Rationale and Objectives
The aim of this study was to assess regional myocardial function in patients with chronic thromboembolic hypertension (CTEPH) before and after successful pulmonary endarterectomy (PEA) using magnetic resonance imaging.
Methods
Twenty-two patients with CTEPH underwent cardiac magnetic resonance imaging before and 12 (11, 17) days after PEA. Mean pulmonary artery pressure was evaluated preoperatively by right heart catheterization and during post-PEA intensive care unit-stay using a Swan-Ganz catheter. Biventricular peak systolic longitudinal, radial, circumferential strain and time-to-peak strain were obtained by tissue-tracking analysis.
Results
Mean pulmonary artery pressure decreased (46 mm Hg (34.5, 55) to 24 mm Hg (16, 27); P < .0001) and stroke volume increased ( P < .0001) after PEA. In the right ventricle (RV) peak radial strain increased in the anterior ( P = .04) and in the inferior wall ( P = .0012) and slightly missed statistical significance in the lateral wall ( P = .051) and septum ( P = .07). Circumferential strain increased in the lateral ( P = .0002) and inferior wall of the RV ( P = .03) and in the lateral as well as in the inferior wall of the left ventricle ( P = .01; P = .03). Radial, longitudinal, and circumferential time-to-peak strain shortened ( P < .0001) with resynchronization of the ventricles 12 days after PEA.
Conclusion
While biventricular resynchronization and recovery of global predominantly RV function was observed, regional circumferential function mainly improved in the lateral and inferior walls of both ventricles and regional radial function in the RV wall and septum 12 days after PEA, suggesting fibers primarily affected by myocardial stress in patients with CTEPH possibly need a relatively longer recovery time.
Background
Chronic thromboembolic pulmonary hypertension (CTEPH) is a life-threatening cause of shortness of breath that leads to chronic elevation of mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance . CTEPH occurs in about 3.8% of patients after acute pulmonary embolism, with a mean survival of patients with mPAP >30 mm Hg of less than 2 years without therapy . Right heart failure is the main cause of death in this patient group. Thus, effective treatment of CTEPH needs to lower pulmonary vascular resistance and to improve cardiac function to improve patient outcome. Currently, pulmonary endarterectomy (PEA) is the treatment of choice to treat CTEPH with a perioperative mortality of 2%–4% and strong scientific evidence for improved patient outcome .
An important factor for clinical improvement and prolonged survival is restored biventricular function after PEA . As right ventricle (RV) and left ventricle (LV) share the interventricular septum, increased right ventricular pressure and volume load lead to septal bowing and result in impaired left ventricular function . Not only global, but also regional impairment of biventricular myocardial function is therefore of growing scientific interest .
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Methods
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MRI Examination
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MRI Data Analysis
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Statistical Analysis
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Results
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TABLE 1
Results—Clinical Data and Global Myocardial Function
Clinical Data Pre (n = 22) Post (n = 22)P Value Age (y) 50.5 (40.75, 60.75) Sex Female (n, %) 7 (31.8) 7 (31.8) Male (n, %) 15 (68.2) 15 (68.2) mPAP (mm Hg) 46 (35, 55) 24 (16, 27) <.0001 LVEF (%) 61 (54, 68) 59 (56, 65) .949 RVEF (%) 35 (25, 51) 48 (41, 57) <.0001 LVSV/BSA (mL/m 2 ) 32 (28, 38) 39 (35, 43) .2538 RVSV/BSA (mL/m 2 ) 35 (28, 40) 40 (35, 45) .1536 LV-EDV/BSA (mL/m 2 ) 55 (47, 68) 64 (59, 70) .0851 RV-EDV/BSA (mL/m 2 ) 106 (76, 128) 83 (60, 99) .0001 RV-EDV/LV-EDV 1.7 (1.4, 2.2) 1.3 (1.1, 1.4) <.0001 LV-ESV/BSA (mL/m 2 ) 23 (15, 30) 25 (21, 31) .2058 RV-ESV/BSA (mL/m 2 ) 69 (46, 95) 41 (28, 54) <.0001 LV-CO (mL/min) 5169 (4117, 6630) 6553 (5349, 7932) .0005 RV-CO (mL/min) 5408 (4702, 6641) 6694 (5532, 8756) .0006 RV-mass/BSA (g/m 2 ) 42 (35, 63) 37 (29, 52) .0006 Pre Post [3-mo follow-up] NYHA class n = 15 n = 14 .002 0 0 (0) 1 (7.1) I. (n, %) 2 (9.5) 5 (35.7) II. (n, %) 5 (23.8) 6 (42.9) III. (n, %) 13 (61.9) 2 (14.3) IV. (n, %) 1 (4.8) 0 (0) 6-min-WD (m) n = 22 n = 15 330 (259, 475) 458 (392, 517) .0498
BSA, body surface area; LV-CO, left ventricular cardiac output; LV-EDV, left ventricular end-diastolic volume; LVEF, left ventricular ejection fraction; LV-ESV, left ventricular end-systolic volume; LVSV, left ventricular stroke volume; mPAP, mean pulmonary artery pressure; NYHA, New York Heart Association; RV-CO, right ventricular cardiac output; RV-EDV, right ventricular end-diastolic volume; RVEF, right ventricular ejection fraction; RV-ESV, right ventricular end-systolic volume; RV-mass, right ventricular mass; RVSV, right ventricular stroke volume; 6-min-WD, 6-min walking distance.
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Right Ventricle
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TABLE 2
Results—Right Ventricular (RV) and Left Ventricular (LV) Regional Myocardial Function
Pre (n = 22) Post (n = 22)P Value ANTERIOR RV-peak strain Radial 5.4 (0.2, 9.6) 10.2 (7.0, 11.4) .0359 Circumferential 4.8 (0.3, 7.7) 1.1 (−4.6, 6.7) .1873 LV-peak strain Radial 20.5 (16.4, 22.6) 22.0 (16.8, 24.9) .6477 Circumferential − 9.4 (−12.5, −5.8) −13.5 (−14.4, −10.9) .1627 RV-time to peak (ms) Radial 340.7 (226.5, 392.7) 291.2 (242.3, 323.4) .095 Circumferential 357.7 (275.8, 513.8) 241.6 (215.8, 266.6) <.0001 LV-time to peak (ms) Radial 305.1 (284.0, 377.0) 255.8 (237.3, 292.6) <.0001 Circumferential 283.6 (230.9, 390.1) 257.0 (242.0, 288.1) .065 LATERAL RV-peak strain Radial 11.4 (9.0, 12.4) 12.3 (14.5, 9.3) .0509 Circumferential −6.5 (−7.9, −3.9) −8.4 (−9.6, −6.6) .0002 Longitudinal −6.2 (−9.7, − 4.0) −7.4 (−9.1, −4.7) .4392 LV-peak strain Radial 24.6 (20.6, 28.8) 26.2 (22.2, 32.7) .2611 Circumferential −15.4 (−17.7, −12.6) −18.1 (−19.9, −16.5) .0057 Longitudinal −11.5 (−14.5, −6.2) −10.3 (−11.8, −7.6) .5604 RV-time to peak (ms) Radial 322.0 (291.0, 348.6) 269.4 (247.0, 310.8) .0074 Circumferential 327.5 (293.4, 370.9) 267.7 (246.3, 303.1) .0004 Longitudinal 313.1 (282,3, 388.4) 286.0 (263.3, 314.6) .0065 LV-time to peak (ms) Radial 276.8 (252.9, 324.3) 264.1 (255.4, 281.7) .3021 Circumferential 279.7 (254.1, 311.6) 276.8 (246.4, 291.1) .7417 Longitudinal 274.7 (244.8, 331.4) 260.7 (228.4, 280.7) .0223 INFERIOR RV-peak strain Radial 12.0 (6.3, 17.4) 17.8 (13.4, 22.3) .0012 Circumferential −5.5 (−9.1, −2.5) −10.4 (−12.8, −6.6) .0327 LV-peak strain Radial 21.2 (18.7, 27.0) 22.2 (19.0, 26.5) .7285 Circumferential −13.1 (−16.0, −8.2) −15.4 (−17.1, −12.6) .0386 RV-time to peak (ms) Radial 345.6 (311.1, 389.8) 271.1 (253.5, 322.1) .0001 Circumferential 365.0 (335.2, 448.1) 283.3 (245.4, 327.5) <.0001 LV-time to peak (ms) Radial 310.1 (250.0, 341.1) 275.7 (260.6, 311.7) .2009 Circumferential 292.5 (237.3, 364.1) 270.4 (250.4, 304.7) .35 SEPTAL LV-peak strain Radial 18.8 (12.9, 22.5) 18.9 (17.3, 24.3) .0696 Circumferential −11.1 (−13.3, −5.2) −11.9 (−14.6, −10.4) .2317 Longitudinal −8.5 (−10.2, −3.8) −9.3 (−10.5, −6.5) .9875 LV-time to peak (ms) Radial 299.0 (277.3, 366.3) 288.1 (268.7, 319.0) .1528 Circumferential 293.1 (265.7, 359.8) 289.1 (252.5, 321.3) .2317 Longitudinal 299.4 (266.1, 346.2) 286.1 (233.9, 319.2) .0359 GLOBAL RV-peak strain Radial 9.0 (6.8, 13.7) 13.1 (10.9, 16.0) .0057 Circumferential −1.6 (−5.9, − 0.8) −6.2 (−8.0, −3.5) .0223 LV-peak strain Radial 22.1 (16.3, 24.1) 21.6 (20.0, 24.1) .6486 Circumferential −12.2 (−15.0, −6.7) −14.4 (−15.4, −13.5) .0201 Longitudinal −9.7 (−11.9, −4.7) −9.9 (−11.2, −7.0) .6486 RV-time to peak (ms) Radial 327.7 (292.7, 368.6) 284.9 (254.3, 306.4) .0002 Circumferential 366.5 (307.6, 413.4) 261.6 (242.4, 286.0) <.0001 LV-time to peak (ms) Radial 297.3 (279.3, 337.3) 280.9 (255.8, 296.7) .0074 Circumferential 285.1 (258.0, 347.7) 280.7 (257.4, 297.6) .06 Longitudinal 287.3 (264.7, 319.0) 267.3 (243.7, 293.2) .0094
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Left Ventricle
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Time-to-Peak Strain
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Discussion
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Limitations
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Conclusion
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