Trans-catheter aortic valve implantation--early recovery of left and preservation of right ventricular function

This study aimed to assess the early effect of trans-catheter aortic valve implantation (TAVI) on right (RV) and left ventricular (LV) function in severe aortic stenosis (AS) patients. Twenty AS patients (age 79±6 years) were examined before, one week and six weeks after TAVI using Doppler echocardiography. LV ejection fraction (EF), long-axis [mitral annular plane systolic excursion (MAPSE)] and RV long-axis [tricuspid annular plane systolic excursion (TAPSE)] function, septal radial motion were studied. Results were compared with 30 AS patients before and one week after aortic valve replacement (AVR) as well as 30 normals (reference group). Before TAVI, LVEF was reduced and E/A was higher than the reference and AVR groups (P<0.05 for all). MAPSE, TAPSE and septal motion were equally reduced in TAVI and AVR patients (P<0.05 for all). One week after the TAVI, EF increased in patients with values <50% before the procedure. In contrast, AVR resulted in reversed septal motion (P<0.001) and depressed TAPSE (P<0.001). The extent of reversed septal motion correlated with that of TAPSE in the patients group as a whole after procedures (r=0.78, P<0.001). Six weeks after TAVI, RV function remained unchanged, but LVEF increased and E/A decreased (P<0.05 for both). Thus, TAVI procedure results in significant early improvement of LV systolic and diastolic function particularly in patients with reduced EF and preserves RV systolic function.     

Right ventricular longitudinal strain and right ventricular stroke work index in patients with severe heart failure: left ventricular assist device suitability for transplant candidates

Background

Right ventricular (RV) systolic function has a critical role in determining the clinical outcome and the success of using left ventricular assist devices in patients with refractory heart failure. RV deformation analysis by speckle tracking echocardiography (STE) has recently allowed the analysis of RV longitudinal function. Using cardiac catheterization as the reference standard, this study aimed to explore the correlation between RV longitudinal function by STE and RV stroke work index (RVSWI) among patients referred for cardiac transplantation.

Methods

Right heart catheterization and transthoracic echo-Doppler were simultaneously performed in 47 patients referred for cardiac transplant assessment due to refractory heart failure (ejection fraction 25.1 ± 4.5%). Thermodilution RV stroke volume and invasive pulmonary pressures were used to obtain RVSWI. RV longitudinal strain (RVLS) by STE was assessed averaging RV free-wall segments (free-wall RVLS). We also calculated. Tricuspid S' and tricuspid annular plane systolic excursion (TAPSE).

Results

No significant correlation was observed for TAPSE on tricuspid S' with RV stroke volume (r = 0.14 and r = 0.06, respectively). A close negative correlation between free-wall RVLS and RVSWI was found (r = −0.82; P < .0001). Furthermore, free-wall RVLS showed the highest diagnostic accuracy (area under the curve of 0.90) with good sensitivity and specificity of 95% and 91%, respectively, to predict depressed RVSWI using a cutoff value less than −11.8%.

Conclusions

Among patients referred for heart transplantation, TAPSE and tricuspid S' did not correlate with invasively obtained RVSWI. RV longitudinal deformation analysis by STE correlated with RVSWI, providing a better estimate of RV systolic performance.     

Dominance of free wall radial motion in global right ventricular function of heart transplant recipients

Assessment of right ventricular (RV) function using conventional echocardiography might be inadequate as the radial motion of the RV free wall is often neglected. Our aim was to quantify the longitudinal and the radial components of RV function using three‐dimensional (3D) echocardiography in heart transplant (HTX) recipients. Fifty‐one HTX patients in stable cardiovascular condition without history of relevant rejection episode or chronic allograft vasculopathy and 30 healthy volunteers were enrolled. RV end‐diastolic (EDV) volume and total ejection fraction (TEF) were measured by 3D echocardiography. Furthermore, we quantified longitudinal (LEF) and radial ejection fraction (REF) by decomposing the motion of the RV using the ReVISION method. RV EDV did not differ between groups (HTX vs control; 96 ± 27 vs 97 ± 2 mL). In HTX patients, TEF was lower, however, tricuspid annular plane systolic excursion (TAPSE) decreased to a greater extent (TEF: 47 ± 7 vs 54 ± 4% [?13%], TAPSE: 11 ± 5 vs 21 ± 4 mm [?48%], P < .0001). In HTX patients, REF/TEF ratio was significantly higher compared to LEF/TEF (REF/TEF vs LEF/TEF: 0.58 ± 0.10 vs 0.27 ± 0.08, P < .0001), while in controls the REF/TEF and LEF/TEF ratio was similar (0.45 ± 0.07 vs 0.47 ± 0.07). Current results confirm the superiority of radial motion in determining RV function in HTX patients. Parameters incorporating the radial motion are recommended to assess RV function in HTX recipients.     

Right Ventricle Dysfunction in Patients With Adult Cystic Fibrosis Enlisted for Lung Transplant

Knowledge of preoperative right heart function of adult patients with cystic fibrosis (CF) awaiting lung transplant (LUTX) is limited. The echocardiography of adult patients with CF enlisted for LUTX was retrospectively analyzed and compared with standards and invasive analyses (right heart catheterization, multigated radionuclide ventriculography). We included 49 patients (reported as mean ± standard deviation; 29 ± 9 years of age; forced expiratory volume in first second of expiration, 31% ± 11% predicted; lung allocation score, 36 ± 5; invasive mean pulmonary artery pressure, 17 ± 5 mm Hg; multigated radionuclide ventriculography right ventricle [RV] ejection fraction, 50% ± 9%). Patients had increased RV end-diastolic area, RV wall thickness, and increased pulmonary artery acceleration time with subnormal tricuspid annular plane systolic excursion, tissue Doppler positive peak systolic velocity, and fraction area change. Subnormal tricuspid annular plane systolic excursion (< 23 mm), tissue Doppler positive peak systolic velocity (< 14 cm/s), and fraction area change (< 49%) had high sensitivity and negative predictive value in predicting impaired RV.ejection fractionA good correlation between echocardiographic estimated and invasively measured systolic pulmonary artery pressure was observed (R² = 0.554, P < .001). Adults with CF awaiting LUTX have morphologic alterations of the right heart, with subclinical impairment of RV systolic function. Echocardiography may be used as a bedside, repeatable, and reliable noninvasive test to screen further deterioration in RV function while on the waiting list for LUTX. More prospective follow-up echocardiographic studies are necessary to confirm such a hypothesis.     

Echocardiographic assessment of right heart function in heart transplant recipients and the relation to exercise hemodynamics

This study aimed to characterize right heart function in heart transplantation (HTx) patients using advanced echocardiographic assessment and simultaneous right heart catheterization (RHC). Comprehensive two‐dimensional (2D) and three‐dimensional (3D) echocardiographic assessment of right heart function was performed in 105 subjects (64 stable HTx patients and 41 healthy controls). RHC was performed at rest and during semi‐supine maximal exercise test. Compared with controls, in conclusion, HTx patients had impaired right ventricle (RV) systolic function in terms of decreased RV‐free wall (FW) global longitudinal strain (GLS) (?20 ± 5% vs. ?28 ± 5%, P < 0.0001) and 3D‐ejection fraction (EF) (50 ± 8% vs. 60 ± 6%, P < 0.0001). In HTx patients, echocardiographic RV systolic function was significantly correlated with NYHA‐class (3D‐RVEF: r = ?0.62, P < 0.0001; RV‐FW‐GLS: r = ?0.41, P = 0.0009) and cardiac allograft vasculopathy (3D‐RVEF: r = ?0.42, P = 0.0005; RV‐FW‐GLS: r = ?0.25, P = 0.0444). RHC demonstrated a good correlation between invasively assessed resting RV‐stroke volume index and exercise capacity (r = 0.58, P < 0.0001) and NYHA‐class (r = ?0.41, P = 0.0009). RV systolic function is reduced in HTx patients compared with controls. 3D RVEF and 2D longitudinal deformation analyses are associated with clinical performance in stable HTx patients and seem suitable in noninvasive routine right heart function evaluation after HTx. Invasively assessed RV systolic reserve was strongly associated with exercise capacity.     

Tricuspid Annular Plane Systolic Excursion (TAPSE) correlates with mean pulmonary artery pressure especially 10 years after pediatric heart transplantation

Tricuspid annular plane systolic excursion (TAPSE) is important in the noninvasive echocardiographic assessment of right heart function. This retrospective observational study shows correlations of TAPSE with invasive right heart catheterization parameters after pediatric heart transplantation (HTx). The study included patients after pediatric HTx with cardiac catheterizations in 2018/2019 and measurement of TAPSE (n = 52 patients with 57 examinations; 50.9% adults, 52.6% female, median age: 18.54 years). TAPSE was compared with normal values. Stepwise, linear and multiple regression were used to show influencing variables on TAPSE. Mean TAPSE z-score was −3.48 (SD: 2.25) and 68.4% of HTx-recipients showed abnormally reduced TAPSE (z-score ←2) compared to normal values. Multiple regression (p-value <0.001; corrected R² = 0.338) showed significant correlations of time since HTx (p-value <0.001) and mPAP (p-value: 0.008) with TAPSE z-scores. Divided into subgroups (time since HTx <10 and ≥10 years), TAPSE and mPAP correlated only ≥10 years after HTx (p-value = 0.002). This study provides data of TAPSE even ≥10 years after pediatric HTx. Most patients showed a decreased TAPSE early after HTx, which improved over time. TAPSE z-scores correlated significantly with time since HTx and mPAP, especially ≥10 years post-HTx. Therefore, TAPSE must be used carefully in the early follow-up.     

Late right ventricular performance after mitral valve repair assessed by exercise echocardiography

Objectives

The aim of the study was to evaluate the right ventricular (RV) performance during exercise in patients who underwent mitral valve repair for chronic mitral valve insufficiency relative to healthy individuals and to assess exercise capacity using a semisupine ergometer.

Methods

We studied 56 patients who underwent mitral valve repair for degenerative posterior mitral leaflet prolapse between 2005 and 2014 and a control group of 13 healthy individuals. Clinical data were collected prospectively, and echocardiographic measurements of RV function were obtained at rest and at peak exercise.

Results

One-third of the study patients had RV systolic dysfunction as indicated by tricuspid annular plane excursion (TAPSE) at rest. Resting TAPSE was lower in the study group (16.7?±?3.3 mm) than in the control group (24.4?±?4.3 mm), p?<?0.001. TAPSE increased in both groups during exercise and exercise was shown to have a significant main effect on TAPSE F(1, 52)?=?80, p?<?0.001. TAPSE increased more in the control group and an interaction was detected between the participant groups (study group vs. control group) and exercise, F(1, 52)?=?24, p?<?0.001. In the study group, Poor postoperative RV function was associated with preoperative left ventricular dilatation but was not correlated with impaired maximum exercise capacity.

Conclusions

Despite the excellent clinical outcome during rest and exercise after mitral valve repair, our results suggest patients that have undergone mitral valve repair due to posterior leaflet prolapse have significantly reduced RV function at rest and during exercise compared to healthy controls at long-term follow-up, as measured by TAPSE.

     

Accuracy of echocardiographic right ventricular parameters in patients with different end-stage lung diseases prior to lung transplantation.

BACKGROUND: Because there are few data available on the accuracy of 2D-echocardiography to assess right ventricular (RV) size and function in patients with far-advanced lung disease, in this prospective study, we compared various echocardiographic RV parameters with RV volumes derived from magnetic resonance imaging (MRI). METHODS: In 32 patients (18 male, 17 female) presenting for lung transplantation, we measured RV end-diastolic and end-systolic area as well as derived RV fractional area change, long-axis diameter, short-axis diameter, tricuspid valve anulus diameter (using 2D apical or sub-costal 4-chamber view), and RV end-diastolic diameter (using M-mode in the parasternal short-axis view). These values were compared with RV end-diastolic and end-systolic volumes derived by MRI, serving as the gold standard. RESULTS: Right ventricular end-diastolic area was the most accurate echocardiographic parameter of RV size (correlation to MRI: r = 0.88, p < 0.001), followed by RV end-diastolic short-axis diameter (r = 0.75, p < 0.001), long axis diameter (r = 0.66, p < 0.001), and tricuspid valve anulus diameter (r = 0.63, p < 0.001). In contrast, M-mode measurement of RV end-diastolic diameter was possible in only 24/35 (68%) patients and showed a weak correlation to MRI-derived RV end-diastolic volume (r = 0.56, p = 0.004). Right ventricular fractional area change correlated well with MRI-derived RV ejection fraction (r = 0.84, p < 0.0001). In a sub-group analysis, patients with vascular lung disease showed best agreement between both methods for RV end-diastolic area and RV fractional area change compared with patients with restrictive or obstructive lung disease. CONCLUSION: This study shows that in patients with far-advanced lung diseases, RV end-diastolic area demonstrated the best correlation with MRI-derived measurement of RV end-diastolic volume, and RV fractional area change compared favorably with MRI-derived ejection fraction. Despite reduced image quality, especially in patients with obstructive lung disease, these parameters can yield clinically valuable information.     

Why do patients with ischemic cardiomyopathy and a substantial amount of viable myocardium not always recover in function after revascularization?

OBJECTIVE: In patients with ischemic cardiomyopathy and a substantial amount of dysfunctional but viable myocardium, myocardial revascularization may improve left ventricular ejection fraction. The aim of this study was to evaluate why not all patients with a substantial amount of viable tissue recover in function after revascularization. METHODS: A total of 118 consecutive patients with a depressed left ventricular ejection fraction (on average 29% +/- 6%) due to chronic coronary artery disease underwent myocardial revascularization. Before revascularization all patients underwent dobutamine stress echocardiography to assess regional dysfunction, left ventricular volumes, and myocardial viability as well as radionuclide ventriculography to determine the left ventricular ejection fraction. Next, 3 to 6 months after revascularization, the left ventricular ejection fraction and regional contractile function were reassessed. Improvement of left ventricular ejection fraction > or = 5% following revascularization was considered clinically significant. RESULTS: Dobutamine stress echocardiography revealed that 489 (37%) of the 1329 dysfunctional segments were viable. A total of 61 (52%) patients had a substantial amount of viable myocardium (> or = 4 viable segments). In these 61 patients the global function was expected to recover > or = 5% after revascularization. However, left ventricular ejection fraction did not improve in 20 (33%) of 61 patients despite the presence of substantial viability. Clinical characteristics and echocardiographic data were comparable between patients with and without improvement. However, patients without improvement had considerably larger end systolic volumes (153 +/- 41 mL vs 133 +/- 46 mL, P =.007). The likelihood of recovery of global function decreased proportionally with the increase of end systolic volume (P <.001, R = 0.43, n = 61). Receiver operating characteristic curve analysis demonstrated that an end systolic volume > or = 140 mL had the highest sensitivity/specificity to predict the absence of global recovery. CONCLUSIONS: In patients with ischemic cardiomyopathy not only the amount of dysfunctional but viable myocardium but also the extent of left ventricular remodeling determines the improvement in function following myocardial revascularization. Patients with a high end systolic volume due to left ventricular remodeling have a decreased likelihood of improvement of global function.     

Right Ventricular Systolic Function Is Not Depressed In Morbid Obesity

Background: The increased pulmonary blood volume associated with the increased total blood volume in morbidly obese patients increases pulmonary artery pressure and pulmonary vascular resistance, resulting in increased right ventricular (RV) afterload. Thus, the morbidly obese may develop RV dysfunction owing to the increased RV afterload. We examined this possibility by assessing RV contractile function in morbidly obese patients, using RV end-systolic pressure-volume relationship and RV systolic time intervals. Methods: Included were 25 morbidly obese patients undergoing gastric bypass surgery under general anesthesia. Pulmonary artery pressure and RV end-systolic volume were measured with a thermodilution pulmonary artery catheter. Pulmonary arterial dicrotic notch pressure was used as an estimate of RV end-systolic pressure. Two data points were used to define RV end-systolic pressure-volume relationship. RV systolic time intervals were determined by simultaneous graphic display of the electrocardiograph, phonocardiograph, and pulmonary artery pressure curve, and were expressed as a pre-ejection period/RV ejection time ratio. Results: The mean slope of right ventricular end-systolic pressure-volume relationship line was 0.54 ± 0.13 and mean pulmonary vascular resistance 274 ± 80 dyne·sec·cm⁻⁵·m⁻². The mean pre-ejection period/RV ejection time ratio was 0.4 ± 0.11. There was an inverse correlation between the pre-ejection/RV ejection time ratio and the slope of RV end-systolic pressure-volume relationship line (R²=0.658, P<0.0001). Conclusion: Our data indicate that RV function is not depressed in morbid obesity despite increased RV afterload.     

Echocardiographic analysis of ventricular geometry and function during repair of congenital septal defects

BACKGROUND: This study investigated changes in left ventricular (LV) geometry and systolic function after corrective surgery for atrial (ASD) and ventricular septal defects (VSD). METHODS: Transesophageal LV short-axis echocardiograms were recorded before and after operative repair of ASD (n = 11) and VSD (n = 7). Preload was measured using LV end-diastolic area indexed for body surface area. Measurements of septal-freewall (D1) and anterior-posterior (D2) endocardial diameters were used to assess LV symmetry from D1/D2. Systolic indices included stroke area, area ejection fraction, and fractional shortening. RESULTS: Preload, stroke area, area ejection fraction, and fractional shortening of D1 increased after ASD repair but decreased after VSD repair (p < 0.05). End-diastolic symmetry increased after ASD closure and decreased after VSD closure (p < 0.05). Increases in stroke area and ejection fraction after ASD correction primarily reflected increased shortening of D1. A positive correlation was found overall between percent change in end-diastolic area (EDA) and percent change in area ejection fraction (r(2) = 0.80, p < 0.0001, n = 18). CONCLUSIONS: Preload was the primary determinant of changes in LV function in this series of ASD and VSD repairs. Intraoperative changes in position of the interventricular septum affected systolic and diastolic LV symmetry and septal free wall shortening. Additional studies are needed to define changes in afterload and contractility as well as diastolic compliance and systolic mechanics.     

Improvement of right ventricular function with transcatheter aortic valve implantation

Background and aim. It has been demonstrated that right ventricular systolic dysfunction develops soon after surgical aortic valve replacement (s-AVR). While the impact of s-AVR or TAVI on the function of the left ventricle has been studied with various imaging modalities, little is known about the impact on right ventricular function (RVF). In the current study, we evaluated the impact of TAVI on RVF using conventional echocardiography parameters. Methods and results. Echocardiography was performed prior to 24 h, 1 month and 6 months after TAVI. RVF was assessed using (1) tricuspid annular plane systolic excursion (TAPSE); (2) RV Tissue Doppler Imaging (S’); (3) right ventricular systolic pressure (RVSP); (4) Fractional area change (FAC); and (5) RV ejection fraction (RVEF). TAVI was performed through the subclavian artery in two patients and femoral artery in 48 patients with an Edwards Sapien XT valve. TAVI was performed on 50 patients between the dates of December 2012 and June 2013. After TAVI, a statistically significant improvement was observed for all parameters related to RVF (RVSP, RVEF, TAPSE, FAC, RVTDI S’). During the 1st and 6th months this statistically significant improvement continued in TAPSE and FAC, and there was no deterioration in RVSP, RVEF, and RVTDI S during the 1st month but a statistically significant improvement continued in the 6th month. Conclusion. RVF assessed by conventional echocardiography did not deteriorate after TAVI in early and midterm follow-up. Further, TAVI provides improvement of RVF and can safely and efficiently be performed in patients with impaired RVF.     

Determination of right ventricular function by transesophageal echocardiography: impact of proximal right coronary artery stenosis

STUDY OBJECTIVE: To investigate whether transesophageal echocardiography (TEE) can provide accurate information on right ventricular (RV) function in patients with right coronary artery (RCA) stenosis, given that a decrease in blood supply from the RCA may invalidate the use of single 2-D echocardiography imaging plane as a guide to RV function. DESIGN: Prospective, nonblinded study. SETTING: University hospital. PATIENTS: 30 adult patients undergoing elective cardiac or vascular procedures. INTERVENTIONS: Patients were classified into two groups according to the presence or absence of the proximal RCA (segment 1 or 2) stenosis. Group A patients had no obstructive lesions in the proximal RCA (n = 15). Group B patients had 75% or greater obstructive lesions in the proximal RCA (n = 15). MEASUREMENTS AND MAIN RESULTS: After induction of anesthesia, RV function was evaluated by both fast-response thermodilution pulmonary artery catheter and TEE. Transesophageal echocardiography-derived RV fractional area change (FAC) and tricuspid annular plane systolic excursion ratio (TAPSE ratio) were compared with thermodilution-derived RV ejection fraction (EF) using linear regression analysis. Transesophageal echocardiography-derived RV end-diastolic area (EDA) was compared with thermodilution-derived end-diastolic volume (EDV). Both methods showed a good correlation in RV, EDV, and EF in Group A, but no correlations in Group B. CONCLUSIONS: Transesophageal echocardiography does not provide reliable information on RVEF and EDV when proximal RCA stenosis is present.     

Hemodynamic Parameters Influencing Clinical Performance of Novacor Left Ventricular Assist System

The interrelationships between hemodynamic variables including right ventricular (RV) performance with filling/ejection dynamics of the Novacor left ventricular assist system (LVAS) were determined in 10 of 11 patients who received LVAS as a bridge to heart transplant. Nine were successfully transplanted. Data were obtained intraoperatively, at periodic intervals up to 48 h postimplant and at explant. The hypotheses investigated included (a) RV performance influences LVAS filling characteristics and (b) LVAS pump output is influenced by systemic vascular resistance (SVR). During the period of LVAS support (2-126 days), pumping characteristics included a mean filling volume of 51 ml (range, 24-70), residual volume of 4.9 ml (range, 1-18), pump rate of 113/min (range, 63-175), and pump output of 5.81/min (range, 2.8-8.2). Multiple regression analysis identified pulmonary vascular resistance (PVR), RV stroke work index (RVSWI), and pulmonary capillary wedge pressure, but not RV ejection fraction, pulmonary artery pressure, or central venous pressure (CVP) as the most important correlates with LVAS filling volume (p less than 0.001, R2 = 0.6). In addition, LVAS pump output was influenced mainly by RVSWI, PVR, and SVR (p less than 0.001, R2 = 0.7). It was concluded that LVAS performance is highly dependent on RV function and systemic/pulmonary vascular resistances.     

Quantification of right ventricular extracellular volume in pulmonary hypertension using cardiac magnetic resonance imaging

PurposeThe purpose of this prospective study was to assess the value of biventricular extracellular volume (ECV) in pre-capillary pulmonary hypertension (PH) obtained using cardiac magnetic resonance imaging (CMR) and to correlate ECV with markers of prognosis such as strain echocardiography and blood biomarkers of fibrosis.Materials and methodsTwelve patients with PH (6 men, 6 women; mean age = 50 ± 16 [SD] years; age range: 22–73 years) underwent the same day: (i), transthoracic echocardiography including measurement of right ventricular (RV) fractional shortening (RVfs), tricuspid annular plane systolic excursion (TAPSE), maximal tricuspid annular velocity, RV global and segmental deformation; (ii), right heart catheterization measuring pulmonary arterial pressures (in mmHg) and cardiac output (in L/min); (iii), CMR at 1.5-T measuring RV volumes and ejection fraction; (iv), native and 15 min post-contrast T1 mapping using modified look-locker inversion-recovery sequence; and (v), serum quantification of two biomarkers of collagen turnover and hematocrit. Non-parametric Mann-Whitney tests were used to search for differences between categorical variables. Spearman correlation test was used for search for correlation between quantitative values.ResultsGlobal RV ECV was 34% ± 4.2 (SD) for our entire population. A significant correlation was found between RV ECV and RVfs (r = 0.6; P = 0.026), S wave velocity (r = 0.7; P = 0.009), TAPSE (r = 0.6; P = 0.040) and RV systolic ejection fraction on CMR (r = 0.6; P = 0.04). There were no correlations between the ECV values in the lateral wall of the RV and in the septum (r = 0.4; P = 0.206). A significant correlation was found between septal ECV and 2D septal strain (r = 0.7; P = 0.013).ConclusionECV in PH as obtained using CMR appears to correlate with known echocardiographic prognostic markers and more specifically with the markers, which assess RV systolic function.     

Long-term follow-up of right ventricular function after Mustard operation for transposition of the great arteries

As development of right ventricular (RV) failure is a potential risk after Mustard operation for transposition of the great arteries, 17 patients were reexamined 5-13 years postoperatively. Comparisons were made with healthy controls. There were no clinical signs of heart failure. Echocardiographically determined RV end-diastolic diameter was increased to 2.5 +/- 0.8 cm (controls: 1.5 +/- 0.4 cm, p less than 0.001). Comparison of RV systolic time intervals (STI) in patients with normal left ventricular (LV) STI revealed decreased RV function, with RPEPI 165 +/- 19 msec (controls 126 +/- 12, p less than 0.001) and RPEP/RVET 0.484 +/- 0.096 (controls 0.284 +/- 0.045, p less than 0.001). Nuclear angiography demonstrated decreased RV ejection fraction (EF), viz. 42.8 +/- 6.6% (normal RV 53 +/- 6%, LV 68 +/- 9%, p less than 0.001). Only two patients showed normal (5%) rise in RV-EF during exercise. There was no evidence of deterioration with passage of time. The results do not justify use of anatomic repair at our center, since the perioperative mortality might then be higher than in the Mustard or Senning procedures.     

Isovolumetric relaxation time of the right ventricle assessed by tissue Doppler imaging

Objectives—The isovolumetric relaxation time of the right ventricle (RV‐IVRT) can be assessed using a method based on ECG and pulsed wave Doppler (PW). Recently pulsed wave Doppler tissue imaging (PW‐DTI) has been introduced in the assessment.

Design—RV‐IVRT obtained by the two methods was compared in 20 consecutive patients as was the time from the R wave on the ECG to the onset of tricuspid flow (R‐T), to the closure of the pulmonic valve (R‐P), to the onset of early diastolic motion of the tricuspid annulus tissue (R‐E) and to the end of the systolic motion (R‐S).

Results—RV‐IVRT obtained by the PW method was significantly (p?<?0.001) shorter than RV‐IVRT obtained by PW‐DTI. R‐S had significantly (p?<?0.001) shorter duration than R‐P, while there was no significant difference between R‐E and R‐T.

Conclusions—The methods are not measuring the same interval. Only the PW method measures RV‐IVRT according to the usual definition. Different reference values have to be used if the methods are used in the assessment of RV diastolic function.     

The influence of pulmonary regurgitation on left ventricular function after repair of tetralogy of Fallot

The influence of right ventricular (RV) volume overload by pulmonary regurgitation (PR) on left ventricular (LV) function was evaluated postoperatively in 23 patients with tetralogy of Fallot (TF). The age at operation was 3.1 +/- 1.7 (mean +/- SD) years. The age at postoperative study was 5.9 +/- 2.0 years. We determined RV end-diastolic volume (%RVEDV), RV ejection fraction (EF), %LVEDV, LV end-systolic volume (%LVESV), LVEF, and LV end-systolic stress (ESS)/%LVESV. Patients were divided into 2 groups on the basis of presence or absence of RV volume overload by PR as follows: The %RVEDV (175 +/- 23%) of group 1 (n = 10) was 150% greater than normal RVEDV. Group 2 (n = 13) had normal %RVEDV (108 +/- 23%). Preoperatively, there had been no differences in hemoglobin, %RVEDV, RVEF, %LVEDV, LVEF, and in the ratio of average cross-sectional area of the left and right pulmonary arteries to cross-sectional area of the normal right pulmonary artery between the 2 groups. Moreover, there were no differences in age at repair, or during postoperative study, nor in the postoperative ratio of RV to LV systolic pressure between the 2 groups. RVEF was significantly less in group 1 than in group 2 (0.53 +/- 0.05 vs 0.58 +/- 0.05, p less than 0.05). %LVEDV and %LVESV in group 1, 138 +/- 10% and 171 +/- 30% respectively, were significantly greater than those in group 2, 116 +/- 11% and 133 +/- 20% respectively (p less than 0.001 in %LVEDV and p less than 0.01 in %LVESV).(ABSTRACT TRUNCATED AT 250 WORDS)     

Study on the late effect of pneumonectomy on right heart pressures using Doppler echocardiography.

OBJECTIVE: Changes in the pulmonary artery systolic pressure (PASP) and the dimensions of the right ventricle (RV) of the heart, six months after pneumonectomy, were evaluated in order to detect the influence of pneumonectomy on right heart function. METHODS: 35 patients undergoing pneumonectomy (Group A) and 17 patients undergoing lobectomy or bilobectomy (Group B) were evaluated prospectively with spirometry, arterial blood gases determination and Doppler echocardiography at rest, preoperatively and six months postoperatively. Patients of both groups had normal preoperative PASP, RV dimensions and left ventricular ejection fraction. PASP was calculated using the equation: PASP=4x(maximal velocity of the tricuspid regurgitant jet)2+10 mmHg. FEV1, FVC, partial pressures of oxygen (pO2) and carbon dioxide in the arterial blood were considered as the main determinants of postoperative lung function. RESULTS: PASP increased significantly six months postoperatively in both groups (P<0.05). Mean PASP in Group A (40.51+/-12.52 mmHg) was significantly higher (P=0.012) than in Group B (32.88+/-5.25 mmHg). Mean PASP after right pneumonectomy (48.33+/-10.61 mmHg) was significantly higher (P=0.002) than after left pneumonectomy (35.26+/-10.83 mmHg). The incidence of RV dilatation was higher in Group A (60%) than in Group B (23.52%). RV dilatation was related with elevated PASP values in both groups (P<0.001 and P=0.034, respectively). Increased age (P<0.001), significant percent FVC reduction from preoperative values (P=0.012) and low pO2 values (P=0.001) were detected as strong predisposing factors for postpneumonectomy PASP elevation. CONCLUSIONS: Pneumonectomy is related with postoperative elevation of PASP and RV dilatation, especially right pneumonectomy. Significant percent FVC reduction, increased age and low pO2 values are the main responsible factors for elevation of the 6-month postoperative PASP values.     

The effect of pericardial incision on right ventricular systolic function: a prospective observational study

Background

Echocardiographic longitudinal markers of right ventricular (RV) systolic function are commonly depressed after coronary artery bypass graft surgery (CABG) despite an uncomplicated course and good clinical recovery. The exact timing and cause of these changes is unknown. The aim of this observational study was to monitor echocardiographic markers of RV systolic function intraoperatively during CABG. We used angle-independent speckle tracking to measure the primary endpoints of tricuspid annular plane systolic excursion (TAPSE) and tricuspid annular systolic velocity (S′) before and after pericardiotomy.

Methods

Twenty-four patients undergoing elective on-pump CABG were enrolled in the study. Speckle tracking-derived TAPSE, S’, free wall systolic strain, RV outflow tract strain, colour tissue Doppler-derived isovolumic acceleration (IVA) and two-dimensional RV dimensions and fractional area change (FAC) were measured at three intraoperative time points: 1) after sternotomy immediately prior to pericardiotomy; 2) after pericardiotomy and placement of pericardial retraction sutures; and 3) following cardiopulmonary bypass after chest closure.

Results

Adequate image quality to perform speckle tracking measurements was obtained in twenty-one patients. We found that there were no significant changes to echocardiographic parameters of RV systolic function between pre- and post-pericardiotomy. The mean (SD) of the primary endpoints were: TAPSE [28.1 (5.1) mm vs 27.7 (7.4) mm, respectively; mean difference, ?0.4 mm; 97.5% confidence interval (CI), ?4.0 to 3.1; P = 0.76] and S′ [10.4 (2.1) cm·sec^?1 vs 10.8 (1.9) cm·sec^?1, respectively; mean difference, 0.4 cm·sec^?1; 97.5% CI, ?0.9 to 1.7; P = 0.48]. Significant reductions in the parameters of RV systolic function were found only after cardiopulmonary bypass and chest closure.

Conclusion

Pericardial opening and suspension had no significant effect on the indices of RV systolic function derived from speckle tracking or colour tissue Doppler.