Right ventricle in pulmonary arterial hypertension: haemodynamics, structural changes, imaging, and proposal of a study protocol aimed to assess remodelling and treatment effects

Abstract

Although right ventricular (RV) failure is the main cause of death in patients with pulmonary arterial hypertension (PAH), there is insufficient data about the effects of PAH treatment on RV geometry and function mainly because the RV assessment has been hampered by its complex crescentic shape, large infundibulum, and its trabecular nature. Echocardiography is a widely available imaging technique particularly suitable for follow-up studies, because of its non-invasive nature, low cost, and lack of ionizing radiation or radioactive agent. Real-time three-dimensional echocardiography (RT3DE) has been shown to be accurate in assessing RV and left ventricular (LV) volumes, stroke volumes, and ejection fractions in comparison with cardiac magnetic resonance imaging. In this review, we describe RV structural and functional changes which occur in patients with PAH and strengths and weaknesses of current non-invasive imaging techniques to assess them. Finally, we describe an ongoing multicentre, prospective observational study involving seven centres expert in treating patients with PAH from four different countries. Investigators will use conventional and advanced echo parameters from RT3DE and speckle-tracking echocardiography to assess the extent of LV and RV remodelling before symptom onset and during pharmacological treatment in patients with PAH. Seventy patients who will survive for at least 1 year will be recruited. All the participating institutions will perform comprehensive standard 2D and Doppler as well as RT3DE examinations with a pre-defined imaging protocol. Measurements will be performed at the core echocardiography laboratory by experienced observers who will be unaware of each patient's treatment assignment and whether the examination was a baseline or a follow-up study. Enrolment duration is expected to be 1 year.

The role of echocardiography in the diagnosis and management of patients with pulmonary hypertension

“…Estimation of Pra based on echocardiographic inferior vena cava (IVC) collapsibility index has been suggested. This index is calculated by subtracting inspiratory from expiratory IVC diameter, and dividing the result by expiratory IVC diameter [26,27].…”

“…Since PH is a very severe disease with high mortality rate [44][45][46][47][48], the identification of noninvasive markers of a poor prognosis will be useful for patient management and follow-up. Several echocardiographic indices have been proposed [26,[49][50][51] and have the common objective of assessing the three main consequences of PH: right heart remodelling, impact on the left heart and RV dysfunction.…”

Use of novel echocardiographic techniques to assess right ventricular geometry and function

“…2). Such a position hampers adequate assessment of the RV including acquisition of complete 3D datasets and affects the image quality [5]. -The RV is significantly more trabeculated than the LV which hinders accurate endocardial delineation and thus accuracy and reproducibility of RV quantitative analysis algorithms [6].…”

A jobb kamrai anatómia és funkció korszerű echokardiográfiás vizsgálata: patológiás és fiziológiás eltérések

“…A krónikus nyomásterhelésre jellegzetes válasz a kamrafal hypertrophiája. Későbbiekben az üreg dilatációja és progresszív myocardialis diszfunkció alakul ki, és ezek a szerkezeti változások a bal kamra funkcióját is rontják [25] (4. ábra). A jobb szívfél nyomásemelke-dése akut jelenség is lehet, döntően pulmonalis embolia következtében, amely számos aspecifikus tünete folytán súlyosan aluldiagnosztizált megbetegedés magas mortalitása ellenére.…”