Role of Two-Dimensional Speckle-Tracking Echocardiography Strain in the Assessment of Right Ventricular Systolic Function and Comparison with Conventional Parameters

Assessing Right Ventricular Function in the Perioperative Setting, Part I: Echo-Based Measurements

This article explores the growing significance of right ventricular (RV) function, particularly in perioperative settings. The right ventricle plays a crucial role in predicting morbidity and mortality, especially in cardiac surgeries. Right ventricular failure is associated with high in-hospital mortality, making accurate assessment vital. The article discusses echocardiographic evaluation, emphasizing both qualitative and quantitative measures, including tricuspid annular plane systolic excursion, fractional area change, and myocardial strain imaging. Understanding RV pathophysiology is essential for effective diagnosis and management, particularly in dynamic perioperative conditions influenced by ventilation, anesthesia, and extracorporeal circulation.

Right ventricular strain and tricuspid annular plane systolic excursion are associated with mortality in inferior ST-elevation myocardial infarction

BACKGROUND

Patients with inferior ST-segment elevation myocardial infarction face a substantial risk for cardiovascular death. While left ventricular function is known to be associated with clinical outcomes in these patients, we evaluated the prognostic impact of tricuspid annular plane systolic excursion (TAPSE) and advanced measures of right ventricular function (free wall strain [FWS] and global longitudinal strain [RVGLS]).

METHODS

Consecutive patients presenting with acute inferior ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention between 01/2012 and 08/2015 were retrospectively analysed. Associations between RV strain measurements and all-cause mortality were evaluated using Cox regression analysis.

RESULTS

207 patients (69.6% male, median 59.0 [IQR: 52.1-70.7] years) were followed for 8.3 (IQR: 7.4-9.3) years, during which 49 patients (23.7%) deceased. Median right ventricular function parameters were significantly better in surviving patients (RVGLS: -17.5% vs. -13.3%, p < .001; FWS: -20.5% vs. -14.8%, p < .001; TAPSE 1.8 cm vs. 1.3 cm, p < .001). All 3 parameters were associated with mortality in univariate and multivariable analysis adjusted for age, sex and the number of comorbidities (chronic kidney disease, hypercholesterinaemia, diabetes mellitus) (adj. hazard ratio [HR] per 1 standard deviation: RVGLS: 1.68 [95% CI: 1.27-2.23, p < .001], FWS: 1.56 [95% CI: 1.56-2.00, p < .001], TAPSE: 1.55 [95% CI: 1.17-2.05, p = .002]). Additionally, right ventricular function was inversely associated with peak troponin T and creatine kinase levels.

CONCLUSIONS

Among patients with inferior ST-segment myocardial infarction, RVGLS, FWS and TAPSE convey crucial prognostic information and might help to identify patients at increased risk requiring intensified monitoring and therapy.

Noninvasive right ventricular myocardial work by pressure-strain loop: a new perspective on right ventricular function and cardiac resynchronization therapy

BACKGROUND

Myocardial work (MW) by noninvasive pressure-strain loop (PSL) is a novel echocardiographic tool that provides a more precise estimation of right ventricular (RV) performance by accounting for the RV loading conditions. The study sought to investigate the impact of cardiac resynchronization therapy (CRT) on RV function and explore the role of RV MW indices in predicting CRT response.

METHODS AND RESULTS

Ninety-one CRT-candidates were prospectively enrolled. left ventricular (LV) MW parameters, RV global longitudinal strain (RV GLS) and RV free wall strain (RV FWS) were obtained. RV MW indices, including RV global work index (RV GWI), RV global constructive work (RV GCW), RV global wasted work (RV GWW), and RV global work efficiency (RV GWE), were measured by PSL analysis. Response to CRT was defined as a reduction in left ventricular end-systolic volume of ≥15% at follow-up. RV GWI significantly increased in responders. CRT caused significant improvements in RV GWI, RV GCW, and RV GWE (P < 0.05). In multivariate analysis, RV GWI (adjusted odds ratio (OR): 1.010; 95% CI: 1.003-1.017; P < 0.05), and LV GCW (adjusted OR: 1.002; 95% CI: 1.000-1.003; P < 0.05) were associated with CRT response. Adding RV GWI to the basal model yielded a significant improvement in continuous net reclassification improvement at 0.284 (p=0.032), while other function parameters failed to improve reclassification.

CONCLUSION

RV MW indices provide a new reference for the quantitative evaluation of RV myocardial performance before and after CRT. Although both RV GWI and LV GCW have prognostic value, RV GWI may better predict the response to CRT.

A Comprehensive Review of Two-Dimensional Speckle-Tracking Echocardiography in Assessing Right and Left Ventricular Function in Diabetic Patients

BACKGROUND

Two-dimensional speckle-tracking echocardiography (2D-STE) has emerged as a valuable tool for assessing cardiac function in patients with type 1 (T1DM) and type 2 diabetes mellitus (T2DM).

HYPOTHESIS

This review synthesizes recent studies utilizing 2D-STE in diabetic patients, highlighting its clinical applications and findings.

METHODS

In this review, relevant studies were identified through comprehensive searches of major scientific databases, including PubMed, Scopus, Google Scholar, ScienceDirect, and other reputable sources.

RESULTS

The results of this study indicate that 2D-STE is capable of detecting subclinical cardiac dysfunction in patients with both T1DM and T2DM, even in instances where conventional echocardiographic parameters appear to be within normal limits. Assessment of right ventricular (RV) function through 2D-STE has demonstrated impaired right ventricular free wall longitudinal strain (RVFWLS) and global longitudinal strain (RVGLS) in individuals with T2DM, which correlates with suboptimal glycemic control. Furthermore, evaluation of left ventricular (LV) function has revealed decreased global longitudinal strain (GLS) and impaired LV twist mechanics in T2DM patients, particularly under conditions of physiological stress. In T1DM patients, 2D-STE has identified early changes in myocardial deformation, with studies reporting reduced LV and RV strain values compared to healthy controls. The technique has also been effective in assessing the impact of disease duration and glycemic control on cardiac function in both T1DM and T2DM.

CONCLUSIONS

These findings underscore the potential of 2D-STE as a sensitive and comprehensive tool for early detection of cardiac dysfunction in both T1DM and T2DM, potentially guiding management strategies and improving outcomes in these high-risk populations.

Risk stratification in Eisenmenger syndrome

Pulmonary arterial hypertension complicating congenital heart disease can progress to the life-threatening irreversible form known as Eisenmenger syndrome. When conservative treatments are inadequate, the risk of death as a result of the disease must be weighed against the risk associated with transplantation. Risk stratification has become a fundamental tool for the prediction of outcomes and the guidance of treatment in pulmonary arterial hypertension. However, the current risk scores for pulmonary arterial hypertension are not specific to pulmonary arterial hypertension with congenital heart disease, and the accurate prediction of risk of death in Eisenmenger syndrome is challenging. Here, experts in paediatric and adult congenital heart disease, Eisenmenger syndrome, risk stratification and pulmonary arterial hypertension have performed a comprehensive literature search to review current data on Eisenmenger syndrome risk stratification. Limited evidence was found. The only multivariable death risk-stratification model based on non-invasive predictors (age, shunt location, resting oxygen saturation, sinus rhythm and pericardial effusion) proposed thus far in Eisenmenger syndrome is awaiting external validation. Shunt location markedly influences outcomes and treatment strategies. Several risk factors have been identified as independent predictors in Eisenmenger syndrome, including the 6-minute walk distance, echocardiographic markers and serum brain natriuretic peptide. However, the use of these variables deserves further evaluation to improve risk stratification in patients with Eisenmenger syndrome.

Assessing Right Ventricular Performance During Prone Ventilation in ARDS Patients Using Speckle Tracking Echocardiography

PURPOSE

Acute respiratory distress syndrome (ARDS) frequently results in right ventricular (RV) dysfunction due to increased afterload and pulmonary vascular resistance. Among the standardized therapeutic strategies for ARDS management, protective ventilation and prone positioning in cases of severe oxygenation deterioration have proven effective, with prone positioning offering additional benefits, including improved RV function, enhanced physiological outcomes such as oxygenation and lung mechanics. This study aims to evaluate the impact of prone positioning on RV performance in ARDS patients using speckle tracking echocardiography (STE).

METHODS

This observational, retrospective, single-center study aimed to evaluate the effects of prone positioning on RV function in patients with ARDS requiring mechanical ventilation. The study included patients with ARDS of varying severities who were passively ventilated. Transthoracic echocardiography was performed to assess RV function, with a specific focus on RV global longitudinal strain (GLS) and RV free wall strain (RVFWS) in both supine and prone positions using STE.

RESULTS

Between August 2021 and April 2024, a total of 16 mechanically ventilated patients were included in the study. Regarding mechanical ventilation parameters, after applying the Bonferroni correction, there was a statistically significant increase in the PaO2/FiO2 ratio during the prone position (p = 0.004). Concerning echocardiographic variables, no statistically significant differences were found in left ventricular ejection fraction, basal RV diameter, RV/left ventricular end-diastolic area ratio, or the values of tricuspid annular tissue S' wave, TAPSE, and RV fractional area change. However, during the prone position, there was a significant decrease in RV GLS (p = 0.009) and RVFWS (p = 0.003).

CONCLUSION

This study provides preliminary insights into the impact of the prone position maneuver on RV systolic function in patients with ARDS, suggesting that strain measured by STE could serve as a sensitive marker for detecting subclinical RV dysfunction. Further research with larger sample sizes and prospective designs is needed to confirm and build upon these findings.

A Non-Invasive Approach to Pulmonary Hypertension

Pulmonary hypertension (PH) is a life-threatening cardiopulmonary disease associated with a poor prognosis, with progressive right ventricular (RV) failure being the main cause of death in this vulnerable population. Right heart catheterization remains the gold standard for assessing pulmonary hemodynamics. However, due to its invasive nature, non-invasive imaging methods are gaining increasing interest. Two-dimensional transthoracic echocardiography serves as the primary screening tool for PH and is widely used to estimate its likelihood. Nevertheless, this technique has several limitations, partially addressed through the assistance of a three-dimensional echocardiography. Cardiac magnetic resonance imaging (CMR) provides a comprehensive evaluation of both the morphology and hemodynamics of right ventricle-pulmonary artery unit, offering essential information for diagnosis, prognosis, and therapeutic monitoring. While two-dimensional cardiac CMR enables non-invasive characterization of pulmonary hemodynamics, advances in 4D-flow cardiac CMR allow for a more detailed analysis. These advancements enable the assessment of flow patterns, energetics, wall shear stress and severity, offering a more nuanced understanding of the disease. This review aims to provide an in-depth summary of the current data on advanced non-invasive imaging techniques for PH.

Association of Glycemic Control With Right Ventricular Function Assessed by Two-Dimensional Speckle-Tracking and Three-Dimensional Echocardiography in Type 2 Diabetes Mellitus

BACKGROUND

Right ventricular (RV) involvement has been reported in type 2 diabetes mellitus (T2DM). The relationship between glycemic control and RV function remains unknown. We aimed to investigate the association between glycemic control and RV function assessed by two-dimensional speckle-tracking echocardiography and three-dimensional echocardiography in T2DM individuals.

METHODS

This study prospectively enrolled 207 patients with T2DM and 84 individuals with normal glucose metabolism. The T2DM patients were divided into 2 subgroups according to glycated hemoglobin (HbA1c) level: controlled (HbA1c < 7.0%, n = 91) and uncontrolled subgroup (HbA1c ≥ 7.0%, n = 116). Right venticular free wall longitudinal strain (RVFWLS) was acquired by two-dimensional speckle-tracking echocardiography, and RV volumes and RV ejection fraction (RVEF) were assessed using three-dimensional echocardiography . Right ventricular coupling to pulmonary circulation was defined as the ratio of RVFWLS/pulmonary artery systolic pressure (PASP).

RESULTS

Controlled and uncontrolled T2DM subgroups had impaired RV function as reflected by reduced RVFWLS and RVEF compared to the normal glucose metabolism group. The reduction in RVFWLS was more pronounced in the uncontrolled subgroup than in the controlled subgroup (P < .001), whereas no significant difference was found in RVEF between these 2 T2DM subgroups. Higher PASP and lower RVFWLS/PASP ratio were also noted in uncontrolled T2DM patients. Additionally, the incidence of RV dysfunction was significantly higher in the uncontrolled T2DM patients than in the controlled subgroup (43.1% vs 17.6%, P < .001). After adjustment for potential clinical confounders, PASP, and left ventricular parameters, HbA1c level was independently associated with RVFWLS (β = 0.290, P = .003) and RVFWLS/PASP ratio (β = 0.028, P = .006).

CONCLUSIONS

Subclinical RV myocardial dysfunction is present in T2DM patients and is more pronounced in patients with uncontrolled blood glucose. HbA1c level is independently associated with subclinical RV myocardial dysfunction, providing further insight into a possible link between poor glycemic control and diabetic cardiomyopathy.

Cardiac Magnetic Resonance Imaging in the Evaluation of Functional Impairments in the Right Heart

Cardiac magnetic resonance (cMRI) imaging has recently become essential in cardiology. cMRI is widely recognized as the most reliable imaging technique for assessing the size and performance of the right ventricle. It allows for objective and functional cardiac tissue evaluations. Early in disease progression, cardiac structure and activity decrease subclinically. Late-phase clinically visible signs have been associated with less favourable outcomes. Subclinical alterations ought to be recognized for rapid evaluations and accurate treatment. An increasing amount of evidence supports cMRI deformation parameter quantification. Strain imaging enables cardiologists to assess heart function beyond traditional measurements. Prognostic information for cardiovascular disease patients is obtained through the right ventricle (RV) strain, including information primarily about the left ventricle (LV). Right atrial (RA) function evaluations using RA strain have been promising in recent studies. Therefore, this narrative review aims to present an overview of the data that are currently available for assessing right myocardial strain and biomechanics using cMRI.

Assessment of right ventricular sequelae by speckle tracking echocardiography in recovered COVID-19 patients

BACKGROUND

TTE is the main modality used to assess RV function, but conventional TTE parameters have limited diagnostic value because they may fail to detect early abnormalities in RV systolic function. Due to its ability to detect subclinical impairment of cardiac function, 2D STE has been widely used to investigate RV function. In this study, we aimed to investigate whether there are sequelae of RV function in recovered COVID-19 patients with pulmonary involvement.

METHODS

This is a prospective observational cohort study of 57 healthy volunteers and 54 patients. Participants had no history of chronic illness and no evidence of respiratory or cardiac symptoms. The patients had been hospitalised with COVID-19 with pulmonary involvement but did not require intensive care unit follow-up or non-invasive mechanical ventilation support. TTE was performed. Demographic and clinical characteristics and laboratory test results were collected.

RESULTS

LVEF, TAPSE, St and FAC were significantly lower in the patient group. LV-LS 3-chamber, LV-GLS, RV-FWS, RV-GLS were significantly lower in the patient group.

CONCLUSIONS

RV-LS and LV-GLS were shown to decrease in the patient group. Although no obvious pathological values were observed in RV parameters on conventional echocardiography, TAPSE, St and FAC values were lower in the patient group.

Right ventricular dysfunction in the critically ill. Echocardiographic evaluation

Right ventricular dysfunction is common in critically ill patients, and is associated with increased mortality. Its diagnosis moreover remains challenging. In this review, we aim to outline the potential mechanisms underlying abnormal biomechanics of the right ventricle and the different injury phenotypes. A comprehensive understanding of the pathophysiology and natural history of right ventricular injury can be informative for the intensivist in the diagnosis and management of this condition, and may serve to guide individualized treatment strategies. We describe the main recommended parameters for assessing right ventricular systolic and diastolic function. We also define how to evaluate cardiac output and pulmonary circulation pressures with echocardiography, with a focus on the diagnosis of acute cor pulmonale and relevant applications in critical disorders such as distress, septic shock, and right ventricular infarction.

Static Immersion and Negative Static Lung Load-Induced Right Ventricle Systolic Function Adaptation: A Risk Factor for Immersion Pulmonary Edema

BACKGROUND

Immersion pulmonary edema (IPE) is a form of hemodynamic edema likely involving individual susceptibility.

RESEARCH QUESTION

Can assessing right ventricle (RV) systolic adaptation during immersion be a marker for IPE susceptibility?

STUDY DESIGN AND METHODS

Twenty-eight divers participated: 15 study participants with a history of IPE (IPE group; mean ± SD age, 40.2 ± 8.2 years; two women) and 13 control participants (no IPE group; mean ± SD age, 43.1 ± 8.5 years; two women) underwent three transthoracic echocardiography studies under three different conditions: dry (participants were in the supine position on an examination table without immersion), surface immersion (participants were floating prone on the water's surface and breathing through a snorkel), and immersion and negative static lung load (divers were submerged 20 cm below the water's surface in the prone position using a specific snorkel connected to the surface for breathing). Echocardiographic measurements included tricuspid annular plane systolic excursion (TAPSE), tissue S' wave, and right ventricle global strain (RVGLS).

RESULTS

For all divers, immersion increased RV preload. In the no IPE group, the increase in RV preload induced by immersion was accompanied by an improvement in the contractility of the RV, as evidenced by increases in TAPSE (17.08 ± 1.15 mm vs 20.89 ± 1.32 mm), S' wave (14.58 ± 2.91 cm/s vs. 16.26 ± 2.77 cm/s), and RVGLS (25.37 ± 2.79 % vs. 27.09 ± 2.89 %). Negative SLL amplified these RV adaptations. In contrast, among divers with IPE, the increase in RV preload did not coincide with an improvement in RV contractility, indicating altered adaptive responses. In the IPE group, the TAPSE values changed from 17.19 ± 1.28 mm to 21.69 ± 1.67 mm and then to 23.55 ± 0.78 mm, respectively, in the dry, surface immersion, and immersion and negative SLL conditions. The S' wave values changed from 13.42 ± 2.94 cm/s to 13.26 ± 2.96 cm/s and then to 12.49 ± 0.77 cm/s, respectively, and the RVGLS values changed from -24.09% ± 2.91% to -23.99% ± 3.38% and then to -21.96% ± 0.55%, respectively.

INTERPRETATION

Changes in RV systolic function induced by immersion (especially with the addition of negative static lung load) vary among divers based on the history of IPE. Analyzing ventricular contractility during immersion, particularly RVGLS, could help to identify individual susceptibility in divers. These findings provide insights for the development of preventive strategies.

TRIAL REGISTRY

Comité de Protection des Personnes; No.: 21.05.05.35821; Recherche Impliquant la Personne Humaine de type 1 (RIPH1) HPS; No.: 2021-A01225-36.

Use of Speckle-Tracking Echocardiography in Septic Cardiomyopathy in Critically Ill Children: A Narrative Review

OBJECTIVES

In critically ill children with severe sepsis, septic cardiomyopathy (SCM) denotes the subset of patients who have myocardial dysfunction with poor response to fluid and inotropic support, and higher mortality risk. The objective of this review was to evaluate the role of speckle-tracking echocardiography (STE) in the diagnosis and prognosis of pediatric SCM in the PICU setting.

DATA SOURCES

We performed detailed searches using PubMed, Scopus, Web of Science, and Google Scholar. Reference lists of all included studies were also examined for further identification of potentially relevant studies.

STUDY SELECTION

Studies with the following medical subject headings and keywords were selected: speckle-tracking echocardiography, strain imaging, global longitudinal strain, echocardiography, sepsis, severe sepsis, septic shock, septic cardiomyopathy, and myocardial dysfunction.

DATA EXTRACTION

The following data were extracted from all included studies: demographics, diagnoses, echocardiographic parameters, severity of illness, PICU management, and outcomes.

DATA SYNTHESIS

STE is a relatively new echocardiographic technique that directly quantifies myocardial contractility. It has high sensitivity in diagnosing SCM, correlates well with illness severity, and has good prognosticating value as compared with conventional echocardiographic parameters. Further studies are required to establish its role in evaluating biventricular systolic and diastolic dysfunction, and to investigate whether it has a role in individualizing treatment and improving treatment outcomes in this group of patients.

CONCLUSIONS

STE is a useful adjunct to conventional measures of cardiac function on 2D-echocardiography in the assessment of pediatric SCM in the PICU.

Effect of left bundle branch pacing on right ventricular function: A 3-dimensional echocardiography study

BACKGROUND

The effect of left bundle branch pacing (LBBP) on right ventricular (RV) function is not well known, and there is conflicting evidence regarding whether cardiac resynchronization therapy improves RV function.

OBJECTIVES

The study aimed to investigate the effect of LBBP on RV function and to evaluate the response of RV dysfunction (RVD) to LBBP.

METHODS

Sixty-five LBBP candidates were prospectively included in the study and underwent echocardiography at baseline and 6-month follow-up. LBBP response was left ventricular (LV) reverse remodeling, defined as a reduction in LV end-systolic volume of ≥15% at follow-up.

RESULTS

Patients were assigned to 2 subgroups on the basis of 3-dimensional echocardiography-derived RV ejection fraction (EF) before LBBP implantation: 30 patients (46%) in the no RVD group and 35 patients (54%) in the RVD group. The RVD group was characterized by higher N-terminal pro-brain natriuretic peptide levels, New York Heart Association functional class, and larger LV/RV size. LBBP induced a significant reduction in QRS duration, LV size, and improvement in LVEF and mechanical dyssynchrony in both the no RVD and RVD groups, and a significant improvement in RV volumes and RVEF in the RVD group (all P<.01). LBBP resulted in a similar percentage reduction in QRS duration, LV dimensions, LV volumes, and percentage improvement in LVEF in RVD and no RVD groups (all P＞.05). LV reverse remodeling (29 of 35 patients vs 27 of 30 patients; P = .323) in the RVD group was similar to that in the no RVD group after LBBP.

CONCLUSION

LBBP induces excellent electrical and mechanical resynchronization, with a significant improvement in RV volumes and function. RVD did not diminish the beneficial effects on LV reverse remodeling after LBBP.

How Right is the Right Ventricle in Predicting Cardiac Mortality in Cardiac Failure: A 6-year Prospective Cohort Study

Aim

Two-dimensional speckle tracking echocardiography (2D-STE) and three-dimensional echocardiography (3DE) may overcome many limitations of the conventional 2D echocardiography (2DE) in assessing right ventricular (RV) function. We sought to determine whether characteristics of the right atrium and right ventricle as measured by 2D-STE and 3DE are associated with cardiac mortality in patients with ischemic heart failure, over a 6-year follow-up.

Materials and Methods

The inclusion criteria were ischemic cardiomyopathy with left ventricular ejection fraction of <40% diagnosed using standard 2DE, 2D-STE, and 3DE examination. Patients were followed for 6 years, and cardiac mortality was recorded.

Results

The study sample comprised a total of 54 participants. During the period of follow-up, 24% (13/54) died. The 2DE models showed that being older, having a higher body mass index (BMI), having higher systolic pulmonary artery pressure (SPAP), and a lower RV global longitudinal strain were associated with cardiac mortality in our cohort after 6-year follow-up. Finally, the 3DE models showed that in addition to being older, having higher BMI, having a higher SPAP baseline, lower baseline 3DE RV stroke volume, and larger 3DE RV end-diastolic volume and 3DE RV end-systolic volume were associated with cardiac mortality over 6-year follow-up.

Conclusion

This study provides evidence that RV dysfunction as seen on 2D-STE and 3DE could be associated with increased risk of cardiac-related mortality in patients with heart failure over 6 years.

Feasibility Value of Right Ventricular Longitudinal Shortening Fraction and the Prognostic Implications in Patients With Heart Transplantation

BACKGROUND

Right ventricular longitudinal shortening fraction (RVLSF) is a 2-dimensional speckle tracking echocardiography parameter based on tricuspid annular displacement analysis that could be used to assess right ventricular (RV) systolic function. The value of RVLSF in the assessment of RV systolic function in recipients of heart transplantation (HT) and whether RVLSF can replace strain parameters remains unknown.

METHODS AND RESULTS

A total of 153 adult patients who underwent HT were consecutively enrolled in this prospective longitudinal study. All subjects were examined by conventional transthoracic 2-dimensional echocardiography and 2-dimensional speckle tracking echocardiography to evaluate the RV end-diastolic basal diameter, RV end-diastolic area, fractional area change, peak systolic velocity of tricuspid annulus, tricuspid annular plane systolic excursion, RV free wall strain, and RVLSF. Cox proportional hazards regression was used to test if the parameters of interest had independent prognostic value for adverse outcome prediction in patients who underwent HT. A significant positive correlation was found between the measurements of RVLSF and RV free wall strain (r=0.927, P<0.001). Compared with the event-free group, the adverse outcome group displayed reduced RVLSF and RV free wall strain and higher age (P<0.001, <0.001, =0.016, respectively) in patients who underwent HT. RVLSF and RV free wall strain were independently associated with poor prognosis in multivariable analysis (both P<0.001).

CONCLUSIONS

RVLSF assessment provides an effective evaluation of RV longitudinal systolic function in the transplanted hearts and has prognostic value for adverse outcomes in patients undergoing HT.

Position Statement on the Use of Myocardial Strain in Cardiology Routines by the Brazilian Society of Cardiology's Department Of Cardiovascular Imaging - 2023

Central Illustration : Position Statement on the Use of Myocardial Strain in Cardiology Routines by the Brazilian Society of Cardiology's Department Of Cardiovascular Imaging - 2023 Proposal for including strain in the integrated diastolic function assessment algorithm, adapted from Nagueh et al.67 Am: mitral A-wave duration; Ap: reverse pulmonary A-wave duration; DD: diastolic dysfunction; LA: left atrium; LASr: LA strain reserve; LVGLS: left ventricular global longitudinal strain; TI: tricuspid insufficiency. Confirm concentric remodeling with LVGLS. In LVEF, mitral E wave deceleration time < 160 ms and pulmonary S-wave < D-wave are also parameters of increased filling pressure. This algorithm does not apply to patients with atrial fibrillation (AF), mitral annulus calcification, > mild mitral valve disease, left bundle branch block, paced rhythm, prosthetic valves, or severe primary pulmonary hypertension.

Evaluation of right ventricular longitudinal strain in pediatric patients with pulmonary hypertension by two-dimensional speckle-tracking echocardiography

Objectives

We aimed to investigate the association between right ventricular longitudinal strain measured by two-dimensional speckle-tracking echocardiography (2D-STE) and right heart catheterization data in pediatric patients with pulmonary hypertension (PH).

Methods

Two groups were evaluated, each consisting of 58 patients. Group 1, patients with PH; Group 2, normal matched controls. Data were collected from 58 patients with PH who underwent invasive hemodynamic evaluation. Standard transthoracic echocardiographic assessment was performed in all patients under the same circumstances. All patients underwent 2D-STE, and off-line analysis generated right ventricle longitudinal strain (RVLS) and right ventricular free wall strain (RVFW) and collected echocardiographic conventional parameters of right ventricular function, including the control group. The relationship between invasive characteristics and right ventricular function parameters was analyzed.

Results

In all, 58 PH patients were included in our study. The mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR) were strongly correlated with right ventricular free wall strain (RVFW) and right ventricular longitudinal strain (RVLS), moderately correlated with the right ventricle myocardial performance index (Tei index), weakly correlated with the transverse diameter of the right ventricle (RV) and the transverse diameter of the right atrium (RA), and moderately negatively correlated with right ventricular fractional area change (RVFAC). In terms of segments of the right ventricular free wall, the basal segment had the highest correlation coefficient with mPAP and PVR (r = 0.413, 0.523, 0.578, r = 0.421, 0.533, 0.575, p < 0.05, respectively). Tricuspid annular plane systolic excursion (TAPSE), main pulmonary artery diameter (MPA), peak systolic velocity of the right ventricle (RV-S'), and RA area parameters were not associated with mPAP and PVR (p > 0.05).

Conclusions

Right ventricular longitudinal strain is a reliable indicator to evaluate right ventricular function in pediatric patients with PH. It can provide valuable reference information for the clinical judgment of the status and severity of the disease in children.

Right heart echocardiography findings in hypoxic pneumonia patients during the COVID-19 pandemic in a South African population

Aims

The right ventricle is affected by Coronavirus disease 19 (COVID-19) via multiple mechanisms, which can result in right ventricular dysfunction (RVD). This study aimed to provide an assessment of right heart function using conventional echocardiography and advanced strain imaging, in patients with hypoxic pneumonia during the COVID-19 pandemic.

Methods and results

This study was an observational, prospective, single-centre study, including adults with hypoxic pneumonia, in two groups: COVID-19 pneumonia; and non-COVID-19 pneumonia. Bedside echocardiography was performed according to a pre-specified protocol and all right heart measurements were done as per standard guidelines. Right ventricular free wall strain (RVFWS) was measured using Philips® QLAB 11.0 speckle tracking software. Descriptive and comparative statistics were used to analyse data. Spearman Rank Order Correlations were used to determine the correlation between right ventricular (RV) parameters and clinical parameters. Univariate and multivariate logistic regression analyses were performed to characterize the predictors of in-hospital mortality. We enrolled 48 patients with COVID-19 pneumonia and 24 with non-COVID-19 pneumonia. COVID-19 patients were significantly older with a higher frequency of hypertension and diabetes and a trend towards a lower severity of illness score. Mean RVFWS yielded the highest estimates for the prevalence of RVD (81%), with no difference between the two pneumonia groups. Median Tricuspid Annular Plane Systolic Excursion (TAPSE) and right ventricular systolic excursion velocity (RVS') were not significantly different between COVID-19 (TAPSE 17.2 and RVS' 12), and non-COVID-19 pneumonia (TAPSE 17.8 and RVS' 12.1) with P values of 0.29 and 0.86, respectively. Non-COVID-19 pneumonia patients with moderate to severe hypoxaemia (PF < 150) were at greater risk of an elevated RV Systolic Pressure >30 mmHg respiratory rate = 3.25 (CI 1.35-7.82) on admission. Troponin levels discriminated between COVID-19 survivors (6 ng/L) and non-survivors (13 ng/L), P = 0.04. The mortality rate for COVID-19 was high (27%) compared to non-COVID-19 pneumonia (12%).

Conclusion

Patients with COVID-19 pneumonia had a similar admission prevalence of RVD when compared to patients with non-COVID-19 pneumonia. Despite preserved traditional parameters of RV systolic function, RVFWS was diminished in both groups, and we propose that RVFWS serves as an important marker of the subclinical disease of RV.

The impact of invasive treatment of superficial venous insufficiency of the lower extremities on cardiac functions

OBJECTIVE

The aim of the study was to investigate the effect of invasive treatment for chronic venous insufficiency (CVI) on cardiac hemodynamics.

METHODS

Fifty three patients diagnosed with saphenofemoral junction or great saphenous vein insufficiency in a level above C3 according to Clinical-Etiology-Anatomy-Pathophysiology classification were included in the study. All the patients underwent 2D echocardiography before and 3 months after the invasive treatment.

RESULTS

In postinvasive treatment echocardiographic assessment, significant decreases in right ventricular end-diastolic diameter (p = 0.006), TAPSE (p = 0.006), tricuspid E wave velocity (p = 0.004), tricuspid E/A ratio (p < 0.001), sPAB (p = 0.017), tricuspid lateral s' wave velocity (p = 0.004), and right ventricular free wall longitudinal strain rate (p = 0.011) were observed.

CONCLUSIONS

The invasive treatment of superficial venous insufficiency of the lower extremities may lead to reduction in the increased venous return in the supine position subclinically.

Early impairment of right ventricular systolic function in patients with prediabetes and type 2 diabetes mellitus: An analysis of two-dimensional speckle tracking echocardiography

BACKGROUND

Type 2 diabetes mellitus is a metabolic disease that affects multiple target organs. Current data on right ventricular damage in type 2 diabetes, especially in prediabetes, are limited. Due to the anatomical characteristics of the right ventricle, the assessment of the right ventricle by conventional echocardiography is difficult, whereas the ultrasound two-dimensional speckle tracking echocardiography can provide information on myocardial systolic function by tracking the motion information of myocardial speckles, which can sensitively reflect myocardial mechanical changes.

AIMS

To assess the effect of prediabetes and diabetes with preserved left ventricular ejection fraction on right ventricular myocardial systolic function and to identify independent risk factors affecting right ventricular systolic function.

METHODS

A total of 49 normoglycaemic (NG) healthy individuals, 43 prediabetics (PDM), and 52 type 2 diabetics (T2DM) were recruited. All study subjects underwent conventional echocardiography and two-dimensional speckle tracking echocardiography (2D-STE).

RESULTS

The right ventricular global longitudinal strain (RVGLS) (20.80 ± 1.96% vs. 18.99 ± 3.20% vs. 16.85 ± 4.01%), left ventricular global longitudinal strain (LVGLS), and interventricular septal longitudinal strain (IVS-LS) (17.28 ± 2. 35% vs. 16.14 ± 3.22% vs. 15.53 ± 3.33%) gradually decreased from the controls, through patients with prediabetes, to those with diabetes (p < .001). Right ventricular free wall strain (RVFW-LS) was higher in the control group (25.63 ± 4.58% vs. 22.83 ± 4.83% vs. 20.79 ± 4.92%) than in the other two groups with a statistically significant difference (p < .001), while RVFW-LS was not statistically different between the prediabetic and diabetic groups. Multivariate regression analysis showed that HbA1c (β = -.626, p < .001), IVS-LS (β = .417, p < .001), and left ventricular end-diastolic diameter (LVEDd) (β = .191, p = .011) were independently correlated with RVGLS.

CONCLUSIONS

Two-dimensional speckle tracking echocardiography can sensitively detect subtle changes in the early impairment of right ventricular systolic function in patients with abnormal glucose metabolism. Type 2 diabetes is the common mechanism causing impaired myocardial mechanics in the right and left ventricles. The reduced global systolic longitudinal strain of the right ventricle was associated with reduced global septal longitudinal strain and left ventricular remodeling. HbA1c is an independent predictor of the global longitudinal strain of the right ventricle, and controlling blood glucose levels may be expected to improve the extent of myocardial damage.

Feasibility of 2-dimensional speckle tracking echocardiography strain analysis of the right ventricle with trans-thoracic echocardiography in intensive care: a literature review and meta-analysis

OBJECTIVES

To identify variables that affect the feasibility of 2-dimensional right ventricular speckle tracking echocardiography (RV-STE) in the intensive care unit.

BACKGROUND

Trans-thoracic echocardiography (TTE) of the right ventricle is challenging. RV-STE is a novel echocardiography method thought to measure global RV function more fully than conventional TTE parameters. The feasibility of RV-STE in ICU populations has not been well described, and variables influencing RV-STE in ICU have not been investigated. This study aimed to address this.

METHODS

A literature review using Ovid MEDLINE(R) was undertaken. We performed meta-analysis with subgroup analysis of; RV-STE type (RV free-wall [RVFWLS] versus RV global longitudinal strain [RVGLS]), study design (prospective versus retrospective), coronavirus disease-19 (COVID-19) study or not, and strain software used. This was followed by meta-regression of proportion of invasive mechanical ventilation (IMV), with and without COVID-19 studies as a co-variate.

RESULTS

Eleven relevant studies from the literature search were identified, reporting an overall feasibility of RV-STE of 83.3% (95%CI 74.6-89.4%). Prospective study design was associated with higher feasibility compared with retrospective studies (p = 0.02). There were no statistical differences on univariate analysis between RVFWLS versus RVGLS, COVID-19 study or not, or strain software used. Meta-regression with COVID-19 study as a covariate demonstrated that higher proportions of IMV were significantly associated with worse feasibility (p = 0.04), as were COVID-19 studies (p < 0.01).

CONCLUSIONS

We have identified three variables associated with poor feasibility; retrospective study design, COVID-19 studies, and proportion of IMV. A prospective study design should be viewed as gold standard to maximise RV-STE feasibility.

Proportion of right ventricular failure and echocardiographic predictors in continuous-flow left ventricular assist device: a systematic review and meta-analysis

Background

Right ventricular failure (RVF) in patients with a continuous-flow left ventricle assist device (CF-LVAD) is associated with higher incidence of mortality. This systematic review aims to assess the overall proportion of RVF and the pre-operative echocardiographic parameters which are best correlating to RVF.

Methods

A systematic research was conducted between 2008 and 2019 on MEDLINE, EMBASE, PUBMED, UPTODATE, OVID, COCHRANE LIBRARY, and Google Scholar electronic databases by performing a PRISMA flowchart. All observational studies regarding echocardiographic predictors of RVF in patients undergoing CF-LVAD implantation were included.

Results

A total number of 19 observational human studies published between 2008 and 2019 were included. We identified 524 RVF patients out of a pooled final population of 1741 patients. The RVF overall proportion was 28.25% with 95% confidence interval (CI) 0.24-0.34. The highest variability of perioperative echocardiographic parameters between the RVF and no right ventricular failure (NO-RVF) groups has been found with tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and right ventricular global longitudinal strain (RVGLS). Their standardized mean deviation (SMD) was - 0.33 (95% CI - 0.54 to - 0.11; p value 0.003), - 0.34 (95% CI - 0.53 to - 0.15; p value 0.0001), and 0.52 (95% CI 0.79 to 0.25; p value 0.0001), respectively.

Conclusions

The echocardiographic predictors of RVF after CF-LVAD placement are still uncertain. However, there seems to be a trend of statistical correlation between TAPSE, FAC, and RVGLS with RVF event after CF-LVAD placement.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-022-01447-7.

Systolic function in dogs with pulmonic stenosis of different severities and the effect of balloon valvuloplasty

INTRODUCTION/OBJECTIVES

Pulmonic stenosis (PS) is one of the most common congenital heart diseases in dogs leading to right ventricular (RV) pressure overload, myocardial remodeling, and potential RV dysfunction. Our objectives were to investigate the extent of RV systolic dysfunction in canine PS and to examine the immediate influence of balloon valvuloplasty (BV) on systolic function.

ANIMALS, MATERIALS AND METHODS

This prospective study evaluated 72 dogs with PS and 86 healthy dogs. Echocardiographic parameters of systolic function included normalized tricuspid annular plane systolic excursion (N-TAPSE), normalized systolic myocardial tissue Doppler velocity of the lateral tricuspid annulus (N-RVFW-S'), fractional area change, and speckle-tracking longitudinal endocardial RV strain. Forty-four dogs underwent BV and were re-examined after surgery.

RESULTS

Systolic function at the basal segment of the RV was significantly lower in the PS group when compared to healthy dogs (mean N-TAPSE 4.29 ± standard deviation 1.18 mm/kg^0.285 vs. 5.60 ± 1.29 mm/kg^0.285; median N-RVFW-S' 5.28 [lower-upper 25% quantile 4.35-6.43 cm/s/kg^0.186] vs. 7.82 [6.73-8.79 cm/s/kg^0.186]; all P<0.001). Global longitudinal RV endocardial strain showed no significant difference between the two groups (-28.50 ± 6.23% vs. 28.61 ± 4.64%; P=0.886), but segmental strain analyses revealed basal hypo- and potential compensatory hyperkinesis of the apical RVFW. Furthermore, BV affected most parameters of systolic function, but not the segmental strain values and N-TAPSE.

CONCLUSIONS

Right ventricular basal longitudinal systolic function is decreased in dogs with PS in comparison to a healthy cohort. Regional and global function does not necessarily coincide.

Biventricular Function is Impaired in Right Ventricular Septal Pacing-A Prospective Study Using Myocardial Strain Imaging

BACKGROUND

Left ventricular (LV) dysfunction is known to occur after right ventricular (RV) pacing; the effect on RV function is less well studied. The aim of this study was to assess the impact of RV mid-septal pacing upon RV function using the novel parameters of speckle-tracking derived RV global longitudinal strain (RV GLS) and RV free wall strain (RV FWS), as well as the conventional parameters RV fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), and tricuspid annular systolic velocity (RV S').

METHODS

Thirty-two (32) consecutive patients with normal baseline LV and RV function requiring permanent pacemaker insertion (for high-grade AV block or sinus node dysfunction) were prospectively recruited. Echocardiography was performed prior to implantation, at 1 day, 1 month and 1 year after implantation, with 29 patients completing follow-up.

RESULTS

After 1 year, three patients (10%) with otherwise normal RV parameters developed abnormal RV strain patterns. Compared to 1 day after implantation, at 1 year significant reductions were observed in mean RV GLS (-24.8 to -21.8%) RV S' (15.1 to 12.2 cm/s), TAPSE (24.2 to 21.9 mm), RV GLS (-24.8 to -21.8%), left ventricular ejection fraction (LVEF) (66.0 to 57.9%), LV GLS (-19.9 to 17.0), all p<0.01. There was a non-significant reduction for RV FWS (-29.0 to -26.7%, p=0.06) and there was no change in RV FAC (49.1 to 46.9%, p=0.24).

CONCLUSION

We report abnormalities of RV strain developing 1 year after pacemaker insertion. Measurement of myocardial strain is emerging as an additional method to detect patients at risk of RV dysfunction in those who have undergone pacemaker implantation.

The effect of type 2 diabetes mellitus on multiple obstructive coronary artery disease

BACKGROUND

Although type 2 diabetes mellitus (T2DM) individuals easily develop three-vessel disease (3VD) coronary artery disease (CAD), there is very little information available about their left ventricle (LV) functions. The purpose of this study is to evaluate the LV function using two-dimensional speckle tracking echocardiography (2-D STE) in T2DM patients with 3VD.

METHODS

One hundred and three consecutive patients with confirmed 3VD CAD were enrolled and divided into two groups, while 53 patients with DM and 50 patients without. The control group was composed of 30 age- and sex-matched healthy individuals. All patients underwent 2-D STE and standard echocardiograms. The durations of DM and the level of HbA1c were also recorded.

RESULT

Between the 3VD-DM and 3VD-non-DM groups, normal echocardiography did not reveal any appreciable differences. However, patients with 3VD-DM had significantly lower global longitudinal strain (GLS) than those with 3VD-non-DM (15.87 ± 2.51 vs.17.56 ± 2.72, p < .05) by 2-D STE strain measurement. Besides, patients whose duration of DM excess 5 years showed significant lower GLS than those with less than 5 years duration (14.25 ± 2.31 vs. 16.65 ± 1.96, p = .007). However, there was no difference in GLS between the 3VD-DM patients with HbA1c ≥ 7% and HbA1c < 7%.

CONCLUSIONS

Compared to patients with 3VD alone, those with 3VD-DM have a lower cardiac function. In 3VD-DM patients, the duration of DM is a significant factor that contributes to cardiac function deterioration, whereas, the glucose control state has limited influence.

Prognostic Impact of Right Ventricular Strain in Isolated Severe Tricuspid Regurgitation

BACKGROUND

Right ventricular (RV) systolic function is an established marker of outcomes in patients with severe tricuspid regurgitation (TR). Timely detection of RV dysfunction using conventional two-dimensional echocardiography is challenging. RV strain has emerged as an accurate and sensitive tool for the evaluation of RV function, with the capability to detect subclinical RV dysfunction. The aim of this study was to evaluate the prognostic value of RV strain parameters in early stages of severe TR.

METHODS

Consecutive patients with at least severe TR (severe, massive, or torrential) and the absence of a formal indication for tricuspid valve intervention in secondary TR evaluated in the Heart Valve Clinic were prospectively included. RV systolic function was measured using conventional echocardiographic indices (RV fractional area change, tricuspid annular plane systolic excursion, and Doppler tissue imaging S wave [S']) and speckle-tracking echocardiography-derived automatic peak global longitudinal strain and free wall longitudinal strain (FWLS) using an automated two-dimensional strain analytic software. A combined end point of hospital admission due to heart failure or all-cause mortality was defined.

RESULTS

A total of 266 patients were enrolled in the study, and 151 were ultimately included. Strain parameters detected a higher percentage of abnormal RV values compared with conventional indices. During a median follow-up period of 26 months (interquartile range, 13-42 months), 35% of the patients reached the combined end point. Cumulative event-free survival was significantly worse in patients with impaired RV global longitudinal strain and RV FWLS. Conventional indices of RV systolic function were not associated with outcomes (P > .05 for all). On multivariate analysis, RV FWLS was independently associated with mortality and heart failure (adjusted hazard ratio for abnormal RV FWLS, 5.90; 95% CI, 3.17-10.99; P < .001).

CONCLUSION

In early stages of severe TR, RV FWLS is more frequently impaired compared with conventional indices of RV function. Among all parameters, RV FWLS is the strongest predictor of mortality and heart failure, independent of additional prognostic markers.

Right ventricle speckle tracking in bronchopulmonary dysplasia: one-year follow-up

BACKGROUND

Bronchopulmonary dysplasia (BPD) is still a major concern in preterm infants and adequate screening methods for secondary right ventricle (RV) failure are needed. Early detection could be aided by taking measurements of RV deformation using speckle tracking echocardiography. A prospective longitudinal study was carried out over 28 months at a tertiary care pediatric cardiology center. Preterm infants < 32 weeks gestational age (GA) were eligible for the study. Enrolled patients were separated in two groups: NO-BPD or BPD. At three timepoints over the first year of life, echocardiogram measurements were performed. Right ventricle strain was studied using speckle tracking analysis and compared to conventional function parameters.

RESULTS

Fifty patients were enrolled in the study, 22 in the NO-BPD group and 28 in the BPD group. RV strain showed no statistical differences between groups. However, the BPD group showed worse RV function than the NO-BPD group, using speckle tracking analysis and other conventional parameters. During the study follow-up, an improvement trend is shown in RV strain.

CONCLUSIONS

RV longitudinal strain and strain rate derived by speckle tracking is feasible in preterm infants. Although there seems to be a good correlation between RV strain and BPD severity, the results of this study were not conclusive. More studies should be carried out to investigate the optimum echocardiographic screening model of RV dysfunction in BPD patients.

What Strain Analysis Adds to Diagnosis and Prognosis in Heart Failure Patients

Heart failure (HF) is a common disease that requires appropriate tools to correctly predict cardiovascular outcomes. Echocardiography represents the most commonly used method for assessing left ventricular ejection fraction and a cornerstone in the detection of HF, but it fails to procure an optimal level of inter-observer variability, leading to unsatisfactory prediction of cardiovascular outcomes. In this review, we discuss emerging clinical tools (global longitudinal strain of the left ventricle, the right ventricle, and the left atrium) that permitted an improvement in the diagnosis and ameliorated the risk stratification across different HF phenotypes. The review analyzes the speckle-tracking contributions to the field, discussing the limitations and advantages in clinical practice.

The relationship between pre-operative right ventricular longitudinal strain and low-cardiac-output syndrome after surgical aortic valve replacement

Objectives

This study was performed to investigate the relationship between right ventricular free wall longitudinal strain (RVFWSL) and low cardiac output syndrome (LCOS) after surgical aortic valve replacement (SAVR) and to further explore its association with readmission within 2 years in patients who developed LCOS after SAVR.

Methods

This single-center retrospective observational study involved consecutive patients who underwent SAVR at our hospital from May 2018 to June 2020. Preoperative echocardiography was obtained within 3 days before SAVR. The longitudinal strain of the right ventricle was analyzed using the right ventricle as the main section, and the RVFWSL and right ventricular four-chamber longitudinal strain (RV4CSL) were obtained. The primary observation was the occurrence of LCOS. The secondary prognostic indicators were mainly the readmission rates within 2 years.

Results

In total, 146 patients were finally included in this study. The RVFWSL was significantly lower in the LCOS group than in the No-LCOS group (16.63 ± 2.10) vs. (23.95 ± 6.33), respectively; P < 0.001). The multivariate regression analysis showed that the RVFWSL was associated with LCOS (odds ratio, 1.676; 95% confidence interval, 1.258-2.232; P < 0.001). The receiver operating characteristic curve showed that the cut-off value for RVFWSL to predict LCOS was less than -18.3, with an area under the curve of 0.879, sensitivity of 100%, and specificity of 80.47%. The multivariate regression analysis showed that LCOS was an independent risk factor for readmission within 2 years in patients undergoing SAVR.

Conclusion

Patients with RVFWSL (<-18.3%) may be an increased risker for LCOS after SAVR. The occurrence of LCOS after SAVR is Yong-jian Zhang a risk factor for readmission within 2 years. Right ventricular function monitoring may have some predictive value for the postoperative prognosis in patients undergoing SAVR.

Prognostic value of feature-tracking right ventricular longitudinal strain in heart transplant recipients

OBJECTIVES

The prognostic value of cardiac magnetic resonance feature tracking (CMR-FT)-derived right ventricular longitudinal strain (RVLS) post-heart transplantation has not been studied. This study aimed to evaluate the prognostic significance of CMR-FT-derived RVLS, in patients post- heart transplantation and to directly compare its value with that of conventional RV ejection fraction (RVEF).

METHODS

In a cohort of consecutive heart transplantation recipients who underwent CMR for surveillance, RVLS from the free wall was measured by CMR-FT. The composite endpoint was all-cause death or major adverse cardiac events. The Cox regression model was used to examine the independent association between RVLS and the endpoint.

RESULTS

A total of 96 heart transplantation recipients were retrospectively included. Over a median follow-up of 41 months, 20 recipients reached the composite endpoint. The multivariate Cox analysis showed that the model with RVLS (hazard ratio [HR]:1.334; 95% confidence interval [CI]:1.148 to 1.549; p < 0.001; Akaike information criterion [AIC] = 140, C-index = 0.831) was better in predicting adverse events than the model with RVEF (HR:0.928; 95% CI: 0.868 to 0.993; p = 0.030; AIC = 149, C-index = 0.751). Furthermore, receiver operating characteristic curves revealed that the accuracy for predicting adverse events was greater for RVLS than RVEF (area under the curve: 0.85 vs 0.76, p = 0.03).

CONCLUSIONS

CMR-FT-derived RVLS is an independent predictor of adverse events in post-heart transplantation, and its predictive value was better than RVEF. Therefore, our study highlighted the importance of evaluating RVLS for risk stratification after heart transplantation.

KEY POINTS

• CMR-RVLS is an independent predictor of adverse events post-heart transplantation and provides greater predictive value. • CMR-RVLS may help clinicians to risk stratification in heart transplantation recipients.

Assessment of right ventricular remodeling in chronic thromboembolic pulmonary hypertension by 2D-speckle tracking echocardiography: A comparison with cardiac magnetic resonance

Background

Right heart remodeling occurs in a substantial proportion of patients with chronic thromboembolic pulmonary hypertension (CTEPH) and significantly affects their prognosis. Two-dimensional speckle-tracking echocardiography (2D-STE) can be used to evaluate myocardial deformation under physiological and pathological conditions. This study aimed to assess the feasibility of 2D-STE for evaluating right ventricular (RV) remodeling in CTEPH patients.

Methods

This retrospective study included 21 CTEPH patients who underwent transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR). Data for the following parameters that can reflect RV function were collected: tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), right ventricular index of myocardial performance (RIMP), peak systolic velocity of the tricuspid annulus (S'), and CMR-right ventricular ejection fraction (CMR-RVEF). The following strain parameters were calculated using post-processing software: STE-RV global longitudinal strain (STE-RVGLS), STE-RV free wall longitudinal strain (STE-RVFWLS), and CMR-RVGLS.

Results

As CMR-RVEF deteriorated, RV remodeling in CTEPH patients became more apparent and was mainly characterized by significant enlargement of the RV, weakening of myocardial deformation, and a decrease in RV contractility (RV area, STE-RVFWLS, STE-RVGLS: mild vs. severe and moderate vs. severe, p < 0.05; CMR-RVGLS: mild vs. severe, p < 0.05; TAPSE: moderate vs. severe, p < 0.05). Moreover, the Pearson correlation coefficient for correlation with CMR-derived RVEF was stronger for RVFWLS than for CMR-GLS (r-value: 0.70 vs. 0.68), and the strain values measured by 2D-STE showed a weak correlation with right heart catheterization data. Bland-Altman analysis showed good agreement between 2D-STE and CMR-feature tracking (FT) for RVGLS (bias = -0.96; 95% limit of agreement from -8.42 to 6.49).

Conclusions

For the measurement of RVGLS, 2D-STE is similarly feasible to CMR-FT and could sensitively identify right heart remodeling.

Magnetic Resonance Imaging Assessment of Right Ventricular Deformation in Patients With Transposition of the Great Arteries

PURPOSE

To detect changes of right ventricular (RV) myocardial deformation in patients with systemic RV (SRV) and transposition of the great arteries (TGA) as compared with individuals without structural heart disease.

MATERIALS AND METHODS

We performed a retrospective analysis of cine steady-state free precession cardiac magnetic resonance imaging sequences acquired using a 1.5 T scanner in short-axis and long-axis views in 25 patients with SRV (16 with atrial switch repair for D-TGA and 9 with congenitally corrected TGA; age range 19 to 68, 13 males). The control group consisted of 25 individuals without structural heart disease (age range 10 to 73, 14 males). Besides routine RV magnetic resonance imaging volumetry, mean longitudinal RV strain was measured on a 4-chamber view, and mean circumferential RV strain on 3 short-axis images (basal, midventricular, and apical) based on feature tracking. The strain parameters were statistically compared between patients with SRV and the control group.

RESULTS

Patients with SRV, compared with the control group, had significantly higher RV-indexed end-diastolic volume (122±40 vs. 70±9 mL/m 2 , P <0.001), lower RV ejection fraction (45±12% vs. 62±6%, P <0.001), and reduced mean longitudinal RV strain (-13.7±3.6% vs. -21.6±2.7%, P <0.001). There was no relevant difference between mean circumferential SRV strain in the basal and midventricular plane; however, in patients with SRV, mean circumferential strain was reduced at the apical level (-12.0±6.1% vs. -17.9±5.6%, P <0.001).

CONCLUSIONS

SRV failure could be explained by reduced longitudinal SRV strain caused by the longitudinal orientation of RV myocardial fibers. In patients with SRV, circumferential RV strain is only reduced in apical segments.

The Balance between the Left and Right Ventricular Deformation Evaluated by Speckle Tracking Echocardiography Is a Great Predictor of the Major Adverse Cardiac Event in Patients with Pulmonary Hypertension

Cardiovascular failure is one of the most relevant causes of death in pulmonary hypertension (PH). With progressive increases of right ventricular (RV) afterload in PH patients, both RV and left ventricular (LV) function impair and RV–LV dyssynchrony develop in parallel. We aimed to analyze the balance between the left and right ventricular deformation to assess the outcome of patients with pulmonary hypertension by means of speckle tracking echocardiography. In this prospective study, 54 patients with invasively diagnosed pulmonary hypertension, and 26 healthy volunteers were included and underwent a broad panel of noninvasive assessment including 2D-echocardiography, 2D speckle tracking, 6-minute walking test and BNP. Patients were followed up for 338.7 ± 131.1 (range 60 to 572) days. There were significant differences in |LVGLS/RVFLS-1| and |LASc/RASc-1| between PH patients and the control group. During the follow up, 13 patients experienced MACEs, which included 7 patients with cardiac death and 6 patients with re-admitted hospital due to right ventricular dysfunction. In the multivariate Cox model analysis, |LVGLS/RVFLS-1| remained independent prognosis of markers (HR = 4.03). Our study findings show that |LVGLS/RVFLS-1| is of high clinical and prognostic relevance in pulmonary hypertension patients and reveal the importance of the balance between the left and right ventricular deformation.

Epicardial adipose tissue and right ventricular function in type 2 diabetes mellitus using two-dimensional speckle tracking echocardiography

BACKGROUND

Epicardial adipose tissue is an emerging cardiovascular risk factor. The aim of this study was to evaluate right ventricular function and investigate its association with EAT in T2DM patients.

METHODS

154 T2DM patients were divided into two groups according to EAT thickness: T2DM with EAT <5 mm and T2DM with EAT ≥5 mm. Seventy non-T2DM patients were enrolled as control group. RV function was evaluated using both conventional echocardiography as well as two-dimensional speckle tracking echocardiography. EAT thickness was measured as the echo-free space between the free wall of the right ventricle and the visceral layer of pericardium at end-systole.

RESULTS

Compared to control group, EAT thickness was significantly higher and RV systolic function and early diastolic function are all impaired in all T2DM patients. In T2DM with EAT ≥5 mm group, RV systolic function and early diastolic function suffered more severe impairment when compared with T2DM with EAT <5 mm group. Multivariate linear regression analysis revealed that EAT was associated with RV systolic and early diastolic dysfunction independent of traditional cardiovascular risk factors.

CONCLUSIONS

Our research suggest that in T2DM patients RV systolic function and early diastolic function are all impaired which are associated with the thickened EAT.

Evaluation of Right Ventricular Myocardial Mechanics by 2- and 3-Dimensional Speckle-Tracking Echocardiography in Patients With an Ischemic or Non-ischemic Etiology of End-Stage Heart Failure

Background

The aims of our study were (1) to assess the right ventricular (RV) myocardial mechanics by two-dimensional (2D) and three-dimensional (3D) speckle-tracking echocardiography (STE) in patients with an ischemic or non-ischemic etiology of end-stage heart failure (HF) and (2) to explore which RV index evaluated by 2D- and 3D-STE was the most powerful indicator for identifying the ischemic and non-ischemic etiologies of end-stage HF.

Methods

A total of 96 patients with left ventricular ejection fraction (LVEF) < 30% were enrolled in our study: 42 patients (mean age, 52 ± 10 years; 9.5% female) with ischemic cardiomyopathy and 54 patients (mean age, 46 ± 14 years; 16.7% female) with non-ischemic cardiomyopathy. A total of 45 healthy subjects (mean age, 46 ± 13 years; 24.4% female) served as controls. The longitudinal strain of the RV free wall (RVFWLS) was determined by both 2D- and 3D-STE.

Results

Compared to controls, patients with an ischemic or non-ischemic etiology of end-stage HF had lower 2D-RVFWLS, 3D-RVFWLS and RV ejection fraction (RVEF) values (P < 0.05). Patients with non-ischemic cardiomyopathies (NICMs) had significantly lower 3D-RVFWLS and RVEF values than in those with ischemic cardiomyopathies (ICMs), whereas 2D-RVFWLS and conventional RV function parameters did not differ between the two subgroups. RVEF was highly related to 3D-RVFWLS (r = 0.72, P < 0.001), modestly related to 2D-RVFWLS (r = 0.51, P < 0.001), and weakly related to conventional RV function indices (r = –0.26 to 0.46, P < 0.05). Receiver operating characteristic curve analysis revealed that the optimal 3D-RVFWLS cut-off value to distinguish NICM from ICM patients was –14.78% (area under the curve: 0.73, P < 0.001), while 2D-RVFWLS and conventional RV echocardiographic parameters did not.

Conclusion

Our study demonstrated the superiority of 3D-RVFWLS over 2D-RVFWLS and conventional RV function indices in identifying the ischemic and non-ischemic etiologies of end-stage HF. These findings support the idea that 3D-RVFWLS may be a promising non-invasive imaging marker for distinguishing NICM from ICM.

Transthoracic Echocardiography-Based Prediction Model of Adverse Event Risk in Patients with COVID-19

Cardiopulmonary disorders cause a significant increase in the risk of adverse events in patients with COVID-19. Therefore, the development of new diagnostic and treatment methods for comorbid disorders in COVID-19 patients is one of the main public health challenges. The aim of the study was to analyze patient survival and to develop a predictive model of survival in adults with COVID-19 infection based on transthoracic echocardiography (TTE) parameters. We conducted a prospective, single-center, temporary hospital-based study of 110 patients with moderate to severe COVID-19. All patients underwent TTE evaluation. The predictors of mortality we identified in univariate and multivariable models and the predictive performance of the model were assessed using receiver operating characteristic (ROC) analysis and area under the curve (AUC). The predictive model included three factors: right ventricle (RV)/left ventricle (LV) area (odds ratio (OR) = 1.048 per 1/100 increase, p = 0.03), systolic pulmonary artery pressure (sPAP) (OR = 1.209 per 1 mm Hg increase, p < 0.001), and right ventricle free wall longitudinal strain (RV FW LS) (OR = 0.873 per 1% increase, p = 0.036). The AUC-ROC of the obtained model was 0.925 ± 0.031 (95% confidence interval (95% CI): 0.863−0.986). The sensitivity (Se) and specificity (Sp) measures of the models at the cut-off point of 0.129 were 93.8% and 81.9%, respectively. A binary logistic regression method resulted in the development of a prognostic model of mortality in patients with moderate and severe COVID-19 based on TTE data. It may also have additional implications for early risk stratification and clinical decision making in patients with COVID-19.

Sustained right ventricular dysfunction in severe COVID-19: The role of disseminated intravascular coagulation

BACKGROUND

Acute right ventricular (RV) failure is common in patients hospitalized with COVID-19. Compared to the conventional echocardiographic parameters, right ventricular longitudinal strain (RVLS) is more sensitive and accurate for the diagnosis of RV systolic dysfunction.

OBJECTIVE

Our purpose was to investigate the sustained RV dysfunction echo-quantified by RVLS in patients recovered from severe COVID-19. Furthermore, we aimed to assess whether disseminated intravascular coagulation (DIC) has a key role to predict the impaired RV strain.

METHODS

Of 198 consecutive COVID-19 patients hospitalized from March 1, 2020, to April 15, 2020, 45 selected patients who survived from severe COVID-19 were enrolled in the study and referred to our echo-lab for transthoracic echocardiography 6-months after discharge. RVLS was calculated as the mean of the strain values of RV free wall. DIC was defined with a validated scoring system: DIC score equal to or more than 5 is compatible with overt-DIC. Categories of acute respiratory distress syndrome (ARDS) were defined based on PaO₂ /FiO₂ ratio.

RESULTS

A total 26 of 45 patients showed impaired RVLS at 6-months' follow-up. DIC score was significantly higher in patients with worse RVLS than in those with better RVLS (4.8 ± .5 vs. 3.6 ± .6, p =.03). Stages of ARDS did not modulate this relationship. Finally, overt-DIC results the only independent predictor of sustained RV dysfunction (OR 1.233, 95% CI 1.041-1.934, p =.043).

CONCLUSIONS

Sustained RV impairment frequently occurs in patients recovered from severe COVID-19. DIC plays a key role, resulting in an independent predictor of sustained RV dysfunction.

Low tricuspid annular plane systolic excursion is associated with a poor outcome in patients with COVID-19: A systematic review and meta-analysis

ABSTRACT

Background: This systematic review and meta-analysis aimed to assess whether tricuspid annular plane systolic excursion (TAPSE) could be used as a prognostic tool in patients with coronavirus disease 19 (COVID-19).

METHODS

Studies on the relationship between TAPSE and COVID-19 since February 2021. Standardized mean difference (SMD) and 95% confidence intervals were used to assess the effect size. The potential for publication bias was assessed using a contour-enhanced funnel plot and Egger test. A meta-regression was performed to assess if the difference in TAPSE between survivors and nonsurvivors was affected by age, sex, hypertension or diabetes.

RESULTS

Sixteen studies comprising 1579 patients were included in this meta-analysis. TAPSE was lower in nonsurvivors (SMD -3.24 (-4.23, -2.26), P < .00001; I2 = 71%), and a subgroup analysis indicated that TAPSE was also lower in critically ill patients (SMD -3.85 (-5.31, -2.38,), P < .00001; I2 = 46%). Heterogeneity was also significantly reduced, I2 < 50%. Pooled results showed that patients who developed right ventricular dysfunction had lower TAPSE (SMD -5.87 (-7.81, -3.92), P = .004; I2 = 82%). There was no statistically significant difference in the TAPSE of patients who sustained a cardiac injury vs those who did not (SMD -1.36 (-3.98, 1.26), P = .31; I2 = 88%). No significant publication bias was detected (P = .8147) but the heterogeneity of the included studies was significant. A meta-regression showed that heterogeneity was significantly greater when the incidence of hypertension was <50% (I2 = 91%) and that of diabetes was <30% (I2 = 85%).

CONCLUSION

Low TAPSE levels are associated with poor COVID-19 disease outcomes. TAPSE levels are modulated by disease severity, and their prognostic utility may be skewed by pre-existing patient comorbidities.

TRIAL RETROSPECTIVELY REGISTERED FEBRUARY ,

PROSPERO CRD42021236731.

Right Ventricular Longitudinal Strain in Patients with Heart Failure

Patients with heart failure (HF) have high morbidity and mortality. Accurate assessment of right ventricular (RV) function has important prognostic significance in patients with HF. However, conventional echocardiographic parameters of RV function have limitations in RV assessments due to the complex geometry of right ventricle. In recent years, speckle tracking echocardiography (STE) has been developed as promising imaging technique to accurately evaluate RV function. RV longitudinal strain (RVLS) using STE, as a sensitive index for RV function evaluation, displays the powerfully prognostic value in patients with HF. Therefore, the aim of the present review was to summarize the utility of RVLS in patients with HF.

Ventricular Myocardial Deformation in Fetuses With Tetralogy of Fallot: A Necessary Field of Investigation

Background: Tetralogy of Fallot (TOF) is one of the most common cyanotic congenital heart defects (CHDs). The patterns of fetal myocardial deformations in TOF have not been well-studied. This study aimed to assess biventricular myocardial deformations in fetuses with TOF compared with normal fetuses.

Methods: A retrospective cohort study of fetuses with TOF and gestational age (GA)-matched controls was conducted at a single tertiary referral center from 2014 to 2020. All enrolled fetuses underwent detailed echocardiography, and four-chamber video-clips were recorded and analyzed offline for deformation assessment by using two-dimensional speckle tracking echocardiography (2D-STE). Comparisons for baseline characteristics, cardiac morphological measurements (ventricular, atrial, and great arterial diameters or ratios, global sphericity index), systolic function parameters [ejection fraction (EF), fractional area change (FAC)], and strain parameters [global longitudinal strain (GLS), global longitudinal strain rate in systole and diastole (GLSRs, GLSRd)] were performed between fetuses with TOF and GA-matched controls.

Results: Fifty-two fetuses with TOF and 52 GA-matched controls were enrolled in this study. Fetuses with TOF exhibited similar left ventricular (LV) EF (58.51 ± 5.11% vs. 57.59 ± 5.38%, P = 0.16) and right ventricular (RV) FAC (43.64 ± 2.89% vs. 44.27 ± 3.04%, P = 0.25), compared to normal fetuses. While, in deformational analysis, TOF fetuses demonstrated significantly lower LV and RV GLS values (−22.57 ± 2.91% vs. −27.39 ± 4.38%, P < 0.001 for LV GLS; −24.27 ± 3.18% vs. −28.71 ± 4.48%, P < 0.001 for RV GLS). Both LV GLS (r = −0.518, P < 0.001) and RV GLS (r = −0.534, P < 0.001) were found negatively correlated with the aortic valve-to-pulmonary valve diameter ratio (AV:PV ratio). Z-scores of PV annulus and main pulmonary artery (MPA) also had positive correlation with LV and RV GLS, respectively.

Conclusions: Decreased biventricular myocardial deformations can appear even in fetuses with TOF with normal systolic ventricular function. Both LV and RV GLS values are correlated with the severity of right ventricular outflow tract obstruction. It indicates 2D-STE may be a more sensitive tool to assess fetal cardiac function than the conventional echocardiographic methods.

Preload Dependency of 2D Right Ventricle Speckle Tracking Echocardiography Parameters in Healthy Volunteers: A Prospective Pilot Study

(1) Background: Right ventricular (RV) strain parameters derived from the analysis of the tricuspid annular displacement (TAD) are emergent two-dimensional speckle tracking echocardiography (2D-STE) parameter used for the quantitative assessment of RV systolic function. Few data are available regarding 2D-STE parameters and their dependency on RV preload. Our aim was to evaluate the effect of an acute change in RV preload on 2D-STE parameters in healthy volunteers. (2) Methods: Acute modification of RV preload was performed by a fluid challenge (FC): an infusion of 500 mL of 0.9% sodium chloride was given over 5 min in supine position. Preload dependency (responder group) was confirmed by a stroke volume increase of at least 10% measured by echocardiography. (3) Results: Among 32 healthy volunteers, 19 (59%) subjects were classified as non-responders and 13 (41%) as responders. In the responder group, the tricuspid annular plane systolic excursion (TAPSE) significantly increased (20 (20-23.5) mm to 24 (20.5-26.5) mm; p = 0.018), while RV strain parameters significantly decreased after FC: -23.5 ((-22.3)-(-27.3))% to -25 ((-24)-(29.6))%; p = 0.03) for RV free wall longitudinal strain and -22.8 ((-20.4)-(-30.7))% to -23.7 ((-21.2)-(-27))%; p = 0.02) for RV four-chamber longitudinal strain. 2D-STE parameters derived from the TAD analysis were not influenced by the FC (all p > 0.05). (4) Conclusions: In young, healthy volunteers, RV strain parameters and TAPSE are preload dependent, while TAD parameters were not. The loading conditions must be accounted for when evaluating RV systolic function by 2D-STE parameters.

Echocardiographic assessment of the right ventricle in COVID-19: a systematic review

Cardiac involvement has been frequently reported in COVID-19 as responsible of increased morbidity and mortality. Given the importance of right heart function in acute and chronic respiratory diseases, its assessment in SARS-CoV-2 infected patients may add prognostic accuracy. Transthoracic echocardiography has been proposed to early predict myocardial injury and risk of death in hospitalized patients. This systematic review presents the up-to-date sum of literature regarding right ventricle ultrasound assessment. We evaluated commonly used echocardiographic parameters to assess RV function and discussed their relationship with pathophysiological mechanisms involved in COVID-19. We searched Medline and Embase for studies that used transthoracic echocardiography for right ventricle assessment in patients with COVID-19.

Association of serum uric acid with biventricular myocardial dysfunction in patients with type 2 diabetes mellitus

BACKGROUND AND AIMS

Increased serum uric acid (SUA) is common in type 2 diabetes mellitus (T2DM) and is associated with left ventricular (LV) myocardial dysfunction. Nonetheless the association of SUA with right ventricular (RV) function in T2DM has not been studied. This study aimed to investigate the association of SUA with biventricular myocardial function in patients with T2DM.

METHODS AND RESULTS

A total of 560 patients with T2DM were enrolled and divided into four groups according to sex-specific quartiles of SUA. Transthoracic echocardiography was performed and two-dimensional speckle tracking was used to measure biventricular myocardial strain, including LV global longitudinal strain (GLS), circumferential strain (CS), radial strain (RS), and RV free wall longitudinal strain (RV-FWLS). The absolute value of all biventricular strain parameters showed a stepwise decrease across SUA quartiles (all P < 0.01). In particular, LV assessment by GLS, CS and RS demonstrated that those in the 4th quartile were impaired compared with the other quartiles (all P < 0.05). Similarly, RV-FWLS of the 4th quartile was significantly impaired compared with the 1st and 2nd quartiles (all P < 0.05). The same reduction in biventricular strain across SUA quartiles was observed in patients with estimated glomerular filtration rate < or ≥60 ml/min/1.73 m², and glycated hemoglobin < or ≥7.0% (all P < 0.05). Multivariable linear regression analysis demonstrated that higher quartile of SUA was independently associated with impaired biventricular myocardial strain (all P < 0.05).

CONCLUSIONS

SUA was independently associated with biventricular myocardial dysfunction in asymptomatic T2DM patients, regardless of renal function or diabetic control.

Inter-observer and Inter-vendor Variability in Strain Measurements in Patients with Single Right Ventricular Anatomy

Myocardial strain offers new insights into ventricular performance, There are software packages from several different companies used to ascertain this, and little data is available in patients with single right ventricle (sRV) physiology. We aimed to compare the analysis of two strain software applications using a cohort of patients with sRV for both inter-vendor and inter-observer variability. Echocardiograms from 85 patients with sRV (122 separate studies) were prospectively evaluated. All had Glenn and/or Fontan palliation. Longitudinal 4-chamber (4LS), inflow/outflow (IO), circumferential, and radial strain were assessed using Velocity Vector Imaging (VVI, Seimens, Munich) and Automated Functional Imaging (AFI, General Electric, Boston) software. In a subset of 45 patients (61 separate studies), strain measurements were obtained by two sonographers so a paired "inter-observer" analysis could be performed. A moderate correlation between measurements made by the two systems was observed. Circumferential strain assessment had the highest R value (0.77) with all others having R values < 0.6. Both software packages showed modest inter-observer reproducibility for longitudinal and circumferential strain. VVI intraclass correlation coefficients (ICC) for 4LS and average circumferential strain (ACS) were 0.6 and 0.58, compared to 0.68 and 0.59 for AFI. Other than radial strain and VVI IO inferior strain, mean strain differences between AFI and VVI were ≤ 1%. Inter-observer variability is modest, however, mean differences are minimal suggesting reasonable clinical reliability. Inter-vendor variability is greater and not as clinically reliable. In patients with sRV, serial assessments with strain should be performed using the same software.