Relationship between Right Ventricular Longitudinal Strain, Invasive Hemodynamics, and Functional Assessment in Pulmonary Arterial Hypertension
01 Sep 2015-Korean Circulation Journal (The Korean Society of Cardiology)-Vol. 45, Iss: 5, pp 398-407
TL;DR: RVLS correlates with functional and invasive hemodynamic parameters in PAH patients and decrease of mPAP and PVR as a result of treatment was associated with improvement of RVLS.
Abstract: Background and Objectives: Right ventricular longitudinal strain (RVLS) is a new parameter of RV function. We evaluated the relationship of RVLS by speckle-tracking echocardiography with functional and invasive parameters in pulmonary arterial hypertension (PAH) patients. Subjects and Methods: Thirty four patients with World Health Organization group 1 PAH (29 females, mean age 45±13 years old). RVLS were analyzed with velocity vector imaging. Results: Patients with advanced symptoms {New York Heart Association (NYHA) functional class III/IV} had impaired RVLS in global RV (RVLSglobal, -17±5 vs. -12±3%, p<0.01) and RV free wall (RVLSFW, -19±5 vs. -14±4%, p<0.01 to NYHA class I/II). Baseline RVLSglobal and RVLSFW showed significant correlation with 6-minute walking distance (r=-0.54 and r=-0.57, p<0.01 respectively) and logarithmic transformation of brain natriuretic peptide concentration (r=0.65 and r=0.65, p<0.01, respectively). These revealed significant correlations with cardiac index (r=-0.50 and r=-0.47, p<0.01, respectively) and pulmonary vascular resistance (PVR, r=0.45 and r=0.45, p=0.01, respectively). During a median follow-up of 33 months, 25 patients (74%) had follow-up examinations. Mean pulmonary arterial pressure (mPAP, 54±13 to 46±16 mmHg, p=0.03) and PVR (11±5 to 6±2 wood units, p<0.01) were significantly decreased with pulmonary vasodilator treatment. RVLSglobal (-12±5 to -16±5%, p<0.01) and RVLSFW (-14±5 to -18±5%, p<0.01) were significantly improved. The decrease of mPAP was significantly correlated with improvement of RVLS global (r=0.45, p<0.01) and RVLSFW (r=0.43, p<0.01). The PVR change demonstrated significant correlation with improvement of RVLS global (r=0.40, p<0.01). Conclusion: RVLS correlates with functional and invasive hemodynamic parameters in PAH patients. Decrease of mPAP and PVR as a result of treatment was associated with improvement of RVLS. (Korean Circ J 2015;45(5):398-407)
Citations
More filters
01 Sep 2018
TL;DR: RVGLS measurement, normal reference values, and the clinical importance of RVGLS are discussed; and RV global longitudinal strain (RVGLS) can be used as an objective index of RV systolic function with prognostic significance.
Abstract: Right ventricular (RV) systolic dysfunction has been identified as an independent prognostic marker of many cardiovascular diseases. However, there are problems in measuring RV systolic function objectively and identification of RV dysfunction using conventional echocardiography. Strain echocardiography is a new imaging modality to measure myocardial deformation. It can measure intrinsic myocardial function and has been used to measure regional and global left ventricular (LV) function. Although the RV has different morphologic characteristics than the LV, strain analysis of the RV is feasible. After strain echocardiography was introduced to measure RV systolic function, it became more popular and was incorporated into recent echocardiographic guidelines. Recent studies showed that RV global longitudinal strain (RVGLS) can be used as an objective index of RV systolic function with prognostic significance. In this review, we discuss RVGLS measurement, normal reference values, and the clinical importance of RVGLS.
68 citations
TL;DR: Special attention is focused on the usefulness of RV echo-evaluation in relation to load for proper decision making before ventricular assist-device implantation in patients with CHF and for optimal timing of listing procedures to transplantation in Patients with end-stage pre-capillary PH.
39 citations
TL;DR: It is concluded that RVFreeWSt may be a suitable non-geometric 2DE surrogate of CMR-RVEF in PAH patients, constituting a powerful independent predictor of long-term outcome in this cohort with relatively preserved functional capacity.
Abstract: Right ventricular (RV) dysfunction harbingers adverse prognosis in pulmonary arterial hypertension (PAH). Although conventional two-dimensional echocardiography (2DE) is limited for RV systolic function quantitation, RV strain can be a useful tool. The diagnostic and prognostic impact of 2DE speckle-tracking RV longitudinal strain was evaluated, including other 2DE systolic indexes, in a group of PAH patients without severe impairment of functional capacity, chronic pulmonary thromboembolism or left ventricular dysfunction. Sixty-six group I PAH patients, 67 % NYHA functional class I or II (none in IV) were studied by 2DE to obtain: RV fractional area change, tricuspid annular plane systolic excursion, RV myocardial performance index, tissue Doppler tricuspid annulus systolic velocity. Global, free wall (RVFreeWSt) and septal RV longitudinal systolic strain were obtained. RV ejection fraction by cardiac magnetic resonance (CMR-RVEF) was also assessed. All patients were followed up to 3.9 years (mean 3.3 years). Combined endpoints were hospitalization for worsening PAH or cardiovascular death. Among all the 2DE indexes of RV systolic function, RVFreeWSt exhibited the best correlation with CMR-RVEF (r = 0.83; p < 0.005). Combined endpoints occurred in 15 (22.7 %) patients (6 hospitalizations and 9 deaths). Multivariate analysis identified RVFreeWSt ≤-14 % as the only 2DE independent variable associated with combined endpoints [HR 4.66 (1.25-17.37); p < 0.05]. We conclude that RVFreeWSt may be a suitable non-geometric 2DE surrogate of CMR-RVEF in PAH patients, constituting a powerful independent predictor of long-term outcome in this cohort with relatively preserved functional capacity.
33 citations
Cites background or methods from "Relationship between Right Ventricu..."
...Several other studies reported the prognostic role of RV longitudinal systolic strain in patients with PAH, including significant proportion of advanced NYHA functional class (III/IV) individuals [11, 12], group IV PAH patients (chronic thromboembolism) [13–16] and low left ventricular (LV) ejection fraction [14], conditions that may affect long-term...
[...]
...A reference point was set at the onset of the QRS complex of the superimposed ECG [12] for all measurements....
[...]
TL;DR: This review discusses the particular challenges and limits in obtaining accurate measurements of RV anatomical and functional parameters and focuses primarily on the difficulties in proper interpretation of the highly load dependent RV ECHO-parameters which complicates the use of this valuable diagnostic and surveillance technique.
Abstract: Introduction: Compared with the left ventricle (LV), the right ventricle (RV) is less suited for evaluation by echocardiography (ECHO). Nevertheless, RV ECHO-assessment has currently emerged as an ...
26 citations
Cites background from "Relationship between Right Ventricu..."
...In patients with pulmonary arterial hypertension (PAH) it was found that RV longitudinal strain and strain rate correlate not only with 6MWD, but also with invasive hemodynamic parameters, and decrease of both mPAP and PVR after treatment was associated with improvement of right ventricle longitudinal strain (RVLS)[63]....
[...]
TL;DR: The measurement and clinical utility of 2-dimensional strain analysis in various cardiovascular diseases is described.
Abstract: Echocardiography is the first and is the most-available imaging modality for many cardiovascular diseases, and echocardiographic parameters can give much important information for diagnosis, treatment, and prognostic evaluations. Left ventricular ejection fraction (LVEF) is the most commonly used echocardiographic parameter for left ventricular (LV) systolic function. Although LVEF is used routinely in daily practice, it is calculated from volumetric change without representing true myocardial properties. Recently, strain echocardiography has been used to objectively measure myocardial deformation. Myocardial strain can give accurate information about intrinsic myocardial function, and it can be used to detect early-stage cardiovascular diseases, monitor myocardial changes with specific therapies, differentiate cardiomyopathies, and predict the prognosis of several cardiovascular diseases. Although strain echocardiography has been applied to measure the right ventricle and left atrium, in addition to analyzing the LV, many cardiologists who are not imaging specialists are unaware of its clinical use and importance. Therefore, this review describes the measurement and clinical utility of 2-dimensional strain analysis in various cardiovascular diseases.
23 citations
References
More filters
TL;DR: Improved RV function following pulmonary vasodilator therapy occurs solely from improvements in longitudinal contraction, suggesting that longitudinal shortening may represent the afterload-responsive element of RV functional recovery.
149 citations
TL;DR: The correlation between left and RV MRI-derived stroke volumes indicates excellent coherence of simultaneous bi-ventricular volume measurements and the assessment of the RV mass, volumes and function by routine breath-hold gradient echo MRI is accurate and highly reproducible.
Abstract: Right ventricular (RV) dysfunction is a predictor of poor outcome in patients with heart disease. Conventional imaging modalities fail to assess RV volumes accurately. We sought to assess the accuracy and reproducibility of routine breath-hold gradient echo magnetic resonance imaging (MRI)-derived RV mass, volumes and function. We assessed (1) The accuracy of in vivo MRI-derived RV mass in comparison to the RV weight in 9 minipigs. (2) Intra- and inter-observer reproducibility of RV mass, end-diastolic (EDV) and end-systolic (ESV) volumes and ejection fraction (EF) in 15 normal volunteers and 10 patients with heart disease. (3) Inter-study reproducibility of the former parameters in 25 coronary artery disease patients. (4) The correlation between right and left ventricular stroke volumes in the total population. Strong statistically significant correlations were found between: (1) MRI-derived RV mass and RV weight (r = 0.98, bias = 2.5 g), (2) Intra-observer measurements of RV mass (r = 0.96, bias = 0.5 g), EDV (r = 0.99, bias = −1.5 ml), ESV (r = 0.98, bias = 0.1 ml) and EF (r = 0.92, bias = −1.4%), (3) Inter-observer measurements of RV mass (r = 0.95, bias = 1.1 g), EDV (r = 0.98, bias = −1.1 ml), ESV (r = 0.98, bias = 1.2 ml) and EF (r = 0.87, bias = −1.9%), (4) Inter-study measurements of RV mass (r = 0.91, bias = −0.1 g), EDV (r = 0.96, bias = 3.8 ml), ESV (r = 0.98, bias = 0.3 ml) and EF (r = 0.90, bias = 0.9%), (5) MRI-derived right and left ventricular stroke volumes (r = 0.87). The assessment of the RV mass, volumes and function by routine breath-hold gradient echo MRI is accurate and highly reproducible. The correlation between left and RV MRI-derived stroke volumes indicates excellent coherence of simultaneous bi-ventricular volume measurements.
112 citations
TL;DR: Dynamic improvement in RV mechanics in response to intensive medical therapy was associated with lower long-term adverse events in patients with ADHF than in patients not showing improvement.
Abstract: Background—Right ventricular (RV) systolic dysfunction is a strong predictor of adverse outcomes in heart failure, yet quantitatively assessing the impact of therapy on this condition is difficult. Our objective was to compare the clinical significance of changes in RV echocardiographic indices in response to intensive medical treatment in patients admitted to the hospital with acute decompensated heart failure (ADHF). Methods and Results—Serial comprehensive echocardiography was performed in 62 consecutive patients with ADHF, and adverse events (death, cardiac transplantation, assist device, heart failure rehospitalization) were prospectively documented. RV peak systolic strain was assessed using speckle-tracking longitudinal strain analysis as the average of the basal, mid-, and apical segment of the RV free wall. Other conventional parameters of RV function (RV fractional area change, RV myocardial performance index, tricuspid annular peak systolic excursion, and tissue Doppler peak tricuspid annular s...
96 citations
TL;DR: The authors conclude that current medical therapies approved for the treatment of PAH can provide sustained benefits in hemodynamic function and exercise capacity and that patients are living longer compared with untreated patients.
62 citations
TL;DR: Monitoring of each patient, whether treated with oral calcium channel blockers, endothelin antagonists, PDE5i, or parenteral prostacycline analogues, is therefore very important because wasting time for less effective therapy might result in irreversible progression of pulmonary vascular lesions with all clinical consequences.
Abstract: Pulmonary arterial hypertension (PAH) is clinically a highly malignant disease. Although pathological changes are limited to the vascular wall, uncontrolled proliferation is mostly directed towards vascular lumen. Pulmonary input impedance usually increases at a rate which cannot be effectively matched by the right ventricular (RV) adaptive mechanisms. A series of consequences including RV dilatation, functional tricuspid regurgitation, decreased pulmonary flow, compromised LV filling, and low systemic cardiac output contribute to a fatal vicious circle. The expected median survival of 2.8 years in conventionally treated idiopathic PAH is indeed similar to that of advanced lung or breast cancer.1
In the last decade, important progress has been made in the understanding of the physiopathology and therapy of this disease. Several drugs interfering with important physiopathological pathways of PAH progression were approved, based on the results of right heart catheterization (RCT).2 None of those therapies permit a cure. Nevertheless, in many patients, it is now possible to slow, stop, and sometimes partly revert the otherwise progressive pulmonary vascular obliteration. This gives the RV chance to adapt to increased afterload. Sustained clinical improvement can sometimes be achieved already with a first-line oral drug. However, the individual long-term response to any form of medical therapy may vary and cannot be predicted. Monitoring of each patient, whether treated with oral calcium channel blockers (CCB), endothelin antagonists, PDE5i, or parenteral prostacycline analogues, is therefore very important. Wasting time for less effective therapy might result in irreversible progression of pulmonary vascular lesions with all clinical consequences.
Current therapeutic algorithm suggests haemodynamic test for pulmonary vasoreactivity and assessment of the WHO functional class (FC) as sufficient for selecting initial therapy. Decisions whether and when to change the oral drug, switch to combination and/or parenteral therapy, perform interventions such as atrial septostomy or list for lung transplantation require …
Corresponding author. Tel: +48 22 4312114; fax: +48 22 4312414. E-mail address : a.torbicki{at}igichp.edu.pl
48 citations