1
|
Li Q, Huang F, Lin W, Cheng Y, Dai Y, Lin W, Lin Z, Zhu P. Impact of 12-Month Late-in-Life Exercise Training on Cardiopulmonary Reserve, Static Cardiac Structure, and Function: A Randomized Clinical Trial. J Am Med Dir Assoc 2024; 25:105117. [PMID: 38945172 DOI: 10.1016/j.jamda.2024.105117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 05/23/2024] [Accepted: 05/23/2024] [Indexed: 07/02/2024]
Abstract
OBJECTIVE Although the cardiac benefits of maintaining a lifelong exercise routine are undisputed, to what extent late-in-life exercise training can ameliorate cardiac aging remains unclear. We examined the impact of a 12-month exercise training program on cardiac reserve, static cardiac structure, and cardiac function in older adults. DESIGN This study was a single-center, randomized trial using Zelen design. Participants in the center-based exercise (CBE) group underwent an individualized multicomponent exercise training program. SETTING AND PARTICIPANTS In total, 120 community-dwelling older adults aged 65-85 years were evenly divided into a CBE group and a control group. METHODS The primary outcome indicator was absolute change in peak oxygen uptake (peakVO2) per kilogram from baseline to 12 months. The secondary outcome indicators were the absolute changes in other cardiopulmonary exercise test indices and cardiac magnetic resonance parameters. This study has been registered at the Chinese Clinical Trial Registry Network (ChiCTR2400081824). RESULTS In total, 47 older adults in the control group and 49 in the CBE group ultimately completed the 12-month follow-up and were analyzed. Of all participants, 52 (46.4%) were men, and the mean age was 71.22 ± 4.55 years. The absolute change in peakVO2/kg was significantly different between the CBE and control groups by +3.32 mL/kg/min (95% CI 2.10-4.53; P < .001), and a sex-related difference was observed. Additionally, the right ventricular peak filling and ejection rate improved to a greater degree in the CBE than control group (+65.57 mL/s, P = .006; +56.39 mL/s, P = .026, respectively). CONCLUSIONS AND IMPLICATIONS A 12-month exercise training program started later in life was effective in improving cardiopulmonary reserve, and men showed a better response to training than women. The right ventricular function increased after late-in-life exercise training.
Collapse
Affiliation(s)
- Qiaowei Li
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, P.R. China; Department of Geriatric Medicine, Fujian Provincial Hospital, Fuzhou, P.R. China; Fujian Provincial Institute of Clinical Geriatrics, Fuzhou, P.R. China; Fujian Key Laboratory of Geriatrics, Fuzhou, P.R. China; Fujian Provincial Center for Geriatrics, Fuzhou, P.R. China
| | - Feng Huang
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, P.R. China; Department of Geriatric Medicine, Fujian Provincial Hospital, Fuzhou, P.R. China; Fujian Provincial Institute of Clinical Geriatrics, Fuzhou, P.R. China; Fujian Key Laboratory of Geriatrics, Fuzhou, P.R. China; Fujian Provincial Center for Geriatrics, Fuzhou, P.R. China
| | - Wei Lin
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, P.R. China; Department of Geriatric Medicine, Fujian Provincial Hospital, Fuzhou, P.R. China
| | - Yanling Cheng
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, P.R. China
| | - Yalan Dai
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, P.R. China
| | - Wenwen Lin
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, P.R. China; Fujian Provincial Institute of Clinical Geriatrics, Fuzhou, P.R. China; Fujian Key Laboratory of Geriatrics, Fuzhou, P.R. China
| | - Zhonghua Lin
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, P.R. China; Department of Rehabilitation Medicine, Fujian Provincial Hospital, Fuzhou, P.R. China.
| | - Pengli Zhu
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, P.R. China; Department of Geriatric Medicine, Fujian Provincial Hospital, Fuzhou, P.R. China; Fujian Provincial Institute of Clinical Geriatrics, Fuzhou, P.R. China; Fujian Key Laboratory of Geriatrics, Fuzhou, P.R. China; Fujian Provincial Center for Geriatrics, Fuzhou, P.R. China.
| |
Collapse
|
2
|
Hemnes AR, Celermajer DS, D'Alto M, Haddad F, Hassoun PM, Prins KW, Naeije R, Vonk Noordegraaf A. Pathophysiology of the right ventricle and its pulmonary vascular interaction. Eur Respir J 2024:2401321. [PMID: 39209482 DOI: 10.1183/13993003.01321-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 07/09/2024] [Indexed: 09/04/2024]
Abstract
The right ventricle and its stress response is perhaps the most important arbiter of survival in patients with pulmonary hypertension of many causes. The physiology of the cardiopulmonary unit and definition of right heart failure proposed in the 2018 World Symposium on Pulmonary Hypertension have proven useful constructs in subsequent years. Here, we review updated knowledge of basic mechanisms that drive right ventricular function in health and disease, and which may be useful for therapeutic intervention in the future. We further contextualise new knowledge on assessment of right ventricular function with a focus on metrics readily available to clinicians and updated understanding of the roles of the right atrium and tricuspid regurgitation. Typical right ventricular phenotypes in relevant forms of pulmonary vascular disease are reviewed and recent studies of pharmacological interventions on chronic right ventricular failure are discussed. Finally, unanswered questions and future directions are proposed.
Collapse
Affiliation(s)
- Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David S Celermajer
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michele D'Alto
- Department of Cardiology, Monaldi Hospital, Naples, Italy
| | - Francois Haddad
- Division of Cardiovascular Medicine, Stanford University and Stanford Cardiovascular Institute, Palo Alto, CA, USA
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Kurt W Prins
- Lillehei Heart Institute, Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, USA
| | | | - Anton Vonk Noordegraaf
- Amsterdam UMC, Vrije Universiteit Amsterdam, Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| |
Collapse
|
3
|
Hagendorff A, Stöbe S, Helfen A, Knebel F, Altiok E, Beckmann S, Bekfani T, Binder T, Ewers A, Hamadanchi A, Ten Freyhaus H, Groscheck T, Haghi D, Knierim J, Kruck S, Lenk K, Merke N, Pfeiffer D, Dorta ER, Ruf T, Sinning C, Wunderlich NC, Brandt R, Ewen S. Echocardiographic assessment of atrial, ventricular, and valvular function in patients with atrial fibrillation-an expert proposal by the german working group of cardiovascular ultrasound. Clin Res Cardiol 2024:10.1007/s00392-024-02491-6. [PMID: 39186180 DOI: 10.1007/s00392-024-02491-6] [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: 06/03/2024] [Accepted: 07/04/2024] [Indexed: 08/27/2024]
Abstract
Echocardiography in patients with atrial fibrillation is challenging due to the varying heart rate. Thus, the topic of this expert proposal focuses on an obvious gap in the current recommendations about diagnosis and treatment of atrial fibrillation (AF)-the peculiarities and difficulties of echocardiographic imaging. The assessment of systolic and diastolic function-especially in combination with valvular heart diseases-by echocardiography can basically be done by averaging the results of echocardiographic measurements of the respective parameters or by the index beat approach, which uses a representative cardiac cycle for measurement. Therefore, a distinction must be made between the functionally relevant status, which is characterized by the averaging method, and the best possible hemodynamic status, which is achieved with the most optimal left ventricular (LV) filling according to the index beat method with longer previous RR intervals. This proposal focuses on left atrial and left ventricular function and deliberately excludes problems of echocardiography when assessing left atrial appendage in terms of its complexity. Echocardiography of the left atrial appendage is therefore reserved for its own expert proposal.
Collapse
Affiliation(s)
- Andreas Hagendorff
- Department of Cardiology, University Hospital Leipzig AöR, Leipzig, Germany.
| | - Stephan Stöbe
- Department of Cardiology, University Hospital Leipzig AöR, Leipzig, Germany
| | - Andreas Helfen
- Department of Kardiologie, Katholische St. Paulus Gesellschaft, St. Marien Hospital Lünen, Lünen, Germany
| | - Fabian Knebel
- Department of Internal Medicine II, Cardiology, Sana Klinikum Lichtenberg, Berlin, Germany
| | - Ertunc Altiok
- Department of Cardiology, Angiology, and Intensive Medicine, University Hospital Aachen, Aachen, Germany
| | - Stephan Beckmann
- Privatpraxis Kardiologie, Beckmann Ehlers Und Partner, Berlin-Grunewald, Germany
| | - Tarek Bekfani
- Department of Cardiology and Angiology, University Hospital Magdeburg AöR, Magdeburg, Germany
| | - Thomas Binder
- Department of Cardiology, University Hospital AKH Wien, Vienna, Austria
| | - Aydan Ewers
- Department of Cardiology and Angiology, BG University Hospital Bergmannsheil, Bochum, Germany
| | - Ali Hamadanchi
- Department of Cardiology, University of Jena, Jena, Germany
| | - Henrik Ten Freyhaus
- Department of Internal Medicine III, Cardiology, University of Cologne, Cologne, Germany
| | - Thomas Groscheck
- Department of Cardiology and Angiology, University Hospital Magdeburg AöR, Magdeburg, Germany
| | - Dariush Haghi
- Kardiologische Praxisklinik Ludwigshafen-Akademische Lehrpraxis of the University of Mannheim, Ludwigshafen, Germany
| | - Jan Knierim
- Department of Internal Medicine and Cardiology, Paulinenkrankenhaus Berlin, Berlin, Germany
| | - Sebastian Kruck
- Praxis Für Kardiologie Cardio Centrum Ludwigsburg, Ludwigsburg, Germany
| | - Karsten Lenk
- Department of Cardiology, University Hospital Leipzig AöR, Leipzig, Germany
| | - Nicolas Merke
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Charité Berlin, Berlin, Germany
| | | | - Elena Romero Dorta
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum Charité Berlin, University of Berlin, Campus Mitte, Berlin, Germany
| | - Tobias Ruf
- Department of Cardiology, Center of Cardiology, Heart Valve Center, University Medical Center Mainz, University of Mainz, Mainz, Germany
| | - Christoph Sinning
- Department of Cardiology, German Centre of Cardiovascular Research (DZHK), University Heart and Vascular Center Hamburg, Hamburg, Germany
| | | | - Roland Brandt
- Department of Cardiology, Kerckhoff Klinik GmbH, Bad Nauheim, Germany
| | - Sebastian Ewen
- Department of Cardiology and Intensive Care Medicine, Schwarzwald-Baar Klinik, Villingen-Schwenningen, Germany
- University Heart Center Freiburg • Bad Krozingen, Freiburg, Germany
| |
Collapse
|
4
|
Alabdaljabar MS, Alexandrino F, Al-Shakarchi N, Kucuk HO, Lloyd JV, Luis SA, Pislaru SV, Pellikka PA, Connolly HM. Right Atrial and Ventricular Strain Analysis in Patients With Carcinoid Heart Disease. J Am Soc Echocardiogr 2024:S0894-7317(24)00294-3. [PMID: 38885799 DOI: 10.1016/j.echo.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 06/04/2024] [Accepted: 06/08/2024] [Indexed: 06/20/2024]
Affiliation(s)
| | | | | | | | - James V Lloyd
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - S Allen Luis
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sorin V Pislaru
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Heidi M Connolly
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
5
|
Addetia K, Lang RM. Unfolding the Mysteries of the Truly Forgotten Chamber. J Am Soc Echocardiogr 2024; 37:506-507. [PMID: 38423399 DOI: 10.1016/j.echo.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 02/22/2024] [Indexed: 03/02/2024]
Affiliation(s)
- Karima Addetia
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Roberto M Lang
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois.
| |
Collapse
|
6
|
Sakhi H, Azarine A. Editorial for "Age- and Sex-Specific MR-Feature Tracking Reference Values of Right Atrial Deformation in Healthy Adults". J Magn Reson Imaging 2024. [PMID: 38655724 DOI: 10.1002/jmri.29408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 03/02/2024] [Indexed: 04/26/2024] Open
Affiliation(s)
- Hichem Sakhi
- Department of Radiology, Hôpital Marie Lannelongue, Fondation Paris Saint-Joseph, Le Plessis-Robinson, France
| | - Arshid Azarine
- Department of Radiology, Hôpital Marie Lannelongue, Fondation Paris Saint-Joseph, Le Plessis-Robinson, France
| |
Collapse
|
7
|
Muraru D, Badano LP, Hahn RT, Lang RM, Delgado V, Wunderlich NC, Donal E, Taramasso M, Duncan A, Lurz P, De Potter T, Zamorano Gómez JL, Bax JJ, von Bardeleben RS, Enriquez-Sarano M, Maisano F, Praz F, Sitges M. Atrial secondary tricuspid regurgitation: pathophysiology, definition, diagnosis, and treatment. Eur Heart J 2024; 45:895-911. [PMID: 38441886 PMCID: PMC11095052 DOI: 10.1093/eurheartj/ehae088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/03/2024] [Accepted: 01/30/2024] [Indexed: 03/16/2024] Open
Abstract
Atrial secondary tricuspid regurgitation (A-STR) is a distinct phenotype of secondary tricuspid regurgitation with predominant dilation of the right atrium and normal right and left ventricular function. Atrial secondary tricuspid regurgitation occurs most commonly in elderly women with atrial fibrillation and in heart failure with preserved ejection fraction in sinus rhythm. In A-STR, the main mechanism of leaflet malcoaptation is related to the presence of a significant dilation of the tricuspid annulus secondary to right atrial enlargement. In addition, there is an insufficient adaptive growth of tricuspid valve leaflets that become unable to cover the enlarged annular area. As opposed to the ventricular phenotype, in A-STR, the tricuspid valve leaflet tethering is typically trivial. The A-STR phenotype accounts for 10%-15% of clinically relevant tricuspid regurgitation and has better outcomes compared with the more prevalent ventricular phenotype. Recent data suggest that patients with A-STR may benefit from more aggressive rhythm control and timely valve interventions. However, little is mentioned in current guidelines on how to identify, evaluate, and manage these patients due to the lack of consistent evidence and variable definitions of this entity in recent investigations. This interdisciplinary expert opinion document focusing on A-STR is intended to help physicians understand this complex and rapidly evolving topic by reviewing its distinct pathophysiology, diagnosis, and multi-modality imaging characteristics. It first defines A-STR by proposing specific quantitative criteria for defining the atrial phenotype and for discriminating it from the ventricular phenotype, in order to facilitate standardization and consistency in research.
Collapse
Affiliation(s)
- Denisa Muraru
- Department of Medicine and Surgery, University of Milano-Bicocca, Piazza dell’Ateneo Nuovo 1, Milan 20126, Italy
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Piazzale Brescia 20, Milan 20149, Italy
| | - Luigi P Badano
- Department of Medicine and Surgery, University of Milano-Bicocca, Piazza dell’Ateneo Nuovo 1, Milan 20126, Italy
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Piazzale Brescia 20, Milan 20149, Italy
| | - Rebecca T Hahn
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Roberto M Lang
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, Chicago, IL, USA
| | - Victoria Delgado
- Department of Cardiology, Hospital University Germans Trias I Pujol, Badalona, Spain
| | | | - Erwan Donal
- CHU Rennes, Inserm, University of Rennes 1, Rennes, France
| | - Maurizio Taramasso
- Department of Cardiac Surgery, HerzZentrum Hirslanden Zürich, Zürich, Switzerland
| | - Alison Duncan
- Heart Division, The Royal Brompton Hospital, London, UK
| | - Philipp Lurz
- Department of Cardiology, Heart Center Leipzig, Leipzig, Germany
- Department of Cardiology and Heart Valve Center, Universitätsmedizin Johannes Gutenberg-University, Langenbeckstr, Mainz 55131, Germany
| | | | - José L Zamorano Gómez
- Department of Cardiology, University Hospital Ramón y Cajal, Ctra Colmenar Viejo Km 9.1, Madrid, Spain
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ralph Stephan von Bardeleben
- Department of Cardiology and Heart Valve Center, Universitätsmedizin Johannes Gutenberg-University, Langenbeckstr, Mainz 55131, Germany
| | | | - Francesco Maisano
- Valve Center IRCCS Ospedale San Raffaele, Cardiac Surgery, University Vita Salute, Milan, Italy
| | - Fabien Praz
- Department of Cardiology, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Marta Sitges
- Cardiovascular Institute, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- CIBER, Centro de Investigación Biomédica en Red, Barcelona, Spain
| |
Collapse
|
8
|
Otto CM, Bartkowiak J, Hahn RT. Right atrial pressure, not Doppler jet velocity, is the problem in estimating pulmonary pressure when tricuspid regurgitation is severe. Heart 2024; 110:311-312. [PMID: 37827552 DOI: 10.1136/heartjnl-2023-323230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2023] Open
Affiliation(s)
- Catherine M Otto
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Joanna Bartkowiak
- Department of Medicine, The New York-Presbyterian/Columbia University Medical Center, New York, New York, USA
| | - Rebecca T Hahn
- Medicine, The New York-Presbyterian/Columbia University Medical Center, New York, New York, USA
| |
Collapse
|
9
|
Randazzo M, Maffessanti F, Kotta A, Grapsa J, Lang RM, Addetia K. Added value of 3D echocardiography in the diagnosis and prognostication of patients with right ventricular dysfunction. Front Cardiovasc Med 2023; 10:1263864. [PMID: 38179507 PMCID: PMC10764503 DOI: 10.3389/fcvm.2023.1263864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/22/2023] [Indexed: 01/06/2024] Open
Abstract
Recent inroads into percutaneous-based options for the treatment of tricuspid valve disease has brought to light how little we know about the behavior of the right ventricle in both health and disease and how incomplete our assessment of right ventricular (RV) physiology and function is using current non-invasive technology, in particular echocardiography. The purpose of this review is to provide an overview of what three-dimensional echocardiography (3DE) can offer currently to enhance RV evaluation and what the future may hold if we continue to improve the 3D evaluation of the right heart.
Collapse
Affiliation(s)
- Michael Randazzo
- Department of Medicine, Section of Cardiology, University of Chicago Heart and Vascular Center, Chicago, IL, United States
| | | | - Alekhya Kotta
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Julia Grapsa
- Department of Cardiology, Guys and St Thomas NHS Trust, London, United Kingdom
| | - Roberto M. Lang
- Department of Medicine, Section of Cardiology, University of Chicago Heart and Vascular Center, Chicago, IL, United States
| | - Karima Addetia
- Department of Medicine, Section of Cardiology, University of Chicago Heart and Vascular Center, Chicago, IL, United States
| |
Collapse
|
10
|
Nyberg J, Jakobsen EO, Østvik A, Holte E, Stølen S, Lovstakken L, Grenne B, Dalen H. Echocardiographic Reference Ranges of Global Longitudinal Strain for All Cardiac Chambers Using Guideline-Directed Dedicated Views. JACC Cardiovasc Imaging 2023; 16:1516-1531. [PMID: 37921718 DOI: 10.1016/j.jcmg.2023.08.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Myocardial deformation by echocardiographic strain imaging is a key measurement in cardiology, providing valuable diagnostic and prognostic information. Reference ranges for strain should be established from large healthy populations with minimal methodologic biases and variability. OBJECTIVES The aim of this study was to establish echocardiographic reference ranges, including lower normal limits of global strains for all 4 cardiac chambers, by guideline-directed dedicated views from a large healthy population and to evaluate the influence of subject-specific characteristics on strain. METHODS In total, 1,329 healthy participants from HUNT4Echo, the echocardiographic substudy of the 4th wave of the Trøndelag Health Study, were included. Echocardiographic recordings specific for each chamber were optimized according to current recommendations. Two experienced sonographers recorded all echocardiograms using GE HealthCare Vivid E95 scanners. Analyses were performed by experts using GE HealthCare EchoPAC. RESULTS The reference ranges for left ventricular (LV) global longitudinal strain and right ventricular free-wall strain were -24% to -16% and -35% to -17%, respectively. Correspondingly, left atrial (LA) and right atrial (RA) reservoir strains were 17% to 49% and 17% to 59%. All strains showed lower absolute values with higher age, except for LA and RA contractile strains, which were higher. The feasibility for strain was overall good (LV 96%, right ventricular 83%, LA 94%, and RA 87%). All chamber-specific strains were associated with age, and LV strain was associated with sex. CONCLUSIONS Reference ranges of strain for all cardiac chambers were established based on guideline-directed chamber-specific recordings. Age and sex were the most important factors influencing reference ranges and should be considered when using strain echocardiography.
Collapse
Affiliation(s)
- John Nyberg
- Department of Circulation and Medical Imaging, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
| | - Even Olav Jakobsen
- Department of Circulation and Medical Imaging, NTNU-Norwegian University of Science and Technology, Trondheim, Norway; Clinic of Cardiology, St. Olavs Hospital, Trondheim, Norway
| | - Andreas Østvik
- Department of Circulation and Medical Imaging, NTNU-Norwegian University of Science and Technology, Trondheim, Norway; Medical Image Analysis, Health Research, SINTEF Digital, Trondheim, Norway
| | - Espen Holte
- Department of Circulation and Medical Imaging, NTNU-Norwegian University of Science and Technology, Trondheim, Norway; Clinic of Cardiology, St. Olavs Hospital, Trondheim, Norway
| | - Stian Stølen
- Clinic of Cardiology, St. Olavs Hospital, Trondheim, Norway
| | - Lasse Lovstakken
- Department of Circulation and Medical Imaging, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
| | - Bjørnar Grenne
- Department of Circulation and Medical Imaging, NTNU-Norwegian University of Science and Technology, Trondheim, Norway; Clinic of Cardiology, St. Olavs Hospital, Trondheim, Norway
| | - Havard Dalen
- Department of Circulation and Medical Imaging, NTNU-Norwegian University of Science and Technology, Trondheim, Norway; Clinic of Cardiology, St. Olavs Hospital, Trondheim, Norway; Department of Medicine, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway.
| |
Collapse
|
11
|
Slivnick JA, Singulane C, Sun D, Eshun D, Narang A, Mazzone S, Addetia K, Patel AR, Zareba KM, Smart S, Kwon JW, Husain A, Cody B, Scheetz S, Asch FM, Goyal A, Sarswat N, Mor-Avi V, Lang RM. Preservation of Circumferential and Radial Left Ventricular Function as a Mitigating Mechanism for Impaired Longitudinal Strain in Early Cardiac Amyloidosis. J Am Soc Echocardiogr 2023; 36:1290-1301. [PMID: 37574149 DOI: 10.1016/j.echo.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/05/2023] [Accepted: 08/01/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND In patients with cardiac amyloidosis (CA), left ventricular ejection fraction (LVEF) is frequently preserved, despite commonly reduced global longitudinal strain (GLS). We hypothesized that nonlongitudinal contraction may initially serve as a mitigating mechanism to maintain cardiac output and studied the relationship between global circumferential (GCS) and radial (GRS) strain with LVEF and extracellular volume (ECV), a marker of amyloid burden. METHODS Patients with CA who underwent cardiac magnetic resonance (CMR; n = 140, 70.7 ± 11.5 years, 66% male) or echocardiography (n = 67, 71 ± 13 years, 66% male) and normal controls (CMR, n = 20; echocardiography, n = 45) were retrospectively identified, and GCS, GLS, and GRS were quantified using feature-tracking CMR or speckle-tracking echocardiography and compared between CA patients with preserved and reduced LVEF (CAHFpEF, CAHFrEF) and controls. The prevalence of impaired strain (magnitudes <2.5th percentile of the controls) was compared between CAHFpEF and CAHFrEF and between ECV quartiles. RESULTS While echocardiography-derived GLS was impaired in both CAHFpEF (-13.4% ± 3.1%, P < .003) and CAHFrEF (-9.1% ± 3.2%, P < .003), compared with controls (-20.8% ± 2.4%), GCS was more impaired in CAHFrEF compared with both controls (-15.6% ± 5.0% vs -32.3% ± 3.3%, P < .003) and CAHFpEF (-30.4% ± 5.7%, P < .003) and did not differ between CAHFpEF and controls (P = .24). The prevalence of abnormal CMR-derived GCS (P < .0001) and GRS (P < .0001) but not GLS (P = .054) varied significantly across ECV quartiles. CONCLUSIONS Among CA patients with preserved LVEF, preserved GCS and GRS, despite near-universally impaired GLS, may be explained by an initial predominantly subendocardial involvement, where mostly longitudinal fibers are located. If confirmed in future studies, these findings may facilitate identification of patients with early stages of CA, when treatments may be most effective.
Collapse
Affiliation(s)
- Jeremy A Slivnick
- Division of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Cristiane Singulane
- Division of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Deyu Sun
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Derek Eshun
- Division of Cardiology, Northwestern Medicine, Chicago, Illinois
| | - Akhil Narang
- Division of Cardiology, Northwestern Medicine, Chicago, Illinois
| | - Steven Mazzone
- Division of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Karima Addetia
- Division of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Amit R Patel
- Division of Cardiology, University of Virginia, Charlottesville, Virginia
| | - Karolina M Zareba
- Division of Cardiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Suzanne Smart
- Division of Cardiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jung Woo Kwon
- Division of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Aliya Husain
- Division of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Brittany Cody
- Division of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Seth Scheetz
- Division of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Federico M Asch
- Division of Cardiology, Medstar Health, Washington, District of Columbia
| | - Akash Goyal
- Division of Cardiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Nitasha Sarswat
- Division of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Victor Mor-Avi
- Division of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Roberto M Lang
- Division of Cardiology, University of Chicago Medical Center, Chicago, Illinois.
| |
Collapse
|
12
|
Appadurai V, Safdur T, Narang A. Assessment of Right Ventricle Function and Tricuspid Regurgitation in Heart Failure: Current Advances in Diagnosis and Imaging. Heart Fail Clin 2023; 19:317-328. [PMID: 37230647 DOI: 10.1016/j.hfc.2023.02.002] [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] [Indexed: 05/27/2023]
Abstract
Right ventricular (RV) systolic dysfunction increases mortality among heart failure patients, and therefore, accurate diagnosis and monitoring is paramount. RV anatomy and function are complex, usually requiring a combination of imaging modalities to completely quantitate volumes and function. Tricuspid regurgitation usually occurs with RV dysfunction, and quantifying this valvular lesion also may require multiple imaging modalities. Echocardiography is the first-line imaging tool for identifying RV dysfunction, with cardiac MRI and cardiac computed tomography adding valuable additional information.
Collapse
Affiliation(s)
- Vinesh Appadurai
- Bluhm Cardiovascular Institute, Northwestern University, 676 North St Clair Street Suite 19-100 Galter Pavilion, Chicago, IL 60611, USA; School of Medicine, The University of Queensland, St Lucia, QLD, 4067 Australia
| | - Taimur Safdur
- Bluhm Cardiovascular Institute, Northwestern University, 676 North St Clair Street Suite 19-100 Galter Pavilion, Chicago, IL 60611, USA
| | - Akhil Narang
- Bluhm Cardiovascular Institute, Northwestern University, 676 North St Clair Street Suite 19-100 Galter Pavilion, Chicago, IL 60611, USA.
| |
Collapse
|
13
|
Cotella JI, Miyoshi T, Mor-Avi V, Addetia K, Schreckenberg M, Sun D, Slivnick JA, Blankenhagen M, Hitschrich N, Amuthan V, Citro R, Daimon M, Gutiérrez-Fajardo P, Kasliwal R, Kirkpatrick JN, Monaghan MJ, Muraru D, Ogunyankin KO, Park SW, Tude Rodrigues AC, Ronderos R, Sadeghpour A, Scalia G, Takeuchi M, Tsang W, Tucay ES, Zhang M, Prado AD, Asch FM, Lang RM. Normative values of the aortic valve area and Doppler measurements using two-dimensional transthoracic echocardiography: results from the Multicentre World Alliance of Societies of Echocardiography Study. Eur Heart J Cardiovasc Imaging 2023; 24:415-423. [PMID: 36331816 DOI: 10.1093/ehjci/jeac220] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/28/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022] Open
Abstract
AIMS Aortic valve area (AVA) used for echocardiographic assessment of aortic stenosis (AS) has been traditionally interpreted independently of sex, age and race. As differences in normal values might impact clinical decision-making, we aimed to establish sex-, age- and race-specific normative values for AVA and Doppler parameters using data from the World Alliance Societies of Echocardiography (WASE) Study. METHODS AND RESULTS Two-dimensional transthoracic echocardiographic studies were obtained from 1903 healthy adult subjects (48% women). Measurements of the left ventricular outflow tract (LVOT) diameter and Doppler parameters, including AV and LVOT velocity time integrals (VTIs), AV mean pressure gradient, peak velocity, were obtained according to ASE/EACVI guidelines. AVA was calculated using the continuity equation. Compared with men, women had smaller LVOT diameters and AVA values, and higher AV peak velocities and mean gradients (all P < 0.05). LVOT and AV VTI were significantly higher in women (P < 0.05), and both parameters increased with age in both sexes. AVA differences persisted after indexing to body surface area. According to the current diagnostic criteria, 13.5% of women would have been considered to have mild AS and 1.4% moderate AS. LVOT diameter and AVA were lower in older subjects, both men and women, and were lower in Asians, compared with whites and blacks. CONCLUSION WASE data provide clinically relevant information about significant differences in normal AVA and Doppler parameters according to sex, age, and race. The implementation of this information into clinical practice should involve development of specific normative values for each ethnic group using standardized methodology.
Collapse
Affiliation(s)
- Juan I Cotella
- University of Chicago, 5758 S. Maryland Avenue, MC 9067, DCAM 5509, Chicago, IL 60637, USA
| | | | - Victor Mor-Avi
- University of Chicago, 5758 S. Maryland Avenue, MC 9067, DCAM 5509, Chicago, IL 60637, USA
| | - Karima Addetia
- University of Chicago, 5758 S. Maryland Avenue, MC 9067, DCAM 5509, Chicago, IL 60637, USA
| | | | - Deyu Sun
- University of Chicago, 5758 S. Maryland Avenue, MC 9067, DCAM 5509, Chicago, IL 60637, USA
| | - Jeremy A Slivnick
- University of Chicago, 5758 S. Maryland Avenue, MC 9067, DCAM 5509, Chicago, IL 60637, USA
| | | | | | | | | | | | | | | | | | | | - Denisa Muraru
- Instituto Auxologico Italiano, IRCCS, San Luca Hospital and University of Milano-Bicocca, Milan, Italy
| | | | | | | | - Ricardo Ronderos
- Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina
| | - Anita Sadeghpour
- Rajaie Cardiovascular Medical and Research Center, Tehran, Islamic Republic of Iran
| | | | - Masaaki Takeuchi
- University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Wendy Tsang
- Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Mei Zhang
- Qilu Hospital of Shandong University, Jinan, China
| | - Aldo D Prado
- Centro Privado de Cardiología, Tucumán, Argentina
| | | | - Roberto M Lang
- University of Chicago, 5758 S. Maryland Avenue, MC 9067, DCAM 5509, Chicago, IL 60637, USA
| |
Collapse
|
14
|
Sumin AN, Gomozova NS, Shcheglova AV, Arkhipov OG. Ethnic differences in right ventricular structure and function in urbanized hypertensive patients in the Gornaya Shoriya region. Sci Rep 2023; 13:4628. [PMID: 36944666 PMCID: PMC10030773 DOI: 10.1038/s41598-023-31834-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/17/2023] [Indexed: 03/23/2023] Open
Abstract
Aim of this study was to compare right ventricular echocardiography parameters in urbanized hypertensive patients of the Shor and non-indigenous ethnic groups in the Mountain Shoria region. The study included patients with arterial hypertension: 58 Shors and 50 non-indigenous urbanized residents, comparable in age, and divided by ethnicity and gender into 4 groups: Shors men (n = 20), Shors women (n = 38) , non-indigenous men (n = 15) and non-indigenous women (n = 35). All underwent echocardiographic examination, and the right heart parameters were studied. Shor men with arterial hypertension had the lowest values of the pulmonary artery index (p = 0.05), the right atrium dimensions (p = 0.04), and the highest values of the blood flow velocity in the right ventricle, et' (p = 0.05) and st' (p = 0.05) in comparison with non-indigenous men. Shor women have the lowest values Et/At ratios (p = 0.05). RV diastolic dysfunction was detected mainly in women compared with men (23.1% and 1.9%, p = 0.0014), somewhat more often in Shors. Ethnicity was one of the factors associated with the right ventricular diastolic dysfunction presence (p = 0.002). Among the factors associated with the RV diastolic dysfunction were risk factors (smoking, obesity), blood pressure, gender, ethnicity, and left ventricular parameters (diastolic dysfunction and the myocardial mass increase). Thus, our study established the influence of ethnic differences on the right heart echocardiographic parameters in Shors and Caucasians with arterial hypertension. The effect of sex on RV diastolic dysfunction was a lot bigger compared to the effect of ethnicity. The revealed differences should improve the assessment of the right heart structure and function in patients with arterial hypertension from small ethnic groups, which will help to improve the diagnosis and treatment of such patients.
Collapse
Affiliation(s)
- Alexey N Sumin
- Laboratory of Comorbidity in Cardiovascular Diseases, Federal State Budgetary Institution "Research Institute for Complex Issues of Cardiovascular Diseases", 6, Sosnoviy Blvd, Kemerovo, Russian Federation, 650002.
| | - Nina S Gomozova
- Laboratory of Comorbidity in Cardiovascular Diseases, Federal State Budgetary Institution "Research Institute for Complex Issues of Cardiovascular Diseases", 6, Sosnoviy Blvd, Kemerovo, Russian Federation, 650002
- Myski City Hospital, Polyclinic No. 1, 23, Pervomajskaya St., Myski, Kemerovo Region, Russian Federation, 652849
| | - Anna V Shcheglova
- Laboratory of Comorbidity in Cardiovascular Diseases, Federal State Budgetary Institution "Research Institute for Complex Issues of Cardiovascular Diseases", 6, Sosnoviy Blvd, Kemerovo, Russian Federation, 650002
| | - Oleg G Arkhipov
- Laboratory of Comorbidity in Cardiovascular Diseases, Federal State Budgetary Institution "Research Institute for Complex Issues of Cardiovascular Diseases", 6, Sosnoviy Blvd, Kemerovo, Russian Federation, 650002
- Ultrasound doctor, Individual entrepreneur, 5, Mira St., Myski, Kemerovo region, Russian Federation, 652845
| |
Collapse
|
15
|
Reference Standards in Quantitative Pediatric Echocardiography: A Guide to the Nuanced World of Z Scores and Nomograms. J Am Soc Echocardiogr 2023; 36:324-326. [PMID: 36549924 DOI: 10.1016/j.echo.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
|
16
|
Normal Ranges of Right Atrial Strain: A Systematic Review and Meta-Analysis. JACC Cardiovasc Imaging 2023; 16:282-294. [PMID: 36648033 DOI: 10.1016/j.jcmg.2022.06.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/10/2022] [Accepted: 06/30/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Standard measures for the clinical assessment of right atrial (RA) function are lacking. OBJECTIVES In this systematic review and meta-analysis, the authors sought to report a reference range for RA deformation parameters in healthy subjects and to identify factors that contribute to reported variations. METHODS The authors conducted a comprehensive search of MEDLINE; MEDLINE In-Process & Other Non-Indexed Citations; Embase; Scopus; and the Cochrane Central Register of Controlled Trials from database inception through October 2021. Studies were included if they reported RA strain or strain rate (SR) using 2-dimensional speckle-tracking echocardiography in healthy volunteers or apparently healthy control patients. Data were extracted by 1 reviewer and then reviewed by 2 independent reviewers. Conflicts were resolved through consensus. Data were combined using the method developed by Siegel and adjusted using the restricted maximum likelihood random-effects model. The normal range was defined as the 95% CI of the mean. Heterogeneity was assessed by the Cochran Q-statistic and the inconsistency index (I2). The quality of the included studies and publication bias were assessed. Effects of clinical variables were sought in a metaregression. RESULTS The search identified 4,111 subjects from 21 studies. The average RA reservoir strain was 44% (95% CI: 25%-63%), contractile strain was 17% (95% CI: 2%-32%), and conduit strain was 18% (95% CI: 7%-28%), with significant between-study heterogeneity and inconsistency. The systolic SR was 2.1 s-1 (95% CI: 0.9-3.4 s-1), early-diastolic SR was -2.0 s-1 (95% CI: -3.3 to -0.8 s-1), and late-diastolic SR was -1.9 s-1 (95% CI: -2.4 to -1.3 s-1), with nonsignificant heterogeneity and inconsistency. Ranges remained wide in healthy volunteers. The metaregression identified only age as significantly associated with systolic SR and no other significant determinants of variation among normal ranges of strain. CONCLUSIONS There are wide reference ranges for RA deformation, and these may limit the utility of this test in clinical practice.
Collapse
|
17
|
Sun ZY, Li Q, Li J, Zhang MW, Zhu L, Geng J. Echocardiographic evaluation of the right atrial size and function: Relevance for clinical practice. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2023; 27:100274. [PMID: 38511096 PMCID: PMC10945901 DOI: 10.1016/j.ahjo.2023.100274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/12/2023] [Accepted: 02/13/2023] [Indexed: 03/22/2024]
Abstract
Right atrial (RA) structural and functional evaluations have recently emerged as powerful biomarkers for adverse events in various cardiovascular conditions. Quantitative analysis of the right atrium, usually performed with volume changes or speckle-tracking echocardiography (STE), has markedly changed our understanding of RA function and remodeling. Knowledge of reference echocardiographic values and measurement methods of RA volumes and myocardial function is a prerequisite to introduce RA quantitation in the clinical routine. This review describes the methodology, benefits and pitfalls of measuring RA size and function by echocardiography based on the current understanding of right atrial anatomy and physiological function and provides the current knowledge of right atrial function in related cardiac diseases.
Collapse
Affiliation(s)
- Zhen-Yun Sun
- Department of Diagnostic Ultrasound, Shandong First Medical University & Shandong Academy of Medical Sciences, China
| | - Qiao Li
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Jun Li
- Department of Diagnostic Ultrasound, Shandong First Medical University & Shandong Academy of Medical Sciences, China
| | - Ming-Wei Zhang
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Ling Zhu
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Jing Geng
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| |
Collapse
|
18
|
Ciampi P, Badano LP, Florescu DR, Villella F, Tomaselli M, Torlasco C, Gavazzoni M, Parati G, Muraru D. Comparison of RA Volumes Obtained Using the Standard Apical 4-Chamber and the RV-Focused Views. JACC Cardiovasc Imaging 2023; 16:248-250. [PMID: 36648037 DOI: 10.1016/j.jcmg.2022.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 07/20/2022] [Accepted: 08/30/2022] [Indexed: 11/17/2022]
|
19
|
Wu J, Huang X, Huang K, Tian Y, Gao Q, Lin B, Tang Y, Chen X, Su M. Dynamic assessment of the tricuspid annulus in a healthy Asian population: A four-dimensional echocardiography study. Echocardiography 2023; 40:113-127. [PMID: 36647764 PMCID: PMC10107205 DOI: 10.1111/echo.15528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 09/11/2022] [Accepted: 12/21/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Tricuspid annulus (TA) geometry and function reference values are limited, especially for Asian populations. We aimed to explore TA using four-dimensional echocardiography (4DE) in a healthy Asian population. METHODS A total of 355 healthy Asian volunteers (median age 34 years; 52% males) were prospectively enrolled. TA geometry and function were analyzed using 4DE throughout the cardiac cycle. RESULTS The TA area, perimeter, and dimensions were smallest at end systole (ES) and largest at late diastole (LD). Normal TA parameters at end diastole (ED) in different sex and age groups were obtained. TA areas, perimeters, and dimensions in males were significantly larger than those in females at ED; BSA-indexed perimeters and BSA-indexed dimensions in males were significantly smaller than those in females at ED. TA parameters correlated well with tricuspid valve (TV) tenting, right ventricle (RV), and right atrium (RA) parameters. CONCLUSIONS Reference values of TA parameters were obtained by 4DE in an Asian population. Quantitative data on TA geometry and function are essential for TA pathology and therapeutics.
Collapse
Affiliation(s)
- Jian Wu
- Department of Echocardiography, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.,School of Medicine, Xiamen University, Xiamen, China.,Xiamen Key Laboratory of Precision Medicine for Cardiovascular Disease, Xiamen, China
| | - Xinyi Huang
- Department of Echocardiography, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.,Xiamen Key Laboratory of Precision Medicine for Cardiovascular Disease, Xiamen, China
| | - Kunhui Huang
- Department of Echocardiography, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.,Xiamen Key Laboratory of Precision Medicine for Cardiovascular Disease, Xiamen, China
| | - Yuan Tian
- Department of Echocardiography, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.,Xiamen Key Laboratory of Precision Medicine for Cardiovascular Disease, Xiamen, China
| | - Qiumei Gao
- Department of Echocardiography, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.,Xiamen Key Laboratory of Precision Medicine for Cardiovascular Disease, Xiamen, China
| | - Biqin Lin
- Department of Ultrasonography, Xiamen Humanity Hospital, Fujian Medical University, Xiamen, China
| | - Yiruo Tang
- Department of Echocardiography, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.,School of Medicine, Xiamen University, Xiamen, China.,Xiamen Key Laboratory of Precision Medicine for Cardiovascular Disease, Xiamen, China
| | - Xu Chen
- Department of Echocardiography, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.,Xiamen Key Laboratory of Precision Medicine for Cardiovascular Disease, Xiamen, China
| | - Maolong Su
- Department of Echocardiography, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.,Xiamen Key Laboratory of Precision Medicine for Cardiovascular Disease, Xiamen, China
| |
Collapse
|
20
|
Richter MJ, Fortuni F, Alenezi F, D'Alto M, Badagliacca R, Brunner NW, van Dijk AP, Douschan P, Gall H, Ghio S, Giudice FL, Grünig E, Haddad F, Howard L, Rajagopal S, Stens N, Stolfo D, Thijssen DHJ, Vizza CD, Zamanian RT, Zhong L, Seeger W, Ghofrani HA, Tello K. Imaging the right atrium in pulmonary hypertension: A systematic review and meta-analysis. J Heart Lung Transplant 2022; 42:433-446. [PMID: 36610927 DOI: 10.1016/j.healun.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 11/27/2022] [Accepted: 11/28/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Right atrial (RA) imaging has emerged as a promising tool for the evaluation of patients with pulmonary hypertension (PH), albeit without systematic validation. METHODS PubMed, Web of Science and the Cochrane library were searched for studies investigating the prognostic value of RA imaging assessment in patients with PH from 2000 to June 2021 (PROSPERO Identifier: CRD42020212850). An inverse variance-weighted meta-analysis of univariable hazard ratios (HRs) was performed using a random effects model. RESULTS Thirty-five studies were included (3,476 patients with PH; 74% female, 86% pulmonary arterial hypertension). Risk of bias was low/moderate (Quality of Prognosis Studies checklist). RA area (HR 1.06; 95% confidence interval [CI] 1.04-1.08), RA indexed area (HR 1.09; 95% CI 1.04-1.14), RA peak longitudinal strain (PLS; HR 0.94; 95% CI 0.91-0.97) and RA total emptying fraction (HR 0.96; 95% CI 0.94-0.98) were significantly associated with combined end-points including death, clinical worsening and/or lung transplantation; RA volume and volume index showed marginal significant associations. RA area (HR 1.06; 95% CI 1.04-1.07), RA indexed area (HR 1.12; 95% CI 1.07-1.17) and RA PLS (HR 0.98; 95% CI 0.97-0.99) showed significant associations with mortality; RA total emptying fraction showed a marginal association. CONCLUSIONS Imaging-based RA assessment qualifies as a relevant prognostic marker in PH. RA area reliably predicts composite end-points and mortality, which underscores its clinical utility. RA PLS emerged as a promising imaging measure, but is currently limited by the number of studies and different acquisition methods.
Collapse
Affiliation(s)
- Manuel J Richter
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Cardio-Pulmonary Institute (CPI), Institute for Lung Health (ILH), Justus-Liebig University, Giessen, Germany.
| | - Federico Fortuni
- Department of Cardiology, San Giovanni Battista Hospital, Foligno, Italy; Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Fawaz Alenezi
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Michele D'Alto
- Cardiology, Second University of Naples, Monaldi Hospital, Naples, Italy
| | - Roberto Badagliacca
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, Italy
| | - Nathan W Brunner
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Arie P van Dijk
- Department of Cardiology, Research Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Philipp Douschan
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Cardio-Pulmonary Institute (CPI), Institute for Lung Health (ILH), Justus-Liebig University, Giessen, Germany; Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Henning Gall
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Cardio-Pulmonary Institute (CPI), Institute for Lung Health (ILH), Justus-Liebig University, Giessen, Germany
| | - Stefano Ghio
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Francesco Lo Giudice
- National Pulmonary Hypertension Service, Department of Cardiology, Hammersmith Hospital, Imperial College NHS Trust, London, UK
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxclinic Heidelberg GmbH at Heidelberg University Hospital, Heidelberg, Germany
| | - Francois Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Luke Howard
- National Pulmonary Hypertension Service, Department of Cardiology, Hammersmith Hospital, Imperial College NHS Trust, London, UK
| | - Sudarshan Rajagopal
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Niels Stens
- Department of Cardiology, Research Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Physiology, Research Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Davide Stolfo
- Department of Cardiology, Azienda Sanitaria Universitaria Integrata, Trieste, Italy; Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Dick H J Thijssen
- Department of Physiology, Research Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands; Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Carmine Dario Vizza
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, Italy
| | - Roham T Zamanian
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA; Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University, Stanford, California, USA
| | - Liang Zhong
- National Heart Centre Singapore, Duke-NUS Medical School, National University of Singapore, Singapore, Singapore; Research on Cardiovascular & Metabolic Disorders, Duke-NUS Medical School, Singapore, Singapore
| | - Werner Seeger
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Cardio-Pulmonary Institute (CPI), Institute for Lung Health (ILH), Justus-Liebig University, Giessen, Germany
| | - Hossein A Ghofrani
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Cardio-Pulmonary Institute (CPI), Institute for Lung Health (ILH), Justus-Liebig University, Giessen, Germany; Department of Medicine, Imperial College London, London, UK
| | - Khodr Tello
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Cardio-Pulmonary Institute (CPI), Institute for Lung Health (ILH), Justus-Liebig University, Giessen, Germany
| |
Collapse
|
21
|
Sørensen EIVIND, Myrstad MARIUS, Solberg MAGNARGANGÅS, Øie ERIK, Tveit ARNLJOT, Aarønæs MARIT. Right heart structure and function in lifelong recreational endurance athletes with and without paroxysmal atrial fibrillation. J Am Soc Echocardiogr 2022; 35:1259-1268. [PMID: 35760278 DOI: 10.1016/j.echo.2022.06.008] [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: 02/03/2022] [Revised: 05/30/2022] [Accepted: 06/05/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Healthy young athletes adapt to the increased demands of endurance exercise with symmetric cardiac remodeling. Male veteran endurance athletes have an increased risk of atrial fibrillation (AF), and some athletes seem susceptible to changes mimicking arrhythmogenic cardiomyopathy. Intense exercise puts a disproportionate hemodynamic load on the right-sided heart chambers. Despite this, data describing right heart structure and function in older veteran athletes are scarce. We aimed to investigate structural and functional characteristics of the right heart in veteran athletes with and without AF to contribute to the understanding of exercise-induced cardiac remodeling in this group. METHODS Three hundred and two male participants, of whom 151 were veteran skiers (62 with paroxysmal AF) and 151 were controls from the general population (62 with paroxysmal AF) underwent an echocardiographic examination in sinus rhythm to evaluate right atrial (RA) and right ventricular (RV) structure and function. While 87 of the participants had never exercised regularly, 50, 43, and 122 men had practiced regular endurance exercise for 1-20, 20-40, and >40 years, respectively. RESULTS RA volume and RV size increased with cumulative years of exercise (p<0.001), with a disproportionate increase in RV size compared with left ventricular (LV) size, regardless of AF status (p<0.001). RA and RV function assessed by strain remained similar despite lifelong exposure to endurance exercise. AF was associated with reduced RA strain irrespective of exposure to exercise (p<0.001). CONCLUSION RA and RV size and RV/LV ratio showed a dose-response relationship with cumulative years of endurance exercise, whereas RA and RV function did not. Indicating that increasing RV/LV ratio may represent a physiological adaptation to prolonged endurance exercise. AF was associated with reduced RA function, regardless of exposure to exercise, suggesting RA functional parameters are more closely linked to AF than RA size in veteran athletes.
Collapse
Affiliation(s)
- E I V I N D Sørensen
- Department of Internal Medicine, Diakonhjemmet Hospital, N-0370, Oslo, Norway; Department of Medical Research, Bærum Hospital Vestre Viken Hospital Trust, N-1346, Gjettum, Norway; Institute of Clinical Medicine, University of Oslo, N-0316, Oslo, Norway.
| | - M A R I U S Myrstad
- Department of Internal Medicine, Bærum Hospital Vestre Viken Hospital Trust, N-1346, Gjettum, Norway; Department of Medical Research, Bærum Hospital Vestre Viken Hospital Trust, N-1346, Gjettum, Norway
| | - M A G N A R G A N G Å S Solberg
- Department of Internal Medicine, Bærum Hospital Vestre Viken Hospital Trust, N-1346, Gjettum, Norway; Department of Medical Research, Bærum Hospital Vestre Viken Hospital Trust, N-1346, Gjettum, Norway
| | - E R I K Øie
- Department of Internal Medicine, Diakonhjemmet Hospital, N-0370, Oslo, Norway
| | - A R N L J O T Tveit
- Department of Medical Research, Bærum Hospital Vestre Viken Hospital Trust, N-1346, Gjettum, Norway; Institute of Clinical Medicine, University of Oslo, N-0316, Oslo, Norway
| | - M A R I T Aarønæs
- Department of Internal Medicine, Diakonhjemmet Hospital, N-0370, Oslo, Norway
| |
Collapse
|
22
|
Lang RM, Cameli M, Sade LE, Faletra FF, Fortuni F, Rossi A, Soulat-Dufour L. Imaging assessment of the right atrium: anatomy and function. Eur Heart J Cardiovasc Imaging 2022; 23:867-884. [PMID: 35079782 DOI: 10.1093/ehjci/jeac011] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/12/2022] [Indexed: 01/07/2023] Open
Abstract
The right atrium (RA) is the cardiac chamber that has been least well studied. Due to recent advances in interventional cardiology, the need for greater understanding of the RA anatomy and physiology has garnered significant attention. In this article, we review how a comprehensive assessment of RA dimensions and function using either echocardiography, cardiac computed tomography, and magnetic resonance imaging may be used as a first step towards a better understanding of RA pathophysiology. The recently published normative data on RA size and function will likely shed light on RA atrial remodelling in atrial fibrillation (AF), which is a complex phenomenon that occurs in both atria but has only been studied in depth in the left atrium. Changes in RA structure and function have prognostic implications in pulmonary hypertension (PH), where the increased right ventricular (RV) afterload first induces RV remodelling, predominantly characterized by hypertrophy. As PH progresses, RV dysfunction and dilatation may begin and eventually lead to RV failure. Thereafter, RV overload and increased RV stiffness may lead to a proportional increase in RA pressure. This manuscript provides an in-depth review of RA anatomy, function, and haemodynamics with particular emphasis on the changes in structure and function that occur in AF, tricuspid regurgitation, and PH.
Collapse
Affiliation(s)
- Roberto M Lang
- Heart and Vascular Center, University of Chicago, 5758 S Maryland Avenue, MC 9067, DCAM 5509, Chicago, IL 60637, USA
| | - Matteo Cameli
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Leila E Sade
- University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, PA, USA.,Department of Cardiology, University of Baskent, Ankara, Turkey
| | | | - Federico Fortuni
- Department of Cardiology, San Giovanni Battista Hospital, Foligno, Italy.,Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Alexia Rossi
- Department of Nuclear Medicine, Zurich University Hospital, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Schlieren, Zurich, Switzerland
| | - Laurie Soulat-Dufour
- Saint Antoine and Tenon Hospital, AP-HP, Pr Ariel Cohen, Sorbonne Université, INSERM, Unité de recherche sur les maladies cardiovasculaires, le métabolisme et la nutrition, ICAN, Paris F-75013, France
| |
Collapse
|
23
|
Muraru D. 22nd Annual Feigenbaum Lecture Right Heart, Right Now: The Role of Three-Dimensional Echocardiography. J Am Soc Echocardiogr 2022; 35:893-909. [DOI: 10.1016/j.echo.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 05/15/2022] [Accepted: 05/15/2022] [Indexed: 10/18/2022]
|
24
|
Khan SS, Beach LB, Yancy CW. Sex-Based Differences in Heart Failure: JACC Focus Seminar 7/7. J Am Coll Cardiol 2022; 79:1530-1541. [PMID: 35422249 DOI: 10.1016/j.jacc.2022.02.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/09/2022] [Indexed: 12/11/2022]
Abstract
Sex-based differences exist in risk, symptoms, and management of heart failure (HF). Women have a higher incidence of HF with preserved ejection fraction compared with men. This may be partially caused by the cardiovascular effects of estrogen and sex-specific risk factors (eg, adverse pregnancy outcomes, premature menopause). Key gaps exist in understanding of gender-based differences in HF, which is a distinctly different concept than sex-based differences. Although evidence-based therapies for HF are available, only limited data address sex-specific efficacy, and no data address gender-based efficacy. Persistent shortcomings in representation of women and gender minority participants in clinical trials limit an actionable database. A comprehensive roadmap to close the sex/gender-based gap in HF includes the following: 1) sex/gender-specific personalized prevention; 2) sex/gender-neutral implementation of evidence-based therapies; and 3) sex/gender-appropriate policy-level initiatives to spur research assessing sex/gender-specific causes of HF; enhance sex/gender-specific subgroup reporting; and promote community engagement of these important patient cohorts.
Collapse
Affiliation(s)
- Sadiya S Khan
- Department of Preventive Medicine; Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lauren B Beach
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Clyde W Yancy
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| |
Collapse
|
25
|
Singulane CC, Singh A, Addetia K, Yamat M, Lang RM. Developing Insights Regarding Tricuspid Valve Regurgitation: Morphology, Assessment of Severity, and the Need for a Novel Grading Scheme. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2022; 6:100026. [PMID: 37273466 PMCID: PMC10236825 DOI: 10.1016/j.shj.2022.100026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 02/17/2022] [Indexed: 06/06/2023]
Abstract
Current understanding that progressive tricuspid regurgitation (TR) is associated with worse outcomes has highlighted the clinical need for a more accurate assessment of TR morphology and severity. This need has been further emphasized owing to the development of a myriad of percutaneous right-sided interventions, which may offer successful treatment of TR in selected patients. Understanding the etiology and quantification of the severity of TR has important implications in the selection of novel therapeutic strategies, i.e., medical vs. percutaneous vs. surgical approaches. Newer grading schemas that better reflect the TR lesion severity have been recently proposed and may facilitate monitoring of the evolution of TR following percutaneous and/or surgical treatment. In this review, we summarize contemporary concepts regarding tricuspid valve morphology, TR etiology, and associated mechanisms and echocardiographic approaches to grade TR severity.
Collapse
Affiliation(s)
| | | | | | | | - Roberto Miguel Lang
- Address correspondence to: Roberto Miguel Lang, MD, FASE, FACC, The University of Chicago Medicine, 5758 S. Maryland Avenue, MR 9067, DCAM 5509, Chicago, IL 6063
| |
Collapse
|
26
|
Singulane CC, Slivnick JA, Addetia K, Asch F, Sarswat N, Soulat-Dufour L, Mor-Avi V, Lang RM. Prevalence of Right Atrial Impairment and Association with Outcomes in Cardiac Amyloidosis. J Am Soc Echocardiogr 2022; 35:829-835.e1. [DOI: 10.1016/j.echo.2022.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/24/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
|
27
|
Soulat-Dufour L, Lang S, Addetia K, Ederhy S, Adavane-Scheuble S, Chauvet-Droit M, Jean ML, Nhan P, Ben Said R, Kamami I, Issaurat P, Capderou E, Arnaud C, Boccara F, Lang RM, Cohen A. Restoring Sinus Rhythm Reverses Cardiac Remodeling and Reduces Valvular Regurgitation in Patients With Atrial Fibrillation. J Am Coll Cardiol 2022; 79:951-961. [PMID: 35272799 DOI: 10.1016/j.jacc.2021.12.029] [Citation(s) in RCA: 62] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/30/2021] [Accepted: 12/06/2021] [Indexed: 10/18/2022]
Abstract
BACKGROUND Cardiac chamber remodeling in atrial fibrillation (AF) reflects the progression of cardiac rhythm and may affect functional regurgitation. OBJECTIVES The purpose of this study was to explore the 3-dimensional echocardiographic variables of cardiac cavity remodeling and the impact on functional regurgitation in patients with AF with/without sinus rhythm restoration at 12 months. METHODS A total of 117 consecutive patients hospitalized for AF were examined using serial 3-dimensional transthoracic echocardiography at admission, at 6 months, and at 12 months (337 examinations). RESULTS During follow-up, 47 patients with active restoration of sinus rhythm (SR) (through cardioversion and/or ablation) had a decrease in all atrial indexed volumes (Vi), end-systolic (ES) right ventricular (RV) Vi, an increase in end-diastolic (ED) left ventricular Vi, and an improvement in 4-chambers function (P < 0.05). Patients with absence/failure of restoration of SR (n = 39) had an increase in ED left atrial Vi and ED/ES RV Vi without modification of 4-chambers function, except for a decrease in left atrial emptying fraction (P < 0.05). Patients with spontaneous restoration of SR (n = 31) had no changes in Vi or function. The authors found an improvement vs baseline in severity of functional regurgitation in patients with active restoration of SR (tricuspid and mitral regurgitation) and in spontaneous restoration of SR (tricuspid regurgitation) (P < 0.05). In multivariable analysis, right atrial and/or left atrial reverse remodeling exclusively correlated with intervention (cardioversion and/or ablation) during 12-month follow-up. CONCLUSIONS Management of AF should focus on restoration of SR to induce anatomical (all atrial Vi, ES RV Vi) and/or functional (4 chambers) cardiac cavity reverse remodeling and reduce severity of functional regurgitation. (Thromboembolic and Bleeding Risk Stratification in Patients With Non-valvular Atrial Fibrillation [FASTRHAC]; NCT02741349).
Collapse
Affiliation(s)
- Laurie Soulat-Dufour
- Department of Cardiology, Saint Antoine and Tenon Hospital, AP-HP, Sorbonne Université, Paris, France; Unité INSERM UMRS 1166 Unité de recherche sur les maladies cardiovasculaires et métaboliques, Institut Hospitalo-Universitaire, Institut de Cardiométabolisme et Nutrition (ICAN), F-75013, Sorbonne Université, Paris, France. https://twitter.com/lsoulatdufour
| | - Sylvie Lang
- Department of Cardiology, Saint Antoine and Tenon Hospital, AP-HP, Sorbonne Université, Paris, France
| | - Karima Addetia
- Section of Cardiology, Heart and Vascular Center, University of Chicago, Chicago, Illinois, USA
| | - Stephane Ederhy
- Department of Cardiology, Saint Antoine and Tenon Hospital, AP-HP, Sorbonne Université, Paris, France
| | | | - Marion Chauvet-Droit
- Department of Cardiology, Saint Antoine and Tenon Hospital, AP-HP, Sorbonne Université, Paris, France
| | - Marie-Liesse Jean
- Department of Cardiology, Saint Antoine and Tenon Hospital, AP-HP, Sorbonne Université, Paris, France
| | - Pascal Nhan
- Department of Cardiology, Saint Antoine and Tenon Hospital, AP-HP, Sorbonne Université, Paris, France
| | - Rim Ben Said
- Department of Cardiology, Saint Antoine and Tenon Hospital, AP-HP, Sorbonne Université, Paris, France
| | - Iris Kamami
- Department of Cardiology, Saint Antoine and Tenon Hospital, AP-HP, Sorbonne Université, Paris, France
| | - Pauline Issaurat
- Department of Cardiology, Saint Antoine and Tenon Hospital, AP-HP, Sorbonne Université, Paris, France
| | - Elodie Capderou
- Department of Cardiology, Saint Antoine and Tenon Hospital, AP-HP, Sorbonne Université, Paris, France
| | - Camille Arnaud
- Department of Cardiology, Saint Antoine and Tenon Hospital, AP-HP, Sorbonne Université, Paris, France
| | - Franck Boccara
- Department of Cardiology, Saint Antoine and Tenon Hospital, AP-HP, Sorbonne Université, Paris, France; Sorbonne Université, GRC n°22, C(2)MV-Complications Cardiovasculaires et Métaboliques chez les patients vivant avec le Virus de l'immunodéficience humaine, Inserm UMR_S 938, Centre de Recherche Saint-Antoine, Institut Hospitalo-Universitaire, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
| | - Roberto M Lang
- Section of Cardiology, Heart and Vascular Center, University of Chicago, Chicago, Illinois, USA
| | - Ariel Cohen
- Department of Cardiology, Saint Antoine and Tenon Hospital, AP-HP, Sorbonne Université, Paris, France; Unité INSERM UMRS 1166 Unité de recherche sur les maladies cardiovasculaires et métaboliques, Institut Hospitalo-Universitaire, Institut de Cardiométabolisme et Nutrition (ICAN), F-75013, Sorbonne Université, Paris, France.
| |
Collapse
|
28
|
Reference values of left and right atrial volumes and phasic function based on a large sample of healthy Chinese adults: A cardiovascular magnetic resonance study. Int J Cardiol 2022; 352:180-187. [DOI: 10.1016/j.ijcard.2022.01.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 01/05/2022] [Accepted: 01/31/2022] [Indexed: 11/17/2022]
|
29
|
Hosseinsabet A, Mahmoudian R, Jalali A, Mohseni-Badalabadi R, Davarpasand T. Normal Ranges of Right Atrial Strain and Strain Rate by Two-Dimensional Speckle-Tracking Echocardiography: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 8:771647. [PMID: 34977185 PMCID: PMC8718502 DOI: 10.3389/fcvm.2021.771647] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/24/2021] [Indexed: 01/31/2023] Open
Abstract
Background: Normal range values of right atrial (RA) phasic function markers are essential for the identification of normal and abnormal values, comparison with reference values, and the clinical meaning of obtained values. Accordingly, we aimed to define the normal range values of RA phasic function markers obtained by 2D speckle-tracking echocardiography through a meta-analysis and determine the main sources of heterogeneity among reported values. Methods: PUBMED, SCOPUS, and EMBASE databases were searched for the following keywords: "right atrial/right atrium" and "strain/speckle/deformation" and "echocardiography." Studies were selected that included a human healthy adult group without any cardiovascular diseases or risk factors and that were written in the English language. For the calculation of each marker of RA phasic functions, a random-effect model was used. Meta-regression was employed to define the major sources of variabilities among reported values. Results: Fifteen studies that included 2,469 healthy subjects were selected for analysis. The normal range values for RA strain and strain rate were 42.7% (95% CI, 39.4 to 45.9%) and 2.1 s-1 (95% CI, 2.0 to 2.1 s-1) during the reservoir phase, respectively, 23.6% (95% CI, 20.7 to 26.6%) and -1.9 s-1 (95% CI, -2.2 to -1.7 s-1) during the conduit phase, correspondingly, and 16.1% (95% CI, 13.6 to 18.6%) and -1.8 s-1 (95% CI, -2.0 to -1.5 s-1) during the contraction phase, respectively. The sources of heterogeneity for the normal range of these markers were the number of participants, the type of software, the method of global value calculation, the right ventricular fractional area change, the left ventricular (LV) ejection fraction, the RA volume index, sex, the heart rate, the diastolic blood pressure, the body mass index, and the body surface area. Conclusions: Using 2D speckle-tracking echocardiography, we defined normal values for RA phasic function markers and identified the sources of heterogeneity as demographic, anthropometric, hemodynamic, and echocardiography factors. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021236578, identifier: CRD42021236578.
Collapse
Affiliation(s)
- Ali Hosseinsabet
- Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Roshanak Mahmoudian
- Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Arash Jalali
- Department of Research, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Mohseni-Badalabadi
- Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Tahereh Davarpasand
- Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
30
|
Miyoshi T, Tanaka H. Standardization of normal values for cardiac chamber size in echocardiography. J Med Ultrason (2001) 2022; 49:21-33. [PMID: 34787741 DOI: 10.1007/s10396-021-01147-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 08/09/2021] [Indexed: 10/19/2022]
Abstract
Echocardiography is used worldwide to evaluate cardiac size and function. To determine what values are abnormal, it is essential to establish normal reference values for echocardiography. The current guidelines for chamber quantification specify normative values for cardiac chambers and recommend that gender and body size be taken into account. However, these normative data were established using databases for which a variety of measurement methods were used and the majority of subjects consisted of Whites in Europe and the United States. However, several regional studies from other countries suggest that cardiac size varies globally. To overcome these limitations, the Normal Reference Ranges for Echocardiography study and the World Alliance of Societies of Echocardiography Normal Values study have recently been conducted to examine similarities and differences in cardiac chamber size and to establish normal reference values while taking worldwide diversity into account. The results from these studies have demonstrated that standardization of normal reference values for cardiac size is important. This review article aims to summarize the current status of normative echocardiographic values for cardiac chamber size.
Collapse
Affiliation(s)
- Tatsuya Miyoshi
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osakasayama, Osaka, 589-8511, Japan.
| | - Hidekazu Tanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| |
Collapse
|
31
|
Addetia K, Miyoshi T, Amuthan V, Citro R, Daimon M, Fajardo PG, Kasliwal RR, Kirkpatrick JN, Monaghan MJ, Muraru D, Ogunyankin KO, Park SW, Ronderos RE, Sadeghpour A, Scalia GM, Takeuchi M, Tsang W, Tucay ES, Tude Rodrigues AC, Zhang Y, Hitschrich N, Blankenhagen M, Degel M, Schreckenberg M, Mor-Avi V, Asch FM, Lang RM. Normal Values of Left Ventricular Size and Function on 3D Echocardiography: Results of the World Alliance of Societies of Echocardiography Study. J Am Soc Echocardiogr 2021; 35:449-459. [PMID: 34920112 DOI: 10.1016/j.echo.2021.12.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/29/2021] [Accepted: 12/07/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Echocardiography remains the most widely used modality to assess left ventricular (LV) chamber size and function. Currently this assessment is most frequently performed using 2D echocardiography (2DE). Yet, 3D echocardiography (3DE) has been shown to be more accurate and reproducible than 2DE. Current normative reference values for 3D LV analysis are predominantly based on data from North America and Europe. The World Alliance of Societies of Echocardiography (WASE) study was a designed to sample normal subjects from around the world to provide more universal global reference ranges. In this study we sought to assess the world-wide feasibility of LV 3DE and report on size and function measurements. METHODS 2262 healthy subjects were prospectively enrolled from 19 centers in 15 countries. 3D LV full-volume datasets were obtained and analyzed offline with vendor-neutral software. Measurements included end-diastolic and end-systolic volumes (EDV, ESV), ejection fraction (EF), global longitudinal and circumferential strain (GLS and GCS). Results were categorized by age (18-40, 41-65 and >65 years), sex and race. RESULTS 1589 subjects (feasibility 70%) had adequate LV datasets for analysis. Mean normal values for indexed EDV, ESV and EF in men and women were 70 ± 15 and 65 ± 12 mL, 28 ± 7 and 25 ± 6 mL and 60 ± 5, 62 ± 5% respectively. Men had larger LV volumes and lower EF than women. GLS and GCS were higher in magnitude in women. In both sexes, LV volumes were lower and EF tended to be higher with increasing age, especially considering the differences between the youngest and oldest age groups. While GLS was similar across age groups in men, in women, the youngest and middle-age cohorts revealed higher magnitudes of GLS when compared to the oldest age group. GCS was higher in magnitude at older age in both men and women. Finally, Asians had smaller chamber sizes and higher EF and absolute strain values than both blacks and whites. CONCLUSIONS Age, sex, and race should be considered when defining normal reference values for LV dimension and function parameters obtained by 3DE.
Collapse
|
32
|
Sex, Age and Race Related Normal Values of Right Ventricular Diastolic Function Parameters: Data from the World Alliance of Societies of Echocardiography Study. J Am Soc Echocardiogr 2021; 35:426-434. [PMID: 34695547 DOI: 10.1016/j.echo.2021.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 10/11/2021] [Accepted: 10/11/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Though the assessment of right ventricular (RV) diastolic function is feasible, it has garnered far less momentum for use compared to its left ventricular counterpart. The scarcity of data defining normative RV diastolic function and the fact that implications of RV diastolic dysfunction in different disease states on outcomes are less well known, both hinder integration into routine clinical assessment. We sought to establish normal values of RV diastolic parameters stratified by sex, age and race using data from the World Alliance of Societies of Echocardiography (WASE) Study. METHODS We analyzed a subset of 888 normal subjects from the WASE database, including measurements of tricuspid valve (TV) inflow E- and A-wave velocities, E-wave deceleration time, TV annular tissue Doppler e' and a' velocities. Additionally, right atrial (RA) maximal volume and RA peak reservoir strain were measured. Patients were grouped by age (<40, 41-65, >65 years), and stratified by sex and race. Differences were analyzed using unpaired t-tests. RESULTS When compared to men, women had significantly higher TV e', E-wave and A-wave velocities, though differences were modest. Increasing age was associated with stepwise lower TV E-wave, e' velocities and TV E/A, higher a' velocities and E/e' ratios. RA peak reservoir strain was also lower and RA ESV trended towards being smaller for older age groups. Asian subjects demonstrated significantly higher a' velocities, lower E-wave, smallest RA ESV and lowest RA peak strain values, compared to whites of both sexes. CONCLUSIONS This study provides normal values for parameters used in the assessment of RV diastolic function stratified by race, sex and age. Our results demonstrate significant differences in RV diastolic parameters between age groups, which manifest in both the individual parameters and composite ratios of TV inflow and annular velocities. While limited sex- and race-related differences were also noted, age appears to have the most significant impact on RV diastolic parameters. These findings may aid in refining the current normative values.
Collapse
|
33
|
Seewöster T, Dinov B, Nedios S, Hindricks G, Sommer P, Kornej J. Biatrial volume ratio predicts low voltage areas in atrial fibrillation. Clin Cardiol 2021; 44:1560-1566. [PMID: 34494677 PMCID: PMC8571553 DOI: 10.1002/clc.23720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 08/08/2021] [Accepted: 08/23/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Left atrial volume (LAV) and low voltage areas (LVAs) are acknowledged markers for worse rhythm outcome after ablation of atrial fibrillation (AF). Some studies reported the importance of increased right atrial volume (RAV) as a predictor for arrhythmia recurrences in AF patients. OBJECTIVE To investigate association between the LAV/RAV ratio and LVAs presence. METHODS Patients undergoing first AF ablation were included. LVAs were assessed peri-procedurally using high-density 3D maps and defined as <0.5 mV. All patients underwent pre-procedural cardiovascular magnetic resonance imaging. LAV (biplane) and RAV (monoplane 4-chamber) were assessed prior to ablation, and the LAV/RAV ratio was calculated. RESULTS The study population included 189 patients (age mean 63 ± 10 years, 33% women, 57% persistent AF, 22% LVAs). There were 149 (79%) patients with LAV > RAV. In univariable analysis LAV > RAV was associated with LVAs (OR 6.803, 95%CI 1.395-26.514, p = .016). The association remained robust in multivariable model after adjustment for persistent AF, CHA2 DS2 -VASc score, and heart rate (OR 5.981, 95%CI 1.256-28.484, p = .025). Using receiver operator curve analysis, LAV > RAV (AUC 0.668, 95%CI 0.585-0.751, p = .001) was significant predictor for LVAs. In multivariable analysis, after adjustment for age, persistent AF, and renal function, RAV≥LAV was threefold higher in males (OR 3.040, 95%CI 1.050-8.802, p = .04). CONCLUSIONS LAV > RAV is useful for the prediction of electro-anatomical substrate in AF. LAV > RAV was associated with LVAs presence, while male sex remained associated with RAV≥LAV and less LVAs.
Collapse
Affiliation(s)
- Timm Seewöster
- Department of Electrophysiology, Heart Center Leipzig - University Hospital of Cardiology, Leipzig, Germany
| | - Borislav Dinov
- Department of Electrophysiology, Heart Center Leipzig - University Hospital of Cardiology, Leipzig, Germany
| | - Sotirios Nedios
- Department of Electrophysiology, Heart Center Leipzig - University Hospital of Cardiology, Leipzig, Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center Leipzig - University Hospital of Cardiology, Leipzig, Germany
| | - Philipp Sommer
- Department of Electrophysiology, Herz- und Diabeteszentrum NRW, Bad Oeynhausen, Germany
| | - Jelena Kornej
- School of Medicine - Cardiovascular Medicine, Boston University, Boston, Massachusetts, USA
| |
Collapse
|
34
|
Singh A, Carvalho Singulane C, Miyoshi T, Prado AD, Addetia K, Bellino M, Daimon M, Gutierrez Fajardo P, Kasliwal RR, Kirkpatrick JN, Monaghan MJ, Muraru D, Ogunyankin KO, Park SW, Ronderos RE, Sadeghpour A, Scalia GM, Takeuchi M, Tsang W, Tucay ES, Tude Rodrigues AC, Vivekanandan A, Zhang Y, Schreckenberg M, Blankenhagen M, Degel M, Hitschrich N, Mor-Avi V, Asch FM, Lang RM. Normal Values of Left Atrial Size and Function and the Impact of Age: Results of the World Alliance Societies of Echocardiography Study. J Am Soc Echocardiogr 2021; 35:154-164.e3. [PMID: 34416309 DOI: 10.1016/j.echo.2021.08.008] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/06/2021] [Accepted: 08/10/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Left atrial (LA) evaluation includes volumetric and functional parameters with an abundance of diagnostic and prognostic implications. Solid normal reference ranges are compulsory for accurate interpretation in individual patients, but previous studies have yielded mixed conclusions regarding the effects of age, sex, and/or race. The present report from the World Alliance Societies of Echocardiography study focuses on two-dimensional (2D) and three-dimensional (3D) measures of LA structure and function, with subgroup analysis by age, sex, and race. METHODS Transthoracic 2D and 3D echocardiographic images were obtained in 1,765 healthy individuals (901 men, 864 women) evenly distributed among age subgroups: 18 to 40 years (n = 745), 41 to 65 years (n = 618), and >65 years (n = 402); the racial distribution was 38.4% white, 39.9% Asian, and 9.7% black. Images were analyzed using dedicated LA analysis software to measure LA volumes and phasic function from 3D volume and 2D strain curves. RESULTS Three-dimensional maximum and minimum LA volumes adjusted for body surface area were nearly identical for men and women, but women demonstrated higher 3D total and passive emptying fractions (EFs). Two-dimensional reservoir strain was similar for both sexes. Age was associated with an incremental rise in LA volumes alongside characteristic shifts in functional indices. Total 2D EF and reservoir and conduit strain varied inversely with age, counteracted by higher booster strain, with a greater magnitude of effect in women. Active 3D EF was significantly higher, while total and passive EFs decreased with age. Interracial differences were noted in LA volumes, without substantial differences in functional indices. CONCLUSION Although similar normal values for LA volumes and strain can be applied to both sexes, meaningful differences in LA size occur with aging. Indices of function also shift with age, with a compensatory rise in booster function, which may serve to counteract observed lower total and passive EFs. Defining age-associated normal values may help differentiate age-associated "healthy" LA aging from pathologic processes.
Collapse
Affiliation(s)
| | | | - Tatsuya Miyoshi
- MedStar Health Research Institute, Washington, District of Columbia
| | - Aldo D Prado
- Centro Privado de Cardiologia, Tucumán, Argentina
| | | | | | | | | | | | | | | | - Denisa Muraru
- University of Milano-Bicocca and Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | | | - Seung Woo Park
- Samsung Medical Center/Sungkyunkwan University School of Medicine, Seoul, Korea
| | | | - Anita Sadeghpour
- Rajaie Cardiovascular Medical Center, Iran University of Medical Sciences, Tehran, Iran
| | | | - Masaaki Takeuchi
- University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Wendy Tsang
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Yun Zhang
- Qilu Hospital of Shandong University, Jinan, China
| | | | | | - Markus Degel
- TomTec Imaging Systems, Unterschleissheim, Germany
| | | | | | - Federico M Asch
- MedStar Health Research Institute, Washington, District of Columbia
| | | | | |
Collapse
|
35
|
Nakanishi K, Daimon M. Aging and myocardial strain. J Med Ultrason (2001) 2021; 49:53-60. [PMID: 34302227 DOI: 10.1007/s10396-021-01115-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/09/2021] [Indexed: 11/28/2022]
Abstract
Advanced age is widely recognized as a key risk factor for incident cardiovascular disease. The age-associated changes in cardiac properties alter the substrate on which cardiovascular disease is superimposed in various ways, and thus affect the development and manifestations of cardiovascular disease (CVD) in the elderly. However, it is still unclear whether age-related cardiac alteration is attributed to aging itself or whether it is secondary to other acquired cardiovascular risk factors. Understanding the association between aging and cardiac functional remodeling might provide insight into the pathogenesis of cardiovascular aging and may help inform possible preventive strategies for CVD in older individuals. Speckle-tracking echocardiography enables the objective and quantitative assessment of subtle myocardial alterations that are undetectable with conventional echocardiography, and has excellent feasibility and reproducibility. Left ventricular (LV) global longitudinal strain, a sensitive measure of LV systolic dysfunction, was found to be an independent risk factor for cardiovascular morbidity and mortality. More recently, deformation imaging has been employed to assess right ventricular (RV) and atrial performance, and impaired RV and atrial strain predict unfavorable outcomes in various clinical settings. This article reviews the association between aging and changes in myocardial strain values and describes future perspectives.
Collapse
Affiliation(s)
- Koki Nakanishi
- Department of Cardiovascular Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Masao Daimon
- Department of Cardiovascular Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.,Department of Clinical Laboratory, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
36
|
Sugimoto T, Dohi K. Current status and issues regarding reference values for echocardiography: a short review. J Med Ultrason (2001) 2021; 49:17-19. [PMID: 34185191 DOI: 10.1007/s10396-021-01108-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 06/02/2021] [Indexed: 10/21/2022]
Abstract
In general, the reference values of diagnostic test parameters are specified based on the values of 95% confidence intervals of those parameters measured in healthy subjects. As heart size varies according to sex, there are sex-related differences in the reference values of echocardiographic parameters. There have been attempts to minimize the variability in the reference values of echocardiographic parameters worldwide by correcting for age-related, sex-related, and body size-related differences. This short review describes the current status and issues regarding the reference values of echocardiographic parameters and discusses the findings of research aimed at resolving these issues.
Collapse
Affiliation(s)
- Tadafumi Sugimoto
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, 514-8507, Japan.
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, 514-8507, Japan
| |
Collapse
|