Tricuspid Annular Plane Systolic Excursion Research Articles

Right ventricular-pulmonary artery coupling assessed by two-dimensional strain predicts in- hospital complications in takotsubo syndrome

Abstract Background and purpose Takotsubo syndrome (TTS) may lead to serious in-hospital complications. Our study aims to investigate the prognostic impact of right ventricular-to-pulmonary artery (RV-PA) coupling in patients with TTS. Methods Consecutive TTS patients were prospectively enrolled. RV function was evaluated by RV global longitudinal strain (RVGLS) and RV free wall strain (RVFWS) and RV-PA coupling was measured as the ratio of either tricuspid annular plane systolic excursion (TAPSE), RVGLS or RVFWS to pulmonary artery systolic pressure (PASP). Data about in-hospital complications (defined as acute heart failure, life-threatening arrhythmias and death from any cause) were collected. Results A total of 80 patients were analysed (71±11 years, female 77.5%) and in-hospital complications occurred in 33 (41%). Patients who experienced in-hospital complications had lower LV ejection fraction (LVEF), lower TAPSE/PASP, RVFWS/PASP and RVGLS/PASP and higher left atrial volume indexed (LAVi) values. LVEF (OR 0.913, 95% CI [0.858–0.971], p=0.004) and RVGLS/PASP (OR 0.098, 95% CI [0.012–0.788], p= 0.029) were independent predictors of in-hospital complications. Receiver operating characteristics (ROC) curve analysis showed an area under the curve (AUC) of 0.696 (95% CI [0.57–0.82], p= 0.002) of RVGLS/PASP for the prediction of in-hospital complications. A cut-off value of RVGLS/PASP of ≤ 0.48 %/mmHg showed a sensitivity and specificity of 75% and 60%, and allowed to identify 24% of patients who experienced in-hospital complications despite a preserved LVEF (≥50%). Conclusion RV-PA coupling assessed by RVGLS/PASP may help identifying TTS patients at higher risk of cardiovascular complications with an additional prognostic value to LVEF alone.

Advanced versus conventional echocardiographic parameters of right ventricular-arterial coupling in heart failure

Abstract Background Right ventricular-arterial coupling (RVAC) is an important predictor of prognosis in heart failure (HF). Several echocardiographic RVAC parameters have been described. However, which one best reflects patient’s prognosis is still matter of debate. Purpose The aim of this study was to compare the predictive value of RVAC parameters derived from advanced echocardiography with that obtained from conventional echocardiography in HF patients. Methods Consecutive patients with stable HF and left ventricular (LV) systolic dysfunction (LVEF<50%, n=193) were studied by echocardiography. RVAC was assessed by tricuspid annular plane systolic excursion (TAPSE)/pulmonary artery systolic pressure (PASP), tissue Doppler imaging Sm velocity (TDI Sm)/PASP, RV free wall longitudinal strain (RVFWLS)/PASP and tridimensional RVEF (3D-RVEF)/PASP. Primary composite endpoint was all-cause death/HF hospitalization. Results After a median follow-up time of 16.3 months, the endpoint occurred in 45 patients. At univariable analysis, all RVAC parameters were significantly associated with the outcome [TAPSE/PASP: HR 0.31 (95% CI 0.17-0.55), P<0.001; TDI Sm/PASP: HR 0.27 (95% CI 0.15-0.49), P<0.001; RVFWLS/PASP: HR 0.19 (95% CI 0.10-0.36), P<0.001; 3D-RVEF/PASP: HR 0.30 (95% CI 0.17-0.55), P<0.001; figure 1]. At multivariable analysis, after adjustment for MAGGIC risk score and NT-proBNP, TAPSE/PASP [HR 0.71 (95% CI 0.38-1.35), P = NS] and TDI Sm/PASP [HR 0.59 (95% CI 0.31-1.10), P = NS] were no longer statistically associated with the endpoint; however, both RVFWLS/PASP [HR 0.36 (95% CI 0.18-0.70), P < 0.01] and 3D-RVEF/PASP [HR 0.55 (95% CI 0.31-0.99), P < 0.05] maintained their prognostic value (figure 2). Conclusions Advanced RVAC echocardiographic parameters (RVFWLS/PASP and 3D-RVEF/PASP) are superior predictors of prognosis than those derived from conventional echocardiography (TAPSE/PASP and TDI Sm/PASP) in a contemporary cohort of HF patients with left ventricular systolic dysfunction.Figure 1Figure 2

TAPSE/sPAP by echocardiography to detect elevated pulmonary vascular resistance> 4 WU in postcapillary pulmonary hypertension patients: insights from the French PH HF registry

Abstract Background Post-capillary pulmonary hypertension (pcPH) lacks effective treatment options. Patients with a PVR > 4 WU, known as combined pcPH (cpcPH), may benefit from investigational drugs like sotatercept. Identifying cpcPH patients suitable for vasodilation therapy in echocardiography labs is critical. Purpose To pinpoint an echocardiographic parameter capable of detecting cpcPH patients with a PVR above 4WU, addressing a common challenge in clinical practice. Methods In this study, 225 participants from the French PH-HF registry, all diagnosed with heart failure and a preserved ejection fraction, were examined. These patients underwent right heart catheterization and got ultrasound examinations within a 24-hour timeframe. The pulmonary vascular resistance were calculated using previously established methods, and data from standard echocardiography, including assessments of diastolic function, were gathered. Results 69 patients exhibited a pulmonary vascular resistance (PVR) greater than 4 WU, while 156 patients had a PVR ≤ 4 WU. Age averaged 69±12 years. Mean pulmonary artery pressure, wedge pressure, cardiac output, and pulmonary vascular resistance were 39±9 mm Hg, 22±4 mm Hg, 5.1±1.7 l/min, and 3.5±2.0 WU, respectively. Comparative analysis between patients with PVR ≤ 4 WU and those with PVR > 4 WU revealed similar ejection fraction (EF), left atrial volume index, and E/A ratio by echocardiography (p=0.97, p=0.69, p=0.43, respectively). However, patients with PVR > 4 WU showed elevated E/e’ (p=0.008), higher systolic pulmonary artery pressure (sPAP, p=0.001), but reduced myocardial S and e’ tissue Doppler velocities (p=0.001) and tricuspid annular plane systolic excursion (TAPSE) (p=10^-5). Notably, the relationship between TAPSE/sPAP and PVR > 4 was curvilinear and strong (p=0.001, FIG 1). Using ROC curve analysis, patients with TAPSE/sPAP < 0.38 mm/mmHg were identified to have PVR > 4 WU with a sensitivity and specificity of 68%. Conclusion Within the scope of postcapillary pulmonary hypertension, right ventricular arterial coupling is a simple ultrasound parameter potentially effective in identifying individuals exhbiting PVR > 4 WU with a good sensitivityFigure 1:PRV and coupling plotFigure 2:RV coupling ROC

Chronic inflammation is associated with impaired cardiac structure and function in patients with inflammatory arthritis: the ARTCADIA Study

Abstract Background Inflammation as an underlying cause of cardiac dysfunction has been underscored in recent years. Patients with inflammatory arthritis (IA) are at risk of being exposed to a high degree of chronic and systemic inflammation. It is therefore important to investigate whether high inflammatory burden impacts cardiac structure and function in patients with IA. Purpose To examine the impact of long-term inflammation on measures of cardiac structure and function in individuals with rheumatoid arthritis (RA) and axial Spondyloarthritis (axSpA), collectively referred to as IA, in a large cohort. Methods In a prospective cohort study, outpatients with a diagnosis of IA were included over two years during their biannual rheumatological routine appointment. In total, 1,285 participants were included. Participants were evaluated at a cardiology research center where echocardiography was performed following a pre-defined protocol. To evaluate chronic inflammation, C-reactive protein (CRP) was averaged from clinical outpatient visits registered in a rheumatological database. Uni- and multivariable linear regressions were used to examine the relationship between echocardiographic measures and log-transformed CRP. Results Among the 1,285 participants, 903 (70%) were diagnosed with RA, 358 (28%) with axSpA, and 24 (2%) with other forms of IA. Mean age was 60 ± 13 years, 64% were female. The median number of outpatient visits was 30 (Interquartile range (IQR): 18 - 48), median disease duration was 12 (IQR: 6 - 20) years, and the median outpatient CRP was 5.7 (IQR: 3.7 – 9.8) mg/L. 519 (40%) patients had hypertension (HT), 113 (9%) diabetes mellitus (DM), 76 (5.9%) ischemic heart disease (IHD) and 35 (2.5%) heart failure (HF). Mean left ventricular (LV) ejection fraction was 54.6 ± 5.7%, mean numerical global longitudinal strain (GLS) was 17.8 ± 2.4%, mean LV mass index (LVMi) was 73 ± 18 g/m2 and mean tricuspid annular plane systolic excursion (TAPSE) was 2.5 ± 0.4 cm. In univariable analyses, higher levels of CRP were significantly associated with lower GLS, p < 0.001; higher E/e’, p = 0.001; higher LVMi, p < 0.001 and lower TAPSE, p = 0.005 (Figure). The associations remained significant after adjusting for clinical characteristics including disease duration, age, sex, blood pressure, body mass index, physical activity, pack-years of smoking, cholesterol, HT, DM, heart rate, atrial fibrillation, IHD and HF (p < 0.05 for all associations). We observed no significant interactions between the IA diagnosis and inflammation across the significant echocardiographic measures. Conclusion In a large cohort of patients with IA, increasing levels of chronic inflammation determined by outpatient CRP was associated with impaired measures of cardiac structure and function and remained significant after adjusting for clinical characteristics. The prognostic and clinical implication of these findings needs to be explored in future studies.Linear regression splines

Comparison of different non-invasive estimates of right ventriculo-arterial coupling as outcome predictors in dilated cardiomyopathy

Abstract Right ventriculo-arterial coupling (RVAC) has emerged as an outcome predictor in pulmonary hypertension, but its role in left-sided HF remains to be clarified. Different non-invasive estimates for RVAC have been proposed, but a direct comparison of their prognostic ability is lacking. We sought to evaluate RVAC non-invasively using five different methods in a cohort of patients with dilated cardiomyopathy (DCM) and to assess their prognostic role. We enrolled 121 consecutive patients with non-ischemic DCM in sinus rhythm, who underwent comprehensive echocardiography, including speckle-tracking and 3D analysis. They were prospectively followed for 19±11 months for a composite endpoint of death, nonfatal cardiac arrest and hospitalization. RVAC was measured using five non-invasive estimates: (1) as the tricuspid annular plane systolic excursion (TAPSE)/pulmonary artery systolic pressure (PASP) ratio; (2) as the right ventricular (RV) global longitudinal strain (RV-GLS)/PASP ratio; (3) as the longitudinal strain of the RV free wall (LS-RVFW)/PASP ratio; (4) as the 3D RV ejection fraction (RVEF)/PASP ratio; and (5) as the 3D RV stroke volume (SV)/3D RV end-systolic volume (ESV) ratio. Mean age in the study cohort was 59±14 years and the majority (74%) were men. 55 patients (46%) reached the endpoint: there were 27 deaths, 5 nonfatal cardiac arrests and 23 readmissions for heart failure. Patients with adverse outcome had lower TAPSE/PASP (0.42±0.23 vs. 0.62±0.33, p<0.001), lower RVEF/PASP (0.96±0.49 vs. 1.47±0.67, p<0.001), lower RV SV/ESV (0.57±0.20 vs. 0.93±0.29, p<0.001) and higher RV-GLS/PASP (-0.25±0.20 vs. -0.38±0.23, p=0.002) and LS-RVFW/PASP (-0.28±0.30 vs. -0.51±0.33, p<0.001), reflecting greater ventriculo-vascular decoupling. In univariate Cox regression, all three RVAC indices were outcome predictors: HR=0.09 [95% CI, 0.02-0.37], p=0.001 for TAPSE/PASP, HR=13.67 [95% CI, 2.77-67.48], p=0.001 for RV-GLS/PASP, HR=8.72 [95% CI, 3.24-23.45], p<0.001 for LS-RVFW/PASP, HR=0.27 [95% CI, 0.14-0.50], p<0.001 for RVEF/PASP, HR=0.004 [95% CI, 0.001-0.019], p<0.001 for RV SV/ESV. In ROC analysis, the SV/ESV ratio had the highest AUC (AUC=0.88, p<0.001), a value lower than 0.74 having 86% sensitivity and 77% specificity for event prediction. After adjustment for age, NYHA class, left ventricular ejection fraction, and maximal left atrial volume, all coupling indices remained independent predictors of outcome: HR=1.90 [95% CI, 1.01-3.57], p=0.047 for TAPSE/PASP, HR=2.15 [95% CI, 1.17-3.96], p=0.01 for RV-GLS/PASP, HR=2.48 [95% CI, 1.34-4.60], p=0.004 for LS-RVFW/PASP, HR=3.19 [95% CI, 1.19-8.52], p=0.02 for RVEF/PASP, HR=7.50 [95% CI, 3.47-16.22], p<0.001 for RV SV/ESV. In DCM, RVAC is significantly more impaired in patients with major adverse events. Non-invasive RVAC was an independent predictor of adverse outcome irrespective of the formula used for estimation, but 3D RV SV/ESV ratio had the greatest prognostic power.

Short-term effects on sacubitril/valsartan therapy on right ventricle work and mechanics in patients with heart failure and reduced ejection fraction

Abstract Introduction In previous studies, sacubitril/valsartan (ARNI) therapy has been shown to have a positive effect on right ventricle (RV) function and on systolic pulmonary artery pressure in addition to improvement of left ventricle (LV) function in patients with heart failure and reduced ejection fraction (HFrEF). Recently, it was shown that a short-term ARNI therapy compared to valsartan-only therapy led to reduced systemic blood pressure and LV mechanical work, contributing to reduced LV myocardial perfusion and oxygen consumption. Purpose This paper aimed to study the effect of short-term ARNI therapy on RV mechanics and work and pulmonary and LV filling pressures compared to valsartan-only therapy in patients with HFrEF. Methods The study was a phase IV, prospective, randomized, double-blind, parallel-group study in patients with NYHA class II–III heart failure and LV ejection fraction (LVEF) <= 35 %. During a 6-week run-in period, all patients received valsartan therapy, which was up-titrated to the highest tolerated dose level (80 mg bid or 160 mg bid) and then randomized to either valsartan or sacubitril/valsartan. Myocardial oxygen consumption, energetic efficiency of cardiac work, and cardiac and systemic hemodynamics were quantified using echocardiography and 11C-acetate PET before and after 6 weeks of therapy (on stable dose) in 55 patients. The analyses were done with ANCOVA adjusting for pre-randomization values. Results The RV myocardial resting perfusion (mean difference of 0.056 (95% CI, 0.02 to 0.109) ml/g/min, p = 0.041) and RV myocardial oxygen consumption (0.005 (0.001 to 0.010) 1/min, p = 0.015) were significantly lower in the ARNI group compared with the valsartan-only group. The left atrial end-diastolic volume indexed to body surface area (geometric mean difference of 1.071 (95% CI, 0 to 1.148) ml/m2, p = 0.048) and the ratio of early mitral inflow velocity to medial mitral annular early diastolic velocity (mean difference of 2.467 (95% CI, 0.096 to 4.838), p = 0.042) were also significantly lower in the ARNI group compared with the control group. There was no difference between the groups in peak systolic right ventricle to right atrial pressure gradient. Still, the tricuspid annular plane systolic excursion was significantly higher in the valsartan-only group compared with the ARNI group (0.221 (0.039 to 0.404) cm, p = 0.018). There was no difference in RV free wall strain, fractional area change or systolic excursion velocity between the treatment arms (p> 0.262). Conclusions In addition to our earlier findings, sacubitril when added to valsartan appears to reduce also right ventricle myocardial perfusion and oxygen consumption. There was also a reduction in left atrial end-diastolic volume and in early mitral inflow to medial mitral annular early diastolic velocity in the sacubitril/valsartan group as compared to the valsartan-only group, which suggest decreased LV filling pressure.

Changes and prognostic impact of right ventricular-to-pulmonary artery coupling after transcatheter aortic valve replacement

Abstract Background The ratio of tricuspid annular plane systolic excursion to systolic pulmonary artery pressure (TAPSE/sPAP), a good noninvasive approach for right ventricular to pulmonary artery (RV/PA) coupling, is of prognostic significance in many cardiovascular diseases. Yet, data regarding RV/PA coupling in transcatheter aortic valve replacement (TAVR) remain sparse. Aims: To assess the change in TAPSE/sPAP between pre- and post-TAVR as well as its long-term prognostic value. Methods: All patients who underwent TAVR for severe aortic stenosis between 2002 and 2022 at a university hospital, with an available TAPSE/sPAP assessed by echocardiography before and after procedure were included in this study. When available, TAPSE/sPAP was correlated with invasive right heart catheterization data. The primary endpoint was 5-years all-cause death or hospitalization for acute heart failure. C-tree analysis was used to find the best TAPSE/sPAP cut-off to be associated with the primary outcome. Results: Two hundred and sixty-nine patients were included in this analysis (median age 85 years, 57% women, 63% NYHA III-IV). Balloon expandable valves was implanted in 90% of cases. TAPSE/sPAP was significantly improved by TAVR (0.52 vs 0.58 mm/mmHg, p=0.02). The lower the TAPSE/sPAP, the higher the NYHA functional class (p=0.0017), the higher the NTproBNP level (p <0.001) and the higher the logistic EuroSCORE (p<0.001). TAPSE/sPAP had a good correlation with pulmonary artery elastance (r=-0.61, p<0.001). Using C-tree analysis, TAPSE/sPAP ≤0.55 mm/mmHg was the best cut-off associated with the primary outcome (p=0.002). In multivariable Cox regression analysis, TAPSE/sPAP remained independently associated with the primary outcome even after adjustment with echocardiography, comorbidities or logistic EuroSCORE (Table 1). Both from baseline and follow-up assessment, patients with TAPSE/sPAP ≤0.55 mm/mmHg had worse event-free survival (Figure 1A-B). Interestingly, change in TAPSE/sPAP provided important prognostic value (Figure 1C). Conclusion: This study emphasizes the prognostic value of TAPSE/sPAP in the field of TAVR and suggest considering RV/PA coupling assessment not only before or after procedure but also the change in TAPSE/sPAP to identify patients at higher risk of worse outcome.Table1.Multivariable Cox analysisFig1.Kaplan meier curves

Hemodynamic monitoring during weaning from mechanical ventilation in critically ill pediatric patients: a prospective observational study

BackgroundCardiovascular dysfunction is a significant factor contributing to weaning failure in mechanically ventilated children. Understanding the cardiopulmonary pathophysiological changes that occur during weaning is a prerequisite for the early recognition of weaning failure of cardiovascular origin. This study aimed to assess the effect of weaning trials on central hemodynamics and to identify the indices predictive of cardiac-related weaning failure.MethodsThis prospective observational study was conducted in the Pediatric Intensive Care Unit (PICU) and included mechanically ventilated patients aged between 2 and 30 months who were on minimal ventilatory settings and ready for weaning. Patients who were hemodynamically unstable, diagnosed with neuromuscular diseases, or diagnosed with cardiac diseases were excluded. Hemodynamic parameters were evaluated during weaning from ventilation via echocardiography and noninvasive cardiometry during pressure support (PS) ventilation and at the end of the spontaneous breathing trial (SBT).ResultsThe study included 50 patients, comprising 30 males (60%) and 20 females (40%) with ages ranging from 2 to 30 months. Echocardiography revealed a significant increase in the cardiac index (CI), tricuspid annular plane systolic excursion (TAPSE), and the E/A ratio at the end of SBT. Moreover, right ventricular systolic pressure (RVSP) significantly decreased. Noninvasive cardiometry revealed a significant increase in the index of contractility (ICON) and CI at the end of SBT (p-value = 0.023 and < 0.001, respectively). Of the 12 (25%) patients who failed their first extubation trial, they exhibited a significantly lower CI and TAPSE (p values = 0.001 and 0.001, respectively).ConclusionThis study identified that weaning from mechanical ventilation in children is associated with hemodynamic changes, which can impact weaning success and reveal potential ventricular dysfunction. Bedside echocardiography was found to detect cardiac dysfunctions during weaning, and noninvasive cardiometry was considered a reliable tool that supports echocardiography for detecting changing trends in CI in PICUs. However, accurate values should be confirmed by echocardiography.

Differential postnatal cardiovascular course of donor-recipient twins and associated pathophysiology-a cohort study.

Fetal echocardiography in twin to twin transfusion pregnancies treated with photocoagulation noted impaired cardiac function. Systematic information about cardiac structure or function and arterial distensibility after birth is not available. This study evaluated cardiovascular function and arterial dynamic properties in survivors of twin to twin transfusion syndrome. Eleven pairs of donor-recipient twins were compared with each other, and with 20 singletons of comparable gestational age. The twin cohort was born at 31.5±2 weeks gestational age; birthweights of donors-recipients were comparable (donors: 1358±421g vs recipients: 1617±460g, P=0.2). Significant inter-twin differences were noted for cardiac function parameters. Recipients had greater septal thickness (donors: 2.3±0.15 vs recipients: 2.7±0.36mm, P=0.01) and globularity (lower sphericity index [donors: 1.76±0.1 vs recipients: 1.62±0.12, P=0.009]). They also had lower cardiac function (tricuspid annular plane systolic excursion [donors: 4.6±0.5 vs recipients: 4.1±0.4mm, P=0.02) and right ventricular fractional area change [donors: 30±1 vs recipients: 27.7±1.3%, P=0.0001]). Comparing with singletons, differences were statistically more significant for recipients. Arterial distensibility however, was more affected in donors (higher arterial wall stiffness index [donors: 2.5±0.2 vs recipients: 2.2±0.2, P=0.008] and lower pulsatile diameter [donors: 51±5 vs recipients: 63±10 µm, P<0.0001). Comparing with singletons, the differences were statistically more significant for donors. Evaluation in the neonatal period noted that cardiac function and arterial distensibility is affected in TTTS twins. These cohorts will benefit from close postnatal follow up for resolution of cardiac and arterial impairments.

Right ventricular-pulmonary artery coupling for prognostication in acute pulmonary embolism.

Acute pulmonary embolism (PE) increases pulmonary pressure and impair right ventricular (RV) function. Echocardiographic investigation can quantify this mismatch as the tricuspid annular plane systolic excursion (TAPSE) to pulmonary arterial systolic pressure (PASP) ratio. The aim of the study was to investigate the prognostic capabilities of TAPSE/PASP ratio in patients with acute PE. We utilized the RIETE registry to analyze consecutive hemodynamically stable PE patients. We used multivariable logistic regression analyses to assess the association between the TAPSE/PASP ratio and 30-day all-cause mortality across the strata of European Society of Cardiology (ESC) risk categories. We included 4,478 patients, of whom 1,326 (30%) had low-risk, 2,425 (54%) intermediate-low risk, and 727 (16%) intermediate-high risk PE. Thirty-day mortality rates were 0.7%, 2.3% and 3.4%, respectively. Mean TAPSE/PASP ratio was 0.65±0.29 in low-risk patients, 0.46±0.30 in intermediate-low risk, and 0.33±0.19 in intermediate-high risk patients. In multivariable analyses, there was an inverse association between TAPSE/PASP ratio and 30-day mortality (adjusted OR 1.32 [95%CI 1.14-1.52] per 0.1 decrease in TAPSE/PASP). TAPSE/PASP ratio below optimal cut-points was associated with increased mortality in low- (<0.40, aOR: 5.88; 95%CI:1.63-21.2), intermediate-low (<0.43, aOR: 2.96; 95%CI:1.54-5.71) and intermediate-high risk patients (<0.34, aOR: 4.37; 95%CI:1.27-15.0). TAPSE/PASP <0.44 showed net reclassification improvement of 18.2% (95%CI:0.61-35.8) vs. RV/LV ratio >1, and 27.7% (95%CI:10.2-45.1) vs. ESC risk strata. Decreased TAPSE/PASP ratio was associated with increased mortality. The ratio may aid in clinical decision-making, particularly for intermediate-risk patients for whom the discriminatory capability of the current risk stratification tools is limited.

Safety and outcomes with use of FlowTriever for mechanical thrombectomy i n acute pulmonary embolism

Objectives: Mortality in the pulmonary embolism (PE) risk categories has historically been reported between 30% and 40% in high-risk and &lt;15% in intermediate-risk group. In those who survive, there is a high rate of morbidity with dyspnea and exercise intolerance. Advanced therapies with a favorable safety profile have the potential to improve outcomes. We present the largest single-center data set studied to-date for safety, mortality, and outcomes post-mechanical thrombectomy including functional assessment 3 months post-discharge. Material and Methods: We analyzed retrospective database of patients with PE undergoing catheter directed mechanical thrombectomy (CDMT). We report clinical characteristics and outcomes stratified by PE risk categories. Comparison in the groups has been made using analysis of variance method. Results: A total of 365 patients were evaluated in the CDMT group. Among these 81 (22%) presented with high-risk and 261 (71%) with intermediate-risk PE. The average age at diagnosis was 61 ± 17 years with male-to-female distribution ratio of 1.2. Most common risk factors being reduced mobility (18%), malignancy (15%), recent surgery (13%), and hormonal therapy (12%). Mortality within 30 days of PE diagnosis was 8.6% (7/81) in high-risk, 1.7% (4/230) in intermediate-high-risk groups. There were no deaths in intermediate-low and low-risk group post-CDMT. Before thrombectomy, 349 (95%) patients had right heart strain, 307 (84%) had elevated troponin, and 197 (54%) had elevated B-type natriuretic peptide. Post-procedure echocardiogram at 3 month revealed improvement in the right ventricular (RV) fractional area change (27.53 ± 10.38% to 39.73 ± 8.3%, P &lt; 0.01), tricuspid annular plane systolic excursion (10.9 ± 8.3 mm to 21.81 ± 4.75 mm), and RV systolic pressure (43.96 ± 14.48 mmHg to 28.47 ± 7.88 mmHg, P &lt; 0.01). At 3 months post-thrombectomy, the majority (74%) of the patients fell into non-to-negligible functional limitation. Conclusion: We present a descriptive analysis of outcomes including improved mortality, and functional assessment of patients undergoing CDMT.

Echocardiographic Assessment of Central Venous Pressure using Inferior Vena Cava Indices: An Estimate Guide for Right Atrial Pressure

Purpose: To assess the correlation between inferior vena cava echocardiographic indices and central venous pressure, right atrial pressure and thus to practice, assessment of inferior vena cava, as a guide for the status of right side of the heart. Materials and Methods: In this descriptive cross-sectional study, a total of (60) patients (males and females) with their age ranging between (18–80) years were admitted to the respiratory care unit. Echocardiographic assessment of inferior vena cava hemodynamics (IVC expiratory, IVC inspiratory diameters and IVC collapsibility index) were carried out. In addition to the standard echocardiography examination, right heart function measurements (Tricuspid Annular Plane Systolic Excursion and right atrial area), in spontaneously and mechanically ventilated, patients were done. Findings: Both IVCe and IVCi diameters showed strong negative correlation with collapsibility index, (r= -0.920 for IVCe and r= -0.964 for IVCi) (P&lt;0.001). There was a positive correlation between TAPSE and IVC-CI (r=0.857, P&lt;0.001). Moreover, RA area was negatively correlated with collapsibility index (r = -0.892, P &lt;0.001). IVC-CI in mechanically ventilated patients (40.11± 1.782) compared to spontaneous breathing (48.91± 1.811) (P &lt;0.001) Implications to Theory, Practice and Policy: There was a linear relationship of IVC collapsibility index with TAPSE but an inverse relation with RA area. Evaluation of IVC diameter and its collapsibility index was an easy and non-invasive method to estimate CVP and RAP and so evaluate right heart performance of critically ill patients. Its use is more helpful in patients who are spontaneously breathing than those who are mechanically ventilated. The study tried to find an estimate predictor of right atrial pressure.

Development of the Pulmonary Embolism Progression (PEP) score for predicting short-term clinical deterioration in intermediate-risk pulmonary embolism: a single-center retrospective study.

Accurate risk stratification in acute intermediate-risk pulmonary embolism (PE) is essential. Current prediction scores lack the ability to forecast impending clinical decline. The Pulmonary Embolism Progression (PEP) score aims to predict short-term clinical deterioration (respiratory failure or hemodynamic instability within 72h) in patients with intermediate-risk PE. This single-center retrospective cohort study analyzed patients with intermediate PE. The outcome of interest was respiratory failure or hemodynamic instability within 72h. A multivariate logistic regression identified five predictive variables for the final PEP score: use of > 4L/min of supplemental oxygen above baseline, lactate > 2.0 mmol/L, high-sensitivity cardiac troponin T (hs-cTnT) > 40 ng/L, tricuspid annular plane systolic excursion (TAPSE) < 13mm, and the combination of central and subsegmental clot. The derivation cohort included 117 patients, and the validation cohort included 70 patients. The area under the receiver operating characteristic (AUROC) curve for the derivation cohort was 0.8671 (95% CI: 0.7946, 0.9292), and for the validation cohort, it was 0.9264 (95% CI: 0.8680, 0.9847). A PEP score of 4 points yielded the highest combination of sensitivity (93%) and specificity (65%). Each incremental point increase in the PEP score raised the probability of clinical deterioration by a factor of 1.933. The PEP score is a reliable tool for predicting the likelihood of clinical deterioration in intermediate-risk PE patients within 72h, potentially aiding in timely clinical decision-making and improving patient outcomes.

Effective tricuspid regurgitation reduction is associated with renal improvement and reduced heart failure hospitalization

BackgroundSeveral studies have demonstrated an association between tricuspid regurgitation (TR) and organ dysfunction including hepatic and renal insufficiency. Improvement of liver function following transcatheter edge-to-edge repair (T-TEER) has already been linked to reduction of venous congestion due to TR reduction. This study analyzes whether TR-reduction using T-TEER is also associated with improved renal function.Methods and resultsThe TRIC-ULM registry includes 92 selected patients undergoing T-TEER between March 2017 and May 2023. Estimated glomerular filtration rate (eGFR) improvement was evident in 53 patients (57%) at 3-months follow-up (FU) and defined by FU eGFR &amp;gt; baseline eGFR. Median age was 80 [interquartile range 75–83] years, pre- and postinterventional TR grades were 4 [3–5] and 1 [1–2], baseline eGFR was 36 [30–53] ml/min and New Yeark Heart Association (NYHA) IV was evident in 15% of patients. Multiple logistic regression analysis revealed TR vena contracta reduction (Odds ratio (OR) 1.35 [95% CI: 1.12–1.64] per mm, p = 0.002) and reduced preinterventional tricuspid annular plane systolic excursion (TAPSE) [OR 0.89 (95% CI: 0.79–0.99) per mm, p = 0.033] to independently predict renal improvement at FU. An eGFR improvement threshold of &amp;gt;9 ml/min was associated with reduced 1-year heart failure hospitalization rates [adjusted hazard ratio 0.22 (95% CI: 0.07–0.62) p = 0.005].ConclusionEffective tricuspid edge-to-edge repair is associated with improved renal function and reduced heart failure hospitalization. In patients without renal improvement at 3-months follow-up, residual tricuspid regurgitation should be reevaluated for reintervention.

Tissue Doppler Right Ventricle Myocardial Performance Index (TDI RV-MPI) Versus Tricuspid Annular Plane Systolic Excursion (TAPSE) in Evaluation of RV dysfunction in Patients with or without LV dysfunction

Introduction: Cardiovascular disease remains a leading cause of death. Right ventricular (RV) function is a strong predictor of outcome in many cardiovascular diseases, but its significance is often neglected. It has often been coined “the forgotten chamber. RV dysfunction may be secondary to left ventricle (LV) dysfunction as a consequence of “Ventricular Interdependence”. As RV dysfunction is associated with high in-hospital morbidity and mortality, early reorganization of RV dysfunction is warranted; but until today it remains a challenging task because of complex structure and asymmetric shape of RV. Objective: Our objective was to compare the efficacy of Tissue Doppler Right Ventricle Myocardial Performance Index (TDI RV-MPI) with Tricuspid Annular Plane Systolic Excursion (TAPSE), as a predictor of RV Systolic dysfunction. Methods: This was a cross-sectional study in patients undergoing comprehensive Transthoracic Echocardiography for any indication. Our aim was to compare Tissue Doppler Right ventricle Myocardial Performance Index (TDI RV-MPI) with TAPSE to predict RV function in patients with or without LV dysfunction .The current study recruited 100 patients who presented to the Cardiology Clinic of Lab Aid Cardiac Hospital. In addition to calculation of conventional, quantitative LVEF done in 2D guided M-mode in Para-sternal long-axis view, RV function was assessed in all subjects by measurement of Tricuspid Annular Plane Systolic Excursion (TAPSE) &amp; Tissue Doppler RV Myocardial Performance Index (TDI RV-MPI). Both were compared in prediction of RV dysfunction in patients with or without LV systolic dysfunction Results: RV dysfunction was found in subjects with LV dysfunction by both TAPSE &amp; TDI RV -MPI. RV dysfunction increased with reducing left ventricular ejection fraction. Normal TAPSE (~24 mm) was evidence of normal TDI RV-MPI (0.2594±0.03269, P&lt;.001), consistent with normal RV function. Of note, reduced TAPSE (~12 mm) was at the same time was evidence of increased TDI RV-MPI (0.7550±0.06351, P&lt;.001), suggestive of RV dysfunction. Simultaneously normal LVEF (~ 55%) was evidence of normal TAPSE (22±1.582 mm, P&lt;.001) &amp; normal TDI RV-MPI (0.25±.0509, P&lt;.001). Reduced LVEF (~25%) was at the same time, evidence of reduced TAPSE (15.50±3.317 mm, P&lt;.001) &amp; increased TDI RV-MPI (0.66±.1150, P&lt;.001). A statistically significant negative correlation of TDI RV-MPI (r=-0.927) was observed with TAPSE (p&lt;0.001). Also statistically significant negative correlation of TDI RV-MPI (r=-0.798) and significant positive correlation of TAPSE (r=0.813) were observed with LVEF (p&lt;0.001). In the analysis TDI RV-MPI maintained significant correlation with both LVEF &amp; TAPSE. In linear regression analysis TAPSE &amp; LVEF were significant independent predictor of TDI RV-MPI. Most important determinants of TDI RV-MPI was TAPSE (R=0.927, p&lt;0.001) . Conclusion: This study demonstrated that in patients with LV dysfunction there was RV dysfunction due to ‘ventricular interdependence’ as detected by both TAPSE &amp; TDI RV-MPI. TDI RV-MPI is a simple, sensitive, reproducible, noninvasive, non-geometirc echocadiographic parameter to provide global assessment of systolic and diastolic function of RV. It has the ability to detect RV dysfunction at an early stage, so as to reduce morbidity and mortality in these patients. It is evident that TDI RV-MPI can be a surrogate of TAPSE even with superior efficacy in RV functional assessment maintaining close relation with LVEF. These observations could guide decision making in daily clinical practice. Bangladesh Crit Care J September 2024; 12 (2): 105-112

Assessment of fetal cardiac function in pregnant women with anemia: prospective case-control study.

To compare fetal cardiac function in pregnant women with iron deficiency anemia (IDA) vs healthy pregnant controls. This was a single-center, prospective, case-control study conducted in a tertiary hospital between November 2022 and September 2023. Women diagnosed with IDA who attended as outpatients at the pregnancy follow-up clinic at 30-34 weeks' gestation or who were hospitalized for intravenous iron treatment owing to profound anemia were included. The control group consisted of randomly selected gestational-age-matched pregnant women with no obstetric complications or comorbidities and who did not have anemia. Patients underwent two-dimensional imaging, followed by pulsed-wave Doppler and M-mode and tissue Doppler imaging (TDI) to evaluate fetal cardiac function. A fetal cardiac score was calculated using systolic, diastolic and global hemodynamic function parameters, and was compared between patients with IDA and those without. The fetal cardiac score was also assessed according to the severity of anemia in the IDA group. A total of 150 patients, comprising 50 patients with IDA and 100 healthy pregnant women at 30-34 weeks' gestation, were included in the study. Of the patients with IDA, 20 had mild, 18 had moderate and 12 had severe anemia. The fetal myocardial performance index and isovolumetric relaxation time were significantly higher in the IDA group compared with the control group (P < 0.0001 for both), while isovolumetric contraction time was similar. Among the fetal tricuspid and mitral valve diastolic parameters, the E, A and E/A values were significantly lower in the IDA group (P < 0.05 for all). Mitral (MAPSE) and tricuspid (TAPSE) annular plane systolic excursions were significantly lower in the IDA group (P < 0.05 for both). The IDA group also had significantly lower values for the TDI parameters mitral and tricuspid E', A', S' and E'/A' ratio and a significantly higher E/E' ratio (P < 0.05 for all). Among the IDA subgroups, a significant decrease was observed in the tricuspid and mitral A, E and E/A ratio in fetuses whose mothers had severe anemia (P = 0.001). M-mode Doppler analysis revealed significantly lower fetal TAPSE and MAPSE in the patient group with severe maternal anemia (P = 0.001 for both). According to the subgroup comparison of TDI findings, the fetuses of mothers with severe anemia had significantly lower tricuspid and mitral E', A', S' and E'/A' ratio values and a significantly higher E/E' ratio (P < 0.05 for all). The fetal cardiac score was significantly higher in the maternal IDA group compared with the control group (P < 0.001). A significant negative correlation was found between maternal hemoglobin level and fetal cardiac score (P < 0.001). We observed differences in fetal systolic and diastolic cardiac function in pregnancies with maternal IDA. Fetal cardiac function was affected more among patients with severe anemia. This study found an increased E/E' ratio in the fetuses of pregnant women with IDA, suggesting decreased fetal heart maturation. Prenatal fetal cardiac evaluation, especially in women with severe anemia, can facilitate a more seamless transition to the postnatal period for these newborns. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Ventricular Dysfunction in Patients With Congenital Diaphragmatic Hernia Who Die After Repair

BackgroundQuantitative echocardiographic (echo) measures of ventricular function predict mortality in pediatric pulmonary hypertension (PH), but studies in congenital diaphragmatic hernia (CDH)-related PH are limited. Few studies report quantitative echo data beyond the first week of life in CDH non-survivors. MethodsA single-center retrospective, cross-sectional, cohort study included CDH patients born between January 2013 and April 2022 who survived to surgical repair but died during the neonatal hospitalization. Quantitative measures of right (RV) and left ventricular (LV) size and function including tricuspid annular plane systolic excursion Z-score (TAPSEZ), RV fractional area change (FAC), RV/LV ratio, LV eccentricity index, LV M-mode dimensions, and RV/LV systolic strain were performed offline on the last echocardiogram before death. Data were compared between patients who died ≤30 days after repair (“early”) vs. >30 days after repair (“late”) using the Wilcoxon rank sum test. ResultsTwenty-five (11 early, 14 late) deceased patients had echo images available for analysis. LV size by end-diastolic dimension Z-score was smaller in patients who died early vs. late after repair [-3.03 (−3.93, −2.51) vs. −0.24 (−2.11, 0.53), p = 0.021]. There were trends toward worse RV function (TAPSEZ, RVFAC, RV global and free wall strain) and LV function (apical 4 chamber strain) in patients who died early vs. late after repair. ConclusionThese preliminary findings support future study of the impact of ventricular hypoplasia and dysfunction on mortality and opportunities for risk stratification based on quantitative echo findings in CDH. Level of EvidenceCohort study, 4.

Right ventricular-pulmonary artery uncoupling in patients with atrial fibrillation on peritoneal dialysis

Background Tricuspid annular plane systolic excursion (TAPSE)/pulmonary artery systolic pressure (PASP) as a noninvasively measured index of right ventricular-pulmonary artery uncoupling is associated with poor outcomes in heart failure patients. However, the relationship by which the TAPSE/PASP is linked to atrial fibrillation (AF) in peritoneal dialysis (PD) patients is not clear. We aimed to investigate the relationship between the TAPSE/PASP and AF in PD patients. Methods This study was divided into two parts. First, we included 329 PD patients. All the subjects provided detailed a medical history, laboratory analysis and transthoracic echocardiography on admission. We evaluated the differences in the TASPE/PASP ratios between the AF and non-AF groups. Second, a total of 121 patients were followed up to compare mortality between the AF and non-AF groups. Results Age, BNP, RDW, LA, and septal E/e’ were significantly higher, and TAPSE/PASP was significantly lower in patients with AF than in those without AF (p < 0.05). Moreover, the TAPSE/PASP was more pronounced in persistent AF patients. PD patients with AF had a greater risk of mortality (7.2%) than did those without AF (3.8%) after an average follow-up of 12 months. Kaplan–Meier analysis revealed that patients with TAPSE/PASP ratios ≤ 0.715 had a greater risk of mortality than did those with TAPSE/PASP ratios > 0.715. Conclusions The results suggested that the TAPSE/PASP was lower in AF patients than in non-AF patients. The TAPSE/PASP may be a useful factor for predicting mortality in AF patients with PD, but large-scale prospective studies are needed for verification.

Incidence of Right Ventricular Dysfunction in an Echocardiographic Referral Cohort.

Incidence rates (IRs) of RV dysfunction (RVD) are unknown. We examined the rates, risk factors, and heart failure (HF) hospitalization hazard associated with incident RVD in patients referred for Transthoracic Echocardiogram (TTE). In this retrospective cohort study, we extracted tricuspid regurgitant velocity (TRV) and tricuspid annular systolic plane excursion (TAPSE) from TTEs at Vanderbilt (2010-2023). We followed patients from their earliest TTE with normal RV function (TAPSE≥17mm) and a reported TRV. The primary outcome was new RVD (TAPSE<17mm), and the secondary outcome was HF hospitalization after second TTE. Poisson regression and multivariable cox models estimated IRs and hazard ratios, adjusted for demographics, comorbidities, and TTE measures. Among 45,753 patients (63 years [IQR 50-72], 45% Male, 13% Black) meeting inclusion criteria, 13,735 (30.1%) underwent a follow up TTE and 4,198 (9.2%) developed RVD. The IR of RVD in the full cohort was 3.2/100 person/years (95%CI 3.1-3.3) and 8.2 (95%CI 8.0-8.5) in the repeat TTE cohort. IRs increased with rising RVSP. Risk factors for incident RVD were most prominently HF (HR 1.88; 95%CI 1.75-2.03), left-sided valvular disease (HR 1.68; 95%CI 1.53-1.85), and other cardiovascular comorbidities. Baseline RVSP >35 mmHg associated with TAPSE decline over time. Incident RVD increased hazard of HF hospitalization (HR 2.02; 95%CI 1.85-2.21). Hazard of HF hospitalization increased when TAPSE declined by ≥5mm. RVD incidence is substantial among patients referred for TTE. Clinical monitoring is warranted if RVSP >35mmHg. Cardiovascular comorbidities drive RVD in this population. Incident RVD associates with increased hazard of HF hospitalization.

Patent Foramen Ovale and Oxygenation in Patients with Cystic Fibrosis.

Patent foramen ovale (PFO) affects about 25% of the population. We studied outcomes in cystic fibrosis (CF). We conducted a case-control study of patients with CF (PwCF) and age and sex-matched controls who underwent agitated saline contrast (bubble) echocardiography, 1998-2020. We assessed PFO impacts using linear, logistic, quasipoisson and proportional hazards models. 59 of 64 PwCF and 88 of 93 controls underwent bubble studies to investigate unexplained hypoxemia or dyspnea. PwCF had higher mean pulmonary artery pressure (PAP, 6.9 mm Hg, 95% Confidence Interval [CI] = 2.35-11.4), reduced tricuspid annular plane systolic excursion (TAPSE, -3.78 mm, CI = -5.64 to -1.93) and similar right ventricular diastolic sizes. Absent hypoxemia, PFO incidence was similar between PwCF and controls; with hypoxemia, PFO was more common in CF (Odds Ratio [OR] = 5.00, CI = 1.32-19.0). In CF, oxygen supplementation occurred at a percent predicted forced expiratory volume in 1 s (FEV1%) 22.5 points higher with PFO. Adjusted for FEV1%, PFO was associated with 0.59 more prior year pulmonary exacerbations (CI = 0.20-0.98) and shorter time to next exacerbation (Hazard Ratio = 1.86, CI = 1.06-3.26). Associations between PFO and hypoxemia or exacerbations were insensitive to PAP, TAPSE and CF transmembrane regulator protein modulator treatments. PFO was not associated with CF time to death or lung transplantation (median 1.87 years) adjusted for age, sex, FEV1% and prior year exacerbation counts. PFO in CF is associated with hypoxemia at higher FEV1% and more pulmonary exacerbations but not survival.