Analysis Of Right Ventricular Function Research Articles

Comprehensive temporal analysis of right ventricular function and pulmonary haemodynamics in mechanically ventilated COVID-19 ARDS patients

BackgroundCardiac injury is frequently reported in COVID-19 patients, the right ventricle (RV) is mostly affected. We systematically evaluated the cardiac function and longitudinal changes in severe COVID-19 acute respiratory distress syndrome (ARDS) admitted to the intensive care unit (ICU) and assessed the impact on survival.MethodsWe prospectively performed comprehensive echocardiographic analysis on mechanically ventilated COVID-19 ARDS patients, using 2D/3D echocardiography. We defined left ventricular (LV) systolic dysfunction as ejection fraction (EF) < 40%, or longitudinal strain (LS) > − 18% and right ventricular (RV) dysfunction if two indices among fractional area change (FAC) < 35%, tricuspid annulus systolic plane excursion (TAPSE) < 1.6 cm, RV EF < 44%, RV–LS > − 20% were present. RV afterload was assessed from pulmonary artery systolic pressure (PASP), PASP/Velocity Time Integral in the right ventricular outflow tract (VTIRVOT) and pulmonary acceleration time (PAcT). TAPSE/PASP assessed the right ventriculoarterial coupling (VACR).ResultsAmong 176 patients included, RV dysfunction was common (69%) (RV–EF 41.1 ± 1.3%; RV–FAC 36.6 ± 0.9%, TAPSE 20.4 ± 0.4mm, RV–LS:− 14.4 ± 0.4%), usually accompanied by RV dilatation (RVEDA/LVEDA 0.82 ± 0.02). RV afterload was increased in most of the patients (PASP 33 ± 1.1 mmHg, PAcT 65.3 ± 1.5 ms, PASP/VTIRVOT, 2.29 ± 0.1 mmHg/cm). VACR was 0.8 ± 0.06 mm/mmHg. LV–EF < 40% was present in 21/176 (11.9%); mean LV–EF 57.8 ± 1.1%. LV–LS (− 13.3 ± 0.3%) revealed a silent LV impairment in 87.5%. A mild pericardial effusion was present in 70(38%) patients, more frequently in non-survivors (p < 0.05). Survivors presented significant improvements in respiratory physiology during the 10th ICU-day (PaO2/FiO2, 231.2 ± 11.9 vs 120.2 ± 6.7 mmHg; PaCO2, 43.1 ± 1.2 vs 53.9 ± 1.5 mmHg; respiratory system compliance—CRS, 42.6 ± 2.2 vs 27.8 ± 0.9 ml/cmH2O, all p < 0.0001). Moreover, survivors presented significant decreases in RV afterload (PASP: 36.1 ± 2.4 to 20.1 ± 3 mmHg, p < 0.0001, PASP/VTIRVOT: 2.5 ± 1.4 to 1.1 ± 0.7, p < 0.0001 PAcT: 61 ± 2.5 to 84.7 ± 2.4 ms, p < 0.0001), associated with RV systolic function improvement (RVEF: 36.5 ± 2.9% to 46.6 ± 2.1%, p = 0.001 and RV–LS: − 13.6 ± 0.7% to − 16.7 ± 0.8%, p = 0.001). In addition, RV dilation subsided in survivors (RVEDA/LVEDA: 0.8 ± 0.05 to 0.6 ± 0.03, p = 0.001). Day-10 CRS correlated with RV afterload (PASP/VTIRVOT, r: 0.535, p < 0.0001) and systolic function (RV–LS, 0.345, p = 0.001). LV–LS during the 10th ICU-day, while ΔRV–LS and ΔPASP/RVOTVTI were associated with survival.ConclusionsCOVID-19 improvements in RV function, RV afterload and RV–PA coupling at day 10 were associated with respiratory function and survival.

Right ventricular function in moderate-to-severe ventricular tricuspid regurgitation: Is there a pseudo-normalization of conventional echocardiographic parameters?

Abstract Background A reliable evaluation of right ventricular (RV) function in the presence of moderate-to-severe tricuspid regurgitation (m/s-TR) is of paramount importance for surgical or interventional risk stratification. Due to the significant systolic regurgitation of blood from the RV to the low-pressure right atrium, conventional echocardiographic parameters could appear normal and thus overestimate RV function (pseudo-normal). The aim of this study was to analyse and compare RV function in trace TR versus m/s-TR by the invasive pressure-volume-loop (PV-loop) technique, the gold standard of RV function analysis, with conventional echocardiographic indices in patients with the ventricular form of mild/no vs. m/s-TR. Methods The study was conducted in 134 patients with HFrEF in a post-hoc analysis (110 from the Magdeburg CRT Responder Trial, and 24 from a local CRT-optimization trial). Results The logistic regression analysis demonstrated that RV size (RV-end-diastolic volume, RVEDV) and RV function (measured as RV fractional area change, FAC), TAPSE, and lower fractional shortening (FS) of proximal the RV-outflow tract (RVOTprox) was closely associated with PV-loop-derived RV total afterload (pulmonary arterial elastance, Ea) and coupling of RV contractility (end-systolic RV elastance, Ees) to Ea (Ees/Ea) (all, p&amp;lt;0.001). Compared to trace TR (n=98, 73%), m/s-TR (n=36, 27%) was accompanied with significant higher total afterloads (Ea: 0.75 vs.0.41, p&amp;lt;0.001) and lower RV-PA coupling ratios (Ees/Ea, 0.4 vs. 0.79, p&amp;lt;0.001). This was associated with enlarged RVs (RVEDV: 210ml vs. 166ml), lower FAC (31% vs. 50%), TAPSE (13mm vs. 18mm), and RVOTprox (22% vs. 39%) (all p&amp;lt;0.001). For better comparability between trace TR and m/s-TR tertiles (T1-T3) of similar afterloads (Ea) were formed. The m/s-TR patients showed significant lower RV-PA coupling ratios than trace TR at the lower two Ea tertiles T1 (p=0.034) and T2 (p&amp;lt;0.001). At Ea T3 the difference was no longer significant (p=0.055). The hemodynamic data are mirrored by significant lower FACs, FS RVOTprox, and TAPSE at T1 and T2 (all p&amp;lt;0.05), and a nonsignificant difference at T3 in m/s-TR. In conclusion: In our cohort of HFrEF patients, echocardiographic RV function reflects very closely the hemodynamic coupling efficiency of RV contractility (Ees) to afterload (Ea) and seems independent from the extent of TR. We found no evidence for pseudo-normal or overestimated echocardiographic RV function in m/s-TR.

336 Right ventricular mechanics in patients affected by pulmonary valve stenosis, before and after percutaneous pulmonary angioplasty

Abstract Aims Pulmonary valve stenosis accounts for 6–9% of all congenital heart diseases. The main effect of this obstructive lesion is a rise in right ventricular pressure; this overload leads to multiple changes in shape, dimensions, and volume of the ventricle. The diagnosis is based on transthoracic echocardiography and invasive heart catheterization. Usually the stenosis is classified into mild, moderate, and severe based on pressure gradient between right ventricle and pulmonary artery and on the ratio between right ventricle and left ventricle systolic pressure. Percutaneous balloon valvuloplasty is the treatment of choice in severe pulmonary valve stenosis in patients of all ages; alternatively surgical valvotomy is an option in selected cases. The aim of this study is to evaluate the mechanical changes of the right ventricle in patients undergoing balloon pulmonary valvuloplasty using transthoracic and speckle-tracking echocardiography (STE). Furthermore, we sought to investigate the correlation between haemodynamic and echocardiographic parameters to better evaluate the degree of pulmonary valve stenosis before and after treatment. Methods and results Forty-three pediatric patients (19 males), mean age 3.2 ± 4.9 years with severe pulmonary valve stenosis and indication for percutaneous balloon valvuloplasty were recruited at the University Hospital of Padua. All patients underwent standard transthoracic echocardiography (TTE), STE with analysis of right ventricle global longitudinal strain (RVGLS) one day before and one day after the procedure. For each patient were collected invasive parameters during the interventional procedure before and after balloon valvuloplasty. After the procedure, there was an immediate statistically significant reduction of both peak-to-peak transpulmonary gradient (Dp post) and ratio between the systolic pressure of right and left ventricle (RV/LV ratio) with a drop of 29.3 ± 14.67 mmHg and 0.43 ± 0.03, respectively. Post-procedural echocardiography showed peak and mean transvalvar pressure gradient drop (50 ± 32.23 and 31 ± 17.97, respectively). The degree of pulmonary valve regurgitation was mild in 8% of patients before the procedure, following the intervention it reached 29% with a statistically significant increase (P = 0.007). However, the incidence of pulmonary valve moderate and severe regurgitation remained stable after the procedure. The analysis of right ventricular function and mechanics showed a significant improvement of Fractional Area Change (FAC) immediately after the procedure (40.11% vs. 44.42%, P = 0,01). On the other hand, right ventricular longitudinal systolic function parameters, TAPSE (P = 0.60) and longitudinal strain (P = 0.31), did not improve significantly after intervention. Finally, pre-procedural invasive RV/LV ratio showed good correlation to echocardiographic transvalvular peak and mean pressure gradient (R = 0.375, P = 0.019 and R = 0.40, P = 0.012, respectively), as well as with FAC (R = 0.31, P = 0.05), TAPSE (R = 0.62, P &amp;lt; 0.001), and RVGLS (R = 0.46, P = 0.01). Conclusions Percutaneous balloon pulmonary valvuloplasty represents an efficient and safe procedure to relieve severe pulmonary valve stenosis. Interestingly, the analysis of right ventricular mechanics on echocardiography demonstrated an immediate global systolic function improvement following afterload reduction. Conversely, longitudinal systolic function did not show improvement immediately after intervention, possibly due to the necessity of longer time to recover. Finally, invasive preprocedural RV/LV ratio demonstrated better correlation with echocardiographic evaluation of stenosis degree and right ventricular function compared to invasive peak-to-peak pressure gradient. Therefore, RV/LV ratio should be preferred for the assessment of pulmonary valve stenosis.

Partitioning the Right Ventricle Into 15 Segments and Decomposing Its Motion Using 3D Echocardiography-Based Models: The Updated ReVISION Method.

Three main mechanisms contribute to global right ventricular (RV) function: longitudinal shortening, radial displacement of the RV free wall (bellows effect), and anteroposterior shortening (as a consequence of left ventricular contraction). Since the importance of these mechanisms may vary in different cardiac conditions, a technology being able to assess their relative influence on the global RV pump function could help to clarify the pathophysiology and the mechanical adaptation of the chamber. Previously, we have introduced our 3D echocardiography (3DE)-based solution—the Right VentrIcular Separate wall motIon quantificatiON (ReVISION) method—for the quantification of the relative contribution of the three aforementioned mechanisms to global RV ejection fraction (EF). Since then, our approach has been applied in several clinical scenarios, and its strengths have been demonstrated in the in-depth characterization of RV mechanical pattern and the prognostication of patients even in the face of maintained RV EF. Recently, various new features have been implemented in our software solution to enable the convenient, standardized, and more comprehensive analysis of RV function. Accordingly, in our current technical paper, we aim to provide a detailed description of the latest version of the ReVISION method with special regards to the volumetric partitioning of the RV and the calculation of longitudinal, circumferential, and area strains using 3DE datasets. We also report the results of the comparison between 3DE- and cardiac magnetic resonance imaging-derived RV parameters, where we found a robust agreement in our advanced 3D metrics between the two modalities. In conclusion, the ReVISION method may provide novel insights into global and also segmental RV function by defining parameters that are potentially more sensitive and predictive compared to conventional echocardiographic measurements in the context of different cardiac diseases.

Right ventricular strain

This review is devoted to comprehensive echocardiographic analysis of right ventricular function - right ventricular strain rate analysis.

P1467 Natural history and outcome of a patient with untreated congenital pulmonary stenosis added value of 3d echo in decision making

Abstract INTRODUCTION congenital pulmonary valve stenosis (PVS) accounts for approximately 7% of all congenital heart defects. In less severe and untreated asymptomatic forms, it might have variable outcomes with progressive stenosis or development and worsening of pulmonary regurgitation . Atrial septal defect (ASD) might be associated in up to 20% of the cases rendering an even more unpredictable outcome and efect on right ventricular (RV) volumes and function. Cardiac magnetic ressonance is considered the gold standard method to measure RV function and volumes. Three dimensional echocardiography (3D echo) emerges as a valuable, redproducible and portable alternative not only for RV volume and function analysis but also for structural evaluation. PURPOSE To describe the added value of 3D echo for the diagnostic work-up, decision making and post surgical outcome in a patient with longstanding untreated PVS associated with ASD. CASE PRESENTATION a 56 year old asymptomatic , non syndromic man , was referred by the cardiac surgeon for a comprehensive echocardiographic evaluation (CEE) due to a previous diagnosis of PVS .The patient was aware of this diagnosis since the age of 17 and no intervention was undertaken at that time. More recently a conventional echocardiogram described a moderate PVS with RV enlargement (RVE) and no futher details regarding RV function or surgical feasibility. CEE showed RVE due to volume overload (VO) with indexed end diastolic volume (EDV) of 144ml/m2 (upper limit 76ml/m2), end sistolic volume (ESV) of 57ml/m2 (upper limit 37ml/m2) and an RV ejection fraction (RVEF) of 60% (lower limit 45%) on 3D echo. RV free wall strain (RVFWS) was -25,3% , TAPSE 32mm and fractional area change 46%, all paramenters within the normal range except for RV volumes. Anatomical analysis showed PVS with three leaflets, partial comissural fusion and retraction of the edges yelding a closure gap of at least 8mm and consequent severe regurgitation. Peak transvalvular gradient was 38mmHg and pulmonary artery was dilated measuring 6.4cm. An ostium secundum atrial septal defect (ASD) with left to right shunt measuring 15x9mm by 3D echo contributed for futher RVVO. With these information , surgical intervention was undertaken and consisted of PV replacement, excision and reconstruction of the pulmonary trunk dilation and correction of the ASD. The patient recovered well and returned three months after, for a new evaluation. At that time RV volumes reduced dramatically with EDV and ESV respectively of 44ml/m2 and 19ml/m2 RVEF of 55,7% and RWFWS of -25,6%. CONCLUSION untreated congenital PVS associated with ASD may have a variable outcome . Follow-up is mandatory. In the present case a CEE including more recent technologies like 3D echo and strain imaging helped in defining anatomical findings and RV function analysis thus stating the appropriatness for surgical intervention. Abstract P1467 Figure. 3Decho pre and post surgical analysis

P990 Multi-plane echocardiographic analysis of right ventricular function in patients with systemic and subpulmonic physiology

Abstract Background Right ventricular (RV) function is recognized as a prognostic factor in congenital heart disease (CHD). Accurate echocardiographic parameters to assess systolic function in systemic RV (sRV) lacking. We previously introduced a novel four-view approach with different RV walls visualized in their long axis from one apical view using 2D-multi-plane transthoracic echocardiographic (TTE) (iRotate). Aims To extensively evaluate RV systolic function using iRotate echocardiography in CHD patients with systemic RV compared with a whole spectrum of CHD patients with abnormally loaded subpulmonic RV. Methods and Results Thirty CHD patients with sRV and 112 age, gender and BSA matched patients with abnormally loaded subpulmonic RV were recruited from the outpatient clinic. All subjects underwent complete TTE with evaluation of TAPSE, TDI S’ and peak systolic global longitudinal RV strain (RV-GLS) from the RV walls using the four-view iRotate model. The feasibility of TAPSE and TDI S’ ranged between 94% and 100%. The feasibility of RV-GLS in CHD was 98%, 69%, 87% and 72% respectively in the lateral, anterior, inferior and inferior coronal view walls. All echocardiographic parameters were significantly lower in sRV compared to versus subpulmonic RV cohort (p &amp;lt; 0.001) (Table). Conclusion This study provides for the first time an extensive RV specific analysis of the systemic RV. The feasibility of all RV parameters in the four-view iRotate model is excellent in CHD and represents a reproducible, easily applicable and complete RV assessment in daily practice. Systolic function is significantly reduced in systemic RV compared to subpulmonic RV physiology. Abstract P990 Figure.

Wave Intensity Analysis of Right Ventricular Function during Pulsed Operation of Rotary Left Ventricular Assist Devices.

Changing the speed of left ventricular assist devices (LVADs) cyclically may be useful to restore aortic pulsatility; however, the effects of this pulsation on right ventricular (RV) function are unknown. This study investigates the effects of direct ventricular interaction by quantifying the amount of wave energy created by RV contraction when axial and centrifugal LVADs are used to assist the left ventricle. In 4 anesthetized pigs, pressure and flow were measured in the main pulmonary artery and wave intensity analysis was used to identify and quantify the energy of waves created by the RV. The axial pump depressed the intensity of waves created by RV contraction compared with the centrifugal pump. In both pump designs, there were only minor and variable differences between the continuous and pulsed operation on RV function. The axial pump causes the RV to contract with less energy compared with a centrifugal design. Diminishing the ability of the RV to produce less energy translates to less pressure and flow produced, which may lead to LVAD-induced RV failure. The effects of pulsed LVAD operation on the RV appear to be minimal during acute observation of healthy hearts. Further study is necessary to uncover the effects of other modes of speed modulation with healthy and unhealthy hearts to determine if pulsed operation will benefit patients by reducing LVAD complications.

2354Speckle-tracking analysis of right ventricular function in Fabry disease - is left ventricle the only diseased chamber?

2354Speckle-tracking analysis of right ventricular function in Fabry disease - is left ventricle the only diseased chamber?

Analysis of Right Ventricular Function in Patients with Hypothyroidism

Analysis of Right Ventricular Function in Patients with Hypothyroidism

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.

Cardiac magnetic resonance analysis of right ventricular function: Comparison of quantification in the short-axis and 4-chamber planes

ObjectiveTo compare the methods of right ventricle segmentation in the short-axis and 4-chamber planes in cardiac magnetic resonance imaging and to correlate the findings with those of the tricuspid annular plane systolic excursion (TAPSE) method in echocardiography. Materials and methodsWe used a 1.5T MRI scanner to study 26 patients with diverse cardiovascular diseases. In all MRI studies, we obtained cine-mode images from the base to the apex in both the short-axis and 4-chamber planes using steady-state free precession sequences and 6mm thick slices. In all patients, we quantified the end-diastolic volume, end-systolic volume, and the ejection fraction of the right ventricle. On the same day as the cardiac magnetic resonance imaging study, 14 patients also underwent echocardiography with TAPSE calculation of right ventricular function. ResultsNo statistically significant differences were found in the volumes and function of the right ventricle calculated using the 2 segmentation methods. The correlation between the volume estimations by the two segmentation methods was excellent (r=0.95); the correlation for the ejection fraction was slightly lower (r=0.8). The correlation between the cardiac magnetic resonance imaging estimate of right ventricular ejection fraction and TAPSE was very low (r=0.2, P<.01). ConclusionBoth ventricular segmentation methods quantify right ventricular function adequately. The correlation with the echocardiographic method is low.

Abstract 18017: Validations for the Reliability of a Dedicated 3-Dimensional Speckle Tracking Imaging System for Right Ventricular Function Analysis

Background: Three-dimensional (3D) imaging has the potential to evaluate right ventricular (RV) function accurately because of its complex geometry. We have developed a dedicated 3D-speckle tracking imaging (STI) system for the right ventricle, and performed validation studies to assess the reliability of 3D-STI derived deformation data. Methods: In 9 anesthetized sheep, RV full volume data sets for 3D-STI were obtained using a 3D echocardiography system (Toshiba Medical Systems) simultaneously with sonomicrometry data at the baseline and during pulmonary artery (PA) banding at moderate and severe levels, and propranolol infusion. In 7 RV segments (basal and mid anterior, basal and mid lateral, basal and mid inferior, and outflow), area change ratio (ACR), longitudinal strain (LS), and circumferential strain (CS) were calculated with prototype 3D-STI software (Figures) and compared with those by sonomicrometry. Results: ACR by 3D-STI strongly correlated with sonomicrometry data (Y=0.78X-5.0, R=0.83, p&lt;0.001). LS and CS also showed significant correlations between the modalities (LS; Y=0.78X-1.8, R=0.79, CS; Y=0.62X-2.9, R=0.77, p&lt;0.001). In segmental analysis, all deformation data showed significant correlations in each segment. During PA banding, PA pressure increased at a moderate (48.4±8.4mmHg) and a severe level (53.9±8.5mmHg mmHg) compared to the baseline (22.5±4.6mmHg). In contrast, 3D-STI data had graded decreases at the baseline, moderate and severe levels (ACR; -32.5±8.3, -24.2±10.0, -16.1±10.9%, p&lt;0.001, LS; -16.0±6.2, -9.5±6.8, -5.1±7.7%, p&lt;0.001, CS; -16.3±5.4, -12.6±7.6, -9.3±7.3%, p=0.003). During propranolol infusion, RV dP/dt was significantly decreased compared to the baseline (807±287 vs. 535±199 mmHg/s, p=0.01), and 3D-STI data also reduced (ACR; -23.3±7.7, LS; -10.4±5.8, CS; -11.5±5.4, p&lt;0.05 vs. baseline). Conclusions: The newly developed 3D-STI system is a reliable modality for RV function analysis.

Effects of Age and Gender on Right Ventricular Systolic and Diastolic Function Using Two-Dimensional Speckle-Tracking Strain

Accurate assessment of the right ventricle is increasingly important. Measures of right ventricular (RV) systolic function, including fractional area change, tissue Doppler (s' velocity), and tricuspid annular plane systolic excursion, show significant variation, and the impacts of age and gender are unclear. The aim of this study was to determine the effects of gender and age on global and segmental RV systolic and diastolic function using both traditional echocardiographic and two-dimensional strain parameters. Detailed transthoracic echocardiographic studies were performed on 142 healthy adult volunteers, with particular emphasis on the right ventricle to determine RV dimensions and function, including fractional area change, tricuspid annular plane systolic excursion, s' velocity, global and segmental systolic strain, and systolic, early diastolic, and late diastolic strain rates. Tricuspid annular plane systolic excursion (r= -0.4, P < .001) and RV s' velocity (r= -0.5, P < .001) aswell as diastolic functional parameters, including transtricuspid peak E velocity and RV free wall e' velocity (r= -0.4, P < .001), decreased with age. Global systolic strain was also reduced, with differential reductions in basal and mid segmental strain with age. Early diastolic strain rate decreased, with a corresponding increase in late diastolic strain rate. RV function parameters, including fractional area change, e' velocity, strain, and strain rate, were significantly lower in men. RV functional analysis by two-dimensional strain demonstrates a small yet significant change in global and segmental RV function with age and gender, and therefore adjustment for these measures is required in the evaluation of RV function.

ABSTRACT 557

Background and aims: Analysis of right ventricular function in patients with a left ventricular assist device (LVAD) is essential when establishing long-term prognosis and evaluating the indication for right ventricular support. Aims: The objective of the study was to compare measurement of cardiac output using the ultrasound cardiac output monitor (USCOM) with measurements obtained using chest ultrasound and a thermodilution catheter. Methods: We performed a prospective study of 2 pediatric patients with LVAD (EXCOR® and Levitronix®). Local Institutional Review Board waived the need for informed consent. For the initial validation, measurements obtained with USCOM (transducer towards the center of the cannula) were compared to those obtained with real EXCOR® flow (25-ml pump X HR [5 bpm]). Indexed cardiac output (iCO) obtained using the USCOM device with the transducer positioned for pulmonary valve flow acquisition was applied for further comparison with transthoracic echocardiography data (VTI x πr2 x HR) (EXCOR® patient) and thermodilution catheter data (Levitronix® patient). Measurements were made by 2 observers in order to compare the degree of interobserver correlation. Results: We obtained 88 measurements. The results from the initial validation were as follows: iCO USCOM 2.5 l/min/m2 (2–2.8) vs EXCOR® 3 l/min/m2 (p=0.4). The results from comparisons of the noninvasive techniques were as follows: 1) EXCOR® iCO USCOM vs echocardiography, 6.1 l/min/m2 (5.2–7.3) vs 6.5 (5.5–7.16) (p=0.9); 2) Levitronix® iCO USCOM vs thermodilution catheter, 3.8 l/min/m2 (2.8–4.3) vs 3 l/min/m2 (2.9–3.1) (p=1). Interobserver correlation was substantial (k=0.8). Conclusions: Measurement of cardiac output using USCOM provides reliable data compared with the real value of GC. Interobserver agreement is very high.

Reply to Koestenberger and Ravekes

We would like to thank Koestenberger et al. [1] for their comments regarding our manuscript titled ‘Disparity in right vs left ventricular recovery during follow-up after ventricular septal defect correction in children’ [2]. We fully agree with Koestenberger et al. [1] that it would be interesting to gain further knowledge regarding ventricular performance in patients with different subtypes of ventricular septal defects (VSDs). The location of the VSD and implanted patch and its relation to the tricuspid valve ring may certainly influence right ventricular (RV) free wall motion. Both tricuspid annular plane systolic excursion (TAPSE) and RV peak systolic tissue Doppler imaging velocity (S0) are assessed at the base of the RV free wall, close to the tricuspid valve ring. Accordingly, both TAPSE and RV S0 could be different in patients with different subtypes of VSDs. Hence, we appreciate the suggestion made by Koestenberger et al. [1] to calculate the z scores of TAPSE and RV S0, as previously defined [3, 4], to shed further light on the subtype analysis. The calculation of preoperative z scores yielded a mean ± standard deviation of TAPSE of 0.9 ± 2.3 and a mean RV S0 z score of 0.6 ± 1.5. One day postoperatively, z scores significantly decreased, displaying a mean TAPSE z score of −5.7 ± 1.3 and a mean RV S0 z score of −4.5 ± 1.2. At medium-term follow-up, z scores were still low, with a mean TAPSE z score of −1.6 ± 1.4 and RV S0 z score of −1.5 ± 0.9. Similar to previous results, one-way analysis of variance of these z scores did not reveal significant differences between subtypes of VSD patients preoperatively or at medium-term follow-up. Yet, considering the small number of patients and relatively large standard deviations of z scores, a lack of statistical power could still be the cause of this absence. Accordingly, these additional analyses could not shed further light on the differences between subtypes. However, current z score calculations do further validate the conclusion of our manuscript, of a persistent impairment of RV performance after surgery for a VSD. In a previous study by our group, including patients with a variety of congenital heart defects, a similar decrease in RV performance following surgery was observed [5]. Furthermore, a longer aortic cross-clamp time was associated with a lower RV S0 in this study. These results emphasize the detrimental role of cardiopulmonary bypass in ventricular deterioration after surgery and highlight the importance of follow-up of RV performance after surgery. Hence, we join Koestenberger et al. [1] in their hope for routine RV function analysis in postoperative VSD patients.

Echokardiographische Notfalldiagnostik

Echocardiography plays an important role in emergency medicine because this non-invasive method is universally available and provides crucial diagnostic findings for acute decision making. The cardiac etiology in the presence of acute chest pain, acute dyspnea, hemodynamic instability or shock, new heart murmurs, chest trauma, peripheral embolism and cardiac arrest can be determined by echocardiography in the emergency scenario. The analysis of left ventricular function documents myocardial ischemia and myocardial infarction. Analysis of right ventricular function documents right heart infarction, pulmonary embolism, tension pneumothorax and sequelae of chest trauma. Echocardiography differentiates between different entities of shock. The analysis of heart valves is a domain of echocardiography. Affections of the pericardium and the hemodynamic sequelae can also be determined. It is obvious that echocardiography with its multiple diagnostic applications can only be well performed, especially in emergency medicine after in-depth education and training in this method.

Feasibility of Right Ventricular Longitudinal Systolic Function Evaluation with Transthoracic Echocardiographic Indices Derived from Tricuspid Annular Motion: A Preliminary Study in Acute Respiratory Distress Syndrome

Assessment of right ventricular (RV) function in patients with acute respiratory distress syndrome (ARDS) remains challenging. Transthoracic echocardiographic (TTE) indices based on longitudinal systolic RV function are now considered as a reliable evaluation of RV function. We investigated feasibility of two methods in ARDS patients. Prospective observational study. TTE was performed after 12-36 hours of mechanical ventilation. Feasibility of tricuspid annular motion (S(t) ), tricuspid annular plane systolic excursion (TAPSE) was compared to usual two-dimensional (2D) study: fractional area change (RV(FAC) ) and ratio of right to left ventricular end-diastolic area (RVEDA/LVEDA). Fifty patients were investigated, with TTE possible in all but two patients. Feasibility was 62% for RV(FAC), 72% for RVEDA/LVEDA, and 96% for TAPSE and S(t). RV dilatation (RVEDA/LVEDA ≥ 0.60) was found in 16 patients, including 4 patients with acute cor pulmonale. A longitudinal RV dysfunction (TAPSE < 12 mm or S(t) < 11.5 cm/sec) was suspected in 30% of patients. Relation between both longitudinal indices was modest (r(2) = 0.36, P < 0.001). TAPSE (but not S(t) ) was found poorly related to RV(FAC) (r(2) = 0.27, P = 0.03). Both indices were related to LV function (S(t) : r(2) = 0.27, TAPSE: r(2) = 0.17, both P < 0.05). Despite a superior feasibility than 2D study, our results suggest that both indices may not bring identical information to echo study. TAPSE may be more adapted to ICU use than S(t) . Both should be further investigated in terms of analysis of RV function and ventricular interdependence. Their relations with LV function may limit their use as sole markers of RV function in this population.

Impact of Ventricular Contrast Medium Attenuation on the Accuracy of Left and Right Ventricular Function Analysis at Cardiac Multi Detector-row CT Compared with Cardiac MRI

The aim of this study was to investigate the impact of ventricular contrast medium attenuation on the accuracy of left ventricular (LV) and right ventricular (RV) function analysis on coronary computed tomographic angiographic (CCTA) imaging compared to cardiac magnetic resonance imaging (CMR). Thirty patients (mean age, 61.9 ± 11.2 years; 14 men) underwent CCTA imaging and CMR. For both the right and left ventricles, end-diastolic volume (EDV), end-systolic volume (ESV), and stroke volume (SV) were computed using multiphase image reconstruction of CCTA data. The accuracy of CCTA imaging was determined by subtracting CCTA measurements from CMR measurements. The accuracy of CCTA imaging was then correlated with the level of LV and RV contrast medium attenuation using regression analysis. In the right ventricle, there was strong correlation between the accuracy of CCTA functional assessment of EDV (R(2) = 0.78, P < .001), ESV (R(2) = 0.36, P < .001), and SV (R(2) = 0.75, P < .001) and the level of RV contrast medium attenuation. In studies with lower RV enhancement (<176 Hounsfield units; n = 15), the mean CCTA deviations of EDV, ESV, and SV from CMR measurements were 43.6 ± 17.4, 11.2 ± 9.64, and 35.1 ± 11.5 mL, respectively. In studies with higher RV attenuation (>176 Hounsfield units; n = 15), these values were 13.6 ± 10, 8.0 ± 5.28, and 13 ± 4.96 mL, respectively. In the left ventricle, there was weak correlation between functional CCTA accuracy and LV attenuation (mean, 358.31 ± 68.71 Hounsfield units), and there was excellent correlation with CMR for LV EDV (R(2) = 0.86, P < .001), ESV (R(2) = 0.85, P < .001), and SV (R(2) = 0.51, P < .001). If computed tomographic evaluation of RV function is desired, attention should be paid to the contrast injection protocol, because the accuracy of RV function analysis depends on the level of contrast medium attenuation. The high contrast medium attenuation that is typically achieved in the left ventricle routinely enables highly accurate measurements compared to CMR.

Abstract 8437: Volumetric Studies of the Right Ventricle Using Anatomically Accurate Expandable Latex Models

Background: Right ventricular (RV) anatomy is far more complex than left ventricular anatomy due to its challenging three-dimensional shape. Recently, TomTec imaging has developed new software known as 4D RV-Function. It is the first software for 3D echo data. This program allows one to study and envisage RV function and RV anatomy. Methods: Clay molds were made from the RVs of 5 sheep hearts. Each mold was layered with liquid latex to form a sac of the right ventricle. A hole was cut at the top of each latex RV model and a tube placed within it for attaching to the pulsatile pump. 4D images were acquired using a GE Vivid I9 ultrasound system. The obtained 4D images were then entered into TomTec's 4D RV Function imaging program to execute the volumes. Results: At all steady states, there was a good correlation between the volumes from TomTec's 4D RV Function analysis program and the actual volumes that were emptied out of the heart at systole and diastole (R=0.93, p&lt;0.001). Conclusions: Volumes of different right ventricle models could be defined quite accurately using TomTec's 4D RV Function program. This will prove useful in the future because it will not only increase diagnostic confidence, but it will ultimately improve the management and treatment of patients with congenital heart disease, heart failure, and pulmonary hypertension.