Normal values for longitudinal function of the right ventricle in healthy women >70 years of age.

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Normal values for longitudinal function of the
right ventricle in healthy women >70 years of age
Alfried Germing1*, Michael Gotzmann1, Ricarda Rauße1, Turgut Brodherr1,
Stephan Holt1, Michael Lindstaedt1, Johannes Dietrich2, Ulrich Ranft3,
Ursula Kra¨mer3, and Andreas Mu¨gge1
1Medizinische Klinik II, Kardiologie und Angiologie, Berufsgenossenschaftliche Universita¨tsklinik Bergmannsheil GmbH, Bu¨rkle-de-la-Camp-Platz 1, D-44789 Bochum, Germany;
2Medizinische Klinik I, Allgemeine Innere Medizin, Endokrinologie und Diabetologie, Berufsgenossenschaftliche Universita¨tsklinik Bergmannsheil GmbH, Bu¨rkle-de-la-Camp-Platz 1,
D-44789 Bochum, Germany; and 3Institut fu¨r Umweltmedizinische Forschung (IUF) an der Heinrich Heine-Universita¨t Du¨sseldorf gGmbH, Auf’m Hennekamp 50, D-40225
Du¨sseldorf, Germany
Received 22 February 2010; accepted after revision 25 March 2010
Aims The application of tricuspid annular plane systolic excursion (TAPSE) as an additional echocardiographic tool to
analyse right ventricular (RV) systolic function has been recently established and two-dimensional-guided M-mode
measurements of systolic long axis function of the RV are simple, repeatable, and highly reproducible. However,
rare data are available on normal values. We aimed to analyse normal values in healthy women .70 years of age.
Methods
and results
In a cross-sectional survey, we investigated a cohort of randomly selected, non-hospitalized women .70 years of age.
History of myocardial infarction, valvular heart disease, and diastolic dysfunction were exclusion criteria. In order to
rule out left ventricular or RV dysfunction, a normal left ventricular ejection fraction and normal values of B-type
natriuretic peptide (BNP) were necessary prior to study inclusion. A detailed echocardiographic examination was
performed. A total of 80 participants were included (mean age 75+ 2.6 years). Mean left ventricular ejection fraction
was 63.8+ 5.7%. Tissue Doppler derived mean E/E′ ratio was 10+2.3. Mean right atrial diameter was
31.3+ 4.7 mm. Mean values for RV outflow tract and RV dimension were 27.3+ 3.6 and 28.8+ 3.7 mm, respect-
ively. Mean TAPSE was 23.7+3.5 mm. Mean value of BNP was normal (42.5+35.7 pg/mL).
Conclusion In women .70 years of age without heart failure, structural heart disease, and neurohormonal activation, normal
TAPSE values are �24 mm.
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Keywords Right ventricular function † TAPSE † Normal values
Introduction
Owing to the complex right ventricular (RV) geometry and poor
acoustic windows, echocardiographic assessment of RV function
remains a challenging problem. Various echocardiographic
markers for assessment of global RV performance have been
described. RV function can be quantified by indices, such as RV
myocardial performance, RV fractional shortening, or by pulsed
wave tissue Doppler imaging.1 New methods as strain and
three-dimensional echocardiography have been recently evalu-
ated.2,3 Normal values for most of the parameters of RV function
have been established in smaller series of individuals.4 –8 The appli-
cation of tricuspid annular plane systolic excursion (TAPSE) as an
additional echocardiographic tool to analyse RV systolic function
has been established and decreased TAPSE is associated with
poor prognosis in patients with pulmonary hypertension and
heart failure.9– 13 Two-dimensional-guided M-mode measurements
of systolic long axis function of the RV free wall are simple, repea-
table, and highly reproducible.5 TAPSE has been shown to corre-
late with ejection fraction derived by radionuclide angiography or
echocardiography.5,11,14 Adult and childhood reference values of
TAPSE measurements are available in the literature.5,15 –17
However, scant data are available on normal values of RV function
in elder people.
We aimed to analyse normal values of TAPSE in healthy women
.70 years of age.
* Corresponding author. Tel: +49 234 302 6050; fax: +49 234 302 6084, Email: alfried.germing@rub.de
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2010. For permissions please email: journals.permissions@oxfordjournals.org.
European Journal of Echocardiography
doi:10.1093/ejechocard/jeq053
European Journal of Echocardiography Advance Access published April 23, 2010
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Methods
The study group was part of the SALIA (Study on the influence of Air
pollution on Lung function, Inflammation, and Aging) cohort which
initially comprised 4874 women. The cohort was previously described
in detail.18 In 2007 and 2008, a supplementary cross-sectional cardio-
vascular study was realized in 311 women. The examination consisted
of medical history, physical examination, measurement of B-type
natriuretic peptide (BNP), and echocardiography. History of myocar-
dial infarction, valvular heart disease, and diastolic dysfunction were
exclusion criteria. A detailed echocardiographic analysis of right
heart geometry and function was performed in 80 individuals who
matched for inclusion and exclusion criteria.
Plasma BNP levels were measured at the same day as echocardio-
graphy study was performed. The blood samples were collected in
EDTA-containing tubes. After prompt centrifugation, BNP was
measured using a chemoluminescent immunoassay kit (Biosite
Triage, San Diego, CA, USA).
Transthoracic echocardiography was performed according to the
recommendations of the American and European Societies of Echocar-
diography19 using a digital ultrasound scanner (Vivid 7, General Elec-
trics, Horton, Norway). Data from three cardiac cycles were
analysed. An experienced cardiologist performed the ultrasound
examination. Right atrial and ventricular dimensions were measured
in apical four-chamber and parasternal short-axis views (Figures 1
and 2). TAPSE was measured by M-mode recordings from the apical
four-chamber view, with the cursor placed at the free wall of the tri-
cuspid annulus (Figure 3). Left ventricular myocardial mass was calcu-
lated according to the Devereux formula.20 Peak velocities of early
(E) and late (A) diastolic filling were derived from the transmitral
Doppler profile. Doppler tissue imaging was taken from septal and
lateral mitral annulus and revealed averaged early (E′) and late (A′) dias-
tolic peak velocities. According to recent recommendations,21,22 dias-
tolic dysfunction was considered as an E/E′ ratio .15, or E/E′ 8–15
plus BNP.200 pg/mL, left atrial volume index.40 mL/m2, and left ven-
tricular myocardial index .122 mg/m2.
Numerical values were expressed as mean+ SD. Continuous
variables were compared between groups using an unpaired t-test
(for normally distributed variables) or Mann–Whitney U-test (for
non-normally distributed variables). x2 analysis was used to compare
categorical variables. All reported probability values were two-tailed,
and P, 0.05 was considered statistically significant. Analyses were
performed with the SPSS statistical software package (version 17.0).
Results
Mean age of all 80 participants was 75+ 2.6 years. Cardiovascular
risk factors were common in our study cohort: hypertension
(n ¼ 47, 58.8%), hypercholesterolaemia (n ¼ 39, 48.8%), and
diabetes (n ¼ 5, 6.3%). There was no history of myocardial
infarction or valvular heart disease.
Mean left ventricular ejection fraction was 63.8+5.7%. Left atrial
volume and left ventricular hypertrophy were not increased in most
participants (mean left atrial volume index 19.5+6 mL/m2 and
mean left ventricular mass index 115.9+27.1 mg/m2). Participants
had a normal left ventricular diastolic function, mean E/E′ ratio 10+
2.3, and mean E/A ratio 0.7+ 0.1. Right atrial and RV dimensions
Figure 1 Measurements of right ventricular diameters. RVD1,
right basal ventricular diameter; RVD2, right mid-ventricular
diameter; RVD3, right ventricular diameter base to apex.
Figure 2 Measurements of right ventricular diameters. RVOT1,
right ventricular outflow tract diameter measured in parasternal
short axis; RVOT2, right ventricular outflow tract diameter
measured in parasternal short axis at the level of pulmonary
artery valve.
Figure 3 Measurement of tricuspid annular plane systolic
excursion (TAPSE).
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were normal. Pulmonary valve acceleration time was not decreased.
Detailed echocardiographic data are listed in Table 1.
In study participants, BNP values were normal (42.5+
35.7 pg/mL) reflecting lack of neurohormonal activation due to
heart failure in study participants.
Discussion
Scant data are available on normal values of RV geometry in elder
healthy individuals and effects of age and gender on TAPSE normal
values have not been completely analysed. Changes in values of
TAPSE with increasing age have been reported. A continuous
increase in levels of TAPSE in healthy individuals from birth to ado-
lescence was demonstrated.16 In this study, young adults had mean
levels of TAPSE of 24.7 mm. Whether there is a further increase in
adults is not known so far. In a study with 36 individuals at a mean
age of 61 years, normal TAPSE were measured with 25.5 mm.6
There is no definite cut-off value for TAPSE. The lower the value
the worse seems to be the cardiovascular outcome.17 Cut-off
values for TAPSE between 15 and 20 mm as markers of depressed
RV function in association with reduced prognosis have been
reported in several patient subgroups.11–13 To our knowledge,
limited data on normal values of TAPSE in elderly healthy
women are presented in the literature.
According to left ventricular ejection fraction, left atrial volume
index, left ventricular mass index, and diastolic function partici-
pants in our study represent a population of healthy individuals
without structural heart disease. In addition, participants with
neurohormonal activation were excluded as reflected by normal
values for BNP. Our morphological findings of right atrial and RV
dimensions are in line with normal ranges recommended by the
American and European Societies of Echocardiography.19
However, guidelines do not provide normal values for different
ages due to missing data. In our study, the mean value of TAPSE
was 23.7 mm. This value corresponds to earlier reports in
adolescents and younger adults.6,16,17 A recent publication on RV
longitudinal function in 22 healthy individuals .70 years of age
found a mean TAPSE value of 18 mm and described a continuous
decrease in TAPSE values during adolescence.23 This is in contrast
to other findings that describe an increase in TAPSE measurements
during childhood and youth.16 According to our data on 80 healthy
women, TAPSE does not further raise or decrease with older age.
In summary, in healthy elderly women .70 years of age, normal
TAPSE values are �24 mm.
Conflict of interest: none declared.
Funding
This study has been supported by Deutsche Gesetzliche Unfallversi-
cherung (DGUV) and Berufsgenossenschaftliche Forschungsanstalt
fu¨r Arbeitsmedizin (BGFA).
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Table 1 Echocardiographic measurements
n Mean
values+ standard
deviation
95% confidence
interval
Age (years) 80 75+2.6 74.31–75.48
Body mass index
(kg/m2)
80 26.7+4.8 25.63–27.78
LAVI (mL/m2) 80 19.5+6.0 18.16–20.82
LVMI (g/m2) 80 115.9+27.1 109.9–121.95
E/A ratio 80 0.7+0.1 0.65–0.72
E/E′ ratio 80 10.0+2.3 9.46–10.48
RVD1 (mm) 69 28.8+3.7 27.92–29.71
RVD2 (mm) 69 27.3+5.7 25.93–28.68
RVD3 (mm) 69 68.8+7.0 67.15–70.51
RVOT1 (mm) 54 27.3+3.6 26.33–28.3
RVOT2 (mm) 52 21.4+3.4 20.45–22.38
RA (mm) 80 31.3+4.7 30.28–32.37
TAPSE (mm) 80 23.7+3.5 22.93–24.47
PVAcc (ms) 60 98.2+25.0 91.73–104.64
LVEF (%) 80 63.8+5.7 62.55–65.07
BNP (pg/mL) 80 42.5+35.7 34.52–50.41
LAVI, left atrial volume index; LVMI, left ventricular mass index; TAPSE, tricuspid
annular plane systolic excursion; RVD1, right basal ventricular diameter; RVD2,
right mid-ventricular diameter; RVD3, right ventricular diameter base to apex;
RVOT1, right ventricular outflow tract diameter measured in parasternal short
axis; RVOT2, right ventricular outflow tract diameter measured in parasternal
short axis at the level of pulmonary artery valve; PVAcc, pulmonary valve
acceleration time; LVEF, left ventricular ejection fraction; BNP, B-type natriuretic
peptide.
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