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Determinants and prognostic impact of afterload mismatch after MitraClip implantation. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Mitral transcatheter edge-to-edge repair (TEER) is a widespread option to treat mitral regurgitation in high-risk patients. The sudden reduction of mitral regurgitation (MR) following TEER abruptly eliminates the low-impedance regurgitant flow into the left atrium, leading to an increase in left ventricle (LV) afterload with possible impairment of LV systolic function, defined afterload mismatch (AM).
Purpose
To explore a new definition of AM and to analyze the determinants and prognostic role of AM in patients with functional MR (FMR) undergoing TEER.
Methods
This was an international multicenter case-control study including adult patients with severe FMR and LVEF ≤35% undergoing TEER between 2012 and 2020. AM was defined as the acute need to initiate or increase inotropic support by a vasoactive inotropic score ≥3 or the need for a mechanical circulatory support following TEER.
Results
80 patients with AM were compared to 80 consecutive patients undergoing TEER not meeting the criteria for AM. Median age was 67 years, 79% of patients were male, had a median LVEDV of 240 ml with severely reduced LVEF (median 26%) and pulmonary hypertension (median 48 mmHg). Median EROA/LVEDV ratio was 0.17 (IQR 0.12–0.24) based on which 37% of the total population presented with proportionate MR. Levosimendan was administered before TEER in 42% of patients while intravenous vasodilators in 43%. In most patients more than 1 clip were needed (2 clips in 88 patients, 3 clips in 11). Patients presenting AM more commonly had a lower EROA/LVEDV ratio (0.14 vs. 0.18, p<0.001) leading to a higher percentage of patients with proportionate MR (55% vs. 22%, p<0.001; Figure 1) and had more clips implanted (p=0.008). AM was graded as mild in 74% of patients, moderate in 15% and severe in 11%. At multivariate analysis, patients with proportionate MR were more likely to develop AM after TEER (OR 2.95, 95% CI: 1.32–6.60, p=0.008), while those treated with levosimendan (OR 0.32, 95% CI: 0.15–0.71, p=0.005) and/or IV vasodilators (OR 0.44, 95% CI: 0.21–0.96, p=0.040) before TEER were less likely to suffer from AM. In-hospital death occurred in 7 cases, all being part of AM group. Patients were more likely to die in-hospital if AM was more severe (OR 2.56, 95% CI: 1.19–5.54, p=0.017), and for higher grades of residual MR (OR 3.35, 95% CI: 1.27–8.79, p=0.014). The 2-year survival rate did not differ significantly between groups (66% vs 75%, HR 1.51, 95% CI: 0.73–3.12, p=0.270; Figure 2). At 2 years 51 patients (32%) were re-hospitalized for HF, independently from post-procedural AM (HR 1.36, 95% CI: 0.70–2.67, p=0.363).
Conclusions
In patients with LVEF ≤35% and severe FMR undergoing TEER, the development of AM predicted in-hospital mortality, while long-term outcomes were not affected by acute AM. The use of levosimendan or intravenous vasodilators during the pre-procedural phase reduced the risk of acute AM.
Funding Acknowledgement
Type of funding sources: None.
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Echocardiographic-derived Pulmonary Artery Pulsatility Index: towards non-invasive evaluation of right ventricular function. Eur Heart J Cardiovasc Imaging 2022. [DOI: 10.1093/ehjci/jeab289.385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background. Pulmonary artery pulsatility index (PAPi)(1) is a powerful predictor of right ventricular failure in patients with acute inferior myocardial infarction(2) and in patients with heart failure undergoing LVAD implantation(3). PAPi derivation requires invasive right heart catheterism (RHC), thus limiting availability and seriate assessment of right ventricular function.
Purpose. Aim of the study was to evaluate accuracy and agreement of echocardiographic derived PAPi (ePAPi) compared to right heart catheterism derived PAPi in heart failure with reduced ejection fraction (HFrEF) patients.
Methods. ePAPi was defined as the ratio of pulmonary artery pulse pressure (sPAP – dPAP) to right atrial pressure (RAP). Systolic pulmonary artery pressure (sPAP) was determined from tricuspid regurgitation (TR) velocity using the simplified Bernoulli equation(4): sPAP = 4 x (peak TR jet velocity)2 + RA pressure. Diastolic pulmonary artery pressure (dPAP) was calculated as: dPAP = 4 x (end-diastolic pulmonary regurgitant velocity)2 + RA pressure. Simplified ePAPi, defined as peak TR pressure to RA pressure ratio was also investigated. Pearson and Spearman correlation tests were performed. A Bland-Altman plot analysis was performed to assess agreement between ePAPi and invasive PAPi. ROC curves were made to assess ePAPi accuracy in identifying patients with low PAPi (defined as PAPi < 2 and PAPi < 3.65).
Results. 66 HFrEF patients (age 59 ± 10 years, 63% males, mean EF: 35 ± 9%) underwent RHC and blinded echocardiogram in a single center Cardiology Departement. Mean invasive derived PAPi was 4.4 ± 3.6, while ePAPi was 3.9 ± 2.3. ePAPi showed an excellent correlation with invasive PAPi (Pearson r: 0.80, p < 0.001; Spearman rho: 0.83, p < 0.001) and good agreement as shown in Bland Altman plot (figure 1). In ROC analysis, ePAPi accurately identified patients with low hemodynamic PAPi < 2 (Sensibility: 100%; Specificity: 87.2%; AUC: 0.97; Youden criterion: ePAPi < 2.3) and PAPi < 3.65 (Sensibility: 81.8%; Specificity: 84%; AUC: 0.89; Youden criterion: ePAPi < 3.6)(figure 2). Simplified ePAPi also showed good correlation and agreement (Pearson r: 0.58, p < 0.001; Spearman rho: 0.81, p < 0.001).
Conclusions. In patients with HFrEF, echocardiographic derived PAPi showed a good agreement and correlation with invasive derived PAPi. ePAPi was also accurate in identifying patients with low PAPi values associated with poor outcomes and may be of interest for non-invasive right ventricular function seriate assessment. Further studies are needed to investigate prognostic implications. Abstract Figure. Abstract Figure 2
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Prognostic implication of sodium nitroprusside vasodilator test in pulmonary hypertension and left heart disease: insights from PUSHON registry. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Definition of combined post and pre-capillary pulmonary hypertension (Cpc-PH) is controversial, despite involving up to 25% of patients with heart failure with reduced ejection fraction (HFrEF). The 2019 World Symposium on PH focused on conflicting results and potential misleading interpretation of mean transpulmonary gradient (TPG) and diastolic transpulmonary gradient (DPG) in predicting outcomes in type 2 PH patients. A new Cpc-PH definition has been proposed, basing on pulmonary arterial wedge pressure (PAWP) >15 mmHg and pulmonary vascular resistance (PVR) >3 WU. In this setting, the role of vasodilator challenge has marginally been explored.
Purpose
This study aims to investigate whether vasodilator test increases prognostic accuracy in PH-LHD comparing to PVR and TPG.
Methods
125 patients with a first diagnosis of PH-LHD were selected within the PUlmonary hypertenSion in rigHt heart catheterization (PUSHON) registry. All patients underwent right heart catheterization and sodium nitroprusside vasodilator infusion. Hemodynamic response was defined as decrease of mean pulmonary arterial pressure (mPAP) <25 mmHg with maintenance of systemic systolic arterial pressure >85 mmHg. Primary endpoint was a composite of cardiac death, heart transplantation and urgent LVAD implant at 2 years.
Results
34 (27%) patients were sodium nitroprusside responders. Normalization of mPAP during acute vasodilator challenge was associated with higher event-free survival at 2 years (HR 2.46, 95% C.I. 1.29–4.69, p=0.006). Responders to nitroprusside showed lower baseline pressure regimens in pulmonary artery (sPAP 56.4±12.9 vs 63.2±12.4 mmHg, p=0.009; mPAP 38.1±6.9 vs 44.7±8.8 mmHg, p=0.001) and lower Wedge Pressure (25.1±6.6 vs 29.8±6.6 mmHg, p=0.001). Also, patients with positive vasodilator test showed better right ventricular function expressed by TAPSE (17.2±4.3 vs 15.4±3.8 mm, p=0.05) and higher EF (34.6±15.3% vs 28.1±13.1%, p=0.023). Interestingly, nitroprusside responders exhibited lower DPG (−0.11±5.30 vs 2.04±5.21 p=0.04). At multivariate analysis PVR and TPG ≥12 mmHg fail to independently predict primary endpoint, while positive vasodilator response was independently associated with better outcome (OR 0.22, 95% C.I. 0.09–0.52, p=0.001). The same results were confirmed in the Cpc-PH subgroup (OR 0.54, 95% C.I. 0.08–0.78, p=0.018).
Conclusions
Nitroprusside vasodilator response was associated with a higher event-free survival at 2 years follow-up in our cohort of patients with PH-LHD. Larger studies with prospective hemodynamic evaluations are needed to support our hypothesis.
Figure 1
Funding Acknowledgement
Type of funding source: None
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