Right ventricular longitudinal strain: a tool for diagnosis and prognosis in light-chain amyloidosis

Objectives: Light-chain (AL) amyloidosis can lead to an infiltrative cardiomyopathy with increased wall thickness (IWT) of very poor prognosis. Our primary aim was to analyse the right ventricle (RV) in patients with IWT to discriminate AL amyloidosis from IWT due to hypertrophic cardiomyopathy (HCM) or to arterial hypertension (HTN). Our secondary aim was to assess if RV dysfunction predicts overall mortality in cardiac AL amyloidosis.

Methods: We retrospectively and consecutively compared clinical, biological and echocardiographic data of 315 patients with IWT: 105 biopsy-proven AL amyloidosis patients, 105 patients with HCM and 105 patients with HTN. The prognostic value of these parameters was analysed in the AL amyloidosis group.

Results: Free-wall right ventricular longitudinal strain (FWRVLS) worse than ?21.2% discriminates AL amyloidosis [area under the curve (AUC)?=?0.744)] from patients with IWT due to other aetiologies. In AL amyloidosis, FWRVLS is the strongest echocardiographic prognostic marker with AUC =0.722 and ?16.5% as the optimal cut-off value, beyond which overall mortality increases significantly. It is also the only independent echocardiographic predictor of overall mortality (HR =1.113; 95%CI 1.029–1.204; p?=?.007), even when adjusted to the Mayo stage and global left ventricular longitudinal strain.

Conclusions: FWRVLS should be considered in the diagnostic and prognostic workup in light-chain amyloidosis.     

二维应变成像评价酒精性心肌病右心室纵向功能的价值

目的：应用二维应变成像（2DSI）技术评价酒精性心肌病（ACM）右心室纵向功能的临床应用价值。方法：酒精性心肌病患者32例,正常对照组35例。对两组行常规超声参数及2DSI参数测定,收缩期参数包括：右心室游离壁基底段、中间段和心尖段收缩期的位移峰值（D）、收缩期应变峰值（S）、收缩期应变率峰值（SRs）;舒张期参数包括：舒张早期应变率峰值（SRe）、舒张晚期应变率峰值（SRa）。结果：常规超声参数比较,ACM组右心室前后径（RVEDd）与对照组比较明显增加（P〈0．05）,两组间右室射血分数（RVEF）无统计学差异。2DSI参数比较,ACM组D、S、SRs、SRe和SRa等参数与对照组比较均显著减低（P〈0．05,P〈0．01）。结论：2DSI可作为有效评价酒精性心肌病右心室纵向功能的一种无创性的新方法。     

Right ventricular strain and strain rate properties in patients with right ventricular myocardial infarction

BACKGROUND: This study was planned to assess strain and strain rate properties of right ventricle in patients with RV myocardial infarction. MATERIAL AND METHOD: Thirty patients with acute inferior myocardial infarction were included in this study. The presence of right ventricular infarction in association with an inferior myocardial infarction was defined by an ST-segment elevation 0.1 mV in lead V4 R. According to this definition, 15 patients had electrocardiographic signs of inferior myocardial infarction without right ventricular infarction (group I), and 15 patients had electrocardiographic signs of inferior myocardial infarction with right ventricular infarction (group II). Echocardiography was performed using a Vivid 5 System (GE Ultrasound; Horten, Norway) and a 2.5-MHz transducer. 2-dimensional color doppler myocardial imaging (CDMI) data for longitudinal function were recorded from the RV free wall using standard apical view. Offline analysis of the myocardial color Doppler data for regional velocity (V), strain rate (Sr), and strain (S) curves was performed using a special software program (EchoPac 6.4 Vingmed, Horten, Norway). They were assessed in basal, middle and apical segments of the RV. The differences between different groups were assessed with the Mann-Whitney U-test. A value of P < 0.05 was considered statistically significant. RESULTS: Systolic tissue velocity, strain, strain rate of basal (4.8 +/- 0.8 cm/s vs 6.5 +/- 1.2 cm/s, -12 +/- 3% vs -24 +/- 5%, 1.28 +/- 0.3/s vs -1.9 +/- 0.4/s; P < 0.001, <0.001, <0.001, respectively) and mid (4.2 +/- 0.5 cm/s vs 5.4 +/- 0.5 cm/s, -16 +/-3% vs -26 +/- 4%, -1.2 +/- 0.3/s vs -2.1 +/- 0.3/s; P < 0.001, <0.001, <0.001, respectively) segments of right ventricle were significantly lower in patients with RV infarction than in patients without RV infarction. There were no differences between groups for apical strain, strain rate, and systolic tissue velocity. CONCLUSION: This study demonstrates that right ventricular strain and strain rate were lower in patients with left ventricular inferior wall myocardial infarction with, compared to without, right ventricular infarction.     

Echocardiographic right and left ventricular measurements in male elite endurance athletes

Echocardiography was used to assess normal values in the rightand left ventricular cavity and wall in 127 male elite enduranceathletes. M-mode and two dimensional measurements of left ventricleand left and right atria were also obtained. All subjects werehigh-performance orienteers, cross-country skiers and middle-distancerunners. They all had a normal electrocardiogram at rest andno echocardiographic evidence of heart disease. With the use of multiple right ventricular cross-sections andtwo-dimensional measurements, we found a significantly greaterright ventricular inflow tract and right and left atrial measurementsin endurance athletes compared with earlier studies of normal,active subjects. The right ventricular free wall was slightlythicker than reported in normal active subjects but the differenceswere small. Left ventricular diastolic diameter was consistentwith previous reports of endurance athletes. Of the 127 subjects,13% had left ventricular wall thickness above 13 mm but noneof the athletes had wall thickness above 15 mm. These data suggestthat cardiac enlargement occurs symmetrically in both rightand left cavities, probably reflecting increased haemodynamicloading, a mechanism by which athletes sustain a high cardiacoutput during exercise.     

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.     

An abnormal right ventricular apical angle is indicative of global right ventricular impairment

The presence of right ventricular (RV) dysfunction is an adverse prognostic indicator but current echocardiographic methods have some limitations. RV apical angles in systole and diastole were correlated with known parameters of RV function in patients without pulmonary hypertension (Group 1) and in patients with pulmonary hypertension (Group 2). RV apical angles were significantly smaller in both systole (22 +/- 7 degrees) and diastole (33 +/- 6 degrees) in Group 1 patients when compared to Group 2 (54 +/- 18 degrees, p < 0.0001 and 59 +/- 17 degrees, p < 0.0001, respectively). RV apical angles, both in systole and diastole, were strongly correlated with RV end-systolic area (R = 0.89, p < 0.0001) and end-diastolic area (R = 0.81, p < 0.0001), respectively. Similarly, the apical systolic and diastolic angle correlated well with decreased tricuspid annular plane systolic excursion (TAPSE, R = -0.76 and R = -0.73, p < 0.001) as well as with decreased RV fractional area change (R = -0.81 and R = -0.77, p < 0.001). Therefore, we conclude that this new measurement of RV apical angle is simple and useful to quantify RV apical structural and functional abnormalities that are well correlated with global RV impairment in patients with chronic pulmonary hypertension.     

Impairment of left and right ventricular longitudinal strain in asymptomatic children with type 1 diabetes

AimThe relationship between type 1 diabetes (T1DM) and cardiac function in children is not well established. The purpose of this study was to investigate whether children and adolescents with T1DM present early asymptomatic abnormalities of left ventricular (LV) and right ventricular (RV) function. In addition, we evaluated the relationship of any such abnormalities with glycemic control and diabetes duration.MethodsThis was a prospective study. Standard echocardiography, tissue Doppler imaging, and two-dimensional strain analysis were performed prospectively in 52 children with T1DM. The results were compared with those from 52 healthy children matched for age and sex.ResultsThere were no significant differences between the two groups in LV ejection fraction or RV systolic function. There was a difference between the two study groups in transtricuspid flow: the E-wave and A-wave velocities were significantly higher in the diabetic group. Left ventricular global longitudinal strain (LV GLS) was significantly lower in children with T1DM (?20.01 ± 1.86% vs. ?22.99 ± 0.98%, respectively; P < .001), as was RV free-wall longitudinal strain (RV FWLS) (?29.13 ± 1.85% vs. ?30.22 ± 1.53%, respectively; P = .002). LV GLS was correlated with diabetes duration (r = 0.444, P < .001) and glycated hemoglobin (HbA1c) (r = 0.683, P < .001); however, no correlation was found between RV FWLS and HbA1c or diabetes duration.ConclusionsOur findings suggest that LV GLS and RV FWLS are impaired in children with T1DM and that the decrease in LV GLS is correlated with diabetes duration and HbA1c levels.     

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.     

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)