Echocardiographic evaluation of the right ventricle: Clinical implications

Evaluation of right ventricular function using conventional and real-time three-dimensional echocardiography in healthy dogs and dogs with myxomatous mitral valve disease

INTRODUCTION/OBJECTIVES

To compare conventional and three-dimensional (3D) echocardiographic indices of right ventricular (RV) systolic function in dogs with various stages of myxomatous mitral valve disease (MMVD), classified according to the 2009 guidelines of the American College of Veterinary Internal Medicine (ACVIM), with those from normal dogs.

ANIMALS

Seventy-eight unsedated dogs (22 healthy controls, 23 ACVIM stage B1 MMVD, 20 ACVIM stage B2 MMVD, and 13 ACVIM stage C MMVD) were included in the study.

MATERIALS AND METHODS

All dogs underwent conventional and 3D echocardiography. Three-dimensional RV end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV), and ejection fraction (EF) were recorded. Right ventricular EDV, ESV, and SV were indexed to bodyweight. Echocardiographic variables were compared across groups using a Kruskal-Wallis test with subsequent post hoc analysis using Dunn's method for multiple comparisons between groups. A P-value of <0.05 was considered significant.

RESULTS

Right ventricular EDV was smaller in stage B1 (P=0.012), stage B2 (P=0.035), and stage C (P=0.004) dogs than in controls. Stage B2 (P=0.003) and stage C (P<0.001) dogs had smaller RV ESV than controls. Stage B1 dogs had smaller RV SV than controls (P=0.012). Right ventricular EF was greater in stage C dogs than in controls (P=0.003) and in stage B1 (P=0.017) dogs.

CONCLUSIONS

Several 3D echocardiographic indices of RV systolic function differ between dogs with advanced MMVD when compared with normal dogs. Further investigation is required to determine if these differences have clinical implications.

Right Ventricular "Bubble Time" to Identify Patients With Right Ventricular Dysfunction

STUDY OBJECTIVE

We propose a novel method of evaluating right ventricular (RV) dysfunction in the emergency department (ED) using RV "bubble time"-the duration of time bubbles from a saline solution flush are visualized in the RV on echocardiography. The objective was to identify the optimal cutoff value for RV bubble time that differentiates patients with RV dysfunction and report on its diagnostic test characteristics.

METHODS

This prospective diagnostic accuracy study enrolled a convenience sample of hemodynamically stable patients in the ED. A sonographer administered a 10-mL saline solution flush into the patient's intravenous catheter, performed a bedside echocardiogram, and measured RV bubble time. Subsequently, the patient underwent a comprehensive cardiologist-interpreted echocardiogram within 36 hours, which served as the gold standard. Patients with RV strain or enlargement of the latter found on an echocardiogram were considered to have RV dysfunction. Bubble time was evaluated by a second provider, blinded to the initial results, who reviewed the ultrasound clips. The primary outcome measure was the optimal cutoff value of RV bubble time that identifies patients with and without RV dysfunction.

RESULTS

Of 196 patients, median age was 67 year, and half were women, with 69 (35.2%) having RV dysfunction. Median RV bubble time among patients with RV dysfunction was 62 seconds (interquartile range [IQR]: 52, 93) compared with 21 seconds (IQR: 12, 32) among patients without (P<.0001). The optimal cutoff value of RV bubble time for identifying patients with RV dysfunction was 40 or more seconds, with a sensitivity of 0.97 (95% CI 0.93 to 1.00) and specificity of 0.87 (95% CI 0.82 to 0.93).

CONCLUSION

In patients in the ED, an RV bubble time of 40 or more seconds had high sensitivity in identifying patients with RV dysfunction, whereas an RV bubble time of less than 40 seconds had good specificity in identifying patients without RV dysfunction. These findings warrant further investigation in undifferentiated patient populations and by emergency physicians without advanced ultrasound training.

Relationship of TAPSE Normalized by Right Ventricular Area With Pulmonary Compliance, Exercise Capacity, and Clinical Outcomes

BACKGROUND

While tricuspid annular plane systolic excursion (TAPSE) captures the predominant longitudinal motion of the right ventricle (RV), it does not account for ventricular morphology and radial motion changes in various forms of pulmonary hypertension. This study aims to account for both longitudinal and radial motions by dividing TAPSE by RV area and to assess its clinical significance.

METHODS

We performed a retrospective analysis of 71 subjects with New York Heart Association class II to III dyspnea who underwent echocardiogram and invasive cardiopulmonary exercise testing (which defined 4 hemodynamic groups: control, isolated postcapillary pulmonary hypertension, combined postcapillary pulmonary hypertension, and pulmonary arterial hypertension). On the echocardiogram, TAPSE was divided by RV area in diastole (TAPSE/RVA-D) and systole (TAPSE/RVA-S). Analyses included correlations (Pearson and linear regression), receiver operating characteristic, and survival curves.

RESULTS

On linear regression analysis, TAPSE/RVA metrics (versus TAPSE) had a stronger correlation with pulmonary artery compliance (r=0.48-0.54 versus 0.38) and peak VO2 percentage predicted (0.23-0.30 versus 0.18). Based on the receiver operating characteristic analysis, pulmonary artery compliance ≥3 mL/mm Hg was identified by TAPSE/RVA-D with an under the curve (AUC) of 0.79 (optimal cutoff ≥1.1) and by TAPSE/RVA-S with an AUC of 0.83 (optimal cutoff ≥1.5), but by TAPSE with only an AUC of 0.67. Similarly, to identify peak VO2 <50% predicted, AUC of 0.66 for TAPSE/RVA-D and AUC of 0.65 for TAPSE/RVA-S. Death or cardiovascular hospitalization at 12 months was associated with TAPSE/RVA-D ≥1.1 (HR, 0.38 [95% CI, 0.11-0.56]) and TAPSE/RVA-S ≥1.5 (HR, 0.44 [95% CI, 0.16-0.78]), while TAPSE was not associated with adverse outcomes (HR, 0.99 [95% CI, 0.53-1.94]). Among 31 subjects with available cardiac magnetic resonance imaging, RV ejection fraction was better correlated with novel metrics (TAPSE/RVA-D r=0.378 and TAPSE/RVA-S r=0.328) than TAPSE (r=0.082).

CONCLUSIONS

In a broad cohort with suspected pulmonary hypertension, TAPSE divided by RV area was superior to TAPSE alone in correlations with pulmonary compliance and exercise capacity. As a prognostic marker of right heart function, TAPSE/RVA-D <1.1 and TAPSE/RVA-S <1.5 predicted adverse cardiovascular outcomes.

In-Hospital versus Out-of-Hospital Pulmonary Embolism: Clinical Characteristics, Biochemical Markers and Echocardiographic Indices

BACKGROUND

A significant proportion of pulmonary embolisms (PEs) occurs in patients during hospitalisation for another reason. However, limited data regarding differences between out-of-hospital PE (OHPE) and in-hospital PE (IHPE) is available. We aimed to compare these groups regarding their clinical characteristics, biochemical markers, and echocardiographic indices.

METHODS

This was a prospective, single-arm, single-centre study. Adult consecutive patients with non-COVID-related PE from September 2019 to March 2022 were included and followed up for 12 months.

RESULTS

The study included 180 (84 women) patients, with 89 (49.4%) suffering from IHPE. IHPE patients were older, they more often had cancer, were diagnosed earlier after the onset of symptoms, they had less frequent pain and higher values of high sensitivity troponin I and brain natriuretic peptide levels compared to OHPE patients. Echocardiographic right ventricular (RV) dysfunction was detected in similar proportions in the 2 groups. IHPE had increased in-hospital mortality (14.6% vs. 3.3%, p = 0.008) and similar post-discharge to 12-month mortality with OHPE patients.

CONCLUSIONS

In this prospective cohort study, IHPE differed from OHPE patients regarding age, comorbidities, symptoms, and levels of biomarkers associated with RV dysfunction. IHPE patients had higher in-hospital mortality compared to OHPE patients and a similar risk of death after discharge.

CILP-1 Is a Biomarker for Backward Failure and Right Ventricular Dysfunction in HFrEF

BACKGROUND

CILP-1 regulates myocardial fibrotic response and remodeling and was reported to indicate right ventricular dysfunction (RVD) in pulmonary hypertension (PH) and heart failure (HF). This study examines CILP-1 as a potential biomarker for RVD and prognosis in heart failure with reduced ejection fraction (HFrEF) patients on guideline-directed medical therapy.

METHODS

CILP-1 levels were measured in 610 HFrEF patients from a prospective registry with biobanking (2016-2022). Correlations with echocardiographic and hemodynamic data and its association with RVD and prognosis were analyzed.

RESULTS

The median age was 62 years (Q1-Q3: 52-72), 77.7% of patients were male, and the median NT-proBNP was 1810 pg/mL (Q1-Q3: 712-3962). CILP-1 levels increased with HF severity, as indicated by NT-proBNP and NYHA class (p < 0.0001, for both). CILP-1 showed a weak-moderate direct association with increased left ventricular filling pressures and its sequalae, i.e., backward failure (LA diameter rs = 0.15, p = 0.001; sPAP rs = 0.28, p = 0.010; RVF rs = 0.218, p < 0.0001), but not with cardiac index (CI) and systemic vascular resistance (SVR). CILP-1 trended as a risk factor for all-cause mortality (crude HR for 500 pg/mL increase: 1.03 (95%CI: 1.00-1.06), p = 0.053) but lost significance when it was adjusted for NT-proBNP (adj. HR: 1.00 (95%CI: 1.00-1.00), p = 0.770). No association with cardiovascular hospitalization was observed.

CONCLUSIONS

CILP-1 correlates with HFrEF severity and may indicate an elevated risk for all-cause mortality, though it is not independent from NT-proBNP. Increased CILP-1 is associated with backward failure and RVD rather than forward failure. Whether CILP-1 release in this context is based on elevated pulmonary pressures or is specific to RVD needs to be further investigated.

What is the real incidence of right ventricular affection in patients with acute pulmonary embolism?

BACKGROUND

Echocardiographic markers of right ventricular dysfunction or pressure overload (RVd/PO) have been used in risk assessment of patients with acute pulmonary embolism (APE). Nevertheless, the role of echocardiography in these patients is incompletely determined. We evaluated the right ventricular function using 'non-conventional' markers of RVd/PO in patients with APE.

METHODS

This was a prospective, single-arm, single-centre study. Consecutive adult patients hospitalised for APE were included. The RV free wall longitudinal strain (RV-FWLS), the fractional area change (FAC), the ratio tricuspid annular plane systolic excursion (TAPSE)/pulmonary arterial systolic pressure (PASP), and the pulmonary vascular resistance (PVR) were evaluated.

RESULTS

One hundred patients (mean age 70.0 ± 13.9 years, female 48%) were screened and 73 had adequate RV-FWLS images. The most common abnormal echocardiographic marker was RV-FWLS (44/73; p < 0.001, for all other echocardiographic indices). Thirty-one patients had either PASP ≥ 36 mmHg or PVR > 2 WU (49.2% of the patients with both indices available). There were significant correlations between RV-FWLS, TAPSE/PASP and PVR with both D-Dimers and B-type natriuretic peptide (BNP), and between FAC and BNP. RF-FWLS differed significantly between patients with a simplified pulmonary embolism severity index (sPESI) score 0 and those with a score ≥1 (p < 0.001).

CONCLUSIONS

RVd/PO coexists with APE in a large proportion of patients. RV-FWLS is the most abnormal echocardiographic sign and is related to clinical and biochemical prognostic indices.

Three-Dimensional, Right Ventricular Surface Strain Computation From Three-Dimensional Echocardiographic Images From Patients With Pediatric Pulmonary Hypertension

Right Ventricular (RV) dysfunction is routinely assessed with echocardiographic-derived global longitudinal strain (GLS). GLS is measured from a two-dimensional echo image and is increasingly accepted as a means for assessing RV function. However, any two-dimensional (2D) analysis cannot visualize the asymmetrical deformation of the RV nor visualize strain over the entire RV surface. We believe three-dimensional surface (3DS) strain, obtained from 3D echo will better evaluate myocardial mechanics. Components of 3DS strain (longitudinal, LS; circumferential, CS; longitudinal-circumferential shear, ɣCL; principal strains PSMax and PSMin; max shear, ɣMax; and principal angle θMax) were computed from RV surface meshes obtained with 3D echo from 50 children with associated pulmonary arterial hypertension (PAH), 43 children with idiopathic PAH, and 50 healthy children by computing strains from a discretized displacement field. All 3DS freewall (FW) normal strain (LS, CS, PSMax, and PSMin) showed significant decline at end-systole in PH groups (p < 0.0001 for all), as did FW-ɣMax (p = 0.0012). FW-θMax also changed in disease (p < 0.0001). Limits of agreement analysis suggest that 3DS LS, PSMax, and PSMin are related to GLS. 3DS strains showed significant heterogeneity over the 3D surface of the RV. Components of 3DS strain agree with existing clinical strain measures, well classify normal -versus- PAH subjects, and suggest that strains change direction on the myocardial surface due to disease. This last finding is similar to that of myocardial fiber realignment in disease, but further work is needed to establish true associations.

Right Ventricular Response to Cardiac Resynchronization Therapy: A Three-Dimensional and Speckle Tracking Echocardiographic Study

Cardiac resynchronization therapy (CRT) induces left ventricle reverse remodeling; however, its effects on right ventricular (RV) volumes and function were not well described. This study aimed to assess the effects of CRT on RV. Of 112 patients, 63 enrolled with a mean age of 62.77 ± 7.23 years, including 40 males (63.5%). All patients met criteria for CRT implantation and were followed at 3-month and 6-month intervals. Standard 2-dimensional/3-dimensional (3D) echocardiography and speckle-tracking analyses were conducted for assessment of LV and left atrium (LA). RV maximum diameters, tricuspid lateral annular systolic velocity, tricuspid annular plane systolic excursion, fractional area change, RV global (RV 4-chamber strain (RV4CSL), and RV free wall strain (RVFWSL), in addition to 3D echocardiographic assessment of RV, were done before CRT implantation and at follow-up visits. Mean follow-up period was 6.76 ± 1.25 months. A total of 48 patients (76.2%) were LV responders (LVR) whereas the rest were nonresponders (LVNR). Both groups had similar baseline characteristics, risk factors, device implantation, and programming values. Only LVR had significant reduction in RV basal diameter, together with significant improvement of RV systolic performance: systolic velocity, fractional area change, RV4CSL, RVFWSL, and 3D-derived RV volumes and ejection fraction, compared with baseline values. In addition, pulmonary arterial systolic pressure decreased in LVR with reduction of tricuspid regurgitation severity. LV response, percentage change of RV4CSL, LA end-systolic volume index, and LA emptying fraction at 3-month follow-up were the most independent predictors of RV response by multivariate analysis. Reduced left ventricular end-systolic volume >13.5% had 92.3% sensitivity and 81.8% specificity. In conclusion, CRT-induced RV reverse remodeling and improved RV-arterial coupling. These effects were associated with left side response to CRT.

The relation of right ventricular outflow tract measurements with in-hospital clinical outcomes after tricuspid valve surgery

Right ventricular (RV) function is a determining factor for clinical outcomes in patients undergoing tricuspid valve surgery (TVS). Our aim was to investigate the importance of the function of the right ventricular outflow tract (RVOT), which is an important anatomical region of the RV, in patients underwent TVS. 104 patients who underwent TVS were analyzed retrospectively. Patients with previous cardiac surgery, congenital heart disease, or heart failure were excluded. The parasternal short-axis view at the level of the aortic root was used to measure RVOT dimensions and RVOT fractional shortening (RVOT-FS). The effect of RVOT diameter and function on major adverse cardiac events (MACE) after TVS was investigated. In our study, MACE, consisting of pacemaker implantation, acute kidney injury, postoperative atrial fibrillation and mortality, was developed at 44 (42.3%) patients.We compared the predictive performances of RVOT end-systolic (RVOTs) diameter, RVOT end-diastolic (RVOTd) diameter, RVOT-FS and RV diameters in prediction of MACE. The model including the RVOTs had higher AUC, R2 and likelihood ratio X2 values (0.775, 0.287 and 25.0, respectively) than RVOTd (0.770, 0.279 and 24.2, respectively) and RVOT-FS (0.750, 0.215 and 18.1, respectively). RVOT diameters showed better performance in predicting MACE than RV diameters. Moreover, there was statistically significant association between RVOTs, RVOTd and MACE (p value were 0.014 and 0.027, respectively), while no association between RVOT-FS and MACE (p value was 0.177). In summary, we determined that the RVOT diameters are important predictors for the in-hospital clinical outcomes of patients who underwent TVS.

Evaluation of right-ventricular function by two-dimensional echocardiography and two-dimensional speckle-tracking echocardiography in patients with successful RCA CTO recanalization

OBJECTIVES

Chronic total occlusion (CTO) of the right coronary artery (RCA) is common in patients with coronary artery disease. Although revascularization techniques and success rates have improved significantly in recent years, there are still no studies investigating possible effects of successful recanalization of RCA CTO on the right-ventricular (RV) function. With this study, we aimed to evaluate RV function after recanalization of the RCA by two-dimensional transthoracic echocardiography (2DE) and additional two-dimensional speckle-tracking echocardiography (2DSTE).

METHODS AND RESULTS

Our analysis included 102 patients undergoing successful RCA CTO recanalization at the University Medical Center of Mainz. All patients underwent 2DE and 2DSTE to assess RV function before PCI procedure and 6 months after successful revascularization. We found an altered RV function in our collective at baseline assessed by 2DSTE with a significant improvement at 6 month follow-up (baseline RV free wall strain: - 20.7 [- 6.3 to - 32.0] % vs. - 23.4 [- 8.3 to - 39.3] % at follow-up, p < 0.001 and baseline RV global strain - 15.9 [- 6.0 to - 25.7] % vs. - 17.9 [- 7.0 to - 29.5] % at follow-up, p < 0.001).

CONCLUSION

RV function was altered in patients with RCA CTO and showed significant improvement after successful recanalization. We also noticed an improvement in patient-reported clinical symptoms. Our study suggests that CTO procedure is a beneficial treatment option in symptomatic patients with RCA CTO.

Comparison of tricuspid and mitral annular plane systolic excursion in determination of acute blood loss in healthy volunteers

Ultrasound is used more and more in determining acute blood loss. This study is to compare tricuspid annular plane systolic excursion (TAPSE) and mitral annular plane systolic excursion (MAPSE) measurement to determine volume loss pre and post blood donation in healthy volunteers. The systolic, diastolic and mean arterial blood pressures and pulses of the donors were measured in the standing and supine position by the attending physician, then, inferior vena cava (IVC), TAPSE and MAPSE measurements were made pre and post blood donation. Statistically significant differences were found in systolic blood pressure and pulse rate values that obtained in the standing position, and in the systolic blood pressure, diastolic blood pressure, mean arterial pressure and pulse values that obtained in the supine position (p < 0.05). The difference between IVC expiration (IVCexp) pre and post blood donation was 4.76 ± 2.94 mm, and the difference in IVC inspiration (IVCins) was 2.73 ± 2.91 mm. In addition, the MAPSE and TAPSE differences were 2.16 ± 1.4 mm and 2.98 ± 2.13 mm, respectively. Statistically significant differences were found between IVCins-exp, TAPSE and MAPSE values. TAPSE and MAPSE can be helpful in the early diagnosis of acute blood loss.

Echocardiographic analysis of dogs before and after surgical treatment of brachycephalic obstructive airway syndrome

Brachycephalic dogs with brachycephalic obstructive airway syndrome (BOAS) are a valuable animal model for obstructive sleep apnea (OSA) in humans. Clinical signs of upper airway obstruction improve after surgical treatment of BOAS, but the impact of surgery on morphology and function of the heart has not been studied. Therefore, we aimed to compare the echocardiographic variables of dogs before and after surgical treatment of BOAS. We included 18 client-owned dogs with BOAS (7 French Bulldogs, 6 Boston Terriers, and 5 Pugs) scheduled for surgical correction. We performed a complete echocardiographic examination before and 6 to 12 (median 9) months after surgery. Seven non-brachycephalic dogs were included in the control group. After surgery, BOAS patients had a significantly (p < 0.05) larger left atrium to aortic ratio (LA/Ao), left atrium in the long axis index, and thickness of the left ventricular posterior wall in diastole index. They also had a higher late diastolic annular velocity of the interventricular septum (Am) and increased global right ventricular strain and left ventricular global strain in the apical 4-chamber view, as well as a higher caudal vena cava collapsibility index (CVCCI). Before surgery, BOAS patients had a significantly lower CVCCI, Am, peak systolic annular velocity of the interventricular septum (Si), and early diastolic annular velocity of the interventricular septum (Ei) compared to non-brachycephalic dogs. After surgery, BOAS patients had a smaller right ventricular internal diameter at base index, right ventricular area in systole index, mitral annular plane systolic excursion index, and tricuspid annular plane systolic excursion index, as well as lower values of Am, Si, Ei, and late diastolic annular velocity of the interventricular septum, and a larger LA/Ao compared to non-brachycephalic dogs. Significant differences between BOAS patients and non-brachycephalic dogs indicate higher right heart pressures and decreased systolic and diastolic ventricular function in BOAS dogs, which is in accordance with the results of studies in OSA patients. In parallel with the marked clinical improvement, right heart pressures decreased, and right ventricular systolic and diastolic function improved after surgery.

Adaptive versus maladaptive right ventricular remodelling

Right ventricular (RV) function and its adaptation to increased afterload [RV-pulmonary arterial (PA) coupling] are crucial in various types of pulmonary hypertension, determining symptomatology and outcome. In the course of disease progression and increasing afterload, the right ventricle undergoes adaptive remodelling to maintain right-sided cardiac output by increasing contractility. Exhaustion of compensatory RV remodelling (RV-PA uncoupling) finally leads to maladaptation and increase of cardiac volumes, resulting in heart failure. The gold-standard measurement of RV-PA coupling is the ratio of contractility [end-systolic elastance (Ees)] to afterload [arterial elastance (Ea)] derived from RV pressure-volume loops obtained by conductance catheterization. The optimal Ees/Ea ratio is between 1.5 and 2.0. RV-PA coupling in pulmonary hypertension has considerable reserve; the Ees/Ea threshold at which uncoupling occurs is estimated to be ~0.7. As RV conductance catheterization is invasive, complex, and not widely available, multiple non-invasive echocardiographic surrogates for Ees/Ea have been investigated. One of the first described and best validated surrogates is the ratio of tricuspid annular plane systolic excursion to estimated pulmonary arterial systolic pressure (TAPSE/PASP), which has shown prognostic relevance in left-sided heart failure and precapillary pulmonary hypertension. Other RV-PA coupling surrogates have been formed by replacing TAPSE with different echocardiographic measures of RV contractility, such as peak systolic tissue velocity of the lateral tricuspid annulus (S'), RV fractional area change, speckle tracking-based RV free wall longitudinal strain and global longitudinal strain, and three-dimensional RV ejection fraction. PASP-independent surrogates have also been studied, including the ratios S'/RV end-systolic area index, RV area change/RV end-systolic area, and stroke volume/end-systolic volume. Limitations of these non-invasive surrogates include the influence of severe tricuspid regurgitation (which can cause distortion of longitudinal measurements and underestimation of PASP) and the angle dependence of TAPSE and PASP. Detection of early RV remodelling may require isolated analysis of single components of RV shortening along the radial and anteroposterior axes as well as the longitudinal axis. Multiple non-invasive methods may need to be applied depending on the level of RV dysfunction. This review explains the mechanisms of RV (mal)adaptation to its load, describes the invasive assessment of RV-PA coupling, and provides an overview of studies of non-invasive surrogate parameters, highlighting recently published works in this field. Further large-scale prospective studies including gold-standard validation are needed, as most studies to date had a retrospective, single-centre design with a small number of participants, and validation against gold-standard Ees/Ea was rarely performed.

Isolated functional tricuspid regurgitation: how to define patients at risk for event?

AIMS

Functional tricuspid regurgitation (TR) is a turning point in cardiac diseases. Symptoms typically appear late. The optimal timing for proposing a valve repair remains a challenge. We sought to analyse the characteristics of right heart remodelling in patients with significant functional TR to identify the parameters that could be used in a simple prognostic model predicting clinical events.

METHODS AND RESULTS

We designed a prospective observational French multicentre study including 160 patients with significant functional TR (effective regurgitant orifice area > 30 mm² ) and left ventricular ejection fraction > 40%. Clinical, echocardiographic, and electrocardiogram data were collected at baseline and at the 1 and 2 year follow-up. The primary outcome was all-cause death or hospitalization for heart failure. At 2 years, 56 patients (35%) achieved the primary outcome. The subset with events showed more advanced right heart remodelling at baseline, but similar TR severity. Right atrial volume index (RAVI) and the tricuspid annular plane systolic excursion to systolic pulmonary arterial pressure (TAPSE/sPAP) ratio, reflecting right ventricular-pulmonary arterial coupling, were 73 mL/m² and 0.40 vs. 64.7 mL/m² and 0.50 in the event vs. event-free groups, respectively (both P < 0.05). None among all the clinical and imaging parameters tested had a significant group × time interaction. The multivariable analysis leads to a model including TAPSE/sPAP ratio > 0.4 (odds ratio = 0.41, 95% confidence limit 0.2 to 0.82) and RAVI > 60 mL/m² (odds ratio = 2.13, 95% confidence limit 0.96 to 4.75), providing a clinically valid prognostic evaluation.

CONCLUSIONS

RAVI and TAPSE/sPAP are relevant for predicting the risk for event at 2 year follow-up in patients with an isolated functional TR.

Behavior of echocardiographic parameters of right ventricular function after tricuspid surgery

Evaluation of right ventricular (RV) function after tricuspid valve surgery is complex. The objective was to identify the most appropriate RV function parameters for this purpose. This prospective study included 70 patients undergoing cardiac and tricuspid valve (TV) surgery. RV size and function parameters were determined at 3 months and 1-year post-surgery. Categorical variables were analyzed with the McNemar test and numerical variables with the Student's t-test for related samples or, when non-normally distributed, the Wilcoxon test. Spearman's rho was used to determine correlations between variables at 3 months and 1 year. RV diameters were reduced at 3 months post-surgery and were then unchanged at 1 year. Tricuspid annular plane systolic excursion (TAPSE) and S' wave values were worse at 3 months and then improved at 1 year (t-score-2.35, p 0.023; t-score-2.68; p 0.010). There was no significant reduction in free wall longitudinal strain (LS) or shortening fraction (SF) at 3 months (t-score 1.421 and - 1.251; p 0.218 and 0.172), and they were only slightly below pre-surgical values at 1 year. No relationship was found between RV function parameters and mortality or major complications. During the first few months after TV surgery, LS may be a more appropriate parameter to evaluate global ventricular function in comparison to TAPSE. At 1 year, good correlations are observed between TAPSE, S' wave, and LS values.

Update on the Practical Role of Echocardiography in Selection, Implantation, and Management of Patients Requiring Left Ventricular Assist Device Therapy

PURPOSE OF REVIEW

Echocardiography is a valuable tool for management of patients with a left ventricular assist device (LVAD). We present an updated review on the practical applications of the role of echocardiography for pre- and postoperative evaluation of patients selected.

RECENT FINDINGS

The LVAD is a temporary or permanent option for patients with advanced heart failure who are unresponsive to other therapy. Use of the device has its own risks, and implantation remains a complex procedure. Transthoracic and transesophageal echocardiography are useful tools for patient evaluation and monitoring both peri- and postoperatively, as we previously presented. Assessment of left and right ventricular function, complications such as thrombus formation or intracardiac shunting, and valvular disease are all important in this assessment. This also aids in predicting postoperative complications. Placement of the device is confirmed intraoperatively, and subsequent ramp studies are used to determine optimal device settings. Right ventricular (RV) failure is the most common postoperative complication and preoperative evaluation of its function is crucial. Studies suggest that tricuspid annular plane systolic excursion, RV fractional area change, and RV global longitudinal strain are strong predictors of RV failure; LV ejection fraction, size, and end-diastolic diameter are also important markers. Aortic regurgitation and mitral stenosis must always be corrected prior to LVAD placement. However, direct visualization before and after implantation, especially to rule out potential contraindications such as thrombi, cannot be overemphasized. Ramp studies remain an integral part of device optimization and may result in greater myocardial recovery than previously realized.

Right ventricular strain measurements in critically ill patients: an observational SICS sub-study

BACKGROUND

Right ventricular (RV) dysfunction is common in critically ill patients and is associated with poor outcomes. RV function is usually evaluated by Tricuspid Annular Plane Systolic Excursion (TAPSE) which can be obtained using critical care echocardiography (CCE). Myocardial deformation imaging, measuring strain, is suitable for advanced RV function assessment and has widely been studied in cardiology. However, it is relatively new for the Intensive Care Unit (ICU) and little is known about RV strain in critically ill patients. Therefore, the objectives of this study were to evaluate the feasibility of RV strain in critically ill patients using tissue-Doppler imaging (TDI) and explore the association between RV strain and conventional CCE measurements representing RV function.

METHODS

This is a single-center sub-study of two prospective observational cohorts (Simple Intensive Care Studies (SICS)-I and SICS-II). All acutely admitted adults with an expected ICU stay over 24 h were included. CCE was performed within 24 h of ICU admission. In patients in which CCE was performed, TAPSE, peak systolic velocity at the tricuspid annulus (RV s') and TDI images were obtained. RV free wall longitudinal strain (RVFWSL) and RV global four-chamber longitudinal strain (RV4CSL) were measured during offline analysis.

RESULTS

A total of 171 patients were included. Feasibility of RVFWSL and RV4CSL was, respectively, 62% and 56% in our population; however, when measurements were performed, intra- and inter-rater reliability based on the intraclass correlation coefficient were good to excellent. RV dysfunction based on TAPSE or RV s' was found in 56 patients (33%) and 24 patients (14%) had RV dysfunction based on RVFWSL or RV4CSL. In 14 patients (8%), RVFWSL, RV4CSL, or both were reduced, despite conventional RV function measurements being preserved. These patients had significantly higher severity of illness scores. Sensitivity analysis with fractional area change showed similar results.

CONCLUSIONS

TDI RV strain imaging in critically ill patients is challenging; however, good-to-excellent reproducibility was shown when measurements were adequately obtained. Future studies are needed to elucidate the diagnostic and prognostic value of RV strain in critically ill patients, especially to outweigh the difficulty and effort of imaging against the clinical value.

Reference values and the Z-score values of tricuspid annular plane systolic excursion in Chinese children

To establish age-specific and body surface area (BSA)-specific reference values of Tricuspid Annular Plane Systolic Excursion (TAPSE) for children under 15 years old in China. A retrospective study was conducted in Children's Hospital Attached to the Capital Institute of Pediatrics. A total of 702 cases were included in this research to establish reference values of TAPSE in Chinese children. SPSS 25.0 (IBM) was used for data analysis. Lambda-mu-sigma method was used to calculate and construct the age-specific and BSA-specific percentiles and Z-score curves of TAPSE. The mean value of TAPSE increased with age and BSA from 0 to 15 years in a nonlinear way and reached the adult threshold (17 mm) until 1 year old. There was no difference between genders. TAPSE values increased with age and BSA in Chinese children aged between 0 and 15 years and there was no difference between boys and girls. A prospective, multicenter cohort study from different parts of China is supposed to be conducted in the future to reflect the whole spectrum of TAPSE in Chinese children.

Association of Right Ventricular Dilation and Dysfunction on Echocardiogram with In-Hospital Mortality Among Patients Hospitalized with COVID-19 Compared with Other Acute Respiratory Illness

BACKGROUND

Although right ventricular (RV) dysfunction is associated with mortality in acute COVID-19, the role of RV dilation is uncertain. The prognostic significance of RV dilation and dysfunction among hospitalized patients with acute COVID-19 compared to other respiratory illnesses.

METHODS

We conducted a retrospective cohort study to examine 225 consecutive adults admitted for acute COVID-19 and 6,150 control adults admitted for influenza, pneumonia or ARDS who had a clinical echocardiogram performed. We used logistic regression models to assess associations between RV parameters and in-hospital mortality adjusted for confounders.

RESULTS

Among those with COVID-19, 48/225 (21.3%) died during the index hospitalization compared to 727/6150 (11.8%) with other respiratory illness (p=0.001). Independent of COVID-19, mild and moderate to severe RV dilation were associated with 1.4 and 2.0 times higher risk of inpatient mortality, respectively (95%CI 1.17 to 1.69; p=0.0003; 95%CI 1.62 to 2.47; p<0.0001, respectively). Similarly, mild and moderate RV dysfunction were associated with 1.4 and 1.7 times higher risk of inpatient mortality (95%CI 1.10 to 1.77; p=0.007; 95%CI 1.17 to 2.42; p=0.005, respectively). Relative to normal RV size and non-COVID-19 acute respiratory illness, mild and moderate RV dilation were associated with 1.4 times and 2.0 times higher risk among those without COVID-19 and 1.9 times higher and 3.0 times higher risk among those with COVID-19, with similar findings for RV dysfunction. Having both RV dilation and dysfunction or RV dilation alone were associated with 1.7 times higher risk while RV dysfunction alone was associated with 1.4 times higher risk compared to normal RV size and function.

CONCLUSIONS

RV dilation and dysfunction are associated with increased risk of inpatient mortality among those with COVID-19 and other respiratory illnesses. Abnormal RV findings may identify those at higher risk of short-term mortality from acute respiratory illness including COVID-19 beyond other risk markers.

RIGHT VENTRICLE FUNCTION IN PATIENTS WITH ANTERIOR MYOCARDIAL INFARCTION: ARE WE SURE IT IS NOT INVOLVED?

The right and left ventricle of heart are intimately connected by anatomical and functional links. Hence, acute changes in cardiac geometry and function can modify the performance and physiology of both sides of the heart, influencing each other. After a brief overview of the anatomy and related imaging techniques for the study of right ventricular function, we report a review on the interesting correlation of acute anterior myocardial infarction and right ventricular function, very often underestimated.

Computational Modeling of Right Ventricular Motion and Intracardiac Flow in Repaired Tetralogy of Fallot

PURPOSE

Patients with repaired Tetralogy of Fallot (rTOF) will develop dilation of the right ventricle (RV) from chronic pulmonary insufficiency and require pulmonary valve replacement (PVR). Cardiac MRI (cMRI) is used to guide therapy but has limitations in studying novel intracardiac flow parameters. This pilot study aimed to demonstrate feasibility of reconstructing RV motion and simulating intracardiac flow in rTOF patients, exclusively using conventional cMRI and an immersed-boundary method computational fluid dynamic (CFD) solver.

METHODS

Four rTOF patients and three normal controls underwent cMRI including 4D flow. 3D RV models were segmented from cMRI images. Feature-tracking software captured RV endocardial contours from cMRI long-axis and short-axis cine stacks. RV motion was reconstructed via diffeomorphic mapping (Deformetrica, deformetrica.org), serving as the domain boundary for CFD. Fully-resolved direct numerical simulations were performed over several cardiac cycles. Intracardiac vorticity, kinetic energy (KE) and turbulent kinetic energy (TKE) was measured. For validation, RV motion was compared to manual tracings, results of KE were compared between CFD and 4D flow.

RESULTS

Diastolic vorticity and TKE in rTOF patients were 4.12 ± 2.42 mJ/L and 115 ± 27/s, compared to 2.96 ± 2.16 mJ/L and 78 ± 45/s in controls. There was good agreement between RV motion and manual tracings. The difference in diastolic KE between CFD and 4D flow by Bland-Altman analysis was - 0.89910 to 2 mJ/mL (95% limits of agreement: - 1.351 × 10^-2 mJ/mL to 1.171 × 10^-2 mJ/mL).

CONCLUSION

This CFD framework can produce intracardiac flow in rTOF patients. CFD has the potential for predicting the effects of PVR in rTOF patients and improve the clinical indications guided by cMRI.

The Role of Conjunctival Microvasculation Combined with Echocardiography in Evaluating Pulmonary Arterial Hypertension in Systemic Lupus Erythematosus

Objective

To explore the role of conjunctival microvasculation combined with echocardiography in evaluating the prognosis of pulmonary arterial hypertension in systemic lupus erythematosus (SLE-PAH).

Methods

We prospectively compared the conjunctival microvascular changes in 17 SLE-PAH patients and 34 SLE patients without PAH in our hospital from January 2020 to December 2020, and we observed the characteristics of conjunctival microvascular changes in SLE-PAH patients. We analyzed the correlation between the corresponding conjunctival microvascular changes and cardiopulmonary function and evaluated the predictive value of the vessel density (VD) and the microvascular flow index (MFI) of conjunctival microvasculation combined with echocardiography in SLE-PAH.

Results

Compared with SLE patients without PAH, the ischemic areas in conjunctival microvasculation were significantly increased in SLE-PAH patients. The VD and MFI of conjunctival microvasculation are significantly correlated with N-terminal prohormone of brain natriuretic peptide and 6-minute walking distance. Combined with the VD and MFI, it can improve the accuracy of echocardiography in assessing the risk of death due to SLE-PAH (94.1% vs. 82.2%).

Conclusion

The ischemic area, VD, and MFI of conjunctival microvasculation in SLE-PAH patients can indicate the occurrence of severe SLE-PAH and improve the accuracy of echocardiography in evaluating the prognosis of SLE-PAH.

The role of tricuspite annular plane systolic excursion as a marker of hypovolemia in healthy blood donor volunteers

AIM

The aim of this study is to compare the diameter of the inferior vena cava with tricuspid annular plane systolic excursion (TAPSE) measurement in order to determine the volume loss before and after blood donation in healthy volunteers.

METHODS

This Institutional Review Board-approved single center, prospective, cross-sectional study included 60 healthy blood donors donating in a tertiary care hospital's blood bank. After obtaining written consent, systolic, diastolic, and mean arterial blood pressures along with pulse rate of the donors were measured in sitting and supine positions by the attending physician, then, inferior vena cava (IVC) and TAPSE measurements were made before and after blood donation.

RESULTS

Statistically significant differences was found between standing systolic blood pressure and pulse rate, lying systolic blood pressure and pulse rate, IVC and TAPSE values before and after blood donation (p < 0.05). There was no difference between the other variables before and after blood donation.

CONCLUSION

Our study revealed that, low IVC and TAPSE values correlated in determining blood loss after blood donation. TAPSE may be useful to predict blood loss in early stages of hypovolemic shock.

Temporal trends in right heart strain in patients undergoing pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension

BACKGROUND

Pulmonary thromboendarterectomy (PTE) is a curative procedure for chronic thromboembolic pulmonary hypertension (CTEPH). Right ventricular free wall strain (RV FWS) and right atrial strain (RAS) are not well studied in a CTEPH population. We sought to determine temporal trends in RAS and RV FWS in patients post-PTE.

METHODS

28 patients undergoing PTE for CTEPH were prospectively enrolled in a surgical database. Comprehensive echocardiographic assessment of the right heart was performed including RV FWS, right atrial volume, and the three components of RAS: reservoir, conduit, and booster strain.

RESULTS

Patients undergoing PTE demonstrated improvement in NYHA functional class (P < 0.001). Hemodynamic assessment showed improvement in mean pulmonary artery pressure from 49.7 ± 8.5 mm Hg to 23.9 ± 6.5 mm Hg (P < 0.001) and pulmonary vascular resistance decreased from 7.8 ± 3.2 wu to 2.4 ± 1.3 wu (P < 0.001). Tricuspid annular plane systolic excursion (TAPSE) and lateral S` declined immediately post-op. RV FWS improved from -14.4 ± 4% to -19 ± 3.4% post-op and -21.2 ± 4.7% at long-term follow-up (P < 0.001). Improvement in RV FWS post-op was driven primarily by increases in the apical and mid segments. RA volume declined significantly during the study period. RA reservoir and conduit strain improved after PTE.

CONCLUSION

Patients undergoing PTE for CTEPH had significant improvement in right heart hemodynamics immediately post-op. Traditional echo metrics of RV performance including TAPSE and lateral S` did not improve. RV FWS improved, which was driven by changes in the apical and mid segments. This highlights that RV FWS is a viable and useful metric to follow in CTEPH patients post-PTE.

Echocardiography in Pulmonary Arterial Hypertension: Comprehensive Evaluation and Technical Considerations

Pulmonary arterial hypertension (PAH) is a rare, progressive disease in which there is a persistent, abnormal increase in pulmonary artery pressure. Symptoms of pulmonary hypertension are nonspecific and mainly associated with progressive right ventricular failure. The diagnosis of PAH is a multistep process and often requires the skillful use of several tests. The gold standard for the diagnosis of PAH is hemodynamic testing. Echocardiography currently plays an important role in the diagnostic algorithm of PAH as it is minimally invasive and readily available. Moreover, many echocardiographic parameters are closely related to pulmonary hemodynamics. It allows assessment of the right heart′s structure and function, estimation of the pressure in the right ventricle, right atrium, and pulmonary trunk, and exclusion of other causes of elevated pulmonary bed pressure. Echocardiographic techniques are constantly evolving, and recently, measurements made using new techniques, especially 3D visualization, have become increasingly important. In echocardiographic assessment, it is crucial to know current guidelines and new reports that organize the methodology and allow standardization of the examination. This review aims to discuss the different echocardiographic techniques used to evaluate patients with PAH.

Correlation Between 2D Strain and Classic Echocardiographic Indices in the Diagnosis of Right Ventricular Dysfunction in COPD

Purpose

This study aims to define which of the right ventricular myocardial deformation indices best correlates with the classic echocardiographic measurements and indices of right ventricular (RV) dysfunction in patients with stable chronic obstructive pulmonary disease (COPD).

Patients and Methods

Ninety-one patients with stable COPD underwent clinical evaluation, spirometry, a 6-minute walk test, and echocardiographic examination. Patients were divided into two groups: “with RV dysfunction” (≥1 classic parameter) and “without RV dysfunction”. We used speckle tracking to estimate myocardial deformation. For all analyses, results were considered significant if p < 0.05.

Results

The mean age across all participants was 65 ± 9 years, with 53% (48/91) being male. Patients in the group with RV dysfunction were able to walk shorter distances and had higher estimated right ventricular systolic pressure (RVSP) and mean pulmonary arterial pressure (mPAP). The RV free wall longitudinal strain (RVFWLS) was the only deformation indices that showed a significant correlation with all classic measurements and indices in the diagnosis of RV dysfunction (Wald test, 10.24; p < 0.01; odds ratio, 1.61). In the ROC curve analysis, the absolute value <20% was the lowest cut-off point of this index for detection of RV dysfunction (AUC = 0.93, S: 95.8%, and E: 88%).

Conclusion

In COPD patients, RVFWLS is the myocardial deformation index that best correlates with classic echocardiographic parameters for the diagnosis of RV dysfunction using <20% as a cut-off point.

Percutaneous Edge-to-Edge Mitral Valve Repair: Beyond the Left Heart

Right ventricular (RV) dysfunction and tricuspid regurgitation (TR) are known to be associated with adverse outcomes in patients undergoing percutaneous mitral valve repair (PMVR). Although the effect of PMVR on left ventricular function is well known, data on the response of the right ventricle to PMVR, and its impact on prognosis, are limited. In this review the authors summarize available data regarding the prognostic role of RV function and TR in PMVR recipients and the possible effects of PMVR on the right heart. Preprocedural tricuspid annular plane systolic excursion < 15 mm, tricuspid annular tissue Doppler S' velocity < 9.5 cm/sec, and moderate or severe TR are reported as predictors of adverse outcome after PMVR. Therefore, they should be carefully evaluated for patient selection. Moreover, emerging data show that the benefit of PMVR may go beyond the left heart, leading to an improvement in RV function and a reduction in TR severity. Among PMVR recipients, improvement in RV function and reduction of TR degree are observed mainly in patients with RV dysfunction at baseline. On the other hand, high postprocedural transmitral pressure gradients seem to be associated with lack of RV reverse remodeling. Timing of mitral intervention with respect to RV impairment and predictors of RV reverse remodeling after PMVR are unknown. Further studies are needed to fill these gaps in evidence.

Atrioventricular plane displacement versus mitral and tricuspid annular plane systolic excursion: A comparison between cardiac magnetic resonance and M-mode echocardiography

INTRODUCTION

Both echocardiography and CMR imaging are used to quantify longitudinal function. Inter-method variability for mitral (MAPSE) and tricuspid (TAPSE) annular plane systolic excursion, and variability between directly measured MAPSE and TAPSE and as based on atrioventricular plane displacement (AVPD) analysis by CMR, are, however, not known. This study, therefore, assessed inter-method variability and variability between annular plane systolic excursion and AVPD-based values in a healthy adult population.

METHODS

Echocardiography and CMR were performed in 111 adults (35 [32-38] years). Method comparisons were assessed with Deming regression, Bland-Altman analysis and coefficient of variation. Observer reproducibility was assessed by the concordance correlation coefficient.

RESULTS

Echocardiography and semi-automatic CMR agreed on MAPSE (17 ± 2 mm vs. 17 ± 2 mm, p = 0.1) and TAPSE (25 ± 3 mm vs. 25 ± 3 mm, p = 0.5), correlated highly between methods (fitted-slope 1.22 [95% CI 1.07-1.38] and 1.12 [95% CI 0.95-1.29]) and showed low bias (0.42 [95% CI - 2.05 to 2.88] and - 0.18 [95% CI - 4.78 to 4.43]). Intra-/inter-observer reproducibility was high for both methods for both MAPSE (echocardiography 0.96/0.86; CMR 0.87/0.85) and TAPSE (echocardiography 0.96/0.95; CMR 0.97/0.96). MAPSE (16 ± 2 mm vs. 17 ± 2 mm; p < 0.001) and TAPSE (24 ± 3 vs. 25 ± 3 mm; p < 0.001) based on AVPD were similar but statistically different compared with semi-automatic CMR.

CONCLUSIONS

Echocardiography and semi-automatic CMR have low variability and provide similar values for MAPSE and TAPSE and are thus interchangeable for follow-up studies. Lateral values based on tracked data from AVPD analysis are not clinically significantly different and could be used as a representation of annular displacement.

Intervendor Agreement for Right Ventricular Global Longitudinal Strain in Children

BACKGROUND

Right ventricular global longitudinal strain (RVGLS) has emerged as an important technique for clinical evaluation of (RV) function. The routine application of RVGLS in pediatrics remains limited by a lack of data on agreement between vendors. The aim of this study was to investigate intervendor agreement for RVGLS between the two commonly used analysis vendors in pediatrics, hypothesizing that RVGLS has good intervendor agreement, although it is likely lower than intravendor agreement (inter- and intraobserver reproducibility).

METHODS

Seventy infants and children with normal cardiac anatomy and varying ventricular function were included after prospectively obtaining RV-focused four-chamber apical images on the GE Vivid E95. Images were analyzed for RVGLS at acquired frame rates in EchoPAC (GE) and TomTec (TT) and in the compressed Digital Imaging and Communications in Medicine format in TT. Intraclass correlation coefficients and Bland-Altman plots were used to test intervendor agreement and intravendor reproducibility.

RESULTS

RVGLS measurements were equally feasible using TT and EchoPAC analysis (92%). There was good to excellent agreement for RVGLS between TT and EchoPAC analysis, with a relatively higher intraclass correlation coefficient between GE and TT at the acquired frame rate (0.85) than between GE and TT at the compressed frame rate (0.75) and significantly higher agreement in patients with abnormal RV function (0.7-0.9) than those with normal function (0.4-0.6). Intra- andinterobserver reproducibility for RVGLS was excellent (intraclass correlation coefficient = 0.74-0.96). Heart rate ≥ 100 beats/min and acquisition frame rate/heart rate ≤ 0.7 were associated with diminished agreement, especially when compressed data were involved.

CONCLUSIONS

RVGLS analyzed using EchoPAC and TT show good agreement, especially when analyzed at acquisition frame rates and in the setting of abnormal RV function. Otherwise, RVGLS should ideally be analyzed using the same vendor, and intervendor comparisons should be undertaken with caution, particularly if data are in a compressed format.

Pulmonary hypertension secondary to pulmonary fibrosis: clinical data, histopathology and molecular insights

Pulmonary hypertension (PH) developing secondarily in pulmonary fibrosis (PF) patients (PF-PH) is a frequent co-morbidity. The high prevalence of PH in PF patients is very concerning since the presence of PH is a strong predictor of mortality in PF patients. Until recently, PH was thought to arise solely from fibrotic destruction of the lung parenchyma, leading to hypoxic vasoconstriction and loss of vascular bed density. Thus, potential cellular and molecular dysregulation of vascular remodeling as a driver of PF-PH has been under-investigated. The recent demonstrations that there is no correlation between the severity of the fibrosis and development of PH, along with the finding that significant vascular histological and molecular differences exist between patients with and without PH have shifted the etiological paradigm of PF-PH. This review aims to provide a comprehensive translational overview of PH in PF patients from clinical diagnosis and outcome to the latest understanding of the histology and molecular pathophysiology of PF-PH.

Do the remodeling effects of sacubitril/valsartan treatment depend upon heart failure duration?

AIMS

The angiotensin receptor and neprilysin inhibitor (ARNI) sacubitril/valsartan (LCZ696) is recommended for the treatment of patients with heart failure in New York Heart Association (NYHA) class II-III and left ventricular ejection fraction (LVEF) 35% or less. We examined the effects of sacubitril/valsartan on cardiac remodeling and their correlation with heart failure duration in patients enrolled in our heart failure clinic from March 2017 to December 2019.

METHODS

Echocardiographic and clinical/laboratory data were collected at baseline and at 6-month and 12-month follow-up visits in 69 patients (age 67 ± 12 years, disease duration 8.4 ± 5.8 years, 93% men).

RESULTS

At both time points, mean NYHA class, NT-proBNP level, LVEF, LV end-systolic volume, and estimated systolic pulmonary pressure significantly (P < 0.05) improved versus baseline, as did the proportion of patients with diastolic dysfunction grade 3 or functional mitral regurgitation grade 3-4. In the subgroup with mean disease duration less than 8.5 years (n = 40), there was a significant improvement in all variables at both time points; in this group, a recovery of right ventricular function was also seen at the 12-month follow-up. On the contrary, patients with heart failure duration of at least 8.5 years (n = 29) showed only a slight improvement in LVEF and mitral regurgitation at 12 months. There were no significant changes in renal function and/or potassium levels in all patients.

CONCLUSION

In patients with a relatively short disease duration, sacubitril/valsartan was associated with a strong favorable remodeling of the left ventricle and improvement in pulmonary circulation.

The left atrium and the right ventricle: two supporting chambers to the failing left ventricle

Heart failure (HF) is mainly caused by left ventricular (LV) impairment of function, hence detailed assessment of its structure and function is a clinical priority. The frequent involvement of the left atrium (LA) and the right ventricle (RV) in the overall cardiac performance has recently gained significant interest with specific markers predicting exercise intolerance and prognosis being proposed. The LA and RV are not anatomically separated from the LV, while the LA controls the inlet the RV shares the interventricular septum with the LV. Likewise, the function of the two chambers is not entirely independent from that of the LV, with the LA enlarging to accommodate any rise in filling pressures, which could get transferred to the RV via the pulmonary circulation. In the absence of pulmonary disease, LA and RV function may become impaired in patients with moderate-severe LV disease and raised filling pressures. These changes can often occur irrespective of the severity of systolic dysfunction, thus highlighting the important need for critical assessment of the function of the two chambers. This review evaluates the pivotal role of the left atrium and right ventricle in the management of HF patients based on the available evidence.

Identifying Risk Factors for Massive Right Ventricular Dilation in Patients With Repaired Tetralogy of Fallot

In repaired tetralogy of Fallot (rTOF), pulmonary insufficiency results in varying degrees of right ventricle (RV) dilation. A subset of patients is diagnosed at initial cardiac magnetic resonance imaging (CMR) with a massively dilated RV, far beyond pulmonary valve replacement (PVR) criteria, which is unlikely to return to normal size after PVR. This study aimed to identify risk factors for massive RV dilation at initial CMR. This nested case-control study included all patients at our institution with rTOF and massive RV dilation (indexed RV end-diastolic volume [RVEDVi] ≥200 ml/m²) on initial CMR. Patients were matched by age at first CMR, gender, and type of repair with rTOF controls with RVEDVi<200 ml/m². In 39 cases (median RVEDVi 227 ml/m², interquartile range [IQR] 213 to 250) and 73 controls (median RVEDVi 155 ml/m², IQR 130 to 169), repair at >6 months of age, longer QRS duration, and non-Caucasian race were significantly associated with massive RV dilation on univariate analysis. In multivariate analysis, repair at >6 months of age (adjusted odds ratio [AOR] 2.90, 95% confidence interval [CI] 1.12 to 7.55, p = 0.03), longer QRS duration (AOR = 1.03, 95% CI 1.01 to 1.05, p = 0.005), and non-Caucasian race (AOR = 7.84, 95% CI 1.76 to 34.8, p = 0.01) remained independently associated with massive RV dilation. Era of repair, history of systemic to pulmonary shunt palliation, genetic anomaly, and additional cardiac lesions did not differ between groups. In conclusion, these risk factors identify a subset of patients who may benefit from earlier CMR evaluation to avoid massive irreversible RV dilation.

The left ventricular ejection fraction: new insights into an old parameter

Accurate evaluation of cardiac function has become increasingly important as the treatment of cardiac disease has become more complex. At the same time, technological advances allow greater accuracy and precision in cardiac measurements. Measurement of left ventricular ejection fraction (LVEF) has been a pillar of cardiac evaluation. Several noninvasive modalities are available to assess LVEF; each has advantages and limitations. This review examines various modalities used to measure LVEF and focuses on the relative strengths and weaknesses of each modality. In some clinical settings, however, LVEF may be too insensitive to convey subtle changes in LV contractility. In certain clinical situations, use of LVEF may be an insufficient measure of left ventricular systolic function. Global longitudinal strain is one such parameter that has shown promise for detecting subtle reductions in left ventricular contractility in subjects with chemotherapy-induced cardiotoxicity.

An association between right ventricular dysfunction and sudden cardiac death

BACKGROUND

The effectiveness of severely reduced left ventricular ejection fraction (LVEF <35%) as a predictor of sudden cardiac death (SCD) has diminished, and improvements in risk stratification await discovery of novel markers. Right ventricular (RV) abnormalities can be observed in conditions such as chronic obstructive pulmonary disease and sleep apnea, which have been linked to SCD.

OBJECTIVE

The purpose of this study was to evaluate whether RV abnormalities were associated with SCD after accounting for LVEF and other patient characteristics.

METHODS

In a large, prospective ongoing community-based study of SCD in the Portland, Oregon, metropolitan area, SCD cases (age ≥18 years; 2002-2014) were compared to controls with coronary artery disease but no SCD. Using a novel archive of digital echocardiograms, a standardized approach was used to evaluate RV basal diameter, RV end-diastolic area, and right ventricular fractional area change (RVFAC).

RESULTS

A total of 350 subjects were studied, including 81 SCD cases (age 68.7 ± 13.6 years; 73% male) and 269 controls (age 66.5 ± 10.2 years; 69% male). In multivariate analysis, RVFAC was significantly associated with SCD (odds ratio 1.14 for each 5% decrease; 95% confidence interval 1.03-1.25; P = .01). When modeled with LVEF ≤35%, RVFAC ≤35% was significantly associated with increased risk of SCD. Individuals with both left ventricular and RV dysfunction had a 3× higher odds of SCD than those with neither (odds ratio 3.19; 95% confidence interval 1.33-7.68; P = .01).

CONCLUSION

RV dysfunction was associated with a significantly increased risk of SCD independent of LVEF and, when combined with LVEF, had additive effects on SCD risk.

Basic and advanced echocardiographic evaluation of myocardial dysfunction in sepsis and septic shock

Sepsis continues to be a leading cause of mortality and morbidity in the intensive care unit. Cardiovascular dysfunction in sepsis is associated with worse short- and long-term outcomes. Sepsis-related myocardial dysfunction is noted in 20%-65% of these patients and manifests as isolated or combined left or right ventricular systolic or diastolic dysfunction. Echocardiography is the most commonly used modality for the diagnosis of sepsis-related myocardial dysfunction. With the increasing use of ultrasonography in the intensive care unit, there is a renewed interest in sepsis-related myocardial dysfunction. This review summarises the current scope of literature focused on sepsis-related myocardial dysfunction and highlights the use of basic and advanced echocardiographic techniques for the diagnosis of sepsis-related myocardial dysfunction and the management of sepsis and septic shock.

The impact of right ventricular function assessed by 2-dimensional speckle tracking echocardiography on early mortality in patients with inferior myocardial infarction

BACKGROUND

Right ventricular (RV) involvement in inferior myocardial infarction (MI) increases in-hospital morbidity and mortality.

HYPOTHESIS

RV systolic dysfunction assessed by 2-dimensional speckle tracking echocardiography (STE) might be a predictor of early mortality in patients with acute inferior MI.

METHODS

Eighty-one consecutive patients with acute inferior MI (mean age, 60.8 ± 12.7 years; 18 females) were included. RV myocardial involvement was defined as an elevation >1 mm in V₁ or V₄ R within 12 hours of symptom onset. RV function was assessed by STE. Patients were followed for 30 days for all-cause mortality.

RESULTS

Thirty-eight patients had RV myocardial involvement, and they had significantly lower tricuspid annular plane systolic excursion (TAPSE), tricuspid annular systolic velocity (RVS), and left ventricular (LV) and RV global longitudinal strain (GLS). Nine patients (11%) died within 30 days. The mean age of mortality group was higher with more female frequency. They had significantly higher pro-BNP, hs-troponin T, and creatinine levels, but lower hemoglobin levels. TIMI 3 flow was significantly less achieved in mortality group. RV myocardial involvement was more frequent in the mortality group, and they had significantly lower TAPSE, RVS, and LV and RV GLS. Multivariate analysis revealed that age and RV GLS were independent predictors of early mortality. RV GLS ≤ -14% predicted early mortality in patients with acute inferior MI with a sensitivity of 88.9% and a specificity of 62.5% (AUC: 0.817, P = 0.002).

CONCLUSIONS

RV GLS may be useful in predicting early mortality in patients with acute inferior MI.

Vendor-Neutral Right Ventricular Strain Measurement

OBJECTIVE

To test the feasibility and reliability of using a vendor-neutral platform to evaluate right ventricular (RV) strain. Reliability was determined by comparing intra- and inter-observer variability between RV strain assessments. The secondary objective was to assess strain's correlation with conventional RV functional parameters to evaluate its feasibility as a RV systolic functional assessment tool.

DESIGN

This is a retrospective study.

SETTING

Tertiary hospital.

PARTICIPANTS

A total of 15 patients who underwent elective coronary artery bypass graft surgery were selected for inclusion.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Images obtained during routine, intraoperative, two-dimensional transesophageal echocardiography (2D TEE) were assessed for longitudinal strain (LS) and conventional parameters, including fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), Doppler tissue imaging (DTI)-derived tricuspid lateral annular systolic velocity wave (S'), and RV dimensions using vendor-neutral software. There was good to excellent intra- and inter-observer reproducibility (intraclass correlation coefficient [ICC] from 0.75 to 1.00) with the exception of basal free wall longitudinal strain (FWLS) (for intra- and inter-observer reproducibility, ICC = 0.670 and 0.749, respectively). FWLS and global longitudinal strain (GLS) showed moderate to strong positive correlation with FAC, TAPSE, and S' (correlation coefficients from 0.667 to 0.721).

CONCLUSION

It is feasible to assess RV strain across multiple platforms in a reproducible and reliable fashion. Furthermore, RV strain demonstrated good correlation with conventional RV functional parameters, suggesting its feasibility as a sensitive RV function assessment tool.

Echocardiographic evaluation of the right ventricle: Clinical implications

Interest in evaluation of the right ventricle (RV) has increased recently. With the growth of new echocardiographic techniques and technology, there has been a corresponding increase in the ability to evaluate the RV, both qualitatively and quantitatively. Older echocardiographic techniques, such as right ventricular fractional area of change, tricuspid annular plane systolic excursion, and tissue S', and newer echocardiographic techniques including 3-dimensional evaluation and global longitudinal strain, can improve our evaluation of RV function. These techniques provide both diagnostic and prognostic data on a large variety of clinical diseases including pulmonary hypertension and congestive heart failure. With the continuing and exponential advances in technology, echocardiography is well poised to become the primary modality to evaluate the RV.