Reduced Right Ventricular Ejection Fraction Research Articles

(360) - Cardiac MRI of Heart Transplant Recipients With Previous CMV Infection Demonstrates Ventricular Hypertrophy and Dysfunction

Purpose: Cytomegalovirus (CMV) infection is common among heart transplant recipients and has adverse direct and indirect host effects. Little is known about the effects of CMV infection on cardiac allograft morphology or function. Cardiovascular MRI (CMR) is the gold standard for assessment of cardiac morphology and function. We hypothesized that history of CMV infection would be associated with myocardial scar, adverse ventricular remodeling, and reduced function. Methods: We retrospectively ascertained the pre-transplant recipient and donor CMV serology and post-transplant CMV infection (documented by CMV DNAemia) of heart transplant recipients who had undergone CMR as part of a separate research protocol. At our institution CMV surveillance is performed as part of a standardized post-transplant protocol and data were retrieved up to the time of their CMR scan. CMR variables of cardiac morphology and function were compared between recipients with and without previous CMV infection and across donor-recipient pre-transplant serology groups. Results: Forty six participants (mean age 51 +/15 yrs, 74% male, mean time since transplantation 3.7 +/4 years) were analyzed, of whom eighteen (39%) had > = 1 documented CMV infection. Previous CMV infection was associated with increased left ventricular (LV) mass (176 vs 143 g, p = 0.006), LV wall thickness (11 vs 9 mm, p = 0.002), LV mass to volume ratio (1.2 vs 1.0, p = 0.01), and reduced diastolic function (E/E` ratio 10 vs 7, p = 0.04). A greater number of CMV infections was associated with reduced right ventricular ejection fraction (RVEF) (r = -0.52, p = 0.03) and larger right ventricular end diastolic volume (r = 0.48, p = 0.05). Higher peak CMV DNAemia was also associated with reduced RVEF (r = -0.49, p = 0.04). There was no association between CMV infection and myocardial scarring. There were no significant differences in cardiac morphology across pre-transplant donor and recipient CMV sero-status groups. Conclusion: Heart transplant recipients with post-transplant CMV infection demonstrate morphologic and functional allograft changes on CMR. CMR may be helpful in characterizing the indirect effects of CMV infection on cardiac allografts.

Murine Cardiosphere-Derived Cells Are Impaired by Age but Not by Cardiac Dystrophic Dysfunction

To be clinically relevant as a therapy for heart failure, endogenous progenitor cells must be isolated and expanded from aged and/or diseased tissue. Here, we investigated the effect of age and cardiac impairment resulting from lack of dystrophin on murine cardiosphere-derived cells (CDCs). CDCs were isolated and expanded from atrial biopsies from wild-type mice aged 1.5, 6, 18, and 24 months and from mdx mice aged 6 and 18 months. Cardiac function was measured in mdx mice and age-matched wild-type mice using high-resolution cine magnetic resonance imaging. CDCs could be isolated and expanded from all mice, however, the number of cells obtained, and their regenerative potential, decreased with age, as demonstrated by decreased expression of stem cell markers, c-kit and Sca-1, and decreased cell proliferation, migration, clonogenicity, and differentiation. Six-month-old mdx mice showed right ventricular (RV) dilation and reduced RV ejection fraction (EF) in comparison to wild-type mice. Older mdx mice displayed significant RV and left ventricular dilation and decreased EF in both ventricles, compared with age-matched wild-type mice. Mdx mouse hearts contained significantly more fibrotic tissue than age-matched wild-type mouse hearts. However, CDCs isolated from mice aged 6 and 18 months had the same number and regenerative potential from mdx mice and age-matched wild-type mice. Thus, the cardiac progenitor cell population is impaired by age but is not substantially altered by the progressive deterioration in function of the dystrophic heart.

Ventricular structure, function, and focal fibrosis in anabolic steroid users: a CMR study

Anabolic steroid (AS) misuse is widespread amongst recreational bodybuilders; however, their effects on the cardiovascular system are uncertain. Our aim was to document the impact of AS use on cardiac structure, function and the presence of focal fibrosis using the gold standard cardiovascular magnetic resonance imaging (CMR). A cross-sectional cohort design was utilised with 21 strength-trained participants who underwent CMR imaging of the heart and speckle-tracking echocardiography. Thirteen participants (30 ± 5 years) taking AS for at least 2 years and currently on a "using"-cycle were compared with age and training-matched controls (n = 8; 29 ± 6 years) who self-reported never having taken AS (NAS). AS users had higher absolute left ventricular (LV) mass (220 ± 45 g) compared to NAS (163 ± 27 g; p < 0.05) but this difference was removed when indexed to fat-free mass. AS had a reduced right ventricular (RV) ejection fraction (AS 51 ± 4 % vs. NAS 59 ± 5 %; p < 0.05) and a significantly lower left ventricular E':A' myocardial tissue velocity ratio [AS 0.99(0.54) vs. NAS 1.78(0.46) p < 0.05] predominantly due to greater tissue velocities with atrial contraction. Peak LV longitudinal strain was lower in AS users (AS -14.2 ± 2.7 % vs. NAS -16.6 ± 1.9 %; p < 0.05). There was no evidence of focal fibrosis in any participant. AS use was associated with significant LV hypertrophy, albeit in-line with greater fat-free mass, reduced LV strain, diastolic function, and reduced RV ejection fraction in male bodybuilders. There was, however, no evidence of focal fibrosis in any AS user.

Prognostic value of cardiovascular magnetic resonance in patients with suspected arrhythmogenic right ventricular cardiomyopathy

Early recognition and accurate risk stratification are important in the management of arrhythmogenic right ventricular cardiomyopathy (ARVC). Identification of predictors of outcome by cardiovascular magnetic resonance (CMR) in patients undergoing evaluation for ARVC is limited. We investigated the predictive value of morphological abnormalities detected by CMR for major clinical events in patients with suspected ARVC. We performed a longitudinal study on 369 consecutive patients with at least one criterion for ARVC. Abnormal CMR was defined by the presence of one of the following: increased right ventricular (RV) volumes, reduced RV ejection fraction, RV regional wall motion abnormalities, myocardial fatty infiltration, and myocardial fibrosis. The end-point was a composite of cardiac death, sustained ventricular tachycardia, ventricular fibrillation, and appropriate ICD discharge. Twenty patients met the composite end-point over a mean follow-up of 4.3±1.5 years. An abnormal CMR was an independent predictor of outcomes (p<0.001). The presence of multiple abnormalities heralded a particular high risk of events (HR 23.0, 95% CI 5.7-93.2, p<0.001 for 2 abnormalities; HR 35.8, 95% CI 9.7-132.6, p<0.001 for 3 or more abnormalities). The positive predictive value of an abnormal CMR study was 21.0% for an adverse event, whilst the negative predictive value of a normal CMR study was 98.8% over the follow-up period. CMR provides important prognostic information in patients under evaluation for ARVC. A normal study portends a good prognosis. Conversely, the presence of multiple abnormalities identifies a high risk group of patients who may benefit from ICD implantation.

Relation of right ventricular mechanics to exercise tolerance in children after tetralogy of Fallot repair

Progressive right ventricular (RV) dysfunction and exercise intolerance are common problems after tetralogy of Fallot (TOF) repair. We investigated RV myocardial deformation and dyssynchrony in children after TOF repair and their association with exercise capacity. Asymptomatic children after TOF repair were investigated by 2-dimensional speckle tracking echocardiography, magnetic resonance, and metabolic exercise study. Patients with RV outflow obstruction were excluded. Peak RV longitudinal strain and strain rate (SR) and dyssynchrony (RV intraventricular delay) were compared with healthy controls. Associations between RV strain, dyssynchrony, and exercise capacity were analyzed. Thirty-nine (81%) of 48 TOF patients and 40 healthy controls had adequate RV strain imaging. The TOF patients had moderately dilated RVs and normal RV ejection fraction. Right ventricular peak systolic strain (-23.2% ± 5.1% vs -28.5% ± 8.5%, P < .001) and SR (-1.46 ± 0.68 vs -2.1 ± 0.8, P < .001) were reduced in TOF patients compared with controls. Right ventricular intraventricular delay was higher in TOF patients (146.0 ± 159 vs 71.0 ± 92 milliseconds, P = .008). Decreased RV strain and SR were associated with increased RV dyssynchrony (strain parameter estimate [PE] 6.31 [2.30], P = .007; SR [PE] 11.32 [3.84], P = .004). Increased RV-left ventricular delay was associated with prolonged QRS duration (PE 0.13 [0.058], P = .03) and reduced RV ejection fraction (PE -2.95 [1.275], P = .02). Reduced RV peak SR was associated with decreased exercise peak oxygen uptake (PE 0.14 [0.07], P = .04). After repair of TOF, asymptomatic children have reduced RV deformation in association with RV dyssynchrony and reduced exercise tolerance.

Functional implications of the right ventricular myocardial performance index in patients after surgical repair of tetralogy of Fallot

The myocardial performance index (MPI) has been proposed to be a simple echocardiographic index of right ventricular (RV) function in patients after surgical repair of tetralogy of Fallot (TOF). However, its functional status remains to be clarified. The functional implications of RV MPI were determined by exploring its relationships with parameters of RV function as derived from cardiovascular magnetic resonance (CMR), and exercise capacity of postoperative TOF patients Thirty patients (11 males), aged 15.6 +/- 3.1 years, who have undergone surgical repair of TOF at 4.0 +/- 1.8 years, were studied. The RV and left ventricular (LV) MPIs determined using pulsed-wave Doppler echocardiography were related to CMR-derived RV and LV ejection fractions, and pulmonary regurgitant fraction and treadmill exercise testing parameters. Log RV MPI correlated positively with log LV MPI (r = 0.38, P = 0.037) and negatively with CMR-derived RV ejection fraction (r = -0.4, P = 0.028) and pulmonary regurgitant fraction (r = -0.4, P = 0.031). No significant correlations were found between LV MPI and any of the CMR parameters. Using receiver operated characteristics analysis, a cutoff value of 0.30 for RV MPI was found to have a sensitivity of 100% and specificity of 74% in predicting a RV ejection fraction <35%. Right ventricular, but not LV, MPI correlated inversely with exercise duration (r = -0.45, P = 0.013) and peak oxygen consumption (VO2 max) (r = -0.56, P = 0.001). Multivariate analysis identified RV MPI (beta = -0.6, P < 0.001), male sex (beta = 0.44, P = 0.01), and duration from surgery (beta = -0.30, P = 0.019) as significant determinants of VO2 max. Increased MPI is a reflection of reduced RV ejection fraction and exercise capacity in patients after TOF repair.

Right Ventricular Volume and Mass Determined by Cine Magnetic Resonance Imaging in HIV Patients with Possible Right Ventricular Dysfunction

Impaired right ventricular (RV) function has been reported to occur in patients with HIV when studied by echocardiography. However, for accurate evaluation of RV function and morphology, first-pass radionuclide ventriculography (RNV) and cine magnetic resonance imaging (cine-MRI) are methods of choice. Studies of RV involvement in patients with HIV are of interest since pulmonary hypertension is a known serious complication of HIV recognized with increasing frequency. The aim of the present study was to characterize cardiac function and geometry in patients with HIV and reduced right ventricular ejection fraction (RVEF). To do so, we screened patients with RNV and performed an additional cine-MRI in those with reduced RVEF determined by RNV. Ninety patients with HIV were included. To evaluate the MRI measures exactly we included 18 age- and gender-matched healthy volunteers to establish reference values. RNV showed in 13 of the 90 patients a reduced RVEF with a standard cutoff value for RVEF of 0.50. Six of these agreed to have an additional MRI investigation performed. These 6 patients with HIV had an RVEF measured by RNV between 0.41-0.49. Measured by MRI the range of RVEF was 0.47-0.55 with 3 below the lower 95% reference limit according to the control group (lower reference limit: 0.49). None of the 6 patients with HIV had dilated right ventricle and only 1 had a marginally increased right ventricular mass index of 43 g/m(2) (reference: <41 g/m(2)). With use of MRI, a few patients with HIV may have a marginally reduced RVEF but normal RV dimensions and mass. Thus, RV dysfunction does not seem to constitute a major clinical problem in this antivirally treated HIV population.

Systolic right ventricular function assessment by pulsed wave tissue Doppler imaging of the tricuspid annulus.

Systolic right ventricular (RV) function is an important predictor in the course of various congenital and acquired heart diseases. So far, tricuspid annular motion velocity in systole as obtained by pulsed wave tissue Doppler imaging (TDI) has rarely been investigated for RV function assessment in a sizeable adult patient population. 258 individuals were included in the study. Among them, there were 107 individuals without cardiovascular disease, 71 patients with predominant RV dysfunction, 40 patients with pulmonary artery hypertension, and 40 patients with predominant left ventricular dysfunction. The reference methods for RV systolic function assessment were biplane two-dimensional echocardiography and magnetic resonance imaging (MRI; n = 31) for the calculation of RV ejection fraction (EF). Lateral tricuspid valve annular motion velocities in systole (TVlat, cm/s) were recorded using pulsed wave TDI from the apical 4-chamber view (long axis function). RV EF as determined by biplane echocardiography correlated significantly with respective values as assessed by MRI: RVEFecho = RV EFMRI + 1.6; r2 = 0.569, p <0.0001. Using the best TVlat threshold of 12 cm/s, distinction between the group with RV dysfunction and the other groups was possible with 86% sensitivity and 83% specificity. There was a direct and significant correlation between TVlat and RV ejection fraction (p <0.0001). Using TVlat thresholds of 12 and 9 cm/s, distinction between normal RV EF (>55%), moderately reduced (30-55%) and severely reduced RV EF (<30%) was possible with 84% sensitivity and 81% specificity, respectively with 83% sensitivity and 67% specificity. Systolic long axis velocity measurement of the lateral tricuspid annulus is useful and accurate to assess RV systolic function in a broad patient population. Thresholds of 12 and 9 cm/s allow differentiation between normal, moderately reduced and severely reduced RV ejection fraction.

Systolic right ventricular function assessment by pulsed wave tissue Doppler imaging of the tricuspid annulus.

Systolic right ventricular (RV) function is an important predictor in the course of various congenital and acquired heart diseases. So far, tricuspid annular motion velocity in systole as obtained by pulsed wave tissue Doppler imaging (TDI) has rarely been investigated for RV function assessment in a sizeable adult patient population. 258 individuals were included in the study. Among them, there were 107 individuals without cardiovascular disease, 71 patients with predominant RV dysfunction, 40 patients with pulmonary artery hypertension, and 40 patients with predominant left ventricular dysfunction. The reference methods for RV systolic function assessment were biplane two-dimensional echocardiography and magnetic resonance imaging (MRI; n = 31) for the calculation of RV ejection fraction (EF). Lateral tricuspid valve annular motion velocities in systole (TVlat, cm/s) were recorded using pulsed wave TDI from the apical 4-chamber view (long axis function). RV EF as determined by biplane echocardiography correlated significantly with respective values as assessed by MRI: RVEFecho = RV EFMRI + 1.6; r2 = 0.569, p <0.0001. Using the best TVlat threshold of 12 cm/s, distinction between the group with RV dysfunction and the other groups was possible with 86% sensitivity and 83% specificity. There was a direct and significant correlation between TVlat and RV ejection fraction (p <0.0001). Using TVlat thresholds of 12 and 9 cm/s, distinction between normal RV EF (>55%), moderately reduced (30-55%) and severely reduced RV EF (<30%) was possible with 84% sensitivity and 81% specificity, respectively with 83% sensitivity and 67% specificity. Systolic long axis velocity measurement of the lateral tricuspid annulus is useful and accurate to assess RV systolic function in a broad patient population. Thresholds of 12 and 9 cm/s allow differentiation between normal, moderately reduced and severely reduced RV ejection fraction.

Right ventricular strain rate and strain analysis in patients with repaired tetralogy of Fallot: possible interventricular septal compensation

Background Indices such as strain rate (SR) and strain (ϵ) are free of geometric assumptions and, thus, may provide new insights into right ventricular (RV) function and compensatory mechanisms in repaired tetralogy of Fallot (TOF). Methods All those with postoperative (>1 year) TOF had echocardiography evaluation of SR and ϵ indices along the RV lateral free wall (RVFW) and the interventricular septum (IVS) in the apical 4-chamber view. Pulmonary regurgitation, pulmonary stenosis, QRS duration, RV ejection fraction, and RV dimension were also measured and compared with control subjects. Results There were 15 patients with TOF (7 ± 4 years old) 6 ± 3 years remote from surgical repair and 25 control subjects (10 ± 5 years old). In the patients with TOF, systolic and diastolic SR and ϵ in the RVFW were significantly reduced but were normal in the IVS. In the RVFW, reduced systolic SR and ϵ correlated with reduced RV ejection fraction ( r = −0.7 [ P < .01] and −0.6 [ P < .03], respectively), and poorer early diastolic SR correlated with poorer RV ejection fraction ( r = 0.7, P < .01). Conclusions In patients with postoperative TOF, systolic and diastolic RV SR and ϵ were impaired in the RVFW but preserved in the IVS. We speculate that IVS myocardial function is preserved as a compensatory mechanism for impaired RVFW function.

Reduced right ventricular ejection fraction as a marker for idiopathic dilated cardiomyopathy compared with ischemic left ventricular dysfunction

Background Evidence for the role of right ventricular (RV) function is emerging in patients with heart failure of different etiologies. Studies conducted in dilated cardiomyopathy (IDC) showed a high prevalence of RV dysfunction unrelated to the severity of pulmonary hypertension. The aim of the study was to investigate the role of RV dysfunction in ischemic versus nonischemic patients. Methods A series of 153 patients with left ventricular (LV) dysfunction (defined as a LV ejection fraction <45%) of either ischemic (n = 61, coronary artery disease [CAD] group) or nonischemic (n = 92, IDC group) origin were studied invasively. Besides routine catheterization data, RV volumes and ejection fractions were obtained angiographically. Reference data were collected in a control group of healthy subjects. RV dysfunction was defined as a RV ejection fraction <35% and ventricular concordance as a <10% difference between RV and LV ejection fraction. The LV/RV end-diastolic volume ratio was calculated to assess the relative dilatation of the ventricular chambers. Hemodynamic and angiographic data were compared in the 2 groups by univariate and multivariate logistic regression analysis. Results Patients with IDC and CAD had comparable LV ejection fractions (29% ± 3% vs 31% ± 8%, P not significant) and mean pulmonary pressures (27 ± 12 mm Hg vs 26 ± 11 mm Hg, P not significant); the LV/RV end-diastolic volume ratio was identical in the 2 groups (1.26 ± 0.4 vs 1.24 ± 0.4, P not significant). RV ejection fraction was significantly lower in IDC compared with CAD (33% ± 10 % vs 46% ± 11%, P <.0001), with a prevalence of RV dysfunction in the IDC group of 65% compared with 16% in the CAD group (P <.0001); similarly, the prevalence of ejection fraction concordance was 74% versus 33%, respectively (P <.0001). At multivariate analysis, a low RV ejection fraction was a powerful independent predictor of IDC compared with CAD (odds ratio 0.91, 95% confidence interval 0.87-0.94, P <.0001). RV dysfunction had a positive predictive value of 75% and a negative predictive value of 78% for the diagnosis of IDC; for ventricular concordance, these values were 81% and 69%, respectively. The correlation between mean pulmonary artery pressure and RV ejection fraction was weaker in the IDC group compared with the CAD group (R2 = 0.032, P =.047 and R2 = 0.172,P <.0001, respectively). Conclusion In the presence of LV dysfunction, a reduced RV ejection fraction is a powerful marker for IDC compared with CAD, independent of age, pulmonary hypertension, LV function, and ventricular dimensions. These findings support the concept that IDC is frequently characterized by a biventricular involvement and that the presence of RV dysfunction represents a distinguishing feature of this disease. (Am Heart J 2001;142:181-9.)