Right Ventricle-Specific Three-Dimensional Wall Motion Tracking for Visualization of Regional Wall Motion Abnormality in Patients With Pulmonary Arterial Hypertension

HomeCirculation: Cardiovascular ImagingVol. 12, No. 4Right Ventricle-Specific Three-Dimensional Wall Motion Tracking for Visualization of Regional Wall Motion Abnormality in Patients With Pulmonary Arterial Hypertension Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessCase ReportPDF/EPUBRight Ventricle-Specific Three-Dimensional Wall Motion Tracking for Visualization of Regional Wall Motion Abnormality in Patients With Pulmonary Arterial Hypertension Hidenori Moriyama, MD, Mitsushige Murata, MD, PhD, Masaharu Kataoka, MD, PhD, Takashi Kawakami, MD, PhD, Jin Endo, MD, PhD, Takashi Kohno, MD, PhD, Yuji Itabashi, MD, PhD, Yoshihiro Seo, MD, PhD, Yasushi Iwao, MD, PhD and Keiichi Fukuda, MD, PhD Hidenori MoriyamaHidenori Moriyama Department of Cardiology (H.M., M.K., T. Kawakami, J.E., T. Kohno, K.K.), Keio University School of Medicine, Tokyo, Japan. , Mitsushige MurataMitsushige Murata Mitsushige Murata, MD, PhD, Center for Preventive Medicine, Keio University School of Medicine, Shinanomachi 35, Shinjuku-ku, Tokyo, 160–8582, Japan. Email E-mail Address: [email protected] Center for Preventive Medicine (M.M, Y. Iwao), Keio University School of Medicine, Tokyo, Japan. , Masaharu KataokaMasaharu Kataoka Department of Cardiology (H.M., M.K., T. Kawakami, J.E., T. Kohno, K.K.), Keio University School of Medicine, Tokyo, Japan. , Takashi KawakamiTakashi Kawakami Department of Cardiology (H.M., M.K., T. Kawakami, J.E., T. Kohno, K.K.), Keio University School of Medicine, Tokyo, Japan. , Jin EndoJin Endo Department of Cardiology (H.M., M.K., T. Kawakami, J.E., T. Kohno, K.K.), Keio University School of Medicine, Tokyo, Japan. , Takashi KohnoTakashi Kohno Department of Cardiology (H.M., M.K., T. Kawakami, J.E., T. Kohno, K.K.), Keio University School of Medicine, Tokyo, Japan. , Yuji ItabashiYuji Itabashi Department of Laboratory Medicine (Y. Itabashi), Keio University School of Medicine, Tokyo, Japan. , Yoshihiro SeoYoshihiro Seo Department of Cardiology, Faculty of Medicine (Y.S.), University of Tsukuba, Japan. , Yasushi IwaoYasushi Iwao Center for Preventive Medicine (M.M, Y. Iwao), Keio University School of Medicine, Tokyo, Japan. and Keiichi FukudaKeiichi Fukuda Department of Cardiology (H.M., M.K., T. Kawakami, J.E., T. Kohno, K.K.), Keio University School of Medicine, Tokyo, Japan. Originally published3 Apr 2019https://doi.org/10.1161/CIRCIMAGING.118.008795Circulation: Cardiovascular Imaging. 2019;12:e008795A 34-year-old woman presented with dyspnea on exertion since 3 months and was admitted to our hospital for further investigation. She had a history of ulcerative colitis but no family history of cardiovascular disease. On the basis of a mean pulmonary artery pressure (mPAP) of 44 mm Hg and pulmonary vascular resistance of 8.5 WU on right heart catheterization, she was diagnosed with pulmonary artery hypertension. Assessment of right ventricular (RV) function by conventional echocardiography revealed tricuspid annular plane systolic excursion of 21 mm, S′ of the tricuspid annulus of 13.0 cm/s, and RV fractional area change of 28%. Furthermore, RV free wall longitudinal strain measured by 2-dimensional (2D) speckle-tracking echocardiography showed a normal value of −20.0%, suggestive of preserved RV systolic function, which conflicted with the clinical conditions (Figure 1A and Movie I in the Data Supplement).Download figureDownload PowerPointFigure 1. Right ventricular free wall longitudinal strain assessed by 2-dimensional speckle-tracking echocardiography before (A) and after treatment (B). RVFLS, right ventricular free wall longitudinal strain.To resolve this contradiction, we performed 3-dimensional (3D) RV analysis using RV-specific 3D wall motion tracking (WMT) software (Canon Medical Systems, Japan). The RV wall was divided into inlet, outflow, and apical segments, as previously described.1Figure 2A and Movie II in the Data Supplement depict heterogeneous wall motion abnormalities assessed by the area change ratio in the RV apical and outflow areas compared with that in the RV inflow area. Consistent with this, the area change ratio in the apical and outflow areas was reduced compared with that in the inlet area (Figure 3A).Download figureDownload PowerPointFigure 2. Right ventricular endocardial surface mapping of area change ratio (ACR). The color mappings represent the magnitude of ACR at end-systole before (A) and after (B) treatment. The upper portion are views from the septum, and lower portion from the free wall. The yellow portion represents the plane of the estimated 2-dimensional 4 chamber view. PV indicates pulmonary valve; and TV, tricuspid valve.Download figureDownload PowerPointFigure 3. Global and segmental strain-time curves during cardiac cycle before (A) and after treatment (B). RV indicates right ventricular.As she had no signs of thromboembolism or shunt placement for congenital heart disease, medical therapy with macitentan and riociguat was initiated. After 15 months, pulmonary artery hypertension improved to an mPAP of 22 mm Hg and pulmonary vascular resistance of 2.6 WU. Although 2D RV echocardiographic measurements showed subtle improvements (tricuspid annular plane systolic excursion of 20 mm, S′ of 13.2 cm/s, RV fractional area change of 33 %, and RV free wall longitudinal strain of −26.0 %; Figure 1B and Movie III in the Data Supplement), RV specific 3D WMT clearly demonstrated amelioration of the area change ratio in the RV apical and outflow areas, resulting in a homogeneous normal RV motion (Figures 2B and 3B and Movie IV in the Data Supplement).This is the first report to demonstrate the detection of heterogeneous RV functional abnormalities and their drastic improvement before and after treatment using only 3D RV-specific analysis. Because the cross-section on 2D RV echocardiographic analyses, such as a 4-chamber view, did not include the RV apical and outflow walls (as shown in Figure 2A), 2D RV speckle-tracking echocardiography showed normal RV systolic function despite the asynergy in the RV apical and outflow areas. On the contrary, 3D RV WMT clearly indicated wall motion abnormalities in the RV apical and outflow areas because of its applicability in evaluating the entire RV wall.Although assessment of RV function would be useful in predicting the prognosis of patients with pulmonary hypertension,2 inaccurate RV analysis may lead to misunderstanding of the disease condition. The utility of 2D RV speckle-tracking echocardiography has been reported despite the complex RV morphology.3 However, it has some inevitable limitations, including inaccurate myocardial tracking because of the through-plane phenomenon (a phenomenon in which the cross-section shifts during the cardiac cycle) or availability of strain measurement only in the longitudinal direction. Moreover, its evaluation was limited within a part of the RV free wall and septal wall.The RV has a complicated shape. Thus, 3D analysis has been considered favorable for RV functional analysis. However, the conventional 3D RV analyses using cardiac magnetic resonance imaging or 4D RV-Function software (TomTec Imaging Systems) enables RV volumetric analysis but not regional RV wall motion analysis.Three-dimensional RV-specific WMT has been recently developed as a novel tool that enables evaluation of global and regional RV function, including the RV outflow area, and measurement of both longitudinal and circumferential strain.1 In the case of RV dysfunction including the outflow area, like in the present case, 3D RV WMT is specifically useful and essential for accurate evaluation of RV function. Notably, in the present case, 3D RV WMT curves (Figure 3) demonstrated that all RV inlet areas (lateral, inferior, and septum) were hyperkinetic to compensate for the reduced contraction in the apical and outflow areas before treatment, whereas the peak area change ratios of RV areas, except that of the inlet lateral area, were almost identical after treatment. Further studies on the significance of RV regional analysis need to be conducted using the 3D RV WMT technique.AcknowledgmentsWe acknowledge Yasuhiko Abe (Canon Medical Systems, Japan) for the technical support for ultrasonography.DisclosuresNone.FootnotesThe Data Supplement is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCIMAGING.118.008795.Mitsushige Murata, MD, PhD, Center for Preventive Medicine, Keio University School of Medicine, Shinanomachi 35, Shinjuku-ku, Tokyo, 160–8582, Japan. Email [email protected]jpReferences1. Ishizu T, Seo Y, Atsumi A, Tanaka YO, Yamamoto M, Machino-Ohtsuka T, Horigome H, Aonuma K, Kawakami Y. Global and regional right ventricular function assessed by novel three-dimensional speckle-tracking echocardiography.J Am Soc Echocardiogr. 2017; 30:1203–1213. doi: 10.1016/j.echo.2017.08.007CrossrefMedlineGoogle Scholar2. van Wolferen SA, Marcus JT, Boonstra A, Marques KM, Bronzwaer JG, Spreeuwenberg MD, Postmus PE, Vonk-Noordegraaf A. Prognostic value of right ventricular mass, volume, and function in idiopathic pulmonary arterial hypertension.Eur Heart J. 2007; 28:1250–1257. doi: 10.1093/eurheartj/ehl477CrossrefMedlineGoogle Scholar3. Fukuda Y, Tanaka H, Sugiyama D, Ryo K, Onishi T, Fukuya H, Nogami M, Ohno Y, Emoto N, Kawai H, Hirata K. Utility of right ventricular free wall speckle-tracking strain for evaluation of right ventricular performance in patients with pulmonary hypertension.J Am Soc Echocardiogr. 2011; 24:1101–1108. doi: 10.1016/j.echo.2011.06.005CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited ByMoriyama H, Kawakami T, Kataoka M, Hiraide T, Kimura M, Endo J, Kohno T, Itabashi Y, Seo Y, Fukuda K and Murata M (2020) Regional Right Ventricular Abnormalities Implicate Distinct Pathophysiological Conditions in Patients With Chronic Thromboembolic Pulmonary Hypertension, Journal of the American Heart Association, 9:21, Online publication date: 3-Nov-2020. Liu S, Bose R, Ahmed A, Maslow A, Feng Y, Sharkey A, Baribeau Y, Mahmood F, Matyal R and Khabbaz K (2020) Artificial Intelligence-Based Assessment of Indices of Right Ventricular Function, Journal of Cardiothoracic and Vascular Anesthesia, 10.1053/j.jvca.2020.01.024, 34:10, (2698-2702), Online publication date: 1-Oct-2020. Tanabe K (2020) Three-Dimensional Echocardiography ― Role in Clinical Practice and Future Directions ―, Circulation Journal, 10.1253/circj.CJ-20-0239, 84:7, (1047-1054), Online publication date: 25-Jun-2020. Murata M (2020) Clinical Significance of Right Ventricular Function in Pulmonary Hypertension, The Keio Journal of Medicine, 10.2302/kjm.2020-0015-IR, 70:3, (60-67), . Tanabe K and Yamaguchi K (2019) Incorporating three-dimensional echocardiography into clinical practice, Journal of Echocardiography, 10.1007/s12574-019-00443-y, 17:4, (169-176), Online publication date: 1-Dec-2019. Farmakis I, Demerouti E, Karyofyllis P, Karatasakis G, Stratinaki M, Tsiapras D, Athanassopoulos G, Voudris V and Giannakoulas G (2021) Echocardiography in Pulmonary Arterial Hypertension: Is It Time to Reconsider Its Prognostic Utility?, Journal of Clinical Medicine, 10.3390/jcm10132826, 10:13, (2826) April 2019Vol 12, Issue 4 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/CIRCIMAGING.118.008795PMID: 30939920 Originally publishedApril 3, 2019 Keywordsventricular functionright ventriclehypertension, pulmonaryechocardiography, three-dimensionalPDF download Advertisement SubjectsEchocardiographyImaging