Right Ventricular Systolic Dysfunction Research Articles

Cardiac magnetic resonance for prophylactic implantable-cardioverter defibrillator therapy international study: prognostic value of cardiac magnetic resonance-derived right ventricular parameters substudy.

Right ventricular systolic dysfunction (RVSD) is an important determinant of outcomes in heart failure (HF) cohorts. While the quantitative assessment of RV function is challenging using 2D-echocardiography, cardiac magnetic resonance (CMR) is the gold standard with its high spatial resolution and precise anatomical definition. We sought to investigate the prognostic value of CMR-derived RV systolic function in a large cohort of HF with reduced ejection fraction (HFrEF). Study cohort comprised of patients enrolled in the CarDiac MagnEtic Resonance for Primary Prevention Implantable CardioVerter DefibrillAtor ThErapy registry who had HFrEF and had simultaneous baseline CMR and echocardiography (n = 2449). RVSD was defined as RV ejection fraction (RVEF) <45%. Kaplan-Meier curves and cox regression were used to investigate the association between RVSD and all-cause mortality (ACM). Mean age was 59.8 ± 14.0 years, 42.0% were female, and mean left ventricular ejection fraction (LVEF) was 34.0 ± 10.8. Median follow-up was 959 days (interquartile range: 560-1590). RVSD was present in 936 (38.2%) and was an independent predictor of ACM (adjusted hazard ratio = 1.44; 95% CI [1.09-1.91]; P = 0.01). On subgroup analyses, the prognostic value of RVSD was more pronounced in NYHA I/II than in NYHA III/IV, in LVEF <35% than in LVEF ≥35%, and in patients with renal dysfunction when compared to those with normal renal function. RV systolic dysfunction is an independent predictor of ACM in HFrEF, with a more pronounced prognostic value in select subgroups, likely reflecting the importance of RVSD in the early stages of HF progression.

Right ventricular performance in patients with heart failure with mildly reduced ejection fraction: the forgotten ventricle.

Right ventricular (RV) function is a major determinant of prognosis and adverse outcomes in patients with heart failure (HF). It is largely unknown if HF with mildly reduced ejection fraction (HFmrEF) patients have some special characteristics in RV function (RVF) that may distinguish them from HF with reduced or preserved ejection fraction (HFrEF or HFpEF) patients. Standard echocardiography was performed to estimate RVF [tricuspid annular systolic velocity (TDSV), plane systolic excursion (TAPSE), TAPSE to pulmonary artery systolic pressure (TAPSE/PASP) and RV myocardial performance index (MPI-TEI index)] in a cross-sectional study. In 306 participants, the RV systolic function evaluated with TAPSE and TDSV was impaired in 39.1 and 24.2%, respectively. TAPSE, TAPSE/PASP and TDSV were lower in HFmrEF compared with HFpEF and higher compared with HFrEF (p < 0.001 for among-groups comparison). RV diastolic dysfunction varied between 12.6 and 43.8% depending on the echocardiographic parameter. Diastolic RVF determined by tricuspid inflow E/A wave ratio (Et/At) was impaired in less patients with HFmrEF compared with those with HFpEF or HFrEF (25.9% vs 48.4% vs 56.3%; p = 0.030, respectively). RV diastolic dysfunction by et'/at' (tissue Doppler tricuspid valve annulus e' and a' waves) was impaired in less patients with HFmrEF compared with HFrEF (11.8% vs 33.3%; p = 0.019). A multivariate regression analysis revealed a significant association between RV and LV systolic dysfunction. The present study shows a high prevalence of RV dysfunction in HFmrEF patients. Study findings provides some new insights on RV and LV systolic dysfunction coupling whereas RV diastolic dysfunction was not dependent on LV systolic dysfunction.

Epicardial adipose tissue and right ventricular function in type 2 diabetes mellitus using two-dimensional speckle tracking echocardiography.

BackgroundEpicardial adipose tissue is an emerging cardiovascular risk factor. The aim of this study was to evaluate right ventricular function and investigate its association with EAT in T2DM patients.Methods154 T2DM patients were divided into two groups according to EAT thickness: T2DM with EAT <5 mm and T2DM with EAT ≥5 mm. Seventy non-T2DM patients were enrolled as control group. RV function was evaluated using both conventional echocardiography as well as two-dimensional speckle tracking echocardiography. EAT thickness was measured as the echo-free space between the free wall of the right ventricle and the visceral layer of pericardium at end-systole.ResultsCompared to control group, EAT thickness was significantly higher and RV systolic function and early diastolic function are all impaired in all T2DM patients. In T2DM with EAT ≥5 mm group, RV systolic function and early diastolic function suffered more severe impairment when compared with T2DM with EAT <5 mm group. Multivariate linear regression analysis revealed that EAT was associated with RV systolic and early diastolic dysfunction independent of traditional cardiovascular risk factors.ConclusionsOur research suggest that in T2DM patients RV systolic function and early diastolic function are all impaired which are associated with the thickened EAT.

Feasibility, Prediction and Association of Right Ventricular Free Wall Longitudinal Strain with 30-Day Mortality in Severe COVID-19 Pneumonia: A Prospective Study.

Introduction: Right ventricular (RV) systolic dysfunction (RVsD) is a common complication of coronavirus infection 2019 disease (COVID-19). The right ventricular free wall longitudinal strain parameter (RV-FWLS) is a powerful predictor of mortality. We explored the performance of RVsD parameters for predicting 30-day mortality and the association between RV-FWLS and 30-day mortality. Methods: COVID-19 patients hospitalized at Amiens University Hospital in the critical care unit with transthoracic echocardiography were included. We measured tricuspid annular plane systolic excursion (TAPSE), the RV S’ wave, RV fractional area change (RV-FAC), and RV-FWLS. The diagnostic performance of RVsD parameters as predictors for 30-day mortality was evaluated by the area under the receiver operating characteristic (ROC) curve (AUC). RVsD was defined by an RV-FWLS < 21% to explore the association between RVsD and 30-day mortality. Results: Of the 116 patients included, 20% (n = 23/116) died and 47 had a RVsD. ROC curve analysis showed that RV-FWLS failed to predict 30-day mortality, as did conventional RV parameters (all p > 0.05). TAPSE (21 (19–26) mm vs. 24 (21–27) mm; p = 0.024) and RV-FAC (40 (35–47)% vs. 47 (41–55)%; p = 0.006) were lowered in the RVsD group. In Cox analysis, RVsD was not associated with 30-day mortality (hazard ratio = 1.12, CI 95% (0.49–2.55), p = 0.78). Conclusion: In severe COVID-19 pneumonia, RV-FWLS was not associated with 30-day mortality.

Incidence of acute myocardial injury and its association with left and right ventricular systolic dysfunction in critically ill COVID-19 patients

BackgroundPrevious studies have found an increase in cardiac troponins (cTns) and echocardiographic abnormalities in patients with COVID-19 and reported their association with poor clinical outcomes. Whether acute injury occurs during the course of critical care and if it is associated with cardiac function is unknown.The purpose of this study was to document the incidence of acute myocardial injury (AMInj) and echocardiographically defined left ventricular (LV) and right ventricular (RV) systolic dysfunction in consecutive patients admitted to an intensive care unit (ICU) for COVID-19. The relationship between AMInj and echocardiographic abnormalities during the first 14 days of ICU admission was studied. Finally, the association between echocardiographic findings, AMInj and clinical outcome was evaluated.MethodsSeventy-four consecutive patients (≥18 years) admitted to the ICU at Linköping University Hospital between 19 Mar 2020 and 31 Dec 2020 for COVID-19 were included. High-sensitivity troponin-T (hsTnT) was measured daily for up to 14 days. Transthoracic echocardiography was conducted within 72 h of ICU admission. Acute myocardial injury was defined as an increased hsTnT > 14ng/l and a > 20% absolute change with or without ischaemic symptoms. LV and RV systolic dysfunction was defined as at least 2 abnormal indicators of systolic function specified by consensus guidelines.ResultsIncreased hsTnT was observed in 59% of patients at ICU admission, and 82% developed AMInj with peak levels at 8 (3–13) days after ICU admission. AMInj was not statistically significantly associated with 30-day mortality but was associated with an increased duration of invasive mechanical ventilation (10 (3–13) vs. 5 days (0–9), p=0.001) as well as ICU length of stay (LOS) (19.5 (11–28) vs. 7 days (5–13), p=0.015). After adjustment for SAPS-3 and admission SOFA score, the effect of AMInj was significant only for the duration of mechanical ventilation (p=0.030).The incidence of LV and RV dysfunction was 28% and 22%, respectively. Only indices of LV and RV longitudinal contractility (mitral and tricuspid annular plane systolic excursion) were associated with AMInj. Echocardiographic parameters were not associated with clinical outcome.ConclusionsMyocardial injury is common in critically ill patients with COVID-19, with AMInj developing in more than 80% after ICU admission. In contrast, LV and RV dysfunction occurred in approximately one-quarter of patients. AMInj was associated with an increased need for mechanical ventilation and ICU LOS but neither AMInj nor ventricular dysfunction was significantly associated with mortality.

Echocardiographic Characteristics of Cardiogenic Shock Patients with and Without Cardiac Arrest.

Cardiac arrest (CA) is associated with worse outcomes in patients with cardiogenic shock (CS). To better understand the contribution of CA on CS, we evaluated transthoracic echocardiography (TTE) parameters in CS patients with and without CA. We retrospectively identified CS patients with a TTE performed near cardiac intensive care unit admission between 2007 to 2018. We compared TTE measurements of left ventricular (LV) and right ventricular (RV) function in patients with and without CA. The primary outcome was all-cause in-hospital mortality, as determined using multivariable logistic regression. We included 1085 patients, 35% of whom had CA. Median age was 70 years and 37% were females. CA patients had higher severity of illness, more invasive mechanical ventilation and greater vasopressor/inotrope use. In-hospital mortality was 31% and was higher in CA patients (45% vs. 23%, p <0.001). Although LV ejection fraction (LVEF) was similar (35% vs. 37%, p = 0.05), CA patients had lower cardiac index, mitral valve E wave peak velocity, E/A ratio and E/e' ratio. TTE variables that were associated with hospital mortality varied, among patients with CA, these included measures of RV pressure and function and among patients without CA, these included parameters reflecting LV systolic function. Doppler assessments of RV systolic dysfunction were the strongest TTE predictors of hospital mortality in CS patients with CA, unlike CS patients without CA in whom LV systolic function was more important. This emphasizes the importance of RV assessment for mortality risk stratification after CA.

Pulmonary artery obstruction index, pulmonary artery diameter and right ventricle strain as prognostic CT findings in patient with acute pulmonary embolism

ObjectiveThis study was designed to determine predictors of pulmonary hypertension and signs of right heart dysfunction caused by pulmonary embolism (PE) that may lead to early detection of high-risk patients. So the predictive value of pulmonary artery obstruction index (PAOI), measured by pulmonary CT angiography (PCTA) in the acute setting, in predicting the patients susceptible to PE cardiac complications was evaluated. Also two other PCTA indices, pulmonary artery diameter (PAD), and right ventricle (RV) strain, in these patients were investigated and their predictive value for cardiac complications on follow up echocardiography were demonstrated. Materials and methodsIn the study 120 patients with a definite diagnosis of PE were included. The PAOI, PAD and RV strain were measured using PCTA at the time of the initial diagnosis. Transthoracic echocardiography was done 6 months after the diagnosis of PE and RV echocardiographic indices were measured. Pearson correlation was used to investigate correlation between PAOI, PAD, RV strain and signs of right heart dysfunction. ResultsPAOI was strongly correlated with systolic pulmonary artery pressure (SPAP) (r=0.83), RV systolic pressure (r=0.78) and RV wall thickness (r=0.61) in long-term follow up echocardiography. A higher rate of RV dysfunction and RV dilation was detected among the patients with higher PAOI (P<0.001). PAOI≥18 was strongly predictive for development of RV dysfunction. Also developments of pulmonary hypertension, RV systolic hypertension, RV dilation, RV dysfunction, and RV hypertrophy were significantly more common among patients with higher PAD and RV strain (P<0.001). ConclusionsPAOI, PAD and RV strain are sensitive and specific PCTA indices that can predict the development of long-term complications such as pulmonary hypertension and right heart dysfunction, at the time of initial PE diagnosis.

Echocardiographic Assessment of Right Ventricular Function in Paediatric Heart Disease: A Practical Clinical Approach

<h2>Abstract</h2> As the right ventricle (RV) plays an integral role in different paediatric heart diseases, the accurate assessment of RV size and function is essential in the diagnosis, management, and prognostication of congenital and acquired cardiac lesions. Yet, echocardiographic evaluation of the RV is challenging because of its complex and variable morphology, its different physiology compared with the left ventricle, and its capability to adapt to different loading conditions associated with congenital and acquired heart diseases within certain ranges. Reliable echocardiographic detection of RV systolic and diastolic dysfunction remains challenging while important for patient management. This review provides an updated, practical approach to assessing RV function in structurally normal hearts and in children with common congenital heart defects and in those with pulmonary hypertension. We also review the impact of tricuspid valve function on RV functional parameters. There is no single functional RV parameter that uniquely describes RV function; instead a combination of different parameters is recommended in clinical practice. Qualitative and quantitative analysis of RV function will be reviewed including more recent techniques such as speckle tracking and 3D echocardiography.

Association Between Right Ventricular Dysfunction and Adverse Outcomes in Peripartum Cardiomyopathy: Insights From the BRO-HF Quebec Cohort Study

BackgroundPeripartum cardiomyopathy (PPCM) is associated with severe morbidity and mortality, and the significance of right ventricular (RV) involvement is unclear. We sought to determine whether RV systolic dysfunction or dilatation is associated with adverse clinical outcomes in women with PPCM. MethodsWe conducted a multicentre retrospective cohort study examining the association between echocardiographic RV systolic dysfunction or dilatation at the time of PPCM diagnosis and clinical outcomes. Clinical endpoints of interest were the need for mechanical support, recovery of left ventricular ejection fraction at follow-up, and a combined endpoint of hospitalization for heart failure, cardiac transplant, or death. ResultsA total of 67 women, median age 30 years (interquartile range: 7), were diagnosed with PPCM between 1994 and 2015 in 17 participating centres. Twin pregnancies occurred in 11%; 62% of women were multiparous; and 24% had preeclampsia. RV systolic function was impaired in 18 (27%) and dilated in 8 (12%). Seven women required ventricular assistance, and 8 experienced the composite outcome during follow-up (25 [interquartile range 61] months). RV dysfunction was associated with the need for mechanical support (odds ratio 10.10 (95% confidence interval: 1.86-54.81), P = 0.007), but neither RV dysfunction nor dilatation was associated with left ventricular ejection fraction recovery, the need for cardiac transplant, heart failure hospitalization, or death. ConclusionsRV dysfunction is associated with the need for mechanical support in women with PPCM. These findings may improve risk stratification of complications and clinical management.

Association between the Right Ventricular Longitudinal Shortening Fraction and Mortality in Acute Respiratory Distress Syndrome Related to COVID-19 Infection: A Prospective Study.

Introduction: Right ventricular systolic dysfunction (RVsD) increases acute respiratory distress syndrome mortality in COVID-19 infection (CARDS). The RV longitudinal shortening fraction (RV-LSF) is an angle-independent and automatically calculated speckle-tracking parameter. We explored the association between RV-LSF and 30-day mortality in CARDS patients. Methods: Moderate-to-severe CARDS patients hospitalized at Amiens University Hospital with transesophageal echocardiography performed within 48 h of intensive care unit admission were included. RVsD was defined by an RV-LSF of <20%. The patients were divided into two groups according to the presence of RVsD. Using multivariate Cox regression, clinical and echocardiographic risk factors predicting 30-day mortality were evaluated. Results: Between 28 February 2020 and 1 December 2021, 86 patients were included. A total of 43% (n = 37/86) of the patients showed RVsD and 22% (n = 19/86) of the patients died. RV-LSF was observed in 26 (23.1–29.7)% of the no-RVsD function group and 16.5 (13.7–19.4)% (p < 0.001) of the RVsD group. Cardiogenic shock (n = 7/37 vs. 2/49, p = 0.03) and acute cor pulmonale (n = 18/37 vs. 10/49, p = 0.009) were more frequent in the RVsD group. The 30-day mortality was higher in the RVsD group (15/37 vs. 4/49, p = 0.001). In a multivariable Cox model, RV-LSF was an independent mortality factor (HR 4.45, 95%CI (1.43–13.8), p = 0.01). Conclusion: in a cohort of moderate-to-severe CARDS patients under mechanical ventilation, RVsD defined by the RV-LSF was associated with higher 30-day mortalities.

Acute cardiac injury (ACI) in COVID-19 pneumonia

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Since the SARS-CoV2 break-out many reports focused on the role of cardiovascular system involvement in the patient’s outcome(1). However, few descriptions exist including only patients with severe ARDS admitted to general ICU. Methods We enrolled adult patients with severe ARDS related to COVID-19 infection consecutively admitted to ICU between February 2020 and March 2021. Acute cardiac injury was defined as a rise and fall of cTnI above the 99th percentile (i.e., ≥ 47 ng/L)(2). Hs-TnI was measured at admission and during ICU stay. Echocardiographic examinations were performed at ICU admission and at the time of worst cTnI. Left ventricular (LV) and right ventricular (RV) systolic dysfunction were defined respectively as LV ejection fraction (LVEF) &amp;lt; 50% and as tricuspid annular plane systolic excursion (TAPSE) &amp;lt; 16 mm. Results A total of 148 patients were included in the analysis. Acute cardiac injury was present in 65 (44.9%) cases at admission. Forty-seven (21.8%) patients had isolated depressed LVEF, 13 (9.0%) had isolated RV systolic dysfunction and 24 (16,4%) presented with biventricular systolic dysfunction. Eithy-two (56.1%) had a worsening of hs-TNI values during the admission of whom a consensual worsening of LVEF and TAPSE was observed in respectively 32 (21.8%) and 28 (19.2%) patients. Cardiac injury at ICU admission yielded an increased risk of in-hospital mortality (OR 1.30 [95% CI 0.71 – 2.38]) (Figure 1 – left panel) as well as the presence of impaired echocardiography (OR 1.85 [95% CI 1.01 – 3.40]) (Figure 1 – right panel). Worst hs-TNI correlated with worst procalcitonin (PCT) values (p &amp;lt;0.001 r20.81) in case of on-going septic shock and 85 % of patients with RV dysfunction had either evidence of pulmonary thrombus at CT scan or high inspiratory peak pressure (&amp;gt; 30 cmH2O) at mechanical ventilation (respectively, p &amp;lt; 0.001 and p &amp;lt;0.01). Bivariable analysis adjusted for the inverse probability of having an impaired echocardiographic exam confirmed the increased risk of in-hospital mortality in patients with cardiac injury (OR 2.01 [95% CI 1.28 – 3.15]) and in presence of altered echocardiography with RV dysfunction yielding a higher risk (OR 2.42 [95% CI 1.29 – 4.55]) compared with biventricular impairment (OR 1.86 [95% CI 0.87 – 4.00]) and isolated LV dysfunction (OR 1.30 [95% CI 0.77 – 2.19]) (Figure 2). Conclusion The use of echocardiography for the detection of cardiac dysfunction, has shown a greater correlation with mortality than the identification of acute cardiac damage using laboratory parameters. Of all the parameters obtained with the echocardiography, right ventricular dysfunction demonstrates the greatest correlation with mortality compared to left or biventricular dysfunction. However, the major cause of LV dysfunction in our population occurred during septic shock while RV dysfunction seemed to be due to pulmonary embolism and/or acute cor pulmonale ARDS-related.

Echocardiography findings in COVID-19 patients admitted to intensive care units: a multi-national observational study (the ECHO-COVID study).

PurposeSeverely ill patients affected by coronavirus disease 2019 (COVID-19) develop circulatory failure. We aimed to report patterns of left and right ventricular dysfunction in the first echocardiography following admission to intensive care unit (ICU).MethodsRetrospective, descriptive study that collected echocardiographic and clinical information from severely ill COVID-19 patients admitted to 14 ICUs in 8 countries. Patients admitted to ICU who received at least one echocardiography between 1st February 2020 and 30th June 2021 were included. Clinical and echocardiographic data were uploaded using a secured web-based electronic database (REDCap).ResultsSix hundred and seventy-seven patients were included and the first echo was performed 2 [1, 4] days after ICU admission. The median age was 65 [56, 73] years, and 71% were male. Left ventricle (LV) and/or right ventricle (RV) systolic dysfunction were found in 234 (34.5%) patients. 149 (22%) patients had LV systolic dysfunction (with or without RV dysfunction) without LV dilatation and no elevation in filling pressure. 152 (22.5%) had RV systolic dysfunction. In 517 patients with information on both paradoxical septal motion and quantitative RV size, 90 (17.4%) had acute cor pulmonale (ACP). ACP was associated with mechanical ventilation (OR > 4), pulmonary embolism (OR > 5) and increased PaCO2. Exploratory analyses showed that patients with ACP and older age were more likely to die in hospital (including ICU).ConclusionAlmost one-third of this cohort of critically ill COVID-19 patients exhibited abnormal LV and/or RV systolic function in their first echocardiography assessment. While LV systolic dysfunction appears similar to septic cardiomyopathy, RV systolic dysfunction was related to pressure overload due to positive pressure ventilation, hypercapnia and pulmonary embolism. ACP and age seemed to be associated with mortality in this cohort.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00134-022-06685-2.

Detection of diabetic cardiomyopathy in Egyptian children and adolescents with longstanding Type 1 diabetes and evaluating the effect of α-tocopherol supplementation on cardiac functions after 1 year; a single center prospective study.

IntroductionDiabetic cardiomyopathy (DCM) is a serious complication that frequently occurs in patients with type 1 diabetes (T1D) necessitating early diagnosis. The aim of the current study was to detect subclinical DCM in Egyptian children and adolescents with T1D and evaluate the effect of antioxidants on myocardial dysfunction.Material and methodsThe current prospective observational cohort study included 81 T1D patients (9-20 years old) with diabetes duration &gt; 4 years compared to 50 age and sex matched non-diabetic controls. Serum N-terminal prohormone of brain natriuretic peptide (NT-proBNP) was assessed in addition to conventional echocardiography, tissue Doppler imaging (TDI) and speckle tracking echocardiography (STE). Patients with myocardial dysfunction were supplemented with vitamin E (α-tocopherol) as an antioxidant for 1 year, then follow up echocardiography was done.ResultsNT-proBNP was elevated in 73 (90.1%) patients, 50.6% had left ventricular (LV) diastolic dysfunction, 14.8% had right ventricular (RV) diastolic dysfunction, 84% had LV systolic dysfunction and 91.4% had RV systolic dysfunction with statistically significant difference compared to controls. There was a significant negative correlation between LV global longitudinal strain (GLS) and NT-proBNP (p&lt;0.001, r=-0.796). ROC curve analysis showed that NT-proBNP at a cut-off point ≥ 195 ng/ml detected LV systolic dysfunction function with 89.7% sensitivity and 84.6% specificity. Follow up after one year of α-tocopherol supplementation revealed significant improvement in LV systolic and diastolic functions as well as RV systolic dysfunction.ConclusionsNT-proBNP and non-conventional echocardiography were useful in early detection of subclinical cardiomyopathy in patients with T1D. Antioxidant treatment improved subclinical myocardial dysfunction in T1D patients.

Prognostic Implications of Right Ventricular Systolic Dysfunction in Cardiac Amyloidosis

Left ventricular (LV) systolic dysfunction in cardiac amyloidosis (CA) is associated with poor prognosis. This study aimed to investigate the prognostic implications of right ventricular (RV) systolic dysfunction in CA. A total of 93 patients diagnosed with CA who underwent standard and speckle-tracking echocardiography were included. During a median follow-up of 17 (5 to 38) months, 42 patients (45%) died. Nonsurvivors were more likely to present with immunoglobulin light-chain amyloidosis and New York Heart Association class III to IV heart failure symptoms. Regarding the echocardiographic characteristics, nonsurvivors had a higher LV apical ratio, worse LV diastolic function, and worse RV systolic function (evaluated with both tricuspid annular plane systolic excursion and RV free wall strain). RV free wall strain was independently associated with all-cause mortality in several multivariable Cox regression models and had incremental prognostic value over conventional parameters of RV function when added to a basal model (including heart failure symptoms, amyloidosis phenotype, and LV global longitudinal strain). Based on spline curve analysis and Youden index, a value of 16% for RV free wall strain was identified as the optimal cutoff to predict outcome and patients with RV free wall strain <16% had a significantly worse short- and long-term survival during follow-up (1- and 3-year cumulative survival: 81% vs 31% and 67% vs 20%, respectively, p <0.001). In conclusion, RV systolic dysfunction is independently associated with poor outcome in patients with CA and the use of advanced echocardiographic parameters, such as RV free wall strain, may be of aid for better risk stratification.

Novel Bridge to Recovery: Right Ventricular Assist Device for Primary Graft Dysfunction in Pediatric Lung Transplantation

<h3>Introduction</h3> Primary graft dysfunction (PGD) is an early complication after lung transplantation (LTx). Extracorporeal membrane oxygenation (ECMO) is used for rescue of refractory hypoxemia due to severe PGD, although ventricular assist device support in PGD after LTx is less well documented. <h3>Case Report</h3> A 9 year old boy with Trisomy 21 underwent bilateral LTx for severe pulmonary arterial hypertension (PAH). Mean PA pressure was 73 mmHg, with a hypertrophied right ventricle (RV) and mild-moderately reduced RV function. He was transplanted with size matched lungs, blood type O- into O+. No HLA antibodies were identified. Marked vasoplegia was seen 8 hours post-operatively. Chest x-ray showed interstitial markings consistent with PGD. At 36 hours, P/F ratio had dropped to 59. Systemic inflammatory response (SIRS) and RV dysfunction resulted in acute kidney injury with Cr 256 µmol/L and hepatic dysfunction with ALT > 4,600. At 40 hours, right ventricular assist device (RVAD) with oxygenator was placed via central cannulation to the main PA and right atrium (RA). Peripheral sites were not available due to prior ECMO. Stenosis was seen of the right upper pulmonary vein. Oxygenation, lung aeration, and biochemical markers improved over 11 days after which he was weaned from RVAD and decannulated. At 8 months post-LTx, he is doing well. Graft function is excellent with most recent FEV₁ at 71% predicted, versus 37% pre-transplant. Acute kidney injury has resolved and liver function has returned to normal. <h3>Summary</h3> This case presents a novel successful approach in providing bridge to recovery for PGD after LTx and RV dysfunction in a pediatric patient with Down syndrome. This was a unique scenario with no peripheral cannulation access, RV systolic and diastolic dysfunction, and multi-system sequelae. Central cannulation (RA-PA) with RVAD/oxygenator allowed adequate support for the PGD to clear. To our knowledge, this is the first publication on RVAD/oxygenator use in pediatric lung PGD. This also documents the first patient with Down syndrome to receive a bilateral LTx in Canada. It is unclear if Down syndrome-related factors increased the risk for PGD; PV stenosis and SIRS may have played a role. Note that RA to aortic cannulation is not advised due to the need to maintain flow to the PAs, since there is no longer bronchial circulation supplying the lungs after transplant.

A Closer Evaluation for Refractory Atrial Fibrillation with Heart Failure, a Case Report

<h3>Introduction</h3> Atrial fibrillation (AF) is highly prevalent after the age of 55 years. However, it can be associated with infiltrative cardiomyopathy. <h3>Case Report</h3> A 63 years old had new onset of palpitation and shortness of breath. He presented to ED with rapid AF at rate of 140 bpm treated with metoprolol, diltiazem and rivaroxiban. The patient started to develop lower limb swelling, dizziness, shortness of breath with walking short distance. His blood pressure was 110/60 mmHg off antihypertensive medication. He had NYHA class III symptoms and significant peripheral edema. A TTE showed a moderate concentric left ventricle hypertrophy IVS 16 mm with mild global systolic dysfunction LVEF 50% restrictive diastolic function and pericardial effusion. The patient had significant myocardial hypertrophy, HFpEF and AF with intolerance to medical therapy we proceeded with PYP bone scan which was equivocal for TTR amyloidosis. The bone to heart ration was 1.27. Cardiac MRI showed progressive decline in LVEF to 27% with severe RV systolic dysfunction EF 28% . There was a diffused subendocardial delayed enhanced lesion. Given these findings hematology workup sent which showed serum Free Lambda of 147mg/L; Free Kappa 6.71mg/L and Kappa/Lambda ratio of 0.05 (0.26 - 1.65). Bone marrow biopsy showed plasma cell percentage up to 40%. Flowcytometry showed lambda restricted plasma cell population together with positive CD38, CD138, CD56 and negative CD19. Fat Pad biopsy positive for Congo red stain consistent of amyloid deposits. He received chemotherapy CyBorDex 4 cycles followed by reduction in plasma cells to 2% in the bone marrow. He had cardiac function recovery. <h3>Summary</h3> AL cardiac amyloidosis can present with cardiac manifestation. High suspicion of underlying infiltrative disease should be investigated in refractor cases AF and HFpEF.

Hidden systolic dysfunction of the right ventricle in patients with increased pulmonary vascular resistance 3 months after COVID-19 pneumonia.

Aim To study the relationship of echocardiographic right ventricular (RV) structural and functional parameters and indexes of pulmonary vascular resistance (PVR) in patients 3 months after COVID-19 pneumonia.Material and methods This cross-sectional, observational study included 96 patients aged 46.7±15.2 years. The inclusion criteria were documented diagnosis of COVID-19-associated pneumonia and patient's willing to participate in the observation. Patients were examined upon hospitalization and during the control visit (at 3 months after discharge from the hospital). Images and video loops were processed, including the assessment of myocardial longitudinal strain (LS) by speckle tracking, according to the effective guidelines. The equation [tricuspid regurgitation velocity/ time-velocity integral of the RV outflow tract × 10 + 0.16] was used to determine PRV. Patients were divided into group 1 (n=31) with increased PRV ≥1.5 Wood units and group 2 (n=65) with PRV &lt;1.5 Wood units.Results At baseline, groups did not differ in main clinical functional characteristics, including severity of lung damage by computed tomography (32.7±22.1 and 36.5±20.4 %, respectively. р=0.418). Echocardiographic linear, planimetric and volumetric parameters did not significantly differ between the groups. In group 1 at the control visit, endocardial LS of the RV free wall (FW) (-19.3 [-17.9; -25.8] %) was significantly lower (р=0.048) than in group 2 (-23.4 [-19.8; -27.8] %), and systolic pulmonary artery pressure (sPAP) according to C. Otto (32.0 [26.0; 35.0] mm Hg and 23.0 [20.0; 28.0] mm Hg) was significantly higher than in group 2 (р&lt;0.001). According to the logistic regression, only endocardial RV FW LS (odds ratio, OR, 0.859; 95 % confidence interval, CI, 0.746-0.989; р=0.034) and sPAP (OR, 1.248; 95 % CI, 1.108-1405; р&lt;0.001) were independently related with the increase in PVR. Spearman correlation analysis detected a moderate relationship between PVR and mean PAP according to G. Mahan (r=0.516; p=0.003) and between PVR and the index of right heart chamber functional coupling with the PA system (r=-0.509; p=0.007) in group 1 at the control visit.Conclusion In patients 3 months after COVID-19 pneumonia, hidden RV systolic dysfunction defined as depressed endocardial RV FW LS to -19.3% is associated with increased PVR ≥1.5 Wood units.

Serum markers of cardiac complications in a systemic sclerosis cohort

Primary cardiac involvement is one of the leading causes of mortality in systemic sclerosis (SSc), but little is known regarding circulating biomarkers for cardiac SSc. Here, we aimed to investigate potential associations between cardiac SSc and candidate serum markers. Serum samples from patients of the Oslo University SSc cohort and 100 healthy controls were screened against two custom-made candidate marker panels containing molecules deemed relevant for cardiopulmonary and/or fibrotic diseases. Left (LV) and right ventricular (RV) dysfunction was assessed by protocol echocardiography, performed within three years from serum sampling. Patients suspected of pulmonary hypertension underwent right heart catheterization. Vital status at study end was available for all patients. Descriptive analyses, logistic and Cox regressions were conducted to assess associations between cardiac SSc and candidate serum markers. The 371 patients presented an average age of 57.2 (± 13.9) years. Female sex (84%) and limited cutaneous SSc (73%) were predominant. Association between LV diastolic dysfunction and tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) (OR 0.41, 95% CI 0.21–0.78, p = 0.007) was identified. LV systolic dysfunction defined by global longitudinal strain was associated with angiopoietin 2 (ANGPT2) (OR 3.42, 95% CI 1.52–7.71, p = 0.003) and osteopontin (OPN) (OR 1.95, 95% CI 1.08–3.52, p = 0.026). RV systolic dysfunction, measured by tricuspid annular plane systolic excursion, was associated to markers of LV dysfunction (ANGPT2, OPN, and TRAIL) (OR 1.67, 95% CI 1.11–2.50, p = 0.014, OR 1.86, 95% CI 1.25–2.77, p = 0.002, OR 0.32, 95% CI 0.15–0.66, p = 0.002, respectively) and endostatin (OR 1.86, 95% CI 1.22–2.84, p = 0.004). In conclusion, ANGPT2, OPN and TRAIL seem to be circulating biomarkers associated with both LV and RV dysfunction in SSc.

Right ventricle systolic function and right ventricle-pulmonary arterycoupling in patients with severe aortic stenosis and the early impact of TAVI.

Few data are available on the prevalence of right ventricle (RV) systolic dysfunction, assessed including RV strain, and RV to pulmonary artery (PA) coupling in patients with aortic stenosis (AS) submitted to TAVI and the early effect of the procedure. We performed standard and speckle tracking echocardiography in 80 patients with severe AS the day before TAVI and within 48h after TAVI. In all patients we measured TAPSE/PASP (cut-off for RV-PA uncoupling 0.31) and in 60/80 we were able to analyze RV global longitudinal strain (RV-GLS) and RV free wall strain (RV-FWS). RVFAC and TAPSE were impaired in 8.3% while RV-GLS and RV-FWS in 45% and 33.3%respectively before TAVI. TAPSE/PASP < 0.31 was documented in 7/80 patients (8.7%) before TAVI. These subjects differed from patients with TAPSE/PASP ≥ 0.31 for: enlarged left ventricular (LV) end-diastolic and end-systolic volumes (p < 0.001), worst LVejection fraction (p < 0.001) and RVFAC (p < 0.001), worst RV-GLS and RV-FWS (p = 0.01 and p = 0.03) and bigger right atrium (RA) area (p < 0.001). After TAVI, RV systolic function did not improve while PASP significantly decreased (p = 0.005) driving the improvement of TAPSE/PASP (p = 0.01). Patients with TAPSE/PASP improvement (51%) differed from the others for worst pre-TAVI diastolic function (E/e' p = 0.045), RVFAC (p = 0.042), RV-GLS (p = 0.049) and RA area (p = 0.02). RV-GLS unveils RV systolic dysfunction in as much as 45% of patients with AS vs only 8.3% revealed by conventional echocardiography. RV systolic function does not significantly improve early after TAVI while RV-PA coupling does. Patients with lower TAPSE/PASP at baseline have worst LV and RV systolic function as well as larger RA. Patients who improve TAPSE/PASP after TAVI are those with worst diastolic function, RV systolic function and larger RA at baseline.

Echocardiographic findings in patients with acute pulmonary embolism at Sohag University Hospitals

BackgroundAcute pulmonary thromboembolism (PTE) is one of the serious medical issues with higher prevalence and mortality rates. As mentioned in several medical reports, most of the chest pain patients, visiting the emergency departments, are usually diagnosed with either acute PTE, acute coronary syndromes, or acute aortic syndromes. The current study aimed to study the risk factors and explore the echocardiographic findings in patients with PTE.ResultsForty patients with acute pulmonary embolism were enrolled in the study. Echocardiography and computed tomography pulmonary angiography (CTPA) were evaluated for all participants. The echocardiography showed that 29 patients (72.5%) had echocardiographic findings suggestive of acute PTE. Twenty-four patients (60%) had tricuspid regurge. Twenty-one patients (52.5%) had dilated right ventricle (RV). Also, 13 patients (32.5%) had an echocardiographic finding of pulmonary hypertension. Furthermore, ten patients (25%) had McConnell’s sign, and 21 patients (52.5%) had RV systolic dysfunction where only two (5%) showed RV thrombosis. Echocardiographic data of the eight high-risk patients showed that 6 patients (75%) had TR, 8 patients (100%) had dilated RV, 5 patients (62.5%) had pulmonary hypertension, 8 patients (100%) had McConnell’s sign, one patient (12.5%) had RV thrombus, and 8 patients (100%) had RV systolic dysfunction.ConclusionThe results revealed that thrombus in the main pulmonary trunk was a high-risk factor for patients with acute pulmonary embolism. The current study suggested that echocardiography is an important bedside imaging tool for the diagnosis of PTE. Echocardiography could detect the tricuspid regurge, pulmonary hypertension, McConnell’s sign, RV dilatation, thrombosis, and dysfunction. Furthermore, echocardiography was considered a non-invasive test for rapid diagnosis of PTE and determining the degree of the risk category (high- or low-risk patients) specially with the presence of McConnell’s sign, dilated RV, and RV systolic dysfunction.