Two- And Three-dimensional Echocardiographic Assessment Of Right Ventricular Function In Patients With Pulmonary Arterial Hypertension

Part Ⅰ:Two-dimensional speckle tracking echocardiography assessed right ventricular function and exercise capacity in pre-capillary pulmonary hypertensionAims:Resting two-dimensional speckle tracking echocardiography(2D-STE)identified right ventricular(RV)systolic function were reported to predict exercise capacity in pulmonary hypertension(PH)patients,but little attention had been payed to 2D-STE detected RV diastolic function.Therefore,we aim to elucidate and compare the relations between 2D-STE identified RV diastolic/systolic functions and peak oxygen consumption(PVO2)determined by cardiopulmonary exercise testing(CPET)in pre-capillary PH.Methods:2D-STE was performed in 66 pre-capillary PH patients and 28 healthy controls.Linear correlation and multivariate regression analyses were performed to evaluate and compare the relations between RV 2D-STE parameters and PVO2.Receiver operating characteristic curves were used to compare the predictive value of 2D-STE parameters in predicting the cut-off—PVO2<11ml/min/kg.Results:There were significant differences of all the 2D-STE parameters between PH patients and healthy controls.In patients,RV-peak global longitudinal strain(GLS,r=-0.498,P<0.001),RV-peak systolic strain rate(GSRs,r=-0.537,P<0.001)and RV-peak early diastolic strain rate(GSRe,r=0.527,P<0.001)significantly correlated with PVO2,but no significant correlation was observed between RV-peak late diastolic strain rate(GSRa,r=0.208,P=0.093)and PVO2.The first multivariate regression analysis of clinical data without echocardiographic parameters identified WHO functional class,NT-proBNP and BMI as independent predictors of PVO2(Model-1,adjusted r2=0.421,P<0.001);Then we added conventional echocardiographic parameters and 2D-STE parameters to the clinical data,identified S(Model-2,adjusted r2=0.502,P<0.001),RV-GLS(Model-3,adjusted r2=0.491,P<0.001),RV-GSRe(Model-4,adjusted r=0.500,P<0.001)and RV-GSRs(Model-5,adjusted r2=0.519,P<0.001)as independent predictors of PVO2,respectively.The predictive power was increased,and Model-5 including RV-GSRs showed the highest predictive capability.ROC curves found RV-GSRs expressed the strongest predictive value(AUC=0.88,P<0.001),and RV-GSRs>-0.65s-1 had a 88.2%sensibility and 82.2%specificity to predict PV02<11ml/min/kg.Conclusions:2D-STE assessed RV function improves the prediction of exercise capacity represented by PVO2 in pre-capillary PH.Part Ⅱ:Two-dimensional speckle tracking echocardiography detected interventricular dyssynchrony predicts exercise capacity and disease severity in pre-capillary pulmonary hypertensionAims:Right ventricular(RV)intraventricular mechanical dyssynchrony detected by 2-dimensional speckle tracking echocardiography(2D-STE)has been reported to be correlated with a decrease in RV contractile efficiency in pulmonary hypertension(PH)patients,while little attention has been paid to biventricular dysfunction.Therefore,we aimed to evaluate the predictive value of 2D-STE detected interventricular dyssynchrony for exercise capacity and disease severity in patients with pre-capillary pulmonary hypertension(PcPH).Methods:Conventional transthoracic echocardiography,2D-STE and cardiopulmonary exercise test(CPET)were performed in all participants.Intra-and inter-ventricular dyssynchrony were calculated as the standard deviation(SD)of the time intervals corrected for heart rate between QRS onset and peak longitudinal strain.Multivariate linear regression analyses were performed to identify independent predictors of peak oxygen consumption(PVO2)during the CPET.Multivariable logistical regression modeling was used to analyze the associations between interventricular dyssynchrony and risk assessment.Results:Sixty-six pre-capillary PH patients were consecutively recruited(19 male and 47 female,average 35 years old).WHO functional class,N-terminal pro-brain natriuretic peptide and body mass index were included as independent predictors in the first multivariate regression analysis of clinical data without echocardiographic parameters(Model-1,adjusted r2=0.423,P<0.001).We subsequently added conventional echocardiographic parameters and 2D-STE parameters to the clinical data,RV fractional area change(Model-2,adjusted r2=0.417,P<0.001),RV global longitudinal strain(Model-3,adjusted r2=0.454,P<0.001),RV intraventricular dyssynchrony(Model-4,adjusted r2=0.474,P<0.001)and interventricular dyssynchrony(Model-5,adjusted r2=0.483,P<0.001)were identified as independent predictors of PVO2.Interventricular dyssynchrony,calculated as the SD of the time intervals of nine segments,was independently associated with risk assessment(odd ratio 1.027,95%CI:1.003-1.052,P=0.03).The area under the receiver-operating characteristic curve was 0.73(P<0.001).Conclusion:Interventricular dyssynchrony detected by 2D-STE contributed to a better evaluation of exercise capacity and disease severity in PcPH patients.Part Ⅲ:Comparison of the capability of risk stratification evaluation between two-and three-dimensional speckle-tracking strain in pre-capillary pulmonary hypertensionAims:To investigate and compare the values of right ventricular longitudinal strain(RVLS)detected by two-dimensional(2D)and three-dimensional(3D)speckle tracking echocardiography in risk stratification evaluation in pre-capillary pulmonary hypertension(PcPH).Methods:We consecutively screened 66 patients diagnosed as PcPH in our center.According to the risk assessment recommended by 2015 ESC Guidelines,all participants were classified into low and intermediate-high risk group.2D-and 3D-strain were measured using off-line softwares(GE EchoPAC version 201 and TomTec 4D RV Function 2.0).Results:Fifty-seven PcPH patients(average 35 years old,18 males and 39 females)were finally enrolled in our study,32(56.1%)were classified in low risk group,while 25(43.9%)were in intermediate-high risk group.Clinical data associated with disease severity,such as NT-proBNP(r=0.574,P<0.001),PVO2(r=-0.484,P<0.001)and 6MWD(r=-0.356,P=0.008)were significantly correlated with 2D-RVLS;while the correlations with 3D-RVLS were weaker.ROC curves for the detection of intermediate-high risk stratification showed 2D-RVLS had the best predictive capacity(area under curve,0.82,95%CI 0.71-0.93,P<0.001).Univariate and Multivariate Logistic regression analyses identified 2D-RVLS as an independent predictor(OR 1.42,95%CI 1.18-1.71,P<0.001)of intermediate-high risk stratification in this cohort of PcPH patients,the predictive capacity-retained(OR 1.45,95%CI 1.18-1.78,P<0.001)after adjusted by age,gender and BMI.While 3DE-STE parameters were not.Conclusions:In conclusion,when used for the detection of intermediate-high risk stratification in PcPH,2D-RVLS was better than 3D-RVLS.Part Ⅳ:The value of three-dimensional echocardiography in risk stratification in pulmonary arterial hypertension:a cross-sectional studyAims:To explore the value of right ventricular(RV)parameters detected by three-dimensional echocardiography(3DE)in risk stratifcation in pulmonary arterial hypertension(PAH)patients.Methods:We prospectively recruited 130 pulmonary hypertension patients from National Center for Cardiovascular Diseases,Fuwai Hospital.Each participant was performed a transthoracic echocardiography and 3DE parameters were measured using an off-line software(4D RV Function 2.0,TomTec).Patients were classifed into low,intermediate-high risk group based on 2015 ESC Guidelines.Results:A total of 91 PAH patients(34±12 years old,25 males)were finally enrolled,among which,42 were classified into low risk group,while 49 were intermediate-high risk group.Compared with low-risk patients,those with intermediate-high risk had significantly larger 3DE-RV volumes,worse ejection fraction(EF)and tricuspid annular plane systolic excursion,and decreased longitudinal strain(LS).Receive operating characteristic curves illustrated all the 3DE parameters were able to predict intermediate-high risk stratification,especially 3D-RVEF(area under curve,0.82,95%CI 0.73-0.91,P<0.001).And 3D-RVEF<26.39%had a 81.6%sensibility and 73.8%specificity to predict intermediate-high risk stratification.Univariate and multivariate Logistic regression analyses identified 3D-RV end-diastolic volume(OR 1.02,95%CI 1.01-1.03,P=0.002)and end-systolic(OR 1.03,95%CI 1.01-1.04,P<0.001)volume,3D-RVEF(OR 0.82,95%CI 0.75-0.90,P<0.001)and LS of free wall(OR 1.17,95%CI 1.05-1.31,P=0.005)as independent predictors of intermediate-high risk stratification.Conclusion:RV volumes,EF and free wall strain detected by 3DE were independent predictors of intermediate-high risk stratification in PAH patients,among which,RVEF showed the best predictive capacity.