Worsened Tricuspid Regurgitation Following Pericardiectomy for Constrictive Pericarditis

Background: Worsening tricuspid regurgitation (TR) severity may occur after pericardiectomy surgery for constrictive pericarditis patients; however, its mechanisms and predictors are not well established. We evaluated the clinical characteristics, associated factors, and outcomes of worsening TR after pericardiectomy. Methods: Consecutive patients undergoing pericardiectomy for constrictive pericarditis without tricuspid valve surgery and with pre- and postoperative echocardiography available during 2000 to 2017 were retrospectively studied. Clinical, imaging, hemodynamic, and mortality characteristics were analyzed by those with and without worsening TR by at least one grade. Results: Among 381 patients (age 61 [17] years, 318 [83.5%] male), 193 (50.7%) had worsening TR post-operatively, and 75 died during the 2.5 (5.4) years follow-up. In univariable analysis, worsening TR was associated with a history of congestive heart failure (47.2% versus 31.9%, P =0.003), increased left atrial volume indexed (23 versus 20 mL/m 2 , P =0.020), reduced right ventricular fractional area change (47% versus 54%, P <0.001), and worsening mitral regurgitation (39.7% versus 16.6%, P <0.001). Worsened TR had a trend toward reduced survival during follow-up (log-rank P =0.080), especially those with worsened TR but no recovery of TR grade on subsequent echocardiography within the first year compared with those without worsened TR (log-rank P =0.02). In multivariable analysis, right ventricular fractional area change, left atrial volume indexed, left ventricular mass indexed, pulmonary artery systolic pressure, and right atrial pressure/pulmonary capillary wedge pressure ratio were most associated with worsened TR, while blood urea nitrogen, hematocrit, lateral and medial e’ tissue Doppler and heart rate were most associated with mortality during follow-up. Conclusions: Worsening TR severity was prevalent after pericardiectomy and had a trend toward reduced survival, especially if TR severity did not recover on subsequent echocardiography. Presence of parameters associated with worsened TR and reduced survival should alert clinicians to carefully manage these patients during follow-up.

Long-Term Electrocardiographic and Echocardiographic Progression of Arrhythmogenic Right Ventricular Cardiomyopathy and Their Correlation With Ventricular Tachyarrhythmias

Background: Prior studies of structural and electrocardiographic changes in arrhythmogenic right ventricular (RV) cardiomyopathy and their role in predicting ventricular arrhythmias (ventricular tachycardia) have shown conflicting results. Methods: We reviewed 405 ECGs, 315 transthoracic echocardiographies, and 441 implantable cardioverter defibrillator interrogations in 64 arrhythmogenic RV cardiomyopathy patients (56% men, mean age [SD], 44.2 [14.6] years) over a mean follow-up of 10 (range, 2.3–19) years. Generalized estimating equations were used to identify the association between ECG abnormalities, clinical variables, and transthoracic echocardiographic measurements (>mild degree of tricuspid regurgitation, RV outflow tract diameter in parasternal long axis and short axis, RV end-diastolic area, fractional area change). Results: There was a 4.65 (95% CI, 0.51%–8.8%) increase in RV end-diastolic area, a 3.75 (95% CI, 1.17%–6.34%) decrease in fractional area change, and 1.9 (95% CI, 1.3–2.8) higher odds (odds ratio) of RV wall motion abnormality with every 5-year increase in age after patients’ first transthoracic echocardiography. >Mild tricuspid regurgitation was an independent predictor of RV enlargement and dysfunction (hazard ratio of >10% drop in fractional area change from baseline [95% CI], 3.51 [1.77–6.95] and hazard ratio of >10% increase in RV end-diastolic area from baseline [95% CI], 4.90 [2.52–9.52]). Patients with implantable cardioverter defibrillator were more likely to develop >mild tricuspid regurgitation and larger structural and functional disease progression. More pronounced increase in RV end-diastolic area was translated into higher rates of any ventricular tachycardia. Inferior T-wave inversions and sum of R waves (mm) in V1 to V3 were predictors of RV enlargement and dysfunction with the former also predicting risk of any ventricular tachycardia. Conclusions: Arrhythmogenic RV cardiomyopathy is a progressive disease. Tricuspid regurgitation is an independent predictor of structural disease progression, which may be exacerbated by use of a transvenous implantable cardioverter defibrillator lead.

Defining the reference range for right ventricular systolic strain by echocardiography in healthy subjects: A meta-analysis

Background Right ventricular (RV) systolic strain has recently demonstrated prognostic value in various cardiovascular diseases. Despite this, the reference range including the lower limit of normal (LLN) and factors associated with RV strain measurements are not well-established. This meta-analysis aimed to determine the mean and LLN of two- (2D) and three-dimensional (3D) right ventricular global (RVGLS), free wall (RVFWLS) and interventricular septal wall (IVSLS) longitudinal strains in healthy individuals and factors that affect strain measurements. Methods In this meta-analysis, Pubmed, Embase and Cochrane databases were searched until 31 July 2020 for eligible studies reporting RVGLS, RVFWLS and/or IVSLS in at least 30 healthy subjects. We pooled the means and LLNs of RV strains by two- (2D) and three- (3D) dimensional echocardiography, and performed meta-regression analyses. Results From 788 articles screened, 45 eligible studies totaling 4439 healthy subjects were eligible for analysis. Pooled means and LLNs with 95% confidence intervals for 2D- RV strains were RVGLS -23.4% (-24.2%, -22.6%) and -16.4% (-17.3%, -15.5%) in 27 studies; RVFWLS -26.9% (-28.0%, -25.9%) and -18.0% (-19.2%, -16.9%) in 32 studies; and IVSLS –20.4% (-22.0%, -18.9%) and -11.5% (-13.6%, -9.6%) in 10 studies, and similar results for 3D- RV strains. Right ventricular fractional area change and vendor software were associated with 2D-RVGLS and RVFWLS means and LLNs. Conclusion We reported the pooled means and LLNs of RV systolic strains in healthy subjects, to define thresholds for abnormal, borderline and normal strains. Important factors associated with RV systolic strains include right ventricular fractional area change and vendor software.

Acute Exercise-Induced Changes in Cardiac Function Relates to Right Ventricular Remodeling Following 12-weeks Hypoxic Exercise Training

Repeated ventricular exposure to alterations in workload may relate to subsequent cardiac remodeling. We examined whether baseline acute changes in right (RV) and left ventricular (LV) function relate to chronic cardiac adaptation to 12-week exercise training. Twenty-one healthy individuals performed 12-week high-intensity endurance running training under hypoxia (fraction of inspired oxygen: 14.5%). Resting transthoracic echocardiography was performed before and after the training programme to assess ventricular structure, function and mechanics (including strain-area/volume loops). In addition, we examined systolic cardiac function during recumbent exercise under hypoxia at baseline (heart rate of 110-120 bpm, 'stress echocardiography'). Fifteen individuals completed training (22.0±2.4y, 10 male). Hypoxic exercise training increased RV size, including diameter and area (all p<0.05). With exception of an increase in RV fractional area change (p=0.03), RV function did not change post-training (all p>0.05). Regarding the RV strain-area loop, lower systolic and diastolic slopes were found post-training (p<0.05). No adaptation in LV structure, function or mechanics were observed (all p>0.05). To answer our primary aim, we found that a greater increase in RV fractional area change during baseline stress echocardiography (r=-0.67, P=0.01) inversely correlated with adaptation in RV basal diameter following 12-week training. In conclusion, 12-week high-intensity running hypoxic exercise training induced right-sided structural remodeling, which was, in part, related to baseline increase in RV fractional area change to acute exercise. These data suggest that acute cardiac responses to exercise may relate to subsequent RV remodeling after exercise training in healthy individuals.

Comparison of semi-automated versus manual quantitative right ventricular assessment in tetralogy of Fallot

Background: Tetralogy of Fallot is a congenital heart defect diagnosed in infancy. Assessment of right ventricular size and function is important for evaluation of patients with tetralogy of Fallot, but these quantitative measures are challenging by echocardiography. This study evaluates a semi-automated software (EchoInsight®, Epsilon Imaging) by comparing its measures to manual measures in children with tetralogy of Fallot. Methods: Echocardiographic measurements were performed using manual techniques and semi-automated software. Right ventricular measurements included end-diastolic and end-systolic area, fractional area change, chamber dimensions, and tricuspid annular plane systolic excursion. Reliability, correlation, and agreement between manual and semi-automated measures were assessed. Results: Echocardiograms for 46 patients were analysed. Intra- and inter-observer reliabilities for semi-automated measures were good with intraclass correlation coefficients all over 0.95 and 0.85, respectively. There was high correlation between manual and semi-automated methods for areas and dimensions (r = 0.91–0.98). Tricuspid annular plane systolic excursion measures and fractional area change also correlated, albeit less strongly. The semi-automated measurements of end-systolic and end-diastolic area were a 20 and 47% higher than manual methods, respectively. The semi-automated method yielded a relative 52% lower fractional area change compared to the manual method. Conclusions: The semi-automated software generates quantitative right ventricular measures in children with tetralogy of Fallot with good reliability and good correlation with manual methods for all measures, but with significant difference between manual and semi-automated techniques for area and functional measures. The specific right ventricular geometry in tetralogy of Fallot children may be why, compared to normal anatomy, greater differences were observed between the two techniques.

Abstract 12606: Meta-analysis of the Normal Ranges of Right Ventricular Strains by Echocardiography in Healthy Adults

Background: Right ventricular (RV) systolic strain has been increasingly shown to be prognostic in some cardiovascular diseases. Despite this, the reference range including the lower limit of normal (LLN) and factors associated with RV strain measurements are not well-established. This meta-analysis aimed to determine the means and LLNs of two- (2D) and three-dimensional (3D) right ventricular global (RVGLS), free wall (RVFWLS) and septal wall (RVSWLS) longitudinal strains in healthy individuals and factors affecting strain measurements. Methods: Pubmed, Embase and Cochrane databases were searched until 31 December 2019 for eligible studies reporting RVGLS, RVFWLS and/or RVSWLS in at least 30 healthy subjects. We pooled the means and LLNs of RV strains by two- (2D) and three- (3D) dimensional echocardiography, and performed meta-regression analyses. Results: From 591 articles screened, 37 eligible studies totaling 2970 subjects were analyzed. Pooled means and LLNs (95% confidence intervals) for 2D- strains were RVGLS -23.3% (-24.3%, -22.3%) and -16.2% (-17.2%, -15.1%) in 22 studies; RVFWLS -27.2% (-28.5%, -25.9%) and 18.5% (-20.0%, -17.1%) in 23 studies; RVSWLS -20.4% (-22.0%, -18.9%) and -11.5% (-13.6%, -9.6%) in 10 studies; and similar results for 3D- RV strains (Table). Right ventricular fractional area change and vendor software were associated with 2D-RVGLS and RVFWLS means and LLNs. Conclusion: We reported the pooled means and LLNs of RV systolic strains in healthy subjects, to define thresholds for abnormal, borderline and normal strains. Important factors associated with RV systolic strains include right ventricular fractional area change and vendor software.

Abstract 14722: The Utility of Tei Index in Subclinical Cardiotoxicity After Chemotherapy

Introduction: It was reported left ventricular global longitudinal strain (LVGLS) was useful to diagnose subclinical cardiotoxicity (SC) after chemotherapy. Doppler Tei index has been known as a noninvasive and useful indicator of systolic and diastolic myocardial performance. Until now, it has not been reported about the utility of Tei index in SC after anthracycline-based chemotherapy. Methods: We retrospectively enrolled patients with malignant lymphoma or acute myeloid leukemia receiving anthracycline-based chemotherapy from 2010 to 2019. Thirty patients were performed echocardiographic examination before and after chemotherapy. We measured LV parameters (LVGLS, LV end-diastolic diameter, LV end-systolic diameter, LV ejection fraction, LV-Tei index), and RV parameters (RV fractional area change, RV-Tei index). Patients were divided into SC and non-SC groups according to a relative percentage reduction in LVGLS of greater than 15% to baselines. Then, we compared LV and RV parameters between groups, and explored which parameters were related to SC. Results: Five patients (16%) were divided into SC group with decreased %ΔGLS (22.5±6.7%). LV end-diastolic diameter, LV end-systolic diameter, and RV fractional area change were slightly higher in non-SC although still no significance. ΔLV-Tei index and ΔRV-Tei index were significantly greater In SC group compared to non-SC group (0.22±0.10 versus 0.15±0.03, p=0.032. 0.18±0.08 versus 0.14±0.02, p=0.014, respectively). ΔLV-Tei index and ΔRV-Tei index significantly correlated with ΔGLS (r=0.46, p=0.009. r=0.39, p=0.03). Receiver-operating characteristic curve analysis identified the optimal ΔLV-Tei index and ΔRV-Tei cutoff for predicting SC as 0.09 and 0.05 (area under the curve of 0.81, p=0.029. 0.86, p=0.028). Conclusions: LV and RV-Tei index was affected by chemotherapy. Our study suggests that Tei index can be a useful indicator for SC after anthracycline-based chemotherapy.

Left ventricular apical rotation is associated with mitral annular function in healthy subjects. Results from the three-dimensional speckle-tracking echocardiographic MAGYAR-Healthy Study

IntroductionLeft ventricular (LV) twist is considered an essential part of LV function due to oppositely directed LV basal and apical rotations. Several factors could play a role in determining LV rotational mechanics in normal circumstances. This study aimed to investigate the relationship between LV rotational mechanics and mitral annular (MA) size and function in healthy subjects.MethodsThe study comprised 118 healthy adult volunteers (mean age: 31.5 ± 11.8 years, 50 males). All subjects had undergone complete two-dimensional (2D) Doppler echocardiography and three-dimensional speckle-tracking echocardiography (3DSTE) at the same time by the same echocardiography equipment.ResultsThe normal mean LV apical and basal rotations proved to be 9.57 ± 3.33 and −3.75 ± 1.98°, respectively. LV apical rotation correlated with end-systolic MA diameter, area, perimeter, fractional area change, and fractional shortening, but did not correlate with any end-diastolic mitral annular morphologic parameters. The logistic regression model identified MA fractional area change as an independent predictor of ≤6° left ventricular apical rotation (P < 0.003).ConclusionsCorrelations could be detected between apical LV rotation and end-systolic MA size and function, suggesting relationships between MA dimensions and function and LV rotational mechanics.