Evaluation of two-dimensional strain echocardiography for quantifying right ventricular function in patients with pulmonary arterial hypertension

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1 1248 Evlution of two-dimensionl strin echocrdiogrphy for quntifying right ventriculr function in ptients with pulmonry rteril hypertension YONG LIU, YONG WANG, YINGYING WANG nd ZHE WEN Deprtment of Ultrsound, Beijing Shijitn Hospitl, Cpitl Medicl University, Beijing , P.R. Chin Received Jnury 31, 2016; Accepted Februry 2, 2017 DOI: /etm Abstrct. The im of the current study ws to evlute the use of two dimensionl strin echocrdiogrphy (2DS) in quntifying right ventriculr (RV) function in ptients with pulmonry rteril hypertension (PAH). A totl of 41 ptients with PAH nd 40 helthy control ptients were recruited to the study. 2DS ws used to determine the strin (ε) nd strin rte (SR) of bsl, middle nd picl segments of the RV free wll. The forementioned indictors were compred with mesurements of RV function tken by conventionl ultrsound nd right hert ctheteriztion. The ε nd SR of ll segments of the right ventriculr free wll were significntly lower in the PAH group, s compred with the control group (P<0.05). In the PAH group, the ε nd SR of the middle nd picl segments were significntly lower compred with bsl segments (P<0.01). The SR of the picl segments were positively correlted with the re nd dimeter of the right ventriculr. The ε of the picl segments were positively correlted with RV re, dimeter nd systolic function. The ε nd SR of picl segments were positively correlted with pulmonry rtery pressure nd pulmonry vsculr resistnce mesured by right hert ctheteriztion. These findings indicted tht 2DS cn ccurtely evlute RV longitudinl systolic function. Introduction Pulmonry rteril hypertension (PAH) is n increse of blood pressure in the pulmonry rtery, with resting men pulmonry rteril pressure (mpap) 25 mmhg. This cn led to incresed lung vsculr resistnce, decresed right ventriculr function, right hert filure nd ftlity (1). PAH hs high disbility nd mortlity rtes, which pose thret Correspondence to: Dr Zhe Wen, Deprtment of Ultrsound, Beijing Shijitn Hospitl, Cpitl Medicl University, 10 Tieyi Rod, Beijing , P.R. Chin E mil: @163.com Key words: two dimensionl strin echocrdiogrphy, pulmonry hypertension, right ventriculr function to ptient helth nd hve notble impct on country's economy (2,3). The complex shpe nd volume dependency of the right ventricle (RV) mke it difficult to ccurtely quntify RV morphology nd function using stndrd echocrdiogrphy (4,5). Two dimensionl strin echocrdiogrphy (2DS) is bsed on strin (ε) nd strin rte (SR) imging (6), nd mesures motion by trcking speckles. These speckles re nturl coustic mrkers, which re evenly nd stbly distributed in myocrdil tissue, nd move synchronously with the tissue. The speckles cn be trcked in successive time frmes of ultrsound imging, nd their movement cn then be used to clculte the tissue's velocity, ε nd SR (7 9). The muscle fibers of the RV predominntly run in longitudinl direction nd the mjor contrctility of RV occurs in the longitudinl plne, which indictes tht globl longitudinl strin cn represent RV function ccurtely (10). The 2DS method hs been frequently used to ssess left ventricle function (7). However, it hs rrely been used to exmine RV function. The current study imed to compre the systolic strin cpcity of the RV free wll in PAH ptients nd helthy control ptients using 2DS, nd to investigte the effect of mpap on right ventriculr systolic strin. Subjects nd methods Subjects. A totl of 41 PAH ptients were recruited from Beijing Shijitn Hospitl (Beijing, Chin) from April 2007 to Februry The inclusion criteri for PAH ptients were s follows: i) No previous history of respirtory disese, crdiovsculr disese or pulmonry embolism, ii) PAH dignosis, bsed on right hert ctheteriztion (RHC) results showing tht resting mpap >25 mmhg (1 mmhg=0.133 kp) nd pulmonry cpillry wedge pressure <15 mmhg. The exclusion criterion ws dignosis with pulmonry relted hypertension other thn PAH, such s left hert ssocited PAH, respirtory ssocited PAH, chronic thromboembolic PAH or mixed PAH, s defined by the 2003 World Helth Orgniztion PAH dignostic criteri (7). All ptients underwent routine chest X rys nd high resolution computed tomogrphy scns. Ptients with severe interstitil lung disese were excluded. A totl of 40 helthy control ptients, with no previous history of smoking, crdiovsculr disese or respirtory disese, were lso recruited. All PAH ptients received RHC 72 h before

2 LIU et l: ECHOCARDIOGRAPHY FOR QUANTIFYING RIGHT VENTRICULAR FUNCTION 1249 nd fter echocrdiogrphy. Written nd informed consent ws obtined from every ptient prior to the study. The study ws pproved by the ethics review bord of Beijing Shijitn Hospitl. Procedures. All ptients underwent RHC in resting stte, ccording to stndrd protocol (11). The crdic output (CO) of ptients with idiopthic PAH (IPAH) ws mesured by thermodilution, nd the CO of ptients with congenitl hert disese (CHD)/PAH ws mesured using the Fick method (11). 2DS ws conducted using crdic ultrsound imging device (Philips ie33), QLAB 7.1 crdiovsculr ultrsound quntifiction softwre (both Philips Medicl Systems, Inc., Bothell, WA, USA) nd DVD storge. Ptients were in the left lterl position nd in resting stte. The chest led electrocrdiogrm recorded the 2DS in the picl four chmber view (frme rte, per sec) for three crdic cycles. QLAB softwre ws used to nlyze the 2DS nd mnully outline the right ventriculr endocrdil surfce. Then QLAB generted the re of interest, djusting its width to mtch the thickness of the ventriculr wll. QLAB trcked myocrdil motion in the re of interest nd mesured the systolic ε nd SR of bsl, middle nd picl segments. The endocrdil border of RV ws mnully trced t systole nd distole. This ws used to clculte the RV re. The chnge rte ws lso clculted. Sttisticl nlysis. SPSS 15.0 (SPSS, Inc., Chicgo, IL, USA) ws used for sttisticl nlysis. Dt re expressed s the men ± stndrd devition. Comprisons between echocrdiogrphy results were performed using t test. Correltions between mesurements of RV function by 2DS, RHC nd conventionl ultrsound were evluted using Person correltion nlysis. P<0.05 ws considered to indicte sttisticlly significnt result. Results Bseline chrcteristics nd echocrdiogrphy. There were 41 ptients in the PAH group (32 cses of IPAH nd 9 cses of CHD PAH) nd 40 helthy ptients in the control group. There were no significnt differences in ge, gender, height, body mss or left ventriculr ejection frction between the two groups (Tble I). The RV re chnge rte nd blood pressure were significntly lower in the PAH group s compred with the control group (P<0.01 nd P<0.05, respectively; Tble I). The distolic nd systolic re of RV nd the tricuspid regurgittion velocity were significntly higher in the PAH group compred with the control group (ll P<0.01; Tble I). ε nd SR of RV free wll segments. In order to evlute differences in RV prmeters between the two groups, ε nd SR were detected nd compred (Figs. 1 nd 2). The ε nd SR of the bsl, middle nd picl segments of RV free wll were significntly lower in the PAH group compred with the control group (P<0.05; Tble II). In the control group, there were no significnt differences in ε nd SR between ech segment of RV free wll (Tble II). In the PAH group, the ε nd SR of the middle nd picl segments were significntly lower compred with the bsl segments (P<0.05; Tble II). These results indicted tht ptients with PAH hd impired RV systolic strin nd strin rtes, compred with controls. Correltion between 2DS nd conventionl ultrsound mesurements of RV function. The correltions between RV function prmeters mesured by 2DS nd conventionl ultrsound re shown in Tble III. The SRs of middle segments were negtively correlted with RV dimeter nd re (P<0.05), nd the SRs of picl segments were positively correlted with RV re (P<0.05). No correltion ws found between the SR of bsl segments nd conventionl ultrsound mesurements. The ε of picl segments ws positively correlted with tricuspid regurgittion flow rte, RV dimeter nd re nd RV re chnge rte (ll P<0.01), s well s with left ventriculr stroke volume (P<0.05). The ε of middle nd bsl segments were negtively correlted with RV re chnge rte nd left ventriculr stroke volume (both P<0.05), but no correltions were found with other conventionl ultrsound mesurements. Correltion between 2DS nd RHC mesurements of RV function. The correltions between RV function prmeters mesured by 2DS nd RHC re shown in Tble IV. The SRs of picl segments were positively correlted with pulmonry rtery pressure (distolic, systolic nd men pressure; P<0.05, P<0.01, P<0.01, respectively) nd totl pulmonry resistnce (P<0.01), nd negtively correlted with stroke volume (P<0.05). The ε of picl segments were positively correlted with pulmonry rtery pressure (distolic, systolic nd men pressure) nd totl pulmonry resistnce nd negtively correlted with stroke volume (ll P<0.01). The ε of middle segments were positively correlted with totl pulmonry resistnce (P<0.01), but no correltion ws detected between other mesured prmeters. Discussion The ntomy of the RV results in it hving low resistnce nd high lod cpcity (12). In pulmonry hypertension, pulmonry vsculr resistnce increses, resulting in incresed RV fterlod, RV hypertrophy nd myocrdil oxygen demnd. It cn lso result in n insufficient blood supply, decresed RV complince nd incresed RV distolic pressure, leding to cvity diltion nd potentilly right hert filure (13 16). The RV is principlly composed of longitudinl muscle (17). Ejection is performed by longitudinl muscle, so the mjority of RV function reserch hs focused on longitudinl muscle (18 20). ε nd SR re indictors of crdic function bsed on myocrdil deformtion. In the current study, 2DS ws used to trck speckles tht were evenly distributed in myocrdium in two dimensionl gry scle imges over multiple time frmes. Movement of the speckles ws trcked nd their reltive movement compred between time frmes. This method overcomes ngle dependence, so tht RV longitudinl motion cn be quntittively recorded (8). The current study demonstrted tht SR nd ε were lower in ech segment of RV in PAH ptients compred with the control group, which is consistent with previous MRI findings (21). Results of the current study lso demonstrted tht SR nd ε in the picl nd middle segments in PAH ptients

3 1250 Tble I. Bseline chrcteristics nd echocrdiogrphy results of PAH nd control groups. Prmeter Control (n=40) PAH (n=41) Gender (mle/femle) 36/4 36/5 Age (yers) 31.8± ±16.2 Brchil rtery systolic pressure (mmhg) 119±13 105±16 Brchil rtery distolic pressure (mmhg) 75±16 55±9 Tricuspid regurgittion velocity (m/sec) 1.9± ±2.3 b RV distolic re (cm 2 ) 15.1± ±13.9 b RV systolic re (cm 2 ) 6.9± ±10.9 b Are chnge rte of RV (%) 50.9± ±10.8 b Left ventriculr ejection frction (%) 65.3± ±15.8 P<0.05 vs. control, b P<0.01 vs. control. PAH, pulmonry rteril hypertension; RV, right ventricle. Tble II. Comprison of ε nd SR between the PAH nd control groups. SR (sec 1) ε Segment PAH (n=41) Control (n=40) PAH (n=41) Control (n=40) Bsl 1.61± ± ± ±12.6 Middle 1.41±0.64,b 1.79± ±5.0,b 32.2±8.3 Apicl 1.22±0.56,b 1.69± ±6.9,b 34.2±9.4 P<0.05 vs. control, b P<0.05 vs. bsl segment. PAH, pulmonry rteril hypertension; SR, strin rte; ε, strin. Figure 1. RV longitudinl ε determined by 2D speckle trcking echocrdiogrphy in control nd PAH groups. The RV wll ws divided into six segments utomticlly. Pek longitudinl ε ws mesured in ech segment t the mid RV free wll nd interventriculr septum. RV, right ventriculr; PAH, pulmonry rteril hypertension; ε, strin. Figure 2. RV longitudinl strin rte determined by 2D speckle trcking echocrdiogrphy in control nd PAH groups. The RV wll ws divided into six segments utomticlly. Pek longitudinl strin ws mesured in ech segment t the mid RV free wll nd interventriculr septum. RV, right ventriculr; PAH, pulmonry rteril hypertension. were significntly lower compred with bsl segments. Apicl segment deformtion ws correlted with RV contrction mesured by RHC nd conventionl ultrsound, suggesting tht under long term pressure, the level of dmge in the RV picl segment ws higher thn in the RV bsl segment. This is likely to be due to the ntomy of the bsl segment, which is composed of smooth myocrdil nd more longitudinl muscle, while the picl segment is composed of trbeculr nd less longitudinl muscle (22,23). This mens tht the picl segment is more esily dmged thn the bsl segment under the sme pressure (24,25). Therefore, this suggests tht ε nd SR of the picl segment re importnt in determining the extent of PAH. It hs previously been reported tht the bsl segment is more severely dmged thn the picl segment in PAH ptients, which is inconsistent with the results of the current study (22,23). This is likely to be due to the ptients included in the studies. Only IPAH nd CHD PAH ptients were included in the current study, while respirtory disese ssocited PAH nd thromboembolic PAH were lso included in previous studies. It hs lso previously been suggested tht the reverse McConnell sign in thromboembolic PAH ptients cn ffect

4 LIU et l: ECHOCARDIOGRAPHY FOR QUANTIFYING RIGHT VENTRICULAR FUNCTION 1251 Tble III. Correltion between two dimensionl strin echocrdiogrphy nd conventionl ultrsound mesurements of RV deformtion in pulmonry rteril hypertension ptients (n=41). Bsl Middle Apicl Prmeter SR r ε r SR r ε r SR r ε r Tricuspid regurgittion pek velocity b RV dimeter b RV distolic re b RV systolic re b RV re chnge rte b Left ventriculr stroke volume P<0.05, b P<0.01. RV, right ventricle; r, correltion coefficient; SR, strin rte; ε, strin. Tble IV. Correltion between two dimensionl strin echocrdiogrphy nd right hert ctheteriztion mesurements of RV deformtion in pulmonry rteril hypertension ptients (n=41). Bsl Middle Apicl Prmeter Vlue SR r ε r SR r ε r SR r ε r Pulmonry rtery systolic pressure (mmhg) 73± b Pulmonry rtery distolic pressure (mmhg) 29± b 0.82 b Men pulmonry rtery pressure (mmhg) 49± b 0.79 b Stroke volume (ml) 55± b Totl pulmonry resistnce (Wood units) 95± b 0.65 b 0.77 b P<0.05, b P<0.01. r, correltion coefficient; SR, strin rte; ε, strin. study results (16). Moreover, the forementioned studies used ultrsound estimtion to evlute RV function nd hemodynmics, while RHC ws used for evlution in the current study. It hs been reported in met nlysis tht conventionl ultrsound cnnot ccurtely evlute the extent of PAH or systolic function (13 15), due to the irregulr shpe of the RV nd technicl limittions of ultrsound in mesuring re chnge rte nd ejection frction. A limittion of the current study is tht only IPAH nd CHD PAH were included, thus no informtion on the impct nd differentition of other types of PAH on the RV hs been provided. Further studies involving dditionl PAH types re required. In conclusion, the longitudinl function of RV in PAH ptients ws demonstrted to be significntly lower compred with the control group, ccording to SR nd ε mesurements mde using 2DS. The longitudinl function ws found to be most significntly reduced in the picl segment. Thus, 2DS is ble to ccurtely evlute RV longitudinl systolic function. Acknowledgements This study ws supported by the Cpitl Helth Reserch nd Development Specil Foundtion of Chin (grnt no ), the Bsic Clinicl Reserch Coopertion Project of Cpitl Medicl University (grnt no. 14JL87) nd the Beijing Municipl Administrtion of Hospitls Incubting Progrm (grnt no. PX ). References 1. Rubin LJ: Primry pulmonry hypertension. N Engl J Med 336: , Oxborough D nd Lord R: Predicting mortlity in pulmonry rteril hypertension: Cn it relly be tht simple? JACC Crdiovsc Imging 8: , Gu S, Hu H nd Dong H: Systemtic review of the economic burden of pulmonry rteril hypertension. Phrmcoeconomics 34: , Ploegstr MJ, Roofthooft MT, Douwes JM, Brtelds B, Elzeng NJ, vn de Weerd D, Hillege HL nd Berger RM: Echocrdiogrphy in peditric pulmonry rteril hypertension: Erly study on ssessing disese severity nd predicting outcome. Circ Crdiovsc Imging 8: pii: e000878, Hddd F, Hunt SA, Rosenthl DN nd Murphy DJ: Right ventriculr function in crdiovsculr disese, prt I: Antomy, physiology, ging, nd functionl ssessment of the right ventricle. Circultion 117: , Pedrinelli R, Cnle ML, Ginnini C, Tlini E, Dell'Omo G nd Di Bello V: Abnorml right ventriculr mechnics in erly systemic hypertension: A two dimensionl strin imging study. Eur J Echocrdiogr 11: , Woo JS, Yu TK, Kim WS, Kim KS nd Kim W: Erly prediction of myocrdil vibility fter cute myocrdil infrction by two dimensionl speckle trcking imging. J Geritr Crdiol 12: , 2015.

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