Normal right ventricular systolic and diastolic function assessed by krypton-81m equilibrium ventriculography

Krypton-81m equilibrium ventriculography was used to study right ventricular function in 23 healthy male volunteers. Technetium-99m lung perfusion scintigraphy was employed to subtract radionuclide activity within lung during image analysis thereby enhancing image quality. The imaging technique was used to generate a time-activity curve for the right ventricle allowing the definition of indices of normal systolic and diastolic function for the right ventricle. At rest, indices of systolic ejection and diastolic filling were comparable to those previously reported for the left ventricle. Using this imaging technique, movement artifact during exercise reduces image quality and limits accurate measurement of these indices to resting studies.Abbreviations RVEF right ventricular ejection fraction     

超声心动图评价右心功能的应用

超声心动图是临床评价右心功能最常用的方法,现就近年来常用的关于评价右心功能的各种超声技术进行综述。     

右心室间隔部心脏起搏研究进展

右心室心尖部起搏改变了正常心脏的激动收缩顺序从而导致心脏组织及电学重塑、心脏收缩功能下降最终发生心力衰竭。右心室间隔部起搏可以获得接近正常生理的心室激动顺序,最大限度保持左、右双心室间正常的电激动顺序和收缩同步性;同时改善左房、左室的收缩同步性,增加左心室的舒张充盈时间,减少二尖瓣反流,有效地避免了起搏对血流动力学和心功能的不良影响。近来短期和长期研究发现右室间隔部心脏起搏可明显改善心脏活动的同步性,从而改善心功能、提高生活质量,认为右室间隔部心脏起搏治疗是对生理性心脏起搏的再认识。文章综述了右室心尖部起搏的病理生理及右室间隔部起搏治疗相关临床试验、显效机制、技术关键及存在的问题。     

Exercise Doppler: functional evaluation of right heart dynamics

Exercise echocardiography is a versatile technique that includes not only two-dimensional imaging, but also Doppler of aortic, mitral, and tricuspid valves. Doppler echocardiography can be useful in the evaluation of global left ventricular systolic and diastolic function, valvular function, transvalvular gradients, and pulmonary artery pressure. The technique lends itself to the study of the cardiac response to exercise in a variety of disease states, including pulmonary, coronary artery, valvular, and congenital heart disease. We review our experience using agitated saline-enhanced Doppler of tricuspid insufficiency to determine pulmonary artery pressure throughout exercise in chronic lung disease.     

经横突—椎弓根单侧穿刺椎体后凸成形术治疗腰椎骨质疏松性压缩骨折

目的探讨经横突—椎弓根单侧穿刺椎体后凸成形术(PKP)治疗腰椎骨质疏松性压缩骨折(LOVCF)的手术技巧及临床疗效。方法回顾性分析2009年1月～2011年3月经横突—椎弓根单侧穿刺PKP治疗32例LOVCF患者的临床资料。用疼痛视觉模拟评分(VAS),骨折椎前缘、中部高度,Cobb’s角评价经横突—椎弓根单侧穿刺PKP的临床疗效。结果 32例患者手术顺利,伤椎内骨水泥分布均匀,术后伤口愈合良好,未出现神经根损伤、骨水泥椎管内渗漏等严重并发症。28例患者获得随访,随访时间12～36个月、平均29个月。与术前相比,术后VAS评分明显好转,后凸角度明显变小,椎体前缘、中部高度有明显恢复(P<0.05)。结论经横突—椎弓根单侧穿刺PKP是治疗LOVCF的一种有效方法。     

The impact of right atrial ischemia on inferior myocardial infarction with extension to right ventricle: transesophageal echocardiographic examination

BACKGROUND: The role of the right atrium in adaptation to the hemodynamic changes produced by extension of myocardial infarction (MI) of the left ventricular inferior wall to the right ventricle is fundamental. HYPOTHESIS: The aim of this study was analyze a group of patients with MI with extension of right chambers, and particularly right atrial alterations, by transesophageal echocardiography and to correlate it with clinical and angiographic variables. METHODS: Thirty patients with right ventricular (RV) MI involving obstruction of the right coronary artery without stenosis of the left coronary artery were included; 18 underwent early reperfusion. Transesophageal echocardiography was performed on all within 5 days of coronary angiography. Follow-up was continued from hospitalization to the present. RESULTS: When patients with right atrial ischemia were compared with those with normal right atrium, the RV wall movement score was significantly greater in the group with right atrial ischemia, severe RV dilatation was more frequent, and association with proximal occlusion of the artery responsible for the MI, as well as absence of right atrial branches and poor collateral circulation, were significant. Hospitalization was more prolonged in this group, and there was a higher incidence of arrhythmias, complete atrioventricular block, and mortality. CONCLUSIONS: Right atrial ischemia associated with RV infarction leads to a higher incidence of complications and higher mortality. Transesophageal echocardiography is a safe, reproducible technique that provides detailed anatomic information about right chambers and aids in the determination of prognosis and therapeutic decisions.     

右室双部位起搏的临床应用

右室双部位起搏是一种阃接的双室起搏技术，操作简单，不增加安置术的风险，同时可以使心室再同步变为可能，增加心肌收缩力，改善心功能，具有较好的临床应用价值。     

Closure of a coronary fistula with a transcatheter implantable coil

Large sized coronary artery fistulas are rare and diagnosed in only 0.05% of adult catheterized patients. Only a minority of these fistulas are operated upon. We describe a percutaneous technique to close a left coronary artery fistula draining into the right atrium in a 30-yr-old male patient. The fistula was closed by implantation of a trefoil coil, inserted through a catheter selectively advanced into the fistula.     

改良PKP操作技术治疗老年骨质疏松性多椎体压缩性骨折

目的改进多椎体压缩骨折行椎体后凸成形术（PKP）的手术技巧。方法回顾、总结和比较多椎体PKP两种手术操作方法的差异。48例60岁以上骨质疏松性多椎体（3个及以上）骨折患者其中,常规手术组（C组）20例82椎,手术节段3～6个椎体（平均4.1椎体）,分布范围T_5～L_5,常规PKP手术技术和流程进行定位、穿刺、球囊扩张、聚甲基丙烯酸甲酯骨水泥灌注,完成一个椎体后行第二个椎体手术。改良手术组（M组）28例112椎体,手术节段3～7个（平均4.0椎体）,分布范围T_4～S_1,采用改良操作技术和流程,定位、经椎弓根基底途径穿刺、双椎体同时穿刺或二重穿刺注射等方法进行手术。两组均局部麻醉下行单侧穿刺手术,术中静脉注射地塞米松20mg,如骨水泥分布未超过中线则增加对侧手术。比较两组术前和术后3d疼痛视觉模拟评分（VAS）、手术时间、骨水泥灌注量、骨水泥外漏发生率和临床并发症。结果 C组和M组术前VAS评分分别为（8.6±2.3）和（8.2±1.9）,术后3 d时VAS评分分别为（3.5±2.6）和（3.2±3.0）,组间比较无明显差异。C组14个椎体（15.73%）行双侧手术,明显高于M组的1个椎体（0.89%）（P〈0.0001）。骨水泥灌注量,C组每例8.0～23.1ml[平均（15.3±3.1）m1],M组每例8.5～25.5 ml[平均（16.2±4.1）ml];骨水泥外漏发生率在C组为19.5%,在M组为1 8.75%,两组间骨水泥总量和外漏率无明显差异（P〉0.05）。C组手术时间每例为70～230min,每椎体（26.9±6.7）min,M组每例45～162min,每椎体（1 6 3±5.2）min,M组每椎体平均手术时间远低于C组（P〈0.001）。两组均末发生临床并发症。结论改进手术操作技术和流程可缩短多椎体PKP手术时间,减少双侧穿刺次数。聚甲基丙烯酸甲酯骨水泥灌注总量在26ml以内可能是安全的。     

Automatic Border Detection to Assess Right Ventricular Function Following Surgical Treatment of Thromboembolic Pulmonary Hypertension

Automatic border detection (ABD) has been developed as a potentially useful means for evaluating ventricular function on line in an automatic fashion. Its success with tracking left ventricular function is established, but little is known about its ability to assess right ventricular (RV) function. Accordingly, 20 patients with severe pulmonary hypertension due to chronic thromboembolic disease underwent standard two-dimensional echocardiography and imaging with ABD before and after pulmonary thromboendarterectomy to correct pulmonary hypertension. ABD-derived results were compared to manually planimetered RV areas calculated from the apical four-chamber view. Doppler tricuspid regurgitant velocity fell significantly with surgery from 4.4 ± 0.6 to 2.9 ± 0.7 m / sec (P < 0.001). The mean values for RV areas derived by manual planimetry and ABD were similar, as was fractional area shortening, which improved significantly with surgery (manual 0.24 ± 0.01 preoperative vs 0.31 ± 0.11 postoperative, P < 0.05; and ABD 0.19 ± 0.05 preoperative vs 0.32 ± 0.15 postoperative, P < 0.001). There was, however, very little correlation between the individual values for ABD versus manually derived RV areas and fractional area shortening, with the best correlation being the RV end-diastolic areas after surgery (y = 0.684x + 7.9, r = 0.564, P = 0.01). These results demonstrate that both manually planimetered RV areas and those determined by ABD can adequately follow changes in ventricular function over time. However, variability within each technique may prevent direct comparison of the absolute values of the two techniques.     

Evaluation of left-to-right shunts in adults with atrial septal defect using first-pass radionuclide cardiography.

Non-invasive determination of left-to-right shunts at the atrial level was performed by a new procedure using first-pass radionuclide measurement of cardiac output of the right and left ventricle. In 23 patients with coronary artery disease without shunt the mean difference between the cardiac outputs of the right and left ventricle was 0.04 l.min-1, the limits of agreement -0.80 to 0.88 l.min-1 and the 95% confidence interval for the bias -0.14 to 0.22 l.min-1. Right-sided cardiac catheterization was performed to assess the severity of the arterio-venous shunt by oximetry in 18 adult patients with atrial septal defects. The range of pulmonary-to-systemic flow ratios was 1.4 to 5.0 (mean 2.7) by oximetry and 1.3 to 4.4 (mean 2.5) by the radionuclide technique. The mean difference between flow ratios measured by the two methods was 0.25, the limits of agreement, -0.85 to 1.35 and the 95% confidence intervals for the bias -0.02 to 0.52. In two patients the difference in flow ratios was more than 1. In one of these the oximetric value was more than 2, and the radionuclide value less than 2. The limits of agreement between flow ratios determined by repeated measurements were -1.05 to 0.97, and by two independent observers -0.75 to 0.77. The present findings suggest that first-pass radionuclide determination of left-to-right shunts through atrial septal defects is both reproducible and accurate when compared to the oximetric technique.     

Diagnosis of Arrhythmogenic Right Ventricular Dysplasia‐Cardiomyopathy: Value of Standard ECG Revisited

Background: The diagnostic dilemma in arrhythmogenic right ventricular dysplasia‐cardiomyopathy (ARVD/C) is that a single diagnostic test does not exist and that there is a need for broadening diagnostic criteria. As standard ECG contributes significantly to clinical diagnosis and represents a tool for screening in family studies ECG data should be revisited. Methods and Results: In a cohort of 265 patients (159 males, mean age 46.8 years) with ISFC/ESC criteria of ARVD/C ECG features were reevaluated. QRS duration in (V1 + V2 + V3)/(V4 + V5 + V6) ≥ 1.2—called localized right precordial QRS prolongation—was present in 261/265 patients (98%) and represents the essential finding. Right precordial epsilon potentials were found in 23% in standard and in 75% in highly amplified and modified recording technique. Right precordial T wave inversions were present in 143 cases (54%) and ST‐segment elevation of different types in 66 patients (25%). Localized prolongation of inferior QRS complexes could be found in 58 cases (22%), complete right bundle branch block with T inversions beyond V2 in most cases in 17 patients (6%), incomplete right bundle branch block in 38 cases (14%), pseudo‐incomplete right bundle branch block in 8 patients (3%), and right precordial R wave reduction in 14 cases (5%). Conclusion: With regard to sensitivity and already known specificity an ECG score for the diagnosis of ARVD/C was developed with high probability of ARVD/C in cases with ≥4 points, possibly without the need for an additional imaging technique. Standard ECG with additional highly amplified and modified recording technique represents a single diagnostic test with high value in the clinical diagnosis of ARVD/C and should be used as a first line tool in noninvasive family screening.           A.N.E. 2003; 8(3):238‐245     

Assessment of Right Ventricular and Right Atrial Systolic and Diastolic Performance Using Automated Border Detection

Noninvasive assessment of right ventricular (RV) function is important clinically, but current techniques have limitations. Acoustic quantification (AQ) is an automated endocardial border detection technique that allows continuous determination of RV and right atrial (RA) area waveforms and may be useful for the assessment of RA and RV systolic and diastolic performance. Fifty patients (10 normal, 40 with RV pathology) were studied. Signal-averaged RA and RV AQ area waveforms were obtained and analyzed to compute parameters of diastolic and systolic function. All groups demonstrated significant diastolic dysfunction on the RA AQ waveform as manifested by a reduced percentage of passive atrial emptying and increased dependence on active atrial emptying. Abnormalities of diastolic performance were noted in all subgroups on RV AQ analysis as evidenced by a reduction in the percentage of ventricular filling occurring during early diastole and an increased contribution from active atrial contraction. This study demonstrates the feasibility of using automated analysis of signal-averaged RA and RV area waveforms for the evaluation of RV systolic and diastolic performance. This technique identified significant systolic and diastolic dysfunction in four groups of commonly seen right heart pathologies including biventricular heart failure, pulmonary hypertension, pressure and volume overloaded RVs, and biventricular hypertrophy.     

In vitro validation of right ventricular volume and mass measurement by real-time three-dimensional echocardiography

OBJECTIVE: To evaluate initially the feasibility and accuracy of real-time three-dimensional echocardiography (RT-3DE) for quantifying right ventricular (RV) volume and wall mass in an in vitro experimental study. METHODS: In ten excised porcine hearts, measurements of RV volume and free wall mass with RT-3DE were outlined and calculated by 2-, 4-, 8- and 16-plane methods with Tom Tec 4D Cardio-View RT 1.0. The results were compared with those of 2D length method and 2D biplane Simpson method. The values of RV silicone latex cast and free wall mass measured by water displacement were served as reference values. RESULTS: RV shapes of excised porcine hearts with RT-3DE were similar to those of the actual anatomic RVs and RV silicone latex casts. From the findings of analysis of variance and Student-Newman-Keuls test, there was no significant difference between measurements of RV volume with RT-3DE 16-plane (mean 64.05 ml), 8-plane (61.83 ml) and the reference values of RV silicone latex casts (62.94 ml). No significant difference was found between measurements of RV free wall mass with 16-plane (72.81 g), 8-plane (71.05 g) and the reference values of RV free wall masses (76.21 g). However, there was significant difference between measurements of RV volume and free wall mass with 2-plane, 2D biplane Simpson method and the reference values. Furthermore, the measurements of RV volume and free wall mass with 16-plane and 8-plane were better correlated with the reference values than those with 4-plane and 2D length method. CONCLUSIONS: RT-3DE will be a valuable technique for quantifying irregular crescentic RV volume and wall mass.     

Necropsy study of right atrial appendage: morphology and quantitative measurements

The right atrial appendage (RAA) of 23 randomly selected autopsied patients was examined at necropsy, and data related to orifice size and appendicular depth measurements and features of the endocardial surface were recorded. The study included 21 men and 2 women aged 71 +/- 15 years (range, 32-91); underlying coronary artery disease was present in 16 patients. The orifice size of the RAA measured 2.0 +/- 1.0 cm (range, 0-5 cm). The orifice size was slightly, but not significantly, smaller in patients over age 70 years compared with those younger than 70. In hearts weighing more than 450 g, the orifice was significantly larger (2.6 cm) than in hearts weighing less (1.4 cm). The appendicular depth averaged 1.2 +/- 0.7 cm (range, 0-2.5 cm), and a significant difference was noted in patients older and younger than 70 years (depth of 0.9 cm vs. 1.5 cm; p less than 0.05). The RAA depth was 0.5 cm or less in 8 patients (35%), 6 of whom represented patients older than 70 years. Antemortem mural thrombi within the RAA were found in three hearts and completely filled the lumen in one. The suitability of the RAA as a site for atrial pacing and secure electrode implantation, particularly when anatomical deficiencies are identified, was also considered. Atrial lead displacement, a relatively common postoperative complication, may be related more to implantation within a shallow appendicular fossa and/or one with larger orifice than to faulty technique.(ABSTRACT TRUNCATED AT 250 WORDS)     

Quantification of right ventricular volumes and function by real time three-dimensional echocardiographic longitudinal axial plane method: validation in the clinical setting

BACKGROUND: Measurement of right ventricular (RV) volumes and right ventricular ejection fraction (RVEF) by three-dimensional echocardiographic (3DE) short-axis disc summation method has been validated in multiple studies. However, in some patients, short-axis images are of insufficient quality for accurate tracing of the RV endocardial border. This study examined the accuracy of long-axis analysis in multiple planes (longitudinal axial plane method) for assessment of RV volumes and RVEF. METHODS: 3DE images were analyzed in 40 subjects with a broad range of RV function. RV end-diastolic (RVEDV) and end-systolic volumes (RVESV) and RVEF were calculated by both short-axis disc summation method and longitudinal axial plane method. RESULTS: Excellent correlation was obtained between the two methods for RVEDV, RVESV, and RVEF (r = 0.99, 0.99, 0.94, respectively; P < 0.0001 for all comparisons). CONCLUSION: 3DE longitudinal-axis analysis is a promising technique for the evaluation of RV function, and may provide an alternative method of assessment in patients with suboptimal short-axis images.     

Effect of ipriflavone on pain due to recent osteoporotic vertebral crush fracture

Aim: Ipriflavone conserves bone mass in postmenopausal osteoporosis. Salmon calcitonin and alendronate, two other anti‐resorptive drugs, have been found to have analgesic effects in osteoporotic acute vertebral fracture. This study aimed to determine if ipriflavone also possesses such an effect. Methods: Thirty‐two women with recent osteoporotic vertebral fractures were randomly assigned to ipriflavone treatment or placebo groups. Ipriflavone was given at the dose of 200 mg three times a day. Non‐steroidal anti‐inflammatory drugs were given ad libitum in both groups. Calcium carbonate (1 g daily) was administered to all subjects. Intensity of pain at rest, on movement and on pressure, pain rating on a 10‐point visual analogue scale, degree of mobility impairment, and supplementary analgesic were assessed at the end of a 3‐month period in both groups to assess the analgesic effect of ipriflavone. Results: Fourteen subjects in the ipriflavone group and 12 in the placebo group completed the trial. After 3 months, all pain variables had decreased significantly in both groups. Intensity of pain at rest and on pressure and supplementary analgesic use were significantly lower in the ipriflavone group compared to the placebo group. Conclusion: The study shows that ipriflavone has an analgesic adjuvant effect in acute osteoporotic vertebral fracture.     

Electroanatomic Mapping of the Right Coronary Artery: A Novel Approach to Ablation of Right Free-Wall Accessory Pathways

Background: Catheter ablation of right free-wall (RFW) accessory pathways continues to be associated with lower success and higher recurrence rates compared with other pathway locations. Reliably identifying the precise location of RFW accessory pathways often contributes to the difficulty in ablating these pathways. Improved localization of RFW accessory pathways has been described utilizing multielectrode right coronary artery (RCA) catheterization. This approach has not been widely adopted, in part due to concerns of prolonged catheter placement within the RCA. We describe the technique of creating a 3-D electroanatomic map of the right atrioventricular groove, limiting the duration of a microcatheter within the RCA, to facilitate ablation of RFW accessory pathways.
Methods and Results: Following intracardiac identification of a RFW accessory pathway, an octapolar microcatheter was placed in the RCA. A 3-D electroanatomic map of the RCA was created during retrograde accessory pathway conduction using ventricular pacing. Immediately following creation of the map, the RCA catheter was removed. Endocardial mapping and ablation of the RFW accessory pathway was performed using the RCA electroanatomic map as a guide. This technique was used in four pediatric patients. The microcatheter was within the RCA for less than 1 min in all patients. Radiofrequency catheter ablation of the RFW accessory pathways were successfully performed with two lesions. There were no complications or recurrences at follow-up.
Conclusions: The creation of a 3-D electroanantomic map of the RCA effectively localizes RFW accessory pathways and facilitates successful ablation. This technique minimizes the duration of RCA instrumentation.     

Estimation of Right Atrial Volume and Function by an Online Echocardiographic Edge Detection System

To define the accuracy of real-time two-dimensional echocardiographic imaging with automatic border detection (ABD) for the assessment of right atrial volume and function, we studied with ABD echocardiography 29 healthy subjects and 43 patients with sinus rhythm and various forms of heart disease. Twenty-three patients had right ventricular (RV) dysfunction (fractional area change < 45%), and 20 had RV hypertrophy from pressure overload. Doppler color flow imaging disclosed moderate-to-severe tricuspid regurgitation (TR) in 20 patients and trivial or no TR in 23. The ABD-derived end-diastolic (EDV) and end-systolic (ESV) volumes by the method of discs were used to compute fractional indexes of right atrial (RA) volume changes. Right atrial emptying fraction (RAEF) percent [(ESV - EDV)/ESV x 100] was calculated. The ABD-derived EDV and ESV correlated well with conventional offline measurements of two-dimensional echocardiographic images in the 43 patients (r = 0.94 for the end-diastolic values; r = 0.93 for the end-systolic values). Intraobserver and interobserver variability showed a high correlation between different measurements (r = 0.97 and 0.90, respectively). RA volumes were significantly higher in the patient population than in the control subjects (148.9 +/- 66.7 ml vs 43.1 +/- 9.2 ml, P < 0.0001). The right atrial emptying fraction (RAEF) was higher in patients with RV pressure overload than in normal subjects (61% +/- 11% vs 46% +/- 9%, P < 0.05) and lower in those with RV dysfunction than in the control subjects (29% +/- 7% vs 46% +/- 9%, P < 0.01). In both groups (RV pressure overload and RV dysfunction), RAEF was higher in patients without or with trivial TR compared with those with significant TR (29% +/- 7% vs 23% +/- 6%; 61% +/- 11% vs 42% +/- 7%; P < 0.05). Thus, changes in right atrial volume and function can be measured noninvasively by the ABD method. This imaging technique may prove to be useful for assessing right atrial size and function under different physiological and pathological conditions and for identifying factors that influence atrial function in right ventricular diseases.     

Evaluation of Global and Regional Right Ventricular Function Using Automated Border Detection Techniques

Quantitative evaluation of right ventricular (RV) function remains challenging due to the complex geometry of this chamber, which precludes the use of simple geometric assumptions. Automated border detection (ABD) techniques, which provide online changes in cardiac chamber dimensions, have been predominantly used for quantitative assessment of global as well as regional left ventricular function. Recently, acoustic quantification has been validated for quantitative evaluation of global RV function, and color kinesis has been used to objectively assess systolic and diastolic regional RV function. In this article, the main studies validating ABD for the objective assessment of global RV function and the current clinical uses of this technique are reviewed. In addition, technical guidelines and limitations of ABD techniques are described, and potential applications of color kinesis for quantitative assessment of regional systolic and diastolic RV performance are detailed. ABD techniques provide new insights into right atrial and RV systolic and diastolic properties. The clinical value of these techniques in the diagnosis, prognosis, and potential guidance of therapeutic management of RV dysfunction remains to be determined.