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Background and Objective: Rapid saline infusion and exercise has been proposed as methods to unmask cardiovascular disease. However, the normal hemodynamic response to rapid saline infusion has not been compared to exercise nor is it known whether the responses are age-dependent.We assessed the hemodynamic response to rapid saline infusion in healthy participants over a wide age-range and compared it to exercise in the same participants.Methods and Results: Fifty healthy participants (young <40 years, n = 16, middle-aged 40-59 years, n = 15, elderly 60-80 years, n = 19) underwent right heart catheterization at rest, during semisupine ergometer exercise at three exercise levels (25%, 50%, and 75% of peak VO2) and after rapid saline infusion (10 ml/kg at a rate of 150 ml/min). Rapid saline infusion significantly increased pulmonary capillary wedge pressure (PCWP) similarly across all age groups (∆PCWP 6 ± 2; 7 ± 2; 6 ± 4 mmHg for the young, middle-aged and elderly respectively) with no correlation between age and ∆PCWP (r = 0.05; p = 0.74). However, there was a negative correlation between age and ∆stroke volume (SV) as elderly participants had a lower increase in SV following rapid saline infusion (r = 0.44; p = 0.002). On the contrary, exercise-induced significantly larger and age-dependent increases in PCWP (r = 0.58; p < 0.0001). Exercise also caused a larger increase in SV compared with rapid fluid loading (p = 0.0003) CONCLUSION: Unlike exercise, rapid saline infusion caused an age-independent increase in PCWP in healthy adults. Suggesting that age-related impairments beyond passive stiffness have a greater impact on exercise-induced increase in PCWP.Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT01974557. [ABSTRACT FROM AUTHOR]

Assessment of right ventricular (RV) function is crucial since RV failure with a reduced cardiac output is associated with compromised outcome in cardiac surgery. Echocardiographic evaluation of RV function is commonly used, and a reduction in tricuspid annular plane systolic excursion (TAPSE) and tricuspid annulus tissue Doppler imaging (S') have been observed independently of clinical signs of RV failure. This has led to uncertainty of these variables' ability to reflect RV function in cardiac surgery [1]. The objective of this study was to describe changes in transoesophageal echocardiographic (TEE) measurements of TAPSE and S' during coronary artery bypass graft (CABG) surgery with detailed haemodynamic monitoring using pulmonary artery catheter (PAC) assessment of RV output in patients undergoing uncomplicated CABG without RV impairment. We prospectively studied 30 patients with concomitant PAC and TEE measurements at four time-points, namely after: anaesthesia induction, sternotomy, cardiopulmonary bypass (CPB) and upon arrival in the intensive care unit (ICU). TAPSE and S' were significantly reduced by 43% (p<.0001) and 22% (p =.006), respectively after CPB without any change in stroke volume (SV). RV ejection fraction (RVEF), RV fractional area change (RVFAC) and global longitudinal strain (RV-GLS) remained unchanged. SV measured with 3D echocardiography correlated with PAC measured SV (r =.66[95% CI.50;.78], p<.0001), but 3D showed a minor, but statistically significant underestimation of SV (8.5 ml (95% CI: 2.7 ml; 14 ml, p =.004). TAPSE and S' were both reduced after CPB despite maintained cardiac output. RVFAC, RVEF and RV-GLS remained stable, however, these measures were unable to detect minor changes in SV. 3D-echocardiography showed a strong correlation with SV measured by thermodilution, but with a consistent underestimation of approximately 10%. Our results suggest that 3D echocardiography is better at tracking RV output than other echocardiographic modalities, however, the clinician should be aware that 3D echocardiography underestimates SV compared to thermodilution. [ABSTRACT FROM AUTHOR]

Critical care following cardiac surgery is a complex task including both cardiac and pulmonary management strategies because optimal postoperative care is essential for outcome [1]. The effect of such interventions on right ventricular (RV) function has not been sufficiently explored. The aim of this study was to investigate what effect ICU interventions have on RV function. Thirty patients were studied in the ICU following coronary artery bypass graft surgery. Transoesophageal echocardiography (TEE) and a pulmonary artery catheter (PAC) were used to assess hemodynamic variables and echocardiographic measures of RV function. TEE evaluation included RV fractional area change, 3D RV ejection fraction, 3D RV stroke volume and RV global longitudinal strain (RV-GLS). Interventions were done separately and included: Trendelenburg position, PEEP 0, 5 and 10 cm H2O, increased oxygen fraction (100%), and AAI, DDD and VVI pacing. Trendelenburg increased global echocardiographic measures of RV function as well as CO 0.44L*min-1 [95%CI: 0.21;0.67] due to an increased stroke volume (SV). Increasing PEEP from 0 to 10 reduced SV and consequently CO by 0.41L*min-1. Pulmonary vascular resistance (PVR) was not significantly changed by different PEEP levels. AAI or DDD pacing at a heart rate 15 beats above baseline increased CO 0.35L*min-1 [95%CI 0.07;0.63]. In contrast VVI pacing decreased CO by 24% (1.2L*min-1 [95%CI 0.9;1.6]). VVI reduced all RV echocardiographic variables. Applying 100% O2 did not affect PVR or haemodynamic state but RV-GLS was significantly improved -4.4% [95%CI: -6.9; -1.9]. In patients with normal RV function undergoing CABG several routine interventions in the ICU affects RV function significantly, in particular PEEP and VVI pacing which induces clinically important reductions in SV. [ABSTRACT FROM AUTHOR]

BACKGROUND: Copeptin, a stable fragment of the vasopressin prohormone, has been shown to be a significant biomarker for morbidity and mortality in heart failure. The aims of this study were to evaluate the influence of plasma sodium on the prognostic significance of copeptin concentrations in heart failure outpatients and to determine whether increased copeptin concentrations predict future development of hyponatremia. METHODS AND RESULTS: A total of 340 heart failure patients with left ventricular systolic dysfunction were followed for 55 months (median) in a Danish heart failure clinic. A baseline measurement of plasma copeptin, N-terminal pro-B-type natriuretic peptide (NT-proBNP), and sodium was performed, and the sodium concentrations were recorded during 3 months after the baseline visit in the heart failure clinic. Patients were divided into 3 groups according to copeptin tertiles. In multivariate Cox proportional hazard models adjusted for confounders, including plasma sodium, loop diuretic dose, and NT-proBNP, copeptin was a significant predictor of hospitalization or death (hazard ratio 1.4, 95% confidence interval 1.1-1.9; P < .019) but did not predict mortality independently from NT-proBNP. Additionally, copeptin concentrations did not predict future development of hyponatremia. CONCLUSIONS: Plasma copeptin levels predict mortality in outpatients with chronic heart failure independently from clinical variables, plasma sodium, and loop diuretic doses. Furthermore, copeptin predicts the combined end point of hospitalization or death independently from NT-proBNP. [ABSTRACT FROM AUTHOR]