Pulmonary Congestion: New Approaches

Hemodynamic Assessment: Do We Need it?

JoAnn Lindenfeld, MD
Professor of Medicine
Director, Heart Failure and Transplantation
Vanderbilt University
Nashville, TN
 Congestion Symptoms are the Most Common
Symptoms Leading to Heart Failure Re-Hospitalization
High right-sided High left-sided Approximate %
Venous pressures filling Patients With
(RAP, JVP) pressures Symptom
PCW,PAD
(LAP, LVEDP)
Shortness of + 70%
breath lying down
Shortness of breath + 85%
with any exertion

Abdominal + 35%
discomfort
Body swelling + 60%

Any of the above 95%

Data from Aggregate ADHERE Registry –Fonarow, Yancy, Sweitzer et al
The Rise in Filling Pressures Begins Days
Before a Heart Failure Event

Zile MR et al. Circiulation

2008;118:1423-31
 The % Change in ePAD prior to a Heart Failure
Event is only about 10%

Zile MR et al. Circiulation 2008;118:1423-31

Pulmonary Capillary Wedge Pressure(PWCP) is a Better
Predictor of Mortality than Cardiac Index

Fonarow GC. Rev Cardiovasc Med 2001;2: Supp2;S7-12

 The Course of Events Preceding a Heart Failure
Event
Physiologic Markers of Acute Decompensation

But when does congestion occur?

Graph adapted from Adamson PB, et al. Curr Heart Fail Reports,
Lung water correlates with pulmonary
capillary wedge pressure

Thompson et al J Cardiovascular Magnetic Res 2016:18: Supp1 :#049

The Correlation Between diastolic PAP and
Thoracic Impedenc is Poor in Chronic HF

Perego GP et al. International J Cardiology 2017;245:196-200

 The Course of Events Preceding a Heart Failure
Event
Physiologic Markers of Acute Decompensation

But when does congestion occur?

Graph adapted from Adamson PB, et al. Curr Heart Fail Reports,
 CardioMEMS™ HF System
Target location for pulmonary
The pulmonary artery pressure
artery pressure sensor
sensor is implanted via a right
heart catheterization procedure
via femoral vein approach.
 CardioMEMS™ HF System

Pulmonary Artery Patient Electronics CardioMEMS™

Pressure Sensor System HF Website
CHAMPION: A Sustained Reduction of Heart Failure
Hospitalizations

≤ 6 months > 6 months

28% RRR 45% RRR
P< 0.0002 P< 0.0001

Abraham WT et al. Lancet. 2011 ;377:658-66

Adamson PH et al. Circulation HF 2014;7:935-44
More medication changes in the PA Guided Pressure
Group than Controls

Costanzo MR et al. JACC Heart Fail. 2016 ;4:333-44

…and it’s important that there were both increases and
decreases in meds

Costanzo MR et al. JACC Heart Fail. 2016 ;4:333-44

PA Pressure Guided Monitoring Appears to Reduce
HFH and Mortality

Givertz MM et al. JACC 2017; 70:1875-86

CHAMPION: A Sustained Reduction of Heart Failure
Hospitalizations

GUIDE-HF
≤ 6 months
28% RRR
• Randomized arm
P< 0.0002 > 6 months
45% RRR
n = 1000 , all LVEF
P< 0.0001 Primary endpoint Mortality +
Heart Failure Hospitalization
• Single arm n = 3500
To compare heart failure
hospitalization vs NT proBNP as
criteria for benefit

Abraham WT et al. Lancet 2011 Abraham WT et al. Lancet. 2011 ;377:658-66

 What do we wish to accomplish?

Improve
symptoms

Shorten
hospitalization

Reduce
readmissions

Reduce
mortality

Reduce AEs
 What do we wish to accomplish?
Symptoms Weight Lung Optivol Heart BNP REDs CardioMEMs
+ signs Ultrasound Logic

Improve
symptoms
++

Shorten
hospitalization

Reduce
readmissions

Reduce
mortality

Reduce AEs
 What do we wish to accomplish?
Symptoms Weight Lung Optivol Heart BNP REDs CardioMEMs
+ signs Ultrasound Logic

Improve
symptoms
++ +

Shorten
hospitalization

Reduce
readmissions

Reduce
mortality

Reduce AEs
 What do we wish to accomplish?
Symptoms Weight Lung Optivol Heart BNP REDs CardioMEMs
+ signs Ultrasound Logic

Improve
symptoms
++ + +

Shorten
hospitalization

Reduce
readmissions
+?
Reduce
mortality

Reduce AEs
Correlation of ReDs with Pulmonary
Capillary Wedge Pressure

Uriel N et al. J Am Heart Assoc. 2018;7:e009175

 Measurement of Lung Water Has Poor
Positive Predictive Value for PCWP

Uriel N et al. J Am Heart Assoc. 2018;7:e009175

 Why Do We Still Need Hemodynamic
Monitoring?
Symptoms Weight Lung Optivol Heart BNP REDs CardioMEMs
+ signs Ultrasound Logic

Improve
symptoms
++ ++ + ++

Shorten
hospitalization
- -
Reduce
readmissions
- +? +++

Reduce mortality
- ???
Reduce AEs
- +