The Reduction in Right Ventricular Longitudinal Contraction Parameters Is Not Accompanied by a Reduction in General Right Ventricular Performance During Aortic Valve Replacement: An Explorative Study

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.

Identifying risk factors for perioperative decline in right ventricular performance in cardiac surgery patients: a prospective observational study in a tertiary care hospital

OBJECTIVES

Impaired right ventricular (RV) function after cardiac surgery is associated with morbidity and long-term mortality. The purpose of this study was to identify factors that play a role in the development of RV dysfunction in the perioperative cardiac surgery setting.

DESIGN

We performed a prospective, observational, single centre study. Over a 2-year period, baseline and perioperative characteristics were recorded. For analysis, subjects were divided into three groups: patients with a ≥3% absolute increase in postoperative RV ejection fraction (RVEF) in comparison to baseline (RVEF+), patients with a ≥3% absolute decrease in RVEF (RVEF-) and patients with a <3% absolute change in RVEF (RVEF=).

SETTING

Tertiary care hospital in the Netherlands.

PARTICIPANTS

We included all cardiac surgery patients ≥18 years of age equipped with a pulmonary artery catheter and admitted to the ICU in 2015-2016. There were no exclusion criteria. A total number of 267 patients were included (65.5% men).

OUTCOME MEASURES

Risk factors for a perioperative decline in RV function.

RESULTS

A reduction in RVEF was observed in 40% of patients. In multivariate analysis, patients with RVEF- were compared with patients with RVEF= (first-mentioned OR) and RVEF+ (second-mentioned OR). Preoperative use of calcium channel blocker (CCB) (OR 3.06, 95% CI 1.24 to 7.54/OR 2.73, 95% CI 1.21 to 6.16 (both p=0.015)), intraoperative fluid balance (FB) (OR 1.45, 95% CI 1.02 to 2.06 (p=0.039)/OR 1.09, 95% CI 0.80 to 1.49 (p=0.575)) and baseline RVEF (OR 1.22; 95% CI 1.14 to 1.30/OR 1.27, 95% CI 1.19 to 1.35 (both p<0.001)) were identified as independent risk factors for a decline in RVEF during surgery.

CONCLUSION

Apart from the impact of the perioperative FB, preoperative use of a CCB as a risk factor for perioperative reduction in RVEF is the most prominent new finding of this study.

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.

Could strain echocardiography help to assess systolic function in critically ill COVID-19 patients?

Strain echocardiography enables the automatic quantification of the global longitudinal strain (GLS), which is a direct measure of ventricular shortening during systole. In the current context of overwhelmed ICUs and clinician shortage, GLS has the advantage to be quick and easy to measure by non-experts. However, little is known regarding its value to assess bi-ventricular systolic function in critically ill COVID-19 patients. Therefore, we designed a study to compare right and left ventricular GLS with classic echo-Doppler indices of systolic function, namely the ejection fraction for the left ventricle (LVEF) and the fractional area change (FAC), the tricuspid annular plane systolic excursion (TAPSE), and the tissue Doppler velocity of the basal free lateral wall (S’) for the right ventricle. Eighty transthoracic echocardiographic evaluations done in 30 ICU patients with COVID-19 were analyzed. We observed a fair relationship (r = 0.73, p < 0.01) between LVEF and left ventricular GLS. The GLS cut-off value of − 22% identified a LVEF < 50% with a sensitivity of 63% and a specificity of 80%. All patients with a GLS > − 17% had a LVEF < 50%. Although statistically significant, relationships between FAC (r = 0.41, p < 0.01), TAPSE (r = 0.26, p < 0.05) and right ventricular GLS were weak. S’ was not correlated with right ventricular GLS. In conclusion, left ventricular GLS was useful to assess left ventricular systolic function. However, right ventricular GLS was poorly correlated with FAC, TAPSE and S’. Further studies are needed to clarify what is the best method to assess right ventricular systolic function in ICU patients with COVID-19.