|Year : 2021 | Volume
| Issue : 1 | Page : 13-16
Echocardiographic assessment of right ventricular function in first myocardial infarction
Amar Prabhudesai MD, DM 1, Kiron Varghese MD, DM 2
1 Department of Cardiology, Goa Medical College, Bambolim, Panaji, Goa, India
2 Department of Cardiology, St. John's Medical College Hospital, Bengaluru, Karnataka, India
|Date of Submission||10-Jul-2020|
|Date of Decision||12-Aug-2020|
|Date of Acceptance||11-Sep-2020|
|Date of Web Publication||27-Mar-2021|
Dr. Amar Prabhudesai
Flat No 302, Building No 8, Mathias Ocean Park Residency, Opposite NIO Colony, Dona Paula, Panaji - 403 004, Goa
Source of Support: None, Conflict of Interest: None
Aim: The aim is to study the right ventricular (RV) function in patients of first myocardial infarction (MI). Methods: This study compared 25 patients of inferior wall MI (IWMI) with or without RVMI and 20 patients of anterior wall MI (AWMI) with 25 healthy age-matched controls. RV function was assessed using Tei index, tricuspid annular plane systolic excursion (TAPSE), tricuspid annular systolic (S'), early diastolic (E'), and late diastolic (A') velocities using tissue Doppler imaging (TDI) at first presentation and after 24 h. Results: In patients with IWMI, the Tei index was significantly increased (0.44 ± 0.09 vs. 0.22 ± 0.05; P < 0.001), TAPSE was reduced (1.25 ± 0.32 cm vs. 2.09 ± 0.26 cm; P < 0.001) and tricuspid annular S'(12.04 ± 1.74 cm/s vs. 16.48 ± 3.38 cm/s; P < 0.001) and E' (10.16 ± 2.23 cm/s vs. 12.32 ± 3.74 cm/s; P = 0.006) significantly decreased on TDI, compared to controls. Interestingly, patients with AWMI also had significantly increased Tei index (0.45 ± 0.16 vs. 0.22 ± 0.05; P < 0.001) and reduced TAPSE (1.52 ± 0.35 cm vs. 2.09 ± 0.26 cm; P < 0.001) and tricuspid annular S' (13.4 ± 2.5 cm/s vs. 16.48 ± 3.38 cm/s; P = 0.001) compared to controls. IWMI patients with associated RVMI had significantly reduced TAPSE (1.01 ± 0.24 cm vs. 1.43 ± 0.25 cm; P < 0.001) but did not differ with respect to the Tei index (0.42 ± 0.09 vs. 0.44 ± 0.09; P = 0.56) compared to those without ECG evidence of RVMI. Serial echocardiography showed significant improvements in measures of RV function. Conclusion: RV function is affected in all cases of MI, including AWMI, due to ventricular interaction and interdependence. Furthermore, RV function improves rapidly on follow-up.
Keywords: Right ventricular myocardial infarction, tricuspid annular plane systolic excursion, Tei index
|How to cite this article:|
Prabhudesai A, Varghese K. Echocardiographic assessment of right ventricular function in first myocardial infarction. J Clin Prev Cardiol 2021;10:13-6
|How to cite this URL:|
Prabhudesai A, Varghese K. Echocardiographic assessment of right ventricular function in first myocardial infarction. J Clin Prev Cardiol [serial online] 2021 [cited 2021 Apr 21];10:13-6. Available from: https://www.jcpconline.org/text.asp?2021/10/1/13/312224
| Introduction|| |
Left ventricular function has been shown to influence prognosis after acute myocardial infarction (MI)., Similarly, right ventricular (RV) dysfunction after MI is associated with an increased risk of shock, arrhythmias, and death.,,, This has been clearly demonstrated in cases of RVMI associated with inferior wall MI (IWMI). However, very few studies have evaluated RV function in anterior wall MI (AWMI). The objective of this study was to evaluate the RV function in all cases of MI, including inferior with or without electrocardiographic evidence of RVMI, as well as AWMI.
| Methods|| |
This study compared RV function in 25 patients of IWMI and 20 patients of AWMI with 25 healthy well-matched controls. Cases of acute MI presenting within 12 h of onset of angina were included. Patients with atrial fibrillation, chronic obstructive pulmonary disease, valvular heart disease, and inadequate Doppler recordings were excluded. Healthy controls were selected based on no significant cardiovascular history, normal ECG, and echocardiogram. Association of RVMI in IWMI was defined as the presence of >1 mm ST-segment elevation in V4R in ECG.
Echocardiography (echo) was performed at admission and between 24 and 72 h post admission with an average of three readings for each variable. The variables assessed were tricuspid annular plane systolic excursion (TAPSE), Tei index or the myocardial performance index (MPI) and the lateral Tricuspid annular systolic (S'), early diastolic (E'), and late diastolic (A') velocities using tissue Doppler imaging (TDI).
For recordings of the Tricuspid inflow velocity pattern, the sample volume of the pulsed Doppler was placed between the tips of the tricuspid leaflets in the apical four-chamber view. The interval between cessation of tricuspid inflow and the beginning of the next inflow was recorded as “a.” RV outflow measurements were done in an apical short-axis view at the level of the pulmonary valve. The ejection time 'b' was derived from the duration of the RV outflow Doppler velocity profile. Tei index was measured as depicted in [Figure 1] as a-b/b. The TAPSE was noted in the apical four chamber view by aligning the M-mode cursor parallel to the motion of the lateral tricuspid valve annulus and measuring the distance of the annular movement between end diastole and end-systole. Tricuspid annular S', E', and A' velocities on TDI were also measured in the four-chamber apical views.
|Figure 1: Depiction of measurement of Tei index or myocardial performance index. The index is calculated by the equation a-b/b, where a represents the interval between the cessation and onset of tricuspid inflow and b represents the ejection time of the right ventricular outflow|
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Ethics approval was obtained from the institutional ethics committee, and written informed consent was obtained from the individual patient.
Statistical analysis was performed using the IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.
The categorical variables were expressed as numbers and percentages and compared using the Chi-square test or the Fisher exact test if the generated 2 × 2 contingency table contained cells with counts ≤5.
Continuous variables were expressed as mean ± standard deviation. The three groups (controls, IWMI, AWMI) were compared using the ANOVA one-way test and intergroup comparison was done using the Bonferroni correction. Comparison between patients of IWMI with or without RVMI was carried out using the independent samples t-test. Serial echo measurements were assessed using the paired-samples t-test.
P ≤ 0.05 (2-tailed) were considered indicative of statistical significance.
| Results|| |
Controls versus inferior wall myocardial infarction versus anterior wall myocardial infarction
The three groups were similar with respect to demographic characteristics and risk factors [Table 1]. As expected, patients with MI had significantly lower left ventricular ejection fraction (LVEF) as compared to controls [Table 1]. Measures of RV function, namely TAPSE, Tei index, tricuspid annular S' and E' were also significantly different [Table 2].
Intergroup comparisons revealed that IWMI patients had significantly higher Tei index (P < 0.001) and significantly lower TAPSE (P < 0.001), tricuspid annular S' (P < 0.001), and E' (P = 0.006) as compared to controls. AWMI patients also had significantly higher Tei index (P < 0.001) and lower TAPSE (P < 0.001) and tricuspid annular S' (P = 0.001) compared to controls. When compared to AWMI patients, IWMI patients had a lower TAPSE (P = 0.017), but did not differ with respect to Tei index (P = 0.99), tricuspid annular S' (P = 0.27), E' (P = 0.61) or A' (P = 0.16).
Inferior wall myocardial infarction + right ventricular myocardial infarction versus inferior wall myocardial infarction
Patients with RVMI were younger but otherwise well-matched for all variables, including LVEF [Table 3]. The patients with RVMI had lower TAPSE but surprisingly did not differ with respect to the Tei index [Table 3].
|Table 3: Baseline characteristics and echocardiographic measurements – inferior wall myocardial infarction with right ventricular myocardial infarction versus without right ventricular myocardial infarction|
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Serial echo measurements
Serial echo measurements in both IWMI and AWMI patients showed significant improvement in TAPSE and Tei index in both the groups as compared to the index measurements at presentation [Table 4].
| Discussion|| |
RV dysfunction after MI is associated with increased risk of shock, arrhythmias, and death.,,, Alam et al. had shown that TAPSE was significantly reduced in patients with IWMI than in healthy individuals. In our study too, patients with IWMI had significantly lower TAPSE as compared to controls (P < 0.001). Patients with ECG evidence of RVMI had even lower values of TAPSE than those without (P < 0.001), which correlates with even worse RV dysfunction. The same was seen in the study done by Alam et al. Surprisingly, even patients of AWMI showed a significantly lower TAPSE as compared to controls (P < 0.001).
Tei et al. demonstrated myocardial performance index (MPI) to correlate closely with + dP/dt, − dP/dt, and tau and does not depend on geometric assumptions. Loading conditions, heart rate, and age significantly affect the individual time intervals in MPI,, but the Tei index needs no correction for blood pressure, heart rate, or age.
Jacob et al. showed that RV MPI was significantly higher in patients with first MI. During follow-up, RV MPI decreased significantly. Similar findings were noted in our study. This rapid improvement in RV MPI may be explained by lower RV afterload and favorable supply: demand ratio of the right ventricle.
Patients with AWMI also showed a prolonged Tei index. This can be attributed to: (i) common interventricular septum, which contributes to the function of both the ventricles. (ii) Diastolic interaction due to the pericardium. (iii) Ventricular syncitium with biochemical changes that affect both the ventricles.
Yoshifuku et al. correlated the severity of RV infarction with the Tei index. Patients with severe RVMI (right atrial pressure >15 mmHg) had a lower TEI index as compared to those with mild/moderate RVMI (right atrial pressure 11–15 mmHg). In our study, IWMI patients with ECG evidence RVMI had significantly lower TAPSE than those without. However, contrary to expectations, they did not differ significantly with respect to the Tei index. This may possibly be due to pseudonormalization of the Tei index in these patients with severe RV infarction as evidenced indirectly by significantly lower TAPSE. The pseudonormalization may be brought about by shortened isovolumic relaxation time due to advanced diastolic dysfunction and high right atrial pressure causing limited increase in the Tei index.
Yilmaz et al. concluded that systolic (S') and early diastolic (E') lateral tricuspid annular velocities are significantly reduced in patients with RVMI. A similar result was seen in the study by Alam et al., which showed that S' was significantly lower in patients with RVMI as compared to those with AWMI or healthy individuals. Oguzhan et al. concluded that the evaluation of tricuspid annular and RV free velocities using color DTI provides a rapid and noninvasive tool for assessing RV function in patients with RVMI. The present study showed significantly reduced S' in patients with AWMI and IWMI compared to controls. However, there was no significant difference in patients of IWMI with or without RVMI. E' was also significantly reduced in patients with IWMI but not in the other groups.
The study was performed on relatively small sample size and hence an effect of RV function derangement on prognosis could not be determined. The invasive hemodynamic assessment was not done. Measuring the right atrial pressure could have helped in elucidating the pseudonormalization of the Tei index in severe RV infarction. Strain imaging software was not installed in the echo machine at the time of undertaking the study; hence RV strain imaging could not be performed.
| Conclusion|| |
RV function is affected in all cases of IWMI irrespective of ECG evidence of RV infarction. RV function is also reduced in AWMI due to ventricular interaction and interdependence. RV function improves rapidly on follow-up. Pseudonormalization of the Tei index may occur in patients of IWMI with RV MI.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]