FIGURES
Figure 1. Apical four-chamber view showing the right atrial
global longitudinal strain (RA-GS) with the measurement of reservoir
(A), conduit (B) and contractile (C) strain phases.
Figure 2 . A) Specimen showing the internal appearance of the
dilated right atrium, the pectinate portion that continues with the
appendage is observed to the right of the observer and the anterior
leaflet of the tricuspid valve is observed below. B) Transthoracic 3D
echocardiogram in four chamber view with mild enlargement of right
atrium. C) Mild pulmonary hypertension SPAP of 44 mmHg. D) Histological
study (stained with Masson, 10X) of the atrial myocardium of a patient,
with mild pulmonary hypertension. The muscle fascicles were mostly cut
transversely or obliquely. Two muscle fascicles are replaced by fibrous
connective tissue rich in collagen fibers that stain blue, and contrast
with the red in which the myocardium is stained. One fascicle is
partially replaced by collagen and another almost entirely. The degree
of fibrosis in the observed fields was calculated at 25%, since in this
image it could reach a little more than a quarter. E) Echocardiography
with velocity vector imaging of a patient with low probability of
pulmonary hypertension, who had a normal global longitudinal strain of
the right atrium (43.5%). Abbreviations : RA-right atrium,
RV-right ventricle.
Figure 3. A) Specimen of the heart of a patient with sPAP of 90
mmHg. Heart cut longitudinally from the atria to the ventricles (entry
routes through the postero-inferior aspect) that allows to appreciate
the dilation of the right cavities. B) Two-dimensional echocardiogram
with Doppler in the apical 4-chamber view, with severe tricuspid
regurgitation, by means of which an average gradient of 77 mmHg was
calculated. C) In the subcostal plane, dilatation of the inferior vena
cava (29.1 mm) and collapse of <50% were detected,
calculating a right atrial pressure was of 15 mmHg. D) Histological
study of the right ventricular myocardium, most of the muscle fibers are
in longitudinal section in red and the fibrous tissue rich in collagen
fibers is observed blue, it extensively replaces the muscle fascicles,
and, in this image, it reaches 75 % or three quarters. The muscle
fibers embedded in the fibrous connective tissue appear elongated and
thinned. Masson 10x.
E) The global longitudinal strain of the right ventricle, using velocity
vector imaging was -14%, in a patient with high probability of PH
(sPAP=92 mmHg). Abbreviations: RA-right atrium, RV-right ventricle,
LA-left atrium, LV-left ventricle.
Figure 4. Correlation of the absolute values of RV-FWS (A) and
RA-GS (B) with logarithmical sPAP. Abbreviations : sPAP: systolic
pulmonary artery pressure; RV-FWS: Right ventricular free wall Strain;
RA-GS: Right atrial global longitudinal strain.
Figure 5. Differences amongst right atrial reservoir (A),
conduit (B) and contractile (C) phases in pulmonary hypertension
categories. Abbreviations : sPAP: systolic pulmonary artery
pressure; RV-FWS: Right ventricular free wall strain; RA-GS: Right
atrial global longitudinal strain.
Figure 6. ROC with the area under the curve of
echocardiographic parameters to identify the discrimination capacity for
low (A) intermediate/high (B) and high (C) probability of pulmonary
hypertension. Abbreviations : ROC= Receiver operator
characteristic; Frac-Short= Fractional shortening; TAPSE= Tricuspid
annular plane systolic excursion; TEI= TEI index; RV-FWS: Right
ventricular free wall strain; RA-GS: Right atrial global longitudinal
strain.
Supplementary Figure 1. Algorithm for patients’ selection
Supplementary Figure 2. Correlation of RV-Fibrosis (A) and
RA-Fibrosis (B) with sPAP. Abbreviations : sPAP: Systolic
pulmonary artery pressure; RV-FWS: Right ventricular free wall strain;
RA-GS: Right atrial global longitudinal strain.
Supplementary Figure 3. Correlation of sPAP using
echocardiographic and right hearth catheterization (A) and Bland-Altman
plot with observed differences between both methods of measured sPAP
(B). Abbreviations : sPAP: systolic pulmonary artery pressure.
Table 1: Echocardiography assessment of population of study.Abbreviations : BSA: Body surface area; RVd: Right Ventricle
Diameter; FAC: Fractional area change; TAPSE: Tricuspid annular plane
systolic excursion; RVS: right ventricular Synchrony.