Estimation of left ventricular function in right ventricular volume and pressure overload. Detection of early left ventricular dysfunction by Tei index

Atrial Septal Defect: Larger Right Ventricular Dimensions and Atrial Volumes as Early as in the First Month After Birth-a Case-Control Study Including 716 Neonates

Atrial septal defect (ASD) is characterized by a left-to-right shunt causing dilatation of the right atrium and right ventricle as well as pulmonary hyperperfusion. The detection of ASDs often occurs late in childhood or adulthood. Little is known about cardiac structure and function in neonates with ASD.We analyzed neonatal echocardiograms from the Copenhagen Baby Heart Study, a multicenter, population-based cohort study of 27,595 neonates. We included 716 neonates with secundum-type ASDs and matched them 1:1 on sex and age at examination with neonates without ASD from the same birth cohort. Neonates with an ASD (median age 11 days, 52% female) had larger right ventricular (RV) dimensions than matched controls (RV longitudinal dimension end-diastole: 27.7 mm vs. 26.7 mm, p < 0.001; RV basal dimension end-diastole: 14.9 mm vs. 13.8 mm, p < 0.001; and RV outflow tract diameter 13.6 mm vs. 12.4 mm, p < 0.001). Atrial volumes were larger in neonates with ASD compared to controls (right atrial end-systolic volume: 2.9 ml vs. 2.1 ml, p < 0.001; and left atrial end-systolic volume 2.0 ml vs. 1.8 ml, p < 0.001). Tricuspid annular plane systolic excursion was larger in neonates with ASD than in controls (10.2 mm vs. 9.6 mm, p < 0.001). Left ventricular dimensions and function did not differ between neonates with ASD and controls. In conclusion, ASDs were associated with altered cardiac dimensions already in the neonatal period, with larger right ventricular dimensions and larger atrial volumes at echocardiography within the first 30 days after birth.ClinicalTrials.gov Identifier: NCT02753348 (April 27, 2016).

Role of Electromechanical Dyssynchrony Assessment During Acute Circulatory Failure and Its Relation to Ventriculo-Arterial Coupling

Introduction

Two parallel paradigms of cardiovascular efficiency and haemodynamic optimisation coexist in haemodynamic research. Targeting ventriculo-arterial (VA) coupling [i.e., the ratio between arterial and ventricular elastance (E_V)] and electromechanical coupling are two promising approaches in acute circulatory failure. However, validation of the parameters of electromechanical coupling in critically ill patients is ongoing. Furthermore, a unifying link between VA and electromechanical coupling may exist, as E_V is correlated with different times of the cardiac cycle.

Materials and Methods

This study was a retrospective analysis of a prospectively collected observational database from one tertiary center ICU. We analyzed the relationship between electromechanical dyssynchrony and acute circulatory failure hemodynamics before and after treatment (i.e., fluid expansion, dobutamine, or norepinephrine infusion). The relationship between electromechanical coupling and VA coupling was also investigated. Adult patients with haemodynamic instability were included. Haemodynamic parameters, including arterial pressure, cardiac index, VA coupling, stroke work index/pressure–volume area (SWI/PVA), t-IVT, and Tei's index, were collected before and after treatment. A t-IVT of >12 s/min was classified as intraventricular dyssynchrony.

Results

We included 54 patients; 39 (72.2%) were classified as having intraventricular dyssynchrony at baseline. These patients with baseline dyssynchrony showed a statistically significant amelioration of t-IVT (from 18 ± 4 s to 14 ± 6 s, p = 0.001), left ventricular E_V [from 1.1 (0.72–1.52) to 1.33 (0.84–1.67) mmHg mL⁻¹, p = 0.001], VA coupling [from 2 (1.67–2.59) to 1.80 (1.40–2.21), p = 0.001], and SWI/PVA [from 0.58 (0.49–0.65) to 0.64 (0.51–0.68), p = 0.007]. Patients without baseline dyssynchrony showed no statistically significant results. The improvement in VA coupling was mediated by an amelioration of E_V. All patients improved their arterial pressure and cardiac index with treatment. The haemodynamic treatment group exhibited no effect on changing t-IVT.

Conclusion

Acute circulatory failure is associated with electromechanical dyssynchrony. Cardiac electromechanical coupling was improved by haemodynamic treatment only if altered at baseline. The improvement of cardiac electromechanical coupling was associated with the improvement of markers of cardiocirculatory efficacy and efficiency (i.e., SWI/PVA and VA coupling). This study was the first to demonstrate a possible link between cardiac electromechanical coupling and VA coupling in patients with acute circulatory failure.

Assessment of ventricular function in patients of atrial septal defect by strain imaging before and after correction

Background:

Atrial septal defect (ASD) is a common congenital heart disease associated with volume overload of Right ventricle (RV) with variable effect on Left ventricle (LV). Two-dimensional (2D) Strain analysis is a new tool for objective analysis of myocardial function. This prospective study evaluated the systolic function of right and left ventricle by conventional 2D echo and strain echo and measured changes in cardiac hemodynamics that occurred in patients of ASD before and after correction.

Patients and Methods:

2D echo and strain analysis of each patient before and at 48 hrs, 3 months and 6 months after correction was performed. Routine 2D echo parameters and global longitudinal strain of both ventricles were measured.

Result:

Improvement in LV ejection fraction (P = 0.0001) and myocardial performance index (MPI) (P < 0.0001) occurred at the end of 6 months, whereas decrease in RV MPI (P < 0.0001) and tricuspid annular plane systolic excursion (P < 0.0001) became statistically significant after 3 months of ASD correction. In comparison to conventional 2D echo, global longitudinal strain of RV decreased significantly only after 48 hours of ASD correction while there was no improvement in left ventricular global longitudinal strain after 6 month of correction.

Conclusion:

There was improvement in RV function with subtle change in LV function by strain imaging and most of these changes were completed within 6 months of ASD correction and nearly correlated with conventional 2DEchocardiography.

Noninvasive Echocardiographic Measures of Pulmonary Vascular Resistance in Children and Young Adults with Cardiomyopathy

BACKGROUND

Patients with cardiomyopathy (CM) are at increased risk for pulmonary hypertension (PH). Data are lacking on the use of noninvasive PH measures by echocardiography in patients with CM. The aim of this study was to evaluate the correlation between Doppler-derived echocardiographic indices and catheterization-based measurement of pulmonary vascular resistance (PVR) in children and young adults with CM.

METHODS

Imaging studies were retrospectively reviewed from pediatric patients with CM who underwent both echocardiography and cardiac catheterization within a 72-hour period. The ratio of peak tricuspid regurgitation velocity to right ventricular outflow tract velocity-time integral, the S/D ratio, and right ventricular myocardial performance index were correlated with invasive PVR. Receiver operating characteristic curves were developed to determine cutoffs for detecting PVR ≥ 6 indexed Wood units, a value associated with higher heart transplantation risk.

RESULTS

Twenty-three patients with CM (median age, 11.7 years; range, 0.5-21 years) met the criteria for analysis, the majority (n = 17 [74%]) of whom had dilated CM. Linear regression showed significant correlations between echocardiography-based ratio of peak tricuspid regurgitation velocity to right ventricular outflow tract velocity-time integral, S/D ratio, and right ventricular myocardial performance index versus invasive PVR (r = 0.84, r = 0.72, and r = 0.72, respectively, P < .001). All echocardiographic measures showed high sensitivity, specificity, and predictive values to detect PVR ≥ 6 indexed Wood units, with ratio of peak tricuspid regurgitation velocity to right ventricular outflow tract velocity-time integral demonstrating the highest area under the curve (0.958; 95% CI, 0.866-1).

CONCLUSIONS

Right-sided Doppler-derived echocardiographic indices correlate with PVR measured by cardiac catheterization in children and young adults with CM. These parameters may serve as useful adjuncts in serial assessment of right ventricular hemodynamics in this population.

Histologic and Hemodynamic Correlates of Right Ventricular Function in a Pressure Overload Model: a Study Using Three-Dimensional Speckle Tracking Echocardiography

The aim of our study was to assess the characterization of right ventricular (RV) deformation using three-dimensional (3D) speckle tracking echocardiography (STE) and association of 3D-STE indices with histologic and hemodynamic parameters in a chronic RV pressure overload animal model. Pulmonary artery banding (PAB) was used to induce RV pressure overload in seven beagles. 3D-STE, histologic and hemodynamic measurements were performed in PAB and sham-operated beagles 3 mo after PAB. RV longitudinal, radial and circumferential strain was measured from 3D-STE. Three mo after PAB, RV longitudinal strain was decreased; whereas radial and circumferential strain remained unchanged in PAB group. RV longitudinal strain was associated with interstitial fibrosis (r = -0.733) in the endocardial layer of the RV free wall. RV circumferential strain was related to dp/dt_max (r = 0.718). The significant correlations of RV 3D-STE indices with histologic and hemodynamic parameters indicate that 3D-STE may be a valuable tool for assessment of ventricular function in RV pressure overload.

Impaired right and left ventricular mechanics in adults with pulmonary hypertension and congenital shunts

AIMS

To assess left ventricle mechanics in Eisenmenger physiology patients with congenital shunts, and their relationship with the right ventricle, and to consider the clinical usefulness of this information.

METHODS

The study involved 28 patients with pulmonary artery hypertension (PAH) and congenital shunt, matched with 28 healthy participants. Standard echocardiography and pulsed wave tissue Doppler imaging were employed to analyze systolic and diastolic ventricular function, the myocardial performance index (MPI) of ventricles, and the strain and strain rate along the left ventricle lateral wall, septum, and right ventricle free wall.

RESULTS

The left ventricle ejection fraction was similar in the two groups. However, despite normal standard left ventricle measures, patients presented parameters of defective myocardial mechanics: mitral peak systolic velocity (S') (cm/s) (8.6 (7.6-10.9) vs. 10.7 (8.6-12.5); P = 0.002) was higher, whereas left ventricle-MPI was lower (0.54 ± 01 vs. 0.32 ± 0.07, P < 0.001). Right ventricle-MPI and right ventricle global strain were correlated significantly with left ventricle-MPI and left ventricle global strain (r = 0.74, P < 0.001; r = 0.442, P < 0.001, respectively). Clinically, the six-minute walking test results were correlated negatively with left ventricle-MPI (r = -0.69, P < 0.001), whereas the functional class was positively correlated (r = 0.36, P < 0.001). In conclusion, left ventricle mechanics and geometry are impaired in Eisenmenger syndrome patients, although conventional evaluation is in the normal range. Our results highlight the significance of ventricular interdependence in PAH and provide a useful tool for improving the clinical management of these patients.

Comparison of late results of arterial switch versus atrial switch (mustard procedure) operation for transposition of the great arteries

Two decades after surgery for transposition of the great arteries, the clinical status, cardiac function, cardiorespiratory performance, and neurohormonal activity of patients who underwent either atrial switch (Mustard) operations or arterial switch operations (ASOs) were compared. Sixty-two patients with simple transposition of the great arteries who underwent either Mustard (n = 34) or ASO (n = 28) procedures were included in this cross-sectional study. Following the same study protocol, clinical workup including echocardiography, stress testing, and blood work was completed for all patients. Mean ages in the 2 groups were comparable, at 20.6 ± 2.1 and 20.6 ± 3.4 years in the ASO and Mustard groups, respectively. All ASO patients were in New York Heart Association class I, whereas 59% of Mustard patients were in class II or III. Peak oxygen uptake was higher in ASO patients (percentage of predicted 80% vs 69%, p <0.01). Compared with healthy subjects, the mean Tei index for systemic ventricle was high in the 2 groups, but this parameter was significantly higher in Mustard than ASO patients (0.60 ± 0.16 vs 0.47 ± 0.14, p <0.01). The median plasma N-terminal pro-brain natriuretic peptide level in ASO patients was within the normal range, but the Mustard group had significantly higher levels (42 ng/ml [range 18 to 323] vs 172 ng/ml [range 26 to 1,018], p <0.0001). In conclusion, this cross-sectional assessment 2 decades after surgery reveals better clinical status in patients who underwent ASO compared with Mustard patients. This holds in terms of cardiac function, cardiorespiratory performance, and neurohormonal activity.

Comparison of the response of the right ventricle with endovascular occlusion and surgical closure in adults with atrial septal defect one year after intervention

BACKGROUND

Use of the Amplatzer septal occluder (ASO) for the closure of secundum atrial septal defect (ASD) has recently become the procedure of choice, while earlier the only treatment for ASD was surgical closure. This study compares the right ventricular indices of the ASO group with the surgical closure group one year after intervention in adults.

METHODS

From January 2008 to February 2010, 38 patients with isolated atrial septal defect of the secundum type one year after surgical (n = 20, age = 27 ± 4 years, 13 females, 7 males) or Amplatzer septal occluder closure (n = 18, age = 25 ± 4 years, 12 females, 6 males) were studied. At the same time, thirty-one age-matched normal subjects (age = 26 ± 6 years, 23 females, 9 males) were included as the control group. Strain and strain rate of the right ventricle were measured.

RESULTS

The mean values of strain of the midportion were -26% ± 11.7%, -8.9% ± 4.2%, and 24.5% ± 7.4% (P < 0.001). Strain rates of the midportion were -2.19 ± 0.6 s(-1), -1.2 ± 0.4 s(-1), -1.9 ± 0.6 s(-1) (P < 0.001) in ASO, surgery, and control groups, respectively.

CONCLUSION

This study showed that the right ventricle might show better performance in the ASO than the surgery group in adults with ASD in midterm follow-up.

Left ventricular function many years after recovery from pre-eclampsia

OBJECTIVE

Epidemiological observations have shown that women with pre-eclampsia are at increased risk for subsequent development of cardiovascular disease. We evaluated maternal haemodynamics in asymptomatic women many years after pre-eclampsia and HELLP (haemolysis, elevated liver enzymes and low platelets) syndrome.

DESIGN

Case-control study.

SETTING

University-based department of obstetrics.

POPULATION

Forty-eight women, 13-18 years after the affected pregnancy: 17 women with a history of HELLP syndrome, 14 women with a history of pre-eclampsia and 17 women following normal pregnancy (control group).

METHODS

Echocardiographic examination was performed in all groups, recording the isovolumetric contraction time and isovolumetric relaxation time (ICT + IVRT), ejection time (ET), myocardial performance index (MPI), transmitral early to atrial filling velocity ratio (MV-E/MV-A), stroke volume (SV) and cardiac output (CO).

MAIN OUTCOME MEASURES

Cardiac function.

RESULTS

Women with previous HELLP syndrome showed a significantly increased MPI (0.34 versus 0.26; P = 0.008) and ICT + IVRT (442.16 versus 415.03; P = 0.01); MV-E/A, SV, ET and CO were not significantly different. Women with a history of pre-eclampsia showed a significantly increased MPI (0.36 versus 0.26; P = 0.006) and decreased ET (317.3 versus 328.93; P = 0.04); ICT + IVRT, MV-E/A, SV and CO were not significantly different.

CONCLUSION

This study confirms epidemiological observations that women with pre-eclampsia are at increased risk for subsequent development of cardiovascular disease. Many years after HELLP syndrome or pre-eclampsia, asymptomatic women have an increased risk for impaired cardiac function as shown by an increased MPI.

Exercise capacity and biventricular function in adult patients with repaired tetralogy of Fallot

BACKGROUND

Adult patients with repaired tetralogy of Fallot (rTOF) often have diminished exercise capacity. The primary objective of this study was to examine whether abnormalities of biventricular function play a role in exercise limitation in patients with rTOF.

METHODS

This was a retrospective review of 99 adult patients with rTOF. Right ventricular (RV) and left ventricular (LV) function were assessed echocardiographically using the myocardial performance index (MPI). Maximal oxygen consumption (VO(2) Max) was measured during a level 1 cardiopulmonary exercise test.

RESULTS

The mean age of the cohort was 34 +/- 11 years (50% females). Although most of the patients reported good functional capacity, the peak Vo(2)max was decreased at 22 +/- 6 mL/kg per minute (66% +/- 13% predicted Vo(2)max for age and sex). The mean RV and LV MPI were 0.30 +/- 0.07 and 0.42 +/- 0.09, respectively. In the multivariate model, higher RV MPI (P = .04) and LV MPI (P = .005) values, representing impaired ventricular function, were associated with diminished Vo(2)max. There was a significant correlation between the RV and LV MPI (r = 0.54, P = .001).

CONCLUSIONS

Impairment of RV and LV function, as measured by MPI, is associated with diminished exercise capacity in patients with repaired tetralogy of Fallot. Furthermore, there is a linear relationship between the RV and LV function suggesting that ventricular interactions are contributing to the limited exercise capacity in this group of patients. Strategies aimed at preserving biventricular function or improving adverse ventricular interactions could help to improve functional capacity in these patients.

Bifocal pacing - A novel cardiac resynchronization therapy? Results of bifocal pacing study and review of the current literature

BACKGROUND

Bifocal pacing (BFP) has been proposed as a more feasible alternative of cardiac resynchronization therapy (CRT).

AIM

To evaluate BFP in patients with severe congestive heart failure and significant intraventricular conduction delay and to compare it with biventricular pacing (BVP).

METHODS

Both echocardiographic examination including tissue Doppler imaging and invasive measurements of cardiac hemodynamics was performed under basal conditions and during BFP and BVP.

RESULTS

50 patients were included: 29 patients with ischemic heart disease (IHD), 21 patients with idiopathic dilated cardiomyopathy (IDCM). Left ventricular (LV) pressure gradient (dp/dt max) increased during BFP compared to the baseline (13.4 %, 95 % CI 9.2-17.6 %, p < 0.0001) and a further increase was achieved during BVP (29.5 %, 95 % CI 23.7-35.4 %, p < 0.0001). A significant correlation was found between the distance of the right ventricular apical and outflow tract leads and percentage of dp/dt max increase in IDCM patients (r = 0.72, p < 0.001), but not in IHD patients. Interventricular mechanical delay (IVMD) decreased in BFP compared to baseline (43 +/- 22 ms vs. 53 +/- 31 ms, p = 0.006). BVP produced even shorter IVMD (22 +/- 19 ms, p < 0.0001). In all patients, the regional systolic contraction times were significantly shortened, corresponding with prolongation of the respective regional diastolic filling times during both BFP (p < 0.05 for all segments) and BVP (p < 0.001 for all segments). The effect of BVP on regional systole shortening was more pronounced.

CONCLUSIONS

BFP improves LV hemodynamics by decreasing the inter- and intraventricular conduction delays. The leads in the right ventricle should be placed at the longest achievable distance. BVP is superior to BFP.

Use of myocardial performance index in pediatric patients with idiopathic pulmonary arterial hypertension

BACKGROUND

The myocardial performance index (MPI) correlates with clinical status in adults with idiopathic pulmonary arterial (PA) hypertension (IPAH). This pediatric study used MPI to assess response to bosentan therapy.

METHODS

The study included 12 children with IPAH and 12 healthy control subjects. MPI was correlated with catheterization data at initiation of bosentan and at a median follow-up of 9 months. Therapy responders were defined by a greater than 20% decrease in mean PA pressure.

RESULTS

Right ventricular MPI for patients with IPAH was 0.64 +/- 0.30 versus 0.28 +/- 0.03 in control subjects (P < .01). It had a strong correlation with mean PA pressure (R = 0.94; P < .001). Right ventricular MPI decreased significantly in responders (range 20%-44%, mean 25%) with a 5% increase in nonresponders.

CONCLUSIONS

Right ventricular MPI in pediatric IPAH correlates with mean PA pressure and response to therapy. This study suggests that this noninvasive Doppler index may be useful to follow up children with IPAH, particularly when tricuspid regurgitation data are insufficient.

Elevated brain natriuretic peptide and reduced exercise capacity in adult patients operated on for tetralogy of fallot is due to biventricular dysfunction as determined by the myocardial performance index

Although tetralogy of Fallot (TOF) can be repaired surgically, residual lesions that cause abnormal ventricular load can eventually lead to heart failure. Subclinical biventricular dysfunction in these patients may be detected only by using suitably sensitive indexes. The Tei index determined by the pulsed Doppler method enables the measurement of left ventricular (LV) and right ventricular (RV) function. This study was designed to evaluate the biventricular Tei indexes in adults with operated congenital heart disease and to correlate these indexes with cardiopulmonary capacity and neurohormonal activation. Fifty-nine patients with surgically corrected TOF and 52 patients with operated left-to-right-shunt defects were included in the study. Patients with TOF showed significantly greater LV and RV Tei indexes than those with left-to-right-shunt defects (LV Tei index 0.50 +/- 0.09 vs 0.34 +/- 0.05, RV Tei index 0.37 +/- 0.1 vs 0.25 +/- 0.06; p <0.0001). Peak oxygen uptake was significantly reduced in the patients with TOF (25 +/- 6 vs 32 +/- 6 ml x kg(-1) x min(-1), p <0.0001) and was correlated inversely with the LV Tei index (r = -0.61, p <0.0001). N-terminal-pro-brain natriuretic peptide was significantly increased in patients with TOF (150 +/- 141 vs 57 +/- 39 pg/ml, p <0.0001). In conclusion, in asymptomatic or minimally symptomatic patients with TOF, biventricular dysfunction is detected by the Tei index. Further indexes for heart failure in these patients are increased circulating plasma N-terminal-pro-brain natriuretic peptide and impaired peak oxygen uptake. The combined determinations of these 3 variables enable the identification of congenital heart disease with impaired cardiac function before they become clinically symptomatic.

Relation of systemic ventricular function quantified by myocardial performance index (Tei) to cardiopulmonary exercise capacity in adults after Mustard procedure for transposition of the great arteries

After Mustard repair for transposition of the great arteries, the right ventricle serves as a chronically overloaded systemic ventricle (SV). Thus, during long-term follow-up, dysfunction of the right ventricle with consecutive heart failure (HF) is not unusual. Early signs and symptoms of HF are depressed parameters of right ventricular (RV) function at rest and exercise intolerance. It was hypothesized that the measurement of RV function parameters, N-terminal pro-brain natriuretic peptide (NT-pro-BNP), and peak oxygen uptake (VO2max) during exercise testing were suitable for the early detection of subclinical HF. In 33 asymptomatic adolescents and adults who had undergone Mustard repair, RV function was analyzed by the myocardial performance index (Tei index). NT-pro-BNP and VO2max were also determined. The corresponding data from 52 patients operated on for left-to-right shunt defects without residual lesions served as reference data. In patients who underwent the Mustard procedure, the Tei index and NT-pro-BNP were elevated (mean Tei index of the SV 0.63 +/- 0.17 vs 0.34 +/- 0.05, p <0.002; mean NT-pro-BNP 240 +/- 230 vs 57 +/- 39 pg/ml, p <0.0001), and VO2max was reduced (27 +/- 6 vs 32 +/- 6 ml x kg(-1) x min(-1), p <0.002). A good correlation was found between the Tei index and VO2max (r = -0.83, p <0.0001). In conclusion, RV function is depressed in most patients with Mustard repair. Ventricular dysfunction in such asymptomatic or minimally symptomatic patients can be detected by measurement of the Tei index, NT-pro-BNP, and VO2max. These parameters are simple and reliable screening methods to stratify patients with impaired cardiac dysfunction before they become symptomatic.

Doppler tissue imaging in assessment of pulmonary hypertension-induced right ventricle dysfunction

We aimed to assess the accuracy of Doppler tissue imaging (DTI) in detecting right ventricle (RV) dysfunction and electromechanical coupling alteration following pulmonary hypertension (PHT) in rat. PHT was induced by chronic hypoxia exposure (hypoxic PHT) or monocrotaline treatment (monocrotaline PHT). In both PHT models, we observed transparietal RV pressure increase and remodeling, including hypertrophy and dilation. Conventional echocardiography provided evidence for pulmonary outflow impairment with midsystolic notch and acceleration time decrease in PHT groups (21.7 +/- 1.6 and 13.2 +/- 2.9 ms in hypoxic and monocrotaline PHT groups vs. 28.1 +/- 1.0 ms in control). RV shortening fraction was decreased in the monocrotaline PHT group compared with the hypoxic PHT and control groups. Combining conventional Doppler and DTI was more helpful to detect RV diastolic dysfunction in the monocrotaline PHT group (E/Ea ratio = 17.0 +/- 1.4) compared with the hypoxic PHT and control groups (11.5 +/- 0.7 and 10.2 +/- 0.4, respectively). Tei index measured using DTI highlighted global RV dysfunction in the monocrotaline PHT group (1.36 +/- 0.24 vs. 0.92 +/- 0.05 and 0.86 +/- 0.05 in the hypoxic PHT and control groups, respectively). Q-Sm time measured from the onset of Q wave to the onset of DTI Sm wave was increased in both PHT groups. PHT-induced electromechanical coupling alteration was confirmed by in vitro activation-contraction delay measurements on isolated RV papillary muscle, and both Q-Sm time and activation-contraction delay were correlated with PHT severity. We demonstrated that Q-Sm time measured in DTI was an easily and convenient index to detect early RV electromechanical coupling alteration in both moderate and severe PHT.

Improvements in cardiac form and function after transcatheter closure of secundum atrial septal defects

OBJECTIVES

We set out to study the effect of transcatheter closure of atrial septal defect (ASD) on right ventricular (RV) and left ventricular (LV) function assessed by myocardial performance index (MPI), as well as left atrial (LA) volumes.

BACKGROUND

The hemodynamic response to the closure of ASD is well-documented in surgically treated patients. However, few studies have documented echocardiographic evaluation of ventricular function in patients undergoing transcatheter closure of ASDs.

METHODS

Pre- and post-ASD device closure echocardiograms of 25 consecutive patients were retrospectively reviewed. Measurements of RV and LV MPI and LA volumes were made.

RESULTS

Twenty-five patients with an average age of 45.5 +/- 16.3 years underwent transcatheter closure of ASD. There was statistically significant improvement in RV MPI (0.35 to 0.28, p = 0.004), LV MPI (0.37 to 0.31, p = 0.04), and LA volume index (25.7 to 21.8 ml/m(2), p < 0.001) after closure of ASD.

CONCLUSIONS

Device closure of ASDs leads to improvement of both RV and LV function as well as reduction in LA volume. These hemodynamic improvements provide insights into the symptomatic benefits gained in closure of ASDs using the transcatheter approach.

Doppler assessment of cardiac function at 11-14 weeks' gestation in fetuses with normal and increased nuchal translucency

OBJECTIVE

To investigate cardiac dysfunction as a potential underlying mechanism for increased nuchal translucency (NT) in fetuses with chromosomal abnormality or heart defects.

METHODS

Myocardial performance index (MPI) and atrioventricular valve E/A ratios for both sides of the heart were measured by Doppler echocardiography in fetuses at 11-14 weeks' gestation. The study groups consisted of 159 normal control fetuses, 199 otherwise normal fetuses but with increased NT > or = 4 mm, 142 fetuses with trisomy 21, 58 with trisomy 18, 19 with trisomy 13, 37 with Turner's syndrome and 24 with isolated heart defects. Groups were compared using Student's t-test and confidence intervals for differences between groups were calculated.

RESULTS

Otherwise normal fetuses with increased NT showed no difference in any of the cardiac Doppler parameters from normal controls. Mean E/A ratio was slightly but significantly increased in trisomy 21 fetuses compared with normal controls (0.604 vs. 0.578 on the right, P = 0.011; 0.581 vs. 0.542 on the left, P = 0.0001). E/A ratio was not significantly different between any of the other groups and the normals but there was a small increase in absolute E-wave velocity in trisomy 18 fetuses. MPI was significantly decreased in trisomy 21 fetuses, (0.330 vs. 0.378, P = 0.002 on the left) and also in Turner's syndrome fetuses (0.301 vs. 0.352 on the right, P = 0.04; 0.320 vs. 0.378 on the left, P = 0.034) implying better performance, but not in the other groups.

CONCLUSIONS

The magnitude and/or direction of the differences shown do not support a major role for cardiac functional abnormality in the development of NT. Important cardiac dysfunction could not be demonstrated in association with increased NT in normal or abnormal fetuses.

Evaluation of right ventricular dysfunction in patients with cardiac amyloidosis using tei index

BACKGROUND

Cardiac amyloidosis is an infiltrative disease causing predominant diastolic dysfunction and systolic dysfunction at its advanced stage. Right ventricular (RV) dysfunction is an independent predictor of poor prognosis in congestive heart failure and cardiomyopathies. However, the assessment of RV function is still technically difficult because of the complicated geometry of the RV. The recently proposed Tei index, obtained from the cardiac time interval analysis, allows noninvasive and quantitative estimation of global ventricular function without geometric evaluation. Therefore, this study was designed to assess RV function for patients with cardiac amyloidosis.

METHODS

Study patients consisted of 30 consecutive patients with biopsy specimen-proven cardiac amyloidosis and 50 control subjects. Patients were classified as having early or advanced stage of cardiac amyloidosis on the basis of mean left ventricular wall thickness < 15 mm or >/= 15 mm. Tei index, defined as the sum of isovolumetric contraction and relaxation time divided by ejection time, was obtained from tricuspid and pulmonary Doppler flow velocity.

RESULTS

RV Tei index was significantly increased for patients with cardiac amyloidosis (0.54 +/- 0.16 vs 0.28 +/- 0.05, amyloidosis vs control, P <.001). The incidences of abnormal RV isovolumetric contraction time, ejection time, isovolumetric relaxation time, and Tei index in all patients with cardiac amyloidosis were 63%, 43%, 73%, and 83%, respectively. The same incidences were 50%, 13%, 63%, and 75% in the early stage and 68%, 54%, 77%, and 86% in the advanced stage, respectively.

CONCLUSION

Patients with cardiac amyloidosis frequently have RV dysfunction even in its early stage. Tei index allows simple, noninvasive, and nongeometric estimation of RV dysfunction in patients with cardiac amyloidosis.

Influence of perindopril on left ventricular global performance during the early phase of inferior acute myocardial infarction: assessment by Tei index

The beneficial effect of angiotensin-converting enzyme inhibitors (ACE inhibitors) on left ventricular (LV) function in patients with acute myocardial infarction (AMI) is widely known. However, controversy exists about their efficacy on patients with small infarcts and preserved LV systolic function. The aim of the present study was to detect the influence of the ACE-I perindopril on the global LV performance in patients with pure inferior AMI (AMI-I) using a Doppler-derived index (DI) that combines systolic and diastolic time intervals (Tei index). Our study included 40 patients with first AMI-I, mean age 60 years +/- 9.06 years (SD) and 24 age- and gender-matched normal patients who constituted the control group (COG). Patients were randomized into two groups to receive the conventional treatment of AMI-I (GCT) or the above therapy plus P (GP). Complete Doppler echocardiography (systolic and diastolic parameters), DI, and systolic blood pressure (SBP) were measured on the 8.07 +/- 1.16(SD) post-infarct day. The same examination was performed to COG. The DI was significantly lower in healthy patients(0.45 +/- 0.23)compared with the value in patients of either GP(0.56 +/- 0.03; P = 0.023)or GCT(0.78 +/- 0.05; P = 0.000). Moreover DI was higher in patients of GCT compared with that of GP(P = 0.000). In addition, perindopril administration decreased isovolumic relaxation time(IRT; 120.00 +/- 4.23 vs. 139.00 +/- 6.74; P = 0.006)and increased significantly ejection time (ET;274.25 +/- 7.35 vs. 253.50 +/- 7.68; P = 0.042). SBP in patients of GP was similar to that of GCT(120.5 +/- 2.85 mmHg vs. 112.5 +/- 3.49 mmHg; P = NS).

CONCLUSIONS

Global LV function (DI) is impaired in patients with AMI-I. Administration of perindopril has a favorable impact on LV performance in patients with AMI-I, achieved through improvement of the diastolic function (IRT), which indirectly improves LV systolic function (ET, DI). This beneficial influence of perindopril is the result of the direct tissue effect of the drug and not its hemodynamic action.

Pseudonormalized Doppler total ejection isovolume (Tei) index in patients with right ventricular acute myocardial infarction

The Doppler total ejection isovolume (Tei) index is useful for estimating global cardiac function. However, the relation between the right ventricular (RV) Tei index and RV infarction has not been investigated. The relation between the RV Tei index and severity of RV infarction was evaluated in 25 patients with inferior wall acute myocardial infarction (13 with and 12 without RV infarction). RV infarction was diagnosed when right atrial pressure was > or = 10 mm Hg or when right atrial pressure/pulmonary capillary wedge pressure was >0.8 by catheterization. The RV Tei index was significantly increased in patients with RV infarction compared with those without (0.53 +/- 0.15 vs 0.38 +/- 0.14, p <0.05). The RV Tei index in patients with severe RV infarction (right atrial pressure > or = 15 mm Hg) was significantly smaller compared with those with mild/moderate RV infarction (right atrial pressure <15 mm Hg) and showed no significant difference in patients with myocardial infarction but without RV infarction (0.44 +/- 0.09 vs 0.61 +/- 0.16 vs 0.38 +/- 0.14, severe RV infarction vs mild/moderate RV infarction vs no RV infarction, p <0.01). The RV Tei index is generally increased in patients with RV infarction; however, severe RV infarction can be manifested with limited or no increase in the Tei index (pseudonormalization).

Effects of valve dysfunction on Doppler Tei index

BACKGROUND

Recently proposed Doppler Tei index, defined as the sum of isovolumic contraction time or mitral valve closure to aortic valve opening time and isovolumic relaxation time or aortic valve closure to mitral valve opening time divided by ejection time, is a simple measure which enables noninvasive estimation of combined systolic and diastolic function and prediction of patients' prognosis. However, effects of valve dysfunction on Tei index have not been investigated. This study was designed to compare Tei index before and after surgical valve replacement or repair to evaluate effects of valve dysfunction on Tei index.

METHODS

Participants consisted of 76 consecutive patients with aortic or mitral valve surgery (26 patients with aortic stenosis [AS], 16 with aortic regurgitation, 17 with mitral stenosis, and 17 with mitral regurgitation). Doppler Tei index was evaluated before and after the surgery by obtaining (a-b)/b, where a is the interval between the cessation and onset of Doppler mitral filling flow and b is the aortic flow ejection time.

RESULTS

Tei index significantly increased after surgery in patients with AS (0.38 +/- 0.07 to 0.49 +/- 0.06, P <.001), aortic regurgitation (0.60 +/- 0.20 to 0.70 +/- 0.18, P <.01), mitral stenosis (0.34 +/- 0.03 to 0.39 +/- 0.04, P <.01), and decreased with no significance in mitral regurgitation (0.50 +/- 0.03 to 0.46 +/- 0.03). Percent change in Tei index after valve surgery was maximal in patients with AS (27 +/- 6 vs 17 +/- 2 vs 16 +/- 6 vs -9% +/- 6%, AS vs aortic regurgitation vs mitral stenosis vs mitral regurgitation, P <.001).

CONCLUSION

Tei index significantly changes after valve surgery especially in patients with AS. Considerations for the effects of valve dysfunction on Tei index are required for its application to evaluate ventricular function in patients with valve disease.

Transcatheter closure of atrial septal defect preserves right ventricular function

OBJECTIVES

To determine the effects of atrial septal defects (ASD) and their closure on systolic and diastolic right and left ventricular function; and by comparing surgical closure with transcatheter device closure, to establish differences attributable to cardiopulmonary bypass.

DESIGN

Cross sectionally guided M mode echocardiographic ventricular long axis function was measured prospectively before and within one week after ASD closure by device in 17 patients and by surgery in 12 patients, and compared with 18 normal subjects.

RESULTS

All indices of right ventricular function were impaired after surgery: mean total excursion, -1.89 cm (95% confidence interval (CI), -2.18 to -1.59); peak shortening rate, -9.09 cm/s (-10.82 to -7.35); peak lengthening rate, -9.26 cm/s (-11.09 to -7.43). Total excursion and peak lengthening rate were preserved after device closure, at -0.12 cm (-0.28 to 0.05) and 0.01 cm/s (-2.29 to 2.31), respectively. Left ventricular free wall function was unchanged after closure by either method, while all septal measurements were reduced after closure by either method (changes ranging from -3.51 to -0.32; 95% CI ranging from -4.90 to -0.13).

CONCLUSIONS

Left ventricular free wall function is unaffected by ASD closure, whereas septal function is impaired, irrespective of the method of closure. Right ventricular function, both systolic and diastolic, is impaired by cardiopulmonary bypass but preserved after device closure. These findings support the transcatheter approach to ASD closure in anatomically suitable defects.

Assessment of cardiac performance using Tei indices in patients undergoing pulmonary thromboendarterectomy

BACKGROUND

This study was designed to evaluate left and right ventricular performance using Tei indices in patients with severe chronic thromboembolic pulmonary hypertension undergoing pulmonary thromboendarterectomy (PTE). The Doppler-derived indices are easily measurable indicators of ventricular function based on nongeometric assessment, which helps overcome some of the difficulties entailed in the geometric assessment of left ventricular (LV) and right ventricular (RV) function in pulmonary hypertension.

METHODS

The indices were derived for 24 patients (aged 54+/-14 years) before and after PTE. Calculation of these indices was based on the duration of two time intervals using the formula (A - B)/B, where A is the interval between cessation and onset of mitral inflow (or tricuspid inflow) and B is LV or RV ejection time. In addition, LV and RV end-diastolic and end-systolic chamber areas were determined using two-dimensional echocardiography, and systolic function was calculated. Mean pulmonary artery pressure was determined invasively.

RESULTS

PTE led to a significant reduction of mean pulmonary artery pressure (46+/-10 versus 25+/-6 mm Hg; p < 0.05). LV and RV indices were abnormally high before surgery, declined significantly afterwards, and then almost matched normal values (0.61+/-0.26 versus 0.37+/-0.18; p < 0.05 and 0.55+/-0.22 versus 0.37+/-0.13; p < 0.05). Geometric assessment of the left and right ventricle also showed impaired systolic function before PTE, with significant improvement after surgery.

CONCLUSIONS

LV and RV Tei indices allow a quantitative assessment of ventricular function in patients undergoing PTE. Lower indices after surgery reflect an improvement of the previously impaired cardiac function. Our results emphasize the value of PTE in the treatment of chronic thromboembolic pulmonary hypertension.