Tricuspid Annular Systolic Velocity: A Useful Measurement in Determining Right Ventricular Systolic Function Regardless of Pulmonary Artery Pressures

Elevated pulmonary capillary wedge pressure, higher blood pressure, and lower cardiac index in infants with bronchopulmonary dysplasia

BACKGROUND

Left ventricular diastolic dysfunction indicated by elevated pulmonary capillary wedge pressure (ePCWP) may worsen cardiorespiratory status in bronchopulmonary dysplasia (BPD), but the scope of ePCWP by cardiac catheterization is not well described.

METHODS

This single-center retrospective cohort study included infants with BPD without congenital heart disease, significant intracardiac shunts, or pulmonary vein stenosis who underwent cardiac catheterization from 2010 to 2021. ePCWP was defined as >10 mmHg. Quantitative measures of ventricular systolic and diastolic function were performed on existing echocardiograms. Patients with and without ePCWP were compared using the Chi-squared or Wilcoxon rank-sum tests. Associations between catheterization hemodynamics and echocardiographic parameters were assessed by simple linear regression.

RESULTS

Seventy-one infants (93% Grade 2 or 3 BPD) met inclusion criteria, and 30 (42%) had ePCWP. Patients with ePCWP were older at catheterization (6.7 vs. 4.5 months, p < 0.001), more commonly underwent tracheostomy (66.7% vs. 29.3%, p = 0.003), and had higher mean systemic blood pressure [64.5 (56.0, 75.0) vs. 47.0 (43.0, 55.0) mm Hg, p < 0.001], higher systemic vascular resistance [11.9 (10.4, 15.6) vs. 8.7 (6.7, 11.2) WU*m2, p < 0.001), and lower cardiac index [3.9 (3.8, 4.9) vs. 4.7 (4.0, 6.3) L/min/m2, p = 0.03] at catheterization. Mean pulmonary artery pressure, pulmonary vascular resistance, and mortality were similar between the groups. Echocardiographic indices of left ventricular diastolic dysfunction did not correlate with PCWP.

CONCLUSIONS

ePCWP was common in infants with severe BPD who underwent cardiac catheterization in this cohort. The association between ePCWP and higher systemic blood pressure supports further study of afterload reduction in this population.

Relevance of the TAS'/PASP Ratio as a Predictor of Outcomes in Patients with Heart Failure with a Reduced Ejection Fraction

BACKGROUND

There is evidence that right ventricular (RV) contractile function, especially its coupling with the pulmonary circulation, has an important prognostic value in patients with left ventricular dysfunction.

AIMS

This study aimed to identify the best echocardiographic parameters of RV function and pulmonary artery systolic pressure (PASP) alone or in the form of the index of right ventricular-pulmonary artery coupling (RV-PA coupling) to determine the best predictor of 1-year major adverse cardiovascular events (MACE), which were defined as cardiovascular death and cardiac decompensation in heart failure patients with reduced ejection fraction (HFrEF).

METHODS AND RESULTS

The study enrolled 191 HFrEF patients (mean age 62.28 ± 12.79 years, 74% males, mean left ventricular ejection fraction (LVEF) 25.53 ± 6.87%). All patients underwent clinical, laboratory, and transthoracic echocardiographic (TTE) evaluation, focusing on assessing RV function and non-invasive parameters of RV-PA coupling. RV function was evaluated using fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), and peak tricuspid annular systolic velocity (TAS'). PASP was estimated by peak tricuspid regurgitation velocity (TRVmax) and corrected by assumed right atrial pressure relative to the dimension and collapsibility of the inferior vena cava. The TAPSE/PASP and TAS'/PASP ratios were taken as an index of RV-PA coupling. During the follow-up (mean period of 340 ± 84 days), 58.1% of patients met the composite endpoint. The independent predictors of one-year outcome were shown to be advanced age, atrial fibrillation, indexed left atrial systolic volume (LAVI), LVEF, TAPSE/PASP, and TAS'/PASP. TAS'/PASP emerged as the strongest independent predictor of prognosis, with a hazard ratio (HR) of 0.67 (0.531-0.840), p < 0.001. Reconstructing the ROC curve 0.8 (0.723-0.859), p < 0.001, we obtained a threshold value of TAS'/PASP ≤ 0.19 (cm/s/mm Hg) (sensitivity 74.0, specificity 75.2). Patients with TAS'/RVSP ≤ 0.19 have a worse prognosis (Log Rank p < 0.001).

CONCLUSIONS

This study confirmed previously known independent predictors of adverse outcomes in patients with HfrEF-advanced age, atrial fibrillation, LAVI, and LVEF-but non-invasive parameters of RV-PA coupling TAPSE/PASP and TAS'/PASP improved risk stratification in patients with HFrEF. Variable TAS'/PASP has been shown to be the most powerful, independent predictor of one-year outcome.

Pulmonary vascular disease in Veterans with post-deployment respiratory syndrome

Exertional dyspnea has been documented in US military personnel after deployment to Iraq and Afghanistan. We studied whether continued exertional dyspnea in this patient population is associated with pulmonary vascular disease (PVD). We performed detailed histomorphometry of pulmonary vasculature in 52 Veterans with biopsy-proven post-deployment respiratory syndrome (PDRS) and then recruited five of these same Veterans with continued exertional dyspnea to undergo a follow-up clinical evaluation, including symptom questionnaire, pulmonary function testing, surface echocardiography, and right heart catheterization (RHC). Morphometric evaluation of pulmonary arteries showed significantly increased intima and media thicknesses, along with collagen deposition (fibrosis), in Veterans with PDRS compared to non-diseased (ND) controls. In addition, pulmonary veins in PDRS showed increased intima and adventitia thicknesses with prominent collagen deposition compared to controls. Of the five Veterans involved in our clinical follow-up study, three had borderline or overt right ventricle (RV) enlargement by echocardiography and evidence of pulmonary hypertension (PH) on RHC. Together, our studies suggest that PVD with predominant venular fibrosis is common in PDRS and development of PH may explain exertional dyspnea and exercise limitation in some Veterans with PDRS.

High-Resolution Transthoracic Echocardiography Accurately Detects Pulmonary Arterial Pressure and Decreased Right Ventricular Contractility in a Mouse Model of Pulmonary Fibrosis and Secondary Pulmonary Hypertension

Background To date, assessment of right ventricular (RV) function in mice has relied extensively on invasive measurements. Echocardiographic advances have allowed adaptation of measures used in humans for serial, noninvasive RV functional assessment in mice. We evaluated the diagnostic performance of tricuspid annular plane systolic excursion (TAPSE), RV peak systolic myocardial velocity (s'), RV myocardial performance index (MPI), and RV fractional area change (FAC) in a mouse model of pulmonary hypertension. Methods and Results Echocardiography was performed on mice at baseline and 3 weeks after induction of pulmonary hypertension using inhaled bleomycin or saline, including adapted measures of TAPSE, s', MPI, and FAC. RV systolic pressure was measured by invasive catheterization, and RV contractility was measured as the peak slope of the RV systolic pressure recording (maximum change pressure/change time). Postmortem morphological assessment of RV hypertrophy was performed. RV systolic pressure was elevated and maximum change pressure/change time was reduced in bleomycin versus control (n=8; P=0.002). Compared with controls, bleomycin mice had reduced TAPSE (0.79±0.05 versus 1.06±0.04 mm; P=0.003), s' (21.3±1.2 versus 29.2±1.3 mm/s; P<0.001), and FAC (20.3±0.7% versus 31.0±1.3%; P<0.001), whereas MPI was increased (0.51±0.03 versus 0.37±0.01; P=0.006). All measures correlated with RV systolic pressure and maximum change pressure/change time. Intraobserver and interobserver variability were minimal. Receiver operating characteristic curves demonstrated that TAPSE (<0.84 mm), s'(<23.3 mm/s), MPI (0.42), and FAC (<23.3%) identified maximum change pressure/change time ≤2100 mm Hg/s with high accuracy. Conclusions TAPSE, s', MPI, and FAC are measurable consistently using high-resolution echocardiography in mice, and are sensitive and specific measures of pulmonary pressure and RV function. This validation opens the opportunity for serial noninvasive measures in mouse models of pulmonary hypertension, enhancing the statistical power of preclinical studies of novel therapeutics.

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.

Factors associated with discontinuation of pulmonary vasodilator therapy in children with bronchopulmonary dysplasia-associated pulmonary hypertension

OBJECTIVE

To evaluate factors associated with discontinuation of pulmonary vasodilator therapy in bronchopulmonary dysplasia-related pulmonary hypertension (BPD-PH).

STUDY DESIGN

Retrospective study of neonatal, echocardiographic, and cardiac catheterization data in 121 infants with BPD-PH discharged on pulmonary vasodilator therapy from 2009-2020 and followed into childhood.

RESULT

After median 4.4 years, medications were discontinued in 58%. Those in whom medications were discontinued had fewer days of invasive support, less severe BPD, lower incidence of PDA closure or cardiac catheterization, and higher incidence of fundoplication or tracheostomy decannulation (p < 0.05). On multivariable analysis, likelihood of medication discontinuation was lower with longer period of invasive respiratory support [HR 0.95 (CI:0.91-0.99), p = 0.01] and worse RV dilation on pre-discharge echocardiogram [HR 0.13 (CI:0.03-0.70), p = 0.017]. In those with tracheostomy, likelihood of medication discontinuation was higher with decannulation [HR 10.78 (CI:1.98-58.59), p < 0.001].

CONCLUSION

In BPD-PH, childhood discontinuation of pulmonary vasodilator therapy is associated with markers of disease severity.

Paradoxical Septal Motion after Uncomplicated Cardiac Surgery: A Consequence of Altered Regional Right Ventricular Contractile Patterns

Paroxysmal interventricular septal motion (PSM) is the movement of the septum toward the right ventricle (RV) during cardiac systole. It occurs frequently after uncomplicated cardiac surgery (CS), including coronary bypass (on-pump and off-pump), valve repair or replacement, and with all types of incisions (sternotomy or mini-thoracotomy). It sometimes resolves quickly but may persist for months or become permanent. Global RV systolic function, stroke volume and ejection fraction remain normal after uncomplicated CS, but regional contractile patterns are altered. There is a decrease in longitudinal shortening but an increase in transverse shortening in the endocardial and epicardial right ventricular muscle fibers, respectively. PSM is a secondary event as there is no loss of septal perfusion or thickening. The increased RV transverse shortening (free wall to septal fibers) may modify septal movement resulting in PSM that compensates for the reduced RV longitudinal shortening, thus preserving normal global right ventricular function.

Right ventricular free wall contractility in subcostal views: A proof-of-concept study to assess right ventricular systolic function

BACKGROUND

Normal right ventricular (RV) function has been traditionally assessed from the apical window. However, in several patients the subcostal window is the only available acoustic.

METHODS

Given the intricate functional and mechanical inter-dependence between longitudinal tricuspid annular (TA) displacement and RV free wall contractility (RVFW), we studied the utility of RVFW inward motion using both M-mode and velocity with tissue Doppler imaging (TDI) from the subcostal transthoracic view.

RESULTS

If a TAPSE value ≥ 2 cm is used to identify normal RV function, an RVFW M-mode value > .8 cm, TA TDI s' velocity > .06 cm/s and TA TDI e' velocity value > .05 cm/s identify normal RV systolic function. Furthermore, ROC curve analysis for the RVFW M-mode showed an area under the curve (AUC) of .753 (95% CI: .604-.868) with a cut-off value > .8, sensitivity 75% and specificity 73%; for TA TDI s' AUC at .822 (95% CI: .681-.919) with a cut-off value > .06, sensitivity 75% and specificity 77% and for TA TDI e' the AUC was .771 (95% CI: .624-.882) with a cut-off value > .05, sensitivity 90% and specificity 46%. Reproducibility of repeat RVFW M-mode, TDI s' and e' measurements was good with strong inter-rater agreement (Kappa > .8).

CONCLUSIONS

The subcostal window appears useful for assessing RV systolic function. Additional studies are now required to prospectively use these measures in the routine evaluation of RV systolic function particularly in patients with suboptimal apical windows.

Tricuspid Annular Systolic Velocity to Left Ventricular Outflow Velocity Time Integral Ratio: Proof of Concept Utility Analysis

Background

The tricuspid annular plane systolic excursion (TAPSE) / pulmonary artery systolic pressure (PASP) ratio has been a useful marker of right ventricular (RV)-pulmonary artery coupling. However, given the intricate functional and mechanical interdependence of the right and left ventricles, we believe this ratio would be less useful when assessing reduced left ventricular (LV) systolic function. Instead, we proposed using the tricuspid annular tissue Doppler imaging systolic velocity to LV outflow tract velocity time integral ratio (TA TDI s’ / LVOT VTI r) for this purpose.

 

Methods

For this proof-of-concept study, a retrospective analysis was conducted on 60 patients with complete echocardiographic studies while in sinus rhythm. The population was divided as follows; Group 1 included 20 individuals with normal left ventricular ejection fraction (LVEF) as well as normal RV and PASP. Group 2 was composed of 20 patients known to have been evaluated or treated for pulmonary hypertension, while group 3 was comprised of 20 patients treated for heart failure (HF). 

Results

TAPSE/PASP ratios were no different from any of the studied groups. However, the proposed TA TDI s' /LVOT VTI r was statistically different among all three groups (Group 1: 0.6 ± 0.1*; Group 2: 0.5 ± 0.1°; and Group 3: 0.8 ± 0.3^#; p < 0.001).

Conclusions

Based on these results, there is now a need for additional prospective studies to explore the overall utility of using this TA TDI s' / LVOT VTI r in day-to-day routine assessments not only for diagnostic purposes but also to determine how this ratio correlates with symptoms and changes with therapy.

A guide to echocardiographic assessment in children and adolescents with pulmonary hypertension

While the current definition of pulmonary hypertension (PH) is still based on haemodynamic variables, transthoracic echocardiography is the most important diagnostic clinical tool for the first assessment and evaluation of a patient, in whom PH is suspected. In addition, it is the most important clinical modality in long term follow-up and the utility of echocardiography has widely been demonstrated in patients with PH. Echocardiography not only reveals the underlying cardiac morphology and diagnosis of any associated cardiac defects. In most patients with PH right ventricular (RV) pressure estimation is feasible. In addition, ventricular systolic and diastolic function, as well as ventricular-ventricular interactions of both ventricles can be assessed by using echocardiography. Maximizing the use of echocardiography by reporting several measures to gain information and quantitatively describe the parameters, that are linked to prognosis, seem particularly appealing in these children, in whom other advanced imaging modalities requiring anaesthesia is associated with a considerable risk. Herein we provide a practical approach and a concise and clinically applicable echocardiographic guidance and present basic variables, which should be obtained at any assessment. Moreover, we present additional advanced echocardiographic measures, that can be applied in a research or clinical setting when progressive PH needs a deeper insight to assess heart function, estimation of pulmonary artery pressures among others, by echocardiography. Finally, clinically relevant studies in view of the prognostic properties with a focus on the most important echocardiographic variables in pediatric PH are summarized.

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.

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.

Transthoracic Right Heart Echocardiography for the Intensivist

BACKGROUND

The impact of critical illness on the right ventricle (RV) can be profound and RV dysfunction is associated with mortality. Intensivists are becoming more facile with bedside echocardiography, however, pedagogy has largely focused on left ventricular function. Here we review measurements of right heart function by way of echocardiographic modalities and list clinical scenarios where the RV dysfunction is a salient feature.

MAIN

RV dysfunction is heterogeneously defined across many domains and its diagnosis is not always clinically apparent. The RV is affected by conditions commonly seen in the ICU such as acute respiratory distress syndrome, pulmonary embolism, RV ischemia, and pulmonary hypertension. Basic ultrasonographic modalities such as 2D imaging, M-mode, tissue Doppler, pulsed-wave Doppler, and continuous Doppler provide clinicians with metrics to assess RV function and response to therapy.

CONCLUSION

The right ventricle is impacted by various critical illnesses with substantial mortality and mortality. Focused bedside echocardiographic exams with attention to the right heart may provide intensivists insight into RV function and provide guidance for patient management.

Detection of persistent systolic and diastolic abnormalities in asymptomatic pediatric repaired tetralogy of Fallot patients with preserved ejection fraction: a CMR feature tracking study

OBJECTIVES

A fast cardiovascular magnetic resonance (CMR) feature tracking was applied to assess ventricular systolic and diastolic function. This study sought to detect right ventricular (RV) systolic and diastolic abnormalities in asymptomatic pediatric repaired tetralogy of Fallot (rTOF) patients with preserved RV ejection fraction (EF).

METHODS

One hundred asymptomatic pediatric rTOF patients with preserved RVEF ≥ 45% and 52 control subjects underwent cine CMR examinations. Tricuspid annular plane systolic excursion (TAPSE); peak tricuspid annular systolic (S_m), early diastolic (E_m), and late diastolic (A_m) velocities; and biventricular global radial (GRS), circumferential (GCS), and longitudinal strains (GLS) were analyzed using CMR feature tracking.

RESULTS

TAPSE, S_m, E_m, A_m, and RV GLS were significantly lower in rTOF patients compared with controls (all p < 0.01). The lower limits (mean-2·standard deviations) of TAPSE, S_m, E_m, and A_m among controls were 10.9 mm, 6.3 cm/s, 8.9 cm/s, and 2.4 cm/s, respectively, and 78%, 75%, 75%, and 19% of rTOF patients had corresponding measurements below these thresholds. Among rTOF patients, RV GLS was significantly lower in females than in males (p < 0.05).

CONCLUSIONS

Despite preserved RVEF, there was a high prevalence of RV systolic and diastolic dysfunction among pediatric rTOF patients, which was detected using fast CMR feature tracking.

KEY POINTS

• There was high prevalence of systolic and diastolic dysfunction in asymptomatic pediatric repaired tetralogy of Fallot (rTOF) patients despite preserved right ventricular (RV) ejection fraction (EF). • Significant correlations were observed between right ventricular (RV) measurements (strains, tricuspid annular plane systolic excursion (TAPSE), peak tricuspid annular early diastolic velocity (E_m), peak tricuspid annular late diastolic velocity (A_m)), and left ventricular (LV) strain measurements, which indicates ventricular-ventricular interactions at systolic and diastolic function level. • Right ventricular (RV) global longitudinal strain (GLS) was lower in female repaired tetralogy of Fallot (rTOF) patients than in males, suggesting females with rTOF may be at a higher risk of developing RV systolic dysfunction than males.

Echocardiography for the Assessment of Pulmonary Hypertension and Congenital Heart Disease in the Young

While invasive assessment of hemodynamics and testing of acute vasoreactivity in the catheterization laboratory is the gold standard for diagnosing pulmonary hypertension (PH) and pulmonary vascular disease (PVD) in children, transthoracic echocardiography (TTE) serves as the initial diagnostic tool. International guidelines suggest several key echocardiographic variables and indices for the screening studies when PH is suspected. However, due to the complex anatomy and special physiological considerations, these may not apply to patients with congenital heart disease (CHD). Misinterpretation of TTE variables can lead to delayed diagnosis and therapy, with fatal consequences, or–on the other hand-unnecessary invasive diagnostic procedures that have relevant risks, especially in the pediatric age group. We herein provide an overview of the echocardiographic workup of children and adolescents with PH with a special focus on children with CHD, such as ventricular/atrial septal defects, tetralogy of Fallot or univentricular physiology. In addition, we address the use of echocardiography as a tool to assess eligibility for exercise and sports, a major determinant of quality of life and outcome in patients with PH associated with CHD.

Effect of Transcatheter Aortic Valve Replacement on Right Ventricular-Pulmonary Artery Coupling

OBJECTIVES

The aim of this study was to test the hypothesis that the acute left ventricular (LV) unloading effect of transcatheter aortic valve replacement (TAVR) would improve right ventricular (RV) function and RV-pulmonary artery (PA) coupling in patients with severe aortic stenosis (AS).

BACKGROUND

RV dysfunction is an ominous prognostic marker in patients undergoing TAVR, suggesting that relief of obstruction might be less beneficial in this cohort. However, the left ventricle and right ventricle influence each other through ventricular interaction, which could lead to improved RV function through LV unloading.

METHODS

Prospective invasive hemodynamic measurements with simultaneous echocardiography were performed in symptomatic patients with severe AS before and immediately after TAVR.

RESULTS

Forty-four patients (mean age 81 ± 8 years, 27% women) with severe AS underwent TAVR. At baseline, right atrial, PA mean (27 ± 7 mm Hg), and pulmonary capillary wedge (16 ± 4 mm Hg) pressures were mildly elevated, with a low normal cardiac index (2.3 l/min/m²). Pulmonary vascular resistance was mildly elevated (222 ± 133 dynes · s/cm⁵) and PA compliance mildly reduced (3.4 ± 01.4 ml/mm Hg). Following TAVR, aortic valve area increased (from 0.8 ± 0.3 to 2.7 ± 1.1 cm²; p < 0.001) with a reduction in mean aortic gradient (from 37 ± 11 to 7 ± 4 mm Hg; p < 0.001) and an increase in cardiac index (from 2.3 ± 0.5 to 2.5 ± 0.6 l/min/m²; p = 0.03). LV stroke work, end-systolic wall stress, and systolic ejection period decreased by 23% to 27% (p < 0.001 for all), indicating substantial LV unloading. RV stroke work (from 16 ± 7 to 18 ± 7 mm Hg · ml; p = 0.04) and tricuspid annular systolic velocities (from 9.5 ± 2.0 to 10.4 ± 3.5 cm/s; p = 0.01) increased, along with a decrease in PVR (194 ± 113 dynes · s/cm⁵; p = 0.03), indicating improvement in RV-PA coupling. Increased RV stroke work following TAVR directly correlated with the magnitude of increase in aortic valve area (r = 0.58; p < 0.001).

CONCLUSIONS

Acute relief in obstruction to LV ejection with TAVR is associated with improvements in RV function and RV-PA coupling. These findings provide new insights into the potential benefits of LV unloading with TAVR on RV dysfunction in patients with severe AS.

A comparison of artificial intelligence-based algorithms for the identification of patients with depressed right ventricular function from 2-dimentional echocardiography parameters and clinical features

Background

Recognizing low right ventricular (RV) function from 2-dimentiontial echocardiography (2D-ECHO) is challenging when parameters are contradictory. We aim to develop a model to predict low RV function integrating the various 2D-ECHO parameters in reference to cardiac magnetic resonance (CMR)-the gold standard.

Methods

We retrospectively identified patients who underwent a 2D-ECHO and a CMR within 3 months of each other at our institution (American University of Beirut Medical Center). We extracted three parameters (TAPSE, S' and FAC_RV) that are classically used to assess RV function. We have assessed the ability of 2D-ECHO derived parameters and clinical features to predict RV function measured by the gold standard CMR. We compared outcomes from four machine learning algorithms, widely used in the biomedical community to solve classification problems.

Results

One hundred fifty-five patients were identified and included in our study. Average age was 43±17.1 years old and 52/156 (33.3%) were females. According to CMR, 21 patients were identified to have RV dysfunction, with an RVEF of 34.7%±6.4%, as opposed to 54.7%±6.7% in the normal RV population (P<0.0001). The Random Forest model was able to detect low RV function with an AUC =0.80, while general linear regression performed poorly in our population with an AUC of 0.62.

Conclusions

In this study, we trained and validated an ML-based algorithm that could detect low RV function from clinical and 2D-ECHO parameters. The algorithm has two advantages: first, it performed better than general linear regression, and second, it integrated the various 2D-ECHO parameters.

A novel prediction of simulated fluid responsiveness by echocardiography assessment of tricuspid annulus tissue velocity with passive leg raising

Background:

Fluid responsiveness can be predicted by the effect of passive leg raising on cardiac output.

Objectives:

This research aimed to compare the changes in cardiac output and the peak systolic velocity values of Tricuspid annulus velocity at the free wall (S’) before and after passive leg raising in healthy volunteers.

Methods:

The study was approved by ethical commission. The desired sample size was 28, and 57 volunteers were included after they signed informed consent. The first measurements, including vital signs, S’, and cardiac output, were taken with the participants lying supine and were performed in the morning after 12 h fast. The participants were then asked to lie in a semirecumbent position for 3 min. After 3 min, the head of the bed was lowered to the supine position and the participants’ legs were elevated at 45°. Secondary measurements were repeated in this position. The differences between vital signs, cardiac output, and S’ measurements before and after passive leg raising were statistically compared. The level of significance was set as p < 0.05.

Results:

The mean values of cardiac output and S’ before passive leg raising was 9.59 L/min and 11.57 cm/s, respectively; however, those increased to 11.44 L/min and 13.72 cm/s after passive leg raising. The average increases were 16.17% for cardiac output and 15.67% for S’. The changes of cardiac output and S’ were statistically significant. The changes of vital signs before and after passive leg raising were statistically insignificant.

Conclusion:

This study has demonstrated the concordance of rise in cardiac output with S’ change by passive leg raising in healthy subjects. Further studies are needed to validate the use of S’ values in critically ill subjects.

Right ventricular function among South East Nigeria children with sickle cell anaemia

BACKGROUND

Sickle cell anaemia (SCA) is characterized by attendant ischemia-reperfusion injury especially to the heart.

METHODS

The aim of this work is to compare the right ventricular function of children with SCA in steady state (subjects) with those with haemoglobin AA genotype (controls), using echocardiography. It is a cross-sectional study, which echocardiographic measurements to assess right ventricular function among children with SCA and their controls.

RESULTS

The mean trans annular plane systolic excursion (TAPSE) in subjects, 28.24 ± 5.23 (Z score: 0.258 ± 1.10) was higher than that in control, 25.82 ± 3.59 (Z score: - 0.263 ± 0.80), and the difference in mean was statistically significant, (t = 2.703, p = 0.008). Significantly higher proportion of subjects with sickle cell anaemia had right ventricular dysfunction (Abnormal TAPSE), 25 (50.0%) when compared with those in control, 11 (22.0%), {χ2 = 8.5, p = 0.0035}. A higher proportion of subjects with sickle cell anaemia (25.5%) had Pulmonary hypertension (RVP) when compared with control (2.0%) and the difference in proportions was found to be statistically significant, (χ2 = 11.668, p = 0.001). The prevalence of right ventricular diastolic dysfunction in subjects was 9.8% while control was 0%.

CONCLUSION

Children with sickle cell anaemia present with right ventricular dysfunction. Prevalence of right ventricular systolic and diastolic dysfunction were higher in subjects. More of the subjects in this study (25.5%) had pulmonary hypertension.

The Prognostic Importance of TAPSE in Early and in Stable Cardiovascular Diseases

The identification of predictors of major cardiovascular events (MACES) represents a big challenge, especially in early and stable cardiovascular diseases. This prospective study comparatively evaluated the prognostic importance of left ventricular (LV) and right ventricular (RV) systolic and diastolic function, pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) in a stable patient’s cohort with cardiovascular risk factors. The LV ejection fraction, mitral annular plane systolic excursion (MAPSE), tricuspid annular plane systolic excursion (TAPSE), functional mitral regurgitation (FMR), doppler tissue imaging of mitral and tricuspid annulus with systolic and diastolic peaks estimation, tricuspid regurgitation velocity (TRV), pulmonary velocity outflow time integral (PVTI), mean pulmonary artery pressure (MPAP) and PVR were estimated at enrollment. During the follow-up, MACES and all-cause mortality were recorded. 369 subjects with or without previous MACES were enrolled. Bivariate analysis revealed LVEF, TAPSE, MPAP, TRV, PVR, LV diastolic function, and FMR were associated with the endpoints. When computing the influence of covariates to the primary endpoint (all-cause mortality and MACES) through Cox analysis, only LV diastolic function and TAPSE entered the final model; for the secondary endpoint (MACES) only TAPSE entered. TAPSE was able to predict MACES and all-cause mortality in early and stable cardiovascular diseases. The use of TAPSE should be implemented.

Echocardiographic Screening Methods for Pulmonary Hypertension: A Practical Review

Pulmonary hypertension (PH) is a debilitating condition defined as mean pulmonary arterial pressure (mPAP) ≥ 25 mmHg. The importance of impaired right ventricular (RV) hemodynamics is increasingly being recognized in treatment of patients with PH. In World Health Organization Group 1 patients with pulmonary arterial hypertension, upfront combination therapy has recently been proposed to improve long-term survival. Also, the mPAP in Group 2 and 3 PH patients has been shown to be strongly associated with clinical outcomes. Thus, screening and monitoring of RV hemodynamics are becoming increasingly important. The gold standard for measuring RV hemodynamics is right heart catheterization (RHC). Although RHC can obtain the most accurate results, it is invasive, cumbersome to patients, and often associated with complications, making it unsuitable for a screening or monitoring modality. Echocardiography is useful in estimating hemodynamic parameters that can be obtained from RHC. Accordingly, the role of echocardiography in evaluating such patients with PH is becoming more important. In this article, we review practical echocardiographic methods in approximating RV hemodynamics for PH.

Increased Sensitivity of Focused Cardiac Ultrasound for Pulmonary Embolism in Emergency Department Patients With Abnormal Vital Signs

BACKGROUND

Focused cardiac ultrasound (FOCUS) is insensitive for pulmonary embolism (PE). Theoretically, when a clot is large enough to cause vital sign abnormalities, it is more likely to show signs of right ventricular dysfunction on FOCUS, although this has not been well quantified. A rapid bedside test that could quickly and reliably exclude PE in patients with abnormal vital signs could be of high utility in emergency department (ED) patients. We hypothesized that in patients with tachycardia or hypotension, the sensitivity of FOCUS for PE would increase substantially.

METHODS

We performed a prospective observational multicenter cohort study involving a convenience sample of patients from six urban academic EDs. Patients suspected to have PE with tachycardia (heart rate [HR] ≥ 100 beats/min) or hypotension (systolic blood pressure [sBP] < 90 mm Hg) underwent FOCUS before computed tomography angiography (CTA). FOCUS included assessment for right ventricular dilation, McConnell's sign, septal flattening, tricuspid regurgitation, and tricuspid annular plane systolic excursion. If any of these were abnormal, FOCUS was considered positive, while if all were normal, FOCUS was considered negative. We a priori planned a subgroup analysis of all patients with a HR ≥ 110 beats/min (regardless of their sBP). We then determined the diagnostic test characteristics of FOCUS for PE in the entire patient population and in the predefined subgroup, based on CTA as the criterion standard. Inter-rater reliability of FOCUS was determined by blinded review of images by an emergency physician with fellowship training in ultrasound.

RESULTS

A total of 143 subjects were assessed for enrollment and 136 were enrolled; four were excluded because they were non-English-speaking and three because of inability to obtain any FOCUS windows. The mean (±SD) age of enrolled subjects was 56 (±7) years, mean (±SD) HR was 114 (±12) beats/min, and 37 (27.2%) subjects were diagnosed with PE on CTA. In all subjects, FOCUS was 92% (95% confidence interval [CI] = 78% to 98%) sensitive and 64% specific (95% CI = 53% to 73%) for PE. In the subgroup of 98 subjects with a HR ≥ 110 beats/min, FOCUS was 100% sensitive (95% CI = 88% to 100%) and 63% specific (95% CI = 51% to 74%) for PE. There was substantial interobserver agreement for FOCUS (κ = 1.0, 95% CI = 0.31 to 1.0).

CONCLUSIONS

A negative FOCUS examination may significantly lower the likelihood of the diagnosis of PE in most patients who are suspected of PE and have abnormal vital signs. This was especially true in those patients with a HR ≥ 110 beats/min. Our results suggest that FOCUS can be an important tool in the initial evaluation of ED patients with suspected PE and abnormal vital signs.

EXPRESS: Statement on imaging and pulmonary hypertension from the Pulmonary Vascular Research Institute (PVRI)

Pulmonary hypertension (PH) is highly heterogeneous and despite treatment advances it remains a life-shortening condition. There have been significant advances in imaging technologies, but despite evidence of their potential clinical utility, practice remains variable, dependent in part on imaging availability and expertise. This statement summarizes current and emerging imaging modalities and their potential role in the diagnosis and assessment of suspected PH. It also includes a review of commonly encountered clinical and radiological scenarios, and imaging and modeling-based biomarkers. An expert panel was formed including clinicians, radiologists, imaging scientists, and computational modelers. Section editors generated a series of summary statements based on a review of the literature and professional experience and, following consensus review, a diagnostic algorithm and 55 statements were agreed. The diagnostic algorithm and summary statements emphasize the key role and added value of imaging in the diagnosis and assessment of PH and highlight areas requiring further research.

Tricuspid annular plane of systolic excursion to prognosticate acute pulmonary symptomatic embolism (TAPSEPAPSE study)

INTRODUCTION

The imaging standard for evaluation of acute pulmonary embolism (PE) includes a computed tomography pulmonary angiogram. Ultrasonography has shown promise in obtaining the tricuspid annular plane systolic excursion (TAPSE) measurements, which may be of clinical importance in patients with acute PE. The objective of this study is to evaluate the diagnostic capability of TAPSE measurements for patients with suspicion for acute PE.

METHODS

We prospectively enrolled patients who came to the emergency department with suspicion of acute PE. Each patient underwent a point-of-care sonogram where a TAPSE measurement was obtained, followed by computed tomography pulmonary angiogram. Based on the computed tomography pulmonary angiogram findings, patients were grouped into 3 categories: no acute PE, clinically insignificant acute PE, or clinically significant acute PE.

RESULTS

We enrolled 87 patients in this study. Twenty-three (26.4%) of these patients were diagnosed with PE. Of patients with PE, 15 (65%) were found to have a clinically significant acute PE. Analysis of mean TAPSE measurements between patients with clinically significant acute PE and those with insignificant or no PE was 15.2 mm and 22.7 mm, respectively (P ≤ .0001). Following receiver operating characteristic curve analysis, optimum TAPSE measurement to identify clinically significant acute PE is 18.2 mm. A cutoff TAPSE measurement of 15.2 mm shows a sensitivity of 53.3% (95% confidence interval, 26.7%-80%) and a specificity of 100% (95% confidence interval, 100%-100%) for the diagnosis of a clinically significant PE.

CONCLUSIONS

Our data suggest that TAPSE measurements less than 15.2 mm have a high specificity for identifying clinically significant acute PE.

Peak systolic velocity of tricuspid annulus is inferior to tricuspid annular plane systolic excursion for 30 days prediction of adverse outcome in acute pulmonary embolism

BACKGROUND

Tricuspid annular plane systolic excursion (TAPSE) is an established index of right ventricular (RV) systolic function and a significant predictor in normotensive patients with pulmonary embolism (PE). Recently, Doppler tissue imaging-derived tricuspid annular systolic velocity (TV S'), a modern parameter of RV function was reported to be useful in the diagnosis and prognosis of a broad spectrum of heart diseases. Therefore, herein, is an analysis of the prognostic value of both parameters in normotensive PE patients.

METHODS

One hundred and thirty nine consecutive PE patients (76 female, age 56.4 ± 19.5 years) were included in this study. All patients were initially anticoagulated. Transthoracic echocardiography was performed on admission. The study endpoint (SE) was defined as PE-related 30-day mortality and/or need for rescue thrombolysis.

RESULTS

Seven (5%) patients who met the criteria for SE presented more severe RV dysfunction at echocardiography. Univariable Cox regression analysis showed that RV/LV ratio predicted SE with hazard risk (HR) 10.6 (1.4-80.0; p = 0.02); TAPSE and TV S' showed HR 0.77 (0.67-0.89), p < 0.001, and 0.71 (0.52-0.97), p = 0.03, respectively. Area under the curve for TAPSE in the prediction of SE was 0.881; 95% CI 0.812-0.932, p = 0.0001, for TV S' was 0.751; 95% CI 0.670-0.820, p = 0.001. Multivariable analysis showed that the optimal prediction model included TAPSE and systolic blood pressure (SBP showed HR 0.89 95% CI 0.83-0.95, p < 0.001 and TAPSE HR 0.67, 95% CI 0.52-0.87, p<0.03). Kaplan-Meier analysis showed that initially PE patients with TAPSE ≥ 18 mm had a much more favorable prognosis that patients with TAPSE < 18 mm (p < 0.01), while analysis of S' was only of borderline statistical significance.

CONCLUSIONS

It seems that TV S' is inferior to TAPSE for 30 day prediction of adverse outcome in acute pulmonary embolism.

The Role of Echocardiography in Neonates and Pediatric Patients on Extracorporeal Membrane Oxygenation

Indications for extracorporeal membrane oxygenation (ECMO) and extracorporeal cardiopulmonary resuscitation (ECPR) are expanding, and echocardiography is a tool of utmost importance to assess safety, effectiveness and readiness for circuit initiation and separation. Echocardiography is key to anticipating complications and improving outcomes. Understanding the patient's as well as the ECMO circuit's anatomy and physiology is crucial prior to any ECMO echocardiographic evaluation. It is also vital to acknowledge that the utility of echocardiography in ECMO patients is not limited to the evaluation of cardiac function, and that clinical decisions should not be made exclusively upon echocardiographic findings. Though echocardiography has specific indications and applications, it also has limitations, characterized as: prior to and during cannulation, throughout the ECMO run, upon separation and after separation from the circuit. The use of specific and consistent echocardiographic protocols for patients on ECMO is recommended.

Right Ventricular Function is Associated With Quality of Life in Patients With Systemic Lupus Erythematosus Associated Pulmonary Arterial Hypertension

BACKGROUND

Right ventricular (RV) function has been identified as an important determinant of outcome in patients with pulmonary hypertension. We aimed to investigate the relationship between echocardiographic-derived RV function and health-related quality of life (HRQOL) in patients with systemic lupus erythematosus associated pulmonary arterial hypertension (SLE-APAH), and to identify the best echocardiographic parameter for evaluating RV function in these patients.

METHODS

Sixty (60) consecutive patients with SLE-APAH (all female, mean age 33.6±8.2years) were recruited from May 2013 to November 2014. Echocardiograph, right heart catheterisation, SLE disease activity index (SLEDAI), and functional status and SF-36 generic questionnaire were assessed.

RESULTS

Echocardiograph-derived RV systolic function was significantly correlated with haemodynamics (p<0.05), with tricuspid annular plane systolic excursion (TAPSE) showing the strongest correlation with pulmonary vascular resistance (R²=0.278, p<0.001) and cardiac index (R²=0.215, p<0.001). Patients with a TAPSE<17mm had a shorter 6-minute-walk-distance (6MWD), lower mixed venous oxygen saturation, and higher plasma N-terminal pro-brain natriuretic peptide (p<0.05). Patients with TAPSE <17mm had lower physical component summary (PCS) and mental component summary (MCS) scores than those with TAPSE ≥17mm (35.5±13.2 vs. 55.0±15.5; 46.3±15.3 vs. 64.8±18.8, respectively, all p<0.05). On multiple regression analysis, a TAPSE <17mm was independently related to lower PCS (β -15.797, 95% confidence interval [CI] -24.746 to -6.848, p=0.001) and lower MCS (β -12.887, 95% CI -24.018 to -1.755, p=0.024).

CONCLUSIONS

TAPSE is a useful index for RV function assessment, and is associated with HRQOL in patients with SLE-APAH.

The use of echocardiographic indices in defining and assessing right ventricular systolic function in critical care research

PURPOSE

Many echocardiographic indices (or methods) for assessing right ventricular (RV) function are available, but each has its strengths and limitations. In some cases, there might be discordance between the indices. We conducted a systematic review to audit the echocardiographic RV assessments in critical care research to see if a consistent pattern existed. We specifically looked into the kind and number of RV indices used, and how RV dysfunction was defined in each study.

METHODS

Studies conducted in critical care settings and reported echocardiographic RV function indices from 1997 to 2017 were searched systematically from three databases. Non-adult studies, case reports, reviews and secondary studies were excluded. These studies' characteristics and RV indices reported were summarized.

RESULTS

Out of 495 non-duplicated publications found, 81 studies were included in our systematic review. There has been an increasing trend of studying RV function by echocardiography since 2001, and most were conducted in ICU. Thirty-one studies use a single index, mostly TAPSE, to define RV dysfunction; 33 used composite indices and the combinations varied between studies. Seventeen studies did not define RV dysfunction. For those using composite indices, many did not explain their choices.

CONCLUSIONS

TAPSE seemed to be the most popular index in the last 2-3 years. Many studies used combinations of indices but, apart from cor pulmonale, we could not find a consistent pattern of RV assessment and definition of RV dysfunction amongst these studies.

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.

Are Measures of Left Ventricular Longitudinal Shortening Affected by Left Atrial Enlargement?

BACKGROUND

Even though left atrial (LA) size and function are intimately related to left ventricular (LV) diastolic dysfunction, the role of LA with regard to LV systolic function is less clear. Consequently, we examined the potential association that might exist between measures of longitudinal LV systolic shortening and LA dilation using LA volume index (LAVI).

METHODS

In this retrospective analysis, data from 75 echocardiograms (mean age 53 ± 14; range 24 - 89 years; mean body surface area (BSA) 2.0 ± 0.3) were analyzed.

RESULTS

Peak global longitudinal (PGLS) correlated best with LV mass index (LVMI) followed by mitral annular systolic excursion (MAPSE), and age. Similar results were obtained when analyzing the best variables that correlated with LAVI. Finally, MAPSE correlated best with PGLS, then with MA tissue Doppler systolic velocity, BSA, and LAVI in that order. All patients had normal LV ejection fraction (LVEF) and normal sinus rhythm when studied.

CONCLUSIONS

LAVI does not directly affect LV systolic function and longitudinal measures of LV shortening are mainly dependent on LV mass. Additional studies are now required to determine how these associations vary when different degrees of LV dilatation and systolic dysfunction are included in the analysis.

Right ventricular function mirrors clinical improvement with use of prostacyclin analogues in pediatric pulmonary hypertension

Pulmonary hypertension (PH) causes significant morbidity and mortality in children due to right ventricular (RV) failure. We sought to determine the effect of prostacyclin analogues on RV function assessed by echocardiography in children with PH. We conducted a retrospective cohort study of children with PH treated with a prostacyclin analogue (epoprostenol or treprostinil) between January 2001 and August 2015 at our center. Data were collected before initiation of treatment (baseline) and at 1–3 and 6–12 months after. Protocolized echocardiogram measurements including tricuspid annular plane systolic excursion (TAPSE) and RV global longitudinal strain were made with blinding to clinical information. Forty-nine individuals (65% female), aged 0–29 years at the time of prostacyclin initiation were included. Disease types included pulmonary arterial hypertension (idiopathic [35%], heritable [2%], and congenital heart disease-associated [18%]), developmental lung disease (43%), and chronic thromboembolic PH (2%). Participants received intravenous (IV) epoprostenol (14%) and IV/subcutaneous (SQ) (67%) or inhaled (18%) treprostinil. Over the study period, prostacyclin analogues were associated with improvement in TAPSE (P = 0.007), RV strain (P < 0.001), and qualitative RV function (P = 0.037) by echocardiogram, and BNP (P < 0.001), functional class (P = 0.047) and 6-min walk distance (P = 0.001). TAPSE and strain improved at early follow up (P = 0.05 and P = 0.002, respectively) despite minimal RV pressure change. In children with PH, prostacyclin analogues are associated with an early and sustained improvement in RV function measured as TAPSE and strain as well as clinical markers of PH severity. RV strain may be a sensitive marker of RV function in this population.

Tricuspid annular plane systolic excursion in dogs with myxomatous mitral valve disease with and without pulmonary hypertension

OBJECTIVES

To evaluate tricuspid annular plane systolic excursion (TAPSE) in dogs with myxomatous mitral valve disease (MMVD) with or without pulmonary hypertension (PH) and to study the correlations with clinical and echocardiographic parameters.

ANIMALS

The study population included 99 dogs with MMVD and tricuspid regurgitation.

METHODS

This is a prospective clinical study. All dogs received a transthoracic echocardiographic evaluation, including 2D, M-mode, echo-Doppler, and tissue Doppler measurements. The TAPSE was measured from the left apical four-chamber view and normalized for the effect of body weight (nTAPSE). The dogs were grouped according to the severity of MMVD (American College of Veterinary Internal Medicine guidelines) and presence/absence and severity of PH. Significant differences between TAPSE or nTAPSE and echocardiographic parameters were analyzed among the MMVD and PH severity groups. Correlations between TAPSE or nTAPSE and echocardiographic parameters were calculated.

RESULTS

Tricuspid annular plane systolic excursion or nTAPSE were not significantly different among dogs of the MMVD or PH severity groups. Significant correlations were obtained between TAPSE and body weight, left ventricular and atrial dimensions, early diastolic septal and early diastolic and systolic tricuspid annulus velocity (p<0.001); nTAPSE was significantly correlated with normalized end-diastolic left ventricular dimension and fractional shortening (p<0.001).

CONCLUSIONS

The results show that neither TAPSE nor nTAPSE are reduced in dogs with MMVD with or without PH. It remains unclear if the right ventricle function is not reduced or if a reduced right ventricle function is masked by the contraction of the left ventricle through ventricular interdependence.

Maximal systolic excursion of the tricuspid annulus is independent of right atrial size and function in chronic pulmonary hypertension

BACKGROUND

Even though the tricuspid annulus (TA) is anatomically and functionally related to right atrioventricular dependence and tricuspid annular plane systolic excursion (TAPSE) is a well-known measure of right ventricular (RV) systolic function, there is paucity of data regarding the potential impact that right atrial (RA) size and function have on TAPSE. Hence, we sought to determine whether RA volumetric and longitudinal measures affect TAPSE in patients with chronic pulmonary hypertension (cPH).

METHODS

In this retrospective study, echocardiographic data from 110 patients were reviewed and the studied population was divided into Group I consisting of 50 patients (50±11 years) without PH and Group II that included 60 patients (55±14 years) with cPH.

RESULTS

Even though RA areas, RA fractional area change, and maximal long-axis length measurements were abnormal in cPH patients, TA tissue Doppler imaging systolic velocity and RV fractional area change were the only useful variables in identifying patients with abnormal TAPSE (P<.0001 and P=.018, respectively). Additionally, TAPSE was independent of all RA measures, left ventricular ejection fraction, and age (P>.05).

CONCLUSIONS

Based on these results, TAPSE does not appear to be influenced by either RA size or function. Additional studies using strain echocardiography to interrogate RA mechanics might now be very useful to advance our understanding of TA motion in cPH patients given recent data showing that RA function accounts for a significantly greater proportion of total right heart function in patients with cPH than in normal subjects.

Strain Imaging Echocardiography: What Imaging Cardiologists Should Know

Despite recent advances in clinical imaging, echocardiography remains as the most accessi-ble and reliable noninvasive. Since knowledge of left ventricular systolic function remains so critically important in determining prognosis; every effort should be made to prevent subjective estimations. The advent of strain imaging echocardiography now offers a readily available and portable imaging tool that not only offers an objective characterization of myocardial dynamics; but also allows for early detection of subclinical left ventricular dysfunction. This review outlines the basic concepts of strain imaging to better understand the mechanism of myocardial function as well their applicability in the least common cardiac diagnosis among current clinical practice.

A novel semiquantitative assessment of right ventricular systolic function with a modified subcostal echocardiographic view

OBJECTIVES

The tricuspid annular plane systolic excursion (TAPSE) is a validated measure of right ventricular function; however, the apical echocardiographic window varies and has limitations in intensive care unit (ICU) patients receiving mechanical ventilation or those with underlying disease and air entrapment. We aimed to evaluate the subcostal echocardiographic assessment of tricuspid annular kick (SEATAK) as an alternative to TAPSE in critically ill patients.

METHODS

To measure SEATAK, we obtained the subcostal inferior vena cava view and used M-mode to measure excursion of the tricuspid annulus (kick). Analysis was performed with JMP for Bland-Altman and Spearman correlations.

RESULTS

We evaluated 45 patients, 26 (57.8%) of whom were women, with a mean age of 60.8 years. We were not able to obtain the apical view to measure TAPSE in 8.9% of the patients. In contrast, SEATAK was measured in all patients. The mean SEATAK and TAPSE were 1.62 cm and 1.93 cm, respectively, with a mean pairwise difference of -0.26 cm (95% CI: -0.19 to -0.35), with the SEATAK value being lower than TAPSE. The overall correlation was strong and significant (ρ = .86, P=.03). The graphical correlation was maintained between TAPSE and SEATAK and the degree of RVF.

CONCLUSION

In patients presenting with RVF in the ICU (or in situations where the apical echocardiographic view is suboptimal for tricuspid annular assessment), SEATAK can be an alternative to TAPSE. Further research is needed to validate and determine the sensitivity and specificity of SEATAK for RVF prognostication.

Tricuspid annular plane systolic excursion correlates with exercise capacity in a cohort of patients with hypoplastic left heart syndrome after Fontan operation

OBJECTIVE

Tricuspid annular plane systolic excursion (TAPSE) is a reproducible measure of right ventricular systolic function. We sought to determine the reliability of TAPSE measurements, to evaluate TAPSE in patients with hypoplastic left heart syndrome (HLHS) relative to normal values, and to correlate values of TAPSE with measures of exercise performance.

DESIGN

Tricuspid annular plane systolic excursion measurements were performed off-line in the cohort of patients with single right ventricle anatomy who had been enrolled in the Sildenafil After Fontan Operation clinical trial. These values were converted to z-scores using age-specific means and standard deviations according to published reference values. Reproducibility of measurements was assessed using the coefficient of variation between two readers. Comparisons between echo measurements and exercise outcomes were assessed using Pearson correlation coefficients.

RESULTS

Forty-four echocardiograms from 11 subjects were included in this analysis. The median age of included subjects was 13 years (range 12-17). The coefficient of variation for TAPSE measurements was 5.0%. TAPSE was significantly diminished relative to reference values, with a median z-score of -7.6. TAPSE values correlated with both maximal oxygen consumption (R=.64; P=.033) and oxygen consumption at the anaerobic threshold (R=.73, P=.017).

CONCLUSIONS

In this small sample of children with HLHS, TAPSE was reproducible, substantially lower than reference values, and correlated well with measures of exercise performance. Further studies are needed to evaluate these findings in a larger cohort and in a longitudinal manner.

Methods for Evaluating Right Ventricular Function and Ventricular-Arterial Coupling

Right ventricular function (RVF) carries great prognostic significance in heart failure and pulmonary hypertension (PH). Although there is considerable focus on RVF in pulmonary arterial hypertension, RVF is also of great importance in group 2 PH. This article will discuss assessment of RVF and evaluation of the Right Ventricle-Pulmonary Artery (RV-PA) coupling relationship. Cardiac imaging modalities allow direct visualization and assessment of RVF. Imaging modalities include the commonly utilized echo-Doppler imaging evaluating RV fractional area change, tricuspid annular plane systolic excursion and Tissue Doppler Imaging, in addition to the increasingly utilized cardiac magnetic resonance. Invasive hemodynamic assessment also plays an important role and can also be employed during exercise to help elucidate functional reserve. Cardiopulmonary exercise testing provides added insight into the mechanisms of cardiopulmonary disease. Cardiac imaging, invasive hemodynamics, and gas exchange stress testing can be combined to give a more sophisticated understanding of RVF. The RV-PA coupling relationship can be assessed using practical and clinically available metrics in order to gain clinically relevant understanding of the patients' physiologic state. RV-PA coupling assessments can be done using invasive, combined noninvasive-invasive, or non-invasive approaches. We also discuss our approaches in the assessment of the RV-PA coupling relationship.

Detection of Early Right Ventricular Dysfunction in Young Patients With Thalassemia Major Using Tissue Doppler Imaging

Background

Myocardial iron overload is the most common cause of mortality in patients with thalassemia major (TM), also known as beta-thalassemia. T2* cardiovascular magnetic resonance imaging (MRI) is the best way of monitoring cardiac iron, and new echocardiographic techniques can be used to assess cardiac function.

Objectives

The aim of this study was to assess the systolic and diastolic right ventricular (RV) function of patients with TM using tissue Doppler imaging (TDI) and to determine whether this echocardiographic technique is an adequate diagnostic tool for the screening and detection of subclinical cardiac dysfunction.

Patients and Methods

Eighty-four patients with TM were evaluated by conventional echocardiography and pulse-wave TDI. The data of the TM group (Group 1) were compared with that of 85 age- and sex-matched healthy controls (Group 2). Cardiovascular T2* MRI examinations were performed in 49 of the 85 patients.

Results

The patients with TM had significantly lower values for weight, height, body mass index, systolic arterial pressure, deceleration time, E’/A’, and ejection time (ET) than the controls. Group 1 also had significantly higher values for peak early diastolic velocity (E) over peak late diastolic velocity (A), peak early diastolic velocity of TDI (E’), peak late diastolic velocity of TDI (A’), E/E’, isovolumetric relaxation time, isovolumetric contraction time, and RV magnetic perfusion imaging (MPI) than Group 2.

Conclusions

RV diastolic dysfunction occurs before systolic deterioration in patients with TM and cannot be screened with conventional echocardiographic techniques. In routine practice, TDI measurements, MPI (for global function) and the E/E’ parameter (for diastolic function) can be used to screen and detect early RV dysfunction.

Right Bundle Branch Block and Electromechanical Coupling of the Right Ventricle: An Echocardiographic Study

Background:

A growing body of evidence suggests that the presence of a right bundle branch block (RBBB) is a negative prognostic indicator in patients with and without preexisting heart disease. Even though electromechanical activation of the right ventricle (RV) in patients with RBBB and pulmonary hypertension (PH) has been investigated; a direct comparison of the presence of RBBB, on the duration of RV mechanical systole using echocardiography has not been studied.

Materials and Methods:

In this retrospective study, we analyzed the echocardiograms of 40 patients by measuring the magnitude and timing of tricuspid annulus plane systolic excursion (TAPSE) and tricuspid annulus systolic velocity (TA S’). Patients were selected to form four groups of ten patients based on the presence or absence of RBBB and PH to determine if RBBB has any effect on the time-to-peak of TAPSE or TA S’, which for our purposes serves as a measure of duration of RV mechanical systole.

Results:

Our results demonstrate that RBBB leads to a measurable prolongation of TAPSE and TA S’ in patients without PH. Time-to-peak of TAPSE or TA S’ was not significantly prolonged in patients with PH.

Conclusions:

The results of this pilot study show that RV mechanical systole is prolonged in patients with RBBB, and the addition of PH attenuates this change. Additional prospective studies are now required to elucidate further the electrical and mechanical dyssynchrony that occurs as a result of RBBB, and how these new echocardiographic measurements can be applied clinically to risk stratify patients with RBBB and PH.

How best to assess right ventricular function by echocardiography

Right ventricular function is a crucial determinant of long-term outcomes of children with heart disease. Quantification of right ventricular systolic and diastolic performance by echocardiography is of paramount importance, given the prevalence of children with heart disease, particularly those with involvement of the right heart, such as single or systemic right ventricles, tetralogy of Fallot, and pulmonary arterial hypertension. Identification of poor right ventricular performance can provide an opportunity to intervene. In this review, we will go through the different systolic and diastolic indices, as well as their application in practice. Quantification of right ventricular function is possible and should be routinely performed using a combination of different measures, taking into account each disease state. Quantification is extremely useful for individual patient follow-up. Laboratories should continue to strive to optimise reproducibility through quality improvement and quality assurance efforts in addition to investing in technology and training for new, promising techniques, such as three-dimensional echocardiography.

Essential echocardiographic evaluation in patients with suspected pulmonary hypertension: an overview for the practicing physician

Prompt and accurate diagnosis of patients presenting with symptoms suggestive of pulmonary arterial hypertension (PAH) is of outmost importance as delays in identifying this clinical entity have detrimental effects on both morbidity and mortality. Initial noninvasive assessment of these patients has traditionally included a number of routine tests of which transthoracic echocardiography (TTE) has been shown to either confirm the presence of structural anomalies of the right ventricle (RV) indicative of PAH or exclude other potential causes of pulmonary hypertension (PH). Consequently, TTE has become a well-validated and readily available imaging tool not only used for this initial screening but also for routine follow-up of PH patients. Since chronic PH is known to unbalance the normal hemodynamic and mechanical homeostatic interaction between the RV and pulmonary circulation; the resulting response is that of an abnormal RV remodeling, clinically translated into progressive RV hypertrophy and dilatation. An enlarged and hypertrophied RV not only would eventually lose effective contractility but also this gradual decline in RV systolic function is the main abnormality in determining adverse clinical outcomes. Therefore, it is of outmost importance that TTE examination be comprehensive but most importantly accurate and reproducible. This review aims to highlight the most important objective measures that can be routinely employed, without added complexity, that will certainly enhance the interpretation and advance our understanding of the hemodynamic and mechanical abnormalities that PH exerts on the RV.

Both Systemic and Pulmonary Artery Stiffness Predict Ventricular Functional Recovery after Successful Percutaneous Closure of Atrial Septal Defects in Adults

BACKGROUND

Percutaneous closure of atrial septal defect (ASD) has become the preferred method in treatment of the majority of cases. The aim of this study was to evaluate the echocardiographic effects of percutaneous closure of secundum ASD in adults and assess which parameters predict good response to closure.

DESIGN

We prospectively included 42 patients with secundum ASD treated successfully with percutaneous device closure. All patients underwent transthoracic echocardiography examination with tissue Doppler imaging before, 24 hours after and within 3 months of intervention. Measurements of arterial stiffness were carried out using a Mobil-O-Graph arteriography system.

RESULTS

Remodeling of heart chambers occurred immediately and persisted at 3 months after ASD closure. Significant decreases were observed in right ventricle (RV) end-diastolic diameter, right atrium volume index, and tricuspid annular plane systolic excursion both after the procedure and at 3 months (P < .01 for all). The RV and left ventricle (LV) tissue Doppler-myocardial performance index demonstrated to decline during follow up (P = .0001). Significant correlations were found between pulse-wave velocity, augmentation index, pulmonary artery stiffness, and LV-RV tissue Doppler-myocardial performance index at third month. Linear regression analyses showed that pulse-wave velocity is the most effective parameter of LV and pulmonary artery stiffness is the most effective parameter of RV functional recovery, respectively, assessed by tissue Doppler-myocardial performance index.

CONCLUSIONS

Percutaneous closure of secundum ASD in adults has various sustained benefits on multiple echocardiographic parameters within 3 months. The changes in RV and LV function after device closure were significantly correlated with the degree of pulmonary artery stiffness and pulse-wave velocity, respectively.