Fractional Area Change Research Articles

Discordance between conventional functional parameters and 3D echocardiography-derived ejection fraction in the detection of right ventricular systolic dysfunction

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): EFOP-3.6.3-VEKOP-16-2017-00009 project. Background The conventional echocardiographic parameters of the right ventricular (RV) systolic function (e.g., tricuspid annular plane systolic excursion - TAPSE, fractional area change - FAC) only partially portray the complex functional characteristics of the RV; therefore, they may fail to capture the full spectrum of RV dysfunction and associated adverse clinical outcomes. 3D echocardiography-derived RV ejection fraction (RVEF) is a well-validated and reproducible parameter that overcomes these limitations. Purpose We aimed to investigate the discordance between TAPSE, FAC and RVEF in RV systolic function grading and associated outcomes. Methods Two retrospective databases from different centers including consecutive patients with various cardiac diseases who underwent clinically indicated 2D and 3D echocardiography (n=750) were analysed. Patients were followed up for the occurrence of all-cause mortality. RVEF was measured by a single, commercially available 3D software package. Guideline-recommended cut-off values were used to indicate RV systolic dysfunction (TAPSE<17 mm, FAC<35%). RVEF <45% served as the "ground truth" of RV dysfunction. Results Among patients with normal RVEF (n=511), 109 (21%) had reduced TAPSE, 168 (33%) had reduced FAC, and 49 (10%) had both reduced TAPSE and FAC. Among patients with reduced RVEF (n=239), 108 (45%) had normal TAPSE, 57 (24%) had normal FAC, and 38 (16%) had both normal TAPSE and FAC. Correspondingly, sensitivity and specificity for discrimination of RV systolic dysfunction (RVEF<45%) were 66% and 70% for TAPSE, and 71% and 76% for FAC on ROC analysis, respectively (Figure 1). During the median follow-up time of 3.7 years, 112 patients (15%) died. Using univariable Cox regression, TAPSE (HR [95% CI]: 0.911 [0.881–0.942]), FAC (0.940 [0.924–0.957]), and RVEF (0.928 [0.913–0.944]) were all significant predictors of mortality (p<0.001). Interestingly, combination of the functional assessments based on either TAPSE or FAC with RVEF separates four risk groups that differ significantly in terms of all-cause mortality (Kaplan-Meier curves, Figure 2, log-rank p<0.05). Conclusion Guideline-recommended cut-off values of conventional echocardiographic parameters of RV systolic function are only modestly associated with RVEF-based assessment. This phenomenon may hinder the proper risk stratification of patients with RV systolic dysfunction.

Impact of pulmonary valve replacement on left and right ventricular function using strain analysis, in children with repaired tetralogy of Fallot

BackgroundIn repaired Tetralogy of Fallot (rTOF), pulmonary regurgitation and resulting right ventricular (RV) and left ventricular (LV) dysfunction are associated with adverse clinical outcomes. We performed an echocardiographic assessment of LV and RV function using Global Longitudinal Strain (GLS) and conventional echo method prior to and following Pulmonary Valvular Replacement (PVR) to help inform proper timing of operation.ResultsA total of 30 rTOF patients (12.17 ± 2.5 years, 70% male) were included. Regarding to LV function, the study revealed a significant reverse correlation between LV GLS (absolute value) and early (mean = 10.4 days) and late (mean = 7.4 months) postop LVEF. Paired T-Test showed significant difference between GLS of LV and RV before and late after operation (op), however, without significant changes early postop. Late postop significant improvements occurred in other conventional echo indices of LV and RV function as well. There was also a significant correlation between echo-measured LVEF & Fraction Area Change (RV FAC) and MRI-derived LVEF & RVEF, respectively.ConclusionIn this cross-sectional study in rTOF patients, RV and LV GLS as well as conventional echocardiographic indices regarding LV and RV function improved significantly after 6 months (mean = 7.4mo) following PVR.

Severe pulmonary regurgitation does not influence exercise capacity in patients with repaired Tetralogy of Fallot

Abstract Funding Acknowledgements Type of funding sources: None. Background Identifying exercise determinants in patients with repaired Tetralogy of Fallot (rTOF) is complex. We sought to investigate exercise performance and to identify the best exercise predictors. Methods We prospectively recruited 100 patients with rTOF, 60 patients with severe PR (SPR), and 40 patients with no PR (control). All patients underwent cardiopulmonary exercise testing with echocardiography. Right ventricle (RV) contractile reserve (CR) was defined by the change in peak systolic velocity (ΔRVS’), and change in fractional area change (ΔFAC). Left ventricle (LV) CR was defined by the change in systolic function (ΔLVS’), and change in global longitudinal strain (ΔLVGLS). Results There was no significant difference in the reduced exercise performance between the SPR and control groups by peak absolute oxygen consumption VO2(1695±627 vs 1744±521, ml/min, p>0.05). During exercise, lower RV CR was observed in the SPR group by ΔRVS’ (41±28 vs 48±20%, p<0.05); and ΔFAC (20±15 vs 23±16, %, p<0.05), while it was greater for LV CR by ΔLVS’ (67±34 vs 61±28%, p<0.05). Change in ΔLVGLS was the same (15±17 vs 16±15, %, p>0.05). There were no associations between exercise measures with the degree of PR and RV volume at rest and during exercise. Augmentation of LVGLS and FAC demonstrated independent associations with peak VO2(r=.55, r=.45, p<0.05). Conclusions There was an overall marked reduction in exercise capacity, but no difference between those with and without PR. The degree of exercise limitation is more dependent upon the ability of RV and LV to augment longitudinal function rather than severity of PR.

Left atrial function as a determinant of symptoms in patients with severe degenerative mitral regurgitation

Abstract Funding Acknowledgements Type of funding sources: None. Background Understanding the pathophisiology of symptoms onset in degenerative mitral regurgitation may be helpful in the management of asymptomatic patients. Left atrium (LA) is far from simply being a passive connection chamber between mitral valve and pulmonary circulation, and the role of left atrial function as a predictor of symptoms onset has not yet been evaluated. The increase in atrial pressure that causes elevation of pulmonary capillary pressures and the onset of dyspnoea may be driven by the reduction of left atrial compliance, which can be assessed by peak atrial longitudinal strain (PALS) derived from speckle tracking echocardiography. Aim To assess the role of left atrial function as a determinant of symptoms in patients with severe degenerative MR. Methods We analysed retrospectively all patients affected by severe degenerative MR evaluated for cardiac surgery between May 2019 and July 2022 at IRCCS San Raffaele Hospital. The cohort was divided in symptomatic (NYHA >I) and asymptomatic (NYHA =I) patients. A comprehensive assessment of LA function was performed including pulmonary venous blood flow, LA ejection fraction, LA fractional atrial change, and PALS. Patients with atrial fibrillation during echocardiographic evaluation, left ventricular disfunction and more than mild left heart valvulopathy associated with MR were excluded. Results The final study population consisted of 408 patients. The grade of MR, assessed by multiparametric approach, was not different between the two groups. Age, history of coronary artery disease, dyslipidaemia, hypertension and history of atrial fibrillation were found to be predictive on symptomatology. Fractional area change (OR: 0.89; CI:0.87–0.91, p <0.001), atrial ejection fraction (OR: 0.92, CI= 0.90–0.94, p <0.001), atrial volume(OR: 1.04, CI: 1.02–1.05, p<0.001), pulmonary artery systolic pressure(OR:1.09, CI:1.06–1.13, p<0.001) and longitudinal atrial strain (OR:0.88, CI:0.85–0.90, p<0.001) but not EROA ( OR:1.06, CI: 0.63–2.30, p = 0.8) were found to be predictive. On multivariate logistic regression, only indexed biplane LA volume (OR: 1.02, CI 1.00–1.07, p = 0.035) and PALS (OR: 1.02, CI: 0.87–0.94, p<0.001) were found to be predictive. The best PALS threshold to identify symptomatic patients was 22% (OR: 3.3, SE 67%, SP 87%). Conclusions LA function is a determinant of symptoms in severe degenerative MR. The reduction of PALS appears to be a predictor of symptoms and a value of PALS < 22% identified symptomatic patients with 85% specificity and 67% sensitivity.

TAPSE/systolic pulmonary artery pressure in patients with repaired TOF: Does it correlate with cardiac magnetic resonance indices?

Abstract Funding Acknowledgements Type of funding sources: None. Background and Purpose Potential benefits and optimal timing of pulmonary valve replacement (PVR) in patients with repaired tetralogy of Fallot (rTOF) are still questionable because of high morbidity due to the need for reinterventions. Cardiac magnetic resonance (CMR) is a valuable tool for the detection of irreversible right ventricular (RV) remodelling. We sought to evaluate the relation between CMR derived volumes and peak tricuspid annular systolic excursion (TAPSE)/invasively measured systolic pulmonary artery pressure (sPAP) ratio in patients who underwent right heart catheterization. Methods One hundred and forty-eight patients with rTOF were evaluated; 26 of the patients either had right ventricular outflow tract obstruction or had corrective surgery with a pulmonary conduit. Patients with severe pulmonary regurgitation underwent CMR to quantify RV volumes and EF either before PVR or as part of the follow-up protocol including those who had previous PVR and recurrent pulmonary regurgitation. Echocardiographic indices of RV function were measured according to the EACVI 2015 recommendations for chamber quantification. In a subset of patients who underwent right heart catheterization, systolic RV pressure, sPAP were recorded and TAPSE/invasively measured sPAP ratio was calculated. CMR derived volumes and EF were compared with TAPSE/sPAP. Results Forty-six patients with matching studies for echo, CMR and right heart catheterization were analyzed. Mean age of the patients were 28.0 ± 7.3 years. Mean tricuspid systolic annular velocity (S’), TAPSE, and fractional area change were 11.4 ± 2.9 cm/sec, 16.8 ± 2.9 cm, and 31.7 ± 4.2 %, respectively. CMR derived end-diastolic volume index, end-systolic volume index and EF were 154.6 ± 38.5 ml/m2, 97.4 ± 26.5 ml/m2and 40.0 ± 7.6 %, respectively. There was a negative correlation between TAPSE/sPAP and CMR derived end-diastolic volume index (r= −0.44, p = 0.049) and end-systolic volume index (r= −0.50, p = 0.024) but not with RV EF. Conclusion In patient with rTOF and significant pulmonary regurgitation, TAPSE/invasively measured sPAP is more strongly correlated to CMR derived end-systolic volume index as opposed to end-diastolic volume index. Our findings support the use of CMR derived end-systolic volume index preferentially in the decision making for PVR.

Normal right ventricular augmentation during stress echocardiography- A comparative study

Abstract Funding Acknowledgements Type of funding sources: None. Background The assessment of right ventricular (RV) contractile reserve (CR) during exercise echocardiography in healthy subjects is not well described. We aimed to describe normal RV CR in healthy cases and to compare CR to patients with defined RV compromise because of previous repair of Tetralogy of Fallot. Methods 40 healthy individuals with satisfactory RV windows were randomly selected and retrospectively analysed from previously published study (marathon study). These cases were compared to 100 adult patients with repaired TOF. We defined RV CR by the change in tricuspid lateral annular systolic velocity (ΔRVS’), change in tricuspid annular plane systolic excursion (ΔTAPSE), and change in fractional area change (ΔFAC). All parameters were evaluated at baseline and at peak stress. Results During exercise, RVS’ was increased by 60±20%, followed by TAPSE 48±15%, and the lowest with FAC by 32±10%. These ranges were significantly higher than in TOF population. RV CR was greater in males than females for all RV functional measures (34±10 vs 28±10, %, p<0.05); (50±10 vs 44±11, %, p<0.05); (61±12 vs 52±11, %, p<0.05), for ΔFAC, ΔTAPSE, and ΔRVS’, respectively. There was no association between RV CR and functional capacity parameters in healthy individuals, whereas in patients with repaired TOF there was a significant association with peak absolute VO2 (ml/min) (r=.36, p<0.001, with ΔFAC). Conclusions We have presented normal values for RV CR parameters in healthy cases during stress echocardiography. RV CR is an important determinant of exercise capacity in patients with abnormal RV function but not in normal subjects.

Right ventricular myocardial work characterization in patients with pulmonary hypertension and association with pulmonary hypertension severity

Abstract Funding Acknowledgements Type of funding sources: None. Background Right ventricular myocardial work (RVMW) assessed by transthoracic echocardiography allows to study and analyze the right ventricular (RV) function non-invasively, using RV pressure-strain loops. The association between these novel indexes of RVMW and invasive hemodynamic parameters has not yet been extensively studied, namely in precapillary pulmonary hypertension (PH) population. Objectives To evaluate the relationship between RVMW and the severity of PH through invasive indices of right heart catheterization (RHC) in a cohort of patients with group I and group IV PH. Methods A prospective registry of pre-capillary PH patients evaluated in a single tertiary center was used. Echocardiography and right heart catheterization were performed in the same day. Dedicated software for left ventricle myocardial work was used for the RV. RV global myocardial work index (RVGWI) was calculated as the area of the RV pressure-strain loops. From RVGWI, RV global constructive work (RVGCW; work contributing to myocardial shortening during systole and lengthening during isovolumic relaxation), RV global wasted work (RVGWW; work contributing to myocardial lengthening during systole and shortening during isovolumic relaxation), and RV global work efficiency (RVGWE; relation between RVGCW and RVGWW) were estimated. Pearson’s correlation was applied to assess correlations between continuous variables. Results 17 pts (80% women, mean age 67 ± 10 years) were included. Conventional echocardiographic parameters for the evaluation of RV systolic function, such as TAPSE, annular tricuspid s’ velocity and fractional area change (FAC), did not correlate with mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR). Strong correlations were found between right ventricle-pulmonary artery (RV-PA) coupling and mPAP (r = -0,655, p = 0,006) and RVP(r = - 0,610, p = 0,017), as well as with RV GLS (r = 0,749, p = 0,001 and r = 0,622, p = 0,01, respectively). Of the RVMW indexes, RVGWI, RVGWW and RVGWE strongly correlated with mPAP and PVR: as these invasive parameters increase, RVGWI (r = -0,581, p = 0,015 and r = -0,536, p = 0,027, respectively) and RVGWE (r = -0,779, p < 0,001 and r = -0,773, p < 0,001, respectively) decline significantly, whereas RVGWW (r = 0,735, p = 0,001 and r = 0,800, p < 0,001) increases. In our population, only RVGCW didn’t correlate significantly with high afterload (r= −0,304, p = 0,235 for mPAP, and r = -0,181, p = 0,488 for RVP). Conclusions New methods to evaluate RV function are crucial in patients with RV hemodynamic overload, since conventional echocardiographic parameters do not perform well. Novel echocardiographic assessment of RVMW are associated with severity of PH in our population.

Right ventricular global longitudinal strain and short-term prognosis in patients with first acute coronary syndrome

Abstract Funding Acknowledgements Type of funding sources: None. Background Right ventricular (RV) dysfunction is recognized as an adverse prognostic feature in patients with Acute Coronary Syndromes (ACS). However, conventional echocardiographic indices for the evaluation of RV function have considerable limitations. Right Ventricular Global Longitudinal Strain (RV GLS) is a novel speckle-tracking echocardiographic index that assesses the overall intramyocardial function of the RV free wall and interventricular septum. Purpose The present study aimed to investigate the short-term prognostic value of RV GLS in patients with first ACS. Methods A total of 300 consecutive patients with first ACS (mean age 61.2±11.8 years, 74% males) were prospectively studied. A comprehensive transthoracic echocardiographic assessment was undertaken within 24 hours after revascularization and in-hospital mortality was assessed. Multiple multivariable Cox Regression analysis models were constructed to compare the predictive value of RV function indices for in-hospital mortality. Only significant variables (P<0.05) in the univariate analysis were included in the models. Due to the limited number of events, all multivariable models were constructed including a maximum of 3 variables. To further assess the prognostic value of RV GLS over a baseline model the change in χ2 was assessed using the likelihood ratio test. The absolute value of strain parameters was used for all analysis. Results Patients with anterior-STEMI had significantly more impaired RV GLS (anterior-STEMI 14.52±5.23 vs. inferior-STEMI 17.41±5.06 vs. lateral-STEMI 19.50±4.17 vs. Non-STEMI 20.61±3.69%, P<0.001). A total of 23 (7.7%) patients died in-hospital after revascularization. In univariate analysis RV GLS was significantly associated with in-hospital mortality (HR=0.717, 95% CI=0.642–0.801, P<0.001). After adjustment for Global Registry of Acute Coronary Event (GRACE) risk score and Left Ventricular Ejection Fraction (LVEF), RV function indices that retained independent association with in-hospital mortality were RV GLS, Fractional Area Change, and Tricuspid Annular Plane Systolic Excursion (Table). The model that included RV GLS demonstrated the highest overall χ2 value (Table). To prove the incremental value of RV GLS on in-hospital mortality prognosis, a baseline model including the GRACE risk score was created, and then LVEF was added. The further addition of RV GLS significantly increased the prognostic value the model (Figure). Conclusions RV GLS measured by transthoracic echocardiography within 24 hours after revascularization in patients with first ACS showed the strongest association with in-hospital mortality outperforming other RV function indices. RV GLS provides additine prognostic information over GRACE risk score and LVEF to predict in-hospital mortality.

Right ventricular function in patients with significant tricuspid regurgitation

Abstract Funding Acknowledgements Type of funding sources: None. Aim The aim of this meta-analysis was to systematically investigate the prognostic value of right ventricular (RV) function in all-comers patients with significant (at least moderate, ≥ 2+) tricuspid regurgitation (TR). Background Chronic significant TR imposes a volume overload to the RV leading to a progressive RV dilatation and dysfunction. A comprehensive assessment of RV function is of paramount importance to guide the therapeutic management of these patients; however, it remains challenging, particularly in presence of altered loading conditions. Methods MEDLINE, ISI Web of Science, and SCOPUS databases were searched for studies published up to July 2022. Studies reporting data on at least one echocardiographic RV function parameter and outcome in patients with significant TR were included. This study was designed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) requirements. The primary endpoint was all-cause long-term mortality (more than one year). Results Out of 3,152 studies, a total of 10 were included in the analytic synthesis, enrolling 3435 subjects. The median follow-up in our study population was 28 [22 – 70] months. All-cause long-term mortality was 40% (95% confidence interval [CI]: 32–49%, p = 0.028; Figure 1). To explore the potential impact of effect size modifiers on all-cause long-term mortality, we performed a meta-regression analysis of the baseline characteristics of the included studies. At long-term, a significant relation was found between RV fractional area change (RV-FAC), tricuspid annular plane systolic excursion (TAPSE), tricuspid annular tissue doppler imaging systolic velocity (TDI s’) and mortality. In particular, RV-FAC was associated with reduced incidence of all-cause mortality [7 studies enrolling 2,611 subjects, intercept 5.18, slope −0.15, P = 0.007; Figure 2]; whereas both TAPSE and TDI s’ were unsatisfactory to predict the outcome in these patients [TAPSE 9 studies enrolling 2,891 subjects, intercept 1.73, slope −0.12, P = 0.36; TDI s’ 5 studies enrolling 1429 subjects, intercept −2.06, slope 0.15, P = 0.78]. Interestingly, diabetes mellitus (DM) and hyperlipidaemia were associated with an increased risk of mortality [DM 9 studies enrolling 3371 subjects, intercept −2.62, slope 0.09, P = 0.004; hyperlipidaemia 6 studies enrolling 2338 subjects, intercept −2.91, slope 0.05, P = 0.01]. Conclusions Significant TR is associated with increased risk of all-cause. To our knowledge, this is the first study to demonstrate that only RV-FAC, and not conventional echocardiographic indexes of RV longitudinal function, correlates with adverse outcomes in patients with significant TR.

Echocardiographic assessment of right ventricular function and right ventriculoarterial coupling in tricuspid regurgitation

Abstract Funding Acknowledgements Type of funding sources: None. Background Echocardiographic evaluation of the cardiopulmonary unit may be difficult in the presence of tricuspid regurgitation (TR) and combined echocardiographic parameters could therefore be useful in such patients. Purpose To assess the variation of simple and combined echocardiographic parameters analysing the cardiopulmonary unit according to the severity of TR. Methods Echocardiographic images were reviewed in 179 patients to assess TR grade according to Hahn’s 5 grades classification. Classical morphological (right ventricle (RV) end diastolic (ED) length and area), function (tricuspid annular plane systolic excursion (TAPSE), RV fractional area change (RVFAC), S’ wave, RV free wall longitudinal strain (RVFWS)) and load (TR Time-velocity integral (TR TVI), pulmonary artery systolic pressure (PASP)) parameters analysing RV were assessed. Combined parameters of function and load (TAPSE/PASP, TR TVI x RVFWS), morphology and load (load adaptation index (LAI) = TR TVI x RVED length/area) and morphology, load, and function (myomechanical index (MMI = RV-RA mean pressure gradient x RVFWS/indexed RAED area x 10–2 ) and morphology-load-function index (MLF = RVED length/area x TR TVI x RVFWS)) were calculated. We used receiver operating characteristic (ROC) curve analysis to analyze the diagnostic value of echocardiographic parameters to predict potential high (>3) or low (<6) surgical risk of mortality according to TRISCORE. Results Simple parameters were significatively different among groups with a nonlinear progression between the 5 levels of severity of TR. Combined parameters were also significatively different among groups. Among them, MMI and MLF had a linear progression between the 5 groups (MMI: grade 1: 0.20±0.09; grade 2: 0.15±0.08; grade 3: 0.10±0.05, grade 4: 0.09±0.08; grade 5: 0.05±0.04 p = 0.000; MLF: grade 1: 7.56±2.06; grade 2: 6.57±2.14; grade 3: 4.85±2.29, grade 4: 4.79±3.17; grade 5: 3.06±1.82 p = 0.000) and had the best predictive value for TRISCORE high and low risk (MMI: AUC =0.889 p = 0.000 for low risk, 0.855 p = 0.000 for high risk; MLF: AUC =0.873 p = 0.000 for low risk, 0.822 p = 0.000 for high risk). Conclusion Combined parameters are relevant to evaluate cardiopulmonary unit in a population presenting with TR, especially when combining morphology, function and load parameters. Their good predictive value for TRISCORE risk suggests a potential role of such parameters in the prognostic assessment of TR patients and in the selection for new percutaneous repair techniques.

Characterization of right-sided strain parameters in atrial and ventricular functional tricuspid regurgitation

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial functional tricuspid regurgitation (A-FTR), defined as TR due to prominent right atrial (RA) dilatation without significant right ventricular (RV) remodelling, has recently emerged as a distinct subtype of FTR, and can be distinguished from ventricular FTR (V-FTR), defined by significant RV remodelling leading to annular dilatation and leaflet tethering. However, so far no data has been reported on the values of RV and RA strain in these patients. Purpose To evaluate potential differences in right-sided strain parameters in patients diagnosed with severe atrial and ventricular FTR. Methods Patients with severe FTR, without a cardiac implantable electronic device, were categorized as V-FTR when in sinus rhythm and either having left-sided cardiac disease, pulmonary hypertension, or moderate/severe RV dysfunction. Patients, in sinus rhythm or atrial fibrillation, with no other cause of annular dilatation and impaired leaflet coaptation than RA dilatation were classified as A-FTR. Extensive echocardiographic assessment was performed, including 2D-speckle-tracking strain analysis. Results A total of 525 patients with severe FTR (mean age 66 ± 15 years, 42% male) were included, of which 401 patients (76%) were classified as V-FTR and 124 patients (24%) as A-FTR. Baseline clinical and echocardiographic characteristics are shown in Figure 1. Patients presented with mild RV dilatation (RV end-diastolic area 12.9 ± 4.0cm2/m2) and RV dysfunction (RV free wall longitudinal strain [FWLS] 18.3 ± 6.8%), and with moderate-to-severe RA dilatation (RA max volume 36.8 [26.9 – 52.2] ml/m2) and moderate-to-severe RA dysfunction (RA reservoir strain 17.0 [11.0 – 27.0] %). Corresponding to the phenotype, patients with A-FTR presented with significantly smaller RV size and better RV function (Figure 1). However, despite overall normal values of RV function by RV fractional area change, tricuspid annular plane systolic excursion (TAPSE) and RV FWLS, 27% of A-FTR patients showed reduced RV FWLS based on cut-off value of −20%. In addition, patients with A-FTR showed more dilated RA, as compared to patients with V-FTR, but with better RA function assessed by 2D-strain values (Figure 1). Notwithstanding, still 73% of the A-FTR-patients showed reduced RA strain values, when using the cut-off reported for normality of 34%. Conclusion Approximately 25% of patients diagnosed with severe FTR presented with A-FTR. These patients presented with significantly better right-sided strain parameters as compared to patients with V-FTR, despite more pronounced RA dilatation.

Prognostic significance of size and function of the subpulmonary left ventricle in patients with a systemic right ventricle

Abstract Funding Acknowledgements Type of funding sources: None. Background Systolic dysfunction of the systemic right ventricle (SRV) is a well-recognized predictor of adverse events in adults with transposition of great arteries (TGA) after atrial switch repair or with congenitally corrected TGA (ccTGA). The prognostic role of subpulmonary left ventricle (LV), however, remains unclear. Purpose To assess the prognostic significance of echocardiographic parameters of subpulmonary LV size and systolic function. Methods All adult patients with the SRV who underwent transthoracic echocardiography in 2010–2018 at a large tertiary referral centre were identified from a digitally recorded echocardiographic database. Biventricular size and function were assessed at the most recent exam. The study endpoint was all-cause mortality and heart or heart-lung transplantation. Results We included 180 patients, 100(55.6%) male, mean age 42.4±12.3 years, of whom 103(57.2%) had undergone Mustard/Senning operations and 77(42.8%) had ccTGA. One half of patients were in NYHA class ≥2 and 113 (63.5%) were receiving heart failure medication(s). During a follow-up period of 4.9[3.8–5.7] years, 28(15.6%) patients died and 4(2.2%) underwent heart or heart-lung transplantation. Univariable predictors of death or transplantation included older age, NYHA class III/IV, history of atrial arrhythmias, presence of pacemaker or cardioverter-defibrillator, high BNP, and echocardiographic markers of both SRV and subpulmonary LV size and function (Figure 1). On multivariable Cox analysis, indexed LV end-systolic diameter (ESDi; HR 2.77 [95%CI 1.35–5.68], p = 0.01), LV fractional area change (FAC; HR 0.7 [95%CI 0.57–0.85], p = 0.002), SRV basal diameter (HR 1.66 [95%CI 1.21–2.29], p = 0.005), and SRV FAC (HR 0.65 [95%CI 0.49–0.87], p = 0.008) remained predictive of mortality or transplantation. On ROC analysis, subpulmonary LV parameters performed better than SRV markers in predicting death or transplantation (Figure 2). Conclusions A raised LV ESDi and reduced LV FAC were strongly associated with mortality and heart or heart-lung transplantation independent of SRV size and function. Accurate echocardiographic assessment of the subpulmonary LV is therefore essential for risk stratification and management of patients with the SRV and should be a part of routine echocardiographic protocols.

Short period of training in 3D echocardiography provides good feasibility and reproducibility of right ventricular assessment in heart failure

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): PROHEART 3D. Background Right ventricular (RV) dysfunction is an independent risk factor for increased mortality and morbidity. Standard approach for assessing is 2-dimensional echocardiography (2DE). However, 2DE is prone to errors due to increased variability of the anatomical cut-planes and geometrical assumptions due to the complex triangular and "wrapped-around" RV shape. Meanwhile, 2DE reflects mainly the RV longitudinal function, at the expense of the radial and global RV functions. 3D echocardiography (3DE) enabled itself as a more accurate method for assessment of cardiac volumes and calculation of ejection fraction (EF), but with a cumbersome learning time-curve. Objectives To establish if trainees in 3DE provide feasible and reproducible 3D measurements of RV size and function, by comparison to 2DE assessment, after a short period of training by an expert in echocardiography. Methods 161 consecutive patients (58±17 years, 71% males, 3D left ventricular EF 35±10%), hospitalized for heart failure (HF), underwent standard precordial 2DE acquisitions and 3DE multi-beat full-volumes of the RV. One expert in both 2DE and 3DE, and one fellow trained for 2 years in 2DE and for 3 months in 3DE, performed measurements of both 2DE and 3DE parameters for RV size and function, in a blinded fashion. 2DE parameters were measured first, in the following order: RV diameter, RV end-diastolic (RVED) and end-systolic (RVES) areas, RV fractional area change (RV FAC), tricuspid annular plane systolic excursion (TAPSE), tricuspid annular systolic velocity (RV S’), and RV free wall longitudinal strain (RV LS). Then, 3D RVED and RVES volumes were measured, and RV ejection fraction (RVEF) was calculated, using a semi-automated software package. Endocardial borders were corrected, as needed. Results Feasibility of 2DE and 3DE was 97% and 92%, respectively, patients being excluded due to poor quality images, similarly for expert vs. trainee. Mean RVED volume was 94.0±30.6 ml/m2, and mean RVEF was 37.3±9.6%. Reproducibility of 2DE parameters obtained by the expert vs. trainee were good for the assessment of RV longitudinal function (TAPSE, RV S', and RV LS), but suboptimal for the assessment of RV size and global function (RV diameter, RV areas, and RV FAC) (Table). Reproducibility of 3DE parameters obtained by the expert vs. trainee were also good, even after a short period of training (3 months) (Table). Conclusions A short period of training in 3DE provides a good feasibility and reproducibility of the assessment of RV size and function, in a large cohort of hospitalized patients with HF. 3DE might be a more reliable method than 2D for the initial assessment of patients with HF.

Validation of American Society of Echocardiography Guideline-Recommended Parameters of Right Ventricular Dysfunction Using Artificial Intelligence Compared With Cardiac Magnetic Resonance Imaging

Right ventricular function is important in evaluation of cardiac function but its assessment by standard transthoracic echocardiographic (TTE) remains challenging. Cardiac magnetic resonance imaging (CMR) is considered the gold standard. The American Society of Echocardiography recommends surrogate measures of RV function and ejection fraction (RVEF) by TTE including fractional area change (FAC), free wall strain (FWS), and tricuspid annular planar systolic excursion (TAPSE), but they require technical expertise in acquisition and quantification. We sought to evaluate the sensitivity, specificity, and positive and negative predictive values (PPV, NPV) of FAC, FWS, and TAPSE derived by a rapid, novel artificial intelligence (AI) software (LVivoRV®) from a single-plane TTE apical 4-chamber (A4C), RV-focused view without ultrasound-enhancing agents for detecting abnormal RV function compared with CMR-derived RVEF. RV dysfunction was defined as RVEF<50% and <40% on CMR. TTE and CMR were performed within a median of 10 days [IQR: 2-32] of each other in 225 consecutive patients without interval procedural or pharmacological intervention. The sensitivity and NPV to detect CMR-defined RV dysfunction when all three AI-derived parameters (FAC, FWS, and TAPSE) were abnormal were 91% and 96%, while those of expert physician-reads were 91% and 97%. Specificities and PPV were lower (50% and 32%) compared with expert physician-read echocardiograms (82% and 56%). AI-derived measurements of FAC, FWS, and TAPSE had excellent sensitivity and NPV for ruling out significant RV dysfunction (CMR RVEF <40%), comparable to that of expert physician readers, but lower specificity. This AI, using ASE guidelines, may serve as a useful screening tool for rapid bedside assessment to exclude significant RV dysfunction.

Papillary muscle approximation in chronic ovine functional tricuspid regurgitation

ObjectiveIsolated tricuspid ring annuloplasty remains the surgical standard for functional tricuspid regurgitation repair but offers suboptimal results when right ventricular dilation and remodeling along with papillary muscle displacement is present. Addressing subvalvular remodeling with papillary muscle approximation may improve clinical outcomes. MethodsFunctional tricuspid regurgitation and biventricular dysfunction were induced in 8 healthy sheep by rapid ventricular pacing (200-240 bpm) for 27 ± 6 days. Subsequently, animals underwent cardiopulmonary bypass for implantation of sonomicrometry crystals on the tricuspid annulus, right ventricle, and papillary muscle tips. Papillary approximation sutures were anchored between anterior-posterior and anterior-septal papillary muscles and externalized through right ventricular free wall to epicardial tourniquets. After weaning from cardiopulmonary bypass, sequential papillary muscle approximations were performed. Simultaneous hemodynamic, sonomicrometry, and echocardiographic data were collected at baseline and after each papillary muscle approximation. ResultsWith rapid pacing, right ventricular fractional area change decreased from 59 ± 6% to 38 ± 8% (P < .001), whereas tricuspid annulus diameter increased from 2.4 ± 0.3 cm to 3.3 ± 0.6 cm (P = .003). Tricuspid regurgitation (0-4+) increased from +0 ± 0 to +3.3 ± 0.7 (P < .001). Both anterior–posterior and anterior–septal papillary muscle approximation significantly reduced functional tricuspid regurgitation from +3.3 ± 0.7 to +2 ± 0.5 and +1.9 ± 0.6, respectively (P < .001). Reduction of tricuspid insufficiency with both subvalvular interventions was associated with decreased distance of the anterior papillary muscle to the annular centroid. ConclusionsPapillary muscle approximations were effective in reducing severe ovine functional tricuspid regurgitation associated with right ventricular dilation and papillary muscle displacement. Further studies are needed to evaluate efficacy of this adjunct to ring annuloplasty in repair of severe functional tricuspid regurgitation.

Quantitative Measures of Right Ventricular Size and Function by Echocardiogram Correlate with Cardiac Catheterization Hemodynamics in Congenital Diaphragmatic Hernia

To evaluate associations between cardiac catheterization (cath) hemodynamics, quantitative measures of right ventricular (RV) function by echocardiogram, and survival in patients with congenital diaphragmatic hernia (CDH). This single-center retrospective cohort study enrolled patients with CDH who underwent index cath from 2003 to 2022. Tricuspid annular plane systolic excursion z score, RV fractional area change, RV free wall and global longitudinal strain, left ventricular (LV) eccentricity index, RV/LV ratio, and pulmonary artery acceleration time were measured from preprocedure echocardiograms. Associations between hemodynamic values, echocardiographic measures, and survival were evaluated by Spearman correlation and Wilcoxon rank sum test, respectively. Fifty-three patients (68% left-sided, 74% liver herniation, 57% extracorporeal membrane oxygenation, 93% survival) underwent cath (39 during index hospitalization, 14 later) including device closure of a patent ductus arteriosus in 5. Most patients (n=31, 58%) were on pulmonary hypertension treatment at cath, most commonly sildenafil (n=24, 45%) and/or intravenous treprostinil (n=16, 30%). Overall, hemodynamics were consistent with precapillary pulmonary hypertension. Pulmonary capillary wedge pressure was >15mm Hg in 2 patients (4%). Lower fractional area change and worse ventricular strain were associated with higher pulmonary artery pressure while higher LV eccentricity index and higher RV/LV ratio were associated with both higher pulmonary artery pressure and higher pulmonary vascular resistance. Hemodynamics did not differ based on survival status. Worse RV dilation and dysfunction by echocardiogram correlate with higher pulmonary artery pressure and pulmonary vascular resistance on cath in this CDH cohort. These measures may represent novel, noninvasive clinical trial targets in this population.

Prognostic Value of Tricuspid Annular Plane Systolic Excursion (TAPSE), Right Ventricular Fractional Area Changes (RV FAC) and Pulses Tissue Doppler S' Wave (PTD S') at 30 Days after Care of Acute Miocardial Infarction Patients in Haji Adam Malik Hospital

Introduction: Echocardiography is a reliable and simple method of hemodynamic monitoring that can be used on every IMA patient. Tricuspid Annular Plane Systolic Excursion (TAPSE), Right Ventricular Fractional Aera Changes (RV FAC), and Pulses Tissue Doppler S' Wave (PTD S') are the three main parameters of ventricular electrocardiography. The purpose of this study is to understand the reliability of the right ventricle function prognostic indicators TAPSE, PTD S', and RV FAC with regard to the MACE at 30 days following the occurrence of the AMI in RSUP H. Adam Malik Medan&#x0D; Method: This study is an ambispective observational analytic study with sampling carried out at one time (cross-sectional study) on 88 AMI patients at the HAM Hospital who were treated from March 2022 to June 2022 and performed echocardiography in the first 24 hours and measured TAPSE, PTD S' and RV FAC. And followed for 30 days to see the MACE in patients. Bivariate test was conducted to assess the correlation between variables. To determine which independent variables were more effective at predicting MACE, a multivariate logistic regression test was then run. The effectiveness of the independent factors in predicting MACE was also assessed using ROC analysis.&#x0D; Results: The total subjects were 88 AMI patients consisting of 39 (44.3%) patients who experienced MACE and 49 (55.6%) patients who didn’t. The prognostic values of TAPSE, PTDS' and RV FAC on MACE at 30 days were related by bivariate analysis with P Value 0.001 but only PTD S’ showed logistic regression results that were consistent with P Value &lt; 0.001. Based on ROC analysis obtained by PTD S' can predict MACE with AUC = 0.894&#x0D; Conclusion: Echocardiographic measurement PTD S’ has a good prognostic value to predict MACE within 30 days in AMI patients.

Effect of different titration methods on right heart function and prognosis in patients with acute respiratory distress syndrome

BackgroundAcute respiratory distress syndrome (ARDS) is a common disease in intensive critical care(ICU), and the use of positive end-expiratory pressure(PEEP) during mechanical ventilation can increase the right heart afterload and eventually cause right heart dysfunction. For these factors causing acute cor pulmonale(ACP), especially inappropriate mechanical ventilation settings, it is important to explore the effect of PEEP on right heart function. ObjectiveTo investigate the effects of three titration methods on right heart function and prognosis in patients with ARDS. MethodsObservational, prospective study in which ARDS patients were enrolled into three distinct PEEP-titration strategies groups: guide, transpulmonary pressure-oriented and driving pressure-oriented. Prognostic indicators, right heart systolic and diastolic echocardiographic function indices, ventilatory parameters, blood gas analysis results, and respiratory mechanics Monitoring indices were collated and analyzed statistically by STATA 15 software. ResultsA total of 62 ARDS patients were enrolled into guide (G) group (n=40) for whom titrated PEEP values were 9±2cm H2O, driving pressure-oriented (DPO) group (n=12) with titrated PEEP values of 10±2cm H2O and transpulmonary pressure-oriented (TPO) group (n=10) with titrated PEEP values of 12±3cm H2O. Values were significantly higher for TPO than for G (p=0.616) or DPO (p=0.011). Compliance was significantly increased after 72 h in the TPO and DPO groups compared with the G group (p<0.001). Mean airway pressure at end-inspiratory obstruction (p=0.047), tricuspid annular plane systolic excursion (TAPSE, p<0.001) and right ventricular area change fraction (RVFAC, p=0.049) were all higher in the TPO and DPO groups than in the G group. E/A indices were significantly better in the TPO group than in the G or DPO groups (p=0.046). No significant differences in 28 day mortality were found among the three groups. Multivariate logistic regression analysis revealed that lung compliance and transpulmonary pressure-oriented PEEP titration method was negatively correlated to the increase in right ventricular systolic dysfunction. ConclusionTranspulmonary pressure-oriented PEEP titration improves oxygenation and pulmonary function and causes less right heart strain when compared to other PEEP-titration methods during mechanical ventilation of ARDS patients.

Normal range of intraoperative three-dimensionally derived right ventricular free-wall strain in coronary artery bypass surgery patients.

Data on intraoperative three-dimensionally derived right ventricular free-wall strain (3D-RV FWS) is sparse. We sought to evaluate the normal range of intraoperative 3D-RV FWS in patients scheduled for coronary artery bypass graft (CABG) surgery and compared to conventional echocardiographic parameters. Prospective observational study. A total of 150 patients with preserved left and right ventricular (RV) function and sinus rhythm, without significant heart valve disease or pulmonary hypertension undergoing isolated on-pump CABG surgery, with an uneventful, complication-free intraoperative course. 3D-RV FWS analysis and conventional echocardiographic assessment of RV function were performed intraoperatively in anesthetized and ventilated patients using transesophageal echocardiography (TEE). TomTec 4D RV-Function 2.0 software for assessment of 3D-RV FWS and three-dimensional right ventricular ejection fraction (3D-RV EF). Philips QLAB 10.8 was used to evaluate tissue velocity of the tricuspid annulus (RV S´), tricuspid annular systolic excursion (TAPSE), and RV fractional area change (FAC). All echocardiographic measurements were performed under stable hemodynamic conditions and predefined fluid management without any vasoactive support or pacing. The prospective observational study was performed in a single university hospital setting. Assessment of 3D-RV FWS was feasible in 95% of patients. No included patient experienced any serious perioperative complication. In our group of patients, median values with interquartile range (IQR) for 3D-RV FWS and 3D-RV EF were -25.2 (IQR -29.9 to -21.8) and 46.3% (IQR 41.0%-50.1%), respectively. RV FAC, RV S´, and TAPSE accounted for 39.7% (IQR 34.5%-44.4%), 14.8cm/s (IQR 11.8-19.0cm/s), and 22mm (IQR 20-25mm). The normal range (2.5% to 97.5% percentile) for 3D-RV FWS was -37.1 to -12.8. There was no relevant correlation of 3D-RV FWS to postoperative outcome in this group of CABG patients. We present distribution values for intraoperative 3D-RV FWS and conventional parameters of RV function assessment in a healthy on-pump CABG patient population without serious perioperative complications. We observed no correlations of these parameters with any of the outcome parameters considered. Therefore, we consider these values to be intraoperative TEE-assessed normal values, which can be expected in on-pump CABG patients.

Disease progression in exercise-induced compared to desmosomal arrhythmogenic cardiomyopathy - a longitudinal cohort study

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Oslo University Hospital, Procardio Center for Innovation Introduction Arrhythmogenic cardiomyopathy (AC) is an inheritable heart disease caused by mutations in genes encoding the cardiac desmosomes, while exercise-induced AC (EiAC) has been proposed as an acquired similar phenotype in athletes. Little is known about the progression of EiAC compared to AC. Purpose To assess functional and structural disease progression in EiAC compared to desmosomal AC during long-term follow-up. Methods We consecutively included probands with definite AC diagnosis according to the 2010 Task Force Criteria and patients with EiAC in a longitudinal cohort study. EiAC was diagnosed in competitive endurance athletes (&amp;gt;24 MET-hours/week for &amp;gt;6 consecutive years) referred with symptomatic ventricular arrhythmias who had no family history, no genetic mutations associated with heart disease, and no other identified etiology after through clinical work-up. All patients in both groups were recommended to avoid high intensity exercise. Progression of the structural phenotype was assessed by regular repeated echocardiographic examinations during long-term follow-up. Right ventricular (RV) function and size were assessed by RV fractional area change (FAC), RV basal diameter (RVD) and RV outflow tract (RVOT) diameter. Disease progression was evaluated and compared using linear mixed model regression. Results Forty-one EiAC patients (15% women, age 45±13 years) and 84 AC probands (51% mutation positive, 35% women, age 43±15) were followed for 6.6 (IQR 3.7-10.5) and 7.9 (IQR 5.2-10.8) years, respectively. Key parameters from 570 echocardiographic examinations (184 EiAC and 386 AC) were assessed. There was no deterioration of RV function during follow-up in EiAC patients, in contrast to AC patients (FAC yearly progression rate: EiAC +0.02% [95% CI -0.27 to 0.31] vs AC -0.60% [95% CI -0.71 to -0.50] per year, p=0.001, Figure left panel). RV size did not increase in EiAC patients in contrast to AC patients (RVD: EiAC +0.01 mm [95% CI -0.00 to 0.03] vs AC +0.78 mm [95% CI 0.68 to 0.89] per year, p&amp;lt;0.001, Figure mid panel, and RVOT: EiAC +0.01 mm [95% CI -0.01 to 0.02] vs AC +0.47 mm [95% CI 0.38 to 0.56] per year, p&amp;lt;0.001, Figure right panel). Conclusion Patients with exercise-induced AC had no evidence of disease progression during long-term follow-up. These patients had a more benign disease trajectory than patients with desmosomal AC. Despite the limited sample size, these results seem reassuring for patients diagnosed with exercise-induced AC.