Scientific Letter
Assessment of right atrial pressure with two-dimensional, Doppler and speckle tracking echocardiography in patients with acute right ventricular myocardial infarction.
Evaluación de la presión de la aurícula derecha con ecocardiografía bidimensional, Doppler y speckle tracking en pacientes con infarto agudo del ventrículo derecho
J.B. Ivey-Mirandaa,
, E.L. Posada-Martínezb, E. Almeida-Gutierrezc, E. Flores-Umanzord, G. Borrayo-Sanchezc, G. Saturno-Chiuc
Corresponding author
a Department of Acute Cardiovascular Care, Cardiology Hospital, Hospital de Cardiología, Centro Mèc)dico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
b Department of Echocardiography, Instituto Nacional de Cardiología Ignacio Chávez, Tlalpan, Mexico City, Mexico
c Department of Education and Research, Hospital de Cardiología, Centro Mèc)dico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
d Institute Clinic Cardiovascular, Hospital Clinic, Barcelona, Spain
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The granulocytes, monocytes, and lymphocytes were identified on dot-plot profile and gated by its CD64 expression. The positive CD64 region is marked by a discontinued line. In patient 4 the positive CD64 granulocytes are rounded by a discontinued circle. In each patient, and from left to right, the CD18 expression is showed in the A dot-plot, the CD11b expression is showed in the B dot-plot, CD11a expression is showed in the C dot-plot and granulocytes CD11b<span class="elsevierStyleSup">+</span>/CD11a<span class="elsevierStyleSup">+</span> are showed in the D dot-plot. mCD64: mean fluorescence intensity or MFI of CD64 in monocytes; gCD64: MFI of CD64 in granulocytes; gCD64<span class="elsevierStyleSup">+</span>: percentage of positive CD64 granulocytes.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. García-Salido, A. Serrano-González, A.M. de Azagra-Garde, M. Nieto-Moro, G.J. Melen, M. Ramírez-Orellana" "autores" => array:6 [ 0 => array:2 [ "nombre" => "A." 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"apellidos" => "López-Herce" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210569117302401" "doi" => "10.1016/j.medin.2017.09.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569117302401?idApp=WMIE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572719301298?idApp=WMIE" "url" => "/21735727/0000004300000007/v1_201910040722/S2173572719301298/v1_201910040722/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letter</span>" "titulo" => "Assessment of right atrial pressure with two-dimensional, Doppler and speckle tracking echocardiography in patients with acute right ventricular myocardial infarction." "tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "443" "paginaFinal" => "446" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J.B. Ivey-Miranda, E.L. Posada-Martínez, E. Almeida-Gutierrez, E. Flores-Umanzor, G. Borrayo-Sanchez, G. Saturno-Chiu" "autores" => array:6 [ 0 => array:4 [ "nombre" => "J.B." "apellidos" => "Ivey-Miranda" "email" => array:1 [ 0 => "betuel.ivey@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "E.L." "apellidos" => "Posada-Martínez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "Almeida-Gutierrez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "E." "apellidos" => "Flores-Umanzor" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "G." "apellidos" => "Borrayo-Sanchez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 5 => array:3 [ "nombre" => "G." "apellidos" => "Saturno-Chiu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Department of Acute Cardiovascular Care, Cardiology Hospital, Hospital de Cardiología, Centro Mèc)dico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Echocardiography, Instituto Nacional de Cardiología Ignacio Chávez, Tlalpan, Mexico City, Mexico" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Education and Research, Hospital de Cardiología, Centro Mèc)dico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Institute Clinic Cardiovascular, Hospital Clinic, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Evaluación de la presión de la aurícula derecha con ecocardiografía bidimensional, Doppler y speckle tracking en pacientes con infarto agudo del ventrículo derecho" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1250 "Ancho" => 1500 "Tamanyo" => 98864 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Decision tree for raised right atrial pressure. Decision tree shows that after the echo 3•8•15<span class="elsevierStyleHsp" style=""></span>mmHg approach, right atrium area further identify patients with raised right atrial pressure. See text for information. RAP<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>right atrial pressure.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In patients with inferior myocardial infarction, right ventricular myocardial infarction (RVMI) can occur in up to 50% of cases.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> It is associated with higher intra-hospital mortality rates.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Management of RVMI includes preload optimization and maintenance of atrio-ventricular synchrony.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Preload optimization is a mainstay of treatment, but it is also a double-edged sword. High filling pressures in the right ventricle can worsen the performance of preload optimization and may lead to right ventricular dilatation and further dysfunction. On the other hand, insufficient preload is associated with low right cardiac output, hypotension and shock.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Right atrial pressure (RAP) is an essential component in the hemodynamic assessment of patients with RVMI.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Unfortunately, RAP measurements are invasive and suffer from complications, and they are not always available to every patient. However, non-invasive evaluation of RAP is feasible with echocardiography and many techniques have been described.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Even so, the usefulness of echocardiography in RAP assessment in patients with RVMI is uncertain.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of this study was to assess whether echocardiography can accurately estimate RAP in patients with RVMI and predict increased RAP levels to guide management. The scope of the study was to assess the right ventricular function with comprehensive echocardiography and to measure the RAP with a central venous catheter.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In this study, patients with RVMI and elevated ST segment were analyzed. Consecutive cases were included from 2015 to 2016. Patients were required to satisfy a third universal definition of myocardial infarction (MI) and an ST-segment elevation of at least 0.1<span class="elsevierStyleHsp" style=""></span>mV in the V4R lead.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> The Cardiology Hospital Ethical Committee revised and approved the protocol, and all of the patients gave written informed consent to participate in the study.</p><p id="par0030" class="elsevierStylePara elsevierViewall">We conducted comprehensive echocardiograms at the bedside immediately after admission. We analyzed the following echocardiographic parameters according to current international guidelines<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a>: tricuspid annular plane systolic excursion (TAPSE), tricuspid <span class="elsevierStyleItalic">S</span>′ wave velocity, global right ventricular longitudinal strain, free wall right ventricular longitudinal strain, right <span class="elsevierStyleItalic">E</span>/<span class="elsevierStyleItalic">E</span>′ ratio, right atrial area, inferior vena cava size and tricuspid regurgitation. We estimated right atrial pressure with the 3•8•15<span class="elsevierStyleHsp" style=""></span>mmHg approach and the 5•10•15•20 approach according to guidelines. In the first approach the RAP is 3<span class="elsevierStyleHsp" style=""></span>mmHg if inferior vena cava diameter is ≤21<span class="elsevierStyleHsp" style=""></span>mm and the diameter changes ≥50% with sniff; RAP is 15<span class="elsevierStyleHsp" style=""></span>mmHg if inferior vena cava diameter is<span class="elsevierStyleHsp" style=""></span>>21<span class="elsevierStyleHsp" style=""></span>mm and the diameter changes <50% with sniff; if neither condition is satisfied the RAP is 8<span class="elsevierStyleHsp" style=""></span>mmHg. In the second approach the RAP is 5<span class="elsevierStyleHsp" style=""></span>mmHg if inferior vena cava diameter is ≤21<span class="elsevierStyleHsp" style=""></span>mm and the diameter changes ≥50% with sniff, if the diameter changes <50% RAP is 10<span class="elsevierStyleHsp" style=""></span>mmHg; RAP is 15<span class="elsevierStyleHsp" style=""></span>mmHg if inferior vena cava diameter is >21<span class="elsevierStyleHsp" style=""></span>mm but the diameter changes ≥50% with sniff, if the diameter changes <50% RAP is 20<span class="elsevierStyleHsp" style=""></span>mmHg. We measured parameters using the average of three consecutive beats in all cases. In cases of atrial fibrillation or atrioventricular block we used the average of five consecutive beats. Strain was analyzed offline with specific software (QLAB version 10.5, Philips Healthcare, Andover, MA, USA). Right ventricular longitudinal strain analyses consisted of a semi-automated process in which three points were selected: the tricuspid annular plane with the free wall and the interventricular septum, and the right ventricular (RV) apex. Right atrial strain analyses consisted of a similar process and three points were selected: the tricuspid annular plane with atrial lateral wall and interatrial septum, and the roof of the right atrium. We visually inspected the strain curves to ensure appropriate tracking. We defined global right ventricular longitudinal strain as the average of seven segments analyzed and free wall right ventricular longitudinal strain as the average of three free wall segments.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Just prior to the echocardiographic examination, we measured RAP with a central venous catheter as previously described in the literature.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> The RAP was measured for three times, and the average was reported in mmHg. We as investigators did not know RAP at either the time of examination or during the offline analysis. We defined increased RAP as being ≥13<span class="elsevierStyleHsp" style=""></span>mmHg.</p><p id="par0040" class="elsevierStylePara elsevierViewall">For statistical analysis we compared groups using the Student's <span class="elsevierStyleItalic">t</span>-test for independent groups. We used simple logistic regression and then we fit a multivariable logistic regression model with stepwise selection; the entry criteria were an association in the univariate analysis and a <span class="elsevierStyleItalic">p</span> value lower than 0.10, and the exit criterion was a <span class="elsevierStyleItalic">p</span> value higher than 0.05. We built a classification tree using the classification and regression tree (CRT) algorithm.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> We used SPSS version 22 (IBM, Chicago, IL, USA) and Stata 12 (StataCorp LP, College Station, TX, USA) for statistical analysis.</p><p id="par0045" class="elsevierStylePara elsevierViewall">From 2015 to 2016, 460 patients had inferior MI and 106 patients fulfilled the right ventricular infarction criteria; 45 patients received a central venous catheter. Reliable RAP and complete echocardiographic was obtained for all of the 45 patients: age 68<span class="elsevierStyleHsp" style=""></span>±10 years, male 71%, diabetes mellitus 58%, hypertension 76%, previous coronary artery disease 18%.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Based on univariate logistic regression, most of right heart echocardiographic variables predicted increased RAP. However, after the multivariate logistic regression, only the RAP assessment with the 3•8•15<span class="elsevierStyleHsp" style=""></span>mmHg approach and the right atrial area remained independent predictors of raised RAP.</p><p id="par0055" class="elsevierStylePara elsevierViewall">A classification tree showed that the right atrium area can be used to further identify patients with a higher probability of having raised RAP after the use of the 3•8•15<span class="elsevierStyleHsp" style=""></span>mmHg approach; see <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">In this study, the 3•8•15<span class="elsevierStyleHsp" style=""></span>mmHg approach and right atrium area exhibited the highest correlation with RAP and were predictors of increased RAP (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">We found that the 3•8•15<span class="elsevierStyleHsp" style=""></span>mmHg approach (the one recommended by current international guidelines)<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> showed the highest correlation with invasively obtained RAP. However, we emphasize that because of the importance of preload in patients with RVMI, accurately assessing RAP is critical. It is extremely important because both a very low and a very high preload have deleterious effects on right ventricular performance.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In this study, the 3•8•15<span class="elsevierStyleHsp" style=""></span>mmHg approach was the best predictor of RAP. This is explained because there is strong evidence to support the fact that inferior vena cava size and collapse during inspiration are closely related to RAP.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,8,10</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Interestingly, novel echocardiographic parameters such strain were associated with RAP, but they did not improve reclassification after the 3•8•15<span class="elsevierStyleHsp" style=""></span>mmHg approach.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The classification tree shows that when a patient has a normal estimated RAP (3 or 8<span class="elsevierStyleHsp" style=""></span>mmHg in the 3•8•15<span class="elsevierStyleHsp" style=""></span>mmHg approach), most patients will have a normal RAP. Therefore, preload optimization with a higher intravascular volume might be indicated depending on the hemodynamic state at that precise moment. However, if the estimated RAP is high (15<span class="elsevierStyleHsp" style=""></span>mmHg in the 3•8•15<span class="elsevierStyleHsp" style=""></span>mmHg approach), the clinician would not administer more volume in order to avoid right ventricular dilatation and dysfunction. However, up to 20% of patients do not have increased RAP and might need higher intravascular volume. The assessment of right atrium area will help to confirm increased RAP. If the right atrium is enlarged or close to the maximum area, 100% of patients will have increased RAP and thus, no further intravascular volume would be necessary. However, if the right atrium area is normal, up to 60% of patients will have normal RAP, and preload optimization might be warranted depending on hemodynamic state.</p><p id="par0085" class="elsevierStylePara elsevierViewall">We note that this is an observational study and thus is susceptible to bias. Variability in echocardiographic measures and sample size are other limitations.</p><p id="par0090" class="elsevierStylePara elsevierViewall">In conclusion, the echocardiography can accurately estimate a raised RAP in patients with RVMI and guide fluid management in these high risk patients.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0095" class="elsevierStylePara elsevierViewall">No funding received for this study.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">We declare that we have no conflicts of interest to declare, relevant to the content of this paper.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1250 "Ancho" => 1500 "Tamanyo" => 98864 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Decision tree for raised right atrial pressure. Decision tree shows that after the echo 3•8•15<span class="elsevierStyleHsp" style=""></span>mmHg approach, right atrium area further identify patients with raised right atrial pressure. See text for information. RAP<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>right atrial pressure.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Data are mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>standard deviation. RAP<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>right atrial pressure.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Normal RAP (<13<span class="elsevierStyleHsp" style=""></span>mmHg)(<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>24) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Raised RAP (≥13<span class="elsevierStyleHsp" style=""></span>mmHg)(<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>21) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Univariate OR (95% CI) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Multivariate OR (95% CI) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left ventricular ejection fraction (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">55<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">47<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.004 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.90 (0.82•0.97) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tricuspid annular plane systolic excursion (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.1<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.008 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.84 (0.73•0.96) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tricuspid <span class="elsevierStyleItalic">S</span>′ wave velocity (cm/seg) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.060 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.82 (0.65•1.02) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Global right ventricular longitudinal strain (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">∧17.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">∧14.2<span class="elsevierStyleHsp" style=""></span>±4.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.24 (1.04•1.48) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Free wall right ventricular longitudinal strain (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">∧17.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">∧14.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.005 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.24 (1.05•1.47) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right <span class="elsevierStyleItalic">E</span>/<span class="elsevierStyleItalic">E</span>′ ratio \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.0<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.052 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.19 (0.99•1.44) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right atrial area (cm<span class="elsevierStyleSup">2</span>) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.36 (1.09•1.69) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.32 (1.04•1.67) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inferior vena cava size (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.004 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.28 (1.06•1.55) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Estimated right atrial pressure (3•8•15) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.0<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.002 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.25 (1.7•1.45) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.18 (1.01•1.39) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Estimated right atrial pressure (5•10•15•20) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.004 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.20 (1.05•1.38) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2141516.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Echocardiographic predictors for raised right atrial pressure.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Right ventricular infarction: frequency, size and topography in coronary heart disease: a prospective study comprising 107 consecutive autopsies from a coronary care unit" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "H.R. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 7 | 15 |
| 2024 October | 52 | 36 | 88 |
| 2024 September | 50 | 28 | 78 |
| 2024 August | 50 | 37 | 87 |
| 2024 July | 50 | 38 | 88 |
| 2024 June | 31 | 32 | 63 |
| 2024 May | 30 | 27 | 57 |
| 2024 April | 35 | 44 | 79 |
| 2024 March | 27 | 28 | 55 |
| 2024 February | 29 | 34 | 63 |
| 2024 January | 37 | 40 | 77 |
| 2023 December | 25 | 29 | 54 |
| 2023 November | 43 | 44 | 87 |
| 2023 October | 33 | 29 | 62 |
| 2023 September | 36 | 42 | 78 |
| 2023 August | 31 | 16 | 47 |
| 2023 July | 33 | 28 | 61 |
| 2023 June | 32 | 15 | 47 |
| 2023 May | 55 | 32 | 87 |
| 2023 April | 42 | 16 | 58 |
| 2023 March | 71 | 25 | 96 |
| 2023 February | 59 | 28 | 87 |
| 2023 January | 57 | 20 | 77 |
| 2022 December | 87 | 36 | 123 |
| 2022 November | 53 | 38 | 91 |
| 2022 October | 93 | 44 | 137 |
| 2022 September | 67 | 33 | 100 |
| 2022 August | 63 | 36 | 99 |
| 2022 July | 44 | 45 | 89 |
| 2022 June | 37 | 21 | 58 |
| 2022 May | 46 | 40 | 86 |
| 2022 April | 54 | 30 | 84 |
| 2022 March | 55 | 43 | 98 |
| 2022 February | 53 | 31 | 84 |
| 2022 January | 66 | 26 | 92 |
| 2021 December | 44 | 46 | 90 |
| 2021 November | 53 | 42 | 95 |
| 2021 October | 69 | 60 | 129 |
| 2021 September | 51 | 21 | 72 |
| 2021 August | 52 | 35 | 87 |
| 2021 July | 37 | 30 | 67 |
| 2021 June | 59 | 22 | 81 |
| 2021 May | 59 | 47 | 106 |
| 2021 April | 176 | 93 | 269 |
| 2021 March | 145 | 26 | 171 |
| 2021 February | 134 | 29 | 163 |
| 2021 January | 92 | 32 | 124 |
| 2020 December | 79 | 12 | 91 |
| 2020 November | 46 | 15 | 61 |
| 2020 October | 38 | 27 | 65 |
| 2020 July | 16 | 4 | 20 |
| 2020 June | 31 | 12 | 43 |
| 2020 May | 30 | 10 | 40 |
| 2020 April | 38 | 13 | 51 |
| 2020 March | 16 | 11 | 27 |
| 2020 February | 35 | 24 | 59 |
| 2020 January | 9 | 6 | 15 |
| 2019 November | 1 | 0 | 1 |
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