Download The effect of septoplasty on pulmonary artery pressure and

Eur Arch Otorhinolaryngol
DOI 10.1007/s00405-016-4042-1
RHINOLOGY
The effect of septoplasty on pulmonary artery pressure and right
ventricular function in nasal septum deviation
Gulay Ozkececi1 • Onder Akci1 • Abdulkadir Bucak2 • Sahin Ulu2 •
Zafer Yalım1 • Abdullah Aycicek2 • Ersel Onrat1 • Alaettin Avsar1
Received: 24 February 2016 / Accepted: 7 April 2016
Ó Springer-Verlag Berlin Heidelberg 2016
Abstract Nasal septum deviation (NSD) can cause
obstruction of the upper airway, which may lead to
increased pulmonary artery pressure (PAP) and right ventricle dysfunction. The aim of the present study was to
evaluate the effect of septoplasty on right ventricular
function and mean PAP of patients with marked NSD. 25
patients with marked NSD (mean age = 31.8 ± 12.3 years)
and
27
healthy
volunteers
(mean
age = 34.5 ± 10.8 years) were enrolled. Echocardiography was performed for all subjects and right ventricular
function and mean PAP were evaluated before and
3 months after septoplasty. Tricuspid annular plane systolic excursion (TAPSE) and tricuspid annulus early diastolic myocardial velocity (E0 ) were significantly lower in
patients with NSD than control subjects, while right ventricle myocardial performance index (RVMPI) and mean
PAP were significantly higher (respectively, p = 0.006,
0.037, 0.049, 0.046). When preoperative and postoperative
findings were compared, the mean PAP decreased whereas
TAPSE increased significantly (respectively, p = 0.007,
0.03). The results of the present study demonstrated that
mean PAP increased and right ventricular function worsened in patients with NSD. However, mean PAP decreased
and right ventricular function tended to recover after
septoplasty.
Keywords Right ventricular function Pulmonary artery
pressure Septoplasty Nasal septum deviation
& Gulay Ozkececi
[email protected]
Materials and methods
1
Department of Cardiology, School of Medicine, Afyon
Kocatepe University, Afyonkarahisar 03200, Turkey
Study population
2
Department of Otorhinolaryngology, School of Medicine,
Afyon Kocatepe University, Afyonkarahisar 03200, Turkey
This study was conducted between January 2014 and July
2015 in our Cardiology and Otorhinolaryngology
Introduction
The nasal septum consists of bone and cartilage. It has a
significant effect on the function of the nose and upper
airway. Septum deformity is a common disorder in the
general population and septum deviation is one of these
disorders. Genetics, environmental factors and trauma are
important etiological factors that play a role in the development of nasal septum deviation (NSD) [1].
NSD may cause obstructions of the upper airway, such
as sleep apnea, adenoid vegetation, hypertrophied tonsils
and nasal polyposis. It has been reported that chronic upper
airway obstruction can give rise to pulmonary hypertension
and right ventricle failure in infants and children due to
chronic alveolar hypoventilation [2–5].
Previous studies have shown that mean pulmonary
artery pressure (PAP) increases compared to the normal
population in patients with markedly deviated septum [6, 7]
and mean PAP decreases after septoplasty [6]. However,
right ventricular function has not yet been evaluated in
these patients. In the present study, we aimed to investigate
the effect of septoplasty on right ventricular function and
pulmonary artery pressure in patients with NSD.
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Eur Arch Otorhinolaryngol
Departments. The Ethics Committee of the Afyon Kocatepe University School of Medicine approved this study.
All patients and control subjects gave informed consent
prior to inclusion.
25 patients who were diagnosed with NSD with anterior
rhinoscopy, nasal endoscopy and acoustic rhinometry
findings and who had septoplasty planned and 28 healthy
controls were included in the study. Diseases causing nasal
obstruction, such as nasal concha hypertrophy, bullous
concha, allergic rhinitis, adenoid hypertrophy and subjects
with hypertension, ischemic heart disease, heart failure,
valvular heart disease, congenital heart disease, renal disease, chronic inflammatory disease, sleep apnea, chronic
obstructive pulmonary disease, interstitial lung disease,
asthma, pulmonary arterial hypertension, chronic thromboembolic pulmonary hypertension, portal hypertension,
chronic hemolytic anemia, pulmonary veno-occlusive disease or smoking were excluded from the study.
Systolic and diastolic blood pressure of all patients and
control subjects were measured on the right arm with a mercury
manometer. Body weight and height were also recorded. Body
mass index (BMI) was calculated as weight in kilograms
divided by the square of height in meters (kg/m2).
Acoustic rhinometry measurements
Acoustic rhinometry (Rhinometrics, Denmark) was performed for all subjects after cleaning the nasal cavity.
Measurements were obtained 10 min after applying the
nasal decongestant xylometazoline (0.01 %) in a relatively
soundless room at normal temperature and humidity to
eliminate mucosal edema or concha hypertrophy. Minimal
cross-sectional area and nasal cavity volume in the first
2 cm and between the 2nd and 5th cm of the nasal cavity
were separately recorded for the deviated and non-deviated
side of the nose.
Echocardiographic assessment
Transthoracic echocardiography was performed preoperatively for all patients and controls by a cardiologist who did
not have any information about clinical features of the
patients. Echocardiographic evaluation was performed using
a Phillips HD 11 XE (Germany) with 3 MHz phased-array
transducer according to the suggestions of the American
Society of Echocardiography [8]. Two-dimensional and
M-mode recordings of subjects were obtained from
parasternal long axis view in the left lateral decubitus position. Tissue Doppler echocardiography (TDE) and conventional Doppler recordings were obtained from the apical
four-chamber view in the supine position. All measurements
were taken in three consecutive cycles and average values
were calculated. M-mode recordings were taken at a speed of
123
100 mm/s. Left and right ventricle diameter and right atrium
diameter were measured and left ventricular ejection fraction was calculated. Acceleration time of pulmonary flow
(PAcT) was measured from the Doppler flow trace obtained
from the parasternal short-axis view using pulsed Doppler
ultrasound with the sample volume placed in the pulmonary
artery just 1 cm distal to the pulmonary valve annulus. PAcT
was obtained from a time measurement from onset of pulmonary arterial flow to the peak flow velocity [9]. The Mean
PAP was calculated according to the Mahan formula (mean
PAP = 90 - (0.62 9 PAcT) [10]. Tissue Doppler images
of the right ventricle were acquired from the apical fourchamber view using a sample volume placed at the lateral
wall of the tricuspid annulus. Peak systolic velocity (S), peak
early diastolic velocity (E0 ) and peak late diastolic velocity
(A0 ) were measured. S duration was measured as ejection
time (ET), the time between the end of the S and the
beginning of the E0 as isovolumetric relaxation time (IRT)
and the time between the end of A0 and the beginning of S as
isovolumetric contraction time (ICT). The right ventricle
Tei-index or myocardial performance index (RVMPI) was
determined as ICT and IRT divided by ET.
The tricuspid annular plane systolic excursion (TAPSE)
was obtained from the apical four-chamber view with the
M mode. The M-mode cursor was situated at the lateral
wall of the tricuspid valve and TAPSE was calculated in
centimeters.
In the postoperative third month, all echocardiographic
measurements were repeated using the same echocardiography device by the same cardiologist for the patient group.
Statistical analysis
Statistical analyses were performed using SPSS version 20.0
(IBM Co., Armonk, NY, USA). Data are expressed as
mean ± SD, medians (interquartile range), or number (%).
Assumptions of normal distributions were tested using the
Kolmogorov–Smirnov test. Categorical variables between
groups were compared using a Chi-square test. Differences
between the patient group and control subjects were tested
using independent sample t test for parametric variables and
Mann–Whitney U test for nonparametric variables. Preoperative and postoperative data were compared with Student’s
t test for parametric variables and Wilcoxon signed rank test
for nonparametric variables in the patient group. An alpha
level of p \ 0.05 was accepted as significant.
Results
The study subjects consisted of 25 diagnosed patients with
NSD who had septoplasty planned (mean age
31.8 ± 12.3 years) and 26 healthy controls (mean
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Table 1 Baseline characteristics of study subjects
Variables
Age, years
Gender (F/M)
BMI (kg/m
2)
Patients with NSD
(n = 25)
Controls
(n = 28)
p
31.8 ± 12.3
34.5 ± 10.8
0.4*
3/22
5/23
0.4
24.9 ± 4.4
26.2 ± 3.2
Table 2 Comparison of echocardiographic parameters in patients
with NSD and control subjects
Variables
Patients with NSD
(n = 25)
Controls
(n = 28)
p
LVDD (mm)
46.6 ± 4.1
46.9 ± 4.3
0.7*
0.2*
LVSD (mm)
31 (21–35)
30 (25–36)
0.25**
EF (%)
RADD (mm)
63.6 ± 4.5
36 (26–40)
64.8 ± 5.1
37.5 (31–46)
0.36*
0.4**
SBP (mmHg)
120 (90–140)
120 (100–130)
0.27**
DBP (mmHg)
75 (60–90)
70 (60–80)
0.8**
Numerical variables were presented as the mean ± standard deviation
and median (interquartile range). P \ 0.05, significant
RVDD (mm)
25 ± 4.3
23.9 ± 3.8
0.3*
TAPSE (cm)
2.42 ± 0.39
2.76 ± 0.45
0.006*
NSD nasal septum deviation, F female, M male, BMI body mass
index, SBP systolic blood pressure, DBP diastolic blood pressure
RVMPI
0.47 ± 0.11
0.41 ± 0.07
0.049*
Mean PAP (mmHg)
22.66 ± 10.3
17.72 ± 6.4
0.046*
S(cm/s)
14.3 ± 2.5
15 ± 2.9
0.7*
* Independent t test,
were used
Chi-square test and ** Mann–Whitney U test
age = 34.5 ± 10.8 years). There were no differences
between the groups in terms of age, gender, BMI, systolic
blood pressure and diastolic blood pressure. Demographics
and blood pressure levels are depicted in Table 1.
There were no significant differences with regard to the
left ventricle diastolic and systolic diameter, left ventricle
ejection fraction, right atrium and ventricle diastolic
diameter, tricuspid S velocity and tricuspid A0 velocity.
TAPSE and tricuspid E0 velocity were significantly lower
in patients with NSD than control subjects, while RVMPI
and mean PAP were significantly higher (respectively,
p = 0.006, 0.037, 0.049, 0.046) (Table 2).
When comparing preoperative and postoperative findings in terms of right ventricular function parameters and
mean PAP, right ventricle diastolic diameter and mean
PAP decreased, whereas TAPSE increased significantly
(respectively, p = 0.02, 0.007, 0.03) (Table 3, Figs. 1, 2).
In addition, we also compared the data of the control
with postoperative data of patients. There were no significant differences between postoperative data of patients
and healthy controls in terms of TAPSE, RVMPI, mean
PAP and tricuspid E0 velocity (Table 4).
Discussion
Findings from the present study showed that mean PAP and
RVMPI increased, while TAPSE and tricuspid E0 velocity
decreased among patients with NSD as compared to control subjects. TAPSE increased, whereas mean PAP
decreased after septoplasty in patients with NSD. However,
although MPI and tissue Doppler parameters did not
change, postoperatively, there were no significant differences between controls and postoperative findings of
patients in terms of these parameters. According to our
knowledge, this is the first study to investigate right
0
E (cm/s)
13.9 ± 3.3
16.6 ± 4.6
0.037*
A0 (cm/s)
14.4 ± 5.4
14.9 ± 4.5
0.7*
Bold represents statistically signicant p values. Numerical variables
were presented as the mean ± standard deviation and median (interquartile range). p \ 0.05, significant
LVDD left ventricle diastolic diamater, LVSD left ventricle systolic
diamater, EF ejection fraction, RADD right atrium diastolic diameter,
RVDD right ventricle diastolic diameter, TAPSE tricuspid annular
plane systolic excursion, RVMPI right ventricle myocardial performance index, PAP pulmonary artery pressure, S tricuspid annulus
systolic myocardial velocity, E0 tricuspid annulus early diastolic
myocardial velocity, A0 tricuspid anulus late diastolic myocardial
velocity
* Independent t test and ** Mann–Whitney U test were used
ventricular systolic and diastolic functions in patients with
NSD.
Chronic upper airway obstruction may cause hypoxia,
hypercarbia and respiratory acidosis. Respiratory acidosis
and hypoxia may cause reversible or irreversible changes
by inducing vasoconstriction in the pulmonary vascular
bed. Increased pulmonary vascular resistance leads to
pulmonary hypertension, right ventricular dysfunction and
eventually cor pulmonale. Previous studies reported that
upper airway obstruction such as adenotonsillar hypertrophy and sleep apnea result in pulmonary hypertension and
cor pulmonale [2, 11–13].
NSD is a frequent cause of obstruction of the upper airways. Hassanpour et al. [7] noted that mean PAP was higher in
patients with markedly deviated septum who were undergoing
septorhinoplasty compared to healthy controls. Fidan et al. [6]
found that mean PAP increases in patients with a markedly
deviated septum; however, it decreases after septoplasty. Our
findings are compatible with the results of previous studies.
However, the superiority of the present study is in the
assessment of right ventricular function.
Right ventricular functions are a major determinant of
prognosis and symptoms in patients with pulmonary
hypertension [14]. Right ventricular evaluation is difficult
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Table 3 Comparison of right
ventricle echocardiographic
findings in the preoperative and
postoperative periods
Variables
Preoperative findings
(n = 25)
Postoperative findings
(n = 25)
p
RADD (mm)
36 (26–40)
38 (29–42)
0.09**
RVDD (mm)
25 ± 4.3
24 ± 4.4
0.02*
RVMPI
0.47 ± 0.11
0.45 ± 0.1
0.35*
S (cm/s)
14 (9–21)
14 (9–22)
0.6**
E0 (cm/s)
13.9 ± 3.3
15 ± 3.9
0.23*
A0 (cm/s)
14.4 ± 5.4
14.1 ± 5.4
0.77*
Bold represents statistically signicant p values. Numerical variables were presented as the mean ± standard
deviation and median (interquartile range). p \ 0.05, significant
RVDD right ventricle diastolic diameter, RVMPI right ventricle myocardial performance index, S tricuspid
annulus systolic myocardial velocity, E0 tricuspid annulus early diastolic myocardial velocity, A0 tricuspid
anulus late diastolic myocardial velocity
* Student’s t test and ** Wilcoxon signed rank test were used
Fig. 1 Mean PAP in patients with nasal septum deviation (PAP
pulmonary artery pressure)
Fig. 2 TAPSE in patients with nasal septum deviation (TAPSE
tricuspid annular plane systolic excursion)
with two-dimensional echocardiography and the correct
results cannot always be obtained since it is a complex
anatomical structure. Therefore, quantitative methods were
developed for assessing right ventricular systolic and diastolic functions. TAPSE evaluates systolic function of the
right ventricle and this decreases with right ventricle systolic
123
dysfunction [15]. Çetin et al. [15] reported a TAPSE
decrease in children with adenotonsillar hypertrophy who
had undergone adenoidectomy/adenotonsillectomy and this
increased postoperatively. All these findings are compatible
with the results of this study. We also found that there was a
decrease in TAPSE values in NSD compared with the control. In addition, these impaired TAPSE values in patients
with NSD improved significantly at 3 months after septoplasty when compared with the preoperative period.
Diastolic function tends to be impaired in the early
stages before systolic function changes [16]. TDE is a
commonly used method for the evaluation of diastolic
dysfunction. E0 velocity is a strong and sensitive marker for
estimating diastolic function [17]. Moustapha et al. [18]
showed that tricuspid E0 velocity is lower in pulmonary
hypertensive patients than in healthy controls. Previous
studies noted that tricuspid E0 velocity decreases in upper
airway obstruction such as adenotonsillar hypertrophy.
However, it significantly improves after the operation [19,
20]. We also determined that tricuspid E0 velocity declined
in patients with NSD compared to controls. Even though
tricuspid E velocity improved, postoperatively in the present study we did not find a statistically significant increase
in E0 velocity after the operation, as in Moustapha’s study.
However, there were no significant differences between
postoperative and control in terms of E velocity. Small
sample size may have led to this result in our study.
MPI assesses both systolic and diastolic function [21].
MPI has high influence and sensitivity in determining right
ventricular function [22]. Blancherd et al. reported a correlation between right ventricle MPI and right heart
hemodynamics obtained by right cardiac catheterization
[23]. Right ventricle MPI can be calculated by pulsed-wave
TDE placed in the tricuspid valve lateral annulus. Duman
et al. showed that RVMPI increases in patients with adenotonsillar hypertrophy compared to controls and declines
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Table 4 Comparison of
echocardiographic parameters
in the postoperative data of
patients with NSD and control
subjects
Variables
Postoperative findings of patients with NSD
n = 25
Findings of controls
n = 28
p
TAPSE (cm)
2.55 ± 0.39
2.76 ± 0.45
0.15
RVMPI
0.45 ± 0.1
0.41 ± 0.07
0.13
Mean PAP (mmHg)
0
E (cm/s)
18.16 ± 8.3
17.72 ± 6.4
0.8
15 ± 3.9
16.6 ± 4.6
0.1
Student’s t test was used
Numerical variables were presented as the mean ± standard deviation. p \ 0.05, significant
TAPSE tricuspid annular plane systolic excursion, RVMPI right ventricle myocardial performance index,
PAP pulmonary artery pressure, E0 tricuspid annulus early diastolic myocardial velocity
significantly after the adenotonsillectomy procedure [12].
Furthermore, Koc et al. found similar results in the same
patient group [20]. The present study showed that RVMPI
is significantly higher in patients with NSD compared to
healthy controls. This finding supports the results of the
previous study. We could not show regression after surgery
in the RVMPI. However, we observed no significant differences between postoperative findings of patients with
NSD and controls in RVMPI. If we could have increased
the number of patients, we could have determined a significant decrease in RVMPI postoperatively.
A few study limitations should also be noted. The main
limitation of our study was the small sample size. We could
not have a large sampling because factors and diseases
affecting right ventricular function and pulmonary artery
pressure were excluded. The other limitation was that
RVMPI was obtained only in TDE measurements and not
calculated by conventional Doppler. However, it is reported
that there is a strong correlation between TDE and conventional Doppler echocardiography for estimating MPI [24].
In conclusion, mean PAP increased and right ventricular
function worsened in patients with NSD. However, mean
PAP decreased and right ventricular function tended to
recover after septoplasty. Therefore, such patients should
have cardiac evaluation and should be encouraged to
undergo septoplasty.
Compliance with ethical standards
The Ethics Committee of the Afyon Kocatepe University School of
Medicine approved this study. All patients and control subjects gave
informed consent prior to inclusion
Conflict of interest
of interest.
All authors declared that there was no conflict
Funding No financial support was received for this study. It was
conducted with the dedication of researchers.
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