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European Journal of Echocardiography 2007 8(6):449-456; doi:10.1016/j.euje.2006.07.011
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Copyright © 2007, The European Society of Cardiology

Echocardiographic right ventricular strain analysis in chronic heart failure

Erwan Donala,*, Manuel Roulaudb, Pascale Raud-Raynierc, Claire De Bisschopb, Christophe Leclercqa, Geneviève Derumeauxd, Jean-Claude Dauberta, Philippe Maboa and André Denjeanb

aDepartment of Cardiology, University Hospital, CCP- CHU Pontchaillou, 35000 Rennes, France
bLaboratory of human performance EA 3813, Poitiers, France
cDepartment of Cardiology, University Hospital, Poitiers, France
dINSERM E 0226, Faculty of Medicine, Lyon, France

Received 16 May 2006; received in revised form 16 July 2006; accepted after revision 26 July 2006.

* This study was funded by a regional institutional grant. Corresponding author. Tel.: +33 2 9928 2507; fax: +33 2 9928 2529. erwan.donal{at}chu-rennes.fr


   Abstract
Top
 Abstract
Introduction
 Study population and methods
 Results
 Discussion
 Conclusions
 References
 
Objective: We sought to compare the additive value of right ventricular (RV) function assessed by longitudinal systolic strain (isin% – ROI: 9.2 at 10.8mm) with cardiopulmonary exercise testing (CPET) or brain natriuretic peptide (BNP) in patients with heart failure (HF).

Method: We studied 19-patients (age=56±8years) in New York Heart Association HF class III–IV, who underwent standard and tissue Doppler echocardiography, CPET and BNP measurements on the same day. RV function was assessed by systolic strain (isin, %, ROI: 9.2–10.8mm) in the mid-segment. Clinical outcomes were examined at 6months.

Results: isin (–19.9±6.8%) was correlated with BNP (R=0.52, P=0.02), slope VE/VCO2 (R=–0.65, P=0.003), peak VO2 (R=0.46, P=0.04) and the maximal workload (Watts) developed during CPET (R=0.54, P=0.02). During follow-up, 1-patient died, 1-underwent heart transplantation, and 4 were re-hospitalized for worsening HF. Patients with major adverse cardiac events (MACE) had a significantly higher mean BNP concentration (852.8ng/mL±1114.3 vs. 201.4±293.8, P=0.03), higher VE/VCO2 (41.3±3.6 vs. 35.0±4.8 P<0.001) and lower isin (–13.9±4.9 vs. –22.2±5.8, P<0.001) than patients who remained MACE-free. By multivariate analysis, ST was the only predictor of MACE.

Conclusion: In HF-patients presenting, RV-function assessed by systolic isin was reliable, easily measurable and a stronger prognosticator than CPET or BNP.

Keywords: BNP brain natriuretic peptide; DTI Doppler tissue imaging; EF ejection fraction; HF heart failure; LV left ventricular; MACE major adverse clinical event; MPI myocardial performance index (Tei index); RV right ventricular; isin strain; TAPSE maximal systolic excursion of the tricuspid annulus measured by M-mode echocardiography; TT Tissue tracking; VO2max peak oxygen consumption during exercise; CPET cardiopulmonary exercise testing; ROI region of interest


   Introduction
Top
 Abstract
 Introduction
Study population and methods
 Results
 Discussion
 Conclusions
 References
 
Patients with chronic heart failure (HF) complain of exercise intolerance, breathlessness and fatigue.1 Incremental exercise testing with metabolic gas exchange, used to measure peak oxygen consumption (VO2max), allows an objective assessment of symptoms and exercise capacity.2,3 The measurement of plasma BNP is also being used increasingly for the prognosis and monitoring of patients with chronic HF.4–6 Although echocardiography and measurements of resting left ventricular (LV) ejection fraction (EF) are regularly performed, they correlate poorly with exercise capacity and symptoms.7 Many patients with low exercise capacity and a poor prognosis have similar LV function than less limited and less seriously ill individuals. Although right ventricular (RV) function remains difficult to assess, especially with echocardiography, it is of prognostic importance in chronic HF.8,9

Doppler tissue imaging (DTI), strain (isin) and tissue tracking (TT) allow a quantitative assessment of regional wall motion and myocardial contractility,10,11 and are more sensitive in the quantification of regional LV longitudinal function than other, more frequently used methods.12 However, few studies published recently have emphasized the use of DTI in the evaluation of right heart function.13,14 Therefore, we have examined the contributions of RV DTI, TT and isin analysis immediately before maximal exercise stress testing, in a homogeneous population of patients with severe chronic HF.


   Study population and methods
Top
 Abstract
 Introduction
 Study population and methods
Results
 Discussion
 Conclusions
 References
 
This study was approved by the appropriate institutional research ethics committee and all patients enrolled had granted their informed written consent. We studied 19 consecutive men, 56±8years of age, referred for prognostic evaluation of chronic HF. The patients enrolled in the study represented a selected severely diseased cohort. The grant obtained to conduct the study allowed performing the exams of the protocol in 20 patients. We decided to exclude afterwards one patient because of an access of atrial fibrillation at the beginning of the protocol. The criteria for inclusion into the study were: a) stable clinical status and no episode of acute cardiac decompensation for ≥1month; b) a LVEF <45% measured by gamma-angioscintigraphy; and c) long-term, optimal and stable pharmacological treatment of HF. The exclusion criteria were: a) no prior detailed study of the etiology of HF; b) history of cardiac surgery; c) hemodynamically significant valvular disease and significant pulmonary arterial hypertension (mean pulmonary arterial pressure >30mmHg; d) presence of an implanted pacing system; e) atrial fibrillation at the time of examination; f) presence of advanced lung disease or other non-cardiac disorder limiting exercise capacity; g) change in drug therapy (particularly diuretic dose) within 2weeks before the study; h) advanced renal or liver insufficiency; i) inability to grant a written informed consent or inclusion in another research protocol within the past 6months; and j) absence of social security-guaranteed health insurance coverage.

Right heart catheterization, performed within the previous 6months, confirmed the absence of a systolic pulmonary artery pressure >45mmHg in all patients.

Echocardiography
Echocardiographic examination, including B-mode color DTI, was performed using a VingMed Vivid 5 scanner (GE Healthcare) equipped with a 2.5MHz phased array transducer. B-mode color Doppler myocardial velocity data was acquired at a frame rate of 147s–1 using an imaging sector angle of 45°.The echocardiogram was obtained just before cardiopulmonary exercise testing (CPET) with the patient lying in a left lateral position. Conventional M-mode imaging was performed in the parasternal, long axis view, and apical views pulsed wave Doppler recordings were obtained during expiration. Care was taken to obtain the narrowest possible angle between the direction of transvalvular flow and the ultrasound beam. Real-time color and pulsed DTI was recorded at the mitral annulus. Color DTI loops of 3 consecutive cardiac cycles were recorded in apical-4 and apical-2 chamber views, and stored in digital format for later analysis. All data were reviewed off-line with an Echopac 6.3.6 software analysis system (GE Healthcare).

Systolic (S) peak velocity was measured as, peak systolic displacement (TT) (Fig. 1).


Figure 1
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  		Figure 1 Representative example of the variables measured on DTI-curve analysis. IVC: isovolumic contraction, S: systole, IVR: isovolumic relaxation, E: early-diastolic peak velocity, A: end-diastolic peak velocity.

 
Peak isin (in %) defined the maximal observed deformation of the myocardium. The highest peak was considered for the analysis. The region of interest was positioned in the upper part of the basal segment of right ventricular free wall. A representative example isin analysis is shown in Fig. 2. The myocardial performance index (MPI) was calculated from flow Doppler as the sum of the contraction and relaxation isovolumic times, divided by the ejection time using the method previously described.15


Figure 2
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  		Figure 2 Representative example of a strain curve. We considered the peak of maximal deformation for the analysis.

 
Cardiopulmonary exercise testing
Each patient underwent 2 symptom-limited bicycle CPET, using an incremental protocol in steps of 10-W/min watts, starting at 30watts, and were encouraged to exercise to exhaustion. During the test, the patients wore a tightly fitting facemask connected to a capnograph and sample tube enabling measurements of on-line ventilation and metabolic gas exchange. A respiratory exchange ratio (VCO2/VO2)>1 indicated that anaerobic threshold had been reached.

Plasma B-type natriuretic peptide concentration measurement
Peripheral venous blood was collected 1h before the first exercise stress test for routine screening tests, including complete cell counts, and measurements of hemoglobin, and electrolyte, creatinine and plasma B-type natriuretic peptide (BNP) concentrations. A second 5-ml venous blood specimen was collected in a tube containing potassium EDTA, 1h after maximal exercise, for measurements of BNP, using a rapid fluorescence immunoassay (Biosite Inc.). The precision, analytic sensitivity and stability of the system have been described previously.16

Reproducibility
Intra- and inter-observer variability, expressed as the mean±standard deviation (SD) of the absolute and percentage differences between measurements, was examined in 10 randomly selected patients. The interval between measurements made by a single observer was >4weeks. The intra-observer variability for isin analysis was 5%, and the absolute inter-observer variability was 7%.

Statistical analyses
Results are presented as means±SD. Unpaired Student's t-tests were used to compare patients with versus without major adverse clinical events (MACE), including death, re-hospitalization for worsening HF, or cardiac transplantation, during a 6-month follow-up. Since the distribution of variables did not follow a Gaussian distribution, a log transformation of the parameters tested was used for correlations. The Spearman correlation coefficient was calculated for single-variable analyses. Relations between variables were also examined using a stepwise multivariate analysis. The sensitivity and specificity were determined by constructing receiver operating curves. The sensitivity/specificity cut-off points are reported as percentages with corresponding 95% confidence intervals. A p-value <0.05 was considered statistically significant. Statistical analyses were conducted using SPSS 10.0 (SPSS Inc., Chicago, IL) and NCSS 2002 (McGraw-Hill, NY) for constructing receiver operating curves.


   Results
Top
 Abstract
 Introduction
 Study population and methods
 Results
Discussion
 Conclusions
 References
 
Patient population
The mean age of the 19 men was 57±13years. Each patient was followed for >6months for management of chronic HF. At the time of CPET, 12 patients were in New York Heart Association (NYHA) functional class III and 7 patients were in class II. The mean angioscintigraphic LVEF was 29±10%. Eight patients had >50% stenoses of ≥1 coronary arteries, and 12 patients presented with idiopathic dilated cardiomyopathy. Medical treatment was optimized for ≥2weeks before the stress test, including furosemide 20 to 60mg/day and spironolactone 12.5 to 25mg/day in all patients, angiotensin-converting enzyme inhibitors in the highest tolerated doses in 18, carvedilol, 12.5 to 50mg/day in 10, bisoprolol, 2.5 to 10mg/day in 8, and an AT1 receptor antagonist of angiotensin 2 in 1 patient. No patient had more than mild-to-moderate mitral regurgitation on transthoracic echocardiogram estimated by the proximal isovelocity surface area method.17

During follow-up, one patient died, one patient underwent heart transplantation, and four were rehospitalized for worsening heart failure.

B-type natriuretic peptide, exercise stress test and echocardiographic measurements
Comparisons of the main study measurements between patients who did versus patients who did not experience MACE during follow-up are shown in Table 1. Peak systolic isin measured in the RV free wall was significantly lower in the group of patients who experienced than in patients who did not experience MACE within 6months of follow-up. Fig. 3 illustrates the values of peak systolic isin, BNP and VE/VCO2 in "the no-MACE" group compared with the "MACE" group. While differences in BNP concentrations and VE/VCO2 ratio were also statistically significant, the difference in peak isin (the only echocardiographic variable that was significantly different between the 2 groups) was particularly marked.


Figure 3
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  		Figure 3 The values of, peak VO2 (A); BNP (B); VE/VCO2 (C); and peak systolic isin (D) in "the no-MACE" group compared with the "MACE" group. In the graph (B), BNP-values before and after the CPET are figuring.

 


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  		Table 1 Comparisons of results of BNP, respiratory and echocardiographic measurements among patients who did versus patients who did not develop MACE over a 6-month follow-up

 
Univariate correlations
Baseline RV peak systolic isin was the only DTI measurement that correlated with: 1) BNP concentrations before (R=–0.52, P=0.02) and 1h after CPET (R=–0.6, P=0.007); 2) peak VO2 (R=0.46, P=0.04); 3) slope of the VE/VCO2 ratio (R=–0.65, P=0.003); 4) percent theoretical maximal O2 consumption (R=0.54, P=0.02); and 5) maximal workload (Watts) developed during CPET (R=0.53, P=0.03). Other echo-Doppler measurements made with or without DTI, whether at baseline or just after treadmill CPET were not correlated with BNP concentrations or CPET-derived measurements. Likewise, no correlation was observed with TAPSE or MPI (Tei-index).15

Stepwise multivariate regression analysis
isin (%, ROI 12mm) recorded in the basal segment of the RV free wall was the only predictor of peak VO2, VE/VCO2 slope, maximal workload, and baseline BNP concentration. It was also the only predictor of MACE (death, rehospitalization for heart failure, cardiac transplantation).

Receiver operating curves
Using a cut-off value of –18.6%, RV peak strain provided a 0.83 sensitivity and 0.92 specificity to predict a MACE at 6-month follow-up (Fig. 4).


Figure 4
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  		Figure 4 The ROC curve of the right ventricular peak strain in regard to its ability to predict a MACE at 6-month follow-up.

 

   Discussion
Top
 Abstract
 Introduction
 Study population and methods
 Results
 Discussion
Conclusions
 References
 
The rapid, accurate and non-invasive evaluation of RV function remains a challenge. Our study provides new information regarding the potential clinical significance of the simple measurement of peak systolic isin in the basal segment of the RV free wall. We demonstrated a correlation between this measurement and other prognostic markers, such as BNP concentration, peak VO2, or slope of the VE/VCO2 ratio. In addition, we observed significant differences in this echocardiographic variable between patients who developed MACE versus patients who remained MACE-free over a 6-month follow-up.

There is, currently, no echocardiographic gold standard to assess RV function.18 In the population studied, there was severe right heart dysfunction. The RV pressure was not elevated (exclusion criteria) and there was no significantly enlarged RV even through we did not provide the RV diameter considering that its measurement was difficult to standardize. Right heart catheterization,8,19 radionuclide ventriculography and magnetic resonance imaging are invasive and non-invasive methods used to measure RVEF.8,19–22 3D echocardiography has been recently proposed in rather small cohorts.23 Measurements of RV volumes and EF by standard two-dimensional echocardiography tend to be inaccurate because of difficulties in the identification of endocardial borders due to prominent trabeculations and the complex anatomy and shape of the RV. This structure, which surrounds the LV is particularly complex, and cannot be imaged in its entirety in a single echocardiographic view. Recording of the tricuspid annular motion using tissue Doppler or M-mode has been proposed by several authors, represents a simple tool to quantify RV function in most patients, and has been correlated with RVEF measured by radionuclide ventriculography.24–28 In our study, these measurements were not correlated with BNP concentration or results of CPET. Our results were less convincing using the TAPSE than using strain (isin) probably because, even in zoom-mode, precise assessment of the TAPSE was sometimes challenging. Among DTI measurements, this study has highlighted the specific importance of isin (%, ROI 19.2–10.8mm) measured in the basal segment of RV free wall. The accuracy of longitudinal systolic isin similarly assessed and compared against sonomicrometry has been demonstrated experimentally.29 The clinical relevance of isin in the assessment of RV performance has also been reported recently in patients with large pulmonary embolisms,13 or repaired tetralogy of Fallot.14 In our study, isin (%) was measured in the basal segment of RV free wall, as previously proposed and to optimize the alignment between the ultrasound beam and the analyzed myocardial segment.

At the 6-month follow-up, isin was the most relevant DTI-derived measurements to separate patients who had experienced MACE from those who had not. Melusin et al. have recently reported the pulsed DTI peak systolic velocity recorded at the base of the RV free wall to be particularly discriminative, with a cut-off value of 10.8cm/s.30 MPI has also been proposed for this purpose.15 Compelling results were reported particularly with regard to the prognosis of chronic HF in patients with pulmonary hypertension.31 RVEF measured by thermodilution or radionuclide ventriculography has been reported as a prognostic marker, and Ghio et al. have proposed to combine RVEF and pulmonary arterial pressure to optimize the prognosis of patients suffering from HF, identifying a population with an especially poor prognosis when pulmonary hypertension and a low RVEF were both present.32 In our study, echocardiography was performed a few minutes before bicycle CPET, and no patient was included in the study who had a systolic pulmonary pressure >45mmHg at right heart catheterization performed within the preceding 6months.

Study limitations
The study population was limited to 19 patients and included no gold standard measurement of RV function. There is, to the best of our knowledge, no consensus regarding the echocardiographic assessment of global RV function. Radionuclide ventriculography does not appear to be an ideal method for patients with severe HF and marked LV dilatation. Furthermore, we were not able to perform a radionuclide ventriculogram on the same day as the CPET and the echocardiogram.


   Conclusions
Top
 Abstract
 Introduction
 Study population and methods
 Results
 Discussion
 Conclusions
References
 
isin (%, ROI 9.2–0.8mm) recorded at the base of the RV free wall was correlated with established prognostic factors in patients suffering from HF. Furthermore, the prognostic value of this easily derived measurement was significantly different among patients who developed versus did not develop MACE over a 6-month follow-up. Further study in a large number of patients is requested to confirm the encouraging sensitivity of this simple parameter to correlate to HF prognosis.


   References
Top
 Abstract
 Introduction
 Study population and methods
 Results
 Discussion
 Conclusions
 References
 

  1. Clark A.L., Sparrow J.L., Coats A.J. Muscle fatigue and dyspnea in chronic heart failure: two sides of the same coin? Eur Heart J (1995) 16:49–52.[Medline]
  2. Clark A.L., Poole-Wilson P.A., Coats A.J. Exercise limitation in chronic heart failure: central role of periphery. J Am Coll Cardiol (1996) 28:1092–1102.[Abstract]
  3. Weber K.T., Kinasewitz G.T., Janicki J.S., Fishman A.P. Oxygen utilization and ventilation during exercise in patients with chronic cardiac failure. Circulation (1982) 65:1213–1223.[Abstract/Free Full Text]
  4. Lemos J.A., McGuire D.K., Drazner M.H. B-type natriuretic peptide in cardiovascular disease. Lancet (2003) 362:316–322.[CrossRef][Web of Science][Medline]
  5. Cowie M.R., Jourdain P., Maisel A., et al. Clinical applications of B-type natriuretic peptide (BNP) testing. Eur Heart J (2003) 24:1710–1718.[Abstract/Free Full Text]
  6. Task Force for the Diagnosis and Treatment of Chronic Heart Failure ESC, W.J. Remme and K. Swedberg. Guidelines for the diagnosis and treatment of chronic heart failure. Eur Heart J (2001) 22:1527–1560.[Free Full Text]
  7. Cohen-Solal A., Logeart D., Guiti C., Dahan M., Gourgon R. Cardiac and peripheral responses to exercise in patients with chronic heart failure. Eur Heart J (1998) 20:931–945.[CrossRef][Web of Science]
  8. Gavazzi A., Berzuini C., Campara C., et al. Value of right ventricular ejection fraction in predicting short-term prognosis of patients with severe chronic heart failure. J Heart Lung Transplant (1997) 16:774–785.[Web of Science][Medline]
  9. De Groote P., Milliaire A., Foucher-Hossein C., et al. Right ventricular ejection fraction is an independent predictor of survival in patients with moderate heart failure. J Am Coll Cardiol (1998) 32:948–954.[Abstract/Free Full Text]
  10. Yip G., Abraham T., Belohlavek M., Khandheria B.K. Clinical applications of strain rate imaging. J Am Soc Echocardiogr (2003) 16:1334–1342.[CrossRef][Web of Science][Medline]
  11. Hatle L., Sutherland G.R. Regional myocardial function—a new approach. Eur Heart J (2000) 21:1337–1357.[Free Full Text]
  12. Fang Z.Y., Yuda S., Anderson V., Short L., Case C., Marwick T.H. Echocardiographic detection of early diabetic myocardial disease. J Am Coll Cardiol (2003) 41:611–617.[Abstract/Free Full Text]
  13. Kjaergaard, Sogaard P., Hassager C. Right ventricular strain in pulmonary embolism by Doppler tissue echocardiography. J Am Soc Echocardiogr (2004) 17:1210–1212.[CrossRef][Web of Science][Medline]
  14. Solarz D.E., Witt S.A., Glascock B.J., Jones F.D., Khoury P.R., Kimball T.R. Right ventricular strain rate and strain analysis in patients with repaired tetralogy of Fallot: possible interventricular septal compensation. J Am Soc Echocardiogr (2004) 17:338–344.[CrossRef][Web of Science][Medline]
  15. Tei C., Dujardin K.S., Hodge D.O., et al. Doppler echocardiographic index for assessment of global right ventricular function. J Am Soc Echocardiogr (1996) 9:838–847.[CrossRef][Medline]
  16. Jourdain P., Funck F., Bellorini M., et al. Bedside B-type natriuretic peptide and functional capacity in chronic heart failure. Eur J Heart Fail (2003) 5:155–160.[CrossRef][Web of Science][Medline]
  17. Pu M., Prior D.L., Fan X., et al. Calculation of mitral regurgitant orifice area with use of a simplified proximal convergence method: initial clinical application. J Am Soc Echocardiogr (2001) 14:180–185.[CrossRef][Web of Science][Medline]
  18. Karatasakis G.T., Karagounis L.A., Kalyvas P.A., et al. Prognostic significance of echocardiographically estimated right ventricular shortening in advance heart failure. Am J Cardiol (1998) 82:329–334.[CrossRef][Web of Science][Medline]
  19. Kaul S., Tei Ch, Hopkins J.M., Shah P.M. Assessment of right ventricular function using two-dimensional echocardiography. Am Heart J (1984) 107:526–531.[CrossRef][Web of Science][Medline]
  20. Di Salvo T.G., Mathier M., Semigran M.J., Dec G.W. Preserved right ventricular ejection fraction predicts exercise capacity and survival in advanced heart failure. J Am Coll Cardiol (1995) 25:1143–1153.[Abstract]
  21. Juillière Y., Barbier G., Feldmann L., Grentzinger A., Danchin N., Cherrier F. Additional predictive value of both left and right ventricular ejection fractions on long-term survival in idiopathic dilated cardiomyopathy. Eur Heart J (1997) 18:276–280.[Abstract/Free Full Text]
  22. Lytrivi I.D., Ko H.H., Srivastava S., et al. Regional differences in right ventricular systolic function as determined by cine magnetic resonance imaging after infundibulotomy. Am J Cardiol (2004) 94:970–973.[CrossRef][Web of Science][Medline]
  23. Angeline E.D., Homma S., Pearson G., Holmes J.W., Laine A.F. Segmentation of real-time three-dimensional ultrasound for quantification of ventricular function: a clinical study on right and left ventricles. Ultrasound Med Biol (2005) 31:1143–1158.[CrossRef][Web of Science][Medline]
  24. Alam M., Hedman A., Nordlander R., Samad B. Right ventricular function before and after an uncomplicated coronary artery bypass graft as assessed by pulsed wave Doppler tissue imaging of the tricuspid annulus. Am Heart J (2003) 146:520–526.[CrossRef][Web of Science][Medline]
  25. Alam M., Wardell J., Andersson E. Right ventricular function in patients with first inferior myocardial infarction: assessment by tricuspid annular motion and tricuspid annular velocity. Am Heart J (2000) 139:710–715.[Web of Science][Medline]
  26. Lindström L., Wilkenshoff U.M., Larsson H., Wrann B. Echocardiographic assessment of arrhythmogenic right ventricular cardiomyopathy. Heart (2001) 86:31–38.[Abstract/Free Full Text]
  27. Meluzin J., Spinarova L., Bakala J., et al. Pulsed Doppler tissue imaging of the velocity of tricuspid annular velocity motion. Eur Heart J (2001) 22:340–348.[Abstract/Free Full Text]
  28. Ghio S., Recusani F., Klersy C., et al. Prognostic usefulness of the tricuspid annular plane systolic excursion in patients with congestive heart failure secondary to idiopathic or ischemic dilated cardiomyopathy. Am J Cardiol (2000) 85:837–842.[CrossRef][Web of Science][Medline]
  29. Jamal F., Bergerot C., Argaud L., Loufouat J., Ovize M. Longitudinal strain quantitates regional right ventricular contractile function. Am J Physiol Heart Circ Physiol (2003) 285:H2842–H2847.[Abstract/Free Full Text]
  30. Meluzin J., Spinarova L., Dusek L., Toman J., Hude P., Krejci J. Prognostic importance of the right ventricular function assessed by Doppler tissue imaging. Eur J Echocardiogr (2003) 4:262–271.[Abstract/Free Full Text]
  31. Yeo T.C., Dujardin K.S., Tei C., Mahoney D.W., McGoon M.D., Seward J.B. 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.[CrossRef][Web of Science][Medline]
  32. Ghio S., Gavazzi A., Campana C., et al. Independent and additive prognostic value of right ventricular systolic function and pulmonary artery pressure in patients with chronic heart failure. J Am Coll Cardiol (2001) 37:183–188.[Abstract/Free Full Text]

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