Right Atrial Area Research Articles

Abstract 12967: Efficacy of Combining Assessment of Right Ventricular Function and Right Atrial Remodeling as Prognostic Factor in Patients With Pulmonary Hypertension

Background: Since survival of patients with pulmonary hypertension (PH) is closely related to right ventricular (RV) function, assessment of RV function is important for patients with PH. Right atrial (RA) area and/or RA pressure have also been reported to serve as prognostic predictors for adverse outcomes for in PH patient. Accordingly, we tested the hypothesis that the addition of RA remodeling to RV function enhances the capability of the latter to predict long-term outcome for PH patients. Methods: We studied 82 PH patients, all of whom underwent echocardiography and right heart catheterization. RV function was calculated by averaging the three regional peak speckle-tracking longitudinal strains from RV free wall (RV-free). RA remodeling was assessed as the RA area traced planimetrically at end-systole. Pre-defined cutoffs for RV dysfunction and RA remodeling were RV-free≤19.4% and RA area of >18cm2, respectively. Long-term unfavorable outcome events were tracked for 2.0 years. Results: RA area correlated with mean RA pressure (r=0.62, p<0.001), as well as with tricuspid E/E’ (r=0.38, p=0.001). However, RA area with RV restrictive filling was significantly larger than with others (all p<0.05). Kaplan-Meier analysis revealed that patients with RV-free ≤19.4% had worse long-term outcomes than those with RV-free >19.4% (log-rank p=0.01), as did patients with RA area>18cm2 compared with those with RA area ≤18cm2 (log-rank p<0.05). For sequential Cox models, a model based on hemodynamic parameters of RV performance (χ2 =3.11) was improved by addition of brain natriuretic peptide, World Health Organization functional class (χ2 =9.24; p<0.05), and RV-free (χ2 =17.11; p=0.005), and further improved by addition of RA area (χ2 =21.36, p<0.05). Conclusions: The combined assessment of RV function and RA remodeling results in more accurate prediction of long-term outcome, and may well have clinical implications for better management of PH patients.

Abstract 18081: Inverse Changes in Atrial Size During Obstructive Apnea

Introduction: Obstructive sleep apnea (OSA) is characterized by large swings in intrathoracic pressure. These pressure changes create an afterload burden on the left ventricle and presumably affect venous return to the right heart, and pooling of blood in the lungs. To better understand cardiac dynamics during OSA we used real time 2-D echocardiography to compare left (LA) and right atrial (RA) areas at baseline and during a series of gasping inspiratory efforts against an occluded airway. Hypothesis: Significant changes in atrial area will occur during inspiratory effort, with an inverse relationship between the two atria. Methods: Each of 14 healthy male subjects <30 years, trained in the Mueller Maneuver (MM), made 5 to 6 maximal gasping efforts to simulate naturally occurring OSA. Concomitant echocardiographic loops were acquired using the apical 4 chamber view. Results: Average baseline (end-systolic) atrial area was 16.6 ± 0.837 cm2 (100 beats; mean ± pooled SD) for the LA and 16.3 ± 0.931 cm2 for the RA. During the MM average LA area was 16.7 ± 1.29 cm2 (252 beats) and average RA area was 15.4 ± 1.69 cm2. For left and right separately, variance in atrial area during the MM exceeded that at baseline (p<0.0001, F-test). During the MM, LA variance increased to 2.38-fold that of baseline, RA variance to 3.30-fold. Further, there was an inverse relationship between LA and RA area during the MM (graph). Visual inspection of digitized loops revealed a sudden decrease in LA area with inspiratory effort. Conclusions: Performance of the MM as a series of gasping efforts (designed to mimic natural OSA) produced marked and mutually inverse variation in LA and RA area as compared with baseline. LA area decreased abruptly with onset of negative inspiratory pressure. Such changes, repeated hundreds of times per night, have the potential to alter atrial structure and function. These data may help explain the strong association between obstructive sleep apnea and atrial fibrillation.

Motions of Galaxies in the Bootes Strip

We explore the structure and kinematics of a dispersed filament of galaxies residing between the Local Void and the Virgo cluster. For such purpose, we consider a sample of 361 galaxies with radial velocities $V_{LG} < 2000$ km/s inside the sky area of RA = [13.0 ... 18.0]$^h$ and Dec. = [$-$5 ... $+$10]$^\circ$. At present, 161 of them have individual distance estimates. The galaxy distribution on peculiar velocities along the strip exhibits the known Virgo-centric infall at RA < 14$^h$ and some signs of outflow from the Local Void at RA > 17$^h$. Majority of the Bootes strip galaxies (56%) belong to 13 groups and 11 pairs, with the most prominent group around NGC5846. The Bootes strip groups reside within [17$-$27]Mpc, being all farther from us than the Virgo cluster. The Bootes filament contains the total stellar mass of $2.7\times10^{12} M_\odot$ and the total virial mass of $9.07\times10^{13} M_\odot$, having the average density of dark matter to be $\Omega_m = 0.09$, i.e. a factor three lower than the global cosmic average.

Right Heart and Pulmonary Vessels Structure and Function

The right ventricle (RV) can be described in terms of 3 components: the inlet, the apex, and the infundibulum. In the normal adult, the RV shows an arrangement suited for pumping blood against low resistance, with a mass about one sixth that of left ventricle (LV) mass, and a larger volume than the LV. The RV is able to manage a progressive increase in the afterload by increasing contractility and remodeling. The gold standard measurement of contractility is maximal elastance (Emax), or the ratio between end-systolic pressure (ESP) and end-systolic volume (ESV), and the best measurement of afterload is arterial elastance (Ea), or the ratio between ESP and stroke volume (SV). The ratio Emax/Ea defines RV-arterial coupling. The optimal energy transfer from the RV to the pulmonary circulation is measured at Emax/Ea ratios of 1.5-2. In the presence of pulmonary hypertension, the SV/ESV ratio may be an acceptable surrogate of Emax/Ea. The right atrium (RA) has 3 anatomical components: the appendage, the venous part, and the vestibule. It is a dynamic structure having different functions: reservoir, conduit, and booster pump function. In case of increased afterload, the RA is enlarged, denoting high RA pressure, as a consequence of elevated RV diastolic pressure. RA area is a strong predictor of adverse clinical outcome in pulmonary arterial hypertension. In patients with severe pulmonary hypertension, in several congenital heart diseases, and in Eisenmenger syndrome, symptoms and prognosis are greatly dependent on RV function and its ability to adapt to a chronic increase in afterload.

Scientific Opinion on the pest categorisation of Ditylenchus destructor Thorne

The Panel on Plant Health performed a pest categorisation of Ditylenchus destructor, the potato rot nematode. D. destructor is listed in Annex II, Part A, Section II of Council Directive 2000/29/EC as a harmful organism known to occur in the Union and relevant for the entire Union. D. destructor is a distinct taxonomic entity that can be identified in a straightforward way, and which is present in the majority of EU member states, although sporadically (but data from systematic surveys are lacking). Many hosts of D. destructor are present in the RA area and the climatic conditions in the whole risk assessment area are favourable for the completion of the pest life cycle. D. destructor can cause significant damage to the below-ground parts (roots, tubers, bulbs) of host crops such as potato and several ornamental plants. However, during recent decades only minor damage has been reported (except in some Eastern European countries). Plants for planting are a pathway for introduction and spread of D. destructor, which may cause severe impacts on the intended use of the plants for planting.

Structure and kinematics of the Bootes filament

AbstractBootes filament of galaxies is a dispersed chain of groups residing on sky between the Local Void and the Virgo cluster. We consider a sample of 361 galaxies inside the sky area of RA = 13h0...18h.5 and Dec = .5°... + 10° with radial velocities VLG &lt; 2000 km/s to clarify its structure and kinematics. In this region, 161 galaxies have individual distance estimates. We use these data to draw the Hubble relation for galaxy groups, pairs as well as the field galaxies, and to examine the galaxy distribution on peculiar velocities. Our analysis exposes the known Virgo-centric infall at RA &lt; 14h and some signs of outflow from the Local Void at RA &gt; 17h. According to the galaxy grouping criterion, this complex contains the members of 13 groups, 11 pairs and 140 field galaxies. The most prominent group is dominated by NGC 5846. The Bootes filament contains the total stellar mass of 2.7 ×1012M⊙ and the total virial mass of 9.07×1013M⊙, having the average density of dark matter to be Ωm = 0.09, i.e. a factor three lower than the global cosmic value.

Utility of combining assessment of right ventricular function and right atrial remodeling as a prognostic factor for patients with pulmonary hypertension.

We tested the hypothesis that the addition of right atrial (RA) remodeling to right ventricular (RV) function enhances the capability of the latter to predict long-term outcome for pulmonary hypertension (PH) patients. We studied 82 PH patients, all of whom underwent echocardiography and right heart catheterization. RV function was calculated by averaging the three regional peak speckle-tracking longitudinal strains from RV free wall (RV-free). RA remodeling was assessed as the RA area traced planimetrically at end-systole. Pre-defined cutoffs for RV dysfunction and RA remodeling were RV-free ≤19.4 % and RA area of >18 cm(2), respectively. Long-term unfavorable outcome events were tracked for 2.0 years. RA area correlated with mean RA pressure (r = 0.62, p < 0.001), as well as with tricuspid E/E' (r = 0.38, p = 0.001). Moreover, RA area in patients with RV restrictive filling was significantly larger than that in patients with others (all p < 0.05). Kaplan-Meier analysis revealed that patients with RV-free ≤19.4 % had worse long-term outcomes than those with RV-free >19.4 % (log-rank p = 0.01), as did patients with RA area >18 cm(2) compared with those with RA area ≤18 cm(2) (log-rank p < 0.05). For sequential Cox models, a model based on hemodynamic parameters of RV performance (χ2 = 3.11) was improved by addition of brain natriuretic peptide, World Health Organization functional class (χ2 = 9.24; p < 0.05), and RV-free (χ2 = 17.11; p = 0.005), and further improved by addition of RA area (χ2 = 21.36, p < 0.05). In conclusion, the combined assessment of RV function and RA area results in more accurate prediction of long-term outcome, and may well have clinical implications for better management of PH patients.

0108: Specific alterations in cardiac function induced by a 300 km mountain ultra-marathon

Although popularity of ultra-long endurance races is growing, data on their consequences on cardiac function are still lacking. Thus, we aimed to assess the progressive cardiac consequences of the World's most challenging mountain ultra-marathon (Tor des Geants; Italy; 300km; 24000 m D+). Resting cardiac evaluations were conducted prior (pre-), during (mid-; km 150) and after (post-) the race on fifteen participants. Left and right ventricle (LV and RV) morphologies, functions and mechanics were assessed using standard tissue Doppler imaging and Speckle tracking echocardiography. Runners completed the race in 126±15 h. From pre- to post-, the increase in stroke volume (SV) (103±19 vs. 110±23 vs. 116±21 mL; p<0.001 from pre- to post-race) was concomitant with the increase in LV early filling (i.e. peak E; 72.9±15.7 vs. 74.6±13.1 vs. 82.1±11.5 cm.s-1; p<0.05). Heart cavity sizes were 12-19% higher at post-. Significant correlations were found between percent changes in peak E and LV end-diastolic volume (r=0.56, p<0.05) or left atrial and right ventricle diastolic areas (r=0.66, p<0.05; r=0.80, p<0.001; respectively). Resting heart rate and LV systolic strain rates demonstrated a biphasic adaptation since they were increased at mid- (55±8 vs. 72±11 bpm, p<0.001) but returned to baseline pre- values at post- (55±8 vs. 59±8 bpm, respectively). Whereas it is well-described that long duration exercise of several hours induces a transient LV dysfunction, we observed specific cardiac adaptations characterized by a progressive increase in SV and diastolic function during much longer exercise; e.g. 4-7 days of mountain running. Our data strongly support the key role of a cardiac volume overload in these alterations. The underlying mechanisms of such specific alterations after an extreme mountain ultra-marathon and their clinical implications remain challenging for the future. Abstract 0108 – Figure : LV end-diastolic volumes and LA, RA and RV end-diastolic areas at pre-, mid- and post-race. Percentage changes from baseline are presented for each size or volume cavity

Abstract 9562: Liver Dysfunction Assessed by Model of End-stage Liver Disease Excluding INR (MELD-XI) Scoring System Predicts Adverse Prognosis in Heart Failure

Background: Liver dysfunction due to end-stage heart failure (HF) is often referred as cardiac or congestive hepatopathy. The composite Model for End-Stage Liver Disease excluding INR (MELD-XI) is a robust scoring system of liver function, and a high score is associated with poor prognosis in heart transplant recipients. However, the impact of MELD-XI scores on cardiac function and prognosis in general HF patients still remains unclear. Methods and Results: We retrospectively analyzed 550 patients with HF who admitted to our hospital. Liver function was estimated by MELD-XI formula (5.11хlog (bilirubin)+ 11.76хlog (creatinine)+9.44). These patients were divided into two groups based on the median MELD-XI score: Group L (MELD-XI &lt;10, n=269) and Group H (MELD-XI ≥10, n=281). We compared echocardiographic findings and cardiac event rates including cardiac deaths and re-hospitalization due to worsening HF between two groups. In echocardiographic paremeters, left atrial volume (LAV), right atrial area (RAA), right ventricular diastolic area (RVAd), right ventricular systolic area (RVAs), inferior vena cava diameter (IVC) were higher, and left ventricular ejection fraction (LVEF) was lower in group H than in group L (LAV: 93.7 vs. 74.0 ml, RAA: 25.0 vs. 16.5 cm 2 , RVAd: 17.1 vs. 15.7 cm 2 , RVAs: 10.6 vs. 9.1 cm 2 , IVC: 15.9 vs. 14.4 mm, LVEF: 45.5 vs. 50.4%, P&lt;0.05, respectively). Right ventricular fractional area change did not differ between 2 groups. In addition, 151 events (52 deaths and 99 re-hospitalizations) occurred during the follow-up period (mean 348 days). Importantly, the event-free rate was significantly higher in group L than in group H (78.4% vs. 66.9%, logrank P =0.001). In the Cox proportional hazard analysis, higher MELD-XI (MELD-XI ≥10) was an independent predictor of cardiac events in HF patients (hazard ratio 1.79, 95% confidence interval 1.29-2.49, P=0.001). Conclusions: A MELD-XI scoring system, a marker of liver function, can identify high risk patients associated with larger right heart volume overload, left ventricular systolic dysfunction, and adverse clinical outcomes in HF.

Circulation: Heart Failure Editors’ Picks

<i>Circulation: Heart Failure</i> Editors’ Picks

Usefulness of right atrial volume index in predicting outcome in chronic systolic heart failure

BackgroundRight ventricular (RV) dysfunction is associated with poor prognosis in patients with heart failure (HF). Echocardiographic assessment of RV systolic function is challenging. The ability to visualize the right atrium (RA) allows a quantitative, highly reproducible assessment of RA volume. ObjectiveThe aim is to study the relationship between the right atrial volume index (RAVI) and prognosis in patients with chronic systolic HF. Methods120 patients with chronic systolic HF and left ventricular ejection fraction (LVEF) <40% were enrolled. The RA volume was calculated by Simpson’s method using single-plane RA area and indexed to body surface area (RAVI). RV systolic assessment was done using the RV fractional area change (RVFAC), and peak systolic velocity (Satri) using tissue Doppler imaging at the tricuspid annulus. The primary endpoint was death, urgent transplantation, or acute HF episode requiring hospital admission during a follow-up of 1year. ResultsFollow up was complete for 117 of 120 patients. Fifty-two patients reached the primary endpoint. The mean RAVI was higher in patients with adverse events (45.5±15ml/m2 versus 25.2±11ml/m2, p<0.001), and increased with worsening LVEF, RVFAC, Satri (Spearman’s r=−0.46, r=−0.45, r=−0.59, p<0.001 for all). RAVI was not correlated with estimates of RV diastolic dysfunction. The cut-off threshold for RAVI to predict the primary endpoint using receiver-operating characteristic curve was 29ml/m2 (area under the curve was 0.89%, 95% confidence interval: 0.82–0.95) with a sensitivity of 92%, and a specificity of 75%. NYHA>2 (OR=2.1, p<0.01), and RAVI (OR=1.6, p<0.05) were found to be independent predictors of adverse outcome. ConclusionIn patients with chronic systolic HF, RAVI is an independent predictor of adverse outcome with a threshold value of 29ml/m2.

Systemic Venous Diameters, Collapsibility Indices, and Right Atrial Measurements in Normal Pediatric Subjects

Compromise of right heart function is an important feature of many forms of congenital heart disease, and right atrial (RA) pressure is clinically relevant. Inferior vena cava (IVC) diameter and inspiratory collapse are indices of RA pressure, but pediatric data are lacking. RA measurements, systemic venous diameters, and Doppler filling fractions were prospectively investigated in healthy volunteer children and adolescents. The IVC was measured in its long axis just above the junction with the hepatic veins in the subxiphoid view and the superior vena cava at its junction with the right atrium in the right parasternal view. The changes in IVC diameter (IVCD) during quiet respiration and with a sniff were recorded. Hepatic venous systolic filling fraction was calculated from Doppler velocities in the first hepatic vein. RA major-axis length, area, and volume were measured from the apical four-chamber view. Three measurements of each parameter were averaged over at least three respiratory cycles. The IVC collapsibility index (IVCCI) was calculated as [(IVCDmax - IVCDmin)/IVCDmax] × 100. Substituting IVCDsniff for IVCDmin in the formula, the IVCCIsniff was calculated. Of 132 subjects enrolled, data in 120 (mean age, 8.3 ± 4.5 years) were analyzed. The maximal (expiratory) and minimal (inspiratory) diameters during free breathing were 12.1 ± 3.8 and 8.9 ± 3.8 mm for the IVC and 11.9 ± 3.4 and 7.9 ± 2.6 mm for the superior vena cava. IVCCImin and IVCCIsniff were 30 ± 13 and 47 ± 18, respectively. The RA major-axis length, area, and indexed maximal volume were 3.7 ± 0.7cm, 10.3 ± 3.6 cm(2), and 22.3 ± 7.0 mL/m(2), respectively. Correlations of maximal superior vena cava and IVC dimensions with bodysurface area were slightly better than with age and much stronger than withRA volume. No significant correlation was found between IVCCIs and age, gender, or indexed RA volume. Measurement of systemic venous diameters, collapsibility indices, and RA volumes is feasible inhealthy children and adolescents. Venous diameters increase predictably with growth and so must be interpreted in light of body surface area. IVCCIs and hepatic venous filling fraction compare closely with those reported in adults. Pediatric nomograms for these parameters are provided, and they should next be evaluated for relation to directly measured RA pressure in this age group.

The right to left atrial and ventricular area ratio, left ventricular area,TAPSE and right ventricular global strain can predict three-year survival in patients with pulmonary hypertension

Two-dimensional (2D), tissue Doppler (TD) and 2D speckle tracking (ST) echocardiography (E) have been used in the functional assessment of right and left atrium and ventricle (RA, LA, RV and LV) in pts with pulmonary hypertension (PH). We aimed to assess the relationship among parameters of 2DE,TDE and STE,and to compare these measures in predicting the three-year mortality (3YM) in pts with PH.Our study group comprised 184 pts (F110,M74,age 49±16 yrs) in whom PH confirmed by cardiac catheterization (Cath) and treated with targeted PH agents. Pulmonary arterial systolic and mean pressures were 96.3±28 and 60.2±14 mm Hg, and PVR and PVR/SVR ratio were 10,6±3,5 WU and 0,49±0,2, respectively. Echocardiography was performed before Cath,and included assessment of pericardial effusion (PE), leftward interatrial septal bulging (IASb), RV, LV, RA and LA area (A), RA/LA and RV/LV area ratio (AR), systolic and diastolic eccentricty indexes (EIs, EId), tricuspid annular systolic excursion and velocity (TAPSE and St), and global and segmentary strain (GS,SS). Analysis of RV and LV longitudinal strain (LS), and LV radial and circumferential strain (RS and CS) were performed using the 6-segment model for RV and LV. Right ventricle GLS showed a mild correlation with LVEIs (r: -0.26,p 2.7 (AUC: 0.69; 0.57-0.80, p=0.004), RV/LV AR >1.26 (AUC: 0.76; 0.64-0.85, p=0.002), LVA <15.3 cm2 (AUC: 0.74; 0.63-0.84, p<0.001), RVGLS <10.2% (AUC: 0.64; 0.52-0.75, p<0.01) and TAPSE <1.5 (AUC: 0.59; 0.48-0.70, p<0.05) were found to be predictors for 3YM. However, other measures derived from 2DE, TDE and STE were not associated with 3YM (p=NS). Invasive RA pressure showed no relation to PE,IASb and RA/LA AR, and IASb was not related to GLS,RS or CS. However, PE was associated with impaired RVGLS and LVRS (p<0.001). In conclusion,relations among the measures of cardiac functions as assessed by 2DE,TDE and STE seem to be complex,and integration of these modalities may increase the accuracy of echocardiography in the risk assessment of pts with PH. An increased RA/LA and RV/LV area ratio, and a decreased LV area, TAPSE and RVGLS can predict three-year mortality in these pts.

Assessing right ventricular systolic function in a population of unselected patients before cardiac surgery: a multiparametric approach is mandatory

Background and aim: According to recent American guidelines, RV dysfunction can be diagnosed on a single parameter: 1) Peak systolic velocity during ejection period (S') <10 cm/sec 2) RV fractional area change (RVFAC) <35%. The aim of our study was to assess these recent recommendations in a large non-selected cohort of patients awaiting cardiac surgery and to evaluate less validated RV function criteria. Methods: Four hundred and thirteen patients (means values of age and LVEF respectively: 70.3±10.3 years and 62±13%) were enrolled of which 63% were awaiting valve surgery, 49% coronary artery bypass grafting and 3% others. To evaluate RV function, the following parameters were obtained: parameters derived from pulsed tissue Doppler at the tricuspid annulus (S', right myocardial performance index (RMPI), isovolumic acceleration (IVA)), RVFAC, and 2D Strain of the basal lateral wall. Indices of RV preload (IVC collapse index and right atrium RA area) and afterload (systolic pulmonary artery pressure, pulmonary vascular resistance) were also recorded. Results: Out of 413 patients, 320 patients (77.5%) had normal RV function (group 1, defined by S'>10cm/s and RVFAC> 35%,). RV dysfunction was probable in 54 patients (group 2, defined by S'<10cm/s OR RVFAC< 35%). RV dysfunction was highly probable in 39 patients (group 3, defined by S'<10cm/s AND RVFAC< 35%). Using group 1 and 3, other less-validated parameters were evaluated: IVA ≤1.8 m/s2 and basal 2D-Strain ≥-17% had both the best diagnostic value to detect RV dysfunction with a sensitivity of 86% and a specificity > 80%. A cut-off value of RMPI30.60 allowed an acceptable discrimination (AUC 0.79) to predict RV dysfunction with a specificity of 80%. Moreover, IVA was found to be the least load-dependent while basal 2D-Strain and RMPI appeared to be afterload and preload dependent. Conclusions: In patients with a suspicion of RV dysfunction, S' and RVFAC are frequently discordant (58% of the patients). Using a group of highly probable RV dysfunction (S'<10cm/s AND RVFAC< 35%), we found that IVA and basal 2D-Strain have both a good diagnostic value. Moreover, contrary to 2D-strain, IVA was not influenced by loading conditions, adding to its diagnostic value. Our results underline the need of a multiparametric approach to diagnose RV dysfunction, and for this setting both IVA and 2D strain could help.

Subxiphoid echocardiographic evaluation of right heart function in patients with chronic obstructive pulmonary disease

PURPOSE: The purpose of this study is to evaluate by subxiphoid echocardiography the sensitivity and specificity of various echocardiographic parameters for early diagnosis and survival of patients with chronic obstructive pulmonary disease (COPD). MATERIAL AND METHODS: Subxiphoid echocardiography was performed in 75 COPD patients to evaluate inferior vena cava dimension (IVCD), its collapsibility index (CI), end-diastolic right ventricular dimension (EDRVD), end-diastolic right ventricular thickness (EDRVT) (M-mode), right atrial area (RAA), right ventricular areas and right ventricular area shortening fraction. Results were compared to those of 30 healthy controls. Patients in sinus rhythm were divided in two according to there NYHA class (I+II and III+IV) an in three according to there acid-base blood gases status. RESULTS: All the indexes were equally and significantly changed in the patients with RVH/PH and those with COPD and atrial fibrillation (AF) when compared to controls. COPD patients with neither ECG criteria for RV hypertrophy (RVH), nor x-ray evidence of pulmonary hypertension (PH) presented with significantly greater EDRVA and RAA and normal IVC/CI. In both cases, according to cardiac and respiratory severity status subdivision, significant changes in any indexes with worsening of cardiac and respiratory failure were observed. Best sensitivity, specificity and predictive accuracy for early diagnosis were established for IVCD/CI and EDRVT. During the two-year study period, seven (9%) patients died in end stage respiratory and heart failure because of considerably reduced right heart performance. CONCLUSION: Subxiphoid echocardiography may be used for early detection of cor pulmonale, evaluation of right heart dysfunction and prognosis in COPD patients. Scripta Scientifica Medica 2013; 45(2): 55-60.

Substrates of atrial arrhythmias: Histological insights from patients with congenital heart disease

The impact of overload duration and age on remodelling process in human atria remains controversial. We analysed histological markers of right atrial (RA) remodelling in CHD patients in order to provide some insights into impacts of age and overload duration on substrates of atrial arrhythmias. Sixty-five CHD patients who underwent initial cardiac surgery were enrolled (median age 18 years). Patients with dominant left atrial overload were excluded. RA tissues resected from CHD patients during surgery were examined by means of histology and immunohistochemistry and compared with RA tissues from age-matched control hearts from post-mortem (n=22, median age 22 years). Patient histories of preoperative SVTs and echocardiography were also examined. The greatest extent of fibrosis, the largest myocyte diameter and the longest capillary distance and the most CD45-positive cell infiltration was observed in CHD samples with SVT, followed by CHD without SVT and then control samples. All histological changes were correlated with age in CHD samples (r=0.462, 0.718, 0.529 and 0.447, respectively) with relatively steep and continuous manner, whereas only myocyte diameter was correlated with age in control samples (r=0.576). RA dimensions and area obtained from echocardiography also correlated with histological markers in CHD patients. Dominant and chronic RA overload due to CHD resulted in time-course related RA structural remodelling, which could provide the background for atrial arrhythmia. The overload duration, rather than age, seems to be a key factor for atrial histological degeneration in the cohort of CHD.

270: Effects of advanced therapies on echocardiographic and Doppler measures, compared with clinical evaluation and BNP in patients with Eisenmenger syndrome

Management options for patients with Eisenmenger syndrome (ES) were limited to palliative measures or transplantation before the advent of advanced therapies (AT). Little data is available on the impact of disease targeting therapies on BNP and echocardiographic variables in patients with ES. We wanted to investigate the effects of AT on echocardiographic measures and BNP in patients with ES. We prospectively included 63 patients with ES who were started on AT (46% were treated with endothelin receptor antagonists, 44.4% with PDE5 inhibitors and 9.6% with an association. Clinical, 6 min walk test and BNP data were collected at baseline (before introduction of AT) and after a mean period of 2years of sustained therapy. Mean age was 42±13 years, most of patients were WHO III (97%) whereas a vast majority had post-tricuspid defects. At baseline, echocardiographic findings were consistent with abnormalities of the RV function and adaptation: overall dilated RV (mean inlet 44.9±6.2 mm), reduced TAPSE (16.4± 3.5 mm). AT was responsible for an improvement in WHO functional class (p=0.001) and walked distance (+35.1 m; p=0.01), however, it was not associated with any change in BNP (p=0.85). RV systolic function and adaptation was improved (decreased systolic/diastolic duration ratio and total isovolumic time, p<0.001 and p=0.003; decreased RV dP/dT, p=0.05; increased TAPSE and tricuspid Sm, p=0.01 and p=0.03), however, no significant right ventricular structural remodeling was observed. Agreement between the echocardiographic score (previously described as associated with outcomes in ES: reduction in TAPSE, RA area, RA/LA ratio or S/D ratio) and clinical response (decrease in WHO and improved 6MWT) was moderate but higher than BNP. Our results support the notion that therapy is associated with improved symptoms, RV systolic function and adaptation but not with reduction in BNP concentrations

Assessment of Inter and Intra-atrial Asynchrony in Patients with Systolic Heart Failure Using Velocity Vector Imaging.

Background:According to previous studies on the deformation properties of the left atrium, the systolic strain and strain rates represent the atrial reservoir function and the early and late diastolic strain rates show the conduit and booster functions, respectively.Objectives:We sought to evaluate the intra and interatrial asynchrony using strain/strain rate imaging in systolic heart failure patients.Patients and Methods:Twenty five patients with systolic heart failure (LVEF ≤ 40%) were enrolled into the study. Asynchrony quantifications were performed according to the standard deviation of time-to peak (TP-SD) of deformation of three segments manually located along the perimeter of the left atrium free wall, right atrium free wall and interatrial septum, as imaged in an apical four-chamber view. We also calculated classic echocardiography parameters such as LV end-diastolic dimension index, LA volume index, RA area, as well as deceleration time (DT) on transmitral pulsed wave Doppler and E/E’ ratio on mitral annular tissue Doppler imaging.Results:In heart failure patients either inter or intra-atrial asynchrony were far more common in comparison with normal subjects (P=0.008 and P=0.007 respectively).Conclusions:Left ventricular systolic heart failure, may result in inter and intra-atrial asynchrony even in clinically stable patients without significant pulmonary hypertension and diastolic dysfunction.

Right Ventricular Diastolic Function in Patients with Thalassemia Major

Dear Editor, We read with great interest the article Echocardiography in Thalassemic Patients on Blood Transfusions and Chelation without Heart Failure written by Rodrigues et al1. They aimed to evaluate cardiac structure and function by conventional Doppler echocardiography and tissue Doppler imaging in patients with thalassemia major (TM) and no clinical evidence of heart failure. They found that left atrium volume index, mitral septal E/Em ratio and duration of reverse pulmonary vein flow were significantly higher in TM than in anemia and healthy groups. However, no differences were found in left and right ventricular structures and systolic function indexes between the groups. We believe that these findings will act as a guide for further studies regarding echocardiographic evaluation of left and right ventricular functions in patients with TM. Contrary to common belief, the right ventricle is not a passive chamber. A large number of acute and chronic diseases have been associated with RV diastolic dysfunction, including both pressure and volume overload pathologies such as primary lung disease, congenital heart disease, cardiomyopathies, ischemic heart disease, systemic diseases2,3. Only a few studies assessed the RV diastolic function. In those studies, the RV diastolic function has been evaluated using Doppler velocities of the transtricuspid flow (E, A, and E/A), tissue Doppler velocities of the tricuspid annulus (E', A', E'/A'), deceleration time, and IVRT. Most commonly used in recent studies are the tricuspid E/E' ratio, RA area or volume, and diastolic strain rate. A good correlation was shown between the tricuspid E/E' ratio and RA volume, and hemodynamic parameters. An E/E' ratio ≥4 had high sensitivity and specificity for predicting RA pressure ≥10 mm Hg in non-cardiac surgery intensive care unit patients4. The current study1 did not evaluate RV diastolic function and RA volume. Further studies should be conducted to assess RA volume and RV tissue Doppler diastolic parameters such as tricuspid E/E' ratio.

Anatomy of Ursa Majoris

A nearby friable cloud in Ursa Majoris contains 270 galaxies with radial velocities 500 < VLG < 1500 km s^-1 inside the area of RA= [11h; 13h] and DEC= [+40deg; +60deg]. At present, 97 galaxies of them have individual distance estimates. We use these data to clarify the structure and kinematics of the UMa complex. According to Makarov & Karachentsev (2011), most of the UMa galaxies belong to seven bound groups, which have the following median parameters: velocity dispersion of 58 km s^-1, harmonic projected radius of 300 kpc, virial mass of 2.10^12 Msol, and virial- mass-to-K-band-luminosity of 27Msol/Lsol. Almost a half of the UMa cloud population are gas-rich dwarfs (Ir, Im, BCD) with active star formation seen in the GALEX UV-survey. The UMa groups reside within 15-19 Mpc from us, being just at the same distance as Virgo cluster. The total virial mass of the UMa groups is 4.10^13 Msol, yielding the average density of dark matter in the UMa cloud to be Omega_m = 0.08, i.e. a factor three lower than the cosmic average. This is despite the fact that the UMa cloud resides in a region of the Universe that is an apparent overdensity. A possible explanation for this is that most mass in the Universe lies in the empty space between clusters. Herewith, the mean distances and velocities of the UMa groups follow nearly undisturbed Hubble flow without a sign of the 'Z-wave" effect caused by infall toward a massive attractor. This constrains the total amount of dark matter between the UMa groups within the cloud volume.