Reduced atrial contribution to left ventricular filling in patients with severe tricuspid regurgitation after tricuspid valvulectomy: a Doppler echocardiographic study

Impact of Diastolic Interventricular Septal Flattening on Clinical Outcome in Patients With Severe Tricuspid Regurgitation

Background

Little is known about the impact of diastolic interventricular septal flattening on the clinical outcome in patients with severe tricuspid regurgitation. This study sought to evaluate the association of diastolic interventricular septal flattening with clinical outcome in patients with severe tricuspid regurgitation.

Methods and Results

We retrospectively studied 407 patients who underwent 2‐dimensional transthoracic echocardiography and were diagnosed with severe tricuspid regurgitation between January 2014 and December 2015. Cardiovascular events were defined as cardiovascular death or admission for heart failure. The magnitude of interventricular septal flattening was calculated by the eccentricity index (EI) of the left ventricle, and hemodynamic parameters were obtained from transthoracic echocardiography. During follow‐up (median, 200 days; interquartile range, 35–1059), 117 of the patients experienced cardiovascular events. By multivariate analysis including potential covariates, EI at end‐diastole and left ventricular ejection fraction were independent predictors of cardiovascular events (hazard ratio, 5.33 [1.63–17.41]; hazard ratio, 0.98 [0.97–0.99], respectively). An EI of 1.2 at end‐diastole was the optimal cutoff value for identifying poor hemodynamic status defined as cardiac index ≤2.2 L/min per m² and right atrial pressure 15 mm Hg, both on transthoracic echocardiography. Patients with D‐shaped left ventricle defined as EI ≥1.2 at end‐diastole showed worse outcomes than those without (adjusted hazard ratio, 1.80 [1.18–2.74]).

Conclusions

Increasing EI at end‐diastole was strongly associated with worse outcomes in patients with severe tricuspid regurgitation. Furthermore, the presence of D‐shaped left ventricle defined as EI ≥1.2 at end‐diastole provides prognostic value for cardiovascular events.

The role of left atrial strain in patients with functional tricuspid regurgitation before and after annuloplasty: a long-term follow-up study

Background

Functional tricuspid regurgitation (TR) is common among patients with left heart disease and may recur during the follow-up period after selective tricuspid valve annuloplasty (TVA). This study aims to analyse the relationship between left atrial (LA) strain and the degree of preoperative functional TR and to explore the role of LA strain in predicting TR recurrence.

Methods

This study included 63 patients with rheumatic mitral stenosis who underwent mitral valve replacement and concomitant TVA. Additionally, 20 healthy controls were enrolled. Preoperative conventional LA echocardiographic parameters and LA strain were measured. The association between LA strain and preoperative functional TR severity was analysed by Pearson correlation. Predictors of recurrent TR were determined by multivariate logistic regression analyses.

Results

Compared with the control group, the mitral stenosis group developed a significant impairment in terms of LA strain. The degree of preoperative functional TR exhibited moderate correlations with LA reservoir strain (r = − 0.57) and LA conduit strain (r = 0.48). During a median follow-up period of 66.4 ± 36.4 months, TR recurred in 18 patients. Preoperative LA reservoir strain and the mean transmitral gradient were predictors of postoperative TR recurrence. When the two indexes were combined to establish a prediction, the sensitivity and specificity of prediction increased. The area under the receiver operating characteristic curve of the combined indicator was higher than those of the single indicators (0.90 vs. 0.70 and 0.72).

Conclusions

LA strain correlates with preoperative functional TR severity in patients with rheumatic mitral stenosis. The LA reservoir strain and preoperative mean transmitral gradient are independent predictive factors for recurrent TR after TVA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12947-021-00264-z.

Improvement of the Left Ventricular Function after Tricuspid Valve Plasty for Traumatic Tricuspid Regurgitation

Traumatic tricuspid regurgitation (TR) is a rare cardiovascular complication in chest trauma. Changes in the left ventricle (LV) function after operation are unclear. A 61-year-old woman who had been involved in a traffic accident 1 month earlier presented with exertional dyspnea. Transthoracic echocardiography (TTE) showed severe tricuspid regurgitation (TR) accompanied by LV dysfunction due to anterior leaflet prolapse with papillary muscle rupture. After tricuspid plasty, the LV function improved, as evidenced by TTE and speckle tracking echocardiography. In conclusion, the early diagnosis of traumatic TR is important, and early surgical intervention might be effective for achieving ventricular function improvement.

Pathophysiology and natural history of atrial septal defect

Atrial septal defects are among the third most common types of congenital heart disease. This group of malformations includes several types of atrial communications allowing shunting of blood between the systemic and the pulmonary circulations. The nature of shunting across the defect in patients with atrial septal defect is of particular interest. Understanding the underlying mechanisms of interatrial shunts and their natural history will help selecting the best timing for closure, before irreversible cardiac and pulmonary injury occur. This review describes the different pathophysiologic mechanisms involved in the direction and magnitude of blood flow through atrial septal defects. The natural history of an individual born with an isolated atrial septal defect is then discussed, including the impact of a longstanding shunt on survival.

Major adverse events and atrial tachycardia in Ebstein's anomaly predicted by cardiovascular magnetic resonance

Objectives

Patients with Ebstein’s anomaly of the tricuspid valve (EA) are at risk of tachyarrhythmia, congestive heart failure and sudden cardiac death. We sought to determine the value of cardiovascular magnetic resonance (CMR) for predicting these outcomes.

Methods

Seventy-nine consecutive adult patients (aged 37±15 years) with unrepaired EA underwent CMR and were followed prospectively for a median 3.4 (range 0.4–10.9) years for clinical outcomes, namely major adverse cardiovascular events (MACEs: sustained ventricular tachycardia/heart failure hospital admission/cardiac transplantation/death) and first-onset atrial tachyarrhythmia (AT).

Results

CMR-derived variables associated with MACE (n=6) were right ventricular (RV) or left ventricular (LV) ejection fraction (EF) (HR 2.06, 95% CI 1.168 to 3.623, p=0.012 and HR 2.35, 95% CI 1.348 to 4.082, p=0.003, respectively), LV stroke volume index (HR 2.82, 95% CI 1.212 to 7.092, p=0.028) and cardiac index (HR 1.71, 95% CI 1.002 to 1.366, p=0.037); all remained significant when tested solely for mortality. History of AT (HR 11.16, 95% CI 1.30 to 95.81, p=0.028) and New York Heart Association class >2 (HR 7.66, 95% CI 1.54 to 38.20, p=0.013) were also associated with MACE; AT preceded all but one MACE, suggesting its potential role as an early marker of adverse outcome (p=0.011).

CMR variables associated with first-onset AT (n=17; 21.5%) included RVEF (HR 1.55, 95% CI 1.103 to 2.160, p=0.011), total R/L volume index (HR 1.18, 95% CI 1.06 to 1.32, p=0.002), RV/LV end diastolic volume ratio (HR 1.55, 95% CI 1.14 to 2.10, p=0.005) and apical septal leaflet displacement/total LV septal length (HR 1.03, 95% CI 1.00 to 1.07, p=0.041); the latter two combined enhanced risk prediction (HR 6.12, 95% CI 1.67 to 22.56, p=0.007).

Conclusion

CMR-derived indices carry prognostic information regarding MACE and first-onset AT among adults with unrepaired EA. CMR may be included in the periodic surveillance of these patients.

The Impact of Sevoflurane on Coupling of the Left Ventricular-to-Systemic Vasculature in Rats With Chronic Pulmonary Hypertension

OBJECTIVES

The relationship between left ventricular function and afterload has not been investigated as much as the right ventricular function under chronic pulmonary hypertension (PH) during anesthesia. This study was designed to investigate effects of sevoflurane on the intrinsic coupling relationship between the left ventricle and systemic vasculature in the presence of PH.

DESIGN

A randomized, controlled study.

SETTING

University hospital.

PARTICIPANTS

Sprague-Dawley rats.

INTERVENTIONS

Monocrotaline (MCT) was injected intraperitoneally to induce a PH model.

MEASUREMENTS AND MAIN RESULTS

Four weeks later, rats with MCT injection demonstrated significantly increased pulmonary arterial pressure and right/left ventricular systolic ratio of ventricular pressure (p < 0.001). Rats were treated with 1.5% sevoflurane inhalation. The PV catheters were inserted and left ventricular pressure-volume loops were measured at baseline, 30, 60, and 90 minutes during sevoflurane treatment. Preload recruitable stroke work and end-systolic elastance were decreased markedly in rats with MCT injection (p < 0.05). However, arterial elastance decreased similarly in both groups. Sarcoplasmic reticulum Ca²⁺-ATPase (SERCA2a) level was decreased and the expression of phospholamban (PLB) was increased in the PH group and after sevoflurane treatment. PH rats suffered further SERCA2/PLB ratio decrease from their already low baseline. The left ventricular contractility and ventricular-vascular coupling were decreased in rats with PH after sevoflurane inhalation.

CONCLUSIONS

Sevoflurane reduced SERCA2a expression and increased PLB expression in PH rats. This partially could explain why the LV contractility and ventricular-to-vasculature coupling of PH rats were attenuated after sevoflurane treatment.

A geometric index to differentiate abnormal from normal septal wall motion on cardiac MRI

BACKGROUND

The definition of abnormal septal wall motion (SWM) is usually performed on a subjective visual assessment with cardiac MR (CMR).

PURPOSE

To quantify SWM using a geometric index and to compare this index to the visual inspection in patients with or without abnormal SWM.

MATERIAL AND METHODS

Cine CMR images of 100 consecutive patients were retrospectively assessed for visual evaluation of SWM and calculation of a convexity septal index (CSI) on mid-ventricular short-axis images, defined as b/a (a = minimal distance from anterior to posterior ventricular junctions; b = maximal distance from septum to a), obtained in end-systole (ES) and end-diastole (ED). Cohen κ, Bland-Altman method, Kruskall-Wallis, Mann-Whitney U, Jonckheere-Terpstra, and Spearman statistics were used to compare the two methods.

RESULTS

At visual evaluation, 73 patients had normal SWM (group A), nine abnormal SWM at ES (group B), and 18 at ES and ED (group C). Median CSI for group A was significantly higher (ES = 0.23, ED = 0.25) than those for group B and C (0.10-0.15) (P < 0.001). Inter-reader reproducibility of visual evaluation was high (κ = 0.841, P < 0.001) while that for CSI was 77%. Average time for visual analysis was 3 min, for quantitative analysis 4 min.

CONCLUSION

CSI is a simple and reproducible way to quantify SWM. ED CSI seems to be sensitive in detecting abnormal SWM in patients with apparently normal SWM at visual evaluation.

Vena contracta width as a predictor of adverse outcomes in patients with severe isolated tricuspid regurgitation

BACKGROUND

The clinical outcomes and predictors of outcomes in isolated tricuspid regurgitation (TR) are poorly defined. The aim of this study was to investigate the determinants of outcomes in severe isolated TR.

METHODS

Seventy-four patients (mean age, 63 ± 12 years; 34 men) with severe isolated TR who satisfied the criteria of (1) TR jet area > 30% of right atrial area or TR jet area > 10 cm(2) and (2) a plethora of inferior vena cava or systolic flow reversal of the hepatic vein were retrospectively analyzed. The primary end points were hospitalization for worsening heart failure, tricuspid valve (TV) surgery, and cardiovascular death.

RESULTS

During the median follow-up period of 53 months, 25 events occurred (three cardiovascular deaths, nine TV surgeries, and 13 hospitalizations for worsening heart failure). Univariate Cox analysis showed that younger age, female gender, larger effective regurgitant orifice, vena contracta width (VCW), and increased right atrial and right ventricular size were associated with cardiovascular events. Increased TV tethering distance and tethering area were also associated with cardiovascular events. In multivariate Cox regression analysis, larger VCW (hazard ratio, 1.72; 95% confidence interval, 1.15-2.57, P < 0.01) was an independent predictor of cardiovascular events. Compared with patients with VCW ≤ 7 mm, those with VCW > 7 mm had poorer long-term outcomes (adjusted hazard ratio, 19.9; P < .01). Increased VCW was also an independent predictor of cardiovascular death and TV surgery (hazard ratio, 1.2; 95% confidence interval, 1.00-1.45; P = .04).

CONCLUSIONS

In severe isolated TR, VCW is a powerful independent predictor of adverse outcomes. Adverse outcomes were considerable for VCW > 7 mm, which suggests that quantification of TR by Doppler echocardiography is crucial for estimating prognosis. TV surgery might be considered for patients with severe isolated TR with VCW > 7 mm.

Right ventricular remodeling determines tricuspid valve geometry and the severity of functional tricuspid regurgitation: a real-time 3-dimensional echocardiography study

Background and Objectives

Right ventricle (RV) remodeling can determine tricuspid valve (TV) geometry and the severity of functional tricuspid regurgitation (TR).

Subjects and Methods

In 53 patients with various degrees of functional TR and in sinus rhythm, RV and TV geometries were analyzed using real-time 3-dimensional echocardiography, including tenting angles of 3 leaflets, septal-lateral and antero-posterior tricuspid annulus diameters and inlet RV dimensions, mid-RV septal-lateral dimension, and the distance between annulus and apex. A mid-systole frame when the TV tenting is smallest was selected for the analysis. RV end-diastolic and end-systolic volumes were measured. The severity of functional TR was determined by distal jet area.

Results

TR distal jet area was mainly determined by septal-lateral annulus diameter (p<0.001) RV inlet dimension (p=0.015), RV end-systolic volume (p=0.010), septal (p=0.019), and anterior leaflet tenting angles (p=0.045) by multiple stepwise linear regression analysis. Leaflet tenting angles were mainly determined by septal-lateral RV inlet dimension. Septal-lateral annulus diameter was determined by septal-lateral RV inlet dimension (p<0.001) and mid RV dimension (p=0.033), whereas antero-posterior annulus diameter was determined by antero-posterior RV inlet dimension (p<0.001).

Conclusion

Functional TR severity is determined by septal-lateral annulus and RV dilation, and tenting of septal and anterior leaflets. TV leaflet tenting is mainly determined by septal-lateral RV inlet dilation, and tricuspid annulus dilation is closely linked with inlet RV dilation.

Pulmonary regurgitation is a powerful factor influencing QRS duration in patients after surgical repair of tetralogy of Fallot

AIMS

QRS prolongation is a negative prognostic factor for the development of ventricular arrhythmia after repair of tetralogy of Fallot (TOF). In this MRI study, we performed a multivariate analysis to determine the influence of volumetric and functional parameters as well as time factors on QRS duration.

METHODS AND RESULTS

Sixty-seven patients after surgical repair of TOF were studied using a 1.5T MRI. Measurement of the ventricles was performed with a multislice-multiphase sequence. Left and right ventricular volumes, ejection fractions (EF) and myocardial masses were determined. Pulmonary regurgitant fraction (PRF) was quantified by velocity encoded flow measurement in the main pulmonary artery. Maximum QRS duration was taken from a 12-channel ECG. Mean maximum QRS duration was 132 ms (+/- 29 ms). Mean PRF was 29.2% (+/- 13.4%). QRS duration correlated significantly with PRF (r = 0.49; p < 0.01; n = 54) and with right ventricular enddiastolic volume index (RVEDVI) (r = 0.29; p < 0.05; n = 67). Multivariate analysis revealed that the combination of PRF, postoperative period, age at surgical repair, and left ventricular (LV) enddiastolic volume are correlated with QRS prolongation.

CONCLUSION

In patients after repair of TOF, pulmonary regurgitation is related to QRS prolongation. Furthermore, even LV size plays a role in the enlargement of the QRS complex.

Evidence of adverse ventricular interdependence in patients with atrial septal defects

Right ventricular (RV) volume overload is associated with left ventricular (LV) distortion and dysfunction. The availability of transcatheter device closure of secundum atrial septal defect (ASD) provides an ideal model for investigating the immediate effects of elimination of RV volume overload and avoiding the confounding effects of surgery on LV function. Echocardiograms before and after device closure of ASD were analyzed for ejection fraction, percent changes in cross-sectional area and circumference, percent changes in free wall and septal endocardial lengths, and eccentricity. We enrolled 34 patients (median age 9 years) who underwent device closure of ASD (pulmonary to systemic shunt 1.6 +/- 0.4). Ejection fraction and LV end-diastolic volume, reflective of chamber preload, were significantly decreased in the presence of RV volume overload and normalized after defect closure with normalization of LV shape. Altered LV geometry secondary to RV volume overload was associated with regional variation in preload,such that diastolic circumference, a surrogate of myofiber preload, increased after closure of ASD secondary to a small increase in LV free wall arc length in conjunction with a much more significant increase in septal length. Thus, LV dysfunction associated with RV volume overload is secondary to altered chamber geometry and decreased myofiber preload. This physiology is immediately reversible and is independent of heart rate and afterload.

Total right ventricular exclusion improves left ventricular function in patients with end-stage congestive right ventricular failure

BACKGROUND

We developed a total right ventricular (RV) exclusion procedure for the treatment of isolated congestive RV failure. The objective of the present study was to elucidate the effects of a complete removal of RV volume overload (RVVO) on the surgically created single left ventricle (LV).

METHODS AND RESULTS

Three adults (2 arrhythmogenic RV dysplasia, 1 Ebstein) and 5 children (all Ebstein) in NYHA class IV underwent the procedure. The RV free wall was resected from the heart, and the tricuspid orifice was closed. Pulmonary blood supply was obtained by a cavopulmonary connection in 6 patients and a systemic-pulmonary shunt in 2. The LV function was evaluated by 2-dimensional echocardiography 1 month after the surgery. All patients are alive. The paradoxical movement of the interventricular septum and geometry of the LV expressed by its eccentricity (2.1 to 1.2, P<0.01) were normalized after the operation in all 8 patients. LV end-diastolic volumes (59% to 109% of normal value, P<0.01), indexed maximal left atrial area (6.5 to 10.5 cm2/m2, P<0.01), LV ejection fraction (27% to 62%, P<0.01), and cardiac index (2.1 to 3.3 L/min/m2, P<0.05) all significantly increased.

CONCLUSIONS

Removal of the RVVO by means of the total RV exclusion procedure provides effective volume loading, restores a cylindrical shape, and improves contractile function of the LV, thus leading to increased systemic output.

Clinical significance of tricuspid valve dysfunction after orthotopic heart transplantation

OBJECTIVES

Tricuspid regurgitation (TR) is common after heart transplantation (OHT), but its clinical relevance is undetermined. This study documents the clinical progress of patients with TR after OHT in relation to the severity of TR.

METHODS

We studied 238 transplant recipients who had survived for at least 12 months after OHT. Tricuspid regurgitation was graded clinically and by assessing regurgitant jet area. Recipients were divided into those with no TR Group 1 (n = 64), those with sub-clinical TR (TR absent clinically and regurgitant jet area <25%, Group 2 (n = 89), and those with clinical TR (with clinical TR or regurgitant jet area > or =25%, Group 3 (n = 85).

RESULTS

We found no significant difference among the groups in terms of age, or pre-operative events. At 12 months after OHT, mean right atrial and pulmonary artery pressures were higher in Group 3 than in Group 1 or Group 2 (p = 0.005 and 0.03, respectively). Right ventricular end-diastolic and end-systolic volumes were smaller for recipients in Groups 1 and 2 compared with those in Group 3 (p = 0.01 and 0.02). The annual development of renal impairment was 0.019 (95% confidence interval [CI], 0.014-0.029), 0.026 (95% CI, 0.022-0.62), and 0.613 (95% CI, 0.346-0.756) in Groups 1, 2, and 3, respectively (p = 0.02). At the most recent follow-up, mean New York Heart Association class for Group 1 was 1.4, for Group 2 was 1.7, and for Group 3 was 2.7 (p = 0.04).

CONCLUSIONS

The integrity of the tricuspid valve has a significant impact on long-term clinical progress of OHT recipients. Recipients with significant TR are more symptomatic and have poorer right-sided heart function compared with those with mild or no TR.

Total right ventricular exclusion procedure: an operation for isolated congestive right ventricular failure

OBJECTIVE

To prevent possible deleterious effects of right ventricular volume overload on cardiorespiratory function, we developed a total right ventricular exclusion procedure for the treatment of end-stage isolated congestive right ventricular failure.

METHODS

Since 1996, this procedure has been performed in 5 patients in New York Heart Association functional class IV: 2 adults with arrhythmogenic right ventricular dysplasia and 3 children with Ebstein anomaly. The entire right ventricular free wall was resected along the atrioventricular groove and then parallel to the interventricular septum, sparing the pulmonary valve and a skeletonized right coronary artery. The orifice of the tricuspid valve was closed with either a polytetrafluoroethylene patch or with its leaflets. The defect of the right ventricular free wall was covered with a polytetrafluoroethylene patch in the 2 patients with arrhythmogenic right ventricular dysplasia and directly closed with the remnant of the free wall in the 3 children with Ebstein anomaly. After resection of a redundant right atrial wall, coronary sinus blood flow was rerouted into the left atrium through an atrial septal defect. A total cavopulmonary connection was constructed in 4 patients and a bidirectional superior cavopulmonary anastomosis in 1 infant. The heart was controlled with a DDD pacemaker in 3 patients.

RESULTS

The patients were extubated at a mean of 14 hours postoperatively (range, 1-38 hours). There were no early or late deaths. At follow-up, ranging from 8 to 57 months, the mean cardiothoracic ratio had decreased from 74% +/- 7% before the operation to 52% +/- 6% (P <.01). All patients are in functional class I. Neither of the patients with arrhythmogenic right ventricular dysplasia have had attacks of ventricular tachycardia nor are they using antiarrhythmic medication.

CONCLUSIONS

The total right ventricular exclusion procedure provides effective decompression of the lung, as well as the left ventricle, and may result in more effective volume loading of a surgically created single ventricle with increased systemic output. We believe that this new surgical option offers rescue treatment for isolated end-stage right ventricular failure in critically ill patients.

Left ventricular function in adults with mild pulmonary insufficiency late after Fallot repair

OBJECTIVE

To assess left ventricular function in adult Fallot patients with residual pulmonary regurgitation.

SETTING

The radiology department of a tertiary referral centre.

PATIENTS

14 patients with chronic pulmonary regurgitation and right ventricular volume overload after repair of tetralogy of Fallot and 10 healthy subjects were studied using magnetic resonance imaging.

MAIN OUTCOME MEASURES

Biventricular volumes, global biventricular function, and regional left ventricular function were assessed in all subjects.

RESULTS

The amount of pulmonary regurgitation in patients (mean (SD)) was 25 (18)% of forward flow and correlated significantly with right ventricular enlargement (p < 0.05). Left ventricular end diastolic volume was decreased in patients (78 (11) v 88 (10) ml/m(2); p < 0.05), ejection fraction was not significantly altered (59 (5)% v 55 (7)%; NS). No significant correlation was found between pulmonary regurgitation and left ventricular function. Overall left ventricular end diastolic wall thickness was significantly lower in patients (5.06 (0.72) v 6.06 (1.06) mm; p < 0. 05), predominantly in the free wall. At the apical level, left ventricular systolic wall thickening was 20% higher in Fallot patients (p < 0.05). Left ventricular shape was normal.

CONCLUSIONS

Adult Fallot patients with mild chronic pulmonary regurgitation and subsequent right ventricular enlargement showed a normal left ventricular shape and global function. Although the left ventricular free wall had reduced wall thickness, compensatory hypercontractility of the apex may contribute to preserved global function.

Asymmetry of right ventricular enlargement in response to tricuspid regurgitation

BACKGROUND

Analysis of right ventricular adaptation to tricuspid regurgitation was studied in 10 heart transplant recipients following inadvertent endomyocardial biopsy disruption of the tricuspid apparatus.

METHODS AND RESULTS

Echocardiography demonstrated progressive diastolic right ventricular cavity enlargement (19.5+/-5.0 to 30.3+/-5.4 cm(2), P<0.0002), with disproportionate elongation along the midminor axis (3.5+/-0.6 to 5. 0+/-0.5 cm, P<0.001). As the right ventricle remodeled to more spherical (and less elliptical) proportions, the end-diastolic right ventricular midminor axis/long axis ratio increased significantly from 0.52+/-0.10 to 0.68+/-0.07, P<0.005.

CONCLUSIONS

Ventricular enlargement due to right ventricular volume overload results in disproportionate dilation along the free wall to septum minor axis.

Echocardiographic evaluation of left ventricular diastolic function in chronic cor pulmonale

In this study we hoped to understand the abnormalities of left ventricular filling dynamics in chronic cor pulmonale. Our findings showed a severe left ventricular diastolic impairment, directly related to a progressive increase in pulmonary hypertension itself, as expressed by correlation analysis between systolic pulmonary artery pressure and the following parameters: transmitral flow velocity in early/late diastole ratio (r = -0.69, p <0.001), isovolumic relaxation time (r = 0.54, p = 0.001), and transmitral flow velocity in early diastole (r = -0.59, p <0.01).

Estimation of left ventricular function in right ventricular volume and pressure overload. Detection of early left ventricular dysfunction by Tei index

Although the effects of right ventricular (RV) volume and pressure overload (RVVO and RVPO) on ventricular septal motion are different, the differential effect on left ventricular (LV) function is still controversial. The Doppler-derived index (Tei index) combining systolic and diastolic ventricular function, defined as the sum of isovolumetric contraction time (ICT) and isovolumetric relaxation time (IRT) divided by ejection time (ET), has been demonstrated to be a useful index to estimate LV function and to predict the prognosis of patients with congestive heart failure. This study was designed to evaluate the differential effects of RVVO and RVPO on LV function using the Tei index. Study patients consisted of 26 age-matched normal subjects, 22 patients with atrial septal defect (ASD) with normal or borderline RV pressure and 25 with primary pulmonary hypertension (PPH). All subjects had normal LV ejection fractions measured with 2-dimensional echocardiogram using biplane Simpson's method (61 +/- 4 vs 61 +/- 4 vs 63 +/- 8%, normal vs ASD vs PPH). Tei index was easily obtained in all subjects from transthoracic Doppler echocardiogram of LV inflow and outflow. Patients with ASD had normal ICT, IRT and ET, resulting in normal Tei index, however, patients with PPH had significantly prolonged ICT and IRT with shortened ET, resulting in a significant increase in Tei index (0.38 +/- 0.04 vs 0.36 +/- 0.03 vs 0.61 +/- 0.22, p < 0.001). Although RVVO due to ASD has no significant effects on LV function, RVPO due to PPH can adversely affect LV function. The Tei index is a simple and sensitive measure to assess LV function caused by RVVO or RVPO.

Tricuspid valve disease. Clinical evaluation, physiopathology, and management

The tricuspid and mitral valves are homologous whose function depends on coordination among components. Isolated tricuspid valve abnormalities are relatively uncommon. Rheumatic disease, chemicals, immunologic and degenerative disorders alter leaflet anatomy and may result in either stenosis, insufficiency or a combination. More often, tricuspid disorders present as a component of congenital syndromes or secondary to pulmonary vascular or let heart disease which alter geometry and function of nonleaflet components.

Ventricular interdependence: significant left ventricular contributions to right ventricular systolic function

This article reviews diastolic and systolic ventricular interaction, and clinical pathophysiological conditions involving ventricular interaction. Diastolic ventricular interdependence is present on a moment-to-moment, beat-to-beat basis, and the interactions are large enough to be of physiological and pathophysiological importance. Although always present, ventricular interdependence is most apparent with sudden postural and respiratory changes in ventricular volume. Left ventricular function significantly affects right ventricular systolic function. Experimental studies have shown that about 20% to 40% of the right ventricular systolic pressure and volume outflow result from left ventricular contraction. This dependency of the right ventricle on the left ventricle helps to explain the right ventricular response to volume overload, pressure overload, and myocardial ischemia. The septum and its position are not the sole mechanism for ventricular interdependence. Ventricular interdependence causes overall ventricular deformation, and is probably best explained by the balance of forces at the interventricular sulcus, the material properties, and cardiac dimensions.

Issues in surgical treatment of endocarditis including intraoperative and postoperative management

Patients with infective endocarditis who require surgical intervention can be divided into four separate groups, in order of incidence: (1) patients with underlying acquired or congenital cardiac lesions or valvar abnormalities, (2) patients with preexisting prosthetic valves, (3) patients with nosocomial infections who are immunosuppressed, and (4) older patients with infection risk or patients with indwelling deep venous catheters. The surgical management for these individual groups and for specific valve lesions is discussed, along with illustrative case studies.

Echo-Doppler evaluation of left ventricular impairment in chronic cor pulmonale

The effects of acute right ventricular (RV) pressure and volume overloads on left ventricular (LV) filling are well known, while the significance of chronic RV pressure overload on LV function has been less studied. To evaluate the LV impairment, 30 patients with chronic cor pulmonale and pulmonary arterial hypertension secondary to chronic obstructive lung diseases (COLDs) were studied. All patients underwent respiratory tests and arterial blood gas assessment. An echo-Doppler examination was made to measure LV ejection fraction (EF), RV and LV end-diastolic and end-systolic diameters and areas, RV/LV area indexes, LV diastolic and systolic eccentricity indexes, mitral and tricuspid flow patterns, and mitral flow velocity in late and early diastole (A/E) indexes. A right heart catheterization was carried out to determine the resting mean pulmonary arterial pressure (mPAP). The data showed a marked enlargement of RV, compressing the left through a leftward shift of interventricular septum. A linear regression analysis detected a significant correlation between mPAP and the following parameters: RV/LV diastolic and systolic area indexes (r=0.75, p<0.0001; r=0.84, p<0.000, respectively), mitral A/E index (r=0.61, p<0.0005), and LV diastolic and systolic eccentricity indexes (r=0.93, p<0.0001; and r=0.83, p<0.0001). No correlations were found between echo-Doppler data and functional respiratory parameters. From these results, we conclude that chronic RV pressure overload induces LV filling impairment despite a normal systolic phase, due to septal leftward shift. In fact, chronic RV pressure overload distorts early diastolic LV geometry delaying LV filling phase, and the functional diastolic impairment of the LV is closely correlated to pulmonary hypertension levels.

Value of proximal regurgitant jet size in tricuspid regurgitation

Recent studies have shown good agreement between proximal regurgitant jet size obtained with transthoracic color flow mapping and regurgitant fraction in patients with mitral regurgitation. To evaluate this in patients with tricuspid regurgitation, we analyzed 40 patients in sinus rhythm, 16 with free jets and 24 with impinging jets, comparing proximal jet size (millimeters) with parameters derived from the Doppler two-dimensional echocardiographic method (regurgitant fraction) and the flow-convergence method (peak flow rate, effective regurgitant orifice area, and momentum). Good agreement was noted between peak flow rate (r = 0.80, p < 0.001), momentum (r = 0.80, p < 0.001), and effective regurgitant orifice area (r = 0.78, p < 0.001), with proximal jet size measured in the apical four-chamber view in patients with free jets. The average of jet proximal size in three planes also had good correlation with peak flow rate (r = 0.75, p < 0.001), regurgitant fraction, momentum, and effective regurgitant orifice area (r = 0.74, p < 0.001). In patients with impinging jets, agreement was fair between effective regurgitant orifice (r = 0.65, p < 0.001), peak flow rate (0.65, p < 0.001), and momentum (r = 0.62, p < 0.001) with mean jet proximal size. Jet proximal size obtained with transthoracic color flow mapping is a good semiquantitative tool for measuring tricuspid regurgitation in free jets that correlates well with established measures of the severity and with new parameters available from analysis of the proximal acceleration field. In patients with eccentrically directed wall jets, the correlation weakens but still appears clinically significant.

Pressure and volume loading of the right ventricle have opposite effects on left ventricular ejection fraction

BACKGROUND

Left ventricular ejection fraction has been reported to be depressed in patients with right ventricular volume overload (RVVO) due to Ebstein's anomaly and uncomplicated atrial septal defect, whereas it is usually preserved in right ventricular pressure overload (RVPO) due to congenital pulmonic stenosis. In the present study, we examined the hypothesis that the differential timing of active displacement of the ventricular septum into the left ventricle in RVPO (end systole) and RVVO (end diastole) results in opposite effects of RVPO and RVVO on left ventricular ejection fraction.

METHODS AND RESULTS

Ten patients with severe tricuspid regurgitation after tricuspid valve resection for endocarditis and 10 patients with primary pulmonary hypertension were studied as models of isolated RVVO and RVPO, respectively. Left ventricular ejection fraction, end-diastolic volume, and regional systolic shortening were measured with the use of echocardiographic techniques in these 20 patients and 10 healthy control subjects. In RVPO, despite marked underfilling of the left ventricle relative to the healthy control subjects (end-diastolic volume, 48 +/- 26 versus 77 +/- 20 mL; P < .02), left ventricular ejection fraction was similar to that of the control subjects (56 +/- 5% versus 60 +/- 4%; P = .07) and only 1 of 10 RVPO patients had an ejection fraction of less than 50%. In contrast, in RVVO the left ventricle was volume replete (end-diastolic volume, 84 +/- 26 versus 77 +/- 20 mL; P = NS), but left ventricular ejection fraction was significantly depressed (51 +/- 4% versus 60 +/- 4%, P < .001) compared with the control subjects, and 4 of 10 RVVO patients had an ejection fraction of less than 50%. Analysis of systolic fractional shortening along two perpendicular short-axis diameters and the mutually orthogonal long axis demonstrated isolated augmentation of fractional shortening in the ventricular septal-to-posterolateral free wall dimension in RVPO (47.4 +/- 13.7% versus 34.2 +/- 13.1%, P < .05) and isolated depression of fractional shortening along that same dimension in RVVO (13.7 +/- 11.8% versus 34.2 +/- 13.1%, P < .001) compared with the control subjects.

CONCLUSIONS

End-systolic leftward ventricular septal shift in RVPO results in isolated augmentation of systolic shortening in the septal-to-free wall dimension, whereas end-diastolic leftward ventricular septal shift in RVVO results in isolated reduction in systolic shortening in the septal-to-free wall dimension. As a result, despite relative underfilling of the left ventricle in RVPO, resting left ventricular ejection fraction is preserved, whereas ejection fraction is depressed for the volume-replete left ventricle of patients with RVVO.

Effect of acute pericardial tamponade on the relative contributions of systolic and diastolic pulmonary venous return: a transesophageal pulsed Doppler study

The effect of acute pericardial tamponade on pulmonary venous return was assessed by transesophageal pulsed Doppler echocardiography. In 14 open-chest anesthetized dogs peak pulmonary venous flow velocities in systole (VJ) and in diastole (VK) were measured during apnea and atrial pacing while acute tamponade was induced by intrapericardial instillation of 0.9% sodium chloride solution. Before intravascular volume expansion, induction of acute tamponade resulted in a significant decline in VK (43 +/- 17 to 19 +/- 8 cm/sec; p < 0.05) but no change in VJ or the ratio VJ/VK. After intravascular volume expansion, induction of acute tamponade resulted in significant reductions in VJ (43 +/- 9 to 29 +/- 10 cm/sec; p < 0.001) and VK (37 +/- 19 to 15 +/- 11 cm/sec; p < 0.001). The effect was disproportionately greater on VK, however, resulting in a significant increase in VJ/VK (1.51 +/- 0.84 to 2.58 +/- 1.41; p < 0.001). The disproportionate effect of acute tamponade on VK suggests that increased pericardial pressure directly constrains diastolic filling of the left atrium as a conduit to the left ventricle and that it does not decrease the systolic and diastolic phases of pulmonary venous return uniformly. Intravascular volume expansion increases cardiac output before acute tamponade, but during acute tamponade it amplifies the disproportionate impact of increased pericardial pressure on left ventricular diastolic filling as the left ventricle is constrained within the fluid-filled pericardial sac.

Which physical factors determine tricuspid regurgitation jet area in the clinical setting?

The visual assessment of jet area has become the most common method used in daily clinic practice to evaluate valvular regurgitation. Despite the high prevalence of tricuspid regurgitation, however, few studies have systematically compared TR jet areas with a quantitative standard. To evaluate this, 40 patients in sinus rhythm with tricuspid regurgitation were analyzed: 16 with centrally directed free jets and 24 with impinging wall jets. The size of the maximal planimetered color jet area (cm2) was compared with parameters derived using the pulsed Doppler 2-dimensional echocardiographic method: regurgitant fraction and the flow convergence method (peak flow rate, effective regurgitant orifice area and momentum). Mean tricuspid regurgitant fraction averaged 33 +/- 15%, peak flow rate 76 +/- 54 cm3/s, effective regurgitant orifice area 27 +/- 21 mm2 and momentum 21,717 +/- 15,014 cm4/s2. An average of 4-chamber, and long- and short-axis areas in free jets correlated well with regurgitant fraction (r = 0.81, p < 0.001), better with peak flow rate (r = 0.94, p < 0.001), effective regurgitant orifice (r = 0.92, p < 0.001) and momentum (r = 0.94, p < 0.001). The correlation was worse, but still significant, in wall jets. For the same peak flow rate, wall jets were 75% of the size of a corresponding free jet. Jet area measurement is a good semiquantitative tool to measure tricuspid regurgitation in free jets, which correlates well with regurgitant fraction and better with new parameters available from analysis of the proximal acceleration field. In patients with eccentrically directed wall jets the correlation with planimetered jet area was worse, but still significant.

Noninvasive assessment of left internal mammary artery graft patency using duplex Doppler echocardiography from supraclavicular fossa

OBJECTIVES

The purpose of this study was to clarify the usefulness of duplex Doppler echocardiography from the supraclavicular fossa for assessment of left internal mammary artery graft patency.

BACKGROUND

A noninvasive method to assess coronary artery bypass graft patency would be useful for clinical diagnosis and long-term follow-up of graft outcome.

METHODS

Duplex Doppler echocardiography from the supraclavicular fossa was performed in 56 consecutive patients who underwent postoperative cardiac catheterization studies, including quantitative angiography. All patients underwent coronary artery bypass graft surgery using the left internal mammary artery graft to the left anterior descending coronary artery.

RESULTS

The left internal mammary artery graft and its flow were detected in 55 (98%) of the 56 patients with duplex Doppler echocardiography from the supraclavicular fossa. According to the quantitative angiographic data, the patients were assigned to three groups: group A (36 patients) with a normal left internal mammary artery graft (< 50% diameter stenosis), group B (9 patients) with intermediate (50% to 75% diameter) graft stenosis and group C (10 patients) with severe (> 75% diameter) graft stenosis. The diastolic/systolic peak velocity ratio was smaller in group C than in groups A and B (p < 0.05), but there was no significant difference between groups A and B. A diastolic/systolic peak velocity ratio < 0.6 predicted severe left internal mammary artery graft stenosis (> 75% diameter stenosis) with a sensitivity and specificity of 100% and 80%, respectively. The diastolic fraction of time-velocity integral was smaller in group C than in groups A and B (p < 0.05), but there was no significant difference between groups A and B. A diastolic fraction < 0.5 predicted significant left internal mammary artery graft stenosis (> 75% diameter stenosis) with a sensitivity and specificity of 90% and 100%, respectively.

CONCLUSIONS

Duplex Doppler echocardiography from the supraclavicular fossa is useful for noninvasive assessment of left internal mammary artery graft patency.

Noninvasive measurement of left internal mammary artery bypass graft flow by duplex Doppler echocardiography from the supraclavicular fossa

To test the ability of duplex Doppler echocardiography from the supraclavicular fossa in detecting the left internal mammary artery (LIMA) graft flow and to verify the flow velocity measurement with this method, we studied 12 consecutive patients who underwent coronary artery bypass graft surgery with the LIMA graft. Duplex Doppler echocardiography detected the LIMA graft flow in 11 (92%) of the 12 patients. In these patients, simultaneous supraclavicular duplex Doppler and Doppler catheter measurements of the LIMA graft flow were performed. There were significant correlations in systolic peak velocity (r = 0.84, p < 0.01) and diastolic peak velocity (r = 0.79, p < 0.01) between the supraclavicular and Doppler catheter methods. There were also significant correlations in the diastolic to systolic peak flow velocity ratio (r = 0.86, p < 0.01) and diastolic fraction (r = 0.90, p < 0.01) between the supraclavicular and Doppler catheter methods. Thus, duplex Doppler echocardiography from the supraclavicular fossa is useful in the detection of the LIMA graft flow and permits accurate noninvasive measurement of the LIMA graft flow.

Doppler echocardiographic demonstration of the differential effects of right ventricular pressure and volume overload on left ventricular geometry and filling

To compare the effects of isolated right ventricular pressure and volume overload on left ventricular diastolic geometry and filling, 11 patients with primary pulmonary hypertension, 11 patients with severe tricuspid regurgitation due to tricuspid valve resection and 11 normal subjects were studied with use of Doppler echocardiographic techniques. Right ventricular systolic overload in primary pulmonary hypertension resulted in substantial leftward ventricular septal shift that was most marked at end-systole and early diastole and decreased substantially by end-diastole. Right ventricular diastolic overload after tricuspid valve resection resulted in maximal leftward ventricular septal shift at end-diastole sparing end-systole and early diastole. The early diastolic distortion of left ventricular geometry associated with right ventricular pressure overload resulted in prolongation of isovolumetric relaxation of the left ventricle (129 +/- 39 ms) and a reduction in early diastolic filling compared with values in normal subjects. Late diastolic distortion of left ventricular geometry associated with right ventricular volume overload had no influence on the duration of left ventricular isovolumetric relaxation (52 +/- 32 ms) but caused a reduction in the atrial systolic contribution to late diastolic filling of the left ventricle compared with values in normal subjects. In patients with right ventricular pressure overload, 52 +/- 16% of left ventricular filling occurred in early diastole compared with 78 +/- 11% in patients with right ventricular volume overload (p less than 0.001). The differential effects of systolic and diastolic right ventricular overload on the pattern of left ventricular filling appear to be related to the timing of leftward ventricular septal displacement.

Alterations in transesophageal pulsed Doppler indexes of filling of the left ventricle after pericardiotomy

The impact of pericardial constraint on patterns of left ventricular filling was measured by transesophageal pulsed Doppler echocardiography in 30 patients undergoing elective nonvalvular cardiac surgery. Peak early left ventricular filling velocity increased from 0.52 +/- 0.11 to 0.56 +/- 0.15 m/s (p less than 0.05) and early left ventricular filling fraction increased from 60 +/- 9% to 65 +/- 9% (p less than 0.005) after pericardiotomy. The study group was retrospectively subdivided into two groups based on the prepericardiotomy mean right atrial pressure, an index of intrapericardial pressure and hence pericardial constraint. In 13 patients with a mean right atrial pressure less than 6 mm Hg, no significant changes in early left ventricular filling were evident after pericardiotomy. In 17 patients with a mean right atrial pressure greater than or equal to 6 mm Hg indicative of a greater degree of pericardial constraint before pericardiotomy, significant increases in peak early filling velocity (0.52 +/- 0.13 to 0.57 +/- 0.19 m/s, p less than 0.05), peak early filling rate (4.29 +/- 0.67 to 4.66 +/- 0.86 stroke volumes/s, p less than 0.05) and early left ventricular filling fraction (57 +/- 7% to 63 +/- 8%, p less than 0.001) were measured after pericardiotomy. Thus, the pericardium does constrain early left ventricular filling and its effects are more pronounced in patients with an elevated right atrial pressure.