Right atrial morphology and function in patients with systemic sclerosis compared to healthy controls: a two-dimensional strain study

Features of Heart Failure with Preserved Ejection Fraction in Patients with Chronic Obstructive Pulmonary Disease and Systemic Sclerosis-Associated Interstitial Lung Diseases

Background/Objectives: This study aims to investigate the potential etiopathogenesis of HFpEF development and identify possible different phenotypes of HFpEF in patients with chronic obstructive pulmonary disease (COPD) and systemic sclerosis-associated interstitial lung diseases (SS-ILDs). It could help clinicians improve early HFpEF personalized detection and management. Methods: This study included 150 patients with chronic lung diseases (CLDs), such as COPD and SS-ILD, who were outside of exacerbation, had no history of chronic heart failure (CHF), and had a left ventricular ejection fraction (LV EF) of ≥50%. The functional status of the lungs, heart, endothelial dysfunction, and acid-base balance was assessed. The results obtained were compared in groups of patients with CLD depending on the presence or absence of HF with preserved ejection fraction (HFpEF). The diagnosis of HFpEF was established based on the HFA-PEFF Score classification. Nonparametric statistical methods were used. Results: In patients with CLD, indicators such as age, longitudinal size of the right atrium, mid-regional pro-atrial natriuretic peptide (MR-proANP), and highly sensitive cardiac troponin T (hsTnT) were higher than in the group of patients without HFpEF. In patients with COPD and HFpEF, statistically significant changes were found in the volume of the left atrium. In patients with SS-ILD and HFpEF, statistically significant differenceswere found in SBP before and after the 6 min walk test (6MWT), the Borg scale before 6MWT, MR-proANP, and the longitudinal dimension of the right atrium. Conclusions: The results of our study allow us to identify two different mechanisms of HFpEF development: In patients with COPD, the predominant factor in the development of HFpEF was hypoxia, while in patients with SS-ILD, myocardial dysfunction with remodeling developed against the background of secondary pulmonary hypertension, highlighting the importance of phenotype-specific evaluation. These findings suggest potential approaches for personalized risk stratification and the development of targeted management strategies for patients with HFpEF.

Prognostic Value of Echocardiographic Coupling Metrics in Systemic Sclerosis-Associated Pulmonary Vascular Disease

BACKGROUND

Ineffective right ventricular (RV) adaptation to increasing pulmonary arterial (PA) afterload in pulmonary vascular disease (PVD) significantly contributes to morbidity and mortality. Pulmonary vascular disease in systemic sclerosis (SSc) arises through various mechanisms, yet detecting abnormal contractile response remains challenging. Here we examine whether echocardiographic RV-PA coupling metrics correlate with invasive pressure-volume (PV) loops, enhancing the prediction of adverse clinical outcomes in SSc-PVD patients.

METHODS

Prospectively enrolled patients with SSc-PVD with paired echocardiogram and PV loops were included. Linear regression and receiver-operating curve analysis were used to assess the relationship between tricuspid annular plane systolic excursion/PA systolic pressure (PASP), fractional area change/PASP, tissue Doppler velocityS'/PASP, and RV free wall strain (RVFWS)/PASP and coupling thresholds defined by end-systolic to end-arterial elastance (Ees/Ea), obtained by the multibeat method. The contribution of right atrial strain (RAS) to RV-PA coupling parameters was also investigated. Kaplan-Meier analysis was used to identify the relationship between coupling ratios and composite outcomes including clinical worsening, lung transplant, and death.

RESULTS

Forty-two patients with SSc were studied, 91% female, with a mean age of 59 ± 12 years and varying degrees of PVD: mean pulmonary artery pressure 29.5 ± 12.8 mm Hg, PVR 4.7 ± 4.2 WU, and PCWP 10.3 ± 4.1 mm Hg. Echocardiographic coupling metrics including tricuspid annular plane systolic excursion/PASP, fractional area change/PASP, tissue Doppler velocity S'/PASP, RVFWSglobal and RVFWSbasal/PASP, and RASreservoir/PASP were linearly associated with Ees/Ea. At cut points obtained through receiver-operating curve analysis, all ratios were predictive of RV-PA uncoupling, defined by Ees/Ea, and composite outcomes. Additionally, RASreservoir/RVFWS correlated with Ees/Ea even after adjustment for PASP, suggesting that diminished RAS further impacts RV performance and coupling.

CONCLUSION

Echocardiographic RV-PA coupling ratios strongly correlate with invasive Ees/Ea and predict adverse clinical outcomes in SSc patients across the spectrum of PVD. Further, we demonstrate how RAS impacts RV performance. These findings may refine risk stratification and prognostication in this at-risk cohort.

Prognostic value of right atrial strain in systemic sclerosis based on tissue tracking analysis using cine cardiac magnetic resonance imaging: a retrospective observational study

Interstitial lung disease and cardiac involvement are common manifestations and prognostic factors of systemic sclerosis. However, it is unclear whether impaired right atrial function associated with interstitial lung disease in systemic sclerosis can be used as a prognostic factor in this patient population. Therefore, this study aimed to investigate the relationship between right atrial function, interstitial lung disease, and prognosis in patients with systemic sclerosis using tissue tracking analysis with cine cardiac magnetic resonance imaging. In this retrospective observational study, a total of 40 patients with systemic sclerosis were enrolled. Tissue tracking analysis was used to obtain time curves of right atrial strain. Reservoir (total strain), conduit (passive strain), and booster (active strain) pump function were calculated, and right atrial strain, interstitial lung disease, and clinical outcomes were examined. An adverse clinical event was defined as all-cause death. Overall, 23 patients had interstitial lung disease (58%). Six patients died during the follow-up (median, 44 months). The total skin score and right ventricular systolic pressure on echocardiography were higher in patients with an event than in those without an event (28 ± 16% vs. 13 ± 13%, P = 0.02; 46.3 ± 10.7 mmHg vs. 36.0 ± 8.5 mmHg, P = 0.01, respectively). Further, right atrial total strain and active strain were significantly lower in patients with an event than in those without an event (14.3 ± 11.3% vs. 25.8 ± 11.4%, P = 0.03; 3.48 ± 2.37 vs. 11.7 ± 6.78, P = 0.007, respectively). Multivariate analysis revealed that active strain was an independent predictor of all-cause death (hazard ratio 0.76, P = 0.029). Kaplan-Meier analysis revealed that the survival rate was significantly higher in patients with right atrial active strain levels above the cutoff 7.4 (P < 0.05). In systemic sclerosis, right atrial booster function was predictive of mortality. Hence, right atrial functional assessment may have incremental prognostic value for patients with systemic sclerosis, leading to better risk stratification.

Cardiac involvement assessment in systemic sclerosis using speckle tracking echocardiography: a systematic review and meta-analysis

OBJECTIVES

Cardiac involvement in patients with systemic sclerosis (SSc) is associated with poor prognosis. Early detection of myocardial impairment is essential for treatment. The present study aimed to systematically review the value of detecting subclinical myocardial impairment in SSc patients using myocardial strain obtained from speckle tracking echocardiography (STE).

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

The PubMed, Embase and Cochrane library databases were searched in the period from the earliest available indexing date to 30 September 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies evaluating myocardial function in SSc patients comparison with healthy controls based on myocardial strain data obtained from STE were included.

DATA EXTRACTION AND SYNTHESIS

Ventricle and atrium data on myocardial strain were extracted to assessing the mean difference (MD).

RESULTS

A total of 31 studies were included in the analysis. Left ventricular global longitudinal strain (MD: -2.31, 95% CI -2.85 to -1.76), left ventricular global circumferential strain (MD: -2.93, 95% CI -4.02 to -1.84) and left ventricular global radial strain (MD: -3.80, 95% CI -5.83 to -1.77) was significantly lower in SSc patients than in healthy controls. Right ventricular global wall strain (MD: -2.75, 95% CI -3.25 to -2.25) was also decreased in SSc patients. STE revealed significant differences in several atrial parameters including left atrial reservoir strain (MD: -6.72, 95% CI -10.09 to -3.34) and left atrial conduit strain (MD: -3.26, 95% CI -6.50 to -0.03), as well as right atrial reservoir strain (MD: -7.37, 95% CI -11.20 to -3.53) and right atrial conduit strain (MD: -5.44, 95% CI -9.15 to -1.73). There were no differences in left atrial contractile strain (MD: -1.51, 95% CI -5.34 to 2.33).

CONCLUSION

SSc patients have a lower strain than healthy controls for the majority of STE parameters, indicating the presence of an impaired myocardium involving both the ventricle and atrium.

The Prognostic Value of Right Atrial and Right Ventricular Functional Parameters in Systemic Sclerosis

Introduction

Right ventricular (RV) function is of particular importance in systemic sclerosis (SSc), since common SSc complications, such as interstitial lung disease and pulmonary hypertension may affect RV afterload. Cardiovascular magnetic resonance (CMR) is the gold standard for measuring RV function. CMR-derived RV and right atrial (RA) strain is a promising tool to detect subtle changes in RV function, and might have incremental value, however, prognostic data is lacking. Therefore, the aim of this study was to evaluate the prognostic value of RA and RV strain in SSc.

Methods

In this retrospective study, performed at two Dutch hospitals, consecutive SSc patients who underwent CMR were included. RV longitudinal strain (LS) and RA strain were measured. Unadjusted cox proportional hazard regression analysis and likelihood ratio tests were used to evaluate the association and incremental value of strain parameters with all-cause mortality.

Results

A total of 100 patients (median age 54 [46–64] years, 42% male) were included. Twenty-four patients (24%) died during a follow-up of 3.1 [1.8–5.2] years. RA reservoir [Hazard Ratio (HR) = 0.95, 95% CI 0.91–0.99, p = 0.009] and conduit strain (HR = 0.93, 95% CI 0.88–0.98, p = 0.008) were univariable predictors of all-cause mortality, while RV LS and RA booster strain were not. RA conduit strain proved to be of incremental value to sex, atrial fibrillation, NYHA class, RA maximum volume indexed, and late gadolinium enhancement (p < 0.05 for all).

Conclusion

RA reservoir and conduit strain are predictors of all-cause mortality in SSc patients, whereas RV LS is not. In addition, RA conduit strain showed incremental prognostic value to all evaluated clinical and imaging parameters. Therefore, RA conduit strain may be a useful prognostic marker in SSc patients.

Diagnosis of Simultaneous Atrial and Ventricular Mechanical Performance in Patients with Systemic Sclerosis

Objective: Cardiac involvement is a predictor of poor prognosis in patients with systemic sclerosis (SSc); therefore, preclinical diagnosis of heart involvement is crucial. Two-dimensional speckle tracking echocardiography (2D-STE), a method for evaluating the myocardial strain, could be helpful for the early diagnosis of cardiac mechanical function abnormalities. In this study, the simultaneous evaluation of all cardiac chambers was studied in patients with SSc, compared with normal individuals. Methods: The results of transthoracic echocardiography (TTE) and 2D-STE of 37 patients with SSc and 37 healthy individuals and the longitudinal strain (LS) of all chambers was precisely evaluated. The collected data were analyzed using SPSS version 16, and independent-sample t test and Chi-square test were used for comparison between the groups. Results: The mean ± SD of the participants' age was 45.7 ± 11.54 (range of 17 to 68) years; most of them were women (75.7%). TTE showed higher left atrial (LA) volume (p < 0.001), right atrial (RA) area (p = 0.007), the severity of ventricular dysfunction (p < 0.05) and inferior vena cava diameter (p = 0.005), compared with the control group. Spectral and tissue Doppler echocardiography showed higher systolic pulmonary arterial pressure (sPAP) and mitral A wave velocity, and lower E/A ratio, E' velocity of left ventricular (LV) septal and lateral wall in the case group (p < 0.05). Color Doppler echocardiography showed a higher frequency of valvular regurgitation in the case group (p < 0.05). The results of 2D-STE showed lower LA roof LS (p < 0.001), LA average LS (p = 0.015), LA global LS (p = 0.028), and LA ejection fraction (LAEF) (p = 0.001), lower mean RA left wall (p = 0.048) and EF (p < 0.001), and higher RV global LS in the case group (p = 0.025). Conclusions: Simultaneous evaluation of all cardiac chambers by 2D-STE provides valuable information about the myocardial involvement in patients with SSc. Therefore, it is suggested to use this method for the early diagnosis of cardiac involvement in such patients.

Speckle tracking echocardiography as a new diagnostic tool for an assessment of cardiovascular disease in rheumatic patients

Chronic inflammation represents the cornerstone of the raised cardiovascular (CV) risk in patients with inflammatory rheumatic diseases (IRD). Standardized mortality ratios are increased in these patients compared to the general population, which can be explained by premature mortality associated with early atherosclerotic events. Thus, IRD patients need appropriate CV risk management in view of this CV disease (CVD) burden. Currently, optimal CV risk management is still lacking in usual care, and early diagnosis of silent and subclinical CVD involvement is mandatory to improve the long-term prognosis of those patients. Although CV involvement in such patients is highly heterogeneous and may affect various structures of the heart, it can now be diagnosed earlier and promptly treated. CV imaging provides valuable information as a reliable diagnostic tool. Currently, different techniques are employed to evaluate CV risk, including transthoracic or trans-esophageal echocardiography, magnetic resonance imaging, or computed tomography, to investigate valve abnormalities, pericardial disease, and ventricular wall motion defects. All the above methods are reliable in investigating CV involvement, but more recently, Speckle Tracking Echocardiography (STE) has been suggested to be diagnostically more accurate. In recent years, the role of left ventricular ejection fraction (LVEF) as the gold standard parameter for the evaluation of systolic function has been debated, and many efforts have been focused on the clinical validation of new non-invasive tools for the study of myocardial contractility as well as to characterize the subclinical alterations of the myocardial function. Improvement in the accuracy of STE has resulted in a large amount of research showing the ability of STE to overcome LVEF limitations in the majority of primary and secondary heart diseases. This review summarizes the additional value that STE measurement can provide in the setting of IRD, with a focus in the different clinical stages.

Systolic Dysfunction in Systemic Sclerosis: Prevalence and Prognostic Implications

Objective

Primary cardiac involvement is presumed to account for a substantial part of disease-related mortality in systemic sclerosis (SSc). Still, there are knowledge gaps on the evolution and total burden of systolic dysfunction in SSc. Here we evaluated prospective left ventricular (LV) and right ventricular (RV) systolic function in an unselected SSc cohort and assessed the burden of systolic dysfunction on mortality.

Methods

From the Oslo University Hospital cohort, 277 SSc patients were included from 2003-2016 and compared with healthy controls. Serial echocardiographies were reevaluated in order to detect change in systolic function. Right heart catheterization was performed on patients suspected of pulmonary hypertension. Descriptive and regression analyses were conducted.

Results

At baseline, LV systolic dysfunction by ejection fraction less than 50%, or a global longitudinal strain greater than -17.0%, was found in 12% and 24%, respectively. RV systolic dysfunction measured by tricuspid annular plane systolic excursion (TAPSE) less than 17 mm was evident in 10%. Follow-up echocardiography was performed after a median of 3.3 years (interquartile range [IQR] 1.5-5.6). At follow-up, LV systolic function remained stable, whereas RV function evaluated by TAPSE deteriorated (mean 23.1 to 21.7 mm, P = 0.005) equaling a 15% prevalence of RV systolic dysfunction. RV systolic function predicted mortality in multivariable models (hazard ratio 0.41, 95% confidence interval [CI] 0.19-0.90, P value 0.027), whereas LV systolic function lost predictive significance when adjusted for TAPSE.

Conclusion

In this unselected and prospective study, systolic dysfunction of the LV and RV was a frequent complication of SSc. LV systolic function remained stable across the observation period, whereas RV function deteriorated and predicted mortality.

[Evaluation of changes in right ventricular myocardial mechanical properties in breast cancer patients receiving pirarubicin using three-dimensional speckle tracking imaging]

OBJECTIVE

To evaluate the changes in the mechanical properties of the right ventricular myocardium (RVM) after chemotherapy using three-dimensional speckle tracking echocardiography (3D-STI).

METHODS

Thirty-six breast cancer patients receiving chemotherapy with pirarubicin underwent examinations with 3D-STI to test the mechanical properties of the RVM before chemotherapy and at the end of the second, fourth, and sixth cycles of chemotherapy (C2, C4, and C6, respectively). Blood levels of hs-cTnI and NT-proBNP were also examined at the same time points. Thirty-one of these patients also underwent ^99mTc-MIBI and ¹⁸F-FDG myocardial perfusion/metabolism imaging at C6. Myocardial perfusion abnormalities and survival outcomes of the patients were analyzed according to radionuclide imaging results.

RESULTS

Compared with that before chemotherapy, RVGLS at C2 was significantly lowered, and both RVGLS and RVGAS were significantly decreased at C4 and further decreased at C6 (P &lt; 0.05) in relation with the cumulative drug dose. The RVGLS and RVGAS differed significantly among patients with different levels of TAPSE, hs-cTnI, and RV-FAC decline after chemotherapy. RVGLS and RVGAS were found to significantly correlate with FAC (r=0.37, 0.26), TAPSE (r=0.43, 0.51), and S' (r=0.21, 0.36) (P &lt; 0.01), and showed a high sensitivity and specificity for identifying RV-FAC decline by &gt; 5%. Myocardial perfusion/metabolic imaging showed normal myocardial perfusion in 17 patients, and abnormal myocardial segments of the RVM were detected in 14 patients, but ¹⁸F-FDG imaging showed that these myocardial segments were all viable; these 14 patients showed significantly decreased RVGLS and RVGAS and significantly increased hs-cTnI level compared with the patients with normal ventricular myocardial perfusion (P &lt; 0.05). ROC curve analysis showed that an absolute value of RVGLS less than 18.2% had a sensitivity of 92.9% for diagnosis of RV impairment with a diagnostic specificity of 88.2% and an area under the curve of 0.87. RVGAS less than 26.8% had a sensitivity of 94.8% and a specificity of 86.6% for diagnosis of RV damage with an area under the curve of 0.86.

CONCLUSIONS

3D-STI can provide a reliable new approach to early diagnosis of changes in the mechanical properties of the RVM related with chemotherapy with pirarubicin in breast cancer patients.

B-type Natriuretic Peptide as a Marker of Different Forms of Systemic Sclerosis

BACKGROUND

Systemic sclerosis (SSc) is an autoimmune connective tissue disease which affects various tissues and organs, including skin, lungs, kidneys, gastrointestinal tract and cardiovascular system. Cardiac involvement is the most commonly recognized problem and a significant cause of morbidity. The brain natriuretic peptide (BNP) is a previously known marker of elevated cardiovascular risk in SSc, but the levels of BNP in various forms of SSc have not been investigated so far.

AIM

The aim of our study was to evaluate the influence of SSc on the function of the right ventricle and the right atrium using the echocardiographic parameters. Moreover, we examined the levels of BNP in different forms of SSc as well as the association of disease severity with the plasma concentrations of BNP.

METHODS

We included 42 patients with newly diagnosed SSc and patients whose disease had been diagnosed earlier. SSc patients and non-SSc control patients were examined by using echocardiography and the concentrations of BNP were determined.

RESULTS

We analyzed differences in the parameters of right ventricle (RV) function and right atrium (RA) function between SSc patients and healthy controls. The two groups had similar distribution of gender, but SSc patients were significantly older than controls. RV wall thickness was increased in SSc patients (p<0.001), while right ventricular end-systolic area (RVESA; p=0.408) and right ventricular end-diastolic area (RVEDA; p=0.368) did not differ among the examinees. In contrast, RA minor-axis dimension (p=0.001) and the tricuspid annular plane systolic excursion (TAPSE) (p=0.001) were significantly higher in SSc patients. Also, we analyzed differences in brain natriuretic peptide (BNP) concentrations between diffuse cutaneous systemic sclerosis (DSSc) and limited cutaneous systemic sclerosis (LSSc) patients. DSSc patients had significantly higher concentrations of BNP. We found that levels of BNP were in significant positive correlations with age (p=0.007), disease duration (p=0.023), C reactive protein (CRP) (p=0.032), right ventricle fractional area change (FAC) (p=0.022), pulmonary vascular resistance (PVR) and Rodnan score (p=0.019).

CONCLUSIONS

Given the obtained results, the laboratory determination of BNP could be useful in differentiating different forms of systemic sclerosis as well as in predicting the severity of the disease and future cardiovascular complications.

Electrocardiographic Findings in Systemic Sclerosis

Systemic sclerosis (SSc) is an autoimmune connective tissue disease which affects various tissues and organs, including skin, lungs, kidneys, gastrointestinal tract and cardiovascular system. Cardiac involvement is the most commonly recognized problem and a significant cause of morbidity. Abnormal ECG is present in 25-75% of patients with SSc and is considered to be an independent predictor of mortality. It is known that the supraventricular arrhythmias are considered as more common in SSc patients, occurring in about two-thirds of the cases, and more often than ventricular tachyarrhythmias. It has been established that right bundle branch block is associated with an increased risk of mortality and that it is an independent predictor of mortality, and should be considered as a marker of the severity of the disease in SSc. Th e prolonged QTc interval is an independent risk factor for a sudden cardiac death reflecting the instability of repolarization and predisposing the onset of cardiac arrhythmias.The prognosis of the disease depends on the SSc subtype and the involvement of internal organs. SSc is a lifelong disease and cannot be cured, but knowing that cardiac dysfunction significantly worsens the prognosis, early detection of cardiac complications and appropriate therapy can influence its progress and improve the patients’ quality of life.

Relation of Right Atrial Mechanics to Functional Capacity in Patients With Systemic Sclerosis

Cardiac involvement in systemic sclerosis (SSc) implies a worse prognosis. Little is known about the right atrial (RA) mechanics in this disease, but recent data suggest that it correlates well with the functional capacity of the patients in conditions with known right heart involvement. Thus we aimed to investigate the abnormalities of the RA function as compared with healthy subjects and to assess the potential correlations between RA mechanics and the functional capacity in SSc patients using 2D speckle tracking technique. A total of 70 SSc patients (age: 57 ± 12 years) were investigated. Functional capacity was measured with 6-minute walk test (6MWT). Echocardiographic parameters of the right ventricular (RV) systolic function (TAPSE, RVFAC), parameters of the tricuspid inflow (E, A), and tricuspid annular systolic (S), early- (e') and late- (a') diastolic myocardial velocities were measured. RV wall thickness was obtained. RA reservoir (ε_R), conduit (ε_CD), and contractile (ε_CT) strain were measured. RA stiffness was calculated as ratio of E/e' to ε_R. Echocardiographic data were compared with an age- and gender-matched group of 25 healthy volunteers. RA ε_R (49.3 ± 10.7 vs 59.6 ± 9.9%, p = 0.000) and ε_CD (26.8 ± 8.1 vs 34.3 ± 7.3%, p = 0.000) were significantly lower in SSc patients. No significant difference was found in ε_CT (22.9 ± 5.8 vs 25.3 ± 5.7%, p = 0.082). RA stiffness was significantly increased in SSc patients (0.11 ± 0.04 vs 0.08 ± 0.02, p = 0.001). 6MWT distance was 391 ± 95m. In stepwise multiple linear regression analysis RV wall thickness (r = -0.289, p = 0.030) and RA stiffness (r = -0.418, p = 0.002) became independent predictors of 6MWT distance. In conclusion, RA ε_R and ε_CD are impaired, while RA stiffness is increased in SSc compared with healthy subjects. Speckle tracking-derived RA stiffness is turned out to be one of the main determinants of the functional capacity in SSc patients.

Assessment of Right Atrium Function in Patients With Systemic Lupus Erythematosus With Different Pulmonary Artery Systolic Pressures by 2-Dimensional Speckle-Tracking Echocardiography

OBJECTIVES

To assess right atrium (RA) function of patients with systemic lupus erythematosus (SLE) and pulmonary artery hypertension (PAH) by 2-dimensional speckle-tracking echocardiography.

METHODS

Thirty matched healthy adults were selected as group A. Then, 102 patients with SLE were divided into 3 groups according to the severity of PAH. Group B included 37 patients without PAH (pulmonary artery [PA] systolic pressure ≤ 30 mm Hg); group C included 34 patients with PAH (PA systolic pressure of 30-50 mm Hg); and group D included 31 patients with PAH (PA systolic pressure ≥ 50 mm Hg). Parameters evaluated included RA maximum volume, minimum volume, preatrial contraction volume, passive ejection fraction (EF), and active EF. The global peak longitudinal systolic strain rate and early and late diastolic strain rates of the RA were obtained by 2-dimensional speckle-tracking echocardiography.

RESULTS

No significant differences were found in all parameters between groups B and A (P > .05). The RA maximum volume, minimum volume, preatrial contraction volume, active EF, and late diastolic strain rate in groups C and D were significantly increased compared with those in groups A and B, and the parameters in group D were significantly higher than those in group C (P < .05). Although the RA passive EF, early diastolic strain rate, and systolic strain rate in groups C and D were significantly decreased compared with those in groups A and B, those in group D were significantly lower than those in group C (P < .05).

CONCLUSIONS

Two-dimensional speckle-tracking echocardiography could effectively assess RA function in patients with SLE who have different severities of PAH.

Increased right atrial volume measured with cardiac magnetic resonance is associated with worse clinical outcome in patients with pre-capillary pulmonary hypertension

AIMS

Pre-capillary pulmonary hypertension (PHpre-cap ) has a poor prognosis, especially when caused by pulmonary arterial hypertension (PAH) associated with systemic sclerosis (SSc-PAH). Whether cardiac magnetic resonance (CMR)-based quantification of atrial volumes in PHpre-cap is beneficial in risk assessment is unknown. The aims were to investigate if (i) atrial volumes using CMR are associated with death or lung transplantation in PHpre-cap , (ii) atrial volumes differ among four unmatched major PHpre-cap subgroups, and (iii) atrial volumes differ between SSc-PAH and idiopathic/familial PAH (IPAH/FPAH) when matched for pulmonary vascular resistance (PVR).

METHODS AND RESULTS

Seventy-five PHpre-cap patients (57 ± 19 years, 53 female, 43 de novo) with CMR and right heart catheterization were retrospectively included. Short-axis stacks of cine images were analysed, and right and left atrial maximum (RAVmax and LAVmax ) and minimum volume (RAVmin and LAVmin ) were indexed for body surface area. Increased (mean + 2 SD) and reduced (mean - 2 SD) volumes were predefined from CMR normal values. Transplantation-free survival was lower in patients with increased RAVmax than in those with normal [hazard ratio (HR) = 2.1, 95% confidence interval (CI) 1.1-4.0] but did not differ between those with reduced LAVmax and normal (HR 2.0, 95% CI 0.8-5.1). RAVmax and RAVmin showed no differences among unmatched or matched groups (P = ns). When matched for PVR, LAVmax , LAVmin , and pulmonary artery wedge pressure were reduced in SSc-PAH compared with IPAH/FPAH (95% CI 0.3-21.4, 95% CI 0.8-19.6, and 95% CI 2-7, respectively).

CONCLUSIONS

Patients with PHpre-cap and increased right atrial volume measured with CMR had worse clinical outcome. When matched for PVR, left atrial volume was lower in SSc-PAH than in IPAH/FPAH, consistent with left-sided underfilling, indicating a potential differentiator between the groups.

Right Ventricle Remodeling and Function in Scleroderma Patients

Scleroderma, known also as systemic sclerosis (SSc), is a severe disease associated with high mortality rates, and right ventricular (RV) remodeling and dysfunction, along with pulmonary artery hypertension (PAH), are among the most important internal organ manifestations of this disease. PAH has a higher prevalence in patients with SSc compared to the general population and represents a significant predictor of mortality in SSc. In patients with SSc, the morphological remodeling and alteration of RV function begin even before the setting of PAH and lead to development of a specific adaptive pattern of the RV which is different from the one recorded in patients with IAPH. These alterations cause worse outcomes and increased mortality rates in SSc patients. Early detection of RV dysfunction and remodeling is possible using modern imaging tools currently available and can indicate the initiation of specific therapeutic measures before installation of PAH. The aim of this review is to summarize the current knowledge related to mechanisms involved in the remodeling and functional alteration of the RV in SSc patients.

Right atrial strain is predictive of clinical outcomes and invasive hemodynamic data in group 1 pulmonary arterial hypertension

Transthoracic echocardiography (TTE) is a practical and widely used tool for risk stratification in pulmonary arterial hypertension (PAH). We hypothesized that right atrial (RA) reservoir function, represented by peak RA systolic strain, correlates with invasive hemodynamic measurements and clinical outcomes in PAH. Patients with group 1 PAH who had TTE within 6 months of index PAH clinic visit and right heart catheterization were included in this retrospective study. Peak RA strain in the 2D apical 4-chamber view was measured with speckle-tracking software. The primary endpoint was a composite of prostacyclin initiation, lung transplantation, and death. RA strain was also measured in healthy control subjects. Among the 37 patients studied, 25 (68%) met the primary endpoint. RA strain was significantly lower among patients who met the primary endpoint than among those who did not (mean 20% vs. 33%, P = 0.002). Strain was lower in PAH patients than in controls (mean 24% vs. 35%, P = 0.0001). RA strain correlated negatively with hemodynamic data including RA pressure (R = -0.31), mean pulmonary arterial pressure (R = -0.33), and pulmonary vascular resistance (R = -0.39), and positively with cardiac index (R = 0.44). In receiver operating characteristic analysis to distinguish between patients meeting the primary endpoint and event-free survivors, RA strain was not significantly different from RA volume, right ventricular (RV) fractional area change, RV basal diameter, or right ventricular systolic pressure (area under the curve 0.82, 0.81, 0.83, 0.86, and 0.97, respectively). Our results demonstrate that RA strain is predictive of clinical outcomes in PAH. Further research is needed to determine if RA strain is independently associated with outcomes in this population.