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Nawaytou HM, Mertens LL. Noninvasive Assessment of Myocardial Work in Children. J Am Soc Echocardiogr 2024:S0894-7317(24)00217-7. [PMID: 38719130 DOI: 10.1016/j.echo.2024.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 04/29/2024] [Accepted: 04/29/2024] [Indexed: 06/07/2024]
Abstract
The noninvasive assessment of ventricular function is an ongoing challenge, with new tools and measurements always being considered and tested. The noninvasive assessment of myocardial work via the pressure-strain relationship is one of the newer tools proposed to evaluate ventricular systolic function. However, prior to using any new tool, one should understand its properties, utility, and limitations. In this commentary we focus on the noninvasive assessment of myocardial work via the pressure-strain relationship from a pediatric point of view. We address the current knowledge and limitations and propose future directions to better understand this tool.
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Affiliation(s)
- Hythem M Nawaytou
- Department of Pediatrics, Division of Cardiology, University of California San Francisco, San Francisco, California.
| | - Luc L Mertens
- Department of Cardiology, Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
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2
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Lopez L, Saurers DL, Barker PCA, Cohen MS, Colan SD, Dwyer J, Forsha D, Friedberg MK, Lai WW, Printz BF, Sachdeva R, Soni-Patel NR, Truong DT, Young LT, Altman CA. Guidelines for Performing a Comprehensive Pediatric Transthoracic Echocardiogram: Recommendations From the American Society of Echocardiography. J Am Soc Echocardiogr 2024; 37:119-170. [PMID: 38309834 DOI: 10.1016/j.echo.2023.11.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2024]
Abstract
Echocardiography is a fundamental component of pediatric cardiology, and appropriate indications have been established for its use in the setting of suspected, congenital, or acquired heart disease in children. Since the publication of guidelines for pediatric transthoracic echocardiography in 2006 and 2010, advances in knowledge and technology have expanded the scope of practice beyond the use of traditional modalities such as two-dimensional, M-mode, and Doppler echocardiography to evaluate the cardiac segmental structures and their function. Adjunct modalities such as contrast, three-dimensional, and speckle-tracking echocardiography are now used routinely at many pediatric centers. Guidelines and recommendations for the use of traditional and newer adjunct modalities in children are described in detail in this document. In addition, suggested protocols related to standard operations, infection control, sedation, and quality assurance and improvement are included to provide an organizational structure for centers performing pediatric transthoracic echocardiograms.
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Affiliation(s)
- Leo Lopez
- Department of Pediatrics Cardiology, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Palo Alto, California.
| | - Daniel L Saurers
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Piers C A Barker
- Duke Children's Hospital & Health Center, Duke University, Durham, North Carolina
| | - Meryl S Cohen
- Cardiac Center and Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Jeanine Dwyer
- Pediatric Heart Institute, Children's Hospital Colorado, Aurora, Colorado
| | - Daniel Forsha
- Ward Family Heart Center, Children's Mercy Kansas City Hospital, Kansas City, Missouri
| | - Mark K Friedberg
- Labatt Family Heart Centre, Division of Cardiology, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Wyman W Lai
- Division of Pediatric Cardiology, University of California School of Medicine, Irvine, California; Department of Pediatrics, Children's Hospital of Orange County, Orange, California
| | - Beth F Printz
- Rady Children's Hospital San Diego and University of California, San Diego, San Diego, California
| | - Ritu Sachdeva
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Neha R Soni-Patel
- Pediatric & Adult Congenital Heart Center, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Dongngan T Truong
- University of Utah and Division of Pediatric Cardiology, Primary Children's Hospital, Salt Lake City, Utah
| | - Luciana T Young
- Seattle Children's Hospital and Pediatric Cardiology, University of Washington School of Medicine, Seattle, Washington
| | - Carolyn A Altman
- Baylor College of Medicine and Texas Children's Heart Center, Texas Children's Hospital, Houston, Texas
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3
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Miles KG, Critser PJ, Evers PD, Cash M, Magness M, Geers E, O'Neil M, Gao Z, Ollberding NJ, Hirsch R. Factors leading to supranormal cardiac index in pediatric pulmonary hypertension patients treated with parenteral prostanoid therapy. Pulm Circ 2023; 13:e12264. [PMID: 37427091 PMCID: PMC10323166 DOI: 10.1002/pul2.12264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 06/06/2023] [Accepted: 06/26/2023] [Indexed: 07/11/2023] Open
Abstract
Parenteral prostanoid therapy (PPT) can result in supranormal cardiac index (SCI; >4 L/min/m2) in pediatric pulmonary hypertension (PPH) patients. We evaluated the incidence, hemodynamic factors, and outcomes associated with SCI in PPH. This retrospective cohort study included 22 PPH patients on PPT from 2005 to 2020. Hemodynamic profiles were compared between the baseline and 3-6 month follow-up catheterization in the SCI and non-SCI cohorts. Cox regression analysis examined time to composite adverse outcome (CAO; Potts shunt, lung transplant, or death) controlling for initial disease severity. SCI developed in 17 (77%) patients, of whom 11 (65%) developed SCI within 6 months. The SCI cohort was characterized by significant augmentation of cardiac index (CI) and stroke volume (SV) as well as reductions in systemic vascular resistance (SVR) and pulmonary vascular resistance (PVR). Conversely, the non-SCI cohort had unchanged SV despite a modest rise in CI as well as persistent vasoconstriction. After median follow-up of 4.3 years (range 0.2-13 years), non-SCI patients were at significantly increased risk for the CAO (5/5: three deaths, two Potts shunts) compared with SCI patients (5/17: two deaths, three lung transplants; adjusted hazard ratio 14.0 [95% confidence interval: 2.1-91.3], p < 0.001). A majority of PPH patients developed SCI within 6-12 months of starting PPT and demonstrated lower risk of adverse outcomes compared with non-SCI patients. These data suggest that change in SVR and SV after 3-6 months of PPT may be early markers of therapeutic response and prognosis.
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Affiliation(s)
- Kimberley G. Miles
- The Heart Institute, Cincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Paul J. Critser
- The Heart Institute, Cincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Patrick D. Evers
- Division of Pediatric CardiologyOregon Health and Sciences UniversityPortlandOregonUSA
| | - Michelle Cash
- The Heart Institute, Cincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Melissa Magness
- The Heart Institute, Cincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Elizabeth Geers
- The Heart Institute, Cincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Meredith O'Neil
- The Heart Institute, Cincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Zhiqian Gao
- The Heart Institute, Cincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Nicholas J. Ollberding
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
- Division of Biostatistics and EpidemiologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Russel Hirsch
- The Heart Institute, Cincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
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4
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Hiremath G, Batlivala S, Callahan R, Thatte N, Rockefeller T, Nawaytou H, Reddy SV, Hussain T, Chabiniok R, Butts R, Vettukattil J, Aregullin EO, Aldweib N, Burkhoff D, Brener MI. Clinical Applications of Pressure-Volume Assessment in Congenital Heart Disease. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100599. [PMID: 39130717 PMCID: PMC11307813 DOI: 10.1016/j.jscai.2023.100599] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 01/02/2023] [Accepted: 01/31/2023] [Indexed: 08/13/2024]
Abstract
Ventricular pressure-volume (PV) loops offer unique insights into cardiovascular mechanics. PV loops can be instrumental in improving our understanding of various congenital heart diseases, including single ventricular physiology, heart failure, and pulmonary hypertension, as well as guiding therapeutic interventions. This review focuses on the theoretical and practical foundations for the acquisition and interpretation of PV loops in congenital heart disease and discusses their clinical applications.
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Affiliation(s)
- Gurumurthy Hiremath
- Division of Pediatric Cardiology, Department of Pediatrics, Masonic Children’s Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Sarosh Batlivala
- Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ryan Callahan
- Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nikhil Thatte
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Toby Rockefeller
- Interventional Pediatric Cardiology, University of Missouri-Kansas City School of Medicine, Children’s Mercy, Kansas City, Missouri
| | - Hythem Nawaytou
- Department of Pediatrics, UCSF Benioff Children’s Hospital and the University of California, San Francisco, California
| | | | - Tarique Hussain
- Pediatric Cardiology, Children’s Medical Center, Dallas, Texas
| | | | - Ryan Butts
- Pediatric Cardiology, Children’s Medical Center, Dallas, Texas
| | - Joseph Vettukattil
- Congenital Heart Center, Spectrum Health Helen DeVos Children’s Hospital, Grand Rapids, Michigan
| | - E. Oliver Aregullin
- Congenital Heart Center, Spectrum Health Helen DeVos Children’s Hospital, Grand Rapids, Michigan
| | - Nael Aldweib
- Division of Cardiovascular Medicine, Oregon Health Sciences University, Portland, Oregon
| | - Daniel Burkhoff
- Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York
| | - Michael I. Brener
- Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York
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5
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Albani S, Stolfo D, Venkateshvaran A, Chubuchny V, Biondi F, De Luca A, Lo Giudice F, Pasanisi EM, Petersen C, Airò E, Bauleo C, Ciardetti M, Coceani M, Formichi B, Spiesshoefer J, Savarese G, Lund LH, Emdin M, Sinagra G, Manouras A, Giannoni A. Echocardiographic Biventricular Coupling Index to Predict Pre-Capillary Pulmonary Hypertension. J Am Soc Echocardiogr 2022; 35:715-726. [DOI: 10.1016/j.echo.2022.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 01/26/2022] [Accepted: 02/03/2022] [Indexed: 10/19/2022]
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Bitterman Y, Hauck A, Manlhiot C, Reyes J, Dragulescu A, Mertens L, Friedberg MK. Serial Assessment of Tricuspid Annular Plane Systolic Excursion Is Associated with Death or Lung Transplant in Children with Pulmonary Arterial Hypertension. J Am Soc Echocardiogr 2021; 34:1320-1322. [PMID: 34461250 DOI: 10.1016/j.echo.2021.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/02/2021] [Accepted: 08/20/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Yuval Bitterman
- Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Amanda Hauck
- Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cedric Manlhiot
- Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Janette Reyes
- Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Andreea Dragulescu
- Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Luc Mertens
- Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mark K Friedberg
- Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
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Richter MJ, Yogeswaran A, Husain-Syed F, Vadász I, Rako Z, Mohajerani E, Ghofrani HA, Naeije R, Seeger W, Herberg U, Rieth A, Tedford RJ, Grimminger F, Gall H, Tello K. A novel non-invasive and echocardiography-derived method for quantification of right ventricular pressure-volume loops. Eur Heart J Cardiovasc Imaging 2021; 23:498-507. [PMID: 33668064 DOI: 10.1093/ehjci/jeab038] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/12/2021] [Indexed: 11/12/2022] Open
Abstract
AIMS We sought to assess the feasibility of constructing right ventricular (RV) pressure-volume (PV) loops solely by echocardiography. METHODS AND RESULTS We performed RV conductance and pressure wire (PW) catheterization with simultaneous echocardiography in 35 patients with pulmonary hypertension. To generate echocardiographic PV loops, a reference RV pressure curve was constructed using pooled PW data from the first 20 patients (initial cohort). Individual pressure curves were then generated by adjusting the reference curve according to RV isovolumic and ejection phase duration and estimated RV systolic pressure. The pressure curves were synchronized with echocardiographic volume curves. We validated the reference curve in the remaining 15 patients (validation cohort). Methods were compared with correlation and Bland-Altman analysis. In the initial cohort, echocardiographic and conductance-derived PV loop parameters were significantly correlated {rho = 0.8053 [end-systolic elastance (Ees)], 0.8261 [Ees/arterial elastance (Ea)], and 0.697 (stroke work); all P < 0.001}, with low bias [-0.016 mmHg/mL (Ees), 0.1225 (Ees/Ea), and -39.0 mmHg mL (stroke work)] and acceptable limits of agreement. Echocardiographic and PW-derived Ees were also tightly correlated, with low bias (-0.009 mmHg/mL) and small limits of agreement. Echocardiographic and conductance-derived Ees, Ees/Ea, and stroke work were also tightly correlated in the validation cohort (rho = 0.9014, 0.9812, and 0.9491, respectively; all P < 0.001), with low bias (0.0173 mmHg/mL, 0.0153, and 255.1 mmHg mL, respectively) and acceptable limits. CONCLUSION The novel echocardiographic method is an acceptable alternative to invasively measured PV loops to assess contractility, RV-arterial coupling, and RV myocardial work. Further validation is warranted.
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Affiliation(s)
- Manuel J Richter
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Klinikstrasse 32, Giessen 35392, Germany
| | - Athiththan Yogeswaran
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Klinikstrasse 32, Giessen 35392, Germany
| | - Faeq Husain-Syed
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Klinikstrasse 32, Giessen 35392, Germany
| | - István Vadász
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Klinikstrasse 32, Giessen 35392, Germany
| | - Zvonimir Rako
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Klinikstrasse 32, Giessen 35392, Germany
| | - Emad Mohajerani
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Klinikstrasse 32, Giessen 35392, Germany
| | - Hossein A Ghofrani
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Klinikstrasse 32, Giessen 35392, Germany.,Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Benekestr. 2-8, Bad Nauheim 61231, Germany.,Department of Medicine, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - Robert Naeije
- Erasme University Hospital, Route de Lennik 808, Brussels 1070, Belgium
| | - Werner Seeger
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Klinikstrasse 32, Giessen 35392, Germany.,Department of Internal Medicine, German Center for Lung Research (DZL), Cardio-Pulmonary Institute (CPI), Justus-Liebig-University Giessen, Aulweg 130, Giessen 35392, Germany
| | - Ulrike Herberg
- Department of Pediatric Cardiology, University of Bonn, Building 30, Venusberg-Campus 1, Bonn 53127, Germany
| | - Andreas Rieth
- Department of Thoracic Surgery, Kerckhoff Heart, Rheuma and Thoracic Center, Benekestr. 2-8, 61231 Bad Nauheim, Germany
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Friedrich Grimminger
- Department of Internal Medicine, German Center for Lung Research (DZL), Cardio-Pulmonary Institute (CPI), Justus-Liebig-University Giessen, Aulweg 130, Giessen 35392, Germany.,Institute for Lung Health (ILH), Justus-Liebig-University Giessen, Giessen, Germany
| | - Henning Gall
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Klinikstrasse 32, Giessen 35392, Germany
| | - Khodr Tello
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Klinikstrasse 32, Giessen 35392, Germany
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8
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Evers PD, Critser PJ, Cash M, Magness M, Hirsch R. Prognostic Value of Change in Cardiac Index After Prostacyclin Initiation in Pediatric Pulmonary Hypertension. Pediatr Cardiol 2021; 42:116-122. [PMID: 32974724 DOI: 10.1007/s00246-020-02460-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 09/16/2020] [Indexed: 10/23/2022]
Abstract
Invasive hemodynamic assessment remains the gold standard for the diagnosis of pediatric pulmonary hypertension and for longitudinal assessment of response to therapy. This analysis sought to describe the changes in hemodynamic variables after initiation of prostacyclin therapy and determine which changes bear predictive power of adverse clinical outcomes. A retrospective chart review of established patients at Cincinnati Children's Hospital with pulmonary arterial hypertension (PAH) who required prostacyclin therapy between 2004 and 2018 was performed. The baseline hemodynamic parameters at diagnosis as well as change in those parameters between initial catheterization and post-prostacyclin initiation catheterization were independent variables. Cox proportional hazard regression and recursive partitioning analysis were used to characterize which hemodynamic factors predicted the composite adverse outcome (CAO) defined as death, lung transplantation, or reverse Pott's shunt surgery. During the study period, 29 patients met inclusion criteria in which there were 7 CAOs: 4 deaths, 3 lung transplants, and 2 reverse Pott's shunts. Median time between catheterizations was 86 days and between the initiation of prostacyclin therapy and the second catheterization was 54 days. Cox regression revealed that only baseline pulmonary artery pressure (> 51 mmHg) and a failure to increase cardiac index illustrated statistically significant hazard for occurrence of the CAO (p < 0.01). These criteria significantly dichotomized the population in a Kaplan-Meier analysis into likelihoods of experiencing the CAO. While controlling for other hemodynamic variables, the absence of augmentation of cardiac index after the initiation of prostacyclin therapy is a valuable prognostic indicator of adverse PAH outcomes in pediatrics.
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Affiliation(s)
- Patrick D Evers
- Division of Pediatric Cardiology, Oregon Health and Sciences University, 707 SW Gaines St. CDRC-P, Portland, OR, 97239, USA.
| | - Paul J Critser
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Michelle Cash
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Melissa Magness
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Russel Hirsch
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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9
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Asymmetric Regional Work Contributes to Right Ventricular Fibrosis, Inefficiency, and Dysfunction in Pulmonary Hypertension versus Regurgitation. J Am Soc Echocardiogr 2020; 34:537-550.e3. [PMID: 33383122 DOI: 10.1016/j.echo.2020.12.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 12/13/2020] [Accepted: 12/13/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Right ventricular (RV) pressure loading from pulmonary hypertension (PH) and volume loading from pulmonary regurgitation (PR) lead to RV dysfunction, a critical determinant of clinical outcomes, but their impact on regional RV mechanics and fibrosis is poorly characterized. The aim of this study was to test the hypothesis that regional myocardial mechanics and efficiency in RV pressure and volume loading are associated with RV fibrosis and dysfunction. METHODS Eight PH, six PR, and five sham-control rats were studied. The PH rat model was induced using Sugen5416, a vascular endothelial growth factor receptor 2 inhibitor, combined with chronic hypoxia. PR rats were established by surgical laceration of the pulmonary valve leaflets. Six (n = 4) or 9 (n = 4) weeks after Sugen5416 and hypoxia and 12 weeks after PR surgery, myocardial strain and RV pressure were measured and RV pressure-strain loops generated. We further studied RV regional mechanics in 11 patients with PH. Regional myocardial work was calculated as the pressure-strain loop area (mm Hg ∙ %). Regional myocardial work efficiency was quantified through wasted work (ratio of systolic lengthening to shortening work). The relation of regional myocardial work to RV fibrosis and dysfunction was analyzed. RESULTS In rats, PH and PR induced similar RV dilatation, but fractional area change (%) was lower in PH than in PR. RV lateral wall work was asymmetrically higher in PH compared with sham, while septal work was similar to sham. In PR, lateral and septal work were symmetrically higher versus sham. Myocardial wasted work ratio was asymmetrically increased in the PH septum versus sham. Fibrosis in the RV lateral wall, but not septum, was higher in PH than PR. RV fibrosis burden was linearly related to regional work and to measures of RV systolic and diastolic function but not to wasted myocardial work ratio. Patients with PH demonstrated similar asymmetric and inefficient regional myocardial mechanics. CONCLUSIONS Asymmetric RV work and increased wasted septal work in experimental PH are associated with RV fibrosis and dysfunction. Future investigation should examine whether assessment of asymmetric regional RV work and efficiency can predict clinical RV failure and influence patient management.
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10
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Ventricular systolic dysfunction with and without altered myocardial contractility: Clinical value of echocardiography for diagnosis and therapeutic decision-making. Int J Cardiol 2020; 327:236-250. [PMID: 33285193 DOI: 10.1016/j.ijcard.2020.11.068] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 02/06/2023]
Abstract
The inability of one of the two or both ventricles to contract normally and expel sufficient blood to meet the functional demands of the body results from a complex interplay between intrinsic abnormalities and extracardiac factors that limit ventricular pump function and is a major cause for heart failure (HF). Even if impaired myocardial contractile function was the primary cause for ventricular dysfunction, with the progression of systolic dysfunction, additionally developed diastolic dysfunction can also contribute to the severity of HF. Although at the first sight, the diagnosis of systolic HF appears quite easy because it is usually defined by reduction of the ejection fraction (EF), in reality this issue is far more complex because ventricular pumping performance depends not only on myocardial contractility, but also largely on loading conditions (preload and afterload), being also influenced by valvular function, ventricular interdependence, pericardial constraint, synchrony of ventricular contrac-tion and heart rhythm. Conventional echocardiography (ECHO) combined with new imaging techniques such as tissue Doppler and tissue tracking can detect early subclinical alteration of ventricular systolic function. However, no single ECHO parameter reveals alone the whole picture of systolic dysfunction. Multiparametric ECHO evaluation and the use of integrative approaches using ECHO-parameter combinations which include also the ventricular loading conditions appeared particularly useful especially for differentiation between primary (myocardial damage-induced) and secondary (hemodynamic overload-induced) systolic dysfunction. This review summarizes the available evidence on the usefulness and limitations of comprehensive evaluation of LV and RV systolic function by using all the currently available ECHO techniques.
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11
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Bernardo RJ, Haddad F, Couture EJ, Hansmann G, de Jesus Perez VA, Denault AY, de Man FS, Amsallem M. Mechanics of right ventricular dysfunction in pulmonary arterial hypertension and heart failure with preserved ejection fraction. Cardiovasc Diagn Ther 2020; 10:1580-1603. [PMID: 33224775 PMCID: PMC7666917 DOI: 10.21037/cdt-20-479] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 06/04/2020] [Indexed: 12/12/2022]
Abstract
Right ventricular (RV) dysfunction is the most important determinant of survival in patients with pulmonary hypertension (PH). The manifestations of RV dysfunction not only include changes in global RV systolic function but also abnormalities in the pattern of contraction and synchrony. The effects of PH on the right ventricle have been mainly studied in patients with pulmonary arterial hypertension (PAH). However, with the demographic shift towards an aging population, heart failure with preserved ejection fraction (HFpEF) has become an important etiology of PH in recent years. There are significant differences in RV mechanics, function and adaptation between patients with PAH and HFpEF (with or without PH), which are related to different patterns of remodeling and dysfunction. Due to the unique features of the RV chamber, its connection with the main pulmonary artery and the pulmonary circulation, an understanding of the mechanics of RV function and its clinical significance is mandatory for both entities. In this review, we describe the mechanics of the pressure overloaded right ventricle. We review the different mechanical components of RV dysfunction and ventricular dyssynchrony, followed by insights via analysis of pressure-volume loop, energetics and novel blood flow patterns, such as vortex imaging. We conduct an in-depth comparison of prevalence and characteristics of RV dysfunction in HFpEF and PAH, and summarize key outcome studies. Finally, we provide a perspective on needed and expected future work in the field of RV mechanics.
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Affiliation(s)
- Roberto J. Bernardo
- Division of Pulmonary, Allergy and Critical Care, Stanford University School of Medicine, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
| | - Francois Haddad
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford, CA, USA
| | - Etienne J. Couture
- Department of Anesthesiology, Quebec Heart and Lung Institute, Quebec, Canada
- Intensive Care Medicine Division, Department of Medicine, Quebec Heart and Lung Institute, Quebec, Canada
- Research Center, Quebec Heart and Lung Institute, Quebec, Canada
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Vinicio A. de Jesus Perez
- Division of Pulmonary, Allergy and Critical Care, Stanford University School of Medicine, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
| | - André Y. Denault
- Department of Anesthesiology and Division of Critical Care, Montreal Heart Institute, Université de Montréal, Montreal, Canada
- Division of Critical Care, Centre Hospitalier de l’Université de Montréal, Montreal, Canada
| | - Frances S. de Man
- Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Department of Pulmonary Medicine, PHEniX laboratory, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Myriam Amsallem
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford, CA, USA
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