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BackgroundThis study analyzed hemodynamic changes in a single patient case following flow diverter-assisted coiling of an ICA bifurcation aneurysm. The stent was deployed toward the M1 segment of the MCA, jailing and reducing blood flow through the A1 segment of the ACA. Here, we used a computational fluid dynamics (CFD) algorithm to quantify ACA flow reduction post-stent deployment and assessed its hemodynamic implications proximally and in distal territories.MethodsAnalysis was conducted using Dr. NEAR flow (Seoul, KR), a software integrated from 3D reconstruction to cerebral vascular hemodynamics. CTA scans from a patient who underwent flow diverter stent placement were used to reconstruct a three-dimensional vascular model. A one-dimensional network model consisting of nodes and edges was generated to represent cerebral circulation (figure 1a). To simulate hemodynamic changes due to stent placement, the diameter of the first node at the ACA bifurcation was progressively reduced to mimic the decrease in cross-sectional area. This area was estimated by averaging the diameters of the first two bifurcation nodes. Using the software’s computational module, blood flow, pressure, and velocity were calculated assuming an ICA inflow of 3 mL/s, and their relationship to cross-sectional area reduction was analyzed.ResultsA 10% stepwise reduction in the first node diameter led to cross-sectional area decreases of 17%, 32%, 46%, and 58% (figure 1b). As cross-sectional area increased, ACA blood flow and pressure increased, while velocity decreased. These results suggest that changes in bifurcation from stent placement significantly impacted hemodynamics.ConclusionWithout knowing the exact stent porosity, we observed that a reduction in cross-sectional area at the ACA bifurcation decreased blood flow and pressure while increasing velocity in the jailed ACA segment. These findings suggest that stent placement alters hemodynamics, which could impact perfusion. Future studies should consider stent mesh design to predict postoperative hemodynamic changes, aiding surgical planning and outcome prediction based on deep learning processes with a clinical dataset.Abstract E-195 Figure 1DisclosuresA. Wu: None. W. Lee: 5; C; NEAR Brain, Inc.. P. Davis: None. K. Scott: None. T. Lee: 5; C; NEAR Brain, Inc. V. Srinivasan: 1; C; Zeiss, Siemens, Medtronic, Stryker. 2; C; Cerenovus, Stryker, Imperative Care, National Football League.

PurposeNet ultrafiltration (UFNET) during continuous renal replacement therapy (CRRT) can control fluid balance (FB), but is usually 0 ml·h−1 in patients with vasopressors due to the risk of hemodynamic instability associated with CRRT (HIRRT). We evaluated a UFNET strategy adjusted by functional hemodynamics to control the FB of patients with vasopressors, compared to the standard of care.MethodsIn this randomized, controlled, open-label, parallel-group, multicenter, proof-of-concept trial, adults receiving vasopressors, CRRT since ≤ 24 h and cardiac output monitoring were randomized (ratio 1:1) to receive during 72 h a UFNET ≥ 100 ml·h−1, adjusted using a functional hemodynamic protocol (intervention), or a UFNET ≤ 25 ml·h−1 (control). The primary outcome was the cumulative FB at 72 h and was analyzed in patients alive at 72 h and in whom monitoring and CRRT were continuously provided (modified intention-to-treat population [mITT]). Secondary outcomes were analyzed in the intention-to-treat (ITT) population.ResultsBetween June 2021 and April 2023, 55 patients (age 69 [interquartile range, IQR: 62; 74], 35% female, Sequential Organ Failure Assessment (SOFA) 13 [11; 15]) were randomized (25 interventions, 30 controls). In the mITT population, (21 interventions, 24 controls), the 72 h FB was −2650 [−4574; −309] ml in the intervention arm, and 1841 [821; 5327] ml in controls (difference: 4942 [95% confidence interval: 2736–6902] ml, P < 0.01). Hemodynamics, oxygenation and the number of HIRRT at 72 h, and day-90 mortality did not statistically differ between arms.ConclusionIn patients with vasopressors, a UFNET fluid removal strategy secured by a hemodynamic protocol allowed active fluid balance control, compared to the standard of care.

Background and aimsThe Bezold Jarisch Reflex (BJR) is considered to contribute to subarachnoid block (SAB) induced hypotension and bradycardia and is mediated by serotonin receptors (5-HT3 subtype). Ondansetron, a 5-HT3 receptor antagonist is assumed to block the effect of serotonin and inhibit the BJR. the aim was to study the effect of intravenous ondansetron on maternal hemodynamics.Methods150 healthy parturients scheduled for elective caesarean section were randomly allocated into two groups of 75 each to receive either 4 mg ondansetron diluted to 10 ml of 0.9% normal saline or 10 ml of 0.9% normal saline 10 minutes before initiation of SAB. Haemodynamic parameters were studied from time of administration of the study drug up to the time of delivery.ResultsBoth the groups were comparable to each other with respect to baseline haemodynamic parameters. SAB induced fall in SBP, DBP and MAP was significantly less in the ondansetron group as compared to placebo from the time of initiation of SAB up to 12 minutes of surgery time (p<0.05). However, the difference in HR between both the groups was not statistically significant. the total use of vasopressors was less in ondansetron group as compared to placebo (p<0.05). Better neonatal outcomes were observed in the ondansetron group.ConclusionsIntravenous ondansetron premedication can successfully attenuate SAB induced fall in SBP, DBP and MAP in parturients undergoing elective cesarean sections.

The effect of haemodynamic monitoring of pulmonary artery pressure has predominantly been studied in the USA. There is a clear need for randomised trial data from patients treated with contemporary guideline-directed-medical-therapy with long-term follow-up in a different health-care system. MONITOR-HF was an open-label, randomised trial, done in 25 centres in the Netherlands. Eligible patients had chronic heart failure of New York Heart Association class III and a previous heart failure hospitalisation, irrespective of ejection fraction. Patients were randomly assigned (1:1) to haemodynamic monitoring (CardioMEMS-HF system, Abbott Laboratories, Abbott Park, IL, USA) or standard care. All patients were scheduled to be seen by their clinician at 3 months and 6 months, and every 6 months thereafter, up to 48 months. The primary endpoint was the mean difference in the Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary score at 12 months. All analyses were by intention-to-treat. This trial was prospectively registered under the clinical trial registration number NTR7673 (NL7430) on the International Clinical Trials Registry Platform. Between April 1, 2019, and Jan 14, 2022, we randomly assigned 348 patients to either the CardioMEMS-HF group (n=176 [51%]) or the control group (n=172 [49%]). The median age was 69 years (IQR 61–75) and median ejection fraction was 30% (23–40). The difference in mean change in KCCQ overall summary score at 12 months was 7·13 (95% CI 1·51–12·75; p=0·013) between groups (+7·05 in the CardioMEMS group, p=0·0014, and –0·08 in the standard care group, p=0·97). In the responder analysis, the odds ratio (OR) of an improvement of at least 5 points in KCCQ overall summary score was OR 1·69 (95% CI 1·01–2·83; p=0·046) and the OR of a deterioration of at least 5 points was 0·45 (0·26–0·77; p=0·0035) in the CardioMEMS-HF group compared with in the standard care group. The freedom of device-related or system-related complications and sensor failure were 97·7% and 98·8%, respectively. Haemodynamic monitoring substantially improved quality of life and reduced heart failure hospitalisations in patients with moderate-to-severe heart failure treated according to contemporary guidelines. These findings contribute to the aggregate evidence for this technology and might have implications for guideline recommendations and implementation of remote pulmonary artery pressure monitoring. The Dutch Ministry of Health, Health Care Institute (Zorginstituut), and Abbott Laboratories.

Introduction: Conduction system pacing is a novel way for delivering cardiac resynchronisation therapy (CRT). This may deliver more effective ventricular resynchronisation than the gold standard, biventricular pacing (BVP). In BVP scar burden is known to impact response but whether this is true for conduction system pacing is unknown. Methods: Patients with standard CRT indications were recruited. They underwent a pre-procedure cardiac MRI, with late gadolinium enhancement to assess scar. Scar burden was quantified as the percentage of the amount of myocardium for each segment and the whole of the left ventricle (total scar). Conduction system pacing with both His bundle CRT (HB-CRT) and left bundle area CRT (LBA-CRT) was attempted in everyone, and the modality that delivered the narrowest QRS duration was selected. The electrical response was measured using non-invasive mapping (ECGi, CardioInsight, Medtronic). The haemodynamic response was measured with a high precision protocol. We investigated the impact of scar on the electrical and haemodynamic response. Results: A total of 26 patients were recruited, 85% male, mean age 69 ± 10 years, ischaemic cardiomyopathy in 35% and mean QRS duration 160 ± 15. LGE was observed in 96% of cases, mean total scar burden was 13 ± 12% (range 1–39%). We found a significant correlation between amount of scar and both the electrical and acute haemodynamic response (Figure 1). Patients with a lower scar burden obtained a greater improvement in both electrical resynchronisation (R=0.55, 95% CI 0.21–0.77, p<0.01, for reduction in left ventricular activation time [LVAT]), and acute haemodynamic response (R=0.5, 95% CI 0.18–0.76, p=0.005 for increase in acute systolic blood pressure). Conclusion: Conduction system pacing appears to be less effective in patients with a high left ventricular scar burden. We observed a strong correlation between scar burden and both ventricular electrical resynchronisation and acute haemodynamic response. This information may help patient selection for conduction system CRT. Alternative CRT modalities or combinations of modalities warrant further investigation in this challenging group of patients. ❑ [Image Omitted]

Introduction: Reducing unnecessary and inappropriate implantable cardioverter defibrillator (ICD) therapies reduces mortality. This was demonstrated in studies that investigated using higher rates for treatment zones and longer detection windows. ICDs currently do not utilise haemodynamic measurements to guide therapies. We have previously shown that a potentially implantable sensor can reliably identify loss of perfusion in ventricular fibrillation. It is possible that programming even longer detection windows could further reduce unnecessary shocks; however, it is not known in how many patients this may be beneficial, and the risk with adopting this approach is that appropriate shocks would be withheld for longer than necessary in the presence of reduced coronary blood flow (CBF). A disadvantage of using higher heart rate zones is that slower haemodynamically compromising VTs are left untreated. We investigated the impact of simulated VT on CBF and invasive blood pressure (BP). The aims were to determine whether detection windows could potentially be safely extended in some patients during VT and to identify what proportion of patients poorly tolerate episodes of slower VT. Methods: We recruited patients undergoing a clinically indicated invasive coronary angiogram. We simulated VT by delivering right ventricular VVI pacing, via a temporary wire. Each patient underwent a randomized ventricular pacing (Vp) protocol (140, 160, 180 and 200 bpm) for a minimum of 30 seconds. During each Vp protocol, continuous 3-lead ECG, invasive beat-by-beat arterial BP and invasive CBF, using a combowire in the mid-left anterior descending artery, were recorded. Significant haemodynamic compromise was defined as a reduction in CBF and/or a sustained drop of 30% in systolic BP (SBP) compared with measurements made during baseline rhythm. Results: A total of 21 patients were recruited, of whom 8 (38%) were female. The mean age was 65 years, and 5 patients (24%) had a left ventricular ejection fraction less than 35%. Data were collected during 145 simulated VT episodes (25 at 200 bpm, 42 at 180 bpm, 39 at 160 and 140 bpm, and 38 at 120 bpm). Results showed that 28% of simulated VT episodes at a rate of 200 bpm were haemodynamically tolerated. This suggests that ICD therapies could potentially be delayed for longer during these VT episodes to allow more time for VT to self-terminate. Haemodynamic compromise was observed in a proportion of slower simulated VT episodes (rates that are below current guidelines for primary prevention programming). For the combined endpoint of decline in CBF and SBP, VT was not tolerated in 11 (28.9%) at 120 bpm, 12 (30.8%) at 140 bpm, 22 (56.4%) at 160 bpm and 28 (66.7%) at 180 bpm. An isolated reduction in CBF had a greater impact on haemodynamic compromise at slower rates (9 (23.7%) at 120 bpm vs 1 (2.6%) at 160 bpm), whereas faster rates were driven by sustained drops in SBP. Proportionally, more patients had haemodynamic compromise at higher heart rates compared with slower heart rates (p=0.016). Conclusion: One-third of simulated VT episodes at 200 bpm were haemodynamically well tolerated. This suggests VT detection windows could potentially be safely extended, with the aim of reducing unnecessary therapies in a significant number of VT episodes. In contrast, many episodes of slower VT were poorly tolerated, implying that therapies may be beneficial. Thus, ICD programming could be further optimized with haemodynamically guided therapies compared with currently used methods, which exclusively rely on the electrogram. [Image Omitted]

Background Fluid loading with crystalloids is the conventional treatment of major hemorrhage but might tend to create fluid overload. We studied hemodynamic profiles of fluid replacement therapies during major surgical hemorrhage and compared the ability of pulse pressure variation (PPV), plethysmographic variation index (PVI), cardiac output (CO) and Guyton´s approach to detect hypovolemia. Methods In this single center randomized controlled trial, fluid replacement therapy to treat hemorrhage in 42 patients was randomized to consist of either 5% albumin (12 mL/kg) or 20% albumin (3 mL/kg) over 30 min, both completed by Ringer lactate replacing blood loss in a 1:1 ratio, or Ringer solution alone in a 3:1 ratio. Measurements included CO, PPV, PVI, arterial and central venous pressures, heart rate (HR) and subsequent calculation of Guyton´s physiological parameters. CO was measured by an esophageal Doppler probe. Results The Ringer-only fluid program resulted in slight hypovolemia (mean, 313 mL), decreased mean arterial pressure (MAP), increased HR, PPV values and vasopressor requirement. The 5% and 20% albumin programs were more effective in filling the vascular system, as evidenced by higher mean circulatory filling pressure and unchanged or decreased PPV over the 5 h observation period. The 20% albumin increased the systemic vascular resistance and the resistance to venous return. Receiver operating characteristics curves indicated that hypovolemia > 500 mL could only be accurately detected by PPV when 5% albumin was used, that PVI was reliable when Ringer was infused, and that CO indicated the hypovolemia when 20% albumin was administered. Conclusions The trends in PPV, PVI, and CO reflected the changes in intravascular volume, but how well they indicated hypovolemia > 500 mL may differ depending on the choice of infusion fluid. Identifying hypovolemia using non-invasive hemodynamic monitors remains challenging and associated with low predictive values. Trial registration number: NCT05391607, May 26, 2022.

Purpose Mortality in circulatory shock is high. Enhanced resolution of shock may improve outcomes. We aim to determine whether adding hemodynamic monitoring with continual transesophageal echocardiography (hTEE) to usual care accelerates resolution of hemodynamic instability. Methods 550 patients with circulatory shock were randomly assigned to four groups stratified using hTEE (hTEE vs usual care) and assessment frequency (minimum every 4 h vs 8 h). Primary outcome was time to resolution of hemodynamic instability, analyzed as intention-to-treat (ITT) analysis at day 6 and in a predefined secondary analysis at days 3 and 28. Results Of 550 randomized patients, 271 with hTEE and 274 patients with usual care were eligible and included in the ITT analysis. Time to resolution of hemodynamic instability did not differ within the first 6 days [hTEE vs usual care adjusted sub-hazard ratio (SHR) 1.20, 95% confidence interval (CI) 0.98–1.46, p  = 0.067]. Time to resolution of hemodynamic instability during the 72 h of hTEE monitoring was shorter in patients with TEE (hTEE vs usual care SHR 1.26, 95% CI 1.02–1.55, p  = 0.034). Assessment frequency had no influence. Time to resolution of clinical signs of hypoperfusion, duration of organ support, length of stay and mortality in the intensive care unit and hospital, and mortality at 28 days did not differ between groups. Conclusions In critically ill patients with shock, hTEE monitoring or hemodynamic assessment frequency did not influence resolution of hemodynamic instability or mortality within the first 6 days. Trial registration and statistical analysis plan ClinicalTrials.gov Identifier: NCT02048566.

Hemodynamic-guided heart failure (HF) management using pulmonary artery (PA) pressures reduces HF hospitalizations (HFHs) in previously hospitalized HF patients with New York Heart Association (NYHA) class III symptoms. It remains uncertain whether this approach reduces not only HFHs but all-cause mortality and if benefits extend to patients with NYHA class II and IV HF or to those symptomatic patients with elevated natriuretic peptides without recent HFH. GUIDE-HF is a prospective trial with 2 arms enrolling patients with HF regardless of ejection fraction (EF). The randomized arm is a single-blind, randomized, controlled trial of PA pressure-guided therapy in NYHA class II-IV patients (n = 1,000) with either a previous HFH or elevated natriuretic peptides (B-type natriuretic peptide/NT-pro–B-type natriuretic peptide). All consenting subjects will receive an implantable PA pressure sensor (CardioMEMS HF System) followed by randomization to either a treatment group, managed with provider remote access to the hemodynamic data, or a control group, managed without provider access to these data. Subjects in the control group will receive scheduled, scripted, sham contacts from the study team to maintain blinding as to their study group assignment. The primary study end point is the composite of cumulative HF events and all-cause mortality at 12 months. Secondary end points include quality-of-life and functional assessments. The single arm of the trial is an observational arm in which NYHA class III patients (n = 2,600) with either a previous HFH or elevated natriuretic peptides (but no recent HFH) will be implanted with a PA pressure sensor and observed for occurrence of the primary composite end point of cumulative HF events and mortality at 12 months. This arm will test the hypothesis that hemodynamic-guided care is similarly effective in HF patients enrolled on the basis of elevated natriuretic peptide levels but no recent HFH and those with a recent HFH. GUIDE-HF is the largest clinical trial of hemodynamic-guided HF management across a broad population of HF patients, with a study design and sample size adequate to examine survival, cumulative HF events, quality of life, and functional capacity.

Amaç: Bu çalışmanın amacı esmolol kullanılarak oluşturulan hipotansif anestezinin DPOAE (distorsiyon ürünü otoakustilk emisyon) yanıtlarına etkisini ve bu yolla koklear monitorizasyonda kullanılabilirliğini araştırmaktır. Gereç ve Yöntemler: Bu çalısma, genel anestezi altında opere edilen 18-65 yaş aralığında, 25 hastayı kapsamaktadır. 50-300 mcg/kg/dk esmolol infüzyonu anestezi indüksiyonuyla eşzamanlı uygulanarak, Bispectral Index (BIS) değeri 40-60 aralığında sürdürüldü. Ameliyat süresince, ortalama arter basıncı bazal değerin %20 altında olacak şekilde esmolol infüzyon dozları ayarlandı. Hemodinamik ve solunumsal parametreler ile otoakustik emisyon ölçümleri indüksiyon öncesi 0. dk, induksiyon sonrası 3. dk., 10. dk. ve 20. dk.’da kaydedildi. Bulgular: İzlem zamanları arasında 1500 Hz, 2000 Hz, 3000 Hz, 4000 Hz, 5000 hz, 6000 Hz’deki DPOAE düzeyleri yönünden istatistiksel olarak anlamlı farklılık görülmedi. Sıfırıncı dakikaya göre 3., 10., 20. dakikadaki DPOAE düzeylerindeki değişim ile hemodinamik ölçümlerde meydana gelen yüzdesel değişim miktarları arasında Bonferroni düzeltmesine göre istatistiksel olarak anlamlı korelasyon saptanmadı. Sonuç: Bu çalışmada esmolol kullanılarak oluşturulan hipotansif anestezinin DPOAE yanıtlarına etkisinin olmadığı saptanmıştır. Bu sonuç kullandığımız prosedürün lateral kafa tabanı cerrahilerinde hipotansif anestezi sağlayarak güvenli koklear monitorizasyona olanak vermesi açısından öneme sahiptir.