|Year : 2019 | Volume
| Issue : 3 | Page : 722-729
Ventricular ejection time: a noninvasive echocardiographic parameter for assessment of severity of congestive heart failure in cardiomyopathic patients
Asmaa A Ali
Department of Cardiology, El Zahraa University Hospital, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
|Date of Submission||20-Aug-2019|
|Date of Decision||27-Oct-2019|
|Date of Acceptance||12-Nov-2019|
|Date of Web Publication||10-Feb-2020|
MD Asmaa A Ali
Department of Cardiology, El Zahraa University Hospital, Faculty of Medicine for Girls, Al-Azhar University, Cairo, 11646
Source of Support: None, Conflict of Interest: None
Background Due to the burden of heart failure (HF) disease, a simple utilized noninvasive tool for identifying its severity in patients is indicated. Timing of mechanical cardiac events, especially left ventricle (LV) ejection, studied since 40 years using a phonocardiogram, an ECG, and echocardiography. This approach is useful, helpful, and valuable for many clinical uses and applications.
Aim The aim was to clarify the validity of right ventricle ejection time (RVET) and left ventricle ejection time (LVET) to assess the severity of HF in dilated cardiomyopathic patients by their correlation with New York Heart Association (NYHA) functional class as a clinical assessment of severity of HF.
Patients and methods The enrolled 85 cases included 55 myopathic patients and 30 age-matched and sex-matched healthy persons who served as the control group. All cases underwent complete transthoracic echocardiography study to measure LV and right ventricle (RV) dimensions, volumes, and functions. LV and RVET are calculated and correlated with NYHA functional class.
Results Patients with dilated cardiomyopathy had significantly increased RV volumes (P<0.001) and significantly lower RV and LV systolic functions. In addition, there was significant decreased LVET and RVET in the cardiomyopathic patients group versus the normal group. Moreover, RVET and LVET had a significant correlation with NYHA functional class (RVET (r=−0.013, P<0.00001), LVET (r=−0.06, P<0.00001).
Conclusion Right ventricular dysfunction is common in dilated cardiomyopathy. LVET and RVET is considered a reliable indicator and simple noninvasive means for clinical assessment of severe HF by using the NYHA functional class.
Keywords: dilated cardiomyopathy, New York Heart Association functional class, right ventricle and left ventricle ejection time, right ventricle systolic function
|How to cite this article:|
Ali AA. Ventricular ejection time: a noninvasive echocardiographic parameter for assessment of severity of congestive heart failure in cardiomyopathic patients. Sci J Al-Azhar Med Fac Girls 2019;3:722-9
|How to cite this URL:|
Ali AA. Ventricular ejection time: a noninvasive echocardiographic parameter for assessment of severity of congestive heart failure in cardiomyopathic patients. Sci J Al-Azhar Med Fac Girls [serial online] 2019 [cited 2020 Feb 29];3:722-9. Available from: http://www.sjamf.eg.net/text.asp?2019/3/3/722/278053
| Introduction|| |
Heart failure (HF) is considered one of the most common and important health-care problems responsible for an increasing yearly hospitalized patients . As idiopathic dilated cardiomyopathy (IDCM) is the second most common cause of HF, and does not only affect the left ventricle (LV) but also the right ventricle (RV) which also contribute by having an important role in the functional capacity of the patients than is often known . Echocardiographic evaluation of the RV volumes and function is difficult and time consuming due to its complex anatomy  Due to the burden of HF disease, a simple to use, noninvasive tool for identifying such patients is needed and even indicated .
| Aim|| |
The present study was designed to clarify the validity of left ventricle ejection time (LVET) and right ventricle ejection time (RVET) by Doppler echocardiography for assessment of the severity of congestive HF in dilated cardiomyopathic patients by determining their correlation with New York Heart Association (NYHA) functional class as a clinical assessment of severity of HF.
| Patients and methods|| |
The total enrolled studied group consisted of 85 participants, 55 consecutive patients with dilated cardiomyopathy (40 men and 15 women, mean age of 56.3±8.3years) and 30 age- matched and sex-matched healthy normal participants as a control group (20 men, 10 women, mean age 41.9±7.9 years).
All patients were divided into two groups (groups A and B) based on NYHA functional class. Group A consisted of patients with NYHA class I and patients with NYHA class II, and group B consisted of patients with NYHA class III and patients with NYHA class IV.
The studied cases were selected from the Cardiology Outpatient Clinic at Al-Zahraa Hospital, Faculty of Medicine for Girls, Al-Azhar University, from July 2018 to May 2019. A person was considered to have DCM if the dilated LV with systolic function is less than 35%. All participants were informed about the purpose of the study and we obtained a verbal consent in presence of a third party and in adherence with the guidelines of the Ethics Committee of Al-Azhar University, Cairo, Egypt.
Exclusion criteria included any one of the following: acute myocardial infarction, patients with atrial fibrillation, atrial flutter, frequent extrasystoles, or atrioventricular block or any serious arrythmia, and patients with organic valvular diseases or severe regurgitation of grades III and IV and those with significant valvular disease affecting accurate estimation of forward cardiac output by RV (i.e. severe pulmonary regurgitation or stenosis) , patients with rheumatic heart disease, congenital heart disease, other preexisting cardiovascular disease like myocarditis due to infective etiology, significant arrhythmia and poor echogenic window.
All the studied individuals were subjected to a full history with special emphasis on demographic data: age, sex, and NYHA functional class assessment. Thorough clinical examination and systemic examination [chest, cardiovascular system (CVS), abdominal and central nervous system including blood pressure measurement] were performed.
All cases underwent complete transthoracic echocardiography study in both supine and left lateral position (including 2D, M-mode, color flow, and spectral Doppler) in the standard views (parasternal long axis, parasternal short axis, apical four-chamber, three-chamber, and two-chamber views) from all accessible windows were obtained with ECG physiosignal displayed with all detected echo-Doppler study with loop recording of two to three cycles. All measurements were made over at least three cardiac cycles and the average value for each parameter was calculated using GE system XD Clear 9 (Vivid -E9GE C 2019 General Electric Company, Ultra sound system, Horten, Norway), Matrix probe M3S multifrequency 2.5 MHz. All images were digitally stored for later off-line analysis at EchoPAC.GE version 210. All parameters were taken according to standards of the American Society of Echocardiography to measure LV dimensions and functions.
The LV dimensions were measured at the midventricular level by M-mode echocardiogram obtained by directing the cursor perpendicularly to the parasternal short-axis view. Left ventricle ejection fraction (LVEF) was calculated by the method of Teichholz on the M-mode echocardiogram, Following biplane LV end-diastolic and end-systolic volumes were assessed from the apical two-chamber and four-chamber images and LVEF was calculated using the biplane Simpson’s formula. In addition, RV size, EF, and fractional area change of the RV were estimated. In addition, LVET was obtained from the apical five-chamber view with the sample volume positioned in LV outflow below the aortic valve; also RVET the RV outflow signal was recorded from the parasternal short-axis view, with the sample volume positioned just below the pulmonary annulus (in the outflow tract below the pulmonary valve). Doppler tracings were obtained with the measurement of the RVET which was measured as the interval from the onset to the end of the RV outflow Doppler profile ([Figure 1])
|Figure 1 Conventional right ventricle outflow Doppler show right ventricle ejection time.|
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Speckle tracking echocardiography
The LV and the RV longitudinal strain were also assessed using 2D STE analysis with QRS onset as the reference point, applying a commercially available strain software package to the RV on EchoPAC version 210. Images were acquired at 70–90 frames per second at end expiration in the apical four-chamber, three-chamber, and two-chamber views. Using the Automated Function Imaging (AFI) software, a point-and-click approach was utilized to identify three anchor points (two basal and one apical), following which the software tracked the endocardial contour to assess RV function by speckle tracking. The LV 2D ST GS % was obtained in all study cases automatically.
Statistical analysis was performed using the Statistical Package for the Social Sciences (version 16.0; SPSS Inc., Chicago, Illinois, USA). Data were expressed as the mean±SD. Differences between groups were analyzed with the unpaired t-test. Possible associations were assessed by Pearson’s and Spearman’s coefficients of correlation. P value less than 0.05 was considered significant.
| Results|| |
The enrolled population included 85 cases who were divided into the patient group (55 patients) with a mean age of 56.0 years and the control group (30 individuals) with a mean age of 53.2 years. Of the patient group 73% were men; 20 patients with NYHA functional class I–II and 35 patients with NYHA functional class III–IV and the patients were maintained on optimal medical therapy. Demographic and clinical characteristics of the enrolled population are summarized in [Table 1].
|Table 1 Baseline demographic and clinical characteristics of the study population|
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In comparison to control, there was significantly increased LV dimensions, volumes, and decreased EF whether by 2D or M-mode (P=0.000) and recent echocardiographic modalities but insignificant lower LVET in the cardiomyopathic group versus the normal one ([Table 2]).
|Table 2 Comparison between baseline left ventricle echocardiographic parameters in the patient group versus normal control group|
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As regards RV, patients with DCM had significantly increased RV volumes (P<0.001), lower RVEF (P<0.001), % FAC (P<0.001), and RVGLS (P<0.001) ([Table 3]). Also, there was significant decreased RVET in the patients group versus the normal group ([Figure 2]).
|Table 3 Comparison between baseline right ventricle echocardiographic parameters in the patient group versus the control group|
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|Figure 2 Comparison between the patient and control groups as regards ejection time of right ventricle and left ventricle.|
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Then the studied patient group (group I) had been classified according to NYHA functional class into two groups: group A with NYHA I–II [20 (36.3%) patients with a mean age of 56.5 years and predominantly men] and group B with NYHA III–IV [35 (63.6%) patients with mean age of 53.8 years] as shown in [Figure 3].
|Figure 3 The number and percent of patients in group a New York Heart Association functional class I–II and group b New York Heart Association functional class III–IV.|
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There was insignificantly decreased LVEDD, LVET, LVEF whether by 2D or M-mode and LVGLS by recent echocardiographic modalities in group B versus group A as shown in [Table 4].
|Table 4 Comparison between baseline left ventricle echocardiographic parameters in patient group A versus group B according to New York Heart Association functional class|
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As regards RV, there was significantly decreased RV systolic function by 2D in group B versus group A. Moreover, there was insignificantly decreased RVET in group B versus group A as shown in [Table 5] and [Figure 4] and [Figure 5].
|Table 5 Comparison between baseline right ventricle echocardiographic parameters in patient group A versus group B according to New York Heart Association functional class|
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|Figure 4 Comparison between baseline left ventricle and right ventricle echocardiographic parameters in patient group A versus group B according to New York Heart Association functional class.|
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|Figure 5 Comparison between left ventricle ejection time and right ventricle ejection time by Doppler echocardiographic in patient group A versus group B according to New York Heart Association functional class.|
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By correlation between the RVET and NYHA functional class, the RVET had an inversely significant correlation with NYHA functional class (r=−0.013, P<0.00001) (decreased with the severity of the NYHA functional class) as shown in [Table 6].
|Table 6 Correlation between right ventricle ejection time and New York Heart Association functional class|
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Also, LVET had an inversely significant correlation with NYHA functional class as shown in [Table 7].
|Table 7 Correlation between left ventricle ejection time and New York Heart Association functional class|
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| Discussion|| |
Transthoracic echocardiography has been one of the most important and reliable methods for the assessment of patients with known cardiomyopathy. The importance of RV systolic function in patients with reduced-EF HF has been proved previously ,. But assessment and evaluation of the right ventricle size or functions have often been neglected because of its complex anatomy.
RV systolic function was assessed in our study by using RV EF, RV FAC, and RV STE. Also, we used Doppler in measuring ejection time in both ventricles. Therefore, this study demonstrated the use of quantifying RV and LV systolic function also by 2D strain (STE) measurement routinely in patients referred for echocardiographic evaluation for known dilated cardiomyopathy. Measurement of myocardial strain using speckle-tracking echocardiography gives information about quantitative evaluation and assessment of ventricular systolic function  because RV contractility occurs mainly in the longitudinal plane .
RV dysfunction often associated with LV dysfunction; therefore, we analyzed RV and LV systolic functions in patients with dilated cardiomyopathy. In this study, evaluation of a novel, simple, and feasible parameter to assess severity of HF patients using Doppler echocardiography to measure RVET and LVET.
Moreover, there was a surprise in this study to find how well RVET and LVET measurements differ between patients with LV systolic dysfunction as opposed to others with normal LV systolic function. Also, it was different in myopathic patients with different NYHA functional class. The studied patients were predominantly men (35 out of 55), their mean age was 56 years with systolic HF due to dilated cardiomyopathy (mean EF 35%). Our findings demonstrated that extremely diminished RVET and LVET were associated with increased NYHA functional class.
The shortening of LVET with LV dysfunction is more complex. In case of LV failure, there is a delay in the onset of ejection, while the velocity of myocardial fiber shortening is decreased and the extent of its shortening is also reduced, so, LVET tends to be shortened ,, and also Because GLS is affected by both the isovolumic contraction period and the degree of myocardial fiber shortening, LVET is shortened in the case of LV dysfunction.
In addition, in this study, the RVET and LVET well correlated with NYHA functional class (P<0.00001).
Patients with dilated cardiomyopathy had a lower LVET than normal participants ([Table 1], [Figure 2]); and this parameter correlates inversely with NYHA functional class ([Table 7]). Our data also showed a negative correlation between RVET and NYHA functional class ([Table 6]).
This is in agreement with a previous study which studied 35 patients with cardiomyopathy whether ischemic or dilated and found that LVET and RVET are higher in normal participants in relation to dilated cardiomyopathy  and inversely correlated with NYHA functional class.
This study have also shown that systolic dysfunction occurs in both ventricles because both ventricles share common muscle bundles, a common interventricular septum, and a pericardium with enhanced systolic ventricular interaction ,.
Despite recent developments in echocardiography, this study demonstrated that LVET and RVET measurements are accurate, reproducible, and may be the simplest method. Also, it can be assessed by conventional methods.
In subgroup analysis by NYHA functional class levels, with decreasing LVEF or GLS values, LVET insignificantly decreased. This is in agreement with a previous study by Patricia and colleagues who studied 134 patients with HF and found that LVET was significantly lower or shortened in the patient group than normal participants. Although ejection times of both ventricles are less attractive for assessment of HF severity than recent echocardiographic modalities as 2D strain or 3D assessment of ventricles, they have some advantages. First, the operator can do it with any conventional ultrasound machines whereas the recent modalities need the last generation and more recent version of echocardiography. Second, it is considered an accurate and rapid measure not depending on experience or requiring a learning curve to be updated. Third, it can be obtained even in case of poor quality window .
This study showed a relationship between clinically assessed HF severity by a bedside clinical marker of severity NYHA classification and (he LVET and RVET in patients with dilated cardiomyopathy; patients with HF have a shortening of the ET. Similar findings were reported by Bruch et al.  and Dujardin et al. .Our study also showed the trend of presentation of patients with HF in our environment (63% of these patients were in NYHA class III–IV). In our environment, where people present in the late stage of severe clinical HF, ET may be more effective because it is not based on a geometric model or on volume measurement. This agreed with the previous study which revealed the trend of presentation of their patients with HF in their environment (41% of patients were in NYHA functional class IV) .
| Conclusion|| |
RV dysfunction is common in dilated cardiomyopathy. LVET and RVET is each considered a reliable indicator of clinically assessed severe HF using the NYHA functional classification and are therefore considered a simple, noninvasive measure useful for assessment of the severity of congestive HF in patients with dilated cardiomyopathy .
Further studies are needed for determination of the value of RVET and LVET compared with other established echocardiographic parameters in assessment of severity of HF patients. Future studies are needed to understand more about the ability of RVET and LVET to predict the prognosis and response to medical therapy.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]