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Chronic thromboembolic disease (CTED) is suboptimally defined by a mean pulmonary artery pressure (mPAP) <25 mmHg at rest in patients that remain symptomatic from chronic pulmonary artery thrombi. To improve identification of right ventricular (RV) pathology in patients with thromboembolic obstruction, we hypothesized that the RV ventriculo‐arterial (Ees/Ea) coupling ratio at maximal stroke work (Ees/Eamax sw) derived from an animal model of pulmonary obstruction may be used to identify occult RV dysfunction (low Ees/Ea) or residual RV energetic reserve (high Ees/Ea). Eighteen open chested pigs had conductance catheter RV pressure‐volume (PV)‐loops recorded during PA snare to determine Ees/Eamax sw. This was then applied to 10 patients with chronic thromboembolic pulmonary hypertension (CTEPH) and ten patients with CTED, also assessed by RV conductance catheter and cardiopulmonary exercise testing. All patients were then restratified by Ees/Ea. The animal model determined an Ees/Eamax sw = 0.68 ± 0.23 threshold, either side of which cardiac output and RV stroke work fell. Two patients with CTED were identified with an Ees/Ea well below 0.68 suggesting occult RV dysfunction whilst three patients with CTEPH demonstrated Ees/Ea ≥ 0.68 suggesting residual RV energetic reserve. Ees/Ea > 0.68 and Ees/Ea < 0.68 subgroups demonstrated constant RV stroke work but lower stroke volume (87.7 ± 22.1 vs. 60.1 ± 16.3 mL respectively, P = 0.006) and higher end‐systolic pressure (36.7 ± 11.6 vs. 68.1 ± 16.7 mmHg respectively, P < 0.001). Lower Ees/Ea in CTED also correlated with reduced exercise ventilatory efficiency. Low Ees/Ea aligns with features of RV maladaptation in CTED both at rest and on exercise. Characterization of Ees/Ea in CTED may allow for better identification of occult RV dysfunction. We have used PV‐loop analysis in a porcine model of pulmonary hypertension to define the optimal Ees/Ea coupling ratio for RV maximal efficiency. We have applied this cut‐off to patients with chronic thromboembolic pulmonary disease and detected occult RV dysfunction.

Right ventricular (RV) diastolic dysfunction was first reported as an indicator for the assessment of ventricular dysfunction in heart failure a little over two decades ago. However, the underlying mechanisms and precise role of RV diastolic dysfunction in heart failure remain poorly described. Complexities in the structure and function of the RV make the detailed assessment of the contractile performance challenging when compared to its left ventricular (LV) counterpart. LV dysfunction is known to directly affect patient outcome in heart failure. As such, the focus has therefore been on LV function. Nevertheless, a strategy for the diagnosis and assessment of RV diastolic dysfunction has not been established. Here, we review the different causal mechanisms underlying RV diastolic dysfunction, summarising the current assessment techniques used in a clinical environment. Finally, we explore the role of load-independent indices of RV contractility, derived from the conductance technique, to fully interrogate the RV and expand our knowledge and understanding of RV diastolic dysfunction. Accurate assessment of RV contractility may yield further important prognostic information that will benefit patients with diastolic heart failure.

At the Royal College of Nursing annual international nursing research Conference in Harrogate it was noticeable that clinical research nurses(CRNs) had real presence. They hosted a packed symposium and presented concurrent papers and posters.

BackgroundThere is strong evidence of FFR guided treatment in multi-vessel disease. Multi-vessel disease is present in up to 66% of patients with CTO in a large registry analysis. The presence of a concomitant CTO may influence the FFR measurement in donor vessel as suggested in previous studies and reports. This has an important implication on clinical decision making for complete revascularisation in patients with chronic total occlusions. There is a growing interest on the influence of collateral circulation, flow, amount of myocardium supplied by donor artery to a CTO and the impact of CTO revascularisation on donor vessel pressure-derived indices. We sought to investigate the physiological impact of CTO recanalisation on donor vessel pressure-derived indices.MethodsThe study participants were patients with angina who had RCA CTO. 34 out of 40 consecutive patients underwent successful PCI to RCA CTOs during the study period were included in the analysis. Coronary pressure-derived indices (resting Pd/Pa, iFR and FFR) were measured pre and post successful RCA CTO PCI in donor vessels. Donor vessel characteristics were graded using the Rentrop and colloateral connexion grading classification.ResultsThe mean age was 61.76 years. The mean estimated CTO duration was 238.72 weeks and CTO length was 32.44 mm. 31 patients had ischaemia and or viability in the RCA territory assessed with cardiac MRI.LAD was the predominant donor vessel in 30 patients and LCX was the minor donor vessel in 4 patients. Percent stenosis on QCA in the predominant and minor donor vessel were 41.43% and 35.05% respectively. The angiographic details are as outlined in table 1. The mean resting Pd/Pa, iFR and FFR pre and post RCA CTO PCI in major donor vessel were (0.891, 0.858, 0.759) and (0.903, 0.882, 0.746) respectively. iFR in the major donor vessel increased from 0.858 to 0.882 (difference, 0.02412 (0.00573 to 0.04250); p=0.012). There were no significant difference in resting Pd/Pa and FFR pre and post CTO PCI (p=0.109 and p=0.388 respectively).The mean resting Pd/Pa, iFR and FFR pre and post RCA CTO PCI in minor donor vessel were (0.982, 0.969, 0.894) and (0.985, 0.979, 0.885) respectively. There were no significant difference in resting Pd/Pa, iFR and FFR pre and post CTO PCI in minor donor vessel (p=0.534, p=0.152, p=0.183 respectively).The mean collateral FFR was 0.310. The mean total ischaemic burden on baseline cardiac MRI in RCA territory was 12.6%.ConclusionSuccessful recanalisation of a RCA CTO results in increase in iFR but no significant difference was seen in resting Pd/Pa and FFR pre-RCA CTO PCI and immediately post recanalisation in predominant donor vessel. Complete collateral regression was not observed in all patients immediately post RCA CTO PCI and this may account for the non-significant change in FFR values.Abstract 24 Table 1Angiographic Characteristics

BackgroundThere is strong evidence of FFR guided treatment in multi-vessel disease. The presence of a concomitant CTO may influence the FFR measurement in donor vessel as suggested in previous studies and reports. This has an important implication on clinical decision making for complete revascularisation in patients with chronic total occlusion. We sought to investigate the influence of collateral regression after successful CTO recanalisation on donor vessel pressure-derived indices.MethodsThe study participants were patients with angina who had RCA CTO. 28 out of 34 consecutive patients underwent successful PCI to RCA CTOs during the study period and completed the follow study (at 3 months post CTO PCI) were included in this analysis. Coronary pressure-derived indices (resting PD/PA, iFR and FFR) were measured pre and post successful RCA CTO PCI in donor vessels and at follow up procedures.ResultsThe mean age was 62.38 years. The mean estimated CTO duration was 238.72 weeks and CTO length was 32.44 mm. 25 patients had ischaemia and or viability in the RCA territory assessed with cardiac MRI. LAD was the major donor vessel in 24 patients and LCX was the minor donor vessel in 4 patients. Percent stenosis on QCA in the major and minor donor vessel were 40.6% and 35.1% respectively. The mean resting Pd/Pa, iFR and FFR pre and post RCA CTO PCI and at follow-up procedures in major donor vessel were (0.893, 0.862, 0.764), (0.907, 0.886, 0.753) and (0.918, 0.901, 0.787) respectively. The mean resting Pd/Pa, iFR and FFR pre and post RCA CTO PCI and at follow-up procedures in minor donor vessel were (0.979, 0.966, 0.890), (0.983, 0.979, 0.880) and (0.981, 0.974, 0.898) respectively. The changes in coronary pressure-derived indices pre and post RCA CTO PCI and at follow up procedures are summarised in table 1. In major donor vessel, there was significant changes in the difference between follow up and pre-CTO PCI values for Pd/Pa, iFR and FFR values (p values 0.006, 0.003 and 0.047 respectively). There was also significant change in the difference between follow up and post-CTO PCI FFR value (P value 0.002). FFR collateral reduced significantly at follow-up (p value 0.000).ConclusionSuccessful recanalisation of a RCA CTO results in increase in major donor vessel coronary pressure-derived indices at follow up procedure associated with the regression of collateral function. In patients with multi-vessel disease, the expected change and the optimal timing to perform PCI in donor vessel should be considered when planning multi-vessel revascularisation in this setting.Abstract 23 Table 1Coronary pressure-derived indices pre and post RCA CTO PCI and at follow up procedures (FU:Follow-up, PCI:Percutaneous Coronary Intervention, FFR: Fractional Flow Reserve, CTO: Chronic Total Occlusion)