Int J Cardiovasc Imaging DOI 10.1007/s10554-016-0862-8

ORIGINAL PAPER

Prognostic value of right ventricular free wall strain in pulmonary hypertension patients with pseudo-normalized tricuspid annular plane systolic excursion values Marco van Kessel1,2 • David Seaton3 • Jonathan Chan2,4,6 • Akira Yamada2,4 • Fiona Kermeen5 • Thomas Butler4 • Surendran Sabapathy2 • Norman Morris2,5

Received: 27 October 2015 / Accepted: 17 February 2016 Ó Springer Science+Business Media Dordrecht 2016

Abstract Pulmonary hypertension (PH) is a progressively fatal disease having a significant impact on right ventricular (RV) function, a major determinant of longterm outcome in PH patients. In our clinic we frequently noticed the combination of PH and reduced RV function, but with discordant Tricuspid Annular Plane Systolic Excursion (TAPSE) values. The present study focuses on whether RV free wall strain measured using 2-dimensional speckle-tracking echocardiography is able to predict mortality in this subgroup of PH patients. 57 patients with PH and RV dysfunction (visual echocardiographic assessment of C2) and pseudo-normalized TAPSE values (defined as C16 mm) were retrospectively evaluated. Patients were divided by RV free -20 % as cut-off value. Follow-up data on all-cause mortality were registered after a median follow-up time of 27.9 ± 1.7 months. RV free of C-20 % was predictive of all-cause mortality after a median followup time of 27.9 ± 1.7 months (HR 3.76, 95 % CI

& Marco van Kessel [email protected] 1

Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands

2

School of Allied Health Sciences, Heart Foundation Research Centre and Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia

3

Queensland Nuclear Imaging, The Prince Charles Campus, Brisbane, Australia

4

Cardiology Department, The Prince Charles Hospital, Brisbane, Australia

5

Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Australia

6

School of Medicine, Griffith University, Gold Coast, Australia

1.02–13.92, p = 0.05). RV free C-20 % remained a significant predictor of all-cause mortality (HR 4.30, 95 % CI 1.11–16.61, p = 0.04) after adjusting for PH-specific treatment. On the contrary, TAPSE was not a significant predictor of all-cause mortality. RV free wall strain provides prognostic information in patients with PH and RV dysfunction, but with normal TAPSE values. Future studies with larger cohorts, longer follow-up periods and inclusion of more echocardiographic parameters measuring LV and RV function could confirm the strength of RV free C-20 % as a predictor of mortality for this subgroup of patients with PH. Keywords Pulmonary hypertension  Echocardiography  Right ventricular function  Mortality Abbreviations PH Pulmonary hypertension RV Right ventricular TAPSE Tricuspid annular plane systolic excursion HR Hazard ratio PAH Pulmonary arterial hypertension ESC European society of cardiology 6MWT Six minute walk test RVSP Right ventricular systolic pressure TR Tricuspid regurgitation PASP Pulmonary artery systolic pressure ASE American society of echocardiography v2 Chi-squared WHO World health organisation BMI Body-mass index 6MWD Six minute walk distance ROC Receiver operating characteristic AUC Area under the curve RV FAC Right ventricular fractional area change

123

Int J Cardiovasc Imaging

LV LVEDV IPAH

Left ventricular Left ventricular end-diastolic volume Idiopathic pulmonary arterial hypertension

Introduction An elevated pulmonary pressure is known as pulmonary hypertension (PH), a progressive and typically fatal disease that can be classified into five groups according to the 5th World Symposium held in Nice, France, in 2013 [1]. PH has a significant impact on right ventricular (RV) function, a major determinant of long-term outcome in PH patients [2, 3]. Assessing RV function is a challenging task because of its complex characteristics, for example the complicated pyramidal shape with muscle fibers being predominantly oriented in a longitudinal plane [4–8]. It is partly due to this complex geometry that RV function is not truly measured by widely used conventional echocardiographic measurements for follow-up procedures, such as Tricuspid Annular Plane Systolic Excursion (TAPSE) [9]. TAPSE reflects RV shortening from base to apex in systole and has value with respect to prognosis [7]. It is also recommended by treatment guidelines in the follow-up of patients with Pulmonary Arterial Hypertension (PAH) [10]. However, when RV dysfunction occurs TAPSE might be pseudo-normalized, since TAPSE is highly dependent on RV loading conditions [11]. Deformation imaging by using 2-dimensional speckletracking echocardiography is a novel method to assess RV function. Speckle-tracking echocardiography reliably determines myocardial deformation and allows for a regional analysis of contraction synchronicity [12–14]. Furthermore, it is free of limitations related to translational cardiac motion associated with physiologic respiratory phases [15]. Studies have already shown the predictive value of RV free wall strain with respect to all-cause mortality in patients with PH [16–19]. Three common patterns on echocardiography are observed in patients with PH. (1) PH with normal RV function and concordant TAPSE values. (2) PH with reduced RV function and concordant TAPSE values. (3) PH with visually reduced RV function and discordant TAPSE values. This latter group is a clinical conundrum and its physiology remains largely undescribed in the literature. The present study aims to determine whether RV free wall strain is able to predict all-cause mortality and thus clinical status in this subgroup of patients with PH. When TAPSE and visual echocardiographic assessment of RV function show this discordance, RV free wall strain could provide more weight when it comes to determining RV function.

123

Methods Fifty-seven patients with PH, who regularly visited a tertiary clinic (The Prince Charles Hospital, Brisbane, Queensland, Australia) as part of their follow-up procedure, were evaluated between April 2012 and February 2014. Only patients having RV dysfunction (visual echocardiographic assessment of C2) and pseudo-normalized TAPSE (defined as C16 mm) were included for evaluation. PH was confirmed by right heart catheterisation based on European Society of Cardiology (ESC) guidelines [10, 20]. Therapy regimes were decided by treating physicians (PH specialists), that are presented in Table 1. All study subjects were followed-up for the occurrence of all-cause mortality until December 2014. Clinical and echocardiographic data were retrospectively extracted from the database of the Pulmonary Hypertension Society of Australia and New-Zealand. Ethics approval for this retrospective evaluation was obtained from The Prince Charles Human Research Ethics Committee. Patients performed a Six Minute Walk Test (6MWT) to assess functional capacity as part of the standard follow-up procedure for patients with PH, and was conducted according to standardized protocols [21]. All study subjects were familiar with the 6MWT, since they all had done a test prior to the onset of the study. Two-dimensional echocardiography (GE Vivid E9 imaging system, GE Healthcare, Milwaukee, WI, U.S.A.) was performed by trained cardiac sonographers in accordance with the American Society of Echocardiography guidelines [22]. A 4 MHz matrix array cardiac transducer on the ultrasound system (Vivid 7 M5S-D, GE Healthcare, Milwaukee, WI, U.S.A.) was used to acquire echocardiographic images and doppler flow profiles from standard parasternal and apical windows, with all system settings adjusted to ensure optimal signal-to-noise ratio and endocardial delineation. Right ventricular systolic pressure (RVSP) was calculated from the tricuspid regurgitation (TR) velocity. TAPSE and pulmonary artery systolic pressure (PASP) were measured as per standard guidelines [22]. The visual assessment of RV function and RV dilatation were evaluated on an ordinal scale (0 = normal, 1 = trivial, 2 = mild, 3 = mild to moderate, 4 = moderate, 5 moderate to severe, 6 = severe). RV free wall strain measurements were performed offline (EchoPAC, BT011, GE Healthcare, Milwaukee, WI. U.S.A.) using semi-automated speckle-tracking algorithms. Frame rate was optimized to C50 frames/s. The RV endocardium was manually delineated and the software then mapped the region of interest to the endocardial border. RV free wall strain was automatically divided into 3 segments (basal, mid and apical). RV free wall strain was respectively

Int J Cardiovasc Imaging Table 1 Baseline patient characteristics

Clinical characteristics

RV free C-20 % (n = 25)

RV free \-20 % (n = 28)

p value

Age (year)

55.7 ± 18.7

53.9 ± 16.6

0.70

Male, n (%)

12 (48.0)

6 (21.4)

0.04

BMI (kg/m2)

28.0 ± 5.8

26.0 ± 6.6

0.26

II

5 (20.0)

17 (60.7)

Prognostic value of right ventricular free wall strain in pulmonary hypertension patients with pseudo-normalized tricuspid annular plane systolic excursion values.

Pulmonary hypertension (PH) is a progressively fatal disease having a significant impact on right ventricular (RV) function, a major determinant of lo...
563B Sizes 0 Downloads 4 Views