Can Echocardiography, Especially Tricuspid Annular Plane Systolic Excursion Measurement, Predict Pulmonary Hypertension and Improve Prognosis in Patients on Long-Term Dialysis?

The Role of Echocardiography in the Diagnosis and Prognosis of Pulmonary Hypertension

The right heart catheterisation constitutes the gold standard for pulmonary hypertension (PH) diagnosis. However, echocardiography remains a reliable, non-invasive, inexpensive, convenient, and easily reproducible modality not only for the preliminary screening of PH but also for PH prognosis. The aim of this review is to describe a cluster of echocardiographic parameters for the detection and prognosis of PH and analyse the challenges of echocardiography implementation in patients with suspected or established PH. The most important echocardiographic index is the calculation of pulmonary arterial systolic pressure (PASP) through the tricuspid regurgitation (TR). It has shown high correlation with invasive measurement of pulmonary pressure, but several drawbacks have questioned its accuracy. Besides this, the right ventricular outflow track acceleration time (RVOT-AT) has been proposed for PH diagnosis. A plethora of echocardiographic indices: right atrial area, pericardial effusion, the tricuspid annular plane systolic excursion (TAPSE), the TAPSE/PASP ratio, tricuspid annular systolic velocity (s'), can reflect the severity and prognosis of PH. Recent advances in echocardiography with 3-dimensional right ventricular (RV) ejection fraction, RV free wall strain and right atrial strain may further assist the prognosis of PH.

A longitudinal study of cardiac structure and function using echocardiography in patients undergoing peritoneal dialysis

Background

Peritoneal dialysis (PD) can be associated with abnormal cardiac structure and function and increased mortality risk. Therefore, in this study, we analyzed the cardiac structure and function dynamic changes using echocardiography during the first 2 years of PD therapy. We also assessed its associations with all-cause mortality risk after 2 years of follow-up.

Methods

End-stage renal disease (ESRD) patients that have started PD from 2011 to 2017, and had echocardiography at baseline and years 1 and 2, were included in this study. Echocardiographic parameters were compared between baseline and year 2. Multivariable Cox models were used to estimate the association between echocardiographic parameters changes and all-cause mortality risk.

Results

We finally enrolled 72 PD patients in this study. The mean right ventricular diameter (RVD) increased from baseline (18.31 mm) to year 1 (18.75 mm) and year 2 (19.65 mm). We also observed a significant decrease in cardiac output (CO) between baseline and year 2. Additionally, a slight decrease trend in ejection fraction (EF) was observed. Finally, every 1 % increase in RVD was associated with a 68.2 % higher mortality risk after dialysis (HR, 1.682; 95 % CI, 1.017–2.783).

Conclusions

Our results demonstrated a susceptibility for deteriorated right cardiac structure and function during the first 2 years of PD treatment. Also, higher all-cause mortality risk was observed after 2 years of PD. Altogether, these results highlighted the need for additional focus on regular echocardiographic examinations during long-term PD management.

Trial registration

The PD-CRISC cohort, registered with the Chinese Clinical Trial Registry (ChiCTR1900023565).

Remodeling of the pulmonary artery in idiopathic pleuroparenchymal fibroelastosis

Idiopathic pleuroparenchymal fibroelastosis (IPPFE) is a rare subtype of idiopathic interstitial pneumonia that consists of alveolar septal elastosis and intra-alveolar collagenosis, which is predominantly located in the upper lobes. The aim of this study was to examine the remodeling of the pulmonary arteries in patients with IPPFE. This study included 18 patients with IPPFE, 24 patients with idiopathic pulmonary fibrosis (IPF), and 5 patients without pulmonary disease as controls. We selected muscular pulmonary arteries and calculated the percentage of the thickness of each layer of the wall (intima, media, and adventitia) in relation to the external diameter. We also quantified the percentage of areas of elastic fiber in the media divided by the whole area of the media (medial elastic fiber score). The percentage of adventitial thickness in IPPFE was significantly higher than that in IPF and in control lungs. The percentage of medial thickness did not differ statistically between IPPFE and IPF. However, the medial elastic fiber score in IPPFE was also significantly larger than that in IPF and control lungs. These results suggest that collagenous thickening of the adventitia and medial elastosis are distinct histological features in the muscular pulmonary arteries of patients with IPPFE.

Assessment of right heart functions in the patients with arteriovenous fistula for hemodialysis access: Right ventricular free wall strain and tricuspid regurgitation jet velocity as the predictors of right heart failure

Objectives

Previous studies have mostly focused on the left-sided cardiovascular changes, but right-sided cardiac changes and predictive factors have not been examined in advance following arteriovenous fistula (AVF) creation. We aimed to identify new parameters which contribute to the prediction of right heart failure (RHF) after AVF creation.

Methods

The study cohort comprised 81 patients who underwent AVF creation between January 2014 and April 2019 in our center. The study cohort was divided into the patients with RHF ( n = 15, 18.5%) and without RHF ( n = 66, 72.5%) following AVF creation.

Results

Mean age of cohort was 49.9 ± 14.7 years (range 23–66) and 39 (48.1%) were men. Approximately 74.07% (60 patients) were in New York Heart Association Class II and III profile preoperatively. Independent predictors for RHF following AVF were right ventricle longitudinal strain (RVLS) free wall <-19% [odds ratio (OR) 2.31, 95% CI 1.02–3.22], and tricuspid regurgitation jet velocity (TRJV) >2.5 m/s [odds ratio (OR) 5.68, 95% CI 1.21–4.38]. Receiver operating characteristic analysis was performed with a resulting area under the curve value of 0.86 (95% CI 0.55–0.89, p = 0.004) for RVLS free wall <-14.2% and 0.81 for TRJV >2.61 m/s (95% CI 0.55–0.89, p = 0.005) in predicting RHF following AVF.

Conclusions

RVLS free wall <-14.2% and TRJV >2.61 m/s were independent predictors of RHF following AVF creation. The patients at risk for having RHF following AVF creation or who may benefit from AVF should be identified with predictive parameters and prospective clinical studies.

Repair or Replacement for Isolated Tricuspid Valve Pathology? Insights from a Surgical Analysis on Long-Term Survival

Background

Long-term follow-up data concerning isolated tricuspid valve pathology after replacement or reconstruction is limited. Current American Heart Association guidelines equally recommend repair and replacement when surgical intervention is indicated. Our aim was to investigate and compare operative mortality and long-term survival in patients undergoing isolated tricuspid valve repair surgery versus replacement.

Material/Methods

Between 1995 and 2011, 109 consecutive patients underwent surgical correction of tricuspid valve pathology at our institution for varying structural pathologies. A total of 41 (37.6%) patients underwent tricuspid annuloplasty/repair (TAP) with or without ring implantation, while 68 (62.3%) patients received tricuspid valve replacement (TVR) of whom 36 (53%) were mechanical and 32 (47%) were biological prostheses.

Results

Early survival at 30 days after surgery was 97.6% in the TAP group and 91.1% in the TVR group. After 6 months, 89.1% in the TAP group and 87.8% in the TVR group were alive. In terms of long-term survival, there was no further mortality observed after one year post surgery in both groups (Log Rank p=0.919, Breslow p=0.834, Tarone-Ware p=0.880) in the Kaplan-Meier Survival analysis. The 1-, 5-, and 8-year survival rates were 85.8% for TAP and 87.8% for TVR group.

Conclusions

Surgical repair of the tricuspid valve does not show survival benefit when compared to replacement. Hence valve replacement should be considered generously in patients with reasonable suspicion that regurgitation after repair will reoccur.