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Tissue deformation imaging in the assessment of the right ventricle: does load dependency matter? Ruxandra Jurcut Department of Cardiology University of Medicine and Pharmacy “Carol Davila” Bucharest, Romania Declaration of conflict of interest: none to declare Agenda Background RV – complex anatomy & function Load & myocardial deformation in theory Demonstration RV myocardial deformation parameters in different loading conditions Take home messages RV remodeling The RV and LV differ markedly in their anatomy, mechanics, and loading conditions: Structure: crescent-shaped, thin-walled RV Hemodynamics: volume pump, ejecting in a low-resistance pulmonary arterial circulation. Special contraction pattern – peristaltic movement 87% from the RV stroke volume – RV sinus (apical 4CV) 80% from the RV stroke volume - longitudinal contraction RV remodeling/failure and prognosis PHT and RV failure - strong predictors of mortality in LV failure, AMI and COPD RV dysfunction is a strong prognostic factor in: PulmReg postrepair for Tetralogy of Fallot systemic RV in TGA RV pressure overload associated with pulmonary valve stenosis - better prognosis than PAH progressive PS induced by PA banding in rats - not associated with RV failure Load and contractility Bijnens et al EJE 2008 Cardiac mechanics – how is it balanced? Frank Starling law SV (ml) SV (ml) ↓ afterload ↑ inotropy ↑ afterload ↓ inotropy LVEDP (mmHg) LVEDP (mmHg) Load, geometry and contractility Laplace’s law RV function assessment Gold standard: pressure-volume loops Demonstrate load dependence of dp/dt, stroke work… Bleeker, Heart 2006 Myocardial deformation imaging – several techniques, several parameters IVA=IVV/t IVV t t Jurcut et al, Eur J Echo 2010 Load and contractility – in theory La Gerche, Jurcut, Voigt, CurrOppCardiol 2011 Load and contractility – in practice Rosner et al, EJE 2008 What happens to RV deformation experimental data Decreased preload (IVC banding) Increased afterload (PA banding) Maintained SRmax Maintained ISAmax Decreased SRmax Maintained ISAmax (SRmax ~ global contractility) Missant et al, Heart 2008 RV and afterload La Gerche et al, MSSE 2011 Any load insensitive measurements? Parameter Equation ß p Srad 33.2-1.5*Ea -0.58 <0.0001 Scirc -12.9+1.4*Ea-0.2*LVMV 0.79 (Ea) <0.0001 -0.52 (LVMV) <0.0001 SRrad 11.5+0.09*PRSW-0.2*LVMV 0.79 (PRSW) <0.001 -0.62 (LVMV) <0.001 SRcirc -4.5-0.04*PRSW -0.61 <0.0001 Legend: Ea = arterial elastance LVMV = LV myocardial volumes PRSW = preload recruitable stroke work Ferferieva et al, AJPHCP 2011 RV deformation - pitfalls Complex geometry - what region to study? Henein et al Heart 2011 RV deformation - pitfalls Regional function – what is normal for RV free wall strain? Paper Technique Basal Mid Apical Kowalski et al, UMB 2001 TDI -19 ± 6% -27 ± 6% -32 ± 6% Dambrauskaite et al, JASE 2007 TDI -42 ± 11% - -41 ± 11% Kittipovanonth et al, JASE 2008 TDI -31 ± 6% -29 ± 6% -26 ± 7% Teske et al, JASE 2008 2DS -22 ± 7% -24 ± 7% -27 ± 9% Jurcut et al, JASE 2011 2DS -29 ± 7% -30 ± 8% -28 ± 8% RV deformation Preload alterations Atrial septal defect Tricuspid regurgitation Pulmonary regurgitation Afterload alterations Pulmonary hypertension Pulmonary stenosis Transposition of the great arteries (“systemic RV”) Atrial septal defect Marciniak et al, Eur Heart J 2007 Open atrial septal defect * Jategaonkar et al, EJE 2009 Atrial septal defect – open vs closed Van de Breune et al, EJE 2011 Pulmonary Reg in repaired ToF R=0.45; p<0.05 Kowalik et al, JASE 2011 Pulmonary Hypertension PASP LVEI Puwanant et al, Circulation 2010 Pulmonary Hypertension PASP LVEI Puwanant et al, Circulation 2010 Pulmonary Hypertension RAP<10 mmHg RAP>10 mmHg *# * -14±1% -19±1% -26±1% Study group RV FW LS ROC curve cutoff Sn Sp Normal PAPs ≤ -27.2% 70% 93.5% PH compensated vs decompensated ≥ -14.9% 61.5% 85% Simon et al, Congest Heart Fail 2009 Increased afterload: PHT vs PStenosis RVP 73±34 mmHg RVP 88±31 mmHg RVP 25±4 mmHg p = 0.37 p<0.001 Jurcut et al, JASE 2011 Arterial PHT F, 25 years RVP = 100 mmHg Pulmonary stenosis F, 27 years RVP = 106 mmHg Increased afterload: PHT vs PStenosis Jurcut et al, JASE 2011 Pulmonary artery banding ~ PulmSten PS Angioproliferative pulmonary vascular remodeling ~ aPHT PHT Bogaard et al, Circulation 2009 TGA – the “systemic right ventricle” TGA – the “systemic right ventricle” Pettersen et al, JACC 2007 TGA – the “systemic right ventricle” Di Salvo et al, Int J Cardiol 2010 TGA – the “systemic right ventricle” Di Salvo et al, Int J Cardiol 2010 Take home messages Take home messages Interpretation of MDI parameters must always incorporate loading conditions: Influence of volume vs pressure overload Influence of geometrical changes (e.g.RV dilation) RV function may not be adequately described by longitudinal function alone. Myocardial adaptation to load: RV wall transverse fibers hypertrophy with increased afterload Different cellular and molecular adaptation mechanisms to pressure overload (e.g. PS vs PHT)