Tricuspid Annular Systolic Velocity Research Articles

P1361 Loading conditions might mimic right ventricular longitudinal dysfunction in patients with chronic left heart disease and forward failure

Abstract Background and aim Right ventricular failure (RVF) in patients with chronic left heart disease (LHD) has important prognostic implications. RV longitudinal function parameters (tricuspid annular plane systolic excursion, TAPSE; peak systolic longitudinal strain, RV-Str; tricuspid annulus systolic velocity, TAPSm) are today commonly used to define RV dysfunction. In the present study we hypothesized that longitudinal RV dysfunction (LDF) might be due to loading conditions and not necessarily RV dysfunction. Methods We retrospectively included 66 patients with LHD (age 52 ± 13 years, males 79%) that underwent right heart catheterization (RHC), ergospirometry (n = 47) and echocardiography (Echo) within 48 hours. Patients were divided into three groups from Echo data: normal RV function (TAPSE ≥17 mm + normal central venous pressure (CVP) from collapsibility of cava inferior, n = 18); LDF (TAPSE < 17 mm + normal CVP, n = 22) and RVF (CVP≥10 mmHg, n = 26). Results Patients with RVF had compared with normal and LDF lower peak VO2, more advanced LHD, enlarged RV and higher RV afterload (Table). Patients with LDF had compared with normal reduced stroke volume index (SVI). The patients with normal and LDF did not differ regarding right atrial pressure (RAP) response during exercise (P = 0.84). The longitudinal parameters did not differ between patients with LDF and RVF. Conclusions Longitudinal parameters in patients with chronic LHD and normal CVP should be interpreted with caution. Loading conditions with reduced stroke volume might mimic LDF. Normal (n = 18) LDF (n = 22) RVF (n = 26) Overall P-value Normal vs LDF Normal vs RVF LDF vs RVF Peak VO2 (mlO2/min/m2) 14.8 ± 3.3 13.5 ± 3 11 ± 2 0.001 0.29 <0.001 0.005 RAP (mmHg) 4 ± 3 4 ± 4 12 ± 3 <0.001 0.55 <0.001 <0.001 PASP (mmHg) 32 ± 13 37 ± 14 47 ± 11 <0.001 0.28 <0.001 0.002 PCWP (mmHg) 10 ± 6 14 ± 7 22 ± 5 <0.001 0.03 <0.001 <0.001 SVI(ml/m2) 43 ± 10 34 ± 6 30 ± 9 <0.001 <0.001 <0.001 0.15 PVR (Wood unit) 2.0 ± 1.1 2.0 ± 0.8 2.3 ± 1.1 0.29 - - - RVdA (cm2) 19 ± 3 22 ± 7 26 ± 7 0.003 0.16 <0.001 0.04 RVsax (mm) 23 ± 4 25 ± 8 34 ± 8 <0.001 0.42 <0.001 <0.001 TAPSE (mm) 21 ± 4 12 ± 3 12 ± 3 <0.001 <0.001 <0.001 0.98 TAPSm (cm/s) 11 ± 3 8 ± 2 8 ± 2 <0.001 <0.001 <0.001 0.55 RV-Str (%) -24 ± 5 -16 ± 5 -15 ± 5 <0.001 <0.001 <0.001 0.87 PASP, pulmonary systolic pressure; PCWP, pulmonary capillary wedge pressure; PVR, pulmonary vascular resistance; RVdA, RV diastolic area; RVsax, RV short axis diameter.

The echocardiographic impact of the systemic hypertension on the right ventricular: A Tunisian Cohort

Only few echocardiographic data are available in literature concerning the impact of the systemic hypertension on the right ventricle (RV) comparing to the left ventricle's impact. To describe the echocardiographic parameters concerning the impact of the systemic hypertension on the RV. Prospective and comparative study including 100 patients from June 2016 to June 2017, subdivided into two groups: Group A (50 patients, systemic hypertension) and group B (50 healthy patient, a control group). We compared the echocardiography parameters of the RV identified in both groups. The RV diameter, the RV ejection fraction (RVEF) and the right ventricular fractional area change (RV-FAC) were preserved and comparable in both groups. RV wall thickness was more increased in group A. The tricuspid annular plane systolic excursion (TAPSE) were comparable in both groups. TEI index was significantly higher ( P < 0.01) and the peak of systolic tricuspid annular motion velocity was significantly lower ( P < 0.01) in group A, reflecting the subclinical and asymptomatic RV systolic dysfunction. The RV global longitudinal strain (GLS-RV) was significantly lower in patient with hypertension. Tissue-Doppler and 2Dstrain were more reliable then RVEF, RV-FAC and TAPSE to determine a latent RV systolic dysfunction. The peak of Ea wave was significantly lower in group A and the peak of Aa wave was significantly higher in this group. The Ea/Aa ratio was lower in patient with hypertension ( P = 0.001) suggesting a RV diastolic dysfunction. Our study confirms that the impact of the systemic hypertension includes the RV as is well known about the LV. Therefore, the functional and morphological analysis of the RV must be evaluated during the regular echocardiographic follow-up of patients with hypertension to allow an early identification of subclinical systolic and diastolic RV dysfunction in order to revise the current therapeutic strategy.

Arterial stiffness in patients with interstitial lung diseases

The aim of this study was to investigate arterial wall stiffness and its relationship with right ventricle systolic function (RVSF) in patients with interstitial lung disease. Methods . Fifty patients with chronic hypersensitivity pneumonitis (HP) and 26 patients with idiopathic pulmonary fibrosis (IPF) were included. Spirometry, body plethysmography were performed, lung diffusion capacity for carbon monoxide (DLCO), blood gases and arterial wall stiffness were measured. High resolution computed tomography (HRCT) of the chest was assessed using Kazerooni scale. Results . The aortic pulse wave velocity (PWV, m/s) was increased in 26 (52%) patients with HP and in 14 patients with IPF. Correlation analysis showed statistically significant association between PWV А o and DLCO (p < 0.05), partial oxygen pressure in the arterial blood (PaO2) (p < 0.05), pulmonary fibrosis (p = 0.001), and the extension of ground glass opacities (p < 0.05). Tricuspid annual plane systolic excursion (TAPSE), right ventricular myocardial performance index (MPI) and tricuspid annular systolic velocity (S’) were significantly related to PWV А o, ambulatory arterial stiffness index (AASI) and augmentation index (AIx) (p < 0.05). Conclusion . Increased arterial stiffness was often found in patients with HP and IPF. The increased arterial stiffness is associated with hypoxemia, pulmonary fibrosis and decreased lung diffusion capacity. The arterial stiffness is also related to the right ventricular systolic dysfunction.

A Comparison of Transesophageal to Transthoracic Echocardiographic Measures of Right Ventricular Function

To assess the concordance between transesophageal echocardiographic (TEE) and transthoracic echocardiograpic (TTE) measures of right ventricular (RV) function using standard 2-dimensional and Doppler methods. The authors hypothesized that there would be significant disagreement in tricuspid annular plane systolic excursion (TAPSE), fractional area change, right-sided index of myocardial performance, and tricuspid annular systolic velocity (S'). Prospective observational. Cardiac operating room at a single academic medical center. All adult patients undergoing elective cardiac surgery at a single tertiary care academic medical center over 6 months. None. The fractional area change, S', TAPSE, right-sided index of myocardial performance, and tricuspid annular diameter were measured with TEE and TTE to assess for concordance using the concordance correlation coefficient and paired t tests, including 95% confidence limits. The study demonstrated that quantitative measures of RV function by TEE correlate poorly with TTE measurements in close temporal proximity under similar hemodynamic conditions. When performing an assessment of RV function, transesophageal echocardiographers should exercise caution when extrapolating data validated by TTE to TEE studies. Measures of RV function by TEE tend to have fair agreement to TTE measurements obtained in close temporal proximity under similar hemodynamic conditions. Most importantly, the present study showed that TAPSE and S' values obtained from the modified transgastric RV inflow view tend to have lower values than those measured with TTE. Given the propensity for underestimating measurements from the modified transgastric RV inflow view, the authors conclude that values equal to or greater than established norms for tricuspid annular motion may be used to establish normal-but not abnormal-RV function.

The evaluation of right ventricular systolic function in patients with repaired Tetralogy of Fallot by conventional echocardiographic methods and speckle tracking echocardiography: Compared with the gold standard cardiac mangenetic resonance

Right ventricular (RV) function is one of the important prognostic factors in patients with repaired Tetralogy of Fallot (TOF). We aimed to assess RV function by conventional echocardiography and two-dimensional speckle tracking echocardiography (2D-STE) in patients with repaired TOF. Twenty-seven (male 17) adolescents and young adult patients (mean age 22.7±6.7years) operated on for TOF and age- and gender-matched healthy controls were included. RV systolic function in both groups were evaluated by fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), RV myocardial performance index (RVMPI) and tricuspid annular peak systolic velocity by pulsed tissue Doppler (tricuspid S'), and also RV global longitudinal strain (RV GLS) obtained from STE. These results were compared with RV ejection fraction (RVEF) measured by cardiac magnetic resonance imaging (CMRI) performed within 3months in patient group. Systolic RVGLS values were significantly lower in patients compared to controls (-17.4±3.1% vs -25.6±3%). Among the echocardiographic parameters, RVGLS had the best correlation with RV EF derived from CMRI (r: -.6). By receiver operating characteristics analysis (ROC), an RV GLS cutoff value of -17.4% had 75% sensitivity and 68.4% specificity in identifying RVEF <45% with an area under curve 0.743 (P<.05). The intra- and inter-observer agreement for RV GLS was excellent. RVGLS is an easy, effective, feasible, and reproducible tool in the evaluation of RV systolic function. So, RVGLS measurement by STE may be one of the routine echocardiographic parameters in the evaluation of RV systolic function in patients with repaired TOF.

Effect of Transcatheter Aortic Valve Replacement on Right Ventricular–Pulmonary Artery Coupling

ObjectivesThe aim of this study was to test the hypothesis that the acute left ventricular (LV) unloading effect of transcatheter aortic valve replacement (TAVR) would improve right ventricular (RV) function and RV–pulmonary artery (PA) coupling in patients with severe aortic stenosis (AS). BackgroundRV dysfunction is an ominous prognostic marker in patients undergoing TAVR, suggesting that relief of obstruction might be less beneficial in this cohort. However, the left ventricle and right ventricle influence each other through ventricular interaction, which could lead to improved RV function through LV unloading. MethodsProspective invasive hemodynamic measurements with simultaneous echocardiography were performed in symptomatic patients with severe AS before and immediately after TAVR. ResultsForty-four patients (mean age 81 ± 8 years, 27% women) with severe AS underwent TAVR. At baseline, right atrial, PA mean (27 ± 7 mm Hg), and pulmonary capillary wedge (16 ± 4 mm Hg) pressures were mildly elevated, with a low normal cardiac index (2.3 l/min/m2). Pulmonary vascular resistance was mildly elevated (222 ± 133 dynes · s/cm5) and PA compliance mildly reduced (3.4 ± 01.4 ml/mm Hg). Following TAVR, aortic valve area increased (from 0.8 ± 0.3 to 2.7 ± 1.1 cm2; p < 0.001) with a reduction in mean aortic gradient (from 37 ± 11 to 7 ± 4 mm Hg; p < 0.001) and an increase in cardiac index (from 2.3 ± 0.5 to 2.5 ± 0.6 l/min/m2; p = 0.03). LV stroke work, end-systolic wall stress, and systolic ejection period decreased by 23% to 27% (p < 0.001 for all), indicating substantial LV unloading. RV stroke work (from 16 ± 7 to 18 ± 7 mm Hg · ml; p = 0.04) and tricuspid annular systolic velocities (from 9.5 ± 2.0 to 10.4 ± 3.5 cm/s; p = 0.01) increased, along with a decrease in PVR (194 ± 113 dynes · s/cm5; p = 0.03), indicating improvement in RV-PA coupling. Increased RV stroke work following TAVR directly correlated with the magnitude of increase in aortic valve area (r = 0.58; p < 0.001). ConclusionsAcute relief in obstruction to LV ejection with TAVR is associated with improvements in RV function and RV-PA coupling. These findings provide new insights into the potential benefits of LV unloading with TAVR on RV dysfunction in patients with severe AS.

P2471Adaptation of ventricular function the first year after heart transplantation assessed with echocardiography

Abstract Background/Introduction Echocardiography is commonly used in evaluation patients after heart transplantation (HTx). Detecting discrete changes in ventricular function is important but challenging using standard echocardiographic parameters. Furthermore, interpretation of findings are complicated by the fact that data on early possible adaptation is sparse. Purpose We sought to detect alterations in biventricular function primarily using speckle tracking derived strain at four time-points during the first year post HTx. Methods Fifty HTx patients (40 males, mean age 50±12 years) were prospectively included. Patients were examined 1, 3, 6 and 12 months after HTx using an iE33 platform with a S5–1 transducer and strain analysis was performed offline with a dedicated software: CMQ, Q-lab 10.3 (Philips Healthcare, Eindhoven, NL). Values were compared using paired t-test and expressed as mean±SD, 95% CI. Results Regarding left ventricular (LV) parameters no difference were detected between 1 and 12 months. LV ejection fraction (EF) was 58±5% vs. 58±7%, global longitudinal strain (GLS) was −15±5% vs. −16±4% and global circumferential strain (GCS) was −22±7% vs. −21±6% respectively. Conventional parameters of right ventricular (RV) function: Tricuspid annular plane systolic excursion (TAPSE) improved from 12±2 mm at 1 month to 15±5 mm (p&lt;0.01) at 12 months and tricuspid annular systolic velocity (S') improved from 8.1±1.9 cm/s to 9.5±2.7 cm/s (p&lt;0.01) at 12 months. Fractional area change (FAC) remained unaltered. Strain measurements of RV function improved gradually between 1 and 12 months. RV GLS was −15±3% vs. −17±3% (p&lt;0.01) and strain for the RV lateral wall (RVfree) was −15±3% vs. −18±3% (p&lt;0.001) respectively. Progressive improvement in RV strain is illustrated in Fig 1. Right ventricular strain post HTx Conclusion Our data indicate that clinically stable HTx recipients have reached steady state regarding LV function already 1 month after transplantation. This suggests that alterations in LV function parameters after this time-point can be used to detect adverse events. On the contrary, right ventricular longitudinal function show significant gradual improvement during the first year following HTx indicating that the RV adaptation-process is extended in comparison to the LV. We found that measurements of LV function at 1 month and RV function at 12 months post HTx are comparable to previously published normal values in clinically stable HTx patients. Nevertheless, further studies addressing possible continuous improvement in RV function beyond 1 year post HTx would be of interest.

P1678Feasibility of comprehensive multi-plane echocardiographic evaluation of right ventricular function pre-LVAD implantation - preliminary results from a single centre experience

Abstract Introduction Right sided heart failure (RVF) is recognized as a major cause of morbidity and mortality after left ventricular assist device (LVAD) implantation. Despite the publication of several risk scores and predication models, identifying patients at risk for RVF after LVAD implantation remains a challenge. The right ventricle is complex in structure and not possible to fully assess from one echocardiographic 2D plane. Our centre previously introduced a novel multi-plane approach whereby four different RV free wall segments (lateral, anterior, inferior and inferior coronal – figure 1) can be imaged from the same echocardiographic position using electronic plane rotation. Purpose The aim of the study was to determine the feasibility of using multi-plane echocardiography to quantify right ventricular function in a small cohort of advanced heart failure patients prior to LVAD implantation. Methods Twelve advanced heart failure patients underwent detailed RV assessment by multi-plane echocardiography prior to LVAD implantation (median -15 [6.3–29.8] days before). Feasibility and values of the established RV functional echo parameters tricuspid annular plane systolic excursion (TAPSE) and tissue Doppler imaging derived tricuspid annular peak systolic velocity (TDI S') were assessed by an experienced sonographer on each of the 4 free wall segments. Mean values were calculated from an average of 3 measurements. Conventional 2D echo parameters and clinical outcome data post LVAD implantation were also collected. Results Feasibility of TAPSE and TDI measurements in all four RV free wall segments was 100%, with the exception of the inferior coronal wall (91.7% – TDI S' only). Mean 4 wall averaged TAPSE was 13.9±5.1mm, whilst mean TDI S' was 9.4±2.6cm/s. Mean TAPSE and TDI values were lower in the inferior and inferior coronal walls (13.3±5.8mm; 8.8±3.1cm/s and 10.9±5.7mm; 8.9±3.7cm/s) than those of the lateral and anterior walls (15.6±5.1mm; 9.9±2.3cm/s and 15.9±5.1mm; 10.1±2.6cm/s). The cohort was split by using a four wall averaged TAPSE value of 16mm as a cutoff. Mean 4 wall averaged TAPSE was 20.6±1.9mm in the &gt;16mm group compared to 10.5±1.7mm for the &lt;16mm group, whilst mean TDI S' was 9.4±2.6cm/s vs 7.7±0.7cm/s. Post LVAD implantation, there were 3 (25%) deaths and 6 (50%) incidences of acute kidney injury. Median length of stay in ICU and hospital was 4 (1–13.5) and 42.5 (30.3–65) days respectively. The &lt;16mm group had higher incidences of negative outcomes and longer stay in both ICU and hospital following LVAD implantation (p: 0.07). Conclusion Multi-plane echocardiographic evaluation of the right ventricle appears feasible in advanced heart failure with potential for a more comprehensive quantification of right ventricular function pre-LVAD implantation. Larger, ideally multi-centre studies are required to further assess these preliminary findings.

P3553Right ventricular echocardiographic composite parameters in predicting major adverse cardiac events in patients with heart failure with reduced ejection fraction

Abstract Background Echocardiography assessment of right ventricle still play an indispensable role in diagnosis, decision-making for further therapy and risk assessment of patients with heart failure with reduced ejection fraction (HFrEF). Aims Our objective was to compare the predictive value of five composite echo parameters of right ventricle (RV) in decompensated patients with HFrEF. Methods and results A total of 191 NYHA III-IV patients admitted for decompensation of advanced HFrEF (EF=25.53±6,87%) were prospectively enrolled. During the follow-up period mean period of 340±84 days, 111 (58.1%) patients met the primary composite endpoint (MACE) of cardiac death, rehospitalization due to repeated decompensation, malignant rhythm disorders, heart attack or stroke. The average time of MACE occurrence was 110.5±98.7 days. Among group of patients with MACE, during the follow-up, there were 34 (30.6%) cardiac related deaths. Re-hospitalization due to cardiovascular causes had 77 patients (69.4%). The study was performed at our hospital between June 2016 and January 2018. Patients were assessed for the following combined echo parameters: (i) relationship of right and left ventricle basal diameter (RVb/LVb x0,1); (ii) relationship of tricuspid annular plane systolic excursion and right ventricle systolic pressure (TAPSE/RVSP mm/mmHg); (iii) relationship of tricuspid annular systolic velocity and right ventricle systolic pressure (TAs'x100/ RVSP cm/s/mmHg); (iv) product of tricuspid annular systolic velocity and pulmonic valve acceleration time (TAs'x PVAcT (cm/s2 x 1000)); (v) product of systolic and diastolic velocity of tricuspid annulus (TAs xTAe). The last three parameters were result of this study and were not mentioned in earlier researches. In this study, univariat analysis of combined RV echo parameters, TAPSE/RVSP, TAs'x100 /RVSP as well as TAs'xPVAcT have been shown to be highly significant predictors of MACE, p=0.001. The TAs'xTAe' product has been also distinguished as a significant predictor of MACE, p=0.04, as well as the ratio RVb/LVb x 0.1, p=0.007. Multivariate analysis of these five combined RV echo parameters shows that significant independent predictor of MACE turned out to be TAs'x100/RVSP (p&lt;0.001, HR = 0.668 (0.531–0.840)). Obtained by reconstruction of the ROC curve (Area = 0.70 (95% CI 0.59–0.75); p&lt;0.001, we have got cut off value of TAs'x100/RVSP = 1.92 (cm/s/mmHg). Kaplan-Meier curves were constructed by comparing the time to the occurrence of MACE. Patients with TAs'x100/RVSP ≤1.92 (cm/s/mmHg) have a significantly worse prognosis (Log Rank p&lt;0.001). Conclusion New variable TAs'x100/RVSP, derived from this research, proved to be the most powerful combined RV echo parameter, independent predictor of one year MACE, with a better predictive value compared to the already described combined parameters in the literature.

New Directions in Right Ventricular Assessment Using 3-Dimensional Echocardiography

ImportanceBefore the introduction of 3-dimensional echocardiography, estimations of right ventricular (RV) size and function by echocardiography were limited to regional approximations of global function. This review describes the novel application of 3-dimensional echocardiography in the assessment of RV size and function, in juxtaposition with what is currently available using 2-dimensional echocardiography.ObservationsTwo-dimensional echocardiographic evaluation of RV size and function includes measures of systolic basal longitudinal excursion (tricuspid annular plane systolic excursion and peak systolic velocity), fractional area change, and free-wall strain, all of which are measured from a single tomographic imaging plane: the RV-focused view. Given this limitation, clinical situations in which more accurate assessment of the RV or close patient follow-up were required were resolved with the use of cardiovascular magnetic resonance, computed tomography, and other modalities to obtain global measures of size and function (ie, volume and ejection fraction). With 3-dimensional echocardiography, both volume and ejection fraction assessments of the RV are possible with an accuracy and reproducibility close to that of cardiovascular magnetic resonance imaging. Further, 3-dimensional RV data sets can be cropped, sliced, and rotated to assess device leads, tricuspid valve leaflets, and RV wall–motion abnormalities. The 3-dimensional RV data set opens the horizon to endless possibilities for further exploration of novel parameters, including 3-dimensional RV shape and 3-dimensional RV deformation analysis.Conclusions and RelevanceThe use of 3-dimensional echocardiography overcomes many of the limitations associated with conventional 2-dimensional echocardiography and has the potential to provide the detailed information required for the complex clinical decision-making that requires accurate, quantitative information about the RV.

ST-Segment Elevation Myocardial Infarction in Patients With Chronic Obstructive Pulmonary Disease: Prognostic Implications of Right Ventricular Systolic Dysfunction as Assessed with Two-Dimensional Speckle-Tracking Echocardiography

Right ventricular (RV) systolic function in patients admitted with ST-segment elevation myocardial infarction (STEMI) with chronic obstructive pulmonary disease (COPD) and its impact on prognosis have not been characterized. The present study aims to compare the prevalence of RV systolic dysfunction in COPD versus non-COPD patients with STEMI and evaluate the prognostic implications. One hundred seventeen STEMI patients with COPD with transthoracic echocardiography performed within 48hours of admission were retrospectively selected. Matched on age, gender, and infarct size (determined by cardiac biomarkers and left ventricular ejection fraction [LVEF]), 207 non-COPD patients were selected. RV dysfunction was defined based on tricuspid annular plane systolic excursion <17mm (TAPSE), tricuspid annular systolic velocity <6cm/s (S'), RV fractional area change <35% (FAC), and RV longitudinal free wall strain (FWSL) measured with speckle-tracking echocardiography >-20%. Patients were followed for the occurrence of all-cause mortality. RV assessment was feasible in 112 COPD and 199 non-COPD patients (mean age, 69±10; 74% male; mean, LVEF 47%±8%). Patients with COPD had significantly lower RV FAC (38%±11% vs 40%±9%; P=.04), equal TAPSE and S' (17.9±3.7 vs 18.1±3.8mm, P=.72; and 8.4±2.2 vs 8.5±2.2cm/sec, P=.605, respectively) and more impaired RV FWSL (-21.1%±6.6% vs -23.4%±6.5%, P=.005), compared with patients without COPD. RV dysfunction was more prevalent in patients with COPD, particularly when assessed with RV FWSL (46% vs 32%; P=.021). During a median follow-up of 30 (interquartile range 1.5-44) months, 49 patients died (16%). Multivariate models stratified for COPD status showed that RV FWS >-20% was independently associated with 5-year all-cause mortality (hazard ratio, 2.05; 95% CI, 1.12-3.76; P=.020), after adjusting for age, diabetes, peak troponin level, and LVEF. Interestingly, RV FAC < 35%, S'< 6cm/sec, and TAPSE < 17mm were not independently associated with survival. In a STEMI population with relatively preserved LVEF, COPD patients had significantly worse RV FWSL compared with patients without COPD. Moreover, RV FWSL>-20% was independently associated with worse survival. In contrast, conventional parameters were not associated with survival.

Serial Changes in Right Ventricular Systolic Function Among Rejection-Free Children and Young Adults After Heart Transplantation

Evolution of right ventricular (RV) systolic function after pediatric heart transplantation (HT) has not been well described. We analyzed echocardiograms performed over the first year after HT among children and young adults who remained rejection-free. Ninety-six patients (median age 7.1 [0.1-24.4] years at HT) were included: 22 infants (≤1year) and 74 noninfants (>1year). Two-dimensional tricuspid annular plane systolic excursion (TAPSE), tissue Doppler-derived tricuspid annular systolic velocity (S'), fractional area change (FAC), myocardial performance index (MPI), and two-dimensional speckle-tracking-derived RV global longitudinal (GLS) and free wall strain (FWS) were assessed. All measures of RV function were impaired immediately after HT and significantly improved over the first year: TAPSE z-score (-8.15±1.88 to -3.94±1.65, P<.0001), S' z-score (-4.30±1.36 to -2.28±1.33, P<.0001), FAC (24.37%±7.71% to 42.02%±7.09%, P<.0001), MPI (0.96±0.47 to 0.41±0.22, P<.0001), GLS (-10.37%±3.86% to -21.05%±3.41%, P<.0001), and FWS (-11.2%±4.08% to -23.66%±4.13%, P<.0001). By 1year post-HT, TAPSE, S', GLS, and FWS, remained abnormal, whereas FAC and MPI nearly normalized. Patients transplanted during infancy demonstrated better recovery of RV systolic function. Although RV systolic function improved over the first year after HT in children and young adults without rejection, measures that assess longitudinal contractility remained abnormal at 1year post-HT. These findings contribute to our understanding of RV myocardial contractility after HT in children and young adultsand improve our ability to assess function quantitatively in this population.

Elevated plasma Pim‐1 and its clinical significance in patients with pulmonary arterial hypertension

This study was aimed to determine plasma Pim-1 levels in patients with pulmonary arterial hypertension (PAH) and to estimate the clinical value of Pim-1 as a biomarker of PAH. This was a single-centre retrospective study in 111 patients with congenital heart disease (CHD) and idiopathic PAH (IPAH). Those CHD patients were divided into two groups: PAH associated with CHD (PAH-CHD) and CHD without PAH (nPAH-CHD). Plasma Pim-1 levels were measured by enzyme-linked immunosorbent assay. (a) Plasma Pim-1 levels were significantly increased in patients with PAH-CHD and IPAH compared with the healthy control group (27.81±11.34ng/mL vs 13.02±5.30ng/mL; 32.81±12.28ng/mL vs 13.02±5.30ng/mL, P<0.05) and nPAH-CHD (27.81±11.34ng/mL vs 17.33±7.99ng/mL; 32.81±12.28ng/mL vs 17.33±7.99ng/mL, P<0.05). Pim-1 levels were substantially increased in patients with severe PAH-CHD compared with mild-to-moderate PAH-CHD (19.12±6.70ng/mL vs 8.54±3.71ng/mL, P<0.05). (b) Pim-1 levels were correlated positively with the mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR) (r=0.582, 0.516; P<0.001, respectively), while negatively with tricuspid annular plane systolic excursion (TAPSE), tricuspid annular plane systolic velocity (S') and right ventricular fractional area changes (RVFAC) (r=-0.375, -0.354, -0.507; P<0.05, respectively). (c) PAH-CHD and severe PAH-CHD was identified by plasma Pim-1 with a cutoff value of 16.8ng/mL (P<0.001) with a sensitivity of 87.3% and a specificity of 65%, and a cutoff value of 20.53ng/mL (P<0.001) with a sensitivity of 87.3% and a specificity of 52%, respectively. Plasma Pim-1 levels were significantly higher in patients with PAH-CHD and IPAH. Plasma Pim-1 may represent an effectively biomarker in patients with PAH.

Cardiac Doppler in patients with primary varicose veins of lower extremities.

This study examines the characteristics of cardiac Doppler in patients with primary varicose veins of lower extremities. We performed retrospective descriptive statistical analysis of cardiac Doppler data of 85 patients with primary varicose veins and compared obtained parameters with normal values. Patients with primary varicose veins in comparison with normal controls have significantly lower early diastolic mitral and tricuspid inflow velocities (E wave), significantly higher late diastolic mitral and tricuspid inflow and annular velocities (A and a' waves), significantly higher systolic mitral and tricuspid annular velocities (s' wave), and they have normal early diastolic mitral and tricuspid annular velocities (e' wave). Cardiac Doppler in patients with primary varicose veins differs significantly from the actual normal values. Possible mechanism of this finding is compensatory increased atrial ejection fraction due to altered preload in patients with primary varicose veins.

Echocardiographic Assessment of Right Ventricular Function in Clinically Well Pediatric Heart Transplantation Patients and Comparison With Normal Control Subjects

Echocardiographic follow-up after pediatric heart transplantation is important because of the lifelong risk for rejection and resultant ventricular dysfunction. Although adult studies have shown that echocardiographic measures of right ventricular function are changed after transplantation, similar results have not been reported in the pediatric population. A single-center retrospective study of echocardiograms obtained among pediatric heart transplant recipients was conducted. All echocardiograms were selected remote from transplantation, rejection, or graft vasculopathy. These criteria identified 127 patients. Right ventricular systolic function was measured using tricuspid annular plane systolic excursion, fractional area change (FAC), and peak systolic tricuspid annular tissue velocity (S'). Results were compared with those in 380 healthy age-matched echocardiographic control subjects. Tricuspid annular plane systolic excursion values in pediatric heart transplant recipients were significantly lower than in control subjects at all ages (P<.0001), with a mean Z score of -3.38. FAC and S' did not vary by age in control patients >6months of age. FAC values in transplantation patients were significantly decreased compared with those in control subjects (P<.0001), but 83% of transplantation patients had FAC values within the control-derived normal range. S' values were also significantly lower in transplantation patients than control subjects (P<.0001). Heart transplantation patients have significantly decreased quantitative metrics of right ventricular function relative to healthy control subjects; longitudinal shortening (tricuspid annular plane systolic excursion and S') is particularly affected. FAC is relatively preserved and may be a better metric in this population. These results establish nomograms of RV function in pediatric heart transplantation patients and in normal pediatric control subjects, which may allow quantification of changes in this vulnerable population.

Assessment of right ventricular systolic function in children with repaired tetralogy of Fallot by multiple-view from single acoustic window with speckle tracking echocardiography.

Challenges remain in quantitative evaluation of right ventricular (RV) function by echocardiography. Multiple-view assessment is believed to provide a more comprehensive quantification of RV function than conventional single-view analysis. Peak systolic longitudinal RV strain (RVLS) measured by speckle tracking echocardiography (STE) has clinical and prognostic value. No study has investigated RV systolic function in the repaired tetralogy of Fallot (rTOF) using a standardized four-view iRotate model from one apical view. Herein, we examined the feasibility and accuracy of the four-view analysis from apical window in quantitation of RVLS among children with rTOF. Thirty-seven children with rTOF and 37 age- and gender-matched controls were prospectively enrolled. Tricuspid annular plane systolic excursion (TAPSE) and tricuspid annular peak systolic velocity (TDI-S' ) and fractional area change(FAC) were obtained. RVLS of four free-walls were analyzed by dedicated RV speckle tracking software. Echocardiographic parameters were compared with the right ventricular ejection fraction (RVEF) measured by the cardiac magnetic resonance (CMR) in children with rTOF. Multi-view RVLS analysis from apical window was feasible in 35 children with rTOF and all the controls. Compared with age- and gender-matched controls, RVLS of the anterior, lateral, inferior-a, and inferior-b walls were significantly reduced in children with rTOF (P<0.001). RVLS of the anterior, lateral, inferior-a, and inferior-b walls correlated well with CMR-RVEF in children with rTOF (r=-0.667, -0.743, -0.808, -0.695, P<0.001). Multi-view analysis of RVLS from apical window can be applied to evaluate the RV function in children with rTOF. RVLS of the inferior wall-a in the aortic view is a novel and accurate indicator of RV function because of its good reproducibility and strong correlation with CMR-RVEF.

Troponin-I levels as a potential prognostic biomarker of sacubitril/valsartan treatment response in heart failure with reduced ejection fraction: Who will benefit most?

Despite robust data on the benefits of sacubitril/valsartan (LCZ696) in patients with chronic heart failure with reduced ejection fraction (HFrEF), there is no evidence yet on prespecified predictive markers of its efficacy. Hypothesis The objective of this study was to identify potential prognostic factors of LCZ696 treatment response. We included 48 symptomatic patients with chronic HFrEF (left ventricular ejection fraction ≤35%) and New York Heart Association (NYHA) class II/III: Group A (N = 23) received LCZ696 (105 ± 30 mg twice daily), whereas it was not prescribed in group B (N = 25) according to physician's judgment. Analysis of biochemical parameters, cardiopulmonary exercise testing, and echocardiographic evaluation was performed at baseline and 6 months later. The baseline serum troponin-I levels (TnI) and peak oxygen uptake (VO2 max) were positively associated with the increase in VO2 max (ΔVO2 max = +14.11%, P < 0.05 vs group B) after sacubitril/valsartan treatment (r = 0.68, P = 0.001 and r = 0.57, P = 0.004, respectively). Positive correlations were reported between ΔVO2 max and the improvements in the ratio of early diastolic filling to myocardial tissue velocity (ΔE/E') and the tricuspid annular peak systolic velocity (ΔSa) in group A (r = 0.58, P = 0.004 and r = 0.60, P = 0.002, respectively). In multiple regression analysis, ΔVO2 max was correlated significantly with TnI (beta = 0.35, P = 0.048), ΔE/E' (beta = 0.36, P = 0.031) and ΔSa (beta = 0.37, P = 0.035). TnI levels may be an independent predictive marker of sacubitril/valsartan efficacy in HFrEF.

17\u03b2-estradiol preserves right ventricular function in rats with pulmonary arterial hypertension: an echocardiographic and histochemical study

Pulmonary arterial hypertension (PAH) is more prevalent in females. Paradoxically, female patients have better right ventricular (RV) function and higher survival rates than males. However, the effects of 17β-estradiol (E2) on RV function in PAH has not been studied. Twenty-four male rats were exposed to monocrotaline (MCT) to induce experimental PAH, while treated with E2 or vehicle respectively. Together with eight control rats, thirty-two rats were examined by echocardiography 4 weeks after drug administration. Echocardiographic measurement of RV function included: tricuspid annular plane systolic excursion (TAPSE), RV index of myocardial performance (RIMP), RV fractional area change (RVFAC) and tricuspid annular systolic velocity (s′). RV free wall longitudinal strain (RVLSFW) and RV longitudinal shortening fraction (RVLSF) were also used to quantify RV function. RV morphology was determined by echocardiographic and histological analysis. TAPSE, RVFAC and s′ were reduced, and RIMP was elevated in the MCT-treated group and vehicle-treated group, when compared with control group (P < 0.01). TAPSE, RVFAC and s′ in the E2 group were higher, while RIMP was lower than those in the MCT-treated group and vehicle-treated group (P < 0.01). Myocardial functional parameters (RVLSFW and RVLSF) were also higher in the E2 group. Enhanced serum E2 levels were closely correlated with the improvement in RV functional parameters and enhancement of serum BNP levels (P < 0.01 for all groups). RV function decreased significantly in male rats with MCT-induced PAH, while E2 exhibited a protective effect on RV function, suggesting that E2 is a critical modulator of sex differences in PAH.

Pilot study shows right ventricular diastolic function impairment in young children with obstructive respiratory disease.

This study determined cardiovascular impairment in young children with obstructive respiratory disease who were assessed using the opening interrupter technique (RINT). This pilot study enrolled 41 children who had been referred to pulmonology and allergology specialists at the University of Catania, Italy, from March to July 2017: 23 (mean age 4.13±0.62years) had chronic coughs and wheezing and 18 controls (mean age 4.27±0.66years) had obstructive chest disease, but were otherwise healthy. Airway resistance was evaluated using RINT and cardiac function by studying the ejection fraction, pulmonary artery systolic pressure (PASP), tricuspid annular plane systolic excursion and tricuspid flow propagation velocity (TFPV). The RINT and PASP values were significantly higher in the patient group when compared to the controls, but the TFPV values were lower. A direct and significant Spearman's correlation coefficient (r) between RINT and PASP values was observed (r=0.81). We found a significant inverse correlation between RINT and TFPV (r=-0.83), as well as TFPV and PASP (r=-0.78). This study showed that children with obstructive respiratory diseases had a major risk of cardiovascular impairment. Impaired diastolic function of the right ventricle occurred very early when airway resistance was abnormally increased.

INFERIOR VENA CAVA DILATATION PREDICTS GLOBAL CARDIAC DYSFUNCTION IN ARDS: A STRAIN ECHOCARDIOGRAPHIC STUDY

SESSION TITLE: Cardiovascular Disease SESSION TYPE: Original Investigations PRESENTED ON: 10/09/2018 02:30 PM - 03:30 PM PURPOSE: The evaluation of the inferior vena cava (IVC) with ultrasound is frequently utilized to gauge intravascular volume in critically ill patients. The reliability of this technique has been questioned on mechanically ventilated patients, and specific data about its use in acute respiratory distress syndrome (ARDS) is practically nonexistent. We examined the utility of IVC diameter in the evaluation of cardiac and hemodynamic performances in patients with ARDS. METHODS: At a quaternary academic center, we did a retrospective cross-sectional analysis of Doppler Echocardiograms of ventilated patients with moderate-severe ARDS. Right ventricular(RV) fractional area change(RVFAC), tricuspid annular plane systolic excursion(TAPSE) and velocity(S'), and IVC diameter were estimated according to the American Society of Echocardiography guidelines. Using speckle tracking echocardiography, RV free wall(RVFWS), RV septal(RVSS) and RV Global longitudinal(RVGLS) strain were calculated. Left ventricular(LV) ejection fraction(LVEF) and LV diastolic function variables were also measured. Pertinent hemodynamic, ventilatory and laboratory data were collected. RESULTS: Fifty-one patients were included. A bimodal IVC classification method created two groups (IVC<2.1cm and IVC≥2.1cm). An IVC≥2.1cm was associated with lower systolic blood pressure (105±15 vs 124±8 mmHg, p:0.002), higher creatinine (1.4±0.6 vs 0.9±0.4 mg/dL, p:0.004), increased lactate (3.2±1.5 vs 1.8±1.2 mmol/L, p:0.002), higher incidence of shock (62% vs 30%, p:0.02), higher central venous pressure(CVP) (16±4 vs 10±4 mmHg, p:0.0001) and higher systolic pulmonary pressure. RVFAC, TAPSE, S', RVFWS and RVGLS (but not RVSS), were also depressed in this group. An IVC≥2.1cm was also associated with lower LVEF (55±12 vs 67±10%, p:0.01) and abnormal LV diastolic function. Positive correlations of RVFAC, TAPSE, S', RVFWS, RVSS and RVGLS with LVEF were observed. CVP and IVC negatively correlated with LVEF. Regression analysis demonstrated that the best predictor of IVC diameter was CVP (R2:0.35, p:0.001) and that the association RVSS+IVC diameter was a strong independent predictor of LVEF (R2:0.25, p:0.002). No significant differences in ventilatory parameters were observed. CONCLUSIONS: In patients with ARDS, an IVC≥2.1cm was independently associated with worse biventricular cardiac function and more abnormal hemodynamic performance. The biventricular interaction of a functionally impaired RV with the LV only partially explained our observations. The role of systemic negative inotropic factors (i.e., inflammatory response mediators) should be considered. CLINICAL IMPLICATIONS: The hemodynamic management of ARDS patients is extremely challenging. Our study suggests that in moderate-severe ARDS, an IVC≥2.1cm is strongly associated with poor global hemodynamic performance and should signal intensivists the potential necessity for a better hemodynamic optimization. DISCLOSURES: No relevant relationships by Romel Garcia-Montilla, source=Web Response No relevant relationships by Stephen Heitner, source=Web Response No relevant relationships by Faryal Imam, source=Web Response Study PI relationship with United Therapeutics Please note: $20001 - $100000 Added 11/29/2017 by Akram Khan, source=Web Response, value=Grant/Research Support study PI relationship with AstraZeneca Please note: $20001 - $100000 Added 11/29/2017 by Akram Khan, source=Web Response, value=Grant/Research Support Study PI relationship with Glaxo SmithKline Please note: $20001 - $100000 Added 11/29/2017 by Akram Khan, source=Web Response, value=Grant/Research Support Study PI relationship with Actelion pharmaceuticals Please note: $20001 - $100000 Added 11/29/2017 by Akram Khan, source=Web Response, value=Grant/Research Support Study PI relationship with National Institute of Health Please note: >$100000 Added 11/29/2017 by Akram Khan, source=Web Response, value=Grant/Research Support Removed 11/29/2017 by Akram Khan, source=Web Response Study PI relationship with Intermune Please note: $20001 - $100000 Added 11/29/2017 by Akram Khan, source=Web Response, value=Grant/Research Support Study PI relationship with Lung LLC Please note: $20001 - $100000 Added 11/29/2017 by Akram Khan, source=Web Response, value=Grant/Research Support Research Grant relationship with Actelion pharmaceuticals Please note: $20001 - $100000 Added 03/02/2018 by Akram Khan, source=Web Response, value=Grant/Research Support Research Grant relationship with AstraZeneca Please note: $20001 - $100000 Added 03/02/2018 by Akram Khan, source=Web Response, value=Grant/Research Support Research Grant relationship with Bristol-Myers Squibb Please note: $5001 - $20000 Added 03/02/2018 by Akram Khan, source=Web Response, value=Grant/Research Support Research Grant relationship with EMD Serono Please note: $5001 - $20000 Added 03/02/2018 by Akram Khan, source=Web Response, value=Grant/Research Support Research Grant relationship with Genentech Please note: $5001 - $20000 Added 03/02/2018 by Akram Khan, source=Web Response, value=Grant/Research Support Research Grant relationship with Glaxo SmithKline Please note: $20001 - $100000 Added 03/02/2018 by Akram Khan, source=Web Response, value=Grant/Research Support Research Grant relationship with Intermune Please note: $20001 - $100000 Added 03/02/2018 by Akram Khan, source=Web Response, value=Grant/Research Support Research Grant relationship with United Therapeutics Please note: >$100000 Added 03/02/2018 by Akram Khan, source=Web Response, value=Grant/Research Support No relevant relationships by Mi Miao, source=Web Response No relevant relationships by Srini Mukundan, source=Web Response No relevant relationships by Kathryn Stinson, source=Web Response