Evaluation of right ventricular dysfunction in patients with cardiac amyloidosis using tei index

The Relationship Between Global Left Ventricular Function, as Indicated by the Tei Index, and Long-Term Survival in Patients With Non-Ischemic, Dilated Cardiomyopathy

AIM

Idiopathic dilated cardiomyopathy (DCM) is one of the leading causes of low ejection fraction (EF) heart failure (HF). The Tei index is a reliable marker that reflects both left ventricular (LV) systolic and diastolic function, and it has prognostic value in patients with DCM. We aimed to investigate the relationship between the Tei index and long-term survival in non-ischemic, DCM patients.

MATERIAL AND METHODS

The present study included 98 patients with non-ischemic DCM. The mean survival time of the patients was 59 mos.

RESULTS

The Tei index was prominently higher in patients who died (0.64±0.08 vs 0.71±0.12, respectively; p=0.01). LV end-systolic volume and LV ejection fraction (LVEF) were independent prognostic factors and predicted worse long-term survival. Additionally, the patients with LVEF ≥32.7 % and the Tei index ≤0.76 had significantly longer survival.

CONCLUSION

The present study showed that the Tei index was significantly associated with mortality and the patients with both low LVEF (≤32.7 %) and high Tei index (≥0.76) values had a shorter life expectancy. As a result, we suggest that the Tei index may be a useful echocardiographic marker to predict long-term survival in DCM patients.

Early Impairment of Right Ventricular Morphology and Function in Transthyretin-Related Cardiac Amyloidosis

Background:

Our study aimed to evaluate right ventricular (RV) morphology and strain (S) in the early stage of familial transthyretin (TTR) cardiac amyloidosis (CA).

Methods and Results:

Thirty-seven patients with transthyretin mutation underwent ^99mTc-3,3-diphosphono-1,2 propanodicarboxylic acid (^99mTc-DPD) scans and/or cardiac magnetic resonance (CMR) to identify TTR CA. Each patient underwent echocardiography to quantify RV dimensions, tricuspid annular plane systolic excursion (TAPSE), systolic pulmonary artery pressure (sPAP), longitudinal (L) strain of the RV free wall, left ventricular (LV) septal thickness (ST), ejection fraction, E/E', LV global (G) L, radial (R), and circumferential (C) S. ^99mTc-DPD and CMR revealed the accumulation in 22 of 37 patients (CA group) and no accumulation in 15 patients (no-CA group). Left ventricular (LV) septal thickness (ST) was higher (P < 0.0001) while LV ejection fraction and E/E' were lower (P < 0.05) in the CA group than the no-CA group. LV-global longitudinal strain (LS) was lower (P < 0.0001) in the CA-group than the no CA-group, whereas LV-global circumferential strain and LV-global radial strain were similar. The CA group showed higher values of RV dimensions (P < 0.05) and sPAP (0.02) and a lower (P = 0.002) TAPSE. Globally, RV-LS was lower (P = 0.005) in the CA group than the no-CA group. Basal and mid segments of the RV free wall showed a lower LS in the CA group than the no-CA group (P < 0.01), while apical S was similar between groups.

Conclusions:

RV deformation, particularly in basal and mid segments, is early impaired in CA.

The prognostic value of Tei index in acute myocardial infarction: a systematic review

Background

Echocardiographic evaluation of left ventricular ejection fraction (LVEF) is used in the risk stratification of patients with an acute myocardial infarction (AMI). However, the prognostic value of the Tei index, an alternative measure of global cardiac function, in AMI patients is not well established.

Methods

We conducted a systematic review, using MEDLINE and EMBASE, to evaluate the prognostic value of the Tei index in predicting adverse outcomes in patients presenting with AMI. The data was collected and narratively synthesised.

Results

A total of 16 studies were including in this review with 2886 participants (mean age was 60 years from 14 studies, the proportion of male patients 69.8% from 14 studies). Patient follow-up duration ranged from during the AMI hospitalisation stay to 57.8 months. Tei index showed a significant association with heart failure episodes, reinfarction, death and left ventricular thrombus formation in 14 out of the 16 studies. However, in one of these studies, Tei index was only significantly predictive of cardiac events in patients where LVEF was <40%. In two further studies, Tei index was not associated with predicting adverse outcomes once LVEF, left ventricular end-systolic volume index and left ventricular early filling time was taken into consideration. In the two remaining studies, there was no prognostic value of Tei index in relation to patient outcomes.

Conclusions

Tei index may be an important prognostic marker in AMI patients, however, more studies are needed to better understand when it should be used routinely within clinical practice.

Effects of Familial Mediterranean Fever on Cardiac Functions in Adults: A Cross-Sectional Study Based on Speckle Tracking Echocardiography

Objectives

This study aims to evaluate the right ventricular (RV) and left ventricular (LV) systolic and diastolic functions with speckle tracking echocardiography in addition to routine echocardiographic measurements in adult familial Mediterranean fever (FMF) patients in order to detect cardiac functions.

Patients and methods

Sixty FMF patients (23 males, 37 females; median age 35 years; interquartile range, 26 to 38 years) and 20 healthy subjects (10 males, 10 females; median age 31 years; interquartile range, 25 to 35 years) were included in the study. The diagnosis was established according to the Tel-Hashomer criteria. All patients were using regular colchicine and they were in the attack-free period. Laboratory examinations included complete blood count, creatinine, and inflammatory markers. In addition to routine echocardiographic examination, RV and LV global longitudinal strains were measured and compared.

Results

Erythrocyte sedimentation rate and C-reactive protein values were higher in FMF group. LV global longitudinal strain was similar among the groups. FMF patients had slightly lower early diastolic trans-mitral flow (E) values than controls. As similar as the mitral E flow, tricuspid E flow was slightly lower in FMF groups than controls. RV ejection fraction was similar and in normal ranges among the groups. RV global longitudinal strain was lower in FMF group than controls. RV Myocardial Performance Index (or Tei index) was higher in FMF group.

Conclusion

The present study indicates low values of mean RV global longitudinal strain and higher Tei index in FMF patients. These results suggest that FMF may cause subclinical RV deterioration.

Right Ventricular Dysfunction Due to Right Ventricular Outflow Tract Patch

Doppler tissue imaging analysis was used to examine the relationship between right ventricular function and right ventricular outflow tract damage in 54 patients with repaired tetralogy of Fallot. The patients were divided into three groups: 16 in whom the right ventricular outflow tract was directly sutured (group DS), 23 who had transventricular patch repair (group TVP), and 15 who had transannular patch repair (group TAP). The control group consisted of 16 age-matched patients who underwent patch closure of a ventricular septal defect (group C). The Tei index was obtained from tricuspid and pulmonary Doppler flow velocities. The right ventricular Tei index was significantly greater in groups TVP and TAP than in group DS. Doppler tissue imaging analysis in groups TVP and TAP showed shorter myocardial systolic velocity, diastolic peak velocity, and atrial diastolic peak velocity, lower peak myocardial velocity and acceleration during isovolumic contraction, and prolonged isovolumic relaxation and contraction times compared to groups DS and C. Right ventricular dysfunction is due to the right ventricular outflow tract patch. Thus, the right ventricular outflow tract may be essential for right ventricular ejection and maintenance of right ventricular function.

Imaging the heart in pulmonary hypertension: an update

Noninvasive imaging of the heart plays an important role in the diagnosis and management of pulmonary hypertension (PH), and several well-established techniques are available for assessing performance of the right ventricle, the key determinant of patient survival. While right heart catheterisation is mandatory for establishing a diagnosis of PH, echocardiography is the most important screening tool for early detection of PH. Cardiac magnetic resonance imaging (CMRI) is also a reliable and practical tool that can be used as part of the diagnostic work-up. Echocardiography can measure a range of haemodynamic and anatomical variables (e.g. pericardial effusion and pulmonary artery pressure), whereas CMRI provides complementary information to echocardiography via high-resolution, three-dimensional imaging. Together with echocardiography and CMRI, techniques such as high-resolution computed tomography and positron emission tomography may also be valuable for screening, monitoring and follow-up assessments of patients with PH, but their clinical relevance has yet to be established. Technological advances have produced new variants of echocardiography, CMRI and positron emission tomography, and these permit closer examination of myocardial architecture, motion and deformation. Integrating these new tools into clinical practice in the future may lead to more precise noninvasive determination of diagnosis, risk and prognosis for PH.

Three-dimensional Speckle Tracking Echocardiography in Light Chain Cardiac Amyloidosis: Examination of Left and Right Ventricular Myocardial Mechanics Parameters

INTRODUCTION AND OBJECTIVES

The study of myocardial mechanics has a potential role in the detection of cardiac involvement in patients with amyloidosis. This study aimed to characterize 3-dimensional-speckle tracking echocardiography-derived left and right ventricular myocardial mechanics in light chain amyloidosis and examine their relationship with brain natriuretic peptide.

METHODS

In patients with light chain amyloidosis, left ventricular longitudinal and circumferential strain (n=40), and right ventricular longitudinal strain and radial displacement (n=26) were obtained by 3-dimensional-speckle tracking echocardiography. Brain natriuretic peptide levels were determined.

RESULTS

All myocardial mechanics measurements showed differences when compared by brain natriuretic peptide level tertiles. Left and right ventricular longitudinal strain were highly correlated (r=0.95, P<.001). Left ventricular longitudinal and circumferential strain were reduced in patients with cardiac involvement (-9±4 vs -16±2; P<.001, and -24±6 vs -29±4; P=.01, respectively), with the most prominent impairment at the basal segments. Right ventricular longitudinal strain and radial displacement were diminished in patients with cardiac involvement (-9±3 vs -17±3; P<.001, and 2.7±0.8 vs 3.8±0.3; P=.002). On multivariate analysis, left ventricular longitudinal strain was associated with the presence of cardiac involvement (odds ratio = 1.6; 95% confidence interval, 1.04 to 2.37; P=.03) independent of the presence of brain natriuretic peptide and troponin I criteria for cardiac amyloidosis.

CONCLUSIONS

Three-dimensional-speckle tracking echocardiography-derived left and right ventricular myocardial mechanics are increasingly altered as brain natriuretic peptide increases in light chain amyloidosis. There appears to be a strong association between left ventricular longitudinal strain and cardiac involvement, beyond biomarkers such as brain natriuretic peptide and troponin I.

Biohumoral markers as predictor of right ventricular dysfunction in AL Amyloidosis

AIM

In AL amyloidosis, the importance of right ventricle (RV) involvement has recently been underlined and its role in predicting prognosis has been emphasized. Little is known about the relationship between RV involvement, N-terminal pro-brain natriuretic peptide (NT-proBNP) and troponin levels. Aim of our study was to clarify the relationship between NT-proBNP and troponin and RV involvement and analyze their independent value as predictors of RV dysfunction.

METHODS AND RESULTS

We examined 76 consecutive patients with biopsy-proven AL amyloidosis. Each patient received complete clinical evaluation, troponin I, NT-proBNP assay and comprehensive echocardiographic evaluation. Considering a tricuspidal annulus plane systolic excursion (TAPSE) value <16 mm, 23 patients (30%) presented RV systolic dysfunction, whereas 53 (70%) did not. Patient with reduced TAPSE had thicker left ventricle (LV) walls and RV free walls, reduced LV fractional shortening, impaired LV diastolic function and worse LV and RV myocardial performance index. For RV dysfunction the best predictive value for NT-proBNP was identified as 2977 ng/l with sensitivity and specificity of 87% and 84%, respectively; best cut-off for troponin I was identified as 0.085 ng/l, with sensitivity and specificity of 85% and 90% respectively. At multivariable logistic regression analysis, both NT-proBNP and troponin I emerged as independent predictors of RV dysfunction presence but troponin appears to have a higher predictive power.

CONCLUSION

Our study demonstrated that cut-off values of 2977 ng/ml for NT-proBNP and 0.085 ng/l for troponin were able to identify a subgroup of AL patients with RV dysfunction. Troponin I is more accurate and seems to be the best biohumoral marker of RV dysfunction.

Right ventricular echocardiographic predictors of postoperative supraventricular arrhythmias after thoracic surgery: a pilot study

BACKGROUND

We used echocardiographically derived myocardial performance index (MPI) to assess changes in global right ventricular function with lung isolation. We hypothesized that changes in MPI with lung isolation may be related to the incidence of postoperative supraventricular tachycardia (SVT).

METHODS

Transesophageal echocardiographic examinations were performed after induction of general anesthesia in patients undergoing elective lung resections. Doppler tissue imaging was used to calculate MPI at baseline and 10 minutes after institution of one-lung ventilation (OLV). Arrhythmias occurring within the first 5 postoperative days were recorded.

RESULTS

Fifty-nine patients completed the study. Nineteen of 59 patients with a normal baseline MPI (<0.40) had a higher incidence of SVT as compared with patients with an abnormal baseline MPI (42% versus 10%; p = 0.012). The MPI worsened during OLV in 46 patients; a worsening of MPI with lung isolation that was normal at baseline was associated with higher incidence of SVT (57% versus 0%; p = 0.045) compared with a worsening of MPI in patients with an abnormal baseline MPI (13% versus 6%; p = 0.62). A normal baseline MPI value that worsened after OLV, left atrial dilation, and advanced age were identified as predictors of postoperative SVT.

CONCLUSIONS

Lung isolation is associated with acute changes in global right ventricular function. A normal baseline MPI that worsens after lung isolation is a better predictor of postoperative SVT as compared with baseline abnormal MPI that does not worsen after lung isolation. Myocardial performance index has a potential to be used as a right ventricular stress test to tolerate OLV before thoracic surgery.

Left ventricular global systolic dysfunction has a significant role in the development of diastolic heart failure in patients with systemic hypertension

Regional left ventricular (LV) systolic dysfunction has been identified in diastolic heart failure (DHF). However, the relationship between regional or global LV systolic function and heart failure symptoms in DHF has not been evaluated in detail. The present study evaluates such relationships in patients with systemic hypertension (HT) and DHF. We assessed LV systolic and diastolic function in 220 consecutive patients with systemic HT and in 30 normal individuals (Control) using Doppler echocardiography. Patients with HT were assigned to groups with DHF, asymptomatic diastolic dysfunction (ADD) and no diastolic dysfunction (Simple HT). Ejection fraction in DHF was significantly decreased (63±8%) compared with the Control, Simple HT and ADD groups (67±5, 66±7 and 68±8%, respectively). Isovolumetric contraction time in DHF (70±30 msec) was significantly increased compared with those in the ADD, Simple HT and Control groups (31±17, 31±15 and 30±19 msec, respectively). Mitral annular systolic velocities were significantly decreased in the DHF and ADD groups (6.4±1.5 and 7.2±1.3 cm sec⁻¹, respectively) compared with those in the Simple HT and Control groups (8.5±1.8 and 8.4±3.0 cm sec⁻¹, respectively), and in the DHF group compared with the ADD group. LV global systolic dysfunction has a significant role in the development of heart failure symptoms associated with DHF in patients with systemic HT.

Brain natriuretic peptide as a biomarker of systemic right ventricular function in patients with transposition of great arteries after atrial switch operation

BACKGROUND

Assessment of systemic right ventricular (RV) function is inherently difficult. In adults, plasma brain natriuretic peptide (BNP) level has been shown to reflect systemic ventricular dysfunction. We sought to test the hypothesis that plasma BNP is a biomarker of systemic RV function in patients after atrial switch operation.

METHODS

We determined the RV function in 44 patients, 35 after Senning and 9 after Mustard operation, aged 19.7+/-4.0 years, by tissue Doppler echocardiography and determination of myocardial performance index (MPI). The results were compared to the left ventricular function of 14 age-matched controls. Their plasma BNP levels were correlated with indices of systemic ventricular function.

RESULTS

Compared with controls, the patients had greater MPI (p<0.001), lower systemic ventricular free wall-annular early diastolic (p<0.001), late diastolic (p<0.001), and systolic velocities (p=0.001), lower septal-annular early diastolic (p<0.001), late diastolic (p<0.001), and systolic velocities (p<0.001), and higher BNP levels (p=0.03). Plasma BNP levels correlated positively with MPI (r=0.43, p=0.001) and negatively with the free wall- and septal-annular myocardial velocities (r=-0.32 to -0.47, p<0.05). The area under the receiver operating characteristic curve for BNP to detect ventricular dysfunction (MPI >0.45) in patients was 0.67 (p=0.04). A BNP level of 36 pg/ml had a sensitivity of 55%, specificity of 86%, positive predictive value 80%, negative predictive value of 64%, and an accuracy of 70% for detecting systemic ventricular dysfunction.

CONCLUSIONS

Plasma BNP has modest accuracy in the detection of systemic RV dysfunction in patients after atrial switch operation.

Exercise capacity and biventricular function in adult patients with repaired tetralogy of Fallot

BACKGROUND

Adult patients with repaired tetralogy of Fallot (rTOF) often have diminished exercise capacity. The primary objective of this study was to examine whether abnormalities of biventricular function play a role in exercise limitation in patients with rTOF.

METHODS

This was a retrospective review of 99 adult patients with rTOF. Right ventricular (RV) and left ventricular (LV) function were assessed echocardiographically using the myocardial performance index (MPI). Maximal oxygen consumption (VO(2) Max) was measured during a level 1 cardiopulmonary exercise test.

RESULTS

The mean age of the cohort was 34 +/- 11 years (50% females). Although most of the patients reported good functional capacity, the peak Vo(2)max was decreased at 22 +/- 6 mL/kg per minute (66% +/- 13% predicted Vo(2)max for age and sex). The mean RV and LV MPI were 0.30 +/- 0.07 and 0.42 +/- 0.09, respectively. In the multivariate model, higher RV MPI (P = .04) and LV MPI (P = .005) values, representing impaired ventricular function, were associated with diminished Vo(2)max. There was a significant correlation between the RV and LV MPI (r = 0.54, P = .001).

CONCLUSIONS

Impairment of RV and LV function, as measured by MPI, is associated with diminished exercise capacity in patients with repaired tetralogy of Fallot. Furthermore, there is a linear relationship between the RV and LV function suggesting that ventricular interactions are contributing to the limited exercise capacity in this group of patients. Strategies aimed at preserving biventricular function or improving adverse ventricular interactions could help to improve functional capacity in these patients.

Effect of nasal continuous positive airway pressure in men on global left ventricular myocardial performance in patients with obstructive sleep apnea syndrome

The influence of obstructive sleep apnea syndrome (OSAS) on left ventricular function remains controversial. We examined the influence of OSAS on global left ventricular function using the myocardial performance index (Tei index) and plasma brain natriuretic peptide (BNP) level and investigated the effect of nasal continuous positive airway pressure (nCPAP) on these parameters. We obtained echocardiographic indexes including the Tei index and BNP concentrations from 27 patients with OSAS whose mean apnea-hypopnea index was 42.2+/-21.5 events/hour and who were undergoing nCPAP and from 22 control subjects. We defined global left ventricular dysfunction (GLVD) as a Tei index >or=0.50 and high BNP as >or=20 pg/ml. Compared with controls, the Tei index of patients with OSAS was significantly increased (p <0.01) and prevalence of GLVD was high (19%, p<0.05). The correlation between the Tei index and apnea-hypopnea index was significant (r=0.447, p<0.05). Although BNP levels were higher in patients with OSAS than in controls, the difference did not reach significance. BNP level was high in 37% of patients with OSAS and in only 9% of controls (p<0.05). The Tei index of patients with OSAS was significantly decreased after 1 month and 3 months of nCPAP (p<0.01), and prevalence of GLVD significantly decreased from 19% to 4% (p<0.05). In contrast, BNP significantly decreased at 3 months after nCPAP (p<0.05). In conclusion, patients with moderate to severe OSAS frequently have impaired global left ventricular myocardial performance, which can be reversed at the early stage after starting nCPAP.

Right ventricular dysfunction in hypertrophic cardiomyopathy as evidenced by the myocardial performance index

BACKGROUND

Left ventricular function in hypertrophic cardiomyopathy (HCM) has been extensively studied, whereas right ventricular function is much less explored. The myocardial performance index (MPI) has been shown to be useful in functional assessment of both ventricles. Furthermore, right ventricular MPI was found to be of predictive value in heart failure due to dilated cardiomyopathy and ischemic heart disease. The aim of this study was, therefore, to evaluate the right ventricular MPI in patients with HCM.

METHODS

Fifty patients with HCM and 250 healthy controls were studied by conventional Doppler echocardiography and Doppler tissue imaging.

RESULTS

Patients showed increased global, 0.48 (0.15) vs. 0.21 (0.14), and regional, 0.71 (0.23) vs. 0.55 (0.17), right ventricular MPI, as compared to controls, p<0.001. Tricuspid annular plane systolic excursion and peak myocardial systolic velocities were also reduced. Patients with dyspnoea had increased global right ventricular MPI (0.53 vs. 0.36, p<0.05) as compared to those without dyspnoea.

CONCLUSION

In the present study, patients with HCM showed evidence of both global and regional right ventricular dysfunction. Previous studies of the right ventricle in HCM have only shown evidence of diastolic dysfunction, contrary to our results, showing impairment of both systolic and diastolic function. This study suggests that HCM should not only be regarded as an isolated disease of the left ventricle, but rather as a biventricular disease. The predictive value of our findings in HCM needs to be assessed in a separate study with special reference to those with and without dyspnoea.

Importance of the echocardiographic evaluation of right ventricular function in patients with AL amyloidosis

BACKGROUND

Patients with AL amyloidosis often present with signs of congestive heart failure.

AIM

This study was prospectively designed to assess the significance of RV dysfunction in AL amyloidosis.

METHODS AND RESULTS

Seventy-four patients with biopsy proven AL amyloidosis underwent a thorough echocardiographic evaluation. A tricuspid annular plane systolic excursion (TAPSE)<17 mm was taken as marker of RV dysfunction. Plasma NT-proBNP determinations were performed in all cases. RV function was normal in 60 patients and reduced in 14 patients. Patients with RV dysfunction had thicker left ventricular (LV) walls (p<0.01), lower LV end-diastolic volumes (p<0.01), lower LV ejection fraction (p<0.01) and more frequently a restrictive LV filling pattern (p<0.01). RV dimensions and RV free wall thickness were not significantly different in the two groups. A thick interventricular septum and a reduced TAPSE were associated with high NT-proBNP levels (both p<0.01). Seven patients died during a median follow-up period of 19 months; TAPSE<17 mm was the only echocardiographic parameter associated with poor survival.

CONCLUSION

In patients with AL amyloidosis, RV dysfunction is associated with more severe involvement of the left ventricle, higher plasma levels of NT-proBNP and with poor prognosis.

Evaluation of right ventricular Tei index (index of myocardial performance) in healthy dogs and dogs with tricuspid regurgitation

Right ventricular (RV) Tei index (index of myocardial performance) has been demonstrated to be clinically useful in estimating RV function in various human cardiac diseases. The purposes of this study were to validate the correlation between RV Tei index and RV function obtained by cardiac catheterization in healthy dogs, and to evaluate the RV Tei index in dogs with tricuspid regurgitation (TR). In healthy dogs, the RV Tei index significantly correlated with the RV peak +dP/dt (r=-0.80, p<0.0001) and -dP/dt (r=0.69, p=0.0001). In normal dogs, the RV Tei index was not significantly correlated with heart rate, body weight, and age. The RV Tei index significantly increased in dogs with moderate to severe TR (0.39 +/- 0.35, p=0.0015), filariasis (0.46 +/- 0.16, p=0.0131), and trivial to mild TR and severe mitral regurgitation (MR; 0.61 +/- 0.14, p=0.0017) when compared with the normal dogs (0.17 +/- 0.10). In addition, the RV Tei index in dogs with TR significantly increased in association with pulmonary hypertension [PH(-), 0.19 +/- 0.09; PH(+), 0.65 +/- 0.14; respectively p<0.0001]. Our study has demonstrated that RV Tei index is a feasible approach to estimate RV function in dogs and is not influenced by heart rate, body weight, and aging. Further investigations are required to clarify the clinical significance of RV Tei index in dogs with right-sided cardiac diseases.

Right ventricular dysfunction and adverse outcome in patients with advanced heart failure

BACKGROUND

In patients with heart failure (HF) from left ventricular systolic dysfunction, the presence of coexistent right ventricular (RV) dysfunction is associated with poor exercise capacity and reduced survival. We sought to determine whether a simple measure of RV function, the RV myocardial performance index (RV MPI), is associated with adverse outcome in a population of advanced heart failure patients selected to receive cardiac resynchronization therapy (CRT).

METHODS AND RESULTS

The RV MPI was measured on 77 consecutive preimplantation echocardiograms. The relationship between RV MPI and the end point of all-cause mortality, transplantation, or ventricular assist device placement was evaluated. The end point occurred in 28 patients (36%) during a median follow-up of 21 months. The median RV MPI was 0.73 (interquartile range 0.51-0.89). Worse RV function, as demonstrated by a higher RV MPI, was seen in those patients who reached the end point compared with those who did not (0.83 vs. 0.69, P = .004). The highest tercile of RV MPI was associated with a 3.3-fold increased risk of poor outcome (95% CI 1.3-8.5). Each 0.1 unit increase in RV MPI was associated with a 16% increased risk (95% CI 8-26). After adjusting for other echocardiographic variables, RV MPI remained significantly associated with the outcome.

CONCLUSION

In a population of advanced HF patients selected to receive CRT, RV dysfunction, as assessed by the RV MPI, is associated with adverse outcome. Wider use of this simple nongeometric parameter may help to identify patients for whom options for further intervention should be carefully evaluated.

Prognostic importance of various echocardiographic right ventricular functional parameters in patients with symptomatic heart failure

Little is known about the prognostic importance of right ventricular (RV) systolic and diastolic function. The purpose of this study was to determine the prognostic power of systolic and diastolic RV functional parameters derived from Doppler tissue imaging of tricuspid annular motion and to assess whether their combination might improve the risk stratification of patients with heart failure. In all, 140 patients with symptomatic heart failure and left ventricular ejection fraction of 40% or less underwent standard echocardiography, Doppler tissue imaging of tricuspid annular motion, and right heart catheterization. They were followed up for a mean period of 17 months for cardiac-related death and nonfatal cardiac events including the implantation of cardioverter-defibrillator and hospitalization for heart failure decompensation. A total of 48 cardiac events occurred; 19 patients died, 26 were hospitalized for heart failure decompensation, and 3 because of the need for implantation of a cardioverter-defibrillator. The peak tricuspid annular velocity during systolic ejection of 10.8 cm/s or less, peak early diastolic tricuspid annular velocity of 8.9 cm/s or less, tricuspid annular acceleration during isovolumic contraction of 2.52 m/s 2 or less, and Doppler RV index (Tei index) of 1.20 or more were found to significantly worsen survival or event-free survival. However, their combination significantly exceeded the predictive potential of individual parameters. The worst survival was predicted by the combination of peak tricuspid annular velocity during systolic ejection of 10.8 cm/s or less plus peak early diastolic tricuspid annular velocity of 8.9 cm/s or less plus tricuspid annular acceleration during isovolumic contraction of 2.52 m/s 2 or less (relative risk 6.17, P < .001), whereas the worst event-free survival was identified by the combination of peak tricuspid annular velocity during systolic ejection of 10.8 cm/s or less plus peak early diastolic tricuspid annular velocity of 8.9 cm/s or less plus Doppler RV index (Tei index) of 1.20 or more (relative risk 3.62, P < .001). In conclusion, the combination of RV systolic and diastolic functional parameters represents a very powerful tool for risk stratification of patients with symptomatic heart failure.

Improvements in cardiac form and function after transcatheter closure of secundum atrial septal defects

OBJECTIVES

We set out to study the effect of transcatheter closure of atrial septal defect (ASD) on right ventricular (RV) and left ventricular (LV) function assessed by myocardial performance index (MPI), as well as left atrial (LA) volumes.

BACKGROUND

The hemodynamic response to the closure of ASD is well-documented in surgically treated patients. However, few studies have documented echocardiographic evaluation of ventricular function in patients undergoing transcatheter closure of ASDs.

METHODS

Pre- and post-ASD device closure echocardiograms of 25 consecutive patients were retrospectively reviewed. Measurements of RV and LV MPI and LA volumes were made.

RESULTS

Twenty-five patients with an average age of 45.5 +/- 16.3 years underwent transcatheter closure of ASD. There was statistically significant improvement in RV MPI (0.35 to 0.28, p = 0.004), LV MPI (0.37 to 0.31, p = 0.04), and LA volume index (25.7 to 21.8 ml/m(2), p < 0.001) after closure of ASD.

CONCLUSIONS

Device closure of ASDs leads to improvement of both RV and LV function as well as reduction in LA volume. These hemodynamic improvements provide insights into the symptomatic benefits gained in closure of ASDs using the transcatheter approach.

Noninvasive prediction of complications with anteroseptal acute myocardial infarction by left ventricular Tei index

BACKGROUND

Tei index has been proposed as a noninvasive and simple index that enables the evaluation of global left ventricular (LV) function and prediction of patient prognosis. However, its use to predict complications with acute myocardial infarction (AMI) is not fully investigated. Therefore, the purpose of this study was to investigate whether or not LV Tei index allows noninvasive prediction of complications with AMI.

METHODS

In all, 80 consecutive patients with anteroseptal AMI were enrolled. LV Tei index was measured at the time of admission as (a - b)/ b , where a is the interval between cessation and onset of mitral filling flow and interval b is the aortic flow ejection time. Subsequent complications including cardiac death, shock, congestive heart failure, ventricular tachycardia/fibrillation, paroxysmal atrial fibrillation/flutter, advanced atrioventricular block requiring pacing, pericardial effusion, and LV aneurysm during the 30 days after the onset of AMI were prospectively evaluated and compared with the initial Tei index at admission.

RESULTS

Complications developed in 31 of 80 (39%) patients with AMI. The Tei index was significantly increased for patients with complications compared with those without them (0.69 +/- 0.16 vs 0.50 +/- 0.11, P < .0001). When Tei index > or = 0.59 was used for the criteria, the sensitivity, specificity, and overall accuracy to predict subsequent complications were 77%, 86%, and 85%, respectively.

CONCLUSION

In patients with anteroseptal AMI, LV Tei index at arrival to the hospital in the acute phase allows noninvasive prediction of subsequent complications.

Assessment of Systemic Right Ventricular Function in Patients With Transposition of the Great Arteries Using the Myocardial Performance Index

Background— Assessment of systemic right ventricular (RV) function is a key point in the follow-up of patients with transposition of the great arteries (TGA). Current echocardiographic assessment of RV function is at best an estimate, and cardiac magnetic resonance (CMR) is considered the gold standard. However, this technique is expensive, has limited availability, and requires significant expertise to acquire and interpret the images. The myocardial performance index (MPI) has recently been studied for assessment of pulmonary RV function and shows promise as a simple yet powerful tool for assessing patients with RV dysfunction of various origins. We set out to compare MPI and CMR assessment of systemic RV function in patients with TGA.

Methods and Results— Data from patients with TGA (11 with congenitally corrected TGA, 18 with surgically corrected TGA) who had CMR within 6 months of their echocardiogram were reviewed. The average systemic RV ejection fraction (RVEF) by CMR was 39.4±11.4%, and the systemic RVMPI for this group was 0.56±0.21. There was a strong negative correlation between the systemic RVMPI and systemic RVEF by CMR ( r =−0.82, P <0.01). The systemic RVEF can be estimated from this formula: RVEF=65%−(45.2×MPI).

Conclusions— MPI can be used in patients with systemic RVs to assess global function and to estimate an EF with good accuracy.