Novel Computed Tomography Angiography Parameter Is Associated with Low Cardiac Index in Patients with Chronic Thromboembolic Pulmonary Hypertension: A Retrospective Analysis.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a complication of incomplete resolution of acute pulmonary embolism. We hypothesize changes in CT Hounsfield Unit gradient (HU-Δ) created by the dispersion of IV contrast through the downstream blood pool correlate with cardiac index (CI). We sought to compare HU-Δ with invasively obtained CI. METHODS: We completed a retrospective analysis of CTEPH patients in which individuals with low CI (<2.2-L/min/m2) were identified. Both absolute and fractional HU-Δ were derived from pulmonary CTA by subtracting the HU value of the left atrium (LA) and left ventricle (LV) from the main pulmonary artery (MPA) (absolute) and expressing them as a percentage of MPA-HU (fractional) on static axial images. These were compared between low and normal CI. RESULTS: Of the 237 patients, 50.2% were female, 53.2% were White, 36.7% were Black. Hemodynamics were mean pulmonary artery (PA) pressure = 45.4 ± 11.2-mmHg, pulmonary vascular resistance = 9.2 ± 4.4-WU, CI = 2.05 ± 0.48-L/min/m2. There was a higher mean MPA-HU = 391.1 ± 113.6 than LA-HU = 251.6 ± 81. In patients with low CI, the HU-Δ was higher, HU-ΔMPA-LA was 148.9 ± 78.4 vs. 124.5 ± 77.2 (p = 0.02), and HU-ΔMPA-LV was 170.7 ± 87 vs. 140 ± 82 (p = 0.009). A HU-ΔMPA-LA = 118 had a sensitivity of 75.6% and specificity of 77% to detect low CI, AUC 0.61, p = 0.003. A HU-ΔPA-LV = 156 had a sensitivity of 77% and specificity of 53% to detect low CI, AUC = 0.62, p = 0.001. A fractional reduction HU-ΔMPA-LA of 35% had a sensitivity and specificity of 79% and 53%, respectively, to detect low CI (AUC 0.65, p < 0.001). A fractional reduction of the HU-ΔMPA-LV of 40% had a sensitivity and specificity of 80% and 55%, respectively, to detect low CI (AUC 0.65, p < 0.001). HU Δ were highly reproducible (Kappa = 0.9, p < 0.001, 95% CI 0.86-0.95). CONCLUSIONS: High HU Δ between MPA-LA and MPA-LV were associated with low CI in patients with CTEPH.

Correlation between severity of obesity and mortality in cardiogenic shock.

INTRODUCTION: Cardiogenic shock (CS) is associated with high mortality despite the development of risk stratification tools and new treatment strategies. Obesity, although a risk factor for cardiovascular disease, is not included in current risk stratification tools for CS. A relationship between mortality and obesity has only been shown in subsets populations of CS; there is not yet a clear relationship between severity of obesity and all-cause CS. OBJECTIVES: In this study we evaluate the relationship between rising body mass index (BMI) and mortality in all-cause CS. METHODS: All patients with BMI measurements and hospitalizations complicated by CS from 2014 to 2019 at a single quaternary care institution were identified. Patients were grouped by obesity classification. Multivariate logistic regression was performed to determine a relationship between higher obesity classifications with 30-day mortality in patients with CS. RESULTS: Seventy-two patients were available for analysis. Mean BMI for those who survived compared to those who did not was 29.7 ± 8 kg/m2 vs 33.7 ± 7.6 kg/m2 (p = 0.04). The odds ratio for mortality with incremental increase in obesity classification was 1.6 (95% CI 1.1 - 2.6, p = 0.03) after adjusting for etiology of CS and other common associations with CS mortality. CONCLUSION: This study suggests that the higher mortality risk with incremental increases in BMI should be taken into account when risk stratifying these patients.

Incidence and Predictors of Acute Limb Ischemia in Patients With Acute Myocardial Infarction-Insight from National Readmission Database.

Acute limb ischemia (ALI) has been a rare complication of acute myocardial infarction (AMI), however, with the increasing use of mechanical circulatory devices it is seen more frequently. The incidence and predictors of ALI in patients with AMI in contemporary clinical practice are unknown. A retrospective review of patients with index hospitalization for AMI in the Nationwide Readmission Database from 2016 to 2019 was done. We evaluated the annual incidence of ALI and its impact on outcomes. We used multivariate logistic regression analysis to determine predictors of ALI. In 1,283,586 patients with AMI, 3,971 patients (0.31%) had ALI and 365 (0.03%) had limb amputation. The 3 major predictors of ALI were peripheral artery disease (odds ratio [OR] 11.91, 95% confidence interval [CI]: 10.78 to 13.51), intravascular microaxial left ventricular assist device (OR 4.39, 95% CI 3.86 to 5.00), and veno-arterial extracorporeal membrane oxygenation (OR 4.37, 95% CI 3.19 to 6.01). Intra-aortic balloon pump had a substantially lower predictive ability (OR 1.81, 95% CI 1.63 to 2.0, p <0.0001) than other forms of mechanical circulatory support. The mortality rate in patients with ALI was significantly higher than those without ALI (19.49% vs 4.85%, p <0.0001). Patients who developed ALI had higher rates of amputation (1.59% vs 0.02%, p <0.0001). This observational nationwide study showed that ALI is an important complication in patients with AMI and is more frequently seen in patients who have peripheral artery disease, and require a left ventricular assist device or venoarterial extracorporeal membrane oxygenation. This complication was also associated with significantly higher in-hospital mortality.

Identifying Patients With a Higher Potential for Recovery Post Left Ventricular Assist Device: A Single-Center Experience.

Background: Few patients with a left ventricular assist device (LVAD) achieve functional myocardial recovery to the point of LVAD explantation. The aim of this study was to highlight some of the hemodynamic and echocardiographic parameters we observed in patients who recovered. Methods: We conducted a retrospective analysis of 7 patients who received the HeartMate II LVAD (Abbott) at Temple Heart and Vascular Institute and subsequently underwent successful explantation following myocardial recovery. We compared baseline characteristics, echocardiographic data, and hemodynamic data. Results: Baseline characteristics of the cohort were as follows: age 51.6 ± 12.0 years, 57.1% male, 42.9% with nonischemic cardiomyopathy, and mean duration of LVAD support of 10.6 months. Comparison of echocardiographic and hemodynamic data (preimplant vs preexplant) revealed the following: left ventricular ejection fraction (%) was 12.8 ± 6.9 vs 52.8 ± 8.1 (P=0.0001), right atrial pressure (mmHg) was 12.3 ± 3.4 vs 5.0 ± 4.0 (P=0.022), mean pulmonary artery pressure (mmHg) was 36.0 ± 7.8 vs 15.4 ± 7.1 (P=0.01), cardiac output (L/min) was 3.6 ± 1.3 vs 5.5 ± 1.8 (P=0.004), and cardiac index (L/min/m2) was 1.8 ± 0.5 vs 2.7 ± 0.7 (P=0.008). Mean LVAD-free survival was 49.1 months. Results were consistent in both ischemic and nonischemic LVAD explants. Conclusion: A potential for LVAD explantation exists in patients with both ischemic and nonischemic cardiomyopathy. Myocardial recovery may be more likely among young patients with nonischemic cardiomyopathy and patients with recently diagnosed ischemic cardiomyopathy. Future prospective studies are needed.