Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography

Right ventricular morphology and function in chronic obstructive pulmonary disease patients living at high altitude

INTRODUCTION

Pulmonary vasculature is affected in patients with chronic pulmonary obstructive disease (COPD). As a result of increased pulmonary resistance, right ventricular morphology and function are altered in COPD patients. High altitude and related hypoxia causes pulmonary vasoconstriction, thereby affecting the right ventricle. We aimed to investigate the combined effects of COPD and altitude-related chronic hypoxia on right ventricular morphology and function.

MATERIALS AND METHODS

Forty COPD patients living at high altitude (1768 m) and 41 COPD patients living at sea level were enrolled in the study. All participants were diagnosed as COPD by a pulmonary diseases specialist depending on symptoms, radiologic findings and pulmonary function test results. Detailed two-dimensional echocardiography was performed by a cardiologist at both study locations.

RESULTS

Oxygen saturation and mean pulmonary artery pressure were higher in the high altitude group. Right ventricular end diastolic diameter, end systolic diameter, height and end systolic area were significantly higher in the high altitude group compared to the sea level group. Parameters of systolic function, including tricuspid annular systolic excursion, systolic velocity of tricuspid annulus and right ventricular isovolumic acceleration were similar between groups, while fractional area change was significantly higher in the sea level groups compared to the high altitude group. Indices of diastolic function and myocardial performance index were similar between groups.

CONCLUSION

An increase in mean pulmonary artery pressure and right ventricular dimensions are observed in COPD patients living at high altitude. Despite this increase, systolic and diastolic functions of the right ventricle, as well as global right ventricular performance are similar in COPD patients living at high altitude and sea level. Altitude-related adaptation to chronic hypoxia could explain these findings.

Osteopontin predicts adverse right ventricular remodelling and dysfunction in pulmonary hypertension

BACKGROUND

Osteopontin (OPN) was found upregulated in several heart failure models and appears to play an important role in myocardial remodelling. As we have previously demonstrated that OPN predicts mortality in patients with pulmonary hypertension (PH), we now evaluated whether OPN also predicts adverse right ventricular (RV) remodelling and dysfunction in PH.

METHODS

We prospectively included 71 patients with PH of different etiology in this study. OPN plasma level were determined by ELISA and assessed for correlation with RV dilatation and dysfunction determined by echocardiography.

RESULTS

OPN plasma values significantly correlated with RV end-diastolic diameter, Tricuspid Annular Plane Systolic Excursion (TAPSE) and Tricuspid Annular Systolic Velocity (TASV) (r = 0·43, P = 0·0002; r = -0·46, P = 0·0006; r = -0·31, P = 0·02). Furthermore, stratification of our study population according to RV end-diastolic diameter and RV dysfunction revealed that patients with enlarged and functionally impaired RV's display higher OPN levels (956 ng/mL vs. 628 ng/mL, P = 0·0005; 1108 ng/mL vs. 792 ng/mL; P = 0·02). Next, we determined OPN cut-off values for the detection of RV remodelling and dysfunction by receiver operating curve analyses and further stratified these parameters in a multivariate analysis. Here, OPN emerged as an independent predictor of RV dilatation and dysfunction. Finally, we demonstrate synergism of OPN and NT-proBNP in the prediction of RV dilatation and dysfunction by calculation of the Rothman Synergy Index.

CONCLUSION

In summary, OPN predicts adverse RV remodelling and dysfunction in PH. Together with our previously published data regarding OPN's value for the prognostication of death in PH, we believe that OPN can improve risk stratification in patients with PH beyond current assessment standards.

A simple echocardiographic prediction rule for hemodynamics in pulmonary hypertension

BACKGROUND

Pulmonary hypertension (PH) has diverse causes with heterogeneous physiology compelling distinct management. Differentiating patients with primarily elevated pulmonary vascular resistance (PVR) from those with PH predominantly because of elevated left-sided filling pressure is critical.

METHODS AND RESULTS

We reviewed hemodynamics, echocardiography, and clinical data for 108 patients seen at a referral PH clinic with transthoracic echocardiogram and right heart catheterization within 1 year. We derived a simple echocardiographic prediction rule to allow hemodynamic differentiation of PH attributed to pulmonary vascular disease (PH(PVD), defined as pulmonary artery wedge pressure [PAWP]≤15 mm Hg and PVR>3 WU). Age averaged 61.3±14.8 years, μPAWP and PVR were 16.4±7.1 mm Hg and 6.3±4.0 WU, respectively, and 52 (48.1%) patients fulfilled PH(PVD) hemodynamic criteria. The derived prediction rule ranged from -2 to +2 with higher scores suggesting higher probability of PH(PVD): +1 point for left atrial anterior-posterior dimension <3.2 cm; +1 for presence of a mid systolic notch or acceleration time <80 ms; -1 for lateral mitral E:e'>10; -1 for left atrial anterior-posterior dimension >4.2 cm. PVR increased stepwise with score (for -2, 0, and +2, μPVR were 2.5, 4.5, and 8.1 WU, respectively), whereas the inverse was true for pulmonary artery wedge pressure (corresponding μPAWP were 21.5, 16.5, and 10.4 mm Hg). Among subjects with complete data, the score had an area under the curve (AUC) of 0.921 for PH(PVD). A score ≥0 had 100% sensitivity and 69.3% positive predictive value for PH(PVD), with 62.3% specificity. No patients with a negative score had PH(PVD). Patients with a negative score and acceleration time >100 ms had normal PVR (μPVR=1.8 WU, range=0.7-3.2 WU).

CONCLUSIONS

We present a simple echocardiographic prediction rule that accurately defines PH hemodynamics, facilitates improved screening and focused clinical investigation for PH diagnosis and management.

The role of tricuspid valve repair and replacement in right heart failure

PURPOSE OF REVIEW

The presence of tricuspid regurgitation in the setting of right ventricular dysfunction is associated with poor prognosis. The purpose of this review is to describe the pathophysiology of functional tricuspid regurgitation, summarize the current reports favoring a more aggressive approach toward tricuspid valve surgery, and discuss the emerging role of tricuspid valve annuloplasty with left ventricular assist device (LVAD) implantation.

RECENT FINDINGS

The rationale for offering tricuspid valve surgery is based upon an understanding of the natural history of functional tricuspid regurgitation in the setting of left heart disease. In this regard, several observations have been made. First, tricuspid regurgitation does not simply go away after correction of left-sided lesions. Second, functional tricuspid regurgitation is a progressive disorder characterized by a spiral of right ventricular chamber enlargement leading to further annular dilatation and more tricuspid regurgitation. Finally, operative mortality for isolated tricuspid valve surgery, particularly re-operative surgery, is quite high and is influenced by right ventricular function.

SUMMARY

The presence of significant tricuspid regurgitation, whether in the context of mitral valve disease or heart failure, should no longer be treated with 'surgical abstention'. Whether the surgical correction of tricuspid regurgitation in left heart disease can definitively improve clinical outcomes should be addressed by prospective clinical trials.

Arrhythmogenic right ventricular cardiomyopathy 2012: diagnostic challenges and treatment

The most common presentation of arrhythmogenic right ventricular cardiomyopathy (ARVC) is palpitations or ventricular tachycardia (VT) of left bundle branch morphology in a young or middle-aged individual. The 12-lead electrocardiogram may be normal or have T-wave inversion beyond V(1) in an otherwise healthy person who is suspected of having ARVC. The most frequent imaging abnormalities are an enlarged right ventricle, decrease in right ventricular (RV) function, and localized wall motion abnormalities. Risk factors for implantable cardioverter defibrillator include a history of aborted sudden death, syncope, young age, decreased left ventricular function, and marked decrease in RV function. Recent results of treatment with epicardial ablation are encouraging.

The impact of repeated marathon running on cardiovascular function in the aging population

BACKGROUND

Several studies have correlated elevations in cardiac biomarkers of injury post marathon with transient and reversible right ventricular (RV) systolic dysfunction as assessed by both transthoracic echocardiography (TTE) and cardiovascular magnetic resonance (CMR). Whether or not permanent myocardial injury occurs due to repeated marathon running in the aging population remains controversial.

OBJECTIVES

To assess the extent and severity of cardiac dysfunction after the completion of full marathon running in individuals greater than 50 years of age using cardiac biomarkers, TTE, cardiac computed tomography (CCT), and CMR.

METHODS

A total of 25 healthy volunteers (21 males, 55 ± 4 years old) from the 2010 and 2011 Manitoba Full Marathons (26.2 miles) were included in the study. Cardiac biomarkers and TTE were performed one week prior to the marathon, immediately after completing the race and at one-week follow-up. CMR was performed at baseline and within 24 hours of completion of the marathon, followed by CCT within 3 months of the marathon.

RESULTS

All participants demonstrated an elevated cTnT post marathon. Right atrial and ventricular volumes increased, while RV systolic function decreased significantly immediately post marathon, returning to baseline values one week later. Of the entire study population, only two individuals demonstrated late gadolinium enhancement of the subendocardium in the anterior wall of the left ventricle, with evidence of stenosis of the left anterior descending artery on CCT.

CONCLUSIONS

Marathon running in individuals over the age of 50 is associated with a transient, yet reversible increase in cardiac biomarkers and RV systolic dysfunction. The presence of myocardial fibrosis in older marathon athletes is infrequent, but when present, may be due to underlying occult coronary artery disease.

Prognostic value of right ventricular longitudinal peak systolic strain in patients with pulmonary hypertension

BACKGROUND

Right ventricular (RV) function is an important prognostic marker in patients with pulmonary hypertension. The present evaluation assessed the prognostic value of RV longitudinal peak systolic strain (LPSS) in patients with pulmonary hypertension.

METHODS AND RESULTS

A total of 150 patients with pulmonary hypertension of different etiologies (mean age, 59±15 years; 37.3% male) were evaluated. RV fractional area change and tricuspid annular plane systolic excursion index were evaluated with 2-dimensional echocardiography. RV LPSS was assessed with speckle-tracking echocardiography. The patient population was categorized according to a RV LPSS value of -19%. Among several clinical and echocardiographic parameters, the significant determinants of all-cause mortality were evaluated. There were no significant differences in age, sex, pulmonary hypertension cause and left ventricular ejection fraction between patients with RV LPSS <-19% and patients with RV LPSS ≥-19%. However, patients with RV LPSS ≥-19% had significantly worse New York Heart Association functional class (2.7±0.6 versus 2.3±0.8; P=0.003) and lower tricuspid annular plane systolic excursion (16±4 mm versus 18±3 mm; P<0.001) than their counterparts. During a median follow-up of 2.6 years, 37 patients died. RV LPSS was a significant determinant of all-cause mortality (HR, 3.40; 95% CI, 1.19-9.72; P=0.02).

CONCLUSIONS

In patients with pulmonary hypertension, RV LPSS is significantly associated with all-cause mortality. RV LPSS may be a valuable parameter for risk stratification of these patients. Future studies are needed to confirm these results in the pulmonary hypertension subgroups.

Quantifying pulmonary regurgitation and right ventricular function in surgically repaired tetralogy of Fallot: a comparative analysis of echocardiography and magnetic resonance imaging

BACKGROUND

Patients with repaired tetralogy of Fallot are monitored for pulmonary regurgitation (PR) and right ventricular (RV) function. We sought to compare measures of PR and RV function on echocardiogram to those on cardiac magnetic resonance (CMR) and to develop a new tool for assessing PR by echocardiogram.

METHODS AND RESULTS

Patients with repaired tetralogy of Fallot (n=143; 12.5±3.2 years) had an echocardiogram and CMR within 3 months of each other. On echocardiogram, RV function was assessed by (1) Doppler tissue imaging of the RV free wall and (2) myocardial performance index. The ratio of diastolic and systolic time-velocity integrals measured by Doppler of the main pulmonary artery was calculated. CMR variables included RV ejection fraction, RV volumes, and pulmonary regurgitant fraction (RF). Pulmonary regurgitation was graded as mild (RF<20%), moderate (RF=20-40%), and severe (RF>40%). On CMR, RF was 34+17% and RV ejection fraction was 61+8%. Echocardiography had good sensitivity identifying cases with RF>20% (sensitivity 97%; 95% CI: 92-99%) but overestimated the amount of PR when RF<20% (false-positive rate 36%; 95% CI: 18-57%). The diastolic and systolic time-velocity integrals on echocardiogram showed moderate correlation with RF on CMR (R=0.60; P<0.0001). On CMR, RF of 20% and 40% corresponded with a diastolic and systolic time-velocity integral of 0.49 (95% CI: 0.44-0.56) and 0.72 (95% CI: 0.68-0.76), respectively. RV myocardial performance index correlated modestly with RV ejection fraction (r=-0.33; P<0.001).

CONCLUSIONS

This study suggests that the diastolic and systolic time-velocity integrals ratio may make a modest contribution to the overall assessment of PR in patients with repaired tetralogy of Fallot and warrants further investigation. However, echocardiography continues to have a limited ability to quantify PR and RV function as compared with CMR.

Catecholamine-induced opening of intrapulmonary arteriovenous anastomoses in healthy humans at rest

The mechanism or mechanisms that cause intrapulmonary arteriovenous anastomoses (IPAVA) to either open during exercise in subjects breathing room air and at rest when breathing hypoxic gas mixtures, or to close during exercise while breathing 100% oxygen, remain unknown. During conditions when IPAVA are open, plasma epinephrine (EPI) and dopamine (DA) concentrations both increase, potentially representing a common mechanism. The purpose of this study was to determine whether EPI or DA infusions open IPAVA in resting subjects breathing room air and, subsequently, 100% oxygen. We hypothesized that these catecholamine infusions would open IPAVA. We performed saline-contrast echocardiography in nine subjects without a patent foramen ovale before and during serial EPI and DA infusions while breathing room air and then while breathing 100% oxygen. Bubble scores (0-5) were assigned based on the number and spatial distribution of bubbles in the left ventricle. Pulmonary artery systolic pressure (PASP) was estimated using Doppler ultrasound, while cardiac output (Q(C)) was measured using echocardiography. Bubble scores were significantly greater during EPI infusions of 80-320 ng·kg(-1)·min(-1) compared with baseline when subjects breathed room air; however, bubble scores did not increase when they breathed 100% oxygen. At comparable Q(C) and PASP, intravenous DA (16 μg·kg(-1)·min(-1)) and EPI (40 ng·kg(-1)·min(-1)) resulted in identical bubble scores. Subsequent studies revealed that β-blockade did not prevent hypoxia-induced opening of IPAVA. We suggest that increases in Q(C) or PASP (or both) secondary to EPI or DA infusions open IPAVA in normoxia. The closing mechanism associated with breathing 100% oxygen is independent from the opening mechanisms.

[Multidetector computed tomography assessment of cardiac comorbidity in patients with chronic obstructive pulmonary disease]

Cardiac comorbidity is one of the most important prognostic factors in lung disease, especially in chronic obstructive pulmonary disease (COPD). The imaging techniques available for the study of this systemic manifestation concomitant with COPD include heart catheterization, transthoracic echocardiography, and magnetic resonance imaging. Multidetector computed tomography (MDCT) represents a significant advance in this field because it enables the acquisition of simultaneous studies of the cardiopulmonary anatomy that go beyond anatomic and morphologic analysis to include a functional approach to this condition. In this article, we review the practical aspects necessary to evaluate cardiac comorbidity in patients with COPD, both from the point of view of pulmonary hypertension and of the analysis of ventricular dysfunction and coronary heart disease.

Prevalence and risk factors associated with pulmonary hypertension in HIV-infected patients on regular follow-up

BACKGROUND

Pulmonary arterial hypertension (PAH) is uncommon among HIV-positive patients. However, it is a potentially life-threatening condition. Transthoracic echocardiography (TTE) is a noninvasive tool validated for PAH screening. The aim of our study was to establish the prevalence and factors associated with PAH in HIV-infected patients.

METHODS

Consecutive HIV-infected individuals attended at one HIV reference clinic in Madrid, Spain, during year 2011 were examined. Demographics and clinical data were recorded and a Doppler echocardiography was performed in all individuals. PAH was considered when right ventricular pressure was more than 35 mmHg (mild if <40 mmHg, moderate if 40-65 mmHg, and severe if >65 mmHg).

RESULTS

Three hundred and ninety-two individuals were examined (83.4% men, median age 47 years, 53% were men who have sex with men and 53% former intravenous drug addicts). Overall, 84% were on HAART, 76% had undetectable HIV viral load and median CD4 cell counts were 577 cells/μl. Cardiovascular risk factors were smoking 50%, arterial hypertension 16% and diabetes mellitus 9%. A total of 28.5 and 4.8% had chronic hepatitis C (CHC) and 4.8% chronic hepatitis B, respectively. PAH was diagnosed in 9.9% of patients (6.4% mild, 2.8% moderate and 0.8% severe). Multivariate logistic regression analysis [odds ratio (OR), 95% confidence interval (CI)] showed that detectable plasma HIV-RNA [OR, 3.3; 95% CI, 1.04-10], CHC [OR, 3.1; 95% CI 1.2-8.2] and female sex [OR, 2.9; 95% CI, 1.04-8.3] were independently associated with PAH.

CONCLUSION

The prevalence of PAH HIV-infected patients on regular follow-up approaches 10%, being moderate-severe in nearly 4% of cases. Patients with CHC and/or uncontrolled HIV replication exhibit a higher risk of PAH.

Pulmonary hypertension in pregnancy: critical care management

Pulmonary hypertension is common in critical care settings and in presence of right ventricular failure is challenging to manage. Pulmonary hypertension in pregnant patients carries a high mortality rates between 30-56%. In the past decade, new treatments for pulmonary hypertension have emerged. Their application in pregnant women with pulmonary hypertension may hold promise in reducing morbidity and mortality. Signs and symptoms of pulmonary hypertension are nonspecific in pregnant women. Imaging workup may have undesirable radiation exposure. Pulmonary artery catheter remains the gold standard for diagnosing pulmonary hypertension, although its use in the intensive care unit for other conditions has slowly fallen out of favor. Goal-directed bedside echocardiogram and lung ultrasonography provide attractive alternatives. Basic principles of managing pulmonary hypertension with right ventricular failure are maintaining right ventricular function and reducing pulmonary vascular resistance. Fluid resuscitation and various vasopressors are used with caution. Pulmonary-hypertension-targeted therapies have been utilized in pregnant women with understanding of their safety profile. Mainstay therapy for pulmonary embolism is anticoagulation, and the treatment for amniotic fluid embolism remains supportive care. Multidisciplinary team approach is crucial to achieving successful outcomes in these difficult cases.

Tricuspid annular peak systolic velocity (S') in children and young adults with pulmonary artery hypertension secondary to congenital heart diseases, and in those with repaired tetralogy of Fallot: echocardiography and MRI data

BACKGROUND

Tricuspid annular peak systolic velocity (S'), as an echocardiographic index to assess right ventricular (RV) systolic function, has not been investigated thoroughly in children and young adults with repaired tetralogy of Fallot (TOF) and pulmonary artery hypertension secondary to congenital heart disease (PAH-CHD).

METHODS

S' values in patients with TOF (n = 183) and PAH-CHD (n = 55) were compared with those in normal subjects. S' values were compared with RV ejection fraction and RV end-diastolic volume index (RVEDVi) determined by magnetic resonance imaging.

RESULTS

S' values became significantly reduced in PAH-CHD patients after 10.4 years of age and after 13.6 years of age in patients with TOF compared with the lower boundary of the ±2-SD interval of normal subjects. Significant positive correlations between S' and RV ejection fraction were seen in patients with TOF (r = 0.66, P < .001) and those with PAH-CHD (r = 0.82, P < .001). Significant negative correlations between S' and RVEDVi were also seen in patients with repaired TOF (r = -0.29, P = .002) and in those with PAH-CHD (r = -0.59, P < .001).

CONCLUSIONS

Although initially preserved, in this prospective study, impaired S' values with increasing age were found in patients with repaired TOF and PAH-CHD. Persistent pressure overload in patients with PAH-CHD as well as volume overload in those with repaired TOF might lead to systolic RV functional impairment and increased RVEDVi. The validity of S' data was supported by magnetic resonance imaging data (RVEDVi and RV ejection fraction).

Cardiovascular abnormalities in sickle cell disease

Sickle cell disease is characterized by recurrent episodes of ischemia-reperfusion injury to multiple vital organ systems and a chronic hemolytic anemia, both contributing to progressive organ dysfunction. The introduction of treatments that induce protective fetal hemoglobin and reduce infectious complications has greatly prolonged survival. However, with increased longevity, cardiovascular complications are increasingly evident, with the notable development of a progressive proliferative systemic vasculopathy, pulmonary hypertension (PH), and left ventricular diastolic dysfunction. Pulmonary hypertension is reported in autopsy studies, and numerous clinical studies have shown that increased pulmonary pressures are an important risk marker for mortality in these patients. In epidemiological studies, the development of PH is associated with intravascular hemolysis, cutaneous leg ulceration, renal insufficiency, iron overload, and liver dysfunction. Chronic anemia in sickle cell disease results in cardiac chamber dilation and a compensatory increase in left ventricular mass. This is often accompanied by left ventricular diastolic dysfunction that has also been a strong independent predictor of mortality in patients with sickle cell disease. Both PH and diastolic dysfunction are associated with marked abnormalities in exercise capacity in these patients. Sudden death is an increasingly recognized problem, and further cardiac investigations are necessary to recognize and treat high-risk patients.

Audit of Cardiac Pathology Detection Using a Criteria-Based Perioperative Echocardiography Service

Transthoracic echocardiography is often used to screen patients prior to non-cardiac surgery to detect conditions associated with perioperative haemodynamic compromise and to stratify risk. However, anaesthetists’ use of echocardiography is quite variable. A consortium led by the American College of Cardiology Foundation has developed appropriate use criteria for echocardiography. At Joondalup Hospital in Western Australia, we have used these criteria to order echocardiographic studies in patients attending our anaesthetic preadmission clinic. We undertook this audit to determine the incidence of significant echocardiographic findings using this approach. In a 22-month period, 606 transthoracic echocardiographic studies were performed. This represented 8.7% of clinic attendees and 1.7% of all surgical patients. In about two-thirds of the patients, the indication for echocardiography was identified on the basis of a telephone screening questionnaire. The most common indications were poor exercise tolerance (27.4%), ischaemic heart disease (20.9%) and cardiac murmurs (16.3%). Over 26% of patients studied had significant cardiac pathology (i.e. moderate or severe echocardiographic findings), most importantly moderate or severe aortic stenosis (8.6%), poor left ventricular function (7.1%), a regional wall motion abnormality (4.3%) or moderate or severe mitral regurgitation (4.1%). Using appropriate use criteria to guide ordering transthoracic echocardiography studies led to a high detection rate of clinically important cardiac pathology in our perioperative service.

Long-term cardiac remodeling and arrhythmias in nonelite marathon runners

Long-term endurance sports are associated with atrial remodeling and atrial arrhythmias. More importantly, high-level endurance training may promote right ventricular (RV) dysfunction and complex ventricular arrhythmias. We investigated the long-term consequences of marathon running on cardiac remodeling as a potential substrate for arrhythmias with a focus on the right heart. We invited runners of the 2010 Grand Prix of Bern, a 10-mile race. Of 873 marathon and nonmarathon runners who applied, 122 (61 women) entered the final analysis. Subjects were stratified according to former marathon participations: control group (nonmarathon runners, n = 34), group 1 (1 marathon to 5 marathons, mean 2.7, n = 46), and group 2 (≥6 marathons, mean 12.8, n = 42). Mean age was 42 ± 7 years. Results were adjusted for gender, age, and lifetime training hours. Right and left atrial sizes increased with marathon participations. In group 2, right and left atrial enlargements were present in 60% and 74% of athletes, respectively. RV and left ventricular (LV) dimensions showed no differences among groups, and RV or LV dilatation was present in only 2.4% or 4.3% of marathon runners, respectively. In multiple linear regression analysis, marathon participation was an independent predictor of right and left atrial sizes but had no effect on RV and LV dimensions and function. Atrial and ventricular ectopic complexes during 24-hour Holter monitoring were low and equally distributed among groups. In conclusion, in nonelite athletes, marathon running was not associated with RV enlargement, dysfunction, or ventricular ectopy. Marathon running promoted biatrial remodeling.

Right ventricular and pulmonary arterial dimensions in adults with osteogenesis imperfecta

We examined right ventricular (RV) and ascending pulmonary artery (PA1) dimensions in adults with osteogenesis imperfecta (OI). The survey included 99 adults with OI divided in 3 clinical types (I, III, and IV) and 52 controls. RV and PA1 dimensions were measured by echocardiography and indexed for body surface area. Scoliosis was registered, and spirometry was performed in 75 patients with OI. All RV dimensions indexed by body surface area were significantly larger in the OI group compared to controls (RV basal dimension 1.9 ± 0.5 vs 1.7 ± 0.3 cm/m(2), p <0.05; RV midcavity dimension 1.7 ± 0.5 vs 1.5 ± 0.3 cm/m(2), p <0.05; RV longitudinal dimension 4.3 ± 1.1 vs 4.0 ± 0.9 cm/m(2), p <0.05). RV outflow tract (RVOT) proximal diameter (1.8 ± 0.4 vs 1.5 ± 0.2 cm/m(2), p <0.05), RVOT distal diameter (1.2 ± 0.2 vs 1.0 ± 0.1 cm/m(2), p <0.05), and PA1 (1.2 ± 0.3 vs 1.0 ± 0.2 cm/m(2), p <0.05) were also significantly larger in the OI group. Furthermore, all RV dimensions and PA1 were significantly larger in patients with OI type III compared to patients with OI types I and IV and controls. There were no differences in RV, RVOT, or PA1 dimensions between patients presenting a restrictive ventilatory pattern (n = 11) and patients a normal ventilatory pattern. Scoliosis was registered in 42 patients. Patients with OI type III had greater RV and PA1 dimensions compared to controls and patients with OI types I and IV. Impaired ventilatory patterns and scoliosis did not have any impact on RV dimensions in these patients. In conclusion, patients with OI had increased RV and PA1 dimensions compared to the control group.

The effect of diabetes mellitus on the ventricular epicardial activation and repolarization in mice

Cardiac repolarization is prolonged in diabetes mellitus (DM), however the distribution of repolarization durations in diabetic hearts is unknown. We estimated the ventricular repolarization pattern and its relation to the ECG phenomena in diabetic mice. Potential mapping was performed on the anterior ventricular surface in healthy (n=18) and alloxan-induced diabetic (n=12) mice with the 64-electrode array. Activation times, end of repolarization times, and activation-recovery intervals (ARIs) were recorded along with limb lead ECGs. ARIs were shorter in the left as compared to right ventricular leads (P<0.05). The global dispersion of repolarization, interventricular and apicobasal repolarization gradients were greater in DM than in healthy animals (P<0.03). The increased dispersion of repolarization and apicobasal repolarization gradient in DM correlated with the prolonged QTc and Tpeak-Tend intervals, respectively. The increased ventricular repolarization heterogeneity corresponded to the electrocardiographic markers was demonstrated in DM.

Mechanisms of exercise-induced pulmonary hypertension in patients with cardiac septal defects

The objective of this study was to investigate mechanisms of exercise-induced pulmonary hypertension in patients with congenital cardiac septal defects. This was a randomized, placebo controlled, crossover drug trial in a single national pediatric cardiology centre that performs congenital cardiac defect surgery. There were 14 patients with cardiac septal defects and known exercise-induced pulmonary hypertension. The intervention consisted of 50 mg oral sildenafil versus placebo. Measurements included supine bicycle exercise echocardiography and oxygen uptake. The outcome measure was right-ventricular systolic pressure as estimated by Doppler tracings of tricuspid regurgitant jet as well as systolic and diastolic longitudinal myocardial velocities by color tissue Doppler echocardiography. Sildenafil did not change exercise right-ventricular systolic pressure during exercise; however, decreased systemic systolic pressure was seen. Enhanced biventricular longitudinal function with sildenafil compared with placebo was indicated by greater tissue Doppler velocities and displacement measurements during exercise. Finally, a less steep increase of right-ventricular pressure during exercise was associated with greater left-ventricular diastolic myocardial tissue Doppler velocity. Exercise-induced pulmonary hypertension in cardiac septal defects does not seem to have a pulmonary vasoconstrictive component, but it may be related to left-ventricular filling pressure. Furthermore, sildenafil improved biventricular systolic performance in this patient group, possibly related to decreased systemic afterload.

Increased procollagen type I C-terminal peptide levels indicate diastolic dysfunction in end-stage renal disease patients undergoing maintenance dialysis therapy

BACKGROUND

Cardiac dysfunction is common among patients with end-stage renal disease. The aim of this study was to explore the determinants of diastolic dysfunction in patients with end-stage renal disease on maintenance hemodialysis.

METHODS

Patients with asymptomatic end-stage renal disease undergoing hemodialysis underwent Doppler tissue imaging analysis and two-dimensional speckle-tracking echocardiography with strain analysis. Blood studies included albumin, cardiac troponin T, and procollagen type I C-terminal peptide (PICP).

RESULTS

All enrolled patients had left ventricular (LV) diastolic dysfunction and were stratified into two groups by a cutoff value of 13 for the ratio of early transmitral flow velocity to the average early diastolic annular velocity (E/e'). Seventy-two of the enrolled patients (87%) had grade 1 diastolic dysfunction, and 11 patients (13%) had higher grades of diastolic dysfunction. The study population did not include a representative sample of patients with the pseudonormal or restrictive filling patterns of diastolic dysfunction. There were no significant differences in gender, age, LV geometric change, ejection fraction, global systolic longitudinal strain and strain rate, and prevalence of comorbidities between groups. Patients with average E/e' ≥ 13 had higher PICP, which was significantly correlated with cardiac troponin T, average E/e', and systolic circumferential strain rate. By multivariate regression analysis, average E/e' level was an independent factor of PICP level (P = .047).

CONCLUSIONS

Hemodialysis patients with high average E/e' ratios showed increased levels of LV filling pressure and higher severity levels of cardiac fibrosis, which occurred before the development of systolic dysfunction. PICP was a potential indicator of diastolic dysfunction and increased LV filling pressure.

Masked hypertension and prehypertension: diagnostic overlap and interrelationships with left ventricular mass: the Masked Hypertension Study

BACKGROUND

Masked hypertension (MHT) and prehypertension (PHT) are both associated with an increase in cardiovascular disease (CVD) risk, relative to sustained normotension. This study examined the diagnostic overlap between MHT and PHT, and their interrelationships with left ventricular (LV) mass index (LVMI), a marker of cardiovascular end-organ damage.

METHODS

A research nurse performed three manual clinic blood pressure (CBP) measurements on three occasions over a 3-week period (total of nine readings, which were averaged) in 813 participants without treated hypertension from the Masked Hypertension Study, an ongoing worksite-based, population study. Twenty-four-hour ambulatory blood pressure (ABP) was assessed by using a SpaceLabs 90207 monitor. LVMI was determined by echocardiography in 784 (96.4%) participants.

RESULTS

Of the 813 participants, 769 (94.6%) had normal CBP levels (<140/90 mm Hg). One hundred and seventeen (15.2%) participants with normal CBP had MHT (normal CBP and mean awake ABP ≥135/85 mm Hg) and 287 (37.3%) had PHT (mean CBP 120-139/80-89 mm Hg). 83.8% of MHT participants had PHT and 34.1% of PHT participants had MHT. MHT was infrequent (3.9%) when CBP was optimal (<120/80 mm Hg). After adjusting for age, gender, body mass index (BMI), race/ethnicity, history of high cholesterol, history of diabetes, current smoking, family history of hypertension, and physical activity, compared with optimal CBP with MHT participants, LVMI was significantly greater in PHT without MHT participants and in PHT with MHT participants.

CONCLUSIONS

In this community sample, there was substantial diagnostic overlap between MHT and PHT. The diagnosis of MHT using an ABP monitor may not be warranted for individuals with optimal CBP.

Quantification of biventricular myocardial function using cardiac magnetic resonance feature tracking, endocardial border delineation and echocardiographic speckle tracking in patients with repaired tetralogy of Fallot and healthy controls

BACKGROUND

Parameters of myocardial deformation have been suggested to be superior to conventional measures of ventricular function in patients with tetralogy of Fallot (ToF), but have required non-routine, tagged cardiovascular magnetic resonance (CMR) techniques. We assessed biventricular myocardial function using CMR cine-based feature tracking (FT) and compared it to speckle tracking echocardiography (STE) and to simple endocardial border delineation (EBD). In addition, the relation between parameters of myocardial deformation and clinical parameters was assessed.

METHODS

Overall, 28 consecutive adult patients with repaired ToF (age 40.4 ± 13.3 years) underwent standard steady-state-free precession sequence CMR, echocardiography, and cardiopulmonary exercise testing. In addition, 25 healthy subjects served as controls. Myocardial deformation was assessed by CMR based FT (TomTec Diogenes software), CMR based EBD (using custom written software) and STE (TomTec Cardiac Performance Analysis software).

RESULTS

Feature tracking was feasible in all subjects. A close agreement was found between measures of global left (LV) and right ventricular (RV) global strain. Interobserver agreement for FT and STE was similar for longitudinal LV global strain, but FT showed better inter-observer reproducibility than STE for circumferential or radial LV and longitudinal RV global strain. Reproducibility of regional strain on FT was, however, poor. The relative systolic length change of the endocardial border measured by EBD yielded similar results to FT global strain. Clinically, biventricular longitudinal strain on FT was reduced compared to controls (P < 0.0001) and was related to the number of previous cardiac operations. In addition, FT derived RV strain was related to exercise capacity and VE/VCO2-slope.

CONCLUSIONS

Although neither the inter-study reproducibility nor accuracy of FT software were investigated, and its inter-observer reproducibility for regional strain calculation was poor, its calculations of global systolic strain showed similar or better inter-oberver reproducibility than those by STE, and could be applied across RV image regions inaccessible to echo. 'Global strain' calculated by EBD gave similar results to FT. Measurements made using FT related to exercise tolerance in ToF patients suggesting that the approach could have clinical relevance and deserves further study.

Congestive hepatopathy and hypoxic hepatitis in heart failure: a cardiologist's point of view

In the setting of long-standing severe chronic heart failure, other organ systems are also involved. The liver is one of the organs that are very sensitive to haemodynamic changes. Differential diagnosis of the liver injury is extremely important in the cardiologist's clinical practice and calls for cardiologist's and hepatologist's collaboration because there are many other diseases that can affect the liver and mimic haemodynamic injury. In this article, liver injuries depending on cardiocirculatory dysfunction such as hypoxic hepatitis and congestive hepatopathy are analysed. The material in the article is presented in two aspects: the evaluation and treatment of heart failure in order to prevent pathologic processes in the liver, and the recognition of the liver injury, including diagnostic tests which are essential for differential diagnosis of different liver pathologies.

Characterization of right atrial function and dimension in top-level athletes: a speckle tracking study

Although many echocardiographic studies are available about the adaptation of left ventricle to intensive training, right heart function has been poorly investigated and no data are available about the right atrial (RA) function in top-level athletes. The aim of the study was to investigate RA function and dimension by standard echocardiography and 2D speckle tracking echocardiography (STE). One hundred top-levels athletes were recruited from professional sports team and were compared with 78 normal subjects. Athletes during an off-training period or during prolonged forced rest resulting from injuries were excluded. Top-level athletes had higher BSA as compared with controls and, as expected, a lower resting heart rate (p ≤ 0.001). RA area, volume, and volume index were significantly greater in athletes than in controls (p ≤ 0.001). This increase was associated with greater right ventricular and inferior vena cava diameters (p ≤ 0.001). Peak atrial longitudinal strain and peak atrial contraction strain values were significantly lower in athletes in comparison with controls (40.92 ± 9.86% vs. 48.00 ± 12.68%, p ≤ 0.001; 13.05 ± 4.84% vs. 15.99 ± 5.74%, p ≤ 0.001, respectively). Interestingly, while athletes presented a higher E/A ratio (p ≤ 0.001) and a lower peak A velocity (p ≤ 0.001), the E/e' ratio did not differ between the two groups. In top-level athletes the RA presents a physiological adaptation to intensive exercise conditioning which determines not only a morphological but also a functional remodeling. We reported for the first time reference values of RA strain in elite athletes, demonstrating that 2D STE is a useful tool to investigate RA longitudinal myocardial deformation dynamics in athlete's heart.

The ABCs of left ventricular assist device echocardiography: a systematic approach

Echocardiography is an important imaging modality used to determine the indication of left ventricular assist device (LVAD) implantation for patients with advanced heart failure (HF) and for serial follow-up to make management decisions in patient care post-implant. Continuous axial-flow LVAD therapy provides effective haemodynamic support for the failing left ventricle, improving both the clinical functional status and quality of life. Echocardiographers must develop a systematic approach to echocardiographic assessment of LVAD implantation and post-LVAD implant cardiac morphology and physiology. This approach must include the evaluation of left and right heart chamber morphology and physiology and the anatomy and physiology of the inflow and outflow cannulas and the rotor pump, and the determination of the degree of tricuspid regurgitation and the presence of interatrial shunts and aortic regurgitation. Collaboration among the echocardiography and HF/transplant teams is essential to obtain this comprehensive evaluation. We outline a systematic approach to evaluating patients with HF who have failed conventional therapy and require LVAD therapy as a bridge to cardiac transplantation or destination therapy.

Right ventricular dysfunction in a hypertensive population stratified by patterns of left ventricular geometry

Introduction

The aim of this study was to assess the prevalence, determinants and correlates of right ventricular (RV) systolic and diastolic dysfunction (RVSD and RVDD, respectively) in hypertensives, stratified by left ventricular (LV) geometric patterns.

Methods

The study was carried out in Aminu Kano Teaching Hospital in Kano, Nigeria, and was cross-sectional in design. Hypertensive subjects referred for echocardiography were consecutively recruited after satisfying the inclusion criteria. RVSD was defined as either tricuspid annular plane systolic excursion (TAPSE) of < 16 mm, or peak velocity of the systolic wave (S_m) in tissue Doppler imaging (TDI) of the RV lateral tricuspid annulus of < 10 cm/s, or both. RVDD was defined as the ratio of < 1.0 of the peak velocities of the early (E_m) to late (A_m) diastolic waves in the TDI of the RV lateral tricuspid annulus. Subjects with normal LV geometry (NG) served as controls, and were compared with those who had eccentric (EH) or concentric (CH) LV hypertrophy or concentric LV remodelling.

Results

A total of 128 subjects were recruited. Overall, the prevalence of RVDD almost doubled that of RVSD in the studied subjects (61.72 vs 32.03%, respectively). Subjects with EH had the highest prevalence of RVSD (52.63%), while those with CH had the lowest prevalence (20.69%) (p < 0.01). By contrast, the prevalence of RVDD was high across the four groups without significant statistical difference; as high as 68.52% in subjects with NG and as low as 42.86% in those with CR. LVEF was the only independent determinant of RVSD after controlling for confounding variables, while age was the only determinant of RVDD. Likewise, age was the only correlate for E_m:A_m ratio, while the best correlate for both TAPSE and S_m was LVEF.

Conclusion

The study has revealed that about two-thirds of the hypertensives had RVDD while about one-third had RVSD. Subjects with EH had the highest prevalence of RVSD, while RVDD was common across all the groups. LVEF and age were the only independent determinants of RVSD and RVDD, respectively.