Right Ventricular Shape Feature Quantification for Evaluation of Pulmonary Hypertension: Feasibility and Preliminary Associations with Clinical Outcome Submitted for Publication

This study aimed to demonstrate feasibility of statistical shape analysis techniques to identify distinguishing features of right ventricle (RV) shape as related to hemodynamic variables and outcome data in pulmonary hypertension (PH).Cardiovascular magnetic resonance images were acquired from 50 patients (33 PH, 17 Non-PH). Contemporaneous right heart catheterization data was collected for all individuals. Outcome was defined by all-cause mortality and hospitalization for heart failure. RV endocardial borders were manually segmented, and 3D surfaces reconstructed at end-diastole and end-systole. Registration and harmonic mapping were then used to create a quantitative correspondence between all RV surfaces. Proper orthogonal decomposition was performed to generate modes describing RV shape features. The first 15 modes captured over 98 % of the total modal energy. Two shape modes, 8 (free wall expansion) and 13 (septal flattening), stood out as relating to PH state (Mode 13: r=0.424, p=0.002. Mode 8: r=0.429, p=0.002). Mode 13 was significantly correlated with outcome (r = 0.438, p = 0.001), more so than any hemodynamic variable. Shape analysis techniques can derive unique RV shape descriptors corresponding to specific, anatomically meaningful features. The modes quantify shape features that had been previously only qualitatively related to PH progression. Modes describing relevant RV features are shown to correlate with clinical measures of RV status, as well as outcomes. These new shape descriptors lay the groundwork for a non-invasive strategy for identification of failing RVs, beyond what is currently available to clinicians.

Prostanoids in pediatric pulmonary hypertension: clinical response, time-to-effect, and dose–response

For pediatric pulmonary arterial hypertension (PAH) patients treated with parenteral prostanoids, response predictors, and the dose–effect relationship are ill defined. We determined the following: (1) which pulmonary vascular hemodynamic variable, after initiating prostanoids, best correlates with a significant clinical response; (2) the time interval after treatment when if no pulmonary hemodynamic improvement has occurred, none is ever likely to; and (3) the relationship between the prostanoid dose and its hemodynamic effects. This is a retrospective cohort study of 31 pediatric patients with Group 1 PAH treated with parenteral prostanoids. We found the following: (1) A fall in mean pulmonary arterial pressure (mPAP) of ≥25% predicted freedom from adverse clinical events with 80.7% accuracy and was also associated with improved functional class. (2) Thirty-three percent of patients who avoided an adverse clinical event demonstrated a ≥25% reduction in mPAP after 1 year of treatment, and 65% by 2 years. (3) Lower mPAP was seldom seen with doses of epoprostenol >60 ng/kg/min (100 ng/kg/min for treprostinil). Cardiac index was positively correlated with the dose of epoprostenol but not treprostinil; cardiac index >4 l/min/m2 was seen at modest as well as high doses. We conclude that a ≥25% fall in mPAP on prostanoids indicates a positive clinical response which, if validated in other studies, may be useful for patient management or clinical trials. Some patients take more than 2 years for this change. Exceptionally high doses were generally not more effective than lower, although we could not determine whether lower doses would have been as effective.

Phylogenic Determinants of Cardiovascular Frailty, Focus on Hemodynamics and Arterial Smooth Muscle Cells

The evolution of the circulatory system from invertebrates to mammals has involved the passage from an open system to a closed in-parallel system via a closed in-series system, accompanying the increasing complexity and efficiency of life’s biological functions. The archaic heart enables pulsatile motion waves of hemolymph in invertebrates, and the in-series circulation in fish occurs with only an endothelium, whereas mural smooth muscle cells appear later. The present review focuses on evolution of the circulatory system. In particular, we address how and why this evolution took place from a closed, flowing, longitudinal conductance at low pressure to a flowing, highly pressurized and bifurcating arterial compartment. However, although arterial pressure was the latest acquired hemodynamic variable, the general teleonomy of the evolution of species is the differentiation of individual organ function, supported by specific fueling allowing and favoring partial metabolic autonomy. This was achieved via the establishment of an active contractile tone in resistance arteries, which permitted the regulation of blood supply to specific organ activities via its localized function-dependent inhibition (active vasodilation). The global resistance to viscous blood flow is the peripheral increase in frictional forces caused by the tonic change in arterial and arteriolar radius, which backscatter as systemic arterial blood pressure. Consequently, the arterial pressure gradient from circulating blood to the adventitial interstitium generates the unidirectional outward radial advective conductance of plasma solutes across the wall of conductance arteries. This hemodynamic evolution was accompanied by important changes in arterial wall structure, supported by smooth muscle cell functional plasticity, including contractility, matrix synthesis and proliferation, endocytosis and phagocytosis, etc. These adaptive phenotypic shifts are due to epigenetic regulation, mainly related to mechanotransduction. These paradigms actively participate in cardio-arterial pathologies such as atheroma, valve disease, heart failure, aneurysms, hypertension, and physiological aging.

Comparison of nebulized ketamine and ketamine with clonidine in postoperative sore throat

Background: Postoperative sore throat (POST) consider a minor ailment in patients receiving general anesthesia with endotracheal intubation, seen in 21-65% cases but it causes significant distress and increases postoperative morbidity and patient dissatisfaction. This study was done to compare nebulized ketamine and ketamine with clonidine to treat POST.Methods: This was a prospective, randomized, double-blind control clinical study. After approval from institution ethical and scientific committee, study was conducted in between May 2015-April 2016. Written and informed consent was obtained from 100 patients of either sex aged between 20-65 years. ASA I-II, undergoing surgery in supine position lasting up to two hour. Patients were randomized into two groups Group K (n=50) nebulized with 50 mg ketamine (1cc) + 3cc NS =4cc, Group KC (n=50) nebulized with ketamine 50mg (1cc) + clonidine 150µg (1cc) + 2cc NS for 15 min, before general anaesthesia with endotracheal intubation. The POST and hemodynamic variable were monitored before nebulization, after nebulization, before induction, on arrival to PACU and at 4, 8, 12, 24 hours post operatively. POST was graded on 4 point scale (0-3).Results: Overall incidence of POST was 46% (Group K-40%, KC-6%). The Incidence and severity of POST were significantly attenuated in Group KC in comparison to Group K at 4 hours (P= 0.002), 8 hours (P=0.000), 12 hours (P= 0.000) and at 24 hours (P=0.000).Conclusions: Preoperative nebulization with clonidine and ketamine mixture compared to ketamine is more effective in dealing with postoperative sore throat with no adverse effects.

EFFECTS OF CARDIAC REHABILITATION ON THE FUNCTIONAL CAPACITY AND HEMODYNAMIC PARAMETERS OF PATIENTS WITH CVD USING 6MWT

OBJECTIVE To evaluate the effects of phase II cardiac rehabilitation (CR) on functional capacity and hemodynamic parameters of patients with CVD STUDY DESIGN Quasi Experimental Study METHODOLOGY 121 individuals were recruited in cardiac phase II rehabilitation program by a simple random sampling, aged between 45-65 years, assessed on day 1 on the basis of medical history and 6 Minute Walk Test (6MWT). The patients were then enrolled into eighteen session of hospital based supervised exercise program according to ACSM’s guidelines. RESULTS The statistical analysis shows the significant changes in the functional status and hemodynamic variables of the participants after exercise session, where the post exercise heart rate was decreased to around 2.2±0.8 beats/minute with the p value of 0.001; systolic and diastolic blood pressure was plummeted to around 12.3±2.5 and 46.1±9.2 mmHg respectively with the p value of 0.00 and 0.001. The rate of exertion has been decreased by 6.2±1.5 (p value =0.0001) and the distance covered was increased to 111.9 meters (p value = 0.0002). CONCLUSION The study has concluded that potency of eighteen session of phase II cardiac rehabilitation is found to be effective in improving the functional status, hemodynamic variable and the myocardial workload of cardiac patients, determined by 6MWT.

Central venous pressure up date: What is it good for?

Central venous pressure is a very common clinical measurement, but it is frequently misunderstood and misused. As with all hemodynamic measurements, it is important to understand its basic principles. Use of CVP for the estimating of cardiac preload and volume status requires an understanding of its determinants. Actually, CVP and cardiac output are determined by the interaction of two function curves: the cardiac function curve and the return curve. There are no data to support the widespread practice of using central venous pressure (CVP) to guide fluid therapy. But, CVP is readily available in many patients. The fact that an isolated measurement of CVP does not predict the response to a fluid bolus does not reduce its importance as a hemodynamic variable. CVP may be usefull taken in the context of the whole clinical picture and over time.

Lower Intraprocedural Systolic Blood Pressure Predicts Good Outcome in Patients Undergoing Endovascular Therapy for Acute Ischemic Stroke

Background: It is unknown if intraprocedural blood pressure (BP) influences clinical outcomes and what BP parameter best predicts outcomes in acute ischemic stroke (AIS) patients who undergo intra-arterial therapy (IAT) for emergent large vessel occlusion. Methods: We retrospectively reviewed 147 patients who underwent IAT for anterior circulation AIS from January 2008 to December 2012 at our institution. Baseline demographics, stroke treatment variables, and detailed intraprocedural hemodynamic variables were collected. Results: The entire cohort consisted of 81 (55%) females with a mean age of 66.9 ± 15.6 years and a median National Institutes of Health Stroke Scale (NIHSS) score of 16 (IQR 11-21). Thirty-six (24.5%) patients died during hospitalization, 25 (17%) achieved a 30-day modified Rankin Scale score of 0-2, and 24 (16.3%) suffered symptomatic parenchymal hematoma type 1/2 hemorrhage. Patients who achieved a good outcome had a significantly lower admission NIHSS score, a higher baseline CT ASPECTS score, and a lower rate of ICA terminus occlusions. Successful recanalization was more frequent in the good-outcome group, while symptomatic hemorrhages occurred only in poor-outcome patients. The first systolic BP (SBP; 146.5 ± 0.2 vs. 157.7 ± 25.6 mm Hg, p = 0.042), first mean arterial pressure (MAP; 98.1 ± 20.8 vs. 109.7 ± 20.3 mm Hg, p = 0.024), maximum SBP (164.6 ± 27.6 vs. 180.9 ± 18.3 mm Hg, p = 0.0003), and maximum MAP (125.5 ± 18.6 vs. 138.5 ± 24.6 mm Hg, p = 0.0309) were all significantly lower in patients who achieved good outcomes. A lower maximum intraprocedural SBP was an independent predictor of good outcome (adjusted OR 0.929, 95% CI 0.886-0.963, p = 0.0005). Initial NIHSS score was the only other independent predictor of a good outcome. Conclusion: Lower intraprocedural SBP was associated with good outcome in patients undergoing IAT for AIS, and maximum SBP was an independent predictor of good outcome. SBP may be the optimal hemodynamic variable to monitor intraprocedurally during IAT and may predict outcome.

Abstract 18892: Clinical and Hemodynamic Factors Influence the Risk of Pulmonary Hypertension in Patients Undergoing Transcatheter Aortic Valve Replacement: Insights from the PARTNER I Trial and Registry

Introduction: Pulmonary hypertension (PH) is associated with increased mortality after surgical or transcatheter aortic valve replacement (TAVR) for aortic stenosis (AS). Hypothesis: We hypothesized that clinical or hemodynamic factors might influence the relationship between significant PH and increased mortality. Methods: Among patients with symptomatic AS at high or prohibitive surgical risk receiving TAVR in the PARTNER I randomized trial or registry, 2180 patients with an invasive measurement of mean pulmonary artery pressure (mPAP) recorded were included. PH was defined as: none (mPAP<25 mmHg), mild (25 to <35), and mod/sev (≥35). Results: One year all-cause mortality was worse with increasing severity of PH: none (n=785, 18.6%), mild (n=838, 22.7%), and mod/sev (n=557, 25.0%) (p=0.01). The association between mod/sev PH (vs. no PH) and 1y mortality varied by sex and renal function (interaction p=0.03 and p=0.06, respectively). In females, mod/sev PH was associated with increased mortality (24.6% vs. 14.1%, HR 1.89, 95% CI 1.32-2.73); in males it was not (24.9% vs. 22.2%, HR 1.12, 95% CI 0.82-1.52). Additionally, mod/sev PH was associated with mortality in those with glomerular filtration rate (GFR) <40 (HR 1.76, 95% CI 1.28-2.42), but not in those with GFR ≥40. In a multivariable Cox PH model of patients with mod/sev PH, oxygen dependent lung disease, cerebrovascular disease, lower GFR, and lower baseline transvalvular mean gradient were each independently associated with increased 1y mortality (p<0.05 for all), whereas pulmonary artery compliance was the only hemodynamic variable associated with mortality (p=0.043) (Table). Conclusions: The relationship between mod/sev PH and increased mortality after TAVR is altered by sex and renal function. While lower pulmonary artery compliance is associated with increased mortality in patients with significant PH, clinical factors appear to be more influential in stratifying risk than hemodynamic indices.