Evaluation of right ventricular function in early period following transcatheter closure of atrial septal defect

Aims: There is limited data on alterations in novel right ventricular (RV) function indices like tricuspid annular plane systolic excursion (TAPSE) and tricuspid annular systolic velocity (TASV) after transcatheter atrial septal defect (ASD) closure. We aimed to evaluate RV function by echocardiography (ECG) with these novel indices in early period in patients with secundum‐type ASD that was closed percutaneously. Methods: Patients were enrolled to study if they had secundum‐type ASD that was suitable for percutaneous closure. Patient population consisted of 4 men and 16 women. Echocardiography was performed before and 1 month after closure. Results: Mean age was 37 ± 16. Mean diameter of ASD and total atrial septum length measured by ECG were 19 ± 6 mm and 49 ± 7 mm, respectively. Mean diameter of defect in transesophageal echocardiography was 20 ± 6 mm. Stretched mean diameter in catheterization was 23 ± 6 mm. One month after closure, there were statistically significant decreases in RV end‐diastolic diameters (43.3 ± 10.7 mm vs. 34.9 ± 5.5 mm; P < 0.001), RV/left ventricular (LV) end‐diastolic diameter ratio (1.1 ± 0.3 vs. 0.87 ± 0.1; P < 0.001), TASV (16.9 ± 3.2 cm/sec vs. 14.3 ± 3.3 cm/sec; P < 0.05), early diastolic tricuspid annular velocity (15.3 ± 3.1 cm/sec vs. 13.4 ± 2.4 cm/sec P <0.05), late diastolic tricuspid annular velocity (16.2 ± 5.4 cm/sec vs. 14.3 ± 6.3 cm/sec; P < 0.05), and TAPSE (29.9 ± 6.2 mm vs. 22.4 ± 7.4 mm; P < 0.001). LV end‐diastolic diameter (38.0 ± 6.9 mm and 40.0 ± 4.5 P < 0.05) was increased, whereas there was no change in LV ejection fraction. Conclusion: Closure of ASD by using Amplatzer devices led to decrease in right heart chamber size, tissue Doppler–derived tricuspid annular velocities and TAPSE in early period. (Echocardiography 2012;29:358‐362)     

Right Ventricular Function in Adult Patients with Eisenmenger Physiology: Insights from Quantitative Echocardiography

Background: The favorable outcomes of Eisenmenger syndrome (ES) relative to other forms of pulmonary arterial hypertension (PAH) have been partially attributed to a unique adaptation of the right ventricle (RV). However, conventional measures of RV function may not adequately express this adaptation. Methods: We studied 23 patients with ES (age 43 ± 17 years, 16 women, pulmonary artery systolic pressure [PASP] 93 ± 26 mmHg), 25 patients with PAH (age 44 ± 13 years, 17 women, PASP 92 ± 19 mmHg), and 25 subjects without known structural disease (age 45 ± 16 years, 17 women). We evaluated long‐ and short‐axis function of the RV with two‐dimensional strain and anatomical M‐mode echocardiography, respectively. Results: Long‐axis function of the RV was comparable between patients with ES and PAH although depressed relative to controls (global strain, ?15.6 ± 4.7, ?14.9 ± 4.3, and ?22.4 ± 2.8%, respectively, P < 0.001; global RV systolic strain rate, ?0.77 ± 0.26, ?0.84 ± 0.24, and ?1.11 ± 0.21 1/sec, respectively, P < 0.001). However, short‐axis RV function was significantly better in patients with ES versus those with PAH and preserved relative to controls (RV fractional shortening by anatomical M‐mode, median [interquartile range], 21%[14–33%], 14%[10–16%], and 26%[22–36%], respectively, P = 0.002 for ES vs. PAH, P = 0.09 for ES vs. controls). This differential was not reflected in conventional measures of RV function (fractional area change, 32 ± 10 vs. 29 ± 8% in ES and PAH, respectively, P = 0.26). Conclusion: In patients with ES, the RV is characterized by preserved short‐axis function, despite a depressed long‐axis function. Thus, conventional assessment of RV function might not be suitable for patients with ES. (Echocardiography 2010;27:937‐945)     

Right ventricular function in patients presenting with non-ST-segment elevation myocardial infarction undergoing an invasive approach

Background

Right ventricular involvement in ST segment elevation myocardial infarction (STEMI) entails an increased morbidity and mortality. However, very scarce data is present on its affection in the setting of non-ST segment elevation myocardial infarction (NSTEMI).

Feasibility of three-dimensional transthoracic echocardiography to evaluate right ventricular volumes in children and comparison to left ventricular values

Background: Three‐dimensional echocardiography (3DE) allows accurate estimation of left ventricular (LV) volumes and function in children. Because of the peculiar morphology of the right ventricle (RV), RV volumes and function assessment remain challenging. 3D software adapted for RV morphology is a promising noninvasive method. Aims: The aims of this study were to evaluate the feasibility of 3D RV analysis in a normal pediatric population and to compare 3D RV to 3D LV measurements. Patients and methods: 3D transthoracic echocardiography was performed in 50 patients (mean age 9.5 years ± 5.1) with normal cardiac anatomy and function. Measurements were performed with the X3‐1 or the X7‐2 matrix probe (iE33, Philips Medical Systems, Andover, MA, USA). Ventricular volumes were analyzed with dedicated analysis software (TomTec Imaging Systems, Munich, Germany). Results: Measurements were possible in 100% of LVs and 94% of RVs. The stroke volumes of the two ventricles correlated well (r = 0.81 [95% CI, 0.68–0.89], P < 0.0001) with a mean difference of 3.6 mL (±9.2). Compared to the LV, the RV had higher mean end‐diastolic volume (53 mL [±29] versus 46 mL [±46], P = 0.020) and end‐systolic volume (29 mL [±17] versus 17 mL [±12], P < 0.0001) but lower mean ejection fraction (49%[±8] versus 67%[±10], P < 0.0001). Conclusion: 3DE using dedicated software is a feasible and reproducible method for RV volume quantification in children with normal hearts. Further studies are needed to validate the accuracy of the measurements. (Echocardiography 2012;29:492‐501)     

The impact of right ventricular function assessed by 2‐dimensional speckle tracking echocardiography on early mortality in patients with inferior myocardial infarction

Background

Right ventricular (RV) involvement in inferior myocardial infarction (MI) increases in‐hospital morbidity and mortality.

Hypothesis

RV systolic dysfunction assessed by 2‐dimensional speckle tracking echocardiography (STE) might be a predictor of early mortality in patients with acute inferior MI.

Methods

Eighty‐one consecutive patients with acute inferior MI (mean age, 60.8 ± 12.7 years; 18 females) were included. RV myocardial involvement was defined as an elevation >1 mm in V₁ or V₄R within 12 hours of symptom onset. RV function was assessed by STE. Patients were followed for 30 days for all‐cause mortality.

Results

Thirty‐eight patients had RV myocardial involvement, and they had significantly lower tricuspid annular plane systolic excursion (TAPSE), tricuspid annular systolic velocity (RVS), and left ventricular (LV) and RV global longitudinal strain (GLS). Nine patients (11%) died within 30 days. The mean age of mortality group was higher with more female frequency. They had significantly higher pro‐BNP, hs‐troponin T, and creatinine levels, but lower hemoglobin levels. TIMI 3 flow was significantly less achieved in mortality group. RV myocardial involvement was more frequent in the mortality group, and they had significantly lower TAPSE, RVS, and LV and RV GLS. Multivariate analysis revealed that age and RV GLS were independent predictors of early mortality. RV GLS ≤ –14% predicted early mortality in patients with acute inferior MI with a sensitivity of 88.9% and a specificity of 62.5% (AUC: 0.817, P = 0.002).

Conclusions

RV GLS may be useful in predicting early mortality in patients with acute inferior MI.     

Right ventricular hypertrophy causes impairment of left ventricular diastolic function in the rat

Right ventricular (RV) pressure overload causes right ventricular hypertrophy in several types of pulmonary and congenital heart diseases. The associated cardiac dysfunction has generally been attributed to alterations in RV function. However, due to global neurohormonal adaptations and mechanical ventricular interaction left ventricular (LV) function could be affected as well.Therefore,LV function, RV function and their interaction were studied in rats with monocrotaline (MCT)-induced RV hypertrophy and control rats. MCT (30 mg/kg) was used to induce pulmonary hypertension, which resulted, after 28 days, in marked RV hypertrophy (RV-weight: control 220 ± 15,MCT 437 ± 34mg,p < 0.05). In Langendorff-perfused hearts with balloons inserted in both the LV and the RV, the diastolic pressure-volume relations showed increased stiffness, and relaxation was prolonged in the LV and RV in the MCT group compared to controls. In the MCT group, developed pressures were increased only in the RV. An increase of LV volume increased RV diastolic pressure to a similar extent in both groups. However, an increase in RV volume did not affect LV diastolic pressure in controls, but significantly increased LV diastolic pressure in the MCT group. LV and RV developed pressure-volume relations were not affected. Calculated circumferential end-diastolic wall stresses (σ) were larger in the MCT group (LV-σ: 0.55 ± 0.02, RV-σ: 1.94 ± 0.30 kN/m², both p< 0.05 to control) compared to controls (LV-σ: 0.34 ± 0.06,RV-σ: 1.23 ± 0.46 kN/m2). In the MCT group, collagen content was increased in the LV, septum and RV compared to controls. In conclusion, structural changes of the RV and LV result in depressed LV diastolic function during RV hypertrophy.     

Two‐Dimensional Longitudinal Strain and Strain Rate Imaging for Assessing the Right Ventricular Function in Patients with Mitral Stenosis

Background: Longitudinal two‐dimensional strain (L2DS) deformation is a novel technique that evaluates global and regional right ventricular (RV) function. The aim of the study was to investigate the systolic function of RV by using this method in patients with pure mitral stenosis (MS). Methods: Conventional echocardiography and L2DS analysis were performed in 45 MS patients and 21 healthy controls. For strain analysis apical four‐chamber views were obtained and by using a software system, peak systolic strain and strain rates were calculated off‐line in each segment. Results: The mean global longitudinal strain (GLS) of the whole RV (?20 ± 7 vs. ?24 ± 6%, P= 0.02) and mean GLS of the septum (?19 ± 7 vs. ?23 ± 5%, P = 0.03) were significantly reduced in the MS patients. Compared with the control group no significant change was determined in the mean GLS of the RV free wall (RVFW). While the mean global longitudinal strain rates (GLSR) of the entire RV and RVFW were similar between the groups, a significant difference in the mean GLSR of the septum (?1.2 ± 0.4 vs. ?1.5 ± 0.3 s^?1, P= 0.005) was determined in the patients with MS. A regional analysis demonstrated that MS patients had significantly reduced strain and strain rates in the basal and mid‐segments of the septum, whereas only lower strain values in the basal RVFW. Conclusions: RV systolic function evaluated by L2DS analysis in patients with MS has shown decreased global and segmental systolic functions. (ECHOCARDIOGRAPHY 2010;27:525‐533)     

Comparison of valvar and right ventricular function following transcatheter and surgical pulmonary valve replacement

Objective

Trans‐catheter (TC) pulmonary valve replacement (PVR) has become common practice for patients with right ventricular outflow tract obstruction (RVOTO) and/or pulmonic insufficiency (PI). Our aim was to compare PVR and right ventricular (RV) function of patients who received TC vs surgical PVR.

Design

Retrospective review of echocardiograms obtained at three time points: before, immediately after PVR, and most recent.

Patients

Sixty‐two patients (median age 19 years, median follow‐up 25 months) following TC (N = 32) or surgical (N = 30) PVR at Yale‐New Haven Hospital were included.

Outcome Measures

Pulmonary valve and right ventricular function before, immediately after, and most recently after PVR.

Results

At baseline, the TC group had predominant RVOTO (74% vs 10%, P < .001), and moderate‐severe PI was less common (61% vs 100%, P < .001). Immediate post‐procedural PVR function was good throughout. At last follow‐up, the TC group had preserved valve function, but the surgical group did not (moderate RVOTO: 6% vs 41%, P < .001; >mild PI: 0% vs 24%, P = .003). Patients younger than 17 years at surgical PVR had the highest risk of developing PVR dysfunction, while PVR function in follow‐up was similar in adults. Looking at RV size and function, both groups had a decline in RV size following PVR. However, while RV function remained stable in the TC group, there was a transient postoperative decline in the surgical group.

Conclusions

TC PVR in patients age <17 years is associated with better PVR function in follow‐up compared to surgical valves. There was a transient decline in RV function following surgical but not TC PVR. TC PVR should therefore be the first choice in children who are considered for PVR, whenever possible.     

The Right Ventricular Response to High Afterload: Comparison between Healthy Persons and Patients with Transposition of the Great Arteries: A 2D Strain Study

Objective: To evaluate the contraction pattern of the systemic right ventricle (RV) in comparison to healthy controls. Methods: 31 patients (14 female, mean age 21.5 ± 3.3 years) with congenital corrected (ccTGA) and surgical corrected (D‐TGA) TGA and 31 age‐matched healthy controls (17 female, mean age 23.1 ± 2.6 years) were included in the study. We compared the contraction pattern of the systemic RV with findings in the right and left ventricle (LV) of healthy controls. Echocardiograms were performed for all patients (19.3 ± 2.5 years after the operation) and all healthy controls. Using a novel computer software (GE Ultrasound, Horton, Norway) that allows automatic frame‐by‐frame tracking of accoustic markers during the heart cycle longitudinal and circumferential strain and strain rate were defined as parameters of myocardial deformation. Results: In the systemic free RV wall, circumferential strain was greater than longitudinal strain (?25.6 ± 4.2% vs. ?15.2 ± 3.9%, P < 0.001), opposite to the contraction pattern of the subpulmonary free RV wall (?17.7 ± 4.1% vs. ?28.3 ± 3.3%, P < 0.001). Compared with controls, segmental analysis of the free RV wall resulted in lower systolic longitudinal and higher systolic circumferential strain and strain rate values. In the free LV wall, circumferential strain was lower than longitudinal strain (?19.1 ± 2.7% vs. ?26.8 ± 4.5%, P < 0.001) in contrast to the data in the systemic free LV wall (?24.5 ± 3.1% vs. ?16.7 ± 3.5%, P < 0.001). Conclusions: Myocardial deformation parameters were significantly different in systemic and normal RV indicating a dependency of myocardial deformation parameters on right ventricular afterload. The use of myocardial deformation imaging identified a shift from longitudinal to circumferential contraction pattern in the systemic RV in comparison to the LV. This might demonstrate a response to the systemic load creating a myocardial hypertrophy. (Echocardiography 2010;27:1256‐1262)     

A soluble guanylate cyclase stimulator,BAY 41-8543, preserves right ventricular function in experimental pulmonary embolism

Pulmonary embolism (PE) increases pulmonary vascular resistance, causing right ventricular (RV) dysfunction, and poor clinical outcome. Present studies test if the soluble guanylate cyclase stimulator BAY 41-8543 reduces pulmonary vascular resistance and protects RV function. Experimental PE was induced in anesthetized, male Sprague–Dawley rats by infusing 25 μm polystyrene microspheres (1.95 million/100 g body wt, right jugular vein) producing moderate PE. Pulmonary artery vascular resistance, estimated as RVPSP/CO, increased 3-fold after 5 h of PE. Treatment with BAY 41-8543 (50 μg/kg, I.V.; given at the time of PE induction) normalized this index by reducing RVPSP and markedly increasing CO, via preservation of heart rate and stroke volume. Ex vivo RV heart function showed minimal changes at 5 h of PE, but decreased significantly after 18 h of PE, including peak systolic pressure (PSP, Control 39 ± 1 mmHg vs. 19 ± 3 PE), +dP/dt (1192 ± 93 mmHg/s vs. 444 ± 64) and ?dP/dt (?576 ± 60 mmHg/s vs. ?278 ± 40). BAY 41-8543 significantly improved all three indices of RV heart function (PSP 35 ± 3.5, +dP/dt 1129 ± 100, ?dP/dt ?568 ± 87). Experimental PE produced increased PVR and RV dysfunction, which were ameliorated by treatment with BAY 41-8543. Thus, there is vasodilator reserve in this model of experimental PE that can be exploited to reduce the stress upon the heart and preserve RV contractile function.     

Echocardiographic Evaluation of Right Ventricular Function in Patients with Acute Pulmonary Embolism: A Study Using Tricuspid Annular Motion

Assessment of right ventricular (RV) function is a challenge due to complex anatomy. We studied systolic and diastolic tricuspid annular excursion and longitudinal RV fractional shortening as geometry‐independent measures in patients with acute pulmonary embolism (PE). Forty patients with PE were studied within 24 hours after admission and after 3 months, and compared to 23 healthy subjects used as controls. We recorded tricuspid annular plane systolic (TAPSE) and diastolic (TAPDE) excursion from the four‐chamber view and calculated RV fractional shortening as TAPSE/RV diastolic length. The diastolic RV function was defined as the ratio of the amplitude of tricuspid annular plane excursion during atrial systole to total tricuspid annular plane diastolic excursion (atrial/total TAPDE). In the acute stage, the TAPSE was decreased in PE compared to healthy subjects (19 ± 5 vs. 26 ± 4 mm, P < 0.001), with greater reduction in patients with increased, compared to normal, RV pressure (16.6 ± 5 vs. 20.5 ± 5 mm, P < 0.05). The atrial/total TAPDE was increased in patients compared to healthy subjects (47 ± 13% vs. 38 ± 7%, P < 0.001) and normalized during the follow‐up. Although the patients were asymptomatic after 3 months, the TAPSE recovered incompletely as compared to healthy subjects (21.4 ± 4 vs. 26 ± 4 mm, P < 0.001). Both systolic and diastolic RV function are impaired in acute PE. Diastolic function recovers faster than systolic; therefore, the atrial contribution to RV filling may be a useful measure to follow changes in diastolic function in PE. (Echocardiography 2010;27:286‐293)     

Ventricular tachycardia ablation in arrhythmogenic right ventricular cardiomyopathy patients with TMEM43 gene mutations

1 Introduction

Catheter ablation of VT in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) is often challenging, frequently requiring multiple or epicardial ablation procedures; TMEM43 gene mutations typically cause aggressive disease. We sought to compare VT ablation outcomes for ARVC patients with and without TMEM43 mutations.

2 Methods

Patients with prior ablation for ARVC‐related VT were reviewed. Demographic, procedural, and follow‐up data were reviewed retrospectively. Patients with confirmed TMEM43 gene mutations were compared to those with other known mutations or who had no known mutations.

3 Results

Thirteen patients (10 male, mean age 49 ± 14 years) underwent 29 ablation procedures (median 2 procedures/patient, range 1–6) with a median of 4 targeted VTs/patient (range 1–9). They were followed for a mean duration of 7.3 ± 4.2 years. Gene mutations included TMEM43 (n = 5), PKP2 (n = 2), DSG2 (n = 2), unidentifiable (n = 4). TMEM patients showed more biventricular involvement compared to non‐TMEM patients (80% vs. 12.5%, P = 0.032), more inducible VTs during their ablation procedures (mean VTs/patient: 5.8 ± 3 vs. 2.6 ± 1, P = 0.021). Acute and long‐term procedural outcomes did not show a significant difference between the two groups, however TMEM patients had worse composite endpoint of death or transplantation (60% vs. 0, P = 0.035; log‐rank P = 0.013).

4 Conclusions

TMEM43 mutation patients were more likely to have biventricular arrhythmogenic substrate and more inducible VTs at EP study. Despite comparable acute VT ablation outcomes, long‐term prognosis is unfavorable.     

Frequency,Time Course,and Possible Causes of Right Ventricular Systolic Dysfunction after Cardiac Transplantation: A Single Center Experience

Background: The frequency and causes of right ventricular (RV) systolic dysfunction early after cardiac transplantation are not well defined. Methods: We investigated the prevalence and causes of RV dysfunction in 27 heart transplant recipients, as measured by lateral tricuspid annular plane excursion (TAPSE) and fractional area change (FAC) at a mean of 15 ± 11 days after transplant. Tissue Doppler imaging was used to assess systolic time velocity integral (TVI) of the RV basal free wall. A subset of 22 patients had follow‐up TAPSE measurement at 406 ± 121 days. Results: RV systolic dysfunction, defined as TAPSE > 2 standard deviation (SD) below values in a control group, was present in 100% (27/27) of patients (P < 0.05). FAC was also significantly lower in patients compared with controls (P < 0.0001). TVI confirmed the presence of RV dysfunction in all 16 patients with both TAPSE and TVI (P < 0.05). Ischemic time (P = 0.017) and posttransplant tricuspid regurgitation (P = 0.024) were independent predictors of early RV dysfunction (r = 0.753). On follow‐up, RV function improved in 15 of 22 patients but all patients remained with TAPSE > 2 SD below controls. Conclusion: This study showed that 100% of patients had reduced RV function early after transplant. Two thirds of patients had partial recovery of RV function during the first year. In all patients, however, RV function remained significantly lower than in controls.     

Right ventricular scar‐related ventricular tachycardia in nonischemic cardiomyopathy: Electrophysiological characteristics,mapping, and ablation of underlying heart disease

1 Background

Right ventricular (RV)‐scar related ventricular tachycardia (VT) is often due to arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) or cardiac sarcoidosis (CS), but some patients whose clinical course has not been described do not fulfill diagnostic criteria for these diseases. We sought to characterize the electrophysiologic substrate and catheter ablation outcomes of such patients, termed RV cardiomyopathy of unknown source (RCUS).

2 Methods and results

Data of 100 consecutive patients who presented with RV cardiomyopathy and/or RV‐related VT for ablation were reviewed (51 ARVC/D, 22 CS; 27 RCUS). Compared to ARVC/D, RCUS patients were older (P = 0.001), less commonly had RV dilatation (P = 0.001) or dysfunction (P = 0.01) and fragmented QRS, parietal block, and T‐wave inversion. Compared to CS, R‐CUS patients had less severe LV dysfunction. Extent and distribution of endocardial/epicardial scar and inducible VTs in RCUS patients were comparable with ARVC/D and CS patients. At a median follow‐up of 23 months, RCUS patients had more favorable VT‐free survival (RCUS 71%, ARVC/D 60%, CS 41%, P = 0.03) and survival free of death or cardiac transplant (RCUS 92%, ARVC/D 92%, CS 62%, P = 0.01). No RCUS patients developed new criteria for ARVC/D or CS in follow‐up.

3 Conclusions

Up to one‐third of patients with RV scar‐related VT are not classifiable as ARVC/D or CS. These patients had a somewhat better prognosis than ARVC/D or sarcoid and did not develop evidence of these diseases during the initial 2 years of follow‐up. The extent to which this population comprises mild ARVC/D, CS, or other diseases is not clear.     

Three‐Dimensional Speckle Tracking Echocardiography–Derived Left Atrial Strain Parameters Are Reduced in Patients with Atrial Fibrillation (Results from the MAGYAR‐Path Study)

Objective: Three‐dimensional (3D) speckle tracking echocardiography (3DSTE) is a novel imaging modality for assessing cardiac function. We aimed to analyze left atrial (LA) function using 3DSTE in patients with atrial fibrillation (AF). Methods: 3DSTE was performed in 20 patients prior to their pulmonary vein isolation for AF. Every patient underwent a complete two‐dimensional echocardiographic study at the same time. 3DSTE‐derived circumferential (CS), longitudinal (LS), radial (RS), 3D (3DS), and area strain (AS) values were measured in the basal (b), mid (m), and superior (s) regions of the LA. 3DSTE‐defined maximal (LA_max) and minimal LA volumes (LA_min) and LA total emptying fraction were calculated automatically. Eleven randomly selected age‐ and gender‐matched healthy volunteers served as controls. Results: Patients with AF had significantly larger LA_max and LA_min and reduced LS, RS and CS.3DS and AS were significantly lower throughout the LA in cases with AF (3DS?b, ?m, ?s [AF patients vs. controls]: ?18 ± 8% vs. ?29 ± 8%, P = 0.001; ?14 ± 6% vs. ?22 ± 7%, P = 0.002; ?10 ± 7% vs. ?20 ± 9%, P = 0.002; AS?b, ?m, ?s [AF patients vs. controls]: 35 ± 15% vs. 52 ± 13%, P = 0.004; 50 ± 21% vs. 72 ± 19%, P = 0.009; 31 ± 21% vs. 65 ± 27%, P < 0.0001, respectively). Conclusions: 3DSTE‐derived “uni‐dimensional” LS, RS, CS, as well as novel strain parameters (3DS, AS) are significantly reduced in patients with AF compared to matched controls. 3DS and AS might be new strain parameters providing further insights into the alterations of LA function in patients developing AF.     

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)     

Abnormalities of right ventricular long axis function after atrial repair of transposition of the great arteries

BACKGROUND—While volume derived global indices of right ventricle (RV) function are frequently abnormal after the Mustard procedure, the mechanism for these abnormalities is poorly understood. RV muscle fibres are predominantly arranged longitudinally and thus indices derived in the long axis may better describe RV function.
METHODS—20 survivors of the Mustard operation were studied (age 7.8-37.3 years, median 14.2 years). Long axis recordings from the apical four chamber view were obtained with the M mode cursor positioned through the lateral angle of the tricuspid valve annulus. M mode traces were recorded on paper and later digitised to derive total atrioventricular ring excursion, peak lengthening rate, and peak shortening rate. These data were averaged and compared with control data for the normal RV and left ventricle (LV).
RESULTS—RV total atrioventricular ring excursion was lower than that for the RV (p < 0.0001) or LV (p < 0.005) of controls. Peak lengthening rate was lower than the normal RV (p < 0.0001) and LV (p < 0.0001) rates. Furthermore, peak shortening rate was less than that of normal RV (p < 0.0001) and normal LV (p < 0.005) controls.
CONCLUSION—Systemic RV long axis function is notably reduced compared with that of either the normal subpulmonary RV or the systemic LV. This presumably reflects the response of the predominantly longitudinally arranged myocardial fibres to increased afterload. However, such measurements may provide a more sensitive marker for progressive changes in global function during long term follow up.


Keywords: Mustard procedure; right ventricular function; transposition of the great arteries     

Right Ventricular Systolic and Diastolic Function as Assessed by Speckle-Tracking Echocardiography Improve With Prolonged Isolated Left Ventricular Assist Device Support

BackgroundRight ventricular (RV) failure is a major cause of morbidity and mortality after left ventricular assist device (LVAD) implantation. Whether RV function deteriorates with prolonged LVAD support is unknown. Speckle-tracking echocardiography provides a sensitive, noninvasive, reproducible, and quantitative assessment of RV systolic and diastolic function.MethodsEchocardiograms were retrospectively reviewed from before and after implantation of a Heartmate II LVAD. Speckle-tracking analysis was performed to measure RV longitudinal systolic strain, strain rate, and diastolic strain rate for each patient at baseline and over discrete time periods after LVAD implantation.ResultsSeventeen patients were included in the analysis, with an average follow-up after LVAD implantation of 234 ± 125 days. RV systolic strain improved in 15 patients, decreasing from −7.4 ± 2.3% to −9.7 ± 3.3% after LVAD (P = .026). Systolic strain rate improved in 11 patients, decreasing from −0.67 ± 0.25%/s to −0.96 ± 0.36%/s (P = .011). RV diastolic strain rate improved in 12 patients, increasing from 0.70 ± 0.33%/s to 1.02 ± 0.40%/s (P = .016).ConclusionsChronic LVAD support improves RV systolic and diastolic function in LVAD patients who did not require an RV assist device. Speckle-tracking echocardiography may offer a noninvasive technique for identifying and monitoring improvements in RV function in LVAD patients.     

Preoperative Right Ventricular Function in Patients with Organic Mitral Regurgitation

Aims: To assess the right ventricular (RV) function in patients with severe mitral regurgitation (MR); to find a relation between preoperative and postoperative parameters. Methods: RV function was echocardiographically assessed by determining the tricuspid annular plane systolic excursion (TAPSE) and the peak systolic velocity of the lateral tricuspid annulus (Sa) in 45 patients with severe organic MR (53.3% men, age 58 ± 10 years). Mean NYHA class was 2.6 ± 0.4, LVEF was 55.3 ± 12%, RV end‐diastolic diameter was 28.7 ± 4.7, left ventricular end‐systolic diameter (LVESD) was 44.6 ± 12.6 mm, and LV end‐diastolic volume (Simpson) was 160.6 ± 50.3 ml. All patients underwent mitral valve replacement with posterior chordal sparing. Results: Mean preoperative TAPSE and Sa were 19.4 ± 4.3 mm and 10.3 ± 3 cm/sec, respectively. RV dysfunction, defined as TAPSE < 22 mm, had 66.6% of the patients, and Sa < 11 cm/sec was found in 62.2% of the patients preoperatively. Preoperative TAPSE and Sa were significantly correlated (P < 0.00001, r = 0.61). Both TAPSE and Sa were correlated with the RV end‐diastolic diameter (P < 0.01), LVESD (P < 0.05) left ventricular dp/dt (P < 0.05), and LVEF (P < 0.0001). Postoperative LVEF was 50% (P < 0.001), Sa 5.3 ± 2 cm/sec (P < 0.001), and TAPSE 8.7 ± 3.2mm (P < 0.001). Twenty‐one patients (46.6%) reached the study end point of decrease of LVEF by more than 10%. Univariate predictors were age (P = 0.04), male gender (P = 0.01), TAPSE (P = 0.007), and Sa (P = 0.009), while a trend was found for regurgitation fraction (P = 0.058) and LV end‐diastolic volume index (P = 0.09). By multivariate analysis, TAPSE (P = 0.01) and Sa (P = 0.01) were predictive for the study end point. Conclusion: The assessment of the RV function by echocardiography is a simple tool that provides prognostic information in patients with MR. (Echocardiography 2010;27:282‐285)     

Strain imaging in morbid obesity: insights into subclinical ventricular dysfunction

Background:

Obesity has become an important health problem throughout the world. Early detection of cardiovascular abnormalities may be useful in the future for patient management. This study aimed to identify subclinical ventricular dysfunction in obese patients.

Hypothesis:

Morbid obesity is associated with ventricular dysfunction.

Methods:

Doppler echocardiogram was performed in 92 morbidly obese and in 31 healthy controls. Conventional echocardiography and tissue Doppler‐based strain imaging were used to analyze ventricular function. Intra‐ and interobserver strain imaging variabilities were tested on 15 randomly selected cases.

Results:

Left ventricular (LV) global strain (22.5% ± 3.5 vs 24.4% ± 2.5, P<0.005) and right ventricular (RV) strain (25.8% ± 5.2 vs 28.2% ± 5.2, P<0.029) were lower in obese patients when compared with healthy controls. Echocardiographic parameters of diastolic function were also different from controls. LV strain correlated with LV mass, E/e′ ratio, left atrial volume, and RV strain. At multivariate analysis, morbid obesity remained a significant determinant of global LV strain, independently of associated comorbidities.

Conclusions:

These findings suggest that incipient biventricular dysfunction is present in morbidly obese patients when new echocardiographic indices are used to investigate ventricular function. In addition, strain imaging may provide a more accurate assessment of the ventricular function in obese patients. © 2011 Wiley Periodicals, Inc. This work was supported by grants from CNPq and FAPEMIG. The authors have no other funding, financial relationships, or conflicts of interest to disclose.