Non-invasive Assessment of Left Ventricular End Diastolic PressureChange with a Single Session of Outpatient Intravenous Diuresis in Patients with Heart Failure with Reduced Ejection Fraction

Background Admissions for acute decompensated heart failure (ADHF) may be prevented by early detection and treatment of elevated cardiac filling pressures before the onset of clinical symptoms. We have developed a noninvasive, handheld, point-of-care device to assess left ventricular end diastolic filling pressure (LVEDP). The device measures the change in pulse amplitude of a finger photoplethysmography signal (PPG) during a Valsalva maneuver (VM), which we previously showed reflects invasively measured LVEDP. Our objective in this study was to determine whether LVEDP changes in HF patients undergoing a session of outpatient intravenous (IV) diuresis. Methods Patients receiving IV diuresis at the Johns Hopkins Bayview Diuresis Clinic were recruited. Each enrolled participant performed a VM with expiratory effort of 20 mmHg into a pressure transducer for 10 seconds, before and after the diuresis session. Participants were guided by an automated graphical user interface. A continuous PPG signal was recorded during the testing. LVEDP was then calculated using an equation derived from a previous study we conducted of patients undergoing left heart catheterization. Urine output (UO) during the diuresis session was also measured. Statistical analysis was performed using t-test and regression testing. Results 37 participants (65 ± 15 years, 43% female, 51% white) underwent a total of 53 sessions of IV diuresis. The mean initial LVEDP was 19 ± 4 mmHg. The mean UO was 1.2 ± 0.6 liters. On average, the LVEDP did not change within the same diuresis session (mean LVEDP change -0.26 ± 3.4 mmHg). In participants with heart failure with reduced ejection fraction (HFrEF, EF ≤ 40%), the change in LVEDP was related to UO (r = 0.53, p = 0.028, n=17). Also in that subgroup, the change in LVEDP trended strongly towards being related to initial LVEDP (r = 0.52, p = 0.057, n=17). Conclusion In patients with HFrEF, the change in LVEDP during a session of outpatient IV diuresis was related to the volume of UO. However, despite the mean UO of all sessions among all patients being 1.2L, mean LVEDP did not change. Multiple outpatient IV diuresis sessions may be needed to obtain a measurable decrease in LVEDP. There was a strong trend toward greater LVEDP decrease with higher initial LVEDP in HFrEF patients. This may be related to the end-diastolic pressure-volume relation, in which a decrease in pressure per given decrease in volume is greater at higher end-diastolic volumes. More studies are warranted to determine if this noninvasive device can help guide outpatient IV diuresis in HF patients.