| 1. |
- Bech-Hanssen, Odd, 1956, et al.
(författare)
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A novel echocardiographic right ventricular dysfunction score can identify hemodynamic severity profiles in left ventricular dysfunction
- 2022
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Ingår i: Cardiovascular Ultrasound. - : Springer Science and Business Media LLC. - 1476-7120. ; 20
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Tidskriftsartikel (refereegranskat)abstract
- Purpose: Recognition of congestion and hypoperfusion in patients with chronic left ventricular dysfunction (LVD) has therapeutic and prognostic implications. In the present study we hypothesized that a multiparameter echocardiographic grading of right ventricular dysfunction (RVD) can facilitate the characterization of hemodynamic profiles. Methods: Consecutive patients (n = 105, age 53 ± 14years, males 77%, LV ejection fraction 28 ± 11%) referred for heart transplant or heart failure work-up, with catheterization and echocardiography within 48h, were reviewed retrospectively. Three hemodynamic profiles were defined: compensated LVD (cLVD, normal pulmonary capillary wedge pressure (PCWP < 15mmHg) and normal mixed venous saturation (SvO2 ≥ 60%)); decompensated LVD (dLVD, with increased PCWP) and LV failure (LVF, increased PCWP and reduced SvO2). We established a 5-point RVD score including pulmonary hypertension, reduced tricuspid annular plane systolic excursion, RV dilatation, ≥ moderate tricuspid regurgitation and increased right atrial pressure. Results: The RVD score [median (IQR 25%;75%)] showed significant in-between the three groups differences with 1 (0;1), 1 (0.5;2) and 3.0 (2;3.5) in patients with cLVD, dLVD and LVF, respectively. The finding of RVD score ≥ 2 or ≥ 4 increased the likelihood of decompensation or LVF 5.2-fold and 6.7-fold, respectively. On the contrary, RVD score < 1 and < 2 reduced the likelihood 11.1-fold and 25-fold, respectively. The RVD score was more helpful than standard echocardiography regarding identification of hemodynamic profiles. Conclusions: In this proof of concept study an echocardiographic RVD score identified different hemodynamic severity profiles in patients with chronic LVD and reduced ejection fraction. Further studies are needed to validate its general applicability. Graphical abstract: [Figure not available: see fulltext.]
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| 2. |
- Bech-Hanssen, Odd, 1956, et al.
(författare)
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Grading right ventricular dysfunction in left ventricular disease using echocardiography: a proof of concept using a novel multiparameter strategy.
- 2021
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Ingår i: ESC heart failure. - : Wiley. - 2055-5822. ; 8:4, s. 3223-3236
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Tidskriftsartikel (refereegranskat)abstract
- Grading right ventricular dysfunction (RVD) in patients with left ventricular (LV) disease has earned little attention. In the present study, we established an echocardiographic RVD score and investigated how increments of the score correspond to RVD at right heart catheterization.We included 95 patients with LV disease consecutively referred for heart transplant or heart failure work-up with catheterization and echocardiography within 48h. The RVD score (5 points) included well-known characteristics of the development from compensated to decompensated right ventricular (RV) function: pulmonary hypertension, reduced RV strain, RV area dilatation, moderate/severe tricuspid regurgitation, and increased right atrial pressure (RAP) by echocardiography. Comparing three groups with increments of RVD score [1 (mild), 2-3 (moderate), and 4-5 (severe)] showed more advanced RVD with increasing RV end-diastolic pressure (P<0.001) and signs of uncoupling to load (reduced ratio between RV and pulmonary artery elastance, P<0.001) and more spherical RV shape (RV area/length, P<0.001). Receiver operating characteristic curve analysis for detection of severe RV (RAP≥10mmHg) showed for the RVD score an area under the curve of 0.88 compared with 0.69, 0.68, and 0.64 for RV strain, tricuspid annular plane systolic excursion, and fractional area change, respectively. A patient with RVD score≥4 had a 6.7-fold increase in likelihood of severe RVD, and no patient with RVD score≤1 had severe RVD.In this proof of concept study, a novel RVD score outperformed the widely used longitudinal parameters regarding grading of RVD severity, with a potential role for refined diagnosis, follow-up, and prognosis assessment in heart failure patients.
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| 3. |
- Fredholm, Martin, 1972, et al.
(författare)
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Inotropic and lusitropic effects of levosimendan and milrinone assessed by strain echocardiography: A randomised trial
- 2018
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Ingår i: Acta Anaesthesiologica Scandinavica. - : Wiley. - 0001-5172. ; 62:9, s. 1246-1254
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundWe compared the direct inotropic and lusitropic effects of two inodilators, milrinone and levosimendan in patients after aortic valve replacement for aortic stenosis. MethodsIn this randomised, blinded study, 31 patients with normal LV function, were randomised to either levosimendan (0.1 and 0.2g/kg/min, n=15) or milrinone (0.4 and 0.8g/kg/min, n=16) after aortic valve replacement. The effects on LV performance, LV strain, systolic (SR-S) and early diastolic (SR-E) strain rate were assessed by a pulmonary artery catheter and transoesophageal two-dimensional speckle tracking echocardiography of the LV inferior wall. To circumvent the inodilator-induced hemodynamic changes on LV systolic and diastolic deformation, central venous pressure (CVP), systolic artery pressure (SAP), and heart rate were maintained constant by colloid infusion, phenylephrine-induced vasoconstriction and atrial pacing, respectively, during drug infusion. ResultsBoth inotropic agents induced a dose-dependent increase in cardiac index and stroke volume index by approximately 20% at the highest infusion rates with no differences between groups (P=.139 and .249, respectively). CVP, pulmonary capillary wedge pressure, SAP and heart rate were maintained constant in both groups. LV strain and SR-S increased with both agents, dose-dependently, by 17%-18% and 25%-30%, respectively, at the highest infusion rates, with no difference between groups (P=.434 and .284, respectively). Both agents improved early LV relaxation with no differences between groups (P=.637). At the higher doses, both agents increased SR-E by 30%. ConclusionsAt clinically relevant infusion rates and a certain increase in LV performance the direct inotropic and lusitropic of milrinone and levosimendan were comparable.
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| 4. |
- Fredholm, Martin, 1972, et al.
(författare)
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Levosimendan or milrinone for right ventricular inotropic treatment?-A secondary analysis of a randomized trial
- 2020
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Ingår i: Acta Anaesthesiologica Scandinavica. - : Wiley. - 0001-5172 .- 1399-6576. ; 64:2, s. 193-201
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Tidskriftsartikel (refereegranskat)abstract
- Background The aim of the present study was to compare the effects of milrinone and levosimendan on right ventricular (RV) inotropy and lusitropy in patients after aortic valve replacement (AVR) for aortic stenosis, a procedure in which an abnormal postoperative RV function may be seen. Methods In a prospective, blinded trial, 31 patients were randomized to receive either milrinone (0.4 and 0.8 µg/kg/min, n = 16) or levosimendan (0.1 and 0.2 µg/kg/min, n = 15) after AVR for aortic stenosis. RV performance, afterload (pulmonary arterial elastance), RV strain, systolic (SR‐S) and early diastolic (SR‐E) strain rate were measured by pulmonary artery thermodilution catheterization and transoesophageal two‐dimensional speckle tracking echocardiography. To circumvent the indirect effects of inodilator‐induced hemodynamic changes on RV systolic and diastolic deformation, pulmonary arterial elastance, central venous pressure and heart rate were maintained constant by atrial pacing, plasma volume expansion with colloids and phenylephrine‐induced vasoconstriction during treatment with the inotropes. Results A dose‐dependent increase in stroke volume index and cardiac index by approximately 20% were seen with both agents at the highest doses, with no difference between groups (P = .792 and 0.744, respectively). In both groups, RV strain and SR‐S dose‐dependently increased by 20% and 15%‐19%, respectively, at the highest doses (P = .742 and 0.259, respectively) with no difference between groups. SR‐E improved by both agents 20%‐24% at the highest dose with no difference between groups (P = .714). Conclusions The direct RV inotropic and lusitropic effects of levosimendan and milrinone were comparable at clinically relevant infusion rates.
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| 5. |
- Fredholm, Martin, 1972, et al.
(författare)
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Load-dependence of myocardial deformation variables - a clinical strain-echocardiographic study
- 2017
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Ingår i: Acta Anaesthesiologica Scandinavica. - : Wiley. - 0001-5172. ; 61:9, s. 1155-1165
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundThe effects of left ventricular (LV) loading on myocardial deformation variables are not well-studied in the clinical setting. In the present study, we evaluated the effects of isolated changes in preload, afterload and heart rate on LV longitudinal strain, systolic (SR-S) and early diastolic strain rate (SR-E) in post-cardiac surgery patients. MethodsTwenty-one patients were studied early after cardiac surgery. Longitudinal myocardial strain and SR were analysed off-line using 2-D speckle echocardiography. The experimental protocol consisted of three consecutive interventions: (1) preload was increased by passive leg elevation, (2) afterload was increased by an infusion of phenylephrine to increase arterial blood pressure by 10-15% and (3) heart rate was increased 10% and 20% by atrial pacing. During both the preload and afterload challenges heart rate was kept constant by atrial pacing. Central venous pressure was kept constant during pacing by infusion of hetastarch/albumin. ResultsThe increase in preload increased LV strain, SR-S and SR-E by 20%, 11% and 17%, respectively. The phenylephrine-induced increase in afterload, did not affect LV strain, SR-S or SR-E. LV strain was not affected while SR-S and SR-E increased by pacing-induced heart rate increase. ConclusionAfter cardiac surgery, systolic and early diastolic strain rate are dependent on both preload and heart rate, while neither of these variables was afterload-dependent. LV strain was preload-dependent but not affected by atrial pacing. When evaluating the direct effects of various pharmacological or other interventions on myocardial contractility and relaxation, preload and heart rate must be controlled.
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| 6. |
- Fredholm, Martin, 1972
(författare)
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Strain echocardiography in cardiac surgery - studies on the effects of loading conditions and inotropic agents on myocardial contraction and relaxation
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Although reductions in myocardial contractility and relaxation are key compo-nents in heart failure (HF), assessment of them is difficult, as clinical measurements deal with a net effect of myocardial contractility, heart filling (preload), outflow impedance (afterload) and heart rate (HR). Echocardiographic (echo) deformation parameters, like strain (myocardial shortening) and strain rate (the speed of deformation, SR), have been proposed to more accu-rately measure myocardial function, but incongruent previous studies have raised concerns that they may be load-dependent. This load-dependency of echo measurements in general also explains the difficulties assessing right ventricular (RV) function whenever left ventricular (LV) failure is present. Lastly, the inodilators milrinone (MIL) and levosimendan (LEV), often used in treating severe HF, have never been compared head-to-head taking this load-dependency into account. Aims and methods: We wanted to evaluate whether strain and SR were dependent on preload, afterload and HR (paper I). While keeping cardiac loading and HR constant, we compared the myocardial effects of MIL vs. LEV in a randomized trial, combining echo (for strain and systolic (SR-S) and diastolic (SR-E) SR) with hemodynamic measurements from a pulmonary artery catheter (papers II–III). We included post-cardiac surgery aortic stenosis patients with normal LV function for papers I–III. In paper IV, we retrospectively compared echo indices of RV function with right heart catheterization data in patients with severe HF, creating three groups: A) right atrial pressure (RAP) <10 mmHg and stroke volume index (SVI) ≥35 ml/m2, B) RAP <10 mmHg and SVI <35 ml/m2, and C) RAP ≥10 mmHg. The RV echo indices were assessed for their ability to identify group B from C. Results: With increased preload by passive leg elevation, cardiac output (CO), strain, SR-S, and SR-E increased significantly, while increased HR by atrial pacing increased only CO, SR-S, and SR-E. Under constant loading and HR, MIL and LEV increased CO by 20%, RV and LV strain by almost 20%, and SR-S and SR-E by almost 30% in both ventricles, with no differences be-tween groups. In paper IV, echo indices of RV longitudinal function (such as TAPSE, S’, FAC and strain) failed to distinguish group B from C, while all RV dimensional measurements could. By combining six RV echo indices into a novel score, the RV failure (RVF) score, significant discrimination between group B and C was found. Conclusions: 1) Strain is preload- and HR-dependent while SR depends on HR. 2) MIL and LEVO have comparable effects on LV and RV systolic and diastolic function. 3) To assess RVF in LV disease, a single-parameter approach is inadequate and we propose a combination of six parameters into a novel RVF score.
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