulmonary artery pressure (PAPS), and TAPSE/PAPS ratios have been poorly investigated in this clinical setting. Methods and results: This is a multicenter Italian study, including consecutive patients hospitalized for COVID-19. In-hospital mortality and pulmonary embolism (PE) were identified as the primary and secondary outcome measures, respectively. The study included 227 (16.1%) subjects (mean age 68 ± 13 years); intensive care unit (ICU) admission was reported in 32.2%. At competing risk analysis, after stratifying the population into tertiles, according to TAPSE, PAPS, and TAPSE/PAPS ratio values, patients in the lower TAPSE and TAPSE/PAPS tertiles, as well as those in the higher PAPS tertiles, showed a significantly higher incidence of death vs. the probability to be discharged during the hospitalization. At univariable logistic regression analysis, TAPSE, PAPS, and TAPSE/PAPS were significantly associated with a higher risk of death and PE, both in patients who were and were not admitted to ICU. At adjusted multivariable regression analysis, TAPSE, PAPS, and TAPSE/PAPS resulted in independently associated risk of in-hospital death (TAPSE: OR 0.85, CI 0.74–0.97; PAPS: OR 1.08, CI 1.03–1.13; TAPSE/PAPS: OR 0.02, CI 0.02 × 10−1–0.2) and PE (TAPSE: OR 0.7, CI 0.6–0.82; PAPS: OR 1.1, CI 1.05–1.14; TAPSE/PAPS: OR 0.02 × 10−1, CI 0.01 × 10−2–0.04). Conclusions: Echocardiographic evidence of RV systolic dysfunction, increased PAPS, and poor RV-arterial coupling may help to identify COVID-19 patients at higher risk of mortality and PE during hospitalization.