Early impairment of myocardial function in systemic sclerosis: non-invasive assessment by Doppler myocardial and strain rate imaging.

BACKGROUND: Aim of the present study was to analyze both left (LV) and right ventricular (RV) myocardial function in patients with Systemic Sclerosis (SSc), and their relation to other instrumental features of the disease. METHODS AND RESULTS: Twenty-five healthy subjects and 23 age- and sex-comparable asymptomatic patients classified as having either diffuse (11 patients) or limited form (12 patients) of SSc underwent clinical examination, serological tests, high-resolution chest-CT, standard Doppler echo, pulsed Doppler myocardial imaging (DMI) and strain rate imaging (SRI) of both LV and RV lateral walls. By chest-CT, 11 patients showed interstitial pulmonary fibrosis. Serological antibodies analysis detected anti-centromere pattern in 8 patients, and anti Scl-70 in 15 patients. LV diameters and ejection fraction were comparable between the two groups, while RV end-diastolic diameter was increased in SSc (p<0.01). Tricuspid inflow E/A ratio was slightly decreased in SSc (p<0.01), while systolic pulmonary pressure was increased (p<0.001). Pulsed DMI detected in SSc impaired myocardial RV early-diastolic (Em) peak velocity (p<0.0001), and prolonged myocardial time intervals at tricuspid annulus level. In SSc, peak systolic RV SR and strain were both reduced in basal, middle and apical RV lateral free walls, and in basal and middle LV lateral walls. By multivariate analysis, independent inverse association of RV peak Em velocity with both Rodnan Skin Score (p<0.0005) and pulmonary systolic pressure (p<0.0001), as well as independent inverse correlation of the same RV peak Em velocity with pulmonary fibrosis (<0.0005) in SSc patients were observed. In addition, RV Em was an independent predictor of the anti Scl-70 antibody pattern (p<0.001). CONCLUSIONS: Pulsed DMI and SRI are valuable non-invasive and easy-repeatable tools for detecting RV and LV myocardial involvement caused by SSc, and may therefore be useful to early identify patients with more diffused and severe form of SSc.     

Is There Any Relationship between Metabolic Parameters and Left Ventricular Functions in Type 2 Diabetic Patients without Evident Heart Disease?

Background: The aim of the present study was to evaluate left ventricle (LV) systolic and diastolic function, using tissue Doppler echocardiography (TDE) and color M-mode flow propagation velocity, in relation to blood glucose status in normotensive patients with type 2 diabetes mellitus (T2DM) who had no clinical evidence of heart disease. Methods: Seventy-two patients with T2DM (mean age 49.1 ± 9.8 years) without symptoms, signs or history of heart disease and hypertension, and 50 ages matched healthy controls (mean age 46.1 ± 9.8 years) had echocardiography. Systolic and diastolic LV functions were detected by using conventional echocardiography, TDE and mitral color M-mode flow propagation velocity (V_E). Fasting blood glucose level (FBG) after 8 hours since eating a meal, postprandial blood glucose level (PPG), and HbA_1C level were determined. The association of FBG, PPG and HbA_1C with the echocardiographic parameters was investigated. Results: It was detected that although systolic functions of two groups were similar, diastolic functions were significantly impaired in diabetics. No relation of FBG and PPG with systolic and diastolic functions was determined. However, HbA_1C was found to be related to diastolic parameters such as E/A, Em/Am, V_E and E/V_E (β=−0.314, P = < 0.05; β=–0.230, P < 0.05; β=–0.602, P < 0.001, β= 0.387, P < 0.005, respectively). In addition to HbA_1C, LV, diastolic functions were also correlated with age and diabetes duration. Conclusion: Diastolic LV dysfunction may develop even in absence of ischemia, hypertension, and LVH in T2DM. FBG and PPG have no effect on LV functions, but HbA_1C levels may affect diastolic parameters.     

Early Diagnosis of Right Ventricular Systolic Dysfunction by Tissue Doppler-Derived Isovolumic Myocardial Acceleration in Patients with Chronic Obstructive Pulmonary Disease

Objectives: The aim of the study was to assess validity of tissue Doppler imaging (TDI)-derived right ventricular (RV) myocardial systolic velocities in early detection of RV systolic dysfunction in chronic obstructive pulmonary disease (COPD). Methods: Ninety COPD patients (50 pure COPD and 40 with right heart failure [RHF]) and 40 controls were enrolled. Respiratory function tests, conventional echocardiographic parameters, and TDI-derived isovolumic myocardial acceleration (IVA), peak myocardial velocity during isovolumic contraction (IVV), peak velocity during systolic ejection (Sa) were measured. Results: All the TDI-derived RV systolic velocities were impaired in COPD (P = 0.0001) compared to controls. IVA was the only parameter that could distinguish the patients with pure COPD and COPD with RHF (P = 0.0001). IVA was found to be significantly correlated with FEV1 (r = 0.41, P = 0.0001), FEV1/FVC (r = 0.43, P = 0.0001), pulmonary artery pressure (r =−0.34, P = 0.001), pulmonary flow acceleration time (r = 0.48, P = 0.0001), and tricuspid annular systolic excursion (r =−0.41, P = 0.0001). In addition, IVA ≤ 2.7 m/sec² was able to predict COPD patients from controls with 81% sensitivity, 98% specificity and IVA ≤ 1.9 m/sec² predicted COPD patients accompanied by RHF with 82% sensitivity, 77% specificity from patients without RHF. Conclusions: TDI-derived RV IVA is a novel, noninvasive echocardiographic index which may be used in the assessment of subclinical RV dysfunction in patients with COPD.     

Right Ventricular Adaptations Along with Left Ventricular Remodeling in Older Athletes

Background: Afterload changes and anatomic interaction between the ventricles cause right ventricle (RV) adaptation along with left ventricle (LV) remodeling. This study was designed to evaluate RV adaptations along with LV remodeling and to determine the effect of aging on both ventricles in a population of older athletes. Methods: Echocardiographic characteristics of 48 endurance trained older athletes were examined by tissue Doppler imaging (TDI) and integrated backscatter (IBS). Results: Mean LV mass index was calculated as 107.8 ± 17.0 g/m² . Twenty-two athletes were > 55 years old. Age was found to be a risk factor for diastolic dysfunction regarding lateral TDI velocities (E_m < A_m) (r = 0.385, P < 0.001). RV long-axis (LAX) diameters were associated with LA volumes and LV masses (r = 0.380, P < 0.01 and r = 0.307, P < 0.05). RV LAX diameters were correlated with RV TDI E-wave (r =−0.285, P < 0.05), RV LAX average, and peak IBS values (r = 0.36, P < 0.05 and r = 0.348, P < 0.05). Conclusions: TDI and IBS are applicable methods to evaluate the relationship between the two ventricles in athletes' heart. Increased RV LAX IBS values indicate increased LV mass and LA volume as a result of RV changes along with LV remodeling. Our data suggest that RV TDI E-wave and average RV IBS values reflect cardiac adaptations of both RV and LV in older athletes.     

Evaluation of Hemodynamic Determinants of Quantitative Tissue Doppler Echocardiography in the Assessment of Left Ventricular Function

The aim of the present study was to determine whether quantitative tissue Doppler echocardiography has a role in the assessment of left ventricular hemodynamics. Thirty patients with suspected or known heart disease, but no wall motion abnormalities, took part in the study. Quantitative tissue Doppler echocardiography was performed using new software for digital analysis of the tissue Doppler signal. Average systolic subendocardial (S1), subepicardial (S2), and transmural (S3) wall velocity data were obtained from the inferoposterior wall and compared with the hemodynamics, including high fidelity pressure readings. S1 and S3 rates were found to be most reliable, being directly related to the peak rate of left ventricular pressure rise (dP/dt_peak) and inversely to systemic vascular resistance (SVR) and resistance index (SVRI). The best correlation was between S1, dP/dt_peak, and SVRI (multiple regression analysis: r = 0.76, P < 0.0001; simple regression analysis relating S1 to dP/dt_peak/SVRI: r = 0.77, SEE = 0.25, P < 0.0001). Thus, wall velocity indices as defined in this study have promise to become helpful in guiding the therapeutic modulation of inotropy and afterload in patients with heart failure.     

Myocardial systolic activation delay in patients with left bundle branch block and either normal or impaired left ventricular function

AIM OF THE STUDY: to evaluate determinants of myocardial activation delay of both left (LV) and right (RV) ventricle in patients with left bundle branch block (LBBB) and either normal or impaired LV ejection fraction (EF). METHODS: From an initial cohort of patients with LBBB, 42 patients with dilated cardiomyopathy (group A) and 33 with normal global LV systolic function (group B), all comparable in age and sex, underwent standard Doppler echo, pulsed Doppler myocardial imaging (DMI), and coronary angiography. Using DMI, the following regional parameters were evaluated in five different basal myocardial segments (LV anterior, inferior, septal, lateral walls-RV lateral wall): systolic (Sm), early- and late-diastolic (Em and Am) peak velocities. As index of myocardial systolic activation was calculated: precontraction time (PCTm) (from the beginning of Q-wave of ECG to the onset of Sm). Intraventricular systolic dyssynchrony was analyzed by difference of PCTm in different LV myocardial segments. Interventricular activation delay was calculated by the difference of PCTm between the most delayed LV segment and RV lateral wall. RESULTS: Patients of group A showed increased heart rate (HR), QRS duration and LV end-diastolic diameter, and reduced LV EF. By DMI, patients of group A showed reduced myocardial peak velocities and a significant intraventricular delay in activation of LV lateral wall, with increased regional PCTm (P < 0.001). In addition, patients with dilated cardiomyopathy showed a more pronounced interventricular dyssynchrony, even after adjustment for HR and QRS duration. By receiver operating characteristic (ROC) curve analysis, a cut-off value of 55 msec of interventricular delay showed 86% sensitivity and 92% specificity in identifying patients with impaired EF. In the overall population, by use of stepwise forward multivariate linear regression analyses, LV end-diastolic diameter (beta coefficient = 0.52; P < 0.001) and LV EF (beta coefficient =-0.58; P < 0.0001) were the only independent determinants of interventricular activation delay. CONCLUSIONS: Pulsed DMI is an effective noninvasive technique for assessing the severity of regional delay in activation of LV walls in patients with LBBB. The impairment of interventricular systolic sychronicity is strongly related to LV dilatation and to the degree of global systolic dysfunction. Therefore, patients with dilated cardiomyopathy suitable for cardiac resynchronization therapy may be better selected.     

Assessment of Right Ventricular Endocardial Dysfunction in Mild-to-Moderate Mitral Stenosis Patients Using Velocity Vector Imaging

Purpose: Right ventricular (RV) function plays an important role in the development of clinical symptoms, exercise capacity, prognosis, and survival in patients with mitral stenosis (MS). The purpose of this study was to evaluate global and regional RV systolic functions using a novel technique, VVI, in mild-to-moderate MS patients without clinical symptoms of heart failure. Methods: The study population consisted of 60 patients (mean age 51.7 ± 11.6 years; 85% female) with isolated rheumatic mitral valve stenosis and 40 age- and sex-matched control subjects (mean age 49.1 ± 10.5 years; 76.7% female). Conventional echocardiography, tissue Doppler imaging (TDI), strain (S), and strain rate (SRs) analysis were performed in all patients. Results: Transmitral mean pressure gradient was 6.1 ± 3.0 mmHg and mean mitral valve area was 1.41 ± 0.31 cm(2) in patients with MS. TDI systolic velocity was significantly lower in MS patients compared to control subjects (0.13 ± 0.03 m/sec vs. 0.17 ± 0.03 m/sec; P < 0.0001). RV-isovolumic acceleration was reduced in MS patients (3.75 ± 1.09 m/sec(2) vs. 4.62 ± 1.0 m/sec(2) ; P = 0.006). RV-myocardial performance index was significantly increased in patients with MS (0.75 ± 0.05 in MS and 0.29 ± 0.04 in controls; P < 0.0001) revealing impaired RV systolic and diastolic function. The mean longitudinal peak systolic S and SR were significantly reduced in patients with MS (P < 0.0001). Conclusion: Our data revealed that RV systolic performance is reduced in patients with mild-to-moderate MS. (Echocardiography 2012;29:25-33).     

Evaluation of the relationship between functional capacity and right ventricular diastolic function in patients with isolated mitral stenosis and sinus rhythm: a tissue Doppler study

AIM: The right ventricular (RV) systolic function is an important determinant of clinical symptoms and exercise capacity in patients with mitral stenosis. No sufficient data are available concerning the effect of RV diastolic function on symptoms of patients with mitral stenosis. In the presence of normal RV systolic function, RV diastolic functions of asymptomatic patients with mitral stenosis of moderate or severe degree were compared to symptomatic ones by pulsed-wave tissue Doppler echocardiography in this study. MATERIALS AND METHODS: The study included 40 patients with mitral stenosis. Patients were classified into two groups according to New York Heart Association (NYHA) class (asymptomatic group NYHA class I, symptomatic group NYHA class II-III). RV diastolic functions were evaluated via pulsed-wave tissue Doppler in terms of isovolumic contraction time (IVCT), systolic wave velocity (S), isovolumic relaxation time (IVRT), early diastolic wave velocity (E'), and late diastolic wave velocity (A'). RESULTS: Statistical difference was not determined in systolic parameters (S, IVCT) between the two groups. However, IVRT (54.21 +/- 11.93 msec vs 86.19 +/- 16.23 msec, P < 0.0001) and A' wave amplitude (10.16 +/- 2.14 cm/sec vs 13.55 +/- 3.35 cm/sec, P < 0.0001) were higher whereas E' wave amplitude (11.68 +/- 1.60 cm/sec and 10.25 +/- 2.73 cm/sec, P = 0.009) and E'/A' ratio (1.18 +/- 0.23 vs 0.76 +/- 0.17, P < 0.0001) were lower in group 2. CONCLUSION: In isolated mitral stenosis, pulsed-wave tissue Doppler may be used for the detection of RV diastolic pathology. Diastolic functions of RV may deteriorate in the presence of normal systolic functions in symptomatic patients with isolated mitral stenosis.     

Longitudinal diastolic myocardial functions are affected by chronic smoking in young healthy people: a study of color tissue Doppler imaging

AIMS: Many cardiac and hemodynamic alterations occur after acute consumption of cigarettes. The aim of this study is to evaluate the effect of chronic smoking on longitudinal myocardial functions of left ventricle in young, healthy people by using color tissue Doppler imaging modalities. METHODS AND RESULTS: Ninety-nine healthy participants were studied. There were 65 smokers and 34 nonsmokers. All subjects were between 20 and 35 years old. Sample volumes were placed on the mid left ventricle in the inner half of the myocardium at the septum, lateral, inferior, and anterior walls. The peak systolic strain (S-S), peak systolic strain rate (S-SR), peak early diastolic SR (E-SR), peak late diastolic SR (A-SR), peak systolic tissue velocity (S-TV), peak early diastolic TV (E-TV), and peak late diastolic TV (A-TV) values were measured. For the systolic parameters S-S, S-SR, and S-TV values were not different between the groups. For the diastolic parameters smokers had lower E-SR and E-TV values than nonsmokers (P = 0.03 for both). Although there was a trend toward higher A-SR and A-TV values in the smokers, they were not reaching the statistical significance. CONCLUSION: Chronic smoking in young, healthy people causes significant alterations in the longitudinal diastolic myocardial function parameters as assessed by color tissue Doppler imaging.     

Assessment of the relationship between functional capacity and right ventricular ultrasound tissue characterization by integrated backscatter in patients with isolated mitral stenosis

AIM: The aim of the present study was to investigate right ventricular (RV) myocardial textural properties in asymptomatic and symptomatic mitral stenosis (MS) patients with normal RV systolic function using integrated backscatter (IBS). METHODS: The study included 40 patients with MS of moderate or severe degree. Patients were classified into 2 groups according to NYHA class (asymptomatic group, NYHA class I, symptomatic group, NYHA class II-III). RV pulsed-wave tissue Doppler imaging (TDI) and IBS analyses were performed in all patients. Isovolumic contraction time (IVCT), systolic wave velocity (S), isovolumic relaxation time (IVRT), early diastolic wave velocity (E), and late diastolic wave velocity (A) were measured by TDI. IBS amplitude (IB) and cyclic variation (CV) of the RV lateral wall in the parasternal long-axis view were measured by IBS. CV was calculated by subtracting systolic IB from diastolic IB. RESULTS: IVRT (54.2 +/- 11.9 ms versus 86.2 +/- 16.2 ms, P < 0.001) and A wave amplitude (10.2 +/- 2.1 cm/s versus 13.6 +/- 1.8 cm/s, P < 0.05) were higher whereas E wave amplitude (11.7 +/- 1.6 cm/s and 10.3 +/- 1.5 cm/s, P < 0.05) and E/A ratio (1.3 +/- 0.3 versus 0.7 +/- 0.1, P < 0.001) were lower in group 2. Symptomatic patients had a lower CV value of RV (9.5 +/- 3.4 dB versus 6.7 +/- 1.9 dB, P = 0.004). There was a positive correlation between CV and E/A (r = 0.964, P < 0.001) CONCLUSION: Symptomatic isolated MS patients had RV echo texture changes and diastolic dysfunction in comparison to asymptomatic ones with similar mitral valve areas in the presence of normal RV systolic function. In isolated MS, both pulsed-wave TDI and IBS may aid in the detection of RV diastolic pathology.     

Associations of right ventricular myocardial function with skin and pulmonary involvement in asymptomatic patients with systemic sclerosis.

BACKGROUND: Systemic sclerosis (SSc) is a multisystem disorder characterized by widespread vascular lesions and fibrosis of the skin and specific internal organs. Cardiac involvement is a common finding in SSc, but often clinically occult. The aim of the present study was to analyze both left and right ventricular (RV) myocardial function in patients with SSc, and their relation to other instrumental features of the disease. METHODS: Twenty-five healthy subjects and 23 age- and sex-comparable asymptomatic patients classified as having either diffuse (11 patients) or limited cutaneous (12 patients) SSc underwent clinical examination, serological analysis, high-resolution chest computed tomography, standard Doppler echocardiography and pulsed Doppler myocardial imaging (DMI) of both the mitral and tricuspid annuli. SSc was classified using the modified Rodnan skin score (mRSS) into high mRSS (score > or = 10) and low mRSS (score < 10). RESULTS: Serological antibody analysis revealed the presence of antinuclear antibody in all patients, an anticentromere pattern in 8 patients, and anti-Scl-70 antibodies in 15 patients. Eleven patients were diagnosed with interstitial pulmonary fibrosis at chest computed tomography. Standard Doppler echocardiography revealed that the left ventricular mass index and ejection fraction were comparable between the two groups, while the RV end-diastolic diameter was increased in SSc (p < 0.01). The tricuspid inflow peak E and E/A ratio were slightly decreased in SSc (p < 0.01), while the systolic pulmonary pressure was increased (p < 0.0001). DMI analysis revealed, in SSc, an impaired RV myocardial early-diastolic (Em) peak velocity (p < 0.001) as well as a prolonged myocardial relaxation time (RTm) (p < 0.001) only at the tricuspid annulus level, even after correction for age, sex, heart rate and left ventricular mass index. Independent inverse associations of the RV Em peak velocity with both the Rodnan skin score (beta coefficient = -0.62, p < 0.0005) and the pulmonary systolic pressure (beta coefficient = 0.71, p < 0.0001), as well as the independent inverse correlation of the same RV Em peak velocity with interstitial pulmonary fibrosis (odds ratio 0.68, 95% confidence interval 0.45-0.83, p < 0.0005) in SSc patients were assessed at multivariate analysis. In addition, the RV Em velocity was an independent predictor of the anti-Scl-70 antibody pattern (odds ratio 0.68, 95% confidence interval 0.45-0.83, p < 0.01). Of note, a RV Em peak velocity < 0.11 m/s well selected SSc patients with pulmonary artery pressure > 35 mmHg, pulmonary fibrosis, a high mRSS, and an anti-Scl-70 antibody pattern. CONCLUSIONS: The relationships of RV myocardial diastolic dysfunction with both skin and pulmonary involvement as well as with the serological antibody pattern emphasizes the ability of DMI to identify patients with a more diffuse and severe form of SSc. This issue may be critical for the early identification of those SSc patients who are at higher risk of cardiac impairment, ideally when they are still asymptomatic before developing severe vasculopathy.     

The impact of hypertension and hypertension-related left ventricle hypertrophy on right ventricle function

AIM: The aim of our study is to determine the effect of hypertension and hypertension-related left ventricle hypertrophy on right ventricle (RV) morphology and function by using RV standard Doppler echocardiographic indices, myocardial Doppler imaging, and strain/strain rate imaging indices. METHODS: We studied 35 patients with arterial hypertension and 30 age- and sex-adjusted control subjects who had no other pathological conditions. Standard transthoracic Doppler echocardiographical measurements, pulsed-wave tissue Doppler from tricuspid anulus (Peak systolic-st, peak early diastolic-et, peak late diastolic velocity-at), reconstructed spectral pulsed-wave tissue Doppler velocities (peak systolic-S, peak early-E, peak late diastolic velocity-A), and strain/strain rate imaging of RV free wall mid region (peak systolic strain-in, peak systolic strain rate-SR) were obtained. RESULTS: Age, body surface area, blood pressure, and heart rate were comparable between two groups. Hypertensive subjects had significantly increased LV end-diastolic septal and posterior wall thickness, left atrial diameter, LV mass, LV mass index, and relative wall thickness during diastole. At the level of right ventricular lateral tricuspid annulus without systolic changes, the majority of diastolic measurements were altered in hypertensives (early diastolic velocity et; 13 +/- 2 vs. 18 +/- 4 m/sec, P < 0.0001, late diastolic velocity at; 20 +/- 4 vs. 14 +/- 3 m/sec, P < 0.0001, early to late diastolic velocity ratio; 0.69 +/- 0.14 vs. 1.32 +/- 0.38, P < 0.0001). The velocity data from two-dimensional color myocardial imaging at the level of RV free wall mid region again showed altered diastolic measurements in hypertensives (E; 8.01 +/- 2.6 vs. 10.4 +/- 3.14 m/sec, P < 0.001, A; 11.5 +/- 2.6 vs. 9.12 +/- 3.7 m/sec, P < 0.0001, E/A ratio; 0.75 +/- 0.41 vs. 1.87 +/- 0.48, P < 0.00). The peak systolic strain of RV free wall mid region was significantly lower in hypertensive individuals than controls (25.666 +/- 5.64 vs. 30.03 +/- 6.78%, P < 0.05). No significant differences were found in other parameters of RV function between hypertensive and control subjects. CONCLUSIONS: The present study demonstrates that besides the manifest morphologic LV adaptations, significant RV functional alterations can be determined by TDI and strain/strain rate imaging in patients arterial hypertension. Both tissue velocities by TDI and strain imaging may be new tools to define and quantitate subtle change in systolic and diastolic function of right ventricular function in arterial hypertension that cannot be determined in standard echocardiographic parameters.     

Restrictive right ventricular physiology: its presence and symptomatic contribution in patients with pulmonary valvular stenosis.

OBJECTIVES: The aim of this study was to examine whether restrictive right ventricular (RV) physiology (the presence of antegrade pulmonary arterial flow in late diastole) occurred in patients with moderate to severe isolated pulmonary valvular stenosis (PVS) and to estimate its prevalence and relationship to RV function and patient symptoms. BACKGROUND: Little is published about RV diastolic performance in adult patients with PVS. METHODS: A total of 43 consecutive patients (age 44 +/- 10 years) with moderate to severe PVS referred to Royal Brompton Hospital from 2002 to 2005 were retrospectively studied. Patient New York Heart Association (NYHA) functional class was recorded. The RV (lateral tricuspid annulus motion) long-axis movement was measured by M-mode and pulsed-wave (PW) tissue Doppler imaging (TDI). Restrictive RV physiology was assessed by PW Doppler echocardiography. RESULTS: Eighteen patients (42%) had restrictive RV physiology. They were more symptomatic (NYHA functional class 1.8 +/- 0.5 vs. 1.3 +/- 0.5; p < 0.001) and had poorer RV long-axis function (TDI peak systolic velocity 7.3 +/- 2.1 cm/s vs. 9.7 +/- 2.7 cm/s; TDI early diastolic velocity 6.6 +/- 1.6 cm/s vs. 8.5 +/- 2.4 cm/s; RV long-axis systolic amplitude 1.3 +/- 0.2 cm vs. 1.5 +/- 0.3 cm; p < 0.01 for all) compared with other PVS patients despite similar RV ejection fraction, myocardial performance index, and RV systolic pressure. The presence of restrictive RV physiology (odds ratio [OR] 6.05, 95% confidence interval [CI] 1.45 to 10.29; p = 0.01) and peak pulmonary valve pressure gradient (OR 1.07, 95% CI 1.01 to 1.13; p = 0.04) were the 2 independent echocardiographic predictors for decreased exercise tolerance in patients on multivariate analysis. CONCLUSIONS: Restrictive RV physiology is common in PVS patients. Its presence is related to a worse deterioration in RV long-axis function and decreased exercise tolerance in patients.     

Quantification of regional right and left ventricular function by ultrasonic strain rate and strain indexes after surgical repair of tetralogy of Fallot

The quantification of regional myocardial function in tetralogy of Fallot (TOF) by conventional M-mode and 2-dimensional echocardiography is difficult because of the complex right ventricular (RV) and altered left ventricular (LV) geometry. In 30 asymptomatic postoperative TOF patients (aged 4 to 16 years) with a low pressure in the right ventricle and with varying degrees of pulmonary regurgitation and in 30 aged-matched healthy children, the ultrasonic-derived regional deformation parameters peak systolic strain rate (SR) and systolic strain (epsilon) were acquired from ventricles and compared. In TOF RV free walls, SR, and epsilon were reduced in the basal, mid-, and apical segments and averaged -1.5 +/- 0.6 second(-1) for SR and -22 +/- 8% for epsilon, respectively (p <0.001 vs normals). Peak systolic SR of the basal RV free wall correlated significantly with the QRS duration of the electrocardiogram (r = 0.81, p <0.0001). Abnormalities in RV deformation were more marked in patients with transannular patches versus infundibular patches. In the septum there was a homogeneous reduction in SR and epsilon in the basal, mid-, and apical segments. These averaged -1.4 +/- 0.3 second(-1) for SR and -19 +/- 4% for epsilon, respectively (p <0.01 vs normals). Longitudinal SR and epsilon values of the 3 LV lateral wall segments (averaged SR = -1.6 +/- 0.4 second(-1), averaged epsilon = -20 +/- 5%; p <0.05 vs normals), and radial SR and epsilon of the LV posterior wall (SR = 3.3 +/- 0.9 second(-1); epsilon = 51 +/- 14%; p <0.05 vs normals) were significantly reduced. Thus, abnormalities in regional RV and LV systolic myocardial function in asymptomatic postoperative TOF patients were quantified by the deformation parameters SR and epsilon. RV deformation abnormalities are associated with electrical depolarization abnormalities.     

Right ventricular dysfunction and exercise capacity after inferior (posterior) wall acute myocardial infarction

Tissue Doppler echocardiography is a novel technique that can be used to diagnose right ventricular (RV) systolic dysfunction. Until recently, there have been no data on the influence of tissue Doppler-derived RV systolic dysfunction on exercise capacity after inferior (posterior) myocardial infarction (MI). We studied 90 consecutive patients (76% men, mean age 61 ± 10 years) with first inferior ST-segment elevation MI and left ventricular ejection fraction ≥45%. RV systolic dysfunction was defined as RV systolic myocardial velocity <11.5 cm/s at the basal segment of the RV free wall assessed by pulse tissue Doppler. Patients were categorized as with or without RV systolic dysfunction (RV systolic myocardial velocity 9.34 ± 1.36 and 13.74 ± 1.58 cm/s, respectively). A cardiopulmonary exercise test was performed before or soon after discharge (day 14 ± 10). Patients with RV systolic dysfunction had lower oxygen consumption assessed as percent predicted oxygen uptake in liters per minute and milliliters per kilogram per minute at their anaerobic threshold (61 ± 11% vs 69 ± 17%, p = 0.007; 53 ± 12% vs 61 ± 19%, p = 0.012, respectively) and at peak exercise (71 ± 12% vs 83 ± 16%, p = 0.0001; 62 ± 14% vs 74 ± 21%, p = 0.002, respectively). Multivariate regression analysis revealed that the following independent factors negatively influenced exercise capacity: RV systolic dysfunction, female gender, age, lower body mass index, current smoking, and maximal troponin I concentration. In conclusion, we found decreased exercise capacity in patients with systolic RV dysfunction assessed by pulse tissue Doppler in patients with inferior (posterior) wall acute MI despite preserved left ventricular function.     

Effects of thyroxine therapy on right ventricular systolic and diastolic function in patients with subclinical hypothyroidism: a study by pulsed wave tissue Doppler imaging

INTRODUCTION: The effects of l-thyroxine (l-T(4)) replacement for subclinical hypothyroidism (SH) on right ventricle (RV) functions has not been previously studied by means of pulsed wave tissue Doppler imaging (PWTDI). We investigated the effects of l-T(4) therapy on RV function in patients with SH using PWTDI. PATIENTS AND METHODS: Fifty-three patients with newly diagnosed SH and 25 controls were evaluated by standard echocardiography and PWTDI. After euthyroidism was restored by l-T(4), measurements were repeated. Myocardial systolic wave (S(m)) velocity, isovolumic acceleration (IVA), myocardial precontraction time (PCT(m)), and PCT(m) to contraction time (CT(m)) ratio were calculated as systolic indices. Early (E(m)) velocity, late (A(m)) velocity, E(m) to A(m) ratio, and myocardial relaxation time (RT(m)) were determined as diastolic measurements. RESULTS: S(m) was similar in patients and controls, whereas IVA was significantly lower in patients with SH (P < 0.001). SH patients had significantly decreased E(m) velocity, whereas A(m) velocity and E(m) to A(m) ratio did not differ. PCT(m) and RT(m) were significantly longer, and PCT(m) to CT(m) ratio was significantly higher in patients (P = 0.002, P = 0.002, P < 0.001, respectively). S(m) velocities were similar before and after l-T(4) replacement, whereas IVA significantly increased after therapy (P < 0.001). E(m) tended to increase (P = 0.05), whereas A(m) and E(m) to A(m) ratio were not changed. PCT(m), PCT(m) to CT(m) ratio, and RT(m) decreased significantly (P < 0.001 for all). CONCLUSIONS: SH is associated with RV systolic and diastolic dysfunction, and l-T(4) treatment improves these abnormalities. PWTDI, especially IVA, may be a suitable tool for the early detection of RV systolic dysfunction.     

Acute smoking-induced alterations in Doppler echocardiographic measurements in chronic smokers

Acute effects of smoking on left ventricular function have been studied previously. However, effects on right ventricular function have not yet been investigated. In this study, we attempted to investigate, through a combination of conventional and tissue Doppler imaging (TDI), the acute effects of smoking on both left and right ventricular function in chronic smokers. Thirty chronic smokers (with smoking habits of > or =1 pack/day for 74 +/- 1.3 years) underwent a complete transthoracic echocardiographic examination (2-dimensional, pulsed-wave Doppler transmitral and transtricuspid recordings, and TDI recordings of mitral and tricuspid annular velocities) by 3.5-MHz sector transducer. Pulsed-wave Doppler indices of left and right ventricular diastolic function-such as mitral and tricuspid inflows, peak early (E) and late (A) velocities, and E/A ratios-were obtained by conventional Doppler and TDI. Echocardiographic indices of the left and right ventricles--including isovolumetric relaxation time, isovolumetric contraction time, ejection time, and myocardial performance index of right ventricle-were also measured before and 30 minutes after each subject smoked a cigarette. Both mitral and tricuspid inflow measurements changed significantly after smoking a cigarette. Among the TDI measurements, mitral lateral annulus and tricuspid lateral annulus (diastolic, but not systolic) velocities changed after smoking a cigarette. Also, the right ventricular myocardial performance index increased immediately after smoking a cigarette. We found that acute cigarette smoking impaired both left and right ventricular diastolic function in chronic smokers.     

Chronic and acute effects of smoking on left and right ventricular relaxation in young healthy smokers

BACKGROUND: Left ventricular (LV) diastolic dysfunction has been observed in cigarette smokers with coronary artery disease. The aim of the study was to assess LV and right ventricular (RV) diastolic function in healthy, young, and slim smokers before and after smoking one cigarette. MATERIAL AND METHODS: The participants were 66 healthy volunteers (age < 40 years; body mass index < 25 kg/m(2)): 33 smokers (study group [HS]) and 33 nonsmokers (control group). Echocardiographic examination was done in the HS before smoking one cigarette (HS-1) and after smoking one cigarette (HS-2). To assess diastolic function of LV and RV mitral valve flow (MVF), pulmonary venous flow (PVF) and tricuspid valve flow (TVF) were evaluated. RESULTS: MVF early to late phase ratio (E/A) was significantly lower in HS-1 and HS-2 than in the control group. The PVF systolic to diastolic phase ratio (S/D) was significantly higher in HS-1 and HS-2 than in the control group. These changes suggest LV diastolic function impairment in the HS, but the MVF pattern remained within the normal range. PVF S/D showed systolic dominance (S/D > 1) typical for impaired LV relaxation and abnormal for this age group. TVF E/A was significantly lower in HS-2 than in HS-1 and control subjects and suggests RV diastolic dysfunction. CONCLUSIONS: The following conclusion are made: (1) MVF and PVF demonstrate LV relaxation impairment in healthy smokers before and after smoking one cigarette; (2) the assessment of PVF is a good method reflecting LV diastolic function changes, even when MVF remains normal; and (3) TVF shows RV relaxation impairment after smoking one cigarette in healthy smokers.     

Dobutamine stress-induced ischemic right ventricular dysfunction and its relation to cardiac output in patients with three-vessel coronary artery disease with angina-like symptoms

We investigated markers of ischemic dysfunction and their relation to overall right ventricular (RV) performance during dobutamine stress echocardiography in patients who had coronary artery disease. Thirty-three patients (58 +/- 10 years old) who had 3-vessel coronary artery disease were compared with 17 age-matched controls (58 +/- 11 years old). RV long-axis amplitude (M mode), systolic and diastolic myocardial tissue Doppler velocities, and filling and ejection velocities were measured, and cardiac output (CO) was calculated at rest and during peak stress. There was no difference in RV size (inlet dimension <3.5 cm), RV systolic long-axis amplitude, systolic and diastolic velocities, peak early/late diastolic velocity ratio, and RV CO between patients and controls at rest. During stress, RV systolic long-axis amplitude increased in controls (from 24 +/- 6 to 30 +/- 5 mm) and CO increased significantly (from 4.9 +/- 1.2 to 12.5 +/- 2.1 L/min, p <0.001 for the 2 items). In contrast, RV amplitude did not change with stress in patients (from 24 +/- 5 to 22 +/- 6 mm, p = NS), and the stress-increment in CO was augmented (from 4.2 +/- 1.2 to 8.3 +/- 2.0 L/min, p <0.001 vs control stress increment). Failure to increase RV systolic amplitude >2 mm was 79% sensitive and 88% specific for detecting ischemic RV dysfunction, and there was a close correlation between stress-induced change in RV systolic amplitude and change in CO in patients (r = 0.56, p <0.001). Early diastolic velocity increased in controls (from 10.8 +/- 3.2 to 13.1 +/- 3.6 cm/s, p <0.01) but did not change in patients (from 11.5 +/- 3.7 to 11.3 +/- 4.8 cm/s, p = NS). RV shortening after ejection did not appear in any control subject but did develop in 8 of 33 patients, thus contributing to the decrease in RV peak early/late diastolic velocity ratio in patients (from 1.1 +/- 0.3 to 0.76 +/- 0.4, p <0.001) compared with that in controls (1.3 +/- 0.3 to 1.0 +/- 0.2, p <0.001). In conclusion, markers of RV dysfunction are not related to left ventricular wall motion score index or long-axis changes with stress.     

Persistent and reversible cardiac dysfunction among amateur marathon runners.

AIMS: Transient systolic and diastolic abnormalities in ventricular function have previously been documented during endurance sports. However, these described alterations may be limited by the techniques applied. We sought, using less load-dependent methods, to characterize both the extent and the chronology of the cardiac changes associated with endurance events. METHODS AND RESULTS: Transthoracic echocardiography (TTE) was performed prior to, immediately after, and approximately 1 month after completion of the 2003 Boston Marathon in 20 amateur athletes. TTE included two-dimensional, spectral and tissue Doppler (TD) and flow propagation velocity (V(p)). After completion of the marathon, global measures of left ventricular (LV) systolic function were unchanged (EF 59 +/- 6 vs. 61 +/- 4% post, P = 0.14), whereas TD-derived measures of LV systolic function [septal strain -23 +/- 5 vs. -17 +/- 4%, P = 0.007; septal strain rate (SR) -1.5 +/- 0.3 vs. -1.1+/- 0.2 s(-1), P = 0.007] and right ventricular (RV) systolic function (RV apical strain -33 +/- 4 vs. -27 +/- 5%, P = 0.001; RV apical SR -2.4 +/- 0.7 vs. -1.8 +/- 0.5, P = 0.002) were reduced. Significant changes in transmitral velocity (E/A ratio 2.0 +/- 0.5 vs.1.3 +/- 0.3, P = 0.005) and TD indices of LV and RV diastolic function (E(a) septal 9.5 +/- 1.8 vs. 8.1 +/- 1.2 cm/s post-marathon, P = 0.01) were also observed, indicating an inherent alteration in LV relaxation. Although all indices of LV and RV systolic function had returned to normal on follow-up, there were persistent diastolic abnormalities (RV E(a), 11.5 +/- 1.5 cm/s pre-marathon vs. 10.0 +/- 1.6 cm/s follow-up, P = 0.01). CONCLUSION: Marathon running leads to transient systolic and more persistent diastolic dysfunction of both the LV and the RV.