© 2014, Wiley Periodicals, Inc. DOI: 10.1111/echo.12835
Echocardiography
ORIGINAL INVESTIGATION
Improvement in Tricuspid Annular Plane Systolic Excursion with Pulmonary Hypertension Therapy in Pediatric Patients Maria Bano, M.D., Usama B. Kanaan, M.D., Alexandra C. Ehrlich, M.S., Courtney McCracken, Ph.D., Gemma Morrow, R.D.C.S., Matthew E. Oster, M.D., M.P.H., and Ritu Sachdeva, M.D. Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia
Background: Tricuspid annular plane systolic excursion (TAPSE) has emerged as a novel and reliable measure of right ventricular (RV) function. The purpose of this study was to determine the effect of pulmonary hypertension (PH) therapy on TAPSE in pediatric patients and compare TAPSE to other quantitative measures of RV function. Methods: A retrospective review of medical records and echocardiograms of patients in the PH clinic from January 2011 to August 2013 was done. Echocardiograms were analyzed prior to initiation or addition of a PH drug and at least 8 weeks later. Following quantitative measures of RV function were compared: TAPSE, TAPSE age-based z-score, RV fractional area change (RVFAC), tricuspid annular S0 , tricuspid inflow E/tricuspid annular E0 velocity (TV E/E0 ), and RV myocardial performance index (RVMPI). Results: Of the 37 patients included in this study (median age 0.6 years), 23 (62.2%) were treatment naive and others had a new PH drug added to their regimen at the time of the baseline echocardiogram. The median duration between the baseline and follow-up echocardiogram was 8 (2–25) months. There was a significant improvement in TAPSE and TAPSE agebased z-score on the follow-up echocardiogram. RVFAC, tricuspid S0 , TV E/E0 , and RVMPI did not show a statistically significant change. Conclusion: In contrast to the other echocardiographic markers of RV function, TAPSE, and TAPSE age-based z-score significantly improve after initiation or addition of PH therapy and can be used for serial noninvasive monitoring of RV function in pediatric PH patients. (Echocardiography 2014;00:1–5) Key words: pulmonary hypertension, tissue Doppler echocardiography Right ventricular (RV) dysfunction is associated with clinical deterioration in patients with pulmonary hypertension (PH).1–3 Medical therapy to decrease pulmonary vascular resistance and improve RV function is the cornerstone of long-term management of PH. It is well-known that the assessment of RV function on echocardiography can be challenging. Methods to assess RV function by echocardiography have included RV fractional area change (RVFAC), Doppler tissue imaging (DTI)-derived velocities, RV myocardial performance index (RVMPI), and tricuspid annular plane systolic excursion (TAPSE).1–4 Among these markers, TAPSE has emerged as a novel, reliable, and reproducible measure of RV function in adults with PH.3–5 Studies evaluating the change, if any, in these echocardiographic markers of RV function with respect to PH therapy, in pediatric population are lacking. The purpose of this study was to determine the effect Address for correspondence and reprint requests: Maria Bano, M.D., 1405 Clifton Road NE, Atlanta, GA 30322, Fax: 770488-9486; E-mail: [email protected]
of PH therapy on TAPSE and compare it to other echocardiographic markers of RV function in pediatric patients. Methods: A retrospective review of medical records of all patients less than 21 years of age, seen in the pediatrics PH clinic from January 2011 to August 2013 at our institution was performed. The Children’s Healthcare of Atlanta Institutional Review Board approved this study. Patients were diagnosed with PH if their mean pulmonary artery pressure was >25 mm Hg on a right heart catheterization.6,7 In patients without a right heart catheterization at the time of diagnosis, PH was diagnosed based on elevated estimated systolic pulmonary artery pressures calculated from peak tricuspid regurgitation (TR) velocity using established Doppler-derived methods along with other convincing evidence of PH like RV dysfunction, dilation and/or hypertrophy.6,8 A single observer (MB) analyzed echocardiograms for each patient at baseline and at least 8 weeks after initiation of PH therapy or addition of a new PH drug to the 1
Bano et al.
patient’s treatment regimen. The following quantitative measures of RV function were compared: for RV systolic function: TAPSE, TAPSE age-based z-score, RVFAC, and DTI-derived tricuspid annular systolic velocity (S0 ); for RV diastolic function: ratio of tricuspid valve inflow early diastolic wave (E wave) and DTI-derived tricuspid annular E0 (E/ E0 ); and for global RV function: RVMPI. TAPSE was measured using M-mode from the apical four-chamber view with the cursor placed at the free wall of the tricuspid annulus (Fig. 1).8 To account for developmental changes, TAPSE age-based z-scores were also recorded.9 RVFAC, defined as (RV end-diastolic area RV endsystolic area)/RV end-diastolic area, was obtained by tracing the RV endocardium in apical fourchamber view in systole and diastole from the annulus, along the free wall to the apex, then back to the annulus, along the interventricular septum.8 Tricuspid annular S0 and E0 velocities were recorded and tricuspid annular E/E0 was derived as a ratio of the tricuspid inflow Doppler peak early diastolic velocity (E) and DTI-derived early diastolic velocity (E0 ).8 RVMPI was obtained using the pulsed Doppler across the tricuspid
inflow and RV outflow tract (RVOT) as previously described.10 Statistical Analysis: The change in markers of RV function between the two echocardiograms was assessed using paired t-tests. SAS version 9.3 for Windows (Cary, NC, USA). was used for analysis and statistical significance was assessed at the 0.05 level. Results: The baseline characteristics of our study population are summarized in Table I. The diagnosis of PH was based on right heart catheterization in 19 of 37 patients. Their mean pulmonary vascular resistance was 11.6 9.2 wood units and mean pulmonary artery pressure was 44.13 14.6 mmHg. The remaining patients were diagnosed based on transthoracic echocardiographic findings. The mean RV systolic pressure derived from the TR peak velocity in these patients was 65.16 25.89 mmHg above the right atrial pressure. In five of these patients, the TR jet was not adequate to predict RV pressures. All five patients were former premature infants with
Figure 1. M-mode through the tricuspid annulus to measure tricuspid annular plane systolic excursion (TAPSE).
2
TAPSE Improves PH Therapy in Children
TABLE I
TABLE II
Baseline Characteristics of the Study Population Total number of patients (n) Gender (male%/female%) Ethnicity, n (%) African American Caucasian Hispanic/Latino Asian Other Primary diagnosis, n (%) Lung disease PH APAH IPAH HPAH Congenital heart disease associated PH, n (%) CAVC PDA PAPVR Discontinuous pulmonary arteries s/p ductal stent Inadvertent LPA clipping during PDA ligation Lung disease PH and preterm n (%) GA >37 weeks n (%) GA
Echocardiography
ORIGINAL INVESTIGATION
Improvement in Tricuspid Annular Plane Systolic Excursion with Pulmonary Hypertension Therapy in Pediatric Patients Maria Bano, M.D., Usama B. Kanaan, M.D., Alexandra C. Ehrlich, M.S., Courtney McCracken, Ph.D., Gemma Morrow, R.D.C.S., Matthew E. Oster, M.D., M.P.H., and Ritu Sachdeva, M.D. Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia
Background: Tricuspid annular plane systolic excursion (TAPSE) has emerged as a novel and reliable measure of right ventricular (RV) function. The purpose of this study was to determine the effect of pulmonary hypertension (PH) therapy on TAPSE in pediatric patients and compare TAPSE to other quantitative measures of RV function. Methods: A retrospective review of medical records and echocardiograms of patients in the PH clinic from January 2011 to August 2013 was done. Echocardiograms were analyzed prior to initiation or addition of a PH drug and at least 8 weeks later. Following quantitative measures of RV function were compared: TAPSE, TAPSE age-based z-score, RV fractional area change (RVFAC), tricuspid annular S0 , tricuspid inflow E/tricuspid annular E0 velocity (TV E/E0 ), and RV myocardial performance index (RVMPI). Results: Of the 37 patients included in this study (median age 0.6 years), 23 (62.2%) were treatment naive and others had a new PH drug added to their regimen at the time of the baseline echocardiogram. The median duration between the baseline and follow-up echocardiogram was 8 (2–25) months. There was a significant improvement in TAPSE and TAPSE agebased z-score on the follow-up echocardiogram. RVFAC, tricuspid S0 , TV E/E0 , and RVMPI did not show a statistically significant change. Conclusion: In contrast to the other echocardiographic markers of RV function, TAPSE, and TAPSE age-based z-score significantly improve after initiation or addition of PH therapy and can be used for serial noninvasive monitoring of RV function in pediatric PH patients. (Echocardiography 2014;00:1–5) Key words: pulmonary hypertension, tissue Doppler echocardiography Right ventricular (RV) dysfunction is associated with clinical deterioration in patients with pulmonary hypertension (PH).1–3 Medical therapy to decrease pulmonary vascular resistance and improve RV function is the cornerstone of long-term management of PH. It is well-known that the assessment of RV function on echocardiography can be challenging. Methods to assess RV function by echocardiography have included RV fractional area change (RVFAC), Doppler tissue imaging (DTI)-derived velocities, RV myocardial performance index (RVMPI), and tricuspid annular plane systolic excursion (TAPSE).1–4 Among these markers, TAPSE has emerged as a novel, reliable, and reproducible measure of RV function in adults with PH.3–5 Studies evaluating the change, if any, in these echocardiographic markers of RV function with respect to PH therapy, in pediatric population are lacking. The purpose of this study was to determine the effect Address for correspondence and reprint requests: Maria Bano, M.D., 1405 Clifton Road NE, Atlanta, GA 30322, Fax: 770488-9486; E-mail: [email protected]
of PH therapy on TAPSE and compare it to other echocardiographic markers of RV function in pediatric patients. Methods: A retrospective review of medical records of all patients less than 21 years of age, seen in the pediatrics PH clinic from January 2011 to August 2013 at our institution was performed. The Children’s Healthcare of Atlanta Institutional Review Board approved this study. Patients were diagnosed with PH if their mean pulmonary artery pressure was >25 mm Hg on a right heart catheterization.6,7 In patients without a right heart catheterization at the time of diagnosis, PH was diagnosed based on elevated estimated systolic pulmonary artery pressures calculated from peak tricuspid regurgitation (TR) velocity using established Doppler-derived methods along with other convincing evidence of PH like RV dysfunction, dilation and/or hypertrophy.6,8 A single observer (MB) analyzed echocardiograms for each patient at baseline and at least 8 weeks after initiation of PH therapy or addition of a new PH drug to the 1
Bano et al.
patient’s treatment regimen. The following quantitative measures of RV function were compared: for RV systolic function: TAPSE, TAPSE age-based z-score, RVFAC, and DTI-derived tricuspid annular systolic velocity (S0 ); for RV diastolic function: ratio of tricuspid valve inflow early diastolic wave (E wave) and DTI-derived tricuspid annular E0 (E/ E0 ); and for global RV function: RVMPI. TAPSE was measured using M-mode from the apical four-chamber view with the cursor placed at the free wall of the tricuspid annulus (Fig. 1).8 To account for developmental changes, TAPSE age-based z-scores were also recorded.9 RVFAC, defined as (RV end-diastolic area RV endsystolic area)/RV end-diastolic area, was obtained by tracing the RV endocardium in apical fourchamber view in systole and diastole from the annulus, along the free wall to the apex, then back to the annulus, along the interventricular septum.8 Tricuspid annular S0 and E0 velocities were recorded and tricuspid annular E/E0 was derived as a ratio of the tricuspid inflow Doppler peak early diastolic velocity (E) and DTI-derived early diastolic velocity (E0 ).8 RVMPI was obtained using the pulsed Doppler across the tricuspid
inflow and RV outflow tract (RVOT) as previously described.10 Statistical Analysis: The change in markers of RV function between the two echocardiograms was assessed using paired t-tests. SAS version 9.3 for Windows (Cary, NC, USA). was used for analysis and statistical significance was assessed at the 0.05 level. Results: The baseline characteristics of our study population are summarized in Table I. The diagnosis of PH was based on right heart catheterization in 19 of 37 patients. Their mean pulmonary vascular resistance was 11.6 9.2 wood units and mean pulmonary artery pressure was 44.13 14.6 mmHg. The remaining patients were diagnosed based on transthoracic echocardiographic findings. The mean RV systolic pressure derived from the TR peak velocity in these patients was 65.16 25.89 mmHg above the right atrial pressure. In five of these patients, the TR jet was not adequate to predict RV pressures. All five patients were former premature infants with
Figure 1. M-mode through the tricuspid annulus to measure tricuspid annular plane systolic excursion (TAPSE).
2
TAPSE Improves PH Therapy in Children
TABLE I
TABLE II
Baseline Characteristics of the Study Population Total number of patients (n) Gender (male%/female%) Ethnicity, n (%) African American Caucasian Hispanic/Latino Asian Other Primary diagnosis, n (%) Lung disease PH APAH IPAH HPAH Congenital heart disease associated PH, n (%) CAVC PDA PAPVR Discontinuous pulmonary arteries s/p ductal stent Inadvertent LPA clipping during PDA ligation Lung disease PH and preterm n (%) GA >37 weeks n (%) GA
