Changes in Right Ventricle Function After Mitral Valve Repair Surgery

Right Ventricular Function in Surgical Treatment of Left Heart

Aim    The aim of this study was to evaluate right ventricular (RV) function during left chamber surgery.Material and methods    This was a single-site prospective cohort study. The study included 197 patients with valvular pathology of heart left chambers. Mean age of patients was 58 [47; 65] years. Precordial echocardiography was performed preoperatively and within one week after surgery.Results    Decreased parameters of the right ventricular (RV) longitudinal function and global contractile function were observed postoperatively in the majority of patients. More noticeable decreases were observed in parameters of the longitudinal function (p<0.001). Analysis of the changes in RV contractility depending on the underlying pathology revealed the greatest changes in the contractile function in the mitral insufficiency group. In the mitral stenosis group, the greatest difference was observed in the tricuspid annular systolic excursion (TAPSE) (p=0.027). In the groups with aortic defects, all parameters of RV contractile function, except for the fractional area change (FAC), showed statistically significant decreases after correction of the underlying defect (p<0.05).Conclusions    Surgical intervention for left heart valvulopathy can result in a decrease in RV function unrelated with systolic deficit of the left ventricle. Modern technologies allow multi-vector assessment of the RV contractile function. To assess the RV function, it is advisable to use a combination of parameters that reflect both global and longitudinal function.

Perioperative Right Ventricular Dysfunction and Abnormalities of the Tricuspid Valve Apparatus in Patients Undergoing Cardiac Surgery

Right ventricular (RV) dysfunction frequently occurs after cardiac surgery and is linked to adverse postoperative outcomes, including mortality, reintubation, stroke, and prolonged ICU stays. While various criteria using echocardiography and hemodynamic parameters have been proposed, a consensus remains elusive. Distinctive RV anatomical features include its thin wall, which presents a triangular shape in a lateral view and a crescent shape in a cross-sectional view. Principal causes of RV dysfunction after cardiac surgery encompass ischemic reperfusion injury, prolonged ischemic time, choice of cardioplegia and its administration, cardiopulmonary bypass weaning characteristics, and preoperative risk factors. Post-left ventricular assist device (LVAD) implantation RV dysfunction is common but often transient, with a favorable prognosis upon resolution. There is an ongoing debate regarding the benefits of concomitant surgical repair of the RV in the presence of regurgitation. According to the literature, the gold standard techniques for assessing RV function are cardiac magnetic resonance imaging and hemodynamic assessment using thermodilution. Echocardiography is widely favored for perioperative RV function evaluation due to its accessibility, reproducibility, non-invasiveness, and cost-effectiveness. Although other techniques exist for RV function assessment, they are less common in clinical practice. Clinical management strategies focus on early detection and include intravenous drugs (inotropes and vasodilators), inhalation drugs (pulmonary vasodilators), ventilator strategies, volume management, and mechanical support. Bridging research gaps in this field is crucial to improving clinical outcomes associated with RV dysfunction in the near future.

Prognostic value of right ventricular remodelling in patients undergoing concomitant aortic and mitral valve surgery

AIMS

Long-term risk stratification and surgical timing remain suboptimal in concomitant aortic and mitral (double) valve surgery. This study sought to examine the predictors, changes, and prognostic implications of right ventricular (RV) remodelling in patients undergoing double-valve surgery.

METHODS AND RESULTS

In 152 patients undergoing double-valve surgery, four RV remodelling patterns were characterized using transthoracic echocardiography: normal RV size and systolic function (Pattern 1); dilated RV (tricuspid annulus diameter >35 mm) with normal systolic function (Pattern 2); normal RV size with systolic dysfunction (percentage RV fractional area change <35%; Pattern 3); and dilated RV with systolic dysfunction (Pattern 4). The primary endpoint was the composite of heart failure hospitalization and all-cause mortality. Patterns 1, 2, 3, and 4 RV remodelling were present in 41, 20, 23, and 16% of patients, respectively. Patients with Stage 4 RV remodelling had worse renal function, higher EuroSCORE II, and impaired left ventricular ejection fraction. During a 3.7-year median follow up, 45 adverse events occurred. Patterns 3 and 4 RV remodelling were associated with significantly higher adverse event rates compared with Pattern 1 (37 and 75% vs. 11%, P < 0.01) and had incremental prognostic value when added to clinical parameters and EuroSCORE II (χ2 increased from 30 to 66, P < 0.01). At 1 year after surgery (n = 100), Patterns 3 and 4 RV remodelling had a higher risk of adverse events compared with Pattern 1.

CONCLUSION

Right ventricular remodelling was strongly related to adverse outcomes and deserves consideration as part of the risk and decision-making algorithms in double-valve surgery.

Right Ventricular Function Improves Early After Percutaneous Mitral Valve Repair in Patients Suffering From Severe Mitral Regurgitation

Background

Percutaneous mitral valve edge-to-edge procedure (PMVR) using the MitraClip^® system (Abbot Vascular, CA) is an established therapy for severe mitral regurgitation (MR) in patients judged inoperable or at high surgical risk. Besides determining exercise capacity, right ventricular (RV) function has prognostic value in heart failure and after cardiac surgery. We therefore investigated the impact of PMVR on RV function in patients with severe MR.

Methods and Results

Sixty-three patients undergoing PMVR at our department were prospectively enrolled. Transthoracic echocardiography was performed before, early (2–12d) after PMVR and after 3 months, including advanced echocardiographic analyses such as 3D imaging and strain analyses. At baseline, all patients presented with advanced heart failure symptoms. Etiology of MR was more often secondary and, if present, left ventricular (LV) dysfunction was predominantly caused by ischemic cardiomyopathy. PMVR substantially reduced MR to a grade ≤ 2 in most patients. Echocardiographic assessment revealed a largely unchanged LV systolic function early after PMVR, while in contrast RV function substantially improved after PMVR [3D RV EF (%): pre 33.7% [27.4; 39.6], post 40.0% [34.5; 46.0] (p < 0.01 vs. pre), 3 months 42.8% [38.3; 48.1] (p < 0.01 vs. pre); 2D RV GLS (%): pre −12.9% [−14.5; −10.5], post −16.0% [−17.9; −12.6] (p < 0.01 vs. pre), 3 months −17.2% [−21.7; −14.9] (p < 0.01 vs. pre)]. Factors that attenuated RV improvement were larger ventricular volumes, lower LV function, secondary MR, and a higher STS score (all p < 0.05).

Conclusion

By using advanced echocardiographic parameters, we discovered an early improvement of RV function after PMVR that is preserved for months, independent from changes in LV function. Improvement of RV function was less pronounced in patients presenting with an advanced stage of heart failure and a higher burden of comorbidities reflected by the STS score.

Association between pre-operative right ventricular impairment on transthoracic echocardiography and outcomes after conventional and minimally invasive mitral valve surgery

BACKGROUND

Right ventricular (RV) impairment may have prognostic value in patients undergoing mitral valve surgery. It is unclear whether RV dysfunction predicts long-term mortality, especially in the era of minimally invasive mitral surgery.

METHODS

We performed a retrospective analysis of consecutive patients referred for conventional (via sternotomy) and minimally invasive mitral valve surgery (MIMVS) between 01 January 2013 and 29 August 2018 in a tertiary cardiac centre. We truncated follow-up times at 25 March 2020. RV impairment was defined by reduced RV longitudinal function (TAPSE <17 mm) and/or dilated basal RV diameter (RVD1 > 42 mm). Primary outcome was all-cause mortality.

RESULTS

The study cohort included 359 patients followed up for a median period of 4.2 (1.8) years. MIMVS approach was performed in 127 (35.4%) and conventional approach in 232 (64.6%) patients of whom 36 (28%) and 45 (19%), respectively, had RV impairment. EuroSCORE II was significantly higher in patients with RV impairment compared with patients with preserved RV function, irrespective of the surgical approach. Consequently, in both groups, patients with RV impairment had significantly higher mortality compared to patients with preserved RV function. RV impairment adjusted for EuroSCORE II predicted mortality in the whole cohort (HR 2.139, 95% CI 1.249-3.663) and in conventional approach (HR 2.361, 95% CI 1.249-4.465) in contrast to MIMVS (HR 1.570, 95% CI 0.493-4.997).

CONCLUSION

In this real world cohort, patients with RV impairment and/or dilation had reduced long-term survival following both conventional surgery and MIMVS. Patients should be referred to surgery prior to worsening of RV function.

The Right Ventricle in the Trans-Catheter Era: A Perspective for Planning Interventions

Dysfunction of the right ventricle (RV) is common in patients with advanced left-sided valve disease and the significant impact of RV dysfunction on both short and long-term outcome is well established. However, considerations of RV function are largely absent in current management guidelines for valve disease and cardiac procedural risk models. As the indications and use of trans-catheter therapies rapidly expand for patients with acquired valvular disease, it is critical for clinicians to understand and consider RV function when making decisions for these patients. This review summarizes contemporary data on the assessment of RV function, the prognostic importance of baseline RV dysfunction on surgical and transcatheter procedures for acquired left-sided valvular disease, and the relative impact of these interventions on RV function. Baseline RV dysfunction is a powerful predictor of poor short- and long-term outcome after any therapeutic intervention for acquired left-sided cardiac valve disease. Surgical intervention for aortic or mitral valve disease is associated with a significant but transient decline in RV function, whereas trans-catheter procedures generally do not appear to have detrimental effects on either longitudinal or global RV function. Guidelines for therapy in patents with acquired left-sided valvular disease should account for RV dysfunction. Whereas surgical intervention in these patients leads to a predictable decline in RV function, trans-catheter therapies largely do not appear to have this effect. Further study is needed to determine the impact of these findings on current practice.

The Predictive Value of Right Ventricular Longitudinal Strain in Pulmonary Hypertension, Heart Failure, and Valvular Diseases

Right ventricular (RV) systolic function has an important role in the prediction of adverse outcomes, including mortality, in a wide range of cardiovascular (CV) conditions. Because of complex RV geometry and load dependency of the RV functional parameters, conventional echocardiographic parameters such as RV fractional area change (FAC) and tricuspid annular plane systolic excursion (TAPSE), have limited prognostic power in a large number of patients. RV longitudinal strain overcame the majority of these limitations, as it is angle-independent, less load-dependent, highly reproducible, and measure regional myocardial deformation. It has a high predictive value in patients with pulmonary hypertension, heart failure, congenital heart disease, ischemic heart disease, pulmonary embolism, cardiomyopathies, and valvular disease. It enables detection of subclinical RV damage even when conventional parameters of RV systolic function are in the normal range. Even though cardiac magnetic resonance-derived RV longitudinal strain showed excellent predictive value, echocardiography-derived RV strain remains the method of choice for evaluation of RV mechanics primarily due to high availability. Despite a constantly growing body of evidence that support RV longitudinal strain evaluation in the majority of CV patients, its assessment has not become the part of the routine echocardiographic examination in the majority of echocardiographic laboratories. The aim of this clinical review was to summarize the current data about the predictive value of RV longitudinal strain in patients with pulmonary hypertension, heart failure and valvular heart diseases.

Perioperative Right Ventricular Dysfunction: Analysis of Outcomes

Right ventricular dysfunction (RVD) is a well-known prognostic factor for adverse outcomes in cardiovascular medicine. The right ventricle (RV) in medically managed heart failure patients and in surgical patients perioperatively generally is overshadowed by left ventricular disease. However, with advancement of various diagnostic tools and better understanding of its functional anatomy, the role of the RV is emerging in many clinical conditions. The failure of one ventricle has significant effect on the function of the other ventricle and it is predominantly due to ventricular interdependence.¹ The etiology of RVD is multifactorial and irrespective of etiology. RVD has been associated with significant increases in morbidity and mortality in various clinical scenarios.^2,3 The primary objective of this comprehensive review is to analyze various etiology-related outcomes of RVD in the perioperative population.

Right ventricular reserve post mitral valve repair is associated with heart failure hospitalization

Right ventricular impairment is a predictor of cardiovascular outcomes in patients with degenerative mitral regurgitation. However, the time course of right ventricular functional changes post-surgical mitral valve repair remains largely unknown. Herein, using right ventricular-focused echocardiography, we aimed to investigate right ventricular reserve and its impact on hospitalization for heart failure after mitral valve repair. In this prospective study, we enrolled 108 patients scheduled to undergo surgical repair of degenerative mitral regurgitation. Echocardiography, including right ventricular strain analysis, was performed prior to, and one month and six months post mitral valve repair. Right ventricular strain that improved one month post-surgery was defined as reserved right ventricular. In addition, any cardiovascular outcomes comprising heart failure that required admission were recorded. The median follow-up duration is 31 months. Despite a significant improvement in mitral valve regurgitant volume post-operatively, left ventricular ejection fraction (LVEF) at six months was similar to LVEF at baseline. There was a transient decrease in LV longitudinal strain at one month that was recovered six months post mitral valve repair. Regarding the right ventricular, in contrast with conventional right ventricular parameters, including right ventricular tissue Doppler S', fractional area change and tricuspid annular plane systolic excursion (TAPSE), only resolution of right ventricular strain at one month predicted the subsequent myocardial recovery. Furthermore, patients with reserved right ventricular had a lower risk of hospitalization for heart failure compared to those with non-reserved right ventricular. Collectively, the early resolution of right ventricular strain is associated with the improvement in right ventricular function (measured by TAPSE) and in heart failure hospitalization in patients who had undergone surgical mitral valve repair for degenerative mitral regurgitation.

Acute changes of global and longitudinal right ventricular function: an exploratory analysis in patients undergoing open-chest mitral valve surgery, percutaneous mitral valve repair and off-pump coronary artery bypass grafting

Background

Right ventricular (RV) function is an important prognostic indicator. The acute effects of cardiac interventions or cardiac surgery on global and longitudinal RV function are not entirely understood. In this study, acute changes of RV function during mitral valve surgery (MVS), percutaneous mitral valve repair (PMVR) and off-pump coronary artery bypass surgery (OPCAB) were investigated employing 3D echocardiography.

Methods

Twenty patients scheduled for MVS, 23 patients scheduled for PMVR and 25 patients scheduled for OPCAB were included retrospectively if patients had received 3D transesophageal echocardiography before and immediately after MVS, PMVR or OPCAB, respectively. RV global and longitudinal function was assessed using a 3D multiparameter set consisting of global right ventricular ejection fraction (RVEF), tricuspid annular plane systolic excursion (TAPSE), longitudinal contribution to RVEF (RVEF_long) and free wall longitudinal strain (FWLS).

Results

Longitudinal RV function was significantly depressed immediately after MVS, as reflected by all parameters (RVEF_long: 20 ± 5% vs. 13 ± 6%, p <  0.001, TAPSE: 13.1 ± 5.1 mm vs. 11.0 ± 3.5 mm, p = 0.04 and FWLS: −20.1 ± 7.1% vs. -15.4 ± 5.1%, p <  0.001, respectively). The global RVEF was slightly impaired, but the difference did not reach significance (37 ± 13% vs. 32 ± 9%, p = 0.15). In the PMVR group, both global and longitudinal RV function parameters were unaltered, whereas the OPCAB group showed a slight reduction of RVEF_long only (18 ± 7% vs. 14 ± 5%, p <  0.01). RVEF_long yielded moderate case-to-case but good overall reproducibility.

Conclusions

TAPSE, FWLS and RVEF_long reflect the depression of longitudinal compared to global RV function initially after MVS. PMVR alone had no impact, while OPCAB had a slight impact on longitudinal RV function. The prognostic implications of these phenomena remain unclear and require further investigation.