Echocardiographic predictors of low risk haemodynamic parameters in patients with pulmonary arterial hypertension

Background A periodic and multiparametric assessment of the risk profile of patients with pulmonary arterial hypertension (PAH) is essential for a low-risk oriented treatment strategy. Haemodynamic parameters anyway cannot be collected at each scheduled outpatients clinic follow-up visit. Purpose To evaluate echocardiographic predictors of haemodynamic low-risk parameters in patients with PAH. Methods Patients with PAH referred to our centre were included up to 31 December 2019. All patients underwent baseline demographic, clinical, WHO functional class, 6-minute walk test, brain natriuretic peptide (BNP), right cardiac catheterization and echocardiographic evaluation. Through a multivariate logistic regression analysis we evaluate the echocardiographic predictors of low risk for: 1) BNP/right atrial pressure (RAP): NT-proBNP <300 ng/l/BNP <50 ng/l AND RAP <8 mmHg; 2) cardiac index (CI)/mixed venous oxygen saturation (SvO2): CI ≥2.5 l/min/m2 AND SvO2 >65%. Echocardiographic parameters cut-offs were chosen on the basis of the ROC curves or Literature data. Results 1020 patients were included. The two analysis were performed independently. 1. Independent echocardiographic predictors of low-risk BNP/RAP were: indexed right atrial area, mitral E/A ratio, dimension and inspiratory collapse of inferior vena cava and indexed left ventricular diastolic volume. We elaborated a score utilizing these parameter cut-offs: an indexed right atrial area of 10.4–15 cm2/m2, a mitral E/A ratio of 0.8, dimension and inspiratory collapse of inferior vena cava indicative of 0–5 vs 5–10 vs 10–20 mmHg and an indexed left ventricular diastolic volume of 32 ml/m2. The score has AUC: 0.62, specificity: 92%, sensitivity: 33%, negative predictive value: 70%, positive predictive value: 69%. 2. Independent echocardiographic predictors of low-risk CI/SvO2 were: S wave at TDI, Tei index, tricuspid annular plane systolic excursion (TAPSE), indexed left ventricular diastolic volume and the severity of the tricuspid regurgitation. We elaborated a score utilizing these parameter cut-offs: an S wave at TDI of 9.5 cm/s, a Tei index of 0.4, a TAPSE of 1.7 cm, an indexed left ventricular diastolic volume of 32 ml/m2 and a mild vs more than mild tricuspid regurgitation. The score has AUC: 0.70, specificity: 89%, sensitivity: 50%, negative predictive value: 71%, positive predictive value: 77%. Conclusion Echocardiographic parameters can be used to rule out the presence of low-risk BNP/RAP values (indexed right atrial area, mitral E/A ratio, dimension and inspiratory collapse of inferior vena cava and indexed left ventricular diastolic volume) and low-risk CI/SvO2 (S wave at TDI, Tei index, TAPSE, indexed left ventricular diastolic volume and severity of tricuspid regurgitation). FUNDunding Acknowledgement Type of funding sources: None.

Higher Incidence of Atrial Fibrillation in Left Ventricular-to-Right Atrial Shunt Patients

Background: The possible association between atrial fibrillation (AF) and left ventricular-to-right atrial shunt (LVRAS) has never been reported yet. The present study investigated the incidence of AF in LVRAS.Methods: This was a retrospective study of consecutive patients undergoing echocardiography at a single tertiary center. Clinical data, laboratory results and echocardiography parameters such as right atrial area (RAA), right ventricular end diastolic diameter (RVDD) and left atrial diameter (LAD) were compared between LVRAS group and non-LVRAS patients, and between AF and non-AF patients. Propensity score matching was performed to decrease the effect of confounders. Logistic regression analysis and mediation analysis were used to estimate the relationship between LVRAS and AF.Results: A total of 3,436 patients were included, and the incidence of LVRAS was 1.16% (n = 40). The LVRAS group had significantly larger RAA, RVDD and LAD compared with non-LVRAS group. Those who suffered from AF showed larger RAA, RVDD and LAD compared with those who maintained sinus rhythm. Multivariable logistic regression showed that gender (OR: 0.608), age (OR: 1.048), LAD (OR: 1.111), mean pulmonary artery blood pressure (mPAP, OR: 1.023), TR (OR: 2.309) and LVRAS (OR: 12.217) were significant factors for AF. RAA could partially mediate the relationship between LVRAS and AF according to the result of mediation analysis.Conclusions: Our study suggested that LVRAS, TR, LAD, mPAP, age and male were risk factors for AF. RA enlargement might underlie mechanism in the higher incidence of AF in LVRAS patients. These findings should be confirmed in larger prospective studies.

Association between right atrial area measured by echocardiography and prognosis among pulmonary arterial hypertension: a systematic review and meta-analysis

ObjectiveThe purpose of this meta-analysis was to evaluate the association between enlarged right atrial area (RAA), as measured by echocardiography, and prognosis of patients with pulmonary arterial hypertension (PAH).DesignSystematic review and meta-analysis.Data sourcesTo identify potential publications, a comprehensive literature search through MEDLINE, the Cochrane database and the Embase database was performed up to December 2019.Eligibility criteria for selecting studiesStudies were included if they reported Cox regression based-HRs with 95% CIs for all-cause mortality or composite endpoint consisting of death and PAH-related events for echocardiography measurements of the RAA or the right atrial area index (RAAI) in patients with PAH.Data extraction and synthesisThe unadjusted HR with 95% CI was extracted for the final pooled analysis. A random-effects model was used to determine the value of RAA/RAAI in the prognosis of patients with PAH. The data heterogeneity among the studies was estimated by the I2 statistic and the Cochran Q-statistic.ResultsTwelve studies with a total of 1085 patients with PAH were finally included in the meta-analysis. These studies had a mean follow-up time ranging from 9.2 months to 5.0 years. Their findings showed that patients with PAH with enlarged RAA/RAAI were associated with poor prognosis. The risk of all-cause mortality in patients with PAH was found to statistically increase by 50% for every 5-unit increase in RAA/RAAI (HR 1.50, 95% CI 1.28 to 1.75, p<0.001). Similarly, the risk of the composite endpoint also significantly increased by 53% for every 5-unit increase in RAA/RAAI (HR 1.53, 95% CI 1.23 to 1.89, p<0.001). Subgroup analyses in which the patients were stratified by RAA and RAAI were consistent with the main results.ConclusionThe meta-analysis suggested that enlarged RAA/RAAI were associated with increased risk of poor prognosis in patients with PAH.

P344 Echocardiography right atrial area and inferior vena cava diameter interest to predict right atrial pressure in pulmonary arterial hypertension

Background Risk stratification in Pulmonary Arterial Hypertension (PAH) is based on multiparametric approach including invasive measurement of invasive right atrial pressure (RAP) by right heart catheterization (RHC). Therefore, following 2015 ESC/ERS pulmonary hypertension (PH) guidelines, RHC are frequently repeated every 4 to 6 months until RAP &lt;8 mmHg. Purpose To explore the interest of right atrial area (RAA) and inferior vena cava (IVC) diameter measured by transthoracic echocardiography, as a surrogate for right atrial preload to detect RAP &lt;8 mm Hg and avoid repeated RHC in PAH patients. Methods From a prospective single PAH referral center, we have included all patients with a diagnosis of PAH (confirmed by PH team). During the follow up, transthoracic echocardiography and a RHC was performed on the same day. RAA (cm2) was measured in the apical four-chamber view, at end-systole, just prior to tricuspid valve opening, excluding the area under tricuspid valve annulus. In the subcostal view, at 1.0 to 2.0 cm from the junction with the right atrium, IVC diameter (mm) was reported. Both RAA and IVC were compared to RAP. Results 97 PAH patients were included (35 males, mean age 65 ± 16y, mean arterial pressure was 45 ± 16 mmHg, cardiac index 3.0 ± 1.0 l/min/m² and right atrial pressure was 7.6 ± 4.7 mm Hg). Both IVC diameter and RAA averaged 18.1 ± 6.3mm and 22.5 ± 8.2 mm by echocardiography, respectively. IVC diameter and RAA had a significant but weak correlation with right atrial pressure &lt;8 mmHg measured by RHC (r = 0.42, p &lt; 0.01 and r = 0.41, p &lt; 0.01, respectively). Targeting a good specificity (Sp = 0.75), ROC curves analysis identified 10 mm for the IVC diameter and 20 cm² for RAA if IVC diameter was &gt; 10 but &lt; 20 mm to predict RAP &lt;8 mmHg (area under the curve = 0.72). Thus, in our cohort, 40% could have been followed-up non-invasively by echocardiography with IVC diameter ≤10 mm or &gt;10 but &lt;20 mm with RAA ≤20 cm² with only 2% of misclassification. For the remaining 58% unclassified PAH patients out of these echocardiographic ranges, RHC would have been requested. Conclusion In a cohort of PAH patients, targeting a low risk clinical worsening or death (identified by RAP &lt;8 mmHg in RHC), echocardiography, with the use of IVC diameter ≤10 mm or &gt;10 but &lt;20 mm with RAA ≤20 cm², right heart catheterisation may be avoided in 40% of cases with extremely low misclassification.

Impact of vitamin D on cardiac structure and function in chronic kidney disease patients with hypovitaminosis D: a randomized controlled trial and meta-analysis

Aims Vitamin D deficiency is associated with cardiovascular events in chronic kidney disease (CKD) yet the impact of supplementation is controversial. Previous active vitamin D supplementation studies did not show improvement in cardiac structure or function but the effect of native vitamin D supplementation in CKD patients with low vitamin D levels is unknown. We have addressed this question via both a randomized double-blind prospective study and a meta-analysis of three randomized placebo-controlled studies. Methods and results We conducted a randomized double-blind, placebo-controlled trial of vitamin D supplementation in stable, non-diabetic, CKD three to four patients with circulating vitamin D &lt;75nmol/L, who were receiving treatment with ACEi or ARB and had high-normal left ventricular (LV) mass. Patients were randomized to receive six directly observed doses of 100 000 IU cholecalciferol (n = 25) or matched placebo (n = 23). The primary endpoint was changed in LV mass index (LVMI) over 52 weeks, as assessed by cardiac magnetic resonance imaging. Secondary endpoints included changes in LV ejection fraction (LVEF); LV and right ventricular volumes and left and right atrial area. Vitamin D concentration increased with the administration of cholecalciferol. The change in LVMI with cholecalciferol [median (inter-quartile range), −0.25 g (−7.20 to 5.30)] was no different from placebo [−4.30 g (9.70 to 2.60)]. There was no difference in changes of LVEF; LV and right ventricular volumes and left and right atrial area. The meta-analysis of three 52-week, randomized placebo-controlled studies using active/native vitamin D supplementation showed no differences in LVMI measurements. Conclusion Vitamin D supplementation does not have beneficial effects on LV mass in CKD patients.

2395LGE CMR predicts sudden death and VT in adults with repaired tetralogy of Fallot - a prospective study with 3500 patient follow up years

Background Adults with repaired tetralogy of Fallot (rtoF) are at risk of ventricular arrhythmia and sudden cardiac death (SCD). Cross-sectional data suggest association of late gadolinium enhancement (LGE) cardiovascular magnetic resonance imaging (CMR) with adverse clinical risk factors Purpose We sought to determine prognosis related to LGE CMR. Methods In this prospective cohort study the primary composite outcome comprised the first of cardiovascular death (SCD or heart failure-related), aborted SCD (successfully resuscitated cardiac arrest or appropriate AICD shock for ventricular fibrillation), and clinical sustained ventricular tachycardia (VT>30 seconds duration). Results In 531 rtoF patients (median age 32; 23–42, 296 (56%) male, NYHA≥II 17%) followed up after LGE CMR for median 5 (1.7–8.9) years, there were 39 primary composite outcomes: 10 SCD, 11 heart failure related deaths (2 perioperative RV failure), 2 aborted SCD and 16 clinical sustained VT events. At study end, there were 28 ventricular arrhythmic events in 28 rtoF patients (10 SCD, 16 clinical sustained VT, 2 aborted VF) that were significantly predicted by RV LGE extent (HR 1.45 CI: 1.3–1.6; P<0.001). Univariable predictors of the primary outcome were RV LGE score; HR: 1.44 (1.31–1.57; p<0.001), (Figure) together with older age; HR: 1.05 (1.02–1.07; P<0.001), late repair; HR: 1.04 (1.02–1.07; p<0.001), lower RV ejection fraction; HR: 0.92 (0.89–0.95; p<0.001), larger RVOT akinetic length; HR: 1.04 (1.02–1.06; p<0.001) larger right atrial area; HR: 1.2 (1.12–1.29; p<0.001); higher BNP levels; HR: 1.01 (1–1.02; p<0.001), lower peak VO2; HR: 0.89 (0.83–0.96; p=0.001), prior atrial arrhythmia; HR: 5.3 (2.8–10.07; p<0.001), and non-sustained VT; HR: 4.1 (2.1–7.7; p<0.001). Inducible VT did not predict the primary outcome; HR: 2.1 (0.57–8; p=0.25) In multivariable analysis both RV LGE score and indexed right atrial area (RAAi) only, remained predictive of the primary outcome (HR 1.29 CI: 1.12–1.49; p<0.001 and HR 1.1 CI: 1.02–1.12; p=0.01, respectively). Patients could accordingly be stratified such that supramedian RV LGE score (≥5) and RAAi ≥16cm2/m2 had 5-year event free survival 84% vs 94% for supramedian RV LGE score (≥5) and RAAi <16cm2/m2 or 98% for inframedian RV LGE score with RAAI<16cm2/m2. Figure. Conclusions For every unit increase in CMR defined RV fibrosis score there is a 44% increased risk of sudden cardiac death and VT. LGE CMR and maximal right atrial area should therefore be incorporated into risk stratification for sudden death in adults with rTOF. Acknowledgement/Funding British heart foundation