Strategic multimodal non-invasive assessment of cardiac performance in patients with heart failure.

AIMS: Although various non-invasive cardiac examinations are known to be predictive of long-term outcomes in patients with heart failure (HF), combining them properly would provide synergism. We aimed to show that non-invasive cardiac assessments targeting left ventricular filling pressure (LVFP), left atrial remodelling, and exercise capacity would provide better prognostication in combination. METHODS AND RESULTS: This prospective observational study included consecutive hospitalized stage A-C HF patients evaluated with N-terminal pro-B-type natriuretic peptide (NT-proBNP), echocardiography including two-dimensional speckle tracking, and cardiopulmonary exercise testing. According to NT-proBNP and echocardiographic semi-quantitative LVFP grading (Echo-LVFP), patients were classified into three LVFP groups: normal range of both Echo-LVFP and NT-proBNP (Group 1), normal range of Echo-LVFP but elevated NT-proBNP (Group 2), and elevated Echo-LVFP and NT-proBNP (Group 3). The adverse outcome was defined as a composite of cardiovascular death, non-fatal acute coronary syndrome, acute stroke, or HF-related hospitalization. Among 224 HF patients (mean age of 63.8 ± 11.6 years, 158 men) analysed, 160 (71.4%) had ischaemic aetiology. During the follow-up of 18.6 ± 9.8 months, event-free survival in Group 2 (n = 56, age of 65.4 ± 12.4) was better than that in Group 3 (n = 45, age of 68.5 ± 11.5) but worse than that in Group 1 (n = 123, mean age of 61.4 ± 10.5) (log-rank P < 0.001). Mechanical left atrial dysfunction (peak longitudinal strain <28%) (adjusted hazard ratio 5.69, 95% confidence interval 1.06-4.48) and limited exercise capacity (peak VO2 per +5 mL/kg/min) (adjusted hazard ratio 0.63, 95% confidence interval 0.46-0.87) were also predictable adverse outcomes. Serial addition of peak VO2 and left atrial strain to the model incrementally enhanced the predictive power of LVFP-based risk stratification for adverse outcomes. CONCLUSIONS: The combination of NT-proBNP and Echo-LVFP could be used to predict adverse outcomes in patients with HF of various stages. Left atrial mechanics and exercise capacity are incremental to prognostication. Non-invasive test findings could be strategically combined to provide an integrative profile of cardiac performance.

The prognostic value of cardiopulmonary exercise testing and HFA-PEFF in patients with unexplained dyspnea and preserved left ventricular ejection fraction.

BACKGROUND: HFA-PEFF and cardiopulmonary exercise testing (CPET) are comprehensive diagnostic tools for heart failure with preserved ejection fraction (HFpEF). We aimed to investigate the incremental prognostic value of CPET for the HFA-PEFF score among patients with unexplained dyspnea with preserved ejection fraction (EF). METHODS: Consecutive patients with dyspnea and preserved EF (n = 292) were enrolled between August 2019 and July 2021. All patients underwent CPET and comprehensive echocardiography, including two-dimensional speckle tracking echocardiography in the left ventricle, left atrium and right ventricle. The primary outcome was defined as a composite cardiovascular event including cardiovascular-related mortality, acute recurrent heart failure hospitalization, urgent repeat revascularization/myocardial infarction or any hospitalization due to cardiovascular events. RESULTS: The mean age was 58 ± 14.5 years, and 166 (56.8%) participants were male. The study population was divided into three groups based on the HFA-PEFF score: < 2 (n = 81), 2-4 (n = 159), and ≥ 5 (n = 52). HFA-PEFF score ≥ 5, VE/VCO2 slope, peak systolic strain rate of the left atrium and resting diastolic blood pressure were independently associated with composite cardiovascular events. Furthermore, the addition of VE/VCO2 and HFA-PEFF to the base model showed incremental prognostic value for predicting composite cardiovascular events (C-statistic 0.898; integrated discrimination improvement 0.129, p = 0.032; net reclassification improvement 1.043, p ≤ 0.001). CONCLUSIONS: CPET could be exploited for the HFA-PEFF approach in terms of incremental prognostic value and diagnosis among patients with unexplained dyspnea with preserved EF.

Abdominal Wall Block Decreases Intraoperative Opioid Con-Sumption by Surgical Pleth Index-Guided Remifentanil Administration in Single-Port Laparoscopic Herniorrhaphy: A Prospective Randomized Controlled Trial.

Abdominal wall blocks (AWBs) can reduce pain during surgery and lessen opioid demand. Since it is difficult to know the exact level of intraoperative pain, it is not known how much the opioid dose should be reduced. In this study, using the surgical pleth index (SPI), which indicates pain index from sympathetic fibers, the amount of remifentanil consumption was investigated. We conducted single-port laparoscopic hernia repair in 64 patients, as follows: the regional block group (R group) was treated with AWB, while the control group (C group) was only subjected to general anesthesia. In both groups, the remifentanil concentration was adjusted to maintain the SPI score between 30 and 40 during surgery. The primary parameter was the amount of remifentanil. A total of 52 patients completed the study (24 in the R group, 28 in the C group). The remifentanil dose during surgery was decreased in the R group (29 ± 21 vs. 56 ± 36 ng/kg/min; p = 0.002). Visual analogue scale score and additional administrated analgesics were also low in the R group. As such, AWB can reduce the remifentanil dose while maintaining the same pain level.