Right Ventricular Thickness Research Articles

Distinguishing Cardiac Amyloidosis and Hypertrophic Cardiomyopathy by Thickness and Myocardial Deformation of the Right Ventricle.

Objectives To compare right ventricular thickness (RVT) and deformation of cardiac amyloidosis (CA) and hypertrophic cardiomyopathy (HCM) patients. Methods Sixty CA (mean age 58 ± 10 years; 33 males (55%)) and sixty HCM patients (mean age 55 ± 14 years; 27 males (45%)) were retrospectively enrolled. RVT, global radical peak strain (GRPS), global longitudinal peak strain (GLPS), and global circumferential peak stain (GCPS) were analyzed. To determine the cutoff values of the RVT and RV strain parameters for distinguishing CA from HCM, the areas under the receiver operating characteristic curve (AUCs) were analyzed. Results RVT of CA patients was significantly thicker than that of HCM patients (7.8 ± 2.1 vs 5.9 ± 1.3, p < 0.001). Moreover, significantly decreased RV-GRPS (12.1 ± 6.9 vs 23.5 ± 12.1, p < 0.001), RV-GCPS (−3.4 ± 2.2 vs −5.6 ± 3.5, p < 0.001), and RV-GLPS (−4.6 ± 2.3 vs −11.1 ± 4.9, p < 0.001) were observed in CA patients compared with HCM patients. RVT and RV strain demonstrate comparable diagnostic accuracy in differentiating CA from HCM. In particular, RV-GLPS combined with RVT showed the best performance for discriminating CA from HCM (AUC = 0.92, 95% CI: 0.85 to 0.96, p = 0.0001). Conclusions Right ventricular myocardial thickness and deformation of CA patients was more severe than HCM patients. RV-GLPS combined with RVT presents an excellent diagnostic performance in distinguishing CA and HCM.

Right Heart Remodeling in Patients with End-Stage Alcoholic Liver Cirrhosis: Speckle Tracking Point of View.

Background: Data regarding cardiac remodeling in patients with alcoholic liver cirrhosis are scarce. We sought to investigate right atrial (RA) and right ventricular (RV) structure, function, and mechanics in patients with alcoholic liver cirrhosis. Methods: This retrospective cross-sectional investigation included 67 end-stage cirrhotic patients, who were referred for evaluation for liver transplantation and 36 healthy controls. All participants underwent echocardiographic examination including strain analysis, which was performed offline. Results: RV basal diameter and RV thickness were significantly higher in patients with cirrhosis. Conventional parameters of the RV systolic function were similar between the observed groups. Global, endocardial, and epicardial RV longitudinal strains were significantly lower in patients with cirrhosis. Active RA function was significantly higher in cirrhotic patients than in controls. The RA reservoir and conduit strains were significantly lower in cirrhotic patients, while there was no difference in the RA contractile strain. Early diastolic and systolic RA strain rates were significantly lower in cirrhotic patients than in controls, whereas there was no difference in the RA late diastolic strain rate between the two groups. Transaminases and bilirubin correlated negatively with RV global longitudinal strain and RV-free wall strain in patients with end-stage liver cirrhosis. The Model for End-stage Liver Disease (MELD) score, predictor of 3-month mortality, correlated with parameters of RV structure and systolic function, and RA active function in patients with end-stage liver cirrhosis. Conclusions: RA and RV remodeling is present in patients with end-stage liver cirrhosis even though RV systolic function is preserved. Liver enzymes, bilirubin, and the MELD score correlated with RV and RA remodeling.

Right ventricular remodelling in mild hypertensive patients: role of left ventricular morpho-functional parameters.

Previous studies suggested that hypertensive patients with left ventricular (LV) hypertrophy display right ventricular (RV) remodelling. Few data are available about RV remodelling in naive hypertensives without severe cardiac organ damage. Our aim was to evaluate the relationship between RV and LV morpho-functional parameters in never-treated patients with grade 1 hypertension and whether central blood pressure (CBP), inflammatory and metabolic parameters are potentially associated with RV remodelling. 150 never-treated subjects without evidence of diabetes or other cardiovascular diseases were enrolled in our study. We recruited 100 patients with mild hypertension (twenty-four hours blood pressure (24 h BP) ≥ 130/80 mmHg) and 50 normotensive subjects matched for gender, age and body mass index. To estimate the LV/RV parameters, we performed echography as well as arterial tonometry to assess pulse wave analysis/velocity (PWA/PWV). We found 24 h BP, CBP and PWV were higher in hypertensive patients than in normotensives. In addition, LV mass index was higher in hypertensives, and greater RV free wall thickness was observed (5.3 ± 1.4 vs 4.6 ± 1.2 mm, P = 0.02). RV thickness correlated with interventricular septum (IVS), systolic CBP and RV E' (r = 0.50, P = 0.0001, r = 0.30, P = 0.003, r = -0.24, P = 0.015); linear regression analysis showed a correlation with only IVS (β = 0.39, P = 0.001). RV E' was correlated with IVS, LV E' and systolic CBP (r = -0.35, P = 0.0001, r = 0.25, P = 0.012, r = -0.24, P = 0.019); the correlation with IVS and LV E' (β = -0.310, P = 0.001; β = 0.27, P = 0.004) was confirmed by linear regression analysis. Our study shows RV remodelling is mostly correlated with IVS thickness, supporting the ventricular interdependence hypothesis.

Right ventricular size and function under riociguat in pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension (the RIVER study)

BackgroundRiociguat is a soluble guanylate cyclase stimulator approved for pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTPEH). The objective of this study was to evaluate right heart size and function assessed by echocardiography during long term treatment with riociguat.MethodsPatients who started riociguat treatment (1.0–2.5 mg tid) within the trials phase II, PATENT, PATENTplus, EAS, CHEST and continued treatment for 3–12 months were included in this study. Echocardiography was analysed off-line at baseline, after 3, 6 and 12 months by investigators who were blinded to clinical data. Last and baseline observation carried forward method (LOCF, BOCF) were performed as sensitivity analysis.ResultsSeventy-one patients (45% PAH, 55% CTEPH; 53.5% female; 60 ± 13 years, mean pulmonary arterial pressure 46 ± 10 mmHg, mean PVR 700 ± 282dynes·sec·cm-5) were included. After 6 months, RA and RV area, RV thickness tricuspid regurgitation velocity showed a significant reduction. After 12 months, patients receiving riociguat therapy showed a significant reduction in right atrial (− 2.6 ± 4.4 cm2, 95% CI -3.84, − 1.33; p < 0.001, n = 49) and right ventricular (RV) area (− 3.5 ± 5.2 cm2, 95% CI -5.1, − 1.9; p < 0.001; n = 44), RV thickness (− 0.76 ± 2.2 mm, 95% CI -1.55, 0.03; n = 32), and a significant increase in TAPSE (2.95 ± 4.78 mm, 95% CI 1.52, 4.39; n = 45) and RV fractional area change (8.12 ± 8.87 mm, 95% CI 4.61, 11.62; n = 27).Both LOCF and BOCF showed similar results but lower effect sizes.ConclusionPatients under long-term treatment with riociguat show significantly reduced right heart size and improved RV function in PAH and CTEPH. Further controlled prospective studies are needed to confirm these results.

The relationship between acidosis and hypercapnia with Cor pulmonale in patients with chronic obstructive pulmonary disease

Introduction: Cor pulmonale or right ventricular (RV) enlargement is cardiovascular complication of the chronic obstructive pulmonary disease (COPD). Hypoxic pulmonary vasoconstriction, hypercapnia, acidosis and pulmonary vascular remodeling are suggested as possible mechanisms of cor pulmonale. In this study, we aimed to evaluate the correlation between acidosis and hypercapnia with corpulmonale in patients with COPD. Methods: In this cross-sectional analytical study, 100 patients (56 men and 44 women with mean age of 66.53 ± 10.63 years) with moderate to severe COPD exacerbation were included. Complete history taking and physical examination as well as atrial blood gas, pulmonary function test (PFT) and echocardiography were performed. Disease severity was defined according to global initiative for obstructive lung disease (GOLD), Modified Medical Research Council (mMRC) and COPD Assessment Test (CAT) criteria. Patients with cor pulmonale were defined and findings were compared between patients with and without cor pulmonale. Results: Forty-two patients had cor pulmonale. There was no significant difference in hypercapnia between groups. Cor pulmonale patients, compared to non-cor pulmonale, had significantly lower forced expiratory volume in the first second (FEV1) (P = 0.020), higher tricuspid regurgitation (TR) (P = 0.001) and pulmonary hypertension (P = 0.020). There was significantly negative correlation between RV thickness with FEV1/forced vital capacity (FCV) (r = -0.239, P = 0.010) and RV size with FEV1/FVC (r = -0.312, P = 0.002) and positive correlation with partial pressure of carbon dioxide (PaCO2) (r = 0.312, P = 0.002) and bicarbonate (HCO3) (r = 0.258, P = 0.009). Conclusion: Cor pulmonale in the course of COPD accompanies with adverse outcome. These patients have worse spirometry and left ventricle echocardiographic findings, but have no difference in arterial blood gas (ABG) findings.

High Intensity Interval Training in a Rat Model of Severe, Angioproliferative Pulmonary Arterial Hypertension

PURPOSE: We previously demonstrated superior benefit of high intensity interval training (HIIT) over continuous exercise training (CET) in a monocrotaline rat model of mild pulmonary arterial hypertension (PAH). Here we investigate HIIT in a model that elicits a more severe, angioproliferative PAH. METHODS: SD rats (~200g, male) received Sugen5416 (20mg/kg), followed by 3 wks of hypoxia (Patm=362 mmHg) and 4 wks of room air to induce PAH (SuHx, n=33). Subgroups of SuHx then underwent 6 wks of treadmill training performed as either HIIT (2 min at ~80-90%VO2reserve [VO2R] + 3 min at 30%VO2R, for 4-5 cycles, n=12), or low intensity CET (45-60 min at 50%VO2R, n=11), with the remainder untrained (SED, n=10). Values are mean±SE. RESULTS: Mortality in SuHx was unexpectedly worse for HIIT (4 deaths at 56, 60, 68, and 71 days), vs. CET (2 deaths at 60, and 73 days), and SED (2 deaths at 66 days). While all animals had similar baseline echocardiographic measures of cardiac output (CO, in uL) and stroke volume (SV, in mL/min), SuHx that died prematurely (n=8) had greater impairment in CO (141±19) and SV (424±52) following PAH induction (at pre-training) compared to surviving SuHx (n=25, 235±26, 598±38). Final CO and SV were higher for both HIIT (239±49, 540±58) and CET (207±41, 529±51) vs. SED (122±12, 405±35) SuHx rats, and were similar to untrained healthy controls (CON, n=6, 268±59, 548±71). SuHx-induced elevation in right ventricular (RV) systolic pressure (mmHg) and RV hypertrophy (as RV mass/LV+septum mass, and as RV thickness on echo in mm) were not improved by training with HIIT (61±7; 0.60±0.07, 2.2±0.2) or CET (60±8; 0.47±0.04, 2.0±0.2), vs. SED (55±8; 0.52±0.06, 2.2±0.2), and were higher than CON (28±3; 0.24±0.01, 1.3±0.1). Final VO2max (ml/kg/min) in SuHx was also not improved for either HIIT (44±1.9) or CET (46±1.7) vs. SED (46±3.8). CONCLUSION: Both HIIT and CET promoted better RV function in SuHx rats despite no amelioration of RV hypertrophy, PAH, or exercise impairment. However, in contrast to previous findings in a mild PAH rat model, exercise training, particularly with HIIT, increased mortality for animals with poorer cardiac function prior to training onset and suggests that further investigation is needed to optimize training approach for patients with more severe RV dysfunction. Funding: NIH-NHLBI R-15 (to MB Brown).

ALTERED ARTERIAL DOPPLER FLOW PATTERN AND PERINATAL OUTCOME IN INTRAUTERINE GROWTH RESTRICTION

ABSTRACTObjectives: Intrauterine growth restriction (IUGR) is one of the common conditions that interfere with the growth of the fetus accounting for 10-15%of pregnant woman. Literature explores a wide range of incidence of perinatal complication including mortality among IUGR pregnancies. Limiteddata available on these complications confined to coastal Karnataka and its association with abnormal arterial Doppler flow pattern. To study theperinatal complications associated with IUGR pregnancies and its prevalence in comparison to healthy controls of comparable gestational age.Methods: This cohort study screened 53 IUGR fetuses by an antenatal scan at gestational age of 27 weeks or more. The diagnosis of IUGR was madeaccording to established criteria from SOGC clinical practice guidelines August 2013. The data also included 48 appropriate for gestational age fetuseswith healthy mothers with the comparable gestational week. Experienced cardiac sonographer and gynecologist performed fetal echocardiography(ECHO) using Vivid 7, GE health-care system ECHO machine with the convex transducer of frequency 1.7-2.4 MHz. The study was conducted at southIndian tertiary care center.Results: This study included 53 IUGR cases and 48 non-IUGR controls. The mean age was 27±4.37 and 26.88±3.14 years in IUGR and non-IUGRgroups, respectively. Fetal Doppler study variables showed a significant decrease in peak aortic velocity and velocity time integral which was notevident on other valves, though mitral antegrade flow during atrial contraction was found to be lower among IUGR group. In two-dimensional chamberquantification of IUGR group revealed significant increase in pulmonary artery dimension, right ventricular (RV) dimension and RV thickness than thecontrol group (p&lt;0.05). The anthropometric parameters such as weight and length; abdomen circumference was significantly lower in IUGR group,whereas head circumference found to be more in IUGR group (p&lt;0.001). The gestational weeks at delivery was significantly different among twogroups with IUGR group depicting the early delivery group. p&lt;0.001(35.58±2.92 and 38.5±0.96 in IUGR and non-IUGR groups, respectively). IUGRgroup also had prolonged neonatal intensive care unit stay when compared to controls (p&lt;0.001).Conclusions: IUGR carries profound course in altered Doppler indices and cardiac function which explore its prediction on mortality and adverseperinatal outcome. This study showed significant perinatal mortality accounting for 5.6% among IUGR cases when compared to normal. Althoughtissue Doppler indices show normal variants, IUGR possesses significant adverse perinatal outcome, however with lesser incidence compared tosevere form of IUGR subsets who show altered tissue annular velocities.Keywords: Intrauterine growth restriction, Echocardiography, Doppler, Perinatal.

Right Ventricular Hypertrophy, Systolic Function, and Disease Severity in Anderson-Fabry Disease: An Echocardiographic Study

Right ventricular (RV) involvement has been described in Anderson-Fabry disease (AFD), especially in patients with established Fabry cardiomyopathy (FC). However, few and controversial data on RV systolic function are available, and there are no specific tissue Doppler studies. Detailed echocardiographic examinations were performed in 45 patients with AFD. FC, defined as maximal left ventricular wall thickness≥15mm, was present in 12. The Mainz Severity Score Index was calculated for each patient. Pulsed tissue Doppler was applied to the RV free wall at the tricuspid annular level and at the septal and lateral corners at the mitral annular level to obtain systolic tissue Doppler velocities (RV Sa, septal Sa, and lateral Sa, respectively). Twelve patients with amyloid light-chain cardiac amyloidosis were studied as a control group. Echocardiography revealed RV hypertrophy (RVH) in 31% of patients with AFD, all but one of whom were male and all of whom had concomitant left ventricular hypertrophy (LVH). All patients with AFD had normal RV fractional area change (47.9±6.5%) and tricuspid annular plane systolic excursion (21.7±3.2mm) and all but one also had normal RV Sa (13.2±2.2cm/sec). RVH positively correlated with indices of LVH (r=0.8, P=.0001, for all parameters evaluated), as well as with Mainz Severity Score Index (r=0.70, P=.0001). Septal and lateral Sa were decreased in almost all patients (means, 7.7±1.8 and 7.9±1.9cm/sec, respectively), irrespective of the presence of LVH. Compared with control subjects with cardiac amyloidosis, patients with FC showed better indices of RV systolic function (P<.001 for all: tricuspid annular plane systolic excursion, RV fractional area change, and RV Sa) despite similar RV wall thickness (6.2±1.2 vs 6.9±1.9mm, P=NS). RVH is common in patients with AFD and correlates with disease severity and LVH. RVH, however, does not significantly affect RV systolic function. Patients with FC have better RV systolic function compared with those with cardiac amyloidosis with similar levels of RV thickness. The combination of low LV Sa values and normal RV Sa values might be helpful in the differential diagnosis of infiltrative heart disease.

Commentary on Electrocardiographic Time to Intrinsicoid Deflection and Heart Failure: the Multi-Ethnic Study of Atherosclerosis.

Regarding the article “Electrocardiographic Time to Intrinsicoid Deflection and Heart Failure: the Multi-Ethnic Study of Atherosclerosis,”1 the intrinsicoid deflection is one of the 6 electrocardiographic (ECG) components that comprise the Romhilt-Estes score, proposed in 1968 for the ECG detection of left ventricular hypertrophy.2 This criterion achieved its place in this group because of its performance in a study of the correlation between various ECG components and heart weight, and left and right ventricular (RV) thickness, all controlled for body weight.3 In this study, it was found that the intrinsicoid deflection time (which was called ventricular activation time in this study) had a higher correlation with total heart weight than the total QRS duration. Intrinsicoid deflection time had a higher correlation with RV thickness than left ventricular thickness, and it was more often found in those patients with symptoms suggesting heart failure (HF). The possibility that increased RV thickness (and increased intrinsicoid deflection time) were related to previous episodes of HF was considered but could not be established by this study. Much more recently, we have studied the ability of the same 6 ECG components, including the intrinsicoid deflection time, to predict all-cause mortality and new cardiovascular disease.4, 5 The overall Romhilt-Estes score is highly predictive of both mortality and new cardiovascular disease, but the surprising finding was that each of the 6 ECG components was independently predictive of these outcomes, and each was unique in its ability to predict specific cardiovascular outcomes. The intrinsicoid deflection time was among the most powerful predictors of incident HF, supporting the observations reported by O'Neal et al. These previous observations suggest that prolongation of the intrinsicoid deflection time in the ECG may be more than a predictor of congestive HF; it may indicate the prior occurrence of episodes of stress-related HF, producing periods of increased pulmonary artery pressure leading to an increased RV thickness. Neither our work nor that of O'Neil is structured to prove this hypothesis, but it raises the level of clinical importance of this ECG measurement and challenges investigators to test this hypothesis in further appropriately designed studies.

ABSTRACTS 7th World Congress of Mountain & Wilderness Medicine A combined meeting of the International Society for Mountain Medicine and the Wilderness Medical Society July 30-August 4, 2016 Telluride, Colorado.

ABSTRACTS 7th World Congress of Mountain & Wilderness Medicine A combined meeting of the International Society for Mountain Medicine and the Wilderness Medical Society July 30-August 4, 2016 Telluride, Colorado.

Quantification of myocardial stiffness using magnetic resonance elastography in right ventricular hypertrophy: initial feasibility in dogs

IntroductionMyocardial stiffness is an important determinant of cardiac function and is currently invasively and indirectly assessed by catheter angiography. This study aims to demonstrate the feasibility of quantifying right ventricular (RV) stiffness noninvasively using cardiac magnetic resonance elastography (CMRE) in dogs with severe congenital pulmonary valve stenosis (PVS) causing RV hypertrophy, and compare it to remote myocardium in the left ventricle (LV). Additionally, correlations between stiffness and selected pathophysiologic indicators from transthoracic echocardiography (TTE) and cardiac magnetic resonance imaging were explored. MethodsIn-vivo CMRE was performed on nine dogs presenting severe congenital PVS using a 1.5T MRI scanner. T1-MOLLI, T2-prepared-bSSFP, gated-cine GRE-MRE and LGE (PSIR) sequences were used to acquire a basal short-axis slice. RV and LV-free-wall (FW) stiffness measurements were compared against each other and also correlated to ventricular mass, RV and LV FW thickness, T1 and T2 relaxation times, and extracellular volume fraction (ECV). Peak transpulmonary pressure gradient and myocardial strain were also acquired on eight dogs by TTE and correlated to RV-FW systolic stiffness. Potential correlations were evaluated by Spearman's rho (rs). ResultsRV-FW stiffness was found to be significantly higher than the LV-FW stiffness both during end-systole (ES) (p=0.002) and end-diastole (ED) (p=0.029). Significant correlations were observed between RV-FW ES and LV-FW ED stiffness versus ECV (rs=0.75; p-value=0.05). Non-significant moderate correlations were found between LV-FW ES (rs=0.54) and RV-FW ED (rs=0.61) stiffness versus ECV. Furthermore, non-significant correlations were found between RV or LV-FW stiffness and the remaining variables (rs<0.54; p-value>0.05). ConclusionThis study demonstrates the feasibility of determining RV stiffness. The positive correlations between stiffness and ECV might indicate some interdependence between stiffness and myocardial extracellular matrix alterations. However, further studies are warranted to validate our initial observations.

Right ventricular thickness as predictor of global myocardial performance in systemic sclerosis: A Doppler tissue imaging study

BackgroundCardiopulmonary involvement in systemic sclerosis (SSc) is a poor prognostic factor, due to pulmonary hypertension and right ventricular dysfunction. We assessed the echocardiographic parameters of right ventricular (RV) function in SSc and correlated echocardiographic findings to clinical features of the disease. MethodsThirty patients with SSc (cases) and 30 healthy, age-matched subjects (controls) were studied. Echocardiography, including tissue Doppler imaging, was used to evaluate cardiac function. ResultsPulmonary hypertension could be documented in only 5 cases by Doppler echo, using Bernoulli principle. RV diastolic function was significantly deranged in cases. RV systolic function and left ventricle (LV) diastolic function were also significantly deranged in the cases. RV thickness was increased in patients with SSc. There were no significant differences in the echocardiographic variables between diffuse and limited subtypes of SSc. Myocardial performance index (MPI) of both ventricles were increased in cases. We could demonstrate RV thickness as the single most important predictor of MPI of both ventricles with sensitivity of 82% and specificity of 72% for RV-MPI and 63% for LV-MPI. Diastolic function was not found to be affected by disease duration or Rodnan skin score. ConclusionPatients with SSc exhibit abnormal RV and LV diastolic functions as well as abnormal RV systolic function. RV wall thickness was found to be simple and the single best predictor of global myocardial performance. RV dysfunction may be a response to intermittent pulmonary arterial hypertension, lung parenchymal involvement, or secondary to LV diastolic dysfunction in SSc.

The Role of MiR‐21 in Right Ventricular Remodeling Secondary to Pulmonary Arterial Pressure Overload

Pulmonary arterial hypertension (PAH) prognosis is related to the degree of right ventricular (RV) dysfunction. While the effects of pulmonary pressure overload on RV remodeling are largely unknown, microRNA‐21 (miR‐21) has been identified as a factor involved in PAH vasculature remodeling and cellular hypertrophy. The goal of this study is to characterize regional structural and functional change in RV after PAH and identify the role of miR‐21. Pulmonary arterial constriction (PAC) induced PAH in 5‐month‐old adult male sheep. Longitudinal echocardiography was used to monitor functional and structural changes. After four weeks, hearts were harvested for histological and molecular examination. Isolated neonatal rat ventricular myocytes (NRVM) were used to define the role of miR‐21 in cardiomyocytes (CM). Elevated PA pressure led to increased RV weight and thickness in PAC sheep. Decreased systolic function was most profound in the RV basal region. Following changes in regional function, miR‐21 was also differentially upregulated in the basal region as determined by RT‐PCR. Interestingly, NRVM treated with a miR‐21 mimic increased mitosis but not cytokinesis compared to controls. Congruently, RV basal CM isolated from PAC animals revealed increased elongated multinuclear cells, supporting the notion of RV pressure overload‐induced hypertrophy. We conclude that PAC led to regional alterations and contributes to adverse global functional changes. The differential upregulation of miR‐21 in basal and altered RV CM remodeling may indicate PAC‐induced regional and global structural and functional RV remodeling.

Echocardiographic predictors of mortality in patients with pulmonary hypertension and cardiopulmonary comorbidities.

ObjectiveWe aimed to identify the echocardiographic measures associated with survival in a patient population with a high prevalence of co-morbid cardiovascular and pulmonary disease that have significantly elevated estimated pulmonary artery systolic pressures (ePASP).BackgroundPulmonary hypertension (PH) is a clinical feature of several cardiopulmonary diseases that are prevalent among elderly. While certain echocardiographic parameters have been shown to be important in the prognosis in specific PH groups, the prognostic relevance of echocardiographic characteristics in a cohort with multiple cardiopulmonary comorbidities is unclear.MethodsWe retrospectively identified 152 patients with ePASP > 60 mmHg by echocardiography over a five year period (6/2006–11/2011) and followed until 4/2013. Candidate clinical and echocardiographic characteristics suggestive of PH severity were compared between deceased and surviving subpopulations. Cox proportional hazard modeling was used to identify echocardiographic predictors of death adjusted for age and clinical characteristics.ResultsThis was a predominantly elderly (age 78.8 ± 10.2 years), male (98.7%) cohort with several cardiopulmonary comorbidities. Overall mortality was high (69.7%, median survival 129 days). After adjusting for age and clinical characteristics, decreased right ventricular (RV) systolic function assessed by tricuspid annular plane systolic excursion (HR 0.56, 95% CI 0.33–0.96, p = 0.034) and increased RV thickness (HR: 4.34, 95% CI: 1.49–12.59, p = 0.007) were independently associated with mortality. In contrast, left ventricular systolic function, left ventricular diastolic parameters, ePASP, or echo-derived pulmonary vascular resistance (PVR) were not associated with increased mortality.ConclusionIn a cohort of patients with PH and high prevalence of cardio-pulmonary comorbidities, RV systolic function and hypertrophy are associated with mortality and may be the most relevant echocardiographic markers for prognosis.

Right ventricular myocardial motion and deformation in adolescents and young adults after repair of coarctation of the aorta.

Alteration of right ventricular (RV) function has been found in patients with pressure-loaded left ventricles due to systemic hypertension and aortic stenosis. We tested the hypothesis that RV mechanics are altered in adolescents and adults with repaired coarctation of the aorta (CoA). Twenty-eight (15 male) patients, aged 23.7 ± 6.5 years, and 28 (14 male) controls were studied. M-mode, tissue Doppler imaging, and speckle tracking echocardiography were performed to assess, respectively, LV mass and RV wall thickness, RV myocardial tissue velocities, and deformation. Systolic (P = 0.14) and diastolic (P = 0.32) blood pressures were similar between patients and controls. Compared with controls, patients had significantly greater LV mass (P = 0.016) and RV anterior wall thickness (P = 0.012). Tricuspid annular systolic (P < 0.001) and early diastolic (P < 0.001) velocities, isovolumic acceleration (P = 0.004), global RV systolic longitudinal strain (P = 0.03), systolic strain rate (P = 0.012), and early (P = 0.021) and late (P = 0.012) diastolic strain rates were significantly lower in patients than controls. Patients with an associated ventricular septal defect (n = 6) requiring closure compared to those without had even lower tricuspid annular systolic (P = 0.01) and early diastolic (P = 0.041) velocities. Left ventricular mass correlated negatively with RV systolic strain rate (r = -0.27, P = 0.045) and tricuspid annular early diastolic velocity (r = -0.40, P = 0.002), while RV anterior wall thickness correlated negatively with tricuspid annular systolic (r = -0.42, P = 0.002) and late diastolic (r = -0.40, P = 0.003) velocities, and positively with e/a ratio (r = 0.31, P = 0.024). RV systolic and diastolic mechanics are impaired in patients late after repair of CoA and related to increased LV mass and RV thickness.

Defining the best echocardiographic parameter to predict acute rejection after heart transplantation

Acute allograft rejection (AR) is the major cause of morbidity and mortality the first year after heart transplantation (HT), beeing endomyocardial biopsy (EB) the gold standard procedure to diagnose it. Our group has previously developed a protocol to evaluate echocardiographic parameters and 2D strain in the first year after HT. Our aim was to evaluate which is the best non-invasive measurement to predict AR. Methods: We prospectively included 34 HT recipients between 2009-12. A median of 7 Echocardiograms and EB were performed for each patient during the first year after HT (the same day). We measured left ventricular (LV) longitudinal strain (Long.S) in 4 and 2-chamber views using speckle tracking. Right ventricular (RV) strain was obtained from a 4-chamber view. AR by EB was graded according to ISHLT recommendations. Results: We analyzed a total of 224 EB and echo exams. AR was detected in 59 EBs (48 1R, 8 2R and 3 3R). 3 different LV parameters and 2 RV measures were significantly associated with AR on univariate analysis, comparing AR vs no-rejection: Interventricular septal thickness (IVST) 12.4±2.1 vs 11.3±1.8, p<0.005, Isovolumic Relaxation Time (IVRT) 80.6±19.4 vs 93.3±17.9, p<0.005; LV long.S -14.6±3.5 vs -17.8±3.5, p<0.005; RV Thickness 5.7±1.3 vs 5.2±1.1, p=0.02; RV Free Wall S -16.6±3.1 vs -23.4±5.3, p<0.005. IVST, LV Long.S and RV free-wall S were the three independent predictors for AR on multivariate analysis (Table 1). The best area under the ROC curve was provided by RV free-wall S (AUC 0.87, CI 0.82-0.92, p<0.001) View this table: Multivariate analysis to predict AR Conclusion: Myocardial deformation parameters, specially free-wall right ventricular longitudinal strain, are useful tools to detect AR in the first year after HT, providing further information over conventional echo parameters. This findings could be usefull to reduce the burden of repeated EB in the early HT period.

High prevalence of right ventricular dysfunction in ICD patients with shocks: a potential new predictor in risk stratification

Despite identifying several risk factors for sudden cardiac death, our ability to predict arrhythmic events in patients with an implantable cardioverter defibrillator (ICD) remains poor. The purpose of this study was to determine if patients who received appropriate ICD shocks had a higher degree of right ventricular (RV) dysfunction at baseline when compared to patients who did not receive ICD shocks. We conducted a 1:2 case-control, retrospective study comparing RV end-diastolic and end-systolic areas (RV ED and RV ES areas, respectively), fractional RV area change, and RV wall thickness in 19 consecutive patients who received appropriate ICD shocks (shock group) with another group of 38 patients who did not receive ICD shocks (no-shock group). There was no significant difference in the RV end-diastolic areas between the groups. However, patients who experienced ICD shocks had a higher RV end-systolic area and a lower RV fractional area change when compared to patients without ICD shocks, 16.3 ± 4.9 cm(2) and 27.7 ± 9.0% in the shock group versus 14.2 ± 4.4 cm(2) and 35.8 ± 10.3% in the no-shock group; (p = 0.08 and 0.004, respectively). Furthermore, the RV wall thickness was greater in patients with ICD shocks when compared to patients without ICD shocks, 0.49 ± 0.05 cm and 0.44 ± 0.04 cm, respectively (p = 0.001). Utilizing a logistic regression analysis and after controlling for variables with univariate significance (p < 0.1), RV wall thickness independently predicted ICD shocks (OR 13.9 mm(-1) change of RV thickness, p = 0.004). Our findings suggest that some measurements of RV function might prove to be useful in predicting future arrhythmic events. Additional prospective studies are needed to test this hypothesis.

Right ventricle–sparing heart transplantation effective against iatrogenic pulmonary hypertension

Background Right heart failure is the predominant cause of death following heart transplantation, occurring with disturbingly high frequency in patients with severe antecedent pulmonary hypertension. We have recently reported a novel technique of heart transplantation that spares the recipient right ventricle, excising only the recipient left ventricle. The resulting model has 2 right hearts and 1 left heart. The aim is to preserve the recipient’s right ventricle, which is already conditioned to pulmonary hypertension. The hope is that, in this way, death due to right heart failure can be prevented in humans. Our prior report was a feasibility study in normal dogs. This study challenges this new technique by creating iatrogenic pulmonary hypertension in the recipient animals. Methods Iatrogenic pulmonary hypertension was created in 4 recipient canines by intravenous injection of the pulmonary toxin monocrotaline pyrrole (single bolus of 3.5 to 4.5 mg/kg intravenously [IV]). Results Within 6 weeks of monocrotaline administration, relative pulmonary hypertension occurred (mean pulmonary artery [PA] pressure 20 mm Hg vs 10 mm Hg for controls [ p < 0.01]) (pulmonary vascular resistance [PVR] 4.2 vs 1.5 Wood units [ P < 0.01]), and right ventricular (RV) hypertrophy developed (RV thickness 11 mm vs 2 mm [ P < 0.04]). Histologic examination confirmed severe muscle infiltration and thickening of the media of the pulmonary arterioles. RV–sparing heart transplantation was performed successfully in all 4 animals with pulmonary hypertension. In all cases, the animals were weaned without difficulty from cardiopulmonary bypass, despite the ambient pulmonary hypertension, on low-dose epinephrine, maintaining systolic blood pressure of 104 mm Hg at right atrial pressure of 7 mm Hg. Both right hearts contracted well without dilation or strain. A single “control” traditional orthotopic transplant experiment in an animal with monocrotaline-induced pulmonary hypertension resulted in immediate death from right heart failure. Conclusions Right ventricle–sparing heart transplantation (“one-and-one-half heart model”) can handle pulmonary hypertension without difficulty. This evidence adds impetus for further pursuance of right ventricle–sparing heart transplantation to decrease the incidence of death from right heart failure in recipients with severe antecedent pulmonary hypertension.