Right ventricular remodelling after transcatheter pulmonary valve implantation.

OBJECTIVES: To define the optimal timing for percutaneous pulmonary valve implantation (PPVI) in patients with severe pulmonary regurgitation (PR) after Fallot's Tetralogy (ToF) correction. BACKGROUND: PPVI among the aforementioned patients is mainly driven by symptoms or by severe right ventricular (RV) dilatation/dysfunction. The optimal timing for PPVI is still disputed. METHODS: Twenty patients [age 13.9 ± 9.2 years, (range 4.3-44.9), male 70%] with severe PR (≥3 grade) secondary to previous correction of ToF, underwent Melody valve (Medtronic, Minneapolis, MN) implantation, after a pre-stent placement. Full echocardiographic assessment (traditional and deformation analysis) and cardiovascular magnetic resonance evaluation were performed before and at 3 months after the intervention. 'Favorable remodelling' was considered the upper quartile of RV size decrease (>20% in 3 months). RESULTS: After PPVI, indexed RV effective stroke volume increased from 38.4 ± 9.5 to 51.4 ± 10.7 mL/m2 , (P = 0.005), while RV end-diastolic volume and strain indices decreased (123.1 ± 24.1-101.5 ± 18.3 mL/m2 , P = 0.005 and -23.5 ± 2.5 to -21 ± 2.5%, P = 0.002, respectively). After inserting pre-PPVI clinical, RV volumetric and deformation parameters in a multiple regression model, only time after last surgical correction causing PR remained as significant regressor of RV remodelling [R2 = 0.60, beta = 0.387, 95%CI(0.07-0.7), P = 0.019]. Volume reduction and functional improvement were more pronounced in patients treated with PPVI earlier than 7 years after last RV outflow tract (RVOT) correction, reaching close-to-normal values. CONCLUSIONS: Early PPVI (<7 years after last RVOT operation) is associated with a more favorable RV reverse remodelling toward normal range and should be considered, before symptoms or RV damage become apparent. © 2017 Wiley Periodicals, Inc.

Apical traction: a novel visual echocardiographic parameter to predict survival in patients with pulmonary hypertension.

AIMS: In some pulmonary hypertension (PH) patients, we noted a motion pattern where the right ventricular (RV) apex is pulled towards to left ventricle (LV) during systole, caused by traction from the LV ('apical traction', AT). Herein, we characterize patients with AT to investigate its prognostic significance. METHODS AND RESULTS: Echocardiograms of 62 pre-capillary PH patients (42 females, age 61 ± 15 years) were retrospectively analysed. The presence of AT was assessed visually and confirmed by speckle-tracking analysis. Fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), RV free-wall longitudinal strain (LS) as well as LV function were measured. A primary end point of death or heart/lung transplantation was set. AT was observed in 31 patients. They had worse functional capacity, lower TAPSE (1.3 ± 0.2 vs. 1.9 ± 0.4, P ≤ 0.001) and FAC (20.3 ± 6.1 vs. 33 ± 7.1%, P ≤ 0.001), worse RV free-wall LS (-12.4 ± 3.4 vs. -20.8 ± 4.9%, P < 0.001), and higher systolic pulmonary arterial pressure (92 ± 15 vs. 75 ± 23, P < 0.001). LV function was similar in both groups. The primary end point occurred in 16 patients with and 8 without AT. AT was an independent predictor of the outcome (HR: 14.826, 95% CI: 1.696-129.642, P = 0.015). CONCLUSION: AT occurs in RVs with impaired systolic function in PH patients. It may serve as a new, easily to assess visual parameter to predict the outcome in these patients. Its prognostic importance needs to be validated by prospective studies.

How to define end-diastole and end-systole?: Impact of timing on strain measurements.

OBJECTIVES: This study aimed to investigate to what extent timing definitions influence strain measurements and which surrogates are reliable and feasible to define end-diastole (ED) and end-systole (ES) during speckle-tracking (STI) analysis. BACKGROUND: Current STI-based strain measurements are highly automated. It remains unclear when a particular analysis software defines the zero baseline and the systolic strain measurement position. METHODS: A total of 60 subjects (20 healthy volunteers, 20 patients with coronary artery disease, and 20 patients with typical left bundle-branch block) underwent a complete echocardiographic examination. In one-half of them, a real M-mode through the mitral valve was acquired for each electrocardiographic (ECG) lead of the echo machine. Timing of peak R and automatic ECG trigger were compared with mitral valve closure for every electrode. Mitral and aortic valve closure, as observed in the apical 3-chamber view, served as reference for ED and ES. With the use of these references, end-systolic global longitudinal strain (ES-GLS) and end-systolic segmental longitudinal strain (ES-SLS) longitudinal end-systolic strain were measured at baseline and after changing the definition of either ED or ES by ±4 frames. Furthermore, strain and volume curves derived from the same tracking, as well as the Doppler interrogation of the valves, were compared with the references. RESULTS: Depending on the selected lead, timing of the ECG-derived time markers changed considerably compared with mitral valve closure. Changing the definition of ED and ES resulted in significantly different ES-GLS and ES-SLS values in all subjects. ES-SLS in dyssynchronous hearts showed the highest sensitivity to timing definition. From all methods, spectral Doppler was the most reliable time marker in all subjects (p > 0.05). CONCLUSIONS: Exact temporal definition of ED and ES has a major impact on the accuracy of strain measurements. After direct observation of the valves, Doppler evaluation is the best means for characterizing ED and ES for STI analysis.

Head-to-Head Comparison of Global Longitudinal Strain Measurements among Nine Different Vendors: The EACVI/ASE Inter-Vendor Comparison Study.

BACKGROUND: This study was planned by the EACVI/ASE/Industry Task Force to Standardize Deformation Imaging to (1) test the variability of speckle-tracking global longitudinal strain (GLS) measurements among different vendors and (2) compare GLS measurement variability with conventional echocardiographic parameters. METHODS: Sixty-two volunteers were studied using ultrasound systems from seven manufacturers. Each volunteer was examined by the same sonographer on all machines. Inter- and intraobserver variability was determined in a true test-retest setting. Conventional echocardiographic parameters were acquired for comparison. Using the software packages of the respective manufacturer and of two software-only vendors, endocardial GLS was measured because it was the only GLS parameter that could be provided by all manufactures. We compared GLSAV (the average from the three apical views) and GLS4CH (measured in the four-chamber view) measurements among vendors and with the conventional echocardiographic parameters. RESULTS: Absolute values of GLSAV ranged from 18.0% to 21.5%, while GLS4CH ranged from 17.9% to 21.4%. The absolute difference between vendors for GLSAV was up to 3.7% strain units (P < .001). The interobserver relative mean errors were 5.4% to 8.6% for GLSAV and 6.2% to 11.0% for GLS4CH, while the intraobserver relative mean errors were 4.9% to 7.3% and 7.2% to 11.3%, respectively. These errors were lower than for left ventricular ejection fraction and most other conventional echocardiographic parameters. CONCLUSION: Reproducibility of GLS measurements was good and in many cases superior to conventional echocardiographic measurements. The small but statistically significant variation among vendors should be considered in performing serial studies and reflects a reference point for ongoing standardization efforts.

Consistent regional heterogeneity of passive diastolic stretch and systolic deformation in the healthy heart: age-related changes in left ventricle contractility.

The consistency of the normal spatial distribution of segmental passive stretch (PreS) and systolic strain (SS) within the left ventricle was investigated and a recently proposed echocardiographic estimate of left ventricular (LV) contractility was used to detect contractility changes with age. Hereto, in 54 healthy subjects, segmental PreS and SS were measured on tissue Doppler images of six left ventricle walls. For each subject, a linear regression line was estimated through the segmental PreS and SS values. The slopes and intercepts of this PreS-SS relationship did not differ between age groups, suggesting no changes in LV contractility with age. Moreover, a consistent regional distribution of PreS was observed, with the highest values measured in the septum, resulting in a similar distribution of SS as a direct consequence of the Frank-Starling mechanism.