Usefulness of the Right Ventricular Systolic to Diastolic Duration Ratio to Predict Functional Capacity and Survival in Children With Pulmonary Arterial Hypertension

      The objective of this study was to investigate the systolic to diastolic duration ratio (S:D ratio) in children with pulmonary arterial hypertension (PAH) and its association with right ventricular (RV) performance, hemodynamics, 6-minute walk test, clinical outcomes, and survival. We reviewed 503 serial echocardiograms in 47 children with PAH (mean pulmonary artery pressure ≥25 mm Hg) and compared the S:D ratio, assessed from Doppler flow of tricuspid valve regurgitation, to that in 47 age-matched controls. We reviewed echocardiograms, catheterization data, 6-minute walk tests, clinical data, lung transplantation, and death and used univariate linear regression models with a maximum likelihood algorithm for parameter estimation to investigate associations between S:D ratio and RV function, hemodynamics, functional capacity, and clinical outcomes. The S:D ratio was significantly higher in patients than in controls (1.38 ± 0.61 vs 0.72 ± 0.16, p <0.001). A higher S:D ratio was associated with worse echocardiographic RV fractional area of change, worse catheterization hemodynamics, shorter 6-minute walk distance, and worse clinical outcomes independent of pulmonary resistance or pressures. An increase of 0.1 in the S:D ratio was associated with a 13% increase in yearly risk for lung transplantation or death (hazard ratio 1.13, p <0.001). An S:D ratio 1.00 to 1.40 was associated with a moderate risk and an S:D ratio >1.40 was associated with a high risk of a negative outcome. In conclusion, in children with PAH, an increased S:D ratio is temporally associated with worse RV function, hemodynamics, exercise capability, clinical status, and survival.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Humbert M.
        • Sitbon O.
        • Simonneau G.
        Treatment of pulmonary arterial hypertension.
        N Engl J Med. 2004; 351: 1425-1436
        • Huez S.
        • Vachiery J.L.
        • Unger P.
        • Brimioulle S.
        • Naeije R.
        Tissue Doppler imaging evaluation of cardiac adaptation to severe pulmonary hypertension.
        Am J Cardiol. 2007; 100: 1473-1478
        • Benza R.
        • Biederman R.
        • Murali S.
        • Gupta H.
        Role of cardiac magnetic resonance imaging in the management of patients with pulmonary arterial hypertension.
        J Am Coll Cardiol. 2008; 52: 1683-1692
        • Friedberg M.K.
        • Rosenthal D.N.
        New developments in echocardiographic methods to assess right ventricular function in congenital heart disease.
        Curr Opin Cardiol. 2005; 20: 84-88
        • Friedberg M.K.
        • Silverman N.H.
        The systolic to diastolic duration ratio in children with heart failure secondary to restrictive cardiomyopathy.
        J Am Soc Echocardiogr. 2006; 19: 1326-1331
        • Friedberg M.K.
        • Silverman N.H.
        Cardiac ventricular diastolic and systolic duration in children with heart failure secondary to idiopathic dilated cardiomyopathy.
        Am J Cardiol. 2006; 97: 101-105
        • Friedberg M.K.
        • Silverman N.H.
        The systolic to diastolic duration ratio in children with hypoplastic left heart syndrome: a novel Doppler index of right ventricular function.
        J Am Soc Echocardiogr. 2007; 20: 749-755
        • Rosenzweig E.B.
        • Widlitz A.C.
        • Barst R.J.
        Pulmonary arterial hypertension in children.
        Pediatr Pulmonol. 2004; 38: 2-22
        • Yock P.G.
        • Popp R.L.
        Noninvasive estimation of right ventricular systolic pressure by Doppler ultrasound in patients with tricuspid regurgitation.
        Circulation. 1984; 70: 657-662
        • Bland J.M.
        • Altman D.G.
        Statistical methods for assessing agreement between two methods of clinical measurement.
        Lancet. 1986; 1: 307-310
        • Miyamoto S.
        • Nagaya N.
        • Satoh T.
        • Kyotani S.
        • Sakamaki F.
        • Fujita M.
        • Nakanishi N.
        • Miyatake K.
        Clinical correlates and prognostic significance of six-minute walk test in patients with primary pulmonary hypertension.
        Am J Respir Crit Care Med. 2000; 161 (487–392)
        • Paciocco G.
        • Martinez F.J.
        • Bossone E.
        • Pielsticker E.
        • Gillespie B.
        • Rubenfire M.
        Oxygen desaturation on the six-minute walk test and mortality in untreated primary pulmonary hypertension.
        Eur Respir J. 2001; 17 (647–352)
        • D'Alonzo G.E.
        • Barst R.J.
        • Ayres S.M.
        • Bergofsky E.H.
        • Brundage B.H.
        • Detre K.M.
        • Fishman A.P.
        • Goldring R.M.
        • Groves B.M.
        • Kernis J.T.
        Survival in patients with primary pulmonary hypertension.
        Ann Intern Med. 1991; 115: 343-349
        • Ishii M.
        • Eto G.
        • Tei C.
        • Tsutsumi T.
        • Hashino K.
        • Sugahara Y.
        • Himeno W.
        • Muta H.
        • Furui J.
        • Akagi T.
        • Fukiyama R.
        • Toyoda O.
        • Kato H.
        Quantitation of the global right ventricular function in children with normal heart and congenital heart disease: a right ventricular myocardial performance index.
        Pediatr Cardiol. 2000; 21: 416-421
        • Patel D.R.
        • Cui W.
        • Gambetta K.
        • Roberson D.A.
        A comparison of Tei index versus systolic to diastolic ratio to detect left ventricular dysfunction in pediatric patients.
        J Am Soc Echocardiogr. 2009; 22: 152-158
        • Weissler A.M.
        • Harris W.S.
        • Schoenfeld C.D.
        Systolic time intervals in heart failure in man.
        Circulation. 1968; 37: 149-159
        • Oreshkov V.I.
        Q-1 or C-1 interval in the diagnosis of mitral stenosis.
        Br Heart J. 1967; 29: 778-782
        • Jezek V.
        Rate of right ventricular isometric pressure increase in the patients with chronic cor pulmonale studied by the ventricular pressure derivative curves.
        Cardiologia. 1966; 48: 461-470
        • Chung C.S.
        • Karamanoglu M.
        • Kovacs S.J.
        Duration of diastole and its phases as a function of heart rate during supine bicycle exercise.
        Am J Physiol Heart Circ Physiol. 2004; 287: H2003-H2008
        • Yeo T.C.
        • Dujardin K.S.
        • Tei C.
        • Mahoney D.W.
        • McGoon M.D.
        • Seward J.B.
        Value of a Doppler-derived index combining systolic and diastolic time intervals in predicting outcome in primary pulmonary hypertension.
        Am J Cardiol. 1998; 81: 1157-1161
        • Dyer K.L.
        • Pauliks L.B.
        • Das B.
        • Shandas R.
        • Ivy D.
        • Shaffer E.M.
        • Valdes-Cruz L.M.
        Use of myocardial performance index in pediatric patients with idiopathic pulmonary arterial hypertension.
        J Am Soc Echocardiogr. 2006; 19: 21-27

      Linked Article

      • Usefulness of Tachycardia in Predicting Survival With Pulmonary Arterial Hypertension
        American Journal of CardiologyVol. 106Issue 10
        • Preview
          The article by the group in Toronto concludes that an increase in the ratio of systolic to diastolic intervals in patients with pulmonary arterial hypertension predicts poorer survival.1 That ratio is determined by heart rate, and tachycardia in basal conditions has long been regarded an indicator of decreased functional capacity. It is not clear whether their method, requiring a Doppler echocardiogram focused on tricuspid regurgitation, is superior to heart rate alone.
        • Full-Text
        • PDF