The value of ventricular gradient for predicting pulmonary hypertension and mortality in hemodialysis patients

Pulmonary hypertension (PHT) is associated with increased mortality in hemodialysis (HD) patients. The ventricular gradient optimized for right ventricular pressure overload (VG-RVPO) is sensitive to early changes in right ventricular overload. The study aimed to assess the ability of the VG-RVPO to detect PHT and predict all-cause and cardiac mortality in HD patients. 265 selected HD patients were enrolled. Clinical, biochemical, electrocardiographic, and echocardiographic parameters were evaluated. Patients were divided into normal and abnormal VG-RVPO groups, and were followed-up for 3 years. Abnormal VG-RVPO patients were more likely to be at high or intermediate risk for PHT, were older, had longer HD vintage, higher prevalence of myocardial infarction, higher parathormone levels, shorter pulmonary flow acceleration time, lower left ventricular ejection fraction, higher values of left atrial volume index, left ventricular mass index, and peak tricuspid regurgitant velocity. Both all-cause and CV mortality were higher in abnormal VG-RVPO group. In multivariate Cox analysis, VG-RVPO remained an independent and strong predictor of all-cause and CV mortality. In HD patients, abnormal VG-RVPO not only predicts PHT, but also all-cause and CV mortality.

Decreased hydraulic forces are incrementally associated with survival beyond conventional measures of diastolic dysfunction

BACKGROUND: Decreased hydraulic forces during diastole contribute to reduced left ventricular (LV) filling and heart failure with preserved ejection fraction. OBJECTIVES: To determine the association between diastolic hydraulic forces, estimated by atrioventricular area difference (AVAD), and both diastolic function and survival. We hypothesized that decreased diastolic hydraulic forces, estimated as AVAD, would associate with survival independent of conventional diastolic dysfunction measures. METHODS: Patients (n=11,734, median [interquartile range] 3.9 [2.4-5.0] years follow-up, 1,213 events) were selected from the National Echo Database Australia based on the presence of relevant transthoracic echocardiographic measures, LV ejection fraction (LVEF) ≥ 50%, heart rate 50-100 beats/minute, the absence of moderate or severe valvular disease, and no prior cardiac surgery. AVAD was calculated as the cross-sectional area difference between the LV and left atrium. LV diastolic dysfunction was graded according to 2016 guidelines. RESULTS: AVAD was weakly associated with E/e prime, left atrial volume index, and LVEF (multivariable global R2=0.15, p<0.001), and not associated with e prime and peak tricuspid regurgitation velocity. Decreased AVAD was independently associated with poorer survival, and demonstrated improved model discrimination after adjustment for diastolic function grading (C-statistic 0.645 vs 0.607) and E/e prime (C-statistic 0.639 vs 0.621), respectively. CONCLUSIONS: Decreased hydraulic forces, estimated by AVAD, are weakly associated with diastolic dysfunction and provide an incremental prognostic association with survival beyond conventional measures used to grade diastolic dysfunction.

Beneficial Effect of Sodium-Glucose Co-transporter 2 Inhibitors on Left Ventricular Function

Background Sodium-glucose cotransporter 2 (SGLT2) inhibitors lowered the risk of cardiovascular events in patients with diabetes or heart failure (HF) with reduced ejection fraction, whether they directly promote cardiac function remains unclear. Therefore, we sought to determine whether SGLT2 inhibitors could improve left ventricular (LV) function in these patients. Methods A literature search was conducted using MEDLINE, EMBASE, and Cochrane Library databases from their inception to 9 July 2021. Randomised clinical trials and cohort studies that reported LV function-related variables were included. Results Thirteen studies comprising 1437 patients (830 SGLT2 inhibitor-treated and 607 non-SGLT2 inhibitor-treated patients) and representing seven RCTs with 640 individuals and six cohort studies with 797 individuals were included in this meta-analysis. LV regression (LV mass, LVM), LV ejection fractions (LVEF), LV volumes (LV end-diastolic volumes and -systolic volumes, LVEDV and LVESV), and LV diastolic function (mitral inflow E velocity to tissue Doppler e’ ratio, E/e’ and left atrial volume index, LAVI) were all significantly improved in patients treated with SGLT2 inhibitors (weighted mean differences, 95% confidence interval, LVM: ‒6.319 g, ‒10.850 to ‒1.789; LVEF: 2.458 %, 0.693 to 4.224; LVEDV: ‒9.134 mL, ‒15.808 to ‒2.460; LVESV: ‒8.440 mL, ‒15.093 to ‒1.787; LAVI: ‒2.791 mL/m 2, ‒4.554 to ‒1.027; E/e’: ‒1.567, ‒2.440 to ‒0.698). Subgroup analysis further confirmed the improvement of LV function mainly in patients with HF or those receiving empagliflozin treatment. Conclusions Treatment with SGLT2 inhibitors can significantly improve LV function in patients with or without diabetes (especially those with HF or undergoing empagliflozin treatment).

Hemodynamic Effects of Permanent His Bundle Pacing Compared to Right Ventricular Pacing Assessed by Two-Dimensional Speckle-Tracking Echocardiography

We compared the effects of right ventricular (RVP; n = 26) and His bundle (HBP; n = 24) pacing in patients with atrioventricular conduction disorders and preserved LVEF. Postoperatively (1D), and after six months (6M), the patients underwent global longitudinal strain (GLS) and peak systolic dispersion (PSD) evaluation with 2D speckle-tracking echocardiography, assessment of left atrial volume index (LAVI) and QRS duration (QRSd), and sensing/pacing parameter testing. The RVP threshold was lower than the HBP threshold at 1D (0.65 ± 0.13 vs. 1.05 ± 0.20 V, p < 0.001), and then it remained stable, while the HBP threshold increased at 6M (1.05 ± 0.20 vs. 1.31 ± 0.30 V, p < 0.001). The RVP R-wave was higher than the HBP R-wave at 1D (11.52 ± 2.99 vs. 4.82 ± 1.41 mV, p < 0.001). The RVP R-wave also remained stable, while the HBP R-wave decreased at 6M (4.82 ± 1.41 vs. 4.50 ± 1.09 mV, p < 0.02). RVP QRSd was longer than HBP QRSd at 6M (145.0 ± 11.1 vs. 112.3 ± 9.3 ms, p < 0.001). The absolute value of RVP GLS decreased at 6M (16.32 ± 2.57 vs. 14.03 ± 3.78%, p < 0.001), and HBP GLS remained stable. Simultaneously, RVP PSD increased (72.53 ± 24.15 vs. 88.33 ± 30.51 ms, p < 0.001) and HBP PSD decreased (96.28 ± 33.99 vs. 84.95 ± 28.98 ms, p < 0.001) after 6 months. RVP LAVI increased (26.73 ± 5.7 vs. 28.40 ± 6.4 mL/m2, p < 0.05), while HBP LAVI decreased at 6M (30.03 ± 7.8 vs. 28.73 ± 8.7 mL/m2, p < 0.01). These results confirm that HBP does not disrupt ventricular synchrony and provides advantages over RVP.

Left Atrial Volume Index Predicts Future Improvement of B-Type Natriuretic Peptide Levels After Transcatheter Aortic Valve Replacement

Background: In patients with symptomatic severe aortic stenosis (AS), those who experienced readmission due to heart failure after transcatheter aortic valve replacement (TAVR) showed poor prognosis. Furthermore, poor BNP improvement is associated with increased morbidity and mortality. However, little is known about the clinical parameters related to the change in BNP levels after TAVR procedure.Methods and Results: This study population consisted of 127 consecutive patients of symptomatic severe AS with preserved ejection fraction (EF) who underwent TF-TAVR. The median BNP level was significantly decreased from 252.5 pg/ml to 146.8 pg/ml in all 127 patients 1 year after TF-TAVR (P<0.01). However, the patients could be divided into 2 groups according to decrease (72%) or increase (28%) in plasma BNP level. Multivariate logistic regression analysis revealed that AV peak velocity, pre-procedural BNP, and larger left atrial volume index (LAVI) were found to be an independent predictor of increased BNP level 1 year after TAVR (OR 0.55, 95% CI 0.38-0.77; p<0.01). LAVI were negatively correlated with the change in BNP level before and 1 year after TAVR (r=0.47, P<0.01). The ROC analysis demonstrated that 52.9ml/m2 was the optimal cut-off value of LAVI for decreasing BNP 1 year after TAVR (area under the curve 0.69) with 64% sensitivity and 70% specificity.Conclusions: In addition to AV peak velocity and pre-procedural BNP, LAVI independently predicts future improvement of BNP levels 1 year after TAVR. Our findings indicate an additive predictive value of assessment of LAVI before TAVR procedure for risk stratification.

Implication of Current ASE/EACVI Left Ventricular Diastolic Function Classification in Predicting 2-Year MACE in Asymptomatic Patients with Diabetes and Hypertension

Background Left ventricular diastolic dysfunction (LVDD) has been shown to be more prevalent in patients with diabetes, and once progress to overt heart failure, carry worse clinical outcomes. Substantial number of patients were classified as indeterminate DF based on the current ASE/EACVI guidelines. The implication of current DF classification in predicting MACE among diabetic patients is not well established. Purpose To assess prognostic impact of current guidelines-based DF classification, and determine predictors of 2-year MACE based on individual LVDD parameters. Methods A total of 111 patients with diabetes and hypertension who attended diabetic clinic follow-up at the primary healthcare settings were enrolled. All patients had no prior cardiovascular events, had preserved left ventricular (LV) ejection fraction on echocardiography and sinus rhythm on ECG at screening. Echocardiography was performed to obtain parameters of LV dimensions, LV volumes and LVDD. The 2016 ASE/EACVI guidelines were applied to classify DF. All patients were followed up until 2 years to assess MACE. Results There were 65 (58.6%) female patients. Mean age was 59.86 (7.45); mean duration of DM was 10.5 (5.41). 80 (72.1%) patients were classified as having normal DF (nDF); 24 (21.6%) patients were classified as indeterminate DF (iDF); 7 patients (6.3%) were classified as LVDD. Patients with LVDD had significantly higher LV mass index (LVMI) (mean 121.72±23.28g/m2 vs 116.62±24.66g/m2 in iDF vs 102.50±22.89g/m2 in nDF); higher left atrial volume index (LAVI) (mean 41.24±10.28ml/m2 vs 30.55±10.07ml/m2 in iDF vs 25.75±6.30ml/m2 in nDF); lower lateral e' velocity (mean 6.35±2.05cm/s vs 7.37±1.73cm/s in iDF vs 8.59±2.13cm/s in nDF); higher septal E/e' ratio (mean 14.89±3.29 vs 12.16±3.99 in iDF vs 9.99±2.35 in nDF); higher average septal-lateral E/e' ratio (mean 14.22±3.77 vs 11.34±3.74 in iDF vs 9.04±2.10 in nDF). Among these 111 patients, 10 patients (9%) reported MACE at 2 years. The risk of 2-year MACE is elevated in both iDF [odds ratio (OR) 3.80, 95% CI 0.87–16.54, p=0.075] and LVDD [OR 7.60, 95% CI 1.11–52.02, p=0.039]. LVMI (OR 1.027, 95% CI 1.004– 1.051, p=0.023), LAVI (OR 1.092, 95% CI 1.017–1.172), and average septal-lateral E/e' ratio (OR 1.276, 95% CI 1.047–1.557, p=0.016) significantly correlated with 2-year MACE. Conclusions LVDD is correlated with increased MACE at 2 years. LVMI, LAVI and average septal-lateral E/e' ratio were predictors of increased risk of MACE at 2 years. Further investigation with larger sample size is warranted. FUNDunding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Health Malaysia