Impairment Of Right Ventricular Function Research Articles

Parameters associated with therapeutic response using peritoneal dialysis for therapy refractory heart failure and congestive right ventricular dysfunction.

BackgroundIn patients with refractory heart failure (HF) peritoneal dialysis (PD) is associated with improved functional status and decrease in hospitalization. However, previous studies did not focus on right ventricular dysfunction as an important pathophysiologic component of cardiorenal syndrome.MethodsIn a prospective cohort study PD was started in 40 patients with refractory right HF (with/without left HF). Refractoriness to conservative therapy was defined as persistent right heart congestion/ascites with intensified diuretic treatment and/or ≥2 hospitalizations within 6 months because of cardiac decompensation despite optimal medical treatment, and/or acute renal failure during intensified conservative treatment of cardiac decompensations.ResultsPatient survival was 55.0% at 1 year, 35.0% at 2 years and 27.5% at 3 years. The number of hospitalization days declined after initiation of PD for both cardiac [13 (IQR 1–53) days before vs. 1 (IQR 0–12) days after start of PD, p<0.001] and unplanned reasons [12 (IQR 3–44) days before vs. 1 (IQR 0–33) days after start of PD, p = 0.007]. Using a combined endpoint including survival time of ≥1 year and either improvement in quality of life or decline in hospitalizations we found that patients with extended ascites, higher systolic pulmonary artery pressure, more marked impairment of right ventricular function and tricuspid valve insufficiency, higher residual renal function as well as those who could perform PD without assistance have benefited most from this therapy.ConclusionsPatients with more pronounced backward failure, less marked residual renal functional impairment and those not depending on assistance for therapy are likely to profit most from PD.

Inhibition of TLR9-NF-κB-mediated sterile inflammation improves pressure overload-induced right ventricular dysfunction in rats.

Recent accumulating evidence suggests that sterile inflammation plays a crucial role in the progression of various cardiovascular diseases. However, its contribution to right ventricular (RV) dysfunction remains unknown. The aim of this study was to elucidate whether toll-like receptor 9 (TLR9)-NF-κB-mediated sterile inflammation plays a critical role in the pathogenesis of RV dysfunction. We performed main pulmonary artery banding (PAB) in rats to induce RV pressure overload and dysfunction. On Day 14 after PAB, the pressure overload impaired RV function as indicated by increased RV end-diastolic pressure concomitant with macrophage infiltration and fibrosis, as well as maximal activation of NF-κB and TLR9. Short-term administration (days 14-16 after PAB) of a specific TLR9 inhibitor, E6446, or an NF-κB inhibitor, pyrrolidine dithiocarbamate (PDTC) significantly attenuated NF-κB activation. Furthermore, long-term administration of E6446 (treatment: days 14-28) or PDTC (prevention: days -1 to 28; treatment: days 14 to 28) improved RV dysfunction associated with mitigated macrophage infiltration and fibrosis in right ventricle and decreased serum brain natriuretic peptide levels. Inhibition of TLR9-NF-κB pathway-mediated sterile inflammation improved PAB-induced RV dysfunction in rats. This pathway plays a major role in the progression of pressure overload-induced RV dysfunction and is potentially a novel therapeutic target for the disorder.

Prospective Echocardiographic Evaluation of the Right Ventricle and Pulmonary Arterial Pressure in Hyperthyroid Patients

Pulmonary arterial hypertension (PAH) occurs in 35% to 65% of hyperthyroid patients. Despite this high frequency, only a few authors have examined the effects of hyperthyroidism treatment on PAH and the right ventricle. We evaluated the effects of hyperthyroidism and its reversal on cardiovascular structure and function using Doppler echocardiography. We prospectively evaluated 32 patients (42.5±11.9years old) with thyrotoxicosis. Exclusion criteria included previous cardiovascular disease. An echocardiogram was performed at the time of hyperthyroidism diagnosis and after normalisation of free thyroxine (T4) levels. Patients were divided into two groups according to the presence or absence of PAH at the diagnosis, or at two moments, before and after T4 normalisation. Graves' disease was the most frequent aetiology (75%) of hyperthyroidism. Pulmonary arterial hypertension was observed in 43.8% of patients. Free T4 concentration was higher in PAH than non-PAH patients. Free T4 normalised after 5 (2.0-10.5; median and percentiles) months of treatment. Cardiac chamber sizes and cardiac output were higher in PAH. Right ventricular (RV) systolic function was impaired in PAH. Cardiac output and free T4 (r=0.42; p<0.05) correlated with pulmonary artery systolic pressure (PASP). Cardiac chamber size, cardiac output, left ventricular ejection fraction, and PASP (34.0±8.6 to 21.7±4.5mmHg) reduced after treatment. Right ventricular myocardial performance index and fractional area change improved after T4 normalisation. Pulmonary arterial hypertension is highly prevalent in hyperthyroid patients and is combined with increased cardiac chambers size and cardiac output, and impaired RV function. Cardiovascular changes are reversible after T4 normalisation in patients without cardiovascular disease.

Inflammation in Right Ventricular Failure: Does It Matter?

Right ventricular (RV) failure is a common consequence of acute and chronic RV overload of pressure, such as after pulmonary embolism and pulmonary hypertension. It has been recently realized that symptomatology and survival of patients with pulmonary hypertension are essentially determined by RV function adaptation to increased afterload. Therefore, improvement of RV function and reversal of RV failure are treatment goals. Currently, the pathophysiology and the pathobiology underlying RV failure remain largely unknown. A better understanding of the pathophysiological processes involved in RV failure is needed, as there is no proven treatment for this disease at the moment. The present review aims to summarize the current understanding of the pathogenesis of RV failure, focusing on inflammation. We attempt to formally emphasize the importance of inflammation and associated representative inflammatory molecules and cells in the primum movens and development of RV failure in humans and in experimental models. We present inflammatory biomarkers and immune mediators involved in RV failure. We focus on inflammatory mediators and cells which seem to correlate with the deterioration of RV function and also explain how all these inflammatory mediators and cells might impact RV function adaptation to increased afterload. Finally, we also discuss the evidence on potential beneficial effects of targeted anti-inflammatory agents in the setting of acute and chronic RV failure.

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

BackgroundRight 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).AimTo assess the affection of right ventricular function in patients presenting with NSTEMI undergoing an invasive procedure.Subjects and methodsOne hundred and fifty patients admitted with a first NSTEMI and eligible for reperfusion therapy via invasive percutaneous coronary intervention. These patients were divided in two groups; group A including patients with normal RV function, and group B including patients with impaired RV function as diagnosed by tricuspid annular plane systolic excursion (TAPSE) cutoff value < 17 mm. All patients underwent angioplasty and were followed up in-hospital and for 3 months.ResultsRV dysfunction occurred in ninety-five (61.3%) patients of the study population. Significant improvement occurred to TAPSE after 3 months in comparison to TAPSE at baseline (15.45 ± 3.21 versus 17.09 ± 4.17 mm). Those with impaired RV function showed improvement of TAPSE after three months as compared to baseline (13.62 ± 2.58 vs 17.16 ± 3.64 p = 0.008). Multivariate analysis determined the independent predictors of RV dysfunction as RVEDD > 26 mm, RVFAC < 35%, RAA > 20 cm2, and TAPSE < 17 mm.ConclusionRV dysfunction is not uncommon in NSTEMI when using the definition of TAPSE < 17 mm. Following up RV function by TAPSE, showed significant improvement after 3 months with successful PCI as compared to baseline. We recommend assessing and following up RV function in all patients admitted with a NSTEMI.

Elevated suppression of tumorigenicity 2 receptor is associated with poor outcome in heart failure with preserved ejection fraction

Soluble suppression of tumorigenicity 2(sST2) receptor is a well-known biomarker implicated in inflammatory diseases. It has already been shown that sST2 is associated with worse outcome in HFrEF. We sought to evaluate the association of sST2 with clinical, laboratory and imaging findings and its prognostic value in HFpEF. Between January 2015 and June 2017, we prospectively enrolled 137 consecutive HFpEF patients (79 ± 8 years, 61% women). Elevated sST2 was determined by an age and sex-adjusted cutoff value (55 ng/ml) corresponding to mean + 2 SD in 31 controls (75 ± 6years, 61% women). All patients underwent complete 2D echo and cMR and were followed up for a composite outcome of mortality and first HF hospitalization. Median sST2 level was 44.5 ng/ml (IQR: 31.6–62.2 ng/ml). Elevated sST2 patients ( n = 46) had an impaired right ventricular (RV) function (FAC 39 ± 10% vs. 43 ± 8%, P = 0.017; RVEF by cMR 53.5 ± 9.8% vs. 58.1 ± 7.8%, P = 0.008) and a higher proportion with pathologic RV/RA gradient ( n = 20 (40%) vs. n = 23 (26%), P = 0.034). They were similar for other clinical, laboratory and imaging characteristics. Multivariate logistic analysis showed that only RVEF by cMR was associated with high sST2 level (OR: 0.94 [0.89–0.99], P = 0.010). During a mean follow-up of 20 ± 8months, 71 patients (52%) reached the combined end point. Cox analysis identified GFR, hemoglobin, sST2, use of loop diuretic and E/e’ ratio as significant predictors of outcome. Only GFR (HR = 0.98 [0.96–0.99], P < 0.001) and sST2 (HR = 3.64 [1.37–9.65], P = 0.009) were significantly associated with the composite outcome even after adjusting for important clinical and imaging covariables. Kaplan Meier event free survival curve showed that high sST2 HFpEF patients had poorer prognosis than low sST2 patients ( P = 0.001, Fig. 1 ). In HFpEF, sST2 is associated with impaired RV function and with a poorer prognosis with higher rate of mortality and first HF hospitalization.

Evaluation of Right Ventricular Function by Speckle-Tracking Echocardiography in Patients with Ankylosing Spondylitis: A Case-Control Study.

We aimed to evaluate the right ventricular (RV) systolic function in patients with ankylosing spondylitis (AS) compared to healthy subjects by using standard echocardiography and speckle-tracking echocardiography (STE) methods. This was a case-control study in which 64 patients (mean age, 55.7 ± 9.2 years; male/female, 53/11), who had AS for at least five years (mean disease duration, 7.1 ± 2.6 years) and 70 age-matched healthy subjects (mean age, 54.9 ± 8.5 years; male/female 55/15) were included. Clinical and laboratory signs of cardiac disease were recorded. The RV systolic function was assessed by standard echocardiography and two-dimensional STE method. Case and control groups did not show significant difference in terms of clinical and laboratory signs of cardiac disease. RV function parameters in standard echocardiography were statistically similar between AS patients and control subjects. However, RV parameters in STE revealed significantly impaired RV function in AS patients compared to control group. RV-free wall longitudinal strain, RV-free wall longitudinal systolic strain rate, RV-free wall longitudinal early diastolic strain rate, RV-free wall longitudinal late diastolic strain rate were lower, and RV-early diastolic strain rate/RV-late diastolic strain rate ratio was higher for the patients in the AS group (p < 0.001 for all). AS is associated with impaired RV function as shown by STE even if there is no clinical or laboratory sign of cardiac abnormality. STE is more effective than standard echocardiography to detect RV function. Therefore we suggest regular evaluation of RV function in patients with AS.

Right ventricular global longitudinal strain predicts survival in patients with pulmonary hypertension receiving specific vasodilator therapy

In patients (pts) with pulmonary hypertension (PH) different right ventricular (RV) function parameters predict outcome. Data regarding the prognostic value of averaged 6-segments RV longitudinal strain (RV-GLS) in PH pts are scarce. To assess the predictive value of 6-segments RV-GLS in PH pts receiving vasodilator therapy. Forty-seven pts (40 ± 15 years, 36 women) with PH treated with either bosentan, sildenafil, or both and 33 controls with similar age and gender (40 ± 11 years, 21 women) were studied. Clinical parameters and biologic (B-type natriuretic peptide, BNP), invasive and echocardiographic parameters of RV function (TAPSE, TDI-derived free-RV wall S- and e’-wave, RV fractional area change (FAC), Tei index, I/H, RV isovolumic acceleration-IVA) were assessed. 6-segments RV-GLS was measured from the apical 4-chamber view by STE. PH pts were followed-up for 23 months (2–49). An endpoint of cardiac death was defined. PH pts had larger right chambers size, PA size and pressures, impaired RV function than controls (all P < 0.001), including RV-GLS (−14.0 ± 4.8% vs. −23.3 ± 2.7%, P < 0.001). During follow-up, 8 pts died. At univariable analysis, predictors of death were: TAPSE (15 ± 3 mm in deceased pts vs. 18 ± 3 mm in surviving pts, P = 0.011), RV-S (9.1 ± 2.1 cm/s vs. 11.5 ± 1.9 cm/s, P = 0.002), FAC (25 ± 9% vs. 36 ± 8%, P = 0.001), RV-GLS (−9.6 ± 4.2% vs. −14.9 ± 4.5%, P = 0.003), IVA (0.16 ± 0.07 cm/s 2 vs. 0.24 ± 0.10 cm/s 2 , P = 0.041) and BNP levels (lnBNP, 5.8 ± 1.0 vs. 4.7 ± 1.5, P = 0.05). ROC curve analysis showed that RV-GLS had the highest predictive value for cardiac death (AUC 0.82, P = 0.005). Cutoff value for RV-GLS derived from ROC curve analysis was used to construct Kaplan-Meier survival curves. A value of −13.2% for RV-GLS predicted cardiac death with 87% sensitivity and 62% specificity. In PH pts, RV function parameters have prognostic value. Six-segments RV-GLS emerged as the strongest predictor of cardiac death with a cutoff value of −13.2% in this setting.

High-risk inferior myocardial infarction: Can speckle tracking predict proximal right coronary lesions?

It is important to diagnose right ventricular (RV) infarction in the setting of acute inferior myocardial infarction (MI). We aimed to improve the diagnostic accuracy of RV infarction and identify a high-risk subset of inferior MI patients with proximal RCA lesions. We tried to find the link between speckle tracking and coronaries in high risk inferior infarction METHODS: This study included 68 patients within 24 hours of first acute inferior MI. Group 1 (n = 49) isolated inferior MI; group 2 (n = 19) inferior and RV MI. echocardiography for RV free wall longitudinal strain (FWLS), RV fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), RV myocardial performance index (MPI) and peak systolic velocity (S'). Group 2 had higher MPI by tissue Doppler and 2D-RV average FWLS, whereas RV FAC, S', and TAPSE were lower (P < 0.001). In group 1, 14.4% had a significant proximal RCA lesion with impaired RV function. RV average FWLS at a cutoff value ≥ - 19.7% can predict proximal RCA culprit lesion with 91.7% sensitivity and 70.5% specificity, which was detected as an independent predictor in multivariate logistic regression (odds ratio: 37.75, P = 0.036). 2D RV average FWLS at a cutoff of ≥ - 19.7% is a useful added tool for diagnosis of RV involvement and an independent predictor to rule in proximal RCA culprit lesion in inferior-wall MI patients in the emergency department.

Effect of Riociguat and Sildenafil on Right Heart Remodeling and Function in Pressure Overload Induced Model of Pulmonary Arterial Banding.

Pulmonary arterial hypertension (PAH) is a progressive disorder characterized by remodeling of the pulmonary vasculature and a rise in right ventricular (RV) afterload. The increased RV afterload leads to right ventricular failure (RVF) which is the reason for the high morbidity and mortality in PAH patients. The objective was to evaluate the therapeutic efficacy and antiremodeling potential of the phosphodiesterase type 5 (PDE5) inhibitor sildenafil and the soluble guanylate cyclase stimulator riociguat in a model of pressure overload RV hypertrophy induced by pulmonary artery banding (PAB). Mice subjected to PAB, one week after surgery, were treated with either sildenafil (100 mg/kg/d, n = 5), riociguat (30 mg/kg/d, n = 5), or vehicle (n = 5) for 14 days. RV function and remodeling were assessed by right heart catheterization, magnetic resonance imaging (MRI), and histomorphometry. Both sildenafil and riociguat prevented the deterioration of RV function, as determined by a decrease in RV dilation and restoration of the RV ejection fraction (EF). Although both compounds did not decrease right heart mass and cellular hypertrophy, riociguat prevented RV fibrosis induced by PAB. Both compounds diminished TGF-beta1 induced collagen synthesis of RV cardiac fibroblasts in vitro. Treatment with either riociguat or sildenafil prevented the progression of pressure overload-induced RVF, representing a novel therapeutic approach.

Impaired right ventricular function as a predictor of early mortality in patients with light‑ chain cardiac amyloidosis assessed in a cardiology department.

INTRODUCTION Light‑chain (AL) amyloidosis is the most common cardiac amyloidosis. Despite progress in treatment, early mortality remains a substantial problem in these patients. OBJECTIVES The aim of this study was to determine a clinical profile of patients diagnosed with AL amyloidosis in a cardiology department, as well as to define the cut‑off point for early mortality and identify predictors of early mortality in this population. PATIENTS AND METHODS The study included 30 patients (14 women; median age, 61.5 years) with AL amyloidosis confirmed by echocardiography and biopsy of 2 organs. RESULTS Six patients were diagnosed with stage II amyloidosis according to the Mayo 2004 classification, and 24 patients-with stage III. Early mortality was defined as death during 102 days after diagnosis and was observed in 14 patients. Patients who died earlier were younger and more frequently reported a weight loss of more than 10 kg and orthostatic hypotension than patients who died later. Moreover, they had higher concentrations of high‑sensitivity troponin T and N‑terminal pro‑B‑type natriuretic peptide (NT‑proBNP) and worse left and right ventricular (RV) contractility. In the Cox models, the age of less than 64 years, NT‑proBNP levels exceeding 4968 pg/ml, RV end‑diastolic diameter of less than 34 mm, and tricuspid annular plane systolic excursion lower than 13 mm were significant predictors of mortality within 102 days after diagnosis. CONCLUSIONS We presented the results of the first Polish prospective noninterventional study on AL amyloidosis diagnosed in the cardiology department. We found that patients have advanced disease at the time of diagnosis. Younger age, impaired RV function, and higher concentrations of cardiac markers are predictors of worse prognosis.

The International Multicenter TriValve Registry: Which Patients Are Undergoing Transcatheter Tricuspid Repair?

ObjectivesThis study sought to develop a large, international registry to evaluate the diffusion of these approaches and investigate patient characteristics and initial clinical results. BackgroundSeveral transcatheter tricuspid valve therapies are emerging as therapeutic options for patients with severe symptomatic tricuspid regurgitation (TR), generally a high-risk surgical population. MethodsThe TriValve (Transcatheter Tricuspid Valve Therapies) registry included 106 high-risk patients (76 ± 9 years of age; 60.4% women; European System for Cardiac Operative Risk Evaluation II 7.6 ± 5.7%) from 11 cardiac centers, with severe TR. ResultsA total of 35% of the patients had prior left heart valve intervention (surgical in 29 of 106 and transcatheter in 8 of 106 patients). Right ventricular (RV) dysfunction (tricuspid annular plane systolic excursion <17 mm) was present in 56.3% of the patients; 95% of the patients were in New York Heart Association functional class III to IV. The etiology of TR was functional in 95.2%, and the mean tricuspid annulus was 45.4 ± 11 mm. In 76.9% of the patients, the main location of the regurgitant jet was central; pre-procedural systolic pulmonary artery pressure was 39.7 ± 13.8 mm Hg; and the inferior vena cava was severely dilated in most of the patients (27.4 ± 6.8 mm). Implanted devices included MitraClip (n = 58), Trialign (n = 17), TriCinch (n = 15), FORMA (n = 7), Cardioband (n = 5), and caval valve implantation (n = 3). One case had combined Trialign + MitraClip. Patients treated with the different techniques were similar in terms of European System for Cardiac Operative Risk Evaluation II and degree of RV dysfunction. In 68% of the cases the tricuspid intervention was performed as an isolated procedure. Procedural success was achieved in 62% of cases. At 30-day follow-up, all-cause mortality was 3.7%, with an overall incidence of major adverse cardiac and cerebrovascular events of 26%; 58% of the patients were New York Heart Association functional class I or II at 30 days. ConclusionsPatients currently undergoing transcatheter tricuspid valve therapy are mostly high risk, with a functional etiology and very severe central regurgitation, and do not have severely impaired RV function. Initial results suggest that transcatheter tricuspid valve therapy is feasible with different techniques, but clinical efficacy requires further investigation.

SY10-5 - Elevation of Central Venous Pressure and Organ Congestion

For the assessment of right-sided heart failure, right ventricular (RV) function is frequently evaluated, and the evaluation of central venous pressure (CVP) or right atrial pressure (RAP), which is reflective of increased RV filling pressure or elevated pre-load due to impaired RV function, is also commonly performed. Assessing IVC with echocardiography is a standard non-invasive method. However, its weak point is a semiquantitative assessment. Moreover, our report shows that body size, measured as BSA, affects the optimal cut-off level of IVC for detecting increased RAP in Japanese HF patients. Transient elastography is a noninvasive method to assess liver stiffness. Recently, using transient elastography, we have revealed that liver congestion represented as liver stiffness (LS) can estimate RAP in HF patients without liver disease. With the analysis in patients admitted due to HF, higher LS at discharge was associated with higher incidence of cardiac events. This result indicates that the presence of liver congestion at discharge may associate with poor outcomes. Elevated CVP is also associated with kidney or intestine congestion. We will introduce and discuss the association of CVP, as an indicator of right-sided heart failure, with organ congestion.

3D echocardiographic evaluation of right ventricular function and strain: a prognostic study in paediatric pulmonary hypertension.

To evaluate right ventricular functional indices using 3D echocardiography (3DE) between normal children and paediatric pulmonary hypertension (PH) patients, and to evaluate these indices as outcome predictors in children with PH. Ninety-six paediatric PH patients from 2014 to 2016 were compared with 40 normal controls. All patients underwent 3DE and off-line analysis generated 3D end-diastolic volume, 3D end-systolic volume, 3D stroke volume, 3D right ventricular (RV) ejection fraction (EF), RV longitudinal strain (LS) free wall and septum, tricuspid annular plane systolic excursion (TAPSE), and fractional area change (FAC). PH patients had higher RV volumes, lower RV EF, lower free wall and septal RVLS, lower TAPSE, and lower FAC compared with normal controls (all P < 0.001). 3D RV EF, free wall RVLS, and FAC are predictors of adverse clinical outcomes [hazard ratio (confidence interval) 0.1 (0.03-0.27], P < 0.001; 0.17 (0.07-0.45), P < 0.001; 0.08 (0.03-0.22); P < 0.001, respectively). Paediatric PH patients have impaired RV function compared with normal children. 3D RV EF, volumes, FAC, and free wall RV strain serve as outcome predictors for paediatric PH patients.

Effect of ventricular function and volumes on exercise capacity in adults with repaired Tetralogy of Fallot

ObjectivesInvestigate the effects of left and right ventricular function and severity of pulmonary valve regurgitation, quantified by cardiac magnetic resonance (CMR), on exercise tolerance in adult patients who underwent ToF repair at a young age. MethodsThis is a retrospective cohort study of 52 patients after ToF surgery and 33 age- and sex-matched healthy volunteers. CMR and cardiopulmonary exercise testing (CPET) were performed on all patients; CPET was performed on control subjects. ResultsThe main finding of CPET was a severe decrease in oxygen uptake at peak exercise VO2peak in TOF patients. The patients were characterized also by lower pulse O2peak and heart rate at peak exercise. Ejection fraction of the right and left ventricles was correlated (r=0,32; p=0,03). Left ventricle ejection fraction was negatively correlated with right ventricular volumes (r=−0,34; p=0,01) and right ventricular mass (r=−046; p<0,00). Right ventricular mass was positively correlated with left ventricular variables (left ventricle end diastolic volume, r=0,43; p=0,002; left ventricle end systolic volume, r=0,54; p<0,00) as was VO2peak: LVEDV (r=0,38; p=0,01); LVESV (r=0,33; p=0,03) and LV mass (r=0,42; p=0,006). ConclusionExercise intolerance in adults with repaired ToF is markedly depressed. The decreased exercise capacity is correlated with impaired RV function and may be associated also with LV dysfunction, which suggests right-to-left ventricular interaction.

Correlation between right ventricular T1 mapping and right ventricular dysfunction in non-ischemic cardiomyopathy.

Right ventricular (RV) fibrosis is increasingly recognized as the underlying pathological substrate in a variety of clinical conditions. We sought to employ cardiac magnetic resonance (CMR) techniques of strain imaging and longitudinal relaxation time (T1) mapping to better examine the relationship between RV function and structure. Our aim was to initially evaluate the feasibility of these techniques to evaluate the right ventricle. We then sought to explore the relationship between RV function and underlying fibrosis, along with examining the evolution of RV remodeling according to the amount of baseline fibrosis. Echocardiography was performed in 102 subjects with non-ischemic cardiomyopathy. Right ventricular parameters were assessed including: fractional area change (FAC) and longitudinal strain. The same cohort underwent CMR. Post-contrast T1 mapping was performed as a marker of fibrosis with a Look-Locker technique using inversion recovery imaging. Mid-ventricular post-contrast T1 values of the RV free wall, RV septum and lateral LV were calculated using prototype analysis software. Biventricular volumetric data including ejection fraction was measured by CMR using a cine short axis stack. CMR strain analysis was also performed to assess 2D RV longitudinal and radial strain. Simultaneous biochemical and anthropometric data were recorded. Subjects were followed over a median time of 29 months (IQR 20-37 months) with echocardiography to evaluate temporal change in RV FAC according to baseline post-contrast T1 values. Longitudinal data analysis was performed to adjust for patient loss during follow-up. Subjects (62% men, 51 ± 15 years) had mild to moderately impaired global RV systolic function (RVEF = 39 ± 15%; RVEDV = 187 ± 69ml; RVESV = 119 ± 68ml) and moderate left ventricular dysfunction at baseline (LVEF 30 ± 17%). Good correlation was observed between mean LV and RV post-contrast T1 values (r = 0.652, p < 0.001), with similar post-contrast T1 values maintained in both the RV free wall and septum (r = 0.761, p < 0.001). CMR RVEF demonstrated a proportional correlation with echocardiographic measures of RV longitudinal function and CMR RV strain (longitudinal r = -0.449, p = 0.001; radial r = -0.549, p < 0.001). RVEF was related to RV post-contrast T1 values, particularly in those with RV dysfunction (free wall T1 r = 0.259 p = 0.027; septal T1 r = 0.421 p < 0.001). RV strain was also related to RV post-contrast T1 values (r = -0.417, p = 0.002). Linear regression analysis demonstrated strain and post-contrast T1 values to be independently associated with RVEF. Subjects with severe RV dysfunction (CMR RVEF <25%) demonstrated lower RV CMR strain (longitudinal p = 0.018; radial p < 0.001), RV T1 values (free wall p = 0.013; septum <0.001) and RV longitudinal echocardiography parameters despite no difference in afterload. During follow-up, those with RV free wall post-contrast T1 values ≥ 350ms demonstrated ongoing improvement in FAC (Δ6%), whilst values <350ms were associated with deterioration in RV function (ΔFAC = -5%) (p = 0.026). CMR provides a comprehensive method by which to evaluate right ventricular function. Post-contrast T1 mapping and CMR strain imaging are technically feasible and provide incremental information regarding global RV function and structure. The proportional relationship between RV function and post-contrast T1 values supports that myocardial fibrosis is a causative factor of RV dysfunction in NICM, irrespective of RV afterload. This same structural milieu also appears integral to the propensity for both positive and negative RV remodeling long-term, suggestive that this is also determined by the degree of underlying RV fibrosis.

Long-term cardiovascular changes following creation of arteriovenous fistula in patients with end stage renal disease.

Short-term studies have reported left ventricular (LV) dilatation following surgical creation of arteriovenous fistulas (AVF) or arteriovenous grafts (AVGs), but chronic cardiac structural and functional changes have not been examined or related to clinical outcomes following AVF/AVG. We sought to characterize the long-term changes in cardiac structure and function in patients undergoing shunt creation for haemodialysis. A retrospective analysis was performed of patients undergoing echocardiography before and after surgical AVF/AVG creation for the initiation of haemodialysis. 137 patients underwent echocardiographic examinations prior to AVF and 2.6 years (median) after AVF creation. Following AVF and dialysis initiation, there were reductions in blood pressure, body weight and estimated plasma volume coupled with modest reverse LV remodelling. In contrast, AVF/AVG creation was associated with significant right ventricular (RV) dilatation and deterioration in RV function. Incident heart failure (HF) developed in 43% of patients in tandem with greater RV remodeling. The development of RV dilation following surgical AVF/AVG was independently associated with increased risk of death [HR 3.9, 95% CI (1.7-9.2), P = 0.001]. In long-term follow-up, RV remodelling and dysfunction develop following AVF/AVG creation and dialysis initiation, despite improved control of LV pressure load through dialysis. Deleterious effects on right heart structure and function are coupled with development of incident HF and increased risk of death. Further study is required to identify patients at greatest risk for detrimental AVF/AVG changes who may benefit from alternate forms of dialysis or potentially ligation of existing AVF.

Randomised controlled trial examining the effect of an outpatient exercise training programme on haemodynamics and cardiac MR parameters of right ventricular function in patients with pulmonary arterial hypertension: the ExPAH study protocol

IntroductionPulmonary hypertension (PH) is a potentially life-threatening condition characterised by elevated pulmonary artery pressure. Early stage PH patients are often asymptomatic. Disease progression is associated with impairment of right ventricular...

Echocardiographic Evaluation of Right Ventricular Function in the Immediate Postoperative Period after Major Pulmonary Resections: A Prospective Observational Study

ABSTRACT Aim We aimed to identify the impact through the use of standard and novel echocardiographic parameters, i.e., speckle tracking echocardiography (STE) to evaluate the right and left ventricular (LV) myocardial function in patients who underwent lung resections. Materials and methods We identified patients that underwent lobectomy or pneumonectomy at our institution in 2016 to 2017. We performed preoperative transthoracic echocardiography (TTE) in each patient and on postoperative days (PODs) 2, 7, and 30 when available. Results Of a total of 26 patients included in the study, 5 underwent pneumonectomy, while the rest underwent lobectomy. Left and right pneumonectomy was performed in 38 and 62% of the patients respectively. None of the patients had right ventricular (RV) dilation or dysfunction on preoperative echocardiograms. Postoperatively, mean LV ejection fraction (LVEF) was 52 (±7.5) %. Mean RV strain in immediate postoperative period (day 2) was –15.1% (reduction of more than 20%). None of the patients progressed to RV failure or had mortality. Estimated RV systolic pressure was 41 (±20) mm Hg. The differences in RV echocardiographic parameters were significantly different pre- and postsurgery. The RV function decreased significantly on POD 2, which improved slightly thereafter. Extent of resection and side of resection did not make a difference in the RV functions. Conclusion After lung resection, patients developed deterioration in RV function that may be reflected by any of the echocardiographic parameters used to assess RV function. Deterioration in RV function is maximum in the immediate postoperative period (day 2), which improves to preoperative level by 4 weeks. How to cite this article Bhat IH, Kumar A, Kumar B, Ganesan R, Mandal B, Dutta V. Echocardiographic Evaluation of Right Ventricular Function in the Immediate Postoperative Period after Major Pulmonary Resections: A Prospective Observational Study. J Perioper Echocardiogr 2017;5(2):42-48.

Effects of exercise training on pulmonary hemodynamics, functional capacity and inflammation in pulmonary hypertension.

Pulmonary hypertension (PH) is characterized by severe exercise limitation mainly attributed to the impairment of right ventricular function resulting from a concomitant elevation of pulmonary vascular resistance and pressure. The unquestioned cornerstone in the management of patients with pulmonary arterial hypertension (PAH) is specific vasoactive medical therapy to improve pulmonary hemodynamics and strengthen right ventricular function. Nevertheless, evidence for a beneficial effect of exercise training (ET) on pulmonary hemodynamics and functional capacity in patients with PH has been growing during the past decade. Beneficial effects of ET on regulating factors, inflammation, and metabolism have also been described. Small case-control studies and randomized clinical trials in larger populations of patients with PH demonstrated substantial improvements in functional capacity after ET. These findings were accompanied by several studies that suggested an effect of ET on inflammation, although a direct link between this effect and the therapeutic benefit of ET in PH has not yet been demonstrated. On this background, the aim of the present review is to describe current concepts regarding the effects of exercise on the pulmonary circulation and pathophysiological limitations, as well as the clinical and mechanistic effects of exercise in patients with PH.