(Circulation. 2000;101:e117.)
© 2000 American Heart Association, Inc.
Circulation Electronic Pages |
Doppler Echocardiographic Index of Global Right Ventricular Function
Northwest Regional Cardiac Centre, Wythenshawe Hospital, Manchester, United Kingdom
Northwest Lung Centre, Wythenshawe Hospital, Manchester, United Kingdom
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To the Editor:
In pulmonary disease, right ventricular dysfunction has an important bearing on prognosis.1 Incalzi et al2 recently demonstrated the prognostic implications of electrocardiographic signs of chronic cor pulmonale in patients with chronic obstructive pulmonary disease. Two electrocardiographic features in particular, an S1S2S3 pattern and a P-wave axis of >90°, suggesting right atrial overload, predicted mortality over 13 years of follow-up. This well-conducted study illustrates the importance of an inexpensive diagnostic technique in risk stratification and is of particular value since the clinical signs of cor pulmonale are too insensitive for routine clinical application. It has been preceded by a wealth of work highlighting the considerable effort that has gone into the identification of a prognostic marker that is widely applicable, noninvasive, and easily interpretable and repeatable.
Of note, the authors indicate the failings of echocardiographic evaluation of the right heart in this setting. They refer to the technical difficulties of transthoracic studies in patients with lung hyperinflation and to the high error when pulmonary artery pressure is estimated based on a tricuspid regurgitant jet, which is present in only a minority of patients. Tei et al3 recently described a Doppler echocardiographic index of global right ventricular function based on tricuspid and pulmonary flow dynamics. Assessment of right ventricular function has been confounded by the asymmetrical geometry of the chamber, but since this index is derived from pulsed-wave Doppler measurements, evaluation can be made independently of 2-D imaging, a further advantage given poor patient echogenicity. The index is reproducible and not affected by heart rate or the severity of tricuspid regurgitation. Among a variety of clinical and echocardiographic variables, the index was the most powerful predictor of prognosis in a study of patients with primary pulmonary hypertension.4 We have calculated the index in patients with interstitial5 and a wide range of other pulmonary conditions, including chronic obstructive pulmonary disease, without any technical difficulties. A useful inverse correlation exists between the index and arterial oxygen tension, and it is both a sensitive and specific indicator of the presence of pulmonary arterial hypertension.
Like the authors, we strongly advocate the use of noninvasive indicators of right ventricular performance in patients with pulmonary disease as a means of identifying those at high risk. This new echocardiographic technique, which can be incorporated into a conventional transthoracic study, may be more practical for this purpose.
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1. Traver GA, Cline MG, Burrows B. Predictors of mortality in chronic obstructive pulmonary disease: a 15 year follow-up study. Am Rev Respir Dis. 1979;119:895–902.[Medline] [Order article via Infotrieve]
2.
Incalzi RA, Fuso L, De Rosa M, Di Napoli A, Basso S,
Pagliari G, Pistelli R. Electrocardiographic signs of chronic cor
pulmonale: a negative prognostic finding in chronic obstructive
pulmonary disease. Circulation. 1999;99:1600–1605.
3. Tei C, Dujardin KS, Hodge DO, Bailey KR, McGoon MD, Tajik AJ, Seward JB. Doppler echocardiographic index for assessment of global right ventricular function. J Am Soc Echocardiogr. 1996;9:838–847.[Medline] [Order article via Infotrieve]
4. Yeo TC, Dujardin KS, Tei C, Mahoney DW, McGoon MD, Seward JB. Value of a Doppler-derived index combining systolic and diastolic time intervals in predicting outcome in primary pulmonary hypertension. Am J Cardiol. 1998;81:1157–1161.[Medline] [Order article via Infotrieve]
5. Burgess MI, Haider Y, Lok S, Egan JJ, Ray SG. A simple echocardiographic index of global right ventricular function in patients with idiopathic pulmonary fibrosis. Am Rev Respir Dis. 1999;159:A51. Abstract.
Response
Respiratory Physiology Department, Catholic University, Rome, Italy
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We have read with great interest the letter by Dr Burgess and colleagues. The proposed method of assessing right ventricular function looks quite promising, especially because of its alleged applicability in various clinical and hemodynamic conditions. The authors demonstrated that this index is easily measurable both in chronic obstructive pulmonary disease (COPD) and in interstitial lung disease and qualifies as a reliable indirect measure of pulmonary hypertension.R1 However, the available evidence supports its role as a prognostic tool only in primary pulmonary hypertension, which is a relatively uncommon condition.R2 Thus, we think that efforts should be made to verify whether this index carries autonomous prognostic implications in COPD as well as in pulmonary hypertension complicating congestive heart failure. Eventually, the response of this index to acute changes in pulmonary artery pressure should be assessed to clarify its predictive power.
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References |
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TopIntroductionReferencesIntroduction References |
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1. Burgess MI, Haider Y, Lok S, Egan JJ, Ray SG. A simple echocardiographic index of global right ventricular function in patients with idiopathic pulmonary fibrosis. Am Rev Respir Dis. 1999;159:A51. Abstract.
2. Yeo TC, Dujardin KS, Tei C, Mahoney DW, McGoon MD, Seward JB. Value of a Doppler-derived index combining systolic and diastolic time intervals in predicting outcome in primary pulmonary hypertension. Am J Cardiol. 1998;81:1157–1161.
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