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•Echocardiographic coupling ratios identify occult right-sided cardiac dysfunction in healthy older adults.•Echocardiographic coupling ratios are associated with 6-minute walk distance, N-terminal pro-B-type natriuretic peptide, and Kansas City Cardiomyopathy Questionnaire score.•Across ratios, fractional area change/pulmonary artery systolic pressure best relates to age-related and gender-related functional and geometric changes.•Incorporation of coupling ratios refines prediction of right ventricular dysfunction and pulmonary hypertension. Right ventricular (RV) to pulmonary arterial (PA) coupling describes the ability of the RV to augment contractility in response to increased afterload. Several echocardiographic indexes of RV-PA coupling have been defined; however, the optimal numerator in the coupling ratio is unclear. We sought to establish which of these ratios is best for assessing RV-PA coupling based on their relations with 6-minute walk distance (6MWD), N-terminal pro-B-type natriuretic peptide (NT-proBNP), and the Kansas City Cardiomyopathy Questionnaire (KCCQ) in aging adults. In this study of 1,611 Multi-Ethnic Study of Atherosclerosis participants who underwent echocardiography at Exam 6, we evaluated the association between different numerators, including tricuspid annular planar systolic excursion (TAPSE), fractional area change (FAC), RV free wall strain, and tissue Doppler imaging S’ velocity to pulmonary artery systolic pressure (PASP) with 6MWD, NT-proBNP, and KCCQ score, adjusted for socioeconomic and cardiovascular disease risk factors. Our cohort had a mean age of 73 ± 8 years, 54% female, 17% Chinese American, 22% African American, 22% Hispanic, and 39% White participants. The mean ( ± SD) TAPSE/PASP, FAC/PASP, tissue Doppler imaging S’ velocity/PASP, and RV free wall strain:PASP ratios were 0.7 ± 0.2, 1.3 ± 0.3, 0.5 ± 0.1, and 0.8 ± 0.2, respectively. All RV-PA coupling indices decreased with age (p <0.0001 for all). TAPSE:PASP ratio was lower in older (³85 years) female (0.59 ± 0.14) versus male (0.65 ± 0.17) participants (p = 0.01), whereas FAC/PASP ratio was higher in the same female versus male participants (p <0.01). TAPSE/PASP and FAC/PASP ratios were significantly and strongly associated with all NT-proBNP, 6MWD, and KCCQ scores in fully adjusted and receiver operating characteristic analysis. In older community-dwelling adults free of heart failure and pulmonary hypertension, both FAC/PASP and TAPSE:PASP ratios are optimal for assessment of RV-PA coupling based on its association with 6MWD, NT-proBNP, and KCCQ score. FAC/PASP ratio has the additional benefit of reflecting age and gender-related geometric and functional changes.

PurposeRight heart catheterization (RHC) is the gold standard for the assessment of pulmonary artery systolic pressures (PASP). Despite high utilization of echocardiography for the non-invasive assessment of PASP, the data comparing real-time non-invasive echocardiographic PASP with invasive PASP is limited. Furthermore, evidence regarding the utility and diagnostic accuracy of ultrasound enhancing agents (UEA) for non-invasive PASP assessment is lacking. To evaluate the accuracy of non-invasive PASP assessment with real-time invasive measures and the incremental benefit of UEA in this setting.MethodsThis was a prospective cohort study of 90 patients, undergoing clinically indicated RHC for hemodynamic assessment. All patients underwent a limited echocardiogram during RHC. Tricuspid regurgitant velocity (TRV) was measured on unenhanced echo, in the setting of centrally administrated agitated saline, then as either centrally administered or peripherally administered UEA.ResultsOf the 90 patients enrolled in our study, 41% had pulmonary hypertension. The overall mean PASP measured by RHC was 32.8 mmHg (+/- 11.3 mmHg). Unenhanced echocardiograms had a moderate correlation with invasive PASP (r = 0.57; p = < 0.001) which improved to a strong correlation with administration of agitated saline (r = 0.75; p = < 0.001) or centrally administered UEA (r = 0.77; p = < 0.001), with the best correlation noted with peripherally administered UEA (r = 0.83; p = < 0.001). Against invasive PASP, agitated saline enhanced PASP had the lowest bias (0.12mmHg; -15.6 to 15.8mmHg) when compared with all other non-invasive measures of PASP.ConclusionsUnenhanced echocardiographic estimation of TRV was found to have a poorer correlation with invasively measured PASP when compared to agitated saline and centrally administered UEA. Agitated saline enhanced PASP demonstrated the lowest bias with invasive PASP when compared to other non-invasive measures of PASP.

BackgroundEchocardiographic parameters of diastolic function depend on cardiac loading conditions, which are altered by positive pressure ventilation. The direct effects of positive end-expiratory pressure (PEEP) on cardiac diastolic function are unknown.MethodsTwenty-five patients without apparent diastolic dysfunction undergoing coronary angiography were ventilated noninvasively at PEEPs of 0, 5, and 10 cmH2O (in randomized order). Echocardiographic diastolic assessment and pressure–volume-loop analysis from conductance catheters were compared. The time constant for pressure decay (τ) was modeled with exponential decay. End-diastolic and end-systolic pressure volume relationships (EDPVRs and ESPVRs, respectively) from temporary caval occlusion were analyzed with generalized linear mixed-effects and linear mixed models. Transmural pressures were calculated using esophageal balloons.Resultsτ values for intracavitary cardiac pressure increased with the PEEP (n = 25; no PEEP, 44 ± 5 ms; 5 cmH2O PEEP, 46 ± 6 ms; 10 cmH2O PEEP, 45 ± 6 ms; p < 0.001). This increase disappeared when corrected for transmural pressure and diastole length. The transmural EDPVR was unaffected by PEEP. The ESPVR increased slightly with PEEP. Echocardiographic mitral inflow parameters and tissue Doppler values decreased with PEEP [peak E wave (n = 25): no PEEP, 0.76 ± 0.13 m/s; 5 cmH2O PEEP, 0.74 ± 0.14 m/s; 10 cmH2O PEEP, 0.68 ± 0.13 m/s; p = 0.016; peak A wave (n = 24): no PEEP, 0.74 ± 0.12 m/s; 5 cmH2O PEEP, 0.7 ± 0.11 m/s; 10 cmH2O PEEP, 0.67 ± 0.15 m/s; p = 0.014; E’ septal (n = 24): no PEEP, 0.085 ± 0.016 m/s; 5 cmH2O PEEP, 0.08 ± 0.013 m/s; 10 cmH2O PEEP, 0.075 ± 0.012 m/s; p = 0.002].ConclusionsPEEP does not affect active diastolic relaxation or passive ventricular filling properties. Dynamic echocardiographic filling parameters may reflect changing loading conditions rather than intrinsic diastolic function. PEEP may have slight positive inotropic effects.Clinical trial registrationhttps://clinicaltrials.gov/ct2/show/NCT02267291, registered 17. October 2014.

BackgroundUsing the tricuspid annular plane systolic excursion (TAPSE)/pulmonary arterial systolic pressure (PASP) ratio as an index of right ventricular load adaptability, we aimed to evaluate early changes in right heart contractile function of patients with group 1 pulmonary artery hypertension (PAH) after sequential combination PAH-specific therapy.MethodsA total of 49 patients with group 1 PAH and 31 control participants were included in the study. The baseline clinical and echocardiographic data of the control and PAH group were compared. Subsequently, clinical and echocardiographic data of PAH patients before treatment and at 6 months after PAH-specific treatment were analyzed.ResultsA significant increase in the TAPSE/PASP ratio was found in patients at 6 months of PAH-specific treatment (0.25 ± 0.14; 0.33 ± 0.16, p < 0.001). Right atrial pressure (8 mm Hg [5–10]; 5 mm Hg [3–8], p < 0.001) and PASP (80.8 ± 30.6 mm Hg; 65.9 ± 25.7 mm Hg, p < 0.001) were significantly lower after sequential combination PAH-specific therapy. Negative correlations were found between the TAPSE/PASP ratio and N‑terminal pro-B-type natriuretic peptide (r = −0.524, p < 0.001), tricuspid regurgitation velocity (r = −0.749, p < 0.001), right atrial area (r = −0.298, p = 0.037), and right atrial pressure (r = −0.463, p = 0.001).ConclusionIn patients with group 1 PAH, echocardiographic evaluation at the early stage of treatment (6 months) shows a significant improvement in the TAPSE/PASP ratio indicating right ventricular load adaptation. Comprehensive studies are needed on the routine use of the TAPSE/PASP ratio in the risk assessment of PAH patients.

Objective This study aims to assess the prognostic significance of non-invasive right ventricle-pulmonary artery coupling in patients with pulmonary hypertension associated with left heart disease (PH-LHD) and identify the relevant clinical factors involved. Methods A cohort of 362 patients diagnosed with PH-LHD was included in this study. Plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels were measured using enzyme-linked immunosorbent assay (ELISA). Echocardiography was employed to screen routine ultrasound parameters. The tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) and S’/PASP ratios were calculated. Participants were categorized into two groups based on the TAPSE/PASP ratio: moderate-to-severe and mild uncoupling groups. Both groups underwent routine follow-up for a period of 3 to 15 months. Clinical events included all-cause mortality, heart failure rehospitalization, and stroke. Clinical events were documented, and a multivariate Cox regression model evaluated the correlation between the TAPSE/PASP ratio and prognosis. The Kaplan-Meier survival analysis was also conducted. Results The moderate-to-severe uncoupling group exhibited significantly higher proportions of males; individuals with a history of smoking, valvular disease, diabetes mellitus, or stroke; and elevated levels of PASP, right ventricular diameter (RVD), left ventricular diameter (LVD), left ventricular end-diastolic (LVED), and lg (NT-proBNP) compared to the mild uncoupling group ( P  < 0.05). Conversely, parameters such as age, TAPSE, S’, S’ /PASP, and left ventricular ejection fraction (LVEF) were significantly lower in the moderate-to-severe uncoupling group compared to the mild uncoupling group ( P  < 0.05). Multivariate Cox regression analysis revealed that TAPSE/PASP (hazard ratio [HR] = 0.150, 95% confidence interval [CI] [0.023, 0.968], P  = 0.046) was a protective factor for the recurrence of clinical events. In contrast, LVED (HR = 1.301, 95% CI (1.004, 1.059), P  = 0.024) and lg (NT-proBNP) (HR = 1.870, 95%CI [1.304, 2.682], P  = 0.001) were independent risk factors for the recurrence of clinical events. KaplanMeier survival analysis demonstrated that the mild uncoupling group exhibited a significantly higher overall survival rate compared to the moderate-to-severe uncoupling group (Log Rank P  = 0.024). Conclusions The TAPSE/PASP ratio is a predictive marker for clinical outcomes in patients with PH-LHD.

Background: Limited research has been conducted to investigate the impact of secondary mitral regurgitation (MR) in heart failure (HF) patients with different levels of estimated pulmonary artery systolic pressure (ePASP). Methods: A total of 468 patients suffering from HF and secondary MR were enrolled and categorized into non-severe and severe MR groups based on the degree of MR. The primary endpoint of the study was a composite of cardiovascular death and a first-heart-failure hospitalization. The secondary endpoints were the primary outcomes, individually. The outcomes of the two groups were compared. Patients were further classified based on whether their ePASP was ≥50 mmHg or <50 mmHg. Subsequently, the outcomes of the non-severe and severe MR groups were compared within each ePASP category. Results: In a median (SD) follow-up of 694 (410) days, severe MR was associated with higher risk for primary endpoints in patients with heart failure, especially in those with ePASP ≥50 mmHg. In patients with ePASP <50 mmHg, the prognostic value of severe MR was diminished. Conclusions: Assessment of the severity of MR can identify heart failure patients who are at greater risks for poor clinical outcomes. Additionally, the prognostic value of secondary MR was more pronounced in patients with elevated ePASP.

Introduction Lung resection surgeries, including lobectomy and pneumonectomy, are cornerstone treatments for lung cancer and other severe pulmonary conditions. Despite their therapeutic benefits, these procedures can compromise cardiopulmonary function, potentially increasing right ventricular (RV) workload due to reduced pulmonary vascular capacity. Such changes may precipitate RV dysfunction, even in patients with normal preoperative cardiac profiles, contributing to postoperative morbidity like dyspnea and arrhythmias. While pulmonary function tests are standard for preoperative risk assessment, cardiac impacts—particularly on the RV—remain insufficiently characterized. This study employs Equilibrium radionuclide ventriculography (ERNV) scanning, a precise radionuclide ventriculography technique, to evaluate biventricular systolic and diastolic changes post-resection, supplemented by echocardiography to measure Right Ventricular Systolic Pressure (RVSP). Methods Twenty patients (mean age 43.8 ± 8.3 years, 10 females, 10 male) undergoing lobectomy ( n  = 15) or pneumonectomy ( n  = 5) from March 2021 to September 2022 were prospectively studied at a tertiary university hospital. Patients with preexisting coronary disease, hypertension, or abnormal pulmonary function (e.g., predicted postoperative FEV1 or DLCO < 60%) were excluded. Cardiac function was assessed preoperatively and two months postoperatively using ERNV scans to quantify right and left ventricular ejection fraction (EF), peak filling rate (PFR), and time to peak filling rate (TPFR). Transthoracic echocardiography measured RVSP concurrently. Statistical analyses included paired t-tests to compare pre- and postoperative indices, general linear models to assess surgery type effects, and regression analyses to correlate resection extent with RV changes. Results Lung resection significantly impaired cardiac performance. Right ventricular EF declined from 48.8 ± 2.6% to 43.7 ± 2.8% ( p  = 0.035) and left ventricular EF from 54.9 ± 2.7% to 51.3 ± 3.3% ( p  < 0.001). Diastolic function deteriorated, with the right PFR decreasing from 1.9 ± 0.2 to 1.7 ± 0.2 EDV/s ( p  < 0.001) and left PFR from 2.4 ± 0.1 to 2.2 ± 0.2 EDV/s ( p  = 0.001), while TPFR increased bilaterally (right: 151.8 ± 18.6 to 161.4 ± 17.6 ms, p  < 0.001; left: 168.9 ± 11.7 to 176.1 ± 13.5 ms, p  < 0.001). RVSP rose from 20 ± 2.6 to 24.9 ± 5.0 mmHg ( p  = 0.001). Pneumonectomy elicited greater reductions in RV indices than lobectomy, with resection extent strongly predicting RVEF decline ( r  = 0.7, p  < 0.001). Conclusion Lung resection induces substantial biventricular systolic and diastolic dysfunction, with severity proportional to resection extent. These findings highlight the utility of ERNV scanning in detecting subtle cardiac changes and emphasize the importance of preoperative cardiac evaluation to anticipate and manage postoperative complications, particularly in extensive resections like pneumonectomy.

This paper develops a method for the minimally invasive, beat-by-beat estimation of the left ventricular pressure–volume loop. This method estimates the left ventricular pressure and volume waveforms that make up the pressure–volume loop using clinically available inputs supported by a short, baseline echocardiography reading. Validation was performed across 142,169 heartbeats of data from 11 Piétrain pigs subject to two distinct protocols encompassing sepsis, dobutamine administration and clinical interventions. The method effectively located pressure–volume loops, with low overall median errors in end-diastolic volume of 8.6%, end-systolic volume of 17.3%, systolic pressure of 19.4% and diastolic pressure of 6.5%. The method further demonstrated a low overall mean error of 23.2% predicting resulting stroke work, and high correlation coefficients along with a high percentage of trend compass ‘in band’ performance tracking changes in stroke work as patient condition varied. This set of results forms a body of evidence for the potential clinical utility of the method. While further validation in humans is required, the method has the potential to aid in clinical decision making across a range of clinical interventions and disease state disturbances by providing real-time, beat-to-beat, patient specific information at the intensive care unit bedside without requiring additional invasive instrumentation.

The variation between rest and peak stress end-systolic pressure–volume relation (ΔESPVR) is an index of myocardial contractility, easily obtained during routine stress echocardiography and never tested during dipyridamole stress-cardiac magnetic resonance (CMR). We assessed the ΔESPVR index in patients with known/suspected coronary artery disease (CAD) who underwent dipyridamole stress-CMR. One-hundred consecutive patients (24 females, 63.76 ± 10.17 years) were considered. ESPVR index was evaluated at rest and stress from raw measurement of systolic arterial pressure and end-systolic volume by biplane Simpson’s method. The ΔESPVR index showed a good inter-operator reproducibility. Mean ΔESPVR index was 0.48 ± 1.45 mmHg/mL/m2. ΔESPVR index was significantly lower in males than in females. ΔESPVR index was not correlated to rest left ventricular end-diastolic volume index or ejection fraction. Forty-six of 85 patients had myocardial fibrosis detected by the late gadolinium enhancement technique and they showed significantly lower ΔESPVR values. An abnormal stress CMR was found in 25 patients and they showed significantly lower ΔESPVR values. During a mean follow-up of 56.34 ± 30.04 months, 24 cardiovascular events occurred. At receiver-operating characteristic curve analysis, a ΔESPVR < 0.02 mmHg/mL/m2 predicted the presence of future cardiac events with a sensitivity of 0.79 and a specificity of 0.68. The noninvasive assessment of the ΔESPVR index during a dipyridamole stress-CMR exam is feasible and reproducible. The ΔESPVR index was independent from rest LV dimensions and function and can be used for a comparative assessment of patients with different diseases. ΔESPVR index by CMR can be a useful and simple marker for additional prognostic stratification.

Evaluate the association between chronic right ventricle (RV) dysfunction by transthoracic echocardiogram (TTE) and outcomes in patients with acute pulmonary embolism (PE). This was a retrospective analysis of TTE findings in acute PEs. TTEs were used to classify the presence of chronic right ventricular pressure overload (RPVO), defined as RV hypertrophy or RV systolic pressure (RVSP) >50 mmHg, acute RVPO, defined as RV dysfunction not meeting the chronic RVPO definition, or no RV dysfunction. The primary outcome was a composite of death or need for advanced PE therapies at 7 days. Of 466 patients, 288 had evidence of RV dysfunction. Thirty percent (140) had evidence of chronic RVPO and 148 patients had evidence of acute RVPO. Chronic RVPO patients were older (P = .004), more likely to have COPD, and had lower heart rates and troponin-t values. The acute RVPO patients included more women and were less likely to have a prior PE. There was no difference in outcomes between the acute and chronic RVPO cohorts. Chronic RVPO patients had lower heart rates and troponin-t values. Despite these differences there were no differences in need for advanced therapeutic interventions or 7 day mortality. •In acute PE, significance of right ventricle pressure overload (RVPO) is unknown.•TTEs of patients with acute PE showed 30% had evidence of chronic RVPO.•Chronic RVPO patients were older and more likely to have COPD.•Acute RVPO patients included more women and were less likely to have a prior PE.•No difference in outcomes between the acute and chronic RVPO cohorts.