Right Atrial Area Research Articles

Larger right atrium than left atrium is associated with all-cause mortality in elderly patients with heart failure.

While left atrial (LA) enlargement is known as an early sign of left heart disease with prognostic implications in heart failure (HF), the importance of right atrial (RA) enlargement is less well studied, and the prognostic implications of interatrial size comparison are insufficiently understood. The aim of this study was to test the hypothesis that RA area larger than LA area in apical four-chamber view is associated with all-cause mortality in elderly patients with HF independent of left ventricular ejection fraction (LVEF). Retrospectively, 289 patients above 65years hospitalized for HF between April 2007 and April 2008, and who underwent an echocardiogram, were enrolled. All-cause mortality was registered during a follow-up of at least 56months. Baseline parameters measured were RA area, LA area, LA volume, LVEF, left ventricular mass (LVM), tissue Doppler systolic velocity of right ventricular free wall (SmRV), presence of severe tricuspid regurgitation (TR), tricuspid gradient, central venous pressure, systolic pulmonary artery pressure, as well as some parameters of diastolic function. In univariate analysis RA larger than LA was associated with all-cause mortality (hazard ratio [HR] of 1.88, P<.001). The relation of RA larger than LA to all-cause mortality remained even after adjusting for age, heart rate, LVEF, atrial fibrillation, percutaneous coronary intervention, LVM index, LA volume index, SmRV, and the presence of severe TR (HR: 1.79, P=.04). RA larger than LA, independently of LVEF, is associated with all-cause mortality in elderly patients hospitalized due to HF.

Two Cases of Primary Atrial Myopathy in Western Sydney

We describe a second case of a severe biatrial enlargement. We previously reported a similar finding in a 79-year-old male with long-standing history of myasthaenia gravis and previously known AF and heart failure with preserved ejection fraction. A 73-year-old female of Sri Lankan background presents with progressive dyspnoea and decreased exercise tolerance over the course of six months. She had no previous cardiac history and minimal comorbidities. On presentation she was haemodynamically uncompromised (BP of 140/88) and mildly tachypnoeic (respiratory rate 22). Examination revealed elevated jugular venous pulse with evidence of large V waves, a grade 4 pansystolic murmur and bi-basal crepitations. There was no hepatomegaly or lower limb oedema. Electrocardiogram revealed presence of new onset atrial fibrillation. Blood tests showed normal cardiac enzymes. Chest x-ray showed gross cardiomegaly but clear lung fields. Transthoracic echocardiogram showed grossly dilated left and right atriums (RA area 72 cm2, LA volume 107.9 ml/m2), disproportionate to the ventricular cavity. There was evidence of early thrombus in the left atrium. No evidence of intracardiac shunts was seen on agitated saline study. She proceeded to have a right heart study which showed normal pulmonary pressures. She was discharged with plans for an outpatient cardiac MRI. Severe biatrial dilatation is rare and remains a poorly understood clinical entity. The present case reflects our second experience with the condition. In both cases, a primary atrial myopathy was the primary diagnosis. We aim to compare these both rare cases and present similarities and clinical dilemmas in treating this rare cardiac disorder.

Echocardiographic Determinants of One-Year All-Cause Mortality in Patients With Chronic Heart Failure Complicated by Significant Functional Tricuspid Regurgitation

BackgroundRight ventricular (RV) dysfunction plays an important role in chronic heart failure (CHF). We evaluated the echocardiographic determinants of 1-year all-cause mortality in CHF patients with clinically relevant functional tricuspid regurgitation (TR). Methods and ResultsA total of 101 consecutive CHF patients (mean age 74 ± 10 years, 53% male) with moderate or severe functional TR were enrolled. Each patient underwent at least 2 echocardiography examinations in an interval of >6 months. Clinical follow-up was made after a median of 305 (interquartile range 164–365) days after the last echocardiography. The primary end point was all-cause mortality. Forty-two patients (42%) died during follow-up. Baseline right atrial (RA) area, TR volume increase and RV enlargement over time were significantly higher in nonsurvivors than survivors (all P < .05). Compared to baseline levels, systolic pulmonary artery pressure (sPAP) was significantly reduced in nonsurvivors during follow-up echocardiography (54 ± 19 vs 49 ± 21 mm Hg; P = .010), but significantly increased in survivors (48 ± 17 vs 54 ± 17 mm Hg; P = .001). Multivariable survival analysis suggested that baseline RA area ≥27 cm2 (hazard ratio [HR] 2.41, 95% confidence interval [CI] 1.21–4.80; P = .013), follow-up TR proximal isovelocity surface area regurgitant volume increase ≥15 mL (HR 2.27, 95% CI 1.20–4.31; P = .012), RV middle diameter increase ≥10 mm (HR 2.38, 95% CI 1.10–5.11; P = .027), and sPAP reduction ≥10 mm Hg (HR 3.04, 95% CI 1.51–6.13; P = .002) were determinants of 1-year all-cause mortality after the last echocardiography. Patients with 2 or 3 of these determinants were faced with significantly increased 1-year mortality (88% or 100%). ConclusionsDynamic RV morphologic and functional changes during serial echocardiography are associated with significantly increased mortality risk in CHF patients with moderate or severe functional TR.

Abstract 13061: Right Atrial Strain Combined With Ve/vco 2 in Early Detection of Systemic Sclerosis Pulmonary Vascular Involvement

Introduction: Systemic sclerosis (SSc) is at risk of developing pulmonary vasculopathy (PV) leading to pulmonary arterial hypertension (PAH), right heart failure and death. Early detection of this life-limiting complication may allow timely therapy and improve patients’ survival. Nevertheless, standard non-invasive screening tests are not fully adequate to identify milder degrees of vascular disease and right heart catheterization is reserved to hemodynamic confirmation. An integrating strategy including reliable specific echocardiographic and CPET parameters may identify “pre-clinic” PV and better characterize patients that warrant further attention. Hypothesis: The aim of this study was to test the value of right atrial (RA) two-dimensional strain echocardiography (2D-STE) combined with VE/VCO2 slope in the early detection of PV in SSc patients. Methods: We recruited 57 asymptomatic, consecutive, SSc patients without previous diagnosis of PAH, referred to our specialized out-patients clinic from April 2015 to March 2016. Six patients were excluded because unsuitable for CPET. The remaining 51 patients (48 female and 3 male - mean age 61±11years) had normal resting pulmonary function, chest X-ray, BNP, blood routine test and standard echo parameters. RA 2D STE was assessed by averaging all segments in dedicated 4-chamber view. During an incremental CPET we analyzed: minute ventilation, workload, peak oxygen uptake, oxygen pulse, anaerobic threshold, ventilatory reserve and VE/VCO2 slope. We also studied 11 matched controls. Results: Despite normal standard CPET parameters, we found that SSc patients had higher VE/VCO2 slope (mean 31,4±5,1 vs. 24,3±3,7; p &lt;0.001) and lower RA strain (mean 21,4±9.0% vs. 27,5±6.0%; p=0,01) than controls. Moreover, VE/VCO2 slope, but not traditional parameters as BNP, RA area, PAPs and TAPSE, showed a significant correlation with RA strain (r=-0.32 p&lt; 0.002). In particular, patients with VE/VCO2 slope &gt;34 had lower strain than patients with VE/VCO2 slope ≤34 (mean 15,6±3,8% vs. 23,8±9,5%; p&lt;0,001). Conclusions: In asymptomatic SSc patients, combined approach with VE/VCO2 slope and RA strain could unmask milder forms of PV, improve SSc patients’ characterization and minimize diagnosis delay.

Right heart function deteriorates in breast cancer patients undergoing anthracycline-based chemotherapy.

BackgroundCardiotoxicity from anthracycline-based chemotherapy is an important cause of early and late morbidity and mortality in breast cancer patients. Left ventricular (LV) function is assessed for patients receiving anthracycline-based chemotherapy to identify cardiotoxicity. However, animal studies suggest that right ventricular (RV) function may be a more sensitive measure to detect LV dysfunction. The purpose of this pilot study was to determine if breast cancer patients undergoing anthracycline-based chemotherapy experience RV dysfunction.MethodsForty-nine breast cancer patients undergoing anthracycline-based chemotherapy at the Ottawa Hospital between November 2007 and March 2013 and who had 2 echocardiograms performed at least 3months apart were retrospectively identified. Right atrial area (RAA), right ventricular fractional area change (RV FAC) and RV longitudinal strain of the free wall (RV LSFW) were evaluated according to the American Society of Echocardiography guidelines.ResultsThe majority (48/49) of patients were females with an average age of 53.4 (95% CI: 50.1–56.7years). From baseline to follow-up study, average LV ejection fraction (LVEF) decreased from 62.22 (95% CI: 59.1–65.4) to 57.4% (95% CI: 54.0–60.9) (P=0.04). During the same time period, the mean RAA increased from 12.1cm2 (95% CI: 11.1–13.0cm2) to 13.8cm2 (95% CI: 12.7–14.9cm2) (P=0.02), mean RV FAC decreased (P=0.01) from 48.3% (95% CI: 44.8–51.74) to 42.1% (95% CI: 38.5–45.6%), and mean RV LSFW worsened from −16.2% (95% CI: −18.1 to −14.4%) to −13.81% (95% CI: −15.1 to −12.5%) (P=0.04).ConclusionThis study demonstrates that breast cancer patients receiving anthracycline-based chemotherapy experience adverse effects on both right atrial size and RV function. Further studies are required to determine the impact of these adverse effects on right heart function and whether this represents an earlier marker of cardiotoxicity.

(387) - Right Ventricular Dyssynchrony and Exercise Capacity in Idiopathic Pulmonary Arterial Hypertension: Insights Form Echocardiography and Cardiopulmonary Exercise Test

(387) - Right Ventricular Dyssynchrony and Exercise Capacity in Idiopathic Pulmonary Arterial Hypertension: Insights Form Echocardiography and Cardiopulmonary Exercise Test

Echocardiographic Reference Values for Right Atrial Size in Children with and without Atrial Septal Defects or Pulmonary Hypertension.

Right atrial (RA) size may become a very useful, easily obtainable, echocardiographic variable in patients with congenital heart disease (CHD) with right-heart dysfunction; however, according studies in children are lacking. We investigated growth-related changes of RA dimensions in healthy children. Moreover, we determined the predictive value of RA variables in both children with secundum atrial septal defect (ASD) and children with pulmonary hypertension (PH) secondary to CHD (PH-CHD). This is a prospective study in 516 healthy children, in 80 children with a secundum ASD (>7 mm superior-inferior dimension), and in 42 children with PH-CHD. We determined three RA variables, i.e., end-systolic major-axis length, end-systolic minor-axis length, and end-systolic area, stratified by age, body weight, length, and surface area. RA end-systolic length and area z scores were increased in children with ASD and PH-CHD when compared to those variables in the healthy control population. Using the Youden Index to determine the best cutoff scores in sex- and age-specific RA dimensions, we observed a sensitivity and specificity up to 94 and 91 %, respectively, in ASD children and 98 and 94 %, respectively, in PH-CHD children. We provide normal values (z scores -2 to +2) for RA size and area in a representative, large pediatric cohort. Enlarged RA variables with scores >+2 were predictive of secundum ASD and PH-CHD. Two-dimensional determination of RA size can identify enlarged RAs in the setting of high volume load (ASD) or pressure load (PH-CHD).

Diastolic Dysfunction Is a Contributing Factor to Exercise Intolerance in COPD

Right ventricular (RV) systolic failure is rare in patients with COPD, but they often develop RV diastolic dysfunction. Left ventricular (LV) diastolic dysfunction is also common in this population. Nevertheless, data are scarce regarding the effect of diastolic dysfunction on the functional capacity in patients with COPD. We investigated the correlation between echocardiographic parameters of RV and LV diastolic function and the exercise capacity in COPD, by using conventional echocardiographic methods and tissue Doppler imaging. 65 patients with COPD (61 ± 9 years) in stages GOLD II-IV were investigated. Functional capacity was measured with 6-minute walk test (6MWT). Right (RA) and left atrial (LA) area index were measured; collapsibility index inferior vena cava was calculated. Parameters of the mitral and tricuspid inflow (E, A) as well as annular systolic (S), early- (e’) and late- (a’) diastolic myocardial longitudinal velocities were measured. E/A, E/e’ and e’/a’ ratios were calculated. 6MWT distance was 330 ± 76 m. LV diastolic dysfunction was found in 48 (74%) patients. LV and RV filling pressures were elevated in 28 (43%) and in 29 (45%) patients, respectively. In the left heart, LA area index showed significant correlation with the functional capacity (r = -0.319; p = 0.011). In stepwise multiple linear regression analysis tricuspid e’/a’ (r = 0.611; p = 0.000), collapsibility index (r = 0.505; p = 0.000), RA area index (r = -0.445; p = 0.000) and body surface area (r = 0.314; p = 0.011) were independent predictors of 6MWT distance. Right ventricular diastolic function and filling pressure have strong influence on the functional capacity in patients with COPD.

Abstract 13135: Association of Three-Dimensional Tricuspid Valve Deformation With Functional Tricuspid Regurgitation

Introduction: Background: Functional tricuspid regurgitation (FTR) is widely recognized as being associated with poor outcomes in patients with various cardiac diseases, and the tricuspid valve (TV) deformation is an important mechanism of FTR. However, the precise assessment of TV deformation by means of two-dimensional echocardiography is limited. Purpose: The purpose of this study was thus to investigate the association of TV deformation with FTR by using three-dimensional transthoracic echocardiography (3D-TTE). Methods: We studied 65 patients with FTR. Their mean age was 60±16 years and 36 patients (55%) were female. FTR was quantified by the ratio of the jet area and corresponding RA area, and more than moderate FTR was defined as significant. 3D-TTE was performed to analyze the tricuspid deformation. Tricuspid tenting height and area were analyzed at the time of maximal systolic closure. TV area index, anterior-posterior (A-P) and septal-lateral (S-L) TV annular diameters were analyzed at end-diastole. Right ventricular longitudinal length, end-diastolic and end-systolic area index (EDAI, ESAI) and right atrial area index (RAA) were also obtained from 3D data set. Results: Twenty-one patients were classified as having significant FTR. Tenting height (6.5±3.1 vs. 4.0±1.8 mm, p&lt;0.001), tenting area (1.3±0.8 vs. 0.7±0.4 cm2, p=0.003), TV area (6.9±1.7 vs. 5.0±1.4 cm2/m2, p&lt;0.001) and S-L (35±4 vs. 28±6 mm, p&lt;0.001) in patients with FTR were significantly larger than those in patients with non-significant FTR, but A-L was not (38±6 vs. 36±7mm). After adjusting for age, ESAI, RAA and tenting height, a multivariate logistic regression analysis showed that TV area (odds ratio 3.1, p=0.04) was independently associated with significant FTR. Conclusions: TV-related parameters were associated with FTR, and TV area was the most important factor for FTR. Our findings by means of 3D-TTE may well have clinical implications for better management of patients with FTR.

Abstract 16817: Correlation of Right Heart Echocardiographic Quantitation With Cpet Parameters to Predict Clinical Outcomes in Patients With Congenital Right Heart Disease

Background: Adults with congenital right heart disease (ACHD) patients have a diminished exercise tolerance compared to healthy population, and abnormal peak VO2 as assessed by cardiopulmonary exercise testing (CPET)significantly predicts outcomes of heart failure and death in this population. Despite this, CPET is not as widely available as echocardiography. Aim: We aim to correlate resting echocardiographic patterns of regional RV contractile function among ACHD patients with peak VO2 and major adverse cardiovascular events (MACE). Methods: We retrospectively recruited 160 ACHD patients who underwent CPET at our hospital . Out of these, 94 patients had complete echocardiographic data for analysis, in studies performed within 1 year of their CPET.RV quantitative parameters measured included: Tricuspid Annular Plane Systolic Excursion (TAPSE), Tissue doppler imaging TDI (S’), RA area, RV dimensions and RV fractional area change % (FAC).These variables were correlated with peak VO2,exercise RV function by ventriculography(RV score) and MACE(heart failure, arrhythmia,death or transplantation)after CPET. Results: The most frequent congenital pathology was Tetralogy of Fallot (35%).14% (n=13) patients had systemic right ventricles.There were 28 MACE during a median follow up of 1.3 years. FAC, TAPSE and S’ significantly correlated with peak VO2 in multivariate analysis.FAC also correlated with RV score. Decrease in FAC was associated with MACE in a continuous fashion while a cutoff value of S’&lt; 9.5 cm/sec was also significantly associated with MACE (p=0.04,HR 2.48)(table) Conclusion: This is a heterogenous group of ACHD lesions and routinely acquired echo RV assessment was able to broadly correlate with exercise and outcome. This differentiates us from other papers which are all lesion specific or based on strain measurements (difficult to peform and reproduce).These findings can also help prioritize patients for more sophisticated testing like CPET.

Right Atrial Function in Pulmonary Arterial Hypertension.

Elevated right atrial (RA) pressure is an established prognostic measure in pulmonary arterial hypertension (PAH). However, little is known about perturbations in RA function in PAH. Reservoir (RA longitudinal strain [RA LS]), conduit (RA early LS rate), and active (RA late LS rate) phases were assessed by 2D speckle tracking in 65 patients with PAH, 6-minute walk distance ≤450 m, and a pulmonary vascular resistance >800 dynes·s/cm(5), despite therapy with at least 2 PAH-specific medications enrolled in the Imatinib in Pulmonary Arterial Hypertension, a Randomized Efficacy Study (IMPRES) trial and were compared with 30 healthy controls of similar age and sex. We studied the association of RA functional measures with invasive pulmonary hemodynamics, cardiac structure and function, and N-terminal pro brain natriuretic peptide. RA LS and early LS rate were reduced in PAH patients compared with controls (27.1±11.6 versus 56.9±12.7, adjusted P<0.001 and -0.6±0.5 versus -1.5±0.5, adjusted P<0.001, respectively) even after adjusting for RA area and invasive RA pressure, whereas RA late LS rate was similar between groups (-1.4±0.7 versus -1.5±0.4, P=0.42). Among PAH patients, worse RA LS correlated with greater RA size (r=-0.50, P<0.0001) and pressure (r=-0.37, P=0.002), but not pulmonary artery pressure (r=-0.07, P=0.58). Worse RA LS was also associated with right ventricular enlargement and dysfunction and higher N-terminal pro brain natriuretic peptide independent of RA size and pressure. RA reservoir and passive conduit functions are impaired in PAH, independent of RA size and pressure, and likely reflect right ventricular failure and overload. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00902174.

Atrial Size and Function in Athletes.

We wanted to explore whether change in LA (left atrium) size would influence LA function, or increase regurgitation in the atrioventricular valves. 595 male elite football players and 47 non-athletic controls were included. End-systolic LA volume and RA area and end-diastolic LV volume and RV area were measured by 2-dimensional (2D) echocardiography Pulsed and colour Doppler were used to estimate tricuspid and mitral regurgitations. 2D longitudinal strain of the 50 football players with the largest LA volumes were compared with the 50 players with the smallest LA volumes. The LA volumes in some athletes with large atria were more than tripled, compared to athletes with small atria. 2D strain however, could not reveal any impairment of LA function in the players with the largest atria, compared to those with the smallest LA. Tricuspid valve regurgitation was found in 343 (58%) of the athletes, compared to 17 (36%) of the controls (p<0.01), while mitral regurgitation was found in 116 (20%) football players and 7 (15%) controls (NS). Furthermore, the RA area was significantly larger in athletes with tricuspid regurgitation compared to athletes without. The present study demonstrated a huge variation in atrial size between the athletes. This variation, however, had no impact on LA function. Tricuspid regurgitation was significantly more prevalent among the athletes, than among the controls.

IS RIGHT HEART FUNCTION ADVERSELY AFFECTED IN BREAST CANCER PATIENTS UNDERGOING ANTHRACYCLINE-BASED CHEMOTHERAPY?

Cardiotoxicity from anthracycline-based chemotherapy is the second leading cause of death in breast cancer patients. Left ventricular function is routinely monitored during therapy to identify cardiotoxicity, however, animal studies suggest that right ventricular (RV) function may also be impaired and potentially allow earlier detection of cardiotoxicity because the thinner RV may be more sensitive to the toxic effects. The purpose of this pilot study was to determine if breast cancer patients undergoing anthracycline-based chemotherapy experience RV dysfunction. 50 breast cancer patients undergoing chemotherapy (receiving at least 240mg/m2 of anthracycline) at The Ottawa Hospital with 2 echocardiograms separated by an interval of at least 3 months were retrospectively identified between November 2007 and March 2013. Right atrial area (RAA), Right ventricular fractional area change (RV FAC) and RV longitudinal-strain of the free wall (RV LSFW)(Figure 1) were evaluated according to the American Society of Echocardiography right heart guidelines. The majority (48/50) of patients were females with an average age of 53.4 years (95% CI: 50.2 to 56.6 years). From baseline to follow-up study, average LV ejection fraction (LVEF) decreased from 62.8% (95% CI: 59.3 to 66.3) to 57.8% (95% CI: 54.5 to 61.1) (p<0.01). During the same time period, the mean RAA increased from 12.0cm2 (95% CI: 11.1 to 13.0cm2) to 13.9 cm2 (95% CI: 12.8 to 14.9cm2) (P = 0.0004), mean RV FAC decreased (P = 0.04) from 46.97% (95% CI: 43.20 to 50.73) to 41.75% (95% CI: 38.18 to 45.31%) and mean RV LSFW increased from -15.7% (95% CI: -17.7 to -13.7%) to -13.4% (95% CI: -14.9 to -11.9%)(P = 0.03). This pilot study confirms that RAA, RV FAC and RV LSFW are adversely affected in breast cancer patients undergoing anthracycline-based chemotherapy. Further studies are required to determine the implications of these adverse effects on right heart function and whether they can provide an earlier marker of cardiotoxicity.

Tricuspid Regurgitation Following Implantation of Endocardial Leads: Incidence and Predictors.

Endocardial leads, permanent pacemaker (PPM), or implantable cardioverter defibrillator (ICD) placed across the tricuspid valve can lead to tricuspid regurgitation (TR). The reported incidence of this complication has varied widely. There are limited data predicting which patients will develop this complication. This study sought to describe the incidence of worsening TR post-PPM or ICD and to identify patient-specific predictors of increased TR following lead placement. Patients (N = 382) who received a PPM or ICD from January 1, 2006 to December 31, 2010 and had echocardiograms both within 365 days prior to and up to 1,200 days after device placement were studied. TR was assessed on a 6-point scale (none/trace, mild, mild to moderate, moderate, moderate to severe, severe). Primary outcome was a two-grade increase in the severity of TR. Echocardiographic and clinical predictors of worsening TR were examined using multivariate regression. A two-grade increase in TR occurred in 10.0% of our patient population. Age, lead position, atrial fibrillation, right atrial (RA) area, right ventricular systolic pressure (RVSP), left atrial area, and severity of mitral regurgitation were univariate predictors of worsening TR post lead placement. In the multivariate analysis, predevice RA area and RVSP were associated with increased TR after endocardial lead placement. Percentage of time spent pacing did not appear to be associated with increased TR. The incidence of increased TR postendocardial lead placement was 10.0%; this is lower than prior estimates. Predevice RA area and RVSP are predictors of increased TR after lead placement.

Extracellular volume quantification by dynamic equilibrium cardiac computed tomography in cardiac amyloidosis

BackgroundCardiac involvement determines outcome in patients with systemic amyloidosis. There is major unmet need for quantification of cardiac amyloid burden, which is currently only met in part through semi-quantitative bone scintigraphy or Cardiovascular Magnetic Resonance (CMR), which measures ECVCMR. Other accessible tests are needed. ObjectivesTo develop cardiac computed tomography to diagnose and quantify cardiac amyloidosis by measuring the myocardial Extracellular Volume, ECVCT. MethodsTwenty-six patients (21 male, 64 ± 14 years) with a biopsy-proven systemic amyloidosis (ATTR n = 18; AL n = 8) were compared with twenty-seven patients (19 male, 68 ± 8 years) with severe aortic stenosis (AS). All patients had undergone echocardiography, bone scintigraphy, NT-pro-BNP measurement and EQ-CMR. Dynamic Equilibrium CT (DynEQ-CT) was performed using a prospectively gated cardiac scan prior to and after (5 and 15 minutes) a standard Iodixanol (1 ml/kg) bolus to measure ECVCT. ECVCT was compared to the reference ECVCMR and conventional amyloid measures: bone scintigraphy and clinical markers of cardiac amyloid severity (NT-pro-BNP, Troponin, LVEF, LV mass, LA and RA area). ResultsECVCT and ECVCMR results were well correlated (r2 = 0.85 vs r2 = 0.74 for 5 and 15 minutes post bolus respectively). ECVCT was higher in amyloidosis than AS (0.54 ± 0.11 vs 0.28 ± 0.04, p<0.001) with no overlap. ECVCT tracked clinical markers of cardiac amyloid severity (NT-pro-BNP, Troponin, LVEF, LV mass, LA and RA area), and bone scintigraphy amyloid burden (p<0.001). ConclusionDynamic Equilibrium CT, a 5 minute contrast-enhanced gated cardiac CT, has potential for non-invasive diagnosis and quantification of cardiac amyloidosis.

Application of percutaneous balloon mitral valvuloplasty in patients of rheumatic heart disease mitral stenosis combined with tricuspid regurgitation.

Background:Tricuspid regurgitation (TR) is frequently associated with severe mitral stenosis (MS), the importance of significant TR was often neglected. However, TR influences the outcome of patients. The aim of this study was to investigate the efficacy and safety of percutaneous balloon mitral valvuloplasty (PBMV) procedure in rheumatic heart disease patients with mitral valve (MV) stenosis and tricuspid valve regurgitation.Methods:Two hundred and twenty patients were enrolled in this study due to rheumatic heart disease with MS combined with TR. Mitral balloon catheter made in China was used to expand MV. The following parameters were measured before and after PBMV: MV area (MVA), TR area (TRA), atrial pressure and diameter, and pulmonary artery pressure (PAP). The patients were followed for 6 months to 9 years.Results:After PBMV, the MVAs increased significantly (1.7 ± 0.3 cm2 vs. 0.9 ± 0.3 cm2, P < 0.01); TRA significantly decreased (6.3 ± 1.7 cm2 vs. 14.2 ± 6.5 cm2, P < 0.01), right atrial area (RAA) decreased significantly (21.5 ± 4.5 cm2 vs. 25.4 ± 4.3 cm2, P < 0.05), TRA/RAA (%) decreased significantly (29.3 ± 3.2% vs. 44.2 ± 3.6%, P < 0.01). TR velocity (TRV) and TR continue time (TRT) as well as TRV × TRT decreased significantly (183.4 ± 9.4 cm/s vs. 254.5 ± 10.7 cm/s, P < 0.01; 185.7 ± 13.6 ms vs. 238.6 ± 11.3 ms, P < 0.01; 34.2 ± 5.6 cm vs. 60.7 ± 8.5 cm, P < 0.01, respectively). The postoperative left atrial diameter (LAD) significantly reduced (41.3 ± 6.2 mm vs. 49.8 ± 6.8 mm, P < 0.01) and the postoperative right atrial diameter (RAD) significantly reduced (28.7 ± 5.6 mm vs. 46.5 ± 6.3 mm, P < 0.01); the postoperative left atrium pressure significantly reduced (15.6 ± 6.1 mmHg vs. 26.5 ± 6.6 mmHg, P < 0.01), the postoperative right atrial pressure decreased significantly (13.2 ± 2.4 mmHg vs. 18.5 ± 4.3 mmHg, P < 0.01). The pulmonary arterial pressure decreased significantly after PBMV (48.2 ± 10.3 mmHg vs. 60.6 ± 15.5 mmHg, P < 0.01). The symptom of chest tightness and short of breath obviously alleviated. All cases followed-up for 6 months to 9 years (average 75 ± 32 months), 2 patients with severe regurgitation died (1 case of massive cerebral infarction, and 1 case of heart failure after 6 years and 8 years, respectively), 2 cases lost access. At the end of follow-up, MVA has been reduced compared with the postoperative (1.4 ± 0.4 cm2 vs. 1.7 ± 0.3 cm2, P < 0.05); LAD slightly increased compared with the postoperative (45.2 ± 5.7 mm vs. 41.4 ± 6.3 mm, P < 0.05), RAD slightly also increased compared with the postoperative (36.1 ± 6.3 mm vs. 28.6 ± 5.5 mm, P < 0.05), but did not recover to the preoperative level. TRA slightly increased compared with the postoperative, but the difference was not statistically significant (P > 0.05). The PAP and left ventricular ejection fraction appeared no statistical difference compared with the postoperative (P > 0.05), the remaining patients without serious complications.Conclusions:PBMV is a safe and effective procedure for MS combined with TR in patients of rheumatic heart disease. It can alleviate the symptoms and reduce the size of TR. It can also improve the quality-of-life and prognosis. Its recent and mid-term efficacy is certain. While its long-term efficacy remains to be observed.

Relationship between severity of pulmonary hypertension and coronary sinus diameter

Introduction and ObjectiveWe investigated the relationship between coronary sinus (CS) diameter and pulmonary artery systolic pressure (PASP) in patients with pulmonary hypertension (PH) and normal left ventricular systolic function. MethodsA total of 155 participants referred for transthoracic echocardiography were included in the study. The study population consisted of 100 patients with chronic PH and 55 control subjects. Patients with PH were divided into two groups according to PASP: those with PASP 36–45 mmHg, the mild PH group (n=53); and those with PASP >45 mmHg, the moderate to severe PH group (n=47). CS diameter was measured from the posterior atrioventricular groove in apical 4-chamber view during ventricular systole according to the formula: mean CS=(proximal CS+mid CS+distal CS)/3. ResultsMean CS diameter was significantly higher in the moderate to severe PH group than in the controls and in the mild PH group (1.12±0.2 cm vs. 0.82±0.1 cm and 0.87±0.1 cm, respectively; p<0.001). It was significantly correlated with right atrial (RA) area (r=0.674, p<0.001), RA pressure (r=0.458, p<0.001), PASP (r=0.562, p<0.001), inferior vena cava diameter (r=0.416, p<0.001), right ventricular E/A ratio (r=−0.290, p<0.001), and E/Em ratio (r=0.235, p=0.004). RA area (β=0.475, p<0.001) and PASP (β=0.360, p=0.002) were found to be independent predictors of CS diameter. ConclusionsA dilated CS was associated with moderate to severe pulmonary hypertension, and RA area and PASP were independent predictors of CS diameter.

Relationship between severity of pulmonary hypertension and coronary sinus diameter

Introduction and ObjectiveWe investigated the relationship between coronary sinus (CS) diameter and pulmonary artery systolic pressure (PASP) in patients with pulmonary hypertension (PH) and normal left ventricular systolic function. MethodsA total of 155 participants referred for transthoracic echocardiography were included in the study. The study population consisted of 100 patients with chronic PH and 55 control subjects. Patients with PH were divided into two groups according to PASP: those with PASP 36–45 mmHg, the mild PH group (n=53); and those with PASP >45 mmHg, the moderate to severe PH group (n=47). CS diameter was measured from the posterior atrioventricular groove in apical 4-chamber view during ventricular systole according to the formula: mean CS=(proximal CS+mid CS+distal CS)/3. ResultsMean CS diameter was significantly higher in the moderate to severe PH group than in the controls and in the mild PH group (1.12±0.2 cm vs. 0.82±0.1 cm and 0.87±0.1 cm, respectively; p<0.001). It was significantly correlated with right atrial (RA) area (r=0.674, p<0.001), RA pressure (r=0.458, p<0.001), PASP (r=0.562, p<0.001), inferior vena cava diameter (r=0.416, p<0.001), right ventricular E/A ratio (r=−0.290, p<0.001), and E/Em ratio (r=0.235, p=0.004). RA area (β=0.475, p<0.001) and PASP (β=0.360, p=0.002) were found to be independent predictors of CS diameter. ConclusionsA dilated CS was associated with moderate to severe pulmonary hypertension, and RA area and PASP were independent predictors of CS diameter.

The relationship between tricuspid regurgitation severity and right atrial mechanics: a speckle tracking echocardiography study.

The aim at this study was to assess the influence of the tricuspid regurgitation volume (TRvol) in right atrium (RA) reservoir phase myocardial mechanics. We included 55 heart failure (HF) patients referred for transthoracic echocardiography during a 2-month period. 18 Had HF with a reduced ejection fraction (HFREF) and 37 HF with a preserved ejection fraction (HFPEF). TR was chronic and functional. TRvol was calculated according to the PISA method. This study of RA used 2D-speckle tracking echocardiography to measure strain (rεR) and strain rate (rSR(R)). The reference frame coincided with the onset of the QRS. RA stiffness was assessed as the ratio: (rE/e')/rε(R). The median age of the sample was 78 (64-84) years, with female gender predominance (63.6%). The median value of rε(R) was 16% (range, 12.7-24.0) and of rSR(R) was 1.57 s(-1) (range, 1.09-2.05). We observed a significant negative correlation between rε(R) (r = -0.68, p < 0.01) and rSR(R) (r = -0.58, p < 0.01) and TRvol. RA mechanics decreased significantly with an increase in the TR grade. We created two multivariate linear regression models for rε(R) and rSR(R), separately for the patients with sinus rhythm or atrial fibrillation. The TRvol was independently associated with rε(R) after adjusting to the RA area, right ventricular longitudinal systolic function and the estimated pulmonary vascular resistance. We demonstrated an increase in RA stiffness with an increase in TR severity, and an association for functional status (NYHA class) and RA compliance. The HFREF group had a significantly lower rε(R) and rSR(R) that the HFPEF patients. According to our study, in HF patients, a chronic volume overload state significantly reduced the RA reservoir phase mechanics.

0548: Heart failure with preserved ejection fraction: an echocardiographic based approach to assess the prognosis. A report from the large prospective KaRen study

KaRen is a prospective study designed to characterize and follow a cohort of heart failure with preserved ejection fraction (HFpEF) patients. HFpEF remains a challenging syndrome. Patients have clinical signs linked to congestion but left ventricular (LV) EF is > 45%. We sought to test the relevance of echocardiographic parameters as predictors of death or hospitalization for cardiovascular reasons. Following an acute HF accompanied with NT-proBNP >300 pg/ml (BNP >100 pg/ml) and LVEF >45%, patients were included (n=349). The patients were reassessed by echo-Doppler after 4-8 weeks. Echocardiographies were standardized and the analysis centralized. LVEF was 62±13%, LV global longitudinal strain: – 15±3%, E/e’:12.9±6.2, Left atrial volume: 49±18 ml/m², Tricuspid regurgitation: 2.9±0.9m/s. Two parameters are correlated with the survival without any death or hospitalisation for cardiovascular reason and could be combined in a score: 2 x (E / e’) + RA area. This score has a theoretical range between 0 and 14. Based on tertiles of the score, censoring (frequencies of death or hospitalization for heart failure) were 48 (37.80), 67 (57.76) and 85 (75.22) in the 1st tertile – poor prognosis (N = 127), the 2nd tertile – intermediate (N = 116) and the 3rd tertile – good prognosis (N = 113), respectively. Combination of simple echocardiographic criteria (right atrial area and E/e’ ratio) was found relevant to predict the long term prognosis in a large cohort of patients diagnosed for heart failure with preserved ejection fraction.