ABC | Volume 111, Nº3, September 2018

Original Article Nemes et al RA function in CA by 3DSTE Arq Bras Cardiol. 2018; 111(3):384-391 Methods Patient population A total of 16 patients (mean age: 64.5±10.1 years, 11males) with biopsy-proven AL-CA were examined. Their results were compared to that of 15 age- and gender‑matched healthy controls (mean age: 58.9 ± 6.9 years, 8 males). Baseline demographic characteristics of patients and controls are presented in Table 1. CA was defined in accordance with the current consensus criteria and practices. 6,13 None of the patients with AL-CA was on anticoagulant treatment, but 2 of them received acetylsalicylic acid. Five patients received β -blockers, 7 patients were on angiotensine-converting enzyme inhibitors, while 11 patients took diuretics. The source of the biopsy was the bone marrow in 3 patients, the subcutis in 3 patients, the kidney in 5 patients, the heart in 3 patients, the gastrointestinal tract in 4 patients and the salivary gland in 1 patient. In 3 cases, samples were collected from more than 1 organ. In 11 out of 16 AL-CA patients, the diagnosis of multiple myeloma was confirmed. In 1 case, no treatment information was available. In all other cases, different types of chemotherapy or immunomodulatory treatment were administered. None of the healthy subjects in the control group had cardiovascular risk factors or any known diseases or received any medications. For cardiac evaluation, complete two-dimensional (2D) Doppler, tissue Doppler echocardiography, 3DSTE and N-terminal pro-B natriuretic peptide (NT-proBNP) level assessment were performed in all patients and controls. The present study was designed as a part of the M otion A nalysis of the heart and G reat vessels b Y three‑dimension A l speckle-t R acking echocardiography in Path ological cases ( MAGYAR-Path ) Study . It has been organized to examine alterations in 3DSTE-derived parameters in different disorders compared to matched healthy controls among others ( magyar means “Hungarian” in Hungarian language). The study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki (and updated versions) and was approved in advance by the local institutional ethical committee. Informed consent was obtained from each subject. Two-dimensional Doppler echocardiography 2D grayscale harmonic images were performed in the lateral decubitus position with using a commercially available ultrasound system (Artida TM , Toshiba Medical Systems, Tokyo, Japan) equipped with a broadband 1-5 MHz PST-30SBP phased-array transducer. During 2DDoppler echocardiography, chamber dimensions, volumes and ejection fraction were measured in accordance with the recommendations. 14,15 Degree of mitral and tricuspid regurgitations was visually quantified by colour Doppler echocardiography. Three-dimensional speckle-tracking echocardiography 3D echocardiographic datasets were acquired with the same Toshiba Artida ultrasound system with a 1-4 MHz PST-25SX matrix phased-array transducer. 16 After gain setting optimalisation, wide-angled pictures were recorded, in which 6 wedge-shaped subvolumes were acquired over 6 consecutive cardiac cycles during a single breath-hold. We used raw data format for further analysis. 3DWall Motion Tracking software version 2.7 (Toshiba Medical Systems, Tokyo, Japan) was used for RA quantifications. Each 3D dataset was displayed in a 5-plane view: an apical 4-chamber (AP4CH) view, an apical 2-chamber (AP2CH) view and 3 short-axis views at different RA levels from the base to the apex. The examiner then set markers in the AP4CH and AP2CH views; in each plane, one marker was placed on the apex (superior region) and two other markers were placed at the edges of the tricuspid valve ring. As the next step, the software automatically detected the endocardium, and 3Dwall motion- tracking analysis was performed through the entire cardiac cycle. During evaluations, RA appendage and the caval veins were excluded from the RA cavity (Figure 1). From the acquired 3Dechocardiographic datasets, time-global RA volume curves were created, allowing the measurement of maximum (V max ) andminimum (V min ) RA volumes and RA volume before atrial contraction (V preA ). V max was measured just before tricuspid valve opening at end‑systole, while V min and V preA were measured just before tricuspid valve closure at end-diastole and at the time of P wave on ECG in early diastole, respectively. The systolic reservoir and diastolic passive (conduit) and active emptying (booster pump) phases of RA function were measured from the RA volumetric datasets: 17 Right atrial stroke volumes – Total Atrial Stroke Volume (TASV): V max −V min (reservoir function) – Passive Atrial Stroke Volume (PASV): V max –V preA (conduit function) – Active Atrial Stroke Volume (AASV): V preA −V min (booster pump/active contraction function) Right atrial emptying fractions – Total Atrial Emptying Fraction: TASV/V max ×100 (reservoir function) – Passive Atrial Emptying Fraction: PASV/V max ×100 (conduit function) – Active Atrial Emptying Fraction: AASV/V preA ×100 (booster pump/active contraction function) Time-strain curves could also be created at the same time from the same 3D echocardiographic datasets. Unidirectional radial, longitudinal, circumferential and complex area and 3D strains could be also measured. Global strains were calculated by the software, which considered the whole RA, while mean segmental strains were obtained as the average of strains of 16 segments. A typical strain curve usually represents two peaks: the first peak indicates the reservoir phase, while the second peak shows characteristics of the booster pump phase of the RA function. 17 Statistical analysis All continuous variables were presented as mean ± standard deviation. Categorical data were presented as frequencies and percentages (%). Comparisons among groups were performed by unpaired Student t test and χ 2 test, when appropriate. Shapiro-Wilks test was used to test normal distribution in every dataset. Pearson correlation coefficient was calculated when needed. A 2-tailed p value < 0.05 was considered to indicate statistical significance. Reproducibility 385