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Single-Beat Estimation of Right Ventricular Contractility and Its Coupling to Pulmonary Arterial Load in Patients With Pulmonary Hypertension.

ABSTRACT: BACKGROUND:An accurate assessment of intrinsic right ventricular (RV) contractility and its relation to pulmonary arterial load is essential for the management of pulmonary hypertension. The pressure-volume relationship with load manipulation is the gold standard assessment used for this purpose, but its clinical application has been hindered by the lack of a single-beat method that is valid for the human RV. In the present study, we sought to validate a novel single-beat method to estimate the preload recruitable stroke work (PRSW) and its derivative for ventriculoarterial coupling in the human RV. METHODS AND RESULTS:A novel single-beat slope of the PRSW relationship (Msw) was derived by calculating the mean ejection pressure when the end-systolic volume was equal to volume-axis intercept of the PRSW relationship. In addition, by using a mathematical transformation of the equation representing the linearity of the PRSW relationship, a novel index for ventriculoarterial coupling, Msw/mean ejection pressure, was developed. RV pressure-volume relationships were measured in 31 patients (including 23 patients with pulmonary hypertension) who were referred for right-sided heart catheterization. In this cohort, the single-beat Msw was strongly correlated with the multiple-beat Msw (r=0.91, P<0.0001). Moreover, a significant correlation was observed between the single- and multiple-beat Msw/mean ejection pressure (r=0.53, P=0.002), with a stronger correlation in those with greater RV systolic pressure (r=0.70, P=0.003). CONCLUSIONS:The novel single-beat approach provided an accurate estimation of indexes for the PRSW relationship and ventriculoarterial coupling. It may be particularly useful in assessing RV adaptation to increased pressure overload.

SUBMITTER: Inuzuka R

PROVIDER: S-EPMC6015338 | biostudies-literature | 2018 May

REPOSITORIES: biostudies-literature

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Single-Beat Estimation of Right Ventricular Contractility and Its Coupling to Pulmonary Arterial Load in Patients With Pulmonary Hypertension.

Inuzuka Ryo R Hsu Steven S Tedford Ryan J RJ Senzaki Hideaki H

Journal of the American Heart Association 20180508 10

<h4>Background</h4>An accurate assessment of intrinsic right ventricular (RV) contractility and its relation to pulmonary arterial load is essential for the management of pulmonary hypertension. The pressure-volume relationship with load manipulation is the gold standard assessment used for this purpose, but its clinical application has been hindered by the lack of a single-beat method that is valid for the human RV. In the present study, we sought to validate a novel single-beat method to estim ...[more]

PMID: 29739798

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Project description:Scleroderma-associated pulmonary arterial hypertension (SSc-PAH) is associated with worse outcome than idiopathic pulmonary arterial hypertension (IPAH), potentially due to worse right ventricular adaptation to load as suggested by pressure-volume loop analysis. The value of non-invasive load-adaptability metrics has not been fully explored in SSc-PAH. This study sought to assess whether patients with incident SSc-PAH have worse echocardiographic load-adaptability metrics than patients with IPAH. Twenty-two patients with incident SSc-PAH were matched 1:1 with IPAH based on pulmonary vascular resistance. Echocardiographic load-adaptability indices were divided into: surrogates of ventriculo-arterial coupling (e.g. right ventricular area change/end-systolic area), indices reflecting the proportionality of load adaptation (e.g. tricuspid regurgitation velocity-time integral normalized for average right ventricular radius), and simple ratios (e.g. tricuspid annular plane systolic excursion/right ventricular systolic pressure). The prognostic value of these indices for clinical worsening (i.e. death, transplant, or hospitalization for heart failure) at one year was explored. The two groups were comprised of patients of similar age, with similar cardiac index, pulmonary resistance, capacitance and NT-proBNP levels ( p > 0.10). There was no difference in baseline right ventricular dimension, function or load-adaptability indices. At one year, eight (36.4%) SSc-PAH patients had experienced clinical worsening (eight hospitalizations and two deaths) versus one hospitalization in the IPAH group. Load adaptation at one year in survivors was not worse in SSc-PAH ( p > 0.33). Patients with IPAH responded better to therapy than SSc-PAH in terms of reduction of right ventricular areas at one year ( p < 0.05). Right ventricular load-adaptability echocardiographic indices do not appear to capture the increased risk of negative outcomes at one year associated with SSc-PAH.

Project description:Right ventricular (RV) pressure overload has a vastly different clinical course in children with idiopathic pulmonary arterial hypertension (iPAH) than in children with pulmonary stenosis (PS). While RV function is well recognized as a key prognostic factor in iPAH, adverse ventricular-ventricular interactions and LV dysfunction are less well characterized and the pathophysiology is incompletely understood. We compared ventricular-ventricular interactions as hypothesized drivers of biventricular dysfunction in pediatric iPAH versus PS Eighteen iPAH, 16 PS patients and 18 age- and size-matched controls were retrospectively studied. Cardiac cycle events were measured by M-mode and Doppler echocardiography. Measurements were compared between groups using ANOVA with post hoc Dunnet's or ANCOVA including RV systolic pressure (RVSP; iPAH 96.8 ± 25.4 mmHg vs. PS 75.4 ± 18.9 mmHg; P = 0.011) as a covariate. RV-free wall thickening was prolonged in iPAH versus PS, extending beyond pulmonary valve closure (638 ± 76 msec vs. 562 ± 76 msec vs. 473 ± 59 msec controls). LV and RV isovolumetric relaxation were prolonged in iPAH (P < 0.001; LV 102.8 ± 24.1 msec vs. 63.1 ± 13.7 msec; RV 95 [61-165] vs. 28 [0-43]), associated with adverse septal kinetics; characterized by rightward displacement in early systole and leftward displacement in late RV systole (i.e., early LV diastole). Early LV diastolic filling was decreased in iPAH (73 ± 15.9 vs. PS 87.4 ± 14.4 vs. controls 95.8 ± 12.5 cm/sec; P = 0.004). Prolonged RVFW thickening, prolonged RVFW isovolumetric times, and profound septal dyskinesia are associated with interventricular mechanical discoordination and decreased early LV filling in pediatric iPAH much more than PS These adverse mechanics affect systolic and diastolic biventricular efficiency in iPAH and may form the basis for worse clinical outcomes. We used clinically derived data to study the pathophysiology of ventricular-ventricular interactions in right ventricular pressure overload, demonstrating distinct differences between pediatric pulmonary arterial hypertension (iPAH) and pulmonary stenosis (PS). Altered timing of right ventricular free wall contraction and profound septal dyskinesia are associated with interventricular mechanical discoordination and decreased early LV filling in iPAH much more than PS These adverse mechanics affect systolic and diastolic biventricular efficiency, independent of right ventricular systolic pressure.

Dataset Information

Single-Beat Estimation of Right Ventricular Contractility and Its Coupling to Pulmonary Arterial Load in Patients With Pulmonary Hypertension.

Publications

Single-Beat Estimation of Right Ventricular Contractility and Its Coupling to Pulmonary Arterial Load in Patients With Pulmonary Hypertension.

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