Right Atrial Deformation in Predicting Outcomes in Pediatric Pulmonary Hypertension

Abstract

Background Elevated right atrial (RA) pressure is a risk factor for mortality and RA size is prognostic of adverse outcomes in pulmonary hypertension (PH). There is limited data on phasic RA function (reservoir, conduit, and pump) in pediatric PH. We sought to evaluate 1) the RA function in pediatric PH patients compared to controls, 2) compare the RA deformation indices with Doppler indices of diastolic dysfunction, functional capacity, biomarkers, invasive hemodynamics, and right ventricular (RV) functional indices, and 3) evaluate the potential of RA deformation indices to predict clinical outcomes. Methods and Results Sixty-six PH patients (mean age 7.9 ±4.7 years) were compared with 36 controls (7.7 ±4.4 years). RA and RV deformation indices were obtained using two-dimensional speckle tracking (2DCPA, TomTec). RA strain, strain rates, emptying fraction (EF), and RV longitudinal strain (LS) were measured. RA function was impaired in PH patients versus controls (p<0.001). There were significant associations between RA function with invasive hemodynamics (p<0.01). RA reservoir, pump function, the rate of RA filling, and atrial minimum volume predicted adverse clinical outcomes (HR (CI) 0.15 (0.03–0.73), p<0.01; 0.05 (0.003–0.43), p <0.004; 0.04 (0.006–0.56), p<0.01; 8.6 (1.6–37.2), p<0.01 respectively). Conclusions RA deformation properties are significantly altered in pediatric PH patients. Progressive worsening of RA reservoir and conduit functions are related to changes in RV diastolic dysfunction. RA reservoir function, pump function, the rate of atrial filling, and atrial minimum volume emerged as outcome predictors in pediatric PH.

Right atrial function in pediatric heart transplant patients by echocardiographic strain measurements

“…Rejection was identified in seven patients (19%). We did not perform inter‐ and intra‐observer variability of RA strain as it has been previously demonstrated to have acceptable intra‐class correlations between observers and within observers …”

“…Ischemia-reperfusion injury from surgery, post-operative pulmonary hypertension could be causing progressive myocardial fibrosis, leading to the lack of RA relaxation and RV diastolic dysfunction. 19 Further large volume investigations of diastolic cardiac function using new imaging modalities in transplanted hearts are necessary to better understand the function of the transplanted heart.…”

“…In fact, Gudmundsson et al reported that RA size was associated with transplant mortality. RA deformation studies have demonstrated that RAF is a useful parameter in detecting early RV diastolic dysfunction in patients with pulmonary hypertension . As there is evidence that early CAV may involve subendocardial tissue ischemia, measures of diastolic dysfunction could be of importance in early diagnosis …”

“…RA deformation studies have demonstrated that RAF is a useful parameter in detecting early RV diastolic dysfunction in patients with pulmonary hypertension. 19 As there is evidence that early CAV may involve subendocardial tissue ischemia, measures of diastolic dysfunction could be of importance in early diagnosis. 20 The primary aim of this study was to assess whether RAF could be an early detector of CAV in PHTx.…”

Noninvasive wave intensity analysis predicts functional worsening in children with pulmonary arterial hypertension

“…Furthermore, we have identified the prognostic role of FDW typically associated with RV compliance and diastolic function. Indeed, previous echocardiographic studies assessing the diastolic strain and strain rate have described a significant prognostic role of diastolic dysfunction and its related indexes in children with PAH (4,14). Biventricular myocardial remodeling has been described using delayed gadolinium studies and mechanical deformation analyses in both the adult and pediatric PAH population (32).…”