Prognostic implications of echocardiographic and hemodynamic profiles in cirrhosis and high-output heart failure

Prognostic significance of left atrial reservoir strain during exercise in patients with heart failure

Background This study aimed to evaluate the association of peak exercise left atrial (LA) reservoir strain with clinical outcomes in patients with heart failure (HF), and the prognostic value across HF phenotypes. Methods We enrolled 150 patients with HF (age 67 ± 15 years, 61% males) who underwent exercise stress echocardiography. LA reservoir strain at rest and peak workload were evaluated using the speckle-tracking echocardiography. The endpoint was a composite of cardiovascular death or hospitalization for HF. Results During a median follow-up of 1.1 years (interquartile range 0.7–2.4 years), 49 patients experienced events. Patients were categorized into two groups on the basis of the median value of LA reservoir strain at peak workload of 16.7%. Kaplan–Meier curves showed that patients with low LA reservoir strain at peak workload had a higher event rate than those with high LA reservoir strain (log-rank test, P < 0.001). LA reservoir strain at peak workload was independently associated with events (hazard ratio: 5.57, 95% confidence intervals: 2.74–11.3, P < 0.001), and provided the incremental prognostic value over clinical factors. When analyzed according to HF phenotype, LA reservoir strain at peak workload was significantly associated with events in both patients with HFpEF and those with HFrEF, with a significant interaction between HF phenotype and LA reservoir strain at peak workload. Conclusion LA reservoir strain at peak workload has prognostic value for adverse outcomes in both HFpEF and HFrEF.

Urinary sodium and right ventricular function in acute heart failure.

Ambulatory low cardiac output state in heart failure: characteristics and outcomes

Abstract Introduction Ambulatory low cardiac output state (LCOS) is a known but poorly described heart failure (HF) phenotype. We aimed to investigate the prevalence, clinical markers, and prognostic importance of ambulatory LCOS. Methods Consecutive ambulatory patients with HF and reduced left ventricular ejection fraction referred for advanced HF assessment were included. All patients underwent right heart catheterization. Patients with LCOS defined as a cardiac index <1.8 L/min/m2 were compared to patients without LCOS. Results In total, 618 patients were included. The mean ± SD age was 52.5 ± 12.5 years, and 78% were male. Low cardiac output state was present in 116 patients (19% [95% CI 16 to 22%]). Patients with LCOS presented with more advanced symptoms, lower systolic blood pressure and LVEF, higher N-terminal pro-B-type natriuretic peptide levels, and were less likely to receive treatment with renin-angiotensin system inhibitors (RASi) compared with patients without LCOS. Absence of RASi therapy was strongly associated with LCOS, odds ratio 2.34 [95% CI 1.44 to 3.74], P < .001. While liver function markers were more elevated in patients with LCOS, renal function was similar between groups. Over a median follow-up of five years, LCOS was independently associated with mortality, hazard ratio 1.86 [95% 1.32 to 2.62], P < .001 (adjusted for age, sex, and advanced therapy). Conclusion LCOS was observed in 19% of ambulatory patients and was strongly associated with mortality, independent of left-sided filling pressures and advanced therapies. Among other factors, the absence of RASi therapy was highly predictive of LCOS.

Frequency and Echocardiographic Correlates of Right Ventricular Dysfunction in Patients With Old Myocardial Infarction and Reduced Ejection Fraction

Background: Old myocardial infarction (MI) with reduced left ventricular ejection fraction (LVEF) is a major cause of cardiovascular morbidity and mortality, particularly in low- and middle-income countries. While left ventricular dysfunction has been extensively studied, right ventricular (RV) involvement remains underappreciated despite evidence of its prognostic relevance in other cohorts. This study aimed to determine the frequency of RV dysfunction and its echocardiographic correlates in patients with old MI and reduced LVEF. Methods: This was a single-centre, hospital-based, observational cross-sectional study conducted over 12 months (April 2021-March 2022) in the Department of Cardiology, Bangladesh Medical University (formerly Bangabandhu Sheikh Mujib Medical University), Dhaka, Bangladesh, following ethical approval. Adults aged >30 years with old MI documented by objective criteria, occurring more than three months before enrolment, and LVEF <40% were recruited by consecutive sampling from inpatient and outpatient services. The primary outcome was the frequency of RV dysfunction, defined a priori for each index as tricuspid annular plane systolic excursion (TAPSE) <17 mm, tricuspid annular systolic velocity (S′) <10 cm/s, RV fractional area change (FAC) <35%, myocardial performance index (MPI) ≥0.55, isovolumic relaxation time (IVRT) >30 ms, isovolumic acceleration (IVA) <1.1 m/s², RV global longitudinal strain (RVGLS) less negative than −17%, and RV free wall strain (RVFWS) less negative than −20%. The secondary outcome was the association between elevated pulmonary artery systolic pressure (PASP >35 mmHg) and each abnormal RV index. Binary logistic regression was performed with each RV index modelled separately as the dependent variable. Results: Of 195 patients screened, 85 were analysed (mean age 59.9 ± 8.1 years; 81.2% male; mean LVEF 32.1 ± 4.1%). Reduced TAPSE and S′ were each present in 62.4%, reduced FAC in 56.5%, elevated MPI in 55.3%, prolonged IVRT in 57.6%, and reduced IVA in 31.8%. Impaired RVGLS and RVFWS were observed in 76.5% and 71.8%, respectively. PASP >35 mmHg was detected in 38.8% and was associated with abnormal S′ (OR 6.39; 95% CI 1.11-36.73; p = 0.038) and prolonged IVRT (OR 8.79; 95% CI 1.72-44.93; p = 0.009). Regional RV wall motion abnormality was not associated with any RV functional index. Conclusion: RV dysfunction is highly prevalent in patients with old MI and reduced LVEF. Abnormality was most frequent for strain-based indices, particularly RVGLS; however, no comparative discrimination or reclassification analysis was performed, so relative diagnostic performance against conventional indices cannot be inferred from these data. Comprehensive RV assessment should be considered in this high-risk population.

Prognostic Value of the HFpEF-ABA Score Among Patients Undergoing Transcatheter Aortic Valve Implantation.

BACKGROUND Aortic stenosis (AS) and heart failure with preserved ejection fraction (HFpEF) share common pathophysiologic features and comorbidities and often co-exist, but their combined prognostic impact is unclear. We aimed to assess HFpEF probability among patients with AS undergoing transcatheter aortic valve implantation (TAVI) and evaluate its impact on clinical presentation and outcomes. METHOD In this retrospective cohort study, consecutive patients with severe AS and preserved left ventricular EF undergoing TAVI were stratified into low (<25%), intermediate (25%-74%) and high (≥75%) HFpEF probability groups using the HFpEF-ABA score (incorporating age, body mass index, and atrial fibrillation history). Demographics, echocardiographic parameters, functional status, quality of life, and outcomes were compared. RESULTS Among 2,175 patients (median age 82 years; interquartile range 78-86; 44.7% female), 2 (0.1%) had low, 735 (36.1%) intermediate, and 1,388 (63.8%) high HFpEF probability. Patients with high HFpEF probability were older, had more typical HFpEF-related comorbidities, and exhibited poorer quality of life, more severe dyspnoea, and increased cardiac remodelling (higher left ventricular mass and dimensions, pulmonary hypertension, and mitral regurgitation), despite less severe traditional markers of AS. Post-TAVI, both groups had similar improvements in valve haemodynamics, and there was no significant difference in the primary composite end point of 12-month HF hospitalisation or mortality between the high and low-intermediate probability groups (odds ratio 1.32; 95% confidence interval 0.92-1.88; p=0.13). However, high HFpEF probability was associated with increased permanent pacemaker implantation, worse post-TAVI functional status, lower quality of life, and a greater risk of 12-month HF hospitalisation. CONCLUSIONS The HFpEF-ABA score identifies a high-risk phenotype of AS patients undergoing TAVI, characterised by adverse cardiac remodelling, poorer functional status, and increased post-TAVI complications. Further studies are required to determine whether HFpEF-specific therapies would benefit this population.

Clinical Significance of Echocardiographic Parameters in Patients with Pulmonary Hypertension Associated with Interstitial Lung Disease

Background: Pulmonary hypertension (PH)-complicating interstitial lung disease (ILD) is a devastating condition that severely limits exercise capacity, diminishes quality of life (QOL), and ultimately determines survival. The pathophysiological assessment of ILD-PH has traditionally focused on right ventricular (RV) parameters reflecting RV pressure overload and dysfunction. However, under extreme RV pressure overload where blood supply to the left heart is severely restricted, the prognostic role of left ventricular (LV) function—which is ultimately responsible for maintaining systemic cardiac output—remains poorly understood. This study aimed to comprehensively evaluate the hemodynamics of ILD patients using non-invasive transthoracic echocardiography, to determine the prognostic importance of LV functional parameters, particularly left ventricular ejection fraction (LVEF). Methods: This single-center, retrospective, observational study included 415 ILD patients diagnosed and treated at the Kanagawa Cardiovascular Respiratory Center. All patients underwent transthoracic echocardiography at diagnosis, from which parameters such as estimated right ventricular systolic pressure (RVSP), tissue Doppler-derived Average e’, and LVEF were obtained. A multivariable Cox proportional hazards model was applied to evaluate the association between these echocardiographic parameters and all-cause mortality. To account for the prognostic impact of the underlying disease, we conducted a stratified analysis of idiopathic pulmonary fibrosis (IPF) and non-IPF cohorts. Furthermore, to evaluate LV function under the most severe hemodynamic compromise, a subgroup analysis was restricted to IPF patients with elevated RVSP (≥median). Results: During a median follow-up of 27.2 months, 75 (18.1%) of the 415 patients died. In the multivariable Cox analysis of the overall cohort, a decreased Average e’ (HR 0.861, p = 0.0038) emerged as a strong independent predictor of poor prognosis. Stratified analysis revealed that in the non-IPF group (n = 208, 15 events), none of the variables achieved statistical significance. Conversely, in the IPF group (N = 207, 60 events), both LV diastolic function (Average e’, p = 0.0199) and LV systolic function (LVEF, HR 0.969, 95% CI 0.940–0.998, p = 0.0305) were extracted as significant prognostic predictors. Most notably, in the stepwise multivariable model restricted to the “IPF with high RVSP” subgroup (N = 104), the prognostic significance of diastolic function (Average e’) was lost (p = 0.4577), whereas LVEF (HR 0.965, 95% CI 0.936–0.995, p = 0.0229) emerged as the sole independent predictor of mortality. Conclusions: In the overall ILD-PH cohort, reduced LV diastolic function (Average e’) is a strong independent predictor of mortality. While elevated RVSP and low BMI showed a trend toward worsening prognosis, they were not statistically significant in multivariable analysis. The prognostic contribution of LV function is primarily driven by the IPF patient group, which has an inherently poor prognosis. Furthermore, in the severe subgroup of IPF patients heavily burdened by right heart overload, LV pump function (LVEF) becomes an independent, critical determinant of ultimate survival. Therefore, routine measurement and careful monitoring of the universal parameter LVEF are of paramount importance for the risk stratification of high-risk patients under such complex hemodynamics.