Left ventricular strain and strain rate by 2D speckle tracking in chronic thromboembolic pulmonary hypertension before and after pulmonary thromboendarterectomy

Nicholas Olson, Jason P Brown, Andrew M Kahn, William R Auger, Michael M Madani, Thomas J Waltman, Daniel G Blanchard, Nicholas Olson, Jason P Brown, Andrew M Kahn, William R Auger, Michael M Madani, Thomas J Waltman, Daniel G Blanchard

Abstract

Background: Echocardiographic evaluation of left ventricular (LV) strain and strain rate (SR) by 2D speckle tracking may be useful tools to assess chronic thromboembolic pulmonary hypertension (CTEPH) severity as well as response to successful pulmonary thromboendarterectomy (PTE).

Methods: We evaluated 30 patients with CTEPH before and after PTE using 2D speckle tracking measurements of LV radial and circumferential strain and SR in the short axis, and correlated the data with right heart catheterization (RHC).

Results: PTE resulted in a decrease in mean PA pressure (44 ± 15 to 29 ± 9 mmHg), decrease in PVR (950 ± 550 to 31 ± 160 [dyne-sec]/cm⁵), and an increase in cardiac output (3.9 ± 1.0 to 5.0 ± 1.0 L/min, p < 0.001 for all). Circumferential and posterior wall radial strain changed by -11% and +15% respectively (p < 0.001 for both). Circumferential SR and posterior wall radial SR changed by -7% and 6% after PTE. While the increase in posterior wall SR with PTE reached statistical significance (p = 0.04) circumferential SR did not (p = 0.07). In addition, septal radial strain and SR did not change significantly after PTE (p = 0.1 and 0.8 respectively). Linear regression analyses of circumferential and posterior wall radial strain and SR revealed little correlation between strain/SR measurements and PVR, mean PA pressure, or cardiac output. However, change in circumferential strain and change in posterior wall radial strain correlated moderately well with changes in PVR, mean PA pressure and cardiac output (r = 0.69, 0.76, and 0.51 for circumferential strain [p < 0.001 for all] and r = 0.7, 0.7, 0.45 for posterior wall radial strain [p = 0.001, 0.001, and 0.02, respectively]).

Conclusions: LV circumferential and posterior wall radial strain change after relief of pulmonary arterial obstruction in patients with CTEPH, and these improvements occur rapidly. These changes in LV strain may reflect effects from improved LV diastolic filling, and may be useful non-invasive markers of successful PTE.

Figures

Figure 1
Figure 1
For 2D speckle tracking, a R.O.I. was selected at the level of the papillary muscles. The myocardium was divided into 6 segments in accordance with the standard 16 segment left ventricular model.
Figure 2
Figure 2
Left ventricular global circumferential strain (top left, dotted) and strain rate (top right, dotted) as well as radial strain (bottom left) and strain rate (bottom right) are displayed from a patient with CTEPH. The septal and posterior walls are outlined in red and purple respectively. The posterior wall radial strain is displayed post-PTE demonstrating the relative the hypokinesis of the septal segment (red).
Figure 3
Figure 3
Linear regression plots of change in posterior wall radial strain (left column) and change in circumferential strain (right column) vs. RHC data. Measures of linear fit (R values) are displayed in table 3. (Circ: circumferential).

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