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Background: Myocardial perfusion is an important determinant of cardiac function. We hypothesized that low coronary perfusion pressure (CPP) would be associated with adverse outcomes in heart failure. Myocardial perfusion impacts the contractile efficiency thus a low CPP would signal low myocardial perfusion in the face of increased cardiac demand as a result of volume overload ., Methods: We analyzed patients with complete hemodynamic data in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness trial using Cox Proportional Hazards regression for the primary outcome of the composite risk of death, heart transplantation, or left ventricular assist device [(LVAD). DT × LVAD] and the secondary outcome of the composite risk of DT × LVAD and heart failure hospitalization (DT × LVADHF). CPP was calculated as the difference between diastolic blood pressure and pulmonary artery wedge pressure. Heart failure categories (ischemic vs non-ischemic) were also stratified based on CPP strata., Results: The 158 patients (56.7 ± 13.6 years, 28.5% female) studied had a median CPP of 40 mmHg (IQR 35-52 mmHg). During 6 months of follow-up, 35 (22.2%) had the composite primary outcome and 109 (69.0%) had the composite secondary outcome. When these outcomes were then stratified based on the median, CPP was associated with these outcomes. Increasing CPP was associated with lower risk of both the primary outcome of DT × LVAD (HR 0.96, 95% CI 0.94-0.99 p = .002) and as well as the secondary outcome of DT × LVADHF ( p = .0008) There was significant interaction between CPP and ischemic etiology ( p = .04)., Conclusion: A low coronary artery perfusion pressure below (median) 40mmHg in patients with advanced heart failure undergoing invasive hemodynamic monitoring with a pulmonary artery catheter was associated with adverse outcomes. CPP could useful in guiding risk stratification of advanced heart failure patients and timely evaluation of advanced heart failure therapies., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ventriculo-arterial (VA) coupling has been shown to have physiologic importance in heart failure (HF). We hypothesized that the systemic arterial pulsatility index (SAPi), a measure that integrates pulse pressure and a proxy for left ventricular end-diastolic pressure, would be associated with adverse outcomes in advanced HF. We evaluated the SAPi ([systemic systolic blood pressure-systemic diastolic blood pressure]/pulmonary artery wedge pressure) obtained from the final hemodynamic measurement in patients randomized to therapy guided by a pulmonary arterial catheter (PAC) and with complete data in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial. Cox proportional hazards regression was performed for the outcomes of (a) death, transplant, left ventricular assist device (DTxLVAD) or hospitalization, (DTxLVADHF) and (b) DTxLVAD. Among 142 patients (mean age 56.8 ± 13.3 years, 30.3% female), the median SAPi was 2.57 (IQR 1.63-3.45). Increasing SAPi was associated with significant reductions in DTxLVAD (HR 0.60 per unit increase in SAPi, 95% CI 0.44-0.84) and DTxLVADHF (HR 0.81 per unit increase, 95% CI 0.70-0.95). Patients with a SAPi ≤ 2.57 had a marked increase in both outcomes, including more than twice the risk of DTxLVAD (HR 2.19, 95% CI 1.11-4.30) over 6 months. Among advanced heart failure patients with invasive hemodynamic monitoring in the ESCAPE trial, SAPi was strongly associated with adverse clinical outcomes. These findings support further investigation of the SAPi to guide treatment and prognosis in HF undergoing invasive hemodynamic monitoring., (© 2022. Springer Japan KK, part of Springer Nature.)

Background: Structural remodeling in chronic systolic heart failure (HF) is associated with neurohormonal and hemodynamic perturbations among HF patients presenting with cardiogenic shock (CS) and HF. Our objective was to test the hypothesis was that atrial remodeling marked by an increased right atrial volume index (RAVI) to left atrial volume index (LAVI) ratio is associated with adverse clinical outcomes in CS., Methods: Patients in this cohort were admitted to the intensive care unit with evidence of congestion (pulmonary capillary wedge pressure > 15) and cardiogenic shock (cardiac index < 2.2, systolic blood pressure < 90 mmHg, and clinical evidence supporting CS) and had an echocardiogram at the time of admission. RAVI was measured using Simpson's method in the apical four-chamber view, while LAVI was measured using the biplane disc summation method in the four and two-chamber views by two independent observers. Cox proportional hazards regression analysis was used to assess the association of RAVI-LAVI with the combined outcome of death or left ventricular assist device (LVAD)., Results: Among 113 patients (mean age 59 ± 14.9 years, 29.2% female), median RAVI/LAVI was 0.84. During a median follow-up of 12 months, 43 patients died, and 65 patients had the combined outcomes of death or LVAD. Patients with RAVI/LAVI ratio above the median had a greater incidence of death or LVAD (Log-rank p ≤ 0.001), and increasing RAVI/LAVI was significantly associated with the outcomes of death or LVAD (HR 1.71 95% CI 1.11-2.64, chi square 5.91, p = 0.010) even after adjustment for patient characteristics, echocardiographic and hemodynamic variables., Conclusion: RAVI/LAVI is an easily assessed novel echocardiographic parameter strongly associated with the survival and or the need for mechanical circulatory support in patients with CS., (© 2021. Japanese Society of Echocardiography.)

Background: Pulmonary artery proportional pulse pressure (PAPP) was recently shown to have prognostic value in heart failure (HF) with reduced ejection fraction (HFrEF) and pulmonary hypertension. We tested the hypothesis that PAPP would be predictive of adverse outcomes in patients with implantable pulmonary artery pressure monitor (CardioMEMS™ HF System, St. Jude Medical [now Abbott], Atlanta, GA, USA)., Methods: Survival analysis with Cox proportional hazards regression was used to evaluate all-cause deaths and HF hospitalisation (HFH) in CHAMPION trial 1 patients who received treatment with the CardioMEMS device based on the PAPP., Results: Among 550 randomised patients, 274 had PAPP ≤ the median value of 0.583 while 276 had PAPP>0.583. Patients with PAPP≤0.583 (versus PAPP>0.583) had an increased risk of HFH (HR 1.40, 95% CI 1.16-1.68, p=0.0004) and experienced a significant 46% reduction in annualised risk of death with CardioMEMS treatment (HR 0.54, 95% CI 0.31-0.92) during 2-3 years of follow-up. This survival benefit was attributable to the treatment benefit in patients with HFrEF and PAPP≤0.583 (HR 0.50, 95% CI 0.28-0.90, p<0.05). Patients with PAPP>0.583 or HF with preserved EF (HFpEF) had no significant survival benefit with treatment (p>0.05)., Conclusion: Lower PAPP in HFrEF patients with CardioMEMS constitutes a higher mortality risk status. More studies are needed to understand clinical applications of PAPP in implantable pulmonary artery pressure monitors., (Copyright © 2021 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Objectives: To compare the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) risk score with the established Society of Thoracic Surgeons (STS) and EuroSCORE II risk prediction models regarding mortality discrimination after aortic and mitral valve surgery., Design: Retrospective cohort study., Setting: Single tertiary academic medical center., Participants: A total of 259 patients who underwent open aortic valve replacement or open mitral valve repair/replacement from 2009-2014., Interventions: Retrospective chart review., Measurements and Main Results: MAGGIC, STS, and EuroSCORE II risk scores for each patient were studied using binary logistic regression and receiver operating characteristic analysis for the primary endpoint of one-year mortality and secondary endpoint of 30-day mortality. One-year mortality C-statistics were similar across risk scores (STS 0.709, 95% confidence interval [CI] 0.578-0.841; MAGGIC 0.673, 95% CI 0.547-0.799; EuroSCORE II 0.642, 95% CI 0.521-0.762; p = 0.56 between STS and MAGGIC; p = 0.20 between STS and EuroSCORE II; and p = 0.69 between MAGGIC and EuroSCORE II). Thirty-day mortality C-statistics also were similar between STS (0.797, 95% CI 0.655-0.939; p < 0.0001 v null hypothesis), MAGGIC (0.721, 95% CI 0.581-0.860; p = 0.33 v STS), and EuroSCORE II (0.688, 95% CI 0.557-0.818; p = 0.06 v STS; p = 0.68 v MAGGIC)., Conclusions: The MAGGIC risk score performs similarly to STS and EuroSCORE II risk models in mortality discrimination after aortic and mitral valve surgery, albeit in a small sample size. This finding has important implications in establishing MAGGIC as a viable prognostic model in this population subset, with fewer variables and ease of use representing key advantages over STS and EuroSCORE II., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose of Review: This review highlights variability in prescribing of nonpharmacologic heart failure with reduced ejection fraction (HFrEF) therapies by race, ethnicity, and gender. The review also explores the evidence underlying these inequalities as well as potential mitigation strategies., Recent Findings: There have been major advances in HF therapies that have led to improved overall survival of HF patients. However, racial and ethnic groups of color and women have not received equitable access to these therapies. Patients of color and women are less likely to receive nonpharmacologic therapies for HFrEF than White patients and men. Therapies including exercise rehabilitation, percutaneous transcatheter mitral valve repair, cardiac resynchronization therapy, heart transplant, and ventricular assist devices all have proven efficacy in patients of color and women but remain underprescribed. Outcomes with most nonpharmacologic therapy are similar or better among patients of color and women than White patients and men. System-level changes are urgently needed to achieve equity in access to nonpharmacologic HFrEF therapies by race, ethnicity, and gender.