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Hahn RT, Lerakis S, Delgado V, Addetia K, Burkhoff D, Muraru D, Pinney S, Friedberg MK. Multimodality Imaging of Right Heart Function: JACC Scientific Statement. J Am Coll Cardiol 2023; 81:1954-1973. [PMID: 37164529 DOI: 10.1016/j.jacc.2023.03.392] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 05/12/2023]
Abstract
Right ventricular (RV) size and function assessed by multimodality imaging are associated with outcomes in a variety of cardiovascular diseases. Understanding RV anatomy and physiology is essential in appreciating the strengths and weaknesses of current imaging methods and gives these measurements greater context. The adaptation of the right ventricle to different types and severity of stress, particularly over time, is specific to the cardiovascular disease process. Multimodality imaging parameters, which determine outcomes, reflect the ability to image the initial and longitudinal RV response to stress. This paper will review the standard and novel imaging methods for assessing RV function and the impact of these parameters on outcomes in specific disease states.
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Affiliation(s)
- Rebecca T Hahn
- Department of Medicine, Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA.
| | | | - Victoria Delgado
- Hospital University Germans Trias i Pujol Hospital, Badalona, Barcelona, Spain
| | - Karima Addetia
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | | | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Sean Pinney
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
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Miles LF, Couture EJ, Potes C, Makar T, Fernando MC, Hungenahally A, Mathieson MD, Perlman H, Perini MV, Thind D, Weinberg L, Denault AY. Preliminary experience with continuous right ventricular pressure and transesophageal echocardiography monitoring in orthotopic liver transplantation. PLoS One 2022; 17:e0263386. [PMID: 35120144 PMCID: PMC8815904 DOI: 10.1371/journal.pone.0263386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 01/19/2022] [Indexed: 11/19/2022] Open
Abstract
Background Despite increasing attention in the cardiac anesthesiology literature, continuous measurement of right ventricular pressure using a pulmonary artery catheter has not been described in orthotopic liver transplantation, despite similarities in the anesthetic approach to the two populations. We describe our preliminary experience with this technique in orthotopic liver transplantation, and by combining various derived measures with trans-esophageal echocardiography, make some early observations regarding the response of these measures of right ventricular function during the procedure. Methods In this case series, ten patients (five men and five women) undergoing orthotopic liver transplantation in our institution had their surgeries performed while monitored with a pulmonary artery catheter with continuous right ventricular port transduction and trans-esophageal echocardiography. We recorded various right ventricular waveform (early-to-end diastolic pressure difference, right ventricular outflow tract gradient, right ventricular dP/dT and right ventricular end-diastolic pressure) and echocardiographic (right ventricular fractional area change, tricuspid annular plane systolic excursion, right ventricular lateral wall strain) and described their change relative to baseline at timepoints five minutes before and after portal vein reperfusion, immediately after hepatic artery reperfusion and on abdominal closure. Results Except for tricuspid annular plane systolic excursion at five minutes prior to reperfusion (mean −0.8 cm; 95% CI−1.4, –0.3; p = 0.007), no echocardiographic metric was statistically significantly different at any timepoint relative to baseline. In contrast, changes in right ventricular outflow tract gradient and right ventricular dP/dt were highly significant at multiple timepoints, generally peaking immediately before or after reperfusion before reducing, but not returning to baseline in the neohepatic phase. Nine of 10 participants in this series demonstrated a degree of dynamic right ventricular outflow tract obstruction, which met criteria for hemodynamic significance (> 25 mmHg) in two participants. These changes were not materially affected by cardiac index. Conclusions Dynamic right ventricular outflow tract obstruction of varying severity appears common in patients undergoing orthotopic liver transplantation. These results are hypothesis generating and will form the basis of future prospective research.
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Affiliation(s)
- Lachlan F. Miles
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
- Department of Anaesthesia, Austin Health, Melbourne, Australia
- * E-mail:
| | - Etienne J. Couture
- Division of Intensive Care Medicine, Department of Anesthesiology and Department of Medicine, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
| | - Cristhian Potes
- Edwards LifeSciences Pty. Ltd., Irvine, California, United States of America
| | - Timothy Makar
- Department of Anaesthesia, Austin Health, Melbourne, Australia
| | | | | | | | - Hannah Perlman
- Department of Anaesthesia, Austin Health, Melbourne, Australia
| | - Marcos V. Perini
- Department of Surgery, The University of Melbourne, Melbourne, Australia
- Victorian Liver and Intestinal Transplant Unit, Austin Health, Melbourne, Australia
| | - Dilraj Thind
- Department of Anaesthesia, Austin Health, Melbourne, Australia
| | - Laurence Weinberg
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
- Department of Anaesthesia, Austin Health, Melbourne, Australia
- Department of Surgery, The University of Melbourne, Melbourne, Australia
| | - André Y. Denault
- Department of Anesthesiology and Critical Care Division, Montreal Heart Institute, Université de Montréal, Montréal, Canada
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Topyła-Putowska W, Tomaszewski M, Wysokiński A, Tomaszewski A. Echocardiography in Pulmonary Arterial Hypertension: Comprehensive Evaluation and Technical Considerations. J Clin Med 2021; 10:jcm10153229. [PMID: 34362015 PMCID: PMC8348437 DOI: 10.3390/jcm10153229] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 07/18/2021] [Accepted: 07/20/2021] [Indexed: 12/21/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare, progressive disease in which there is a persistent, abnormal increase in pulmonary artery pressure. Symptoms of pulmonary hypertension are nonspecific and mainly associated with progressive right ventricular failure. The diagnosis of PAH is a multistep process and often requires the skillful use of several tests. The gold standard for the diagnosis of PAH is hemodynamic testing. Echocardiography currently plays an important role in the diagnostic algorithm of PAH as it is minimally invasive and readily available. Moreover, many echocardiographic parameters are closely related to pulmonary hemodynamics. It allows assessment of the right heart′s structure and function, estimation of the pressure in the right ventricle, right atrium, and pulmonary trunk, and exclusion of other causes of elevated pulmonary bed pressure. Echocardiographic techniques are constantly evolving, and recently, measurements made using new techniques, especially 3D visualization, have become increasingly important. In echocardiographic assessment, it is crucial to know current guidelines and new reports that organize the methodology and allow standardization of the examination. This review aims to discuss the different echocardiographic techniques used to evaluate patients with PAH.
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Sivakumar K, Mohakud A, Singh A, Sagar P. A Pilot Project to Identify Simple Echocardiographic Tools as an Alternative to Cardiac Magnetic Resonance Imaging to Predict a Reduced Right Ventricular Ejection Fraction in Patients with Repaired Tetralogy of Fallot. JOURNAL OF THE INDIAN ACADEMY OF ECHOCARDIOGRAPHY & CARDIOVASCULAR IMAGING 2021. [DOI: 10.4103/jiae.jiae_26_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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The Association of Pretransplant Pulmonary Hypertension With Patient and Graft Survival After Kidney Transplantation: A Retrospective Cohort Study. Transplant Proc 2020; 52:3023-3032. [PMID: 32665088 DOI: 10.1016/j.transproceed.2020.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 05/06/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Pulmonary hypertension (PH) has been well characterized in end-stage kidney disease and carries a grave prognosis. Its relationship to kidney transplantation outcomes is uncertain. The purpose of the present study was to characterize PH in kidney transplant candidates and to evaluate the relationship of PH to post-transplantation outcomes. METHODS A retrospective review of medical records and echocardiographic findings in all patients listed and transplanted at a large urban academic medical center from 2010 to 2015 was undertaken. PH (defined as echocardiographic evidence of pulmonary artery systolic pressure ≥ 35 mm Hg) was assessed along with demographics, and comorbidities for its relationship to patient, and graft survival by univariable and multivariable analysis. RESULTS Of 733 patients, 15.6% (115) had PH. PH in this population was primarily due to left ventricular (LV) diastolic dysfunction. Patient survival (78.3% vs 89.6%, P = .02) and the composite of patient and graft survival (70.7% vs 85.0%, P = .04) was reduced at 5 years in patients with PH as compared to patients with No PH, respectively. However, multivariable analysis suggested that age at presentation, race, and left ventricular systolic function but not PH were significantly associated with patient mortality or graft loss. CONCLUSION Reduced patient and graft survival seen in patients with pulmonary hypertension appears to be related to risk factors other than the pulmonary hypertension itself; therefore, pretransplant PH should not be considered as a barrier to kidney transplantation.
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Early Single-Site Experience With Transcatheter Tricuspid Valve Replacement. JACC Cardiovasc Imaging 2019; 12:416-429. [DOI: 10.1016/j.jcmg.2018.08.034] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 08/01/2018] [Accepted: 08/01/2018] [Indexed: 11/19/2022]
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Abstract
PURPOSE OF REVIEW The function of the right ventricle (RV) is intimately linked to its preload (systemic volume status) and afterload (pulmonary vasculature). In this review, we explore current knowledge in RV physiology, RV function assessment, causes of right heart failure (RHF), and specific treatment strategies for RHF. RECENT FINDINGS We examine the evidence behind new pharmacological therapies available, such as macitentan and riociguat in the treatment of specific etiologies of RHF. We will also focus on RHF in the setting of heart failure with preserved ejection fraction (HFpEF) and in the presence of left ventricular assist devices (LVAD), looking at current treatment recommendations, including mechanical circulatory support. Lastly, we will look to the horizon for the latest research on RHF, including the molecular basis of RHF and potential novel treatment methods for this old yet poorly understood syndrome. Disturbances in this complex relationship result in the clinical syndrome of RHF. Despite advances in the management of left heart diseases, much work remains to be done to understand and manage RHF.
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Affiliation(s)
- Weiqin Lin
- Section of Heart Failure and Cardiac Transplantation, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH, 44195, USA
| | | | - W H Wilson Tang
- Section of Heart Failure and Cardiac Transplantation, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH, 44195, USA. .,Center for Clinical Genomics, Cleveland Clinic, Cleveland, OH, USA.
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Schneider M, Aschauer S, Mascherbauer J, Ran H, Binder C, Lang I, Goliasch G, Binder T. Echocardiographic assessment of right ventricular function: current clinical practice. Int J Cardiovasc Imaging 2018; 35:49-56. [PMID: 30191507 PMCID: PMC6373282 DOI: 10.1007/s10554-018-1428-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 07/26/2018] [Indexed: 01/05/2023]
Abstract
Echocardiographic evaluation of right ventricular (RV) function is a challenge due to the complex anatomy of the RV. Several transthoracic echocardiographic methods have been suggested for the quantification of RV function. However, many of the parameters are time consuming and need dedicated hardware and software. We suspected that the majority of the established markers are not used on a wide basis. In a multinational online survey, we evaluated the use of current clinical standards for the quantification of RV function in clinical practice. Through the network of an Ultrasound Online Teaching Platform, echocardiographers were invited to participate in an open online survey. The participants were asked about the parameters (eyeballing, TAPSE, S', fractional area change, RIMP, 3D-EF, dp/dt, longitudinal strain) they used in clinical practice. A total of 1150 participants from 109 countries completed the survey. Only eyeballing (72%), TAPSE (69%), and S' (31%) were commonly used in clinical routine. These methods were applied significantly less common in low-income economies when compared to high-income economies. Twenty-three percent of all participants stated to rely on eyeballing only, when evaluating RV function in clinical routine. New technologies, such as global longitudinal strain (3%) and 3D echocardiography (1%) were rarely applied independent of region and economic strength. Eyeballing and TAPSE are the most widely used methods in echocardiography for the assessment of RV function. Although advanced parameters such as longitudinal strain and 3D echocardiography were shown to be highly accurate, they are rarely used in clinical routine.
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Affiliation(s)
- Matthias Schneider
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Stefan Aschauer
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Julia Mascherbauer
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Hong Ran
- Department of Echocardiography, Nanjing First Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Christina Binder
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Irene Lang
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Georg Goliasch
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Thomas Binder
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Kasprzak JD, Huttin O, Wierzbowska-Drabik K, Selton-Suty C. Imaging the Right Heart-Pulmonary Circulation Unit. Heart Fail Clin 2018; 14:361-376. [DOI: 10.1016/j.hfc.2018.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Gilliland YE, Lavie CJ, Ahmad H, Bernal JA, Cash ME, Dinshaw H, Milani RV, Shah S, Bienvenu L, White CJ. Development and Implementation of a Quality Improvement Process for Echocardiographic Laboratory Accreditation. Echocardiography 2016; 33:459-71. [PMID: 26757247 DOI: 10.1111/echo.13129] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
We describe our process for quality improvement (QI) for a 3-year accreditation cycle in echocardiography by the Intersocietal Accreditation Commission (IAC) for a large group practice. Echocardiographic laboratory accreditation by the IAC was introduced in 1996, which is not required but could impact reimbursement. To ensure high-quality patient care and community recognition as a facility committed to providing high-quality echocardiographic services, we applied for IAC accreditation in 2010. Currently, there is little published data regarding the IAC process to meet echocardiography standards. We describe our approach for developing a multicampus QI process for echocardiographic laboratory accreditation during the 3-year cycle of accreditation by the IAC. We developed a quarterly review assessing (1) the variability of the interpretations, (2) the quality of the examinations, (3) a correlation of echocardiographic studies with other imaging modalities, (4) the timely completion of reports, (5) procedure volume, (6) maintenance of Continuing Medical Education credits by faculty, and (7) meeting Appropriate Use Criteria. We developed and implemented a multicampus process for QI during the 3-year accreditation cycle by the IAC for Echocardiography. We documented both the process and the achievement of those metrics by the Echocardiography Laboratories at the Ochsner Medical Institutions. We found the QI process using IAC standards to be a continuous educational experience for our Echocardiography Laboratory physicians and staff. We offer our process as an example and guide for other echocardiography laboratories who wish to apply for such accreditation or reaccreditation.
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Affiliation(s)
- Yvonne E Gilliland
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Medical Center, Ochsner Clinical School - The University of Queensland School of Medicine, New Orleans, Louisiana
| | - Carl J Lavie
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Medical Center, Ochsner Clinical School - The University of Queensland School of Medicine, New Orleans, Louisiana
| | - Homaa Ahmad
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Medical Center, Ochsner Clinical School - The University of Queensland School of Medicine, New Orleans, Louisiana
| | - Jose A Bernal
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Medical Center, Ochsner Clinical School - The University of Queensland School of Medicine, New Orleans, Louisiana
| | - Michael E Cash
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Medical Center, Ochsner Clinical School - The University of Queensland School of Medicine, New Orleans, Louisiana
| | - Homeyar Dinshaw
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Medical Center, Ochsner Clinical School - The University of Queensland School of Medicine, New Orleans, Louisiana
| | - Richard V Milani
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Medical Center, Ochsner Clinical School - The University of Queensland School of Medicine, New Orleans, Louisiana
| | - Sangeeta Shah
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Medical Center, Ochsner Clinical School - The University of Queensland School of Medicine, New Orleans, Louisiana
| | - Lisa Bienvenu
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Medical Center, Ochsner Clinical School - The University of Queensland School of Medicine, New Orleans, Louisiana
| | - Christopher J White
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Medical Center, Ochsner Clinical School - The University of Queensland School of Medicine, New Orleans, Louisiana
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Falahatpisheh A, Rickers C, Gabbert D, Heng EL, Stalder A, Kramer HH, Kilner PJ, Kheradvar A. Simplified Bernoulli's method significantly underestimates pulmonary transvalvular pressure drop. J Magn Reson Imaging 2015; 43:1313-9. [PMID: 26584006 DOI: 10.1002/jmri.25097] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 11/03/2015] [Indexed: 11/06/2022] Open
Abstract
PURPOSE To determine whether neglecting the flow unsteadiness in simplified Bernoulli's equation significantly affects the pulmonary transvalvular pressure drop estimation. MATERIALS AND METHODS 3.0T magnetic resonance imaging (MRI) 4D velocity mapping was performed on four healthy volunteers, seven patients with repaired tetralogy of Fallot, and thirteen patients with transposition of the great arteries repaired by arterial switch. Pulmonary transvalvular pressure drop was estimated based on two methods: General Bernoulli's Equation (GBE), ie, the most complete form; and Simplified Bernoulli's Equation (SBE), known as 4V(2) . More than 2300 individual pressure drop measurements were used to compare the simplified and the general Bernoulli's methods. A linear mixed-effects model was employed for statistical analyses, fully accounting for clustering of observations among the methods and systolic phases. RESULTS The simplified Bernoulli's method systematically underestimated the pressure drop compared to general Bernoulli's method during the entire systolic phase (P < 0.05), including the peak systole, where on average ΔpSBE/ΔpGBE=78%. CONCLUSION The simplified Bernoulli method underestimated the pressure drop during all systolic phases in all the studied subjects. Therefore, it is necessary to take into account the flow unsteadiness for more accurate estimation of the pressure drop. J. Magn. Reson. Imaging 2016;43:1313-1319.
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Affiliation(s)
- Ahmad Falahatpisheh
- University of California Irvine, Department of Biomedical Engineering, Edwards Lifesciences Center of Advanced Cardiovascular Technology; Irvine California USA
| | - Carsten Rickers
- University Hospital Schleswig-Holstein Campus Kiel, Department of Pediatric Cardiology; Kiel Germany
| | - Dominik Gabbert
- University Hospital Schleswig-Holstein Campus Kiel, Department of Pediatric Cardiology; Kiel Germany
| | - Ee Ling Heng
- Royal Brompton Hospital, London, UK, NIHR Cardiovascular Biomedical Research Unit of Royal Brompton and Harefield NHS Foundation Trust and Imperial College; London UK
| | | | - Hans-Heiner Kramer
- University Hospital Schleswig-Holstein Campus Kiel, Department of Pediatric Cardiology; Kiel Germany
| | - Philip J. Kilner
- Royal Brompton Hospital, London, UK, NIHR Cardiovascular Biomedical Research Unit of Royal Brompton and Harefield NHS Foundation Trust and Imperial College; London UK
| | - Arash Kheradvar
- University of California Irvine, Department of Biomedical Engineering, Edwards Lifesciences Center of Advanced Cardiovascular Technology; Irvine California USA
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The Right Ventricle: A Comprehensive Review From Anatomy, Physiology, and Mechanics to Hemodynamic, Functional, and Imaging Evaluation. ACTA ACUST UNITED AC 2015. [DOI: 10.5812/acvi.35717] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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