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Muminov K. P.,
Republican Specialized Scientific Practical Center of Therapy and Medical Rehabilitation E-mail: mbshakur@mail.ru
ALTERATIONS IN THE RIGHT CHAMBERS OF HEART IN COPD
Abstract: The research demonstrated that in case of COPD progression we could observe step-by-step remodeling of the right chambers of heart such as dilatation of the cavity of the right ventricle (RV) at the early stages with further development of hypertrophy of its myocardium and diastolic dysfunction. Thickening of the RV wall above 5.0 mm, increase of the pressure in pulmonary artery more than 20 mm of mercury column, the size of RV more than 70 mm, and its diastolic dysfunction can be considered to be unfavorable echometric parameters.
Keywords: chronic obstructive pulmonary disease, echocardiography, right chambers of heart.
At the moment COPD is a pathology possessing systemic position in B and M modes. We determined the thickness effects at certain stages. Important extra pulmonary effects are cardiovascular pathologies [1; 3; 4; 10; 11]. According to researches, risk of death due to cardiovascular pathology in patients with COPD is 2-3 folds increased. Hypoxia in case of COPD promotes inadequate perfusion of organs and tissues. Activation of neuro humoral compensatory mechanisms for the satisfaction of the increased metabolic demands in cases of COPD initially has adaptive character. However, later almost all compensatory mechanisms transform to pathogenic factors promoting further dysfunction of heart and formation of significant alterations in hem dynamics [6; 7; 13].
At the same time the problem of the impact of cardiovascular disorders on the prognosis and remote outcomes in COPD cases requires clarification. Traditionally, secondary pulmonary hypertension and involvement of the right chambers of heart into the pathologic process, i. e. development of cor pulmonale and its decompensation is considered to be prognostically unfavorable symptom [5, 9, 12]. But the parameters of Doppler echocardiography in the checking of right chambers of heart in the patients with COPD, the most actual for the evolution of the disease are still not clear.
The objective of this research was the study of echometric parameters of the right chambers of heart at the different COPD stages.
Material and research methods. We observed 150 patients with COPD I, II, and III stages. The average age of the patients was 47 ± 1.5 years old. Dependently on the severity of the progression the patients were divided to three groups. The first group involved 54 patients with light degree of chronic obstructive pulmonary diseases, the second group 59 patients with mild severe progression of COPD, and the third group consisted of 37 patients with severe COPD. The control group included 20 healthy people of the corresponding age. Ecocardiographic tests were performed in parastenal
of the wall of right ventricle (RVWT), linear size of the RV and RA, thickness of inter ventricular septum (IVS), terminal systolic and diastolic sizes of RV. We calculated terminal diastolic volume (TDV) of the right ventricle using L. E. Tei-ccholz's formula [8]. RV ejaculation fraction was calculated according to the value of the maximal linear systolic velocity of the lateral part of fibrous ring of tricuspid valve Sm in impulse-wave Doppler (ID) mode. Sm parameters below 11.5 sm/sec correspond to the RV ejaculation fraction less than 45% and indicate RV systolic dysfunction [2]. RV diastolic function (RVDF) was assessed using impulse-wave Doppler (ID). We measured E peak (cm/s) and A peak (cm/s) above the cuspids of tricuspid valve, the time of E peak inhibition (E peak DT, mc), E/A ratio. Average pressure in pulmonary artery (mAPPA, mm of m.c) was calculated according to the duration of the intervals of systolic flow in pulmonary artery using Kitabatake formula (1988). Statistical processing of the received data was performed with the help of variation statistical methods using applied STATICTICA 6,0 software. Statistical significance of the difference of mean values was determined by means of Student's criterion with significance level р < 0.05.
Results and discussion. Results of the research demonstrated that the size of RA and RV long axis were increased to 14% and 11% in the third group of the patients compared to the first one (p < 0.05). perpendicular axis of the RV was almost unchanged in the patients with light and mild COPD and increase nearly to 11% in the patients with severe progression.
More significant alterations involved the parameters characterizing RV hypertrophy. So, RV free wall thickness and IVS increased to 8% and 18% compared to the desirable values in the II group and 20% and 29% in the III group, respectively. RV ejaculation fraction was in normal limits, and that indicated average SM values above 11.5 cm/sec.
ALTERATIONS IN THE RIGHT CHAMBERS OF HEART IN COPD
Table 1 - Basic parameters and hem dynamic values of the right chambers of heart in patients with COPD
Parameter COPD I stage (n=54) COPD II stage (n=59) COPD III stage (n=37) Control (n=37)
APPA, mm. m.c 16. 30 ± 0.87 25.0 ± 1.22* 32.4 ± 1.31* 14.4 ± 0.70
RA, mm 34.2 ± 5.0 36.4 ± 3.4 39.7 ± 7.0* 32.4 ± 3.5
LRV, mm 66.0 ± 3.3 69.4 ± 5.2* 74.3 ± 6.0* 65.2 ± 4.2
SRA, mm 30.1 ± 3.4 30.4 ± 3.8 34.8 ± 3.4* 29.9 ± 2.2
RVWT, mm 5.0 ± 0.63 5.2 ± 0.71 6.0 ± 0.72* 4.8 ± 0.56
IVS 0.92 ± 2.0 1.11 ± 2.3* 1.28 ± 3.1* 0.9 ± 1.7
KCO RV 82.7 ± 3.0 53.1 ± 2.32* 44.6 ± 2.61* 84.2 ± 3.9
TDV RV 119.5 ± 3.56 125.3 ± 3.44* 132.4 ± 3.06* 118.8 ± 3.63
Sm sm/sec 15.0 ± 2.2 14.0 ± 2.1 13.8 ± 2.5 15.2 ± 1.1
E RV cm/s 50.2 ± 3.5 47.5 ± 9.1 55.6 ± 8.8* 49.1 ± 4.1
A RV, cm/s 40.7 ± 3.2 42.1 ± 7.4* 34.9 ± 5.9* 38.0 ± 4.06
E\A ratio, units. 1.23 ± 0.104 1.11 ± 0.160* 1.59 ± 0.173* 1.29 ± 0.075
Note: * - p < 0.05 compared to the control
Differences in the values of diastolic peaks on impulse-wave Doppler from the lateral side between the groups testify development of diastolic dysfunction of the RV with COPD progression. Thus, in the first group of the patients E and a peaks and their ratio were compatible to the control values. In cases of COPD mild progression there was notable inhibition of E peak velocity and acceleration of A peak values (47.5 cm/sec and 42.1 cm/sec) and decrease of RV E/A ratio to 16.2 compared to the control indicating prevailing of the patients with diastolic dysfunction of the RV relaxation type in that group. in case of severe COPD we observed a significant E peak rise and A peak decrease (55.6 cm/sec and 34.9 cm/sec) and E/A increase to 18.8% in relation to the standard values, respectively. Thus, comparative analysis of echogeo-metric parameters of heart showed, that COPD progression was linked with more expressed diastolic dysfunction of the right ventricle, while systolic dysfunction had no significant differences in the studied groups of patients.
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Analysis of the results also showed, that early hem dynamic disorders in case of COPD are pulmonary hypertension, indicated by the increase of average pressure in pulmonary artery. So, starting from the II stage of COPD APPA increases to 34.8% in comparison with the I stage of the pathology. In case of severe stage APPA increases to 47% compared to the I stage and to 22.3% compared to the II stage.
Thus, in cases of COPD progression we observed step-by-step remodeling of the right chambers of heart such as dilatation of the cavity of the right ventricle at the early stages, with further development of hypertrophy of its myocardium and diastolic dysfunction. Significant thickening of the right ventricular wall (> 5.0 mm), increase ofAPPA (> 20 mm of m.c.), size of the right ventricle > 70 mm, and diastolic dysfunction of the right ventricle can be considered to be unfavorable echometric parameters of COPD progression.
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