Optimizing right ventricular focused four-chamber views using three-dimensional imaging,a comparative magnetic resonance based study

Obtaining focused right ventricular (RV) apical view remains challenging using conventional two-dimensional (2D) echocardiography. This study main objective was to determine whether measurements from RV focused views derived from three-dimensional (3D) echocardiography (3D-RV-focused) are closely related to measurements from magnetic resonance (CMR). A first cohort of 47 patients underwent 3D echocardiography and CMR imaging within 2 h of each other. A second cohort of 25 patients had repeat 3D echocardiography to determine the test–retest characteristics; and evaluate the bias associated with unfocused RV views. Tomographic views were extracted from the 3D dataset: RV focused views were obtained using the maximal RV diameter in the transverse plane, and unfocused views from a smaller transverse diameter enabling visualization of the tricuspid valve opening. Measures derived using the 3D-RV-focused view were strongly associated with CMR measurements. Among functional metrics, the strongest association was between RV fractional area change (RVFAC) and ejection fraction (RVEF) (r?=?0.92) while tricuspid annular plane systolic excursion moderately correlated with RVEF (r?=?0.47), all p?<?0.001. Among RV size measures, the strongest association was found between RV end-systolic area (RVESA) and volume (r?=?0.87, p?<?0.001). RV unfocused views led on average to 10% underestimation of RVESA. The 3D-RV-focused method had acceptable test–retest characteristics with a coefficient of variation of 10% for RVESA and 11% for RVFAC. Deriving standardized RV focused views using 3D echocardiography strongly relates to CMR-derived measures and may improve reproducibility in RV 2D measurements.     

Correlation between right ventricular T<Subscript>1</Subscript> mapping and right ventricular dysfunction in non-ischemic cardiomyopathy

Right ventricular (RV) fibrosis is increasingly recognized as the underlying pathological substrate in a variety of clinical conditions. We sought to employ cardiac magnetic resonance (CMR) techniques of strain imaging and longitudinal relaxation time (T₁) mapping to better examine the relationship between RV function and structure. Our aim was to initially evaluate the feasibility of these techniques to evaluate the right ventricle. We then sought to explore the relationship between RV function and underlying fibrosis, along with examining the evolution of RV remodeling according to the amount of baseline fibrosis. Echocardiography was performed in 102 subjects with non-ischemic cardiomyopathy. Right ventricular parameters were assessed including: fractional area change (FAC) and longitudinal strain. The same cohort underwent CMR. Post-contrast T₁ mapping was performed as a marker of fibrosis with a Look-Locker technique using inversion recovery imaging. Mid-ventricular post-contrast T₁ values of the RV free wall, RV septum and lateral LV were calculated using prototype analysis software. Biventricular volumetric data including ejection fraction was measured by CMR using a cine short axis stack. CMR strain analysis was also performed to assess 2D RV longitudinal and radial strain. Simultaneous biochemical and anthropometric data were recorded. Subjects were followed over a median time of 29 months (IQR 20–37 months) with echocardiography to evaluate temporal change in RV FAC according to baseline post-contrast T₁ values. Longitudinal data analysis was performed to adjust for patient loss during follow-up. Subjects (62% men, 51?±?15 years) had mild to moderately impaired global RV systolic function (RVEF?=?39?±?15%; RVEDV?=?187?±?69 ml; RVESV?=?119?±?68 ml) and moderate left ventricular dysfunction at baseline (LVEF 30?±?17%). Good correlation was observed between mean LV and RV post-contrast T₁ values (r?=?0.652, p?<?0.001), with similar post-contrast T₁ values maintained in both the RV free wall and septum (r?=?0.761, p?<?0.001). CMR RVEF demonstrated a proportional correlation with echocardiographic measures of RV longitudinal function and CMR RV strain (longitudinal r?=??0.449, p?=?0.001; radial r?=??0.549, p?<?0.001). RVEF was related to RV post-contrast T₁ values, particularly in those with RV dysfunction (free wall T₁ r?=?0.259 p?=?0.027; septal T₁ r?=?0.421 p?<?0.001). RV strain was also related to RV post-contrast T₁ values (r?=??0.417, p?=?0.002). Linear regression analysis demonstrated strain and post-contrast T1 values to be independently associated with RVEF. Subjects with severe RV dysfunction (CMR RVEF <25%) demonstrated lower RV CMR strain (longitudinal p?=?0.018; radial p?<?0.001), RV T₁ values (free wall p?=?0.013; septum <0.001) and RV longitudinal echocardiography parameters despite no difference in afterload. During follow-up, those with RV free wall post-contrast T₁ values?≥?350 ms demonstrated ongoing improvement in FAC (Δ6%), whilst values <350 ms were associated with deterioration in RV function (ΔFAC?=??5%) (p?=?0.026). CMR provides a comprehensive method by which to evaluate right ventricular function. Post-contrast T₁ mapping and CMR strain imaging are technically feasible and provide incremental information regarding global RV function and structure. The proportional relationship between RV function and post-contrast T₁ values supports that myocardial fibrosis is a causative factor of RV dysfunction in NICM, irrespective of RV afterload. This same structural milieu also appears integral to the propensity for both positive and negative RV remodeling long-term, suggestive that this is also determined by the degree of underlying RV fibrosis.     

Normal references of right ventricular strain values by two-dimensional strain echocardiography according to the age and gender

Right ventricular (RV) strain values by 2-dimensional strain echocardiography (STE) can be used as objective markers of RV systolic function. However, there is little data about normal reference RV strain values according to age and gender. We measured normal RV strain values by STE. RV strain values were analyzed from the digitally stored echocardiographic images from NORMAL (Normal echOcardiogRaphic diMensions and functions in KoreAn popuLation) study for the measurement of normal echocardiographic values performed in 23 Korean university hospitals. We enrolled total 1003 healthy persons in the NORMAL study. Of them, we analyzed 2-dimensional RV strain values in 493 subjects (261 females, mean 47?±?15 years old) only with echocardiographic images by GE machines. Their LV systolic and diastolic functions were normal. RV fractional area change was 48?±?6% and tricuspid annular plane systolic excursion was 23?±?3 mm. Total RV global longitudinal peak systolic strain (RVGLS_total) was ?21.5?±?3.2%. Females had higher absolute RVGLS_total (?22.3?±?3.3 vs ?20.7?±?2.9%, p?<?0.001) than males. Younger (<50 years old) females had higher absolute RVGLS_total (?22.9?±?3.2 vs ?20.5?±?2.8%, p?<?0.001) than age matched males. RVGLS_total in females gradually increased according to age (p for trend?=?0.002) and becomes almost similar in age ≥50 years. However, this trend was not seen in males (p for trend?=?0.287), and younger males had similar RVGLS_total value to that of older males (age ≥50 years, ?20.5?±?2.8 vs ?20.9?±?3.1%, p?=?0.224). We calculated normal RVGLS values in normal population. Females have higher absolute strain values than males, especially in younger age groups (<50 years old).     

Tricuspid annular dilation in patients undergoing early mitral valve surgery: is it an old story?

Patients with mitral valve prolapse (MVP), undergoing early surgery for severe regurgitation, are usually characterized by a low degree of right chambers’ remodeling. In this selected population, the mechanisms leading to tricuspid annular (TA) dilatation (TAD) are not well understood. In this setting, we aimed to evaluate, using three-dimensional echocardiography (3DE), how right chambers affect TA size and might contribute to functional tricuspid regurgitation (FTR) progression. We studied 159 patients treated with early isolated surgery for MVP, characterized by: sinus rhythm; normal biventricular function; normal or elevated pulmonary artery pressure; tricuspid regurgitation (TR)?≤?mild; no concomitant cardiac disease. All patients reached a 3-year echocardiographic follow-up. Based on two-dimensional echocardiography, patients were divided in Group 1 (N?=?68, 43%, TAD, TA?≥?21 mm/m²) and Group 2 (N?=?91, 57%, no TAD, TA?<?21 mm/m²). By 3DE, Group 1 showed larger TA size, right atrial (RA) volume and right ventricular (RV) conical remodeling compared to Group 2 (p?<?0.05). The multivariate analysis revealed that RA volume, RV basal diameter and function were independently correlated to TA size (p?<?0.05). At the 3-year follow-up there was a low incidence of FTR, with a trend towards FTR progression in Group 1 (p?=?0.07). In patients undergoing early surgery for MVP, TAD seems to result from distinctive early-onset geometrical changes of the right chambers, preceding TR, RV dilatation and pulmonary hypertension at rest. An integrated approach, including right chambers’ assessment by 3DE, might help to better recognized patients at higher risk for TAD and, potentially for FTR.

     

The relation between quantitative right ventricular ejection fraction and indices of tricuspid annular motion and myocardial performance.

BACKGROUND: Assessment of right ventricular (RV) function remains challenging because of complex RV chamber geometry and a paucity of easily derived and objective functional methods. METHODS: Visual 2-dimensional echocardiographic estimates of RV ejection fraction (EF), tricuspid annular plane systolic excursion, Doppler tissue imaging, and myocardial performance index (MPI) were compared with biplanar Simpson's rule RV EF in 101 consecutive patients. Data were analyzed using simple linear regression and receiver operating characteristic curves. RESULTS: RV EF was significantly correlated with tricuspid annular plane systolic excursion (r = 0.48, P <.0001), Doppler tissue imaging peak systolic velocity (r = 0.45, P <.0001), and MPI (r = -0.38, P =.006). Using a Simpson's RV EF < 50%, the sensitivity, specificity, and positive and negative predictive values of tricuspid annular plane systolic excursion < 1.5 cm were 59%, 94%, 71%, and 89%; of Doppler tissue imaging peak systolic velocity < 10 cm/s were 59%, 92%, 67%, and 89%; and of MPI < 0.40 were 100%, 35%, 29%, and 100%, respectively. The area under the receiver operating characteristic curves was similar for the 3 indices. CONCLUSIONS: Measurements of tricuspid annular motion are easy to obtain, correlate with Simpson's RV EF, and have a high specificity and negative predictive value for detecting abnormal RV systolic function; and the MPI, although not specific, has high sensitivity and negative predictive value for detecting abnormal RV systolic function.     

Reproducibility of peak filling and peak emptying rate determined by cardiovascular magnetic resonance imaging for assessment of biventricular systolic and diastolic dysfunction in patients with pulmonary arterial hypertension

Right ventricular (RV) and left ventricular (LV) diastolic stiffness may be independent contributors to disease progression in pulmonary arterial hypertension (PAH). The aims of this study are to assess reproducibility of peak emptying rate (PER) and early diastolic peak filling rate (PFR) for both the RV and the LV in PAH and study their relationship to stroke volume (SV). Triple weekly repetition of 20 (totalling 60) cardiovascular magnetic resonance (CMR) scans, were done on 10 patients with PAH and 10 healthy controls. RV and LV volumes were measured over the full cardiac cycle. PER and PFR were calculated as the first derivative of the time–volume relationship in both the RV and the LV and indexed to body surface area. Reproducibility and the relation to SV were studied in a mixed model. PFR was lower in PAH in both the RV (PAH?=?170 mL/m²/s, controls?=?236 mL/m²/s [p?<?0.01]) and in the LV (PAH?=?209 mL/m²/s, controls?=?311 mL/m²/s [p?<?0.01]). PERs were not significantly different between patients and controls. Reproducibility of PER and PFR was high. A trial targeting normalization of PFR requires a total sample size of <?20. PER and PFR in both ventricles were strongly associated with stroke volume (all four: p?<?0.01). Biventricular diastolic dysfunctions are strongly associated with stroke volume, and CMR can quantify them with high reproducibility, enabling small sample sizes for trials of therapies targeting diastolic dysfunction to increase survival.     

A comprehensive analysis of cardiac valve plane displacement in healthy adults: age-stratified normal values by cardiac magnetic resonance

Cardiac valve plane displacement (CVPD) reflects longitudinal LV function. The purpose of the present study was to determine regional heterogeneity of CVPD in healthy adults to provide normal values by cardiac magnetic resonance (CMR). We measured the anterior aortic plane systolic excursion (AAPSE); the anterior, anterolateral, inferolateral, inferior, and inferoseptal mitral annular plane systolic excursion (MAPSE); and the lateral tricuspid annulus plane systolic excursion (TAPSE). Systolic excursion was measured as the distance from peak end-diastolic to peak end-sysstolic annular position (peak-to-peak) in cine images acquired in 2-, 3- and 4-chamber views. Echocardiographic measurements of CVPD were performed in M-Mode as previously described. We retrospectively analyzed 209 healthy Caucasians (57% men), who participated in the Heidelberg normal cohort between March 2009 and September 2014. The analysis was possible in all participants. Mean values were: AAPSE?=?14?±?3 mm (8–20); MAPSE_anterior?=?14?±?3 mm (8–20); MAPSE_{anterolateral}?=?16?±?3 mm (10–22); MAPSE_{inferolateral}?=?16?±?3 mm (10–22); MAPSE_inferior?=?17?±?3 mm (11–23); MAPSE_inferoseptal?=?13?±?3 mm (7–19) and TAPSE?=?26?±?4 mm (18–34) respectively. MAPSE was significantly elevated in lateral compared to septal regions (p?=?0.0001). Sex-differences for CVPD were not found. Age-dependency of CVPD revealed distinct regional differences. AAPSE decreased the most with age (B=?0.48; p?=?0.0001), whereas MAPSE_inferior was the least age-dependent site (B=?0.17; p?=?0.01). AAPSE revealed favorable intra-/interobserver reproducibility and interstudy agreement. Intermethod-comparison of CMR and M-Mode echocardiography showed good agreement between both measurements of CVPD. Age-stratified normal values of regional CVPD are provided. AAPSE revealed the most pronounced age-related decrease and provided favorable reproducibility compared to other regions of cardiac valve plane.     

The clinical value of assessing right ventricular diastolic function after balloon pulmonary angioplasty in patients with chronic thromboembolic pulmonary hypertension

Chronic thromboembolic pulmonary hypertension (CTEPH) has a poor prognosis because of the associated progressive right heart failure. Accurate evaluation of right ventricular (RV) function would thus be useful to predict prognosis. However, the significance of RV diastolic function remains unclear. We aimed to identify which echocardiographic measures are most accurate, and potentially useful, in assessing RV diastolic function in patients with CTEPH, and to study the effects of balloon pulmonary angioplasty (BPA) on them. We enrolled 53 CTEPH patients who underwent BPA. Echocardiographic parameters, including two-dimensional speckle-tracking echocardiography, were compared to the hemodynamic parameters measured by right heart catheterization before and after BPA. RV strain rate during early diastole (SR_E), tricuspid e′ and right atrial area (RAA) were ameliorated after BPA, concomitant with a decrease in the time constant of the RV pressure curve during diastole (tau), indicating the improvement of RV diastolic function. Among them, SR_E had the strongest correlation with tau (r?=???0.39, p?<?0.001). Furthermore, the receiver operating characteristic analyses revealed that E/SR_E (AUC 0.704) and inferior vena cava diameter (AUC 0.726) had a stronger association with higher mean right atrial pressure than RAA (AUC 0.632). In contrast, RAA had a stronger correlation with 6 min-walk distances than SR_E (r?=???0.39, p?<?0.001 vs. r?=?0.30, p?=?0.005). Taken together, echocardiographic assessment of RV diastolic function might be associated with hemodynamics as well as exercise tolerance in patients with CTEPH, indicating its benefits in evaluating the therapeutic effects of BPA.     

Echocardiographic assessment of regional right ventricular systolic function using two-dimensional strain echocardiography and evaluation of the predictive ability of longitudinal 2D-strain imaging for pulmonary arterial hypertension in systemic sclerosis patients

Systemic sclerosis (SSc) is a generalized connective tissue disorder, and SSc patients are at risk of developing pulmonary arterial hypertension (PAH). The aims of this study are to evaluate the right ventricular regional systolic function using two-dimensional speckle-tracking echocardiography (2D STE) and to determine the predictive ability of peak longitudinal systolic strain (PLSS) at the RV lateral wall for PAH in SSc patients. 80 SSc patients (mean age 51?±?12 years) were included in the study. Echocardiography and 2D STE were performed at baseline and after 12 months. RHC was performed only in SSc patients with clinical indications. PLSS at the apical segment of the RV free wall was significantly impaired in PAH patients compared with non-PH patients (–14.6?±?5.9 vs. ??22.2?±?7.5%, p?=?0.034). PLSS at the basal, mid, and apical segments of the RV free wall was lower in both groups at follow-up compared to baseline, but the drop in strain values was statistically significant only in the non-PH group (p?<?0.05). Right atrial area (OR 1.758; p?=?0.023), peak tricuspid regurgitation velocity (OR 24.23; p?=?0.011) and PLSS at the apical segment of the RV lateral wall (OR 2.47; p?=?0.005) were independent predictors of PAH. A cut-off value of ??14.48% PLSS at the apical segment of the RV lateral wall resulted in 100% specificity for predicting PAH in SSc patients. RV pressure overload affects RV systolic function as manifested by impaired RV longitudinal deformation. Evaluating RV regional systolic function with 2D STE could be useful as an additional echocardiographic parameter for screening PAH in SSc patients.     

Right ventricular function declines after cardiac surgery in adult patients with congenital heart disease

Right ventricular function (RVF) is often selectively declined after coronary artery bypass graft surgery. In adult patients with congenital heart disease (CHD) the incidence and persistence of declined RVF after cardiac surgery is unknown. The current study aimed to describe RVF after cardiac surgery in these patients. Adult CHD patients operated between January 2008 and December 2009 in the Academic Medical Centre in Amsterdam were studied. Clinical characteristics, laboratory tests, surgical data and intensive care unit outcome were obtained from medical records. RVF was measured by trans-thoracic echocardiography (TTE) and expressed by tricuspid annular plane systolic excursion (TAPSE), tissue Doppler imaging (RV S’) and myocardial performance index (MPI) pre-operatively and direct, at intermediate and late follow up. Of a total of 185 operated, 86 patients (mean age 39?±?13?years, 54% male) had echo data available. There was a significant fall in RVF after cardiac surgery. TAPSE and RV S’ were significantly higher and MPI was significantly lower pre-operatively compared to direct post-operative values (TAPSE 22?±?5 versus 13?±?3?mm (P?<?0.01), RV S’ 11?±?4 versus 8?±?2?cm/s (P?<?0.01) and MPI 0.36?±?0.14 vs 0.62?±?0.25; P?<?0.01). There were no significant differences in left ventricular function pre-operatively compared to post-operative values. Right-sided surgery was performed in 33, left-sided surgery in 37 and both sided surgery in 16 patients. Decline in RVF was equal for those groups. Patients with severe decline in RVF, were patients who underwent tricuspid valve surgery. Decline in RVF was associated with post-operative myocardial creatine kinase level and maximal troponin T level. There was no association between decline in RVF and clinical outcome on the intensive care unit. 18?months post-operatively, most RVF parameters had recovered to pre-operative values, but TAPSE which remained still lower (P?<?0.01). CHD patients have a decline in RVF directly after cardiac surgery, regardless the side of surgery. Although a gradual improvement was observed, complete recovery was not seen 18?months post-operatively.     

Balloon pulmonary angioplasty improves interventricular dyssynchrony in patients with inoperable chronic thromboembolic pulmonary hypertension: a cardiac MR imaging study

To use cardiac magnetic resonance imaging (MRI) to investigate the effect of balloon pulmonary angioplasty (BPA) on interventricular dyssynchrony and its associations with ventricular interaction, which impairs LV function in patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH). This prospective observational study was approved by our institutional review board. Cardiac MRI and right heart catheterization were conducted before BPA sessions and at the follow up after BPA in 20 patients with CTEPH. We measured right ventricular (RV) and left ventricular (LV) end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV), and ejection fraction (EF) using MRI. For the LV and RV free walls, the time to peak (T_peak) of circumferential strain was calculated as a parameter for interventricular dyssynchrony. Following BPA, the RV-EDV and -ESV were significantly decreased, and the RVEF was significantly increased. Conversely, BPA led to significantly increased LV EDV and SV without changing LVESV. The left-to-right free wall delay (L–R delay) in T_peak strain decreased from 105?±?44 ms to 47?±?67 ms (p?<?0.001). Increased LV EDV (r?=?0.65, p?<?0.01), SV (r?=?0.74, p?<?0.001) and 6-minute walk distance (6MWD) (r?=?0.54, p?<?0.05) were correlated to the reduction in L–R delay. In patients with inoperable CPEPH, BPA improved interventricular dyssynchrony, which was strongly associated with increased SV and 6MWD. The assessment of interventricular dyssynchrony using cardiac MRI has an important role in evaluating ventricular interaction, which reduces LVSV and exercise tolerance.     

Measurement of cardiac valve and aortic blood flow velocities in stroke patients: a comparison of 4D flow MRI and echocardiography

4D flow MRI is an emerging technique that allows quantification of 3D blood flow in vivo. However, comparisons with methods of blood velocity quantification used in clinical routine are sparse. Therefore, we compared velocity quantification using 4D flow MRI with transthoracic and transesophageal echocardiography at the mitral and aortic valves and the aorta. Forty-eight stroke patients (age 67.3?±?15.0 years) were examined by 4D flow MRI. Blood flow velocities were assessed using standardized 2D analysis planes positioned in the mitral valve (MV), aortic valve (AV), ascending aorta (AAo), and descending aorta (DAo) and were compared with echocardiography. MRI showed moderate-high correlations of systolic velocity values for the MV (r?=?0.67, p?<?0.001), AV (r?=?0.77, p?<?0.001), AAo (r?=?0.93, p?<?0.001), and DAo (r?=?0.76, p?<?0.001) along with moderate-high intraclass-correlation-coefficients: MV 0.79 (95% CI 0.62, 0.88), AV 0.86 (95% CI 0.75, 0.92), AAo 0.96 (95% CI 0.93, 0.98), and DAo 0.83 (95% CI 0.70, 0.90). However, MRI underestimated absolute systolic blood flow velocities compared with echocardiography by 8.6% for the MV (p?=?0.07), 3.1% for the AV (p?=?0.48), 10.7% for the AAo (p?=?0.09), and 15.0% for the DAo (p?=?0.01). Blood flow velocities obtained using 4D flow MRI and echocardiography at the MV, AV, and the ascending and DAo showed moderate to high correlations. Underestimation of absolute velocity values by MRI was low. Thus, 4D flow MRI seems ideally suited to comprehensively assess cardiac and aortic pathologies and related hemodynamic changes in future studies.     

Impact of surgical pulmonary valve replacement on ventricular mechanics in children with repaired tetralogy of Fallot

Impaired ventricular myocardial mechanics are observed in patients with repaired tetralogy of Fallot (rTOF). Effects of pulmonary valve replacement (PVR) on ventricular remodeling are controversial. The objective was to assess the impact of surgical PVR on ventricular mechanics in pediatric patients after rTOF. Speckle-tracking analysis was performed in 50 rTOF children, aged 12.6?±?3.3 years, pre-operatively and 14.5?±?2.2 months post-PVR. Early post-operative studies 2.2?±?0.6 months post-PVR were performed in 28 patients. Cardiac magnetic resonance (CMR) pre- and post-PVR was collected. Mid-term post-PVR right ventricular (RV) longitudinal strain increased above pre-operative strain (?19.2?±?2.7 to ?22.0?±?3.0%, p?<?0.001) with increases observed in individual RV segments. Left ventricular (LV) strain did not differ at medium-term follow-up. LV and RV longitudinal strain was reduced early post-operatively, followed by recovery of biventricular systolic strain by mid-term follow-up. CMR RV end-diastolic indexed volumes correlated with RV strain pre-operatively (r?=?0.432, p?=?0.005) and at mid-term follow-up (r?=?0.532, p?=?0.001). Volume-loaded RVs had reduced early RV basal longitudinal strain compared to pressure-loading conditions. Reversed basal counterclockwise rotation was associated with lower mid-term global LV and basal RV strain compared to patients with normal rotation. An increase in mid-term global and regional RV strain beyond pre-operative values suggests positive RV remodeling and adaptation occurs in children post-PVR. Patients with larger pre-operative RV volumes had lower RV strain post-operatively. The impact of LV rotation on RV mechanics highlights the presence of ventriculo-ventricular interactions. These findings have important clinical implications in pediatric rTOF patients towards identifying pre-operative factors that predict RV post-operative remodeling.     

Right ventricular function in grown-up patients after correction of congenital right heart disease

Aims

We investigated whether a correlation exists between biomarkers of the neurohumoral system and clinical markers in grown-up patients with congenital heart disease (GUCH) and right ventricular function.

Methods and results

Prospective, cross-sectional, multicenter study of 104 GUCH patients (median) 16?years (range 6?C43?years) after corrective surgery with RV pressure and/or volume overload and 54 healthy controls. Clinical, functional, and laboratory parameters were assessed. Natriuretic peptide levels were significantly increased in GUCH patients (NTproBNP 101 vs. 25?pg/ml, p?<?0.001), but we observed no differences in norepinephrine, aldosterone, angiotensin II and Endothelin-1 levels. NTproBNP correlated significantly with clinical markers such as NYHA classification, prolonged QRS duration and reduced exercise capacity (VO₂ peak) (all p?<?0.001), as well as self-reported quality of life (p?<?0.001). MRI and echocardiography derived RV volumes were elevated and ejection fraction reduced in the patients (both p?<?0.001). Tissue Doppler parameter showed significantly restricted ventricular longitudinal systolic function (longitudinal tricuspid valve movement, 1.7 vs. 2.3?cm, p?<?0.001), suggesting stiffness and reduced RV compliance.

Conclusion

In conclusion, grown-up patients with congenital right heart disease NTproBNP correlates well with various clinical markers of RV failure, such as prolongation of QRS duration, exercise capacity, echocardiography and MRI parameters, and quality of life.     

Regional contribution to ventricular stroke volume is affected on the left side,but not on the right in patients with pulmonary hypertension

To develop more sensitive measures of impaired cardiac function in patients with pulmonary hypertension (PH), since detection of impaired right ventricular (RV) function is important in these patients. With the hypothesis that a change in septal function in patients with PH is associated with altered longitudinal and lateral function of both ventricles, as a compensatory mechanism, we quantified the contributions of these parameters to stroke volume (SV) in both ventricles using cardiac magnetic resonance (CMR). Seventeen patients (10 females) evaluated for PH underwent right heart catheterization (RHC) and CMR. CMR from 33 healthy adults (13 females) were used as controls. Left ventricular (LV) atrioventricular plane displacement (AVPD) and corresponding longitudinal contribution to LVSV was lower in patients (10.8?±?3.2 mm and 51?±?12?%) compared to controls (16.6?±?1.9 mm and 59?±?9?%, p?<?0.0001 and p?<?0.01, respectively). This decrease did not differ in patient with ejection fraction (EF) >50?% and <50?% (p?=?0.5) and was compensated for by increased LV lateral contribution to LVSV in patients (49?±?13?% vs. 37?±?7?%, p?=?0.001). Septal motion contributed less to LVSV in patients (5?±?8?%) compared to controls (8?±?4?%, p?=?0.05). RV AVPD was lower in patients (12.0?±?3.6 mm vs. 21.8?±?2.2 mm, p?<?0.0001) but longitudinal and lateral contribution to RVSV did not differ between patients (78?±?17?% and 29?±?16?%) and controls (79?±?9?% and 31?±?6?% p?=?0.7 for both) explained by increased RV cross sectional area in patients. LV function is affected in patients with PH despite preserved global LV function. The decreased longitudinal contribution and increased lateral contribution to LVSV was not seen in the RV, contrary to previous findings in patients with volume loaded RVs.     

Diagnostic and prognostic value of right ventricular strain in patients with pulmonary arterial hypertension and relatively preserved functional capacity studied with echocardiography and magnetic resonance

Right ventricular (RV) dysfunction harbingers adverse prognosis in pulmonary arterial hypertension (PAH). Although conventional two-dimensional echocardiography (2DE) is limited for RV systolic function quantitation, RV strain can be a useful tool. The diagnostic and prognostic impact of 2DE speckle-tracking RV longitudinal strain was evaluated, including other 2DE systolic indexes, in a group of PAH patients without severe impairment of functional capacity, chronic pulmonary thromboembolism or left ventricular dysfunction. Sixty-six group I PAH patients, 67?% NYHA functional class I or II (none in IV) were studied by 2DE to obtain: RV fractional area change, tricuspid annular plane systolic excursion, RV myocardial performance index, tissue Doppler tricuspid annulus systolic velocity. Global, free wall (RVFreeWSt) and septal RV longitudinal systolic strain were obtained. RV ejection fraction by cardiac magnetic resonance (CMR-RVEF) was also assessed. All patients were followed up to 3.9 years (mean 3.3 years). Combined endpoints were hospitalization for worsening PAH or cardiovascular death. Among all the 2DE indexes of RV systolic function, RVFreeWSt exhibited the best correlation with CMR-RVEF (r = 0.83; p?<?0.005). Combined endpoints occurred in 15 (22.7?%) patients (6 hospitalizations and 9 deaths). Multivariate analysis identified RVFreeWSt ≤?14?% as the only 2DE independent variable associated with combined endpoints [HR 4.66 (1.25–17.37); p?<?0.05]. We conclude that RVFreeWSt may be a suitable non-geometric 2DE surrogate of CMR-RVEF in PAH patients, constituting a powerful independent predictor of long-term outcome in this cohort with relatively preserved functional capacity.     

Left ventricular mechanics in isolated mild mitral stenosis: a three dimensional speckle tracking study

In a fraction of patients with mild mitral stenosis, left ventricular systolic function deteriorates despite the lack of hemodynamic load imposed by the dysfunctioning valve. Neither the predisposing factors nor the earlier changes in left ventricular contractility were understood adequately. In the present study we aimed to evaluate left ventricular mechanics using three-dimensional (3D) speckle tracking echocardiography. A total of 31 patients with mild rheumatic mitral stenosis and 27 healthy controls were enrolled to the study. All subjects included to the study underwent echocardiographic examination to collect data for two- and three-dimensional speckle-tracking based stain, twist angle and torsion measurements. Data was analyzed offline with a echocardiographic data analysis software. Patients with rheumatic mild MS had lower global longitudinal (p?<?0.001) circumferential (p?=?0.02) and radial (p?<?0.01) strain compared to controls, despite ejection fraction was similar for both groups [(p?=?0.45) for three dimensional and (p?=?0.37) for two dimensional measurement]. While the twist angle was not significantly different between groups (p?=?0.11), left ventricular torsion was significantly higher in mitral stenosis group (p?=?0.03). All strain values had a weak but significant positive correlation with mitral valve area measured with planimetry. Subclinical left ventricular systolic dysfunction develops at an early stage in rheumatic mitral stenosis. Further work is needed to elucidate patients at risk for developing overt systolic dysfunction.     

The ventricular residence time distribution derived from 4D flow particle tracing: a novel marker of myocardial dysfunction

4D flow cardiac magnetic resonance (CMR) imaging allows visualisation of blood flow in the cardiac chambers and great vessels. Post processing of the flow data allows determination of the residence time distribution (RTD), a novel means of assessing ventricular function, potentially providing additional information beyond ejection fraction. We evaluated the RTD measurement of efficiency of left and right ventricular (LV and RV) blood flow. 16 volunteers and 16 patients with systolic dysfunction (LVEF?<?50%) underwent CMR studies including 4D flow. The RTDs were created computationally by seeding virtual ‘particles’ at the inlet plane in customised post-processing software, moving these particles with the measured blood velocity, recording and counting how many exited per unit of time. The efficiency of ventricular flow was determined from the RTDs based on the time constant (RTDc?=???1/B) of the exponential decay. The RTDc was compared to ejection fraction, T1 mapping and global longitudinal strain (GLS). There was a significant difference between groups in LV RTDc (healthy volunteers 1.2?±?0.13 vs systolic dysfunction 2.2?±?0.80, p?<?0.001, C-statistic?=?1.0) and RV RTDc (1.5?±?0.15 vs 2.0?±?0.57, p?=?0.013, C-statistic?=?0.799). The LV RTDc correlated significantly with LVEF (R?=???0.84, P?<?0.001) and the RV RTDc had significant correlation with RVEF (R?=???0.402, p?=?0.008). The correlation between LV RTDc and LVEF was similar to GLS and LVEF (0.926, p?<?0.001). The ventricular residence time correlates with ejection fraction and can distinguish normal from abnormal systolic function. Further assessment of this method of assessment of chamber function is warranted.     

Association with right atrial strain with right atrial pressure: an invasive validation study

Echocardiographic assessment of right atrial pressure (RAP) from inferior vena cava (RAP_IVC) dimension may underestimate catheter-derived (RAP_C). As right atrial (RA) deformation, measured by speckle tracking, is preload-dependent, we hypothesized that RA strain may improve estimation of RAP_C. Right atrial strain components [RA reservoir function (?R), peak RA contraction (?CT) and RA conduit function (?CD)] were measured in 125 of 175 patients who had echocardiography and invasive measures of RAP (median difference 1 day). To determine whether RA strain measures differentiated patients with correct vs incorrect RAP_IVC assessment, categories with RAP_IVC values?<?3, 8 and >?15 mmHg were compared with RAP_C groups?<?3, 4–7, 8–10, 11–14 and >?15 mmHg. Non-invasively determined RAP was significantly lower (p?=?0.001) than invasively determined RAP_C, with a weak correlation (r?=?0.35, p?<?0.001). RA strain components were associated with RA size, RV function and IVC size. In those with RAP_IVC?>?15 mmHg, half of patients were categorized into RAP?<?10 mmHg. There were no significant differences in RA characteristics that differentiated patients in whom echocardiographic estimation of RAP was inaccurate. Right atrial strain measures were feasible, and had associations with RA size, RV systolic function and IVC size. Right atrial strain was significantly different between those with normal vs raised pressure, but it did not identify those with incorrect echocardiographic assessment of RAP.     

Comprehensive echocardiographic assessment of biventricular function in the rabbit,animal model in cardiovascular research: feasibility and normal values

Quantification of cardiac structure and function is central in cardiovascular research. Rabbits are valuable research models of cardiovascular human disease; however, there is little normal data available. The aim of this study was to investigate feasibility and provide normal values for comprehensive echocardiographic assessment of biventricular function in rabbits. New Zealand white rabbits underwent trans-thoracic echocardiography using a general electric (GE) Vivid 7/E9 system with a 10 MHz transducer, under light sedation, to evaluate biventricular function and dimensions. Images for two-dimensional, M-mode, tissue Doppler imaging (TDI) and speckle-tracking strain echocardiography were acquired and analysed. 55 male rabbits (sized matched with a newborn human baby) were studied, mean weight was 2.9?±?0.23 kg. Adequate images were obtained in 90% for the left ventricle (LV) and 80% for the right ventricle (RV). Two-dimensional speckle-tracking strain was feasible in 60%. Average heart rate was 248?±?36 beats per minute; LV ejection faction 72?±?8.0; RV fractional area change 45.9?±?9.0%; RV myocardial performance index 0.39?±?0.35; tricuspid annular planar systolic excursion 0.60?±?0.24 cm. LV TDI parameters were S’ 8.6?±?3.1 cm/s; E’ 12.0?±?4.46 cm/s. RV TDI parameters were S’ 10.49?±?3.18; E’ 14.95?±?4.64 cm/s. LV and RV global peak systolic longitudinal strain were ?17?±?5 and ?22?±?8%, respectively. Comprehensive investigation of biventricular dimensions and function by echocardiography is feasible in the rabbit. Apical views and strain imaging have lower feasibility. Normal values of LV and RV functional parameters are with comparable values to human children. Animal cardiovascular research is key to develop new goals in clinical practice.