Evaluation of longitudinal right ventricular mechanical dyssynchrony before and early after cardiac resynchronization therapy: a strain imaging study

The right ventricular [RV] dyssynchrony has not been extensively and the existing literature has established the effect of cardiac resynchronization therapy [CRT] on the left ventricular [LV] dyssynchrony, but there is a death of data on the effect of CRT on the forgotten ventricle. We sought to evaluate the presence of mechanical right ventricular dyssynchrony in patients with systolic heart failure, selected for CRT, and track the changes early afterward utilizing the longitudinal strain analysis. Thirty-six patients with severe left ventricular systolic dysfunction, candidated for CRT, were enrolled in this study. Mechanical dyssynchrony was assessed using tissue Doppler echocardiography. The time interval between the onset delay was calculated as the absolute value of the difference in the time-to-peak measurements between the RV and spetum. The RV dyssynchrony was defined as the calculated delay in strain imaging, which was +/- 2 SD above the mean value for the control subjects [20 cases]. The RV function was evaluated using the RV fractional area change [RVFAC], tricuspid annulus plane systolic excursion [TAPSE], and peak systolic strain values of the RV free wall. Four to 7 days after CRT implantation, echocardiographic reevaluations were done. The calculated cut-off value for the RV dyssynchrony was 41.5 msec, according to which the pre-CRT analysis specified two patient groups: Group 1 [16 cases] with RV dyssynchrony and Group 2 [20 patients] without RV dyssynchrony. Significant improvement in the RV dyssynchrony was noted in Group 1 after CRT [30 +/- 28.9 msec vs. 68.8 +/- 21 msec; p value <0.01 vs. 14 +/- 10 msec vs. 19 +/- 16.5 msec; p value = 0.18 respectively]. A significant correlation was found between the severity of the RV dyssynchrony and peak systolic strain in the RV free wall [r = -0.5; p value <0.05]. No significant relation was found between the RV dyssynchrony and right ventricle fractional area change [RVFAC], LV mechanical dyssynchrony, time-to-peak systolic strain in the RV free wall, QRS width, or morphology. In group I, the peak systolic strain increased insignificantly [p value = 0.15 for the basal segment; p value = 0.20 for the mid segment]. A moderately significant correlation was found between the RV mechanical delay before CRT vs. the post-CRT values [r = 0.4; p value = 0.01]. Early after CRT, the RV mechanical delay can improve and the significant improvement is seen in patients with baseline RV mechanical dyssynchrony

Syncope as the clinical presentation of pulmonary thromboembolism

Pulmonary thromboembolism [PTE] has a wide spectrum of presentations, and its cardinal manifestations include chest pain, dyspnea, and syncope. Syncope as an initial presentation of PTE occurs in 10-14% of patients and is not restricted to massive PTEs. It can also occur in the setting of non- massive cases probably due to a vasovagal mechanism or the occurrence of conduction disturbances in preexisting complete left bundle-branch block. The next point discussed here is the use of thrombolytic therapy for submassive PTE with a normal blood pressure while marked right ventricular dyskinesia or dysfunction occurs