Unsupervised sequence-to-sequence learning for automatic signal quality assessment in multi-channel electrical impedance-based hemodynamic monitoring.

BACKGROUND AND OBJECTIVE: This study proposes an unsupervised sequence-to-sequence learning approach that automatically assesses the motion-induced reliability degradation of the cardiac volume signal (CVS) in multi-channel electrical impedance-based hemodynamic monitoring. The proposed method attempts to tackle shortcomings in existing learning-based assessment approaches, such as the requirement of manual annotation for motion influence and the lack of explicit mechanisms for realizing motion-induced abnormalities under contextual variations in CVS over time. METHOD: By utilizing long-short term memory and variational auto-encoder structures, an encoder-decoder model is trained not only to self-reproduce an input sequence of the CVS but also to extrapolate the future in a parallel fashion. By doing so, the model can capture contextual knowledge lying in a temporal CVS sequence while being regularized to explore a general relationship over the entire time-series. A motion-influenced CVS of low-quality is detected, based on the residual between the input sequence and its neural representation with a cut-off value determined from the two-sigma rule of thumb over the training set. RESULT: Our experimental observations validated two claims: (i) in the learning environment of label-absence, assessment performance is achievable at a competitive level to the supervised setting, and (ii) the contextual information across a time series of CVS is advantageous for effectively realizing motion-induced unrealistic distortions in signal amplitude and morphology. We also investigated the capability as a pseudo-labeling tool to minimize human-craft annotation by preemptively providing strong candidates for motion-induced anomalies. Empirical evidence has shown that machine-guided annotation can reduce inevitable human-errors during manual assessment while minimizing cumbersome and time-consuming processes. CONCLUSION: The proposed method has a particular significance in the industrial field, where it is unavoidable to gather and utilize a large amount of CVS data to achieve high accuracy and robustness in real-world applications.

Automatic assessment of left ventricular function for hemodynamic monitoring using artificial intelligence and transesophageal echocardiography.

We have developed a method to automatically assess LV function by measuring mitral annular plane systolic excursion (MAPSE) using artificial intelligence and transesophageal echocardiography (autoMAPSE). Our aim was to evaluate autoMAPSE as an automatic tool for rapid and quantitative assessment of LV function in critical care patients. In this retrospective study, we studied 40 critical care patients immediately after cardiac surgery. First, we recorded a set of echocardiographic data, consisting of three consecutive beats of midesophageal two- and four-chamber views. We then altered the patient's hemodynamics by positioning them in anti-Trendelenburg and repeated the recordings. We measured MAPSE manually and used autoMAPSE in all available heartbeats and in four LV walls. To assess the agreement with manual measurements, we used a modified Bland-Altman analysis. To assess the precision of each method, we calculated the least significant change (LSC). Finally, to assess trending ability, we calculated the concordance rates using a four-quadrant plot. We found that autoMAPSE measured MAPSE in almost every set of two- and four-chamber views (feasibility 95%). It took less than a second to measure and average MAPSE over three heartbeats. AutoMAPSE had a low bias (0.4 mm) and acceptable limits of agreement (- 3.7 to 4.5 mm). AutoMAPSE was more precise than manual measurements if it averaged more heartbeats. AutoMAPSE had acceptable trending ability (concordance rate 81%) during hemodynamic alterations. In conclusion, autoMAPSE is feasible as an automatic tool for rapid and quantitative assessment of LV function, indicating its potential for hemodynamic monitoring.

Pulse contour techniques for perioperative hemodynamic monitoring: A nationwide carbon footprint and cost estimation.

BACKGROUND: The question of environmentally sustainable perioperative medicine represents a new challenge in an era of cost constraints and climate crisis. The French Society of Anaesthesia and Intensive Care (SFAR) recommends stroke volume optimization in high-risk surgical patients. Pulse contour techniques have become increasingly popular for stroke volume monitoring during surgery. Some require the use of specific disposable pressure transducers (DPTs), whereas others can be used with standard DPTs. OBJECTIVE: Quantify and compare the carbon footprint and cost of pulse contour techniques using specific and standard DPTs on a yearly basis and at a national level. METHODS: We estimated the number of high-risk surgical patients monitored every year in France with a pulse contour technique, and the plastic waste, carbon footprint and cost associated with the use of specific and standard DPTs. MAIN FINDINGS: When compared to pulse contour techniques working with a standard DPT, techniques requiring a specific DPT are responsible for an increase in carbon dioxide emission estimated at 65-83 tons/yr and for additional hospital cost estimated at €67 million/yr. If, as recommended by the SFAR, all high-risk surgical patients were monitored, the difference would reach 179-227 tons/yr for the environmental impact and €187 million/yr for the economic impact. CONCLUSION: From an environmental and economic standpoint, pulse contour techniques working with standard DPTs should be recommended for the perioperative hemodynamic monitoring of high-risk surgical patients.

Eficacia y seguridad del equipo de monitoreo hemodinámico no invasivo por biorreactancia en pacientes con sepsis o shock séptico atendidos en el área de emergencias / Eficácia e segurança de equipamentos de monitorização hemodinâmica não invasiva por biorreatância em pacientes com sepse ou choque séptico atendidos na área de emergência

ANTECEDENTES: En el marco de la metodología ad hoc para evaluar solicitudes de tecnologías sanitarias, aprobada mediante Resolución de Instituto de Evaluación de Tecnologías en Salud e Investigación N°111-IETSI-ESSALUD-2021, se ha elaborado el presente dictamen, el cual expone la evaluación de la eficacia y seguridad del equipo de monitoreo hemodinámico no invasivo por biorreactancia (EMHB) en pacientes con sepsis o shock séptico que son atendidos en área de emergencias. De este modo, la Dra. Guiliana Patricia Matos Ibérico, jefa del departamento de emergencia del Hospital Nacional Edgardo Rebagliati Martins (HNERM), siguiendo la Directiva N° 001-IETSI-ESSALUD-2018, envía al Instituto de Evaluación de Tecnologías en Salud e Investigación (IETSI) la solicitud de inclusión del equipo biomédico EMHB en el Petitorio de Dispositivos Médicos de EsSalud. ASPECTOS GENERALES: De acuerdo con el tercer consenso internacional para sepsis y shock séptico, la sepsis se define como una disfunción orgánica potencialmente mortal causada por una respuesta desregulada del ser humano ante la infección (Singer et al. 2016). Así, un estudio de datos provenientes de 195 países reportó que la mortalidad asociada a sepsis representa 19.7 % de las muertes globales (Rudd et al. 2020). Muchos pacientes que llegan a los servicios de emergencias presentan signos y síntomas compatibles con sepsis (McNevin et al. 2016) y una proporción variable evoluciona a sepsis severa o shock séptico (McNevin et al. 2018). De estos últimos, alrededor del 34 % son admitidos a las unidades de cuidados intensivos (UCI), lo que indica que la mayoría de pacientes con sepsis son tratados en emergencias (Rezende et al. 2008). La rápida administración de fluidoterapia (fluidos endovenosos) es clave para el paciente con sepsis a fin de evitar desenlaces graves (L. Evans et al. 2021). Sin embargo, se ha documentado que el exceso de fluidos se encuentra asociado a complicaciones clínicas, duración de la estancia hospitalaria y mortalidad (Boyd et al. 2011; Jones et al. 2008), por lo que resulta necesario optimizar cuidadosamente las cantidades de fluidos administrados. METODOLOGÍA: Se llevó a cabo una búsqueda bibliográfica exhaustiva con el objetivo de identificar la mejor evidencia sobre la eficacia y seguridad del EMHB. La búsqueda bibliográfica se realizó en las bases de datos PubMed, The Cochrane Library y LILACS. Asimismo, se realizó una búsqueda manual dentro de las páginas web pertenecientes a grupos que realizan evaluación de tecnologías sanitarias (ETS) y guías de práctica clínica (GPC) incluyendo el National Institute for Health and Care Excellence (NICE), Canadian Agency for Drugs and Technologies in Health (CADTH), Scottish Medicines Consortium (SMC), Scottish Intercollegiate Guidelines Network (SIGN), Institute for Clinical and Economic Review (ICER), el Instituto de Calidad y Eficiencia en la Atención de la Salud (IQWiG, por sus siglas en alemán), la Base Regional de Informes de Evaluación de Tecnologías en Salud de las Américas (BRISA), la OMS, el Ministerio de Salud del Perú (MINSA) y el Instituto de Evaluación de Tecnologías en Salud e Investigación (IETSI). RESULTADOS: Luego de la búsqueda bibliográfica (febrero del 2022) y la selección de la evidencia, se identificaron dos GPC (L. Evans et al. 2021; Instituto de Evaluación de Tecnologías en Salud e Investigación 2018) y un ECA (Kuan et al. 2016) los cuales fueron considerados para inclusión en el presente documento. CONCLUSIÓN: Por lo expuesto, el IETSI no aprueba el uso del equipo de monitoreo hemodinámico no invasivo por biorreactancia (EMHB) para pacientes con sepsis o shock séptico atendidos en el área de emergencias.

Avaliação da segurança e viabilidade do protocolo de sentar-levantar observando os efeitos hemodinâmicos agudos em idosos hospitalizados / Assessment of the safety and feasibility of the sit-up protocol observing acute hemodynamic effects in hospitalized elderly

Introdução: o processo de envelhecimento associado à hospitalização prolongada gera diminuição de massa e de força muscular dos membros inferiores, sendo necessárias intervenções para minimizar esses efeitos deletérios, como o treinamento de sentar-levantar. Este treinamento utiliza o peso do próprio corpo e é um movimento essencial para a manutenção da independência funcional. As respostas cardiovasculares agudas estão relacionadas com a segurança desta atividade, por isso é imprescindível a monitorização constante. Objetivo: avaliar a segurança e a viabilidade da realização do protocolo de sentar-levantar, observando os efeitos hemodinâmicos agudos em idosos hospitalizados. Metodologia: em uma amostra composta de idosos com estabilidade clínica, realizou-se um protocolo de sentar-levantar progressivo, com oito níveis em apenas uma sessão. Avaliaram-se variáveis hemodinâmicas, como pressão arterial sistólica e diastólica, pressão arterial média, frequência cardíaca e duplo produto, em repouso e após 1 min, 10 min e 30 min, sendo analisados e comparados médias e desvio-padrão. Resultados: observou-se um leve aumento nas variáveis pressão arterial sistólica, na frequência cardíaca e duplo produto, com normalização nos minutos seguintes ao protocolo. A pressão arterial diastólica e a arterial média apresentaram uma discreta diminuição no decorrer das mensurações. Observaram-se poucos eventos adversos na amostra, os quais foram solucionados após o repouso. Houve significância estatística entre a maior parte das variáveis, porém não houve significância clínica. Conclusão: o protocolo de sentarlevantar é viável e seguro em idosos hospitalizados, desde que seja realizado de acordo com os critérios de elegibilidade e monitorados.

Introduction: the aging process associated with prolonged hospitalization generates a decrease in muscle mass and strength in the lower limbs, requiring interventions to minimize these harmful effects, such as sit-to-stand training. This training uses the body's own weight and is an essential movement for the maintenance of functional independence. Acute cardiovascular responses are related to the safety of this activity, so constant monitoring is essential. Objective: evaluate the safety and feasibility of performing the sit-to-stand protocol, observing the acute hemodynamic effects in hospitalized elderly. Methods: in a sample composed of elderly people with clinical stability, a progressive sit-to-stand protocol was performed, with eight levels in just one session. Hemodynamic variables were evaluated, such as systolic and diastolic blood pressure, mean arterial pressure, heart rate and double product, at rest and after 1 min, 10 min and 30 min, and means and standard deviations were analyzed and compared. Results: there was a slight increase in the variables systolic blood pressure, heart rate and double product, with normalization in the minutes following the protocol. Diastolic blood pressure and mean arterial pressure showed a slight decrease during the measurements. Few adverse events were observed in the sample, which were resolved after rest. There was statistical significance among most of the variables, but there was no clinical significance. Conclusion: the sit-to-stand protocol is feasible and safe in hospitalized elderly, as long as it is performed according to eligibility criteria and monitored.

Nurses' Educational Needs Assessment for Hemodynamic Monitoring in Intensive Care Units.

INTRODUCTION: Hemodynamic monitoring is widely accepted as a cornerstone of intensive care units (ICUs). So, the main objective of this study was to evaluate the educational needs assessment of nurses for hemodynamic monitoring in ICUs. METHODS: The present descriptive-analytical study was conducted to evaluate the educational needs assessment of ICU nurses in terms of the hemodynamic monitoring. The research sample included 100 ICU nurses selected from the hospitals affiliated to Shahid Beheshti University of Medical Sciences, Tehran. For data collection, researcher-made observational checklist and researcher-made questionnaire of clinical reasoning skills were used to assess the educational needs for hemodynamic monitoring. RESULTS: The findings from the clinical practice checklists on hemodynamic monitoring revealed that nurses' practice was moderate in all 10 cases of monitoring with a mean of 79.30% (SD = 15.32%). Moreover, the nurses included were given a 9-item questionnaire regarding clinical reasoning skills. Accordingly, the results of this questionnaire indicated that nurses' clinical reasoning skills were at a poor level with a mean of 52.56% (SD = 8.71%). DISCUSSION: The findings suggested that the development of continuing education programs in the area of clinical reasoning skills for hemodynamic monitoring should be more emphasized on. Also, nurses need to learn how to examine the patient carefully, find nursing diagnoses, set goals of care, and plan nursing interventions for their patients. They should also be able to assess how they affected the patient after performing the interventions. Furthermore, attention should be paid on improving practical skills for hemodynamic monitoring.

Point-of-Care Echocardiography and Hemodynamic Monitoring in Cirrhosis and Acute-on-Chronic Liver Failure in the COVID-19 Era.

Point-of-Care (POC) transthoracic echocardiography (TTE) is transforming the management of patients with cirrhosis presenting with septic shock, acute kidney injury, hepatorenal syndrome and acute-on-chronic liver failure (ACLF) by correctly assessing the hemodynamic and volume status at the bedside using combined echocardiography and POC ultrasound (POCUS). When POC TTE is performed by the hepatologist or intensivist in the intensive care unit (ICU), and interpreted remotely by a cardiologist, it can rule out cardiovascular conditions that may be contributing to undifferentiated shock, such as diastolic dysfunction, myocardial infarction, myocarditis, regional wall motion abnormalities and pulmonary embolism. The COVID-19 pandemic has led to a delay in seeking medical treatment, reduced invasive interventions and deferment in referrals leading to "collateral damage" in critically ill patients with liver disease. Thus, the use of telemedicine in the ICU (Tele-ICU) has integrated cardiology, intensive care, and hepatology practices across the spectrum of ICU, operating room, and transplant healthcare. Telecardiology tools have improved bedside diagnosis when introduced as part of COVID-19 care by remote supervision and interpretation of POCUS and echocardiographic data. In this review, we present the contemporary approach of using POC echocardiography and offer a practical guide for primary care hepatologists and gastroenterologists for cardiac assessment in critically ill patients with cirrhosis and ACLF. Evidenced based use of Tele-ICU can prevent delay in cardiac diagnosis, optimize safe use of expert resources and ensure timely care in the setting of critically ill cirrhosis, ACLF and liver transplantation in the COVID-19 era.

Accuracy assessment of noninvasive cardiac output monitoring in the hemodynamic monitoring in critically ill patients.

BACKGROUND: The consistency of cardiac output (CO) measured by noninvasive cardiac output monitoring (NICOM), pulse index continuous cardiac output (PiCCO), and ultrasound in the hemodynamic monitoring of critically ill patients was studied. Using the NICOM built-in passive leg raising (PLR) test, stroke volume index variation (∆SVI) was calculated and was used to predict volume responsiveness in patients with circulatory shock (excluding cardiogenic shock). METHODS: Critically ill patients requiring hemodynamic monitoring were admitted during the study period. The CO of each included patient under hemodynamic monitoring was measured by NICOM plus PiCCO or ultrasound, and the consistency of the measured COs was analyzed. By the NICOM built-in PLR test, ∆SVI was calculated and was used to predict volume responsiveness. RESULTS: The CO of 58 patients was measured by NICOM and ultrasound, and the COs measured by these two methods were consistent. The CO of 40 patients was measured by NICOM and PiCCO, and the COs measured by these two methods were consistent. The volume responsiveness of all 98 patients was assessed by the NICOM built-in PLR test. A total of 60 patients had ∆SVI >10%, so they underwent the fluid challenge. Among them, 43 patients were positive by both the NICOM built-in PLR and fluid challenge. When using ∆SVI to predict volume responsiveness in patients with circulatory shock (excluding cardiogenic shock), the area under the receiver operating characteristic curve was 0.754 (95% confidence interval, 0.626-0.856), and the cut-off value was 18% (sensitivity: 88.37%, specificity: 52.94%), indicating that ∆SVI has value in predicting the volume responsiveness of patients with noncardiogenic circulatory shock. CONCLUSIONS: NICOM had good consistency with ultrasound and PiCCO in the hemodynamic monitoring of critically ill patients and can be for hemodynamic monitoring and evaluation in critically ill patients. The ∆SVI obtained by the NICOM built-in PLR test has certain clinical value in predicting the volume responsiveness of patients with circulatory shock (excluding cardiac shock) and provides a method for evaluating the volume responsiveness of critically ill patients.

Doppler echocardiography for assessment of systemic vascular resistances in cardiogenic shock patients.

OBJECTIVE: Impaired vascular tone plays an important role in cardiogenic shock. Doppler echocardiography provides a non-invasive estimation of systemic vascular resistance. The aim of the present study was to compare Doppler echocardiography with the transpulmonary thermodilution method for the assessment of systemic vascular resistance in patients with cardiogenic shock. METHODS: This prospective monocentric comparison study was conducted in a single cardiology intensive care unit (Hopital Nord, Marseille, France). We assessed the systemic vascular resistance index by both echocardiography and transpulmonary thermodilution in 28 patients admitted for cardiogenic shock, on admission and after the introduction of an inotrope or vasopressor treatment. RESULTS: A total of 35 paired echocardiographic and transpulmonary thermodilution estimations of the systemic vascular resistance index were compared. Echocardiography values ranged from 1309 to 3526 dynes.s.m2/cm5 and transpulmonary thermodilution values ranged from 1320 to 3901 dynes.s.m2/cm5. A statistically significant correlation was found between echocardiography and transpulmonary thermodilution (r=0.86, 95% confidence interval (CI) 0.74, 0.93; P<0.0001). The intraclass correlation coefficient was 0.84 (95% CI 0.72, 0.92). The mean bias was -111.95 dynes.s.m2/cm5 (95% CI -230.06, 6.16). Limits of agreement were -785.86, 561.96. CONCLUSIONS: Doppler echocardiography constitutes an accurate non-invasive alternative to transpulmonary thermodilution to provide an estimation of systemic vascular resistance in patients with cardiogenic shock.

Global Survey of Outcomes of Neurocritical Care Patients: Analysis of the PRINCE Study Part 2.

BACKGROUND: Neurocritical care is devoted to the care of critically ill patients with acute neurological or neurosurgical emergencies. There is limited information regarding epidemiological data, disease characteristics, variability of clinical care, and in-hospital mortality of neurocritically ill patients worldwide. We addressed these issues in the Point PRevalence In Neurocritical CarE (PRINCE) study, a prospective, cross-sectional, observational study. METHODS: We recruited patients from various intensive care units (ICUs) admitted on a pre-specified date, and the investigators recorded specific clinical care activities they performed on the subjects during their first 7 days of admission or discharge (whichever came first) from their ICUs and at hospital discharge. In this manuscript, we analyzed the final data set of the study that included patient admission characteristics, disease type and severity, ICU resources, ICU and hospital length of stay, and in-hospital mortality. We present descriptive statistics to summarize data from the case report form. We tested differences between geographically grouped data using parametric and nonparametric testing as appropriate. We used a multivariable logistic regression model to evaluate factors associated with in-hospital mortality. RESULTS: We analyzed data from 1545 patients admitted to 147 participating sites from 31 countries of which most were from North America (69%, N = 1063). Globally, there was variability in patient characteristics, admission diagnosis, ICU treatment team and resource allocation, and in-hospital mortality. Seventy-three percent of the participating centers were academic, and the most common admitting diagnosis was subarachnoid hemorrhage (13%). The majority of patients were male (59%), a half of whom had at least two comorbidities, and median Glasgow Coma Scale (GCS) of 13. Factors associated with in-hospital mortality included age (OR 1.03; 95% CI, 1.02 to 1.04); lower GCS (OR 1.20; 95% CI, 1.14 to 1.16 for every point reduction in GCS); pupillary reactivity (OR 1.8; 95% CI, 1.09 to 3.23 for bilateral unreactive pupils); admission source (emergency room versus direct admission [OR 2.2; 95% CI, 1.3 to 3.75]; admission from a general ward versus direct admission [OR 5.85; 95% CI, 2.75 to 12.45; and admission from another ICU versus direct admission [OR 3.34; 95% CI, 1.27 to 8.8]); and the absence of a dedicated neurocritical care unit (NCCU) (OR 1.7; 95% CI, 1.04 to 2.47). CONCLUSION: PRINCE is the first study to evaluate care patterns of neurocritical patients worldwide. The data suggest that there is a wide variability in clinical care resources and patient characteristics. Neurological severity of illness and the absence of a dedicated NCCU are independent predictors of in-patient mortality.

Are Peripherally Inserted Central Catheters Suitable for Cardiac Output Assessment With Transpulmonary Thermodilution?

OBJECTIVES: Peripherally inserted central catheters are increasingly used in ICU as an alternative to centrally inserted central catheters for IV infusion. However, their reliability for hemodynamic measurements with transpulmonary thermodilution is currently unknown. We investigated the agreement between transpulmonary thermodilution measurements obtained with bolus injection through peripherally inserted central catheter and centrally inserted central catheter (reference standard) using a transpulmonary thermodilution-calibrated Pulse Contour hemodynamic monitoring system (VolumeView/EV1000). DESIGN: Prospective method-comparison study. SETTING: Twenty-bed medical-surgical ICU of a teaching hospital. PATIENTS: Twenty adult ICU patients who required hemodynamic monitoring because of hemodynamic instability and had both peripherally inserted central catheter and centrally inserted central catheter in place. INTERVENTION: The hemodynamic measurements obtained by transpulmonary thermodilution after injection of a cold saline bolus via both centrally inserted central catheter and either a single-lumen 4F or a double-lumen 5F peripherally inserted central catheter using were compared. In order to rule out bias related to manual injection, measurements were repeated using an automated rapid injection system. MEASUREMENTS AND MAIN RESULTS: A total of 320 measurements were made. Cardiac index was significantly higher when measured with double-lumen 5F peripherally inserted central catheter than with centrally inserted central catheter (mean, 4.5 vs 3.3 L/min/m; p < 0.0001; bias, 1.24 L/min/m [0.27, 2.22 L/min/m]; bias percentage, 31%). Global end-diastolic index, extravascular lung water index, and stroke volume index were also overestimated (853 ± 240 vs 688 ± 175 mL/m, 12.2 ± 4.2 vs 9.4 ± 2.9 mL/kg, and 49.6 ± 14.9 vs 39.5 ± 9.6 mL/m, respectively; p < 0.0001). Lower, albeit significant differences were found using single-lumen 4F peripherally inserted central catheter (mean cardiac index, 4.2 vs 3.7 L/min/m; p = 0.043; bias, 0.51 L/min/m [-0.53, 1.55 L/min/m]; bias percentage, 12.7%). All differences were confirmed, even after standardization of bolus speed with automated injection. CONCLUSIONS: Bolus injection through peripherally inserted central catheter for transpulmonary thermodilution using EV1000 led to a significant overestimation of cardiac index, global end-diastolic index, extravascular lung water index, and stroke volume index, especially when double-lumen 5F peripherally inserted central catheter was used (ClinicalTrial.gov NCT03834675).

Updates in heart failure 30-day readmission prevention.

Heart failure (HF) and HF 30-day readmission rates have been a major focus of efforts to reduce health care cost in the recent era. Since the implementation of the Affordable Care Act (ACA) in 2012 and the Hospital Readmission Reduction Program (HRRP), concerted efforts have focused on reduction of 30-day HF readmissions and other admission diagnoses targeted by the HRRP. Hospitals and organizations have instituted wide-ranging programs to reduce short-term readmissions, but the data supporting these programs is often mixed. In this review, we will discuss the challenges associated with reducing HF readmissions and summarize the rationale and effect of specific programs on HF 30-day readmission rates, ranging from medical therapy and adherence to remote hemodynamic monitoring. Finally, we will review the effect that the focus on reducing 30-day HF readmissions has had on the care of the HF patient.

[Evaluation of cardiac MRI in the follow up assessment of patients with pulmonary arterial hypertension]. / Évaluation de l'IRM cardiaque dans le suivi des patients ayant une hypertension artérielle pulmonaire (EVITA). IRM cardiaque dans le suivi de l'hypertension artérielle pulmonaire.

Haemodynamic follow up in pulmonary arterial hypertension (PAH) is currently based on right heart catheterisation (RHC). The primary objective of the EVITA study is to compare the use of cardiac magnetic resonance imaging (cMRI) with RHC in the identification of an unfavourable hemodynamic status. The secondary objectives are to determine the role of cMRI in the follow up process. Patients will undergo at diagnosis and at follow up visits both RHC and cMRI. Patients will be followed and treated according to the current guidelines. The primary endpoint will be an unfavourable haemodynamic status defined by cardiac index<2.5L/min/m2 or a right atrial pressure≥8mm Hg measured with RHC compared with a cardiac index<2.5L/min/m2 or right ventricle ejection fraction<35% or an absolute decrease of 10% from the previous measurement with cMRI. Exact values of sensitivity, specificity and 95% confidence intervals will be computed. A population of 180 subjects will have a power of 90% with an α risk of 5%. Univariate and multivariate Cox analysis will allow answering to the secondary objectives. We expect to demonstrate that cMRI could be partly used instead of RHC in the follow up of patients with PAH.

[Functional assessment of primary lesion of the great saphenous vein when deciding upon stripping]. / Funktsional'naia otsenka pervichnogo porazheniia bol'shoi podkozhnoi veny pri reshenii voprosa o stripinge.

The purpose of the study was to examine a possibility of functional assessment of the great saphenous vein (GSV) with the help of a day orthostatic loading test for prognosis of restoration of the function of the GSV afterremoving its varicose tributaries in patients with primary varicose veins. Our prospective study included a total of sixty-five 29-to-53-year-old patients (15 men and 50 women, mean age - 36.7 years). The total number of the lower limb examined amounted to 87. All patients underwent ultrasonographic examination (duplex scanning) prior to operation, 1 and 12 months thereafter. The study was carried out using a day orthostatic loading test consisting in duplex scanning performed twice during 24 hours: in the evening after 18:00 hours and in the morning before 10:00 hours after a good night's rest. It was demonstrated that the day orthostatic loading test characterized the degree of preservation of the muscular-tonic properties of the GSV, making it possible to predict reversibility of reflux along it after removing the varicose tributaries, hence it may be used as a criterion for individualization of the choice of the scope of surgical intervention. A high orthostatic gradient prior to operation suggests preservation of the potential of the muscular-tonic function of the GSV; its decrease after surgery demonstrates reduction of the volemic loading on the GSV.

Assessment of fluid responsiveness: recent advances.

PURPOSE OF REVIEW: In the field of prediction of fluid responsiveness, the most recent studies have focused on validating new tests, on clarifying the limitations of older ones, and better defining their modalities. RECENT FINDINGS: The limitations of pulse pressure/stroke volume variations are numerous, but recent efforts have been made to overcome these limitations, like in case of low tidal volume ventilation. Following pulse pressure/stroke volume variations, new tests have emerged which assess preload responsiveness by challenging cardiac preload through heart-lung interactions, like during recruitment manoeuvres and end-expiratory/inspiratory occlusions. Given the risk of fluid overload that is inherent to the 'classical' fluid challenge, a 'mini' fluid challenge, made of 100 ml of fluid only, has been developed and investigated in recent studies. The reliability of the passive leg raising test is now well established and the newest publications have mainly aimed at defining several noninvasive estimates of cardiac output that can be monitored to assess its effects. SUMMARY: Research in this field is still very active, such that several indices and tests of fluid responsiveness are now available. They may contribute to reduce excessive fluid balance by avoiding unnecessary fluid administration and, also, by ensuring safe fluid removal.

Use of the ClearSight® System for Continuous Noninvasive Hemodynamic Monitoring during Heart Valve Interventions: Review of the Literature and Single-Site Experience.

During interventional and structural cardiology procedures, such as mitral valve (MitraClip, BMV), aortic valve (TAVR, BAV), tricuspid valve (MitraClip), left atrial appendage (Watchman, Lariat), atrial septum (ASD/PFO closure), and coronary artery intervention (high-risk PCI), among others, patients are at a high risk of hemodynamic instability and require continuous monitoring. This is conventionally achieved through arterial catheterization and transpulmonary thermodilution. However, such invasive techniques are time-consuming and have been associated with steep learning curves, vascular complications, and increased risk of infection. In line with the ongoing simplification and improvement of the catheter-based valve intervention, it is logical to investigate the effectiveness of continuous noninvasive hemodynamic monitoring in this setting. Over the last 2 years, our team has performed over 400 valve procedures with continuous hemodynamic monitoring via the noninvasive ClearSight system. This system is based on a finger-cuff and automated volume-clamp technology integrated into a simplified clinical platform (EV1000 NI). Although current evidence suggests that the technology results in slight differences in arterial pressure (AP) and cardiac output (CO) relative to the current, commercially available, invasive approaches, we have found the bias to be acceptable. Both the noninvasive and the invasive approaches have the same percentage of error when compared to the true CO and provide beat-by-beat detection of acute changes facilitating shorter response times. In addition to AP and CO, the system provides up-to-date information on stroke volume (SV), stroke volume variation (SVV), and systemic vascular resistance, which can be useful in aiding decision-making and provide better postoperative outcomes, such as shorter length of stay (LOS), decreased postoperative infection, decreased postoperative arrhythmia, decreased postoperative renal failure, decreased postoperative congestive heart failure (CHF), and decreased readmission. Additionally, the simplicity of the system setup has translated into a time saving of up to 3 hours per day, allowing one team to perform an additional 2 to 3 valve interventions without moving rooms. Moving forward, a formal study comparing patient outcomes and cost-effectiveness between invasive and noninvasive hemodynamic monitoring techniques in valve replacement would be insightful.