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Fraile-Gutiérrez V, Zapata-Fenor L, Blandino-Ortiz A, Guerrero-Mier M, Ochagavia-Calvo A. Right ventricular dysfunction in the critically ill. Echocardiographic evaluation. Med Intensiva 2024; 48:528-542. [PMID: 39079775 DOI: 10.1016/j.medine.2024.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 05/06/2024] [Accepted: 05/20/2024] [Indexed: 09/04/2024]
Abstract
Right ventricular dysfunction is common in critically ill patients, and is associated with increased mortality. Its diagnosis moreover remains challenging. In this review, we aim to outline the potential mechanisms underlying abnormal biomechanics of the right ventricle and the different injury phenotypes. A comprehensive understanding of the pathophysiology and natural history of right ventricular injury can be informative for the intensivist in the diagnosis and management of this condition, and may serve to guide individualized treatment strategies. We describe the main recommended parameters for assessing right ventricular systolic and diastolic function. We also define how to evaluate cardiac output and pulmonary circulation pressures with echocardiography, with a focus on the diagnosis of acute cor pulmonale and relevant applications in critical disorders such as distress, septic shock, and right ventricular infarction.
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Affiliation(s)
| | - Lluis Zapata-Fenor
- Department of Intensive Care Medicine, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Aaron Blandino-Ortiz
- Department of Intensive Care Medicine, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Manuel Guerrero-Mier
- Department of Intensive Care Medicine, Hospital Universitario Virgen de Valme, Seville, Spain
| | - Ana Ochagavia-Calvo
- Department of Intensive Care Medicine, Hospital Universitario de Bellvitge de L'Hospitalet de Llobregat, Barcelona, Spain
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Cohen A, Li T, Bielawa N, Nello A, Gold A, Gorlin M, Nelson M, Carlin E, Rolston D. Right Ventricular "Bubble Time" to Identify Patients With Right Ventricular Dysfunction. Ann Emerg Med 2024; 84:182-194. [PMID: 38597847 DOI: 10.1016/j.annemergmed.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 01/10/2024] [Accepted: 02/08/2024] [Indexed: 04/11/2024]
Abstract
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.
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Affiliation(s)
- Allison Cohen
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY.
| | - Timmy Li
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY
| | - Nicholas Bielawa
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY
| | - Alexander Nello
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY
| | - Allen Gold
- Department of Emergency Medicine, St. Barnabas Hospital, Bronx, NY
| | - Margaret Gorlin
- Biostatistics Unit, Office of Academic Affairs, Northwell Health, New Hyde Park, NY
| | - Mathew Nelson
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY
| | - Edward Carlin
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY
| | - Daniel Rolston
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY
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Arfsten H, König A, Geller W, Bodner L, Dannenberg V, Prausmüller S, Bartko PE, Binder T, Hengstenberg C, Goliasch G, Schneider-Reigbert M. Annular remodelling predicts outcome in isolated severe tricuspid regurgitation: a registry-based echocardiographic analysis. Eur Heart J Cardiovasc Imaging 2024; 25:795-803. [PMID: 38198413 DOI: 10.1093/ehjci/jeae012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/28/2023] [Accepted: 12/30/2023] [Indexed: 01/12/2024] Open
Abstract
AIMS Depending on volume status, secondary tricuspid regurgitation (sTR) has a strong dynamic component. In contrast, associated structural dilatation of the tricuspid annulus and the right heart chambers may be less volume dependent. This study aimed to assess the prognostic value of right heart remodelling in isolated severe sTR (isoTR). METHODS AND RESULTS A total of 36 000 patients from the longitudinal echocardiographic database of our tertiary centre were screened for severe isoTR [vena contracta (VC) ≥ 7 mm] in the absence of atrial fibrillation (AF), other valve disease, and/or reduced systolic left ventricular function. Echocardiographic examinations were re-read, focusing on right ventricular (RV) parameters and on quantitative and qualitative parameters of isoTR. All-cause mortality was defined as the primary endpoint. Two hundred and sixteen patients fulfilled the inclusion criteria. Severe TR was predominant; only few were classified in the new grades massive [n = 23 (10%)] and torrential TR [n = 4 (2%)]. During a median follow-up of 35 months (20-53), all-cause mortality was 31% (n = 67). Multivariate Cox regression analysis revealed no association of VC, effective regurgitant orifice area, or regurgitant volume with all-cause mortality. However, indexed RV end-diastolic diameter (P < 0.001), indexed right atrial dimensions (P = 0.019), and particularly tricuspid valve (TV) annulus diameter diastole index (P = 0.002) and TV annulus diameter systole index (P = 0.001) were significantly associated with outcome. CONCLUSION Severe isolated TR in the absence of AF is a rare finding with a grim prognosis. Tricuspid annular diameter dimensions rather than quantitative measures of TR proved to be of significant prognostic value indicating a continuous remodelling leading to a 'point of no return' with a dismal outcome.
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Affiliation(s)
- Henrike Arfsten
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Wien, Austria
| | - Andreas König
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Wien, Austria
| | - Welf Geller
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Wien, Austria
| | - Lorenz Bodner
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Wien, Austria
| | - Varius Dannenberg
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Wien, Austria
| | - Suriya Prausmüller
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Wien, Austria
| | - Philipp E Bartko
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Wien, Austria
| | - Thomas Binder
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Wien, Austria
| | - Christian Hengstenberg
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Wien, Austria
| | - Georg Goliasch
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Wien, Austria
| | - Matthias Schneider-Reigbert
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Wien, Austria
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Augustenburger Platz 1, 13353 Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Centre for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
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Zhang B, Lu S, Guo H, Xu J, Xiao Z, Tang J. Relationship between ODI and sleep structure of obstructive sleep apnea and cardiac remodeling. Sleep Breath 2024; 28:173-181. [PMID: 37453997 DOI: 10.1007/s11325-023-02872-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 04/27/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE The purpose of the study was to evaluate the quantitative relationship between Oxygen Desaturation Index (ODI) and sleep structure of obstructive sleep apnea (OSA) and cardiac remodeling. METHODS In this study, patients were enrolled from January 2015 to October 2022, and were divided into 3 groups according to AHI: patients with AHI < 15, patients with 15 ≤ AHI < 30, and 260 patients with AHI ≥ 30. Stratified linear regression was used to analyze independent risk factors for cardiac remodeling in OSA. RESULTS A total of 479 patients were enrolled. We found that compared with AHI < 15 group (n = 120), the group with AHI > 30 (n = 260) had increased left atrial anteroposterior diameter, left ventricular end-diastolic internal diameter, left ventricular posterior wall thickness, right ventricular anteroposterior diameter, and interventricular septal thickness (P < 0.05). The group with 15 ≤ AHI ≤ 30 (n = 99) had increased left atrial anteroposterior diameter (P < 0.05). Multivariate linear regression revealed that N2 sleep was an independent risk factor for left ventricular posterior wall thickness, with positive correlation (p < 0.05). N3 sleep was an independent risk factor for transverse right atrial diameter and right ventricular anteroposterior diameter, with negative correlation (P < 0.05). ODI was an independent risk factor for interventricular septal thickness, with positive correlation (P < 0.05). The arousal index was an independent risk factor for increased left atrial anteroposterior diameter, with positive correlation (P < 0.05). CONCLUSIONS Increased ODI is an independent risk factor for interventricular septal thickness, while decreased slow wave sleep is an independent risk factor for right heart remodeling in OSA.
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Affiliation(s)
- Baokun Zhang
- Department of Neurology, Shandong Provincial Qianfoshan Hospital, Cheeloo College of Medicine, Shandong University, NO. 16766 Jingshi Road, Jinan, Shandong, 250012, People's Republic of China
| | - Shanshan Lu
- Department of Neurology, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Neuroimmunology, Jinan, People's Republic of China
| | - Huiying Guo
- Department of Neurology, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Neuroimmunology, Jinan, People's Republic of China
| | - Juanjuan Xu
- Department of Neurology, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Neuroimmunology, Jinan, People's Republic of China
| | - Zhang Xiao
- Department of Neurology, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Neuroimmunology, Jinan, People's Republic of China
| | - Jiyou Tang
- Department of Neurology, Shandong Provincial Qianfoshan Hospital, Cheeloo College of Medicine, Shandong University, NO. 16766 Jingshi Road, Jinan, Shandong, 250012, People's Republic of China.
- Department of Neurology, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Neuroimmunology, Jinan, People's Republic of China.
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O'Donnell C, Sanchez PA, Celestin B, McConnell MV, Haddad F. The Echocardiographic Evaluation of the Right Heart: Current and Future Advances. Curr Cardiol Rep 2023; 25:1883-1896. [PMID: 38041726 DOI: 10.1007/s11886-023-02001-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2023] [Indexed: 12/03/2023]
Abstract
PURPOSE OF REVIEW To discuss physiologic and methodologic advances in the echocardiographic assessment of right heart (RH) function, including the emergence of artificial intelligence (AI) and point-of-care ultrasound. RECENT FINDINGS Recent studies have highlighted the prognostic value of right ventricular (RV) longitudinal strain, RV end-systolic dimensions, and right atrial (RA) size and function in pulmonary hypertension and heart failure. While RA pressure is a central marker of right heart diastolic function, the recent emphasis on venous excess imaging (VExUS) has provided granularity to the systemic consequences of RH failure. Several methodological advances are also changing the landscape of RH imaging including post-processing 3D software to delineate the non-longitudinal (radial, anteroposterior, and circumferential) components of RV function, as well as AI segmentation- and non-segmentation-based quantification. Together with recent guidelines and advances in AI technology, the field is shifting from specific RV functional metrics to integrated RH disease-specific phenotypes. A modern echocardiographic evaluation of RH function should focus on the entire cardiopulmonary venous unit-from the venous to the pulmonary arterial system. Together, a multi-parametric approach, guided by physiology and AI algorithms, will help define novel integrated RH profiles for improved disease detection and monitoring.
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Affiliation(s)
- Christian O'Donnell
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Pablo Amador Sanchez
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Bettia Celestin
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael V McConnell
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Francois Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University School of Medicine, Stanford, CA, USA
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Defoe M, Lam W, Becher H, Lydell C, Hong Y, Sidhu S. Right ventricular ejection fraction derived from intraoperative three-dimensional transesophageal echocardiography versus cardiac magnetic resonance imaging. Can J Anaesth 2023; 70:1576-1586. [PMID: 37752378 DOI: 10.1007/s12630-023-02569-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 04/14/2023] [Accepted: 05/09/2023] [Indexed: 09/28/2023] Open
Abstract
PURPOSE Right ventricle (RV) assessment is critical during cardiac surgery. Traditional assessment consists of visual estimation and measurement of validated parameters. Cardiac magnetic resonance imaging (cMRI) is the gold standard for RV analysis, and transthoracic three-dimensional (3D) echocardiography is validated against this. We aimed to show that intraoperative 3D transesophageal echocardiography (TEE) RV assessment is feasible and can produce results that correlate with cMRI. METHODS We recruited cardiac surgery patients who underwent cMRI within the preceding twelve preoperative months. An anesthetic protocol was followed pre-sternotomy and a 3D RV data set was acquired. We used TOMTEC 4D RV-Function to derive RV end-diastolic volume (EDV), end-systolic volume (ESV), and ejection fraction (EF). We compared these data with the corresponding MRI values. RESULTS Twenty-five patients were included. Transesophageal echocardiography EDV and ESV differed from MRI measurements with a mean bias of -53 mL (95% confidence interval [CI], -80 to 26) and -21 mL (95% CI, -34 to -9). Transesophageal echocardiography EF did not differ significantly, with a mean bias of -4% (95% CI, -8 to 1). Results were unchanged after excluding MRIs older than 180 days. Correlation coefficients for EDV, ESV, and EF were r = 0.85, 0.91, and 0.80, respectively. Interclass correlation coefficients for EDV, ESV, and EF were 0.86, 0.89, and 0.96, respectively. CONCLUSIONS Intraoperative TEE RV, EDV, and ESV are underestimated relative to cMRI because of analysis, anesthetic, and ventilation factors. The EF showed a low mean difference, and all values showed strong correlation with MRI. Reproducibility and feasibility were excellent and increased use in clinical practice should be considered.
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Affiliation(s)
- Marc Defoe
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada
| | - Wing Lam
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada
| | - Harald Becher
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada
| | - Carmen Lydell
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Yongzhe Hong
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Surita Sidhu
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada.
- Department of Anesthesiology and Pain Medicine, University of Alberta, 2-150 Clinical Sciences Building, 11350 83rd Avenue, Edmonton, AB, T6G 2G3, Canada.
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Honarbakhsh S, Protonotarios A, Monkhouse C, Hunter RJ, Elliott PM, Lambiase PD. Right ventricular function is a predictor for sustained ventricular tachycardia requiring anti-tachycardic pacing in arrhythmogenic ventricular cardiomyopathy: insight into transvenous vs. subcutaneous implantable cardioverter defibrillator insertion. Europace 2023; 25:euad073. [PMID: 37213071 PMCID: PMC10202497 DOI: 10.1093/europace/euad073] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 02/14/2023] [Indexed: 05/23/2023] Open
Abstract
AIMS Arrhythmogenic right ventricular cardiomyopathy (ARVC) patients develop ventricular arrhythmias (VAs) responsive to anti-tachycardia pacing (ATP). However, VA episodes have not been characterized in accordance with the device therapy, and with the emergence of the subcutaneous implantable cardioverter defibrillator (S-ICD), the appropriate device prescription in ARVC remains unclear. Study aim was to characterize VA events in ARVC patients during follow-up in accordance with device therapy and elicit if certain parameters are predictive of specific VA events. METHODS AND RESULTS This was a retrospective single-centre study utilizing prospectively collated registry data of ARVC patients with ICDs. Forty-six patients were included [54.0 ± 12.1 years old and 20 (43.5%) secondary prevention devices]. During a follow-up of 12.1 ± 6.9 years, 31 (67.4%) patients had VA events [n = 2, 6.5% ventricular fibrillation (VF), n = 14], 45.2% VT falling in VF zone resulting in ICD shock(s), n = 10, 32.3% VT resulting in ATP, and n = 5, 16.1% patients had both VT resulting in ATP and ICD shock(s). Lead failure rates were high (11/46, 23.9%). ATP was successful in 34.5% of patients. Severely impaired right ventricular (RV) function was an independent predictor of VT resulting in ATP (hazard ratio 16.80, 95% confidence interval 3.74-75.2; P < 0.001) with a high predictive accuracy (area under the curve 0.88, 95%CI 0.76-1.00; P < 0.001). CONCLUSION VA event rates are high in ARVC patients with a majority having VT falling in the VF zone resulting in ICD shock(s). S-ICDs could be of benefit in most patients with ARVC with the absence of severely impaired RV function which has the potential to avoid consequences of the high burden of lead failure.
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Affiliation(s)
- Shohreh Honarbakhsh
- The Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS trust, West Smithfield, London WC1 8BE, UK
- William Harvey Research Institute, Queen Mary’s University of London, London, E1, UK
| | - Alexander Protonotarios
- The Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS trust, West Smithfield, London WC1 8BE, UK
| | - Christopher Monkhouse
- The Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS trust, West Smithfield, London WC1 8BE, UK
| | - Ross J Hunter
- The Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS trust, West Smithfield, London WC1 8BE, UK
| | - Perry M Elliott
- The Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS trust, West Smithfield, London WC1 8BE, UK
| | - Pier D Lambiase
- The Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS trust, West Smithfield, London WC1 8BE, UK
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Ibekwe SO, Potluri V, Palvadi R, Best GT. Use of Point-of-Care Ultrasound and Focus-Assessed Transthoracic Echocardiography to Diagnose Acute Right Heart Failure Due to Fat Emboli in a Parturient. Cureus 2022; 14:e28585. [PMID: 36185894 PMCID: PMC9521511 DOI: 10.7759/cureus.28585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2022] [Indexed: 11/17/2022] Open
Abstract
Fat embolism syndrome (FES), causing right heart dysfunction, is a rare disease that is often difficult to diagnose with imaging modalities such as computed tomography (CT). FES is the clinical presentation that follows the entry of fat globules into the systemic circulation, which typically results in respiratory failure, scattered petechiae, cardiovascular collapse, and neurological sequelae. It is mostly observed in the cases of orthopedic trauma but may occur in any circumstance where fat can enter the circulatory system. In this case report, the authors describe an atypical presentation of FES in a 24-week parturient. The use of bedside point-of-care ultrasonography (POCUS) and the focus-assessed transthoracic echocardiography (FATE) protocol aided in the prompt diagnosis of right heart failure and helped to confirm the diagnosis of FES with more advanced imaging technology.
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Arthur L, Knecht K, Ferry J, Grigsby D, Spencer H, Zakaria D. Serial assessment of right ventricular function can detect acute cellular rejection in children with heart transplantation. Pediatr Transplant 2022; 26:e14231. [PMID: 35043516 PMCID: PMC9086092 DOI: 10.1111/petr.14231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 12/31/2021] [Accepted: 01/03/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Echocardiographic markers of ACR are essential for early recognition and management. The literature's primary focus has been on the LV with little attention given to the RV. This study aimed to investigate echocardiographic right ventricular indices in the detection of ACR and to evaluate their utility as prognostic indicators of graft integrity. METHODS We performed a retrospective chart review of children with biopsy-proven ACR following orthotopic heart transplant and an echocardiogram within 24 h of biopsy. Selected echocardiographic markers were compared at baseline, during ACR, and at follow-up. RESULTS Forty-eight patients (56% male) had a total of 84 ACR episodes. Decrease in RV FAC (mean - 17.1%, p < .001) and TAPSE (mean - 8.9%, p < .001) with increase in left ventricular posterior wall thickness in diastole and systole (LVPWTd) (mean + 9.0%, p = .012) and LVPWTs (mean + 8.3%, p = .016) were found during ACR. Interestingly, these parameters improved following the episode of rejection. Additionally, these markers were compared after recovery between children with and without graft failure. RV dysfunction (FAC and TAPSE) and changes in LV posterior wall thickness were not found to have prognostic significance for graft integrity in children with heart transplantation. CONCLUSIONS RV echocardiographic functional parameters should be considered as valuable adjuncts in rejection surveillance. Further, the presence of RV dysfunction does not have prognostic significance for graft integrity but is reversible as ongoing damage was not detectable by such.
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Affiliation(s)
- Lindsay Arthur
- Arkansas Children’s Hospital, Little Rock, Arkansas, USA
| | - Kenneth Knecht
- Arkansas Children’s Hospital, Little Rock, Arkansas, USA
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Jennifer Ferry
- Arkansas Children’s Hospital, Little Rock, Arkansas, USA
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Debby Grigsby
- Arkansas Children’s Hospital, Little Rock, Arkansas, USA
| | - Horace Spencer
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Dala Zakaria
- Arkansas Children’s Hospital, Little Rock, Arkansas, USA
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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Kostura M, Smalley C, Koyfman A, Long B. Right heart failure: A narrative review for emergency clinicians. Am J Emerg Med 2022; 58:106-113. [PMID: 35660367 DOI: 10.1016/j.ajem.2022.05.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 05/18/2022] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Right heart failure (RHF) is a clinical syndrome with impaired right ventricular cardiac output due to a variety of etiologies including ischemia, elevated pulmonary arterial pressure, or volume overload. Emergency department (ED) patients with an acute RHF exacerbation can be diagnostically and therapeutically challenging to manage. OBJECTIVE This narrative review describes the pathophysiology of right ventricular dysfunction and pulmonary hypertension, the methods to diagnose RHF in the ED, and management strategies. DISCUSSION Right ventricular contraction normally occurs against a low pressure, highly compliant pulmonary vascular system. This physiology makes the right ventricle susceptible to acute changes in afterload, which can lead to RHF. Patients with acute RHF may present with an acute illness and have underlying chronic pulmonary hypertension due to left ventricular failure, pulmonary arterial hypertension, chronic lung conditions, thromboemboli, or idiopathic conditions. Patients can present with a variety of symptoms resulting from systemic edema and hemodynamic compromise. Evaluation with electrocardiogram, laboratory analysis, and imaging is necessary to evaluate cardiac function and end organ injury. Management focuses on treating the underlying condition, optimizing oxygenation and ventilation, treating arrhythmias, and understanding the patient's hemodynamics with bedside ultrasound. As RHF patients are preload dependent they may require fluid resuscitation or diuresis. Hypotension should be rapidly addressed with vasopressors. Cardiac contractility can be augmented with inotropes. Efforts should be made to support oxygenation while trying to avoid intubation if possible. CONCLUSIONS Emergency clinician understanding of this condition is important to diagnose and treat this life-threatening cardiopulmonary disorder.
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Affiliation(s)
- Matthew Kostura
- Department of Emergency Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Courtney Smalley
- Department of Emergency Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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11
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Tsipis A, Petropoulou E. Echocardiography in the Evaluation of the Right Heart. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2021.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The significance of the right ventricle (RV) as a predictor of outcome in a series of cardiac conditions has recently been recognized. Consequently, more studies are now focusing on improving the assessment of the RV. Its primary function is to support adequate pulmonary perfusion pressure in different circulatory and loading situations and to ensure that there is a low systemic venous pressure. Echocardiography is the first-line method of choice due to its accuracy when assessing RV structure and function, as well as its wide availability. The geometry of the RV is complex and its evaluation can be difficult. Integrating and combining multiple parameters may be a more reliable way to determine normal or abnormal function. Novel techniques are increasingly being performed more routinely in clinical practice and are facilitating diagnosis and treatment choices.
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Affiliation(s)
- Angelos Tsipis
- Department of Cardiology, Metropolitan General Hospital, Athens, Greece
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12
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Malakan Rad E, Amani S, Ilali HM, Sedaghat A, Zanjani KS, Moghadam EA, Shabanian R, Zeinaloo AA. Color tissue doppler imaging of tricuspid annular plane systolic and diastolic excursion in children: A comparison of normal, volume-overloaded and pressure overloaded right ventricles. Echocardiography 2022; 39:496-513. [PMID: 35187704 DOI: 10.1111/echo.15321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 01/07/2022] [Accepted: 02/01/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Tricuspid annular plane (TAP) systolic excursion (TAPSE) is a reproducible M-mode parameter for the measurement of longitudinal shortening of the right ventricle (RV). To date, all attention has been focused on the systolic excursion of TAP and the diastolic excursion of the annular plane back to the base has been ignored. This study aims to compare the quantitative (excursion, slope, and duration) and qualitative (velocity, acceleration, and indentation) characteristics of TAP systolic and diastolic excursion, using color tissue Doppler imaging, in three groups of children with normal RV (NORV), volume overloaded RV (VORV), and pressure overloaded RV (PORV) and normal pulmonary arterial pressure. SUBJECTS AND METHODS A prospective case-control study was performed in three groups of children with normal heart, VORV and PORV. TAPSE and tricuspid annular plane diastolic excursion (TAPDE) were quantitatively and qualitatively analyzed and compared between the three groups. Statistical analysis was performed using IBM SPSS Statistics for Windows. RESULTS TAPSE, TAPDE, TAPSE slope, TAPSE slope/TAPDE slope, TAPDE duration and TAPDE duration/RR interval were lower in PORV (TAPSE: PORV: 14.45 ± 4.30, NORV: 20.45 ± 5.46, P = .003, TAPDE:PORV: 14.39 ± 4.61, NORV: 20.28 ± 5.65, P = .004, TAPSE slope:PORV: 4.79 ± 1.40, NORV: 7.15 ± 1.98, P = .001, .001, TAPDE duration:PORV: 201.1 ± 87.9 ms, NORV: 292.1 ± 97.9, P = .006, TAPDE duration/RR interval: PORV: .37 ± .09, NORV: .48 ± .08, P = .0002). CONCLUSION Pressure-overload on RV produced more impairment of TAPSE and TAPDE patterns than volume overload. Values of TAPSE and TAPDE in patients with VORV and PORV stay in two ends of the normal spectrum. The harmful impact of pre-tricuspid volume overload seems to be less than the post-tricuspid volume overload.
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Affiliation(s)
- Elaheh Malakan Rad
- Department of Pediatric Cardiology, Children's Medical Center (Pediatric Center of Excellence) affiliated to Tehran University of Medical Sciences, Tehran, Iran
| | - Sude Amani
- Department of Pediatric Cardiology, Children's Medical Center (Pediatric Center of Excellence) affiliated to Tehran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Mirzaei Ilali
- Department of Pediatric Cardiology, Children's Medical Center (Pediatric Center of Excellence) affiliated to Tehran University of Medical Sciences, Tehran, Iran
| | - Abdullah Sedaghat
- Department of Pediatric Cardiology, Children's Medical Center (Pediatric Center of Excellence) affiliated to Tehran University of Medical Sciences, Tehran, Iran
| | - Keyhan Sayadpour Zanjani
- Department of Pediatric Cardiology, Children's Medical Center (Pediatric Center of Excellence) affiliated to Tehran University of Medical Sciences, Tehran, Iran
| | - Ehsan Aghaei Moghadam
- Department of Pediatric Cardiology, Children's Medical Center (Pediatric Center of Excellence) affiliated to Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Shabanian
- Department of Pediatric Cardiology, Children's Medical Center (Pediatric Center of Excellence) affiliated to Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Akbar Zeinaloo
- Department of Pediatric Cardiology, Children's Medical Center (Pediatric Center of Excellence) affiliated to Tehran University of Medical Sciences, Tehran, Iran
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Veitla V, Bhasin B. Focused Cardiac Assessment in Kidney Care. POCUS JOURNAL 2022; 7:45-50. [PMID: 36896102 PMCID: PMC9994304 DOI: 10.24908/pocus.v7ikidney.14996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Point of care ultrasonography (POCUS) is considered to be a very useful and informative extension of the bedside physical exam. The information obtained from POCUS allows for real time assessment for expedited decision making to improve efficiency in patient care and management. Many programs across the country are now incorporating POCUS into their training schedules to allow their residents, fellows, and faculty to gain competence in the techniques and varied clinical uses of POCUS [1-3]. In nephrology, POCUS has been used at the bedside for access planning, dialysis catheter placement, and to guide kidney biopsies to mention a few applications [4]. There is a wide scope for POCUS in nephrology in addition to kidney and bladder assessment. This includes focused cardiac ultrasound to evaluate the heart for structural and functional abnormalities and lung ultrasound as well. These bedside ultrasound assessments help with point of care management decisions pertaining to volume assessment in acute and chronic kidney disease, adjustment of ultrafiltration goals in dialysis patients, and evaluation of hypotension and dyspnea.
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Affiliation(s)
- Vineet Veitla
- Division of Nephrology, Medical College of Wisconsin Milwaukee, WI
| | - Bhavna Bhasin
- Division of Nephrology, Medical College of Wisconsin Milwaukee, WI
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Ahmadi A, Renaud JM, Promislow S, Burwash IG, Dwivedi G, Klein R, Zelt JGE, deKemp RA, Beanlands RS, Mielniczuk LM. Increased myocardial oxygen consumption rates are associated with maladaptive right ventricular remodeling and decreased event-free survival in heart failure patients. J Nucl Cardiol 2021; 28:2784-2795. [PMID: 32383088 DOI: 10.1007/s12350-020-02144-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 02/14/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Reduced left ventricular (LV) function is associated with increased myocardial oxygen consumption rate (MVO2) and altered sympathetic activity, the role of which is not well described in right ventricular (RV) dysfunction. METHODS AND RESULTS 33 patients with left heart failure were assessed for RV function/size using echocardiography. Positron emission tomography (PET) was used to measure 11C-acetate clearance rate (kmono), 11C-hydroxyephedrine (11C-HED) standardized uptake value (SUV), and retention rate. RV MVO2 was estimated from kmono. 11C-HED SUV and retention indicated sympathetic neuronal function. A composite clinical endpoint was defined as unplanned cardiac hospitalization within 5 years. Patients with (n = 10) or without (n = 23) RV dysfunction were comparable in terms of sex (male: 70.0 vs 69.5%), LV ejection fraction (39.6 ± 9.0 vs 38.6 ± 9.4%), and systemic hypertension (70.0 vs 78.3%). RV dysfunction patients were older (70.9 ± 13.5 vs 59.4 ± 11.5 years; P = .03) and had a higher prevalence of pulmonary hypertension (60.0% vs 13.0%; P = .01). RV dysfunction was associated with increased RV MVO2 (.106 ± .042 vs .068 ± .031 mL/min/g; P = .02) and decreased 11C-HED SUV and retention (6.05 ± .53 vs 7.40 ± 1.39 g/mL (P < .001) and .08 ± .02 vs .11 ± .03 mL/min/g (P < .001), respectively). Patients with an RV MVO2 above the median had a shorter event-free survival (hazard ratio = 5.47; P = .01). Patients who died within the 5-year follow-up period showed a trend (not statistically significant) for higher RV MVO2 (.120 ± .026 vs .074 ± .038 mL/min/g; P = .05). CONCLUSIONS RV dysfunction is associated with increased oxygen consumption (also characterized by a higher risk for cardiac events) and impaired RV sympathetic function.
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Affiliation(s)
- Ali Ahmadi
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Jennifer M Renaud
- National Cardiac PET Centre, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Steven Promislow
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Ian G Burwash
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Girish Dwivedi
- Harry Perkins Institute of Medical Research, The University of Western Australia, Perth, Australia
| | - Ran Klein
- Division of Nuclear Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Jason G E Zelt
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Robert A deKemp
- National Cardiac PET Centre, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Rob S Beanlands
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
- National Cardiac PET Centre, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Lisa M Mielniczuk
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada.
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Chriqui LE, Monney P, Kirsch M, Tozzi P. Prediction of right ventricular failure after left ventricular assist device implantation in patients with heart failure: a meta-analysis comparing echocardiographic parameters. Interact Cardiovasc Thorac Surg 2021; 33:784-792. [PMID: 34368839 DOI: 10.1093/icvts/ivab177] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 04/21/2021] [Accepted: 05/04/2021] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES Between 10% and 40% of patients who receive a left ventricular assistance device (LVAD) suffer from right ventricular failure (RVF) shortly after the device is implanted. Patients with post-LVAD RVF tend to have poor outcomes. Only a few predictive factors concerning the right ventricle (RV) have been investigated. Our goal was to search for non-invasive variables that correlate with RV function, focusing on echocardiographic parameters of the RV. METHODS We selected 3 parameters: tricuspid annular plane systolic excursion, right ventricular fractional area change and right ventricular global longitudinal strain. We searched the literature and pooled relevant studies in a meta-analysis. Finally, we performed a statistical analysis to confirm whether each parameter was a reliable predictor of RVF after LVAD implantation. RESULTS We retained 19 articles involving a total of 1561 patients. We found a pooled standardized mean deviation of -0.13 cm for the tricuspid annular plane systolic excursion, with the lower and upper tails of -0.21 and -0.04 cm, respectively. Concerning the right ventricular fractional area change, the averaged standardized mean deviation was equal to -2.61%, with the lower and upper extremities of -4.12% and -1.09%, respectively. Finally, regarding the global longitudinal strain, the standardized mean deviation was equal to -2.06% with an uncertainty value between -3.23% and -0.88%. CONCLUSIONS The tricuspid annular plane systolic excursion could be a reliable parameter in RVF prediction. The right ventricular fractional area change and global longitudinal strain are likely to be stronger predictors of RVF after LVAD implantation. Prospective studies should be carried out to confirm this observation.
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Affiliation(s)
| | - Pierre Monney
- Service of Cardiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Matthias Kirsch
- Service of Cardiovascular Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Piergiorgio Tozzi
- Service of Cardiovascular Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
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Erdoğan M, Kaya Kalem A, Öztürk S, Erdöl MA, Kayaaslan B, Özbebek YE, Güner R. Interleukin-6 level is an independent predictor of right ventricular systolic dysfunction in patients hospitalized with COVID-19. Anatol J Cardiol 2021; 25:555-564. [PMID: 34369883 PMCID: PMC8357443 DOI: 10.5152/anatoljcardiol.2021.24946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE Cytokine storm with elevated levels of multiple proinflammatory cytokines and inflammatory system activation underlie the pathogenesis of coronavirus disease 2019 (COVID-19). In this study, we aimed to investigate whether increased interleukin (IL)-6 levels can predict right ventricular (RV) systolic impairment in patients hospitalized with COVID-19. METHODS This prospective, observational study included 100 consecutive patients hospitalized with mild and moderate COVID-19. All the patients underwent chest computerized tomography, detailed laboratory tests including IL-6, and two dimensional (2D) transthoracic echocardiography (TTE) with assessment of 2D conventional and Doppler echocardiography parameters and RV systolic functions. RESULTS After the elimination of six patients with exclusion criteria, the remaining patients were classified into two groups, namely normal RV systolic functions (n=60) and impaired RV systolic functions (n=34). IL-6 levels were significantly higher in patients with impaired RV systolic functions than in those with normal RV systolic functions (20.3, 4.6, p<0.001, respectively). Tricuspid annular plane systolic excursion and RV derived tissue Doppler imaging (TDI) S' measurements were similar between the two groups. RV fractional area change was significantly lower, and RV TDI derived index of myocardial performance was significantly higher in patients with impaired RV systolic functions. In multivariate analysis, IL-6 levels independently predicted deterioration in RV systolic function at a significant level (odds ratio: 1.12, 95% confidence interval: 1.04-1.20, p=0.003). CONCLUSION IL-6 is an independent predictor of RV systolic impairment in patients hospitalized with mild and moderate COVID-19 suggesting a possible pathogenetic mechanism. IL-6 levels can be used to predict RV systolic impairment in patients suffering from this infection.
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Affiliation(s)
- Mehmet Erdoğan
- Department of Cardiology, Ankara Yıldırım Beyazıt University; Ankara-Turkey
- Department of Cardiology, Ministry of Health, Ankara City Hospital; Ankara-Turkey
| | - Ayşe Kaya Kalem
- Department of Infectious Disease and Clinical Microbiology, Faculty of Medicine, Ankara Yıldırım Beyazıt University; Ankara-Turkey
| | - Selçuk Öztürk
- Department of Cardiology, Faculty of Medicine, Yozgat Bozok University; Yozgat-Turkey
| | - Mehmet Akif Erdöl
- Department of Cardiology, Ministry of Health, Ankara City Hospital; Ankara-Turkey
| | - Bircan Kayaaslan
- Department of Infectious Disease and Clinical Microbiology, Faculty of Medicine, Ankara Yıldırım Beyazıt University; Ankara-Turkey
| | - Yunus Emre Özbebek
- Department of Cardiology, Ankara Yıldırım Beyazıt University; Ankara-Turkey
| | - Rahmet Güner
- Department of Infectious Disease and Clinical Microbiology, Faculty of Medicine, Ankara Yıldırım Beyazıt University; Ankara-Turkey
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Schneider M, Dannenberg V, König A, Geller W, Binder T, Hengstenberg C, Goliasch G. Prognostic Value of Echocardiographic Right Ventricular Function Parameters in the Presence of Severe Tricuspid Regurgitation. J Clin Med 2021; 10:jcm10112266. [PMID: 34073744 PMCID: PMC8197252 DOI: 10.3390/jcm10112266] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/10/2021] [Accepted: 05/20/2021] [Indexed: 12/16/2022] Open
Abstract
Background: Presence of severe tricuspid regurgitation (TR) has a significant impact on assessment of right ventricular function (RVF) in transthoracic echocardiography (TTE). High trans-valvular pendulous volume leads to backward-unloading of the right ventricle. Consequently, established cut-offs for normal systolic performance may overestimate true systolic RVF. Methods: A retrospective analysis was performed entailing all patients who underwent TTE at our institution between 1 January 2013 and 31 December 2016. Only patients with normal left ventricular systolic function and with no other valvular lesion were included. All recorded loops were re-read by one experienced examiner. Patients without severe TR (defined as vena contracta width ≥7 mm) were excluded. All-cause 2-year mortality was chosen as the end-point. The prognostic value of several RVF parameters was tested. Results: The final cohort consisted of 220 patients, 88/220 (40%) were male. Median age was 69 years (IQR 52–79), all-cause two-year mortality was 29%, median TAPSE was 19 mm (15–22) and median FAC was 42% (30–52). In multivariate analysis, TAPSE with the cutoff 17 mm and FAC with the cutoff 35% revealed non-significant hazard ratios (HR) of 0.75 (95%CI 0.396–1.421, p = 0.38) and 0.845 (95%CI 0.383–1.867, p = 0.68), respectively. TAPSE with the cutoff 19 mm and visual eyeballing significantly predicted survival with HRs of 0.512 (95%CI 0.296–0.886, p = 0.017) and 1.631 (95%CI 1.101–2.416, p = 0.015), respectively. Conclusions: This large-scale all-comer study confirms that RVF is one of the main drivers of mortality in patients with severe isolated TR. However, the current cut-offs for established echocardiographic parameters did not predict survival. Further studies should investigate the prognostic value of higher thresholds for RVF parameters in these patients.
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Hockstein MA, Haycock K, Wiepking M, Lentz S, Dugar S, Siuba M. Transthoracic Right Heart Echocardiography for the Intensivist. J Intensive Care Med 2021; 36:1098-1109. [PMID: 33853435 DOI: 10.1177/08850666211003475] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The impact of critical illness on the right ventricle (RV) can be profound and RV dysfunction is associated with mortality. Intensivists are becoming more facile with bedside echocardiography, however, pedagogy has largely focused on left ventricular function. Here we review measurements of right heart function by way of echocardiographic modalities and list clinical scenarios where the RV dysfunction is a salient feature. MAIN RV dysfunction is heterogeneously defined across many domains and its diagnosis is not always clinically apparent. The RV is affected by conditions commonly seen in the ICU such as acute respiratory distress syndrome, pulmonary embolism, RV ischemia, and pulmonary hypertension. Basic ultrasonographic modalities such as 2D imaging, M-mode, tissue Doppler, pulsed-wave Doppler, and continuous Doppler provide clinicians with metrics to assess RV function and response to therapy. CONCLUSION The right ventricle is impacted by various critical illnesses with substantial mortality and mortality. Focused bedside echocardiographic exams with attention to the right heart may provide intensivists insight into RV function and provide guidance for patient management.
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Affiliation(s)
- Maxwell A Hockstein
- Departments of Emergency Medicine and Critical Care, 8405MedStar Washington Hospital Center, Washington, DC, USA
| | - Korbin Haycock
- Department of Emergency Medicine, 4608Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Matthew Wiepking
- Department of Emergency Medicine and Surgery, 12223University of Southern California-Keck School of Medicine, Los Angeles, CA, USA
| | - Skyler Lentz
- Division of Emergency Medicine and Pulmonary Disease & Critical Care Medicine, Department of Surgery and Medicine, Larner College of 12352Medicine-University of Vermont, Burlington, VT, USA
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Matthew Siuba
- Department of Critical Care Medicine, Respiratory Institute, 2569Cleveland Clinic, Cleveland, OH, USA
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Woulfe KC, Walker LA. Physiology of the Right Ventricle Across the Lifespan. Front Physiol 2021; 12:642284. [PMID: 33737888 PMCID: PMC7960651 DOI: 10.3389/fphys.2021.642284] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/05/2021] [Indexed: 01/27/2023] Open
Abstract
The most common cause of heart failure in the United States is ischemic left heart disease; accordingly, a vast amount of work has been done to elucidate the molecular mechanisms underlying pathologies of the left ventricle (LV) as a general model of heart failure. Until recently, little attention has been paid to the right ventricle (RV) and it has commonly been thought that the mechanical and biochemical properties of the RV are similar to those of the LV. However, therapies used to treat LV failure often fail to improve ventricular function in RV failure underscoring, the need to better understand the unique physiologic and pathophysiologic properties of the RV. Importantly, hemodynamic stresses (such as pressure overload) often underlie right heart failure further differentiating RV failure as unique from LV failure. There are significant structural, mechanical, and biochemical properties distinctive to the RV that influences its function and it is likely that adaptations of the RV occur uniquely across the lifespan. We have previously reviewed the adult RV compared to the LV but there is little known about differences in the pediatric or aged RV. Accordingly, in this mini-review, we will examine the subtle distinctions between the RV and LV that are maintained physiologically across the lifespan and will highlight significant knowledge gaps in our understanding of pediatric and aging RV. Consideration of how RV function is altered in different disease states in an age-specific manner may enable us to define RV function in health and importantly, in response to pathology.
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Affiliation(s)
- Kathleen C Woulfe
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Lori A Walker
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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Harbrücker M, Natale M, Kim SH, Müller J, Ansari U, Huseynov A, Zworowsky MV, Borggrefe M, Hoffmann U, Lang S, Fatar M, Roth T, Kittel M, Bertsch T, Akin I, Behnes M. Copeptin reliably reflects longitudinal right ventricular function. Ann Clin Biochem 2021; 58:270-279. [PMID: 33430599 DOI: 10.1177/0004563221989364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Data is limited evaluating novel biomarkers in right ventricular dysfunction. Normal right heart function improves the prognosis of patients with heart failure. Therefore, this study investigates the association between the novel biomarker copeptin and right heart function compared to NT-proBNP. METHODS Patients undergoing routine echocardiography were enrolled prospectively. Right ventricular function was assessed by tricuspid annular plane systolic excursion (TAPSE) and further right ventricular and atrial parameters. Exclusion criteria were age under 18 years, left ventricular ejection fraction < 50% and moderate to severe valvular heart disease. Blood samples were taken for biomarker measurements within 72 h of echocardiography. RESULTS Ninety-one patients were included. Median values of copeptin increased significantly according to decreasing values of TAPSE (P = 0.001; right heart function grade I: tricuspid annular plane systolic excursion; TAPSE > 24 mm: 5.20 pmol/L; grade II: TAPSE 18-24 mm: 8.10 pmol/L; grade III: TAPSE < 18 mm: 26.50 pmol/L). Copeptin concentrations were able to discriminate patients with decreased right heart function defined as TAPSE < 18 mm (area under the curves [AUC]: copeptin: 0.793; P = 0.001; NT-proBNP: 0.805; P = 0.0001). Within a multivariable linear regression model, copeptin was independently associated with TAPSE (copeptin: T: -4.43; P = 0.0001; NT-proBNP: T: -1.21; P = 0.23). Finally, copeptin concentrations were significantly associated with severely reduced right heart function (TAPSE < 18 mm) within a multivariate logistic regression model (copeptin: odds ratio: 0.94; 95% confidence interval: 0.911-0.975; P = 0.001). CONCLUSIONS This study demonstrates that the novel biomarker copeptin reflects longitudinal right heart function assessed by standardized transthoracic echocardiography compared with NT-proBNP.
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Affiliation(s)
- Melissa Harbrücker
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michèle Natale
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Seung-Hyun Kim
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Julian Müller
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Uzair Ansari
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Aydin Huseynov
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Max von Zworowsky
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Martin Borggrefe
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Ursula Hoffmann
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Siegfried Lang
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Marc Fatar
- Department of Neurology (M.F.), University Medical Centre Mannheim, Mannheim, Germany
| | - Thomas Roth
- Central Laboratory (T.R.), University Hospital Erlangen, Erlangen, Germany
| | - Maximilian Kittel
- Faculty of Medicine Mannheim, Institute of Clinical Chemistry and Laboratory Medicine (M.K.), University Medical Centre Mannheim (UMM), University of Heidelberg, Heidelberg, Germany
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine (T.B.), Nuremberg General Hospital, Paracelsus Medical University, Nuremberg, Germany
| | - Ibrahim Akin
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michael Behnes
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
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Riesenhuber M, Spannbauer A, Gwechenberger M, Pezawas T, Schukro C, Stix G, Schneider M, Goliasch G, Anvari A, Wrba T, Khazen C, Andreas M, Laufer G, Hengstenberg C, Gyongyosi M. Pacemaker lead-associated tricuspid regurgitation in patients with or without pre-existing right ventricular dilatation. Clin Res Cardiol 2021; 110:884-894. [PMID: 33566185 PMCID: PMC8166708 DOI: 10.1007/s00392-021-01812-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 01/28/2021] [Indexed: 01/19/2023]
Abstract
Background Transcatheter tricuspid valve intervention became an option for pacemaker lead-associated tricuspid regurgitation. This study investigated the progression of tricuspid regurgitation (TR) in patients with or without pre-existing right ventricular dilatation (RVD) undergoing pacemaker implantation. Methods Patients were included if they had implantation of transtricuspid pacemaker lead and completed echocardiography before and after implantation. The cohort was divided in patients with and without RVD (cut-off basal RV diameter ≥ 42 mm). TR was graded in none/mild, moderate, and severe. Worsening of one grade was defined as progression. Survival analyses were plotted for 10 years. Results In total, 990 patients were analyzed (24.5% with RVD). Progression of TR occurred in 46.1% of patients with RVD and in 25.6% of patients without RVD (P < 0.001). Predictors for TR progression were RV dilatation (OR 2.04; 95% CI 1.27–3.29; P = 0.003), pre-existing TR (OR 4.30; 95% CI 2.51–7.38; P < 0.001), female sex (OR 1.68; 95% CI 1.16–2.43; P = 0.006), single RV lead (OR 1.67; 95% CI 1.09–2.56; P = 0.018), mitral regurgitation (OR 2.08; 95% CI 1.42–3.05; P < 0.001), and enlarged left atrium (OR 1.98; 95% CI 1.07–3.67; P = 0.03). Survival-predictors were pacemaker lead-associated TR (HR 1.38; 95% CI 1.04–1.84; P = 0.028), mitral regurgitation (HR 1.34; 95% CI 1.02–1.77; P = 0.034), heart failure (HR 1.75; 95% CI 1.31–2.33; P < 0.001), kidney disease (HR 1.62; 95% CI 1.25–2.11; P < 0.001), and age ≥ 80 years (HR 2.84; 95% CI 2.17–3.71; P < 0.001). Conclusions Patients with RVD receiving pacemaker suffered from increased TR progression, leading to decreased survival. Graphic abstract ![]()
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Affiliation(s)
| | | | | | - Thomas Pezawas
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Christoph Schukro
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Günter Stix
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | | | - Georg Goliasch
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Anahit Anvari
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Thomas Wrba
- Medical University of Vienna, IT Systems and Communications, Vienna, Austria
| | - Cesar Khazen
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Günther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Mariann Gyongyosi
- Department of Cardiology, Medical University of Vienna, Vienna, Austria.
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
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22
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Sahin A, Kaya H, Avci O. Cancer antigen-125 is a predictor of mortality in patients with pulmonary arterial hypertension. Clin Biochem 2020; 89:58-62. [PMID: 33382999 DOI: 10.1016/j.clinbiochem.2020.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 12/06/2020] [Accepted: 12/22/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Carbohydrate antigen 125 (CA 125), known as a tumor marker for ovarian cancer, has been reported to increase and be associated with severity in heart failure and chronic obstructive pulmonary disease. Patients with pulmonary arterial hypertension may also die due to developing right heart failure. The aim of this study is to evaluate the prognostic role of CA-125 in PAH patients. METHODS A total of 40 consecutive patients with PAH were evaluated prospectively. The mean age of patients was 52 ± 11 years (12% males, 88% females) with a median follow-up period of 16 months. RESULTS After follow-up period, 12 out of 40 patients (30%) died. CA-125 levels were higher among those who died compared to those who survived [78.5 (11.0-292) vs. 27.5 (2.10-138) U/ml, p = 0.001]. The optimal cut-off value of CA-125 to predict mortality was found as 35.29 U/ml, with 85.7% specificity and 75% sensitivity. In multivariable Cox proportional-hazards model with forward stepwise method; CA-125 > 35.32 U/ml on admission (HR = 7.645, 95% CI: 1.356-43.121, p = 0.021), age (HR = 1.132, 95% CI: 1.040-1.233, p = 0.004), TAPSE (HR = 0.740, 95% CI: 0.549-0.998, p = 0.048) and uric acid (HR = 1.444, 95% CI: 1.022-2.042, p = 0.037) remained associated with an increased risk of death. CONCLUSION In this study, we showed for the first time that serum CA-125 values were an independent predictor for the long-term mortality in PAH patients.
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Affiliation(s)
- Anil Sahin
- Cardiology Department, University of Health Sciences Antalya Training and Research Hospital, Antalya, Turkey.
| | - Hakki Kaya
- Cardiology Department, Canakkale Onsekiz Mart University, Canakkale, Turkey.
| | - Onur Avci
- Anesthesiology and Reanimation Department, Sivas Cumhuriyet University, Sivas, Turkey.
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23
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Park J, Kwak JE, Cho YJ, Choi HJ, Choi H, Chae MS, Park CS, Choi JH, Hong SH. Therapeutic hypothermia after cardiac arrest during living-donor liver transplant surgery: A case report. Medicine (Baltimore) 2020; 99:e22513. [PMID: 33157915 PMCID: PMC7647609 DOI: 10.1097/md.0000000000022513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
RATIONALE Therapeutic hypothermia is an effective medical treatment for neurological recovery after cardiac arrest. Here, we describe a case of successful mild therapeutic hypothermia after cardiac arrest during living-donor liver transplantation. PATIENT CONCERNS A 54-year-old woman with alcoholic liver cirrhosis was admitted for living-donor liver transplantation. Cardiac arrest occurred during the anhepatic phase. After cardiopulmonary resuscitation, spontaneous circulation returned, but the bispectral index level remained below 10 until the end of surgery. DIAGNOSES Neurological injury caused by global cerebral hypoperfusion was suspected. INTERVENTIONS The patient was treated with mild therapeutic hypothermia for 24hours after resuscitation targeting a core body temperature of 34°C with surface cooling using ice bags. OUTCOMES The patient recovered consciousness about 22 hours after the event. However, she showed symptoms of delirium even when discharged. At the 3-month follow-up exam, she showed no specific neurological complications. The transplanted liver showed no problems with regeneration. LESSONS Mild therapeutic hypothermia may be safely adopted in cases of cardiac arrest in liver transplant patients and is beneficial for neurological recovery.
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Affiliation(s)
- Jaesik Park
- Department of Anesthesiology and Pain Medicine
| | - Ju Eun Kwak
- Department of Anesthesiology and Pain Medicine
| | | | - Ho Joong Choi
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hoon Choi
- Department of Anesthesiology and Pain Medicine
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Santens B, Van De Bruaene A, De Meester P, D'Alto M, Reddy S, Bernstein D, Koestenberger M, Hansmann G, Budts W. Diagnosis and treatment of right ventricular dysfunction in congenital heart disease. Cardiovasc Diagn Ther 2020; 10:1625-1645. [PMID: 33224777 DOI: 10.21037/cdt-20-370] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Right ventricular (RV) function is important for clinical status and outcomes in children and adults with congenital heart disease (CHD). In the normal RV, longitudinal systolic function is the major contributor to global RV systolic function. A variety of factors contribute to RV failure including increased pressure- or volume-loading, electromechanical dyssynchrony, increased myocardial fibrosis, abnormal coronary perfusion, restricted filling capacity and adverse interactions between left ventricle (LV) and RV. We discuss the different imaging techniques both at rest and during exercise to define and detect RV failure. We identify the most important biomarkers for risk stratification in RV dysfunction, including abnormal NYHA class, decreased exercise capacity, low blood pressure, and increased levels of NTproBNP, troponin T, galectin-3 and growth differentiation factor 15. In adults with CHD (ACHD), fragmented QRS is independently associated with heart failure (HF) symptoms and impaired ventricular function. Furthermore, we discuss the different HF therapies in CHD but given the broad clinical spectrum of CHD, it is important to treat RV failure in a disease-specific manner and based on the specific alterations in hemodynamics. Here, we discuss how to detect and treat RV dysfunction in CHD in order to prevent or postpone RV failure.
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Affiliation(s)
- Béatrice Santens
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Alexander Van De Bruaene
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Pieter De Meester
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Michele D'Alto
- Department of Cardiology, University "L. Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Sushma Reddy
- Department of Pediatrics (Cardiology), Stanford University, California, United States of America
| | - Daniel Bernstein
- Department of Pediatrics (Cardiology), Stanford University, California, United States of America
| | | | - Georg Hansmann
- Department of Pediatric Cardiology and Critical care, Hannover Medical School, Hannover, Germany
| | - Werner Budts
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
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Daly M, Long B, Koyfman A, Lentz S. Identifying cardiogenic shock in the emergency department. Am J Emerg Med 2020; 38:2425-2433. [PMID: 33039227 DOI: 10.1016/j.ajem.2020.09.045] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 09/16/2020] [Accepted: 09/17/2020] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Cardiogenic shock is difficult to diagnose due to diverse presentations, overlap with other shock states (i.e. sepsis), poorly understood pathophysiology, complex and multifactorial causes, and varied hemodynamic parameters. Despite advances in interventions, mortality in patients with cardiogenic shock remains high. Emergency clinicians must be ready to recognize and start appropriate therapy for cardiogenic shock early. OBJECTIVE This review will discuss the clinical evaluation and diagnosis of cardiogenic shock in the emergency department with a focus on the emergency clinician. DISCUSSION The most common cause of cardiogenic shock is a myocardial infarction, though many causes exist. It is classically diagnosed by invasive hemodynamic measures, but the diagnosis can be made in the emergency department by clinical evaluation, diagnostic studies, and ultrasound. Early recognition and stabilization improve morbidity and mortality. This review will focus on identification of cardiogenic shock through clinical examination, laboratory studies, and point-of-care ultrasound. CONCLUSIONS The emergency clinician should use the clinical examination, laboratory studies, electrocardiogram, and point-of-care ultrasound to aid in the identification of cardiogenic shock. Cardiogenic shock has the potential for significant morbidity and mortality if not recognized early.
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Affiliation(s)
- Madison Daly
- Division of Emergency Medicine, The University of Vermont Medical Center, United States of America
| | - Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, United States of America
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, United States of America
| | - Skyler Lentz
- Division of Emergency Medicine, Department of Surgery, The University of Vermont Larner College of Medicine, United States of America.
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26
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Decreased Expression of Canstatin in Rat Model of Monocrotaline-Induced Pulmonary Arterial Hypertension: Protective Effect of Canstatin on Right Ventricular Remodeling. Int J Mol Sci 2020; 21:ijms21186797. [PMID: 32947968 PMCID: PMC7554857 DOI: 10.3390/ijms21186797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 09/14/2020] [Accepted: 09/14/2020] [Indexed: 11/16/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a progressive disease which causes right ventricular (RV) failure. Canstatin, a C-terminal fragment of type IV collagen α2 chain, is expressed in various rat organs. However, the expression level of canstatin in plasma and organs during PAH is still unclear. We aimed to clarify it and further investigated the protective effects of canstatin in a rat model of monocrotaline-induced PAH. Cardiac functions were assessed by echocardiography. Expression levels of canstatin in plasma and organs were evaluated by enzyme-linked immunosorbent assay and Western blotting, respectively. PAH was evaluated by catheterization. RV remodeling was evaluated by histological analyses. Real-time polymerase chain reaction was performed to evaluate RV remodeling-related genes. The plasma concentration of canstatin in PAH rats was decreased, which was correlated with a reduction in acceleration time/ejection time ratio and an increase in RV weight/body weight ratio. The protein expression of canstatin in RV, lung and kidney was decreased in PAH rats. While recombinant canstatin had no effect on PAH, it significantly improved RV remodeling, including hypertrophy and fibrosis, and prevented the increase in RV remodeling-related genes. We demonstrated that plasma canstatin is decreased in PAH rats and that administration of canstatin exerts cardioprotective effects.
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27
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Schneider M, Ran H, Pistritto AM, Gerges C, Heidari H, Nitsche C, Gerges M, Hengstenberg C, Mascherbauer J, Binder T, Lang I, Goliasch G. Pulmonary artery to ascending aorta ratio by echocardiography: A strong predictor for presence and severity of pulmonary hypertension. PLoS One 2020; 15:e0235716. [PMID: 32628737 PMCID: PMC7337354 DOI: 10.1371/journal.pone.0235716] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 06/19/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The pulmonary artery (PA) to ascending aorta diameter ratio (PA:A) has been evaluated in numerous studies analyzing cardiac magnetic resonance (CMR) and computed tomography (CT) data. Previously, no transthoracic echocardiography (TTE) cutoffs have been published. We sought to evaluate (1) the feasibility to image the pulmonary trunk in a prospective cohort, and (2) the ability of PA:A derived by TTE to predict pulmonary hypertension (PH). METHODS We performed a post-hoc analysis of a prospectively recruited consecutive cohort of patients referred to our tertiary center cardiology department due to suspicion for PH. Invasive hemodynamic assessment and quasi-simultaneous TTE was performed in all participants. RESULTS A total of 84 patients were included in the analysis, median age was 70.5 years (IQR 58-75), 46 (55%) were female. The PA was significantly wider in the PH group (28mm vs. 22.5mm, p<0.001) with a resulting median PA:A of 0.84 vs. 0.66 (p<0.001). Both PA diameter (r = 0.524 and r = 0.44, both p<0.001) and PA:A (r = 0.652 and 0.697, both p<0.001) significantly correlated with mPAP and with PVR, respectively. Area under the curve for the detection of PH was 0.853 (95%CI 0.739-0.967, p<0.001). CONCLUSION The PA can be visualized in almost all echocardiographic exams, especially when it is dilated. A view showing the pulmonary trunk should be included in every routine TTE. An increased PA:A should raise suspicion for PH and prompt further evaluation and follow-up examinations of these patients.
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Affiliation(s)
- Matthias Schneider
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
- * E-mail:
| | - Hong Ran
- Department of Echocardiography, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | | | - Christian Gerges
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Houtan Heidari
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Christian Nitsche
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Mario Gerges
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | | | - Julia Mascherbauer
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Thomas Binder
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Irene Lang
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Georg Goliasch
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
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28
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Rozenbaum Z, Maret E, Lax L, Shmilovich H, Finkelstein A, Steinvil A, Halkin A, Banai S, Cohen D, Topilsky Y, Berliner S, Fleischmann D, Aviram G. Impact of right ventricular volumes on the outcomes of TAVR: a volumetric analysis of preprocedural computed tomography. EUROINTERVENTION 2020; 16:e121-e128. [PMID: 31566570 DOI: 10.4244/eij-d-19-00651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim of this study was to assess the prognostic implications of increased right ventricle volume index (RVVI) using cardiac-gated computed tomography angiography (CCTA) data among patients undergoing transcatheter valve replacement (TAVR). METHODS AND RESULTS CCTA of 323 patients who underwent TAVR at Stanford University Medical Center (CA, USA) and Tel Aviv Medical Center (Israel) between 2013 and 2016 was analysed by an automatic four-chamber volumetric software and grouped into quartiles according to RVVI. Higher one-year mortality rates were noted for the upper quartiles - 5%, 4.9%, 8.6%, and 16% (p=0.039), in Q1 <59 ml/m2, Q2 59-69 ml/m2, Q3 69-86 ml/m2, and Q4 >86 ml/m2, respectively. However, the differences were not significant after propensity score adjustments. Sub-analyses of Q1 demonstrated an escalating risk for one-year mortality in concordance to RVVI: HR 2.28, HR 2.76, and HR 4.7, for the upper 25th, 15th, and 5th percentiles, respectively (p<0.05 for all comparisons). After propensity score adjustments for clinical and echocardiographic characteristics, only the upper 5th percentiles (RVVI >120 ml/m2) retained statistical significance (HR 2.82, 95% CI: 1.02-7.78, p=0.045). Notably, 68.7% of patients from this group were considered low-intermediate risk for surgery. CONCLUSIONS Cardiac volumetric data by CCTA performed for procedural planning may help to predict outcome in patients undergoing TAVR.
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Affiliation(s)
- Zach Rozenbaum
- Department of Cardiology, Tel Aviv Medical affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Isreal
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Dannenberg V, Goliasch G, Hengstenberg C, Binder T, Gabriel H, Schneider M. Detection of atrial shunt lesions with a single echocardiographic parameter. Wien Klin Wochenschr 2020; 132:295-300. [PMID: 32356100 PMCID: PMC7297847 DOI: 10.1007/s00508-020-01659-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 04/07/2020] [Indexed: 11/25/2022]
Abstract
Background Unrepaired left to right atrial shunt lesions can cause significant right ventricular (RV) volume overload. The parameter pulmonary to systemic shunt volume ratio (Qp:Qs) has been shown to detect even small differences between left and right ventricular stroke volume; however, four parameters are needed for its calculation. This study was carried out to evaluate the accuracy of the single parameter right ventricular outflow tract (RVOT) velocity time integral (VTI) to identify atrial shunt lesions. Methods All patients who underwent transesophageal echocardiography (TEE) examination at this institution between 1 January 2013 and 1 January 2018 were retrospectively analyzed. The RVOT-VTI was measured in the transthoracic echocardiography performed immediately before each TEE. The diagnostic accuracy for detection of atrial shunt lesions was tested. Results A total of 2797 patients with a median age of 67 years (interquartile range, IQR 54–77 years) were included in the final analysis. A total of 113 (4%) patients had a relevant atrial shunt lesion. The mean RVOT-VTI of the shunt group was 25 cm (SD ± 8.1 cm) and was significantly higher than that of the non-shunt group with 17 cm (SD ± 4.8 cm) (p < 0.001). The area under the curve (AUC) was 0.81. A total of 106 patients (93.8%) of the shunt group had a VTI of ≥16 cm. If the RVOT-VTI was <16 cm, the negative predictive value was 99.3%. If the RVOT-VTI was ≥25 cm, 22% of patients proved to have a significant shunt lesion. Conclusion In this large retrospective analysis it could be shown that a low RVOT-VTI predicted the absence of significant atrial shunt lesions, while a high RVOT-VTI predicted the presence. The parameter should be applied in all patients with suspected atrial shunt lesions where calculation of Qp:Qs is impossible. Electronic supplementary material The online version of this article (10.1007/s00508-020-01659-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Varius Dannenberg
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Georg Goliasch
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Christian Hengstenberg
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Thomas Binder
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Harald Gabriel
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Matthias Schneider
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Right ventricular transverse displacement increases following cardiac surgery: possibly compensating loss in tricuspid annular plane systolic excursion (TAPSE). J Clin Monit Comput 2020; 34:1139-1148. [DOI: 10.1007/s10877-020-00466-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 01/21/2020] [Indexed: 12/22/2022]
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31
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Bindra BS, Patel Z, Patel N, Choudhary KV, Patel V. Cor Triatriatum Dexter as an Incidental Finding: Role of Two-Dimensional Transthoracic Echocardiography. Cureus 2019; 11:e5683. [PMID: 31720152 PMCID: PMC6823002 DOI: 10.7759/cureus.5683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Cor triatriatum dexter (CTD) is a rare congenital cardiac anomaly in which a membranous structure divides the right atrium (RA) into two chambers. Persistence of the right valve of the sinus venosus, which usually regresses as a part of normal embryological development, is responsible for membranous partition. There is a high incidence of right-sided congenital abnormalities of the heart associated with this condition. Clinical manifestations vary depending on the degree of partitioning or septation of the RA. We present a case of CTD discovered as an incidental finding during transthoracic echocardiography and further discuss the role of two-dimensional echocardiography as a noninvasive diagnostic tool.
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Affiliation(s)
- Bikramjit S Bindra
- Internal Medicine, Government Medical College and Hospital, Chandigarh, IND
| | - Zeel Patel
- Internal Medicine, Ahmedabad Municipal Corporation Medical Education Trust Medical College, Ahmedabad, IND
| | - Neel Patel
- Internal Medicine, Interfaith Medical Center, Brooklyn, USA
| | | | - Vinod Patel
- Cardiology, Mount Sinai Hospital, New-York City, USA
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