ABC | Volume 111, Nº3, September 2018

Original Article Kanar et al RV function after pulmonary rehabilitation program Arq Bras Cardiol. 2018; 111(3):375-381 score in COPD patients. 23 Our data are in agreement with these 2DE studies of RV function in COPD patients undergoing PR program. Study limitations Several limitations of our study merit consideration. The main limitation was the small size of the study population. Moreover, RV strain was assessed only in the 4-chamber view of the six segments of the RV; however, the RV longitudinal function measured in the inlet chamber accounts for about 80% of RV function. 24 If we had followed up the study population, we could have investigated the impact of PR program on RV function, as well as mortality and morbidity. Finally, we did not compare our results with those of CMR. However, previous studies of LV speckle tracking–derived strain have already validated CMR use. Furthermore, althoughmagnetic resonance imaging is considered the gold standard for determining RV volume and function, it is currently limited by cost and availability and is deemed unsuitable after the implantation of a cardiac pacemaker. 25 Conclusion Our study demonstrated that RV dysfunction improved after PR program in patients with COPD. STE might be as effective as the more established measurements of global RV function (i.e., TAPSE, RVEF, and MPI). RV global and regional strain assessment is a simple and effective tool in the routine clinical assessment of patients with COPD in order to explore the relationship between RV function and exercise tolerance. Author contributions Conception and design of the research, acquisition of data, obtaining financing, writing of the manuscript: Kanar BG, Ozmen I, Yildirim EO, Ozturk M, Sunbul M; Analysis and interpretation of the data and statistical analysis: Kanar BG, Sunbul M; Critical revision of the manuscript for intellectual content: Sunbul M. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This study is not associatedwith any thesis or dissertationwork. Ethics approval and consent to participate This study was approved by the Ethics Committee of the Marmara University under the protocol number 70737436- 050.06.04. All the procedures in this study were in accordance with the 1975 Helsinki Declaration, updated in 2013. Informed consent was obtained from all participants included in the study. 1. Chen X, Tang S, Liu K, Li Q, Kong H, Zeng X, et al. Therapy in stable chronic obstructive pulmonary disease patients with pulmonary hypertension: a systematic review and meta-analysis. J Thorac Dis. 2015;7(3):309-19. 2. Rudski LG, LaiWW, Afilalo J, Hua L, HandschumacherMD, Chandrasekaran K, et al. Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from the American Society of Echocardiography: Endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010;23(7):685-713. 3. Rice JL, Stream AR, Fox DL, Geraci MW, Vandivier RW, Dorosz JL, et al. Speckle tracking echocardiography to evaluate for pulmonary hypertension in chronic obstructive pulmonary disease. COPD. 2016, 13(5):595-600. 4. Vitarelli A, Mangieri E, Terzano C, Gaudio C, Salsano F, Rosato E, et al. Three- dimensionalechocardiographyand2D-3Dspeckle-trackingimaginginchronic pulmonaryhypertension:diagnosticaccuracyindetectinghemodynamicsigns of right ventricular (RV) failure. J AmHeart Assoc. 2015;4(3):e001584. 5. Troosters T, Casaburi R, Gosselink R, Decramer M. Pulmonary rehabilitation in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2005;172(1):19-38. 6. Cuttica MJ, Kalhan R, Shlobin OA, Ahmad S, Gladwin M, Machado RF, et al. Categorization and impact of pulmonary hypertension in patients with advanced COPD. Respir Med. 2010;104(12):1877-82. 7. Han MK, McLaughlin VV, Criner GJ, Martinez FJ. Pulmonary diseases and the heart. Circulation. 2007;116(25):2992-3005. 8. Caminiti G, Cardaci V, Conti V, D’Antoni V, Murugesan J, Battaglia D, et al. Right ventricular systolic dysfunction is related to exercise intolerance in patients with chronic obstructive pulmonary disease. J CardiopulmRehabil Prev. 2015;35(1):70-4. 9. CutticaMJ, Shah SJ, Rosenberg SR, Orr R, Beussin L, Dematte JE, et al. Right heart structural changes are independently associatedwith exercise capacity in non-severe COPD. PLoS One. 2011, 6(12):e29069. 10. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002;166(1):111-7. 11. Caminiti G, Volterrani M, Murugesan J, Baratta P, D’Antoni V, Sposato B, et al. Tricuspid annular plane systolic excursion is related to performance at six minute walking test in patients with heart failure undergoing exercise training. Int j Cardiol. 2013;169(1):91-2. 12. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Erhande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2015;16(3):233-70. 13. Dandel M, Lehmkuhl H, Knosalla C, Suramelashvii N, Hetzer R. Strain and strain rate imaging by echocardiography – basic concepts and clinical applicability. Curr Cardiol Rev. 2009;5(2):133-48. 14. Pirat B, McCullochML, Zoghbi WA. Evaluation of global and regional right ventricular systolic function in patients with pulmonary hypertension using a novel speckle tracking method. Am J Cardiol. 2006;98(5):699-704. References 380