Three-dimensional right-ventricular regional deformation and survival in pulmonary hypertension

Prognostic values of right ventricular echocardiography functional parameters for mortality prediction in precapillary pulmonary hypertension: a systematic review and meta-analysis

BACKGROUND

Echocardiographic prognostic indicators of precapillary pulmonary hypertension (PH) mortality has been inconclusive. This study aims to examine the prognostic values of right ventricular echocardiographic functional parameters in predicting precapillary PH mortality.

METHODS

Systematic searches were conducted in the ScienceDirect, Medline, and Cochrane databases for longitudinal studies. Assessments included means and hazard ratios (HRs) for Tricuspid Annular Plane Systolic Excursion (TAPSE), Right Ventricular Systolic Pressure (RVSP), Right Ventricular Longitudinal Strain (RVLS), Right Ventricular Fractional Area Change (RVFAC), Right Ventricular Ejection Fraction (RVEF), and Right Ventricular Index of Myocardial Performance (RIMP).

RESULTS

The meta-analysis included 24 cohort studies comprising 2171 participants. Mean values were as follows: TAPSE 17.62 mm, RVSP 77.50 mmHg, RVLS - 16.78%, RVFAC 29.81%, RVEF 37.56%, and RIMP 0.52. TAPSE (HR: 1.28; 95% CI 1.17-1.40; p < 0.001), RVLS (HR: 1.74; 95% CI 1.34-2.26; p < 0.001), RVFAC (HR: 1.40; 95% CI 1.13-1.75; p < 0.001), RVEF (HR: 1.08; 95% CI 1.02-1.15; p = 0.01), and RIMP (HR: 1.51; 95% CI 1.23-1.86; p < 0.001) emerged as significant prognosticators of precapillary PH mortality, with the exception of RVSP (HR: 1.04; 95% CI 0.99-1.09; p = 0.14). TAPSE summary receiver operating characteristics (sROC) analysis yielded an area under the curve (AUC) of 0.85 [95% CI 0.81-0.88] with a sensitivity of 0.81 [95% CI 0.63-0.91] and a specificity of 0.74 [95% CI 0.54-0.87]. RVLS sROC resulted in an AUC of 0.74 [95% CI 0.70-0.78] with a sensitivity of 0.74 [95% CI 0.57-0.86] and a specificity of 0.69 [95% CI 0.64-0.75].

CONCLUSIONS

TAPSE, RVLS, RVFAC, RVEF, and RIMP demonstrated promise as valuable prognostic indicators for precapillary PH mortality.

Non-invasive imaging techniques for early diagnosis of bilateral cardiac dysfunction in pulmonary hypertension: current crests, future peaks

Pulmonary arterial hypertension (PAH) is a chronic and progressive disease that eventually leads to heart failure (HF) and subsequent fatality if left untreated. Right ventricular (RV) function has proven prognostic values in patients with a variety of heart diseases including PAH. PAH is predominantly a right heart disease; however, given the nature of the continuous circulatory system and the presence of shared septum and pericardial constraints, the interdependence of the right and left ventricles is a factor that requires consideration. Accurate and timely assessment of ventricular function is very important in the management of patients with PAH for disease outcomes and prognosis. Non-invasive modalities such as cardiac magnetic resonance (CMR) and echocardiography (two-dimensional and three-dimensional), and nuclear medicine, positron emission tomography (PET) play a crucial role in the assessment of ventricular function and disease prognosis. Each modality has its own strengths and limitations, hence this review article sheds light on (i) ventricular dysfunction in patients with PAH and RV-LV interdependence in such patients, (ii) the strengths and limitations of all available modalities and parameters for the early assessment of ventricular function, as well as their prognostic value, and (iii) lastly, the challenges faced and the potential future advancement in these modalities for accurate and early diagnosis of ventricular function in PAH.

Role and application of three-dimensional transthoracic echocardiography in the assessment of left and right ventricular volumes and ejection fraction: a UK nationwide survey

Three-dimensional echocardiography (3DE) imaging has permitted advancements in the quantification of left ventricular (LV) and right ventricular (RV) volumes and ejection fraction. We evaluated the availability of 3DE equipment / analysis software, the integration of 3DE assessment of the LV and RV in routine clinical practice, current training provisions in 3DE, and aimed to ascertain barriers preventing the routine use of 3DE for volumetric analysis. Through the British Society of Echocardiography (BSE) regional representatives' network, echocardiographers were invited to participate in an open online survey. A total of 181 participants from echocardiography departments in the United Kingdom (UK), the majority from tertiary centres (61%), completed the 28-question survey. For 3DE quantification, 3DE-LV was adopted more frequently than 3DE-RV (48% vs 11%, respectively). Imaging feasibility was a recognised factor in 3DE RV and LV adoption. Many respondents had access to 3D probes (93%). The largest observed barriers to 3DE routine use were training deficiencies, with 83% reporting they would benefit from additional training opportunities and the duration of time permitted for the scan, with 68% of responders reporting allowances of less than the BSE standard of 45-60 min per patient (8% < 30-min). Furthermore, of those respondents who had undertaken professional accreditation, competence in 3DE was not formally assessed in 89%. This UK survey also reported good accessibility to magnetic resonance imaging (72%), which was related to overall 3DE adoption. In summary, although 3DE is now readily available, it remains underutilised. Further training opportunities, integrated formal assessment, improved adoption of BSE minimum recommended scanning times, alongside industry and societal support, may increase 3DE utilisation in routine practice.

The Echocardiographic Evaluation of the Right Heart: Current and Future Advances

PURPOSE OF REVIEW

To discuss physiologic and methodologic advances in the echocardiographic assessment of right heart (RH) function, including the emergence of artificial intelligence (AI) and point-of-care ultrasound.

RECENT FINDINGS

Recent studies have highlighted the prognostic value of right ventricular (RV) longitudinal strain, RV end-systolic dimensions, and right atrial (RA) size and function in pulmonary hypertension and heart failure. While RA pressure is a central marker of right heart diastolic function, the recent emphasis on venous excess imaging (VExUS) has provided granularity to the systemic consequences of RH failure. Several methodological advances are also changing the landscape of RH imaging including post-processing 3D software to delineate the non-longitudinal (radial, anteroposterior, and circumferential) components of RV function, as well as AI segmentation- and non-segmentation-based quantification. Together with recent guidelines and advances in AI technology, the field is shifting from specific RV functional metrics to integrated RH disease-specific phenotypes. A modern echocardiographic evaluation of RH function should focus on the entire cardiopulmonary venous unit-from the venous to the pulmonary arterial system. Together, a multi-parametric approach, guided by physiology and AI algorithms, will help define novel integrated RH profiles for improved disease detection and monitoring.

Echocardiography Imaging of the Right Ventricle: Focus on Three-Dimensional Echocardiography

Right ventricular function strongly predicts cardiac death and adverse cardiac events in patients with cardiac diseases. However, the accurate right ventricular assessment by two-dimensional echocardiography is limited due to its complex anatomy, shape, and load dependence. Advances in cardiac imaging and three-dimensional echocardiography provided more reliable information on right ventricular volumes and function without geometrical assumptions. Furthermore, the pathophysiology of right ventricular dysfunction and tricuspid regurgitation is frequently connected. Three-dimensional echocardiography allows a more in-depth structural and functional evaluation of the tricuspid valve. Understanding the anatomy and pathophysiology of the right side of the heart may help in diagnosing and managing the disease by using reliable imaging tools. The present review describes the challenging echocardiographic assessment of the right ventricle and tricuspid valve apparatus in clinical practice with a focus on three-dimensional echocardiography.

Prognostic value of the right ventricular ejection fraction using three-dimensional echocardiography: Systematic review and meta-analysis

AIMS

Three-dimensional echocardiography (3DE) is a robust method for measuring the right ventricular (RV) ejection fraction (EF), which is closely associated with outcomes. We performed a systematic review and meta-analysis (1) to examine the prognostic value of RVEF and (2) to compare its prognostic value with that of left ventricular (LV) EF and LV global longitudinal strain (GLS). We also performed individual patient data analysis to validate the results.

METHODS AND RESULTS

We searched articles reporting the prognostic value of RVEF. Hazard ratios (HR) were re-scaled using the within-study standard deviation (SD). To compare predictive values of RVEF and LVEF or LVGLS, the ratio of HR related to a 1-SD reduction of RVEF versus LVEF or LVGLS was calculated. Pooled HR of RVEF and pooled ratio of HR were analyzed in a random-effects model. Fifteen articles with 3,228 subjects were included. Pooled HR of a 1-SD reduction of RVEF was 2.54 (95% confidence interval (CI): 2.15-3.00). In subgroup analysis, RVEF was significantly associated with outcome in pulmonary arterial hypertension (PAH) (HR: 2.79, 95% CI: 2.04-3.82) and cardiovascular (CV) diseases (HR: 2.23, 95%CI: 1.76-2.83). In studies reporting HRs for both RVEF and LVEF or RVEF and LVGLS in the same cohort, RVEF had 1.8-fold greater prognostic power per 1-SD reduction than LVEF (ratio of HR: 1.81, 95%CI: 1.20-2.71), but had predictive value similar to that of LVGLS (ratio of HR: 1.10, 95%CI: 0.91-1.31) and to LVEF in patients with reduced LVEF (ratio of HR: 1.34, 95%CI: 0.94-1.91). In individual patient data analysis (n = 1,142), RVEF < 45% was significantly associated with worse CV outcome (HR: 4.95, 95% CI: 3.66-6.70), even in patients with reduced or preserved LVEF.

CONCLUSIONS

The findings of this meta-analysis highlight and support the use of RVEF assessed by 3DE to predict CV outcomes in routine clinical practice in patients with CV diseases and in those with PAH.

Association of Right Ventricular Functional Parameters With Adverse Cardiopulmonary Outcomes: A Meta-analysis

AIMS

We aimed to confirm that three-dimensional echocardiography-derived right ventricular ejection fraction (RVEF) is better associated with adverse cardiopulmonary outcomes than the conventional echocardiographic parameters.

METHODS

We performed a meta-analysis of studies reporting the impact of unit change of RVEF, tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and free-wall longitudinal strain (FWLS) on clinical outcomes (all-cause mortality and/or adverse cardiopulmonary outcomes). Hazard ratios (HRs) were rescaled by the within-study SDs to represent standardized changes. Within each study, we calculated the ratio of HRs related to a 1 SD reduction in RVEF versus TAPSE, or FAC, or FWLS, to quantify the association of RVEF with adverse outcomes relative to the other metrics. These ratios of HRs were pooled using random-effects models.

RESULTS

Ten independent studies were identified as suitable, including data on 1,928 patients with various cardiopulmonary conditions. Overall, a 1 SD reduction in RVEF was robustly associated with adverse outcomes (HR = 2.64 [95% CI, 2.18-3.20], P < .001; heterogeneity: I² = 65%, P = .002). In studies reporting HRs for RVEF and TAPSE, or RVEF and FAC, or RVEF and FWLS in the same cohort, head-to-head comparison revealed that RVEF showed significantly stronger association with adverse outcomes per SD reduction versus the other 3 parameters (vs TAPSE, HR = 1.54 [95% CI, 1.04-2.28], P = .031; vs FAC, HR = 1.45 [95% CI, 1.15-1.81], P = .001; vs FWLS, HR = 1.44 [95% CI, 1.07-1.95], P = .018).

CONCLUSION

Reduction in three-dimensional echocardiography-derived RVEF shows stronger association with adverse clinical outcomes than conventional right ventricular functional indices; therefore, it might further refine the risk stratification of patients with cardiopulmonary diseases.

Right Ventricular Strain by Magnetic Resonance Feature Tracking Is Largely Afterload-Dependent and Does Not Reflect Contractility: Validation by Combined Volumetry and Invasive Pressure Tracings

Cardiac magnetic resonance (CMR) is currently the gold standard for evaluating right ventricular (RV) function, which is critical in patients with pulmonary hypertension. CMR feature-tracking (FT) strain analysis has emerged as a technique to detect subtle changes. However, the dependence of RV strain on load is still a matter of debate. The aim of this study was to measure the afterload dependence of RV strain and to correlate it with surrogate markers of contractility in a cohort of patients with chronic thromboembolic pulmonary hypertension (CTEPH) under two different loading conditions before and after pulmonary endarterectomy (PEA). Between 2009 and 2022, 496 patients with 601 CMR examinations were retrospectively identified from our CTEPH cohort, and the results of 194 examinations with right heart catheterization within 24 h were available. The CMR FT strain (longitudinal (GLS) and circumferential (GCS)) was computed on steady-state free precession (SSFP) cine CMR sequences. The effective pulmonary arterial elastance (Ea) and RV chamber elastance (Ees) were approximated by dividing mean pulmonary arterial pressure by the indexed stroke volume or end-systolic volume, respectively. GLS and GCS correlated significantly with Ea and Ees/Ea in the overall cohort and individually before and after PEA. There was no general correlation with Ees; however, under high afterload, before PEA, Ees correlated significantly. The results show that RV GLS and GCS are highly afterload-dependent and reflect ventriculoarterial coupling. Ees was significantly correlated with strain only under high loading conditions, which probably reflects contractile adaptation to pulsatile load rather than contractility in general.

Imaging the right atrium in pulmonary hypertension: A systematic review and meta-analysis

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.

Right ventricular size and function evaluated by various echocardiographic indices in dogs with pulmonary hypertension

BACKGROUND

Three-dimensional (3D) echocardiography and 2-dimensional (2D) strain measurements of the right ventricle (RV) are important indices in humans with pulmonary hypertension (PH) and need further evaluation in dogs with PH.

OBJECTIVES

To evaluate various RV size and function indices in dogs with PH and to examine differences between pre- and postcapillary PH.

ANIMALS

A total of 311 client-owned dogs: 100 dogs with PH, 31 with postcapillary and 69 with precapillary PH, and 211 healthy control dogs.

METHODS

Retro- and prospective, multicenter study. Size and function of the RV was determined using several indices, derived using dedicated RV software, including 3D RV end-diastolic volume (EDVn), end-systolic volume (ESVn), ejection fraction, 2D global and free wall RV longitudinal strain (RVLS), end-diastolic area, end-systolic area, fractional area change, tricuspid annular plane systolic excursion, and tissue Doppler imaging-derived systolic myocardial velocity of the lateral tricuspid annulus (S'n).

RESULTS

The EDVn (1.8 vs 2.5 mL/kg^0.942 , P < .01) and ESVn (0.8 vs 1.2 mL/kg^0.962 , P < .001) were significantly larger in the PH group compared to healthy controls. Free wall RVLS was decreased in dogs with severe PH compared to controls (-24% vs -29.6%, P < .001). Dogs with precapillary PH had worse RV systolic function than dogs with postcapillary PH.

CONCLUSION

Three-dimensional echocardiography of the RV is a promising tool to detect RV changes in dogs with PH. Also, 2D strain measurements are able to detect decreased RV function and offer several advantages compared to conventional indices.

Echocardiographic Assessment of Right Ventricular Function in Paediatric Heart Disease: A Practical Clinical Approach

As the right ventricle (RV) plays an integral role in different paediatric heart diseases, the accurate assessment of RV size and function is essential in the diagnosis, management, and prognostication of congenital and acquired cardiac lesions. Yet, echocardiographic evaluation of the RV is challenging because of its complex and variable morphology, its different physiology compared with the left ventricle, and its capability to adapt to different loading conditions associated with congenital and acquired heart diseases within certain ranges. Reliable echocardiographic detection of RV systolic and diastolic dysfunction remains challenging while important for patient management. This review provides an updated, practical approach to assessing RV function in structurally normal hearts and in children with common congenital heart defects and in those with pulmonary hypertension. We also review the impact of tricuspid valve function on RV functional parameters. There is no single functional RV parameter that uniquely describes RV function; instead a combination of different parameters is recommended in clinical practice. Qualitative and quantitative analysis of RV function will be reviewed including more recent techniques such as speckle tracking and 3D echocardiography.

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

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

Characterizing interactions between cardiac shape and deformation by non-linear manifold learning

In clinical routine, high-dimensional descriptors of the cardiac function such as shape and deformation are reduced to scalars (e.g. volumes or ejection fraction), which limit the characterization of complex diseases. Besides, these descriptors undergo interactions depending on disease, which may bias their computational analysis. In this paper, we aim at characterizing such interactions by unsupervised manifold learning. We propose to use a sparsified version of Multiple Manifold Learning to align the latent spaces encoding each descriptor and weighting the strength of the alignment depending on each pair of samples. While this framework was up to now only applied to link different datasets from the same manifold, we demonstrate its relevance to characterize the interactions between different but partially related descriptors of the cardiac function (shape and deformation). We benchmark our approach against linear and non-linear embedding strategies, among which the fusion of manifolds by Multiple Kernel Learning, the independent embedding of each descriptor by Diffusion Maps, and a strict alignment based on pairwise correspondences. We first evaluated the methods on a synthetic dataset from a 0D cardiac model where the interactions between descriptors are fully controlled. Then, we transfered them to a population of right ventricular meshes from 310 subjects (100 healthy and 210 patients with right ventricular disease) obtained from 3D echocardiography, where the link between shape and deformation is key for disease understanding. Our experiments underline the relevance of jointly considering shape and deformation descriptors, and that manifold alignment is preferable over fusion for our application. They also confirm at a finer scale the characteristic traits of the right ventricular diseases in our population.

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

BACKGROUND

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

AIMS

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

METHODS AND RESULTS

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

CONCLUSIONS

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

Evaluation and Comparison of Quantitative Right Ventricular Strain Assessment by Cardiac Magnetic Resonance in Pulmonary Hypertension Using Feature Tracking and Deformable Registration Algorithms

RATIONALE AND OBJECTIVE

Deformable registration algorithms (DRA) has been used to detect left ventricular myocardial changes, however, its clinical utility in right ventricular (RV) function has not been evaluated. In this study, we aim to evaluate and compare quantitative RV strain assessment by cardiac magnetic resonance in pulmonary hypertension (PH) using feature tracking (FT) and DRA.

MATERIALS AND METHODS

Thirty patients were confirmed to have PH using right heart catheterization, and 16 healthy controls were evaluated with cardiac magnetic resonance. Global and segmental RV strain was measured by DRA and FT methods. Intraclass correlation coefficients (ICCs), coefficient of variation, and Bland-Altman analysis were used to assess and compare the interobserver and intraobserver variability of the DRA and FT methods.

RESULTS

DRA was more sensitive than FT in the detection of RV circumferential and septal dysfunction. The global longitudinal strain (GLS) obtained by the two methods was reduced in mild-moderate PH patients (mean pulmonary artery pressure≤45 mm Hg), and the GLS and global circumferential strain (GCS) were reduced in severe PH patients (mean pulmonary artery pressure >45 mm Hg). DRA and FT methods demonstrate similar observer agreement in global strain using ICC (ICC greater than 0.90), but RV strain derived from DRA had lower variability using COV ([8%-14%] for DRA versus [11%-39%] for FT).For segmental longitudinal strain, DRA showed higher ICC and lower COV compared with that of the FT method. Correlations between RVEF and RV global strain parameters were strong (p < 0.01):GLS-DRA, r = -0.696; GLS-FT, r = -0.832; GCS-DRA, r = -0.745; and GCS-FT, r = -0.817. GLS-DRA was weakly correlated with mPAP (r = 0.385, p < 0.05).In multiple linear regression analysis, RVEF and mPAP were independent predictors of GLS-DRA (R² = 0.57, p < 0.01).

CONCLUSIONS

The DRA method is more sensitive and robust for RV myocardial strain measurements than FT method.

Right Ventricular Function Predicts Adverse Clinical Outcomes in Patients With Chronic Thromboembolic Pulmonary Hypertension: A Three-Dimensional Echocardiographic Study

Background: Right ventricular (RV) function plays a vital role in the prognosis of patients with chronic thromboembolic pulmonary hypertension (CTEPH). We used new machine learning (ML)-based fully automated software to quantify RV function using three-dimensional echocardiography (3DE) to predict adverse clinical outcomes in CTEPH patients.

Methods: A total of 151 consecutive CTEPH patients were registered in this prospective study between April 2015 and July 2019. New ML-based methods were used for data management, and quantitative analysis of RV volume and ejection fraction (RVEF) was performed offline. RV structural and functional parameters were recorded using 3DE. CTEPH was diagnosed using right heart catheterization, and 62 patients underwent cardiac magnetic resonance to assess right heart function. Adverse clinical outcomes were defined as PH-related hospitalization with hemoptysis or increased RV failure, including conditions requiring balloon pulmonary angioplasty or pulmonary endarterectomy, as well as death.

Results: The median follow-up time was 19.7 months (interquartile range, 0.5–54 months). Among the 151 CTEPH patients, 72 experienced adverse clinical outcomes. Multivariate Cox proportional-hazard analysis showed that ML-based 3DE analysis of RVEF was a predictor of adverse clinical outcomes (hazard ratio, 1.576; 95% confidence interval (CI), 1.046~2.372; P = 0.030).

Conclusions: The new ML-based 3DE algorithm is a promising technique for rapid 3D quantification of RV function in CTEPH patients.

The Role of Four-Dimensional Automatic Right Ventricular Quantification Technology to Determine RV Function and Hemodynamics in Patients With Pulmonary Hypertension Compared With Right Heart Catheterization

Background: Four-dimensional automatic right ventricular quantification technology (4D auto-RVQ) is a new method that can simultaneously measure right ventricular (RV) structure and strain. The role of 4D auto-RVQ in determining RV function and hemodynamics is not clear. The role of 4D auto-RVQ in determining RV function and hemodynamics is not clear. We assessed the 4D auto-RVQ to measure right heart structure, function, and hemodynamics in patients with pulmonary hypertension (PHTN) correlated with right heart catheterization (RHC).

Methods: We enrolled a prospective cohort of 103 patients with PHTN and 25 healthy controls between September 2017 and December 2018. All patients with PHTN underwent echocardiography and RHC. Patients were included if they underwent two-dimensional (2D) and 4D auto-RVQ echocardiographic sequences on the same day as RHC. We analyzed RV functional indices using 2D and 4D auto-RVQ analyses. We divided patients with PHTN into three groups according to echocardiographic image quality as follows: high (n = 24), average (n = 48), and poor (n = 4). Hemodynamic parameters were measured using RHC, including mean right atrial pressure, mean pulmonary arterial pressure, RV cardiac index (RV-CI), and pulmonary vascular resistance.

Results: There were significant differences in most 2D and 4D auto-RVQ parameters between patients with PHTN and healthy controls. Interobserver variability showed significant agreement with 4D auto-RVQ for most measurements except for 4D end-diastolic volume. Indices measured by auto 4D-RVQ in the high-quality image group had a good correlation with RHC but not in the average- and poor-quality image group. Mid-RV diameter showed the best predictive power for the right RV-CI [area under the curve (AUC) 0.935; 95% confidence interval (CI), 0.714–0.997; p < 0.001]. RV end-systolic volume >121.50 mL had a 71.43% sensitivity and a 100% specificity to predict right RV-CI (AUC, 0.890; 95% CI, 0.654–0.986; p < 0.001).

Conclusions: 4D auto-RVQ may be used to estimate RV function and some hemodynamic changes compared with RHC in PHTN patients with high image quality. Furthermore, a large sample of the study is needed to evaluate RV function by 4D auto-RVQ in PHTN patients with average image quality.

Right Ventricular Function and Its Coupling With Pulmonary Circulation in Precapillary Pulmonary Hypertension: A Three-Dimensional Echocardiographic Study

Objective: To assess right ventricular (RV) function and RV-pulmonary arterial (PA) coupling by three-dimensions echocardiography and investigate the ability of RV-PA coupling to predict adverse clinical outcomes in patients with precapillary pulmonary hypertension (PH). Methods: We retrospectively collected a longitudinal cohort of 203 consecutive precapillary PH patients. RV volume, RV ejection fraction (RVEF), and RV longitudinal strain (RVLS) were quantitatively determined offline by 3D echocardiography. RV-PA coupling parameters including the RVEF/PA systolic pressure (PASP) ratio, pulmonary arterial compliance (PAC), and total pulmonary resistance (TPR) were recorded. Results: Over a median follow-up period of 20.9 months (interquartile range, 0.1-67.4 months), 87 (42.9%) of 203 patients experienced adverse clinical outcomes. With increasing World Health Organization functional class (WHO-FC), significant trends were observed in increasing RV volume, decreasing RVEF, and worsening RVLS. RV arterial coupling (RVAC) and PAC were lower and TPR was higher for WHO-FC III+IV than WHO-FC I or II. The RVEF/PASP ratio showed a significant correlation with RVLS. RVAC had a stronger correlation with the RVEF/PASP ratio than other indices. Multivariate Cox proportional-hazard analysis identified a lower 3D RVEF and worse RVLS as strong predictors of adverse clinical events. RVAC, TPR, and PAC had varying degrees of predictive value, with optimal cutoff values of 0.74, 11.64, and 1.18, respectively. Conclusions: Precapillary-PH with RV-PA uncoupling as expressed by a RVEF/PASP ratio <0.44 was associated with adverse clinical outcomes. PAC decreased and TPR increased with increasing WHO-FC, with TPR showing better independent predictive value.

Accuracy of fully automated right ventricular quantification software with 3D echocardiography: direct comparison with cardiac magnetic resonance and semi-automated quantification software

AIMS

The aim of this study was to determine the accuracy and reproducibility of a novel, fully automated 3D echocardiography (3DE) right ventricular (RV) quantification software compared with cardiac magnetic resonance (CMR) and semi-automated 3DE RV quantification software.

METHODS AND RESULTS

RV volumes and the RV ejection fraction (RVEF) were measured using a fully automated software (Philips), a semi-automated software (TomTec), and CMR in 100 patients who had undergone both CMR and 3DE examinations on the same day. The feasibility of the fully automated software was 91%. Although the fully automated software, without any manual editing, significantly underestimated RV end-diastolic volume (bias: -12.6 mL, P < 0.001) and stroke volume (-5.1 mL, P < 0.001) compared with CMR, there were good correlations between the two modalities (r = 0.82 and 0.78). No significant differences in RVEF between the fully automated software and CMR were observed, and there was a fair correlation (r = 0.72). The RVEF determined by the semi-automated software was significantly larger than that by CMR or the fully automated software (P < 0.001). The fully automated software had a shorter analysis time compared with the semi-automated software (15 s vs. 120 s, P < 0.001) and had a good reproducibility.

CONCLUSION

A novel, fully automated 3DE RV quantification software underestimated RV volumes but successfully approximated RVEF when compared with CMR. No inferiority of this software was observed when compared with the semi-automated software. Rapid analysis and higher reproducibility also support the routine adoption of this method in the daily clinical workflow.

Speckle Tracking Imaging in Patients with Pulmonary Hypertension

BACKGROUND

Right ventricular (RV) systolic dysfunction is a strong predictor of mortality in pulmonary hypertension (PH). The goal of this study was to investigate whether right atrium (RA) and RV myocardial strain related to PH using speckle tracking echocardiography provide a superior estimation of RV systolic function than 2-dimensional (2D)-echo.

METHODS

This cross-sectional study analyzed 22 patients with a diagnosis of PH stratified by right heart catheterization, and they were compared to a control group of 22 age- and sex-matched healthy subjects.

RESULTS

Global longitudinal peak systolic strain measured in the RV free wall from the apical 4 chamber view was −15% vs. −14.5% when measured from the subcostal view (p = 0.99). Mean longitudinal strain during reservoir phase, and longitudinal strain rate during atrial reservoir and passive conduit function was significantly impaired measured in the right atrial free wall in patients with PH.

CONCLUSIONS

This study showed impaired LV contractility in patients with PH assessed by speckle tracking strain. RV free wall longitudinal strain does not correlate with any of the measurements of RV systolic function obtained by 2D echocardiography. A major strength of RV longitudinal strain is its ability to assess the RV function without the limitations of 2D parameters. The subcostal RV strain is a feasible and accurate alternative to conventional RV strain from the apical view in patients with poor acoustic apical 4-chamber windows. The RA strain and strain rates values may be a valuable additive to assess right-sided heart function.

Partitioning the Right Ventricle Into 15 Segments and Decomposing Its Motion Using 3D Echocardiography-Based Models: The Updated ReVISION Method

Three main mechanisms contribute to global right ventricular (RV) function: longitudinal shortening, radial displacement of the RV free wall (bellows effect), and anteroposterior shortening (as a consequence of left ventricular contraction). Since the importance of these mechanisms may vary in different cardiac conditions, a technology being able to assess their relative influence on the global RV pump function could help to clarify the pathophysiology and the mechanical adaptation of the chamber. Previously, we have introduced our 3D echocardiography (3DE)-based solution-the Right VentrIcular Separate wall motIon quantificatiON (ReVISION) method-for the quantification of the relative contribution of the three aforementioned mechanisms to global RV ejection fraction (EF). Since then, our approach has been applied in several clinical scenarios, and its strengths have been demonstrated in the in-depth characterization of RV mechanical pattern and the prognostication of patients even in the face of maintained RV EF. Recently, various new features have been implemented in our software solution to enable the convenient, standardized, and more comprehensive analysis of RV function. Accordingly, in our current technical paper, we aim to provide a detailed description of the latest version of the ReVISION method with special regards to the volumetric partitioning of the RV and the calculation of longitudinal, circumferential, and area strains using 3DE datasets. We also report the results of the comparison between 3DE- and cardiac magnetic resonance imaging-derived RV parameters, where we found a robust agreement in our advanced 3D metrics between the two modalities. In conclusion, the ReVISION method may provide novel insights into global and also segmental RV function by defining parameters that are potentially more sensitive and predictive compared to conventional echocardiographic measurements in the context of different cardiac diseases.

Prognostic Value of Right Ventricular Ejection Fraction Assessed by 3D Echocardiography in COVID-19 Patients

Background: RVEF (right ventricular ejection fraction) measured by three-dimensional echocardiography (3DE) has been used in evaluating right ventricular (RV) function and can provide useful prognostic information in other various cardiovascular diseases. However, the prognostic value of 3D-RVEF in coronavirus disease 2019 (COVID-19) remains unknown. We aimed to investigate whether 3D-RVEF can predict the mortality of COVID-19 patients.

Methods: A cohort of 128 COVID-19-confirmed patients who had undergone echocardiography were studied. Thirty-one healthy volunteers were also enrolled as controls. COVID-19 patients were divided into three subgroups (general, severe, and critical) according to COVID-19 severity-of-illness. Conventional RV structure and function parameters, RV free wall longitudinal strain (FWLS) and 3D-RVEF were acquired. RVFWLS was measured by two-dimensional speckle tracking echocardiography. RVEF was acquired by 3DE.

Results: Compared with controls, 2D-RVFWLS and 3D-RVEF were both significantly decreased in COVID-19 patients (−27.2 ± 4.4% vs. −22.9 ± 4.8%, P < 0.001; 53.7 ± 4.5% vs. 48.5 ± 5.8%, P < 0.001). Critical patients were more likely to have a higher incidence of acute cardiac injury and acute respiratory distress syndrome (ARDS), and worse prognosis than general and severe patients. The critical patients exhibited larger right-heart chambers, worse RV fractional area change (RVFAC), 2D-RVFWLS, and 3D-RVEF and higher proportion of pulmonary hypertension than general and severe patients. Eighteen patients died during a median follow-up of 91 days. The multivariate Cox regression analysis revealed the acute cardiac injury, ARDS, RVFAC, RVFWLS, and 3D-RVEF were independent predictors of death. 3D-RVEF (chi-square to improve 18.3; P < 0.001), RVFAC (chi-square to improve 4.5; P = 0.034) and 2D-RVFWLS (chi-square to improve 5.1; P = 0.024) all provided additional prognostic value of higher mortality over clinical risk factors. Moreover, the incremental predictive value of 3D-RVEF was significantly (P < 0.05) higher than RVFAC and RVFWLS.

Conclusion: 3D-RVEF was the most robust independent predictor of mortality in COVID-19 patients and provided a higher predictive value over conventional RV function parameters and RVFWLS, which may be helpful to identify COVID-19 patients at a higher risk of death.

Right ventricular area strain from 3-dimensional echocardiography: Mechanistic insight of right ventricular dysfunction in pediatric pulmonary hypertension

BACKGROUND

Right ventricular (RV) function is a major contributor to the outcome of pulmonary arterial hypertension (PAH). Adult studies demonstrated that regional and global changes in RV deformation are prognostic in PAH using 3-dimensional echocardiography (3DE). However, regional and global dynamic changes in RV mechanics have not been described in pediatric PAH. We compared 3DE RV regional and global deformation between pediatric patients who had associated PAH with congenital heart disease (APAH-CHD), pediatric patients who had idiopathic PAH (IPAH), and normal controls, and evaluated the clinical outcomes.

METHODS

A total of 48 controls, 47 patients with APAH-CHD, and 45 patients with IPAH were evaluated. 3DE RV sequences were analyzed and post-processed to extract global and regional deformation (circumferential, longitudinal, and area strain). Statistical analyses compared the sub-groups on the basis of global and regional deformation, and outcome analysis was performed.

RESULTS

Patients with PAH had significantl8y different global and regional deformation (p < 0.001) compared with controls. Patients with APAH-CHD and and those with IPAH significantly differed in global circumferential strain (p < 0.010), area strain (inlet septum, p = 0.041), and circumferential strain at the inlet septum (p < 0.019), apex free wall (p < 0.004), and inlet free wall (p < 0.004). Circumferential strain at the inlet free wall and circumferential, longitudinal, and area strain at the apex free wall were predictors of adverse events.

CONCLUSIONS

RV regional and global strain differ between controls and pediatric patients with PAH. RV apical free-wall area strain provides insight into the mechanism of RV dysfunction in pediatric patients with PAH, with regional strain emerging as outcome predictors, suggesting that this novel measure may be considered as a future measure of RV function.

Adaptation and Maladaptation of the Right Ventricle in Pulmonary Vascular Diseases

The right ventricle is coupled to the low-pressure pulmonary circulation. In pulmonary vascular diseases, right ventricular (RV) adaptation is key to maintain ventriculoarterial coupling. RV hypertrophy is the first adaptation to diminish RV wall tension, increase contractility, and protect cardiac output. Unfortunately, RV hypertrophy cannot be sustained and progresses toward a maladaptive phenotype, characterized by dilation and ventriculoarterial uncoupling. The mechanisms behind the transition from RV adaptation to RV maladaptation and right heart failure are unraveled. Therefore, in this article, we explain the main traits of each phenotype, and how some early beneficial adaptations become prejudicial in the long-term.

Association between right atrial area measured by echocardiography and prognosis among pulmonary arterial hypertension: a systematic review and meta-analysis

OBJECTIVE

The purpose of this meta-analysis was to evaluate the association between enlarged right atrial area (RAA), as measured by echocardiography, and prognosis of patients with pulmonary arterial hypertension (PAH).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

To identify potential publications, a comprehensive literature search through MEDLINE, the Cochrane database and the Embase database was performed up to December 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies were included if they reported Cox regression based-HRs with 95% CIs for all-cause mortality or composite endpoint consisting of death and PAH-related events for echocardiography measurements of the RAA or the right atrial area index (RAAI) in patients with PAH.

DATA EXTRACTION AND SYNTHESIS

The unadjusted HR with 95% CI was extracted for the final pooled analysis. A random-effects model was used to determine the value of RAA/RAAI in the prognosis of patients with PAH. The data heterogeneity among the studies was estimated by the I² statistic and the Cochran Q-statistic.

RESULTS

Twelve studies with a total of 1085 patients with PAH were finally included in the meta-analysis. These studies had a mean follow-up time ranging from 9.2 months to 5.0 years. Their findings showed that patients with PAH with enlarged RAA/RAAI were associated with poor prognosis. The risk of all-cause mortality in patients with PAH was found to statistically increase by 50% for every 5-unit increase in RAA/RAAI (HR 1.50, 95% CI 1.28 to 1.75, p<0.001). Similarly, the risk of the composite endpoint also significantly increased by 53% for every 5-unit increase in RAA/RAAI (HR 1.53, 95% CI 1.23 to 1.89, p<0.001). Subgroup analyses in which the patients were stratified by RAA and RAAI were consistent with the main results.

CONCLUSION

The meta-analysis suggested that enlarged RAA/RAAI were associated with increased risk of poor prognosis in patients with PAH.

Three-dimensional right ventricular shape and strain in congenital heart disease patients with right ventricular chronic volume loading

AIMS

Right ventricular (RV) function assessment is crucial in congenital heart disease patients, especially in atrial septal defect (ASD) and repaired Tetralogy of Fallot (TOF) patients with pulmonary regurgitation (PR). In this study, we aimed to analyse both 3D RV shape and deformation to better characterize RV function in ASD and TOF-PR.

METHODS AND RESULTS

We prospectively included 110 patients (≥16 years old) into this case-control study: 27 ASD patients, 28 with TOF, and 55 sex- and age-matched healthy controls. Endocardial tracking was performed on 3D transthoracic RV echocardiographic sequences and output RV meshes were post-processed to extract local curvature and deformation. Differences in shape and deformation patterns between subgroups were quantified both globally and locally. Curvature highlights differences in RV shape between controls and patients while ASD and TOF-PR patients are similar. Conversely, strain highlights differences between controls and TOF-PR patients while ASD and controls are similar [global area strain: -31.5 ± 5.8% (controls), -34.1 ± 7.9% (ASD), -24.8 ± 5.7% (TOF-PR), P < 0.001, similar significance for longitudinal and circumferential strains]. The regional and local analysis highlighted differences in particular in the RV free wall and the apical septum.

CONCLUSION

Chronic RV volume loading results in similar RV shape remodelling in both ASD and TOF patients while strain analysis demonstrated that RV strain is only reduced in the TOF group. This suggests a fundamentally different RV remodelling process between both conditions.

Importance of Nonlongitudinal Motion Components in Right Ventricular Function: Three-Dimensional Echocardiographic Study in Healthy Volunteers

BACKGROUND

Global right ventricular (RV) function is determined by the interplay of different motion components related to the myofiber architecture, and the relative importance of these components is still not thoroughly characterized. The aims of this study were to quantify the relative contributions of longitudinal, radial, and anteroposterior motion components to global RV function and to examine their determining factors in a large cohort of healthy volunteers using three-dimensional echocardiography.

METHODS

Three hundred healthy adults with a balanced age range and an equal sex distribution were investigated at two centers. A three-dimensional mesh model of the right ventricle was generated, and its motion was decomposed along the three anatomically relevant axes. Multiplicative relative contributions were measured by dividing the ejection fraction (EF) values generated by shortening in the longitudinal, radial, and anteroposterior directions by global RV EF (longitudinal EF index [LEFi], radial EF index [REFi], and anteroposterior EF index, respectively). The circumferential contribution was defined as shortening in the radial and anteroposterior directions, omitting only longitudinal shortening.

RESULTS

Circumferential EF index was markedly higher compared with LEFi (79 ± 7% vs 47 ± 9%, P < .001). LEFi (47 ± 9%) and anteroposterior EF index (49 ± 7%) were found to be similar in the pooled population, whereas REFi (44 ± 10%) was lower (P < .001). In younger individuals (20-39 years of age), the relative contribution of longitudinal shortening was significantly higher compared with the radial component; however, in the older age groups, LEFi and REFi were comparable. Age, body surface area, heart rate, and RV end-diastolic volume were independent predictors of LEFi and REFi, but all with opposite effects on the two motion directions.

CONCLUSIONS

In contrast to the traditional viewpoint, the contributions of the radial and anteroposterior motion directions may be of comparable significance with that of longitudinal shortening in determining global RV function. Standard parameters referring only to longitudinal shortening of the right ventricle may be inadequate to characterize RV function thoroughly.

Three-dimensional biventricular strains in pulmonary arterial hypertension patients using hyperelastic warping

BACKGROUND AND OBJECTIVE

Evaluation of biventricular function is an essential component of clinical management in pulmonary arterial hypertension (PAH). This study aims to examine the utility of biventricular strains derived from a model-to-image registration technique in PAH patients in comparison to age- and gender-matched normal controls.

METHODS

A three-dimensional (3D) model was reconstructed from cine short- and long-axis cardiac magnetic resonance (CMR) images and subsequently partitioned into right ventricle (RV), left ventricle (LV) and septum. The hyperelastic warping method was used to register the meshed biventricular finite element model throughout the cardiac cycle and obtain the corresponding biventricular circumferential, longitudinal and radial strains.

RESULTS

Intra- and inter-observer reproducibility of biventricular strains was excellent with all intra-class correlation coefficients > 0.84. 3D biventricular longitudinal, circumferential and radial strains for RV, LV and septum were significantly decreased in PAH patients compared with controls. Receiver operating characteristic (ROC) analysis showed that the 3D biventricular strains were better early markers (Area under the ROC curve = 0.96 for RV longitudinal strain) of ventricular dysfunction than conventional parameters such as two-dimensional strains and ejection fraction.

CONCLUSIONS

Our highly reproducible methodology holds potential for extending CMR imaging to characterize 3D biventricular strains, eventually leading to deeper understanding of biventricular mechanics in PAH.

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

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

Right ventricular mechanical pattern in patients undergoing mitral valve surgery: a predictor of post-operative dysfunction?

Aims

The PREPARE‐MVR study (PRediction of Early PostoperAtive Right vEntricular failure in Mitral Valve Replacement/Repair patients) sought to investigate the alterations of right ventricular (RV) contraction pattern in patients undergoing mitral valve replacement/repair (MVR) and to explore the associations between pre‐operative RV mechanics and early post‐operative RV dysfunction (RVD).

Methods and results

We prospectively enrolled 42 patients (63 ± 11 years, 69% men) undergoing open‐heart MVR. Transthoracic three‐dimensional (3D) echocardiography was performed pre‐operatively, at intensive care unit discharge, and 6 months after surgery. The 3D model of the RV was reconstructed, and RV ejection fraction (RVEF) was calculated. We decomposed the motion of the ventricle to compute longitudinal ejection fraction (LEF) and radial ejection fraction (REF). Pulmonary artery catheterization was performed to monitor RV stroke work index (RVSWi). RVEF was slightly decreased after MVR [52 (50–55) vs. 51 (46–54)%; P = 0.001], whereas RV contraction pattern changed notably. Before MVR, the longitudinal shortening was the main contributor to global systolic RV function [LEF/RVEF vs. REF/RVEF; 0.53 (0.47–0.58) vs. 0.33 (0.22–0.42); P < 0.001]. Post‐operatively, the radial motion became dominant [0.33 (0.28–0.43) vs. 0.46 (0.37–0.51); P = 0.004]. However, this shift was temporary as 6 months later the two components contributed equally to global RV function [0.44 (0.38–0.50) vs. 0.41 (0.36–0.49); P = 0.775]. Pre‐operative LEF was an independent predictor of post‐operative RVD defined as RVSWi < 300 mmHg⋅mL/m² [OR = 1.33 (95% CI: 1.08–1.77), P < 0.05].

Conclusions

MVR induces a significant shift in the RV mechanical pattern. Advanced indices of RV mechanics are associated with invasively measured parameters of RV contractility and may predict post‐operative RVD.

Echocardiographic assessment of the right heart in adults: a practical guideline from the British Society of Echocardiography

The structure and function of the right side of the heart is influenced by a wide range of physiological and pathological conditions. Quantification of right heart parameters is important in a variety of clinical scenarios including diagnosis, prognostication, and monitoring response to therapy. Although echocardiography remains the first-line imaging investigation for right heart assessment, published guidance is relatively sparse in comparison to that for the left ventricle. This guideline document from the British Society of Echocardiography describes the principles and practical aspects of right heart assessment by echocardiography, including quantification of chamber dimensions and function, as well as assessment of valvular function. While cut-off values for normality are included, a disease-oriented approach is advocated due to the considerable heterogeneity of structural and functional changes seen across the spectrum of diseases affecting the right heart. The complex anatomy of the right ventricle requires special considerations and echocardiographic techniques, which are set out in this document. The clinical relevance of right ventricular diastolic function is introduced, with practical guidance for its assessment. Finally, the relatively novel techniques of three-dimensional right ventricular echocardiography and right ventricular speckle tracking imaging are described. Despite these techniques holding considerable promise, issues relating to reproducibility and inter-vendor variation have limited their clinical utility to date.

Comparison of the capability of risk stratification evaluation between two- and three-dimensional speckle-tracking strain in pre-capillary pulmonary hypertension

To investigate and compare the value of right ventricular longitudinal strain detected by two-dimensional and three-dimensional speckle-tracking echocardiography in risk stratification evaluation in pre-capillary pulmonary hypertension. We consecutively screened 66 patients diagnosed with pre-capillary pulmonary hypertension in our center. According to the risk assessment recommended by 2015 European Society of Cardiology Guidelines, all participants were classified into low- and intermediate-high-risk group. Two-dimensional and three-dimensional strains were measured using off-line softwares (GE EchoPAC version 201 and TomTec, 4D RV Function 2.0). Fifty-seven pre-capillary pulmonary hypertension patients (average 35 years old, 18 males and 39 females) were finally enrolled in our study, 32 (56.1%) were classified in low-risk group, while 25 (43.9%) were in the intermediate-high-risk group. Clinical data associated with disease severity, such as N-terminal pro-brain natriuretic peptide (r = 0.574, P < 0.001), peak oxygen consumption (r = -0.484, P < 0.001), and 6-min walking distance (r = -0.356, P = 0.008) were significantly correlated with two-dimensional right ventricular longitudinal strain; while the correlations with three-dimensional right ventricular longitudinal strain were weaker. Receiver operating characteristic curves for the detection of intermediate-high risk stratification showed two-dimensional right ventricular longitudinal strain had the best predictive capacity (area under curve, 0.82, 95% CI: 0.71-0.93, P < 0.001). Univariate and Multivariate Logistic regression analyses identified two-dimensional right ventricular longitudinal strain as an independent predictor (OR: 1.42, 95% CI: 1.18-1.71, P < 0.001) of intermediate-high risk stratification in this cohort of pre-capillary pulmonary hypertension patients, the predictive capacity retained (OR: 1.45, 95% CI: 1.18-1.78, P < 0.001) after adjusted by age, gender, and body mass index, while three-dimensional speckle-tracking echocardiography parameters were not. In conclusion, when used for the detection of intermediate-high risk stratification in pre-capillary pulmonary hypertension, two-dimensional right ventricular longitudinal strain was better than three-dimensional right ventricular longitudinal strain.

The value of three-dimensional echocardiography in risk stratification in pulmonary arterial hypertension: a cross-sectional study

To explore the value of right ventricular (RV) parameters detected by three-dimensional echocardiography (3DE) in risk stratification in pulmonary arterial hypertension (PAH) patients. We prospectively recruited 130 pulmonary hypertension patients from National Center for Cardiovascular Diseases, Fuwai Hospital. Each participant was performed a transthoracic echocardiography and 3DE parameters were measured using an off-line software (4D RV Function 2.0, TomTec). Patients were classified into low, intermediate-high risk group based on 2015 ESC Guidelines. A total of 91 PAH patients (34 ± 12 years old, 25 males) were enrolled, among which, 42 were classified into low risk group, while 49 were intermediate-high risk group. Compared with low-risk patients, those with intermediate-high risk had significantly larger 3DE-RV volumes, worse ejection fraction (EF) and tricuspid annular plane systolic excursion, and decreased longitudinal strain (LS). Receive operating characteristic curves illustrated all the 3DE parameters were able to predict intermediate-high risk stratification, especially 3D-RVEF (area under curve, 0.82, 95% CI 0.73-0.91, P < 0.001). And 3D-RVEF < 26.39% had a 81.6% sensibility and 73.8% specificity to predict intermediate-high risk stratification. Univariate and multivariate Logistic regression analyses identified 3D-RV end-diastolic (OR 1.02, 95% CI 1.01-1.03, P = 0.002) and end-systolic (OR 1.03, 95% CI 1.01-1.04, P < 0.001) volumes, 3D-RVEF (OR 0.82, 95% CI 0.75-0.90, P < 0.001) and LS of free wall (OR 1.17, 95% CI 1.05-1.31, P = 0.005) as independent predictors of intermediate-high risk stratification. In conclusion, RV volumes, EF and free wall strain detected by 3DE were independent predictors of intermediate-high risk stratification in PAH patients, among which, RVEF showed the best predictive capacity.

Characterization of the anisotropic deformation of the right ventricle during open heart surgery

Digital Image Correlation (DIC) was used for studying the anisotropic behavior of the thin walled right ventricle of the human heart. Strains measured with Speckle Tracking Echocardiography (STE) were compared with the DIC data. Both DIC and STE were used to measure longitudinal strains of the right ventricle in the beginning of an open-heart surgery as well as after the cardiopulmonary bypass. Based on the results, the maximum end-systolic strains obtained with the DIC and STE change similarly during the surgery with less than 10% difference. The difference is largely due to the errors in matching the longitudinal direction in the two methods, sensitivity of the measurement to the positioning of the virtual extensometer of in both STE and DIC, and physiological difference of the measurements as the DIC measures the top surface of the heart whereas the STE obtains the data from below. The anisotropy of the RV was measured using full field principal strains acquired from the DIC displacement fields. The full field principal strains cover the entire region of interest instead of just two points as the virtual extensometer approach used by the STE. The principal strains are not direction dependent measures, and therefore are more independent of the anatomy of the patient and the exact positioning of the virtual strain gage or the STE probe. The results show that the longitudinal strains alone are not enough to fully characterize the behavior of the heart, as the deformation of the heart can be very anisotropic, and the anisotropy changes during the surgery, and from patient to patient.

New electromechanical substrate abnormalities in high-risk patients with Brugada syndrome

BACKGROUND

The relationship between the typical electrocardiographic pattern and electromechanical abnormalities has never been systematically explored in Brugada syndrome (BrS).

OBJECTIVES

The aims of this study were to characterize the electromechanical substrate in patients with BrS and to evaluate the relationship between electrical and mechanical abnormalities.

METHODS

We enrolled 50 consecutive high-risk patients with BrS (mean age 42 ± 7.2 years), with implantable cardioverter-defibrillator implantation for primary or secondary prevention of ventricular tachyarrhythmias (ventricular tachycardia/ventricular fibrillation [VT/VF]), undergoing substrate mapping and ablation. Patients underwent 3-dimensional (3D) echocardiography with 3D wall motion/deformation quantification and electroanatomic mapping before and after ajmaline administration (1 mg/kg in 5 minutes); 3D mechanical changes were compared with 50 age- and sex-matched controls. The effect of substrate ablation on electromechanical abnormalities was also assessed.

RESULTS

In all patients, ajmaline administration induced Brugada type 1 pattern, with a significant increase in the electrical substrate (P < .001), particularly in patients with previous spontaneous VT/VF (P = .007). Induction of Brugada pattern was associated with lowering of right ventricular (RV) ejection fraction (P < .001) and worsening of 3D RV mechanical function (P < .001), particularly in the anterior free wall of the RV outflow tract, without changes in controls. RV electrical and mechanical abnormalities were highly correlated (r = 0.728, P < .001). By multivariate analysis, only the area of RV dysfunction was an independent predictor of spontaneous VT/VF (odds ratio 1.480; 95% confidence interval 1.159-1.889; P = .002). Substrate ablation abolished both BrS-electrocardiographic pattern and mechanical abnormalities, despite ajmaline rechallenge.

CONCLUSION

BrS is an electromechanical disease affecting the RV. The typical BrS pattern reflects an extensive RV arrhythmic substrate, driving consistent RV mechanical abnormalities. Substrate ablation abolished both Brugada pattern and mechanical abnormalities.

3-Dimensional Echocardiography: Latest Developments and Future Directions

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

Right ventricular mechanical pattern in health and disease: beyond longitudinal shortening

Right ventricular (RV) function has proven to be a prognostic factor in heart failure with reduced and preserved ejection fraction and in pulmonary hypertension. RV function is also a cornerstone in the management of novel clinical issues, such as mechanical circulatory support devices or grown-up congenital heart disease patients. Despite the notable amount of circumferentially oriented myofibers in the subepicardial layer of the RV myocardium, the non-longitudinal motion directions are often neglected in the everyday assessment of RV function by echocardiography. However, the complex RV contraction pattern incorporates different motion components along three anatomically relevant axes: longitudinal shortening with traction of the tricuspid annulus towards the apex, radial motion of free wall often referred as the "bellows effect", and anteroposterior shortening of the chamber by stretching the free wall over the septum. Advanced echocardiographic techniques, such as speckle-tracking and 3D echocardiography allow an in-depth characterization of RV mechanical pattern, providing better understanding of RV systolic and diastolic function. In our current review, we summarize the existing knowledge regarding RV mechanical adaptation to pressure- and/or volume-overloaded states and also other physiologic or pathologic conditions.

Assessment of Right Ventricular Function in Pulmonary Hypertension with Multimodality Imaging

Pulmonary hypertension (PH) is defined as resting mean pulmonary artery pressure ≥ 25 mmHg and is caused by multiple etiologies including heart, lung or other systemic diseases. Evaluation of right ventricular (RV) function in PH is very important to plan treatment and determine prognosis. However, quantification of volume and function of the RV remains difficult due to complicated RV geometry. A number of imaging tools has been utilized to diagnose PH and assess RV function. Each imaging technique including conventional echocardiography, three-dimensional echocardiography, strain echocardiography, computed tomography and cardiac magnetic resonance imaging has-advantages and limitations and can provide unique information. In this article, we provide a comprehensive review of the utility, advantages and shortcomings of the multimodality imaging used to evaluate patients with PH.

Characterization of Right Ventricular Deformation in Pulmonary Arterial Hypertension Using Three-Dimensional Principal Strain Analysis

BACKGROUND

Pulmonary arterial hypertension (PAH) can cause maladaptive right ventricular (RV) functional changes associated with adverse prognosis that are challenging to accurately quantify noninvasively. The aim of this study was to explore principal strain (PS) with contraction angle analysis using three-dimensional echocardiography to characterize RV deformation changes in patients with PAH.

METHODS

Three-dimensional echocardiography was performed in 37 patients with PAH and 20 healthy control subjects with two-component (primary and secondary) PS and principal contraction angle analysis. Patients were stratified according to World Health Organization (WHO) functional class.

RESULTS

Primary PS differed significantly between patients with PAH and healthy control subjects (-20.2 ± 3.3% vs -26.8 ± 3.3%, P = .01), while secondary PS was not significantly different (3.6 ± 5.1% vs -2.5 ± 4.7%, P = .12). Principal contraction angle was significantly lower in patients with PAH (63 ± 22° vs 71 ± 7°, P = .01), with the greatest reduction for the RV free wall. Primary PS and principal contraction angle differed significantly between WHO class I and II and class III and IV patients (-23.9 ± 4.7% vs -18.1 ± 4.8% [P = .03] and 69 ± 9° vs 58 ± 14° [P = .03], respectively), while secondary PS was not significantly different between groups (P = .13). Compared with healthy control subjects, septal principal contraction angle was not different in patients with WHO class I and II PAH (P = .62), but it was significantly reduced in those with WHO class III and IV PAH (P < .01). The area under the curve for primary PS to differentiate patients with PAH by WHO functional class was 0.81 (95% CI, 0.77-0.89; P = .01). Primary PS intraclass correlation coefficients for intraobserver and interobserver variability were 0.91 (95% CI, 0.88-0.93) and 0.86 (95% CI, 0.81-0.88), respectively.

CONCLUSIONS

PS analysis using three-dimensional echocardiography provides comprehensive quantification of RV deformation and characterizes alterations occurring in PAH that are associated with WHO functional class.

Exercise-induced shift in right ventricular contraction pattern: novel marker of athlete's heart?

Data about the functional adaptation of the right ventricle (RV) to intense exercise are limited. Our aim was to characterize the RV mechanical pattern in top-level athletes using three-dimensional echocardiography. A total of 60 elite water polo athletes (19 ± 4 yr, 17 ± 6 h of training/wk, 50% women and 50% men) and 40 healthy sedentary control subjects were enrolled. We measured the RV end-diastolic volume index (RVEDVi) and ejection fraction (RVEF) using dedicated software. Furthermore, we determined RV global longitudinal (RV GLS) and circumferential strain (RV GCS) and the relative contribution of longitudinal ejection fraction (LEF) and radial ejection fraction (REF) to RVEF using the ReVISION method. Athletes also underwent cardiopulmonary exercise testing [O₂ consumption (V̇o₂)/kg]. Athletes had significantly higher RVEDVi compared with control subjects (athletes vs. control subjects, 88 ± 11 vs. 65 ± 10 ml/m², P < 0.001); however, they also demonstrated lower RVEF (56 ± 4% vs. 61 ± 5%, P < 0.001). RV GLS was comparable between the two groups (-22 ± 5% vs. -23 ± 5%, P = 0.24), whereas RV GCS was significantly lower in athletes (-21 ± 4% vs. -26 ± 7%, P < 0.001). Athletes had higher LEF and lower REF contribution to RVEF (LEF/RVEF: 0.50 ± 0.07 vs. 0.42 ± 0.07, P < 0.001; REF/RVEF: 0.33 ± 0.08 vs. 0.45 ± 0.08, P < 0.001). Moreover, the pattern of RV functional shift correlated with V̇o₂/kg (LEF/RVEF: r = 0.30, P < 0.05; REF/RVEF: r = -0.27, P < 0.05). RV mechanical adaptation to long-term intense exercise implies a functional shift; the relative contribution of longitudinal motion to global function was increased, whereas the radial shortening was significantly decreased, in athletes. Moreover, this functional pattern correlates with aerobic exercise performance, representing a potential new resting marker of an athlete's heart. NEW & NOTEWORTHY Intensive regular physical exercise results in significant changes of right ventricular morphology and function. By separate quantification of the right ventricular longitudinal and radial function, a relative dominance of longitudinal motion and a decrease in radial motion can be observed compared with sedentary controls. Moreover, this contraction pattern correlates with cardiopulmonary fitness. According to these results, this functional shift of the right ventricle may represent a novel marker of an athlete's heart.

Right Ventricular Function Evolution With Pregnancy in Repaired Tetralogy of Fallot

This case illustrates the evolution of right ventricular (RV) 3-dimensional (3D) area strain during pregnancy in a patient with repaired Tetralogy of Fallot. The report highlights impairment in RV function with pregnancy, suggesting the importance of prepregnancy RV systolic function assessment, especially using 3D echocardiography.