Abstract
Objective
To evaluate the left ventricular eccentricity index (EI) across different pulmonary hypertension (PH) probability groups and cardiac cycle phases.
Methods
This retrospective study enrolled 121 client-owned dogs with PH between February 2020 and July 2024. History, radiography, echocardiography, and other medical recordings were reviewed. Dogs with PH were diagnosed and classified according to the American College of Veterinary Internal Medicine consensus guidelines. The EI was measured at end diastole (EId) and end systole (EIs). The t, Mann-Whitney U, and Kruskal-Wallis tests were used to compare EI between PH groups. Receiver operating characteristic curve analysis was applied to assess the EI for predicting PH and right-sided congestive heart failure. Pearson correlation analysis was used to evaluate the correlation of EId and EIs with both tricuspid regurgitation velocity and right pulmonary artery distensibility index.
Results
This study enrolled 37 healthy (control) and 84 dogs with PH. Both EId and EIs were significantly different between the control and PH groups (EId/EIs, 1.16/1.13 vs 1.31/1.66). An EIs value of 1.22 distinguished the 2 groups with a sensitivity of 0.7 and specificity of 1 (AUC, 0.78). Both EId and EIs were positively correlated with tricuspid regurgitation velocity but not with the right pulmonary artery distensibility index.
Conclusions
The EI is useful for evaluating septal flattening in dogs with PH under various conditions. The EId showed inferior power to the EIs in assessing PH but aided screening for right-sided congestive heart failure and volume overload.
Clinical Relevance
The EI can help clinicians to more accurately assess PH probabilities, specifically regarding ventricles.
Pulmonary hypertension (PH) is a pathological hemodynamic condition characterized by systolic and mean pulmonary arterial pressure values above 30 and 25 mm Hg, respectively. There are several hemodynamic causes of PH, including increased pulmonary blood flow, increased pulmonary vascular resistance, increased pulmonary venous pressure, or a combination thereof.1
Right heart catheterization remains the gold standard for the diagnosis of PH; however, its use in small animal practice is limited owing to the risks associated with general anesthesia, invasiveness, and cost.2 Therefore, PH is generally presumptively diagnosed based on relevant clinical signs, radiography, and echocardiography. The American College of Veterinary Internal Medicine (ACVIM) consensus guidelines recommend a diagnosis based on clinical signs and echocardiographic findings, categorizing PH into low-, intermediate-, and high-probability groups. On echocardiography, the diagnosis of PH is supported by the evaluation of tricuspid regurgitation velocity (TRv) and abnormal anatomical findings in the ventricles, pulmonary artery, right atrium, and caudal vena cava. The ACVIM consensus guidelines further propose that the clinical definition of PH should include dogs with an intermediate or high probability of PH.4
Under normal conditions, pressure in the left ventricle (LV) is always higher than that in the right ventricle (RV) throughout the entire cardiac cycle.3 This interventricular pressure gradient maintains the normal round shape of the interventricular septum. Septal flattening occurs when the RV pressure exceeds that of the LV.4,5 Septal flattening is generally evaluated subjectively,6,7 but the LV eccentricity index (EI) can be used to quantitatively assess septal flattening with minimal intra- and interobserver variability in both human and dogs.8,9 The EI can be easily measured from a routinely assessed view (the right parasternal short-axis papillary muscle view).10 In human medicine, the EI is used to evaluate RV hemodynamics and predict RV dysfunction in pediatric PH patients.8,11,12 Two prior studies9,13 evaluated EI in dogs with PH but with different classification criteria; therefore, the results are not applicable to probability groups, as recommended by the ACVIM.
The present study aimed to evaluate the EI across different PH probability groups and cardiac cycle phases (diastole and systole), hypothesizing that the EI increases with increasing PH probability. We further hypothesized that EI would exhibit a correlation with indexes that are used to assess PH in dogs, such as TRv and the right pulmonary artery distensibility (RPAD) index.
Methods
Animals
This retrospective study involved a review of the medical records of dogs that presented to the Jeonbuk National University Animal Medical Center between February 2020 and July 2024. Dogs that had undergone thoracic radiography and echocardiography were enrolled. All dogs with PH were evaluated in this study. Dogs with arrhythmias, poor-quality imaging, or a lack of concurrent ECG monitoring during echocardiography were excluded. The control group comprised clinically healthy dogs with no cardiovascular abnormalities.
Diagnosis and classification of PH
Dogs with PH were classified into low-, intermediate-, and high-probability groups, according to the ACVIM consensus guidelines. The control and low-probability groups were reclassified as the nonclinically defined PH group, while the intermediate- and high-probability groups were reclassified as the clinically defined PH group. Left heart disease (LHD) was considered a contributing factor to PH, either independently or in conjunction with other comorbidities, if left atrial enlargement was observed. Therefore, all dogs with left atrial enlargement were included in the LHD group. The right-sided congestive heart failure (RCHF) group included dogs that presented with ascites or were prescribed diuretics to manage ascites.
Echocardiography
Echocardiographic examinations were conducted by a single trained observer (MS) with ECG monitoring using a Philips EPIC 7C (Philips Medical System) with 3- to 8-MHz and 4- to 12-MHz phased transducers. All echocardiographic examinations were performed under the supervision of the corresponding author (CP). All patients underwent complete echocardiographic examinations, including 2-D, M-mode, and Doppler examinations. All echocardiographic values were measured using the trailing-edge-to-leading-edge method. The maximum TRv values from distinct peak signals across various views were chosen.14,15 The RPAD index was measured in the right parasternal short-axis view at the level of the pulmonary artery using either 2-D or M-mode.7,16 The mean values from 3 consecutive cardiac cycles were used.
Left ventricular EI
The LV EI was measured from the right parasternal short-axis papillary muscle view at both end systole and end diastole. The D1 was initially measured just above the papillary muscles as the longest LV diameter parallel to the interventricular septum. The D2 was defined as the longest LV diameter perpendicular to D1. The EI was calculated as D1/D2 to 2 decimal places. End systole EI (EIs) and end diastole EI (EId) were measured at the end of the T wave and the peak of the QRS complex, respectively (Figure 1), using a commercial DICOM viewer (INFINITT DICOM viewer; version 3.0.11.6; INFINITT Healthcare).
Left ventricular eccentricity index (EI) measurements from the right parasternal short axis view using the trailing-edge-to-leading-edge method. The D1 was measured just above the papillary muscles as the longest left ventricular diameter parallel to interventricular septum, and the D2 was measured as the longest left ventricular diameter perpendicular to D1. The EI was calculated as D1/D2. End diastole EI (EId) was measured at the peak of the QRS complex (A and C). End systole EI (EIs) was measured at the end of the T wave (B and D). The interventricular septum maintains a normal round shape in a healthy dog (A and B). In contrast, EI is increased in pulmonary hypertension (PH) dogs as the pressure of the right ventricle increases (C and D).
Citation: American Journal of Veterinary Research 2025; 10.2460/ajvr.24.11.0339
Statistical analysis
All statistical analyses were performed using commercial statistical software (IBM SPSS 29.0.1.0; SPSS Inc), and significance was set at a P value of < .05. Continuous variables are reported as the mean and range (minimum and maximum), and the categorical data are reported as proportions. The Shapiro-Wilk test was used to assess the normality of the distribution of continuous variables.
Comparisons of EIs and EId between the control and PH groups, between clinically defined PH and nonclinically defined PH groups, between the LHD and non-LHD groups, and between the RCHF and non-RCHF groups were conducted using the t test and Mann-Whitney U test for parametric and nonparametric data, respectively. Comparisons among the PH probability groups were performed using both the Jonckheere-Terpstra and Kruskal-Wallis tests. When statistically significant differences were identified, post hoc pairwise comparisons were performed using the Mann-Whitney U test with Bonferroni correction.
Receiver operating characteristic (ROC) curve analysis was applied to identify the discriminative abilities of EId and EIs. Area under the curve values below 0.5, 0.6, 0.7, 0.8, and 0.9 were classified as indicating failure, poor, fair, good, and excellent discriminative ability, respectively.17 The optimal cutoff values of EIs and EId for distinguishing the PH group, clinically defined PH group, and RCHF group, with the optimal combination of sensitivity and specificity, were determined using the Youden index. Pearson correlation analysis was used to assess the relationship between EIs and EId, TRv, and the RPAD index.
Results
The present study reviewed 150 dogs, including 110 diagnosed with PH and 40 healthy dogs. Of these, 29 were excluded, resulting in a final study population of 121 dogs, comprising 84 dogs in the PH group and 37 in the control group. The PH group was further categorized into low-probability (n = 20), intermediate-probability (22), and high-probability (42) groups. Accordingly, patients were further divided into nonclinically defined PH (n = 57) and clinically defined PH groups (64; Table 1). Considering each patient's history, the LHD (n = 28) and non-LHD (56) groups were divided into PH dogs. In non-LHD group, the causes of PH were classified as follows: idiopathic (n = 6), respiratory disease related (24), pulmonary thromboembolism (1), heartworm infection (27), and multifactorial causes (2). All dogs in the LHD group had myxomatous mitral valve degeneration (MMVD), and 2 dogs had concurrent aortic insufficiency. Finally, 21 dogs had a history of RCHF, whereas 63 did not. No medication was administered in the control group. In the low-probability group, 2 dogs received sildenafil, 2 received pimobendan, 6 received furosemide, 2 received enalapril, and 2 received spironolactone. In the intermediate-probability group, 11 dogs received sildenafil, 6 received pimobendan, 6 received furosemide, 2 received enalapril, 2 received spironolactone, and 1 received amlodipine. In the high-probability group, 14 dogs received sildenafil, 10 received pimobendan, 7 received furosemide, 6 received enalapril, 5 received spironolactone, and 3 received amlodipine.
Summary characteristics of 121 client-owned dogs reviewed in this study.
| PH | ||||
|---|---|---|---|---|
| Nonclinically defined PH | Clinically defined PH | |||
| Control | Low probability | Intermediate probability | High probability | |
| No. cases | 37 | 20 | 22 | 42 |
| Male/female | 19/18 | 12/8 | 15/7 | 17/25 |
| Age (y) | 7.03 ± 4.36 | 9.45 ± 3.49 | 12.14 ± 3.52 | 10.24 ± 3.89 |
| Weight (kg) | 10.06 ± 9.40 | 6.34 ± 4.51 | 6.82 ± 5.45 | 10.80 ± 9.84 |
Values are reported as the mean ± SD. Clinically healthy dogs without any cardiovascular disease were included as the control group (n = 37). Pulmonary hypertension (PH) dogs were grouped according to American College of Veterinary Internal Medicine consensus guidelines as low (n = 20), intermediate (22), and high (42) probability. Control and low-probability dogs were reclassified as nonclinically defined PH group (n = 57). Intermediate- and high-probability dogs were reclassified as the clinically defined PH group (n = 64).
All continuous data followed normality, except for the EIs of the low-probability group, and the EIs and RPAD index of the RCHF group. Dogs diagnosed with PH were younger than the control dogs (7 [1 to 17] vs 10.5 years [1 to 17], P < .001). There was no significant difference in body weight between the 2 groups (10 [1.6 to 49] vs 8.7 kg [1.7 to 44], P < .416). The sex distribution between the 2 groups also showed no difference (male/female: 19/18 vs 44/40, P < .24; Table 1).
There was a significant difference in both EId and EIs between the control and PH groups (1.16 [0.87 to 1.55] vs 1.31 [0.8 to 3.01], P < .001; and 1.13 [0.65 to 2.49] vs 1.66 [0.68 to 6.23], P < .002). A significant rank order of EId and EIs existed among the control, low-, intermediate-, and high-probability groups (P < .003 and P < .001, respectively). Post hoc tests revealed an EId difference between the control and high-probability groups (P = .001) and an EIs difference between the control and intermediate-probability groups (P = .008), between the control and high-probability groups (P = .001), and between the low-probability and high-probability groups (P = .001; Table 2; Figure 2).
Summary of the echocardiographic variables of the control, low-probability, intermediate-probability, and high-probability groups.
| Control | Low probability | Intermediate probability | High probability | |
|---|---|---|---|---|
| No. cases | 37 | 20 | 22 | 42 |
| EId | 1.16 ± 0.16 | 1.16 ± 0.17 | 1.19 ± 0.20 | 1.47 ± 0.50a |
| EIs | 1.13 ± 0.33 | 1.30 ± 0.26 | 1.42 ± 0.32a | 2.00 ± 1.21a,b |
| TRv (m/s) | 2.57 ± 0.47 | 3.15 ± 0.36 | 4.30 ± 0.91 | |
| RPAD index (%) | 35.92 ± 13.50 | 27.85 ± 13.31 | 23.61 ± 16.12 |
Values are reported as the mean ± SD. Dogs were grouped as described in Table 1. Post hoc pairwise comparisons were performed, and significant values are labeled.
EId = Left ventricular eccentricity index at end diastole. EIs = Left ventricular eccentricity index at end systole. RPAD = Right pulmonary artery distensibility index. TRv = Tricuspid regurgitation velocity.
Difference from the control group.
Difference from the low-probability group.
Box plot illustrating the EId (A and C) and EIs (B and D) values in 121 dogs reviewed in this study. Dogs with PH were grouped according to the American College of Veterinary Internal Medicine consensus guidelines. The box contains the 25th and 75th percentiles. Lines inside the boxes indicate the mean, and the circles outside the boxes indicate the outliers. Post hoc pairwise comparisons were performed, and significant values are labeled. *P < .001, **P < .008, ***P < .002.
Citation: American Journal of Veterinary Research 2025; 10.2460/ajvr.24.11.0339
The nonclinically and clinically defined PH groups both showed significant differences in EId and EIs (1.17 [0.91 to 1.78] vs 1.36 [0.8 to 3.01], P = .002; and 1.18 [0.95 to 1.7] vs 1.78 [0.68 to 6.23], P = .001, respectively). The EId also showed a significant difference between the control and non-LHD groups (1.16 [0.87 to 1.55] vs 1.34 [0.91 to 2.70], P = .003), while no significant difference was found the between control and LHD groups (1.16 [0.87 to 1.55] vs 1.27 [0.80 to 3.01], P = .235). The EIs showed a significant difference between the control and non-LHD groups (1.13 [0.65 to 2.49] vs 1.80 [0.68 to 6.23], P = .006) and between the control and LHD groups (1.13 [0.65 to 2.49] vs 1.38 [0.73 to 2.70], P = .001). Non-RCHF and RCH groups also had significant differences in both EId and EIs (1.25 [0.80 to 3.01] vs 1.51 [0.91 to 2.7], P = .01; and 1.48 [0.68 to 3.95] vs 2.21 [0.94 to 6.23], P = .005; Table 3).
Summary of echocardiographic measurements of the non-LHD, LHD, non-RCHF, and RCHF groups among PH dogs.
| Non-LHD group | LHD group | Non-RCHF group | RCHF group | |
|---|---|---|---|---|
| No. cases | 56 | 28 | 63 | 21 |
| EId | 1.34 ± 0.37 | 1.27 ± 0.45 | 1.25 ± 0.35 | 1.51 ± 0.47b |
| EIs | 1.80 ± 0.96 | 1.38 ± 0.40a | 1.48 ± 0.55 | 2.21 ± 1.25b |
| TRv (m/s) | 3.73 ± 1.13 | 3.38 ± 0.59 | 3.34 ± 0.77 | 4.43 ± 1.14b |
| RPAD index (%) | 24.97 ± 14.45 | 33.71 ± 16.17a | 31.60 ± 14.56 | 17.40 ± 13.20b |
| LA/Ao ratio | 1.84 ± 0.46 | |||
| LVIDdN | 1.67 ± 0.36 | |||
| Peak E (m/s) | 1.06 ± 0.31 |
The ROC curve did not reveal a significant cutoff value for EId between the control and PH groups (P = .069). An EIs value of 1.22 predicted PH with a sensitivity/specificity of 0.71/1 (AUC, 0.78 [95% CI, 0.69 to 0.87], P = .001). The EId and EIs values of 1.49 and 1.22 predicted clinically defined PH with sensitivity/specificity of 0.25/0.97 and 0.80/0.67, respectively (AUC, 0.62 [95% CI, 0.52 to 0.72], P = .018; and AUC, 0.78 [95% CI, 0.70 to 0.86], P = .001, respectively). The EId and EIs values of 1.34 and 1.66 predicted RCHF with sensitivity/specificity of 0.57/0.81 and 0.67/0.83, respectively (AUC, 0.70 [95% CI, 0.56 to 0.84], P = .005; and AUC, 0.78 [95% CI, 0.67 to 0.89], P = .001, respectively; Figure 3).
Receiver operating characteristic curves distinguishing between control and PH groups (A) and non–right-sided congestive heart failure and right-sided congestive heart failure groups (B). The AUC of EId was 0.60 (A) and 0.70 (B). Receiver operating characteristic curve analysis of EId revealed no statistically significant differences in A (P = .069). The AUCs of EIs were 0.78 in both A and B.
Citation: American Journal of Veterinary Research 2025; 10.2460/ajvr.24.11.0339
Both EId and EIs were positively correlated with TRv (r = 0.51, P < .001; and r = 0.44, P < .001, respectively). In contrast, neither value was significantly correlated with the RPAD index (P < .439 and P < .545, respectively).
Discussion
This is the first study to evaluate EI in dogs with PH classified by PH probability using TRv and anatomic sites, as recommended by the ACVIM consensus guidelines.6 Previously, dogs with PH were classified as having mild, moderate, or severe PH based solely on the TRv.18 Because the accuracy of TRv in reflecting the actual pressure gradient is controversial,19,20 we considered it more reasonable to evaluate multiple anatomical sites, in addition to the TRv. Both EId and EIs were significantly different between the control and PH groups, between the clinically and nonclinically defined PH groups, and between the RCHF and non-RCHF groups. This is consistent with previous studies in both dogs9 and humans,21 suggesting that EI could serve as an additional tool for assessing dogs with PH.
The EIs in the high-probability group was elevated compared with the control and low-probability groups, whereas the EIs in the intermediate-probability group was only elevated compared with the control group. This differs slightly from a previous study,9 in which the moderate and severe groups showed a significant difference. Nonetheless, both intermediate- and high-probability groups of dogs are clinically defined as PH, and PH-specific treatment is indicated when clinical signs are present.6 Consequently, differentiating between these 2 groups may not have significant clinical value. Different classification criteria may have influenced the discrepancies between this study and the previous one.9 In the previous study,9 dogs were classified as no PH (< 2.7 m/s TRv; < 2.2 m/s pulmonary regurgitation velocity [PRv]), mild PH (2.7 to 3.5 m/s TRv; 2.2 to 2.5 m/s PRv), moderate PH (3.5 to 4.3 m/s TRv; 2.5 to 3.0 m/s PRv), and severe PH (> 4.3 m/s TRv; > 3.0 m/s PRv) based on TRv and PRv. In contrast, we classified dogs using TRv values of 3.0 and 3.4 m/s along with an assessment of anatomical sites, following ACVIM consensus guidelines. These differing PH classification criteria possibly affected the classification of some dogs.
The EId showed a significant difference only between the control and high-probability groups in the current study, while the severe PH group had a higher EId compared to all other groups (control, mild, and moderate PH) in a prior study.9 In cases of RV pressure overload, increased RV pressure during systole leads to systolic septal flattening. As RV failure progresses due to PH, pulmonary blood flow decreases, and RV end-diastolic pressure increases subsequently.3 Additionally, eccentric hypertrophy and annulus dilation in advanced PH can result in increased tricuspid regurgitation,22 thus deteriorating volume overload. Consequently, at advanced PH, septal flattening can be observed throughout the whole diastole,3 including end diastole, as evaluated in the current study. In a previous study,9 dogs with TRv ≥ 3.5 m/s were categorized as having moderate PAH, whereas according to the ACVIM consensus guidelines,6 all of these cases would fall into the high-probability group. Therefore, this discrepancy likely contributed to the observed differences in EId between the 2 studies. Unlike the previous study,9 where all PH dogs with significantly elevated TRv were grouped as a single severe PH group, our study classified dogs with lower TRv but with anatomical evidence of PH into the high-probability group. This alternative classification approach may explain why the difference in EId was only observed between the high-probability and control groups.
In the ROC curve analysis, the EIs fairly differentiated the PH group from the control group, the clinically defined PH group from the nonclinically defined PH group, and the RCHF group from the non-RCHF group. This indicates that EIs are useful for assessing dogs with PH, regardless of their probabilities. However, EId did not effectively differentiate between the control and PH groups and showed poor discriminative ability (AUC, 0.62 [95% CI, 0.52 to 0.72]) between the clinically defined and nonclinically defined PH groups. Although inferior to EIs, EId fairly differentiated between the RCHF and non-RCHF groups. Additionally, in the authors’ experience, EId was easier to measure than EIs due to the distinct endocardium of the LV, and EId showed lower observer variation than EIs in previous studies in humans8 and dogs.9 In human medicine, EId has been identified as a reliable indicator of RV dysfunction, volume overload, and poor prognosis in PH patients,20,23–25 although relying solely on septal motion to assess ventricular function is not recommended.15 Considering the results of prior studies in humans, along with those of the current study, EId may provide additional information for screening RCHF and RV dysfunction in dogs with PH.
As the presence of LHD could influence septal flattening through ventricular interdependence,26 we expected that the LHD group would not show significant differences in EIs and EId compared with the control group. However, a significant difference in EIs was found between the control and LHD groups. The study population of the LHD group, in which all patients had MMVD, either alone or with other concurrent LHD, seemed to contribute to this result. Patients with MMVD show decreased afterload due to mitral regurgitation and even decreased LV contractility in advanced cases. This, in combination with increased systolic pressure in the RV, can result in increased EIs. Our result contrasts with that of a previous study13 where neither EId nor EIs showed significant differences between dogs with PH with concurrent MMVD and control dogs. This discrepancy may be due to differences in the population size or grouping criteria. No significant difference in EId was found between our study and the previous study.13 Based on previous studies22,27 and our results, the EId appears to be more sensitive to volume overload than to pressure overload. In dogs with MMVD and significant left atrial enlargement, the diastolic pressure of the LV is expected to increase owing to increased left atrial pressure.28 In this situation, increased diastolic pressure in the RV can be masked, resulting in normal or even underestimated EId, depending on severity.
Because right heart catheterization is impractical in small-animal practice, comprehensive echocardiographic evaluation is crucial for assessing dogs with PH. Although TRv or PRv reflects pulmonary arterial pressure to some extent, it remains imperfect.19 Therefore, evaluating additional echocardiographic signs of PH is important. Therefore, the accurate evaluation of individual anatomical sites is essential in PH assessment and supports its use in diagnosing PH. The EI evaluates the ventricles through septal flattening, whereas the RPAD index evaluates the pulmonary artery, specifically its stiffness and resistance.29–31 These pathophysiologically relevant anatomical differences likely explain why neither EId nor EIs correlated with the RPAD index, while both showed a correlation with TRv. Considering these results, both EId and EIs could provide additional information regarding the probability of PH, particularly those associated with ventricles.
When comparing this study with the previous study,9 both studies are retrospective and involve a similar number of cases. However, our study differs in that it classifies groups based on multiple anatomical parameters rather than relying on regurgitation velocities, as done in the previous study.9 This approach aligns with the ACVIM consensus guideline recommendation to assess multiple anatomic parameters for a more integrative evaluation of PH. In this study, the cutoff values tend to be lower compared to previous findings.9 As mentioned above, the difference in cutoff values is thought to be due to variations in grouping criteria. In a clinical setting, this difference should be considered.
The primary limitation of this study was that the diagnosis of PH was not directly confirmed through right heart catheterization. As the TRv may not accurately reflect the actual pressure gradient,19 right heart catheterization is necessary to accurately diagnose PH. It is also essential to distinguish precapillary from postcapillary PH. Consequently, a biased grouping of the LHD group could have existed. Although the classification and grouping of dogs were performed following the ACVIM consensus guidelines, some inevitable subjectivity may have been involved in the process. In the septal flattening situation due to eccentric hypertrophy of RV, the endocardial border of LV in the systolic phase was hard to define in some cases. It can be compared with EI measured by other modalities such as cardiac MRI,32 so further study is needed. Additionally, all dogs with PH were included, regardless of prior medication use (eg, phosphodiesterase type 5 inhibitors and diuretics), and sedation during the examination was not recorded or controlled. These factors, particularly phosphodiesterase type 5 inhibitors and diuretics, can influence all the measurements taken in this study. However, in a clinical setting, such effects cannot be fully controlled; therefore, all cases were included in our statistical analysis. This retrospective nature of the study may have affected the results. Finally, a significant difference in age was observed between the control and PH groups. In addition, the number of dogs in each group was uneven. Both the RCHF and LHD groups included fewer than 30 dogs. These population differences may have influenced the statistical significance of the results.
In conclusion, EI can help evaluate septal flattening and the probability of PH in dogs quantitatively. Specifically, EIs may be useful for the evaluation of septal flattening in dogs with PH, while EId may be beneficial in screening for RCHF.
Acknowledgments
None reported.
Disclosures
The authors have nothing to disclose. No AI-assisted technologies were used in the composition of this manuscript.
Funding
The authors have nothing to disclose.
ORCID
Minsuk Kim https://orcid.org/0000-0001-8791-3010
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