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Normal values for longitudinal function of the right ventricle in healthy women >70 years of age

Alfried Germing, Michael Gotzmann, Ricarda Rauße, Turgut Brodherr, Stephan Holt, Michael Lindstaedt, Johannes Dietrich, Ulrich Ranft, Ursula Krämer, Andreas Mügge
DOI: http://dx.doi.org/10.1093/ejechocard/jeq053 725-728 First published online: 23 April 2010

Abstract

Aims The application of tricuspid annular plane systolic excursion (TAPSE) as an additional echocardiographic tool to analyse right ventricular (RV) systolic function has been recently established and two-dimensional-guided M-mode measurements of systolic long axis function of the RV are simple, repeatable, and highly reproducible. However, rare data are available on normal values. We aimed to analyse normal values in healthy women >70 years of age.

Methods and results In a cross-sectional survey, we investigated a cohort of randomly selected, non-hospitalized women >70 years of age. History of myocardial infarction, valvular heart disease, and diastolic dysfunction were exclusion criteria. In order to rule out left ventricular or RV dysfunction, a normal left ventricular ejection fraction and normal values of B-type natriuretic peptide (BNP) were necessary prior to study inclusion. A detailed echocardiographic examination was performed. A total of 80 participants were included (mean age 75 ± 2.6 years). Mean left ventricular ejection fraction was 63.8 ± 5.7%. Tissue Doppler derived mean E/E′ ratio was 10 ± 2.3. Mean right atrial diameter was 31.3 ± 4.7 mm. Mean values for RV outflow tract and RV dimension were 27.3 ± 3.6 and 28.8 ± 3.7 mm, respectively. Mean TAPSE was 23.7 ± 3.5 mm. Mean value of BNP was normal (42.5 ± 35.7 pg/mL).

Conclusion In women >70 years of age without heart failure, structural heart disease, and neurohormonal activation, normal TAPSE values are ∼24 mm.

  • Right ventricular function
  • TAPSE
  • Normal values

Introduction

Owing to the complex right ventricular (RV) geometry and poor acoustic windows, echocardiographic assessment of RV function remains a challenging problem. Various echocardiographic markers for assessment of global RV performance have been described. RV function can be quantified by indices, such as RV myocardial performance, RV fractional shortening, or by pulsed wave tissue Doppler imaging.1 New methods as strain and three-dimensional echocardiography have been recently evaluated.2,3 Normal values for most of the parameters of RV function have been established in smaller series of individuals.48 The application of tricuspid annular plane systolic excursion (TAPSE) as an additional echocardiographic tool to analyse RV systolic function has been established and decreased TAPSE is associated with poor prognosis in patients with pulmonary hypertension and heart failure.913 Two-dimensional-guided M-mode measurements of systolic long axis function of the RV free wall are simple, repeatable, and highly reproducible.5 TAPSE has been shown to correlate with ejection fraction derived by radionuclide angiography or echocardiography.5,11,14 Adult and childhood reference values of TAPSE measurements are available in the literature.5,1517 However, scant data are available on normal values of RV function in elder people.

We aimed to analyse normal values of TAPSE in healthy women >70 years of age.

Methods

The study group was part of the SALIA (Study on the influence of Air pollution on Lung function, Inflammation, and Aging) cohort which initially comprised 4874 women. The cohort was previously described in detail.18 In 2007 and 2008, a supplementary cross-sectional cardiovascular study was realized in 311 women. The examination consisted of medical history, physical examination, measurement of B-type natriuretic peptide (BNP), and echocardiography. History of myocardial infarction, valvular heart disease, and diastolic dysfunction were exclusion criteria. A detailed echocardiographic analysis of right heart geometry and function was performed in 80 individuals who matched for inclusion and exclusion criteria.

Plasma BNP levels were measured at the same day as echocardiography study was performed. The blood samples were collected in EDTA-containing tubes. After prompt centrifugation, BNP was measured using a chemoluminescent immunoassay kit (Biosite Triage, San Diego, CA, USA).

Transthoracic echocardiography was performed according to the recommendations of the American and European Societies of Echocardiography19 using a digital ultrasound scanner (Vivid 7, General Electrics, Horton, Norway). Data from three cardiac cycles were analysed. An experienced cardiologist performed the ultrasound examination. Right atrial and ventricular dimensions were measured in apical four-chamber and parasternal short-axis views (Figures 1 and 2). TAPSE was measured by M-mode recordings from the apical four-chamber view, with the cursor placed at the free wall of the tricuspid annulus (Figure 3). Left ventricular myocardial mass was calculated according to the Devereux formula.20 Peak velocities of early (E) and late (A) diastolic filling were derived from the transmitral Doppler profile. Doppler tissue imaging was taken from septal and lateral mitral annulus and revealed averaged early (E′) and late (A′) diastolic peak velocities. According to recent recommendations,21,22 diastolic dysfunction was considered as an E/E′ ratio >15, or E/E′ 8–15 plus BNP >200 pg/mL, left atrial volume index >40 mL/m2, and left ventricular myocardial index >122 mg/m2.

Figure 1

Measurements of right ventricular diameters. RVD1, right basal ventricular diameter; RVD2, right mid-ventricular diameter; RVD3, right ventricular diameter base to apex.

Figure 2

Measurements of right ventricular diameters. RVOT1, right ventricular outflow tract diameter measured in parasternal short axis; RVOT2, right ventricular outflow tract diameter measured in parasternal short axis at the level of pulmonary artery valve.

Figure 3

Measurement of tricuspid annular plane systolic excursion (TAPSE).

Numerical values were expressed as mean ± SD. Continuous variables were compared between groups using an unpaired t-test (for normally distributed variables) or Mann–Whitney U-test (for non-normally distributed variables). χ2 analysis was used to compare categorical variables. All reported probability values were two-tailed, and P < 0.05 was considered statistically significant. Analyses were performed with the SPSS statistical software package (version 17.0).

Results

Mean age of all 80 participants was 75 ± 2.6 years. Cardiovascular risk factors were common in our study cohort: hypertension (n = 47, 58.8%), hypercholesterolaemia (n = 39, 48.8%), and diabetes (n = 5, 6.3%). There was no history of myocardial infarction or valvular heart disease.

Mean left ventricular ejection fraction was 63.8 ± 5.7%. Left atrial volume and left ventricular hypertrophy were not increased in most participants (mean left atrial volume index 19.5 ± 6 mL/m2 and mean left ventricular mass index 115.9 ± 27.1 mg/m2). Participants had a normal left ventricular diastolic function, mean E/E′ ratio 10 ± 2.3, and mean E/A ratio 0.7 ± 0.1. Right atrial and RV dimensions were normal. Pulmonary valve acceleration time was not decreased. Detailed echocardiographic data are listed in Table 1.

View this table:
Table 1

Echocardiographic measurements

nMean values ± standard deviation95% confidence interval
Age (years)8075 ± 2.674.31–75.48
Body mass index (kg/m2)8026.7 ± 4.825.63–27.78
LAVI (mL/m2)8019.5 ± 6.018.16–20.82
LVMI (g/m2)80115.9 ± 27.1109.9–121.95
E/A ratio800.7 ± 0.10.65–0.72
E/E′ ratio8010.0 ± 2.39.46–10.48
RVD1 (mm)6928.8 ± 3.727.92–29.71
RVD2 (mm)6927.3 ± 5.725.93–28.68
RVD3 (mm)6968.8 ± 7.067.15–70.51
RVOT1 (mm)5427.3 ± 3.626.33–28.3
RVOT2 (mm)5221.4 ± 3.420.45–22.38
RA (mm)8031.3 ± 4.730.28–32.37
TAPSE (mm)8023.7 ± 3.522.93–24.47
PVAcc (ms)6098.2 ± 25.091.73–104.64
LVEF (%)8063.8 ± 5.762.55–65.07
BNP (pg/mL)8042.5 ± 35.734.52–50.41
  • LAVI, left atrial volume index; LVMI, left ventricular mass index; TAPSE, tricuspid annular plane systolic excursion; RVD1, right basal ventricular diameter; RVD2, right mid-ventricular diameter; RVD3, right ventricular diameter base to apex; RVOT1, right ventricular outflow tract diameter measured in parasternal short axis; RVOT2, right ventricular outflow tract diameter measured in parasternal short axis at the level of pulmonary artery valve; PVAcc, pulmonary valve acceleration time; LVEF, left ventricular ejection fraction; BNP, B-type natriuretic peptide.

In study participants, BNP values were normal (42.5 ± 35.7 pg/mL) reflecting lack of neurohormonal activation due to heart failure in study participants.

Discussion

Scant data are available on normal values of RV geometry in elder healthy individuals and effects of age and gender on TAPSE normal values have not been completely analysed. Changes in values of TAPSE with increasing age have been reported. A continuous increase in levels of TAPSE in healthy individuals from birth to adolescence was demonstrated.16 In this study, young adults had mean levels of TAPSE of 24.7 mm. Whether there is a further increase in adults is not known so far. In a study with 36 individuals at a mean age of 61 years, normal TAPSE were measured with 25.5 mm.6

There is no definite cut-off value for TAPSE. The lower the value the worse seems to be the cardiovascular outcome.17 Cut-off values for TAPSE between 15 and 20 mm as markers of depressed RV function in association with reduced prognosis have been reported in several patient subgroups.1113 To our knowledge, limited data on normal values of TAPSE in elderly healthy women are presented in the literature.

According to left ventricular ejection fraction, left atrial volume index, left ventricular mass index, and diastolic function participants in our study represent a population of healthy individuals without structural heart disease. In addition, participants with neurohormonal activation were excluded as reflected by normal values for BNP. Our morphological findings of right atrial and RV dimensions are in line with normal ranges recommended by the American and European Societies of Echocardiography.19 However, guidelines do not provide normal values for different ages due to missing data. In our study, the mean value of TAPSE was 23.7 mm. This value corresponds to earlier reports in adolescents and younger adults.6,16,17 A recent publication on RV longitudinal function in 22 healthy individuals >70 years of age found a mean TAPSE value of 18 mm and described a continuous decrease in TAPSE values during adolescence.23 This is in contrast to other findings that describe an increase in TAPSE measurements during childhood and youth.16 According to our data on 80 healthy women, TAPSE does not further raise or decrease with older age.

In summary, in healthy elderly women >70 years of age, normal TAPSE values are ∼24 mm.

Conflict of interest: none declared.

Funding

This study has been supported by Deutsche Gesetzliche Unfallversicherung (DGUV) and Berufsgenossenschaftliche Forschungsanstalt für Arbeitsmedizin (BGFA).

References

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