Global Right Ventricular Dysfunction Research Articles

Right Ventricular Function and Exercise Tolerance in Patients with ST-Elevation Myocardial Infarction.

Following ST-segment elevation myocardial infarction (STEMI), patients with cardiac dysfunction have limitations in performing physical activity. Right ventricular (RV) function is a determinant in improving functional capacity, and cardiac rehabilitation (CR) is essential for this patient cohort. To evaluate the association of RV function with exercise tolerance after a CR program in patients with STEMI. Retrospective cohort study in patients with STEMI from January to December 2019. They underwent an echocardiographic assessment of RV function before a 16-session CR program. A cardiopulmonary exercise (CPX) testing was performed before and after the CR program. We analyzed whether RV function measured before CR was significantly associated with exercise tolerance before and after the CR program and the degree of improvement. Comorbidity, demographic and anatomic variables were documented. A p-value < 0.05 was considered statistically significant. A total of 109 patients were included. Of all, 3.7% had global RV dysfunction, 10.1% had radial RV dysfunction, and 11% had longitudinal RV dysfunction. An association between radial or longitudinal RV dysfunction and the absence of improvement in cardiorespiratory fitness (> 1 peak VO2equivalents) was observed (p = 0.028, p = 0.008, respectively). A significant correlation was observed between longitudinal RV dysfunction with initial peak VO2equivalents (pVO2eq) (p = 0.046), final pVO2eq (p = 0.003), and difference in pVO2eq (p = 0.009). A correlation was also identified between global RV dysfunction and the initial pVO2eq (p = 0.045), final pVO2eq (p = 0.012), and difference in pVO2eq (p = 0.032). RV dysfunction is associated with a lower capacity to exercise; CR programs can be extended or modified in these patients.

The relationship between RV strain and haemodynamic parameters in patients with pulmonary arterial hypertension

Abstract Funding Acknowledgements Type of funding sources: None. Background Pulmonary arterial hypertension (PAH) is a progressive disease leading to right ventricular (RV) failure and death. Risk stratification is crucial for patient management. Guideline recommends several imaging parameters for screening and risk stratification. Right ventricular 2-dimensional speckle tracking strain (RVS) is a promising parameter, as it is angle-independent, less load-dependent, and highly reproducible. We aimed to determine the relationship between invasive haemodynamic parameters and simultaneously measured RV global (RVGLS) and RV free wall strain (RVFWS). Methods A single-centre prospective cohort of 17 patients with idiopathic and systemic sclerosis-related PAH (54±15 years, 89% female) were consecutively enrolled. Right heart catheterisation was performed in all patients according to the recommendation of the recent guideline. The patients underwent simultaneous transthoracic echocardiography, complying with the rules of asepsis, and also, particular attention was paid to the standard zero reference level during the recordings. Results The RVGLS showed a strong correlation with systolic and mean pressure measured invasively in the RV (p&amp;lt;0.005, r−0.8 and p&amp;lt;0.05, r−0.73). Also observed was a strong correlation between RVGLS and mean pulmonary arterial pressure (mPAP) and pulmonary vascular resistance (PVR) (p&amp;lt;0.005, r−0.749, and p&amp;lt;0.005, r−0.005- Figure 1.). RVGLS correlated with NT-proBNP level (p&amp;lt;0.05, r−0.58), but, we did not find a relationship between RVFWS and invasively measured parameters. Conclusion In our cohort of patients with PAH, RVGLS correlated well with simultaneously measured haemodynamic parameters. RVFWS was not shown to have a relationship with RHC parameters. The observation highlights the importance of global RV dysfunction caused by elevated PVR and mPAP.

Abstract 9592: The Super Relaxed State of Myosin Contributes to the Pathogenesis of Right Ventricular Dysfunction in Pulmonary Hypertension

Introduction: Patients with pulmonary hypertension (PH) often succumb to right ventricular (RV) failure yet little is known regarding the underlying pathological mechanisms. Recently, the transition of myosin from the disordered relaxed (DRX) to the super relaxed (SRX) state during diastole has been identified as a pathological feature contributing to myocardial dysfunction in heart failure. Using synchrotron radiation (SR) x-ray diffraction (SAXS), the proximity of myosin heads relative to actin in the in situ beating rat heart can be evaluated in different layers of the myocardial wall. We performed SR SAXS at different timepoints post-PH induction with simultaneous PV-loop acquisition to assess if SRX transition contributes to progressive global RV dysfunction in a rat model of PH. Methods: PH was induced in rats using the Sugen5416/3-week 10% hypoxia method, with rats being returned to normoxia for 3- (SuHx3wk) or 6-weeks (SuHx6wk) after the hypoxic period. SR SAXS was performed at BL40XU, SPring-8 Synchrotron, Japan. Global and site-specific RV myofilament phosphorylation status was also examined. Results: Compared to control rats (n=7), SuHx3wk (n=7) and SuHx6wk (n=7) rats exhibited progressive increases in RV size, RV end systolic pressure (ESP), RV dP/dt max and dP/dt min (all P&lt;0.05 vs. Control). In the deeper subendocardial layer of the RV free wall, there were virtually no myosin heads within the proximity of actin at end diastole in SuHx6wk rats, whereas in the control and SuHx3wk rats, around 30-50% of myosin heads were in proximity to actin (P&lt;0.05, SuHx6wk vs. Control and SuHx3wk). No significant differences in diastolic sarcomere length were found, suggesting a transition of myosin from DRX to SRX in the SuHx6wk rats. Importantly, indices for global RV function (ESP, dP/dt max, dP/dt min ) significantly correlated with diastolic myosin mass transfer values. Analysis of RV myofilament phosphorylation revealed a progressive and significant reduction in MLC-2v phosphorylation over the time course of PH in rats. Conclusion: PH is associated with progressive changes in global RV function, which may be attributed to a transition from DRX to SRX state of myosin in the RV. Reduced MLC-2v phosphorylation may underlie the DRX to SRX transition in PH.

Right Ventricular Contraction Patterns in Patients Undergoing Transcatheter Tricuspid Valve Repair for Severe Tricuspid Regurgitation.

This study investigated patterns of right ventricular (RV) contraction by using cardiac magnetic resonance (CMR) imaging in patients undergoing transcatheter tricuspid valve repair (TTVR). The role of RV function in patients with severe tricuspid regurgitation undergoing TTVR is poorly understood. Global RV dysfunction was defined as CMR-derived RV ejection fraction (RVEF)≤45% and longitudinal RV dysfunction was defined as tricuspid annular plane systolic excursion (TAPSE)<17mm on echocardiography. Patients were stratified into 3 types of RV contraction: type I, TAPSE≥17 and RVEF >45%; type II, TAPSE<17 and RVEF >45%; and type III, TAPSE<17 and RVEF≤45%. CMR feature tracking was performed to assess longitudinal and circumferential RV strain. The primary outcome was a composite of all-cause mortality or first heart failure hospitalization. Of 79 patients (median age 79 years, 51% female), 18 (23%) presented with global and 40 (51%) presented with longitudinal RV dysfunction. The composite outcome occurred in 22 patients (median follow-up 362days). Global RV dysfunction but not longitudinal RV dysfunction (hazard ratio: 6.62; 95% confidence interval: 2.77-15.77; and hazard ratio: 1.30; 95% confidence interval: 0.55-3.08, respectively) was associated with the composite outcome. Compared with type I RV contraction, patients with type II RV contraction exhibited increased circumferential strain, with a preservation of RVEF despite diminished longitudinal strain. Patients with type III RV contraction exhibited both diminished longitudinal and circumferential strain, resulting in an impaired RVEF. Patients with type III RV contraction showed the worst survival (P< 0.001). Global RV dysfunction is a predictor of outcomes among TTVR patients. Tricuspid regurgitation patientscan be stratified into 3 types of RV contraction, in which a loss of longitudinal function can be compensated by increasing circumferential function, preserving RVEF and favorable outcomes.

P5553Right ventricular involvement in hypertrophic cardiomyopathy: insights from a tertiary centre

Abstract Introduction Hypertrophic cardiomyopathy (HCM) is the main cause of sudden cardiac death in the young and a cause of heart failure (HF) and death at any age. Nevertheless, adverse long-term outcomes are not easy to predict. Objectives To assess the prevalence and prognostic value of right ventricular (RV) involvement in patients (pts) with HCM. Methods Retrospective single-centre study of consecutive pts with HCM evaluated in a specialized consultation. Selected those submitted to cardiac magnetic resonance imaging (CMR) as the gold-standard for RV assessment. The primary endpoint (PE) was a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, ventricular arrhythmias with hemodynamic instability and unplanned HF admission. Results Of a total of 181 pts, 104 fulfilled the inclusion criteria (mean age at first consultation 62.1±9.7 years, 63.5% male). Septal asymmetric phenotype was the most frequent (73.1%) and 24 pts (23.1%) had rest LV outflow tract obstruction. Mean value of maximum wall thickness was 18.8±4.6 mm. Regarding CMR parameters (Fig A), 5.8% had RV dysfunction and 2.9% RV free wall hypertrophy; no patient presented RV dilation. Late gadolinium enhancement (LGE) of joint points was observed in 47.1%. During follow-up (FU, mean 56.6±29.5 months), survival free of RV dysfunction was 94.3%. Only 5 pts developed RV compromise assessed by echocardiographic parameters: TAPSE 12.0±3.4 mm and pulsed tissue Doppler systolic annular velocity (tricuspid S') wave 7.3±0.9 cm/s. These pts were significantly older (p&lt;0.01) and had higher values of average tissue doppler E/E' ratio at diagnosis (p&lt;0.01). Global RV involvement (at diagnosis or during FU) were associated with increased values of indexed left atrial area (p&lt;0.01), LV dysfunction (p=0.01), LGE of joint points (p=0.01) and higher values of NT-proBNP (p=0.01). In multivariate logistic regression, left atrial enlargement was the only independent predictor of global RV dysfunction (OR 1.9, 95% CI 1.1–3.2, p=0.01) and average E/E' ratio an independent predictor of RV dysfunction during FU (OR 1.3, 95% CI 1.1–1.5, p&lt;0.01). PE rate was 10.6%. It was significantly higher in pts with global RV involvement and there was a significant difference in survival analysis (Fig B). Average E/E' ratio (OR 1.5, 95% CI 1.1–1.9, p=0.01) and RV ejection fraction (OR 0.8, 95% CI 0.7–0.9, p=0.01) were independent predictors of the outcome. Conclusions Although not common, RV dysfunction was associated with a higher rate of cardiovascular events. Average E/E' ratio, as a measure of left ventricular filling pressure, was a risk factor for both RV dysfunction and PE. Higher values of RV ejection fraction were protective of adverse events occurrence. Together, these results support a potential role of RV function in the risk stratification of HCM pts.

The right ventricular fibroblast secretome drives cardiomyocyte dedifferentiation.

RationaleIn virtually all models of heart failure, prognosis is determined by right ventricular (RV) function; thus, understanding the cellular mechanisms contributing to RV dysfunction is critical. Whole organ remodeling is associated with cell-specific changes, including cardiomyocyte dedifferentiation and activation of cardiac fibroblasts (Cfib) which in turn is linked to disorganization of cytoskeletal proteins and loss of sarcomeric structures. However, how these cellular changes contribute to RV function remains unknown. We’ve previously shown significant organ-level RV dysfunction in a large animal model of pulmonary hypertension (PH) which was not mirrored by reduced function of isolated cardiomyocytes. We hypothesized that factors produced by the endogenous Cfib contribute to global RV dysfunction by generating a heterogeneous cellular environment populated by dedifferentiated cells.ObjectiveTo determine the effect of Cfib conditioned media (CM) from the PH calf (PH-CM) on adult rat ventricular myocytes (ARVM) in culture.Methods and resultsBrief exposure (<2 days) to PH-CM results in rapid, marked dedifferentiation of ARVM to a neonatal-like phenotype exhibiting spontaneous contractile behavior. Dedifferentiated cells maintain viability for over 30 days with continued expression of cardiomyocyte proteins including TnI and α-actinin yet exhibit myofibroblast characteristics including expression of α-smooth muscle actin. Using a bioinformatics approach to identify factor(s) that contribute to dedifferentiation, we found activation of the PH Cfib results in a unique transcriptome correlating with factors both in the secretome and with activated pathways in the dedifferentiated myocyte. Further, we identified upregulation of periostin in the Cfib and CM, and demonstrate that periostin is sufficient to drive cardiomyocyte dedifferentiation.ConclusionsThese data suggest that paracrine factor(s) released by Cfib from the PH calf signal a phenotypic transformation in a population of cardiomyocytes that likely contributes to RV dysfunction. Therapies targeting this process, such as inhibition of periostin, have the potential to prevent RV dysfunction.

Right Ventricular Strain and Dyssynchrony Assessment in Arrhythmogenic Right Ventricular Cardiomyopathy: Cardiac Magnetic Resonance Feature-Tracking Study.

Analysis of right ventricular (RV) regional dysfunction by cardiac magnetic resonance (CMR) imaging in arrhythmogenic RV cardiomyopathy (ARVC) may be inadequate because of the complex contraction pattern of the RV. Aim of this study was to determine the use of RV strain and dyssynchrony assessment in ARVC using feature-tracking CMR analysis. Thirty-two consecutive patients with ARVC referred to CMR imaging were included. Thirty-two patients with idiopathic RV outflow tract arrhythmias and 32 control subjects, matched for age and sex to the ARVC group, were included for comparison purpose. CMR imaging was performed to assess biventricular function; feature-tracking analysis was applied to the cine CMR images to assess regional and global longitudinal, circumferential, and radial RV strains and RV dyssynchrony (defined as the SD of the time-to-peak strain of the RV segments). RV global longitudinal strain (-17±5% versus -26±6% versus -29±6%; P<0.001), global circumferential strain (-9±4% versus -12±4% versus -13±5%; P=0.001), and global radial strain (18 [12-26]% versus 22 [15-32]% versus 27 [20-39]%; P=0.015) were significantly lower and SD of the time-to-peak RV strain in all 3 directions were significantly higher among patients with ARVC compared with patients with RV outflow tract arrhythmias and controls. RV global longitudinal strain >-23.2%, SD of the time-to-peak RV longitudinal strain >113.1 ms, and SD of the time-to-peak RV circumferential strain >177.1 ms allowed correct identification of 88%, 75%, and 63% of ARVC patients with no or only minor CMR criteria for ARVC diagnosis. Strain analysis by feature-tracking CMR helps to objectively quantify global and regional RV dysfunction and RV dyssynchrony in patients with ARVC and provides incremental value over conventional cine CMR imaging.

Effects of endoscopic lung volume reduction on right ventricular myocardial function in patients with advanced emphysema

Endoscopic lung volume reduction (ELVR) using endobronchial valve implantation provides a minimally invasive, effective technique for patients with severe progressive and irreversible lung emphysema. However, its impact on right ventricular (RV) function is unknown. We therefore assessed the extent of global and regional RV dysfunction in patients undergoing ELVR by use of speckle tracking echocardiography based on RV deformation analysis and correlated the results with the clinical outcomes using exercise capacity testing and Nt-proBNP-levels.

Functional analysis of the anatomical right ventricular components: should assessment of right ventricular function after repair of tetralogy of Fallot be refined?

Follow-up after tetralogy of Fallot (ToF) repair is directed to detect timely right ventricular (RV) dysfunction by following pulmonary regurgitation and global RV size, with little attention for the effective contribution of regional RV dysfunction. This study investigates the contribution of regional RV dysfunction on exercise capacity after ToF repair. Forty-two patients were investigated with cardiac magnetic resonance imaging for regional RV dysfunction in relation to global RV function by functional quantification of the sinus and outflow part of the RV. The impact of regional and global RV dysfunction on clinical status was studied by exercise testing. Global RV function was lower than sinus function (ejection fraction (EF) 52±12% vs 58±10%, P<0.001), attributable to the adverse influence of right ventricular outflow tract (RVOT) dysfunction (EF 34±17%). Percent predicted peak VO2 correlated better with the RV sinus ejection fraction compared with the global RV ejection fraction (r=0.51, P=0.001 vs r=0.44, P=0.004). Multivariate analysis revealed the EF of RV sinus (β=0.34, 95% CI 0.07-0.61, P=0.013) and the extent of RVOT akinesia (β=-0.28, 95% CI -0.50; -0.06, P=0.015) as significant determinants of exercise capacity. Impaired exercise performance occurred in 43% of the patients, and was independently determined by the type of repair (transventricular vs transatrial: OR 6.0, 95% CI 1.31-17.3, P=0.02) by associating greater sinus and RVOT dysfunction. Functional analysis of the RV components shows that exercise capacity after repair of ToF is better predicted by systolic function of the RV sinus as the extent of RVOT dysfunction commonly leads to underestimation of global RV function. This method of differential quantification of regional RV function might be more appropriate than assessment of global RV function during the long-term follow-up of repaired ToF patients.

Global and Regional Right Ventricular Dysfunction in Pulmonary Hypertension

Pulmonary hypertension (PH) is known to affect the right ventricular (RV) function. To assess the extent of global and regional RV dysfunction in PH patients. We performed a cross-sectional study on 20 controls (age 62 ± 15 years, 7 males) and 35 patients (age 67 ± 12 years, 13 males) with PH of mixed etiologies and assessed RV inflow and outflow tracts (OTs) function, using speckle tracking echocardiography (STE) based myocardial deformation and its time relations. RV inlet and OT dimensions (2D), inlet myocardial velocities (TDI), myocardial strain and strain rate (SR), TAPSE (M-mode), ejection and filling times (pulsed-wave [PW] Doppler), and pulmonary artery acceleration (PAc) were measured. RV inlet and OT were dilated (P < 0.001 for both) and TAPSE (P < 0.001), inlet velocities (P < 0.001), basal and mid-cavity strain, SR and longitudinal displacement reduced (P < 0.001 for all). The time to peak systolic SR at basal, mid-cavity (P < 0.001 for both), and RVOT (P = 0.007) was short as was that to peak displacement (P < 0.001 for all). The time to peak pulmonary ejection correlated with time to peak SR at RVOT (r = 0.7, P < 0.001) in controls, but with that of the mid-cavity in patients (r = 0.71, P < 0.001). PAc was faster (P = 0.001) and RV filling time shorter in patients (P = 0.03) with respect to controls. PH has drastic effects on RV structure and intrinsic myocardial function, significantly disturbing its ejection time relations and overall pump performance. Increased RV afterload results in RV configuration changes with the inflow tract determining peak ejection rather than OT.

Correlates of Impaired Global Right Ventricular Function in Patients With a Reperfused Acute Myocardial Infarction and Without Right Ventricular Infarction

BackgroundThe frequency and clinical correlates of global right ventricular (RV) dysfunction in patients treated with primary percutaneous coronary intervention for a first acute ST-elevation myocardial infarction (STEMI) without a coexisting...

The strain-encoded (SENC) MR imaging for detection of global right ventricular dysfunction in pulmonary hypertension

The aim of this study was to explore whether the regional peak longitudinal (LS) and circumferential strains (CS) at the right ventricular (RV) free wall could be used to identify global RV dysfunction in relation to RV ejection fraction (RVEF) and plasma concentration of brain natriuretic peptide (BNP) in pulmonary hypertension (PH). A total of 37 consecutive patients diagnosed with PH and 13 healthy control subjects were included. Fast strain encoded and routine cine MRI was performed. The LS and CS at three RV levels were quantified and their relations with RVEF and BNP were investigated. Receiver operating characteristic (ROC) analysis was employed to assess the diagnostic utility of strain encoded MRI for the detection of low RVEF. Significant correlations with LS were observed for RVEF and BNP. Compared to CS, LS showed better correlation with RVEF. The mid-ventricular level of RV was the most sensitive site for evaluation of RV dysfunction. According to our ROC analysis, LS showed higher sensitivity and specificity to detect low RVEF. Compared to CS, LS showed stronger correlations with RVEF and BNP and could be a good detector of RV dysfunction in PH.

Apical right ventricular dysfunction in patients with pulmonary hypertension demonstrated with magnetic resonance

ObjectiveTo evaluate segmental right ventricular (RV) dysfunction in pulmonary hypertension (PH) using cardiac magnetic resonance (CMR).DesignCross-sectional analysis in a retrospective cohort of consecutive adult patients.SettingMount Sinai Hospital in New York.Patients192...

Reconciling the Protean Manifestations of Arrhythmogenic Cardiomyopathy

Medical conception of a disease begins with in vivo observation and develops with recognition of cognate findings on gross anatomy, histology, and cellular pathology. It was histopathology that established myocyte disarray as the cardinal feature of hypertrophic cardiomyopathy, present even in cases where left ventricular (LV) hypertrophy is subtle or absent. To this day, clinical-pathological association retains its historical value as the primary means of gaining insight into underlying disease processes. Enhancing its appeal is its accessibility to physicians, most of whom are familiar with histopathology from medical school and attuned to visual diagnosis. Article see p 632 With the advent of molecular genetics, however, the limitations of clinical-pathological association have become apparent and nowhere more so than in the inherited arrhythmia syndromes. In the long-QT and Brugada syndromes and catecholaminergic polymorphic ventricular tachycardia, a structurally normal heart belies the propensity to ventricular arrhythmia and sudden cardiac death (SCD). How this might be possible began to unravel with the isolation of mutations in genes encoding ion channels, transporters, and binding proteins. Genetic studies also have provided fresh insights into diseases with an obvious pathological substrate, such as hypertrophic cardiomyopathy, in which sarcomeric mutations predominate. Families with a high incidence of SCD and myocyte disarray but minimal LV hypertrophy were found to have mutations in troponin T,1 lending further support to the inclusion of this phenotype within the spectrum of hypertrophic cardiomyopathy. Redefining diseases according to their genetic etiology, while attractive, is less straightforward than immediately obvious. Defects in sarcomeric components, for example, have been implicated in both hypertrophic cardiomyopathy and dilated cardiomyopathy. In some heritable disorders, such as dilated cardiomyopathy, marked locus heterogeneity precludes delineation of a single genetic determinant. The ultimate solution to disease classification involves going 1 step further and identifying a unifying molecular mechanism, which may …

Clinical Summaries

Clinical Summaries

Abstract 5781: Evaluation of Global and Regional Right Ventricular Systolic Function in Patient Prosthesis Mismatch after Mitral Valve Replacement using Velocity Vector Imaging

The aim of this study was to compare right ventricular (RV) global and regional systolic function in patients with and without patient prosthesis mismatch (PPM) after isolated mitral valve replacement (MVR) using Velocity Vector Imaging (VVI) method. The PPM group consisted of 20 patients that underwent isolated MVR with an indexed effective orifice area (EOA) ≤ 1.2 cm 2 /m 2 determined by continuity equation and indexed for body surface area. The non-PPM group consisted of 20 patients that also underwent isolated MVR with an indexed EOA &gt; 1.2cm 2 /m 2 . Echocardiographic images in apical planes were analyzed for RV volumes, ejection fractions, myocardial velocity, strain and strain rate at the basal, mid and apical segments of RV free wall and ventricular septum using VVI. The demographic and preoperative data were similar between PPM and non-PPM groups. Evidence of PA hypertension defined as systolic PA pressure &gt; 40 mmHg was present in 50% of patients in PPM group, whereas none of the patients in non-PPM group had PA hypertension. RV volumes were significantly increased, and RV ejection fraction, peak systolic myocardial velocities, strain and strain rates were significantly impaired in patients with PPM compared to non-PPM group (p&lt;0.001 for all). Indexed EOA correlated strongly with myocardial velocities, strain and strain rates in all segments of the RV (p&lt;0.05 for all). Multivariate stepwise regression analysis demonstrated that indexed EOA and systolic PA pressure were the independent determinants of basal free wall peak systolic strain (β=0.547, p&lt;0.001 and β=−0.304, p=0.033 respectively) and strain rate (β=0.497, p=0.001 and β=−0.332, p = 0.026 respectively). Using receiver-operating characteristics analysis cut-off values for basal free wall peak systolic strain and strain rate in determining patients with indexed EOA ≤ 1.2 cm 2 /m 2 were −25.62 % (sensitivity 85%, specificity 95%) and −1.87 1/s (sensitivity 95%, specificity 95%) respectively. PPM after MVR is associated with RV global and regional RV dysfunction. Two-dimensional echocardiography has some limitations in evaluating RV function due to its complex geometry. VVI is a feasible modality in assessment of RV global and regional RV function.

Quantification of right ventricular function in acute pulmonary embolism: relation to extent of pulmonary perfusion defects

The relation of the extent of obstruction of the pulmonary vasculature in pulmonary embolism (PE) and impact on right ventricular (RV) hemodynamics is not well established. This study evaluated the relation of size of perfusion defects and changes in echocardiographic measures of global and regional RV dysfunction in 58 consecutive patients with non-massive PE. Patients were compared with 58 age-matched controls that had normal ventilation/perfusion scintigraphies. A 2D, Doppler and Tissue Doppler echocardiography performed on the same day, quantified RV pressure and global and regional performance. Intermediate and large pulmonary emboli were associated with a significant impact on RV pressure and function. For small pulmonary emboli obstructing <25% of the pulmonary vasculature, the acceleration time of the pulmonary artery (PA) outflow was significantly shortened, 85 +/- 22 ms vs. 117 +/- 35 ms, P < 0.0001. Peak systolic strain in the middle segment of RV free wall was reduced in patients with perfusion defect greater than 25%, -1 +/- 13% vs. -13 +/- 17%, P < 0.001. Mid ventricular longitudinal dysfunction consistent with the 'McConnell-sign' is found in patients with moderate degrees of perfusion defects, whereas the acceleration time of the PA flow is reduced even in patients with small pulmonary emboli.

Usefulness of Tricuspid Annular Velocity in Identifying Global RV Dysfunction in Patients with Primary Pulmonary Hypertension: A Comparison with 3D Echo‐Derived Right Ventricular Ejection Fraction

While right ventricular (RV) function and size are important clinical markers in several cardiac conditions, the assessment of RV function by two-dimensional (2D) echocardiography remains challenging, due to the complexity of RV geometry. We therefore sought to compare an easily-measured parameter, peak systolic velocity of tricuspid annulus (TAPSV) obtained by tissue Doppler imaging (TDI), to right ventricular ejection fraction (RVEF) measured by real time three-dimensional echocardiography (RT3DE) and to explore what TAPSV cutoff values would be useful in detecting global RV dysfunction. We enrolled 20 patients affected by primary pulmonary hypertension and 30 consecutive healthy volunteers, who underwent transthoracic echocardiography, RT3DE and tissue Doppler evaluation. TAPSV had a statistically significant correlation with RVEF (r = 0.66, P < 0.001). With RV dysfunction defined as RVEF <40%, a TAPSV cutoff value of 9.5 cm/sec yielded the best compromise between sensitivity, specificity, and positive predictive value and negative predictive value. In conclusion, a TAPSV cutoff value of 9.5 cm/sec yields significantly high sensitivity and specificity and appears to be a valid compromise in detecting RV dysfunction, TAPSV values however are not useful in evaluating the severity of RV dysfunction.

Quantitative assessment of right ventricular function using doppler tissue imaging in fetuses with and without heart failure

Background Previous reports have established the use of Doppler tissue imaging (DTI) for noninvasive assessment of ventricular function, but the technique has not been validated for diagnosis of fetal cardiac failure. Objective The purpose of this study was to assess right ventricular (RV) function in fetuses with heart failure using DTI. Methods In all, 43 fetuses (36 control, 7 heart failure) were assessed using pulsed Doppler echocardiography combined with DTI. RV peak myocardial velocities during early diastole (Ea), atrial contraction, and systole were measured; and tricuspid peak velocities during early diastole (E) and atrial contraction. The ratio of E/Ea was used as an index of filling pressure were measured. From DTI, a Doppler-derived index of combined systolic/diastolic myocardial performance (DTI-Tei index) was measured. Results Compared with control fetuses, the mean Ea was significantly lower and the mean E was significantly higher in fetuses with heart failure, although these parameters did overlap between the 2 groups. The mean RV myocardial wall-motion velocity during atrial contraction, ratio of Ea/RV myocardial wall-motion velocity during atrial contraction, and RV myocardial wall-motion velocity during systole did not differ between the 2 groups. Compared with control fetuses, the mean E/Ea was significantly higher (9.71 ± 0.91 vs 6.20 ± 0.97; P < .0001) and the mean DTI-Tei index was significantly greater (0.79 ± 0.11 vs 0.55 ± 0.05; P < .0001) in fetuses with heart failure. In addition, the DTI-Tei index z score was >2 in all fetuses with heart failure. Conclusions This study demonstrated a clinically important application of DTI-derived tricuspid annular velocities in fetuses with heart failure. Although DTI velocities were not sufficiently sensitive to identify fetuses with heart failure versus control fetuses, DTI-Tei index and E/Ea were useful and sensitive indicators of global RV dysfunction.

Impairment in Right Ventricular Performance after Left Ventricular Aneurysm Surgery

To study the effect of operation for left ventricular (LV) aneurysm on right ventricular (RV) performance, we studied 50 patients before operation with right heart catheterization, RV angiography, and radionuclide ventriculography. Forty patients were followed up and underwent the same investigations 10 ± 4 months after operation. At baseline, regional RV dysfunction was observed in 89% of the patients whereas global RV dysfunction was present in approximately a third. After operation, no changes in RV regional dysfunction or RV pressures were observed. However, a significant increase in RV end-diastolic ( p > 0.03) and end-systolic volume indices ( p > 0.02) along with a significant decrease in resting and exercise RV ejection fractions ( p > 0.05) was found. We were unable to demonstrate any significant relationship between preoperative RV dysfunction and surgical outcome. We conclude that RV dysfunction is common in patients with LV aneurysm. Current techniques of operative intervention for this type of aneurysm seem to be followed by RV dilatation and impairment in RV function.