Linda Ordway

3D echocardiography to evaluate right atrial pressure in acutely decompensated heart failure correlation with invasive hemodynamics.

OBJECTIVES This study examined the utility of 3-dimensional right atrial volume index (3D-RAVi), combined with 2-dimensional echocardiographic (2DE) parameters, for the identification of elevated right atrial pressure (RAP) in patients with heart failure. BACKGROUND Accurate noninvasive determination of RAP is clinically important for the management of patients with heart failure. Although 2DE methods have been used to noninvasively estimate RAP, the accuracy of these parameters has limitations when estimating RAP in an individual patient. Three-dimensional echocardiography (3DE) provides tomographic imaging of right atrial volume that may be helpful in refining the noninvasive assessment of hemodynamics in patients with heart failure. METHODS 2DE and 3DE studies were examined in 40 initial patients who were admitted for acutely decompensated heart failure. Simultaneous pulmonary artery catheter monitoring was performed. The relationship between echocardiographic parameters and RAP was examined in this derivation group. The findings from the derivation group were then prospectively tested in a validation group of 40 additional patients. RESULTS Mean RAP was 11 ± 5 mm Hg (range 2 to 22 mm Hg). 3D-RAVi correlated with RAP (r = 0.51, p < 0.001), whereas 2-dimensional right atrial volume index did not. Inferior vena cava (IVC) diameter ≥2 cm and IVC respirophasic collapse <40% also correlated with RAP (p < 0.001 and p = 0.028, respectively). Based on receiver-operator characteristic curve analysis, 3D-RAVi ≥35 ml/m(2) was the optimal 3D-RAVi cutpoint for identifying RAP >10 mm Hg. The value of 3D-RAVi ≥35 ml/m(2), combined with IVC measures, for predicting RAP >10 mm Hg was prospectively tested in the validation group. 3D-RAVi ≥35 ml/m(2) in combination with IVC ≥2 cm had a high accuracy (88%) for identifying RAP >10 mm Hg and had a higher accuracy than the combination of IVC ≥2 cm and IVC collapse <40% (accuracy: 68%, p = 0.038). CONCLUSIONS In patients with heart failure, 3D-RAVi in conjunction with IVC parameters has a high accuracy for detection of elevated RAP. The addition of 3D-RAVi to 2DE methods may be helpful in the noninvasive estimation of right atrial pressure.

Bivalirudin for treatment of LVAD thrombosis: a case series.

Both platelet- and fibrin-rich thrombi have been described in patients with pump thrombosis associated with continuous flow left ventricular assist devices (LVADs). Bivalirudin is a direct thrombin inhibitor that also inhibits platelet adhesion. Compared to heparin, this hirudin analog is less immunogenic, binds to both free- and clot-bound fibrin, and has a lower risk of major bleeding. In a recently published algorithm on the step-wise approach to the diagnosis and management of LVAD thrombosis, direct thrombin inhibitors were included as a treatment option in the setting of persistent hemolysis, power spikes, and heart failure symptoms. Evidence to support the use of a direct thrombin inhibitor for LVAD thrombosis is limited and anecdotal. We describe the first case series to date of the use of bivalirudin as an alternative to heparin in six hemodynamically stable patients with a total of ten hospitalizations for HeartMate II LVAD thrombosis.

A Cost-Saving Strategy for Inpatient Management of Advanced Decompensated Heart Failure Patients: The Cardiomyopathy Unit

BACKGROUND This article analyzes the relative costs and revenues of the Tufts Medical Center Cardiomyopathy Unit (CMU), a recent innovation for grouping and managing advanced decompensated heart failure patients. METHODS AND RESULTS We selected a retrospective sample of all patients with the primary diagnosis of heart failure, primary procedure of pulmonary artery catheterization, and with no other hospitalization procedures, admitted to Tufts Medical Center between 2000 and 2006. Regression models were used to estimate the cost for the intervention group and controls. Propensity analysis was used to test for selection bias in the comparison groups. We identified 114 hospitalizations meeting these criteria. Patients in the CMU group were well-balanced compared with controls with respect to demographic and clinical variables. Estimated direct medical costs for CMU and control groups were

Right Ventricular Dysfunction is an Independent Predictor of Length of Stay Following Left Ventricular Assist Device Implantation

11,817 (95% CI

Evaluation of Tolvaptan Use in the Advanced Heart Failure Population

7678-

Treatment of LVAD Thrombus: Experience with a Bivalirudin Dosing Protocol

16,106) and

Five-Year Experience with Pulmonary Artery Catheters in an Intermediate Care Environment: Utilization and Infection Rates

17,236 (95% CI

Abstract 4726: How Reliable is Left Atrial Volume in Estimating Left Atrial Pressure in Advanced Heart Failure Patients? Three-Dimensional Echocardiographic and Catheterization Studies

11,199-

Abstract 2846: Pulsed and Tissue Doppler Indices of Left Atrial Pressure Revisited: Doppler-Catheterization Correlative Studies Demonstrate Their Futility in Advanced Heart Failure Patients

23,493), respectively. A similar pattern of cost differentials was displayed among propensity-matched sample groups. Net revenue was

A Cost Saving Strategy for Hemodynamic Monitoring of Heart Failure Patients: The Cardiomyopathy Unit

12,609 (95% CI