Diagnostic utility of right atrial reservoir strain to identify elevated right atrial pressure in heart failure

Clinical Utility of Atrioventricular Coupling Index in Cardiovascular Disease

Atrioventricular coupling refers to the synchronized interaction between the atrial and ventricular phases of contraction and relaxation within the cardiac cycle. Atrioventricular coupling can be assessed by the left atrioventricular coupling index and right atrioventricular coupling index. These indices provide a comprehensive assessment of the functional interdependence between the atrial and ventricular chambers, and offer insights into cardiac performance beyond traditional markers. Atrioventricular coupling indices are critical for aiding in risk stratification and clinical decision-making, ultimately improving patient outcomes. This review focuses on the clinical utility of atrioventricular coupling in various cardiac pathologies.

Ultrasound-Based assessment of systemic congestion in pulmonary hypertension

PURPOSE OF REVIEW

Systemic congestion is a common manifestation in pulmonary hypertension (PH) associated with morbidity and mortality. Its extent can be difficult to define and is usually determined by subjective medical history and physical examinations, leading to delay in decision-making. We conducted a literature review to collect evidence on imaging tools aimed at detecting and defining severity of venous congestion in PH.

RECENT FINDINGS

We discussed pathophysiology and outlined a structured approach in the management of venous congestion. Point-of-care ultrasound becomes more accessible and aids in gauging the severity of systemic congestion. Venous excess ultrasound (VExUS) grading system analyzes the inferior vena cava, hepatic vein, portal vein, and intrarenal vein and provides a comprehensive assessment of systemic congestion. Nonetheless, almost all available studies were performed in unselected populations, and data on PH is scarce. Herein, we discuss the imaging methods proposed in systemic congestion as they apply to PH.

SUMMARY

VExUS offers fast, convenient assessment of volume status. Despite the promising data on VExUS, it should be emphasized that ultrasound should be placed in the context of a comprehensive evaluation and should not replace basic examination. Further research is needed to establish its role in PH and verify its clinical utility in guiding fluid management.

Right atrial strain measured by 2D speckle-tracking echocardiography is associated with poor cardiac outcomes in patients with heart failure

Right heart failure (HF) is a poor prognostic factor in patients with HF. The right atrial (RA) function has attracted less attention than the right ventricular (RV) function. The association of RA reservoir strain evaluated by 2D speckle-tracking echocardiography (2DSTE) with clinical outcomes in patients with HF remains unclear. We prospectively enrolled patients with HF admitted to our hospital. We measured the RA, RV, left atrial (LA), and left ventricular (LV) strain using 2DSTE before discharge. The RA reservoir strain (RASr) was measured in the global right atrium. The primary endpoints were cardiac death and worsening of HF requiring rehospitalization or intravenous diuretics. Among 226 patients with HF, 72 primary endpoints were recorded during a median follow-up period of 1081 days. Kaplan-Meier analysis showed a higher cardiac event rate in the low RASr group than in the high RASr group (P = 0.0089). Multivariate Cox hazard analysis showed that RASr was independently associated with cardiac events after adjusting for confounding factors [hazard ratio (HR) 0.71; 95% confidence interval (CI) 0.51-0.96; P = 0.0347]. Decreased RASr could be a feasible marker of cardiac events in patients with HF.

Normal ranges of right atrial strain by contemporary echocardiography software: a prospective comparative cohort study

BACKGROUND

Right atrial (RA) strains (RASr, RAScd, and RASct) are increasingly used in clinical and research settings, such as heart failure and pulmonary hypertension, but their feasibility and reference ranges across different strain software vendors are not well established. We aim to evaluate and compare two-dimensional RA strain values, reference ranges, and related factors across four strain software vendors in healthy subjects.

METHODS

Healthy subjects (n = 100) undergoing echocardiography during January-April 2023 were prospectively studied, with equal numbers by age groups, gender, and GE versus Philips scans. RA strains were quantified using TomTec version 51.02 (Autostrain LA), EchoPAC version 206 (AFI-LA), Velocity-Vector Imaging (VVI) version 2.00, and Epsilon software (5.0.2.11295) for statistical analyses.

RESULTS

Overall means and lower limits of normal (LLNs) of each type of RA strain by strain vendor, age group, sex, and scanner vendor were reported. For example, RASr (%) means and LLNs (95% confidence intervals) were 41.2 (38.5, 43.0) and 29.6 (26.5, 32.7) for TomTec, 35.9 (34.4, 37.3) and 27.0 (24.5, 29.5) for EchoPAC, 44.8 (42.3, 47.3) and 27.6 (23.3, 31.9) for VVI, and 38.9 (36.7, 41.0) and 25.5 (21.7, 29.3) for Epsilon, respectively. Linear mixed model regression showed EchoPAC and VVI had significantly lower RASr and higher RAScd magnitude than TomTec, with older age linked to lower RASr and RAScd magnitudes.

CONCLUSION

TomTec and VVI were vendor-neutral for measuring RA strains, while EchoPAC worked only on GE scans. Normal values, lower limits of normal, and related factors for RA strain measurements by vendor were established for clinical use.

The Impact of Right Atrial Function on Prognosis and Renal Function in Patients With Tricuspid Regurgitation

Tricuspid regurgitation (TR) is related to survival, and right atrial (RA) size and function may play a role. This study aimed to assess the impact of RA function measured by strain (RA strain [RAS]) on outcome and end-organ congestion. We enrolled 134 patients (mean age 73 ± 13 years, 62% women) with any TR grade or etiology and a complete echocardiogram, clinical follow-up, and renal function assessment. The primary end point was a combination of overall mortality and right-sided heart failure hospitalization, and the secondary end point was worsening renal function (WRF). After a median follow-up of 23.5 months (interquartile range 12 to 34 months), the combined end point was reached by 31% of patients. Patients with RAS ≤18% showed lower event-free survival (log-rank p <0.001). In the multivariable analysis, RAS ≤18% (HR 3.1, 95% CI 1.1 to 8.8) and pulmonary artery systolic pressure (PASP) (hazard ratio [HR] 1.02, 95% confidence interval [CI] 1 to 1.05) were independent predictors of the primary end point. Patients with RAS ≤18% and PASP >45 mm Hg had the worst outcome (HR 4.3, 95% CI 2 to 9.5). RAS ≤18% (odds ratio 3.22, 95% CI 1.11 to 9.33) and PASP >45 mm Hg (OR 3.2, 95% CI 1.15 to 8.88) were independent predictors of WRF, adjusting for TR severity, left and right ventricular function, age, gender, diabetes, diuretics, atrial fibrillation. The addition of RAS ≤18% had incremental power over PASP and echocardiographic variables of TR severity and right or left ventricular function to predict WRF (p = 0.026). In conclusion, RA function measured by RAS independently predicts mortality and hospitalizations in patients with TR and independently and incrementally predicts WRF over time.

Echocardiographic assessment of patient hemodynamics in heart failure

Heart failure (HF) is a clinical syndrome which is due to cardiac structural and/or functional abnormalities that result in elevated intra-cardiac pressures and/or inadequate cardiac output. Hemodynamic assessment in HF allows the identification and characterization of cardiac dysfunction, systemic and/or pulmonary congestion and the eventual impairment of systemic perfusion which are fundamental to phenotype HF, risk stratify HF patients and to guide their treatment. Patient hemodynamics can be characterized invasively with right heart catheterization but also non-invasively with the use of echocardiography and other non-invasive ultrasound tools. The aim of the present review is to summarize the main echocardiographic and ultrasound parameters to characterize the hemodynamics of patients with HF and help clinicians to make the most of these non-invasive tools to guide HF patient management.

Echocardiographic Assessment of Right Ventricular Diastolic Function in Children and Adults: Present State and Future Directions

Diastolic function plays an important but often overlooked role in overall ventricular performance and is comprised of a sequence of events, which together result in adequate filling at low filling pressures. From a physiologic point of view there are 2 distinct, yet related periods that drive diastole: active relaxation and late filling. Much of the literature on diastolic function focuses on the left ventricle, however, there are significant differences in morphology, physiology, and adaptation between ventricles. Echocardiographic assessment of right ventricular diastolic function is challenging because of our imperfect understanding of right ventricular physiology, suboptimal imaging tools, and the use of models that have been built using the left ventricle. Conventional assessment includes inferior vena cava size, right atrial volume, and the use of Doppler to quantify tissue and blood velocity. In adults, the tricuspid valve E wave to A wave ratio (TV E/A) used in combination with early diastolic tricuspid valve annular velocity (e') and inferior vena cava size can be used to classify diastolic impairment, however, in children these are dependent to a greater degree on age and pathology. Right atrial and ventricular strain suffers from fewer limitations and might show incremental benefit, however, remains understudied, particularly in children. Novel methods made possible with ultrafast ultrasound provide a means to noninvasively assess intraventricular pressure differences as a measure of active relaxation, and shear wave velocity to directly assess myocardial stiffness, however, these remain in preclinical stages. In this review we discuss right ventricular diastolic physiology, the current state, and limitations of echocardiographic evaluation, and explore promising new methods for its assessment.

Age- and Sex-Specific MR-Feature Tracking Reference Values of Right Atrial Deformation in Healthy Adults

BACKGROUND

Although right atrial (RA) myocardial deformation has important implications for patient diagnosis, prognosis, and risk stratification, its implementation in clinical practice has been hampered by limited normal reference values, especially in Asian populations.

PURPOSE

To establish age- and sex-specific reference values for RA strain, strain rate (SR), and displacement based on a large sample of healthy Chinese adults using MR-feature tracking (MR-FT).

STUDY TYPE

Retrospective.

POPULATION

524 healthy Chinese adults (287 male; mean age 43.7 ± 11.9 years).

FIELD STRENGTH/SEQUENCE

1.5T/balanced steady-state free precession.

ASSESSMENT

RA deformation parameters, including reservoir, conduit, and booster strain (εs, εe, and εa), peak positive, early negative, and late negative SR (SRs, SRe, and SRa), and total, passive, and active displacement (Ds, De, and Da), were assessed using MR-FT.

STATISTICAL TESTS

Student's t-test, one-way ANOVA, coefficients of determination (r2), intraclass correlation coefficients (ICC), and Bland-Altman plots. A P value <0.05 was considered significant.

RESULTS

Women demonstrated significantly greater magnitudes of RA deformation parameters than men: εs (57.4% ± 15.1% vs. 44.3% ± 12.6%), εe (37.5% ± 13.4% vs. 27.4% ± 10.9%), εa (19.9% ± 5.7% vs. 16.9% ± 5.0%), SRs (2.62 ± 0.88 sec-1 vs. 2.00 ± 0.63 sec-1), SRe (-2.98 ± 1.26 sec-1 vs. -2.16 ± 0.92 sec-1), SRa (-2.28 ± 0.75 sec-1 vs. -1.84 ± 0.62 sec-1), Ds (-7.80 ± 1.90 mm vs. -7.46 ± 1.70 mm), and De (-4.84 ± 1.31 mm vs. -4.49 ± 1.21 mm). For both sexes, aging was significantly associated with decreased RA reservoir and conduit function (εs, SRs, Ds, εe, SRe, and De), and with increased εa and Da. RA deformation measurements had good to excellent intraobserver and interobserver reproducibility, with ICCs ranging from to 0.790 to 0.972.

DATA CONCLUSION

This study provides age- and sex-specific reference values of RA strain, SR, and displacement based on a large cohort of healthy Chinese adults using MR-FT.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY: Stage 2.

Prognostic impact of right atrial strain in systemic lupus erythematosus with pulmonary arterial hypertension

OBJECTIVE

The aim of this study was to assess right atrial (RA) function, including RA phase strain, via speckle-tracking echocardiography (STE) in a cohort of systemic lupus erythematosus (SLE) patients with pulmonary arterial hypertension (PAH) and in particular to explore the relationship between RA phase strain and the occurrence of cardiovascular events.

METHODS

STE analyses of RA function were evaluated in patients with SLE-PAH and in 33 healthy control subjects. Clinical associations, serum biomarkers, echocardiographic data, survival times, and adverse cardiovascular events were evaluated.

RESULTS

A total of 66 patients with SLE-PAH were enrolled; they were divided into two groups based on the occurrence of adverse clinical events. RA phase strain was significantly reduced in patients with events than in patients without events. The endpoint was defined as the combined outcome of all-cause mortality, right heart failure, and rehospitalization due to disease progression. During a mean follow-up of 17.2 ± 9.9 months, 23 patients (35%) reached the endpoint. Compared with patients with RA reservoir strain (RASr) ≥33.45%, patients with RASr < 33.45% had more adverse long-term outcomes (log rank p < .0001). RASr was independently associated with adverse clinical outcomes according to multivariate analysis (p = .010).

CONCLUSION

Our data suggest that RA function has prognostic value for SLE-PAH patients, and strain analysis revealed that the worse the RA function is, the worse the prognosis.

Heart rate variability-based prediction of early cardiotoxicity in breast-cancer patients treated with anthracyclines and trastuzumab

BACKGROUND

Cardiotoxicity is a recognized complication in breast cancer (BC) patients undergoing chemotherapy with anthracyclines with or without trastuzumab. However, the prognostic value of heart rate variability (HRV) indexes for early cardiotoxicity development remains unknown.

METHODS

Fifty BC patients underwent TTE assessment before and three months after chemotherapy. HRV indexes were obtained from continuous electrocardiograms in supine position with spontaneous breathing, active standing, and supine position with controlled breathing. The magnitude of change (Δ) between supine-standing and supine-controlled breathing was calculated. Variables were compared using t-test or ANOVA. Cardiotoxicity predictive value was assessed by ROC curve analysis. A p value of < 0.05 was considered significant.

RESULTS

TTE revealed reduced left atrial conduit strain in the cardiotoxicity group. Mean heart rate increased during all maneuvers at follow-up, with no differences in HRV indexes between patients with or without cardiotoxicity. However, a lower Δ in supine-controlled breathing of several HRV indexes predicted early cardiotoxicity identified by echocardiography (e.g. SDNN ≤ -8.44 ms: Sensitivity = 75%, Specificity = 69%).

CONCLUSIONS

BC patients treated with chemotherapy maintain cardiac autonomic responses to physiological stimuli after 3 months of chemotherapy. However, a lower Δ during active standing and controlled breathing before chemotherapy may predict early cardiotoxicity.

Prognostic Implication of Right Ventricular Free Wall Longitudinal Strain and Right Atrial Pressure Estimated By Echocardiography in Patients With Severe Functional Tricuspid Regurgitation

BACKGROUND

The interaction between right ventricular (RV) function and pulmonary hypertension is crucial for prognosis of patients with severe functional tricuspid regurgitation. RV free wall longitudinal strain (RVFWLS) has been reported to detect RV systolic dysfunction earlier than other conventional parameters. Although pulmonary artery systolic pressure measured by Doppler echocardiography is often underestimated in severe functional tricuspid regurgitation, right atrial pressure (RAP) estimated by echocardiography may be viewed as a prognostic factor. Impact of RAP and RVFWLS on outcome in patients with severe functional tricuspid regurgitation remains unclear. The aim of the present study was to investigate prognostic implication of RAP, RVFWLS, and their combination in this population.

METHODS AND RESULTS

We retrospectively examined 377 patients with severe functional tricuspid regurgitation. RAP, pulmonary artery systolic pressure, RV fractional area change, and RVFWLS were analyzed. RAP of 15 mm Hg was classified as elevated RAP. All-cause death at 2-year follow-up was defined as the primary end point. RVFWLS provided better prognostic information than RV fractional area change by receiver operating characteristic curve analysis. In the multivariable Cox regression analysis, elevated RAP and RVFWLS of ≤18% were independent predictors of clinical outcome. Patients with RVFWLS of ≤18% had higher risk of all-cause death than those without by Kaplan-Meier curve analysis. Furthermore, when patients were stratified into 4 groups by RAP and RVFWLS, the group with elevated RAP and RVFWLS of ≤18% had the worst outcome.

CONCLUSIONS

Elevated RAP and RVFWLS of ≤18% were independent predictors of all-cause death. The combination of elevated RAP and RVFWLS effectively stratified the all-cause death.

Relation of Right Atrial Strain to Mortality in Infants With Single Right Ventricles

We explored associations of surveillance testing in infants with single right ventricle (sRV) physiology with clinical outcomes. This prospective, single-center study included patients with sRV who had initial palliative surgery (September 2019 to December 2020). Echocardiograms and B-type naturetic peptide (BNP) obtained as a pair within 24 hours as part of clinical care were included. The primary outcome was death/heart transplant. Secondary outcomes included interstage duration of milrinone use, hospital length of stay, and no digoxin use. sRV functional assessment (subjective grade, fractional area change, tricuspid annular plane systolic excursion, global longitudinal strain, right atrial strain [RAS]) was performed offline. Associations between echocardiography, BNP, and clinical outcomes were determined. Of 26 subjects (47 encounters), 20 had hypoplastic left heart syndrome (77%). Median age at data collection was 50 days (interquartile range 26 to 90). In most encounters (73%), sRV function was subjectively normal. Median BNP was 332 pg/ml (interquartile range 160 to 1,085). A total of 5 patients (19%) met the primary outcome and had lower RAS (14.1 vs 21.3, p = 0.038), but all other parameters were similar to transplant-free survivors. RAS (16.1%, 0.83) had the highest area under curve, followed by global longitudinal strain (-14.4%, 0.77). Higher RAS was associated with fewer days on milrinone (coefficient -1.37, 95% confidence interval [CI] -2.54 to -0.20, p = 0.02) and higher odds of digoxin use (odds ratio 1.09, 95% CI 1.01 to 1.18, p = 0.047). Higher BNP was only associated with a lower odds of digoxin use (odds ratio 0.69, 95% CI 0.5 to 0.96, p = 0.03). In conclusion, RAS is a potentially important imaging marker in infants with sRV and merits further investigation in larger studies.

Right atrial reservoir strain and right ventricular strain improves in patients recovered from hospitalisation for non-severe COVID-19

PURPOSE

Those hospitalised with coronavirus disease 2019 (COVID-19) have recently been shown to have impaired right ventricular (RV) strain, but data about the course of heart function after discharge are limited. Our aim was to compare right ventricular strain and right atrial reservoir strain (RASr) associated with COVID-19 between acute disease (during hospitalisation) and follow-up (after discharge).

METHODS

In this retrospective single-center study, we analysed the echocardiograms of 43 patients hospitalised for non-severe COVID-19 between December 2020 and March 2021, undergoing echocardiography both during and after hospitalisation. In addition to conventional echocardiographic parameters, we applied 2-dimensional speckle tracking to obtain RV global longitudinal strain (RV-GLS), RV free wall strain (RV-FWS), and RASr.

RESULTS

Mean (standard deviation) age of the study population was 50 (9) years, and 18 (42%) of the participants were women. Median duration between exams was 6 months (range, 5-7 months). Both mean RV-GLS and mean RV-FWS significantly increased at follow-up (-20.8 [3.8] vs. -23.5 [2.8], p < 0.001 and -23.3 [4.2] vs. -28.2 [2.8], p < 0.001; respectively), and RASr significantly improved as well (-32.3 [6.6] vs. -41.9 [9.8], p < 0.001).

CONCLUSION

In patients hospitalised for non-severe COVID-19 pneumonia, RV-GLS, RV-FWS, and RASr improved significantly between acute disease and 6 months after discharge.

Normal Ranges of Right Atrial Strain and Strain Rate by Two-Dimensional Speckle-Tracking Echocardiography: A Systematic Review and Meta-Analysis

Background: Normal range values of right atrial (RA) phasic function markers are essential for the identification of normal and abnormal values, comparison with reference values, and the clinical meaning of obtained values. Accordingly, we aimed to define the normal range values of RA phasic function markers obtained by 2D speckle-tracking echocardiography through a meta-analysis and determine the main sources of heterogeneity among reported values. Methods: PUBMED, SCOPUS, and EMBASE databases were searched for the following keywords: "right atrial/right atrium" and "strain/speckle/deformation" and "echocardiography." Studies were selected that included a human healthy adult group without any cardiovascular diseases or risk factors and that were written in the English language. For the calculation of each marker of RA phasic functions, a random-effect model was used. Meta-regression was employed to define the major sources of variabilities among reported values. Results: Fifteen studies that included 2,469 healthy subjects were selected for analysis. The normal range values for RA strain and strain rate were 42.7% (95% CI, 39.4 to 45.9%) and 2.1 s^-1 (95% CI, 2.0 to 2.1 s^-1) during the reservoir phase, respectively, 23.6% (95% CI, 20.7 to 26.6%) and -1.9 s^-1 (95% CI, -2.2 to -1.7 s^-1) during the conduit phase, correspondingly, and 16.1% (95% CI, 13.6 to 18.6%) and -1.8 s^-1 (95% CI, -2.0 to -1.5 s^-1) during the contraction phase, respectively. The sources of heterogeneity for the normal range of these markers were the number of participants, the type of software, the method of global value calculation, the right ventricular fractional area change, the left ventricular (LV) ejection fraction, the RA volume index, sex, the heart rate, the diastolic blood pressure, the body mass index, and the body surface area. Conclusions: Using 2D speckle-tracking echocardiography, we defined normal values for RA phasic function markers and identified the sources of heterogeneity as demographic, anthropometric, hemodynamic, and echocardiography factors. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021236578, identifier: CRD42021236578.

Accuracy of echocardiographic estimates of pulmonary artery pressures in pulmonary hypertension: insights from the KARUM hemodynamic database

Accurate assessment of pulmonary artery (PA) pressures is integral to diagnosis, follow-up and therapy selection in pulmonary hypertension (PH). Despite wide utilization, the accuracy of echocardiography to estimate PA pressures has been debated. We aimed to evaluate echocardiographic accuracy to estimate right heart catheterization (RHC) based PA pressures in a large, dual-centre hemodynamic database. Consecutive PH referrals that underwent comprehensive echocardiography within 3 h of clinically indicated right heart catheterization were enrolled. Subjects with absent or severe, free-flowing tricuspid regurgitation (TR) were excluded. Accuracy was defined as mean bias between echocardiographic and invasive measurements on Bland–Altman analysis for the cohort and estimate difference within ± 10 mmHg of invasive measurements for individual diagnosis. In 419 subjects, echocardiographic PA systolic and mean pressures demonstrated minimal bias with invasive measurements (+ 2.4 and + 1.9 mmHg respectively) but displayed wide limits of agreement (− 20 to + 25 and − 14 to + 18 mmHg respectively) and frequently misclassified subjects. Recommendation-based right atrial pressure (RAP) demonstrated poor precision and was falsely elevated in 32% of individual cases. Applying a fixed, median RAP to echocardiographic estimates resulted in relatively lower bias between modalities when assessing PA systolic (+ 1.4 mmHg; 95% limits of agreement + 25 to − 22 mmHg) and PA mean pressures (+ 1.4 mmHg; 95% limits of agreement + 19 to − 16 mmHg). Echocardiography accurately represents invasive PA pressures for population studies but may be misleading for individual diagnosis owing to modest precision and frequent misclassification. Recommendation-based estimates of RAP_mean may not necessarily contribute to greater accuracy of PA pressure estimates.