Evaluation of Right Intraventricular Dyssynchrony by Two-Dimensional Strain Echocardiography in Patients With Pulmonary Arterial Hypertension

doi:10.1016/j.echo.2008.05.005

Journal of the American Society of Echocardiography

Volume 21, Issue 9, September 2008, Pages 1028-1034

https://doi.org/10.1016/j.echo.2008.05.005 Get rights and content

Background

Right ventricular (RV) function has major prognostic implications for patients with pulmonary arterial hypertension (PAH). Intraventricular dyssynchrony might play an important role in RV dysfunction in these patients.

Methods

Thirty-six patients with PAH without right bundle branch block (mean age 44 ± 14 yr, 24 women) and 39 controls (mean age 43 ± 18 yr, 26 women) were evaluated. Global and segmental RV longitudinal deformation parameters were recorded by 2-dimensional strain echocardiography from apical 4-chamber views using a 6-segment RV model. The standard deviation of the heart rate–corrected intervals from QRS onset to peak strain for the 6 segments (RV-SD₆) was used to quantify right intraventricular dyssynchrony.

Results

RV-SD₆ was significantly higher in patients with PAH compared with controls (63 ± 21 vs 25 ± 15ms, P < .001). Dyssynchrony in patients with PAH was found to derive mainly from delayed contraction of the basal and mid RV free wall. In patients with PAH, RV-SD₆ was strongly correlated with RV fractional area change (β = −.519, P = .002), RV myocardial performance index (β = .427, P = .009), and RV global strain (β = .512, P = .002); in models controlling for RV systolic pressure, RV size, and QRS duration, RV-SD₆ was still an independent predictor of RV fractional area change (β = −.426, P = .005) and RV global strain (β = .358, P = .031). RV function was significantly worse in the subgroup of patients with PAH (n = 25) with RV-SD₆ > 55 ms (the upper 95% limit in controls).

Conclusion

Right intraventricular dyssynchrony, as quantified by 2-dimensional strain echocardiography, is prevalent in PAH and is associated with more pronounced RV dysfunction. The clinical implications of these findings remain to be determined in follow-up studies.

Section snippets

Patients

Forty stable outpatients with PAH were selected according to the following criteria: (1) PAH defined according to the World Health Organization's Revised Nomenclature and Classification of Pulmonary Hypertension (Category 1)12, 13 and (2) clinically stable for ≥1 month before evaluation. Patients with (1) congenital heart disease, (2) bundle branch block or paced rhythm, (3) atrial fibrillation or flutter, or (4) LV ejection fraction ≤45% by the modified Simpson's rule were excluded from the

Baseline Characteristics and Standard Echocardiography

Optimal tracking of all RV segments was possible in 36 of 40 patients with PAH (90.0%) and 39 of 40 controls (97.5%). Only these patients were included in subsequent analyses. The baseline characteristics and standard echocardiographic parameters of the study groups are presented in Table 1. Of the 36 patients with PAH included in the study, 6 had underlying autoimmune diseases (2 with systemic lupus erythematosus, 1 with scleroderma, 1 with mixed connective tissue disease, 1 with Sjögren's

Discussion

We found a considerable degree of mechanical intraventricular dyssynchrony in the right ventricles of patients with PAH. This was clearly demonstrated by the comparative analyses of the segmental t_s in patients with PAH and controls in our 6-segment RV model and was effectively described by the proposed RV-SD₆ parameter (63 ± 21 ms in patients with PAH vs 25 ± 15 ms in controls). We identified the mid and basal free wall as the main regions causing intraventricular delay; our findings are in

Conclusion

In summary, our findings suggest that right intraventricular dyssynchrony can be effectively described by a feasible and reproducible 2DS echocardiographically derived measure, the RV-SD₆. On the basis of this metric, we found that RV dyssynchrony was present in a substantial proportion of patients with PAH and that this dyssynchrony adversely affected RV function. It is unclear at this point, however, whether this dyssynchrony is merely a synonym for RV dysfunction or represents an independent

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Evaluation of Right Intraventricular Dyssynchrony by Two-Dimensional Strain Echocardiography in Patients With Pulmonary Arterial Hypertension

Background

Methods

Results

Conclusion

Section snippets

Patients

Baseline Characteristics and Standard Echocardiography

Discussion

Conclusion

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