Associazione Nazionale Medici Cardiologi Ospedalieri



Non-invasive assessment of cardiac hemodynamics by bio-impedance in a patient with heart failure and excellent response to cardiac resynchronization therapy.

Giannotti Santoro Mario Livorno(LI) – Cardiologia UTIC Ospedali Riuniti di Livorno | Puccioni Enrico Livorno(LI) – Cardiologia UTIC Ospedali Riuniti di Livorno | Pro Francesco Pisa(PI) – Free Lance

Patient Presentation: We present a 78-year-old patient admitted to our Cardiology Unit for chronic heart failure with severe left ventricular dysfunction, atrial fibrillation, and recent percutaneous aortic valve replacement and an NYHA IIb class. His therapy was fully optimized. The patient was evaluated during the recovery period. An echocardiogram confirmed severe left ventricular dysfunction (LVEF = 30%). The ECG demonstrated atrial fibrillation with episodes of severe bradycardia and tachycardia. The QRS duration was 145 msec.

Diagnosis and Management: Cardiac pacing implantation was indicated for heart rate stabilization. To assess the patient ‘s clinical status and optimize therapy, we performed a non-invasive bio-impedance Cardiac hemodynamic evaluation using the NICaS device before the implantation (Figure 1). This device provides accurate(1,2,3) information on cardiovascular, respiratory, and fluid parameters in a non-invasive and reproducible manner (Figure 2).

The analysis revealed a low stroke volume (47 ml), low stroke index (26.0 ml/m2), low cardiac output (3.34 L/min), low cardiac index (1.85 L/min/m2), high peripheral resistance (2344 dyn*s/cm5), and high body water (38.0 kg) (see Figure 3). The patient underwent cardiac resynchronization therapy and defibrillator (CRTD) implantation. The patient was discharged with the same therapy as admission, except for the addition of a low dose of digitalis to improve rate control.

Follow-Up: The first follow-up was performed after 3 months. Electronic control revealed regular device function, with ventricular pacing of 99%. The patient showed an improvement in dyspnea, with a NYHA class of I. The echocardiogram showed a significant improvement in the left ventricular ejection fraction (50%).

We performed a repeat analysis with NICaS, demonstrating improvement in all hemodynamic parameters (Figure 3): stroke volume 60 ml (+13 ml), stroke index 35.5 ml/m2 (+9.5), cardiac output 5.11 L/min (+1.77), cardiac index 3.02 L/min/m2 (+1.17), peripheral resistance 1236 dyn*s/cm5 (-1108).

Conclusion: The non-invasive bioimpedance-based system – Nicas, allows for the accurate assessment and monitoring of the patient ‘s hemodynamics. In our patient, the implantation of a CRTD has led to a significant improvement in clinical status, left ventricular ejection fraction, and all hemodynamic parameters, clearly demonstrated through an easy-to-use office non-invasive modality.