Imaging the right heart: the use of integrated multimodality imaging

Pathophysiology, diagnosis and management of right ventricular failure: A state of the art review of mechanical support devices

The function of the right ventricle (RV) is to drive the forward flow of blood to the pulmonary system for oxygenation before returning to the left ventricle. Due to the thin myocardium of the RV, its function is easily affected by decreased preload, contractile motion abnormalities, or increased afterload. While various etiologies can lead to changes in RV structure and function, sudden changes in RV afterload can cause acute RV failure which is associated with high mortality. Early detection and diagnosis of RV failure is imperative for guiding initial medical management. Echocardiographic findings of reduced tricuspid annular plane systolic excursion (<1.7) and RV wall motion (RV S' <10 cm/s) are quantitatively supportive of RV systolic dysfunction. Medical management commonly involves utilizing diuretics or fluids to optimize RV preload, while correcting the underlying insult to RV function. When medical management alone is insufficient, mechanical circulatory support (MCS) may be necessary. However, the utility of MCS for isolated RV failure remains poorly understood. This review outlines the differences in flow rates, effects on hemodynamics, and advantages/disadvantages of MCS devices such as intra-aortic balloon pump, Impella, centrifugal-flow right ventricular assist devices, extracorporeal membrane oxygenation, and includes a detailed review of the latest clinical trials and studies analyzing the effects of MCS devices in acute RV failure.

The mechanics of congenital heart disease: from a morphological trait to the functional echocardiographic evaluation

Advances in pediatric cardiac surgery have resulted in a recent growing epidemic of children and young adults with congenital heart diseases (CHDs). In these patients, congenital defects themselves, surgical operations and remaining lesions may alter cardiac anatomy and impact the mechanical performance of both ventricles. Cardiac function significantly influences outcomes in CHDs, necessitating regular patient follow-up to detect clinical changes and relevant risk factors. Echocardiography remains the primary imaging method for CHDs, but clinicians must understand patients' unique anatomies as different CHDs exhibit distinct anatomical characteristics affecting cardiac mechanics. Additionally, the use of myocardial deformation imaging and 3D echocardiography has gained popularity for enhanced assessment of cardiac function and anatomy. This paper discusses the role of echocardiography in evaluating cardiac mechanics in most significant CHDs, particularly its ability to accommodate and interpret the inherent anatomical substrate in these conditions.

Perioperative Right Ventricular Dysfunction and Abnormalities of the Tricuspid Valve Apparatus in Patients Undergoing Cardiac Surgery

Right ventricular (RV) dysfunction frequently occurs after cardiac surgery and is linked to adverse postoperative outcomes, including mortality, reintubation, stroke, and prolonged ICU stays. While various criteria using echocardiography and hemodynamic parameters have been proposed, a consensus remains elusive. Distinctive RV anatomical features include its thin wall, which presents a triangular shape in a lateral view and a crescent shape in a cross-sectional view. Principal causes of RV dysfunction after cardiac surgery encompass ischemic reperfusion injury, prolonged ischemic time, choice of cardioplegia and its administration, cardiopulmonary bypass weaning characteristics, and preoperative risk factors. Post-left ventricular assist device (LVAD) implantation RV dysfunction is common but often transient, with a favorable prognosis upon resolution. There is an ongoing debate regarding the benefits of concomitant surgical repair of the RV in the presence of regurgitation. According to the literature, the gold standard techniques for assessing RV function are cardiac magnetic resonance imaging and hemodynamic assessment using thermodilution. Echocardiography is widely favored for perioperative RV function evaluation due to its accessibility, reproducibility, non-invasiveness, and cost-effectiveness. Although other techniques exist for RV function assessment, they are less common in clinical practice. Clinical management strategies focus on early detection and include intravenous drugs (inotropes and vasodilators), inhalation drugs (pulmonary vasodilators), ventilator strategies, volume management, and mechanical support. Bridging research gaps in this field is crucial to improving clinical outcomes associated with RV dysfunction in the near future.

Tricuspid regurgitation, right ventricular function, and renal congestion: a cardiorenal triangle

There is a growing interest in the evaluation of tricuspid regurgitation due to its increasing prevalence and detrimental impact on clinical outcomes. Historically, it has been coined the "forgotten" defect in the field of valvular heart disease due to the lack of effective treatments to improve prognosis. However, the development of percutaneous treatment techniques has led to a new era in its management, with promising results and diminished complication risk. In spite of these advances, a comprehensive exploration of the pathophysiological mechanisms is essential to establish clear indications and optimal timing for medical and percutaneous intervention. This review will address the most important aspects related to the diagnosis, pathophysiology and treatment of tricuspid regurgitation from a cardiorenal perspective, with a special emphasis on the interaction between right ventricular dysfunction and the development of hepatorenal congestion.

Right ventricular ejection fraction derived from intraoperative three-dimensional transesophageal echocardiography versus cardiac magnetic resonance imaging

PURPOSE

Right ventricle (RV) assessment is critical during cardiac surgery. Traditional assessment consists of visual estimation and measurement of validated parameters. Cardiac magnetic resonance imaging (cMRI) is the gold standard for RV analysis, and transthoracic three-dimensional (3D) echocardiography is validated against this. We aimed to show that intraoperative 3D transesophageal echocardiography (TEE) RV assessment is feasible and can produce results that correlate with cMRI.

METHODS

We recruited cardiac surgery patients who underwent cMRI within the preceding twelve preoperative months. An anesthetic protocol was followed pre-sternotomy and a 3D RV data set was acquired. We used TOMTEC 4D RV-Function to derive RV end-diastolic volume (EDV), end-systolic volume (ESV), and ejection fraction (EF). We compared these data with the corresponding MRI values.

RESULTS

Twenty-five patients were included. Transesophageal echocardiography EDV and ESV differed from MRI measurements with a mean bias of -53 mL (95% confidence interval [CI], -80 to 26) and -21 mL (95% CI, -34 to -9). Transesophageal echocardiography EF did not differ significantly, with a mean bias of -4% (95% CI, -8 to 1). Results were unchanged after excluding MRIs older than 180 days. Correlation coefficients for EDV, ESV, and EF were r = 0.85, 0.91, and 0.80, respectively. Interclass correlation coefficients for EDV, ESV, and EF were 0.86, 0.89, and 0.96, respectively.

CONCLUSIONS

Intraoperative TEE RV, EDV, and ESV are underestimated relative to cMRI because of analysis, anesthetic, and ventilation factors. The EF showed a low mean difference, and all values showed strong correlation with MRI. Reproducibility and feasibility were excellent and increased use in clinical practice should be considered.

Multi-modality cardiac image computing: A survey

Multi-modality cardiac imaging plays a key role in the management of patients with cardiovascular diseases. It allows a combination of complementary anatomical, morphological and functional information, increases diagnosis accuracy, and improves the efficacy of cardiovascular interventions and clinical outcomes. Fully-automated processing and quantitative analysis of multi-modality cardiac images could have a direct impact on clinical research and evidence-based patient management. However, these require overcoming significant challenges including inter-modality misalignment and finding optimal methods to integrate information from different modalities. This paper aims to provide a comprehensive review of multi-modality imaging in cardiology, the computing methods, the validation strategies, the related clinical workflows and future perspectives. For the computing methodologies, we have a favored focus on the three tasks, i.e., registration, fusion and segmentation, which generally involve multi-modality imaging data, either combining information from different modalities or transferring information across modalities. The review highlights that multi-modality cardiac imaging data has the potential of wide applicability in the clinic, such as trans-aortic valve implantation guidance, myocardial viability assessment, and catheter ablation therapy and its patient selection. Nevertheless, many challenges remain unsolved, such as missing modality, modality selection, combination of imaging and non-imaging data, and uniform analysis and representation of different modalities. There is also work to do in defining how the well-developed techniques fit in clinical workflows and how much additional and relevant information they introduce. These problems are likely to continue to be an active field of research and the questions to be answered in the future.

A new assessment method for right ventricular diastolic function using right heart catheterization by pressure-volume loop

Diastolic stiffness coefficient (β) and end-diastolic elastance (Eed) are ventricular-specific diastolic parameters. However, the diastolic function of right ventricle had not been investigated sufficiently due to the lack of established evaluation method. We evaluated the validity of these parameters calculated using only data of right heart catheterization (RHC) and assessed it in patients with restrictive cardiomyopathy (RCM) and cardiac amyloidosis. We retrospectively analyzed 46 patients with heart failure who underwent RHC within 10 days of cardiac magnetic resonance (CMR). Right ventricular end-diastolic volume and end-systolic volume were calculated using only RHC data, which were found to be finely correlated with those obtained from CMR. β and Eed calculated by this method were also significantly correlated with those derived from conventional method using CMR. By this method, β and Eed were significantly higher in RCM with amyloidosis group than dilated cardiomyopathy group. In addition, the β and Eed calculated by our method were finely correlated with E/A ratio on echocardiography. We established an easy method to estimate β and Eed of right ventricle from only RHC. The method finely demonstrated right ventricular diastolic dysfunction in patients with RCM and amyloidosis.

Right ventricular-pulmonary arterial uncoupling in mild-to-moderate asthma

OBJECTIVE

Persistent pulmonary hypertension and resulting right ventricular (RV) failure are highly encountered phenomenon in severe pulmonary diseases. However, in this study, we aimed to examine the effects of mild-to-moderate asthma on RV functions, pulmonary arterial stiffness (PAS), and coupling of RV to the pulmonary artery (PA) in the absence of overt pulmonary hypertension.

METHODS

We enrolled 53 patients with mild-to-moderate asthma, and 50 healthy control subjects. A comprehensive two dimensional transthoracic echocardiography was performed on each individual. The parameters measuring RV function were all examined. PAS was calculated by dividing maximal frequency shift of pulmonary flow by pulmonary acceleration time. RV-PA coupling was estimated by the tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) ratio (TAPSE/PASP).

RESULTS

Baseline demographics, clinical and laboratory parameters of both groups were similar (p > 0.05). Most of conventional echocardiographic parameters measuring RV function were impaired in patients with asthma compared to control subjects. PAS values were significantly higher in the asthma group [24 (21-26) vs. 20 (18-22), p < 0.001], and TAPSE/PASP ratio was significantly lower in the asthma group versus the control group [0.81 ± 0.08 vs. 0.96 ± 0.11, p < 0.001]. Multilinear regression analysis revealed PAS, TAPSE, and PASP as independent predictors of TAPSE/PASP ratio.

CONCLUSION

Mild-to-moderate asthma was shown to be associated with both subclinical RV dysfunction and increased PAS values. TAPSE/PASP ratio was also markedly decreased, suggesting RV-PA uncoupling even in the absence of overt pulmonary hypertension. PAS referring RV afterload was shown to be an independent predictor of TAPSE/PASP ratio.

Utility of the tricuspid annular tissue doppler systolic velocity and pulmonary artery systolic pressure relationship in right ventricular systolic function assessment: A pilot study

BACKGROUND

Tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) ratio has been validated as a valuable noninvasive measure of right ventricular (RV) elastance and systolic function. However, the more reliable TA systolic (s') velocity measure of RV systolic function compared to TAPSE has not been previously studied.

METHODS

We conducted a pilot study using several variables of RV function in 50 patients with the main aim to determine which numerical expression between TA TDI s'/PASP and TAPSE/PASP ratio was most useful.

RESULTS

In a stepwise multiple regression analysis, TA TDI s'/PASP ratio (p < .0002); LVOT VTI/RVOT VTI ratio (p < .0002); RVOT VTI (p < .0047); TAPSE/PASP ratio (p < .0259) and TA TDI e' (p < .0292) were best in discriminating normal versus abnormal RV systolic function. Using receiver operator curve analysis, cut-off values for both TA TDI s'/PASP (>3.9 mm/c/mmHg) had 82.1% sensitivity and 77.3% specificity while the TAPSE/PASP (>.61 mm/mmHg) had 89.3% sensitivity and 68.2% specificity in identifying normal RV function in our studied population.

CONCLUSION

Our results indicate that TA TDI s'/PASP is a better mathematical expression when examining the relationship between RV contractility and RV resistance relationship. Furthermore, we also found that inclusion of RVOT VTI, RV diastolic properties, and left ventricular systolic function are important determinants of RV systolic function assessments and should be routinely included. Additional prospective studies are now needed to confirm these results using hemodynamic data.

Right ventricular strain related to pulmonary artery pressure predicts clinical outcome in patients with pulmonary arterial hypertension

Aims

In pulmonary arterial hypertension (PAH), the right ventricle (RV) is exposed to an increased afterload. In response, RV mechanics are altered. Markers which would relate RV function and afterload could therefore aid to understand this complex response system and could be of prognostic value. The aim of our study was to (i) assess the RV-arterial coupling using ratio between RV strain and systolic pulmonary artery pressure (sPAP), in patients with PAH, and (ii) investigate the prognostic value of this new parameter over other echocardiographic parameters.

Methods and results

Echocardiograms of 65 pre-capillary PAH patients (45 females, age 61 ± 15 years) were retrospectively analysed. Fractional area change (FAC), sPAP, tricuspid annular plane systolic excursion, and RV free-wall (FW) longitudinal strain (LS) were measured. A primary endpoint of death or heart/lung transplantation described clinical endpoint. Patients who reached a clinical endpoint had worse functional capacity (New York Heart Association), reduced RV function, and higher sPAP. Left ventricle function was similar in both groups. Only RVFW LS/sPAP ratio was found as an independent predictor of clinical endpoint in multivariable analysis (hazard ratio 8.3, 95% confidence interval 3.2–21.6, P &lt; 0.001). The RWFW LS/sPAP (cut-off 0.19) demonstrated a good accuracy for the prediction of reaching the clinical endpoint, with a sensitivity of 92% and specificity of 82.5%.

Conclusion

RVFW LS/sPAP ratio significantly predicts all-cause mortality and heart–lung transplantation, and was superior to other well-established parameters, in patients with pre-capillary PAH. We therefore propose RVFW LS/sPAP as a new prognostic echocardiographic marker.

Detection of early signs of right ventricular systolic impairment in unoperated Ebstein's anomaly by cardiac magnetic resonance feature tracking

BACKGROUND

Cardiovascular magnetic resonance feature-tracking analysis (CMR-FT) provides a quantitative assessment of myocardial contraction with potential for diagnostic and prognostic ability in a wide spectrum of diseases. Ebstein's anomaly (EA) is a rare congenital heart disease characterized by apical displacement of the tricuspid valve. However, it is also considered a disorder of development affecting the global right ventricular myocardium. Aim of our study is to describe the complex contractile mechanics of the functional right ventricle (RV) in patients affected by EA through CMR-FT.

METHODS

Fifty surgery-free EA patients who had undergone a complete CMR protocol at our institution between January 2017 and December 2020 were selected for the retrospective study. A historical control group of twenty-five healthy subjects was also included. CMR-FT analysis was performed at a dedicated workstation by manually tracing RV endo- end epicardial borders on steady-state-free-precession (SSFP) cine images. Strain values were calculated. Apical displacement of the tricuspid valve (TV) was measured on a 4-chamber cine image from the right atrio-ventricular junction to the functional annulus of the TV.

RESULTS

EA patients presented significantly impaired RV global radial strain (GRS) and global circumferential strain (GCS) compared to controls (P<0.0001 and P=0.0008, respectively). In a subgroup analysis, GRS was significantly compromised in patients with a severely displaced TV (>16 mm/m²) compared to milder forms (P=0.03) and to controls (P<0.0001). Among EA patients with a preserved ejection fraction, 12 (48%) vs. 6 (24%) controls had reduced both GRS and GCS.

CONCLUSIONS

The contractile pattern of the functional RV in EA is characterised by prevalent alterations in the short-axis direction as indicated by reduced GRS and GCS. Strain values might be reduced prior to routine used functional parameters like RV ejection fraction (RVEF) and can possibly serve as an early predictor of myocardial dysfunction in EA patients.

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.

Right ventricular free wall strain in acutely decompensated heart failure patients with ischemic and non-ischemic cardiomyopathy

AIMS

Right ventricular (RV) dysfunction is a predictor of adverse outcomes among patients with HF with reduced ejection fraction (HFrEF); however, differences in RV parameters in HFrEF patients with ischemic (ICM) and non-ischemic cardiomyopathies (NICM) are not well understood. We investigated echocardiographic characteristics, including RV strain, in patients with acute decompensated heart failure (ADHF) and compared patients with ICM and NICM etiology.

METHODS

Consecutive patients who presented with ADHF and NYHA class III-IV were prospectively enrolled if they had LVEF < 40% and history of ICM or NICM. All patients underwent clinical exam, laboratory evaluation and 2-D echocardiographic assessment of the left ventricular (LV) and RV function, LV and RV global longitudinal strain (LVGLS, RVGLS), and RV free wall strain (RVfwLS).

RESULTS

Of 84 patients, 44 had ICM and 40 NICM. The groups had similar blood pressure, NT-proBNP, and echocardiographic parameters of LV function including LVGLS. Absolute RVGLS values were lower than RVfwLS values in both groups. Patients with NICM had significantly lower RVfwLS, but not RVGLS, compared to patients with ICM (-13% to -17%, p = 0.006). Similar differences in RVfwLS were seen in patients in NYHA class III (NICM vs ICM: -13% and -17%, respectively, 95% CI: -8.5 to -.5) and NYHA class IV (NICM vs ICM: -13.8% and -17%, respectively, 95% CI: -6.4 to -.59).

CONCLUSION

Among patients hospitalized with ADHF, patients with nonischemic etiology compared with the patients with ICM, have more severe RV dysfunction measured by RVfwLS, despite similar extent of LV impairment and the same functional limitation class.

Right Ventricular Strain, Brain Natriuretic Peptide, and Mortality in Congenital Diaphragmatic Hernia

Rationale: Brain-type natriuretic peptide (BNP) correlates with pulmonary hypertension as demonstrated by echocardiogram in congenital diaphragmatic hernia (CDH); however, its association with right ventricular (RV) function and mortality is unknown.Objectives: To characterize the relationships between echocardiogram-derived RV strain, BNP, and mortality in diaphragmatic hernia.Methods: We performed a single-center retrospective cohort study of infants with CDH and at least one BNP-echocardiogram pair within a 24-hour period. RV global longitudinal strain (GLS) and free-wall strain (FWS) were measured on existing echocardiograms. Associations among strain, BNP, and mortality were tested using mixed-effect linear and logistic regression models. Survival analysis was stratified by BNP and strain abnormalities.Results: There were 220 infants with 460 BNP-echocardiogram pairs obtained preoperatively (n = 237), ≤1 week postoperatively (n = 35), and >1 week postoperatively ("recovery"; n = 188). Strain improved after repair (P < 0.0001 for all periods). Higher BNP level was associated with worse strain in recovery but not before or immediately after operation (estimate [95% confidence interval] for recovery: GLS, 1.03 [0.50-1.57]; P = 0.0003; FWS, 0.62 [0.01-1.22]; P = 0.047). BNP and strain abnormalities were associated with an extracorporeal-membrane oxygenation requirement. Higher BNP level in recovery was associated with greater mortality (odds ratio, 11.2 [1.2-571.3]; P = 0.02). Abnormal strain in recovery had high sensitivity for detection of mortality (100% for GLS; 100% for FWS) but had low specificity for detection of mortality (28% for GLS; 48% for FWS).Conclusions: Persistent RV dysfunction after CDH repair may be detected by a high BNP level and abnormal RV strain.

Age-changes in right ventricular function-pulmonary circulation coupling: from pediatric to adult stage in 1899 healthy subjects. The RIGHT Heart International NETwork (RIGHT-NET)

The present study analyzes age-specific changes in RV function and RV-PA coupling in a large cohort of apparently healthy subjects with a wide age-range, to identify reference values and to study the influence of clinical and echocardiographic cofactors. 1899 Consecutive healthy subjects underwent a standardized transthoracic echocardiographic examination. Tricuspid annular plane systolic excursion (TAPSE) and systolic pulmonary artery pressure (SPAP) were measured. Ventriculo-arterial coupling was then inferred from the TAPSE/SPAP ratio. A quantile regression analysis was used to estimate quantiles 0.05, 0.10, 0.50 (median), 0.90, and 0.95 of TAPSE, SPAP and TAPSE/SPAP. The association between age and each of these values was determined. The mean age of the group was 45.2 ± 18.5 years (range 1 to 102 years), 971 were males. SPAP increased with age, whereas TAPSE and TAPSE/SPAP ratio decreased. Upon multivariate modeling, the most significant positive associations for TAPSE were body surface area (BSA) driven by the pediatric group, stroke volume (SV), E/A and negatively heart rate and E/e' ratio. SPAP was positively associated with increasing age, SV, E/A, E/e' and negatively with BSA. TAPSE/SPAP ratio was negatively associated with age, female sex, and E/e' and positively with BSA. A preserved relationship between TAPSE and SPAP was found across the different age groups. TAPSE, SPAP and TAPSE/SPAP demonstrate important trends and associations with advancing age, impaired diastolic function, affected by female sex and BSA However the relationship between TAPSE and SPAP is relatively well preserved across the age spectrum.

Age- and Sex-Specific Changes in CMR Feature Tracking-Based Right Atrial and Ventricular Functional Parameters in Healthy Asians

Cardiovascular magnetic resonance (CMR) is the reference standard for non-invasive assessment of right-sided heart function. Recent advances in CMR post-processing facilitate quantification of tricuspid annular (TA) dynamics and longitudinal strains of the right ventricle (RV) and right atrium (RA). We aimed to determine age- and sex-specific changes in CMR-derived TA dynamics, and RV and RA functional parameters in healthy Asian adults. We studied 360 healthy subjects aged 21-79 years, with 30 men and 30 women in each of the six age groups. Functional parameters of RV and RA were measured on standard four-chamber cine CMR using fast feature tracking: (1) TA peak velocities (systolic velocity S', early diastolic velocity E', late diastolic velocity A') and TA plane systolic excursion (TAPSE); (2) RV global longitudinal strain (GLS) and strain rates; and (3) RA phasic longitudinal strains and strain rates. S' and TAPSE exhibited negative correlations with age. RV GLS was significantly higher in females than in males but not associated with age in both sexes. Females had similar E', lower A', and higher E'/A' ratios compared to males. Positive associations of E' and E'/A', and negative association of A' with age were observed in both sexes. Females had higher RA reservoir and conduit strains compared to males. There were significantly negative and positive associations between RA conduit and booster strains, respectively, with age. Age- and sex-specific reference ranges were established, and associations revealed, for fast CMR feature tracking parameters of right heart function in a large normal Asian population.

Strain generation and right ventricular systolic function: The sum of all its parts

BACKGROUND

Speckle-tracking echocardiography (STE) has provided a reliable means to enhance characterization and quantification of global right ventricular (RV) systolic function. The use of Automated Functional Imaging (AFI) software has been previously used to quantify RV longitudinal peak global strain (PGS) values during two-dimensional (2D) transthoracic echocardiographic examinations. However, there is a paucity of data regarding relative strain contribution of each individual regional segments when compared with global strain assessment. Consequently, our goal was to use AFI STE to examine the strain contribution of each regional segment when assessing RV function.

METHODS

A retrospective analysis was performed on 107 patients that met our study criteria to correlate 2D TTE measures of RV systolic function to both RV AFI STE longitudinal peak global strain (PGS) and each individual regional RV free wall (RVFw) and inter-ventricular septum (IS) strain values.

RESULTS

We found that TTE variables of RV systolic function only correlated with PGS (RVFAC; P < .0001, TAPSE; P < .0001, and TA TDI S'; P < .0001) but none of the six individual regional AFI strain values. When PGS was not included in the multivariate analysis, only the mid RVFw and mid IS strain regions correlated with measures of RV systolic function.

CONCLUSIONS

Regional differences do exist with regards to strain generation along the RVFw and IS. These differences could be physiologically and anatomically explained based on our current understanding of RV muscle fiber arrangement. Further research is now needed to better characterize RV function in different clinical entities.

Improving Right Ventricular Function by Increasing BMP Signaling with FK506

Right Ventricular (RV) function is the predominant determinant of survival in patients suffering from pulmonary arterial hypertension (PAH). In pre-clinical models, pharmacological activation of bone morphogenetic protein (BMP) signaling with FK506 (Tacrolimus) improved RV function by decreasing RV afterload. FK506 therapy further stabilized three end-stage PAH patients. Whether FK506 has direct effects on the pressure overloaded RV is yet unknown. We hypothesized that increasing cardiac BMP signaling with FK506 improves RV structure and function in a model of fixed RV afterload after pulmonary artery banding (PAB). Direct cardiac effects of FK506 on the microvasculature and RV fibrosis were studied after surgical PAB in wildtype and heterozygous Bmpr2 mutant mice. Right ventricular function and strain were assessed longitudinally via cardiac magnetic resonance (CMR) imaging during continuous FK506 infusion. Genetic lineage tracing of endothelial cells (ECs) was performed to assess the contribution of ECs to fibrosis. Molecular mechanistic studies were performed in human cardiac fibroblasts (hCFs) and endothelial cells. In mice, low BMP signaling in the RV exaggerated PAB-induced RV fibrosis. FK506 therapy restored cardiac BMP signaling, reduced RV fibrosis in a BMP-dependent manner independent from its immunosuppressive effect, preserved RV capillarization and improved RV function and strain over the time-course of disease. Endothelial mesenchymal transition was a rare event and did not significantly contribute to cardiac fibrosis after PAB. Mechanistically, FK506 required ALK1 in hCFs as BMPR2 co-receptor to reduce TGFβ1-induced proliferation and collagen production. Our study demonstrates that increasing cardiac BMP signaling with FK506 improves RV structure and function independent from its previously described beneficial effects on pulmonary vascular remodeling.

Feasibility, Reproducibility and Validation of Right Ventricular Volume and Function Assessment Using Three-Dimensional Echocardiography

Three-dimensional echocardiography (3DE) is advised for right ventricular (RV) assessment. Data regarding the optimal acquisition settings and optimization are still scarce. We aimed to evaluate the feasibility, reproducibility and validation of 3DE for RV volume and function assessment, using cardiac magnetic resonance (CMR) as gold standard. Thirty healthy volunteers and 36 consecutive patients were prospectively included. CMR was performed in the latter. Standard apical four-chamber view (A4CV), focused A4CV and modified A4CV were used for 3DE RV acquisition. Feasibility (and the effect of changes in settings) was evaluated. Intra and interobserver analyses were performed by three observers (expert vs. novice). RV parameters by echocardiography were compared to CMR. Feasibility of acquisition was 16.7% for A4CV, 80.0% for focused A4CV and 16.7% for modified A4CV. Changes in settings had no significant influence on feasibility and further analysis. Intraobserver variability was good in both expert and novice, interobserver variability was good between experienced observers. Compared to CMR, 3DE volumes were significantly lower with fair to moderate correlation (EDV: 91.1 ± 24.4 mL vs. 144.3 ± 43.0 mL (p < 0.001), r = 0.653 and ESV: 48.1 ± 16.4 mL vs. 60.4 ± 21.2 mL (p < 0.001), r = 0.530, by multi-beat 3DE and CMR respectively). These findings suggest that standardization is needed in order to implement this technique in clinical practice, thus further studies are required.

Prognostic implications of cardiac damage classification based on computed tomography in severe aortic stenosis

AIMS

An echocardiographic staging system of severe aortic stenosis (AS) based on additional extra-valvular cardiac damage has been associated with prognosis after transcatheter aortic valve implantation (TAVI). Multidetector row computed tomography (MDCT) is key in the evaluation of AS patients undergoing TAVI and can potentially detect extra-valvular cardiac damage. This study aimed at evaluating the prognostic implications of an MDCT staging system of severe AS in patients undergoing TAVI.

METHODS AND RESULTS

A total of 405 patients (80 ± 7 years, 52% men) who underwent full-beat MDCT prior to TAVI were included. The extent of cardiac damage was assessed by MDCT and classified in five categories; Stage 0 (no cardiac damage), Stage 1 (left ventricular damage), Stage 2 (left atrium and mitral valve damage), Stage 3 (right atrial damage), and Stage 4 (right ventricular damage). Twenty-seven (7%) patients were stratified as Stage 0, 96 (24%) as Stage 1, 152 (38%) as Stage 2, 78 (19%) as Stage 3, and 52 (13%) as Stage 4. During a median follow-up of 3.7 (IQR 1.7-5.5) years, 150 (37%) died. On multivariable Cox regression analysis, cardiac damage Stage 3 (HR vs. Stage 0: 4.496, P = 0.039) and Stage 4 (HR vs. Stage 0: 5.565, P = 0.020) were independently associated with all-cause mortality.

CONCLUSION

The MDCT-based staging system of cardiac damage in severe AS effectively identifies the patients who are at higher risk of death after TAVI.

Performance of the right ventricular outflow tract/aortic diameter as a novel predictor of risk in patients with acute pulmonary embolism

Right ventricular (RV) enlargement, determined via the ratio of the right to left ventricular diameters (RV/LV) by CT imaging is used to classify the severity of acute pulmonary embolism (PE) and impacts treatment decisions. The RV/LV ratio may be an unreliable marker of RV dysfunction, due in part to the complex RV geometry. This study compared the RV/LV ratio to a novel metric, the ratio of the right ventricular to aortic outflow tract diameters (RVOT/Ao) in patients with acute PE treated with catheter-directed therapies (CDT). RVOT/Ao and RV/LV ratios were measured on CT images from 103 patients who received CDT for acute submassive or massive PE and were compared to RV dysfunction severity determined by transthoracic echocardiography. Ratios and biomarkers on admission were assessed for correlation with invasively-measured hemodynamics [right atrial (RA) pressure, mean pulmonary artery (PA) pressure, cardiac output (CO)]. RVOT/Ao but not RV/LV ratios were increased in patients with moderate or severe RV dysfunction compared to those without RV dysfunction (p < 0.05). Neither ratio showed significant correlation with RA (r = 0.09 vs 0.055, p > 0.05), mean PA pressure (r = 0.167 vs 0.146, p > 0.05), or CO (r = 0.021 vs - 0.183, p > 0.05). proBNP correlated with mean PA pressure (r = 0.377, p < 0.05). The RVOT/Ao ratio may be better at assessing RV dysfunction than the RV/LV ratio in patients presenting with acute PE. Although currently accepted protocols rely on the RV/LV ratio in determining when CDT are of benefit, the RVOT/Ao ratio may be a more useful tool in identifying high risk patients.

Cardiovascular magnetic resonance-assessed fast global longitudinal strain parameters add diagnostic and prognostic insights in right ventricular volume and pressure loading disease conditions

BACKGROUND

Parameters of myocardial deformation may provide improved insights into right ventricular (RV) dysfunction. We quantified RV longitudinal myocardial function using a fast, semi-automated method and investigated its diagnostic and prognostic values in patients with repaired tetralogy of Fallot (rTOF) and pulmonary arterial hypertension (PAH), who respectively exemplify patients with RV volume and pressure overload conditions.

METHODS

The study enrolled 150 patients (rTOF, n = 75; PAH, n = 75) and 75 healthy controls. RV parameters of interest were fast global longitudinal strain (GLS) and strain rates during systole (GLSRs), early diastole (GLSRe) and late diastole (GLSRa), obtained by tracking the distance from the medial and lateral tricuspid valve insertions to the RV epicardial apex on cine cardiovascular magnetic resonance (CMR).

RESULTS

The RV fast GLS exhibited good agreement with strain values obtained by conventional feature tracking approach (bias - 4.9%, error limits (± 2·standard deviation) ± 4.3%) with fast GLS achieving greater reproducibility and requiring reduced analysis time. Mean RV fast GLS was reduced in PAH and rTOF groups compared to healthy controls (PAH < rTOF < healthy controls: 15.1 ± 4.9 < 19.3 ± 2.4 < 24.4 ± 3.0%, all P < 0.001 in pairwise comparisons). In rTOF patients, RV fast GLS was significantly associated with metabolic equivalents, peak oxygen consumption (PVO2) and percentage of predicted PVO2 achieved during cardiopulmonary exercise testing. Lower RV fast GLS was associated with subnormal exercise capacity in rTOF (area under the curve (AUC) = 0.822, sensitivity = 72%, specificity = 91%, cut-off = 19.3%). In PAH patients, reduced RV fast GLS was associated with RV decompensated hemodynamics (AUC = 0.717, sensitivity = 75%, specificity = 58%, cut-off = 14.6%) and higher risk of clinical worsening (AUC = 0.808, sensitivity = 79%, specificity = 70 %, cut-off = 16.0%).

CONCLUSIONS

Quantitative RV fast strain and strain rate parameters assessed from CMR identify abnormalities of RV function in rTOF and PAH and are predictive of exercise capacity, RV decompensation and clinical risks in these patients. Trial registry Clinicaltrials.gov: NCT03217240.

Comparison of the Usefulness of Strain Imaging by Echocardiography Versus Computed Tomography to Detect Right Ventricular Systolic Dysfunction in Patients With Significant Secondary Tricuspid Regurgitation

Assessment of right ventricular (RV) systolic function in patients with significant secondary tricuspid regurgitation (STR) remains challenging. In patients with severe aortic stenosis treated with transcatheter aortic valve implantation (TAVI), STR and RV enlargement have been associated with poor outcomes. In these patients, speckle tracking echocardiography (STE) may detect RV systolic dysfunction better than 3-dimensional (3D) RV ejection fraction (EF). The purpose of this study was to investigate the prevalence of RV dysfunction when assessed with STE in patients with significant STR (≥3+) compared with patients without significant STR (<3+) matched for 3D RV dimensions and RVEF on dynamic computed tomography (CT). Patients with dynamic CT data before TAVI were evaluated retrospectively. To assess the performance of RV-free wall strain (RVFWS) for identifying patients with impaired RV systolic function, patients were subsequently matched 1:1 based on age, gender, indexed RV end-diastolic volume (RVEDVi), indexed RV end-systolic volume (RVESVi), RVEF, and left ventricular ejection fraction (LVEF). In a total 267 patients (80 ± 8 years, 48% male), significant STR (≥3+) was observed in 67 patients. Patients with STR≥3+ had larger RVEDVi, larger RVESVi, lower LVEF, and more impaired RVFWS compared with patients with STR<3+ (n = 200). After propensity score matching, patients with STR≥3+ (n = 53) had significantly more impaired RVFWS compared with patients with STR<3+ (n = 53): -18.2 ± 5.0% versus -21.1 ± 3.7%, p = 0.001. In conclusion, patients with significant STR have more pronounced RV systolic dysfunction as assessed with STE than the patients without significant STR despite having similar 3D RV dimensions and RVEF on dynamic CT.

Cardiac resynchronization therapy for the failing systemic right ventricle: A systematic review

Patients with a systemic right ventricle (SRV) are at high risk for development of heart failure early in life. An SRV is encountered in patients with congenitally corrected transposition of the great arteries (CCTGA) or dextro-transposition of the great arteries (DTGA) with previous atrial switch repair (Mustard or Senning procedure). Progressive heart failure is one of the leading cause of mortality in these patients. Therefore, cardiac resynchronization therapy (CRT) has gained increasing momentum for use in this challenging congenital heart disease (CHD) population. However, current guidelines differ in recommendations for CRT in patients with an SRV as evidence supporting CRT has thus far only been described in case reports and retrospectively in relatively small study populations. In fact, the European Society of Cardiology Guideline for the management of grown-up congenital heart disease consider CRT to be 'experimental' in this population. This systematic review critically summarizes current literature on CRT in SRV patients and provides future perspectives for further research in this challenging and growing CHD population.

Review: Contrast-enhanced magnetic resonance in the diagnosis and management of cardiac sarcoidosis

Sarcoidosis is a relatively rare inflammatory condition which potentially carries high morbidity and substantial mortality. Due to the fact that it does not subject patients to ionizing radiation, has high temporal, spatial and contrast resolutions, cardiovascular magnetic resonance imaging (CMR) has become an important diagnostic and prognostic modality in the evaluation for cardiac involvement in this condition. This review provides relevant clinical and pathophysiological background on cardiac sarcoidosis, whilst detailing the role of CMR imaging in the diagnosis, and management of this condition.

Right ventricular involvement is an important prognostic factor and risk stratification tool in suspected cardiac sarcoidosis: analysis by cardiac magnetic resonance imaging

BACKGROUND

Late gadolinium enhancement imaging (LGE) of the left ventricle (LV) by cardiac magnetic resonance (CMR) has prognostic value for patients with cardiac sarcoidosis (CS). Right ventricle (RV) dysfunction is also associated with adverse outcomes in patients with heart failure. Therefore, we sought to determine if RV LGE and dysfunction predicted adverse events in patients with suspected CS.

METHODS

In 103 consecutive patients with suspected CS who underwent CMR, functional and remodeling indexes of both the LV and RV were measured and the extent and localization of LGE were also analyzed. Major adverse cardiac events (MACE) were defined as cardiovascular mortality, severe ventricular tachyarrhythmia, hospitalization with heart failure, and advanced atrioventricular block.

RESULTS

During a median follow-up of 20.6 months, Kaplan-Meier analysis showed that decreased RV ejection fraction (EF) was associated with MACE (P < 0.001) and receiver operating characteristics curve (ROC) analysis indicated good predictive performance of RV EF for MACE (area under the ROC = 0.834). RV EF operated independently of LV EF or LGE extent for predicting MACE. In addition, the presence of LGE in RV was independently associated with MACE (P = 0.011), and a combined analysis of RV EF and RV LGE showed better risk stratification for MACE (P < 0.001).

CONCLUSIONS

Both RV EF and LGE were independently associated with MACE and enhanced risk stratification in patients with suspected CS. CMR may be a useful tool for detecting myocardial function and fibrosis in both the LV and RV.

Fusion of 3D real-time echocardiography and cine MRI using a saliency analysis

PURPOSE

This paper presents a novel 3D multimodal registration strategy to fuse 3D real-time echocardiography images with cardiac cine MRI images. This alignment is performed in a saliency space, which is designed to maximize similarity between the two imaging modalities. This fusion improves the quality of the available information.

METHODS

The method performs in two steps: temporal and spatial registrations. A temporal alignment is firstly achieved by nonlinearly matching pairs of correspondences between the two modalities using a dynamic time warping. A temporal registration is then carried out by applying nonrigid transformations in a common saliency space where normalized cross correlation between temporal pairs of salient volumes is maximized.

RESULTS

The alignment performance was evaluated with a set of 18 subjects, 3 with cardiomyopathies and 15 healthy, by computing the Dice score and Hausdorff distance with respect to manual delineations of the left ventricle cavity in both modalities. A Dice score and Hausdorff distance of [Formula: see text] and [Formula: see text], respectively, were obtained. In addition, the deformation field was estimated by quantifying its foldings, obtaining a 98% of regularity in the deformation field.

CONCLUSIONS

The 3D multimodal registration strategy presented is performed in a saliency space. Unlike state-of-the-art methods, the presented one takes advantage of the temporal information of the heart to construct this common space, ending up with two well-aligned modalities and regular deformation fields. This preliminary study was evaluated on heterogeneous data composed of two different datasets, healthy and pathological cases, showing similar performances in both cases. Future work will focus on testing the presented strategy in a larger dataset with a balanced number of classes.

Right Ventricular Failure: Pathophysiology, Diagnosis and Treatment

The prognostic significance of the right ventricle (RV) has recently been recognised in several conditions, primarily those involving the left ventricle, the lungs and their vascular bed, or the right-sided chambers. Recent advances in imaging techniques have created new opportunities to study RV anatomy, physiology and pathophysiology, and contemporary research efforts have opened the doors to new treatment possibilities. Nevertheless, the treatment of RV failure remains challenging. Optimal management should consider the anatomical and physiological particularities of the RV and include appropriate imaging techniques to understand the underlying pathophysiological mechanisms. Treatment should include rapid optimisation of volume status, restoration of perfusion pressure and improvement of myocardial contractility and rhythm, and, in case of refractory RV failure, mechanical circulatory support.

Cardiovascular Magnetic Resonance-Based Three-Dimensional Structural Modeling and Heterogeneous Tissue Channel Detection in Ventricular Arrhythmia

Geometrical structure of the myocardium plays an important role in understanding the generation of arrhythmias. In particular, a heterogeneous tissue (HT) channel defined in cardiovascular magnetic resonance (CMR) has been suggested to correlate with conduction channels defined in electroanatomic mapping in ventricular tachycardia (VT). Despite the potential of CMR for characterization of the arrhythmogenic substrate, there is currently no standard approach to identify potential conduction channels. Therefore, we sought to develop a workflow to identify HT channel based on the structural 3D modeling of the viable myocardium within areas of dense scar. We focus on macro-level HT channel detection in this work. The proposed technique was tested in high-resolution ex-vivo CMR images in 20 post-infarct swine models who underwent an electrophysiology study for VT inducibility. HT channel was detected in 15 animals with inducible VT, whereas it was only detected in 1 out of 5 animal with non-inducible VT (P < 0.01, Fisher’s exact test). The HT channel detected in the non-inducible animal was shorter than those detected in animals with inducible VTs (inducible-VT animals: 35 ± 14 mm vs. non-inducible VT animal: 9.94 mm). Electrophysiology study and histopathological analyses validated the detected HT channels. The proposed technique may provide new insights for understanding the macro-level VT mechanism.

Right ventricular total isovolumic time: Reference value study

BACKGROUND

There is lack of noninvasive indices to detail the right side cardiovascular physiology. Total isovolumic time (tIVT) is a sensitive marker of left ventricular electromechanical efficiency and systolic-diastolic interaction. The aim of the study was to evaluate normal reference value of the right ventricular tIVT with increasing age.

METHODS AND RESULTS

One hundred and eighty-one healthy volunteers (51% male) underwent transthoracic echocardiography. The population was divided into four categories according to age: A < 30 years; B 30-39 years; C 40-49 years; and C ≥ 50 years old. tIVT was computed in seconds/minutes as: 60 - (tET + tFT). tET and tFT are the total ejection and filling time adjusted by the heart rate, measured, respectively, from the onset to the end of the right ventricle (RV) forward flow through the pulmonary valve and from the onset of the E-wave and the end of the A-wave at the level of the tricuspid valve. The mean RV tIVT was 7 ± 1.1 s/min and increased significantly with age, from a 3.4 to 9.7 s/min(P < 0.0001). Significant correlation was found between tIVT and trans-tricuspid E/E' (P < 0.0001; 0.78 (95% CI: 0.715-0.831) while weaker between tIVT and E/A (P = 0.001; -0.283 95% CI: -0.413 to -0.143).

CONCLUSION

The normal values of RV tIVT increase with age and correlate significantly with Doppler diastolic parameters.

The Association between the Pulmonary Arterial Obstruction Index and Atrial Size in Patients with Acute Pulmonary Embolism

Purpose

Pulmonary embolism (PE) is a common and potentially fatal form of venous thromboembolism. The aim of this study is to investigate the association between the pulmonary arterial obstruction index and atrial size in patients with acute pulmonary embolism.

Basic Procedure

The study consisted of 86 patients with clinical symptoms of PE. Out of 86 individuals, 50 patients were diagnosed with PE and considered as the patient group. The others were considered as the control group. All patients were scanned by a multidetector CT scanner. Using the radiology workstation, an expert radiologist calculated the left atrium (LA) and right atrium (RA) areas from planimetric measurements obtained from free-hand delineation of the atrial boarders using an electronic pen. Quantitative volumetric measurements of LA and RA were obtained from original axial images.

Main Findings

There were 25 males and 25 females with PE, who had a mean age of 58 years. There was not a significant difference in the positive history of diabetes mellitus, hypertension, asthma, chronic obstructive pulmonary diseases, ischemic heart disease, and smoking between patients and control group. There was a significant negative correlation between almost all LA measurements and the PAOI. RA area and volume had the highest area under the curves for recognizing larger clot burden.

Principal Conclusions

A higher clot load is associated with a smaller LA size and increased RA/LA ratios, measured with CTPA. Atrial measurements are correlated with POAI, and they could be used as sensitive parameters in predicting heart failure in patients with PE.

A Primer on Multimodal Imaging and Cardiology-Radiology Congenital Heart Interface

Pediatric cardiology imaging laboratories in the present day have several modalities for imaging of congenital and acquired cardiovascular disease. These modalities include echocardiography, cardiovascular magnetic resonance imaging, cardiac computed tomography and nuclear imaging. The utility and limitations of multimodal imaging is described herein along with a framework for establishing a cardiology-radiology interface.

Right and Left Ventricular Strain Patterns After the Atrial Switch Operation for D-Transposition of the Great Arteries-A Magnetic Resonance Feature Tracking Study

Introduction: Adult survivors of the atrial switch operation for transposition of the great arteries present with a systemic morphologic right ventricle and a subpulmonary morphologic left ventricle. This physiology can be considered a model for the effects of long-term right ventricular pressure overload and of decreased left ventricular afterload. We aimed to determine the impact of these chronically altered loading conditions on myocardial deformation of the ventricles.

Materials and methods: Two-dimensional steady state free precession cine images of 29 patients after atrial repair (age 29 ± 7 years) and 19 controls (24 ± 10 years; n.s.) were post-processed with feature tracking software (TomTec 2D CPA). Volumes, ejection fractions, global and free wall longitudinal and circumferential strains of both ventricles were compared between both groups.

Results: Systemic right ventricular global longitudinal strain was decreased in patients compared to controls (−12.9 ± 3.3% vs. −18.9 ± 4.6%, p < 0.001), while right ventricular circumferential strain was unchanged (−15.8 ± 3.4% vs. −15.1 ± 5%; n.s.). Left ventricular longitudinal strain was similar in both groups (−17 ± 5.6% vs. −17.5 ± 4.6%; n.s.), but global left ventricular circumferential strain was lower in patients (−20.7 ± 4.1% vs. −27.3 ± 4.5%, p < 0.001). The systemic right ventricle, compared to the systemic left ventricle, showed decreased global longitudinal (p < 0.001) and circumferential strain (p < 0.001). The subpulmonary left ventricle, compared to the subpulmonary right ventricle, demonstrated similar longitudinal (p = 0.223) but higher circumferential strain (p < 0.001).

Conclusions: In patients after atrial switch repair for transposition of the great arteries, the systemic right ventricle shows poor longitudinal strain, but maintains normal right ventricular circumferential strain. The left ventricle shows higher circumferential strain than the right ventricle, in both systemic and subpulmonary positions.

Sex-specific echocardiographic reference values: the women's point of view

: Clinical presentation, diagnosis and outcomes of cardiac diseases are influenced by the activity of sex steroid hormones. These hormonal differences explain the later development of heart diseases in women in comparison with men and the different clinical picture, management and prognosis. Echocardiography is a noninvasive and easily available technique for the analysis of cardiac structure and function. The aim of the present review is to underline the most important echocardiographic differences between sexes. Several echocardiographic studies have found differences in healthy populations between women and men. Sex-specific difference of some of these parameters, such as left ventricular (LV) linear dimensions and left atrial volume, can be explained on the grounds of smaller body size of women, but other parameters (LV volumes, stroke volume and ejection fraction, right ventricular size and systolic function) are specifically lower in women, even after adjusting for body size and age. Sex-specific differences of standard Doppler and Tissue Doppler diastolic indices remain controversial, but it is likely for aging to affect LV diastolic function more in women than in men. Global longitudinal strain appears to be higher in women during the childbearing age - a finding that also highlights a possible hormonal influence in women. All these findings have practical implications, and sex-specific reference values are necessary for the majority of echocardiographic parameters in order to distinguish normalcy from disease. Careful attention on specific cut-off points in women could avoid misinterpretation, inappropriate management and delayed treatment of cardiac diseases such as valvular disease and heart failure.

Detection and quantitation of right ventricular reversible perfusion defects by stress SPECT myocardial perfusion imaging: A proof-of-principle study

BACKGROUND

In patients with right dominant coronary circulation, the right ventricular (RV) myocardium and the inferior region of the left ventricular (LV) myocardium share a common source of blood flow. We hypothesized that stress/rest SPECT myocardial perfusion imaging (MPI) could detect reversible perfusion defects in the RV in some patients with LV inferior wall perfusion abnormalities.

MATERIAL AND METHODS

We identified 2 groups of patients with LV inferior wall perfusion defects (with or without defects in other regions of LV myocardium) from our database. Patients in group 1 (n = 17) had reversible perfusion defects in the RV free wall by visual analysis, while patients in group 2 (n = 17) did not. The images were processed with filtered back projection and, separately, with iterative reconstruction. The images were then re-processed using an automated quantitative software that is specifically designed to include the RV in the region of interest.

RESULTS

There were 76% men in group 1 and 94% in group 2 (P <0.05). The mean age was 65±20 in group 1 vs. 63±18 years in group 2 (P < 0.05). The stress type was exercise in 30% in group 1 and 35% in group 2, with the remaining patients studied with pharmacological stress testing (P = NS). The presence of RV reversible perfusion defects using filtered back projection was more evident in 13 patients (75%), while it was better seen with iterative reconstruction in 4 patients (25%). By automated analysis, the RV reversible perfusion defect size was 19 ± 14% of RV myocardium.

CONCLUSION

This proof-of-principle study demonstrates that reversible RV perfusion defects suggestive of ischemia can be detected by SPECT myocardial perfusion imaging in some patients with LV inferior ischemia by visual analysis and can be quantitated by automated programs. Further studies on the diagnostic and prognostic relevance of assessing RV ischemia on SPECT MPI are needed.

Right ventricular basal inflow and outflow tract diameters overestimate right ventricular size in subjects with sigmoid-shaped interventricular septum: a study using three-dimensional echocardiography

Sigmoid-shaped ventricular septum (SS), a frequently encountered minor abnormality in echocardiographic examinations of the elderly, may have some influence on RV shape. We aimed to determine the influence of SS on the accuracy of the 6 RV linear diameter measurements in the light of three-dimensional echocardiographic (3DE) RV volume. The aorto-septal angle (ASA) was measured in the parasternal long-axis view using two-dimensional echocardiography (2DE) as an index of SS in 70 patients without major cardiac abnormalities who were subdivided into 35 with SS (ASA ≤ 120°) and 35 without SS (NSS). We measured RV end-diastolic volume (RVEDV) using 3DE; in addition, using 2DE, we measured basal RV diameter, mid-cavity diameter, longitudinal diameter and end-diastolic area in the apical four-chamber view; proximal RV outflow tract (RVOT) diameter in the parasternal long-axis view; and proximal and distal RVOT diameters in the parasternal short-axis view. RVEDV did not differ between the SS and NSS groups. The SS group had greater basal RV diameter and proximal and distal RVOT diameters than the NSS group. RV mid-cavity diameter, longitudinal diameter, and end-diastolic area did not differ between the groups. Among the 2DE parameters of RV size, RV end-diastolic area was most strongly correlated with RVEDV (r = 0.67), followed by RV mid-cavity diameter (r = 0.58). When SS is present, the echocardiographic basal RV diameter and RVOT diameters overestimate RV size, and the measurement of RV end-diastolic area and mid-cavity diameter more correctly reflect 3D RV volume.

The Utility of Eccentricity Index as a Measure of the Right Ventricular Function in a Lung Resection Cohort

Context

Right ventricular (RV) dysfunction occurs after lung resection and is associated with postoperative morbidity. Noninvasive evaluation of the RV is challenging, particularly in the postoperative period. A reliable measure of RV function would have value in this population.

Aims

This study compares eccentricity index (EI) obtained by transthoracic echocardiography (TTE) with cardiovascular magnetic resonance (CMR) determined measures of RV function in a lung resection cohort. CMR is the reference method for noninvasive assessment of RV function.

Design and Setting

Prospective observational cohort study at a single tertiary hospital.

Materials and Methods

Twenty-eight patients scheduled for elective lung resection underwent contemporaneous TTE and CMR imaging preoperatively, on postoperative day (POD) 2 and at 2-month. Systolic and diastolic EI was measured offline from anonymized and randomized TTE and CMR images.

Statistical Analysis

Bland-Altman analysis was performed to determine agreement between EI^TTE and EI^CMR. Changes over time and comparison with CMR determined RV ejection fraction (RVEF^CMR) was assessed.

Results

Bland-Altman analysis showed a negligible mean difference between EI^TTE and EI^CMR, but limits of agreement were wide (SD 0.24 and 0.28). There were no significant changes in EI^TTE and EI^CMR over time (P > 0.35). We found no association between EI^TTE with RVEF^CMR at all-time points (P > 0.22). Systolic and diastolic EI^CMR on POD 2 demonstrated moderate association with RVEF^CMR (r = -0.54 and r = -0.59, P ≤ 0.01). At 2-month, only diastolic EI^CMR correlated with RVEF^CMR (r = -0.43, P = 0.03). There were no meaningful associations between EI^TTE and EI^CMR with TTE-derived RV systolic pressure (P > 0.31).

Conclusions

TTE determined EI is not useful as a noninvasive method of assessing RV function following lung resection.

B-type Natriuretic Peptide as a Marker of Different Forms of Systemic Sclerosis

BACKGROUND

Systemic sclerosis (SSc) is an autoimmune connective tissue disease which affects various tissues and organs, including skin, lungs, kidneys, gastrointestinal tract and cardiovascular system. Cardiac involvement is the most commonly recognized problem and a significant cause of morbidity. The brain natriuretic peptide (BNP) is a previously known marker of elevated cardiovascular risk in SSc, but the levels of BNP in various forms of SSc have not been investigated so far.

AIM

The aim of our study was to evaluate the influence of SSc on the function of the right ventricle and the right atrium using the echocardiographic parameters. Moreover, we examined the levels of BNP in different forms of SSc as well as the association of disease severity with the plasma concentrations of BNP.

METHODS

We included 42 patients with newly diagnosed SSc and patients whose disease had been diagnosed earlier. SSc patients and non-SSc control patients were examined by using echocardiography and the concentrations of BNP were determined.

RESULTS

We analyzed differences in the parameters of right ventricle (RV) function and right atrium (RA) function between SSc patients and healthy controls. The two groups had similar distribution of gender, but SSc patients were significantly older than controls. RV wall thickness was increased in SSc patients (p<0.001), while right ventricular end-systolic area (RVESA; p=0.408) and right ventricular end-diastolic area (RVEDA; p=0.368) did not differ among the examinees. In contrast, RA minor-axis dimension (p=0.001) and the tricuspid annular plane systolic excursion (TAPSE) (p=0.001) were significantly higher in SSc patients. Also, we analyzed differences in brain natriuretic peptide (BNP) concentrations between diffuse cutaneous systemic sclerosis (DSSc) and limited cutaneous systemic sclerosis (LSSc) patients. DSSc patients had significantly higher concentrations of BNP. We found that levels of BNP were in significant positive correlations with age (p=0.007), disease duration (p=0.023), C reactive protein (CRP) (p=0.032), right ventricle fractional area change (FAC) (p=0.022), pulmonary vascular resistance (PVR) and Rodnan score (p=0.019).

CONCLUSIONS

Given the obtained results, the laboratory determination of BNP could be useful in differentiating different forms of systemic sclerosis as well as in predicting the severity of the disease and future cardiovascular complications.

Prognostic value of echocardiographic parameters in pediatric patients with Ebstein's anomaly

BACKGROUND

Accurate risk stratification of patients with Ebstein's anomaly (EA) is crucial. Aim of the study was to assess the prognostic value of echocardiography, including 2D speckle tracking (STE) derived myocardial deformation indices, for predicting outcome in pediatric and young adult unrepaired EA patients.

METHODS

Fifty consecutive EA patients (1 day-18 years, 52% males) underwent echocardiography and were followed for a mean follow-up of 60 ± 41 months for clinical outcome (ventricular tachyarrhythmia, heart failure, need for surgery and/or death). Clinical and instrumental features of EA patients with stable disease were compared with those of EA patients with progressive disease.

RESULTS

Twenty-four (48%) EA patients had progressive disease. A more severe grade of tricuspid valve (TV) displacement [59.7 mm/m² (IQR 27.5-83) vs 28.4 mm/m² (IQR 17.5-47); p = 0.002], a lower functional right ventricle (RV) fractional area change (FAC) (29.2 ± 7.7% vs 36.7 ± 9.6%; p = 0.004), a higher Celermajer index [0.8 (IQR 0.7-0.98) vs 0.55 (IQR 0.4-0.7); p = 0.000], a lower functional RV-longitudinal strain (-10.2 ± 6.2% vs -16.2 ± 7.3%; p = 0.003) and a lower right atrium peak systolic strain (RA-PALS) (25.2 ± 13.5% vs 36.3 ± 12.5%; p = 0.004) were detected in progressive disease group compared to stable one, respectively. Functional RV-FAC and RA-PALS were independent predictors of progressive disease at multivariate analysis.

CONCLUSION

Our study demonstrated for the first time the prognostic role of RV-FAC and RA-PALS in a long-term follow-up of EA young patients. A complete echocardiographic evaluation should be regular part in the evaluation and risk-stratification of EA children.

Right ventricular end-systolic area as a simple first-line marker predicting right ventricular enlargement and decreased systolic function in children referred for cardiac magnetic resonance imaging

AIM

To assess the accuracy of simple cardiovascular magnetic resonance imaging (CMR) parameters for first-line analysis of right ventricle (RV) dysfunction in children to identify those who require in-depth analysis and those in whom simple assessment is sufficient.

MATERIALS AND METHODS

Sixty paediatric CMR studies were analysed. The following CMR parameters were measured: RV end-diastolic and end-systolic area (4CH EDA and 4CH ESA), fractional area change (FAC), RV diameter in end-diastole (RVD1), tricuspid annular plane systolic excursion (TAPSE), and RV outflow tract diameter in end-diastole (RVOT prox). They were correlated with RV end-diastolic volume (RVEDVI) and RV ejection fraction (RVEF).

RESULTS

RVEDVI correlated best with 4CH ESA (r=0.85, <0.001) and EDA (r=0.82, <0.001). For RVEF only a moderate reverse correlation was found for 4CH ESA (-0.56, <0.001), 4CH EDA (-0.49, 0.001) and positive correlation for FAC (0.49, <0.001). There was no correlation between TAPSE and RVEF and only weak between RVD1 and RVEDVI. A 4CH ESA cut-off value of 8.5 cm²/m² had a very high diagnostic accuracy for predicting an enlarged RV (AUC=0.912, p<0.001, sensitivity 92.3%, specificity 79%) and a cut-off value of 10.5 cm²/m² was also a good predictor of depressed RV systolic function (AUC=0.873, p<0.001, sensitivity 83%, specificity 89%).

CONCLUSION

For routine screening in clinical practice, 4CH ESA seems a reliable and easy method to identify patients with RV dysfunction.

Are objective measures of tricuspid annular motion and velocity used as frequently as recommended by current guidelines? A pilot study

In this retrospective study 420 echocardiograms from a single center were reviewed showing that TAPSE was acquired in 66% while TA TDI s’ signals were recorded in 98% of all echocardiograms. Based on these results greater efforts are required to standardize acquisition and reporting of objective measurements of RV function.

Echocardiographic Evaluation of Ventricular Function-For the Neonatologist and Pediatric Intensivist

In the neonatal and pediatric intensive care setting, bedside cardiac ultrasound is often used to assess ventricular dimensions and function. Depending upon the underlying disease process, it is necessary to be able to evaluate the systolic and diastolic function of left and or right ventricles. The systolic function of left ventricle is mostly assessed qualitatively on visual inspection "eye-balling" and quantitatively by measuring circumferential fraction shortening or calculating the ejection fraction by Simpson's planimetry. The assessment of left ventricular diastolic function relies essentially on the mitral valve and pulmonary venous Doppler tracings or tissue Doppler evaluation. The right ventricular particular shape and anatomical position does not permit to use the same parameters for measuring systolic function as is used for the LV. Tricuspid annular plane systolic excursion (TAPSE) and S' velocity on tissue Doppler imaging are more often used for quantitative assessment of right ventricle systolic function. Several parameters proposed to assess right ventricle systolic function such as fractional area change, 3D echocardiography, speckle tracking, and strain rate are being researched and normal values for children are being established. Diastolic function of right ventricle is evaluated by tricuspid valve and hepatic venous Doppler tracings or on tissue Doppler evaluation. The normal values for children are pretty similar to adults while normal values for the neonates, especially preterm infants, may differ significantly from adult population. The normal values for most of the parameters used to assess cardiac function in term neonates and children have now been established.

Risk factors associated with perioperative morbidity and mortality following isolated tricuspid valve replacement

BACKGROUND

Reports of isolated tricuspid valve replacement (iTVR) are relatively rare. The present study aimed to evaluate independent risk factors of perioperative morbidity and mortality after iTVR.

MATERIALS AND METHODS

We retrospectively reviewed 118 consecutive patients (42 males; mean age, 49.1 ± 12.9 y) who underwent iTVR from May 2003 to April 2016 in our center. The multivariate logistic regression model was used to analyze the independent risk factors associated with perioperative morbidity and mortality following iTVR.

RESULTS

One hundred one patients (85.6%) were classified as New York Heart Association functional class III or IV preoperatively. The overall perioperative mortality was 11.8% (14/118), and a significant difference was observed between the nonreoperative group and the reoperative group (6.7% versus 18.3%, P = 0.047). The multivariate logistic regression analyses identified that preoperative New York Heart Association functional class IV (OR [odds ratio] = 15.43, 95% CI [confidence interval] = 3.46-68.83, P = 0.000) and ascites (OR = 4.88, 95% CI = 1.24-19.27, P = 0.024) were independent risk factors of perioperative deaths. The previous cardiac surgery (OR = 3.28, 95% CI = 1.41-7.62, P = 0.006) was independently associated with perioperative major adverse events.

CONCLUSIONS

The present study revealed that iTVR has relatively high mortality and morbidity rates. Timely surgery may be recommended for this high-risk cohort of patients before the development of severe heart and end-organ failure.

Automated localization and segmentation techniques for B-mode ultrasound images: A review

B-mode ultrasound imaging is used extensively in medicine. Hence, there is a need to have efficient segmentation tools to aid in computer-aided diagnosis, image-guided interventions, and therapy. This paper presents a comprehensive review on automated localization and segmentation techniques for B-mode ultrasound images. The paper first describes the general characteristics of B-mode ultrasound images. Then insight on the localization and segmentation of tissues is provided, both in the case in which the organ/tissue localization provides the final segmentation and in the case in which a two-step segmentation process is needed, due to the desired boundaries being too fine to locate from within the entire ultrasound frame. Subsequenly, examples of some main techniques found in literature are shown, including but not limited to shape priors, superpixel and classification, local pixel statistics, active contours, edge-tracking, dynamic programming, and data mining. Ten selected applications (abdomen/kidney, breast, cardiology, thyroid, liver, vascular, musculoskeletal, obstetrics, gynecology, prostate) are then investigated in depth, and the performances of a few specific applications are compared. In conclusion, future perspectives for B-mode based segmentation, such as the integration of RF information, the employment of higher frequency probes when possible, the focus on completely automatic algorithms, and the increase in available data are discussed.

Right ventricular involvement in cardiac sarcoidosis demonstrated with cardiac magnetic resonance

AIMS

Cardiac involvement in sarcoidosis is reported in up to 30% of patients. Left ventricular involvement demonstrated by contrast-enhanced cardiac magnetic resonance has been well validated. We sought to determine the prevalence and distribution of right ventricular late gadolinium enhancement in patients diagnosed with pulmonary sarcoidosis.

METHODS AND RESULTS

We prospectively evaluated 87 patients diagnosed with pulmonary sarcoidosis with contrast-enhanced cardiac magnetic resonance for right ventricular involvement. Pulmonary artery pressures were non-invasively evaluated with Doppler echocardiography. Patient characteristics were compared between the groups with and without right ventricular involvement, and right ventricular enhancement was correlated with pulmonary hypertension, ventricular mass, volume, and systolic function. Left ventricular late gadolinium enhancement was demonstrated in 30 patients (34%). Fourteen patients (16%) had right ventricular late gadolinium enhancement, with sole right ventricular enhancement in only two patients. The pattern of right ventricular enhancement consisted of right ventricular outflow tract enhancement in 1 patient, free wall enhancement in 8 patients, ventricular insertion point enhancement in 10 patients, and enhancement of the right side of the interventricular septum in 11 patients. Pulmonary arterial hypertension correlated with the presence of right ventricular enhancement (P < 0.001). Right ventricular enhancement correlated with systolic ventricular dysfunction (P < 0.001), hypertrophy (P = 0.001), and dilation (P < 0.001).

CONCLUSIONS

Right ventricular enhancement was present in 16% of patients diagnosed with pulmonary sarcoidosis and in 48% of patients with left ventricular enhancement. The presence of right ventricular enhancement correlated with pulmonary arterial hypertension, right ventricular systolic dysfunction, hypertrophy, and dilation.