Right heart dysfunction: from pathophysiologic insights to therapeutic options: a translational overview

Sacubitril/valsartan on right ventricular-pulmonary artery coupling and albumin-bilirubin score in heart failure in Chinese patients with reduced ejection fraction

OBJECTIVE

Impaired right ventricular (RV)-pulmonary arterial (PA) coupling, calculated by measuring the tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP), can be used as an early indicator of right ventricular dysfunction (RVD) in patients with heart failure with a reduced ejection fraction (HFrEF). Patients suffering from HFrEF experience improvements in left ventricular (LV) function through the administration of sacubitril/valsartan therapy. In addition, the albumin-bilirubin (ALBI) score was associated with the fluid overload status and adverse clinical outcomes in patients with heart failure. This study aimed to assess whether angiotensin receptor-neprilysin inhibitor (ARNI) affects the TAPSE /PASP in patients with HFrEF, and whether there is a correlation between changes in the ALBI score and ARNI treatment.

METHODS

A retrospective observational study was conducted on 305 patients with HFrEF and RVD who were hospitalized between June 2020 and December 2021. One year after treatment, laboratory test results, ALBI score, transthoracic echocardiography (TTE), New York Heart Association classification, Minnesota Living with Heart Failure Questionnaire scores and changes in relevant variables were reevaluated.

RESULTS

Compared to before sacubitril/valsartan treatment, the ALBI was found to be significantly reduced after one year of follow-up (-2.42 ± 0.37 vs. -2.51 ± 0.32, p < 0.001). Additionally, A significant improvement was demonstrated in the following echocardiography parameters assessing RV function after 1 year of treatment with sacubitril/valsartan: TAPSE (15 ± 1 vs. 18 ± 2 mm, p < 0.001), PASP (45 ± 8 vs. 40 ± 9 mmHg, p < 0.001), pulmonary artery diastolic pressure (PADP) (22 ± 4 vs. 19 ± 4 mmHg, p < 0.001), RV-PA coupling (0.35 ± 0.08 vs. 0.48 ± 0.12, p < 0.001), and RV s'(8.7 ± 2.2 vs. 9.5 ± 2.6 cm/s, p < 0.001). Multivariate analysis showed that the improvement of RV-PA coupling was associated with baseline PASP (r: -0.45, p < 0.001) and PADP (r: -0.45, p < 0.001).

CONCLUSIONS

Sacubitril/valsartan improves RV-PA conjugation in patients with RVD and HFrEF, and has a positive impact on the ALBI score by improving liver function in patients with HFrEF.

Early detection of immune checkpoint inhibitor-related subclinical cardiotoxicity: A pilot study by using speckle tracking imaging and three-dimensional echocardiography

Background

Early detection of subclinical cardiotoxicity of immune checkpoint inhibitor (ICI) therapy can be challenging.

Objective

To evaluate subclinical cardiac dysfunction using two-dimensional speckle tracking imaging (2D-STI) and three-dimensional echocardiography in Chinese patients.

Methods

Fifty-five consecutive patients with malignant tumors treated by immunotherapy were included. They were examined by echocardiography before immunotherapy and after immunotherapy. Left ventricular ejection fraction (LVEF) was calculated in three-dimensional imaging. Moreover, left ventricular global longitudinal peak systolic strain (LVGLS), left ventricular global circumferential peak systolic strain (LVGCS), right ventricular global longitudinal systolic strain (RVGLS), right ventricular free wall longitudinal peak systolic strain (RVFWLS), and tricuspid annular plane systolic excursion (TAPSE) were evaluated. Clinical and laboratory parameters were recorded. Cardiac toxicity events were defined as the presence of heart failure symptoms, LVEF reduction, and increase in troponin. Subclinical cardiac toxicity was defined as cardiac dysfunction associated with ICI treatment, with absent or delayed ICI-associated cardiotoxicity clinical symptoms.

Results

Compared with baseline, the LVGLS, TAPSE, and RVGLS significantly deteriorated after ICI treatment [(-18.63 ± 2.53)% vs. (-17.35 ± 2.58)%, P = 0.000; 18.29 ± 6.23 vs. 14.57 ± 3.81, P = 0.0001; and (-18.45 ± 4.65)% vs. (-14.98 ± 3.85)%, P = 0.0001, respectively]. LVGLS (-17.35 ± 2.58, P = 0.000), TAPSE (14.57 ± 3.81, P = 0.0001), and RVGLS [(-14.98 ± 3.85)%, P = 0.0001] were decreased after ICI immunotherapy. Kaplan-Meier curve analysis showed that LVGLS was more sensitive than the cardiac toxicity events to assess ICI-related subclinical cardiac dysfunction (log-rank P = 0.205). The ROC curve showed that the cutoff value of ΔLVGLS was -13%.

Conclusion

Subclinical cardiac dysfunction can be detected using two-dimensional speckle-tracking imaging. LVGLS, RVGLS, and TAPSE are more sensitive indices for detection.

Clinical trial registration

[https://www.chictr.org.cn/showprojen.aspx?proj=27498], identifier [ChiCTR1800016216].

Effects of Sodium-Glucose Co-Transporter-2 Inhibition on Pulmonary Arterial Stiffness and Right Ventricular Function in Heart Failure with Reduced Ejection Fraction

Background and Objectives: In addition to left ventricular (LV) functions, right ventricular (RV) functions and pulmonary arterial stiffness (PAS) may be adversely affected in patients with heart failure with reduced ejection fraction (HFrEF). Sodium-glucose co-transporter-2 (SGLT2) inhibitor therapy positively affects LV functions as well as having functional and symptomatic benefits in HFrEF patients. In this study, we aimed to evaluate the effects of SGLT2 inhibitor treatment on RV function and PAS in HFrEF patients. Materials andMethods: 168 HFrEF patients with New York Heart Association (NYHA) class ≥2 symptoms despite optimal medical treatment and who were started on SGLT2 inhibitor therapy were included in this retrospective study. NYHA classification, N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, Minnesota Living with Heart Failure Questionnaire (MLWHFQ) scores, laboratory tests, and transthoracic echocardiography (TTE) measurements were recorded before treatment and at the end of the 6-month follow-up. Results: The mean age of the patients was 62.7 ± 11.4 years, and 38 (22.6%) were women. RV function (RV fractional area change (FAC) (33.8 ± 6.4% vs. 39.2 ± 7.3%, p < 0.001); tricuspid annular plane systolic excursion (TAPSE) (18.4 ± 3.8 mm vs. 19.6 ± 3.6 mm, p < 0.001); RV S’ (10 (8 − 13) cm/s vs. 13 (10 − 16) cm/s, p < 0.001); RV myocardial performance index (RV MPI) (0.68 ± 0.12 vs. 0.59 ± 0.11, p < 0.001); mean pulmonary artery pressure (mPAP) (39.6 ± 7.8 mmHg vs. 32 ± 6.8 mmHg, p = 0.003)) and PAS (24.2 ± 4.6 kHz/ms vs. 18.6 ± 3.1 kHz/ms, p < 0.001) values at the 6-month follow-up after SGLT2 inhibitor therapy significantly improved. It was found that SGLT2 inhibitor treatment provided significant improvement in NYHA classification, MLWHFQ scores, and NT-proBNP levels (2876 ± 401 vs. 1034 ± 361, p < 0.001), and these functional and symptomatic positive changes in HFrEF patients were significantly correlated with positive changes in LVEF, PAS, and RV functional status. Conclusions: SGLT2 inhibitor treatment results in symptomatic and functional well-being in HFrEF patients, as well as positive changes in RV function and PAS.

Risk Factors of Right Ventricular Dysfunction and Adverse Cardiac Events in Patients with Repaired Tetralogy of Fallot

Aim: This study evaluates the risk factors associated with right ventricular (RV) dilation and dysfunction leading to pulmonary valve replacement (PVR) or adverse cardiac events in repaired Tetralogy of Fallot (rToF) patients. Methods: Data from all rToF patients who underwent magnetic resonance imaging (MRI) evaluation at our hospital between February 2007 and September 2020 were collected. Results: Three hundred and forty-two patients (60% males, 42% older than 18 years), with a median age of 16 years (IQR 13–24) at the time of MRI, were included. All patients underwent complete repair at a median age of 8 months (IQR 5–16), while palliation was performed in 56 patients (16%). One hundred and forty-four patients (42%) subsequently received pulmonary valve replacement (PVR). At the multivariate analysis, male gender was an independent predictor for significant RV dilation, RV and left ventricular (LV) dysfunction. Transventricular ventricular septal defect (VSD) closure and previous palliation significantly affected LV function and RV size, respectively. Male gender and the transventricular VSD closure were independent predictors for PVR. Conclusions: Male gender and surgical history (palliation, VSD closure approach) significantly affected the long-term outcomes in rToF patients and should be taken into consideration in the follow-up management and in PVR timing in this patient population.

Predictors of right ventricular function improvement with sacubitril/valsartan in a real-life population of patients with chronic heart failure

Background

Observational studies have demonstrated that treatment with sacubitril/valsartan may improve left ventricular (LV) systolic and diastolic function in subjects with reduced LV ejection fraction (LVEF) in real‐world studies. Subjects with heart failure and reduced EF (HFrEF), however, are also characterized by an impaired right ventricular (RV) function. We therefore aimed to evaluate whether also RV function may improve after S/V therapy and possible predictors of RV improvement could be identified at echocardiography and tissue Doppler imaging.

Methods

Fifty consecutive patients (67 ± 8 years, LVEF 28 ± 6%, male 86%) with chronic HFrEF and NYHA class II‐III were followed up for 6 months after therapy with S/V. LV&RV function was assessed at baseline and after 6 months of therapy.

Results

After 6‐month therapy with S/V a significant improvement was shown in the following echocardiography parameters assessing RV function: PAsP (31 ± 11 vs. 35 ± 10 mmHg, p < 0.001), TAPSE (19 ± 3 vs. 18 ± 3 mm, p < 0.001), RV FAC (38 ± 7 vs. 34 ± 6 mm, p < 0.001), RV S’ (12 ± 2 vs. 10 ± 2 cm/s, p < 0.001), RV‐FW‐LS (−20 ± 5 vs. −18 ± 5%, p < 0.001), RV‐4Ch‐LS (−16 ± 5 vs. −14 ± 5%, p < 0.001). At multivariable analysis improvement in RV‐FW‐LS was associated to baseline levels of RV S’ (r 0.75, p < 0.01) and RAV (r –0.32, p < 0.05).

Conclusions

In a real‐world scenario, 6‐month therapy with S/V was associated with an improved RV function in HFrEF. RV function improvement may be predicted by assessing baseline RV S’ and right atrial volume values.

Congestion occurrence and evaluation in acute heart failure scenario: time to reconsider different pathways of volume overload

Although congestion is considered to be the main reason for hospital admission in patients with acute heart failure, a simplistic view considering idro saline retention and total body volume accumulation did not provide convincing data. Clinical congestion occurrence is often the tip of the iceberg of several different mechanisms ranging from increased filling pressure to extravascular fluid accumulation and blood flow redistribution. Therefore, the clinical evaluation is often restricted to a simple physical examination including few and inaccurate signs and symptoms. This superficial approach has led to contradictory data and patients have not been evaluated according to a more realistic clinical scenario. The integration with new diagnostic ultrasonographic and laboratory tools would substantially improve these weaknesses. Indeed, congestion could be assessed by following the most recognized HF subtypes including primitive cardiac defect, presence of right ventricular dysfunction, and organ perfusion. Moreover, there is a tremendous gap regarding the interchangeable concept of fluid retention and redistribution used with a univocal meaning. Overall, congestion assessment should be revised, considering it as either central, peripheral, or both. In this review, we aim to provide different evidence regarding the concept of congestion starting from the most recognized pathophysiological mechanisms of AHF decompensation. We highlight the fact that a better knowledge of congestion is a challenge for future investigation and it could lead to significant advances in HF treatment.

Cardiorespiratory fitness and right ventricular mechanics in uncomplicated diabetic patients: Is there any relationship?

AIMS

This study investigated the association between cardiorespiratory fitness and right ventricular (RV) strain in uncomplicated diabetic patients.

METHODS

This cross-sectional study involved 70 controls and 61 uncomplicated patients with type 2 diabetes, who underwent laboratory analysis, comprehensive echocardiographic study and cardiopulmonary exercise testing.

RESULTS

RV endocardial and mid-myocardial longitudinal strains were significantly reduced in diabetic subjects (- 27.5 ± 4.2% vs. - 25.3 ± 4.3%, p = 0.004 for endocardial strain; - 25.6 ± 3.5% vs. - 24.1 ± 3.2%, p = 0.012 for mid-myocardial strain). The same was revealed for endocardial and mid-myocardial of RV free wall. There was no difference in RV epicardial strain. VO₂ was significantly lower in the diabetic group (27.8 ± 4.5 ml/kg/min vs. 21.5 ± 4.2 ml/kg/min, p < 0.001), whereas ventilation/carbon dioxide slope was significantly higher in diabetic subjects (25.4 ± 2.9 vs. 28.6 ± 3.3). Heart rate recovery was significantly lower in diabetic patients. HbA1c and global RV endocardial longitudinal strain were independently associated with peak VO₂ and oxygen pulse in the whole study population.

CONCLUSION

Diabetes impacts RV mechanics, but endocardial and mid-myocardial layers are more affected than epicardial layer. RV endocardial strain and HbA1c were independently associated with cardiorespiratory fitness in the whole study population. Our findings show that impairment in RV strain and cardiorespiratory fitness may be useful indicators in early type 2 diabetes, prior to the development of further complications.