Julia Grapsa

Three-Dimensional Speckle Tracking of the Right Ventricle : Toward Optimal Quantification of Right Ventricular Dysfunction in Pulmonary Hypertension

BACKGROUND Quantitative assessment of right ventricular (RV) systolic function largely depends on right ventricular ejection fraction (RVEF). Three-dimensional speckle tracking (3D-ST) has been used extensively to quantify left ventricular function, but its value for RV assessment has not been established. OBJECTIVES This study sought to prospectively assess whether 3D-ST would be a reliable method for assessing RV systolic function and whether strain values were associated with survival. METHODS Comprehensive 2-dimensional echocardiographic assessment, 3D-ST of the RV free wall, and measurement of RVEF was performed in 97 consecutive patients with established pulmonary hypertension (PHT) (RVEF 31.4 ± 9.6%, right ventricular systolic pressure [RVSP] 76.5 ± 26.2 mm Hg) and 60 healthy volunteers (RVEF 43.8 ± 9.4%, RVSP 25.9 ± 4.3 mm Hg). RESULTS Area strain (AS) (-24.3 ± 7.3 vs. -30.8 ± 7.2; p < 0.001), radial strain (23.2 ± 14.4 vs. 34.9 ± 18.2; p < 0.001), longitudinal strain (LS) (-15.5 ± 3.8 vs. -17.9 ± 4.4; p = 0.001), and circumferential strain (CS) (-12.2 ± 4.5 vs. -15.7 ± 6.1; p < 0.001) were all reduced in patients with PHT, compared with normal individuals. AS and CS strongly correlated to RVEF (r = 0.851, r = -0.711; p < 0.001). Systolic dyssynchrony index was greater in PHT (0.14 ± 0.06 vs. 0.11 ± 0.07; p = 0.003) and correlated to RVEF (r = -0.563, p < 0.001). AS (hazard ratio [HR]: 3.49; 95% confidence interval [CI]: 1.21 to 7.07; p = 0.017), CS (HR: 4.17; 95% CI: 1.93 to 12.97; p < 0.001), LS (HR: 7.63; 95% CI: 1.76 to 10.27; p = 0.001), and RVEF (HR: 2.43; 95 CI: 1.00 to 5.92; p = 0.050) were significant determinants of all-cause mortality. Only AS (p = 0.029) and age (p = 0.087) were predictive of death after logistic regression analysis. CONCLUSIONS PHT patients have reduced RV strain patterns and more dyssynchronous ventricles compared with controls, which was relatable to clinical outcomes. AS best correlated with RVEF and provides prognostic information independent of other variables.

Original InvestigationThree-Dimensional Speckle Tracking of the Right Ventricle: Toward Optimal Quantification of Right Ventricular Dysfunction in Pulmonary Hypertension

BACKGROUND Quantitative assessment of right ventricular (RV) systolic function largely depends on right ventricular ejection fraction (RVEF). Three-dimensional speckle tracking (3D-ST) has been used extensively to quantify left ventricular function, but its value for RV assessment has not been established. OBJECTIVES This study sought to prospectively assess whether 3D-ST would be a reliable method for assessing RV systolic function and whether strain values were associated with survival. METHODS Comprehensive 2-dimensional echocardiographic assessment, 3D-ST of the RV free wall, and measurement of RVEF was performed in 97 consecutive patients with established pulmonary hypertension (PHT) (RVEF 31.4 ± 9.6%, right ventricular systolic pressure [RVSP] 76.5 ± 26.2 mm Hg) and 60 healthy volunteers (RVEF 43.8 ± 9.4%, RVSP 25.9 ± 4.3 mm Hg). RESULTS Area strain (AS) (-24.3 ± 7.3 vs. -30.8 ± 7.2; p < 0.001), radial strain (23.2 ± 14.4 vs. 34.9 ± 18.2; p < 0.001), longitudinal strain (LS) (-15.5 ± 3.8 vs. -17.9 ± 4.4; p = 0.001), and circumferential strain (CS) (-12.2 ± 4.5 vs. -15.7 ± 6.1; p < 0.001) were all reduced in patients with PHT, compared with normal individuals. AS and CS strongly correlated to RVEF (r = 0.851, r = -0.711; p < 0.001). Systolic dyssynchrony index was greater in PHT (0.14 ± 0.06 vs. 0.11 ± 0.07; p = 0.003) and correlated to RVEF (r = -0.563, p < 0.001). AS (hazard ratio [HR]: 3.49; 95% confidence interval [CI]: 1.21 to 7.07; p = 0.017), CS (HR: 4.17; 95% CI: 1.93 to 12.97; p < 0.001), LS (HR: 7.63; 95% CI: 1.76 to 10.27; p = 0.001), and RVEF (HR: 2.43; 95 CI: 1.00 to 5.92; p = 0.050) were significant determinants of all-cause mortality. Only AS (p = 0.029) and age (p = 0.087) were predictive of death after logistic regression analysis. CONCLUSIONS PHT patients have reduced RV strain patterns and more dyssynchronous ventricles compared with controls, which was relatable to clinical outcomes. AS best correlated with RVEF and provides prognostic information independent of other variables.

Right ventricular remodelling in pulmonary arterial hypertension with three-dimensional echocardiography: comparison with cardiac magnetic resonance imaging.

AIMS Right ventricular (RV) mass and volume calculations are important correlates of survival in patients with pulmonary arterial hypertension (PAH). We tested the hypothesis that RV mass, volumes and function could be measured accurately with real-time three-dimensional echocardiography (3DE) in patients with PAH and compared those against cardiac magnetic resonance (CMR). METHODS AND RESULTS Sixty consecutive PAH patients and 20 normals were examined with 3DE and CMR. RV end-diastolic volumes (EDV), end-systolic (ESV), stroke volume (SV), ejection fraction (EF), and mass were measured in all patients and in normals. Two independent observers assessed variability using the Bland-Altman analysis agreement. RV volumes (in mL) and mass were similar between 3DE and CMR in PAH patients: [EDV (in mL) 183.2 +/- 38 vs. 187.3 +/- 41, P = 0.32; ESV (in mL) 122 +/- 33 vs. 126 +/- 36, P = 0.99; SV (in mL) 63 +/- 15 vs. 65 +/- 19, P = 0.06; EF (in %) 33 +/- 7 vs. 31 +/- 9, P = 0.16 and RV mass (g) 99 +/- 20 vs. 96 +/- 22, P = 0.42], respectively. Interobserver variability was similar between 3DE and CMR in PAH for all variables, with CMR showing less interobserver variability for EDV compared with 3DE in both patients and normals (patients: mean bias: CMR-EDV: 0.4 +/- 16 mL vs. 3DE-EDV: 6.9 +/- 17.9 and in normals: CMR-EDV: 0.1 +/- 9.8 vs. 3DE-EDV: 5.7 +/- 16.3, respectively), whereas EF and RV mass were poorly reproducible with no correlation between observers for 3DE and CMR. CONCLUSIONS RV remodelling in PAH patients can be accurately assessed with both 3DE and CMR. Both modalities are robust and reproducible with CMR being more reproducible for measurements of EF and RV mass.

Echocardiographic assessment of pulmonary hypertension: standard operating procedure

Patients with suspected pulmonary hypertension (PH) should be evaluated using a multimodality approach to ensure that they receive a correct diagnosis. The series of investigations required includes clinical evaluation, noninvasive imaging techniques and right heart catheterisation (considered to be the “gold standard” for the diagnosis of PH). Current guidelines recommend that a detailed echocardiographic assessment is performed in all patients with suspected PH. In this review we summarise a protocol adopted by the National Pulmonary Hypertension Centres of UK and Ireland and approved by the British Society of Echocardiography for the evaluation of these patients. The views and measurements described are recommended for diagnosis, assisting in prognosis and providing a noninvasive means of following disease progression or response to therapy.

EACVI/EHRA Expert Consensus Document on the role of multi-modality imaging for the evaluation of patients with atrial fibrillation

Atrial fibrillation (AF) is the commonest cardiac rhythm disorder. Evaluation of patients with AF requires an electrocardiogram, but imaging techniques should be considered for defining management and driving treatment. The present document is an expert consensus from the European Association of Cardiovascular Imaging (EACVI) and the European Heart Rhythm Association. The clinical value of echocardiography, cardiac magnetic resonance (CMR), computed tomography (CT), and nuclear imaging in AF patients are challenged. Left atrial (LA) volume and strain in echocardiography as well as assessment of LA fibrosis in CMR are discussed. The value of CT, especially in planning interventions, is highlighted. Fourteen consensus statements have been reached. These may serve as a guide for both imagers and electrophysiologists for best selecting the imaging technique and for best interpreting its results in AF patients.

Atrial septal defect closure is associated with a reduced prevalence of atrial tachyarrhythmia in the short to medium term: a systematic review and meta-analysis

Atrial tachyarrhythmias are a common complication of atrial septal defects. The objective was to determine the effect of atrial septal defect closure on pre-existing atrial tachyarrhythmias and to investigate if such an effect is present after either surgical or percutaneous closure. Medline, EMBASE, Cochrane Library, and Google Scholar databases were searched between 1967 and 2009. The search was expanded using the ‘related articles’ function and reference lists of key studies. All studies reporting pre- and post- closure incidence (or prevalence) of atrial tachyarrhythmias in the same patient groups were included. Data were independently extracted by two authors according to a pre-defined protocol. Incongruities were settled by consensus decision. Twenty six studies were identified including 1841 patients who underwent surgical closure and 945 who underwent percutaneous closure. Meta-analysis using a random effects model demonstrated a reduction in the prevalence of atrial tachyarrhythmias following atrial septal defect closure [OR = 0.66 (95% CI 0.57-0.77)]. This effect was demonstrated after both percutaneous [OR = 0.49 (95% CI 0.32-0.76)] and surgical closure [OR = 0.72 (95% CI 0.60-0.87)]. Immediate (<30 days) and mid-term (30 days - 5 years) follow-up also demonstrated a reduction in AT prevalence [ORs of 0.80 (95% CI 0.66-0.97) and 0.47 (95% CI 0.36-0.62) respectively]. Atrial septal defect closure, whether surgical or percutaneous, is associated with a reduction in the post-closure prevalence of pre-existing atrial tachyarrhythmias and atrial fibrillation in the short to medium term.

Morphologic and functional remodeling of the right ventricle in pulmonary hypertension by real time three dimensional echocardiography.

The aims of this study were to assess the right ventricle in different causes of pulmonary hypertension (PH) and to assess the changes of the tricuspid apparatus during this remodeling. The functional and morphologic changes of the right ventricle and the tricuspid apparatus in relation to different causes of PH remain elusive. A total of 141 consecutive patients were prospectively recruited, of whom 55 had pulmonary arterial hypertension (PAH), 32 had chronic thromboembolic disease (CTED), and 34 had PH secondary to mitral regurgitation (MR). Twenty age- and gender-matched healthy volunteers were also studied to serve as controls. Real-time 3-dimensional echocardiography was used to assess right ventricular (RV) volumes and tricuspid valve mobility. Overall, RV diastolic volumes were greater and RV ejection fractions lower in patients with PAH compared to those with CTED and MR (186.4 ± 48.8 vs 113.5 vs 109.4 ml, p < 0.001, and 33.2% vs 36.8% vs 66.8%, p < 0.001, respectively). Among the 3 PH groups, tricuspid valve mobility was most restricted in the CTED group and least restricted in the MR group. Tricuspid tenting volume was greater in the CTED and PAH groups than in the MR group (p < 0.01). Most patients with PAH (54.6%) had at least moderate tricuspid regurgitation, while in the CTED group, most (59.4%) had mild and only 37.5% had moderate tricuspid regurgitation (p < 0.01). Conversely, patients with MR (85%) had only mild tricuspid regurgitation. There was no correlation between RV systolic pressures and the RV ejection fraction or tenting volume. In conclusion, this study demonstrates that different causes of PH may lead to diverse RV remodeling, with the most adverse remodeling being in patients with PAH. In addition, changes of the tricuspid apparatus also differed, with the most adverse effects seen in patients with CTED.

The effect of bariatric surgery on echocardiographic indices: a review of the literature

Obesity is the new epidemic and is associated with an increased risk of diastolic and systolic heart failure. Effective treatment options with drastic results such as bariatric surgery have raised interest in the possible reversal of some of the cardiovascular sequelae. Many studies have assessed individually the effect of weight loss on specific echocardiographic indices, mostly employing nonhomogeneous groups. The purpose of this narrative review is to summarise the effect of bariatric surgery on echocardiographic indices of biventricular function and to help in the understanding of the expected echocardiographic changes in bariatric patients after weight‐loss surgery

Right ventricular function in patients with pulmonary hypertension; the value of myocardial performance index measured by tissue Doppler imaging

AIMS Myocardial performance index (MPI) measured by conventional Doppler is routinely used to assess right ventricular (RV) systolic function in patients with pulmonary hypertension (PH). Our aim was to determine whether MPI measured by Doppler tissue imaging (tMPI) is effective in assessing RV function in these patients. METHODS AND RESULTS Retrospectively, we have studied 196 patients with chronic PH [pulmonary arterial systolic pressure (PASP) 81 +/- 40 mmHg] and 37 healthy volunteers (PASP of 27 +/- 7 mmHg). According to the exclusion criteria, 172 patients were included in the final study cohort. All patients were evaluated for RV systolic function by different parameters. MPI was measured by both conventional and tissue Doppler imaging. Bland-Altman analysis showed moderate agreement between MPI and tMPI (the mean difference was -0.02, absolute difference = -0.32 to 0.29; 95% intervals of agreement, percentage of average = -46.6 to 40.8%). In 50 consecutive PH patients where additional parameters were calculated, we found a significant correlation between tMPI and RV ejection fraction (r = -0.73, P< 0.0001) and RV fractional area change (r = -0.58, P< 0.0001). No significant inter- and intra-observer variability was identified. CONCLUSION This study demonstrated a moderate agreement between two methods of measuring MPI. A good correlation of tMPI with RV ejection fraction and RV fractional area change was found indicating that tMPI might be superior to MPI Doppler. tMPI is a parameter unaffected by RV geometry and importantly has the advantage of simultaneously recording the time intervals from the same cardiac cycle.

Standardization of adult transthoracic echocardiography reporting in agreement with recent chamber quantification, diastolic function, and heart valve disease recommendations: an expert consensus document of the European Association of Cardiovascular Imaging

Aims This European Association Cardiovascular Imaging (EACVI) Expert Consensus document aims at defining the main quantitative information on cardiac structure and function that needs to be included in standard echocardiographic report following recent ASE/EACVI chamber quantification, diastolic function, and heart valve disease recommendations. The document focuses on general reporting and specific pathological conditions such as heart failure, coronary artery and valvular heart disease, cardiomyopathies, and systemic diseases. Methods and results Demographic data (age, body surface area, blood pressure, and heart rhythm and rate), type (vendor and model) of ultrasound system used and image quality need to be reported. In addition, measurements should be normalized for body size. Reference normal values, derived by ASE/EACVI recommendations, shall always be reported to differentiate normal from pathological conditions. This Expert Consensus document suggests avoiding the surveillance of specific variable using different ultrasound techniques (e.g. in echo labs with high expertise in left ventricular ejection fraction by 3D and not by 2D echocardiography). The report should be also tailored in relation with different cardiac pathologies, quality of images, and needs of the caregivers. Conclusion The conclusion should be concise reflecting the status of left ventricular structure and function, the presence of left atrial and/or aortic dilation, right ventricular dysfunction, and pulmonary hypertension, leading to an objective communication with the patient health caregiver. Variation over time should be considered carefully, taking always into account the consistency of the parameters used for comparison.