Prognostic value of echocardiographic parameters for right ventricular function in patients with acute non-massive pulmonary embolism

Pulmonary Embolism in the Elderly: From Symptoms to Speckle Tracking Echocardiography

(1) Background: There are little data about the differences in clinical and echocardiographic characteristics between elderly (aged ≥ 65 years) and younger patients with acute pulmonary embolism (PE). (2) Methods: Consecutive patients diagnosed with PE in a tertiary hospital were identified. Clinical characteristics, biomarkers and transthoracic echocardiography indices including right ventricular free wall longitudinal strain (RV-FWLS) were recorded. (3) Results: Of 200 patients enrolled, 19 patients had high-risk PE and were excluded from the study. Compared to younger patients, elderly patients with PE had less frequently pain and typical symptoms and more often were hospitalized due to another reason before the PE diagnosis. The elderly had higher values of D-dimer, high-sensitivity troponin I and brain natriuretic peptide (BNP). Echocardiographic differences were noted and the elderly had lower values of pulmonary vascular acceleration time, RV E/A ratio and lower tricuspid annular plane systolic excursion/pulmonary artery systolic pressure ratio. The RV-FWLS index did not show a statistically significant difference in distribution between age groups ≥ 65 and <65 years old. The RV diameter was similar across all age groups. (4) Conclusions: The elderly have differences compared with younger patients with PE regarding the mode of presentation, the values of biomarkers like D-dimer, BNP and troponins and some echocardiographic indices of RV affection.

Right Ventricular Longitudinal Strain-Related Indices in Acute Pulmonary Embolism

Pulmonary embolism (PE) is correlated with serious morbidity and mortality. Efforts have been made to establish and validate mortality predictive scores based mainly on clinical parameters. Patients with PE and traditional indices of echocardiographic right ventricular (RV) dysfunction or pressure overload have a higher probability of a worse outcome. During the last two decades, studies regarding the use of two-dimensional speckle-tracking echocardiography (2DSTE) and its derived indices in the setting of acute PE have been conducted. In this comprehensive review of the literature, we aimed to summarize these studies. Safe conclusions and comparisons among the reviewed studies are prone to statistical errors, mainly because the studies published were heterogenous in design, different 2DSTE-derived parameters were tested, and different clinical outcomes were used as endpoints. Nonetheless, RV strain indices and, more commonly, regional longitudinal strain of the RV free wall have shown a promising correlation with mortality, assisting in the differential diagnosis between PE and other acute or chronic disorders.

Critical Care Ultrasound in Shock: A Comprehensive Review of Ultrasound Protocol for Hemodynamic Assessment in the Intensive Care Unit

Shock is a life-threatening condition that requires prompt recognition and treatment to prevent organ failure. In the intensive care unit, shock is a common presentation, and its management is challenging. Critical care ultrasound has emerged as a reliable and reproducible tool in diagnosing and classifying shock. This comprehensive review proposes an ultrasound-based protocol for the hemodynamic assessment of shock to guide its management in the ICU. The protocol classifies shock as either low or high cardiac index and differentiates obstructive, hypovolemic, cardiogenic, and distributive etiologies. In distributive shock, the protocol proposes a hemodynamic-based approach that considers the presence of dynamic obstruction, fluid responsiveness, fluid tolerance, and ventriculo-arterial coupling. The protocol gives value to quantitative measures based on critical care ultrasound to guide hemodynamic management. Using critical care ultrasound for a comprehensive hemodynamic assessment can help clinicians diagnose the etiology of shock and define the appropriate treatment while monitoring the response. The protocol's use in the ICU can facilitate prompt recognition, diagnosis, and management of shock, ultimately improving patient outcomes.

The role of echocardiography in pulmonary embolism for the prediction of in-hospital mortality: a retrospective study

PURPOSE

Pulmonary Embolism (PE) is the third leading cause of cardiovascular death, following myocardial infarction and stroke. The latest European Society of Cardiology (ESC) guidelines on PE recommend short-term prognostic stratification based on right ventricular (RV) overload detected by transthoracic echocardiography (TTE) or contrast-enhanced chest CT. The aim of the study is to find out which of the signs of right ventricular dysfunction best predicts in-hospital mortality (IHM).

METHODS

This is a monocentric, retrospective study including adult patients admitted from the emergency department with a c-e cCT confirmed diagnosis of PE between January 2018 and December 2022 who underwent a TTE within 48 h.

RESULTS

509 patients (median age 76 years [IQR 67-84]) were included, with 7.1% IHM. At univariate analysis, RV/LV ratio > 1 (OR 2.23, 95% CI 1.1-4.5), TAPSE < 17 mm (OR 4.73, 95% CI 2.3-9.8), the D-shape (OR 3.73, 95% CI 1.71-8.14), and LVEF < 35% (OR 5.78, 95% CI 1.72-19.47) resulted significantly correlated with IHM. However, at multivariate analysis including also haemodynamic instability, PESI class > II, and abnormal hs-cTnI levels, only LVEF < 35% (OR 5.46, 95% CI 1.32-22.61) resulted an independent predictor of IHM.

CONCLUSION

Despite the recognised role of TTE in the early management of patients with circulatory shock and suspected PE, signs of RV dysfunction have been shown to be poor predictors of IHM, whereas severely reduced LVEF is an independent risk factor for in-hospital death.

Perioperative echocardiographic strain analysis: what anesthesiologists should know

PURPOSE

Echocardiographic strain analysis by speckle tracking allows assessment of myocardial deformation during the cardiac cycle. Its clinical applications have significantly expanded over the last two decades as a sensitive marker of myocardial dysfunction with important diagnostic and prognostic values. Strain analysis has the potential to become a routine part of the perioperative echocardiographic examination for most anesthesiologist-echocardiographers but its exact role in the perioperative setting is still being defined.

CLINICAL FEATURES

This clinical report reviews the principles underlying strain analysis and describes its main clinical uses pertinent to the field of anesthesiology and perioperative medicine. Strain for assessment of left and right ventricular function as well as atrial strain is described. We also discuss the potential role of strain to aid in perioperative risk stratification, surgical patient selection in cardiac surgery, and guidance of anesthetic monitor choice and clinical decision-making in the perioperative period.

CONCLUSION

Echocardiographic strain analysis is a powerful tool that allows seeing what conventional 2D imaging sometimes fails to reveal. It often provides pathophysiologic insight into various cardiac diseases at an early stage. Strain analysis is readily feasible and reproducible thanks to the use of highly automated software platforms. This technique shows promising potential to become a valuable tool in the arsenal of the anesthesiologist-echocardiographer and aid in perioperative risk-stratification and clinical decision-making.

The Effects of Radiofrequency Catheter Ablation for Atrial Fibrillation on Right Ventricular Function

BACKGROUND AND OBJECTIVE

The effects of radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF) on right ventricular (RV) function are not well known.

METHODS

Patients who underwent RFCA for AF and underwent pre- and post-procedural echocardiography were enrolled consecutively. Fractional area change (FAC), RV free-wall longitudinal strain (RVFWSL), and RV 4-chamber strain including the ventricular septum (RV4CSL) were measured. Changes in FAC, RVFWSL, and RV4CSL before and after RFCA were compared among paroxysmal AF (PAF), persistent AF (PeAF), and long-standing persistent AF (LSPeAF) groups.

RESULTS

A total of 164 participants (74 PAF, 47 PeAF, and 43 LSPeAF; age, 60.8 ± 9.8 years; men, 74.4%) was enrolled. The patients with PeAF and LSPeAF had worse RV4CSL (p<0.001) and RVFWSL (p<0.001) than those with PAF and reference values. Improvements in RVFWSL and RV4CSL after RFCA were significant in the PeAF group compared with the PAF and LSPeAF groups (ΔRV4CSL, 8.4% [5.1, 11.6] in PeAF vs. 1.0% [-1.0, 4.1] in PAF, 1.9% [-0.2, 4.4] in LSPeAF, p<0.001; ΔRVFWSL, 9.0% [6.9, 11.5] in PeAF vs. 0.9% [-1.4, 4.9] in PAF, 1.0% [-1.0, 3.6] in LSPeAF, p<0.001). In patients without recurrence, improvements in RVFWSL and RV4CSL after RFCA were significant in the PeAF group compared to the LSPeAF group.

CONCLUSIONS

RV systolic function is more impaired in patients with PeAF and LSPeAF than in those with PAF. RV systolic function is more improved after RFCA in patients with PeAF than in those with PAF or LSPeAF.

Comparison of diuretics and fluid expansion in the initial treatment of patients with normotensive acute pulmonary embolism: a systematic review and meta-analysis

BACKGROUND

Right ventricular (RV) dysfunction is the main cause of death in patients with normotensive acute pulmonary embolism (PE). The optimal management for this subset of patients remains uncertain. This systematic review and meta-analysis focused on the comparison of diuretics and fluid expansion in patients with acute PE presenting with RV dysfunction and haemodynamic stability.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines considering only RTCs. The authors searched the traditional and grey literature through 1 November 2022. Meta-analysis used open source packages in R. Inverse variance fixed-effects models with OR as the effect measure were used for primary analyses. The main outcomes defined in this review protocol included pulmonary arterial systolic pressure (PASP), creatinine value changes and N-terminal pro-B-type natriuretic peptide during the first 24 hours.

RESULTS

Four studies with a total of 452 patients met the inclusion criteria. The baseline characteristics of patients were similar across all studies. Overall, patients receiving diuretics had a significant 24 hours reduction in pro-B-type natriuretic peptide (standard mean difference of -41.97; 95% CI -65.79 to -18.15), and PASP (standard mean difference of -5.96; 95% CI -8.06 to -3.86). This group had significantly higher creatinine levels (standard mean difference of 7.74; 95% CI 5.04 to 10.45). The quality of the studies was heterogeneous; two had a low risk of bias, and the other two had a high risk of bias.

CONCLUSIONS

Very few studies have compared the efficacy and safety of diuretics and fluid expansion in normotensive patients with acute PE with RV failure. Overall, furosemide appears to reduce RV dysfunction in this subset of patients compared with fluid expansion. Further research is required to confirm these findings.

Post-Pulmonary Embolism Impairment Six Months after Acute Pulmonary Embolism: A Prospective Registry

BACKGROUND

Little evidence is available on post-pulmonary embolism impairment (PPEI), a recently defined complication of pulmonary embolism (PE) encompassing dysfunctional clinical and imaging parameters. In the present study, we sought to evaluate its frequency with a focus on the main components.

METHODS

In this prospective registry, we included patients with a confirmed diagnosis of acute PE and focused on those with initial right ventricular (RV) dysfunction. Their baseline, pre-discharge, and 6 month follow-up clinical and imaging characteristics were recorded. The main study outcomes were incomplete RV functional recovery, exercise capacity limitations (based on the 6 minute walk test), and their combination, which defines PPEI, within six months of acute PE.

RESULTS

Of 170 consecutive patients with a confirmed diagnosis of acute PE, 123 accepted to participate in the follow-up study, of whom 87 had initial RV dysfunction. The 6 month rates of incomplete RV functional recovery, signs of an intermediate-to-high echocardiographic probability of PH, and exercise limitations were observed in 58.6, 32.1, and 45.9%, respectively. A total of 22 (25.2%; 95% CI 15.5-34.4%) patients had PPEI. The RV/LV ratio and the fractional area change on discharge after acute PE were more often impaired among patients with incomplete RV recovery, exercise limitations, and a high probability of PH at 6 months. In contrast, an initial impaired RV diastolic function indices appeared to characterize patients with a limited exercise capacity at 6 months.

DISCUSSION

PPEI affects one fourth of patients surviving acute PE with half of them presenting with RV dysfunction or exercise limitations.

A Multimodality Imaging Approach to Defining Risk in Patients With Acute Pulmonary Embolism

BACKGROUND

Morbidity and mortality for acute pulmonary embolism (PE) remain high. Therapies such as catheter-directed thrombolysis may improve outcomes, but these are generally reserved for higher-risk patients. Imaging may help guide the use of the newer therapies, but current guidelines focus more on clinical factors. Our goal was to create a risk model that incorporated quantitative echocardiographic and computed tomography (CT) measures of right ventricular (RV) size and function, thrombus burden, and serum biomarkers of cardiac overload or injury.

METHODS

This was a retrospective study of 150 patients evaluated by a PE response team. Echocardiography was performed within 48 hours of diagnosis. Computed tomography measures included RV/left ventricular (LV) ratio and thrombus load (Qanadli score). Echocardiography was used to obtain various quantitative measures of RV function. We compared characteristics of those who met the primary endpoint (7-day mortality and clinical deterioration) to those who did not. Receiver operating curve analysis was used to assess the performance of different combinations of clinically relevant features and the association with adverse outcomes.

RESULTS

Fifty-two percent of patients were female, with age 62 ± 17 years, systolic blood pressure 123 ± 25 mm Hg, heart rate 98 ± 19, troponin 3.2 ± 35 ng/dL, and b-type natriuretic peptide (BNP) 467 ± 653. Fourteen (9.3%) were treated with systemic thrombolytics, 27 (18%) underwent catheter-directed thrombolytics, 23 (15%) were intubated or required vasopressors, and 14 (9.3%) died. Patients who met the primary endpoint (44%) versus those who did not (56%) had lower RV S' (6.6 vs 11.9 cm/sec; P < .001) and RV free wall strain (-10.9% vs -13.6%; P = .005), higher RV/LV ratio on CT, and higher serum BNP and troponin levels. Receiver operating curve analysis demonstrated an area under the curve of 0.89 for a model that included RV S', RV free wall strain and tricuspid annular plane systolic excursion/RV systolic pressure ratio from echo, thrombus load and RV/LV ratio from CT, and troponin and BNP levels.

CONCLUSION

A combination of clinical, echo, and CT findings that reflect the hemodynamic effects of the embolism identified patients with adverse events related to acute PE. Optimized scoring systems that focus on reversible abnormalities attributable to PE may allow more appropriate triaging of intermediate- to high-risk patients with PE for early interventional strategy.

Indexing of Speckle Tracking Longitudinal Strain of Right Ventricle to Body Surface Area Does Not Improve Its Efficiency in Diagnosis and Mortality Risk Stratification in Patients with Acute Pulmonary Embolism

BACKGROUND

Acute pulmonary embolism (PE) is associated with a serious mortality rate. Thus, the rapid diagnosis and identification of patients at high risk of death is pivotal. The search for echocardiographic parameters for this purpose continues. Recent publications reveal correlations between myocardial longitudinal strain (LS) and body surface area (BSA). The aim of the study was to evaluate the usefulness of indexing the right ventricular (RV) speckle tracking LS to BSA in detecting PE and stratifying the risk of 30-day all-cause mortality.

METHODS

the prospective cross-sectional observational study group consisted of 167 consecutive patients (76 men, 45.5%) aged 69.5 ± 15.3 years, and they were referred for computed tomography pulmonary angiography. Patients underwent a transthoracic echocardiographic examination within 24 h of admission to the hospital ward. RVLS and their derivatives indexed to BSA were included in the analysis.

RESULTS

PE was confirmed in 88 patients, while 79 patients had no radiological features of PE. The only echocardiographic parameters that differed between subgroups were pulmonary flow acceleration (Act), McConnell's sign, LS of the middle segment of the RV free wall, and its derivative indexed to BSA. During the 30-day follow-up of a subgroup of subjects with PE, 12 patients died. The mortality predictors with increasing prediction value included a RV free wall mid-segment LS (cut-off value: -21%, Area Under the Curve-AUC 0.6, p = 0.02) and its derivative indexed to BSA (-14 %/m², AUC 0.62, p = 0.003), body mass index (24.7 kg/m², AUC 0.63, p = 0.002), D-dimer serum concentration (3559 pg/mL, AUC 0.66, p < 0.001), Act (67 ms, AUC 0.67, p < 0.001), septal basal LS (-15%, AUC 0.68, p = 0.02), RV free wall basal segment LS (-14%, AUC 0.7, p = 0.015), age (66 years, AUC 0.74, p = 0.004), NT-proBNP (1120 pg/mL, AUC 0.75, p = 0.01), troponin T (66 ng/mL, AUC 0.78, p = 0.005), and the complex score of the Pulmonary Embolism Severity Index (AUC 0.88, p < 0.001).

CONCLUSIONS

indexing of RVLS to BSA does not improve its prognostic value in patients with acute PE.

Role of echocardiography in acute pulmonary embolism

Although pulmonary embolism (PE)-related mortality rate has decreased because of prompt diagnosis and effective therapy use, acute PE remains a potentially lethal disease. Due to its increasing prevalence, clinicians should pay attention to diagnosing and managing patients with acute PE. Echocardiography is the most commonly used method for diagnosing and managing acute PE; it also provides clues about hemodynamic instability in an emergency situation. It has been validated in the early risk stratification and impacts management strategies for treating acute PE. In hemodynamically unstable patients with acute PE, echocardiographic detection of right ventricular dysfunction is an indication for administering thrombolytics. In this review article, we discuss the role of echocardiography in the diagnosis and management of patients with acute PE.

Right ventricular free wall strain in acutely decompensated heart failure patients with ischemic and non-ischemic cardiomyopathy

AIMS

Right ventricular (RV) dysfunction is a predictor of adverse outcomes among patients with HF with reduced ejection fraction (HFrEF); however, differences in RV parameters in HFrEF patients with ischemic (ICM) and non-ischemic cardiomyopathies (NICM) are not well understood. We investigated echocardiographic characteristics, including RV strain, in patients with acute decompensated heart failure (ADHF) and compared patients with ICM and NICM etiology.

METHODS

Consecutive patients who presented with ADHF and NYHA class III-IV were prospectively enrolled if they had LVEF < 40% and history of ICM or NICM. All patients underwent clinical exam, laboratory evaluation and 2-D echocardiographic assessment of the left ventricular (LV) and RV function, LV and RV global longitudinal strain (LVGLS, RVGLS), and RV free wall strain (RVfwLS).

RESULTS

Of 84 patients, 44 had ICM and 40 NICM. The groups had similar blood pressure, NT-proBNP, and echocardiographic parameters of LV function including LVGLS. Absolute RVGLS values were lower than RVfwLS values in both groups. Patients with NICM had significantly lower RVfwLS, but not RVGLS, compared to patients with ICM (-13% to -17%, p = 0.006). Similar differences in RVfwLS were seen in patients in NYHA class III (NICM vs ICM: -13% and -17%, respectively, 95% CI: -8.5 to -.5) and NYHA class IV (NICM vs ICM: -13.8% and -17%, respectively, 95% CI: -6.4 to -.59).

CONCLUSION

Among patients hospitalized with ADHF, patients with nonischemic etiology compared with the patients with ICM, have more severe RV dysfunction measured by RVfwLS, despite similar extent of LV impairment and the same functional limitation class.

The addition of echocardiographic parameters to PESI risk score improves mortality prediction in patients with acute pulmonary embolism: PESI-Echo score

AIMS

Pulmonary embolism severity index (PESI) has been developed to help physicians make decisions about the treatment of patients with pulmonary embolism (PE). The combination of echocardiographic parameters could potentially improve PESI's mortality prediction. To assess the additional prognostic value of tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP) when combined with the PESI score in patients with PE to predict short-term mortality.

METHODS AND RESULTS

A multicentric prospective study database of patients admitted with PE in 75 academic centres in Argentina between 2016 and 2017 was analysed. Patients with an echocardiogram at admission with simultaneous measurement of TAPSE and PASP were included. PESI risk score was calculated blindly and prospectively, and in-hospital all-cause mortality was assessed. Of 684 patients, 91% had an echocardiogram, PASP and TAPSE could be estimated simultaneously in 355 (57%). All-cause in-hospital mortality was 11%. The receiver operating characteristic analysis showed an area under the curve (AUC) [95% confidence interval (CI)] of 0.76 (0.72-0.81), 0.74 (0.69-0.79), and 0.71 (0.62-0.79), for the PESI score, PASP, and TAPSE parameters, respectively. When PESI score was combined with the echocardiogram parameters (PESI + PASP-TAPSE = PESI-Echo), an AUC of 0.82 (0.77-0.86) was achieved (P = 0.007). A PESI-Echo score ≥128 was the optimal cut-off point for predicting hospital mortality: sensitivity 82% (95% CI 67-90%), specificity 69% (95% CI 64-74%). The global net reclassification improvement was 9.9%.

CONCLUSIONS

PESI-Echo score is a novel tool for assessing mortality risk in patients with acute PE. The addition of echocardiographic parameters to a validated clinical score improved the prediction of hospital mortality.

What are the echocardiographic findings of acute right ventricular strain that suggest pulmonary embolism?

INTRODUCTION

Pulmonary embolism (PE) is a potentially fatal disease encountered in the hospital setting. Prompt diagnosis and management can improve outcomes and survival. Unfortunately, a PE may be difficult to diagnose in a timely manner. Point-of-care ultrasound (POCUS) can assist in the evaluation for suspected PE by assessing for acute right ventricular strain. Physicians should thus be aware of these echocardiographic findings.

OBJECTIVE

This manuscript will review ten echocardiographic findings of right ventricular strain that may suggest a diagnosis of PE. It will provide a description of each finding along with the associated pathophysiology. It will also summarize the literature for the diagnostic utility of echocardiography for this indication, while providing reference parameters where applicable. Along with labeled images and video clips, the review will then illustrate how to evaluate for each of the ten findings, while offering pearls and pitfalls in this bedside evaluation.

DISCUSSION

The ten echocardiographic findings of right ventricular strain are: increased right ventricle: left ventricle size ratio, abnormal septal motion, McConnell's sign, tricuspid regurgitation, elevated pulmonary artery systolic pressure, decreased tricuspid annular plane systolic excursion, decreased S', pulmonary artery mid-systolic notching, 60/60 sign, and speckle tracking demonstrating decreased right ventricular free wall strain.

CONCLUSIONS

Physicians must recognize and understand the echocardiographic findings and associated pathophysiology of right ventricular strain. In the proper clinical context, these findings can point toward a diagnosis of PE and thereby lead to earlier initiation of directed management.

Evaluating the Right Ventricle in Acute and Chronic Pulmonary Embolism: Current and Future Considerations

The right ventricle (RV), due to its morphologic and physiologic differences, is susceptible to sudden increase in RV afterload, as noted in patients with acute pulmonary embolism (PE). Functional impairment of RV function is a stronger presage of adverse outcomes in acute PE than the location or burden of emboli. While current iterations of most clinical prognostic scores do not incorporate RV dysfunction, advancements in imaging have enabled more granular and accurate assessment of RV dysfunction in acute PE. RV enlargement and dysfunction on imaging is noted only in a subset of patients with acute PE and is dependent on underlying cardiopulmonary reserve and clot burden. Specific signs like McConnell's and "60/60" sign are noted in less than 20% of patients with acute PE. About 2% of patients with acute PE develop chronic thromboembolic pulmonary hypertension, characterized by continued deterioration in RV function in a subset of patients with a continuum of RV function from preserved to overt right heart failure. Advances in molecular and other imaging will help better characterize RV dysfunction in this population and evaluate the response to therapies.

One-Year Echocardiographic, Functional, and Quality of Life Outcomes After Ultrasound-Facilitated Catheter-Based Fibrinolysis for Pulmonary Embolism

Accelerated tPA (tissue-type plasminogen activator) dosing regimens for ultrasound-facilitated, catheter-directed fibrinolysis improve short-term computed tomographic-measured right ventricular (RV)-to-left ventricular diameter ratio in massive and submassive pulmonary embolism. The impact on RV remodeling, functional status, and quality of life over the long-term remains unclear.

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 (G_20–40, G_41–60 and G_61–80). 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 G_61–80 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.

Echocardiography-Derived Stroke Volume Index Is Associated With Adverse In-Hospital Outcomes in Intermediate-Risk Acute Pulmonary Embolism: A Retrospective Cohort Study

BACKGROUND

There remains uncertainty in the optimal prognostication and management of patients with intermediate-risk pulmonary embolism (PE). Transthoracic echocardiography can identify right ventricular dysfunction to recognize intermediate-high-risk patients.

RESEARCH QUESTION

Is echocardiographic-derived stroke volume index (SVI) associated with death or cardiopulmonary decompensation in intermediate-risk patients with PE?

STUDY DESIGN AND METHODS

and Methods: We retrospectively evaluated echocardiographic-derived variables that included SVI in normotensive patients with acute PE who were admitted between January 2012 and March 2017. SVI was determined with the use of the Doppler velocity-time integral in the left or right ventricular outflow tract. The primary outcome was in-hospital PE-related death or cardiopulmonary decompensation. We used logistic regression to determine the association between SVI and outcomes and receiver operating characteristic analysis to compare the performance of SVI and other echocardiographic measures.

RESULTS

The primary outcome occurred in 26 of the 665 intermediate-risk patients (3.9%) with PE. Univariate logistic regression showed an OR of 1.37 (95% CI, 1.23-1.52; P < .001) per 1-mL/m² decrease in SVI for the primary outcome. Bivariate logistic regression showed that SVI was independent of age, sex, heart rate, tricuspid regurgitation velocity, tricuspid annular plane systolic excursion, troponin, and Bova score. SVI had the highest C-statistic of 0.88 (95% CI, 0.81-0.96) of all echocardiographic variables with a Youden's J-statistic that identifies an optimal cut-point of 20.0 mL/m², which corresponds to positive and negative likelihood ratios of 6.5 (95% CI, 5.0-8.6) and 0.2 (95% CI, 0.1-0.5) for the primary outcomes, respectively.

INTERPRETATION

Low SVI was associated with in-hospital death or cardiopulmonary decompensation in acute PE. SVI had excellent performance compared with other clinical and echocardiographic variables.

Prognostic Value of Electrocardiography in Elderly Patients with Acute Pulmonary Embolism

BACKGROUND

Electrocardiographic (ECG) signs of right ventricular strain could be used as a simple tool to risk-stratify patients with acute pulmonary embolism.

METHODS

We studied consecutive patients aged ≥65 years with acute pulmonary embolism in a prospective multicenter cohort study. Two readers independently analyzed 12 predefined ECG signs of right ventricular strain in all patients. The outcome was the occurrence of an adverse clinical event, defined as death from any cause within 90 days or a complicated in-hospital course. We determined the interrater reliability for each ECG sign and examined the association between right ventricular strain signs and adverse events using logistic regression, adjusting for the Pulmonary Embolism Severity Index and cardiac troponin.

RESULTS

Overall, 320/390 patients (82%) showed at least one ECG sign of right ventricular strain. The interrater reliability for individual ECG signs was highly variable (ᴋ 0.40-0.95). Patients with ≥1 of the 3 classic signs of right ventricular strain (S1Q3T3, right bundle branch block, or T wave inversions in V1-V4) had a higher incidence of adverse events than those without (13% vs 6%; P = .026). After adjustment, the presence of ≥1 of the 3 classic signs of right ventricular strain (odds ratio 2.11; 95% confidence interval, 1.00-4.46) and the number of right ventricular strain signs present were significantly associated with adverse events (odds ratio 1.35 per sign; 95% confidence interval, 1.08-1.69).

CONCLUSIONS

ECG signs of right ventricular strain are common in elderly patients with acute pulmonary embolism. Although such signs may have prognostic value, their variable reliability and the rather modest prognostic effect size may limit their usefulness in the risk stratification of pulmonary embolism.

Role of echocardiography in managing acute pulmonary embolism

The role of echocardiography in acute pulmonary embolism (PE) remains incompletely defined. Echocardiography cannot reliably diagnose acute PE, and it does not improve prognostication of patients with low-risk acute PE who lack other clinical features of right ventricular (RV) dysfunction. Echocardiography, however, may yield additional prognostic information in higher risk patients and can aid in distinguishing acute from chronic RV dysfunction. Specific echocardiographic markers of RV dysfunction have the potential to enhance prognostication beyond existing risk models. Until these markers are subjected to rigorous prospective studies, the therapeutic utility and economic value of echocardiography in acute PE are uncertain.

Two-dimensional Echocardiographic Assessment of Myocardial Strain: Important Echocardiographic Parameter Readily Useful in Clinical Field

Echocardiography is the first and is the most-available imaging modality for many cardiovascular diseases, and echocardiographic parameters can give much important information for diagnosis, treatment, and prognostic evaluations. Left ventricular ejection fraction (LVEF) is the most commonly used echocardiographic parameter for left ventricular (LV) systolic function. Although LVEF is used routinely in daily practice, it is calculated from volumetric change without representing true myocardial properties. Recently, strain echocardiography has been used to objectively measure myocardial deformation. Myocardial strain can give accurate information about intrinsic myocardial function, and it can be used to detect early-stage cardiovascular diseases, monitor myocardial changes with specific therapies, differentiate cardiomyopathies, and predict the prognosis of several cardiovascular diseases. Although strain echocardiography has been applied to measure the right ventricle and left atrium, in addition to analyzing the LV, many cardiologists who are not imaging specialists are unaware of its clinical use and importance. Therefore, this review describes the measurement and clinical utility of 2-dimensional strain analysis in various cardiovascular diseases.