Arq Bras CardiolabcArquivos Brasileiros de CardiologiaArq. Bras. Cardiol.0066-782X1678-4170Sociedade Brasileira de Cardiologia - SBC3pQGqCptbLfpDPbTnL9DWGvS0066-782X201800150038210.5935/abc.20180183Short EditorialRight Ventricular Evaluation with Speckle Tracking Echocardiography in COPD after a Pulmonary Rehabilitation ProgramBrindeiroDjairFilho1Real Hospital Português de Beneficência em PernambucoServiço de Ecocardiografia do RecifeRecifePEBrazilServiço de Ecocardiografia do Recife (SECOR) - Real Hospital Português de Beneficência em Pernambuco, Recife, PE - BrazilMailing Address: Djair Brindeiro Filho, Av. Beira Mar, 2965/1201. Postal Code 54400-010, Piedade, Jaboatão dos Guararapes, PE - Brazil. E-mail: dbfpe@globo.com0920181113382383This 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 work is properly cited.Keywords:Chronic obstructive pulmonary disease (COPD)Two-dimensional EchoStrainSpeckle TrackingPulmonary Rehabilitation
Chronic obstructive pulmonary disease (COPD) is a serious public health problem, and is often related to smoking.1 In advanced stages of COPD, the presence of PAH is a common development. PAH progression rate in COPD is usually slow (an increase of < 1 mmHg per year). However, the presence of even moderate PAH is a strong predictor of mortality.2 During stable periods of the disease, the increase in mean pulmonary artery pressure is usually mild to moderate. However, severe PAH may occasionally occur in COPD patients COPD.3
Conventional two-dimensional (2D) echo parameters allow a reasonable assessment of RV Function. In the 1990s, the use of tissue Doppler (TD) to measure the intramyocardial velocity gradient allowed measuring the rate of myocardial strain and its percentage (strain rate and strain). About ten years ago, the speckle tracking technique, based on the tracking of the speckles which two-dimensional echo images, allowed assessing myocardial strain without limitation by the DT insonation angle.4 2D-STE strain can not only quantify the overall RV function, but it can also identify discrete, localized contractile losses, providing information regarding the pathophysiological mechanisms that lead to right ventricular failure.5 In a heterogeneous group of patients, RV lateral wall longitudinal strain showed a strong correlation with RV ejection fraction calculated by cardiac magnetic resonance.6 Peak longitudinal strain is a significant prognostic determinant in PAH patients, with greater value compared to other known clinical and echocardiographic predictors of mortality.7
Several studies have used 2D-STE in chronic PAH patients. Several authors advocate this method for serial evaluation of PAH patients since RV free-wall strain has proved an independent predictor of clinical deterioration and mortality after medical therapy is initiated.8 Although 2D-STE is widely used in various clinical conditions, the guidelines on echocardiographic evaluation of RV function strongly recommends including other measures into echocardiographic examination and report.9 In addition to the fact that there are no reference values, RV ST2D can be influenced by image quality, reverberation and other artifacts.10
The literature clearly shows the benefit of pulmonary rehabilitation (PR) programs. A prospective randomized study showed the effectiveness of respiratory training as an additional treatment of severe chronic PAH.11 In this issue, Kanar et al. evaluated the RV function using 2D-STE with 46 COPD and 32 control patients.12 The authors compared the 2D-STE values for the two groups and for patients before and after a pulmonary rehabilitation program. The conventional parameters for 2D-echo and 2D-STE showed a similar correlation between COPD and control patients, but RV longitudinal strain showed greater sensitivity in examining the relationship between RV function and exercise tolerance. The main limitations are pointed out in the article. There is no information on whether 2D-STE measurements were made in apnea or at the time of pre and post PR breathing. Since RV is sensitive to preload variations, the values could be influenced by respiratory variation. In any case, the usefulness of ST2D to evaluate RV in COPD was well demonstrated. Although there is controversy on the effectiveness of pulmonary rehabilitation programs in PAH,13 the authors demonstrated in an original way, i.e., through ST2D, that RV improves after PR, thus creating new perspectives for the use of PR in COPD patients.
Short Editorial regarding the article: Right Ventricular Functional Improvement after Pulmonary Rehabilitation Program in Patients with COPD Determined by Speckle Tracking Echocardiography
References1 Pauwels RA, Buist AS, Calverley PMA, Jenkins CR, Hurd S. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD). Am J Respir Crit Care Med. 2001;163(5):1256-76.PauwelsRABuistASCalverleyPMAJenkinsCRHurdSGlobal Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD)Am J Respir Crit Care Med20011635125612762 Seeger W, Adir Y, Barberá JA, Champion H, Coghlan JG, Cottin V, et al. Pulmonary hypertension in chronic lung diseases. J Am Coll Cardiol 2013;62(25 Suppl):D109-D116.SeegerWAdirYBarberáJAChampionHCoghlanJGCottinVPulmonary hypertension in chronic lung diseasesJ Am Coll Cardiol20136225 SupplD109D1163 Chaouat A, Bugnet AS, Kadaoui N, Schott R, Enache I, Ducolone A, et al. Severe pulmonary hypertension and chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2005;172(2):189-94.ChaouatABugnetASKadaouiNSchottREnacheIDucoloneASevere pulmonary hypertension and chronic obstructive pulmonary diseaseAm J Respir Crit Care Med200517221891944 Del CastilloJM, Herszkowicz N, Ferreira C. Speckle Tracking - A Contratilidade miocárdica em sintonia fina. Rev bras ecocardiogr imagem cardiovasc. 2010;23(3):46-54.Del CastilloJMHerszkowiczNFerreiraCSpeckle Tracking - A Contratilidade miocárdica em sintonia finaRev bras ecocardiogr imagem cardiovasc201023346545 Meris A, Faletra F, Conca C, Klersy C, Regoli F, Klimusina J, et al. Timing and magnitude of regional right ventricular function: a speckle tracking-derived strain study of normal subjects and patients with right ventricular dysfunction. J Am Soc Echocardiogr. 2010;23(8):823-31.MerisAFaletraFConcaCKlersyCRegoliFKlimusinaJTiming and magnitude of regional right ventricular function: a speckle tracking-derived strain study of normal subjects and patients with right ventricular dysfunctionJ Am Soc Echocardiogr20102388238316 Focardi M, Cameli M, Carbone SF, Massoni A, De Vito R, Lisi M, et al. Traditional and innovative echocardiographic parameters for the analysis of right ventricular performance in comparison with cardiac magnetic resonance. Eur Heart J Cardiovasc Imaging. 2015;16(1):47-52.FocardiMCameliMCarboneSFMassoniADe VitoRLisiMTraditional and innovative echocardiographic parameters for the analysis of right ventricular performance in comparison with cardiac magnetic resonanceEur Heart J Cardiovasc Imaging201516147527 Haeck ML, Scherptong RW, Marsan NA, Holman ER, Schalij MJ, Bax JJ, et al. Prognostic value of right ventricular longitudinal peak systolic strain in patients with pulmonary hypertension. Circ Cardiovasc Imaging 2012;5(5):628-36.HaeckMLScherptongRWMarsanNAHolmanERSchalijMJBaxJJPrognostic value of right ventricular longitudinal peak systolic strain in patients with pulmonary hypertensionCirc Cardiovasc Imaging2012556286368 Fukuda Y, Tanaka H, Sugiyama D, Ryo K, Onishi T, Fukuya H, et al. Utility of right ventricular free wall speckle-tracking strain for evaluation of right ventricular performance in patients with pulmonary hypertension. J Am Soc Echocardiogr. 2011;24(10):1101-8.FukudaYTanakaHSugiyamaDRyoKOnishiTFukuyaHUtility of right ventricular free wall speckle-tracking strain for evaluation of right ventricular performance in patients with pulmonary hypertensionJ Am Soc Echocardiogr20112410110111089 Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr 2010;23(7):685-713.RudskiLGLaiWWAfilaloJHuaLHandschumacherMDChandrasekaranKGuidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of EchocardiographyJ Am Soc Echocardiogr201023768571310 Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Erhande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2015;16(3):233-70.LangRMBadanoLPMor-AviVAfilaloJArmstrongAErhandeLRecommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular ImagingEur Heart J Cardiovasc Imaging201516323327011 Mereles D, Ehlken N, Kreuscher S, Ghofrani S, Hoeper MM, Halank M,et al. Exercise and respiratory training improve exercise capacity and quality of life in patients with severe chronic pulmonary hypertension. Circulation. 2006;114(14):1482-9.MerelesDEhlkenNKreuscherSGhofraniSHoeperMMHalankMExercise and respiratory training improve exercise capacity and quality of life in patients with severe chronic pulmonary hypertensionCirculation2006114141482148912 Kanar BG, Ozmen I, Yildirim EO, Ozturk M, Sunbul M. Right ventricular functional improvement after pulmonary rehabilitation program in patients with COPD determined by Speckle Tracking echocardiography. Arq Bras Cardiol. 2018; 111(3):375-381.KanarBGOzmenIYildirimEOOzturkMSunbulMRight ventricular functional improvement after pulmonary rehabilitation program in patients with COPD determined by Speckle Tracking echocardiographyArq Bras Cardiol2018111337538113 Galiè N, Humbert M, Vachiery JL, Gibs S, Lang I, Torbicki A, et al; ESC Scientific Document Group. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Heart J. 2016;37(1):67-119.GalièNHumbertMVachieryJLGibsSLangITorbickiAESC Scientific Document Group2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT)Eur Heart J201637167119MinieditorialAvaliação Ventricular Direita com Ecocardiografia Speckle Tracking na DPOC após Programa de Reabilitação PulmonarBrindeiroDjairFilho1Serviço de Ecocardiografia do Recife (SECOR) - Real Hospital Português de Beneficência em Pernambuco, Recife, PE - BrasilCorrespondência: Djair Brindeiro Filho, Av. Beira Mar, 2965/1201. CEP 54400-010, Piedade, Jaboatão dos Guararapes, PE - Brasil. E-mail: dbfpe@globo.comPalavras-chave:Doença Pulmonar Obstrutiva Crônica (DPOC)Ecocardiografia BidimensionalStrainSpeckle TrackingReabilitação Pulmonar
A doença pulmonar obstrutiva crônica (DPOC) é grave problema de saúde pública, e com frequência está relacionada ao tabagismo.1 Nas fases avançadas da DPOC, a presença de HAP é uma consequência comum. A taxa de progressão de HAP na DPOC é normalmente lenta (um aumento de < 1 mmHg por ano). No entanto, a presença de HAP, mesmo moderada, é um forte preditor de mortalidade.2 Durante os períodos estáveis da doença, o aumento da pressão arterial pulmonar média é geralmente leve a moderado. Entretanto, HAP grave ocasionalmente ocorre em pacientes com DPOC.3
Os parâmetros convencionais do eco bidimensional (2D) possibilitam uma avaliação razoável da Função do VD. Na década de 90, a utilização do Doppler tissular (DT) para medida do gradiente de velocidade intramiocárdica permitiu aferir a taxa de deformação do miocárdio e sua porcentagem (strain rate e strain). Há cerca de dez, anos a técnica do speckle tracking, baseada no rastreamento dos pontos que formam a imagem do eco bidimensional, possibilitou avaliar o strain miocárdico, sem a limitação do ângulo de insonação do sinal do DT.4 O strain por speckle tracking com o 2D (2D-STE) não só viabiliza a quantificação da função global do VD, mas também identifica perdas contrácteis discretas e localizadas, fornecendo informações em relação aos mecanismos fisiopatológicos que conduzem à insuficiência ventricular direita.5 Em um grupo heterogêneo de pacientes, O strain longitudinal da parede lateral do VD mostrou uma forte correlação com a fração de ejeção do VD calculada pela ressonância cardíaca magnética.6 O pico do strain longitudinal é um determinante prognóstico significativo em pacientes com HAP, e fornece valor incremental sobre outros conhecidos preditores clínicos e ecocardiográficos de mortalidade.7
Vários estudos já utilizaram a análise do 2D-STE em doentes com HAP crónica. Diversos autores defendem a utilização do método para avaliação seriada dos doentes com HAP, uma vez que o strain da parede livre do VD mostrou ser um preditor independente de deterioração clínica e mortalidade após a instituição da terapêutica médica.8 Apesar do 2D-STE ser amplamente utilizado em diversas condições clínicas, as Diretrizes para avaliação ecocardiográfica do VD afirmam ser altamente recomendável que outras medidas sejam incorporadas ao exame e ao relatório ecocardiográfico.9 Além de não existir valores de referência correntemente recomendados, o ST2D do VD pode ser influenciado pela qualidade da imagem, reverberação e outros artefatos.10
A literatura disponível mostra claramente o benefício do programa reabilitação pulmonar (RP). Estudo prospectivo randomizado demonstrou a eficácia do treinamento respiratório como tratamento adicional da HAP crônica grave.11 Nessa edição, Kanar et al.,12 avaliaram a função do VD com o 2D-STE em 46 pacientes com DPOC e 32 controles. Os autores compararam os valores do 2D-STE entre os dois grupos e dos pacientes, antes a após programa de reabilitação pulmonar. Os parâmetros convencionais do eco bidimensional e o 2D-STE mostraram correlação semelhante entre os pacientes com DPOC e os controles, mas o strain longitudinal do VD mostrou maior sensibilidade para investigar a relação entre a função do VD e a tolerância ao exercício. As principais limitações estão assinaladas no artigo. Não há informações se as medidas do 2D-STE foram feitas em apneia ou no mesmo momento da respiração pré e pós RP. Sendo o VD sensível às variações da pré-carga, os valores poderiam ser influenciados pela variação respiratória. De qualquer forma, está bem demonstrada a utilidade do ST2D na avaliação do VD na DPOC. Embora haja controvérsia sobre a eficácia dos programas de reabilitação pulmonar na HAP,13 os autores demonstraram, de forma original com o ST2D, que ocorre melhora do VD após a RP, criando novas perspectivas para o uso da RP em pacientes com DPOC.
Minieditorial referente ao artigo: Melhora da Função Ventricular Direita após Programa de Reabilitação Pulmonar em Pacientes com DPOC Avaliada por Ecocardiografia Speckle Tracking