Right ventricular dysfunction as an independent predictor of short- and long-term mortality in patients with heart failure

Evaluating fetal tricuspid and mitral annular plane systolic excursion (TAPSE and MAPSE) using spatiotemporal image correlation (STIC) M-mode

OBJECTIVES

This study aimed to evaluate the feasibility and reliability of tricuspid and mitral annular plane systolic excursion measurements (TAPSE and MAPSE) applying M-mode spatiotemporal image correlation (STIC) technology in low-risk pregnancies.

METHODS

An initial retrospective pilot study was carried out to assess repeatability, followed by a larger mixed cross-sectional and prospective longitudinal study, both evaluating low-risk singleton pregnancies between 22+6 and 39+1 weeks. As only annuli capture was necessary, STIC acquisition parameters were set to the minimum volume angle of 15° and acquisition time of 7.5 s.

RESULTS

A total of 330 volumes were analysed offline applying STIC M-mode. Acquisition rates were 96.9 % for TAPSE and 93.7 % MAPSE in the pilot study (n=32) and 98.0 % for both in the longitudinal study (n=102). Both study designs revealed good repeatability for both sides of the heart, with higher intraclass correlation coefficients (ICCs) for TAPSE (0.84-0.94) compared to MAPSE (0.80-0.88). Good repeatability was demonstrated for both sides of the heart, more so for TAPSE than MAPSE, with ICCs for TAPSE 0.84-0.91 and MAPSE 0.75-0.76, comparable to prior ICCs for STIC repeatability.

CONCLUSIONS

Modified STIC acquisition settings specifically tailored for capturing the longitudinal annular displacement may improve STIC TAPSE and MAPSE acquisition rates, optimising image quality for precise measurement and potentially bringing these modalities closer to clinical application.

Current and Future Role of Ultrasonography in the Cardiac Intensive Care Unit

The contemporary practice of ultrasonography in the cardiac intensive care unit integrates the principles of echocardiography with whole-body imaging to create a more expansive paradigm of critical care ultrasonography (CCUS). This article will review the use of CCUS for diagnostic assessment, monitoring, therapeutic guidance, and prognosis.

Validation of American Society of Echocardiography Guideline-Recommended Parameters of Right Ventricular Dysfunction Using Artificial Intelligence Compared With Cardiac Magnetic Resonance Imaging

BACKGROUND

Right ventricular (RV) function is important in the evaluation of cardiac function, but its assessment using standard transthoracic echocardiography (TTE) remains challenging. Cardiac magnetic resonance imaging (CMR) is considered the gold standard. The American Society of Echocardiography recommends surrogate measures of RV function and RV ejection fraction (RVEF) by TTE, including fractional area change (FAC), free wall strain (FWS), and tricuspid annular planar systolic excursion (TAPSE), but they require technical expertise in acquisition and quantification.

METHODS

The aim of this study was to evaluate the sensitivity, specificity, and positive and negative predictive values of FAC, FWS, and TAPSE derived using a rapid, novel artificial intelligence (AI) software (LVivoRV) from a single-plane transthoracic echocardiographic apical four-chamber, RV-focused view without ultrasound-enhancing agents for detecting abnormal RV function compared with CMR-derived RVEF. RV dysfunction was defined as RVEF < 50% and RVEF < 40% on CMR.

RESULTS

TTE and CMR were performed within a median of 10 days (interquartile range, 2-32 days) of each other in 225 consecutive patients without interval procedural or pharmacologic intervention. The sensitivity and negative predictive value to detect CMR-defined RV dysfunction when all three AI-derived parameters (FAC, FWS, and TAPSE) were abnormal were 91% and 96%, while those of expert physician reads were 91% and 97%. Specificity and positive predictive value were lower (50% and 32%) compared with expert physician-read echocardiograms (82% and 56%).

CONCLUSIONS

AI-derived measurements of FAC, FWS, and TAPSE had excellent sensitivity and negative predictive value for ruling out significant RV dysfunction (CMR RVEF < 40%), comparable with that of expert physician readers, but lower specificity. Thus AI, using American Society of Echocardiography guidelines, may serve as a useful screening tool for rapid bedside assessment to exclude significant RV dysfunction.

Right Ventricular Free Wall Strain and Effect of Defibrillator Implantation in Patients With Nonischemic Systolic Heart Failure

BACKGROUND

Patients with nonischemic systolic heart failure have an increased risk of malignant ventricular arrhythmias and sudden cardiovascular death. Because the risk is less pronounced than for patients with ischemic cause of heart failure more discriminating tools are needed to identify patients most likely to benefit from implantable cardioverter-defibrillator (ICD) implantation. Right ventricular (RV) dysfunction is associated with a worse prognosis, but whether RV free wall strain (RV-FWS) measured with echocardiography can identify the patients most likely to benefit from ICD implantation is not known.

METHODS AND RESULTS

In this extended follow-up analysis of the Danish Study to Assess the Efficacy of ICDs in Patients with Non-ischemic Systolic Heart Failure on Mortality (DANISH) trial, RV-FWS was measured with echocardiography in 445 patients before randomization. RV dysfunction was defined as an RV-FWS of greater than -20%. The primary end point was all-cause mortality. The median RV-FWS was -18% (quartiles -23% to -14%), and RV dysfunction was measured in 255 patients (57%). During a median follow-up of 5.7 years, 170 patients (38%) died. There was a statistically significant interaction between RV dysfunction and the effect of ICD implantation (P = .003), also after adjusting for known cardiovascular risk factors (P = .01). ICD implantation significantly decreased all-cause mortality in patients with RV dysfunction (hazard ratio 0.54, 95% confidence interval 0.36-0.80, P = .002), but not in patients with normal RV function (hazard ratio 1.34, 95% confidence interval 0.84-2.12, P = .22).

CONCLUSIONS

In patients with nonischemic systolic heart failure, RV dysfunction on echocardiography was associated with a greater effect of ICD implantation and could be used to select patients with benefit from ICD treatment.

Reverse Remodeling and Functional Improvement of Left Ventricle in Patients with Chronic Heart Failure Treated with Sacubitril/Valsartan: Comparison between Non-Ischemic and Ischemic Etiology

Sacubitril/valsartan (SV) has been demonstrated to reduce cardiovascular mortality, hospitalization for heart failure and to induce reverse ventricular remodeling. The present study was designed to confirm the effects of SV in a selected population of patients with HFrEF and to evaluate the different responses between patients with an ischemic or a non-ischemic etiology. A total of 79 patients with indication of SV were recruited prospectively during a timelapse of 4 years. SV was overall associated to a reduction of end-diastolic and end-systolic volume, of NT-proBNP levels, furosemide dosage and NYHA functional class, together with an increase in EF. These changes were more evident in patients with non-ischemic dilated cardiomyopathy, who showed a significant improvement in ventricular volumes, ejection fraction, TAPSE and blood levels of NT-proBNP. Kaplan-Meier curves confirmed a greater benefit in terms of ejection-fraction improvement in non-ischemic patients compared to the ischemic group. The results of the present study confirm the positive effect of SV on NYHA functional class, NT- proBNP, left ventricular volumes and EF in HFrEF patients, showing evidence of association of SV with ventricular remodeling in patients with dilated cardiomyopathy of non-ischemic etiology compared to the ischemic group.

Right ventricular dysfunction in patients with new-onset heart failure: longitudinal follow-up during guideline-directed medical therapy

AIMS

Improvement in left ventricular ejection fraction (LVEF) after up-titration of guideline-directed medical therapy (GDMT) has been well described in heart failure (HF) patients. Less is known about the prevalence and clinical course of right ventricular dysfunction (RVD) in patients with new-onset HF.

METHODS AND RESULTS

From 2012 to 2018, 625 patients with a recent (<3 months) diagnosis of HF were referred to a specialized nurse-led HF clinic for protocolized up-titration of GDMT. RVD, defined as tricuspid annular plane systolic excursion (TAPSE) <17 mm, was assessed at baseline and at the follow-up visit. Patients were followed for the combined endpoint of all-cause mortality and HF hospitalization for a mean of 3.3 ± 1.9 years. Of the 625 patients, 241 (38.6%) patients had RVD at baseline. Patients with RVD were older, more symptomatic, had a lower LVEF, and more often had a history of cardiothoracic surgery and atrial fibrillation. After a median follow-up of 9 months, right ventricular function normalized in 49% of the patients with baseline RVD. RVD at baseline was associated with a higher risk of the combined endpoint (hazard ratio [HR] 1.62, 95% confidence interval [CI] 1.21-2.18). Right ventricular function normalization was associated with a lower risk for the combined endpoint (HR 0.56, 95% CI 0.31-0.99), independent of baseline TAPSE, age, sex, and LVEF.

CONCLUSION

More than one-third of patients with new-onset HF have RVD. RVD is associated with a higher risk of all-cause mortality and HF hospitalization. Recovery of RVD regularly occurs during up-titration of GDMT and is associated with improved clinical outcomes.

Point-of-care echocardiography of the right heart improves acute heart failure risk stratification for low-risk patients: The REED-AHF prospective study

OBJECTIVES

Validated acute heart failure (AHF) clinical decision instruments (CDI) insufficiently identify low-risk patients meriting consideration of outpatient treatment. While pilot data show that tricuspid annulus plane systolic excursion (TAPSE) is associated with adverse events, no AHF CDI currently incorporates point-of-care echocardiography (POCecho). We evaluated whether TAPSE adds incremental risk stratification value to an existing CDI.

METHODS

Prospectively enrolled patients at two urban-academic EDs had POCechos obtained before or <1 h after first intravenous diuresis, positive pressure ventilation, and/or nitroglycerin. STEMI and cardiogenic shock were excluded. AHF diagnosis was adjudicated by double-blind expert review. TAPSE, with an a priori cutoff of ≥17 mm, was our primary measure. Secondary measures included eight additional right heart and six left heart POCecho parameters. STRATIFY is a validated CDI predicting 30-day death/cardiopulmonary resuscitation, mechanical cardiac support, intubation, new/emergent dialysis, and acute myocardial infarction or coronary revascularization in ED AHF patients. Full (STRATIFY + POCecho variable) and reduced (STRATIFY alone) logistic regression models were fit to calculate adjusted odds ratios (aOR), category-free net reclassification index (NRI_cont ), ΔSensitivity (NRI_events ), and ΔSpecificity (NRI_nonevents ). Random forest assessed variable importance. To benchmark risk prediction to standard of care, ΔSensitivity and ΔSpecificity were evaluated at risk thresholds more conservative/lower than the actual outcome rate in discharged patients.

RESULTS

A total of 84/120 enrolled patients met inclusion and diagnostic adjudication criteria. Nineteen percent experiencing the primary outcome had higher STRATIFY scores compared to those event free (233 vs. 212, p = 0.009). Five right heart (TAPSE, TAPSE/PASP, TAPSE/RVDD, RV-FAC, fwRVLS) and no left heart measures improved prediction (p < 0.05) adjusted for STRATIFY. Right heart measures also had higher variable importance. TAPSE ≥ 17 mm plus STRATIFY improved prediction versus STRATIFY alone (aOR 0.24, 95% confidence interval [CI] 0.06-0.91; NRI_cont  0.71, 95% CI 0.22-1.19), and specificity improved by 6%-32% (p < 0.05) at risk thresholds more conservative than the standard-of-care benchmark without missing any additional events.

CONCLUSIONS

TAPSE increased detection of low-risk AHF patients, after use of a validated CDI, at risk thresholds more conservative than standard of care.

Long-term impacts of different dialysis modalities on right ventricular function in patients with end-stage renal disease

BACKGROUND

Right ventricular dysfunction is a major cause of heart failure and mortality in end-stage renal disease patients. Scarce data is available regarding the comparison of echocardiographic right ventricular function in end-stage renal disease patients on hemodialysis (HD) and peritoneal dialysis (PD). The aim of the study was to evaluate the long-term impacts of different dialysis modalities on right ventricular function assessed by conventional echocardiography, in end-stage renal disease patients with preserved left ventricular function.

METHODS

The study included 120 patients grouped as follows: PD (n = 40), HD with arterio-venous fistula (n = 40), and healthy control subjects (n = 40). Conventional echocardiography was performed on all patients. A classification of right ventricular function was defined in HD patients by using tricuspid annular plane systolic excursion (TAPSE), right ventricular myocardial performance index (RV-MPI), fractional area change (FAC), and tricuspid lateral annulus systolic velocity (Sa) values. Correlation analysis was performed by using the right ventricular dysfunction score, clinical, and echocardiographic parameters.

RESULTS

The mean age of the study population was 51.9 ± 13.1 years and 47.5% were females. TAPSE and Sa velocity were found to be significantly lower and RV-MPI was significantly higher in patients undergoing HD, compared with control and PD patients. Logistic regression analysis showed that HD treatment was an independent risk factor for developing right ventricular dysfunction.

CONCLUSION

RV function was impaired in patients undergoing HD compared with patients on PD.

Impact of borderline pulmonary hypertension due to left heart failure on mortality in a multicenter registry study: A 3-year survivorship analysis

Background

Patients with left heart failure (LHF) are often associated with the development of pulmonary hypertension (PH) which leads to an increased risk of death. Recently, the diagnostic standard for PH has changed from mean pulmonary arterial pressure (mPAP) ≥25 mmHg to >20 mmHg. Nonetheless, the effect of borderline PH (mPAP: 21–24 mmHg) on the prognosis of LHF patients is unclear. This study aimed to investigate the relationship between borderline PH and 3-year clinical outcomes in LHF patients.

Methods

A retrospective analysis of a prospective cohort study was done for LHF patients who underwent right heart catheterization (RHC) between January 2013 and November 2016. The primary outcome was all-cause mortality; the secondary outcome was rehospitalization.

Results

Among 344 patients, 62.5% were identified with a proportion of PH (mPAP ≥ 25), 10.8% with borderline PH (21–24), and 26.7% with non-PH (≤20), respectively. Multivariable Cox analysis revealed that borderline PH patients had a higher adjusted mortality risk (HR = 3.822; 95% CI: 1.043–13.999; p = 0.043) than non-PH patients. When mPAP was treated as a continuous variable, the hazard ratio for death increased progressively with increasing mPAP starting at 20 mmHg (HR = 1.006; 95% CI: 1.001–1.012). There was no statistically significant difference in adjusted rehospitalization between borderline PH and non-PH patients (HR = 1.599; 95% CI: 0.833–3.067; p = 0.158).

Conclusions

Borderline PH is independently related to increased 3-year mortality in LHF patients. Future research is needed to evaluate whether more close monitoring, and managing with an intensifier improves clinical outcomes in borderline PH caused by LHF.

Clinical trials registration

www.clinicaltrials.gov NCT02164526.

Genetic analysis of right heart structure and function in 40,000 people

Congenital heart diseases often involve maldevelopment of the evolutionarily recent right heart chamber. To gain insight into right heart structure and function, we fine-tuned deep learning models to recognize the right atrium, right ventricle and pulmonary artery, measuring right heart structures in 40,000 individuals from the UK Biobank with magnetic resonance imaging. Genome-wide association studies identified 130 distinct loci associated with at least one right heart measurement, of which 72 were not associated with left heart structures. Loci were found near genes previously linked with congenital heart disease, including NKX2-5, TBX5/TBX3, WNT9B and GATA4. A genome-wide polygenic predictor of right ventricular ejection fraction was associated with incident dilated cardiomyopathy (hazard ratio, 1.33 per standard deviation; P = 7.1 × 10-13) and remained significant after accounting for a left ventricular polygenic score. Harnessing deep learning to perform large-scale cardiac phenotyping, our results yield insights into the genetic determinants of right heart structure and function.

Sacubitril/Valsartan in the Treatment of Right Ventricular Dysfunction in Patients With Heart Failure With Reduced Ejection Fraction: A Real-world Study

OBJECTIVE

There is increasing evidence supporting the efficacy of sacubitril/valsartan for treating left heart failure, but few studies have investigated its effects on right ventricular (RV) dysfunction. This study aimed to explore the effects of sacubitril/valsartan on RV dysfunction among patients with heart failure with reduced ejection fraction (HFrEF).

METHODS

A total of 93 patients with HFrEF with RV dysfunction who were hospitalized from January 2018 through June 2019 were included in this retrospective observational study. All patients received their first sacubitril/valsartan treatment as in patients during the study period. We excluded 11 patients who were lost to follow-up or had incomplete heart echocardiography data. After 6 months of follow-up, we re-evaluated New York Heart Association Functional Classification and performed echocardiography to identify changes in relevant variables after treatment.

RESULTS

At baseline, 24% of the patients had an initial sacubitril/valsartan regimen of 12/13 mg twice daily and 76% of the patients had an initial dose of 24/26 mg twice daily. During follow-up, 27% of patients increased their dosage to 49/50 mg twice daily, 68% of patients were taking 24/26 mg twice daily, and 5% of the patients were still taking 12/13 mg twice daily. We found that sacubitril/valsartan treatment was associated with significant improvements in the following RV function indicators: tricuspid annular plane systolic excursion, tricuspid annular s' peak velocity (S'), RV fractional area change, and pulmonary artery systolic pressure (PASP). Crude linear regression analysis revealed that a tricuspid annular plane systolic excursion improvement was positively correlated with a change in left ventricular ejection fraction (LVEF) and negatively correlated with a change in left ventricular end-systolic volume (LVESV). However, these correlations were nonexistent after adjusting for multiple echocardiographic variables.

CONCLUSIONS

In patients with RV dysfunction and HFrEF, sacubitril/valsartan may improve RV remodeling. This influence may be independent of left cardiac remodeling.

Assessment of preoperative and postoperative cardiac function in children with adenotonsillar hypertrophy: a prospective cohort study

PURPOSE

Chronic upper airway obstruction caused by adenotonsillar hypertrophy is one of the major cause of morbidity in children. It can lead to Obstructive Sleep Apnoea Syndrome, Pulmonary Hypertension, Cor Pulmonale and right heart failure. The study aimed to evaluate and compare various parameters of cardiac function with the help of echocardiography preoperatively and postoperatively in children undergoing adenotonsillectomy.

METHODOLOGY

A prospective cohort study was conducted on 23 patients at an apex care institute, under the age group of 4-12 years, who were diagnosed with adenotonsillar hypertrophy. Preoperative symptom analysis and Echocardiographic examination were done. After the assessment, all patients underwent surgery in the form of adenotonsillectomy. Follow-up symptom analysis and echocardiographic examination was done after 3 months postoperatively.

RESULTS

Significant improvement in the obstructive symptoms were noted in postoperative group as expected (p =  < 0.001) and also in parameters such as mPAP (p =  < 0.001), TAPSE (p =  < 0.001), TAV (p = 0.001), Ejection fraction (p = 0.027) and RVMPI (p = 0.044) were improved in postoperative group. 4 patients had Grade 1 Right ventricular diastolic dysfunction, which disappeared in three patients postoperatively.

CONCLUSION

We have concluded that there can be subclinical cardiac dysfunctions which occurs as a result of chronic upper airway obstruction due to untreated adenotonsillar hypertrophy. Routine cardiac screening in children presenting with sleep disordered breathing associated with adenotonsillar hypertrophy may be helpful in identifying and preventing the development of cardiopulmonary complication. These changes can be reversed by performing adenotonsillectomy.

Prognostic impact of right ventricular function affected by pulmonary hypertension in hospitalized heart failure patients

BACKGROUND

Pulmonary hypertension (PH) may affect right ventricular (RV) function; however, the prognostic implications of RV function in patients with heart failure and PH remain unclear. We aimed to investigate the impact of RV function on the prognosis of hospitalized heart failure patients with and without PH.

METHODS

This observational study initially included 1,349 consecutive hospitalized heart failure patients. After excluding patients who died in hospital, whose left ventricular (LV) function was preserved, and whose echocardiography data were incomplete, 573 patients with heart failure and reduced LV ejection fractions (HFrEF) were analyzed. The patients were grouped according to RV dysfunction that was defined as an RV-tissue Doppler imaging systolic velocity (RV-TDI s') of ≤9.5 cm/s. The primary endpoint was a composite of cardiovascular death and rehospitalization as a consequence of heart failure.

RESULTS

Overall, the patients with reduced RV function had significantly higher event rates than those with preserved RV function (log-rank test p = 0.01). This prognostic impact was observed in the patients with PH (p = 0.001) and was not evident among the patients without PH (p = 0.39). In the patients with PH, reduced RV function independently predicted the prognosis after adjusting for the covariates (adjusted hazard ratio: 3.12; 95% confidence interval: 1.44 to 6.73).

CONCLUSION

RV dysfunction that was estimated during hospitalization using the RV-TDI s', which is a simply determined index, may predict clinical outcomes in hospitalized patients with HFrEF and PH after discharge, but not in those without PH.

Prognostic value of right ventricular echocardiographic measures in patients with heart failure with reduced ejection fraction

PURPOSE

Right ventricular (RV) dysfunction is associated with poor outcome in patients with heart failure. In order to better predict mortality in this patient group we wanted to compare the prognostic value of conventional and advanced RV echocardiographic measures.

METHODS

Echocardiographic examinations were retrieved from 701 patients. End point was all-cause mortality and follow-up 100%. RV parameters were measured offline in accordance with current guidelines. Speckle tracking was derived using the algorithm originally designed for the left ventricle.

RESULTS

During follow-up (median: 39 months) 118 patients (16.8%) died. RV global longitudinal strain (GLS) and RV free wall strain (FWS) remained associated with mortality after multivariable adjustment independent of Tricuspid annular plane systolic excursion (TAPSE) (RV GLS: HR 1.07, 95%CI 1.02-1.13, p = 0.010, per 1% decrease) (RV FWS: HR 1.05, 95%CI 1.01-1.09, p = 0.010, per 1% decrease). This seemed to be caused by significant associations in men. All RV estimates provided prognostic information incremental to established risk factors and significantly increased C-statistics.

CONCLUSIONS

RV GLS and FWS were associated with mortality in HFrEF patients after multivariable adjustment independent of TAPSE. TAPSE, however, remained as the strongest prognosticator in women. More research is needed to identify whether speckle tracking could be superior to conventional RV measures in identifying HFrEF patients with poor outcome.

Clinical implications of antegrade diastolic pulmonary artery flow in adults

BACKGROUND

End-diastolic opening of the pulmonary valve and subsequent antegrade diastolic pulmonary artery flow (ADPAF) reflect restrictive right ventricular (RV) physiology in children. However, this has attracted little attention in adults.

PURPOSE

To clarify the clinical implications of ADPAF in adults.

METHODS AND RESULTS

The study population consisted of 23,049 consecutive adult patients who underwent echocardiography in our hospital between 2008 and 2015. ADPAF was found in 17 patients (0.07%). The simultaneous recording of RV and pulmonary artery pressures revealed marked elevation of RV diastolic pressure, which exceeded pulmonary artery pressure at the time of atrial contraction. These results suggested that ADPAF implies RV restriction. Based on the level of tricuspid annular plane systolic excursion (TAPSE), we classified these patients into two groups: reduced RV function (R-RVF) group (12 patients with TAPSE <17 mm) and preserved RV function (P-RVF) group (5 patients with TAPSE ≥17 mm). In the R-RVF group, four patients died, one patient underwent left ventricular assist device implantation, and two patients underwent unplanned hospitalization for heart failure during follow-up. The R-RVF group had poorer prognosis and higher mortality rate compared with the P-RVF group.

CONCLUSIONS

ADPAF reflects RV restriction in adults. ADPAF suggests a less favorable prognosis in patients with R-RVF.

Combined evaluation of right ventricular function using echocardiography in non-ischaemic dilated cardiomyopathy

Aims

Although comprehensive assessment of right ventricular (RV) function using multiple echocardiographic parameters is recommended for management of patients with non‐ischaemic dilated cardiomyopathy (DCM), it is unclear which RV parameters to combine. Additionally, normalization of RV parameters by estimated pulmonary artery systolic pressure (PASP), in consideration of RV–pulmonary artery coupling, may be clinically significant. The aim of our study was to elucidate the best combination of echocardiographic RV functional parameters, with or without indexing for PASP, to predict outcome in patients with heart failure with reduced ejection fraction secondary to DCM.

Methods and results

We retrospectively analysed 109 DCM patients with left ventricular ejection fraction <40%. RV size was assessed by RV end‐diastolic area (RVEDA) and RV end‐systolic area (RVESA) from RV‐focused apical four‐chamber view. RV function was assessed by fractional area change (FAC) and tricuspid annular plane systolic excursion (TAPSE) and by RV longitudinal strain (RVLS) using two‐dimensional speckle‐tracking echocardiography. All functional parameters were also indexed for estimated PASP. Cox analyses were used to evaluate the association of RV morphology and functional parameters with 1 year outcome (composite of left ventricular assist device implantation and all‐cause death). Area under the curve was used to compare prognostic values. Mean age was 44 ± 14 years, and 76 (69.7%) were men. Mean left ventricular ejection fraction was 21.9%, median RVEDA was 22.1 cm², FAC was 27.0%, TAPSE was 15.0 mm, and RVLS was −12.5%. Forty‐one (37.6%) patients experienced the primary outcome. Multivariate Cox analysis revealed that RVEDA, RVESA, FAC, TAPSE, RVLS, FAC/PASP, and RVLS/PASP were independent predictors for primary outcome (all P < 0.05). However, normalization with PASP did not improve area under the curve for any RV functional parameters. When we evaluate hazard ratios according to the combination of two echocardiographic parameters of RV function, patients with impairment of both FAC (<27%) and RVLS (>−8.6%) had significantly higher hazard ratio than those with either impairment alone (11.3 vs. 3.4, P < 0.001); the other combinations did not improve prognostic value.

Conclusions

Normalizing echocardiographic RV parameters for PASP did not improve the prognostic values for our population. Meanwhile, combined evaluation of FAC and RVLS improved risk stratification in patients with heart failure with reduced ejection fraction secondary to DCM.

Evaluating of Red Blood Cell Distribution Width, Comorbidities and Electrocardiographic Ratios as Predictors of Prognosis in Patients with Pulmonary Hypertension

Pulmonary hypertension is a rare condition that impairs patients' quality of life and life expectancy. The development of noninvasive instruments may help elucidate the prognosis of this cardiorespiratory disease. We aimed to evaluate the utility of routinely performed noninvasive test results as prognostic markers in patients with pulmonary hypertension. We enrolled 198 patients with mean pulmonary artery pressure >25 mmHg measured at cardiac catheterisation or echocardiographic pulmonary artery systolic pressure > 40 mmHg and tricuspid regurgitation Vmax >2.9 m/s, and clinical information regarding management and follow-up studies from the date of diagnosis. Multivariate analysis revealed that female sex [HR: 0.21, (95% CI: 0.07-0.64); p = 0.006], the presence of collagenopathies [HR: 8.63, (95% CI: 2.38-31.32); p = 0.001], an increased red blood cell distribution width [HR: 1.25, (95% CI: 1.04-1.49); p = 0.017] and an increased electrocardiographic P axis (P°)/T axis (T°) ratio [HR: 0.93, (95% CI: 0.88-0.98); p = 0.009] were severity-associated factors, while older age [HR: 1.57, (95% CI: 1.04-1.28); p = 0.006], an increased QRS axis (QRS°)/T° ratio [HR: 1.21, (95% CI: 1.09-1.34); p < 0.001], forced expiratory volume in 1 s [HR: 0.94, (95% CI: 0.91-0.98); p = 0.01] and haematocrit [HR: 0.93, (95% CI: 0.87-0.99); p = 0.04] were mortality-associated factors. Our results support the importance of red blood cell distribution width, electrocardiographic ratios and collagenopathies for assessing pulmonary hypertension prognosis.

Echocardiographic Assessment of Right Ventricular-Arterial Coupling in Predicting Prognosis of Pulmonary Arterial Hypertension Patients

In response to an increased afterload in pulmonary arterial hypertension (PAH), the right ventricle (RV) adapts by remodeling and increasing contractility. The idea of coupling refers to maintaining a relatively constant relationship between ventricular contractility and afterload. Twenty-eight stable PAH patients (mean age 49.5 ± 15.5 years) were enrolled into the study. The follow-up time of this study was 58 months, and the combined endpoint (CEP) was defined as death or clinical deterioration. We used echo TAPSE as a surrogate of RV contractility and estimated systolic pulmonary artery pressure (sPAP) reflecting RV afterload. Ventricular–arterial coupling was evaluated by the ratio between these two parameters (TAPSE/sPAP). In the PAH group, the mean pulmonary artery pressure (mPAP) was 47.29 ± 15.3 mmHg. The mean echo-estimated TAPSE/sPAP was 0.34 ± 0.19 mm/mmHg and was comparable in value and prognostic usefulness to the parameter derived from magnetic resonance and catheterization (ROC analysis). Patients who had CEP (n = 21) had a significantly higher mPAP (53.11 ± 17.11 mmHg vs. 34.86 ± 8.49 mmHg, p = 0.03) and lower TAPSE/sPAP (0.30 ± 0.21 vs. 0.43 ± 0.23, p = 0.04). Patients with a TAPSE/sPAP lower than 0.25 mm/mmHg had worse prognosis, with log-rank test p = 0.001. the echocardiographic estimation of TAPSE/sPAP offers an easy, reliable, non-invasive prognostic parameter for the comprehensive assessment of hemodynamic adaptation in PAH patients.

Exercise hemodynamics in heart failure patients with preserved and mid-range ejection fraction: key role of the right heart

OBJECTIVE

We sought to explore whether classification of patients with heart failure and mid-range (HFmrEF) or preserved ejection fraction (HFpEF) according to their left ventricular ejection fraction (LVEF) identifies differences in their exercise hemodynamic profile, and whether classification according to an index of right ventricular (RV) function improves differentiation.

BACKGROUND

Patients with HFmrEF and HFpEF have hemodynamic compromise on exertion. The classification according to LVEF implies a key role of the left ventricle. However, RV involvement in exercise limitation is increasingly recognized. The tricuspid annular plane systolic excursion/systolic pulmonary arterial pressure (TAPSE/PASP) ratio is an index of RV and pulmonary vascular function. Whether exercise hemodynamics differ more between HFmrEF and HFpEF than between TAPSE/PASP tertiles is unknown.

METHODS

We analyzed 166 patients with HFpEF (LVEF ≥ 50%) or HFmrEF (LVEF 40-49%) who underwent basic diagnostics (laboratory testing, echocardiography at rest, and cardiopulmonary exercise testing [CPET]) and exercise with right heart catheterization. Hemodynamics were compared according to echocardiographic left ventricular or RV function.

RESULTS

Exercise hemodynamics (e.g. pulmonary arterial wedge pressure/cardiac output [CO] slope, CO increase during exercise, and maximum total pulmonary resistance) showed no difference between HFpEF and HFmrEF, but significantly differed across TAPSE/PASP tertiles and were associated with CPET results. N-terminal pro-brain natriuretic peptide concentration also differed significantly across TAPSE/PASP tertiles but not between HFpEF and HFmrEF.

CONCLUSION

In patients with HFpEF or HFmrEF, TAPSE/PASP emerged as a more appropriate stratification parameter than LVEF to predict clinically relevant impairment of exercise hemodynamics. Stratification of exercise hemodynamics in patients with HFpEF or HFmrEF according to LVEF or TAPSE/PASP, showing significant distinctions only with the RV-based strategy. All data are shown as median [upper limit of interquartile range] and were calculated using the independent-samples Mann-Whitney U test or Kruskal-Wallis test. PVR pulmonary vascular resistance; max maximum level during exercise.

Percutaneous Edge-to-Edge Mitral Valve Repair: Beyond the Left Heart

Right ventricular (RV) dysfunction and tricuspid regurgitation (TR) are known to be associated with adverse outcomes in patients undergoing percutaneous mitral valve repair (PMVR). Although the effect of PMVR on left ventricular function is well known, data on the response of the right ventricle to PMVR, and its impact on prognosis, are limited. In this review the authors summarize available data regarding the prognostic role of RV function and TR in PMVR recipients and the possible effects of PMVR on the right heart. Preprocedural tricuspid annular plane systolic excursion < 15 mm, tricuspid annular tissue Doppler S' velocity < 9.5 cm/sec, and moderate or severe TR are reported as predictors of adverse outcome after PMVR. Therefore, they should be carefully evaluated for patient selection. Moreover, emerging data show that the benefit of PMVR may go beyond the left heart, leading to an improvement in RV function and a reduction in TR severity. Among PMVR recipients, improvement in RV function and reduction of TR degree are observed mainly in patients with RV dysfunction at baseline. On the other hand, high postprocedural transmitral pressure gradients seem to be associated with lack of RV reverse remodeling. Timing of mitral intervention with respect to RV impairment and predictors of RV reverse remodeling after PMVR are unknown. Further studies are needed to fill these gaps in evidence.

Tricuspid annular plane systolic excursion for the evaluation of right ventricular function in functional cardiac CT compared to MRI

AIM

To compare ejection fraction estimated by tricuspid annular plane systolic excursion (TAPSE) using cardiac computed tomography (CT) and cardiac magnetic resonance imaging (MRI) to the non-invasive reference standard, volumetric quantification of right ventricular ejection fraction (RVEF) by cardiac magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Thirty-one patients, who had undergone functional cardiac CT angiogram and cardiac MRI within 12 months, were evaluated retrospectively. Right ventricular (RV) volumes were processed using automated cardiac analysis software for CT, and manually processed by Simpson's method for MRI. MR-TAPSE was defined as the difference in length between two separate reference lines drawn at end diastole and end systole from the lateral tricuspid annulus to the right ventricular apex measured on four-chamber CINE images. CT-TAPSE was determined in an analogous manner on four-chamber reformatted images.

RESULTS

MR-TAPSE correlated moderately with MR-RVEF, (r=0.57, p<0.001). CT-TAPSE was found to correlate moderately well with MR-RVEF (r=0.58, p<0.001) and CT-RVEF (r=0.63, p<0.001). Bland-Altman analysis repeated with various multiplication factors for CT-TAPSE and MR-RVEF, determined a multiplication factor of 2.7 resulted in the lowest bias (0.74%).

CONCLUSION

CT-TAPSE is an easily obtainable parameter of RV function and is correlated with CT-RVEF and MR-RVEF. It can function as a quick check to rapidly validate CT right volumetry and estimate MR-RVEF.

Forgotten No More-The Role of Right Ventricular Dysfunction in Heart Failure with Reduced Ejection Fraction: An Echocardiographic Perspective

During the last decade, studies have raised awareness of the crucial role that the right ventricle plays in various clinical settings, including diseases primarily linked to the left ventricle. The assessment of right ventricular performance with conventional echocardiography is challenging. Novel echocardiographic techniques improve the functional assessment of the right ventricle and they show good correlation with the gold standard represented by cardiac magnetic resonance. This review summarizes the traditional and innovative echocardiographic techniques used in the functional assessment of the right ventricle, focusing on the role of right ventricular dysfunction in heart failure with reduced ejection fraction and providing a perspective on recent evidence from literature.

Body composition and ventricular function in hemodialysis patients

There is no evidence about the potential role of body composition on cardiovascular mortality in dialysis patients. The aim of this study was to assess the relationship between body composition and changes in ventricular function. We conducted an observational study over a population of 78 patients on chronic hemodialysis. A transthoracic echocardiogram and a bioimpedance were performed at the beginning and at the end of the study. The mean follow-up time was 30.6 months. Patients who had a higher fat tissue index (FTI > 9.20 kg/m² ) experienced a worsening in right and left ventricular function. They developed a greater fall in tricuspid annular plane systolic excursion (TAPSE) (-1 ± 4.3 mm) and left ventricular ejection fraction (LVEF)(-4.2 ± 6.8%), compared to those with lower FTI (p = 0.032 and p = 0.045, respectively). No associations were found between any other echocardiography or body composition parameters and overall mortality. Patients with right ventricular dysfunction (determined as TAPSE) experienced a tendency to higher mortality rate along the study (HR for mortality of 13.5 (95% CI, 1.1-166.7; p = 0.041)]. A higher fat tissue index could be associated with a deleterious effect over right and left ventricular function in dialysis patients.

Right ventricular dysfunction assessed by cardiovascular magnetic resonance is associated with poor outcome in patients undergoing transcatheter mitral valve repair

Aims

To evaluate whether CMR-derived RV assessment can facilitate risk stratification among patients undergoing transcatheter mitral valve repair (TMVR).

Background

In patients undergoing TMVR, only limited data exist regarding the role of RV function. Previous studies assessed the impact of pre-procedural RV dysfunction stating that RV failure may be associated with increased cardiovascular mortality after the procedure.

Methods

Sixty-one patients underwent CMR, echocardiography and right heart catheterization prior TMVR. All-cause mortality and heart failure hospitalizations were assessed during 2-year follow-up.

Results

According to RV ejection fraction (RVEF) <46%, 23 patients (38%) had pre-existing RV dysfunction. By measures of RV end-diastolic volume index (RVEDVi), 16 patients (26%) revealed RV dilatation. Nine patients (15%) revealed both. RV dysfunction was associated with increased right and left ventricular volumes as well as reduced left ventricular (LV) ejection fraction (all p<0.05). During follow-up, 15 patients (25%) died and additional 14 patients (23%) were admitted to hospital due to heart failure symptoms. RV dysfunction predicted all-cause mortality even after adjustment for LV function. Similarly, RVEDVi was a predictor of all-cause mortality even after adjustment for LVEDVi. Kaplan-Meier survival analysis unraveled that, among patients presenting with CMR indicative of both, RV dysfunction and dilatation, the majority (78%) experienced an adverse event during follow-up (p<0.001).

Conclusion

In patients undergoing TMVR, pre-existing RV dysfunction and RV dilatation are associated with reduced survival, in progressive additive fashion. The assessment of RV volumes and function by CMR may aid in risk stratification prior TMVR in these high-risk patients.

Echocardiographic evaluation of pulmonary hypertension, right ventricular function, and right ventricular-pulmonary arterial coupling in patients with rheumatoid arthritis

INTRODUCTION

Rheumatoid arthritis (RA) patients are at increased risk for developing cardiovascular disease, including right heart failure. The evaluation of right ventricle (RV) using the relationship between tricuspid annular plane systolic excursion (TAPSE) and right ventricular systolic pressure (RVSP) is of clinical prognostic relevance. Mild echocardiographic pulmonary hypertension (ePH) has been associated with worse RV function. The aim of this study was to evaluate RV function as measured by TAPSE to RVSP ratio in rheumatoid arthritis patients compared to matched healthy controls.

METHOD

A case-control study with 67 RA patients aged 40 to 75 years that fulfilled the 2010 ACR/EULAR criteria and 45 matching controls was included. A transthoracic echocardiogram was performed to all patients. TAPSE was measured as the distance traveled from end-diastole to end-systole. RVSP was calculated using the modified Bernoulli equation. Comparisons were done using Chi-square and Mann-Whitney's U test or Student's t test.

RESULTS

Patients with RA had significantly reduced ventricular function (TAPSE 23 [21-25] vs 25 [23-26], p = 0.033) and TAPSE/RVSP ratio was significantly lower in RA-patients than controls (TAPSE to RVSP ratio 0.809 [0.67-1.01] vs 0.933 [0.79-1.11], p = 0.009). RA-patients with mild ePH had similar RV function, evaluated by TAPSE, in comparison to RA-patients with normal RVSP.

CONCLUSION

RA-patients had worse RV function measured by TAPSE and worse TAPSE/RVSP ratio than controls. Also, RA-patients with mild ePH had reduced right ventricular-pulmonary arterial coupling in comparison with patients with RA and normal RVSP. These echocardiographic findings could justify aggressive treatment for these patients and assess their evolution. Key Points • Right ventricular (RV) function and RV coupling with the pulmonary artery (RV-PA coupling) were worse in patients with RA in comparison to healthy controls. • Values of right ventricular systolic pressure (RVSP) were similar between RA-patients and non-RA controls. • Prevalence of normal RVSP, mild echocardiographic pulmonary hypertension (ePH), and pulmonary hypertension was similar between RA-patients and non-RA matched controls •Patients with RA and mild ePH had reduced RV-PA coupling in comparison with RA-patients with normal RVSP.

Change in right ventricular systolic function after continuous renal replacement therapy initiation and renal recovery

OBJECTIVE

To describe the associations between right ventricular (RV) function and outcomes of patients with acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT).

METHODS

This is a retrospective study, conducted 2006-2015 at an academic hospital in USA. We included patients with AKI requiring CRRT who had paired echocardiograms within 2 weeks before and after CRRT initiation. We defined improvement in RV systolic function as 2-point improvement on the semiquantitative scale.

RESULTS

The cohort included 201 patients. The mean(±SD) age was 59(±16) years with 83(41%) female. The median time of the pre and post echocardiograms relative to CRRT initiation were - 1 day (IQR-3;0) prior to and 3 days (IQR1;7) after CRRT initiation. Thirty-one (15%) patients showed an improvement in their RV function. Using a multivariable logistic regression model, improvement in RV systolic function was associated with lower odds of major adverse kidney events (composite of mortality, need for dialysis or persistently elevated serum creatinine) at 90 days with odds ratio (OR) of 0.37(95%CI:0.17-0.84, p.016). Positive cumulative fluid balance was associated with lower odds of improvement in RV function (OR 0.95 per 1-l increase, p 0.045).

CONCLUSION

Serial assessment of RV function among patients with AKI requiring CRRT could provide prognostic value.

A successful case of heart transplantation concurrent with pulmonary thromboendarterectomy

INTRODUCTION

Pre-transplant irreversible pulmonary hypertension and high pulmonary vascular resistance are generally considered as contraindications for orthotopic heart transplantation due to the high risk of right ventricular dysfunction after transplantation. However, there is no consensus on whether reversible pulmonary hypertension increases the incidence of post-transplant complications and mortality.

CASE REPORT

A patient with acute heart failure and pulmonary artery occlusion successfully underwent heart transplantation concurrent with pulmonary thromboendarterectomy.

DISCUSSION AND CONCLUSION

This case illustrates that heart transplantation concurrent with pulmonary thromboendarterectomy can be performed successfully with meticulous operability assessment, superb surgical technique and careful perioperative management.

Synergy in the heart: RV systolic function plays a key role in optimizing LV performance during exercise

The right ventricle (RV) is often overlooked in the evaluation of cardiac performance and treatment of left ventricular (LV) heart diseases. However, recent evidence suggests the RV may play an important role in maintaining systemic cardiac function and delivering stroke volume (SV). We used exercise cardiac magnetic resonance and biomechanical modeling to investigate the role of the RV in LV stroke volume regulation. We studied SV augmentation during exercise by pharmacologically inducing negative chronotropy (sHRi) in healthy volunteers and investigating training-induced SV augmentation in endurance athletes. SV augmentation during exercise after sHRi is achieved differently in the two ventricles. In the RV, the larger SV is driven by increasing contraction down to lower end-systolic volume (ESV; P < 0.001). In the LV, SV augmentation is achieved through an increase in end-diastolic volume (EDV; P < 0.001), avoiding contraction to a lower ESV. The same mechanism underlies the enhanced SV response observed in athletes. Changes in atrial area during SV augmentation suggest that the improved LV EDV response is sustained by the larger RV contractions. Using our biomechanical model, we explain this behavior by showing that the RV systolic function-driven regulation of LV SV optimizes the energetic cost of LV contraction and leads to minimization of the total costs of biventricular contraction. In conclusion, this work provides mechanistic understanding of the pivotal role of the RV in optimizing LV SV during exercise. It demonstrates why optimizing RV function needs to become a key part of therapeutic strategies in patients and training for athletes.NEW & NOTEWORTHY The right ventricle appears to have an important impact on maintaining systemic cardiac function and delivering stroke volume. However, its exact role in supporting left ventricular function has so far been unclear. This study demonstrates a new mechanism of ventricular interaction that provides mechanistic understanding of the key importance of the right ventricle in driving cardiac performance.

Management of the Patient with Heart Failure and an Implantable Pulmonary Artery Hemodynamic Sensor

Purpose of Review

Heart failure (HF) management guided by hemodynamics obtained from an implantable pulmonary artery pressure (PAP) sensor (CardioMEMS) improves symptoms and reduces HF hospitalizations (HFH). This paper reviews the theoretical basis of pulmonary vascular physiology, summarizes recently published data about CardioMEMS, and provides practical guidelines for patient selection and management.

Recent Findings

Compared to patients managed by standard care, HF patients randomized to PAP-guided treatment have a higher frequency of medication adjustments, resulting in lower PAP and fewer HFH. Real-world analyses further support associations between implant of the CardioMEMS sensor with reductions in PAP, hospitalizations, and mortality.

Summary

Implantable, wireless hemodynamic sensor technology is a promising remote monitoring platform for chronic HF. A phased approach using a treatment algorithm may improve the efficiency and effectiveness of pressure-guided therapy.

Importance of Nonlongitudinal Motion Components in Right Ventricular Function: Three-Dimensional Echocardiographic Study in Healthy Volunteers

BACKGROUND

Global right ventricular (RV) function is determined by the interplay of different motion components related to the myofiber architecture, and the relative importance of these components is still not thoroughly characterized. The aims of this study were to quantify the relative contributions of longitudinal, radial, and anteroposterior motion components to global RV function and to examine their determining factors in a large cohort of healthy volunteers using three-dimensional echocardiography.

METHODS

Three hundred healthy adults with a balanced age range and an equal sex distribution were investigated at two centers. A three-dimensional mesh model of the right ventricle was generated, and its motion was decomposed along the three anatomically relevant axes. Multiplicative relative contributions were measured by dividing the ejection fraction (EF) values generated by shortening in the longitudinal, radial, and anteroposterior directions by global RV EF (longitudinal EF index [LEFi], radial EF index [REFi], and anteroposterior EF index, respectively). The circumferential contribution was defined as shortening in the radial and anteroposterior directions, omitting only longitudinal shortening.

RESULTS

Circumferential EF index was markedly higher compared with LEFi (79 ± 7% vs 47 ± 9%, P < .001). LEFi (47 ± 9%) and anteroposterior EF index (49 ± 7%) were found to be similar in the pooled population, whereas REFi (44 ± 10%) was lower (P < .001). In younger individuals (20-39 years of age), the relative contribution of longitudinal shortening was significantly higher compared with the radial component; however, in the older age groups, LEFi and REFi were comparable. Age, body surface area, heart rate, and RV end-diastolic volume were independent predictors of LEFi and REFi, but all with opposite effects on the two motion directions.

CONCLUSIONS

In contrast to the traditional viewpoint, the contributions of the radial and anteroposterior motion directions may be of comparable significance with that of longitudinal shortening in determining global RV function. Standard parameters referring only to longitudinal shortening of the right ventricle may be inadequate to characterize RV function thoroughly.

Prognostic implications of tricuspid annular plane systolic excursion/pulmonary arterial systolic pressure ratio in septic shock patients

Background

To explore the association between the ratio of tricuspid annular plane systolic excursion (TAPSE) and pulmonary arterial systolic pressure (PASP), and long- and short-term outcomes in mechanically ventilated septic shock patients.

Methods

Septic shock patients admitted to the intensive care unit (ICU) were screened for enrollment. Echocardiographic parameters including TAPSE and tricuspid regurgitation velocity, haemodynamic and respiratory parameters, and prognostic data were obtained.

Results

One hundred eighteen subjects were enrolled in this study, among whom 75 survived and 43 died at the one-year follow-up. ROC curve analysis revealed that the TAPSE/PASP ratio was able to assess one-year all-cause mortality with an area under the curve of 0.817 (95% CI: 0.739–0.896, p < 0.001) and the optimal cutoff value was 0.50 mm/mmHg. Kaplan-Meier survival analysis showed that one-year all-cause mortality was significantly higher in patients with TAPSE/PASP ≤0.5 mm/mmHg than in patients with TAPSE/PASP > 0.5 mm/mmHg (log-rank 32.934, p < 0.001). According to the Cox regression survival analyses, the TAPSE/PASP ratio was independently associated with one-year all-cause mortality (HR 0.007, 95% CI:0.000–0.162, p = 0.002) and ICU mortality (HR 0.027, 95% CI:0.001–0.530, p = 0.017). According to the multivariable analysis, the TAPSE/PASP ratio was an independent variable associated with mechanical ventilation (MV) duration (standard coefficient − 0.240, p = 0.010).

Conclusion

The TAPSE/PASP ratio demonstrated prognostic value for one-year all-cause mortality, ICU mortality and MV duration in mechanically ventilated septic shock patients.

Right ventricular assessment can improve prognostic value of Euroscore II

BACKGROUND

The aim of this multicenter prospective study was to evaluate the prognostic weight of preoperative right ventricular assessment on early mortality in cardiac surgery.

METHODS

This is a multicenter prospective observational study performed by the Italian Group of Research for Outcome in Cardiac Surgery (GIROC) including 11 centers. From October 2017 to March 2019, out of 923 patients undergoing cardiac surgery, 28 patients with some missing data were excluded and 895 patients were enrolled in the study right ventricular dilatation was defined as a basal end-diastolic diameter >42 mm. The right ventricle (RV) function was assessed using the combination of three parameters: fractional area changing (FAC), tricuspid annular plane systolic excursion (TAPSE), and S'-wave using tissue Doppler imaging (TDI-S'); RV dysfunction was defined as the presence of at least two of the following cutoffs: FAC <35%, TAPSE <17 mm, and TDI S' <9.5 mm RESULTS: Among the entire cohort, 624 (70%) showed normal RV, 92 (10%) isolated RV dilatation, 154 (17%) isolated RV dysfunction, and 25 (3%) both RV dilatation and dysfunction. Non-surviving patients showed a significantly higher rate of RV alteration at multivariable analysis, RV status was found to be an independent predictor for higher in-hospital mortality beside Euroscore II.

CONCLUSIONS

This prospective multicenter observation study shows the importance to assess RV preoperatively and to include both RV function and dimension in a risk score model such as Euroscore II to implement its predictivity, since PH cannot always mirror the status of the right ventricle.

Minimally Invasive Mechanical Circulatory Support Through the Perioperative Pulmonary Thromboendarterectomy Period: A Case Report

A 64-year-old man being evaluated for pulmonary thromboendarterectomy (PTE) preoperatively experienced pulseless electrical activity secondary to right ventricular failure while undergoing bronchoscopy. After return of spontaneous circulation, a percutaneous right ventricular assist device (RVAD) was placed through the right internal jugular vein. He continued on right ventricular support with demonstration of right ventricular recovery over the following 8 days, and subsequently underwent PTE for treatment of his primary condition. He recovered and was weaned from his RVAD support uneventfully. The need for RVAD support has traditionally been a contraindication for PTE; however, circulatory assist devices have been used as a salvage procedure for right-heart failure after PTE. This case highlights the potential for percutaneous mechanical circulatory support in treating severe perioperative right ventricular dysfunction, and to facilitate successful recovery in patients undergoing PTE.

Sacubitril/valsartan improves right ventricular function in a real-life population of patients with chronic heart failure: The Daunia Heart Failure Registry

Background

Previous studies and case-series showed improvement in left ventricular (LV) function and reverse remodeling after sacubitril/valsartan therapy in real-world studies. We therefore aimed to evaluate whether also right ventricular (RV) function may improve after sacubitril/valsartan therapy.

Methods

Sixty consecutive patients with chronic heart failure and NYHA class II-III were followed up for 12 months after therapy with sacubitril/valsartan. Left and (RV) function was assessed at baseline and after 12 months of therapy.

Results

At 12-month control, therapy with sacubitril/valsartan was associated with a significant improvement in a series of echo parameters: LVEF (p < 0.05), LV end-systolic volume (p < 0.01), left atrium area (p < 0.05).Right ventricular echo parameters were also improved after sacubitril/valsartan therapy: PAsP (31.0 ± 12.8 vs 34.7 ± 12.5 mmHg, p < 0.05), TAPSE (17.8 ± 3.9 vs 16.5 ± 4.0 mm, p < 0.001); mean PAsP reduction was 3.7 ± 11.4 mmHg (-6.3 ± 37.7%), mean TAPSE increase 1.3 ± 2.5 mm (+9.5 ± 15.7%).Indexed (%) improvement in PAsP (r 0.33, p < 0.01) and TAPSE (r -0.42, p < 0.01) values were proportional to baseline levels. Improvement in PAsP and TAPSE were independent of left ventricular improvements except for PAsP and end-systolic volumes (r 0.44, p < 0.01).

Conclusions

In a real world scenario, sacubitril/valsartan was associated with an improved RV function.

Prognostic Value of the Echocardiographic Probability of Pulmonary Hypertension in Patients with Acute Decompensated Heart Failure

The prognostic value of pulmonary hypertension (PH) estimated by echocardiography in unselected patients with acute decompensated heart failure (ADHF) is poorly studied. Between November 2014 and September 2018, 657 patients were recruited in a prospective registry of ADHF (ClinicalTrials.gov NCT02444416). The probability of pulmonary hypertension was based on European Society of Cardiology (ESC) guidelines for echocardiographic evaluation. The median survival without all-cause mortality or readmission was 7 months. During the median follow-up period of 15 months, there were 450 events including 185 deaths. In multivariate analysis, the hazard ratio (HR) of all-cause mortality or readmission for patients with a high probability of PH was 1.67 (95% CI 1.29–2.17, p < 0.001) as compared to patients with a low or intermediate probability. The left ventricular ejection fraction (LVEF) and right ventricular function (RVF) were not associated with the primary outcome—HR 1.02 (95% CI 0.81–1.29; p = 0.84) and 0.96 (95% CI 0.76–1.23; p = 0.77) respectively. In patients admitted for ADHF, a high probability of PH as evaluated by echocardiography provided the highest independent prognostic value for mortality and readmission, whereas LVEF and RVF were not associated with prognosis. The identification of patients at high risk of PH by non-invasive measurement conveys important prognostic information and may guide management.

Assessment of prognosis in immunoglobulin light chain amyloidosis patients with severe heart failure: a predictive value of right ventricular function

Although the benefit of updated therapeutic regimens, including bortezomib, on the survival of immunoglobulin light chain (AL) amyloidosis patients with heart failure (HF) has been reported, predictors of mortality in the patients treated with the updated therapy remain unclear. We retrospectively enrolled AL amyloidosis patients who had severe HF at the time of diagnosis and received the updated therapy, including bortezomib (n = 19, 61 ± 6 years old, 68% male). Severe HF was defined as the presence of both NYHA functional class III or IV and BNP > 200 pg/ml or NT-pro-BNP > 900 pg/ml. One-year mortality rate during follow-up after commencement of the treatment was 37%. Left ventricular morphological parameters and indexes of left ventricular diastolic function on admission were similar in the non-survivors and survivors. However, non-survivors had higher incidences of atrial fibrillation and ventricular tachycardia, higher serum total bilirubin levels (1.34 ± 0.55 vs. 0.61 ± 0.29 mg/dl), higher right atrial volume index (RAVI 49.7 ± 29.9 vs. 27.3 ± 6.8 ml/m²), lower tricuspid annular peak velocities during systole (RVs' 8.0 ± 1.8 vs. 11.6 ± 3.7 cm/sec) and late diastole (RVa' 3.4 ± 0.9 vs. 11.4 ± 5.3 cm/sec), and larger inferior vena cava dimension (22.7 ± 6.4 vs. 16.3 ± 4.9 mm) than those in survivors. Kaplan-Meier curve analyses showed that larger RAVI and lower RVs' and RVa', but not left ventricular systolic/diastolic dysfunction, predicted higher mortality during 1-year follow-up. The present results suggest that the presence of right-sided heart abnormality on admission is associated with high 1-year mortality in AL amyloidosis patients with severe HF under the updated therapeutic regimens.

Incremental Prognostic Value of Right Ventricular Strain in Patients With Acute Decompensated Heart Failure

BACKGROUND

Although 2-dimensional strain analyses based on speckle tracking echocardiography have been used to detect myocardial deformation, the prognostic impact of 2-dimensional strain is unclear in patients with acute decompensated heart failure (HF). We investigated whether left ventricular and right ventricular (RV) strain parameters assessed by speckle tracking echocardiography provide incremental prognostic information in hospitalized patients because of acute decompensated HF.

METHODS AND RESULTS

Six hundred eighteen patients (age, 72±13 years; 38% women; ejection fraction, 46±16%) hospitalized for acute decompensated HF underwent clinical and echocardiographic evaluation just before discharge. We performed strain analyses of left ventricular global longitudinal strain and left ventricular global circumferential strain. We also analyzed RV longitudinal strain only from the free wall (RV-fwLS) and from all segments of the RV global longitudinal strain wall by using Tomtec software. The primary composite end point was cardiovascular death and readmission for HF. There were 34.8% cardiac events during a median follow-up of 427 days. In multivariate Cox models, among echocardiographic parameters, only impaired RV-fwLS (≥-13.1%; hazard ratio, 1.51; 95% CI, 1.12-2.04; P=0.01) was independently associated with cardiac events. Adding RV-fwLS to clinical risk evaluation (age, New York Heart Association class III/IV, blood urea nitrogen, and brain natriuretic peptide) markedly improved prognostic utility and consequently increased net reclassification improvement by 0.30 ( P=0.01).

CONCLUSIONS

RV-fwLS is an independent predictor of cardiac events in acute decompensated HF and provides greater prognostic power than standard echocardiographic parameters.

Tricuspid annular plane systolic excursion is correlated with poor outcome in surgery for rheumatic heart valvular disease

BACKGROUND

Right ventricular (RV) function is a major determinant of clinical outcome, but its function indices have not been studied well in surgery for rheumatic valvular heart disease. The aim of this study was to determine the correlation of tricuspid annular plane systolic excursion (TAPSE) with outcome of rheumatic heart valve surgery.

METHODS

A prospective comparative study was conducted including 100 eligible patients who were divided into two groups based on RV function as assessed by TAPSE measured by two-dimensional (2D) echocardiography preoperatively. Those with TAPSE less than 15 mm were included in group 1 and those with TAPSE of 15 or more were included in group 2.

RESULTS

50 patients were included in group 1 and 50 patients in group 2. Mean age of the patients was 56.78 ± 15.21 years in group 1 and 54.46 ± 15.03 years in group 2 (P = 0.444). 34 (34%) patients underwent aortic valve replacement (AVR), 35 (35%) underwent both aortic and mitral valves replacement, and 31 (31%) ones had mitral valve replacement (MVR). A significant difference was found between the duration of ventilation (5.15 ± 2.80 hours in group 1 vs. 3.72 ± 2.71 hours in group 2, P = 0.001), postoperative inotropic requirement [more than 24 hours in 18 (36%) patients in group 1 vs. 7 (14%) patients in group 2, P = 0.003], total intensive care unit (ICU) stay (8.92 ± 3.62 days in group 1 vs. 5.20 ± 2.06 days in group 2, P = 0.001), and mortality [7 (14%) in group 1 vs. 2 (4%) in group 2, P = 0.038].

CONCLUSION

TAPSE less than 15 mm in patients undergoing surgical correction for rheumatic valvular heart disease leads to poor outcomes. These patients need special attention perioperatively.

Usefulness of right ventricular contraction pressure index to predict short-term mortality and right heart failure in patients who underwent continuous-flow left ventricular assist device implantation

Background:

Right ventricular stroke work index is a useful but invasively measured parameter that can be used to predict right heart failure following continuous-flow left ventricular assist device implantation. Right ventricular contraction pressure index is a novel parameter that was developed to measure right ventricular stroke work index with echocardiography. We aimed to investigate the clinical usefulness of right ventricular contraction pressure index to predict short-term mortality and right heart failure in patients who underwent continuous-flow left ventricular assist device implantation.

Methods:

A total of 49 patients who participated in institutional advanced heart failure registry and underwent continuous-flow left ventricular assist device implantation with a bridge-to-candidacy indication were analyzed retrospectively. Right ventricular contraction pressure index was calculated using offline measurements. Demographic, clinical and outcome data were obtained from the registry data. Patients were grouped according to right ventricular contraction pressure index quartiles.

Results:

Patients within the lowest right ventricular contraction pressure index quartile had a trend toward higher short-term mortality (46.2%, p = 0.056) and combined short-term mortality and definitive right heart failure (53.8%, p = 0.054) at 15th day postoperatively. Similarly, short-term survival or survival free of definite right heart failure were significantly lower in the lowest right ventricular contraction pressure index quartile (log-rank p = 0.045 and log-rank p = 0.03, respectively). In a proportional hazards model that included echocardiographic parameters, right ventricular contraction pressure index was an independent predictor for short-term mortality (odds ratio: 6.777, 95% confidence interval: 1.118–41.098, p = 0.037), but not for combined short-term mortality and definite right heart failure. No such associations were found for long-term mortality. Right ventricular contraction pressure index had a statistically significant correlation with invasively measured pulmonary capillary wedge pressure, pulmonary vascular resistance, mean pulmonary pressure, and right ventricular stroke work index.

Conclusion:

Right ventricular contraction pressure index was found as a useful parameter for determining short-term postoperative mortality in patients undergoing continuous-flow left ventricular assist device implantation.

Right ventricular systolic function in Nigerians with heart failure secondary to hypertensive heart disease

Background

Right ventricular (RV) dysfunction has been shown to be a major contributor to the adverse outcomes in subjects with heart failure. Few studies evaluating the right ventricle in heart failure subjectshave been carried out in Sub-Saharan Africa. This studywas therefore designed to evaluate the right ventricular systolic function in subjects with heart failure secondary to hypertensive heart disease presenting to the University College Hospital, Ibadan Nigeria.

Methodology

Seventy-six subjects with heart failure secondary to hypertension and 92 normal controls underwent clinical, electrocardiographic and echocardiographic evaluation. Indices of right ventricular systolic function that were measured include tricuspid annular plane systolic excursion (TAPSE), tissue Doppler derived tricuspid peak systolic lateral annulus velocity(S′) and right ventricular fractional areachange(RVFAC).

Results

Sixty-two (81.6%) heart failure subjects had right ventricular systolic dysfunction, 31(40.8%) had abnormal TAPSE, 42(55.5%) had abnormal S′ while 49(64.5%) had abnormal RVFAC. Elevated pulmonary artery systolic pressure was found in 25(32.9%) of the subjects. There was no relationship between the indices of right ventricular systolic function and the estimated systolic pulmonary artery pressures. The independent predictor of right ventricular systolic dysfunction was the right atrial size.

Conclusion

Right ventricular systolic function is impaired in patients with heart failure secondary to hypertensive heart disease. There is no relationship between the indices of right ventricular systolic function and systolic pulmonary artery pressure. Further studies are needed to assess right ventricular systolic function in Nigerians.

Predictors of early mortality after transcatheter aortic valve implantation

Objectives

To investigate whether preoperative echocardiographic evaluation of ventricular function, especially right ventricular systolic and diastolic parameters including speckle-tracking analysis, could aid in the prediction of 30-day mortality after transcatheter aortic valve implantation (TAVI) in patients with aortic stenosis.

Methods

This is a prospective observational cohort study including 227 patients accepted for TAVI at the University Hospital of North Norway and Oslo University Hospital from February 2010 through June 2013. All patients underwent preoperative transthoracic echocardiography with retrospective speckle-tracking analysis. Primary endpoint was all-cause 30-day mortality.

Results

All-cause 30-day mortality was 8.7 % (n = 19). Independent predictors of 30-day mortality were systolic pulmonary arterial pressure (SPAP) > 60 mm Hg (HR: 7.7, 95% CI: 1.90 to 31.3), heart failure (HR: 2.9, 95% CI: 1.1 to 7.78), transapical access (HR: 3.8, 95% CI: 1.3 to 11.2), peripheral artery disease (HR: 6.0, 95% CI: 2.0 to 18.0) and body mass index (HR: 0.73, 95% CI: 0.61 to 0.87). C-statistic for the model generated was 0.91 (95% CI: 0.85 to 0.98). Besides elevated SPAP, no other echocardiographic measurements were found to be an independent predictor of early mortality.

Conclusion

Except for elevated systolic pulmonary artery pressure, our data suggests that clinical rather than echocardiographic parameters are useful predictors of 30-day mortality after TAVI.

Prognostic significance of electrocardiographic right ventricular hypertrophy in the general population

BACKGROUND

Echocardiographically detected right ventricular hypertrophy (RVH) is associated with cardiovascular disease (CVD) and mortality. However, the prognostic significance of electrocardiographic (ECG)RVH criteria as predictors of poor outcomes in the general population is unclear.

METHODS

This study included 7857 participants (59.8 ± 13.4 years, 52.6% women) from the Third National Health and Nutrition Examination Survey. Sixteen different ECG-RVH criteria were created from digitally recorded and centrally processed electrocardiograms. All-cause mortality was ascertained using the National Death Index. Cox proportional hazards analysis was used to examine the association between baseline ECG-RVH criteria and all-cause mortality.

RESULTS

The prevalence of RVH varied widely among the criteria. The lowest ECG-RVH prevalence was 0.09% (using S > R in I, II, III) while the highest prevalence was 20.7% (using (R I + S III) - (S I + R III) < 15 mm). During a median follow-up of 14 years, 2812 deaths occurred. The mortality rate was highest among participants with ECG-RVH defined as R:S ratio V₅ < 0.75. In multivariable adjusted models, 9 out of the 16 ECG-RVH criteria were significantly associated with all-cause mortality. When ECG-RVH was defined as the presence of any ECG-RVH criteria, each additional ECG-RVH criteria was associated with 6% increased risk of all-cause mortality (HR (95% CI):1.06(1.03,1.10)).

CONCLUSIONS

There is a wide variation in the prevalence of ECG-RVH when different criteria are applied in the general population. However, the presence of ECG-RVH by most criteria regardless of prevalence was associated with poor prognosis suggesting that appropriate choice of criteria may enhance the utilization of these ECG markers in risk stratification.

Novel Insights and Treatment Strategies for Right Heart Failure

PURPOSE OF REVIEW

The function of the right ventricle (RV) is intimately linked to its preload (systemic volume status) and afterload (pulmonary vasculature). In this review, we explore current knowledge in RV physiology, RV function assessment, causes of right heart failure (RHF), and specific treatment strategies for RHF.

RECENT FINDINGS

We examine the evidence behind new pharmacological therapies available, such as macitentan and riociguat in the treatment of specific etiologies of RHF. We will also focus on RHF in the setting of heart failure with preserved ejection fraction (HFpEF) and in the presence of left ventricular assist devices (LVAD), looking at current treatment recommendations, including mechanical circulatory support. Lastly, we will look to the horizon for the latest research on RHF, including the molecular basis of RHF and potential novel treatment methods for this old yet poorly understood syndrome. Disturbances in this complex relationship result in the clinical syndrome of RHF. Despite advances in the management of left heart diseases, much work remains to be done to understand and manage RHF.