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The Compensatory Reserve Index Responds to Acute Hemodynamic Changes in Patients with Congenital Heart Disease: A Proof of Concept Study

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Abstract

Patients with congenital heart disease (CHD) who undergo cardiac procedures may become hemodynamically unstable. Predictive algorithms that utilize dense physiologic data may be useful. The compensatory reserve index (CRI) trends beat-to-beat progression from normovolemia (CRI = 1) to decompensation (CRI = 0) in hemorrhagic shock by continuously analyzing unique sets of features in the changing pulse photoplethysmogram (PPG) waveform. We sought to understand if the CRI accurately reflects changing hemodynamics during and after a cardiac procedure for patients with CHD. A transcatheter pulmonary valve replacement (TcPVR) model was used because left ventricular stroke volume decreases upon sizing balloon occlusion of the right ventricular outflow tract (RVOT) and increases after successful valve placement. A single-center, prospective cohort study was performed. The CRI was continuously measured to determine the change in CRI before and after RVOT occlusion and successful TcPVR. Twenty-six subjects were enrolled with a median age of 19 (interquartile range (IQR) 13–29) years. The mean (± standard deviation) CRI decreased from 0.66 ± 0.15 1-min before balloon inflation to 0.53 ± 0.16 (p = 0.03) 1-min after balloon deflation. The mean CRI increased from a pre-valve mean CRI of 0.63 [95% confidence interval (CI) 0.56–0.70] to 0.77 (95% CI 0.71–0.83) after successful TcPVR. In this study, the CRI accurately reflected acute hemodynamic changes associated with TcPVR. Further research is justified to determine if the CRI can be useful as an early warning tool in patients with CHD at risk for decompensation during and after cardiac procedures.

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Acknowledgements

The authors wish to thank the Children’s Hospital Colorado catheterization laboratory for their assistance with the study.

Funding

Development of the CRI algorithm was supported in part by funding from the US Army Medical Research and Material Command (USAMRMC) under Grant Nos. DM09027, W81XWH-15--2-0007, W81XWH-09-1-0750, W81XWH-09-C-0160, W81XWH-11-2-0091, W81XWH-11-2-0085, W81XWH-12-2-0112, and W81XWH-13-C-0121. The views, opinions, and/or findings contained in this manuscript are those of the authors and should not be construed as an official Department of the Army position, policy or decision unless so designated by other documentation. Additional support was provided by NIH/NCATS Colorado CTSA Grant Number UL1 TR002535. Contents are the authors’ sole responsibility and do not necessarily represent official NIH views.

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Author notes

  1. Gareth Morgan and John S. Kim are co-senior authors.

Authors and Affiliations

  1. Division of Cardiology, Department of Pediatrics, Children’s Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, B100, Aurora, CO, 80045, USA

    Daniel E. Ehrmann, Jenny E. Zablah, Gareth Morgan & John S. Kim

  2. Department of Anesthesia, University of Colorado School of Medicine, Aurora, CO, USA

    David K. Leopold

  3. Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA

    Ryan Phillips, Niti Shahi & Steven L. Moulton

  4. Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA

    Kristen Campbell

  5. Division of Pediatric Cardiology, University of North Carolina, Chapel Hill, NC, USA

    Michael Ross

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Contributions

DEE: Concept/design, data analysis/interpretation, drafting article, critical revision of article, approval of article, data collection. DKL: Concept/design, data analysis/interpretation, critical revision of article, approval of article, data collection. RP: Critical revision of article, approval of article, data collection. NS: Critical revision of article, approval of article, data collection. KC: Statistics, critical revision of article, approval of article. MR: Concept/design, critical revision of article, approval of article. JEZ: Critical revision of article, approval of article. SLM: Critical revision of article, approval of article. GM: Concept/design, data analysis/interpretation, critical revision of article, approval of article. JSK: Concept/design, data analysis/interpretation, critical revision of article, approval of article, data collection.

Corresponding author

Correspondence to Daniel E. Ehrmann.

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Conflict of interest

Drs. Ehrmann and Kim have no conflicts of interests to declare. Dr. Moulton developed the compensatory reserve index algorithm utilized in this study. The underlying intellectual property is assigned to Flashback Technologies, Inc (Boulder, Colorado) and the Regents of the University of Colorado. Dr. Moulton licensed the technology from the University of Colorado and co-founded Flashback Technologies, Inc. Dr. Moulton is a consultant at Flashback Technologies, has an equity interest in the company, and receives royalty payments through the University of Colorado. Drs. Leopold, Morgan, Phillips, Shahi, Ross, Zablah, and Ms. Campbell have no conflicts of interest to declare.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (Colorado Multi-Institutional Review Board at the University of Colorado) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study.

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Ehrmann, D.E., Leopold, D.K., Phillips, R. et al. The Compensatory Reserve Index Responds to Acute Hemodynamic Changes in Patients with Congenital Heart Disease: A Proof of Concept Study. Pediatr Cardiol 41, 1190–1198 (2020). https://doi.org/10.1007/s00246-020-02374-3

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