|Year : 2020 | Volume
| Issue : 3 | Page : 290-294
Assessment of right ventricular function using right ventricular outflow tract-systolic excursion in inferior wall myocardial infarction and angiographic correlation to proximal right coronary artery stenosis
Samy H Nouh, Ibrahim F Said, Ahmed M Badr
Department of Cardiology, Al-Azhar University, Cairo, Egypt
|Date of Submission||27-Mar-2020|
|Date of Decision||25-Apr-2020|
|Date of Acceptance||02-Jun-2020|
|Date of Web Publication||30-Oct-2020|
Ahmed M Badr
206 8th District, 6 of October, Giza, 11834
Source of Support: None, Conflict of Interest: None
Background There are inadequate studies validating the efficacy of several echocardiographic parameters of right ventricular (RV) function in assessing RV infarction and predicting stenosis of proximal right coronary artery (RCA). Most of them evaluated a single parameter and many lacked angiographic correlations.
Aim To evaluate RV systolic function using systolic excursion of right ventricular outflow tract (RVOT-SE) by echocardiography with correlation to stenosis of proximal RCA in patients with first incident of acute inferior wall myocardial infarction.
Patients and methods Parasternal short-axis view at the level of the aortic valve was obtained using M-mode echocardiography, and RVOT-SE was defined as the RVOT-SE anterior wall. It was measured in 50 patients who underwent CA after acute Inferior ST elevaion myocardial (STEMI).
Results Patients with reduced RV function were identified with tricuspid annular plane systolic excursion (TAPSE) below 16 mm. RVOT-SE optimal cutoff values to predict RV systolic dysfunction was SE=5.4 mm with a sensitivity of 91.7% and specificity of 99.97% (area under the curve=0.935, P=0.00). RVOT-SE prediction of proximal RCA stenosis was with a sensitivity of 91.4% and specificity of 90.2%. The study showed significant positive correlations with RV-fractional area change and TAPSE (P=0.00) and significant negative correlations with tissue Doppler myocardial performance index and pulsed wave myocardial performance index (P=0.00).
Conclusion RVOT-SE is a naive and precise method for assessing RV systolic function. This study suggested the use of RVOT-SE as a parameter of RV function paired with other indices such as TAPSE.
Keywords: inferior wall myocardial infarction, right coronary artery stenosis, right ventricular outflow tract-systolic excursion
|How to cite this article:|
Nouh SH, Said IF, Badr AM. Assessment of right ventricular function using right ventricular outflow tract-systolic excursion in inferior wall myocardial infarction and angiographic correlation to proximal right coronary artery stenosis. Al-Azhar Assiut Med J 2020;18:290-4
|How to cite this URL:|
Nouh SH, Said IF, Badr AM. Assessment of right ventricular function using right ventricular outflow tract-systolic excursion in inferior wall myocardial infarction and angiographic correlation to proximal right coronary artery stenosis. Al-Azhar Assiut Med J [serial online] 2020 [cited 2023 Mar 23];18:290-4. Available from: http://www.azmj.eg.net/text.asp?2020/18/3/290/299574
| Introduction|| |
In inferior wall ST elevaion myocardial (STEMI), concomitant presence of right ventricular (RV) myocardial infarction imposes an amplified risk of complications such as arrhythmia, shock, and even death . Proximal right coronary artery (RCA) occlusion is usually responsible for RV myocardial infarction in inferior wall STEMI . However, ECG changes are transient and disappear in half of cases within 10 h making it a less reliable instrument in late presentations . There are inadequate studies validating the efficacy of several echocardiographic parameters of RV function in assessing RV infarction and predicting proximal RCA stenosis. Many evaluated only a single parameter of RV function and lacked angiographic correlations . Current quantitative indices such as fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), and tissue Doppler myocardial performance index (TD-MPI) all have their limitations .
FAC does not certainly represent the ejection fraction of the entire RV; TAPSE measures displacement of the lateral RV wall longitudinally, whereas the RV has a complex three-dimensional structure and parameters of TD are angle related and there is inadequate normal statistics . A new tool for evaluating RV function is therefore needed. Right ventricular outflow tract-systolic excursion (RVOT-SE) is a naive and easy method for RV systolic function estimation.
RVOT-SE is defined as the endocardial surface SE of the anterior wall of the RVOT relative to the transducer.
| Aim|| |
We aim to evaluate RV function using RVOT-SE by echocardiography with correlation of proximal RCA stenosis in patients with first incidence of acute inferior wall myocardial infarction.
| Patients and methods|| |
Study population Patients suffering from inferior ST segment elevation myocardial infarction.
Patients suffering from inferior ST segment elevation myocardial infarction presenting within 24 h of symptoms onset.
Abnormal ventricular function previously documented or inferior wall MI, bundle branch block, paced rhythm or atrial fibrillation, pulmonary hypertension with RV systolic pressure by echo more than 40 mmHg, valvular heart disease more than mild as per ACC/AHA criteria, congenital heart diseases, pericardial effusion, pulmonary embolism, poor echo window, and ECG with lead V4R not taken within 6 h of symptoms onset. All patients signed a formal consent to be included in the study. All work was performed with the approval of the Al-Azhar ethics committee and they were subjected to the following.
Proper history taking including:
Age, sex, and risk factors of coronary artery disease: hypertension, diabetes mellitus, smoking status, family history, and dyslipidemia.
History of previous ischemic events or percutaneous coronary intervention.
Thorough clinical examination including accurate assessment of the vital data, Killip class, and other complications of acute myocardial infarction.
12-lead surface ECG before the procedure and right-sided ECG.
A standard transthoracic echocardiogram was performed by experienced cardiologists who was blinded to the study using a commercially available system. Images were obtained using a 2.5 MHz transducer. Conventional two-dimensional echocardiography including M-mode was performed on all patients according to the American Society of Echocardiography recommendations. Values of all the echocardiographic parameters are obtained as the average value of five consecutive cardiac cycles.
Angiographic evaluations were done by experienced cardiologists, who was blinded to the study. Coronary angiography was performed by the femoral approach and multiple views were obtained. Images were recorded on a digital system.
| Results|| |
Fifty patients had inferior STEMI at the Egyptian Railway Medical Hospital between October 2018 and December 2019 were considered to participate in this prospective study.
The sample size of patients with inferior STEMI was subdivided into two groups according to coronary angiography results into group I, which included n=28 patients who had inferior STEMI with proximal RCA proximal lesion and group II which included n=22 patients who had inferior STEMI without proximal RCA proximal lesion.
In both groups men were more likely to have inferior STEMI (82% in group I vs. 82% in group II with P=0.63); the mean age in patients with proximal RCA stenosis is 52.04±7.37 in group I vs. 53.50±7.48 in group II with P=0.49; however, there was no significant difference between both groups regarding diabetes mellitus, hypertension, smoking, ST-elevation (V4R), primary PCI, or use of pharmacoinvasive therapy ([Table 1]).
|Table 1 Comparison between two groups: presence of proximal stenosis in right coronary artery and absence of proximal right coronary artery stenosis according to patient demographics, personal data, and risk factors|
Click here to view
Left ventricular ejection fraction was lower in the first group. Various parameters of RV function showed significant difference between the two groups. RV-FAC and TAPSE were significantly lower while MPI by pulsed Doppler and TD were higher in the proximal RCA group ([Table 2]).
|Table 2 Comparison between two groups: presence of proximal lesion in right coronary artery and absence of proximal right coronary artery lesion according to echocardiographic parameters|
Click here to view
MPI-TDI=0.55 and RV-FAC=35, a cutoff indication of RV systolic dysfunction ,. TAPSE predicted RV systolic failure with good sensitivity and specificity when figures are less than 1.6 cm ,, but for RVOT-SE new cutoff values had to be determined by constructing the receiver operating characteristic curve. We constructed receiver operating characteristic curves for RVOT-SE to obtain optimal cutoff values to predict RVSD. SE, 5.4 predicted proximal RCA lesion with a sensitivity of 91.7% and a specificity of 99.97% (area under the curve=0.935, P=0.00) with positive correlation with RV-FAC and RVSD (P=0.00) and negative correlation with TD-MPI and pulsed wave (PW)-MPI (P=0.00) ([Table 3] and [Figure 1]).
|Figure 1 Receiver operating characteristic curve for the prediction of proximal RCA stenosis. RCA, right coronary artery.|
Click here to view
| Discussion|| |
The first main finding of this study was that patients with impaired RV systolic function had significant impairment of RVOT-SE.
TAPSE predicted RV systolic failure with good sensitivity and specificity when figures are less than 1.6 cm ,. TAPSE was significantly lower in patients with proximal RCA lesion. Earlier studies had exhibited good correlation of TAPSE with RV infarction ECG evidence, but with a low number of patients and there was no angiographic correlation . Also, in inferior wall STEMI, TAPSE is an independent predictor of mortality . TAPSE is confined to longitudinal function of RV free wall and the status of LV function may have an influence on it which are principal limitations in measurement .
We found RVOT-SE to be a highly distinctive simple parameter of RV function. It can be evaluated visually without a need for a precise measurement as the difference in RVOT-SE between patients with normal and reduced RV function was so clear.
SE in group I was 4.63±2.63 and P value of 0.001.
SE in group II was 11.56±2.94 and P value of 0.001.
Our study showed that RVOT-SE below 5.4 mm identified RV systolic dysfunction with a sensitivity of 91.7% and specificity of 99.97% and the significantly lower values of the RVOT-SE suspected proximal RCA lesion.
This was a little different from that reported by Asmer et al. . They reported that the best cutoff value of RVOT-SE was less than 6 mm with 100% sensitivity and 100% specificity to diagnose impaired RV systolic function, which completely separated patients with impaired RV function from patients with preserved RV function.
There was a significant positive correlation between RVOT-SE with the following parameters: TAPSE and RV-FAC and significant negative correlations with TD-MPI and PW-MPI.
There was high statistically significant difference between each group in TAPSE, FAC, PW-MPI, TD-MPI, and SE. The figures of TAPSE, FAC, and RVOT-SE were lower in proximal RCA stenosis group; however, the figures of PW-MPI and TD-MPI were higher in the same group.
In the current study, ejection fraction representing LV systolic function was reduced in both groups and this was accredited to the fact that the same pathology affecting RV simultaneously affects LV and also due to interventricular dependence. LV ejection fraction was lower in the proximal RCA group proving the significance of RV infarction hemodynamic in inferior wall STEMI.
| Conclusions|| |
RVOT-SE is a naive and precise method for assessing RV systolic function. This study suggested the use of RVOT-SE as a parameter of RV function paired with other indices such as TAPSE. Additional larger sample size studies are required to determine the value of RVOT-SE when compared with the presently used imaging techniques in patients with several diseases of the right heart.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mehta SR, Eikelboom JW, Natarajan MK, Diaz R, Yi C, Gibbons RJ et al.
Impact of right ventricular involvement on mortality and morbidity in patients with inferior myocardial infarction. J Am Coll Cardiol 2001; 37:37–43.
Shiraki H, Yoshikawa T, Anzai T, Negishi K, Takahashi T, Asakura Y et al.
Association between preinfarction angina and a lower risk of right ventricular infarction. N Engl J Med 1998; 338:941–947.
Braat SH, Brugada P, de Zwaan C, Coenegracht JM, Wellens HJ. Value of electrocardiogram in diagnosing right ventricular involvement in patients with an acute inferior wall myocardial infarction. Br Heart J 1983; 49:368–372.
Tei C, Dujardin KS, Hodge DO, Bailey KR, McGoon MD, Tajik AJ et al.
Doppler echocardiographic index for assessment of global right ventricular function. J Am Soc Echocardiogr 1996; 9:838–847.
Lai WW, Gauvreau K, Rivera ES, Saleeb S, Powell AJ, Geva T. Accuracy of guideline recommendations for two-dimensional quantification of the right ventricle by echocardiography. Int J Cardiovasc Imaging 2008; 24:691–698.
Jose L, Jeroen B, Juhani K, Sechtem U, Lancellotti P, Badano L. The ESC textbook of cardiovascular imaging. 2nd ed. New York: Oxford University Press 2015. 343.
Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K et al.
Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr 2010; 23:685–713.
Zornoff LA, Skali H, Pfeffer MA, St John Sutton M, Rouleau JL, Lamas GA et al.
Right ventriculardysfunction and risk of heart failure and mortality after myocardial infarction. J Am Coll Cardiol 2002; 39:1450–1455.
Alam M, Wardell J, Andersson E, Samad BA, Nordlander R. Right ventricular function in patients with first inferior myocardial infarction: assessment by tricuspid annular motion and tricuspid annular velocity. Am Heart J 2000; 139:710–715.
Asmer I, Adawi S, Ganaeem M, Shehadeh J, Shiran A. Right ventricular outflow tract systolic excursion: a novel echocardiographic parameter of right ventricular function. Eur Heart J Cardiovasc Imaging 2012; 13:871–877.
[Table 1], [Table 2], [Table 3]