Towards the automatic detection and correction of abnormal arterial pressure waveforms.

Both over and underdamping of the arterial pressure waveform are frequent during continuous invasive radial pressure monitoring. They may influence systolic blood pressure measurements and the accuracy of cardiac output monitoring with pulse wave analysis techniques. It is therefore recommended to regularly perform fast flush tests to unmask abnormal damping. Smart algorithms have recently been developed for the automatic detection of abnormal damping. In case of overdamping, air bubbles, kinking, and partial obstruction of the arterial catheter should be suspected and eliminated. In the case of underdamping, resonance filters may be necessary to normalize the arterial pressure waveform and ensure accurate hemodynamic measurements.

Feasibility and Accuracy of Noninvasive Continuous Arterial Pressure Monitoring during Transcatheter Atrial Fibrillation Ablation.

INTRODUCTION: Transcatheter atrial fibrillation (AF) ablation is still carried out with continuous invasive radial arterial blood pressure (IBP) monitoring in many centers. Continuous noninvasive blood pressure (CNBP) measurement using the volume-clamp method is a noninvasive alternative method used in ICU. No data on CNBP reliability are available in the electrophysiology lab during AF ablation, where rhythm variations are common. BACKGROUND: The objective of the present study was to compare continuous noninvasive arterial pressure measured with the ClearSight device (Edwards Lifesciences, Irvine, CA, USA) with invasive radial artery pressure used as the reference method during AF ablation. METHODS: We prospectively enrolled 55 consecutive patients (age 62 ± 11 years, 80% male) undergoing transcatheter AF ablation (62% paroxysmal, 38% persistent) at our center. Standard of care IBP monitoring via a radial cannula and a contralateral noninvasive finger volume-clamp CNBP measurement device were positioned simultaneously in all patients for the entire procedure. Bland-Altman analysis was used to analyze the agreement between the two techniques. RESULTS: A total of 1219 paired measurements for systolic, diastolic, and mean arterial pressure were obtained in 55 subjects, with a mean (SD) of 22 (9) measurements per patient. The mean bias (SD) was -12.97 (13.89) mmHg for systolic pressure (level of agreement -14.24-40.20; correlation coefficient 0.84), -1.85 (8.52) mmHg for diastolic pressure (level of agreement -18.54-14.84; correlation coefficient 0.77) and 2.31 (8.75) mmHg for mean pressure (level of agreement -14.84-19.46; correlation coefficient 0.85). CONCLUSION: In patients undergoing AF ablation, CNBP monitoring with the ClearSight device showed acceptable agreement with IBP monitoring. Larger studies are needed to confirm the potential clinical implications of continuous noninvasive BP monitoring during AF ablation.

Intraarterial catheter diameter and dynamic response of arterial pressure monitoring system: a randomized controlled trial.

The dynamic response (DR) of the arterial pressure monitoring system (APMS) may depend on the intraarterial catheter (IAC) diameter. We hypothesized that adequate DR would be more common when using a smaller IAC. We compared the DR of the AMPS (Auto Transducer™) between three IACs (BD Angiocath Plus™) with different diameters. 353 neurosurgical patients were randomized into three groups undergoing catheterization with a 20-, 22-, or 24-gauge IAC: 20G (n = 119), 22G (n = 117), and 24G (n = 117) groups, respectively. The DR, which depends on the natural frequency and damping coefficient, was divided into four types: adequate (primary outcome measure), underdamped, overdamped, and unacceptable. The frequency of intraoperative IAC malfunction was noted. Adequate DR was observed more frequently in the 22G and 24G groups than the 20G group (13.7% and 15.4% vs. 4.2%, P = 0.011 and 0.004, respectively). The frequency of underdamped DR was higher in the 20G group than the 24G group (86.6% vs. 69.2%, P = 0.001), whereas overdamped DR was more frequent in the 24G group than the 20G and 22G groups (6.0% vs. 0.0% and 0.0%, P = 0.007 and 0.014, respectively). IAC malfunctioned more frequently during surgery in the 24G group than the 20G and 22G groups (15.4% vs. 0.0% and 1.7%, P < 0.001 and P < 0.001, respectively). The frequency of adequate DR was low regardless of the IAC diameter. Nonetheless, in terms of DR and IAC malfunction, a 22-gauge BD Angiocath Plus™ was more suitable for invasive blood pressure monitoring with Auto Transducer™ than a 20- or 24-gauge BD Angiocath Plus™. Registration Registry: ClinicalTrials.gov. Registration number: NCT03642756. Date of Registration: July 27, 2018.

Accuracy and precision of continuous non-invasive arterial pressure monitoring in critical care: A systematic review and meta-analysis.

OBJECTIVE: To summarize the evidence regarding the accuracy of continuous non-invasive arterial pressure measurements in adult critical care patients. RESEARCH METHODOLOGY: Medline, EMBASE, and CINAHL were searched for studies that included adult critical care patients reporting the agreement between continuous non-invasive and invasive arterial pressure measurements. The studies were selected and assessed for risk of bias using the Revised Quality Assessment of Diagnostic Accuracy Studies tool by two independent reviewers. The Grading of Recommendations, Assessment, Development and Evaluations approach was used. Pooled estimates of the mean bias and limits of agreement with outer 95% confidence intervals (termed population limits of agreement) were calculated. RESULTS: Population limits of agreement for systolic blood pressure were wide, spanning from -36.13 mmHg to 28.28 mmHg (18 studies; 785 participants). Accuracy of diastolic blood pressure measurements was highly inconsistent across studies, resulting in imprecise estimates for the population limits of agreement. Population limits of agreement for mean arterial pressure spanned from -39.96 mmHg to 44.36 mmHg (17 studies; 765 participants). The evidence was rated as very low-quality due to very serious concerns about heterogeneity and imprecision. CONCLUSION: Substantial differences in blood pressure were identified between measurements taken from continuous non-invasive and invasive monitoring devices. Clinicians should consider this broad range of uncertainty if using these devices to inform clinical decision-making in critical care.

Perioperative Continuous Noninvasive Arterial Pressure Monitoring for Neuroendovascular Interventions: Prospective Study for Evaluation of the Vascular Unloading Technique.

BACKGROUND: Blood pressure monitoring is crucial during neuroendovascular procedures. Intraoperative hemodynamic instability is associated with complications, which underscores the importance of continuous monitoring. Although direct measurement with an intra-arterial catheter is the gold standard for determining arterial pressure, it is costly, time-consuming, and associated with complications. The novel ClearSight system offers a noninvasive technique for monitoring arterial pressure via a finger cuff. This study compared noninvasive arterial pressure measurements with the gold standard method. METHODS: Simultaneous recording of noninvasive and invasive arterial pressure was performed in patients undergoing neuroendovascular interventions. Both techniques were compared employing linear regression, Lin's correlation coefficient, Bland-Altman, and error grid analysis. RESULTS: The study enrolled 24 consecutive patients. The concordance correlation coefficient between both methods was 0.3526 (95% confidence interval [0.3134, 0.3906]) for mean arterial pressure and 0.4680 (95% confidence interval [0.4353, 0.4995]) and for systolic arterial pressure. The mean (SD) of the differences was 0.81 (17.86) mm Hg (95% limits of agreement [-52.52, 54.14]) for mean arterial pressure and 5.38 (14.64) mm Hg (95% limits of agreement [-45.12, 56.08]) for systolic arterial pressure. Error grid analysis demonstrated that the majority of measurements lie in regions with no or low risk for patients (mean arterial pressure, 71.0% and 24.4%; systolic arterial pressure, 59.2% and 25.8%). CONCLUSIONS: The ClearSight system provided accurate measurements of arterial blood pressure compared with invasive methods and within safe clinical parameters. This method may serve as a safe and reliable alternative for invasive blood pressure monitoring during neuroendovascular procedures.

Ambulatory pulmonary artery pressure monitoring in advanced heart failure patients.

Heart failure (HF) is an emerging epidemic associate with significant morbidity, mortality, and health care expenditure. Although there were major advances in pharmacologic and device based therapies for the management of HF, mortality of this condition remains high. Accurate monitoring of HF patients for exacerbations is very important to reduce recurrent hospitalizations and its associated complications. With the failure of clinical signs, tele-monitoring, and laboratory bio-markers to function as early markers of HF exacerbations, more sophisticated techniques were sought to accurately predict the circulatory status in HF patients in order to execute timely pharmacological intervention to reduce frequent hospitalizations. CardioMEMSTM (St. Jude Medical, Inc., Saint Paul, Minnesota) is an implantable, wireless pulmonary arterial pressure (PAP) monitoring system which transmits the patient's continuous PAPs to the treating health care provider in the ambulatory setting. PAP-guided medical therapy modification has been shown to significantly reduce HF-related hospitalization and overall mortality. In advanced stages of HF, wireless access to hemodynamic information correlated with earlier left ventricular assist device implantation and shorter time to heart transplantation.

Specific characteristics of intracardiac hemodynamics and vegetative regulation in healthy young individuals with normal heart geometry and concentric remodeling of left ventricle.

OBJECTIVE: Introduction: Heart remodeling is a complex multifactor process determining the prognosis of the patient with any cardio-vascular pathology. There are convincing observations and conclusions in literature about the formation of concentric remodeling of LV prior to the appearance of any changes in AP [4, 5]. But until now there is no common point of view as to the factors involved in remodeling both the myocardium and the vessels, especially in the absence of the major known causative factor - arterial hypertension. From this perspective the study of relationship between cardiac and vascular remodeling as well as the factors involved in their development, especially in young individuals, is urgent. The aim of this work was a comparative study of characteristic features of intracardiac hemodynamics, daily profile of arterial pressure, daily ECG monitoring data and vegetative regulation in young apparently healthy individuals (18-44 years) with normal heart geometry and those with concentric remodeling of left ventricle. PATIENTS AND METHODS: Materials and Methods: Apparently healthy persons aged 18 to 42 years, mean age 25.3±0.6 years, were included in the study. There were 56 males (73.7%) and 20 females (26.36%). All participants of the study were divided into two equal groups consisting of 38 persons according to relative wall thickness (RWT) value of the left ventricle: the patients with RWT > 0.42 (concentric remodeling of left ventricle) and those with RWT ≤ 0.42 (normal geometry of left ventricle). RESULTS: Results and Conclusion: The analysis of obtained findings revealed comparatively larger sizes of left heart cavities, comparatively higher rate of AP morning rise and daily variability of predominantly systolic arterial pressure, decreased activity of parasympathetic nervous system, greater number of supraventricular premature beats mainly at night time as well as the signs of connective tissue dysplasia in the patients with concentric remodeling of left ventricle. More than half of young persons with concentric remodeling of left ventricle showed the signs of connective tissue heart dysplasia, namely prolapse of mitral valve and abnormal left ventricular chords. Those specific characteristics of heart structure, daily profile of arterial pressure and variability of cardiac rhythm can be considered the signs associated with concentric remodeling of left ventricle.

Continuous Right Radial Arterial Pressure Monitoring as a Guide to Dissection of a Thoracic Inlet Neurofibroma.

Excision of tumors in the thoracic inlet entail a risk of injury to subclavian vessels due to their close proximity. A right radial artery line can sensitively and continuously monitor the occurrence of right subclavian artery compression and warn the surgeon of its proximity and prevent injury. We describe a case of thoracic inlet tumor in a 12-year-old child, wherein the use of radial artery pressure monitoring guided the surgeon to separate the subclavian artery from the tumor to which it was adherent.

Study of agreement of aortic, radial and femoral blood pressures during aortic endografting.

PURPOSE: To estimate the agreement between radial or femoral, and ascending aortic invasive blood pressure values. PATIENTS AND METHODS: Prospective study on 32 patients who underwent an aortic endografting under general anesthesia. After deploying the prosthesis under controlled hypotension, a catheter was introduced in the aorta to measure the staged systolic (SAP), diastolic (DAP) and mean (MAP) arterial pressures, in particular at the level of ascending aorta and femoral artery. RESULTS: No differences were observed between SAP, DAP or MAP measured in the aorta versus femoral or radial arteries. A better agreement was observed between the aortic and femoral MAP (bias of 1mmHg, limits of agreement between: -8.8mmHg and +10.8mmHg) than between the aortic and the radial MAP (bias of 1.7mmHg, limits of agreement between: -14.1mmHg and +17.5mmHg). The comparison between radial and femoral MAP was not satisfying (bias of -4.7mmHg and limits of agreement between -19.1mmHg and +9.7mmHg). CONCLUSION: The femoral MAP is more accurate to predict value of the aortic MAP than the radial MAP in a hypotensive setting. The clinician should be aware of these discrepancies in conditions of hemodynamic impairment to optimize the treatment.

Comportamiento del fenómeno dipper en una comunidad / Behavior of dipper phenomenon in community

OBJETIVOS: describir el comportamiento del fenómeno dipper (caída de la presión nocturna entre 10-20 por ciento con respecto a la presión diurna), y su relación con otras variables, en una muestra representativa de la población adulta del consultorio 55-1 del reparto Flores, en el municipio Playa, Ciudad de la Habana. MÉTODOS: se midió la variabilidad de la presión arterial mediante la técnica de monitoreo ambulatorio de presión arterial. Se efectuó una investigación observacional, descriptiva y transversal, con una muestra de 120 pacientes, obtenida por muestreo aleatorio simple. Se procesaron los resultados mediante el paquete estadístico SSPS v 13. RESULTADOS: predominaron los casos de dipper con 53 por ciento, que coincide con los estudios publicados, los casos no dipper y dipper acentuado resultaron 38 y 9 por ciento respectivamente. Se determinó una relación estadísticamente significativa entre las cargas tensionales sistólicas y las diastólicas nocturnas con los casos no dipper. CONCLUSIONES: se encontró un porcentaje elevado (47 por ciento) de pacientes no dipper y dipper acentuado, que coincide con otras investigaciones realizadas por otros autores. Por su valor para predecir complicaciones cardiovasculares y cerebrovasculares, no solo en hipertensos sino en población general, se considera recomendable extender el estudio a la Atención Primaria de Salud(AU)

OBJECTIVES: to describe the behavior of dipper phenomenon (falling of nocturnal pressure between 10-20 percent regarding the diurnal pressure) and its relation to other variables in a representative sample of adult population from the 55-1 consulting room of the Flores parceling in the Playa municipality of Ciudad de La Habana. METHODS: variability of arterial pressure was measured by ambulatory monitoring technique. A observational, descriptive and cross-sectional research was carried out in a sample including 120 patients achieved by simple randomized sampling. The results were processed by a SSPS v 13 statistic package. RESULTS: there was predominance of dipper cases with a 53 percent coinciding with the results published and the non-dipper and marked dipper cases were of the 38 and the 9 percent, respectively. A significant statistic relation was determined among the nocturnal systolic and diastolic pressures charges with the non dipper cases. CONCLUSIONS: there was a high percentage (47 percent) of non dipper and marked dipper patients coinciding with other researchers performed by other authors. Due to its usefulness to predict the cardiovascular and cerebrovascular complications, not only in the hypertensive ones but in the general population, it is recommendable to extend the study to Primary Health Care(AU)

Comportamiento del fenómeno dipper en una comunidad / Behavior of dipper phenomenon in community

OBJETIVOS: describir el comportamiento del fenómeno dipper (caída de la presión nocturna entre 10-20 por ciento con respecto a la presión diurna), y su relación con otras variables, en una muestra representativa de la población adulta del consultorio 55-1 del reparto Flores, en el municipio Playa, Ciudad de la Habana. MÉTODOS: se midió la variabilidad de la presión arterial mediante la técnica de monitoreo ambulatorio de presión arterial. Se efectuó una investigación observacional, descriptiva y transversal, con una muestra de 120 pacientes, obtenida por muestreo aleatorio simple. Se procesaron los resultados mediante el paquete estadístico SSPS v 13. RESULTADOS: predominaron los casos de dipper con 53 por ciento, que coincide con los estudios publicados, los casos no dipper y dipper acentuado resultaron 38 y 9 por ciento respectivamente. Se determinó una relación estadísticamente significativa entre las cargas tensionales sistólicas y las diastólicas nocturnas con los casos no dipper. CONCLUSIONES: se encontró un porcentaje elevado (47 por ciento) de pacientes no dipper y dipper acentuado, que coincide con otras investigaciones realizadas por otros autores. Por su valor para predecir complicaciones cardiovasculares y cerebrovasculares, no solo en hipertensos sino en población general, se considera recomendable extender el estudio a la Atención Primaria de Salud

OBJECTIVES: to describe the behavior of dipper phenomenon (falling of nocturnal pressure between 10-20 percent regarding the diurnal pressure) and its relation to other variables in a representative sample of adult population from the 55-1 consulting room of the Flores parceling in the Playa municipality of Ciudad de La Habana. METHODS: variability of arterial pressure was measured by ambulatory monitoring technique. A observational, descriptive and cross-sectional research was carried out in a sample including 120 patients achieved by simple randomized sampling. The results were processed by a SSPS v 13 statistic package. RESULTS: there was predominance of dipper cases with a 53 percent coinciding with the results published and the non-dipper and marked dipper cases were of the 38 and the 9 percent, respectively. A significant statistic relation was determined among the nocturnal systolic and diastolic pressures charges with the non dipper cases. CONCLUSIONS: there was a high percentage (47 percent) of non dipper and marked dipper patients coinciding with other researchers performed by other authors. Due to its usefulness to predict the cardiovascular and cerebrovascular complications, not only in the hypertensive ones but in the general population, it is recommendable to extend the study to Primary Health Care