Download rv_systolic_dysfunction

Evaluation of right ventricular systolic function in pediatric patients with dilated
cardiomyopathy
Authors
Hala Agha* , Hossam Hussein, InasAbdelsattar , NaglaaMosaad , GaserAbdelmohsen
, DoaaAbdelaziz,
Department of Pediatrics, Pediatric Cardiology Division, Specialized Pediatric
Hospital, Cairo University.
*Author of correspondence
HalaMounir Agha
Address: Pediatric Department, Pediatric Cardiology Division, Specialized Pediatric
hospital, Faculty of Medicine, Cairo University. Kasr Al Aini Street, Cairo, Egypt.
Postal code: 11562
E mail:[email protected]
Telephone: 00202-0101113284/ 00202-35699959
Evaluation of right ventricularsystolic function in pediatric patients with dilated
cardiomyopathy
Abstract
Background: Data regarding the right ventricular assessment in pediatric dilated
cardiomyopathy (DCM) are sparse. Aim of study: To evaluate the right ventricular as
well as the left ventricular functions in DCM.Methods: Echocardiographic
examination was done using TDI &conventional echo for 20 DCM pediatric patients
comparing them to another 27 normal matched controls. Tricuspid annular plan
systolic excursion (TAPSE) and the following RV indices; S' velocity, isovolumic
acceleration (IVA), TDI derived myocardial performance index (MPI) were
measured. Results: RV of the studied patients showed significant systolic
dysfunction; TAPSE, S' velocity, IVA had significantly reduced values and MPI was
significantly prolonged compared to controls [17 (15-21) mm,11 (8.5-13) cm/sec, 2.4
(1.7-3)m/s², 0.48(0.43-0.52)versus 21 (18-23) mm, 14 (13-18) cm/sec, 4.3 (3.9-5.3)
m/s²,0.25 (0.22-0.27), p= 0.015, <0.0001, <0.0001,<0.0001 respectively]. Moreover
TAPSE ,S' and IVA were significantly correlated to LV S' (r=0.5, 0.7, 0.6with P value
0.0001,<0.0001, <0.0001respectively ) Also, RV MPI by TDI was correlated to LV
MPI by TDI (r =0.7 P <0.0001 ).TDI derived RV MPI and IVA had high sensitivity
and specificity [sensitivity=100%, specificity=92.6%, AUC=0.98 and cut-off value
>0.29, sensitivity =80%, specificity=92.6, AUC=0.9 and cut-off value ≤ 3
respectively]. Conclusion: In pediatric dilated cardiomyopathy the right ventricular
systolic affection is evident beside the left ventricular dysfunction. So, nonconventional echocardiographic evaluation of RV function is recommended in dilated
cardiomyopathy.
Key words:DCM, RV, TDI, MPI, IVA.
Introduction:
Dilated cardiomyopathy is the most common form of cardiomyopathy in children;
it is characterized by left ventricular dysfunction and dilatation with progressive heart
failure that may lead to death.[1],[2].In routine echocardiographic examination of
these patients ,most of the studies focus mainly on the assessment of the left
ventricular function forgetting the right ventricle ( RV),because of its complex shape
that prevents application of any geometrical assumption for its functional
assessment.As theRV and the left ventricle ( LV) share the interventricular septum
(IVS), their functions are closely linked together. The RV contains mainly transverse
muscle fibers in its free wall beside it shares oblique fibers in the interventricular
septum with the LV,so LV contraction contributes in the RV contraction via the
interventricular septum, so assessment of RV function in these patients is of
paramount importance.[3]. Tissue Doppler imaging (TDI) is a modality that is present
in most of available echocardiographic machines, itis used for assessment of the
peak myocardial velocity and time, but this modality could be affected by the angle of
ultrasound beams to the targeted myocardial wall beside it is load dependent. [4] .
TDI could be also used for evaluation of Isovolumeic acceleration (IVA),the index of
RV systolic function that may be load independent.[5]
The aim of this studywas to evaluate the RV systolic function in pediatric
patients with idiopathic dilated cardiomyopathy using TDI, and correlate it to the LV
dysfunction evaluated by conventional echo and tissue Doppler imaging.
Methodology:
This is a cross sectional case controlstudythat conducted on Twenty (20)pediatric
patients who have been diagnosed as idiopathic dilated cardiomyopathy and referred
to the pediatric cardiology outpatient clinic of the Cairo University Specialized
Pediatric Hospital (CUSPH), Faculty of Medicine, Cairo University, and compared to
thirty two (27) age, sex, weight and body surface area matched control,attended the
general outpatient clinics of Cairo University Children Hospital, for minor complains
e.g. abdominal pain, sore throat ,headache.
Inclusion criteria:

Children diagnosed as idiopathic dilated cardiomyopathy with
echocardiographic features of decreased systolic function (ejection fraction <
50%, Fractional shortening < 28% and enlarged left ventricular end-diastolic
dimension >+2 z score).
Exclusion criteria:

Congenital structural heart disease,Acquired valvular or coronary (e.g.
Kawasaki) heart disease, arrhythmias induced cardiomyopathy.

Myocardial dysfunction secondary to acute or chronic systemic disease (e.g.
major sepsis, renal failure, collagen vascular disease, Anthracycline toxicity
etc.)
All patients were subjected to the following:
1- Informed consents were obtained from the patients or their caring relatives,
after approval of the Ethical Committee of Cairo University.
2- Full history taking including: age, sex, duration of illness since diagnosis and
New York Heart Association (NYHA) score of heart failure.
3- General examination: weight, height, body surface area, heart rate and blood
pressure.
4- Imaging:
Echocardiographic examination was performed by pediatric cardiologists
familiar with TDI and 2D-STE for all cases in supine and left lateral positions using
General Electric (GE, Vivid-5) system with probe 3 or 5MHz (multi frequency
transducer) according to the age of patient. The ECG cable was connected to the
ultrasound machine to define and to time the cardiac cycle events; the beginning of
QRS complexes was used as a reference point.All patients were receiving anti- failure
medications in the form of Digoxin , Diuretics and angiotensin converting enzyme
inhibitors (ACEI).
Conventional Echo-Doppler measures:
1- M-mode measurements:

M-mode measurements were done at the level of the tips of the mitral valve
leaflets in the parasternal long-axis view of the left ventricle. Left ventricular
dimensions, Left ventricular fractional shortening (FS) and ejection fraction
(EF) were measured.

Tricuspid annular plan systolic excursion (TAPSE) at tricuspid annulus , as
well as MAPSE at lateral mitral annulus in apical 4 chamber view[6],[7](
figure 1, 2)
Figure 1: Illustrating measurement of
Figure 2: Illustrating measurement of
Tricuspid annular plan systolic excursion
Mitral annular plan systolic excursion
(TAPSE) at tricuspid annulus
MAPSE at lateral mitral annulus in apical
4 chamber view
2- Conventional Dopplermeasurements:

Doppler velocities were measured for the mitral and tricuspid valves using
apical four-chamber view; for the aortic valve using the apical 5 chamber
view, and for the pulmonary valve using parasternal short-axis view.The
following Doppler parameters were measured: Mitral peak E and A wave
velocities.

(Tei index) was calculated as the sum of isovolumic contraction time (ICT)
and isovolumic relaxation time (IRT) divided by ventricular ejection time (ET)
(Tei = ICT+IRT/ET).[8]For LV Tei index,pulsed wave Doppler with cursor
line placed midway between anterior mitral leaflet and left ventricular outflow
in the same cycle was used [9] while Tei index of RV was measured using this
formula ( a- b)/ b, a is the time between the end of A wave of tricuspid inflow
to the beginning of E wave of tricuspid inflow in the next cardiac cycle
obtained by PW Doppler at tricuspid inflow at apical 4chamber view , b is the
pulmonary ejection time obtained by PW Doppler at pulmonary valve in
parasternal short axis view. To reduce the effect of respiration on blood
velocities and as breath holding is not applicable in young children, three
cardiac cycles were recorded and the average velocity was measured.
Tissue Doppler imaging (TDI):
Pulsed wave Tissue Doppler imaging (PW-TDI) was done, care was taken to
increase the frame rate to be more than 180 frame/second ( by decreasing sector
width and depth) to improve temporal resolution; moreover care was taken also
to align the ultrasound beam parallel( interrogation angle not more than 15˚) to
the target wall during measurements. To reduce the effect of respiration on tissue
velocities and as breath holding is not applicable in young children, three cardiac
cycles were recorded and the average velocity and average times were
calculated. The following parameters were measured:

Systolic (S´) myocardial velocities at the basal segments of the lateral LV
wall, septal wall, and RV free wall.

Myocardial performance index (MPI) (Tei index): intervals measurements
were performed within one cardiac cycle. The Tei index was calculated as: Tei
= (ICT+IRT)/ET, for MPI of the RV using PW-TDI at tricuspid annulus, for
LV using PW-TDI at the lateral mitral annulus and basal septum [10],[11].
(figure 3)

IVA (isovolumic acceleration) at tricuspid annulus in apical 4 chamber view,
IVA= peak S1/acceleration time of S1 (time from the start of S1 to the peak of
S1) [5]. (figure 4).
Figure 3: illustrating calculation of myocardial
Figure 4:Illustrating calculation of isovolumic
performance index of Right ventricle by tissue
acceleration at tricuspid annulus in apical 4
doppler
chamber view
Statistical analysis:
Statistical analysis was performed using Statistical Package for Social Science (SPSS,
Chicago, Illinois, USA, version 19). Data were tested for normality using
Kolmogorov Smirnov and Shapiro tests, normally distributed data were expressed as
mean ±SD, non-normally distributed data were expressed as median and interquartile
range,categorical data were summarized as percentages. Comparisons between groups
were calculated using: nonparametric Mann-Whitney test for non-normally distributed
data, Student's T test for normally distributed data and Chi square test for categorical
data. Correlation between variables was evaluated using Pearson and Spearman
correlation coefficients. ROC curve analysis was performed for RV and LV
parameters. P-values < 0.05 were considered significant.
Results:
The control group was properly matched tocases as there was no significant difference
between them regarding age, sex, weight, height, body surface area, heart rate and
blood pressure (table 1).70% of patients were NYHA II, 55% of them had moderate
mitral regurgitation (table 2).
RV function:
The RV of the studied patients showed significant systolic dysfunction compared to
the control group as TAPSE, S' and IVA showed significant reduction [17(1521),11(8.5-13),2.4(1.7-3) versus 21(18-23),14(13-18),4.3(3.9-5.3). P=
0.015,<0.0001,<0.0001 respectively], while Doppler derived MPI and TDI derived
MPI showed significant prolongation in comparison to control group [0.4(0.280.60),0.48(0.43-0.52) versus 0.10(0.06-0.18),0.25 (0.22-0.27), p<0.0001respectively],
(figures 5 to 9),table 3).Moreover TAPSE, RV S', RV IVA were correlated toS' of
lateral wall of LV(r = 0.5,0.7,0.6 with P 0.0001,<0.0001, <0.0001respectively ) Also,
RV MPI by TDI was correlated to LV MPI by TDI (r =0.7 P <0.0001 ).
35
P value 0.015
30
25
20
15
10
5
TAPSE
cases
TAPSE
control
Figure 5: Box and whisker graph comparing
Figure 6: Box and whisker graph comparing S' of
Tricuspid annular plan systolic excursion (TAPSE)
RV in cases versus control with significant
at tricuspid annulus in cases versus control with
reduction in cases
significant reduction in cases
Figure 7: Box and whisker graph
Figure 8: Box and whisker graph comparing
comparingisovolumic acceleration at tricuspid
myocardial performance index of Right ventricle
annulus in cases versus control with significant
by tissue doppler in cases versus control with
reduction in cases
significant prolongation in cases
LV function:
The LV of the patients group showed marked systolic impairment compared to the
control group. The FS, EF, MAPSE, S' at basal septum, S' at LV LW, IVA at septum,
IVA at LVLW all showed significant reduction [22(16.5-24.7),44(35.5-47.7),7.5(510.5),5(4-5.7),4(3-6),1.2(0.9-1.5),0.9(0.6-1.4) versus 37(36-42),68(66-74),11(1013),8(7-9),9(8-10),3.3(2.5-4),2.8(2-3.3) respectively with p<0.0001]. The MPI of
patients developed significant prolongation in comparison to the control group for
both Doppler derived MPI [0.60(0.50-0.80) versus 0.18 (0.11-0.3), p<0.0001] and
TDI derived MPI [0.64(0.60-0.80) versus0.31 (0.27-0.35), p<0.0001], (table 4).
ROC curve analysis:
ROC curve analysis was done for RV parameters , it revealed that the RV parameters
derived by tissue Doppler especially the MPI and IVA showed higher sensitivity and
specificity (for TDI derived MPI: sensitivity=100%,specificity=92.6%, AUC=0.98
and cut-off value >0.29.For IVA: sensitivity =80%, specificity=92.6, AUC=0.9 and
cut-off value ≤ 3)( figure 9 and 10) .
IVA RV
RV MPI by TDI
100
Cut-off value >0.29
Sensitivity100%
specificity 92.6%
80
Sensitivity
80
Sensitivity
100
60
40
Cut-off value<3
sensitivity 80%
specificity 92.6%
60
40
20
20
0
0
0
20
40
60
80
0
100
20
40
60
80
100
100-Specificity
100-Specificity
Figure 9: illustrating ROC curve of
Figure 10 Illustrating ROC curve
myocardial performance index of Right
ofisovolumic acceleration at tricuspid
ventricle by tissue doppler
annulus
Table -1: Demographic data of the studied groups
Age ( years)
Weight ( Kg)
Height (cm)
BSA (m²)
Heart rate
SBP
Patients
(Mean ± SD)
n= 20
5.9 ± 3.7
18.6 ± 9.4
107. 1 ± 20.15
0.73 ± 0.25
103.9 ± 20
101.1 ± 12.7
Control
(Mean ± SD)
n= 27
6.1 ± 4.13
21.5 ± 13.3
117.14 ± 22.7
0.8 ± 0.3
110±18
94.2±12.3
P value
0.89
0.55
0.14
0.55
0.743
0.235
DBP
58.50 ± 13.27
59 ± 11.8
0.354
Sex
12(60%)
17 (63%)
0.8*
 Male n (%)
8 (40%)
10 (37%)
 Female n (%)
*: Chi square test was used, Kg: kilogram, cm: centimeter, m²: square meter, BSA: body
surface area, SBP: systolic blood pressure, DBP: diastolic blood pressure.
Table 2: Patients' characteristics
character
value
Duration since diagnosis ( months) Mean ±SD
51.35± 41.11
NYHA score

NYHA I n (%)
2(10%)

NYHA II n (%)
14(70%)

NYHA III n (%)
4(20%)
Duration of QRS (m.sec)
96±22.7
Degree of MR

Grade I n (%)
9(45%)

Grade II n (%)
11(55%)
NYHA: New York Heart Association, MR: mitral regurgitation, m.sec: millisecond.
Table 3: Right ventricular parameters of the studied groups
Patients
Control
P value
n= 20
n= 27
17(15-21)
21(18-23)
0.015
TAPSE (mm) ‡
11(8.5-13)
14(13-18)
<0.0001
S‫ ׳‬RV (cm/sec) ‡
2.4(1.7-3)
4.3(3.9-5.3)
<0.0001
IVA RV (m/sec²)‡
0.41(0.28-0.60)
0.10(0.06-0.18)
<0.0001
RV MPI by Doppler‡
0.48(0.43-0.52)
0.25 (0.22-0.27)
<0.0001
MPI by TDI‡
*: data are expressed as mean ±SD, ‡ Data are expressed as median andinterquartile range (25th, 75th
percentile), TAPSE: tricuspid annular plan systolic excursion, IVA: Isovolumeic acceleration, LW:
lateral wall, RV: right ventricle, MPI: myocardial performance index, TDI: tissue Doppler imaging,
cm: centimeter, cm/sec: centimeter per second, m/sec²: meter per second².
Table 4: Left ventricular parameters of the studied groups
Parameters
M- Mode parameters:
 FS (%) *
 EF (%) *
 LA diameter (cm) *
 LVDD (cm) ‡
 MAPSE septum( mm) *
 MAPSE LV LW (mm) *
TDI systolic parameters:
 S' septum (cm/sec) *
 S ' LV LW (cm/sec) *
 IVA septum(m/sec²)*
 IVA LV LW (m/sec²)*
Patients (n=20)
Control (n= 27)
P value
22(16.5-24.7)
44(35.5-47.7)
2.85(2.6-3.5)
5 (4.7-5.6)
6.5(5-8.7)
7.5(5-10.5)
37(36-42)
68(66-74)
2.2(2-2.40)
3.5(3.1-3.8)
11(10-12)
11(10-13)
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
5(4-5.7)
4(3-6)
1.2(0.9-1.5)
0.9(0.6-1.4)
8(7-9)
9(8-10)
3.3(2.5-4)
2.8(2-3.3)
<0.0001
<0.0001
<0.0001
<0.0001
Tei index:


MPI by Doppler*
MPI by TDI *
0.60(0.50-0.70)
0.18(0.11-0.3)
<0.0001
0.64(0.60-0.80)
0.31(0.27-0.35)
<0.0001
‡: data are expressed as mean ±SD, *: Data are expressed as median and interquartile range
(25th, 75th percentile), FS: fractional shortening, EF: ejection fraction, LVDD: left ventricular
diastolic diameter, LAD: left atrial dimension, MAPSE: mitral annular plane systolic
excursion, IVA: isovolumeic acceleration, LV: left ventricle , LW lateral wall, cm:
centimeter, cm/sec: centimeter per second, m/sec²: meter per second², MPI: myocardial
performance index, TDI: tissue Doppler imaging.
Table 5: Correlation between LV and RV parameters
Correlated parameters
Correlation coefficient
P value
0.6
0.55
0.7
0.6
0.7
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
0.7
0.7
0.44
0.6
0.6
<0.0001
<0.0001
0.002
<0.0001
<0.0001
S' RV
LV systolic parameters





FS
EF
MAPSE LW
IVA LV LW
S' LV LW
IVA RV





FS
EF
MAPSE LW
IVA LV LW
S' LV LW
TAPSE
0.55
0.0001
 MAPSE LW
0.44
0.002
 IVA LV LW
0.5
0.0001
 S' LV LW
RV MPI by TDI
0.7
<0.0001
 LV MPI at LW by TDI
FS: fractional shortening, TAPSE: tricuspid annular plane systolic excursion, RV: right
ventricle, MAPSE: mitral annular plane systolic excursion, LV: left ventricle, LW: lateral
wall, TDI: tissue Doppler imaging.
Table 6: ROC curve analysis of RV and LV parameters
TAPSE
S' RV
IVA RV
MPI(TDI)
Sensitivity
(%)
55
70
80
100
Specificity
(%)
88.9
88.9
92.6
92.6
Cut- off
value
≤17
≤12
≤3
>0.29
AUC (95% confidence
interval)
0.74(0.62-0.84)
0.88(0.76-0.94)
0.91(0.82-0.97)
0.98(0.88-0.99)
P value
0.014
<0.0001
<0.0001
<0.0001
TAPSE: tricuspid annular plane systolic excursion, RV: right ventricle, IVA: isovolumeic acceleration,
MPI: myocardial performance index, TDI: tissue Doppler imaging, AUC: area under curve.
Discussion:
Dilated cardiomyopathy is characterized by marked left ventricular systolic
dysfunction, that is easily assessed by conventional echocardiography namely FS and
EF.Dilated cardiomyopathy is the most common form of cardiomyopathy in children.
The most common cause of dilated cardiomyopathy is idiopathic (>60%), followed by
familial cardiomyopathy, active myocarditis, and other causes.[1].The RV is usually
forgotten during echocardiographic assessment of patients with dilated
cardiomyopathy due to its complex shape that not fit with any geometrical
assumption, so the majority of the studies were focusing on LV assessment, in this
study we aimed to study the systolic function of the RV beside the LV function and
ventricular interaction using TDI combining it with conventional echocardiographic
parameters.
Patient characteristics:
There was no significant change between the cases and control regardingage, sex,
weight and body surface area which mean that the two groups were well matched,
even the heart rate didn’t show significant change between patients and control
despite >90% of patient were NYHAII&NYHAIIIand 55% of them had mitral
regurge grade II, this may be due to that all patients were receiving Digoxin that
known to delay atrioventricular conduction and hence the heart rate beside other antifailure medications (Diuretics, ACE Is).
Right ventricular function of the studied groups:
The RV of the studied patients showed significant systolic dysfunction compared to
control, as TAPSE, S' and IVA showed significant decrease, more over they were
significantly correlated toS'of the LV, this may be due to theclosely linked LV and
RV functions. The RV has mainly transverse muscle fibers in its free wall beside it
shares oblique fibers in the interventricular septum with the left ventricle (LV) so LV
contraction augments RV contraction, a conditiondefined as systolic ventricular
interaction. In dilated cardiomyopathy the impaired systolic and diastolic functions of
LV beside mitral regurgitation lead to pulmonary venous congestion and pulmonary
hypertension increasing the RV after load, and making right ventricular
contractionmore dependent on the oblique septal fibers which are mechanicallymore
efficient than the free wall transverse fibers, and as known that the global LV
deformation is markedly diminished including the interventricular septum containing
these oblique fibers, thisleads to decreased systolic ventricular interaction, and
reduction of RV deformation. Moreover, as the LV acquires more spherical shape, the
septal fibers become less oblique decreasing their mechanical efficiency with more
and more deterioration of RV deformation, this explanation was supported by
Schwarz and his colleagues who explained relation between RV and LV
dysfunction[3].
As the MPI reflects both systolic and diastolic functions of the ventricle which are
affected in our patients so the MPI of RV either measured by TDI or conventional
Doppler was significantly increased in cases compared to control group. Previous
studies reported similar results[3] ,[12].Interestingly the TDI derived MPI of RV
could discriminate between patients and normal individuals with a very high
sensitivity (100%) and specificity (92.6%) with cut –off value >0.29 and showed
significant correlation to the LVMPI by TDI, so it can be used in routine
echocardiographic evaluation in these patients.
Most of the RV parameters like TAPSE, S' are load dependent varying with
different loading conditions and with respiration ,unlike IVA that is load independent
.IVA in our study was significantly correlated to systolic parameters of LV with
higher sensitivity (80%) and specificity(92.6%), so it can be used in assessment of RV
systolic function.
LV dysfunction:
The left ventricle of the studied patient showed significant dilatation with
deterioration of systolic function assessed by conventional parameters like FS,EFand
MAPSE, MAPSE represents the longitudinal shortening of LV and could be used as
an easy sensitive tool of LV systolic function.[13],[14],[15]. TDI S' velocity of LV at
both septum and lateral walls as well as IVA, also showed significant reduction in
patient group and strongly correlated to systolic parameters assessed byconventional
parameters like FS,EFand MAPSE.
Conclusion:
In pediatric patients with idiopathic dilated cardiomyopathy, not only the LV that
becomes affected but also the RV, which develops significant systolic dysfunction
(detected mainly by TDI) even if not involved in disease process, this might be due to
ventricular interaction. RV assessment using TDI and LV assessment using TDI
should be a part of routine echocardiographic evaluation in pediatric patients with
dilated cardiomyopathy.
Limitation of the study:
The main limitations of this study were that all patients were receiving anti failure
treatment so we couldn’t study the effect of treatment on cardiac function, moreover
most of patients hadn't tricuspid regurgitation or the regurgitation jet had poor signal,
so evaluation of pulmonary arterial pressure was difficult. The N-terminal-pro brain
natriuretic peptide (NT-pro-BNP) wasn’t t measured in this study and might be of
value to support the echocardiographic findings.
References
1.
Park MK (2008) Park’s Pediatric Cardiology for Practitioners, 5th ed. 261.
2.
Luk a, Ahn E, Soor GS, Butany J (2009) Dilated cardiomyopathy: a review. J
Clin Pathol 62:219–225. doi: 10.1136/jcp.2008.060731
3.
Schwarz K, Singh S, Dawson D, Frenneaux MP (2013) Right ventricular
function in left ventricular disease: pathophysiology and implications. Heart
Lung Circ 22:507–11. doi: 10.1016/j.hlc.2013.03.072
4.
Kukulski T, Hübbert L, Arnold M, et al. (2000) Normal Regional Right
Ventricular Function and Its Change with Age: A Doppler Myocardial Imaging
Study. J Am Soc Echocardiogr 13:194–204. doi: 10.1067/mje.2000.103106
5.
Vogel M (2002) Validation of Myocardial Acceleration During Isovolumic
Contraction as a Novel Noninvasive Index of Right Ventricular Contractility:
Comparison With Ventricular Pressure-Volume Relations in an Animal Model.
Circulation 105:1693–1699. doi: 10.1161/01.CIR.0000013773.67850.BA
6.
Ghio S, Recusani F, Klersy C, et al. (2000) Prognostic usefulness of the
tricuspid annular plane systolic excursion in patients with congestive heart
failure secondary to idiopathic or ischemic dilated cardiomyopathy. Am J
Cardiol 85:837–842. doi: 10.1016/S0002-9149(99)00877-2
7.
López-Candales A, Rajagopalan N, Gulyasy B, et al. (2007) Comparative
echocardiographic analysis of mitral and tricuspid annular motion: Differences
explained with proposed anatomic-structural correlates. Echocardiography
24:353–359. doi: 10.1111/j.1540-8175.2006.00408.x
8.
Tei C, Dujardin KS, Hodge DO, et al. (1996) Doppler echocardiographic index
for assessment of global right ventricular function. J Am Soc Echocardiogr
9:838–847. doi: 10.1016/S0894-7317(96)90476-9
9.
Quiñones M a., Otto CM, Stoddard M, et al. (2002) Recommendations for
quantification of Doppler echocardiography: A report from the Doppler
quantification task force of the nomenclature and standards committee of the
American Society of Echocardiography. J Am Soc Echocardiogr 15:167–184.
doi: 10.1067/mje.2002.120202
10.
Rojo EC, Rodrigo JL, Pérez de Isla L, et al. (2006) Disagreement between
tissue Doppler imaging and conventional pulsed wave Doppler in the
measurement of myocardial performance index. Eur J Echocardiogr 7:356–364.
doi: 10.1016/j.euje.2005.08.004
11.
Ayhan SS, Özdemir K, Kayrak M, et al. (2012) The evaluation of doxorubicininduced cardiotoxicity: comparison of Doppler and tissue Doppler-derived
myocardial performance index. Cardiol J 19:363–8. doi: 10.5603/CJ.2012.0066
12.
Groner A, Yau J, Lytrivi ID, et al. (2013) The role of right ventricular function
in paediatric idiopathic dilated cardiomyopathy. Cardiol Young 23:409–15.
doi: 10.1017/S104795111200114X
13.
Bergenzaun L, Öhlin H, Gudmundsson P, et al. (2013) Mitral annular plane
systolic excursion (MAPSE) in shock: a valuable echocardiographic parameter
in intensive care patients. Cardiovasc Ultrasound 11:16. doi: 10.1186/14767120-11-16
14.
Koestenberger M, Nagel B, Ravekes W, et al. (2012) Left ventricular long-axis
function: reference values of the mitral annular plane systolic excursion in 558
healthy children and calculation of z-score values. Am Heart J 164:125–31.
doi: 10.1016/j.ahj.2012.05.004
15.
Taşolar H1, Mete T, Çetin M, Altun B, Ballı M, Bayramoğlu A OY (2014)
Mitral annular plane systolic excursion in the assessment of left ventricular
diastolic dysfunction in obese adults. Anadolu Kardiyol Derg. doi:
10.5152/akd.2014.5561