Reference values of right ventricular end-diastolic area defined by ethnicity and gender in a young adult population: the CARDIA study

Outcomes of Adults With Unrepaired Partial Anomalous Pulmonary Venous Return and Intact Atrial Septum

BACKGROUND

The purpose of this study was to describe the correlates and outcomes in adults with unrepaired partial anomalous pulmonary venous return and intact atrial septum (PAPVR-IAS).

METHODS AND RESULTS

We identified adults with PAPVR-IAS who received care at the Mayo Clinic, while those with unrepaired PAPVR-IAS comprised the reference group. Clinical indices (New York Heart Association class, peak oxygen consumption, and NT-proBNP [N-terminal pro-B-type natriuretic peptide]) and echo-derived right heart indices (right atrial [RA] volume, RA reservoir strain, right ventricular [RV] free wall strain, RV end-diastolic area, and RV systolic pressure) were assessed at baseline and 3-year and 5-year follow-up. There were 80 patients and 38 patients with unrepaired versus repaired PAPVR-IAS, respectively. The clinical predictors of surgical repair were the number of anomalous veins, RA volume, and RV end-diastolic area. The PAPVR-IAS risk score, derived from these clinical predictors, was associated with surgical repair (adjusted odds ratio, 1.37 [95% CI, 1.24-1.65] per unit increase in risk score; area under the curve, 0.742). Among patients with unrepaired PAPVR-IAS with 3-year (n=73) and 5-year follow-up (n=36), there was no temporal change in clinical indices (New York Heart Association class, predicted peak oxygen consumption, and NT-proBNP) and right heart indices (RA volume index, RA reservoir strain, RV end-diastolic area index, RV free wall strain, and RV systolic pressure).

CONCLUSIONS

The PAPVR-IAS risk score can be used to assess the odds of requiring surgical repair. Furthermore, there was no temporal deterioration in clinical and right heart indices during follow-up in adults with unrepaired PAPVR-IAS.

Multiparametric evaluation of right ventricular function in pulmonary arterial hypertension associated with congenital heart disease

INTRODUCTION AND OBJECTIVES

Outcome in patients with congenital heart diseases and pulmonary arterial hypertension (PAH) is closely related to right ventricular (RV) function. Two-dimensional echocardiographic parameters, such as strain imaging or RV end-systolic remodeling index (RVESRI) have emerged to quantify RV function.

METHODS

We prospectively studied 30 patients aged 48±12 years with pretricuspid shunt and PAH and investigated the accuracy of multiple echocardiographic parameters of RV function (tricuspid annular plane systolic excursion, tricuspid annular peak systolic velocity, RV systolic-to-diastolic duration ratio, right atrial area, RV fractional area change, RV global longitudinal strain and RVESRI) to RV ejection fraction measured by cardiac magnetic resonance.

RESULTS

RV ejection fraction <45% was observed in 13 patients (43.3%). RV global longitudinal strain (ρ [Spearman's correlation coefficient]=-0.75; P=.001; R²=0.58; P=.001), right atrium area (ρ=-0.74; P <.0001; R²=0.56; P <.0001), RVESRI (ρ=-0.64; P <.0001; R²=0.47; P <.0001), systolic-to-diastolic duration ratio (ρ=-0.62; P=.0004; R²=0.47; P <.0001) and RV fractional area change (ρ=0.48; P=.01; R²=0.37; P <.0001) were correlated with RV ejection fraction. RV global longitudinal strain, RVESRI and right atrium area predicted RV ejection fraction <45% with the greatest area under curve (0.88; 95%CI, 0.71-1.00; 0.88; 95%CI, 0.76-1.00, and 0.89; 95%CI, 0.77-1.00, respectively). RV global longitudinal strain >-16%, RVESRI ≥ 1.7 and right atrial area ≥ 22 cm² predicted RV ejection fraction <45% with a sensitivity and specificity of 87.5% and 85.7%; 76.9% and 88.3%; 92.3% and 82.4%, respectively.

CONCLUSIONS

RVESRI, right atrial area and RV global longitudinal strain are strong markers of RV dysfunction in patients with pretricuspid shunt and PAH.

The Coronary Artery Risk Development In Young Adults (CARDIA) Study: JACC Focus Seminar 8/8

The CARDIA (Coronary Artery Risk Development in Young Adults) study began in 1985 to 1986 with enrollment of 5,115 Black or White men and women ages 18 to 30 years from 4 US communities. Over 35 years, CARDIA has contributed fundamentally to our understanding of the contemporary epidemiology and life course of cardiovascular health and disease, as well as pulmonary, renal, neurological, and other manifestations of aging. CARDIA has established associations between the neighborhood environment and the evolution of lifestyle behaviors with biological risk factors, subclinical disease, and early clinical events. CARDIA has also identified the nature and major determinants of Black-White differences in the development of cardiovascular risk. CARDIA will continue to be a unique resource for understanding determinants, mechanisms, and outcomes of cardiovascular health and disease across the life course, leveraging ongoing pan-omics work from genomics to metabolomics that will define mechanistic pathways involved in cardiometabolic aging.

Prognostic Significance of Echocardiographic Measures of Cardiac Remodeling in the Community

PURPOSE OF REVIEW

Echocardiography is a noninvasive tool of choice for evaluating cardiac structure and function in numerous cardiac conditions ranging from congenital heart disease, myocardial diseases, coronary artery disease (CAD), valvulopathies, arrhythmias, and pericardial disorders. We review the prognostic significance of echocardiographic indices of cardiac remodeling in the general population.

RECENT FINDINGS

Recent meta-analyses have confirmed the prognostic significance of echocardiographic measurements (left ventricular mass/hypertrophy, systolic and diastolic dysfunction, left atrial dimensions and function, and strain rate measures) in asymptomatic people in the community for adverse clinical outcomes including CAD, stroke, heart failure, atrial fibrillation, sudden death, and all-cause mortality. The clinical utility of screening echocardiography has been examined comprehensively in hypertensive patients, where it is challenged by measurement variability. Echocardiographic measures predict cardiovascular disease outcomes consistently in multiple community-based epidemiological studies. However, the clinical utility of screening asymptomatic individuals with echocardiography in population-based settings is limited.

Patient characteristics and surgical variables associated with intraoperative reduced right ventricular function

OBJECTIVE

Perioperative right ventricular function is a significant predictor of patient outcomes after cardiac surgery. This prospective study aimed to identify perioperative factors associated with reduced intraoperative right ventricular function.

METHODS

Right ventricular function was assessed at the beginning and end of surgery by standardized transesophageal echocardiographic measurements, including tricuspid annular plane systolic excursion, peak systolic longitudinal right ventricular strain, and fractional area change, in 109 adult patients undergoing cardiac surgery at Cleveland Clinic. Associations between right ventricular function and 33 patient characteristics and perioperative factors were analyzed by random forest machine learning. The relative importance of each variable in predicting right ventricular function at the end of surgery was determined.

RESULTS

Longer aortic clamp duration and lower baseline right ventricular function were highly important variables for predicting worse right ventricular function measured by tricuspid annular plane systolic excursion, right ventricular strain, and fractional area change at the end of surgery. For example, right ventricular function after longer aortic clamp times of 100-120 minutes was worse (median [Q1, Q3] tricuspid annular plane systolic excursion 1.0 [0.9, 1.1] cm) compared with right ventricular function after shorter aortic clamp times of 50 to 70 minutes (tricuspid annular plane systolic excursion 1.5 [1.3, 1.7]; P = .001). Right ventricular strain at the end of surgery was reduced in patients with worse baseline right ventricular function compared with those with higher baseline right ventricular function (end of surgery right ventricular strain in lowest quartile -13.7 [-16.6, -12.4]% vs highest quartile -17.7 [-18.6, -15.3]% of baseline right ventricular function; P = .043).

CONCLUSIONS

Intraoperative decline in right ventricular function is associated with longer aortic clamp time and worse baseline right ventricular function. Efforts to optimize these factors, including better myocardial protection strategies, may improve perioperative right ventricular function.

The Obesity Paradox in Patients with Significant Tricuspid Regurgitation: Effects of Obesity on Right Ventricular Remodeling and Long-Term Prognosis

BACKGROUND

Obesity may cause right ventricular (RV) remodeling due to volume overload. However, obesity is also associated with better prognosis compared with normal weight in patients with various cardiac diseases. The aim of this study was to assess the impact of obesity on RV remodeling and long-term prognosis in patients with significant (moderate and severe) tricuspid regurgitation (TR).

METHODS

A total of 951 patients with significant TR (median age, 70 years; interquartile range, 61-77 years; 50% men) were divided into three groups according to body mass index (BMI): normal weight (BMI 18.5-24.9 kg/m²), overweight (BMI 25-29.9 kg/m²), and obese (BMI ≥ 30 kg/m²). Patients with congenital heart disease, peripheral edema, active endocarditis, and BMI < 18.5 kg/m² were excluded. RV size and function for each group were measured using transthoracic echocardiography and compared with reference values of healthy study populations. The primary end point was all-cause mortality. Event rates were compared across the three BMI categories.

RESULTS

Four hundred seventy-six patients (50%) with significant TR had normal weight, 356 (37%) were overweight, and 119 (13%) were obese. RV end-diastolic and end-systolic areas were larger in overweight and obese patients compared with normal-weight patients. However, no differences in RV systolic function were observed. During a median follow-up period of 5 years, 358 patients (38%) died. Five-year survival rates were significantly better in overweight and obese patients compared with patients with normal weight (65% and 67% vs 58%, respectively, P < .001 and P = .005). In multivariate analysis, overweight and obesity were independently associated with lower rates of all-cause mortality compared with normal weight (hazard ratios, 0.628 [95% CI, 0.493-0.800] and 0.573 [95% CI, 0.387-0.848], respectively).

CONCLUSIONS

In patients with significant TR, overweight and obese patients demonstrated more RV remodeling compared with patients with normal weight. Nevertheless, a higher BMI was independently associated with better long-term survival, confirming the obesity paradox in this context.

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.

Regression equations for calculation of z scores for echocardiographic measurements of right heart structures in healthy Han Chinese children

OBJECTIVE

Clinical decision making in children with congenital and acquired heart disease relies on measurements of cardiac structures using two-dimensional echocardiography. We aimed to establish z-score regression equations for right heart structures in healthy Chinese Han children.

METHODS

Two-dimensional and M-mode echocardiography was performed in 515 patients. We measured the dimensions of the pulmonary valve annulus (PVA), main pulmonary artery (MPA), left pulmonary artery (LPA), right pulmonary artery (RPA), right ventricular outflow tract at end-diastole (RVOTd) and at end-systole (RVOTs), tricuspid valve annulus (TVA), right ventricular inflow tract at end-diastole (RVIDd) and at end-systole (RVIDs), and right atrium (RA). Regression analyses were conducted to relate the measurements of right heart structures to 4body surface area (BSA). Right ventricular outflow-tract fractional shortening (RVOTFS) was also calculated. Several models were used, and the best model was chosen to establish a z-score calculator.

RESULTS

PVA, MPA, LPA, RPA, RVOTd, RVOTs, TVA, RVIDd, RVIDs, and RA (R²  = 0.786, 0.705, 0.728, 0.701, 0.706, 0.824, 0.804, 0.663, 0.626, and 0.793, respectively) had a cubic polynomial relationship with BSA; specifically, measurement (M) = β0 + β1 × BSA + β2 × BSA²  + β3 × BSA.³ RVOTFS (0.28 ± 0.02) fell within a narrow range (0.12-0.51).

CONCLUSIONS

Our results provide reference values for z scores and regression equations for right heart structures in Han Chinese children. These data may help interpreting the routine clinical measurement of right heart structures in children with congenital or acquired heart disease. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:293-303, 2017.

Two-dimensional echocardiographic right ventricle measurements adjusted to body mass index and surface area in a normal population

BACKGROUND

To determine reference echocardiographic values in a normal population and assess their correlation with body mass index (BMI) and body surface area.

METHODS

An expert cardiologist performed two-dimensional echocardiography with triplicate right ventricle (RV) size measurements in 80 subjects with normal heart condition. Results were correlated with anthropometric data.

RESULTS

Base-to-apex length in four-chamber view (RVD3) and above-pulmonic valve in short-axis view in males, as well as mid-RV diameter in standard four-chamber view (RVD), basal RV diameter, and mid RV diameter in RV-focused four-chamber view in females, were significantly correlated with BMI. All RV variables were significantly correlated with BMI in 20-30-year-old subjects. All RV variables except RVD3 and above-aortic valve in short-axis view (proximal) were significantly correlated with BMI in 35-55-year-old subjects. All RV parameters were significantly correlated with body surface area, except for RVD and in 20-35-year-old subjects.

CONCLUSIONS

RV echocardiographic values must be adjusted to anthropometric characteristics for proper diagnosis and management of cardiac disorders. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:204-210, 2017.

Prognostic value of diastolic wall strain in patients with chronic heart failure with reduced ejection fraction

Left ventricular (LV) diastolic dysfunction plays a crucial role in heart failure with reduced ejection fraction (HFrEF). LV stiffness is a main component of diastolic function, but its role and prognostic value in HFrEF patients remains unclear. This study aimed to determine whether diastolic wall strain (DWS) as a noninvasive and simple marker of LV stiffness can predict the prognosis of HFrEF patients who were administrated chronic beta blockade enough. We enrolled 75 HFrEF patients who were administrated chronic beta blockade. We evaluated the echocardiographic parameters and plasma brain natriuretic peptide (BNP) before the induction of beta blockade and also obtained pulmonary artery wedge pressure (PAWP) from the right heart catheterization. DWS was obtained from standard M-mode echocardiography as follows: DWS = [(LV posterior wall thickness (LVPWT) at end-systole - LVPWT at end-diastole)/LVPWT] at end-systole. DWS did not correlate with other echocardiographic parameters and PAWP. We defined primary outcome as HF hospitalization or cardiovascular death and followed for 7 years. The incidence rate was higher in low DWS than high DWS patients (p = 0.04). Other echocardiographic parameters could not be significant predictors of HFrEF outcome under the condition of enough beta blocker therapy. In multivariate analysis, DWS was the independent contributor to the event-free time. Impaired LV stiffness evaluated with DWS was associated with worse outcome and DWS might be an independent prognostic factor in HFrEF patients with chronic beta blockade.

Atrial flutter: Clinical risk factors and adverse outcomes in the Framingham Heart Study

BACKGROUND

Few epidemiologic cohort studies have evaluated atrial flutter (flutter) as an arrhythmia distinct from atrial fibrillation (AF).

OBJECTIVE

The purpose of this study was to examine the clinical correlates of flutter and its associated outcomes to distinguish them from those associated with AF in the Framingham Heart Study.

METHODS

We reviewed and adjudicated electrocardiograms (ECGs) previously classified as flutter or AF/flutter and another 100 ECGs randomly selected from AF cases. We examined the clinical correlates of flutter by matching up to 5 AF and 5 referents to each flutter case using a nested case referent design. We determined the 10-year outcomes associated with flutter with Cox models.

RESULTS

During mean follow-up of 33.0 ± 12.2 years, 112 participants (mean age 72 ± 10 years, 30% women) developed flutter. In multivariable analyses, smoking (odds ratio [OR] 2.84, 95% confidence interval [CI] 1.54-5.23), increased PR interval (OR 1.28 per SD, 95% CI 1.03-1.60), myocardial infarction (OR 2.25, 95% CI 1.05-4.80) and heart failure (OR 5.22, 95% CI 1.26-21.64) were associated with incident flutter. In age- and sex-adjusted models, flutter (vs referents) was associated with 10-year increased risk of AF (hazard ratio [HR] 5.01, 95% CI 3.14-7.99), myocardial infarction (HR 3.05, 95% CI 1.42-6.59), heart failure (HR 4.14, 95% CI 1.90-8.99), stroke (HR 2.17, 95% CI 1.13-4.17), and mortality (HR 2.00, 95% CI 1.44-2.79).

CONCLUSION

We identified the clinical correlates associated with flutter and observed that flutter was associated with multiple adverse outcomes.

Reference ranges for and determinants of right ventricular area in healthy adults by two-dimensional echocardiography

BACKGROUND

The right ventricular (RV) area is important for diagnosis and follow-up in patients with various diseases, such as in pulmonary hypertension.

OBJECTIVES

The aim of this study was to define the reference ranges of the end-diastolic RV area in healthy adults and to assess the determining factors.

METHODS

In the first part of the study 860 healthy subjects (37.6% female; mean age 28 ± 5.84; 395 endurance athletes, 255 strength athletes and 210 non-athletes) were prospectively assessed. In the second part we performed a pooled analysis of studies published between 1979 and 2014 describing the RV area in healthy subjects (n = 5,248). Statistical analysis included the calculation of reference ranges and the analysis of determining factors.

RESULTS

Mean end-diastolic RV areas in 860 healthy subjects were significantly larger in endurance athletes (25.1 ± 2.0 cm(2)) compared with strength athletes (22.9 ± 1.7 cm(2)) and non-athletes (16.7 ± 2.0 cm(2), p < 0.001). In the synopsis of both data sets, mean end-diastolic RV area was significantly larger in European/American males (17 cm(2)) compared with females (14 cm(2), p < 0.001) and in Asian males (16 cm(2)) compared with females (13 cm(2), p < 0.001). The area increased with body surface area and older age.

CONCLUSION

This is the largest data set to define RV size in healthy adults aged <50 years. RV area was determined by age, gender, body surface area, ethnicity and high-level exercise training. High standard deviations resulted in high values for the upper limit of the reference range, which might therefore not be useful as cut-off values for screening purposes. Gender- and ethnicity-specific reference ranges should be used. Further studies in subjects aged >50 years as well as in children are needed.

Acute hemodynamic effects of riociguat in patients with pulmonary hypertension associated with diastolic heart failure (DILATE-1): a randomized, double-blind, placebo-controlled, single-dose study

BACKGROUND:

Deficient nitric oxide-soluble guanylate cyclase-cyclic guanosine monophosphate signaling results from endothelial dysfunction and may underlie impaired cardiac relaxation in patients with heart failure with preserved left ventricular ejection fraction (HFpEF) and pulmonary hypertension (PH). The acute hemodynamic effects of riociguat, a novel soluble guanylate cyclase stimulator, were characterized in patients with PH and HFpEF.

METHODS:

Clinically stable patients receiving standard HF therapy with a left ventricular ejection fraction > 50%, mean pulmonary artery pressure (mPAP) ≥ 25 mm Hg, and pulmonary arterial wedge pressure (PAWP) > 15 mm Hg at rest were randomized to single oral doses of placebo or riociguat (0.5, 1, or 2 mg). The primary efficacy variable was the peak decrease in mPAP from baseline up to 6 h. Secondary outcomes included hemodynamic and echocardiographic parameters, safety, and pharmacokinetics.

RESULTS:

There was no significant change in peak decrease in mPAP with riociguat 2 mg (n = 10) vs placebo (n = 11, P = .6). However, riociguat 2 mg significantly increased stroke volume (+9 mL [95% CI, 0.4-17]; P = .04) and decreased systolic BP (−12 mm Hg [95% CI, −22 to −1]; P = .03) and right ventricular end-diastolic area (−5.6 cm² [95% CI, −11 to −0.3]; P = .04), without significantly changing heart rate, PAWP, transpulmonary pressure gradient, or pulmonary vascular resistance. Riociguat was well tolerated.

CONCLUSIONS:

In patients with HFpEF and PH, riociguat was well tolerated, had no significant effect on mPAP, and improved exploratory hemodynamic and echocardiographic parameters.

TRIAL REGISTRY:

ClinicalTrials.gov; No.: NCT01172756; URL: www.clinicaltrials.gov

Reference absolute and indexed values for left and right ventricular volume, function and mass from cardiac computed tomography

INTRODUCTION

Left ventricular (LV) and right ventricular (RV) volumetric and functional parameters are important biomarkers for morbidity and mortality in patients with heart failure.

PURPOSE

To retrospectively determine reference mean values of LV and RV volume, function and mass normalised by age, gender and body surface area (BSA) from retrospectively electrocardiographically gated 64-slice cardiac computed tomography (CCT) by using automated analysis software in healthy adults.

MATERIALS AND METHODS

The study was approved by the institutional review board with a waiver of informed consent. Seventy-four healthy subjects (49% female, mean age 49.6 ± 11) free of hypertension and hypercholesterolaemia with a normal CCT formed the study population. Analyses of LV and RV volume (end-diastolic, end-systolic and stroke volumes), function (ejection fraction), LV mass and inter-rater reproducibility were performed with commercially available analysis software capable of automated contour detection. General linear model analysis was performed to assess statistical significance by age group after adjustment for gender and BSA. Bland-Altman analysis assessed the inter-rater agreement.

RESULTS

The reference range for LV and RV volume, function, and LV mass was normalised to age, gender and BSA. Statistically significant differences were noted between genders in both LV mass and RV volume (P-value < 0.0001). Age, in concert with gender, was associated with significant differences in RV end-diastolic volume and LV ejection fraction (P-values 0.027 and 0.03). Bland-Altman analysis showed acceptable limits of agreement (±1.5% for ejection fraction) without systematic error.

CONCLUSION

LV and RV volume, function and mass normalised to age, gender and BSA can be reported from CCT datasets, providing additional information important for patient management.

Reproducibility and correlations of right ventricular end-diastolic volume index measured by real-time three-dimensional echocardiography

BACKGROUND

To correlate right ventricular volumes measured by real-time three-dimensional echocardiography (RT3DE) with left ventricular volume indices in patients with or without left-sided heart diseases.

METHODS

For this retrospective, we reviewed 806 consecutive RT3DE examinations with quantitative evaluation of both the left and the right (RV) ventricle. We excluded cases of disease or surgery that would directly affect the size of the RV (eg, intracardiac shunt, significant tricuspid, or pulmonic regurgitation) as well as poor sonographic image quality, leaving a total of 701 studies for analysis. RV volumetric quantification was performed using dedicated software.

RESULTS

Linear regression analysis showed that left ventricular stroke volume index significantly correlated with RV end-diastolic volume index (RVEDVI) (r = 0.78, p < 0.0001). Overall, 4% (28 of 701) of the patients had RVEDVI lower than 50 ml/m(2) , and 12% (84 of 701) had RVEDVI greater than 100 ml/m(2) . Intraclass correlation coefficient ranged from 0.91 to 0.99 for intraobserver and 0.85 to 0.98 for interobserver reproducibility.

CONCLUSIONS

RT3DE was feasible and reproducible for quantifying RV volume. In patients without known primary RV pathology, RV volume strongly correlated with left ventricular stroke volume.