Title:

Lateral annular systolic excrusion ratio in assessment of right ventricular

function in patients with chronic obstructive airway disease

Type: original article

Authors:
Zahraa mohammed abass

Department of Medicine, College of Medicine, University of Babylon,

Hilla, Iraq.
Email: z3071991@gmail.com
Phone: +964772599686
*Corresponding author

Safaa Jawad Kadhem

Dept. of Medicine, Hammurabi College of Medicine, University of
Babylon, Hilla, Iraq
Email: safaajawadk@yahoo.com
Running title:
Lateral annular systolic excrusion ratio in assessment of right ventricular
function in patients with chronic obstructive airway disease.

* Corresponding author
Dr.Zahraa mohammed abass
Department of Medicine, College of Medicine,
University of Babylon,
Hilla, Iraq.
Email: z3071991@gmail.com
Introduction
Nowadays, one of the top three causes of death globally is chronic
obstructive pulmonary disease (COPD), accounting for 90% of deaths
that take place in low- and middle-income countries (LMICs).(1,2) In
2012, COPD claimed the lives of almost 3 million people, or 6% of all
fatalities worldwide. One significant public health issue that can be
treated and prevented is COPD.
The World Health Organization (WHO) lists COPD as one of the top 10
global causes of death [3]. Global Burden of Disease (GBD) study
indicates that 251 million cases of COPD were reported globally in 2016
[4]. It places a heavy burden on affected individuals, mostly because of
its high expense and detrimental effects on their quality of life [5]. One
significant cause of death is COPD.
Cor-pulmonale refers to the structural and functional adaptations of
the RV to increases in afterload caused by respiratory system disorders.
By using these compensatory mechanisms, the RV can maintain a
significantly elevated PAP without causing a drop in CO. In patients with
advanced COPD, the mean PAP at rest is often twice that of healthy
adults, and during exercise, it can rise to 30 or 40 mm Hg, with the
systolic PAP in the systemic circulation approaching diastolic values.
More sensitive diagnostic techniques have identified RV dysfunction in
up to half of the patients with moderate to severe COPD. The
prevalence of cor pulmonale increases with the severity of airway
obstruction, occurring in 40% of patients with a FEV1 of less than 1.0 L
and in 70% of patients with a FEV1 of less than 0.6 L. However, cor
pulmonale in these studies was determined by clinical or ECG criteria
that are insensitive predictors of RV dysfunction in patients with COPD.
Cor pulmonale is more common in patients with chronic bronchitis than
in those with emphysema, which is probably because it is also higher in
those with hypoxemia, CO2 retention, and polycythemia.(5)
To assess the anatomy and function of complex strcture like RV
especially in patients with hyperinflated lungs poses a major limitation
in echocardiography.(6)
There is a need for a single parameter that is easy to measure,LASER is
a novel measure of RV function that can be easily applicable in variety
of patients settings.(7)

Patients and methods

This is a cross-sectional study with analytic element.
The data collection was carried out in the respiratory
consultation clinc and echocardiography department of merjan
teaching hospital from JANUARY to JUNE 2024.
50 patients with stable diagnosis of COPD of varying severity
were compared with other 50 healthy control of similar age and
sex distribution.
The patients underwent complete resting conventional
echocardiography by measuring as follows:
Right ventricular size assessment by measuring (RV basal
diam,RV mid diam,RV length,RVOT diam,RV thickness).
Right ventricle systolic and diastolic function assessment by
measuring (TAPSE,FAC,S`,MPI,LASER,TRPG).
All size measures were taken in end-diastole in RV focused
view using 2.5 MHZ probe GE vivid E9.
Statistical analysis

Statistical analysis were performed using SPSS 16.0 for windows

Inc.An expert statistical advice was consulted for tests
used.Data of quantitative variables were expressed as mean+_
SD .Differences in each variable between control and patients
were compared using paired-sample student's t-test and
Microsoft excel also used.In all tests , P-Value <0.05 considered
to be statistically significant unless another levels were stated.
Ethical Approval

The study was conducted in accordance with the ethical principles that have their origin in the
Declaration of Helsinki. It was carried out with patients verbal and analytical approval before
conducting the study. The study protocol and the subject information and consent form were
reviewed and approved by a local committee on publication ethics at Babil Health Directorate
under the reference No. 360 on 15 july 2022.

Results
Demographic distribution
Demographic Healthy Group Patients Group P-Value
Data (Control)

Gender Male Number Male Number 0.945

(16) (24)
Female Number Female Number
(14) (21)
 Age (Year) 43.12±1.46 51.36±1.86 0.037

Weight(Kg) 80.15±2.16 77.18±2.66 0.875

Height (cm) 167.03±1.25 164.21±1.98 0.456

Body surface 1.86±0.14 1.12±0.11 0.0267

area(m²)

2.rigth ventricular thickness

Right Ventricular Thickness in cm

Control
Patients
*

Figure(1):-A comparison of the right ventricular thickness between control and patients groups

3.fractional area change FAC

 Percent of fractional area change Fractional Area Change

45
 40
35
30
25
20
15
10
5
0
Patients Control

Figure(2):-A comparison of the fractional area change between control and patients groups

3.Lateral annular systolic excrusion ratio

Lateral annular Systolic Excursion Ratio

Percent of mean lateral annular systolic

0.25

0.2

excursion

0.15

0.1

0.05

0
Patients Control

Figure(3):-A comparison of the lateral annular systolic excursion ratio between control and
patients groups.

Correlation between lateral annular systolic excursion and tricuspid

annular plane systolic excursion
There was a significant negative correlation between lateral annular systolic
excursion and tricuspid annular plane systolic excursion among patients with
chronic obstructive pulmonary disease as shown in the table(2).
LASER TAPSE

LASER pearson 1 -0.374

correlation 0.11
Sig.(2-tailed) 45
n 45
Tapse pearson -0.374 1
correlation 0.11
Sig .(2-tailed) 45 45
n

Discussion:
The evaluation of right ventricular (RV) function has become
increasingly important in medical practice in light of new data
emphasizing the central prognostic role of the RV in various disorders.
However, describing RV function using conventional 2D
echocardiography is challenging since the RV has a complex geometry
and the trabeculated myocardium hampers endocardial delineation. Its
retrosternal position limits the visualization of the RV anterior wall by
restricting the transthoracic window.(7)
Furthermore, a marked load dependence of conventional
echocardiographic parameters of RV function complicates the result
interpretation.(8)
In COPD, the assessment of right ventricular function is difficult, due to
marked increase in intrathoracic gas, expansion of the thoracic cage,
and alterations in the position of the heart, making it difficult to
visualize the ventricle by means of echocardiography. (9)
In our study we included 50 patients with chronic airway obstruction
with age and sex matched healthy controls.
In analysis of our study parameters there was non-significant
differneces in RV basal diameter between healthy and control group.
This finding is similar to another study by mutlu et al. and mohammed
et al. who didn’t find any significant correlation between COPD severity
and RV size.(10)
This contrary to what have been shown by Hilde et al who shows that
RV dilatation was found in early stages of COPD.(11)
There was also diffrences in RVOT diameter between pateints and
controls.this finding is similar to a study done by B Gyik et al who found
an association between RVOT size and RV function in patients with
COPD.(12)
There was a significant differences in RVFWT between patient and
control.this finding is similar to another study by ramsey et al (13) who
studied sub-clincal right ventricle dysfunction in COPD patients.
In the analysis of RV systolic function we studied conventional
parameters like S`,TAPSE,FAC and our novel parameters LASER.
Fractional area change with cut off value <35% (according to ASE
guidelines) was much lower in pateints than in controls group.this is
similar to what found by kannappan et al in assessment of echo-graphic
predictors of RV dysfunction in pateints with COPD.(14)
Lateral annular systolic excrusion ratio is a novel parameter of RV
function that assess longtiundal function of right ventricle like TAPSE
and combine this fractional shortening of RV base to apex during both
systole and diastole so it can assess both regional and global RV
function,with a cutoff value of 0.2 LASER can be widely applicable
across a variety of pateints settings(15).
In our study there was a significant difference between LASER in
healthy and control groups,this is similar only to fractional area change
which was significantely different between patients and
control,although our results shows that there is no significant
correlation between the two measures,further studies needed to be
done to show the strength of LASER in comparsin to other gold
standard measures like FAC,however this is contrary to what have been
shown by jonthan et al in which both LASER and FAC have moderate
positive correlation.(16)
TAPSE as widely applicable measure of RV function didn’t show any
significant difference between patients and control,in fact it was
normal in almost cases with COPD,this similar to what found by Yaser et
al and kannapan et al in which TAPSE was >18mm in patients with
COPD with varying severity.(17,18).
Our results also shows significant negative correlation between TAPSE
and LASER this is can be explained by angle dependency of TAPSE and
being estimated by M-mode it tends to be affected by cardiac
transitional motion,while being a 2D measure LASER is less affected by
cardiac motion.
Through the measurement of myocardial wall velocities by spectral
analyses, pulsed DTI presents a hightemporal resolution (about 4 to 5
ms), which allows calculation of the time intervals throughout the
cardiac cycle.Because of its preload independence,pulsed DTI has been
used in combination with standard Doppler to predict mean right atrial
pressure,In the present study, DTI of the tricuspid annulus was done
measuring s`,IVRT,IVRT was siginficantely prolonged in pateints
compared to controls,this is similar to what have been shown by Pio et
al who have shown that IVRT is siginficantely prolonged in patient with
COPD and can even predict sub-clincal RV involvement.(19)
Lastly PAP was normal patient with COPD even though there was
siginficantely different between patients and controls,this can
explained by weak Doppler siginal that could be obtained in COPD
pateints because of poor image quality and inaccuracy of PAP
measurement by TRV as compared to RHC as shown by selim at al(20).

Conclusion
Laser is an interesting novel measure of right ventricular
function,however more studies needed to be done to confirm
strength of LASER in comparsion to gold standard RV function
measurement.
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