Peak Tricuspid Regurgitation Velocity Research Articles

Echocardiographic Predictors of Long-Term Mortality in Patients Presenting With Acute Pulmonary Embolism

Pulmonary embolism (PE) is associated with a high mortality; whether echocardiographic evaluation at presentation predicts long-term adverse outcomes is of importance. We sought to determine if a composite of routinely obtained echocardiographic parameters could determine long-term adverse events in PE patients. Right ventricular (RV) size and function and right atrial (RA) size were retrospectively evaluated in 233 consecutive PE patients with an inpatient echocardiogram, and compared with 70 healthy controls; mortality at 3 years was confirmed. PE patients had increased RV size (RV parasternal long-axis diameter [RVPLAX] and RV end-diastolic volume [p < 0.001 for both]) and RA area (p < 0.001). RV function was reduced in PE patients (RV fractional area change and RV ejection fraction [p <0.001 for both]). Peak tricuspid regurgitation (TR) velocity was higher in the PE group. At follow-up (3.0 ± 2.1 years), 61 patients died; multivariable analysis demonstrated RVPLAX diameter >37 mm (hazard ratio [HR] 2.3, 95% confidence interval [CI] 1.3 to 4.2; p = 0.005), RA area >20 cm2 (HR 2.0, 95% CI 1.1 to 3.5; p = 0.016), and TR velocity >2.9 ms-1 (HR 1.9, 95% CI 1.1 to 3.4; p = 0.021), were independent echocardiographic predictors of mortality. Patients with all 3 "risk markers" had ∼17-fold increased mortality compared with those with no "risk markers" (HR 16.9, 95% CI 6.1 to 47.2; p < 0.001). In conclusion, a composite of routinely collected echocardiographic parameters, namely an enlarged RA and RV (RVPLAX diameter), and TR velocity, were independent predictors of mortality in PE patients, with an exponential increase in mortality when all 3 parameters were significantly altered. Prospective validation is required to confirm these preliminary observations.

Correlation between changes in brain natriuretic peptide and echocardiographic features in persistent pulmonary hypertension of newborn

Objective: To investigate the correlation between changes in brain natriuretic peptide (BNP) and echocardiographic features in persistent pulmonary hypertension of newborn (PPHN).Patients and methods: A total of 76 patients with PPHN treated in our hospital from March 2017 to February 2018 were divided into mild group (n = 33), moderate group (n = 22) and severe group (n = 21) according to the pulmonary arterial systolic pressure, and they were compared with 30 normal newborns (control group) during the same period. All newborns underwent echocardiography, the BNP level was detected, and the correlation between echocardiographic features and BNP changes was analyzed.Results: The BNP level in control group was significantly lower than those in PPHN groups, and it was constantly increased from mild group to severe group (p<.05). There were no significant differences in left atrial diameter (LA) and left ventricular diameter (LV) among groups (p>.05), while there were significant differences in the right atrial diameter (RA), right ventricular diameter (RV) and peak velocity of tricuspid regurgitation (VTR) (p<.05). BNP had no correlations with LA and LV (p>.05), but had positive correlations with RA, RV and VTR (r = 0.527, 0.503 and 0.524, p<.05).Conclusion: The BNP level of patients with PPHN increases with the increasing severity of disease. BNP has close correlations with echocardiographic features of neonatal patients. Predicting the BNP changes via echocardiography is of certain value in guiding the clinical treatment.

Improvement of diastolic function in patients with heart failure and reduced ejection fraction treated by sacubitril/valsartan

Patients with heart failure and reduced ejection fraction (HF rEF) have a poor prognosis, even worse when diastolic dysfunction progresses. The purpose of our work was to evaluate the reversibility of diastolic dysfunction after sacubitril/valsartan administration in patients with HF REF. A total of 65 patients in NYHA functional class 2–3 and treated by ACE inhibitor or AAR2, were prospectively assigned to equimolar sacubitril/valsartan replacement. To classify diastolic dysfunction according to the ASE/EACVI guidelines published in 2016, transmitral E and A waves velocities, septal and lateral E’ tissue velocities, indexed left atrium volume and peak velocity of tricuspid regurgitation were collected. From multiparametric approach, patients were subsequently categorized as diastolic dysfunction grade 1, 2 or 3. Patients with atrial fibrillation or missing data have been classified as undetermined. Mean age was 61.6 ± 12.6 yo and 78.0% patients were males. Mean ejection fraction was 29.6 ± 7.17%. Overall, after 153.59 ± 115.25 days of treatment with sacubitril/valsartan, E/A ratio decreased from 1.9 ± 1.5 to 1.04 ± 0.72 ( P < 0.05), as well as E/Ea ratio from 2.04 ± 1.49 to 1.03 ± 0.74 ( P < 0.01), tricuspid regurgitation peak velocity from 2.95 ± 0.58 to 2.47 ± 0.54 m/s ( P < 0.01) and left atrial volume from 60.42 ± 25.81 to 44.72 ± 20.90ml/m 2 ( P < 0.05). Subsequently, both left ventricular diastolic function and filling pressure improved significantly ( P < 0.05, Fig. 1 ). In patients with heart failure and reduced ejection fraction, administration of sacubitril/valsartan was associated with improvement of diastolic dysfunction and filling pressure.

Specific treatment of pulmonary artery hypertension in Eisenmenger patients: About 4 cases

Eisenmenger's syndrome is defined by the appearance of cyanosis during the evolution of left-right shunts, due to a progressive alteration of the pulmonary arteriolar bed, leading to an increase in pulmonary vascular resistance. This evolution of the shunt towards a reaction of Eisenmenger, makes that its simple surgical closure becomes useless. The only surgical treatment is pulmonary transplantation, or cardiopulmonary transplantation. The interest of specific medical treatment of pulmonary arterial hypertension in Eisenmenger Syndrome remains controversial. Evaluate the impact of the specific treatment of PAH on Eisenmenger patients. We report the evolution over 1 year of 4 patients with congenital heart diseases in Eisenmenger. For each patient we evaluated NYHA functional class, 6 MWT, echocardiographic and hemodynamic parameters. Two of our patients had atrioventricular canal defect: – one complete; – the other partial; 2 patients with patent arterial duct. These patients were put under specific treatment of PAH: sildenafil + macitentan. Clinically, there was a slight improvement in the dyspnoea stage from stage III to II, with an average of 6MWT at 287 m. On the echocardiographic plan Peak tricuspid regurgitation velocity which averaged 4.59 m/s decreased to 3.5 m/s after one year of treatment with PASP by tricuspid regurgitation on average at 93 mmHg at the beginning of the treatment then at 70 mmHg at 1 year. Humodynamically, the PAPm (mmHg) were at 38 before specific treatment and decreased to 32 at the end of treatment, with a cardiac output that went from 2.3 to 2.5 l/min/m 2 , and an RVP of 7 to 5 wood units. We did not notice any complications and no deaths were reported. We noted that despite improved dyspnoea and quality of life in these patients, the prognosis of patients undergoing Eisenmenger treatment under PAH specific therapy remains reserved.

Diastolic Dysfunction and the New Recommendations for Echocardiographic Assessment of Left Ventricular Diastolic Function: Summary of Guidelines and Novelties in Diagnosis and Grading

Diastolic function represents the filling property of the heart during diastole. Diastole comprises four phases: isovolumic relaxation, rapid filling, slow filling (diastasis), and active filling. Diastolic function is correlated to heart rate, atrial systolic function, ventricular compliance, preload, heart rhythm, and atrioventricular valve function. Diastolic dysfunction is a common condition; therefore, assessment of diastolic function should be a part of every routine echocardiogram. The latest recommendations for assessment of left ventricular diastolic function are practical and simple to implement in daily practice, and these recommendations are mainly based on six parameters: E wave, E/A ratio, septal or lateral e′, average E/e′, left atrial volume indexed, and peak tricuspid regurgitation velocity. The values of these parameters interact differently within many algorithms to diagnose and classify diastolic dysfunction. A summary is presented of the latest guidelines regarding assessment of diastolic function by echocardiography.

Tricuspid regurgitation velocity versus right ventricular systolic pressure in the echocardiographic evaluation of pulmonary hypertension

Background In consecutive patients who underwent right heart catheterization for pulmonary hypertension (PH) diagnosis, we evaluate ECS/ERS 2015 PH guidelines regarding the echocardiographic suggestions to proceed to PH diagnosis. Methods We enrolled patients referred to Right heart catheterization (RHC) for hemodynamic assessment of presumed PH at respiratory institute Cleveland Clinic. We compared the RHC pulmonary hemodynamic determinations with transthoracic echocardiographic right ventricle systolic pressure (RVSP) and peak tricuspid regurgitation velocity (TRV). Results We included 136 patients in the analysis, where 88 (64.7%) were females and 98 (72%) were of white race. New York Heart Association functional class was II or III in 113 (81%) patients. Peak TRV was significantly associated with BMI (R, 0.192; P=0.048), pulmonary artery systolic (R, 0.37; P Conclusions The use of the last guideline TRV composite analysis improves echocardiographic specificity and positive predictive value, but lacks sensitivity.

Improvement of diastolic function in patients with heart failure and reduced ejection fraction treated by sacubitril/valsartan

Heart failure and reduced ejection fraction (HF rEF) has a poor prognosis, even worse when diastolic dysfunction progresses from grade 1 to the unfavorable grade 3. The purpose of our work was to evaluate the reversibility of diastolic dysfunction before and after sacubitril/valsartan administration in patients with HF REF. A total of 43 patients in NYHA functional class 2–3 and treated by ACE inhibitor or AAR2, were prospectively assigned to equimolar sacubitril/valsartan replacement. To classify diastolic dysfunction according to the ASE/EACVI guidelines published in 2016, transmitral E and A waves velocities, septal and lateral E’ tissue velocities, indexed left atrium volume and peak velocity of tricuspid regurgitation were collected. From multiparametric approach, Patients were subsequently categorized as diastolic dysfunction grade 1, 2 or 3. Patients with atrial fibrillation or missing data have been classified as undetermined. Mean age was 58.9 ± 14.9 yo and 72.7% patients were males. Ejection fraction averaged 30.5 ± 7.2 Overall, after 6.1 ± 3.6 months of treatment with sacubitril/valsartan, E/A ratio decreased from 1.9 ± 1.5 to 1.04 ± 0.72 ( P < 0.05), the E/Ea ratio decreased from 14.8 ± 6.5 vs. 10.5 ± 5.2 ( P < 0.05), tricuspid regurgitation peak velocity decreased from 3.0 ± 0.7 to 2.5 ± 0.5 m/s ( P = 0.03) and left atrial volume decreased from 53.3 ± 29.7 to 40.6 ± 13.7 ml/m 2 ( P < 0.05). Subsequently, both left-ventricular diastolic function and filling pressure improved significantly ( P < 0.05, Fig. 1 ). In patients with heart failure and reduced ejection fraction, administration of sacubitril/valsartan was associated with improvement of diastolic dysfunction and filling pressure.

Doppler-defined pulmonary hypertension in sepsis and septic shock

BackgroundThe association of pulmonary hypertension (PH) in patients with sepsis is lesser understood. MethodsThis was a retrospective study of adult patients admitted to the intensive care unit during 2007–2014 for sepsis and septic shock, with echocardiography performed <72 h. PH was defined as tricuspid regurgitation peak velocity (TRV) > 3 m/s on Doppler echocardiography. Patients with prior PH, pulmonary stenosis, or without measurable TRV were excluded. Outcomes included 28-day mortality, one-year survival and length of stay. ResultsEighty-three, of 241 (34.4%) patients included, had PH. Patients with PH were older and had greater cardiovascular comorbidity but similar illness severity, including acute respiratory distress syndrome and mechanical ventilation use. PH was an independent predictor of 28-day mortality (odds ratio 3.6 [95% confidence interval 1.1–12.5] p = .04). In a proportional hazards model, PH was an independent predictor of one-year survival (hazard ratio 1.7 [95% confidence interval 1.1–2.7]; p = .03). Severity of PH was associated with worse one-year survival but not 28-day mortality. ConclusionsIn patients with sepsis and septic shock, PH is common and is noted to be associated with higher short and long-term mortality. Further studies are needed to understand the mechanisms by which PH is associated with outcomes.

Abstract 158: Pediatric In-Hospital Cardiac Arrest Associated With Pulmonary Hypertension: A Common Pathophysiology

Introduction: In laboratory studies, pulmonary hypertension (PH) during CPR worsens outcomes but can be ameliorated with inhaled nitric oxide (iNO). The prevalence of pre-arrest PH among children with IHCA and its impact on outcomes are not well described. Hypothesis: We hypothesized that among children with IHCA, pre-arrest PH would be common and associated with worse survival to discharge. Methods: Retrospective single-center cohort study of consecutive pediatric ICU patients (1/1/2006 - 12/31/2017) with an echocardiogram in the 48 hours preceding IHCA, excluding those with cyanotic congenital heart disease. Echocardiograms were analyzed by a cardiologist blinded to other patient data. PH was defined as abnormal septal position and/or peak tricuspid regurgitant velocity &gt; 2.8 m/sec. Patient and arrest characteristics and treatments were compared between subjects with and without PH using non-parametric tests. Logistic regression evaluated the association between PH and outcome, adjusting a priori for age and initial arrest rhythm, as well as for candidate variables associated with survival (p&lt;0.10). Results: Of 284 IHCA subjects, 57 (20%) had an evaluable echocardiogram. PH was present in 20/57 (35%); 9/20 (45%) had no prior clinical history of PH. Children with PH had worse RV systolic function as measured by median fractional area change (32% vs. 45%; p=0.005), RV global longitudinal strain (-15% vs. -21.1%; p=0.046), and tricuspid annular plane systolic excursion z-score (-4.50 vs. -3.53; p=0.17). Children with PH had more RV dilation (median RV:LV end-diastolic area ratio 0.90 vs. 0.52; p=0.005) and similar rates of qualitative LV dysfunction (45% vs. 59%, p=0.40). Children with PH were more likely to receive iNO [16/20 (80%) vs. 12/37 (32%); p&lt;0.001] and isoproterenol [9/20 (45%) vs. 1/37 (3%); p&lt;0.001] during CPR. There were no differences in other IHCA characteristics. On multivariable analysis, PH was not associated with ROSC [14/20 (70%) vs. 24/37 (65%); adjOR 1.30 (0.25 - 6.69); p=0.77] or survival to hospital discharge [8/20 (40%) vs. 10/37 (27%); adjOR 1.17 (0.22 - 6.44); p=0.85]. Conclusions: PH was present in 35% of children with IHCA. In a cohort with a high frequency of treatment with iNO during CPR, PH was not associated with survival.

Left atrial strain - an early marker of left ventricular diastolic dysfunction in patients with hypertension and paroxysmal atrial fibrillation

Background2D strain imaging of the left atrium (LA) is a new echocardiographic method which allows us to determine contractile, conduit and reservoir functions separately. This method is particularly useful when changes are subtle and not easily determined by traditional parameters, as it is in arterial hypertension and atrial fibrillation (AF). The aims of our study were: to determine LA contractile, conduit and reservoir function by 2D strain imaging in patients with mild arterial hypertension and paroxysmal AF; to assess LA contractile, conduit and reservoir functions’ relation with LV diastolic dysfunction (DD) parameters.MethodsLA contractile, conduit and reservoir functions together with echocardiographic signs of LV DD were assessed in 63 patients with arterial hypertension and paroxysmal AF. Patients were grouped according to number of signs showing LV DD (annular e’ velocity: septal e’ < 7 cm/s, lateral e’ < 10 cm/s, average E/e’ ratio > 14, LA volume index > 34 ml/m2, peak tricuspid regurgitation velocity > 2.8 m/s) present. Number of patients with 0 signs – 17, 1 sign – 26, 2 signs – 19. Contractile, conduit and reservoir functions were compared between the groups.ResultsMean contractile, conduit and reservoir strains in all the patients were − 14.14 (± 5.83) %, 15.98 (± 4.85) % and 31.03 (± 7.64) % respectively. Contractile strain did not differ between the groups. Conduit strain was higher in patients with 0 signs compared with other groups (p = 0.016 vs 1 sign of LV DD and p = 0.001 vs 2 signs of LV DD). Reservoir strain was higher in patients with 0 signs compared with other groups (p = 0.014 vs 1 sign of LV DD and p < 0.001 vs 2 signs of LV DD).ConclusionsThe patients with paroxysmal AF and primary arterial hypertension have decreased reservoir, conduit and pump LA functions even in the absence of echocardiographic signs of LV DD. With increasing number of parameters showing LV DD, LA conduit and reservoir functions decrease while contractile does not change. LA conduit and reservoir functions decrease earlier than the diagnosis of LV DD can be established according to the guidelines in patients with primary arterial hypertension and AF.

Two distinct clinical phenotypes of pulmonary arterial hypertension secondary to systemic lupus erythematosus

Pulmonary arterial hypertension (PAH) is a severe complication of systemic lupus erythematosus (SLE), and SLE-PAH is the most common connective tissue disease (CTD)-associated PAH in Chinese patients.1 The prognosis of...

Echocardiographic assessment of pulmonary hypertension: a guideline protocol from the British Society of Echocardiography

Pulmonary hypertension is defined as a mean arterial pressure of ≥25 mmHg as confirmed on right heart catheterisation. Traditionally, the pulmonary arterial systolic pressure has been estimated on echo by utilising the simplified Bernoulli equation from the peak tricuspid regurgitant velocity and adding this to an estimate of right atrial pressure. Previous studies have demonstrated a correlation between this estimate of pulmonary arterial systolic pressure and that obtained from invasive measurement across a cohort of patients. However, for an individual patient significant overestimation and underestimation can occur and the levels of agreement between the two is poor. Recent guidance has suggested that echocardiographic assessment of pulmonary hypertension should be limited to determining the probability of pulmonary hypertension being present rather than estimating the pulmonary artery pressure. In those patients in whom the presence of pulmonary hypertension requires confirmation, this should be done with right heart catheterisation when indicated. This guideline protocol from the British Society of Echocardiography aims to outline a practical approach to assessing the probability of pulmonary hypertension using echocardiography and should be used in conjunction with the previously published minimum dataset for a standard transthoracic echocardiogram.

Impact of right ventricular dysfunction and end-diastolic pulmonary artery pressure estimated from analysis of tricuspid regurgitant velocity spectrum in patients with preserved ejection fraction.

We aimed to analyse the association between right haemodynamic parameters, right ventricular (RV) dysfunction parameters, and outcomes in patients with preserved ejection fraction (EF). Retrospective analysis of right haemodynamic (systolic pulmonary pressure and end-diastolic pulmonary pressure based on tricuspid regurgitation (TR) velocity at pulmonary valve opening time), and RV parameters including size (end-diastolic and end-systolic area), function (RV fractional area change, Tei index, Tricuspid Annular Plane Systolic Excursion, and speckle tracking derived free wall strain), from 557 consecutive patients with preserved EF [EF ≥ 50%; age 64.9 + 20; 52% female; co-morbidity Charlson index 4.7 (2.9, 6.4)]. All cause and cardiac mortality were retrospectively analysed and correlated to echo haemodynamic and co-morbid parameters. TR velocity at pulmonary valve opening time and calculated end-diastolic pulmonary artery pressure were obtainable in 71% of patients. The best haemodynamic univariate predictor of mortality was calculated end-diastolic pulmonary artery pressure [hazard ratio 1.06 (1.04-1.07); P < 0.0001], superior to TR peak velocity and systolic pulmonary artery pressure. Elevated end-diastolic pulmonary artery pressure was associated with all cause and cardiac mortality even when adjusted for all significant clinical (age, gender, and Charlson index), and echo (stroke volume index, left atrial volume index, systolic pulmonary pressure, E/e', and Tei index) parameters. Tei index was superior to all other RV functional parameters (P < 0.05 for all parameters). TR velocity at pulmonary valve opening time and calculated end-diastolic pulmonary artery pressure are obtainable in most patients, and add prognostic information on top of clinical and routine haemodynamic and diastolic parameters.

Left and right ventricular morphology and function in athletes with elevated pulmonary systolic arterial pressure.

The objective of the study was to evaluate the prevalence and potential impact of elevated pulmonary arterial systolic pressure (PASP) on left and right cardiac morphology and function in young elite athletes. In total, 85 professional athletes (40 endurance, 20 strength, and 25 mixed training, mean age 17.8±4.0) and 50 sedentary controls (mean age 18.6±3.3) underwent transthoracic echocardiographic examination. Two-dimensional measurements of the right (RV) and left ventricle (LV) were obtained. PASP was estimated from the peak tricuspid regurgitant velocity (TRV). Speckle tracking-derived longitudinal LV and RV strain measurements (RV_LS) were calculated for function estimation. Maximum TRV (2.2±0.3 vs 2.0±0.2m/s, P<.01) and PASP (26±5 vs 22±5mmHg, P<.01) were higher in athletes compared to controls. PAPS above 30mmHg (35±3mmHg, range 31-40mmHg) was identified in 11 athletes (12.9%). Athletes with elevated PASP demonstrated higher LV mass (P<.01), LV stroke volume indexed (P<.01), larger RV-end-systolic area (ESAi), RV-end-diastolic area (EDAi), right atrium ES volume and ED volume, and decreased RV fractional area change (FAC) (P<.01) when compared to matched controls and higher RV-EDAi (13.0±1.6 vs 11.1±1.5, P<.01), RV-ESAi (8.2±1.5 vs 6.1±0.9, P<.01), and significantly reduced RV FAC (38.1±5.8 vs 44.6±2.5, P<.01) when compared to matched athletes. LV global longitudinal strain and RV_LS showed no differences between the groups. Pulmonary arterial systolic pressure elevation in young athletes is associated with pronounced right ventricular enlargement, even when compared to matched athletes. Conventional and speckle tracking echocardiography showed preserved right ventricular function.

Right ventricle performances with echocardiography and 99mTc myocardial perfusion imaging in pulmonary arterial hypertension patients.

Right heart catheterization is commonly used to measure right ventricle hemodynamic parameters and is the gold standard for pulmonary arterial hypertension diagnosis; however, it is not suitable for patients' long-term follow-up. Non-invasive echocardiography and nuclear medicine have been applied to measure right ventricle anatomy and function, but the guidelines for the usefulness of clinical parameters remain to be established. The goal of this study is to identify reliable clinical parameters of right ventricle function in pulmonary arterial hypertension patients and analyze the relationship of these clinical parameters with the disease severity of pulmonary arterial hypertension. In this study, 23 normal subjects and 23 pulmonary arterial hypertension patients were recruited from January 2015 to March 2016. Pulmonary arterial hypertension patients were classified into moderate and severe pulmonary arterial hypertension groups according to their mean pulmonary arterial pressure levels. All the subjects were subjected to physical examination, chest X-ray, 12-lead electrocardiogram, right heart catheterization, two-dimensional echocardiography, and technetium 99m (99mTc) myocardial perfusion imaging. Compared to normal subjects, the right heart catheterization indexes including right ventricle systolic pressure, right ventricle end diastolic pressure, pulmonary artery systolic pressure, pulmonary artery diastolic pressure, pulmonary vascular resistance, and right ventricle end systolic pressure increased in pulmonary arterial hypertension patients and were correlated with mean pulmonary arterial pressure levels. Echocardiography parameters, including tricuspid regurgitation peak velocity, tricuspid regurgitation pressure gradient, tricuspid annular plane systolic excursion and fractional area, right ventricle-myocardial performance index, were significantly associated with the mean pulmonary arterial pressure levels in pulmonary arterial hypertension patients. Furthermore, myocardial perfusion imaging was not observed in the normal subjects but in pulmonary arterial hypertension patients, especially severe pulmonary arterial hypertension subgroup, and showed potential diagnostic properties for pulmonary arterial hypertension. In conclusion, mean pulmonary arterial pressure levels are correlated with several right heart catheterization and echocardiography markers in pulmonary arterial hypertension patients; echocardiography and 99mTc myocardial perfusion can be used to evaluate right ventricle performance in pulmonary arterial hypertension patients. Impact statement In this study, we analyzed the clinical parameters for evaluating RV function, including right ventricle catheterization (RHC), echocardiography, and technetium 99m (99mTc) myocardial perfusion imaging (MPI) in normal Asian subjects and PAH patients ( n = 23 for each group). Our results demonstrated that six RHC indexes, four echocardiography indexes and MPI index were significantly altered in PAH patients and correlated with the levels of mean pulmonary arterial pressure. Importantly, we evaluated the diagnostic performance of MPI and found that MPI has a strong diagnostic accuracy in PAH patients. The findings from this study will be of interest to clinical investigators who make diagnosis and therapeutic strategies for PAH patients.

Noninvasive Echocardiographic Measures of Pulmonary Vascular Resistance in Children and Young Adults with Cardiomyopathy

Patients with cardiomyopathy (CM) are at increased risk for pulmonary hypertension (PH). Data are lacking on the use of noninvasive PH measures by echocardiography in patients with CM. The aim of this study was to evaluate the correlation between Doppler-derived echocardiographic indices and catheterization-based measurement of pulmonary vascular resistance (PVR) in children and young adults with CM. Imaging studies were retrospectively reviewed from pediatric patients with CM who underwent both echocardiography and cardiac catheterization within a 72-hour period. The ratio of peak tricuspid regurgitation velocity to right ventricular outflow tract velocity-time integral, the S/D ratio, and right ventricular myocardial performance index were correlated with invasive PVR. Receiver operating characteristic curves were developed to determine cutoffs for detecting PVR ≥ 6 indexed Wood units, a value associated with higher heart transplantation risk. Twenty-three patients with CM (median age, 11.7years; range, 0.5-21years) met the criteria for analysis,the majority (n=17 [74%]) of whom had dilated CM. Linear regression showed significant correlations between echocardiography-based ratio of peak tricuspid regurgitation velocity to right ventricular outflow tract velocity-time integral, S/D ratio, and right ventricular myocardial performance index versus invasive PVR (r=0.84, r=0.72, and r=0.72, respectively, P<.001). All echocardiographic measures showed high sensitivity, specificity, and predictive values to detect PVR ≥ 6 indexed Wood units, with ratio of peak tricuspid regurgitation velocity to right ventricular outflow tract velocity-time integral demonstrating the highest area under the curve (0.958; 95% CI, 0.866-1). Right-sided Doppler-derived echocardiographic indices correlate with PVR measured by cardiac catheterization in children and young adults with CM. These parameters may serve as useful adjuncts in serial assessment of right ventricular hemodynamics in this population.

Pulmonary hypertension in interstitial lung disease: Limitations of echocardiography compared to cardiac catheterization.

In interstitial lung disease (ILD), pulmonary hypertension (PH) is a major adverse prognostic determinant. Transthoracic echocardiography (TTE) is the most widely used tool when screening for PH, although discordance between TTE and right heart catheter (RHC) measured pulmonary haemodynamics is increasingly recognized. We evaluated the predictive utility of the updated European Society of Cardiology/European Respiratory Society (ESC/ERS) TTE screening recommendations against RHC testing in a large, well-characterized ILD cohort. Two hundred and sixty-five consecutive patients with ILD and suspected PH underwent comprehensive assessment, including RHC, between 2006 and 2012. ESC/ERS recommended tricuspid regurgitation (TR) velocity thresholds for assigning high (>3.4 m/s), intermediate (2.9-3.4 m/s) and low (<2.8 m/s) probabilities of PH were evaluated against RHC testing. RHC testing confirmed PH in 86% of subjects with a peak TR velocity >3.4 m/s, and excluded PH in 60% of ILD subjects with a TR velocity <2.8 m/s. Thus, the ESC/ERS guidelines misclassified 40% of subjects as 'low probability' of PH, when PH was confirmed on subsequent RHC. Evaluating alternative TR velocity thresholds for assigning a low probability of PH did not significantly improve the ability of TR velocity to exclude a diagnosis of PH. In patients with ILD and suspected PH, currently recommended ESC/ERS TR velocity screening thresholds were associated with a high positive predictive value (86%) for confirming PH, but were of limited value in excluding PH, with 40% of patients misclassified as low probability when PH was confirmed at subsequent RHC.

Echocardiographic assessment of regional right ventricular systolic function using two-dimensional strain echocardiography and evaluation of the predictive ability of longitudinal 2D-strain imaging for pulmonary arterial hypertension in systemic sclerosis patients.

Systemic sclerosis (SSc) is a generalized connective tissue disorder, and SSc patients are at risk of developing pulmonary arterial hypertension (PAH). The aims of this study are to evaluate the right ventricular regional systolic function using two-dimensional speckle-tracking echocardiography (2D STE) and to determine the predictive ability of peak longitudinal systolic strain (PLSS) at the RV lateral wall for PAH in SSc patients. 80 SSc patients (mean age 51 ± 12years) were included in the study. Echocardiography and 2D STE were performed at baseline and after 12months. RHC was performed only in SSc patients with clinical indications. PLSS at the apical segment of the RV free wall was significantly impaired in PAH patients compared with non-PH patients (-14.6 ± 5.9 vs. - 22.2 ± 7.5%, p = 0.034). PLSS at the basal, mid, and apical segments of the RV free wall was lower in both groups at follow-up compared to baseline, but the drop in strain values was statistically significant only in the non-PH group (p < 0.05). Right atrial area (OR 1.758; p = 0.023), peak tricuspid regurgitation velocity (OR 24.23; p = 0.011) and PLSS at the apical segment of the RV lateral wall (OR 2.47; p = 0.005) were independent predictors of PAH. A cut-off value of - 14.48% PLSS at the apical segment of the RV lateral wall resulted in 100% specificity for predicting PAH in SSc patients. RV pressure overload affects RV systolic function as manifested by impaired RV longitudinal deformation. Evaluating RV regional systolic function with 2D STE could be useful as an additional echocardiographic parameter for screening PAH in SSc patients.

Early Detection of Diastolic Dysfunction in Diabetic Patients (Single Center Cross Sectional Study)

Background: Left ventricular diastolic dysfunction in asymptomatic patients with diabetes mellitus may represent the early stage of diabetic cardiomyopathy even in patients without structural cardiac disease or systemic hypertension and have a preserved left ventricular systolic function. Objectives: To determine the prevalence of left ventricular diastolic dysfunction in asymptomatic patients with diabetes mellitus. Methods: A cross sectional study was carried out on 86 diabetics and compared with 65 age and sex matched controls. Detailed history, physical examination , specific investigations and transthoracic echocardiography study (including conventional pulse wave Doppler and tissue Doppler imaging) were done to assess the diastolic function. Results: Left ventricular diastolic dysfunction is more prevalent in diabetic patients comparing with control group (62.3% versus 12.8%, p<0.05) and this correlated independently with increasing age, duration of the disease and glycated hemoglobin level. Conclusion: Diastolic dysfunction can occur in diabetic patients even in young patients and those with shorter duration of disease. Tissue Doppler imaging, left atrial size and peak tricuspid regurgitation velocity are sensitive indices of LV diastolic dysfunction.

Multi-view approach for the diagnosis of pulmonary hypertension using transthoracic echocardiography

Pulmonary hypertension (PH) is a disease with severe morbidity and mortality. Echocardiography plays an essential role in the screening of PH. The quality of the acquired continuous wave Doppler signal is the major limitation of the method and can greatly affect the accuracy of estimated pulmonary pressures. The aim of this study was to evaluate the clinical need to image from multiple ultrasound windows in patients with suspected pulmonary hypertension. We prospectively evaluated 65 patients (43% male, mean age 67.2 years) with echocardiography and right heart catheterization. 17% had invasively normal pulmonary pressures, 83% had pulmonary hypertension. Peak tricuspid regurgitation (TR) velocity was imaged in five echocardiographic views. Sufficient Doppler signal was recorded in 94% of the patients. Correlation for overall peak TR velocity with invasively measured systolic pulmonary artery pressure was r = 0.83 (p < 0.001). Considering all five imaging windows resulted in a sensitivity of 87%, and a specificity of 91% for correct diagnosis of PH with an AUC of 0.89, which was significantly better as compared to sole imaging from the right ventricular modified apical four-chamber view (AUC 0.85, p = 0.0395). Additional imaging from atypical views changed the overall peak TR velocity in 32% of the patients. A multiple-view approach changed the echocardiographic diagnosis of PH in 11% of the patients as opposed to sole imaging from an apical four-chamber view. This study comprehensively assessed the impact on clinical decision making when evaluating patients with an echocardiographic multiplane approach for suspected PH. This approach substantially increased sensitivity without a decrease in specificity.