Three-dimensional echocardiography and 2D-3D speckle-tracking imaging in chronic pulmonary hypertension: diagnostic accuracy in detecting hemodynamic signs of right ventricular (RV) failure

Abstract

Background: Our aim was to compare three-dimensional (3D) and 2D and 3D speckle-tracking (2D-STE, 3D-STE) echocardiographic parameters with conventional right ventricular (RV) indexes in patients with chronic pulmonary hypertension (PH), and investigate whether these techniques could result in better correlation with hemodynamic variables indicative of heart failure.

Methods and results: Seventy-three adult patients (mean age, 53±13 years; 44% male) with chronic PH of different etiologies were studied by echocardiography and cardiac catheterization (25 precapillary PH from pulmonary arterial hypertension, 23 obstructive pulmonary heart disease, and 23 postcapillary PH from mitral regurgitation). Thirty healthy subjects (mean age, 54±15 years; 43% male) served as controls. Standard 2D measurements (RV-fractional area change-tricuspid annular plane systolic excursion) and mitral and tricuspid tissue Doppler annular velocities were obtained. RV 3D volumes and global and regional ejection fraction (3D-RVEF) were determined. RV strains were calculated by 2D-STE and 3D-STE. RV 3D global-free-wall longitudinal strain (3DGFW-RVLS), 2D global-free-wall longitudinal strain (GFW-RVLS), apical-free-wall longitudinal strain, basal-free-wall longitudinal strain, and 3D-RVEF were lower in patients with precapillary PH (P<0.0001) and postcapillary PH (P<0.01) compared to controls. 3DGFW-RVLS (hazard ratio 4.6, 95% CI 2.79 to 8.38, P=0.004) and 3D-RVEF (hazard ratio 5.3, 95% CI 2.85 to 9.89, P=0.002) were independent predictors of mortality. Receiver operating characteristic curves showed that the thresholds offering an adequate compromise between sensitivity and specificity for detecting hemodynamic signs of RV failure were 39% for 3D-RVEF (AUC 0.89), -17% for 3DGFW-RVLS (AUC 0.88), -18% for GFW-RVLS (AUC 0.88), -16% for apical-free-wall longitudinal strain (AUC 0.85), 16 mm for tricuspid annular plane systolic excursion (AUC 0.67), and 38% for RV-FAC (AUC 0.62).

Conclusions: In chronic PH, 3D, 2D-STE and 3D-STE parameters indicate global and regional RV dysfunction that is associated with RV failure hemodynamics better than conventional echo indices.

Keywords: chronic pulmonary hypertension; echocardiography; right ventricular function; speckle‐tracking echocardiography; three‐dimensional echocardiography.

Figure 1.

Representative 3D RV volumes and ejection fraction in normal controls and PH patients. A, Three‐dimensional RV ejection fraction (3D‐RVEF) in a normal subject. 3D‐RVEF=59%. B, Decrease of 3D‐RVEF in a patient with chronic PH. 3D‐RVEF=35%. C, Regional three‐dimensional RV ejection fraction. RV components are illustrated in a three‐dimensional reconstruction of the echocardiographic images seen in a front view. 1, inlet; 2, apical trabecular; 3, outlet component. EDV indicates end‐diastolic volume; EF, ejection fraction; ESV, end‐systolic volume; P, pulmonary outflow; PH, pulmonary hypertension; RV, right ventricular; RVEF, RV ejection fraction; SV, stroke volume; T, tricuspid inflow.

Figure 2.

Representative 2D and 3D RV strain images in normal controls and PH patients. A, Speckle‐tracking apical view showing global and regional RV longitudinal strain in a normal subject. Global RV longitudinal strain (G‐RVLS)=−28%. B, Speckle‐tracking apical view showing global and regional free‐wall RV longitudinal strain in a normal subject. Free wall (FW) is labeled by asterisks. Global free‐wall RV longitudinal strain (GFW‐RVLS)=−36%. C, Decrease of GFW‐RVLS in a patient with chronic PH. GFW‐RVLS=−13%. D, 3D RV speckle‐tracking multiplane view in a normal subject. 3D global longitudinal strain (3D G‐RVLS) was −26%. 3D global longitudinal strain of RV free‐wall (3D GFW‐RVLS) was then calculated excluding septal segments. FW is labeled by asterisks. AVC indicates aortic valve closure; ED, end‐diastolic; ES, end‐systolic; PH, pulmonary hypertension; RV, right ventricular.

Figure 3.

Bar graph depicting global and segmental strain changes in RV free wall in PH patients. RV global‐free‐wall longitudinal strain (GFW‐RVLS, top left) with higher decrease of RV global strain in precapillary PH (pre‐c) compared to postcapillary PH (post‐c). Apical‐free‐wall longitudinal strain (AFW‐RVLS, top right), mid‐free‐wall longitudinal strain (MFW‐RVLS, bottom left), and basal‐free‐wall longitudinal strain (BFW‐RVLS, bottom right) in normal subjects and patients with PH and RV segmental involvement. *SS vs C: P<0.0001; CHD vs C: P<0.0001; COPD vs C: P<0.001; MR vs C: P<0.01. ^†SS vs C: P<0.0001; CHD vs C: P<0.0005; COPD vs C: P<0.01; MR vs C: P<0.01. ^‡SS vs C: P<0.001; CHD vs C: P<0.001; COPD vs C: not significative; MR vs C: not significative. ^§SS vs C: P<0.0005; CHD vs C: P<0.0005; COPD vs C: P<0.001; MR vs C: P<0.05. C indicates controls; CHD, congenital heart disease; COPD, chronic obstructive pulmonary disease; MR, mitral regurgitation; PH, pulmonary hypertension; RV, right ventricular; SS, systemic sclerosis.

Figure 4.

Incremental value of three‐dimensional RV ejection fraction (3D‐RVEF) and global‐free‐wall RV longitudinal strain (3DGFW‐RVLS) over standard echocardiographic variables in predicting precapillary PH (PCWP <15 mm Hg). Step 1 included RVSP (right ventricular systolic pressure)+MV‐E/E_a (ratio of early diastolic mitral inflow velocity to early diastolic mitral annular velocity: values <12 suggest normal LV diastolic function). Step 2 included RVSP+MV‐E/E_a+3DGFW‐RVLS. Step 3 included RVSP+MV‐E/E_a+3DGFW‐RVLS+3D‐RVEF. *Step 1 vs step 2: χ² values 76.1 vs 81.8, P<0.005; ^†Step 2 vs step 3: χ² values 81.8 vs 90.9, P=0.004. LV indicates left ventricular; MV, mitral valve; PCWP, pulmonary capillary wedge pressure; PH, pulmonary hypertension; RV, right ventricular.