Right Ventricle Inflow Research Articles

Tetralogy of Fallot regurgitation energetics and kinetics: an intracardiac flow analysis of the right ventricle using computational fluid dynamics.

Repaired Tetralogy of Fallot (rTOF) patients suffer from pulmonary regurgitation and may require pulmonary valve replacement (PVR). Cardiac magnetic resonance imaging (cMRI) guides therapy, but conventional measurements do not quantify the intracardiac flow effects from pulmonary regurgitation or PVR. This study investigates intracardiac flow parameters of the right ventricle (RV) of rTOF by computational fluid dynamics (CFD). cMRI of rTOF patients and controls were retrospectively included. Feature-tracking captured RV endocardial contours from long-axis/short-axis cine. Ventricular motion was reconstructed via diffeomorphic mapping, serving as domain boundary for CFD simulations. Vorticity (1/s), viscous energy loss (ELoss, mJ/L) and turbulent kinetic energy (TKE, mJ/L) were quantified in RV outflow tract (RVOT) and RV inflow. These parameters were normalized against total RV kinetic energy (KE) and RV inflow vorticity to derive dimensionless metrics. Vorticity contours by Q-criterion were qualitatively compared. rTOF patients (n = 15) had mean regurgitant fraction 38 ± 12% and RV size 162 ± 35mL/m2. Compared to controls (n = 12), rTOF had increased RVOT vorticity (142.6 ± 75.6/s vs. 40.4 ± 11.8/s, p < 0.0001), Eloss (55.6 ± 42.5 vs. 5.2 ± 4.4mJ/L, p = 0.0004), and TKE (5.7 ± 5.9 vs. 0.84 ± 0.46mJ/L, p = 0.0003). After PVR, there was decrease in normalized RVOT Eloss/TKE (p = 0.0009, p = 0.029) and increase in normalized tricuspid inflow vorticity/KE (p = 0.0136, p = 0.043), corresponding to reorganization of the "donut"-shaped tricuspid ring-vortex. The intracardiac flow in rTOF patients can be simulated to determine the impact of PVR and improve the clinical indications guided by cardiac imaging.

Cone repair after tricuspid valve replacement in Ebstein anomaly.

Cone repair after tricuspid valve replacement in Ebstein anomaly.

Regional and Temporal Variation of Ventricular and Conduction Tissue Activity During Ventricular Fibrillation in Canines.

[Figure: see text].

Novel Technique for the Measurement of Fetal Right Modified Myocardial Performance Index Using Synchronized Images of Right Ventricular Inflow and Outflow and Clinical Application to Twin‐to‐Twin Transfusion Syndrome

ObjectiveTo evaluate the reproducibility of the fetal right modified myocardial performance index (Mod‐MPI) obtained by synchronizing the inflow and outflow images of the right ventricle (RV) and to evaluate its feasibility through clinical application to twin‐to‐twin transfusion syndrome (TTTS).MethodsWe prospectively evaluated 77 normal fetuses. Two experienced operators individually measured the right Mod‐MPI using two different methods: (1) separate recording of the RV inflow and outflow using pulsed‐wave Doppler (conventional method) and (2) synchronization of RV inflow and outflow images using the MPI + ™ function based on the closure click of the pulmonary valve (new method). To evaluate the clinical utility of the new method, we measured the right Mod‐MPI in 33 TTTS fetuses using the new method before and after the fetoscopic laser coagulation (FLC).ResultsThere was no statistical difference in Mod‐MPI values between the two methods (p = .242). For both operators, the intra‐ and interoperator reproducibility of Mod‐MPI was high with both methods (ICCs &gt;0.950). Among the components of Mod‐MPI measured using the new method, ejection time showed the highest reproducibility, whereas isovolumetric relaxation time demonstrated the lowest reproducibility. In TTTS fetuses, the Mod‐MPI significantly decreased after FLC in recipients, and there was no difference in MPI values before and after FLC in donors.ConclusionRight Mod‐MPI measurement after the synchronization of RV inflow and outflow images is a reliable technique for evaluating fetal right cardiac function. This novel method can also independently evaluate the systolic and diastolic functions of the right heart.

The feasibility of measurement of different right ventricular systolic function parameters by intraoperative trans-esophageal echocardiography and their interchangeability with transthoracic echocardiography in pediatric patients undergoing cardiac surgery- interim results from an ongoing study

Introduction All the parameters recommended for functional assessment of right ventricle (RV) in children are based on transthoracic echocardiographic (TTE) measurements¹. Intraoperative echocardiography during pediatric cardiac surgery is, however, mainly dependent on trans-esophageal echocardiography (TEE). We planned to determine the feasibility of measurement of different RV systolic function parameters by intraoperative TEE and their interchangeability with TTE in pediatric patients undergoing cardiac surgery. Methods This ongoing single-centre, observational study has been registered (CTRI/2019/06/019743) after Institutional Ethics Committee clearance. After written, informed, parental consent, pediatric patients (1-18 years) undergoing corrective surgery for congenital heart diseases- are included. TEE transducer is inserted after induction of general anaesthesia. TTE examination is performed using Apical four-chamber (A4C) view. TEE examination is performed within 10 minutes of performing TTE, while keeping heart rate, mean arterial pressure and central venous pressure within 10% of that during performing TTE. Mid-esophageal four-chamber RV-focused (ME4C) view, Mid-esophageal modified bicaval view (MBC), Transgastric RV inflow view (TGRVI), Deep transgastric RV view (DTG-RV)- are used. All the recorded images/clips are analysed offline later, using Echopac-113 (GE) software. Fractional Area Change (FAC), Tricuspid annular plane systolic excursion (TAPSE), Tricuspid annular systolic velocity by pulsed-wave tissue Doppler (RV S’), Right ventricular index of myocardial performance (RIMP) (by tissue Doppler), Right ventricular free wall strain (RVFWS)- are measured. Feasibility is assessed as ability to acquire an image/loop deemed readable during the examination. Readable image/loop is defined as ability to completely delineate the endocardial border of the RV and tricuspid annulus in 2D-mode, to obtain completely traceable lines in M-mode (MM) and Angled M- mode (AMM), to obtain optimally aligned and completely traceable envelopes of pulsed wave Tissue-Doppler velocities. Agreement between TTE and TEE measured parameters are assessed by Bland-and-Altmann analysis. Results 42 patients has been recruited and analysed so far. The Mean±SD age of the patients was 6.5±4.6 years. Feasibility of measuring all the studied parameters was > 85% in all the TEE views (Table 1). There was good Intra- and Inter-observer reliability (Intra-class Correlation Coefficient > 0.8) of measurements of all the parameters in all the views (Both TTE and TEE) utilised. In comparison to TTE measurements, there were low bias in TEE measured parameters in: AMM measured TAPSE in ME4C and MBC views, FAC in ME4C view, RIMP in DTG-RV and TGRVI views, RVFWS in all the utilised views (Table 1). The limits of agreements, however, were wide (Table 1). Discussion Despite high feasibility, wide limits of agreement prevents intraoperative TEE measured RV function parameters to be used interchangeably with those measured by TTE for individual pediatric cardiac surgical patients.

Myocardial Ischemia Correlates with Right Ventricular Dysfunction in Patients with Noncompaction Cardiomyopathy

Noncompaction cardiomyopathy (NCM) results from an arrest of the myocardial compaction process in the embryonic period, leading to the impaired formation of the microvasculature. Predominantly left ventricle is affected, however right ventricle (RV) involvement and its functional impact in NCM remains undefined. We sought to analyze a potential correlation between myocardial ischemia and RV failure in this patient cohort. We enrolled 41 NCM patients (28 male, 13 female), aged 21 to 70 years. At baseline we performed echocardiography to measure RVID (RV inflow diastolic diameter), TAPSE (tricuspid annular plane systolic excursion), Sto (systolic tissue Doppler velocity on tricuspid annulus) and RV FAC (fractional area change). Significant myocardial ischemia was defined as summed difference score (SDS)≥2 on myocardial SPECT at rest and on stress. Myocardial ischemia has been shown in 11 patients (27%, Group A), 30 patients showed no significant ischemic changes (73%, Group B). Groups did not differ in sex (82% male vs. 63% male in Group B, P=0.454), age (48±13 years vs. 47±15 years in Group B, P=0.855), kidney function (serum creatinine 76±11µmol/L vs. 81±26µmol/L in Group B, P=0.565) or liver function (serum bilirubine 12.4±7.1µmol/L vs. 13.3±6.5µmol/L in Group B, P=0.686). When compared to Group B, Group A had significantly lower FAC (30.7±7.7% vs. 44.9±10.2%, P<0.001), greater RVID (3.3±0.6cm vs. 2.9±0.5cm, P=0.016), lower TAPSE (1.9±0.6cm vs. 2.5±0.4cm, P<0.001), higher NT-proBNP levels (1691±1883pg/mL vs. 422±877pg/mL, P=0.006). There was a trend toward lower Sto (10.7±2.6cm/s vs. 12.4±2.4cm/s, P=0.081). Overall, higher SDS was associated with lower FAC (r=-0.51, P=0.006), higher RVID (r=0.41, P=0.032), lower TAPSE (r=-0.49, P=0.008) and higher levels of NT-proBNP (r=0.66, P<0.001). In patients with NCM myocardial ischemia appears to correlate with larger RV size and worse RV function.

P3527Echocardiographic assessment of the right ventricle in chronic heart failure with focus on patients with atrial fibrillation

Abstract Background Assessment of the right ventricle (RV) in heart failure (HF) is challenging and requires applicable methods and parameters. Atrial fibrillation (AF) is a common and clinically significant arrhythmia in 30–50% of HF patients. Assessment of the RV function in patients with AF is problematic. Still little is known about RV function in HF and AF patients. The aim of the study was to assess RV function in HF with focus on AF patients. Methods Patients with HF of ischemic etiology, NYHA II-III, LVEF ≤40%, with AF and sinus rhythm (SR), underwent two- and three- dimensional echocardiography (2DE and 3DE) for assessment of the RV with use of multiple parameters. The RV was examined for: linear dimensions, end-diastolic and end-systolic areas adjusted to body surface area (RV EDA and RV ESA/BSA) and end-diastolic and end-systolic volumes adjusted to lean body mass (RV EDV and RV ESV/LBM) to reflect volume overload and in terms of right ventricular pressure (RVSP) as an index of pressure overload. RV systolic function was assessed with 2DE: tricuspid annular plane systolic excursion (TAPSE), right ventricular fractional area change (RV FAC), tricuspid lateral annular systolic velocity (s') and 3DE parameters: right ventricular ejection fraction (RVEF) and free wall right ventricular longitudinal strain (FW RVLS). Also, TAPSE/RVSP parameter was included. Results The study included 126 patients: 94 with AF and 32 with SR. Within the AF group 28 patients were treated medically, 41 had RV pacing (pacemaker or an implantable cardioverter-defibrillator, ICD) and 25 had cardiac resynchronisation therapy (CRT). In comparison with SR group AF patients had: larger RV inflow tract dimension (4.49±0.85 vs. 3.95±0.72 cm; p=0.0017), RV EDA/BSA (12.7±3.9 vs. 11.1±3.0 cm2/m2; p=0.0358) and RV ESA/BSA (8.0±3.0 vs. 6.7±2.4 cm2/m2; p=0.0226). Similarly, patients with AF had greater RV volumes in 3DE than patients with SR: RV EDV/LBM (1.82±0.60 vs. 1.61±0.38ml/kg, p=0.0267) and RV ESV/LBM (1.11±0.40 ml/kg vs. 0.81±0.28, p&lt;0,0001). Also, in patients with AF right ventricular systolic pressure (RVSP) was higher (40.8±10.2 vs. 34.0±8.1 mmHg, p=0,0010). No differences in TAPSE and RVFAC were found but the relation TAPSE/RVSP was higher in AF than in SR group (0.51±0.21 vs. 0.65±0.24 cm/mmHg; p=0.0046). Also, in AF patients in comparison to SR group some parameters had worse values: s' (9.7±2.31 vs. 12.1±3.83, p=0.014), RVEF (37.2±7.3 vs. 48.2±7.5, p&lt;0.0001 and FW RVLS (−18.3±4.6 vs. −23.9±4.23%, p&lt;0,0001). Within the AF group no significant differences in studied variables depending on RV pacing or CRT were found. Conclusions Larger volumes and higher pressure overload of the RV were observed in patients with AF in comparison to SR. Systolic function of the RV seems to be more depressed in AF compared to SR patients with systolic heart failure. Further research in larger groups is required to identify the most applicable and valuable methods of RV evaluation.

Echocardiographic assessment of right ventricle adaptation to endurance training in young rowers - speckle tracking echocardiography.

The aim of this study was to determine the relationship between the degree of cardiorespiratory fitness and the function of the right ventricle (RV). 117 rowers, age 17.5±1.5 years. All subjects underwent cardiopulmonary exercise. Standard echocardiography and 2D speckle tracking echocardiography with evaluation of longitudinal strain in each segment of the RV (basal – RVLS-B; mid – RVLS-M, apical – RVLS-A) and global RV free-wall strain (RVLS-G) were performed. RVLS-B values were lower compared to the RVLS-M (-25.8±4.4 vs -29.3±3.5; p<0.001) and RVLS-A values (-25.8±4.4 vs -26.2±3.4; p=0.85). Correlations between VO2max and RVLS were observed in men: RVLS-G strain (r = 0.43; p <0.001); RVLS-B (r = 0.30; p = 0.02); RVLS-M (r = 0.38; p = 0.02). A similar relationship was not observed in the group of women. The strongest predictors corresponding to a change in global and basal strain were VO2max and training time: RVLS-G (VO2max: β = 0.18, p = 0.003; training time: β = -0.39; p = 0.02) and RVLS-B (VO2max: β = 0.23; p = 0.0001 training time: β = -1.16; p = 0.0001). The global and regional reduction of RV systolic function positively correlates with the level of fitness, and this relationship is observed already in young athletes. The character of the relationship between RV deformation parameters and the variables that determine the physical performance depend on gender. The dependencies apply to the proximal fragment of the RV inflow tract, which may be a response to the type of flow during exercise in endurance athletes.

Ventricular structure in ARVC: going beyond volumes as a measure of risk

BackgroundAltered right ventricular structure is an important feature of Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC), but is challenging to quantify objectively. The aim of this study was to go beyond ventricular volumes and diameters and to explore if the shape of the right and left ventricles could be assessed and related to clinical measures. We used quantifiable computational methods to automatically identify and analyse malformations in ARVC patients from Cardiovascular Magnetic Resonance (CMR) images. Furthermore, we investigated how automatically extracted structural features were related to arrhythmic events.MethodsA retrospective cross-sectional feasibility study was performed on CMR short axis cine images of 27 ARVC patients and 21 ageing asymptomatic control subjects. All images were segmented at the end-diastolic (ED) and end-systolic (ES) phases of the cardiac cycle to create three-dimensional (3D) bi-ventricle shape models for each subject. The most common components to single- and bi-ventricular shape in the ARVC population were identified and compared to those obtained from the control group. The correlations were calculated between identified ARVC shapes and parameters from the 2010 Task Force Criteria, in addition to clinical outcomes such as ventricular arrhythmias.ResultsBi-ventricle shape for the ARVC population showed, as ordered by prevalence with the percent of total variance in the population explained by each shape: global dilation/shrinking of both ventricles (44 %), elongation/shortening at the right ventricle (RV) outflow tract (15 %), tilting at the septum (10 %), shortening/lengthening of both ventricles (7 %), and bulging/shortening at both the RV inflow and outflow (5 %). Bi-ventricle shapes were significantly correlated to several clinical diagnostic parameters and outcomes, including (but not limited to) correlations between global dilation and electrocardiography (ECG) major criteria (p = 0.002), and base-to-apex lengthening and history of arrhythmias (p = 0.003). Classification of ARVC vs. control using shape modes yielded high sensitivity (96 %) and moderate specificity (81 %).ConclusionWe presented for the first time an automatic method for quantifying and analysing ventricular shapes in ARVC patients from CMR images. Specific ventricular shape features were highly correlated with diagnostic indices in ARVC patients and yielded high classification sensitivity. Ventricular shape analysis may be a novel approach to classify ARVC disease, and may be used in diagnosis and in risk stratification for ventricular arrhythmias.

Accurate and reproducible measurements of right ventricular function in daily practice.

REFER TO THE PAGE 113-120 Traditionally right ventricle (RV) has been considered as a conduit or passive-dependent chamber mainly affected by loading conditions.1) Therefore, except for special situations such as pulmonary hypertension or complex congenital heart disease, main interest has been focused on left ventricle (LV).2) One of the reasons of eagerness for left sided parameters may come from complexity of RV morphology and different movement of RV during systole and diastole compared to LV.3) Therefore accurate measurement of RV volume and function in daily practice has lots of barriers to overcome. However, more and more evidences have suggested RV myocardial function itself has independent prognostic value not only in primary RV disease but also in LV diseases such as dilated cardiomyopathy or ischemic cardiomyopathy.4),5) Therefore need for reporting RV function is increasing in several disease entities. The causes of RV dysfunction in LV dysfunction can be explained by multiple mechanisms. Firstly, LV failure increase in pulmonary venous and arterial pressure, partly as a protective mechanism against pulmonary edema, then induce RV dysfunction; secondly, the same cardiomyopathy process may simultaneously affect the RV; thirdly, RV myocardial ischemia due to concomitant coronary artery disease; fourthly, ventricular inter-dependence due to septal dysfunction or limited pericardial compartment.3) RV dysfunction ultimately cause systemic venous congestion and reduced renal perfusion, thereby it deteriorates neurohormal status.6) Current gold standard for accurate measurements of RV systolic function is cardiac magnetic resonance imaging (CMR)-derived ejection fraction from stacked short axis cine images scanned with steady-state free precession sequence.7) The most advantage of CMR is accurate 3-dimensional measurements of RV systolic and diastolic volume without geometric assumption. However, CMR-derived RV volume measurement takes time and needs more learning period than conventional 2-dimensional echocardiographic measurements because of handling of RV inflow plane and outflow plane. Most of all, patients need undergo additional expensive exam. In this point of view easy and reproducible way of measurements are deadly needed with conventional echocardiography. Currently, RV fractional area change, tricuspid annular plane systolic excursion (TAPSE) and tricuspid annular velocity are widely used.8) However, RV fractional area change has limitations in terms of poor endocardial border delineation and negligence of geometric change. As RV changes from eccentric-crescent shape to oval shape as increase in preload or afterload, this limitation might be augmented in really sick RV. Easy and practical method is measurement of TAPSE or tricuspid annular velocity by tissue Doppler imaging based on concept that the RV long axis fiber movements mainly contribute to systolic function. But these two parameters are largely affected by tethering motion of adjacent myocardium. Speckle tracking echocardiography or velocity vector imaging can provide index of longitudinal myocardial deformation by escaping tethering effects.9),10) In this issue, Park et al.11) introduced global longitudinal strain of RV with validation by comparison with CMR-derived RV ejection fraction. One of the interesting findings of the study is that the investigators used vendor independent analyzing software, velocity vector imaging. With applying this program, RV strain can be measured during every conventional echocardiography examination. Algorithm of the tracking system has advantages for measuring longitudinal strain in thin walled myocardium such as RV or left atrium. But, in this study, the authors skipped assessment of inter-vendor measurements variability with an analyzing software. Although the authors commented in the limitation, this step should be done and clarified before using these results in daily practice, because we need specific cut-off value for RV dysfunction which can be used in any vendors like ejection fraction. Regarding prediction of outcome, RV strain measured by vendor independent program should show incremental value to left sided parameters which is more reproducible and more widely used in daily practice. On the point of view, if this study could have included LV strain, the result would be more solid. Inclusion of EuroScore II12) as a compact covariate for multivariable analysis seems reasonable in the situation of small number of study end-points. Despite some limitations, the study results can provide new way of accurate and convenient RV functional measurements in busy echo-lab.

Clinical utility gene card for: arrhythmogenic right ventricular cardiomyopathy (ARVC).

Name of the disease (synonyms) Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inheritable disease characterized by structural and functional abnormalities of the right ventricle (RV), with or without concomitant left ventricular (LV) disease. The diagnosis ARVC is made when a patient fulfils the recently revised criteria. Criteria encompass global and/or regional dysfunction and structural changes; repolarization abnormalities; depolarization and conduction abnormalities; arrhythmias; family history/the results of genetic testing; and tissue characterization by endomyocardial biopsy. Either localized or diffuse atrophy, with subsequent replacement by fibrous and fatty tissue mainly of the RV outflow tract, RV inflow tract and RV apex (‘triangle of dysplasia’) represent the histopathological characteristics of ARVC. Synonyms: arrhythmogenic right ventricular dysplasia (ARVD); arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D); arrhythmogenic cardiomyopathy (ACM); arrhythmogenic left-dominant cardiomyopathy; and arrhythmogenic LV cardiomyopathy (ALVC). OMIM# of the disease 107970; 600996; 602086; 602087; 604400; 604401; 607450; 609040; 610193; 610476; 611528. Name of the analyzed genes or DNA/chromosome segments (1) Cytoskeletal protein genes: (a) Desmin gene (DES), locus 2q35#; (b) Titin gene (TTN), locus 2q31.2#. (2) Nuclear envelope protein genes: (a) Lamin A/C gene (LMNA), locus 1q22#. (3) Desmosomal protein genes: (a) Desmocollin 2 gene (DSC2), locus 18q12.1; (b) Desmoglein 2 gene (DSG2), locus 18q12.1; (c) Desmoplakin gene (DSP), locus 6p24.3; (d) Junction plakoglobin gene (JUP), locus 17q21.2; (e) Plakophilin 2 gene (PKP2), locus 12p11.21. (4) Calcium/sodium-handling genes: (a) Phospholamban gene (PLN), locus 6q22.31#; (b) Ryanodine receptor 2 gene (RYR2), locus 1q43*. (5) Other genes: (a) Alpha-T-catenin (CTNNA3), locus 10q21.3#; (b) Transforming growth factor-β3 (TGFβ3), locus 14q24.3*; (c) Transmembrane protein 43 (TMEM43), locus 3p25.1. #Indicates gene not yet annotated as ARVC related in the OMIM database; *indicates the involvement of these genes is based on single publications and therefore controversial. OMIM# of the gene(s) (1) Cytoskeletal protein genes: (a) 125660 and (b) 188840#. (2) Nuclear envelope protein genes: (a) 150330#. (3) Desmosomal protein genes: (a) 125645; (b) 125671; (c) 125647; (d) 173325; and (e) 602861. (4) Calcium/sodium-handling genes: (a) 172405# and (b) 180902*. (5) Other genes: (a) 607667#; (b) 190230*; and (c) 612048. #Indicates gene not yet annotated as ARVC related in the OMIM database; *denotes the involvement of these genes is based on single publications and therefore controversial.

Eliminating Ventricular Tachycardia by Targeting Premature Ventricular Contractions in Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy

Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is an electrophysiological curiosity. Unlike most forms of ventricular tachycardia (VT) due to a structural pathogenesis, it commonly originates from the right ventricle (RV) rather than the left ventricle, and in contrast to most forms of malignant ventricular arrhythmias due to a molecular defect, ARVD/C develops from mutations in desmosomal proteins rather than ion channels. Therefore, ARVD/C stands alone as an example of a cardiomyopathy, which is expressed primarily in the RV and is associated with VT and sudden cardiac death. Article see p 160 In general, ARVD/C is an autosomal dominant disease. The precise correlation between mutations in desmosomal proteins and disease expression is unclear, but desmosomal proteins are integral to cell adhesion, are involved with transcriptional regulation of genes that govern adipogenesis and apoptosis, and facilitate electrical conductivity between cells through regulation of gap junctions.1 Pathologically, there is a progressive loss of cardiomyocytes with fibrofatty replacement. Although initially confined to the RV, and in particular, to the RV inflow tract, the RV outflow tract and apex, progression of fibrofatty replacement in the remainder of the RV and left ventricle may occur. This process begins in the subepicardium and midmyocardium, and subsequently migrates to the subendocardium. Because of the presence of patchy scar interspersed with normal myocardium, the demonstration of entrainment during tachycardia, as well as the presence of anatomic barriers like the tricuspid annulus, re-entry is well established as the arrhythmogenic mechanism of VT in ARVD/C.2 Most, but not all, of these circuits are due to macroreentry, with a minority due to focal re-entry.3,4 The study by Philips et al5 in this issue of the journal suggests that activation mapping and pace mapping of frequent premature ventricular contractions (PVCs) can identify focal sites where successful ablation of …

Organised right ventricular remodelling in aortic stenosis even after valve replacement

Organised right ventricular remodelling in aortic stenosis even after valve replacement

267: Multiparametric assessment of the Right Ventricle by echography in patients with repaired Tetralogy of Fallot undergoing pulmonary valve replacement: a comparative study with MRI

Evaluation of the right ventricle (RV) using echography is challenging in patients with repaired Tetralogy of Fallot (rTOF). The objective of this study was to evaluate the feasibility and the accuracy of a multiparametric echographic approach including 2D strain and 3D for RV volumes and function assessment, in comparison with MRI. we performed an echographic study including 2D TAPSE, S’TDI, Tei indice, Fractional area change (FAC)), 2D strain and 3D, and an MRI in 26 consecutive patients with rTOF before PVR and one year after surgery. TAPSE, S’ TDI and 2D strain parameters were poorly correlated with MRI regarding RV function assessment. FAC was well correlated with REVF before and after PVR (r=0.70, p<0.01and r=0.68, p<0.01, respectively). Despite RV volumes underestimation, 3D analysis was well correlated with MRI values in both pre and post-operative assessment (r=0.88, p<0.01 and r=0.91, p<0.01 respectively for RVEDV; r=0.92, p<0.01 and r=0.95, p<0.01 respectively for RVESV). Global approach of RV function using 2D (FAC) or (3D) parameters seems reliable in patients with rTOF. The commonly used TAPSE and S’TDI focused on segmental analysis of RV inflow are less sensitive probably because RV inflow is less affected by RV remodelling related to initial surgical repair.

Pulmonary hypertension: role of septomarginal trabeculation and moderator band complex assessed by cardiac magnetic resonance imaging

In the right ventricle (RV), the septomarginal trabecula (SMT) arises as a muscular band originating from the interventricular septum (IVS) at the lower segment of the crista supraventricularis. It forms a functional unit with the moderator band, which attaches to the lateral free wall of the RV [1, 2]. Strategically situated between the RV inflow and outflow tracts, the whole unit serves to help emptying blood into the pulmonary trunk during systole. Thus, it should be anticipated that the SMT may undergo changes in RV hypertrophy secondary to chronic pulmonary hypertension.

Heart Failure in Children

Why is heart failure in children important? If we just consider the number of individuals affected, adult heart failure is clearly a more compelling public health problem. However, the relatively small numbers belie the overall economic and social impact of pediatric heart failure. When a child is admitted to the hospital for heart failure, the costs are considerably higher for children than adults because of the frequent need for surgical or catheter-based intervention. The demands of medical care can fray the family structure and adversely affect parental economic productivity. When a child dies of heart failure, the economic impact is magnified enormously because of the number of potentially productive years lost per death. For these and other reasons, heart failure in children is a serious public health concern. In addition, growing numbers of children with heart failure are reaching adulthood because of the successful application of medical and surgical heart failure therapies and the improved outcomes of congenital heart surgery. A greater understanding of the pathophysiology of heart failure in childhood may help inform therapeutic strategies once these children become adults. Furthermore, given the recent explosion of research in the impact of cardiac development and cardiogenetics on pediatric cardiovascular disease, it is not outside the realm of possibility for a pediatric discovery to be made that will also benefit adults with heart failure. We may not yet be able to agree on a definition of heart failure, but the cardinal symptoms, dyspnea, anasarca (“dropsy”), and cachexia, were well recognized in antiquity.1 These symptoms were not specific for cardiac pathology, and it was not until the 17th century, when William Harvey definitively identified the heart as an organ that pumped blood rather than generating heat, that the heart could begin to be understood as a source of dyspnea, edema, and …

Prenatal Diagnosis of Ebstein's Anomaly

Ebstein’s anomaly accounts for 0.5% of all congenital heart diseases. The condition is characterized by >8 mm/m2 displacement of the septal and posterobasal tricuspid leaflets toward the apex of the right ventricle (RV). This causes “atrialization” of the RV inflow tract, with decreased size of the RV and right atrial (RA) dilatation. The anterior valve is rarely displaced, but tends to be large and redundant. Associated tricuspid regurgitation (TR) and atrial shunt are common. Fetal echocardiography allows the diagnosis of Ebstein disease and is an aid to planning management of the condition during gestation and after birth. Pulmonary hypoplasia, severe TR, and pericardial effusion are signs of a poor prognosis. We present the case of a 21-week-gestation fetus referred for atrial dilatation. Fetal echocardiography showed a horizontally oriented heart, severe cardiomegaly with right cavity predominance, and considerable RA dilatation. A pronounced, 4.6-mm separation (S) was seen between the tricuspid and mitral valves. The mitral IMAGES IN CARDIOLOGY

Guidelines for Performing a Comprehensive Epicardial Echocardiography Examination: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists

TABLE OF CONTENTSIntroduction 921General Guidelines 922Training and Certification 922Indications for TEE 923Management of Patient Sedation 927Sedation and Anesthesia 929Probe Insertion Techniques 930Instrument Controls 930Instrument Manipulation 931Comprehensive Imaging Examination 932ME Views 932TG

Guidelines for Performing a Comprehensive Epicardial Echocardiography Examination: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists

Scott T. Reeves, MD, FASE, Kathryn E. Glas, MD, FASE, Holger Eltzschig, MD, Joseph P. Mathew, MD, FASE, David S. Rubenson, MD, FASE, Gregg S. Hartman, MD, and Stanton K. Shernan, MD, FASE, for the Council for Intraoperative Echocardiography of the American Society of Echocardiography, Charleston, South Carolina; Atlanta, Georgia; Tubingen, Germany; Durham, North Carolina; La Jolla, California; and Lebanon, New Hampshire

Tricuspid Annular Velocity in Patients Undergoing Cardiac Operation Using Transesophageal Echocardiography

The complex geometry of the right ventricle (RV) and poor endocardial definition make quantitative assessment of RV function difficult. Doppler tissue imaging may be helpful in quantifying RV function through measurement of tricuspid annular velocity (TAV). This prospective study assessed the feasibility of using color Doppler tissue imaging to measure TAV using a novel transgastric RV inflow view in patients undergoing cardiac surgery. We used the transgastric RV inflow view and measured the TAV using Doppler tissue imaging and quantitative analysis software. We also measured left ventricular fractional area of contraction and hemodynamic variables. We compared values before and after cardiopulmonary bypass in patients undergoing coronary artery bypass graft. TAV could be measured in 19 of 23 patients (83%) undergoing coronary artery bypass graft. There was a significant decrease postbypass in TAV: isovolumic acceleration was 1.71 +/- 0.59 versus 1.32 +/- 0.66 m/s2, isovolumic velocity was 4.34 +/- 1.19 versus 3.13 +/- 1.35 cm/s, and systolic annular descent velocity was 5.15 +/- 1.15 versus 3.77 +/- 1.18 cm/s. There was a significant change in heart rate and cardiac index without any change in stroke volume index. There was no change in left ventricular function (fractional area of contraction: 54 +/- 10 vs 52 +/- 10%). Determination of TAV using the transgastric RV inflow view is feasible and may provide quantitative information on systolic RV function in patients undergoing coronary artery bypass graft. We found a decrease in systolic TAV after cardiopulmonary bypass without a significant change in stroke volume index.