Indices Of Right Ventricular Function Research Articles

Potts Shunt Improves Right Ventricular Function and Coupling With Pulmonary Circulation in Children With Suprasystemic Pulmonary Arterial Hypertension.

Pulmonary arterial hypertension is a progressive disease with poor outcomes in children. Right ventricular (RV) function is the most important determinant of the prognosis. Novel application of Potts shunt between left pulmonary artery and descending aorta has been introduced in an attempt to improve the survival. However, the effect of Potts shunt creation on RV function, RV-PA coupling, and survival has not been studied. We evaluated the first 12 consecutive pediatric patients (9 male, median age 11.2 years and weight 32.8 kg) who underwent elective Potts shunt placement for suprasystemic pulmonary arterial hypertension between 2013 and 2017 with echocardiographic indices of RV function, RV work, RV-PA coupling, and pulmonary hemodynamics. Of 12 patients, 1 was excluded because of insufficient preshunt data, 2 died, 1 required lung transplant, and 8 survived for a median of 27 months postshunt. In survivors, WHO functional class significantly ( P=0.01) improved and the majority (5 of 8) came off pulmonary vasodilators at the most recent follow-up. Postshunt RV systolic function improved ( P=0.03), RV afterload decreased ( P <0.01), RV work decreased ( P=0.02), and RV-proximal PA coupling improved ( P<0.01). This proof of concept study shows that Potts shunt allows improvement in functional status and mid-term transplant-free survival in the majority of the recipients by improvement in RV systolic function and RV-PA coupling in children with suprasystemic pulmonary arterial hypertension.

Right Ventricular and Pulmonary Vascular Function are Influenced by Age and Volume Expansion in Healthy Humans

Patients with heart failure (HF) often show signs of right ventricular (RV) dysfunction. The RV function of coupled with the pulmonary circulation (tricuspid annular plane systolic excursion [TAPSE]/pulmonary arterial systolic pressure [PASP]) has been shown to divide HF patients into distinct prognostic strata, but less is known about which factors influence this prognostic marker, and whether those factors can be modified. We sought to obtain normative values and discern the individual effects of age, sex, and fluid overload on RV function. Sixty healthy subjects aged 20-80 years were enrolled in this prospective study. Right heart catheterization with hemodynamic measurements were performed at rest after a rapid saline solution infusion (10 mL/kg, 150 mL/min). Linear regression and Spearman correlation models were used to estimate associations between TAPSE/PASP and relevant variables. In healthy persons of all ages, the median (5th-95th percentiles) normative TASPE-PASP ratio was 1.25 (0.81-1.78) mm/mm Hg. The correlation between progressive age and declining TAPSE/PASP was significant (r = -0.35; P = .006). Sex did not influence TAPSE/PASP (P = .30). Rapid fluid expansion increased central venous pressure from 5 ± 2 mm Hg to 11 ± 4 mm Hg after fluid infusion (P < .0001). This resulted in a 32% decrease in the TAPSE-PASP ratio after fluid infusion, compared to baseline (P < .0001). The TAPSE-PASP ratio was affected by age, but not sex. TAPSE/PASP is not only a reflection of intrinsic RV function and pulmonary vascular coupling, but fluid status also dynamically affects this index of RV function. Normative values with invasive measurements were obtained for future assessment of HF patients.

The use of echocardiographic indices in defining and assessing right ventricular systolic function in critical care research.

Many echocardiographic indices (ormethods) for assessing right ventricular (RV) function are available, but each has its strengths and limitations. In some cases, there might be discordance between the indices. We conducted a systematic review to audit the echocardiographic RV assessments in critical care research to see if a consistent pattern existed. We specifically looked into the kind and number of RV indices used, and how RV dysfunction was defined in each study. Studies conducted in critical care settings and reported echocardiographic RV function indices from 1997 to 2017 were searched systematically from three databases. Non-adult studies, case reports, reviews and secondary studies were excluded. These studies' characteristics and RV indices reported were summarized. Out of 495 non-duplicated publications found, 81 studies were included in our systematic review. There has been an increasing trend of studying RV function by echocardiography since 2001, and most were conducted in ICU. Thirty-one studies use a single index, mostly TAPSE, to define RV dysfunction; 33 used composite indices and the combinations varied between studies. Seventeen studies did not define RV dysfunction. For those using composite indices, many did not explain their choices. TAPSE seemed to be the most popular index in the last 2-3years. Many studies used combinations of indices but, apart from cor pulmonale, we could not find a consistent pattern of RV assessment and definition of RV dysfunction amongst these studies.

Proximal pulmonary vascular stiffness as a prognostic factor in children with pulmonary arterial hypertension.

Main pulmonary artery (MPA) stiffness and abnormal flow haemodynamics in pulmonary arterial hypertension (PAH) are strongly associated with elevated right ventricular (RV) afterload and associated with disease severity and poor clinical outcomes in adults with PAH. However, the long-term effects of MPA stiffness on RV function in children with PAH remain poorly understood. This study is the first comprehensive evaluation of MPA stiffness in children with PAH, delineating the mechanistic relationship between flow haemodynamics and MPA stiffness as well as the prognostic ability of these measures regarding clinical outcomes. Fifty-six children diagnosed with PAH underwent baseline cardiac magnetic resonance (CMR) acquisition and were compared with 23 control subjects. MPA stiffness and wall shear stress (WSS) were evaluated using phase contrast CMR and were evaluated for prognostic potential along with standard RV volumetric and functional indices. Pulse wave velocity (PWV) was significantly increased (2.8 m/s vs. 1.4 m/s, P < 0.0001) and relative area change (RAC) was decreased (25% vs. 37%, P < 0.0001) in the PAH group, correlating with metrics of RV performance. Decreased WSS was associated with a decrease in RAC over time (r = 0.679, P < 0.001). For each unit increase in PWV, there was approximately a 3.2-fold increase in having a moderate clinical event. MPA stiffness assessed by non-invasive CMR was increased in children with PAH and correlated with RV performance, suggesting that MPA stiffness is a major contribution to RV dysfunction. PWV is predictive of moderate clinical outcomes, and may be a useful prognostic marker of disease activity in children with PAH.

Prognostic Impact of Pulmonary Artery Pulsatility Index (PAPi) in Patients With Advanced Heart Failure: Insights From the ESCAPE Trial

BackgroundThe pulmonary artery pulsatility index (PAPi), defined as the ratio of pulmonary artery pulse pressure to right atrial pressure, emerged as a powerful predictor of right ventricular (RV) failure in patients with acute inferior myocardial infarction and those undergoing left ventricular assist device placement; however, its prognostic utility in the advanced heart failure population remains largely unknown. Methods and ResultsWe comparatively analyzed PAPi with traditional indices of RV function including RV stroke work index and right atrial/pulmonary capillary wedge pressure ratio (RAP/PCWP) in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness trial. Median PAPi score was 2.35 in 190 patients. PAPi was significantly associated with clinical (jugular venous distention, ascites, edema), echocardiographic (right atrial size, vena cava size, tricuspid regurgitation velocity), and hemodynamic signs of RV failure (RAP, PCWP); all P < .05. In addition, PAPi was associated with the measures of left ventricular function, including ejection fraction, cardiac index, and PCWP (all P < .05). In Cox regression analysis, PAPi was an independent predictor of primary endpoint of death or hospitalization at 6 months (hazard ratio 0.91 [95% confidence interval 0.84–0.99], P = .022), whereas RA pressure, RV stroke work index, or RA/PCWP were not. ConclusionsPAPi serves as a marker of RV dysfunction and strongly predicts adverse clinical events in patients with advanced heart failure. Incorporating PAPi into existing risk models can substantially improve patient selection for advanced therapies and clinical outcomes in this population.

Influence of different dynamic sporting disciplines on right ventricular Structure and function in elite male athletes

Our objective was to assess the influence of different levels of exposure to dynamic training on right ventricular (RV) structure, function and mechanics in elite male athletes. We recruited 492 male elite athletes aged between 18 and 30 years old. Athletes were grouped according to their sporting discipline using the Mitchell Classification as Low Dynamic (LD), Moderate Dynamic (MD) or High Dynamic (HD). All participants underwent 2D, Doppler, tissue Doppler and strain (ε) echocardiography with a focused and comprehensive assessment of the right heart. Athletes involved in MD sports had the largest absolute RV chamber size and when scaled to body size RVOT PLAX, RVOT2, RVD1 and RVD3 were larger in HD compared to MD and LD athletes. There were no between group differences in conventional RV functional indices as well as global RV ε (LD: − 23.4 ± 3.1 vs. MD: − 22.7 ± 2.7 vs. HD: − 23.5 ± 2.6, %) and strain rate (P > 0.01). The base to apex ε gradient in the RV septum was lower in the MD athletes compared to HD and LD due to a lower apical septal ε which significantly correlated with absolute RV chamber size. After scaling for body size there was evidence of larger RV cavities in both MD and HD athletes compared to LD athletes. Global RV function, ε and strain rate were not different between groups. MD athletes had lower apical septal ε that contributed to a smaller base-to-apex ε gradient that is partially associated with larger absolute RV chamber dimensions.

Echocardiographic Estimates of Right Ventricular Systolic Function in Dogs with Myxomatous Mitral Valve Disease.

BackgroundRight ventricular (RV) dysfunction independently predicts outcomes in human myxomatous mitral valve disease (MMVD). There is limited information regarding RV systolic function in dogs with MMVD.HypothesisRight ventricular systolic function differs among stages of disease, decreasing in decompensated MMVD.AnimalsThirty‐sixclient‐owned dogs with MMVD not receiving oral cardiovascular medications.MethodsProspective clinical study. Dogs were categorized according to disease severity as ACVIM Stage B1, B2, or C. Seven echocardiographic indices of RV systolic function were measured. Groups were compared by 1‐way ANOVA and Tukey's HSD test. Frequencies of cases with cardiac remodeling falling outside previously established reference intervals were compared using Fisher's exact test. Intra‐ and interobserver measurement variability was calculated for each RV function index.ResultsThe indices TAPSE (P = 0.029), RV StL (P = 0.012), and RV StRL (P = 0.041) were significantly different between groups. A greater proportion of B2 dogs (7 of 12) had TAPSE values above reference intervals compared with B1 (2 of 12) or C (2 of 12) dogs (P = 0.027). Measurement variability of TAPSE, RV S', and RV StG was clinically acceptable.Conclusions and Clinical ImportanceRight ventricular systolic function differs between stages of MMVD, increasing in stage B2, and declining in stage C. The prognostic importance of RV function indices, particularly TAPSE, might be worth evaluating in dogs with MMVD.

The repeatability and characteristics of right ventricular longitudinal strain imaging by speckle-tracking echocardiography in healthy dogs

IntroductionTo assess the repeatability and characteristics of echocardiographic indices of the right ventricular (RV) function derived from speckle-tracking echocardiography. AnimalsFourteen laboratory Beagles and 103 privately owned dogs without cardiac disease were involved in this study. Materials and methodsRight ventricular longitudinal strain, strain rate, and a strain-related index for assessing RV dyssynchrony derived from speckle-tracking echocardiography were obtained by two different observers using five Beagles. Within-day, between-day, and interobserver coefficients of variation and the intraclass correlation coefficient of speckle-tracking echocardiography indices were determined. Both speckle-tracking echocardiography and conventional indices of RV function, including the peak velocity of systolic tricuspid annular motion, tricuspid annulus plane systolic excursion, fractional area change, and the Tei index, were obtained from 14 Beagles and 103 privately owned dogs. Relationships between echocardiographic indices and the body weight, heart rate, age, and sex were estimated by regression analysis. ResultsSpeckle-tracking echocardiographic indices showed good within-day repeatability, between-day and interobserver repeatability were moderate to good. In large dogs, RV longitudinal strain, strain rate, and fractional area change were significantly decreased, while the index of RV dyssynchrony, systolic tricuspid annular motion, tricuspid annulus plane systolic excursion, and the Tei index were increased. All speckle-tracking and conventional echocardiographic indices were correlated with the body weight. Discussion and conclusionsThe speckle-tracking echocardiography indices were highly repeatable and body weight affected speckle-tracking echocardiography indices in dogs. Further studies are needed to apply speckle-tracking echocardiography indices in dogs with cardiac disease.

Changes in right ventricular function assessed by echocardiography in dog models of mild RV pressure overload.

The assessment of hemodynamic change by echocardiography is clinically useful in patients with pulmonary hypertension. Recently, mild elevation of the mean pulmonary arterial pressure (PAP) has been shown to be associated with increased mortality. However, changes in the echocardiographic indices of right ventricular (RV) function are still unknown. The objective of this study was to validate the relationship between echocardiographic indices of RV function and right heart catheterization variables under a mild RV pressure overload condition. Echocardiography and right heart catheterization were performed in dog models of mild RV pressure overload induced by thromboxane A2 analog (U46619) (n=7). The mean PAP was mildly increased (19.3±1.1mm Hg), and the cardiac index was decreased. Most echocardiographic indices of RV function were significantly impaired even under a mild RV pressure overload condition. Multivariate analysis revealed that the RV free wall longitudinal strain (RVLS), standard deviation of the time-to-peak longitudinal strain of RV six segments (RV-SD) by speckle-tracking echocardiography, and Tei index were independent echocardiographic predictors of the mean PAP (free wall RVLS, β=-0.60, P<.001; RV-SD, β=0.40, P=.011), pulmonary vascular resistance (free wall RVLS, β=-0.39, P=.020; RV-SD, β=0.47, P=.0086; Tei index, β=0.34, P=.047), and cardiac index (Tei index, β=-0.65, P<.001). Free wall RVLS, RV-SD, and Tei index are useful for assessing the hemodynamic change under a mild RV pressure overload condition.

Maintained right ventricular pressure overload induces ventricular-arterial decoupling in mice.

What is the central question of this study? The aim was to investigate whether complementary assessment of non-invasive ultrasound imaging together with closed chest-derived intracardiac pressure-volume catheterization is applicable to mice for an in-depth characterization of right ventricular (RV) function even upon maintained pressure overload. What is the main finding and its importance? Characterization of RV function by the complementary use of echocardiographic imaging together with pressure-volume catheterization reveals ventricular-arterial decoupling upon maintained pressure overload, where RV systolic function correlates with ventricular-arterial coupling rather than contractility, whereas diastolic function correlates well with RV diastolic pressure. This combined approach allows us to phenotype RV function and dysfunction better in genetically modified and/or pharmacologically treated mice. Assessment of right ventricular (RV) function in rodents is a challenge because of the complex RV anatomy and structure. To date, the best characterization of RV function has been achieved by accurate cardiovascular phenotyping, involving a combination of non-invasive imaging and intracardiac pressure-volume measurements. We sought to investigate the feasibility of two complementary phenotyping techniques for the evaluation of RV function in an experimental mouse model of sustained RV pressure overload. Mice underwent either sham surgery (n=5) or pulmonary artery banding (n=8) to induce isolated RV pressure overload. After 3weeks, indices of RV function were assessed by echocardiography (Vevo2100) and closed chest-derived invasive pressure-volume measurements (PVR-1030). Pulmonary artery banding resulted in RV hypertrophy and dilatation accompanied by systolic and diastolic dysfunction. Invasive RV haemodynamic measurements demonstrated an increased end-systolic elastance and arterial elastance after pulmonary artery banding compared with sham operation, resulting in ventricular-arterial decoupling. Regression analysis revealed that tricuspid annular plane systolic excursion is correlated with ventricular-arterial coupling (r²=0.77, P=0.002) rather than with RV contractility (r²=-0.61, P=0.07). Furthermore, the isovolumic relaxation time to ECG-derived R-R interval and the ratio of the early diastolic peak velocity measured by pulsed wave Doppler to the early diastolic peak obtained during tissue Doppler imaging correlate well with RV end-diastolic pressure (r²=0.87, P=0.0001 and r²=0.82, P=0.0009, respectively). Commonly used indices of systolic RV function are associated with RV-arterial coupling rather than contractility, whereas diastolic indices well correlate with end-diastolic pressure when there is maintained pressure overload.

Does Late Gadolinium Enhancement Still have Value? Right Ventricular Internal Mechanical Work, Ea/Emax and Late Gadolinium Enhancement as Prognostic Markers in Patients with Advanced Pulmonary Hypertension via Cardiac MRI

Investigate the impact of Right Ventricular (RV) Internal Work (IW), ratio of arterial to ventricular end-systolic elastance (Ea/Emax), and RV Insertion Point (IP) Late Gadolinium Enhancement (LGE) on outcome in Pulmonary Hypertension (PH) patients. LGE is well known to be present within the RVIPs and Inter Ventricular Septum (IVS) in PH patients, but its prognostic role remains complex and potentially overestimated via 2D qualitative relative to the 3D quantitative measures now available. However, Ea/Emax, a measure of ventricular-arterial coupling and IW, when added to external cardiac work i.e. the P-V loop area as correlates to the heart's energy demands, might fundamentally improve measures of prognosis as they interrogate physiology beyond just the RV. Cardiac Magnetic Resonance Imaging (CMR) of 124 PH patients (age = 60±13, 85F) referred to a large tertiary PH center, was retrospectively examined for RV volumetric and functional indices and RVIP LGE%. Right Heart Catheterizations (RHC) performed within 1±2 months of the CMR were reviewed. Ea/Emax was derived as RV End-Systolic Volume (ESV/RVSV). IW was estimated as RVESV ×(RV end-systolic pressure-RV diastolic pressure). Patients were followed from date of CMR for up to 5 years for MACE (death, hospitalized RV failure, initiation of parenteral prostacyclin, sustained ventricular arrhythmia or referral for lung transplantation). MACE was high; 48/124 (39%) patients had MACE by 1.6±1.3 years. Neither RVIP nor IVS LGE using visual assessment or even 3D quantization predicted MACE. The strongest predictor of MACE was RVIW (OR=1.00013, p<0.002), vs. mPAP, RV mass, RV EF and IP LGE. Surprisingly, neither a single time-point RVIP nor whole IVS LGE% can predict outcome in the largest cohort of PH patients studied to date when compared with conventional or contemporary metrics of disease progression. CMR-LGE appears to lose its' prognostic value in PH patients in stark contradistinction to all other left and right-sided human myocardial pathologies.

Abstract 13869: The Usefulness of Echocardiographic Indices of Right Ventricular Systolic Function in Patients With Interstitial Pneumonia

Introductions: It is well known that interstitial pneumonia (IP) may induce pulmonary hypertension, but there have been few studies about right ventricular (RV) function in patients with IP and usefulness of echocardiographic indices in its evaluation. Methods: We retrospectively investigated 200 consecutive patients with IP. Patients with left heart failure or emphysema were excluded. Conventional left ventricular (LV) parameters and indices of RV function, such as tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and longitudinal strain of right ventricular free wall (RVLS) were evaluated. As a substitute for pulmonary vascular resistance, pressure gradient calculated by peak velocity of tricuspid regurgitation (TRPG) / cardiac output (CO) was used. Stage of IP was classified as mild, moderate, and severe, based on the degree of fibrosis and involvement area with CT images. Results: The mean age was 70.5±8.7 years (122 males (61%)). Stage of IP was graded as mild in 96 patients (48%), moderate in 71 patients (35.5%), and severe in 33 patients (16.5%). All LV parameters were normal at all stages of IP. FAC, which is an index of transverse RV systolic function, has not decreased until IP became severe (42.4±7.9 at mild vs. 40.7±7.5 at moderate vs. 32.7±7.1% at severe stage). On the other hand, TAPSE and RVLS, which are indices of longitudinal RV systolic function, showed graded reduction as stage of IP progressed (TAPSE: 21.1±3.0 vs. 18.0±3.3 vs. 15.2±3.2 mm; p&lt;0.01, RVLS: -20.2±4.2 vs. -18.3±5.0 vs. -15.1±3.9%; p&lt;0.01) and these indices have decreased at earlier stage of IP although TRPG and TRPG/CO were not elevated at this stage. (TRPG: 22.5±3.9 vs. 28.2±10.0mmHg, TRPG/CO: 5.0±1.7 vs. 6.1±2.1; mild vs. moderate). In ROC analysis, TAPSE (AUC=0.82) showed high predictive value for distinguishing between mild and moderate /severe IP, and the optimal cut-off values were 18.4mm (sensitivity: 80.0%, specificity: 70.2%). Conclusion: RV dysfunction progressed as stage of IP progressed. TAPSE and RVLS as the indices of longitudinal RV systolic function are useful to detect the earlier stage of RV dysfunction in patients with IP.

Clinical Manifestations and Diagnosis of Right Ventricular Failure

Right ventricular (RV) failure is a complex clinical syndrome characterized by impaired RV filling and ejection. RV function is altered in the setting of either pressure overload or volume overload. RV failure may result from a primary reduction of myocardial contractility caused by ischemia, cardiomyopathy, or arrhythmia, but left ventricular (LV) failure remains the leading cause. As RV dysfunction progresses to RV failure, the RV chamber becomes more spherical and tricuspid regurgitation is aggravated, leading to increasing venous congestion. Ventricular interdependence may result in impaired LV filling, a decrease in LV stroke volume, and low cardiac output. The important clinical manifestations of RV failure are fluid retention, decreased systolic reserve, low cardiac output, or arrhythmias. The initial diagnosis is based on clinical history and physical examination. A chest X-ray, electrocardiogram, and biochemical tests should be routinely obtained to evaluate the underlying causes and comorbidities. Bedside echocardiography provides valuable information on cardiac structure and function. RV ejection fraction is the most commonly used index of RV function although it is a highly load-dependent index. (Korean J Med 2016;91:131-138)

PP.09.05] HEMODIALYSIS IMPROVES RIGHT VENTRICULAR SIZING AND REDUCES PULMONARY CIRCULATION LOADING IN PATIENTS WITH END-STAGE RENAL DISEASE

Objective: The effect of acute pre-load reduction during hemodialysis on right ventricular (RV) function is not well understood. Accordingly, the aim of this study was to evaluate acute changes in novel echocardiographic and tissue Doppler-derived indices of RV function during the first and second weekly dialysis sessions. Design and method: A total of 41 adult patients receiving standard thrice-weekly hemodialysis for at least 3 months participated in this study. Two-dimensional echocardiographic and tissue-Doppler imaging studies were performed with a standard cardiac ultrasound device (Vivid 7, GE, Horten, Norway) shortly before and after the first and second weekly dialysis sessions. Results: Significant reductions from pre- to post dialysis were noted in body weight (1st session: 72.2 ± 12.6 vs 69.3 ± 12.5 kg, p < 0.001; 2nd session: 71.5 ± 12.7 vs 68.9 ± 12.5 kg, p < 0.001) and in systolic BP (1st session: 145.5 ± 21.6 vs 135.9 ± 23.5 mmHg, P < 0.05; 2nd session: 143.1 ± 19.8 vs 135.2 ± 20.4 mmHg, P < 0.05). RV end-diastolic diameter (1st session: 3.47 ± 0.97 vs 3.09 ± 0.83 cm, P < 0.001; 2nd session: 3.40 ± 0.83 vs 3.10 ± 0.88 cm, P < 0.001) and right atrial volume index (1st session: 27.33 ± 10.65 vs 21.30 ± 10.16 cm, P < 0.001; 2nd sessions: 27.83 ± 13.94 vs 23.04 ± 13.19 cm, P < 0.001) were reduced between the start and end of both sessions studied. Similarly, significant intradialytic reductions in inferior-vena-cava diameter were evident during both dialysis sessions (1st session: 1.93 ± 0.41 vs 1.54 ± 0.45 cm, P < 0.001; 2nd sessions: 1.76 ± 0.40 vs 1.37 ± 0.40 cm, P < 0.001). Acute pre-load reduction was accompanied by improvement in RV systolic pressure (1st session: 44.64 ± 16.25 vs 33.14 ± 12.43 mmHg, P < 0.001; 2nd session: 37.72 ± 14.46 vs 30.48 ± 13.36 mmHg, p < 0.001) and in tricuspid regurgitation maximum velocity (TRVmax) (1st session: 2.86 ± 0.54 vs 2.53 ± 0.54, cm/sec, P < 0.001; 2nd session: 2.68 ± 0.55 vs 2.46 ± 0.54 cm/sec, P < 0.001). Indices reflecting RV diastolic function remained unchanged from pre- to postdialysis in both sessions. RV systolic function assessed by peak systolic RV velocity (Sm-RV) remained stable in both occasions (1st session: 0.15 ± 0.04 vs 0.15 ± 0.04, m/sec P = 0.575; 2nd session 0.14 ± 0.03 vs 0.15 ± 0.04 m/sec; P = 0.149). Conclusions: This study shows that pre-load reduction during hemodialysis improves RV sizing parameters and reduces pulmonary circulation loading, without affecting the systolic and diastolic performance of right ventricle.

Mesenchymal stem cells preserve neonatal right ventricular function in a porcine model of pressure overload.

Limited therapies exist for patients with congenital heart disease (CHD) who develop right ventricular (RV) dysfunction. Bone marrow-derived mesenchymal stem cells (MSCs) have not been evaluated in a preclinical model of pressure overload, which simulates the pathophysiology relevant to many forms of CHD. A neonatal swine model of RV pressure overload was utilized to test the hypothesis that MSCs preserve RV function and attenuate ventricular remodeling. Immunosuppressed Yorkshire swine underwent pulmonary artery banding to induce RV dysfunction. After 30 min, human MSCs (1 million cells, n = 5) or placebo (n = 5) were injected intramyocardially into the RV free wall. Serial transthoracic echocardiography monitored RV functional indices including 2D myocardial strain analysis. Four weeks postinjection, the MSC-treated myocardium had a smaller increase in RV end-diastolic area, end-systolic area, and tricuspid vena contracta width (P < 0.01), increased RV fractional area of change, and improved myocardial strain mechanics relative to placebo (P < 0.01). The MSC-treated myocardium demonstrated enhanced neovessel formation (P < 0.0001), superior recruitment of endogenous c-kit+ cardiac stem cells to the RV (P < 0.0001) and increased proliferation of cardiomyocytes (P = 0.0009) and endothelial cells (P < 0.0001). Hypertrophic changes in the RV were more pronounced in the placebo group, as evidenced by greater wall thickness by echocardiography (P = 0.008), increased cardiomyocyte cross-sectional area (P = 0.001), and increased expression of hypertrophy-related genes, including brain natriuretic peptide, β-myosin heavy chain and myosin light chain. Additionally, MSC-treated myocardium demonstrated increased expression of the antihypertrophy secreted factor, growth differentiation factor 15 (GDF15), and its downstream effector, SMAD 2/3, in cultured neonatal rat cardiomyocytes and in the porcine RV myocardium. This is the first report of the use of MSCs as a therapeutic strategy to preserve RV function and attenuate remodeling in the setting of pressure overload. Mechanistically, transplanted MSCs possibly stimulated GDF15 and its downstream SMAD proteins to antagonize the hypertrophy response of pressure overload. These encouraging results have implications in congenital cardiac pressure overload lesions.

Impact of Norwood versus hybrid palliation on cardiac size and function in hypoplastic left heart syndrome

ObjectiveThe hybrid approach for hypoplastic left heart syndrome (HLHS) could theoretically result in better preservation of right ventricular (RV) function then the Norwood procedure. The aim of this study was...

Impact of intracoronary eptifibatide on the right ventricular function in patients with acute inferior myocardial infarction

Background and aim Distal embolization during primary percutaneous coronary intervention of the proximal right coronary artery (RCA) leads to impairment of flow of right ventricular (RV) branches and RV dysfunction. Glycoprotein IIb/IIIa receptor antagonists improve microcirculation and decrease the incidence of distal embolization. In the present study we aimed to assess RV function in patients with acute inferior ST-segment elevation myocardial infarction who received intracoronary (i.c.) bolus eptifibatide, and to compare them with patients who received a standard intravenous (i.v.) dose. Patients and methods Sixty-six patients with acute inferior myocardial infarction who underwent primary percutaneous coronary intervention and whose culprit lesion was RCA proximal to major RV branch were included in the present study. Patients were divided into two groups. In the first group, 36 patients received double bolus intracoronary eptifibatide followed by i.v. infusion. In the second group, 30 patients received standard i.v. dose. Forty-eight hours after the index procedure, all the patients underwent standard echocardiography assessment of RV function using conventional two-dimensional and tissue Doppler imaging. Results There were no significant differences regarding baseline characteristics, final Thrombolysis In Myocardial Infarction (TIMI) flow, and left ventricular systolic function between the two groups. RV function indices, including tricuspid annular plane systolic excursion, myocardial performance index-tissue Doppler imaging, and RV fractional area change, were significantly better in patients who received i.c. bolus eptifibatide (P Conclusion I.c. double bolus eptifibatide followed by i.v. infusion was found to be superior to the standard i.v. dose with respect to RV function in patients with acute inferior ST-segment elevation myocardial infarction due to proximal RCA occlusion.

Echocardiographic Diagnosis of Acute Pulmonary Embolism in Patients with McConnell's Sign.

"McConnell's sign" (McCS), described as hypo- or akinesis of the right ventricular (RV) free wall with preservation of the apex, is associated with acute pulmonary embolism (aPE). However, the sensitivity of McCS for the detection of aPE is limited. We sought to evaluate in patients with McCS, whether echocardiographic parameters of global and regional RV function could differentiate between patients with and without aPE. We reviewed echocardiograms of 81 patients with McCS, who underwent CT or V/Q studies for suspected PE, and 40 normal controls (NL). Echocardiograms were analyzed to measure pulmonary artery systolic pressure (PASP), tricuspid regurgitation (TR) by vena contracta width, conventional indices of RV function, and speckle tracking-derived longitudinal free wall strain. ROC analysis was performed to evaluate the diagnostic accuracy of these parameters for diagnosis of aPE. Fifty-five of eighty-one (68%) had PE (McCS + PE), while 26 of 81 (32%) did not (McCS - PE). Compared to NL, global and segmental RV strain were lower in patients with McCS, contrary to the notion of normal apical function. In McCS + PE, compared to McCS - PE: (1) PASP, fractional area change and TR were significantly lower; (2) strain magnitude was significantly lower globally and in basal and apical segments. Individual parameters had similar diagnostic accuracy by ROC analysis, which further improved by combining parameters. In McCS - PE, 69% of patients had pulmonary hypertension (PH). McCS and aPE are not synonymous. RV free wall strain may aid in differential diagnosis of patients with McCS evaluated for aPE. Specifically, McCS should prompt an inquiry for evidence of PH, which would indicate that aPE is less likely.

Relationship between Exercise Parameters and Noninvasive Indices of Right Ventricular Function in Patients with Biventricular Circulation and Systemic Right Ventricle.

In patients with systemic right ventricles (RVs) in a biventricular circulation, exercise capacity and RV function often deteriorate over time and echocardiographic assessment of systemic RV function is difficult. The purpose of this study was to examine the relationship between exercise capacity and RV function and to determine which noninvasive imaging parameters correlate most closely with exercise capacity. Patients with a systemic RV (D-loop transposition of the great arteries [TGA] after atrial switch procedure or physiologically "corrected" TGA) who underwent cardiopulmonary exercise testing (CPX) and noninvasive imaging (cardiac magnetic resonance [CMR] and echocardiography [echo]) within 1 year of CPX were identified. Regression analysis was used to evaluate the relationship between exercise variables and noninvasive indices of ventricular function. We identified 92 patients with 149 encounters (mean age 31.0 years, 61% men, 70% D-loop TGA) meeting inclusion criteria. Statistically significant correlations between % predicted peak oxygen uptake (%pVO2 ) and RV ejection fraction (EF) (r = 0.29, P = .0007), indexed RV end-systolic volume (r = -0.25, P = .002), and Tei index (r = -0.22, P = .03) were found. In patients without additional hemodynamically significant lesions, the correlations between %pVO2 and RV EF (r = 0.37, P = .0007) and the Tei index (r = -0.28, P = .03) strengthened and a correlation emerged between %pVO2 and dP/dtic (r = 0.31, P = .007). On multivariable analysis, Tei index was the only statistically significant correlate of %pVO2 (P = .04). In patients with systemic RVs in a biventricular circulation, CMR-derived RVEF and echo-derived Tei index correlate with %pVO2 . On multivariable analysis, the Tei index was the strongest predictor of peak %pVO2 response.

Impact of Initial Shunt Type on Cardiac Size and Function in Children With Single Right Ventricle Anomalies Before the Fontan Procedure: The Single Ventricle Reconstruction Extension Trial

BackgroundIn children with single right ventricular (RV) anomalies, changes in RV size and function may be influenced by shunt type chosen at the time of the Norwood procedure. ObjectivesThe study sought to identify shunt-related differences in echocardiographic findings at 14 months and ≤6 months pre-Fontan in survivors of the Norwood procedure. MethodsWe compared 2-dimensional and Doppler echocardiographic indices of RV size and function, neo-aortic and tricuspid valve annulus dimensions and function, and aortic size and patency at 14.1 ± 1.2 months and 33.6 ± 9.6 months in subjects randomized to a Norwood procedure using either the modified Blalock-Taussig shunt (MBTS) or right ventricle to pulmonary artery shunt (RVPAS). ResultsAcceptable echocardiograms were available at both time points in 240 subjects (114 MBTS, 126 RVPAS). At 14 months, all indices were similar between shunt groups. From the 14-month to pre-Fontan echocardiogram, the MBTS group had stable indexed RV volumes and ejection fraction, while the RVPAS group had increased RV end-systolic volume (p = 0.004) and decreased right ventricular ejection fraction (RVEF) (p = 0.004). From 14 months to pre-Fontan, the treatment groups were similar with respect to decline in indexed neo-aortic valve area, >mild neo-aortic valve regurgitation (<5% at each time), indexed tricuspid valve area, and ≥moderate tricuspid valve regurgitation (<20% at each time). ConclusionsInitial Norwood shunt type influences pre-Fontan RV remodeling during the second and third years of life in survivors with single RV anomalies, with greater RVEF deterioration after RVPAS. Encouragingly, other indices of RV function remain stable before Fontan regardless of shunt type. (Comparison of Two Types of Shunts in Infants with Single Ventricle Defect Undergoing Staged Reconstruction—Pediatric Heart Network; NCT00115934)