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*Address correspondence to: Dr. Chung-Lieh Hung, Cardiovascular Medicine ... Memorial Hospital, 92, Section 2, Chungshan North Road, Taipei, Taiwan. ..... Spencer KT, Bednarz J, Mor-Avi V, et al. ... Hecbert SR, Post W, Pearson GD, et al.
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Effect of Biventricular Structure and Function on Tricuspid Annular Displacement in Heart Failure Patients With or Without Systolic Dysfunction: A Two-dimensional Speckle Tracking Study Hui-Chun Lin1, Charles Jia-Yin Hou1,3, Ta-Chuan Hung1,3, Hung-I Yeh1,2, Chung-Lieh Hung1,3* Tricuspid annular motion is used to estimate biventricular function but is limited by its angle dependency. Two-dimensional speckle tracking echocardiography (STE), an angleindependent technique, may provide a more objective assessment. The objective of our study was to investigate the role of STE-based tricuspid annular displacement (TAD) in evaluating biventricular function. A total of 106 patients with heart failure were divided into three groups categorized by global left ventricular (LV) ejection fraction and 20 normal subjects served as the control group. TAD was assessed by STE in both the right ventricular septal and free wall annulus from the four-chamber view. Parameters including LV volume, peak systolic tricuspid annular velocity, right ventricular fraction area change and LV mass were compared among different groups and correlated with TAD. TAD was linearly correlated with peak systolic tricuspid annular velocity (free wall annulus, r = 0.58; septal annulus, r = 0.69; both p < 0.0001) and right ventricular fraction area change (free wall annulus, r = 0.70; septal annulus r = 0.79; p < 0.01). There was a graded decrease in TAD among the different groups of heart failure patients categorized by worsening LV ejection fraction. TAD was lower in patients with preserved LV ejection fraction heart failure compared with that in the control group (p < 0.01). A negative linear correlation between LV mass and TAD (free wall annulus, r = −0.35; septal annulus, r = −0.34; p < 0.01) was also observed. TAD not only reflected biventricular systolic function but also appeared to be inversely related to LV mass. Patients with heart failure symptoms with or without impaired LV systolic function had a lower TAD when compared with normal individuals.

KEY WORDS — heart failure, peak systolic tricuspid annular velocity, speckle tracking echocardiography, tricuspid annular displacement ■ J Med Ultrasound 2010;18(3):115–123 ■ Received: May 6, 2009

Accepted: February 2, 2010

1

Cardiovascular Medicine and Medical Research, Mackay Memorial Hospital, 2Taipei Medical University, Mackay Medicine, Nursing and Management College and Taipei Medical University, Taipei, Taiwan.

3

*Address correspondence to: Dr. Chung-Lieh Hung, Cardiovascular Medicine and Medical Research, Mackay Memorial Hospital, 92, Section 2, Chungshan North Road, Taipei, Taiwan. E-mail: [email protected]

©Elsevier & CTSUM. All rights reserved.

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Introduction

Materials and Methods

Right ventricular (RV) systolic dysfunction in patients with heart failure has been previously reported to be a powerful predictor of both cardiovascular morbidity and mortality [1–3]. Therefore, RV functional assessment could be of significant clinical value. The traditional method for RV functional evaluation by calculating RV fractional area change (RVFAC) relies on high image quality and is limited to images with good endocardial border tracing. Additionally, tricuspid annular motion, which is technically more feasible and represents longitudinal RV contraction [4–6], has recently been reported to represent global RV function. Recently, accumulating data have shown that both tricuspid annular plane systolic excursion (TAPSE) and peak systolic tricuspid annular velocity (PSTAV) are attractive alternatives to estimating RV performance with simplicity in clinical practice [7]. Unfortunately, these modalities are limited by their angle-dependency between cardiac motion and the echo beam [8], leading to a possible estimation error. Two-dimensional speckle tracking echocardiography (STE), a new echocardiographic technology based on gray-scale B-mode images, is relatively angle-independent and may allow automatic, objective assessment of myocardial function using continuous frame-by-frame motion [9,10]. Use of tricuspid annular displacement (TAD) can be easily quantified for assessment of longitudinal RV function from the four-chamber view. Interestingly, TAPSE has recently been shown to reflect not only RV but also left ventricular (LV) functional changes. Based on the theory of ventricular interdependence, LV functional disturbance may attenuate RV function [11–14]. Similarly, left ventricular longitudinal function assessment based on mitral annular motion is able to detect early deterioration of LV function [15–17] before changes of ventricular dilatation and remodeling [18]. However, it is unknown to what extent ventricular dysfunction and clinical manifestations have an impact on TAD. Therefore, we investigated the role of TAD in patients presenting with clinical heart failure symptoms with various extents of ventricular systolic functional decay.

Patient population

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This study comprised a total of 126 participants, including 106 patients with symptoms (at least New York Heart Association Functional class II) or signs of heart failure (evidence of pulmonary congestion/edema or lower leg edema by chest X-ray or physical examination) from the outpatient clinics of Mackay Memorial Hospital. The first group consisted of 36 patients with a left ventricular ejection fraction (LVEF) below 35% or LV end-diastolic diameter greater than 55 mm (defined as the dilated cardiomyopathy [DCM] group [19]); the second group consisted of 30 patients with LVEF ranging from 35–49% (defined as the systolic heart failure [SHF] group); the third group consisted of 40 patients with LVEF greater or equal to 50% (defined as the diastolic heart failure [DHF] group). Twenty normal volunteers served as the control group. Baseline demographics and medications were all obtained from the medical records or by chart review. Patients who underwent any valve replacement procedures and those with tricuspid/pulmonary stenosis, tricuspid regurgitation of at least a moderate degree or significant other valve disease were excluded from this study. All participants were in sinus rhythm. Major cardiac arrhythmias that precluded steadily analyzable tracking with various cycle lengths were also excluded from this study. This study was approved by the Mackay Memorial Hospital, international ethical review committees (MMH-I-S-626) and all patients gave informed consent.

Traditional echocardiographic measurements A cardiovascular ultrasound system (iE33; Philips, Andover, Massachusetts, USA) equipped with a multiple frequency phased array S5 transducer (2.5– 4.0 MHz) was used in this study. All subjects were in the left free wall decubitus position during echocardiographic acquisition with the examination protocol performed in accordance with the recommendations of the American Society of Echocardiography [20]. LVEF was calculated using the Simpson’s

Automatic Tricuspid Annular Tracking in Heart Failure rule algorithm from the apical four-chamber view with the following formula: LVEF = [(LV end-diastolic volume – LV end-systolic volume)/LV end-diastolic volume] × 100%. LV mass was assessed by the following formula: LVmass (g) = 0.8 × {1.05 × [(LVID + IVST + PWT)3 – (LVID)3]} + 0.6, where LVID is the left ventricular internal dimension, IVST is the intraventricular septum thickness and PWT is the posterior wall thickness. Relative wall thickness was further assessed by using the following equation: relative wall thickness = (2 × PWT/LVID) × 100. Ventricular diastolic parameters including early mitral inflow Doppler, late mitral inflow Doppler, deceleration time of E (DT) and isovolumic relaxation time (IVRT) were all obtained from the LV apical four-chamber view with adequate settings.

Assessment of tricuspid annular displacement and velocity A novel tissue tracking commercialized software (2DQ, QLab, version 6.0 or 7.0; Figure 53 LLC, Baltimore, Maryland, USA) based on 2D (B-mode) images was used to track TA motion in an off-line fashion. We predefined the widest transverse axis of

TA and the longest longitudinal axis of RV on the apical four-chamber view. The widest transverse axis consisted of two points: one in the septal and the other in the free wall aspects of the TA (Fig. 1). Another point at the apical area of the RV was placed at the longest distance vertical to the widest transverse axis as possible. The landmarks were manually placed, followed by automatic frame-by-frame tracking of TA throughout the whole cardiac cycle by QLab software with the highest frames possible (an average of more than 60 frames per second [fps]). A color-encoded display of TA motion through the whole systolic phase was then acquired with quantitative analysis of longitudinal TA displacement defined as TAD, presented as TMAD1 on the free wall and TMAD2 on the septal aspect of TA (Fig. 1). Similarly, PSTAV was obtained by utilizing the Doppler myocardial imaging method including that obtained from the basal segment from the both free wall and septal aspect of the TA from the apical four-chamber view with the highest frame rates possible (average 80–120 fps). The ultrasound beam was adjusted to parallel the cardiac long axis as much as possible. RVFAC was calculated in

A

B

C

D

Fig. 1. Automatic tracking with objective quantification of tricuspid annular displacement (TAD) by QLab software in both the septum and free wall. (A) Upper plane shows a normal person and the TAD free wall aspect is presented as TMAD1 and the septal aspect is presented as TMAD2. (B) TAD in patients with diastolic heart failure, (C) systolic heart failure, and (D) dilated cardiomyopathy. J Med Ultrasound 2010 • Vol 18 • No 3

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H.C. Lin, C.J.Y. Hou, T.C. Hung, et al 35 randomly selected participants in our study group according to the following equation as previously described [5]: RVFAC = [(RV end-diastolic – RV end-systolic area)/RV end-diastolic area] × 100%.

Reproducibility Repeated measurements of TAD from 20 randomly selected participants in this study determined interobserver and intraobserver variability. Coefficient of variation of 95% limits of agreement from the Bland-Altman method were used for variability analysis. Intraobserver variability was defined as the mean of the absolute difference between two measurements from a single observer on a given echocardiography study. Interobserver variability was similarly defined by using the difference between measurements from two independent observers.

Statistical analysis All data were analyzed using the statistical STATA software program (Stata Corp., College Station, Texas, USA). Continuous data were presented as mean ± SD. Categorical data were reported as a percentage and tested by the χ2 or Fisher’s exact test as appropriate. Linear regression analysis was performed to display the relationship between TAD RVFAC and PSTAV. One-way analysis of variance was used to compare the difference in variables among groups; post hoc analysis was used for paired comparisons between each group. Any two-sided p less than 0.05 was considered to be statistically significant.

Results Differences in ventricular structure and baseline data between the groups The demographic data of all participants are shown in Table 1. No significant differences in age and sex were observed among the four groups. Parameters with respect to LV function and LV mass measurements are also displayed in Table 1. The average blood pressure, either systolic or diastolic, was higher in the heart failure groups compared

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with the control group (all p < 0.05). In addition, there was a significant increase in the thickness of the LV posterior wall and septum in patients with DHF compared with the control group. Similarly, the thickness of the LV posterior wall and septum in DHF group was significantly greater than those of the DCM group. Patients with DCM had the largest LV end-diastolic volume and the lowest LVEF. In patients with DHF, LV end-diastolic volume and ejection fraction were not significantly different compared with those of the control group. Moreover, in patients with SHF, the mean LV end-diastolic volume and LVEF values were in between the DHF and DCM groups, suggesting a graded decrease in LVEF and an increase in LV end-diastolic volume from the DHF to the DCM group (p < 0.05). There was a significantly larger LV mass in patients with DCM and SHF compared with the DHF and control subjects. Diastolic parameters including mitral inflow DT and IVRT were also significantly different among the groups, with a shorter DT in the SHF and DCM groups compared with the other groups. In addition, a significantly graded decrease of IVRT was observed from the control to the DHF, SHF to DCM groups.

Validation and correlation among TAD, RVFAC, and PSTAV The values of TAD and PSTAV of the four groups are shown in Table 2. There were significant differences in TAD and PSTAV among the four groups (p < 0.001 for both the septal and free walls). However, there was no significant difference in TAD between the DCM and SHF groups (post hoc test, p = 0.582 for the septal wall and p = 0.325 for the free wall). As expected, septal PSTAV showed no significant difference between the DCM and SHF groups (post hoc test, p = 0.529). Unexpectedly, there was a significant difference in lateral PSTAV between these two groups (post hoc test, p = 0.007). There was a strong linear correlation between RVFAC and TAD (septum, r = 0.79; p = 0.0008; free wall, r = 0.70; p = 0.006). In addition, TAD had a strong correlation with PSTAV (free wall, r = 0.58; septum, r = 0.69, both p < 0.0001; Fig. 2).

Automatic Tricuspid Annular Tracking in Heart Failure Table 1. Comparison of participants demographics, parameters on left ventricular (LV) function and mass Heart failure SHF (n = 30)

DHF (n = 40)

Control (n = 20)

67.6/32.4

55.2/44.8

55.3/44.7

38.4/61.5

NS

67.1 ± 16.0

66.6 ± 15.0

63.5 ± 13.0

61.5 ± 8.0

NS

SBP

136.7 ± 19.1

141.9 ± 23.3

139.1 ± 18.7

121.5 ± 11.4

p < 0.05*†‡

DBP

79.5 ± 12.3

82.7 ± 12.8

81.2 ± 12.2

67.3 ± 11.7

p < 0.05*†‡

1.0 ± 0.2

1.1 ± 0.2

1.2 ± 0.2

1.0 ± 0.1

p = 0.007*, p = 0.01

Groups Sex (M/F) (%) Age (yr)

DCM (n = 36)

p

LV echo parameter PW (cm) IVS (cm)

1.1 ± 0.2

1.1 ± 0.2

1.1 ± 0.2

1.0 ± 0.1

p = 0.05*

LVIDd (cm)

5.9 ± 0.8

5.6 ± 1.1

4.9 ± 0.7

4.8 ± 0.4

p = 0.02†, p < 0.0001‡ , p = 0.002§

LVEDV (mL)

178.5 ± 51.4

174.5 ± 79.6

117.6 ± 37.4

110 ± 20.8

p = 0.003†, p = 0.001‡, p < 0.0001§

LVESV (mL)

124.6 ± 40.3

98.3 ± 48.6

47.9 ± 16.7

34.9 ± 10.6

p < 0.0001†‡§ p = 0.02¶

27.7 ± 5.9 38 ± 9.5

42.2 ± 4.2 40 ± 6.5

59.3 ± 5.6 43.5 ± 7.8

68.9 ± 5.6 40.0 ± 6.5

p < 0.0001†‡§ p = 0.014

263.7 ± 79.2

270.4 ± 131.2

225.0 ± 90.6

164.6 ± 19.7

LVEF (%) RWT (%) LV mass (g)



p = 0.007†, p = 0.01‡

E (cm/s)

86.1 ± 13.9

75.1 ± 18.2

64 ± 9.0

74.1 ± 13.5

p < 0.001

A (cm/s)

45 ± 17.2

58.4 ± 19.7

58.4 ± 19.7

64.9 ± 13.6

p = 0.005§, p = 0.011†, p < 0.001

DT (ms) IVRT (ms)

147 ± 24.4 71 ± 5.1

169.9 ± 23.4 78.3 ± 4.0

226.9 ± 34.8 88.3 ± 8.7

201.8 ± 19.7 80.3 ± 6.5

63.3

65

36.2

0

Diabetes

47.6

40

40

0



Coronary artery disease

67.3

65

33.3

0



Hyperlipidemia

27.6

30

26.7

0



2.7

2.6

1.6

0



p < 0.0001†‡§ p = 0.005*, p < 0.0001†§ , p = 0.015¶

Medication history (%) Hypertension

NYHA Fc



Analysis of variance was used to compare the variables. *Differences between the control and DHF groups; †between the control and SHF groups; ‡ between the control and DCM groups; §between the DHF and SHF groups; between the DHF and DCM groups; ¶between the SHF and DCM groups. DCM = dilated cardiomyopathy; SHF = systolic heart failure; DHF = diastolic heart failure; SBP = systolic blood pressure; DBP = diastolic blood pressure; LV = left ventricular; PW = posterior wall thickness; IVS = interventricular septum thickness; LVIDd = LV internal dimension measurement in diastole; LVEDV = LV end diastolic volume; LVESV = LV end systolic volume; LVEF = LV ejection fraction; RWT = relative wall thickness; E = early diastolic mitral inflow Doppler; A = late diastolic mitral inflow Doppler; DT = deceleration time of E wave; IVRT = iso-volumic relaxation time; NYHA Fc = New York Heart Association Functional Class.

Relationship between TAD and LV structure and function A graded reduction of both TAD in the septal and free walls was observed among the control, DHF, SHF and DCM patient groups (trend, p < 0.01, Fig. 3).

Patients with a lower LVEF had a lower value of TAD (r = 0.68 vs. r = 0.61 for septal and free wall, p < 0.001) and a lower value of PSTAV (r = 0.66 vs. r = 0.57 for septal and free wall, p < 0.001). Although there was no significant difference in LVEF between J Med Ultrasound 2010 • Vol 18 • No 3

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H.C. Lin, C.J.Y. Hou, T.C. Hung, et al Table 2. Parameters of tricuspid annular displacement and velocity Groups

DCM (n = 36)

SHF (n = 30)

DHF (n = 40)

Control (n = 20)

Analysis of variance

Post hoc p

5.3 ± 0.4

6.4 ± 0.4

11.4 ± 0.4

14.3 ± 0.6

10.0 ± 0.7

12.5 ± 0.9

18.1 ± 0.7

28.1 ± 1.7

F = 32.59 p < 0.00001 F = 26.40 p < 0.00001

p = 0.001*, p < 0.0001†‡§ p = 0.582¶ p < 0.0001*†‡§ , p = 0.325¶

3.5 ± 0.2

4.7 ± 0.3

7.0 ± 0.3

7.5 ± 0.5

7.2 ± 0.5

9.7 ± 0.7

12.2 ± 0.3

12.5 ± 0.5

F = 50.33 p < 0.00001 F = 14.22 p < 0.00001

p < 0.0001†‡§ p = 0.529¶ p = 0.002†, p < 0.0001‡§ , p = 0.007¶

TAD Septal (mm) Free wall (mm) PSTAV Septal (cm/s) Free wall (cm/s)

*Differences between the control and DHF groups; †between control and SHF group; ‡between the control and DCM groups; §between the DHF and SHF groups; between the DHF and DCM groups; ¶between the SHF and DCM groups. DCM = dilated cardiomyopathy; SHF = systolic heart failure; DHF = diastolic heart failure; TAD = tricuspid annular displacement; PSTAV = peak systolic tricuspid annular velocity.

TAD septum (mm)

20

ψ = 0.423 × χ + 1.03, 95% CI: 0.37–0.48, p < 0.001 R2 = 0.69 Adjusted R2 = 0.68

B 40 TAD free-wall (mm)

A

15 10 5

30 20 10

0

0

C

2 4 6 PSTAV septum (cm/sec)

20

2

8

D

r = 0.3368, p = 0.0001

15 10 5 0 –5

4 6 8 PSTAV free-wall (cm/sec)

40 TAD free-wall (mm)

0

TAD septum (mm)

ψ = 0.31 × χ + 4.19, 95% CI: 0.26–0.36, p < 0.001 R2 = 0.58 Adjusted R2 = 0.58

10

r = 0.3431, p = 0.0001

30 20 10 0 –10

0

200

EF ≥ 50%

400 LV mass (g)

600

EF > 35 & < 50%

800

EF < 35%

0

95% Cl

200

400 LV mass (g)

600

800

Fitted values

Fig. 2. (A,B) Correlation between tricuspid annular displacement (TAD), peak systolic tricuspid annular velocity (PSTAV) from Doppler myocardial imaging. (C,D) Correlation between TAD and left ventricular (LV) mass. A good correlation between PSTAV and TAD was observed on both the septum and free wall. In addition,there appeared to be an inverse relationship between LV mass and TAD with a larger LV mass related to a reduction in TAD value. Moreover, persons with a lower LV ejection fraction (EF) also seemed to have a lower TAD regardless of the LV mass from this scatter plot.

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Automatic Tricuspid Annular Tracking in Heart Failure the DHF and control groups, the DHF patients still had a lower TAD value than did the control group (septal wall, p = 0.001; free wall, p < 0.0001; Table 2). Although patients with DCM had a smaller value of TAD than the SHF group, there was no significant difference in TAD between these groups (septal wall, p = 0.582; free wall, p = 0.325; Table 2). Linear regression analysis demonstrated a strong negative correlation between TAD and LV mass (septal wall, r = − 0.34; free wall, r = − 0.34; both p < 0.0001; Fig. 2). Moreover, LV end-diastolic volume in each subject showed a significant negative correlation with TAD (septal wall, r = − 0.41; free wall, r = − 0.36; both p < 0.001). However, there was no significant difference between TAD and relative wall thickness. The intraobserver and interobserver variability were less than 5%.

Our study demonstrated that automatic TAD correlated not only with RV function and systolic tricuspid annular myocardial velocity, but correlated with LVEF. It appears that LV structure and function may have an impact on TAD. We found that while patients with HF had a relatively preserved LVEF, they also had

reduced TAD. A similar finding has been reported by Lopez-Candales et al [13]. They demonstrated that TAPSE is not only determined by RV systolic function but also appears to depend on LV systolic function. They also found that TAPSE < 2.0 cm was associated with some degree of either RV or LV systolic dysfunction, whereas a value > 2.0 cm suggested normal biventricular systolic function. Previous studies [21] using pulse-wave Doppler tissue imaging reported that patients with congestive heart failure had significantly smaller tricuspid annular velocities compared with healthy volunteers. Lamia et al [14] reported that TAPSE was more strongly related to LVEF than to indices of RV function in critically ill patients under different fluid load or receiving inotropic status. They concluded that a worse LV systolic function was associated with a smaller value of TAD, which is compatible with poor RV function. We found that heart failure patients with a preserved systolic function had a mean free wall TAD of 18.1 mm and normal controls was 28.1 mm. Furthermore, a mean free-wall TAD of 10 mm or less was associated with severely impaired LV function with generalized ventricular chamber dilatation. As expected, we found that patients with DHF had a smaller value of TAD than control subjects despite no significant differences in LVEF. This finding suggests that TAD may have the

A

B

Discussion

Trend p < 0.01

Trend p < 0.01

40

15

TAD free-wall (mm)

TAD septum (mm)

20

10

5

0

30

20

10

0 DCM

SHF

DHF

Control

DCM

SHF

DHF

Control

Fig. 3. A graded reduction of tricuspid annular displacement (TAD) from normal to heart failure patients with worsening left ventricular ejection fraction (LVEF) was observed. TAD was lower for patients with heart failure symptoms and preserved LVEF when compared with the normal control group. There were no significant differences for TAD in the systolic heart failure (SHF) and dilated cardiomyopathy (DCM) groups. DHF = diastolic heart failure. J Med Ultrasound 2010 • Vol 18 • No 3

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H.C. Lin, C.J.Y. Hou, T.C. Hung, et al potential to identify early-stage heart failure even with preserved LVEF. Therefore, our data may help to serve as a useful clinical reference relating TAD to different stage LV functional changes and clinical heart failure symptoms. Importantly, the parameter TAD was not only angle-independent by 2D STE but also was automatically calculated in a very short time. This technique may potentially provide a more rapid and feasible evaluation of biventricular function in patients with heart failure. It is recently believed that ventricular geometric alteration and remodeling, either on the left or right side in terms of chamber dilatation, is considered to confer prognostic value in patients with heart failure despite preserved or systolic dysfunction [22]. One of the most important issues of geometrical LV remodeling is an increase in LV mid-cavity size, mass and workload of the heart, which is then detrimental to cardiac function. Many studies have shown that LV mass is a strong indicator for LV structural alterations and a marker for LV remodeling, which is associated with cardiovascular risks [23,24]. Our data also demonstrated an inverse linear correlation between TAD and LV mass where an increase in LV mass was correlated with a decrease in TAD value. Therefore, TAD appears to be associated with LV structural alteration and the remodeling process, and could reflect early cardiac damage. Interestingly, our data demonstrated no significant differences in TAD between patients with DCM and SHF. Although both ventricular long-axis and short-axis functions are jeopardized by cardiac diseases, it is likely that long-axis function deteriorates much earlier before short-axis function is affected [25−27]. Thus, in an overwhelmed failing heart, longitudinal function may be severely impaired and fail to make any difference regardless of cavity dilation. TAD, a parameter reflecting longitudinal function, may not be used to differentiate between patients with DCM and SHF. There are several limitations to our study. First, the potential impact and extent of the hemodynamic load on biventricular function reflected by TAD was not assessed in our study. Future investigations focusing on RV or LV with an acute pressure or volume

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load on TAD may determine this issue. Second, our tracking technique was only applicable for longitudinal tracking, and therefore, both circumferential and radial cardiac mechanics were not feasible in this study. Third, the time differences in terms of interventricular asynchrony based on TAD assessment may also play a role in understanding the full spectrum of heart failure pathophysiology but was not addressed in our study.

Conclusion Our data suggested that automatic TAD, an objective assessment of right ventricular longitudinal function, could be clinically feasible and easily applied, not only in the adjunctive assessment of biventricular systolic functional evaluation, but also in predicting earlier stage heart failure. In addition, we found that cardiac longitudinal contraction worsen indicating subclinical dysfunction, even in patients with preserved LVEF.

References 1. Polak JF, Holman BL, Wynne J, et al. Right ventricular ejection fraction: an indicator of increased mortality in patients with congestive heart failure associated with coronary artery disease. J Am Coll Cardiol 1983;2:217–24. 2. Juilliere Y, Barbier G, Feldmann L, et al. Additional predictive value of both left and right ventricular ejection fractions on long-term survival in idiopathic dilated cardiomyopathy. Eur Heart J 1997;18:276–80. 3. De Groote P, Millaire A, Foucher-Hossein C, et al. Right ventricular ejection fraction is an independent predictor of survival in patients with moderate heart failure. J Am Coll Cardiol 1998;32:948–54. 4. Ueti OM, Camargo EE, Ueti Ade A, et al. Assessment of right ventricular function with Doppler echocardiographic indices derived from tricuspid annular motion: comparison with radionuclide angiography. Heart 2002;88:244–8. 5. Miller D, Farah MG, Liner A, et al. The relation between quantitative right ventricular ejection and indices of tricuspid annular motion and myocardial performance. J Am Soc Echocardiogr 2004;17:443–7.

Automatic Tricuspid Annular Tracking in Heart Failure 6. Saxena N, Rajaqopalan N, Edelman K, et al. Tricuspid annular systolic velocity: a useful measurement in determining right ventricular function regardless of pulmonary artery pressures. Echocardiography 2006;23: 750–5. 7. Bleeker GB, Steendijk P, Holman ER, et al. Assessing right ventricular function: the role of echocardiography and complementary technologies. Heart 2006; 92 (Suppl):i19–26. 8. Spencer KT, Bednarz J, Mor-Avi V, et al. Automatic endocardial border detection and evaluation of left ventricular function from contrast-enhanced images using modified acoustic quantification. J Am Soc Echocardiogr 2002;15:777–81. 9. Helle-Valle T, Crosby J, Edvardsen T, et al. New noninvasive method for assessment of left ventricular rotation: speckle tracking echocardiography. Circulation 2005;111:1141–7. 10. De Cara JM, Toledo E, Salgo IS, et al. Evaluation of left ventricular systolic function using automatic angle-independent motion tracking of mitral annular displacement. J Am Soc Echocardiogr 2005;18:1266–9. 11. Yu CM, Lin H, Yang H, et al. Progression of systolic abnormalities in patients with isolated diastolic heart failure and diastolic dysfunction. Circulation 2002;105: 1195–201. 12. Yip G, Wang M, Zhang Y, et al. Left ventricular long axis function in diastolic heart diastolic failure is reduced in both diastole and systole: time for a redefinition? Heart 2002;87:121–5. 13. Lopez-Candales A, Rajaqopalan N, Saxena N, et al. Right ventricular systolic function is not the sole determinant of tricuspid annular motion. Am J Cardiol 2006;98:973–7. 14. Lamia B, Teboul JL, Monnet X, et al. Relationship between the tricuspid annular plane systolic excursion and right and left ventricular function in critically ill patients. Intensive Care Med 2007;33:2143–9. 15. Bore AA, Santamore WP. Ventricular interdependence. Prod Cardiovasc Dis 1981;23:365–88. 16. Saleh S, Liakopoulos OJ, Buckberg GD. The septum motor of biventricular function. Eur J Cardiothorac Surg 2006;29:S126–38. 17. Sliwa K, Woodiwiss A, Candy G, et al. Effect of pentoxifylline on cytokine profiles and left ventricular performance in patients with decompensated congestion heart failure secondary to idiopathic dilated cardiomyopathy. Am J Cardiol 2002;15:1118–22.

18. Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American society of echocardiography’s guidelines and standards committee and the chamber quantification writing group, developed in conjunction with the European association of echocardiography, a branch of the European society of cardiology. J Am Soc Echocardiogr 2005;18:1440–63. 19. Alam M, Wardell J, Anderesson E, et al. Assessment of left ventricular function using mitral annular velocities in patients with congestive heart failure with or without the presence of significant mitral regurgitation. J Am Soc Echocardiogr 2003;16:240–5. 20. Wilson EM, Spinale FG. Myocardial remodeling and matrix metalloproteinase in heart failure: turmoil within the interstitium. Ann Med 2001;33: 623–34. 21. Hecbert SR, Post W, Pearson GD, et al. Traditional cardiovascular risk factors in relation to left ventricular mass, volume and systolic function by cardiac magnetic resonance imaging: the multiethnic study. J Am Coll Cardiol 2006;48:2285–92. 22. Bluemke DA, Kronmal RA, Lima JAC, et al. The relationship of left ventricular mass and geometry to incident cardiovascular event: the MESA study. J Am Coll Cardiol 2008;52:2148–55. 23. Onose Y, Oki T, Mishiro Y, et al. Influence of aging on systolic left ventricular wall motion velocities along the long and short axes in clinically normal patients determined by pulsed tissue Doppler imaging. J Am Soc Echocardiogr 1999;12:921–6. 24. Fang ZY, Leano R, Marwick TH. Relationship between longitudinal and radial contractility in subclinical diabetic heart disease. Clin Sci 2004;106:53–60. 25. Koulouris SN, Kostopoulos KG, Triantafyllou KA, et al. Impaired systolic dysfunction of left ventricular longitudinal fibers: a sign of early hypertensive cardiomyopathy. Clin Cardiol 2005;28:282–6. 26. Zhang Q, Fung JW, Yip G, et al. Improvement of left ventricular myocardial short-axis, but not long-axis function or torsion after cardiac resynchronization therapy—an assessment by two-dimensional speckle tracking. Heart 2008;94:1464–71. 27. Wang J, Khoury DS, Yue Y, et al. Preserved left ventricular twist and circumferential deformation, but depressed longitudinal and radial deformation in patients with diastolic heart failure. Eur Heart J 2008; 29:1283–9.

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