Global Right Ventricular Research Articles

The Prognostic Importance of Right Ventricular Longitudinal Strain in Patients with Cardiomyopathies, Connective Tissue Diseases, Coronary Artery Disease, and Congenital Heart Diseases.

Right ventricular (RV) systolic function represents an important independent predictor of adverse outcomes in many cardiovascular (CV) diseases. However, conventional parameters of RV systolic function (tricuspid annular plane excursion (TAPSE), RV myocardial performance index (MPI), and fractional area change (FAC)) are not always able to detect subtle changes in RV function. New evidence indicates a significantly higher predictive value of RV longitudinal strain (LS) over conventional parameters. RVLS showed higher sensitivity and specificity in the detection of RV dysfunction in the absence of RV dilatation, apparent wall motion abnormalities, and reduced global RV systolic function. Additionally, RVLS represents a significant and independent predictor of adverse outcomes in patients with dilated cardiomyopathy (CMP), hypertrophic CMP, arrhythmogenic RV CMP, and amyloidosis, but also in patients with connective tissue diseases and patients with coronary artery disease. Due to its availability, echocardiography remains the main imaging tool for RVLS assessment, but cardiac magnetic resonance (CMR) also represents an important additional imaging tool in RVLG assessment. The findings from the large studies support the routine evaluation of RVLS in the majority of CV patients, but this has still not been adopted in daily clinical practice. This clinical review aims to summarize the significance and predictive value of RVLS in patients with different types of cardiomyopathies, tissue connective diseases, and coronary artery disease.

Echocardiographic assessment of chamber size and ventricular function during the first year after heart transplantation.

Detecting changes in ventricular function after orthotopic heart transplantation (OHT) using transthoracic echocardiography (TTE) is important but interpretation of findings is complicated by lack of data on early graft adaptation. We sought to evaluate echocardiographic measures of ventricular size and function the first year following OHT including speckle tracking derived strain. We also aimed to compare echocardiographic findings to haemodynamic parameters obtained by right heart catheterization (RHC). Fifty OHT patients were examined prospectively with TTE and RHC at 1, 6, and 12months after OHT. Left ventricle (LV) was assessed with fractional shortening, ejection fraction and systolic tissue velocities. Right ventricular (RV) evaluation included tricuspid annular plane systolic excursion (TAPSE), systolic tissue velocity (S´) and fractional area change (FAC). LV global longitudinal and circumferential strain and RV global longitudinal strain (GLS) and RV lateral wall strain (RVfree) were analysed. No relevant changes occurred in LV echocardiographic parameters, whereas all measures of RV function improved significantly during follow-up. There was an increase in TAPSE (12.4±3.3mm to 14.4±4.3mm, p<.01), FAC (36%±8% to 41%±8%, p<.01), RV GLS (-15.8%±4% to -17.8%±3.6%, p<.01), and RVfree (-15.5%±3.7% to -18.6%±3.6%, p<.001). Between 1 and 12months, pulmonary pressures decreased, whereas pulmonary vascular resistance did not. Stable OHT recipients reached steady state regarding LV function 1month after transplantation. In contrast, RV function displayed gradual improvement the first year following OHT, indicating delayed RV adaptation as compared to the LV. Improved RV function parameters were independent of invasively measured pulmonary pressures.

Impairment of right ventricular longitudinal strain associated with severity of pneumonia in patients recovered from COVID-19.

Myocardial injury caused by COVID-19 was reported in hospitalized patients previously. But the information about cardiac consequences of COVID-19 after recovery is limited. The aim of the study was comprehensive echocardiography assessment of right ventricular (RV) in patients recovered from COVID-19. This is a prospective, single-center study. After recovery from COVID-19, echocardiography was performed in consecutive 79 patients that attended follow-up visits from July 15 to November 30, 2020. According to the recovery at home vs hospital, patients were divided into two groups: home recovery (n = 43) and hospital recovery (n = 36). Comparisons were made with age, sex and risk factor-matched control group (n = 41). In addition to conventional echocardiography parameters, RV global longitudinal strain (RV-GLS) and RV free wall strain (RV-FWS) were determined using 2D speckle-tracking echocardiography (2D STE). Of the 79 patients recovered from COVID-19, 43 (55%) recovered at home, while 36 (45%) required hospitalization. The median follow-up duration was 133 ± 35 (87–184) days. In patients recovered from hospital, RV-GLS and RV-FWS were impaired compared to control group (RV-GLS: −17.3 ± 6.8 vs. −20.4 ± 4.9, respectively [p = 0.042]; RV-FWS: −19.0 ± 8.2 vs. −23.4 ± 6.2, respectively [p = 0.022]). In subgroup analysis, RV-FWS was impaired in patients severe pneumonia (n = 11) compared to mild-moderate pneumonia (n = 28), without pneumonia (n = 40) and control groups (−15.8 ± 7.6 vs. −21.6 ± 7.6 vs. −20.8 ± 7.7 vs. −23.4 ± 6.2, respectively, [p = 0.001 for each]) and RV-GLS was impaired compared to control group (−15.2 ± 6.9 vs. −20.4 ± 4; respectively, [p = 0.013]). A significant correlation was detected between serum CRP level at hospital admission and both RV-GLS and RV-FWS (r = 0.285, p = 0.006; r = 0.294, p = 0.004, respectively). Age (OR 0.948, p = 0.010), male gender (OR 0.289, p = 0.009), pneumonia on CT (OR 0.019, p = 0.004), and need of steroid in treatment (OR 17.424, p = 0.038) were identifed as independent predictors of impaired RV-FWS (> −18) via multivariate analysis. We demonstrated subclinic dysfunction of RV by 2D-STE in hospitalized patients in relation to the severity of pneumonia after recovery from COVID-19. 2D-STE supplies additional information above standard measures of RV in this cohort and can be used in the follow-up of these patients.

Assessment of Right Ventricular Contractile Patterns Using Cardiac Magnetic Resonance Imaging Would Reflect the Underlying Mechanism of Right Ventricular Dysfunction

<h3>Purpose</h3> Right ventricular (RV) function has been recognized as an important prognostic factor in patients with heart failure. However, previous studies have focused on the global RV function such as RV ejection fraction (RVEF), not on RV contractile pattern. Cardiac magnetic resonance imaging (CMR) is a powerful imaging modality to assess RV morphological change together with its global systolic function.The purpose of this study is to elucidate the difference of RV contractile patterns in various heart diseases with RV dysfunction using CMR. <h3>Methods</h3> The CMR data obtained from 50 patients with RV dysfunction and 23 control subjects were analyzed.The patients with RV dysfunction were classified into 3 groups according to the etiology of RV dysfunction; RV volume-overload group (Group V, n=16, consisting of those with atrial septal defect), RV-dominant myocyte degeneration (Group M, n=17, consisting of arrhythmogenic right ventricular cardiomyopathy), and pericarditis group (Group P, n=17). The RV longitudinal contractile pattern (FLC: fractional longitudinal change) and the radial contractile pattern (FTC: fractional transverse change) were measured using a 4-chamber view of Cine-CMR. The ratio of transverse to longitudinal contraction (T/L ratio=FTC/FLC) was calculated. <h3>Results</h3> Both FLC and FTC significantly decreased in Groups M and P, while Group V showed relatively preserved FTC compared to control subjects. The T/L ratio was significantly lower in Group M than the other groups, while the value tended to be higher in Group V and P than the control (Figure). <h3>Conclusion</h3> Impaired transverse contractile pattern as reflected by the reduced T/L ratio may indicate the degeneration of RV myocardium itself, whereas this value tends to be preserved in patients with RV dysfunction due to volume overload. RV contractile pattern may help to understand the disease progression and the underlying cause of RV dysfunction.

Novel Echocardiographic Algorithm for Right Ventricular Mass Quantification: Cardiovascular Magnetic Resonance and Clinical Prognosis Validation

Right ventricular hypertrophy (RVH) provides a key remodeling index alterable by pulmonary hypertension. Although echocardiography commonly integrates linear wall thickness and chamber dimensions to quantify left ventricular remodeling, the utility of an equivalent right ventricular (RV)-based approach is unknown. This was a retrospective analysis of 200 patients undergoing transthoracic echocardiography and cardiac magnetic resonance (CMR) within 30days (median= 3days; interquartile range, 15days), stratified by echocardiography-quantified pulmonary artery systolic pressure (<35, 35 to <55, 55 to <75, or ≥75mm Hg). Echocardiographic assessment included RV linear dimensions in parasternal long-axis and apical four-chamber views and wall thicknesses in parasternal long-axis, four-chamber, and subcostal views. Subcostal wall thickness was integrated with chamber diameters to calculate RV mass, which was tested in relation to CMR-quantified RV mass and all-cause mortality. Echocardiography-based quantification of all linear dimensions was feasible in 95% of patients (190 of 200). RV wall thicknesses in all orientations increased in relation to pulmonary artery systolic pressure (P<.001) and was greater among patients with, versus those without, CMR-evidenced RVH (P<.001 for all). Correlations between echocardiography and CMR were greatest for RV basal diameter (r=0.73), RV subcostal wall thickness (r=0.71), and global RV mass (r=0.82; P<.001 for all). Echocardiography-derived global RV mass cutoffs were established in a derivation cohort and tested in a validation cohort. Results demonstrated good sensitivity and specificity (75.5% and 74.0%, respectively) in relation to CMR-quantified RVH. During follow-up (median, 4.2years), 18% of patients (n=36) died. Echocardiography-evidenced RVH (hazard ratio, 1.98; 95% CI, 1.09-3.88; P=.048) conferred similar mortality risk compared with RVH on CMR (hazard ratio, 2.41; 95% CI, 1.22-4.78; P=.01). Echocardiography-quantified RV parameters provide a robust index of RV afterload. Global RV mass calculated using a novel echocardiographic formula based on readily available linear indices yields good diagnostic performance for CMR-evidenced RVH and confers increased mortality risk.

Partitioning the Right Ventricle Into 15 Segments and Decomposing Its Motion Using 3D Echocardiography-Based Models: The Updated ReVISION Method.

Three main mechanisms contribute to global right ventricular (RV) function: longitudinal shortening, radial displacement of the RV free wall (bellows effect), and anteroposterior shortening (as a consequence of left ventricular contraction). Since the importance of these mechanisms may vary in different cardiac conditions, a technology being able to assess their relative influence on the global RV pump function could help to clarify the pathophysiology and the mechanical adaptation of the chamber. Previously, we have introduced our 3D echocardiography (3DE)-based solution—the Right VentrIcular Separate wall motIon quantificatiON (ReVISION) method—for the quantification of the relative contribution of the three aforementioned mechanisms to global RV ejection fraction (EF). Since then, our approach has been applied in several clinical scenarios, and its strengths have been demonstrated in the in-depth characterization of RV mechanical pattern and the prognostication of patients even in the face of maintained RV EF. Recently, various new features have been implemented in our software solution to enable the convenient, standardized, and more comprehensive analysis of RV function. Accordingly, in our current technical paper, we aim to provide a detailed description of the latest version of the ReVISION method with special regards to the volumetric partitioning of the RV and the calculation of longitudinal, circumferential, and area strains using 3DE datasets. We also report the results of the comparison between 3DE- and cardiac magnetic resonance imaging-derived RV parameters, where we found a robust agreement in our advanced 3D metrics between the two modalities. In conclusion, the ReVISION method may provide novel insights into global and also segmental RV function by defining parameters that are potentially more sensitive and predictive compared to conventional echocardiographic measurements in the context of different cardiac diseases.

Right-left ventricular shape variations in tetralogy of Fallot: associations with pulmonary regurgitation

BackgroundRelationships between right ventricular (RV) and left ventricular (LV) shape and function may be useful in determining optimal timing for pulmonary valve replacement in patients with repaired tetralogy of Fallot (rTOF). However, these are multivariate and difficult to quantify. We aimed to quantify variations in biventricular shape associated with pulmonary regurgitant volume (PRV) in rTOF using a biventricular atlas.MethodsIn this cross-sectional retrospective study, a biventricular shape model was customized to cardiovascular magnetic resonance (CMR) images from 88 rTOF patients (median age 16, inter-quartile range 11.8–24.3 years). Morphometric scores quantifying biventricular shape at end-diastole and end-systole were computed using principal component analysis. Multivariate linear regression was used to quantify biventricular shape associations with PRV, corrected for age, sex, height, and weight. Regional associations were confirmed by univariate correlations with distances and angles computed from the models, as well as global systolic strains computed from changes in arc length from end-diastole to end-systole.ResultsPRV was significantly associated with 5 biventricular morphometric scores, independent of covariates, and accounted for 12.3% of total shape variation (p < 0.05). Increasing PRV was associated with RV dilation and basal bulging, in conjunction with decreased LV septal-lateral dimension (LV flattening) and systolic septal motion towards the RV (all p < 0.05). Increased global RV radial, longitudinal, circumferential and LV radial systolic strains were significantly associated with increased PRV (all p < 0.05).ConclusionA biventricular atlas of rTOF patients quantified multivariate relationships between left–right ventricular morphometry and wall motion with pulmonary regurgitation. Regional RV dilation, LV reduction, LV septal-lateral flattening and increased RV strain were all associated with increased pulmonary regurgitant volume. Morphometric scores provide simple metrics linking mechanisms for structural and functional alteration with important clinical indices.

The influence of training status on right ventricular morphology and segmental strain in elite pre-adolescent soccer players

Cardiac modifications to training are a product of the genetic pre-disposition for adaptation and the repetitive haemodynamic loads that are placed on the myocardium. Elite pre-adolescent athletes are exposed to high-intensity training at a young age with little understanding of the physiological and clinical consequences. It is unclear how right ventricular (RV) structure and function may respond to this type of stimulus. The aim of this study was to compare RV structure and strain across the cardiac cycle and within individual segments in elite soccer players (SP) and controls (CON). Methods: Twenty-two highly trained, male pre-adolescent SP and 22 age-and sex-matched recreationally active individuals CON were investigated using 2D echocardiography, including myocardial speckle tracking to assess basal, mid-wall, apical and global longitudinal strain and strain rate during systole (SRS) and diastole (SRE and SRA). Results: greater RV cavity size was identified in the SP compared to CON (RVD1 SP: 32.3 ± 3.1 vs. CON: 29.6 ± 2.8 (mm/m2)0.5; p = 0.005). No inter-group differences were noted for peak global RV strain (SP: − 28.6 ± 4.9 vs CON: − 30.3 ± 4.0%, p = 0.11). Lower mid-wall strain was demonstrated in the SP compared to CON (SP: − 27.9 ± 5.8 vs. CON: − 32.2 ± 4.4%, p = 0.007). Conclusion: Soccer training has the potential to increase RV size in pre-adolescent players. The unique segmental analyses used in this study have identified inter-group differences that were masked by global strain evaluations. The clinical and physiological implications of these findings warrant further investigation.

Left atrial strain can predict right ventricular impairment and developement of atrial fibrilation in patients with severe mitral stenosis better than transmitral gradients

Abstract Funding Acknowledgements Type of funding sources: None. Introduction. Rheumatic heart disease is a major health problem in developing countries and remains the leading cause of mitral valve stenosis (MS) and valve replacement in adults. Left atrial (LA) inflammation due to rheumatic carditis, pressure overload because of mitral stenosis, lead to fibrosis and remodeling to progressive lost of LA reservoir/compliant capacity that might be responsible of the pressure backward load to the pulmonary circulation. The aims of the study were to determine if 1) there is any correlation between LA strain parameters with pulmonary systolic arterial pressure (PASP) and other parameters related with pulmonary pressure and right ventricular (RV) function and 2) if LA strain can better identify those patients who developed atrial fibrilation (AF). Methods. Strain of the LA was measured in 101 patients retrospectively enrolled with severe MS using two dimensional speckle tracking (2DSTE). Sixty of them were in sinus rhythm (SR) and 40 in atrial fibrillation (AF). The LA 2DSTE was measured from the 4 chamber view of 2 consecutive cycles at expiration and offline evaluated. Based on the QRS onset, the positive peak strain curve was defined as LA end systolic strain. The end of the reservoir phase was defined as 1 frame before mitral valve opening (LA- RES). When the patient was in SR, immediately after the P wave, LA contractile function was identified (LA-booster). Strain of the free wall and global RV was measured in 4CH. A standard echocardiographic assessment was done in accordance with the recommendation of the American Society of Echocardiography. Results. Patients mean age was 47.4 ± 11.9 years, 30 males and 71 females. Mean gradient across the mitral valve (MV) was 8.3 ± 5.1 mmHg and the MV area derived by pressure half time was 1.3 ± 0.3 cm2, LVEF was 51.79 ± 11.3%. Right ventricular (RV) function parameters were TAPSE 19.6 ± 5.2 mm, S` 10.5 ± 2.5 cm/s, RV fraction area change 35.6 ± 9.1% and RV free wall peak strain – 17.96 ± 6.5%. LVMi 51.79 ± 11.3 gr/m2, SVi 34.6 ± 10.3 ml/m2. LA-RES 11.18 ± 3.7%, LA volume in systole 128.3 ± 48.3 ml, LAEF 20.1 ± 12.5%. The group was divided according to tertiles of LA-RES (group 1, 33 patients, strain was &amp;lt; =7%, group 2, 32 patients with strain between 8 and 13%, group 3, 32 patients, strain &amp;gt; =14%). There was a decrease in PASP (group 1, 42.3 ± 17.8 mmHg; group 2, 38.3 ± 17.9 mmHg; group 3, 31.6 ± 17.9 mmHg, p =0.028) and PVR (group 1, 2.5 ± 1; group 2, 2.0 ± 0.6; group 3, 1.6 ± 0.4, p&amp;lt; 0.0001) as LA-RES increased. RV function represented by TAPSE, Sm, RVFAC and RV free wall strain significantly increased as LA-RES increased. The area under the ROC curve was calculated for LA-RES, MV mean gradient, MV area derived by PHT and LA systolic volume as a predictors of AF. LA-RES was the one that better predicted the presence of AF. Conclusion. In severe MS, LA-RES was able to better identify those with higher PASP and worst RV function. Moreover LA-RES was also able to better predict those patients who developed AF.

Hemodialysis: effects of preload reduction on novel echocardiographic parameters of left ventricular function

Abstract Funding Acknowledgements Type of funding sources: None. Background Echocardiography has been widely used to study cardiac function in patients with end-stage renal disease on hemodialysis (HD), but cardiac function assessment by measuring cardiac dimensions and their rate of change is load dependent, therefore it is influenced by volume depletion. Effects of acute volume reduction on left (LV) and right ventricular (RV) function are still not well understood. Some studies investigated myocardial mechanics after dialysis using speckle tracking echocardiography (STE) but their relative load-dependency makes STE indices unable to account for changes in pre- and afterload. Myocardial work (MW) incorporates both deformation and load into its analysis and is an emerging tool to study LV myocardial function. There are no data about the effects of hemodialysis on LV MW. Purpose This study aimed to evaluate acute changes of novel echocardiographic indices of both LV and RV function after a HD session. Methods Patients with end-stage renal disease undergoing HD were prospectively enrolled. A transthoracic echo, including STE calculation of LV global longitudinal strain (GLS) and free wall RV strain, was performed before and after hemodialysis. Parameters of MW such as global work index (GWI), global constructive work (GCW), global work efficiency (GWE) and global wasted work (GWW) were quantified using a commercially available software package. Results 27 patients were enrolled, mean baseline parameters were: LV end-diastolic volume 136 ± 38 mL, LV ejection fraction (LVEF) 56.9 ± 7.5%, LV GLS -17.1 ± 4.1%, RV free wall strain -26.9 ± 5.6%, GWI 2117 ± 602 mmHg%, GCW 2299 ± 633 mmHg%, GWW 137 ± 88 mmHg, GWE 93 ± 3.6%, systolic arterial pressure 145 ± 26 mmHg and diastolic pressure 80 ± 16mmHg. After hemodialysis we observed a significative reduction in LV GLS (p = 0.04), RV strain (p = 0.002), GWI (p = 0.002, Figure I) and GCW (p = 0.004). No significative changes in LVEF and blood pressure were observed. Comparing patients using a LVEF cut-off of 55% (19 patients with LVEF≥55%, 8 patients &amp;lt;55%) we observed a significative reduction of LV GLS (p = 0.004), GWI (p &amp;lt; 0.001), GCW (p &amp;lt; 0.001) only in patients with LVEF ≥55% while RV strain and LV volume showed a reduction in both groups. We observed no significative differences in extracted volumes between the groups (2.6 vs 2.1 liters,p = 0.3). Patients with normal LVEF showed a significative negative variation (D) of LVEF (-1 vs 3%), GWI (-551 vs 38 mmHg%) and GCW (-522 vs 11 mmHg%). Correlations were found between DGWI and extracted volume (r= 0.46, p = 0.01), basal GWI and both DLVEF (r= 0.39, p = 0.04) and DLV GLS (r= 0,42, p = 0.02), basal LV GLS and DLVEF (r= 0.5, p &amp;lt; 0.01). Conclusions Our preliminary data show that, immediately after the HD session, there is a reduction in biventricular STE-derived systolic parameters. Patients with normal LV systolic function are more sensitive to acute volume changes and entity of volume depletion seems to be correlated with MW reduction. Abstract Figure.

Evolution of biventricular T1 values in patients with right-sided congenital heart disease

Abstract Funding Acknowledgements Type of funding sources: None. Background Conflicting reports exist on the prevalence and clinical impact of interstitial fibrosis in right ventricular (RV) congenital heart disease (CHD). This study evaluates the longitudinal evolution of native myocardial T1 relaxation time (T1) in RV CHD. Methods On a 1.5T scanner, an ECG-triggered modified Look-Locker inversion recovery sequence (scheme 3(3)3(3)5) was acquired on a short-axis basal slice covering the RV and left ventricle (LV) on two consecutive CMR exams. Global and segmental (LV = 6, RV = 4) RV and LV T1 values were calculated (Figure). Results Mean time between CMR exams for 36 included patients (age 34 ± 2y) was 22 ± 2 months. All LV segments and 81/88% of RV segments of first and second CMR could be analyzed, respectively. T1 increased mildly but not significantly (table). There was no relationship of T1 to pulmonary regurgitation fraction, pulmonary stenosis or RV enddiastolic volume (p &amp;gt; 0.05). Global RV T1 of the second CMR was related to RV ejection fraction (RVEF): r = 0.353, 3.0 ± 1.4, p = 0.038. T1 of the infero-septal LV segment of first and second CMR, global LV T1 of second CMR and increase of T1 of global LV, anterior, antero-lateral and –septal LV segments, were related to age at CMR: r = 0.333 - 0.463, p &amp;lt; 0.05, respectively. Conclusions Native T1 values increased mildly in patients with stable RV CHD, which was not statistically significant probably due to the short to median follow-up. Global RV T1 appears to be related to RVEF which could be sign of increasing interstitial fibrosis whereas the relationship of LV T1 to age might be a physiological finding. First CMR native T1 (ms) Second CMR native T1 (ms) p LV Global 1007 ± 37 1014 ± 39 0.413 LV Anterior 994 ± 53 999 ± 54 0.710 LV Antero-lateral 965 ± 63 981 ± 58 0.186 LV Infero-lateral 1000 ± 52 1004 ± 63 0.695 LV Inferior 1035 42 1037 ± 50 0.744 LV Infero-septal 1028 ± 35 1036 ± 43 0.282 LV Antero-septal 1016 ± 38 1024 ± 48 0.347 RV Global 1091 ± 90 1096 ± 85 0.410 RV Inferior 1112 ± 104 1115 ± 118 0.696 RV Infero-lateral 1061 ± 130 1077 ± 115 0.425 RV Antero-lateral 1046 ± 127 1080 ± 109 0.088 RV Anterior 1088 ± 156 1108 ± 154 0.410 Abstract Figure. Determination of biventricular T1 values

Prognostic utility of quantitative offline 2D-echocardiography in hospitalized patients with COVID-19

Funding AcknowledgementsType of funding sources: None.BackgroundThe severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was declared as a pandemic by the World Health Organization (WHO) on 11 March 2020. Clinical presentation ranges from asymptomatic to acute respiratory distress syndrome (ARDS) that can lead to death. Patients with concomitant cardiac diseases have an extremely poor prognosis, and SARS-CoV-2 may cause direct acute and chronic damage to the cardiovascular system. Echocardiography may provide useful information, especially in critical care patients, because it can be performed quickly at the bedside. However, the recommendations relating to the use of echocardiography in the COVID-19 pandemic must be considered only as expert suggestions due to the lack of evidence-based scientific outcome data. To date, there is no means to predict the impact of the virus on patient outcome probably because the pathophysiology of COVID-19 remains unexplained.PurposeTo assess the prognostic utility of quantitative 2D-echocardiography, including strain, in patients with COVID-19 disease.MethodsCOVID-19 patients admitted to the San Paolo University Hospital of Milan, that underwent a clinically indicated echocardiographic exam were included in the study. To limit contamination all measurements were performed offline. Quantitative measurements were obtained by an operator blinded to the clinical data.ResultsAmong the 49 patients, non-survivors (33%) had worse respiratory parameters, index of multiorgan failure and worse markers of lung involvement. Right Ventricular (RV) dysfunction (as assessed by conventional and 2-dimensional speckle tracking, fig. 1) was a common finding and a powerful independent predictor of mortality. At the ROC curve analyses, RV free-wall longitudinal strain (LS) showed an AUC 0.77 ± 0.08 in predicting death, p = 0.008, and global RV LS (RV-GLS) showed an AUC 0.79 ± 0.04, p = 0.004. This association remained significant after correction for age (OR= 1.16, 95%CI 1.01-1.34, p = 0.029 for RV free-wall LS and OR = 1.20, 95%CI 1.01-1.42, p = 0.033 for RV-GLS), for oxygen partial pressure at arterial gas analysis/fraction of inspired oxygen (OR= 1.28, 95%CI 1.04-1.57, p = 0.021 for RV free wall-LS and OR = 1.30, 95%CI 1.04-1.62, p = 0.020 for RV-GLS) and for the severity of pulmonary involvement measured by a computed tomography lung score (OR = 1.27, 95%CI 1.02-1.19, p = 0.034 for RV free-wall LS, and OR = 1.30, 95%CI 1.04-1.63, p = 0.022 for RV-GLS).ConclusionsIn patients hospitalized with COVID-19, offline quantitative 2D-echocardiographic assessment of cardiac function is feasible. Parameters of RV function are frequently abnormal and have an independent prognostic value over markers of lung involvement. Early identification of RV dysfunction with speckle tracking might be useful not only to guide management acutely (i.e. fluid management, monitoring high-PEEP response in intubated patients) but also to tailor follow-up subsequently. Figure 1

Can right ventricular speckle tracking imaging be used in arrhytmogenic cardiomyopathy screening? A study of healthy paediatric athletes with and without echocardiographic modified task force criteria

Abstract Funding Acknowledgements Type of funding sources: Other. Main funding source(s): The study was support by a contractual research partnership between the University of Bristol and Canon Medical Systems UK. Background Arrhytmogenic cardiomyopathy (ACM) is a major cause of sudden cardiac death among young athletes. Screening these individuals can be challenging due to right ventricular (RV) exercise-related remodelling, particularly right ventricular outflow tract (RVOT) dilation. Recent studies have also shown that peak RV longitudinal strain (Sl) measured by speckle tracking echocardiography (STE) is reduced in adolescents with definite and borderline ACM. The prevalence of RV changes meeting ACM criteria in healthy paediatric athletes, and whether these changes are associated with abnormal RV strain values is not known. Purpose The aim of this study is to evaluate the prevalence of healthy paediatric athletes meeting the ACM echocardiographic modified Task Force Criteria (mTFC) for RVOT dilation, and how this relates to RV longitudinal systolic function. Methods Athletes under 18 years old undergoing comprehensive pre-participation screening (2014-2017) at two sports academies were included. Global (RV-Sl) and free wall peak systolic strain (FW-Sl) were calculated using STE. Three groups were defined: meeting the major mTFC for RVOT size (M-mTFC), meeting the minor mTFC (m-mTFC) and not meeting the mTFC (no-mTFC). RV-Sl and FW-Sl were compared using the Kruskall Wallis test. Results A total of 247 boys (11.1-18 years, median 14.6 years) were included, with diverse ethnicity (53.1% Arab, 27.6% Black, 17.6% White, and 1.7% other) and sports background (50.6% football, 27.9% athletics, 21.5% other). Of these n = 22 were in the M-mTFC group (8.9%), n = 93 in the m-mTFC group (37.7%) and n = 132 in the no-mTFC group (53.4%). No regional RV wall motion abnormalities were observed. There were no differences in RV-Sl or FW-Sl by mTFC Group (Table 1). Conclusions In healthy paediatric athletes, 9% met the major mTFC, and 38% met the minor mTFC for RVOT size. RV longitudinal strain was found to be similar between those who met the mTFC and those who did not. This highlights the probable non-pathological adaptations reflected by RVOT dilation in these individuals, as opposed to those seen in ACM. The results of this study suggest that STE can be a valuable tool in ACM screening in paediatric athletes, especially in cases where RV remodelling is present. RV peak longitudinal strain by mTFC All M-mTFC n = 22 m-mTFC n = 93 no-mTFC n = 132 p value for between group comparison Global RV Sl (median, IQR) -23.3% (-25.2;-21.7) -23.3% (-25.5;-21.7) -23.4% (-25;-21.7) -23.3% (-25.5;-21.7) p = 0.8 Free wall RV Sl (median, IQR) 27.7% (-30;-25.2) -27.6% (-29.3;-25.2%) -28.1% (-29.7;-25) -27.5 (-30.5;-25.4) p = 0.9

The Hidden Value of Assessing Right Ventricular Performance with Exercise in Hypertensive Patients with Left Ventricular Diastolic Dysfunction

Background: Right ventricular (RV) dysfunction could develop during exercise in patients with both hypertension and left ventricular diastolic dysfunction and may contribute to the patient symptoms. The objective is to assess RV function, both at rest and during exercise in patients with hypertension and left ventricular diastolic dysfunction. Methods: We included 30 patients with hypertension and resting LV diastolic dysfunction. The systolic function of the right ventricle was assessed by TAPSE (Tricuspid Annular Plane Systolic Excursion) and S, while E/A ratio, annular lateral E’, E/E’ and E’/A’ were used to measure diastolic function. The global function of the right ventricle was assessed by measuring the right indexed myocardial performance. The dimensions and pulmonary pressures were also measured. Results: The following parameters of RV systolic function were increased significantly with exercise: TAPSE (P = 0.0054), S’ (P = 0.0045). Moreover, the following diastolic parameters of the RV increased significantly with exercise: E/E’ (P = 0.05), A’ (P = 0.04). The global RV function showed also a significant increase (P = 0.0011). The three RV dimensions as well as the pulmonary artery pressures also increased during exercise (P = 0.000004, 0.001, and 0.00000064 respectively). In addition, the presence of resting LV grade II DD predicted significantly higher pulmonary pressures during exercise (P = 0.006). The advanced resting grade of LVDD predicted significantly the presence of advanced grade of RVDD with exercise (P = 0.037). Conclusions: Some patients who have both hypertension and LV diastolic dysfunction showed structural and functional changes of the right ventricle at rest. However, all patients had RV functional changes during exercise.

Right ventricular ejection fraction as predictor of outcome in acute heart failure using RV ellipsoid model: A retrospective analysis of a prospective cross-sectional study.

ObjectivesThe right ventricular (RV) function is an important prognostic factor in acute and chronic heart failure (HF). Echocardiography is an essential imaging modality with established parameters for RV function which are useful and easy to perform. However, these fail to reflect global RV volumes due to reliability on one acoustic window. It is therefore attractive to calculate RV volumes and ejection fraction (RVEF/E) using an ellipsoid geometric model which has been validated against MRI in healthy adults but not in the HF patients.DesignThis is a retrospective analysis of a prospective cross-sectional study enrolling 418 consecutive patients with symptoms of HF according to a predefined study protocol. All patients underwent echocardiographic assessment of RV function using Tricuspid Annular Plane Systolic Excursion (TAPSE) and RV fractional area change (RVFAC) and RVEF/E.SettingSingle centre study with multiple locations for acute in-patients including high dependency units.ParticipantsPatients with acute or exacerbation of chronic HF older than 18 y.o.Main outcome measuresAbility of RVEF/E to predict patient outcomes compared with two established parameters of RV function over two-year follow-up period. Primary outcome measure was all-cause mortality.ResultsRVEF/E is equal to TAPSE & RVFAC in predicting outcome (p ≤ 0.01 vs p ≤ 0.01) and provides additional benefit of RV volume estimation based on standard 2D echo measurements.ConclusionsIn this study we have shown that RVEF/E derived from ellipsoid model is not inferior to well established measures of RV function as a prognostic indicator of outcome in the acute HF.

Assessment of Right Ventricular Function in Patients with Cor Pulmonale: Strain Imaging Study

Background: Cor pulmonale is one of the leading causes of heart failure. Speckle tracking echocardiography is a potential modality for evaluation of systolic and diastolic functions, myocardial mechanics and other cardiac pathophysiological processes. Objective: This study aims to assess the right ventricular (RV) function in patients with cor pulmonale using Strain Imaging and conventional echocardiography. Methods: Fifty patients with cor pulmonale compared to twenty age and sex matched controls selected for echocardiographic examination for assessment of RV indices; Pulmonary Artery Systolic Pressure (PASP), Tricuspid Annular systolic Excursion (TAPSE), Fractional Area Change (FAC), Tissue Doppler Imaging (TDI), Strain and Strain rate of RV free wall in addition to conventional left ventricular data. Results: TAPSE (1.4±0.16 vs 2.3±0.31 cm), RV FAC (30.5±4.3% vs 47.2±4.5%), PASP (60.98±15.6 vs 18.9±5.41 mmHg) and Systolic velocity of tricuspid annulus S' (8.9±1.4 vs 13.4±1.9 cm/sec) were significantly impaired in patients vs controls respectively with p<0.001 for all. Also, The global RV free wall peak systolic longitudinal strain (ε sys) for patients was 16.9±3.4% vs 25.2±2.9%, The RV free wall systolic strain rate (S^-1 s) was 0.98±0.18 vs 1.7±0.18, RV free wall early diastolic strain rate (S^-1 e) was 1.2±0.25 vs 1.92±0.28 and RV free wall late diastolic strain rate (S^-1 a) was 1.11±0.27 vs 1.8±0.21 with (p<0.001 for all). The RV free wall systolic Longitudinal Strain (ε sys) was negatively correlated with PASP (r=-0.950, p<0.001) and positively correlated with TAPSE, RV FAC and Systolic velocity of tricuspid annulus S' (r=0.635, r=0.919, r=0.890 respectively with p<0.001 for all). Conclusion: Strain and Strain Rate are reliable tools to assess systolic and diastolic functions of the RV in patients with cor pulmonale even at early disease stages and correlate well with other conventional echo parameters for RV assessment.

Clinical Significance of Guanylate Cyclase Stimulator, Riociguat, on Right Ventricular Functional Improvement in Patients with Pulmonary Hypertension

Background: Riociguat is a soluble guanylate cyclase stimulator that improves hemodynamics in patients with pulmonary hypertension (PH). Accumulating evidence implicates the additional effect of riociguat on the increase in cardiac output. However, its mechanisms have not been fully understood. This study aimed to investigate whether riociguat could ameliorate right ventricular (RV) contraction as well as hemodynamics. Methods: We studied 45 patients with pulmonary arterial hypertension (14) or chronic thromboembolic pulmonary hypertension (31) and evaluated hemodynamics, using right-sided heart catheterization, before and after the administration of riociguat. RV function was assessed by echocardiography, including speckle-tracking echocardiography. Results: Riociguat significantly improved the WHO functional class and reduced the mean pulmonary arterial pressure and vascular resistance. In addition, the cardiac index increased. RV remodeling was ameliorated after riociguat administration as assessed by the echocardiographic parameters, such as RV diameter and RV area index. RV function, including RV fractional area change and RV global longitudinal strain, also significantly improved, and their improvement was even observed in patients with mild PH after pulmonary endarterectomy or balloon pulmonary angioplasty. Furthermore, covariance analysis revealed that RV global longitudinal strain and RV fractional area change improved after riociguat administration, even with the same mean pulmonary arterial pressure, implicating the improvement of RV contractile function by riociguat, regardless of RV loading. Conclusions: Riociguat not only improved the hemodynamics of patients with PH but also ameliorated the echocardiographic parameters with RV function. RV strain could detect the subtle improvement in mild PH, and riociguat may have a benefit even after intervention, as assessed by speckle-tracking echocardiography.

Abstract 14298: Right Ventricular Strain Before and After Balloon Pulmonary Angioplasty in Chronic Thromboembolic Pulmonary Hypertension

Background: Right ventricular (RV) function is impaired in chronic thromboembolic pulmonary hypertension (CTEPH). Balloon pulmonary angioplasty (BPA) may be an alternative treatment for patients (pts) who are not candidates for pulmonary thromboendarterectomy (PTE). We assessed the RV global and segmental strain patterns in pts who underwent BPA. Methods: Between 12/2016 and 5/2019, 22 pts had completed BPA treatment and had transthoracic echocardiograms (echos) before and after treatment. Of those 22 pts, 14 had echos with adequate imaging of the RV. Epsilon EchoInsight® was used to measure global and segmental RV strain. Tricuspid annular plane excursion (TAPSE) was also measured. Paired t-tests were used to determine mean differences for pre &amp; post BPA, and Pearson correlation coefficient was used to determine association with hemodynamics. Results: RV global longitudinal strain (GLS) significantly improved after BPA (-11.1±3.4 to -16.2±2.9 % p&lt;0.05). The apical and mid segmental strain also significantly improved after BPA (-5.0±9.1 to -12.5±7.5%, p=0.03; -13.3±6.2 to -17.5±5.4%, p&lt;0.01 respectively). Basal strain did not significantly change (-15.2±6.3 to -18.5±9.2%, p=0.22). Furthermore, TAPSE did not change significantly (1.87±0.5 to 1.95±0.5 cm, p=0.55). Hemodynamically, mean pulmonary arterial pressure (mPAP) and pulmonary vascular resistance (PVR) significantly decreased (40.3±10.5 to 34.0±10.3 mmHg, p=0.001 and 5.9±3.1 to 3.9±1.8 WU, p=0.01) while cardiac output remained unchanged (5.6±2.0 to 5.7±1.1 L/min, p=0.86). There was no correlation between improvement in RV GLS and decrease in mPAP and PVR. Conclusion: RV function as measured by RV GLS significantly improved after BPA, though only the mid and apical segments improved. TAPSE and RV basal strain did not change after BPA. Previous studies have shown that GLS did not improve significantly after PTE. Furthermore, TAPSE significantly decreases after PTE. The reasons for the difference in RV function after PTE vs BPA are not entirely clear, but may be due to operability and location of disease, as well as immediate post-operative RV stunning after PTE.

Cardiac magnetic resonance feature tracking of the right ventricle in convalescent Kawasaki disease in a large single center.

BackgroundThe changes in right ventricular (RV) contractility of Kawasaki disease (KD) still remain unclear.HypothesisWe aimed to determine whether RV systolic dysfunction can be detected by cardiac magnetic resonance (CMR) feature tracking and to find its association with coronary artery lesions (aneurysm, thrombosis and stenosis).MethodsPeak systolic myocardial longitudinal, radial and circumferential strain and the strain rate (RVSL, RVSR, RVSC, RVSRL, RVSRR and RVSRC) in the global RV and three levels (basal, middle and apical) were measured in 66 patients with convalescent KD. A total of 20 controls were included. Comparisons were made with controls and among KD subgroups divided with coronary artery lesions.ResultsRVSC (−10.575% vs. −10.760%), RVSL (−18.150% vs. −18.712%) and RVSRC (−0.815/s vs. −0.924/s) were slightly lower in KD group without significant difference. All the strain and strain rate presented lowest in the basal level. In subgroup comparison, lower RVSL and RVSRL were observed in the giant coronary artery aneurysm (CAA) group; RVSR (15.844% vs. 16.897%), RVSRR (1.245/s vs. 1.322/s) and RVSRC (−0.715/s vs. −0.895/s) were lower in thrombosed group; RVSRL (−1.27/s vs. −1.503/s) were lower in stenosis group. All the comparison in subgroups did not reach significant difference. From the analysis of receiver operating characteristic curve, RVSRL had a better ability to identify KD with giant CAA and stenosis. For the identification of thrombosis, RVSRC had a better ability.ConclusionsLower strain and strain rates of RV were detected in convalescent KD. More pronounced in those with persisting coronary artery lesions.

3D right ventricular ejection fraction and longitudinal strain are independent predictors of major adverse cardiovascular events in patients with rrhythmogenic right ventricular cardiomyopathy

Abstract Introduction Evaluation of right ventricular (RV) function is essential in the follow up of patients with arrhythmogenic right ventricular cardiomyopathy (ARVC). Role of advance echocardiography including 3D transthoracic echocardiography (3DTTE) for evaluation of 3D RV function and RV longitudinal strain in predicting prognosis in ARVC patients, has not been well investigated. Purpose We aimed to evaluate 3DTTE parameters in predicting major advance cardiovascular events (MACE) defined as ventricular arrhythmia, cardiac hospitalization, heart transplantation, and death in ARVC patients. Methods Forty-eight definite ARVC subjects based on the 2010 Task force criteria were evaluated with standard 2D transthoracic echocardiography (2DTTE) and 3DTTE. Patients with poor image quality were excluded. RV function was evaluated by 2D and 3D TTE including: fractional area change (FAC), RV global and free wall longitudinal strain (RV2DGLS and RV2DFWLS) and 3D RV ejection fraction (RV3DEF), RV global and free wall longitudinal strain (RV3DGLS, and RV3DFWLS). The patients were followed up for a median period of 12 months (6–18 months) to record MACE. Results Forty-eight patients with mean age =38.5±14 years; 79.2% male, and mean RV3DEF =30.33%, were included. During the mean follow up 12 months, 12 patients (25%, with mean RV3DEF = 24.8±9%) experienced MACE whereas mean RV3EF in patient without any cardiovascular events during follow up was 34.21±9%. The most common causes of hospitalization were arrhythmia, right-sided heart failure, and RV clot as the following: Ventricular arrhythmia in 7 patients (14.6%, with mean RV3DEF = 29.01±8.82%), RV clot in 2 cases (4.2%, with mean RV3DEF = 20.2%), right-sided heart failure in 3 patients (6.3%, with mean RV3DEF = 16.83±3.6%) that 2 of them (2.1%, with mean RV3DEF = 14.58±0.63) underwent heart transplantation. Logistic regression analysis revealed RV3DTTE (p-value = 0.03, OR=0.90, CI: 0.82–0.99), RV3DGLS (p-value = 0.05, OR=1.27, CI: 0.99–1.61) and RV3DFWLS (p-value = 0.01, OR=1.29, CI: 1.05–1.59), predicted cardiac adverse events, but there were no significant association between RV2DGLS, RV2DEWLS and FAC with MACE. Conclusion RV3DEF, RV3DGLS, and RV3DFWLS were powerful predictors of morbidity and mortality and can be useful as a valuable method in the prediction of major cardiovascular complications in ARVC patients. Funding Acknowledgement Type of funding source: None