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We previously published a comparative study of 2-D speckle tracking longitudinal strain from RV free wall (RV-free) as an independent echocardiographic predictor of hemodynamic RV performance including mPAP and PVR, and current conventional echocardiographic techniques including tricuspid annular plane systolic excursion (TAPSE), RV fractional area change (RVFAC), RV index of myocardial performance (RIMP), and tissue Doppler-derived tricuspid lateral annular systolic velocity (S'). 6 Of the conventional techniques, TAPSE is well known as a highly reproducible and robust non-invasive measure of RV function and is predictive of outcome for patients with PH. 7, 8 The present objective was to test the hypothesis that RV-free can predict long-term outcome after the addition of PH-specific drugs for the treatment of PH. We also tested the hypothesis that the addition of an RV-free-based assessment to that based on TAPSE using conventional echocardiographic parameters can enhance the capability of the ulmonary hypertension (PH) is a clinical syndrome characterized by progressive increases in pulmonary vascular load, leading to marked increases in pulmonary artery pressure and exercise intolerance, and is usually associated with a poor outcome. 1-5 The natural history of patients with PH is heterogeneous, with more rapid clinical deterioration seen in patients with the highest degree of right ventricular (RV) dysfunction. Recently, several investigators reported that PH-specific drugs reduced the mortality and morbidity for patients with PH. 3 Consequently, interest is high in the assessment of RV performance for predicting long-term outcome after treatment with PH-specific drugs. While the assessment of RV function has thus become increasingly important in the management of patients with PH, most standard techniques for assessing RV hemodynamics, such as mean pulmonary artery pressure (mPAP) or pulmonary vascular resistance (PVR) are invasive and time-consuming. Background: The development of right ventricular (RV) dysfunction in pulmonary hypertension (PH) patients is associated with adverse outcome, so that the assessment of RV function has become increasingly important in the management of such patients. The present objective was to test the hypothesis that RV free-wall longitudinal speckle-tracking strain (RV-free), an independent echocardiographic predictor of hemodynamic RV performance, can predict long-term outcome.

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BackgroundWe have previously reported strain dyssynchrony index assessed by two-dimensional speckle tracking strain, and a marker of both dyssynchrony and residual myocardial contractility, can predict response to cardiac resynchronization therapy (CRT). A newly developed three-dimensional (3-D) speckle tracking system can quantify endocardial area change ratio (area strain), which coupled with the factors of both longitudinal and circumferential strain, from all 16 standard left ventricular (LV) segments using complete 3-D pyramidal datasets. Our objective was to test the hypothesis that strain dyssynchrony index using area tracking (ASDI) can quantify dyssynchrony and predict response to CRT.MethodsWe studied 14 heart failure patients with ejection fraction of 27 ± 7% (all≤35%) and QRS duration of 172 ± 30 ms (all≥120 ms) who underwent CRT. Echocardiography was performed before and 6-month after CRT. ASDI was calculated as the average difference between peak and end-systolic area strain of LV endocardium obtained from 3-D speckle tracking imaging using 16 segments. Conventional dyssynchrony measures were assessed by interventricular mechanical delay, Yu Index, and two-dimensional radial dyssynchrony by speckle-tracking strain. Response was defined as a ≥15% decrease in LV end-systolic volume 6-month after CRT.ResultsASDI ≥ 3.8% was the best predictor of response to CRT with a sensitivity of 78%, specificity of 100% and area under the curve (AUC) of 0.93 (p < 0.001). Two-dimensional radial dyssynchrony determined by speckle-tracking strain was also predictive of response to CRT with an AUC of 0.82 (p < 0.005). Interestingly, ASDI ≥ 3.8% was associated with the highest incidence of echocardiographic improvement after CRT with a response rate of 100% (7/7), and baseline ASDI correlated with reduction of LV end-systolic volume following CRT (r = 0.80, p < 0.001).ConclusionsASDI can predict responders and LV reverse remodeling following CRT. This novel index using the 3-D speckle tracking system, which shows circumferential and longitudinal LV dyssynchrony and residual endocardial contractility, may thus have clinical significance for CRT patients.

TAPSE may be overestimated in PH patients with clockwise rotation resulting from left ventricular compression. TAPSE should thus be evaluated carefully in PH patients with marked apical rotation.