Right Ventricular End-systolic Volume Research Articles

Correlation between Electrocardiogram Changes and Right Ventricular Systolic Function in Patients with Chronic Atrial Fibrillation

Background: Chronic atrial fibrillation (CAF) induces various electric disturbances, and a single mutation can cause multifarious phenotypes or combinations. Identifying the correlation of electrocardiogram changes corresponding to the disorders of electrical activity with right ventricular systolic function (RVSF) is important for the treatment and prognosis of CAF. Therefore, this study explored the correlation of electrocardiogram changes and RVSF in patients with CAF. Methods: From March 2022, to March 2023, 97 patients with CAF admitted to the Department of Cardiology of our hospital (study group) and 100 normal people who received health examination (control group) were subjected to echocardiogram and electrocardiogram to record relevant parameters for correlation analysis. Results: Significant differences were found in the electrocardiogram indices and right heart function parameters between the two groups. The study group had significantly higher heart rate, QTc interval, QT interval and T wave time than the control group (p < 0.05). The study group showed significantly higher right ventricular end-diastolic volume (RVEDV) and right ventricular end-systolic volume (RVESV), and lower right ventricular stroke volume (RVSV) and right ventricular ejection fraction (RVEF) than the control group (p < 0.05). Pearson correlation analysis showed that QTc interval, QT interval, and T wave time were positively correlated with RVESV (p < 0.05); QTc interval, QT interval, and T wave time were negatively correlated with RVSV (p < 0.05); and QTc interval was negatively correlated with RVEF (p < 0.05). Conclusion: A correlation exists between electrocardiogram changes and RVSF in patients with CAF.

Improvement in right heart function following kidney transplantation in esrd patients: insights from speckle tracking echocardiography analysis.

Chronic kidney disease (CKD) is commonly associated with unfavorable cardiovascular outcomes and remains the leading cause of mortality in individuals with end-stage renal disease (ESRD). Despite substantial knowledge about the impact of CKD on the left heart, the right heart, which holds significant clinical relevance, has often been overlooked and inadequately assessed in ESRD patients who have undergone kidney transplant (KTx). This study aimed to evaluate the effects of KTx on the right heart chambers in ESRD patients. 57 adult KTx candidates were enrolled in this prospective longitudinal study, while 49 of them were included in the final assessment. Patients underwent a comprehensive cardiac assessment, including conventional echocardiography, speckle tracking echocardiography, and three-dimensional heart modeling both before and after surgery. Echocardiographic assessments showed significant increases in right ventricular (RV) ejection fraction, RV fractional area change (RVFAC), tricuspid annular plain systolic excursion, RV fractional shortening, right atrial (RA) reservoir, conduit, and booster strains, and RV global longitudinal strain (RVGLS). Moreover, significant reductions in RV end-diastolic volume (RVEDV), RV end-systolic volume (RVESV), RV stroke volume, RV end-diastolic diameter (RVEDD) in mid-cavity view, systolic pulmonary artery pressure was observed (all P values < 0.05). However, no significant difference was found in S velocity, as well as RVEDD in basal and apex-to-annulus view. Moreover, pre-KTx measurements of RVGLS, RVEDD (apex-to-annulus diameter), RV fractional shortening, and S velocity were predictors of RVGLS after KTx. RA conduit strain was also identified as a predictor of RA conduit strain after KTx. Additionally, age, RVEDV, RVESV, RVFAC, and RA reservoir strain before KTx were identified as independent predictors of RA reservoir strain after KTx. The findings of this study demonstrate a significant improvement in right heart function following KTx. Furthermore, strain analysis can provide valuable insights for predicting right heart function after KTx.

Atrial Shunt Device Effects on Cardiac Structure and Function in Heart Failure With Preserved Ejection Fraction

Although the results of A Study to Evaluate the Corvia Medical Inc IASD System II to Reduce Elevated Left Atrial Pressure in Patients with Heart Failure (REDUCE LAP-HF II) trial were neutral overall, atrial shunt therapy demonstrated potential efficacy in responders (no latent pulmonary vascular disease and no cardiac rhythm management device). Post hoc analyses were conducted to evaluate the effect of shunt vs sham stratified by responder status. To evaluate the effect of atrial shunt vs sham control on cardiac structure/function in the overall study and stratified by responder status. This was a sham-controlled randomized clinical trial of an atrial shunt device in heart failure with preserved ejection fraction (HFpEF)/HF with mildly reduced EF (HFmrEF). Trial participants with evaluable echocardiography scans were recruited from 89 international medical centers. Data were analyzed from April 2023 to January 2024. Atrial shunt device or sham control. Changes in echocardiographic measures from baseline to 1, 6, 12, and 24 months after index procedure. The modified intention-to-treat analysis of the REDUCE LAP-HF II trial included 621 randomized patients (median [IQR] age, 72.0 [66.0-77.0] years; 382 female [61.5%]; shunt arm, 309 [49.8%]; sham control arm, 312 [50.2%]). Through 24 months, 212 of 217 patients (98%) in the shunt arm with evaluable echocardiograms had patent shunts. In the overall trial population, the shunt reduced left ventricular (LV) end-diastolic volume (mean difference, -5.65 mL; P <.001), left atrial (LA) minimal volume (mean difference, -2.8 mL; P =.01), and improved LV systolic tissue Doppler velocity (mean difference, 0.69 cm/s; P <.001) and LA emptying fraction (mean difference, 1.88 percentage units; P =.02) compared with sham. Shunt treatment also increased right ventricular (RV; mean difference, 9.58 mL; P <.001) and right atrial (RA; mean difference, 9.71 mL; P <.001) volumes but had no effect on RV systolic function, pulmonary artery pressure, or RA pressure compared with sham. In the shunt arm, responders had smaller increases in RV end-diastolic volume (mean difference, 5.71 mL vs 15.18 mL; interaction P =.01), RV end-systolic volume (mean difference, 1.58 mL vs 7.89 mL; interaction P =.002), and RV/LV ratio (mean difference, 0.07 vs 0.20; interaction P <.001) and larger increases in transmitral A wave velocity (mean difference, 5.08 cm/s vs -1.97 cm/s; interaction P =.02) compared with nonresponders randomized to the shunt, suggesting greater ability to accommodate shunted blood through the pulmonary circulation enabling LA unloading. In this post hoc analysis of the REDUCE LAP-HF II trial, over 2 years of follow-up, atrial shunting led to reverse remodeling of left-sided chambers and increases in volume of right-sided chambers consistent with the shunt flow but no change in RV systolic function compared with sham. Changes in cardiac structure/function were more favorable in responders compared with nonresponders treated with the shunt, supporting the previously identified responder group hypothesis and mechanism, although further evaluation with longer follow-up is needed. ClinicalTrials.gov Identifier: NCT03088033.

Assessing right ventricular peak strain in myocardial infarction patients with mitral regurgitation by cardiac magnetic resonance feature tracking.

Although it is known that mitral regurgitation (MR) in patients with myocardial infarction (MI) may increase the right ventricular (RV) afterload, leading to RV dysfunction, the exact detrimental effects on RV function and myocardial peak strain remain unresolved. In this study, we assessed the impact of MR on the impairment of RV myocardial deformation in patients with MI and explored the independent influential factors of RV peak strain. A total of 199 MI participants without or with MR were retrospectively assessed in this study. The cardiovascular magnetic resonance examination protocol included a late gadolinium-enhanced (LGE) imaging technique and a cine-balanced steady-state free precession sequence. Statistical tests, including two independent sample t-test or Mann-Whitney U-test, analysis of variance, Kruskal-Wallis test, and multiple linear regression analysis models were performed. The MI (MR+) group exhibited significantly lower RV strain parameters in the radial, circumferential and longitudinal directions when compared to the control and the MI (MR-) groups (both P<0.05). The RV global longitudinal peak strain (GLPS) in the MI group significantly decreased when compared with that in the control group (P<0.05). As moderate-severe MR worsened in patients with MI, RV myocardial global peak strain and the peak systolic strain rate (PSSR) gradually decreased. Multiple linear regression analysis revealed that left ventricular (LV) GLPS, triglycerides, and age were independently correlated with RV GLPS (all P<0.05). RV end-systolic volume (RVESV) acted as an independent association factor for RV global peak strain. MR may exacerbate the impairment of RV peak strain and functions in patients with MI. LV GLPS was positively correlated with RV GLPS. However, RVESV, triglycerides, and age acted as independent risk factors associated with worsening RV GLPS.

Ferumoxytol-Enhanced Cardiac Cine MRI Reconstruction Using a Variable-Splitting Spatiotemporal Network.

Balanced steady-state free precession (bSSFP) imaging is commonly used in cardiac cine MRI but prone to image artifacts. Ferumoxytol-enhanced (FE) gradient echo (GRE) has been proposed as an alternative. Utilizing the abundance of bSSFP images to develop a computationally efficient network that is applicable to FE GRE cine would benefit future network development. To develop a variable-splitting spatiotemporal network (VSNet) for image reconstruction, trained on bSSFP cine images and applicable to FE GRE cine images. Retrospective and prospective. 41 patients (26 female, 53 ± 19 y/o) for network training, 31 patients (19 female, 49 ± 17 y/o) and 5 healthy subjects (5 female, 30 ± 7 y/o) for testing. 1.5T and 3T, bSSFP and GRE. VSNet was compared to VSNet with total variation loss, compressed sensing and low rank methods for 14× accelerated data. The GRAPPA×2/×3 images served as the reference. Peak signal-to-noise-ratio (PSNR), structural similarity index (SSIM), left ventricular (LV) and right ventricular (RV) end-diastolic volume (EDV), end-systolic volume (ESV), and ejection fraction (EF) were measured. Qualitative image ranking and scoring were independently performed by three readers. Latent scores were calculated based on scores of each method relative to the reference. Linear mixed-effects regression, Tukey method, Fleiss' Kappa, Bland-Altman analysis, and Bayesian categorical cumulative probit model. A P-value <0.05 was considered statistically significant. VSNet achieved significantly higher PSNR (32.7 ± 0.2), SSIM (0.880 ± 0.004), rank (2.14 ± 0.06), and latent scores (-1.72 ± 0.22) compared to other methods (rank >2.90, latent score < -2.63). Fleiss' Kappa was 0.52 for scoring and 0.61 for ranking. VSNet showed no significantly different LV and RV ESV (P = 0.938) and EF (P = 0.143) measurements, but statistically significant different (2.62 mL) EDV measurements compared to the reference. VSNet produced the highest image quality and the most accurate functional measurements for FE GRE cine images among the tested 14× accelerated reconstruction methods. 3 TECHNICAL EFFICACY: Stage 1.

Meta-Analysis of Normal Reference Values for Right and Left Ventricular Quantification by Cardiovascular Magnetic Resonance.

Cardiovascular magnetic resonance (CMR) reference values are relied upon to accurately diagnose left ventricular (LV) and right ventricular (RV) pathologies. To date, reference values have been derived from modest sample sizes with limited patient diversity and attention to 1 but not both commonly used tracing techniques for papillary muscles and trabeculations. We sought to overcome these limitations by meta-analyzing normal reference values for CMR parameters stemming from multiple countries, vendors, analysts, and patient populations. We comprehensively extracted published and unpublished data from studies reporting CMR parameters in healthy adults. A steady-state free-precession short-axis stack at 1.5T or 3T was used to trace either counting the papillary muscles and trabeculations in the LV volume or mass. We used a novel Bayesian hierarchical meta-analysis model to derive the pooled lower and upper reference values for each CMR parameter. Our model accounted for the expected differences between tracing techniques by including informative prior distributions from a large external data set. A total of 254 studies from 25 different countries were systematically reviewed, representing 12 812 healthy adults, of which 52 were meta-analyzed. For LV parameters counting papillary muscles and trabeculations in the LV volume, pooled normative reference ranges in men and women, respectively, were as follows: LV ejection fraction of 52% to 73% and 54% to 75%, LV end-diastolic volume index of 60 to 109 and 56 to 96 mL/m2, LV end-systolic volume index of 18 to 45 and 16 to 38 mL/m2, and LV mass index of 41 to 76 and 33 to 57 g/m2. For LV parameters counting papillary muscles and trabeculations in the LV mass, pooled normative reference ranges in men and women, respectively, were as follows: LV ejection fraction of 57% to 74% and 57% to 75%, LV end-diastolic volume index of 60 to 97 and 55 to 88 mL/m2, LV end-systolic volume index of 18 to 37 and 15 to 34 mL/m2, and LV mass index of 50 to 83 and 38 to 65 g/m2. For RV parameters, pooled normative reference ranges in men and women, respectively, were as follows: RV ejection fraction of 47% to 68% and 49% to 71%, RV end-diastolic volume index of 64 to 115 and 57 to 99 mL/m2, RV end-systolic volume index of 23 to 52 and 18 to 42 mL/m2, and RV mass index of 14 to 29 and 13 to 25 g/m2. Our Bayesian hierarchical meta-analysis provides normative reference values for CMR parameters of LV and RV size, systolic function, and mass, encompassing both tracing techniques across a diverse multinational sample of healthy men and women.

Right ventricular-pulmonary arterial coupling ratio derived from 3-dimensional echocardiography predicts outcomes in systemic lupus erythematosus-associated pulmonary arterial hypertension patients.

Systemic lupus erythematosus (SLE) is a complex autoimmune connective tissue disease (CTD) that is an important cause of devastating pulmonary arterial hypertension (PAH), and persistent progression of PAH can lead to right heart failure, predicting a poor prognosis for SLE patients. Right ventricular-pulmonary arterial (RV-PA) coupling with echocardiography has been demonstrated to be a noninvasive alternative method for evaluating PAH patients' predictive outcomes. Whether the ratio of right ventricular stroke volume (RVSV) to right ventricular end-systolic volume (RVESV) measured by three-dimensional echocardiography (3DE) is a new index of RV-PA coupling has not been discussed as a new predictor for the clinical outcome of systemic lupus erythematosus-associated pulmonary arterial hypertension (SLE-PAH). From June 2019 to February 2023, 46 consecutive patients with SLE-PAH were enrolled prospectively, and their clinical data and echocardiographs were studied and analyzed. The control group consisted of 30 healthy subjects matched for age, sex, and body surface area (BSA). The main endpoints of this study were a composite of all-cause mortality and adverse clinical events. Baseline clinical characteristics and echocardiographic assessments were analyzed. During a median of 24months (IQR 18-31), 16 of 46 SLE-PAH patients (34.7%) experienced endpoint-related events. At baseline, patients who experienced mortality or adverse events had a worse WHO functional class (WHO FC) and lower anti-double-stranded DNA (dsDNA) antibody levels. The right ventricular (RV) systolic dysfunction in SLE-PAH subjects was significantly worse than that in the healthy control group, especially in SLE-PAH patients in the endpoint event group. Compared to controls, patients with SLE-PAH had a lower RVSV/RVESV ratio. In the group comparison, patients who had experienced an endpoint event had a sequentially worse ratio (1.86 (1.65-2.3) versus 1.30 (1.09-1.46) versus 0.64 (0.59-0.67), p < .001). There were statistically significant associations between the RVSV/RVESV ratio to routine RV systolic function and clinical parameters. The RVSV/RVESV ratio was negatively correlated with the WHO FC (r = -0.621, p < .001) and positively correlated with the anti-dsDNA level. The ROC curve showed that the optimal cutoff for RVSV/RVESV < 0.712 determined a higher risk of poor prognosis. Kaplan‒Meier survival curves showed that an RVSV/RVESV ratio >0.712 was associated with more favorable long-term outcomes. The 3DE-derived SV/ESV ratio as a noninvasive alternative surrogate of RV-PA coupling was an eximious indicator for identifying endpoint events in SLE-PAH patients and can provide a diagnostic basis for clinical intervention.

Cardiovascular magnetic resonance reference values of right ventricular volumetric variables in patients with hypoplastic left heart syndrome

Cardiovascular magnetic resonance (CMR) has established itself as the gold standard for serial assessment of systemic right ventricular (RV) performance but due to the lack of standardized RV reference values for hypoplastic left heart syndrome (HLHS) patients, the interpretation of RV volumetric data in HLHS remains difficult. Therefore, this study aimed to close this gap by providing CMR reference values for the systemic RV in HLHS patients. CMR scans of 160 children, adolescents, and young adults (age range 2.2-25.2years, 106 males) with HLHS were retrospectively evaluated. All patients were studied following total cavopulmonary connection. Short-axis stacks were used to measure RV end-diastolic and end-systolic volumes (RVEDV, RVESV), RV stroke volume (RVSV), RV ejection fraction (RVEF), and RV end-diastolic myocardial mass (RVEDMM). Univariable and multiple linear regression analyses were performed to assess associations between RV parameters and demographic and anthropometric characteristics. Following the results of the regression analysis, reference graphs and tables were created with the Lambda-Mu-Sigma method. Multiple linear regression analysis showed strong associations between body height and RVEDV, RVESV as well as RVSV. Age was highly associated with RVEDMM. Therefore, percentile curves and tables were created with respect to body height (RVEDV, RVESV, RVSV) and age (RVEDMM). The influence of demographic and anthropometric parameters on RVEF was mild, thus no percentile curves and tables for RVEF are provided. We were able to define CMR reference values for RV volumetric variables for HLHS patients. These data might be useful for the assessment and interpretation of CMR scans in these patients and for research in this field.

Speckle tracking echocardiography for diagnosis of right ventricular failure in children with totally corrected tetralogy of Fallot in Sulaimani, Iraq

ObjectivesThe study was aimed at using speckle tracking echocardiography as a novel technique to diagnose right ventricular failure (RVF) in children with total correction of tetralogy of Fallot (TOF) through surgery. MethodsA quasi-experimental study was performed at the Children's Heart Hospital of Sulaimani for 9 months. A total of 150 children with completely repaired TOF were enrolled to investigate RVF. Conventional echocardiographic data were recorded, including right ventricular (RV) ejection fraction (EF), tricuspid annular plane systolic excursion (TAPSE), myocardial performance index (MPI), and RV end-systolic and diastolic volume (RVESV and RVEDV). Additionally, speckle tracking was performed for the regional and longitudinal strain and strain rate in four-chamber apical view. RVF diagnosis was determined on the basis of electrocardiography measurement of P-wave dispersion, T-wave dispersion, and QRS duration. ResultsChildren with repaired TOF who were diagnosed with RVF through conventional echocardiography exhibited abnormalities with respect to children with normal RV function, including a TAPSE of 1.3 ± 0.11 cm, RVEF of 35.5 ± 6.72, RVESV of 69.8 ± 15.13 ml, RVEDV of 110.1 ± 14.13 ml, MPI of 0.60 ± 0.12, and Pmax of 52.4 ± 14.08. The use of speckle tracking in RVF diagnosis revealed a relatively lower longitudinal strain and strain rate (−12.1 ± 2.3 and −0.9 ± 0.3, respectively) in the children with RVF. Moreover, longitudinal right ventricular strain was positively correlated with TAPSE (r = 0.656) and EF (r = 0.675), and negatively correlated with RVEDV (r = −0.684), RVESV (r = −0.718), MPI (r = −0.735), and Pmax (r = −0.767). ConclusionsThe application of speckle tracking with the longitudinal RV strain and strain rate to estimate RV function in children with repaired TOF is a new advanced method that, compared with conventional echo, significantly improves the diagnosis of regional myocardial deformations and cardiac muscle motion velocity.

Comparison of prognostic value among echocardiographic surrogates of right ventricular-pulmonary arterial coupling: A three-dimensional echocardiographic study.

Right ventricular (RV)-pulmonary arterial (PA) coupling is important in various cardiac diseases. Recently, several echocardiographic surrogates for RV-PA coupling have been proposed and reported to be useful in predicting outcomes. However, it remains unclear which surrogate is the most clinically relevant. This study aimed to comprehensively compare the prognostic value of different echocardiographic RV-PA coupling surrogates. We retrospectively reviewed 242 patients with various cardiac conditions who underwent comprehensive transthoracic echocardiography with three-dimensional RV data. In addition to conventional parameters including tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and PA systolic pressure (PASP), we analyzed RV free wall and global longitudinal strain (FWLS and GLS). We also obtained RV ejection fraction (RVEF), stroke volume (SV), and end-systolic volume (ESV) using three-dimensional RV analysis. RV-PA coupling surrogates were calculated as TAPSE/PASP, FAC/PASP, FWLS/PASP, GLS/PASP, RVEF/PASP, and SV/ESV. The study endpoint was a composite outcome of all-cause death or cardiovascular hospitalization within 1 year. In multivariable analysis, all the RV-PA coupling surrogates were independent predictors of the outcome. Among the surrogates, the model with TAPSE/PASP showed the lowest prognostic value in model fit and discrimination ability, whereas the model with RVEF/PASP exhibited the highest prognostic value. The partial likelihood ratio test indicated that the model with RVEF/PASP was significantly better than the model with TAPSE/PASP (p<.024). All the RV-PA coupling surrogates were independent predictors of the outcome. Notably, RVEF/PASP had the highest prognostic value among the surrogates.

CMR imaging to study biventricular pacing effects on the right ventricle in left bundle branch block patients

Abstract Background Cardiac resynchronization therapy (CRT) is an established treatment strategy for selected patients with symptomatic heart failure, left ventricular (LV) systolic dysfunction, and a left bundle branch block conduction abnormality. The effect of CRT on right ventricular (RV) function and possible reverse remodeling however, is less well understood and conflicting data are present. Moreover, the difficulty to accurately measure RV hemodynamics non-invasively may also hamper research on RV function in CRT patients. Recent development of cardiac magnetic resonance (CMR) conditional CRT-devices allows for proper patient follow-up as BIV-pacing can be performed during the CMR exam. Therefore, this study assesses the effects of BIV-pacing on change in RV volumes and function using CMR. Methods Ten patients eligible for CRT-D implantation according to the ESC guidelines were prospectively enrolled in this study. All patients underwent CMR imaging at baseline including cine imaging for volume and function assessment. Six weeks after CRT-D implantation, patients received a follow-up CMR scan which consisted of a two-staged imaging protocol. First, patients were scanned during BIV-pacing and thereafter the CRT was turned off and patients were scanned during intrinsic rhythm. RV end systolic volume (ESV), end diastolic volume (EDV), and ejection fraction (RVEF) were assessed on cine images. RV volumes and function before and after device implantation are compared using paired samples T-tests and results are displayed in the figure. Results RV ESV, EDV, and RVEF were not different at CRT-on as compared to baseline (ESV; 94.0±20.3ml vs. 88.9±21.1ml, p=0.44, EDV; 182.4±29.5ml vs. 175.1±22.8ml, p=0.37, and RVEF; 48.6±6.6% vs. 49.6±8.1%, p=0.75). Also, an acute deterioration in RVEF was observed when switching CRT-off (48.6±6.6% vs. 41.1±5.7%, p=0.02). Moreover, RV function was significantly worse during CRT-off compared to baseline in terms of RVEF (41.1±5.7% vs. 49.6±8.1%, p&amp;lt;0.01) and higher volumes (ESV; 119.0±26.4ml vs. 88.9±21.1ml, p&amp;lt;0.001, EDV; 200.8±34.2ml vs. 175.1±22.8ml, p&amp;lt;0.01). Conclusions This study showed that RV hemodynamics did not benefit from CRT. Moreover, turning off CRT at follow-up had an instantaneous negative effect on RV function as compared to BIV-pacing, leading to even worse RV hemodynamics as compared to baseline measurements.

Tricuspid regurgitation in pulmonary arterial hypertension: relations with right ventricular function and prognosis

Abstract Background Pulmonary arterial hypertension (PAH) is a devastating disease characterized by progressive pulmonary vascular remodeling and increased pulmonary vascular resistance (PVR), subsequent right ventricular (RV) failure and premature death (1). Progressive RV overload leads to RV dilatation, which in turn induces tethering of the tricuspid valve and functional valvular regurgitation (2,3). As such, severity and the progression of tricuspid regurgitation (TR), as evaluated by echocardiographic qualitative analysis, are reported to associate with a poor prognosis in PAH (4,5). However, it has remained unclear to what extent the severity of TR directly impacts RV hemodynamics and prognosis of PAH patients. Purpose This study aimed to explore the consequences of TR for RV function and prognosis in PAH using a volumetric analysis by cardiac magnetic resonance (CMR). Methods 92 PAH patients, mean pulmonary arterial pressure (mPAP) ≥25 mmHg and pulmonary artery wedge pressure ≤15 mmHg, with available CMR data from January 1st 2010 to August 31st 2021 were included in this study. TR volume was calculated as the difference between the stroke volume (SV) of RV and pulmonary artery (PA). TR severity was graded as no or mild (TR&amp;lt;30 mL), moderate (30≤TR&amp;lt;45 mL) and severe (TR≤45 mL). Hemodynamic assessment was performed by right heart catheterization. Event free survival was estimated from the time of the CMR scan to cardiopulmonary death or lung transplantation. Results In the studied cohort, 74% of PAH patients had no or mild TR, 16% had moderate TR, and 10% had severe TR (Table 1). A greater TR volume was characterized by increased NT-proBNP, increased mPAP, PVR and mean right atrial pressure (mRAP), and increased RV volume. Additionally, RVSV was higher while PASV was lower. There was no difference in RV ejection fraction (RVEF). Pearson correlation analysis showed a good correlation between TR volume and parameters of PAH severity, such as NT-proBNP, RV end-systolic volume (RVESV), mRAP and cardiac index (CI) (Figure 1). ROC curves analysis revealed that the optimal cut-off value of TR volume was 30 mL. Kaplan-Meier survival analysis demonstrated that TR volume ≥30 mL was strongly associated with a poor event free survival (Figure 2). Conclusion 26% of PAH patients had a TR volume 30 ≥mL. TR severity showed a good correlation with PAH disease severity. TR volume 30 ≥mL, i.e. moderate or severe TR, was strongly associated with a poor prognosis in PAH patients.TableFigure

Effect of empagliflozin on CMR-estimated pulmonary capillary wedge pressure in patients with type 2 diabetes, or prediabetes, and heart failure with reduced ejection fraction (SUGAR-DM-HF)

Abstract Background/Introduction Pulmonary capillary wedge pressure (PCWP) is a measure of left ventricular (LV) filling pressure usually invasively assessed during right heart catheterisation. A cardiac magnetic resonance (CMR) imaging-based model to non-invasively estimate PCWP was recently developed. Purpose In this exploratory analysis of the SUGAR-DM-HF trial (NCT03485092) we assessed the association of CMR-estimated PCWP (CMR-PCWP) with other imaging and circulating biomarker measures of congestion in patients with heart failure and reduced ejection fraction (HFrEF) and type 2 diabetes or prediabetes. We also investigated the effect of empagliflozin on CMR-PCWP and the relationship between CMR-PWCP and the remodelling effect of empagliflozin. Methods A total of 105 patients with HFrEF were randomly assigned 1:1 to empagliflozin 10 mg once daily or placebo. CMR-PCWP and other ultrasound and circulating biomarker measures of congestion were estimated at baseline and 36 weeks. CMR-PCWP (mmHg) was calculated using the formula: 6.1352 + (0.07204*left atrial volume) + (0.02256*LV mass). Results 105 patients with HFrEF, mean age 69 years, 73% males, mean left ventricular ejection (LVEF) 33% were randomised. Mean baseline CMR-PCWP was 15.0 mmHg. CMR-PCWP was ≥15 mmHg in 52 (50% patients) at baseline. At baseline, patients with higher PCWP (≥15 mmHg) were more frequently male, had higher body mass index, higher N-terminal pro-B-type natriuretic peptide (NT-proBNP), and a greater number of B-lines on lung ultrasound (LUS). Peripheral oedema was present in 69% and 57% of patients with higher PCWP and lower PCWP, respectively (p = 0.18). Pulmonary crepitations were present in 13% and 11% of patients with higher and lower PCWP, respectively (p = 0.74). At baseline, CMR-derived PCWP correlated with log-NT-proBNP (r = 0.31, p&amp;lt;0.001), left atrial (LA) volume (r = 0.94, p&amp;lt;0.001), E/e’ (r = 0.36, p = 0.02), MRI-derived LV volumes (LV end-systolic volume: r = 0.56 p&amp;lt;0.001; LV end-diastolic volume: r = 0.62 p&amp;lt;0.001), LVEF (r=-0.26 p = 0.01), and right ventricular (RV) volumes (RV end-systolic volume: r = 0.56 p&amp;lt;0.001; RV end-diastolic volume: r = 0.61 p&amp;lt;0.001). Mean CMR-PCWP decreased from baseline to 36 weeks by -0.37 (95% CI -0.78 to 0.05) mmHg and -0.17 (95% CI -0.69 to 0.36) mmHg in the empagliflozin and placebo groups, respectively; placebo-corrected difference -0.43 mmHg (95% CI -1.09 to 0.23), p = 0.20 (Figure 1). The beneficial effect of empagliflozin on reducing LV end-systolic volume index was not modified by baseline CMR-PCWP (p interaction = 0.98). Conclusions In patients with HFrEF, higher non-invasively measured CMR-derived PCWP was associated with NT-proBNP, MRI-derived LV and RV volumes and LUS markers of congestion. There were no between group difference in CMR-derived PCWP, although this study was not powered for this outcome.Figure 1

Right ventricular diastolic adaptation to pressure overload in different rat strains

Abstract Background Different rat strains are used in various animal models of pulmonary hypertension and right ventricular (RV) failure. No systematic assessment has been performed to test differences in RV response to pressure overload between rat strains. Purpose We compared RV adaptation to pulmonary trunk banding (PTB) in Wistar, Sprague Dawley, and Fischer344 rats by hemodynamic profiling focusing on diastolic function. Methods Age-matched male rat weanlings were randomized to sham operation (Wistar sham, n=5; Sprague Dawley sham, n=4; Fischer344 sham, n=4) or PTB (Wistar PTB, n=8; Sprague Dawley PTB, n=8; Fischer344 PTB, n=8). RV function was evaluated after five weeks by echocardiography, cardiac MRI, and invasive pressure-volume measurements and RV remodelling assessed by histological analyses. Results At end of study, Fischer344 rats weighed 25 % less than Wistar and Sprague Dawley rats. PTB increased RV systolic pressures four-fold, and RV failure was evident by a decrease in cardiac index (Wistar PTB: 1.8±0.2 mL/s/m2 vs. Wistar sham: 3.9±0.2 mL/s/m2, p&amp;lt;0.0001; Sprague Dawley PTB: 1.7±0.1 mL/s/m2 vs. Sprague Dawley sham: 3.0±0.3 mL/s/m2, p=0.0029; Fischer344 PTB: 2.1±0.2 mL/s/m2 vs. Fischer344 sham: 3.8±0.3 mL/s/m2, p&amp;lt;0.0001). There was a 2.4-fold increase in RV end-systolic volume index in Wistar PTB and Sprague Dawley PTB compared with sham, while Fischer344 PTB rats were less affected with only a 2.0-fold increase in RV end-systolic volume index compared with Fischer344 sham. Diastolic and right atrial impairment were evident by increased end-diastolic elastance, filling pressure, and E/e’ in PTB rats compared with sham, again Fischer344 PTB the least affected. PTB increased RV fibrosis in all groups compared with sham, though Fischer344 PTB showed a trend towards a smaller increase in RV fibrosis (Fischer344 PTB: 9.2±0.4 % vs Wistar PTB: 10.7±0.2 %, p=0.0919). Conclusions PTB caused RV failure in all rats subjected to the procedure including signs of diastolic dysfunction. Despite similar increase in RV systolic pressure, Fischer344 PTB rats showed less RV dilatation and where more able to sustain diastolic function compared with Wistar and Sprague Dawley PTB rats. All three rat strains are suitable for PTB and studies of RV failure.

4D flow MRI-derived energy loss and RV workload in adults with tetralogy of Fallot

PurposeTo assess flow energy loss (EL) pattern inside the pulmonary circulation in adult patients with repaired tetralogy of Fallot (TOF), particularly in TOF with pulmonary stenosis (PS) and pulmonary regurgitation (PR), as a cardiac workload parameter and its relationship to symptoms and major adverse cardiovascular events (MACE). MethodsProspectively, 51 consecutive TOF adults after intracardiac repair, who underwent four-dimensional flow magnetic resonance imaging, were enrolled. All of them had significant PR (PR regurgitant fraction >25 %). TOF patients who had already reached the conventional criteria were excluded. We defined MACE as the following: 1) fatal arrhythmias, 2) sudden cardiac death, 3) surgical pulmonary valvular repair (PVR), 4) right heart failure (HF) needing diuretics and/or hospitalization within 2 years. ResultsA total of 15 patients had MACE; 1) 10 patients underwent PVR within 2 years, 2) 2 patients had ventricular tachycardia, and 3) 6 patients developed right HF (overlapped). Right ventricular (RV) end diastolic volume index (EDVI), RV end systolic volume index (ESVI), average EL/cardiac output (CO), and diastolic EL/CO in patients with MACE were greater than ones without MACE. On a multivariate logistic analysis, the diastolic EL/CO ratio and RVEDVI had the highest odds with MACE in all TOF (odds ratio, 40.7 and 1.15. 95%CI, 1.83–905 and 1.02–13.0; p-value, 0.02 and 0.03). In sub-analysis within 29 patients with moderate PS with PR, and 10 patients with MACE showed higher diastolic EL/CO. Average and diastolic EL/CO negatively correlated with RV ejection fraction (EF) in this sub-analysis. ConclusionsHigh EL, particularly, high diastolic EL/CO, were the important factors for MACE in adult TOF. Higher diastolic EL/CO was also related to lower RV EF and deteriorated RV function in adult TOF with PS and PR. Right-sided EL can be a sensitive marker of excessive cardiac workload which integrates both afterload and preload in adult patients with TOF, beyond the RV size.

Right ventricular ejection fraction derived from intraoperative three-dimensional transesophageal echocardiography versus cardiac magnetic resonance imaging.

Right ventricle (RV) assessment is critical during cardiac surgery. Traditional assessment consists of visual estimation and measurement of validated parameters. Cardiac magnetic resonance imaging (cMRI) is the gold standard for RV analysis, and transthoracic three-dimensional (3D) echocardiography is validated against this. We aimed to show that intraoperative 3D transesophageal echocardiography (TEE) RV assessment is feasible and can produce results that correlate with cMRI. We recruited cardiac surgery patients who underwent cMRI within the preceding twelve preoperative months. An anesthetic protocol was followed pre-sternotomy and a 3D RV data set was acquired. We used TOMTEC 4D RV-Function to derive RV end-diastolic volume (EDV), end-systolic volume (ESV), and ejection fraction (EF). We compared these data with the corresponding MRI values. Twenty-five patients were included. Transesophageal echocardiography EDV and ESV differed from MRI measurements with a mean bias of -53mL (95% confidence interval [CI], -80 to 26) and -21mL (95% CI, -34 to -9). Transesophageal echocardiography EF did not differ significantly, with a mean bias of -4% (95% CI, -8 to 1). Results were unchanged after excluding MRIs older than 180days. Correlation coefficients for EDV, ESV, and EF were r = 0.85, 0.91, and 0.80, respectively. Interclass correlation coefficients for EDV, ESV, and EF were 0.86, 0.89, and 0.96, respectively. Intraoperative TEE RV, EDV, and ESV are underestimated relative to cMRI because of analysis, anesthetic, and ventilation factors. The EF showed a low mean difference, and all values showed strong correlation with MRI. Reproducibility and feasibility were excellent and increased use in clinical practice should be considered.

Echocardiographic determination of right ventricular volumes and ejection fraction: Validation of a truncated cone and rhomboid pyramid formula.

Echocardiographic assessment of right ventricular (RV) measurements may be challenging. The aim of this study was to develop a formula for calculation of RV volumes and function based on measurements of linear dimensions by 2-dimensional (2D) transthoracic echocardiography (TTE) in comparison to cardiovascular magnetic resonance (CMR). 129 consecutive patients with standard TTE and RV analysis by CMR were included. A formula based on the geometric assumptions of a truncated cone minus a truncated rhomboid pyramid was developed for calculations of RV end-diastolic volume (EDV) and RV end-systolic volume (ESV) by using the basal diameter of the RV (Dd and Ds) and the baso-apical length (Ld and Ls) in apical 4-chamber TTE views: RV EDV = 1.21 * Dd2 * Ld, and RV ESV = 1.21 * Ds2 * Ls. Calculations of RV EDV (ΔRV EDV = 10.2±26.4 ml to CMR, r = 0.889), RV ESV (ΔRV ESV = 4.5±18.4 ml to CMR, r = 0.921) and RV EF (ΔRV EF = 0.5±4.0% to CMR, r = 0.905) with the cone-pyramid formula (CPF) highly agreed with CMR. Impaired RV function on CMR (n = 52) was identified with a trend to higher accuracy by CPF than by conventional echocardiographic parameters (tricuspid annular plane systolic excursion (TAPSE) and fractional area change (FAC)). Calculations of RV volumes and RV function by 2D TTE with the newly developed CPF were in high concordance to measurements by CMR. Accuracy for detection of patients with reduced RV function were higher by the proposed 2D TTE CPF method than by conventional echocardiographic parameters of TAPSE and RV FAC.

Comparison and Validity of Fragmented QRS (fQRS) Against Cardiac Magnetic Resonance (CMR) in Predicting Right Heart Function in Tetralogy of Fallot Patients After Reconstructive Surgery

Background: Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. Patients with repaired TOF (rTOF) expose to moderate to severe pulmonary regurgitation (PR), right ventricular (RV) dysfunction, and RV failure. Although cardiac magnetic resonance (CMR) provides details of RV function and structure, an electrocardiogram (ECG) is accessible and inexpensive. Objectives: We aimed to assess the correlation between clinical symptoms and ECG parameters with CMR findings. Methods: This cross-sectional study assessed the patients with rTOF who underwent CMR between May 2020 and September 2022 in Imam Reza Hospital. The signs and symptoms of rTOF were assessed, and a pediatric cardiologist interpreted ECG parameters. We considered CMR findings, clinical symptoms, and ECG parameters with CMR findings in rTOF. In addition, fragmented QRS (fQRS), the additional spikes within the QRS complex, was used to indicate conduction disturbance due to myocardial scar or fibrosis. Data were analyzed by SPSS version 18. Results: Among 42 patients with rTOF, 20 patients were male. Although the QT correction (QTc) had a significant correlation with CMR parameters, fQRS showed a positive correlation with right ventricular ejection fraction (RVEF) less than 47% (OR 2.06, 95% CI 1.45 - 2.93; P-value = 0.005), right ventricular end-diastolic volume (RVEDV) more than 150 mL/m2 (OR 4.4, 95% CI 2.03 - 9.5; P-value = 0), and right ventricular end-systolic volume (RVESV) more than 80 mL/m2 (OR 2.83, 95% CI 1.59 - 5.04; P-value = 0). We found a murmur in the clinical examination of 64.3% of patients. Our results showed that tachycardia and tachypnea were the most common signs in these patients. Surgery at a young age was significantly correlated to lower ascending aortic volume, right pulmonary artery size, left pulmonary artery size, right atrium and left atrium volume, and main pulmonary artery flow. Conclusions: Compared to other ECG parameters, fQRS could strongly predict RVESV, RVEDV, and RVEF as the right heart indexes. Besides, repair surgery at a younger age reduces the possibility of needing pulmonary valve replacement surgery at older ages. Therefore, clinicians should consider these issues in patients.

Establishing minimally important differences for cardiac MRI end-points in pulmonary arterial hypertension.

Cardiac magnetic resonance (CMR) is the gold standard technique to assess biventricular volumes and function, and is increasingly being considered as an end-point in clinical studies. Currently, with the exception of right ventricular (RV) stroke volume and RV end-diastolic volume, there is only limited data on minimally important differences (MIDs) reported for CMR metrics. Our study aimed to identify MIDs for CMR metrics based on US Food and Drug Administration recommendations for a clinical outcome measure that should reflect how a patient "feels, functions or survives". Consecutive treatment-naïve patients with pulmonary arterial hypertension (PAH) between 2010 and 2022 who had two CMR scans (at baseline prior to treatment and 12 months following treatment) were identified from the ASPIRE registry. All patients were followed up for 1 additional year after the second scan. For both scans, cardiac measurements were obtained from a validated fully automated segmentation tool. The MID in CMR metrics was determined using two distribution-based (0.5sd and minimal detectable change) and two anchor-based (change difference and generalised linear model regression) methods benchmarked to how a patient "feels" (emPHasis-10 quality of life questionnaire), "functions" (incremental shuttle walk test) or "survives" for 1-year mortality to changes in CMR measurements. 254 patients with PAH were included (mean±sd age 53±16 years, 79% female and 66% categorised as intermediate risk based on the 2022 European Society of Cardiology/European Respiratory Society risk score). We identified a 5% absolute increase in RV ejection fraction and a 17 mL decrease in RV end-diastolic or end-systolic volumes as the MIDs for improvement. Conversely, a 5% decrease in RV ejection fraction and a 10 mL increase in RV volumes were associated with worsening. This study establishes clinically relevant CMR MIDs for how a patient "feels, functions or survives" in response to PAH treatment. These findings provide further support for the use of CMR as a clinically relevant clinical outcome measure and will aid trial size calculations for studies using CMR.

Comprehensive echocardiographic assessment of right ventricular function, pulmonary arterial elastic properties and ventricular-vascular coupling in adult patients with repaired tetralogy of fallot: clinical significance of 3D derived indices.

We aimed to comprehensively analyze by three-dimensional speckle-tracking echocardiography (3DSTE) and Doppler echocardiography right ventricular (RV) performance, pulmonary arterial (PA) elastic properties and right ventricular-pulmonary artery coupling (RVPAC) in patients with repaired tetralogy of Fallot (rTOF) and assess the feasibility and clinical utility of related echocardiographic indices. Twenty-four adult patients with rTOF and twenty-four controls were studied. RV end-diastolic volume(3D-RVEDV), RV end-systolic volume(3D-RVESV), RV ejection fraction(3D-RVEF), RV longitudinal strain(3D-RVLS) and RV area strain(3D-RVAS) were calculated by 3DSTE. RV end-systolic area (RVESA) was obtained by planimetry. Pulmonary regurgitation (PR) was assessed as trivial/mild or significant by cardiac magnetic resonance (CMR) and color-Doppler. Pulmonary artery (PA) elastic properties were determined using two-dimensional/Doppler echocardiography. RV systolic pressure (RVSP) was measured using standard Doppler methods. RVPAC was assessed using various 3DSTE-derived parameters (3DRVAS/RVSP, 3DRVLS/RVESA, 3DRVAS/RVESV). Overall, 3DRVEF and 3DRVAS were impaired in rTOF patients compared with controls. PA pulsatility and capacitance were reduced (p = 0.003) and PA elastance was higher (p = 0.0007) compared to controls. PA elastance had a positive correlation with 3DRVEDV (r = 0.64, p = 0.002) and 3DRVAS (r = 0.51, p = 0.02). By ROC (receiver operating characteristics) analysis, 3DRVAS/RVESV, 3DRVAS/RVSP and 3DRVLS/RVESA cutoff values of 0.31%/mmHg, 0.57%/mmHg and 0.86%/mmHg, respectively, had 91%, 88% and 88% sensitivity and 81%, 81% and 79% specificity in identifying exercise capacity impairment. In rTOF patients increased 3DSTE-derived RV volumes and impaired RV ejection fraction and strain are associated with reduced PA pulsatility and capacitance and increased PA elastance. 3DSTE-derived RVPAC parameters using different afterload-markers are accurate indices of exercise capacity.