Assessing Myocardial Function in Infants with Pulmonary Hypertension: The Role of Tissue Doppler Imaging and Tricuspid Annular Plane Systolic Excursion

Abstract

Transthoracic echocardiography is the most common noninvasive method of evaluating pulmonary hypertension (PH) in infants. Identification of reliable, quantitative indices of myocardial function may enhance the diagnostic value of echocardiography in this population. We hypothesized that pulsed wave tissue Doppler imaging (TDI) and tricuspid annular plane systolic excursion (TAPSE) would be reproducible measurements and would suggest decreased ventricular function, in infants with PH. This retrospective case-control study involved subjects diagnosed clinically and echocardiographically with PH at <12 months of age, matched with controls by age and gestational age (GA). TAPSE was measured by M-mode in the apical 4-chamber view. TDI velocities were averaged from three consecutive cardiac cycles. Observers were blinded to patient identity and clinical status. Fifty-seven subjects, including 35 term or near-term infants ≥35 weeks GA [mean GA 39 weeks (±1.7), median age 1 day (range 0-2)] and 22 preterm infants [median GA 25.4 weeks (24.1-26.6), age 66 days (4-128)], were matched with 57 controls. Subjects with PH had lower TAPSE (term p < 0.001, preterm p = 0.03) and TAPSE indexed to body surface area (term p < 0.001, preterm p = 0.005). Mitral annular, septal, and tricuspid annular systolic (S') and early diastolic (E') TDI velocities were also decreased compared to controls (all p < 0.05). Intraclass correlation demonstrated 84-99% agreement between observers in measuring TDI and 92% for TAPSE. Intraobserver reliability for these measures was 98-99% and 96%, respectively. We concluded that TDI and TAPSE are reproducible indices of myocardial function and may serve as useful adjuncts to standard echocardiographic measures in infants with PH.

Diminished right ventricular function at diagnosis of pulmonary hypertension is associated with mortality in bronchopulmonary dysplasia

“…41 Z-scores for TAPSE in both preterm and term infants have also been derived from populational studies 51,52 and this marker has been described as a reproducible index of RV function in infants with PH (96% intra-observer and 92% inter-observers agreement). 53 With the increasing use of echocardiography for screening, degree of PH at diagnosis may be difficult to interpret when assessing individual patients. Our data suggest that a thorough assessment of RV performance may augment the detection of patients that are at the highest risk for poor outcomes.…”

“…FAC in neonates has good inter‐ (93%) and intra‐observer (94%) reliability and reference values in that population have been established 41 . Z‐scores for TAPSE in both preterm and term infants have also been derived from populational studies 51 , 52 and this marker has been described as a reproducible index of RV function in infants with PH (96% intra‐observer and 92% inter‐observers agreement) 53 . With the increasing use of echocardiography for screening, degree of PH at diagnosis may be difficult to interpret when assessing individual patients.…”

The Importance of Tissue Doppler Imaging and M‐Mode Ultrasonography in Fetuses With Preterm Premature Rupture of Membranes

“…16,23 In addition, a previous study found that TAPSE is a reproducible and reliable method and is decreased in both term and preterm infants with pulmonary hypertension compared with controls. 24 Some authors suggest that TAPSE measurement should be added to fetal heart function assessment because it contributes more to right ventricular dominance and cardiac output in the prenatal period. 16,25 Various studies have found a significant decrease in TAPSE in fetal growth restriction and twin-to-twin syndrome co-existing with fetal hemodynamic and vascular changes.…”

“…It is a parameter that increases according to gestational age and fetal weight in healthy fetuses 16,23 . In addition, a previous study found that TAPSE is a reproducible and reliable method and is decreased in both term and preterm infants with pulmonary hypertension compared with controls 24 . Some authors suggest that TAPSE measurement should be added to fetal heart function assessment because it contributes more to right ventricular dominance and cardiac output in the prenatal period 16,25 .…”

Echocardiographic Measurements of Right Ventricular Mechanics in Infants with Bronchopulmonary Dysplasia at 36 Weeks Postmenstrual Age

“…However, most measures reported in this study have been shown to be highly feasible and reproducible in premature infants using specific image acquisition and post-processing data analysis protocols. 24, 30, 41, 55 Lastly, we were unable to account for all variables that may have impacted the EI such as PH medications, positive pressure ventilation and PDAs. The impact of these variables on right heart function and clinical course using serial measures of EI as a potentially useful metric over time is worth future study.…”