Assessment of Right Ventricular Function Using 2D Speckle Tracking Echocardiography in End Stage Renal Disease Patients on Regular Dialysis..

Document Type : Original Article

Authors

1 Faculty of medicine Alazhar university

2 Cardiology department, Faculty of medicine, Al-Azhar university, Cairo

3 Cardiology department, Faculty of medicine, Al-Azhar univesrity, Cairo

Abstract

Background: Chronic kidney disease (CKD) seems to be a serious issue which is becoming increasingly prevalent worldwide. The prevalence of hypertension, DM, and cardiovascular illnesses all contribute to an increase in the burden of CKD.
Aim of the Work: Utilizing 2D speckle tracking echocardiography as a noninvasive and quantitative method to evaluate the function of the RV in chronic hemodialysis patients.
Patients and Methods: This research compared 50 chronic hemodialysis patients (group I) referred to the Department of Cardiology at Sayed Galal University Hospital to 10 healthy individuals (group II) of matched age and gender. They were assessed for baseline characteristics, admission data, electrocardiography and echocardiographic parameters.
Results: Hemodialysis patients had significantly lower RV global longitudinal strain. The global RVLS (right ventricle longitudinal strain) has been shown to be significantly inversely related to age and RV diameters (longitudinal diameter and mid cavity diameter) and tricuspid E∕A ratio. While it showed significant positive correlation with FAC and LV ejection fraction. In group I patients, the tricuspid valve's E wave velocity and the tricuspid E/A ratio were both substantially lower. The tricuspid valve's A\ wave velocity was considerably higher in group I patients. A significant reduction has been found in the tricuspid valve E\ and S velocities in group I patients, whereas the A velocities of the tricuspid valve were significantly enhanced. In group I patients, MPI was significantly higher

Keywords


INTRODUCTION

Cardiovascular morbidity and mortality are higher in people with ESRD. The major cause of mortality in this group of people is cardiovascular disease. 1

Previous studies revealed that in individuals with chronic renal failure, systolic RV function and diastolic function both decrease, which is linked to poor clinical results.2

A variety of techniques, including catheterization, MRI, and echocardiography, can be utilized to evaluate right ventricular function.

Numerous echocardiography parameters, like fractional    area   change   (FAC),  tricuspid     annular

 

systolic velocities, tricuspid annular plane systolic excursion (TAPSE), and myocardial performance

index (MPI), have been well established for evaluating right ventricle systolic and diastolic function.3

A study revealed that strain analysis of the RV and RA in two dimensions may be utilized to assess the right heart's physio-mechanics. Furthermore, it may offer characteristics that are not dependent on load status, which is very beneficial in individuals with right heart disease.4

This research aimed to assess right ventricular function in chronic hemodialysis patients using non-invasive techniques like traditional, tissue Doppler, and speckle tracking echocardiography.

PATIENTS AND METHODS

This research was performed at the Cardiology Department of Sayed Galal University Hospital as a single-center, cross-sectional, comparative study from September 2020 to March 2021.

A total of 61 individuals receiving hemodialysis on a regular basis were evaluated. Six patients were eliminated owing to valvular and ischemic heart disease, three patients were removed due to atrial fibrillation, and two patients have been ruled out owing to bad picture quality. The final study population included 50 patients (group I) who were matched by gender, age, and risk factors to ten patients (group II). The ethics council of Al-Azhar University's Faculty of Medicine approved the study after patients who participated in the research gave their informed consent.

The study included individuals over the age of 18 who had ESRD and were on continuous hemodialysis. Patients with one or more of the following conditions were barred from participating in the study: left ventricular systolic dysfunction [EF50%], coronary arteries, moderate to severe pericardial disease, congenital heart disease, significant valvular heart disease, non-sinus rhythm, prior renal transplantation, non-renal causes of pulmonary hypertension, suboptimal echocardiographic image, and patient refusal.

All patients underwent a complete physical examination, which included taking their age, gender, DM, HTN, and smoking, as well as a full clinical investigation, which included taking their pulse and measuring their blood pressure (systolic and diastolic) and cardiac auscultation and laboratory investigation: CBC, lipid profile, kidney function tests, and electrolytes.

Electrocardiography: Patients' heart rate and rhythm were assessed using a 12-lead surface ECG with a paper speed of 25 mm/s and an amplification of 10 mm/mv to rule out ischemic or other ECG changes.

Echocardiography: The images were all taken with the patients in the standard left lateral position with a stable ECG reading.

Conventional echocardiographic parameters:

Right atrial diameters:In the apical 4 chamber view, the right atrium's maximum long axis was measured parallel to the inter-atrial septum, and the minor axis was measured as the line connecting the midlevel of the right atrium free wall to the inter-atrial septum and running perpendicular to the long axis at the mid atrial level.5

Dimensions of the right ventricle: RV basal measurement (in the basal one-third), mid cavity (at the LV papillary muscles' level), and longitudinal dimensions on a 4-chamber right ventricle-focused image must be performed in people with right-sided cardiac illness. 6

FAC in the right ventricle is computed by dividing (end-diastolic area-end-systolic area) by 100 and expressed as a percentage. FAC is produced in the apical 4 chamber view by tracing the endocardium of the right ventricular in systole and diastole. 7

Pulmonary artery systolic pressure (PASP):The right ventricular systolic pressure (RVSP) was calculated from peak TR jet velocity utilizing the simplified Bernoulli equation and trying to combine such a result with a guesstimate of the RA pressure: RVSP = 4 (V) 2 + RA pressure, where V is the peak velocity (in m/sec) of the tricuspid valve regurgitant jet, and RA pressure is calculated using IVC diameter and respiratory variations. 8

TAPSE was calculated by passing an M-mode cursor through the tricuspid annulus and measuring the longitudinal motion of the annulus at maximum systole with a typical apical four-chamber window. (8)

The left ventricular ejection fraction (LVEF) is determined utilizing the formula: (EDV-ESV)/EDV = EF. This was accomplished by amending Simpson's rule. 9

Tissue Doppler echocardiographic parameters:

The peak annular systolic velocity (S), early (E') and late (A') peak annular diastolic velocities, and systolic velocity period have been calculated using the ejection time (ET), isovolumetric relaxation time (IVRT, time between the end of ET and the starting of E"), and isovolumetric contraction time (IVCT, time between the end of A' and the starting of ET).

To get a global evaluation of the RV's systolic and diastolic functions, the TDI-derived MPI was computed by dividing the total of IVCT and IVRT by the ET. 10

Speckle tracking echocardiography:

RV global longitudinal strain:At end-systole, the RV free wall's endocardial boundary was manually traced and automatically modified to accommodate the whole myocardium. To guarantee appropriate tracking, the thickness of the myocardium was manually adjusted to the area of interest.11

The strain rate and RV strain are important characteristics to consider when evaluating the RV's systolic function on a global and regional scale. The percentage of RV free wall shortening from base to apex during systole is defined as the longitudinal strain rate. (12)

SPSS vs.25 was used for data administration and statistical analysis. Means and standard deviations have been utilized to sum up numerical data. Numbers and percentages have been utilized to summarize categorical data. To compare numerical variables between two groups, the Mann-Whitney U test has been utilized. To compare categorical variables, the Chi-square test has been utilized. Correlation analysis was conducted as needed using Pearson or Spearman correlation. The letter "r" denotes the correlation coefficient. This study's p values were all two-sided. If the P value is < 0.05, it is deemed significant.

RESULTS

 

 

   

Group I

(n = 50)

Group II

(n = 10)

P value

Age (years)

Mean ±SD

52 ±9.

50 ±4.

0.190

Sex

Male n (%)

Female n (%)

30 (60%)

20(40%)

5 (50%)

5(50%)

0.277

BMI

Mean ±SD

28.58±5.23

28.20±5.98

0.838

Table 1: Patient's demographics. Regarding age and gender, both groups were similar.

 

Group I(n=50)

Group II(n=10)

P value

DM

21 (42%)

3 (30%)

0.280

HTN

28 (56%)

5 (50%)

0.565

Smoking

10 (20%)

2 (20%)

0.4

SBP (mmHg)

116 ±13

116 ±14

0.971

DBP (mmHg)

73 ±10

72 ±11

0.626

Hb

9.97±1.00

12.10±1.54

<0.001**

Urea

93.20±100.32

26.50±5.06

0.041*

Creatinin

5.19±1.43

0.86±0.19

<0.001**

Table 2: Both groups' risk factors and clinical characteristics: Both groups had comparable risk factors. Hemoglobin, urea and creatinin were measured for all patients. There were no statistically significant differences in blood pressure between the two groups at the time of presentation.

 

Group I(n = 50)

Group II (n = 10)

 
 

Mean

±SD

Mean

±SD

P value

RV longitudinal diameter (cm)

5.6

0.8

5

0.7

0.002

RV mid cavity diameter (cm)

2.5

0.6

2.1

0.2

<0.001

RV basal diameter (cm)

3.4

0.6

2.9

0.6

<0.001

RV systolic area (cm2)

18.35

2.91

9.21

2.15

<0.001

RV diastolic area (cm2)

23.08

1.65

15.61

1.29

<0.001

TAPSE (cm)

2.3

0.2

2.5

0.2

<0.001

PASP (mmHg)

51.9

11.9

24.9

2.2

<0.001

FAC (%)

40.8

5.2

47.5

6.3

<0.001

RA longitudinal diameter (cm)

4.6

0.6

3.8

0.6

<0.001

RA transverse diameter (cm)

3.6

0.7

2.9

0.6

<0.001

RA systolic area (cm2)

29.4

13

18.4

1.5

0.002

Tricuspid E wave

42.5

12.8

71.4

9.2

<0.001

Tricuspid A wave

66

14.9

39.9

4.1

<0.001

Tricuspid E/ wave

9.73

1.89

14.19

1.79

<0.001

Tricuspid A/ wave

14.21

2.64

12.09

1.46

<0.001

Tricuspid S wave

10

3.1

12.9

1.5

<0.001

Tricuspid E/A ratio

1.04

0.35

1.51

0.05

<0.001

Tricuspid E\E/ ratio

5.92

2.1

5.11

0.48

0.605

MPI

0.6

0.1

0.5

0.1

0.004

LV EF (%)

66

5.8

67.9

6.7

0.358

Table 3: Echocardiographic parameters (conventional and tissue Doppler): Regarding conventional echocardiographic measures, group I patients had larger right ventricular diameters (longitudinal, mid cavity, and basal) and areas (systolic and diastolic) and right atrial diameters (longitudinal and transverse).  When compared to group II patients, RV FAC and TAPSE were significantly lower in group I patients. In group I patients, the tricuspid valve's E wave velocity and the tricuspid E/A ratio were both substantially lower. In group I, the tricuspid valve's A wave velocity was substantially enhanced. The difference between the two groups in LV ejection percentage has not been statistically significant. Regarding Tissue Doppler echocardiographic parameters, The E/ and S velocities of the tricuspid valve were substantially decreased in group I patients. In group I, the tricuspid valve A/ velocity was substantially higher. In comparison to group II, MPI was considerably greater in group I.

 

 

GroupI (n=50)

GroupII (n=10)

 
 

Mean

±SD

Mean

±SD

P value

RVGLS

-16.87

4.16

-22.54

1.48

<0.001

Table 4: Speckle tracking echocardiographic parameter of RVGLS.

 

RV strain

 

R

P value

Age(years)

-0.281

0.005

RV longitudinal diameter(cm)

-0.326

0.001

RV mid cavity diameter(cm)

-0.372

<0.001

RA transverse diameter

-0.24

0.016

 Tricuspid E/A ratio

-0.246

0.014

FAC

0.313

0.002

 LV EF (%)

0.241

0.016

Table 5: Correlation between RV global longitudinal strain and other parameters. RVGLS was significantly decreased in group I patients. It has been shown to be inversely linked to age, the diameters of the RV (longitudinal diameter, mid-cavity diameter), the RA transverse diameter, and the tricuspid E/A ratio. While it exhibited a significant positive connection with FAC and LV ejection fraction.

 

DISCUSSION

In hemodialysis patients, right ventricular dysfunction (RVD) is frequent. Furthermore, because to interventricular contact, RV dysfunction may influence LV filling. RVD detection will aid in the identification of patients with a higher CV risk. 13

As a result, a precise and efficient technique of evaluating RV function was necessary. TAPSE and the right ventricular myocardial performance index were the most often utilized echocardiographic measures in previous RV function investigations. While this study used RV speckle tracking to evaluate right ventricular function. 14

In this study, the differences in systolic and diastolic blood pressure have not been substantial.

This wasn't similar to the study performed by Sun et al., 2018 on the long-term effects of hemodialysis on the RV assessed via 3D speckle tracking echocardiography. They found that patients on maintenance hemodialysis possessed considerably greater systolic and diastolic blood pressure. 15

 The longitudinal, mid cavity, and basal diameters of the right ventricle were substantially enlarged in group I patients (p value 0.001). Additionally, RV areas (systolic and diastolic) were substantially enlarged (p value 0.001) in group I patients. Whereas RV FAC was substantially reduced (p value 0.001) in group I patients.

These results were consistent with Karavelioglu et al., 2015 who assessed RV functions in non-diabetic, normotensive hemodialysis patients. They discovered that ESRD patients had a substantially larger RV end diastolic area than controls. While FAC was substantially lower in patients with ESRD, this was due to decreased RV systolic function. 16

 While Tamulenaite et al., 2018 researchers that examined changes in left and right ventricular mechanics and functions in ESRD patients receiving hemodialysis obtained findings that differed from ours on RV FAC, which had not been observed to be altered by preload decrease. This may be explained by maintaining radial RV distortion in individuals with ESRD while decreased RV longitudinal function (TAPSE, RV S, and RV GLS). 17

In the current study, patients in group I had significantly higher estimated PASP and RV MPI.In group I patients, TAPSE (tricuspid annular plane systolic excursion) was considerably reduced.

These results were consistent with Karavelioglu et al., 2015 who discovered that ESRD patients had significantly higher mean and systolic pulmonary artery pressures (p values 0.001 and 0.006, respectively). Furthermore, they found that RV MPI was substantially higher in the ESRD group (p =0.007). TAPSE was significantly lower in the ESRD group (p =0.003).16

Also, El-Deen et al., 2015 assessed the RV function in hemodialysis patients using tissue Doppler. The researchers discovered a significant rise in RV MPI in hemodialysis patients when compared to the control group. They found that TDI MPI had a higher sensitivity and specificity for assessing RV function in dialysis patients than RV FAC.18

In the current study, patients in Group I had significantly larger right atrial diameters than patients in Group II.

These results were consistent with Tamulenaite et al., 2018 They reported that RA volume index was significantly increased in the hemodialysis group (p value -0.012).17

 In the current study regarding the RV diastolic functions, tricuspid E velocity, E/A ratio and E/ velocity were significantly decreased in group I patients.

 This was consistent with Karavelioglu et al., 2015 who reportedthat tricuspid E velocity, tricuspid E/A ratio and tricuspid E/ velocity were significantly decreased in ESRD group indicating RV diastolic dysfunction. 16

Similarly, Rudhani et al., 2010 who evaluated the diastolic performance of the left and right ventricles in hemodialysis sufferers, found that the tricuspid E wave velocity and E/A ratio were significantly lower in hemodialysis patients, while the A wave was significantly higher. Tissue Doppler imaging revealed that tricuspid S and E\ velocity were significantly reduced in hemodialysis patients.19

This was similar to El-Deen et al., 2015 when hemodialysis patients were compared to controls. The A, IVRT, E/E ratio, IVCT, and lateral TDI MPI values were considerably higher in the hemodialysis group (p0.001). Individuals undergoing hemodialysis had significantly lower E, E/A ratio, and S (p0.001). 18

In the current study, right ventricular global longitudinal strain (RVGLS %) was considerably decreased in patients of group I compared with group II patients (-16.87 ± 4.16 vs. -22.54 ± 1.48%, P < 0.001). The relationship between peak global RVLS and FAC was strong positive (r = 0.313, P value = 0.002).

These results were consistent with Tamulenaite et al., 2018. They reported that the hemodialysis group patients had significantly lower RVGLS values compared with the controls. 17

Ali et al., 2016, compared right and left ventricular function in hemodialysis sufferers to newly diagnosed uremic patients with maintained systolic function and found that the hemodialysis group's RV global longitudinal strain was significantly lower (-8.55 vs.-10.86, p value 0.018).20

CONCLUSION

Patients on chronic hemodialysis had bigger RV and RA diameters. The RV-FAC and TAPSE were both lower in chronic hemodialysis patients. Patients on chronic hemodialysis had significantly reduced global longitudinal strain in the right ventricle. RVGLS was shown to have a significant negative relationship with age, RV diameters, RA maximum diameter, and tricuspid E/A ratio.  While it exhibited a substantial positive association with FAC.

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