Right ventricular functional recovery after acute myocardial infarction: relation with left ventricular function and interventricular septum motion. GISSI-3 echo substudy

Paradoxical increase in left atrial strains early after Covid-19 infection, a result of comprehensive recovery phase four-chamber strains study

Cardiac consequences of Covid-19 infection have been mentioned in various studies as a serious risk factor for in-hospital mortality. However, the existence of residual cardiac dysfunction after the acute phase is seldom investigated especially in people without a history of specific medical disease. One hundred health care workers with positive reverse transcription-polymerase chain reaction test underwent comprehensive 2D and 3D echocardiography six to eight weeks after infection. Patients were classified into Mild, Moderate, and Severe groups based on their clinical characteristics of covid-19 infection, and all echocardiographic parameters were compared between the three groups. Left ventricular (LV) stroke volume index was reduced in all groups compared to normal ranges and was more prominent in the severe group (P-value < 0.05). 3D-derived LV global longitudinal strain (GLS) was significantly lower in the severe group in comparison to the mild group (- 19.3 ± 1 Vs. - 22.2 ± 2, P-value < 0.001) and correlated with highly sensitive CRP level at the acute phase. Left atrial (LA) strains, including LA peak strain, LA contraction strain, and LA reservoir strain, were considerably higher and LA volume index was significantly lower in the clinically severe covid patients. Analysis based on the extent of lung involvement showed significantly increased 3D-derived right ventricular volumes in patients who experienced severe pneumonia despite normalized strains. Conclusion: subclinical LV dysfunction as reduced stroke volume index and GLS exists in the early recovery phase of normal individuals with severe course of covid-19. LA function indicated by LA strains paradoxically increases in severe covid-19 infection in this phase.

Speckle-tracking echocardiographic evaluation of the right ventricle in patients with ischemic left ventricular dysfunction

BACKGROUND

The comprehensive assessment of right ventricular (RV) performance is of paramount importance because it is has been recognized as a strong prognostic factor in a variety of clinical settings. The aim herein was to evaluate the usefulness of RV longitudinal strain imaging by speckle-tracking echocardiography (STE) in daily clinical practice, especially in the context of RV systolic function and its changes after acute coronary syndrome (ACS).

METHODS

This prospective study enrolled 63 patients with ischemic injury (left ventricular ejection fraction [LVEF] ≤ 45%). Additionally, a subgroup was created: patients with ACS treated with successful percutaneous coronary intervention. The clinical and echocardiographic parameters, including STE, were analyzed.

RESULTS

Significant correlations for both RV free-wall (RVFWSL) and four-chamber (RV4CSL) longitudinal strain evaluated by STE with New York Heart Association class, LVEF, E/E' ratio, as well as conventional parameters of RV function were found. RVFWSL was able to detect subtle RV functional abnormalities, unreachable for traditional indices. RV recovery after ACS was not related to higher LVEF but better contractility of the interventricular septum (IVS) assessed by STE.

CONCLUSIONS

Right ventricular strain proved to be a useful two-dimensional echocardiographic method to detect impaired RV performance, which showed a significant relationship with clinical and other echocardiographic indices. The IVS played a vital role in RV recovery among ACS survivors.

Impact of percutaneous coronary intervention in right coronary artery on right ventricular function in patients with acute myocardial infarction

Background: Right ventricular (RV) dysfunction is a potent predictor of mortality and morbidity following acute myocardial infarction (AMI). Despite the fact that elective percutaneous coronary intervention (PCI) has significantly decreased myocardial damage to the left ventricle, there is a lack of information regarding the effect of PCI on RV function. Aim: This study aimed to examine the effect of right coronary artery (RCA) revascularization on the systolic and diastolic functions of the right ventricle following acute inferior wall myocardial infarction. Methods: Fifty-nine patients diagnosed with acute inferior wall myocardial infarction after RCA revascularization were prospectively investigated between April 2018 and January 2020. The patients underwent 2D echocardiography. RV systolic and diastolic functions were reported before and after the PCI procedure and compared using echocardiographic RV systolic and diastolic parameters. Results: After PCI, echocardiographic RV systolic and diastolic functions significantly improved in the proximal and mid RCA in terms of TAPSE, RVFAC, and E/A. Significant improvement was found in the mid RCA in terms of S' velocity (p = 0.008) and in the proximal RCA in terms of E/e' (p = 0.021). Overall echocardiographic systolic and diastolic parameters in patients with RV dysfunction following PCI were improved [TAPSE (37.29% vs. 81.82%), S' velocity (37.29% vs. 68.18%), RVFAC (33.90% vs. 90.00%), and E/A (33.90% vs. 75.00%)]. Conclusion: Our findings revealed that patients with RV dysfunction showed remarkable improvement after RCA revascularization. Hence, in future cases, RCA revascularization may become an appropriate treatment alternative for the recovery of patients with RV dysfunction.

Prognostic Relevance of Right Ventricular Remodeling after ST-Segment Elevation Myocardial Infarction in Patients Treated With Primary Percutaneous Coronary Intervention

ST-segment elevation myocardial infarction (STEMI) often leads to changes in right ventricular (RV) function and size over time. The prognostic implications of RV remodeling after STEMI, however, are unknown. RV remodeling in patients who underwent STEMI with primary percutaneous coronary intervention (PCI) was defined by RV end-systolic area (RV ESA) change at 6 months after STEMI compared with baseline. The optimal threshold of RV ESA change (≥40%) to define RV remodeling was derived from spline curve analysis. Long-term outcomes were compared between patients with and without RV remodeling. A total of 2,280 patients were analyzed (mean age 60 ± 11 years, 76% were men). RV remodeling was present in 315 patients (14%). After a median follow-up of 76 months (interquartile range 51 to 106 months), 271 patients (12%) died (primary end point) and the composite end point of all-cause mortality and HF hospitalization (secondary end point) was observed in 292 patients (13%). After adjustment for various risk factors, including tricuspid annular plane systolic excursion (TAPSE), post-STEMI RV remodeling was independently associated with a higher risk of all-cause mortality (hazard ratio [HR] = 1.44, 95% confidence interval [CI] 1.02 to 2.02, p = 0.038) and the composite of all-cause mortality and HF hospitalization (HR = 1.41, 95% CI 1.02 to 1.96, p = 0.040). Finally, patients with RV remodeling had a significantly lower survival rate (Log-rank, p = 0.006) and event-free survival rate than those without RV remodeling during follow-up (log-rank, p = 0.006). RV post-infarct remodeling is associated with mortality and HF hospitalization, independent of RV systolic function.

Role of N-terminal pro-B-type natriuretic peptide and troponin T in predicting right ventricular recovery in myocardial infarction

OBJECTIVES

The determinants of right ventricular (RV) recovery after successful revascularization in ST-elevation myocardial infarction (STEMI) patients are not clear. Besides, the relationship between Troponin T (TnT), N-terminal pro-B-type natriuretic peptide (NT-proBNP) and improvement in RV function is also unknown. This study hypothesizes that a lower TnT and NT-proBNP level would be associated with RV recovery.

METHODS

One hundred forty-eight STEMI patients were included in our study. Echocardiography were performed before and 12-18 weeks after discharge. Patients were divided into three groups according to the changes in tricuspid annular plane systolic excursion (TAPSE) as 53 patients with ≥10% change, 41 patients with 1-9% change, and 54 patients ≤0% change. RV recovery was accepted as ≥10% TAPSE improvement and the predictors of RV recovery were investigated.

RESULTS

RV recovery was detected in 35.8% of the patients. Low baseline left ventricular ejection fraction (OR: 0.91 [0.84-0.98], p=0.023), NT-proBNP (OR: 0.93 [0.89-0.98], p=0.014), TnT (OR: 0.84 [0.68-0.93], p=0.038), inferior myocardial infarction (OR: 2.66 [1.10-6.40], p=0.028), wall motion score index ratio (OR: 0.93 [0.88-0.97], p=0.002) and post-percutaneous coronary intervention TIMI flow 3 (OR: 5.84 [1.41-24.22], p=0.015) were determined as independent predictors of RV recovery. Being in the high TnT group 4.2 times, and being in the high NT-proBNP group 5.3 times could predict the failure to achieve RV recovery. Furthermore, when high TnT level was combined with high NT-proBNP level, the odds ratio of failure to achieve RV recovery was the highest (OR: 8.03 [2.59-24.89], p<0.001).

CONCLUSIONS

Lower TnT and lower NT-proBNP level was associated with better improvement in RV function in STEMI patients.

Short- and long-term prognostic value of right ventricular function in patients with first acute ST elevation myocardial infarction treated by primary angioplasty

INTRODUCTION

Limited data are known about the prognostic value of right ventricle (RV) function in patients with first acute ST-segment elevation myocardial infarction (STEMI). The aim of this study was to investigate the prognostic value of RV dysfunction in predicting both in-hospital and long-term outcomes in these patients, irrespective of the site of necrosis.

METHODS

We enrolled 502 consecutive patients with first acute STEMI treated with primary angioplasty and underwent echocardiography within 48 hours of admission. RV function was evaluated by RV myocardial performance index (RVMPI), RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), pulsed tissue Doppler S' wave velocity, and RV global longitudinal strain (RVGLS) of the free wall. The occurrence of in-hospital major adverse cardiac events (MACE) and 1-year survival rate were recorded.

RESULTS

In MACE group, RVFAC, TAPSE, and RV S' wave velocity were lower. However, RVMPI, RVGLS, and TR Vmax. were higher than MACE free group (P < .001). In multivariable analysis adjusted for other variables that predicted adverse outcomes, RVFAC < 35% (P < .001), TAPSE < 17 mm (P < .001), RVGLS > -17% (P < .001), RV S' wave velocity < 9.5 cm/s (P = .02), RVMPI > 0.43 (P < .001), and TR Vmax. > 2.8 m/s (P = .01) were strong independent predictors of in-hospital MACE. Lower 1-year survival was noted in patients with RV dysfunction, documented by these cutoffs values.

CONCLUSION

RV dysfunction, evidenced by multiparametric echocardiography, is predictive for adverse in-hospital outcomes, and lower 1-year survival rate in first acute STEMI regardless of the site of necrosis.

Right coronary artery ligation in mice: a novel method to investigate right ventricular dysfunction and biventricular interaction

Right ventricular (RV) dysfunction can lead to complications after acute inferior myocardial infarction (MI). However, it is unclear how RV failure after MI contributes to left-sided dysfunction. The aim of the present study was to investigate the consequences of right coronary artery (RCA) ligation in mice. RCA ligation was performed in C57BL/6JRj mice ( n = 38). The cardiac phenotypes were characterized using high-resolution echocardiography performed up to 4 wk post-RCA ligation. Infarct size was measured using 2,3,5-triphenyltetrazolium chloride staining 24 h post-RCA ligation, and the extent of the fibrotic area was determined 4 wk after MI. RV dysfunction was confirmed 24 h post-RCA ligation by a decrease in the tricuspid annular plane systolic excursion ( P < 0.001) and RV longitudinal strain analysis ( P < 0.001). Infarct size measured ex vivo represented 45.1 ± 9.1% of the RV free wall. RCA permanent ligation increased the RV-to-left ventricular (LV) area ratio ( P < 0.01). Septum hypertrophy ( P < 0.01) was associated with diastolic septal flattening. During the 4-wk post-RCA ligation, LV ejection fraction was preserved, yet it was associated with impaired LV diastolic parameters ( E/ E', global strain rate during early diastole). Histological staining after 4 wk confirmed the remodeling process with a thin and fibrotic RV. This study validates that RCA ligation in mice is feasible and induces RV heart failure associated with the development of LV diastolic dysfunction. Our model offers a new opportunity to study mechanisms and treatments of RV/LV dysfunction after MI. NEW & NOTEWORTHY Right ventricular (RV) dysfunction frequently causes complications after acute inferior myocardial infarction. How RV failure contributes to left-sided dysfunction is elusive because of the lack of models to study molecular mechanisms. Here, we created a new model of myocardial infarction by permanently tying the right coronary artery in mice. This model offers a new opportunity to unravel mechanisms underlying RV/left ventricular dysfunction and evaluate drug therapy.

Acute right ventricular myocardial infarction

INTRODUCTION

Acute right ventricular myocardial infarction (RVMI) is observed in 30-50% of patients presenting with inferior wall myocardial infarction (MI) and, occasionally, with anterior wall MI. The clinical consequences vary from no hemodynamic compromise to severe hypotension and cardiogenic shock depending on the extent of RV ischemia. Areas covered: The pathophysiological mechanisms, diagnostic steps, and novel therapeutic approaches of acute RVMI are described. Expert commentary: Diagnosis of acute RVMI is based on physical examination, cardiac biomarkers, electrocardiography, and coronary angiography, whereas noninvasive imaging modalities (echocardiography, cardiac magnetic resonance imaging) play a complementary role. Early revascularization, percutaneous or pharmacological, represents key step in the management of RMVI. Maintenance of reasonable heart rate and atrioventricular synchrony is essential to sustain adequate cardiac output in these patients. When conventional treatment is not successful, mechanical circulatory support, including right ventricle assist devices, percutaneous cardiopulmonary support, and intra-aortic balloon pump, might be considered. The prognosis associated with RVMI is worse in the short term, compared to non-RVMI, but those patients who survive hospitalization have a relatively good long-term prognosis.

The change in right ventricular systolic function according to the revascularisation method used, following acute ST -segment elevation myocardial infarction

OBJECTIVE

The level of right ventricular (RV) systolic function has prognostic importance in right ventricular ST-segment elevation myocardial infarction (RV-STEMI). This study aimed to evaluate the changes in RV systolic function in patients with RV-STEMI according to the revascularisation method used for their management.

METHODS

The first group consisted of 132 patients who received primary percutaneous coronary intervention (PPCI). The 78 patients who had received thrombolytic therapy (TT) in external centres before referral to our centre for PCI within three to 12 hours of RV-STEMI were included in the second group. All patients were evaluated by conventional and two-dimensional speckle-tracking echocardiography.

RESULTS

There were 172 male patients and their mean age was 63.7 ± 11.8 years. There were no significant differences between the two groups with regard to right ventricular systolic parameters at admission and at the one-month follow-up visit. The echocardiographic changes between admission and the one-month follow up were investigated for the patients included in the study groups. Mean values of each parameter observed at the one-month follow up were significantly increased compared to those at admission within each group.

CONCLUSION

Our study demonstrated that PCI within three to 12 hours following TT provided similar benefits on right ventricular systolic function compared to PPCI in patients with RV-STEMI.

The change in right ventricular systolic function according to the revascularisation method used, following acute ST -segment elevation myocardial infarction

OBJECTIVE

The level of right ventricular (RV) systolic function has prognostic importance in right ventricular ST-segment elevation myocardial infarction (RV-STEMI). This study aimed to evaluate the changes in RV systolic function in patients with RV-STEMI according to the revascularisation method used for their management.

METHODS

The first group consisted of 132 patients who received primary percutaneous coronary intervention (PPCI). The 78 patients who had received thrombolytic therapy (TT) in external centres before referral to our centre for PCI within three to 12 hours of RV-STEMI were included in the second group. All patients were evaluated by conventional and two-dimensional speckle-tracking echocardiography.

RESULTS

There were 172 male patients and their mean age was 63.7 ± 11.8 years. There were no significant differences between the two groups with regard to right ventricular systolic parameters at admission and at the one-month follow-up visit. The echocardiographic changes between admission and the one-month follow up were investigated for the patients included in the study groups. Mean values of each parameter observed at the one-month follow up were significantly increased compared to those at admission within each group.

CONCLUSION

Our study demonstrated that PCI within three to 12 hours following TT provided similar benefits on right ventricular systolic function compared to PPCI in patients with RV-STEMI.

Determination of reference values for tricuspid annular plane systolic excursion in healthy Turkish children

Objective:

Tricuspid annular plane systolic excursion (TAPSE) is an echocardiographic measurement used for evaluating right ventricular systolic function. While established reference values of TAPSE exist for the adult population, only a limited number of studies have attempted to evaluate reference values for the pediatric population. The aim of the present study was to determine the reference values for TAPSE in healthy children in Turkey.

Methods:

A total of 765 healthy children aged between 0 and 18 years, all of whom were referred to our clinic with cardiac murmurs, were evaluated prospectively. Patients with no cardiac pathologies or other disorders were excluded from the study. The measurement of TAPSE was obtained using a 2D-guided M-mode technique with echocardiography, and the relationship between age and surface area with TAPSE was investigated. The statistical analysis was carried out using the SPSS 20.0 software package (SPSS Inc., Chicago, IL, USA, 2012).

Results:

The mean TAPSE value was found to be 19.56±5.54 mm, and no significant difference was identified between male and female children. TAPSE values showed a positive correlation with increasing age and surface area. The mean TAPSE value was 9.09±1.36 mm in newborns and 25.91±3.60 mm in the 13-18 years age group. A negative correlation was seen between TAPSE and heart rate.

Conclusion:

In the present study, the reference values for TAPSE in healthy Turkish children were presented in percentile tables and the corresponding z-scores were determined. These reference values may be useful in daily practice for the evaluation of right ventricular systolic function in children.

Right ventricular function in dilated cardiomyopathy and ischemic heart disease: assessment with non-invasive imaging

Background

Dilated cardiomyopathy and ischaemic heart disease can both lead to right ventricular (RV) dysfunction. Direct comparisons of the two entities regarding RV size and function using state-of-the-art imaging techniques have not yet been performed. We aimed to determine RV function and volume in dilated cardiomyopathy and ischaemic heart disease in relation to left ventricular (LV) systolic and diastolic function and systolic pulmonary artery pressure.

Methods and results

A well-characterised group (cardiac magnetic resonance imaging, echocardiography, coronary angiography and endomyocardial biopsy) of 46 patients with dilated cardiomyopathy was compared with LV ejection fraction (EF)-matched patients (n = 23) with ischaemic heart disease. Volumes and EF were determined with magnetic resonance imaging, diastolic LV function and pulmonary artery pressure with echocardiography.

After multivariable linear regression, four factors independently influenced RVEF (R² = 0.51, p < 0.001): LVEF (r = 0.54, p < 0.001), ratio of peak early and peak atrial transmitral Doppler flow velocity as measure of LV filling pressure (r = − 0.52, p < 0.001) and tricuspid regurgitation flow velocity as measure of pulmonary artery pressure (r = − 0.38, p = 0.001). RVEF was significantly worse in patients with dilated cardiomyopathy compared with ischaemic heart disease: median 48 % (interquartile range (IQR) 37–55 %) versus 56 % (IQR 48–63 %), p < 0.05.

Conclusions

In patients with dilated cardiomyopathy and ischaemic heart disease, RV function is determined by LV systolic and diastolic function, the underlying cause of LV dysfunction, and pulmonary artery pressure. It was demonstrated that RV function is more impaired in dilated cardiomyopathy.

The assessment of septal wall motion in patients undergoing CABG by myocardial perfusion-gated SPECT

PURPOSE

In this study, we aimed to assess the presence and prevalence of paradoxical septal motion (PSM) by myocardial perfusion-gated single-photon emission computed tomography (SPECT) imaging in patients undergoing coronary artery bypass grafting (CABG).

METHODS

A total of 172 patients (145 men and 27 women, with a mean age of 64.81 ± 8.93 years) undergoing CABG surgery were included in the study. All selected scintigraphic studies of the patients undergoing CABG were reprocessed. Semiquantitative interpretation of septal perfusion, wall motion, and wall thickening was performed with QPS and QGS programs. Phase analysis parameters were also obtained using the Emory Cardiac Toolbox. According to myocardial perfusion-gated SPECT results, the patients were trichotomized as follows: group 1 (nonischemic PSM): regular perfusion and thickening of the septal wall and abnormal motion of the septal wall; group 2 (ischemic PSM): abnormal perfusion, motion, and thickening of the septal wall; group 3 (non-PSM): normal perfusion, motion, and thickening of the septal wall. The data in each of the three groups were compared using Student's t-test and one-way analysis of variance.

RESULTS

No PSM (normal perfusion, motion, and thickening of the septal wall) was observed in 19.2% of patients undergoing CABG, whereas nonischemic PSM (regular perfusion and thickening of the septal wall and abnormal motion of the septal wall) was observed in 60.5% of patients and ischemic PSM (abnormal perfusion, motion and thickening of the septal wall) was seen in 20.3% of patients.

CONCLUSION

According to our study results, PSM is fairly common in patients undergoing CABG. It will be beneficial to use myocardial perfusion scintigraphy-gated SPECT, which is a noninvasive examination method, to identify the presence of PSM and investigate whether it is accompanied by ischemia or infarction.

The effect of elective percutaneous coronary intervention of the right coronary artery on right ventricular function

BACKGROUND

Right Ventricular (RV) dysfunction has been introduced as a predictor of mortality in acute myocardial infarction.

OBJECTIVES

This study aimed to investigate the effect of right coronary revascularization on systolic and diastolic RV dysfunction.

PATIENTS AND METHODS

This study was conducted on unstable angina patients who were candidate for elective Percutaneous Revascularization Intervention (PCI) on the right coronary artery. The participants were initially evaluated by transthoracic echocardiography and tissue Doppler imaging prior to PCI and the RV function parameters were assessed. Echocardiography was repeated two months after PCI and the results were compared with baseline. Paired t-test was used to compare the pre- and post-procedural measurements. Besides, Pearson's correlation was used to find out the linear association between the RV function parameters and Left Ventricular Ejection Fraction (LVEF). P value < 0.05 was considered as statistically significant.

RESULTS

This study was conducted on 30 patients (mean age = 60.00 ± 8.44 years; 24 [80%] males). In the pre-procedural echocardiography, 15 patients (50%) had normal RV function, 14 patients (46.7%) had grade-1 RV dysfunction, and only 1 patient (3.3%) had grade-2 RV dysfunction. Following PCI, however, all the patients had normal systolic and diastolic RV functions. Comparison of echocardiographic RV function parameters showed an improvement in both systolic and diastolic functional parameters of the RV. Nonetheless, no significant correlation was observed between these parameters and Left Ventricular (LV) function.

CONCLUSIONS

A significant improvement was found in RV function, but not LV function, after right coronary PCI. Revascularization of the right coronary artery may be beneficial for the patients who suffer from RV failure due to ischemia.

Determinants of right ventricular remodeling following ST-segment elevation myocardial infarction

Right ventricular (RV) function after ST-segment elevation myocardial infarction (STEMI) has important prognostic implications. However, the changes in RV function over time after STEMI and the incidence of RV remodeling remain unknown. The present study evaluated changes in RV dimensions and function in contemporary patients with first STEMI and assessed the independent determinants of RV dysfunction at follow-up. Patients with first STEMI (n = 940, 60 ± 11 years, 77% men) treated with primary percutaneous coronary intervention underwent echocardiography at baseline and 6- and 12-month follow-up. The prevalence of RV dysfunction (tricuspid annular plane systolic excursion [TAPSE] ≤15 mm) decreased significantly at 6 months follow-up (from 15% to 8%, p <0.001) and the incidence of RV remodeling (increase in RV end-diastolic area [RVEDA] ≥20%) was observed in 200 patients (25%). Absolute changes in RVEDA were independently associated with absolute changes in wall motion score index and left ventricular (LV) remodeling (p <0.001 for both parameters), whereas absolute changes in TAPSE were independently related with absolute changes in wall motion score index and mitral regurgitation grade (p <0.001 for both parameters). Independent correlates of RV dysfunction at 6 months follow-up were multivessel coronary disease (odds ratio [OR] 2.13), peak cardiac troponin T (OR 1.05), angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers use (OR 0.27), baseline LV ejection fraction (OR 0.96) and baseline TAPSE (OR 0.88). In conclusion, despite the non-negligible incidence of RV remodeling in patients with first STEMI, RV function improves early after STEMI. Multivessel coronary disease, infarct size, baseline LV ejection fraction and TAPSE and the nonuse of angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers are independent determinants of RV dysfunction.

The challenges in the management of right ventricular infarction

In recent years, right ventricular (RV) infarction seems to be underdiagnosed in most cases of acute myocardial ischaemia despite its frequent association with inferior-wall and, occasionally, anterior-wall myocardial infarction (MI). However, its initial management is drastically different from that of left ventricular MI, and studies have indicated that RV infarction remains associated with significant morbidity and mortality, even in the mechanical reperfusion era. The pathophysiology of RV infarction involves the interaction between the right and left ventricle (LV), and the mechanism has been clarified with the advent of diagnostic non-invasive modalities, such as echocardiography and cardiac magnetic resonance. In recent years, considerable progress has been made in the treatment of RV infarction; early revascularization remains the cornerstone of the management, and fluid resuscitation, with appropriate target selection, is necessary to maintain appropriate preload. Early recognition in intensive care with clear understanding of the pathophysiology is essential to improve its prognosis. In terms of management, the support strategy for RV dysfunction is different from that for LV dysfunction since the former may often be temporary. Along with early reperfusion, maintenance of an adequate heart rate and atrioventricular synchrony are essential to sustain a sufficient cardiac output in patients with RV infarction. In refractory cases, more intensive mechanical support is required, and new therapeutic options, such as Tandem-Heart or percutaneous cardiopulmonary support systems, are being developed.

Tricuspid regurgitation duration correlates with cardiovascular magnetic resonance-derived right ventricular ejection fraction and predict prognosis in patients with pulmonary arterial hypertension

AIMS

Right ventricular (RV) failure is known to be the main cause of mortality and is closely related to prognosis in patients with pulmonary arterial hypertension (PAH). A decrease in the duration of tricuspid regurgitation corrected for heart rate (TRDc) has recently been shown to be associated with advanced RV failure and poor clinical outcomes. The aim of the present study was to investigate whether TRDc correlates with RV parameters assessed using cardiovascular magnetic resonance (CMR) and has prognostic significance in patients with PAH.

METHODS AND RESULTS

Thirty-seven consecutive patients with PAH (28 females, age 46 ± 14 years) underwent a 6 min walk test, right heart catheterization, echocardiography, and CMR within a 48 h period. Tricuspid regurgitation duration corrected for heart rate, tricuspid annular plane systolic excursion (TAPSE), Tei index, and tricuspid valve lateral annular systolic velocity were measured on echocardiography, and RV end-systolic and end-diastolic volumes and ejection fraction were measured on CMR. Tricuspid regurgitation duration corrected for heart rate was positively correlated with RV ejection fraction as measured on CMR (r = 0.400, P = 0.014). On multivariate regression analysis, TRDc was also significantly correlated with RV ejection fraction even after adjusting for the eccentric index, Tei index, and TAPSE (P = 0.034). During a median follow-up period of 487 days, there were seven events (19%) including two cardiac deaths and five inpatient admissions for heart failure. The event-free survival rate was significantly higher for patients with TRDc >400 ms than those with TRDc ≤400 ms (P = 0.040).

CONCLUSION

Tricuspid regurgitation duration corrected for heart rate correlated with CMR-derived RV ejection fraction, and decreased TRDc was associated with cardiovascular mortality and rehospitalization in patients with PAH. Therefore, TRDc could be a useful echocardiographic surrogate marker for predicting RV dysfunction and prognosis in patients with PAH.

Right ventricular ejection fraction measured by multigated planar equilibrium radionuclide ventriculography is an independent prognostic factor in patients with ischemic heart disease

BACKGROUND

The number of studies on the prognostic value of the right ventricular ejection fraction (RVEF) in patients with ischemic heart disease (IHD) is limited, whereas it is widely accepted that the left ventricular ejection fraction (LVEF) is a strong prognostic factor. We assessed whether RVEF measured by multigated planar equilibrium radionuclide ventriculography (RNV) is an independent prognostic factor in patients with IHD.

METHODS AND RESULTS

We retrospectively identified 347 consecutive patients with IHD (mean age 71 ± 11 years; 18% women) who underwent multigated planar equilibrium RNV between 2004 and 2008 to determine the LVEF, which also provided the RVEF (mean 44.7% ± 11.0%). We categorized patients according to RVEF in ≥40% (n = 240) and <40% (n = 107). Patients were followed for a median of 826 days (range 3-2,400) for the occurrence of events [all-cause mortality (n = 60), cardiac mortality (n = 33), and cardiac hospitalization (n = 78)]. Cox regression analysis with significant univariate predictors [coronary artery revascularization (P = .003), diuretics (P = .03), and statins (P < .001)] showed that an RVEF <40% was associated with a 2.90 (1.68-5.00)-fold higher risk of all-cause death. Accordingly, a decreased RVEF was associated with a 2.15 (1.34-3.43)-fold increase in the risk of cardiac hospitalization and a 5.11(2.32-11.23)-fold risk of cardiac death.

CONCLUSION

RVEF measured by multigated planar equilibrium RNV is an independent prognostic factor in patients with chronic IHD.

Transthoracic echocardiography in children and young adults with congenital heart disease

Transthoracic echocardiography (TTE) is the first-line tool for diagnosis and followup of pediatric and young adult patients with congenital heart disease (CHD). Appropriate use of TTE can reduce the need for more invasive modalities, such as cardiac catheterization and cardiac magnetic resonance imaging. New echocardiographic techniques have emerged more recently: tissue Doppler imaging, tissue tracking (strain and strain rate), vector velocity imaging (VVI), myocardial performance index, myocardial acceleration during isovolumic acceleration (IVA), the ratio of systolic to diastolic duration (S/D ratio), and two dimensional measurements of systolic right ventricular (RV) function (e.g., tricuspid annular plane systolic excursion, TAPSE). These may become valuable indicators of ventricular performance, compliance, and disease progression. In addition, three-dimensional (3D) echocardiography when performed for the assessment of valvular function, device position, and ventricular volumes is being integrated into routine clinical care. In this paper, the potential use and limitations of these new echocardiographic techniques in patients with CHD are discussed. A particular focus is on the echocardiographic assessment of right ventricular (RV) function in conditions associated with increased right ventricular volume (e.g., pulmonary regurgitation after tetralogy of Fallot repair) or pressure (e.g., pulmonary hypertension) in children and young adults.

Systolic right ventricular function in children and young adults with pulmonary artery hypertension secondary to congenital heart disease and tetralogy of Fallot: tricuspid annular plane systolic excursion (TAPSE) and magnetic resonance imaging data

OBJECTIVE

  The tricuspid annular plane systolic excursion (TAPSE), as echocardiographic index to assess right ventricular (RV) systolic function, has not been investigated thoroughly in children and young adults with tetralogy of Fallot (TOF) and pulmonary artery hypertension secondary to congenital heart disease (PAH-CHD).

PATIENTS

  TAPSE values of 49 patients with PAH-CHD and 156 patients with TOF were compared with age-matched normal subjects. TAPSE values were also compared with RV ejection fraction (RVEF) and RV indexed end-diastolic volume (RVEDVi) determined by magnetic resonance imaging in PAH-CHD and TOF patients.

RESULTS

  Patients with a PAH-CHD showed a positive correlation between TAPSE with RVEF (r= 0.81; P < 0.001) and a negative correlation between TAPSE with RVEDVi (r=-0.67; P < 0.001). Similarly, in our TOF patients, a positive correlation between TAPSE with RVEF (r= 0.65; P < 0.001) and a negative correlation between TAPSE with RVEDVi (r=-0.42; P < 0.001) was seen.

CONCLUSIONS

  Significant pressure overload in PAH-CHD patients and volume overload in TOF patients lead to a decreased systolic RV function, determined by TAPSE and magnetic resonance imaging and to increased RVEDVi values, determined by MRI, with time.

Non-Invasive Imaging for Congenital Heart Disease: Recent Innovations in Transthoracic Echocardiography

Transthoracic echocardiography (TTE) is an important tool for diagnosis and follow-up of patients with congenital heart disease (CHD). Appropriate use of TTE can reduce the need for more invasive and complex modalities, such as cardiac catheterization and cardiac magnetic resonance imaging. New echocardiographic techniques have emerged for the assessment of ventricular systolic and diastolic function: Tissue Doppler imaging, tissue tracking, strain and strain rate imaging, vector velocity imaging (VVI), myocardial performance index, myocardial acceleration during isovolumic contraction (IVA), the ratio of systolic to diastolic duration (S/D ratio), and other measurements of systolic right ventricular (RV) function like tricuspid annular plane systolic excursion (TAPSE). These modalities may become valuable indicators of ventricular performance, compliance and disease progression, with the caveat of preload-dependency of the variables measured. In addition, three-dimensional (3D) echocardiography for the assessment of cardiac anatomy, valvular function, device position, ventricular volumes and ejection fraction is integrated into routine clinical care. In this review, we discuss the potential use and limitations of these new echocardiographic techniques in patients with CHD. A particular focus is on the echocardiographic assessment of right ventricular (RV) function by means of tissue Doppler imaging, tissue tracking, and three-dimensional imaging, in conditions associated with increased right ventricular volume or pressure load.

Right ventricular ischemic injury in patients with acute ST-segment elevation myocardial infarction: characterization with cardiovascular magnetic resonance

BACKGROUND

Experimental data show that the right ventricle (RV) is more resistant to ischemia than the left ventricle. To date, limited data are available in humans because of the difficulty of discriminating reversible from irreversible ischemic damage. We sought to characterize RV ischemic injury in patients with reperfused myocardial infarction using cardiovascular magnetic resonance.

METHODS AND RESULTS

In 3 tertiary centers, 242 consecutive patients with reperfused acute ST-segment elevation myocardial infarction were studied with cardiovascular magnetic resonance at 1 week and 4 months after myocardial infarction. T2-weighted and postcontrast cardiovascular magnetic resonance scans were used to depict myocardial edema and late gadolinium enhancement, respectively. Early after infarction, RV edema was common (51% of patients), often associated with late gadolinium enhancement (31% of patients). Remarkably, RV edema and late gadolinium enhancement were found in 33% and 12% of anterior left ventricular infarcts, respectively. Baseline regional and global RV functions were inversely related to the presence and extent of RV edema and RV late gadolinium enhancement. At follow-up, a significant decrease in frequency (25/242 patients; 10%) and extent of RV late gadolinium enhancement was observed (P<0.001). With the use of multivariable analysis, the presence of RV edema was an independent predictor of RV global function improvement during follow-up (β-coefficient=0.221, P=0.003).

CONCLUSIONS

Early postinfarction RV ischemic injury is common and is characterized by the presence of myocardial edema, late gadolinium enhancement, and functional abnormalities. RV injury is not limited to inferior infarcts but is commonly found in anterior infarcts as well. Cardiovascular magnetic resonance findings suggest reversibility of acute RV dysfunction with limited permanent myocardial damage at 4-month follow-up.

Impact of right ventricular contractility on left ventricular dyssynchrony in patients with chronic systolic heart failure

BACKGROUND

Cardiac resynchronization therapy (CRT) is an important therapeutic approach for patients with symptomatic heart failure. The assessment of mechanical dyssynchrony, however, remains an issue. Little data are available regarding the influence of the right ventricle (RV) on left ventricle (LV) mechanical dyssynchrony as assessed by echocardiography.

AIMS

We sought to assess the impact of RV contractility on LV function and dyssynchrony.

METHODS

A total of 40 patients with congestive heart failure were analyzed. Twenty had RV dysfunction, as defined by a tricuspid annular systolic peak of tissue Doppler (SaRV)<11.5 cm/s, while the remaining 20 had SaRV>11.5 cm/s. All patients underwent echocardiography in order to determine RV function, LV function, and dyssynchrony.

RESULTS

The two populations were similar regarding diastolic function, atrio-ventricular conduction and interventricular dyssynchrony. Patients with RV dysfunction showed significantly more severe LV longitudinal dyssynchrony (130±103 ms vs. 62±59 ms; p=0.01). In addition, SaRV (systolic peak recorded at the tricuspid annulus) was correlated with LV longitudinal dyssynchrony (r=0.47; p=0.001). In contrast, LV radial contractility and dyssynchrony (103±110 ms vs. 100±78 ms; p=0.5) were not affected by RV function.

CONCLUSION

Quantitative analysis of RV function is important when assessing LV function and dyssynchrony in patients with systolic heart failure. RV function is associated with intra-LV dyssynchrony, particularly when considering longitudinal function.

The associations between tricuspid annular plane systolic excursion (TAPSE), ventricular dyssynchrony, and ventricular interaction in heart failure patients

AIMS

Ventricular interactions may be mediated by loading conditions and biventricular timing and coordination. We sought to understand the relationships between right (RV) and left ventricular (LV) function and dyssynchrony, examine the RV correlates of LV dyssynchrony, and determine whether improved loading conditions affect inter-ventricular interaction.

METHODS AND RESULTS

In 25 heart failure patients [15 with left ventricular ejection fraction (LVEF) < 40%; 10 with LVEF >/= 50%], Doppler echocardiography and invasive bi-ventricular pressure-volume haemodynamics were obtained at baseline and 30 min after infusion of the recombinant B-type natriuretic peptide vasodilator nesiritide. RV and LV intra-ventricular dyssynchrony was measured invasively using a pressure-conductance catheter. Patients with reduced LVEF had greater LV dyssynchrony (31 +/- 3 vs. 24 +/- 7%; P = 0.003) compared to those with preserved LVEF. Tricuspid annular plane systolic excursion (TAPSE) had the highest correlation with LV dyssynchrony (r = -0.52; P = 0.0002) compared to other RV echocardiographic parameters. The association between TAPSE and LV dyssynchrony was independent of RVEF and LVEF (P = 0.008). There were no acute changes in the correlations between LV dyssynchrony and TAPSE after nesiritide.

CONCLUSION

TAPSE and LV dyssynchrony are strongly associated, independent of RV and LV ejection fraction. Of the RV echocardiographic parameters, TAPSE has the highest predictive value of LV dyssynchrony, and remained significant after vasodilator unloading.

Anesthetic Considerations in the Patient With Valvular Heart Disease Undergoing Noncardiac Surgery

Valvular heart disease can be an important finding in patients presenting for noncardiac surgery. Valvular heart disease and resulting comorbidity, such as heart failure or atrial fibrillation, significantly increase the risk for perioperative adverse events. Appropriate preoperative assessment, adequate perioperative monitoring, and early intervention, should hemodynamic disturbances occur, may help prevent adverse events and improve patient outcome. This review article aims to guide the practitioner in the various aspects of anesthetic management in the perioperative care of patients with valvular heart disease. The pharmacological approach to optimization of patient outcome with drugs, such as βblockers and lipid-lowering medications (statins), is an evolving field, and recent developments are discussed in this article.

Right heart function and scleroderma: insights from tricuspid annular plane systolic excursion

OBJECTIVE

The purpose of this study was to evaluate the use of echocardiographic parameters as predictors of rehospitalization in scleroderma patients.

METHODS

Echocardiographic studies were conducted in 38 patients with systolic scleroderma (SSc) to assess cardiopulmonary function. Forty-five age-matched volunteers without any sign of heart failure served as the control group. Transmitral flow pattern, tricuspid annular plane systolic excursion (TAPSE), left ventricular ejection fraction (LVEF), and right ventricular ejection fraction (RVEF) were evaluated. All patients were subsequently followed for one year.

RESULTS

Peak transmitral early-diastolic velocity (mitral E) and TAPSE measurements were significantly different between SSc and control patients (mitral E: 74.1 +/- 16.3 vs. 83.5 +/- 17.0 cm/s with P = 0.012; TAPSE: 2.4 +/- 0.43 vs. 1.9 +/- 0.39 cm with P < 0.0001). LVEF was similar, but RVEF was lower in the SSc group (LVEF: 61.7 +/- 9.7 vs. 61.7 +/- 5.8% with P = 0.962; RVEF: 49.6 +/- 6.8 vs. 39.2 +/- 6.7% with P < 0.0001). A strong correlation was found between TAPSE and RVEF. A TAPSE less than 1.96 cm indicted a RVEF less than 40% with a sensitivity of 81% and specificity of 78%. Contrary to expectation, pulmonary artery systolic pressure (PASP) did not correlate well with RV function (r = 0.261, r2= 0.068, P = 0.016). Finally, the frequency of rehospitalization was inversely correlated with RVEF and TAPSE in SSc patients.

CONCLUSIONS

We can predict the rehospitalization rate of SSc patients by TAPSE and RVEF, suggesting the involvement of heart, skin, lung, and other organs in scleroderma patients.