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Echocardiographic longitudinal systolic displacement indices of right ventricular systolic function in hypoplastic left heart syndrome Supaluck Kanjanauthai MD, Vivian Cui MD, David Gamboa MD, David A Roberson MD The Heart Institute for Children ,Advocate Hope Children’s Hospital, Oak Lawn, IL
Background
Echo parameters
Method
Patients
N = 68
Right ventricular ejection fraction ( RVEF) calculated by using the formula
RVEF = End Diastolic volume ‐ End Systolic Volume x 100%
Hope
Children’s
Hospital
Results
In Hypoplastic left heart syndrome ( HLHS ), left ventricle is hypoplastic ,therefore, “Right ventricle” ™ Fractional area change (FAC): measured in apical 4 chamber view
becomes a systemic single ventricle. Right ventricular function is an important determinant of clinical status in HLH patients. Unfortunately, a proportion of patients with HLHS will develop clinically significant RV dysfunction overtime. Echocardiographic assessment of RV function remains challenging because of the RV‐FAC = End Diastolic area ‐ End Systolic area x 100 %
complex geometry of the right ventricle. End Diastolic area
Contrary to the left ventricle (LV), in which both longitudinal and circumferential shortening play an important role in ventricular contraction, for the right ventricle (RV) longitudinal fiber shortening is the major component. Prior studies of LV systolic function in children have shown that mitral annular displacement has a linear relation with ejection fraction (EF). Therefore, we hypothesized that measuring ™ TDI derived Peak S wave velocity (S’) , IVCT and Tei index measured in apical 4 chamber view
tricuspid and pulmonary annular systolic displacement towards the RV apex in hypoplastic left heart syndrome (HLHS) would be useful to evaluate RV systolic function
Peak S wave velocity (S’)
RV Tei index = a – b
Objective
IVCT
b
To develop clinically applicable and quantitative echocardiographic parameters to assess RV systolic function in HLHS patient.
Total of 68 patients , divided into 3 groups, as shown in the flow chart below
Pediatric
Echo Lab
™ Pulsed wave tissue Doppler imaging tricuspid annular displacement index (Dx) calculated as the S wave velocity time integral divided by the end diastolic distance from the TV annulus to the RV apex
Table 1.
Clinical Features
NL control
HLH
RVEF≥50%
HLH
RVEF<50%
27
21
20
-
Male/Female
14/13
11/10
8/12
-
Age (months)
22.8±41.6(8.0)
19.3±44.1(9.6)
29.9±43.7(9.8)
0.746
0.39±0.32
133±25
0.37±0.33
131±29
0.46±0.28
122±29
0.656
0.367
NL control
HLH
RVEF≥50%
HLH
RVEF<50%
P value
RVEF (%)
61.0±4.8
54.4±2.9 a
32.8±12.9 b, c
<0.001
Clinical Features number
BSA (m2)
HR (bmp)
Table 2.
Parameters measured
in each groups including
three new parameters
Displacement index(Dx),
D‐TV and D‐PV
a, P<0.05 compared to normal control group;
b, P<0.01 compared to normal control group; c, P<0.01 compared to HLH RVEF≥50% group
Parameters
P value
FAC (%)
45.8±6.8
38.1±5.9 b
22.0±11.3 b, c
<0.001
S’ velocity (cm/s)
9.2±4.0
7.0±1.3 a
4.4±1.2 b, c
<0.001
IVCT (ms)
30±10
37±14
69±15 b, c
<0.001
Tei index
0.25±0.05
0.31±0.07 b
0.56±0.10 b, c
<0.001
TV-DX (%)
33.5±7.7
27.4±5.0
14.3±4.0
<0.001
D-TV (%)
23.9±6.5
17.2±3.4 b
9.2±3.8 b, c
<0.001
D-PV (%)
16.1±4.6
16.7±5.1
8.7±3.2 b, c
<0.001
RVEF and 3 new parameters
b
b, c
ROC curve
End Diastolic volume
RV volume = 2/3 x height x area of RV
Dx (%)= S‐VTI x 100 %
L*
*L= distance from annulus to apex at end‐diastole
* For HLHS patients from all and various stages
of palliation were included
All the patients had 2D Echo which was obtained by Phillips i33 machine and using S‐5 /speckle probe. Images were obtained including 2D pictures and tissue doppler imaging (TDI). Xcelera software (TMAD) was utilized in order to measure longitudinal displacement of tricuspid valve and pulmonary valve.
The echo parameters that we collected from all patients included the following : ™ Fractional area change of RV ™ TDI derived TV Displacement index (Dx‐TV)†
™ TDI derived Peak S wave velocity (S’)
™ TMAD tricuspid valve (TMAD‐TV) †
™ TDI derived Isovolemic contraction time (IVCT)
™ TMAD pulmonary valve (TMAD‐PV) †
™ TDI derived Tei index † 3 new parameters ; never studied before in HLHS
RVEF vs TV‐Dx
™ Speckle tracking 2‐D echo derived systolic longitudinal displacement of the tricuspid valve annulus (D‐TV)
was measured in the apical view and pulmonary valve annulus systolic displacement (D‐PV) was measured in the subcostal saggital view using a tissue motion annular displacement program (TMAD, Philips Ultrasound).
ROC
Cut-off
Point
Sensitivity
TDI TV-DX
22.0%
94.7%
93.2%
D - TV
14.5%
95.2%
93.6%
D - PV
13.0%
84.2%
75.8%
Specificity
RVEF vs D‐TV
Conclusions
RVEF vs D‐PV
TMAD tricuspid valve Normal heart TMAD tricuspid valve
HLHS
TMAD pulmonary valve
Normal heart
TMAD pulmonary valve
HLHS
TV DX, D‐TV, D‐PV: ™ Correlate with EF and other parameters of RV
systolic function in normals and HLH
™ High sensitivity and specificity
™ Useful to quantify RV systolic function in HLH