Assessment of right ventricular systolic function by tissue Doppler echocardiography

This thesis summarizes a series of studies performed in order to assess the clinical usefulness of a novel echocardiographic technology that allows non-invasive assessment of regional right ventricular myocardial velocities and deformation: tissue Doppler echocardiography. While the technology is a promising tool for improving our understanding of right ventricular hemodynamics, several aspects of the technology must be evaluated. The accuracy and reproducibility of the technology is evaluated in vitro, and normal values, impact of changes in loading of the right ventricle, response to exercise and pharmacological pulmonary vasodilatation is established in normal subjects. The diagnostic and prognostic importance of adding tissue Doppler echocardiography to conventional echocardiographic and clinical parameters was evaluated in studies on patients with diseases associated with different modes of impact on right ventricular hemodynamics: pulmonary embolism, Arrhythmogenic right ventricular cardiomyopathy and pulmonary regurgitation, the latter in an animal model. The conclusions of the thesis are: Color tissue Doppler echocardiography accurately measures velocities, SR and strain in vitro. No systematic bias between ultrasound systems can be found, and accuracy of the measurements is good. However, the reproducibility of measurements in a test-retest design can limit the usefulness of the technology in daily clinical use, as 25% to 80% of change would be needed for the technology to identify a change in individual patients [I]. Normal values of tissue Doppler based measurements of RV regional velocities, SR and strain exist, and apply to both sexes and in all age groups with the exception of slightly decreasing values in strain with increasing age. Increasing preload and afterload changes regional myocardial velocities, but no changes in SR, strain or isovolumic acceleration could be observed [II and III]. Tissue Doppler echocardiography of the RV free wall in non-massive pulmonary embolism quantifies degree of RV dysfunction, and supports the existence of the McConnell sign of mid-ventricular RV dysfunction. Echocardiographic signs of RV dysfunction are present if > 25% of the pulmonary vascular bed is obstructed. However, Tissue Doppler echocardiography and deformation analysis has no independent value over other clinical and quantitative echocardiographic measures of RV size, pressure and function in these patients [IV and V]. Regional deformation of the RV free wall has significant prognostic importance in a population suspected of first non-massive pulmonary embolism, and is significantly associated with adverse events in patients with proven pulmonary embolism, however, it does not add to the information gained from other quantitative echocardiographic measures of LV and RV function and pressure [VI]. Changes in tissue Doppler based measures of RV systolic function can be used to monitor the effect of selective vasodilation by phosphodiestares-5 inhibition in hypoxic pulmonary hypertension and exercise in normal individuals. Phosphodiestares-5 inhibition by sildenafil may predominantly be effective during hypoxia in resting conditions, and may improve the blunted response in RV contractility seen with exercise in hypoxia [VII]. Reduced RV free wall deformation can be quantified by tissue Doppler echocardiography in patients with confirmed Arrhythmogenic Right Ventricular Cardiomyopathy, but the clinical application of the technique may be limited by considerable overlap with normal values [VIII]. Acute RV volume loading in free pulmonary regurgitation is associated with abrupt geometric changes in the RV structure including significant dilatation, but is well tolerated with only mild reduction in measures of global RV systolic function as estimated by 2D echocardiography in an experimental animal model. Regional RV myocardial function is also only mildly reduced. Also no differences in global or regional RV function can be observed after 1-3 months of pulmonary regurgitation [IX and X]. Relief of free pulmonary regurgitation by percutaneus pulmonary valve replacement in an animal model is associated with immediate reverse remodeling of the RV. No changes in tissue Doppler based measures of RV contractility can be identified [X].