Quantitative assessment of regional right ventricular function with color kinesis

The association of Pulmonary Hypertension and right ventricular systolic function - updates in diagnosis and treatment

Right ventricular (RV) systolic function is an essential but neglected component in cardiac evaluation, and its importance to the contribution to overall cardiac function is undermined. It is not only sensitive to the effect of left heart valve disease but is also more sensitive to changes in pressure overload than the left ventricle. Pulmonary Hypertension is the common and well-recognized complication of RV systolic dysfunction. It is also the leading cause of pulmonary valve disease and right ventricular dysfunction. Patients with a high pulmonary artery pressure (PAP) and a low RV ejection fraction have a seven-fold higher risk of death than heart failure patients with a normal PAP and RV ejection fraction. Furthermore, it is an independent predictor of survival in these patients. In this review, we examine the association of right ventricular systolic function with Pulmonary Hypertension by focusing on various pathological and clinical manifestations while assessing their impact. We also explore new 2022 ESC/ERS guidelines for diagnosing and treating right ventricular dysfunction in Pulmonary Hypertension.

Diagnostic, prognostic and clinical value of left ventricular radial strain to identify paradoxical septal motion in ventilated patients with the acute respiratory distress syndrome: an observational prospective multicenter study

BACKGROUND

Acute cor pulmonale (ACP) is prognostic in patients with acute respiratory distress syndrome (ARDS). Identification of paradoxical septal motion (PSM) using two-dimensional echocardiography is highly subjective. We sought to describe feature-engineered metrics derived from LV radial strain changes related to PSM in ARDS patients with ACP of various severity and to illustrate potential diagnostic and prognostic yield.

METHODS

This prospective bicentric study included patients under protective ventilation for ARDS related to COVID-19 who were assessed using transesophageal echocardiography (TEE). Transgastric short-axis view at mid-papillary level was used to visually grade septal motion, using two-dimensional imaging, solely and combined with LV radial strain: normal (grade 0), transient end-systolic septal flattening (grade 1), prolonged end-systolic septal flattening or reversed septal curvature (grade 2). Inter-observer variability was calculated. Feature engineering was performed to calculate the time-to-peak and area under the strain curve in 6 LV segments. In the subset of patients with serial TEE examinations, a multivariate Cox model analysis accounting for new-onset of PSM as a time-dependent variable was used to identify parameters associated with ICU mortality.

RESULTS

Overall, 310 TEE examinations performed in 182 patients were analyzed (age: 67 [60-72] years; men: 66%; SAPSII: 35 [29-40]). Two-dimensional assessment identified a grade 1 and grade 2 PSM in 100 (32%) and 48 (15%) examinations, respectively. Inter-rater reliability was weak using two-dimensional imaging alone (kappa = 0.49; 95% CI 0.40-0.58; p < 0.001) and increased with associated LV radial strain (kappa = 0.84, 95% CI 0.79-0.90, p < 0.001). The time-to-peak of mid-septal and mid-lateral segments occurred significantly later in systole and increased with the grade of PSM. Similarly, the area under the strain curve of these segments increased significantly with the grade of PSM, compared with mid-anterior or mid-inferior segments. Severe acute cor pulmonale with a grade 2 PSM was significantly associated with mortality. Requalification in an upper PSM grade using LV radial strain allowed to better identify patients at risk of death (HR: 6.27 [95% CI 2.28-17.2] vs. 2.80 [95% CI 1.11-7.09]).

CONCLUSIONS

In objectively depicting PSM and quantitatively assessing its severity, TEE LV radial strain appears as a valuable adjunct to conventional two-dimensional imaging.

[Quantification of right ventricular function by 2D speckle imaging and three dimensional echography. Comparison with MRI]

PURPOSE

The echocardiographic assessment of right ventricular (RV) function requires many different parameters. We studied and compared with magnetic resonance imaging (MRI) two markers of RV function derived from new imaging tools: 2D speckle imaging (2DSI) and three dimensional echography.

METHODS AND RESULTS

Thirty-two patients (19 with RV ejection fraction [RVEF]< or =45%) underwent both complete echocardiography--including standard parameters of RV function (fractional area change [FAC], Tei index, systolic velocity of tricuspid annulus by DTI), 3D full-volume acquisition on RV--and MRI for the evaluation of RV volumes and RVEF. 2DSI was applied to high frame rate cine loops centred on the RV free wall with measurement of peak systolic strain (%) in the basal, median and apical segments of this wall. Strain, especially in RV median and apical segments, is reduced in patients with RVEF less or equal to 45% (median strain: -16.39+/-5.27 vs. -24.74+/-8.00 [p=0.002]; apical strain -13.01+/-6.84 vs. 22.53+/-11.32 [p=0.03]) with a very good correlation with RVEF (r=-0.717, p=0.0001) but also with the usual echographic parameters of RV function, (FAC: r=0.019; Tei: r=0.01; peak systolic velocity: r=0.002). The 3D RVEF is also but poorly correlated with MRI RVEF, (r=0.447, p=0.017). Furthermore, 3D significantly underestimated RV volumes. By multivariate analysis, apical strain (p=0.004) and FAC (p=0.029) were predictive of a decreased RVEF.

CONCLUSION

Apical strain as measured from 2DSI seems a promising parameter in the estimation of RV function. 3D estimation of RVEF is more disappointing because of an important underestimation of RV volumes.

Quantification of regional volume and systolic function of the left ventricle by real-time three-dimensional echocardiography

Real-time three-dimensional (3D) echocardiography (RT-3DE) provides a unique technique to evaluate left ventricular regional function in a 3D format. We aimed to explore whether the left ventricular segmental volume and systolic function is uniform and to establish normal values of volume and systolic function parameters of 16 regions in healthy subjects. RT-3DE was performed in 41 normal subjects and four-dimensional (4D)-left ventricle (LV) analysis software and a TomTec workstation were used to analyze data for regional end-diastolic volume (EDV(R)), regional end-systolic volume (ESV(R)), regional stroke volume (SV(R)), regional ejection fraction (EF(R)), ratio of SV(R) to global SV (SV(R/G)) and ratio of SV(R) to global EDV (EF(R/G)). All regional volume and systolic function parameters were not uniform among the left ventricular walls. They all increased in the order of inferior, posterior, lateral, septal, anterior and antero-septal walls with an increasing trend from the apical, middle to basal segments. The systolic function (EF(R), SV(R/G) and EF(R/G)) of the anterior and antero-septal walls was significantly higher than that of the lateral, inferior and posterior walls. And the intra- and interobserver variability for EDV(R), ESV(R), SV(R/G) and EF(R/G) ranged from 2.9% to 5.8%. In conclusion, the regional volume and systolic function of the left ventricle is not uniform and, therefore, a normal left ventricle cannot be regarded as a symmetric model for assessing the regional systolic function. This information may improve the accuracy of RT-3DE techniques in the assessment of the left ventricular regional function. (E-mail: zhangyun@sdu.edu.cn and yaogh@yahoo.com).

Regional right ventricular dysfunction in chronic pulmonary hypertension

OBJECTIVE

Right ventricular (RV) failure is the main cause of mortality in patients with pulmonary hypertension (PH). Therefore, there is an increasing interest for the assessment of RV function. This study aimed to evaluate the regional RV function in patients with PH by using ultrasonic strain rate imaging.

METHODS

In all, 27 patients with PH and 27 control subjects were studied by ultrasonic strain rate imaging. The regional longitudinal deformation was measured in the RV free wall divided into two segments. A subgroup of 16 patients had concomitant invasive hemodynamic measurements.

RESULTS

In patients with PH, deformation parameters were significantly lower compared with that of control subjects (basal strain rate -2.28 +/- 0.9 vs -2.94 +/- 0.9 s(-1); strain -28 +/- 13% vs -42 +/- 11%; apical strain rate -1.05 +/- 1.38 vs -2.60 +/- 0.9 s(-1); strain -13 +/- 16% vs -41 +/- 11%, respectively). The deformation parameters in the apical segment were reduced more than in the basal segment (the segment-wise comparison with P < .002 for strain rate and P < .0001 for strain) in the patient group. The reduction of the apical deformation was related to the severity of RV afterload. Strong correlations were found between the apical strain and invasively measured mean pulmonary arterial pressure (R = 0.82, P < .0001) and pulmonary vascular resistance (R = 0.73, P < .001) and echocardiographically estimated hemodynamic parameters, RV size and global function, and exercise capacity (evaluated by a 6-minute walk test expressed as a percentage of the expected value).

CONCLUSION

Strain rate imaging provides a new tool to quantify regional RV dysfunction in patients with PH and reveals a characteristic regional pattern of abnormal RV free wall function.

Comparison of echocardiographic and cardiac magnetic resonance imaging for assessing right ventricular function in adults with repaired tetralogy of fallot

Adults with repaired tetralogy of Fallot and significant chronic pulmonary regurgitation are at risk for progressive right ventricular (RV) dilatation and dysfunction. The assessment of RV function is important in the management in these patients. There is still a lack of an adequate geometric model to quantify RV function by echocardiography. The myocardial performance index (MPI) is a nonvolumetric method to quantify global ventricular function. In this study, the accuracy of MPI obtained by echocardiography to quantify RV function was assessed in 57 adults with repaired tetralogy of Fallot. The MPI measurement was compared with the RV ejection fraction (EF) derived by cardiac magnetic resonance imaging. There was a negative linear correlation between the MPI and the RVEF (r = 0.73, p <0.001). A MPI cutoff of > or =0.40 had a sensitivity of 81% and a specificity of 85% to diagnose a RVEF <35%. A MPI cutoff of <0.25 had a sensitivity of 70% and a specificity of 89% to identify patients with RVEFs > or =0.50. In a multivariate regression model, the MPI was not affected by the degree of pulmonary regurgitation, the presence of tricuspid regurgitation, or the QRS duration. In conclusion, the Doppler-derived MPI is a simple and reliable method for the evaluation of RV systolic function in adults with repaired tetralogy of Fallot.

Dyskinesis in Chagasic myocardium: centerline analysis of wall motion using cardiac-gated magnetic resonance images of mice

We report on the use of centerline analysis of cardiac-gated magnetic resonance images to measure wall motion abnormalities in mice infected with Trypanosoma cruzi. To our knowledge, this is the first report of segmental wall motion abnormalities in an animal model of Chagas' disease. Chagas' disease patients with severe cardiac involvement exhibit mild hypokinesis in an extensive region of the left ventricle and dyskinesis in the apical region. We observed dyskinetic segments in a similar region of the hearts of infected wild-type mice. Dyskinesis was not observed in infected mice lacking macrophage inflammatory protein-1alpha, a chemokine that may play an important role in the cardiac remodeling that is normally observed in mouse models of Chagas' disease and in human patients. This study aimed to demonstrate the utility of cardiac-gated magnetic resonance imaging and centerline analysis as a straightforward method for monitoring regional left ventricular wall motion in transgenic and/or diseased mice.

Quantifying regional right ventricular function in tetralogy of Fallot

Right ventricular (RV) function is notoriously difficult to quantify. Patients with tetralogy of Fallot (TOF) have decreased systolic performance. We measure regional RV performance using MRI with 1-dimensional myocardial tissue tagging. By tagging cine-MRI in two views, we measured regional shortening in 12 regions throughout the RV. We image 32 pediatric patients: 21 normal patients and 11 patients with repaired TOF. We establish a normal range for each RV region. TOF patients have decreased shortening on a region-by-region basis. We conclude that regional RV performance can be measured using this technique, and that decreased performance can be demonstrated in TOF patients.

An Abnormal Right Ventricular Apical Angle is Indicative of Global Right Ventricular Impairment

The presence of right ventricular (RV) dysfunction is an adverse prognostic indicator but current echocardiographic methods have some limitations. RV apical angles in systole and diastole were correlated with known parameters of RV function in patients without pulmonary hypertension (Group 1) and in patients with pulmonary hypertension (Group 2). RV apical angles were significantly smaller in both systole (22 +/- 7 degrees) and diastole (33 +/- 6 degrees) in Group 1 patients when compared to Group 2 (54 +/- 18 degrees, p < 0.0001 and 59 +/- 17 degrees, p < 0.0001, respectively). RV apical angles, both in systole and diastole, were strongly correlated with RV end-systolic area (R = 0.89, p < 0.0001) and end-diastolic area (R = 0.81, p < 0.0001), respectively. Similarly, the apical systolic and diastolic angle correlated well with decreased tricuspid annular plane systolic excursion (TAPSE, R = -0.76 and R = -0.73, p < 0.001) as well as with decreased RV fractional area change (R = -0.81 and R = -0.77, p < 0.001). Therefore, we conclude that this new measurement of RV apical angle is simple and useful to quantify RV apical structural and functional abnormalities that are well correlated with global RV impairment in patients with chronic pulmonary hypertension.

Hemodynamic assessment of critically ill patients using echocardiography Doppler

PURPOSE OF REVIEW

The evaluation of hemodynamic status in critically ill patients is a leading recommended indication of transesophageal echocardiography in the intensive care unit. Advantages and diagnostic yield of transesophageal echocardiography in this setting are particularly relevant when considering limitations and questioned prognostic impact of pulmonary artery catheterization.

RECENT FINDINGS

Recent clinical studies have been performed to validate and assess the value of transesophageal echocardiography in determining cardiac output, cardiac preload dependence, right ventricular function, and left ventricular filling pressure. In addition, diagnostic capacity and therapeutic impact of transesophageal echocardiography have been widely reported in various intensive care unit settings.

SUMMARY

Transesophageal echocardiography appears well suited for the determination of cardiac index and to track its variations after therapeutic interventions. Although repeated measurements of left ventricular end-diastolic dimension allows to accurately track preload variations, a single determination is not reliable to predict fluid responsiveness in intensive care unit patients. Identification of preload dependence in hemodynamically unstable patients currently tends to rely mainly on dynamic parameters that use cardiopulmonary interactions under mechanical ventilation. Transesophageal echocardiography also allows to adequately assess right ventricular function and left ventricular filling pressure using combined Doppler modalities. Adequate education and training of intensivists and anesthesiologists is crucial to further develop the use of transesophageal echocardiography in the intensive care unit setting. Despite the absence of randomized controlled studies documenting transesophageal echocardiography benefits on patient outcome, present evidence and experience strongly recommend a larger use of echocardiography Doppler for a comprehensive functional hemodynamic assessment of critically ill patients with circulatory failure.

Intraoperative assessment of diastolic function: utility of echocardiography

PURPOSE OF REVIEW

This review discusses the current and future applications of different echocardiographic modalities in evaluating diastolic function intraoperatively.

RECENT FINDINGS

Normal diastolic function is required for optimal cardiac performance. There is sufficient evidence to support the significant prevalence of preoperative diastolic dysfunction and its incidence following cardiac surgery, however controversy still exists regarding the impact of diastolic dysfunction on adverse outcomes. Echocardiography provides a relatively safe, practical and noninvasive means to evaluate perioperative diastolic function, however conventional measures may be limited by the impact of changes in heart rate, rhythm and loading conditions. Newer echocardiographic modalities are reportedly less sensitive to acute changes in loading conditions, and may therefore complement the use of conventional echocardiographic techniques in the perioperative period.

SUMMARY

The availability of effective technology for diagnosing the presence and progression of perioperative diastolic function should assist in the identification of high-risk cardiac surgical patients who may benefit from appropriate triaging and therapeutic intervention.

Factors influencing late course of residual valvular and infundibular gradients following pulmonary valve balloon dilatation

BACKGROUND

Though acute and follow-up benefits of pulmonary valve balloon dilatation (PVBD) for pulmonic valve stenosis are well known, the late course of residual gradients at individual valvular and infundibular levels is not well described. Furthermore, the factors influencing this late course have not been studied.

MATERIALS AND METHODS

We assessed the transpulmonary gradients by echo-Doppler in 96 patients (61 male, mean age 10.7 years) at a mean follow-up interval of 58.8+/-32.1 months (minimum 2 years) following PVBD. The patients were divided into three groups based on the residual gradients at valvular and infundibular levels immediately following PVBD as assessed by pull-back of an end-hole catheter across the right ventricular outflow tract: Group A with minor pressure gradients at both valvular and infundibular levels of less than 30 mmHg (n=60, 62.5%), Group B with predominantly infundibular gradients of more than 30 mmHg with a valvular gradient of less than 30 mmHg (n=27, 28.1%), and Group C with a residual valvular gradient of greater than 30 mmHg irrespective of the infundibular gradient (n=9, 9.4%). Demographic characteristics, hemodynamic parameters and procedural variables were correlated with the change in gradient at follow-up (late fall) and with long-term results.

RESULTS

The mean follow-up trans-pulmonary gradient was 20+/-14 mmHg which was significantly lower than that immediately post-PVBD (43+/-32 mmHg), P<0.001. The late fall (mean 24+/-29, range -55 to 110 mmHg) varied widely depending upon the acute result group: patients in Groups A and B showed significant late fall of 9+/-12 mmHg (P<0.05 for follow-up gradient compared to that following PVBD) and 58+/-31 mmHg (P<0.0001), respectively, while patients in Group C showed an insignificant late fall of 14+/-37 mmHg (P=0.21). In particular, each one of the patients in Group B showed decrease in trans-pulmonary gradients. On multivariate analysis, the extent of infundibular gradient emerged as the most important predictor of late fall (coefficient of determination 75%, P<0.0001). Patients who underwent PVBD at less than 2 years of age had a significantly greater late fall (41+/-33 mmHg) as compared to older patients (22+/-25 mmHg), P<0.05. A sub-optimal long-term result (transpulmonary gradient >25 mmHg, n=24) was significantly related to older age (P<0.001), dysplastic valve morphology (P=0.002), greater baseline trans-pulmonary gradients (P<0.001) and higher post-PVBD gradients (P=0.04).

CONCLUSIONS

The long-term course of patients following PVBD depends upon the site and magnitude of the residual gradients. Even high residual infundibular gradients show marked reduction at follow-up, especially in infancy.

Recent advances in echocardiographic evaluation of left ventricular anatomy, perfusion, and function

This article provides a brief overview of several recently developed, emerging technologies and discusses their potential uses on clinical grounds. These new technologies include three-dimensional imaging, objective automated evaluation of ventricular function with acoustic quantification, assessment of regional ventricular performance using color kinesis and tissue Doppler imaging, harmonic imaging, and power Doppler imaging. Our hope is that readers will gain a better understanding of the principles underlying these technological advances, which will help them to integrate these new techniques efficiently into their clinical practices.

Detection of regional temporal abnormalities in left ventricular function during acute myocardial ischemia

Echocardiographic diagnosis of myocardial ischemia is based on visualizing hypokinesis, which occurs late in the ischemic cascade. We hypothesized that temporal changes in endocardial motion may constitute sensitive early markers of ischemia. Two protocols were performed in 19 anesthetized pigs. Protocol 1 included 54 intracoronary balloon occlusions. Transthoracic images were acquired at baseline and every 15 s during 5 min of occlusion and reperfusion. In protocol 2, ischemia was induced in 12 animals by use of graded dobutamine infusion, after creating significant partial occlusions without a resting wall motion abnormality. Systolic and diastolic endocardial motion was color encoded using color kinesis and analyzed using custom software. All ischemic episodes caused detectable and reversible changes. The earliest sign of ischemia was tardokinesis in 31/54 occlusions, whereas hypokinesis appeared first in 23/54 cases. Dobutamine-induced ischemia caused tardokinesis first in 9/12 and hypokinesis in 3/12 animals. Reversible ischemic changes in regional left ventricular performance can be objectively detected using analysis of echocardiographic images and will likely improve the early noninvasive diagnosis of acute ischemia.