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Right ventricular systolic strain in patients with pulmonary hypertension: clinical feasibility, reproducibility, and correlation with ejection fraction

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Abstract

Background

Right ventricular (RV) systolic function is the major determinant of prognosis in patients with pulmonary hypertension (PH) with quantitative assessment by speckle-tracking strain echocardiography emerging as a viable candidate measure.

Method

We evaluated a prospective cohort of 231 patients with known or suspected PH referred for clinical echocardiography. All underwent measurement of RV free-wall systolic strain by sonographer staff. Digital images were recorded for blinded offline assessment by an expert echocardiographer. Reproducibility was assessed using the analysis methods of Bland–Altman and the Cohen’s-Kappa coefficient.

Results

RV strain was feasible in 213 (92%). The average RV systolic pressure was 59 ± 22 mmHg. RV systolic strain correlated with functional class, NT-proBNP, and the degree of RV enlargement. The average free-wall systolic strain was − 20 ± 7% (range  − 2 to  − 37%). The RV strain measures (clinical practice versus blinded expert) had an excellent correlation with a normal distribution (R2 0.87, p < 0.0001). By Bland–Altman analysis, the mean difference in measurement was − 1.7% (95% CI − 1.4 to − 2.1) with a correlation of 0.93, p value of < 0.0001. The reproducibility of RV strain for clinically relevant thresholds was also excellent (Kappa coefficients 0.68–0.83). There was no effect on the variability of strain measures across body mass, pulmonary pressures, or rhythm. RV strain correlated with RV diastolic volumes and ejection fraction with RV free wall strain being the best echo predictor for a reduction in ejection fraction.

Conclusion

Here RV systolic strain was found to be highly feasible and reproducible in clinical practice with excellent levels of agreement for clinically relevant thresholds.

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Abbreviations

2D:

2-Dimensional

6MWD:

6-Minute walk distance

BMI:

Body mass index

CI:

95% Confidence interval

MPI:

Myocardial performance index

NT-proBNP:

N-terminal proB-type natriuretic peptide

PA:

Pulmonary artery

PH:

Pulmonary hypertension

RA:

Right atria/atrial

RV:

Right ventricle

TAPSE:

Tricuspid annular plane systolic excursion

TR:

Tricuspid valve regurgitation

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Authors and Affiliations

  1. Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA

    Ramaimon Tunthong, Abdalla A. Salama, Conor M. Lane, Nowell M. Fine, Vidhu Anand, Ratnasari Padang, Jeremy J. Thaden, Sorin V. Pislaru & Garvan C. Kane

  2. Non-Invasive Cardiology Department, Bangkok Hospital Headquarters, BDMS, Bangkok, Thailand

    Ramaimon Tunthong

  3. Department of Cardiovascular Diseases, Suez Canal University, Ismailia, Egypt

    Abdalla A. Salama

  4. Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada

    Nowell M. Fine

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Conflict of Interest

Ramaimon Tunthong, Abdalla A. Salama, Conor M. Lane, Nowell M. Fine, Vidhu Anand, Ratnasari Padang, Sorin V. Pislaru, and Garvan C. Kane declare that they have no conflict of interest.

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All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later versions. A waiver of informed consent was obtained from all patients in accordance with institutional policy.

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12574_2022_593_MOESM1_ESM.pptx

Supplemental Figure: The correlations between the measures of RV strain performed by a sonographer as part of routine clinical care versus those measured offline by an expert cardiologist were similar between obese (BMI ≥ 30 kg/m2) and non-obese (BMI < 30 kg/m2) individuals (A); between those in sinus rhythm or in atrial fibrillation (B) or those with a right ventricular systolic pressure (RVSP) of <50 mm Hg or ≥ 50 mm Hg (C)

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Tunthong, R., Salama, A.A., Lane, C.M. et al. Right ventricular systolic strain in patients with pulmonary hypertension: clinical feasibility, reproducibility, and correlation with ejection fraction. J Echocardiogr 21, 105–112 (2023). https://doi.org/10.1007/s12574-022-00593-6

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