Dynamic assessment of right ventricular volumes and function by real-time three-dimensional echocardiography: a comparison study with magnetic resonance imaging in 100 adult patients

Right Ventricle Function: The Role of the Forgotten Chamber in Mitral Valve Surgery

BACKGROUND

Referred to as the "forgotten chamber," the right ventricle (RV) is now widely acknowledged as a significant factor, particularly in certain cardiovascular pathologies. Despite historically being undervalued in comparison to the left ventricle, the RV function is deemed crucial in determining patient outcomes following mitral valve (MV) surgery. In the context of MV surgery, it is important to note that the RV is highly susceptible to dysfunction before, during, and after the surgical procedure. This vulnerability is also partly compounded by a lack of precise preoperative assessment, appropriate intraoperative management, and sufficient postoperative care for the RV. Moreover, it is notable that the current preoperative risk-score evaluation does not encompass considerations for the RV.

OBSERVATIONS

Sophisticated assessment methodologies, including echocardiography, cardiac magnetic resonance imaging, and invasive hemodynamic procedures, play a pivotal role in accurately evaluating the RV function in patients undergoing MV surgery. These methodologies offer invaluable insights into the extent of RV dysfunction both pre- and postoperatively. By furnishing precise measurements of RV performance, these techniques contribute to risk stratification, guide perioperative management, and may enhance surgical outcomes. Their integration into routine clinical practice is essential for optimizing patient care in the context of MV surgery.

CONCLUSIONS

This review highlights the importance of evaluating the RV before surgery, ensuring proper perioperative care, and utilizing advanced imaging to monitor RV function in order to predict the outcomes. The goal is to enhance surgical outcomes by thoroughly assessing and supporting RV function during the surgical process.

Detection of cardiac amyloidosis using machine learning on routine echocardiographic measurements

BACKGROUND

Cardiac amyloidosis (CA) is an underdiagnosed, progressive and lethal disease. Machine learning applied to common measurements derived from routine echocardiogram studies can inform suspicion of CA.

OBJECTIVES

Our objectives were to test a random forest (RF) model in detecting CA.

METHODS

We used 3603 echocardiogram studies from 636 patients at Cedars-Sinai Medical Center to train an RF model to predict CA from echocardiographic parameters. 231 patients with CA were compared with 405 control patients with negative pyrophosphate scans or clinical diagnosis of hypertrophic cardiomyopathy. 19 common echocardiographic measurements from echocardiogram reports were used as input into the RF model. Data was split by patient into a training data set of 2882 studies from 486 patients and a test data set of 721 studies from 150 patients. The performance of the model was evaluated by area under the receiver operative curve (AUC), sensitivity, specificity and positive predictive value (PPV) on the test data set.

RESULTS

The RF model identified CA with an AUC of 0.84, sensitivity of 0.82, specificity of 0.73 and PPV of 0.76. Some echocardiographic measurements had high missingness, suggesting gaps in measurement in routine clinical practice. Features that were large contributors to the model included mitral A-wave velocity, global longitudinal strain (GLS), left ventricle posterior wall diameter end diastolic (LVPWd) and left atrial area.

CONCLUSION

Machine learning on echocardiographic parameters can detect patients with CA with accuracy. Our model identified several features that were major contributors towards identifying CA including GLS, mitral A peak velocity and LVPWd. Further study is needed to evaluate its external validity and application in clinical settings.

Biventricular function in preterm infants with patent ductus arteriosus ligation: A three-dimensional echocardiographic study

BACKGROUND

The detailed hemodynamics after patent ductus arteriosus (PDA) ligation in preterm infants remain unknown. We aimed to clarify the effect of surgical ligation on left ventricular (LV) and right ventricular (RV) volume and function.

METHODS

Echocardiography was performed in 41 preterm infants (median gestational age: 25 weeks) before and after PDA ligation. Global longitudinal strain was determined using three-dimensional speckle-tracking echocardiography. These values were compared with those in 36 preterm infants without PDA (non-PDA).

RESULTS

Preoperatively, the PDA group had greater end-diastolic volume (EDV) and cardiac output (CO) in both ventricles, a higher LV ejection fraction (LVEF) (53% vs 44%) and LV global longitudinal strain, and a lower RVEF (47% vs 52%) than the non-PDA group. At 4-8 h postoperatively, the two groups had a similar LVEDV and RVEDV. However, the PDA group had a lower EF and CO in both ventricles than the non-PDA group. At 24-48 h postoperatively, the RVEF was increased, but the LVEF remained decreased, and LVCO was increased.

CONCLUSIONS

PDA induces biventricular loading and functional abnormalities in preterm infants, and they dramatically change after surgery. Three-dimensional echocardiography may be beneficial to understand the status of both ventricles.

IMPACT

Preterm infants are at high risk of hemodynamic compromise following a sudden change in loading conditions after PDA ligation. Three-dimensional echocardiography enables quantitative and serial evaluation of ventricular function and volume in preterm infants with PDA. PDA induces biventricular loading and functional abnormalities in preterm infants, and they dramatically change after surgery.

Artificial intelligence: The future for multimodality imaging of right ventricle

The crucial pathophysiological and prognostic roles of the right ventricle in various diseases have been well-established. Nonetheless, conventional cardiovascular imaging modalities are frequently associated with intrinsic limitations when evaluating right ventricular (RV) morphology and function. The integration of artificial intelligence (AI) in multimodality imaging presents a promising avenue to circumvent these obstacles, paving the way for future fully automated imaging paradigms. This review aimed to address the current challenges faced by clinicians and researchers in integrating RV imaging and AI technology, to provide a comprehensive overview of the current applications of AI in RV imaging, and to offer insights into future directions, opportunities, and potential challenges in this rapidly advancing field.

Improvement in right heart function following kidney transplantation in esrd patients: insights from speckle tracking echocardiography analysis

Chronic kidney disease (CKD) is commonly associated with unfavorable cardiovascular outcomes and remains the leading cause of mortality in individuals with end-stage renal disease (ESRD). Despite substantial knowledge about the impact of CKD on the left heart, the right heart, which holds significant clinical relevance, has often been overlooked and inadequately assessed in ESRD patients who have undergone kidney transplant (KTx). This study aimed to evaluate the effects of KTx on the right heart chambers in ESRD patients. 57 adult KTx candidates were enrolled in this prospective longitudinal study, while 49 of them were included in the final assessment. Patients underwent a comprehensive cardiac assessment, including conventional echocardiography, speckle tracking echocardiography, and three-dimensional heart modeling both before and after surgery. Echocardiographic assessments showed significant increases in right ventricular (RV) ejection fraction, RV fractional area change (RVFAC), tricuspid annular plain systolic excursion, RV fractional shortening, right atrial (RA) reservoir, conduit, and booster strains, and RV global longitudinal strain (RVGLS). Moreover, significant reductions in RV end-diastolic volume (RVEDV), RV end-systolic volume (RVESV), RV stroke volume, RV end-diastolic diameter (RVEDD) in mid-cavity view, systolic pulmonary artery pressure was observed (all P values < 0.05). However, no significant difference was found in S velocity, as well as RVEDD in basal and apex-to-annulus view. Moreover, pre-KTx measurements of RVGLS, RVEDD (apex-to-annulus diameter), RV fractional shortening, and S velocity were predictors of RVGLS after KTx. RA conduit strain was also identified as a predictor of RA conduit strain after KTx. Additionally, age, RVEDV, RVESV, RVFAC, and RA reservoir strain before KTx were identified as independent predictors of RA reservoir strain after KTx. The findings of this study demonstrate a significant improvement in right heart function following KTx. Furthermore, strain analysis can provide valuable insights for predicting right heart function after KTx.

Validating real-time three-dimensional echocardiography against cardiac magnetic resonance, for the determination of ventricular mass, volume and ejection fraction: a meta-analysis

INTRODUCTION

Real-time three-dimensional echocardiography (RT3DE) is currently being developed to overcome the challenges of two-dimensional echocardiography, as it is a much cheaper alternative to the gold standard imaging method, cardiac magnetic resonance (CMR). The aim of this meta-analysis is to validate RT3DE by comparing it to CMR, to ascertain whether it is a practical imaging method for routine clinical use.

METHODS

A systematic review and meta-analysis method was used to synthesise the evidence and studies published between 2000 and 2021 were searched using a PRISMA approach. Study outcomes included left ventricular end-systolic volume (LVESV), left ventricular end-diastolic volume (LVEDV), left ventricular ejection fraction (LVEF), left ventricular mass (LVM), right ventricular end-systolic volume (RVESV), right ventricular end-diastolic volume (RVEDV) and right ventricular ejection fraction (RVEF). Subgroup analysis included study quality (high, moderate), disease outcomes (disease, healthy and disease), age group (50 years old and under, over 50 years), imaging plane (biplane, multiplane) and publication year (2010 and earlier, after 2010) to determine whether they explained the heterogeneity and significant difference results generated on RT3DE compared to CMR.

RESULTS

The pooled mean differences for were - 5.064 (95% CI - 10.132, 0.004, p > 0.05), 4.654 (95% CI - 4.947, 14.255, p > 0.05), - 0.783 (95% CI - 5.630, 4.065, p > 0.05, - 0.200 (95% CI - 1.215, 0.815, p > 0.05) for LVEF, LVM, RVESV and RVEF, respectively. We found no significant difference between RT3DE and CMR for these variables. Although, there was a significant difference between RT3DE and CMR for LVESV, LVEDV and RVEDV where RT3DE reports a lower value. Subgroup analysis indicated a significant difference between RT3DE and CMR for studies with participants with an average age of over 50 years but no significant difference for those under 50. In addition, a significant difference between RT3DE and CMR was found in studies using only participants with cardiovascular diseases but not in those using a combination of diseased and healthy participants. Furthermore, for the variables LVESV and LVEDV, the multiplane method shows no significant difference between RT3DE and CMR, as opposed to the biplane showing a significant difference. This potentially indicates that increased age, the presence of cardiovascular disease and the biplane analysis method decrease its concordance with CMR.

CONCLUSION

This meta-analysis indicates promising results for the use of RT3DE, with limited difference to CMR. Although in some cases, RT3DE appears to underestimate volume, ejection fraction and mass when compared to CMR. Further research is required in terms of imaging method and technology to validate RT3DE for routine clinical use.

Right ventricular-pulmonary arterial coupling ratio derived from 3-dimensional echocardiography predicts outcomes in systemic lupus erythematosus-associated pulmonary arterial hypertension patients

BACKGROUND

Systemic lupus erythematosus (SLE) is a complex autoimmune connective tissue disease (CTD) that is an important cause of devastating pulmonary arterial hypertension (PAH), and persistent progression of PAH can lead to right heart failure, predicting a poor prognosis for SLE patients. Right ventricular-pulmonary arterial (RV-PA) coupling with echocardiography has been demonstrated to be a noninvasive alternative method for evaluating PAH patients' predictive outcomes. Whether the ratio of right ventricular stroke volume (RVSV) to right ventricular end-systolic volume (RVESV) measured by three-dimensional echocardiography (3DE) is a new index of RV-PA coupling has not been discussed as a new predictor for the clinical outcome of systemic lupus erythematosus-associated pulmonary arterial hypertension (SLE-PAH).

METHODS

From June 2019 to February 2023, 46 consecutive patients with SLE-PAH were enrolled prospectively, and their clinical data and echocardiographs were studied and analyzed. The control group consisted of 30 healthy subjects matched for age, sex, and body surface area (BSA). The main endpoints of this study were a composite of all-cause mortality and adverse clinical events. Baseline clinical characteristics and echocardiographic assessments were analyzed.

RESULTS

During a median of 24 months (IQR 18-31), 16 of 46 SLE-PAH patients (34.7%) experienced endpoint-related events. At baseline, patients who experienced mortality or adverse events had a worse WHO functional class (WHO FC) and lower anti-double-stranded DNA (dsDNA) antibody levels. The right ventricular (RV) systolic dysfunction in SLE-PAH subjects was significantly worse than that in the healthy control group, especially in SLE-PAH patients in the endpoint event group. Compared to controls, patients with SLE-PAH had a lower RVSV/RVESV ratio. In the group comparison, patients who had experienced an endpoint event had a sequentially worse ratio (1.86 (1.65-2.3) versus 1.30 (1.09-1.46) versus 0.64 (0.59-0.67), p < .001). There were statistically significant associations between the RVSV/RVESV ratio to routine RV systolic function and clinical parameters. The RVSV/RVESV ratio was negatively correlated with the WHO FC (r = -0.621, p < .001) and positively correlated with the anti-dsDNA level. The ROC curve showed that the optimal cutoff for RVSV/RVESV < 0.712 determined a higher risk of poor prognosis. Kaplan‒Meier survival curves showed that an RVSV/RVESV ratio >0.712 was associated with more favorable long-term outcomes.

CONCLUSIONS

The 3DE-derived SV/ESV ratio as a noninvasive alternative surrogate of RV-PA coupling was an eximious indicator for identifying endpoint events in SLE-PAH patients and can provide a diagnostic basis for clinical intervention.

Echocardiographic determination of right ventricular volumes and ejection fraction: Validation of a truncated cone and rhomboid pyramid formula

BACKGROUND

Echocardiographic assessment of right ventricular (RV) measurements may be challenging. The aim of this study was to develop a formula for calculation of RV volumes and function based on measurements of linear dimensions by 2-dimensional (2D) transthoracic echocardiography (TTE) in comparison to cardiovascular magnetic resonance (CMR).

METHODS

129 consecutive patients with standard TTE and RV analysis by CMR were included. A formula based on the geometric assumptions of a truncated cone minus a truncated rhomboid pyramid was developed for calculations of RV end-diastolic volume (EDV) and RV end-systolic volume (ESV) by using the basal diameter of the RV (Dd and Ds) and the baso-apical length (Ld and Ls) in apical 4-chamber TTE views: RV EDV = 1.21 * Dd2 * Ld, and RV ESV = 1.21 * Ds2 * Ls.

RESULTS

Calculations of RV EDV (ΔRV EDV = 10.2±26.4 ml to CMR, r = 0.889), RV ESV (ΔRV ESV = 4.5±18.4 ml to CMR, r = 0.921) and RV EF (ΔRV EF = 0.5±4.0% to CMR, r = 0.905) with the cone-pyramid formula (CPF) highly agreed with CMR. Impaired RV function on CMR (n = 52) was identified with a trend to higher accuracy by CPF than by conventional echocardiographic parameters (tricuspid annular plane systolic excursion (TAPSE) and fractional area change (FAC)).

CONCLUSION

Calculations of RV volumes and RV function by 2D TTE with the newly developed CPF were in high concordance to measurements by CMR. Accuracy for detection of patients with reduced RV function were higher by the proposed 2D TTE CPF method than by conventional echocardiographic parameters of TAPSE and RV FAC.

Evaluation of pulmonary artery stiffness and right ventricle functions in polycythemia vera patients by transthoracic echocardiography

INTRODUCTION

Polycythemia vera (PV) is known to be a subgroup of chronic myeloproliferative neoplasms and is recognized as a cause of pulmonary hypertension (PH). Pulmonary artery stiffness (PAS) is a relatively new noninvasive echocardiographic index developed to evaluate the structural features and functions of the pulmonary vascular bed. In this study, we aimed to evaluate right ventricular (RV) functions and PAS in PV patients and healthy controls.

METHODS

A group of 65 consecutive PV patients and 40 healthy controls were included in the study. RV global longitudinal strain (RVGLS) and RV free wall longitudinal strain were (RVFwLS) evaluated using two-dimensional (2D) strain echocardiography. RV volume, systolic and diastolic functions were evaluated with three-dimensional (3D) echocardiography. PAS was calculated using the maximum frequency shift (MFS) and acceleration time of the pulmonary artery flow trace.

RESULTS

PAS values were significantly higher in the PV group than in the control group (25.2 ± 5.2 vs. 18.2 ± 4.2, p < .001). We found that tricuspid annular plane systolic excursion (TAPSE) (p < .001), RV fractional area change (p < .001) and RV ejection fraction (p < .001) measurements evaluated by 3D echocardiography were significantly lower in the PV group.

CONCLUSION

In our study, PAS values were higher in PV patients than in the healthy control group. Patients with PV may have subclinical RV dysfunction, and PAS value can be used in the early diagnosis of PH and RV dysfunction in this patient group.

Right to left ventricular volume ratio is associated with mortality in congenital diaphragmatic hernia

BACKGROUND

Congenital diaphragmatic hernia (CDH) is associated with high neonatal mortality. We performed this study to test the hypothesis that left ventricular (LV) and right ventricular (RV) volumes assessed by three-dimensional echocardiography may be associated with mortality in CDH.

METHODS

This study was a single-center retrospective cohort study involving 35 infants with CDH. RV and LV end-diastolic volume (RVEDV and LVEDV, respectively) were measured by three-dimensional echocardiography and were corrected by birth body weight (BBW) on day 1. RVEDV/BBW, LVEDV/BBW, and LVEDV/RVEDV were compared between CDH survivors and non-survivors. Receiver-operating characteristic curve analysis was performed to assess the predictive ability for mortality of the echocardiographic parameters.

RESULTS

Comparing CDH non-survivors (n = 6) with survivors (n = 29), respectively, RVEDV/BBW was significantly larger (2.54 ± 0.33 vs 1.86 ± 0.35 ml/kg; P < 0.01), LVEDV/BBW was significantly smaller (0.86 ± 0.21 vs 1.22 ± 0.33 ml/kg; P < 0.001), and LVEDV/RVEDV was significantly lower (0.34 ± 0.06 vs 0.66 ± 0.18; P < 0.001). The area under the curve for LVEDV/RVEDV was the largest (0.98).

CONCLUSIONS

Three-dimensional echocardiographic volume imbalance between the RV and LV was remarkable in CDH non-survivors. The LVEDV/RVEDV ratio may be associated with mortality in CDH.

IMPACT

Mortality with congenital diaphragmatic hernia (CDH) is high, and evaluating left and right ventricular structures and functions may be helpful in assessing the prognosis. Three-dimensional (3D) echocardiography indicated that the left ventricular end-diastolic volume/right ventricular end-diastolic volume ratio within 24 h after birth was associated with mortality in CDH infants. The usefulness of this ratio should be validated in prospective multicenter studies involving larger numbers of patients.

The Dysfunctional Right Ventricle in Dilated Cardiomyopathies: Looking from the Right Point of View

Dilated cardiomyopathies (DCMs) are a heterogenous group of primary myocardial diseases, representing one of the leading causes of heart failure, and the main indication for heart transplantation. While the degree of left ventricular dilation and dysfunction are two key determinants of adverse outcomes in DCM patients, right ventricular (RV) remodeling and dysfunction further negatively influence patient prognosis. Consequently, RV functional assessment and diagnosing RV involvement by using an integrative approach based on multimodality imaging is of paramount importance in the evaluation of DCM patients and provides incremental prognostic and therapeutic information. Transthoracic echocardiography remains the first-line imaging modality used for the assessment of the RV, and newer techniques such as speckle-tracking and three-dimensional echocardiography significantly improve its diagnostic and prognostic accuracy. Nonetheless, cardiac magnetic resonance (CMR) is considered the gold standard imaging modality for the evaluation of RV size and function, and all DCM patients should be evaluated by CMR at least once. Accordingly, this review provides a comprehensive overview of the anatomy and function of the RV, and the pathophysiology, diagnosis, and prognostic value of RV dysfunction in DCM patients, based on traditional and novel imaging techniques.

Venous waveform analysis detects acute right ventricular failure in a rat respiratory arrest model

BACKGROUND

Peripheral intravenous analysis (PIVA) has been shown to be more sensitive than central venous pressure (CVP) for detecting hemorrhage and volume overload. We hypothesized that PIVA is superior to CVP for detecting right ventricular (RV) failure in a rat model of respiratory arrest.

METHODS

Eight Wistar rats were studied in accordance with the ARRIVE guidelines. CVP, mean arterial pressure (MAP), and PIVA were recorded. Respiratory arrest was achieved with IV Rocuronium. PIVA utilizes Fourier transform to quantify the amplitude of the peripheral venous waveform, expressed as the "f1 amplitude". RV diameter was measured with transthoracic echocardiography.

RESULTS

RV diameter increased from 0.34 to 0.54 cm during arrest, p = 0.001, and returned to 0.33 cm post arrest, p = 0.97. There was an increase in f1 amplitude from 0.07 to 0.38 mmHg, p = 0.01 and returned to 0.08 mmHg, p = 1.0. MAP decreased from 119 to 67 mmHg, p = 0.004 and returned to 136 mmHg, p = 0.50. There was no significant increase in CVP from 9.3 mmHg at baseline to 10.5 mmHg during respiratory arrest, p = 0.91, and recovery to 8.6 mmHg, p = 0.81.

CONCLUSIONS

This study highlights the utility of PIVA to detect RV failure in small-caliber vessels, comparable to peripheral veins in the human pediatric population.

IMPACT

Right ventricular failure remains a diagnostic challenge, particularly in pediatric patients with small vessel sizes limiting invasive intravascular monitor use. Intravenous analysis has shown promise in detecting hypovolemia and volume overload. Intravenous analysis successfully detects right ventricular failure in a rat respiratory arrest model. Intravenous analysis showed utility despite utilizing small peripheral venous access and therefore may be applicable to a pediatric population. Intravenous analysis may be helpful in differentiating various types of shock.

Comparison between Automatic and Semiautomatic System for the 3D Echocardiographic Multiparametric Evaluation of RV Function and Dimension

Background: The right ventricle (RV) plays a pivotal role in cardiovascular diseases and 3-dimensional echocardiography (3DE) has gained acceptance for the evaluation of RV volumes and function. Recently, a new artificial intelligence (AI)–based automated 3DE software for RV evaluation has been proposed and validated against cardiac magnetic resonance. The aims of this study were three-fold: (i) feasibility of the AI-based 3DE RV quantification, (ii) comparison with the semi-automatic 3DE method and (iii) assessment of 2-dimensional echocardiography (2DE) and strain measurements obtained automatically. Methods: A total of 203 subject (122 normal and 81 patients) underwent a 2DE and both the semi-automatic and automatic 3DE methods for Doppler standard, RV volumes and ejection fraction (RVEF) measurements. Results: The automatic 3DE method was highly feasible, faster than 2DE and semi-automatic 3DE and data obtained were comparable with traditional measurements. Both in normal subjects and patients, the RVEF was similar to the two 3DE methods and 2DE and strain measurements obtained by the automated system correlated very well with the standard 2DE and strain ones. Conclusions: results showed that rapid analysis and excellent reproducibility of AI-based 3DE RV analysis supported the routine adoption of this automated method in the daily clinical workflow.

Comprehensive echocardiographic evaluation of the right heart in patients with pulmonary vascular diseases: the PVDOMICS experience

AIMS

There is a wide spectrum of diseases associated with pulmonary hypertension, pulmonary vascular remodelling, and right ventricular dysfunction. The NIH-sponsored PVDOMICS network seeks to perform comprehensive clinical phenotyping and endophenotyping across these disorders to further evaluate and define pulmonary vascular disease.

METHODS AND RESULTS

Echocardiography represents the primary non-invasive method to phenotype cardiac anatomy, function, and haemodynamics in these complex patients. However, comprehensive right heart evaluation requires the use of multiple echocardiographic parameters and optimized techniques to ensure optimal image acquisition. The PVDOMICS echo protocol outlines the best practice approach to echo phenotypic assessment of the right heart/pulmonary artery unit.

CONCLUSION

Novel workflow processes, methods for quality control, data for feasibility of measurements, and reproducibility of right heart parameters derived from this study provide a benchmark frame of reference. Lessons learned from this protocol will serve as a best practice guide for echocardiographic image acquisition and analysis across the spectrum of right heart/pulmonary vascular disease.

Utility of Real-Time Three-Dimensional Echocardiography for the Assessment of Right Ventricular Morphology and Function in Large Animal Models

Real-time three-dimensional echocardiography (RT3DE) enables a noninvasive assessment of right ventricular (RV) morphology. However, no study has evaluated the relationship between RV function obtained by RT3DE and RV pressure-volume loops. This hypothesis-driven, experimental study aimed to assess the utility of RT3DE in the evaluation of RV morphology and function. Ten anesthetized beagle dogs sequentially underwent dobutamine infusion, acute infusion of lactated Ringer’s solution, and furosemide administration to alter RV contractility and loading conditions. RV pressure-volume loop-derived hemodynamic measurements and echocardiography, including two-dimensional speckle-tracking echocardiography and RT3DE, were performed in each study protocol. Bland−Altman analysis showed strong agreement in RV volume, ejection fraction, and stroke volume obtained by right heart catheterization and RT3DE. Multiple regression analyses revealed that the peak myocardial velocity of the lateral tricuspid annulus (RV s’) and global RV longitudinal strain rate were significantly associated with end-systolic elastance (adjusted r2 = 0.66, p < 0.001). RV s’, RV free wall longitudinal strain, and RT3DE-derived stroke volume/end-systolic RV volume ratio were associated with RV pressure-volume loops-derived end-systolic/arterial elastance ratio (adjusted r2 = 0.34, p < 0.001). RT3DE could detect the changes in catheterization-derived RV volume with a strong agreement and might be useful in estimating RV-pulmonary arterial coupling.

High-Throughput Precision Phenotyping of Left Ventricular Hypertrophy With Cardiovascular Deep Learning

IMPORTANCE

Early detection and characterization of increased left ventricular (LV) wall thickness can markedly impact patient care but is limited by under-recognition of hypertrophy, measurement error and variability, and difficulty differentiating causes of increased wall thickness, such as hypertrophy, cardiomyopathy, and cardiac amyloidosis.

OBJECTIVE

To assess the accuracy of a deep learning workflow in quantifying ventricular hypertrophy and predicting the cause of increased LV wall thickness.

DESIGN, SETTINGS, AND PARTICIPANTS

This cohort study included physician-curated cohorts from the Stanford Amyloid Center and Cedars-Sinai Medical Center (CSMC) Advanced Heart Disease Clinic for cardiac amyloidosis and the Stanford Center for Inherited Cardiovascular Disease and the CSMC Hypertrophic Cardiomyopathy Clinic for hypertrophic cardiomyopathy from January 1, 2008, to December 31, 2020. The deep learning algorithm was trained and tested on retrospectively obtained independent echocardiogram videos from Stanford Healthcare, CSMC, and the Unity Imaging Collaborative.

MAIN OUTCOMES AND MEASURES

The main outcome was the accuracy of the deep learning algorithm in measuring left ventricular dimensions and identifying patients with increased LV wall thickness diagnosed with hypertrophic cardiomyopathy and cardiac amyloidosis.

RESULTS

The study included 23 745 patients: 12 001 from Stanford Health Care (6509 [54.2%] female; mean [SD] age, 61.6 [17.4] years) and 1309 from CSMC (808 [61.7%] female; mean [SD] age, 62.8 [17.2] years) with parasternal long-axis videos and 8084 from Stanford Health Care (4201 [54.0%] female; mean [SD] age, 69.1 [16.8] years) and 2351 from CSMS (6509 [54.2%] female; mean [SD] age, 69.6 [14.7] years) with apical 4-chamber videos. The deep learning algorithm accurately measured intraventricular wall thickness (mean absolute error [MAE], 1.2 mm; 95% CI, 1.1-1.3 mm), LV diameter (MAE, 2.4 mm; 95% CI, 2.2-2.6 mm), and posterior wall thickness (MAE, 1.4 mm; 95% CI, 1.2-1.5 mm) and classified cardiac amyloidosis (area under the curve [AUC], 0.83) and hypertrophic cardiomyopathy (AUC, 0.98) separately from other causes of LV hypertrophy. In external data sets from independent domestic and international health care systems, the deep learning algorithm accurately quantified ventricular parameters (domestic: R2, 0.96; international: R2, 0.90). For the domestic data set, the MAE was 1.7 mm (95% CI, 1.6-1.8 mm) for intraventricular septum thickness, 3.8 mm (95% CI, 3.5-4.0 mm) for LV internal dimension, and 1.8 mm (95% CI, 1.7-2.0 mm) for LV posterior wall thickness. For the international data set, the MAE was 1.7 mm (95% CI, 1.5-2.0 mm) for intraventricular septum thickness, 2.9 mm (95% CI, 2.4-3.3 mm) for LV internal dimension, and 2.3 mm (95% CI, 1.9-2.7 mm) for LV posterior wall thickness. The deep learning algorithm accurately detected cardiac amyloidosis (AUC, 0.79) and hypertrophic cardiomyopathy (AUC, 0.89) in the domestic external validation site.

CONCLUSIONS AND RELEVANCE

In this cohort study, the deep learning model accurately identified subtle changes in LV wall geometric measurements and the causes of hypertrophy. Unlike with human experts, the deep learning workflow is fully automated, allowing for reproducible, precise measurements, and may provide a foundation for precision diagnosis of cardiac hypertrophy.

Quantification of chronic aortic regurgitation using left and right ventricular stroke volumes obtained from two new automated three-dimensional transthoracic echocardiographic software: feasibility and accuracy

The present study aimed to evaluate the feasibility and accuracy of chronic aortic regurgitation (CAR) quantification using left and right ventricular stroke volumes (LVSV and RVSV, respectively) obtained from two new automated three-dimensional transthoracic echocardiographic software-Dynamic HeartModel (DHM) and 3D Auto RV. Patients (n=116) with more than mild isolated CAR were included and divided into two groups: central (n=53) and eccentric CAR (n=63) groups. LVSV and RVSV were automatically measured by DHM and 3D Auto RV. Next, aortic regurgitant volume (ARVol) was calculated three ways: as the difference between LVSV and RVSV, by the two-dimensional proximal isovelocity surface area (PISA) method, and using effective regurgitant orifice area derived from real-time three-dimensional echocardiography (RT3DE) multiplied by CAR velocity time integral (the reference standard). DHM plus 3D Auto RV correlated well with RT3DE in ARVol measurement in both groups (central, r = 0.90; eccentric, r = 0.96), with no significant difference based on consistency analysis. In the eccentric group, PISA led to an obvious underestimation (mean difference= - 4.20 ml, P < 0.05). The kappa agreement between DHM plus 3D Auto RV and RT3DE in grading CAR severity in both groups was good (central, k = 0.89; eccentric, k = 0.86), but that between PISA and RT3DE in the eccentric CAR group was suboptimal (k = 0.74). This study indicates that ARVol quantification using DHM plus 3D Auto RV is feasible and reproducible in patients with more than mild isolated CAR. This new method has great correlation and agreement with RT3DE in ARVol measurement, with evident advantages over PISA in eccentric CAR.

Three-Dimensional Echocardiography Assessment of Right Ventricular Volumes and Function: Technological Perspective and Clinical Application

Right ventricular (RV) function has important prognostic value in a variety of cardiovascular diseases. Due to complex anatomy and mode of contractility, conventional two-dimensional echocardiography does not provide sufficient and accurate RV function assessment. Currently, three-dimensional echocardiography (3DE) allows for an excellent and reproducible assessment of RV function owing to overcoming these limitations of traditional echocardiography. This review focused on 3DE and discussed the following points: (i) acquisition of RV dataset for 3DE images, (ii) reliability, feasibility, and reproducibility of RV volumes and function measured by 3DE with different modalities, (iii) the clinical application of 3DE for RV function quantification.

The right ventricular involvement in dilated cardiomyopathy: prevalence and prognostic implications of the often-neglected child

Dilated cardiomyopathy (DCM) is a primary heart muscle disease characterized by left or biventricular systolic impairment. Historically, most of the clinical attention has been devoted to the evaluation of left ventricular function and morphology, while right ventricle (RV) has been for many years the forgotten chamber. Recently, progresses in cardiac imaging gave clinicians precious tools for the evaluation of RV, raising the awareness of the importance of biventricular assessment in DCM. Indeed, RV involvement is far from being uncommon in DCM, and the presence of right ventricular dysfunction (RVD) is one of the major negative prognostic determinants in DCM patients. However, some aspects such as the possible role of specific genetic mutations in determining the biventricular phenotype in DCM, or the lack of specific treatments able to primarily counteract RVD, still need research. In this review, we summarized the current knowledge on RV involvement in DCM, giving an overview on the epidemiology and pathogenetic mechanisms implicated in determining RVD. Furthermore, we discussed the imaging techniques to evaluate RV function and the role of RV failure in advanced heart failure.

4D imaging of fetal right ventricle-feasibility study and a review of the literature

Functional analysis of the fetal cardiovascular system is crucial for the assessment of fetal condition. Evaluation of the right ventricle with standard 2D echocardiography is challenging due to its complex geometry and irregular muscle fibers arrangement. Software package TOMTEC 4D RV-Function is an analysis tool which allows assessment of right ventricular function based on volumetric measurements and myocardial deformation. The aim of this study was to determine the feasibility of this method in fetal echocardiography. The retrospective study was conducted in the high-flow Referral Center for Fetal Cardiology. We recorded 4D echocardiographic sequences of 46 fetuses with normal hearts. Following parameters were calculated: end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV) and ejection fraction (EF), right ventricle longitudinal free-wall (RVLS free-wall) and septal strain (RVLS septum). Tei index was calculated as a standard measure or RV function for comparison. 4D assessment was feasible in 38 out of 46 fetuses (83%). RV volumetric parameters-EDV, ESV and SV-increased exponentially with gestational age. Functional parameters-RV Tei index, EF and strains-were independent of gestational age. Mean EF was 45.2% (± 6%), RV free-wall strain was - 21.2% and RV septal strain was - 21.5%. There was a statistically significant correlation between septal and free-wall strains (r = 0.51, p = 0.001) as well as between EF and RV free-wall strain (r = - 0.41, p = 0.011). 4D RV assessment is feasible in most fetuses. Its clinical application should be further investigated in larger prospective studies.

Subclinical right ventricular dysfunction in patients with mitral stenosis

BACKGROUND

Right ventricular (RV) dysfunction is a strong predictor of poor outcomes of patients with mitral stenosis (MS). The aim of this study was to detect a subclinical right ventricular dysfunction in patients with MS.

METHODS

We conducted a prospective study from January 2015 to June 2019 in 104 asymptomatic patients with MS (mean age: 46.1 ± 4.27 years), and compared to a group of 52 age and sex matched healthy subjects. Standard and speckle tracking echocardiography were performed; parameters of RV function were measured and compared.

RESULTS

Although they were in normal range, RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), tissue Doppler and pulsed wave Doppler RV myocardial performance index (MPI) and peak systolic velocity (S') were decreased in patients with MS (p < 0.05). The global RV longitudinal strain (LSGRV) and the longitudinal strain of the free wall of the right ventricular (LSFRV) were lower in patients with MS (p, respectively, at 0.001 and < 0.001), 53.5% (n = 47) of patients had LSFRV < - 20%. A significant difference was noted between LSFRV and 2D strain of the septal wall (p = 0.002). No difference was found between patients with severe MS and moderate MS regarding LSFRV and LSGRV. No correlation between LSFRV and FAC (p = 0.85), MPI (p = 0.62), TAPSE (p = 0.31) and S' (p = 0.78) was found.

CONCLUSION

Our study showed the presence of subclinical systolic dysfunction of the right ventricle in patients with MS.

A Clinical Approach to Multimodality Imaging in Pulmonary Hypertension

Pulmonary hypertension (PH) is a clinical condition characterized by progressive elevations in mean pulmonary artery pressures and right ventricular dysfunction, associated with significant morbidity and mortality. For resting PH to develop, ~50-70% of the pulmonary vasculature must be affected, suggesting that even mild hemodynamic abnormalities are representative of advanced pulmonary vascular disease. The definitive diagnosis of PH is based upon hemodynamics measured by right heart catheterization; however this is an invasive and resource intense study. Early identification of pulmonary vascular disease offers the opportunity to improve outcomes by instituting therapies that slow, reverse, or potentially prevent this devastating disease. Multimodality imaging, including non-invasive modalities such as echocardiography, computed tomography, ventilation perfusion scans, and cardiac magnetic resonance imaging, has emerged as an integral tool for screening, classifying, prognosticating, and monitoring response to therapy in PH. Additionally, novel imaging modalities such as echocardiographic strain imaging, 3D echocardiography, dual energy CT, FDG-PET, and 4D flow MRI are actively being investigated to assess the severity of right ventricular dysfunction in PH. In this review, we will describe the utility and clinical application of multimodality imaging techniques across PH subtypes as it pertains to screening and monitoring of PH.

Right Ventricular Volumes, Ejection Fraction, and Systolic Function Indices in Normal Neonates by Three-Dimensional Speckle-Tracking Echocardiography

The aim of this study was to test the feasibility of measuring right ventricular (RV) volumes, ejection fraction (EF), and systolic function indices in neonates using three-dimensional speckle-tracking echocardiography (3D-STE). Thirty-eight neonates underwent complete echocardiographic evaluation, including the acquisition of three full-volume 3D datasets or more from each of the apical, parasternal, and subcostal windows while naturally sleeping. Datasets were analyzed using a commercially available software (Tomtec). Global RV 3D volumes and EF were measured. In addition, 2D free wall longitudinal strain (LS), tricuspid valve annulus (TVA), tricuspid annular plane systolic excursion (TAPSE) and its index to RV length (TAPSEi), and fractional area change (FAC) were obtained from a non-shortened apical 4-chamber view of the RV, derived from the 3D dataset. Three or more datasets obtained from the apical window were available for analysis for each subject. At least one dataset was adequate for analysis in all subjects. Mean indexed 3D diastolic, systolic, stroke volumes, and EF were measured at 28.5 ± 3.4 ml/m², 13 ± 2.0 ml/m², 15.6 ± 1.9 ml/m², and 54.6 ± 3.2%, respectively. Free wall 2D LS was calculated at (- 27.9 ± 2.5%). In addition, mean TVA measured 11.1 ± 0.8 mm, TAPSE measured 6.8 ± 0.9 mm, and TAPSEi and FAC were calculated at 24.2 ± 2.1 and 46 ± 3.4%, respectively. 3D-STE is feasible in normal neonates without the need for sedation. Reference values of RV 3D volumes and 2D indices of systolic function were obtained. These data could be helpful in patients where the size or systolic function of the RV is in question. Larger studies are required to establish nomograms for the above indices in this age group.

Value of 3D right ventricular function over 2D assessment in acute pulmonary embolism

BACKGROUND

Pulmonary embolism (PE) is a common life-threatening disease, with mortality related to right ventricular (RV) dysfunction.

AIMS

To investigate the value of 3D global and regional RV strain in patients with acute PE and at 1 month, as compared to a control population.

METHODS AND RESULTS

We conducted a longitudinal case-control prospective study, including 24 consecutive intermediate-risk PE patients. All patients underwent 2D and 3D transthoracic echocardiography within 12 hours of PE diagnosis and 1 month after hospital discharge. A control group was recruited, consisting of healthy volunteers matched on age and sex with PE patients. 3D RV echocardiographic sequences were analyzed by commercial RV-specific software and output meshes were post-processed to extract regional deformation. 3D echocardiographic 1-month follow-up was available in 18 patients. During acute PE, area strain was substantially altered in the RV free wall and within the trabecular septum. PE patients initially had RV dysfunction as assessed by 2D and 3D parameters. At follow-up, 2D parameters were restored compared to the control group, contrary to 3D RV area and circumferential strains. The McConnell's sign was identified in 83% of patients and was associated with reduced apical and global RV area strain.

CONCLUSIONS

Our 3D RV strain study demonstrates an incomplete recovery of 3D strain parameters 1 month after an episode of intermediate-risk acute PE despite restored 2D parameters. Further studies are required to assess the prognostic role and implications of this residual RV strain impairment after PE.

Contraction Patterns of the Right Ventricle Associated with Different Degrees of Left Ventricular Systolic Dysfunction

Supplemental Digital Content is available in the text.

Background:

The functional adaptation of the right ventricle (RV) to the different degrees of left ventricular (LV) dysfunction remains to be clarified. We sought to (1) assess the changes in RV contraction pattern associated with the reduction of LV ejection fraction (EF) and (2) analyze whether the assessment of RV longitudinal, radial, and anteroposterior motion components of total RVEF adds prognostic value.

Methods:

Consecutive patients with left-sided heart disease who underwent clinically indicated transthoracic echocardiography were enrolled in a single-center prospective observational study. Adverse outcome was defined as heart failure hospitalization or cardiac death. Cross-sectional analysis using the baseline 3-dimensional echocardiography studies was performed to quantify the relative contribution of the longitudinal, radial, and anteroposterior motion components to total RVEF.

Results:

We studied 292 patients and followed them for 6.7±2.2 years. In patients with mildly and moderately reduced LVEF, the longitudinal and the anteroposterior components of RVEF decreased significantly, while the radial component increased resulting in preserved total RVEF (RVEF: 50% [46%–54%] versus 47% [44%–52%] versus 46% [42%–49%] in patients with no, mild, or moderate LV dysfunction, respectively; data presented as median and interquartile range). In patients with severe LV systolic dysfunction (n=34), a reduction in all 3 RV motion components led to a significant drop in RVEF (30% [25%-39%], P<0.001). In patients with normal RVEF (>45%), the anteroposterior component of total RVEF was a significant and independent predictor of outcome (hazard ratio, 0.960 [CI, 0.925–0.997], P<0.001).

Conclusions:

In patients with left-sided heart disease, there is a significant remodeling of the RV associated with preservation of the RVEF in patients with mild or moderate LV dysfunction. In patients with normal RVEF, the measurement of the anteroposterior component of RV motion provided independent prognostic value.

3D Echocardiography for Rheumatic Heart Disease Analysis: Ready for Prime Time

Rheumatic heart disease (RHD) remains to be a very important health issue worldwide, mainly in underdeveloped countries. It continues to be a leading cause of morbidity and mortality throughout developing countries. RHD is a delayed non-suppurative immunologically mediated inflammatory response to the throat infection caused by a hemolytic streptococcus from the A group (Streptococcus pyogenes). RHD keeps position 1 as the most common cardiovascular disease in young people aged <25 years considering all the continents. The disease can lead to valvular cardiac lesions as well as to carditis. Rheumatic fever valvular injuries lead most commonly to the fusion and thickening of the edges of the cusps and to the fusion, thickening, and shortening of the chordae and ultimately to calcification of the valves. Valvular commissures can also be deeply compromised, leading to severe stenosis. Atrial and ventricular remodeling is also common following rheumatic infection. Mixed valvular lesions are more common than isolated valvular disorders. Echocardiography is the most relevant imaging technique not only to provide diagnostic information but also to enable prognostic data. Further, it presents a very important role for the correction of complications after surgical repair of rheumatic heart valvulopathies. Three-dimensional (3D) echocardiography provides additional anatomical and morphofunctional information of utmost importance for patients presenting rheumatic valvopathies. Accordingly, three-dimensional echocardiography is ready for routine use in patients with RHD presenting with valvular abnormalities.

Echocardiography in Pulmonary Arterial Hypertension: Is It Time to Reconsider Its Prognostic Utility?

Pulmonary arterial hypertension (PAH) is characterized by an insult in the pulmonary vasculature, with subsequent right ventricular (RV) adaptation to the increased afterload that ultimately leads to RV failure. The awareness of the importance of RV function in PAH has increased considerably because right heart failure is the predominant cause of death in PAH patients. Given its wide availability and reduced cost, echocardiography is of paramount importance in the evaluation of the right heart in PAH. Several echocardiographic parameters have been shown to have prognostic implications in PAH; however, the role of echocardiography in the risk assessment of the PAH patient is limited under the current guidelines. This review discusses the echocardiographic evaluation of the RV in PAH and during therapy, and its prognostic implications, as well as the potential significant role of repeated echocardiographic assessment in the follow-up of patients with PAH.

The prognostic value of right ventricular longitudinal strain and 3D ejection fraction in patients with dilated cardiomyopathy

Several studies showed that right ventricular (RV) dysfunction is a powerful predictor in heart failure (HF). Advanced echocardiographic techniques such as speckle-tracking imaging and three-dimensional (3D) echocardiography proved to be accurate tools for RV assessment, but their clinical significance remains to be clarified. The aim of this study was to evaluate the role of two-dimensional (2D) RV strain and 3D ejection fraction (RVEF) in predicting adverse outcome in patients with non-ischemic dilated cardiomyopathy (DCM). We prospectively screened 81 patients with DCM and sinus rhythm, 50 of whom were enrolled and underwent comprehensive echocardiography, including RV strain and 3D RV volumetric assessment. Patients were followed for a composite endpoint of cardiac death, nonfatal cardiac arrest and acute worsening of HF requiring hospitalization. After a median follow-up of 16 months, 29 patients reached the primary endpoint. Patients with events had more impaired RV global longitudinal strain (− 10.5 ± 4.5% vs. − 14.3 ± 5.2%, p = 0.009), RV free wall longitudinal strain (− 12.9 ± 8.7% vs. − 17.5 ± 7.1%, p = 0.046) and 3D RVEF (38 ± 8% vs. 47 ± 9%, p = 0.001). By Cox proportional hazards multivariable analysis, RV global longitudinal strain and RVEF were independent predictors of outcome after adjustment for age and NYHA class. RVEF remained the only independent predictor of events after further correction for echocardiographic risk factors. By receiver-operating characteristic analysis, the optimal RVEF cut-off value for event prediction was 43.4% (area under the curve = 0.768, p = 0.001). Subjects with RVEF > 43.4% showed more favourable outcome compared to those with RVEF < 43.4% (log-rank test, p < 0.001). In conclusion, 3D RVEF is an independent predictor of major adverse cardiovascular events in patients with DCM.

Echocardiographic evaluation of the Athlete's heart

Cardiac response to prolonged, intense exercise induces phenotypic and physiologic adaptive changes that improve myocardial ability to meet oxygen demands. These adaptations, termed "athletes' heart," have been extensively studied. The importance of this entity arises from the increasing numbers of athletes as well as the drive for physical fitness in the general population leading to adaptive cardiac changes that need to be differentiated from life-threatening cardiovascular diseases. A number of pathologic entities may share phenotypic changes with the athletes' heart such as hypertrophic cardiomyopathy, dilated cardiomyopathy, Marfan's syndrome, and arrhythmogenic right ventricular cardiomyopathy. Cardiologists need to be cognizant of these overlapping findings to appropriately diagnose diseases and prevent catastrophic outcomes especially in young and healthy individuals who may not show any symptoms until they engage in intense exercise. It is equally important to recognize and distinguish normal, exercise-adaptive cardiac changes to provide accurate screening and guidance to young elite athletes. Echocardiography is a valuable modality that allows comprehensive initial evaluation of cardiac structures, function, and response to exercise. Several different echocardiographic techniques including M-Mode, 2D echo, Doppler, tissue Doppler, color tissue Doppler, and speckle tracking have been used in the evaluation of cardiac adaptation to exercise. The following discussion is a review of literature that has expanded our knowledge of the athlete's heart.

Forgotten No More-The Role of Right Ventricular Dysfunction in Heart Failure with Reduced Ejection Fraction: An Echocardiographic Perspective

During the last decade, studies have raised awareness of the crucial role that the right ventricle plays in various clinical settings, including diseases primarily linked to the left ventricle. The assessment of right ventricular performance with conventional echocardiography is challenging. Novel echocardiographic techniques improve the functional assessment of the right ventricle and they show good correlation with the gold standard represented by cardiac magnetic resonance. This review summarizes the traditional and innovative echocardiographic techniques used in the functional assessment of the right ventricle, focusing on the role of right ventricular dysfunction in heart failure with reduced ejection fraction and providing a perspective on recent evidence from literature.

Assessment of Subclinical Deterioration of Right Ventricular Function by Three-Dimensional Speckle Tracking Echocardiography in Breast Cancer Patients Undergoing Anthracycline-Based Chemotherapy

Objective

This study was aimed at assessing the longitudinal strain changes of RV function using three-dimensional speckle tracking echocardiography (3D STE) in breast cancer patients receiving anthracycline chemotherapy.

Patients and Methods

A total of 95 women with breast cancer receiving epirubicin (360 mg/m²) underwent 3D STE at baseline, the end of chemotherapy and 12 months after chemotherapy. 3D STE assessment included RV ejection fraction (EF), LV global longitudinal strain (GLS), RV GLS, and RV free wall longitudinal strain (RV FWLS). Meanwhile, serum hs‐cTnI and NT-proBNP were measured. Chemotherapy-related cardiac dysfunction (CTRCD) was defined as an absolute decrease in 3D LVEF > 10% to a value <50%, while a percent reduction of 3D LV GLS > 15% indicated subclinical CTRCD.

Results

Subclinical CTRCD occurred in 10 (10.5%) patients during follow-up. Compared to baseline, the 3D GLS of LV and GLS and FWLS of RV decreased significantly at 12months after chemotherapy (all p<0.01). Variations of 3D RV GLS and RV FWLS had a good discrimination for predicting subclinical CTRCD. The variation of 3D RV FWLS was the only independent predictor of subclinical CTRCD (OR, 1.37; 95% CI, 1.12–2.87; p = 0.028) in multivariate analysis. The cutoff value with −17.5% of 3D RV FWLS variation had a high predictive accuracy for subclinical CTRCD, with an AUC of 0.74, 80.5% sensitivity and 65.8% specificity. The association between 3D RV FWLS and the cumulative dose of anthracyclines was calculated by Spearman’s test (r = −0.71, p < 0.001).

Conclusion

Longitudinal strain analysis by 3D STE allows the identification of subclinical RV dysfunction when conventional indices of RV function are unaffected. 3D RV FWLS was superior to other parameters in early detection of the development of CTRCD in breast cancer patients receiving epirubicin therapy.

Right ventricular dysfunction in patients with diffuse large B-cell lymphoma undergoing anthracycline-based chemotherapy: a 2D strain and 3D echocardiography study

To investigate whether 2D strain and 3D echocardiography could early identify the impaired right ventricular (RV) function after anthracycline exposure. Sixty-one patients with diffuse large B-cell lymphoma treated with anthracycline were studied. Echocardiography was conducted at baseline, after the third cycle of the chemotherapy, after the completion of the chemotherapy, and follow-up at 10 months after the initiation of chemotherapy. RV global longitudinal strain (RV GLS) and RV free wall longitudinal strain (RV FWLS) were calculated using speckle tracking echocardiography. RV ejection fraction (RVEF) was analyzed by 3D echocardiography. RV systolic dysfunction was defined by ≥ 2 RV parameters below the threshold value, and cardiotoxicity was defined as a reduction in left ventricular EF > 10 to < 53%. After the third cycle of chemotherapy, only RV GLS was significantly decreased, while after the completion of the chemotherapy, RV GLS, RV FWLS, and RVEF were all significantly decreased compared with baseline measurements. At the end of follow-up, 9 patients (14.8%) were diagnosed with RV systolic dysfunction, and 16 patients (26.2%) had at least 1 abnormal RV function parameter. The proportion of RV systolic dysfunction was significantly higher in patients with cardiotoxicity than in patients without cardiotoxicity, yielding an odds ratio of 5.143. A percentage decrease in RV FWLS and RVEF were independent predictors of RV systolic dysfunction. Two-dimensional strain and 3D echocardiography are valuable methods for evaluating anthracycline-related impairment of RV function in DLBCL patients receiving chemotherapy. RV FWLS and RVEF are reliable predictors of RV systolic dysfunction.

Evaluation of right ventricular performance and impact of continuous positive airway pressure therapy in patients with obstructive sleep apnea living at high altitude

Obstructive sleep apnea syndrome (OSAS) can lead to alterations in right ventricular (RV) performance and pulmonary vascular haemodynamics. Additionally, altitude-related hypoxia is associated with pulmonary vasoconstriction, and the effect of high-altitude on the pulmonary circulation in OSAS patients can be further altered. We sought to assess alterations in RV morphology and function in OSAS patients living at high altitude by way of 2-dimensional speckle tracking echocardiography (2D-STE), real-time 3- dimensional echocardiography (RT-3DE) and cardiac biomarkers. We also evaluate the impact of continuous positive airway pressure (CPAP) treatment on RV performance. Seventy-one patients with newly diagnosed OSAS and thirty-one controls were included in this study. All individuals were assessed for cardiac biomarkers as well as underwent 2D-STE and RT-3DE. Forty-five OSAS patients underwent CPAP therapy for at least 24 weeks and were studied before and after CPAP treatment. RT-3DE was used to measure RV volume, and calculate RV 3D ejection fraction (3D RVEF). Peak systolic strain was determined. Cardiac biomarkers, including C-reactive protein (CRP), N-terminal pro-B-type natriuretic peptide, and cardiac troponin T were also measured. Right atrium volume index, RV volume, RV volume index, systolic pulmonary artery pressure (sPAP), pulmonary vascular resistance (PVR) and level of serum CRP were significantly higher in OSAS group, while OSAS patients showed lower 3D RVEF and RV longitudinal strains. Compared to the patients with sPAP < 40 mmHg, RV longitudinal strains in patients with sPAP ≥ 40 mmHg were lower. Both RV global longitudinal strain and sPAP were associated with apnea–hypopnea index. Patients treated with 6 months of CPAP therapy had significant improvement in RV geometry and performance. RV structural abnormalities and RV function impairments were observed in OSAS patients living at moderate high altitude compared to control highlanders. The reversibility of these changes after application of CPAP were further confirmed.

Prognostic Value of the Right Ventricular Ejection Fraction, Assessed by Fully Automated Three-Dimensional Echocardiography: A Direct Comparison of Analyses Using Right Ventricular-Focused Views versus Apical Four-Chamber Views

BACKGROUND

Right ventricular (RV) three-dimensional echocardiographic (3DE) data sets are acquired from either the RV-focused view (RVFV) or the apical four-chamber view (4CV). The prognostic value of 3DE RV ejection fraction (RVEF) was investigated using fully automated RV quantification software, and how measurement values with 3DE data sets from the RVFV compare with those from the 4CV was determined.

METHODS

One hundred seventy-four patients who had undergone both cardiac magnetic resonance (CMR) and 3DE imaging were retrospectively selected. RV 3DE data sets were acquired from both the RVFV and the 4CV and were analyzed separately using fully automated RV quantification software. Primary end points were cardiac events, including cardiac death, heart failure requiring hospitalization, nonfatal myocardial infarction, and ventricular tachyarrhythmia.

RESULTS

The feasibility of RVEF measurements on 3DE imaging from the RVFV and 4CV was 92% and 92%, respectively. There was good correlation (r = 0.83) and small bias (0.3%) between RVEF from the RVFV and that from the 4CV. Similar results were obtained when only data from patients whose echocardiograms had poor image quality in one or both views were analyzed (r = 0.83, bias = 1.7%, n = 78). Although fully automated analysis in both the RVFV and 4CV significantly underestimated RV volumes compared with CMR, neither measurement differed significantly for RVEF compared with CMR. During a median follow-up period of 12.5 months, 21 patients experienced primary end points. RVEF assessed by CMR and 3DE imaging was significantly associated with cardiac events. RVEF using fully automated analysis had a significant association with cardiac events, even in patients with poor image quality (RVFV: hazard ratio, 0.90 [P = .009, n = 44]; 4CV: hazard ratio, 0.90 [P = .009, n = 68]).

CONCLUSIONS

RV 3DE data sets from the RVFV and 4CV yielded similar RVEF values using fully automated software. RVEFs from both approaches had significant association with outcomes. Thus, both provide accurate information regarding RV function and risk for adverse outcomes.

Test–retest reliability of left and right ventricular systolic function by new and conventional echocardiographic and cardiac magnetic resonance parameters

Aims 

Reproducible evaluation of left (LV) and right ventricular (RV) function is crucial for clinical decision-making and risk stratification. We evaluated whether speckle-tracking echocardiography (STE) and cardiac magnetic resonance feature-tracking (cMR-FT) global longitudinal (GLS) and circumferential strains allow better test–retest reproducibility of LV and RV systolic function than conventional cMR and echocardiographic parameters.

Methods and results 

Thirty healthy volunteers and 20 chronic heart failure patients underwent cMR and STE twice on separate days to evaluate test–retest coefficient of variation (CV), intraclass correlation coefficient (ICC) and estimated sample sizes for significant changes in LV and RV function. Among LV parameters, cMR-left ventricular ejection fraction (LVEF) had the highest reproducibility (CV = 6.7%, ICC = 0.98), significantly better than cMR-FT-GLS (CV = 15.1%, ICC = 0.84), global circumferential strains (CV = 11.5%, ICC = 0.94) and echocardiographic LVEF (CV = 11.3%, ICC = 0.93). STE-LV-GLS (CV = 8.9%, ICC = 0.94) had significantly better reproducibility than cMR-FT-LV-GLS. Among RV parameters, STE-RV-GLS (CV = 7.3%, ICC = 0.93) had significantly better CV than cMR-right ventricular ejection fraction (RVEF) (CV = 13%, ICC = 0.82). cMR-FT-RV-GLS (CV = 43%, ICC = 0.39) performed poorly with significantly lower reproducibility than all other RV parameters. Owing to their superior interstudy reproducibility, cMR-LVEF (n = 12), cMR-RVEF (n = 41), STE-LV-GLS and STE-RV-GLS (both n = 14) were the parameters allowing the lowest calculated sample sizes to detect 10% change in LV or RV systolic function.

Conclusion 

STE-LV-GLS and STE-RV-GLS showed higher test–retest reliability than other echocardiographic measurements of LV and RV function. They also allowed smaller calculated sample sizes, supporting the use of STE-LV and RV-GLS for longitudinal follow-up of LV and RV function.

Levels of agreement between cardiac magnetic resonance and conductance catheter measurements of right ventricular volumes after pulmonary artery banding

BACKGROUND

Pressure-volume analysis is the gold standard for quantifying pump function of the right ventricle (RV); however, volume measurements based on a conductive catheter may be imprecise. The reference method for volume assessment is cardiac magnetic resonance (CMR).

PURPOSE

To determine the levels of agreement between RV volume measurements obtained by cine CMR, phase-contrast CMR (PC CMR), and a conductance catheter in an animal model.

MATERIAL AND METHODS

CMR was performed in 20 sheep three months after pulmonary artery banding. Ejection fraction (EF), end-diastolic (EDV), end-systolic (ESV), and stroke volumes (SV) were obtained by cine CMR and conductance catheter.

RESULTS

Statistically significant differences between cine CMR and conductance catheter derived volume measurements were found for EDV (P < 0.001), ESV (P < 0.05), and SV (P < 0.05). Bland-Altman analysis showed very poor agreement between the two methods: EDV, bias 36.27 mL, agreement of limits 1.96-70.57 mL; ESV, bias 15.33 mL, agreement of limits -6.89-37.55 mL; and SV, bias 20.69 mL, agreement of limits 8.01-49.10 mL. Good agreement was found for SV between cine CMR and PC CMR (bias -7.0 mL, agreement of limits -24.01-9.98 mL), while SV derived from PC CMR measurements showed poor agreement with conductance catheter (bias 27.76 mL, agreement of limits -3.84-59.26 mL).

CONCLUSION

Poor agreement between the conductance catheter and CMR RV volume measurements was found. PC CMR and cine CMR measurements of SV agreed well.

Presence and prognostic value of ventricular diastolic function in arrhythmogenic right ventricular cardiomyopathy

INTRODUCTION

Limited data exist regarding the presence and importance of diastolic parameters in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC). We sought to evaluate RV diastolic parameters and echo-based diastolic predictors of major adverse cardiovascular events (MACE).

METHOD

48 patients with a definitive diagnosis of ARVC were included and followed for 6-18 months. A comprehensive standard two-dimensional (2D) transthoracic echocardiography (TTE) with precise evaluation of systolic and diastolic indices of both ventricles was done. RV isovolumetric relaxation time (IVRT), RV myocardial performance index (MPI), and right atrial (RA) volume were evaluated.

RESULTS

48 patients (mean age = 38.5 ± 14 years; 79.2% male) were enrolled. 27.3% had grade I, 68.2% had grade II, and 4.5% had grade III RV diastolic dysfunction. In 12-month follow-up, 12 patients (25%, with mean RV3DEF = 24.8 ± 9%) experienced MACE and required hospitalization: ventricular tachyarrhythmia in 7 patients (14.6%), RV clot in 2 subjects (4.2%), and right-sided failure in 3 cases (6.3%). In logistic regression analysis, tissue Doppler velocity of tricuspid annulus (e' TV) (P = .02, OR = 0.581, CI = 0.368-0.917), peak E mitral valve (P = .043, OR = 0.95, CI = 0.913-0.999), tissue Doppler velocity of septal e' (P = .052, OR = 0.733, CI = 0.536-1.003), and MPI (P = .009, OR = 95, CI = 3.083-2942) were powerful predictors of MACE.

CONCLUSION

In our study, RV diastolic function parameters including e' TV and e' MV, RA volume and area, and RV MPI were powerful predictors of MACE and may be considered during the baseline and follow-up of the ARVC patients.

Right ventricular three-dimensional echocardiography: the current status and future perspectives

This review focused on right ventricular (RV) three-dimensional echocardiography (3DE) and discussed the following agenda. First, we summarized the clinical RV anatomy and function-related RV3DE use followed by the explanations about 3DSTE image acquisition, including pitfall. Next, we reviewed the reliability and feasibility of RV volume and RV ejection fraction measurements during the last decade. Besides, we described the techniques that might overcome the dropout images at RV anterior and out tract including the current limitations. Finally, speckle tracking echocardiography by RV3DE and novel RV shape assessment were reviewed. This review will help you get comprehensive information on the current status and future perspectives of RV3DE.

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 II: What About Catheters?

An-depth assessment of right ventricular function is important in a many perioperative settings. After exploring 2-dimensional echo-based evaluation, other proposed monitoring modalities are discussed. Pressure-based methods of right ventricular appraisal is discussed. Flow-based assessment is reviewed. An overview of the state of current right ventricular 3-dimensional echocardiography and its potential to construct clinical pressure-volume loops in conjunction with pressure measurements is provided. An overview of right ventricular assessment modalities that do not rely on 2-dimensional echocardiography is discussed. Tailored selection of monitoring modalities can be of great benefit for the perioperative physician. Integrating modalities offers optimal estimations of right ventricular function.

3-Dimensional Echocardiography: Latest Developments and Future Directions

The ongoing refinements in 3-dimensional (3D) echocardiography technology continue to expand the scope of this imaging modality in clinical cardiology by offering new features that stem from the ability to image the heart in its complete dimensionality. Over the years, countless publications have described these benefits and tested new frontiers where 3D echocardiographic imaging seemed to offer promising ways to improve patients' care. These include improved techniques for chamber quantification and novel ways to visualize cardiac valves, including 3D printing, virtual reality, and holography. The aims of this review article are to focus on the most important developments in the field in the recent years, discuss the current utility of 3D echocardiography, and highlight several interesting future directions.

The feasibility of contrast echocardiography in the assessment of right ventricular size and function

BACKGROUND

Right ventricle (RV) evaluation requires dedicated imaging to achieve a comprehensive functional and anatomical assessment. Right ventricular imaging could be technically difficult which results in suboptimal visibility and inconsistent assessment between observers. The aim of this study was to assess feasibility and the additive value of contrast enhancement for right ventricular evaluation.

METHODS

Eighty patients referred for clinically indicated echocardiography studies were included. Patients with irregular rhythms were excluded. Dedicated RV-focused view was attained; RV dimensions measured, and RV segment visualization and wall motion were assessed with and without contrast enhancement. Paired sample t test was used to compare continuous variables, Wilcoxon signed-rank test to compare segments visualization on enhanced versus (vs) nonenhanced images, and Cohen kappa coefficient to assess the agreement of wall motion between two observers. Reproducibility was measured by the absolute mean difference method.

RESULTS

A total of 240 total segments of 80 patients were analyzed, and 178 (74%) were visible on unenhanced while 221 (92%) on enhanced images, P < .05. Further, RV measurements on enhanced images were consistently larger on RV focused, SAX, and RVOT. Inter- and intra-observer reproducibility showed a higher reproducibility with a lower bias on enhanced images. Absolute agreement on RV segmental wall motion between two independent observers was higher on enhanced images. Percent agreement was 78% on UE vs 89% on CE.

CONCLUSION

Contrast RV imaging is feasible and improves RV segment visualization and inter-observer agreement. Compared with unenhanced images, RV measurements on contrast images are larger and more reproducible with lower bias.

Right Ventricular Function, Right Ventricular-Pulmonary Artery Coupling, and Heart Failure Risk in 4 US Communities: The Atherosclerosis Risk in Communities (ARIC) Study

Importance

Limited data exist on the prevalence and prognostic importance of right ventricular (RV) dysfunction for heart failure (HF) in the general population.

Objective

To assess the prevalence of RV dysfunction and its association with HF and mortality in a community-based elderly cohort.

Design, Setting, and Participants

Cross-sectional and time-to-event analysis of participants in the Atherosclerosis Risks in the Community (ARIC), a multicenter, population-based cohort study at the fifth study visit from 2011 to 2013, with a median follow-up of 4.1 years. This study included 1004 elderly participants in the ARIC study attending the fifth study visit who underwent both 3-dimensional and 2-dimensional RV echocardiography. Three-dimensional echocardiography data were analyzed between September 15, 2015, and July 24, 2016.

Exposures

Right ventricular ejection fraction (RVEF), RV-pulmonary artery (PA) coupling defined by the RVEF/PA systolic pressure (PASP) ratio, and RV longitudinal strain by 3-dimensional echocardiography.

Main Outcomes and Measures

For cross-sectional analysis, the prevalence of RV dysfunction across ACCF/AHA HF stages (0; A, at elevated risk for HF but without structural heart disease or clinical HF; B, structural heart disease but without clinical HF; and C, prevalent HF). For time-to-event analysis, a composite of incident HF hospitalization or all-cause death among participants free of HF at visit 5.

Results

Of the 1004 participants, mean (SD) age was 76 (5) years, 385 were men (38%), and 121 were black (12%). Mean (SD) RVEF was 53% (8%). Right ventricular EF, RVEF/PASP, and RV longitudinal strain were each progressively lower across advancing HF stages. Using reference limits from stage 0 participants, RVEF was abnormal in 103 asymptomatic persons with stage A HF (15%) and 27 with stage B HF (24%). Among participants free of HF at baseline, lower RVEF and worse RV-PA coupling (ie, lower RVEF/PASP ratio) both were associated with incident HF or death independent of LVEF and N-terminal pro b-type natriuretic peptide (hazard ratio, 1.20; 95% CI, 1.02-1.42 per 5% decrease in RVEF; P = .03; hazard ratio, 1.65, 95% CI, 1.15-2.37 per 0.5 unit decrease in RVEF/PASP ratio; P = .007).

Conclusions and Relevance

Right ventricular function and RV-PA coupling declined progressively across American College of Cardiology Foundation/American Heart Association HF stages. Among persons free of HF, lower RVEF was associated with incident HF or death independent of LVEF or N-terminal pro b-type natriuretic peptide.