Assessment of right ventricular function in young patients with anterior ST segment elevation myocardial infarction undergoing primary percutaneous coronary intervention by speckle-tracking imaging study

Said S Montaser; Mahmoud K Ahmed; Amal A Amin; Karim M Gamal

doi:10.4103/mmj.mmj_110_21

ORIGINAL ARTICLE

Year : 2021 | Volume : 34 | Issue : 4 | Page : 1228-1232

Assessment of right ventricular function in young patients with anterior ST segment elevation myocardial infarction undergoing primary percutaneous coronary intervention by speckle-tracking imaging study

Said S Montaser¹, Mahmoud K Ahmed¹, Amal A Amin², Karim M Gamal²
¹ Department of Cardiology, Faculty of Medicine, Menoufia University, Menofia, Egypt
² Department of Cardiology, National Heart Institute, Cairo, Egypt

Date of Submission	02-Jun-2021
Date of Decision	05-Jul-2021
Date of Acceptance	11-Jul-2021
Date of Web Publication	24-Dec-2021

Correspondence Address:
Karim M Gamal
MBBCh, 27 Suleiman Najib Street, Ninth District, Obour
Egypt

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/mmj.mmj_110_21

Abstract

Objective
To asses s right ventricular (RV) function in patients with anterior ST segment elevation myocardial infarction (MI) undergoing primary percutaneous coronary intervention (PCI) by speckle-tracking imaging study.
Patients and methods
A total of 150 consecutive patients less than 40 years with anterior ST segment elevation MI and have a single left anterior-descending artery disease who underwent successful primary PCI were enrolled in the study. Patients with a history of prior MI, PCI, coronary-artery bypass graft, those who had a bundle-branch block, PCI, coronary-artery bypass graft, those who had a bundle-branch block on baseline ECG, pulmonary hypertension (primary and secondary), primary valvular heart disease, lung disease, cardiomyopathy, systemic illness (renal, hepatic, and malignancy), and bad echogenic window all were excluded. Echocardiography was performed during the hospital stay to assess ventricular function. RV function was assessed by RV fractional area change, tricuspid annular plane systolic excursion, tricuspid annular systolic and diastolic velocities, and two-dimensional-derived strain and strain rate of the RV free wall.
Results
RV free-wall peak systolic strain, systolic strain rate, and early diastolic strain rate were significantly lower in patient groups (−15.36 ± 2.60 vs. −25.07 ± 1.49, P = 0.006, −1.09 ± 0.18 vs. −1.78 ± 0.10, P = 0.005, and 1.45 ± 0.33 vs. 2.19 ± 0.56 with P = 0.004, respectively). Also, systolic and early diastolic tricuspid annular and early diastolic peak velocities were lowered in patient groups than in controls, in addition, there was no significant difference between both groups regarding RV size, dimension, and fractional area changes.
Conclusion
RV function in patients with anterior MI is significantly affected even after rapid PCI and recanalization of left anterior-descending in young patients. Strain and strain rate are new, useful imaging techniques for detection of early RV dysfunction in patients with anterior MI.

Keywords: anterior ST-elevation myocardial infraction, right ventricular function, speckle tracking

How to cite this article:
Montaser SS, Ahmed MK, Amin AA, Gamal KM. Assessment of right ventricular function in young patients with anterior ST segment elevation myocardial infarction undergoing primary percutaneous coronary intervention by speckle-tracking imaging study. Menoufia Med J 2021;34:1228-32

How to cite this URL:
Montaser SS, Ahmed MK, Amin AA, Gamal KM. Assessment of right ventricular function in young patients with anterior ST segment elevation myocardial infarction undergoing primary percutaneous coronary intervention by speckle-tracking imaging study. Menoufia Med J [serial online] 2021 [cited 2022 May 26];34:1228-32. Available from: http://www.mmj.eg.net/text.asp?2021/34/4/1228/333222

Introduction

Acute myocardial infarction (MI) is characterized by a loss of myocardial tissue with subsequent alteration in ventricular geometry that causes impairment of the systolic and diastolic functions of affected ventricles. Right ventricular (RV) involvement after an acute left ventricular (LV) MI has been shown to be associated with higher morbidity and mortality ^[1].

RV dysfunction may be primarily attributed to an abnormality of RV myocardium or secondary to LV dysfunction, as a consequence of 'ventricular interdependence' between the two ventricles. Hence, the earliest recognition of RV dysfunction is warranted, but till today, it remains a challenging task because of the complex structure and asymmetric shape of RV ^[2],[3]. Subclinical RV dysfunction is known in patients with right coronary-territory ischemia. RV functions in LV anterior infarction have been the subject of several studies but with significant discrepancies in the results ^{[4],[5],[6],[7],[8],[9]}.

Nowadays, strain and strain-rate imaging is the most frequent echocardiographic modalities used for evaluation of subclinical and clinical myocardial damage.

The aim of the study was to assess RV function in patients with anterior ST segment elevation MI undergoing primary percutaneous coronary intervention (PCI) by speckle-tracking imaging study.

Patients and methods

One hundred and fifty patients less than 40 years presented with anterior MI and underwent successful primary PCI to left anterior-descending (LAD) at Menoufia University Hospital and National Heart Institute (patient group) compared with 45 patients suspected to have ischemic heart disease, but coronary angiography revealed no significant coronary stenosis (control group).

Patients with a history of prior MI, PCI, coronary-artery bypass graft, those who had bundle-branch block on baseline ECG, pulmonary hypertension (primary and secondary), valvular heart disease, lung disease, cardiomyopathy, systemic illness (renal, hepatic, and malignancy), and who had a bad echogenic window, all were excluded from the study.

All patients provided an informed consent and the study protocol was approved by Menoufia University ethical committee. All patients were subjected to comprehensive history taking, general and local clinical examination, and standard 12-lead ECG, conventional echocardiographic examination was performed for both groups by using the commercially available Ultrasound Supply , Diagnostx, LLC 5735 Benjamin Center Dr. Tampa, FL, 33634 USA GE Vivd 5 and 9 machine, and assessment of RV was done by fractional area changes, tricuspid annular plane systolic excursion, and by pulsed-wave Doppler tissue imaging where S-, E-, and A-wave peak velocities were measured at the lateral tricuspid annulus site ^[10].

Speckle tracking of the RV free wall was done where the peak systolic strain and systolic and diastolic strain rate were measured.

Statistical analysis

Data were collected and entered into the computer using SPSS (Statistical Package for Social Science) program for statistical analysis (version 13; SPSS Inc., Chicago, Illinois, USA). Numerical data were summarized as means and SDs. Categorical data were summarized as frequencies and percentages. Comparison between two groups for numerical variables was done using Mann–Whitney U test. Categorical variables were compared using χ² test. All P values were two-sided. Graphic presentation of data was done by using pie chart, single and multiple bar charts by using Excel 2016. P value less than 0.05 is considered significant ^[11].

Results

Patients' group included 150 patients, 117 were male and 33 were female. The control group included 45 patients (39 males and six females), with no significant difference regarding age, sex, and risk factors between the two groups [Table 1].

Table 1: Demographic and risk factors between myocardial infarction group and control group

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Regarding conventional echocardiographic examination, patients' group had lower LV systolic function (ejection fraction was 47.7 ± 7.1 in MI group vs. 64 ± 5.4 in control group, P < 0.001) and increase in end-diastolic/end-systolic dimensions (5.64 ± 0.49/4.43 ± 0.35 in MI group vs. 4.34 ± 0.48/2.98 ± 0.36 in control group, P = 0.044 and 0.045, respectively) [Table 2].

Table 2: M-mode measurements of left ventricle dimensions and left ventricular systolic function between myocardial infarction group and control group

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No statistically significant difference was found between both groups regarding RV size, dimension, and fractional area changes. Doppler tissue examination revealed reduction of systolic S-wave and diastolic E-wave peak velocities in patients' group.

S-wave peak velocity (10.35 ± 2.08 vs. 15.27 ± 1.32, P = 0.031) and tricuspid annular early diastolic peak velocity E' (8.99 ± 1.94 vs. 14.40 ± 1.32, P = 0.037). In addition, global longitudinal free-wall strain was significantly higher in the control group (−15.36 ± 2.60 in MI group vs. −25.07 ± 1.49 in control group, P = 0.006), and RV peak systolic strain rate was reduced in MI group than control group (−1.09 ± 0.18 vs. −1.78 ± 0.10, P = 0.005). RV peak early diastolic strain rate was also significantly higher in the control group compared with the patients' group (−1.45 ± 0.33 in MI group vs. −2.19 ± 0.56 in control group with P = 0.004). Finally, RV global function assessed with tissue Doppler RV-MPI (Tei index) was significantly affected as the MPI was higher in MI group (0.65 ± 0.11 vs. 0.38 ± 0.02 in control group with P < 0.001) [Table 3]; [Figure 1], [Figure 2].

Table 3: Echocardiographic assessment of the right ventricle in study groups

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Figure 1: Two-dimesnional speckle-tracking strain analysis of the right ventricle.

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Figure 2: Example of right ventricular global longitudinal strain measurement.

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Discussion

RV dysfunction is associated with high in-hospital morbidity and mortality. Hence, early recognition of RV dysfunction is warranted, but until today, it remains a challenging task because of the complex structure and asymmetric shape of RV ^[2]. Standard two-dimensional echocardiographic evaluation of RV volumes and ejection fraction is cumbersome due to difficulty in the exact delineation of RV endocardial borders because of prominent trabeculations and crescentic shape of the RV ^[3]. RV functions in LV anterior infarction have been the subject of several studies, but with significant discrepancies in the results ^{[4],[5],[6],[7],[8],[9]}.

We aimed to assess the RV function in patients with anterior ST segment elevation MI undergoing primary PCI by speckle-tracking imaging study, and we chose young patients less than 40 years to avoid the age effect on ventricular myocardium, as shown by Tsverava and Tsverava^[12] who studied the influence of age on the RV tissue Doppler parameters in 258 normal persons from 6- to 82-year-old and found significant changes with age as there is reduction of Doppler velocities of systolic and diastolic waves.

Also, we chose to assess the RV function by assessing the RV free wall by STE as peak RV longitudinal strain, which quantifies the maximal shortening in the RV free wall from apex to base, and is likely to be a good estimator of RV function because 80% of the stroke volume is generated by longitudinal shortening of the RV free wall ^[11].

In our study, we found in the patient group that there was significant impairment of the RV systolic function (as proved by lowered systolic peak longitudinal strain and systolic strain rate and lower annular S-wave peak velocity) and RV diastolic function (as proved by lowered RV early diastolic strain rate and lowered early diastolic annular peak velocity 'E wave') in patients with anterior MI even after rapid recanalization of infarct-related artery by primary PCI.

These findings were in concordance with Gaber ^[13], who studied RV function with DTI-based speckle tracking in 60 patients with isolated LAD occlusion compared with 20 control patients, and they reported that the RV mean strain and strain-rate values were significantly lower in patient groups than controls.

Also, Sonmez et al.^[14] support our results that the strain and strain-rate values of the RV free-wall segments in the patient group (who had experienced their first anterior MI and had undergone successful PCI) were significantly lower than those of the control group.

Other several theories have been proposed to explain RV dysfunction in patients with LV dysfunction, and even started very early since 1910 as the hypothesis that enlargement of the LV could affect function of the RV was advanced in 1910. These theories depend on shared interventricular septum (IVS), annulus, and pericardium between both ventricles as systolic dysfunction of IVS and systolic ventricular interaction, annular interaction, and pericardial interaction effect of tethered LV anterior myocardium ^[15]. Their limitation was in their inability to explain systolic and diastolic dysfunction in parts of RV away from IVS.

Thus, none of the previously proposed theories could explain our observation of systolic dysfunction in parts of RV remote from IVS and LV anterior wall.

Review of the anatomy showed that the two ventricles share common muscle fibers. Once a group of myocardial fibers over a ventricle are damaged, the remaining part of the myocardial fiber crossing over to the other ventricle is unlikely to be absolutely normal. There was some degree of dysfunction of the part of the myocardial fiber crossing over to the other ventricle ^[16]. Such an extension of myocardial dysfunction to the other ventricle (MI) could give some explanations to our finding.

Limitations of the study

Absence of follow-up of the patients to study the impact of the emerging result.
We did not compare our result with the gold standard MRI for evaluation of the RV function.

Conclusion

RV function in patients with anterior MI is significantly affected even after rapid PCI and recanalization of LAD in young patients. Strain and strain rate are new, useful imaging techniques for detection of early RV dysfunction in patients with anterior MI.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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