ABC | Volume 111, Nº3, September 2018

Original Article Right Ventricular Functional Improvement after Pulmonary Rehabilitation Program in Patients with COPD Determined by Speckle Tracking Echocardiography Batur Gonenc Kanar, 1 Ipek Ozmen, 2 Elif Ozari Yildirim, 2 Murat Ozturk, 2 Murat Sunbul 1 Marmara University, 1 Istanbul – Turquia Sureyyapasa Chest Medicine Research and Training Hospital, 2 Istanbul - Turquia Mailing Address: Murat Sunbul • Marmara Universitesi Eðitim ve Araþtýrma Hastanesi, Pendik. 34899, Istanbul – Turkey E-mail: drmuratsunbul@gmail.com , dresraaydin@yahoo.com Manuscript received November 11, 2017, revised manuscript April 11, 2018, accepted April 11, 2018 DOI: 10.5935/abc.20180123 Abstract Background: Although right ventricular (RV) dysfunction in pulmonary diseases has been associated with increased morbidity, tools for RV dysfunction identification are not well defined. Objective: The aim of this study was to evaluate the magnitude of RV dysfunction by means of speckle tracking echocardiography (STE) in patients with chronic obstructive pulmonary disease (COPD) and to investigate whether STE could be used as an index of RV improvement after a pulmonary rehabilitation (PR) program. Methods: Forty-six patients with COPD undergoing PR program and 32 age-sex matched healthy subjects were enrolled. RV function was evaluated at admission and after PR program by conventional two-dimensional echocardiography (2DE) and STE. In addition, exercise tolerance of subjects was evaluated using the six-minute walk test (6MWT). Results: COPD patients had worse RV function according to STE and 2DE as well. STE was more sensitive than conventional 2DE in determining RV improvement after PR program – RV global longitudinal strain (LS): 20.4 ± 2.4% vs. 21.9 ± 2.9% p < 0.001 and RV free wall LS: 18.1 ± 3.4% vs. 22.9 ± 3.7%, p < 0.001). RV free wall LS was directly related to distance walked at baseline 6MWT (r = 0.58, p < 0.001) and to the change in the 6MWT distance (6MWTD ∆) (r = 0.41, p = 0.04). Conclusions: We conclude that STE might be as effective as 2DE for evaluation of global and regional RV functions. STE may become an important tool for assessment and follow-up of COPD patients undergoing PR program to determine the relationship between RV function and exercise tolerance. (Arq Bras Cardiol. 2018; 111(3):375-381) Keywords: Ventricular Dysfunction, Right / rehabilitation; Pulmonary Disease, Chronic Obstructive / rehabilitation; Echocardiography / methods; Strain, Speckle Tracking. Introduction The right ventricle plays an important role in the morbidity and mortality of patients with signs and symptoms of cardiopulmonary disease. 1 Although transthoracic two‑dimensional echocardiography (2DE) provides important information about the right ventricular (RV) anatomy and function, the RV complex geometry and crescent-shaped structure wrapped around the left ventricle (LV) make accurate assessment difficult. 2 Moreover, conventional 2DE measures, including velocity and displacement-based analyses, can be affected by translational motion of the heart and respiratory variation. The new echocardiographic method of speckle tracking echocardiography (STE) assesses myocardial deformation on grayscale (B-mode) images and can be used to evaluate both global and regional myocardial strain without being limited by the Doppler beam angle. 3,4 Patients with advanced chronic respiratory disease regularly experience distressing symptoms despite optimal pharmacological treatment. Pulmonary rehabilitation (PR) complements conventional medical therapy, and has been clearly demonstrated to reduce dyspnea, increase exercise performance, and improve RV functions. 5 Today, is well known that chronic obstructive pulmonary disease (COPD) patients experience substantial mortality and morbidity from RV function impairment. 6,7 A number of studies have used conventional 2DE to evaluate the RV in patients with cardiopulmonary diseases, but there is relatively limited information concerning the assessment of RV performance by means of speckle tracking‑derived strain. 8,9 Therefore, we sought to analyze the use of STE in the assessment of global and regional RV function and impact of PR program on it. Methods Study design and participants Subjects were recruited from Sureyyapasa Chest Medicine and Thoracic Surgery Research and Training Hospital, Istanbul, Turkey. Fifty-seven patients with moderate-to-very severe COPD (Global Initiative for Chronic Obstructive Lung Disease, GOLD classes 2-4) were enrolled in the study. Six patients 375