Assessment of Right Ventricular-Pulmonary Arterial Coupling in Chronic Pulmonary Regurgitation

BackgroundWe hypothesized that noninvasively measured right ventricular (RV) to pulmonary arterial (RV-PA) coupling would be abnormal in chronic pulmonary regurgitation (PR) even in the setting of normal RV ejection fraction, and that RV-PA coupling indices would have a better correlation with peak oxygen consumption (VO₂) compared with RV systolic indices alone.MethodsThis was a retrospective study of 129 adults (repaired tetralogy of Fallot [TOF] n = 84 and valvular pulmonic stenosis [VPS] with previous intervention n = 45) with ≥ moderate native PR and RV ejection fraction > 50%. The 84 TOF patients were propensity matched with 84 patients with normal echocardiogram (control); age 28 ± 7 years and male sex n = 39 (46%). RV-PA coupling was measured according to fractional area change (FAC)/RV systolic pressure (RVSP) and tricuspid annular plane systolic excursion (TAPSE)/RVSP.ResultsRV systolic function indices were similar between TOF and control groups (FAC 43 ± 6% vs 41 ± 5% [P = 0.164] and TAPSE 22 ± 5 mm vs 24 ± 6 mm [P = 0.263]). However, RV-PA coupling was lower in the TOF group (FAC/RVSP 1.10 ± 0.29 vs 1.48 ± 0.22 [P < 0.001]; TAPSE/RVSP 0.51 ± 0.15 vs 0.78 ± 0.11 [P < 0.001]) because of higher RV afterload (RVSP 42 ± 3 mm Hg vs 31 ± 3 mm Hg [P = 0.012]). FAC/RVSP (r = 0.61; P < 0.001) and TAPSE/RVSP (r = 0.69; P < 0.001) correlated with peak VO₂ especially in the patients with impaired exercise capacity whereas FAC and TAPSE were independent of peak VO₂. Similar comparisons between VPS and control groups showed no difference in TAPSE and FAC between groups, but lower FAC/RVSP and TAPSE/RVSP in the VPS group.ConclusionsThere is abnormal RV-PA coupling in chronic PR, and noninvasively measured RV-PA coupling might potentially be prognostic because of its correlation with exercise capacity.     

Automated 3-Dimensional Single-Beat Real-Time Volume Colour Flow Doppler Echocardiography in Children: A Validation Study of Right and Left Heart Flows

Background

Novel quantification of stroke volume according to mitral inflow and aortic outflow using automated real-time 3-dimensional volume colour flow Doppler echocardiography (3D-RT-VCFDE) is more accurate than 2-dimensional echocardiography and has excellent correlation with cardiac magnetic resonance imaging-based flows in adults. This technology is applied for the first time to the right heart and in children.

Right Ventricular Function and Beneficial Effects of Cardiac Rehabilitation in Patients With Systolic Chronic Heart Failure

Background

It has been recognized that a comprehensive cardiac rehabilitation (CR) program improves mortality in patients with chronic heart failure. On the other hand, the magnitude of the improvement in exercise capacity after CR differs among individuals. The aim of this study was to assess the echocardiographic determinants of responders to CR using preload stress echocardiography.

Iron Deficiency Is Associated With Impaired Biventricular Reserve and Reduced Exercise Capacity in Patients With Unexplained Dyspnea

BackgroundIron deficiency (ID) is frequent and associated with diminished exercise capacity in heart failure (HF), but its contribution to unexplained dyspnea without a HF diagnosis at rest remains unclear.Methods and ResultsConsecutive patients with unexplained dyspnea and normal echocardiography and pulmonary function tests at rest underwent prospective standardized cardiopulmonary exercise testing with echocardiography in a tertiary care dyspnea clinic. ID was defined as ferritin of <300 µg/L and a transferrin saturation of <20% and its impact on peak oxygen uptake (peakVO₂), biventricular response to exercise, and peripheral oxygen extraction was assessed. Of 272 patients who underwent cardiopulmonary exercise testing with echocardiography, 63 (23%) had ID. For a similar respiratory exchange ratio, patients with ID had lower peakVO₂ (14.6 ± 7.6 mL/kg/minvs 17.8 ± 8.8 mL/kg/min; P = .009) and maximal workload (89 ± 50 watt vs 108 ± 56 watt P = .047), even after adjustment for the presence of anemia. At rest, patients with ID had a similar left ventricular and right ventricular (RV) contractile function. During exercise, patients with ID had lower cardiac output reserve (P < .05) and depressed RV function by tricuspid s' (P = .004), tricuspid annular plane systolic excursion (P = .034), and RV end-systolic pressure-area ratio (P = .038), with more RV–pulmonary artery uncoupling measured by tricuspid annular plane systolic excursion/systolic pulmonary arterial pressure ratio (P = .023). RV end-systolic pressure-area ratio change from rest to peak exercise, as a load-insensitive metric of RV contractility, was lower in patients with ID (2.09 ± 0.72 mm Hg/cm² vs 2.58 ± 1.14 mm Hg/cm²; P < .001). ID was associated with impaired peripheral oxygen extraction (peakVO₂/peak cardiac output; P = .036). Cardiopulmonary exercise testing with echocardiography resulted in a diagnosis of HF with preserved ejection fraction in 71 patients (26%) based on an exercise E/e' ratio of >14, with equal distribution in patients with (28.6%) or without ID (25.4%, P = .611). None of these findings were influenced in a sensitivity analysis adjusted for a final diagnosis of HFpEF as etiology for the unexplained dyspnea.ConclusionsIn patients with unexplained dyspnea without clear HF at rest, ID is common and associated with decreased exercise capacity, diminished biventricular contractile reserve, and decreased peripheral oxygen extraction.     

Prognostic Value of Right Ventricular Strain Using Speckle-Tracking Echocardiography in Pulmonary Hypertension: A Systematic Review and Meta-analysis

Background

Right ventricular (RV) strain imaging using speckle-tracking echocardiography (STE) is a quantitative method of assessing RV systolic function that has shown prognostic utility in patients with pulmonary hypertension (PH). However, its prognostic value for a large and mixed PH population remains poorly defined.

Left ventricular diastolic performance at rest is essential for exercise capacity in patients with non-complicated myocardial infarction

IntroductionIn patients with recent myocardial infarction (MI) limited exercise capacity during physical activity is an important symptom and the base for future treatment. The myocardial injury after MI leads to both systolic and diastolic left ventricular (LV) dysfunction.ObjectiveThe aim of this study was to assess the relevance of systolic and diastolic LV function for cardiopulmonary exercise capacity in patients with prior MI.MethodsSixty-five consecutive patients after first MI without signs and symptoms of heart failure, aged 52 ± 6 years, were included in the study. The following echo parameters were evaluated: LV ejection fraction (LVEF), peak early and late diastolic velocities (E, A), deceleration time of E wave (dec t E), ratio of early trans-mitral to early annular diastolic velocities (E/e′), velocity propagation of early filling (Vp), and diameters and volumes of LV and left atrium (LA). CPET variables included: oxygen uptake at peak exercise (peak VO₂), oxygen pulse (VO₂ HR), VE/VCO₂ slope, circulatory power (CP) and recovery half time (T1/2).ResultsSignificant correlations were demonstrated between peak VO₂ and E/e’ (p < 0.001), peak VO₂ and dec t E (p < 0.001), VO₂ HR and E/e′ (p = 0.002) and between VE/VCO₂ and E/e′ (p < 0.001). Twenty patients with elevated LV filling pressure achieved significantly lower peak VO₂ (1624 vs. 1932 ml, p = 0.027) VO₂ HR (11.70 vs. 14.05, p = 0.011) and CP (287,073 vs. 361,719, p = 0.014). By using multivariate regression model we found that only E/e′ (p = 0.001) and dec t E (p = 0.008) significantly contributed to peak VO₂.ConclusionsDiastolic dysfunction, particularly LV filling pressure, determine exercise capacity, despite differences in LV ejection fraction in patients with prior MI.     

Determinants of exercise capacity in patients with heart failure without left ventricular hypertrophy

BackgroundDeterminants of exercise intolerance in a phenotype of heart failure with preserved ejection fraction (HFpEF) with normal left ventricular (LV) structure have not been fully elucidated.MethodsCardiopulmonary exercise testing and exercise-stress echocardiography were performed in 44 HFpEF patients without LV hypertrophy. Exercise capacity was determined by peak oxygen consumption (peak VO₂). Doppler-derived cardiac output (CO), transmitral E velocity, systolic (LV-s′) and early diastolic mitral annular velocities (e′), systolic pulmonary artery (PA) pressure (SPAP), tricuspid annular plane systolic excursion (TAPSE), and peak systolic right ventricular (RV) free wall velocity (RV-s′) were measured at rest and exercise. E/e′ and TAPSE/SPAP were used as an LV filling pressure parameter and RV-PA coupling, respectively.ResultsDuring exercise, CO, LV-s′, RV-s′, e′, and SPAP were significantly increased (p < 0.05 for all), whereas E/e′ remained unchanged and TAPSE/SPAP was significantly reduced (p < 0.001). SPAP was higher and TAPSE/SPAP was lower at peak exercise in patients showing lower-half peak VO₂. In univariable analyses, LV-s′ (R = 0.35, p = 0.022), SPAP (R = ?0.40, p = 0.008), RV-s′ (R = 0.47, p = 0.002), and TAPSE/SPAP (R = 0.42, p = 0.005) were significantly correlated with peak VO₂. In multivariable analyses, not only SPAP, but also TAPSE/SPAP independently determined peak VO₂ even after the adjustment for clinically relevant parameters.ConclusionsIn HFpEF patients without LV hypertrophy, altered RV-PA coupling by exercise could be associated with exercise intolerance, which might not be caused by elevated LV filling pressure.     

Improving Prenatal Diagnosis of Coarctation of the Aorta

Background

The purpose of the study was to evaluate the association between fetal echocardiographic measurements and the need for intervention (primary coarctation repair, staged coarctation repair, or catheter intervention) in prenatally diagnosed coarctation of the aorta.

Effects of Riociguat on Right Ventricular Remodelling in Chronic Thromboembolic Pulmonary Hypertension Patients: A Prospective Study

Background

The effects of riociguat treatment on right ventricular (RV) metabolism, perfusion, and output in patients with chronic thromboembolic pulmonary hypertension (CTEPH) are unknown. In this study, RV changes associated with riociguat therapy were investigated.

Right ventricular longitudinal strain correlates well with right ventricular stroke work index in patients with advanced heart failure referred for heart transplantation

BackgroundRight ventricular (RV) systolic function has a critical role in determining the clinical outcome and success of using left ventricular assist devices (LVADs) in patients with refractory heart failure. Tissue Doppler and M-mode measurements of tricuspid systolic motion (tricuspid S′ and tricuspid annular plane systolic excursion [TAPSE]) are the most currently used methods for the quantification of RV longitudinal function; RV deformation analysis by speckle-tracking echocardiography (STE) has recently allowed the analysis of global RV longitudinal function. Using cardiac catheterization as the reference standard, this study aimed at exploring the correlation between RV longitudinal function by STE and RV stroke work index (RVSWI) in patients referred for cardiac transplantation.Methods and ResultsRight-side heart catheterization and transthoracic echo Doppler were simultaneously performed in 41 patients referred for cardiac transplantation evaluation for advanced systolic heart failure. Thermodilution RV stroke volume and invasive pulmonary pressures were used to obtain RVSWI. RV longitudinal strain (RVLS) by STE was assessed averaging all segments in apical 4-chamber view (global RVLS) and by averaging RV free-wall segments (free-wall RVLS). Tricuspid S′ and TAPSE were also calculated. No significant correlations were found for TAPSE or tricuspid S′ with RVSWI (r = 0.14; r = 0.06; respectively). Close negative correlations between global RVLS and free-wall RVLS with the RVSWI were found (r = ?0.75; r = ?0.82; respectively; both P < .0001). Furthermore, free-wall RVLS demonstrated the highest diagnostic accuracy (area under the receiver operating characteristic (ROC) curve 0.90) and good sensitivity and specificity of 92% and 86%, respectively, to predict depressed RVSWI using a cutoff value of less than ?11.8%.ConclusionsIn a group of patients referred for heart transplantation, TAPSE and tricuspid S′ did not correlate with invasively obtained RVSWI. RV longitudinal deformation analysis by STE correlated well with RVSWI, providing a better estimation of RV systolic performance.     

Effects of the Metabolic Syndrome on Right Heart Mechanics and Function

Background

We sought to investigate right ventricular (RV) and right atrial (RA) deformation obtained using 3-dimensional echocardiography (3DE) and 2-dimensional (2DE) strain in subjects with the metabolic syndrome (MS).

Methods

This cross-sectional study included 108 untreated subjects with the MS and 75 control subjects similar according to sex and age. The MS was defined by the presence ≥ 3 American Heart Association/National Heart, Lung, and Blood Institute criteria. All the subjects underwent adequate laboratory analyses and complete 2DE and 3DE examination.

Results

2DE global longitudinal strain of the RV was significantly decreased in the MS group compared with the control subjects (−24 ± 5 vs −27 ± 5%; P < 0.001). Similar results were obtained for the RA longitudinal strain (40 ± 5 vs 44 ± 7%; P < 0.001). Systolic and early diastolic RV and RA strain rates were decreased, whereas late diastolic strain rates were increased among the MS participants compared with the control subjects. 3DE RV ejection fraction was significantly decreased in the MS subjects (55 ± 4 vs 58 ± 4%; P < 0.001). The multivariate analysis of MS criteria showed that systolic blood pressure, waist circumference, and fasting glucose were independently associated with RV and/or RA myocardial function and deformation.

Conclusions

RV mechanics and RA mechanics, assessed using 3DE and 2DE strain, were significantly deteriorated in the MS subjects. Among all MS risk factors, systolic blood pressure, abdominal circumference, and fasting glucose were the most responsible for the right heart remodelling.     

Assessment of Right Ventricular and Right Atrial Systolic and Diastolic Performance Using Automated Border Detection

Noninvasive assessment of right ventricular (RV) function is important clinically, but current techniques have limitations. Acoustic quantification (AQ) is an automated endocardial border detection technique that allows continuous determination of RV and right atrial (RA) area waveforms and may be useful for the assessment of RA and RV systolic and diastolic performance. Fifty patients (10 normal, 40 with RV pathology) were studied. Signal-averaged RA and RV AQ area waveforms were obtained and analyzed to compute parameters of diastolic and systolic function. All groups demonstrated significant diastolic dysfunction on the RA AQ waveform as manifested by a reduced percentage of passive atrial emptying and increased dependence on active atrial emptying. Abnormalities of diastolic performance were noted in all subgroups on RV AQ analysis as evidenced by a reduction in the percentage of ventricular filling occurring during early diastole and an increased contribution from active atrial contraction. This study demonstrates the feasibility of using automated analysis of signal-averaged RA and RV area waveforms for the evaluation of RV systolic and diastolic performance. This technique identified significant systolic and diastolic dysfunction in four groups of commonly seen right heart pathologies including biventricular heart failure, pulmonary hypertension, pressure and volume overloaded RVs, and biventricular hypertrophy.     

Right Ventricular Function and Prognosis in Stable Heart Failure Patients

BackgroundRight ventricular ejection fraction (RVEF) is a mortality predictor in heart failure (HF) patients. There are controversial results regarding the influence of RVEF on other important prognostic variables. The purpose of this study was to investigate the effect of RVEF on exercise parameters obtained during cardiopulmonary exercise testing (CPET), creatinine and B-type natriuretic peptide (BNP) levels, and a composite outcome of death, heart transplantation, or ventricular assist device implantation in ambulatory HF patients.Methods and ResultsThis retrospective cohort study included 246 ambulatory HF patients with CPET and RVEF evaluated with the use of first-pass radionuclide angiography. We analyzed the impact of RVEF on other prognostic factors with the use of multivariable linear regression. The mean age was 49 ± 12 years. The mean peak VO₂ was 16.4 ± 5.7 mL kg⁻¹ min⁻¹, mean peak VE/VCO₂ 34.1 ± 9.1, mean creatinine 1.17 ± 0.40 mg/dL, and median BNP 158 pg/mL (interquartile range 374 pg/mL). The mean left ventricular ejection fraction was 35 ± 12% and the mean RVEF 38 ± 10%. For every 10% decrease in RVEF, peak VO₂ decreased 0.97 mL kg⁻¹ min⁻¹ (P < .05), creatinine increased 0.12 mg/dL (P < .01), and log BNP increased 0.26 (P < .05).ConclusionsWe found an independent association between RVEF and prognostic markers in HF patients. Worsening RV function may exert its negative effect on prognosis through increasing congestion (elevated BNP), affecting renal blood flow (increased creatinine) and limiting left ventricular preload, thereby reducing exercise tolerance.     

Determinants and Prognostic Significance of Serial Right Heart Function Changes in Patients With Cardiac Amyloidosis

BackgroundRight heart function is an important prognostic determinant in cardiac amyloidosis. In this study we characterized serial changes in right and left heart function and evaluated their prognostic significance.MethodsCardiac amyloidosis patients with baseline and follow-up echocardiograms were included. Right and left heart function measured at baseline, 1 year, and most recent follow-up were compared and correlated with all-cause mortality or cardiovascular hospitalization.ResultsNinety-three patients were included; 36 (39%) with light chain amyloidosis and 57 (61%) with transthyretin amyloidosis. Among measures of right heart function for the study population and light chain and transthyretin amyloidosis subtypes, only absolute right ventricular (RV) free wall longitudinal strain (FWLS) changed significantly from baseline to 1 year and most recent follow-up echocardiogram. After a median of 26 months (range, 14-35 months), 21 (22%) patients died and 17 (18%) had a cardiovascular hospitalization. Baseline RV FWLS was significantly associated with the primary endpoint (hazard ratio, 1.2 per % change; 95% confidence interval, 0.8-2.6; P < 0.01), whereas change from baseline to 1 year was not for any measure of right heart function. Baseline left ventricular (LV) global longitudinal strain (GLS) and 1 year change were significantly associated with the primary end point. Change in RV FWLS at 1 year was significantly correlated with baseline LV GLS (r = 0.68; P = 0.01) and change at 1 year follow-up (r = 0.72; P < 0.01).ConclusionsIn cardiac amyloidosis patients, baseline RV FWLS was associated with adverse outcomes whereas changes at follow-up was not. Change in RV FWLS was significantly correlated with baseline and follow-up change in LV GLS, possibly reflecting progressive biventricular amyloid deposition.     

Aerobic Exercise Training Improves Right- and Left Ventricular Systolic Function in Patients with COPD

Abstract

Objective: The aim of this study was to investigate the effects of moderate continuous training (MCT) and high intensity aerobic interval training (AIT) on systolic ventricular function and aerobic capacity in COPD patients. Methods: Seventeen patients with COPD (64 ± 8 years, 12 men) with FEV₁ of 52.8 ± 11% of predicted, were randomly assigned to isocaloric programs of MCT at 70% of max heart rate (HR) for 47 minutes) or AIT (～90% of max HR for 4×4 minutes) three times per week for 10 weeks. Baseline cardiac function was compared with 17 age- and sex-matched healthy individuals. Peak oxygen uptake (VO_2-peak) and left (LV) and right ventricular (RV) function examined by echocardiography, were measured at baseline and after 10 weeks of training. Results: At baseline, the COPD patients had reduced systolic function compared to healthy controls (p < 0.05). After the training, AIT and MCT increased VO_2-peak by 8% and 9% and work economy by 7% and 10%, respectively (all p < 0.05). LV and RV systolic function both improved (p < 0.05), with no difference between the groups after the two modes of exercise training. Stroke volume increased by 17% and 20%, LV systolic tissue Doppler velocity (S’) by 18% and 17% and RV S’ by 15% after AIT and MCT, respectively (p < 0.05). Conclusion: Systolic cardiac function is reduced in COPD. Both AIT and MCT improved systolic cardiac function. In contrast to other patient groups studied, higher exercise intensity does not seem to have additional effects on cardiac function or aerobic capacity in COPD patients.     

Right Ventricular Systolic and Diastolic Function as Assessed by Speckle-Tracking Echocardiography Improve With Prolonged Isolated Left Ventricular Assist Device Support

BackgroundRight ventricular (RV) failure is a major cause of morbidity and mortality after left ventricular assist device (LVAD) implantation. Whether RV function deteriorates with prolonged LVAD support is unknown. Speckle-tracking echocardiography provides a sensitive, noninvasive, reproducible, and quantitative assessment of RV systolic and diastolic function.MethodsEchocardiograms were retrospectively reviewed from before and after implantation of a Heartmate II LVAD. Speckle-tracking analysis was performed to measure RV longitudinal systolic strain, strain rate, and diastolic strain rate for each patient at baseline and over discrete time periods after LVAD implantation.ResultsSeventeen patients were included in the analysis, with an average follow-up after LVAD implantation of 234 ± 125 days. RV systolic strain improved in 15 patients, decreasing from −7.4 ± 2.3% to −9.7 ± 3.3% after LVAD (P = .026). Systolic strain rate improved in 11 patients, decreasing from −0.67 ± 0.25%/s to −0.96 ± 0.36%/s (P = .011). RV diastolic strain rate improved in 12 patients, increasing from 0.70 ± 0.33%/s to 1.02 ± 0.40%/s (P = .016).ConclusionsChronic LVAD support improves RV systolic and diastolic function in LVAD patients who did not require an RV assist device. Speckle-tracking echocardiography may offer a noninvasive technique for identifying and monitoring improvements in RV function in LVAD patients.     

Tissue Doppler imaging adds incremental value in predicting exercise capacity in patients with congestive heart failure

Left ventricular (LV) systolic and diastolic parameters derived from Doppler echocardiography have been used widely to predict functional capacity but diastolic filling is affected by various factors. Tissue Doppler imaging (TDI) that records systolic and diastolic velocities within the myocardium and at the corners of the mitral annulus, has been shown to provide additional information about regional and global LV function. The goal of this study was to examine whether TDI-derived parameters add incremental value to other standard Doppler echocardiographic measurements in predicting exercise capacity. The study enrolled 59 consecutive patients with stable congestive heart failure (CHF). The etiology of heart failure was coronary artery disease in 42 patients and dilated cardiomyopathy in 17. Twenty-three age-matched healthy subjects were recruited as controls. Conventional echocardiographs and TDI were obtained. Early (Ea) and late (Aa) diastolic and systolic (Sa) mitral annulus velocities, the Ea/Aa and E/Ea ratios, were measured by pulsed wave TDI placed at the septal side of the mitral annulus and results were compared with results of cardiopulmonary exercise testing. Systolic and early diastolic velocities of mitral annulus were decreased and the E/Ea ratio was increased in the restrictive group as compared to controls (P = 0.02, P = 0.03, P < 0.001, respectively) but there was no significant difference in late diastolic velocity and the Ea/Aa ratio between the restrictive group and controls. The average peak VO₂ of the patients were 14.9 ± 4.9 ml/min per kg. Achieved peak VO₂ of the patients with E/Ea ratio ≤7.5 was 17.4 ± 5 vs 12.2 ± 3 ml/min per kg for those with E/Ea >7.5 (P < 0.001). Interestingly, the patients with the nonrestrictive pattern and E/Ea ratio >7.5 had reduced exercise capacity, as did the group with restrictive LV filling patterns (12.8 ± 3.3 vs 12.9 ± 4.0 ml/min per kg, P = 0.9). Similarly, there was no significant difference in the mean exercise capacity between the patients with a nonrestrictive pattern vs restrictive pattern with E/Ea ratio ≤7.5 (16.1 ± 5.0 vs 15.4 ± 5.1 ml/min per kg, P = 0.78). Univariate analysis demonstrated that the peak Sa (r = 0.30, P = 0.03), peak Ea (r = 0.38, P = 0.004) and peak Aa (r = 0.35, P = 0.009) correlated significantly with maximum exercise capacity. No relationship was observed between the Ea/Aa ratio and peak VO₂ (r = −0.09, P = 0.48). By multivariate analysis, including age and heart rate, the E/Ea ratio was found to be an independent prognostic factor at peak VO₂ (P < 0.001. In contrast, the comparison of the maximum transmitral early diastolic velocity and the mitral annulus TDI velocity, that is E/Ea ratio, had strong correlation with peak VO₂ (r = −0.46, P < 0.001). Receiver operating characteristic (ROC) analysis was performed for prediction of limited exercise capacity from the E/Ea ratio. An E/Ea ratio ≤7.5 was able to predict peak VO₂ ≤14 ml/min per kg with a sensitivity of 84% and a specificity of 74%. If restrictive pattern or an E/Ea ratio >7.5 was used, 21 out of 24 patients in the reduced exercise capacity group were identified with 16 false positives in the preserved exercise capacity group (P = 0.001). Mitral annular systolic and diastolic velocities of TDI were associated with cardiopulmonary exercise capacity in patients with LV systolic dysfunction. Index of the E/Ea ratio was found to be the most powerful predictor of peak oxygen uptake.     

Prognostic Impact of Worsening Renal Function in Hospitalized Heart Failure Patients With Preserved Ejection Fraction: A Report From the JASPER Registry

BackgroundThe characteristics and prognostic impact of persistent worsening renal function (WRF; defined as an increase in serum creatinine of >0.3 mg/dL during hospitalization) on heart failure with preserved ejection fraction have not yet been fully examined.Methods and ResultsThis was a post hoc analysis of the Japanese Heart Failure Syndrome with Preserved Ejection Fraction (JASPER) registry. We divided 523 patients with heart failure with preserved ejection fraction: the WRF group (n = 92 [17.6%]) and the non-WRF group (n = 431 [82.4%]). The WRF group showed a higher systolic blood pressure on admission and a higher prevalence of atherosclerotic diseases, respectively. Logistic regression analysis revealed that systolic blood pressure and loop diuretics were associated with WRF development (P < .05). The Kaplan-Meier analysis (median, 732 days) showed a higher all-cause death in the WRF group, as well as a higher composite end point of all-cause death or rehospitalization for HF (log-rank P < .001). The Cox proportional hazard analysis revealed WRF to be a predictor of both all-cause death (hazard ratio, 2.725; 95% confidence interval, 1.709–4.344; P < .001) and the composite end point (hazard ratio, 2.083; 95% confidence interval, 1.488–2.914; P < .001).ConclusionsPersistent WRF was associated with systolic blood pressure, atherosclerotic diseases, diuretics, and poor postdischarge prognosis in patients with heart failure with preserved ejection fraction.     

Left Ventricular Systolic Dysfunction and Cardiovascular Outcomes in Tetralogy of Fallot: Systematic Review and Meta-analysis

BackgroundAlthough there are robust data about the pathophysiology and prognostic implications of left ventricular (LV) systolic dysfunction in patients with acquired heart disease, similar prognostic data about LV systolic dysfunction are sparse in the tetralogy of Fallot (TOF) population. The purpose of this study was to perform a meta-analysis of all studies that assessed the relationship between LV ejection fraction (LVEF) and cardiovascular adverse events (CAEs) defined as death, aborted sudden death, or sustained ventricular tachycardia.MethodsWe used random-effects models to calculate hazard ratios (HRs) and 95% confidence intervals (CIs).ResultsOf the 1,809 citations, 7 studies with 2,854 patients (age 28 ± 4 years) were included. During 5.6 ± 3.4 years' follow-up, there were 82 deaths, 17 aborted sudden cardiac deaths, and 56 sustained ventricular tachycardia events. Overall, CAEs occurred in 5.1% (144 patients). As a continuous variable, LVEF was a predictor of CAE (HR 1.29, 95% CI, 1.09-1.53, P = 0.001) per 5% decrease in LVEF. Similarly, LVEF < 40% was also a predictor of CAE (HR 3.22, 95% CI, 2.16-4.80, P < 0.001).ConclusionsLV systolic dysfunction was an independent predictor of CAE, and we observed a 30% increase in the risk of CAE for every 5% decrease in LVEF, and a 3-fold increase in the risk of CAE in patients with LVEF <40% compared with other patients. These findings underscore the importance of incorporating LV systolic function in clinical risk stratification of patients with TOF and the need to explore new treatment options to address this problem.     

Echocardiographic Evaluation of Right Ventricular Function in Patients with Acute Pulmonary Embolism: A Study Using Tricuspid Annular Motion

Assessment of right ventricular (RV) function is a challenge due to complex anatomy. We studied systolic and diastolic tricuspid annular excursion and longitudinal RV fractional shortening as geometry‐independent measures in patients with acute pulmonary embolism (PE). Forty patients with PE were studied within 24 hours after admission and after 3 months, and compared to 23 healthy subjects used as controls. We recorded tricuspid annular plane systolic (TAPSE) and diastolic (TAPDE) excursion from the four‐chamber view and calculated RV fractional shortening as TAPSE/RV diastolic length. The diastolic RV function was defined as the ratio of the amplitude of tricuspid annular plane excursion during atrial systole to total tricuspid annular plane diastolic excursion (atrial/total TAPDE). In the acute stage, the TAPSE was decreased in PE compared to healthy subjects (19 ± 5 vs. 26 ± 4 mm, P < 0.001), with greater reduction in patients with increased, compared to normal, RV pressure (16.6 ± 5 vs. 20.5 ± 5 mm, P < 0.05). The atrial/total TAPDE was increased in patients compared to healthy subjects (47 ± 13% vs. 38 ± 7%, P < 0.001) and normalized during the follow‐up. Although the patients were asymptomatic after 3 months, the TAPSE recovered incompletely as compared to healthy subjects (21.4 ± 4 vs. 26 ± 4 mm, P < 0.001). Both systolic and diastolic RV function are impaired in acute PE. Diastolic function recovers faster than systolic; therefore, the atrial contribution to RV filling may be a useful measure to follow changes in diastolic function in PE. (Echocardiography 2010;27:286‐293)