Usability of myocardial work parameters to demonstrate subclinical myocardial involvement in normotensive individuals with exaggerated hypertensive response in treadmill exercise testing.

Early determination of changes in myocardial functions is essential for the protection of cardiovascular diseases. This study aimed to evaluate myocardial work parameters in healthy individuals who developed an exaggerated hypertensive response during the treadmill exercise test procedure. The study included a total of 64 patients for whom an exercise electrocardiography test was planned for functional capacity evaluation. The study population was divided according to the presence of exaggerated hypertensive response to exercise (EBPRE) (SBP/DBP ≥210/105 mmHg in males ≥190/105 mmHg in females) and normal blood pressure response to exercise (NBPRE). Patients' echocardiographic evaluations were made at rest, and myocardial work parameters were calculated. There was no statistical difference between the groups (NBPRE vs. EBPRE, respectively) in terms of left ventricular 2,3 and 4 chamber strains and global longitudinal strain (GLS) values (-20.6 ± -2.3, -19.7 ± -1.9, p:.13; -21.3 ± -2.7, -21 ± -2.4, p:.68; -21.2 ± -2.2, -21.2 ± -2.3, p:.93; and -20.8 ± -1.5, -20.4 ± -1.5, p:.23, respectively). Global constrictive work (GCW), global waste work (GWW), and global work efficiency (GWE) were not statistically different between the two groups (2374 ± 210, 2465 ± 204, p:.10; 142 ± 64, 127 ± 42, p:.31; 94.3 ± 2.5, 95.1 ± 1.5, p:.18, respectively). In contrast, global work index (GWI) parameters were different between the two groups (2036 ± 149, 2147 ± 150, p < .001). The GWI was independently associated with EBPRE (odds ratio with 95% 3.32 (1.02-11.24), p = .03). The partial effect plots were used for GWI to predict EBPRE, according to the results, an increase in GWI predicts probability of exaggerated hypertensive response. In conclusion, Myocardial work analyses might be used to identify early signs of myocardial involvement in normotensive patients with EBPRE.

Combination anticoagulation strategy in pregnancy with mechanical valves: The KYBELE study.

BACKGROUND: Optimal first-trimester anticoagulation is still challenging in pregnant women with mechanical heart valves (MHVs) requiring high-dose warfarin. This multicenter prospective study aims to determine the optimal anticoagulation regimens for pregnant patients with MHVs. METHODS: All women were allocated to one of three treatment options during first trimester including lone low-molecular-weight heparin (LMWH), combination of LMWH + 2.5 mg warfarin, and LMWH+4 mg warfarin. Primary maternal outcome included a combination of death, thromboembolism, severe bleeding, and need for treatment of mechanical valve thrombosis (MVT). Any fetal loss was determined as primary fetal outcome. RESULTS: The study included 78 pregnancies in 65 women with MHVs. Primary maternal outcome rate was 44%, 12.5%, 3.5%, respectively. The rates of primary maternal outcome (44 vs 3.5%, P < .001), obstructive MVT (16 vs 0%, P = .04), MVT requiring treatment (28 vs 0%, P = .003), and cerebral embolism (24 vs 3.4%, P = .041) were found to be significantly higher in lone LMWH group compared to LMWH + 4 mg warfarin group. Moreover, the rates of primary maternal outcome (12.5 vs 44%, P = .015) and treatment for MHV thrombus (4.2 vs 28%, P = .049) were significantly lower in LMWH + 2.5 mg warfarin group compared to lone LMWH group. The incidences of fetal loss were 8 (32%) in the lone LMWH group, 8 (33.3%) in LMWH + 2.5 mg warfarin group, and 11 (37.9%) in LMWH + 4 mg warfarin group (P = .890 for 3-group).Warfarin related-embryopathy was not observed in any case. CONCLUSIONS: The combined anticoagulation strategy of LMWH plus low-dose warfarin during the first trimester of pregnancy may result in less maternal complications with comparable fetal outcomes in patients with MHVs. CONDENSED ABSTRACT: Low-molecular-weight heparin (LMWH) is thought to be safer for the fetus, however it is suspected to be less protective for the mother. To solve this dilemma, the authors suggested a novel anticoagulation strategy in pregnant women with prosthetic valves. Seventy-eight pregnancies of 65 women (median age 32 [27-35] years) were included in the study. A combination of LMWH and a reduced dose warfarin were associated with low rates of thrombus-related complications in pregnant patients with mechanical heart valves.

Remembering the Occam's Razor: Could Simple Electrocardiographic Findings Provide Relevant Predictions for Current Hemodynamic Criteria of Pulmonary Hypertension?

BACKGROUND: We evaluated the predictive value of electrocardiographic (ECG) findings for pulmonary hemodynamics assessed by right heart catheterization (RHC). METHODS: Our study population comprised 562 retrospectively evaluated patients who underwent RHC between 2006 and 2022. Correlations between ECG measures and pulmonary arterial systolic and mean pressures (PASP and PAMP) and pulmonary vascular resistance (PVR) were investigated. Moreover, receiver operating characteristic (ROC) curve analysis assessed the predictive value of ECG for pulmonary hypertension (PH) and precapillary PH. RESULTS: The P-wave amplitude (Pwa) and R/S ratio (r) in V1 and V2, Ra in augmented voltage right (aVR), right or indeterminate axis, but not P wave duration (Pwd) or right bundle branch block (RBBB) significantly correlated with PASP, PAMP, and PVR (P <.001 for all). The partial R2 analysis revealed that amplitude of R wave (Ra) in aVR, R/Sr in V1 and V2, QRS axis, and Pwa added to the base model provided significant contributions to variance for PASP, PAMP, and PVR, respectively. The Pwa > 0.16 mV, Ra in aVR > 0.05 mV, QRS axis > 100° and R/Sr in V1 > 0.9 showed the highest area under curve (AUC) values for PAMP > 20 mm Hg. Using the same cutoff value, Ra in aVR, Pwa, QRS axis, and R/Sr in V1 showed highest predictions for PVR > 2 Wood Units (WU). CONCLUSION: In this study, Pwa, Ra in aVR, right or indeterminate axis deviations, and R/Sr in V1 and V2 showed statistically significant correlations with pulmonary hemodynamics, and Ra in aVR, R/Sr in V2 and V1, QRS axis, and Pwa contributed to variance for PASP, PAMP, and PVR, respectively. Moreover, Pwa, Ra in aVR, QRS axis, and R/Sr in V1 seem to provide relevant predictions for PH and precapillary PH.

A Novel Composed Index to Evaluate the Right Ventricle Free-Wall Adaptation Against Ventricular Wall Stress in Acute Pulmonary Embolism.

BACKGROUND: Pulmonary embolism severity index and simplified pulmonary embolism severity index have been utilized in initial risk evaluation in patients with acute pulmonary embolism. However, these models do not include any imaging measure of right ventricle function. In this study, we proposed a novel index and aimed to evaluate the clinical impact. METHODS: Our study population comprised retrospectively evaluated 502 patients with acute pulmonary embolism managed with different treatment modalities. Echocardiographic and computed tomographic pulmonary angiography evaluations were performed at admission to the emergency room within maximally 30 minutes. The formula of our index was as follows: (right ventricle diameter × systolic pulmonary arterial pressure-echo)/(right ventricle free-wall diameter × tricuspid annular plane systolic excursion). RESULTS: This index value showed significant correlations to clinical and hemodynamic severity measures. Only pulmonary embolism severity index, but not our index value, independently predicted in-hospital mortality. However, an index value higher than 17.8 predicted the long-term mortality with a sensitivity of 70% and specificity of 40% (areas under the curve = 0.652, 95% CI, 0.557-0.747, P =.001). According to the adjusted variable plot, the risk of long-term mortality increased until an index level of 30 but remained unchanged thereafter. The cumulative hazard curve also showed a higher mortality with high-index value versus low-index value. CONCLUSIONS: Our index composed from measures of computed tomographic pulmonary angiography and transthoracic echocardiography may provide important insights regarding the adaptation status of right ventricle against pressure/wall stress in acute pulmonary embolism, and a higher value seems to be associated with severity of the clinical and hemodynamic status and long-term mortality but not with in-hospital mortality. However, the pulmonary embolism severity index remained as the only independent predictor for in-hospital mortality.

Reappraisal of the Transthoracic Echocardiographic Algorithm in Predicting Pulmonary Hypertension Redefined by Updated Pulmonary Artery Mean Pressure Threshold.

BACKGROUND: Although an adopted echocardiography algorithm based on tricuspid regurgitation jet peak velocity and suggestive findings for pulmonary hypertension has been utilized in the non-invasive prediction of pulmonary hypertension probability, the reliability of this approach for the updated hemodynamic definition of pulmonary hypertension remains to be determined. In this study, for the first time, we aimed to evaluate the tricuspid regurgitation jet peak velocity and suggestive findings in predicting the probability of pulmonary hypertension as defined by mean pulmonary arterial pressure > 20 mm Hg and > 25 mm Hg, respectively. METHODS: Our study group was comprised of the retrospectively evaluated 1300 patients (age 53.1 ± 18.8 years, female 62.1%) who underwent right heart catheterization with different indications between 2006 and 2018. All echocardiographic and right heart catheterization assessments were performed in accordance with the European Society of Cardiology/European Respiratory Society 2015 Pulmonary Hypertension Guidelines. RESULTS: Although tricuspid regurgitation jet peak velocity showed a significant relation with mean pulmonary arterial pressure in both definitions, suggestive findings offered a significant contribution only in predicting mean pulmonary arterial pressure ≥ 25 mm Hg but not for mean pulmonary arterial pressure > 20 mm Hg. In predicting the mean pulmonary arterial pressure > 20 mm Hg, tricuspid regurgitation jet peak velocity and suggestive findings showed an odds ratio of 2.57 (1.59-4.14, P <.001) and 1.25 (0.86-1.82, P =.16), respectively. In predicting the mean pulmonary arterial pressure ≥ 25 mm Hg, tricuspid regurgitation jet peak velocity, and suggestive findings showed an odds ratio of 2.33 (1.80-3.04, P <.001) and 1.54 (1.15-2.08, P <.001), respectively. The tricuspid regurgitation jet peak velocity > 2.8 m/s and tricuspid regurgitation jet peak velocity > 3.4 m/s were associated with 70% and 84% probability of mean pulmonary arterial pressure > 20 mm Hg and 60% and 76% probability of mean pulmonary arterial pressure ≥ 25 mm Hg, respectively. CONCLUSIONS: In contrast to those in predicting the mean pulmonary arterial pressure ≥ 25 mm Hg, suggestive findings did not provide a significant contribution to the probability of mean pulmonary arterial pressure > 20 mm Hg predicted by tricuspid regurgitation jet peak velocity solely. The impact of the novel mean pulmonary arterial pressure threshold on the echocardiographic prediction of pulmonary hypertension remains to be clarified by future studies.

A New Index for the Prediction of In-Hospital Mortality in Patients with Acute Pulmonary Embolism: The Modified Shock Index.

BACKGROUND: Pulmonary embolism severity index, its simplified version, and shock index have been used for risk stratification in acute pulmonary embolism. In this study, we proposed a modification in severity index and evaluated the correlates and prognostic value of modification in severity index in this setting. METHODS: The study group comprised retrospectively evaluated 181 patients with acute pulmonary embolism. Systematic workup including pulmonary embolism severity index, its simplified version, shock index, biomarkers, and echocardiographic and multidetector computed tomography assessments was performed in all patients. Moreover, we calculated modification in severity index by multiplying original shock index (heart rate/systolic blood pressure ratio) and a third component, 1/pulse oxymetric saturation (pSat O2%) ratio. The primary endpoint was defined as all-cause mortality and hemodynamic collapse during the hospital stay. RESULTS: On the basis of initial risk stratification, ultrasound-assisted thrombolysis, systemic tissue-type plasminogen activator, and unfractionated heparin therapies were utilized in 83 (45.9%), 37 (20.4%), and 61 (33.7%) patients, respectively. The primary end-point occurred in 13 (7.2%) patients. Receiver-operating curve analysis revealed that modification in severity index had the highest area under the curve of 0.739 (0.588-0.890, P =.002) compared with shock index, pulmonary embolism severity index, or its simplified version. The modification in severity index > 0.989 predicted primary endpoint with 73% sensitivity and 54% specificity. CONCLUSIONS: The modification in severity index seems to be a simple, quick, and compre-hensive risk assessment tool for bedside evaluation at initial stratification, in monitoring the clinical benefit from therapies, and decision-making for escalation to other reperfusion strategies in patients with acute pulmonary embolism. However, the prognostic value of modification in severity index needs to be validated with further studies.

An Eight-year, Single-center Experience on Ultrasound Assisted Thrombolysis with Moderate-dose, Slow-infusion Regimen in Pulmonary Embolism.

BACKGROUND: There is limited data on moderate-dose with slow-infusion thrombolytic regimen by ultrasound-asssisted-thrombolysis (USAT) in patients with acute pulmonary embolism (PE). AIMS: In this study, our eight-year experience on USAT with moderate-dose, slow-infusion tissue-type plasminogen activator (t-PA) regimen in patients with PE at intermediate-high- and high-risk was presented, and short-, and long-term effectiveness and safety outcomes were evaluated. METHODS: Our study is based on the retrospective evaluation of 225 patients with PE having multiple comorbidities who underwent USAT. RESULTS: High- and intermediate-high-risk were noted in 14.7% and in 85.3% of patients, respectively. Mean t-PA dosage was 35.4±13.3 mg, and the infusion duration was 26.6±7.7 h. Measures of pulmonary artery (PA) obstruction and right ventricle (RV) dysfunction were improved within days (p<0.0001 for all). During the hospital stay, major and minor bleeding and mortality rates were 6.2%, 12.4%, and 6.2%, respectively. Bleeding and unresolved PE accounted for 50% and 42.8% of in-hospital mortality, respectively. Age, rate, and duration of t-PA were not associated with in-hospital major bleeding and mortality. Oxygen saturation exceeded 90% in 91.2% of patients at discharge. During follow-up of median 962 (610-1894) days, high-risk status related to 30-day mortality, whereas age >65 years was associated with long-term mortality. CONCLUSION: Our real-life experience with USAT with moderate-dose, slow-infusion t-PA regimen in patients with PE at high-and intermediate-high risk demonstrated clinically relevant improvements in PA obstructive burden and RV dysfunction. Age, rate or infusion duration of t-PA was not related to major bleeding or mortality risk, whereas unresolved obstruction remained as a lethal issue.

The Consistent Effectiveness and Safety of Macitentan Therapies Across Idiopathic and Congenital Heart Disease-Associated PulmonaryArterial Hypertension: A Single-Center Experience.

BACKGROUND: In this single-center study, we evaluated efficacy and safety issues and predictors of survival in patients with idiopathic and congenital heart disease-associated pulmonary arterial hypertension who were under macitentan therapies. METHOD: Our study retrospectively evaluated 221 patients with pulmonary arterial hypertension enrolled in our single-center study, and mono, dual, and triple macitentan therapies were noted in 30, 115, and 76 patients, respectively. The longitudinal changes in clinical, neurohumoral, and echocardiographic measures of pulmonary arterial hypertension were evaluated. The Registry to Evaluate Early and Long-Term Pulmonary Arterial Hypertension Disease Management, Registry to Evaluate Early and Long-Term Pulmonary Arterial Hypertension Disease Management 2.0, and Registry to Evaluate Early and Long- Term Pulmonary Arterial Hypertension Disease Management Lite 2 scores at baseline, Swedish PAH Registry, Comparative Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension registry, and French Pulmonary Hypertension Network registry risk status both at baseline and first control were assessed. RESULT: The median follow-up period was 1068 [415-2245] days. Macitentan was associated with significant improvements in functional class, 6-minute walk distance, N-terminal pro-brain natriuretic peptide (NT-proBNP), and echocardiographic measures without any deterioration of hemoglobin or hepatic enzymes. The low-risk scores with each model at baseline and/or first control are related to significantly better survival. Age, gender, and log-NT-proBNP in time-fixed and idiopathic pulmonary arterial hypertension, and log-NT-proBNP in time-dependent Cox proportional hazard regression analyses were independent predictors of mortality. CONCLUSION: Mono- or sequential combination macitentan therapies were associated with sustained benefits in functional class, 6-minute walk distance, NT-proBNP, and echocardiographic measures in patients with idiopathic pulmonary arterial hypertension and congenital heart disease-associated pulmonary arterial hypertension, and low-risk scores at baseline and/or first controls can be translated to better survival.

Maternal and Fetal Outcomes in Pregnant Women with Pulmonary Arterial Hypertension: A Single-Center Experience and Review of Current Literature.

BACKGROUND: Although pregnancy in women with pulmonary arterial hypertension has been considered a high-risk condition, current data regarding pregnancy with pulmonary arterial hypertension are scarce. In this study, we aimed to evaluate our single-center data on maternal and fetal outcomes in pregnant women with PAH and review currently available risk-based management strategies. METHODS: Our single-center study group comprised 35 women who became pregnant after the diagnosis of pulmonary arterial hypertension or in whom pulmonary arterial hypertension was diagnosed within early post-partum period. Clinical, laboratory, echocardiographic, and hemodynamic characteristics of pregnant and non-pregnant productive women with pulmonary arterial hypertension were compared, and similar comparison was also repeated for survivors and non-survivors in pregnant patient group. RESULTS: Pregnancy was noted in 15% of the 228 females with pulmonary arterial hypertension who were of hormonally productive ages, generally well-tolerated until delivery. Elective abortion and pre-term delivery were documented in 1 (2.8%) and 12 (35.3%) pregnant women, respectively. Switching to sildenafil was the standard medication during pregnancy. Cesarian section was the preferred method of delivery in all pregnant women with pulmonary arterial hypertension and was performed without any complication. Clinic deteoriation within the first week of delivery was observed in 5 (41.6%) patients. Maternal mortality was noted in 13 (37.1%) patients and was documented to cumulate within the first month of delivery. However, any sign predicting post-partum clinical deterioration was not found. No fetal mortality was observed. CONCLUSION: Despite the development of advanced therapies, pregnancy in pulmonary arterial hypertension still carries a high mortality risk and requires multi-disciplinary expert center care with more proactive management strategies.

Relationship between right atrial pressure and the Model for End-Stage Liver Disease (MELD) score in patients with advanced heart failure.

Background: This study aims to investigate the association between right atrial pressure and the Model for End-Stage Liver Disease score and to evaluate the ability of this scoring system to accurately predict the value of right atrial pressure. Methods: Between April 2016 and November 2018, a total of 137 patients (118 males, 19 females; median age: 49 years; range, 40 to 54 years) with advanced heart failure who were candidates for left ventricular assist device implantation or heart transplantation were retrospectively analyzed. We developed a formula calculated by using the biochemical and cardiac catheterization parameters of the patients. Results: There was a strong correlation between the right atrial pressure and the scores (r=0.510, p<0.001). The estimated right atrial pressure was calculated as "2 + (0.92 x Model for End-Stage Liver Disease Score)" (unstandardized coefficient 0.920, t value 7.674, p<0.001). The Model for End-Stage Liver Disease score was found to be an independent predictor of high right atrial pressure (odds ratio=1.491, 95% confidence interval: 1.244-1.786, p<0.001). The calculated area under the curve was 0.789 (95% confidence interval: 0.710-0.867, p<0.001) and the cut-off value of the Model for End-Stage Liver Disease score in the prediction of high right atrial pressure was 10.5 with 75% sensitivity and 73% specificity. Conclusion: We define a method to calculate right atrial pressure obtained by using the Model for End-Stage Liver Disease score without the need for cardiac catheterization during the hospitalization and follow-up period of patients with advanced heart failure.

Prognostic Impact of Nutritional Indices in Candidates for Heart Transplantation.

OBJECTIVE: No study has thus far evaluated the association of controlling nutritional status (CO NUT) score and prognostic nutritional index (PNI) with prognosis in candidates listed for heart transplantation (HT). Therefore, in this study, we aimed to investigate the impact of these nutritional indices on prognosis in these candidates. METHODS: In this retrospective study, a total of 195 candidates for HT were included. Over a median follow-up period of 503.5 days, the patients were grouped as survivors (n=121) and non-survivors (n = 74). Malnutrition was defined as CONUT score ≥2 (CONUT-defined malnu trition) and PNI ≤38 (PNI-defined malnutrition). RESULTS: The CONUT-defined malnutrition was observed in 19.8% and 39.2% of the survivors and non-survivors (P = .003), and the PNI-defined malnutrition was observed in 7.4% and 16.2% of the survivors and non-survivors (P = .032). The univariate analysis revealed that the CONUT score from 0 to 2 (hazard ratio [HR]: 1.41, 95% confidence interval [CI]: 1.11-1.79, P =.004) and PNI from 45.5 to 54.5 (HR: 0.78, 95% CI: 0.64-0.95, P = .001), the CONUT-defined malnutrition (HR: 2.48, 95% CI: 1.55-3.97, P < .001) and the PNI-defined malnutrition (HR: 1.97, 95% CI: 1.01-3.86, P = .04) were associated with mortality. In the multivariate adjusted models, the CO NUT-defined malnutrition was an independent predictor of mortality, whereas the PNI-defined malnutrition was not a predictor of mortality (HR: 1.92, 95% CI: 1.12-3.27, P = .001 and HR: 1.64, 95% CI: 0.80-3.40, P = .18). The log-rank test revealed that the CONUT-defined malnutri tion and the PNI-defined malnutrition were associated with decrease in survival rate. CONCLUSION: Although both the CONUT score and the PNI score were associated with prognosis in candidates for HT, the CONUT score was superior to the PNI score in predicting mortality.

Electrophysiologic Changes and Their Effects on Ventricular Arrhythmias in Patients with Continuous-Flow Left Ventricular Assist Devices.

Ventricular arrhythmias (VAs) continue even after left ventricular assist device (LVAD) implantation. The effect of LVAD on VAs is controversial. We investigated electrophysiologic changes after LVAD and its effects on VAs development. A total of 107 implantable cardioverter-defibrillator (ICD) patients, with LVAD, were included in this study. Electrocardiographic parameters including QRS duration (between the beginning of the QRS complex and the end of the S wave), QT duration (between the first deflection of the QRS complex and the end of the T wave) corrected QT (QTc), QTc dispersion, fragmented QRS (F-QRS), and ICD recordings before, and post-LVAD first year were analyzed. All sustained VAs were classified as polymorphic ventricular tachycardia (PVT) or monomorphic VT (MVT). The QRS, QT, QTc durations, and QTc dispersion had decreased significantly after LVAD implantation (p < 0.001 for all). Also MVT increased significantly from 28.9% to 49.5% (p = 0.019) whereas PVT decreased from 27.1% to 4.67% (p = 0.04) compared to pre-LVAD period. A strong correlation was found between QT shortening and the decrease in PVT occurrence. Besides, the increase in the F-QRS after LVAD was associated with post-LVAD de nova MVT development. Finally, F-QRS before LVAD was found as an independent predictor of post-LVAD late VAs in multivariate analysis. Pre-existing or newly developed F-QRS was associated with post-LVAD late VAs, and it may be used to determine the risk of VAs after LVAD implantation.

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 RV 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 LV assist device 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 (hazard ratio [HR]: 0.75, 95% confidence interval [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 1 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 effects of severe functional mitral regurgitation on right ventricular function in patients with advanced heart failure who were on waiting list for heart transplant.

Background: This study aims to investigate the effects of severe functional mitral regurgitation on the parameters that reflect right ventricular function such as tricuspid annular plane systolic excursion and right ventricular stroke work index in potential heart transplant recipients. Methods: Between January 2015 and January 2017, a total of 282 consecutive patients (250 males, 32 females; mean age: 46±10 years; range, 18 to 66 years) with advanced heart failure who were referred for heart transplantation were retrospectively analyzed. The patients were divided into two groups as severe (n=84) and non-severe functional mitral regurgitation (n=198). Patients" medical histories, demographic characteristics, echocardiographic evaluations, and findings of right heart catheterization were recorded. Results: The two groups were similar in terms of left ventricular ejection fraction, the New York Heart Association functional class, Interagency Registry for Mechanically Assisted Circulatory Support profile, and the duration of heart failure (p>0.05). Both groups were also similar with respect to tricuspid annular plane systolic excursion and right ventricular stroke work index. Functional mitral regurgitation was the only statistically significant variable in the univariate analysis for tricuspid annular plane systolic excursion (odds ratio [OR]: 0.58; 95% confidence interval [CI] 0.34-0.97; p=0.04), with no significant effect in the multivariate analysis. In the univariate analysis for right ventricular stroke work index, pulmonary arterial systolic pressure (OR: 0.77; 95% CI 0.67-0.88; p<0.001) was a significant variable and also had a significant effect in the multivariate analysis (OR: 0.92; 95% CI 0.87-0.97; p=0.003). In the tertile analyses, there were no significant differences between the two groups with respect to tricuspid annular plane systolic excursion and right ventricular stroke work index. Conclusion: We found no significant difference in right ventricular functions between the severe and non-severe functional mitral regurgitation groups in patients with advanced heart failure who had relatively short follow-up. Right ventricle can maintain its normal function at early stage. Adaptive remodeling of right ventricle may have an effect on these findings. Severe functional mitral regurgitation may be associated with adverse effects on advanced heart failure by increasing the right ventricular afterload.

Effect of Group 2 Pulmonary Hypertension Subgroups on Outcomes: Impact of the Updated Definition of Pulmonary Hypertension.

BACKGROUND: Pulmonary hypertension (PH) is a common complication of end-stage heart failure (ESHF) and associated with increased mortality. The definition of PH has recently been changed from a mean pulmonary arterial pressure (PAPm) ≥25 mmHg to a PAPm >20 mmHg. Since this change, there are no data evaluating group 2 PH subgroups on outcomes. The purpose of this study was to determine the impact of updated group 2 PH subgroups on outcomes, as well as to evaluate the clinical, echocardiographic, and haemodynamic characteristics of subgroups, and determine predictors of PH in patients with ESHF. METHOD: A total of 416 patients with ESHF with left ventricular ejection fraction (LVEF) ≤25% were divided into three groups. Pulmonary hypertension was defined as PAPm >20 mmHg. Primary outcome was defined as left ventricular assist device (LVAD) implantation, urgent heart transplantation (HT), or death. Secondary outcome was defined as LVAD implantation and HT. RESULTS: Over a median follow-up of 503.5 days, combined pre- and postcapillary PH (Cpc-PH) displayed greater risk of primary outcome than those with isolated postcapillary (Ipc-PH) (hazard ratio [HR], 1.57; 95% confidence interval [CI], 1.29-1.91; p<0.001) and those with no PH (HR, 2.47; 95% CI, 1.68-3.63; p<0.001). Patients with Ipc-PH demonstrated greater risk than those with no PH (HR, 1.57; 95% CI, 1.57-1.90; p<0.001). Likelihood ratios of updated PH criteria and old PH criteria (PAPm ≥25 mmHg) in identifying primary outcome were 75.6 (R2=0.179) and 72.09 (R2=0.164). Patients with PAPm 21-24 mmHg had a higher primary outcome than those with PAPm ≤20 mmHg. Severe mitral regurgitation, LVEF, grade 3 diastolic dysfunction, diabetes, and cardiac output were predictors of PH. CONCLUSIONS: Pulmonary hypertension increases the risk of LVAD, urgent HT, or death, and Cpc-PH further increases risk in patients with ESHF. Compared to the previous definition, a new PH definition better discriminates death, going to urgent HT, or LVAD implantation for PH subgroups.

Ischaemic versus non-ischaemic: how does heart failure aetiology affect pulmonary arterial capacitance and pulmonary artery pulsatility index in end-stage heart failure?

BACKGROUND: The aetiology of heart failure may have different effects on right ventricular (RV) function, pulmonary pressures and RV afterload. Pulmonary arterial capacitance (PAC) and pulmonary artery pulsatility index (PAPi) are novel haemodynamic indices used in determining RV afterload and RV function, respectively. We aimed to investigate whether there was a difference in PAC and PAPi between ischaemic cardiomyopathy (ICMP) and non-ischaemic cardiomyopathy (NICMP) in patients with end-stage heart failure. METHODS AND RESULTS: A total of 215 subjects undergoing evaluation for heart transplantation or left ventricular (LV) assist device were classified into two groups: ICMP (n = 101) and NICMP (n = 114). The patients with LV ejection fraction ≤ 25% were included in the study. ICMP group had lower PAC and higher PAPi values compared to NICMP group [1.25 (0.82-1.86) vs. 1.58 (1.02-2.21), p = 0.002 and 3.4 (2.2-5.0) vs. 2.5 (1.7-4.0); p = 0.007]. Pulmonary vascular resistance, pulmonary artery systolic and mean pressure were higher in ICMP group compared to NICMP group [3.5 ± 1.8 vs. 2.9 ± 2.3, p = 0.004; 59.0 (42.0-73.0) vs. 46.0 (37.0-59.0), p < 0.001, 35.0 (27.0-46.0) vs. 31.0 (23.0-39.0), p = 0.002]. The patients with ICMP had higher tricuspid annular plane systolic excursion and less RV dilatation. ICMP was an independent risk factor for pulmonary hypertension (OR: 4.02, 95% CI: 1.13-14.24, p = 0.031). CONCLUSION: ICMP was associated with lower PAC and higher PAPi. These results indicated that an ischaemic aetiology is associated with higher RV afterload and better RV function in the end-stage heart failure.

A seven-year single-center experience on AngioJet rheolytic thrombectomy in patients with pulmonary embolism at high risk and intermediate-high risk.

BACKGROUND AND AIM: Angiojet Rheolytic thrombectomy (ART) has been utilized as a catheter-based treatment in acute pulmonary embolism (PE). In this study based on our seven-year experience on ART in patients with PE, we evaluated efficacy and safety outcomes of ART. METHODS: Our study is based on retrospective evaluation of 56 patients with high- and intermediate-high-risk PE, age (62 years; interquartile-range (IQR): 50-73) who underwent ART. RESULTS: High- and intermediate-high-risk were noted in 21.4 % and in 78.6 % of patients, respectively. ART duration was 304(IQR: 246-468) seconds. Measures of obstruction, right to left ventricle diameter ratio (RV/LV ratio), right to left atrial diameter ratio and pulmonary arterial pressures were improved (p<0.001 for all). During hospital stay, acute renal failure, major and minor bleeding, and mortality rates were 37.5%, 7.1%, 12.5%, and 8.9%, respectively. Aging related to post-procedural nephropathy while high-risk status was associated with in-hospital mortality (p=0.006) and long-term mortality. CONCLUSIONS: The ART resulted in significant and clinically relevant improvements in the pulmonary arterial thrombotic burden, RV strain and hemodynamics in patients with PE at high- and intermediate-high-risk. Aging increased the risk of post-procedural nephropathy whereas baseline high-risk status predicted in-hospital and long-term mortality.

Impaired endothelium-dependent and endothelium-independent systemic vasodilatory reserve in pulmonary hypertension regardless the clinical group: A generalized dysfunction beyond the pulmonary arteries?

OBJECTIVE: Endothelium-dependent (ED) and endothelium-independent (EI) flow-mediated vasodilatation (FMD) have been used as measures of systemic arterial vasodilatory reserve. In this study, we aimed to assess both ED-FMD and EI-FMD in different groups with pulmonary hypertension (PH), and to investigate the relationship of these measures with clinical, echocardiographic, and invasive parameters of diseases severity and targeted treatment status. METHODS: Our study population comprised 41 patients with PH [28 (68.2%) women, age 46.3±19.6 years] including idiopathic pulmonary arterial hypertension, Eisenmenger syndrome, and chronic thromboembolic PH in whom diagnosis were confirmed in accordance with current guidelines and 17 age and sex-matched healthy controls. The brachial artery (BA) was used for assessment of FMD with Duplex ultrasound, and serial changes in diameter were recorded at baseline, 1, and 3 minutes after termination of 2-minute external occlusive compression for ED-FMD, and after sublingual intake of glycerol trinitrate for EI-FMD, respectively. RESULTS: Compared with controls, overall the PH group showed significantly lower ED-FMD (0.65±0.21 vs. 0.30±0.23 and 0.65±0.18 vs. 0.24±0.21) and EI-FMD (0.67±0.15 vs. 0.37±0.25 and 0.75±0.20 vs. 0.32±0.24) responses at 1st and 3rd min (p<0.001 for all). All these changes in the values of ED-FMD and EI-FMD were comparable among the PH subgroups. Neither ED-FMD nor EI-FMD were correlated with measures of PH severity and targeted therapy (TT) status (p>0.05). CONCLUSION: Our results suggest an impaired BA vasodilatory reserve in patients with PH regardless of the clinical subgroup. Although these findings seem to be consistent with systemic dysfunction, acute FMD may not reflect the severity of PH and cannot be used as a potential surrogate for outcome in this setting.

Endovascular treatment of upper extremity ischemia due to radiation-induced arteritis.

Symptomatic occlusion of the peripheral arteries due to radiation-induced arteritis (RIA) is an extremely rare condition. Patients generally present with the symptoms of ischemic claudication months or years after radiotherapy. Treatment options for symptomatic patients include surgical or endovascular interventions. Although success rate of percutaneous angioplasty in RIA is lower than in atherosclerotic disease, there are several case reports in the literature to demonstrate successful percutaneous angioplasty for RIA. In this report, we presented a case with right upper extremity occlusion due to RIA treated by percutaneous angioplasty successfully.