Right ventricular function after repair of tetralogy of Fallot: an echocardiographic and clinical evaluation.

Is MRI the Preferred Method for Evaluating Right Ventricular Size and Function in Patients With Congenital Heart Disease?

OBJECTIVESTo assess the incremental prognostic value of right ventricular free wall longitudinal strain over conventional risk scores in predicting the peri-operative mortality in patients with severe tricuspid regurgitation (TR) undergoing isolated tricuspid valve (TV) surgery.METHODSWe retrospectively enrolled 110 consecutive patients with severe TR who underwent isolated TV surgery between November 2016 and July 2022 at San Raffaele Hospital, Milan, Italy. Exclusion criteria were previous TV surgery, urgent surgery, complex congenital heart disease, active endocarditis and inadequate acoustic window. Baseline clinical data were included, as well as laboratory tests and clinical risk score, as TRI-SCORE and MELD-XI. The clinical outcome was peri-operative mortality, defined as all-cause mortality within 30 days.RESULTSThe final cohort included 79 patients. The end-point occurred in 7 patients (9%), who died within 30 days after isolated TV surgery. Receiver operator characteristic curves analysis showed that, among parameters of right ventricular function, right ventricular free wall longitudinal strain was the best parameter to predict peri-operative mortality (AUC: 0.854, 95% CI 0.74–0.96, P = 0.005, sensitivity 68%, specificity 100%). At univariable analysis, left ventricular ejection fraction, diabetes mellitus, creatinine, estimated glomerular filtration rate, serum sodium, MELD-XI, TRI-SCORE, right ventricular areas, right ventricular global longitudinal strain, right ventricular free wall longitudinal strain, fractional area change and the ratio between right ventricular free wall longitudinal strain/pulmonary arterial systolic pressure were significantly associated with the end-point. The combination of TRI-SCORE and right ventricular Strain, evaluating right ventricular systolic function with speckle-tracking echocardiography, outperformed classic TRI-SCORE in outcome prediction (AUC 0.874 vs 0.787, P = 0.05).CONCLUSIONSRight ventricular free wall longitudinal strain has an incremental prognostic value over conventional parameters and significantly improves the ability of clinical scores to predict peri-operative mortality in patients undergoing isolated TV surgery.

Letter to the Editor: Influence of right ventricular structure and function on hospital outcomes in COVID-19 patients

Right ventricular dysfunction is a common complication after surgical correction of tetralogy of Fallot. The assessment of right ventricular systolic function using cardiac magnetic resonance is the gold method. Our study aimed to compare the diagnostic accuracy of echocardiographic parameters in identifying right ventricular systolic dysfunction in comparison to cardiac magnetic resonance in children with repaired tetralogy of Fallot. Fifty-six patients with corrected tetralogy of Fallot were included in the study. Right ventricular fractional area change, Tricuspid annular plane systolic excursion, right ventricular peak systolic tricuspid annular velocity, two-dimensional right ventricular global longitudinal strain, and two-dimensional right ventricular free wall strain were measured using echocardiography. Right ventricular ejection fraction and pulmonary regurgitant fraction were assessed using cardiac magnetic resonance. Twenty (35.7%) patients showed right ventricular systolic dysfunction using cardiac magnetic resonance-derived right ventricular ejection fraction%, while 36 patients had normal right ventricular systolic function. Patients with right ventricular systolic dysfunction had significantly lower right ventricular fractional area change, tricuspid annular plane systolic excursion, right ventricular S', 2D-right ventricular global longitudinal strain, 2D-right ventricular free wall strain compared to those with normal right ventricular systolic function. Right ventricular ejection fraction% was directly correlated to tricuspid annular plane systolic excursion, right ventricular fractional area change, right ventricular S', 2D-right ventricular global longitudinal strain, and 2D-right ventricular free wall strain. Receiver operating characteristic curve revealed that 2D-right ventricular free wall strain and 2D-right ventricular global longitudinal strain had 70% sensitivity, 94.4% specificity, and 85% predictive accuracy, while right ventricular S' and RV fractional area change had 100 % sensitivity in detection of right ventricular dysfunction, but they showed lower specificity, 30.6% and 52.8% respectively. 2D-right ventricular global longitudinal strain and 2D-right ventricular FWL have good diagnostic value for right ventricular systolic dysfunction comparable to cardiac magnetic resonance in children with repaired tetralogy of Fallot.

Objective To compare the value of right ventricular (RV) free wall longitudinal strain (FWLS) by speckle tracking echocardiography (STE) and conventional parameters in evaluation of RV dysfunction in chronic thromboembolic pulmonary hypertension (CTEPH). Methods Sixty CTEPH patients were enrolled as group A and 45 pulmonary embolism (PE) patients with normal pulmonary pressure were enrolled as group B in this study. CTEPH patients were divided into 2 subgroups using the World Health Organization (WHO) function classification: patients with WHO Ⅰ-Ⅱ were designated as group A1 and those with WHO Ⅲ-Ⅳ were designated as group A2. Conventional RV functional parameters including tricuspid annular plane systolic excursion (TAPSE), tissue Doppler-derived tricuspid annular systolic velocity (S′), fractional area change (FAC), RV index of myocardial performance (RVIMP), and STE-derived RV FWLS were measured and compared. Clinical right heart failure (RHF) was defined as the presence of symptoms of heart failure and signs of systemic circulation congestion during hospitalization. Results Compared to group B, group A patients had significant enlarged right heart dimension and impaired RV systolic function parameters (all P<0.001). The TAPSE, S′, FAC, and RV FWLS showed significant differences between CTEPH patients with mild (group A1) and severe symptoms (group A2) (all P<0.01), while RVIMP showed no significant difference (P=0.188). On receiver operating characteristic analysis, FWLS had the largest AUC to identify RHF (AUC=0.864, P<0.001), when the cutoff value was 15.05%, the sensitivity was 85.71%, and the specificity was 64.29%, respectively. On binary logistic regression analysis, only right atria area (OR=1.212, 95%CI=1.004-1.48, P=0.046) and RV FWLS (OR=0.662, 95%CI=0.470-0.933, P=0.018) were identified as independent predictor of RHF. Conclusions Compared with conventional parameters, RV FWLS showed advantages in identifying abnormal RV function in CTEPH patients. Key words: Echocardiography; Pulmonary embolism; Hypertension, pulmonary; Ventricular function, right; Strain

The Complex Relationship That Is RV-PA Coupling and Its Relevance to Managing Congenital Heart Disease

BackgroundRight ventricular function has been identified as an important prognostic factor in children with pulmonary arterial hypertension. The aim of the study was to assess the deformation pattern and prognostic value of right ventricular longitudinal strain in children with pulmonary arterial hypertension.MethodsWe prospectively evaluated 46 children (25 with pulmonary arterial hyperetension and 21 age and sex matched controls) using conventional and speckle-tracking echocardiography, brain natriuretic peptide levels and clinical status expressed by WHO functional class and 6-min walking test. According to the clinical status after 12 months of follow-up, the pulmonary arterial hypertension patients were divided in two groups: non-worsening (13) and worsening (12).ResultsRight ventricular free wall longitudinal strain and strain rate were significantly lower in children with PAH compared with controls (−24.72 ± 3.48 vs −15.60 ± 3.40, p = 0.0001 and −1.44 ± 0.09 vs −1.09 ± 0.15, p = 0.0001, respectively). There was a more expressed decrease of basal than apical region of right ventricular free wall longitudinal strain/strain rate in pulmonary arterial hypertension patients compared with controls (strain: p = 0.0001 vs p = 0.07 and strain rate: p = 0.0001 vs p = 0.002). Comparing worsening and non-worsening pulmonary arterial hypertension patients there was a significant difference in Mid right ventricular free wall longitudinal strain (−14.00 ± 3.13 vs. −20.76 ± 4.62, p = 0.0001). In multivariable logistic regression analysis Mid right ventricular free wall longitudinal strain was an independent predictor of worsening in pulmonary arterial hypertension children (OR 0.45; 95 % CI: 0.21–0.96, p = 0.041). In ROC curve analysis a cut-off value of Mid right ventricular free wall longitudinal strain of −18.50 % predicted clinical worsening in pulmonary arterial hypertension children, with a sensitivity and specificity of 91.7 and 30.8 %, respectively (area under curve = 0.88 ± 0.06, 95 % CI: 0.75–1.00, p = 0.001).ConclusionsTwo-dimensional speckle-tracking echocardiography is a complementary non-invasive tool for assessment of right ventricular function in children with severe pulmonary arterial hypertension, allowing also clinical prediction and segmental analysis of right ventricular myocardial performance in these patients.

Right Ventricular Dysfunction in COVID-19 ECMO—A Red Herring or the Real Deal?

A 54-year-old man with end-stage heart failure due to hypertrophic cardiomyopathy was admitted because of acute hemodynamic deterioration accompanied by disabling dyspnea and asthenia at rest, in association with fluid overload, poor urinary output, and a contextual increase of neurohormonal activation (brain natriuretic peptide level, 4,168 pg/mL). He was already enrolled for heart transplantation at our center. Despite continuing inotropic support (with milrinone) and high-dose diuretics, the patient developed evidence of kidney and liver dysfunction and deteriorated to Class II Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs). The heart team considered him a possible candidate for left ventricular assist device (LVAD) implantation as a bridge to transplantation. Preimplantation echocardiographic evaluation revealed severely impaired left ventricular (LV) systolic function with only mild LV dilation (Fig. 1). Right ventricular (RV) evaluation revealed a fractional area change (34%) below the range of normal value (Fig. 2), low tricuspid annular plane systolic excursion (12 mm) (Fig. 3), and a tissue-Doppler peak systolic velocity (8 cm/s) of the tricuspid annulus, again below the range of normal (Fig. 4). Fig. 1 Transthoracic echocardiogram (apical 4-chamber view) shows a mildly dilated left ventricle with markedly reduced systolic function and preserved left ventricular wall thickness. Note also the severe left atrial enlargement. Fig. 2 Transthoracic echocardiogram (apical off-axis view), focused on the right ventricle. Note the visually preserved free wall longitudinal function, with reduced fractional area change. Fig. 3 M-mode transthoracic echocardiogram, at the level of the lateral tricuspid annulus, revealed low (12 mm) tricuspid annular plane systolic excursion and low longitudinal right ventricular function. Fig. 4 Tissue-Doppler image at the level of the lateral tricuspid annulus reveals a peak systolic velocity of 8 cm/s, indicating relatively low right ventricular longitudinal function. In contrast, the value for RV free-wall longitudinal strain obtained with use of 2-dimensional speckle-tracking echocardiography and EchoPAC PC software (GE Medical Systems; Horten, Norway) was high (−16%), predicting good RV performance after implantation. The 2-dimensional speckle-tracking echocardiograms (Fig. 5) were obtained through offline analysis of grayscale conventional transthoracic images acquired during breath-hold and with a stable electrocardiogram recording. For each figure, 3 consecutive heart cycles were recorded and averaged. The frame rate was set between 60 and 80 frames. Fig. 5 Two-dimensional speckle-tracking echocardiography (transthoracic apical off-axis view) was used to measure A) right ventricular free wall longitudinal strain (RVFWLS) and B) right ventricular global longitudinal strain (RVGLS). In A), the manual tracing ... The patient successfully underwent LVAD implantation during a short hospital stay.

To research the value of Autostrain right ventricular (RV) technology in detecting and preventing right ventricular myocardial injury in patients undergoing breast cancer chemotherapy by providing an imaging basis for early identification. To examine the changes in various cardiac function parameters before and after chemotherapy, two-dimensional echocardiography was employed 48 h before chemotherapy, 48 h after the fourth cycle of chemotherapy, and 48 h after the eighth cycle of chemotherapy, respectively. The patients included those with breast cancer who underwent surgery and were primarily administered anthracycline-based chemotherapeutic drugs. (1) Compared with the pre-chemotherapy period, the absolute values of the right ventricular global longitudinal strain (RV4CSL) and right ventricular free-wall longitudinal strain (RVFWSL) decreased after the fourth chemotherapy cycle, and no significant differences were observed in tricuspidannular plane systolic excursion (TAPSE), right ventricular Tei index, and right ventricular fractional area change (FAC); (2) Compared with the pre-chemotherapy period, the absolute values of RV4CSL and RVFWSL decreased after the eighth chemotherapy cycle. TAPSE and FAC decreased, the right ventricular Tei index increased; (3) Compared with the end of the fourth chemotherapy cycle, the absolute values of RV4CSL and RVFWSL decreased at the end of the eighth chemotherapy cycle. TAPSE, right ventricular Tei index and FAC were not significantly different. (4) Pearson correlation analysis revealed a correlation between the absolute value of RV4CSL, the absolute value of RVFWSL, right ventricular Tei index, TAPSE and FAC. The absolute values of RV4CSL and RVFWSL are sensitive indices that reflect changes in the right ventricular myocardium in the early stages of chemotherapy. They can reflect the effects of anthracycline on the right ventricular myocardium of patients with breast cancer earlier than the TAPSE, FAC and right ventricular Tei indices. A relationship exists between the absolute value of RVFWSL, the absolute value of RV4CSL, right ventricular Tei index, TAPSE, FAC and anthracycline-induced alterations in the right ventricular myocardium. This study is helpful for early detection of right ventricular myocardial function injury caused by anthracyclines in breast cancer patients, and provides imaging basis for early clinical detection and prevention of right ventricular myocardial injury.

PurposeEarly detection of right ventricular dysfunction is essential in the assessment of patients with repaired tetralogy of Fallot. Because right ventricular dysfunction in many postoperative tetralogy of Fallot patients is...

Introduction The detrimental impact of pulmonary regurgitation (PR) on right ventricular (RV) function of patients after repair of tetralogy of Fallot (TOF) is recognized. Although tricuspid annular isovolumic acceleration (IVA) is useful for the evaluation of RV function, it requires complicated measurement. Tricuspid annular plane systolic excursion (TAPSE) is measured easily and has also been validated as a marker of RV systolic function. Hypothesis We assessed the hypothesis that IVA has advantage to the stratification of the detrimental impact of PR on RV systolic function after TOF repair compared with TAPSE. Methods We prospectively examined patients after TOF repair. Patients &lt;1 year after the repair, those with the history of sustained arrhythmia and those who required concomitant tricuspid and/or pulmonary valve surgery were excluded from the study. IVA was measured by dividing the myocardial velocity during isovolumic contraction by the time interval from the onset of the myocardial velocity during the isovolumic contraction to the time at the peak velocity of this wave. TAPSE was measured using M-mode echocardiography with the M-line passing through the lateral annulus of tricuspid valve in the apical 4-chamber plane. PR jets were evaluated in the parasternal short-axis plane. PR degree was assessed by the number of correspondence to the following conditions; 1) diastolic flow reversal in the main pulmonary artery, 2) diastolic flow reversal in the branch pulmonary arteries, 3) pressure half-time of PR signal &lt;100 msec and 4) the ratio of the duration of the PR signal to the total duration of diastole &lt;0.77. PR degree was graded from 0 to 4. Results Twenty-two patients were enrolled to the study. Age, female, period after the TOF repair and body height of the patients were 11±6 years, 55%, 9±5 years and 137±28 cm, respectively. In all the patients, IVA and TAPSE were 160±27 cm/sec2 and 12±2 mm, respectively. PR degrees were graded as 2, 3 and 4 in 4, 14 and 4 patients, respectively. By the Kruskal-Wallis test, only IVA showed a significant difference among the 3 PR degrees. Conclusion In conclusion, IVA can be a useful index for the stratification of RV function in patients after TOF repair with various degrees of PR.

Funding Acknowledgements Type of funding sources: None. BACKGROUND Assessment of right ventricular systolic function using strain imaging analysis from two-dimensional echocardiography has been identified to have powerful predictive value. Utilization of right ventricular strain may provide additional information in the management of COVID-19 patients. OBJECTIVE To determine and analyze the right ventricular systolic function using longitudinal strain imaging among COVID-19 patients. METHOD This is a prospective cohort study of the right ventricular function using speckle tracking echocardiography among COVID-19 patients. The study included two dimensional (2D) echocardiographic studies among 137 adult patients with laboratory-confirmed COVID-19 from September to November 2020. Analysis of Variance (ANOVA) was used to compare more than two groups with numerical data. Pearson Correlation was utilized to determine correlation between numerical variables. RESULTS The results showed a total of 35 patients (25.54%) to have abnormal right ventricular free wall strain. The results showed that there was a significant direct correlation between right ventricular free wall strain and the echocardiographic parameters of tricuspid annular plane systolic excursion (TAPSE) (r = 0.277; p = 0.001), S’ (r = 0.166; p = 0.050), right ventricular fractional area change (r = 0.298; p &amp;lt; 0.0001) and left ventricular ejection fraction (LVEF) (r = 0.176; p = 0.040). There was a significant inverse correlation noted between right ventricular free wall strain and the echocardiographic parameters of the tricuspid regurgitation (r=-0.284; p = 0.001), pulmonary arterial systolic pressure (r=-0.209; p = 0.014) and left atrial size (r=-0.209; p = 0.014). There was a significant difference in the right ventricular free wall strain according to the severity of COVID-19 infection (p = 0.032). Moreover, a significant difference was also noted between right ventricular free wall strain and mortality (p = 0.0001). The mean right ventricular free wall strain of patients who died was significantly lower than those who were discharged with a mean of 18.92% and 23.59% respectively. CONCLUSION Right ventricular free wall strain using speckle tracking echocardiography, can be used for risk stratification for patients with COVID-19. It also showed that it is has significant correlation with the severity of the disease and mortality. These findings together with other conventional echocardiographic parameters, may provide clinicians additional information in the management of these patients.

This study aimed to assess alterations in right ventricular (RV) function following percutaneous coronary intervention (PCI) in patients with chronic coronary syndromes utilizing three-dimensional speckle tracking echocardiography (3D-STE). A prospective study was conducted involving 136 patients diagnosed with chronic coronary syndromes undergoing PCI, constituting the study group, alongside 110 age- and gender-matched healthy volunteers serving as the control group. Echocardiographic evaluations, including both conventional and three-dimensional assessments, were performed on all study participants at 1-week, 6, and 12 months post-PCI. Parameters such as tricuspid annular plane systolic excursion (TAPSE) were derived from conventional echocardiography, while tricuspid lateral annular systolic velocity (S') was measured via tissue Doppler imaging. 3D-STE was utilized to quantify metrics including right ventricular fractional area change (RVFAC), right ventricular free wall longitudinal strain (RVFWLS), right ventricular global longitudinal strain (RVGLS), right ventricular stroke volume (RVSV), and right ventricular ejection fraction (RVEF). TAPSE, S', RVFAC, RVFWLS, RVGLS, RVSV, and RVEF exhibited significant increases from 1-week to 6 months post-PCI (p < 0.05). However, from 6 to 12 months post-PCI, RVFAC, RVGLS, RVSV, and RVEF demonstrated no notable changes (p > 0.05). Meanwhile, TAPSE, S', and RVFWLS sustained significant elevations: TAPSE (19.63±3.253% to 22.603±2.885%, p < 0.001); S' (10.57±2.643 to 12.61±2.189cm/s, p < 0.001); RVFWLS (18.64±2.745% to 19.926±3.291%, p = 0.002). At 12 months post-PCI, S', RVFAC, RVGLS, RVSV, and RVEF remained lower than those of the healthy control group, but the differences were not statistically significant (p > 0.05). However, RVFWLS was significantly lower compared to the healthy control group (19.926 ± 3.291%vs. 22.10 ± 1.994%, p < 0.001). Following PCI, right ventricular systolic function in patients with chronic coronary syndromes improves significantly over time. However, even at the 12-month post-PCI mark, RVFWLS remains lower than that of the control group. Notably, 3D-STE emerges as a noninvasive method for quantifying right ventricular systolic function post-PCI in chronic coronary syndrome patients.

Objective: To evaluate the right ventricular function using two-dimensional speckle tracking echocardiography (2-D STE) and analyze the associated risk factors of right ventricular dysfunction in patients with silicosis. Methods: All 104 patients with silicosis treated in the Department of Occupational Medicine and Toxicology in Beijing Chao-Yang Hospital, Capital Medical University from May 2021 to September 2022 were enrolled in this study in October 2022. The clinical information of patients such as general data, arterial blood gas analysis and pulmonary function test were collected. The right ventricular function of patients was evaluated by 2-D STE-derived right ventricular free wall longitudinal strain (RVFWLS) and conventional echocardiographic-derived parameters, including right ventricular fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE) and doppler tissue imaging-derived tricuspid lateral annular systolic velocity (S'), respectively. Based on their RVFWLS, the patients were divided into right ventricular dysfunction group and normal right ventricular function group. Risk factors for right ventricular dysfunction in patients with silicosis were analyzed using binary logistic regression analysis. Results: A total of 104 silicosis patients were enrolled, with aneverage age (65.52±11.18) years old, among whom including 57 cases diagnosed with stage Ⅰ/Ⅱ silicosis and 47 cases diagnosed with stage Ⅲ silicosis. 26 (25.00%) patients concurrent right ventricular dysfunction. The abnormal rates of RVFAC, TAPSE and S' in patients were 16.35% (17 cases), 21.15% (22 cases) and 6.73% (7 cases), respectively. The RVFAC and TAPSE in right ventricular dysfunction group were lower than those in normal right ventricular function group, and the incidence of pulmonary arterial systolic pressure ≥36 mmHg was higher than that in normal right ventricular function group (P<0.05). Logistic regression analysis showed that arterial partial pressure of oxygen (OR=0.932, 95%CI: 0.885-0.981, P=0.007) was the protective factor, and the forced expiratory volume in 1 second (FEV(1)) /forced vital capacity (FVC) ratio<70% (OR=5.484, 95%CI: 1.049-28.662, P=0.044) and stage Ⅲ silicosis (OR=6.343, 95%CI: 1.698-23.697, P=0.007) were the risk factors for silicosis patients concurrent right ventricular dysfunction. Conclusion: The incidence of right ventricular dysfunction is higher in patients with stage Ⅲ silicosis than that in patients with stage Ⅰ/Ⅱ silicosis. Using 2-D STE can help the early detection of silicosis with right ventricular dysfunction. Hypoxemia, airflow limitation and the stage Ⅲ silicosis are the risk factors for silicosis patients concurrent right ventricular dysfunction.