Characterizing the Blood Pressure Response to Physical Counterpressure Manoeuvres Using Surface Electromyography in Adults With Long Covid

Orthostatic intolerance (OI) is common in Long Covid. Physical counterpressure manoeuvres (PCM) may improve OI in other disorders. We characterised the blood pressure-rising effect of PCM using surface electromyography (sEMG) and investigated its association with fatigue in adults with Long Covid. Participants performed an active stand with beat-to-beat hemodynamic monitoring and sEMG of both thighs, including PCM at 3-minutes post-stand. Multivariable linear regression investigated the association between change in systolic blood pressure (SBP) and change in normalised root mean square (RMS) of sEMG amplitude, controlling for confounders including the Chalder Fatigue Scale (CFQ). In 90 participants (mean age 46), mean SBP rise with PCM was 13.7 (SD 9.0) mmHg. In regression, SBP change was significantly, directly associated with change in RMS sEMG ( 0.25 , 95% CI 0.07-0.43, P = 0.007);however, CFQ was not significant. PCM measured by sEMG augmented SBP without the influence of fatigue. Copyright © 2013 IEEE.

Acute kidney injury in COVID 19 - an update on pathophysiology and management modalities.

Acute kidney injury (AKI), characterised by fluid imbalance and overload, is prevalent in severe disease phenotypes of coronavirus disease 2019 (COVID-19). The elderly immunocompromised patients with pre-existing comorbidities being more risk-prone to severe COVID-19, the importance of early diagnosis and intervention in AKI is imperative. Histopathological examination of COVID-19 patients with AKI reveals viral invasion of the renal parenchyma and evidence of AKI. The definitive treatment for AKI includes renal replacement therapy and renal transplant. Immunosuppressant regimens and its interactions with COVID-19 have to be further explored to devise effective treatment strategies in COVID-19 transplant patients. Other supportive strategies for AKI patients include hemodynamic monitoring and maintenance of fluid balance. Antiviral drugs should be meticulously monitored in the management of these high-risk patients. We have focussed on the development of renal injury provoked by the SARS-CoV-2, the varying clinical characteristics, and employment of different management strategies, including renal replacement therapy, alongside the emerging cytokine lowering approaches.

Hemodynamic-Guided Heart Failure Management in Patients With Either Prior HF Hospitalization or Elevated Natriuretic Peptides.

BACKGROUND: In patients with symptomatic heart failure (HF) and previous heart failure hospitalization (HFH), hemodynamic-guided HF management using a wireless pulmonary artery pressure (PAP) sensor reduces HFH, but it is unclear whether these benefits extend to patients who have not been recently hospitalized but remain at risk because of elevated natriuretic peptides (NPs). OBJECTIVES: This study assessed the efficacy and safety of hemodynamic-guided HF management in patients with elevated NPs but no recent HFH. METHODS: In the GUIDE-HF (Hemodynamic-Guided Management of Heart Failure) trial, 1,000 patients with New York Heart Association (NYHA) functional class II to IV HF and either previous HFH or elevated NP levels were randomly assigned to hemodynamic-guided HF management or usual care. The authors evaluated the primary study composite of all-cause mortality and total HF events at 12 months according to treatment assignment and enrollment stratum (HFH vs elevated NPs) by using Cox proportional hazards models. RESULTS: Of 999 evaluable patients, 557 were enrolled on the basis of a previous HFH and 442 on the basis of elevated NPs alone. Those patients enrolled by NP criteria were older and more commonly White persons with lower body mass index, lower NYHA class, less diabetes, more atrial fibrillation, and lower baseline PAP. Event rates were lower among those patients in the NP group for both the full follow-up (40.9 per 100 patient-years vs 82.0 per 100 patient-years) and the pre-COVID-19 analysis (43.6 per 100 patient-years vs 88.0 per 100 patient-years). The effects of hemodynamic monitoring were consistent across enrollment strata for the primary endpoint over the full study duration (interaction P = 0.71) and the pre-COVID-19 analysis (interaction P = 0.58). CONCLUSIONS: Consistent effects of hemodynamic-guided HF management across enrollment strata in GUIDE-HF support consideration of hemodynamic monitoring in the expanded group of patients with chronic HF and elevated NPs without recent HFH. (Hemodynamic-Guided Management of Heart Failure [GUIDE-HF]; NCT03387813).

Spontaneous Hemorrhage in Severe Forms of Covid 19 Infections

Background: This research paper is an expression of a desire to view COVID 19 from the perspective of a spontaneous hemorrhage induced on different organ systems. Introduction of a stratified approach to the problem of hemorrhage has become an im-perative in medical treatment. Aim(s): To determine the real figure of spontaneous hemorrhage cases in severe forms of infections caused by Covid 19. Material(s) and Method(s): The research included 745 patients that suffered from severe forms of infections caused by Covid 19 who were treated in a Respiratory clinic in Tuzla University Clinical Center during 2020 and 2021. The spontaneous hemorrhage was determined on the grounds of laboratory parameters of blood counts and CRP, hemo-dynamic monitoring of TA and pulse, and CT imagining diagnostic technique. Result(s): The study presents information about the medical treatment outcome in the case of 5 patients (0,67%) who experienced spontaneous hemorrhage as a part of Covid 19 infection in relation to the total number of 745 patients who were treated during that period in the Respiratory clinic as Covid patients with severe forms of infection. Out of 5 patients who acquired spontaneous hemorrhage 3 were operated. For 4 patients the outcome was lethal. One of the female patients who was in the group of those who were not operated and who had undergone a conservative treatment has survived. In our group of analyzed patients two patients suffered from the hematoma of the front abdominal wall, two had retroperitoneal hematoma and one patient acquired hemorrhage in the abdomen and thoracic with the developing DIC. Conclusion(s): Relatively low percentage of cases developing spontaneous hemorrhage 5 (0, 67%) but relatively high mortality rate in the cases where it did occur, 4 out of 5 monitored patients, requires certain suggestions that are being presented in this study as to how to approach the cases of spontaneous hemorrhage in the severe forms of Covid 19 infections in more consistent manner in order to improve the outcome of the medical treatment of these cases.Copyright © 2012, University Clinical Center Tuzla. All rights reserved.

Spontaneous Hemorrhage in Severe Forms of Covid 19 Infections

Background: This research paper is an expression of a desire to view COVID 19 from the perspective of a spontaneous hemorrhage induced on different organ systems. Introduction of a stratified approach to the problem of hemorrhage has become an imperative in medical treatment. Aim(s): To determine the real figure of spontaneous hemorrhage cases in severe forms of infections caused by Covid 19. Material(s) and Method(s): The research included 745 patients that suffered from severe forms of infections caused by Covid 19 who were treated in a Respiratory clinic in Tuzla University Clinical Center during 2020 and 2021. The spontaneous hemorrhage was determined on the grounds of laboratory parameters of blood counts and CRP, hemodynamic monitoring of TA and pulse, and CT imagining diagnostic technique. Result(s): The study presents information about the medical treatment outcome in the case of 5 patients (0,67%) who experienced spontaneous hemorrhage as a part of Covid 19 infection in relation to the total number of 745 patients who were treated during that period in the Respiratory clinic as Covid patients with severe forms of infection. Out of 5 patients who acquired spontaneous hemorrhage 3 were operated. For 4 patients the outcome was lethal. One of the female patients who was in the group of those who were not operated and who had undergone a conservative treatment has survived. In our group of analyzed patients two patients suffered from the hematoma of the front abdominal wall, two had retroperitoneal hematoma and one patient acquired hemorrhage in the abdomen and thoracic with the developing DIC. Conclusion(s): Relatively low percentage of cases developing spontaneous hemorrhage 5 (0, 67%) but relatively high mortality rate in the cases where it did occur, 4 out of 5 monitored patients, requires certain suggestions that are being presented in this study as to how to approach the cases of spontaneous hemorrhage in the severe forms of Covid 19 infections in more consistent manner in order to improve the outcome of the medical treatment of these cases.Copyright © 2019 by Acta Medica Saliniana.

Systemic and Cerebral Effects of Physiotherapy in Mechanically Ventilated Subjects.

BACKGROUND: Physiotherapy may result in better functional outcomes, shorter duration of delirium, and more ventilator-free days. The effects of physiotherapy on different subpopulations of mechanically ventilated patients on respiratory and cerebral function are still unclear. We evaluated the effect of physiotherapy on systemic gas exchange and hemodynamics as well as on cerebral oxygenation and hemodynamics in mechanically ventilated subjects with and without COVID-19 pneumonia. METHODS: This was an observational study in critically ill subjects with and without COVID-19 who underwent protocolized physiotherapy (including respiratory and rehabilitation physiotherapy) and neuromonitoring of cerebral oxygenation and hemodynamics. PaO2 /FIO2 , PaCO2 , hemodynamics (mean arterial pressure [MAP], mm Hg; heart rate, beats/min), and cerebral physiologic parameters (noninvasive intracranial pressure, cerebral perfusion pressure using transcranial Doppler, and cerebral oxygenation using near-infrared spectroscopy) were assessed before (T0) and immediately after physiotherapy (T1). RESULTS: Thirty-one subjects were included (16 with COVID-19 and 15 without COVID-19). Physiotherapy improved PaO2 /FIO2 in the overall population (T1 = 185 [108-259] mm Hg vs T0 = 160 [97-231] mm Hg, P = .02) and in the subjects with COVID-19 (T1 = 119 [89-161] mm Hg vs T0 = 110 [81-154] mm Hg, P = .02) and decreased the PaCO2 in the COVID-19 group only (T1 = 40 [38-44] mm Hg vs T0 = 43 [38-47] mm Hg, P = .03). Physiotherapy did not affect cerebral hemodynamics, whereas increased the arterial oxygen part of hemoglobin both in the overall population (T1 = 3.1% [-1.3 to 4.9] vs T0 = 1.1% [-1.8 to 2.6], P = .007) and in the non-COVID-19 group (T1 = 3.7% [0.5-6.3] vs T0 = 0% [-2.2 to 2.8], P = .02). Heart rate was higher after physiotherapy in the overall population (T1 = 87 [75-96] beats/min vs T0 = 78 [72-92] beats/min, P = .044) and in the COVID-19 group (T1 = 87 [81-98] beats/min vs T0 = 77 [72-91] beats/min, P = .01), whereas MAP increased in the COVID-19 group only (T1 = 87 [82-83] vs T0 = 83 [76-89], P = .030). CONCLUSIONS: Protocolized physiotherapy improved gas exchange in subjects with COVID-19, whereas it improved cerebral oxygenation in non-COVID-19 subjects.

Treatment Fluid Volume May Predict Stroke Volume Improvement

INTRODUCTION: Cardiac function is known to be negatively impacted by sepsis. Monitoring Cardiac Output (CO) and Stroke Volume (SV) trends over the course of treatment may provide insight into cardiac function and may be used to predict patient outcome. In the FRESH study, we have previously shown the impact of the volume of administered treatment fluid on fluid balance and patient outcome. The goal of this study was to explore the relationship between volume of fluid and stroke volume improvement in septic patients. METHOD(S): The Starling Registry study is an observational registry study evaluating trends in CO and SV over time as related to patient outcome (NCT04648293). Patients that exhibited an overall improvement in SV (first SV measurement compared to last SV measurement) were compared to those who did not exhibit improvement. RESULT(S): A total of 201 patients received hemodynamic monitoring during their stay at three different ICUs. 46% were female, and the average age was 63 years. 72% of the patients had sepsis, and 20% of patients were positive for COVID. When patients who improved their stroke volume over the course of treatment were compared to those who did not improve, results indicate that SV improved patients had received a total volume fluid of 1241 ml, while patients did not improve received 893 ml fluid, for a difference of 348 ml (p=0.018). CONCLUSION(S): Registry patients with minimal change in stroke volume appear to receive less fluid volume. FRESH and other studies have shown improved outcomes in restricting fluid in non-preload dependent (non-fluid responsive) state. Further research in the phenotype of nonresponsive patients may be helpful in identifying new methods to improve outcomes in this group.

Stroke Volume Change May Predict Outcome in Patients with Lv/Rv Dysfunction

INTRODUCTION: Cardiac function is known to be negatively impacted by sepsis. Monitoring Cardiac Output (CO) and Stroke volume (SV) trends over the course of treatment may provide insight into cardiac function and may be used to predict patient outcome. In the FRESH study, we have previously shown that patients who improve CO and SV exhibit improved outcome such as decreased mortality and decreased need for ventilation. The goal of this study was to explore the relationship between the change in stroke volume and cardiac output in patients with LV and RV Dysfunction. METHOD(S): The Starling Registry study is an observational registry study evaluating trends in CO and SV over time as related to patient outcome (NCT04648293). Patients that exhibited an overall improvement in CO (first CO measurement compared to last CO measurement) were compared to those who did not exhibit improvement. RESULT(S): 71 patients with LV/RV dysfunction received hemodynamic monitoring during their stay across 4 units at 3 hospitals. 48% were female, and the average age was 68 years. 67% of the patients had sepsis, and 17% of patients were positive for COVID. Notably, in this population of LV/ RV dysfunction, patients with COVID (p=0.016), pneumonia (p=0.034) and those that required oxygen treatment (p=0.034) were less likely to improve Cardiac Output following fluid challenge. CONCLUSION(S): Patients with LV/RV dysfunction represent a vulnerable population. We have previously shown the benefits of trending cardiac output and stroke volume in this patient population (ATS, 2018). Trends observed in this population may help indicate which patients may be at risk for more negative outcome.

Trans-Thoracic Echocardiography in Prone Position during COVID-19 Pandemics

Introduction. During SARS-CoV-2 pandemic there was a surge in number of patients requiring ICU admission, monitoring devices, mechanical ventilation and prone positioning. In such conditions, proper hemodynamic assessment resulted challenging, whilst the need to evaluate right ventricle (RV) performance and pulmonary resistances in prone position ventilation was impellent. Aim. We explored the feasibility of a novel approach to assess both hemodynamics and cardiac function by trans-thoracic echocardiography (TTE) during mechanical ventilation before and after prone positioning. Materials and Methods. TTE was performed in eight patients before and 1 hour after prone positioning (TTEp), alongside standard hemodynamic monitoring. In order to obtain enough physical space to position the TTE-probe, we deflated the lower-thoracic section of the air-mattress, and placed the probe between the mattress surface and the thorax of the patient. Both apical-4-chambers and apical-5-chambers views were obtained. Results. We observed an overall improvement in the RV function parameters after pronation, although not statistically significant. In one case, prone position showed a reduction in TAPSE by 43% and an increase in PAPs by 9%, compared to the supine values. The same case showed a negative outcome. Conclusions. Despite trans-esophageal echocardiography remains the gold standard in patients in prone position, limited availability and the need for skilled sonographers limit its feasibility during pandemics. Though, TTEp guarantees resource-saving and time-effectiveness since multiple information can be drawn even on a single view.

"Tool-in-Lesion" Accuracy of Galaxy System: Robotic-Assisted, Electromagnetic Navigation Bronchoscopy with Integrated Tool-in-Lesion-Tomosynthesis Technology: The Match Study

SESSION TITLE: Late Breaking Procedures Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: The Galaxy SystemTM (Noah Medical, San Carlos, CA) is a novel robotic endoluminal platform using electromagnetic navigation combined with integrated tomosynthesis technology and augmented fluoroscopy. It provides intraprocedural imaging to correct CT-to-body divergence and novel confirmation of tool-in-lesion. The primary aim of this study was to assess the tool-in-lesion accuracy of the robotic bronchoscope with integrated digital tomosynthesis and augmented fluoroscopy. METHOD(S): Over four separate days, four operators (the authors) conducted the experiment using four pigs. Each physician performed between 4 and 6 nodule biopsies for 20 lung nodule biopsies. A porcine model (S. s. domesticus) was utilized. Each pig was anesthetized with volatile gas and underwent tracheostomy with an 8.5 endotracheal tube and bilateral chest tube thoracostomy. Anesthesia was monitored by a veterinarian with invasive hemodynamic monitoring. Under CT fluoroscopic guidance, simulated lung nodules were created by percutaneous injection of a gelatinous agar solution containing purple dye and radiopaque material into the lung periphery. A CT was then performed for pre-procedure planning. Using Galaxy's "Tool in Lesion TOMO+" with augmented fluoroscopy, the physician navigated to the lung nodules and a tool (needle) was placed into the lesion. Tool in lesion was defined by the needle in or tangential to the lesion determined by CBCT. Center strike was defined as the needle in the middle third in three orthogonal angles (axial, sagittal, and coronal) on CBCT. RESULT(S): Lung nodules' average size was 16.3+/-0.97 mm and were predominantly in the lower lobes (65%). Only 15% (3/20) had a bronchus sign and the average distance to the pleura was 6.88+/-5.5 mm. All four operators successfully navigated to all (100%) of the lesions in an average of 3 minutes and 39 seconds. The median number of tomosynthesis sweeps was 3 and augmented fluoroscopy was utilized in most cases (17/20 or 85%). Tool in lesion after final tomography sweep was 100% (20/20). Biopsy yielding purple pigmentation on microscopic or gross examination was also 100% (20/20). Center strike rate was 60%. CONCLUSION(S): The Galaxy SystemTM demonstrated successful digital tomography confirmed tool in lesion success in 100% (20/20) of lesions as confirmed by CBCT. Successful biopsy was achieved in 100% of lesions as confirmed by intralesional pigment acquisition. CLINICAL IMPLICATIONS: The combination of robotic navigation, catheter maneuverability and real-time correction for CT body divergence capitalizes on the strengths of all three technologies to improve diagnosis. Additional clinical trials are warranted to see if high success rates can be reproduced in patients. DISCLOSURES: Consultant relationship with Medtronic ILS Please note: $20001 - $100000 by Krish Bhadra, value=Consulting fee Consultant relationship with Veractye Please note: $1-$1000 by Krish Bhadra, value=Consulting fee Consultant relationship with Bodyvision Please note: $1001 - $5000 by Krish Bhadra, value=Consulting fee Consultant relationship with Merit Endotek Please note: $1001 - $5000 by Krish Bhadra, value=Consulting fee Consultant relationship with Boston Scientific Please note: $1001 - $5000 by Krish Bhadra, value=Consulting fee Human Factor Testing relationship with Auris Surgical Robotics Please note: $1001 - $5000 by Krish Bhadra, value=Consulting fee Consultant relationship with Intuitive Surgical Robotics Please note: $5001 - $20000 by Krish Bhadra, value=Consulting fee Consultant relationship with Biodesix Please note: $5001 - $20000 by Krish Bhadra, value=Consulting fee Consultant relationship with Noah Medical Please note: 5/2020 Added 06/01/2022 by Krish Bhadra, value=Consulting fee Speaker relationship with Body Vision Please note: 2015 - present Added 05/29/2022 by Douglas Hogarth, value=Ownership interest Consultant relationship with Magnisity Please note: 2021 - present Added 05/29/2022 by Douglas Hogarth, value=Ownership interest Consultant relationship with Auris (J&J Ethicon) Please note: 2014-present Added 05/29/2022 by Douglas Hogarth, value=Honoraria Consultant relationship with Boston Scientific Please note: 2008 - present Added 05/29/2022 by Douglas Hogarth, value=Consulting fee Consultant relationship with Medtronic Please note: 2010-2019 Added 05/29/2022 by Douglas Hogarth, value=Consulting fee Consultant relationship with Broncus Please note: 2017-2021 Added 05/29/2022 by Douglas Hogarth, value=Consulting fee Consultant relationship with PulmonX Please note: $5001 - $20000 by Douglas Hogarth, value=Consulting fee Removed 06/08/2022 by Douglas Hogarth Consultant relationship with Spiration Please note: $5001 - $20000 by Douglas Hogarth, value=Consulting fee Removed 06/08/2022 by Douglas Hogarth Consultant relationship with Eolo Please note: $20001 - $100000 by Douglas Hogarth, value=Ownership interest Removed 06/08/2022 by Douglas Hogarth Consultant relationship with Noah Please note: 2019 - present Added 06/08/2022 by Douglas Hogarth, value=Ownership interest Consultant relationship with Noah Please note: 2019 - present Added 06/08/2022 by Douglas Hogarth, value=Consulting fee Consultant relationship with Medtronic Corporation Please note: $5001 - $20000 by Amit Mahajan, value=Consulting fee Consultant relationship with Boston Scientific Corporation Please note: $1001 - $5000 by Amit Mahajan, value=Consulting fee Consultant relationship with Pulmonx Corporation Please note: $5001 - $20000 by Amit Mahajan, value=Consulting fee Consultant relationship with Ambu USA Please note: $1-$1000 by Amit Mahajan, value=Consulting fee Consultant relationship with Circulogene Please note: $1001 - $5000 by Amit Mahajan, value=Consulting fee Consultant relationship with Medtronic/Covidien Please note: $1001 - $5000 by Otis Rickman, value=Consulting fee Copyright © 2022 American College of Chest Physicians

RAPIDLY PROGRESSIVE PERIMYOCARDITIS IN SARS-COV-2 INFECTION

SESSION TITLE: Extraordinary Cardiovascular Reports SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: The COVID-19 pandemic has resulted in millions of deaths worldwide. Many cases involved a primary pulmonary process, yet myocarditis associated with COVID-19 has been observed.1 We present a novel case of rapidly progressive fulminant peri-myocarditis with minimal lung involvement in acute COVID-19 infection. CASE PRESENTATION: A 39-year-old female with no medical history presented with chest pain and dyspnea with an acute COVID-19 infection. She had a brief cardiac arrest with rapid ROSC and no intubation. Chest CT angiogram showed essentially normal pulmonary parenchyma and moderate pericardial effusion. EKG showed sinus tachycardia with global ST segment elevation. An echocardiogram showed an ejection fraction (EF) of 25% with a moderate sized pericardial effusion and right ventricle collapse. She was transferred for emergent drainage of the effusion to our institution. Her circulatory shock initially improved following pericardial drainage, yet she declined warranting increasing vasopressor and inotropic support. An emergent echo showed an EF of less than 10% and no re-accumulation of pericardial fluid. It was clear that the patient required mechanical circulatory support (MCS) and was transferred to the catheterization lab. While in the lab, the patient suffered cardiac arrest and an Impella device was placed during prolonged ACLS without achieving ROSC. Venoarterial ECMO cannulation was then performed. She was transferred to a cardiac transplant center where she later developed multi-organ failure leading to death. DISCUSSION: While COVID-19 has been shown to affect multiple organs apart from the lungs, this case was notable due to minimal pulmonary involvement. The patient's manifestation of her infection was almost entirely cardiac in nature. MCS was discussed in the catheterization lab at the time of pericardial drain insertion. The decision was made to not pursue MCS as the patient's shock had improved. Additionally, the patient did not undergo pulmonary arterial catheter (PAC) placement. Prompt placement of a PAC has been associated with early access to MCS and reduced in-hospital mortality.2 Perhaps we would have obtained MCS earlier if PAC data supported this intervention before the patient deteriorated. It will be important to consider primary cardiac manifestations of COVID-19 infection and early consideration of invasive hemodynamic monitoring to identify a need for timely MCS. CONCLUSIONS: We present the first reported case of fulminant peri-myocarditis in the absence of acute hypoxemic respiratory failure or radiographic pulmonary parenchymal lung abnormality. Isolated rapidly progressive cardiogenic shock secondary to COVID-19 associated peri-myocarditis is a phenomenon important for critical care clinicians to be aware of during this pandemic. One should have a low threshold to establish invasive hemodynamic monitoring and consideration for early MCS in these cases. Reference #1: Siripanthong B, Nazarian S, Muser D, et al. Recognizing COVID-19-related myocarditis: The possible pathophysiology and proposed guideline for diagnosis and management. doi:10.1016/j.hrthm.2020.05.001 Reference #2: Osman M, Syed M, Patel B, et al. Invasive Hemodynamic Monitoring in Cardiogenic Shock Is Associated With Lower In-Hospital Mortality. Journal of the American Heart Association J Am Heart Assoc. 2021;10:21808. doi:10.1161/JAHA.121.021808 DISCLOSURES: No relevant relationships by Samuel Bullick No relevant relationships by Jonathan Greenberg No relevant relationships by Scott Slusarenko

FLUID RESPONSIVENESS AND PATIENT OUTCOMES

SESSION TITLE: Sepsis: Beyond 30cc/kg and Antibiotics SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Cardiac function is known to be negatively impacted by sepsis. Stroke volume (SV) change in response to Passive Leg Raise (PLR) is an effective method to predict fluid responsiveness (FR) or cardiac response to preload expansion. We have previously shown that short-term sepsis resuscitation phenotypes based responses to passive leg raise (PLR) can identify discrete patient sub-groups. The goal of this study was to identify resuscitation phenotypes and explore the relationship between the cardiac physiology and patient outcome. METHODS: The Starling Registry study is an observational registry study evaluating trends in cardiac output (CO) and SV over time as related to patient outcome (NCT04648293). Patients were classified as FR if SV increased ≥ 10% when measured with non-invasive bioreactance (Starling Monitor, Baxter Healthcare). Patients were characterized Non FR if SV increased <10%. Patients were grouped into 6 different sextets based on the percentage of FR PLRs within each group. RESULTS: 222 critical care patients received hemodynamic monitoring during their ICU stay across two different hospitals. 46 % were female, and the average age was 64 years. 65% of the patients had sepsis, and 20% of patients were positive for COVID. There were an equal percentage of septic patient in whose who were not FR (68%) and patients who were 100% FR (65%, p=0.334). Patients who were not FR received significantly less resuscitation fluid (609 ml) compared to patients who were 100% FR (1094 ml, p<0.0001). Patients who were 100% FR exhibited a decreased incidence of mortality (20.2%) compared to patient with 0% incidence FR (35.5%, p= 0.028). CONCLUSIONS: Short-term sepsis resuscitation phenotypes based responses to PLR identify discrete patient sub-groups. We have previously shown patients who improve CO in response to the resuscitation exhibited improved outcome. The ability to respond to the addition of IV fluid by increasing CO and SV may improve perfusion and lead to decreased adverse events. As there were an equal number of septic patients in both groups, a 0% incidence of FR may reflect a reduced EF or cardiac dysfunction instead of peripheral leakage. The results provided by a real time dynamic assessment may predict patient outcome and demonstrate physiology based on fluid responsiveness. CLINICAL IMPLICATIONS: Monitoring cardiac function closely is a high priority to prevent clinically relevant changes in patient outcome. DISCLOSURES: Employee relationship with Cheetah Medical Please note: >$100000 by Douglas Hansell, value=Salary Stock Holder relationship with Baxter Please note: 13 years Added 03/29/2022 by Kai Harenski, value=Stocks No relevant relationships by Muhammad Ali Javed Speaker/Speaker's Bureau relationship with Cheetah Medical Inc Please note: $1001 - $5000 by Heath Latham, value=Consulting fee Removed 03/28/2022 by Heath Latham Speaker/Speaker's Bureau relationship with Baxter Please note: 1/2021 - 3-2022 Added 03/28/2022 by Heath Latham, value=Consulting fee Employee relationship with Baxter Healthcare Please note: 15 months by Jennifer Sahatjian, value=Salary

Fluid balance neutralization secured by hemodynamic monitoring versus protocolized standard of care in critically ill patients requiring continuous renal replacement therapy: study protocol of the GO NEUTRAL randomized controlled trial.

BACKGROUND: Fluid overload is associated with worse outcome in critically ill patients requiring continuous renal replacement therapy (CRRT). Net ultrafiltration (UFNET) allows precise control of the fluid removal but is frequently ceased due to hemodynamic instability episodes. However, approximately 50% of the hemodynamic instability episodes in ICU patients treated with CRRT are not associated with preload dependence (i.e., are not related to a decrease in cardiac preload), suggesting that volume removal is not responsible for these episodes of hemodynamic impairment. The use of advanced hemodynamic monitoring, comprising continuous cardiac output monitoring to repeatedly assess preload dependency, could allow securing UFNET to allow fluid balance control and prevent fluid overload. METHODS: The GO NEUTRAL trial is a multicenter, open-labeled, randomized, controlled, superiority trial with parallel groups and balanced randomization with a 1:1 ratio. The trial will enroll adult patients with acute circulatory failure treated with vasopressors and severe acute kidney injury requiring CRRT who already have been equipped with a continuous cardiac output monitoring device. After informed consent, patients will be randomized into two groups. The control group will receive protocolized fluid removal with an UFNET rate set to 0-25 ml h-1 between inclusion and H72 of inclusion. The intervention group will be treated with an UFNET rate set on the CRRT of at least 100 ml h-1 between inclusion and H72 of inclusion if hemodynamically tolerated based on a protocolized hemodynamic protocol aiming to adjust UFNET based on cardiac output, arterial lactate concentration, and preload dependence assessment by postural maneuvers, performed regularly during nursing rounds, and in case of a hemodynamic instability episode. The primary outcome of the study will be the cumulative fluid balance between inclusion and H72 of inclusion. Randomization will be generated using random block sizes and stratified based on fluid overload status at inclusion. The main outcome will be analyzed in the modified intention-to-treat population, defined as all alive patients at H72 of inclusion, based on their initial allocation group. DISCUSSION: We present in the present protocol all study procedures in regard to the achievement of the GO NEUTRAL trial, to prevent biased analysis of trial outcomes and improve the transparency of the trial result report. Enrollment of patients in the GO NEUTRAL trial has started on June 31, 2021, and is ongoing. TRIAL REGISTRATION: ClinicalTrials.gov NCT04801784. Registered on March 12, 2021, before the start of inclusion.

To drain, or not to drain: Diagnostic and therapeutic challenges associated with cardiac tamponade in Right heart sided heart failure and pulmonary hypertension

Background: In clinical practice, cardiac tamponade is not an all-or-none phenomenon, but rather a continuum of hemodynamic impairment. Diagnosis depends on an overall assessment of clinical and echocardiographic findings, hemodynamic measurements, and other corresponding patient-level variables must be considered to make a diagnosis to initiate timely intervention.1 The identification of cardiac tamponade in the presence of severe pulmonary hypertension and right ventricular failure can be even more challenging, because the classic findings are often not observed. Our patient clearly had hemodynamic compromise (orthostatic collapses and then persistent hypotension from a large pericardial effusion but did not exhibit the common features of tamponade on ECHO. This can be explained by the preexisting, markedly elevated right-sided pressures, which prevented typical findings of pulsus paradoxus, right atrial and ventricular diastolic collapse, and equalization of diastolic pressures.1 Case presentation: 44 Years old lady background of Interstitial lung disease, pulmonary artery hypertension, Right heart failure and anti-synthetase syndrome. Recently required Intensive care admission for COVID pneumonitis and was discharged on home oxygen. Now admitted to hospital after she boarded the flight without oxygen and became unwell. She was treated on lines of exacerbation of interstitial lung disease, Right heart failure and moderate pericardial effusion without signs of tamponade in ECHO and was given adequate diuresis and responded very well to it. Her oxygen requirement came down and she clinically improved. Few days after, she developed diarrhea and prerenal Acute kidney injury while in ward and became borderline hypotensive which improved after her diuretic doses were reduced and then held. She then after few days started to develop orthostatic collapses with hypotension and then became persistently hypotensive. Her CT Pulmonary angiogram showed unchanged moderate circumferential pericardial effusion, and no Pulmonary embolism. She was reviewed by Critical care outreach team and an urgent bedside Echocardiogram was performed to rule out features of tamponade which showed moderate pericardial effusion, severely dilated Right heart with massive Right ventricular pressures compressing her Left ventricle. She was urgently reviewed by cardiology and was taken to Intensive care unit for invasive hemodynamic monitoring, where she was given inotropes and inhaled pulmonary artery vasodilators. The decision was taken to cautiously diurese and not to drain the pericardial effusion due to risk of developing further instability by increasing right ventricular expansion causing further collapse and pressure on Left ventricle. Discussion and conclusion: Our case stresses on the importance of Bedside Echocardiogram in timely identifying the atypical features of cardiac tamponade and to understand the different hemodynamics and mechanism of obstructive shock in patients with pre-existing right sided heart failure. After the establishing that patient was in obstructive cardiogenic shock with atypical findings of tamponade, the next most important step was to decide whether to drain the pericardial effusion or not. In our literature search, we found that the drainage of a large pericardial effusion in patients with pulmonary hypertension has been accompanied by catastrophic, sudden hemodynamic collapse and it has been postulated that the presence of pericardial fluid limits right ventricular distension in response to pressure and volume overload. When the pericardial fluid is removed, rapid enlargement of the right ventricle causes: (1) reduced right ventricular systolic function due to muscle fiber distension;and (2) compression of the left ventricle, which leads to impaired diastolic filling and left ventricular outflow track obstruction.1.

Safety during interhospital helicopter transfer of ventilated COVID-19 patients. No clinical relevant changes in vital signs including non-invasive cardiac output.

BACKGROUND: During the COVID-19 pandemic in The Netherlands, critically ill ventilated COVID-19 patients were transferred not only between hospitals by ambulance but also by the Helicopter Emergency Medical Service (HEMS). To date, little is known about the physiological impact of helicopter transport on critically ill patients and COVID-19 patients in particular. This study was conducted to explore the impact of inter-hospital helicopter transfer on vital signs of mechanically ventilated patients with severe COVID-19, with special focus on take-off, midflight, and landing. METHODS: All ventilated critically ill COVID-19 patients who were transported between April 2020 and June 2021 by the Dutch 'Lifeliner 5' HEMS team and who were fully monitored, including noninvasive cardiac output, were included in this study. Three 10-min timeframes (take-off, midflight and landing) were defined for analysis. Continuous data on the vital parameters heart rate, peripheral oxygen saturation, arterial blood pressure, end-tidal CO2 and noninvasive cardiac output using electrical cardiometry were collected and stored at 1-min intervals. Data were analyzed for differences over time within the timeframes using one-way analysis of variance. Significant differences were checked for clinical relevance. RESULTS: Ninety-eight patients were included in the analysis. During take-off, an increase was noticed in cardiac output (from 6.7 to 8.2 L min-1; P < 0.0001), which was determined by a decrease in systemic vascular resistance (from 1071 to 739 dyne·s·cm-5, P < 0.0001) accompanied by an increase in stroke volume (from 88.8 to 113.7 mL, P < 0.0001). Other parameters were unchanged during take-off and mid-flight. During landing, cardiac output and stroke volume slightly decreased (from 8.0 to 6.8 L min-1, P < 0.0001 and from 110.1 to 84.4 mL, P < 0.0001, respectively), and total systemic vascular resistance increased (P < 0.0001). Though statistically significant, the found changes were small and not clinically relevant to the medical status of the patients as judged by the attending physicians. CONCLUSIONS: Interhospital helicopter transfer of ventilated intensive care patients with COVID-19 can be performed safely and does not result in clinically relevant changes in vital signs.

Single center experience with left atrial pressure remote monitoring in advanced heart failure patients

Background: Advanced heart failure (HF) is a complex clinical syndrome with scarce therapeutic options. Despite growing body of research in the field, no alternative end-stage solution is available for those individuals who are not eligible for heart transplant and mechanical circulatory support. The efficacy of implantable hemodynamic monitoring is currently being tested. Clinical manifestations of congestive HF appear late in the progression to acute decompensation, whereas intracardiac pressures rise gradually and can anticipate, even by weeks, the symptoms onset, thus offering a sweet spot to timely face an incipient acute decompensation. To date, the only implantable monitoring systems which received the regulatory agencies approval is a PAP sensor allowing PAP-guided management in symptomatic patients with reduced left ventricular ejection fraction (LVEF <35%). Although right-sided pressures data have proved their usefulness, they do not always correlate with left heart chambers pressures, so that PAP indirect estimation of left ventricular filling pressure can be misleading in some clinical contexts. Purpose. The V-LAP system is the latest-generation device, capable of monitoring the left atrial pressure (LAP) directly, by an intracardiac leadless sensor, transmitting LAP data wirelessly to an external reader. It is designed to offer a continuously updated status of the left-sided hemodynamics in order to improve the outcomes of advanced chronic HF-patient by reducing HF-related hospitalizations. Methods: In our center, V-LAP was implanted in five NYHA class III HF patients, not eligible for heart transplant, with a history of frequent hospital readmission and recurrently elevated proBNP levels. After confirmation of the device reliability, LAP trends have been remotely monitored over time in order to guide therapy optimization. Results: Over a median follow-up time of 18 months, LAP - driven therapy adjustments succeeded in noticeably reducing LAP and no HF-related hospitalization occurred in all patients considered. Morover, functional capacity improved in three out of five patients (NYHA class from III to II), and this was paralleled by an increase in the perceived quality of life as indicated by the KCCQ summary score (67.01±15.95 at baseline vs 83.21±11.94 at latest follow-up). The overall compliance of our patients to daily LAP measurements was > 90%, attesting a remarkable patient usability and acceptance. Conclusion: Preliminary data from V-LAP application at our institution expressed optimistic efficacy, along with remarkable reliability and ease of use, encouraging patients to adhere with a high compliance rate. In covid-19 era, VLAP revealed to be an excellent tool to control HF patients avoiding medical contacts and in-hospital exposure. While further study is needed, heart failure patient management guided by the V-LAP system may have the potential to significantly improve clinical outcomes.

Cardiac output change predicts patient outcome

Introduction: Cardiac function is known to be negatively impacted by sepsis. Monitoring Cardiac Output (CO) trends over the course of treatment may provide insight into cardiac function and may be used to predict patient outcome. The goal of this study was to explore the relationship between the change in stroke volume and outcome in critically ill patients. Methods: The Starling Registry study is an observational registry study evaluating trends in CO and SV (Stroke Volume) over time as related to patient outcome (NCT04648293). Patients that exhibited an overall improvement in CO (first CO measurement compared to last CO measurement) were compared to those who did not exhibit improvement. Results: A total of 229 critical care patients received hemodynamic monitoring during their ICU stay across three different hospitals. 48% were female, and the average age was 64 years. 64% of the patients had sepsis, and 17% of patients were positive for COVID. Notably, patients who exhibited an overall improvement in CO exhibited a decrease need for mechanical ventilation (4.8% vs 15%, p = 0.041) and a trend toward a decrease in mortality (16.4%) compared to those who did not improve (28.0%, p = 0.080) (Fig. 1). Conclusions: We have previously shown that patients who show an improvement in CO in response to the resuscitation exhibited improved outcome. Trending cardiac output over a 1-3 day monitoring period revealed additional usefulness in predicting patients with improved outcome. These results highlight the importance of trending hemodynamics in therapy. (Figure Presented).

Successful Treatment of Severely Hypotensive Pediatric Patients with Multisystem Inflammatory Syndrome in Children (MIS-C) with the Guidance of Invasive Hemodynamic Monitoring: A Report of Three Cases

Introduction: Since the beginning of the coronavirus disease 2019 (COVID-19) outbreak, it was assumed that infection rate in pediatric patients is lower than in adults and that infection is less severe in children than adult patients. Recently, there have been several reports and case series presenting critically-ill children with COVID-19, but still, severe hypotension is rare in pediatric patients with COVID-19. Case Presentation: We describe three pediatric cases with COVID-19 who presented with multi-system organ failure and severe hypotension treated with the guidance of the parameters of an invasive continuous hemodynamic monitoring device. We also compare their parameters with few articles on pediatric sepsis parameters. Conclusions: Although we usually start the treatment of hypotensive pediatric patients with hydration and epinephrine as an inotrope, in our cases, we required a different treatment plan according to the hemodynamic monitoring parameters, which indicates the value of the utilization of these devices in pediatric intensive care units

AMBULATORY HEMODYNAMIC-GUIDED CARE FOR PATIENTS WITH CHRONIC HEART FAILURE: AN UPDATED META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

Background: Outpatient hemodynamic-guided heart failure (HF) management is suggested to decrease HF morbidity. With the recent publication of results from the GUIDE-HF trial, we performed an updated meta-analysis of related randomized controlled trials (RCTs). Methods: A PubMed literature search was conducted to identify RCTs exploring the benefit of remote hemodynamic monitoring. The studied demographic included adults diagnosed with HF that were implanted with continuous hemodynamic monitoring devices, regardless of ejection fraction, and with NYHA severity ranging from II-IV. The primary outcome examined was the rate of HF hospitalizations before the COVID-19 pandemic. Random Effects Hartung-Knapp method was used to estimate the pooled odds ratio (OR). Additional sensitivity analysis, using data from the GUIDE-HF trial, was conducted to evaluate the impact of the pandemic on the overall results. Results: A significant decrease in hospitalizations was noted with an estimated pooled OR 0.62 [95% CI 0.41 - 0.94] after including the pre-COVID-19 GUIDE-HF results in the meta-analysis. The I2 statistic was estimated at 38% (p = 0.18). Further sensitivity analysis revealed that this benefit lost statistical significance with the overall results of the GUIDE-HF trial, OR 0.66 [95% CI 0.42 - 1.02]. Conclusion: Our results show that remote hemodynamic monitoring significantly decreases HF-related hospitalizations. Limitations to our findings include;1) GUIDE-HF trial contributed to 35% of the overall results 2) Follow-up time was variable amongst the RCTs 3) Results including data since COVID-19 affected the frequency of HF patient follow-up, possibly affecting the overall results from the GUIDE-HF trial. Given the evolving circumstances relating to the COVID-19 pandemic, further investigations on the pragmatic utility of hemodynamic-guided HF management are warranted.

Remote pulmonary artery hemodynamic monitoring as outpatient in heart failure

Case Report Role of PA pressure monitoring in preventing recurrent hospital admissions in HF Case presentation A 67-year-old male with a past medical history of nonischemic cardiomyopathy, HFrEF NYHAIII StageC, hypertension, and DM with recent LHC in 2019 showed mild diffuse atherosclerosis was managed conservatively. He received an implantable PA monitoring device (CardioMEMS) in March 2021 to remotely monitor his home PA pressures on a daily basis. The average diastolic PA pressures were in the range of 5-10 mmHg since insertion of the ambulatory device with routine HF medication and lifestyle modifications. The daily monitoring system began to sense gradually raising diastolic PA from 19-22 mmg Hg. The patient was contacted to screen for any acute worsening of heart failure. He reported worsening of shortness of breath and a decrease in appetite corresponding to raising End DP PA pressure by the CardioMEMS. The patient was advised to 2X Lasix and report to the outpatient clinic. In the next 3-4 days, Diastolic PA began trending upward, peaking in the range of 25-30 mmg Hg. The patient was scheduled for an urgent outpatient visit;at this, we noted that there were no signs of fluid overload in the peripheries or any significant weight gain but worsening of his shortness of breath with all other examinations appearing normal. The patient's diuretics regiment was further intensified in this encounter. Subsequent ambulatory pulmonary diastolic pressure begins to trend down towards his usual range of 10 mmHg with the improvement of the patient's symptom of shortness of breath. His diuretics were gradually stepped down, and he continued to maintain his usual state health with improvement in his clinical outcomes. Discussion In clinical practice, ambulatory hemodynamic monitoring of a patient with cardioMEMS made clinicians take medicine one step closer to the patient's home and intercept treatment earlier, even before any worsening clinical signs, helping avoid hospitalization and at the same time improve patients quality of life in HF. GUIDE-HF study of 1000 patients reported that hemodynamics-guided management of heart failure did not result in lowering the composite endpoint rate of mortality but indicated a possible benefit primarily driven by a lower heart failure hospitalization rate compared with the control group.2 In this new era of COVID, we can mitigate the need for our patients to come to the medical facility frequently and to be able to keep our advanced HF patients safe and healthy at home. Conclusion Ambulatory hemodynamic monitoring based on pulmonary pressure guided therapy for HF has shown beyond doubt that lower PA pressure, lower rates of heart failure are associated with hospital admission. These devices can sense very early changes in patient clinical conditions even before any early signs of fluid overload appear. Above all, it builds a huge patient-provider trust by knowing your patients' hemodynamics the best.