Right Ventricular Ejection Research Articles

Right ventricular ejection fraction assessed by computed tomography in patients undergoing transcatheter tricuspid valve intervention

Abstract Background The role of right-ventricular (RV) function in patients with tricuspid regurgitation (TR) undergoing transcatheter tricuspid valve interventions (TTVI) is poorly understood. Although cardiac computed tomography (CCT) provides elaborate three-dimensional (3D) visualization of the entire anatomy of the RV and theoretically allows to assess the global RV systolic function. Nevertheless, the utility of the functional assessments of the RV using CCT remains unclear in patients undergoing TTVI. Purpose This study investigated the association of right-ventricular ejection fraction (RVEF) assessed by CCT with clinical outcome in patients undergoing TTVI. Methods We retrospectively assessed 3D-RVEF by using pre-procedural CCT images in patients undergoing TTVI with either edge-to-edge repair or annuloplasty device. RV dysfunction (RVD) was defined as a CT-RVEF <45%. The primary outcome was a composite outcome, consisting of all-cause mortality and hospitalization due to heart failure, within one year after TTVI. Results Of 157 patients, 58 (36.9%) presented with CT-RVEF <45%. Patients with CT-RVEF <45% were more likely to be male, to have a previous history of coronary artery disease, and had higher EuroSCORE II and a lower LVEF compared to those with CT-RVEF ≥45%, while the severity of TR was comparable between the groups. Among the patients with CT-RVEF <45%, acute procedural success was achieved in 93.1%, and in-hospital mortality was 1.7%, which were comparable to those with CT-RVEF ≥45%. Patients with CT-RVEF <45% had an improvement in New York Heart Association functional class at follow-up compared to baseline; however, CT-RVEF <45% was associated with a higher risk of the composite outcome (adjusted hazard ratio: 3.23; 95% confidence interval: 1.52–6.88; p=0.002) (Figure 1). Furthermore, CT-RVEF had an additional value to stratify the risk of the composite outcome beyond two-dimensional transthoracic echocardiographic (TTE) assessments (Figure 2). In addition, patients with CT-RVEF <45% exhibited an attenuated association between a reduction in TR to <3+ and a lower incidence of the composite outcome after TTVI compared to those with CT-RVEF ≥45%. Conclusions TTVI is safe and feasible regardless of baseline RV function, while RVD, defined as 3D-RVEF <45%, is associated with a higher risk of the composite outcomes within one year after TTVI. Furthermore, our findings suggest that the prognostic benefits of TR reduction might be attenuated in patients with RVD. Given the additional prognostic value of CT-RVEF to the conventional echocardiographic assessments, the assessments of 3D-RVEF with CCT may refine the patient selection for TTVI. Funding Acknowledgement Type of funding sources: None.

The Importance of Functional and Feature-Tracking Cardiac MRI Parameters in Prediction of Adverse Cardiac Events and Cardiac Mortality in Thalassemia Patients

Despite some investigations about the role of cardiovascular magnetic resonance (CMR) imaging in thalassemia, there are a few studies regarding the feature-tracking (FT). We evaluated the role of T2*, functional, and FT values for the determining of adverse cardiac events (ACE). One-hundred-fifty-nine patients with thalassemia-major (49.7% female, mean-age=32 ± 9.8 year) were followed for 8 - 64 (median=36) months. CMR derived functional, FT, and T2* as well as ACE (heart failure hospitalization, cardiac mortality, pulmonary hypertension, and arrhythmias) were recorded. Also, variables were analyzed for cardiac death prediction separately. Seventeen patients (10.7%) developed ACE. The right-ventricular ejection fraction (RVEF) was the strongest indicator of ACE (OR: 0.85, 95% - CI: 0.790 - 0.918; p < 0.001) and cardiac mortality (OR: 0.88, 95%-CI: 0.811 - 0.973; p=0.01). RVEF ≤ 39% and ≤ 37% predicted ACE and mortality with sensitivity of 62.5% and 71.43% and specificity of 95.77% and 93.38%, respectively. Additionally, myocardial-T2* was a predictor of mortality (OR: 0.90, 95%-CI: 0.814 - 0.999; p = 0.04). T2* ≤ 10 months predicted death with 85.71% sensitivity and 85.91% specificity. RV global longitudinal strain (GLS) was the strongest strain parameter for the indication of ACE and death (OR: 0.81, 95%-CI: 0.740 - 0.902; p < 0.001 and OR: 0.81, 95%- CI: 0.719 - 0.933; p = 0.003, respectively). RV GLS ≤ 16.43% and ≤ 15.63% determined ACE and death with sensitivity of 52.94% and 71.43% and specificity of 90%, respectively. Our results underscore the role of FT and non-contrast CMR parameters as valuable markers of ACE in thalassemia.

Prognostic Significance of Feature-Tracking Right Ventricular Global Longitudinal Strain in Non-ischemic Dilated Cardiomyopathy.

Aims: Left ventricular global longitudinal strain (GLS) by cardiac magnetic resonance feature tracking (CMR-FT) analysis has shown an incremental prognostic value compared to classical parameters in non-ischemic dilated cardiomyopathy (NICM). However, less is known about the role of right ventricular (RV) GLS. Our objective was to evaluate the prognostic impact of RV-GLS by CMR-FT analysis in a population of NICM patients.Methods: In this multicenter study, we examined NICM patients evaluated with a comprehensive CMR-FT study. Major cardiac events (MACEs) were considered as the study primary outcome measure and were defined as a composite of (a) cardiovascular death, (b) cardiac transplant or destination therapy ventricular assist device, (c) hospitalization for life-threatening ventricular arrhythmias or implantable cardiac defibrillator appropriate intervention. Heart failure (HF) related events, including hospitalizations and life-threatening arrhythmia-related events were considered as secondary end-points. Receiver operating time-dependent analysis were used to calculate the possible additional effect of RV-GLS to standard evaluation.Results: We consecutively enrolled 273 patients. During a median follow-up of 39 months, 41 patients (15%) experienced MACEs. RV-GLS and LV late gadolinium emerged as the strongest prognostic CMR-FT variables: their association provided an estimated 3-year MACEs rate of 29%. The addition of RV-GLS significantly improved the prognostic accuracy in predicting MACEs with respect to the standard evaluation including LGE (areas under the curve from 0.71 [0.66–0.82] to 0.76 [0.66–0.86], p = 0.03). On competing risk analysis, RV-GLS showed a significant ability to reclassify overall both HF-related and life-threatening arrhythmia-related events, regardless of LV and RV ejection fraction.Conclusions: In NICM patients, RV-GLS showed a significant prognostic role in reclassifying the risk of MACEs, incremental with respect to standard evaluation with standard prognostic parameters.

Three-dimensional echocardiography in transcatheter edge-to-edge tricuspid valve repair

Abstract Background Transcatheter tricuspid valve repair (TTVR) is a new treatment option for severe tricuspid regurgitation (TR). First reports have reported conflicting results on development of right ventricular (RV) function after TTVR and questioned the role of conventional echocardiographic parameters to predict outcome. Purpose The aim of this study was to evaluate 3D echocardiography for the comprehensive assessment of RV function and its prognostic value for TTVR-treated patients. Methods We included patients undergoing TTVR from February 2017 to July 2019 who had preprocedural 3D assessment of RV volumes and ejection fraction. At follow-up (FU), 3D echo was performed to evaluate right ventricular reverse remodeling. All-cause mortality was assessed as clinical endpoint. Results 75 patients treated with TTVR for isolated, severe TR had 3D echo assessment. TTVR reduced TR from grade ≥3+ to ≤2+ in 83.1% of patients at discharge. 3D-RV end-diastolic volume (−46.3 ml, p&amp;lt;0.001), end-systolic volume (−22.0 ml, p=0.027) and 3D-RV ejection fraction (−4.7%, p&amp;lt;0.001) decreased at short-term FU at 1-month and remained stable at 6-month FU. An impaired preprocedural 3D-RVEF &amp;lt;44% conferred higher mortality risk (Figure), and was an independent predictor for 1-year mortality (hazard ratio 5.32, p=0.033) in multivariable analysis. Tricuspid annular systolic excursion (TAPSE) and RV fractional area change were not predictive for this endpoint. Importantly, the observed decrease of 3D-RVEF function after TTVR was not associated with outcome (p=0.22 for decrease of 3D-RVEF vs. no decrease of 3D-RVEF in Kaplan-Meier analysis). Instead, left ventricular stroke volume index increased by 9.2% from 26.0 to 28.4 ml/m2 (p&amp;lt;0.01) Conclusion TTVR leads to right ventricular reverse remodeling and decrease of RV systolic function after TTVR. Impaired preprocedural RV systolic function is associated with worse clinical outcome. In contrast, the observed decrease of RV systolic function after TTVR was not associated with outcome. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Klinikum der Universtität München Figure 1

Value of echocardiography using knowledge-based reconstruction in determining right ventricular volumes in pulmonary sarcoidosis: comparison with cardiac magnetic resonance imaging.

Right ventricular (RV) dysfunction in sarcoidosis is associated with adverse outcomes. Assessment of RV function by conventional transthoracic echocardiography (TTE) is challenging due to the complex RV geometry. Knowledge-based reconstruction (KBR) combines TTE measurements with three-dimensional coordinates to determine RV volumes. The aim of this study was to investigate the accuracy of TTE-KBR compared to the gold standard cardiac magnetic resonance imaging (CMR) in determining RV dimensions in pulmonary sarcoidosis. Pulmonary sarcoidosis patients prospectively received same-day TTE and TTE-KBR. If performed, CMR within 90 days after TTE-KBR was used as reference standard. Outcome parameters included RV end-diastolic volume (RVEDV), end-systolic volume (RVESV), stroke volume (RVSV) and ejection fraction (RVEF). 281 patients underwent same day TTE and TTE-KBR. In total, 122 patients received a CMR within 90 daysof TTE and were included. TTE-KBR measured RVEDV and RVESV showed strong correlation with CMR measurements (R = 0.73, R = 0.76), while RVSV and RVEF correlated weakly (R = 0.46, R = 0.46). Bland-Altman analyses (mean bias ± 95% limits of agreement), showed good agreement for RVEDV (ΔRVEDVKBR-CMR, 5.67 ± 55.4mL), while RVESV, RVSV and RVEF showed poor agreement (ΔRVESVKBR-CMR, 21.6 ± 34.1mL; ΔRVSVKBR-CMR, -16.1 ± 42.9mL; ΔRVEFKBR-CMR, -12.9 ± 16.4%). The image quality and time between CMR and TTE-KBR showed no impact on intermodality differences and there was no sign of a possible learning curve. TTE-KBR is convenient and shows good agreement with CMR for RVEDV. However, there is poor agreement for RVESV, RVSV and RVEF. The use of TTE-KBR does not seem to provide additional value in the determination of RV dimensions in pulmonary sarcoidosis patients.

P3685Can 3D echocardiography give a contribute to the diagnosis of Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)?

Abstract Background The diagnosis of ARVC is based on the structural assessment of the heart with 2D echocardiography (2DE) and cardiovascular MRI (CMR) to detect the presence of global and segmental right ventricular (RV) abnormalities. Little is known about the diagnostic value of 3D echocardiography (3DE) in ARVC. The aim of this study was to assess whether a combination of 2DE and 3DE could replace 2DE and CMR combination with similar diagnostic accuracy in patients with suspected ARVC. Methods Thirty-nine subjects (59% males, 47±15 years, 41% with desmosomal mutations) with suspected or confirmed diagnosis of ARVC underwent evaluation of the RV with the use of CMR, 2DE, 3DE. 3DE and CMR were independently used to obtain RV volumes, ejection fraction and presence of segmental RV abnormalities. These studies were blindly classified as meeting none, minor, or major criteria for ARVC in accordance with the 2010 TFC. Kappa statistics were used to assess the concordance between 2DE-CMR and 2DE-3DE diagnostic approaches. Results Using the 2DE-CMR approach, patients were classified as follows: 5 not affected, 8 with possible, 9 with borderline and 17 with definite ARVC diagnosis. The evaluation of TFC criteria with the 2DE-3DE approach yielded a high degree of concordance with the standard of care (2DE-CMR approach, K=0.93 with 95% CI: 0.84–1.0). There was complete agreement between the 2DE-CMR and 2DE-3DE approaches for individuals with definite ARVC diagnosis (n=17) and in individuals not affected by ARVC (n=5). Two patients with possible and borderline ARVC diagnosis using the 2DE-CMR approach were confirmed as definite ARVC with 2DE-3DE approach. Contribution of 3D echo to ARVC Conclusions The use of 2D and 3D echocardiography allows bedside evaluation of patients with suspected ARVC, which is diagnostically comparable to that obtained using the traditional combination of 2DE-CMR. This information is particularly relevant for patients who cannot undergo CMR such as patients with ICD.

Horizontal Long Axis Imaging Plane for Evaluation of Right Ventricular Function on Cardiac Magnetic Resonance Imaging.

Purpose:The purpose of this study was to evaluate a horizontal long axis (HLA) magnetic resonance imaging (MRI) plane aligned to the long axis of the right ventricular (RV) cavity for functional analysis by comparing the measurement variability and time required for the analysis with that using a short-axis (SAX) image orientation.Materials and Methods:Thirty-four cardiac MRI exams with cine balanced steady-state free precession image stacks in both the SAX and the HLA of the RV (RHLA) were evaluated. Two reviewers independently traced RV endocardial borders on each image of the cine stacks. The time required to complete each set of traces was recorded, and the RV end-diastolic volume, end-systolic volume, and ejection fraction were calculated. Analysis times and RV measurements were compared between the two orientations.Results:Analysis time for each reviewer was significantly shorter for the RHLA stack (reviewer 1 = 6.4 ± 1.8 min, reviewer 2 = 6.0 ± 3.3 min) than for the SAX stack (7.5 ± 2.1 and 6.9 ± 3.6 min, respectively; P < 0.002). Bland–Altman analysis revealed lower mean differences, limits of agreement, and coefficients of variation for RV measurements obtained with the RHLA stack.Conclusions:RV functional analysis using a RHLA stack resulted in shorter analysis times and lower measurement variability than for a SAX stack orientation.

Right ventricular function in pulmonary hypertension due to left heart disease by two-dimensional speckle tracking and real time three-dimensional echocardiography

Objective The aim of this study was to assess right ventricular (RV) function in pulmonary hypertension due to left heart disease (LHD-PH) by two-dimensional speckle tracking echocardiography (2D-STE) and real-time three-dimensional echocardiography (RT-3DE) and to compare them with conventional echocardiography in identifying reactive PH.Subjects and methods The study consisted of 40 controls and 65 patients with LHD-PH. According to pulmonary vascular resistance, patients were divided into a passive PH and a reactive PH group. RV fractional area change (FAC), myocardial performance index (MPI) and systolic velocity (S’) were acquired by conventional echocardiography. Longitudinal peak systolic strain (LS) was measured at the basal (LSbas), middle (LSmid) and apical (LSapi) segments of RV free wall by 2D-STE, and global free wall LS (LSfw) was calculated. RV end-diastolic volume (EDV), end-systolic volume (ESV), ejection fraction (EF) and stroke volume (SV) were acquired using RT-3DE.Results Compared with the passive PH group, LSbas, LSfw, EF, FAC and S’ decreased in reactive PH group (all P < 0.05). However, they showed no significant differences between controls and the passive PH group (all P> 0.05). EDV, ESV and MPI increased gradually as the disease progressed (all P < 0.05). By logistic regression analysis, only LSbas and EF were independently associated with reactive PH. By ROC analysis, they were indicative of reactive PH with sensitivity of 83% and 86%, and specificity of 89% and 81%.Conclusions RV presented gradual dilatation with deteriorated systolic function that occurred late. 2D strain and3D volumetric assessments were able to identity reactive PH better than conventional echocardiography.

The pitfall of pulse pressure variation in the cardiac dysfunction condition.

We read with interest the recent articles in Critical Care about the limitations of pulse pressure variation (PPV) for predicting fluid responsiveness [1, 2]. We believe that cardiac dysfunction should be included in this list of PPV limitations. During right ventricular (RV) dysfunction, the inspiration would increase RV afterload and lead to a decrease in RV ejection during mechanical ventilation. Thus, a high PPV is due to afterload variation, and the RV dysfunction would result in a false-positive PPV. Studies had suggested that the evaluation of RV function was important when determining the predictability of PPV [3, 4]. During left ventricular (LV) dysfunction, the increase in pleural pressure that facilitates LV ejection is more pronounced (afterload reduction). Thus, the effect of squeezing the pulmonary blood volume during early inspiration on the LV ejection is amplified and is defined as the dUp. In other words, a high PPV may be due to dUp variation, which would result in a false-positive PPV. Tavernier and colleagues [5] found that the prominence of dUp and absence of dDown might suggest hypervolemia and cardiac contraction dysfunction. However, Biais and colleagues [2] did not present data for cardiac function in their study. Moreover, cardiac dysfunction is common in critically ill patients. We inferred that this could become a confounding factor for the outcome. Hence, it is worth paying attention to the pitfall of PPV in critically ill patients with cardiac dysfunction.

Knowledge-based 3D reconstruction of the right ventricle: comparison with cardiac magnetic resonance in adults with congenital heart disease.

AimAssessment of right ventricular (RV) function is a challenge, especially in patients with congenital heart disease (CHD). The aim of the present study is to assess whether knowledge-based RV reconstruction, used in the everyday practice of an echo-lab for adult CHD in a tertiary referral center, is accurate when compared to cardiac magnetic resonance (CMR) examination.Subjects and methodsAdult patients who would undergo CMR for assessment of the RV were asked to undergo an echo of the heart for further knowledge-based reconstruction (KBR). Echocardiographic images were acquired in standard views using a predefined imaging protocol. RV volumes and ejection fraction (EF) calculated using knowledge-based technology were compared with the CMR data of the same patient.ResultsNineteen consecutive patients with congenital right heart disease were studied. Median age of the patients was 28 years (range 46 years). Reconstruction was possible in 16 out of 19 patients (85%). RV volumes assessed with this new method were smaller than with CMR. Indexed end diastolic volumes were 114±17 ml vs 121±19 ml, P<0.05 and EFs were 45±8% vs 47±9%, P<0.05 respectively. The correlation between the methods was good with an intraclass correlation of 0.84 for EDV and 0.89 for EF, P value <0.001 in both cases.ConclusionKBR enables reliable measurement of RVs in patients with CHDs and can be used in clinical practice for analysis of volumes and EFs.

Abstract 18017: The Modified History in Young Patients With Repaired Tetralogy of Fallot: A Longitudinal Magnetic Resonance Study

Introduction: No large scale longitudinal information is available on the change of ventricular size and function as well as of exercise tolerance in survivors after Tetralogy of Fallot (TOF) repair during childhood and adolescence. Objective: The objective of this study was to assess the rate of progression of right ventricular (RV) size and pulmonary regurgitation (PR) in relationship to clinical status and outcomes in pediatric TOF patients from a contemporary surgical era. Methods: We analyzed 429 cardiac magnetic resonance (CMR) studies (from 2001-2014) of 267 patients (age at CMR 13.5 +/-2.8 years) after TOF repair prior to any pulmonary valve replacement (PVR), including 96 patients with serial CMRs. Measurements of biventricular volumes, mass, function, and PR were performed by a single observer. Serial ECGs, Holters, echocardiograms, and exercise tests were reviewed. Results: No deaths occurred in our cohort. Three patients (1.1%) had non-sustained ventricular tachycardia and 4 (1.5%) had supraventricular tachycardia. Sixty seven (25%) patients underwent PVR at a mean age15.5 +/- 2.3 years.There was a linear progression of BSA-indexed RV end-diastolic volume (EDVi) at 3 ml/m2 per year (p.a., p&lt;0.001). PR volume changed only minimally over time while PR fraction progressed at a rate of 0.7% p.a. (p&lt;0.001). RV and LV ejection fractions (EFs) deteriorated over time (0.5% p.a., p&lt;0.001 and 0.4% p.a., p=0.001, respectively). RV and LV EDVi increased (p=0.02 and p=0.001, respectively) and RV EF (p&lt;0.001) decreased more rapidly in boys than in girls. Right atrial (RA) length correlated inversely with VO2max (% predicted, p=0.02). In a multivariable analysis, worsening PR fraction, RV EF, RA length, and LV EDVi were all predictors of PVR in the future. Conclusions: This study describes the rate and dynamic of progression of biventricular size and function in children after TOF repair in the hitherto largest cohort, with apparent differences between boys and girls. RA length was inversely correlated with exercise intolerance.The need for PVR is predicted by the degree of RV dysfunction as well as LV and RA enlargement. The latter may deserve routine assessment in patients after TOF repair.

Altered Right Ventricular Kinetic Energy Work Density and Viscous Energy Dissipation in Patients with Pulmonary Arterial Hypertension: A Pilot Study Using 4D Flow MRI.

IntroductionRight ventricular (RV) function has increasingly being recognized as an important predictor for morbidity and mortality in patients with pulmonary arterial hypertension (PAH). The increased RV after-load increase RV work in PAH. We used time-resolved 3D phase contrast MRI (4D flow MRI) to derive RV kinetic energy (KE) work density and energy loss in the pulmonary artery (PA) to better characterize RV work in PAH patients.Methods4D flow and standard cardiac cine images were obtained in ten functional class I/II patients with PAH and nine healthy subjects. For each individual, we calculated the RV KE work density and the amount of viscous dissipation in the PA.ResultsPAH patients had alterations in flow patterns in both the RV and the PA compared to healthy subjects. PAH subjects had significantly higher RV KE work density than healthy subjects (94.7±33.7 mJ/mL vs. 61.7±14.8 mJ/mL, p = 0.007) as well as a much greater percent PA energy loss (21.1±6.4% vs. 2.2±1.3%, p = 0.0001) throughout the cardiac cycle. RV KE work density and percent PA energy loss had mild and moderate correlations with RV ejection fraction.ConclusionThis study has quantified two kinetic energy metrics to assess RV function using 4D flow. RV KE work density and PA viscous energy loss not only distinguished healthy subjects from patients, but also provided distinction amongst PAH patients. These metrics hold promise as imaging markers for RV function.

Right ventricular outflow tract systolic excursion: a useful method for determining right ventricular systolic function.

Assessment of right ventricular (RV) systolic function is not an easy task. Although RV fractional area change (FAC) and tricuspid annular plane systolic excursion (TAPSE) are useful in the assessment of RV function, their use can be sometimes limited. Right ventricular outflow tract systolic excursion (RVOT_SE) is a new way to evaluate RV systolic function. The aim of this study was to assess the correlation between RVOT_SE and other RV systolic function assessment methods. RVOT_SE was defined as the systolic excursion of the RV outflow tract anterior wall endocardium. A total of 104 patients with a wide range of RV systolic function, ejection fraction, and pulmonary artery systolic pressure were studied. We also measured another four ways to evaluate RV systolic function, FAC, TAPSE, right ventricular outflow tract fractional shortening (RVOT_FS), and tricuspid annular systolic excursion velocity S' (Tissue S'). There was a strong correlation between RVOT_SE and each one of the four studied ways to evaluate RV systolic function. Multivariate regression analysis showed that the independent variables correlated with RVOT_SE were RVOT_FS (p<0.0001), FAC (p=0.005) and TAPSE (p=0.023). RVOT_SE diagnosed patients with reduced RV systolic function with 98% sensitivity and 96% specificity. There was no correlation between RVOT_SE and ejection fraction, or between RVOT_SE and pulmonary artery systolic pressure in patients with reduced RV systolic function. Intra-observer and inter-observer reproducibility were favorable for RVOT_SE and all four studied ways. RVOT_SE is a simple, accurate, and promising method for evaluating RV systolic function.

Is there a relationship between right-ventricular and right atrial mechanics and functional capacity in hypertensive patients?

We sought to assess right-ventricular and right atrial deformation in patients with arterial hypertension by two-dimensional speckle tracking imaging and three-dimensional echocardiography (3DE), and define the relationship between right-ventricular mechanics and exercise capacity in the study population. This cross-sectional study included recently diagnosed untreated hypertensive patients, well controlled hypertensive patients, treated patients with unsatisfactory controlled blood pressure and control individuals adjusted by sex and age. All the patients underwent complete two-dimensional echocardiography and 3DE examination, as well as cardiopulmonary exercise testing. Right-ventricular strain, and systolic and early diastolic strain rates were significantly decreased in the untreated and the uncontrolled hypertensive patients in comparison with the controls and the well controlled participants. Similar results were obtained for right atrial strain and strain rates. 3DE right-ventricular volumes were increased, whereas 3DE right-ventricular ejection fraction was decreased in the uncontrolled hypertensive patients in comparison with the controls and the well treated patients. Differences in 3DE right-ventricular volumes disappeared after adjustment for body surface area. Considering the whole study population, global right-ventricular strain (β = 0.29, P = 0.018) and 3D right-ventricular stroke volume (β = 0.22, P = 0.041) were independently associated with peak oxygen uptake (VO(2max)) which was significantly decreased in the untreated and the uncontrolled hypertensive patients in comparison with the remaining two groups. Our study showed that right-ventricular and right atrial mechanics, as well as exercise capacity, are significantly deteriorated in the hypertensive patients who are untreated or ineffectively treated. Global right-ventricular strain and 3DE right-ventricular stroke volume are independently associated with functional capacity in the whole study population.

Reproducibility of CMR right ventricle volumetric measurements is independent of reader experience under a standardized protocol

The right ventricle’s complex geometry makes it challenging to measure its size and function. Though volumetric CMR is generally considered the gold standard, standardized reading protocols are necessary. We sought to investigate whether a specific reading protocol can supersede cardiology training in right ventricular (RV) measurements. We aimed to evaluate the reproducibility of RV measurements done by both an experienced and a novice CMR reader. Methods During a training period an experienced (Level III trained) CMR reader and a CMR novice (high school student) jointly interpreted 50 cine SSFP studies obtained in the left ventricular short-axis orientation as contiguous stack encompassing both ventricles in their entirety. The standardized endocardial tracing protocol was delimited by the pulmonary valve and the tricuspid valve planes; interpretation was augmented using cinereview and cross-referencing with orthogonal cine images. RV stroke volume (RVSV) and ejection fraction (RVEF) were calculated from end diastolic volume (RVEDV) and end systolic volume (RVESV). After the training period, we randomly selected 24 anonymized datasets from a representative sample (50% men; median age 63 years[range 48-78]), and the two readers independently read the studies twice, in a random order and on different days. Reproducibility was evaluated with coefficients of variation (CV) and concordance correlation coefficients (Rho). Results Mean ± SD measurements and CV did not differ between the experienced and the novice reader, respectively, for RVEDV (124.4 ± 30.1 vs 125.0 ± 30.1 mL; CV: 0.05 vs 0.04; P = NS), RVESV (45.6 ± 14.4 45.8 ± 13.4 mL; CV: 0.11 vs 0.09; P = NS), RVSV (78.9 ± 18.8 vs 79.2 ± 18.7 mL; CV: 0.05 vs 0.03; P = NS), RVEF (63.6 ± 5.4 vs 63.4 ± 5%; CV: 0.04 vs 0.04: P = NS). The concordance correlation coefficients and 95% limits of agreement are shown in the Table 1.

Right ventricular wall motion abnormalities n Thalassemia Major patients

Background Movement abnormalities in the left ventricle (LV) were shown to be not really frequent in thalassemia major (TM) patients but they were associated with age, myocardial iron overload, LV dilation and dysfunction, and myocardial fibrosis. No data are available about the prevalence and the correlates of right ventricular (RV) wall motion abnormalities. This study investigated the relationship between RV and LV motion abnormalities and between RV motion and function in a large cohort of well-treated TM patients. Methods CMR was performed in 1092 TM patients (537 male; 30.6 ± 8.5 years) enrolled in the Myocardial Iron Overload in Thalassemia (MIOT) Network. Cine images were acquired to evaluate wall motion and to quantify RV volumes and ejection fraction (EF). Results

Regional Analysis of Longitudinal Systolic Function of the Right Ventricle After Corrective Surgery of Tetralogy of Fallot Using Myocardial Isovolumetric Acceleration Index

To assess regional longitudinal systolic function of the right ventricle in patients with repaired tetralogy of Fallot (TOF) by tissue Doppler imaging-derived isovolumetric acceleration (IVA) index and determine the effect of right-ventricular (RV) enlargement on regional systolic function. In 30 consecutive TOF patients and 30 age-matched controls, myocardial velocity of the RV ventricular free wall in the basal and middle regions were examined in the apical four-chamber view. Peak myocardial velocity during IVA was recorded on the free RV wall. IVA index was calculated as the difference between baseline and peak velocity divided by their time interval. In 23 of the studied TOF patients, magnetic resonance imaging was performed on the same day to determine global RV volume and ejection fraction. IVA index of the RV lateral free wall was significantly lower in the basal (8.31 ± 6.00 vs. 19.00 ± 10.85 m/s(2), p = 0.0001) and middle segments (6.56 ± 5.22 vs. 16.17 ± 7.44 m/s(2), p = 0.0001) in patients than in controls. Among TOF patients, a negative correlation was found between IVA index in the middle segment and RV end-diastolic volume/body surface area (r = -0.549, p < 0.01). Similar to other longitudinal RV wall parameters, the IVA index showed a decreased value in the RV free wall, which is related to the impaired regional and global longitudinal RV systolic dysfunction. RV enlargement adversely affects regional longitudinal systolic function.

Quantitative Three Dimensional Echocardiographic Assessment of the Right Ventricle Can Identify Risk of Right Ventricular Failure in Patients Undergoing Left Ventricular Assist Device Surgery

Purpose Right ventricular failure (RVF) is associated with significant morbidity following left ventricular assist device (LVAD) surgery. Hemodynamic, clinical, and 2-dimensional echocardiographic variables poorly discriminate patients at risk of RVF. We examined the utility of 3-dimensional echocardiography (3DE) right ventricular (RV) volumetric assessment to identify patients at risk of RVF. Methods and Materials RVF was defined as need for inotropic infusion for >14 days following LVAD surgery or RV assist device (RVAD) placement. Preoperative RV volumes and ejection fraction (RVEF) were measured, blinded to clinical data, from transthoracic 3DE full volume data sets in 29 patients. Univariate analyses were used to compare baseline variables and 3DE RV indices among patients with and without RVF. Multivariate logistic regression was used to adjust for baseline covariates. Results 25 patients (86%) received continuous flow LVADs. 13 patients (45%) had RVF 2 required RVAD support and 11 required prolonged inotropes. Cardiac index (CI), RV stroke work index (RVSWI), indexed RV end diastolic and systolic volumes (RVEDVI & RVESVI) and RVEF were associated with RVF. RVEDVI (OR 1.082 (1.00, 1.17), p=0.049) and RVESVI (OR 1.117 (1.00, 1.25), p=0.049) remained associated with RVF after adjusting for RVSWI. Conclusions Quantitative 3DE is a promising method for pre-LVAD RV assessment. RV volumes assessed by 3DE are predictive of RVF in LVAD recipients, independent of RVSWI. Comparison of 3DE and baseline variables among patients with and without RVF. No RVF (mean±SD) RVF (mean±SD) P-value RVEDVI (ml/m2) 46 ± 13 65 ± 21 0.008 RVESVI (ml/m2) 30 ± 9 53 ± 22 0.0095 RVEF (%) 33 ± 9 23 ± 12 0.014 RVSWI (mmHg ml/m2) 644 ± 267 400 ± 175 0.0092 CI (l/min/m2) 2.3 ± 0.6 1.9 ± 0.3 0.047 Total Bilirubin (mg/dL) 1.4 ± 0.8 1.6 ± 0.9 0.68 BUN (mg/dL) 24 ± 13 17 ± 8 0.06 Right atrial pressure/PCWP ratio 0.4 ± 0.1 0.6 ± 0.2 0.09 Right atrial pressure (mmHg) 10 ± 4 14 ± 7 0.17

Reference values for right atrial and right ventricular morphology and function using cardiovascular magnetic resonance imaging

Background The right ventricular (RV) morphology and function are important parameters for the diagnosis of cardiopulmonary diseases and serve as predictors for the longterm outcome. To date there are little data about right heart characteristics due to its complex anatomy. Since cardiac magnetic resonance (CMR) is the gold-standard for the evaluation of left and right cardiac anatomy and function we sought to investigate and provide reference values for the entire right heart acquired in a large population of healthy volunteers. Methods We studied a group 119 healthy volunteers (60 male, 59 female) which consisted of three age groups of nearly equal size (I: 20-34 yrs.,II: 35-49 yrs.,III: ≥50 yrs.). CMR images were acquired on a 1.5 T whole body MRI applying a standard cine SSFP sequence. Right atrial (RA) function and morphology as well as RV sizes were assessed in a 4-chamber view. For the measurement of the RV volumes and function short axis views were used. End-diastolic and end-systolic volumes and diameters (EDV, ESV, EDD, ESD), RV stroke volume and ejection fraction (SV, EF) were measured. As the emptying of the RA is a combination of active and passive mechanisms we tried to quantify the contribution of the contraction by measuring the RA contractive stroke volume (RA CSV) and ejection fraction (RA CEF). Furthermore the RV end-diastolic and end-systolic length (EDL, ESL) and the RA end-diastolic and endsystolic area (EDA, ESA) were quantified. Body surface area (BSA) was calculated using the Mosteller formula. A p-value <0.05 was regarded as statistically significant. Results

Right ventricular function in dilated cardiomyopathy: relation to location of focal myocardial fibrosis

Background Severe right ventricular dysfunction (RVD) is an important prognostic parameter in dilated cardiomyopathy (DCM). The relationship between myocardial fibrosis of the left ventricle (LV) and particularly the septum and right ventricular (RV) function remains poorly understood. We sought to investigate this relationship in a large cohort of DCM patients using cardiovascular magnetic resonance (CMR). Methods We studied 257 patients (52±15ys,193men) with known DCM using a clinical 1.5 T CMR scanner (Philips Achieva). Short axis slices covering entirely both ventricles were acquired using standard SSFP-sequences for measurement of LV and RV volumes and ejection fraction (EF). Focal myocardial fibrosis was assessed in late gadolinium enhancement (LGE) CMR images acquired 10 minutes after i.v. injection of 0.2mmol/kg Gd-DTPA (Magnevist). SSFP and LGE CMR images were assessed by different observers who were blinded to measurement results and clinical data. Severe RVD was defined as RVEF<35%. In a subgroup of patients (n=96) invasive measurement of pulmonary artery pressure was performed. Results Mean LVEF was 35±14% while mean RVEF was 42 ±13%. Focal myocardial fibrosis was present in 92 (36%) patients and was located a) intra-murally within the inter-ventricular septum in 29 patients (LGE -septum) or b) sub-epicardially/diffuse in 63 patients (any-LGE). None of the patients had sub-endocardial LGE. LGEseptum patients exhibited a significantly higher RVEF (49±12%; vs. 40±14%;p=0.006), a higher RV EDV index (115±43 ml/m2; vs. 99±23 ml/m2 ;p=0.05) and a higher RV ESV index (73±45 ml/m2; vs. 52±22 ml/m2 ;p=0.01)