Prognostic Importance of Pulmonary Artery Pulsatility Index and Right Ventricular Stroke Work Index in End-Stage Heart Failure Patients

Background: Right ventricular (RV) failure is an important cause of morbidity and mortality in patients with left ventricular (LV) end-stage heart failure (ESHF). Pulmonary artery pulsatility index (PAPi) and right ventricular stroke work index (RVSWI) are invasive parameters related to RV function. This study aimed to investigate the prognostic impact of PAPi and RVSWI in these patients. Methods and Results: In this study, 416 patients with ESHF were included. The adverse cardiac event (ACE) was defined as left ventricular assist device (LVAD) implantation, urgent heart transplantation, or cardiac mortality. There were 218 ACE cases and 198 non-ACE cases over a median follow-up of 503.50 days. Patients with ACE had lower PAPi and similar RVSWI compared to those without ACE (3.1±1.9 vs. 3.7±2.3, P=0.003 and 7.3±4.9 vs. 6.9±4.4, P=0.422, respectively). According to the results of multivariate analysis, while PAPi (from 2 to 5.65) was associated with ACE, RVSWI (from 3.62 to 9.75) was not associated with ACE (HR: 0.75, 95% CI (0.55-0.95), P=0.031; HR: 0.79, 95% CI: (0.58-1.09), P=0.081, , respectively). Survival analysis revealed that PAPi ≤2.56 was associated with a higher ACE risk compared to PAPi >2.56 (HR: 1.46, 95% CI: 1.11-1.92, P=0.006). PAPi ≤2.56 could predict ACE with 56.7% sensitivity and 51.3% specificity at one year. Furthermore, the association between RVSWI and ACE was nonlinear (J-curve pattern). Low and high values seem to be associated with higher ACE risk compared to intermediate values. Conclusion: The low PAPi was an independent risk for ACE and it had a linear association with it. However, RVSWI seems to be have a nonlinear association with ACE (J-curve pattern).

The Prognostic Role of Right Ventricular Stroke Work Index during Liver Transplantation

Right heart-associated hemodynamic parameters including intraoperative pulmonary vascular resistance (PVR) were reported to be associated with patient survival after liver transplantation. We investigated whether intraoperative stroke work indexes of both ventricles could have a better prognostic value than PVR. We reviewed 683 cases at a tertiary care academic medical center. We collected intraoperative variables of baseline central venous pressure, baseline right ventricle end-diastolic volume, mixed venous oxygen saturation, intraoperative PVR and right and left ventricular stroke work indexes. Time-weighted means or area under the curve of intraoperative right and left ventricular stroke work indexes were calculated as exposure variables. One-year all-cause mortality or graft failure was our primary outcome. Cox proportional hazard regression analysis was performed to evaluate the association between exposure variables and one-year all-cause mortality or graft failure. Kaplan–Meier survival curve analysis of our primary outcome was performed for different time-weighted mean ventricular stroke work index groups. Cubic spline curve analysis was performed to evaluate the linear relationship between our exposure variables and primary outcome. Time-weighted mean right ventricular stroke work index was significantly associated with one-year all-cause mortality or graft failure (hazard ratio 1.21, 95% confidence interval (CI) 1.12–1.36, p < 0.001). However, there was no significant association between time-weighted mean left ventricular stroke work index, time-weighted mean PVR, PVR at the end of surgery and one-year mortality. Area under the curve of right ventricular stroke work index was also significantly associated with one-year mortality or graft failure (hazard ratio 1.24, 95% CI 1.15–1.37, p < 0.001). Kaplan–Meier survival curve analysis showed a significant difference in the survival between different mean right ventricular stroke work index groups (Log-rank test: p = 0.002). Cubic spline function curve showed the gradual increase in the risk of mortality with a positive slope with time-weighted mean right ventricular stroke work index. In conclusion, intraoperative elevated right ventricular stroke work index was significantly associated with poor patient or graft survival after liver transplantation. Intraoperative right ventricular stroke work index could be an intraoperative hemodynamic goal and prognostic marker for mortality after liver transplantation.

Abstract 217: Cooling Beneficially Impacts Cardiac Performance on Arrest Survivors Undergoing Targeted Temperature Management

Introduction: Targeted temperature management (TTM) is a widely accepted neuroprotective strategy in the management of comatose cardiac arrest (CA) survivors. The beneficial impact of TTM on cardiac performance in this population remains debatable. Hypothesis: Mild cooling enhances cardiac performance in arrest survivors undergoing TTM. Methods: We reviewed prospectively collected data on all CA survivors undergoing TTM at our CICU between Jan15 and Jun17. Enrollment was restricted to cases with invasive hemodynamics (iHDs) available at TTM initiation, every 8 hrs at target temperature (32-34°C) and at rewarming completion (>36°C), unless precluded by mortality. Those with cooling initiated before admission and temperature of <36°C prior to iHDs were excluded. iHDs included temperature (Temp), heart rate (HR), mean blood pressure (MAP), right atrial pressure (RAP), pulmonary wedge pressure (PCWP), systemic vascular resistance (SVR) and Fick Cardiac Index (CI). Left and right ventricular stroke work indices were calculated (LVSWI & RVSWI).We also assessed changes induced by cooling, and overall improvements in cardiac performance and iHDs over time at completion of rewarming controlling for temp change using longitudinal data analysis. Results: 46 arrest survivors with average age of 61 years, 65% male, 83% out-hospital arrest with a shockable rhythm (74%) were evaluated. HR decreased with cooling (p<0.001), to return to baseline after rewarming (p=0.6). MAP, SVR and PCWP decreased by cooling (p<0.001 for all), with sustained improvement after rewarming (p <0.001 for all). LVSWI increased with cooling (p<0.001), with return to baseline after rewarming (p=0.6). Similar findings were encountered with RAP and RVSWI. Conclusion: Mild cooling during TTM improves cardiac performance indices. At TTM completion, there is a sustained decrease in filling pressures without a change in LVSWI indicative of improved contractile performance during cooling.