Assessment of acute right ventricular dysfunction induced by right coronary artery occlusion using echocardiographic atrioventricular plane displacement

Tricuspid annular plane systolic excursion and mitral annular plane systolic excursion cardiac reference values in 1300 healthy children: Single-center results

BACKGROUND

Tricuspid annular plane systolic excursion (TAPSE) and mitral annular plane systolic excursion (MAPSE) are two echocardiographic parameters which provide reliable information about the longitudinal myocardial functions of the right and left ventricles in both adult and pediatric population. The aim of this study was to determine the TAPSE and MAPSE reference values in healthy children aged 0-18 years.

METHODS AND RESULTS

This prospective study included 1300 healthy children evaluated with two-dimensional echocardiography. In addition to routine echocardiographic examination, the right and left ventricular systolic functions were assessed by TAPSE and MAPSE measurements. Statistical analyses were carried out in the groups of subjects stratified according to age and body surface area. The mean and standard deviation values and z-scores of TAPSE and MAPSE were developed in each group.

CONCLUSIONS

The determination of reference values for TAPSE and MAPSE in healthy children will be of guidance in the evaluation of both healthy children and those with congenital or acquired heart diseases in which the right and left ventricular systolic functions are affected. The reference values obtained will contribute to the clinical practice and the future studies.

Echocardiographic assessment of the right ventricle in the current era: Application in clinical practice

The right ventricle has unique structural and functional characteristics. It is now well recognized that the so-called forgotten ventricle is a key player in cardiovascular physiology. Furthermore, there is accumulating evidence that demonstrates right ventricular dysfunction as an important marker of morbidity and mortality in several commonly encountered clinical situations such as heart failure, pulmonary hypertension, pulmonary embolism, right ventricular myocardial infarction, and adult congenital heart disease. In contrast to the left ventricle, echocardiographic assessment of right ventricular function is more challenging as volume estimations are not possible without the use of three-dimensional (3D) echocardiography. Guidelines on chamber quantification provide a standardized approach to assessment of the right ventricle. The technique and limitations of each of the parameters for RV size and function need to be fully understood. In this era of multimodality imaging, echocardiography continues to remain a useful tool for the initial assessment and follow-up of patients with right heart pathology. Several novel approaches such as 3D and strain imaging of the right ventricle have expanded the usefulness of this indispensable modality.

Essential echocardiographic evaluation in patients with suspected pulmonary hypertension: an overview for the practicing physician

Prompt and accurate diagnosis of patients presenting with symptoms suggestive of pulmonary arterial hypertension (PAH) is of outmost importance as delays in identifying this clinical entity have detrimental effects on both morbidity and mortality. Initial noninvasive assessment of these patients has traditionally included a number of routine tests of which transthoracic echocardiography (TTE) has been shown to either confirm the presence of structural anomalies of the right ventricle (RV) indicative of PAH or exclude other potential causes of pulmonary hypertension (PH). Consequently, TTE has become a well-validated and readily available imaging tool not only used for this initial screening but also for routine follow-up of PH patients. Since chronic PH is known to unbalance the normal hemodynamic and mechanical homeostatic interaction between the RV and pulmonary circulation; the resulting response is that of an abnormal RV remodeling, clinically translated into progressive RV hypertrophy and dilatation. An enlarged and hypertrophied RV not only would eventually lose effective contractility but also this gradual decline in RV systolic function is the main abnormality in determining adverse clinical outcomes. Therefore, it is of outmost importance that TTE examination be comprehensive but most importantly accurate and reproducible. This review aims to highlight the most important objective measures that can be routinely employed, without added complexity, that will certainly enhance the interpretation and advance our understanding of the hemodynamic and mechanical abnormalities that PH exerts on the RV.

Right ventricular function impaired in children and adolescents with severe idiopathic scoliosis

BACKGROUND

Although it is speculated that scoliosis may induce cardiac dysfunction, there is no report about evaluation of cardiac function, especially right cardiac function in patients with scoliosis. Therefore, we evaluated right ventricular function in idiopathic scoliotic patients with mild to severe curves and compared them with healthy children and adolescents matched in age, then explored relationship between scoliosis and right ventricular function.

METHODS

Thirty-seven patients diagnosed with idiopathic scoliosis with a mean age of 16y/o (range, 8-25y/o) and an average spine curve of 77.5°Cobb (range, 30-157°) were studied by echocardiography. TAD was obtained using M-mode echocardiography. Similar examination was performed in a control group of 17 healthy individuals in matched-age. According to the different curve degree, all patients were divided into 3 groups (mild, moderate and severe). Comparison was done among the groups and the relationship between TAD and spine curve of Cobb was analyzed.

RESULTS

Patients with severe scoliosis showed depressed TAD. There was good correlation between TAD and spine curve of Cobb.

CONCLUSIONS

Patients with severe scoliosis showed a significant lower right ventricular systolic function.

Right ventricular involvement in patients with coronary artery disease

PURPOSE OF REVIEW

RV involvement in coronary artery disease (CAD) includes isolated infarction and involvement in left ventricular infarction. Right ventricular involvement with left ventricular infarction has unique clinical signs and symptoms, requires different management, and has worse prognosis than left ventricular infarcts without right ventricular involvement. Although the right ventricle (RV) is geometrically complex, advances in echocardiography, nuclear imaging, computed tomography, and magnetic resonance imaging technologies have helped to optimally visualize its structure and function and to better elucidate its role in CAD.

RECENT FINDINGS

Newer noninvasive imaging modalities to visualize the RV are highlighted and their emerging clinical utilities are emphasized, including three-dimensional echocardiography, tissue Doppler velocity and strain imaging, computed tomography, and MRI.

SUMMARY

The RV is often involved in CAD. Available imaging modalities demonstrate different aspects of right ventricular involvement, yielding new insights into pathophysiology, clinical care, and management. As imaging technologies widen in their scope, cardiologists will increasingly have the imaging tools to integrate information on right ventricular morphology, hemodynamics, and function, enabling appropriate care for patients with right ventricular involvement in CAD.

Pulmonary arterial hypertension in rheumatic mitral stenosis: does it affect right ventricular function and outcome after mitral valve replacement?

Right ventricular function affects the outcome in valvular heart disease but less is known about the relation between indices of dysfunction and outcome. Seventy patients undergoing mitral valve replacement between April 2007 and April 2008 for predominant rheumatic mitral stenosis were included in the study. Two groups were formed based on right ventricular systolic pressure (RVSP), <or=40 mmHg (group I, n=16) and >41 mmHg (group II, n=54). Right ventricle (RV) function indices were studied by echocardiography. RVSP reduced significantly in group II (P=0.0001) but not in group I. Brain natriuretic peptide (BNP) was raised in all cases and reduced significantly postoperatively. Tricuspid annular plane excursion, myocardial performance index, RV descent and tricuspid valve annular shortening (TV shortening) conformed to RV dysfunction in both groups, and did not change significantly postoperatively. Regression analysis for outcome revealed TV shortening as the only significant factor (P=0.03). Receiver operating characteristic of TV shortening and adverse outcome showed worse outcome with TV shortening of <11%. RV dysfunction was observed in all cases irrespective of RVSP. TV shortening of <11% was associated with adverse outcome. Postoperative fall in BNP levels may indicate a trend towards recovery.

Relationship between the tricuspid annular plane systolic excursion and right and left ventricular function in critically ill patients

OBJECTIVE

Echocardiographic recording of the tricuspid annular plane systolic excursion (TAPSE) has been recommended for assessing right ventricular function in cardiac patients. The ability of TAPSE to reflect right ventricular function at baseline and to monitor acute changes in right ventricular function was tested in critically ill patients.

DESIGN

Prospective study.

SETTING

A 24-bed medical intensive care unit.

PATIENTS

Eighty-six patients admitted for acute respiratory failure, circulatory failure, or coma.

INTERVENTIONS

In 40 patients, the examination was repeated after volume expansion (n = 15), passive leg raising (n = 5), or dobutamine infusion (n = 20).

MEASUREMENTS AND RESULTS

The right ventricular fractional area change, TAPSE, the left ventricular ejection fraction, and the ratio of right to left ventricular end-diastolic area were measured using Doppler echocardiography. In the overall population, TAPSE (19+/-5 mm) was positively related to left ventricular ejection fraction (r2 = 0.31, p < 0.001) and right ventricular fractional area change and was negatively related to age and to the ratio of right to left ventricular end-diastolic area. Multivariate analysis indicated that only left ventricular ejection fraction and age were independently related to TAPSE (multiple r2 = 0.36, p < 0.001). Following dynamic interventions, the changes in TAPSE were linearly related to changes in left ventricular ejection fraction (r2 = 0.65, p < 0.01) but notto changes in the right ventricular fractional area change.

CONCLUSIONS

Unexpectedly, TAPSE was more strongly related to left ventricular ejection fraction than to indices of right ventricular function in critically ill patients. The potential interest of TAPSE as a dynamic marker of left ventricular systolic function deserves further study.

Value of assessment of tricuspid annulus: real-time three-dimensional echocardiography and magnetic resonance imaging

Aim

To detect the accuracy of real-time three-dimensional echocardiography (RT3DE) and two-dimensional echocardiography (2DE) for tricuspid annulus (TA) assessment compared with magnetic resonance imaging (MRI).

Methods

Thirty patients (mean age 34 ± 13 years, 60% males) in sinus rhythm were examined by MRI, RT3DE, and 2DE for TA assessment. End-diastolic and end-systolic TA diameter (TAD) and TA fractional shortening (TAFS) were measured by RT3DE, 2DE, and MRI. End-diastolic and end-systolic TA area (TAA) and TA fractional area changes (TAFAC) were measured by RT3DE and MRI. End-diastolic and end-systolic right ventricular (RV) volumes and ejection fraction (RV-EF) were measured by MRI.

Results

The TA was clearly delineated in all patients and visualized as an oval-shaped by RT3DE and MRI. There was a good correlation between TAD_MRI and TAD_3D (r = 0.75, P = 0.001), while TAD_2D was fairly correlated with TAD_3D and TAD_MRI (r = 0.5, P = 0.01 for both). There were no significant differences between RT3DE and MRI in TAD, TAA, TAFS, and TAFAC measurements, while TAD_2D and TAFS_2D were significantly underestimated (P < 0.001). TAFS_2D was not correlated with RV-EF, while TAFS_3D and TAFAC_3D were fairly correlated with RV-EF (r = 0.49, P = 0.01, and r = 0.47, P = 0.02 respectively).

Conclusion

RT3DE helps in accurate assessment of TA comparable to MRI and may have an important implication in the TV surgical decision-making processes. RT3DE analysis of TA function could be used as a marker of RV function.

Tricuspid annular displacement predicts survival in pulmonary hypertension

RATIONALE

Right ventricular (RV) function is an important determinant of prognosis in pulmonary hypertension. However, noninvasive assessment of the RV function is often limited by complex geometry and poor endocardial definition.

OBJECTIVES

To test whether the degree of tricuspid annular displacement (tricuspid annular plane systolic excursion [TAPSE]) is a useful echo-derived measure of RV function with prognostic significance in pulmonary hypertension.

METHODS

We prospectively studied 63 consecutive patients with pulmonary hypertension who were referred for a clinically indicated right heart catheterization. Patients underwent right heart catheterization immediately followed by transthoracic echocardiogram and TAPSE measurement.

RESULTS

In the overall cohort, a TAPSE of less than 1.8 cm was associated with greater RV systolic dysfunction (cardiac index, 1.9 vs. 2.7 L/min/m2; RV % area change, 24 vs. 33%), right heart remodeling (right atrial area index, 17.0 vs. 12.1 cm(2)/m), and RV-left ventricular (LV) disproportion (RV/LV diastolic area, 1.7 vs. 1.2; all p < 0.001), versus a TAPSE of 1.8 cm or greater. In patients with pulmonary arterial hypertension (PAH; n = 47), survival estimates at 1 and 2 yr were 94 and 88%, respectively, in those with a TAPSE of 1.8 cm or greater versus 60 and 50%, respectively, in subjects with a TAPSE less than 1.8 cm. The unadjusted risk of death (hazard ratio) in patients with a TAPSE less than 1.8 versus 1.8 cm or greater was 5.7 (95% confidence interval, 1.3-24.9; p = 0.02) for the PAH cohort. For every 1-mm decrease in TAPSE, the unadjusted risk of death increased by 17% (hazard ratio, 1.17; 95% confidence interval, 1.05-1.30; p = 0.006), which persisted after adjusting for other echocardiographic and hemodynamic variables and baseline treatment status.

CONCLUSIONS

TAPSE powerfully reflects RV function and prognosis in PAH.

Angiographic right and left ventricular function in arrhythmogenic right ventricular dysplasia

We prospectively documented right ventricular (RV) and left ventricular (LV) volumes and ejection fractions in a large series of patients with arrhythmogenic RV dysplasia/cardiomyopathy (ARVD/C). Eighty-five patients with ARVD/C and 11 controls underwent 2 successive orthogonal right and left monoplane x-ray-digitized cineangiographies. Volumes were calculated using the hemielliptical RV and ellipsoidal LV models. All controls and 58 of 85 patients (ARVD/C-I) had a RV ejection fraction > or =35% and 27 patients had a RV ejection fraction <35% (ARVD/C-II). Tricuspid annulus plane systolic excursion (TAPSE) was lower in ARVD/C-II than in ARVD/C-I patients (6 +/- 3 vs 14 +/- 3 mm) and controls (16 +/- 2 mm) (each p <0.001). In patients with ARVD/C, TAPSE was positively related to RV ejection fraction (r = 0.79) and to crista supraventricularis shortening (r = 0.81) (each p <0.001). Sensitivity and specificity of TAPSE <12 mm in identifying patients with RV ejection fraction <35% were 96% and 78%, respectively. LV ejection fraction was > or =50% in 68 patients, 40% to 49% in 10, and <40% in 7. Diffuse RV outflow tract aneurysm was observed in 9 patients, all belonging to ARVD/C-II, and this sign identified patients with LV ejection fraction <40% with 86% sensitivity and 96% specificity. In conclusion, 68% of ARVD/C patients had normal RV ejection fraction and RV volumes, and 80% of ARVD/C patients had normal LV ejection fraction. Decreased TAPSE <12 mm and a diffuse RV outflow tract aneurysm were sensitive and specific indicators of RV ejection fraction <35% and LV ejection fraction <40%, respectively.

Three-dimensional assessment of two-dimensional technique for evaluation of right ventricular function by tricuspid annulus motion

BACKGROUND

Measurement of tricuspid annulus motion (TAM) is an easy way to estimate right ventricular ejection fraction (RVEF). However the accuracy of two-dimensional (2-D) methods for analyzing the three-dimensional (3-D) structure of the tricuspid annulus has not been evaluated.

OBJECTIVE

This study evaluated the accuracy with which 2-D measurements of TAM reflect RVEF using 3-D reconstructions of the heart at end diastole (ED) and end systole (ES).

METHODS

2-D echocardiographic studies were performed on 12 subjects and used to reconstruct the RV and tricuspid annulus in 3-D at ED and ES. Measurements of TAM from medial and lateral positions on the annulus were selected from the standard echocardiographic apical four-chamber view. The minimum and maximum possible TAM values, RV volumes, and movement of the apex of the heart along the trajectory of TAM were calculated from the 3-D reconstructions.

RESULTS

TAM correlated highly with RVEF (r > or = 0.90). Values found by 2-D and 3-D techniques were not significantly different. Correcting TAM for apex motion did not improve correlation. Summation of medial and lateral TAM data increased correlation values slightly relative to lateral TAM alone. Regional aberrant contractility degraded the predictive value of TAM.

CONCLUSION

Estimation of RVEF from 2-D echo measurement of TAM is accurate, especially when medial and lateral TAM are summed, except in patients with severe apical RV dysfunction.