Adjusting Therapy in Pulmonary Arterial Hypertension – The Role of Novel Echocardiographic Techniques

2010 ◽  
Vol 6 (2) ◽  
pp. 38
Author(s):  
John G Coghlan ◽  
Denis Pellerin ◽  
◽  
Keyword(s):  
Right Ventricular ◽  
Large Scale ◽  
Systolic Function ◽  
Right Atrial ◽  
Strain Rate Imaging ◽  
Standard Clinical Practice ◽  
Volumetric Assessment ◽  
Ventricular Response ◽  
Survival Studies ◽  
Right Ventricular Diastolic Function

In theory, echocardiography allows an accurate measurement of pulmonary artery pressure, approximate right atrial pressure, cardiac output, right ventricular diastolic function and non-volumetric assessment of systolic function, as well as some insight into the structural alterations of right ventricular architecture. Unfortunately, the vast array of possible measures complicates distillation of the few parameters that provide reproducible prognostically important information. The modest reductions in afterload achieved with current therapies (<5mmHg on average) and the unpredictability of right ventricular response, coupled with the complexity of the populations treated, means that only large-scale survival studies should be considered when determining which parameters inform patient management. Of currently widely used measures, only tricuspid annular plane systolic excursion (TAPSE) and pericardial effusion are recommended when adjusting therapy. Increased use of contrast echo, strain rate imaging, vector velocity imaging and 3D echocardiography appear to hold most hope for the future; however, none as yet has the database to support inclusion in standard clinical practice.

Adjusting Therapy in Pulmonary Arterial Hypertension – The Role of Novel Echocardiographic Techniques

2010 ◽  
Vol 6 (4) ◽  
pp. 26
Author(s):  
John G Coghlan ◽  
Denis Pellerin ◽  
◽  
Keyword(s):  
Right Ventricular ◽  
Large Scale ◽  
Systolic Function ◽  
Right Atrial ◽  
Strain Rate Imaging ◽  
Standard Clinical Practice ◽  
Volumetric Assessment ◽  
Ventricular Response ◽  
Survival Studies ◽  
Right Ventricular Diastolic Function

In theory, echocardiography allows an accurate measurement of pulmonary artery pressure, approximate right atrial pressure, cardiac output, right ventricular diastolic function and non-volumetric assessment of systolic function, as well as some insight into the structural alterations of right ventricular architecture. Unfortunately, the vast array of possible measures complicates distillation of the few parameters that provide reproducible prognostically important information. The modest reductions in afterload achieved with current therapies (<5mmHg on average) and the unpredictability of right ventricular response, coupled with the complexity of the populations treated, means that only large-scale survival studies should be considered when determining which parameters inform patient management. Of currently widely used measures, only tricuspid annular plane systolic excursion (TAPSE) and pericardial effusion are recommended when adjusting therapy. Increased use of contrast echo, strain rate imaging, vector velocity imaging and 3D echocardiography appear to hold most hope for the future; however, none as yet has the database to support inclusion into standard clinical practice.

scholarly journals Prognostic Value of Echocardiographic Right Ventricular Function Parameters in the Presence of Severe Tricuspid Regurgitation

2021 ◽  
Vol 10 (11) ◽  
pp. 2266
Author(s):  
Matthias Schneider ◽  
Varius Dannenberg ◽  
Andreas König ◽  
Welf Geller ◽  
Thomas Binder ◽  
...  
Keyword(s):  
Right Ventricular ◽  
Ventricular Function ◽  
Tricuspid Regurgitation ◽  
Right Ventricular Function ◽  
Prognostic Value ◽  
Large Scale ◽  
Systolic Function ◽  
Left Ventricular ◽  
Severe Tricuspid Regurgitation ◽  
Vena Contracta

Background: Presence of severe tricuspid regurgitation (TR) has a significant impact on assessment of right ventricular function (RVF) in transthoracic echocardiography (TTE). High trans-valvular pendulous volume leads to backward-unloading of the right ventricle. Consequently, established cut-offs for normal systolic performance may overestimate true systolic RVF. Methods: A retrospective analysis was performed entailing all patients who underwent TTE at our institution between 1 January 2013 and 31 December 2016. Only patients with normal left ventricular systolic function and with no other valvular lesion were included. All recorded loops were re-read by one experienced examiner. Patients without severe TR (defined as vena contracta width ≥7 mm) were excluded. All-cause 2-year mortality was chosen as the end-point. The prognostic value of several RVF parameters was tested. Results: The final cohort consisted of 220 patients, 88/220 (40%) were male. Median age was 69 years (IQR 52–79), all-cause two-year mortality was 29%, median TAPSE was 19 mm (15–22) and median FAC was 42% (30–52). In multivariate analysis, TAPSE with the cutoff 17 mm and FAC with the cutoff 35% revealed non-significant hazard ratios (HR) of 0.75 (95%CI 0.396–1.421, p = 0.38) and 0.845 (95%CI 0.383–1.867, p = 0.68), respectively. TAPSE with the cutoff 19 mm and visual eyeballing significantly predicted survival with HRs of 0.512 (95%CI 0.296–0.886, p = 0.017) and 1.631 (95%CI 1.101–2.416, p = 0.015), respectively. Conclusions: This large-scale all-comer study confirms that RVF is one of the main drivers of mortality in patients with severe isolated TR. However, the current cut-offs for established echocardiographic parameters did not predict survival. Further studies should investigate the prognostic value of higher thresholds for RVF parameters in these patients.

scholarly journals Right ventricular diastolic function in canine models of pressure overload, volume overload, and ischemia

2002 ◽  
Vol 283 (5) ◽  
pp. H2140-H2150 ◽  
Author(s):  
Ares Pasipoularides ◽  
Ming Shu ◽  
Ashish Shah ◽  
Scott Silvestry ◽  
Donald D. Glower
Keyword(s):  
Right Ventricular ◽  
Diastolic Function ◽  
Diastolic Pressure ◽  
Systolic Function ◽  
Pressure Overload ◽  
Volume Overload ◽  
Exponential Model ◽  
Filling Pressure ◽  
Sigmoidal Model ◽  
Right Ventricular Diastolic Function

By limiting filling, abnormalities of right ventricular (RV) diastolic function may impair systolic function and affect adaptation to disease. To quantify diastolic RV pressure-volume relations and myocardial compliance (MC), a new sigmoidal model was developed. RV micromanometric and sonomicrometric data in alert dogs at control ( n = 16) and under surgically induced subacute (2–5 wk) RV pressure overload ( n = 6), volume overload ( n = 7), and ischemia ( n = 6) were analyzed. The conventional exponential model detected no changes from control in the passive filling pressure-volume (Ppf-V) relations. The new sigmoidal model revealed significant quantifiable changes in Ppf-V relations. Maximum RV MC (MCmax), attained during early filling, is reduced from control in pressure overload ( P = 0.0016), whereas filling pressure at maximum MC (PMCmax) is increased ( P = 0.0001). End-diastolic RV MC increases significantly in volume overload ( P = 0.0131), whereas end-diastolic pressure is unchanged. In ischemia, MCmax is decreased ( P = 0.0102), with no change in PMCmax. We conclude that the sigmoidal model quantifies important changes in RV diastolic function in alert dog models of pressure overload, volume overload, and ischemia.

scholarly journals Right Ventricular Diastolic Performance in Patients With Chronic Thromboembolic Pulmonary Hypertension Assessed by Echocardiography

2021 ◽  
Vol 8 ◽  
Author(s):  
Hong Meng ◽  
Wu Song ◽  
Sheng Liu ◽  
David Hsi ◽  
Lin-Yuan Wan ◽  
...  
Keyword(s):  
Pulmonary Hypertension ◽  
Right Ventricular ◽  
Diastolic Dysfunction ◽  
Systolic Function ◽  
Characteristic Curve ◽  
Three Dimensional ◽  
Chronic Thromboembolic Pulmonary Hypertension ◽  
Right Atrial ◽  
Pulmonary Endarterectomy ◽  
Thromboembolic Pulmonary Hypertension

Background: There have been no systemic studies about right heart filling pressure and right ventricular (RV) distensibility in patients with chronic thromboembolic pulmonary hypertension (CTEPH). Therefore, we aimed to explore combinations of echocardiographic indices to assess the stages of RV diastolic dysfunction.Methods and Results: We recruited 32 healthy volunteers and 71 patients with CTEPH. All participants underwent echocardiography, cardiac catheterization (in patients with CTEPH), and a 6-min walk test (6MWT). The right atrial (RA) end-systolic area was adjusted for body surface area (BSA) (indexed RA area). RV global longitudinal diastolic strain rates (SRs) and RV ejection fraction (EF) were measured by speckle tracking and three-dimensional echocardiography (3D echo), respectively. All 71 patients with CTEPH underwent pulmonary endarterectomy. Of the 71 patients, 52 (73%) had decreased RV systolic function; 12 (16.9%), 26 (36.6%), and 33 (46.5%) patients had normal RV diastolic pattern, abnormal relaxation (stage 1), and pseudo-normal patterns (stage 2), respectively. The receiver operating characteristic curve analysis showed that the optimal cut-off values of early diastolic SR &lt;0.8 s−1 and indexed RA area &gt; 8.8 cm2/BSA had the best accuracy in identifying patients with RV diastolic dysfunction, with 87% sensitivity and 82% specificity. During a mean follow-up of 25.2 months after pulmonary endarterectomy, the preoperative indexed RA area was shown as an independent risk factor of the decreased 6MWT distance.Conclusions: Measuring early diastolic SR and indexed RA area would be useful in stratifying RV diastolic function.

scholarly journals Amelioration of right ventricular systolic function and stiffness in a patient with idiopathic pulmonary arterial hypertension treated with oral triple combination therapy

2018 ◽  
Vol 8 (2) ◽  
pp. 204589401876535 ◽  
Author(s):  
Toshitaka Nakaya ◽  
Ichizo Tsujino ◽  
Hiroshi Ohira ◽  
Takahiro Sato ◽  
Taku Watanabe ◽  
...  
Keyword(s):  
Pulmonary Arterial Hypertension ◽  
Arterial Hypertension ◽  
Right Ventricular ◽  
Systolic Function ◽  
Right Atrial ◽  
Arterial Elastance ◽  
Triple Combination Therapy ◽  
Pulmonary Vasodilators ◽  
Pulmonary Arterial ◽  
Rv Function

Right ventricular (RV) function is an important determinant of the prognosis in patients with pulmonary arterial hypertension (PAH). In the context of recent therapeutic progress, there is an increasing need for better monitoring of RV function for management of PAH. We present the case of a 42-year-old woman with idiopathic PAH who was treated with three oral pulmonary vasodilators, i.e. tadalafil, ambrisentan, and beraprost. At the baseline assessment, the mean pulmonary arterial pressure (mPAP) was 45 mmHg, cardiac index (CI) was 1.36 L/min/m2, and pulmonary vascular resistance (PVR) was elevated to 21.3 Wood units (WU). However, three months after the start of combination treatment, mPAP and PVR decreased to 42 mmHg and 7.5 WU, respectively, and conventional indices of RV function, such as CI, right atrial area, and right atrial pressure also improved. Beyond three months, however, there were no further improvements in mPAP, PVR, or indices of RV function. In addition, we calculated three recently introduced indices of intrinsic RV function: end-systolic elastance (Ees; an index of RV contractility), Ees/arterial elastance ratio (Ees/Ea; an index of RV/pulmonary arterial coupling), and β (an index of RV stiffness) using cardiac magnetic resonance imaging and Swan-Ganz catheterization measurements. Notably, in contrast to conventional parameters, Ees, Ees/Ea, and β showed persistent improvement during the entire two-year follow-up. The application of Ees, Ees/Ea, and β may play an additional role in a comprehensive assessment of RV function in PAH.

scholarly journals Right Atrial and Ventricular Adaptation to Chronic Right Ventricular Pressure Overload

Circulation ◽  
2005 ◽  
Vol 112 (9_supplement) ◽  
Author(s):  
Sydney L. Gaynor ◽  
Hersh S. Maniar ◽  
Jeffrey B. Bloch ◽  
Paul Steendijk ◽  
Marc R. Moon
Keyword(s):  
Pulmonary Hypertension ◽  
Pulmonary Artery ◽  
Right Ventricular ◽  
Right Atrium ◽  
Systolic Function ◽  
Pressure Overload ◽  
Right Atrial ◽  
Chronic Pulmonary Hypertension ◽  
The Right ◽  
Conduit Function

Background— Increased mortality in patients with chronic pulmonary hypertension has been associated with elevated right atrial (RA) pressure. However, little is known about the effects of chronic right ventricular (RV) pressure overload on RA and RV dynamics or the adaptive response of the right atrium to maintain RV filling. Methods and Results— In 7 dogs, RA and RV pressure and volume (conductance catheter) were recorded at baseline and after 3 months of progressive pulmonary artery banding. RA and RV elastance (contractility) and diastolic stiffness were calculated, and RA reservoir and conduit function were quantified as RA inflow with the tricuspid valve closed versus open, respectively. With chronic pulmonary artery banding, systolic RV pressure increased from 34±7 to 70±17 mm Hg ( P <0.001), but cardiac output did not change ( P >0.78). RV elastance and stiffness both increased ( P <0.05), suggesting preserved systolic function but impaired diastolic function. In response, RA contractility improved (elastance increased from 0.28±0.12 to 0.44±0.13 mm Hg/mL; P <0.04), and the atrium became more distensible, as evidenced by increased reservoir function (49±14% versus 72±8%) and decreased conduit function (51±14% versus 28±8%; P <0.002). Conclusions— With chronic RV pressure overload, RV systolic function was preserved, but diastolic function was impaired. To compensate, RA contractility increased, and the atrium became more distensible to maintain filling of the stiffened ventricle. This compensatory response of the right atrium likely plays an important role in preventing clinical failure in chronic pulmonary hypertension.

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