Comparison of the Tei index with invasive measurements of right ventricular function

RV in COPD - The complicated matters of the heart - Correlation of ECHO and biomarker with COPD severity and outcome

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) have an increased risk of cardiovascular involvement, which is among the leading causes of morbidity and mortality worldwide. Echocardiography (ECHO) could be a reliable, non-invasive tool for predicting the risk of cardiovascular modalities in patients with COPD. Combining the ECHO parameters with highly selective cardiac troponin could predict the severity and outcome of patients with COPD.

METHODS

This prospective observational study was conducted at a tertiary care hospital in South India. All patients who met the criteria were included. Patients with other concomitant chronic lung diseases were excluded. An echocardiographic examination was performed, and blood samples for hs-Tnt were taken on admission for patients admitted with COPD. Categorical variables were analyzed using Pearson's Chi-square test, and the T-test was used to compare the means. One-way analysis of variance (ANOVA) followed by the Bonferroni multiple comparison tests was done to compare different echo parameters concerning COPD severity.

RESULTS

The mean tricuspid annulus plane systolic excursion (TAPSE) and right ventricle (RV) fraction area change (FAC) values were lower with the increase in the disease severity (P < 0.001). There was a significant increase in the mean systolic pressures in the right atrium and ventricle in patients with severe COPD (P < 0.001). The mean hs-TnT values were significantly higher in patients with severe COPD (18.86 ± 18.12) and correlated well with the increase in the severity of the disease (P < 0.001). Changes in the echo parameters, such as mean TAPSE and RV FAC values, negatively correlated with COPD severity. There was an increase in systolic pressure in both atria and ventricles with the progression of COPD. Troponin helped predict mortality during hospitalization.

CONCLUSION

Comprehensive echocardiographic parameters, such as TAPSE and RV FAC, help assess the disease's severity, predict mortality, and evaluate whether the proper ventricular function is reliable. Troponin is a valuable adjunct that is an independent and strong predictor of overall mortality in patients with COPD.

Tei Index and its Relation to Outcome of Critically Ill Children on Continuous Renal Replacement Therapy

OBJECTIVES

To evaluate echocardiographic parameters, especially the Tei index as a predictor of outcome in critically ill children on continuous renal replacement therapy (CRRT).

METHODS

This cohort study included all critically ill patients admitted at the Pediatric intensive care unit (PICU) and underwent CRRT. Functional echocardiography and Pediatric Risk of Mortality Index (PRISM) III were used to evaluate the participants. Both the Tei index and the Vasoactive inotropic score (VIS) were estimated.

RESULTS

The study included 35 patients with an age range of 6 mo to 14 y. The Tei indexes, VIS, and PRISM III were reported as predictors of mortality with a sensitivity of 88%, 83%, and 94% and a specificity of 73%, 79%, and 89% respectively. In survivors, the mean Tei index score, median VIS, and mean PRISM values were 0.44 ± 0.1, 3.8 (0-40), and 12.06 ± 3.35, respectively. However, in non-survivors, the mean Tei index, median VIS, and mean PRISM score were 0.59 ± 0.16, 0.60 (0-342.5), and 22.94 ± 8.93, respectively.

CONCLUSIONS

The Tei index could be used as a predictor for poor outcomes in children receiving CRRT. It is correlated to the PRISM score and VIS.

Diastolic ventricular function in persistent pulmonary hypertension of the newborn

Background

Persistent pulmonary hypertension of the newborn (PPHN) is usually considered a consequence of impaired pulmonary circulation. However, little is known regarding the role of cardiac dysfunction in PPHN. In this study, we hypothesized that the tolerance for pulmonary hypertension in newborn infants depends on the biventricular function. The aim of this study is to evaluate biventricular cardiac performance by using Tissue Doppler Imaging (TDI) in an healthy newborn infants with asymptomatic pulmonary hypertension and in newborn infants with PPHN.

Methods

Right and left cardiac function were investigated using conventional imaging and TDI in 10 newborn infants with PPHN ("PPHN") and 10 asymptomatic healthy newborn infants ("asymptomatic PH").

Results

Systolic pulmonary artery pressure (PAP) as assessed by TDI and the mean systolic velocity of the right ventricular (RV) free wall were similar in both groups. The isovolumic relaxation time of the right ventricle at the tricuspid annulus was significantly longer in the "PPHN" than in the "asymptomatic PH" group (53 ± 14 ms vs. 14 ± 4 ms, respectively; p < 0.05). Left ventricular (LV) function was normal in both groups with a systolic velocity (S'LV) at the LV free wall groups (6 ± 0.5 cm/s vs. 8.3 ± 5.7 cm/s, p > 0.05).

Conclusion

The present results suggest that high PAP with or without respiratory failure is not associated with altered right systolic ventricular function and does not affect LV function in newborn infants. PPHN is characterized by a marked right diastolic ventricular dysfunction. These data suggest that the hypoxic respiratory failure in PPHN results, at least in part, from diastolic RV dysfunction and right to left shunting across the foramen ovale. We propose that the severity of the respiratory failure is more related to the RV diastolic dysfunction than the pulmonary artery pressure.

Is there any relationship between biomarkers and echocardiographic markers in patients with pulmonary stenosis underwent balloon valvuloplasty?

BACKGROUND

Congenital pulmonary stenosis (PS) is a progressive disease. Balloon pulmonary valvuloplasty (BPV) is the treatment of choice in valvular PS.

AIM

We aim to study the relationship between biomarkers and echocardiographic markers in valvular PS and to assess the impact of BPV on these markers.

PATIENTS AND METHODS

Patients with moderate and severe valvular PS amenable for BPV were recruited. Serum troponin I was measured. Echocardiographic assessment of PS and right ventricular (RV) function was done. All patients underwent BPV. Troponin level and echocardiographic data were re-assessed 2 weeks and 6 months after BPV.

RESULTS

Fifty patients with valvular PS were recruited. There was significant correlation between peak SPG and troponin (P < .001). Troponin was significantly decreased 2 weeks after BPV. Similarly, there was an initial improvement in RV function. After 6 months of follow-up, we divided patients into two groups: Group A: 36 patients with no restenosis. Group B: 14 patients with restenosis. There were high significant differences between both groups regarding troponin level and RV functions with re-elevated troponin in Group B that correlated with peak PG (r = .9, P < .001). RV function parameters in Group B became significantly worse 6 months after BPV than those after the initial 2 weeks.

CONCLUSION

Troponin correlates with the severity of PS and associates with RV dysfunction. Both troponin and RV functions improved with BPV. Recurrent elevation of troponin and impairment of RV function is associated with PV restenosis and could be set as an indication for repeated balloon dilatation of PV.

Right Ventricular Tissue Doppler Myocardial Performance Index in Children with Pulmonary Hypertension: Relation to Invasive Hemodynamics

Right ventricular (RV) failure is a significant cause of morbidity and mortality in patients with pulmonary hypertension (PH). Myocardial performance index measured by tissue Doppler imaging (TDI-MPI) has been useful in assessing RV dysfunction in adults with PH. However, TDI-MPI as a marker for RV dysfunction or disease severity has not been evaluated in pediatric PH. The aim of this study was to investigate TDI-MPI and correlate with invasive hemodynamics in pediatric PH patients. Eighty pediatric PH patients undergoing cardiac catheterization and simultaneous transthoracic echocardiography were analyzed. RV TDI-MPI was averaged over three cardiac cycles and measured under each condition of vasodilatory testing during the catheterization. TDI-MPI was compared between PH patients and age-matched controls and correlated to invasive hemodynamics. RV TDI-MPI was increased in PH patients compared to controls (0.49 vs. 0.35, p < 0.0001). Significant associations (beta ± SE) are seen between RV TDI-MPI and baseline mean pulmonary arterial pressures (0.0002 ± 0.001, p < 0.05), indexed pulmonary vascular resistance (0.007 ± 0.002, p < 0.002), and pulmonary-to-systemic arterial pressure ratio (0.146 ± 0.063, p < 0.05). No statistically significant associations were seen with vasodilatory testing. RV TDI-MPI is elevated in children with PH, suggestive of RV dysfunction. RV TDI-MPI shows correlation with severity of PH at baseline but lacks sensitivity to evaluate the RV response to acute changes in afterload in children with PH. Therefore, while RV TDI-MPI can help identify RV dysfunction in children with PH, its utility as a non-invasive surrogate marker for acute changes in hemodynamics is limited.

Acute Right Ventricular Dysfunction in Intensive Care Unit

The role of the left ventricle in ICU patients with circulatory shock has long been considered. However, acute right ventricle (RV) dysfunction causes and aggravates many common critical diseases (acute respiratory distress syndrome, pulmonary embolism, acute myocardial infarction, and postoperative cardiac surgery). Several supportive therapies, including mechanical ventilation and fluid management, can make RV dysfunction worse, potentially exacerbating shock. We briefly review the epidemiology, pathophysiology, diagnosis, and recommendations to guide management of acute RV dysfunction in ICU patients. Our aim is to clarify the complex effects of mechanical ventilation, fluid therapy, vasoactive drug infusions, and other therapies to resuscitate the critical patient optimally.

Clinical Utility of Echocardiography for the Diagnosis and Prognosis in Children with Bronchopulmonary Dsyplasia

Background

Bronchopulmonary dysplasia (BPD) may result in chronic pulmonary artery hypertension and right ventricular (RV) dysfunction. Various echocardiographic assessments of RV dysfunction have been used to determine whether echocardiographic measurements of premature infants with BPD could provide sensitive measures of RV function that correlates with BPD severity.

Methods

Twenty-eight control subjects without BPD (non BPD group), 28 patients with mild BPD, 11 patients with moderate BPD, and six patients with severe BPD underwent echocardiograms with standard measurement such as ejection fraction by M-mode, tricuspid regurgitation pressure gradient, myocardial performance index (MPI) derived from pulse Doppler, and tissue Doppler imaging (TDI) measurements. BPD severity was classified by the NICHD/NHLBI/ORD workshop rating scale. Twenty-eight control subjects without BPD (non BPD group), 28 patients with mild BPD, 11 patients with moderate BPD, and six patients with severe BPD underwent echocardiograms with standard measurement such as ejection fraction by M-mode, tricuspid regurgitation pressure gradient, myocardial performance index (MPI) derived from pulse Doppler, and TDI measurements. BPD severity was classified by the NICHD/NHLBI/ORD workshop rating scale.

Results

None of the standard echocardiographic findings was significantly different between the control group and BPD groups. However, mean septal TDI-MPI of the severe BPD group (0.68 ± 0.06) was significantly (p < 0.01) higher than that of the non-BPD (0.58 ± 0.10) or the mild BPD group (0.59 ± 0.12). In addition, mean RV TDI-MPI of the severe BPD group (0.71 ± 0.13) was significantly (p < 0.05) higher than that of the non-BPD group (0.56 ± 0.08) or the mild BPD group (0.60 ± 0.125). Linear regression showed a good correlation between the severity of BPD and RV TDI-MPI (p = 0.01, R = 0.30) or septal TDI-MPI (p = 0.04, R = 0.24).

Conclusion

Echocardiographic evaluation of RV function based on an assessment of RV TDI-MPI can provide RV dysfunction parameter in premature infants with BPD.

Clinical study of right ventricular longitudinal strain for assessing right ventricular dysfunction and hemodynamics in pulmonary hypertension

This study aimed to appraise the application of right ventricular longitudinal strain for assessing right ventricular dysfunction and severe hemodynamic changes in pulmonary hypertension. The study included 53 patients clinically diagnosed with PH. Tissue Doppler-derived tricuspid lateral annular systolic velocity (s'), early diastolic peak velocity (e'), late diastolic peak velocity (a'), tricuspid annular plane systolic excursion (TAPSE), RV index of myocardial performance (RIMP), and right ventricular fractional area change (FAC) were determined. The STI parameter was RV free wall longitudinal peak systolic strain (RV LPSS). The patients were assigned into two groups based on a RV LPSS value of - 19%.RV LPSS, s', TAPSE, RIMP, FAC, a' and e'/a' showed significant differences. PH patients with an RV LPSS≥ -19% exhibited a lower RV function (P < 0.05). RV LPSS was negatively correlated with TAPSE (r = -0.326, P < 0.05) and FAC (r = -0.495, P < 0.001) and positively correlated with RIMP (r = 0.508, P < 0.001). The optimal cut-off value of RV LPSS to reveal an mPAP ≥ 45 mmHg defined based on the receiver operating characteristic curve analysis was - 19.26% with a sensitivity of 83.9% and a specificity of 73.4%.Distinguishing the degree of RV dysfunction by 2D-STI may help physicians to determine the state of cardiac function and degree of PH in patients and offer a basis for subsequent clinical diagnosis and therapy. Our study demonstrates the superiority of RV LPSS for uncovering severe PH over the traditional echocardiographic parameters.

Echocardiographic parameters for assessing successful balloon mitral valvuloplasty in juvenile age groups

BACKGROUND

Different echocardiographic parameters have been studied and validated for assessing the severity of mitral stenosis; however, scant data are available for these markers in the context of balloon mitral valvuloplasty in juvenile age groups (ages ⩽20 years).

OBJECTIVES

The aim of the present study was to find out the utility of echocardiographic parameters such as mitral valve separation index, left atrial volume, right ventricular systolic pressure, tricuspid annular plane systolic excursion, tricuspid annular systolic velocity, and right ventricular Tei index in predicting success of balloon mitral valvuloplasty and their relation to mitral valve area in juvenile mitral stenosis.

METHODS

We carried out a prospective single-centre study involving 52 juvenile mitral stenosis patients undergoing elective valvuloplasty. Success was defined as an increase in mitral valve area ⩾50% or ⩾1.5 cm2. Echocardiographic measurements were taken before and 24 hours after the procedure and statistical analyses were carried out.

RESULTS

The mean age of the study population was 14.3 years (SD ±4.55), ranging from 7 to 20 years. Valvuloplasty was successful in 49 out of 52 patients. The mean valve area improved from 0.89 (SD ±0.16) to 1.73 (SD ±0.22) cm2/m2 (p<0.01), and the mean mitral valve gradient decreased from 19.87 (SD ±7.89) to 7.45 (SD ±2.07) (p=0.021). All the surrogate parameters improved favourably after valvuloplasty (p<0.01). The decrease in right ventricular systolic pressure was a better indicator of the success followed by the increase in valve separation index (area under the curve 0.81 and 0.76, respectively).

CONCLUSIONS

All the surrogate markers studied showed favourable improvement, and right ventricular systolic pressure reduction and improved mitral valve separation index were better indicators of successful valvuloplasty.

Plasma myostatin levels are related to the extent of right ventricular dysfunction in exacerbation of chronic obstructive pulmonary disease

OBJECTIVE

To investigate the relationship between plasma myostatin levels and right ventricle (RV) dysfunction (RVD) in acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

METHODS

The study recruited 84 patients with AECOPD. Plasma myostatin was analyzed and tricuspid annular plane systolic excursion (TAPSE) < 16 mm was used as the main indicator for RVD.

RESULTS

Plasma myostatin levels were significantly higher in 47 patients with RVD than 37 ones without (P < 0.005). Multivariate regression analysis revealed that myostatin levels correlated significantly with TAPSE values and RV myocardial performance index (p < 0.001) among the study patients.

CONCLUSION

Plasma myostatin is a potential biomarker for improving diagnosis of RVD in AECOPD.

The Effect of Tonsillectomy and Adenoidectomy on Right Ventricle Function and Pulmonary Artery Pressure by Using Doppler Echocardiography in Children

Objectives

The purpose of the present study is to emphasize the efficacy of the myocardial performance index and tricuspid annular plane systolic excursion (TAPSE) in the determination of impaired cardiac functions and recovery period following the treatment in children with adenoid and/or tonsillar hypertrophy.

Methods

Fifty-three healthy children after routine laboratory, imaging and clinical examinations, with adenoid and/or tonsillar hypertrophy were evaluated before and 3 months after adenotonsillectomy for cardiac functions using M mode and Doppler echocardiography.

Results

The mean age of cases was 6.4±3.0 years, 34 (65%) were male, and 19 (35%) were female. Pulmonary hypertension was observed to be mild in 3 patients and moderate in 1 patient preoperatively. When the preoperative and postoperative echocardiographic measurements of the patients were compared, the tricuspid valve E wave velocity, the E/A ratio (E, early diastolic flow rate; A, late diastolic flow rate), and the TAPSE values were determined to be significantly higher postoperatively (P<0.05). The tricuspid valve deceleration time, the isovolumetric relaxation time and the systolic pulmonary artery pressure were found to be significantly lower compared to the preoperative values (P<0.05).

Conclusion

Adenoidectomy and/or tonsillectomy may prevent cardiac dysfunctions that can develop in the later periods due to adenoid and/or tonsil hypertrophy in children, before the appearance of the clinical findings of cardiac failure.

Higher Plasma Myostatin Levels in Cor Pulmonale Secondary to Chronic Obstructive Pulmonary Disease

Objective

To analyze plasma myostatin levels and investigate their relationship with right ventricular (RV) function in patients with cor pulmonale secondary to chronic obstructive pulmonary disease (COPD).

Methods

The study recruited 81 patients with advanced COPD and 40 age-matched controls. The patients were divided into two groups: those with cor pulmonale and those without. Echocardiography was used to evaluate RV function and morphology, and the value of tricuspid annular plane systolic excursion (TAPSE) less than 16 mm was considered RV dysfunction. Plasma myostatin levels were analyzed by enzyme-linked immunosorbent assay, and B-type natriuretic peptide (BNP) levels were analyzed as a comparison of myostatin.

Results

The data detected cor pulmonale in 39/81 patients, with the mean value of TAPSE of 14.3 mm. Plasma myostatin levels (ng/mL) were significantly higher in patients with cor pulmonale (16.68 ± 2.95) than in those without (13.56 ± 3.09), and much higher than in controls (8.79±2.79), with each p<0.01. Significant differences were also found in plasma BNP levels among the three groups (p<0.05). Multivariate regression analysis suggested that myostatin levels were significantly correlated with the values of TAPSE and RV myocardium performance index among the COPD patients, and that BNP levels were significantly correlated only with systolic pulmonary arterial pressure, with each p<0.05.

Conclusions

Plasma myostatin levels are increased in COPD patients who have cor pulmonale. Stronger correlations of plasma myostatin levels with echocardiographic indexes of the right heart suggest that myostatin might be superior to BNP in the early diagnosis of cor pulmonale in COPD.

Relationship between echocardiographic and cardiac magnetic resonance imaging-derived measures of right ventricular function in patients with chronic thromboembolic pulmonary hypertension

BACKGROUND

Echocardiography is widely used to evaluate right ventricular (RV) function. However, the value of echocardiographic parameters to assess RV function in patients with chronic thromboembolic pulmonary hypertension (CTEPH) is unknown. In this study, we analyzed the correlations between echocardiographic parameters and the RV ejection fraction (RVEF) as measured by cardiac magnetic resonance (CMR) imaging to systematically elucidate the role of echocardiographic parameters in the assessment of RV function in patients with CTEPH.

METHODS

Echocardiography was used to measure the tissue Doppler-derived tricuspid lateral annular systolic velocity (S'), fractional area change (FAC), myocardial performance index (MPI), and tricuspid annular plane systolic excursion (TAPSE). CMR was used to measure the RV end-diastolic volume (RVEDV) and end-systolic volume (RVESV), and the RVEF was calculated.

RESULTS

A significant positive correlation was found between S' and RVEF (r=0.689, P<0.0001) and between FAC and RVEF (r=0.423, P=0.022), a significant negative correlation was found between MPI and RVEF (r=-0.387, P=0.048), and no correlation was found between TAPSE and RVEF (r=0.451, P=0.22).

CONCLUSION

Echocardiography can be routinely used in the clinical setting to measure S', FAC, and MPI for the evaluation of right heart function in patients with CTEPH.

Short-term thyroid hormone excess affects the heart but does not affect adrenal activity in rats

Background

Hyperthyroidism (Hy) exerts a broad range of influences on a variety of physiological parameters. Its disruptive effect on cardiovascular system is one of its most remarkable impacts. Moreover, Hy has been clinically associated with stress - induced hyperactivation of the hypothalamic-pituitary-adrenal axis.

Objective

Evaluate the impact of short-term Hy on cardiac performance and adrenal activity of rats.

Methods

Induction of Hy in Wistar rats through injections of T3 (150 µg/kg) for 10 days (hyperthyroid group - HG) or vehicle (control group). The cardiovascular performance was evaluated by: echocardiography (ECHO); heart weight/body weight (mg/gr) ratio; contractility of isolated papillary muscles (IPM) and direct measurement of blood pressures. Adrenal activity was evaluated by adrenal weight/body weight (mg/gr) ratio and 24-hour fecal corticosterone (FC) levels on the, 5^th and 10^th days of T3 treatment.

Results

In HG, the ECHO showed reduction of the End Systolic and End Diastolic Volumes, Ejection, Total Diastolic and Isovolumic Relaxation Times, Diastolic and Systolic Areas and E/A ratio. Heart Rate, Ejection Fraction and Cardiac Output increased. The heart weight/body weight ratio was higher. Similarly, in IPM, the maximum rate of force decay during relaxation was higher in all extracellular calcium concentrations. Systolic blood pressure (SBP) levels were higher. (p ≤ 0.05). On the other hand, there was no difference in the adrenal weight/body weight ratio or in the 24-hour FC levels.

Conclusions

Hy induces positive inotropic, chronotropic and lusitropic effects on the heart by direct effects of T3 and increases SBP. Those alterations are not correlated with changes in the adrenal activity.

Assessment of RV Function in Patients of (COPD)

INTRODUCTION

Chronic Obstructive Pulmonary Disease (COPD) has considerable effects on cardiac functions primarily affecting the pulmonary vasculature and then right ventricle along with left ventricle. One of the important causes of increased morbidity and mortality associated with COPD is cor pulmonale. Echocardiography provides a rapid, non-invasive method to evaluate cardiac changes. Our aim was to evaluate RVfunction in COPD as per guidelines of American Society of Echocardiography with an aim to find a simpler way of predicting cardiac morbidity.

MATERIALS AND METHODS

A cross sectional observational study was conducted on 17 COPD patients attending Respiratory Medicine outdoor of R. G. KAR Medical College, Kolkata, India, through history taking, clinical examination, PFT (PFT) and Echocardiography. Statistical analysis was done by using Statistical Package for the Social Sciences (SPSS) version-17.

RESULTS

Fractional area change of RV (FAC-%) was positively correlated with Forced Expiratory Volume in One Second (FEV1) (r = 0.4879), FEV1/ Forced Vital Capacity (FVC) ratio (r = 0.5048) and Peak Expiratory Flow Rate (PEFR) (r = 0.5361). There was strong negative correlation of Systolic Pulmonary Artery Pressure (SPAP) with FEV1/FVC ratio (r = -0.5553) and PEFR (r = - 0.4604). Right Index of Myocardial Performance (RIMP) of right ventricle was negatively correlated with FEV1/FVC ratio (r = - 0.598), PEFR (r = - 0.619), Forced Expiratory Flow (FEF) 25-75 (r = -0.515). Tricuspid annular plane systolic excursion (TAPSE) did not show any association with PFT parameters though it showed strong positive correlation with RV wall thickness.

CONCLUSION

This study substantiates that FAC% and RIMP can be vital prognostic factors for RV function apart from SPAP, TAPSE to define RV dysfunction and predict morbidity in COPD.

Right ventricular myocardial performance index is decreased with severe pressure-overload cardiac hypertrophy in young rats

Although the right ventricular (RV) myocardial performance index (MPI) usually is increased in the presence of RV dysfunction and pressure overload, debate continues over the correlation between the RV MPI and functional derangement in patients with RV pressure-overload congenital heart disease (CHD). To address this controversy, this study took serial measurements of the RV MPI in addition to invasive RV hemodynamic measurements during the acute stage of mild to severe pressure overload. Right ventricle pressure overload was induced by partial pulmonary arterial banding (PAB) in 3-week-old rats. The rats were divided into two groups: mild pulmonary stenosis (PS) group (20-40 % stenosis; n = 20) and severe PS group (40-70 % stenosis; n = 28). Sham-treated animals (sham group; n = 30) underwent the same surgical procedure without PAB. Pressure-overload RV hypertrophy was documented by weighing the heart, by evaluating echocardiograms, and by evaluating cardiac hypertrophy-associated gene expression. The RV MPI was checked 1, 2, 3, 5, and 8 weeks after PAB. The MPI was calculated as the sum of the isovolumic contraction time and the isovolumic relaxation time (IRT) divided by the ejection time. The RV MPI of the mild PS group did not differ significantly from that of the sham group. The RV MPI of the severe PS group, however, was lower than that of the sham group (0.27 ± 0.01 vs 0.29 ± 0.01) 2 to 8 weeks after PAB: 0.19 ± 0.01 at 2 weeks (P < 0.001), 0.16 ± 0.01 at 3 weeks (P < 0.001), 0.20 ± 0.01 at 5 weeks (P = 0.021), and 0.18 ± 0.01 at 8 weeks (P < 0.001) after PAB. The decreased RV MPI was associated with decreased IRT and increased ejection time. RV hypertrophy contributes to the decrease in the RV MPI in the severe pressure-overload condition.

Echocardiographic parameters in patients with pulmonary arterial hypertension: correlations with right ventricular ejection fraction derived from cardiac magnetic resonance and hemodynamics

BACKGROUND

Echocardiography is the most convenient method used to evaluate right ventricular function, and several echocardiographic parameters were studied in previous studies. But the value of these parameters to assess the right ventricular function in patients with pulmonary arterial hypertension (PAH) has not been well defined.

METHODS

Patients with PAH were observed prospectively. Right heart catheterization, echocardiography and cardiac magnetic resonance (CMR) were performed within 1 week interval. The correlations between echocardiographic parameters and right ventricular ejection fraction (RVEF) derived from CMR as well as hemodynamics were analyzed.

RESULTS

Thirty patients were enrolled including 24 with idiopathic PAH, 5 with PAH associated with connective tissue diseases and 1 with hereditary PAH. All echocardiographic parameters except right ventricular myocardial performance index (RVMPI) correlated significantly with RVEF (tricuspid annual plane systolic excursion [TAPSE], r = 0.440, P = 0.015; tricuspid annular systolic excursion velocity [S'], r = 0.444, P = 0.016; isovolumic acceleration [IVA], r = 0.600, P = 0.001; right ventricular fraction area change [RVFAC], r = 0.416, P = 0.022; ratio of right ventricular transverse diameter to left ventricular transverse diameter [RVETD/LVETD], r = -0.649, P<0.001; RVMPI, r = -0.027, P = 0.888). After adjusted for mean right atrial pressure, mean pulmonary arterial pressure and pulmonary vascular resistance (PVR), only IVA and RVETD/LVETD could independently predict RVEF. Four echocardiographic parameters displayed significant correlations with PVR (TAPSE, r = -0.615, P<0.001; S', r = -0.557, P = 0.002; RVFAC, r = -0.454, P = 0.012; RVETD/LVETD, r = 0.543, P = 0.002).

CONCLUSIONS

The echocardiographic parameters IVA and RVETD/LVETD can reflect RVEF independently regardless of hemodynamics in patients with PAH. In addition, TAPSE, S', RVFAC and RVETD/LVETD can also reflect PVR in PAH patients.

Inhaled epoprostenol therapy for pulmonary hypertension: Improves oxygenation index more consistently in neonates than in older children

The purpose of this study was to determine the efficacy of inhaled epoprostenol for treatment of acute pulmonary hypertension (PH) in pediatric patients and to formulate a plan for a prospective, randomized study of pulmonary vasodilator therapy in this population. Inhaled epoprostenol is an effective treatment for pediatric PH. A retrospective chart review was conducted of all pediatric patients who received inhaled epoprostenol at a tertiary care hospital between October 2005 and August 2007. The study population was restricted to all patients under 18 years of age who received inhaled epoprostenol for greater than 1 hour and had available data for oxygenation index (OI) calculation. Arterial blood gas values and ventilator settings were collected immediately prior to epoprostenol initiation, and during epoprostenol therapy (as close to 12 hours after initiation as possible). Echocardiograms were reviewed during two time frames: Within 48 hours prior to therapy initiation and within 96 hours after initiation. Of the 20 patients in the study population, 13 were neonates, and the mean OI for these patients improved during epoprostenol administration (mean OI before and during therapy was 25.6±16.3 and 14.5±13.6, respectively, P=0.02). Mean OI for the seven patients greater than 30 days of age was not significantly different during treatment (mean OI before and during therapy was 29.6±15.0 and 25.6±17.8, P=0.56). Improvement in echocardiographic findings (evidence of decreased right-sided pressures or improved right ventricular function) was demonstrated in 20% of all patients. Inhaled epoprostenol is an effective therapy for the treatment of selected pediatric patients with acute PH. Neonates may benefit more consistently from this therapy than older infants and children. A randomized controlled trial is needed to discern the optimal role for inhaled prostanoids in the treatment of acute PH in childhood.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Dual pulsed-wave Doppler tracing of right ventricular inflow and outflow: single cardiac cycle right ventricular tei index and evaluation of right ventricular function

BACKGROUND AND OBJECTIVES

The reliability and usefulness of the right ventricular (RV) Tei index (RTX) remains controversial because it has not been possible to simultaneously measure RV inflow and outflow. However, dual pulsed-wave Doppler (DPD) enables flow velocities to be obtained at different sampling sites simultaneously. In this study we evaluated the feasibility and reliability of RTX values obtained by DPD (RTX(DPD)).

SUBJECTS AND METHODS

Forty-one patients who underwent cardiac catheterization and echocardiography for RV volume or pressure overloading conditions were evaluated. Symptom-limited exercise treadmill testing with expired gas analysis was performed and maximal exercise capacity was measured.

RESULTS

RTX by conventional flow Doppler (RTX(CFD), 0.262±0.164) was similar to RTX(DPD) (0.253±0.117, p=NS), whereas RTX by tissue Doppler echocardiography (RTX(TDE), 0.447±0.125) was significantly larger than RTX(DPD) (p<0.001). Based on multiple regression analysis, maximal exercise capacity was independently related to RTX(DPD) (β=-0.60, p<0.001), mid-RV dimension (β=-0.26, p=0.012), left ventricular ejection fraction (β=0.22, p=0.023), and early diastolic tricuspid annular velocity (β=0.21, p=0.048).

CONCLUSION

It is feasible and reliable to evaluate RV function using RTX(DPD) values. However, to evaluate the clinical usefulness of RTX(DPD), additional studies are required with a large number of patients and long-term follow-up.

N-terminal-pro-B type natriuretic peptide as a useful tool to evaluate pulmonary hypertension and cardiac function in CDH infants

OBJECTIVE

In congenital diaphragmatic hernia (CDH) the severity of pulmonary hypertension (PH) is considered, by several authors, determinant of clinical outcome. Plasmatic N-terminal-pro-B type natriuretic peptide (NT-proBNP) might be useful in diagnosis and management of PH in newborns, although its interest in CDH infants remains to be defined. Early NT-proBNP levels were assessed in CDH infants and correlated with cardiovascular echocardiographic parameters.

PATIENTS AND METHODS

28 newborns, CDH and age-matched controls were enrolled in a prospective study. Clinical condition, NT-proBNP plasmatic levels, echo parameters of PH and biventricular function were assessed at 24 h after delivery as well as survival outcome.

RESULTS

Estimated mean pulmonary pressure and NT-proBNP were significantly higher in CDH than control infants. NT-proBNP significantly correlated with estimated pulmonary artery pressure, right ventricular Tei index, and tricuspid E/A ratio. Additionally, we found that CDH infants with NT-proBNP >11,500 pg/ml experienced a worse prognosis.

CONCLUSIONS

We demonstrated that PH is associated with NT-proBNP elevation and diastolic impairment in CDH infants. Early elevations in NT-proBNP levels seem to alert for a subset of CDH infants with worse prognosis.

Right ventricular failure complicating heart failure: pathophysiology, significance, and management strategies

Right heart failure most commonly results from the complication of left heart failure (systolic or nonsystolic dysfunction) or pulmonary hypertension. Over the past decade, greater attention has been paid to the role of right ventricular failure in the morbidity and mortality associated with cardiomyopathy and pulmonary hypertension. The right ventricle is distinct from the left ventricle not only in its spatial localization, but also in its response to increased afterload and signaling mechanisms. This article discusses the role of right ventricular failure in the setting of heart failure as well as the clinical diagnosis and management of right ventricular failure.

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

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

Improved right ventricular-vascular coupling during active pulmonary hypertension

Right ventricular adaptation to pulmonary hypertension (PH) is an important prognostic factor. Pulmonary artery (PA) smooth muscle activation attenuates arterial dysfunction during acute PH. We investigated the role of the pulmonary artery vascular smooth muscle activation on the right ventricular-vascular coupling during acute PH. PA flow, pressure, and diameter, right ventricular and aortic pressures were recorded in six anesthetized sheep. Acute PH was induced by phenylephrine (APH) and PA mechanical constriction (PPH). We calculated the PA buffering function, the incremental elastic modulus and pulmonary vascular compliance. Pulmonary vascular impedance and right ventricular hydraulic power were calculated through Fourier approach. We also quantified the magnitude and timing of the reflected wave. Right ventricular-vascular coupling was assessed by the energy transmission ratio. Pulmonary buffering function and vascular compliance increased (P<0.05) and arterial wall stiffness decreased (P<0.05) during APH with respect to PPH. Although total input resistance increased and reflected wave came back earlier during PH states (P<0.05), only PPH produced a rightward shift of the pulmonary impedance and a more prominent reflected wave. Accordingly, APH determined a minor increase of total hydraulic power with a smaller pulsatile to total power ratio and energy transmission ratio (P<0.05). In conclusion, isobaric PA vasoconstriction prevents the pulsatile hydraulic load to increase by preserving the PA buffering function and the reflected wave magnitude. Thus, vascular smooth muscle activation of the main PA improves the energy transfer from the right ventricle to the hypertensive pulmonary circulation, and this may play relevant role in the right ventricular adaptation to acute PH.