Right Ventricular Strain for Prediction of Survival in Patients With Pulmonary Arterial Hypertension

doi:10.1378/chest.10-2015

Chest

Volume 139, Issue 6, June 2011, Pages 1299-1309

https://doi.org/10.1378/chest.10-2015 Get rights and content

Background

Pulmonary arterial hypertension (PAH) is a devastating illness of pulmonary vascular remodeling, right-sided heart failure, and limited survival. Whether strain-based measures of right ventricular (RV) systolic function predict future right-sided heart failure and/or death is untested.

Methods

RV longitudinal systolic strain and strain rate were evaluated by echocardiography in 80 patients with World Health Organization group 1 pulmonary hypertension (PH) (72% were functional class [FC] III or IV). Survival status was assessed over 4 years.

Results

All patients had a depressed RV systolic strain (−15% ± 5%) and strain rate (−0.80 ± 0.29 s⁻¹). Of the parameters assessed, average RV free wall systolic strain worse than −12.5% identified a cohort with greater severity of disease (82% were FC III/IV), greater RV systolic dysfunction (RV stroke volume index 26 ± 9 mL/m²), and higher right atrial pressure (12 ± 5 mm Hg). Patients with an RV free wall strain worse than −12.5% were associated with a greater degree of disease progression within 6 months, a greater requirement for loop diuretics, and/or a greater degree of lower extremity edema, and it also predicted 1-, 2-, 3-, and 4-year mortality (unadjusted 1-year hazard ratio, 6.2; 2.1–22.3). After adjusting for age, sex, PH cause, and FC, patients had a 2.9-fold higher rate of death per 5% absolute decline in RV free wall strain at 1 year.

Conclusions

Noninvasive assessment of RV longitudinal systolic strain and strain rate independently predicts future right-sided heart failure, clinical deterioration, and mortality in patients with PAH.

Section snippets

Study Population

We studied consecutive adult patients ≥ 18 years of age with PAH, first seen at the Mayo Clinic Rochester, between December 2003 and March 2006, who were naive to PAH-specific therapy. Individuals were included if they fulfilled the contemporary diagnostic criteria for PAH (ie, group 1 PH with mean pulmonary artery pressure [mPAP] ≥ 25 mm Hg at rest occurring in the setting of increases in precapillary pulmonary resistance). Patients with congenital systemic-to-pulmonary shunts were excluded.

Results

The baseline characteristics of the study population are summarized in Table 1 and echocardiographic variables in Table 2. The majority of patients were WHO FC III (63%) or IV (9%), with elevated RAP and PVRI, with significant depression in cardiac index, mixed venous oxygen saturation, and RV stroke volume index. Patients had, on average, moderate-severe/severe enlargement of the RA and RV. Conventional measures of RV function were significantly reduced (lateral tricuspid annular systolic

Discussion

RV function is an important determinant of outcome in PAH. The assessment of RV function is challenging, however, because of its geometry and the plethora of suggested invasive and noninvasive techniques. Speckle-tracking strain echocardiography has emerged as an easily obtained and angle-independent noninvasive technique for assessing global and regional RV function. Here, the RV longitudinal systolic strain and strain rate were significantly decreased in patients with PAH. An RV free wall

Conclusions

In conclusion, noninvasive assessment of RV longitudinal systolic function by strain and strain rate independently predicts future right-sided heart failure, clinical deterioration, and mortality in patients with PAH. Speckle-tracking-based strain has the advantage of being widely available, objective, cost effective, and safe. Emerging ultrasound technologies such as speckle-strain may play an important role in predicting prognosis, monitoring the efficacy of specific therapeutic

Acknowledgments

Author contributions: Dr Kane had access to the data and takes responsibility for the integrity and accuracy of the data and analysis.

Dr Sachdev: contributed to study design, data acquisition and analysis, and preparation of the manuscript.

Dr Villarraga: contributed to study design, data analysis, and preparation of the manuscript.

Dr Frantz: contributed to study design, data analysis, and preparation of the manuscript.

Dr McGoon: contributed to study design, data and analysis, and preparation of

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Citation Excerpt :
Consequently, current guidelines discourage surgery for TV pathologies in patients with substantial RV dysfunction and PH.61 Although TTVI is feasible in this subset of patients, hepatic congestion, renal dysfunction, and the lack of procedural success are predictive factors for a worse outcome.62 Care must be taken when evaluating both RV function and PH, owing to the high dependency of both values on loading conditions and on TR severity, and owing to the complex interplay between TR severity, RV function, and PH.63,64 New measurements including RV systolic excursion velocity or strain adequately assess RV load dependency and independently predict poor outcomes in patients with PH. However, their exact value in TTVI is as yet unclear.65 When evaluating PH, sole echocardiographic assessment is insufficient to identify patients that will benefit from interventions, because there may be a high discrepancy between echocardiographic and invasive measurements.
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Funding/Support: This work was supported by the Mayo Clinic CR20 program.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

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Original ResearchPulmonary Vascular DiseaseRight Ventricular Strain for Prediction of Survival in Patients With Pulmonary Arterial Hypertension

Background

Methods

Results

Conclusions

Section snippets

Study Population

Results

Discussion

Conclusions

Acknowledgments

Chest

Lancet

Chest

Am J Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

Ultrasound Med Biol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Soc Echocardiogr

Am J Cardiol

Am J Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Coll Cardiol

J Am Coll Cardiol

Int J Cardiol

Chest

Original Research
Pulmonary Vascular Disease
Right Ventricular Strain for Prediction of Survival in Patients With Pulmonary Arterial Hypertension