Ventricular Free Wall Longitudinal Strain Research Articles

Assessment of biventricular function by three-dimensional speckle-tracking echocardiography in clinically well pediatric heart transplantation patients.

The biventricular function plays an important role in the prognosis of pediatric heart transplantation (HTx) patients. Therefore, in this study, we aimed to evaluate the biventricular function of pediatric HTx patients by three-dimensional (3D) speckle-tracking echocardiography (3D-STE). We enrolled 30 clinically well pediatric HTx patients and 30 healthy controls with a similar distribution of sex and age to the HTx. All participants underwent comprehensive two-dimensional (2D) and 3D echocardiography. Left ventricular (LV) global longitudinal strain (GLS), global circumferential strain (GCS), left and right ventricular ejection fraction (LVEF and RVEF, respectively), and right ventricular free wall longitudinal strain (RV FWLS) were acquired by 3D-STE. Moreover, the correlations between strains and clinical data were explored. Compared with controls, LV GLS was decreased in pediatric HTx patients (P<.05), while LV GCS and LVEF showed no difference. LV GLS showed a weak correlation with cold ischemic time in HTx group (r=0.396, P<.05). Meanwhile, RVEF and RV FWLS were significantly lower in the HTx group (P<.05). In the HTx group, RV FWLS showed a weak correlation with the preoperative mean pulmonary artery pressure (r=0.420, P<.05) and postoperative pulmonary artery systolic pressure (r=0.465, P<.05). The 3D-biventricular mechanical functions were decreased in clinically well pediatric HTx patients. The provided characteristics and appropriate normal values of biventricular mechanical functions can be the basis in subsequent studies in the pediatric HTx patients.

Global Right Heart Assessment with Speckle-Tracking Imaging Improves the Risk Prediction of a Validated Scoring System in Pulmonary Arterial Hypertension

Right ventricular (RV) function and right atrial (RA) remodeling are major determinants of outcome in pulmonary arterial hypertension (PAH). Strain echocardiography is emerging as a valuable approach for the study of RV and RA function. We sought to assess the incremental prognostic value of serial combined speckle-tracking examination of right chambers in newly diagnosed therapy-naïve PAH patients. The study endpoint was a composite of all-cause mortality, hospitalizations due to worsening PAH, and initiation of parenteral prostanoids. Patients were assessed at baseline and at first revaluation after initiation of treatment. Right ventricular free-wall longitudinal strain (FWLS) and RA peak atrial longitudinal strain (PALS) were used as measures of RV and RA function. Eighty-three patients were included. Mean RV-FWLS and RA-PALS were -13.9%±6.1% and 23.1%±11.4%. The best performing prognostic score among the Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension, French Pulmonary Hypertension Registry, and Registry to Evaluate Early and Long-Term Pulmonary Arterial Hypertension Disease Management (REVEAL) scores was the REVEAL (area under the curve=0.79, P<.001). With the identified cutoffs, both RV-FWLS (hazard ratio for RV-FWLS<-13.2%=0.366; 95% CI, 0.159-0.842; P=.018) and RA-PALS (hazard ratio for RA-PALS>20%=0.399; 95% CI, 0.176-0.905; P=.028) were independently associated with the primary outcome after correction for the REVEAL score. The combined assessment of RV-FWLS and RA-PALS in addition to the REVEAL score determined a net improvement in prediction of 0.439 (95% CI, 0.070-0.888, P=.04). At 5months (interquartile range, 4-8) of follow-up, RV-FWLS and RA-PALS improved significantly only in patients free from the primary outcome (P<.001 and P=.001, respectively). The combined assessment of RV-FWLS and RA-PALS determined an improvement in outcome prediction of validated prognostic risk scores and should be considered within the multiparametric evaluation of patients with PAH.

Right ventricular free wall longitudinal strain and strain rate quantification with cardiovascular magnetic resonance based tissue tracking

Cardiovascular magnetic resonance based tissue tracking (CMR-TT) was reported to provide detailed insight into left ventricular mechanical features. However, inadequate knowledge of the right ventricle (RV) mechanical deformation has been acquired by this advanced technique so far. It was the aim of this study to establish reference values of RV free wall (RVFW) global, regional and segmental longitudinal peak strain and strain rate (LS and LSR), and to investigate the gender- and age-related difference as well as the base-to-apex gradient of RVFW-LS and LSR with CMR-TT. 150 healthy volunteers (75 males/females) were retrospectively and continuously recruited and subdivided into three age groups (G20–40, G41–60 and G61–80). RVFW global, regional (basal, middle-cavity and apical) and segmental LS (GLS, RLS, SLS) along with systolic and diastolic LSR were generated by post-hoc CMR-TT analysis of standard steady-state free precession long-axis four-chamber view cine images acquired at 1.5T field strength. The reference value of myocardial RVFW-GLS was − 24.9 ± 5.2%. We found that females showed more negative GLS than males except in the youngest group, and no age-related difference of GLS was observed in both gender groups. RLS and SLS presented with the same age-related tendency as GLS. The basal and middle-cavity LS were similar between each other and significantly larger than apical LS. RVFW-GLSR resulted as − 1.73 ± 0.58 s−1 and 1.69 ± 0.65 s−1 during systolic and diastolic phases, respectively. The diastolic GLSR of males tended to decline with the ageing and was significantly lower than that of females in G61–80 group. Regional and segmental LSR showed significant gender-related differences in certain basal and apical region/segments without any age-related effects. CMR-TT overcomes the difficulty in measuring RV global and segmental deformation. The establishment of the vendor-, gender- and segment-specific reference values of RVFW-LS and LSR is essential for the rapid and efficient utilization of CMR-TT modality in the clinical routine.

Determinants and Prognostic Significance of Serial Right Heart Function Changes in Patients With Cardiac Amyloidosis

BackgroundRight heart function is an important prognostic determinant in cardiac amyloidosis. In this study we characterized serial changes in right and left heart function and evaluated their prognostic significance. MethodsCardiac amyloidosis patients with baseline and follow-up echocardiograms were included. Right and left heart function measured at baseline, 1 year, and most recent follow-up were compared and correlated with all-cause mortality or cardiovascular hospitalization. ResultsNinety-three patients were included; 36 (39%) with light chain amyloidosis and 57 (61%) with transthyretin amyloidosis. Among measures of right heart function for the study population and light chain and transthyretin amyloidosis subtypes, only absolute right ventricular (RV) free wall longitudinal strain (FWLS) changed significantly from baseline to 1 year and most recent follow-up echocardiogram. After a median of 26 months (range, 14-35 months), 21 (22%) patients died and 17 (18%) had a cardiovascular hospitalization. Baseline RV FWLS was significantly associated with the primary endpoint (hazard ratio, 1.2 per % change; 95% confidence interval, 0.8-2.6; P < 0.01), whereas change from baseline to 1 year was not for any measure of right heart function. Baseline left ventricular (LV) global longitudinal strain (GLS) and 1 year change were significantly associated with the primary end point. Change in RV FWLS at 1 year was significantly correlated with baseline LV GLS (r = 0.68; P = 0.01) and change at 1 year follow-up (r = 0.72; P < 0.01). ConclusionsIn cardiac amyloidosis patients, baseline RV FWLS was associated with adverse outcomes whereas changes at follow-up was not. Change in RV FWLS was significantly correlated with baseline and follow-up change in LV GLS, possibly reflecting progressive biventricular amyloid deposition.

P931 Feasibility of comprehensive multi-plane right ventricular free wall longitudinal strain evaluation pre-LVAD implantation - preliminary results from a single centre experience

Abstract Introduction Right ventricular failure (RVF) is recognized as a major cause of morbidity and mortality after left ventricular assist device (LVAD) implantation and identifying patients at risk remains a challenge. Given its structural complexity, it is not possible to fully assess the RV from one echocardiographic 2D plane and entire free wall visualization is more challenging in advanced heart failure patients with very severely dilated left ventricles. 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 focused RV views and electronic plane rotation. Purpose The aim of the study was to determine the feasibility of using multi-plane echocardiography (MPE) to quantify right ventricular free wall longitudinal strain (RV-FWLS) in a small cohort of advanced heart failure patients prior to LVAD implantation. Methods Sixteen advanced heart failure patients underwent detailed RV assessment by MPE prior to LVAD implantation (median - 15 [6.3-29.8] days before). Feasibility and values of RV-FWLS were retrospectively assessed by an experienced sonographer on each of the 4 free wall segments using specialised RV strain analysis software. Feasibility was confirmed if all regions of the free wall were visualised and tracked appropriately throughout the cardiac cycle. Standard right heart 2D echo parameters and pre-implant right heart catheterisation (RHC) data were also collated. Results Mean RV-FWLS and feasibility in the four segments were as follows: lateral -12.4 ± 4.3% (81.3%); anterior -12.7 ± 6.1% (62.5%); inferior -11.8 ± 4.7% (75.0%); inferior coronal -11.6 ± 3.9% (43.8%). TAPSE values on the same segments were feasible in 100% of cases and mean values were as follows: lateral 15.1 ± 4.9mm; anterior 15.3 ± 4.7mm; inferior 13.4 ± 5.2mm; inferior coronal 11.4 ± 5.1mm. Mean pulmonary artery pressure (mPAP) measured by RHC was 27.2 ± 11mmHg. There was a slightly stronger negative correlation of RV-FWLS with increased mPAP in the lateral, anterior and inferior RV free wall segments compared to TAPSE (r²: -0.07-0.11 v -0.01-0.05). Conclusion There is reasonable feasibility for assessing RV-FWLS using MPE in 3 out of the 4 free wall segments and mean values were considerably lower than normal reference values. A stronger negative correlation with increasing mPAP suggests that RV dysfunction may be detected better by strain than by TAPSE measurement in pre-LVAD recipients. Larger, multi-centre studies are required to further assess these preliminary findings. Abstract P931 Figure. Multi-plane RV imaging with strain

P1282 Follow-up evaluation of right chambers mechanics is associated with prognosis in group 1 pulmonary arterial hypertension

Abstract Background Pulmonary arterial hypertension (PAH) is a severe disease that progressively leads to right ventricular (RV) failure and cardiovascular death. Evaluation of right heart mechanics by means of 2-dimensional speckle tracking echocardiography (2D-STE) has displayed to be a promising tool to estimate prognosis in PAH patients. Purpose To evaluate the association between right ventricular free wall longitudinal strain (RVFWLS) and right peak atrial longitudinal strain (RPALS) at follow-up after initiation of specific vasodilator therapy in PAH patients, with outcomes. Methods 83 subjects diagnosed with PAH Group 1 at three University Hospitals (Hammersmith Hospital, London, United Kingdom; Trieste University Hospital, Trieste, Italy; FTGM, Pisa, Italy), who were naive from specific treatment for PAH at the time of diagnosis, were retrospectively enrolled in this study. Standard echocardiographic parameters were collected. Outcomes were defined as the combination of all-cause mortality, hospitalization for PAH and first prostanoid administration. We investigated the correlation between RVFWLS and RPALS with outcomes adjusting for validated echocardiographic parameters strongly associated with prognosis in PAH (right atrial area – RAA and pericardial effusion – PE) and patients’ haemodynamics. Results 30 patients experienced outcomes during a median follow-up time of 33 months. Median RVFWLS at follow-up was -15.8% (IQR: -12.1%/- 21.1%). Median RPALS at follow-up was 25% (IQR: 17.9%/36.6%). In the multivariate analysis, RVFLWS at follow-up was independently associated with outcomes (95% confidence interval [CI]: 1.01 – 1.24, p = 0.04), irrespectively from RAA (95% CI: 0.98 – 1.20, p = 0.12) and pulmonary arterial systolic pressure (PASP, 95% CI: 0.99 – 1.06, p = 0.12). We also observed a trend towards superiority of RPALS at follow-up (95% CI 0.90 – 1.00, p = 0.07) over RAA (95% CI: 0.98 – 1.20, p = 0.14) and PASP (95% CI: 0.99 - 1.05, p= 0.31). Finally, RPALS (95% CI: 0.88 – 1.00, p = 0.05) was independently associated with outcomes over PE (95% CI: 0.14 – 1.89, p = 0.32) and RVFWLS (95% CI: 0.97 – 1.20, p = 0.16). Conclusions In PAH group 1, assessment of both RVFWLS and RPALS at follow-up is associated with outcomes, independently from standard echocardiographic parameters.

Prognostic value of right ventricular free wall longitudinal strain in a large cohort of outpatients with left-side heart disease

Right ventricular free wall longitudinal strain (RVFWLS) has been proposed as an accurate and sensitive measure of right ventricular function that could integrate other conventional parameters such as tricuspid annulus plane systolic excursion (TAPSE) and fractional area change (FAC%). The aim of the present study was to evaluate the relationship between RVFWLS and outcomes in stable asymptomatic outpatients with left-sided structural heart disease. We enrolled 458 asymptomatic patients with left-side heart diseases and any ejection fraction who were referred for echocardiography to two Italian centres. The composite endpoint of death for any cause and heart failure hospitalization was used as primary outcome of this analysis. After a mean follow-up of 5.4 ± 1.2 years, 145 patients (31%) reached the combined endpoint. Most of echocardiographic parameters were related to outcomes, including right ventricular functional parameters. Mean value of RVFWLS in our cohort was -21 ± 8% and it was significantly related to the combined endpoint and in multivariable Cox-regression model; when tested with other echocardiographic parameters that were significantly related to outcome at univariate analysis, RVFWLS maintained its independent association with outcome (hazard ratio 0.963, 95% confidence interval 0.948-0.978; P = 0.0001). The best cut-off value of RVFWLS to predict outcome was -22% (area under the curve 0.677; P < 0.001; sensitivity 70%; 65% specificity). RVFWLS may help clinicians to identify patients with left-sided structural heart disease at higher risk for first heart failure hospitalization and death for any cause.

P1479Deterioration in right ventricular strain precedes occurrence of pulmonary hypertension in patients with preclinical diastolic disfunction

Abstract Preclinical diastolic disfunction (PDD) often progresses to heart failure and distinct clinical predictors for this transformation are yet to be defined. Since deterioration of longitudinal strain (LS) can occur before the changes of more conventional parameters, we assumed that right ventricular free wall longitudinal strain (RVLS) might start deteriorating before the pulmonary hypertension can be established. Methods We followed up 243 patients (143 female) 67±9 years with PDD for 3 years. All patients had an impaired relaxation or pseudo normal transmitral patterns and E/e' 8–13 at rest, normal NT-proBNP values, and systolic pulmonary artery pressure (sPAP) ≤30 mm Hg. PDD was diagnosed by stress echocardiography (SE) if E/e' ≥13, transmittal E wave deceleration time reduction &gt;50ms, systolic pulmonary artery pressure (sPAP) &lt;30 mmHg, and patients remained asymptomatic during SE. RVLS as average of RV free wall 3 segments values, left atrial peak reservoir LS (LALS) as average of two LA basal segments in four chamber view and left ventricular peak systolic global LS (LVGLS) were measured by speckle tracking (ST). ST and SE was performed with 6 months intervals. 35 healthy subject served as controls. Results Patients with PDD had higher RVLS, LVGLS, and lower LALS compared with controls (RVLS –23.2±4.2% vs –27.3±5.1%, p&lt;0.001; LVGLS –17.8±5.2% vs –21.9±2.8%, p&lt;0.001; LALS 39.7±3.7% vs 44.1±4.9%, p&lt;0.002). 76 (31.3%) patients developed sPAP increase &gt;30 mmHg at rest or SE during follow up of which 34 (44.7%) had dyspnea. Patients with increased sPAP had higher RVLS and lower LALS values at baseline compared with the rest of PDD patients without significant differences in other parameters (RVLS –17.9±2.8% vs –24.8±3.6%, p&lt;0.002; LALS 37.7±2.3% vs 41.5±3.6%, p&lt;0.003; LVGLS –17.4±4.8% vs –18.2±5.1%, p&gt;0.05). Both LALS and RVLS correlated with LA end diastolic volume index (LALS r=0.51, p&lt;0.01; RVLS r=0.54, p&lt;0.01). Additionally RVLS was an independent predictor of sPAP rise (OR=2.7; 95% CI=2.43–6.92; p&lt;0.01). Conclusion RVLS is an independent predictor of sPAP increase in patients with PDD.

Rapid improvement in right ventricular free wall longitudinal strain measures after successful percutaneous mitral commissurotomy

Percutaneous mitral commissurotomy (PMC) is currently the treatment of choice for patients with symptomatic mitral stenosis (MS) that have favorable valvular characteristics. We aimed to evaluate the effect of PMC on the longitudinal strain of the right ventricular (RV) free wall in patients with severe MS. This prospective study recruited patients who underwent PMC. Transesophageal and transthoracic echocardiographic examinations were performed. The mitral valve area (MVA) was measured by three-dimensional evaluation. The RV longitudinal strain was measured via the speckle-tracking method. A total of 42 patients with a maximum MVA of 1.5cm2 underwent PMC in our study. The MVA increased significantly after the procedure (pre-PMC MVA=0.94±0.20 cm2 vs post-PMC MVA=1.45±0.18 cm2 ; P<.01). Systolic pulmonary artery pressure decreased from 46.05±14.08mm Hg preprocedurally to 35.86±7.53mm Hg postprocedurally (P<.01). The mean RV free wall longitudinal strain was -19.00±5.14%, which rose significantly after PMC to -20.97±3.81 (P<.05). There were postprocedural increases, albeit nonsignificant, in the tricuspid annular peak systolic excursion, the peak systolic Doppler velocity of the RV free wall, and fractional area change. The improvement in the RV longitudinal strain was more prominent in the patients with an MVA of less than 1.0cm2 . There was a significant post-PMC rise in the RV free wall longitudinal strain measures in our study population, demonstrating an immediate improvement in the RV systolic function of the patients.

Changes in left and right ventricular two-dimensional echocardiographic speckle-tracking indices in pediatric LVAD population: A retrospective clinical study.

Echocardiographic strain and strain-rate imaging is a promising tool for the evaluation of myocardial segmental function, for the early detection of myocardial dysfunction, and for the prediction of reverse remodeling. We aimed at studying the changes in left and right ventricular function in pulsatile left ventricular assist device pediatric patients by two-dimensional echocardiography and two-dimensional speckle-tracking echocardiography. Echocardiographic and clinical data of patients implanted with a pulsatile-flow left ventricular assist device from 2011 to 2018 were retrospectively reviewed before and after implantation at 1, 3, and 6 months. A total of 18 patients were enrolled. Median age and weight at implantation were 9 months (5-23 months) and 5.85 kg (4.85-8.75 kg), respectively; median left ventricular assist device support was 181 (114.5-289.5) days. 13 patients (73%) were transplanted and 5 patients (27%) died. At follow-up: left ventricular ejection fraction increase at 1 month (p = 0.001) and 3 months (p = 0.01), left ventricular global longitudinal strain improvement at 1 month (p = 0.0008) and 3 months (p = 0.02), and right ventricular free-wall longitudinal strain increase at 1 month (p = 0.01). At short term after left ventricular assist device implantation, both left ventricular and right ventricular mechanics improved. The temporary benefit seems to decrease over time. The worsening of left ventricular function has been followed by a worsening of right ventricular function probably due to the ventricular interdependence.

Evaluation of right ventricular systolic function and effects of maintenance hemodialysis on it in uremic patients by 4D RV Volume

Objective To evaluate the right ventricular systolic function in uremia patients and the effects of maintenance hemodialysis on right ventricular systolic function by volume and strain parameters obtained by 4D RV Volume. Methods Seventy-six patients with uremia and twenty-two controls were selected. According to left ventricular ejection fraction (LVEF), uremia patients were divided into normal LVEF uremia group and decreased LVEF uremia group. Then normal LVEF uremia group was divided into maintenance hemodialysis group and non-dialysis group. Conventional ultrasound parameters included: LVEF, pulmonary artery systolic pressure (PASP) and tricuspid annular plane systolic excursion (TAPSE-2D). 4D RV Volume parameters included: right ventricular end-diastolic volume (RVEDV), tricuspid annular plane systolic excursion (TAPSE-4D), right ventricular area change rate (FAC), right ventricular ejection fraction (RVEF) and right ventricular free wall longitudinal systolic strain (RV-GLSfree). Results ①Compared with the control group, TAPSE-2D decreased significantly in the decreased LVEF uremia group (P 0.05). Compared with the control group and normal LVEF uremia group, PASP increased significantly in the decreased LVEF uremia group (P 0.05). Compared with the control group, PASP and RVEDV increased and TAPSE-4D, FAC, RVEF and RV-GLSfree decreased significantly in uremia hemodialysis group and non-dialysis group (P 0.05). Conclusions 4D RV Volume could early and accurately evaluate the right ventricular systolic dysfunction in uremia patients. Furthermore, when evaluating right ventricular systolic function in uremia patients treated with maintenance hemodialysis, indices such as right ventricular strain and volume parameters should be comprehensively considered. Key words: Ultrasonography; Uremia; Ventricular function, right; Dialysis; 4D RV Volume; Three-dimensional strain

Evaluation of the effect of 17β-estradiol on right ventricular function in a rat model of pulmonary arterial hypertension by echocardiography

Objective To evaluate right ventricular (RV) function in male rats with pulmonary arterial hypertension (PAH) induced by Monocrotaline (MCT) and discuss the effect of 17β-estradiol (E2) on RV function in PAH rats. Methods Thirty-two male SD rats were randomly divided into 4 groups(n=8): MCT group, MCT+ E2 group, MCT+ Veh group and control group. MCT group, MCT+ E2 group and MCT+ Veh group were given monocrotaline through intraperitoneal injection. MCT+ E2 group and MCT+ Veh group were also treated with E2 and placebo at the same time respectively. Echocardiography was performed four weeks later after MCT injection. Right heart catheterization was performed after echocardiography. Echocardiography right ventricular function parameters included: tricuspid annular plane systolic excursion (TAPSE), RV index of myocardial performance (RIMP), right ventricular fractional area change (RVFAC), tissue Doppler-derived tricuspid lateral annular systolic velocity (s′) and right ventricular free wall longitudinal strain (RVLSFW). Results Compared with control group, TAPSE, RVFAC and RVLSFW decreased, and RIMP increased in MCT group, (P 0.05). Moreover, Pearson correlation analysis showed that the serum E2 level was positively correlated with TAPSE, RVFAC, s′ and RVLSFW(r=0.845, P<0.001; r=0.859, P<0.001; r=0.802, P=0.006, respectively), and negatively correlated with RIPM(r=-0.803, P<0.001). Conclusions RV function in male PAH rats induced by MCT decreased significantly, while E2 could improve RV function in PAH rats and has a protective effect on RV function. Echocardiography could contribute to the quantitative evaluation of RV function in PAH rats induced by MCT. Key words: Echocardiography; Hypertension, pulmonary; Ventricular function, right; Estradiol; Rat

Right ventricular free wall longitudinal strain and stroke work index for predicting right heart failure after left ventricular assist device therapy.

Right heart failure (RHF) is an important prognostic factor in continuous-flow left ventricular assist device (LVAD) therapy. We aimed to assess the clinical variables associated with RHF after LVAD implantation and to compare their performance against currently available RHF predictive scoring systems. The study cohort comprised 57 patients who underwent LVAD therapy between January 2012 and May 2018 in our centre. The mean age of the patients was 39.9 ± 18.3 years, and 43 (81.1%) of them were men. Thirty-eight patients (66.6%) were in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile I or II. The study cohort was divided into the patients with RHF postoperatively (n = 20, 35.1%) and without RHF (n = 37, 64.9%). Independent predictors for RHF were preoperative right ventricular ejection fraction <25% [odds ratio (OR) 4.68, 95% confidence interval (CI) 1.41-15.5; P = 0.01], right ventricular stroke work index <400 mmHg ml-1 (OR 3.73, 95% CI 1.01-13.7; P = 0.04), right ventricular outflow tract systolic excursion <7 mm (OR 1.55, 95% CI 0.31-0.84; P = 0.002), right ventricular outflow tract fractional shortening <15% (OR 1.62, 95% CI 0.34-0.78; P = 0.02), right ventricular free wall longitudinal strain ≤19% (OR 3.13, 95% CI 1.01-2.43; P = 0.003), right ventricular fractional area change <27% (OR 3.71, 95% CI 1.15-11.9; P = 0.02) and prealbumin <14 mg/dl (OR 3.45, 95% CI 1.07-11.03; P = 0.03). Modest diagnostic performance for RHF was detected in 4 of 7 validated scoring systems with resulting area under the curve values of 0.70 (95% CI 0.55-0.84; P = 0.001) for the Seattle Heart Failure Model; 0.68 (95% CI 0.49-0.81, P = 0.03) for the Fitzpatrick's; 0.68 (95% CI 0.53-0.83, P = 0.028) for the acute physiology and chronic health evaluation (APACHE) II; and 0.66 (95% CI 0.50-0.82, P = 0.04) for the model for end-stage liver disease scoring systems. However, we found best discrimination performance of the score with a resulting area under the curve value of 0.94 (95% CI 0.55-0.89, P = 0.03) for right ventricular free wall longitudinal strain ≥-15.5% and 0.82 for right ventricular stroke work index <400 mmHg ml-1 m-2 in predicting RHF. Right ventricular free wall longitudinal strain ≥-15.5% and right ventricular stroke work index <400 mmHg ml-1 m-2 were independent predictors of RHF following LVAD implantation. Currently available prediction risk scores had the modest power of accuracy in the low INTERMACS profile Turkish population.

Evaluation of a single hemodialysis on right ventricular function in patients by 3-dimensional speckle tracking imaging

Objective To evaluate the change of right ventricular function before and after single hemodialysis by 3-dimensional speckle tracking imaging(3D-STI). Methods Seventy-six patients with end-stage renal disease(ESRD) and 35 controls were included.ESRD patients were divided into normal left ventricular ejection fraction group(LVEF≥50%, 46 cases, group A)and decreased LVEF group(LVEF<50%, 30 cases, group B). Conventional echocardiography and 3D-STI parameters including right ventricular end diastolic volume(RVEDV), right ventricular end systolic volume (RVESV), right ventricular ejection fraction(RVEF), right ventricular septal longitudinal strain[RVLS(Septum)], right ventricular free wall longitudinal strain [RVLS(Freewall )], basal segment of right ventricular diameter[RVDd(base )], right ventricular middle diameter [RVDd(mid )], right ventricular long diameter (RVLD) and the upper and lower right ventricular fractional area change (FAC) were performed in patients and controls before and after a single hemodialysis. Results ①RVEDV, RVESV, RVDd(base), RVDd(mid), RVLD before a single hemodialysis in group A and B were significantly higher than those in control group (all P<0.05). RVEF, RVLS Freewall, RVLS(Septum) and FAC in group A and B were significantly lower than those in control group (all P<0.05). ②RVEDV, RVESV, RVEF, RVLD, RVLS(Freewall) were significantly lower in group A after a single hemodialysis(all P<0.05); RVEDV, RVESV, RVEF, RVLS(Freewall), RVLS(Septum) were significantly lower in group B after a single hemodialysis(all P<0.05); RVEDV, RVESV, RVEF, RVLS(Septum) and RVLS(Freewall) in group B before a single hemodialysis were lower than those in group A (all P<0.05). The difference of RVLS Septum decrease in group B after a single hemodialysis was higher than that in group A(P<0.05); The linear correlations analysis showed that the difference of body weight before and after a single hemodialysis was negatively related with the difference of RVLS(Freewall) before and after a single hemodialysis(group A: r=0.351, P=0.017; group B: r=0.696, P=0.000). Conclusions A single hemodialysis may have injurious effects on right ventricular systolic function and reduce strain value, which is more significant in group B(LVEF<50%). Cardiac dysfunction of patients may be remitted by reasonable control of water intake. Key words: Echocardiography; End-stage renal disease; Hemodialysis; Ventricular function, right; Three-dimensional speckle tracking imaging

Echocardiographic study of right ventricular dysfunction in patients with chronic thromboembolic pulmonary hypertension: Comparison of the right ventricular free wall longitudinal strain and conventional parameters

Objective To compare the value of right ventricular (RV) free wall longitudinal strain (FWLS) by speckle tracking echocardiography (STE) and conventional parameters in evaluation of RV dysfunction in chronic thromboembolic pulmonary hypertension (CTEPH). Methods Sixty CTEPH patients were enrolled as group A and 45 pulmonary embolism (PE) patients with normal pulmonary pressure were enrolled as group B in this study. CTEPH patients were divided into 2 subgroups using the World Health Organization (WHO) function classification: patients with WHO Ⅰ-Ⅱ were designated as group A1 and those with WHO Ⅲ-Ⅳ were designated as group A2. Conventional RV functional parameters including tricuspid annular plane systolic excursion (TAPSE), tissue Doppler-derived tricuspid annular systolic velocity (S′), fractional area change (FAC), RV index of myocardial performance (RVIMP), and STE-derived RV FWLS were measured and compared. Clinical right heart failure (RHF) was defined as the presence of symptoms of heart failure and signs of systemic circulation congestion during hospitalization. Results Compared to group B, group A patients had significant enlarged right heart dimension and impaired RV systolic function parameters (all P<0.001). The TAPSE, S′, FAC, and RV FWLS showed significant differences between CTEPH patients with mild (group A1) and severe symptoms (group A2) (all P<0.01), while RVIMP showed no significant difference (P=0.188). On receiver operating characteristic analysis, FWLS had the largest AUC to identify RHF (AUC=0.864, P<0.001), when the cutoff value was 15.05%, the sensitivity was 85.71%, and the specificity was 64.29%, respectively. On binary logistic regression analysis, only right atria area (OR=1.212, 95%CI=1.004-1.48, P=0.046) and RV FWLS (OR=0.662, 95%CI=0.470-0.933, P=0.018) were identified as independent predictor of RHF. Conclusions Compared with conventional parameters, RV FWLS showed advantages in identifying abnormal RV function in CTEPH patients. Key words: Echocardiography; Pulmonary embolism; Hypertension, pulmonary; Ventricular function, right; Strain

Assessment of right ventricular function by free wall longitudinal strain in organic mitral regurgitation

Organic mitral regurgitation (MR) is a frequent heart valve disease which influences ventricular functions and impacts cardiovascular outcome. Right Ventricular Free Wall Longitudinal Strain (RVLS) is a good prognosticator in heart failure. Hence, we aimed to study its determinants in organic MR. One hundred ninety-two patients (60 ± 15 years, 125 males) with mild to severe chronic organic MR were prospectively enrolled and underwent a comprehensive echocardiography with RVLS assessment. RV ejection fraction (EF) was also measured by cardiac magnetic resonance (CMR) imaging ( n = 128) or radionuclide angiography ( n = 6) in 134 patients (70%) Patients were stratified into 2 groups according to RVLS ≤ −26% (normal function) or > −26% (RV dysfunction). Patients with RV dysfunction exhibited a more severe condition with greater MR (SOR MR: 0.46 ± 0.25 cm 2 versus 0.38 ± 0.22 cm 2 , P = 0.023), were more symptomatic (NYHA 2.0 ± 0.9 versus 1.5 ± 0.6, P < 0.0001), had a lower left ventricular global longitudinal strain (LVGLS) (−19.6 ± 3.9% versus −21.5 ± 2.8%, P = 0.0001) and a lower RV EF by CMR/radionuclide Imaging (45.8 ± 10% versus 50.2 ± 7%, P = 0.0037). RVLS correlated with TAPSE ( r = −0.40, P < 0.0001), RV Fractional shortening ( r = −0.38, P < 0.0001), TEI index ( r = 0.3, P < 0.0001) and tricuspid annular systolic velocity ( r = −0.27, P < 0.0001). In addition, RVLS correlated only weakly ( r = −0.40, P < 0.0001) with RV EF. In multivariate analysis, pathophysiological determinants of RVLS were rhythm ( β = −0.26, P < 0.0001), pulmonary vascular resistance (Abbas formula, β = 0.26, P < 0.0001), LVGLS ( β = 0.19, P = 0.01) and LV end-systolic volume ( β = 0.15, P = 0.028). RVLS correlates with classical echocardiographic parameters of RV function. RVLS is influenced by pulmonary vasculature resistance (ventriculo-arterial coupling) and LV function (RV to LV interdependence), in agreement with previous findings. As a simple parameter, RVLS could be added to the routine assessment of RV function in organic MR.

Prognostic of the right ventricular strain in organic mitral regurgitation

Organic mitral regurgitation (MR) is a frequent heart valve disease which influences ventricular functions and impacts cardiovascular outcome. Right Ventricular Free Wall Longitudinal Strain (RVLS) is a good prognosticator in heart failure. Hence, we aimed to study its predictive value in organic MR. Two hundred fifty-eight patients (59 ± 15 years, 154 males) with mild to severe organic MR were prospectively enrolled with a complete echocardiography including RV free wall and LV global longitudinal strain assessment. Out of 181 patients with moderate to severe MR, 101 had normal LV and RV function (NoDysf), 40 patients (22%) had an isolated LV dysfunction (≤ −20%, LVdysf), 17 (9%) had an isolated RV dysfunction (≤ −21%, RVdysf), 23 (13%) had a biventricular dysfunction (BiVdysf). Biventricular dysfunction was strongly associated with worse structural (tricuspid annulus diameter: 22.2 ± 3.5 mm/m 2 vs. 19.2 ± 3.5 mm/m 2 , P = 0.0003) and functional RV remodeling (RV fractional shortening: 27.6 ± 9.6% vs. 38.3 ± 11.4%, P < 0.0001, TAPSE: 19.4 ± 5.3 mm vs. 25 ± 4.6 mm, P < 0.0001, tricuspid annular S wave velocity: 12.6 ± 2.9 cm/s vs. 15.5 ± 3.1 cm/s, P = 0.0001) compared with NoDysf. Pulmonary pressure (51.4 ± 20.4 mmHg vs. 39.11 ± 4 mmHg, P = 0.0002) and resistances (Abbas formula: 0.36 ± 0.15 vs. 0.22 ± 0.08, P < 0.0001) were increased in BiVdysf. Forty-nine patients (19%) experienced a cardiovascular events during the follow up period (21.6 ± 14.4 months). At 40 months follow-up, survival free of event was impaired in patients with BiVdysf compared with other groups (Nodysf: 73.2 ± 6%, RVDysf: 70.2 ± 13%, LVDysf: 66 ± 10% and BiVDysf: 41 ± 19%, P = 0.011). In organic MR, we identified by echocardiographic strain modality a sub-group of patients (BiVDysf), which portends a higher cardiovascular risk. The adjunction of RV longitudinal strain assessment in the clinical work-up of these patients could improve the evaluation of cardiovascular risk and may be helpful in the clinical-decision making process.

Assessment of the correlation between the severity of interstitial lung disease and clinical parameters by cardiopulmonary ultrasound performance

Objective To evaluate the application value of cardiopulmonary ultrasound(CPUS) in patients with interstitial lung diseases(ILD). Methods Ninety patients with clinically diagnosed interstitial lung diseases and 30 healthy subjects were included in this study. The conventional echocardiographic parameters and right ventricular free wall longitudinal strain (RVLS_FW) were measured in all patients and healthy subjects. The degree of pulmonary fibrosis or the disease severity of each ILD patient was scored using a semi-quantitative scoring method. Patients′ pulmonary function parameters and clinical outcome score (GAP score) were recorded. Fourteen patients belong to other types of ILD and 19 patients with incomplete clinical data were unable to perform GAP scoring, finally 57 patients′ clinical and ultrasonographic parameters were measured. On the basis of the pulmonary arterial systolic pressure (PASP) obtained by Doppler echocardiography, 90 patients were divided into two groups: ILD patients with pulmonary hypertension(ILDPH, PASP ≥36 mmHg, 1 mmHg=0.133 kPa) and ILD patients without PH (ILDNPH, PASP<36 mmHg). Comparsion between ILDPH, ILDNPH and healthy subjects were then evaluated. According to the GAP score, all cases were divided into three groups: low risk, moderate risk and high risk. Statistical analysis was performed to examine the relationship between CPUS parameters and clinical parameters. Results ①Compared with ILDNPH patients, ILDPH patients had significantly lower right ventricular function, wider basal right ventricular diameter (RVD), proximal right ventricular outflow diameter (DRVOT1) and right pulmonary artery diameter (DRPA). Compared with healthy subjects, ILDNPH patients had mildly lower right ventricular function and wider left pulmonary artery diameter (DLPA ) and right ventricular outflow tract dimensions at the distal or pulmonic valve (DRVOT2). ②A good correlation was found between lung ultrasound (LUS) scores and pulmonary function parameters, especially diffusion capacity for carbon monoxide of the lung(DLco)(r=-0.68, P<0.001). ③With the increased risk of patients, the right ventricular function was gradually decreased, DRVOT2, DRPA, DLPA were gradually widened, and the lung ultrasound score was gradually increased. A weak correlation was found between GAP scores with RVLS_FW, LUS scores, DRPA(r=0.44, 0.34, 0.31, P<0.05). Conclusions CPUS parameters are useful in the assessment of interstitial lung disease and could reflect the prognosis of ILD patients to some extent. Therefore, on the basis of GAP scores, addition of RVLS_FW and LUS score will be more helpful to evaluate the prognosis of ILD patients. Key words: Cardiopulmonary ultrasound; Lung diseases, interstitial; GAP score; Pulmonary function test

Incremental value of right heart metrics and exercise performance to well-validated risk scores in dilated cardiomyopathy.

Risk stratification in heart failure (HF) relies on several established clinical risk scores, however, myocardial deformation, right heart metrics, and exercise performance have not usually been considered. This study sought to assess the incremental value of advanced echocardiographic and cardiopulmonary exercise testing (CPX) parameters to validated risk scores in HF. The Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) and Metabolic Exercise Test Data Combined with Cardiac and Kidney Indexes (MECKI) scores were applied to 208 ambulatory patients with dilated cardiomyopathy (DCM) who completed echocardiography in conjunction with CPX as part of the Stanford Exercise Testing registry. Patients were followed for the composite end point of death, heart transplant, left ventricular device implantation, and hospitalization for acute HF. Mean age, left ventricular ejection fraction (LVEF), and left ventricular global longitudinal strain (LVGLS) were 47 ± 13 years, 33 ± 13%, and -10.6 ± 4.4%, respectively, while right ventricular free-wall longitudinal strain was -18.8 ± 5.5%. Partial correlation mapping identified strong correlations between LVEF, LVGLS, and LV systolic strain rate, with a moderate correlation between these metrics and peak VO2. Over a median follow up of 5.3 years, the composite end point occurred in 60 patients. Cox proportional hazards identified MAGGIC score [hazard ratio (HR) (2.04 [1.39-3.01], P < 0.01], peak VO2 HR (0.52 [0.28-0.97], P = 0.04), and right atrial volume indexed (RAVI) HR (1.31 [1.07-1.61], P < 0.01) as independent correlates of outcome. RAVI remained an independent correlate when combined with the MECKI score (2.21 [1.59-3.07]), P < 0.01, RAVI, 1.33 [1.06-1.67], P = 0.01). Our study demonstrates that RAVI is complementary to well-validated HF risk scores and highlights the importance of exercise performance in DCM.

Maturational Patterns of Systolic Ventricular Deformation Mechanics by Two-Dimensional Speckle-Tracking Echocardiography in Preterm Infants over the First Year of Age

The aim of this study was to determine the maturational changes in systolic ventricular strain mechanics by two-dimensional speckle-tracking echocardiography in extremely preterm neonates from birth to 1year of age and discern the impact of common cardiopulmonary abnormalities on the deformation measures. In a prospective multicenter study of 239 extremely preterm infants (<29weeks gestation at birth), left ventricular (LV) global longitudinal strain (GLS) and global longitudinal systolic strain rate (GLSRs), interventricular septal wall (IVS) GLS and GLSRs, right ventricular (RV) free wall longitudinal strain and strain rate, and segmental longitudinal strain in the RV free wall, LV free wall, and IVS were serially measured on days 1, 2, and 5 to 7, at 32 and 36weeks postmenstrual age, and at 1year corrected age (CA). Premature infants who developed bronchopulmonary dysplasia or had echocardiographic findings of pulmonary hypertension were analyzed separately. In uncomplicated preterm infants (n=103 [48%]), LV GLS and GLSRs remained unchanged from days 5 to 7 to 1year CA (P=.60 and P=.59). RV free wall longitudinal strain, RV free wall longitudinal strain rate, and IVS GLS and GLSRs significantly increased over the same time period (P<.01 for all measures). A significant base-to-apex (highest to lowest) segmental longitudinal strain gradient (P<.01) was seen in the RV free wall and a reverse apex-to-base gradient (P<.01) in the LV free wall. In infants with bronchopulmonary dysplasia and/or pulmonary hypertension (n=119 [51%]), RV free wall longitudinal strain and IVS GLS were significantly lower (P<.01), LV GLS and GLSRs were similar (P=.56), and IVS segmental longitudinal strain persisted as an RV-dominant base-to-apex gradient from 32weeks postmenstrual age to 1year CA. This study tracks the maturational patterns of global and regional deformation by two-dimensional speckle-tracking echocardiography in extremely preterm infants from birth to 1year CA. The maturational patterns are ventricular specific. Bronchopulmonary dysplasia and pulmonary hypertension leave a negative impact on RV and IVS strain, while LV strain remains stable.