Background Peripheral venous pressure (PVP) has been shown to be a reliable surrogate for right atrial pressure in assessing congestion in patients with heart failure (HF). Liver fibrosis markers and ...scores can be useful in assessing organ injury in patients with acute HF. This study aimed to investigate the association of liver fibrosis markers and scores with PVP in patients with acute HF. Methods and Results The 7S domain of the collagen type IV N-terminal propeptide (P4NP 7S), aspartate aminotransferase-to-platelet ratio index, fibrosis-4, and nonalcoholic fatty liver disease fibrosis score were determined along with PVP measurements before discharge in 229 patients with acute HF. The strongest correlation with PVP was found for P4NP 7S (Pearson
=0.40). Patients with high P4NP 7S levels (≥median 6.2 ng/mL) had an increased risk of cardiovascular death or HF hospitalization (adjusted hazard ratio HR, 1.80 95% CI, 1.09-3.04,
=0.02). The concomitant high PVP (≥mean 8 mm Hg)/high P4NP 7S group, in contrast to the high PVP/low P4NP 7S or low PVP/high P4NP 7S group, had a significant risk relative to the low PVP/low P4NP 7S group for cardiovascular death or HF hospitalization (adjusted HR, 2.63 95% CI, 1.43-5.05,
=0.002). A sustained elevation in PVP for 1 month postdischarge was associated with a persistent increase in P4NP 7S. Conclusions The study demonstrated the relationship between the liver fibrosis marker P4NP 7S and congestion. PVP and P4NP 7S could be useful for assessing congestion-related organ injury and predicting prognosis in patients with acute HF.
Congestion is a major cause of hospitalization for heart failure (HF). Peripheral venous pressure (PVP) strongly correlates with right atrial pressure. We recently reported that high PVP at discharge ...portends a poor prognosis in patients hospitalized for HF. In the same population, we aimed to analyze changes in PVP after discharge and to evaluate prognostic implications of post-discharge PVP.
PVP was measured at the forearm vein of 163 patients in the 1-month post-discharge follow-up visit. The primary outcome was a composite of cardiovascular death or re-hospitalization for HF after the 1-month follow-up visit up to 1 year after discharge.
Post-discharge PVP correlated with jugular venous pressure, the inferior vena cava diameter, and brain-type natriuretic peptide levels. The cumulative incidence of the primary outcome event was significantly higher in patients with PVP above the median (6 mmHg) than in those with median PVP or lower (39.8% versus 16.9%, Log-rank P = 0.04). Age- and sex-adjusted risk of PVP per 1 mmHg for the primary outcome measure was significant (hazard ratio: 1.12 95% confidence interval 1.03–1.21). 35% of patients who had PVP ≤6 mmHg at discharge had PVP >6 mmHg at the 1-month follow-up. PVP significantly decreased from discharge to 1-month follow-up in patients without the primary outcome event (from 6 4–10 to 6 4–8 mmHg, P=0.01), but remained high in those with the primary outcome event (from 8 5–11 to 7 5–10.5 mmHg, P = 0.9).
PVP measurements during the early post-discharge period may be useful to identify high risk patients.
Trial registration number: UMIN000034279.
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•Post-discharge congestion can be assessed by peripheral venous pressure (PVP).•PVP at 1-month post-discharge correlated with subsequent clinical outcomes.•Sustained increase in PVP after discharge portends worse clinical outcomes.•PVP may be useful to monitor congestion status and identify high risk patients.
Abstract
Background
Although infective endocarditis (IE) in pregnancy is rare, maternal and foetal mortality rates are very high. We herein report the successful treatment of a case of IE with ...simultaneous emergent caesarean section and mitral valve replacement performed at 27 weeks of gestation.
Case summary
A 29-year-old woman at 27 weeks of gestation was referred for congestive heart failure (HF) due to infective endocarditis (IE) with large mobile vegetations and overt disruption of the mitral valve. We held a multi-disciplinary conference and decided to perform mitral valve replacement immediately after caesarean section because of the high risk of embolism and sepsis, worsening and unstable haemodynamics, and sufficient foetal maturity for delivery. Although coronary artery embolization and asymptomatic multiple cerebral infarctions were observed, her post-operative course was uneventful. Ultimately, the patient was discharged 29 days after surgery. The neonate was treated in the NICU until the expected delivery date and was discharged home on Day 95 of life.
Discussion
Difficulties are associated with the selection of an operative plan and its timing for IE during pregnancy. Heart failure due to IE requires urgent surgery when medical treatment cannot stabilize the patient. However, cardiopulmonary bypass and medicine for pregnant women adversely affect the foetus. Therefore, the timing of surgery and delivery needs to be selected by a multi-disciplinary team and in consideration of the maternal condition and foetal maturity.
Congestion is the major cause of hospitalization for heart failure (HF). Traditional bedside assessment of congestion is limited by insufficient accuracy. Peripheral venous pressure (PVP) has ...recently been shown to accurately predict central venous congestion. We examined the association between PVP before discharge and post-discharge outcomes in hospitalized patients with acute HF.
Bedside PVP measurement at the forearm vein and traditional clinical examination were performed in 239 patients. The association with the primary composite endpoint of cardiovascular death or HF hospitalization and the incremental prognostic value beyond the established HF risk score was examined. The PVP correlated with peripheral oedema, jugular venous pressure, and inferior vena cava diameter, but not with brain-type natriuretic peptide. The 1-year incidence of the primary outcome measure in the first, second, and third tertiles of PVP was 21.4, 29.9, and 40.7%, respectively (log-rank P = 0.017). The adjusted hazard ratio of PVP per 1 mmHg increase for the 1-year outcome was 1.08 95% confidence interval (1.03-1.14), P = 0.004. When added onto the Meta-Analysis Global Group in Chronic HF risk score, PVP significantly increased the area under the receiver-operating characteristic curve for predicting the outcome from 0.63 (0.56-0.71) to 0.70 (0.62-0.77), P = 0.02), while traditional assessments did not. The addition of PVP also yielded significant net reclassification improvement 0.46 (0.19-0.74), P < 0.001.
The PVP at discharge correlated with prognosis. The results warrant further investigation to evaluate the clinical application of PVP measurement in the care of HF.
UMIN000034279.
BACKGROUNDAlthough infective endocarditis (IE) in pregnancy is rare, maternal and foetal mortality rates are very high. We herein report the successful treatment of a case of IE with simultaneous ...emergent caesarean section and mitral valve replacement performed at 27 weeks of gestation. CASE SUMMARYA 29-year-old woman at 27 weeks of gestation was referred for congestive heart failure (HF) due to infective endocarditis (IE) with large mobile vegetations and overt disruption of the mitral valve. We held a multi-disciplinary conference and decided to perform mitral valve replacement immediately after caesarean section because of the high risk of embolism and sepsis, worsening and unstable haemodynamics, and sufficient foetal maturity for delivery. Although coronary artery embolization and asymptomatic multiple cerebral infarctions were observed, her post-operative course was uneventful. Ultimately, the patient was discharged 29 days after surgery. The neonate was treated in the NICU until the expected delivery date and was discharged home on Day 95 of life. DISCUSSIONDifficulties are associated with the selection of an operative plan and its timing for IE during pregnancy. Heart failure due to IE requires urgent surgery when medical treatment cannot stabilize the patient. However, cardiopulmonary bypass and medicine for pregnant women adversely affect the foetus. Therefore, the timing of surgery and delivery needs to be selected by a multi-disciplinary team and in consideration of the maternal condition and foetal maturity.
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