The prognostic value of right ventricular longitudinal strain and 3D ejection fraction in patients with dilated cardiomyopathy.

Several studies showed that right ventricular (RV) dysfunction is a powerful predictor in heart failure (HF). Advanced echocardiographic techniques such as speckle-tracking imaging and three-dimensional (3D) echocardiography proved to be accurate tools for RV assessment, but their clinical significance remains to be clarified. The aim of this study was to evaluate the role of two-dimensional (2D) RV strain and 3D ejection fraction (RVEF) in predicting adverse outcome in patients with non-ischemic dilated cardiomyopathy (DCM). We prospectively screened 81 patients with DCM and sinus rhythm, 50 of whom were enrolled and underwent comprehensive echocardiography, including RV strain and 3D RV volumetric assessment. Patients were followed for a composite endpoint of cardiac death, nonfatal cardiac arrest and acute worsening of HF requiring hospitalization. After a median follow-up of 16 months, 29 patients reached the primary endpoint. Patients with events had more impaired RV global longitudinal strain (- 10.5 ± 4.5% vs. - 14.3 ± 5.2%, p = 0.009), RV free wall longitudinal strain (- 12.9 ± 8.7% vs. - 17.5 ± 7.1%, p = 0.046) and 3D RVEF (38 ± 8% vs. 47 ± 9%, p = 0.001). By Cox proportional hazards multivariable analysis, RV global longitudinal strain and RVEF were independent predictors of outcome after adjustment for age and NYHA class. RVEF remained the only independent predictor of events after further correction for echocardiographic risk factors. By receiver-operating characteristic analysis, the optimal RVEF cut-off value for event prediction was 43.4% (area under the curve = 0.768, p = 0.001). Subjects with RVEF > 43.4% showed more favourable outcome compared to those with RVEF < 43.4% (log-rank test, p < 0.001). In conclusion, 3D RVEF is an independent predictor of major adverse cardiovascular events in patients with DCM.

The Role of Left-Atrial Mechanics Assessed by Two-Dimensional Speckle-Tracking Echocardiography to Differentiate Hypertrophic Cardiomyopathy from Hypertensive Left-Ventricular Hypertrophy.

Hypertrophic cardiomyopathy (HCM) and arterial hypertension (HTN) are conditions with different pathophysiology, but both can result in left-ventricular hypertrophy (LVH). The role of left-atrial (LA) functional changes detected by two-dimensional speckle-tracking echocardiography (STE) in indicating LVH etiology is unknown. METHODS: We aimed to characterize LA mechanics using STE in LVH patients with HCM and HTN. LA 2D volumetric and STE parameters were analyzed in 86 LVH patients (43 HCM and 43 isolated HTN subjects) and 33 age- and sex-matched controls. RESULTS: The volumetric study showed that LA reservoir and conduit function were impaired in the HCM group compared to controls, while, in the HTN group, only LA conduit function was deteriorated. The HCM group had all three STE-derived LA functions impaired compared to controls. The HTN group, consistently with volumetric analysis, had solely LA conduit function reduced compared to controls. Ratios of LA booster-pump strain (S) and strain rate (SR) to interventricular septum (IVS) thickness were the most accurate parameters to discriminate between HCM and HTN. The subgroup harboring sarcomeric pathogenic (P)/likely pathogenic (LP) variants had reduced LA booster-pump S and SR compared with the genotype-negative subgroup. CONCLUSIONS: LA reservoir, conduit, and pump functions are decreased in HCM compared to HTN patients with similar LVH. We report the ratios between LA contraction S/SR and IVS thickness as novel parameters with high accuracy in discriminating LVH due to HCM. The presence of P/LP variants in sarcomeric or sarcomeric-associated genes could be associated with more severe LA dysfunction.

Right ventricular-arterial coupling - A new perspective for right ventricle evaluation in heart failure patients undergoing cardiac resynchronization therapy.

BACKGROUND: Right ventricular - arterial (RV-PA) coupling can be estimated by echocardiography using the ratio between (TAPSE) and pulmonary arterial systolic pressure (PASP). TAPSE/PASP ratio proved to be a prognostic parameter in patients with heart failure and reduced ejection fraction (HFrEF). OBJECTIVE: To evaluate the significance of RV-PA coupling in patients with HFrEF undergoing cardiac resynchronization therapy (CRT). METHODS: Patients undergoing CRT in our center between January 2017 and November 2019 were eligible. Response to CRT was defined by a reduction of more than 15% of left ventricle systolic volume (LVESV) one year after CRT. Primary endpoint was a composite of HF hospitalizations and death during follow-up. RESULTS: 54 patients (Age 64.0 ± 13.8 years; 58% male; left ventricular ejection fraction (LVEF) 28.4 ± 1.3%) were prospectively included. After a mean follow-up of 31 ± 12.9months, the primary endpoint had occurred in 18 (33.3%) patients. A lower TAPSE/PASP ratio was associated with baseline worse HF symptoms, lower LVEF and long-term less LV reverse remodeling (P < .05). After one year CRT improved RV systolic function (TAPSE, RV global longitudinal strain, P < .05), but not TAPSE/PASP ratio (P = .4). The ratio TAPSE/PASP (AUC=0.834) ≥ 0.58 mm/mm Hg showed good sensitivity (90%) and specificity (81.8%) for predicting response to CRT while a ratio <0.58 mm/mm Hg was associated with a higher risk of death and HF hospitalizations during the follow-up (HR 5.37 95%CI [1.6-18], P < .001). CONCLUSION: RV-PA coupling evaluation using TAPSE/PASP ratio predicts CRT response. A lower TAPSE/PASP ratio is associated with a higher risk of adverse cardiovascular events.

Forgotten No More-The Role of Right Ventricular Dysfunction in Heart Failure with Reduced Ejection Fraction: An Echocardiographic Perspective.

During the last decade, studies have raised awareness of the crucial role that the right ventricle plays in various clinical settings, including diseases primarily linked to the left ventricle. The assessment of right ventricular performance with conventional echocardiography is challenging. Novel echocardiographic techniques improve the functional assessment of the right ventricle and they show good correlation with the gold standard represented by cardiac magnetic resonance. This review summarizes the traditional and innovative echocardiographic techniques used in the functional assessment of the right ventricle, focusing on the role of right ventricular dysfunction in heart failure with reduced ejection fraction and providing a perspective on recent evidence from literature.

Prognostic Value of Right Ventricular Function Assessed by Echocardiography in Patients Presenting With a First Acute ST Elevation Myocardial Infarction Treated By Primary PCI.

Aims: Informations regarding the prognostic value of right ventricular function changes in the setting of a first acute ST elevation myocardial infarction irrespective of the site of the necrosis and of the left ventricular systolic function are scarce. Purpose of the study was to assess the relation between parameters reflecting global and systolic right ventricular function assessed by conventional, speckle tracking and three-dimensional echocardiography and in hospital major cardiac events (MACE). Materials and Methods: We have prospectively analyzed a cohort of 44 consecutive patients (mean age 62,71 years, 70.5 % males) presenting with a first STEMI (2,3 % Topol 1, 38 ,6 % Topol 2, 20,6 % Topol 3, 31,8 % Topol 4, 6,8 % Topol5) treated by primary angioplasty. Patients with previous history of cardiac or pulmonary diseases were excluded. All patients underwent during hospitalization conventional 2D echocardiography and special techniques ( 2D speckle tracking echocardiography and also 3D echocardiography) RV global function was quantified by RV myocardial performance index (RV MPI) determined by PW Doppler ,whereas RV systolic function was studied using regional parameters like TAPSE , pulsed Doppler S wave and RV free wall 2D strain and global parameters like RV fractional area change (RV FAC) or RV ejection fraction ( RVEF) determined by 3D echocardiography . LV systolic function was described by LV ejection fraction (LVEF). The combined endpoint of major adverse cardiovascular events (MACE) was defined by all cause mortality, reinfarction, need for revascularization and occurrence of heart failure during hospitalization. The association between MACE and RV functional parameters was assessed by bivariate correlation analysis followed by binary logistic regression. Results: Initially, regardless of the site of necrosis, the only RV functional parameter correlated with MACE was RV MPI (OR 9.17; 95% CI: 1.03 -83.7). After adjustment for LVEF all RV functional parameters were correlated with MACE: TAPSE (OR: 1.83; 95% CI : 0.41- 8.23), RV MPI (OR: 8.07; 95% CI : 0.9- 72.07), RVFAC (OR: 1.22; 95% CI : 0.25- 5.98) , RV free wall strain (OR : 1.04; 95% CI : 0.21- 5.08) , S wave (OR: 2.46 ; 95% CI : 0.14- 42.82), RVEF (OR: 0.83 ; 95% CI : 0.20- 3.43). Conclusions: Our study reveals that RV functional parameters are predictive for in hospital MACE beyond LV systolic function and regardless of the culprit coronary artery. Among these parameters, RV MPI seems to have the greatest predictive value for short term MACE in STEMI patients.

Imaging Atherosclerosis by Carotid Intima-media Thickness in vivo: How to, Where and in Whom ?

Carotid intima-media thickness (CIMT) can be reliably determined in vivo by carotidian ultrasound and is an accessible and reliable method to assess subclinical atherosclerosis. Available epidemiological data showed that CIMT is significantly correlated with future cardiovascular events. However it has limited value to help risk stratification on top of standard risk-derived functions such as Framingham risk score. It is particularly useful in individuals classified as being at intermediate or high risk by the presence of multiple conventional risk factors.CIMT HAS A CLASS IIA (LOE: B) reccommendation for cardiovascular risk assessment according to the practice guidelines published in 2010, emphasizing the presence of high risk if the common carotid artery intima-media thickness is above the 75(th) percentile. There is no indication to measure IMT in patients with full-blown atherosclerotic carotid disease, although carotidian ultrasound still remains a very useful tool to assess the severity of disease even in these subjects.Progression of CIMT (also associated with increasing age) can be delayed by some drugs (statins, colestipol and niacin) and by risk factors modification. However, there is no consistent data demonstrating a link between progression of CIMT and coronary and cerebral events. Subsequently, studies using CIMT progression as primary outcome to indicate the influence of a certain therapy on cardiovascular risk are inherently misleading as suggested in the recently published ACC/AHA Guidelines.

Systemic inflammation and early atheroma formation: are they related?

Atherosclerosis is a chronic inflammatory disease started by endothelial injury and defined by arterial wall load with free and esterified cholesterol, followed by subintimal focal recruitment of circulating monocytes and T-lymphocytes that heals by fibrosis and calcification. Inflammation plays a crucial role in atherogenesis either by local cellular mechanisms or humoral consequences easily measurable in plasma. In most cases inflammation and endothelial dysfunction are triggered by cardiovascular risk factors: hypercholesterolemia, hypertension, smoking or diabetes. In other cases inflammation precedes atherosclerotic changes that occur in autoimmune diseases, as systemic lupus erythematosus and rheumatoid arthritis. In these diseases atherogenesis is mostly independent from conventional risk factors. Irrespective of its cause systemic inflammation is correlated with cardiovascular events, but currently there are controversial results regarding inflammatory markers and early atherosclerotic process. We designed a study to identify if the amplitude of inflammation expressed by multiple serum markers is correlated with the severity of the atherosclerotic process measured by coronary atheroma volume and carotid intima-media thickness. The selected inflammatory markers are associated with different pathogenic steps in atherogenesis: acute phase reactants (C-reactive protein); pro-inflammatory cytokines (TNF-alpha, interleukin-6 and -18); endothelium activation markers (soluble VCAM-1, ICAM-1); and specific factors (anticardiolipinic antibodies). We aim to enrol the two different patient subsets with early atherosclerosis: one with conventional risk factors and one with autoimmune diseases without traditional risk factors, in whom inflammation is part of the systemic disease progression.