The forgotten chamber: the importance of the right ventricle

How Right is the Right Ventricle in Predicting Cardiac Mortality in Cardiac Failure: A 6-year Prospective Cohort Study

Aim

Two-dimensional speckle tracking echocardiography (2D-STE) and three-dimensional echocardiography (3DE) may overcome many limitations of the conventional 2D echocardiography (2DE) in assessing right ventricular (RV) function. We sought to determine whether characteristics of the right atrium and right ventricle as measured by 2D-STE and 3DE are associated with cardiac mortality in patients with ischemic heart failure, over a 6-year follow-up.

Materials and Methods

The inclusion criteria were ischemic cardiomyopathy with left ventricular ejection fraction of <40% diagnosed using standard 2DE, 2D-STE, and 3DE examination. Patients were followed for 6 years, and cardiac mortality was recorded.

Results

The study sample comprised a total of 54 participants. During the period of follow-up, 24% (13/54) died. The 2DE models showed that being older, having a higher body mass index (BMI), having higher systolic pulmonary artery pressure (SPAP), and a lower RV global longitudinal strain were associated with cardiac mortality in our cohort after 6-year follow-up. Finally, the 3DE models showed that in addition to being older, having higher BMI, having a higher SPAP baseline, lower baseline 3DE RV stroke volume, and larger 3DE RV end-diastolic volume and 3DE RV end-systolic volume were associated with cardiac mortality over 6-year follow-up.

Conclusion

This study provides evidence that RV dysfunction as seen on 2D-STE and 3DE could be associated with increased risk of cardiac-related mortality in patients with heart failure over 6 years.

Right ventricular dysfunction in patients with acute respiratory distress syndrome receiving venovenous extracorporeal membrane oxygenation

Acute respiratory distress syndrome is characterized by non-cardiogenic pulmonary edema, decreased pulmonary compliance, and abnormalities in gas exchange, especially hypoxemia. Patients with acute respiratory distress syndrome (ARDS) who receive support with venovenous (V-V) extracorporeal membrane oxygenation (ECMO) usually have severe lung disease. Many patients with ARDS have associated pulmonary vascular injury which can result in elevated pulmonary vascular resistance and right heart dysfunction. Since V-V ECMO relies upon preserved cardiac function, right heart failure has important implications for patient evaluation, management, and outcomes. Worsening right heart function complicates ARDS and disease processes. Given the increasing use of ECMO to support patients with ARDS, an understanding of right ventricular-ECMO and cardiopulmonary interactions is essential for the clinician. A narrative review of the manifestations of right heart dysfunction, as well as diagnosis and management strategies for the patient with ARDS on ECMO, is provided.

Molecular mechanisms and targets of right ventricular fibrosis in pulmonary hypertension

Right ventricular fibrosis is a stress response, predominantly mediated by cardiac fibroblasts. This cell population is sensitive to increased levels of pro-inflammatory cytokines, pro-fibrotic growth factors and mechanical stimulation. Activation of fibroblasts results in the induction of various molecular signaling pathways, most notably the mitogen-activated protein kinase cassettes, leading to increased synthesis and remodeling of the extracellular matrix. While fibrosis confers structural protection in response to damage induced by ischemia or (pressure and volume) overload, it simultaneously contributes to increased myocardial stiffness and right ventricular dysfunction. Here, we review state-of-the-art knowledge of the development of right ventricular fibrosis in response to pressure overload and provide an overview of all published preclinical and clinical studies in which right ventricular fibrosis was targeted to improve cardiac function.

Prognostic value of right ventricular strain and peak oxygen consumption in heart failure with reduced ejection fraction

Our purpose is to evaluate the combined predictive value of cardiopulmonary exercise testing (CPET) and echocardiographic evidence of left ventricular (LV) and right ventricular (RV) strain in predicting mortality and heart transplant (HTx) in a series of outpatients with heart failure with reduced ejection fraction (HFrEF). A retrospective cohort study of 66 patients with HFrEF (median age, 57 years; 51% women) who underwent CPET and echocardiography (up to 90 days apart) to assess prognosis. The primary outcome was a composite of death and need for HTx. At a median follow-up of 27 [20-39] months, 19 patients (29%) experienced the primary outcome. In unadjusted analysis, most echocardiographic and CPET parameters were associated with the primary outcome, including percentage of predicted peak oxygen consumption (ppVO₂), VE/VCO₂ slope, LV ejection fraction, and LV and RV longitudinal strain. After adjusting for other clinical, echocardiographic and CPET variables, RV free wall longitudinal strain and ppVO₂ remained significantly associated with the primary outcome. Kaplan-Meier survival curves for death and HTx, based on the best cutoff values, showed lower survival rates in patients with impairment in both ppVO₂ and RV FW-LS than in those with one or neither parameter impaired (p < 0.001). RV dysfunction and low cardiorespiratory fitness were independent markers of death and need for HTx. Impairment of both ppVO₂ and RV FW-LS had a strong additive impact on prognostic assessment in this cohort of patients with HFrEF.

The right ventricle under pressure: Anatomy and imaging in sickness and health

The right ventricle (RV) is an important structure which serves a multitude of vital physiological functions in health. For many years, the left ventricle has dominated the focus of understanding in both biology and pathophysiology and the RV was felt to be more of a passive structure which rarely had an effect on disease states. However, it is increasingly recognised that the RV is essential to the homoeostasis of normal physiology and disturbances in RV structure and function have a substantial effect on patient outcomes. Indeed, the prognosis of diseases of lung diseases affecting the pulmonary vasculature and left heart disease is intimately linked to the function of the right ventricle. This review sets out to describe the developmental and anatomical complexities of the right ventricle while exploring the modern techniques employed to image and understand its function from a clinical perspective.

Improved Right Ventricular Systolic Function After Cardiac Resynchronization Therapy in Patients With Heart Failure

BACKGROUND

Since the introduction of cardiac resynchronization therapy (CRT) to improve left ventricular function, the effect of CRT on the right ventricle in patients with heart failure has not been well described.

METHODS

We evaluated the effect of CRT on right ventricular systolic function in 20 patients (80% men; mean [SD] age, 58.5 [9.8] y) with cardiomyopathy and right ventricular systolic dysfunction (New York Heart Association class III or IV, left ventricular ejection fraction ≤35%, and QRS interval ≥120 ms). The median follow-up time was 15 months. Right ventricular systolic function, defined as a tricuspid annular plane systolic excursion (TAPSE) index of 16 mm or less, was evaluated in patients before and after CRT.

RESULTS

Twelve (60%) patients had ischemic cardiomyopathy, and 12 (60%) patients had left bundle branch block detected using surface electrocardiogram. The mean (SD) QRS duration was 160.5 (24.4) ms. From before CRT to the time of follow-up after CRT, the mean (SD) ejection fraction increased significantly from 22.5% (5.6%) to 29.4% (7.4%) (P < .001). The mean (SD) TAPSE index also increased significantly from 13.70 (1.78) mm to 16.50 (4.77) mm (P = .018). Eleven (55%) patients showed improved right ventricular systolic function (TAPSE ≥16 mm) after CRT. Patients with a favorable right ventricular response to CRT were significantly older (64.6 [8.2] y vs 53.6 [8.4] y, respectively) and more likely to have nonischemic origin of cardiomyopathy than were patients with unimproved right ventricular function (66.7% vs 18.2%, respectively).

CONCLUSION

Our findings indicate that CRT is associated with improved right ventricular systolic function in patients with heart failure and right ventricular systolic dysfunction. Patients with nonischemic heart disease more often show improved right ventricular function after CRT.

Three-Dimensional Echocardiography Assessment of Right Ventricular Volumes and Function: Technological Perspective and Clinical Application

Right ventricular (RV) function has important prognostic value in a variety of cardiovascular diseases. Due to complex anatomy and mode of contractility, conventional two-dimensional echocardiography does not provide sufficient and accurate RV function assessment. Currently, three-dimensional echocardiography (3DE) allows for an excellent and reproducible assessment of RV function owing to overcoming these limitations of traditional echocardiography. This review focused on 3DE and discussed the following points: (i) acquisition of RV dataset for 3DE images, (ii) reliability, feasibility, and reproducibility of RV volumes and function measured by 3DE with different modalities, (iii) the clinical application of 3DE for RV function quantification.

Determination of Cross-Directional and Cross-Wall Variations of Passive Biaxial Mechanical Properties of Rat Myocardia

Heart myocardia are critical to the facilitation of heart pumping and blood circulating around the body. The biaxial mechanical testing of the left ventricle (LV) has been extensively utilised to build the computational model of the whole heart with little importance given to the unique mechanical properties of the right ventricle (RV) and cardiac septum (SPW). Most of those studies focussed on the LV of the heart and then applied the obtained characteristics with a few modifications to the right side of the heart. However, the assumption that the LV characteristics applies to the RV has been contested over time with the realisation that the right side of the heart possesses its own unique mechanical properties that are widely distinct from that of the left side of the heart. This paper evaluates the passive mechanical property differences in the three main walls of the rat heart based on biaxial tensile test data. Fifteen mature Wistar rats weighing 225 ± 25 g were euthanised by inhalation of 5% halothane. The hearts were excised after which all the top chambers comprising the two atria, pulmonary and vena cava trunks, aorta, and valves were all dissected out. Then, 5 × 5 mm sections from the middle of each wall were carefully dissected with a surgical knife to avoid overly pre-straining the specimens. The specimens were subjected to tensile testing. The elastic moduli, peak stresses in the toe region and stresses at 40% strain, anisotropy indices, as well as the stored strain energy in the toe and linear region of up to 40% strain were used for statistical significance tests. The main findings of this study are: (1) LV and SPW tissues have relatively shorter toe regions of 10–15% strain as compared to RV tissue, whose toe region extends up to twice as much as that; (2) LV tissues have a higher strain energy storage in the linear region despite being lower in stiffness than the RV; and (3) the SPW has the highest strain energy storage along both directions, which might be directly related to its high level of anisotropy. These findings, though for a specific animal species at similar age and around the same body mass, emphasise the importance of the application of wall-specific material parameters to obtain accurate ventricular hyperelastic models. The findings further enhance our understanding of the desired mechanical behaviour of the different ventricle walls.

Prognostic Importance of Pulmonary Artery Pulsatility Index and Right Ventricular Stroke Work Index in End-Stage Heart Failure Patients

BACKGROUND

Right ventricular (RV) failure is an important cause of morbidity and mortality in patients with left ventricular (LV) end-stage heart failure (ESHF). Pulmonary artery pulsatility index (PAPi) and right ventricular stroke work index (RVSWI) are invasive parameters related to RV function. This study aimed to investigate the prognostic impact of PAPi and RVSWI in these patients.

METHODS AND RESULTS

In this study, 416 patients with ESHF were included. The adverse cardiac event (ACE) was defined as left ventricular assist device (LVAD) implantation, urgent heart transplantation, or cardiac mortality. There were 218 ACE cases and 198 non-ACE cases over a median follow-up of 503.50 days. Patients with ACE had lower PAPi and similar RVSWI compared to those without ACE (3.1±1.9 vs. 3.7±2.3, P=0.003 and 7.3±4.9 vs. 6.9±4.4, P=0.422, respectively). According to the results of multivariate analysis, while PAPi (from 2 to 5.65) was associated with ACE, RVSWI (from 3.62 to 9.75) was not associated with ACE (HR: 0.75, 95% CI (0.55-0.95), P=0.031; HR: 0.79, 95% CI: (0.58-1.09), P=0.081, , respectively). Survival analysis revealed that PAPi ≤2.56 was associated with a higher ACE risk compared to PAPi >2.56 (HR: 1.46, 95% CI: 1.11-1.92, P=0.006). PAPi ≤2.56 could predict ACE with 56.7% sensitivity and 51.3% specificity at one year. Furthermore, the association between RVSWI and ACE was nonlinear (J-curve pattern). Low and high values seem to be associated with higher ACE risk compared to intermediate values.

CONCLUSION

The low PAPi was an independent risk for ACE and it had a linear association with it. However, RVSWI seems to be have a nonlinear association with ACE (J-curve pattern).

Apolipoprotein E4 Is Associated with Right Ventricular Dysfunction in Dilated Cardiomyopathy-An Animal and In-Human Comparative Study

ApoE abnormality represents a well-known risk factor for cardiovascular diseases. Beyond its role in lipid metabolism, novel studies demonstrate a complex involvement of apoE in membrane homeostasis and signaling as well as in nuclear transcription. Due to the large spread of apoE isoforms in the human population, there is a need to understand the apoE’s role in pathological processes. Our study aims to dissect the involvement of apoE in heart failure. We showed that apoE-deficient rats present multiple organ damages (kidney, liver, lung and spleen) besides the known predisposition for obesity and affected lipid metabolism (two-fold increase in tissular damages in liver and one-fold increase in kidney, lung and spleen). Heart tissue also showed significant morphological changes in apoE^−/− rats, mostly after a high-fat diet. Interestingly, the right ventricle of apoE^−/− rats fed a high-fat diet showed more damage and affected collagen content (~60% less total collagen content and double increase in collagen1/collagen3 ratio) compared with the left ventricle (no significant differences in total collagen content or collagen1/collagen3 ratio). In patients, we were able to find a correlation between the presence of ε4 allele and cardiomyopathy (χ² = 10.244; p = 0.001), but also with right ventricle dysfunction with decreased TAPSE (15.3 ± 2.63 mm in ε4-allele-presenting patients vs. 19.8 ± 3.58 mm if the ε4 allele is absent, p < 0.0001*) and increased in systolic pulmonary artery pressure (50.44 ± 16.47 mmHg in ε4-allele-presenting patients vs. 40.68 ± 15.94 mmHg if the ε4 allele is absent, p = 0.0019). Our results confirm that the presence of the ε4 allele is a lipid-metabolism-independent risk factor for heart failure. Moreover, we show for the first time that the presence of the ε4 allele is associated with right ventricle dysfunction, implying different regulatory mechanisms of fibroblasts and the extracellular matrix in both ventricles. This is essential to be considered and thoroughly investigated before the design of therapeutical strategies for patients with heart failure.

Biventricular Morphology and Function Reference Values Derived From a Large Sample of Healthy Chinese Adults by Magnetic Resonance Imaging

Background: Quantification of cardiac structure and function is essential for diagnostic interpretation and clinical decision making. We sought to establish cardiovascular magnetic resonance (CMR) reference values of left and right ventricular (LV and RV) morphology and function based on a large sample of healthy Chinese adults. Methods: Five hundred fifty validated healthy Chinese adults (aged 21-70 years; 323 men) free of hypertension, diabetes, and obesity were included in this study. All the subjects were stratified by gender (men and women) and age decades. On cine CMR, measurements of biventricular end-diastolic, end-systolic, and stroke volumes (EDV, ESV, and SV), ejection fraction (EF), and end-diastolic LV wall thickness (LVWT) and mass (LVM) were obtained. Results: Men had greater LVEDV (111.6 ± 19.8 vs. 94.6 ± 15.6 ml), LVESV (36.5 ± 9.8 vs. 28.2 ± 7.9 ml), LVM (121.1 ± 19.9 vs. 86.1 ± 14.5 g), global end-diastolic LVWT (8.1 ± 1.1 vs. 6.7 ± 1.0 mm), RVEDV (128.0 ± 23.6 vs. 101.7 ± 17.0 ml), and RVESV (53.5 ± 13.7 vs. 36.8 ± 8.9 ml), while women had greater LVEF (67.5 ± 5.4 vs. 70.4 ± 5.7%) and RVEF (58.5 ± 5.2 vs. 64.0 ± 5.3%) (all p < 0.001). For both men and women, age was negatively correlated with LVEDV (r = -0.31 and r = -0.32), LVESV (r = -0.37 and r = -0.47), RVEDV (r = -0.31 and r = -0.29), and RVESV (r = -0.33 and r = -0.44), while it was positively correlated with LVEF (r = 0.28 and r = 0.43) and RVEF (r = 0.28 and r = 0.41) (all p < 0.001). Aging was associated with increasing global end-diastolic LVWT and LVM/LVEDV in both sexes (all p < 0.001). Older age was associated with increasing LVM only in women (r = 0.36, p < 0.001), not in men (r = 0.05, p = 0.359). Conclusions: We systematically provide age-, sex-, and body size-specific CMR reference values for biventricular morphology and function based on a large sample of healthy Chinese adults. Biventricular structure and function are significantly associated with age and sex.

A 'holistic' sonographic view on congenital heart disease - How automatic reconstruction using fetal intelligent navigation echocardiography (FINE) eases the unveiling of abnormal cardiac anatomy part I: Right heart anomalies

Attempting a comprehensive examination of the fetal heart remains challenging for unexperienced operators as it emphasizes the acquisition and documentation of sequential cross-sectional and sagittal views and inevitably results in diminished detection rates of fetuses affected by congenital heart disease. The introduction of four-dimensional spatio-temporal image correlation (4D STIC) technology facilitated a volumetric approach for thorough cardiac anatomic evaluation by the acquisition of cardiac 4D datasets. By analyzing and re-arranging of numerous frames according to their temporal event within the heart cycle, STIC allows visualization of cardiac structures as an endless cine loop sequence of a complete single cardiac cycle in motion. However, post-analysis with manipulation and repeated slicing of the volume usually requires experience and in-depth anatomic knowledge, which limits the widespread application of this advanced technique in clinical care and unfortunately leads to the underestimation of its diagnostic value to date. Fetal intelligent navigation echocardiography (FINE), a novel method that automatically generates and displays nine standard fetal echocardiographic views in normal hearts, has shown to be able to overcome these limitations. Very recent data on the detection of congenital heart defects (CHDs) using the FINE method revealed a high sensitivity and specificity of 98% and 93%, respectively. In this two-part manuscript, we focused on the performance of FINE in delineating abnormal anatomy of typical right and left heart lesions and thereby emphasized the educational potential of this technology for more than just teaching purposes. We further discussed recent findings in a pathophysiological and/or functional context.

Right ventricular myocardial mechanics: Multi-modal deformation, microstructure, modeling, and comparison to the left ventricle

The right ventricular myocardium, much like the rest of the right side of the heart, has been consistently understudied. Presently, little is known about its mechanics, its microstructure, and its constitutive behavior. In this work, we set out to provide the first data on the mechanics of the mature right ventricular myocardium in both simple shear and uniaxial loading and to compare these data to the mechanics of the left ventricular myocardium. To this end, we tested ovine tissue samples of the right and left ventricle under a comprehensive mechanical testing protocol that consisted of six simple shear modes and three tension/compression modes. After mechanical testing, we conducted a histology-based microstructural analysis on each right ventricular sample that yielded high resolution fiber distribution maps across the entire samples. Equipped with this detailed mechanical and histological data, we employed an inverse finite element framework to determine the optimal form and parameters for microstructure-based constitutive models. The results of our study show that right ventricular myocardium is less stiff then the left ventricular myocardium in the fiber direction, but similarly exhibits non-linear, anisotropic, and tension/compression asymmetric behavior with direction-dependent Poynting effect. In addition, we found that right ventricular myocardial fibers change angles transmurally and are dispersed within the sheet plane and normal to it. Through our inverse finite element analysis, we found that the Holzapfel model successfully fits these data, even when selectively informed by rudimentary microstructural information. And, we found that the inclusion of higher-fidelity microstructural data improved the Holzapfel model's predictive ability. Looking forward, this investigation is a critical step towards understanding the fundamental mechanical behavior of right ventricular myocardium and lays the groundwork for future whole-organ mechanical simulations.

Short- and long-term prognostic value of right ventricular function in patients with first acute ST elevation myocardial infarction treated by primary angioplasty

INTRODUCTION

Limited data are known about the prognostic value of right ventricle (RV) function in patients with first acute ST-segment elevation myocardial infarction (STEMI). The aim of this study was to investigate the prognostic value of RV dysfunction in predicting both in-hospital and long-term outcomes in these patients, irrespective of the site of necrosis.

METHODS

We enrolled 502 consecutive patients with first acute STEMI treated with primary angioplasty and underwent echocardiography within 48 hours of admission. RV function was evaluated by RV myocardial performance index (RVMPI), RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), pulsed tissue Doppler S' wave velocity, and RV global longitudinal strain (RVGLS) of the free wall. The occurrence of in-hospital major adverse cardiac events (MACE) and 1-year survival rate were recorded.

RESULTS

In MACE group, RVFAC, TAPSE, and RV S' wave velocity were lower. However, RVMPI, RVGLS, and TR Vmax. were higher than MACE free group (P < .001). In multivariable analysis adjusted for other variables that predicted adverse outcomes, RVFAC < 35% (P < .001), TAPSE < 17 mm (P < .001), RVGLS > -17% (P < .001), RV S' wave velocity < 9.5 cm/s (P = .02), RVMPI > 0.43 (P < .001), and TR Vmax. > 2.8 m/s (P = .01) were strong independent predictors of in-hospital MACE. Lower 1-year survival was noted in patients with RV dysfunction, documented by these cutoffs values.

CONCLUSION

RV dysfunction, evidenced by multiparametric echocardiography, is predictive for adverse in-hospital outcomes, and lower 1-year survival rate in first acute STEMI regardless of the site of necrosis.

Acute right heart failure: future perspective with the PERKAT RV pulsatile right ventricular support device

Acute right heart failure is associated with impaired prognosis in cardiogenic shock. Since most pharmacological therapies are not evaluated for the failing right ventricle, or even contraindicated, there is a need for rapid minimal invasive circulatory right heart support. The PERKAT RV is such a device for acute therapy in congestive heart failure. It reduces the central venous pooling by pumping blood from the inferior vena cava into the pulmonary artery with flow rates of up to 4 litres/min. The device was evaluated in an animal model of acute pulmonary embolism after careful in vitro tests. PERKAT RV increased cardiac output by 59% in sheep suffering from acute right heart failure. We await the first human implantation in the near future. Based on the PERKAT concept, future devolvement will also focus on left heart support.

Associations between short-term exposure to gaseous pollutants and pulmonary heart disease-related mortality among elderly people in Chengdu, China

BACKGROUND

Pulmonary heart disease (PHD) has become a global burden, especially in low- and middle-income countries. However, very few studies have assessed the influence of air pollution on PHD. This is the first study to explore the association between gaseous pollutants and PHD-related mortality in the central Sichuan Basin of southwestern China.

METHODS

Data on PHD-related mortality among elderly people (aged 60 and older) from 2013 to 2017 were collected from the Population Death Information Registration and Management System (PDIRMS). Data on air pollutants were collected from all 24 Municipal Environmental Monitoring Sites in Chengdu, and data on daily temperature, relative humidity, and atmospheric pressure were collected from the Chengdu Municipal Meteorological Bureau. An epidemiological design of time-stratified case-crossover was conducted to assess the association between short-term exposure to ambient gaseous pollutants and PHD-related mortality among elderly people.

RESULTS

About 54,920 PHD-related deaths among people aged 60 and older were reported. After controlling for daily temperature, relative humidity, and atmospheric pressure, an IQR concentration increase in levels of sulfur dioxide (SO₂) (13 μg/m³), nitrogen dioxide (NO₂) (17 μg/m³), and ozone (O₃) (74 μg/m³) was associated with 7.8, 6.2, and 5.5% increases in PHD-related mortality in people aged 60 and older, respectively. People over age 70 might have even higher susceptibility to PHD-related mortality associated with SO₂, NO₂, and O₃. Females and individuals with alternative marital statuses (widowed, divorced, or never married) had twice and more than twice the PHD-related mortality risk associated with SO₂ and NO₂ than males and married individuals, respectively.

CONCLUSIONS

Increased concentrations of ambient SO₂, NO₂, and O₃ were significantly and positively associated with PHD-related mortality in Chengdu, China. Sociodemographic factors - including gender, age, and marital status - may modify the acute health effects of gaseous pollutants.

Quantitative assessment of systolic and diastolic right ventricular function by echocardiography and speckle-tracking imaging: a prospective study in 104 dogs

Our aim was (1) to determine the within-day and between-day variability of several indices of systolic and diastolic right ventricular (RV) function by using conventional echocardiography and speckle-tracking echocardiography (STE) (Study 1), (2) to quantify these variables in a large healthy canine population (n = 104) with Doppler-derived estimated systolic pulmonary arterial pressure (SPAP) and left ventricular (LV) function, and (3) to establish the corresponding reference intervals (Study 2). For both studies, RV variables included tricuspid annular plane systolic excursion (TAPSE), right fractional area change (RFAC), STE longitudinal systolic strain (StS) of the RV free wall (RVFW) and of the entire RV (i.e., global RV StS), STE longitudinal systolic RVFW strain rate (SRS), and the diastolic early:late strain rate ratio. All but one within- and between-day coefficients of variation (13/14) were < 15%, the lowest being observed for TAPSE (3.6–9.8%), global RV StS (3.8–9.9%), and RVFW StS (3.7–7.3%). SPAP was weakly and negatively correlated with the TAPSE:body weight ratio (r_s = −0.26, p = 0.01) and RVFW SRS (r_s = −0.23, p < 0.05). Reference intervals (lower and upper limits with 90% confidence intervals) were provided for all variables. STE provides a non-invasive evaluation of RV function that may be used for clinical investigations in canine cardiology.

Fibroblasts and the extracellular matrix in right ventricular disease

Right ventricular failure predicts adverse outcome in patients with pulmonary hypertension (PH), and in subjects with left ventricular heart failure and is associated with interstitial fibrosis. This review manuscript discusses the cellular effectors and molecular mechanisms implicated in right ventricular fibrosis. The right ventricular interstitium contains vascular cells, fibroblasts, and immune cells, enmeshed in a collagen-based matrix. Right ventricular pressure overload in PH is associated with the expansion of the fibroblast population, myofibroblast activation, and secretion of extracellular matrix proteins. Mechanosensitive transduction of adrenergic signalling and stimulation of the renin-angiotensin-aldosterone cascade trigger the activation of right ventricular fibroblasts. Inflammatory cytokines and chemokines may contribute to expansion and activation of macrophages that may serve as a source of fibrogenic growth factors, such as transforming growth factor (TGF)-β. Endothelin-1, TGF-βs, and matricellular proteins co-operate to activate cardiac myofibroblasts, and promote synthesis of matrix proteins. In comparison with the left ventricle, the RV tolerates well volume overload and ischemia; whether the right ventricular interstitial cells and matrix are implicated in these favourable responses remains unknown. Expansion of fibroblasts and extracellular matrix protein deposition are prominent features of arrhythmogenic right ventricular cardiomyopathies and may be implicated in the pathogenesis of arrhythmic events. Prevailing conceptual paradigms on right ventricular remodelling are based on extrapolation of findings in models of left ventricular injury. Considering the unique embryologic, morphological, and physiologic properties of the RV and the clinical significance of right ventricular failure, there is a need further to dissect RV-specific mechanisms of fibrosis and interstitial remodelling.

Tricuspid valve imaging

The right ventricle and tricuspid valve (TV) have long been neglected by cardiologists. Functional tricuspid regurgitation (TR) is nowadays the most common cause of severe TR and is emerging as a prognostic factor in many heart diseases. A multimodality imaging approach is fundamental for defining the pathophysiology of TR, using both two-dimensional and three-dimensional echocardiography, as well as CT scan. In particular, 3D echocardiography can characterize TV apparatus and tricuspid annulus; CT offers complementary information about annular structure, and its relationship with the right coronary artery. The following review will describe TV anatomy, define transthoracic and transesophageal echocardiographic views for evaluating TV morphology, function and TR grading with some clues on interventional perspectives.

Maternal nutrient restriction during pregnancy and lactation leads to impaired right ventricular function in young adult baboons

KEY POINTS

Maternal nutrient restriction induces intrauterine growth restriction (IUGR) and leads to heightened cardiovascular risks later in life. We report right ventricular (RV) filling and ejection abnormalities in IUGR young adult baboons using cardiac magnetic resonance imaging. Both functional and morphological indicators of poor RV function were seen, many of which were similar to effects of ageing, but also with a few key differences. We observed more pronounced RV changes compared to our previous report of the left ventricle, suggesting there is likely to be a component of isolated RV abnormality in addition to expected haemodynamic sequelae from left ventricular dysfunction. In particular, our findings raise the suspicion of pulmonary hypertension after IUGR. This study establishes that IUGR also leads to impairment of the right ventricle in addition to the left ventricle classically studied.

ABSTRACT

Maternal nutrient restriction induces intrauterine growth restriction (IUGR), increasing later life chronic disease including cardiovascular dysfunction. Our left ventricular (LV) CMRI studies in IUGR baboons (8 M, 8 F, 5.7 years - human equivalent approximately 25 years), control offspring (8 M, 8 F, 5.6 years), and normal elderly (OLD) baboons (6 M, 6 F, mean 15.9 years) revealed long-term LV abnormalities in IUGR offspring. Although it is known that right ventricular (RV) function is dependent on LV health, the IUGR right ventricle remains poorly studied. We examined the right ventricle with cardiac magnetic resonance imaging in the same cohorts. We observed decreased ejection fraction (49 ± 2 vs. 33 ± 3%, P < 0.001), cardiac index (2.73 ± 0.27 vs. 1.89 ± 0.20 l min-1 m-2 , P < 0.05), early filling rate/body surface area (BSA) (109.2 ± 7.8 vs. 44.6 ± 7.3 ml s-1  m-2 , P < 0.001), wall thickening (61 ± 3 vs. 44 ± 5%, P < 0.05), and longitudinal shortening (26 ± 3 vs. 15 ± 2%, P < 0.01) in IUGR animals with increased chamber volumes. Many, but not all, of these changes share similarities to normal older animals. Our findings suggest IUGR-induced pulmonary hypertension should be further investigated and that atrial volume, pulmonic outflow and interventricular septal motion may provide valuable insights into IUGR cardiovascular physiology. Overall, our findings reaffirm that gestational and neonatal challenges can result in long-term programming of poor offspring cardiovascular health. To our knowledge, this is the first study reporting IUGR-induced programmed adult RV dysfunction in an experimental primate model.

Clostridium perfringens sepsis complicated by right ventricular cardiogenic shock

Clostridium perfringens sepsis has been ascribed a dismal prognosis when associated with massive intravascular haemolysis. We present a 71-year-old woman's fatal case which was compounded by isolated right ventricular cardiogenic shock. In this context, combined use of transthoracic echocardiography and pulmonary artery catheter monitoring is able to yield an individualized hemodynamic resuscitation. We discuss key aspects related to right and left heart mechanical efficiency, hypothesize as to the pulmonary hypertension mechanism of our case and set to emphasize a physiologically based framework for right ventricular failure hemodynamic management.

Physiological mechanisms of pulmonary hypertension

Pulmonary hypertension is usually related to obstruction of pulmonary blood flow at the level of the pulmonary arteries (eg, pulmonary embolus), pulmonary arterioles (idiopathic pulmonary hypertension), pulmonary veins (pulmonary venoocclusive disease) or mitral valve (mitral stenosis and regurgitation). Pulmonary hypertension is also observed in heart failure due to left ventricle myocardial diseases regardless of the ejection fraction. Pulmonary hypertension is often regarded as a passive response to the obstruction to pulmonary flow. We review established fluid dynamics and physiology and discuss the mechanisms underlying pulmonary hypertension. The important role that the right ventricle plays in the development and maintenance of pulmonary hypertension is discussed. We use principles of thermodynamics and discuss a potential common mechanism for a number of disease states, including pulmonary edema, through adding pressure energy to the pulmonary circulation.

Cardiorespiratory interactions: Noncontact assessment using laser Doppler vibrometry

The application of a noncontact physiological recording technique, based on the method of laser Doppler vibrometry (LDV), is described. The effectiveness of the LDV method as a physiological recording modality lies in the ability to detect very small movements of the skin, associated with internal mechanophysiological activities. The method is validated for a range of cardiovascular variables, extracted from the contour of the carotid pulse waveform as a function of phase of the respiration cycle. Data were obtained from 32 young healthy participants, while resting and breathing spontaneously. Individual beats were assigned to four segments, corresponding with inspiration and expiration peaks and transitional periods. Measures relating to cardiac and vascular dynamics are shown to agree with the pattern of effects seen in the substantial body of literature based on human and animal experiments, and with selected signals recorded simultaneously with conventional sensors. These effects include changes in heart rate, systolic time intervals, and stroke volume. There was also some evidence for vascular adjustments over the respiration cycle. The effectiveness of custom algorithmic approaches for extracting the key signal features was confirmed. The advantages of the LDV method are discussed in terms of the metrological properties and utility in psychophysiological research. Although used here within a suite of conventional sensors and electrodes, the LDV method can be used on a stand-alone, noncontact basis, with no requirement for skin preparation, and can be used in harsh environments including the MR scanner.

A case report of lethal post-viral lymphocytic myocarditis with exclusive location in the right ventricle

The inflammatory involvement of vital organs may represent a dangerous and life-threatening situation: in particular, the inflammation of the myocardial tissue of the heart may lead to severe consequences since the clinical history of the disease may be completely asymptomatic, any clinical sign may be lacking, thus preventing correct diagnosis and treatment. This may occur even in the case of myocarditis and may lead to unexpected death whose cause can be assessable only by means of a thorough histopathological examination. The article reports the case of 61-year old female who developed a flu-like syndrome with very few symptoms, followed by sudden death in three weeks. The autopsy and following histopathological investigations identified the cause of death in a post-viral lymphocytic myocarditis, probably related to the previous infectious disease, and alternative causes (as arrhythmic ventricular dysplasia, vasculitis, sarcoidosis and giant cell myocarditis) were excluded. The exclusive location in the right ventricle was a peculiar finding. The case highlights the importance of the myocardium of the right ventricle, a tissue which is often less considered even in histopathological surveys. The exclusive location of myocarditis in the right ventricle is a rare event but in this case fully responsible for death.

Multimodality Evaluation of the Right Ventricle: An Updated Review

The assessment of the volumes, function, and mechanics of the right ventricle (RV) is very challenging because of the anatomical complexity of the RV. Because RV structure, function, and deformation are very important predictors of cardiovascular morbidity and mortality in patients with heart failure, pulmonary hypertension, congenital heart disease, or arrhythmogenic RV cardiomyopathy, it is of great importance to use an appropriate imaging modality that will provide all necessary information. In everyday clinical practice, 2-dimensional echocardiography (2DE) represents a method of first choice in RV evaluation. However, cardiac magnetic resonance (CMR) remained the gold standard for RV assessment. The development of new imaging tools, such as 3-dimensional echocardiography (3DE), provided reliable data, comparable with CMR, and opened a completely new era in RV imaging. So far, 3DE has shown good results in determination of RV volumes and systolic function, and there are indications that it will also provide valuable data about 3-dimensional RV mechanics, similar to CMR. Two-dimensional echocardiography-derived strain is currently widely used for the assessment of RV deformation, which has been proven to be a more significant predictor of functional capacity and survival than CMR-derived RV ejection fraction. The purpose of this review is to summarize currently available data about RV structure, function, and mechanics obtained by different imaging modalities, primarily 2DE and 3DE, and their comparison with CMR and cardiac computed tomography.

The right atrium, a forgotten cardiac chamber: An updated review of multimodality imaging

Despite several limitations, two-dimensional echocardiography (2DE) is the standard method for assessing the right atrium (RA) in everyday clinical routine. Cardiac magnetic resonance remains the current "gold standard" for RA visualization and volume quantification. The development of 2DE-derived strain imaging has enabled assessing RA deformation and phasic function in various pathologic conditions. Three-dimensional echocardiography was demonstrated to be more accurate and reproducible than 2DE for cardiac chamber quantification, while also allowing the evaluation of RA phasic function without geometric assumption. The purpose of this review is to summarize currently available data about RA anatomy, phasic function, and mechanics acquired by different imaging modalities.

Sleep disordered breathing and enlargement of the right heart after myocardial infarction

Structural and functional integrity of the right heart is important in the prognosis after acute myocardial infarction (AMI). The objective of this study was to assess the impact of sleep disordered breathing (SDB) on structure and function of the right heart early after AMI.

54 patients underwent cardiovascular magnetic resonance 3–5 days and 12 weeks after AMI, and were stratified according to the presence of SDB, defined as an apnoea–hypopnoea index of ≥15 events·h−1.

12 weeks after AMI, end-diastolic volume of the right ventricle had increased significantly in patients with SDB (n=27)versusthose without (n=25) (mean±sd14±23%versus0±17%, p=0.020). Multivariable linear regression analysis accounting for age, sex, body mass index, smoking, left ventricular mass and left ventricular end-systolic volume showed that the apnoea–hypopnoea index was significantly associated with right ventricular end-diastolic volume (B-coefficient 0.315 (95% CI 0.013–0.617); p=0.041). From baseline to 12 weeks, right atrial diastolic area increased more in patients with SDB (2.9±3.7 cm2versus1.0±2.4 cm2, p=0.038; when adjusted for left ventricular end systolic volume, p=0.166).

SDB diagnosed shortly after AMI predicts an increase of right ventricular end-diastolic volume and possibly right atrial area within the following 12 weeks. Thus, SDB may contribute to enlargement of the right heart after AMI.

Right ventricular cardiomyopathies: a multidisciplinary approach to diagnosis

The physiological importance of the right ventricle (RV) has been underestimated over the past years. Finally in the early 1950s through the 1970s, cardiac surgeons recognized the importance of RV function. Since then, the importance of RV function has been recognized in many acquired cardiac heart disease. RV can be mainly or together with left ventricle (LV) affected by inherited or acquired cardiomyopathy. In fact, RV morphological and functional remodeling occurs more common during cardiomyopathies than in ischemic cardiomyopathies and more closely parallels LV dysfunction. Moreover, there are some cardiomyopathy subtypes showing a predominant or exclusive involvement of the RV, and they are probably less known by cardiologists. The clinical approach to right ventricular cardiomyopathies is often challenging. Imaging is the first step to raise the suspicion and to guide the diagnostic process. In the differential diagnosis, cardiologists should consider athlete's heart, congenital heart diseases, multisystemic disorders, and inherited arrhythmias. However, a multiparametric and multidisciplinary approach, involving cardiologists, experts in imaging, geneticists, and pathologists with a specific expertise in these heart muscle disorders is required.

Evaluation of the right ventricular function in pneumoconiosis patients using volume-time curves obtained by real-time three-dimensional echocardiography

The study was aimed to evaluate the right ventricular function in pneumoconiosis patients by real-time three-dimensional echocardiography. A total of 80 individuals including 44 consecutive pneumoconiosis patients and 36 age- and gender-matched healthy volunteers as controls were prospectively recruited for the study. All the patients underwent two- and three-dimensional echocardiography. Measurements of the right ventricle included tricuspid regurgitation pressure (TRPG), anterior and posterior wall thickness and range of motion (TH1, TH2, M1, M2), right end-diastolic volume and end-systolic volume. The right ventricular ejection fraction (RVEF) was also calculated. The RVEF of healthy volunteers ranged from 50 to 78 %, whereas that of the pneumoconiosis patients varied from 29 to 73 %. An increase in TRPG caused a significant (p = 0.006) decrease in RVEF (by 77.3 %), suggesting the two variables were negatively correlated (r = -0.643, p < 0.01). In comparison with normal, the volume-time curves of the pneumoconiosis patients showed a lower trough. Use of real-time three-dimensional echocardiography provides with added clinical information needed to evaluate right ventricular function in pneumoconiosis patients.

Right ventricular mechanics in hypertrophic cardiomyopathy using feature tracking

Objectives: Right ventricular (RV) mechanics in hypertrophic cardiomyopathy (HCM) are poorly understood. We investigate global and regional deformation of the RV in HCM and its relationship to LV phenotype, using 2D strain vector velocity imaging (VVI). Methods: 100 HCM patients (42% females, 41 ± 19 years) and 30 control patients were studied using VVI. Longitudinal peak systolic strain (ϵ_sys), strain rate (SR), time to peak (ϵ) (TTP), displacement of RV free wall (RVFW) and septal wall were analyzed. Similar parameters were quantified in LV septal, lateral, anterior and inferior segments. Intra-V-delay was defined as SD of TTP. Inter-V-delay was estimated from TTP difference between the most delayed LV segment & RVFW. Results: ϵ_sys and SR of both RV & LV, showed loss of base to apex gradient and significant decline in HCM (p < 0.001). Deformation variables estimated from RVFW were strongly correlated with each other (r = 0.93, p < 0.0001). Both were directly related to LV ϵ_sys, SR_sys, SR_e, ejection fraction (EF)%, RVFW displacement (P < 0.001) and inversely related to age, positive family history (p < 0.004, 0.005), RV wall thickness, maximum wall thickness (MWT), intra-V-delay, LA volume (P < 0.0001), LVOT gradient (p < 0.02, 0.005) respectively. ROC curves were constructed to explore the cut-off point that discriminates RV dysfunction. Global and RVFW ϵ_sys: − 19.5% shows 77, 70% sensitivity & 97% specificity, SR_sys: − 1.3s^− 1 shows 82, 70% sensitivity & 30% specificity. Multivariate analyses revealed that RVFW displacement (β = − 0.9, p < 0.0001) and global LV SR_sys (β = 5.9, p < 0.0001) are independent predictors of global RV deformation. Conclusions: Impairment of RV deformation is evident in HCM using feature tracking. It is independently influenced by LV mechanics and correlated to the severity of LV phenotype. RVFW deformation analysis and global RV assessment are comparable.

Quantifying longitudinal right ventricular dysfunction in patients with old myocardial infarction by using speckle-tracking strain echocardiography

BACKGROUND

We investigated longitudinal right ventricular (RV) function assessed using speckle-tracking strain echocardiography in patient with myocardial infarction (MI), and identified the contributing factors for RV dysfunction.

METHODS

We retrospectively studied 71 patients with old MI (the OMI group) and 45 normal subjects (the Control group) who underwent a transthoracic echocardiography. Global and free wall RV peak systolic strains (PSSs) in the longitudinal direction were measured by using speckle-tracking strain echocardiography. Left ventricular (LV) PSSs were measured in the longitudinal, radial and circumferential directions. Cardiac hemodynamics including peak systolic pulmonary artery pressure was also assessed non-invasively. Plasma brain natriuretic peptide (BNP) levels were measured in all patients.

RESULTS

In the OMI group, 73% of the patients had a normal estimated peak systolic pulmonary artery pressure of less than 35 mmHg. Global and free wall RV PSS were impaired in the OMI group compared with the Control group, and these RV systolic indices were significantly associated with heart rate, logarithmic transformed plasma BNP, greater than 1 year after onset of MI, Doppler-derived estimated pulmonary vascular resistance, LV systolic indices, LV mass index, infarcted segments within a territory of the left circumflex artery and residual total occlusion in the culprit right coronary artery. Multivariable linear regression analysis indicated that reduced longitudinal LV PSS in the 4-chamber view and BNP levels ≥500 pg/ml were independently associated with reduced global and free wall RV PSS. Moreover, when patients were divided into 3 groups according to plasma BNP levels (BNP <100 pg/ml; n = 31, 100 ≤BNP <500 pg/ml; n = 24, and BNP ≥500 pg/ml; n = 16), only patients with BNP ≥500 pg/ml had a strong correlation between RV PSS and longitudinal LV PSS in the 4-chamber view (r = 0.78 for global RV PSS and r = 0.71 for free wall RV PSS, p <0.05).

CONCLUSION

Longitudinal RV systolic strain depends significantly on longitudinal LV systolic strain especially in patients with high plasma BNP levels, but not on estimated peak systolic pulmonary artery pressure. These results indicate that process of RV myocardial dysfunction following MI may be governed by neurohormonal activation which causing ventricular remodeling rather than increased RV afterload.

Right ventricular cardiovascular magnetic resonance imaging: normal anatomy and spectrum of pathological findings

BACKGROUND

The right ventricle (RV) has been defined as the "forgotten chamber", as its role in cardiac physiopathology has long been underestimated. Nevertheless, the RV is involved in a wide range of pathological conditions and its altered function may significantly affect the patient's clinical status.

METHODS

A selection of the most common cardiovascular magnetic resonance (CMR) features in a spectrum of pathological conditions is illustrated. Although its complex morphology, thin myocardium and trabeculated apex, RV can be accurately imaged by CMR, revealing its involvement in ischaemic and non-ischaemic heart disease. CMR has emerged as the pre-eminent modality in monitoring ventricular performance in congenital heart disease, pulmonary hypertension and cardiomyopathies. Arrhythmogenic right ventricular cardiomyopathy is a difficult diagnosis and the recently revised task force criteria confirmed a crucial role of CMR to increase diagnostic accuracy, by combining detection of RV dilation, regional wall motion and structural abnormalities. Moreover, a multiparametric approach of CMR is often necessary for delineation and characterisation of cardiac masses.

CONCLUSION

CMR, combining assessment of morphology, structure and function, has definitively emerged as the reference technique to evaluate a large variety of RV diseases.

TEACHING POINTS

• CMR offers unique advantages for imaging of many RV congenital, ischaemic and non-ischaemic diseases. • Because of high reproducibility, CMR has a crucial role in decision-making for chronic RV pathology. • The use of CMR increases detection of RV disease as infarction or arrhythmogenic cardiomyopathy.

Current and evolving echocardiographic techniques for the quantitative evaluation of cardiac mechanics: ASE/EAE consensus statement on methodology and indications endorsed by the Japanese Society of Echocardiography

Echocardiographic imaging is ideally suited for the evaluation of cardiac mechanics because of its intrinsically dynamic nature. Because for decades, echocardiography has been the only imaging modality that allows dynamic imaging of the heart, it is only natural that new, increasingly automated techniques for sophisticated analysis of cardiac mechanics have been driven by researchers and manufacturers of ultrasound imaging equipment. Several such techniques have emerged over the past decades to address the issue of reader's experience and inter-measurement variability in interpretation. Some were widely embraced by echocardiographers around the world and became part of the clinical routine, whereas others remained limited to research and exploration of new clinical applications. Two such techniques have dominated the research arena of echocardiography: (1) Doppler-based tissue velocity measurements, frequently referred to as tissue Doppler or myocardial Doppler, and (2) speckle tracking on the basis of displacement measurements. Both types of measurements lend themselves to the derivation of multiple parameters of myocardial function. The goal of this document is to focus on the currently available techniques that allow quantitative assessment of myocardial function via image-based analysis of local myocardial dynamics, including Doppler tissue imaging and speckle-tracking echocardiography, as well as integrated back- scatter analysis. This document describes the current and potential clinical applications of these techniques and their strengths and weaknesses, briefly surveys a selection of the relevant published literature while highlighting normal and abnormal findings in the context of different cardiovascular pathologies, and summarizes the unresolved issues, future research priorities, and recommended indications for clinical use.

Echocardiographic evaluation of heart in chronic obstructive pulmonary disease patient and its co-relation with the severity of disease

Background:

Chronic obstructive pulmonary disease (COPD) has considerable effects on cardiac functions, including those of the right ventricle, left ventricle, and pulmonary blood vessels. Most of the increased mortality associated with COPD is due to cardiac involvement. Echocardiography provides a rapid, noninvasive, portable, and accurate method to evaluate the cardiac changes.

Aims:

To assess the cardiac changes secondary to COPD by echocardiography and to find out the correlation between echocardiographic findings and severity of COPD, if there is any.

Materials and Methods:

A total 40 of patients of COPD were selected and staged by pulmonary function test (PFT) and evaluated byechocardiography.

Results:

On echocardiographic evaluation of COPD, 50% cases had normal echocardiographic parameters. Measurable tricuspid regurgitation (TR) was observed in 27/40 cases (67.5%). Pulmonary hypertension (PH), which is defined as systolic pulmonary arterial pressure (sPAP)> 30 mmHg was observed in 17/27 (63%) cases in which prevalence of mild, moderate, and severe PH were 10/17 (58.82%), 4/17 (23.53%), and 3/17 (17.65%), respectively. The frequencies of PH in mild, moderate, severe, and very severe COPD were 16.67%, 54.55%, 60.00%, and 83.33%, respectively. Right atrial pressure was 10 mmHg in 82.5% cases and 15 mmHg in 17.5% cases. Cor pulmonale was observed in 7/17 (41.17%) cases; 7.50% cases had left ventricle (LV) systolic dysfunction and 47.5% cases had evidence of LV diastolic dysfunction defined as A ≥ E (peak mitral flow velocity of the early rapid filling wave (E), peak velocity of the late filling wave caused by atrial contraction (A) on mitral valve tracing) Left ventricle hypertrophy was found in 22.5% cases.

Conclusion:

Prevalence of PH has a linear relationship with severity of COPD and severe PH is almost associated with cor pulmonale. Echocardiography helps in early detection of cardiac complications in COPD cases giving time for early interventions.

Pulmonary vascular stiffness: measurement, modeling, and implications in normal and hypertensive pulmonary circulations

This article introduces the concept of pulmonary vascular stiffness, discusses its increasingly recognized importance as a diagnostic marker in the evaluation of pulmonary vascular disease, and describes methods to measure and model it clinically, experimentally, and computationally. It begins with a description of systems-level methods to evaluate pulmonary vascular compliance and recent clinical efforts in applying such techniques to better predict patient outcomes in pulmonary arterial hypertension. It then progresses from the systems-level to the local level, discusses proposed methods by which upstream pulmonary vessels increase in stiffness, introduces concepts around vascular mechanics, and concludes by describing recent work incorporating advanced numerical methods to more thoroughly evaluate changes in local mechanical properties of pulmonary arteries.

Current and evolving echocardiographic techniques for the quantitative evaluation of cardiac mechanics: ASE/EAE consensus statement on methodology and indications endorsed by the Japanese Society of Echocardiography

Echocardiographic imaging is ideally suited for the evaluation of cardiac mechanics because of its intrinsically dynamic nature. Because for decades, echocardiography has been the only imaging modality that allows dynamic imaging of the heart, it is only natural that new, increasingly automated techniques for sophisticated analysis of cardiac mechanics have been driven by researchers and manufacturers of ultrasound imaging equipment.Several such technique shave emerged over the past decades to address the issue of reader's experience and inter measurement variability in interpretation.Some were widely embraced by echocardiographers around the world and became part of the clinical routine,whereas others remained limited to research and exploration of new clinical applications.Two such techniques have dominated the research arena of echocardiography: (1) Doppler based tissue velocity measurements,frequently referred to as tissue Doppler or myocardial Doppler, and (2) speckle tracking on the basis of displacement measurements.Both types of measurements lend themselves to the derivation of multiple parameters of myocardial function. The goal of this document is to focus on the currently available techniques that allow quantitative assessment of myocardial function via image-based analysis of local myocardial dynamics, including Doppler tissue imaging and speckle-tracking echocardiography, as well as integrated backscatter analysis. This document describes the current and potential clinical applications of these techniques and their strengths and weaknesses,briefly surveys a selection of the relevant published literature while highlighting normal and abnormal findings in the context of different cardiovascular pathologies, and summarizes the unresolved issues, future research priorities, and recommended indications for clinical use.

Right ventricular ejection fraction and left ventricular dyssynchrony by 3D echo correlate with functional impairment in patients with dilated cardiomyopathy

BACKGROUND

The aim of the study was to detect if right ventricular (RV) ejection fraction assessed by real-time 3-dimensional echocardiography (RT3DE) could predict patients with dilated cardiomyopathy (DCM) with greater functional impairment in response to cardiopulmonary exercise.

METHODS AND RESULTS

Seventy chronic heart failure patients with DCM (55.5 ± 9.1 years; 48 males; 30 ischemic; New York Heart Association Class III: 48) underwent both left ventricular (LV) and RV analysis by RT3DE. Postprocessing software provided data of RT3DE systolic dyssynchrony index of 16 LV segments (systolic dyssynchrony index [SDI]) and of both LV and RV ejection fraction. Cardiac magnetic resonance was performed in a subgroup of 40 DCM patients to confirm RT3DE measurements. All the patients underwent also bicycle cardiopulmonary exercise test with evaluation of oxygen consumption (VO2) peak% (percentage of the predicted value), VE/VCO2 slope, and circulatory power (CP). Mean LV ejection fraction was 29.8 ± 4.6%. RT3DE LV SDI index was 8.4.4 ± 4.2, and RV ejection fraction was 51.3 ± 4.6%. By cardiopulmonary test, mean VO2 peak was 15.2 ± 4.4 mL·kg·min, and mean CP was 2.1 ± 0.8. By univariable analyses, significant correlations were detectable between SDI index and VO2 peak% (r = -0.56; P < .0001) and peak CP (r = -0.48; P < .0005). Also RV ejection fraction directly correlated with VO2 peak% (r = 0.58; P < .0001) and inversely with VE/VCO2 slope (r = -0.44; P < .001). By multivariable analysis, SDI index (β coefficient = -0.46; P < .001) and 3D RV ejection fraction (β coefficient = 0.42; P < .001) emerged as the only independent determinants of VO2 peak% during cardiopulmonary test.

CONCLUSIONS

Increased LV electromechanical dyssynchrony and impaired RV function in DCM patients are independently associated with worse ability to perform aerobic exercise.