- Email: [email protected]
Right Ventricular Free Wall Apical Longitudinal Strain Responds Sensitively to the Treatment of Pulmonary Arterial Hypertension
Abstracts
S195
Conclusions: Reopening of CTO in symptomatic patients with baseline resting perfusion defects is associated with improved microvascular flow, and improved regional and global myocardial function. MCE may be a useful tool for selecting CTO patients who will benefit from intervention.
464
doi:10.1016/j.hlc.2010.06.471
Concord Repatriation General Hospital, Australia
463
Background: The cardiac apex plays a key role in left ventricular function, and may also be important for the right ventricle (RV). We have investigated whether RV apical function as measured by RV free wall (RVFW) apical deformation is altered in PAH, and whether this correlates with RV pressure, pulmonary vascular compliance (PAC) and pulmonary vascular resistance (PVR). Method: Seventeen controls and nineteen chronic PAH patients were studied. A 3.5 MHz transducer (GE, Vivid 7) was used to acquire apical 4-chamber and 3-chamber views (frame rate 50–80). RVFW segmental peak systolic longitudinal strains were obtained by using Automated Function Imaging. PAC and PVR were calculated from echo data. Results: RVFW longitudinal strain (LS) in apex (−29 ± 5.2%) and mid (−27 ± 3.8%) RV free wall were significantly higher than that in base (−24 ± 3.7%, p = 0.002 vs. apex and p = 0.039 vs. mid-segment). In patients with PAH, RVFW LS was significantly reduced in the apex and mid segments (−13.1 ± 4.4% and −17.8 ± 5.4%, respectively, p = 0.000) relative to controls, but was not significantly reduced in the basal segment. RVLS fwApex correlated most closely with RV pressure, PVC and PVR (Table).
Right and Left Ventricular Structure and Function in Systemic Amyloidosis E. Chia 1,∗ , Q. Lo 1 , M. Lin 2 , J. Taper 2 , D. Gottlieb 2 , R. Phoon 2 , G. Stewart 2 , D. Richards 1 , L. Thomas 1 1 Liverpool
Hospital, Australia Hospital (on behalf of the Amyloid Investigator Group), Australia
2 Westmead
Background: Left ventricular changes in amyloidosis (AS) are well described; however little is known of its consequences on the right ventricle (RV). Method: Transthoracic echocardiograms were performed in 33 patients with AS referred to a single centre, 19 of whom had known cardiac involvement. Left and right ventricular volumes and systolic and diastolic function were assessed using Simpson’s ejection fraction, tissue Doppler annular velocities and strain imaging by velocity vector imaging (VVI). Results: Patients with known cardiac involvement had higher NT-proBNP and a lower mean arterial BP. There was no difference in ventricular volumes; however LVEF and LV strain and left ventricular diastolic function were reduced (data not shown). Although RVEF was normal, RV strain was reduced suggesting early subclinical RV dysfunction in those with cardiac involvement. Atrial volumes were significantly larger in those with cardiac involvement. Conclusion: In this cohort of AS patients, left sided systolic and diastolic involvement is clearly seen Right ventricular subclinical involvement was only evident by VVI strain analysis with associated RA enlargement. AS with no cardiac involvement (n = 15) MAP (mm Hg) NT-proBNP LA vol indexed (ml/cm2 ) RA vol indexed (ml/cm2 ) RVEDV (ml) RVEF (%) RV sys strain (%)
95.0 10.4 26.8 16.3 31.9 59.1 24.5
± ± ± ± ± ± ±
7.6 11.0 7.6 3.7 12.7 10.2 11.1
AS with cardiac involvement (n = 18) 82.0 925.3 38.9 26.0 35.7 56.3 20.3
± ± ± ± ± ± ±
25.0* 1634.7* 12.9* 9.5* 6.5 9.7 9.7*
*p < 0.05 when compared with AS with no cardiac involvement. doi:10.1016/j.hlc.2010.06.472
Right Ventricular Free Wall Apical Longitudinal Strain Correlates with Right Ventricular Pressure in Patients with Pulmonary Arterial Hypertension W. Zhao ∗ , T. Chung, B. Costa, L. Kritharides
RVLS fwApex RVLS fwMid RVLS fwBase
RV pressure (r)
PVR (r)
PAC (r)
0.707** 0.622** 0.409**
0.544** 0.423** 0.291*
−0.642** −0.467** −0.244
** Correlation is significant at the 0.01 level * correlation is significant at the 0.05 level. Conclusion: RVFW apical deformation is reduced in chronic PAH and may be a novel, sensitive parameter of RV performance and pulmonary haemodynamics. doi:10.1016/j.hlc.2010.06.473 465 Right Ventricular Free Wall Apical Longitudinal Strain Responds Sensitively to the Treatment of Pulmonary Arterial Hypertension W. Zhao 1,2,∗ , T. Chung 1,2 , B. Costa 1,2 , L. Kritharides 1,2 1 Concord 2 Anzac
Repatriation General Hospital, Australia Research Institute, Australia
Background: Sensitive markers of RV function, and its response to treatment, may predict long-term treatment outcome in patients with pulmonary arterial hypertension (PAH). We evaluated the sensitivity of various echo param-
ABSTRACTS
Heart, Lung and Circulation 2010;19S:S1–S268
S196
Heart, Lung and Circulation 2010;19S:S1–S268
Abstracts
ABSTRACTS
eters, including the novel parameter of RV free wall apical longitudinal strain (RVLS fwApex), to the introduction of therapy in patients with PAH. Method: Seventeen normal controls and eighteen chronic PAH patients on Bosentan or Sildenafil therapy were compared. PAH patients were also evaluated for 6–12 months after treatment. Apical 4-chamber and 3-chamber views (frame rate 50–80) were obtained by using 3.5 MHz transducer (GE, Vivid 7). RV segmental peak systolic longitudinal strains were obtained using Automated Function Imaging (AFI) method. Results (shown in Table). RVLS fwApex (%) RVLS fwMid (%) RVLS fwBase(%) RVGLS (%) PAC (ml/mm Hg) PVR (woods units) RVAC (fractional) TAM (cm) RV pressure SMW (M)
Normal
PAH baseline
−29.2 ± 5.2 −26.9 ± 3.8 −23.9 ± 3.7 −23.9 ± 2.9 4.9 ± 1.6 1.6 ± 0.3 0.42 ± 0.05 2.4 ± 0.3 18.8 ± 4.2 n/a
−13.6 −18.1 −20.5 −16.0 2.4 2.7 0.39 2.0 52.7 308
± ± ± ± ± ± ± ± ± ±
4.1## 5.0## 6.4# 3.0## 1.2## 0.8## 0.09 0.5### 23.8## 123
6 m F/U (n = 18)
12 m F/U (n = 14)
−18.4 −21.4 −21.3 −18.6 2.8 2.2 0.37 2.2 48.8 341
−19 −22.3 −24.1 −19.1 2.8 2.2 0.4 2.1 50 360
± ± ± ± ± ± ± ± ± ±
5.8 5.4 6.1 3.7 1.0 0.5 0.09 0.6 22.9 130
± ± ± ± ± ± ± ± ± ±
6.1* 6.1 6.4 4.1 1.1 0.6 0.1 0.6 23 150
# p < 0.05 compare with normal, ## p < 0.001 compare with
normal, ### p < 0.01 compare with normal, *p < 0.05 one-way ANOVA. Conclusion: RVLS fwApex responds more sensitively to therapy in PAH patients than conventional echo parameters. It may have a role in assessing the response to therapy in PAH patients. doi:10.1016/j.hlc.2010.06.474 466 Subclinical Myocardial Disease in Type 2 Diabetes: Mechanistic Insights from Resting and Exercise Haemodynamics C. Jellis ∗ , T. Stanton, R. Leano, J. Martin, T. Marwick The University of Queensland, Australia Background: Patients with type 2 diabetes mellitus (T2DM) may have subclinical myocardial dysfunction identified at rest, or unmasked with exercise. We sought to examine the correlates of the myocardial exercise response in T2DM. Methods: Myocardial dysfunction was sought with resting and exercise echocardiography (ExE) in 167 healthy T2DM (97 men, 55 ± 10 y). Myocardial ischaemia was excluded by ExE. Standard echocardiography and color TDI measures (early diastolic tissue velocity [Em], strain and strain rate) were acquired at baseline and peak stress. Calibrated integrated backscatter (cIB) was calculated from the resting parasternal long axis view. Longitudinal diastolic functional reserve index (LDFRI) post exercise was defined as Em[1 − (1/Embase )]. Clinical, anthropometric and metabolic data were collected at rest and stress. Results: Subclinical myocardial dysfunction at baseline (n = 24) was independently associated with weight (OR = 1.02, p = 0.04) and HbA1c (OR = 1.36, p = 0.03). This
group displayed an impaired exercise response, independently associated with reduced exercise capacity (OR = 0.84, p = 0.034) and LDFRI (OR = 0.69, p = 0.001). Inducible myocardial dysfunction (stress Em < 9.9 cm/s) was identified post-exercise in 70 of the remaining 143 subjects. This finding was associated with cIB (OR = 1.08, p = 0.04) and lower peak heart rate (OR = 0.97, p = 0.002) but not metabolic control. Conclusions: The intensity of metabolic derangement in T2DM is associated with subclinical resting myocardial dysfunction, but not with myocardial exercise response. The association of abnormal stress response with nonmetabolic factors suggests a possible role for myocardial fibrosis and cardiac autonomic neuropathy. doi:10.1016/j.hlc.2010.06.475 467 Substantial Weight Reduction by Laparoscopic Gastric Banding Consistently Improved Myocardial Function M. Asrar Ul Haq 1,∗ , M. Butler 2 , A. Ellims 2 , A. Taylor 2 , P. O’Brien 3 , C. Wong 1,2 1 The
Northern Hospital, Victoria, Australia IDI Heart and Diabetes Institute, Melbourne, Australia 3 Centre for Obesity Research and Education, Melbourne, Australia 2 Baker
Background: Weight reduction by dieting and exercise has been shown to improve left ventricular LV function. We evaluated for myocardial benefit of substantial weight reduction through laparoscopic gastric banding in severely obese patients (BMI > 35 kg/m2 ). Methods: 30 patients including 15 obese patients who underwent laparoscopic gastric banding had LV function assessed using the sensitive tissue Doppler imaging [systolic (sm) and early diastolic (em) velocities] and strain imaging. Patients with significant primary valvular disease or known coronary vascular disease were excluded. Follow up echocardiogram was performed >4 months after surgery. Results: The mean age was 49 ± 7 years for the obese patients with an average BMI of 43 ± 8 kg/m2 . Compared to healthy controls the LV tissue velocities were reduced at baseline (sm 5.0 ± 0.9 cm/s vs. 6.6 ± 0.9 cm/s and em 6.2 ± 1.7 cm/s vs. 8.2 ± 2.1 cm/s, p < 0.05). There was significant improvement in myocardial function measures post-laparoscopic banding sm (mean pre: 5.0 ± 0.9, mean post: 5.9 ± 0.8 cm/s; p < 0.005) as well as em (mean pre: 6.17 ± 1.5, mean post: 6.91 ± 1.3 cm/s; p < 0.05). No significant correlation was established between improvement in BMI and change in LV function, however consistent improvement seen in sm, and em at 4 months. Conclusion: Laparoscopic gastric banding has a beneficial effect on myocardium evidenced by consistent improvement in LV tissue velocities seen in most patients. doi:10.1016/j.hlc.2010.06.476
S195
Conclusions: Reopening of CTO in symptomatic patients with baseline resting perfusion defects is associated with improved microvascular flow, and improved regional and global myocardial function. MCE may be a useful tool for selecting CTO patients who will benefit from intervention.
464
doi:10.1016/j.hlc.2010.06.471
Concord Repatriation General Hospital, Australia
463
Background: The cardiac apex plays a key role in left ventricular function, and may also be important for the right ventricle (RV). We have investigated whether RV apical function as measured by RV free wall (RVFW) apical deformation is altered in PAH, and whether this correlates with RV pressure, pulmonary vascular compliance (PAC) and pulmonary vascular resistance (PVR). Method: Seventeen controls and nineteen chronic PAH patients were studied. A 3.5 MHz transducer (GE, Vivid 7) was used to acquire apical 4-chamber and 3-chamber views (frame rate 50–80). RVFW segmental peak systolic longitudinal strains were obtained by using Automated Function Imaging. PAC and PVR were calculated from echo data. Results: RVFW longitudinal strain (LS) in apex (−29 ± 5.2%) and mid (−27 ± 3.8%) RV free wall were significantly higher than that in base (−24 ± 3.7%, p = 0.002 vs. apex and p = 0.039 vs. mid-segment). In patients with PAH, RVFW LS was significantly reduced in the apex and mid segments (−13.1 ± 4.4% and −17.8 ± 5.4%, respectively, p = 0.000) relative to controls, but was not significantly reduced in the basal segment. RVLS fwApex correlated most closely with RV pressure, PVC and PVR (Table).
Right and Left Ventricular Structure and Function in Systemic Amyloidosis E. Chia 1,∗ , Q. Lo 1 , M. Lin 2 , J. Taper 2 , D. Gottlieb 2 , R. Phoon 2 , G. Stewart 2 , D. Richards 1 , L. Thomas 1 1 Liverpool
Hospital, Australia Hospital (on behalf of the Amyloid Investigator Group), Australia
2 Westmead
Background: Left ventricular changes in amyloidosis (AS) are well described; however little is known of its consequences on the right ventricle (RV). Method: Transthoracic echocardiograms were performed in 33 patients with AS referred to a single centre, 19 of whom had known cardiac involvement. Left and right ventricular volumes and systolic and diastolic function were assessed using Simpson’s ejection fraction, tissue Doppler annular velocities and strain imaging by velocity vector imaging (VVI). Results: Patients with known cardiac involvement had higher NT-proBNP and a lower mean arterial BP. There was no difference in ventricular volumes; however LVEF and LV strain and left ventricular diastolic function were reduced (data not shown). Although RVEF was normal, RV strain was reduced suggesting early subclinical RV dysfunction in those with cardiac involvement. Atrial volumes were significantly larger in those with cardiac involvement. Conclusion: In this cohort of AS patients, left sided systolic and diastolic involvement is clearly seen Right ventricular subclinical involvement was only evident by VVI strain analysis with associated RA enlargement. AS with no cardiac involvement (n = 15) MAP (mm Hg) NT-proBNP LA vol indexed (ml/cm2 ) RA vol indexed (ml/cm2 ) RVEDV (ml) RVEF (%) RV sys strain (%)
95.0 10.4 26.8 16.3 31.9 59.1 24.5
± ± ± ± ± ± ±
7.6 11.0 7.6 3.7 12.7 10.2 11.1
AS with cardiac involvement (n = 18) 82.0 925.3 38.9 26.0 35.7 56.3 20.3
± ± ± ± ± ± ±
25.0* 1634.7* 12.9* 9.5* 6.5 9.7 9.7*
*p < 0.05 when compared with AS with no cardiac involvement. doi:10.1016/j.hlc.2010.06.472
Right Ventricular Free Wall Apical Longitudinal Strain Correlates with Right Ventricular Pressure in Patients with Pulmonary Arterial Hypertension W. Zhao ∗ , T. Chung, B. Costa, L. Kritharides
RVLS fwApex RVLS fwMid RVLS fwBase
RV pressure (r)
PVR (r)
PAC (r)
0.707** 0.622** 0.409**
0.544** 0.423** 0.291*
−0.642** −0.467** −0.244
** Correlation is significant at the 0.01 level * correlation is significant at the 0.05 level. Conclusion: RVFW apical deformation is reduced in chronic PAH and may be a novel, sensitive parameter of RV performance and pulmonary haemodynamics. doi:10.1016/j.hlc.2010.06.473 465 Right Ventricular Free Wall Apical Longitudinal Strain Responds Sensitively to the Treatment of Pulmonary Arterial Hypertension W. Zhao 1,2,∗ , T. Chung 1,2 , B. Costa 1,2 , L. Kritharides 1,2 1 Concord 2 Anzac
Repatriation General Hospital, Australia Research Institute, Australia
Background: Sensitive markers of RV function, and its response to treatment, may predict long-term treatment outcome in patients with pulmonary arterial hypertension (PAH). We evaluated the sensitivity of various echo param-
ABSTRACTS
Heart, Lung and Circulation 2010;19S:S1–S268
S196
Heart, Lung and Circulation 2010;19S:S1–S268
Abstracts
ABSTRACTS
eters, including the novel parameter of RV free wall apical longitudinal strain (RVLS fwApex), to the introduction of therapy in patients with PAH. Method: Seventeen normal controls and eighteen chronic PAH patients on Bosentan or Sildenafil therapy were compared. PAH patients were also evaluated for 6–12 months after treatment. Apical 4-chamber and 3-chamber views (frame rate 50–80) were obtained by using 3.5 MHz transducer (GE, Vivid 7). RV segmental peak systolic longitudinal strains were obtained using Automated Function Imaging (AFI) method. Results (shown in Table). RVLS fwApex (%) RVLS fwMid (%) RVLS fwBase(%) RVGLS (%) PAC (ml/mm Hg) PVR (woods units) RVAC (fractional) TAM (cm) RV pressure SMW (M)
Normal
PAH baseline
−29.2 ± 5.2 −26.9 ± 3.8 −23.9 ± 3.7 −23.9 ± 2.9 4.9 ± 1.6 1.6 ± 0.3 0.42 ± 0.05 2.4 ± 0.3 18.8 ± 4.2 n/a
−13.6 −18.1 −20.5 −16.0 2.4 2.7 0.39 2.0 52.7 308
± ± ± ± ± ± ± ± ± ±
4.1## 5.0## 6.4# 3.0## 1.2## 0.8## 0.09 0.5### 23.8## 123
6 m F/U (n = 18)
12 m F/U (n = 14)
−18.4 −21.4 −21.3 −18.6 2.8 2.2 0.37 2.2 48.8 341
−19 −22.3 −24.1 −19.1 2.8 2.2 0.4 2.1 50 360
± ± ± ± ± ± ± ± ± ±
5.8 5.4 6.1 3.7 1.0 0.5 0.09 0.6 22.9 130
± ± ± ± ± ± ± ± ± ±
6.1* 6.1 6.4 4.1 1.1 0.6 0.1 0.6 23 150
# p < 0.05 compare with normal, ## p < 0.001 compare with
normal, ### p < 0.01 compare with normal, *p < 0.05 one-way ANOVA. Conclusion: RVLS fwApex responds more sensitively to therapy in PAH patients than conventional echo parameters. It may have a role in assessing the response to therapy in PAH patients. doi:10.1016/j.hlc.2010.06.474 466 Subclinical Myocardial Disease in Type 2 Diabetes: Mechanistic Insights from Resting and Exercise Haemodynamics C. Jellis ∗ , T. Stanton, R. Leano, J. Martin, T. Marwick The University of Queensland, Australia Background: Patients with type 2 diabetes mellitus (T2DM) may have subclinical myocardial dysfunction identified at rest, or unmasked with exercise. We sought to examine the correlates of the myocardial exercise response in T2DM. Methods: Myocardial dysfunction was sought with resting and exercise echocardiography (ExE) in 167 healthy T2DM (97 men, 55 ± 10 y). Myocardial ischaemia was excluded by ExE. Standard echocardiography and color TDI measures (early diastolic tissue velocity [Em], strain and strain rate) were acquired at baseline and peak stress. Calibrated integrated backscatter (cIB) was calculated from the resting parasternal long axis view. Longitudinal diastolic functional reserve index (LDFRI) post exercise was defined as Em[1 − (1/Embase )]. Clinical, anthropometric and metabolic data were collected at rest and stress. Results: Subclinical myocardial dysfunction at baseline (n = 24) was independently associated with weight (OR = 1.02, p = 0.04) and HbA1c (OR = 1.36, p = 0.03). This
group displayed an impaired exercise response, independently associated with reduced exercise capacity (OR = 0.84, p = 0.034) and LDFRI (OR = 0.69, p = 0.001). Inducible myocardial dysfunction (stress Em < 9.9 cm/s) was identified post-exercise in 70 of the remaining 143 subjects. This finding was associated with cIB (OR = 1.08, p = 0.04) and lower peak heart rate (OR = 0.97, p = 0.002) but not metabolic control. Conclusions: The intensity of metabolic derangement in T2DM is associated with subclinical resting myocardial dysfunction, but not with myocardial exercise response. The association of abnormal stress response with nonmetabolic factors suggests a possible role for myocardial fibrosis and cardiac autonomic neuropathy. doi:10.1016/j.hlc.2010.06.475 467 Substantial Weight Reduction by Laparoscopic Gastric Banding Consistently Improved Myocardial Function M. Asrar Ul Haq 1,∗ , M. Butler 2 , A. Ellims 2 , A. Taylor 2 , P. O’Brien 3 , C. Wong 1,2 1 The
Northern Hospital, Victoria, Australia IDI Heart and Diabetes Institute, Melbourne, Australia 3 Centre for Obesity Research and Education, Melbourne, Australia 2 Baker
Background: Weight reduction by dieting and exercise has been shown to improve left ventricular LV function. We evaluated for myocardial benefit of substantial weight reduction through laparoscopic gastric banding in severely obese patients (BMI > 35 kg/m2 ). Methods: 30 patients including 15 obese patients who underwent laparoscopic gastric banding had LV function assessed using the sensitive tissue Doppler imaging [systolic (sm) and early diastolic (em) velocities] and strain imaging. Patients with significant primary valvular disease or known coronary vascular disease were excluded. Follow up echocardiogram was performed >4 months after surgery. Results: The mean age was 49 ± 7 years for the obese patients with an average BMI of 43 ± 8 kg/m2 . Compared to healthy controls the LV tissue velocities were reduced at baseline (sm 5.0 ± 0.9 cm/s vs. 6.6 ± 0.9 cm/s and em 6.2 ± 1.7 cm/s vs. 8.2 ± 2.1 cm/s, p < 0.05). There was significant improvement in myocardial function measures post-laparoscopic banding sm (mean pre: 5.0 ± 0.9, mean post: 5.9 ± 0.8 cm/s; p < 0.005) as well as em (mean pre: 6.17 ± 1.5, mean post: 6.91 ± 1.3 cm/s; p < 0.05). No significant correlation was established between improvement in BMI and change in LV function, however consistent improvement seen in sm, and em at 4 months. Conclusion: Laparoscopic gastric banding has a beneficial effect on myocardium evidenced by consistent improvement in LV tissue velocities seen in most patients. doi:10.1016/j.hlc.2010.06.476