|Year : 2013 | Volume
| Issue : 2 | Page : 68-71
Right ventricle myocardial performance index versus Simpson's right ventricle ejection fraction in patients with isolated left ventricle anterior myocardial infarction
Monika Maheshwari, Sita Ram Mittal
Department of Cardiology, Jawahar Lal Nehru Medical College, Ajmer, Rajasthan, India
|Date of Web Publication||23-Jul-2013|
Navin-Niwas, 434/10, Bapu Nagar, Ajmer, Rajasthan
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Right ventricle (RV) dysfunction may be secondary to left ventricle (LV) dysfunction in patients of isolated left ventricle anterior myocardial infarction as a consequence of "Ventricular Interdependence". As RV dysfunction is associated with high in-hospital morbidity and mortality, early recognization of RV dysfunction is warranted; but until today it remains a challenging task because of complex structure and asymmetric shape of RV.
Aims and Objectives: Our aim in the present study was to compare Simpson's right ventricle ejection fraction (RVEF) with right ventricle myocardial performance index (RV-MPI) to predict RV function in patients with isolated left ventricle anterior myocardial infarction (LV-AMI).
Materials and Methods: We conducted the present study at the Department of Cardiology of Jawahar Lal Nehru Medical College and Associate Group of Hospitals, Ajmer. The control group comprised of twenty five. Age, sex, BMI, pulse and blood pressure matched healthy subjects without history of heart disease, systemic hypertension, diabetes, any other systemic illness and with normal findings in resting and exercise ECG, Echocardiography and Coronary Angiography. Sub-group-1 consisted of 25 patients with hemodynamically significant stenosis of proximal left anterior descending artery (LAD) with patent first septal perforator (S 1 ). Sub-group-2 was composed of s5 patients with hemodynamically significant stenosis of both LAD and left circumflex artery (LCx.). Both subgroups had fully patent right coronary artery (RCA) from proximal to distal end.
Results: RV-MPI value determined using pulsed doppler echocardiography was 0.40 ± 0.19 in healthy subjects. However RV-MPI was increased in both subgroups of LV-AMI with significant increase in subgroup-2 ( P < 0.005) as compared to subgroup-1 patients ( P < 0.01). Simpson's RVEF was not significantly different between the groups ( P > 0.05).
Conclusion: The findings in this study demonstrate that RV-MPI is a more sensitive, non-geometric echocardiographic parameter than Simpson's RVEF in detecting early RV dysfunction. Early detection of RV dysfunction is important to reduce morbidity and mortality in these patients.
Keywords: Isolated left ventricle anterior myocardial infarction, right ventricle myocardial performance index, Simpson′s right ventricle ejection fraction
|How to cite this article:|
Maheshwari M, Mittal SR. Right ventricle myocardial performance index versus Simpson's right ventricle ejection fraction in patients with isolated left ventricle anterior myocardial infarction. Heart Views 2013;14:68-71
|How to cite this URL:|
Maheshwari M, Mittal SR. Right ventricle myocardial performance index versus Simpson's right ventricle ejection fraction in patients with isolated left ventricle anterior myocardial infarction. Heart Views [serial online] 2013 [cited 2023 Mar 30];14:68-71. Available from: https://www.heartviews.org/text.asp?2013/14/2/68/115500
| Introduction|| |
The importance of right ventricle (RV) function as a predictor of outcome among patients with heart failure, myocardial infarction, and pulmonary embolism has been established.  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 complex structure and asymmetric shape of RV.  Standard 2-dimensional echocardiographic evaluation of RV volumes and ejection fraction is cumbersome due to difficulty in exact delineation of RV endocardial borders because of prominent trabeculations and crescentric shape of the RV. 
| Aims and Objectives|| |
The present study aims to compare Simpson's right ventricle ejection fraction (RVEF) with right ventricle myocardial performance index (RV-MPI) and to predict RV function in patients with isolated left ventricle anterior myocardial infarction (LV-AMI).
| Materials and Methods|| |
The present study was conducted at Department of Cardiology of Jawahar Lal Nehru Medical College and Associate Group of Hospitals, Ajmer.
The study group comprised of 50 patients with isolated LV-AMI having history of characteristic ischemic chest pain (>30 minutes), ST segment elevation >1 mm in anterior leads I, aVL, V 1 -V 6 , and positive serum cardiac markers (CPK-MB, troponin I). Patient with inferior myocardial infarction, significant valve disease, chronic obstructive lung disease, strong clinical suspicion of pulmonary embolism, atrial fibrillation, atrial flutter, frequent supraventricular or ventricular ectopics, bundle branch block/advanced (second degree/complete) atrioventricular block, and significant pericardial effusion were excluded. Any associated RV infarction was strictly excluded by electrocardiography (ECG), echocardiography, and right coronary angiography. Study patients were further subdivided into two subgroups according to the infarct-related artery.
Sub-group-1 comprised of 25 patients with hemodynamically significant stenosis of proximal left anterior descending artery (LAD) with patent first septal perforator (S 1 ).
Sub-group-2 comprised of 25 patients with hemodynamically significant stenosis of both LAD and left circumflex artery (LCx). Both subgroups had fully patent right coronary artery (RCA) from proximal to distal end.
The control group comprised of 25 age, sex, body mass index (BMI), pulse, and blood pressure matched healthy subjects without history of heart disease, systemic hypertension, diabetes, any other systemic illness, and with normal findings in resting and exercise ECG, echocardiography, and coronary angiography.
Design of study
In all patients with isolated LV-AMI, the following detailed analysis was done:
Complete analysis of various leads was performed according to previously described method. 
A transthoracic 2D echocardiographic examination was performed with patients in left lateral decubitus position, 2-4 days after the AMI. The equipment used was Siemens transthoracic echocardiographic machine G-50 and CV-70 with 3.5 MHz transducer. With the use of apical four chamber view Simpson's RVEF was calculated as percentage of changes in RV chamber volumes between diastole and systole using formula: [Figure 1]. With the use of pulmonary and transtricuspid Doppler flow in short axis and apical -4 chamber view RV-MPI was calculated using formula = [Figure 2]a and b.
|Figure 1: Line diagram of transthoracic echocardiogram (apical 4 chamber view) showing calculation of RVEF by Simpson's method|
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|Figure 2: (a) Line diagram of transthoracic echocardiogram (pulmonary and trans tricuspid Doppler flow) showing calculation of RV-IVCT. (RV-IVCT= (Q-P) Q-A)), (b) Line diagram of transthoracic echocardiogram (pulmonary and trans tricuspid Doppler flow) showing calculation of RV-IVRT. (RV-IVRT = (Q-E) Q-P))|
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This was performed through a percutaneus femoral/radial artery approach under local anesthesia using Judkin's Left and Right-6/Tiger-5 French Catheter. Left coronary artery (LCA) was visualized with nonionic dye in RAO caudal 40/40°, RAO cranial 40/30°, LAO cranial 60/35°, LAO caudal 60/40°, AP caudal 0/35°, and AP cranial 0/30° views. RCA was visualized in LAO cranial 40° and left lateral views. Views were changed when required for optimal visualization of the coronary arteries Patients of anterior myocardial infarction showing stenosis of isolated proximal LAD artery, with patent S 1 branch or stenosis of both LAD and LCx arteries with fully patent RCA from proximal to its distal end along with its branches were included in study.
Data were expressed as mean + SD. Comparison of all variables in both groups was done by using "unpaired Student's test". Degree of freedom was calculated and P value was obtained. The results of P value were interpreted as follows: P > 0.05 - Not significant (NS), P < 0.025 - significant (S), P < 0.01 - very significant (VS), P < 0.005 - highly significant (HS).
[Table 1] shows the basal clinical characteristics and left ventricle (LV) echocardiographic parameters of the groups. There was no significant difference in age, gender, BMI, pulse rate, and blood pressure between the groups ( P > 0.05). Left ventricle ejection fraction (LVEF) by M-mode and Simpson's method and LV fractional shortening were reduced significantly in both subgroups of LV-AMI as compared with healthy subjects ( P < 0.005). LV systolic dysfunction was more in subgroup-2 as compared to subgroup-1 patients [Table 1]. RV-MPI value was determined using pulsed Doppler echocardiography. The value in healthy subjects was 0.40 + 0.19. RV-MPI was increased in both subgroups of LV-AMI with significant increase in subgroup-2 ( P < 0.005) as compared with subgroup-1 patients ( P < 0.01) [Table 2]. Simpson's RVEF was not significantly different between the groups ( P > 0.05) [Table 2].
| Discussion|| |
RV dysfunction may be secondary to LV dysfunction, as a consequence of "Ventricular Interdependence". There is close anatomic association between the two ventricles, as they are encircled by common muscle fibers, share a common septal wall and are enclosed within a common pericardium. So forces are transmitted from one ventricle to the other ventricle through myocardium and pericardium, independent of neural, humoral, and circulatory effects.
Millar, et al.  reported that RV-MPI value >0.40 has 100% sensitivity and 100% positive predictive value to diagnose RV dysfunction. In our study we found that in spite Simpson's RVEF being normal, RV-MPI was significantly prolonged in both subgroups of LV-AMI suggesting RV-MPI is a more simple, sensitive, and accurate parameter contrary to RVEF to assess RV functions.  It requires no geometric assumptions. Adequate Doppler images can be acquired even when 2D image quality is suboptimal. Since RV-MPI integrates both isovolumic and ejection phase indices, it becomes abnormal before an ejection phase measure such as Simpson's RVEF indicates an abnormality.  Further it provides global assessment of systolic and diastolic function of RV, independent of heart rate  and loading conditions. 
| Conclusion|| |
The findings in this study demonstrate that even in patients with isolated LV-AMI there is RV dysfunction due to 'ventricular interdependence'. RV-MPI is a sensitive, nongeometric echocardiographic parameter, to detect RV dysfunction at an early stage so as to reduce morbidity and mortality in these patients.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]
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