RESUMO
OBJECTIVES: Arrhythmogenic cardiomyopathy (ACM) is a complex cardiac disorder associated with ventricular arrhythmias. Understanding the relationship between mechanical uncoupling and cardiac structural changes in ACM patients is crucial for improved risk stratification and management. METHODS: In this study, we enrolled 25 ACM patients (median age 34 years, 72% men) based on the 2019 Modified Task Force and Padua criteria. Patients were categorized by the presence or absence of clinically relevant ventricular tachycardia (crVT), necessitating emergency interventions. Right ventricular-arterial coupling (VAC) was assessed using echocardiography. Low-rank regression splines were employed to model left ventricular ejection fraction (LVEF) and right ventricular ejection fraction (RVEF) in relation to VAC. RESULTS: Positive associations were observed between VAC and LVEF (ρ = 0.472, p = 0.023), RVEF (ρ = 0.522, p = 0.038), and right ventricular (RV) indexed stroke volume (ρ = 0.79, p < 0.001). Patients with crVT exhibited correlations with RV shortening, reduced RVEF (39.6 vs. 32.2%, p = 0.025), increased left ventricular (LV) mass (38.99 vs. 45.55, p = 0.045), and LV end-diastolic volume (LVEDV) (56.99 vs. 68.15 mL/m2, p = 0.045). Positive associations for VAC were noted with LVEDV (p = 0.039) and LV mass (p = 0.039), while negative correlations were observed with RVEF by CMR (p = 0.023) and RV shortening by echocardiography (p = 0.026). CONCLUSIONS: Our findings underscore the significance of right VAC in ACM, demonstrating correlations with RV and LVEF, RV stroke volume, and clinically relevant arrhythmias. Insights into RVEF, LV mass, and end-diastolic volume provide valuable contributions to the understanding of ACM pathophysiology and may inform risk assessment strategies.
OBJETIVOS: La miocardiopatía arritmogénica (MCA) es un trastorno cardíaco complejo asociado con arritmias ventriculares (AV). Comprender la relación entre el desacoplamiento mecánico y los cambios estructurales cardíacos en pacientes con MCA es crucial para una estratificación de riesgos y una gestión mejorada. MÉTODOS: En este estudio, reclutamos a 25 pacientes con MCA (edad media 34 años, 72% hombres) basándonos en los criterios del Task Force 2019 y los criterios de Padua. Los pacientes se clasificaron según la presencia o ausencia de taquicardia ventricular clínicamente relevante (crVT), que requería intervenciones de emergencia. Se evaluó el acoplamiento ventricular derecho-arterial (VAC) mediante ecocardiografía. Se utilizaron low-rank regression splines para modelar la fracción de eyección del ventrículo izquierdo (FEVI) y la fracción de eyección del ventrículo derecho (FEVD) en relación con el VAC. RESULTADOS: Se observaron asociaciones positivas entre el VAC y la FEVI (ρ = 0.472, p = 0.023), la FEVD (ρ = 0.522, p = 0.038) y el volumen de eyección indexado del ventrículo derecho (ρ = 0.79, p < 0.001). Los pacientes con crVT mostraron correlaciones con acortamiento del ventrículo derecho, disminución de la FEVD (39.6 vs. 32.2%, p = 0.025), aumento de la masa ventricular izquierda (38.99 vs. 45.55, p = 0.045) y volumen diastólico final del ventrículo izquierdo (VDVI) (56.99 vs. 68.15 mL/m2, p = 0.045). Se observaron asociaciones positivas para el VAC con el VDVI (p = 0.039) y la masa ventricular izquierda (p = 0.039), mientras que se observaron correlaciones negativas con la FEVD por RMC (p = 0.023) y el acortamiento del ventrículo derecho por ecocardiografía (p = 0.026). CONCLUSIONES: Nuestros hallazgos subrayan la importancia del VAC derecho en la MCA, demostrando correlaciones con la FEVD y FEVI, el volumen de eyección del ventrículo derecho y arritmias clínicamente relevantes. Las percepciones sobre la FEVD, la masa ventricular izquierda y el volumen diastólico final proporcionan contribuciones valiosas para comprender la fisiopatología de la MCA y pueden informar estrategias de evaluación de riesgos.
Assuntos
Displasia Arritmogênica Ventricular Direita , Volume Sistólico , Humanos , Masculino , Feminino , Adulto , Displasia Arritmogênica Ventricular Direita/fisiopatologia , Displasia Arritmogênica Ventricular Direita/diagnóstico por imagem , Volume Sistólico/fisiologia , Pessoa de Meia-Idade , Ecocardiografia/métodos , Imageamento por Ressonância Magnética/métodos , Taquicardia Ventricular/fisiopatologia , Taquicardia Ventricular/diagnóstico por imagem , Taquicardia Ventricular/etiologia , Estudo de Prova de Conceito , Adulto Jovem , Função Ventricular Direita/fisiologia , Função Ventricular Esquerda/fisiologiaRESUMO
The aim of the study was to evaluate hypertension treatment effects on mechanical efficiency of the cardiovascular system and cardiac reverse remodeling in hypertensive patients. This is an observational prospective study, consecutive hypertension patients. Left ventricle mass index measured by Devereux 2D method and diastolic function following the Guidelines from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Left ventricular end systolic elastance (Ees) was measured by Guarracino calculator, the effective arterial elastance (Ea) and ventricular-arterial coupling (VAC) measured by Sunagawa et al. single beat method adapted by Chen et al. in human ventricles. The sample was analyzed in quartiles (Q) according to VAC. Follow-up 2 years. In total, 288 patients, mean age 56.3 ± 12.5 years and 168 patients (58.3%) males. VAC increased from 0.303 ± 0.07 to 0.54 ± 0.25 (p < 0.005) in Q1 mainly due to a reduction in Ees from 5.25 ± 2.3 to 3.68 ± 0.25 mmHg/ml (p < 0.01), while Ea increased from 1.5 ± 0.53 to 1.64 ± 0.56 mmHg/ml (p = NS). The frequency of LVH was reduced from 31.9 to 10.8% in Q1 (p < 0.025). The frequency of normal diastolic function increased from 75 to 94.6% (p < 0.01) in Q1, from 78.7 to 100% in Q2 (p < 0.005), from 87.1 to 100% (p < 0.025) in Q3 and from 88.7 to 100% (0,025) in Q4. Patients with the worst ventricular-arterial uncoupling were the most benefited from hypertension treatment. Regression of left ventricular hypertrophy was observed only in the group of patients with the worst ventricular-arterial uncoupling, while improvement in diastolic function was demonstrated in all quartiles of patients.
Assuntos
Ventrículos do Coração , Hipertensão , Masculino , Humanos , Adulto , Pessoa de Meia-Idade , Idoso , Feminino , Ventrículos do Coração/diagnóstico por imagem , Estudos Prospectivos , Hipertensão/complicações , Hipertensão/tratamento farmacológico , Hipertrofia Ventricular Esquerda/diagnóstico por imagem , Ecocardiografia , Função Ventricular EsquerdaRESUMO
BACKGROUND: Pulmonary arterial (PA) stiffness has an essential contribution to the right ventricular (RV) failure pathogenesis. A comprehensive and multiparameter risk assessment allows predicting mortality and guiding treatment decisions in PA hypertension (PAH). We characterize PA remodeling with intravascular ultrasound (IVUS) in prevalent and stable patients with PAH according to the ESC/ERS risk table and analyze the RV-PA coupling consequences. METHODS: Ten control subjects and 20 prevalent PAH adult patients underwent right heart catheterization (RHC) with simultaneous IVUS study. We estimated cardiac index (CI), pulmonary vascular resistance, and compliance (PVR, PAC) by standard formulas. From IVUS and RHC data, PA diameter, wall thickness/luminal diameter ratio, and indexes of stiffness (pulsatility, compliance, distensibility, incremental elastic modulus - Einc-, and the stiffness index ß) were measured. We evaluated RV-PA coupling by the ratio of tricuspid annular plane systolic excursion to systolic pulmonary arterial pressure (TAPSE/sPAP). The individual average risk was calculated by assigning a score of 1 (low-risk -LR-), 2 (intermediate-risk -IR-), and 3 (high-risk -HR-) for each of seven variables (functional class, six-minute walking test, brain natriuretic peptide, right atrial area and pressure, CI, and PA oxygen saturation) and rounding the average value to the nearest integer. RESULTS: All PA segments interrogated showed increased vessel diameter, wall cross-sectional area (WCSA), and stiffness in patients with PAH compared to control subjects. 45% corresponded to LR, and 55% corresponded to IR PAH patients. The different measurements of PA stiffness showed significant correlations with TAPSE/sPAP (r = 0.6 to 0.76) in PAH patients. The IR group had higher PA stiffness and lower relative WCSA than LR patients (P < 0.05), and it is associated with a lower PAC and TAPSE/sPAP (P < 0.05). CONCLUSION: In prevalent PAH patients, the severity of proximal PA remodeling is related to the risk stratification and associated with PAC and RV-PA coupling impairment beyond the indirect effect of the mean PA pressure. The concomitant assessment of IVUS and hemodynamic parameters at diagnosis and follow-up of PAH patients could be a feasible and safe tool for risk stratification and treatment response of the PA vasculopathy during serial hemodynamic measurements.
RESUMO
Resumen: Introducción: La mejor forma de evaluar la eficiencia miocárdica es mediante el análisis del acoplamiento ventrículo-arterial. Este complejo análisis puede realizarse de manera no invasiva mediante ecocardiografía Doppler. Material y métodos: Se realizó un estudio longitudinal, prospectivo, analítico con los pacientes hospitalizados en la Unidad de Cuidados Intensivos del Hospital San Ángel Inn Universidad ingresados en estado de choque (definido como una frecuencia cardiaca > 120 latidos por minuto o un lactato venoso > 4 mmol/L o un lactato > 2 mmol/L más alguna de las siguientes: frecuencia cardiaca > presión sistólica, presión sistólica < 90 mmHg). Se registraron las siguientes variables: edad, género, diagnóstico de ingreso, tensión arterial sistólica y diastólica, tensión arterial media, frecuencia cardiaca y lactato sérico; un ecocardiografista experto realizó las mediciones ecocardiográficas necesarias para obtener el cálculo del acoplamiento ventrículo-arterial. Un residente de terapia intensiva de primer año obtuvo, tras un entrenamiento de cuatro horas, los siguientes valores mediante USCOM (monitor de gasto cardiaco por ultrasonido): SMII, FTC y PKR. Resultados: Se estudiaron n = 47 personas con diagnóstico de estado de choque, género masculino n = 23 (48.9%), edad n = 59 (41-73); de estos, hubo n = 22 individuos con choque séptico (53.7%), n = 11 con síndrome coronario (26.8%), n = 7 con cor pulmonale (17.1%), n =1 con tromboembolia pulmonar (2.4%). El acoplamiento ventrículo-arterial medido por ecocardiografía fue de 0.74 (0.63-1.1). El acoplamiento arterial medido por USCOM fue de 0.72 (0.63-0.9), con una correlación de r de 0.8, un porcentaje de error de 24% y una p < 0.002. El acoplamiento medido por ecocardiografía con un punto de corte de ≤ 0.7 predice mortalidad con una sensibilidad de 100% y una especificidad de 50%, con un área debajo de la curva de 0.75 (0.59-0.96), p = 0.46. El acoplamiento medido por USCOM con un punto de corte de 0.7 predice mortalidad con una sensibilidad de 80%, especificidad de 60% y un área debajo de la curva de 0.79 (0.64-0.95) p = 0.02. Conclusiones: Es posible que el acoplamiento ventrículo-arterial sea medido a la cabecera del enfermo por personal médico con un entrenamiento de cuatro horas de una manera comparable a como lo haría un ecocardiografista experto. Esto permite emplear estos complejos análisis hemodinámicos de una manera no invasiva en el día a día de la atención del enfermo grave.
Abstract: Introduction: The best way to assess myocardial efficiency is by analyzing arterial-ventricular coupling. This complex analysis can be performed noninvasively by Doppler echocardiography. Material and methods: A longitudinal, prospective, analytical study was performed with patients hospitalized in the Intensive Care Unit of the Hospital San Ángel Inn Universidad admitted in shock (defined as a heart rate > 120 beats per minute or venous lactate > 4 mmol/L or lactate > 2 mmol/L plus one of the following: heart rate > systolic pressure, systolic pressure < 90 mmHg). The following variables were recorded: age, gender, admission diagnosis, systolic and diastolic blood pressure, mean arterial pressure, heart rate and serum lactate; an expert cardiologist performed the echocardiographic measurements required for calculating the ventricular-arterial coupling. A resident of intensive therapy obtained after a four-hour training the following values by the ultrasonic cardiac output monitor USCOM: SMII, FTC and PKR. Results: We studied n = 47 patients diagnosed with shock; male n = 23 (48.9%), age n = 59 (41-73); n = 22 patients had septic shock (53.7%), n = 11 coronary syndromes (26.8%), n = 7 cor pulmonale (17.1%), n = 1 pulmonary embolism (2.4%). The arterial- ventricular coupling was measured by echocardiography: 0.74 (0.63-1.1). The arterial-ventricular coupling by USCOM was 0.72 (0.63 to 0.9), with a correlation of r of 0.8, an error rate of 24% and a p < 0.002. The arterial-ventricular coupling by echocardiography with a cutoff of ≤ 0.7 predicts mortality with a sensitivity of 100% and specificity of 50%, with an area under the curve of 0.75 (from 0.59 to 0.96), p = 0.46. The arterial-ventricular coupling by USCOM with a cutoff of 0.7 predicts mortality with an 80% of sensitivity, specificity of 60%, with an area under the curve of 0.79 (0.64 to 0.95) p = 0.02. Conclusions: It is possible to have the arterial-ventricular coupling measured in critically ill patients at their bedside by medical personnel with a four-hour training in a manner comparable to that of an expert echocardiographer. This allows the use of these complex hemodynamic analysis in a non-invasive way in the day-to-day care of the seriously ill.
Resumo: Introdução: A melhor maneira de avaliar a eficiência do miocárdio é através da análise do acoplamento ventrículo arterial. Esta análise complexa pode ser realizada de forma não invasiva por ecocardiografia Doppler. Material e métodos: Estudo longitudinal, prospectivo, analítico com pacientes internados na Unidade de Cuidados Intensivos do Hospital San Angel Inn Universidad, admitidos em estado de choque, definido como uma frequência cardíaca > 120 batimentos por minuto ou lactato venoso > 4 mmol/L ou lactato > 2 mmol/L, mais algum dos seguintes procedimentos: frequência cardíaca > pressão sistólica, pressão sistólica < 90 mmHg. Registrou-se as seguintes variáveis, idade, sexo, diagnóstico de admissão, pressão arterial sistólica, diastólica, pressão arterial média, freqüência cardíaca e lactato sérico, um ecocardiografista realizou medidas ecocardiográficas necessárias para obter o cálculo do acoplamento ventrículo arterial. Um residente de terapia intensiva, do primeiro ano, posterior a 4 horas de capacitação obteve os seguintes valores com USCOM: SMII, FTC e PKR. Resultados: Foram estudadas n: 47 pacientes com diagnóstico de choque, gênero masculino n: 23 (48.9%), idade n: 59 (41-73), de estes n: 22 pacientes com choque séptico (53.7%), n: 11 com síndromes coronárias (26.8%), n: 7 com Cor pulmonale (17.1%), n: 1 com tromboembolismo pulmonar (2.4%). O acoplamento ventrículo arterial foi medido por ecocardiografia foi de 0.74 (0.63-1.1). O acoplamento arterial medido por USCOM foi de 0.72 (0.63 a 0.9) com uma correlação de r de 0.8, uma taxa de erro de 24% e uma p < 0.002. O acoplamento medido por ecocardiografia com um limite de exclusão de ≤0.7 prediz a mortalidade com uma sensibilidade de 100% e especificidade de 50%, com uma área sob a curva de 0.75 (0.59-0.96) p: 0.46. O acoplamento medido por USCOM com um corte de 0.7 prediz a mortalidade com uma de sensibilidade 80% e uma especificidade de 60%, com uma área sob a curva de 0.79 (0.64-0.95) p: 0.02. Conclusões: É possível medir o acoplamento ventrículo arterial à cabeceira do paciente pelo médico, com uma capacitação de quatro horas, de uma forma comparável à realizada por um ecocardiografista. Permitindo usar esta complexa análise hemodinâmica, de uma forma não invasiva, no dia a dia do atendimento do paciente grave.
RESUMO
Right ventricular function (RVF) carries great prognostic significance in heart failure and pulmonary hypertension (PH). Although there is considerable focus on RVF in pulmonary arterial hypertension, RVF is also of great importance in group 2 PH. This article will discuss assessment of RVF and evaluation of the Right Ventricle-Pulmonary Artery (RV-PA) coupling relationship. Cardiac imaging modalities allow direct visualization and assessment of RVF. Imaging modalities include the commonly utilized echo-Doppler imaging evaluating RV fractional area change, tricuspid annular plane systolic excursion and Tissue Doppler Imaging, in addition to the increasingly utilized cardiac magnetic resonance. Invasive hemodynamic assessment also plays an important role and can also be employed during exercise to help elucidate functional reserve. Cardiopulmonary exercise testing provides added insight into the mechanisms of cardiopulmonary disease. Cardiac imaging, invasive hemodynamics, and gas exchange stress testing can be combined to give a more sophisticated understanding of RVF. The RV-PA coupling relationship can be assessed using practical and clinically available metrics in order to gain clinically relevant understanding of the patients' physiologic state. RV-PA coupling assessments can be done using invasive, combined noninvasive-invasive, or non-invasive approaches. We also discuss our approaches in the assessment of the RV-PA coupling relationship.
Assuntos
Ventrículos do Coração/fisiopatologia , Hipertensão Pulmonar/fisiopatologia , Artéria Pulmonar/fisiopatologia , Disfunção Ventricular Direita/fisiopatologia , Função Ventricular Direita/fisiologia , Ecocardiografia Doppler , Teste de Esforço , Ventrículos do Coração/diagnóstico por imagem , Humanos , Hipertensão Pulmonar/diagnóstico , Hipertensão Pulmonar/etiologia , Disfunção Ventricular Direita/complicações , Disfunção Ventricular Direita/diagnósticoRESUMO
BACKGROUND: The hemodynamic basis for increased pulse pressure (PP) with aging remains controversial. The classic paradigm attributes a predominant role to increased pulse wave velocity (PWV) and premature wave reflections (WRs). A controversial new paradigm proposes increased forward pressure wave amplitude (FWA), attributed to proximal aortic characteristic impedance (Zc), as the predominant factor, with minor contributions from WRs. Based on theoretical considerations, we hypothesized that (rectified) WRs drive the increase in FWA, and that the forward pressure wave does not depend solely on the interaction between flow and Zc (QZc product). METHODS AND RESULTS: We performed 3 substudies: (1) open-chest anesthetized dog experiments (n=5); (2) asymmetric T-tube model-based study; and (3) human study in a diverse clinical population (n=193). Animal experiments demonstrated that FWA corresponds to peak QZc only when WRs are minimal. As WRs increased, FWA was systematically greater than QZc and peaked well after peak flow, analogous to late-systolic peaking of pressure attributable to WRs. T-tube modeling confirmed that increased/premature WRs resulted in increased FWA. Magnitude and timing of WRs explained 80.8% and 74.3% of the variability in the difference between FWA and peak QZc in dog and human substudies, respectively. CONCLUSIONS: Only in cases of minimal reflections does FWA primarily reveal the interaction between peak aortic flow and proximal aortic diameter/stiffness. FWA is strongly dependent on rectified reflections. If interpreted out of context with the hemodynamic principles of its derivation, the FWA paradigm inappropriately amplifies the role of the proximal aorta in elevation of FWA and PP.