Right Ventricle Pulmonary Artery Research Articles

Isoproterenol improves hemodynamics and right ventricle-pulmonary artery coupling after heart transplantation.

Right ventricular failure (RVF) is a major cause of early mortality after heart transplantation (HT). Isoproterenol (Iso) has chronotropic, inotropic, and vasodilatory properties, which might improve right ventricle function in this setting. We aimed to investigate the hemodynamic effects of isoproterenol on patients with post-HT RVF. We conducted a 1-yr retrospective observational study including patients receiving isoproterenol (Iso) and dobutamine for early RVF after HT. A comprehensive multiparametric hemodynamic evaluation was performed successively three times: no isoproterenol, low doses: 0.025 µg/kg/min, and high doses: 0.05 µg/kg/min (henceforth, respectively, called no Iso, low Iso, and high Iso). From June 2022 to June 2023, 25 patients, median [interquartile range (IQR) 25-75] age 54 [38-61] yr, were included. Before isoproterenol was introduced, all patients received dobutamine, and 15 (60%) were on venoarterial extracorporeal membrane oxygenation (VA-ECMO). Isoproterenol significantly increased heart rate from 84 [77-99] (no Iso) to 91 [88-106] (low Iso) and 102 [90-122] beats/min (high Iso, P < 0.001). Similarly, cardiac index rose from 2.3 [1.4-3.1] to 2.7 [1.8-3.4] and 3 [1.9-3.7] L/min/m2 (P < 0.001) with a concomitant increase in indexed stroke volume (28 [17-34] to 31 [20-34] and 33 [23-35] mL/m2, P < 0.05). Effective pulmonary arterial elastance and pressures were not modified by isoproterenol. Pulmonary vascular resistance (PVR) tended to decrease from 2.9 [1.4-3.6] to 2.3 [1.3-3.5] wood units (WU), P = 0.06. Right ventricular ejection fraction/systolic pulmonary artery pressure (sPAP) evaluating right ventricle-pulmonary artery (RV-PA) coupling increased after isoproterenol from 0.8 to 0.9 and 1%·mmHg-1 (P = 0.001). In conclusion, in post-HT RVF, isoproterenol exhibits chronotropic and inotropic effects, thereby improving RV-PA coupling and resulting in a clinically relevant increase in the cardiac index.NEW & NOTEWORTHY This study offers a detailed and comprehensive hemodynamic investigation at the bedside, illustrating the favorable impact of isoproterenol on right ventricular-pulmonary arterial coupling and global hemodynamics. It elucidates the physiological effects of an underused inotropic strategy in a critical clinical scenario. By enhancing cardiac hemodynamics, isoproterenol has the potential to expedite right ventricular recovery and mitigate primary graft dysfunction, thereby reducing the duration of mechanical support and intensive care unit stay posttransplantation.

Qp/Qs in ostium secundum atrial septal defect mitigates right ventricular dysfunction in patients with secondary pulmonary hypertension

Abstract Background Ostium-secundum atrial septal defect (OS-ASD) can potentially lead to pulmonary hypertension (PH) and associated right ventricle (RV) - pulmonary artery (PA) uncoupling. This, in turn, may eventually result in RV systolic dysfunction. Notwithstanding, whether the characteristics of the OS-ASD could mitigate this relationship is unclear. Purpose To evaluate a potential interaction of the OS-ASD shunt (Qp/Qs ratio) on the relationship with RV–PA coupling and RV systolic function in patients with secondary PH. Methods We designed a cross-sectional study of 63 adult patients with OS-ASD in which we performed a conventional transthoracic echocardiogram using Vivid 9X-clear equipment (GE Vingmed Ultrasound, Horten, Norway). We evaluated the OS-ASD shunt and other echocardiographic parameters, including the tricuspid annular plane systolic excursion (TAPSE), the systolic pulmonary artery pressure (sPAP) ratio and the right ventricular free wall longitudinal strain (RVFWLS). Polynomic adjusted correlations were performed to model the relationship between the TAPSE/sPAP ratio and the RVFWLS, then we evaluated an interaction effect of the OS-ASD shunt (Qp/Qs ratio), respectively adjusted for age, sex, body mass index, body surface area and right atrial area. Results In our study, 49 (78%) subjects were male, with a mean age of 41.8 (±15) years; 7.94% (n=5) had mild PH, 42.9% (n=27) had moderate PH and 49.2% (n=31) had severe PH. Mean echocardiographic parameters were: TAPSE 24.5 (±5.1) mm , sPAP of 55.9 (±20.7) mmHg, TAPSE/sPAP 0.49 (±0.2) mm/mmHg, RVFWLS -25.6 (±6.6) % and Qp/Qs 2.9 (±0.9). We observed a quadratic relationship between the TAPSE/sPAP ratio and the RVFWLS (r=0.691, p &amp;lt; 0.001; Figure 1). OS-ASD shunt had a positive interaction effect (β=10.9, 95% CI: 2.09-19.6, p=0.018) on the relationship between TAPSE/sPAP and RVFWLS after adjusting for covariates (Figure 2). Conclusions In conclusion, in patients with OS-ASD, the RV systolic function decreases as the RV-PA uncoupling increases, as reflected in the quadratic regression between the TAPSE/sPAP and the RVFWLS. Moreover, the increase in OS-ASD shunt decreases RVFWLS values in relationship to the TAPSE/sPAP ratio as observed in the interaction model. These results could suggest that the OS-ASD characteristics could potentially mitigate RV dysfunction in patients with secondary PH.Figure 1.Quadratic regressionFigure 2.Interaction model

Right ventricular myocardial work by echocardiography: non-invasive assessment of right ventricle function in patients with pulmonary hypertension

Abstract Background Right ventricular myocardial work (RVMW) assessed by transthoracic echocardiography allows to study and analyze the right ventricular (RV) function non-invasively, using RV pressure-strain loops. The association between these novel indexes of RVMW and invasive hemodynamic parameters has not yet been extensively studied, namely in precapillary pulmonary hypertension (PH) population. In right heart catheterization, stroke volume directly reflects right ventricular function in response to its load, and has prognostic implication in PH. Objectives To evaluate the relationship between RVMW and stroke volume index (SVi) measured invasively by right heart catheterization (RHC), in a cohort of patients with group I and group IV PH. Methods A prospective registry of pre-capillary PH patients evaluated in a single tertiary center was used. Echocardiography and RHC were performed in the same day. Dedicated software for left ventricle myocardial work was used for the RV. RV global myocardial work index (RVGWI) was calculated as the area of the RV pressure-strain loops. From RVGWI, RV global constructive work (RVGCW; work contributing to myocardial shortening during systole and lengthening during isovolumic relaxation), RV global wasted work (RVGWW; work contributing to myocardial lengthening during systole and shortening during isovolumic relaxation), and RV global work efficiency (RVGWE; relation between RVGCW and RVGWW) were estimated. Pearson’s correlation was applied to assess correlations between continuous variables. Results 17 pts (80% women, mean age 67 ± 10 years) were included. The average of mean pulmonary arterial pressure (mPAP) was 33 mmHg (± 9,5), of pulmonary vascular resistance (PVR) was 5,7 WU (± 5,1) and of SVi was 40,7 ml/m2 (± 10,8). Conventional echocardiographic parameters for the evaluation of RV systolic function, such as TAPSE, annular tricuspid s’ velocity and fractional area change (FAC), did not correlate with SVi. Moreover, right ventricle-pulmonary artery (RV-PA) coupling and RV GLS also did not correlate with this invasive parameter of right ventricle function. Of the RVMW indexes, RVGWW and RVGWE strongly correlated with SVi: as this invasive parameter decreases, RVGWW (r = -0,560, p = 0,019) increases significantly, whereas RVGWE (r= 0,539, p = 0,026) declines (Fig 1). In our population, RVGWI and RVGCW didn’t correlate significantly with SVi. Conclusions Finding non-invasive methods to evaluate RV function is essential in patients with RV hemodynamic overload, since conventional echocardiographic parameters do not perform well, and RV function is central in prognosis assessment in this population. Novel echocardiographic assessment of RVMW seems to provide a promising index of RV function in PH patients, as demonstrated with its correlation with SVi.Figure 1:Correlation of RVMW with SVi.

Association between postoperative exposure to fine particulate matter and patency of the right ventricle–pulmonary artery conduit

BackgroundAmbient air pollution is a leading risk factor for cardiovascular diseases. No study has investigated the association between exposure to fine particulate matter <2.5 μm in aerodynamic diameter (PM2.5) and the prognosis of patients undergoing surgery for the right ventricle–pulmonary artery (RV-PA) conduit. MethodsFrom 2013 to 2020, patients with six complicated congenital heart defects who had undergone surgery for the RV–PA conduit were selected. Four conduit materials were used: bovine jugular vein graft (BJV), pulmonary homograft (PHG), aortic homograft (AHG), and handmade tri-leaflet expanded polytetrafluoroethylene (ePTFE) conduit. Telephone interviews were used to confirm the postoperative address of patients. The monthly average PM2.5 concentration was obtained from the ChinaHighPM2.5 dataset using the place of residence of patients. By comparing findings of echocardiography undertaken before patients' return to their residence and during re-examination, we defined an increase in the trans-conduit peak velocity of ≥1.5 m/s as the study endpoint. ResultsWe enrolled 232 patients. Compared with BJV conduits, homografts (AHGs and PHGs) (0.052 (95 % CI = 0.005–0.558), P = 0.015) and ePTFE conduits (0.009 (95 % CI = 0.002–0.054), P < 0.001) were protective factors. The cumulative monthly PM2.5 concentration (10 μg/m3) was a risk factor (1.014 (95 % CI = 1.001–1.026), P = 0.028). Winter experience was a risk factor (1.971 (95 % CI: 1.021–3.804), P = 0.043). In the subgroup analysis, Spearman correlation analysis indicated BJV conduits (r = 0.680, P < 0.001), PHGs (r = 0.559, P = 0.020), and AHGs (r = 0.745, P = 0.021) had medium-to-high positive correlations between the cumulative PM2.5 concentration and change in the conduit velocity. For ePTFE, the correlation was weak and not significant (r = 0.222, P = 0.073). ConclusionsPostoperative exposure to PM2.5 affects the patency of biologic prosthetic conduits (especially xenografts). The increase in the velocity of the ePTFE conduit is not associated with PM2.5 exposure, and is a suitable material for patients living in areas with high pollutant concentrations.

New 2022 ESC/ERS definition of pulmonary hypertension: can we rely on the same non-invasive echocardiographic parameters?

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The hemodynamic definition of pulmonary hypertension (PH) has been updated, with lowering of the mean pulmonary arterial pressure (mPAP) threshold from 25 to 20 mmHg according to the new 2022 ESC/ERS Guidelines. Although there is no single echocardiographic parameter that reliably informs about PH status, some of the echocardiographic parameters cut-offs remained the same, including a peak tricuspid regurgitation velocity (PTRV) &amp;gt;2.8m/s. The potential underdiagnosis of PH has not been evaluated. Objectives To evaluate the screening power of the standard echocardiographic parameters to detect PH according to the new guidelines and to establish new predictors. Methods A prospective registry of consecutive intermediate-high- and high-risk PE pts submitted to CDT in a single tertiary center was used. 3 months after the procedure, the patients were submitted to a right heart catheterization and echocardiogram to screen chronic thromboembolic pulmonary hypertension (CTEPH). According to new PH criteria, patients were divided in two groups, and echocardiographic parameters were analyzed regarding their predictive power. A ROC curve analysis was performed to evaluate optimal cut-offs in predicting PH according the new guidelines. Results 17 pts (60% women, mean age 59 ± 16 years) were included. Among these, 7 pts (41,2%) were diagnosed with pre-capillary PH by RHC at 3 months of follow-up. Among echocardiographic parameters, PTRV (p 0.015), presence of tricuspid regurgitation (0.034) and right ventricle-pulmonary artery (RV-PA) coupling (p 0.041) were significantly different between groups (Fig 1 A). Other parameters, such as right ventricle dilation (p 0.849), TAPSE (p 0.100), annular tricuspid s’ velocity (p 0.646), right ventricle outflow tract acceleration time (p 0.229) and the presence of pericardial effusion (p 0.849) did not show significant differences. Regarding the PTRV, a ROC curve analysis revealed an PTRV optimal cut-off of 2.6 m/s (pressure gradient 27mmHg) in our population (AUC 0.911, p 0.030, Sn 71.4%, Sp 100%), compared to the conventional cut-off of 2.8 m/s (pressure gradient 31 mmHg) (p 0.470, Sn 28.6%, Sp 100%). The use of PTRV &amp;gt; 2.6 m/s allows to reduce false negatives without losing specificity (Fig 1 B, C and D). Conclusion With the recent update in PH criteria, the use of the conventional PTRV cut-off leads to a significant underdiagnosis in our population. Lowering the PTRV threshold seems to increase sensitivity, without losing specificity. Other standard echocardiographic parameters did not seem to predict accurately the presence of PH.

Right ventricular myocardial work characterization in patients with pulmonary hypertension and association with pulmonary hypertension severity

Abstract Funding Acknowledgements Type of funding sources: None. Background Right ventricular myocardial work (RVMW) assessed by transthoracic echocardiography allows to study and analyze the right ventricular (RV) function non-invasively, using RV pressure-strain loops. The association between these novel indexes of RVMW and invasive hemodynamic parameters has not yet been extensively studied, namely in precapillary pulmonary hypertension (PH) population. Objectives To evaluate the relationship between RVMW and the severity of PH through invasive indices of right heart catheterization (RHC) in a cohort of patients with group I and group IV PH. Methods A prospective registry of pre-capillary PH patients evaluated in a single tertiary center was used. Echocardiography and right heart catheterization were performed in the same day. Dedicated software for left ventricle myocardial work was used for the RV. RV global myocardial work index (RVGWI) was calculated as the area of the RV pressure-strain loops. From RVGWI, RV global constructive work (RVGCW; work contributing to myocardial shortening during systole and lengthening during isovolumic relaxation), RV global wasted work (RVGWW; work contributing to myocardial lengthening during systole and shortening during isovolumic relaxation), and RV global work efficiency (RVGWE; relation between RVGCW and RVGWW) were estimated. Pearson’s correlation was applied to assess correlations between continuous variables. Results 17 pts (80% women, mean age 67 ± 10 years) were included. Conventional echocardiographic parameters for the evaluation of RV systolic function, such as TAPSE, annular tricuspid s’ velocity and fractional area change (FAC), did not correlate with mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR). Strong correlations were found between right ventricle-pulmonary artery (RV-PA) coupling and mPAP (r = -0,655, p = 0,006) and RVP(r = - 0,610, p = 0,017), as well as with RV GLS (r = 0,749, p = 0,001 and r = 0,622, p = 0,01, respectively). Of the RVMW indexes, RVGWI, RVGWW and RVGWE strongly correlated with mPAP and PVR: as these invasive parameters increase, RVGWI (r = -0,581, p = 0,015 and r = -0,536, p = 0,027, respectively) and RVGWE (r = -0,779, p &amp;lt; 0,001 and r = -0,773, p &amp;lt; 0,001, respectively) decline significantly, whereas RVGWW (r = 0,735, p = 0,001 and r = 0,800, p &amp;lt; 0,001) increases. In our population, only RVGCW didn’t correlate significantly with high afterload (r= −0,304, p = 0,235 for mPAP, and r = -0,181, p = 0,488 for RVP). Conclusions New methods to evaluate RV function are crucial in patients with RV hemodynamic overload, since conventional echocardiographic parameters do not perform well. Novel echocardiographic assessment of RVMW are associated with severity of PH in our population.

Cardiac Computed Tomographic Angiography Evaluation of Right Ventricle-Pulmonary Artery Conduits with Surgical Correlation.

Right ventricle-pulmonary artery (RV-PA) conduits are used in the treatment of certain congenital heart disease (CHD). RV-PA conduit complications might develop over time and require intervention. To evaluate how well cardiac computed tomographic angiography (CCTA) performs compared to transthoracic echocardiography (TTE) in evaluating RV-PA conduit complications by using surgical findings as the reference standard. A retrospective chart review of all patients over a 5-year period who underwent CCTA for RV-PA conduit evaluation was performed. Patient demographics and clinical data were recorded. Preoperative CCTA and TTE findings were compared to the operative findings for concordance or discordance. Forty-one patients were included, 51% females. The complications were conduit stenosis (28.68%), infection (7.17%) and aneurysm/pseudoaneurysm (6.15%). TTE and CCTA were consistently able to visualize focal conduit stenosis (96%). The greatest discrepancy between TTE and CCTA was in evaluating for aneurysm/pseudoaneurysm, where TTE detected only 2/6 (33%) compared to CCTA which detected 6/6 (100%) of the cases. However, TTE was slightly better at detecting conduit infection (3/7, 43%) compared to CCTA (2/7, 29%). Note that 5 out of 7 patients with endocarditis had bovine jugular graft. CCTA and TTE provide similar diagnostic accuracy evaluating certain types of RV-PA conduit complications. However, certain complications were only visualized on CCTA or TTE making both modalities complementary to each other during diagnostic evaluation.

Vanillic Acid Alleviates Right Ventricular Function in Rats With MCT-Induced Pulmonary Arterial Hypertension

This study examined the molecular processes behind the effects of vanillic acid (VA) on right ventricular (RV) hypertrophy and function in rats with monocrotaline (MCT)-induced pulmonary arterial hypertension (PAH). There were 40 male Sprague‒Dawley (SD) rats that were separated into 4 groups: Control, PAH, MCT + VA (50 mg/kg/d), and MCT + VA (100 mg/kg/d). Male SD rats were injected with MCT once under the skin to create the PAH model (40 mg/kg). RV morphological properties were evaluated using Masson and hematoxylin and eosin (H&amp;E) staining. Echocardiography was used to evaluate RV functioning and right ventricle–pulmonary artery (RV-PA) coupling. In addition, Rho-associated protein kinase (ROCK) pathway-related factors were evaluated using Western blotting. Enzyme-linked immunosorbent assay (ELISA) was used to detect inflammatory markers as well as atrial natriuretic peptide (ANP) and brain-type natriuretic peptide (BNP) in the blood of PAH rats. As a result, VA effectively reduced the development of RV cardiomyocyte hypertrophy and fibrosis in PAH rats; levels of ANP, BNP, and inflammatory markers in the blood of PAH rats were also significantly decreased by VA intervention. Additionally, VA enhanced RV functioning and RV-PA coupling in PAH rats. In response to VA, the expression of proteins related to the ROCK pathway (ROCK1, ROCK2, NFATc3, P-STAT3, and Bax) was downregulated, whereas Bcl-2 expression was elevated. This study found that VA could attenuate RV remodeling and improve RV-PA coupling in PAH rats. RV remodeling and dysfunction may be linked to the dysregulation of the ROCK pathway, and the protective action of VA on RV function may be due to a block in the ROCK signaling pathway or its downstream signaling molecules.

A Simple Echocardiographic Approach in Assessing the Prognosis of Comatose Patients with Acute Intracerebral Hemorrhage by Using Right Ventricle-Pulmonary Artery Coupling.

It remains a challenge to judge whether comatose patients with acute intracerebral hemorrhage (ICH) can wake up. Here, we aimed to investigate the changes in right ventricle-pulmonary artery (RV-PA) coupling over time in these patients and to evaluate its performance for discriminating between those who woke up within 60days and those who did not. Thirty-five comatose patients with acute spontaneous ICH underwent bedside echocardiography on days 1, 3, and 5 after onset with the measurement of tricuspid annular plane systolic excursion and mean pulmonary artery pressure. The RV-PA coupling (the ratio of tricuspid annular plane systolic excursion to mean pulmonary artery pressure) was calculated. Within 60days of the onset of coma, 11 individuals awakened and survived, and 24 individuals died. In awakened patients, RV-PA couplings did not differ among days 1, 3, and 5 (1.62 ± 0.38 vs. 1.61 ± 0.32 vs. 1.64 ± 0.25mm/mm Hg, P > 0.05), whereas in unawakened patients, they decreased drastically from day 1 to day 3 and then to day 5 (1.26 ± 0.32 vs. 0.63 ± 0.05 vs. 0.43 ± 0.06mm/mm Hg, P < 0.05). The area under receiver operating characteristic curve of 0.992 for the ratio of RV-PA coupling on day 5 to day 1 of the coma was superior to that for the Glasgow Coma Scale (area under receiver operating characteristic curve of 0.606) in the discrimination of comatose patients with ICH who woke up within 60days from those who did not. The optimal cutoff value was 0.536, with a sensitivity of 100.00%, a specificity of 96.24%, and an accuracy of 97.13%. Right ventricle-pulmonary artery coupling demonstrated a high performance for discriminating comatose patients with ICH who woke up within 60days from those who did not.

Non-invasive assessment of right ventricular function and pulmonary pressures in cardiogenic shock remains challenging: don't pack away the PAC just yet

Abstract Background Cardiogenic shock (CS) is associated with high levels of morbidity and mortality despite advances in treatment. Patients with right ventricle (RV) dysfunction have been shown to have poorer outcomes. It is suggested that invasive monitoring through pulmonary artery catheter (PAC) placement can assist in guiding management to improve survival, though they are associated with adverse events. Purpose This study assessed the utility of non-invasive, echocardiographic assessment of RV performance and pulmonary artery pressures (PAP) in patients with CS. Methods Consecutive patients admitted to a North American quaternary cardiac intensive care unit who had PAC placement were recruited into this study. Invasive haemodynamic assessment was followed by transthoracic echocardiography (TTE) performed by a critical care cardiologist, blinded to the invasive measurements. TTE images were later reported by a second cardiologist, blinded to the invasive measurements and the patient. Correlations between RV and pulmonary invasive and non-invasive parameters were evaluated using Pearson's correlation. Results Overall, 96 assessments of 60 patients were compared. Patients were predominantly male (73%), aged 58±14 years and SCAI stage C (55%) and D (22%) at the time of assessment. Invasive measurements of right heart and pulmonary function was possible in all patients. Mean RAP was 8.5±4.7 mmHg, systolic PAP 37.5±9.9 mmHg, diastolic PAP 18.1±6.5 mmHg, mean PAP 25.1±7.2 mmHg, pulmonary capillary wedge pressure (PCWP) 16.0±16.4 mmHg, pulmonary vascular resistance (PVR) 157±99dyn s cm–5, RV stroke work index (RVSWI) 7.0±3.9 g min/m2 and PAP index (PAPi) 2.9±4.2. When compared to non-invasive echocardiographic parameters, there was little correlation with invasive values (Table). RVSWI moderately correlated with peak tricuspid regurgitation (TR) velocity, tricuspid annular plane systolic excursion (TAPSE) and estimated systolic PAP; while peak TR velocity was mild-moderately correlated with PAP and PCWP. No single non-invasive parameter demonstrated strong prediction of invasive values. Conclusion Non-invasive assessment of right heart and pulmonary haemodynamic parameters is of limited validity when compared with invasive monitoring through PAC in patients with CS. PAC remains the most reliable method of assessing the RV haemodynamic profile in CS. Future studies should evaluate the clinical benefit of invasive haemodynamic monitoring in this population. Funding Acknowledgement Type of funding sources: None.

Impact of Right Ventricle-Pulmonary Artery Coupling on Clinical Outcomes in the PARTNER 3 Trial.

Physiologic right ventricle-pulmonary artery (RV-PA) coupling may be impaired in patients with aortic stenosis (AS). This study aimed to assess the incidence and prognostic significance of impaired RV-PA coupling in low-risk patients with symptomatic severe AS undergoing transcatheter aortic valve replacement or surgical aortic valve replacement. RV-PA coupling was measured by transthoracic echocardiography as the ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) in patients in the PARTNER (Placement of Aortic Transcatheter Valve) 3 trial. The primary endpoint was the composite of all-cause mortality, stroke, and rehospitalization at the 2-year follow-up. Among 570 low-risk patients included in the analysis, RV-PA uncoupling was defined by a TAPSE/PASP ratio≤ 0.55mm/mmHg. At baseline, 222 of 570 (38.9%) patients had RV-PA uncoupling. At 2 years, patients with baseline RV-PA uncoupling had an increased incidence of the primary endpoint (19.1% vs 9.9%, P = 0.002), all-cause mortality (5.9% vs 0.6%, P< 0.001), cardiovascular mortality (4.1% vs 0.6%, P = 0.003), and rehospitalization (13.5% vs 7.3%, P = 0.018). On multivariable analysis, baseline RV-PA uncoupling remained an independent predictor of the primary endpoint at 2 years (HR: 1.92; 95%CI: 1.04-3.57; P = 0.038). In patients with symptomatic severe AS at low surgical risk undergoing transcatheter aortic valve replacement or surgical aortic valve replacement, baseline RV-PA uncoupling defined by TAPSE/PASP ≤ 0.55mmHg was associated with adverse clinical outcomes at 2 years, including all-cause mortality, cardiovascular mortality, and rehospitalization.

Effects of Cardiac Contractility Modulation Therapy on Right Ventricular Function: An Echocardiographic Study

Background. Cardiac contractility modulation (CCM) is a novel device-based therapy for patients with heart failure with reduced and mild reduced ejection fraction (HFrEF/HFmrEF). CCM increases cardiac performance and produces reverse left ventricular remodeling, with improved symptoms, functional capacity, quality of life, and reduced HF-related hospitalizations. However, to date, little evidence is available on the effects of CCM on right ventricle (RV) function. Therefore, we analyzed the effects of CCM on RV systolic function and RV–pulmonary artery (PA) coupling. Methods. Twenty-one (65 ± 12.5 years) patients with NYHA class III, ejection fraction &lt; 40% and QRS &lt; 120 ms were assessed at baseline. During follow up, two patients had died, and so nineteen patients were evaluated six months after CCM therapy. Using echocardiography, tricuspid annular systolic excursion (TAPSE), myocardial systolic excursion velocity (RVs), and RV free-wall strain was measured. PA systolic pressure (PASP) was estimated from tricuspid regurgitation, adding the right atrial pressure estimation. The RV-PA coupling was calculated as TAPSE/PASP ratio. Results. After six months, patients who underwent CCM therapy showed a reduction in RV diameters and improved RV systolic function, as evidenced by the increase in both TAPSE (16.6 ± 4.2 mm vs. 18.5 ± 3.6 mm; p &lt; 0.05), RVs (10.1 ± 1.8 cm/s vs. 11.3 ± 11.4 cm/s; p &lt; 0.05), and RV strain (−13.7 ± 1.8% vs. −15.6 ± 2.3%; p &lt; 0.05). CCM also determined a reduction in PASP (34.2 ± 9.8 mmHg vs. 28 ± 6.2 mmHg; p &lt; 0.05) and an increase in the TAPSE/PASP ratio (0.52 ± 0.14 mm/mmHg vs. 0.66 ± 0.23 mm/mmHg; p &lt; 0.05). Conclusions. At six months, CCM increases RV reverse remodeling and performance, reducing RV size and improving RV systolic function, PASP, and RV-PA coupling.

Perinatal changes of right ventricle-pulmonary artery coupling and its value in predicting persistent pulmonary hypertension of the newborn.

Right ventricle-pulmonary artery (RV-PA) coupling is an independent predictor of outcome in pulmonary arterial hypertensionin adults. Here, we aimed to investigate the changes in RV-PA coupling during the perinatal period, and to evaluate its performance on predicting persistent pulmonary hypertension of the newborn (PPHN). A total of 1196 fetuses underwent a dedicated echocardiography screening for foetal heart defects during second trimester (24-27 weeks' gestation), third trimester (34-37 weeks' gestation) and neonatal period (within 14 days after delivery) with the measurement of tricuspid annular plane systolic excursion (TAPSE) and mean pulmonary artery pressure (MPAP). The RV-PA coupling (TAPSE/MPAP ratio) was calculated. Six fetuses were diagnosed as persistent pulmonary hypertension of the newborn(PPHN). In normal fetuses, RV-PA coupling had been increasing from the second trimester to the third trimester and then to the neonatal period (0.12 ± 0.02 vs. 0.18 ± 0.05 vs. 0.23 ± 0.08 mm/mmHg, p < 0.05), while it had been decreasing during the same period of time in abnormal fetuses (0.18 ± 0.02 vs. 0.17 ± 0.02 vs. 0.17 ± 0.01 mm/mmHg, p < 0.05). There was a strong positive correlation between RV-PA coupling and gestational age (GA) in normal fetuses (r = 0.71, p < 0.0001). The area under receiver operating characteristic curve (AUC) of 0.989 for RV-PA coupling during second trimester was superior to that for RV-PA coupling during third trimester (AUC: 0.536) in predicting PPHN. The optimal cutoff value was 0.16 mm/mmHg, with a sensitivity of 100.00%, a specificity of 96.36%and an accuracy of 97.73%. RV-PA coupling had close relation with GA in normal fetuses. It was a strong predictor of PPHN.

An Eight-year, Single-center Experience on Ultrasound Assisted Thrombolysis with Moderate-dose, Slow-infusion Regimen in Pulmonary Embolism.

There is limited data on moderate-dose with slow-infusion thrombolytic regimen by ultrasound-asssisted-thrombolysis (USAT) in patients with acute pulmonary embolism (PE). In this study, our eight-year experience on USAT with moderate-dose, slow-infusion tissue-type plasminogen activator (t-PA) regimen in patients with PE at intermediate-high- and high-risk was presented, and short-, and long-term effectiveness and safety outcomes were evaluated. Our study is based on the retrospective evaluation of 225 patients with PE having multiple comorbidities who underwent USAT. High- and intermediate-high-risk were noted in 14.7% and in 85.3% of patients, respectively. Mean t-PA dosage was 35.4±13.3 mg, and the infusion duration was 26.6±7.7 h. Measures of pulmonary artery (PA) obstruction and right ventricle (RV) dysfunction were improved within days (p<0.0001 for all). During the hospital stay, major and minor bleeding and mortality rates were 6.2%, 12.4%, and 6.2%, respectively. Bleeding and unresolved PE accounted for 50% and 42.8% of in-hospital mortality, respectively. Age, rate, and duration of t-PA were not associated with in-hospital major bleeding and mortality. Oxygen saturation exceeded 90% in 91.2% of patients at discharge. During follow-up of median 962 (610-1894) days, high-risk status related to 30-day mortality, whereas age >65 years was associated with long-term mortality. Our real-life experience with USAT with moderate-dose, slow-infusion t-PA regimen in patients with PE at high-and intermediate-high risk demonstrated clinically relevant improvements in PA obstructive burden and RV dysfunction. Age, rate or infusion duration of t-PA was not related to major bleeding or mortality risk, whereas unresolved obstruction remained as a lethal issue.

Preservation of Right Ventricular Contractility After Transient Phenylephrine‐Induced Pressure Overload in Swine

ObjectiveWe have previously demonstrated that a transient phenylephrine (PE)‐induced rise in systemic arterial blood pressure leads to reversible left ventricular (LV) systolic dysfunction in the absence of ischemia (i.e., “stretch‐induced stunning”). However, the extent to which this phenomenon occurs in the right ventricle (RV) is unclear. Accordingly, the present study was designed to assess changes in pulmonary artery (PA) pressure and RV function during and after systemic administration of PE in swine.MethodsClosed‐chest propofol‐anesthetized swine (n=5) were instrumented with a Swan‐Ganz catheter and an admittance catheter for continuous measurement of PA pressure, RV pressure, and RV volume (ADV500; Transonic SciSense, Inc.). Ventricular end‐diastolic and end‐systolic volumes were assessed by multi‐detector computed tomography with iodinated contrast (1 mL/kg at 4 mL/s) before, during, and 30‐minutes after transient pressure overload elicited by a 1‐hour intravenous infusion of PE (18 mg/hour). Load‐independent RV systolic function was derived from RV pressure‐volume loops collected during inferior vena cava occlusion at baseline and 30 min after PE.ResultsPE elicited a significant rise in PA pressure (27±1/14±1 to 43±1/23±31mmHg; p&lt;0.05) and RV pressure (25±2/3±1 to 44±2/8±2 mmHg; p&lt;0.05) that normalized 30‐minutes after the end of the infusion period (PA: 28±1/11±1 mmHg; RV: 29±5/4±2 mmHg). This was accompanied by a significant increase in RV end‐diastolic and end‐systolic volumes and decrease in RV ejection fraction that tended to persist 30‐minutes after cessation of PE (Table; top panel). However, load‐dependent (dP/dtmax) and load‐independent (ESPVR and PRSW) parameters of RV systolic function were preserved after PE‐induced TPO (Table; bottom panel).ConclusionsDespite causing a significant rise in RV preload volume and pressure, transient PE‐induced pressure overload is not associated with RV contractile dysfunction during the post‐infusion period. The absence of stretch‐induced stunning in the RV may be linked to inherent differences in compliance relative to the LV as well as a diminished pressor response to PE in the pulmonary vs. systemic circulation.

Right ventricle-pulmonary artery coupling in repaired tetralogy of fallot with pulmonary regurgitation: clinical implications

Abstract Funding Acknowledgements Type of funding sources: None. Background The right ventricle-pulmonary artery (RV-PA) coupling is a strong prognostic marker in several clinical settings, but only few studies focused on its role in repaired Tetralogy of Fallot (rToF) with pulmonary regurgitation (PR). Aim of this study was to assess whether differences exist in RV-PA coupling, estimated as by echocardiography, between patients with rToF and PR with (i-PVR) or without (ni-PVR) indication for pulmonary valve replacement (PVR). 3 Materials and Methods The study population included 40 rToF patients allocated to two groups: 20 i-PVR and 20 ni-PVR; 40 healthy controls were also included. All subjects underwent echocardiogram, while Cardiac magnetic resonance (CMR) was available in 27/40 rToF patients. RV-PA coupling was assessed by echocardiographic TAPSE/PASP and RV stroke volume/RV end systolic volume (RVSV/RVESV) by CMR. Results TAPSE was similar in i-PVR vs ni-PVR (19.0 ± 3.4 vs 18.8 ± 2.7 mm, p = 0.85) while RV-PA coupling was significantly worse in i-PVR vs ni-PVR (TAPSE/PASP 0.8 ± 0.3 vs 1.1 ± 0.5 mm/mmHg, p = 0.009) as well as in i-PVR vs controls (p = 0.02) while there was no difference between ni-PVR and controls (p = 0.29). CMR data confirmed the echo results, with a significant difference in RV-PA coupling between i-PVR and ni-PVR (RVSV/RVESV 0.9 ± 0.2 vs 1.2 ± 0.3 mL/min/mL, p = 0.01). Conclusions This study shows the presence of worse RV-PA uncoupling, despite normal RV systolic function, in rToF patients with indication to PVR. RV-PA coupling could be a sensitive marker of a progressive maladaptive RV response to long-standing volume overload in rToF prior to the onset of clinical symptoms and RV systolic dysfunction. Abstract Figure. example of an i-PVR patient

Right ventricle-pulmonary artery coupling in repaired tetralogy of Fallot with pulmonary regurgitation: Clinical implications

Right ventricle-pulmonary artery (RV-PA) coupling is a strong prognostic marker in several clinical settings, but few studies have focused on its role in repaired tetralogy of Fallot (rToF) with pulmonary regurgitation. To assess whether differences exist in RV-PA coupling, estimated by echocardiography, between patients with rToF and pulmonary regurgitation with or without an indication for pulmonary valve replacement (PVR). The study population included 40 patients with rToF, who were allocated to two groups: 20 with an indication for PVR (i-PVR group); and 20 without an indication for PVR (ni-PVR group). Forty healthy controls were also included. All subjects underwent echocardiography, and cardiac magnetic resonance (CMR) was available in 27/40 patients with rToF. RV-PA coupling was assessed by echocardiographic tricuspid annular plane systolic excursion/pulmonary arterial systolic pressure (TAPSE/PASP) and right ventricular stroke volume/right ventricular end-systolic volume (RVSV/RVESV) by CMR. TAPSE was similar in the i-PVR and ni-PVR groups (19.0±3.4 vs 18.8±2.7mm; P=0.97) whereas RV-PA coupling was significantly worse in the i-PVR group versus the ni-PVR group (TAPSE/PASP 0.8±0.3 vs 1.1±0.5mm/mmHg; P=0.001), and in the i-PVR group versus the control group (P=0.02); there was no difference between the ni-PVR and control groups (P=0.29). CMR data confirmed the echocardiography results, with a significant difference in RV-PA coupling between the i-PVR and ni-PVR groups (RVSV/RVESV 0.9±0.2 vs 1.2±0.3mL/min/mL; P=0.01). This study demonstrates worse RV-PA coupling, despite normal RV systolic function, in patients with rToF with an indication for PVR. RV-PA coupling could be a sensitive marker of a progressive maladaptive RV response to long-standing volume overload in rToF before the onset of clinical symptoms and RV systolic dysfunction.

Prognostic significance of right ventricle to pulmonary artery coupling in patients with mitral regurgitation treated with the MitraClip system.

To evaluate the prognostic impact of baseline tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) ratio, as an expression of the right ventricle-pulmonary artery (RV-PA)coupling, in patients with mitral regurgitation (MR) treated with the MitraClip. Impaired RV to PA coupling is considered a marker of RV dysfunction. From February 2016 to February 2020, a total of 165 patients were evaluated and stratified in two groups according to a prespecified value of TAPSE/PASP ratio ≤ 0.36. The median patients' age was 79 (men: 62.4%). Sixty-three patients (38.1%) presented TAPSE/PASP ≤ 0.36 and were then compared with patients with TAPSE/PASP > 0.36. Functional MR etiology was more frequent in TAPSE/PASP ≤ 0.36 (71.4%; p = 0.046). Acute technical success was achieved in 92.7% of the population, without any significant difference between the two groups of study and with sustained results at 30-day (device success: 85.5%; procedural success: 84.8%). On multivariate Cox regression analysis, after correction for body mass index, chronic kidney disease and left ventricle ejection fraction ≥30% but <50%, TAPSE/PASP ≤ 0.36 remained a sustained predictor of mortality and hospitalization for heart failure at one year after MitraClip (hazard ratio: 3.87; 95% confidence interval: 1.83-8.22; p ≤ 0.001). Kaplan-Meier all-cause mortality and heart failure hospitalization rates at one year were consequently higher in patients with TAPSE/PASP ≤ 0.36 (39.4% vs. 14.8%; log-rank p ≤ 0.001). Baseline TAPSE/PASP ratio seems independently associated with all-cause mortality and heart failure hospitalization after MitraClip both in functional and degenerative MR.

Blueberry extract improves redox balance and functional parameters in the right ventricle from rats with pulmonary arterial hypertension.

Pulmonary arterial hypertension (PAH) is a disease characterized by increased pulmonary vascular resistance and right ventricle (RV) failure. In this context, oxidative stress is an essential element contributing to PAH's pathophysiology. Thus, blueberry (BB), which has a high antioxidant capacity, emerges as a natural therapeutic approach in PAH. This work evaluated the effect of BB extract on redox balance in RV in a PAH's animal model. Male Wistar rats (200 ± 20g) (n = 72) were randomized into eight groups: control (CTR); monocrotaline (MCT); CTR and MCT treated at doses of 50, 100, and 200mg/kg BB. PAH was induced by administration of MCT (60mg/kg, intraperitoneal). Rats were treated with BB orally for 5weeks (2weeks before monocrotaline and 3weeks after monocrotaline injection). On day 35, rats were submitted to echocardiography and catheterization, then euthanasia and RV harvesting for biochemical analyses. RV hypertrophy, observed in the MCT groups, was reduced with BB treatment. MCT elevated RV systolic pressure and pressure/time derivatives, while the intervention with BB decreased these parameters. PAH decreased RV output and pulmonary artery outflow acceleration/ejection time ratio, while increased RV diameters, parameters restored by BB treatment. Animals from the MCT group showed elevated lipid peroxidation and NADPH oxidase activity, outcomes attenuated in animals treated with BB, which also led to increased catalase activity. Treatment with BB partially mitigated PAH, which could be associated with improvement of RV redox state. Such findings constitute an advance in the investigation of the role of BB extract in chronic progressive cardiovascular diseases that involve the redox balance, such as PAH.

Increased Pulmonary Arterial Stiffness and Impaired Right Ventricle-Pulmonary Artery Coupling In PCOS.

ResumoFundamento:A síndrome dos ovários policísticos (SOP) é a doença endócrino-metabólica mais comum em mulheres em idade reprodutiva, e ocorre em uma a cada 10 mulheres. A doença inclui irregularidade menstrual e excesso de hormônios masculinos e é a causa mais comum de infertilidade em mulheres. A dispneia é um sintoma frequente e muitas vezes acredita-se que seja decorrente da obesidade, mas não se sabe se é decorrente de disfunção cardíaca.Objetivo:Avaliar o acoplamento ventrículo-arterial (VDAP) e a rigidez arterial pulmonar em pacientes com SOP.Métodos:Foram incluídos 44 pacientes com SOP e 60 controles; amostras de sangue venoso foram coletadas para exames laboratoriais e ecocardiograma transtorácico 2-D, Modo-M e com Doppler tecidual foram realizados em todos os participantes. Um valor de p<0,05 foi considerado estatisticamente significativo.Resultados:Quando comparadas ao grupo controle, as pacientes com SOP apresentaram valores maiores de rigidez da artéria pulmonar (p = 0,001), que se correlacionaram positivamente com o índice HOMA-IR (r = 0,545 e p <0,001). O acoplamento VDAP também estava comprometido em 34% dos pacientes do estudo.Conclusão:A rigidez da artéria pulmonar está aumentada e o acoplamento VDAP está comprometido em pacientes com SOP. (Arq Bras Cardiol. 2021; 116(4):806-811)