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Feasibility of semi-recumbent bicycle exercise Doppler echocardiography for the evaluation of the right heart and pulmonary circulation unit in different clinical conditions: the RIGHT heart international NETwork (RIGHT-NET)

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Abstract

Exercise Doppler echocardiography (EDE) is a well-validated tool in ischemic and valvular heart diseases. However, its use in the assessment of the right heart and pulmonary circulation unit (RH-PCU) is limited. The aim of this study is to assess the semi-recumbent bicycle EDE feasibility for the evaluation of RH-PCU in a large multi-center population, from healthy individuals and elite athletes to patients with overt or at risk of developing pulmonary hypertension (PH). From January 2019 to July 2019, 954 subjects [mean age 54.2 ± 16.4 years, range 16–96, 430 women] underwent standardized semi-recumbent bicycle EDE with an incremental workload of 25 watts every 2 min, were prospectively enrolled among 7 centers participating to the RIGHT Heart International NETwork (RIGHT-NET). EDE parameters of right heart structure, function and pressures were obtained according to current recommendations. Right ventricular (RV) function at peak exercise was feasible in 903/940 (96%) by tricuspid annular plane systolic excursion (TAPSE), 667/751 (89%) by tissue Doppler-derived tricuspid lateral annular systolic velocity (S′) and 445/672 (66.2%) by right ventricular fractional area change (RVFAC). RV—right atrial pressure gradient [RV–RA gradient = 4 × tricuspid regurgitation velocity2 (TRV)] was feasible in 894/954 patients (93.7%) at rest and in 816/954 (85.5%) at peak exercise. The feasibility rate in estimating pulmonary artery pressure improved to more than 95%, if both TRV and/or right ventricular outflow tract acceleration time (RVOT AcT) were considered. In high specialized echocardiography laboratories semi-recumbent bicycle EDE is a feasible tool for the assessment of the RH-PCU pressure and function.

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Data availability

The data that support the findings of this study are available on request from the corresponding author [EB].

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Acknowledgements

Co-Principal Investigators: Eduardo Bossone (A Cardarelli Hospital, Naples, Italy), Luna Gargani (Institute of Clinical Physiology, CNR, Pisa, Italy), Robert Naeije (Free University of Brussels, Brussels, Belgium). Study Coordinator: Francesco Ferrara (Cava de’ Tirreni and Amalfi Coast Division of Cardiology, University Hospital, Salerno, Italy). Co-Investigators: William F. Armstrong, Theodore John Kolias (University of Michigan, Ann Arbor, USA); Eduardo Bossone, Rosangela Cocchia, Ciro Mauro, Chiara Sepe (A Cardarelli Hospital, Naples, Italy); Filippo Cademartiri, Brigida Ranieri, Andrea Salzano (IRCCS SDN, Diagnostic and Nuclear Research Institute, Naples, Italy); Francesco Capuano (Department of Industrial Engineering, Università di Napoli Federico II, Naples, Italy); Rodolfo Citro, Rossella Benvenga, Michele Bellino, Ilaria Radano (University Hospital of Salerno, Salerno, Italy); Antonio Cittadini, Alberto Marra, Roberta D’Assante, Salvatore Rega (Federico II University of Naples, Italy); Michele D’Alto, Paola Argiento (University of Campania "Luigi Vanvitelli", Naples, Italy); Antonello D’Andrea (Umberto I° Hospital Nocera Inferiore, Italy); Francesco Ferrara, Carla Contaldi (Cava de’ Tirreni and Amalfi Coast Hospital, University Hospital of Salerno, Italy); Luna Gargani, Matteo Mazzola, Marco Raciti (Institute of Clinical Physiology, CNR, Pisa, Italy); Santo Dellegrottaglie (Ospedale Medico-Chirurgico Accreditato Villa dei Fiori, Acerra—Naples, Italy); Nicola De Luca, Francesco Rozza, Valentina Russo (Hypertension Research Center, University Federico II of Naples, Italy); Giovanni Di Salvo (University of Padova, Italy; Imperial College, London, UK); Stefano Ghio, Stefania Guida (I.R.C.C.S. Policlinico San Matteo, Pavia, Italy); Ekkerard Grunig, Christina A. Eichstaedt (Heidelberg University Hospital, Germany); Marco Guazzi, Francesco Bandera, Valentina Labate (IRCCS Policlinico San Donato, University of Milan, Milan, Italy); André La Gerche (Baker Heart and Diabetes Institute, Melbourne, Australia); Giuseppe Limongelli, Giuseppe Pacileo, Marina Verrengia (University of Campania "Luigi Vanvitelli", Naples, Italy); Jaroslaw D. Kasprzak, Karina Wierzbowska-Drabik (Bieganski Hospital, Medical University of Lodz Poland); Gabor Kovacs, Philipp Douschan (Medical University of Graz, Graz, Austria); Antonella Moreo, Francesca Casadei, Benedetta De Chiara, (Niguarda Hospital, Milan, Italy); Robert Naeije (Free University of Brussels, Brussels, Belgium); Ellen Ostenfeld (Lund University, Skåne University Hospital, Sweden); Gianni Pedrizzetti (Department of Engineering and Architecture, University of Trieste); Francesco Pieri, Fabio Mori, Alberto Moggi-Pignone (Azienda Ospedaliero-Universitaria Careggi, Florence, Italy); Lorenza Pratali (Institute of Clinical Physiology, CNR, Pisa, Italy); Nicola Pugliese (Department of Clinical and Experimental Medicine, University of Pisa, Italy); Rajan Saggar (UCLA Medical Center,Los Angeles, USA); Rajeev Saggar (Banner University Medical Center, Phoenix, Arizona, USA); Christine Selton-Suty, Olivier Huttin, Clément Venner (University Hospital of Nancy, France); Walter Serra, Francesco Tafuni (University Hospital of Parma, Italy); Anna Stanziola, Maria Martino, Giovanna Caccavo (Department of Respiratory Disease, Federico II University, Monaldi Hospital, Naples, Italy); István Szabó (University of Medicine and Pharmacy of Târgu Mureş, Târgu Mureş, Romania); Albert Varga, Gergely Agoston, (University of Szeged, Szeged, Hungary); Darmien Voilliot (Centre Hospitalier Lunéville, France); Olga Vriz (Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia); Mani Vannan, Sara Mobasseri, Peter Flueckiger, Shizhen Liu (Piedmont Heart Institute, USA.

Author information

Author notes

  1. Eduardo Bossone and Jaroslaw D. Kasprzak contributed equally to this work.

Authors and Affiliations

  1. Cardio-Thoracic-Vascular Department, University Hospital “San Giovanni Di Dio E Ruggi D’Aragona”, Salerno, Italy

    Francesco Ferrara, Rodolfo Citro & Carla Contaldi

  2. Institute of Clinical Physiology - C.N.R, Pisa, Italy

    Luna Gargani & Eduardo Bossone

  3. Free University of Brussels, Brussels, Belgium

    Robert Naeije

  4. Azrieli Heart Center and Center for Pulmonary Vascular Diseases, Jewish General Hospital, McGill University, Montreal, QC, Canada

    Lawrence Rudski

  5. Division of Cardiovascular Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA

    William F. Armstrong, Ekkehard Grünig & Theodore John Kolias

  6. I Department and Chair of Cardiology, Bieganski Hospital, Medical University of Lodz, Lodz, Poland

    Karina Wierzbowska-Drabik & Jaroslaw D. Kasprzak

  7. Department of Cardiology, University of Campania “Luigi Vanvitelli”, Naples, Italy

    Paola Argiento, Michele D’Alto & Giuseppe Limongelli

  8. Heart Failure Unit and Cardiopulmonary Laboratory, IRCCS Policlinico San Donato University Hospital, Milan, Italy

    Francesco Bandera & Marco Guazzi

  9. Department for Biomedical Sciences for Health, University of Milano, Milan, Italy

    Francesco Bandera & Marco Guazzi

  10. IRCCS SDN, Naples, Italy

    Filippo Cademartiri & Brigida Ranieri

  11. Department of Translational Medical Sciences, Federico II University, Naples, Italy

    Antonio Cittadini, Alberto Maria Marra & Andrea Salzano

  12. Cardiology Division, A Cardarelli Hospital, Naples, Italy

    Rosangela Cocchia, Ciro Mauro & Eduardo Bossone

  13. Department of Cardiology, Umberto I Hospital Nocera Inferiore, Nocera Inferiore, Italy

    Antonello D’Andrea

  14. Center of Pulmonary Hypertension, Thoraxklinik Heidelberg at Heidelberg University Hospital, Heidelberg, Germany

    Ekkehard Grünig

  15. A. De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy

    Antonella Moreo

  16. Lung & Heart-Lung Transplant and Pulmonary Hypertension Programs, David Geffen School of Medicine, UCLA, Los Angeles, USA

    Rajan Saggar

  17. Department of Respiratory Diseases, Monaldi Hospital, University “Federico II”, Naples, Italy

    Anna Agnese Stanziola

  18. Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

    Olga Vriz

  19. Piedmont Heart Institute, Marcus Heart Valve Center, Atlanta, USA

    Mani Vannan

Authors
  1. Francesco Ferrara
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  2. Luna Gargani
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  3. Robert Naeije
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  4. Lawrence Rudski
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Consortia

the RIGHT Heart International NETwork (RIGHT-NET)

  • Eduardo Bossone
  • , Luna Gargani
  • , Robert Naeije
  • , Francesco Ferrara
  • , William F. Armstrong
  • , Theodore John Kolias
  • , Eduardo Bossone
  • , Rosangela Cocchia
  • , Ciro Mauro
  • , Chiara Sepe
  • , Filippo Cademartiri
  • , Brigida Ranieri
  • , Andrea Salzano
  • , Francesco Capuano
  • , Rodolfo Citro
  • , Rossella Benvenga
  • , Michele Bellino
  • , Ilaria Radano
  • , Antonio Cittadini
  • , Alberto Marra
  • , Roberta D’Assante
  • , Salvatore Rega
  • , Michele D’Alto
  • , Paola Argiento
  • , Antonello D’Andrea
  • , Francesco Ferrara
  • , Carla Contaldi
  • , Luna Gargani
  • , Matteo Mazzola
  • , Marco Raciti
  • , Santo Dellegrottaglie
  • , Nicola De Luca
  • , Francesco Rozza
  • , Valentina Russo
  • , Giovanni Di Salvo
  • , Stefano Ghio
  • , Stefania Guida
  • , Ekkerard Grunig
  • , Christina A. Eichstaedt
  • , Marco Guazzi
  • , Francesco Bandera
  • , Valentina Labate
  • , André La Gerche
  • , Giuseppe Limongelli
  • , Giuseppe Pacileo
  • , Marina Verrengia
  • , Jaroslaw D. Kasprzak
  • , Karina Wierzbowska-Drabik
  • , Gabor Kovacs
  • , Philipp Douschan
  • , Antonella Moreo
  • , Francesca Casadei
  • , Benedetta De Chiara
  • , Robert Naeije
  • , Ellen Ostenfeld
  • , Gianni Pedrizzetti
  • , Francesco Pieri
  • , Fabio Mori
  • , Alberto Moggi-Pignone
  • , Lorenza Pratali
  • , Nicola Pugliese
  • , Rajan Saggar
  • , Rajeev Saggar
  • , Christine Selton-Suty
  • , Olivier Huttin
  • , Clément Venner
  • , Walter Serra
  • , Francesco Tafuni
  • , Anna Stanziola
  • , Maria Martino
  • , Giovanna Caccavo
  • , István Szabó
  • , Albert Varga
  • , Gergely Agoston
  • , Darmien Voilliot
  • , Olga Vriz
  • , Mani Vannan
  • , Sara Mobasseri
  • , Peter Flueckiger
  •  & Shizhen Liu

Contributions

FF, EB analyzed and interpreted the patient data; FF, LG, KWD, PA, FB, RC, CC, MD, AD, AMM, AM, BR, AS, AAS and OV enrolled patients and/or analyzed the echocardiographic data; FF, LR, RN, WA, FC, RC, AC, EG, MG, TK, GL, CM, RS, MV and EB have drafted the work and substantively revised it; FF, JK and EB have designed the study were major contributors in writing the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Eduardo Bossone.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

The study was approved by the institution’s ethics board C.E. Campania Sud (parere n. 84 r.p.s.o.; determina n. 101 del 14-12-2015).

Informed consent

Informed consent was obtained from the participants prior to inclusion to the study. Patients signed informed consent regarding publishing their data.

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The members of The RIGHT Heart International NETwork (RIGHT-NET) are listed in Acknowledgements.

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Ferrara, F., Gargani, L., Naeije, R. et al. Feasibility of semi-recumbent bicycle exercise Doppler echocardiography for the evaluation of the right heart and pulmonary circulation unit in different clinical conditions: the RIGHT heart international NETwork (RIGHT-NET). Int J Cardiovasc Imaging 37, 2151–2167 (2021). https://doi.org/10.1007/s10554-021-02243-x

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