Accepted Manuscript Assessment of RV function in OSAS and effects of CPAP treatment: a pilot study with 3D and speckle-tracking echocardiography Antonio Vitarelli, MD, FACC, Claudio Terzano, MD, Maurizio Saponara, MD, Carlo Gaudio, MD, Enrico Mangieri, MD, Lidia Capotosto, MD, Mario Pergolini, MD, Simona D’Orazio, MD, Giovanna Continanza, MD, Ester Cimino, MD PII:

S0828-282X(15)00076-8

DOI:

10.1016/j.cjca.2015.01.029

Reference:

CJCA 1562

To appear in:

Canadian Journal of Cardiology

Received Date: 3 December 2014 Revised Date:

25 January 2015

Accepted Date: 25 January 2015

Please cite this article as: Vitarelli A, Terzano C, Saponara M, Gaudio C, Mangieri E, Capotosto L, Pergolini M, D’Orazio S, Continanza G, Cimino E, Assessment of RV function in OSAS and effects of CPAP treatment: a pilot study with 3D and speckle-tracking echocardiography, Canadian Journal of Cardiology (2015), doi: 10.1016/j.cjca.2015.01.029. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT CJC-D-14-01611R2 - 2nd revision

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Assessment of RV function in OSAS and effects of CPAP treatment: a pilot study with 3D and speckle-tracking echocardiography

Antonio Vitarelli*, MD, FACC, Claudio Terzano*, MD, Maurizio Saponara†, MD, Carlo Gaudio*, MD, Enrico Mangieri*, MD, Lidia Capotosto*, MD, Mario Pergolini‡, MD, Simona D’Orazio*, MD, Giovanna Continanza*, MD, Ester Cimino*, MD - Cardio-Respiratory*, Otolaryngology†, and

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Word count:

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Medicine‡ Depts, Sapienza University, Rome, Italy

2957 (excluding abstract, references, figure legends, and tables) 5526 (including abstract, references, figure legends, and tables)

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Running title: RV function in OSAS

Address for correspondence: Antonio Vitarelli, M.D. Via Lima 35 00198 Rome, Italy telephone number: 39/6/85301427, FAX number: 39/6/8841926, E-mail: [email protected] [email protected]

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ACCEPTED MANUSCRIPT Brief Summary

Right ventricular (RV) function in OSAS was assessed by three-dimensional (3D) echocardiography and speckle tracking echocardiography (STE) and changes evaluated after

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continuous positive airway pressure (CPAP) treatment. Thirty-seven patients with OSAS without comorbidities and thirty controls were studied. 3D RV ejection fraction and RV dyssynchrony were abnormal in patients compared to controls and associated with OSAS severity both in the presence

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and absence of pulmonary hypertension. RV-3D-STE abnormalities improved after chronic

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application of CPAP therapy.

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ACCEPTED MANUSCRIPT Abstract

Background. It is known that obstructive sleep apnea syndrome (OSAS) can affect right ventricular (RV) performance even in the absence of systemic hypertension and other known

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cardiac or obstructive pulmonary disease. The purpose of the present study was to assess RV function in OSAS by three-dimensional (3D) echocardiography and speckle tracking echocardiography (STE) and evaluate changes after continuous positive airway pressure (CPAP)

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treatment.

Methods. Thirty-seven patients with OSAS without comorbidities and thirty controls were

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studied with 3D-echocardiography and STE. Fifteen patients underwent CPAP therapy and were studied before and after treatment. RV 3D ejection fraction was calculated. Peak-systolic strain was determined. RV dyssynchrony was defined as standard deviation of the six time to peak-systolic strain values.

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Results. 3D RV ejection fraction was lower and RV dyssynchrony was greater in patients with moderate-severe OSAS compared to controls both in the presence and absence of pulmonary hypertension. 3D RV ejection fraction and RV dyssynchrony were independently associated with

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apnoea-hypopnea index. Patients treated with CPAP had significant changes in RV parameters. Conclusions. 3D RV ejection fraction and RV dyssynchrony were abnormal in OSAS

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patients compared to controls and associated with OSAS severity. RV-3D-STE abnormalities improved after chronic application of CPAP.

Key words: obstructive sleep apnea syndrome, echocardiography, right ventricular function, speckle tracking imaging, pulmonary hypertension

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ACCEPTED MANUSCRIPT Introduction. Obstructive sleep apnea syndrome (OSAS) is the most common form of sleep-disordered breathing characterized by excessive daytime sleepiness, choking or gasping during sleep, recurrent awakenings from sleep, unrefreshing sleep, and sleep monitoring demonstrating five or more

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obstructive apneas/hypopneas per hour during sleep(1,2). Definitions of OSAS are based on respiratory and neurophysiologic indices but recent reports showed that cardiovascular sequelae could be more important since complications such as coronary artery disease, heart failure, systemic

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and pulmonary hypertension, and arrhythmias, increase morbidity and mortality. Studies on this subject have assessed the effects of OSAS on the left ventricle (LV) and tested the impact of OSAS

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treatment with continuous positive airway pressure (CPAP) on LV changes(3–7). Early determination of RV dysfunction in patients with OSAS and pulmonary hypertension is also important in preventing progression to heart failure even the absence of overlapping chronic lung disease, morbid obesity, or left-sided heart disease(8-10). However, data on RV dysfunction and

on this chamber(9-11).

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structural changes in patients with OSAS is not always clear as well as the effects of CPAP therapy

Moreover, since the RV has a complex crescent shape and is wrapped around the LV, it is

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difficult to assess RV functions with conventional two-dimensional echocardiography. The 2D speckle tracking echocardiography (STE) is a new two-dimensional technique that assesses

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myocardial deformation and deformation rate by tracking speckles in the myocardium on grayscale (B-mode) images and can be used to evaluate both global and regional myocardial wall strain (12,13). Three-dimensional echocardiography (3DE) is also regarded as a promising tool for quantifying RV volumes and function with good correlation to magnetic resonance imaging (MRI), and is a robust, accurate, and reproducible modality for RV volume and function measurements(14). In the literature, although there are several studies in which the effects of CPAP therapy on RV myocardial performance in patients with OSAS were determined with conventional echocardiography(11), there are only few reports that assessed them with STE(12,13) and 3DE(14) 4

ACCEPTED MANUSCRIPT and a comparative analysis has not been performed. We hypothesized that in patients with OSAS the use of new echocardiographic techniques improves the assessment of RV dysfunction. The purpose of the present study was twofold: first, we aimed to evaluate the association between OSAS

abnormalities are reversible with CPAP therapy.

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severity and these new RV function parameters, and secondly to establish whether RV function

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For detailed methodological information and statistical analysis, see Supplementary Materials.

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A cohort of thirty-seven sleep apnea patients without comorbidities and thirty controls was examined with polysomnography(15) and echocardiography. Established echocardiographic criteria were used for assessment of right chambers(16-23). Three-dimensional echocardiographic images(Figure1) were stored digitally for offline analysis using dedicated software. STE

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acquisitions were also obtained, with analyses being performed retrospectively and offline. The general principles that underlie STE modalities have been previously described(24-29). All patients underwent overnight polysomnography using a standard technique. Apnoea-

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hypopnoea index(AHI) was defined as the number of apnoeas and/or hypopnoeas per hour. OSAS was defined as ≥5 AHI events per hour in the presence of clinical symptoms suggesting

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OSAS(15,30,31). On the basis of AHI, patients were classified (1,2) into mild(>5,15,40mmHg) was found in 20 patients and normal right ventricular pressure values in 17 patients. Increased RV wall thickness compared to controls was found in 18/20 patients with PH and 2/17 patients with normal pulmonary pressures. 3D-RVEF and RV-SD6 were lower(Figure 2) in patients with OSAS and pulmonary hypertension compared to the 6

ACCEPTED MANUSCRIPT control group(p

Assessment of Right Ventricular Function in Obstructive Sleep Apnea Syndrome and Effects of Continuous Positive Airway Pressure Therapy: A Pilot Study.

It is known that obstructive sleep apnea syndrome (OSAS) can affect right ventricular (RV) performance even in the absence of systemic hypertension an...
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