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Background: Obesity-related exercise intolerance may be associated with pulmonary vascular and right ventricular dysfunction. This study tested the hypothesis that decreased pulmonary vascular reserve and right ventricular (RV)-pulmonary arterial (PA) uncoupling contributes to exercise limitation in subjects with obesity. Methods: Seventeen subjects with obesity were matched to normo-weighted healthy controls. All subjects underwent; exercise echocardiography, lung diffusing capacity (DL) for nitric oxide (NO) and carbon monoxide (CO) and an incremental cardiopulmonary exercise test. Cardiac output (Q), PA pressure (PAP) and tricuspid annular plane systolic excursion (TAPSE) were recorded at increasing exercise intensities. Pulmonary vascular reserve was assessed by multipoint mean PAP (mPAP)/Q relationships with more reserve defined by lesser increase in mPAP at increased Q, and RV-PA coupling was assessed by the TAPSE/systolic PAP (sPAP) ratio. Results: At rest, subjects with obesity displayed lower TAPSE/sPAP ratios (1.00 ± 0.26 vs. 1.19 ± 0.22 ml/mmHg, P < 0.05), DLCO and pulmonary capillary blood volume (52 ± 11 vs. 64 ± 13 ml, P < 0.01) compared to controls. Exercise was associated with steeper mPAP-Q slopes, decreased TAPSE/sPAP and lower peak O2 uptake (VO2peak). The changes in TAPSE/sPAP at exercise were correlated to the body fat mass (R = 0.39, P = 0.01) and VO2peak (R = 0.44, P < 0.01). Conclusion: Obesity is associated with a decreased pulmonary vascular and RV-PA coupling reserve which may impair exercise capacity.
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AIMS: To explore the effects of age and sex in adolescents vs. young or middle-aged adults on pulmonary vascular function and right ventricular-arterial (RV-PA) coupling as assessed by exercise stress echocardiography. METHODS AND RESULTS: Forty healthy adolescents aged 12-15 years were compared with 40 young adults aged 17-22 years and 40 middle-aged adults aged 30-50 years. Sex distribution was equal in the three groups. All the subjects underwent an exercise stress echocardiography. A pulmonary vascular distensibility coefficient α was determined from multipoint pulmonary vascular pressure-flow relationships. RV-PA coupling was assessed by the tricuspid annular plane systolic excursion (TAPSE) to systolic pulmonary artery pressure (PASP) ratio, who has been previously validated by invasive study. While cardiac index and mean PAP were not different, adolescents compared to young and middle-aged adults, respectively had higher pulmonary vascular distensibility coefficients α (1.60 ± 0.31%/mmHg vs. 1.39 ± 0.29%/mmHg vs. 1.20 ± 0.35%/mmHg, P < 0.00001). Adolescents and young adults compared to middle-aged adults, respectively had higher TAPSE/PASP ratios at rest (1.24 ± 0.18 mm/mmHg and 1.22 ± 0.17 mm/mmHg vs. 1.07 ± 0.18 mm/mmHg, P < 0.008) and during exercise (0.86 ± 0.24, 0.80 ± 0.15 and 0.72 ± 0.15 mm/mmHg, P < 0.04). The TAPSE/PASP ratio decreased with exercise. There were no sex differences in α or TAPSE/PASP. CONCLUSION: Compared to adults, adolescents present with a sex-independent more distensible pulmonary circulation. Resting and exercise RV-PA coupling is decreased in middle-aged adults.
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Circulación Pulmonar , Disfunción Ventricular Derecha , Adolescente , Ecocardiografía Doppler , Ecocardiografía de Estrés , Humanos , Persona de Mediana Edad , Estudios Prospectivos , Arteria Pulmonar/diagnóstico por imagen , Función Ventricular Derecha , Adulto JovenRESUMEN
OBJECTIVES: Pulmonary hypertension (PH) is characterized by marked and sustained elevation of pulmonary vascular resistance and pulmonary artery pressure, and subsequent right-sided heart failure. Right ventricular (RV) function and exercise capacity have been recognized as important prognostic factors for PH. Our aim was to investigate RV contractile reserve and exercise capacity during a leg-positive pressure (LPP) maneuver. METHODS: The study population comprised 43 PH patients and 17 normal controls. All patients underwent echocardiography at rest and during LPP stress. Exercise capacity was assessed by 6-minute walk distance for PH patients. RV relative wall thickness was calculated from dividing by RV free wall thickness by basal RV linear dimensions at end-diastole. RV function was calculated by averaging peak speckle-tracking longitudinal strain from the RV free wall. RV contractile reserve was assessed as the difference in RV free wall strain at rest and during LPP stress. Changes in left ventricular stroke volume (ΔSV) during LPP stress were also calculated. RESULTS: ΔSV and RV contractile reserve of PH patients were significantly lower than of controls (3.6 ± 6.0 mL vs 8.5 ± 2.3 mL, and 8.2 ± 11.9% vs 14.5 ± 6.6%; both P < 0.01). RV contractile reserve of PH patients with ΔSV <3.3 mL was significantly lower than of PH patients with ΔSV >3.3 mL (3.9 ± 13.2% vs 12.3 ± 8.9%; P = 0.02). ΔSV had also significant correlation with 6-minute walk distance (r = 0.42, P = 0.006). Multivariate regression analysis showed that RV relative wall thickness was an independent determinant parameter of ΔSV during LPP stress for PH patients (ß = 3.2, P = 0.003). CONCLUSIONS: Preload stress echocardiography in response to LPP maneuver, a noninvasive and easy-to-use procedure for routine clinical use, proved to be useful for the assessment of RV contractile reserve and exercise capacity of PH patients.
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Ecocardiografía Doppler/métodos , Tolerancia al Ejercicio/fisiología , Ventrículos Cardíacos/diagnóstico por imagen , Hipertensión Pulmonar/diagnóstico , Contracción Miocárdica/fisiología , Función Ventricular Derecha/fisiología , Prueba de Esfuerzo , Femenino , Estudios de Seguimiento , Ventrículos Cardíacos/fisiopatología , Humanos , Hipertensión Pulmonar/fisiopatología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Arteria Pulmonar/diagnóstico por imagen , Arteria Pulmonar/fisiopatología , Presión Esfenoidal Pulmonar , Resistencia Vascular/fisiologíaRESUMEN
Systemic hypertension is a risk factor for left heart failure, mostly with preserved ejection fraction. Left heart failure is a cause of pulmonary hypertension and eventual right ventricular (RV) failure. There has been report of altered RV function in mild to moderate hypertension with preserved systolic as well as diastolic function of the left ventricle. The pathophysiology of this complication of hypertension is unclear. Preserving the RV and preventing the development of pulmonary vascular disease may be considered among the targets of optimized therapy for systemic hypertension.
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Hipertensión Pulmonar/etiología , Hipertensión/complicaciones , Circulación Pulmonar/fisiología , Disfunción Ventricular Derecha/etiología , Función Ventricular Derecha/fisiología , Insuficiencia Cardíaca/fisiopatología , Ventrículos Cardíacos/fisiopatología , HumanosRESUMEN
NEW FINDINGS: What is the central question of this study? Right ventricular dyssynchrony in severe pulmonary hypertension is associated with a poor prognosis. However, it has recently been observed in patients with lung or connective tissue disease and pulmonary artery pressure at the upper limits of normal. The mechanisms of right ventricular dyssynchrony in pulmonary hypertension remain uncertain. What is the main finding and its importance? Acute hypoxic breathing, but not normoxic exercise, induces an increase in right ventricular dyssynchrony detected by speckle tracking echocardiography in healthy subjects. These results add new insights into the determinants of right ventricular dyssynchrony, suggesting a role for systemic factors added to afterload in the pathophysiology of right ventricular inhomogeneity of contraction. ABSTRACT: Pulmonary hypertension (PH) has been shown to be associated with regional inhomogeneity (or dyssynchrony) of right ventricular (RV) contraction. Right ventricular dyssynchrony is an independent predictor of decreased survival in advanced PH, but has also been reported in patients with only mildly elevated pulmonary artery pressure (PAP). The mechanisms of RV dyssynchrony in PH remain uncertain. Our aim was to evaluate RV regional function in healthy subjects during acute hypoxia and during exercise. Seventeen healthy subjects (24 ± 6 years) underwent a speckle tracking echocardiography of the RV at rest in normoxia and every 15 min during a 60 min exposure to hypoxic breathing ( F I O 2 12%). Ten of the subjects also underwent an incremental cycle ergometry in normoxia to 100 W, with the same echocardiographic measurements. Dyssynchrony was measured as the SD of the times to peak systolic strain of the four basal and mid RV segments corrected for the heart rate (RV-SD4). RV-SD4 increased during hypoxia from 12 ± 7 to 22 ± 11 ms in spite of mild increases in mean PAP (mPAP) from 15 ± 2 to 20 ± 2 mmHg and pulmonary vascular resistance (PVR) from 1.18 ± 0.15 to 1.4 ± 0.15 Wood units (WU). During exercise RV-SD4 did not significantly change (from 12 ± 6 ms to 14 ± 6 ms), while mPAP increased to 25 ± 2 mmHg and PVR was unchanged. These data show that in healthy subjects, RV contraction is inhomogeneous in hypoxia but not during exercise. Since PAP increases more during exercise, RV dyssynchrony in hypoxia may be explained by a combination of mechanical (RV afterload) and systemic (hypoxia) factors.
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Ejercicio Físico/fisiología , Hipoxia/fisiopatología , Resistencia Vascular/fisiología , Disfunción Ventricular Derecha/fisiopatología , Función Ventricular Derecha/fisiología , Adulto , Ecocardiografía/métodos , Femenino , Frecuencia Cardíaca/fisiología , Humanos , Hipertensión Pulmonar/fisiopatología , Masculino , Respiración , Adulto JovenRESUMEN
AIM: A fluid challenge with rapid saline infusion during right heart catheterization has been shown to be useful for the differential diagnosis between pre- and post-capillary pulmonary hypertension. The aim of this study was to evaluate the prognostic relevance of fluid challenge-induced changes in pulmonary hemodynamics in patients with pulmonary arterial hypertension (PAH). METHODS: Overall, 118 PAH patients (mean age 57⯱â¯15â¯years, 80 female) underwent hemodynamic measurements before and after rapid saline infusion (7â¯mL/kg in 10â¯min) and were followed up for 19⯱â¯4â¯months. RESULTS: Thirty-two patients (27%) had a clinical worsening event defined as the occurrence of one of the following: death, lung transplantation, initiation of parenteral prostanoids, or worsening of PAH (defined as the presence of all of the three following components: a decrease in the 6-minute walk distance of at least 15% from baseline, worsening of PAH symptoms, and need for new PAH treatment). Cardiac index (CI), stroke volume and pulmonary artery compliance were lower whereas right atrial pressure (RAP), the ratio of RAP to pulmonary artery wedge pressure (PAWP) and pulmonary vascular resistance were higher in patients with a clinical worsening event versus patients without events, both at baseline and after fluid challenge (all pâ¯<â¯0.01). At multivariable Cox proportional hazards regression analysis, a post-fluid challenge CI <2.8â¯L/min/m2 (hazard ratio 0.0143; 95% confidence interval 0.006-0.3383; pâ¯=â¯0.009) was the only independent predictor of outcome. CONCLUSIONS: CI measured after a fluid challenge is an independent predictor of outcome in PAH.
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Cateterismo Cardíaco/métodos , Progresión de la Enfermedad , Hipertensión Pulmonar/diagnóstico , Hipertensión Pulmonar/fisiopatología , Cloruro de Sodio/administración & dosificación , Resistencia Vascular/fisiología , Adulto , Anciano , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Pronóstico , Resistencia Vascular/efectos de los fármacosRESUMEN
OBJECTIVES: The closure of atrial septal defect (ASD) results in normalized left ventricular (LV) and right ventricular (RV) geometry, and can increase LV stroke volume (LVSV), but the parameters associated with this increase after the closure of ASD remain uncertain. METHODS: Seventy ASD patients, who underwent transcatheter closure, were studied. Their mean age was 57.80 ± 16.88 years, 42 (60%) were female, and LV ejection fraction (LVEF) was 66.76% ± 7.91% (all ≥55%). Transthoracic echocardiography was performed before and 3 months after the procedure. Global longitudinal strain (GLS) was determined as the average peak speckle tracking strain of 18 segments from the 3 standard apical views, LV dispersion was defined as standard deviation of time-to-peak strain from the same views, and RV systolic function was calculated by averaging the 3-regional peak speckle tracking longitudinal strains from the RV free wall. A significant relative increase in LVSV between before and 3 months after the closure was defined as ∆LVSV ≥15%. Twenty age-, gender-, and LVEF-matched controls served as the control group. RESULTS: Global longitudinal strain (GLS) and RV free wall strain were similar for ASD patients and controls, but LV dispersion in ASD patients was significantly larger. Global longitudinal strain (GLS) remained unchanged after transcatheter closure, whereas RV free wall strain and LV dispersion decreased significantly. An important finding of the multivariate logistic regression analysis showed that ∆LV dispersion was the only independent determinant of increased LVSV after the closure (OR 1.023; 95% CI 1.001-1.046; P < .01). CONCLUSIONS: The assessment of LV dispersion may well have clinical implications for better management of ASD patients after transcatheter closure.
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Cateterismo Cardíaco , Ecocardiografía , Defectos del Tabique Interatrial/cirugía , Ventrículos Cardíacos/diagnóstico por imagen , Dispositivo Oclusor Septal , Función Ventricular Izquierda/fisiología , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Although right ventricular (RV) pacing is the only effective treatment for patients with symptomatic bradycardia, it creates left ventricular (LV) dyssynchrony, which can induce LV dysfunction and heart failure. The current criterion for consideration of cardiac resynchronization therapy (CRT) is LV ejection fraction (LVEF) ≤ 35%, but indication for CRT in patients required for RV pacing with LVEF > 35% remains unclear.We studied 40 patients, all LVEF ≥ 35%, who had undergone implantable cardioverter-defibrillator implantation with RV pacing < 5%. Echocardiography was performed at baseline and during RV pacing. LV dyssynchrony was defined as anteroseptal-to-posterior wall delay from the mid-LV short-axis view using two-dimensional speckle-tracking radial strain (significant: ≥ 130 ms). Patients were divided into two groups based on baseline LVEF: normal LVEF ( ≥ 50%; n = 20) and mildly reduced LVEF (35-50%; n = 20).LVEF and LV dyssynchrony in patients with mildly reduced LVEF deteriorated significantly during RV pacing compared to those in patients with normal LVEF. Moreover, changes in LV dyssynchrony during RV pacing significantly correlated with changes in LVEF (r = -0.44, P < 0.01). Multivariate logistic regression analysis showed that baseline LVEF was the only independent predictor and baseline LVEF < 48% predictive of significant LV dyssynchrony during RV pacing.The extent of RV pacing-induced LV dysfunction may be associated with baseline LV function. These adverse effects on patients with mildly reduced LVEF of 35-50% and indications for RV pacing due to bradycardia can thus be prevented by CRT.
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Bradicardia/complicaciones , Estimulación Cardíaca Artificial/métodos , Ventrículos Cardíacos/fisiopatología , Medición de Riesgo/métodos , Disfunción Ventricular Derecha/etiología , Función Ventricular Izquierda/fisiología , Anciano , Bradicardia/fisiopatología , Bradicardia/terapia , Ecocardiografía , Femenino , Estudios de Seguimiento , Ventrículos Cardíacos/diagnóstico por imagen , Humanos , Incidencia , Japón/epidemiología , Masculino , Pronóstico , Estudios Prospectivos , Factores de Riesgo , Volumen Sistólico/fisiología , Disfunción Ventricular Derecha/diagnóstico , Disfunción Ventricular Derecha/epidemiologíaRESUMEN
Left ventricular (LV) diastolic dysfunction and longitudinal systolic dysfunction were identified in patients with diabetes mellitus (DM). This study's aim was to investigate the impact of LV longitudinal systolic function on LV diastolic function in DM patients with preserved LV ejection fraction (LVEF). We studied 177 DM patients with preserved LVEF (all ≥50%), and 82 age-, gender- and LVEF-matched healthy volunteers as control. Global longitudinal strain (GLS) was defined as the average peak strain of 18 segments from standard apical views, GLS <18% as subclinical LV systolic dysfunction (LVSD), and LV dispersion as the standard deviation of time-to-peak strain from the same views. For DM patients with LVSD (n = 74), E/A and E' were lower, and E/E' and isovolumic relaxation time (IVRT) were greater than for DM patients without LVSD (n = 103) and normal controls (n = 82). Moreover, these parameters were lower for DM patients without LVSD than for normal controls. Multivariate analysis revealed that GLS was a strong determinative factor for E' and E/E' (ß = 0.30, p < 0.001 and ß = -0.25, p < 0.001, respectively), as was LV dispersion for E-wave deceleration time and IVRT (ß = 0.21, p = 0.002 and ß = 0.30, p < 0.001, respectively) independently of age. For normal subjects, however, only age was associated with all LV diastolic parameters. In conclusions, in contrast to age-related LV diastolic dysfunction in normal subjects, in DM patients with preserved LVEF, LV diastolic function was associated with LV longitudinal systolic function and LV dispersion independently of age. Our findings have obvious clinical implications for the management of DM patients.
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Cardiomiopatías Diabéticas/fisiopatología , Disfunción Ventricular Izquierda/fisiopatología , Función Ventricular Izquierda , Adulto , Anciano , Enfermedades Asintomáticas , Fenómenos Biomecánicos , Estudios de Casos y Controles , Estudios Transversales , Cardiomiopatías Diabéticas/diagnóstico por imagen , Cardiomiopatías Diabéticas/etiología , Diástole , Progresión de la Enfermedad , Ecocardiografía Doppler , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Variaciones Dependientes del Observador , Valor Predictivo de las Pruebas , Estudios Prospectivos , Reproducibilidad de los Resultados , Factores de Riesgo , Factores de Tiempo , Disfunción Ventricular Izquierda/diagnóstico por imagen , Disfunción Ventricular Izquierda/etiologíaRESUMEN
Single breath measurements of lung diffusing capacity (DL) for carbon monoxide (CO) and nitric oxide (NO) were performed in age-, sex-, weight- and height-matched 32 sub-Saharan Africans (13 women) and 32 Caucasian Europeans, and repeated in 14 of each group at 80% of maximum exercise capacity. In Africans versus Caucasians respectively, DLNO was 153±31 vs 176±38ml/mmHg/min at rest (P<0.001) and 210±48 vs 241±52ml/mmHg/min at exercise (P<0.01) while hemoglobin-adjusted DLCO was 29±6 vs 34±6ml/mmHg/min at rest (P<0.001), and 46±11 vs 51±13ml/mmHg/min at exercise (P<0.01). However there were no differences in DLCO/alveolar volume(VA) (KCO) and DLNO/VA(KNO). The sitting-to-standing height ratio was lower in the Africans. Differences in lung volume with respect to body height explain lower DLNO and DLCO in sub-Saharan Africans as compared to Caucasian Europeans.
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Población Negra , Capacidad de Difusión Pulmonar , Población Blanca , Adulto , África del Sur del Sahara , Estatura , Monóxido de Carbono , Europa (Continente) , Ejercicio Físico/fisiología , Femenino , Humanos , Masculino , Óxidos de Nitrógeno , Consumo de Oxígeno , Descanso/fisiología , Caracteres SexualesRESUMEN
BACKGROUND: Fluid challenge may help in the differential diagnosis between pre- and postcapillary pulmonary hypertension (PH). However, the test is still in need of standardization and better defined clinical relevance. METHODS: Two hundred twelve patients referred for PH underwent a right-sided heart catheterization with measurements before and after rapid infusion of 7 mL/kg of saline. PH was defined as mean pulmonary artery pressure ≥ 25 mm Hg, and postcapillary PH was defined as pulmonary artery wedge pressure (PAWP) > 15 mm Hg. An increase in PAWP ≥ 18 mm Hg was considered diagnostic for postcapillary PH. At baseline, 66 patients received a diagnosis of no PH; 22, of postcapillary PH; and 124, of precapillary PH (mostly pulmonary arterial hypertension). RESULTS: After fluid challenge, five of 66 patients with no PH (8%) and eight of 124 with precapillary PH (6%) had the diagnosis reclassified as postcapillary PH. Fluid challenge was associated with an increase in PAWP by 7 ± 2 mm Hg in postcapillary PH and 3 ± 1 mm Hg in both precapillary PH and no-PH groups. Between-group differences were significant, but there was overlap. There were no adverse events related to fluid challenge. Prediction bands calculated from quadratic fits of the PAWP responses in pooled control subjects with no PH and patients with precapillary PH helped confirm 18 mm Hg as the cutoff for diagnosing postcapillary PH. CONCLUSIONS: Fluid challenge with 7 mL/kg saline increases PAWP, more in postcapillary than in precapillary PH or in control subjects with no PH. A cutoff value of 18 mm Hg allows reclassification of 6% to 8% of patients with precapillary PH or normal hemodynamic characteristics at baseline.
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Hipertensión Pulmonar , Presión Esfenoidal Pulmonar , Cloruro de Sodio/farmacología , Resistencia Vascular , Adulto , Anciano , Cateterismo Cardíaco/métodos , Femenino , Transferencias de Fluidos Corporales , Humanos , Hipertensión Pulmonar/diagnóstico , Hipertensión Pulmonar/fisiopatología , Infusiones Intravenosas/métodos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Circulación Pulmonar , Reproducibilidad de los ResultadosRESUMEN
Left ventricular (LV) hypertrophy (LVH) is an independent cardiovascular risk factor for heart failure (HF) patients. The renin-angiotensin system plays a key role in LVH, and since olmesartan increases plasma angiotensin-(1-7) through an increase in angiotensin-converting enzyme-related carboxypeptidase (ACE2) expression, it was hypothesized to reduce LVH, unlike other angiotensin II receptor blockers (ARBs). The objective of this study was therefore to investigate the effects of a changeover from other ARBs to olmesartan on LVH in HF patients. Participants enrolled in this prospective trial were 64 outpatients with stable HF who had received ARBs other than olmesartan for more than 1 year (age: 59 ± 13 years). Transthoracic echocardiography and laboratory tests were performed before and 6 months after administration of olmesartan. Other drugs were not changed during follow-up. The primary end point was defined as a change in LV mass index (LVMI) from baseline up to 6 months after administration of olmesartan. No significant changes were observed in blood pressures and heart rate after administration of olmesartan. LVMI showed a significant decrease from 119 ± 38 to 110 ± 24 g/m2 (p = 0.007) 6 months after administration of olmesartan, and further decreased from 110 ± 24 to 103 ± 35 g/m2 (p = 0.0003) after 12 months. Moreover, this reduction tended to be more prominent in patients with LVH. In conclusions, LVH in HF patients was reduced by the changeover to olmesartan. This finding may well have clinical implications for better management of HF patients.
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Bloqueadores del Receptor Tipo 1 de Angiotensina II/administración & dosificación , Sustitución de Medicamentos/métodos , Insuficiencia Cardíaca/prevención & control , Hipertrofia Ventricular Izquierda/tratamiento farmacológico , Imidazoles/administración & dosificación , Tetrazoles/administración & dosificación , Relación Dosis-Respuesta a Droga , Ecocardiografía Doppler de Pulso , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/etiología , Humanos , Hipertrofia Ventricular Izquierda/complicaciones , Hipertrofia Ventricular Izquierda/fisiopatología , Masculino , Persona de Mediana Edad , Pacientes Ambulatorios , Estudios Prospectivos , Sistema Renina-Angiotensina/efectos de los fármacos , Factores de Riesgo , Volumen Sistólico/efectos de los fármacos , Resultado del TratamientoRESUMEN
Mid-term right ventricular (RV) reverse remodeling after treatment in patients with pulmonary hypertension (PH) is associated with long-term outcome as well as baseline RV remodeling. However, baseline factors influencing mid-term RV reverse remodeling after treatment and its prognostic capability remain unclear. We studied 54 PH patients. Mid-term RV remodeling was assessed in terms of the RV area, which was traced planimetrically at the end-systole (RVESA). RV reverse remodeling was defined as a relative decrease in the RVESA of at least 15% at 10.2 ± 9.4 months after treatment. Long-term follow-up was 5 years. Adverse events occurred in ten patients (19%) and mid-term RV reverse remodeling after treatment was observed in 37 (69%). Patients with mid-term RV reverse remodeling had more favorable long-term outcomes than those without (log-rank: p = 0.01). Multivariate logistic regression analysis showed that RV relative wall thickness (RV-RWT), as calculated as RV free-wall thickness/RV basal linear dimension at end-diastole, was an independent predictor of mid-term RV reverse remodeling (OR 1.334; 95% CI, 1.039-1.713; p = 0.03). Moreover, patients with RV-RWT ≥0.21 showed better long-term outcomes than did those without (log-rank p = 0.03), while those with RV-RWT ≥0.21 and mid-term RV reverse remodeling had the best long-term outcomes. Patients with RV-RWT <0.21 and without mid-term RV reverse remodeling, on the other hand, had worse long-term outcomes than other sub-groups. In conclusions, RV-RWT could predict mid-term RV reverse remodeling after treatment in PH patients, and was associated with long-term outcomes. Our finding may have clinical implications for better management of PH patients.
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Antihipertensivos/uso terapéutico , Hipertensión Pulmonar/tratamiento farmacológico , Hipertrofia Ventricular Derecha/etiología , Disfunción Ventricular Derecha/etiología , Función Ventricular Derecha/efectos de los fármacos , Remodelación Ventricular/efectos de los fármacos , Anciano , Área Bajo la Curva , Distribución de Chi-Cuadrado , Supervivencia sin Enfermedad , Ecocardiografía Doppler , Femenino , Humanos , Hipertensión Pulmonar/complicaciones , Hipertensión Pulmonar/diagnóstico por imagen , Hipertensión Pulmonar/fisiopatología , Hipertrofia Ventricular Derecha/diagnóstico por imagen , Hipertrofia Ventricular Derecha/fisiopatología , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Valor Predictivo de las Pruebas , Modelos de Riesgos Proporcionales , Curva ROC , Recuperación de la Función , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Disfunción Ventricular Derecha/diagnóstico por imagen , Disfunción Ventricular Derecha/fisiopatologíaRESUMEN
There has been revival of interest in exercise testing of the pulmonary circulation for the diagnosis of pulmonary vascular disease, but there still is uncertainty about body position and the most relevant measurements. Doppler echocardiography pulmonary hemodynamic measurements were performed at progressively increased workloads in 26 healthy adult volunteers in supine, semirecumbent, and upright positions that were randomly assigned at 24-h intervals. Mean pulmonary artery pressure (mPAP) was estimated from the maximum tricuspid regurgitation jet velocity. Cardiac output was calculated from the left ventricular outflow velocity-time integral. Pulmonary vascular distensibility α-index, the percent change of vessel diameter per millimeter mercury of mPAP, was calculated from multipoint mPAP-cardiac output plots. Body position did not affect maximum oxygen uptake (Vo2max), maximum respiratory exchange ratio, ventilatory equivalent for carbon dioxide, or slope of mPAP-cardiac output relationships, which was on average of 1.5 ± 0.4 mmHg·l-1·min-1 Maximum mPAP, cardiac output, and total pulmonary vascular resistance were, respectively, 34 ± 4 mmHg, 18 ± 3 l/min, and 1.9 ± 0.3 Wood units. However, the semirecumbent position was associated with a 10% decrease in maximum workload. Furthermore, cardiac output-workload or cardiac output-Vo2 relationships were nonlinear and variable. These results suggest that body position does not affect maximum exercise testing of the pulmonary circulation when results are expressed as mPAP-cardiac output or maximum total pulmonary vascular resistance. Maximum workload is decreased in semirecumbent compared with upright exercise. Workload or Vo2 cannot reliably be used as surrogates for cardiac output.
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Presión Sanguínea/fisiología , Ejercicio Físico/fisiología , Postura/fisiología , Arteria Pulmonar/fisiología , Circulación Pulmonar/fisiología , Resistencia Vascular/fisiología , Adulto , Velocidad del Flujo Sanguíneo/fisiología , Gasto Cardíaco/fisiología , Ecocardiografía Doppler/métodos , Prueba de Esfuerzo/métodos , Femenino , Ventrículos Cardíacos/metabolismo , Ventrículos Cardíacos/fisiopatología , Hemodinámica/fisiología , Humanos , Masculino , Oxígeno/metabolismo , Consumo de Oxígeno/fisiología , Arteria Pulmonar/metabolismo , Adulto JovenRESUMEN
BACKGROUND: Right ventricular (RV) systolic function is one of the most important determinants of outcome for pulmonary hypertension (PH) patients, but the factors influencing prognosis vary widely. Elevated right atrial (RA) pressure is reported to be one of these prognostic factors, but its functional importance has scarcely been assessed. METHODS: Eighty-two PH patients, all of whom underwent echocardiography and right heart catheterization, were recruited. RV function was assessed by two-dimensional speckle tracking longitudinal strain from RV-focused apical four-chamber view and calculated by averaging the three regional peak strains from the RV free wall (RV-free). RA function was determined as the sum of three peak strain values comprising reservoir, conduit, and contractile function (sum of RA strain). RESULTS: Sum of RA strain correlated significantly with hemodynamic parameters such as mean right atrial pressure (r = -0.35, P = 0.002) and end-diastolic RV pressure (r = -0.29, P = 0.008). Patients with sum of RA strain ≥30.2% experienced more favorable outcomes than those with sum of RA strain <30.2% (log-rank P = 0.001). Furthermore, patients with impaired RV systolic function (RV-free <20%) and RA function (sum of RA strain <30.2%) showed the worst outcome (P = 0.001). A sequential Cox model based on clinical variables (χ(2) = 5.8) was improved by addition of RV-free (χ(2) = 8.7; P < 0.05) and further improved by addition of sum of RA strain (χ(2) = 12.0; P < 0.01). CONCLUSION: Right atrial strain appears to be a valuable additive factor for predicting outcomes for PH patients, and comprehensive functional assessment of right-sided heart using speckle tracking strain may have potential clinical implications for better management of PH patients.
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Ecocardiografía/métodos , Diagnóstico por Imagen de Elasticidad/métodos , Hipertensión Pulmonar/diagnóstico por imagen , Hipertensión Pulmonar/fisiopatología , Disfunción Ventricular Derecha/diagnóstico por imagen , Disfunción Ventricular Derecha/fisiopatología , Femenino , Humanos , Hipertensión Pulmonar/complicaciones , Interpretación de Imagen Asistida por Computador/métodos , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Volumen Sistólico , Disfunción Ventricular Derecha/etiología , Función Ventricular DerechaRESUMEN
AIMS: Current guidelines recommend implantation of prophylactic implantable cardioverter-defibrillators (ICD) in patients with left ventricular (LV) ejection fraction (EF) <35%. We explored the prognostic factors of fatal ventricular arrhythmias for heart failure (HF) patients with LVEF ≥35%. METHODS AND RESULTS: We retrospectively studied 72 patients with LVEF of 52 ± 12% (all ≥35%) who had undergone ICD implantation. Heterogeneity of LV regional myocardial contraction was defined as standard deviation of peak strain (dyssynergy index) and time-to-peak strain (dispersion index) from 18 LV segments determined by speckle tracking. Fatal ventricular arrhythmias with appropriate ICD therapy occurred in 34 patients (47%) during a median follow-up of 17 months. Receiver operating characteristic curve analysis identified dispersion index ≥101 ms and dyssynergy index ≥6.1% as predictors of fatal ventricular arrhythmias (P = 0.004 and P = 0.0001, respectively). In addition, the combination of dispersion index ≥101 ms and dyssynergy index ≥6.1% was the most predictive of fatal ventricular arrhythmias with a sensitivity of 77%, specificity of 79%, and area under the curve of 0.795 (P < 0.0001). A sequential Cox model based on clinical and conventional echocardiographic variables including age, gender, HF aetiology, and LVEF (χ(2) = 4.8) was improved, but not statistically significant (χ(2) = 4.9; P = 0.82), by addition of global longitudinal strain, whereas improvement by the addition of the dispersion index (χ(2) = 8.9; P = 0.04) and further improvement by the addition of the dyssynergy index (χ(2) = 20.2; P < 0.005). CONCLUSION: Combined assessment of LV dyssynergy and dispersion can enhance predictive capability for fatal ventricular arrhythmias in patients with LVEF ≥35% and may have potential for better management of such patients.
Asunto(s)
Arritmias Cardíacas/mortalidad , Arritmias Cardíacas/fisiopatología , Desfibriladores Implantables , Disfunción Ventricular Izquierda/mortalidad , Disfunción Ventricular Izquierda/fisiopatología , Ecocardiografía , Determinación de Punto Final , Femenino , Sistema de Conducción Cardíaco/fisiopatología , Humanos , Interpretación de Imagen Asistida por Computador , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Volumen SistólicoRESUMEN
BACKGROUND: Transcatheter closure is a well-established treatment for patients with atrial septal defect (ASD), but long-term outcome prognostic factors for adults have not been fully identified yet. METHODS: Forty-nine consecutive patients (age 57 ± 17 years, 59% female), who underwent transcatheter closure of ASD, were the subjects of this study. Transthoracic echocardiography was performed before and midterm after the procedure (6 ± 1 months). Isovolumic contraction peak velocity (IVV) was measured at the lateral site of the tricuspid annulus using spectral tissue Doppler imaging, and ΔIVV was determined as the absolute change at midterm follow-up. Long-term unfavorable outcome events, tracked for 19 ± 9 months, were prespecified as primary end points comprising newly developed atrial fibrillation, cerebral infarction, and heart failure. RESULTS: Symptomatic improvement, defined as an improvement in New York Heart Association functional class by one grade or more at midterm after the procedure, was observed in 24 patients (49%), and the remaining 25 (51%) were classified as not symptomatically improved. ΔIVV was significantly larger for patients with symptomatic improvement than for those without (from 11.5 ± 4.3 cm/s to 14.2 ± 3.7 cm/s vs. from 11.8 ± 4.1 cm/s to 12.5 ± 2.9 cm/s; P = 0.045). An important finding of the multivariate Cox proportional-hazards analysis was that only ΔIVV was independently associated with cardiovascular events (HR: 0.701; 95% CI 0.537-0.916; P = 0.01). Kaplan-Meier analysis showed that more patients with enhanced ΔIVV presented with favorable long-term outcome than those with diminished ΔIVV (log-rank P = 0.0001). CONCLUSIONS: IVV, which is a less volume-sensitive parameter, can be useful for comprehensive evaluation of ASD patients referred for transcatheter closure.
Asunto(s)
Cateterismo Cardíaco , Defectos del Tabique Interatrial/diagnóstico por imagen , Defectos del Tabique Interatrial/cirugía , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/fisiopatología , Dispositivo Oclusor Septal , Velocidad del Flujo Sanguíneo/fisiología , Ecocardiografía Doppler , Femenino , Estudios de Seguimiento , Defectos del Tabique Interatrial/fisiopatología , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
BACKGROUND: Current guidelines recommend the routine use of tricuspid annular plane systolic excursion (TAPSE) as a simple method for estimating right ventricular (RV) function. However, when ventricular apical longitudinal rotation (apical-LR) occurs in pulmonary hypertension (PH) patients, it may result in overestimated TAPSE. METHODS: We studied 105 patients with PH defined as mean pulmonary artery pressure >25 mmHg at rest measured by right heart cardiac catheterization. TAPSE was defined as the maximum displacement during systole in the RV-focused apical four-chamber view. RV free-wall longitudinal speckle tracking strain (RV-free) was calculated by averaging 3 regional peak systolic strains. The apical-LR was measured at the peak rotation in the apical region including both left and right ventricle. The eccentricity index (EI) was defined as the ratio of the length of 2 perpendicular minor-axis diameters, one of which bisected and was perpendicular to the interventricular septum, and was obtained at end-systole (EI-sys) and end-diastole (EI-dia). Twenty age-, gender-, and left ventricular ejection fraction-matched normal controls were studied for comparison. RESULTS: The apical-LR in PH patients was significantly lower than that in normal controls (-3.4 ± 2.7° vs. -1.3 ± 1.9°, P = 0.001). Simple linear regression analysis showed that gender, TAPSE, EI-sys, and EI-dia/EI-sys were associated with apical-LR, but RV-free was not. Multiple regression analysis demonstrated that gender, EI-dia/EI-sys, and TAPSE were independent determinants of apical-LR. CONCLUSIONS: TAPSE may be overestimated in PH patients with clockwise rotation resulting from left ventricular compression. TAPSE should thus be evaluated carefully in PH patients with marked apical rotation.
Asunto(s)
Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/fisiopatología , Hipertensión Pulmonar/complicaciones , Disfunción Ventricular Derecha/diagnóstico por imagen , Disfunción Ventricular Derecha/fisiopatología , Femenino , Humanos , Hipertensión Pulmonar/fisiopatología , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Sístole , Disfunción Ventricular Derecha/complicacionesRESUMEN
AIMS: The purpose of this study was to investigate the prognostic impact of the changes in ventriculo-arterial (VA) coupling during dobutamine stress on the cardiovascular events for patients with dilated cardiomyopathy (DCM). METHODS AND RESULTS: For this study, 89 DCM patients with ejection fractions of 32 ± 10% and 30 normal controls were recruited. Ees was estimated with the non-invasive single-beat method using three-dimensional echocardiography at rest and during dobutamine stress (20 µg/kg/min). Effective arterial elastance (Ea) was calculated as left ventricular (LV) end-systolic pressure divided by stroke volume, and VA coupling was calculated as Ea/Ees. Event-free survival was then tracked for 32 months. At baseline, VA coupling was far from optimal in patients with DCM compared with controls (Ea/Ees: 2.49 ± 1.02 vs. 1.04 ± 0.21, P < 0.001). During the follow-up period, 22 patients developed adverse cardiovascular events. During dobutamine stress, VA coupling was significantly improved in patients without cardiovascular events (from 2.47 ± 1.09 to 1.59 ± 0.68, P < 0.001), but remained unchanged in those with cardiovascular events. A multivariate Cox proportional-hazards analysis revealed that age, NYHA functional class (>II), and the change in VA coupling during dobutamine stress were the independent determinants of cardiovascular events (P < 0.05, <0.01, and <0.001, respectively). When patients were divided into two subgroups based on the finding of receiver operating characteristic curve analysis, patients with good VA coupling reserve (cut-off: change in VA coupling> 0.29) showed significantly favourable event-free survival than those with poor VA coupling reserve (P < 0.001). CONCLUSIONS: Improvement in VA coupling during dobutamine stress is an important determinant of cardiovascular outcome for patients with DCM.