Background: While right atrial (RA) enlargement is an established marker for adverse outcomes, the prognostic importance of RA dysfunction independent of RA size in pulmonary arterial hypertension (PAH) is not known. Methods and Results: Study subjects with PAH were prospectively enrolled from 2010 to 2014. RA function was measured using RA speckle-tracking longitudinal strain (LS) and strain rate (SR) during each phase of the cardiac cycle: (I) RA reservoir (peak longitudinal strain [PLS], peak systolic SR [PSSR]), (II) RA conduit (peak early diastolic SR [PEDSR]), and (III) RA active contraction (peak active contraction strain [PACS], peak contraction SR [PCSR]). The primary outcome was a composite of time to hospitalization or death assessed on follow up. A total of 63 subjects had complete echocardiographic data. Of these, 91% were females and the mean age was 58 ± 12 years. During the follow-up period (range:1–58 months), 39 were hospitalized or had died. After multivariable adjustment for age, gender and LA size, PLS, PACS, and PEDSR were significantly associated with increased risk of the composite outcome (p=0.0005, p=0.0167 and p=0.0054 respectively). Conclusion: Right atrial dysfunction independently predicts mortality and hospitalizations in patients with pulmonary arterial hypertension.

PurposeThe aim of this study was to evaluate the utility of adding quantitative assessments of cardiac function from echocardiography to clinical factors in predicting the outcome of patients with acute pulmonary embolism (PE).MethodsPatients with a diagnosis of acute PE, based on a positive ventilation perfusion scan or computed tomography (CT) chest angiogram, were identified using the Duke University Hospital Database. Of these, 69 had echocardiograms within 24–48 h of the diagnosis that were suitable for offline analysis. Clinical features that were analyzed included age, gender, body mass index, vital signs and comorbidities. Echocardiographic parameters that were analyzed included left ventricular (LV) ejection fraction (EF), regional, free wall and global RV speckle-tracking strain, RV fraction area change (RVFAC), Tricuspid Annular Plane Systolic Excursion (TAPSE), pulmonary artery acceleration time (PAAT) and RV myocardial performance (Tei) index. Univariable and multivariable regression statistical analysis models were used.ResultsOut of 69 patients with acute PE, the median age was 55 and 48 % were female. The median body mass index (BMI) was 27 kg/m2. Twenty-nine percent of the cohort had a history of cancer, with a significant increase in cancer prevalence in non-survivors (57 % vs 29 %, p = 0.02). Clinical parameters including heart rate, respiratory rate, troponin T level, active malignancy, hypertension and COPD were higher among non-survivors when compared to survivors (p ≤ 0.05). Using univariable analysis, NYHA class III symptoms, hypoxemia on presentation, tachycardia, tachypnea, elevation in Troponin T, absence of hypertension, active malignancy and chronic obstructive pulmonary disease (COPD) were increased in non-survivors compared to survivors (p ≤ 0.05). In multivariable models, RV Tei Index, global and free (lateral) wall RVLS were found to be negatively associated with survival probability after adjusting for age, gender and systolic blood pressure (p ≤ 0.05).ConclusionThe addition of echocardiographic assessment of RV function to clinical parameters improved the prediction of outcomes for patients with acute PE. Larger studies are needed to validate these findings.

No abstract

In pulmonary hypertension (PH), measurement of various echocardiographic parameters that assess right heart function is recommended by current clinical guidelines. Limited data exists on the combined value of clinical and echocardiographic parameters in precapillary PH in the modern era of therapy. We examined the association of clinical and echocardiographic parameters with surrogate outcomes (6-minute walk distance) and hard outcomes (hospitalization or death) in patients with precapillary PH. A cohort of patients with an established diagnosis of precapillary PH who underwent transthoracic echocardiography at the Duke Echo Lab were prospectively enrolled from 2010 to 2014. Univariable and multivariable models were constructed to examine the relation of clinical and echocardiographic parameters with surrogate and hard outcomes. Of the 98 patients with analyzable echocardiograms with good image quality, 85 were woman, mean age was 59.4 years, and 47% had ≥World Health Organization functional class III symptoms. The mean 6-minute walk distance was 354(±132) m, and 83% were on pulmonary arterial hypertension medications. At 24 months, the cumulative incidence rate for hospitalization or death was 47%. In univariable analyses, the REVEAL (Registry to Evaluate Early and Long-term PAH Disease Management) risk score (HR 1.72 per 1 SD (2.81) increment, 95% CI 1.34, 2.22; p=<0.001), RV global longitudinal strain (RVGLS) (HR 1.54 per 1 SD (5.31) worsening, 95% CI , 2.12; p=0.008) and log-2 NT proBNP (HR 1.43 per 1-fold increase, 95% CI 1.25, 1.63; p=<0.001) were significantly associated with hospitalization or death.

Congenital defects involving anomalous chordae of the mitral valve with attachment in the left atrium are an extremely rare finding and may result in valvular insufficiency. Few cases have been reported in the literature with multiple variations in anatomical location and insertion of aberrant chordae within the left ventricle and left atrium. Reported cases have presented with cardiovascular symptoms leading to diagnosis of anomalous mitral valve chordae. We present a case of a young female in which an aberrant mitral valve chorda was an incidental finding on transesophageal echocardiography.