Right Ventricular Strain for Prediction of Survival in Patients With Pulmonary Arterial Hypertension


      Pulmonary arterial hypertension (PAH) is a devastating illness of pulmonary vascular remodeling, right-sided heart failure, and limited survival. Whether strain-based measures of right ventricular (RV) systolic function predict future right-sided heart failure and/or death is untested.


      RV longitudinal systolic strain and strain rate were evaluated by echocardiography in 80 patients with World Health Organization group 1 pulmonary hypertension (PH) (72% were functional class [FC] III or IV). Survival status was assessed over 4 years.


      All patients had a depressed RV systolic strain (−15% ± 5%) and strain rate (−0.80 ± 0.29 s−1). Of the parameters assessed, average RV free wall systolic strain worse than −12.5% identified a cohort with greater severity of disease (82% were FC III/IV), greater RV systolic dysfunction (RV stroke volume index 26 ± 9 mL/m2), and higher right atrial pressure (12 ± 5 mm Hg). Patients with an RV free wall strain worse than −12.5% were associated with a greater degree of disease progression within 6 months, a greater requirement for loop diuretics, and/or a greater degree of lower extremity edema, and it also predicted 1-, 2-, 3-, and 4-year mortality (unadjusted 1-year hazard ratio, 6.2; 2.1–22.3). After adjusting for age, sex, PH cause, and FC, patients had a 2.9-fold higher rate of death per 5% absolute decline in RV free wall strain at 1 year.


      Noninvasive assessment of RV longitudinal systolic strain and strain rate independently predicts future right-sided heart failure, clinical deterioration, and mortality in patients with PAH.
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        • D'Alonzo GE
        • Barst RJ
        • Ayres SM
        • et al.
        Survival in patients with primary pulmonary hypertension. Results from a national prospective registry.
        Ann Intern Med. 1991; 115: 343-349
        • Farber HW
        • Loscalzo J
        Pulmonary arterial hypertension.
        N Engl J Med. 2004; 351: 1655-1665
        • McLaughlin VV
        • Presberg KW
        • Doyle RL
        • American College of Chest Physicians
        • et al.
        Prognosis of pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines.
        Chest. 2004; 126: 78S-92S
        • Barst RJ
        • Rubin LJ
        • Long WA
        • The Primary Pulmonary Hypertension Study Group
        • et al.
        A comparison of continuous intravenous epoprostenol (prostacyclin) with conventional therapy for primary pulmonary hypertension.
        N Engl J Med. 1996; 334: 296-302
        • Channick RN
        • Simonneau G
        • Sitbon O
        • et al.
        Effects of the dual endothelin-receptor antagonist bosentan in patients with pulmonary hypertension: a randomised placebo-controlled study.
        Lancet. 2001; 358: 1119-1123
        • Kisch-Wedel H
        • Kemming G
        • Meisner F
        • et al.
        The prostaglandins epoprostenol and iloprost increase left ventricular contractility in vivo.
        Intensive Care Med. 2003; 29: 1574-1583
        • Mendeloff EN
        • Meyers BF
        • Sundt TM
        • et al.
        Lung transplantation for pulmonary vascular disease.
        Ann Thorac Surg. 2002; 73 (discussion 217-209): 209-217
        • Menzel T
        • Wagner S
        • Kramm T
        • et al.
        Pathophysiology of impaired right and left ventricular function in chronic embolic pulmonary hypertension: changes after pulmonary thromboendarterectomy.
        Chest. 2000; 118: 897-903
        • Montalescot G
        • Drobinski G
        • Meurin P
        • et al.
        Effects of prostacyclin on the pulmonary vascular tone and cardiac contractility of patients with pulmonary hypertension secondary to end-stage heart failure.
        Am J Cardiol. 1998; 82: 749-755
        • Miyamoto S
        • Nagaya N
        • Satoh T
        • et al.
        Clinical correlates and prognostic significance of six-minute walk test in patients with primary pulmonary hypertension. Comparison with cardiopulmonary exercise testing.
        Am J Respir Crit Care Med. 2000; 161: 487-492
        • Bustamante-Labarta M
        • Perrone S
        • De La Fuente RL
        • et al.
        Right atrial size and tricuspid regurgitation severity predict mortality or transplantation in primary pulmonary hypertension.
        J Am Soc Echocardiogr. 2002; 15: 1160-1164
        • Stupi AM
        • Steen VD
        • Owens GR
        • Barnes EL
        • Rodnan GP
        • Medsger Jr, TA
        Pulmonary hypertension in the CREST syndrome variant of systemic sclerosis.
        Arthritis Rheum. 1986; 29: 515-524
        • Tei C
        • Dujardin KS
        • Hodge DO
        • et al.
        Doppler echocardiographic index for assessment of global right ventricular function.
        J Am Soc Echocardiogr. 1996; 9: 838-847
        • Voelkel NF
        • Quaife RA
        • Leinwand LA
        • National Heart, Lung, and Blood Institute Working Group on Cellular and Molecular Mechanisms of Right Heart Failure
        • et al.
        Right ventricular function and failure: report of a National Heart, Lung, and Blood Institute working group on cellular and molecular mechanisms of right heart failure.
        Circulation. 2006; 114: 1883-1891
        • Rushmer RF
        • Crystal DK
        • Wagner C
        The functional anatomy of ventricular contraction.
        Circ Res. 1953; 1: 162-170
        • Rushmer RF
        • Thal N
        The mechanics of ventricular contraction; a cinefluorographic study.
        Circulation. 1951; 4: 219-228
        • Langeland S
        • Wouters PF
        • Claus P
        • et al.
        Experimental assessment of a new research tool for the estimation of two-dimensional myocardial strain.
        Ultrasound Med Biol. 2006; 32: 1509-1513
        • Forfia PR
        • Fisher MR
        • Mathai SC
        • et al.
        Tricuspid annular displacement predicts survival in pulmonary hypertension.
        Am J Respir Crit Care Med. 2006; 174: 1034-1041
        • Giusca S
        • Dambrauskaite V
        • Scheurwegs C
        • et al.
        Deformation imaging describes right ventricular function better than longitudinal displacement of the tricuspid ring.
        Heart. 2010; 96: 281-288
        • Ingul CB
        • Torp H
        • Aase SA
        • Berg S
        • Stoylen A
        • Slordahl SA
        Automated analysis of strain rate and strain: feasibility and clinical implications.
        J Am Soc Echocardiogr. 2005; 18: 411-418
        • Leitman M
        • Lysyansky P
        • Sidenko S
        • et al.
        Two-dimensional strain-a novel software for real-time quantitative echocardiographic assessment of myocardial function.
        J Am Soc Echocardiogr. 2004; 17: 1021-1029
        • Perk G
        • Tunick PA
        • Kronzon I
        Non-Doppler two-dimensional strain imaging by echocardiography—from technical considerations to clinical applications.
        J Am Soc Echocardiogr. 2007; 20: 234-243
        • Reisner SA
        • Lysyansky P
        • Agmon Y
        • Mutlak D
        • Lessick J
        • Friedman Z
        Global longitudinal strain: a novel index of left ventricular systolic function.
        J Am Soc Echocardiogr. 2004; 17: 630-633
        • Amundsen BH
        • Helle-Valle T
        • Edvardsen T
        • et al.
        Noninvasive myocardial strain measurement by speckle tracking echocardiography: validation against sonomicrometry and tagged magnetic resonance imaging.
        J Am Coll Cardiol. 2006; 47: 789-793
        • Hurlburt HM
        • Aurigemma GP
        • Hill JC
        • et al.
        Direct ultrasound measurement of longitudinal, circumferential, and radial strain using 2-dimensional strain imaging in normal adults.
        Echocardiography. 2007; 24: 723-731
        • Korinek J
        • Wang J
        • Sengupta PP
        • et al.
        Two-dimensional strain—a Doppler-independent ultrasound method for quantitation of regional deformation: validation in vitro and in vivo.
        J Am Soc Echocardiogr. 2005; 18: 1247-1253
        • Teske AJ
        • De Boeck BW
        • Olimulder M
        • Prakken NH
        • Doevendans PA
        • Cramer MJ
        Echocardiographic assessment of regional right ventricular function: a head-to-head comparison between 2-dimensional and tissue Doppler-derived strain analysis.
        J Am Soc Echocardiogr. 2008; 21: 275-283
        • Dambrauskaite V
        • Delcroix M
        • Claus P
        • et al.
        Regional right ventricular dysfunction in chronic pulmonary hypertension.
        J Am Soc Echocardiogr. 2007; 20: 1172-1180
        • Huez S
        • Vachiéry JL
        • Unger P
        • Brimioulle S
        • Naeije R
        Tissue Doppler imaging evaluation of cardiac adaptation to severe pulmonary hypertension.
        Am J Cardiol. 2007; 100: 1473-1478
        • Pirat B
        • McCulloch ML
        • Zoghbi WA
        Evaluation of global and regional right ventricular systolic function in patients with pulmonary hypertension using a novel speckle tracking method.
        Am J Cardiol. 2006; 98: 699-704
        • Meng H
        • Villarraga HR
        • Lee P
        • et al.
        Pulmonary hypertension is associated with regional right ventricular systolic dysfunction and dyssynchrony: strain and strain rate assessment using velocity vector imaging technique.
        Circulation. 2007; 116: 331
        • Stevens LA
        • Coresh J
        • Greene T
        • Levey AS
        Assessing kidney function—measured and estimated glomerular filtration rate.
        N Engl J Med. 2006; 354: 2473-2483
        • Lang RM
        • Bierig M
        • Devereux RB
        • Chamber Quantification Writing Group
        • American Society of Echocardiography's Guidelines and Standards Committee
        • European Association of Echocardiography
        • et al.
        Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology.
        J Am Soc Echocardiogr. 2005; 18: 1440-1463
        • Aduen JF
        • Castello R
        • Lozano MM
        • et al.
        An alternative echocardiographic method to estimate mean pulmonary artery pressure: diagnostic and clinical implications.
        J Am Soc Echocardiogr. 2009; 22: 814-819
        • Mahapatra S
        • Nishimura RA
        • Oh JK
        • McGoon MD
        The prognostic value of pulmonary vascular capacitance determined by Doppler echocardiography in patients with pulmonary arterial hypertension.
        J Am Soc Echocardiogr. 2006; 19: 1045-1050
        • Haddad F
        • Zamanian R
        • Beraud AS
        • et al.
        A novel non-invasive method of estimating pulmonary vascular resistance in patients with pulmonary arterial hypertension.
        J Am Soc Echocardiogr. 2009; 22: 523-529
        • Sitbon O
        • Humbert M
        • Jaïs X
        • et al.
        Long-term response to calcium channel blockers in idiopathic pulmonary arterial hypertension.
        Circulation. 2005; 111: 3105-3111
        • Fuster V
        • Steele PM
        • Edwards WD
        • Gersh BJ
        • McGoon MD
        • Frye RL
        Primary pulmonary hypertension: natural history and the importance of thrombosis.
        Circulation. 1984; 70: 580-587
        • Raymond RJ
        • Hinderliter AL
        • Willis PW
        • et al.
        Echocardiographic predictors of adverse outcomes in primary pulmonary hypertension.
        J Am Coll Cardiol. 2002; 39: 1214-1219
        • Champion HC
        • Michelakis ED
        • Hassoun PM
        Comprehensive invasive and noninvasive approach to the right ventricle-pulmonary circulation unit: state of the art and clinical and research implications.
        Circulation. 2009; 120: 992-1007
        • Sitbon O
        • Humbert M
        • Nunes H
        • et al.
        Long-term intravenous epoprostenol infusion in primary pulmonary hypertension: prognostic factors and survival.
        J Am Coll Cardiol. 2002; 40: 780-788
        • Ghio S
        • Klersy C
        • Magrini G
        • et al.
        Prognostic relevance of the echocardiographic assessment of right ventricular function in patients with idiopathic pulmonary arterial hypertension.
        Int J Cardiol. 2010; 140: 272-278
        • van Wolferen SA
        • Marcus JT
        • Boonstra A
        • et al.
        Prognostic value of right ventricular mass, volume, and function in idiopathic pulmonary arterial hypertension.
        Eur Heart J. 2007; 28: 1250-1257
        • Leather HA
        • Ama' R
        • Missant C
        • Rex S
        • Rademakers FE
        • Wouters PF
        Longitudinal but not circumferential deformation reflects global contractile function in the right ventricle with open pericardium.
        Am J Physiol Heart Circ Physiol. 2006; 290: H2369-H2375
        • Dandel M
        • Lehmkuhl HB
        • Hetzer R
        • et al.
        Tricuspid annulus systolic excursion for assessment of right ventricular function: Limitations and sources of misinterpretation in patients with pulmonary hypertension.
        J Am Soc Echocardiogr. 2010; 23: B9
        • Badesch DB
        • Raskob GE
        • Elliott CG
        • et al.
        Pulmonary arterial hypertension: baseline characteristics from the REVEAL Registry.
        Chest. 2010; 137: 376-387
        • Matias C
        • Isla LP
        • Vasconcelos M
        • et al.
        Speckle-tracking-derived strain and strain-rate analysis: a technique for the evaluation of early alterations in right ventricle systolic function in patients with systemic sclerosis and normal pulmonary artery pressure.
        J Cardiovasc Med (Hagerstown). 2009; 10: 129-134
        • Schattke S
        • Knebel F
        • Grohmann A
        • et al.
        Early right ventricular systolic dysfunction in patients with systemic sclerosis without pulmonary hypertension: a Doppler Tissue and Speckle Tracking echocardiography study.
        Cardiovasc Ultrasound. 2010; 8: 3
        • Bellavia D
        • Michelena HI
        • Martinez M
        • et al.
        Speckle myocardial imaging modalities for early detection of myocardial impairment in isolated left ventricular non-compaction.
        Heart. 2010; 96: 440-447
        • Bellavia D
        • Pellikka PA
        • Abraham TP
        • et al.
        Evidence of impaired left ventricular systolic function by Doppler myocardial imaging in patients with systemic amyloidosis and no evidence of cardiac involvement by standard two-dimensional and Doppler echocardiography.
        Am J Cardiol. 2008; 101: 1039-1045