Right atrial function is associated with right venticular diastolic stiffness: RA–RV interaction in pulmonary arterial hypertension

Wessels, Jeroen N.; Mouratoglou, Sophia-Anastasia; Wezenbeek, Jessie van; Handoko, M. Louis; Marcus, J. Tim; Meijboom, Lilian J.; Westerhof, Berend E.; Bogaard, Harm Jan; Strijkers, Gustav J.; Vonk‐Noordegraaf, Anton; Man, Frances S. de

doi:10.1183/13993003.01454-2021

Cited by 25 publications

(15 citation statements)

References 25 publications

(42 reference statements)

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“…46 Poor RV diastolic function resulted in lower RV passive filling and improvements in RV diastolic function with treatment were associated with improved RV active filling and stroke volume. 47 These findings suggest that RA dysfunction assessed by STE may be a sensitive marker of right-sided overload preceding echocardiographic manifestations of RV failure, with important prognostic implications.…”

Section: Speckle-tracking Echocardiographymentioning

confidence: 82%

Novel Approaches to Imaging the Pulmonary Vasculature and Right Heart

Alenezi

Covington

Mukherjee³

et al. 2022

Circulation Research

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There is an increased appreciation for the importance of the right heart and pulmonary circulation in several disease states across the spectrum of pulmonary hypertension and left heart failure. However, assessment of the structure and function of the right heart and pulmonary circulation can be challenging, due to the complex geometry of the right ventricle, comorbid pulmonary airways and parenchymal disease, and the overlap of hemodynamic abnormalities with left heart failure. Several new and evolving imaging modalities interrogate the right heart and pulmonary circulation with greater diagnostic precision. Echocardiographic approaches such as speckle-tracking and 3-dimensional imaging provide detailed assessments of regional systolic and diastolic function and volumetric assessments. Magnetic resonance approaches can provide high-resolution views of cardiac structure/function, tissue characterization, and perfusion through the pulmonary vasculature. Molecular imaging with positron emission tomography allows an assessment of specific pathobiologically relevant targets in the right heart and pulmonary circulation. Machine learning analysis of high-resolution computed tomographic lung scans permits quantitative morphometry of the lung circulation without intravenous contrast. Inhaled magnetic resonance imaging probes, such as hyperpolarized 129Xe magnetic resonance imaging, report on pulmonary gas exchange and pulmonary capillary hemodynamics. These approaches provide important information on right ventricular structure and function along with perfusion through the pulmonary circulation. At this time, the majority of these developing technologies have yet to be clinically validated, with few studies demonstrating the utility of these imaging biomarkers for diagnosis or monitoring disease. These technologies hold promise for earlier diagnosis and noninvasive monitoring of right heart failure and pulmonary hypertension that will aid in preclinical studies, enhance patient selection and provide surrogate end points in clinical trials, and ultimately improve bedside care.

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Section: Speckle-tracking Echocardiographymentioning

confidence: 82%

Novel Approaches to Imaging the Pulmonary Vasculature and Right Heart

Alenezi

Covington

Mukherjee³

et al. 2022

Circulation Research

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“… 100 Thus, non‐invasive measurement of RA parameters for PH risk stratification 34 somewhat embodies assessment of RV diastolic function, as suggested by the authors. 100 However, RA impairment and RA pressure increase may not always be the consequence of RV dysfunction per se and must be evaluated in the context of the underlying disease, as recently shown by van Wezenbeek et al ., comparing PAH and PH in HFpEF at matched levels of pressure overload. 101 Consequently, simple non‐invasive surrogates of RV diastolic function are sought and may attract attention in the near future.…”

Section: Discussionmentioning

confidence: 99%

“…Wessels et al . recently demonstrated that RV diastolic impairment alters right atrial (RA) function in PAH 100 . Thus, non‐invasive measurement of RA parameters for PH risk stratification 34 somewhat embodies assessment of RV diastolic function, as suggested by the authors 100 .…”

Section: Discussionmentioning

confidence: 99%

“…24 Wessels et al recently demonstrated that RV diastolic impairment alters right atrial (RA) function in PAH. 100 Thus, non-invasive measurement of RA parameters for PH risk stratification 34 somewhat embodies assessment of RV diastolic function, as suggested by the authors. 100 However, RA impairment and RA pressure increase may not always be the consequence of RV dysfunction per se and must be eval-uated in the context of the underlying disease, as recently shown by van Wezenbeek et al, comparing PAH and PH in HFpEF at matched levels of pressure overload.…”

Section: Discussionmentioning

confidence: 99%

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Adaptive versus maladaptive right ventricular remodelling

et al. 2022

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Right ventricular (RV) function and its adaptation to increased afterload [RV–pulmonary arterial (PA) coupling] are crucial in various types of pulmonary hypertension, determining symptomatology and outcome. In the course of disease progression and increasing afterload, the right ventricle undergoes adaptive remodelling to maintain right‐sided cardiac output by increasing contractility. Exhaustion of compensatory RV remodelling (RV–PA uncoupling) finally leads to maladaptation and increase of cardiac volumes, resulting in heart failure. The gold‐standard measurement of RV–PA coupling is the ratio of contractility [end‐systolic elastance (Ees)] to afterload [arterial elastance (Ea)] derived from RV pressure–volume loops obtained by conductance catheterization. The optimal Ees/Ea ratio is between 1.5 and 2.0. RV–PA coupling in pulmonary hypertension has considerable reserve; the Ees/Ea threshold at which uncoupling occurs is estimated to be ~0.7. As RV conductance catheterization is invasive, complex, and not widely available, multiple non‐invasive echocardiographic surrogates for Ees/Ea have been investigated. One of the first described and best validated surrogates is the ratio of tricuspid annular plane systolic excursion to estimated pulmonary arterial systolic pressure (TAPSE/PASP), which has shown prognostic relevance in left‐sided heart failure and precapillary pulmonary hypertension. Other RV–PA coupling surrogates have been formed by replacing TAPSE with different echocardiographic measures of RV contractility, such as peak systolic tissue velocity of the lateral tricuspid annulus (S′), RV fractional area change, speckle tracking‐based RV free wall longitudinal strain and global longitudinal strain, and three‐dimensional RV ejection fraction. PASP‐independent surrogates have also been studied, including the ratios S′/RV end‐systolic area index, RV area change/RV end‐systolic area, and stroke volume/end‐systolic volume. Limitations of these non‐invasive surrogates include the influence of severe tricuspid regurgitation (which can cause distortion of longitudinal measurements and underestimation of PASP) and the angle dependence of TAPSE and PASP. Detection of early RV remodelling may require isolated analysis of single components of RV shortening along the radial and anteroposterior axes as well as the longitudinal axis. Multiple non‐invasive methods may need to be applied depending on the level of RV dysfunction. This review explains the mechanisms of RV (mal)adaptation to its load, describes the invasive assessment of RV–PA coupling, and provides an overview of studies of non‐invasive surrogate parameters, highlighting recently published works in this field. Further large‐scale prospective studies including gold‐standard validation are needed, as most studies to date had a retrospective, single‐centre design with a small number of participants, and validation against gold‐standard Ees/Ea was rarely performed.

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“…This leads to elevation of RAP (29). Namely, RAP is a surrogate marker of both right ventricular diastolic function and right ventricular diastolic stiffness (30)(31)(32)(33). Furthermore, these series of processes lead to reduction of venous return to the right ventricle, and result in loss of right ventricular stroke volume and right ventricular dysfunction.…”

Section: Discussionmentioning

confidence: 99%

Renal Venous Stasis Index Reflects Renal Congestion and Predicts Adverse Outcomes in Patients With Heart Failure

Ohara

Yoshihisa

Horikoshi

et al. 2022

Front. Cardiovasc. Med.

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BackgroundIt has been recently reported that the renal venous stasis index (RVSI) assessed by renal Doppler ultrasonography provides information to stratify pulmonary hypertension that can lead to right-sided heart failure (HF). However, the clinical significance of RVSI in HF patients has not been sufficiently examined. We aimed to examine the associations of RVSI with parameters of cardiac function and right heart catheterization (RHC), as well as with prognosis, in patients with HF.MethodsWe performed renal Doppler ultrasonography, echocardiography and RHC in hospitalized patients with HF (n = 388). RVSI was calculated as follows: RVSI = (cardiac cycle time-venous flow time)/cardiac cycle time. The patients were classified to three groups based on RVSI: control group (RVSI = 0, n = 260, 67%), low RVSI group (0 < RVSI ≤ 0.21, n = 63, 16%) and high RVSI group (RVSI > 0.21, n = 65, 17%). We examined associations of RVSI with parameters of cardiac function and RHC, and followed up for cardiac events defined as cardiac death or worsening HF.ResultsThere were significant correlations of RVSI with mean right atrial pressure (mRAP; R = 0.253, P < 0.001), right atrial area (R = 0.327, P < 0.001) and inferior vena cava diameter (R = 0.327, P < 0.001), but not with cardiac index (R = −0.019, P = 0.769). During the follow-up period (median 412 days), cardiac events occurred in 60 patients. In the Kaplan–Meier analysis, the cumulative cardiac event rate increased with increasing RVSI (log-rank, P = 0.001). In the multivariate Cox proportional hazard analysis, the cardiac event rate was independently associated with RVSI (high RVSI group vs. control group: hazard ratio, 1.908; 95% confidence interval, 1.046–3.479, P = 0.035).ConclusionRVSI assessed by renal Doppler ultrasonography reflects right-sided overload and is associated with adverse prognosis in HF patients.

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Right atrial function is associated with right venticular diastolic stiffness: RA–RV interaction in pulmonary arterial hypertension

Cited by 25 publications

References 25 publications

Novel Approaches to Imaging the Pulmonary Vasculature and Right Heart

Novel Approaches to Imaging the Pulmonary Vasculature and Right Heart

Adaptive versus maladaptive right ventricular remodelling

Renal Venous Stasis Index Reflects Renal Congestion and Predicts Adverse Outcomes in Patients With Heart Failure

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