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There is growing interest in invasive hemodynamic assessment in cardiogenic shock, primarily due to the widespread adoption of mechanical circulatory support (MCS). Invasive hemodynamic assessment is central to two aspects of cardiogenic shock management: (1) the phenotyping of cardiogenic shock, and (2) the assessment of response to therapy. Phenotyping of cardiogenic shock serves to guide timely therapeutic intervention, and the assessment of hemodynamic response to therapy directs the escalation or de-escalation of therapy, including MCS. This review aims to discuss these two aspects of hemodynamic assessment in cardiogenic shock. Firstly, the physiologic underpinnings of a phenotyping schema, and the implication of the cardiogenic shock phenotype on the MCS strategy in cardiogenic shock will be discussed. Secondly, the concept of cardiac power output and 'effective' oxygen delivery will be discussed in relation to hemodynamic response to therapy in cardiogenic shock.

OBJECTIVES Right heart failure (RHF) is a major complication following left ventricular assist device (LVAD) implantation. Pulmonary artery pulsatility index (PAPi) has been evaluated as a haemodynamic marker for RHF, but PAPi is dependent on pulmonary vascular resistance (PVR). We conducted a systematic review to assess the relationship between PAPi and RHF and death in patients undergoing LVAD implantation and examined the relationship between PAPi cut-off and PVR. METHODS We searched PubMed, EMBASE, CENTRAL and manually screened retrieved references to identify all clinical studies reporting PAPi in adult patients with a durable LVAD. Eligibility criteria were prespecified and 2 reviewers independently screened and extracted data; the Newcastle–Ottawa Scale was used to assess quality of non-randomized studies. This study was prospectively registered on PROSPERO (CRD42021259009). RESULTS From 283 unique records, we identified 16 studies reporting haemodynamic assessment in 20 634 adult patients with an implanted durable LVAD. Only 2 studies reported on mortality and in both, a lower PAPi was significantly associated with death. Fifteen studies reported RHF data and, in 10 studies, a lower PAPi was significantly associated with RHF. Six studies reported on PAPi cut-offs ranging from 0.88 to 3.3; and the cut-offs were directly related to PVR (r = 0.6613, P = 0.019). CONCLUSIONS Lower PAPi was associated with RHF and death following LVAD implantation, but a single PAPi cut-off cannot be defined, as it is dependent on PVR.

Extracorporeal membrane oxygenation (ECMO) was first started for humans in early 1970s by Robert Bartlett. Since its inception, there have been numerous challenges with extracorporeal circulation, such as coagulation and platelet activation, followed by consumption of coagulation factors and platelets, and biocompatibility of tubing, pump, and oxygenator. Unfractionated heparin (heparin hereafter) has historically been the defacto anticoagulant until recently. Also, coagulation monitoring was mainly based on bedside activated clotting time and activated partial thromboplastin time. In the past 50 years, the technology of ECMO has advanced tremendously, and thus, the survival rate has improved significantly. The indication for ECMO has also expanded. Among these are clinical conditions such as postcardiopulmonary bypass, sepsis, ECMO cardiopulmonary resuscitation, and even severe coronavirus disease 2019 (COVID-19). Not surprisingly, the number of ECMO cases has increased according to the Extracorporeal Life Support Organization Registry and prolonged ECMO support has become more prevalent. It is not uncommon for patients with COVID-19 to be on ECMO support for more than 1 year until recovery or lung transplant. With that being said, complications of bleeding, thrombosis, clot formation in the circuit, and intravascular hemolysis still remain and continue to be major challenges. Here, several clinical ECMO experts, including the “Father of ECMO”—Dr. Robert Bartlett, describe the history and advances of ECMO.

Background There are few reports of mechanical circulatory support (MCS) in patients with cardiogenic shock (CS) due to end-stage heart failure (ESHF). We evaluated our institutional MCS strategy and compared the outcomes of INTERMACS 1 and 2 patients with CS due to ESHF. Methods Retrospective analysis of prospectively collected data (November 2014 to July 2019) from a single centre. ESHF was defined by a diagnosis of HF prior to presentation with CS. Other causes of CS (eg: acute myocardial infarction) were excluded. We compared the clinical course, complications and 90-day survival of patients with CS due to ESHF in INTERMACS profile 1 and 2. Results We included 60 consecutive patients with CS due to ESHF Differences in baseline characteristics were consistent with the INTERMACS profiles. The duration of MCS was similar between INTERMACS 1 and 2 patients (14 (10–33) vs 15 (7–23) days, p = 0.439). There was no significant difference in the number of patients with complications that required intervention. Compared to INTERMACS 2, INTERMACS 1 patients had more organ dysfunction on support and significant lower 90-day survival (66% vs 34%, p = 0.016). Conclusion Our temporary MCS strategy, including earlier intervention in patients with CS due to ESHF at INTERMACS 2 was associated with less organ dysfunction and better 90-day survival compared to INTERMACS 1 patients.

Background: Early assessment of response to Impella in cardiogenic shock may guide escalation of mechanical circulatory support. Therapeutic goal and response to Impella have not previously been defined. This study tested the hypothesis that targeting 3-h post- Impella cardiac power output index (CPOi)—“hemodynamic response”—in cardiogenic shock is associated with 12-h lactate clearance. Methods: Single-center study of 37 consecutive patients who underwent left-sided Impella support for cardiogenic shock due to either acute myocardial infarction or decompensated heart failure. Patients who achieved 3-h post-Impella CPOi ⩾ 0.30 W/m2 were defined as Impella “hemodynamic responder.” Results: Twelve of the thirty-seven patients achieved 3-h post-impella CPOi ⩾ 0.30 W/m2 (“hemodynamic responders”). Post-Impella CPOi correlated with 12-h lactate ( r = −0.779, p Conclusion: Patients who achieved early 3-h post-Impella CPOi of ⩾0.30 W/m2 have greater lactate clearance and better short-term survival. Early post-Impella CPOi of 0.30 W/m2 may be used as a therapeutic goal and define favorable response to Impella in cardiogenic shock.

Protocolized team-based care has been shown to improve outcomes in cardiogenic shock (CS) in patients with end-stage heart failure (ESHF). This study tested the hypothesis that protocolized care improves survival by reducing multi-organ dysfunction prior to orthotopic heart transplantation (OHT) or durable left ventricular assist device (LVAD).We developed a protocolized Recognize/rescue-Optimization-Stabilization-Exit/de-Escalation (ROSE) framework for CS due to ESHF. Six-month survival pre-ROSE (2014-2018) and post-ROSE (2018-2021) were compared. The Sequential Organ Failure Assessment (SOFA) score was calculated as a measure of multi-organ dysfunction pre-MCS and pre-"Exit" therapy (OHT, LVAD or recovery).101 consecutive patients with CS due to ESHF who were deteriorating on inotropes (INTERMACS 1 or 2) were included (63 in Pre-ROSE and 38 in Post-ROSE). The proportions of patients who died on support (26 (41%) vs 11 (29%), p = 0.213) or bridged to "Exit" therapy were comparable between Pre- and Post-ROSE: OHT (28 (44%) vs 21 (55%), p = 0.292); durable LVAD (8 (13%) vs 5 (13%), p = 0.947); or recovery (1 (2%) vs 1 (3%), p = 0.715). SOFA score prior to "Exit" therapy was higher Pre-ROSE compared to Post-ROSE (4 (2-7) vs 2 (1-5), p = 0.012). Six-month survival from initial MCS (71% vs 41%, p = 0.004) and in patients who underwent "Exit" therapy (100% vs 71%, p = 0.001) were higher Post-ROSE vs Pre-ROSE, respectively. Higher pre-"Exit" SOFA score was associated with 6-month survival. None of the patients with Pre-"Exit" SOFA score ≥ 9 survived at 6 months.Protocolization of CS care in ESHF improved six-month survival by improving multi-organ dysfunction (SOFA score) prior to OHT and LVAD implant.

Background Left ventricular assist device (LVAD) implantation significantly impacts on a recipient’s symptoms and quality of life. Capturing their experiences and post implant journey is an important part of clinical practice, research and device design evolution. Patient reported outcome measures (PROMs) are a useful tool for capturing that experience. However, patient reported outcome measures need to reflect recipients’ experiences. Discussions with a patient partner group found that none of the frequently used cardiology PROMs captured their unique experiences. Aims To capture the experiences and important issues for LVAD recipients. Develop a conceptual map of domains and items that should be reflected in patient reported outcomes. Methods Group concept mapping (GCM) web-based software was used to remotely capture and structure recipients’ experiences across a wide geographical area. GCM is a semi-quantitative mixed method consisting of 3 stages: item generation, item sorting and rating (importance, relevance and frequency). Patient partners were involved in all aspects of the study design and development. Results 18 LVAD recipients consented to take part. 101 statements were generated and multi-dimensional scaling, and hierarchical cluster analysis identified 9 clusters. Cluster themes included: Activities, Partner/family support, Travel, Mental wellbeing, Equipment and clothing, Physical and cognitive limitations, LVAD Restrictions, LVAD Challenges and positive impact of the LVAD (LVAD Positives). LVAD Positives were scored highest across all the rating variables, e.g., frequency (2.85), relevance (2.44) and importance (2.21). Other domains rated high for importance included physical and cognitive limitations (2.19), LVAD restrictions (2.11), Partner/family support (2.02), and Equipment and clothing (2.01). Conclusion Online GCM software facilitated the inclusion of geographically dispersed recipients and provided useful insights into the experiences of LVAD recipients. The conceptual framework identifies important domains and items that should be prioritised and included in patient reported outcomes in future research, LVAD design evolution, and clinical practice.

Background: Current practice in cardiogenic shock is guided by expert opinion in guidelines and scientific statements from professional societies with limited high quality randomized trial data to inform optimal patient management. An international panel conducted a modified Delphi process with the intent of identifying aspects of cardiogenic shock care where there was uncertainty regarding optimal patient management. Methods: An 18-person multidisciplinary panel comprising international experts was convened. A modified RAND/University of California Los Angeles appropriateness methodology was used. A survey comprising 70 statements was completed. Participants anonymously rated the appropriateness of each statement on a scale of 1 to 9: 1 to 3 inappropriate, 4 to 6 uncertain, and 7 to 9 appropriate. A summary of the results was discussed as a group, and the survey was iterated and completed again before final analysis. Results: There was broad alignment with current international guidelines and consensus statements. Overall, 44 statements were rated as appropriate, 19 as uncertain, and 7 as inappropriate. There was no disagreement with a disagreement index Conclusions: While there was broad alignment with current guidance, an expert panel found several aspects of care where there was clinical equipoise, further highlighting the need for randomized controlled trials to better guide patient management and decision making in cardiogenic shock.

Aims The CardioMEMS HF System Post‐Market Study (COAST) was designed to evaluate the safety, effectiveness, and feasibility of haemodynamic‐guided heart failure (HF) management using a small sensor implanted in the pulmonary artery of New York Heart Association (NYHA) Class III HF patients in the UK, Europe, and Australia. Methods and results COAST is a prospective, international, multicentre, open‐label clinical study (NCT02954341). The primary clinical endpoint compares annualized HF hospitalization rates after 1 year of haemodynamic‐guided management vs. the year prior to sensor implantation in patients with NYHA Class III symptoms and a previous HF hospitalization. The primary safety endpoints assess freedom from device/system‐related complications and pressure sensor failure after 2 years. Results from the first 100 patients implanted at 14 out of the 15 participating centres in the UK are reported here. At baseline, all patients were in NYHA Class III, 70% were male, mean age was 69 ± 12 years, and 39% had an aetiology of ischaemic cardiomyopathy. The annualized HF hospitalization rate after 12 months was 82% lower [95% confidence interval 72–88%] than the previous 12 months (0.27 vs. 1.52 events/patient‐year, respectively, P

Background Based on theoretical physiology, the ratio of pulmonary artery pulse pressure to mean pulmonary pressure (PP-MPAP), termed proportional pulmonary pulse pressure, provides a measure of coupling between the right ventricle and the pulmonary circulation. This study tested the hypothesis that lower PP-MPAP ratio was associated with left ventricular (LV) distension in patients with cardiogenic shock who underwent extracorporeal life support (ECLS). Methods This is a retrospective observational single-centre study of 22 patients with cardiogenic shock who underwent ECLS as the primary support modality without and with LV distension and Impella unloading. The relationship between post-support PP-MPAP and 12-hour lactate clearance was also assessed. Results Of the 22 patients: 10 patients underwent additional Impella unloading due to LV distension (Group 1) and 12 patients on ECLS only without LV distension (Group 2). As predicted by the theoretical model, PP-MPAP on ECLS dropped in Group 1 (pre-Impella) from 0.473 ± 0.067 to 0.372 ± 0.087, p < 0.001; but increased in Group 2 patients without LV distension (0.518 ± 0.070 to 0.549 ± 0.072, p = 0.002). Impella support in Group 1 increased PP-MPAP (0.372 ± 0.087 to 0.615 ± 0.094, p < 0.001). On multiple regression analysis, post-support PP-MPAP was significantly associated with 12-hour lactate clearance. Conclusion Changes in PP-MPAP is associated hemodynamic response to ECLS and 12-hour lactate clearance. This simple parameter may guide therapeutic optimization in cardiogenic shock and ECLS.

Aim: The clinical and cost-effectiveness of left ventricular assist device (LVAD) therapy for patients with advanced heart failure (HF) who are ineligible for heart transplantation is debated in UK. This study develops an indirect comparison between the fully magnetically levitated HeartMate 3 (HM 3) LVAD and medical therapy (MT) to evaluate expected clinical and cost-effectiveness in the UK National Health Service (NHS) context. Methods: We performed an economic analysis comparing the HM3 pump against the HeartMate II LVAD (MOMENTUM 3), and then another analysis comparing MT with the first and second generation HeartMate XVE pump LVAD and HeartMate II LVAD for the same patient population (REMATCH and ROADMAP, respectively). By bridging those two analyses, an indirect comparison between HM3 and MT in the form of a network meta-analysis was developed. A literature search was performed to select the most appropriate pair of studies for this purpose. Outcomes were adjusted to produce Kaplan-Meier curves for the cost-effectiveness evaluation by using a decision-analytic model. Data were extrapolated linearly over a 5-year time horizon. Uncertainty and additional scenarios were addressed by one-way and probabilistic sensitivity analysis. Local costs and health utility were used from England, thereby representing the UK context. Results: The incremental cost-effectiveness ratio (ICER) for LVAD versus MT in transplant ineligible patients with advanced HF was estimated to be £47,361 per quality-adjusted life year (QALY) gained, with a 97.1% probability of being cost-effective at £50,000. In a sub-group of patients who are inotropic therapy dependent (INTERMACS 1-3 severity profile), the ICER was £45,616, while for a population with less-ill ambulatory HF (INTERMACS profile 4-7) the ICER changed to £65,018. Conclusion: This study provides evidence that HM3 LVAD therapy in advanced HF patients ineligible for heart transplantation may be cost-effective compared to MT in the NHS UK-England context. The ICER is lowest for patients dependent on inotropic support, but exceeds the willingness to pay threshold of £50,000 in ambulatory non-inotropic therapy dependent advanced HF patients.

Background A series of insults on the donor heart result in pathophysiological changes that manifest as primary graft dysfunction (PGD) post-orthotopic heart transplantation. The objectives of this study were: (i) describe the pathophysiology of severe PGD using an established cardiovascular model; and (ii) the evolution of the pathophysiology during recovery from severe PGD. Methods Hemodynamic data from 20 consecutive patients with severe PGD (need for mechanical circulatory support, MCS) at baseline (T0), 6 h (T6) and "recovery" (explant of support), and 20 consecutive patients without severe PGD were used to model the pathophysiology using the cardiovascular model described by Burkhoff and Dickstein. Results There was a progressive (from T0 to T6) up- and leftward shift in the diastolic pressure-volume relationship, especially of the right ventricle (RV), resulting in reduced capacitance. RV end-systolic elastance (Ees) was significantly elevated in severe PGD but preload-recruitable stroke work (PRSW) was significantly lower compared to patients without severe PGD. "Recovery" (after liberation from MCS) was associated with improvement in RV Ees, chamber capacitance and PRSW, although they remained significantly lower than patients without severe PGD. Conclusion Severe PGD of the dominant right heart failure phenotype is characterized by reduced chamber capacitance, increased "stiffness" and impaired contractility. Complete normalization was not required for successful weaning of MCS.

This review will discuss the practical applications based on the physiology that underpins some of these commonly used haemodynamic parameters. Haemodynamic parameters are integral to the management of cardiogenic shock. Some of these are easily measured and ubiquitous, such as arterial blood pressure and central venous pressure. Others, such as the use of pulmonary artery catheters, continue to be discussed and debated. The management of cardiogenic shock is challenging. Clinicians employ a range of haemodynamic parameters to diagnose and guide therapeutic interventions in cardiogenic shock. Understanding the physiologic basis for these parameters will aid the interpretation and clinical application in cardiogenic shock.

Objectives: To evaluate the value of cardiac power output index (CPOi) in predicting severe primary graft dysfunction (PGD) after heart transplantation (defined as mechanical circulatory support [MCS] and/or mortality Design: Observational cohort study. Setting: A heart transplant center in the United Kingdom. Participants: Consecutive patients who underwent heart transplantation from January 2014 to December 2019 (n = 160). Twenty patients were excluded, as MCS was instituted immediately after transplant. Interventions: None. Measurements and Main Results: Hemodynamic data on return to the intensive care unit (time 0, T0) and at 6 hours (T6) were collected to calculate CPOi at both points in 140 consecutive patients—22 patients developed severe PGD. The CPOi at T0 correlated with donor-recipient predicted heart mass and inversely with inotrope score. Patients who developed severe PGD had significantly lower CPOi at T0 and T6. The areas under the receiver operating characteristic curve for CPOi at T0 and T6 for the development of severe PGD were 0.90 and 0.92, respectively. Adjusting for vasoactive-inotrope score did not improve discrimination. The probability of severe PGD if CPOi at T0 0.34 W/m2 and >0.33 W/m2, respectively. After adjusting for baseline differences, CPOi at T6 (odds ratio 0.78; 95% CI 0.67-0.91, p = .001) was significantly associated with severe PGD. Conclusion: Low CPOi at T0 is associated with severe PGD. Serial assessment of CPOi increases the diagnostic probability of severe PGD.

Left ventricular assist devices are used in heart failure patients as bridge to transplantation or increasingly as a destination therapy. These patients frequently have renal dysfunction and many reach end-stage renal failure. If haemodialysis is required, minimization of infection risk is essential. Arteriovenous grafts have been recommended for these patients due to hypothetical concerns regarding fistula maturation due to continuous flow. A case is described where a brachiocephalic arteriovenous fistula was successfully formed and used for dialysis without issue. This is one case of a small number in the literature where arteriovenous fistulas have been used in left ventricular assist device patients and it appears that concerns are unfounded and good outcomes have been reported. It would appear from this experience that approaches to vascular access for dialysis in patients with continuous-flow left ventricular assist devices are in accordance with vascular access guidelines and standard practice.

Left ventricle (LV) distension is a complication of venoarterial extracorporeal membrane oxygenation (VA-ECMO) support. The effects of Impella on the pulmonary circulatory physiology were studied in a single-center study of six consecutive patients on VA-ECMO support who had LV unloading with Impella. Right ventricular stroke volume, pulmonary hemodynamics, and partial pressure of end-tidal CO2 (PETCO2 ) were measured on echocardiogram, pulmonary artery catheter, and capnography, respectively. The addition of Impella CP increased total blood flow and reduced pulmonary artery wedge pressure. There was a small reduction in arterial oxygen saturation as Impella increased LV output. The increase in pulmonary artery capacitance (PCap) exceeded the reduction in pulmonary vascular resistance (PVR), thereby increasing the pulmonary artery time constant (product of PCap and PVR). The right ventricular stroke volume increased and the improvement in pulmonary hemodynamics and blood flow were associated with reduced arterial-PETCO2 gradient. The Impella CP unloads the LV during VA-ECMO support, increasing total flow, reducing RV afterload, and facilitating RV output and pulmonary blood flow with improvement in gas exchange.

The use of left ventricular assist devices (LVADs) has increased significantly over the past few years, in part because heart transplant activity has plateaued, but also because of the improving clinical outcomes with contemporary continuous-flow LVAD. As such, there is now a growing population of patients with continuous-flow LVADs. Management of these patients is complicated by the altered circulatory physiology, because continuous-flow LVADs provide a parallel circulation from the heart to the aorta, which interacts with the native left heart (systemic) circulation with consequent effects on the right heart circulation. In addition, the displayed pump parameters can mislead the unwary clinician. An understanding of LVAD physiology can guide clinicians in the management of patients with LVADs. This review describes the basic design of axial and centrifugal continuous-flow LVADs, the functional anatomy and physiology of continuous-flow LVADs, and the interaction between the heart and the LVAD. leading to a discussion about the interpretation of the pump parameters in clinical practice.

Changes within the Coronary veins secondary to pacing leads have not been described, this study assessed these changes in explanted hearts. Macroscopically fibrous sheaths formed around longstanding leads, leading to slit like channels for venous return in smaller veins. Histologically changes included bland fibrosis, a foreign body response to the lead, a chronic inflammatory response and inflammatory destruction of the media. Individuals responded in different ways with no clear relationship of changes to duration of the lead.

Pulmonary artery pulsatility index (PAPi) is a haemodynamic parameter that is derived from right atrial and pulmonary artery pulse pressures. A number of reports have described the prognostic value of PAPi in patients with advanced heart failure and cardiogenic shock. However, the derivation and physiological interpretation of this parameter have received little attention. This review will examine the physiological interpretation and clinical data for PAPi.

Acute decompensated heart failure is the most common acute heart failure phenotype. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide bridging support for patients with acute decompensated heart failure to transplantation. We studied the association between baseline (6 months), pre-ECMO (24 h) parameters and outcome of VA-ECMO support in patients with severe acute decompensated heart failure.We included 26 consecutive patients with acute decompensated heart failure (acute myocarditis, myocardial infarction or post-cardiotomy shock were excluded) who were bridged with peripheral VA-ECMO to transplantation. Data within six months (baseline) and immediately pre-ECMO were collected. Model for end-stage liver disease (MELD) with sodium (MELD-Na) and without international normalized ratio (MELD-XI) scores were calculated. Outcome was defined as death at 30 days following VA-ECMO support.Thirteen of the 26 patients died within 30 days of VA-ECMO support. Univariate associations with 30-day mortality were baseline MELD-XI, baseline sodium, creatinine, bilirubin, pre-ECMO alanine aminotransferase and lactate. However, only baseline MELD-XI score (hazard ratio 2.678 (95% CI 1.085-6.607), p=0.033) was associated 30-day survival on logistic regression analysis. Survivors demonstrated greater reduction in inotropic and vasoactive drug support and improvement in alanine aminotransferase and lactate levels. Using a threshold based on the median MELD-XI of 14.1, 30-day survival in patients with a baseline MELD-XI ⩽ 14.1 was 69% compared with 31% in patients with baseline MELD-XI14.1 ( p=0.046).Baseline MELD-XI score, but not pre-ECMO parameters, is independently associated with outcomes from VA-ECMO support in patients with acute decompensated heart failure.

Cardiogenic shock remains a highly lethal condition. Conventional therapy including revascularization and mechanical circulatory support aims to improve cardiac output and oxygen delivery, but increasing basic and clinical observations indicate wider circulatory and cellular abnormalities, particularly at the advanced stages of shock. Progressive cardiogenic shock is associated with microcirculatory and cellular abnormalities. Cardiogenic shock is initially characterized by a failure to maintain global oxygen delivery; however, progressive cardiogenic shock is associated with the release of pro-inflammatory cytokines, derangement of the regulation of regional blood flow, microcirculatory abnormalities, and cellular dysoxia. These abnormalities are analogous to septic shock and may not be reversed by increase in oxygen delivery, even to supranormal levels. Earlier mechanical circulatory support in cardiogenic shock may limit the development of microcirculatory and cellular abnormalities.

Background Mixed pulmonary hypertension (PH) in heart failure (HF) is defined by transpulmonary gradient ≥ 12 and/or pulmonary vascular resistance (PVR) ≥ 240 dyne/s/cm −5 , but diastolic pressure gradient (DPG) ≥ 7 mmHg has been proposed more recently. We evaluated the acute hemodynamic response to sodium nitroprusside (SNP) specifically in relation to the proposed DPG criterion ≥7 mmHg and the prognostic significance of response to SNP in patients with mixed PH and advanced HF. Methods Ninety-eight consecutive patients with advanced HF and mixed PH underwent cardiac catheterization and acute SNP infusion. Baseline hemodynamic parameters included transpulmonary gradient, PVR, DPG, and pulmonary capacitance (PCap). Hemodynamic response to SNP was defined as a reduction in PVR of at least 20%. The composite endpoint was death/heart transplantation/mechanical circulatory support. Results Sixty of the 98 patients were SNP responders. SNP resulted in significant reductions in filling pressures and PVR and increase in stroke volume and PCap. DPG (not baseline PVR) was significantly associated with hemodynamic response to SNP on logistic regression analysis. The sensitivity and specificity of a DPG ≥7 mmHg to identify nonresponders to SNP were 74% and 97%, respectively. At median follow-up of 218 (148–324) days, 13 and 19 patients of the SNP responders and nonresponders, respectively, met the composite endpoint ( P = .021 by log-rank test). Hemodynamic response to SNP and PCap were independently associated with the composite outcome of survival free from transplantation/mechanical circulatory support. Conclusion Baseline DPG ≥ 7 mmHg is associated with poor PVR response to SNP. PVR response to SNP and PCap are associated with a more favorable prognosis in patients with advanced HF and mixed PH.