The Predictive Value of Right Ventricular Longitudinal Strain in Pulmonary Hypertension, Heart Failure, and Valvular Diseases

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

BACKGROUND

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

HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Evaluation of Right and Left Ventricular Deformation Analysis in İdiopathic Right Bundle Branch Block by Speckle Tracking Echocardiography

BACKGROUND

Idiopathic right bundle branch block (RBBB) is often seen as harmless and common. However, many studies show it might be linked to negative health outcomes. So, it is crucial to fully understand how RBBB affects the heart's ventricles.

OBJECTIVES

This study aims to examine the right and left ventricular systolic functions in patients with idiopathic RBBB and compare them to those in a healthy control group.

MATERIAL AND METHODS

Echocardiographic images were obtained from patients with idiopathic RBBB and healthy control participants. Conventional echocardiographic parameters were measured. Two-dimensional (2D) speckle tracking strain analysis was used to assess deformation indices.

RESULTS

Thirty-nine patients with idiopathic RBBB and 35 healthy participants were included in the study. There were no significant differences in the chamber dimensions of the left ventricle (LV) and right ventricle (RV) between the groups. LV ejection fraction (EF), RV fractional area change (FAC), and tricuspid annular plane systolic excursion (TAPSE) measurements were similar between the groups. LV global longitudinal strain (GLS) (-25.5 ± 5.7% vs. -22.1 ± 4.2%, p < 0.05), RV GLS (-26.9 ± 4.6% vs. -24.0 ± 4.4%, p < 0.05), and interventricular septum longitudinal strain (IVS LS) (-24.3 ± 4.9% vs. -19.1 ± 4.2%, p < 0.05) were significantly reduced in patients with idiopathic RBBB compared to controls, indicating impaired myocardial shortening. Significant differences were also observed in LV (15 [5-30] vs. 30 [20-60], p < 0.05) and RV (18 [7-35] vs. 36 [24-80], p < 0.05) mechanical dispersion, with the differences being more pronounced for the RV between the groups. LV torsion (2.1 ± 0.6 vs. 1.6 ± 0.5, p < 0.05) was also worse in patients with idiopathic RBBB.

CONCLUSION

Our findings show that idiopathic RBBB significantly affects the longitudinal strain and synchronization of both the LV and RV.

Evaluating pulmonary stenosis and regurgitation impact on cardiac strain and strain rate in a porcine model via magnetic resonance feature tracking

BACKGROUND

Pulmonary stenosis (PS) is common in congenital heart disease and an integral finding in Tetralogy of Fallot (TOF). Pulmonary regurgitation (PR) is more commonly found following surgery in repaired TOF. We aimed to evaluate the haemodynamic effects of PS and PR on cardiac physiology in a porcine model using cardiac magnetic resonance-based feature tracking (CMR-FT) deformation imaging.

METHODS

CMR-FT was performed in 14 pigs before and 10-12 weeks after surgery. Surgery included either pulmonary artery banding to simulate PS (n = 7), or an incision to the pulmonary valve to simulate PR (n = 7). CMR-FT assessment included left and right ventricular global longitudinal (LV/RV GLS) and LV circumferential (GCS) strain and strain rates (SR) as well as left and right atrial reservoir/conduit/booster pump (LA/RA Es, Ee, Ea) strain and SR.

RESULTS

RV GLS was significantly reduced following PS compared to PR induction (PS -7.51 vs. PR -23.84, p < 0.001). RV GLS improved after induction of PR (before - 20.50 vs. after - 23.84, p = 0.018) as opposed to PS (before - 11.73 vs. after - 7.51, p = 0.128). Similarly, RA Es (PS 14.22 vs. PR 27.34, p = 0.017) and Ee (PS 8.65 vs. PR 20.51, p = 0.004) were decreased in PS compared to PR with detrimental impact of PS (Es before 23.20 vs. after 14.22, p = 0.018, Ee before 15.04 vs. after 8.65, p = 0.028) but not PR (Es before 31.65 vs. after 27.34, p = 0.176, Ee before 20.63 vs. after 20.51, p = 0.499).

CONCLUSIONS

In a porcine model of RV pressure vs. volume overload, increased after- but not preload shows detrimental impact on RV and RA physiology.

Glycoprotein 130 Antagonism Counteracts Metabolic and Inflammatory Alterations to Enhance Right Ventricle Function in Pulmonary Artery Banded Pigs

Background

Right ventricular dysfunction (RVD) is a risk factor for death in multiple cardiovascular diseases, but RV-enhancing therapies are lacking. Inhibition of glycoprotein-130 (GP130) signaling with the small molecule SC144 improves RV function in rodent RVD via anti-inflammatory and metabolic mechanisms. However, SC144's efficacy and molecular effects in a translational large animal model of RVD are unknown.

Methods

4-week-old castrated male pigs underwent pulmonary artery banding (PAB). After 3 weeks, PAB pigs were randomized into 2 groups (daily injections of SC144 [2.2 mg/kg, PAB-SC144, n=5] or vehicle [PAB-Veh, n=5] for 3 weeks). Five age-matched pigs served as controls. Cardiac MRI quantified RV size/function. Right heart catheterization evaluated hemodynamics. Single-nucleus RNA sequencing delineated cell-type specific changes between experimental groups. Electron microscopy evaluated RV mitochondrial morphology. Phosphoproteomics identified dysregulated RV kinases. Lipidomics and metabolomics quantified lipid species and metabolites in RV tissue. Quantitative proteomics examined RV mitochondrial protein regulation.

Results

SC144 significantly improved RV ejection fraction (Control: 60±4%, PAB-Veh: 22±10%, PAB-SC144: 37±6%) despite similar RV afterload. Single-nucleus RNA sequencing demonstrated PAB-Veh pigs had lower cardiomyocyte and higher macrophage/lymphocyte/pericyte/endothelial cell abundances as compared to control, and many of these changes were blunted by SC144. SC144 combatted the downregulation of cardiomyocyte metabolic genes induced by PAB. Kinome enrichment analysis suggested SC144 counteracted RV mTORC1 activation. Correspondingly, SC144 rebalanced RV autophagy pathway proteins and improved mitochondrial morphology. Integrated lipidomics, metabolomics, and proteomics analyses revealed SC144 restored fatty acid metabolism. Finally, CellChat analysis revealed SC144 restored pericyte-endothelial cell cross-talk.

Conclusion

GP130 antagonism blunts elevated immune cell abundance, reduces pro-inflammatory gene transcription in macrophages and lymphocytes, rebalances autophagy and preserves fatty acid metabolism in cardiomyocytes, and restores endothelial cell and pericyte communication to improve RV function.

Echocardiographic Assessment of Biventricular Mechanics in Patients with Mild-to-Moderate Idiopathic Pulmonary Fibrosis: A Systematic Review and Meta-Analysis

Background: Over the last few years, a few imaging studies have performed conventional transthoracic echocardiography (TTE) implemented with speckle tracking echocardiography (STE) for the assessment of biventricular mechanics in patients with non-advanced idiopathic pulmonary fibrosis (IPF). This systematic review and meta-analysis aimed at evaluating the overall effect of mild-to-moderate IPF on the main indices of biventricular systolic function assessed by TTE and STE. Methods: All imaging studies assessing right ventricular (RV)-global longitudinal strain (GLS), left ventricular (LV)-GLS, tricuspid annular plane systolic excursion (TAPSE), and left ventricular ejection fraction (LVEF) in IPF patients vs. healthy controls, selected from PubMed, Scopus, and EMBASE databases, were included. Continuous data (RV-GLS, LV-GLS, TAPSE, and LVEF) were pooled as standardized mean differences (SMDs) comparing the IPF group with healthy controls. The SMD of RV-GLS was calculated using the random-effect model, whereas the SMDs of LV-GLS, TAPSE, and LVEF were calculated using the fixed-effect model. Results: The full texts of 6 studies with 255 IPF patients and 195 healthy controls were analyzed. Despite preserved TAPSE and LVEF, both RV-GLS and LV-GLS were significantly, although modestly, reduced in the IPF patients vs. the controls. The SMD was large (-1.01, 95% CI -1.47, -0.54, p < 0.001) for RV-GLS, medium (-0.62, 95% CI -0.82, -0.42, p < 0.001) for LV-GLS, small (-0.42, 95% CI -0.61, -0.23, p < 0.001) for TAPSE, and small and not statistically significant (-0.20, 95% CI -0.42, 0.03, p = 0.09) for LVEF assessment. Between-study heterogeneity was high for the studies assessing RV-GLS (I2 = 80.5%), low-to-moderate for those evaluating LV-GLS (I2 = 41.7%), and low for those measuring TAPSE (I2 = 16.4%) and LVEF (I2 = 7.63%). The Egger's test yielded a p-value of 0.60, 0.11, 0.31, and 0.68 for the RV-GLS, LV-GLS, TAPSE, and LVEF assessment, respectively, indicating no publication bias. On meta-regression analysis, none of the moderators was significantly associated with effect modification for RV-GLS (all p > 0.05). The sensitivity analysis supported the robustness of the results. Conclusions: RV-GLS impairment is an early marker of subclinical myocardial dysfunction in mild-to-moderate IPF. STE should be considered for implementation in clinical practice for early detection of RV dysfunction in IPF patients without advanced lung disease.

The value of lung ultrasound score combined with echocardiography in assessing right heart function in patients undergoing maintenance hemodialysis and experiencing pulmonary hypertension

AIMS

This study explores the clinical application of lung ultrasound scoring(LUS) combined with echocardiography in assessing right heart function in patients undergoing maintenance hemodialysis(MHD) and those with elevated pulmonary artery systolic pressure(PASP), as well as the correlation between LUS and right ventricular(RV) function.

METHODS

Eighty five patients who underwent MHD combined with elevated PASP, at the First Central Hospital of Baoding City were selected. Divided into three groups based on PASP, and perform echocardiography and lung ultrasound examinations. Compare the right heart function parameters and LUS among the three groups. Using Pearson correlation analysis to examine the relationship between LUS and right heart function parameters. Perform multivariate logistic regression analysis to identify predictive factors for RV systolic dysfunction. A receiver operating characteristic (ROC) curve and calculate the area under the curve(AUC) to compare the diagnostic efficacy of various parameters.

RESULTS

Patients undergoing MHD exhibited varying degrees of reduced left ventricular (LV) and RV systolic function. Correlation analysis revealed that Tricuspid annular plane systolic excursion (TAPSE), Fractional area change (FAC), and Tricuspid annular peak systolic velocity(S') were negatively correlated with LUS(r = -0.81, -0.86, -0.69), while Right ventricular free wall longitudinal strain(RVFWLS) was positively correlated with LUS (r = 0.85, P < 0.05). The ROC curve indicated that the combination of LUS and RVFWLS had the highest area under the curve (AUC = 0.963), followed by the combination of LUS and TAPSE (AUC = 0.847), LUS and FAC(AUC = 0.937), and LUS combined with S'(AUC = 0.940). All combinations demonstrated higher AUC values than the individual indicators.

CONCLUSIONS

Patients with MHD combined with elevated PASP, the RV function parameters are associated with LUS, which may serve as a valuable reference indicator for assessing RV function. The use of LUS to evaluate right heart function in these patients, alongside traditional two-dimensional parameters, holds significant clinical value.

Mitral Regurgitation Evaluation in Modern Echocardiography: Bridging Standard Techniques and Advanced Tools for Enhanced Assessment

Mitral regurgitation (MR) is one of the most common valvular heart diseases worldwide. Echocardiography remains the first line and most effective imaging modality for the diagnosis of mitral valve (MV) pathology and quantitative assessment of MR. The advent of three-dimensional echocardiography has significantly enhanced the evaluation of MV anatomy and function. Furthermore, recent advancements in cardiovascular imaging software have emerged as step-forward tools, providing a powerful support for acquisition, analysis, and interpretation of cardiac ultrasound images in the context of MR. This review aims to provide an overview of the contemporary workflow for echocardiographic assessment of MR, encompassing standard echocardiographic techniques and the integration of semiautomated and automated ultrasound solutions. These novel approaches include advancements in segmentation, phenotyping, morphological quantification, functional grading, and chamber quantification.

Pulmonary Embolism in the Elderly: From Symptoms to Speckle Tracking Echocardiography

(1) Background: There are little data about the differences in clinical and echocardiographic characteristics between elderly (aged ≥ 65 years) and younger patients with acute pulmonary embolism (PE). (2) Methods: Consecutive patients diagnosed with PE in a tertiary hospital were identified. Clinical characteristics, biomarkers and transthoracic echocardiography indices including right ventricular free wall longitudinal strain (RV-FWLS) were recorded. (3) Results: Of 200 patients enrolled, 19 patients had high-risk PE and were excluded from the study. Compared to younger patients, elderly patients with PE had less frequently pain and typical symptoms and more often were hospitalized due to another reason before the PE diagnosis. The elderly had higher values of D-dimer, high-sensitivity troponin I and brain natriuretic peptide (BNP). Echocardiographic differences were noted and the elderly had lower values of pulmonary vascular acceleration time, RV E/A ratio and lower tricuspid annular plane systolic excursion/pulmonary artery systolic pressure ratio. The RV-FWLS index did not show a statistically significant difference in distribution between age groups ≥ 65 and <65 years old. The RV diameter was similar across all age groups. (4) Conclusions: The elderly have differences compared with younger patients with PE regarding the mode of presentation, the values of biomarkers like D-dimer, BNP and troponins and some echocardiographic indices of RV affection.

Echocardiography in the Ventilated Patient: What the Clinician Has to Know

Heart and lung sharing the same anatomical space are influenced by each other. Spontaneous breathing induces dynamic changes in intrathoracic pressure, impacting cardiac function, particularly the right ventricle. In intensive care units (ICU), mechanical ventilation (MV) and therefore positive end-expiratory pressure (PEEP) are often applied, and this inevitably influences cardiac function. In ventilated patients, the use of positive pressures leads to an increase in intrathoracic pressure and, consequently, to a reduction in the right ventricular preload and thus cardiac output. The clinician working in the intensive care unit must be able to assess the effects MV has on the heart in order to set it up appropriately and to manage any complications. The echocardiographic evaluation of the ventilated patient has the main purpose of studying the right ventricle; in fact, they are the ones most affected by PEEP. It is therefore necessary to assess the size, thickness, and systolic function of the right ventricle. In the mechanically ventilated patient, it may be difficult to assess the volemic status and fluid responsiveness, in fact, the study of the inferior vena cava (IVC) is not always reliable in these patients. In patients with MV, it is preferable to assess fluid responsiveness with dynamic methods such as the end-expiration occlusion (EEO) test, passive leg raise (PLR), and fluid challenge (FC). The study of the diaphragm is also essential to identify possible complications, manage weaning, and provide important prognostic information. This review describes the basis for echocardiographic evaluation of the mechanically ventilated patient with the aim of supporting the clinician in managing the consequences of MV for heart-lung interaction.

Right ventricle free wall longitudinal strain screening of lung transplant candidates

BACKGROUND

Lung transplant (LUTX) candidates have subclinical right ventricular (RV) dysfunction, which has not yet been assessed by speckle-tracking echocardiography (STE)-derived RV free-wall longitudinal strain (RVFWLS). To evaluate the prevalence of RV dysfunction by RVFWLS and its relationship with conventional RV echocardiographic indexes in LUTX candidates.

METHODS

In a single-center prospective observational cohort study, from January 2021 to March 2023 consecutive LUTX candidates underwent cardiac catheterization, radionuclide ventriculography, standard and STE. The diagnostic accuracy of RV ejection fraction by ventriculography (RVEF), tricuspid annular plane excursion (TAPSE), fractional area change (FAC), tricuspid peak annulus systolic velocity (S') versus RVFWS were computed.

RESULTS

Thirty-four patients (female, 41%) with a mean age of 48 [36-59] years old enlisted for pulmonary fibrosis (35%) and cystic fibrosis (30%) were included. At cardiac catheterization, only 7 (23%) had pulmonary hypertension. Around 15-25% presented right heart enlargement. Tricuspid regurgitation was present in 20 (60%) of the patients. Median RVFWLS was -20.1% [-22.5%--17%], being impaired (> -20%) in 16 (47%) of the patients. RVFWLS identified the highest percentage (47%) of RV dysfunction, compared to TAPSE (32%), S' (27%), FAC (26%), and ventriculography (15%), which had very low sensitivity for detecting RV dysfunction compared to RVFWLS.

CONCLUSIONS

In patients enlisted for LUTX, RV dysfunction assessed by STE-derived RVFWLS is highly prevalent. STE can detect RV dysfunction better than standard two-dimensional echocardiography and ventriculography. Further studies are urgently needed to define the clinical implications and the prognostic value of RV dysfunction measured with RVFWLS.

Use of Right Ventricular Free-Wall Strain in a Multivariable Estimate of Right Ventricular-Arterial Coupling in Pediatric Pulmonary Arterial Hypertension

BACKGROUND

Right ventricular-arterial coupling (RVAC) describes the relationship between right ventricular contractility and pulmonary vascular afterload. Noninvasive surrogates for RVAC using echocardiographic estimates of right ventricular function, such as tricuspid annular plane systolic excursion (TAPSE), have been shown to correlate with invasively measured RVAC and predict clinical outcomes in pediatric pulmonary arterial hypertension. However, given the limitations of TAPSE at accurately estimating right ventricular function in children, we hypothesized that a multivariable estimate of RVAC using right ventricular free-wall longitudinal strain (RVFW-LS) may perform better than those utilizing TAPSE at predicting clinical outcomes.

METHODS

In all, 108 children from 2 institutions with pulmonary arterial hypertension underwent hemodynamic catheterization with simultaneous echocardiography. In a retrospective analysis, hybrid (echo and invasive) RVAC metrics included TAPSE/pulmonary vascular resistance (PVRi) and RVFW-LS/PVRi. Noninvasive echocardiographic metrics were TAPSE/echo-derived pulmonary artery systolic pressure (PASP) and RVFW-LS/PASP.

RESULTS

RVFW-LS correlated with PVRi (r=0.315, P=0.01), though TAPSE did not (r=0.058, P=0.64). PVRi, PASP, and RVAC metrics declined in patients with worse World Health Organization Functional Class (n=108), while TAPSE and RVFW-LS did not. PVRi, PASP, RVFW-LS/PVRi, TAPSE/PVRi, and RVFW-LS/PASP predicted the outcome variable of transplant or death (area under the curve, 0.771 [P<0.001], 0.729 [P=0.004], 0.748 [P=0.002], 0.732 [P=0.009], and 0.714 [P=0.01], respectively), while TAPSE/PASP, RVFW-LS, and TAPSE did not (area under the curve, 0.671, 0.603, and 0.525, respectively). In patients without a history of repaired congenital heart disease (n=88), only RVFW-LS/PASP, PVRi, PASP, and RVFW-LS/PVRi predicted outcomes (area under the curve, 0.738 [P=0.002], 0.729 [P=0.01], 0.729 [P=0.01], and 0.729 [P=0.015], respectively).

CONCLUSIONS

In the pediatric population, baseline PVRi and echo-estimated PASP were strongly associated with adverse clinical outcomes, but TAPSE and RVFW-LS were not. Estimates of RVAC utilizing RVFW-LS were superior to those utilizing TAPSE-however, only marginally additive to PASP and PVRi at predicting the adverse clinical outcome in patients without a history of repaired congenital heart disease.

Anthracycline-Induced Subclinical Right Ventricular Dysfunction in Breast Cancer Patients: A Systematic Review and Meta-Analysis

AIM

This meta-analysis aims to evaluate the impact of anthracycline chemotherapy on subclinical right ventricular (RV) dysfunction in breast cancer patients, using traditional echocardiographic parameters and strain-based measures, such as the RV global longitudinal strain (RV GLS) and the RV free-wall longitudinal strain (RV FWLS).

METHODS AND RESULTS

A systematic search was conducted according to PRISMA guidelines, including 15 studies with a total of 1148 breast cancer patients undergoing anthracycline chemotherapy. The primary outcome was the evaluation of changes in RV GLS and RV FWLS pre- and post-chemotherapy. Secondary outcomes included changes in traditional echocardiographic parameters: TAPSE, FAC, and TDI S'. Meta-analysis revealed significant declines in RV function post-chemotherapy across all parameters. RV GLS decreased from 23.99% to 20.35% (SMD: -0.259, p < 0.0001), and RV FWLS from 24.92% to 21.56% (SMD: -0.269, p < 0.0001). Traditional parameters like TAPSE, FAC, and TDI S' also showed reductions, but these were less consistent across studies. A meta-regression analysis showed no significant relationship between post-chemotherapy left ventricular ejection fraction (LVEF) and the changes in RV GLS and RV FWLS, suggesting that RV dysfunction may not be solely a consequence of LV impairment.

CONCLUSIONS

Anthracycline chemotherapy induces subclinical RV dysfunction in breast cancer patients. RV strain analysis, especially 3D strain, shows greater sensitivity in detecting early dysfunction. However, further research is needed to clarify the clinical significance and prognostic value of these findings, as well as the role of routine RV strain analysis in guiding early interventions.

Cardiac Surgery and Transcatheter Intervention for Valvular Heart Disease in Carcinoid Syndrome: Risk Factors, Outcomes, and Evolving Therapeutic Strategies

Carcinoid heart disease (CHD) affects right-sided valves and causes significant mortality and morbidity. Even though the pathophysiology of the disease is not entirely understood, it is known that chronic exposure to high levels of circulating serotonin is the main factor responsible for developing valvular heart disease. Cardiac imaging plays a critical role in the management of CHD, so the final diagnosis can be performed through multimodal imaging techniques and the measurement of biomarkers. Moreover, in observational studies, surgical treatment of carcinoid-induced valve disease has been found to improve outcomes. Despite advancements in pre-operative preparation in recent years, mortality rates remain high in elderly patients and those with multiple comorbidities due to the risk of intra-operative carcinoid crisis and high post-operative bleeding. In this comprehensive review, we will analyze the causes of carcinoid syndrome and how it can result in severe right heart failure. The role of different imaging modalities in detecting heart valve disease will be discussed together with the therapeutic options at our disposal, such as medical treatment, surgery, and the novel role of transcatheter intervention.

The Relationship Between Right Ventricular Longitudinal Strain and Adverse Outcome in Hypertensive Patients: 10-year Follow-up

INTRODUCTION

Previous studies showed the importance of right ventricular (RV) remodeling in patients with arterial hypertension and RV longitudinal strain was recognized as very sensitive parameter for detection of subtle cardiac impairment. However, its clinical importance in arterial hypertension has not been established so far.

AIM

The present study aimed to evaluate the association between RV longitudinal strain (global and free-wall) on adverse outcomes measured by MACE in the large group of hypertensive patients who were followed for mean period of 10 years.

METHODS

This retrospective study finally included 544 hypertensive patients who underwent full echocardiographic examination including 2D speckle tracking imaging. between January 2010 and December 2014. MACE was considered as the primary outcome and it was defined by all-cause mortality, cardiovascular mortality, myocardial infarction, coronary artery by-pass, coronary stent implantation, stroke, development of heart failure, and occurrence of atrial fibrillation during follow-up.

RESULTS

Patients who experienced MACE were older than those who did not. There was no difference in demographic and clinical parameters between MACE and non-MACE patients. There was no difference in RV diameter, but MACE patients had higher RV wall thickness. RV systolic function parameters were similar between the two groups. RV global and free-wall longitudinal strain were significantly lower in MACE patients (-22.3 ± 3.6 vs. -24.7 ± 3.9%, p < 0.001 and - 25.8 ± 4.2 vs. -28.1 ± 4.5%, p < 0.001; respectively). Reduced RV GLS [OR 1.10; 95%: 1.02-1.20] and reduced RV free-wall longitudinal strain [OR 1,21; 95%CI: 1.05-1.39] were independently of clinical and echocardiographic parameters related with adverse outcome measured by MACE.

CONCLUSION

RV GLS and RV free-wall longitudinal strain were independently related with adverse outcomes during 10-year follow-up in initially uncomplicated hypertensive patients.

Right ventricular dysfunction in the critically ill. Echocardiographic evaluation

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

A novel method for the evaluation of right ventricular dysfunction in acute pulmonary embolism: Myocardial work indices

PURPOSE

The presence of right ventricular dysfunction indicates a higher risk status in patients with pulmonary embolism (PE). The RV strain evaluated by speckle-tracking echocardiography seems to be more reliable method in the evaluation of RV dysfunction as compared to standard echocardiographic measures. In this study, we aimed to determine the value of myocardial-work indices in evaluating serial changes of RV function in acute PE.

METHODS

Our study comprised 83 consecutive acute PE patients who admitted to our tertiary cardiovascular hospital. Echocardiography was performed within the first 24-hours of hospitalization, and RV and LV myocardial-work parameters were obtained along with standard echocardiographic parameters. The change in the RV/LVr detected on tomography was selected as the primary outcome measure, and its' predictors were analyzed with classical linear regression and a generalized additive model (GAM).

RESULTS

Among the LV-RV strain and myocardial work parameters, the RV global longitudinal strain (GLS) has borderline statistical significance in predicting the RV/LVr change whereas the RV global work efficiency (RV-GWE) strongly predicted RV/LVr change (p: 0.049 and <0.001, respectively).

CONCLUSION

In this study, classical linear regression and GAM analyses showed that RV-GWE seems to offer a better prediction of RV/LVr change in patients with acute PE.

Multimodality Imaging for Right Ventricular Function Assessment in Severe Tricuspid Regurgitation

Severe tricuspid regurgitation (TR) is a pathological condition associated with worse cardiovascular outcomes. In the vicious cycle of right ventricular compensation and maladaptation to TR, the development of right ventricle (RV) dysfunction has significant prognostic implications, especially in patients undergoing surgical or percutaneous treatments. Indeed, RV dysfunction is associated with increased operative morbidity and mortality in both surgical and percutaneously treated patients. In this context, the identification of clinical or subtle right ventricle dysfunction plays a critical role inpatient selection and timing of surgical or percutaneous tricuspid valve intervention. However, in the presence of severe TR, evaluation of RV function is challenging, given the increase in preload that may lead to an overestimation of systolic function for the Frank-Starling law, reduced reliability of pulmonary artery pressure estimation, the sensitivity of RV to afterload that may result in afterload mismatch after treatment. Consequently, conventional echocardiographic indices have some limitations, and the use of speckle tracking for right ventricular free wall longitudinal strain (RV-FWLS) analysis and the use of 3D echocardiography for RV volumes and ejection fraction estimation are showing promising data. Cardiac magnetic resonance (CMR) represents the gold standards for volumes and ejection fraction evaluation and may add further prognostic information. Finally, cardiac computer tomography (CCT) provides measurements of RV and annulus dimensions that are particularly useful in the transcatheter field. Identification of subtle RV dysfunction may need, therefore, more than one imaging technique, which will lead to tip the balance between medical therapy and early intervention towards the latter before disease progression. Therefore, the aim of this review is to describe the main imaging techniques, providing a comprehensive assessment of their role in RV function evaluation in the presence of severe TR.

Regional Strain of Right Ventricle From Computed Tomography Improves Risk Stratification of Right Ventricle Failure

Patients who undergo implantation of a left ventricular assist device (LVAD) are at a high risk for right ventricular failure (RVF), presumably due to poor right ventricular (RV) function before surgery. Cine computerized tomography (cineCT) can be used to evaluate RV size, function, and endocardial strain. However, CT-based strain measures in patients undergoing workup for LVAD implantation have not been evaluated. We quantified RV strain in the free wall (FW) and septal wall (SW) in patients with end-stage heart failure using cineCT. Compared to controls, both FW and SW strains were significantly impaired in heart failure patients. The difference between FW and SW strains predicted RV failure after LVAD implantation (area-under-the curve [AUC] = 0.82). Cine CT strain can be combined with RV volumetry to risk-stratify patients. In our study, patients with preserved RV volumes and poor strain had a higher rate of RV failure (57%), than those with preserved volume and preserved strain (0%). This suggests that CT could improve risk stratification of patients receiving LVADs and that strain metrics were particularly useful in risk-stratifying patients with preserved RV volumes.

Relationship of TAPSE Normalized by Right Ventricular Area With Pulmonary Compliance, Exercise Capacity, and Clinical Outcomes

BACKGROUND

While tricuspid annular plane systolic excursion (TAPSE) captures the predominant longitudinal motion of the right ventricle (RV), it does not account for ventricular morphology and radial motion changes in various forms of pulmonary hypertension. This study aims to account for both longitudinal and radial motions by dividing TAPSE by RV area and to assess its clinical significance.

METHODS

We performed a retrospective analysis of 71 subjects with New York Heart Association class II to III dyspnea who underwent echocardiogram and invasive cardiopulmonary exercise testing (which defined 4 hemodynamic groups: control, isolated postcapillary pulmonary hypertension, combined postcapillary pulmonary hypertension, and pulmonary arterial hypertension). On the echocardiogram, TAPSE was divided by RV area in diastole (TAPSE/RVA-D) and systole (TAPSE/RVA-S). Analyses included correlations (Pearson and linear regression), receiver operating characteristic, and survival curves.

RESULTS

On linear regression analysis, TAPSE/RVA metrics (versus TAPSE) had a stronger correlation with pulmonary artery compliance (r=0.48-0.54 versus 0.38) and peak VO2 percentage predicted (0.23-0.30 versus 0.18). Based on the receiver operating characteristic analysis, pulmonary artery compliance ≥3 mL/mm Hg was identified by TAPSE/RVA-D with an under the curve (AUC) of 0.79 (optimal cutoff ≥1.1) and by TAPSE/RVA-S with an AUC of 0.83 (optimal cutoff ≥1.5), but by TAPSE with only an AUC of 0.67. Similarly, to identify peak VO2 <50% predicted, AUC of 0.66 for TAPSE/RVA-D and AUC of 0.65 for TAPSE/RVA-S. Death or cardiovascular hospitalization at 12 months was associated with TAPSE/RVA-D ≥1.1 (HR, 0.38 [95% CI, 0.11-0.56]) and TAPSE/RVA-S ≥1.5 (HR, 0.44 [95% CI, 0.16-0.78]), while TAPSE was not associated with adverse outcomes (HR, 0.99 [95% CI, 0.53-1.94]). Among 31 subjects with available cardiac magnetic resonance imaging, RV ejection fraction was better correlated with novel metrics (TAPSE/RVA-D r=0.378 and TAPSE/RVA-S r=0.328) than TAPSE (r=0.082).

CONCLUSIONS

In a broad cohort with suspected pulmonary hypertension, TAPSE divided by RV area was superior to TAPSE alone in correlations with pulmonary compliance and exercise capacity. As a prognostic marker of right heart function, TAPSE/RVA-D <1.1 and TAPSE/RVA-S <1.5 predicted adverse cardiovascular outcomes.

Perioperative echocardiographic strain analysis: what anesthesiologists should know

PURPOSE

Echocardiographic strain analysis by speckle tracking allows assessment of myocardial deformation during the cardiac cycle. Its clinical applications have significantly expanded over the last two decades as a sensitive marker of myocardial dysfunction with important diagnostic and prognostic values. Strain analysis has the potential to become a routine part of the perioperative echocardiographic examination for most anesthesiologist-echocardiographers but its exact role in the perioperative setting is still being defined.

CLINICAL FEATURES

This clinical report reviews the principles underlying strain analysis and describes its main clinical uses pertinent to the field of anesthesiology and perioperative medicine. Strain for assessment of left and right ventricular function as well as atrial strain is described. We also discuss the potential role of strain to aid in perioperative risk stratification, surgical patient selection in cardiac surgery, and guidance of anesthetic monitor choice and clinical decision-making in the perioperative period.

CONCLUSION

Echocardiographic strain analysis is a powerful tool that allows seeing what conventional 2D imaging sometimes fails to reveal. It often provides pathophysiologic insight into various cardiac diseases at an early stage. Strain analysis is readily feasible and reproducible thanks to the use of highly automated software platforms. This technique shows promising potential to become a valuable tool in the arsenal of the anesthesiologist-echocardiographer and aid in perioperative risk-stratification and clinical decision-making.

Assessing right ventricular peak strain in myocardial infarction patients with mitral regurgitation by cardiac magnetic resonance feature tracking

Background

Although it is known that mitral regurgitation (MR) in patients with myocardial infarction (MI) may increase the right ventricular (RV) afterload, leading to RV dysfunction, the exact detrimental effects on RV function and myocardial peak strain remain unresolved. In this study, we assessed the impact of MR on the impairment of RV myocardial deformation in patients with MI and explored the independent influential factors of RV peak strain.

Methods

A total of 199 MI participants without or with MR were retrospectively assessed in this study. The cardiovascular magnetic resonance examination protocol included a late gadolinium-enhanced (LGE) imaging technique and a cine-balanced steady-state free precession sequence. Statistical tests, including two independent sample t-test or Mann-Whitney U-test, analysis of variance, Kruskal-Wallis test, and multiple linear regression analysis models were performed.

Results

The MI (MR+) group exhibited significantly lower RV strain parameters in the radial, circumferential and longitudinal directions when compared to the control and the MI (MR-) groups (both P<0.05). The RV global longitudinal peak strain (GLPS) in the MI group significantly decreased when compared with that in the control group (P<0.05). As moderate-severe MR worsened in patients with MI, RV myocardial global peak strain and the peak systolic strain rate (PSSR) gradually decreased. Multiple linear regression analysis revealed that left ventricular (LV) GLPS, triglycerides, and age were independently correlated with RV GLPS (all P<0.05). RV end-systolic volume (RVESV) acted as an independent association factor for RV global peak strain.

Conclusions

MR may exacerbate the impairment of RV peak strain and functions in patients with MI. LV GLPS was positively correlated with RV GLPS. However, RVESV, triglycerides, and age acted as independent risk factors associated with worsening RV GLPS.

A roadmap for therapeutic discovery in pulmonary hypertension associated with left heart failure. A scientific statement of the Heart Failure Association (HFA) of the ESC and the ESC Working Group on Pulmonary Circulation & Right Ventricular Function

Pulmonary hypertension (PH) associated with left heart failure (LHF) (PH-LHF) is one of the most common causes of PH. It directly contributes to symptoms and reduced functional capacity and negatively affects right heart function, ultimately leading to a poor prognosis. There are no specific treatments for PH-LHF, despite the high number of drugs tested so far. This scientific document addresses the main knowledge gaps in PH-LHF with emphasis on pathophysiology and clinical trials. Key identified issues include better understanding of the role of pulmonary venous versus arteriolar remodelling, multidimensional phenotyping to recognize patient subgroups positioned to respond to different therapies, and conduct of rigorous pre-clinical studies combining small and large animal models. Advancements in these areas are expected to better inform the design of clinical trials and extend treatment options beyond those effective in pulmonary arterial hypertension. Enrichment strategies, endpoint assessments, and thorough haemodynamic studies, both at rest and during exercise, are proposed to play primary roles to optimize early-stage development of candidate therapies for PH-LHF.

Understanding Tricuspid Regurgitation Post Cardiac Transplantation; Why "Anatomical" and "Functional" Just Won't Cut It

Tricuspid regurgitation (TR) is common after cardiac transplantation and results in poorer outcomes. Transplant recipients are at high prohibitive risk for redo surgical procedures because of risks associated with a subsequent sternotomy, immunosuppression, and renal failure. Percutaneous therapies have recently become available and may be an option for transplant recipients. However, transplant recipients have complex geometry, and there is a myriad of causes of TR posttransplant. There is a need for careful patient selection for all percutaneous valve interventions, and this is particularly true in transplant recipients who suffer from right ventricular failure and rejection and may undergo repeated endomyocardial biopsies. Cognizant of the rapid developments in this space, this review article focuses on the causes of TR, treatments, and future therapies in heart transplantation recipients to the transplant cardiologist navigate this complex area.

Right ventricular free wall and four-chamber longitudinal strain in relation to incident heart failure in the general population

AIMS

Right ventricular free wall (RVFWLS) and four-chamber longitudinal strain (RV4CLS) are associated with adverse events in various patient populations including patients with heart failure (HF). We sought to investigate the prognostic value of RVFWLS and RV4CLS for the development of incident HF in participants from the general population.

METHODS AND RESULTS

Participants from the 5th Copenhagen City Heart Study (2011-2015) without known chronic ischaemic heart disease or HF at baseline were included. RVFWLS and RV4CLS were obtained using two-dimensional speckle-tracking echocardiography from the right ventricular (RV)-focused apical four-chamber view. The primary endpoint was incident HF. Among 2740 participants (mean age 54 ± 17 years, 42% male), 43 (1.6%) developed HF during a median follow-up of 5.5 years (IQR 4.5-6.3). Both RVFWLS and RV4CLS were associated with an increased risk of incident HF during follow-up independent of age, sex, hypertension, diabetes, body mass index and tricuspid annular plane systolic excursion (TAPSE), (HR 1.06, 95%CI 1.00-1.11, P = 0.034, per 1% absolute decrease and HR 1.14, 95%CI 1.05-1.23, P = 0.001, per 1% absolute decrease, respectively). Left ventricular ejection fraction (LVEF) modified the association between RV4CLS and incident HF (P for interaction = 0.016) such that RV4CLS was only of prognostic importance among those with LVEF < 55% (HR 1.21, 95%CI 1.11-1.33, P < 0.001 vs. HR 0.94, 95%CI 0.80-1.10, P = 0.43 in patients with LVEF ≥ 55%).

CONCLUSION

In participants from the general population, both RVFWLS and RV4CLS were associated with a greater risk of incident HF independent of important baseline characteristics and TAPSE, and LVEF modified the relationship between RV4CLS and incident HF.

Prognostic Value of a New Right Ventricular-to-Pulmonary Artery Coupling Parameter Using Right Ventricular Longitudinal Shortening Fraction in Patients Undergoing Transcatheter Aortic Valve Replacement: A Prospective Echocardiography Study

Introduction: Right-ventricular-to-pulmonary artery (RV-PA) coupling, measured as the ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP), has emerged as a predictor factor in patients undergoing transcatheter aortic valvular replacement (TAVR). Right ventricular longitudinal shortening fraction (RV-LSF) outperformed TAPSE as a prognostic parameter in several diseases. We aimed to compare the prognostic ability of two RV-PA coupling parameters (TAPSE/PASP and the RV-LSF/PASP ratio) in identifying MACE occurrences. Method: A prospective and single-center study involving 197 patients who underwent TAVR was conducted. MACE (heart failure, myocardial infarction, stroke, and death within six months) constituted the primary outcome. ROC curve analysis determined cutoff values for RV-PA ratios. Multivariable Cox regression analysis explored the association between RV-PA ratios and MACE. Results: Forty-six patients (23%) experienced the primary outcome. No significant difference in ROC curve analysis was found (RV-LSF/PASP with AUC = 0.67, 95%CI = [0.58-0.77] vs. TAPSE/PASP with AUC = 0.62, 95%CI = [0.49-0.69]; p = 0.16). RV-LSF/PASP < 0.30%.mmHg-1 was independently associated with the primary outcome. The 6-month cumulative risk of MACE was 59% (95%CI = [38-74]) for patients with RV-LSF/PASP < 0.30%.mmHg-1 and 17% (95%CI = [12-23]) for those with RV-LSF/PASP ≥ 0.30%.mmHg-1; (p < 0.0001). Conclusions: In a contemporary cohort of patients undergoing TAVR, RV-PA uncoupling defined by an RV-LSF/PASP < 0.30%.mmHg-1 was associated with MACE at 6 months.

Right ventricle assessment before tricuspid valve interventions

In the latest ESC/EACTS Guidelines for the Management of Valvular Heart Disease, right ventricular dilatation and dysfunction, severe pulmonary hypertension and tricuspid annulus dilatation were reported to be the most important parameters to consider in patient selection for tricuspid valve interventions. Indeed, comprehensive right ventricular assessment is crucial in patients with severe tricuspid regurgitation who may benefit from transcatheter or surgical procedures. However, the only guideline parameter considered for intervention has been tricuspid annular dilatation in the presence of at least mild to moderate tricuspid regurgitation, with no other right ventricular markers used in the decision-making process for invasive treatment. Notably, challenges in the assessment of right ventricular function may limit establishing thresholds for defining right ventricular dysfunction. The aim of this review is to summarize current evidence on the prognostic significance of right ventricular function in patients with tricuspid regurgitation undergoing percutaneous or surgical interventions.

Multi-omic and multispecies analysis of right ventricular dysfunction

BACKGROUND

Right ventricular failure (RVF) is a leading cause of morbidity and mortality in multiple cardiovascular diseases, but there are no treatments for RVF as therapeutic targets are not clearly defined. Contemporary transcriptomic/proteomic evaluations of RVF are predominately conducted in small animal studies, and data from large animal models are sparse. Moreover, a comparison of the molecular mediators of RVF across species is lacking.

METHODS

Transcriptomics and proteomics analyses defined the pathways associated with cardiac magnetic resonance imaging (MRI)-derived values of RV hypertrophy, dilation, and dysfunction in control and pulmonary artery banded (PAB) pigs. Publicly available data from rat monocrotaline-induced RVF and pulmonary arterial hypertension patients with preserved or impaired RV function were used to compare molecular responses across species.

RESULTS

PAB pigs displayed significant right ventricle/ventricular (RV) hypertrophy, dilation, and dysfunction as quantified by cardiac magnetic resonance imaging. Transcriptomic and proteomic analyses identified pathways associated with RV dysfunction and remodeling in PAB pigs. Surprisingly, disruptions in fatty acid oxidation (FAO) and electron transport chain (ETC) proteins were different across the 3 species. FAO and ETC proteins and transcripts were mostly downregulated in rats but were predominately upregulated in PAB pigs, which more closely matched the human response. All species exhibited similar dysregulation of the dilated cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy pathways.

CONCLUSIONS

The porcine metabolic molecular signature was more similar to human RVF than rodents. These data suggest there may be divergent molecular responses of RVF across species, and pigs may more accurately recapitulate metabolic aspects of human RVF.

The association of Pulmonary Hypertension and right ventricular systolic function - updates in diagnosis and treatment

Right ventricular (RV) systolic function is an essential but neglected component in cardiac evaluation, and its importance to the contribution to overall cardiac function is undermined. It is not only sensitive to the effect of left heart valve disease but is also more sensitive to changes in pressure overload than the left ventricle. Pulmonary Hypertension is the common and well-recognized complication of RV systolic dysfunction. It is also the leading cause of pulmonary valve disease and right ventricular dysfunction. Patients with a high pulmonary artery pressure (PAP) and a low RV ejection fraction have a seven-fold higher risk of death than heart failure patients with a normal PAP and RV ejection fraction. Furthermore, it is an independent predictor of survival in these patients. In this review, we examine the association of right ventricular systolic function with Pulmonary Hypertension by focusing on various pathological and clinical manifestations while assessing their impact. We also explore new 2022 ESC/ERS guidelines for diagnosing and treating right ventricular dysfunction in Pulmonary Hypertension.

Perioperative Quality Initiative (POQI) consensus statement on perioperative assessment of right ventricular function

BACKGROUND

The right ventricle (RV) plays a central  role in the maintenance of effective cardiac pump function. Despite overwhelming evidence that perioperative RV dysfunction (RVD) and failure (RVF) are associated with poor clinical outcomes, there are very few published recommendations or guidelines for comprehensive, evidence-based RV assessment on the risk of developing either during the perioperative period.

MAIN TEXT

To address this gap, the Perioperative Quality Initiative-IX (POQI-IX) investigators group, comprised of clinical experts in anesthesiology, cardiovascular surgery, internal medicine, critical care medicine, and advanced practice nursing, has developed a consensus statement based on current literature, published society recommendations, and the clinical expertise of the group. Herein, the group provides recommendations and evidence-based tools related to perioperative RV assessment, functional screening, staging, and the clinical implications of each. These assessment tools are based on comprehensive patient evaluation consisting of physical examination, biomarker data, imaging, and hemodynamic assessment.

CONCLUSION

This review presents a comprehensive tool for assessing perioperative RV function. We hope that this simple, intuitive tool can be applied to all phases of perioperative care and thereby improve patient outcomes.

What is the real incidence of right ventricular affection in patients with acute pulmonary embolism?

BACKGROUND

Echocardiographic markers of right ventricular dysfunction or pressure overload (RVd/PO) have been used in risk assessment of patients with acute pulmonary embolism (APE). Nevertheless, the role of echocardiography in these patients is incompletely determined. We evaluated the right ventricular function using 'non-conventional' markers of RVd/PO in patients with APE.

METHODS

This was a prospective, single-arm, single-centre study. Consecutive adult patients hospitalised for APE were included. The RV free wall longitudinal strain (RV-FWLS), the fractional area change (FAC), the ratio tricuspid annular plane systolic excursion (TAPSE)/pulmonary arterial systolic pressure (PASP), and the pulmonary vascular resistance (PVR) were evaluated.

RESULTS

One hundred patients (mean age 70.0 ± 13.9 years, female 48%) were screened and 73 had adequate RV-FWLS images. The most common abnormal echocardiographic marker was RV-FWLS (44/73; p < 0.001, for all other echocardiographic indices). Thirty-one patients had either PASP ≥ 36 mmHg or PVR > 2 WU (49.2% of the patients with both indices available). There were significant correlations between RV-FWLS, TAPSE/PASP and PVR with both D-Dimers and B-type natriuretic peptide (BNP), and between FAC and BNP. RF-FWLS differed significantly between patients with a simplified pulmonary embolism severity index (sPESI) score 0 and those with a score ≥1 (p < 0.001).

CONCLUSIONS

RVd/PO coexists with APE in a large proportion of patients. RV-FWLS is the most abnormal echocardiographic sign and is related to clinical and biochemical prognostic indices.

Myocardial deformation parameters assessed by CMR feature tracking in chronic heart failure: the influence of an optimal medical therapy on myocardial remodelling

BACKGROUND

Myocardial deformation parameters have been shown to yield early detection of pathological changes in chronic heart failure (CHF). Aim of our study was to evaluate myocardial deformation changes under optimal medical therapy (OMT) in CHF patients.

METHODS

CHF patients were examined longitudinally with two cardiac magnetic resonance imaging (CMR) examinations at a median time interval of 140 days. Left and right ventricular volumes were quantified, and deformation analysis was performed using feature tracking, respectively.

RESULTS

57 patients were included into the study. There was a high rate of OMT with a prescription of beta blockers in 98.2% and ACE-inhibitors/Angiotensin receptor blockers in 93.0%. In the total cohort, there were indications of positive remodelling with a significant improvement in left ventricular (LV) ejection fraction (38.9% ± 11.6 vs. 43.0% ± 12.7, p = 0.009), LV enddiastolic volume indexed (92.1 ml/m2 ± 23.5 vs. 87.2 ml/m2 ± 21.2, p = 0.007), LV mass (140.3 g ± 35.7 vs. 128.0 g ± 34.4, p = 0.001) and right ventricular global longitudinal strain (RV GLS) (-18.1% ± 5.1 vs. -20.3% ± 4.5, p < 0.001) during follow-up.

DISCUSSION

Patients with CHF and OMT show positive reverse remodelling with improvement of LV volumes and function and RV GLS. This has a potential impact on the surveillance of this patient group, which should be further investigated in larger prospective studies.

Prognostic value of right ventricular longitudinal strain in patients with secondary mitral regurgitation undergoing transcatheter edge-to-edge mitral valve repair

AIMS

To evaluate the prognostic impact of pre-procedural right ventricular longitudinal strain (RVLS) in patients with secondary mitral regurgitation (SMR) undergoing transcatheter edge-to-edge repair (TEER) in comparison with conventional echocardiographic parameters of RV function.

METHODS AND RESULTS

This is a retrospective study including 142 patients with SMR undergoing TEER at two Italian centres. At 1-year follow-up 45 patients reached the composite endpoint of all-cause death or heart failure hospitalization. The best cut-off value of RV free-wall longitudinal strain (RVFWLS) to predict outcome was -18% [sensitivity 72%, specificity of 71%, area under curve (AUC) 0.78, P < 0.001], whereas the best cut-off value of RV global longitudinal strain (RVGLS) was -15% (sensitivity 56%, specificity 76%, AUC 0.69, P < 0.001). Prognostic performance was suboptimal for tricuspid annular plane systolic excursion, Doppler tissue imaging-derived tricuspid lateral annular systolic velocity and fractional area change (FAC). Cumulative survival free from events was lower in patients with RVFWLS ≥ -18% vs. RVFWLS < -18% (44.0% vs. 85.4%; < 0.001) as well as in patients with RVGLS ≥ -15% vs. RVGLS < -15% (54.9% vs. 81.7%; P < 0.001). At multivariable analysis FAC, RVGLS and RVFWLS were independent predictors of events. The identified cut-off of RVFWLS and RVGLS both resulted independently associated with outcomes.

CONCLUSION

RVLS is a useful and reliable tool to identify patients with SMR undergoing TEER at high risk of mortality and HF hospitalization, on top of other clinical and echocardiographic parameters, with RVFWLS offering the best prognostic performance.

Right vs. left ventricular longitudinal strain for mortality prediction after transcatheter aortic valve implantation

Introduction

This study aims at exploring biventricular remodelling and its implications for outcome in a representative patient cohort with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI).

Methods and results

Pre-interventional echocardiographic examinations of 100 patients with severe AS undergoing TAVI were assessed by speckle tracking echocardiography of both ventricles. Association with mortality was determined for right ventricular global longitudinal strain (RVGLS), RV free wall strain (RVFWS) and left ventricular global longitudinal strain (LVGLS). During a median follow-up of 1,367 [959-2,123] days, 33 patients (33%) died. RVGLS was lower in non-survivors [-13.9% (-16.4 to -12.9)] than survivors [-17.1% (-20.2 to -15.2); P = 0.001]. In contrast, LVGLS as well as the conventional parameters LV ejection fraction (LVEF) and RV fractional area change (RVFAC) did not differ (P = ns). Kaplan-Meier analyses indicated a reduced survival probability when RVGLS was below the -14.6% cutpoint (P < 0.001). Lower RVGLS was associated with higher mortality [HR 1.13 (95% CI 1.04-1.23); P = 0.003] independent of LVGLS, LVEF, RVFAC, and EuroSCORE II. Addition of RVGLS clearly improved the fitness of bivariable and multivariable models including LVGLS, LVEF, RVFAC, and EuroSCORE II with potential incremental value for mortality prediction. In contrast, LVGLS, LVEF, and RVFAC were not associated with mortality.

Discussion

In patients with severe AS undergoing TAVI, RVGLS but not LVGLS was reduced in non-survivors compared to survivors, differentiated non-survivors from survivors, was independently associated with mortality, and exhibited potential incremental value for outcome prediction. RVGLS appears to be more suitable than LVGLS for risk stratification in AS and timely valve replacement.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Sepsis-Induced myocardial dysfunction: heterogeneity of functional effects and clinical significance

Sepsis is a life-threatening disease state characterized by organ dysfunction and a dysregulated response to infection. The heart is one of the many organs affected by sepsis, in an entity termed sepsis-induced cardiomyopathy. This was initially used to describe a reversible depression in ejection fraction with ventricular dilation but advances in echocardiography and introduction of new techniques such as speckle tracking have led to descriptions of other common abnormalities in cardiac function associated with sepsis. This includes not only depression of systolic function, but also supranormal ejection fraction, diastolic dysfunction, and right ventricular dysfunction. These reports have led to inconsistent definitions of sepsis-induced cardiomyopathy. Just as there is heterogeneity among patients with sepsis, there is heterogeneity in the cardiac response; thus resuscitating these patients with a single approach is likely suboptimal. Many factors affect the heart in sepsis including inflammatory mediators, catecholamine responsiveness, and pathogen related toxins. This review will discuss different functional effects characterized by echocardiographic changes in sepsis and their prognostic and management implications.

Indexing of Speckle Tracking Longitudinal Strain of Right Ventricle to Body Surface Area Does Not Improve Its Efficiency in Diagnosis and Mortality Risk Stratification in Patients with Acute Pulmonary Embolism

BACKGROUND

Acute pulmonary embolism (PE) is associated with a serious mortality rate. Thus, the rapid diagnosis and identification of patients at high risk of death is pivotal. The search for echocardiographic parameters for this purpose continues. Recent publications reveal correlations between myocardial longitudinal strain (LS) and body surface area (BSA). The aim of the study was to evaluate the usefulness of indexing the right ventricular (RV) speckle tracking LS to BSA in detecting PE and stratifying the risk of 30-day all-cause mortality.

METHODS

the prospective cross-sectional observational study group consisted of 167 consecutive patients (76 men, 45.5%) aged 69.5 ± 15.3 years, and they were referred for computed tomography pulmonary angiography. Patients underwent a transthoracic echocardiographic examination within 24 h of admission to the hospital ward. RVLS and their derivatives indexed to BSA were included in the analysis.

RESULTS

PE was confirmed in 88 patients, while 79 patients had no radiological features of PE. The only echocardiographic parameters that differed between subgroups were pulmonary flow acceleration (Act), McConnell's sign, LS of the middle segment of the RV free wall, and its derivative indexed to BSA. During the 30-day follow-up of a subgroup of subjects with PE, 12 patients died. The mortality predictors with increasing prediction value included a RV free wall mid-segment LS (cut-off value: -21%, Area Under the Curve-AUC 0.6, p = 0.02) and its derivative indexed to BSA (-14 %/m², AUC 0.62, p = 0.003), body mass index (24.7 kg/m², AUC 0.63, p = 0.002), D-dimer serum concentration (3559 pg/mL, AUC 0.66, p < 0.001), Act (67 ms, AUC 0.67, p < 0.001), septal basal LS (-15%, AUC 0.68, p = 0.02), RV free wall basal segment LS (-14%, AUC 0.7, p = 0.015), age (66 years, AUC 0.74, p = 0.004), NT-proBNP (1120 pg/mL, AUC 0.75, p = 0.01), troponin T (66 ng/mL, AUC 0.78, p = 0.005), and the complex score of the Pulmonary Embolism Severity Index (AUC 0.88, p < 0.001).

CONCLUSIONS

indexing of RVLS to BSA does not improve its prognostic value in patients with acute PE.

Assessment of Right Ventricular Function-a State of the Art

PURPOSE OF REVIEW

The right ventricle (RV) has a complex geometry and physiology which is distinct from the left. RV dysfunction and failure can be the aftermath of volume- and/or pressure-loading conditions, as well as myocardial and pericardial diseases.

RECENT FINDINGS

Echocardiography, magnetic resonance imaging and right heart catheterisation can assess RV function by using several qualitative and quantitative parameters. In pulmonary hypertension (PH) in particular, RV function can be impaired and is related to survival. An accurate assessment of RV function is crucial for the early diagnosis and management of these patients. This review focuses on the different modalities and indices used for the evaluation of RV function with an emphasis on PH.

Predicting hospitalization by TAPSE/SPAP and the role of spironolactone in asymptomatic heart failure patients

Aim: To appraise the prediction of tricuspid annular plane systolic excursion (TAPSE)/systolic pulmonary artery pressure (SPAP) with regard to hospitalization and the effect of spironolactone use. Materials & methods: A total of 245 patients were evaluated for the study. Patients were followed for 1 year and cardiovascular outcomes were determined. Results: It was determined that TAPSE/SPAP was an independent predictor of hospitalization. A 0.1-mmHg decrease in TAPSE/SPAP was associated with a 9% increase in relative risk. No event was observed above the 0.47 level. Negative correlation with TAPSE (uncoupling) began in the spironolactone group when SPAP was ≥43 and in nonusers when SPAP was 38 (Pearson's correlation coefficient: -,731 vs -,383; p < 0.001 vs p = 0.037). Conclusion: TAPSE/SPAP measurement may be useful in predicting 1-year hospitalization in asymptomatic heart failure patients. This ratio was also found to be higher in patients who used spironolactone.

The heart of the matter: Right heart imaging indicators for treatment escalation in pulmonary arterial hypertension

Right heart (RH) structure and function are major determinants of symptoms and prognosis in pulmonary arterial hypertension (PAH). RH imaging provides detailed information, but evidence and guidelines on the use of RH imaging in treatment decisions are limited. We conducted a Delphi study to gather expert opinion on the role of RH imaging in decision-making for treatment escalation in PAH. A panel of 17 physicians with expertise in PAH and RH imaging used three surveys in a modified Delphi process to reach consensus on the role of RH imaging in PAH. Survey 1 used open-ended questions to gather information. Survey 2 contained Likert scale and other questions intended to identify consensus on topics identified in Survey 1. Survey 3 contained Likert scale questions derived from Survey 2 and summary information on the results of Survey 2. The Delphi panel reached consensus that RH imaging is likely to improve the current risk stratification algorithms and help differentiate risk levels in patients at intermediate risk. Tricuspid annular plane systolic excursion, right ventricular fractional area change, right atrial area, tricuspid regurgitation, inferior venae cavae diameter, and pericardial effusion should be part of routine echocardiography in PAH. Cardiac magnetic resonance imaging is valuable but limited by cost and access. A pattern of abnormal RH imaging results should prompt consideration of hemodynamic evaluation and possible treatment escalation. RH imaging is an important tool for decisions about treatment escalation in PAH, but systematically collected evidence is needed to clarify its role.

Obstructive Sleep Apnea and Right Ventricular Remodeling: Do We Have All the Answers?

Obstructive sleep apnea (OSA) syndrome is a very important sleep-related breathing disorder related to increased cardiovascular and overall morbidity and mortality. It is associated with multisystemic target organ damage due to micro- and macrovascular changes, resulting in carotid and coronary atherosclerosis, increased arterial stiffness, retinal damage, microalbuminuria, and cardiac remodeling. The latter consists of left ventricular (LV) hypertrophy, as well as diastolic and systolic dysfunction. The increasing burden of evidence shows that OSA also induces right ventricular (RV) remodeling that is more difficult to diagnose, but may also contribute to cardiovascular morbidity and mortality in these patients. Conventional echocardiographic parameters for assessment of RV systolic and diastolic functions are often not sensitive enough to detect subclinical and subtle changes in the RV function. Data published over last decade showed that the RV function, particularly systolic, is impaired in OSA patients and related with its severity. However, the introduction of speckle tracking echocardiography and the particularly longitudinal strain enabled the earlier detection of functional and mechanical changes even when conventional echocardiographic parameters of RV systolic function remained unchanged. The 3D echocardiography provided the possibility to evaluate the entire RV, with its unique shape, and determine 3D RV ejection fraction, which is comparable with results obtained by cardiac magnetic resonance. The use of this modality also provided a new insight into RV systolic (dys)function in OSA patients. In addition to weight loss, which has been proven very helpful in OSA patients, the only approved therapeutic approach is continuous positive airway pressure (CPAP) therapy. It is very important to assess if this therapy induces any improvement in cardiac structure and function. Limited data on this topic show that RV longitudinal strain is a more sensitive parameter rather than other conventional RV indexes in the detection of improvement in RV systolic function and mechanics. The aim of this review article is to summarize the current understanding of RV structural, functional, and mechanical changes in patients with OSA. Furthermore, we sought to provide the current knowledge regarding the effect of CPAP therapy on RV reverse remodeling in OSA patients.

A Multi-omic and Multi-Species Analysis of Right Ventricular Failure

Right ventricular failure (RVF) is a leading cause of morbidity and mortality in multiple cardiovascular diseases, but there are no approved treatments for RVF as therapeutic targets are not clearly defined. Contemporary transcriptomic/proteomic evaluations of RVF are predominately conducted in small animal studies, and data from large animal models are sparse. Moreover, a comparison of the molecular mediators of RVF across species is lacking. Here, we used transcriptomics and proteomics analyses to define the molecular pathways associated with cardiac MRI-derived values of RV hypertrophy, dilation, and dysfunction in pulmonary artery banded (PAB) piglets. Publicly available data from rat monocrotaline-induced RVF and pulmonary arterial hypertension patients with preserved or impaired RV function were used to compare the three species. Transcriptomic and proteomic analyses identified multiple pathways that were associated with RV dysfunction and remodeling in PAB pigs. Surprisingly, disruptions in fatty acid oxidation (FAO) and electron transport chain (ETC) proteins were different across the three species. FAO and ETC proteins and transcripts were mostly downregulated in rats, but were predominately upregulated in PAB pigs, which more closely matched the human data. Thus, the pig PAB metabolic molecular signature was more similar to human RVF than rodents. These data suggest there may be divergent molecular responses of RVF across species, and that pigs more accurately recapitulate the metabolic aspects of human RVF.

Right Ventricle and Radiotherapy: More Questions than Answers

The injury of the left ventricle (LV) during anticancer therapy has long been recognized, and guidelines recommend a specific set of parameters for determination of LV impairment. The influence of anticancer therapy on the right ventricle (RV) has been insufficiently investigated, and there are only a few studies that have considered the effect of radiotherapy on RV remodeling. On the other hand, large number of patients with different types of cancers located in the chest are treated with radiotherapy, and the negative clinical effects of this treatment such as accelerated coronary artery disease, valve degeneration and heart failure have been documented. The anatomical position of the RV, which is in the front of the chest, is responsible for its large exposure during radiation treatment, particularly in patients with left-sided breast and lung cancers and mediastinal cancers (hematological malignancies, esophagus cancers, thymomas, etc.). For the same reason, but also due to its anatomical complexity, the RV remains under-investigated during echocardiographic examination, which remains the cornerstone of cardiac imaging in everyday practice. In the last decade many new echocardiographic imaging techniques that enable better evaluation of RV structure, function and mechanics appeared, and they have been used in detection of early and late signs of RV injuries in oncological patients. These investigations are related to some important restrictions that include limited numbers of patients, used parameters and imaging techniques. Many questions about the potential impact of these changes and possible predictions of adverse events remain to be evaluated in future large longitudinal studies. The current body of evidence indicates an important role of radiotherapy in RV remodeling, and therefore, the aim of this review is to summarize currently available data regarding RV changes in patients with various oncological conditions and help clinicians in the assessment of possible cardiac damage.

Impact of SGLT2 Inhibitor Therapy on Right Ventricular Function in Patients with Heart Failure and Reduced Ejection Fraction

Background: The impact of sodium-glucose cotransporter-2 inhibitors (SGLT2is) in addition to optimal medical therapy (OMT) on the right ventricular (RV) systolic function using advanced echocardiographic analysis among outpatients with heart failure and a reduced ejection fraction (HFrEF) has thus far been poorly investigated. Methods: This was a single-center, prospective, single-blinded study in which an echocardiographic expert was blinded to the allocation of the treatment. A total of 36 outpatients with HFrEF were randomized to either OMT or OMT+SGLT2i. Both groups underwent an echocardiographic examination of the RV systolic function at the baseline and at the 3-month follow-up (3mFU). Results: The patients in both groups did not significantly differ with respect to the relevant baseline comorbidities, therapy, and clinical characteristics. The patients receiving OMT+SGLT2i showed a significant improvement from the baseline to the 3mFU in all the measured RV echocardiographic parameters, while for the OMT group, a significant improvement after the 3mFU was observed for TAPSE and s'. The mean percent change from the baseline to the 3mFU was significant when comparing OMT+SGLT2i to the OMT group concerning RV FWS (+91% vs. +28%, p = 0.039), TR maxPG (-27% vs. +19%, p = 0.005), and TR Vmax (-17% vs. +13%, p = 0.008), respectively. Conclusions: Adding SGLT2i to OMT in patients with HFrEF resulted in a greater improvement in the RV systolic function from the baseline to the 3mFU compared to the OMT alone.

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

Background

Functional mitral regurgitation (FMR) is a known risk factor for right ventricular dysfunction (RV_DYS). 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 RV_DYS and prognostication of all-cause mortality and heart failure hospitalization remain unknown.

Results

32% of patients had RV_DYS (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 RV_DYS 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 RV_DYS (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 RV_DYS irrespective of modality which provides incremental diagnostic value and improves risk stratification for event free survival beyond conventional RV indices.

Right Ventricle in Arterial Hypertension: Did We Forget Something?

Right ventricular remodeling has been neglected in patients with arterial hypertension as all studies have concentrated on the left ventricle and left atrial-ventricular and ventricular-arterial coupling. The development of novel imaging techniques has revealed significant impairment in the RV structure, systolic and diastolic function, and, afterwards, RV longitudinal mechanics. However, these changes are subclinical and can be detected only after comprehensive imaging analysis. The latest findings confirm the importance of RV hypertrophy, systolic, and diastolic dysfunction in the prediction of cardiovascular adverse events in the hypertensive population, representing an important clinical implication of these parameters. In clinical practice, 2D echocardiography is widely used for the evaluation of RV remodeling. However, existing techniques are largely underused and limited to a few basic parameters (RV thickness and TAPSE), which are not nearly enough for a detailed assessment of RV remodeling. In addition, 3D echocardiography provides the possibility of accurate evaluation of RV volumes and ejection fraction, which are comparable with results obtained by cardiac magnetic resonance (CMR)-a gold standard for the evaluation of the RV. The use of 3D echocardiography is limited due to its low availability, the lack of adequate software necessary for the calculation of results, and the necessity for a higher level of expertise. CMR provides all information required for a detailed assessment of RV structural, functional, and mechanical remodeling, and it is considered the reference method for this type of evaluation. Furthermore, it is the only technique that may provide tissue characterization and evaluation of the interstitial space, which is essential for hypertensive heart disease. The aim of this review is to provide the current level of evidence regarding RV remodeling in patients with arterial hypertension evaluated with different imaging techniques and various parameters from each method.

The impact of different left ventricular geometric patterns on right ventricular deformation and function in the elderly with hypertension: A two-dimensional speckle tracking and three-dimensional echocardiographic study

Objective

This study aimed to evaluate the impact of different left ventricular geometric patterns on right ventricular deformation and function in the elderly with essential hypertension via two-dimensional speckle tracking and three-dimensional echocardiography.

Methods

A total of 248 elderly people with essential hypertension were divided into four groups based on the left ventricular mass index (LVMI) and relative wall thickness (RWT): the normal geometric, concentric remodeling, eccentric hypertrophy, and concentric hypertrophy groups. Moreover, 71 participants were recruited as the control group. These participants were examined by two-dimensional speckle tracking and three-dimensional echocardiography to obtain the right ventricular strain parameters, three-dimensional volume, and function parameters.

Results

The right ventricular strain parameters decreased gradually from the normal geometric group to the concentric hypertrophy group (P &lt; 0.05), and the strain parameters in the concentric remodeling, eccentric hypertrophy, and concentric hypertrophy groups were lower than those in the control and normal geometric groups (P &lt; 0.05). The right ventricular three-dimensional echocardiographic parameters only changed in the eccentric hypertrophy group (P &lt; 0.05) and the concentric hypertrophy group (P &lt; 0.05) in the form of an increase in volume and a decrease in function. Multivariate linear regression analysis showed that the right ventricular free wall longitudinal strain was independently associated with the systolic blood pressure (SBP), LVMI, and RWT (P &lt; 0.05) and was primarily affected by the LVMI (normalized β = 0.637, P &lt; 0.05).

Conclusion

The systolic function of the right ventricular myocardium declined in the elderly with essential hypertension due to impaired myocardial mechanics. The right ventricular strain parameters could indicate mechanical damage in the concentric remodeling group earlier than the right ventricular three-dimensional volume and function parameters. The right ventricular free wall longitudinal strain was primarily subject to the LVMI.