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. 2016 Feb;17(2):177-83.
doi: 10.1093/ehjci/jev131. Epub 2015 Jun 1.

Apical traction: a novel visual echocardiographic parameter to predict survival in patients with pulmonary hypertension

Serkan Unlu  1 , Konstantinos Farsalinos  2 , Koen Ameloot  2 , Ana M Daraban  2 , Agnieszka Ciarka  2 , Marion Delcroix  3 , Jens-Uwe Voigt  4
Affiliations

Apical traction: a novel visual echocardiographic parameter to predict survival in patients with pulmonary hypertension

Serkan Unlu et al. Eur Heart J Cardiovasc Imaging. 2016 Feb.

Abstract

Aims: In some pulmonary hypertension (PH) patients, we noted a motion pattern where the right ventricular (RV) apex is pulled towards to left ventricle (LV) during systole, caused by traction from the LV ('apical traction', AT). Herein, we characterize patients with AT to investigate its prognostic significance.

Methods and results: Echocardiograms of 62 pre-capillary PH patients (42 females, age 61 ± 15 years) were retrospectively analysed. The presence of AT was assessed visually and confirmed by speckle-tracking analysis. Fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), RV free-wall longitudinal strain (LS) as well as LV function were measured. A primary end point of death or heart/lung transplantation was set. AT was observed in 31 patients. They had worse functional capacity, lower TAPSE (1.3 ± 0.2 vs. 1.9 ± 0.4, P ≤ 0.001) and FAC (20.3 ± 6.1 vs. 33 ± 7.1%, P ≤ 0.001), worse RV free-wall LS (-12.4 ± 3.4 vs. -20.8 ± 4.9%, P < 0.001), and higher systolic pulmonary arterial pressure (92 ± 15 vs. 75 ± 23, P < 0.001). LV function was similar in both groups. The primary end point occurred in 16 patients with and 8 without AT. AT was an independent predictor of the outcome (HR: 14.826, 95% CI: 1.696-129.642, P = 0.015).

Conclusion: AT occurs in RVs with impaired systolic function in PH patients. It may serve as a new, easily to assess visual parameter to predict the outcome in these patients. Its prognostic importance needs to be validated by prospective studies.

Keywords: apical traction; pulmonary hypertension; right ventricular function; speckle-tracking echocardiography; survival.

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Figures

Figure 1
Figure 1
Schematic of the mechanism of apical traction as it can be observed in the apical four-chamber view. Impaired contraction of the RV and traction from the normally contracting LV results in abnormal motion of the cardiac apex towards the left (blue arrows). Grey, diastole; red, systole.
Figure 2
Figure 2
Principle of the calculation of apical traction. (A) To estimate the traction of the apex (AT4CV) perpendicular to the longitudinal axis of the heart, two local displacement curves (dxL, dxR) (B) are obtained from both sides of the apex, e.g. by means of speckle tracking. (C) Then, the left-sided displacement curve (dxL) is inverted, which allows averaging. (D) Apical traction is then measured as displacement of the apex (dxaveraged) during systole, i.e. between mitral valve closure (MVC) and aortic valve closure (AVC).
Figure 3
Figure 3
Scatter plot of the apical traction amplitude in relation to the difference between RV and LV function as measured by RV free-wall GLS and LV GLS. The regression analysis revealed a significant correlation, suggesting a relation between AT and the imbalance in RV and LV function.
Figure 4
Figure 4
Kaplan–Meier survival curves for freedom from death or heart–lung transplant (HLTx) of patients with (AT) and without (Non-AT) apical traction.
Figure 5
Figure 5
Probability of freedom from death or heart–lung transplant, with the effect of co-variables from multivariable Cox regression analysis (Table 4). AT, patients with apical traction; Non-AT, patients without apical traction.
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