We previously published a comparative study of 2-D speckle tracking longitudinal strain from RV free wall (RV-free) as an independent echocardiographic predictor of hemodynamic RV performance including mPAP and PVR, and current conventional echocardiographic techniques including tricuspid annular plane systolic excursion (TAPSE), RV fractional area change (RVFAC), RV index of myocardial performance (RIMP), and tissue Doppler-derived tricuspid lateral annular systolic velocity (S'). 6 Of the conventional techniques, TAPSE is well known as a highly reproducible and robust non-invasive measure of RV function and is predictive of outcome for patients with PH. 7, 8 The present objective was to test the hypothesis that RV-free can predict long-term outcome after the addition of PH-specific drugs for the treatment of PH. We also tested the hypothesis that the addition of an RV-free-based assessment to that based on TAPSE using conventional echocardiographic parameters can enhance the capability of the ulmonary hypertension (PH) is a clinical syndrome characterized by progressive increases in pulmonary vascular load, leading to marked increases in pulmonary artery pressure and exercise intolerance, and is usually associated with a poor outcome. 1-5 The natural history of patients with PH is heterogeneous, with more rapid clinical deterioration seen in patients with the highest degree of right ventricular (RV) dysfunction. Recently, several investigators reported that PH-specific drugs reduced the mortality and morbidity for patients with PH. 3 Consequently, interest is high in the assessment of RV performance for predicting long-term outcome after treatment with PH-specific drugs. While the assessment of RV function has thus become increasingly important in the management of patients with PH, most standard techniques for assessing RV hemodynamics, such as mean pulmonary artery pressure (mPAP) or pulmonary vascular resistance (PVR) are invasive and time-consuming. Background: The development of right ventricular (RV) dysfunction in pulmonary hypertension (PH) patients is associated with adverse outcome, so that the assessment of RV function has become increasingly important in the management of such patients. The present objective was to test the hypothesis that RV free-wall longitudinal speckle-tracking strain (RV-free), an independent echocardiographic predictor of hemodynamic RV performance, can predict long-term outcome.
BackgroundLeft ventricular (LV) longitudinal systolic dysfunction has been identified even in asymptomatic patients with diabetes mellitus (DM) and preserved LV ejection fraction (LVEF). However, its relevant clinical features have not been fully evaluated.MethodsWe studied 144 asymptomatic DM patients without coronary artery disease. Their mean age was 57 ± 15 years, 79 (55%) were female, and mean LVEF was 66 ± 4% (all ≥50%). Global longitudinal strain (GLS) was determined as the average peak strain of 18 segments from the three standard apical views, and was expressed as an absolute value. With the pre-defined cutoff for subclinical LV systolic dysfunction in DM patients with preserved LVEF set at GLS < 18%, this dysfunction was detected in 53 patients (37%).ResultsMultivariate logistic regression analysis revealed that type 2 DM, hypertriglyceridemia, overweight/obesity, nephropathy and neuropathy were independently associated with GLS < 18%, with nephropathy being the highest risk factor (OR: 5.26; 95% CI 2.111-13.12, p < 0.001). For sequential logistic regression models, a model based on clinical variables including gender, type 2 DM and DM duration (χ2 = 24.1) was improved by addition of overweight/obesity and hypertriglyceridemia (χ2 = 45.6, p < 0.001), and further improved by addition of nephropathy and neuropathy (χ2 = 70.2, p < 0.001) as variables. Furthermore, albuminuria significantly correlated with GLS (r = −0.51, p < 0.001), and a multivariate regression model showed it to be the factor most closely associated with GLS (β = −0.33, p < 0.001).ConclusionsDiabetic complications, hypertriglyceridemia and overweight/obesity were closely associated with early stage of LV systolic longitudinal myocardial dysfunction in asymptomatic DM patients with preserved LVEF. Our findings can be clinically noticeable for the management of DM patients.
P ulmonary hypertension (PH) is a progressive disease associated with significant morbidity and mortality with advanced treatment options based on its stage of evolution. See Clinical Perspective See Editorial by TorbickiPatient outcomes in PH have been associated with right ventricular (RV) structural and functional changes described as RV adaptation where patients show minimal or no symptoms that progresses to a decompensated phase of RV adverse remodeling associated with catastrophic clinical deterioration and death within a year.1-3 The detection of RV adverse remodeling heralding RV failure in PH is of great importance to manage advanced treatment strategies, including continuous vasodilator infusions or lung transplantation. The contemporary clinical approach to assess for the advanced stage of PH is by invasive right heart catheterization hemodynamic data, which are important but imperfect. Morphological RV adverse remodeling in PH is clinically relevant, 2,4 but a means to quantify these changes has been challenging because of complexities of RV anatomy. Direct noninvasive quantification of the RV pathophysiology has become recently possible with technological advances in 3-dimensional (3D) echocardiography, including RV time-volume and time-strain data. 5 Accordingly, the objectives of this study were to (1) determine novel quantitative 3D echocardiographic RV structural and functional indices in patients with PH compared with normal subjects, and (2) to test the hypothesis that pathophysiological RV changes occurring with adaption and adverse remodeling in PH quantified by 3D echocardiography are associated with important patient outcomes. [6][7][8][9] The practical clinical impact is to support the potential adjunctive role of noninvasive 3D echocardiography with invasive hemodynamic data Background-Adverse right ventricular (RV) remodeling has significant prognostic and therapeutic implications to patients with pulmonary hypertension (PH). However, differentiating RV adaption from adverse remodeling associated with poor outcomes is difficult. We hypothesized that novel 3-dimensional (3D) wall motion tracking echocardiography can differentiate morphological features of RV adaption from adverse remodeling heralding an unfavorable short-term prognosis in patients with PH. Methods and Results-We studied 112 subjects: 92 patients with PH and 20 normal controls with 3D wall motion tracking for RV end-systolic volume index (ESVi), RV ejection fraction (EF), and RV global area strain. Patients with PH also had invasive hemodynamic measurements. Pressure-volume relations classified patients with PH into 3 groups, such as RV adapted, RV adapted-remodeled, and RV adverse-remodeled. The predefined combined end point was PHrelated hospitalization, death, or lung surgery (lung transplantation or pulmonary endarterectomy) during 6 months.
P eripartum cardiomyopathy (PPCM) is a pregnancy-associated cardiomyopathy of unknown cause resulting in considerable morbidity and mortality in young, otherwise healthy women. The natural history of PPCM seems to be variable although the rarity of this disease and the inconsistent diagnostic criteria that have been used in previous case series and research studies make it difficult to accurately describe the range of disease progression. Retrospective studies of patients with PPCM in the United States have shown that mortality is as high as 18%, [1][2][3][4][5][6] and left ventricular (LV) ejection fraction (LVEF) returns to normal at 6 months to 1 year in only 40% to 62% of patients. 3,[6][7][8] See Clinical PerspectiveGiven the relatively high rates of death and persistent LV dysfunction in patients with PPCM, establishing reliable predictors of outcome is important to enable clinicians to provide optimal care for these patients. Previous retrospective studies have shown numerous factors to be associated with recovery of LV function, but none has been validated in a large prospective cohort and none has focused on right ventricular (RV) function. RV function at diagnosis has been shown to predict outcomes among patients with other types of acute cardiomyopathies, 9-14 so it seems reasonable to expect that RV function at baseline predicts LV recovery and cardiac events in patients with PPCM as well.The Investigations of Pregnancy-Associated Cardiomyopathy (IPAC) study was a multicenter prospective study of the demographics, inflammatory pathogenesis, treatment, and clinical predictors of outcome for patients with PPCM in North America.15 PPCM is a diffuse process that affects biventricular function to a variable degree, and we hypothesized that patients who manifest RV dysfunction at presentation Background-Peripartum cardiomyopathy has variable disease progression and left ventricular (LV) recovery. We hypothesized that baseline right ventricular (RV) size and function are associated with LV recovery and outcome. Methods and Results-Investigations of Pregnancy-Associated Cardiomyopathy was a prospective 30-center study of 100 peripartum cardiomyopathy women with LV ejection fraction (LVEF) <45% within 13 weeks after delivery. Baseline RV function was assessed by echocardiographic end-diastolic area, end-systolic area, fractional area change, tricuspid annular plane excursion, and RV speckle-tracking longitudinal strain. LV recovery was defined as LVEF of ≥50% at 1 year, persistent severe LV dysfunction as LVEF of ≤35%, and major events as death, transplant, or LV assist device implantation. RV measurements were feasible for 90 of the 96 patients (94%) with echocardiograms available. Mean baseline LVEF was 36±9%. RV fractional area change was <35% in 38% of patients. Of 84 patients with 1-year followup data, 63 (75%) had LV recovery and 11 (13%) had LVEF of ≤35% or a major event (4 LV assist devices and 2 deaths). Tricuspid annular plane excursion and RV strain did not predict outcome. Baseline RV fractional ...
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