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AIMS: To assess the accuracy of measuring the right atrial volume (RAV) using two-dimensional echocardiography (2DE) in a right ventricular focused (RVF) view compared to the conventional apical 4-chamber (4Ch) view in patients with secondary tricuspid regurgitation (STR). We also compared the clinical correlates of the measures obtained using different methods. METHODS AND RESULTS: The accuracy of RAV measurements obtained from 2DE- 4Ch and RVF views in 384 patients with STR were compared using three-dimensional echocardiography (3DE) as a reference. We used the analysis of variance to test the differences among RAVs obtained from the different 2DE and 3DE acquisitions and the receiving operating characteristics (ROC) curves to evaluate the association with the composite endpoint of hospitalization for heart failure or death. Compared to 3DE, RAV was significantly more underestimated when measurements were obtained from 4Ch rather than RVF (-24% vs. -14%, respectively, p<0.001 for both). RAV underestimation in 4Ch and RVF view was relatively larger in lower grades of STR (-28% vs. -17% in mild, -23% vs. -14% in moderate, and -19% vs. -11% in severe STR, p=0.001), and in the atrial compared to ventricular (-28% vs. -22%; p=0.002) STR. RAV measured by 3DE and RVF showed the highest area under the curve (AUC=0.67 for 3DE vs 0.64 for RVF, p=0.05), while 4Ch was significantly less related to the outcomes (AUC: 0.61, p=0.021 vs 3DE RAV). CONCLUSIONS: In patients with STR, the use of RVF view improved the accuracy of 2DE RAV measurement as compared to the conventional 4Ch-derived measurements.
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BACKGROUND: In patients with secondary tricuspid regurgitation (STR), right atrial remodeling (RAR) is a proven marker of disease progression. However, the prognostic value of RAR, assessed by indexed right atrial volume (RAVi) and reservoir strain (RAS), remains to be clarified. Accordingly, the aim of our study is to investigate the association with outcome of RAR in patients with STR. METHODS: We enrolled 397 patients (44% men, 72.7 ± 13 years old) with mild to severe STR. Complete two-dimensional and speckle-tracking echocardiography analysis of right atrial and right ventricular (RV) size and function were obtained in all patients. The primary end point was the composite of death from any cause and heart failure hospitalization. RESULTS: After a median follow-up of 15 months (interquartile range, 6-23), the end point was reached by 158 patients (39%). Patients with RAS <13% and RAVi >48 mL/m2 had significantly lower survival rates compared to patients with RAS ≥13% and RAVi ≤48 mL/m2 (log-rank P < .001). On multivariable analysis, RAS <13% (hazard ratio, 2.11; 95% CI, 1.43-3.11; P < .001) and RAVi > 48 mL/m2 (hazard ratio, 1.49; 95% CI, 1.01-2.18; P = .04) remained associated with the combined end point, even after adjusting for RV free-wall longitudinal strain, significant chronic kidney disease, and New York Heart Association class. Secondary tricuspid regurgitation excess mortality increased exponentially with values of 18.2% and 51.3 mL/m2 for RAS and RAVi, respectively. In nested models, the addition of RAS and RAVi provided incremental prognostic value over clinical, conventional echocardiographic parameters of RV size and function and RV free-wall longitudinal strain. CONCLUSIONS: In patients with STR, RAR was independently associated with mortality and heart failure hospitalization. Assessment of RAR could improve risk stratification of patients with STR, potentially identifying those who may benefit from optimization of medical therapy and a closer follow-up.
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Remodelación Atrial , Ecocardiografía , Atrios Cardíacos , Insuficiencia de la Válvula Tricúspide , Humanos , Masculino , Femenino , Insuficiencia de la Válvula Tricúspide/fisiopatología , Insuficiencia de la Válvula Tricúspide/complicaciones , Anciano , Atrios Cardíacos/diagnóstico por imagen , Atrios Cardíacos/fisiopatología , Remodelación Atrial/fisiología , Ecocardiografía/métodos , Pronóstico , Estudios de Seguimiento , Tasa de Supervivencia , Persona de Mediana Edad , Progresión de la EnfermedadRESUMEN
BACKGROUND: The assessment of ventricular secondary mitral regurgitation (v-SMR) severity through effective regurgitant orifice area (EROA) and regurgitant volume (RegVol) calculations using the proximal isovelocity surface area (PISA) method and the two-dimensional echocardiography volumetric method (2DEVM) is prone to underestimation. Accordingly, we sought to investigate the accuracy of the three-dimensional echocardiography volumetric method (3DEVM) and its association with outcomes in v-SMR patients. METHODS: We included 229 patients (70 ± 13 years, 74% men) with v-SMR. We compared EROA and RegVol calculated by the 3DEVM, 2DEVM, and PISA methods. The end point was a composite of heart failure hospitalization and death for any cause. RESULTS: After a mean follow-up of 20 ±11 months, 98 patients (43%) reached the end point. Regurgitant volume and EROA calculated by 3DEVM were larger than those calculated by 2DEVM and PISA. Using receiver operating characteristic curve analysis, both EROA (area under the curve, 0.75; 95% CI, 0.68-0.81; P = .008) and RegVol (AUC, 0.75; 95% CI, 0.68-0.82; P = .02) measured by 3DEVM showed the highest association with the outcome at 2 years compared to PISA and 2DEVM (P < .05 for all). Kaplan-Meier analysis demonstrated a significantly higher rate of events in patients with EROA ≥ 0.3 cm2 (cumulative survival at 2 years: 28% ± 7% vs 32% ± 10% vs 30% ± 11%) and RegVol ≥ 45 mL (cumulative survival at 2 years: 21% ± 7% vs 24% ± 13% vs 22% ± 10%) by 3DEVM compared to those by PISA and 2DEVM, respectively. In Cox multivariable analysis, 3DEVM EROA remained independently associated with the end point (hazard ratio, 1.02, 95% CI, 1.00-1.05; P = .02). The model including EROA by 3DEVM provided significant incremental value to predict the combined end point compared to those using 2DEVM (net reclassification index = 0.51, P = .003; integrated discrimination index = 0.04, P = .014) and PISA (net reclassification index = 0.80, P < .001; integrated discrimination index = 0.06, P < .001). CONCLUSIONS: Effective regurgitant orifice area and RegVol calculated by 3DEVM were independently associated with the end point, improving the risk stratification of patients with v-SMR compared to the 2DEVM and PISA methods.
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Ecocardiografía Tridimensional , Insuficiencia Cardíaca , Insuficiencia de la Válvula Mitral , Masculino , Humanos , Femenino , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Ecocardiografía Doppler en Color/métodos , Ecocardiografía Tridimensional/métodos , Curva ROC , Índice de Severidad de la EnfermedadRESUMEN
BACKGROUND: Although the assessment of left atrial (LA) mechanics has been reported to refine atrial fibrillation (AF) risk prediction, it doesn't completely predict AF recurrence. The potential added role of right atrial (RA) function in this setting is unknown. Accordingly, this study sought to evaluate the added value of RA longitudinal reservoir strain (RASr) for the prediction of AF recurrence after electrical cardioversion (ECV). METHODS: We retrospectively studied 132 consecutive patients with persistent AF who underwent elective ECV. Complete two-dimensional and speckle-tracking echocardiography analyses of LA and RA size and function were obtained in all patients before ECV. The end point was AF recurrence. RESULTS: During a 12-month follow-up, 63 patients (48%) showed AF recurrence. Both LASr and RASr were significantly lower in patients experiencing AF recurrence than in patients with persistent sinus rhythm (LASr, 10% ± 6% vs 13% ± 7%; RASr, 14% ± 10% vs 20% ± 9%, respectively; P < .001 for both). Right atrial longitudinal reservoir strain (area under the curve = 0.77; 95% CI, 0.69-0.84; P < .0001) was more strongly associated with the recurrence of AF after ECV than LASr (area under the curve = 0.69; 95% CI, 0.60-0.77; P < .0001). Kaplan-Meier curves showed that patients with both LASr ≤ 10% and RASr ≤ 15% had a significantly increased risk for AF recurrence (log-rank, P < .001). However, at multivariable Cox regression, RASr (hazard ratio, 3.26; 95% CI, 1.73-6.13; P < .001) was the only parameter independently associated with AF recurrence. Right atrial longitudinal reservoir strain was more strongly associated with the occurrence of AF relapse after ECV than LASr, and LA and RA volumes. CONCLUSION: Right atrial longitudinal reservoir strain was independently and more strongly associated than LASr with AF recurrence after elective ECV. This study highlights the importance of assessing the functional remodeling of both the RA and LA in patients with persistent AF.
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Fibrilación Atrial , Humanos , Fibrilación Atrial/diagnóstico por imagen , Fibrilación Atrial/terapia , Cardioversión Eléctrica/métodos , Estudios Retrospectivos , Atrios Cardíacos/diagnóstico por imagen , Ecocardiografía/métodos , RecurrenciaRESUMEN
AIMS: In functional tricuspid regurgitation (FTR) patients, tricuspid leaflet tethering and relatively low jet velocity could result in proximal flow geometry distortions that lead to underestimation of TR. Application of correction factors on two-dimensional (2D) proximal isovelocity surface area (PISA) equation may increase its reliability. This study sought to evaluate the impact of the corrected 2D PISA method in quantifying FTR severity. METHODS AND RESULTS: In 102 patients with FTR, we compared both conventional and corrected 2D PISA measurements of effective regurgitant orifice area [EROA vs. corrected (EROAc)] and regurgitant volume (RegVol vs. RegVolc) with those obtained by volumetric method (VM) using three-dimensional echocardiography (3DE), as reference. Both EROAc and RegVolc were larger than EROA (0.29 ± 0.26 vs. 0.22 ± 0.21â cm2; P < 0.001) and RegVol (24.5 ± 20 vs. 18.5 ± 14.25â mL; P < 0.001), respectively. Compared with VM, both EROAc and RegVolc resulted more accurate than EROA [bias = -0.04â cm2, limits of agreement (LOA) ± 0.02â cm2 vs. bias = -0.15â cm2, LOA ± 0.31â cm2] and RegVol (bias = -3.29â mL, LOA ± 2.19â mL vs. bias = -10.9â mL, LOA ± 13.5â mL). Using EROAc and RegVolc, 37% of patients were reclassified in higher grades of FTR severity. Corrected 2D PISA method led to a higher concordance of TR severity grade with the VM method (ĸ = 0.84 vs. ĸ = 0.33 for uncorrected PISA, P < 0.001). CONCLUSION: Compared with VM by 3DE, the conventional PISA underestimated FTR severity in about 50% of patients. Correction for TV leaflets tethering angle and lower velocity of FTR jet improved 2D PISA accuracy and reclassified more than one-third of the patients.
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Ecocardiografía Tridimensional , Insuficiencia de la Válvula Tricúspide , Humanos , Insuficiencia de la Válvula Tricúspide/diagnóstico por imagen , Ecocardiografía Doppler en Color/métodos , Reproducibilidad de los Resultados , Ecocardiografía Tridimensional/métodosRESUMEN
INTRODUCTION: The tricuspid valve (TV) and the right heart chambers are complex three-dimensional structures that are difficult to assess using tomographic imaging techniques. The progressive aging of the general population and the advancements in treating left-sided heart diseases by transcatheter procedures have contributed to the tricuspid regurgitation (TR) becoming a major public health problem associated with progression to refractory heart failure and poor outcome. Recent advances in multimodality cardiac imaging allow a better understanding of the pathophysiology of TR that may translate in better management of patients. AREAS COVERED: Three-dimensional echocardiography, cardiac magnetic resonance, and computed tomography provide complementary information to i. assess the TV complex; ii. identify the etiology and the mechanisms of TR; iii. evaluate its severity and hemodynamic consequences; iv. explore the remodeling of the right heart chambers; and v. properly plan, guide, and monitor the transcatheter interventions aimed to reduce the severity of TR. EXPERT OPINION: We need thorough understanding of both the TV and the right heart chamber geometry and function to understand the pathophysiology of TR. The integrated use of multimodality cardiac imaging is pivotal to assess patients with TR and to identify tailored and timely treatment of TR in properly selected patients.
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Ecocardiografía Tridimensional , Implantación de Prótesis de Válvulas Cardíacas , Insuficiencia de la Válvula Tricúspide , Hemodinámica , Humanos , Imagen Multimodal , Válvula Tricúspide/diagnóstico por imagen , Válvula Tricúspide/cirugía , Insuficiencia de la Válvula Tricúspide/diagnóstico por imagen , Insuficiencia de la Válvula Tricúspide/cirugíaRESUMEN
BACKGROUND: Acute exposure to high altitude (>2500â¯m) is known to induce a rise in blood pressure (BP) and the appearance of sleep related breathing alterations, in particular central sleep apneas and periodic breathing. Little information is available on whether this is the case in humans also for acute exposure to moderate altitude (between 1500 and 2500â¯m). Aim of this study was to evaluate the effects of acute exposure of healthy volunteers to moderate altitude on conventional and ambulatory BP as well as on the frequency and severity of breathing alterations during sleep. METHODS: Forty-four healthy lowlanders underwent 24-hour ambulatory BP monitoring and nocturnal cardio-respiratory sleep study at sea level and during acute (1-2â¯days after arrival) exposure to moderate altitude (2035â¯m, Sestriere, Italy). The key variables investigated included average systolic and diastolic BP and heart rate over daytime, night-time and 24â¯h, the frequency of obstructive and central apneas/hypopnoeas and the behaviour of oxygen saturation during sleep. RESULTS: Compared to sea level, during moderate altitude exposure mean systolic/diastolic BP increased significantly during daytime (respectively from 125.6⯱â¯10.9 to 130.6⯱â¯12.3, pâ¯=â¯0.0032 and from 78.8⯱â¯6.7 to 81.8⯱â¯7.7â¯mmHg, pâ¯=â¯0.0048) and during night-time (respectively from 102.4⯱â¯12.4 to 107.4⯱â¯12.7, pâ¯=â¯0.0028, and from 62.0⯱â¯8.2 to 65.8⯱â¯8.2â¯mmHg, pâ¯=â¯0.0014), with no change in nocturnal BP dipping. BP increase was more evident in participants aged over 40â¯years. Apnea-hypopnea index (AHI) increased from 1.60 (0.40-2.90) to 5.4 (2.90-10.60), pâ¯<â¯0.0001), mainly because of increasing frequency of hypopneas and central apneas, in particular in males aged over 40â¯years. No association was found between size of BP changes and AHI. CONCLUSION: Our results indicate that in healthy subjects even exposure to moderate altitude may induce significant, although mild, changes in ambulatory BP and in respiratory patterns during sleep with gender and age-related differences. Further studies are needed to explore the clinical relevance of these findings.