Improvement In Right Ventricular Systolic Function Research Articles

How to assess and treat right ventricular electromechanical dyssynchrony in post-repair tetralogy of Fallot: insights from imaging, invasive studies, and computational modelling.

Right bundle branch block (RBBB) and resulting right ventricular (RV) electromechanical discoordination are thought to play a role in the disease process of subpulmonary RV dysfunction that frequently occur post-repair tetralogy of Fallot (ToF). We sought to describe this disease entity, the role of pulmonary re-valvulation, and the potential added value of RV cardiac resynchronization therapy (RV-CRT). Two patients with repaired ToF, complete RBBB, pulmonary regurgitation, and significantly decreased RV function underwent echocardiography, cardiac magnetic resonance, and an invasive study to evaluate the potential for RV-CRT as part of the management strategy. The data were used to personalize the CircAdapt model of the human heart and circulation. Resulting Digital Twins were analysed to quantify the relative effects of RV pressure and volume overload and to predict the effect of RV-CRT. Echocardiography showed components of a classic RV dyssynchrony pattern which could be reversed by RV-CRT during invasive study and resulted in acute improvement in RV systolic function. The Digital Twins confirmed a contribution of electromechanical RV dyssynchrony to RV dysfunction and suggested improvement of RV contraction efficiency after RV-CRT. The one patient who underwent successful permanent RV-CRT as part of the pulmonary re-valvulation procedure carried improvements that were in line with the predictions based on his Digital Twin. An integrative diagnostic approach to RV dysfunction, including the construction of Digital Twins may help to identify candidates for RV-CRT as part of the lifetime management of ToF and similar congenital heart lesions.

Obstructive Sleep Apnea and Right Ventricular Remodeling: Do We Have All the Answers?

Obstructive sleep apnea (OSA) syndrome is a very important sleep-related breathing disorder related to increased cardiovascular and overall morbidity and mortality. It is associated with multisystemic target organ damage due to micro- and macrovascular changes, resulting in carotid and coronary atherosclerosis, increased arterial stiffness, retinal damage, microalbuminuria, and cardiac remodeling. The latter consists of left ventricular (LV) hypertrophy, as well as diastolic and systolic dysfunction. The increasing burden of evidence shows that OSA also induces right ventricular (RV) remodeling that is more difficult to diagnose, but may also contribute to cardiovascular morbidity and mortality in these patients. Conventional echocardiographic parameters for assessment of RV systolic and diastolic functions are often not sensitive enough to detect subclinical and subtle changes in the RV function. Data published over last decade showed that the RV function, particularly systolic, is impaired in OSA patients and related with its severity. However, the introduction of speckle tracking echocardiography and the particularly longitudinal strain enabled the earlier detection of functional and mechanical changes even when conventional echocardiographic parameters of RV systolic function remained unchanged. The 3D echocardiography provided the possibility to evaluate the entire RV, with its unique shape, and determine 3D RV ejection fraction, which is comparable with results obtained by cardiac magnetic resonance. The use of this modality also provided a new insight into RV systolic (dys)function in OSA patients. In addition to weight loss, which has been proven very helpful in OSA patients, the only approved therapeutic approach is continuous positive airway pressure (CPAP) therapy. It is very important to assess if this therapy induces any improvement in cardiac structure and function. Limited data on this topic show that RV longitudinal strain is a more sensitive parameter rather than other conventional RV indexes in the detection of improvement in RV systolic function and mechanics. The aim of this review article is to summarize the current understanding of RV structural, functional, and mechanical changes in patients with OSA. Furthermore, we sought to provide the current knowledge regarding the effect of CPAP therapy on RV reverse remodeling in OSA patients.

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

To describe the associations between right ventricular (RV) function and outcomes of patients with acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT). 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 2weeks before and after CRRT initiation. We defined improvement in RV systolic function as 2-point improvement on the semiquantitative scale. 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-1day (IQR-3;0) prior to and 3days (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 90days 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). Serial assessment of RV function among patients with AKI requiring CRRT could provide prognostic value.

Right Ventricular Reverse Remodeling after Pulmonary Endarterectomy in Patients with Chronic Thrombo Embolic Pulmonary Hypertension

Purpose Chronic thrombo-embolic pulmonary hypertension (CTEPH) leads to right ventricular (RV) adverse remodeling if left untreated. We recently compared RV features between CTEPH patients and healthy controls. We found that capillary rarefaction, myocardial fibrosis, cardiomyocytes hypertrophy and increased macrophages infiltration were associated with impaired ventricular-arterial coupling, RV dysfunction and increased glucose uptake. Pulmonary endarterectomy (PE) is the treatment of choice for CTEPH, resulting in a marked decrease in RV afterload. In this study, we sought to investigate the correlations between preoperative RV pathological features and postoperative RV function and metabolism. Methods We followed 9 CTEPH patients undergoing PE during which we performed RV biopsies. RV phenotype was assessed using cardiac magnetic resonance, resting echocardiography and 18-Fluoro-Deoxi-Glucose Positron Emission Tomography before PE, and at 1- and 6-months post operatively. Results RV systolic pressures decreased in all patients at 1 month follow-up. Similarly, indices of RV function, remodeling, glucose uptake and coupling as assessed by the Stroke Volume/End Systolic Volume ratio significantly improved at 6 months follow-up. Improvement of RV ejection fraction and RV end systolic volume index were correlated to pre-operative cardiomyocytes hypertrophy (Figure 1). There was a trend for an association between RV fibrosis and moderate improvement in RV systolic function after PE. Preoperative macrophage infiltration and capillary density did not impact on postoperative RV functional recovery. Conclusion After PE, RV phenotype was associated with marked improvement in RV systolic function 6 months, which correlated with pre-operative cardiomyocytes hypertrophy. RV fibrosis was not associated with impaired outcomes and did not limit RV functional recovery in this study. Chronic thrombo-embolic pulmonary hypertension (CTEPH) leads to right ventricular (RV) adverse remodeling if left untreated. We recently compared RV features between CTEPH patients and healthy controls. We found that capillary rarefaction, myocardial fibrosis, cardiomyocytes hypertrophy and increased macrophages infiltration were associated with impaired ventricular-arterial coupling, RV dysfunction and increased glucose uptake. Pulmonary endarterectomy (PE) is the treatment of choice for CTEPH, resulting in a marked decrease in RV afterload. In this study, we sought to investigate the correlations between preoperative RV pathological features and postoperative RV function and metabolism. We followed 9 CTEPH patients undergoing PE during which we performed RV biopsies. RV phenotype was assessed using cardiac magnetic resonance, resting echocardiography and 18-Fluoro-Deoxi-Glucose Positron Emission Tomography before PE, and at 1- and 6-months post operatively. RV systolic pressures decreased in all patients at 1 month follow-up. Similarly, indices of RV function, remodeling, glucose uptake and coupling as assessed by the Stroke Volume/End Systolic Volume ratio significantly improved at 6 months follow-up. Improvement of RV ejection fraction and RV end systolic volume index were correlated to pre-operative cardiomyocytes hypertrophy (Figure 1). There was a trend for an association between RV fibrosis and moderate improvement in RV systolic function after PE. Preoperative macrophage infiltration and capillary density did not impact on postoperative RV functional recovery. After PE, RV phenotype was associated with marked improvement in RV systolic function 6 months, which correlated with pre-operative cardiomyocytes hypertrophy. RV fibrosis was not associated with impaired outcomes and did not limit RV functional recovery in this study.

Potts Shunt Improves Right Ventricular Function and Coupling With Pulmonary Circulation in Children With Suprasystemic Pulmonary Arterial Hypertension.

Pulmonary arterial hypertension is a progressive disease with poor outcomes in children. Right ventricular (RV) function is the most important determinant of the prognosis. Novel application of Potts shunt between left pulmonary artery and descending aorta has been introduced in an attempt to improve the survival. However, the effect of Potts shunt creation on RV function, RV-PA coupling, and survival has not been studied. We evaluated the first 12 consecutive pediatric patients (9 male, median age 11.2 years and weight 32.8 kg) who underwent elective Potts shunt placement for suprasystemic pulmonary arterial hypertension between 2013 and 2017 with echocardiographic indices of RV function, RV work, RV-PA coupling, and pulmonary hemodynamics. Of 12 patients, 1 was excluded because of insufficient preshunt data, 2 died, 1 required lung transplant, and 8 survived for a median of 27 months postshunt. In survivors, WHO functional class significantly ( P=0.01) improved and the majority (5 of 8) came off pulmonary vasodilators at the most recent follow-up. Postshunt RV systolic function improved ( P=0.03), RV afterload decreased ( P <0.01), RV work decreased ( P=0.02), and RV-proximal PA coupling improved ( P<0.01). This proof of concept study shows that Potts shunt allows improvement in functional status and mid-term transplant-free survival in the majority of the recipients by improvement in RV systolic function and RV-PA coupling in children with suprasystemic pulmonary arterial hypertension.

Interplay Between RV Function and CRT, Which One Affects the Other?

Background: Cardiac resynchronization therapy (CRT) is an established treatment of heart failure with reduced EF (HFrEF) and wide QRS complex. Nearly 30% of candidates are non-responders. One of the suggested mechanisms of inadequate response is the reduced baseline RV function; also the effect of CRT on right ventricular systolic function has not been well studied. We examined the effect of CRT on right ventricular (RV) dimensions and overall systolic function and whether RV function prior to CRT could have an impact on CRT response. Methods: 30 patients with a mean age of 51.9 ± 9.2 years including 9 (30%) females, with advanced HF (EF 120 ms, or non-LBBB > 150 ms, with NYHA class III or ambulatory class IV) were enrolled and underwent CRT implantation. Standard two dimensional (2D) echocardiography, tissue Doppler imaging, for assessment of Left ventricular (LV) end-diastolic (LVEDV), and end-systolic volumes (LVESV), ejection fraction, RV maximum basal (RVD1 basal), maximum mid (RVD2 mid) transverse, maximum longitudinal (RVD3 long) diameters, TAPSE, fractional area change (FAC), right ventricle index of myocardial performance(RIMP) and tricuspid lateral annular systolic velocity (S’), were done before CRT implantation and at the end of the follow up period (6 months). Patients presenting with reduction of LVESV of >15% were considered responders. Results: 20 (67%) cases were responders. Both groups were similar regarding demographic, clinical, ECG, and echocardiographic criteria at baseline however, the RA volume and RV transverse diameters were smaller and systolic function parameters were significantly better in the responders group prior to CRT compared to non-responders (NR) group. At the end of the follow up, only the responders group had further significant reduction in RV basal, mid and longitudinal diameters together with significant improvement in RV systolic function, in contrast to non-responders group who showed more RV dilatation and more decline of RV systolic function, compared to baseline readings(with P value 40 % has 85% sensitivity and 90 % specificity (P value= 0.004). TAPSE of >20 mm has 85% sensitivity and 80 % specificity (P value=0.002), S' of >10 cm/s % has 85% sensitivity and 70 % specificity (P value=0.001) and RIMP of <0.52 has 85% sensitivity and 70 % specificity (P value=0.003) in predicting CRT response. Conclusions: CRT induces RV reverse remodeling and improves RV systolic function particularly in cardiac volumetric responders. RV systolic dysfunction before CRT implantation could identify patients that might not benefit from CRT thus helping proper patient selection and optimizing CRT response.

Improvement in Right Ventricular Systolic Function after Cardiac Resynchronization Therapy Correlates with Left Ventricular Reverse Remodeling

Cardiac resynchronization therapy (CRT) improves left ventricular (LV) systolic function in heart failure (HF). However, the effects of CRT on right ventricular (RV) systolic function are not fully understood. We aimed to determine echocardiographic correlates of improvement in RV systolic function after CRT. Fifty-four patients (61.9 ± 10.5 years; 43 men; LV ejection fraction 24.6 ± 4.0%; QRS duration > 120 ms) with HF were enrolled. Standard echocardiography, strain rate (SR), and tissue Doppler imaging were performed in all patients before and 6 months after CRT. Pulsed-wave TDI-derived systolic indices of RV included systolic (RV(S) ) and isovolumic velocity (RV(IVV)) and isovolumic acceleration (RV(IVA)). Response to CRT was defined as decline in LV end-systolic volume (LVESV) ≥ 10%. When indices of RV systolic function were assessed between responders and nonresponders, in responders (38 patients, 70.4%) RV end-diastolic diameters (RVD1-3), mid-RV strain, and mid-RV SR improved significantly (P < 0.01, for all). RV(S) (10.77 ± 4.29 vs 12.62 ± 4.10 cm/sec, P = 0.005), RV(IVV) (14.71 ± 5.88 vs 18.52 ± 6.62 cm/sec, P < 0.001), and RV(IVA) (1.69 ± 0.70 vs 2.39 ± 0.77 m/sec(2) , P < 0.001) significantly increased among responders. There was no significant change in these parameters among nonresponders. Pearson's analyses revealed moderate positive correlations between reduction of LVESV and ΔRV(IVV) (r = 0.467, P = 0.001) and ΔRV(IVA) (r = 0.473, P = 0.001), respectively. RV diameters and systolic indices after CRT improved only in the responder group. Improvement in RV systolic performance after CRT is correlated with the reduction of LVESV.

What is the time course of reversal of tachycardia-induced cardiomyopathy?

Although the reversal of tachycardia-induced cardiomyopathy has been described previously, the time course of improvement in biventricular systolic function associated with tachycardia-induced cardiomyopathy has not been described. We present the case of a tachycardia-induced cardiomyopathy associated with atrial fibrillation. A transthoracic and transoesophageal echocardiogram performed the day prior to ablation revealed severe right and left ventricular (LV) systolic dysfunction. New York Heart Association Class IV symptoms and LV function were noted to improve 12 h after a successful catheter ablation. However, right ventricular (RV) systolic function remained depressed. A transthoracic echocardiogram demonstrated improvement of RV systolic function 5 months later. A 59-year-old male with a history of symptomatic paroxysmal atrial fibrillation (AF) refractory to dofetilide was referred for catheter ablation. Despite medical therapy, the patient had episodes of AF associated with New York Heart Association (NYHA) Class IV symptoms. Prior to ablation, a transthoracic echocardiogram (TTE) revealed a left ventricular ejection fraction (LVEF) of 25–30%. The patient underwent a successful wide area circumferential ablation of his pulmonary veins with confirmation of entrance and exit block and no inducible arrhythmias. On discharge …

Delayed improvement of right ventricular diastolic function and regression of right ventricular mass after percutaneous pulmonary valve implantation in patients with congenital heart disease

Percutaneous pulmonary valve implantation (PPVI) has been introduced as therapy for right ventricular (RV) to pulmonary artery conduit dysfunction in patients with congenital heart disease. It has been shown that RV systolic function improved early after PPVI. The effects of PPVI on RV diastolic function and RV hypertrophy have not yet been studied. The objective of this study is to assess early and late changes in systolic and diastolic RV function and RV mass after PPVI. Fourteen patients underwent PPVI (7 male, median age 15 years). Cardiac magnetic resonance imaging was performed before and at 2 time points after PPVI (at 1 and 16 months). Right ventricular volume and systolic and diastolic function as well as RV mass were assessed. At 1 and 16 months after PPVI, the RV mass decreased from 28.6 +/- 2.1 to 25.6 +/- 2.2 g/m(2) (P = .03) and to 22.3 +/- 2.1 g/m(2) (P = .002). E/A volume ratio increased from 1.91 +/- 0.4 to 2.6 +/- 0.4 (not significant [NS]) and to 3.3 +/- 0.4 (P = .01). E/A peak flow ratio increased from 1.34 +/- 0.14 to 1.48 +/- 0.16 (NS) and to 1.73 +/- 0.14 (P = .04). E-wave deceleration time increased from 142 +/- 25 to 160 +/- 27 milliseconds (NS) and to 211 +/- 26 milliseconds (P = .007). At 1 month, RV end-diastolic volume decreased from 124 +/- 8 to 113 +/- 8 mL (P = .01) and RV ejection fraction increased from 36% +/- 2% to 46% +/- 2% (P = .001) without further improvement at 16 months. After PPVI, in contrast to rapid improvement of RV systolic function, the improvement of RV diastolic function is delayed. The reduction of RV mass appears to be the underlying mechanism for improvement of RV diastolic function. Long follow-up for patients with PPVI is recommended.

Acute effects of biventricular pacing on right ventricular function assessed by tissue Doppler imaging

The benefits of cardiac resynchronization therapy (CRT) on functional status, left ventricular (LV) remodelling and survival in patients with drug-refractory congestive heart failure (CHF), LV systolic dysfunction, and wide QRS have been demonstrated in randomized trials. However, the impact of CRT on right ventricular (RV) function, an independent prognostic factor in CHF remains questionable. This study examined the acute effects of various pacing modes on RV function in recipients of CRT systems. Echocardiographic examinations were performed in 15 patients (median age: 67 years, range 49-78), to compare RV function during atrial (AAI), RV and LV pacing, and biventricular (BiV) pacing, in random order. At baseline, the median LV ejection fraction was 20% (range 10-35) and the median LV end-diastolic diameter was 78 mm (range 62-85). Right ventricular function was impaired, with a median 36% fractional shortening of RV surfaces (7-59). Tissue Doppler systolic peak of velocity (Sa) recorded at the tricuspid annulus increased significantly from 9.9 cm/s (range 4.7-16.5) during AAI pacing, 10 cm/s (range 5.4-20.3) during RV pacing, and 11.7 cm/s (range 4.6-16.7) during LV pacing to 12.6 cm/s (range 6.6-19.1) during BiV pacing (P < 0.01). Trends toward improvements in other indices of RV function, particularly myocardial performance index and systolic excursion of the tricuspid annulus, were also observed. This short-term study showed a significant improvement in RV systolic function during BiV pacing compared with AAI, RV, or LV pacing in CRT recipients.