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Vandenheuvel M, Bouchez S, Labus J, Wouters P, Mauermann E. Assessing Right Ventricular Function in the Perioperative Setting, Part I: Echo-Based Measurements. Anesthesiol Clin 2025; 43:283-304. [PMID: 40348544 DOI: 10.1016/j.anclin.2025.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2025]
Abstract
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.
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Affiliation(s)
- Michael Vandenheuvel
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Belgium
| | | | - Jakob Labus
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Patrick Wouters
- Department Basic and Applied Medical Sciences, Ghent University Hospital, Belgium
| | - Eckhard Mauermann
- Department of Anesthesia, Zurich City Hospital, Birmensdorferstrasse, Switzerland.
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Venkateshvaran A, Edbom F, Arvidsson S, Kovacs A, Lindqvist P. Three-Dimensional Echocardiographic Assessment of Right Ventricular Global Myocardial Work and Ventricular-Pulmonary Coupling in ATTR Cardiac Amyloidosis. J Clin Med 2025; 14:668. [PMID: 39941339 PMCID: PMC11818410 DOI: 10.3390/jcm14030668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2024] [Revised: 01/13/2025] [Accepted: 01/19/2025] [Indexed: 02/16/2025] Open
Abstract
Background: Right ventricular (RV) function is inadequately investigated and routinely overlooked in transthyretin amyloid cardiomyopathy (ATTR-CM). Novel imaging distinguishers between intrinsic RV myocardial disease in ATTR-CM and primary RV overload disorder phenotypes may enhance mechanistic and pathophysiological understanding of RV dysfunction. We aimed to investigate RV performance in ATTR-CM employing comprehensive 2D and 3D echocardiography, and to compare these indices with primary RV afterload disease. Methods: We investigated conventional and novel indices of RV contractile function, myocardial work and ventricular-vascular coupling in 21 well-characterized ATTR-CM patients, 10 PAH patients and 12 healthy controls. RV long axis function and pulmonary artery (PA) systolic pressure were evaluated using 2D Doppler echocardiography. RV ejection fraction (RVEF), volumes, global longitudinal strain (GLS) and novel myocardial work indices were analyzed by 3D echocardiography. RV elastance (Ees), afterload (Ea) and RV-PA coupling (Ees/Ea) were estimated using the single-beat volume method. Results: ATTR-CM showed lower RVEF, GLS and Ees, and a higher RV global myocardial work index (GWI), constructive work (GCW), Ea and reduced RV-PA coupling compared with controls. RV EF, stroke volume, GLS and circumferential strain did not differ between ATTR-CM and PAH. However, GWI, GCW, Ees and Ea were lower in ATTR-CM. RV-pulmonary coupling displayed strong association with RV 3D strain (r = 0.84, p < 0.001), whereas RV Ees (contractility) was related to RV GWI (r = 0.54, p < 0.001). Conclusions: ATTR-CM displayed lower RV performance, higher GMW and reduced RV-PA coupling. Myocardial work indices Ees and Ea are novel distinguishers of RV dysfunction phenotypes. The clinical and prognostic value of these novel variables warrant further investigation.
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Affiliation(s)
- Ashwin Venkateshvaran
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, 22185 Lund, Sweden
| | - Fredrik Edbom
- Department of Diagnostics and Intervention, Clinical Physiology, Umeå University, 90187 Umeå, Sweden (P.L.)
| | - Sandra Arvidsson
- Department of Diagnostics and Intervention, Clinical Physiology, Umeå University, 90187 Umeå, Sweden (P.L.)
| | - Attila Kovacs
- Argus Cognitive, Inc., Hanover, NH 03755, USA
- Department of Experimental Cardiology and Surgical Techniques, Semmelweis University, 1085 Budapest, Hungary
| | - Per Lindqvist
- Department of Diagnostics and Intervention, Clinical Physiology, Umeå University, 90187 Umeå, Sweden (P.L.)
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Aggarwal K, Pathan MS, Dhalani M, Kaur IP, Anamika F, Gupta V, Jayaraman DK, Jain R. Elevated Perspectives: Unraveling Cardiovascular Dynamics in High-Altitude Realms. Curr Cardiol Rev 2025; 21:19-26. [PMID: 39506447 PMCID: PMC12060922 DOI: 10.2174/011573403x308818241030051249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 09/07/2024] [Accepted: 10/01/2024] [Indexed: 11/08/2024] Open
Abstract
High-altitude regions pose distinctive challenges for cardiovascular health because of decreased oxygen levels, reduced barometric pressure, and colder temperatures. Approximately 82 million people live above 2400 meters, while over 100 million people visit these heights annually. Individuals ascending rapidly or those with pre-existing cardiovascular conditions are particularly vulnerable to altitude-related illnesses, including Acute Mountain Sickness (AMS) and Chronic Mountain Sickness (CMS). The cardiovascular system struggles to adapt to hypoxic stress, which can lead to arrhythmias, systemic hypertension, and right ventricular failure. Pathophysiologically, high-altitude exposure triggers immediate increases in cardiac output and heart rate, often due to enhanced sympathetic activity. Over time, acclimatisation involves complex changes, such as reduced stroke volume and increased blood volume. The pulmonary vasculature also undergoes significant alterations, including hypoxic pulmonary vasoconstriction and vascular remodelling, contributing to conditions, like pulmonary hypertension and high-altitude pulmonary edema. Genetic adaptations in populations living at high altitudes, such as gene variations linked to hypoxia response, further influence these physiological processes. Regarding cardiovascular disease risk, stable coronary artery disease patients generally do not face significant adverse outcomes at altitudes up to 3500 meters. However, those with unstable angina or recent cardiac interventions should avoid high-altitude exposure to prevent exacerbation. Remarkably, high-altitude living correlates with reduced cardiovascular mortality rates, possibly due to improved air quality and hypoxia-induced adaptations. Additionally, there is a higher incidence of congenital heart disease among children born at high altitudes, highlighting the profound impact of hypoxia on heart development. Understanding these dynamics is crucial for managing risks and improving health outcomes in high-altitude environments.
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Affiliation(s)
| | | | - Mayank Dhalani
- GMERS Medical College & Hospital, Gotri, Vadodara, Gujrat, India
| | - Inder P. Kaur
- University of Mississippi Medical Center, Jackson, Mississippi, MS 39216, USA
| | - Fnu Anamika
- University College of Medical Sciences, New Delhi, India
| | | | | | - Rohit Jain
- Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA
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Slavich M, Ricchetti G, Demarchi B, Cavalli G, Spoladore R, Federico A, Federico F, Bezzi C, Margonato A, Fragasso G. Clinical and functional effects of beta-blocker therapy discontinuation in patients with biventricular heart failure. J Cardiovasc Med (Hagerstown) 2024; 25:141-148. [PMID: 38149700 DOI: 10.2459/jcm.0000000000001571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
BACKGROUND Nearly two-thirds of patients with heart failure with reduced ejection fraction (HFrEF) have right ventricular dysfunction, previously identified as an independent predictor of reduced functional capacity and poor prognosis. Beta-blocker therapy (β-BT) reduces mortality and hospitalizations in patients with HFrEF and is approved as first-line therapy regardless of concomitant right ventricular function. However, the exact role of sympathetic nervous system activation in right ventricular dysfunction and the potential usefulness (or harmfulness) of β-BT in these patients are still unclear. OBJECTIVES The aim of the study is to evaluate the medium-term effect of β-BT discontinuation on functional capacity and right ventricular remodelling based on cardiopulmonary exercise testing (CPET), echocardiography and serum biomarkers in patients with clinically stable biventricular dysfunction. METHODS In this single-centre, open-label, prospective trial, 16 patients were enrolled using the following criteria: patients were clinically stable without signs of peripheral congestion; NYHA II-III while on optimal medical therapy (including β-BT); LVEF 40% or less; echocardiographic criteria of right ventricular dysfunction. Patients were randomized 1 : 1 either to withdraw (group 0) or continue (group 1) β-BT. In group 0, optimal heart rate was obtained with alternative rate-control drugs. Echo and serum biomarkers were performed at baseline, after 3 and 6 months; CPET was performed at baseline and 6 months. Mann--Whitney U test was adopted to determine the relationships between β-BT discontinuation and effects on right ventricular dysfunction. RESULTS At 6 months' follow up, S' DTI improved (ΔS': 1.01 vs. -0.92 cm/s; P = 0.03), while estimated PAPs (ΔPAPs: 0.8 vs. -7.5 mmHg; P = 0.04) and echo left ventricular-remodelling (ΔEDVi: 19.55 vs. -0.96 ml/mq; P = 0.03) worsened in group 0. In absolute terms, the only variables significantly affected by β-BT withdrawal were left ventricular EDV and ESV, appearing worse in group 0 (mean EDVi 115 vs. 84 ml/mq; mean ESVi 79 vs. 53.9 ml/mq, P = 0.03). No significant changes in terms of functional capacity were observed after β-BT withdrawal. CONCLUSION In HFrEF patients with concomitant right ventricular dysfunction, β-BT discontinuation did not produce any beneficial effects. In addition, despite maintenance of optimal heart rate control, β-BT discontinuation induced worsening of left ventricular remodelling. Our study corroborates the hypothesis that improvement in left ventricular function may likewise be a major determinant for improvement in right ventricular function, reducing pulmonary wedge pressure and right ventricular afterload, with only a marginal action of its negative inotropic effect. In conclusion, β-BT appears beneficial also in heart failure patients with biventricular dysfunction.
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Affiliation(s)
- Massimo Slavich
- Department of Cardiology, IRCCS San Raffaele Scientific Institute
| | | | - Barbara Demarchi
- Department of Cardiology, IRCCS San Raffaele Scientific Institute
| | - Giulio Cavalli
- Immunology, Rheumatology, Allergology and Rare Diseases Unit, IRCCS Ospedale San Raffaele
| | | | - Anna Federico
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Carolina Bezzi
- Nuclear Medicine Department, IRCCS San Raffaele Scientific Institute
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Johannesen J, Fukuda R, Zhang DT, Tak K, Meier R, Agoglia H, Horn E, Devereux RB, Weinsaft JW, Kim J. Direct comparison of echocardiography speckle tracking and cardiac magnetic resonance feature tracking for quantification of right ventricular strain: a prospective intermodality study in functional mitral regurgitation. Echo Res Pract 2022; 9:11. [PMID: 36316750 PMCID: PMC9623949 DOI: 10.1186/s44156-022-00011-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 09/20/2022] [Indexed: 11/05/2022] Open
Abstract
Background Functional mitral regurgitation (FMR) is a known risk factor for right ventricular dysfunction (RVDYS). RV global longitudinal strain (GLS) is an emerging index of RV function; however, the magnitude of agreement between RV GLS by echocardiography (echo) and cardiac magnetic resonance (CMR) and the relative utility of each modality for both the diagnosis of RVDYS and prognostication of all-cause mortality and heart failure hospitalization remain unknown. Results 32% of patients had RVDYS (EF < 50%) on CMR, among whom there was more advanced NYHA class and lower LV and RV ejection fraction (all p < 0.05). RV GLS was impaired in patients with RVDYS whether quantified via STE or FT-CMR, with strong correlation between modalities (r = 0.81). Both STE and FT-CMR derived GLS yielded excellent detection of RVDYS (AUC 0.94 for both), paralleling similar performance for free wall strain by both modalities (FT-CMR AUC 0.94, STE AUC 0.92) with lower accuracy demonstrated by STE derived septal strain (STE AUC 0.78 and FT-CMR AUC 0.92). RV S’ and TAPSE showed lower diagnostic accuracy (RV S’ AUC 0.77 and TAPSE AUC 0.81). During median follow up of 51 months (IQR 42, 60 months), all-cause mortality or HF hospitalization occurred in 25% (n = 25). Both STE and FT-CMR derived RV GLS stratified risk for adverse prognosis (STE p = 0.007, FT-CMR p = 0.005) whereas conventional RV indices, TAPSE and RV S’, did not (TAPSE p = 0.30, S’ p = 0.69). Conclusion RV GLS is a robust marker of RVDYS irrespective of modality which provides incremental diagnostic value and improves risk stratification for event free survival beyond conventional RV indices.
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Affiliation(s)
- Justin Johannesen
- grid.5386.8000000041936877XDivision of Cardiology, Department of Medicine, Weill Cornell Medicine/New York Presbyterian Hospital, 525 East 68th Street, New York, NY 10021 USA
| | - Rena Fukuda
- grid.5386.8000000041936877XDivision of Cardiology, Department of Medicine, Weill Cornell Medicine/New York Presbyterian Hospital, 525 East 68th Street, New York, NY 10021 USA
| | - David T. Zhang
- grid.5386.8000000041936877XDivision of Cardiology, Department of Medicine, Weill Cornell Medicine/New York Presbyterian Hospital, 525 East 68th Street, New York, NY 10021 USA
| | - Katherine Tak
- grid.5386.8000000041936877XDivision of Cardiology, Department of Medicine, Weill Cornell Medicine/New York Presbyterian Hospital, 525 East 68th Street, New York, NY 10021 USA
| | - Rachel Meier
- grid.5386.8000000041936877XDivision of Cardiology, Department of Medicine, Weill Cornell Medicine/New York Presbyterian Hospital, 525 East 68th Street, New York, NY 10021 USA
| | - Hannah Agoglia
- grid.5386.8000000041936877XDivision of Cardiology, Department of Medicine, Weill Cornell Medicine/New York Presbyterian Hospital, 525 East 68th Street, New York, NY 10021 USA
| | - Evelyn Horn
- grid.5386.8000000041936877XDivision of Cardiology, Department of Medicine, Weill Cornell Medicine/New York Presbyterian Hospital, 525 East 68th Street, New York, NY 10021 USA
| | - Richard B. Devereux
- grid.5386.8000000041936877XDivision of Cardiology, Department of Medicine, Weill Cornell Medicine/New York Presbyterian Hospital, 525 East 68th Street, New York, NY 10021 USA
| | - Jonathan W. Weinsaft
- grid.5386.8000000041936877XDivision of Cardiology, Department of Medicine, Weill Cornell Medicine/New York Presbyterian Hospital, 525 East 68th Street, New York, NY 10021 USA
| | - Jiwon Kim
- grid.5386.8000000041936877XDivision of Cardiology, Department of Medicine, Weill Cornell Medicine/New York Presbyterian Hospital, 525 East 68th Street, New York, NY 10021 USA
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Tsarova K, Morgan AE, Melendres-Groves L, Ibrahim MM, Ma CL, Pan IZ, Hatton ND, Beck EM, Ferrel MN, Selzman CH, Ingram D, Alamri AK, Ratcliffe MB, Wilson BD, Ryan JJ. Imaging in Pulmonary Vascular Disease-Understanding Right Ventricle-Pulmonary Artery Coupling. Compr Physiol 2022; 12:3705-3730. [PMID: 35950653 DOI: 10.1002/cphy.c210017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The right ventricle (RV) and pulmonary arterial (PA) tree are inextricably linked, continually transferring energy back and forth in a process known as RV-PA coupling. Healthy organisms maintain this relationship in optimal balance by modulating RV contractility, pulmonary vascular resistance, and compliance to sustain RV-PA coupling through life's many physiologic challenges. Early in states of adaptation to cardiovascular disease-for example, in diastolic heart failure-RV-PA coupling is maintained via a multitude of cellular and mechanical transformations. However, with disease progression, these compensatory mechanisms fail and become maladaptive, leading to the often-fatal state of "uncoupling." Noninvasive imaging modalities, including echocardiography, magnetic resonance imaging, and computed tomography, allow us deeper insight into the state of coupling for an individual patient, providing for prognostication and potential intervention before uncoupling occurs. In this review, we discuss the physiologic foundations of RV-PA coupling, elaborate on the imaging techniques to qualify and quantify it, and correlate these fundamental principles with clinical scenarios in health and disease. © 2022 American Physiological Society. Compr Physiol 12: 1-26, 2022.
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Affiliation(s)
- Katsiaryna Tsarova
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ashley E Morgan
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Lana Melendres-Groves
- Division of Pulmonary and Critical Care Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Majd M Ibrahim
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Christy L Ma
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Irene Z Pan
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah, USA
| | - Nathan D Hatton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Emily M Beck
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Meganne N Ferrel
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Dominique Ingram
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ayedh K Alamri
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | | | - Brent D Wilson
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - John J Ryan
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Rong LQ, Lopes AJ, Mitlak HW, Palumbo MC, Mick S, Kim J, Levine RA, Wong SC, Reisman M, Devereux RB, Gaudino M, Weinsaft JW. Relative Impact of Surgical Mitral Repair and MitraClip on Annular Remodeling-A Potential Mechanism for Therapeutic Response to Mitral Repair for Degenerative Mitral Regurgitation. J Cardiothorac Vasc Anesth 2022; 36:1279-1287. [PMID: 34600832 PMCID: PMC9027699 DOI: 10.1053/j.jvca.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/23/2021] [Accepted: 09/03/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Three-dimensional transesophageal echocardiography (TEE) is widely used to guide decision-making for mitral repair. The relative impact of surgical mitral valve repair (MVr) and MitraClip on annular remodeling is unknown. The aim was to determine the impact of both mitral repair strategies on annular geometry, including the primary outcome of annular circumference and area. DESIGN This was a retrospective observational study of patients who underwent mitral intervention between 2016 and 2020. SETTING Weill Cornell Medicine, a single, large, academic medical center. PARTICIPANTS The population comprised 50 patients with degenerative mitral regurgitation (MR) undergoing MVr. INTERVENTIONS Elective MVr and TEE. MEASUREMENTS AND MAIN RESULTS Patients undergoing MitraClip or surgical MVr were matched (1:1) for sex and coronary artery disease. Mitral annular geometry indices were quantified on intraprocedural three-dimensional TEE. Mild or less MR on follow-up transthoracic echocardiography defined optimal response. Patients undergoing MitraClip were older (80 ± eight v 66 ± six years; p < 0.001) but were otherwise similar to surgical patients. Patients undergoing MitraClip had larger baseline left atrial and ventricular sizes, increased tenting height, and volume (p < 0.01), with a trend toward increased annular area (p = 0.23). MitraClip and surgery both induced immediate mitral annular remodeling, including decreased area, circumference, and tenting height (p < 0.001), with greater remodeling with surgical repair. At follow-up (4.1 ± 9.0 months) optimal response (≤ mild MR) was ∼twofold more common with surgery than MitraClip (81% v 46%; p = 0.02). The relative reduction in annular circumference (odds ratio [OR] 1.05 [1.00-1.09] per cm; p = 0.04) and area (OR 1.03 [1.00-1.05] per cm2; p = 0.049) were both associated with optimal response. CONCLUSIONS Surgical MVr and MitraClip both reduce annular size, but repair-induced remodeling is greater with surgery and associated with an increased likelihood of optimal response.
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Affiliation(s)
- Lisa Q Rong
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY.
| | | | - Hannah W Mitlak
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Maria C Palumbo
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Stephanie Mick
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Jiwon Kim
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Robert A Levine
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - S Chiu Wong
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Mark Reisman
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Richard B Devereux
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Jonathan W Weinsaft
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
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Ohara K, Imamura T, Ihori H, Chatani K, Nonomura M, Kameyama T, Inoue H. Association between Right Ventricular Function and Exercise Capacity in Patients with Chronic Heart Failure. J Clin Med 2022; 11:jcm11041066. [PMID: 35207338 PMCID: PMC8877496 DOI: 10.3390/jcm11041066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 02/15/2022] [Accepted: 02/17/2022] [Indexed: 02/05/2023] Open
Abstract
Background: The association between right ventricular function and exercise capacity in patients with chronic heart failure remains uncertain. Several studies very recently mentioned the association between right ventricular reserve and exercise capacity, whereas the implication of tricuspid annular plane systolic excursion (TAPSE) remains uninvestigated. We aimed to assess the impact of TAPSE on exercise capacity in cardiac rehabilitation candidates. Methods: Data from patients with chronic heart failure who received cardiopulmonary exercise tests and transthoracic echocardiography prior to cardiac rehabilitation were retrospectively collected, and their association was investigated. Results: A total of 169 patients with chronic heart failure (70.3 ± 11.7 years old, 74.6% men) were included. Tertiled tricuspid annular plane systolic excursion significantly stratified anaerobic threshold (10.2 ± 2.2, 11.4 ± 2.2, and 12.2 ± 2.8 mm; p < 0.01) and peak oxygen consumption (15.9 ± 4.5, 18.3 ± 5.3, and 19.8 ± 5.6 mm; p < 0.01). In the multivariate logistic regression analyses, TAPSE was an independent factor associated with anaerobic threshold and peak oxygen consumption (p < 0.05 for both). Conclusions: Right ventricular impairment was associated with reduced exercise capacity in patients with chronic heart failure. Such knowledge would be useful to estimate patients’ exercise capacity and prescribe cardiac rehabilitation. Its longitudinal association and clinical implication need further studies.
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Affiliation(s)
- Kazumasa Ohara
- Internal Medicine, Saiseikai Toyama Hospital, Toyama 931-8533, Japan; (K.O.); (H.I.); (K.C.); (M.N.); (T.K.); (H.I.)
| | - Teruhiko Imamura
- The Second Department of Internal Medicine, University of Toyama, Toyama 930-0194, Japan
- Correspondence: ; Tel.: +81-764342281; Fax: +81-764345026
| | - Hiroyuki Ihori
- Internal Medicine, Saiseikai Toyama Hospital, Toyama 931-8533, Japan; (K.O.); (H.I.); (K.C.); (M.N.); (T.K.); (H.I.)
| | - Kenichi Chatani
- Internal Medicine, Saiseikai Toyama Hospital, Toyama 931-8533, Japan; (K.O.); (H.I.); (K.C.); (M.N.); (T.K.); (H.I.)
| | - Makoto Nonomura
- Internal Medicine, Saiseikai Toyama Hospital, Toyama 931-8533, Japan; (K.O.); (H.I.); (K.C.); (M.N.); (T.K.); (H.I.)
| | - Tomoki Kameyama
- Internal Medicine, Saiseikai Toyama Hospital, Toyama 931-8533, Japan; (K.O.); (H.I.); (K.C.); (M.N.); (T.K.); (H.I.)
| | - Hiroshi Inoue
- Internal Medicine, Saiseikai Toyama Hospital, Toyama 931-8533, Japan; (K.O.); (H.I.); (K.C.); (M.N.); (T.K.); (H.I.)
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Hassanin M, Ong G, Connelly KA. Right Ventricle Longitudinal Strain: A New Tool in Functional Tricuspid Regurgitation Prognostication. Can J Cardiol 2021; 37:945-948. [PMID: 33845137 DOI: 10.1016/j.cjca.2021.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/28/2021] [Accepted: 04/01/2021] [Indexed: 10/21/2022] Open
Affiliation(s)
- Magdi Hassanin
- Division of Cardiology and Keenan Research Center for Biomedical Science, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Géraldine Ong
- Division of Cardiology and Keenan Research Center for Biomedical Science, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kim A Connelly
- Division of Cardiology and Keenan Research Center for Biomedical Science, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
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10
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Bening C, Sales VL, Alhussini K, Radakovic D, Benitez RC, Madrahimov N, Keller D, Leyh R. Clinically inapparent right heart dysfunction is associated with reduced myofilament force development in coronary artery disease. BMC Cardiovasc Disord 2021; 21:125. [PMID: 33663396 PMCID: PMC7934411 DOI: 10.1186/s12872-021-01926-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/15/2021] [Indexed: 11/30/2022] Open
Abstract
Background Right ventricular dysfunction after CABG is associated with poor peri- and postoperative outcomes. We aimed to identify clinical and experimental predictors for preoperative inapparent right ventricular dysfunction and therefore hypothesized that reduced myofilament force development as well as altered levels of biomarkers might predict inapparent right ventricular dysfunction. Methods From 08/2016 to 02/2018, 218 patients scheduled for CABG were divided into two groups (TAPSE ≥ 20 mm, n = 178; TAPSE < 20 mm, n = 40). Baseline serum samples for biomarkers (Galectin, TGFß1, N Acyl-SDMA, Arginine, ADMA and Pentraxin-3), clinical laboratory and transthoracic echocardiographic parameters were evaluated. To examine the myocardial apparatus of the right ventricle intraoperative right auricular tissue was harvested for stepwise skinned fiber force measurements. Results Patients with TAPSE < 20 mm had a higher incidence of DM (55 vs. 34%, p = 0.018), preoperative AFib (43 vs. 16%, p < 0.001), reduced GFR (67 ± 18 vs. 77 ± 24 ml/min/1.73 m2, p = 0.013), larger LA area (22 ± 6 vs. 20 ± 5 cm2, p = 0.005) and reduced LVEF (50 vs. 55%, p = 0.008). Furthermore, higher serum ADMA (0.70 ± 0.13 vs. 0.65 ± 0.15 µmol/l, p = 0.046) and higher serum Pentraxin-3 levels (3371 ± 1068 vs. 2681 ± 1353 pg/dl, p = 0.004) were observed in these patients. Skinned fiber force measurements showed significant lower values at almost every step of calcium concentration (pCa 4.52 to pCa 5.5, p < 0.01 and pCa 5.75–6.0, p < 0.05). Multivariable analysis revealed DM (OR 2.53, CI 1.12–5.73, Euro Score II (OR 1.34, CI 1.02–1.78), preoperative AF (OR 4.86, CI 2.06–11.47), GFR (OR 7.72, CI 1.87–31.96), albumin (OR 1.56, CI 0.52–2.60), Pentraxin-3 (OR 19.68, CI 14.13–25.24), depressed LVEF (OR 8.61, CI 6.37–10.86), lower force values: (pCa 5.4; OR 2.34, CI 0.40–4.29 and pCa 5.2; OR 2.00, CI 0.39–3.60) as predictors for clinical inapparent right heart dysfunction. Conclusions These preliminary data showed that inapparent right heart dysfunction in CAD is already associated with reduced force development of the contractile apparatus.
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Affiliation(s)
- C Bening
- Department of Thoracic and Cardiovascular Surgery, Zentrum Operative Medizin, University of Wuerzburg, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany. .,Comprehensive Heart Failure Centre (CHFC) Würzburg, University of Wuerzburg, Wuerzburg, Germany.
| | - V L Sales
- Department of Thoracic and Cardiovascular Surgery, Zentrum Operative Medizin, University of Wuerzburg, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany
| | - K Alhussini
- Department of Thoracic and Cardiovascular Surgery, Zentrum Operative Medizin, University of Wuerzburg, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany.,Comprehensive Heart Failure Centre (CHFC) Würzburg, University of Wuerzburg, Wuerzburg, Germany
| | - D Radakovic
- Department of Thoracic and Cardiovascular Surgery, Zentrum Operative Medizin, University of Wuerzburg, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany
| | - R Cris Benitez
- Department of Thoracic and Cardiovascular Surgery, Zentrum Operative Medizin, University of Wuerzburg, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany
| | - N Madrahimov
- Department of Thoracic and Cardiovascular Surgery, Zentrum Operative Medizin, University of Wuerzburg, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany
| | - D Keller
- Department of Thoracic and Cardiovascular Surgery, Zentrum Operative Medizin, University of Wuerzburg, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany
| | - R Leyh
- Department of Thoracic and Cardiovascular Surgery, Zentrum Operative Medizin, University of Wuerzburg, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany.,Comprehensive Heart Failure Centre (CHFC) Würzburg, University of Wuerzburg, Wuerzburg, Germany
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11
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Kim J, Volodarskiy A, Sultana R, Pollie MP, Yum B, Nambiar L, Tafreshi R, Mitlak HW, RoyChoudhury A, Horn EM, Hriljac I, Narula N, Kim S, Ndhlovu L, Goyal P, Safford MM, Shaw L, Devereux RB, Weinsaft JW. Prognostic Utility of Right Ventricular Remodeling Over Conventional Risk Stratification in Patients With COVID-19. J Am Coll Cardiol 2020; 76:1965-1977. [PMID: 33092732 PMCID: PMC7572068 DOI: 10.1016/j.jacc.2020.08.066] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/20/2020] [Accepted: 08/27/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is a growing pandemic that confers augmented risk for right ventricular (RV) dysfunction and dilation; the prognostic utility of adverse RV remodeling in COVID-19 patients is uncertain. OBJECTIVES The purpose of this study was to test whether adverse RV remodeling (dysfunction/dilation) predicts COVID-19 prognosis independent of clinical and biomarker risk stratification. METHODS Consecutive COVID-19 inpatients undergoing clinical transthoracic echocardiography at 3 New York City hospitals were studied; images were analyzed by a central core laboratory blinded to clinical and biomarker data. RESULTS In total, 510 patients (age 64 ± 14 years, 66% men) were studied; RV dilation and dysfunction were present in 35% and 15%, respectively. RV dysfunction increased stepwise in relation to RV chamber size (p = 0.007). During inpatient follow-up (median 20 days), 77% of patients had a study-related endpoint (death 32%, discharge 45%). RV dysfunction (hazard ratio [HR]: 2.57; 95% confidence interval [CI]: 1.49 to 4.43; p = 0.001) and dilation (HR: 1.43; 95% CI: 1.05 to 1.96; p = 0.02) each independently conferred mortality risk. Patients without adverse RV remodeling were more likely to survive to hospital discharge (HR: 1.39; 95% CI: 1.01 to 1.90; p = 0.041). RV indices provided additional risk stratification beyond biomarker strata; risk for death was greatest among patients with adverse RV remodeling and positive biomarkers and was lesser among patients with isolated biomarker elevations (p ≤ 0.001). In multivariate analysis, adverse RV remodeling conferred a >2-fold increase in mortality risk, which remained significant (p < 0.01) when controlling for age and biomarker elevations; the predictive value of adverse RV remodeling was similar irrespective of whether analyses were performed using troponin, D-dimer, or ferritin. CONCLUSIONS Adverse RV remodeling predicts mortality in COVID-19 independent of standard clinical and biomarker-based assessment.
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Affiliation(s)
- Jiwon Kim
- Division of Cardiology, Weill Cornell Medicine, New York, New York; Department of Radiology, Weill Cornell Medicine, New York, New York.
| | | | - Razia Sultana
- Division of Cardiology, Weill Cornell Medicine, New York, New York
| | | | - Brian Yum
- Division of Cardiology, Weill Cornell Medicine, New York, New York
| | - Lakshmi Nambiar
- Division of Cardiology, Weill Cornell Medicine, New York, New York
| | - Romina Tafreshi
- Division of Cardiology, Weill Cornell Medicine, New York, New York
| | - Hannah W Mitlak
- Division of Cardiology, Weill Cornell Medicine, New York, New York
| | - Arindam RoyChoudhury
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
| | - Evelyn M Horn
- Division of Cardiology, Weill Cornell Medicine, New York, New York
| | - Ingrid Hriljac
- Division of Cardiology, Weill Cornell Medicine, New York, New York
| | - Nupoor Narula
- Division of Cardiology, Weill Cornell Medicine, New York, New York
| | - Sijun Kim
- New York Presbyterian Hospital-Queens, Queens, New York
| | | | - Parag Goyal
- Division of Cardiology, Weill Cornell Medicine, New York, New York; General Internal Medicine, Weill Cornell Medicine, New York, New York
| | - Monika M Safford
- General Internal Medicine, Weill Cornell Medicine, New York, New York
| | - Leslee Shaw
- Department of Radiology, Weill Cornell Medicine, New York, New York
| | | | - Jonathan W Weinsaft
- Division of Cardiology, Weill Cornell Medicine, New York, New York; Department of Radiology, Weill Cornell Medicine, New York, New York
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12
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Cherneva RV, Denchev SV, Cherneva ZV. Cardio-pulmonary-exercise testing, stress-induced right ventricular diastolic dysfunction and exercise capacity in non-severe chronic obstructive pulmonary disease. Pulmonology 2020; 27:194-207. [PMID: 32943349 DOI: 10.1016/j.pulmoe.2020.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 04/28/2020] [Accepted: 06/08/2020] [Indexed: 11/18/2022] Open
Affiliation(s)
| | | | - Zheina Vlaeva Cherneva
- Medical Institute of the Ministry of Internal Affairs, Clinic of Cardiology, Sofia, Bulgaria.
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13
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Palumbo MC, Rong LQ, Kim J, Navid P, Sultana R, Butcher J, Redaelli A, Roman MJ, Devereux RB, Girardi LN, Gaudino MFL, Weinsaft JW. Prosthetic aortic graft replacement of the ascending thoracic aorta alters biomechanics of the native descending aorta as assessed by transthoracic echocardiography. PLoS One 2020; 15:e0230208. [PMID: 32163486 PMCID: PMC7067394 DOI: 10.1371/journal.pone.0230208] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 02/24/2020] [Indexed: 01/16/2023] Open
Abstract
Introduction In patients with ascending aortic (AA) aneurysms, prosthetic graft replacement yields benefit but risk for complications in the descending aorta persists. Longitudinal impact of AA grafts on native descending aortic physiology is poorly understood. Methods Transthoracic echocardiograms (echo) in patients undergoing AA elective surgical grafting were analyzed: Descending aortic deformation indices included global circumferential strain (GCS), time to peak (TTP) strain, and fractional area change (FAC). Computed tomography (CT) was used to assess aortic wall thickness and calcification. Results 46 patients undergoing AA grafting were studied; 65% had congenital or genetically-associated AA (30% bicuspid valve, 22% Marfan, 13% other): After grafting (6.4±7.5 months), native descending aortic distension increased, irrespective of whether assessed based on circumferential strain or area-based methods (both p<0.001). Increased distensibility paralleled altered kinetics, as evidenced by decreased time to peak strain (p = 0.01) and increased velocity (p = 0.002). Augmented distensibility and flow velocity occurred despite similar pre- and post-graft blood pressure and medications (all p = NS), and was independent of pre-surgical aortic regurgitation or change in left ventricular stroke volume (both p = NS). Magnitude of change in GCS and FAC was 5–10 fold greater among patients with congenital or genetically associated AA vs. degenerative AA (p<0.001), paralleling larger descending aortic size, greater wall thickness, and higher prevalence of calcific atherosclerotic plaque in the degenerative group (all p<0.05). In multivariate analysis, congenital/genetically associated AA etiology conferred a 4-fold increment in magnitude of augmented native descending aortic strain after proximal grafting (B = 4.19 [CI 1.6, 6.8]; p = 0.002) independent of age and descending aortic size. Conclusions Prosthetic graft replacement of the ascending aorta increases magnitude and rapidity of distal aortic distension. Graft effects are greatest with congenital or genetically associated AA, providing a potential mechanism for increased energy transmission to the native descending aorta and adverse post-surgical aortic remodeling.
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Affiliation(s)
- Maria C. Palumbo
- Departments of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, United States of America
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Lisa Q. Rong
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, United States of America
| | - Jiwon Kim
- Department of Medicine (Cardiology), Weill Cornell Medicine, New York, New York, United States of America
| | - Pedram Navid
- Department of Medicine (Cardiology), Weill Cornell Medicine, New York, New York, United States of America
| | - Razia Sultana
- Department of Medicine (Cardiology), Weill Cornell Medicine, New York, New York, United States of America
| | - Jonathan Butcher
- Department of Biomedical Engineering, Cornell University, Ithaca, New York, United States of America
| | - Alberto Redaelli
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Mary J. Roman
- Department of Medicine (Cardiology), Weill Cornell Medicine, New York, New York, United States of America
| | - Richard B. Devereux
- Department of Medicine (Cardiology), Weill Cornell Medicine, New York, New York, United States of America
| | - Leonard N. Girardi
- Departments of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, United States of America
| | - Mario F. L. Gaudino
- Departments of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, United States of America
| | - Jonathan W. Weinsaft
- Department of Medicine (Cardiology), Weill Cornell Medicine, New York, New York, United States of America
- * E-mail:
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14
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Kim J, Palumbo MC, Khalique OK, Rong LQ, Sultana R, Das M, Jantz J, Nagata Y, Devereux RB, Wong SC, Bergman GW, Levine RA, Ratcliffe MB, Weinsaft JW. Transcatheter MitraClip repair alters mitral annular geometry - device induced annular remodeling on three-dimensional echocardiography predicts therapeutic response. Cardiovasc Ultrasound 2019; 17:31. [PMID: 31878931 PMCID: PMC6933704 DOI: 10.1186/s12947-019-0181-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 12/11/2019] [Indexed: 01/05/2023] Open
Abstract
Background Echocardiography (echo) is widely used to guide therapeutic decision-making for patients being considered for MitraClip. Relative utility of two- (2D) and three-dimensional (3D) echo predictors of MitraClip response, and impact of MitraClip on mitral annular geometry, are uncertain. Methods The study population comprised patients with advanced (> moderate) MR undergoing MitraClip. Mitral annular geometry was quantified on pre-procedural 2D transthoracic echocardiography (TTE) and intra-procedural 3D transesophageal echocardiography (TEE); 3D TEE was used to measure MitraClip induced changes in annular geometry. Optimal MitraClip response was defined as ≤mild MR on follow-up (mean 2.7 ± 2.5 months) post-procedure TTE. Results Eighty patients with advanced MR underwent MitraClip; 41% had optimal response (≤mild MR). Responders had smaller pre-procedural global left ventricular (LV) end-diastolic size and mitral annular diameter on 2D TTE (both p ≤ 0.01), paralleling smaller annular area and circumference on 3D TEE (both p = 0.001). Mitral annular size yielded good diagnostic performance for optimal MitraClip response (AUC 0.72, p < 0.01). In multivariate analysis, sub-optimal MitraClip response was independently associated with larger pre-procedural mitral annular area on 3D TEE (OR 1.93 per cm2/m2 [CI 1.19–3.13], p = 0.007) and global LV end-diastolic volume on 2D TTE (OR 1.29 per 10 ml/m2 [CI 1.02–1.63], p = 0.03). Substitution of 2D TTE derived mitral annular diameter for 3D TEE data demonstrated a lesser association between pre-procedural annular size (OR 5.36 per cm/m2 [CI 0.95–30.19], p = 0.06) and sub-optimal MitraClip response. Matched pre- and post-procedural TEE analyses demonstrated MitraClip to acutely decrease mitral annular area and circumference (all p < 0.001) as well as mitral tenting height, area, and volume (all p < 0.05): Magnitude of MitraClip induced reductions in mitral annular circumference on intra-procedural 3D TEE was greater among patients with, compared to those without, sub-optimal MitraClip response (>mild MR) on followup TTE (p = 0.017); greater magnitude of device-induced annular reduction remained associated with sub-optimal MitraClip response even when normalized for pre-procedure annular circumference (p = 0.028). Conclusions MitraClip alters mitral annular geometry as quantified by intra-procedural 3D TEE. Pre-procedural mitral annular dilation and magnitude of device-induced reduction in mitral annular size on 3D TEE are each associated with sub-optimal therapeutic response to MitraClip.
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Affiliation(s)
- Jiwon Kim
- Department of Medicine (Cardiology), Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10021, USA.
| | - Maria Chiara Palumbo
- Department of Medicine (Cardiology), Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10021, USA.,Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Omar K Khalique
- Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Lisa Q Rong
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Razia Sultana
- Department of Medicine (Cardiology), Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10021, USA
| | - Mukund Das
- Department of Medicine (Cardiology), Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10021, USA
| | - Jennifer Jantz
- Department of Medicine (Cardiology), Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10021, USA
| | - Yasfumi Nagata
- Division of Cardiology -Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard B Devereux
- Department of Medicine (Cardiology), Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10021, USA
| | - Shing Chiu Wong
- Department of Medicine (Cardiology), Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10021, USA
| | - Geoffrey W Bergman
- Department of Medicine (Cardiology), Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10021, USA
| | - Robert A Levine
- Division of Cardiology -Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mark B Ratcliffe
- Department of Bioengineering, University of California, San Francisco, USA.,Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Jonathan W Weinsaft
- Department of Medicine (Cardiology), Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10021, USA
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15
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Abstract
Objective: It is well known that the altitude may affect the cardiovascular system. However, there were a few data related to the effect of altitude on the adverse outcome in patients with heart failure with reduced ejection fraction (HFREF). The aim of the present study was to investigate the role of intermediate high altitude on the major adverse cardiovascular outcome in patients with HFREF. Methods: Patients with HFREF admitted to the outpatient clinics at the first center at sea level and the second center at 1890 m were prospectively enrolled in the study. HFREF was defined as symptoms/signs of heart failure and left ventricular ejection fraction <40%. The major adverse cardiac outcome (MACE) was defined as all-cause death, stroke, and re-hospitalization due to heart failure. The median follow-up period of the study population was 27 months. Results: The study included 320 (58.55% male, mean age 65.7±11.2 years) patients. The incidence of all-cause death was 8.5%, stroke 6.1%, re-hospitalization due to decompensated heart failure 34.3%, and MACE 48.9%. In Kaplan-Meier analysis, patients with HFREF living at high altitude had more MACE (71.1% vs. 25.3%, log rank p=0.005) and presented with more stroke (11.3% vs. 2.1%, log rank p=0.001) and re-hospitalization due to heart failure (65.1% vs. 20.1%, log rank p<0.001) rates than those at low altitude in the follow-up; however, the rate of all-cause death was similar (9.4% vs. 8.1%, log rank p=0.245). Conclusion: In the present study, we demonstrated that the intermediate high altitude is the independent predictor of MACE in patients with HFREF. High altitude may be considered as a risk factor in decompensating heart failure.
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16
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Assessing Right Ventricular Function in the Perioperative Setting, Part I: Echo-Based Measurements. Anesthesiol Clin 2019; 37:675-695. [PMID: 31677685 DOI: 10.1016/j.anclin.2019.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This article reviews transesophageal echocardiography-based assessment of perioperative right ventricular function and failure, including catheter-based methods, three-dimensional echocardiography, and their combination to make pressure-volume loops. It outlines right ventricular pathophysiology, multiple assessment methods, and their relationship to analogous transthoracic echocardiogram measurements. technologies used and developed for transthoracic or left ventricular assessment show significant limitations when applied to transesophageal assessment of the right ventricle. The article provides an overview of right ventricular assessment modalities that can be used in transesophageal echocardiography. Ultimately, clinicians must know limitations of measurements, synthesize information, and assess it in the clinical context.
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17
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Rong LQ, Rahouma M, Neuburger PJ, Arguelles G, Emerson J, Mauer E, Tam C, Shore-Lesserson L, Pryor KO, Gaudino M. Use of Pulmonary Artery Pulsatility Index in Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 34:1220-1225. [PMID: 31653496 DOI: 10.1053/j.jvca.2019.09.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/16/2019] [Accepted: 09/18/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE This study evaluated whether the pulmonary artery pulsatility index (PAPi) collected before and after cardiopulmonary bypass (CPB) is predictive and diagnostic of new onset right ventricular (RV) failure in the elective cardiac surgical population. DESIGN This was a prospective observational study of patients who underwent cardiac surgery between 2017 and 2019. SETTING Weill Cornell Medicine, a single large academic medical center. PARTICIPANTS The study comprised 119 patients undergoing elective cardiac surgery. INTERVENTIONS Cardiopulmonary bypass, transesophageal echocardiography, pulmonary artery catheter, and elective cardiac surgery. MEASUREMENTS AND MAIN RESULTS Echocardiographic and hemodynamic data were collected at 2 time points: pre-CPB and post-chest closure/post-CPB. Patients with and without post-CPB RV dysfunction fractional area of change (<35%) were compared, and receiver operating characteristic curves were constructed. One hundred and nineteen patients undergoing elective surgery-coronary artery bypass grafting (23%), aortic valve replacement (21%), aortic surgery (19%), and combined surgery (37%)-were evaluated. Post-CPB RV dysfunction was associated with lower pre-CPB PAPi values (2.0 ± 1.0 v 2.5 ± 1.2; p = 0.001 and p = 0.03) and higher pre-CPB central venous pressure (8.3 ± 3.6 and 6.9 ± 2.7; p = 0.003 and p = 0.02, respectively). Pre-CPB PAPi (0.98 [95% confidence interval {CI} 0.96-0.99]), end systolic area (0.99 [95% CI 0.98-0.99]), and end diastolic area (1.01 [95% CI 1.001-1.02]) were independently associated with RV dysfunction in multivariable modeling, with a lower PAPi and end systolic area and higher end diastolic area demonstrating a greater risk of RV dysfunction post-CPB (post-CPB area under the curve for PAPi 0.80 [95% CI 0.71-0.88; sensitivity = 0.68, specificity = 0.93, optimal cutoff = 1.9]). CONCLUSIONS PAPi measured pre-CPB is a potential predictor and marker of post-CPB RV dysfunction and may have diagnostic utility in cardiac surgery. Additional, large-scale studies are needed to confirm this finding.
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Affiliation(s)
- Lisa Q Rong
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY.
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Peter J Neuburger
- Department of Anesthesiology, New York University Hospital, New York, NY
| | | | | | - Elizabeth Mauer
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY
| | - Christopher Tam
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | | | - Kane O Pryor
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
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18
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Incremental Utility of Right Ventricular Dysfunction in Patients With Myeloproliferative Neoplasm-Associated Pulmonary Hypertension. J Am Soc Echocardiogr 2019; 32:1574-1585. [PMID: 31587969 DOI: 10.1016/j.echo.2019.07.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 07/09/2019] [Accepted: 07/10/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Myeloproliferative neoplasm (MPN) has been associated with pulmonary hypertension (PH) on the basis of small observational studies, but the mechanism and clinical significance of PH in MPN are not well established. The aims of this study were to expand understanding of PH in a well-characterized MPN cohort via study of PH-related symptoms, mortality risk, and cardiac remodeling sequalae of PH using quantitative echocardiographic methods. METHODS The population comprised a retrospective cohort of patients with MPN who underwent transthoracic echocardiography: Doppler-derived pulmonary arterial systolic pressure applied established cutoffs for PH (≥35 mm Hg) and advanced PH (≥50 mm Hg); right ventricular (RV) performance was assessed via conventional indices (tricuspid annular plane systolic excursion [TAPSE], S') and global longitudinal strain. Symptoms and mortality were discerned via standardized review. RESULTS Three hundred one patients were studied; 56% had echocardiography-demonstrated PH (20% advanced) paralleling a high prevalence (67%) among patients with invasively quantified PASP. PH was associated with adverse left ventricular (LV) remodeling indices, including increased myocardial mass and diastolic dysfunction (P ≤ .001 for all): LV mass and filling pressure (P < .01) were associated with PH independent of LV ejection fraction. RV dysfunction by strain and TAPSE and S' increased in relation to PH (P ≤ .001) and was about threefold greater among patients with advanced PH compared with those without PH. Patients with RV dysfunction were more likely to report dyspnea, as were those with advanced PH (P < .05). During median follow-up of 2.2 years, all-cause mortality was 27%. PH grade (hazard ratio, 1.9; 95% CI, 1.1-3.0; P = .012) and TAPSE- and S'-demonstrated RV dysfunction (hazard ratio, 3.3; 95% CI, 1.3-8.2; P = .01) were independently associated with mortality; substitution of global longitudinal strain for TAPSE and S' yielded similar associations of RV dysfunction with death (hazard ratio, 3.2; 95% CI, 1.5-6.7; P = .003) independent of PH. CONCLUSIONS PH is highly prevalent in patients with MPN and is linked to LV diastolic dysfunction; echocardiography-quantified RV dysfunction augments risk for mortality independent of PH.
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Rong LQ, Neuburger PJ, De Paulis S, Kim J. Thinking Outside the Heart: An Innovative Approach of Speckle Tracking With Transesophageal Echocardiography. J Cardiothorac Vasc Anesth 2019; 33:2645-2646. [DOI: 10.1053/j.jvca.2019.07.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 07/22/2019] [Accepted: 07/24/2019] [Indexed: 11/11/2022]
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20
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Rong LQ, Yum B, Abouzeid C, Palumbo MC, Brouwer LR, Devereux RB, Girardi LN, Weinsaft JW, Gaudino M, Kim J. Echocardiographic predictors of intraoperative right ventricular dysfunction: a 2D and speckle tracking echocardiography study. Cardiovasc Ultrasound 2019; 17:11. [PMID: 31174537 PMCID: PMC6556018 DOI: 10.1186/s12947-019-0161-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 05/29/2019] [Indexed: 11/16/2022] Open
Abstract
Background Intraoperative or post procedure right ventricular (RV) dysfunction confers a poor prognosis in the post-operative period. Conventional predictors for RV function are limited due the effect of cardiac surgery on traditional RV indices; novel echocardiographic techniques hold the promise to improve RV functional stratification. Methods Comprehensive echocardiographic data were collected prospectively during elective cardiac surgery. Tricuspid annular plane systolic excursion (TAPSE), peak RV systolic velocity (S′), and RV fractional area change (FAC) were quantified on transesophageal echo (TEE). RV global and regional (septal and free wall) longitudinal strain was quantified using speckle-tracking echo in RV-focused views. Two intraoperative time points were used for comparison: pre-sternotomy (baseline) and after chest closure. Results The population was comprised of 53 patients undergoing cardiac surgery [15.1% coronary artery bypass graft (CABG) only, 28.3% valve only, 50.9% combination (e.g. valve/CABG, valve/aortic graft) surgeries], among whom 38% had impaired RV function at baseline defined as RV FAC < 35%. All conventional RV functional indices including TAPSE, S′ and FAC declined immediately following CPB (1.5 ± 0.3 vs.1.1 ± 0.3 cm, 8.0 ± 2.1 vs. 6.2 ± 2.5 cm/s, 36.8 ± 9.3 vs. 29.3 ± 10.6%; p < 0.001 for all). However, left ventricular (LV) and RV hemodynamic parameters remained unchanged (LV ejection fraction (EF): 56.8 ± 13.0 vs. 55.8 ± 12.9%; p = 0.40, pulmonary artery systolic pressure (PASP): 26.5 ± 7.4 vs 27.3 ± 6.7 mmHg; p = 0.13). Speckle tracking echocardiographic data demonstrated a significant decline in RV global longitudinal strain (GLS) [19.0 ± 6.5 vs. 13.5 ± 6.9%, p < 0.001]. Pre-procedure FAC, GLS and free wall strain predicted RV dysfunction at chest closure (34.7 ± 9.1 vs. 41.6 ± 8.1%, p = 0.01, 17.7 ± 6.5 vs. 21.8 ± 5.4%; p = 0.03, 20.3 ± 6.4 vs. 24.2 ± 5.8%; p = 0.04), whereas traditional linear RV indices such as TAPSE and RV S′ at baseline had no impact on intraoperative RV dysfunction (p = NS for both). Conclusions Global and regional RV function, as measured by 2D indices and strain, acutely decline intraoperatively. Impaired RV strain is associated with intraoperative RV functional decline and provides incremental value to traditional RV indices in predicting those who will develop RV dysfunction.
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Affiliation(s)
- Lisa Q Rong
- Department of Anesthesiology, Weill Cornell Medicine/New York Presbyterian, New York, NY, USA
| | - Brian Yum
- Department of Medicine/Cardiology Division, Weill Cornell Medical College, 525 East 68th Street, New York, NY, 10021, USA
| | - Christiane Abouzeid
- Department of Medicine/Cardiology Division, Weill Cornell Medical College, 525 East 68th Street, New York, NY, 10021, USA
| | - Maria Chiara Palumbo
- Department of Medicine/Cardiology Division, Weill Cornell Medical College, 525 East 68th Street, New York, NY, 10021, USA
| | - Lillian R Brouwer
- Department of Medicine/Cardiology Division, Weill Cornell Medical College, 525 East 68th Street, New York, NY, 10021, USA
| | - Richard B Devereux
- Department of Medicine/Cardiology Division, Weill Cornell Medical College, 525 East 68th Street, New York, NY, 10021, USA
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine/New York Presbyterian, New York, NY, USA
| | - Jonathan W Weinsaft
- Department of Medicine/Cardiology Division, Weill Cornell Medical College, 525 East 68th Street, New York, NY, 10021, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine/New York Presbyterian, New York, NY, USA
| | - Jiwon Kim
- Department of Medicine/Cardiology Division, Weill Cornell Medical College, 525 East 68th Street, New York, NY, 10021, USA.
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Kim J, Alakbarli J, Palumbo MC, Xie LX, Rong LQ, Tehrani NH, Brouwer LR, Devereux RB, Wong SC, Bergman GW, Khalique OK, Levine RA, Ratcliffe MB, Weinsaft JW. Left ventricular geometry predicts optimal response to percutaneous mitral repair via MitraClip: Integrated assessment by two- and three-dimensional echocardiography. Catheter Cardiovasc Interv 2019; 93:1152-1160. [PMID: 30790417 PMCID: PMC6537596 DOI: 10.1002/ccd.28147] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 01/28/2019] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To assess impact of left ventricular (LV) chamber remodeling on MitraClip (MClp) response. BACKGROUND MitraClip is the sole percutaneous therapy approved for mitral regurgitation (MR) but response varies. LV dilation affects mitral coaptation; determinants of MClp response are uncertain. METHODS LV and mitral geometry were quantified on pre- and post-procedure two-dimensional (2D) transthoracic echocardiography (TTE) and intra-procedural three-dimensional (3D) transesophageal echocardiography (TEE). Optimal MClp response was defined as ≤mild MR at early (1-6 month) follow-up. RESULTS Sixty-seven degenerative MR patients underwent MClp: Whereas MR decreased ≥1 grade in 94%, 39% of patients had optimal response (≤mild MR). Responders had smaller pre-procedural LV end-diastolic volume (94 ± 24 vs. 109 ± 25 mL/m2 , p = 0.02), paralleling smaller annular diameter (3.1 ± 0.4 vs. 3.5 ± 0.5 cm, p = 0.002), and inter-papillary distance (2.2 ± 0.7 vs. 2.5 ± 0.6 cm, p = 0.04). 3D TEE-derived annular area correlated with 2D TTE (r = 0.59, p < 0.001) and was smaller among optimal responders (12.8 ± 2.1 cm2 vs. 16.8 ± 4.4 cm2 , p = 0.001). Both 2D and 3D mitral annular size yielded good diagnostic performance for optimal MClp response (AUC 0.73-0.84, p < 0.01). In multivariate analysis, sub-optimal MClp response was associated with LV end-diastolic diameter (OR 3.10 per-cm [1.26-7.62], p = 0.01) independent of LA size (1.10 per-cm2 [1.02-1.19], p = 0.01); substitution of mitral annular diameter for LV size yielded an independent association with MClp response (4.06 per-cm2 [1.03-15.96], p = 0.045). CONCLUSIONS Among degenerative MR patients undergoing MClp, LV and mitral annular dilation augment risk for residual or recurrent MR, supporting the concept that MClp therapeutic response is linked to sub-valvular remodeling.
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Affiliation(s)
- Jiwon Kim
- Greenberg Cardiology Division, Weill Cornell Medicine (New York, New York)
| | - Javid Alakbarli
- Greenberg Cardiology Division, Weill Cornell Medicine (New York, New York)
| | | | - Lola X. Xie
- Division of Cardiology, Memorial Sloan Kettering Cancer Center (New York, New York)
| | - Lisa Q. Rong
- Greenberg Cardiology Division, Weill Cornell Medicine (New York, New York)
| | - Nathan H. Tehrani
- Greenberg Cardiology Division, Weill Cornell Medicine (New York, New York)
| | - Lillian R. Brouwer
- Greenberg Cardiology Division, Weill Cornell Medicine (New York, New York)
| | | | - Shing Chiu Wong
- Greenberg Cardiology Division, Weill Cornell Medicine (New York, New York)
| | | | - Omar K. Khalique
- Division of Cardiology, Columbia University Medical Center (New York, New York)
| | - Robert A. Levine
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School (Boston, MA)
| | - Mark B. Ratcliffe
- Department of Bioengineering, University of California, San Francisco, Veterans Affairs Medical Center (San Francisco, CA)
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Kim J, Alakbarli J, Yum B, Tehrani NH, Pollie MP, Abouzeid C, Di Franco A, Ratcliffe MB, Poppas A, Levine RA, Devereux RB, Weinsaft JW. Tissue-based markers of right ventricular dysfunction in ischemic mitral regurgitation assessed via stress cardiac magnetic resonance and three-dimensional echocardiography. Int J Cardiovasc Imaging 2019; 35:683-693. [PMID: 30460581 PMCID: PMC6510229 DOI: 10.1007/s10554-018-1500-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 11/13/2018] [Indexed: 01/19/2023]
Abstract
Ischemic mitral regurgitation (iMR) augments risk for right ventricular dysfunction (RVDYS). Right and left ventricular (LV) function are linked via common coronary perfusion, but data is lacking regarding impact of LV ischemia and infarct transmurality-as well as altered preload and afterload-on RV performance. In this prospective multimodality imaging study, stress CMR and 3-dimensional echo (3D-echo) were performed concomitantly in patients with iMR. CMR provided a reference for RVDYS (RVEF < 50%), as well as LV function/remodeling, ischemia and infarction. Echo was used to test multiple RV performance indices, including linear (TAPSE, S'), strain (GLS), and volumetric (3D-echo) approaches. 90 iMR patients were studied; 32% had RVDYS. RVDYS patients had greater iMR, lower LVEF, larger global ischemic burden and inferior infarct size (all p < 0.05). Regarding injury pattern, RVDYS was associated with LV inferior ischemia and infarction (both p < 0.05); 80% of affected patients had substantial viable myocardium (< 50% infarct thickness) in ischemic inferior segments. Regarding RV function, CMR RVEF similarly correlated with 3D-echo and GLS (r = 0.81-0.87): GLS yielded high overall performance for CMR-evidenced RVDYS (AUC: 0.94), nearly equivalent to that of 3D-echo (AUC: 0.95). In multivariable regression, GLS was independently associated with RV volumetric dilation on CMR (OR - 0.90 [CI - 1.19 to - 0.61], p < 0.001) and 3D echo (OR - 0.43 [CI - 0.84 to - 0.02], p = 0.04). Among patients with iMR, RVDYS is associated with potentially reversible processes, including LV inferior ischemic but predominantly viable myocardium and strongly impacted by volumetric loading conditions.
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Affiliation(s)
- Jiwon Kim
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, 525 East 68th Street, New York, NY, 10021, USA.
| | - Javid Alakbarli
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, 525 East 68th Street, New York, NY, 10021, USA
| | - Brian Yum
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, 525 East 68th Street, New York, NY, 10021, USA
| | - Nathan H Tehrani
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, 525 East 68th Street, New York, NY, 10021, USA
| | - Meridith P Pollie
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, 525 East 68th Street, New York, NY, 10021, USA
| | - Christiane Abouzeid
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, 525 East 68th Street, New York, NY, 10021, USA
| | - Antonino Di Franco
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, 525 East 68th Street, New York, NY, 10021, USA
| | - Mark B Ratcliffe
- Division of Cardiology, Department of Surgery, University of California, San Francisco, Veterans Affairs Medical Center, San Francisco, CA, USA
- Department of Bioengineering, University of California, San Francisco, Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Athena Poppas
- Lifespan Cardiovascular Institute, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Robert A Levine
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard B Devereux
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, 525 East 68th Street, New York, NY, 10021, USA
| | - Jonathan W Weinsaft
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, 525 East 68th Street, New York, NY, 10021, USA
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Zhou X, Ferrara F, Contaldi C, Bossone E. Right Ventricular Size and Function in Chronic Heart Failure. Heart Fail Clin 2019; 15:205-217. [DOI: 10.1016/j.hfc.2018.12.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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24
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Kampaktsis PN, Albert BJ, Kim J, Xie LX, Brouwer LR, Tehrani NH, Villanueva M, Choi DY, Szulc M, Ratcliffe MB, Levine RA, Devereux R, Weinsaft JW. Impact of Mitral Regurgitation Severity and Cause on Effort Tolerance-Integrated Stress Myocardial Perfusion Imaging and Echocardiographic Assessment of Patients With Known or Suspected Coronary Artery Disease Undergoing Exercise Treadmill Testing. J Am Heart Assoc 2019; 8:e010974. [PMID: 30808228 PMCID: PMC6474934 DOI: 10.1161/jaha.118.010974] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 01/30/2019] [Indexed: 01/19/2023]
Abstract
Background Mitral regurgitation ( MR ) has the potential to impede exercise capacity; it is uncertain whether this is because of regurgitation itself or the underlying cause of valvular insufficiency. Methods and Results The population comprised 3267 patients who underwent exercise treadmill myocardial perfusion imaging and transthoracic echocardiography within 6±8 days. MR was present in 28%, including 176 patients (5%) with moderate or greater MR . Left ventricular systolic function significantly decreased and chamber size increased in relation to MR , paralleling increments in stress and rest myocardial perfusion deficits (all P<0.001). Exercise tolerance (metabolic equivalents of task) decreased stepwise in relation to graded MR severity ( P<0.05). Workload was significantly lower with mild versus no MR (mean±SD, 9.8±3.0 versus 10.1±3.0; P=0.02); magnitude of workload reduction significantly increased among patients with advanced versus those with mild MR (mean±SD, 8.6±3.0 versus 9.8±3.0; P<0.001). MR -associated exercise impairment was accompanied by lower heart rate and blood pressure augmentation and greater dyspnea (all P<0.05). Both functional and nonfunctional MR subgroups demonstrated significantly decreased effort tolerance in relation to MR severity ( P≤0.01); impairment was greater with functional MR ( P=0.04) corresponding to more advanced left ventricular dysfunction and dilation (both P<0.001). Functional MR predicted reduced metabolic equivalent of task-based effort (B=-0.39 [95% CI, -0.62 to -0.17]; P=0.001) independent of MR severity. Among the overall cohort, advanced (moderate or greater) MR was associated with reduced effort tolerance (B=-1.36 [95% CI, -1.80 to -0.93]; P<0.001) and remained significant ( P=0.01) after controlling for age, clinical indexes, stress perfusion defects, and left ventricular dysfunction. Conclusions MR impairs exercise tolerance independent of left ventricular ischemia, dysfunction, and clinical indexes. Magnitude of exercise impairment parallels severity of MR .
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Affiliation(s)
| | | | - Jiwon Kim
- Department of MedicineWeill Cornell Medical CollegeNew YorkNY
- Department of Medicine and RadiologyWeill Cornell Medical CollegeNew YorkNY
| | - Lola X. Xie
- Memorial Sloan Kettering Cancer CenterNew YorkNY
| | | | | | | | - Daniel Y. Choi
- Department of MedicineWeill Cornell Medical CollegeNew YorkNY
| | | | - Mark B. Ratcliffe
- Veterans Affairs Medical CenterUniversity of CaliforniaSan FranciscoCA
| | | | | | - Jonathan W. Weinsaft
- Department of MedicineWeill Cornell Medical CollegeNew YorkNY
- Department of Medicine and RadiologyWeill Cornell Medical CollegeNew YorkNY
- Memorial Sloan Kettering Cancer CenterNew YorkNY
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Farag AA, Heo J, Tauxe L, Bhambhvani P, Germano G, Kavanagh P, Iskandrian AE, Hage FG. Detection and quantitation of right ventricular reversible perfusion defects by stress SPECT myocardial perfusion imaging: A proof-of-principle study. J Nucl Cardiol 2019; 26:266-271. [PMID: 28685253 DOI: 10.1007/s12350-017-0954-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Accepted: 05/23/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND In patients with right dominant coronary circulation, the right ventricular (RV) myocardium and the inferior region of the left ventricular (LV) myocardium share a common source of blood flow. We hypothesized that stress/rest SPECT myocardial perfusion imaging (MPI) could detect reversible perfusion defects in the RV in some patients with LV inferior wall perfusion abnormalities. MATERIAL AND METHODS We identified 2 groups of patients with LV inferior wall perfusion defects (with or without defects in other regions of LV myocardium) from our database. Patients in group 1 (n = 17) had reversible perfusion defects in the RV free wall by visual analysis, while patients in group 2 (n = 17) did not. The images were processed with filtered back projection and, separately, with iterative reconstruction. The images were then re-processed using an automated quantitative software that is specifically designed to include the RV in the region of interest. RESULTS There were 76% men in group 1 and 94% in group 2 (P <0.05). The mean age was 65±20 in group 1 vs. 63±18 years in group 2 (P < 0.05). The stress type was exercise in 30% in group 1 and 35% in group 2, with the remaining patients studied with pharmacological stress testing (P = NS). The presence of RV reversible perfusion defects using filtered back projection was more evident in 13 patients (75%), while it was better seen with iterative reconstruction in 4 patients (25%). By automated analysis, the RV reversible perfusion defect size was 19 ± 14% of RV myocardium. CONCLUSION This proof-of-principle study demonstrates that reversible RV perfusion defects suggestive of ischemia can be detected by SPECT myocardial perfusion imaging in some patients with LV inferior ischemia by visual analysis and can be quantitated by automated programs. Further studies on the diagnostic and prognostic relevance of assessing RV ischemia on SPECT MPI are needed.
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Affiliation(s)
- Ayman A Farag
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Lyons Harrison Research building 306, 1900 University BLVD, Birmingham, AL, 35294, USA
| | - Jack Heo
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Lyons Harrison Research building 306, 1900 University BLVD, Birmingham, AL, 35294, USA
| | - Lindsey Tauxe
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Lyons Harrison Research building 306, 1900 University BLVD, Birmingham, AL, 35294, USA
| | - Pradeep Bhambhvani
- Division of Molecular Imaging and Therapeutics, Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - Ami E Iskandrian
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Lyons Harrison Research building 306, 1900 University BLVD, Birmingham, AL, 35294, USA
| | - Fadi G Hage
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Lyons Harrison Research building 306, 1900 University BLVD, Birmingham, AL, 35294, USA.
- Section of Cardiology, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA.
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Raina A, Meeran T. Right Ventricular Dysfunction and Its Contribution to Morbidity and Mortality in Left Ventricular Heart Failure. Curr Heart Fail Rep 2019; 15:94-105. [PMID: 29468529 DOI: 10.1007/s11897-018-0378-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE In patients with left-sided HF, there has been less emphasis on the pathophysiology of the RV in terms of diagnostic evaluation and treatment, versus focus on structural abnormalities of the LV. This review seeks to delineate the importance of RV dysfunction in terms of its contribution to symptomatic limitations and cardiovascular outcomes in patients with left-sided HF. RECENT FINDINGS Recent studies have demonstrated that RV dysfunction is common in both HFpEF and HFrEF, but more pronounced in HFrEF. LV dysfunction and atrial fibrillation are most commonly associated with RV dysfunction in left-sided HF. RV dysfunction may develop due to afterload-dependent and afterload-independent pathways. Regardless, RV dysfunction is strongly associated with functional limitations and worsened survival in patients with left-sided HF. In patients with HFpEF, a recent study showed that RV failure was the most common cause of overall mortality. Among LVAD patients and patients post-cardiac transplantation, RV dysfunction is also strongly associated with survival. Despite a number of previous and ongoing clinical trials that target the RV directly or decrease RV afterload in left-sided HF, there are no definitive therapies specifically targeting RV dysfunction in left-sided HF patients CONCLUSIONS: RV dysfunction is an important determinant of symptomatic limitations and cardiovascular outcomes in patients with left-sided HF. Further research is needed to developed pharmacotherapy that may target the RV specifically in left-sided HF patients.
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Affiliation(s)
- Amresh Raina
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA, USA. .,Pulmonary Hypertension Program, Section of Heart Failure/Transplant/MCS & Pulmonary Hypertension, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA, 15212-4772, USA.
| | - Talha Meeran
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA, USA
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Tajima M, Nakayama A, Uewaki R, Mahara K, Isobe M, Nagayama M. Right ventricular dysfunction is associated with exercise intolerance and poor prognosis in ischemic heart disease. Heart Vessels 2018; 34:385-392. [DOI: 10.1007/s00380-018-1253-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 08/31/2018] [Indexed: 01/19/2023]
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van Duin RWB, Houweling B, Uitterdijk A, Duncker DJ, Merkus D. Pulmonary vasodilation by phosphodiesterase 5 inhibition is enhanced and nitric oxide independent in early pulmonary hypertension after myocardial infarction. Am J Physiol Heart Circ Physiol 2017; 314:H170-H179. [PMID: 28986358 DOI: 10.1152/ajpheart.00370.2017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Myocardial infarction (MI) may result in pulmonary hypertension (PH). Inhibition of phosphodiesterase 5 (PDE5), the enzyme responsible for the breakdown of cGMP in vascular smooth muscle, has become part of the contemporary therapeutic armamentarium for pulmonary arterial hypertension and may also be beneficial for PH secondary to MI. Nitric oxide (NO) is an important activator of cGMP synthesis and can be enhanced in early PH and decreased in severe PH. In the present study, we investigated if PDE5 inhibition ameliorates pulmonary hemodynamics in swine with PH secondary to MI and whether NO is essential. The PDE5 inhibitor EMD360527 was administered in awake, chronically instrumented swine with or without MI. At rest, PDE5 inhibition produced pulmonary vasodilation as evidenced by a decrease in pulmonary vascular resistance, which was more pronounced in MI ( n = 5) compared with normal swine ( n = 10, P ≤ 0.01) and was accompanied by an increase in stroke volume in MI swine. Both pulmonary vasodilation and increased stroke volume were maintained during exercise, suggesting that this therapy may improve exercise capacity in patients with PH secondary to MI. Interestingly, prior inhibition of NO significantly enhanced ( P ≤ 0.01) pulmonary vasodilation by PDE5 inhibition in both normal ( n = 8) and MI swine ( n = 5, P ≤ 0.05 vs. normal). This suggests that the increased vasodilator responses to PDE5 inhibition after MI were not due to an increase in NO-induced cGMP production. These observations indicate that PDE5 inhibition represents an interesting pharmacotherapeutic approach in early PH after a recent MI to prevent overt PH. NEW & NOTEWORTHY This research article is the first to describe that pulmonary vasodilation to phosphodiesterase 5 inhibition is enhanced and nitric oxide independent in resting and exercising swine with pulmonary hypertension as a result of myocardial infarction. This suggests that phosphodiesterase 5 inhibition can normalize pulmonary hemodynamics in postcapillary pulmonary hypertension after a recent myocardial infarction and may improve exercise capacity.
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Affiliation(s)
- Richard W B van Duin
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research School COEUR, Erasmus MC, Rotterdam , The Netherlands
| | - Birgit Houweling
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research School COEUR, Erasmus MC, Rotterdam , The Netherlands
| | - André Uitterdijk
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research School COEUR, Erasmus MC, Rotterdam , The Netherlands
| | - Dirk J Duncker
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research School COEUR, Erasmus MC, Rotterdam , The Netherlands
| | - Daphne Merkus
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research School COEUR, Erasmus MC, Rotterdam , The Netherlands
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Di Franco A, Kim J, Rodriguez-Diego S, Khalique O, Siden JY, Goldburg SR, Mehta NK, Srinivasan A, Ratcliffe MB, Levine RA, Crea F, Devereux RB, Weinsaft JW. Multiplanar strain quantification for assessment of right ventricular dysfunction and non-ischemic fibrosis among patients with ischemic mitral regurgitation. PLoS One 2017; 12:e0185657. [PMID: 28961271 PMCID: PMC5621708 DOI: 10.1371/journal.pone.0185657] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 09/16/2017] [Indexed: 01/20/2023] Open
Abstract
Background Ischemic mitral regurgitation (iMR) predisposes to right ventricular (RV) pressure and volume overload, providing a nidus for RV dysfunction (RVDYS) and non-ischemic fibrosis (NIF). Echocardiography (echo) is widely used to assess iMR, but performance of different indices as markers of RVDYS and NIF is unknown. Methods iMR patients prospectively underwent echo and cardiac magnetic resonance (CMR) within 72 hours. Echo quantified iMR, assessed conventional RV indices (TAPSE, RV-S’, fractional area change [FAC]), and strain via speckle tracking in apical 4-chamber (global longitudinal strain [RV-GLS]) and parasternal long axis orientation (transverse strain). CMR volumetrically quantified RVEF, and assessed ischemic pattern myocardial infarction (MI) and septal NIF. Results 73 iMR patients were studied; 36% had RVDYS (EF<50%) on CMR among whom LVEF was lower, PA systolic pressure higher, and MI size larger (all p<0.05). CMR RVEF was paralleled by echo results; correlations were highest for RV-GLS (r = 0.73) and lowest for RV-S’ (r = 0.43; all p<0.001). RVDYS patients more often had CMR-evidenced NIF (54% vs. 7%; p<0.001). Whereas all RV indices were lower among NIF-affected patients (all p≤0.006), percent change was largest for transverse strain (48.3%). CMR RVEF was independently associated with RV-GLS (partial r = 0.57, p<0.001) and transverse strain (r = 0.38, p = 0.002) (R = 0.78, p<0.001). Overall diagnostic performance of RV-GLS and transverse strain were similar (AUC = 0.93[0.87–0.99]|0.91[0.84–0.99], both p<0.001), and yielded near equivalent sensitivity and specificity (85%|83% and 80%|79% respectively). Conclusion Compared to conventional echo indices, RV strain parameters yield stronger correlation with CMR-defined RVEF and potentially constitute better markers of CMR-evidenced NIF in iMR.
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Affiliation(s)
- Antonino Di Franco
- Department of Medicine, Weill Cornell Medical College, New York City, New York, United States of America
| | - Jiwon Kim
- Department of Medicine, Weill Cornell Medical College, New York City, New York, United States of America
| | - Sara Rodriguez-Diego
- Department of Medicine, Weill Cornell Medical College, New York City, New York, United States of America
| | - Omar Khalique
- Department of Medicine, Columbia University, New York, New York, United States of America
| | - Jonathan Y. Siden
- Department of Medicine, Weill Cornell Medical College, New York City, New York, United States of America
| | - Samantha R. Goldburg
- Department of Medicine, Weill Cornell Medical College, New York City, New York, United States of America
| | - Neil K. Mehta
- Department of Medicine, Weill Cornell Medical College, New York City, New York, United States of America
| | - Aparna Srinivasan
- Department of Medicine, Weill Cornell Medical College, New York City, New York, United States of America
| | - Mark B. Ratcliffe
- Department of Surgery, University of California San Francisco, San Francisco, California, United States of America
| | - Robert A. Levine
- Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Filippo Crea
- Department of Cardiology, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Richard B. Devereux
- Department of Medicine, Weill Cornell Medical College, New York City, New York, United States of America
| | - Jonathan W. Weinsaft
- Department of Medicine, Weill Cornell Medical College, New York City, New York, United States of America
- * E-mail:
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Abstract
OPINION STATEMENT Right ventricular (RV) structure and function is clinically important in a wide range of conditions. While conventional echocardiography (echo) methods are widely used, its limitations in RV assessment due its complex geometry are well recognized. New applications of traditional echo methods as well as emerging echo techniques including 3-dimensional (3D) echo and speckle tracking strain have the potential to overcome limitations of conventional echo, though widespread clinical use remains to be seen. Volumetric methods using cardiac magnetic resonance (CMR) and computed tomography (CT) provide accurate assessment of RV function without geometric assumptions. In addition, tissue characterization imaging for myocardial scar and fat using CMR and CT provides important information regarding the RV beyond structure and function alone and has clinical applications for diagnosis and prognosis in a broad range of pathologies. Limitations also exist for these two advanced modalities including availability and patient suitability for CMR and need for contrast and radiation exposure for CT. The complementary role of each modality for the RV as well as emerging evidence for the use of each imaging method in diagnosis and management of RV pathologies is outlined in this study.
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