AUCTORES
Globalize your Research
Case Report | DOI: https://doi.org/10.31579/2642-1674/008
1 Hospital da Cruz Vermelha – Cruz Vermelha Brasileira- Filial do Estado do Paraná e Instituto Saber e Aprender – Curso de Especialização em Ecocardiografia Transtorácica
*Corresponding Author: Liz Andréa V Baroncini, Hospital da Cruz Vermelha – Cruz Vermelha Brasileira- Filial do Estado do Paraná e Instituto Saber e Aprender – Curso de Especialização em Ecocardiografia Transtorácica,
Citation: Liz Andréa V Baroncini, Kenia U, Ana C Camarozano , Daniela D Carmo , Jerônimo A Fortunato (2019). Right ventricle Outflow Tract Acceleration Time: Correlation with Left Ventricular Diastolic Function.J Clin Imag. Interven Radiology 3(1); Doi: 10.31579/2642-1674/008
Copyright: ©2020 Liz Andréa V Baroncini, This is an open-access article distributed under the terms of The Creative Commons. Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 08 November 2019 | Accepted: 22 December 2019 | Published: 03 January 2020
Keywords: diastole, Doppler echocardiography, left ventricular dysfunction, pulmonary artery
Running Title: Pulmonary Acceleration Time and Diastolic Function
Background: There are no available data about the measurement of acceleration time at the right ventricle outflow tract (AcT) and its relevance in the analysis of the left ventricular diastolic function (LVDF).
Objective: To correlate AcT with echocardiographic parameters of LVDF.
Method: Eighty-seven patients (58.4±14.5 years; 52% women) submitted to transthoracic echocardiogram assessing spectral and tissue Doppler of the transmitral flow and mitral annulus, AcT, left atrial volume (LAV), and pulmonary artery systolic pressure (PASP). Patients with systolic dysfunction of the LV and grades II and III diastolic dysfunction (DD) were excluded. Main analyses were performed using the Spearman’s Correlation Coefficient (SCC) and Pearson’s Linear Correlation Coefficient (PLCC).
Results: A negative correlation between AcT value and age (PLCC – 0.36; Student’s t-test; p <0.001) and a positive correlation between AcT and E/A ratio (SCC 0.38; p<0.001), between AcT and E/e’ ratio (SCC 0.26; p=0.01), between AcT and E wave of the mitral flow (PLCC 0.36; p= 0.001) were found. LAV and PASP did not correlate with AcT. In patients with a normal diastolic function, AcT was higher when compared with the AcT in patients with Grade I DD (0.150±0.029ms versus 0.127±0.023ms; p<0.001; Student’s t-test). The threshold suggested in this subgroup of patients was 0.135s.
Conclusions: The present study correlated, unprecedentedly, AcT with echocardiographic parameters of the LV diastolic function. AcT values lower than 0.135s were associated with grade I diastolic dysfunction and higher than 0.135s values were associated with normal diastole.
Diastole is a complex process of the cardiac cycle, dependent on the active myocardial relaxation, ventricular compliance, ventricular synchrony, ventricular diastolic suction, myocardial viscoelasticity, atrial contraction, pericardial restriction, interaction between right ventricle (RV) and left ventricle (LV) and the erectile function of the coronary arteries[1]. An altered RV-LV interaction leads to a diastolic dysfunction characterized by an increased dependence of the left ventricle filling in relation to the left atrial contraction [2]. Additionally, the diastolic function is affected by clinical factors such as age, systemic arterial hypertension and pulmonary arterial hypertension[3-4].
In this regard, at the transthoracic echocardiography (TTE), the assessment of the left ventricle diastolic function (LVDD) must be performed by integrating several techniques including the analysis of the spectral Doppler of the mitral flow, the tissue Doppler of the mitral annulus, pulmonary veins flow, the estimates of the pulmonary artery systolic pressure (PASP) and of the left atrial volume (LAV)[1]. PASP is most commonly determined by estimating the peak tricuspid regurgitant velocity, not always present, by means of the continuous wave Dopplerp [5], adding the right atrial pressure by assessing the inferior vena cava. An alternate option to estimate the pulmonary arterial pressure is to measure the right ventricle outflow tract acceleration time (AcT), which presented high correlation with PASP in previous studies, with a reference value of 105ms [5-7]. Nevertheless, there are no published studies correlating its value with the conventional variables of the LV diastolic function assessed at TTE. Hence, the present study seeks to correlate AcT with the traditionally used variables at ETT to assess the LVDD, among them, E and A waves, E/A ratio, and isovolumetric relaxation time (IVRT) trough spectral Doppler of the mitral flow, septal and lateral e’ waves at tissue Doppler of the mitral annulus, E/e´ ratio (E/mean between septal and lateral e’), LAV and PASP.
This observational and transversal study includes 94 patients, from both genders, any ethnic background, over 18 years of age, from an outpatient cardiology unit of a public hospital, recommended by the assistant physician to undergo transthoracic echocardiogram for any clinical indication. The patients’ selection did not follow any statistical criterion, but that of convenience, that is, according to their availability to participate in the research study. For each patient, a protocol form with clinical and echocardiographic parameters was completed. Analyzed demographic data included age, gender, body mass index (BMI), presence of hypertension, diabetes mellitus (DM), dyslipidemia, coronary arterial disease (CAD), history of current or former smoking, and frequent or continuous use of prescribed drugs. Diagnoses for hypertension, DM, dyslipidemia, and CAD were recorded in the patients’ medical files and/or reported by the patients themselves (referral information data).
Patients underwent a complete bidimensional transthoracic echocardiogram with the Phillips IE 33, Envisor or Vivid E General Electric models. In all acoustic views, all standard measurements and echocardiographic analyses were conducted in each patient and the sonographic analyses were performed by two experienced echocardiographers, holders of echocardiography certificates from the Cardiovascular Imaging Department of the Brazilian Society of Cardiology.
Exclusion criteria included patients with (a) significant valvular heart disease (moderate and severe); (b) prosthetic heart valves; (c) pulmonary emphysema or chronic obstructive pulmonary disease; (d) moderate to severe pulmonary arterial hypertension (PASP > 50 mmHg); (e) atrial fibrillation or pacemaker rhythm; f) dilated cardiomyopathy or ischemic cardiomyopathy with regional wall motion abnormality or myocardial segmental thickness of left ventricle; (g) LV systolic dysfunction (ejection fraction <52% for men and <54% for women); (h) grades II and III LVDD; and (i) inappropriate acoustic window for AcT analysis.
In this study, the main echocardiographic variables assessed were: (a) at the transmitral spectral Doppler, the E wave velocity, A wave velocity, E/A ratio and isovolumetric relaxation time (IVRT); (b) from the mitral annular tissue Doppler imaging, septal e’ wave velocity, lateral e’ wave velocity, mean velocity between septal e’ and lateral e’; (c) E/e’ ratio (E wave velocity/mean velocity between septal e’ and lateral e’); (d) acceleration time at the right ventricle outflow tract (AcT), measured on the short axis view toward the heart base vessels, at the tip of the pulmonary valve leaflet, from the start to the peak of the systolic flow; (e) left atrial volume (LAV) and (f) pulmonary artery systolic pressure (PASP), measured by the tricuspid regurgitation peak velocity, when present (Figures 1 and 2).
Statistical Analysis
The results obtained were described by means, medians, minimum and maximum values, and standard deviations (quantitative variables) or by frequencies and percentages (categorical variables). To assess the association between two quantitative variables, Pearson’s or Spearman's linear correlation coefficient was used. The comparison of two groups in relation to the quantitative variables was performed by the student's' t test for independent samples. The one-way analysis of variance (ANOVA) was used to compare more than two groups. The Kolmogorov-Smirnov normality test examined whether the variables were normally distributed. Values of p<0.05 indicated statistical significance. To determine an AcT threshold that was associated with the normal diastole versus grade I dysfunction, a ROC curve was adjusted. Data were analyzed with the IBM SPSS Statistics Software 20.0, Armonk, NY: IBM Corp.
Seven patients, out of the 94 initially selected, were excluded from the study. Final analysis included 87 patients, 58.4±14.5 years; 45 (52%) women. Clinical characteristics of the studied cohort are listed in Table 1.
Values from the identified echocardiographic variables corroborate those values from the available literature (Table 2).
A negative and significant correlation (Spearman’s correlation coefficient (SCC) between AcT value and age (SCC – 0.36; p = 0.001) and a tendency between AcT value and wave A (SCC -0.21; p = 0.05) were observed. Additionally, positive and significant correlations were identified between AcT value and E/A ratio (SCC 0.38; p=<0.001), between AcT and lateral e’ wave (SCC 0.22; p=0.04), between AcT and E/e’ ratio (SCC 0.26; p=0.01) and between AcT and E wave (SCC 0.36; p= 0.001). The other variables did not correlate with AcT (Table 3, Figure 3).
BMI = Body Mass Index; IVRT = Isovolumetric Relaxation Time; PASP = Pulmonary Artery Systolic Pressure.
Only 5 patients presented AcT values lower than 105ms and these values did not correlate with PASP increase or with any other variable (data not shown). AcT value was not influenced by gender, BMI, presence hypertension, DM, dyslipidemia, CAD or smoking (data not shown). Lower AcT values were identified in patients affected by LVDD grade I when compared to patients with preserved LVDD (0.127±0.023 versus 0.150±0.29ms; p<0.001). The threshold suggested by the ROC curve adjustment was 0.135s. Hence, AcT values lower than 0.135s were associated with the presence of a LVDD grade I and values higher than 0.135s with normal diastole, with sensitivity and specificity thresholds estimated in 70.2% and 70.4%, respectively. (Figure 4).
BMI = Body Mass Index; IVRT = Isovolumetric Relaxation Time; PASP = Pulmonary Artery Systolic Pressure.
The present study presented unprecedent correlation of AcT absolute values with echocardiographic variables representatives of LV diastolic function. Concomitantly, the same values have shown to change with age increase. Previous studies report that LV diastolic function changes and progresses with age[11-12], independent of a LV preserved systolic function, and may even lead to heart failure with normal LV ejection fraction[13-15]. Similarly, the systolic pressure in the pulmonary artery progressively increases with age both at rest and during exercise[16-17]. AcT values identified in this study follow the same alterations. The rigid exclusion criteria applied enabled the assessment of the LV diastolic function and AcT without the influence of other factors, such as the presence of a significant pulmonary arterial hypertension, systolic dysfunction or advanced grades of LV diastolic dysfunction, which might lead to different interpretations. These same criteria determined homogeneity in the studied cohort. Hence, it was possible to observe that correlation of E/A ratio at mitral spectral Doppler decreases with age (following the decrease of wave E velocity and increase of A wave). Values of septal and lateral e’ waves of the mitral annulus at tissue Doppler also decreased. These findings corroborate former studies involving a larger cohort of patients[18-19]. Similarly, AcT values followed the same values obtained for the LV diastolic function variables used in this study: the age increase correlated with AcT lower values, the lower AcT values correlated significantly with lower values of the E/A ratio, with lower values of E and lateral e’ waves. However, E/e’ ratio presented a positive correlation with AcT value, specifically, lower AcT values correlated with lower values of the E/e’ ratio. This finding may be accounted for by analyzing the behavior of lateral and septal e’ waves that decrease with age (about 10 to 15 years earlier) when compared with E wave of spectral Doppler, which decreases at a late stage, as described by Kadappu KK et al. In the present study, a stronger negative correlation of age with septal and lateral e’ waves in relation to E wave of the spectral Doppler was observed. Hence, in an early stage of the diastolic dysfunction, without the increase of the filling pressures of the left atrium (LA), the E/e’ ratio is still low, as is the AcT value, since e’ waves decrease more sharply than E wave in this phase. Similar explanation is provided for the lack of correlation between IVRT and Act values. It is known that IVRT prolongs with age; however, when there is an increase in the filling pressures, IVRT shortens21. The selected severe exclusion criteria also enabled assessment of AcT in quasi-normality conditions. PASP mean value was 28mmHg and its maximum value was 40mmHg, values considered to be within normality for the age range in the studied population[22]. Hence, a correspondence between AcT and PASP would only be expected in the presence of significant pulmonary hypertension, which was not the purpose of this study. However, when patients with a normal LV diastolic function and those with grade I diastolic dysfunction were compared, the latter presented lower AcT values, suggesting an increase in the pulmonary arterial pressure in this group, although still within their normal values. AcT values below 105ms are considered abnormal or reveal an increase in the pulmonary arterial pressure (PAH) [23]. Conversely, by excluding patients with a significant pulmonary arterial hypertension from the studied cohort, AcT values below 105ms were not expected. However, in an unprecedent way, it was possible to identify an alteration in AcT value in patients without a significant PAH, with an initial alteration of the LV diastolic function when compared with a preserved LV diastolic function. Some limitations of this study include the small number of participants, lack of data about the size and function of the right chambers and lack of analysis of the intra- and inter-observer measurement variability in relation to AcT, as errors may occur, considering that AcT values are affected by heart rates, cardiac output, RV systolic function and technical difficulties such as the angle of the ultrasonic beam[5].
Conclusions
The present study correlated significantly and unprecedentedly AcT with echocardiographic parameters of the LV diastolic function, presenting lower values in individuals with grade I diastolic dysfunction. The threshold suggested by the ROC curve was 0.135s, with AcT values lower than 0.135s associated with grade I diastolic dysfunction and higher than 0.135s values associated with normal diastole.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
