Utility of right ventricular Tei index in the noninvasive evaluation of chronic thromboembolic pulmonary hypertension before and after pulmonary thromboendarterectomy.

OBJECTIVES: We evaluated the utility of tissue Doppler-derived right ventricular (RV) Tei (or myocardial performance) index in patients with chronic thromboembolic pulmonary hypertension (CTEPH) before and after pulmonary thromboendarterectomy (PTE) and assessed correlations with mean pulmonary artery pressure (mPAP), pulmonary vascular resistance (PVR), and cardiac output (CO). BACKGROUND: The assessment of RV function is limited with 2-dimensional echocardiography. The RV Tei index, an indicator of RV myocardial performance, is derived by Doppler measurements and is unaffected by RV geometry. The use of tissue Doppler imaging (at the lateral tricuspid annulus) for RV Tei index calculation is simple and eliminates the need for pulsed-wave Doppler recordings of both RV inflow and outflow. METHODS: Ninety-three patients with CTEPH were prospectively studied along with 13 control patients. Right ventricular tissue Doppler imaging and right heart catheterization were performed before and after PTE. Right ventricular Tei index was compared with values of mPAP, PVR, and CO with the use of linear regression. RESULTS: Right ventricular Tei index was 0.52 +/- 0.19 in patients with CTEPH and 0.27 +/- 0.09 in control patients (p < 0.0001). After PTE, RV Tei index decreased to 0.33 +/- 0.10 (p < 0.0001). Pulmonary vascular resistance correlated well with RV Tei index before (r = 0.78, p < 0.0001) and after (r = 0.67, p < 0.0001) surgery. Also, the absolute change in Tei index in each patient after PTE correlated well with the concomitant change in PVR (r = 0.75, p < 0.0001). RV Tei index did not correlate as well with mPAP (pre-operatively: r = 0.55, p < 0.0001; post-operatively: r = 0.26, p = 0.03) or CO (pre-operatively: r = 0.57, p < 0.0001; post-operatively: r = 0.43, p < 0.0001). CONCLUSIONS: These results demonstrate a correlation between RV Tei index and right heart hemodynamics (particularly PVR) in CTEPH. Because PVR is difficult to estimate noninvasively -- and yet correlates with disease severity -- the RV Tei index may be a valuable noninvasive parameter for monitoring disease severity in CTEPH and outcome after PTE.

Noninvasive assessment of pulmonary vascular resistance using Doppler tissue imaging of the tricuspid annulus.

BACKGROUND: Pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) are important hemodynamic parameters in patients with advanced cardiopulmonary disease. We undertook this study to determine whether Doppler tissue imaging of the tricuspid annulus could be used to assess PAP and PVR noninvasively. METHODS: We studied 50 consecutive patients with suspected chronic thromboembolic pulmonary hypertension referred to our center for evaluation. We performed preoperative transthoracic echocardiography with Doppler tissue imaging of the tricuspid annulus. All patients then underwent cardiac catheterization with invasive determination of cardiac output, PAP, and PVR. RESULTS: The systolic velocity of the tricuspid annulus (tS(m)) had an inverse relationship with catheterization-derived mean PAP, with a correlation coefficient of -0.493 (P = .0003). The inverse correlation of tS(m) with catheterization-derived PVR was more striking, with a correlation coefficient of -0.710 (P < .0001). Based on the data, we derived the following logarithmic regression equation: PVR = 3698 - 1227 x ln(tS(m)). CONCLUSIONS: Doppler tissue imaging of the lateral tricuspid annulus is a useful clinical tool that can provide a noninvasive estimate of PVR in patients with chronic thromboembolic pulmonary hypertension. In this population, decreasing values of tS(m) predicted progressively higher measurements of PVR.

Abnormal left ventricular diastolic filling in chronic thromboembolic pulmonary hypertension: true diastolic dysfunction or left ventricular underfilling?

OBJECTIVES: The purpose of this study was to investigate the cause of abnormal left ventricular (LV) Doppler diastolic filling characteristics in chronic thromboembolic pulmonary hypertension (CTEPH). BACKGROUND: In CTEPH, LV diastolic function often appears abnormal. It is unclear whether this "impaired relaxation" (E

Assessment of diastolic function with Doppler tissue imaging after cardiac surgery: effect of the "postoperative septum" in on-pump and off-pump procedures.

Doppler tissue imaging (DTI) of mitral annular velocity is useful in assessing diastolic function. Most centers record at the septal or lateral segments of the annulus. Cardiopulmonary bypass produces changes in the motion of the interventricular septum. We evaluated the use of DTI after operation with and without cardiopulmonary bypass. 18 patients scheduled for cardiac surgery were prospectively examined. Nine underwent cardiopulmonary bypass. Nine had operation without bypass. DTI was performed 4 +/- 3 days before operation and again 31+/- 7 days afterwards. Early diastolic velocities of the lateral and septal segments of the mitral annulus were measured. Ejection fraction and transmitral diastolic early-to-late filling (E/A) ratios were also assessed. Early diastolic septal mitral annular velocity decreased (7.9 +/- 1.2 to 5.9 +/- 1.1 cm/s [P= .001]) after on-pump operation whereas lateral segment velocity remained unchanged (8.5 +/- 2.9 to 8.2 +/- 3.7 cm/s [P = .30]). E/A ratio did not change after operation (1.28 +/- 0.25 to 1.21 +/- 0.47 [P = .45]). In contrast, septal segment velocity in the off-pump group trended higher after operation (5.3 +/- 1.9 to 6.0 +/- 1.5 cm/s [P = .20]). Lateral segment velocity and E/A ratio also increased somewhat, but changes were not significant (6.2 +/- 1.7 to 6.7 +/- 2.9 cm/s [P = .15] and 1.1 +/- 0.5 to 1.2 +/- 0.4 [P = .13], respectively). Ejection fraction increased in both groups. Early diastolic velocity of the septal mitral annulus decreases after operation with cardiopulmonary bypass, but does not change after off-pump operation. In contrast, early diastolic velocity of the lateral segment is not affected by either on-pump or off-pump operation. Measuring lateral segment velocity is recommended for diastolic DTI after cardiopulmonary bypass, as septal DTI may incorrectly suggest diastolic dysfunction.