Right Heart Function in Scleroderma: Insights from Myocardial Doppler Tissue Imaging

Right Ventricular Subclinical Dysfunction in SLE Patients Correlates with Metabolomic Fingerprint and Organ Damage

Systemic lupus erythematosus (SLE) is a chronic inflammatory disease, and several studies have suggested possible early RV involvement. Aim of the study was to evaluate the 3D echo parameters of the right ventricle (RV) and the metabolomic profile to correlate both with SLE severity. Forty SLE patients, free of cardiovascular disease, were enrolled and the following 3D parameters were evaluated: the RV ejection fraction (RV-EF), longitudinal strain of the interventricular septum (Septal LS), longitudinal strain of the free wall (Free-LS) and the fractional area change (FAC). In addition, a metabolomic analysis was performed. Direct correlations were observed between TAPSE values and the RV 3D parameters. Then, when splitting the population according to the SDI value, it was found that patients with higher cumulative damage (≥3) had significantly lower FAC, RV-EF, Septal LS, and Free-LS values; the latter three parameters showed a significant correlation with the metabolic profile of the patients. Furthermore, the division based on SDI values identified different metabolic profiles related to the degree of RV dysfunction. The RV dysfunction induced by the chronic inflammatory state present in SLE can be identified early by 3D echocardiography. Its severity seems to be related to systemic organ damage and the results associated with a specific metabolic fingerprint constituted by 2,4-dihydroxybutyric acid, 3,4-dihydroxybutyric acid, citric acid, glucose, glutamine, glycine, linoleic acid, oleic acid, phosphate, urea, and valine.

Diastolic Function Assessment of Left and Right Ventricles by MRI in Systemic Sclerosis Patients

BACKGROUND

Heart involvement is frequent although often clinically silent in systemic sclerosis (SSc) patients. Early identification of cardiac involvement can be improved by noninvasive methods such as MRI, in addition to transthoracic echocardiography (TTE).

PURPOSE

To assess the ability of phase-contrast (PC)-MRI to detect subclinical left (LV) and right (RV) ventricular diastolic dysfunction in SSc patients.

STUDY TYPE

Prospective.

POPULATION

Thirty-five consecutive SSc patients (49 ± 14 years) and 35 sex- and age-matched healthy controls (48.6 ± 13.5 years) who underwent TTE and MRI in the same week.

FIELD STRENGTH/SEQUENCE

5 T/PC-MRI using a breath-hold velocity-encoded gradient echo sequence.

ASSESSMENT

LV TTE (E/E') and LV and RV PC-MRI indices of diastolic function (LV early and late transmitral [E_M , Ef_M , A_M , Af_M ] and RV transtricuspid [E_T , Ef_T , A_T , Af_T ] peak filling flow velocities and flow rates, as well as LV [ E M ' ] and RV [ E T ' ] peak longitudinal myocardial velocities during diastole) were measured.

STATISTICAL TESTS

Two-tailed t-test, Wilcoxon test, or Fischer test for comparison of variables between SSc and healthy control groups; sensitivity, specificity, receiver-operating-characteristic (ROC) area under the curve (AUC) to assess discriminative ability of variables. A P-value <0.05 was considered statistically significant.

RESULTS

TTE LV E/E' and MRI E_M / E M ' and E_T / E T ' were significantly higher in SSc patients than in controls (8.27 ± 1.25 vs. 6.70 ± 1.66; 9.43 ± 2.7 vs. 6.51 ± 1.50; 6.51 [4.70-10.40] vs. 4.13 [3.22-5.75], respectively) and separated SSc patients and healthy controls with good sensitivity (68%, 71%, and 80%), specificity (85%, 94%, and 62%), and AUC (0.787, 0.807, and 0.765). LV Ef_M was significantly higher in SSc patients than in controls (347.1 ± 113.7 vs. 284.7 ± 94.6) as RVAf_T (277 [231-355] vs. 220 [154-253] mL/sec) with impaired relaxation pattern (Ef_T /Af_T , 0.95 [0.87-1.21] vs. 1.12 [0.93-1.47]).

DATA CONCLUSION

MRI was able to detect LV and RV diastolic dysfunction in SSc patients with good accuracy in the absence of LV systolic dysfunction at echocardiography. Use of MRI can allow to better assess the early impact of myocardial fibrosis related to SSc.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY STAGE: 2.

Defining primary systemic sclerosis heart involvement: A scoping literature review

BACKGROUND

Clinically evident primary heart involvement due to systemic sclerosis (SHI) is considered a poor prognostic factor and is a leading cause of systemic sclerosis (SSc) related death. Yet, there remains no consensus definition of SHI and poor understanding of the natural history and risk factors for the development of SHI.

METHODS

We performed a scoping literature review of published articles with a primary focus of SHI to capture previously used definitions of SHI and items used to measure SHI. Any factors reported to be associated with an increased risk of SHI were recorded.

RESULTS

Of the 2436 records identified in a search of MEDLINE, EMBASE and PubMed databases, 295 were included in the final scoping review. Analysis of the literature revealed studies of variable quality, generally low patient numbers and highly heterogeneous definitions of SHI within studies. There is no clear consensus from the literature as to the scope of SHI and the prognostic significance of sub-clinical investigation abnormalities commonly detected.

CONCLUSION

The lack of a standardised definition of SHI remains a significant unmet need in SSc. The results of this review will assist in the development of consensus classification criteria to enable more accurate quantification of the burden of SHI, identification of factors associated with increased risk of developing SHI, and evaluation of the efficacy of any novel therapeutic strategies.

Pseudo-infarction pattern in diffuse systemic sclerosis. Evaluation using cardiovascular magnetic resonance

BACKGROUND

Diffuse systemic sclerosis (dSSc) is characterized by vascular lesions and fibrosis. Cardiac involvement, although silent, accounts for 36% of deaths. We hypothesized that cardiovascular magnetic resonance (CMR) can clarify the pathophysiology of Q waves in dSSc patients.

PATIENTS-METHODS

105 dSSc, aged 48±2years, with atypical symptoms and normal routine assessment, were evaluated by ECG and CMR using a 1.5 T system. Biventricular function was assessed by steady-state free-precession sequence (SSFP). To identify fibrosis, late gadolinium enhanced areas (LGE) were evaluated 15min after injection of 0.2mmol/kg gadolinium-DTPA and expressed as % of LV mass.

RESULTS

Q waves in V1-V5 (Group A), II, III, AVF (Group B) and I, AVL, II, III, AVF, V1-V5 (Group C) were found in 25/105, 8/105 and 5/105 dSSc, respectively. In 25 dSSc with Q in V1-V6, patchy intramyocardial LGE was detected in 24/25 and involved 8±2% of LV mass. LGE involved the intraventricular septum (IVS) in 11/24 and the lateral wall (LAT) in 5/24 dSSc. Only in 1/25 dSSc, an anterior, transmural LGE, due to LAD occlusion, was identified. In 8 dSSc with Q in II, III, AVF, patchy intramyocardial LGE was detected in the inferior wall and involved 5±2% of LV mass. In 5 dSSc with Q in V1-V5, II, III, AVF, patchy intramyocardial LGE was detected in anterior and inferolateral wall and involved 9±2% of LV mass.

CONCLUSION

CMR unveiled that the pattern of myocardial fibrosis in dSSc with Q waves is due to the systemic disease and not to CAD.

Right ventricular thickness as predictor of global myocardial performance in systemic sclerosis: A Doppler tissue imaging study

BACKGROUND

Cardiopulmonary involvement in systemic sclerosis (SSc) is a poor prognostic factor, due to pulmonary hypertension and right ventricular dysfunction. We assessed the echocardiographic parameters of right ventricular (RV) function in SSc and correlated echocardiographic findings to clinical features of the disease.

METHODS

Thirty patients with SSc (cases) and 30 healthy, age-matched subjects (controls) were studied. Echocardiography, including tissue Doppler imaging, was used to evaluate cardiac function.

RESULTS

Pulmonary hypertension could be documented in only 5 cases by Doppler echo, using Bernoulli principle. RV diastolic function was significantly deranged in cases. RV systolic function and left ventricle (LV) diastolic function were also significantly deranged in the cases. RV thickness was increased in patients with SSc. There were no significant differences in the echocardiographic variables between diffuse and limited subtypes of SSc. Myocardial performance index (MPI) of both ventricles were increased in cases. We could demonstrate RV thickness as the single most important predictor of MPI of both ventricles with sensitivity of 82% and specificity of 72% for RV-MPI and 63% for LV-MPI. Diastolic function was not found to be affected by disease duration or Rodnan skin score.

CONCLUSION

Patients with SSc exhibit abnormal RV and LV diastolic functions as well as abnormal RV systolic function. RV wall thickness was found to be simple and the single best predictor of global myocardial performance. RV dysfunction may be a response to intermittent pulmonary arterial hypertension, lung parenchymal involvement, or secondary to LV diastolic dysfunction in SSc.

Association of Right Atrial Mechanics with Hemodynamics and Physical Capacity in Patients with Idiopathic Pulmonary Arterial Hypertension: Insight from a Single-Center Cohort in Northern Sweden

AIMS

Role of right atrial mechanics has not been studied in idiopathic pulmonary arterial hypertension (IPAH). We sought to investigate the correlation between the right sided, particularly right atrial mechanics, hemodynamic parameters, and functional capacity prior to initiation of treatment.

METHODS AND RESULTS

Twenty-five subjects (63 ± 17 years, 13 males) with newly diagnosed IPAH by right heart catheterization (RHC) underwent speckle tracking echocardiography (STE) of the right ventricle (RV) and right atrium (RA). All the patients had a six-minute walk test (6MWD) performed, functional class (WHO-FC) assessed, and plasma NT-proBNP estimated. STE strain imaging of RA and RV was performed offline. STE of the RA myocardium yielded characteristic strain (S%) and strain rate (SR) curves with clear delineation of its reservoir (RA-RS%), conduit (RA-SR E), and booster pump functions (RA-SR A). In IPAH, RHC-obtained pulmonary vascular resistance (PVR) and pulmonary artery systolic pressure (PASP), respectively, were 7.3 ± 5.6 Wood units and 66 ± 24 mmHg. RA-RS% was associated negatively with PVR (r = -0.46; P < 0.05) and positively with stroke volume and cardiac output (all P < 0.05). Both right atrial pressure (RAP) obtained by RHC as well as RA-SR E had significant association with WHO-FC (Multiple R = 0.7; P = 0. 01 and 0.007, respectively). RA strain rate during systole and RAP had significant association with 6MWD (Multiple R = 0.7; P = 0.01 and 0.006, respectively).

CONCLUSION

Right atrium mechanics not only correlate well with RHC-obtained hemodynamics, but also correlate with functional capacity in treatment-naive IPAH.

Evaluation of global function of the heart in scleroderma patients

OBJECTIVE

Scleroderma is a connective tissue disease characterized by diffuse vascular lesions and fibrosis of the skin and major organs including lungs, kidneys, and heart. When cardiac involvement is clinically evident, it is recognized as a poor prognostic factor. The early detection of cardiac involvement in scleroderma would be desirable both for implementation of preventive measures in the early stages of the disease and for optimal treatment.

METHODS

Left (LV) and right (RV) ventricular function were examined in 31 scleroderma patients and 21 healthy controls. Conventional and tissue Doppler echocardiography was used to evaluate systolic and diastolic function. Systolic indices including systolic (S) velocity, isovolumetric acceleration (IVA), ejection time (ET), and isovolumetric contraction time (IVCT) were measured. Early diastolic (E) velocity, late diastolic (A) velocity, E/A and E'/A' ratios, isovolumetric relaxation time (IVRT), and deceleration time (DT) were the diastolic measurements obtained. Myocardial performance index (Tei index) calculated by 2 different methods was used to assess global ventricular function.

RESULTS

In our study; mitral S velocity, biventricular ET, E', E/A, E'/A', RV IVA, LV IVA, and tricuspid S velocity were significantly lower in scleroderma patients. Mitral DT, IVCT, and biventricular IVRT, were significantly higher in scleroderma patients (P < 0.0001). In addition, RV and LV Tei indices were significantly increased in scleroderma patients compared with the control group (P < 0.0001 and P < 0.001, respectively).

CONCLUSIONS

In scleroderma patients, global function was depressed prior to the onset of clinical symptoms. Biventricular diastolic and systolic function abnormalities were also observed.

Saudi Guidelines on the Diagnosis and Treatment of Pulmonary Hypertension: Pulmonary arterial hypertension associated with connective tissue diseases

The explosive growth of medical literature on pulmonary hypertension (PH) has led to a steady increase in awareness of this disease within the medical community during the past decade. The recent revision of the classification of PH is presented in in the main guidelines.

Group 1 PH or pulmonary arterial hypertension (PAH) is a heterogeneous group and includes PH due to inheritable, drug-induced, and toxin-induced causes and to such underlying systemic causes as connective tissue diseases, human immunodeficiency viral infection, portal hypertension, congenital heart disease, and schistosomiasis.

Systemic sclerosis (SSc) is an autoimmune multisystem disorder, which affects over 240 persons per million in the United States.[1] Its manifestations are not confined to the skin but may also involve the lungs, kidneys, peripheral circulation, musculoskeletal system, gastrointestinal tract, and heart.

The outcome of PAH associated with SSc is worse when compared to other subtypes of PAH.

In this review, we summarize available information about the pulmonary vascular and cardiac manifestations of SSc with special emphasis on their prognostic implications as well as the peculiarity of their detection.

An official American Thoracic Society Statement: pulmonary hypertension phenotypes

BACKGROUND

Current classification of pulmonary hypertension (PH) is based on a relatively simple combination of patient characteristics and hemodynamics. This limits customization of treatment, and lacks the clarity of a more granular identification based on individual patient phenotypes. Rapid advances in mechanistic understanding of the disease, improved imaging methods, and innovative biomarkers now provide an opportunity to define PH phenotypes on the basis of biomarkers, advanced imaging, and pathobiology. This document organizes our current understanding of PH phenotypes and identifies gaps in our knowledge.

METHODS

A multidisciplinary committee with expertise in clinical care (pulmonary, cardiology, pediatrics, and pathology), clinical research, and/or basic science in the areas of PH identified important questions and reviewed and synthesized the literature.

RESULTS

This document describes selected PH phenotypes and serves as an initial platform to define additional relevant phenotypes as new knowledge is generated. The biggest gaps in our knowledge stem from the fact that our present understanding of PH phenotypes has not come from any particularly organized effort to identify such phenotypes, but rather from reinterpreting studies and reports that were designed and performed for other purposes.

CONCLUSIONS

Accurate phenotyping of PH can be used in research studies to increase the homogeneity of study cohorts. Once the ability of the phenotypes to predict outcomes has been validated, phenotyping may also be useful for determining prognosis and guiding treatment. This important next step in PH patient care can optimally be addressed through a consortium of study sites with well-defined goals, tasks, and structure. Planning and support for this could include the National Institutes of Health and the U.S. Food and Drug Administration, with industry and foundation partnerships.

Therapies for scleroderma-related pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH), a common complication of systemic sclerosis, carries a very severe prognosis and is one of the leading causes of death in patients who suffer from it. Indeed, response to modern medical therapy has been disappointing in scleroderma-related PAH compared with other forms of PAH from the WHO group 1 classification of diseases, despite similar histological changes involving the pulmonary vasculature. This review discusses specific features of scleroderma-related PAH, currently available and US FDA-approved therapy for this syndrome, as well as potential future therapeutic developments based on newly acquired knowledge of this disorder.

Serum endothelin-1 and NT-proBNP, but not ADMA, endoglin and TIMP-1 levels, reflect impaired right ventricular function in patients with systemic sclerosis

Background

Heart and pulmonary involvement is a leading cause of systemic sclerosis (SSc)-related deaths.

Objectives

The aim of our study was to assess if biochemical markers of right ventricular (RV) overload, endothelial function and collagen metabolism can predict RV dysfunction assessed by Doppler echocardiography in SSc patients.

Methods

We prospectively studied 111 consecutive patients (101 F, 10 M, age 54.2 ± 13.8 years) with diagnosed SSc (mean disease duration 9.4 ± 11.4 years) and a group of 21 age-matched subjects (18 F, 3 M, age 49.3 + 10.5 years). We performed transthoracic echocardiography (Phillips iE 33) and measured serum endothelin-1 (ET-1), N-terminal pro-brain natriuretic peptide (NT-proBNP), asymmetric dimethylarginine (ADMA), endoglin and human tissue inhibitor of matrix metalloproteinase (TIMP-1) concentration.

Results

Median serum NT-proBNP level in SSc patients was 133.5 (range 21.86–17,670 pg/ml) and was significantly higher than in controls (p = 0.0002). Moreover, the median serum ET-1 level of 1.49 (range 0.26–8.75 pg/ml) was higher in SSc patients (p = 0.002). However, no significant differences in ADMA, TIMP-1 and endoglin serum concentration between SSc patients and controls were observed. Serum NT-proBNP concentration correlated positively with echocardiographic signs of RV overload: tricuspid regurgitation pressure gradient (r = 0.38, p = 0.0004) and RV Tei index (r = 0.25, p = 0.01). ET-1 serum level correlated negatively with tricuspid annular plane systolic excursion (r = −0.4, p = 0.01) and positively with inferior vena cava diameter measured at expiration (r = 0.38, p = 0.0002). The echocardiographic signs of RV overload were significantly more pronounced in the highest NT-proBNP tertile (>195 pg/ml) group than in the lowest one (<88 pg/ml).

Conclusions

Serum ET-1 and NT-proBNP, but not endoglin, ADMA and TIMP-1 levels correlating with the echocardiographic parameters of RV overload, can be considered as noninvasive indicators of RV dysfunction in SSc patients.

Pulmonary arterial hypertension in connective tissue diseases

Pulmonary arterial hypertension (PAH) may complicate diverse connective tissue diseases (CTDs). Approximately 10% of patients with systemic sclerosis develop PAH, the prevalence being much lower in other CTDs. However, PAH is an important contributor to morbidity and mortality in all forms of CTD. Despite similarities in presentation, hemodynamic perturbations, and pathogenesis, patients with CTD-associated PAH (CTD-PAH) usually have a poorer response to PAH-specific medications and poorer prognosis than patients with idiopathic PAH (IPAH). Select patients with CTD-PAH may be candidates for lung transplantation, but results are less favorable than for IPAH because of comorbidities and complications specifically associated with CTD.

Systemic sclerosis and the heart: current diagnosis and management

PURPOSE OF REVIEW

When present clinically, cardiac involvement in systemic sclerosis (SSc) is a major risk factor for death. It is therefore vitally important to understand the epidemiology, screening, diagnosis, and treatment of the cardiac manifestations of SSc.

RECENT FINDINGS

The epidemiology of cardiac involvement in SSc has been the subject of several recent studies. Most importantly, the prevalence of overt left ventricular (LV) systolic dysfunction and its associated risk factors have been defined, and patients with diffuse cutaneous SSc appear to be most susceptible to direct cardiac involvement. From a diagnostic and screening standpoint, tissue Doppler echocardiography and natriuretic peptides have provided fresh insight into subclinical cardiac dysfunction in SSc. Newer techniques, such as speckle-tracking echocardiography, diffuse myocardial fibrosis imaging, and absolute myocardial perfusion imaging, are poised to further advance our knowledge. Lastly, there is now consistent observational data to suggest a central role for calcium channel blockers in the treatment of microvascular ischemia and prevention of overt LV systolic dysfunction, although randomized controlled trials are lacking.

SUMMARY

Recent studies have improved our understanding of cardiac involvement in SSc. Nevertheless, key questions regarding screening, diagnosis, and treatment remain. Novel diagnostic techniques and multicenter studies should yield important new data, which will hopefully ultimately result in improved outcomes.

Reactivity of pulmonary circulation and right ventricle function to inhaled nitric oxide in systemic sclerosis patients

Systemic sclerosis (SSc) is complicated by pulmonary hypertension and right ventricle (RV) failure in approximately 10% of the patients. Factors influencing the reactivity of pulmonary circulation to vasodilators are not established, while the examination of vasoreactivity is important in determining the treatment, because systemic administration of oral vasodilators can induce severe adverse events in nonresponders. The mechanism of RV failure in SSc is unclear and may result either from increased RV afterload or intrinsic myocardial disease. The aim of the study was to assess the reactivity of pulmonary circulation to inhaled nitric oxide (iNO) and to evaluate its influence on RV function in SSc patients with elevated right ventricle systolic pressure (RVSP). In 60 SSc patients aged 24-73 (58 females, two males; 33 patients with limited SSc and 27 with diffuse SSc), echocardiographic examination with tissue Doppler echocardiography (TDE) was performed. RV function was measured by systolic (S) and early diastolic (E) velocity of tricuspid annulus by TDE. In patients with RVSP >45 mmHg, the reactivity of pulmonary circulation was assessed by iNO test. High-resolution computerized tomography (HRCT) was performed to assess the extent of pulmonary fibrosis. Of 14 SSc subjects with elevated RVSP (13 females, one male; RVSP 47-62 mmHg), positive reaction to iNO was observed in five (RVSP decreased from 51.6 ± 3.7 to 32.24 ± 2.3 mmHg); nine patients were not reactive (RVSP 53.5 ± 5.7 mmHg before iNO vs. 49.6 ± 6.7 mmHg). RV systolic function was decreased in patients with elevated RVSP as compared to the patients with normal pulmonary pressure (S velocity 13.2 ± 1.3 vs. 14.4 ± 1.6 cm/s, respectively, p < 0.05). Significant increase of RV systolic function during iNO test was found in reactive patients only (S velocity before iNO 12.8 ± 1.2 cm/s, during iNO 14.5 ± 1.5 cm/s, p < 0.01). RVSP decrease strongly correlated with S velocity increase (r = 0.95, p < 0.0001). Response to iNO was found only in limited form of SSc; diffuse SSc patients showed no response. Pulmonary fibrosis on HRCT was more frequent in subjects nonreactive to iNO (67% of patients) than in the reactive group (40% of patients). The reactivity of pulmonary circulation to iNO in SSc patients with elevated RVSP was found predominantly in limited form of the disease. Pulmonary fibrosis typical for diffuse SSc was more frequent in nonreactive subjects. Elevated pulmonary pressure plays an important role in RV systolic dysfunction. Pulmonary pressure decrease during iNO test leads to the improvement of RV systolic function. Therapy for right-heart failure in reactive SSc patients should be directed, if possible, at the decrease in pulmonary resistance.

Scleroderma lung disease

Pulmonary involvement is second in frequency only to esophageal involvement as a visceral complication of systemic sclerosis (SSc) and has surpassed renal involvement as the most common cause of death. Interstitial lung disease and pulmonary vascular disease, particularly pulmonary arterial hypertension, are the most commonly encountered types of lung involvement. Chronic aspiration, airway disease, neuromuscular weakness, extrinsic pulmonary restrictive pathology, pleural effusions, pneumothorax, and lung cancer cause clinically significant disease and occur commonly enough to be routinely considered in the assessment of the SSc patient with respiratory symptoms. Affected patients have a significantly worse prognosis than patients with SSc who are free of pulmonary involvement.

Lung involvement in systemic sclerosis

Scleroderma is a multisystem disease characterized by a severe inflammatory process and exuberant fibrosis. Lung involvement is a frequent complication and a leading cause of morbidity and mortality in this syndrome. Two major pulmonary syndromes are associated with scleroderma; a pulmonary vascular disorder evolving over time into relatively isolated pulmonary arterial hypertension (PAH), and interstitial lung disease (ILD). Each syndrome, when present, is a cause of morbidity and significantly reduces survival of scleroderma patients when compared to patients free of lung complication. When pulmonary hypertension and ILD are combined, survival is further reduced. Current therapy appears to have no meaningful effect on either condition and, thus, there is a need for better understanding of underlying pathogenic mechanisms. This review focuses on clinical, diagnostic, and therapeutic features of PAH and ILD as well as other frequent but less debilitating lung complications of scleroderma.

Early Detection of Cardiac Involvement in Systemic Sclerosis Assessed by Tissue-Doppler Echocardiography: Relationship with Neurohormonal Activation and Endothelial Dysfunction

Objective.

Cardiopulmonary complications are common in patients with systemic sclerosis (SSc). We assessed cardiac involvement in patients with SSc using echocardiography and investigated the association of N-terminal pro-brain natriuretic peptide (NT-proBNP) and asymmetric dimethylarginine (ADMA) with echocardiographic measures of myocardial function in sera of patients with SSc who had no symptoms of heart failure.

Methods.

We prospectively studied 52 patients with SSc (mean age 55.7 ± 10.1 yrs, 51 women), with conventional and tissue-Doppler echocardiography. Plasma NT-proBNP and ADMA levels were measured in all patients. Data were compared with those obtained from 25 healthy controls comparable for age and sex.

Results.

Patients with SSc had impaired left ventricular (LV) and right ventricular diastolic function expressed by inverted ratio of peak early to peak late transmitral (Mit E/A) and transtricuspid velocity and increased left atrial diameter compared with controls. Peak systolic mitral lateral annular motion velocity and peak early diastolic mitral lateral annular motion velocity (LV Em) were lower, while LV E/Em ratio was higher, in patients with SSc compared to controls. ADMA was significantly related with LV Em and E/Em ratio. NT-proBNP was associated with Mit E, Mit E/A ratio and mitral deceleration time. Significant correlation was also observed between NT-proBNP and ADMA levels.

Conclusion.

Depressed cardiac function is common, even in asymptomatic patients with SSc. NT-proBNP and ADMA are significantly correlated with echocardiographic abnormalities, providing a potent link for cardiac function, neuroendocrine derangement, and endothelial dysfunction in patients with SSc who have cardiac disease.

Early right ventricular systolic dysfunction in patients with systemic sclerosis without pulmonary hypertension: a Doppler Tissue and Speckle Tracking echocardiography study

Background

Isovolumetric acceleration (IVA) is a novel tissue Doppler parameter for the assessment of systolic function. The aim of this study was to evaluate IVA as an early parameter for the detection of right ventricular (RV) systolic dysfunction in patients with systemic sclerosis (SSc) without pulmonary hypertension.

Methods

22 patients and 22 gender- and age-matched healthy subjects underwent standard echocardiography with tissue Doppler imaging (TDI) and speckle tracking strain to assess RV function.

Results

Tricuspid annular plane systolic excursion (TAPSE) (23.2 ± 4.1 mm vs. 26.5 ± 2.9 mm, p < 0.006), peak myocardial systolic velocity (Sm) (11.6 ± 2.3 cm/s vs. 13.9 ± 2.7 cm/s, p = 0.005), isovolumetric contraction velocity (IVV) (10.3 ± 3 cm/s vs. 14.8 ± 3 cm/s, p < 0.001) and IVA (2.3 ± 0.4 m/s² vs. 4.1 ± 0.8 m/s², p < 0.001) were significant lower in the patient group. IVA was the best parameter to predict early systolic dysfunction with an area under the curve of 0.988.

Conclusion

IVA is a useful tool with high-predictive power to detect early right ventricular systolic impairment in patients with SSc and without pulmonary hypertension.

Echocardiography as an Outcome Measure in Scleroderma-related Pulmonary Arterial Hypertension: A Systematic Literature Analysis by the EPOSS Group

Objective.

To assess the validation status of echocardiography with continuous Doppler (echo-Doppler) as an outcome measure in pulmonary arterial hypertension associated with systemic sclerosis (PAH-SSc).

Methods.

Structured literature review on full-text English articles was performed using the PubMed and Cochrane databases. Assessment of validation of echo-Doppler was based on the OMERACT filter criteria with the domains truth (face, content, construct, and criterion validity), discrimination, and feasibility.

Results.

Out of 35 studies eligible for analysis, only 5 included well defined PAH-SSc subgroups (World Health Organization criteria). Echo was considered as having face validity based on expert opinion and high number of studies using echo for evaluation of patients with SSc. Echo was considered partially validated with respect to criterion validity based on significant correlations between echo measures and right-heart catheterization in patients with SSc at risk of PAH/PH. However, echo was found to lack specificity (lack of content validity), since measurements of echo pulmonary pressure may be influenced by left-heart disease and interstitial lung disease. Data from general populations of patients with scleroderma indicate that evaluation of pulmonary artery pressure by echo might not be available in all PAH-SSc patients because of technical factors. No studies enabling evaluation of the discriminant capacity over time and treatment of echo in PAH-SSc could be identified.

Conclusion.

Further studies are needed to fully validate echo-Doppler as an outcome measure in PAH-SSc. These studies would include cross-sectional analysis of baseline measures and longitudinal data of placebo and verum groups in randomized controlled trials of patients with PAH-SSc.

Differential strain and velocity generation along the right ventricular free wall in pulmonary hypertension

BACKGROUND

In contrast to the homogeneously distributed deformation properties within the left ventricle, the right ventricular (RV) free wall (RVFW) shows a more inhomogeneous distribution. It has been demonstrated that pulmonary hypertension (PH) results in significant RVFW mechanical delay.

OBJECTIVE

To assess the effect of the degree of pulmonary arterial systolic pressure on the RVFW strain gradient and on myocardial velocity generation.

METHODS

Peak longitudinal strain and velocity data were collected from three different segments (basal, mid- and apical) of the RVFW in 17 normal individuals and 31 PH patients.

RESULTS

A total of 144 RV wall segments were analyzed. RVFW strain values in individuals without PH were higher in the mid and apical segments than in the basal segment. In contrast, RVFW strain in PH patients was higher in basal segments and diminished toward the apex. In terms of RVFW velocities, both groups showed decremental values from basal to apical segments. Basal and mid-RVFW velocities were significantly lower in PH patients than in individuals without PH.

CONCLUSIONS

PH results in significant alterations of strain and velocity generation that occurs along the RVFW. Of these abnormalities, the reduction in strain from the mid and apical RVFW segments was most predictive of PH. It is important to be aware of these differences in strain generation when studying the effect of PH on the right ventricle. Additional studies are required to determine whether these differences are due to RV remodelling.

Cardiac magnetic resonance imaging with pharmacological stress perfusion and delayed enhancement in asymptomatic patients with systemic sclerosis

OBJECTIVE

To assess cardiac involvement in asymptomatic patients with systemic sclerosis (SSc) by cardiac magnetic resonance imaging (MRI).

METHODS

Ten asymptomatic patients with SSc (all female; mean age 59.5+/-9.4 yrs) underwent contrast enhanced cardiac MRI on a 1.5 T MRI device. Adenosine triphosphate was used for stress and rest perfusion to assess perfusion defects due to microvascular impairment or ischemia, and delayed enhanced (DE) imaging was obtained for the assessment of myocardial necrosis and fibrosis. We evaluated the pathophysiological associations of stress perfusion combined with DE imaging with SSc disease severity measures.

RESULTS

Stress perfusion defects were seen in 5 out of 9 patients (56%): 4 had nonsegmental subendocardial perfusion defects and one had a segmental subendocardial perfusion defect. Three patients were found to have DE. DE was not observed in any patient without perfusion defect; and among the 5 patients with perfusion defects, 3 (60%) had DE. Two of the 3 had DE in segments not matching the region of nonsegmental perfusion defects. The remaining one had a segmental subendocardial DE matching the region of a segmental perfusion defect. Perfusion defects were seen in 75% of patients with a history of digital ulceration compared to only 20% of those without history of ulceration.

CONCLUSION

Subclinical myocardial involvement, as detected by cardiac MRI, was frequent in asymptomatic patients with SSc. Cardiac MRI may aid in understanding the pathophysiological mechanism of SSc.

Echocardiographic and right heart catheterization techniques in patients with pulmonary arterial hypertension

BACKGROUND

The cardiovascular assessment of patients with suspected pulmonary arterial hypertension (PAH) involves Doppler echocardiography and often subsequent confirmation by right heart catheterization (RHC). However, there appears to be limited consensus on the appropriate technique(s) for assessing PAH, and thus no clear, comprehensive guidelines exist for assessment of PAH. The aim of this paper is to review the Doppler echocardiographic and RHC techniques for the diagnosis and/or assessment of PAH.

METHOD

We searched Medline (1966 to August 2006) and EMBASE (1980 to August 2006) bibliographic databases to allow identification of all potentially relevant studies and review articles. In addition, the reference lists of included articles were scanned to identify relevant references and unpublished reports missed by the search strategy.

RESULTS

Our findings show that recommendations for the echocardiographic assessment of PAH at rest or with exercise are heterogeneous. Clinical practice guidelines provide limited details. Although more specific information regarding echocardiographic techniques can be obtained from individual research articles, the techniques employed and the methods used to calculate specific hemodynamic variables do not appear to be consistent throughout the literature. RHC techniques for the confirmation of PAH are more consistent, albeit less frequently reported. The literature search identified several articles where indications and considerations for the catheterization of patients with PAH are discussed, together with safety considerations and principles for the accurate assessment of hemodynamic variables.

CONCLUSION

Although clinical practice guidelines and numerous research studies provide details of echocardiographic measures in patients with PAH, greater consensus and standardisation of measurement techniques is required. A minimum dataset for the evaluation of PAH by these techniques is suggested.

Myocardial tissue Doppler-based indexes to distinguish right ventricular volume overload from right ventricular pressure overload

The objective of this study was to develop tissue Doppler parameters that could be used to differentiate right ventricular (RV) volume overload from RV pressure overload. The RV-pressure-overload group consisted of 40 patients with severe pulmonary hypertension, and the RV-volume-overload group consisted of 40 patients who had an atrial septal defect without evidence of right-to-left shunt, significant pulmonary hypertension, or Eisenmenger's complex. Another 40 healthy subjects were enrolled and served as a control group. Routine echocardiography and tissue Doppler imaging were performed. RV myocardial performance index was determined based on data collected during tissue Doppler imaging over the lateral tricuspid annulus. In patients with RV pressure overload, tissue Doppler parameters showed characteristically lower systolic velocity over the tricuspid annulus (RV myocardial systolic wave [Sm]) and longer isovolumic relaxation time (RV-IVRT). Nevertheless, in patients with RV volume overload, RV-Sm increased significantly, but early-diastolic velocity over tricuspid annulus was relatively low. In conclusion, RV-MPI, RV-Sm/early-diastolic velocity over tricuspid annulus, and RV-IVRT/RV-Sm were all useful to differentiate RV pressure overload from volume overload, although RV-IVRT/RV-Sm was the best parameter, with excellent sensitivity and specificity.

Pattern and distribution of myocardial fibrosis in systemic sclerosis: a delayed enhanced magnetic resonance imaging study

OBJECTIVE

To assess the prevalence and pattern of myocardial fibrosis as detected by delayed enhanced magnetic resonance imaging (DE-MRI) in patients with systemic sclerosis (SSc), and to evaluate a possible association between myocardial fibrosis and cardiac arrhythmias.

METHODS

Forty-one patients with SSc underwent 24-hour Holter monitoring, Doppler echocardiography, and DE-MRI following gadolinium administration.

RESULTS

Technically acceptable DE-MRIs were obtained in 36 patients with SSc. Enhancement on DE-MRI, consistent with myocardial fibrosis, was observed in 24 of these patients (66%), and it was invariably midwall with a linear pattern, mostly involving basal and midcavity segments of the left ventricle. The volume of enhancement (total volume percentage index [TVPI]) did not differ between patients with diffuse SSc and those with limited SSc (mean +/- SD 1.46 +/- 1.73% versus 1.44 +/- 1.77%; P = 0.98). Patients with a long duration (> or = 15 years) of Raynaud's phenomenon had a greater number of enhancing segments (mean +/- SD 6.55 +/- 4.93 versus 2.96 +/- 3.46; P = 0.017) and a greater TVPI (mean +/- SD 2.44 +/- 1.97% versus 1.02 +/- 1.43%; P = 0.02) than those with a duration of Raynaud's phenomenon <15 years. Nineteen patients with SSc (53%) had abnormal Holter study results. Compared with patients with normal Holter study results, those with abnormal results had a greater number of enhancing segments (mean +/- SD 5.4 +/- 4.8 versus 2.5 +/- 2.9; P < 0.05) and a greater TVPI (mean +/- SD 2.1 +/- 1.9% versus 0.8 +/- 1.2%; P < 0.05).

CONCLUSION

DE-MRI can identify myocardial fibrosis in a significant percentage of patients with SSc and may be a useful noninvasive tool for determining cardiac involvement.

Correlation of Tricuspid Annular Velocities With Invasive Hemodynamics in Pulmonary Hypertension

The authors performed tissue Doppler imaging of the tricuspid annulus in patients with pulmonary hypertension to assess its correlation with invasive indices of right ventricular function. The study population consisted of 32 patients with suspected pulmonary hypertension who underwent pulsed tissue Doppler imaging of the tricuspid annulus and right heart catheterization. Peak systolic (Sa), early diastolic (Ea), and late diastolic (Aa) velocities of the lateral tricuspid annulus were measured and correlated with hemodynamic variables. Peak Sa demonstrated excellent correlation with hemodynamic variables, including cardiac index (r=0.78; P<.001), pulmonary vascular resistance (r=-0.79; P<.001), and transpulmonary gradient (r=-0.72; P<.001). Peak Sa <10 cm/s predicted cardiac index <2.0 L/min/m2 with 89% sensitivity and 87% specificity. In conclusion, tissue Doppler imaging of the tricuspid annulus is a complementary method to assess right ventricular function in pulmonary hypertensive patients.

Incidence of pulmonary hypertension and its clinical relevance in patients with interstitial pneumonias: comparison between idiopathic and collagen vascular disease associated interstitial pneumonias

OBJECT

This study was undertaken to investigate the frequency of pulmonary hypertension (PH), and clinical parameters associated with PH in patients with idiopathic interstitial pneumonias (IIPs) and collagen vascular disease-associated interstitial pneumonias (CVD-IPs).

PATIENTS AND METHODS

Retrospective analyses were performed in 163 consecutively enrolled patients (78 IIPs and 85 CVD-IPs) who were being evaluated for PH by Doppler echocardiography. PH was defined as an estimated systolic pulmonary artery pressure (sPAP) of > or = 40 mmHg. The frequency of PH was evaluated and clinical parameters were compared between patients with PH and those without PH.

RESULTS

Among patients successfully evaluated for sPAP by echocardiography, 20 of 70 (28%) patients with IIPs and 17 of 80 (21%) patients with CVD-IPs had PH. Among patients with IIP and CVD-IP, those with PH were more frequently treated with supplemental oxygen. Patients with IIP who had PH tended to be older and had decreased % diffusion capacity of carbon monoxide (%DLCO). Additionally, in patients with IIP, sPAP was negatively correlated with %DLCO. However, this association was not found in patients with CVD-IP. Patients with CVD-IP who had PH were predominantly male.

CONCLUSION

PH was frequently observed in patients with both IIPs (28%) and CVD-IPs (21%) in the chronic phase of the disease. PH should be evaluated in patients with IPs who need supplemental oxygen, IIP patients with decreased diffusing capacity, and in patients with CVD-IP.