Ratio of Mixed Venous Oxygen Saturation-to-Pulmonary Capillary Wedge Pressure: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program

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.

Circulating Blood-Based Biomarkers in Pulmonary Hypertension

Pulmonary hypertension (PH) is a serious hemodynamic condition, characterized by increased pulmonary vascular resistance (PVR), leading to right heart failure (HF) and death when not properly treated. The prognosis of PH depends on etiology, hemodynamic and biochemical parameters, as well as on response to specific treatment. Biomarkers appear to be useful noninvasive tools, providing information about the disease severity, treatment response, and prognosis. However, given the complexity of PH, it is impossible for a single biomarker to be adequate for the broad assessment of patients with different types of PH. The search for novel emerging biomarkers is still ongoing, resulting in a few potential biomarkers mirroring numerous pathophysiological courses. In this review, markers related to HF, myocardial remodeling, inflammation, hypoxia and tissue damage, and endothelial and pulmonary smooth muscle cell dysfunction are discussed in terms of diagnosis and prognosis. Extracellular vesicles and other markers with complex backgrounds are also reviewed. In conclusion, although many promising biomarkers have been identified and studied in recent years, there are still insufficient data on the application of multimarker strategies for monitoring and risk stratification in PH patients.

Ethnic differences in right ventricular structure and function in urbanized hypertensive patients in the Gornaya Shoriya region

Objective of this study was to compare right ventricular echocardiography parameters in urbanized hypertensive patients of the Shor and non-indigenous ethnic groups in the Mountain Shoria region. Methods The study included patients with arterial hypertension: 58 Shors and 50 non-indigenous urbanized residents, comparable in age, and divided by ethnicity and gender into 4 groups: Shors men (n = 20), Shors women (n = 38), non-indigenous men (n = 15) and non-indigenous women (n = 35). All underwent echocardiographic examination, and the right heart parameters were studied. Results Shor men with arterial hypertension had the lowest values ​​of the pulmonary artery index, the right atrium dimensions, and the highest values ​​of the blood flow velocity in the right ventricle, et' and st' in comparison with non-indigenous men. Shor women have the lowest values Et and Et/At ratios. RV diastolic dysfunction was detected mainly in women, somewhat more often in Shors. Ethnicity was one of the factors associated with the right ventricular diastolic dysfunction presence. Among the factors associated with the RV diastolic dysfunction were risk factors (smoking, obesity), blood pressure, gender, ethnicity, and left ventricular parameters (diastolic dysfunction and the myocardial mass increase). Conclusion Our study established the influence of ethnic differences on the right heart echocardiographic parameters in Shors and Caucasians with arterial hypertension. The revealed differences should improve the assessment of the right heart structure and function in patients with arterial hypertension from small ethnic groups, which will help to improve the diagnosis and treatment of such patients.

Risk Factors of Pregnancy Outcome in Patients with Pulmonary Hypertension

OBJECTIVE: The purpose of this study is to explore the factors affecting the pregnancy outcome of patients with pulmonary hypertension, and to design a digital model predicting the pregnancy outcome of patients and judge whether patients have the conditions to continue pregnancy. METHODS: The clinical data of patients with pregnancy complicated with pulmonary hypertension hospitalized in Guangdong Provincial People's Hospital from January 1, 2014 to December 31, 2020 were retrospectively analyzed. The severity of pulmonary hypertension, the structural and functional indexes measured by echocardiography were compared, and the effects on maternal and neonatal outcomes were analyzed. RESULTS: A total of 158 patients met the inclusion and exclusion criteria. The results showed that tricuspid regurgitation velocity (P<0.001), right ventricular diameter (P<0.05), right atrial diameter (P<0.05), pulmonary artery diameter (P<0.001) and cardiac function classification (P<0.001) were risk factors for maternal outcomes; Tricuspid regurgitation velocity (P<0.001) and structural changes of right heart were risk factors for neonatal outcomes. By multivariate logistic regression analysis, tricuspid regurgitation velocity (P<0.001), cardiac function (P<0.05) and superior inferior diameter of right atrium (P<0.05) were significant risk factors for maternal outcomes, while tricuspid regurgitation velocity (P<0.001) and superior inferior diameter of right atrium (P<0.05) were significant risk factors for neonatal outcomes. Using significant risk factors, a risk score system was established to predict the pregnancy outcome. CONCLUSION: in this study, we analyzed the clinical data of patients with pregnancy complicated with pulmonary hypertension in our hospital in recent years, and found that the changes of right heart structure (the acceleration of tricuspid regurgitation velocity, and the increase of right atrium, right ventricular diameter, right ventricular outflow tract anteroposterior diameter and main pulmonary artery diameter), are influencing factors of pregnancy outcomes in patients with pulmonary hypertension. In addition, we preliminarily designed a risk score through multi factor analysis, which is helpful to predict the possible outcome of puerperium and neonatal outcomes of patients, and to provide some reference for clinicians and patients to make decisions on whether to continue pregnancy in clinical practice.

Intravascular leiomyomatosis with cardiac extension: a case report

Background Intravascular leiomyomatosis with intracardiac extension is a rare benign tumor seen exclusively in women, characterized by proliferation of uterine smooth muscle cells through the venous circulation into the inferior vena cava and the right heart chambers. Case summary A 47 years old women with history of previous hysterectomy due to myomatosis, presented with nausea, anorexia and bilateral lower limb swelling over the preceding two months. An outpatient abdominal ultrasound discovered a mass in the Inferior vena cava. Echocardiogram and Computed tomography demonstrated a large intravascular mass extending from the pelvis to the right heart chambers. The tumor was completely removed in a concomitant open-heart surgery and laparotomy. Post operative course was uncomplicated. A month later the patient was feeling well and in good clinical condition. The histological analysis consisted with intravascular leiomyomatosis. Discussion Intracardiac leiomyomatosis is a rare clinical condition which requires high index of suspicion. Multimodality imaging is usually required to establish the preoperative diagnosis, although the final diagnosis is achieved with tissue investigation. Complete surgical resection of the tumor is curative and associated with good long-term prognosis.

Echocardiographic probability of pulmonary hypertension: a validation study

BackgroundAccording to current guidelines, the diagnosis of pulmonary hypertension (PH) relies on echocardiographic probability followed by right heart catheterization. How echocardiography predicts PH recently re-defined by a mean pulmonary artery pressure (mPAP) >20 mmHg instead of ≥25 mmHg and pulmonary vascular disease defined by a pulmonary vascular resistance (PVR) >3 or >2 Wood units has not been established.MethodsA total of 278 patients referred for PH underwent a comprehensive echocardiography followed by a right heart catheterization. Fifteen patients (5.4%) were excluded because of insufficient quality echocardiography.ResultsWith PH defined by a mPAP >20 mmHg, 23 patients had no PH, 146 had pre-capillary and 94 post-capillary PH. At univariate analysis, maximum velocity of tricuspid regurgitation (TRV) ≥2.9 and ≤3.4 m s−1, left ventricle (LV) eccentricity index >1.1, right ventricle (RV) outflow tract (OT) notching or acceleration time <105 ms, RV-LV basal diameter >1 and PA diameter predicted PH, whereas inferior vena cava diameter and right atrial area did not. At multivariable analysis, only TRV ≥2.9 m s−1 independently predicted PH. Additional independent prediction of PVR >3 Wood units was offered by LV eccentricity index >1.1 and RVOT acceleration time <105 ms and/or notching, but with no improvement of optimal combination of specificity and sensibility or positive prediction.ConclusionsEchocardiography as recommended in current guidelines can be used to assess the probability of re-defined PH in a referral center. However, the added value of indirect signs is modest and sufficient quality echocardiographic signals may not be recovered in some patients.

Hybrid extracorporeal membrane oxygenation (ECMO) cannulation following traumatic pneumonectomy: A case report

A 28-year-old man presented in extremis after a motorcycle crash. Following traumatic pneumonectomy, he developed right heart failure and was placed on veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) only to transition to veno-arteriovenous (VAV) ECMO due to persistent hypoxemia. Resulting flow limitation caused distal ischemia of his left leg, requiring thrombectomy and fasciotomy. Potential loss of limb necessitated transitioning to veno-venous (VV) ECMO from which he was successfully decannulated thereafter. ECMO can bridge recovery following the most dire injuries, and hybrid strategies can ameliorate post-operative complications; however, ECMO itself carries significant risks that must be weighed against intended benefit.