Assessment of the right ventricle by echocardiography: a primer for cardiac sonographers

Unified adult transthoracic echocardiographic report: an expert consensus document of the Egyptian Working Group of Echocardiography

BACKGROUND

Physicians face complexity in interpreting the results of echocardiography (ECHO) due to the variability across ECHO laboratories. Many international organizations published reports to reduce the inter-variability in ECHO reporting. However, with the evolution of imaging modalities, significant improvements in ECHO reporting are essential to eliminate any previous discrepancies. The Egyptian Working Group of Echocardiography (EEWG) aimed to prepare a standardized, updated, simple, and comprehensive ECHO reporting in Egypt to offer consistency, guarantee that all the crucial features are fulfilled, and ease practitioners' communication to maximize clinical decision-making.

MAIN TEXT

Relevant articles were retrieved and reviewed to explore the current state of TTE reporting practices, existing guidelines, and challenges faced by physicians in interpreting TTE results. Identified gaps and areas for improvement were then employed to establish the outline for the standardization approach. This report addresses crucial components such as demographic data, measurements, and interpretative summaries. It emphasizes left ventricle measurements and systolic function assessment, incorporating advanced techniques like speckle tracking and three-dimensional imaging. The significance of evaluating diastolic function, examining the right ventricle, and assessing valves, pericardium, and aorta are also discussed.

CONCLUSION

The current consensus goals to streamline communication among practitioners contribute to a more unified approach to interpreting ECHO results. Our initiative marks a significant step forward in enhancing the standardization and quality of ECHO reporting in Egypt. By introducing this report and encouraging continuous learning, the working group aims to raise the overall reporting quality and facilitate interpretation across diverse echocardiographic settings. This concerted effort improves patient care by ensuring consistency, accuracy, and relevance in interpreting echocardiographic findings.

Impact of graft reperfusion on cardiac function assessed by transesophageal echocardiography during liver transplantation: an observational retrospective study

Cardiovascular instability is common during the reperfusion phase of orthotopic liver transplantation (OLT), and some patients experience a postreperfusion syndrome (PRS). However, there are no reports comparing the cardiac dysfunction between patients with PRS and those without. Thus, the aim of this study was to evaluate cardiac dysfunction in patients exhibiting PRS. This observational retrospective study included 34 patients who underwent OLT and were monitored with transesophageal echocardiography (TEE). The right ventricular/left ventricular (RV/LV) end diastolic area, tricuspid annular plane systolic excursion (TAPSE), left ventricular ejection fraction (LVEF) by Simpson method, pulsed Doppler of the mitral valve, and tissue Doppler motion of the mitral annulus were determined. Echocardiographic measurements were registered at the beginning of surgery and at 1 and 30 min after vascular unclamping. Patients with PRS (PRS group) were identified, and their echocardiographic parameters of ventricular function were compared with those in patients without PRS (non-PRS group). To check the evolution of diastolic-systolic dysfunction, general linear model-repeated measures were estimated. No patient presented systolic/diastolic dysfunction on the basal echocardiogram. One minute after vascular unclamping, the incidence of RV dilation was 4.5 times greater in patients with PRS (Cramer´s V > 0.6), and the incidence of RV systolic dysfunction was 62.5% in patients with PRS compared to 15.40% in patients without PRS (Cramer´s V = 0.45). The incidence of LV systolic dysfunction was 25% in patients with PRS compared to 0% in those without (Cramer´s V = 0.45), and left ventricular diastolic dysfunction was 4.8 times greater in patients with PRS (Cramer´s V = 0.45). No patient presented diastolic dysfunction type III. There were significant differences between groups in the evolutionary pattern at 1 and 30 min after unclamping for RV dilation (p = 0.008) and for TAPSE (p = 0.014). Liver graft reperfusion may alter cardiac function. Cardiac dysfunction was more frequent in patients with PRS. These patients exhibited temporary dysfunction of the RV associated with a varying degree of LV diastolic-systolic dysfunction. Trial registration: clinicaltrials.gov (NCT05175534). January 03, 2022; "retrospectively registered".

The association of Pulmonary Hypertension and right ventricular systolic function - updates in diagnosis and treatment

Right ventricular (RV) systolic function is an essential but neglected component in cardiac evaluation, and its importance to the contribution to overall cardiac function is undermined. It is not only sensitive to the effect of left heart valve disease but is also more sensitive to changes in pressure overload than the left ventricle. Pulmonary Hypertension is the common and well-recognized complication of RV systolic dysfunction. It is also the leading cause of pulmonary valve disease and right ventricular dysfunction. Patients with a high pulmonary artery pressure (PAP) and a low RV ejection fraction have a seven-fold higher risk of death than heart failure patients with a normal PAP and RV ejection fraction. Furthermore, it is an independent predictor of survival in these patients. In this review, we examine the association of right ventricular systolic function with Pulmonary Hypertension by focusing on various pathological and clinical manifestations while assessing their impact. We also explore new 2022 ESC/ERS guidelines for diagnosing and treating right ventricular dysfunction in Pulmonary Hypertension.

Pulmonary vascular stenosis scoring in fibrosing mediastinitis

Aims

This study aims to develop a scoring system for evaluating the degree of pulmonary vascular stenosis in fibrosing mediastinitis (FM).

Methods and results

A retrospective single-centre study was conducted on 56 patients with FM in China between April 2014 and August 2021. The involvement of pulmonary vessels in patients with FM was assessed using dual-phase computed tomography pulmonary angiography, and we found that 85.7% of the patients had both pulmonary artery (PA) and vein (PV) involvement. PA involvement was mainly located proximal to both the upper PA and the bilateral basal trunk levels in the lower lungs. The involvement of the superior PV was more common than that of the inferior PV, and the right inferior PV was the least involved. Most of these lesions exhibited moderate or severe stenosis. Additionally, a scoring system for evaluating the degree of pulmonary vascular stenosis was developed. A correlation analysis revealed a negative correlation between the final pulmonary vascular score and the pulmonary arterial pressure, pulmonary vascular resistance, and maximum tricuspid regurgitation velocity. The calculated score of 17.1 was the best cut-off value for the diagnosis of mild and severe pulmonary hypertension (PH).

Conclusion

We successfully developed a scoring system for pulmonary vascular stenosis that can be used to evaluate the severity of pulmonary vessel involvement and PH. This scoring system may be relevant in the future development of target-based strategies for percutaneous interventions.

Hypertrophy of the right ventricle by pulmonary artery banding in rats: a study of structural, functional, and transcriptomics alterations in the right and left ventricles

Introduction: Right ventricular remodeling with subsequent functional impairment can occur in some clinical conditions in adults and children. The triggering factors, molecular mechanisms, and, especially, the evolution over time are still not well known. Left ventricular (LV) changes associated with right ventricular (RV) remodeling are also poorly understood. Objectives: The study aimed to evaluate RV morphological, functional, and gene expression parameters in rats submitted to pulmonary artery banding compared to control rats, with the temporal evolution of these parameters, and to analyze the influence of RV remodeling by pulmonary artery banding in rats and their controls over time on LV geometry, histology, gene expression, and functional performance. Methods: Healthy 6-week-old male Wistar-EPM rats weighing 170-200 g were included. One day after the echocardiogram, depending on the animals undergoing the pulmonary artery banding (PAB) procedure or not (control group), they were then randomly divided into subgroups according to the follow-up time: 72 h, or 2, 4, 6, or 8 weeks. In each subgroup, the following were conducted: a new echocardiogram, a hemodynamic study, the collection of material for morphological analysis (hypertrophy and fibrosis), and molecular biology (gene expression). The results were presented as the mean ± standard deviation of the mean. A two-way ANOVA and Tukey post-test compared the variables of the subgroups and evolution follow-up times. The adopted significance level was 5%. Results: There was no significant difference among the subgroups in the percentage of water in both the lungs and the liver (the percentage of water in the lungs ranged from 76% to 78% and that of the liver ranged from 67% to 71%). The weight of the right chambers was significantly higher in PAB animals in all subgroups (RV PAB weighed from 0.34 to 0.48 g, and control subjects, from 0.17 to 0.20 g; right atrium (RA) with PAB from 0.09 to 0.14 g; and control subjects from 0.02 to 0.03 g). In the RV of PAB animals, there was a significant increase in myocyte nuclear volume (97 μm3-183.6 μm3) compared to control subjects (34.2 μm3-57.2 μm3), which was more intense in subgroups with shorter PAB follow-up time, and the fibrosis percentage (5.9%-10.4% vs. 0.96%-1.18%) was higher as the PAB follow-up time was longer. In the echocardiography result, there was a significant increase in myocardial thickness in all PAB groups (0.09-0.11 cm compared to control subjects-0.04-0.05 cm), but there was no variation in RV diastolic diameter. From 2 to 8 weeks of PAB, the S-wave (S') (0.031 cm/s and 0.040 cm/s), and fractional area change (FAC) (51%-56%), RV systolic function parameters were significantly lower than those of the respective control subjects (0.040 cm/s to 0.050 cm/s and 61%-67%). Furthermore, higher expression of genes related to hypertrophy and extracellular matrix in the initial subgroups and apoptosis genes in the longer follow-up PAB subgroups were observed in RV. On the other hand, LV weight was not different between animals with and without PAB. The nuclear volume of the PAB animals was greater than that of the control subjects (74 μm3-136 μm3; 40.8 μm3-46.9 μm3), and the percentage of fibrosis was significantly higher in the 4- and 8-week PAB groups (1.2% and 2.2%) compared to the control subjects (0.4% and 0.7%). Echocardiography showed that the diastolic diameter and LV myocardial thickness were not different between PAB animals and control subjects. Measurements of isovolumetric relaxation time and E-wave deceleration time at the echocardiography were different between PAB animals and control subjects in all subgroups, but there were no changes in diastolic function in the hemodynamic study. There was also increased expression of genes related to various functions, particularly hypertrophy. Conclusion: 1) Rats submitted to pulmonary artery banding presented RV remodeling compatible with hypertrophy. Such alterations were mediated by increased gene expression and functional alterations, which coincide with the onset of fibrosis. 2) Structural changes of the RV, such as weight, myocardial thickness, myocyte nuclear volume, and degree of fibrosis, were modified according to the time of exposure to pulmonary artery banding and related to variations in gene expression, highlighting the change from an alpha to a beta pattern from early to late follow-up times. 3) The study suggests that the left ventricle developed histological alterations accompanied by gene expression modifications simultaneously with the alterations found in the right ventricle.

Comprehensive ultrasound imaging of right ventricular remodeling under surgically induced pressure overload in mice

This study reports a new methodology for right heart imaging by ultrasound in mice under right ventricular (RV) pressure overload. Pulmonary artery constriction (PAC) or sham surgeries were performed on C57BL/6 male mice at 8 wk of age. Ultrasound imaging was conducted at 2, 4, and 8 wk postsurgery using both classical and advanced ultrasound imaging modalities including electrocardiogram (ECG)-based kilohertz visualization, anatomical M-mode, and strain imaging. Based on pulsed Doppler, the PAC group demonstrated dramatically enhanced pressure gradient in the main pulmonary artery (MPA) as compared with the sham group. By the application of advanced imaging modalities in novel short-axis views of the ventricles, the PAC group demonstrated increased thickness of RV free wall, enlarged RV chamber, and reduced RV fractional shortening compared with the sham group. The PAC group also showed prolonged RV contraction, asynchronous interplay between RV and left ventricle (LV), and passive leftward motion of the interventricular septum (IVS) at early diastole. Consequently, the PAC group exhibited prolongation of LV isovolumic relaxation time, without change in LV wall thickness or systolic function. Significant correlations were found between the maximal pressure gradient in MPA measured by Doppler and the RV systolic pressure by catheterization, as well as the morphological and functional parameters of RV by ultrasound.NEW & NOTEWORTHY The established protocol overcomes the challenges in right heart imaging in mice, thoroughly elucidating the changes of RV, the dynamics of IVS, and the impact on LV and provides new insights into the pathophysiological mechanism of RV remodeling.

Pre-Existing Right Ventricular Dysfunction as an Independent Risk Factor for Post Intubation Cardiac Arrest and Hemodynamic Instability in Critically Ill Patients: A Retrospective Observational Study

BACKGROUND

Post intubation cardiac arrest and hemodynamic instability are serious adverse events encountered in critically ill patients. The association of pre-existing right ventricular (RV) dysfunction with post intubation cardiac arrest and hemodynamic instability in critically ill patients is unknown.

METHODS

This is a retrospective matched cohort study of adult critically ill patients who underwent intubation from July 2016 to December 2019. The study was conducted at a quaternary medical center in Houston, Texas. A total of 340 critically ill patients who underwent intubation in the intensive care units, wards, and the emergency room were included. The study cohort was categorized into 4 groups based on the pre-existing RV function: normal function, mild dysfunction, moderate dysfunction, and severe dysfunction. Cardiac arrest and/or hemodynamic instability within one hour post intubation were the primary study outcomes. Secondary outcomes included in hospital and 60-day mortality.

RESULTS

Study patients were of mean age of 61.95 ± 14.28 years, including 132 (39%) females and 208 (61%) males. The primary outcomes were significantly worse in mild, moderate, and severe RV dysfunction groups compared to the normal RV function group (34.12%-P = 0.014, 47.06%-P < 0.001, 51.67%-P < 0.001, vs. 17.56%). In a multivariable logistic regression analysis, pre-existing moderate (OR = 2.65, P = 0.013) and severe RV dysfunction groups (OR = 2.66, P = 0.015) were associated with statistically significant higher cardiac arrest and hemodynamic instability post intubation. Pre-existing severe RV dysfunction was associated with statistically significant higher in hospital mortality (62.35%-P < 0.001). The multivariable Cox-regression analysis showed that pre-existing severe RV dysfunction was associated with a statistically significant higher 60-day mortality (HR = 2.57, P = 0.001).

CONCLUSIONS

Pre-existing moderate and severe RV dysfunctions were independently associated with significantly higher cardiac arrest and/or hemodynamic instability post intubation in critically ill patients. Pre-existing RV function may serve as a mortality predictor in critically ill patients undergoing endotracheal intubation.

Non-Invasive Assessment of Right Ventricle to Arterial Coupling for Prognosis Stratification of Fibrotic Interstitial Lung Diseases

Background: The coupling of the right ventricle (RV) to the pulmonary circulation is an indicator of RV performance that can be non-invasively estimated by echocardiography. There are no data about its use in patients affected by fibrotic interstitial lung diseases (f-ILD). Methods: Fifty f-ILD patients, including 27 cases with idiopathic pulmonary fibrosis (IPF) (M = 37; mean age 67 ± 7 years), were studied with standard and speckle-tracking echocardiography and compared with 30 age-matched healthy volunteers. The mean patient follow-up was 70 ± 4 months. Results: Fibrotic ILD patients had a larger right ventricle (RV) and worse diastolic function because the RV global longitudinal strain (GLS) was significantly lower and the systolic pulmonary artery pressure (sPAP) estimates were higher in comparison with those of controls. Conversely, tricuspid annular systolic excursion (TAPSE) did not differ between controls and patients. Median values of TAPSE/sPAP and RV GLS/sPAP were significantly reduced in f-ILD patients (p < 0.0001). Patients with an RV GLS/sPAP below the median value had a shorter survival time (61 vs. 74 months, p = 0.01); this parameter was an independent predictor of a worse outcome. Conclusion: Low estimates of RV GLS/sPAP are predictive of worse outcomes in f-ILD patients. RV coupling seems to be a promising surrogate biomarker of RV performance to discriminate the patient phenotype with significant management and prognosis implications.

cRGD Urokinase Liposomes for Thrombolysis in Rat Model of Acute Pulmonary Microthromboembolism

Purpose

To study the thrombolytic effect and safety of cRGD urokinase liposomes (cRGD-UK-LIP) in rats with acute pulmonary microthromboembolism (APMTE), and explore the application value of echocardiography (ECHO) in animal models.

Patients and Methods

Ninety-six SD rats were randomized into 6 groups (16/group): normal control, sham operation, APMTE, normal saline (NS), free urokinase (UK), cRGD-UK-LIP. Four groups (APMTE, NS, UK, cRGD-UK-LIP) of rats were injected with autologous thrombus to induce APMTE. Samples were injected into 3 groups (NS, UK, cRGD-UK-LIP) of rats after modeling. Echocardiography was used to assess right ventricle (RV) function and morphology in rats. Six rats in each group were randomly selected and pulmonary artery pressure (PAP) of them was measured through ECHO-guided transthoracic puncture. Finally, the rats were killed and their tissues were taken for pathological examination.

Results

Compared with normal control or sham operation group, rats in APMTE group had enlarged RV, decreased RV function, increased PAP, and lung tissue of them showed postthromboembolic appearance. There was no significant difference between NS group and APMTE group. RV morphology and function of rats in the UK group and cRGD-UK-LIP group were better and vessels with residual thrombus in these 2 groups were less than APMTE group, especially in the cRGD-UK-LIP group. In terms of PAP, only cRGD-UK-LIP group was significantly lower than APMTE group. No hyperemia, bleeding and swelling were observed in heart, liver and kidney of rats in each group.

Conclusion

A rat model of APMTE was successfully established. cRGD-UK-LIP has better thrombolytic effect than free urokinase and it is safe. Echocardiography is not merely an important way to evaluate the morphology and function of RV, transthoracic puncture measurement under the guidance of it can be an effective way to monitor PAP in animal models.

Pulmonary artery capacitance and pulmonary vascular resistance as prognostic indicators in acute pulmonary embolism

Aims

The non-invasive calculation of right ventricular (RV) haemodynamics as pulmonary artery (PA) capacitance (PAC) and pulmonary vascular resistance (PVR) have proved to be feasible, easy to perform, and of high prognostic value. We, therefore, evaluated whether baseline PAC and PVR could predict clinical outcomes for patients with acute pulmonary embolism (PE).

Methods and results

We prospectively followed 373 patients [mean (standard deviation) age, 64.1 (14.9) years; 58.4% were men, and 27.9% had cancer] who had acute PE and transthoracic echocardiography within 1 day of diagnosis from 1 March 2013 through 30 June 2020. Pulmonary artery capacitance was calculated as left ventricular stroke volume/(PA systolic pressure − PA diastolic pressure). Pulmonary vascular resistance was calculated as (tricuspid regurgitant velocity/RV outflow tract velocity time integral) × 10 + 0.16. These two variables were calculated retrospectively from the values obtained with transthoracic echocardiography. Pulmonary artery capacitance was acquired in 99 (27%) patients and PVR in 65 (17%) patients. Univariable and bivariable logistic regression analyses, and receiver operating characteristic curves were used to evaluate the ability of these haemodynamic measurements to predict mortality up to 6 months. After using bivariable models to adjust individually for age, cancer, and pulmonary hypertension. Pulmonary vascular resistance was associated with all-cause mortality at 3 months [area under the curve (AUC) 0.75, 95% confidence interval (CI) 0.61–0.86; P = 0.01], and 6 months (AUC 0.81; 95% CI 0.69–0.91; P≤ 0.03). Pulmonary artery capacitance was associated with all-cause mortality at 30 days (AUC 0.95; 95% CI 0.82–0.99; P &lt; 0.001) and 3 months (AUC 0.84; 95% CI 0.65–0.99; P = 0.003).

Conclusion

Non-invasive measurement of RV haemodynamics could provide prognostic information of patients with acute PE. Pulmonary artery capacitance and PVR are potentially important predictors of all-cause mortality in these patients and should be explored in future studies.

In vivo evaluation of bioprinted cardiac patches composed of cardiac-specific extracellular matrix and progenitor cells in a model of pediatric heart failure

Pediatric patients with congenital heart defects (CHD) often present with heart failure from increased load on the right ventricle (RV) due to both surgical methods to treat CHD and the disease itself. Patients with RV failure often require transplantation, which is limited due to lack of donor availability and rejection. Previous studies investigating the development and in vitro assessment of a bioprinted cardiac patch composed of cardiac extracellular matrix (cECM) and human c-kit + progenitor cells (hCPCs) showed that the construct has promise in treating cardiac dysfunction. The current study investigates in vivo cardiac outcomes of patch implantation in a rat model of RV failure. Patch parameters including cECM-inclusion and hCPC-inclusion are investigated. Assessments include hCPC retention, RV function, and tissue remodeling (vascularization, hypertrophy, and fibrosis). Animal model evaluation shows that both cell-free and neonatal hCPC-laden cECM-gelatin methacrylate (GelMA) patches improve RV function and tissue remodeling compared to other patch groups and controls. Inclusion of cECM is the most influential parameter driving therapeutic improvements, with or without cell inclusion. This study paves the way for clinical translation in treating pediatric heart failure using bioprinted GelMA-cECM and hCPC-GelMA-cECM patches.

Prognostic impact of right ventricular function affected by pulmonary hypertension in hospitalized heart failure patients

BACKGROUND

Pulmonary hypertension (PH) may affect right ventricular (RV) function; however, the prognostic implications of RV function in patients with heart failure and PH remain unclear. We aimed to investigate the impact of RV function on the prognosis of hospitalized heart failure patients with and without PH.

METHODS

This observational study initially included 1,349 consecutive hospitalized heart failure patients. After excluding patients who died in hospital, whose left ventricular (LV) function was preserved, and whose echocardiography data were incomplete, 573 patients with heart failure and reduced LV ejection fractions (HFrEF) were analyzed. The patients were grouped according to RV dysfunction that was defined as an RV-tissue Doppler imaging systolic velocity (RV-TDI s') of ≤9.5 cm/s. The primary endpoint was a composite of cardiovascular death and rehospitalization as a consequence of heart failure.

RESULTS

Overall, the patients with reduced RV function had significantly higher event rates than those with preserved RV function (log-rank test p = 0.01). This prognostic impact was observed in the patients with PH (p = 0.001) and was not evident among the patients without PH (p = 0.39). In the patients with PH, reduced RV function independently predicted the prognosis after adjusting for the covariates (adjusted hazard ratio: 3.12; 95% confidence interval: 1.44 to 6.73).

CONCLUSION

RV dysfunction that was estimated during hospitalization using the RV-TDI s', which is a simply determined index, may predict clinical outcomes in hospitalized patients with HFrEF and PH after discharge, but not in those without PH.

The Right Ventricle in the Trans-Catheter Era: A Perspective for Planning Interventions

Dysfunction of the right ventricle (RV) is common in patients with advanced left-sided valve disease and the significant impact of RV dysfunction on both short and long-term outcome is well established. However, considerations of RV function are largely absent in current management guidelines for valve disease and cardiac procedural risk models. As the indications and use of trans-catheter therapies rapidly expand for patients with acquired valvular disease, it is critical for clinicians to understand and consider RV function when making decisions for these patients. This review summarizes contemporary data on the assessment of RV function, the prognostic importance of baseline RV dysfunction on surgical and transcatheter procedures for acquired left-sided valvular disease, and the relative impact of these interventions on RV function. Baseline RV dysfunction is a powerful predictor of poor short- and long-term outcome after any therapeutic intervention for acquired left-sided cardiac valve disease. Surgical intervention for aortic or mitral valve disease is associated with a significant but transient decline in RV function, whereas trans-catheter procedures generally do not appear to have detrimental effects on either longitudinal or global RV function. Guidelines for therapy in patents with acquired left-sided valvular disease should account for RV dysfunction. Whereas surgical intervention in these patients leads to a predictable decline in RV function, trans-catheter therapies largely do not appear to have this effect. Further study is needed to determine the impact of these findings on current practice.

Evaluation of echocardiographic derived parameters for right ventricular size and function using cardiac magnetic resonance imaging

BACKGROUND

Cardiac Magnetic Resonance Imaging (cMRI) is the gold standard for right ventricular (RV) assessment due to its high spatial resolution. The American Society of Echocardiography (ASE) recommends eight structural and six functional quantitative parameters for evaluation of the RV. This study sought to simplify echocardiographic RV assessment by examining the relative diagnostic value of the echo recommended parameters by applying them to cMRI imaging of the RV.

METHODS

We applied ASE recommended measures of RV size and function to 56 cMRI's and compared them to RV volumetric analysis obtained from cMRI. Pearsons' correlation coefficient was used to compare ASE prescribed parameters to corresponding cMRI calculated RV end diastolic volume (RVEDV) and RV ejection fraction (RVEF). The diagnostic performance of each parameter in predicting abnormal RV size or function was analyzed using receiver operator characteristic curves. Youden-J index was used to determine optimal sensitivity/specificity cut-points. Stepwise regression modeling was performed to identify measurements independently associated with RV size or RVEF.

RESULTS

RV end diastolic area (RVEDA) correlated best with RVEDV (r = .76, p < 0.001) and RV fractional area change (RVFAC) correlated best with RVEF (r = .7, p < 0.001). The best ASE parameter for identifying RV dilatation was RVEDA (Youden-J index = .84), the optimal cutoff was 32.3 cm² which yielded sensitivity/specificity of 84% and 100%, respectively. The best parameter for diagnosing RV dysfunction was RVFAC (Youden-J index = .52), with an optimal cutoff of 42% leading to sensitivity/specificity of 64% and 88%, respectively.

CONCLUSION

The area based echocardiographic parameters for RV size and function, RVEDA and RV fractional area change outperform linear measurements in predicting RV dilation and RV systolic dysfunction. These parameters should be examined in further echocardiographic based studies as the primary parameters to guide quantitative RV assessment.

Echocardiographic assessment of right ventricular systolic function in healthy Beagle dogs compared to high field cardiac magnetic resonance imaging

Ten healthy Beagle dogs were used to compare selected echocardiographic parameters of right ventricular (RV) systolic function with high field cardiac magnetic resonance imaging (MRI). All dogs underwent complete transthoracic echocardiography before and during anesthesia, as well as cardiac MRI with determination of morphology-based ejection fraction, and phase contrast angiography-derived stroke volume. A correlation analysis was carried out between echocardiographic and MRI parameters. The values of fractional area change, tricuspid annular plane systolic excursion, tissue Doppler imaging derived peak velocity of the isovolumic contraction wave and systolic wave of the lateral tricuspid valve annulus showed lower values under general anesthesia. Of all echocardiographic parameters of RV systolic function, only fractional area change (r = 0.671, P = 0.034) and tissue Doppler imaging derived peak velocity of the systolic wave of the lateral tricuspid valve annulus (r = 0.768; P = 0.01), showed a significant correlation with MRI derived stroke volume. None of the echocardiographic parameters correlated with MRI derived ejection fraction. When evaluating the RV echocardiographically, fractional area change and peak velocity of the systolic wave of the lateral tricuspid valve annulus appear to be the most reliable predictors of RV systolic function when compared to MRI under anesthesia.

[The assessment of right ventricular structure and function in patients with different cardiovascular diseases using modern echocardiographic technologies and magnetic resonance imaging]

AIM

To perform comparative analysis of right ventricular (RV) structure and function in patients with various cardiovascular diseases using modern echocardiographic technologies in comparison with magnetic resonance imaging (MRI).

MATERIALS AND METHODS

The study included 85 patients. Group 1 consisted of 32 patients with idiopathic pulmonary hypertension (IPH) (mean age 35.910.2 years). Group 2 included 27 patients with arterial hypertension (AH) grade 3 (mean age 58.612.3 years). Group 3 consisted of 26 patients with chronic heart failure (CHF) (mean age 56.115.3 years). Control group included 28 healthy volunteers (mean age 38.710.9 years). The main method was transthoracic echocardiography (TTE) using modern technologies, such as three-dimensional echocardiography (3DE), tissue Doppler imaging (TDI), and speckle tracking echocardiography (STE). In some patients and healthy volunteers 3DE data were compared with MRI data.

RESULTS

Patients with IPH and CHF had minimal RV ejection fraction (EF) both according to 3DE and MRI. Correlation analysis revealed close correlation between RV volumes and EF according to 3DE and MRI. Minimal values of systolic indicator STV according to TDI were observed in patients with CHF. In all groups, including control group, the highest values of STV were obtained at the level of the basal segments and the lowest values at the level of apical segments. STE revealed the same pattern as TDI. According to STE minimal RV strain was observed in IPH and CHF groups and significantly differed not only from control group, but also from AH group.

CONCLUSION

The lowest values of RV EF and strain were observed in IPH and CHF groups. There were no significant differences in these indicators between the groups, that dictates the need for thorough assessment of RV structure and function not only in patients with precapillary, but also with postcapillary pulmonary hypertension. The results of the study confirm good comparability of 3DE and MRI in assessing RV volumes and EF.

Right ventricular diastolic function in aging: a head-to-head comparison between phase-contrast MRI and Doppler echocardiography

To evaluate right ventricle (RV) diastolic function from phase-contrast MRI (PC-MRI) in aging. 89 healthy individuals (50 men, 43 ± 15 years) underwent cardiac MRI including 2D PC-MRI (1.5T) and reference Doppler echocardiography of both ventricles on the same day. Conventional echocardiographic parameters were estimated: early (E, cm/s) and atrial (A) peak velocities as well as myocardial early peak longitudinal velocity (E'). PC-MRI images were analyzed using custom software, providing: E', E and A waves along with respective peak flow rates (Ef, Af, mL/s) and filling volume (mL), for both ventricles. Intra- and inter-observer reproducibility was studied in 30 subjects and coefficients of variation (CoV) as well as intra-class correlation coefficients (ICC) were provided. RV diastolic function indices derived from PC-MRI data were reproducible (CoV ≤ 21%, ICC ≥ 0.75) and reliable as reflected by significant associations with left ventricular diastolic function indices assessed using both echocardiography (linear regression Pearson correlation coefficient r ≤ 0.59) and PC-MRI (r ≤ 71). Despite the fair associations between RV echocardiography and PC-MRI (r ≤ 0.25), the highest correlation with age was obtained for MRI Ef/Af ratio (r = - 0.64, p < 0.0001 vs. r = - 0.40, p = 0.0001 for echocardiographic E/A). Among PC-MRI E/A ratios, highest correlations with age were observed for flow rate and mean velocity ratios (r = - 0.61, p < 0.0001) as compared to maximal velocity ratios (r = - 0.56, p < 0.0001). Associations with age for E' were equivalent between PC-MRI (mean velocity: r = - 0.40, p < 0.0001; maximal velocity: r = - 0.36, p = 0.0005) and echocardiography (r = - 0.36, p = 0.0006). Finally, the significant and age-independent associations between RV mass/end-diastolic volume and E' were stronger for PC-MRI (mean velocity: r = - 0.36, p = 0.0006; maximal velocity: r = - 0.28, p = 0.007) than echocardiography (r = - 0.09, p = 0.38). PC-MRI tricuspid inflow and annulus myocardial velocity parameters were reproducible and able to characterize age-related variations in RV diastolic function.

Impaired Right and Left Ventricular Longitudinal Function in Patients with Fibrotic Interstitial Lung Diseases

Background: Left ventricular (LV) and right ventricular (RV) dysfunction is recognized in idiopathic pulmonary fibrosis (IPF). Little is known about cardiac involvement in non-idiopathic pulmonary fibrosis (no-IPF). This issue can be explored by advanced echocardiography. Methods: Thirty-three clinically stable and therapy-naive fibrotic IPF and 28 no-IPF patients, and 30 healthy controls were enrolled. Exclusion criteria were autoimmune systemic diseases, coronary disease, heart failure, primary cardiomyopathies, chronic obstructive lung diseases, pulmonary embolism, primary pulmonary hypertension. Lung damage was evaluated by diffusion capacity for carbon monoxide (DLCO_sb). All participants underwent an echo-Doppler exam including 2D global longitudinal strain (GLS) of both ventricles and 3D echocardiographic RV ejection fraction (RVEF). Results: We observed LV diastolic dysfunction in IPF and no-IPF, and LV GLS but not LV EF reduction only in IPF. RV diastolic and RV GLS abnormalities were observed in IPF versus both controls and no-IPF. RV EF did not differ significantly between IPF and no-IPF. DLCO_sb and RV GLS were associated in the pooled pulmonary fibrosis population and in the IPF subgroup (β = 0.708, p < 0.001), independently of confounders including pulmonary arterial systolic pressure. Conclusion: Our data highlight the unique diagnostic capabilities of GLS in distinguishing early cardiac damage of IPF from no-IPF patients.

Assessing Right Ventricular Function in the Perioperative Setting, Part I: Echo-Based Measurements

This article reviews transesophageal echocardiography-based assessment of perioperative right ventricular function and failure, including catheter-based methods, three-dimensional echocardiography, and their combination to make pressure-volume loops. It outlines right ventricular pathophysiology, multiple assessment methods, and their relationship to analogous transthoracic echocardiogram measurements. technologies used and developed for transthoracic or left ventricular assessment show significant limitations when applied to transesophageal assessment of the right ventricle. The article provides an overview of right ventricular assessment modalities that can be used in transesophageal echocardiography. Ultimately, clinicians must know limitations of measurements, synthesize information, and assess it in the clinical context.

Improvements of right ventricular function and hemodynamics after balloon pulmonary angioplasty in patients with chronic thromboembolic pulmonary hypertension

PURPOSE

Right ventricular (RV) function is an important factor in the prognosis of chronic thromboembolic pulmonary hypertension (CTEPH) in patients. In our study, we aimed to evaluate the timing and magnitude of regional RV function before and after balloon pulmonary angioplasty (BPA) using speckle tracking echocardiography (STE) and their relation to clinical and hemodynamic parameters in patients with CTEPH.

MATERIAL AND METHOD

We enrolled 20 CTEPH patients and 19 healthy subjects in our study. Enrolled patients underwent echocardiography, right heart catheterization (RHC), and 6-minute walk distance (6MWD) test at baseline and after the BPA.

RESULTS

In hemodynamic RHC measurements and clinical evaluations, mean pulmonary artery pressure (median: 53.5 mm Hg vs 37.0 mm Hg, P = .001) and pulmonary vascular resistance (median: 12 Wood units [WU] vs 7 WU, P = .001) and pro-brain natriuretic peptide level decreased and 6MWD increased after BPA sessions. There was no statistically significant difference between before and after the BPA sessions in conventional echocardiographic measurements. In STE analysis, the electromechanical delay (EMD) between RV free wall (RVF) and LV lateral wall (LVL) (median: 65 ms vs 47.5 ms, P = .01) and RV peak systolic strain dispersion index (52 ms vs 29 ms, P = .001) were higher in patients with CTEPH than healthy controls before the BPA. Both these parameters decreased significantly after BPA.

CONCLUSION

Chronic thromboembolic pulmonary hypertension was associated with RV electromechanical delay and dispersion based on the STE analysis. Balloon pulmonary angioplasty might have an important impact on the improvement of both RV function and hemodynamics.

Tricuspid annular plane systolic excursion is correlated with poor outcome in surgery for rheumatic heart valvular disease

BACKGROUND

Right ventricular (RV) function is a major determinant of clinical outcome, but its function indices have not been studied well in surgery for rheumatic valvular heart disease. The aim of this study was to determine the correlation of tricuspid annular plane systolic excursion (TAPSE) with outcome of rheumatic heart valve surgery.

METHODS

A prospective comparative study was conducted including 100 eligible patients who were divided into two groups based on RV function as assessed by TAPSE measured by two-dimensional (2D) echocardiography preoperatively. Those with TAPSE less than 15 mm were included in group 1 and those with TAPSE of 15 or more were included in group 2.

RESULTS

50 patients were included in group 1 and 50 patients in group 2. Mean age of the patients was 56.78 ± 15.21 years in group 1 and 54.46 ± 15.03 years in group 2 (P = 0.444). 34 (34%) patients underwent aortic valve replacement (AVR), 35 (35%) underwent both aortic and mitral valves replacement, and 31 (31%) ones had mitral valve replacement (MVR). A significant difference was found between the duration of ventilation (5.15 ± 2.80 hours in group 1 vs. 3.72 ± 2.71 hours in group 2, P = 0.001), postoperative inotropic requirement [more than 24 hours in 18 (36%) patients in group 1 vs. 7 (14%) patients in group 2, P = 0.003], total intensive care unit (ICU) stay (8.92 ± 3.62 days in group 1 vs. 5.20 ± 2.06 days in group 2, P = 0.001), and mortality [7 (14%) in group 1 vs. 2 (4%) in group 2, P = 0.038].

CONCLUSION

TAPSE less than 15 mm in patients undergoing surgical correction for rheumatic valvular heart disease leads to poor outcomes. These patients need special attention perioperatively.

Speckle tracking echocardiographic deformation indices in Chagas and idiopathic dilated cardiomyopathy: Incremental prognostic value of longitudinal strain

Background

Chagas cardiomyopathy (CDC) is associated with a poor prognosis compared to other cardiomyopathies. Speckle tracking echocardiography (STE), which provides direct assessment of myocardial fiber deformation, may be useful in predicting prognosis.

Objective

This study assessed STE in CDC and compared with idiopathic cardiomyopathy (IDC), and also examined the incremental prognostic information of STE over left ventricular ejection fraction (LVEF) in these patients.

Methods

We enrolled 112 patients, age of 56.7 ± 11.8 years, 81 with CDC and 31 with IDC. STE indices were obtained at baseline in all patients. The endpoint was a composite of death, hospitalization for heart failure, or need for heart transplantation.

Results

Patients with IDC had worse LV systolic function compared to CDC, with LVEF of 34.5% vs 41.3%, p = 0.004, respectively. After adjustment for LVEF, there were no differences in STE values between CDC and IDC. During a median follow-up of 18.2 months (range, 11 to 22), 26 patients met the composite end point (24%). LV longitudinal strain was a strong predictor of adverse events, incremental to LVEF and E/e' ratio (HR 1.463, 95% CI 1.130–1.894; p = 0.004). The risk of cardiac events increased significantly in patients with GLS > - 12% (log-rank p = 0.035).

Conclusions

STE indices were abnormal in patients with dilated cardiomyopathy, without differences between CDC and IDC. LV longitudinal strain was a powerful predictor of outcome, adding prognostic information beyond that provided by LVEF and E/e' ratio.

Timing and magnitude of regional right ventricular function and their relationship with early hospital mortality in patients with acute pulmonary embolism

OBJECTIVE

Right ventricular (RV) dysfunction in acute pulmonary embolism (APE) has been associated with increased mortality and morbidity. The aim of the present study was to assess the timing and magnitude of regional RV functions using speckle-tracking echocardiography (STE) and their relationship to early hospital mortality in patients with APE.

METHODS

One hundred forty-two patients were prospectively studied at the onset of an acute episode and after a median follow-up period of 30 days. Their clinical and laboratory characteristics were recorded. For all patients, conventional two-dimensional echocardiography and STE were performed within 24 h after the diagnosis of APE.

RESULTS

Twenty-eight (19.7%) patients died during the hospitalization follow-up. Patients who died during hospitalization were older and had higher high sensitivity cardiac troponin T levels, and a higher percentage of patients had simplified Pulmonary Embolism Severity Indexes. In STE analyses, they had lower RV free wall peak longitudinal systolic strain (PLSS) and higher RV peak systolic strain dispersion indexes. The time to PLSS difference between RV free wall and LV lateral was longer in patients who died during hospitalization than in those who survived, and this was an independent predictor of early hospital mortality with 85.7% sensitivity and 75.0% specificity in patients with APE.

CONCLUSION

APE was associated with RV electromechanical delay and dispersion. Electromechanical delay index might be useful to predict early hospital mortality in patients with APE.

Etiology of right ventricular restrictive physiology early after repair of tetralogy of Fallot in pediatric patients

BACKGROUND

Right ventricular restrictive physiology (RVRP) is a common finding after repair of Tetralogy of Fallot (TOF). The characteristic feature of RVRP is the presence of a direct end-diastolic flow (EDFF) during atrial contraction in the main pulmonary artery. This end-diastolic forward flow is caused by increased right ventricular end-diastolic pressure due to right ventricular myocardial stiffness and decreased right ventricular compliance.

OBJECTIVE

Our main objective is to found out the etiology of RVRP in pediatrics patients who underwent for complete repair of Tetralogy of Fallot (TOF).

METHODS

A total of 50 TOF patients have registered for this study in our hospital from January 2017 to September 2018. The patients were divided in two groups, group A with restrictive physiology and group B without restrictive physiology. The patients selected for this study includes TOF patients, TOF patients with atrial septal defect (ASD), and TOF patients with patent ductus arteriosus (PDA). Ventricular hypertrophy and right heart enlargement were evaluated by electrocardiogram and echocardiography. The other parameters we used to compare between these two groups were sex, age, weight, cardio pulmonary bypass (CPB) time, aortic cross clamping time, transannular patch, SP0₂, RV/LV pressure, ventricular hypertrophy, right heart (RH) enlargement, tricuspid annular plane systolic excursion (TAPSE), pulmonary artery systolic pressure (PASP), TAPSE/PASP ratio, pulmonary annular diameter, intubation time, PICU stay and hematocrit (HCT).

RESULTS

RVRP was identified in 28 patients (58%). Lower SP0₂ (mean: 84.3 ± 7.9%) with p-value 0.015, transannular patch repair (n = 22, 78.5%) with p-value< 0.001, longer cardiopulmonary bypass (CPB) time (mean: 117.6 ± 23 min) with p-value< 0.001, longer aortic cross clamping time (mean: 91.4 ± 20.26 min) with p-value< 0.001, lower TAPSE, lower PASP,lower TAPSE/PASP ratio and presence of hypertrophy (p-value < 0.001) were identified as etiology for restrictive physiology. It was also found that 77% TOF patients with ASD have a higher risk of RVRP in our study.

CONCLUSIONS

In TOF patient's etiology for right ventricular restrictive physiology are associated with lower SP0_2, transannular patch repair, longer CPB and longer aortic cross clamping time, hypertrophy, lower TAPSE, lower PASP and lower TAPSE/PASP ratio.

Reproducibility of the assessment of myocardial function through tissue Doppler imaging in very low birth weight infants

OBJECTIVES

This study aims to analyze the variability between two trained neonatologists when performing consecutive echocardiograms using tissue Doppler imaging (TDI) and conventional methods in very low birth weight infant (VLBWI).

METHODS

Two serial echocardiograms were performed in 30 VLBWI infants. The echocardiographic parameters analyzed were tricuspid annular plane systolic excursion (TAPSE), A', E', and S' waves, and myocardial performance index acquired by TDI (MPI-TDI) of both ventricles and shortening fraction (SF). The intra-observer and inter-observer agreements and the intra-operator agreement were analyzed using quantitative and qualitative statistical methods.

RESULTS

The intra-observer agreement was very good, TAPSE, and TDI-derived parameters had an intra-class correlation (ICC) > 0.8. TDI-derived velocities had a coefficient of variation (COV) < 11%, while MPI-TDI had a COV between 20%-28%. The inter-observer agreement was excellent. There was greater variability when analyzing intra-operator agreement, with the least variable parameter being TAPSE. According to PABAK, the variability presented moderately substantial agreement.

CONCLUSIONS

Tricuspid annular plane systolic excursion is very reproducible between observers and operators. Measurements of TDI wave velocities are more reproducible than MPI-TDI. TDI is sufficiently reproducible in the VLBWI if adequate training is performed, and guidelines are followed to obtain standardized echocardiographic images.

A closer look at right ventricular 3D volume quantification by transthoracic echocardiography and cardiac MRI

AIM

To compare right ventricular (RV) volumetry using state-of-the-art three-dimensional (3D) transthoracic echocardiography (3DE) and cardiac magnetic resonance imaging (CMR) near-simultaneously in a clinical setting.

MATERIALS AND METHODS

Forty-seven consecutive patients received comprehensive echocardiography including 3DE within 30 minutes of CMR. RV volumetry was performed offline with semi-automated 3D endocardial border tracing as well as manual delineation of the compacted myocardium in short-axis views by CMR.

RESULTS

Forty-two examinations (89%) could be analysed offline by 3D RV reconstruction. Mean RV volumes assessed by CMR and 3DE were 215±63 and 127±42 ml for end-diastole (RV-EDV), as well as 110±43 and 62±27 ml for end-systole (RV-ESV). RV-EDV, RV-ESV, and RV stroke volume measured by 3DE were significantly lower than RV volumetry by CMR. Mean bias were -88, -48, and -41 ml, respectively. Mean RV ejection fraction (-EF) showed a non-significant deviation of +2% between 3DE and CMR and the correlation coefficient was r=0.58 for RV-EF.

CONCLUSION

RV-EF can be assessed reliably using transthoracic 3DE in patients with good image quality; however, absolute RV volumes measured by 3DE show a systematic deviation to CMR volumetry that has been previously neglected and requires careful interpretation regarding anatomical cardiac imaging.

Three-dimensional echocardiographic evaluation of the right ventricle in patients with uncomplicated systemic lupus erythematosus

Our aim was to identify subclinical right ventricular (RV) alterations in systemic lupus erythematosus (SLE) by combining standard and three-dimensional echocardiography (3DE). Fifty SLE patients without concomitant cardiac disease and 50 healthy controls, matched for age and gender, were enrolled. Disease damage was evaluated by inflammatory markers and SLE damage index. All patients underwent an echo-Doppler examination with 3DE assessment of RV function, RV septal and lateral longitudinal strain. The two groups had comparable body mass index and blood pressure. RV transversal middle diameter and pulmonary arterial pressure were significantly higher in SLE compared to controls. By 3DE, RV end-systolic volume ( p = 0.037) was greater, whereas stroke volume ( p = 0.023), ejection fraction ( p < 0.0001) and septal and lateral longitudinal strain (both p < 0.0001) were lower in SLE. SLE damage index ≥ 1 was negatively associated with tricuspid annular plane systolic excursion (TAPSE) ( p < 0.002), tricuspid E/A ratio ( p = 0.003), RV ejection fraction ( p < 0.05), lateral longitudinal strain ( p < 0.0001) and septal longitudinal strain ( p = 0.04). By separate multivariate models, after adjusting for age, C reactive protein and proBNP, SLE damage index was independently associated with TAPSE ( p = 0.009) and RV lateral longitudinal strain ( p = 0.007). In conclusion, a subclinical RV systolic dysfunction is detectable in SLE by 3DE, RV lateral wall strain being a key parameter. RV dysfunction is associated with cumulative disease damage.

Modified Tricuspid Annular Plane Systolic Excursion for Assessment of Right Ventricular Systolic Function

BACKGROUND

Tricuspid annular plane systolic excursion (TAPSE) has become a popular tool for assessing right ventricular (RV) systolic function because of its ease of application. TAPSE using transesophageal echocardiography (TEE) is limited by alignment with the lateral wall of the RV. Modified TAPSE (m-TAPSE) is a novel method for measuring TAPSE. m-TAPSE is the difference in the ‘apical to lateral tricuspid annulus distance’ during diastole and systole. The aim of the present study was to compare prospectively m-TAPSE with the most commonly used parameter TAPSE and near-gold standard 2D echocardiographic parameter RV fractional area change (RV FAC).

METHODS

We conducted a prospective observational study of 125 consecutive patients undergoing coronary artery bypass graft surgery in a single tertiary care center. Post-anesthetic induction TAPSE was recorded using transthoracic echocardiography (TTE). m-TAPSE was recorded using TEE in the mid-esophageal four-chamber view. RV FAC was also assessed using TEE. m-TAPSE < 16 mm, TAPSE < 16 mm and RV FAC < 35% were taken as cut-offs for RV systolic dysfunction. Correlations were assessed using the Pearson correlation coefficient. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated using 2 × 2 cross table.

RESULTS

m-TAPSE was significantly correlated with TAPSE (r = 0.797, p < 0.001). Similarly, a significant correlation was observed between m-TAPSE and RV FAC (r = 0.602, p < 0.001). The sensitivity, specificity, PPV, NPV, and accuracy of m-TAPSE were 100%, 98.3%, 80%, 100% and 98.4%, respectively.

CONCLUSIONS

m-TAPSE correlated well with both RV FAC and TAPSE. Therefore, m-TAPSE can be considered an easily measurable alternative parameter for evaluating RV systolic function in a busy intraoperative setting.

The clinical features, outcomes and genetic characteristics of hypertrophic cardiomyopathy patients with severe right ventricular hypertrophy

Introduction

Severe right ventricular hypertrophy (SRVH) is a rare phenotype in hypertrophic cardiomyopathy (HCM) for which limited information is available. This study was undertaken to investigate the clinical, prognostic and genetic characteristics of HCM patients with SRVH.

Methods

HCM with SRVH was defined as HCM with a maximum right ventricular wall thickness ≥10 mm. Whole-genome sequencing (WGS) was performed in HCM patients with SRVH. Multivariate Cox proportional hazards regression models were used to identify risk factors for cardiac death and events in HCM with SRVH. Patients with apical hypertrophic cardiomyopathy (ApHCM) were selected as a comparison group. The clinical features and outcomes of 34 HCM patients with SRVH and 273 ApHCM patients were compared.

Results

Compared with the ApHCM group, the HCM with SRVH group included younger patients and a higher proportion of female patients and also displayed higher cardiovascular morbidity and mortality. The multivariate Cox proportional hazards regression models identified 2 independent predictors of cardiovascular death in HCM patients with SRVH, a New York Heart Association class ≥III (hazard ratio [HR] = 8.7, 95% confidence interval (CI): 1.43-52.87, p = 0.019) and an age at the time of HCM diagnosis ≤18 (HR = 5.5, 95% CI: 1.24-28.36, p = 0.026). Among the 11 HCM patients with SRVH who underwent WGS, 10 (90.9%) were identified as carriers of at least one specific sarcomere gene mutation. MYH7 and TTN mutations were the most common sarcomere mutations noted in this study. Two or more HCM-related gene mutations were observed in 9 (82%) patients, and mutations in either other cardiomyopathy-related genes or ion-channel disease-related genes were found in 8 (73%) patients.

Conclusions

HCM patients with SRVH were characterized by poor clinical outcomes and the presentation of multiple gene mutations.

Three-dimensional transesophageal echocardiography: Principles and clinical applications

A basic understanding of evolving 3D technology enables the echocardiographer to master the new skills necessary to acquire, manipulate, and interpret 3D datasets. Single button activation of specific 3D imaging modes for both TEE and transthoracic echocardiography (TTE) matrix array probes include (a) live, (b) zoom, (c) full volume (FV), and (d) color Doppler FV. Evaluation of regional LV wall motion by RT 3D TEE is based on a change in LV chamber subvolume over time from altered segmental myocardial contractility. Unlike standard 2D TEE, there is no direct measurement of myocardial thickening or displacement of individual segments.

Right ventricular remodelling after transcatheter pulmonary valve implantation

OBJECTIVES

To define the optimal timing for percutaneous pulmonary valve implantation (PPVI) in patients with severe pulmonary regurgitation (PR) after Fallot's Tetralogy (ToF) correction.

BACKGROUND

PPVI among the aforementioned patients is mainly driven by symptoms or by severe right ventricular (RV) dilatation/dysfunction. The optimal timing for PPVI is still disputed.

METHODS

Twenty patients [age 13.9 ± 9.2 years, (range 4.3-44.9), male 70%] with severe PR (≥3 grade) secondary to previous correction of ToF, underwent Melody valve (Medtronic, Minneapolis, MN) implantation, after a pre-stent placement. Full echocardiographic assessment (traditional and deformation analysis) and cardiovascular magnetic resonance evaluation were performed before and at 3 months after the intervention. 'Favorable remodelling' was considered the upper quartile of RV size decrease (>20% in 3 months).

RESULTS

After PPVI, indexed RV effective stroke volume increased from 38.4 ± 9.5 to 51.4 ± 10.7 mL/m² , (P = 0.005), while RV end-diastolic volume and strain indices decreased (123.1 ± 24.1-101.5 ± 18.3 mL/m² , P = 0.005 and -23.5 ± 2.5 to -21 ± 2.5%, P = 0.002, respectively). After inserting pre-PPVI clinical, RV volumetric and deformation parameters in a multiple regression model, only time after last surgical correction causing PR remained as significant regressor of RV remodelling [R²  = 0.60, beta = 0.387, 95%CI(0.07-0.7), P = 0.019]. Volume reduction and functional improvement were more pronounced in patients treated with PPVI earlier than 7 years after last RV outflow tract (RVOT) correction, reaching close-to-normal values.

CONCLUSIONS

Early PPVI (<7 years after last RVOT operation) is associated with a more favorable RV reverse remodelling toward normal range and should be considered, before symptoms or RV damage become apparent. © 2017 Wiley Periodicals, Inc.

Time From the Beginning of the Right Ventricle Isovolumetric Contraction to the Peak of the S Wave: A New TDI Indicator for the Non-Invasive Estimation of Pulmonary Hypertension

Background

Echocardiography is a key screening tool in the diagnostic algorithm of pulmonary hypertension (PH). In addition, tissue doppler imaging (TDI) is a promising method for the noninvasive estimation of pulmonary artery pressure (PAP).

Objectives

The aim of this study was to validate the accuracy of measuring the time from the beginning of the right ventricular isovolumetric contraction time (RV IVRT) to the peak of the S wave in the TDI of the base of the RV free wall (time to peak or TTP), as an indicator for the non-invasive estimation of pulmonary hypertension.

Patients and Methods

In this diagnostic test study, 60 consecutive patients referred for right heart catheterization (RHC) were enrolled. A pulse-wave TDI was performed before the cardiac catheterization, with a mean interval of 1 hour between the two measurements. The TDI variables, such as the RV IVRT, myocardial performance index (MPI), and the new “time to peak” parameter, were measured at the lateral basal RV free wall. The patients were divided into two sub-groups according to the RHC findings: no-PH (mean PAP < 25 mmHg) and PH (mean PAP ≥ 25 mmHg) groups. Then, we calculated the specificity and sensitivity of the TDI parameters (including the TTP) for the diagnosis of PH.

Results

In our study, the TTP showed a significant inverse relationship with the PAP. Based on our results, a TTP of less than 127 ms could be used to predict PH, with a sensitivity and specificity of about 70% (AUC = 0.746 ± 0.064).

Conclusions

Based on the results of this study, we suggest the use of a novel “time from the beginning of isovolumetric contraction to the peak of the S wave” (TTP) parameter in the TDI of the base of the RV free wall to predict PH with acceptable accuracy in comparison with RHC.

Prospective validation of right ventricular role in primary graft dysfunction after lung transplantation

Primary graft dysfunction is a significant cause of lung transplant morbidity and mortality, but its underlying mechanisms are not completely understood. The aims of the present study were: 1) to confirm that right ventricular function is a risk factor for severe primary graft dysfunction; and 2) to propose a clinical model for predicting the development of severe primary graft dysfunction.A prospective cohort study was performed over 14 months. The primary outcome was development of primary graft dysfunction grade 3. An echocardiogram was performed immediately before transplantation, measuring conventional and speckle-tracking parameters. Pulmonary artery catheter data were also measured. A classification and regression tree was made to identify prognostic models for the development of severe graft dysfunction.70 lung transplant recipients were included. Patients who developed severe primary graft dysfunction had better right ventricular function, as estimated by cardiac index (3.5±0.8 versus 2.6±0.7 L·min^-1·m^-2, p<0.01) and basal longitudinal strain (-25.7±7.3% versus -19.5±6.6%, p<0.01). Regression tree analysis provided an algorithm based on the combined use of three variables (basal longitudinal strain, pulmonary fibrosis disease and ischaemia time), allowing accurate preoperative discrimination of three distinct subgroups with low (11-20%), intermediate (54%) and high (75%) risk of severe primary graft dysfunction (area under the receiver operating characteristic curve 0.81).Better right ventricular function is a risk factor for the development of severe primary graft dysfunction. Preoperative estimation of right ventricular function could allow early identification of recipients at increased risk, who would benefit the most from careful perioperative management in order to limit pulmonary overflow.

Interobserver and Intraobserver Agreement on Qualitative Assessments of Right Ventricular Dysfunction With Echocardiography in Patients With Pulmonary Embolism

OBJECTIVES

To evaluate observer agreement using qualitative goal-directed echocardiographic criteria for right ventricular (RV) dysfunction prognostication in submassive pulmonary embolism (PE).

METHODS

Two emergency physicians and 2 cardiologists independently reviewed 31 packets of goal-directed echocardiographic video clips consisting of at least 3 windows obtained by emergency physicians from normotensive patients with PE. Nine packets were repeated to assess for intraobserver agreement. Right ventricular dysfunction criteria on goal-directed echocardiography were as follows: RV enlargement was present, with a right-to-left ventricular basal diameter ratio of 1.0 or higher and blunting of the apex of the RV in 2 or more different windows; RV systolic dysfunction was present if the tricuspid annulus moved toward the apex 10 mm or less and there was RV free wall hypokinesis; and septal deviation was present with any flattening or deviation of the ventricular septum toward the left ventricle.

RESULTS

Among the 4 participants, there was 83.9% agreement on the presence or absence of RV enlargement (κ = 0.84), 74.2% agreement on the presence or absence of RV systolic dysfunction (κ = 0.69), and 71.0% agreement on the presence or absence of septal deviation (κ = 0.59). Intraobserver agreement was 100% for each RV dysfunction variable for each observer (κ = 1.0).

CONCLUSIONS

Agreement was substantial for both severe RV enlargement and RV systolic dysfunction and moderate for septal deviation. Right ventricular dysfunction assessment with qualitative goal-directed echocardiographic criteria is reproducible for PE risk stratification.

Echocardiographic Evaluation of the Right Heart

The appropriate use of echocardiography may reduce the need for invasive diagnostic cardiac procedures. The right side of the heart has recently gained interest among cardiologists as it became clear that abnormalities of the right heart morphology and function are associated with increased morbidity and mortality. Echocardiography is easy to perform, relatively cheap, readily available and do not pose the risk of ionizing radiation. Conventional 2D and, more recently, 3D echocardiography provides pertinent anatomic and physiologic information about the right side of the heart. Because of the advantages and simplicity of echocardiography it continues to be an excellent tool for evaluating the structure and function of the right side of the heart. This review outlines the uses of echocardiography in evaluating the right heart structure and function.

A new comprehensive 12-segment approach to right ventricular systolic and diastolic functions by 2D speckle tracking echocardiography in healthy individuals

BACKGROUND

2D speckle tracking echocardiography (2DSTE) was proved to be accurate for the assessment of the RV function. However, normal values for RV strain refer mostly to 3- or 6-segment models, excluding the contribution of other RV walls to RV function. We analyze RV function by 2DSTE in a normal population, using parasternal two-(2C) and apical four-chamber (4C) RV views, and creating a new 12-segment model for a potential better definition of RV function.

METHODS

We prospectively evaluated 100 normals using 2DE and STE. We assessed the RV systolic function from regional strain (basal, mid, and apical), and at the level of each wall: lateral (LS), septal (SS), inferior (IS), and anterior (AS), and also global strain for 4C (4CGS), and 2C (2CGS). Global systolic strain rate (SRs) was measured from 2C and 4C views. Diastolic function was assessed from early (SRe) and late global strain rate (SRl), for both views.

RESULTS

A total of 70 healthy individuals (48±15 years, 34 men) were suitable for concomitant 4C and 2CRV analysis. Feasibility of the STE analysis was 87.8%. We found significantly lower SS by comparison with LS, AS, and IS (P<.001). All S/SR parameters (GS, SRs, and SRe) were higher in 2C view than in 4C view (P<.001). All systolic S/SR parameters did not change with age. The early diastolic SR decreased, while the late diastolic SR increased with age.

CONCLUSION

Our 12-segment RV strain model is feasible. Moreover, 2DSTE analysis using 2C and 4C views of the RV does not provide similar information. Rather, they offer complementary data. This might be of particularly clinical interest in diseases with regional RV dysfunction.

Three-Dimensional Tricuspid Annular Motion Analysis from Cardiac Magnetic Resonance Feature-Tracking

Right ventricular (RV) dysfunction is known to be highly correlated with mortality and morbidity; nevertheless, imaging-based assessment of RV anatomy and physiology lags far behind that of the left ventricle. In this study, we advance RV imaging using cardiac magnetic resonance (CMR) to accomplish the following aims: (i) track the motion of six tricuspid annular (TA) sites using a semi-automatic tracking system; (ii) extract clinically important TA measurements-systolic velocity (Sm), early diastolic velocity (Em), late diastolic velocity (Am), and TA plane systolic excursion (TAPSE)-for each TA site and compare these CMR-derived measurements in healthy subjects vs. patients with heart failure, repaired tetralogy of Fallot, pulmonary hypertension, and hypertrophic cardiomyopathy; (iii) investigate how the TA motion related measurements compare with information provided by invasive right heart catheterization (RHC); (iv) evaluate the rate of change in surface area swept out by the reconstructed tricuspid annulus over time and (v) assess the reproducibility of this CMR-based technique. Results indicate that TA motion parameter data obtained in three dimensions using the proposed CMR-based systematic methodology achieve superior diagnostic performance (Sm: AUC = 0.957; TAPSE: AUC = 0.981) compared to two-dimensional CMR imaging. Both Sm and TAPSE from CMR correlated positively with dP/dt _max/IP from RHC (Sm: r = 0.621, p < 0.01; TAPSE: r = 0.648, p < 0.01). Our highly reproducible and robust methodology holds potential for extending CMR imaging to characterization of TA morphology and dynamic behaviour, eventually leading to deeper understanding of RV function and improved diagnostic capability.

Effects of Obstructive Sleep Apnea and Obesity on Cardiac Remodeling: The Wisconsin Sleep Cohort Study

STUDY OBJECTIVES

To characterize the prospective associations of obstructive sleep apnea (OSA) with future echocardiographic measures of adverse cardiac remodeling.

METHODS

This was a prospective long-term observational study. Participants had overnight polysomnography followed by transthoracic echocardiography a mean (standard deviation) of 18.0 (3.7) y later. OSA was characterized by the apnea-hypopnea index (AHI, events/hour). Echocardiography was used to assess left ventricular (LV) systolic and diastolic function and mass, left atrial volume and pressure, cardiac output, systemic vascular resistance, and right ventricular (RV) systolic function, size, and hemodynamics. Multivariate regression models estimated associations between log10(AHI+1) and future echocardiographic findings. A secondary analysis looked at oxygen desaturation indices and future echocardiographic findings.

RESULTS

At entry, the 601 participants were mean (standard deviation) 47 (8) y old (47% female). After adjustment for age, sex, and body mass index, baseline log10(AHI+1) was associated significantly with future reduced LV ejection fraction and tricuspid annular plane systolic excursion (TAPSE) ≤ 15 mm. After further adjustment for cardiovascular risk factors, participants with higher baseline log10(AHI+1) had lower future LV ejection fraction (β = -1.35 [standard error = 0.6]/log10(AHI+1), P = 0.03) and higher odds of TAPSE ≤ 15 mm (odds ratio = 6.3/log10(AHI+1), 95% confidence interval = 1.3-30.5, P = 0.02). SaO2 desaturation indices were associated independently with LV mass, LV wall thickness, and RV area (all P < 0.03).

CONCLUSIONS

OSA is associated independently with decreasing LV systolic function and with reduced RV function. Echocardiographic measures of adverse cardiac remodeling are strongly associated with OSA but are confounded by obesity. Hypoxia may be a stimulus for hypertrophy in individuals with OSA.