Tricuspid Annular Systolic Velocity Research Articles

Right ventricular echocardiographic parameters and prediction of stroke volume in ischemic cardiogenic shock: A retrospective study

PurposeThis study investigated which commonly used right ventricular (RV) echocardiographic parameter correlates best with stroke volume (SV) estimated by Doppler echocardiography in ischemic cardiogenic shock (CS). Materials and methodsWe retrospectively reviewed the records of 100 patients admitted to the ICU over 34 months with CS. Tricuspid annular plane systolic excursion (TAPSE), Tricuspid annulus systolic velocity (RV S′), Tricuspid regurgitation maximum velocity (TR Vmax), and RV outflow tract velocity time integral (RVOT VTI) were correlated to SV. ResultsMean age was 62.6 ± 12.7 years and 78% were male. The mean SV, TAPSE, RV S′, TR Vmax, and RVOT VTI were 47 ± 16 ml, 16 ± 5 mm, 11 ± 4 mm/s, 1.97 ± 0.73 m/s, and 12.7 ± 5 cm, respectively. RVOT VTI correlated best to SV (r = 0.39 p = 0.01) compared to TAPSE, RV S′, and TR Vmax (r = 0.26 p = 0.01, r = 0.15 p = 0.21, r = 0.03 p = 0.78). RVOT VTI independently predicted SV. Univariate analysis demonstrated that only RVOT VTI predicted SV (OD = 1.18 p = 0.04) and had the best area under the curve (0.70, p = 0.03). ConclusionRVOT VTI correlated better (albeit weakly) to and best predicted SV compared to TAPSE, RV S′, and TR Vmax in patients admitted to intensive care with CS. This study suggests that RVOT VTI has the potential as a therapeutic target to optimize SV in CS.

Correlation Between Right Ventricular Echocardiography Measurements and Functional Capacity in Patients With Pulmonary Arterial Hypertension.

Accelerometry is an emerging option for real-time evaluation of functional capacity in patients with pulmonary arterial hypertension (PAH). This prospective pilot study assesses the relationship between functional capacity by accelerometry and right ventricular measurements on echocardiography for this high-risk cohort. Patients with PAH were prospectively enrolled and underwent 6-Minute Walk Test and cardiopulmonary exercise testing. They were given a Fitbit, which collected steps and sedentary time per day. Echocardiographic data included right ventricular global longitudinal, free wall, and septal strain; tricuspid regurgitant peak velocity; tricuspid annular plane systolic excursion; tricuspid annular plane systolic velocity; right ventricular myocardial performance index; and pulmonary artery acceleration time. Pairwise correlations were performed. The final analysis included 22 patients aged 13 to 59 years. Tricuspid regurgitant peak velocity had a negative correlation with 6-Minute Walk Test (r = -0.58, P = .02), peak oxygen consumption on exercise testing (r = -0.56, P = .03), and average daily steps on accelerometry (r = -0.59, P = .03), but a positive correlation with median sedentary time on accelerometry (r = 0.64, P = .02). Pulmonary artery acceleration time positively correlated with peak oxygen consumption on exercise testing (r = 0.64, P = .002). There was no correlation between right ventricular strain measurements and functional capacity testing. In this pilot study, tricuspid regurgitant jet and pulmonary artery acceleration time were the echocardiographic variables that correlated most with accelerometry data. With further echocardiographic validation, accelerometry can be a useful, noninvasive, and cost-effective tool to monitor disease progression in patients with PAH.

Significance of strictly defined idiopathic tricuspid regurgitation.

Moderate to severe tricuspid regurgitation (TR) is known to cause right ventricular (RV) failure and death. Although TR is traditionally classified as primary or secondary, recently, a new class of TR called idiopathic TR has been proposed, with varying definitions among different studies. The data were retrospectively collected for the period of January to June 2018 for 8711 patients from the patient cohort of the National Cheng Kung University Hospital echocardiography laboratory. A total of 670 patients (7.7%) with moderate-to-severe TR were included. Idiopathic TR was diagnosed strictly using a new systematic approach. The distribution of significant TR included 74 (11.0%) primary TR cases, 48 (7.2%) with pacemaker-related TR, 267 (39.9%) with left heart disease, 24 (3.6%) with congenital heart disease, 6 (0.9%) with RV myopathy, 105 (15.7%) with pulmonary hypertension, and 146 (21.8%) with idiopathic TR. The mean age in primary and idiopathic TR groups was older ( p = 0.004), with lower estimated pulmonary pressure ( p < 0.001), higher RV fraction area change (FAC, p < 0.001), and tricuspid annulus systolic velocity (S', p = 0.004) compared with functional TR group. Multivariate analysis showed that idiopathic TR ( p = 0.002) and primary TR ( p = 0.008) had better RV FAC than functional TR. Idiopathic TR was associated with better RV function than the other secondary TRs. Thus, idiopathic TR should be strictly defined and regarded as a distinct type of TR.

3D-echocardiography for evaluation of the right ventricle in patients with repaired Tetralogy of Fallot: a comparison study with cardiac magnetic resonance

Abstract Background Patients with repaired Tetralogy of Fallot (ToF) need periodic instrumental assessments, due to complications they can meet during lifetime. Right ventricle (RV) dilation and dysfunction are some examples that explain why those patients regularly undergo Cardiac Magnetic Resonance (CMR), currently the gold standard method to detect these complications. Purpose 3D-echocardiography is an emerging tool to study RV, but there is little data supporting its use in congenital heart diseases. This study aimed at evaluating its accuracy in assessing RV dimensions and systolic function in ToF patients, in comparison to CMR. Methods 34 patients were prospectively enrolled after CMR performance. They all underwent standard 2D-echocardiography and Multi-Beat-ECG-triggered 3D Full-Volume acquisition. RV End Diastolic Volume (RV-EDV), End Systolic Volume and Ejection Fraction (RV-EF) were defined both in 3D-echocardiography and CMR. Results Post-hoc analysis of 3D images was performed through a vendor-independent software in 30 patients, resulting in a feasibility of 88%. A Bland-Altman analysis was performed, showing that 3D-echocardiography underestimates the RV-EDV/BSA of −27.39 mL/m2 on average (CI 95%: −29.46; −25.31, SD: 5.68 mL/m2), compared to CMR, as expected. However, when compared to normality reference, 3D-echocardiography identified RV dilatation with a significant correlation to CMR (V=0.66, p&amp;lt;0.001). Moreover, ROC curves showed that 3D-echo-RV-EDV/BSA is the echocardiographic measure that best correlates to CMR in detecting RV dilatation (AUC 1, CI 95%: 1.00; 1.00), followed by RVOT diameter in PLAX (AUC 0.89, CI 95%: 0.69; 0.99). Youden analysis suggested 77 mL/m2 (Se 95%, Sp 100%; J 0,95) as optimal limit to define RV dilatation in 3D-echocardiography. Regarding the RV-EF, the Bland-Altman analysis showed that 3D-echocardiography overestimates the RV-EF by 1,97% on average (CI 95%: 0.01; 3.95, SD: 5.43), compared to CMR. Secondly, accuracy of different echocardiographic parameters (both 2D and 3D) in detecting a RV systolic impairment was analyzed: ROC curves showed that RV-EF in 3D echocardiography is the measurement that best correlates to CMR in detecting RV dysfunction (AUC 0.92, CI 95%: 0.79–1.00), followed by Fractional Area Change (FAC) (AUC 0.78, CI 95%: 0.60; 0.96). Tricuspid Annular Plane Systolic Excursion (TAPSE) and tricuspid valve annular motion velocities in systole (S'-TDI), instead, showed very poor correlation. Conclusions 3D-echocardiography showed good agreement with CMR in defining RV dimensions and systolic function in ToF patients, even more than the bidimensional measurements cardiologists are used to. This could lead to a wider use of this tool in daily clinical practice, involving a reduction in the execution of the numerous CMR patients usually undergo. Moreover, it could be a valid instrument in patients with contraindication to CMR. Funding Acknowledgement Type of funding sources: None.

Inflammation and echocardiographic ventricular function in patients with a systemic right ventricle and heart failure

Abstract Background Clinical deterioration is fast once heart failure (HF) develops in patients with a systemic right ventricle (sRV) [1]. Despite its established role in HF patients with a normal heart anatomy [2,3], little is known about the contribution of inflammation in sRV-HF patients. Aims To assess inflammation and echocardiography in sRV patients with or without HF and to relate inflammation to echocardiographic ventricular function. Methods In this cross-sectional prospective study, patients with a sRV due to Senning/Mustard repair or due to congenitally corrected transposition of the great arteries (ccTGA) were consecutively enrolled at the outpatient clinic of a single, tertiary care center. Echocardiography and venipuncture were performed on the same day. C-reactive protein (CRP), red cell distribution width (RDW), neutrophil-lymphocyte ratio (NLR), myeloperoxidase (MPO), myeloperoxidase and citrullinated histone H3-DNA complexes (MPO-DNA and H3Cit-DNA) and interleukin 10 were measured. Patients were stratified based on the presence or absence of HF, with HF defined as having signs and/or symptoms of HF requiring medical therapy plus one of the following: impaired ventricular function with elevated intracardiac pressures, elevated N-terminal pro-brain natriuretic peptide, and/or peak oxygen consumption in lowest quartile (according to published norms for TGA patients). Comparative statistics and univariate correlations were performed. Results Eighty-seven patients were included (mean age 39 years; 69% male; 25% ccTGA, 68% NYHA class I) from which one third (29/87) had HF. Most inflammatory markers were significantly higher in the HF group compared to non-HF: CRP (4.3 vs 2.21 mg/dL; P=0.016), RDW (13.6 vs 12.7 fL; P&amp;lt;0.001), NLR (3.6 vs 2.9; P=0.01), MPO (171 vs 139 ng/mL; P=0.03) and MPO-DNA (1.4 vs 1.2; P=0.04). When assessing systolic function, HF patients had: i) lower strain of the sRV free wall (10.9 vs 13.1%; P=0.008), ii) lower mitral annular plane systolic excursion (MAPSE) (1.7 vs 2.1 cm; P&amp;lt;0.001) and iii) lower strain rate (SR) of the subpulmonary LV (spLV) (1.0 vs 1.3 S-1; P=0.03). The spLV was also more hypertrophied (end-diastolic LV posterior wall 0.99 vs 0.79 cm; P=0.007) and more dilated (end-diastolic LV internal diameter 4.1 vs 3.3 cm; P=0.006) in HF. CRP and RDW showed the strongest correlations (Spearman correlation coefficient r&amp;gt;0.29) with LV and RV ventricular function. CRP correlated with lateral tricuspid annular systolic velocity (r=−0.313**), strain of the free wall (r=−0.317**) and global longitudinal strain (r=−0.292**) of the sRV. RDW correlated with MAPSE (r=−0.313**). **P&amp;lt;0.01. Conclusions sRV patients in HF have more systemic inflammation and lower RV free wall strain. With more remodeling and a lower MAPSE and SR of the spLV, the LV cannot be ignored when evaluating HF in sRV patients. Correlation between inflammation and ventricular systolic function, however, is limited. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ERA-CVD JTC2019 (Fonds Wetenschappelijk Onderzoek G0G1719N to K.M. and A.V.D.B); German Bundesministerium für Bildung und Forschung 01KL2001 to T.W.)

Utility of the tricuspid annular tissue doppler systolic velocity and pulmonary artery systolic pressure relationship in right ventricular systolic function assessment: A pilot study.

Tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) ratio has been validated as a valuable noninvasive measure of right ventricular (RV) elastance and systolic function. However, the more reliable TA systolic (s') velocity measure of RV systolic function compared to TAPSE has not been previously studied. We conducted a pilot study using several variables of RV function in 50 patients with the main aim to determine which numerical expression between TA TDI s'/PASP and TAPSE/PASP ratio was most useful. In a stepwise multiple regression analysis, TA TDI s'/PASP ratio (p &lt; .0002); LVOT VTI/RVOT VTI ratio (p &lt; .0002); RVOT VTI (p &lt; .0047); TAPSE/PASP ratio (p &lt; .0259) and TA TDI e' (p &lt; .0292) were best in discriminating normal versus abnormal RV systolic function. Using receiver operator curve analysis, cut-off values for both TA TDI s'/PASP (&gt;3.9 mm/c/mmHg) had 82.1% sensitivity and 77.3% specificity while the TAPSE/PASP (&gt;.61 mm/mmHg) had 89.3% sensitivity and 68.2% specificity in identifying normal RV function in our studied population. Our results indicate that TA TDI s'/PASP is a better mathematical expression when examining the relationship between RV contractility and RV resistance relationship. Furthermore, we also found that inclusion of RVOT VTI, RV diastolic properties, and left ventricular systolic function are important determinants of RV systolic function assessments and should be routinely included. Additional prospective studies are now needed to confirm these results using hemodynamic data.

TVnet: automated global analysis of tricuspid valve plane motion in CMR long-axis cines with residual neural networks for assessment of right ventricular function

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Clarendon Fund, John Fell Oxford University Press Research Fund, Oxford BHF Centre of Research Excellence (RE/18/3/34214), Alison Brading Memorial Graduate Scholarship in Medical Science, National Institute for Health Research Oxford Biomedical Research Centre, National Institutes of Health (R01HL144706). Background Right ventricular (RV) function evaluation is an integral part of comprehensive cardiac assessment, including for pulmonary hypertension, congenital heart disease and arrhythmogenic RV cardiomyopathy (ARVC) [1]. It is commonly assessed by measuring tricuspid annular plane systolic excursion (TAPSE) and peak systolic velocity (RV s’) on echocardiography [2]. However, it is highly sensitive to imaging window and small changes in the beam angle, limiting reliability [3]. Cardiovascular magnetic resonance (CMR) is the imaging gold-standard for assessing RV structure and function, and is highly reproducible. CMR can assess tricuspid valve (TV) motion using four-chamber (4Ch) and RV two-chamber (2Ch) cines, with high diagnostic performance when compared against single-plane analysis [4]. However, manual placement of the TV insertion points is highly time-consuming for routine clinical workflows. TVnet, a deep-learning framework for automatically tracking the TV in 4Ch cines [5] has been recently validated, but without the orthogonal plane (RV 2Ch) which is helpful to more reliably characterise TV motion. Purpose We further extend TVnet to automatically track RV 2Ch cines and derive analysis of global TV motion parameters (global TAPSE and RV s’) on par with expert level performance. Methods 74 patients undergoing CMR (1.5T Siemens MR scanner) with 4Ch and RV 2Ch views were retrospectively included in this ethically-approved study. The patients had the following cardiovascular conditions: myocardial infarction (n=43), ARVC (n=28) and Takotsubo cardiomyopathy (n=3). The dual-stage deep-learning pipeline with a residual neural network backbone [5, 6] (Figure 1A) was trained using 69 patient datasets and 15 patients were randomly chosen for testing. The TVnet trained on 4Ch cines [5] was used to automatically annotate the 4Ch cines of the testing set for global analysis comparison. For manual reference, the software Segment [7] was used to manually annotate the TV insertion points in all imaging data (1,865 RV 2Ch images, 375 4Ch images). The global TAPSE and RV s’ were derived as the mean perpendicular motion from the end-diastolic plane from both chamber views (Figure 1B). Results TVnet achieved a fast processing accuracy (&amp;lt;1 second per cine) and successfully tracked the TV insertion points from the RV 2Ch cine with a plane tracking error of 0.08±0.83 mm. The integrated pipeline yielded an excellent clinical-metric agreement with the manual reference (Figure 2) for both global TAPSE (error=0.42±0.68 mm, ICC=0.95) and RV s’ (error=-0.10±0.71 cm/s, ICC=0.85). Conclusion TVnet demonstrated excellent performance in both tracking the TV insertion points in RV 2Ch cines and deriving global TAPSE and RV s’ compared to manual reference. TVnet can eventually provide a complete automatic inline analysis of TV plane motion for a fast, reliable and reproducible assessment of RV function in routine clinical workflows. (A) TVnet pipeline (B) Metric derivationCorrelation and Bland-Altman plots

Multiparametric evaluation of right ventricular function in pulmonary arterial hypertension associated with congenital heart disease

Introduction and objectivesOutcome in patients with congenital heart diseases and pulmonary arterial hypertension (PAH) is closely related to right ventricular (RV) function. Two-dimensional echocardiographic parameters, such as strain imaging or RV end-systolic remodeling index (RVESRI) have emerged to quantify RV function. MethodsWe prospectively studied 30 patients aged 48±12 years with pretricuspid shunt and PAH and investigated the accuracy of multiple echocardiographic parameters of RV function (tricuspid annular plane systolic excursion, tricuspid annular peak systolic velocity, RV systolic-to-diastolic duration ratio, right atrial area, RV fractional area change, RV global longitudinal strain and RVESRI) to RV ejection fraction measured by cardiac magnetic resonance. ResultsRV ejection fraction <45% was observed in 13 patients (43.3%). RV global longitudinal strain (ρ [Spearman's correlation coefficient]=−0.75; P=.001; R2=0.58; P=.001), right atrium area (ρ=−0.74; P <.0001; R2=0.56; P <.0001), RVESRI (ρ=−0.64; P <.0001; R2=0.47; P <.0001), systolic-to-diastolic duration ratio (ρ=−0.62; P=.0004; R2=0.47; P <.0001) and RV fractional area change (ρ=0.48; P=.01; R2=0.37; P <.0001) were correlated with RV ejection fraction. RV global longitudinal strain, RVESRI and right atrium area predicted RV ejection fraction <45% with the greatest area under curve (0.88; 95%CI, 0.71-1.00; 0.88; 95%CI, 0.76-1.00, and 0.89; 95%CI, 0.77-1.00, respectively). RV global longitudinal strain >−16%, RVESRI ≥ 1.7 and right atrial area ≥ 22 cm2 predicted RV ejection fraction <45% with a sensitivity and specificity of 87.5% and 85.7%; 76.9% and 88.3%; 92.3% and 82.4%, respectively. ConclusionsRVESRI, right atrial area and RV global longitudinal strain are strong markers of RV dysfunction in patients with pretricuspid shunt and PAH.

The effect of gestational diabetes mellitus on fetal right heart growth in late-term pregnancy: A prospective study.

Gestational diabetes mellitus (GDM) is a complication of pregnancy strongly associated with an increased risk of structural fetal abnormalities. As the fetal heart grows quickly during the late-term pregnancy period, it is important to understand fetal heart growth before birth. This study explored how GDM affects fetal heart growth by evaluating basic echocardiography indicators during late pregnancy. This prospective, longitudinal study included 63 GDM patients (GDM group) and 67 healthy pregnant women (control group). All subjects underwent fetal echocardiography scans at gestational weeks 28-32, 32-36, and 36-40. Twelve echocardiographic indicators were assessed at each observation and analyzed by using a mixed model. The left atrial diameter (LA) and left ventricular end-diastolic diameter (LV) similarly increased from the first to the third observation. The right ventricular end-diastolic diameter (RV) was significantly different between the groups, and a group × time interaction was detected. The tricuspid annular peak systolic velocity (s') increased more rapidly in the GDM than the control group during the first to second observations, and the group × time interaction was significant. The increase in the tricuspid annular plane systolic excursion (TAPSE) of the GDM group was "slow-fast", while that of the control group was "fast-slow", during three observations. After adjusting covariates, the group difference and interaction effect of TAPSE and RV remained significant. The differences in fetal right heart indicators between the GDM and control groups suggest that GDM may affect the structure and functional growth of the fetal right heart during late-term pregnancy.

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

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

Effects of a Long-Term Wearable Activity Tracker-Based Exercise Intervention on Cardiac Morphology and Function of Patients with Cystic Fibrosis.

Several studies have shown that patients with cystic fibrosis (CF), even at a young age, have pulmonary and cardiac abnormalities. The main complications are cardiac right ventricular (RV) systolic and/or diastolic dysfunction and pulmonary hypertension, which affects their prognosis. Exercise training (ET) is recommended in patients with CF as a therapeutic modality to improve physical fitness and health-related quality of life. However, questions remain regarding its optimal effective and safe dose and its effects on the patients’ cardiac function. The study aimed to provide a wearable activity tracker (WAT)-based ET to promote physical activity in CF patients and assess its effects on cardiac morphology and function. Forty-two stable CF individuals (aged 16.8 ± 3.6 years) were randomly assigned to either the intervention (Group A) or the control group (Group B). Group A participated in a 1-year WAT-based ET program three times per week. All patients underwent a 6-min walking test (6-MWT) and an echocardiographic assessment focused mainly on RV anatomy and function at the baseline and the end of the study. RV systolic function was evaluated by measuring the tricuspid annular plane systolic excursion (TAPSE), the systolic tricuspid annular velocity (TVS’), the RV free-wall longitudinal strain (RVFWSL), and the right ventricular four-chamber longitudinal strain (RV4CSL). RV diastolic function was assessed using early (TVE) and late (TVA) diastolic transtricuspid flow velocity and their ratio TVE/A. Pulmonary artery systolic pressure (PASP) was also estimated. In Group A after ET, the 6MWT distance improved by 20.6% (p < 0.05), TVA decreased by 17% (p < 0.05), and TVE/A increased by 13.2% (p < 0.05). Moreover, TAPSE, TVS’, RVFWSL, and RV4CSL increased by 8.3% (p < 0.05), 9.0% (p < 0.05), 13.7% (p < 0.05), and 26.7% (p < 0.05), respectively, while PASP decreased by 7.6% (p < 0.05). At the end of the study, there was a significant linear correlation between the number of steps and the PASP (r = −0.727, p < 0.01) as well as the indices of RV systolic function in Group A. In conclusion, WAT is a valuable tool for implementing an effective ET program in CF. Furthermore, ET has a positive effect on RV systolic and diastolic function.

Right Ventricular Dysfunction Is Associated With Increased Mortality in Patients Requiring Venovenous Extracorporeal Membrane Oxygenation: Issues With the Method.

To the Editor: We read with interest the article published by Maharaj et al.1 The authors’ aim was to investigate the correlation between echocardiographic parameters and survival in patients supported by venovenous extracorporeal membrane oxygenation (VV-ECMO). The authors retrospectively collected clinical and echocardiographic data from 17 patients over 1 year period. The echocardiograms were a mixture of transthoracic (TTE) and transesophageal (TEE) scans. Visual assessment and right ventricle (RV) fractional area change (FAC) were used as the parameters for RV systolic function as measured by two independent blinded experts, and an average was used for statistical analysis. In patients who did not survive, significant RV dysfunction by visual assessment was more prevalent in nonsurvivors. In addition, median value for FAC in nonsurvivors was significantly lower (11.3% [10.3–15] vs. 30.1% [27.6–31.4], respectively). RV FAC is performed by tracing the endocardial border area of the RV in end systole (ESA) and end diastole (EDA), and it is calculated as EDA − ESA/EDA.2 This method renders FAC open to intra- and interobserver variabilities. A previous study demonstrated FAC to exhibit limited and nonstatistically significant intraobserver (r, 0.56; p = 0.06) and interobserver (r, 0.46; p = 0.16) agreements.2 In addition, mean intra- and interobserver differences were high (mean, 1.86%; 95% CI, −9.25% to −12.96%; and mean, 4.00%; 95% CI, −7.72% to −15.72%, respectively). FAC variability was worst compared with other RV systolic function parameters (e.g., Tricuspid annular plane systolic excursion and velocity). Where FAC is used for RV systolic function assessment, intra- and interobserver variabilities should be assessed and cited providing a guide to results reliability. The authors used a mixture of TEE and TTE to obtain FAC. The two modalities were considered comparable, and thus, values from both modalities were incorporated in the FAC comparison. A recent study compared TTE and TEE in the assessment of RV function using the same parameters in 100 patients undergoing cardiac surgery.3 The TTE and TEE were performed in close temporal proximity under the same loading conditions. The study demonstrated that RV parameters had fair agreement between modalities but not identical. FAC comparison demonstrated correlation concordance coefficient between TTE and TEE of 0.31 (95% CI, 0.12–0.48), suggesting limited agreement and that FAC results are not interchangeable between the two modalities. This result casts a shadow on the feasibility of incorporating FAC from TTE and TEE in the same statistical comparison. Association between a continuous independent parameter (e.g., RV FAC) and categorical dependent parameter (e.g., mortality) requires in-depth statistical analysis. Logistic regression is the most commonly statistical method used to investigate such association.4 A multivariate model is constructed to incorporate all likely and significantly different independent parameters to investigate which parameters predict outcome. Furthermore, receiver operator curve (ROC) analysis is usually performed to establish sensitivity and specificity of the independent parameter in predicting the dependent parameter.5 Without such analysis, association between FAC and mortality could not be convincingly established. Fractional area change is a method of RV systolic function assessment with high observer variability. FAC is not interchangeable between TTE and TEE. Further statistical analysis is required to establish association between RV FAC and outcome.

Right Ventricular Dysfunction Predicts Outcome in Acute Heart Failure.

AimThe severity of cardiac impairment in acute heart failure (AHF) predicts outcome, but challenges remain to identify prognostically important non-invasive parameters of cardiac function. Left ventricular ejection fraction (LVEF) is relevant, but only in those with reduced LV systolic function. We aimed to assess the standard and advanced parameters of left and right ventricular (RV) function from echocardiography in predicting long-term outcomes in AHF.MethodsA total of 418 consecutive AHF patients presenting over 12 months were prospectively recruited and underwent bedside echocardiography within 24 h of recruitment. We retrospectively assessed 8 RV and 5 LV echo parameters of the cardiac systolic function to predict 2-year mortality, using both guideline-directed and study-specific cutoffs, based on the maximum Youden indices via ROC analysis. For the RV, these were the tricuspid annular plane systolic excursion, RV fractional area change, tissue Doppler imaging (TDI) peak tricuspid annular systolic wave velocity, both peak- and end-systolic RV free wall global longitudinal strain (RV GLS) and strain rate (mean RV GLSR), RV ejection fraction (RVEF) derived from a 2D ellipsoid model and the ratio of the TAPSE to systolic pulmonary artery pressure (SPAP). For the LV, these were the LVEF, mitral regurgitant ΔP/Δt (MR dP/dt), the lateral mitral annular TDI peak systolic wave velocity, LV GLS, and the LV GLSR.ResultsA total of 7/8 parameters of RV systolic function were predictive of 2-year outcome, with study cutoffs like international guidelines. A cutoff of < −1.8 s–1 mean RV GLSR was associated with worse outcome compared to > −1.8 s–1 [HR 2.13 95% CI 1.33–3.40 (p = 0.002)]. TAPSE:SPAP of > 0.027 cm/mmHg (vs. < 0.027 cm/mmHg) predicted worse outcome [HR 2.12 95% CI 1.53–2.92 (p < 0.001)]. A 3-way comparison of 2-year mortality by LVEF from the European Society of Cardiology (ESC) guideline criteria of LVEF > 50, 41–49, and < 40% was not prognostic [38.6% vs. 30.9 vs. 43.9% (p = 0.10)]. Of the 5 parameters of LV systolic function, only an MR dP/dt cutoff of < 570 mmHg was predictive of adverse outcome [HR 1.63 95% CI 1.01–2.62 (p = 0.047)].ConclusionWith cutoffs broadly like the ESC guidelines, we identified RV dysfunction to be associated with adverse prognosis, whereas LVEF could not identify patients at risk.

Mechanical property evaluation of the right ventricular myocardium in cancer patients with chemotherapy by echocardiography: a systematic review and meta-analysis.

BackgroundCancer therapy-related cardiotoxicity has recently become an area of intense research. As the prognostic role of the right ventricle (RV) in a variety of cardiovascular diseases has been confirmed, and several studies have paid increased attention to RV function in cancer patients who have underwent chemotherapy, we provide a meta-analysis to objectively evaluate the mechanical properties of the right ventricular myocardium by echocardiography in this population.MethodsWe systematically searched Embase, PubMed, and Cochrane databases were applied to search for studies (published before August 11, 2021) comparing RV contraction measured by echocardiography at baseline to follow-up in cancer patients who underwent chemotherapy or radiotherapy. The mechanical properties of the right ventricular myocardium were pulmonary artery systolic pressure (PASP), tricuspid annular plane systolic excursion (TAPSE), systolic velocity of tricuspid annulus (S'), right ventricular free wall longitudinal strain (RVFWLS), right ventricular global longitudinal strain (RVGLS), and right ventricular fractional area change (RVFAC). We analyzed pooled data using a random-effects model and assessed risk of bias in the included studies using the Newcastle-Ottawa Scale.ResultsTwenty-one trials were enrolled (N=1,355 participants). Cancer patients who underwent chemotherapy but not radiotherapy showed an increase in PASP [standardized mean difference (SMD) =0.161, 95% CI: 0.007 to 0.316) compared with the condition at baseline, as well as reductions in TAPSE (SMD =−0.543, 95% CI: −0.698 to −0.389), S' (SMD =−0.507, 95% CI: −0.748 to −0.266), RVFWLS (SMD =0.833, 95% CI: 0.549 to 1.118) and RVGLS (SMD =1.017, 95% CI: 0.751 to 1.283). There was no significant difference in RVFAC (SMD =−0.097, 95% CI: −0.213 to 0.018). Furthermore, these indicators pointed to a deterioration of right ventricular contraction function in cancer patients who underwent chemotherapy and radiotherapy. The risk of bias of the included studies evaluated by the Newcastle-Ottawa Scale was medium to high.DiscussionRight ventricular contraction function would deteriorate in cancer patients who underwent chemotherapy and radiotherapy, especially with the prolongation of chemotherapy duration and accumulation of chemotherapeutic drugs. Further studies are needed to establish the definition of right ventricular systolic dysfunction in clinical practice.

Lack of right ventricular hypertrophy is associated with right heart failure in patients with left ventricular failure.

Presence of right heart failure (RHF) is associated with a worse prognosis in patients with left ventricular failure (LVF). While the cause of RHF secondary to LVF is multifactorial, an increased right ventricular (RV) afterload is believed as the major cause of RHF. However, data are scarce on the adaptive responses of the RV in patients with LVF. Our aim was to understand the relationship of right ventricular hypertrophy (RVH) with RHF and RV systolic and diastolic properties in patients with LVF. 55 patients with a left ventricular ejection fraction of 40% or less were included in the present study. A comprehensive two-dimensional transthoracic echocardiographic examination was done to all participants. 12 patients (21.8%) had RHF, and patients with RHF had a significantly lower right ventricular free wall thickness (RVFWT) as compared to patients without RHF (5.3 ± 1.7mm vs. 6.6 ± 0.9mm, p = 0.02) and the difference remained statistically significant after adjusting for confounders (Δx̅:1.34mm, p = 0.002). RVFWT had a statistically significant correlation with tricuspid annular plane systolic excursion (r = 0.479, p < 0.001) and tricuspid annular lateral systolic velocity (r = 0.360, p = 0.007), but not with the indices of the RV diastolic function. None of the patients with concentric RVH had RHF, while 22.2% of patients with eccentric RVH and 66.7% of patients without RVH had RHF (p < 0.01 as compared to patients with concentric RVH). In patients with left ventricular systolic dysfunction, absence of RVH was associated with worse RV systolic performance and a significantly higher incidence of RHF.

Effect of Sacubitril/Valsartan on the Right Ventricular Function and Pulmonary Hypertension in Patients With Heart Failure With Reduced Ejection Fraction: A Systematic Review and Meta-Analysis of Observational Studies.

BackgroundSacubitril/valsartan (S/V) demonstrated significant effects in improving left ventricular performance and remodeling in patients with heart failure with reduced ejection fraction. However, its effects on the right ventricle remain unclear. This systematic review and meta‐analysis aimed to assess the impact of S/V on right ventricular function and pulmonary hypertension.Methods and ResultsWe searched PubMed, Embase, Cochrane Library, and Web of Science from January 2010 to April 2021 for studies reporting right ventricular and pulmonary pressure indexes following S/V treatment. The quality of included studies was assessed using the Newcastle‐Ottawa scale. Variables were pooled using a random‐effects model to estimate weighted mean differences with 95% CIs. We identified 10 eligible studies comprising 875 patients with heart failure with reduced ejection fraction (mean age, 62.2 years; 74.0% men), all of which were observational. Significant improvements on right ventricular function and pulmonary hypertension after S/V initiation were observed, including tricuspid annular plane systolic excursion (weighted mean difference, 1.26 mm; 95% CI, 0.33–2.18 mm; P=0.008), tricuspid annular peak systolic velocity (weighted mean difference, 0.85 cm/s; 95% CI, 0.25–1.45 cm/s; P=0.005), and systolic pulmonary arterial pressure (weighted mean difference, 7.21 mm Hg; 95% CI, 5.38–9.03 mm Hg; P<0.001). Besides, S/V had a significant beneficial impact on left heart function, which was consistent with previous studies. The quadratic regression model revealed a certain correlation between tricuspid annular plane systolic excursion and left ventricular ejection fraction after excluding the inappropriate data (P=0.026).ConclusionsThis meta‐analysis verified that S/V could improve right ventricular performance and pulmonary hypertension in heart failure with reduced ejection fraction, which did not seem to be fully dependent on the reverse remodeling of left ventricle.RegistrationURL: https://www.crd.york.ac.uk/prospero; Unique identifier: CRD42021247970.

The effect of intravenous ferric carboxymaltose on right ventricular function - insights from the IRON-CRT trial.

Ferric carboxymaltose (FCM) improves left ventricular function in heart failure with reduced ejection fraction (HFrEF). Yet, the effect of FCM on right ventricular (RV) function remains insufficiently elucidated. This is a pre-defined analysis of the IRON-CRT trial in which symptomatic HFrEF patients with iron deficiency and reduced left ventricular ejection fraction (LVEF) despite optimal medical therapy and cardiac resynchronization therapy (CRT) underwent 1:1 randomization to FCM or placebo in a double-blind fashion. RV function was measured as the change from baseline to 3-month follow-up in RV fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE) and pulsed Doppler peak velocity at the RV lateral annulus (RV S'), systolic pulmonary artery pressure (SPAP) and its coupling to the right ventricle (TAPSE/SPAP ratio). The RV contractile reserve was measured as the change in TAPSE during incremental pacing at 70, 90 and 110 bpm. A total of 75 patients underwent randomization and received FCM (n=37) or placebo (n=38). At baseline 72.5% had RV dysfunction and 70% had RV dilatation. At 3-month follow-up, patients receiving FCM had a significant improvement in RV FAC (+4.1% [+1.4% - +6.9%] vs. -2.2% [-4.9% - +0.6%] in the placebo group, p=0.002) and TAPSE (+0.98 mm [+0.28 mm - +1.62 mm] vs. -0.19 mm [-0.85 mm - +0.48 mm] in the placebo group, p=0.020), but not RV S'. Patients receiving FCM had a numerically lower SPAP (p=0.073) and significant improvement in TAPSE/SPAP ratio (+0.097 [+0.048 - +0.146] vs. +0.002 [-0.046 - +0.051] in the placebo group, p=0.008). At baseline both groups had diminished RV contractile reserve during incremental pacing, which was attenuated at 3-month follow-up in the FCM group (p=0.004). Patients manifesting more RV function improvement were more likely to exhibit higher degrees of LVEF improvement (p < 0.05 for all). Treatment with FCM in HFrEF patients results in an improvement in RV function and structure and improves the RV contractile reserve.

Ventricular Myocardial Function and Central Hemodynamics in Patients with Secondary Atrial Septal Defect and Persistent or Paroxysmal Atrial Fibrillation

Background. Atrial fibrillation (AF) is the world’s most frequent arrhythmia associated with significant morbidity and mortality. Non-invasive multimodal imaging provides all necessary information for tactical decisions about radiofrequency catheter ablation and other methods of pharmacological and invasive AF treatment. Survival of patients with congenital heart diseases (CHDs) has grown over the past years. Still, there is a significant gap in evidence-based data regarding management of such patients with AF. Previously in Ukraine there were no studies of echocardiography parameters in patients with CHDs with paroxysmal or persistent AF, namely, those to find predictors for successful AF treatment before atrial septal defect (ASD) surgical or percutaneous closure.&#x0D; The aim. To evaluate ventricular myocardial function and central hemodynamics in patients with secondary ASD and paroxysmal or persistent AF compared to patients with paroxysmal or persistent AF without CHD.&#x0D; Methods. Weexamined54patients(36[66.7%]menand18[33.3%]women)aged61.4±9.8yearswithsecondaryASDand paroxysmal or persistent AF. Control group included 56 patients (38 [67.9%] men and 18 [32.1%] women) without CHD with non-valvular paroxysmal or persistent AF. All the patients underwent transthoracic and transesophageal echocardiography with tissue Doppler imaging and speckle-tracking echocardiography for longitudinal myocardial strain evaluation.&#x0D; Results. The patients in the study and control groups were comparable in terms of age and gender as well as comorbidities and cardiovascular risk factors. There were significant differences in the left heart remodeling indices and central hemodynamics alteration grades, for instance, the patients of the study group had significantly higher grade of left ventricular (LV) hypertrophy. Patients with ASD also had significantly more dilated LV and left atrium (LA) cavities and higher combined indices of LV filling pressure – E/E’ (14.9±4.2 vs. 9.6±5.3, p&lt;0.0001) and E/Vp (2.84±0.44 vs. 2.25±0.61, p&lt;0.0001), explaining more frequent AF in patients with ASD. The study group patients also had significantly higher systolic (sPAP) (52.4±2.8 vs. 44.6±3.2, p&lt;0.0001) and mean (mPAP) (38.6±4.3 vs. 31.7±1.9, p&lt;0.0001) pulmonary artery pressure compared to control group, as well as significantly worse all known indices of right ventricle (RV) myocardial function and right chambers overload. Global RV longitudinal strain strongly correlated with RV fractional area change (r = 0.75; p&lt;0.0001), and especially highly with tricuspid annular plane systolic excursion (r = 0.97; p&lt;0.0001) and tricuspid annular peak systolic velocity S’ (r = 0.98; p&lt;0.0001) during tissue Doppler imaging, making it trustworthy and valuable predictor of RV myocardial dysfunction and its potential restoration after defect correction. Patients with ASD much more often had significant moderate-to-severe functional tricuspid regurgitation (92.6% vs. 53.4%, p&lt;0.0001) with significantly higher central venous pressure indices (16.4±2.4 vs. 10.2±2.5, p&lt;0.0001) as per significantly wider inferior vena cava (IVC) (1.89±0.31 vs. 1.43±0.42, p&lt;0.0001) and it’s higher inspiratory collapse. IVC diameter strongly correlated with integral RV filling pressure (that is, right atrial pressure) index E/E’ (r = 0.98; p&lt;0.0001). Also, study group demonstrated significantly more frequent LA appendage thrombosis (40.7% vs. 21.4%, p=0.029) along with much more marked spontaneous contrast phenomenon and lower LA appendage expulsion rate (26.7±5.1 vs. 34.3±7.2, p&lt;0.0001).&#x0D; Conclusions. Stratification of patients with ASD complicated by paroxysmal or persistent AF for radiofrequency catheter ablation requires thorough echocardiographic examination with targeted certain indices evaluation aiming at earlier intervention in order to earlier diagnosis and invasive or surgical treatment in this specific patient group, namely LV hypertrophy grade, left chambers dilation with LV global systolic function evaluation, pulmonary hypertension grade as per sPAP and mPAP evaluation, as well as combined right chambers overload grade indices, including RV myocardial function by all methods including speckle-tracking echocardiography.

Changes in echocardiographic parameters of the donor's heart before and after heart transplantation and their relationship with post-transplant survival.

BackgroundHeart transplantation is now widely performed in China, but the current entry criteria for heart transplantation donors are simple and lack reliable standards; there are still no studies on the effect of preoperative echocardiographic parameters of heart transplantation donors on the prognosis of the recipient. Therefore, the aim of this study is twofold: (I) to observe the characteristics of changes in echocardiographic parameters of the donor’s heart before and after heart transplantation and (II) to study the relationship between the changes in echocardiographic parameters of the donor’s heart pre- and post-transplant and transplant recipient survival.MethodsA total of 29 patients who underwent orthotopic heart transplant in our hospital from October 2016 to October 2019 were enrolled in this study. All recipients were followed up until April 2020. Echocardiographic data were collected pre-transplantation (donor) and at 1 week and 1 month post-transplant (recipient).ResultsCompared with the pretransplanted donor’s heart, there was an increase in the interventricular septal diameter, left ventricular posterior wall diameter, right atrium diameter and right ventricular diameter, while a decrease was found in the tricuspid annular systolic displacement and tricuspid annular peak systolic velocity at 1 week post-transplant. The survival curve showed that the postoperative survival time in the right atrium/ventricle ≥32 mm group was better than that in the right atrium/ventricle <32 mm group. The survival curve also showed that the postoperative survival time in the right atrium/ventricle enlargement <2 mm group was better than that in the right atrium/ventricle enlargement ≥2 mm group.ConclusionsIn the early post-transplant period, ventricular myocardial thickening, right heart enlargement and a decrease in right heart function were observed in the post-transplanted heart compared to the pretransplanted donor’s heart. Postoperative survival was higher among heart transplant patients who received a heart with right atrium/ventricle ≥32 mm. Postoperative survival was lower among heart transplant patients whose right atrium/ventricle was dilated ≥2 mm at 1 month postoperatively compared with the pretransplanted donor’s heart.

Right ventricular mechanics in anthracycline chemotherapy: insights into the PROACT PLUS study

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): South Tees Research and Development Fund Background Anthracyclines are highly effective chemotherapy agents used in the treatment of many breast and haematological malignancies. However, one of the well-recognised associated risks with their use includes cardiotoxicity which can lead to heart failure and poor prognosis. Most studies have focused on the effects of these agents on the left ventricular systolic function. Right ventricular (RV) mechanics in anthracycline chemotherapy have so far been neglected. Purpose The PROACT PLUS study is an observational, prospective, cohort study which assesses the effects of anthracyclines on the RV systolic and diastolic measures using 2 dimensional conventional echocardiography and speckle tracking imaging (STE). Methods From October 2018 to March 2020, patients with a new diagnosis of lymphoma or breast cancer undergoing anthracycline chemotherapy were recruited into the PROACT PLUS study. Echocardiography was performed pre-chemotherapy (V1) and 1 month post chemotherapy (V2). Using vendor-independent software (TomTec Imaging Systems, 2D Cardiac Performance Analysis, Unterschleisshiem, Germany), offline analysis of tricuspid annular plane systolic excursion (TAPSE), RV fractional area change (FAC), tricuspid annular systolic velocity (S’), RV global longitudinal strain (RV GLS), RV myocardial longitudinal strain (RV myoGLS), RV free wall strain (RV FWS), RV- and RV free wall peak systolic (PS) strain-rates, end-systolic (ES) strain-rates, early-diastolic (ED) strain-rates and late-diastolic (LD) strain-rates were measured. This study was ethically approved by the Health Research Association (REC reference 18/EM/0177). Results 62 patients were recruited into this study. Of these, 7 passed away during treatment and 5 failed to attend their follow-up appointment at V2. Of the remaining patients, a significant deterioration in the RV GLS (-25.4% vs. -22.5%, p &amp;lt; 0.0001), RV myoGLS (-22.4% vs. -20.9%, p = 0.005), RV ED strain-rate (1.08 1/s vs. 0.9 1/s, p = 0.01) and RV free wall ED strain-rate (1.24 1/s vs. 1.07 1/s, p = 0.02) was seen between V1 and V2. No statistical significant change was observed in the conventional and other strain measures of RV function. A total number of 6 patients developed left ventricular systolic dysfunction at V2 with ≥ 10% drop in the LV ejection fraction (LVEF) to &amp;lt; 53%. In this group of patients, there was a statistical significant reduction in the RV FWS (-25.5% vs. -22.7%, p = 0.03) which was not evident in the group of patients with preserved LVEF. Conclusion These findings suggest that adverse effects of anthracyclines are not purely confined to the LV, and RV systolic and diastolic changes are evident during treatment with anthracyclines, emphasising the global effect of these agents. A comprehensive RV assessment needs to be taken into consideration during the assessment of cardiotoxicity in patients undergoing chemotherapy treatment.