Right Ventricular Wall Thickness Research Articles

Echocardiographic Pulmonary to Left Atrial Ratio in Dogs (ePLAR): A Differential Marker of Pre- and Postcapillary Pulmonary Hypertension

Pulmonary Hypertension (PH) in dogs is a complicated syndrome that could be primary, due to idiopathic or genetic causes, or secondary due to pulmonary disease, pulmonary thromboembolism, heartworm disease, heart failure. Due to the inability of the routine use of right heart catheterization in veterinary patients, there is a lack of differential criteria between PH forms. This study was performed to verify ePLAR as a differential marker in PH forms. Analyze wide specter of echocardiography-derived markers and novel ePLAR-marker to find efficient parameters in PH differentiation and ePLAR accuracy. We studied 59 dogs of different sex, age and breed. Groups were formed according to a primary pathology: Healthy dogs (HD, n = 8); dogs with MMVD and postcapillary PH (PostPH, n = 23); dogs with MMVD and precapillary PH (PrePH, n = 28). Animals in the study were diagnosed with the primary disease by standard echocardiographic methods and algorithms. In Post PH, LA was significantly larger than in the PrePH and the control. Left vertical walls were thicker in the PrePH than in the PostPH. Left ventricle diameter was higher in the PostPH than in the control and the Pre-PH. PV was smaller in the PrePH than in the Post PH and the control (р<0.001 and р<0.021). PV/RPA in the PrePH was lower than in the control and in the PostPH (р<0.001). AT was lower in the PrePH and the PostPH. AT/ET ratio was higher in the control to both experimental. AT/ET was lower in the PrePH to the PostPH. RV was dilated both in the PrePH and the PostPH to control. RV wall thickness was increased in the PrePH in comparison to both control and PostPH. Significant reductionin E-wave velocity for both the PrePH and PostPH to control and PostPH; reduction in A-wave; decreased Е/А. TR velocity was higher in both experimental to control, but didn't differ between each other. ePLAR increased in the PrePH and PostPH to control. In this study we found several echocardiographic parameters to differentiate Pre-and Post-PH forms: LA, LA/Ao, LV diameter, LV/RPA, IVS thickness and a novel in veterinary studies index - EPLAR.

Abstract 11365: Electronic Cigarette Vaping with or Without Heating Induces Differential Pathological Remodeling in the Lungs and Right Heart

Introduction: One of the obstacles in dissecting the specific underlying mechanisms of electronic cigarette (EC) “vaping”-related health effects is the complexity in the chemical composition of EC aerosols. As various chemicals are generated through the heating coil in addition to the intact components presented in the aerosol, we hypothesize that the heating-associated by-products and the intact components would have differential pathological impact to the remodeling of right ventricular (RV) and pulmonary system. Methods: Using a prototype exposure system, C57BL/6 mice were exposed to room air or EC vapor with and without heating the EC liquid (ECL) for 3 hours per day, 5 days per week for 6 months. Echocardiography with color Doppler was used to evaluate cardiac structure and function. To assess inflammatory and fibrotic signaling, Western-blotting was performed. Results: Comparable plasma cotinine levels were found between heating and non-heating exposure, respectively (59.34±8.57ng/mL vs 59.02± 4.83ng/mL; n=5-7). Without heating exposure caused thinning of RV free wall (0.57±0.028 mm control vs 0.43±0.03 mm exposed; p&lt;0.05), whereas with heating, an increase in the RV wall thickness (0.79±0.06 mm exposed, p&lt;0.01) and a reduction in RV chamber size at diastole (1.57±0.04mm control vs 1.34±0.03mm exposed, p&lt;0.01) were observed. While exposure without heating elevates peak pulmonary artery (PA) pressure (2.46±0.31 mmHg control vs 3.34±0.13 mmHg exposed; p&lt;0.05), a lower peak (1.36± 0.12 mmHg exposed; p&lt;0.05) and mean pressure gradient (0.75±0.08 mmHg control vs 0.51± 0.05 mmHg exposed; p&lt;0.05) were recorded with heating exposure. As for pulmonary response, exposure without heating did not affect NF-κB p-p65 level, but reduced p65 expression to 37% of controls (±6%, n=5, p&lt;0.0001) and increased TGF-β1 by 67% (±11%, n=5, p&lt;0.05). In contrast, exposure with heated ECL did not affect p65 and TGF-β1 but increased p-p65/p65 by 39.4% (±5%, n = 5, p &lt; 0.05), indicating activation of NF-κB inflammatory signaling. Conclusions: EC exposure without heating the ECL resulted in fibrotic lung, higher peak PA pressure and RV dystrophy without obvious pulmonary inflammation. Heating the ECL, however, contribute to RV hypertrophy and pulmonary inflammation.

Abstract 14366: Pulmonary Hypertension-Induced RV Hypertrophy and Dysfunction is Associated With Reduced Activity and Abundance of Complex IV in Respiratory Supercomplexes

Introduction: PH results in RV hypertrophy, fibrosis and impaired function resulting in RV failure. PH is associated with impaired heart metabolism and mitochondrial respiration. Mitochondrial supercomplexes (mSC) are assemblies of multiple electron transport chain (ETC) complexes that consist of physically associated complex I, III and IV to enhance respiration. We determined if activity and/or abundance of mSC’s is altered in a rat model of PH. Methods: PH was induced in SD-rats by Sugen-Hypoxia (3 weeks) followed by normoxia (4 weeks) . Control (n=11) and PH (n=10) were subjected to echocardiography and isolation of LV and RV mitochondria. Clear native PAGE with equal amounts mitochondrial protein was used for SC abundance and activity with immunoblot or in gel activity with specific substrates. Results: PH animals had significantly reduced PAT and TAPSE, increased RV wall thickness and hypertrophy (RV/LVS). Western analysis of total protein fractions demonstrated reductions in representative CI, II, III, and IV proteins in RV indicating reduced mitochondrial content in PH. Assays with normalized mitochondrial protein showed activity (100+/- 3.6 vs 64.0+/-3.8 %, p&lt;.01) and abundance (100+/-1.8 vs 49.3 +/-1.1, p=.02) of complex IV in mitochondrial SCs was severely reduced in PH animals compared to control. There were no differences in total CIV activity or abundance in lower order ETC assemblies (100 vs 97.5%, p=.78). TAPSE, PAT and RV Wall thickness significantly correlated with CIV SC activity (r=.71, .66, and -.80 respectively P&lt;.01). CIII abundance was lower in SCs (P=.01) but total CIII unchanged. CI activity in SC assemblies was reduced in PH but this was not significant (100+/-12 vs 77.4 +/-8.2, p=.14). Overall levels of CI were unchanged. There were no changes in CII activity or abundance in RV or LV. In the LV, activity of CIV in SC was reduced in PH (100+/-6 vs 78+/-6, p=.02) but to a lesser extent than RV. There were also decreases in overall abundance of CIII and CIV assemblies in the LV in PH. Conclusion: The data support the concept that although mitochondrial abundance may be altered, there are also significant alterations associated with assembly and activity of mitochondrial SCs in the RV with pronounced differences in complex IV assembled into SCs.

Abstract 11925: Comparison of Right Ventricular Outflow Tract-Dominant Hypertrophic Type With Diffuse Type Using Cardiac CT for J Waves and Clinical Parameters in Pulmonary Hypertensive Patients

Introduction: J waves are specific in patients with hypothermia, idiopathic ventricular fibrillation, or brain damage. Patients with pulmonary hypertension (PH) may show right ventricular (RV) hypertrophy and fibrosis, leading to abnormal ECG findings. On cardiac CT of PH, two RV hypertrophic (RVH) types are seen, namely RV outflow tract dominant and RV diffuse. Hypothesis: We hypothesize that these two morphological RVH types might have different effects on ECG findings including J waves, and clinical severity in PH patients. Method: We retrospectively analyzed 43 PH patients (33 females, 55±15 yrs, 31 chronic thromboembolic PH, 7 idiopathic pulmonary arterial (PA) hypertension). Cases were divided into 3 groups: RV outflow tract dominant RVH (gp 1) (N=6), RVH diffuse (gp 2) (N=26), and no RVH (gp 3) (N=11). Results: In gp 1, one (17%) had J waves in II, III, and aVF leads with a maximum RV wall thickness on end-diastole 7.5mm. In gp 2, three (12%) had J waves in II, III, and aVF leads with maximum RV wall thickness on end-diastole 6.7, 6.1, and 5.6mm, respectively. In gp 3, none (0%) had J waves. In gp 1, all six (100%) had a negative T wave in V1-3 leads or beyond and in gp 2, 24 (92%) had a negative T wave in V1-3 leads or beyond (P=0.483). There were significant positive correlations between maximum RV wall thickness in end-diastole and plasma brain natriuretic peptide (BNP) in gp 1 (R=0.44) but no correlations in gp 2. There were significant positive correlations between maximum RV wall thickness in end-diastole and estimated PA systolic pressure (PASP) on TTE in gp 1 (R=0.38) but no correlations in gp 2. Conclusions: In 32 PH participants with an organized RV myocardial change, such as RV outflow tract dominant and diffuse type RVH, 17% and 12% had J waves in II, III, and aVF leads and most of them had a negative T wave in V1-3 leads or beyond. Only RV outflow tract dominant RVH showed significant positive correlations between maximum RV wall thickness in end-diastole, plasma BNP and estimated PASP.

Abstract 17189: Radiation-induced Accelerated Multi-valve Disease In A Patient With Subaortic Membrane

A 69-year-old woman with history of right breast cancer status post lumpectomy and radiation (4.2 cGy) 18 months prior, presented with progressive NYHA class III dyspnea. TTE obtained prior to her cancer diagnosis was notable for normal LV size and wall thickness, a subaortic membrane with systolic mean Doppler gradient of 21 mmHg and a mildly thickened mitral valve without significant stenosis or regurgitation. On presentation, TTE was notable for severely increased concentric LV wall thickness (LV mass index 140 g/m 2 ), preserved ejection fraction, increased RV wall thickness, subaortic stenosis with systolic mean Doppler gradient 35 mmHg, moderate-severe aortic regurgitation, thickened mitral valve with posterior leaflet tethering and anterior leaflet override causing severe mitral regurgitation and moderate mitral stenosis (valve area 1.7 cm 2 by pressure half-time). She underwent a surgical intervention with septal myectomy, subaortic membrane resection, aortic root reconstruction, aortic and mitral valve replacement with bioprostheses. She did well post-operatively and had complete resolution of symptoms following cardiac rehabilitation. Radiation-induced valvular heart disease is linked to the total dose of radiation, use of sequential chemotherapy and time since irradiation, with a typical latency of 10-20 years. However, there is paucity of data regarding the influence of these variables in patients with pre-existing valve disease. This case illustrates dramatic acceleration of underlying aortic and mitral valve pathology in a patient with a subaortic membrane, 18 months after radiation. We also noted development of significant concentric LV hypertrophy that was disproportionate to the degree of obstruction across the sub-aortic membrane. Potential candidates for radiation therapy must be carefully screened for pre-existing valve disease, which should warrant increased vigilance and early screening for progressive valve disease.

Correlation Between Quantitative Uptake of 99mTC-DPD and Echocardiographic Parameters in Cardiac ATTR: A Novel Follow-Up Strategy.

Aims: There has been a paradigm shift in diagnosis of cardiac transthyretin amyloidosis (ATTR) with non-invasive techniques including technetium-99m 3,3-diphosphono-1,2-propanodicarboxylic acid (99mTc-DPD) bone scintigraphy. We evaluated structural and functional biventricular alterations by transthoracic echocardiography (TTE) and determined the correlation with 99mTc-DPD tracer uptake in ATTR.Materials and Methods: ATTR patients (wild-type, hereditary or asymptomatic transthyretin [TTR] variant carriers) with 99mTc-DPD and TTE were selected; 99mTc-DPD uptake was analyzed quantitatively. TTE assessment of left ventricle (LV) and right ventricle (RV) parameters was performed.Results: Forty ATTR patients (wild-type n = 17; hereditary ATTR and TTR variant carriers n = 23; median age 68.8 ± 22 years) were included. TTE parameters displaying good correlation with 99mTc-DPD tracer uptake included LV average wall thickness (r = 0.837), LV indexed mass (LVMI; r = 0.802), RV wall thickness (r = 0.610), average e' (r = −0.830), E/e' ratio (r = 0.786), LV global longitudinal strain (GLS; r = 0.714) and RV GLS (r = 0.632; p < 0.001 for all). Hereditary ATTR and TTR variant carriers without cardiac tracer uptake had normal echocardiographic parameters. Receiver operating characteristic curves demonstrated strong diagnostic accuracies for structural (LV wall thickness, LVMI and RV wall thickness; area under the curve (AUC) of 0.96 for all) and functional (LV and RV GLS; AUC of 0.86 and 0.88, respectively) parameters.Conclusion: Good correlations between TTE biventricular structural and functional parameters were demonstrated with quantitative 99mTc-DPD uptake. Echocardiography may potentially assume a significant role in longitudinal follow-up for monitoring disease progression and for evaluating treatment response.

Role of cardiac magnetic resonance in stratifying the prognosis of patients with pulmonary arterial hypertension

Abstract Background Pulmonary arterial hypertension (PAH) is a rare disease characterized by a complex remodeling of heart structures. Cardiac magnetic resonance (CMR) is the gold standard for a non-invasive evaluation of right ventricle (RV) volumes and mass. Purpose To define the relationship between clinical, functional, biochemical, haemodynamic and CMR parameters and survival in patients with PAH. Methods Consecutive patients with PAH referred to our centre underwent clinical, functional, brain natriuretic peptide (BNP) plasma levels, haemodynamic and CMR evaluation. All patients were treated according to current guidelines. Univariate Cox analysis for survival was performed. Parameters with a p-value &amp;lt;0.1 at the univariate analysis were included in the multivariate analysis. Results One hundred forty-seven patients with PAH (mean age 49±17 years, 69% female) were included in the study. Etiology of PAH was: idiopathic/heritable (49%), associated with connective tissue disease (19%), congenital heart disease (12%), portal hypertension/HIV infection (12%) and pulmonary veno-occlusive disease (8%). Thirty-six patients died during follow-up. Parameters significantly associated with mortality at the univariate analysis were age [Hazard Ratio (95% Confidence Interval): 1.043 (1.020–1.067); p&amp;lt;0.001], six-minute walk test (6MWT) [HR: 0.995 (0.993–0.998); p&amp;lt;0.001], WHO-functional class [HR: 2.489 (1.025–6.041); p=0.044], idiopathic-heritable-congenital heart disease aetiology [HR: 0.182 (0.085–0.389); p&amp;lt;0.001], connective tissue disease aetiology [HR: 2.274 (1.099–4.704); p=0.027], pulmonary veno-occlusive disease aetiology [HR: 5.864 (2.328–14.773); p&amp;lt;0.001], right atrial pressure [HR: 1.098 (1.032–1.169); p=0.003], pulmonary artery oxygen saturation [HR: 0.947 (0.921–0.975); p&amp;lt;0.001], BNP levels [HR: 2.214 (1.213–4.039); p=0.010], RV wall thickness [HR: 0.633 (0.399–1.006); p=0.053], RV end diastolic volume [HR: 1.012 (1.003–1.021); p=0.007], RV end systolic volume [HR: 1.014 (1.003–1.024); p=0.011]. Parameters independently associated with mortality at the multivariate analysis were age [HR: 1.035 (1.006–1.064); p=0.018], idiopathic-heritable-congenital heart disease aetiology [HR: 0.355 (0.146–0.860); p=0.022], pulmonary veno-occlusive disease aetiology [HR: 3.129 (1.071–9.143); p=0.037], pulmonary artery oxygen saturation [HR: 0.953 (0.919–0.989); p=0.011], RV wall thickness [HR: 0.527 (0.300–0.927); p=0.026], RV end systolic volume [HR: 1.016 (1.003–1.029); p=0.014]. Conclusion RV wall thickness and RV end-systolic volume are associated with prognosis in patients with PAH independently from clinical and haemodynamic characteristics. These parameters may be used in the overall risk stratification of PAH patients. Funding Acknowledgement Type of funding sources: None.

Effect of the number of parity on right heart chamber quantification

Abstract Introduction Pregnancy is a process that causes several physiological changes including all systems as well as cardiovascular system. Ventricular hypertrophy and dilation of cardiac chambers are seen as a result of these changes. Although there are studies about pregnancy-related changes in echocardiographic examination; there is no data about the long-term effects of parity on these alterations. Therefore, we have evaluated the long-term effect of pregnancy on right ventricular (RV) dilation and RV hypertrophy and their relation to the parity number. Methods This prospective study included a total of 600 women (200 consecutive women who had no parity, 200 women who had a parity number of 1 to 4 and 200 women who had a parity number of more than 4). Right chambers' measurements were compared between the groups. Results In echocardiographic analysis, RV and right atrial dimensions and areas and RV wall thickness were higher in parous women. On the other hand, RV systolic function parameters were significantly lower in parous women. These significant changes showed a gradual increase or decrease by increasing parity number. By multivariate hierarchical logistic regression analysis, the 4 independent factors that increased the risk of RV dilation were age (OR: 1.16 CI: 1.10 – 1.20), body mass index (OR: 1.05, CI: 1.02 to 1.08), smoking (OR: 1.87, CI: 1.28 to 4.02), and giving a birth (OR: 3.94 CI: 1.82 – 8.81). There were also independent relationship between the number of parity and RV hypertrophy even after adjustment for several confounders. Conclusion Pregnancy-related physiological changes mostly resolve after delivery. This study about long-term effects of pregnancy on RV has demonstrated that there is a significant relation between the number of parity and either RV dilation or RV hypertrophy. Each parity had also additive effect on these changes. Funding Acknowledgement Type of funding sources: None.

The prognostic value of cardiac magnetic resonance in assessment of right ventricular function after percutaneous balloon mitral valvuloplasty

Abstract Background Mitral stenosis (MS) results in right ventricular (RV) dysfunction secondary to chronic pulmonary hypertension. Poor outcomes have been reported in patients with persistent chronic RV dysfunction. Persistence RV dysfunction can affect the clinical improvement after percutaneous balloon mitral valvuloplasty (PBMV). Cardiac Magnetic Resonance (CMR) is emerged as a highly sensitive technique for assessment of RV function (RVF). Purpose To investigate RV function 3 months after PBMV using a variety of robust parameters associated with prognosis. Methods A prospective observational study was conducted in a tertiary University hospital included 31 patients with symptomatic uncomplicated MS with favorable morphology and having sinus rhythm who underwent PBMV. All patients were subjected to TTE and CMR examination 24 hours directly before and 3 months after PBMV for assessment of RV size and function. Results CMR showed reduced RV myocardial mass (36.1±6.1 vs 28.0±5.4g, P&amp;lt;0.001), RV end-diastolic volume (RV EDV) (123.5±31.3 vs 109.5±22.7 ml, P=0.03) and TR regurgitant fraction (19.6±8.6 vs 14.7±4.9%, P&amp;lt;0.001) On the other hand, there were increase in each of RV ejection fraction (60.0±10.4 vs 63.13±7.8%, P&amp;lt;0.001), RV stroke volume (SV) (50.2±15.1 vs 33.2±12.2 ml, P&amp;lt;0.001) and RV stroke index (44.2±7.7 vs 50.3±8.6 ml/beat/m2 &amp;lt;0.001). TTE showed improved systolic RV function parameters measured by fractional area change (42.1±7.8 vs 51.7±5.4%, P&amp;lt;0.00), Tei Index (0.6±0.1 vs 0.5±0.1, P&amp;lt;0.001) and TAPSE (22.2±3.3 vs 25.7±5.1 mm, P=0.04). Among RV diastolic parameters, there were an increase in TV-TDI E' (12.0±3.0 vs 14.0±2.0 cm/s, P&amp;lt;0.001), TV-TDI A' (13.0±3.0 vs 11.0±2.0 cm/s, P&amp;lt;0.001) and TV-TDI E'/A' (1.0±0.5 vs 1.3±0.3, P&amp;lt;0.001) with significantly decreased RV wall thickness (5.7±0.7 vs 4.3±0.8 mm P&amp;lt;0.001) 3 months after PBMV. Among patients who showing improved RV parameters by TTE, ten patients (32,3%) showed non improved RV end systolic volume, EDV, SV and stroke index by CMR. Conclusion Follow-up of RV function by TTE after PBMV yielded nearly similar results compared to CMR. However, CMR identified a subgroup of patient with persistent RV dysfunction 3 months after PBMV. That contributes to define the role of cardiac MRI in the evaluation of the prognosis in patients with MS. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Assiut University hospital and Al Orman Institute

Right Ventricular Myocardial Adaptation Assessed by Two-Dimensional Speckle Tracking Echocardiography in Canine Models of Chronic Pulmonary Hypertension.

Background: Pulmonary hypertension (PH) is a life-threatening disease in dogs characterized by an increase in pulmonary arterial pressure (PAP) and/or pulmonary vascular resistance. Right ventricle adapts to its pressure overload through various right ventricular (RV) compensative mechanisms: adaptive and maladaptive remodeling. The former is characterized by concentric hypertrophy and increased compensatory myocardial contractility, whereas the latter is distinguished by eccentric hypertrophy associated with impaired myocardial function.Objectives: To evaluate the RV adaptation associated with the increase of PAP using two-dimensional speckle tracking echocardiography.Animals: Seven experimentally induced PH models.Methods: Dogs were anesthetized and then a pulmonary artery catheter was placed via the right jugular vein. Canine models of PH were induced by the repeated injection of microspheres through the catheter and monitored pulmonary artery pressure. Dogs were performed echocardiography and hemodynamic measurements in a conscious state when baseline and systolic PAP (sPAP) rose to 30, 40, 50 mmHg, and chronic phase. The chronic phase was defined that the sPAP was maintained at 50 mmHg or more for 4 weeks without injection of microspheres.Results: Pulmonary artery to aortic diameter ratio, RV area, end-diastolic RV wall thickness, and RV myocardial performance index were significantly increased in the chronic phase compared with that in the baseline. Tricuspid annular plane systolic excursion was significantly decreased in the chronic phase compared with that in the baseline. The RV longitudinal strain was significantly decreased in the sPAP30 phase, increased in the sPAP40 and sPAP50 phases, and decreased in the chronic phase.Conclusions: Changes in two-dimensional speckle tracking echocardiography-derived RV longitudinal strain might reflect the intrinsic RV myocardial contractility during the PH progression, which could not be detected by conventional echocardiographic parameters.

Acetazolamide Improves Right Ventricular Function and Metabolic Gene Dysregulation in Experimental Pulmonary Arterial Hypertension.

Background: Right ventricular (RV) performance is a key determinant of mortality in pulmonary arterial hypertension (PAH). RV failure is characterized by metabolic dysregulation with unbalanced anaerobic glycolysis, oxidative phosphorylation, and fatty acid oxidation (FAO). We previously found that acetazolamide (ACTZ) treatment modulates the pulmonary inflammatory response and ameliorates experimental PAH.Objective: To evaluate the effect of ACTZ treatment on RV function and metabolic profile in experimental PAH.Design/Methods: In the Sugen 5416/hypoxia (SuHx) rat model of severe PAH, RV transcriptomic analysis was performed by RNA-seq, and top metabolic targets were validated by RT-PCR. We assessed the effect of therapeutic administration of ACTZ in the drinking water on hemodynamics by catheterization [right and left ventricular systolic pressure (RVSP and LVSP, respectively)] and echocardiography [pulmonary artery acceleration time (PAAT), RV wall thickness in diastole (RVWT), RV end-diastolic diameter (RVEDD), tricuspid annular plane systolic excursion (TAPSE)] and on RV hypertrophy (RVH) by Fulton's index (FI) and RV-to-body weight (BW) ratio (RV/BW). We also examined myocardial histopathology and expression of metabolic markers in RV tissues.Results: There was a distinct transcriptomic signature of RVH in the SuHx model of PAH, with significant downregulation of metabolic enzymes involved in fatty acid transport, beta oxidation, and glucose oxidation compared to controls. Treatment with ACTZ led to a pattern of gene expression suggestive of restored metabolic balance in the RV with significantly increased beta oxidation transcripts. In addition, the FAO transcription factor peroxisome proliferator-activated receptor gamma coactivator 1-alpha (Pgc-1α) was significantly downregulated in untreated SuHx rats compared to controls, and ACTZ treatment restored its expression levels. These metabolic changes were associated with amelioration of the hemodynamic and echocardiographic markers of RVH in the ACTZ-treated SuHx animals and attenuation of cardiomyocyte hypertrophy and RV fibrosis.Conclusion: Acetazolamide treatment prevents the development of PAH, RVH, and fibrosis in the SuHx rat model of severe PAH, improves RV function, and restores the RV metabolic profile.

Additional diagnostic value of right ventricular parameters in Transthyretin cardiac amyloidosis

Transthyretin cardiac amyloidosis (ATTR) is an increasingly recognized cause of heart failure which remains a challenging diagnosis even with the advanced of multimodal imaging. Most of the studies focused on left ventricular function and remodelling. We hypothesized that right ventricle could be of addictive value to discriminate patients with confirmed ATTR. We included 299 patients with suspected ATTR evaluated by clinical examination and echocardiography. Diagnostic performances of conventional morphological and functional echocardiographic parameters were analysed. ATTR patients ( n = 109, mean age 80y ± 9, 72% male) had greater LV mass with more severe concentric remodelling as compared to controls (n = 190, mean age 71y ± 16, 51% male). LV global longitudinal strain was lower in ATTR (10.9 ± 3.7 vs. 14.5 ±4.5%; P < 0.001). Relative apical longitudinal sparing (RALS) (1.57 ± 1.6 vs. 0.86 ± 0.4; P < 0.001, AUC 0.76) and Ejection Fraction/Longitudinal strain ratio (EFSR) (4.59 ± 1.4 vs. 3.94 ± 1.1; P < 0.001; AUC 0.66) were also significantly different. When focusing on right heart parameters, ATTR patients had larger RV wall thickness (7.2 ± 1.9 vs. 4.9 ± 1.4 cm; P < 0.001); depressed systolic function: TAPSE (16.1 ± 5.6 vs. 20.9 ± 5.4 mm; P< 0.001), S’ tricuspid (10.6 ± 4.1 vs. 12.4 ± 3.2 cm/s; P < 0.001). RV free wall LS was lower in ATTR (16.9 ± 5.7 vs. 20.6 ± 6.6%; P < 0.001). RV hypertrophy showed the best diagnostic performance among RV parameters to discriminate ATTR patients (AUC 0.86). Right atrium area (AUC 0.73) and TAPSE (AUC 0.70) were also discriminant ( Fig. 1 ). Right ventricular parameters have their own place and interest in the diagnostic algorithm of ATTR especially when usual left ventricular deformation pattern have lower diagnostic performance in non-selected population. RV and RA remodelling together with parameters of RV function had interesting diagnostic performance for the ATTR diagnosis.

Short-Term CPAP Improves Biventricular Function in Patients with Moderate-Severe OSA and Cardiometabolic Comorbidities.

Obstructive sleep apnea (OSA) is the most common form of sleep-disordered breathing, exhibiting an increasing prevalence and several cardiovascular complications. Continuous positive airway pressure (CPAP) is the gold-standard treatment for moderate-severe OSA, but it is associated with poor patient adherence. We performed a prospective study that included 57 patients with newly diagnosed moderate-severe OSA, prior to CPAP initiation. The objective of our study was to assess the impact of short-term CPAP on ventricular function in patients with moderate-severe OSA and cardiometabolic comorbidities. The patients underwent a clinical exam, ambulatory blood pressure monitoring and comprehensive echocardiographic assessment at baseline and after 8 weeks of CPAP. Hypertension, obesity and diabetes were highly prevalent among patients with moderate-severe OSA. Baseline echocardiographic parameters did not significantly differ between patients with moderate and severe OSA. Short-term CPAP improved left ventricular global longitudinal strain (LV-GLS), isovolumetric relaxation time, transmitral E wave amplitude, transmitral E/A ratio, right ventricular (RV) diameter, RV wall thickness, RV systolic excursion velocity (RV S‘) and tricuspid annular plane systolic excursion (TAPSE). Short-term CPAP improves biventricular function, especially the LV-GLS, which is a more sensitive marker of CPAP-induced changes in LV systolic function, compared to LVEF. All these benefits are dependent on CPAP adherence.

Inhibition of mTOR by rapamycin does not improve hypoxic pulmonary hypertension-induced right heart failure in old mice.

Inhibition of the mammalian target of rapamycin (mTOR) by rapamycin attenuates heart failure (HF) and age-associated changes in left ventricular (LV) function. Rapamycin has also been suggested as a therapy for pulmonary hypertension (PH) and concomitant right heart failure (PH-RHF) based on reports of elevated mTOR signaling in young models with PH. However, rapamycin has yet to be tested in the setting of aging, PH, and right heart disease despite the fact that RV function predicts survival in both age-related HF as well as several pulmonary disease states including PH. Thus we tested the hypothesis that rapamycin treatment would attenuate hypoxic PH-RHF in old mice using a mouse model of hypobaric hypoxia (HH)-induced PH and right ventricular (RV) remodeling. Exposure to HH resulted in significant loss of body weight which was exacerbated by rapamycin. HH elevated lung and RV weight, RV wall thickness as well as RV systolic dysfunction as evidenced by RV stroke volume and cardiac output. While rapamycin rescued pulmonary artery acceleration time in males, it generally did not improve other indexes cardiopulmonary remodeling or function. As expected, HH induced expression of hypoxia-regulated genes in the RV and the lungs; however, this transcriptional activation was attenuated by rapamycin, representing a potential mechanism by which rapamycin is detrimental in the aged RV in the setting of chronic hypoxia. Together, we demonstrate that rapamycin is not a viable therapeutic in hypoxic PH in old mice, likely due to exacerbated loss of body weight in this setting. We suggest that future efforts should take into consideration the differences between the RV and LV and the interaction between mTOR and hypoxia in the setting of age-related disease.

Índice de obstrucción de la arteria pulmonar, diámetro de la arteria pulmonar y strain del ventrículo derecho como hallazgos pronósticos de la tomografía computarizada en el paciente con embolia pulmonar aguda

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.

Synthesis of CT Imaging and Right Heart Catheterization Enables Single-Beat RV-PA Coupling Estimations in Heart Failure Patients

<h3>Purpose</h3> Right ventricular-pulmonary arterial (RV-PA) coupling has been shown to predict RV failure in PH patients. However, current clinical approaches require physiological assumptions which may be invalid in heart failure patients. We utilized functional CT and right heart catheterization (RHC) to construct single-beat pressure-volume (PV) loops, assess the impact of coupling assumptions, and compare impact on predicting patient outcomes. <h3>Methods</h3> Heart failure patients who underwent advanced therapy evaluation between since 9/2017 with ECG-gated contrast-enhanced CT scans and RHC within 14 days were enrolled. PV loops were generated via synchronizing CT-derived volume and RHC-derived pressure waveforms. A model using PV data and RV wall thickness was used to fit RV and PA elastance. We compared our approach to two clinical alternatives: volumetric approach, which estimates coupling as stroke volume / end-systolic volume (SV/ESV), and pressure adjusted approach, estimated as (SV * ESP) / (ESV * mPAP). The prognostic value of the coupling approaches was evaluated using a composite endpoint of heart transplant due to ventricular decompensation, VAD implantation with RV failure, or cardiac related death within 30 days. <h3>Results</h3> 22 patients met inclusion criteria and within 30 days, 7 had the composite endpoint (3 deaths, 2 RV failure post VAD, 2 transplants), and 15 did not (2 VAD with no RV failure, 13 no events). Compared to the single-beat PV-loop based approach, both the volumetric approach (75.2% reduction) and pressure-adjusted approach (45.6% reduction) underestimated coupling. PV-derived coupling was significantly (p<0.05) lower in patients with adverse outcomes (0.80±0.32) than in those free from adverse events (1.21±0.43), but volumetric and pressure-adjusted were not (p>0.05). <h3>Conclusion</h3> Functional CT and RHC can be used to derive single-beat measures of coupling and differentiate between patients with and without short-term adverse outcomes.

Novel Echocardiographic Algorithm for Right Ventricular Mass Quantification: Cardiovascular Magnetic Resonance and Clinical Prognosis Validation

Right ventricular hypertrophy (RVH) provides a key remodeling index alterable by pulmonary hypertension. Although echocardiography commonly integrates linear wall thickness and chamber dimensions to quantify left ventricular remodeling, the utility of an equivalent right ventricular (RV)-based approach is unknown. This was a retrospective analysis of 200 patients undergoing transthoracic echocardiography and cardiac magnetic resonance (CMR) within 30days (median= 3days; interquartile range, 15days), stratified by echocardiography-quantified pulmonary artery systolic pressure (<35, 35 to <55, 55 to <75, or ≥75mm Hg). Echocardiographic assessment included RV linear dimensions in parasternal long-axis and apical four-chamber views and wall thicknesses in parasternal long-axis, four-chamber, and subcostal views. Subcostal wall thickness was integrated with chamber diameters to calculate RV mass, which was tested in relation to CMR-quantified RV mass and all-cause mortality. Echocardiography-based quantification of all linear dimensions was feasible in 95% of patients (190 of 200). RV wall thicknesses in all orientations increased in relation to pulmonary artery systolic pressure (P<.001) and was greater among patients with, versus those without, CMR-evidenced RVH (P<.001 for all). Correlations between echocardiography and CMR were greatest for RV basal diameter (r=0.73), RV subcostal wall thickness (r=0.71), and global RV mass (r=0.82; P<.001 for all). Echocardiography-derived global RV mass cutoffs were established in a derivation cohort and tested in a validation cohort. Results demonstrated good sensitivity and specificity (75.5% and 74.0%, respectively) in relation to CMR-quantified RVH. During follow-up (median, 4.2years), 18% of patients (n=36) died. Echocardiography-evidenced RVH (hazard ratio, 1.98; 95% CI, 1.09-3.88; P=.048) conferred similar mortality risk compared with RVH on CMR (hazard ratio, 2.41; 95% CI, 1.22-4.78; P=.01). Echocardiography-quantified RV parameters provide a robust index of RV afterload. Global RV mass calculated using a novel echocardiographic formula based on readily available linear indices yields good diagnostic performance for CMR-evidenced RVH and confers increased mortality risk.

The relationships between serum heart-type fatty acid-binding protein and right ventricular echocardiographic indices in chronic obstructive pulmonary disease.

Heart-type Fatty Acid-Binding Protein (H-FABP) has been used in the diagnosis of myocardial damage. In this study, we assessed the relationships between serum H-FABP as a marker of cardiac injury and right ventricle (RV) echocardiographic indices in patients with stable COPD. In this case-control study, 84 participants were investigated (50 COPD patients and 34 healthy subjects). After obtaining consent, 3 mL of fasting whole blood sample was collected from each of the participants to test their serum H-FABP. Echocardiography was performed on all participants by cardiologists. Serum H-FABP was found to be significantly correlated with smoking history (P<0.01), Systolic Pulmonary Artery Pressure (S-PAP), RV Wall Thickness (RV-WT), and Tricuspid annulus posts systolic excursion (TAPSE) (P<0.01 for all). RV Basal Diameter (RV-BD), RV Mid Diameter (RV-MD), and Fractional area change percentage (FAC%) were not observed to have any correlation with serum H-FABP. Also, the comparative analysis showed statistically significant differences between mean RV-MD (P<0.001), RV-BD, FAC%, S-PAP, RV-WT (P<0.001), and TAPSE (P<0.05) of patients at different GOLD stages. There was a significant correlation between the adjusted serum level of H-FABP and the airflow limitation based on FEV1 (P<0.001). The correlation between serum H-FABP and RV echocardiographic indices such as S-PAP, RV-WT, and TAPSE, can be related to RV function in COPD patients. Moreover, RV echocardiographic indices are significantly correlated with the severity of COPD as classified in various GOLD stages.

Characteristics of idiopathic tricuspid regurgitation

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Science and Technology, Executive Yuan, Taiwan Background Tricuspid regurgitation (TR) were traditionally classified as primary and secondary TR. Recently a new category of TR was developed and named as idiopathic TR. However, diagnosis and characteristics of idiopathic TR were not consisted. We tried to identify idiopathic TR by a new systemic approach and studied its characteristics. Methods 207 consecutive patients (mean age 71.2 ± 14.7 years, 40.6% male) identified as significant TR (moderate and severe) by echocardiography were recruited. We classified TR by a new systemic approach. The classification process started from identified primary TR, then pacemaker related TR, left heart disease related TR, congenital heart related TR, right ventricular (RV) myopathy, pulmonary hypertension and, finally idiopathic TR step by step. Results There were 29 (14%) primary TR, 18 (8.7%) pacemaker related, 81 (39.1 %) left heart diseases, 6 (2.9%) congenital heart diseases, 3 (1.4%) RV myopathy, 27 (13%) pulmonary hypertension, and 43 (20.8%) idiopathic TR. Mean age of idiopathic TR was 72.9 ± 11.4 years and 39.5% was male which were not different from other groups. Atrial fibrillation was presented highest in patients with pacemaker related TR (77.8%) and left heart disease (55.6%), lowest in primary TR (24.1%) and pulmonary HT (25.9%), and modest in idiopathic TR (44.2%). Among the echocardiographic characteristics of right heart measurements, idiopathic TR had lowest TR maximal velocity (3.0 ± 0.3 m/s), pulmonary (41.2 ± 8.7 mmHg) and right atrium pressure (5.3 ± 0.3 mmHg; all p &amp;lt;0.001). Idiopathic TR had smallest RV wall thickness (4.5 ± 1.4 mm; p = 0.008), tricuspid annulus diameter (3.2 ± 0.7 cm; p = 0.001), and right atrial area (18.9 ± 8.4 cm2; p &amp;lt;0.001). RV function represented as tricuspid annulus velocity S’ (12.8 ± 3.3 cm/s; p = 0.011) and RV fractional area change FAC (42.6 ± 16.0 %; p &amp;lt;0.001) were best in idiopathic TR. RV dysfunction (FAC &amp;lt; 35%) was lowest (14%) in idiopathic TR. Conclusions Idiopathic TR had better RV function then other types of TR. Idiopathic TR can be regarded as a unique disease category in studying TR.

Measuring myocardial extracellular volume of the right ventricle in patients with congenital heart disease

The right ventricle´s (RV) characteristics—thin walls and trabeculation—make it challenging to evaluate extracellular volume (ECV). We aimed to assess the feasibility of RV ECV measurements in congenital heart disease (CHD), and to introduce a novel ECV analysis tool. Patients (n = 39) and healthy controls (n = 17) underwent cardiovascular magnetic resonance T1 mapping in midventricular short axis (SAX) and transverse orientation (TRANS). Regions of interest (ROIs) were evaluated with regard to image quality and maximum RV wall thickness per ROI in pixels. ECV from plane ROIs was compared with values obtained with a custom-made tool that derives the mean T1 values from a “line of interest” (LOI) centered in the RV wall. In CHD, average image quality was good (no artifacts in the RV, good contrast between blood/myocardium), and RV wall thickness was 1–2 pixels. RV ECV was not quantifiable in 4/39 patients due to insufficient contrast or wall thickness < 1 pixel. RV myocardium tended to be more clearly delineated in SAX than TRANS. ECV from ROIs and corresponding LOIs correlated strongly in both directions (SAX/TRANS: r = 0.97/0.87, p < 0.001, respectively). In conclusion, RV ECV can be assessed if image quality allows sufficient distinction between myocardium and blood, and RV wall thickness per ROI is ≥ 1 pixel. T1 maps in SAX are recommended for RV ECV analysis. LOI application simplifies RV ECV measurements.