Right Ventricular End-diastolic Area Research Articles

The role of right ventricular volumes and inferior vena cava diameters in the evaluation of volume status before colonoscopy

Background/aim Ultrasonographic measurements of inferior vena cava (IVC) diameters and right ventricle (RV) volumes are important tools for the evaluation of intravascular volume. The current study investigates the association of IVC diameters and RV volumes before colonoscopy in prediction of postanesthesia hypotension.Materials and methodsSeventy patients scheduled for colonoscopy were included in the study. Preoperatively, expirium (dIVC max) and inspirium (dIVC min) IVC diameters were measured using M-mode ultrasonography and the collapsibility index (IVC-CI) was calculated. Ventricular volumes and areas were also measured using transthoracic echocardiography. Postanesthesia hypotension was defined as mean arterial blood pressure of <60 mmHg or a decrease of >30% in the mean arterial pressure after sedation.Results Minimum and maximum IVC diameters were significantly lower (P = 0.005 and P < 0.001, respectively) and IVC-CI was significantly higher (P < 0.001) in patients who developed hypotension. Similarly, right ventricular end-diastolic area (RV-EDA), right ventricular end-systolic area (RV-ESA), right ventricular end-diastolic volume (RV-EDV), right ventricular end-systolic volume (RV-ESV), and left ventricular end-systolic volume (LV-ESV) values were significantly lower in patients with hypotension (P < 0.05). Logistic regression analysis showed that dIVC min and RV-ESA were independent predictors of hypotension.Conclusion IVC diameters and RV-ESA, RV-EDA, RV-ESV, and RV-EDV are good indicators of preoperative volume status and can be used to predict the patients at risk of developing hypotension.

The Incremental Value of Right Ventricular Size and Strain in the Risk Assessment of Right Heart Failure Post - Left Ventricular Assist Device Implantation

Right heart failure (RHF) after left ventricular assist device (LVAD) implantation is associated with high morbidity and mortality. Existing risk scores include semiquantitative evaluation of right ventricular (RV) dysfunction. This study aimed to determine whether quantitative evaluation of both RV size and function improve risk stratification for RHF after LVAD implantation beyond validated scores. From 2009 to 2015, 158 patients who underwent implantation of continuous-flow devices who had complete echocardiographic and hemodynamic data were included. Quantitative RV parameters included RV end-diastolic (RVEDAI) and end-systolic area index, RV free-wall longitudinal strain (RVLS), fractional area change, tricuspid annular plane systolic excursion, and right atrial area and pressure. Independent correlates of early RHF (<30 days) were determined with the use of logistic regression analysis. Mean age was 56 ± 13 years, with 79% male; 49% had INTERMACS profiles ≤2. RHF occurred in 60 patients (38%), with 20 (13%) requiring right ventricular assist device. On multivariate analysis, INTERMACS profiles (adjusted odds ratio 2.38 [95% confidence interval [CI] 1.47-3.85]), RVEDAI (1.61 [1.08-2.32]), and RVLS (2.72 [1.65-4.51]) were independent correlates of RHF (all P < .05). Both RVLS and RVEDAI were incremental to validated risk scores (including the EUROMACS score) for early RHF after LVAD (all P < .01). RV end-diastolic and strain are complementary prognostic markers of RHF after LVAD implantation.

Relative Importance of Baseline and Longitudinal Evaluation in the Follow-Up of Vasodilator Therapy in Pulmonary Arterial Hypertension

ObjectivesThe aim of this study was to evaluate the relative value of baseline and follow-up echocardiographic assessment of pulmonary artery systolic pressure (PASP) and right ventricular (RV) function in assessing response to vasodilator therapy in pulmonary arterial hypertension (PAH). BackgroundRoutine follow-up of PASP and RV function is widely obtained in patients undergoing treatment for PAH, but the value of this reassessment is uncertain. MethodsOf 162 prospectively recruited patients with PAH, 96 were included in this analysis of patients with ≥3 sequential echocardiographic studies. PASP and RV function (including right ventricular free wall strain [RVFWS]) were measured at baseline and on follow-up 2-dimensional echocardiography. Univariate and multivariate Cox regression with nested models was used to determine incremental and independent predictors of all-cause mortality. ResultsChanges between visits were minimal for all parameters (RVFWS, p = 0.46; RV end diastolic area, p = 0.48; tricuspid annular plane systolic excursion, p = 0.32; PASP, p = 0.66; right atrial area, p = 0.39; and inferior vena cava, p = 0.25). Over 3 years of follow-up, 29 patients died. Baseline RVFWS was an independent predictor of outcome (hazard ratio [HR]: 0.90; 95% confidence interval [CI]: 0.83 to 0.97; p = 0.007), incremental to PASP and other clinical covariates (C statistic = 0.74, p = 0.001). Those who died showed no differences in RVFWS (p = 0.50), PASP (p = 0.90), and tricuspid annular plane systolic excursion (p = 0.83) between visits. When baseline measures and follow-up time were accounted for, mean changes in RVFWS (HR: 0.78; 95% CI: 0.63 to 0.96; p = 0.002), right atrial area (HR: 1.20; 95% CI: 1.07 to 1.40; p = 0.003), and inferior vena cava (HR: 66.5; 95% CI: 8.5 to 520.5; p < 0.001) over follow-up were significant in predicting outcome. ConclusionsIn PAH, baseline RV function (RVFWS) is a strong predictor of outcome, independent of PASP. Changes throughout therapy appear minimal, and only changes in RVFWS, inferior vena cava, size, and right atrial area were associated with outcome.

Echocardiographic evaluation of the right ventricular dimension and systolic function in dogs with pulmonary hypertension.

BackgroundRight ventricular (RV) enlargement and dysfunction are associated with prognosis in humans with pulmonary hypertension (PH).Hypothesis/ObjectivesTo assess RV size and systolic function in dogs with PH and to determine if they are associated with disease severity and right‐sided congestive heart failure (R‐CHF).Animals89 dogs with PH and 74 healthy dogs.MethodsProspective observational study. PH was classified according to the tricuspid regurgitation pressure gradient. RV end‐diastolic area (RVEDA) index was calculated as RVEDA divided by body surface area. RV systolic function was assessed with the tricuspid annular plane systolic excursion (TAPSE) and the RV fractional area change (FAC) normalized for body weight (TAPSEn and FACn, respectively).ResultsRVEDA index was higher in dogs with moderate PH (10.8 cm2/m2; range, 6.2‐14.4 cm2/m2) and severe PH (12.4 cm2/m2; range, 7.7‐21.4 cm2/m2) than in those with mild PH (8.4 cm2/m2; range, 4.8‐11.6 cm2/m2) and control dogs (8.5 cm2/m2; range, 2.8‐11.6 cm2/m2; P < .001). RVEDA index was significantly higher in dogs with R‐CHF (13.7 cm2/m2; range, 11.0‐21.4 cm2/m2) than in dogs without R‐CHF (9.4 cm2/m2; range, 4.8‐17.1 cm2/m2; P < .001). The severity of tricuspid regurgitation (TR) was the only independent predictor of the RVEDA index (P < .001). TAPSEn and FACn were not significantly different among varying degrees of PH severity and between dogs with and without R‐CHF.Conclusions and Clinical ImportanceThe RVEDA index can be used to evaluate RV size in dogs. It can provide additional information in dogs with PH and predict R‐CHF. Severity of TR is the main determinant of RV enlargement in dogs with PH.

Short-Axis Diastolic Ventricular Area Ratio as a New Index in Screening Patients with Repaired Tetralogy of Fallot.

Right ventricular (RV) end-diastolic volume measured by cardiovascular magnetic resonance imaging (CMR) is a criterion for pulmonary valve replacement in patients with tetralogy of Fallot (TOF). We sought to determine if the ratio of echocardiographic, short-axis RV-to-left ventricular (LV) end-diastolic areas (EDA) could be used to predict RV volume on CMR. We retrospectively reviewed the echocardiograms of all patients with repaired TOF who underwent CMR at our institution from 2011 to 2015 and also had an echocardiogram within 6 months of the CMR. The short-axis RV and LV EDAs were measured and the ratio of the two was calculated. Results were compared with CMR RV end-diastolic volume index (RVEDVi) and RV:LV end-diastolic volume ratio. The sensitivity and specificity values predicting RV volumes > 150ml/m2 were calculated. Fifty-eight studies met inclusion criteria. There were 47 studies with RVEDVi < 150ml/m2 and 11 with RVEDVi > 150ml/m2. RV:LV EDA and CMR RV:LV end-diastolic volume ratio correlated strongly (r = 0.76, p < 0.0001). An RV:LV EDA ≥ 1.57 had a 90% sensitivity to predict RVEDVi > 150ml/m2 (area under the curve = 0.74, 95% CI 1.5-27.9; p = 0.012). An RV:LV EDA ≥ 1.88 had an 81% specificity to detect RV volume index > 150ml/m2. Short-axis RV:LV EDA correlates well with an increased RVEDVi as measured by CMR. This new and simple measure can be used to predict optimal timing for CMR in anticipation of pulmonary valve replacement in repaired TOF.

Right ventricular end-systolic area as a simple first-line marker predicting right ventricular enlargement and decreased systolic function in children referred for cardiac magnetic resonance imaging

To assess the accuracy of simple cardiovascular magnetic resonance imaging (CMR) parameters for first-line analysis of right ventricle (RV) dysfunction in children to identify those who require in-depth analysis and those in whom simple assessment is sufficient. Sixty paediatric CMR studies were analysed. The following CMR parameters were measured: RV end-diastolic and end-systolic area (4CH EDA and 4CH ESA), fractional area change (FAC), RV diameter in end-diastole (RVD1), tricuspid annular plane systolic excursion (TAPSE), and RV outflow tract diameter in end-diastole (RVOT prox). They were correlated with RV end-diastolic volume (RVEDVI) and RV ejection fraction (RVEF). RVEDVI correlated best with 4CH ESA (r=0.85, <0.001) and EDA (r=0.82, <0.001). For RVEF only a moderate reverse correlation was found for 4CH ESA (-0.56, <0.001), 4CH EDA (-0.49, 0.001) and positive correlation for FAC (0.49, <0.001). There was no correlation between TAPSE and RVEF and only weak between RVD1 and RVEDVI. A 4CH ESA cut-off value of 8.5cm2/m2 had a very high diagnostic accuracy for predicting an enlarged RV (AUC=0.912, p<0.001, sensitivity 92.3%, specificity 79%) and a cut-off value of 10.5cm2/m2 was also a good predictor of depressed RV systolic function (AUC=0.873, p<0.001, sensitivity 83%, specificity 89%). For routine screening in clinical practice, 4CH ESA seems a reliable and easy method to identify patients with RV dysfunction.

The right ventricular outflow tract in pediatric pulmonary hypertension-Data from the European Pediatric Pulmonary Vascular Disease Network.

The right ventricular outflow tract (RVOT) is pivotal for adequate RV function and known to be adversely affected by elevated pulmonary arterial pressure (PAP) in adults with pulmonary hypertension (PH). Aim of this study was to determine the effects of increased RV pressure afterload in children with PH on RVOT size, function, and flow parameters. We conducted a transthoracic echocardiographic study in 51 children with PH (median age: 5.3years; range 1.5months to 18years) and determined the following RVOT variables: RVOT diameter, RVOT velocity time integral (VTI), ratio of tricuspid regurgitation velocity (TRV)/RVOT VTI, and RVOT systolic excursion (SE). In our pediatric PH cohort, the age-specific RVOT diameter z-score was higher compared to normal values. Deviation from normal RVOT diameter values increased with age, disease severity, and New York Heart Association functional class. Significant correlations were found between RVOT diameter and the RV end-diastolic area and right atrial area. The age-specific RVOT VTIz-score values were significantly lower in children with PH vs healthy controls. The TRV/RVOT VTI ratio increased with rising systolic RV pressure, while the RVOT SE was similar between PH children and control subjects. In pediatric PH cohort, the RVOT VTI is decreased, and the TRV/RVOT VTI ratio and the RVOT diameter increased compared to healthy subjects. Assessment of RVOT variables, together with established RV parameters, allows for a comprehensive assessment of global right heart size and performance in children with PH.

Hemodynamic correlates of right ventricular dilation in pulmonary hypertension due to HFpEF

Right ventricular (RV) remodelling and pulmonary hypertension (PH) are increasingly recognized in heart failure with preserved ejection fraction (HFpEF), with high prevalence and poor outcome. Factors leading to RV dilation in PH-HFpEF patients are unknown. We thought to determine the hemodynamic correlates of RV dilation in HFpEF patients with PH. We analysed hemodynamic, echocardiographic and clinical characteristics of 93 PH-HFpEF patients (60 women) enrolled prospectively in our center. PH-HFpEF was defined by a resting mean pulmonary artery pressure (mPAP) ≥ 25 mmHg and pulmonary artery wedge pressure (PAWP) > 15 mmHg RV dilation was defined as end diastolic right ventricular area (EDRVA) > 20 cm2 at echocardiography. Mean age (± SD) was 69 ± 12 years, mPAP was 40 ± 10 mmHg, PAWP was 21 ± 4 mmHg. 30 PH-HFpEF patients (31%) had RV dilation. The Pearson correlation coefficients between indexed EDRVA and hemonynamic parameters were 0.39 for right atrial pressure (RAP) and 0.36 for diastolic gradient (each P < 0.001) and 0.20 for effective arterial elastance Ea (P = 0.049). There was no correlation between EDRVA and PAWP, pulmonary vascular resistance, pulmonary arterial compliance or pulmonary arterial stiffness. In PH-HFpEF patients, we documented a significant relationship between RV remodeling and both RAP and the diastolic pressure gradient. Amongst the classic parameters quantifying pulmonary arterial, only Ea weakly contributed.

Prognostic relevance of right heart reverse remodeling in idiopathic pulmonary arterial hypertension

Right ventricular (RV) failure is a major determinant of symptoms and shortened survival in pulmonary arterial hypertension (PAH). This study assessed the prognostic relevance of increased right heart (RH) dimensions determined by echocardiography and RH reverse remodeling (RHRR) with targeted therapies in idiopathic PAH (IPAH). The study prospectively monitored 102 therapy-naïve IPAH patients for the presence of clinical worsening. Baseline evaluation included RH catheterization and echocardiography. RHRR at the 1-year follow-up was defined by a decrease in RV end-diastolic area, right atrial area, and the left ventricular systolic eccentricity index. At the 1-year follow-up, 18 of 102 patients (17.6%) presented with RHRR. A decrease in pulmonary vascular resistance was the only independent determinant of RHRR. The 94 surviving patients were monitored for 995 ± 529 days. RHRR was an independent prognostic factor and significantly improved the power of the prognostic model based on traditional clinical and hemodynamic parameters. The respective event-free survival rates at 1, 3, and 5 years were 94%, 94%, and 94% in patients with RHRR and 75%, 55%, and 24% in those without RHRR (p = 0.0001). Interestingly, RHRR was able to further stratify patients' risk assessment through the Registry to Evaluate Early And Long-term PAH Disease Management risk score. RHRR after 1 year of treatment is an independent predictor of prognosis in IPAH. The likelihood of RHRR is proportional to decreased pulmonary vascular resistance.

Afterload Dependence of Right Ventricular Myocardial Strain

Right ventricular (RV) free wall strain (RVFWS) is a feasible method for quantitation and follow-up of RV function and may have benefits over traditional markers such as fractional area change. However, like all ejection phase parameters, RVFWS is difficult to assess in the presence of changing afterload. The aim of this study was to compare RVFWS and traditional RV function parameters for tracking progress of RV function in patients with pulmonary arterial hypertension (PAH) over a range of pulmonary artery systolic pressure (PASPs). Sequential echocardiograms were collected retrospectively at two time points between 2005 and 2015 in 187 patients (71% women; mean age, 63±14years) undergoing pulmonary vasodilator therapy for group 1 PAH. Patients were either studied during PAH therapy (n=111) or before and after treatment initiation (n=76). Standard measurements of RV and left ventricular function and PASP were performed, and speckle-tracking strain was used to calculate RVFWS. The linear response of RVFWS to afterload (PASP) was assessed using a standard regression equation. Because it is unclear if the response might be nonlinear, a quadratic association (PASP squared) was also used in the regression model. At visit 1, patients with PAH showed impaired functional capacity (mean 6-min walk distance, 371±131m), increased PASP (mean, 54±26mmHg), and borderline RVFWS (mean, 18±6%). Patients before PAH therapy showed more pronounced reduction in 6-min walk distance (mean, 302±136m) and RVFWS (mean, 16±5%). RVFWS at baseline was associated with PASP (R2=0.25, P=.001), RV end-diastolic area (R2=0.36, P<.001), and fractional area change (R2=0.21, P<.001). Change in RVFWS was more strongly associated with ΔPASP (std β=-0.20, P=.02) than ΔPASP squared (std β=0.11, P=.20). RVFWS showed strength over fractional area change for sequential RV assessment over a range of PASP changes. Afterload changes should be taken into account in the evaluation of RVFWS during PAH follow-up, with the relationship to PASP likely to be linear.

Left Ventricular Stiffness in Adolescents and Young Adults with Repaired Tetralogy of Fallot

Left ventricular (LV) remodeling after tetralogy of Fallot (TOF) repair may influence LV stiffness. We hypothesized that LV stiffness is altered after TOF repair and related to myocardial calibrated integrated backscatter (cIB) and LV diastolic myocardial deformation. Seventy-seven TOF patients and 80 controls were studied. LV stiffness was assessed by diastolic wall strain (DWS) as defined by (LVPWsystole-LVPWdiastole)/LVPWsystole, where LVPW is LV posterior wall thickness, and stiffness index as defined by (E/e/LV end-diastolic dimension), where E and e are respectively early diastolic transmitral inflow and mitral annular velocities. Septal and LVPW cIB and LV diastolic strain rates were determined. Patients had significantly lower DWS (p < 0.001), higher stiffness index (p < 0.001), and greater cIB (p < 0.001). LV DWS correlated negatively with LV stiffness index (r = −0.31, p < 0.001), septal cIB (r = −0.21, p = 0.01), E/e ratio (r = −0.30, p < 0.001) and RV end-diastolic area (r = −0.31, p < 0.001), and positively with LV early (r = 0.33, p < 0.001) and late (r = 0.20, p = 0.01) diastolic strain rates and RV fractional area change (FAC) (r = 0.24, p = 0.003). Multivariate analysis revealed E/e (β = −0.26, p = 0.008), RV end-diastolic area (β = −0.20, p = 0.02), and RV FAC (β = 0.18, p = 0.01) as significant correlates of DWS. Left ventricular stiffening occurs after TOF repair and is related to impaired LV diastolic myocardial deformation, myocardial cIB, and RV volume overload.

Influence of gender on right ventricle adaptation to endurance exercise: an ultrasound two-dimensional speckle-tracking stress study.

Characteristic right ventricle (RV) remodelling is related to endurance exercise in male athletes (MAs), but data in female athletes (FAs) are scarce. Our aim was to evaluate sex-related influence on exercise-induced RV remodelling and on RV performance during exercise. Forty endurance athletes (>10 training hours/week, 50% female) and 40 age-matched controls (<3h moderate exercise/week, 50% female) were included. Echocardiography was performed at rest and at maximum cycle-ergometer effort. Both ventricles were analysed by standard and speckle-tracking echocardiography. Endurance training induced similar structural and functional cardiac remodelling in MAs and FAs, characterized by bi-ventricular dilatation [~34%, left ventricle (LV); 29%, RV] and normal bi-ventricular function. However, males had larger RV size (p < 0.01), compared to females: RV end-diastolic area (cm2/m2): 15.6 ± 2.2 vs 11.6 ± 1.7 in athletes; 12.2 ± 2.7 vs 8.6 ± 1.6 in controls, respectively, and lower bi-ventricular deformation (RV global longitudinal strain (GLS) (%): -24.0 ± 3.6 vs -29.2 ± 3.1 in athletes; -24.9 ± 2.5 vs -30.0 ± 1.9 in controls, and LVGLS: -17.5 ± 1.4 vs -21.9 ± 1.9 in athletes; -18.7 ± 1.2 vs -22.5 ± 1.5 in controls, respectively, p < 0.01). During exercise, the increase in LV function was positively correlated (p < 0.01) with increased cardiac output (∆%LV ejection fraction, r = +0.46 and ∆%LVGLS, r = +0.36). Improvement in RV performance was blunted at high workloads, especially in MAs. Long-term endurance training induced similar bi-ventricular remodelling in MAs and FAs. Independently of training load, males had larger RV size and lower bi-ventricular deformation. Improvement in RV performance during exercise was blunted at high workloads, especially in MAs. The potential mechanisms underlying these findings warrant further investigation.

Cardiac dysfunction of pulmonary artery aneurysm in patients with pulmonary arterial hypertension

BackgroundPulmonary artery aneurysm (PAA) occurs in some patients with pulmonary arterial hypertension (PAH). We evaluated the characteristics of cardiac dysfunction in patients with PAH complicated by PAA. MethodsEchocardiography and right-heart catheterization were performed in 130 PAH patients to measure the maximum dimensions of the main pulmonary artery (MPA) trunk and evaluate right ventricular (RV) and left ventricular (LV) function. ResultsA diameter of >40mm was defined as PAA in the MPA trunk. The maximum MPA diameter was >40mm in 32 of 130 PAH patients (24.6%: Group PAA). Systolic pulmonary artery pressure (68.0±18.5 vs. 58.9±21.6mm Hg, P=0.0354) and pulmonary capillary wedge pressure (10.8±3.9 vs. 7.7±2.6mm Hg, P<0.0001) were significantly higher in Group PAA than in Group non-PAA. RV end-diastolic area index (19.6±6.8 vs. 14.9±5.1 cm²/m², P<0.0001), and RV fractional area change (32.3±7.8 vs. 37.3±8.8%, P=0.0048) and RV longitudinal strain (−15.4±5.1 vs. −20.4±6.1, P=0.0012) were significantly lower, and E/e′ was significantly higher (8.1±2.2 vs. 6.7±1.4, P=0.0002) in Group PAA than in Group non-PAA. ConclusionsIn PAH patients with PAA, RV was larger and RV dysfunction was more severe, and LV diastolic dysfunction appeared. It is important to investigate the appearance of PAA and the severity of RV and LV dysfunction in PAH patients with PAA.

Multidirectional left ventricle and longitudinal right ventricle deformation analysis by two-dimensional speckle tracking echocardiography in young elite athletes

Objective By using a multiparametric two-dimensional speckle tracking analysis we aimed at investigating whether high performance sport induces changes in the left and right ventricular mechanics in young subjects.Methods and results Young elite athletes (n = 37, mean age 17.5 ± 3.7 years) divided by type of activity in endurance athletes [EAs] (n = 30) and strength athletes [SAs] (n = 7) and sedentary subjects (n = 22, mean age 20.1 ± 4.6 years) were prospectively enrolled. The subjects were analysed using standard two-dimensional echocardiography and two-dimensional speckle tracking echocardiography. Left ventricle (LV) deformation measurements included global peak systolic (GLPSS) and maximum longitudinal strain (GLMS), circumferential (GCMS) and radial strain (GRMS). Additionally, LV postsystolic index (PSI) and rotational components were investigated. Right ventricle (RV) deformation evaluation consisted of mean longitudinal peak systolic strain (LPSS). Athletes presented increased LV mass (P <0.05) and hypertrophy of the RV free wall (P <0.01) No difference regarding LV volumes or ejection fraction was found. RV end-systolic (P <0.05) and end-diastolic area (P <0.01) and RA end-systolic (P <0.05) and end-diastolic volumes (P <0.05) were larger in athletes. GLPSS (P <0.01) and GLMS (P <0.05) were decreased in athletes, with SAs presenting the lowest values, while no significant differences concerning PSI, GCMS, GRMS or the rotational components were found in athletes when compared to controls. RV LPSS was similar in both groups.Conclusions Young performance athletes demonstrate a subtle but significant reduction of LV longitudinal deformation, more pronounced in strength performers while circumferential and radial deformations as well as the RV longitudinal strain.

Mesenchymal stem cells preserve neonatal right ventricular function in a porcine model of pressure overload.

Limited therapies exist for patients with congenital heart disease (CHD) who develop right ventricular (RV) dysfunction. Bone marrow-derived mesenchymal stem cells (MSCs) have not been evaluated in a preclinical model of pressure overload, which simulates the pathophysiology relevant to many forms of CHD. A neonatal swine model of RV pressure overload was utilized to test the hypothesis that MSCs preserve RV function and attenuate ventricular remodeling. Immunosuppressed Yorkshire swine underwent pulmonary artery banding to induce RV dysfunction. After 30 min, human MSCs (1 million cells, n = 5) or placebo (n = 5) were injected intramyocardially into the RV free wall. Serial transthoracic echocardiography monitored RV functional indices including 2D myocardial strain analysis. Four weeks postinjection, the MSC-treated myocardium had a smaller increase in RV end-diastolic area, end-systolic area, and tricuspid vena contracta width (P < 0.01), increased RV fractional area of change, and improved myocardial strain mechanics relative to placebo (P < 0.01). The MSC-treated myocardium demonstrated enhanced neovessel formation (P < 0.0001), superior recruitment of endogenous c-kit+ cardiac stem cells to the RV (P < 0.0001) and increased proliferation of cardiomyocytes (P = 0.0009) and endothelial cells (P < 0.0001). Hypertrophic changes in the RV were more pronounced in the placebo group, as evidenced by greater wall thickness by echocardiography (P = 0.008), increased cardiomyocyte cross-sectional area (P = 0.001), and increased expression of hypertrophy-related genes, including brain natriuretic peptide, β-myosin heavy chain and myosin light chain. Additionally, MSC-treated myocardium demonstrated increased expression of the antihypertrophy secreted factor, growth differentiation factor 15 (GDF15), and its downstream effector, SMAD 2/3, in cultured neonatal rat cardiomyocytes and in the porcine RV myocardium. This is the first report of the use of MSCs as a therapeutic strategy to preserve RV function and attenuate remodeling in the setting of pressure overload. Mechanistically, transplanted MSCs possibly stimulated GDF15 and its downstream SMAD proteins to antagonize the hypertrophy response of pressure overload. These encouraging results have implications in congenital cardiac pressure overload lesions.

The Prognostic Utility of a Simplified Biventricular Echocardiographic Index of Cardiac Remodeling in Patients with Pulmonary Hypertension

Right ventricular (RV) remodeling has been associated with outcomes in patients with pulmonary hypertension (PH). However, the additive prognostic significance of RV remodeling and left ventricular (LV) morphology in PH is unclear. The objective of this study was to test the hypothesis that the ratio of RV end-diastolic area to LV end-diastolic area is a biventricular index predictive of outcome in patients with PH. In total, 139 patients with precapillary PH (mean age, 55±15years; 75% women) and 22 control subjects (mean age, 40±17years; 73% women) were studied. The apical four-chamber view was used to measure the RV-to-LV end-diastolic area ratio as an index of biventricular cardiac remodeling. RV free wall and global strain were measured using speckle-tracking echocardiography. The study design was prospective, with all-cause mortality over 5years predefined as the outcome event. Patients with PH had significantly larger RV to LV end-diastolic area ratios than normal subjects, as expected (1.06 vs 0.67, P<.0001). There were 72 deaths over 5years. Using a cutoff value of 0.93, patients with RV-to-LV ratios≥0.93 had significantly higher all-cause mortality (hazard ratio,1.84; 95% CI, 1.14-2.96; P=.019). RV global strain was also significantly associated with survival using a cutoff of ≥-15% (hazard ratio, 1.66; 95% CI, 1.03-2.67; P=.044). In a multivariate analysis, only age and biventricular index were independent predictors of survival among other clinical and echocardiographic features. The RV-to-LV end-diastolic area ratio is a simplified biventricular echocardiographic index of cardiac remodeling that is predictive of long-term survival in patients with PH.

Right Ventricular Systolic Function Responses to Acute and Chronic Pulmonary Hypertension: Assessment with Myocardial Deformation

The distinction between right ventricular (RV) dysfunction due to an acute etiology (pulmonary embolism [PE]) or chronic afterload (pulmonary arterial hypertension [PAH]) has important therapeutic implications. The aim of this study was to test the hypothesis that RV remodeling would alter RV free wall strain (RVFWS) and differentiate chronic from acute RV afterload. In this retrospective study, patients with PE (n=45) who underwent echocardiography within 48hours of computed tomographic pulmonary angiography were matched 1:1 for age, gender, and pulmonary artery systolic pressure with patients with PAH (n=45) and a larger unmatched PAH control group (n=116). RV function was evaluated with end-diastolic area, fractional area change (FAC), and RVFWS by two-dimensional speckle-tracking. The ability of RVFWS to distinguish acute from chronic RV dysfunction was assessed using receiver operating characteristic curves, and its incremental value was sought with stepwise models. RV end-diastolic area, FAC, and RVFWS were significantly impaired in patients with PE (P<.001), with no significant differences in other clinical variables. In matched patients, receiver operating characteristic curve analysis revealed that RVFWS had significantly better discriminative power than the McConnell sign (P=.02), with a cutoff of -17.9%, sensitivity of 87.5%, specificity of 62.5%, and an area under the curve of 0.76. Sequential logistic regression demonstrated an incremental and independent benefit of using RVFWS to predict acute PE versus chronic PAH (P=.01). Observer concordance was superior for RVFWS compared with FAC (P<.01). RVFWS is more predictive than RV end-diastolic area and less variable than FAC in distinguishing acute from chronic RV pressure overload. RVFWS adds incremental and independent information to standard measures of RV function in assessing the acuity of pulmonary hypertension.

Progressive and biphasic cardiac responses during extreme mountain ultramarathon.

Investigations on the cardiac function consequences of mountain ultramarathon (MUM) >100 h are lacking. The present study assessed the progressive cardiac responses during the world's most challenging MUM (Tor des Géants; Italy; 330 km; 24,000 m of cumulative elevation gain). Resting echocardiographic evaluation of morphology, function, and mechanics of left and right ventricle (LV and RV) including speckle tracking echocardiography was conducted in 15 male participants (46 ± 13 yr) before (pre), during (mid; 148 km), and after (post) the race. Runners completed the race in 126 ± 15 h. From pre to post, the increase in stroke volume (SV) (103 ± 19 vs. 110 ± 23 vs. 116 ± 21 ml; P < 0.001 at pre, mid, and post) was concomitant to the increase in LV early filling (peak E; 72.9 ± 15.7 vs. 74.6 ± 13.1 vs. 82.1 ± 11.5 cm/s; P < 0.05). Left and right atrial end-diastolic areas, RV end-diastolic area, and LV end-diastolic volume were 12-19% higher at post compared with pre (P < 0.05). Resting heart rate and LV systolic strain rates demonstrated a biphasic adaptation with an increase from pre to mid (55 ± 8 vs. 72 ± 11 beats/min, P < 0.001) and a return to baseline values from mid to post (59 ± 8 beats/min). Significant correlations were found between pre-to-post percent changes in peak E and LV end-diastolic volume (r = 0.63, P < 0.05) or RV (r = 0.82, P < 0.001) or atrial end-diastolic areas (r = 0.83, P < 0.001). An extreme MUM induced a biphasic pattern of heart rate in parallel with specific cardiac responses characterized by a progressive increase in diastolic filling, biventricular volumes, and SV. The underlying mechanisms and their clinical implications remain challenging for the future.

Assessment of right ventricular systolic and diastolic parameters in pulmonary sarcoidosis

The clinical manifestations of cardiac involvement are seen in about 5% of patients with sarcoidosis; however, the incidence of cardiac involvement is higher in the autopsy series. About 14% of...

Echocardiographic assessment of right ventricular functions in patients with proximal right coronary artery chronic total occlusion.

To assess right ventricular functions by echocardiography in patients with proximal right coronary artery (RCA) CTO and correlating it with clinical and angiographic variables. We studied 60 consecutive patients with CTO of the proximal RCA and no other significant lesions in the left coronary system. Echocardiography was performed in order to measure left ventricular (LV) dimensions, LVEF, RV end diastolic area (RVEDA), RV end systolic area (RVESA), RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), Doppler myocardial performance index (MPI), trans-tricuspid E and A waves, E/A ratio, S', e' and a'. Grades of coronary collaterals was assessed. Doppler MPI showed negative correlation with TAPSE (r=-0.8997, p<0.0001) and RVFAC (r=-0.928, p<0.0001). Positive correlation with trans-tricuspid E/A ratio (r=0.893, p<0.0001) and E/e' ratio (r=0.783, p<0.0001). Patients with no evidence of MI had more well-developed (grade 3) coronary collaterals (83.8 vs. 17.4%). Patients with evidence of MI had lower RVFAC 38.13±5.39 versus 45.08±4.99% (p<0.0001), lower TAPSE 20.17±3.85 versus 25.35±3.46mm (p<0.0001), higher MPI 0.4±0.08 versus 0.31±0.05 (p<0.0001), higher trans-tricuspid E/A ratio 1.79±0.38 versus 1.13±0.36 (p<0.0001) and E/e' ratio 5.23±1.02 versus 3.61±0.88 (p<0.0001). Patients with poorly developed collaterals had lower TAPSE and RVFAC and a higher MPI (p<0.0001 for each). Patients with proximal RCA CTOs and evidence of inferior wall MI have significant impairment of RV functions in addition to poorly developed coronary collaterals. Those with proximal RCA CTOs and well-developed coronary collaterals have better RV functions.