Abnormal right ventricular myocardial strain generation in mild pulmonary hypertension

BACKGROUND: Although right ventricular (RV) dyssynchrony has been identified in patients with severe pulmonary hypertension due to significant RV enlargement and compromise in systolic function, a more clinically relevant question pertains to RV mechanical properties in patients with mild elevation in pulmonary artery systolic pressures (PASP). METHODS: Several echocardiographic parameters and peak longitudinal strain were measured in 40 patients and divided into two groups of 20 patients based on their PASP. RESULTS: Group I included 20 individuals (mean age 48 +/- 16 years with a mean PASP of 27 +/- 5 mmHg) and Group II included 20 patients (mean age 63 +/- 14 years with a mean PASP of 49 +/- 7 mmHg.) All time intervals were adjusted for heart rate. RV fractional area change and tricuspid annular plane systolic excursion for Group I (62 +/- 12% and 2.74 +/- 0.56 cm) and Group II (49 +/- 14%; P < 0.02 and 2.09 +/- 0.40; P < 0.002) were both normal. However, Group II had lower peak longitudinal RV free wall (RVF) strain (-27.3 +/- 7.1 % vs. -31.9 +/- 8.7%, P < 0.04), longer time to peak RVF strain (448 +/- 57 ms vs. 411 +/- 43 ms; P < 0.03) and evidence of significant RV dyssynchrony (-83 +/- 55 ms vs. 1 +/- 17 ms, P < 0.00001) in contrast to Group I. CONCLUSION: In conclusion, mild elevations in PASP affect the mechanical properties of the RV and result in RV dyssynchrony despite absence of gross abnormalities in RV size or function.     

Regional right ventricular strain pattern in patients with acute pulmonary embolism

Aims: Right ventricular (RV) dysfunction is a frequent consequence of pulmonary embolism (PE) and a marker of increased risk. However, current qualitative methods assessing RV function are imprecise. We sought to determine whether RV strain analysis would have clinical utility in patients with PE compared with normal controls. Methods and results: We compared 75 acute PE subjects (mean age 54 ± 16) with 30 normal controls (mean age 50 ± 15). Regional RV longitudinal strain was assessed using offline speckle tracking software to obtain strain and strain rate data from the basal, mid, and apical free wall and septum. Global RV free wall and septal strain was significantly reduced in PE subjects (?14.17 (±5.96) vs ?24.92 (±4.16), P < 0.0001; ?14.99 (±5.55) vs ?18.54 (±7.34), P = 0.0082). Regional RV strain was markedly reduced in PE subjects in all regions of the free wall and in the mid and basal septum (P < 0.05). Strain rates of PE subjects were significantly reduced in all segments of the RV free wall (P < 0.05). In 36 PE subjects with regional RV dysfunction (“McConnell sign”), strain in the apical free wall was significantly reduced in comparison to those without (?10.08 vs ?13.51; P = 0.0420), in parallel with higher RV:LV ratios (1.30, ±1.01 vs 0.78, ±0.16; P = 0.0035) and lower RV fractional area change (32.06, ±14.42 vs 42.52, ±11.61; P = 0.0021). Conclusions: Regional RV longitudinal strain is altered in the free wall and mid and basal septum in subjects with acute PE. Strain rates are only reduced in the RV free wall. (Echocardiography 2012;29:464‐470)     

Evaluation of right ventricular regional volume and systolic function in patients with pulmonary arterial hypertension using three-dimensional echocardiography

Objective: To evaluate right ventricular (RV) regional volume and systolic function in patients with pulmonary arterial hypertension (PAH) using real time three‐dimensional echocardiography (RT3DE), and to explore the relationship between parameters measured by RT3DE and right heart catheterization (RHC). Methods: RT3DE images were acquired from 24 patients with PAH and 27 normal controls for evaluation and analysis to obtain RV regional end‐diastolic volume (EDV), end‐systolic volume (ESV), ejection fraction (EF) in three compartments (inflow, body, and outflow). Conventional echocardiographic parameters were calculated and recorded. RHC was performed in 17 patients to obtain pulmonary artery systolic pressure (PASP) and pulmonary vascular resistance (PVR). Results: RV regional EDV and ESV were significantly higher while regional EF was significantly lower in the PAH patients when compared with controls (P < 0.001). In the PAH group, EDV was similar in the inflow and body compartment, both higher than that in the outflow compartment (P < 0.05); EF was the highest in the inflow compartment and the lowest in the body compartment (P < 0.05). RV regional EF in the inflow compartment and global EF were negatively correlated with PASP (r =–0.766, –0.816, P < 0.001) and PVR (r =–0.529, –0.656, P < 0.05). Conclusions: In patients with PAH, RV regional volume was enlarged and systolic function was impaired with distinct characteristics; regional EF in the inflow compartment and global EF were inversely correlated with PASP and PVR. Evaluation of RV regional systolic function using RT3DE may play a potential role in the noninvasive assessment of the severity of PAH. (Echocardiography 2012;29:706‐712)     

Tei指数对慢性阻塞性肺病肺动脉高压患者的右心功能评价

目的:应用Tei指数评价慢性阻塞性肺病（chronic obstructive pulmonary disease,COPD）伴肺动脉高压(pulmonary hypertension,PH)患者的右心功能。方法: 临床确诊的慢性阻塞性肺病伴肺动脉高压(COPD+PH)患者68例,另30例正常人作为对照组。根据三尖瓣反流压差,超声估测肺动脉收缩压,并按其分别判定为重度PH组、中度PH组和轻度PH组。超声常规测量参数包括右心室前后径、右心房横径、肺动脉主干内径,并计算右心室Tei指数。结果: 68例COPD+PH患者中,重度PH组22例,中度PH组30例,轻度PH组16例;与对照组相比,重度PH组和中度PH组右心大小、Tei指数均有统计学差异,轻度PH组无明显右心形态改变,Tei指数无统计学差异。结论: 右心室Tei指数可作为COPD伴中重度PH患者右心功能评价的参考指标。     

Usefulness of right ventricular strain assessment in submassive pulmonary thromboembolism undergoing ultrasound‐facilitated thrombolysis

Massive and submassive pulmonary thromboembolism carry significant morbidity and mortality. We present an elderly female who was diagnosed with a submassive pulmonary embolism by computed tomographic angiography and treated with ultrasound‐facilitated thrombolysis (UFT). This case demonstrates the usefulness of right ventricular longitudinal strain measurements by two‐dimensional speckle tracking echocardiography in the evaluation of right ventricular function before and after UFT. Evaluation of right ventricle longitudinal strain by speckle tracking echocardiography may supplement other parameters in the assessment of right ventricular function in these patients.     

超声二维应变成像技术在评价甲状腺功能亢进患者右室纵向收缩功能中的运用

目的:应用超声二维应变成像技术评价甲状腺功能亢进(甲亢)患者右室纵向收缩功能。方法:根据甲亢的临床症状和相关辅助检查分为单纯性甲亢组(43例)和甲亢性心脏病组(20例),正常对照组33例。经胸采集并存贮3个心动周期标准心尖四腔二维图像,运用EchoPAC超声工作站进行脱机分析,在二维应变的模式下,测量右室游离壁和室间隔右室面基底段、中间段及心尖段6个节段的纵向收缩期峰值应变和右室整体收缩峰值应变值,并比较各收缩期峰值应变在3组间的差异。同时测量并分析右室舒张末横径(RVED)、右室射血分数(RVEF)、右室面积变化率(RVPCA)及三尖瓣环收缩期峰值速度(TVSPV)等指标与右室整体收缩峰值应变的相关性。结果:甲亢性心脏病组右室游离壁及室间隔基底段、中间段、心尖段及右室整体的收缩期峰值应变较正常对照组和单纯性甲亢组均显著减低,差异具有统计学意义(P<0.001);单纯性甲亢组右室游离壁及室间隔基底段、中间段、心尖段及右室整体的收缩期峰值应变较正常对照组稍减低,但差异无统计学意义(P>0.05);RVED、RVEF、RVPCA及TVSPV与右室整体收缩期峰值应变均具有良好的相关性(r分别为=-0.355、0.3...     

Tissue Doppler assessment of longitudinal right and left ventricular strain and strain rate in pulmonary artery hypertension

Tissue Doppler imaging (TDI) in 38 adult patients with pulmonary artery hypertension of varied etiology and normal left ventricular systolic function by two-dimensional transthoracic echocardiography showed significantly reduced peak systolic strain (SS) in all three segments of left ventricular free wall and ventricular septum and two of three segments of right ventricular free wall when compared to 29 adults with no clinical or echocardiographic evidence of heart disease and normal left and right ventricular systolic function. A similar reduction in peak diastolic strain (DS) was also noted in all three segments of left ventricular free wall and ventricular septum and one of three segments of right ventricular free wall. This reduction in strain indices in patients with pulmonary hypertension was noted irrespective of whether right ventricular systolic function was normal or reduced as assessed by two-dimensional transthoracic echocardiography. SS and DS rates also showed reductions in patients with pulmonary artery hypertension. Our study shows the potential value of TDI indices in identifying reduced regional left ventricular systolic and diastolic longitudinal function in patients with pulmonary artery hypertension and normal left ventricular systolic function by two-dimensional transthoracic echocardiography. This reduction in left ventricular function was noted in patients with both normal and reduced right ventricular systolic functions by two-dimensional echocardiography.     

Cardiac correlates of exercise induced pulmonary hypertension in patients with chronic heart failure due to left ventricular systolic dysfunction

BACKGROUND: Patients with chronic heart failure (CHF) due to left ventricular systolic dysfunction (LVSD) may develop pulmonary hypertension at rest and during exercise. The cardiac correlates of pulmonary hypertension have been ascertained in the resting state, but seldom during exercise in these patients. AIMS: We sought to determine the cardiac correlates of exercise induced pulmonary hypertension in patients with LVSD by monitoring the estimated pulmonary artery systolic pressure (PASP) by continuous Doppler echocardiography during semirecumbent bicycle exercise. METHODS: Eighty-five patients (mean age 57 +/- 13 years, 75% male) with CHF due to LVSD (LV ejection fraction [EF] <45%, mean LVEF 26 +/- 8%) were studied. RESULTS: Mitral effective regurgitant orifice area and E-wave were independent predictors of resting PASP. Resting PASP and exercise induced changes in PASP were unrelated (r =-0.08, P = 0.45). Decrease in LV end-systolic volume, increase in left atrial (LA) area, resting LV asynchrony, and decreased tricuspid annular plane systolic excursion (TAPSE) were independent predictors of exercise PASP. CONCLUSIONS: Resting LV asynchrony, impaired LV contractile reserve, and increase in LA dilatation correlate with the severity of exercise induced pulmonary hypertension in patients with CHF due to LVSD, while right ventricular systolic dysfunction is inversely related to the severity of exercise induced pulmonary hypertension.     

Assessment of right ventricular systolic function using tricuspid annular-plane systolic excursion in Nigerians with systemic hypertension

Aim

Right ventricular (RV) systolic function in patients with hypertensive heart disease (HHD) is not well characterised. The primary aim of this study was to assess the systolic function of the right ventricle in patients with HHD using tricuspid annular-plane systolic excursion (TAPSE).

Methods

The study was cross-sectional in design and carried out in Kano, Nigeria. Patients were recruited if they had HHD on echocardiography and were at least 15 years of age. Patients with other cardiac pathologies such as ischaemic and valvular heart diseases were excluded. Patients were considered to have abnormal RV systolic function if they had reduced values of TAPSE (< 15 mm). A p-value of < 0.05 was considered statistically significant.

Results

A total of 186 patients were serially recruited over seven months. Of these, 131 (70.4%) had normal RV systolic function (group 1) and 55 patients (29.6%) had abnormal function (group 2). Group 2 patients were older (p = 0.002) and had a higher prevalence of peripheral oedema (p = 0.002), moderate to severe dyspnoea, higher heart rate and lower left ventricular ejection fraction (p < 0.001). Atrial arrhythmias were also more prevalent among group 2 patients (p < 0.05). The best correlate to TAPSE was the septal mitral annularplane systolic excursion (r = +0.541, p < 0.001). Several variables such as age predicted the presence of reduced TAPSE.

Conclusion

The study found that almost one-third of patients with HHD in Kano had RV systolic dysfunction as defined by reduced TAPSE, and these patients had a greater prevalence of factors associated with morbidity and mortality.     

Subclinical right ventricular dysfunction in diabetes mellitus--an ultrasonic strain/strain rate study.

AIMS: While left ventricular dysfunction has been recognized to be a common complication of diabetes mellitus, data regarding right ventricular (RV) performance in patients with diabetes are incomplete. The aim of the study was to determine the preclinical effects of diabetes on regional RV systolic and diastolic function in asymptomatic persons with diabetes using the echocardiographic strain/strain rate technique. METHODS: Groups studied consisted of 33 subjects with diabetes only (DM; aged 57.3 +/- 12.9 years) and 40 subjects with coexisting diabetes and hypertension (DMHT; aged 57.5 +/- 10.5 years). In all patients with diabetes, coronary artery disease and pulmonary hypertension were excluded. Thirty-six healthy age-matched persons served as control subjects. In each patient an echocardiographic study with strain/strain rate imaging was performed. Analysis of RV deformation data included assessment of systolic strain, peak systolic strain rate (SRs) and peak early diastolic strain rate (SRe) obtained from the basal and apical segments of the RV free wall. RESULTS: Significantly lower values of systolic strain and SRs in the basal and apical segment of the RV free wall in the DM and DMHT groups as compared with control subjects indicated impairment of RV systolic function. Similarly, decreased SRe in patients with diabetes in both RV segments examined reflected abnormalities of RV diastolic performance. The systolic defects were more pronounced in the apical than in the basal segment. All measured parameters were similar in the two groups with diabetes. CONCLUSION: Diabetes mellitus is associated with subclinical RV systolic and diastolic dysfunction, regardless of coexisting hypertension.     

Correlation between right ventricular indices and clinical improvement in epoprostenol treated pulmonary hypertension patients

The aim of this study was to evaluate which parameter of right ventricular (RV) echocardiographic best mirrors the clinical status of patients with pulmonary arterial hypertension. Patients with pulmonary arterial hypertension on epoprostenol therapy were identified via hospital registry. Twenty patients, (16 females, 4 males) were included in the study, 9 with primary pulmonary hypertension and 11 with other diseases. Echocardiograms before therapy and at 22.7 (+/-9.3) months into therapy were compared. The right ventricular myocardial performance index (RVMPI) was measured as the sum of the isometric contraction time and the isometric relaxation time divided by right ventricular ejection time. Other measures included peak tricuspid regurgitation jet velocity (TRV), pulmonary artery systolic pressure (PASP), pulmonary valve velocity time integral (PVVTI), PASP/PVVTI (as an index of total pulmonary resistance) and symptoms by New York Heart Association (NYHA) functional class. Echo parameters of right ventricular function were analyzed in patients, before and during therapy. There was significant improvement of NYHA class in patients following epoprostenol therapy (P < 0.0001). Peak tricuspid regurgitant jet velocity (pre 4.2 +/- 0.6 m/sec, post 3.8 +/- 0.7 m/sec, P = 0.02) and PASP/PVVTI (pre 6.7 +/- 3.3 mmHg/m per second, post 4.8 +/- 2.2 mmHg/m per second, P < 0.0001) were significantly improved during treatment. RVMPI did not improve (pre 0.6 +/- 0.3, post 0.6 +/- 0.3, P = 0.54). Changes in NYHA class did not correlate with changes in RVMPI (P = 0.33) or changes in PASP/PVVTI (P = 0.58). Despite significant improvements in TRV, PASP/PVVTI, and NYHA class, there was no significant change in RVMPI on epoprostenol therapy. Changes in right ventricular indices were not correlated with changes in NYHA class.     

Usefulness of tricuspid annular velocity in identifying global RV dysfunction in patients with primary pulmonary hypertension: a comparison with 3D echo-derived right ventricular ejection fraction

While right ventricular (RV) function and size are important clinical markers in several cardiac conditions, the assessment of RV function by two-dimensional (2D) echocardiography remains challenging, due to the complexity of RV geometry. We therefore sought to compare an easily-measured parameter, peak systolic velocity of tricuspid annulus (TAPSV) obtained by tissue Doppler imaging (TDI), to right ventricular ejection fraction (RVEF) measured by real time three-dimensional echocardiography (RT3DE) and to explore what TAPSV cutoff values would be useful in detecting global RV dysfunction. We enrolled 20 patients affected by primary pulmonary hypertension and 30 consecutive healthy volunteers, who underwent transthoracic echocardiography, RT3DE and tissue Doppler evaluation. TAPSV had a statistically significant correlation with RVEF (r = 0.66, P < 0.001). With RV dysfunction defined as RVEF <40%, a TAPSV cutoff value of 9.5 cm/sec yielded the best compromise between sensitivity, specificity, and positive predictive value and negative predictive value. In conclusion, a TAPSV cutoff value of 9.5 cm/sec yields significantly high sensitivity and specificity and appears to be a valid compromise in detecting RV dysfunction, TAPSV values however are not useful in evaluating the severity of RV dysfunction.