Measures Of Right Ventricular Function Research Articles

Serial Strain Analysis Identifies Hypoplastic Left Heart Syndrome Infants at Risk for Cardiac Morbidity and Mortality: A Pilot Study

Validated, objective measures of right ventricular (RV) function assessment in hypoplastic left heart syndrome (HLHS) are needed. In other populations, speckle-tracking echocardiography-derived strain is a sensitive measure that outperforms conventional parameters of RV function. We hypothesized that speckle-tracking echocardiography-derived measures of RV function would be worse in patients with HLHS who have a poor cardiac outcome. Prospective serial echocardiography was performed in 35 infants with HLHS during the first 6months of life. Patients not undergoing staged palliation or with other variants of single RV were excluded. Traditional RV measurements and strain analysis were performed from standard apical and basal views. The primary outcome of cardiac death, heart transplantation, or persistent ≥moderate RV dysfunction was examined using Cox regression analysis, and receiver operating characteristic curve analyses were performed to derive cutoff values. At median follow-up of 10.9months (interquartile range 5.6, 15.2), eight patients reached the outcome and demonstrated worse RV strain measures compared with those without the outcome. A post-Norwood global longitudinal strain (GLS) of>-16% (area under the curve [AUC]=0.76; P=.04) and pre-Glenn GLS>-13% (AUC, 0.98; P≤.01) were highly sensitive and specific for poor outcome. Other thresholds included post-Norwood GLS rate (GLSr)>-1.15 %/s (AUC, 0.78; P=.03), pre-Glenn GLSr=-0.85%/sec (AUC, 0.89; P<.01), post-Glenn circumferential strain rate>-0.85%/sec (AUC, 0.92; P<.01), and GLSr>-0.85%/sec (AUC, 0.84; P=.02). Strain analysis may help identify at-risk HLHS infants. In this pilot study, interstage strain indices were worse in infants with HLHS who had a poor cardiac outcome.

The Utility of Eccentricity Index as a Measure of the Right Ventricular Function in a Lung Resection Cohort.

Context:Right ventricular (RV) dysfunction occurs after lung resection and is associated with postoperative morbidity. Noninvasive evaluation of the RV is challenging, particularly in the postoperative period. A reliable measure of RV function would have value in this population.Aims:This study compares eccentricity index (EI) obtained by transthoracic echocardiography (TTE) with cardiovascular magnetic resonance (CMR) determined measures of RV function in a lung resection cohort. CMR is the reference method for noninvasive assessment of RV function.Design and Setting:Prospective observational cohort study at a single tertiary hospital.Materials and Methods:Twenty-eight patients scheduled for elective lung resection underwent contemporaneous TTE and CMR imaging preoperatively, on postoperative day (POD) 2 and at 2-month. Systolic and diastolic EI was measured offline from anonymized and randomized TTE and CMR images.Statistical Analysis:Bland–Altman analysis was performed to determine agreement between EITTE and EICMR. Changes over time and comparison with CMR determined RV ejection fraction (RVEFCMR) was assessed.Results:Bland–Altman analysis showed a negligible mean difference between EITTE and EICMR, but limits of agreement were wide (SD 0.24 and 0.28). There were no significant changes in EITTE and EICMR over time (P > 0.35). We found no association between EITTE with RVEFCMR at all-time points (P > 0.22). Systolic and diastolic EICMR on POD 2 demonstrated moderate association with RVEFCMR (r = −0.54 and r = −0.59, P ≤ 0.01). At 2-month, only diastolic EICMR correlated with RVEFCMR (r = −0.43, P = 0.03). There were no meaningful associations between EITTE and EICMR with TTE-derived RV systolic pressure (P > 0.31).Conclusions:TTE determined EI is not useful as a noninvasive method of assessing RV function following lung resection.

Assessment of right ventricular outflow tract fractional shortening as a measure of right ventricular function in chronic heart failure patients

Background: assessment of RV function is a major component of the management and prognostication of heart failure (HF) patients. Its complexity makes this task difficult and therefore not appropriately considered. Right ventricular outflow tract fraction (RVOT FS) can serve that purpose if done. The functional capacity of a HF patient must always be assessed and decision made on that basis. Aim of the study: this study aimed to investigate the applicability of RVOT FS in assessment of RV function and also its relation to functional capacity. Patients and methods: seventy-one (71) patients with heart failure with reduce ejection fraction (HFrEF) were studied prospectively and nineteen (19) control healthy individuals (normal ECG, normal left and right ventricular function and no cardiac risk factors). A 2D guided M-mode was taken in the parasternal short axis view to determine RVOT FS and a six-minute walk test (6MWT) was done to determine their functional capacity. Results: there was a reduced RVOT FS reduced in the HFrEF group (p value =0.005), 6MWT D was reduced in the HFrEF group (p value <0.001), there was a positive correlation of RVOT FS with RVFAC (r=0.839, p value<0.001) TAPSE (r=0.830, p value<0.001), S’(r=0.830, p value<0.001) 6MWT D (r=0.953, p value<0.001) and a negative correlation with RIMP(r=-0.867, p value<0.001), RV FLS(r=-0.878, p value<0.001), SPAP(r=-0.633, p value<0.001). 6MWTD with RVFAC (r=0.851, p value<0.001) TAPSE (r=0.825, p value<0.001), S’ (r=0.837, p value<0.001), RVOT FS (r=0.953, p value<0.001) and a negative correlation with RIMP (r=-0.827, p value<0.001), RV FLS (r=-0.902, p value<0.001), SPAP (r=-0.621, p value<0.001). RVOT FS between HF subgroups significant (p value<0.001). Conclusion: RVOT FS is a simple and reliable parameter that can be used in assessment of RV function and has very positive correlation with functional capacity assessed by 6MWT.

Assessment of right ventricular outflow tract fractional shortening as a measure of right ventricular function in chronic heart failure patients

Background: assessment of RV function is a major component of the management and prognostication of heart failure (HF) patients. Its complexity makes this task difficult and therefore not appropriately considered. Right ventricular outflow tract fraction (RVOT FS) can serve that purpose if done. The functional capacity of a HF patient must always be assessed and decision made on that basis. Aim of the study: this study aimed to investigate the applicability of RVOT FS in assessment of RV function and also its relation to functional capacity. Patients and methods: seventy-one (71) patients with heart failure with reduce ejection fraction (HFrEF) were studied prospectively and nineteen (19) control healthy individuals (normal ECG, normal left and right ventricular function and no cardiac risk factors). A 2D guided M-mode was taken in the parasternal short axis view to determine RVOT FS and a six-minute walk test (6MWT) was done to determine their functional capacity. Results: there was a reduced RVOT FS reduced in the HFrEF group (p value =0.005), 6MWT D was reduced in the HFrEF group (p value <0.001), there was a positive correlation of RVOT FS with RVFAC (r=0.839, p value<0.001) TAPSE (r=0.830, p value<0.001), S’(r=0.830, p value<0.001) 6MWT D (r=0.953, p value<0.001) and a negative correlation with RIMP(r=-0.867, p value<0.001), RV FLS(r=-0.878, p value<0.001), SPAP(r=-0.633, p value<0.001). 6MWTD with RVFAC (r=0.851, p value<0.001) TAPSE (r=0.825, p value<0.001), S’ (r=0.837, p value<0.001), RVOT FS (r=0.953, p value<0.001) and a negative correlation with RIMP (r=-0.827, p value<0.001), RV FLS (r=-0.902, p value<0.001), SPAP (r=-0.621, p value<0.001). RVOT FS between HF subgroups significant (p value<0.001). Conclusion: RVOT FS is a simple and reliable parameter that can be used in assessment of RV function and has very positive correlation with functional capacity assessed by 6MWT.

Abstract 17280: A New in vivo Imaging Protocol for Non-Invasive Detection of Right Ventricular Dysfunction in a Pulmonary Hypertension Mouse Model

Introduction: Accurate measurements of right ventricular (RV) function are critical for studying novel therapies impacting the heart and pulmonary circulation. Until now, assessment in mouse models has relied on invasive measures. Improvements in mouse echocardiography may facilitate application of measures recently validated in humans, including tricuspid annular plane systolic excursion (TAPSE) and RV-S’ (systolic excursion velocity), to allow non-invasive assessment of RV function. Aims: To apply and validate TAPSE and RV-S’ using high-resolution echocardiography for the measurement of RV function in a mouse model of pulmonary hypertension (PH). Methods: Echocardiography was performed on mice 3 weeks after induction of PH using inhaled bleomycin or saline control. PAT, TAPSE and RV-S’ were recorded in mice using a 55-mHz transducer (Visualsonics, Vevo3100). Invasive measurements of right ventricular systolic pressure (RVSP) were obtained via catheterisation of the internal jugular vein, prior to culling. Results: RVSP was significantly elevated in bleomycin-treated mice ( 33.41±0.8mmHg n=10) compared to controls ( 25.66±0.9mmHg n=11; p&lt;0.0001). Similarly, RV hypertrophy was observed in bleomycin mice [RV:body weight 1.156±0.03g/kg n=11] compared with control ( 0.968±0.02g/kg n=12; p=0.0002). TAPSE was sensitive to these differences, being significantly reduced in bleomycin mice ( 0.5739±0.020mm n=8) compared with control ( 0.7387±0.033mm n=10; p=0.0012), and correlated significantly with invasive RVSP (r 2 =0.7218; p&lt;0.0001). RV-S’ was also reduced in bleomycin mice (18.14±0.98mm/s n=7) compared with control (25.38±1.24mm/s n=8; p=0.0006) and correlated strongly with RVSP (r 2 =0.6378; p=0.0011). The correlation of both TAPSE and RV-S’ with RVSP compared favourably to the previously used surrogate measure of RVSP in mice, PAT (r 2 =0.5278; p=0.0002). Conclusions: TAPSE and RV-S’ can be applied in mouse echocardiography, and are sensitive, non-invasive measures of PH and RV dysfunction, comparing well with gold-standard invasive right ventricular systolic pressures. This may benefit the power of future preclinical studies of novel therapies in pulmonary hypertension and RV dysfunction.

A Comparison of Left- and Right-Sided Strain Software for the Assessment of Intraoperative Right Ventricular Function

To compare intraoperative right ventricular (RV) strain measurements made with left ventricular (LV) strain software commonly found on the echocardiography machine (Philips QLAB chamber motion quantification, version 10.7, Philips, Amsterdam, The Netherlands), with offline analysis using the dedicated RV strain software (EchoInsight, version 2.2.6.2230, Epsilon Imaging, Ann Arbor, MI). Prospective, nonrandomized, observational study. Single tertiary level, university-affiliated hospital. The study comprised 48 patients undergoing transesophageal echocardiography for cardiac or noncardiac surgery. Two-dimensional (2D) and 3-dimensional (3D) images of the right ventricle were obtained. Intraoperative 2D images were analyzed in real time for RV free wall strain (FWS) and global longitudinal strain (GLS) using QLAB chamber motion quantification (CMQ) LV strain software on the echocardiography machine. Two dimensional images were then analyzed offline to determine the RV FWS and GLS using EchoInsight RV-specific strain software. Three-dimensional images were then analyzed offline to detemine the 3D RV ejection fraction (3D RV EF) using TomTec 4D RV function (Unterschleissheim, Germany). Spearman's correlation and Bland-Altman analyses were used to characterize the relationship between RV strain measurements. Both types of strain measurements were compared to a reference standard of 3D RV EF. Intraoperative RV strain measurements using LV-specific strain software correlated with offline RV strain measurements using the RV-specific strain software (FWS rho = 0.85; GLS rho = 0.81). The bias and limits of agreement were 0.75% (- 6.66 to 8.17) for FWS and -4.53% (-11.55 to 2.50) for GLS. The sensitivity and specificity for RV dysfunction for the intraoperative LV-specific software were 94% (95% confidence interval [CI] 73-100) and 70% (95% CI 51-85), respectively, for RV FWS and 94% (95% CI 73-100) and 67% (95% CI 47-83), respectively, for RV GLS. The sensitivity and specificity for RV dysfunction for the offline RV-specific software were 89% (95% CI 65-99) and 73% (95% CI 54-88), respectively, for RV FWS and 94% (95% CI 73-100) and 30% (95% CI 15-49), respectively, for RV GLS. Intraoperative RV strain measurements using LV-specific strain software commonly available on the echocardiography machine (QLAB CMQ) correlate with offline RV strain measurements using RV-specific strain software (EchoInsight). The bias and limits of agreement for these left- and right-sided strain software suggest that these 2 measures of RV function cannot be used interchangeably. Both, however, were sensitive measures of RV dysfunction and therefore are likely clinically relevant.

17\u03b2-estradiol preserves right ventricular function in rats with pulmonary arterial hypertension: an echocardiographic and histochemical study

Pulmonary arterial hypertension (PAH) is more prevalent in females. Paradoxically, female patients have better right ventricular (RV) function and higher survival rates than males. However, the effects of 17β-estradiol (E2) on RV function in PAH has not been studied. Twenty-four male rats were exposed to monocrotaline (MCT) to induce experimental PAH, while treated with E2 or vehicle respectively. Together with eight control rats, thirty-two rats were examined by echocardiography 4 weeks after drug administration. Echocardiographic measurement of RV function included: tricuspid annular plane systolic excursion (TAPSE), RV index of myocardial performance (RIMP), RV fractional area change (RVFAC) and tricuspid annular systolic velocity (s′). RV free wall longitudinal strain (RVLSFW) and RV longitudinal shortening fraction (RVLSF) were also used to quantify RV function. RV morphology was determined by echocardiographic and histological analysis. TAPSE, RVFAC and s′ were reduced, and RIMP was elevated in the MCT-treated group and vehicle-treated group, when compared with control group (P < 0.01). TAPSE, RVFAC and s′ in the E2 group were higher, while RIMP was lower than those in the MCT-treated group and vehicle-treated group (P < 0.01). Myocardial functional parameters (RVLSFW and RVLSF) were also higher in the E2 group. Enhanced serum E2 levels were closely correlated with the improvement in RV functional parameters and enhancement of serum BNP levels (P < 0.01 for all groups). RV function decreased significantly in male rats with MCT-induced PAH, while E2 exhibited a protective effect on RV function, suggesting that E2 is a critical modulator of sex differences in PAH.

Echocardiographic Measurements of Right Ventricular Mechanics in Infants with Bronchopulmonary Dysplasia at 36 Weeks Postmenstrual Age

To test the hypothesis that specific echocardiographic measurements of right ventricular (RV) mechanics at 36 weeks postmenstrual age (PMA) are associated with the severity of bronchopulmonary dysplasia (BPD). A subset of 93 preterm infants (born between 27 and 29 weeks of gestation) was selected retrospectively from a prospectively enrolled cohort. BPD was defined using the National Institutes of Health workshop definition, with modifications for oxygen reduction testing and altitude. The cohort was divided into no-BPD and BPD groups using previously published methodology for analyses. Echocardiographic measurements of RV function (ie, tricuspid annular plane systolic excursion, fractional area of change, systolic-to-diastolic ratio, tissue Doppler myocardial performance index, and RV strain), RV remodeling/morphology (end-systolic left ventricular eccentricity index), and RV afterload (pulmonary artery acceleration time measure) were evaluated at 36 weeks PMA. Multivariable logistic regression determined associations between RV measurements and BPD severity. Compared with the no-BPD cohort, the BPD group had lower birth weight z-scores (P = .04) and trended toward a male predominance (P = .08). After adjusting for birth weight z-score, gestational age, and sex, there were no between-group differences in echocardiographic measurements except for the eccentricity index (scaled OR [0.1-unit increase], 1.49; 95% CI, 1.13-2.12; P = .01). Among conventional and emerging echocardiographic measurements of RV mechanics, eccentricity index was the sole variable independently associated with BPD severity in this study. The eccentricity index may be a useful echocardiographic measurement for characterizing RV mechanics in patients with BPD at 36 weeks PMA.

\u201cLow-\u201d versus \u201chigh\u201d-frequency oscillation and right ventricular function in ARDS. A randomized crossover study

BackgroundRecent, large trials of high-frequency oscillation (HFO) versus conventional ventilation (CV) in acute respiratory distress syndrome (ARDS) reported negative results. This could be explained by an HFO-induced right ventricular (RV) dysfunction/failure due to high intrathoracic pressures and hypercapnia. We hypothesized that HFO strategies aimed at averting/attenuating hypercapnia, such as “low-frequency” (i.e., 4 Hz) HFO and 4-Hz HFO with tracheal-gas insufflation (HFO-TGI), may result in an improved RV function relative to “high-frequency” (i.e., 7 Hz) HFO (which may promote hypercapnia) and similar RV function relative to lung protective CV.MethodsWe studied 17 patients with moderate-to-severe ARDS [PaO2-to-inspiratory O2 fraction ratio (PaO2/FiO2) < 150]. RV function was assessed by transesophageal echocardiography (TEE). Patients received 60 min of CV for TEE-guided, positive end-expiratory pressure (PEEP) “optimization” and subsequent stabilization; 60 min of 4-Hz HFO for “study mean airway pressure (mPaw)” titration to peripheral oxygen saturation ≥ 95%, without worsening RV function as assessed by TEE; 60 min of each tested HFO strategy in random order; and another 60 min of CV using the pre-HFO, TEE-guided PEEP setting. Study measurements (i.e., gas exchange, hemodynamics, and TEE data) were obtained over the last 10 min of pre-HFO CV, of each one of the three tested HFO strategies, and of post-HFO CV.ResultsThe mean “study HFO mPaw” was 8–10 cmH2O higher relative to pre-HFO CV. Seven-Hz HFO versus 4-Hz HFO and 4-Hz HFO-TGI resulted in higher mean ± SD right-to-left ventricular end-diastolic area ratio (RVEDA/LVEDA) (0.64 ± 0.15 versus 0.56 ± 0.14 and 0.52 ± 0.10, respectively, both p < 0.05). Higher diastolic/systolic eccentricity indexes (1.33 ± 0.19/1.42 ± 0.17 versus 1.21 ± 0.10/1.26 ± 0.10 and 1.17 ± 0.11/1.17 ± 0.13, respectively, all p < 0.05). Seven-Hz HFO resulted in 18–28% higher PaCO2 relative to all other ventilatory strategies (all p < 0.05). Four-Hz HFO-TGI versus pre-HFO CV resulted in 15% lower RVEDA/LVEDA, and 7%/10% lower diastolic/systolic eccentricity indexes (all p < 0.05). Mean PaO2/FiO2 improved by 77–80% during HFO strategies versus CV (all p < 0.05). Mean cardiac index varied by ≤ 10% among strategies. Percent changes in PaCO2 among strategies were predictive of concurrent percent changes in measures of RV function (R2 = 0.21–0.43).ConclusionsIn moderate-to-severe ARDS, “short-term” 4-Hz HFO strategies resulted in better RV function versus 7-Hz HFO, partly attributable to improved PaCO2 control, and similar or improved RV function versus CV.Trial registrationThis study was registered 40 days prior to the enrollment of the first patient at ClinicalTrials.gov, ID no. NCT02027129, Principal Investigator Spyros D. Mentzelopoulos, date of registration January 3, 2014.

Late right ventricular performance after mitral valve repair assessed by exercise echocardiography

ObjectivesThe aim of the study was to evaluate the right ventricular (RV) performance during exercise in patients who underwent mitral valve repair for chronic mitral valve insufficiency relative to healthy individuals and to assess exercise capacity using a semisupine ergometer.MethodsWe studied 56 patients who underwent mitral valve repair for degenerative posterior mitral leaflet prolapse between 2005 and 2014 and a control group of 13 healthy individuals. Clinical data were collected prospectively, and echocardiographic measurements of RV function were obtained at rest and at peak exercise.ResultsOne-third of the study patients had RV systolic dysfunction as indicated by tricuspid annular plane excursion (TAPSE) at rest. Resting TAPSE was lower in the study group (16.7 ± 3.3 mm) than in the control group (24.4 ± 4.3 mm), p < 0.001. TAPSE increased in both groups during exercise and exercise was shown to have a significant main effect on TAPSE F(1, 52) = 80, p < 0.001. TAPSE increased more in the control group and an interaction was detected between the participant groups (study group vs. control group) and exercise, F(1, 52) = 24, p < 0.001. In the study group, Poor postoperative RV function was associated with preoperative left ventricular dilatation but was not correlated with impaired maximum exercise capacity.ConclusionsDespite the excellent clinical outcome during rest and exercise after mitral valve repair, our results suggest patients that have undergone mitral valve repair due to posterior leaflet prolapse have significantly reduced RV function at rest and during exercise compared to healthy controls at long-term follow-up, as measured by TAPSE.

The Forgotten Ventricle? The Left Ventricle in Right-Sided Congenital Heart Disease.

The right ventricle has frequently been described as the forgotten ventricle in the circulation. However, its importance both in acquired and congenital heart disease is now unquestioned. This recognition has led to improved risk stratification and development of algorithms for intervention, which incorporate measurements of right ventricular function as key components of the assessment of many conditions. Indeed, such has been the emphasis on characterizing right ventricular dysfunction; the contribution of left ventricular dysfunction to the outcomes of diseases traditionally thought of as right sided has perhaps been underappreciated. In this review, we remind ourselves of the biventricular nature of almost all cardiovascular diseases and, in particular, how the left ventricle can both be a culprit in causation of, and a potential therapeutic target for, late morbidity and mortality in congenital heart disease.

Intraoperative Transesophageal Echocardiography and Right Ventricular Failure After Left Ventricular Assist Device Implantation

To determine whether intraoperative measures of right ventricular (RV) function using transesophageal echocardiography are associated with subsequent RV failure after left ventricular assist device (LVAD) implantation. Retrospective, nonrandomized, observational study. Single tertiary-level, university-affiliated hospital. The study comprised 100 patients with systolic heart failure undergoing elective LVAD implantation. Transesophageal echocardiographic images before and after cardiopulmonary bypass were analyzed to quantify RV function using tricuspid annular plane systolic excursion (TAPSE), tricuspid annular systolic velocity (S'), fractional area change (FAC), RV global longitudinal strain, and RV free wall strain. A chart review was performed to determine which patients subsequently developed RV failure (right ventricular assist device placement or prolonged inotrope requirement ≥14 days). Nineteen patients (19%) subsequently developed RV failure. Postbypass FAC was the only measure of RV function that distinguished between the RV failure and non-RV failure groups (21.2% v 26.5%; p = 0.04). The sensitivity, specificity, and area under the curve of an abnormal RV FAC (<35%) for RV failure after LVAD implantation were 84%, 20%, and 0.52, respectively. No other intraoperative measure of RV function was associated with subsequent RV failure. RV failure increased ventilator time, intensive care unit and hospital length of stay, and mortality. Intraoperative measures of RV function such as tricuspid annular plane systolic excursion, tricuspid annular systolic velocity, and RV strain were not associated with RV failure after LVAD implantation. Decreased postbypass FAC was significantly associated with RV failure but showed poor discrimination.

Assessment of Tricuspid Annular Motion by Speckle Tracking in Anesthetized Patients Using Transesophageal Echocardiography.

The perioperative assessment of right ventricular (RV) function remains a challenge. Tricuspid annular plane systolic excursion (TAPSE) using M-mode is a widely used measure of RV function. However, accurate alignment of the ultrasound beam with the direction of annular movement can be difficult with transesophageal echocardiography (TEE) to measure TAPSE, precluding effective use of M-mode to measure annular excursion. Tracking of specular reflectors in the myocardium may provide an angle-independent method to assess annular motion with TEE. We hypothesized that TEE speckle tracking of the lateral tricuspid annular motion represents a comparable measurement to the well-validated M-mode TAPSE on transthoracic echocardiogram (TTE), and may be considered as a reasonable alternative to TAPSE. This is a prospective, observational cohort study. We included all patients, who were in sinus rhythm, with a preoperative TTE within 3 months of scheduled cardiac surgery that required intraoperative TEE. Tissue motion annular displacements (TMAD) of the lateral (L), septal (S), and midpoint (M) tricuspid annulus were measured (QLAB Cardiac Motion Quantification; Philips Medical, Andover, MA) after induction of general anesthesia. This was compared to the preoperative M-mode TAPSE on TTE. Seventy-two consecutive patients who met eligibility requirements were enrolled from September to November 2016. Twelve were excluded due to poor image quality, allowing TMAD to be analyzed in 60 patients. TMAD was analyzed offline and TMAD analysis was able to track tricuspid annular motion in all patients. The mean TMAD (L), TMAD (S), and TMAD (M) were 17.4 ± 5.2, 10.2 ± 4.8, and 14.2 ± 4.8 mm, respectively. TMAD (L) showed close correlation with M-mode TAPSE on TTE (r = 0.87, 95% confidence interval, 0.79-0.92; P < .01). All patients with a preoperative TAPSE <17 mm had a TMAD (L) <17 mm, while 71% of those with a TAPSE ≥ 17 mm had a TMAD (L) ≥ 17 mm. There was strong positive correlation between TMAD (L) and intraoperative RV fractional area change (r = 0.86, 95% confidence interval, 0.77-0.91; P < .01). Reproducibility analysis of TMAD within and across observers showed excellent correlation. TMAD is a quick and angle-independent method to quantitatively assess RV longitudinal function by TEE. It correlates strongly with M-mode TAPSE on TTE. Because TMAD and TAPSE were not simultaneously measured in this study, their correlation is subject to differences in loading conditions, general anesthesia, and changes in the disease process. TMAD may be easily applied in routine clinical settings and its role in the perioperative environment deserves to be further explored.

Normal Reference Ranges for Transthoracic Echocardiography Following Heart Transplantation

Heart function following heart transplantation (HTx) is influenced by numerous factors. It is typically evaluated using transthoracic echocardiography, but reference values are currently unavailable for this context. The primary aim of the present study was to derive echocardiographic reference values for chamber size and function, including cardiac mechanics, in clinically stable HTx patients. The study enrolled 124 healthy HTx patients examined prospectively. Patients underwent comprehensive two-dimensional echocardiographic examinations according to contemporary guidelines. Results were compared with recognized reference values for healthy subjects. Compared with guidelines, larger atrial dimensions were seen in HTx patients. Left ventricular (LV) diastolic volume was smaller, and LV wall thickness was increased. With respect to LV function, both ejection fraction (62±7%, P<.01) and global longitudinal strain (-16.5±3.3%, P<.0001) were lower. All measures of right ventricular (RV) size were greater than reference values (P<.0001), and all measures of RV function were reduced (tricuspid annular plane systolic excursion 15±4mm [P<.0001], RV systolic tissue Doppler velocity 10±6cm/sec [P<.0001], fractional area change 40±8% [P<.0001], and RV free wall strain -16.9±4.2% [P<.0001]). Ejection fraction and LV global longitudinal strain were significantly lower in patients with previous rejection. The findings of this study indicate that the distribution of routinely used echocardiographic measures differs between stable HTx patients and healthy subjects. In particular, markedly larger RV and atrial volumes and mild reductions in both LV and RV longitudinal strain were evident. The observed differences could be clinically relevant in the assessment of HTx patients, and specific reference values should be applied in this context.

Evaluation of the Clinical Utility of Transesophageal Echocardiography and Invasive Monitoring to Assess Right Ventricular Function During and After Pulmonary Endarterectomy

Patients undergoing pulmonary endarterectomy (PEA) have impaired right ventricular function. The authors sought to assess the clinical utility of commonly used perioperative echocardiographic and right heart catheter measurements in patients undergoing PEA. A single-center prospective observational study. The study was conducted in a quaternary care cardiac surgical center in the United Kingdom. Patients undergoing PEA between April 2015 and January 2016. Thermodilution cardiac index and echocardiography variables were measured at 3 time points: before sternotomy (T1), after pericardial incision (T2), and after sternal closure (T3). Six-month follow-up echocardiography and 6-minute walk (6-MWT) test were performed. Fifty patients were recruited and complete data sets were available for 41 patients. Tricuspid annular plane systolic excursion declined after pericardial incision and cardiopulmonary bypass (T1: 15 ± 4 mm, T2: 13 ± 4 mm, T3: 7 ± 2 mm; p < 0.0001), returning to baseline 6 months postoperatively. Cardiac index (T1: 2.5 ± 0.7 L/min/m2, T2: 2.6 ± 0.6 L/min/m2, T3: 2.3 ± 0.5 L/min/m2; p = 0.07) and right ventricular fractional area change (T1: 36 ± 11%, T2: 40 ± 12%, T3: 40 ± 9%; p = 0.12) were preserved perioperatively. 6-MWT improved from baseline (294 ± 111 m) to follow-up (357 ± 107 m) (p < 0.001). Pulmonary vascular resistance at T3 correlated moderately with follow-up 6-MWT (R = -0.60). In patients undergoing PEA, invasive measurements and echocardiography assessment of right ventricular function are not interchangeable. Tricuspid annular plane systolic excursion is not a reliable measure of right ventricular function perioperatively. Pulmonary vascular resistance shows moderate correlation with postoperative functional capacity.

Interleukin-6 is independently associated with right ventricular function in pulmonary arterial hypertension

An elevated serum level of interleukin-6 (IL-6) in pulmonary arterial hypertension (PAH) patients results in a greater symptom burden and increased mortality; however, the mechanisms underlying these observations remain unclear. Because both pre-clinical and clinical data associate elevated IL-6 levels with impaired cardiac function, we hypothesized that the adverse effects of IL-6 in PAH result, in part, from right ventricular (RV) dysfunction. We analyzed the relationship between IL-6 and RV function in 40 patients with PAH identified in our institutional PAH registry. Serum IL-6 levels was quantified by enzyme-linked immunoassay. PAH patients had higher IL-6 levels than age- and gender-matched controls. Circulating IL-6 levels correlated inversely with echocardiography-based measures of RV function and RV-pulmonary artery (RV-PA) coupling. When dividing PAH patients by median IL-6 level, patients with higher IL-6 had significantly worse RV function (fractional area change [FAC] 23 ± 12% vs 38 ± 11%, tricuspid annular plane systolic excursion [TAPSE] 1.3 ± 0.3 cm vs 2.1 ± 0.5 cm), impaired RV-PA coupling (0.6 ± 0.5%/mm Hg vs 0.9 ± 0.5%/mm Hg), higher right atrial pressure (13 ± 7 mm Hg vs 9 ± 5 mm Hg), reduced cardiac index (2.0 ± 0.5 liters/min/m2 vs 2.8 ± 1.0 liters/min/m2) and lower stroke volume (48 ± 20 ml vs 70 ± 28 ml). In contrast, the relationships between IL-6 and mean pulmonary artery pressure (mPAP), pulmonary vascular resistance (PVR) and pulmonary arterial compliance (PAC) were not significant. Finally, IL-6 was independently associated with RV function and RV-PA coupling after adjusting for static (PVR) and pulsatile (PAC) after-load on the RV. Serum IL-6 levels are independently associated with RV function and RV-PA coupling in PAH. Patients with higher IL-6 levels have more severe RV dysfunction and diminished RV-PA coupling despite a comparable severity of pulmonary vascular disease.

Evaluation of two-dimensional strain echocardiography for quantifying right ventricular function in patients with pulmonary arterial hypertension.

The aim of the current study was to evaluate the use of two-dimensional strain echocardiography (2DS) in quantifying right ventricular (RV) function in patients with pulmonary arterial hypertension (PAH). A total of 41 patients with PAH and 40 healthy control patients were recruited to the study. 2DS was used to determine the strain (ε) and strain rate (SR) of basal, middle and apical segments of the RV free wall. The aforementioned indicators were compared with measurements of RV function taken by conventional ultrasound and right heart catheterization. The ε and SR of all segments of the right ventricular free wall were significantly lower in the PAH group, as compared with the control group (P<0.05). In the PAH group, the ε and SR of the middle and apical segments were significantly lower compared with basal segments (P<0.01). The SR of the apical segments were positively correlated with the area and diameter of the right ventricular. The ε of the apical segments were positively correlated with RV area, diameter and systolic function. The ε and SR of apical segments were positively correlated with pulmonary artery pressure and pulmonary vascular resistance measured by right heart catheterization. These findings indicated that 2DS can accurately evaluate RV longitudinal systolic function.

Right-Sided Cardiac Dysfunction in Heart Failure With Preserved Ejection Fraction and Worsening Renal Function.

In urban populations, worsening renal function (WRF) is well established in patients hospitalized with acute decompensated heart failure with preserved ejection fraction (HFpEF). However, the mechanisms for development of WRF in the setting of acute HF in HFpEF are unclear. In the present study, we sought to characterize conventional echocardiographic measures of right ventricular (RV) chamber size and function to determine whether RV dysfunction and/or adverse RV remodeling is related to WRF in patients with HFpEF. Our study included 104 adult patients with HFpEF (EF ≥ 55%) with technically adequate 2-dimensional echocardiograms performed during their hospitalization for acute decompensated HF to determine echocardiographic predictors of WRF, defined as a serum creatinine (Cr) increase of ≥ 0.3mg/dl within 72hours of hospitalization. Thirty-eight of the 104 patients (36%) developed WRF (mean Cr increase= 0.9 ± 0.1mg/dl) during the hospitalization (mean age ± SD of 64 ± 12years, 27 women [71%], 29 black [76%]). There were no significant differences in LV medial E/e' ratio and RV systolic pressure by WRF status or in linear dimensions of RV and right atrial size. RV fractional area change, a measure of RV function, however, was significantly decreased in HFpEF patients with WRF compared with the no WRF group (p= 0.003), whereas RV free wall thickness (p= 0.001) was increased. In conclusion, linear and volumetric measures of dimensions of right atrial and RV chamber size did not distinguish HFpEF patients with and without WRF. However, in HFpEF patients with WRF during acute HF hospitalization, there was a significant decrease in RV function and a significant increase in RV free wall thickness compared with matched patients with no WRF. These findings suggest that adverse RV remodeling and RV dysfunction occur in HFpEF patients with WRF.

Right ventricular free-wall longitudinal speckle tracking strain in patients with pulmonary arterial hypertension under specific treatment.

Right ventricular (RV) dysfunction is a major determinant of outcomes in patients with pulmonary arterial hypertension (PAH), although the optimal measure of RV function is poorly defined. We evaluated the utility of RV free-wall speckle tracking strain as an assessment tool for RV function in patients with PAH who are already under specific treatment compared with conventional echocardiographic parameters and investigated the relationship of RV free-wall strain with clinical hemodynamic parameters of RV performance. Right ventricular free-wall strain was evaluated in 92 patients (Group-1 and Group-4 pulmonary hypertension) who were on PAH-specific treatment for at least 3months. Right atrial (RA) area, RV FAC, TAPSE, tricuspid S, functional class, 6-minute walking distance, and NT-proBNP were studied. The mean duration of follow-up was 222±133days. All patients were under PAH-specific treatment, and mean RV free-wall strain was -13.16±6.3%. RV free-wall strain correlated well with functional class (r=.312, P=.01), NT-proBNP (r=.423, P=.0001), RA area (r=.427, P=.0001), FAC (r=-.637, P=.0001), TAPSE (r=-.524, P=.0001), tricuspid S (r=-.450, P=.0001), 6-minute walking distance (r=-.333, P=.002). RV free-wall strain significantly correlated with all follow-up adverse events, death, and clinical right heart failure (RHF) (P=.04, P=.03, P=.02, respectively). According to the receiver operator characteristic analysis, the cutoff value for RV free-wall strain for the development of clinical RHF was -12.5% (sensitivity: 71%, specificity: 67%) and for all cardiovascular adverse events (death included) was -12.5% (sensitivity: 54%, specificity: 64%). Assessment of RV free-wall strain is a feasible, easy-to-perform method and may be used as a predictor of RHF, clinical deterioration, and mortality in patients already under PAH-specific treatment.

Young Investigator Award Session: Clinical Science429Patient-specific numerical mitral valve modelling in secondary mitral regurgitation: clinical validity of a promising technique430Importance of the measurement of right ventricular function when exercising patients with asymptomatic severe primary mitral regurgitation431Echocardiographic deformation imaging and computer simulation for electromechanical substrate characterization in arrhythmogenic right ventricular cardiomyopathy432The right ventricle of olympic athletes: characteristics and implications for the

Young Investigator Award Session: Clinical Science429Patient-specific numerical mitral valve modelling in secondary mitral regurgitation: clinical validity of a promising technique430Importance of the measurement of right ventricular function when exercising patients with asymptomatic severe primary mitral regurgitation431Echocardiographic deformation imaging and computer simulation for electromechanical substrate characterization in arrhythmogenic right ventricular cardiomyopathy432The right ventricle of olympic athletes: characteristics and implications for the