Indices Of Right Ventricular Function Research Articles

Association of the right ventricular ejection adjusted by the regurgitant volume with outcomes in patients with secondary tricuspid regurgitation - a three-dimensional echocardiographic study

Abstract Introduction In patients with secondary tricuspid regurgitation (STR), the chronic volume overload caused by the regurgitant volume (RegVol) may lead to an overestimation of the right ventricular (RV) systolic function when evaluated using traditional echocardiographic parameters. Purpose We sought to overcome this limitation in patients with STR by investigating whether the effective RV ejection fraction (eRVEF) – which is the RVEF calculated after subtracting the RegVol from the total RV stroke volume – has a stronger association with outcomes compared to tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), RV free-wall strain (RV-FWS), and RVEF. Methods The study included consecutive patients with a first diagnosis of STR (ranging from mild to severe) undergoing complete two-, three-dimensional (3D), and Doppler echocardiography. eRVEF was computed as forward RV stroke volume (fRVSV)/ RV end-diastolic volume, where fRVSV was obtained by subtracting the STR RegVol obtained with the PISA method from the total RVSV obtained with 3D echocardiography. The endpoint was a composite of heart failure hospitalization (HHF) and all-cause death. Results 513 patients (mean age 75±13 years, 53% female, 39% atrial STR, 58% severe STR) were included in the final cohort. After a mean follow-up of 18±15 months, 195 patients (38%) reached the composite endpoint (97 HHF and 98 all-cause deaths). At time-dependent receiver operating characteristic analysis, eRVEF (AUC 0.72, 95%CI 0.68-0.77) demonstrated a stronger association with outcome than TAPSE (AUC 0.64, 95%CI 0.59-0.69, p= 0.01), FAC (AUC 0.55, 95%CI 0.50-0.60, p<0.001), RV-FWS (AUC 0.63, 95%CI 0.58-0.68, p= 0.003), and RVEF (AUC 0.65, 95%CI 0.59-0.70, p=0.006) (Figure 1). The spline curve of mortality risk showed that the cut-off value of eRVEF associated with an excess event rate was 20%, whereas, for the conventional RVEF, it was 45%. By separating the study population into 4 groups according to eRVEF value (higher and lower than 20%) and RVEF value (higher and lower than 45%), the highest cumulative rate of events was observed in the patients with both eRVEF and RVEF reduced values (event rate at 2 years 74 ± 5%, log-rank <0.0001) (Figure 2). Interestingly, patients with eRVEF<20% and RVEF≥45% had a significantly worse outcome than patients with eRVEF≥20% and RVEF<45%. At univariate Cox regression analysis, eRVEF <20% was associated with a 3-fold increased risk of experiencing the composite outcome [hazard ratio (HR): 3.54 [2.61-4.79], p<0.0001]. On three different models of multivariable Cox regression analysis, eRVEF as a continuous variable remained independently associated with the composite outcome (HR: 0.96; 95% CI= 0.94 -1.0; p<0.001). Conclusions eRVEF showed a stronger association with the composite endpoint of all-cause mortality and HHF compared to the conventional echocardiographic indices of RV function in a large group of STR patients. Figure 1. Figure 2.

Reply to Letter to the Editor: "Is Right Ventricle- to-Left Ventricle Diameter Ratio, A Static Parameter Measured by Computed Tomography Pulmonary Angiography, An Effective Index of Right Ventricular Function?''.

Reply to Letter to the Editor: "Is Right Ventricle- to-Left Ventricle Diameter Ratio, A Static Parameter Measured by Computed Tomography Pulmonary Angiography, An Effective Index of Right Ventricular Function?''.

Is Right Ventricle-to-Left Ventricle Diameter Ratio, A Static Parameter Measured by Computed Tomography Pulmonary Angiography, An Effective Index of Right Ventricular Function?

Is Right Ventricle-to-Left Ventricle Diameter Ratio, A Static Parameter Measured by Computed Tomography Pulmonary Angiography, An Effective Index of Right Ventricular Function?

Impact of Length Indexing of Deformation in Echocardiographic Evaluation of Right Ventricular Function.

When assessing right ventricular (RV) function by echocardiography, some discordance between the deformational indices is predicted on the basis of the influence of RV length. RV free wall longitudinal strain (RVFWS) is relatively independent of RV length, whereas tricuspid annular plane systolic excursion (TAPSE) reflects the strain-length product. Systolic annular velocity (s'; distance over time) is also likely to be influenced by length. The aim of this study was to test the hypothesis that indexing TAPSE and s' to RV length would lead to better congruency with RVFWS. Two separate cohorts were identified from retrospective data: (1) subjects with normal cardiac function (n=75) and (2) a cohort with high likelihood of potential RV dysfunction determined by the study indication of either pulmonary hypertension or pulmonary embolism (n=50). RV functional indices of TAPSE, RV s', RVFWS, and fractional area change were verified and remeasured by an expert. Correlations and concordance maps between RVFWS and either TAPSE or RV s' were made with and without indexing the latter measurements to RV length. Predictive accuracy for detecting abnormal RVFWS were made using receiver operating characteristics analysis. In normal subjects, indexing either TAPSE or RV s' to RV length led to an improvement in the correlation coefficient (from 0.59 to 0.68 for TAPSE, from 0.41 to 0.58 for RV s') and the variance (F statistic from 64.9 to 105.3 for TAPSE from 24.7 to 63.9 for RV s') for correlations with RVFWS. In all subjects, categorical concordance with RVFWS was improved by indexing TAPSE and s' to RV length primarily because of correction of underperformance to detect abnormal RVFWS in subjects with long RV length and better discrimination as normal for subjects with short RV length. Indexing to RV length improved the C statistic for detecting abnormal RVFWS for both TAPSE (0.80 vs 0.87, P=.03) and RV s' (0.65 vs 0.77, P=.002). Indexing TAPSE and RV s' to RV length improves concordance of these deformational measurements with RVFWS and their ability to classify those with RV dysfunction according to RVFWS. Indexing TAPSE and RV s' to length is particularly effective for interpreting paradoxical information such as low TAPSE and s' in normal patients with short RV length and those with increased RV length who have normal TAPSE and s' values but other evidence of RV dysfunction.

Abstract 4132909: Hemodynamic Indices of Right Ventricular Function Differentially Predict Adverse Clinical Outcomes in Heart Failure with Preserved vs Reduced Ejection Fraction

Background: While the critical role of right ventricular dysfunction (RVD) in heart failure (HF) is increasingly recognized, the prevalence and prognostic impact of RVD across HF subtypes is poorly understood. Research Questions/Aims: We aimed to characterize differences in hemodynamic indices of RV function among patients with HF with preserved vs reduced ejection fraction (HFpEF, EF≥50% vs HFrEF, EF<50%) and to examine associations of RVD with longitudinal clinical outcomes by HF subtype. Methods: We identified patients with prevalent HF undergoing clinically indicated right heart catheterization at Massachusetts General Hospital (2005-2016). We examined three RV hemodynamic indices: right atrial to wedge pressure ratio (RA/PCWP), RV stroke work index (RVSWI), and pulmonary artery pulsatility index (PAPi). We used multivariable linear regression to assess differences in RV indices in HFpEF vs HFrEF. We then used Cox models to examine the association of each index with HF hospitalizations (HFH), major adverse cardiac events (MACE), and death, stratified by HF subtype. Models were adjusted for age, sex, BMI, hypertension, diabetes, lung disease, sleep apnea, and prior MI. Results: Of 2,062 patients (age 66 years, 33% women), 1,242 (60%) had HFrEF and 820 (40%) had HFpEF. RVD (RVSWI <450 mm Hg*ml/m 2 ) was present in 27% of HFrEF vs 21% of HFpEF patients. Those with HFpEF had higher RA/PCWP (β 0.12, SE 0.05, p=0.012) and RVSWI (β 0.22, SE 0.05, p<0.001) relative to HFrEF. Over 4.1 median years follow-up, 915 HFH, 1,066 MACE, and 1,116 death events occurred. Among those with HFrEF, lower PAPi was associated with greater risk of HFH (HR 0.84 (0.77, 0.92); p<0.001) and MACE (HR 0.88 (0.81, 0.96); p=0.003), and higher RVSWI was associated with greater risk of death (HR 1.17, (1.07, 1.27); p<0.001, Figure ). In contrast, in those with HFpEF, only higher RA/PCWP was associated with greater risk of death (HR 1.11 (1.00, 1.23); p=0.042). Conclusion: RVD occurs frequently in both HFrEF and HFpEF, and hemodynamic measures of RV function are associated with greater risk of MACE, death, and HFH. Importantly, the prognostic value of RV indices varied by HF subtype, highlighting key differences in the role of RVD in HFrEF vs HFpEF.

Vmax as an Index of right ventricular function in pulmonary hypertension

Abstract Background For assessing right ventricular function in pulmonary hypertension (PH), the optimal approach is through the use of load-independent parameters. While pressure-volume (PV) loops are not feasible in clinical settings, the maximum velocity of the contractile element under no load, known as Vmax, serves as an alternative measure that could be derived only from right-heart catheterization (RHC). Objectives To determine Vmax in patients undergoing RHC and to evaluate its correlation with echocardiographic parameters. Methods 15 PH patients scheduled for risk stratification were subjected to RHC and echocardiography. The contractile velocity element (VCE) was calculated as VCE = 1 / (28.8 x P) x dP/dt, with P representing RV pressure in mm Hg and dP/dt its first derivative in mmHg/s. The P vs. VCE plot displays a peak VCE value, leading into a linear slope (red line, figure 1A) with Vmax as the zero-pressure intercept. Vmax was compared with 6 different echocardiographic parameters of RV function. Results They were six females and 9 males aging 61±6 y. Mean PH was 37,6±10,1 mm Hg and Vmax averaged 2,1±0,9 length/s (range from 0,8 to 4,4 length/s). Figure 1B illustrates 3 patients with deteriorated, mildly reduced and normal VCE. When compared to Vmax, tricuspid peak systolic tissue Doppler velocity and TAPSE shown the best correlation while RV fractional area change demonstrated the worse correlation (figure 2). Conclusion Vmax, an indicator of right ventricular systolic function that does not depend on load, can be obtained through right heart catheterization. Both tissue Doppler peak systolic velocity and tricuspid annular plane systolic excursion (TAPSE) have demonstrated a strong correlation with Vmax.Invasive pressureECHO parameters

The Effect of Cardiac Resynchronization Therapy on Right Ventricular Function: A Systematic Review and Meta-Analysis.

Background: Right ventricular (RV) failure is an important predicting factor regarding overall and event-free survival regardless of baseline left ventricular (LV) function in patients with severe heart failure (HF). Previous studies have indicated that cardiac resynchronization therapy (CRT) improves LV and RV reverse remodeling in patients with systolic dyssynchrony within the left ventricle. However, there is conflicting evidence regarding the role of CRT in RV function. The aim of this systematic review and meta-analysis was to examine the implications of CRT on RV function indices. Methods: A systematic literature search was conducted using the MedLine and EMBASE databases and the Cochrane Library from their inception until 18 March 2024. Eligible were studies providing information on RV function indices, both at baseline and after CRT. Evidence was summarized using random-effects meta-analytic models. Results: In total, 30 studies were deemed eligible. CRT resulted in a significant improvement in right ventricular fractional area change (mean difference (MD) 5.11%, 95% confidence interval (CI) 2.83 to 7.39), tricuspid annular plane systolic excursion (TAPSE, MD 1.63 mm, 95% CI 1.10 to 2.16), and myocardial systolic excursion velocity (MD 1.85 cm/s, 95% CI 1.24 to 2.47) as well as a significant decrease in pulmonary artery systolic pressure (MD -6.24 mmHg, 95% CI -8.32 to -4.16). A non-significant effect was observed on TAPSE to PASP ratio and right ventricular global longitudinal strain. Conclusions: Our meta-analysis demonstrates that CRT is associated with a significant improvement in echocardiographic parameters of RV function. Further investigation is necessary to elucidate how these changes, both independently and in conjunction with LV improvement, impact patients' long-term prognosis, and to identify the specific patient populations expected to derive the greatest benefit.

Exploratory analysis of the accuracy of echocardiographic parameters for the assessment of right ventricular function and right ventricular–pulmonary artery coupling

AbstractEchocardiography is a widely used modality for the assessment of right ventricular (RV) function; however, few studies have comprehensively compared the accuracy of echocardiographic parameters using invasively obtained reference values. Therefore, this exploratory study aimed to compare the accuracy of echocardiographic parameters of RV function and RV–pulmonary artery (PA) coupling. We calculated four indices of RV function (end‐systolic elastance [Ees] for systolic function [contractility], τ for relaxation, and β and end‐diastolic elastance [Eed] for stiffness), and an index of RV–PA coupling (Ees/arterial elastance [Ea]), using pressure catheterization, cardiac magnetic resonance imaging, and a single‐beat method. We then compared the correlations of RV indices with echocardiographic parameters. In 63 participants (54 with pulmonary hypertension (PH) and nine without PH), Ees and τ correlated with several echocardiographic parameters, such as RV diameter and area, but the correlations were moderate (|correlation coefficients (ρ)| < 0.5 for all parameters). The correlations of β and Eed with echocardiographic parameters were weak, with |ρ| < 0.4. In contrast, Ees/Ea closely correlated with RV free wall longitudinal strain (RVFW‐LS)/estimated systolic PA pressure (eSPAP) (ρ = −0.72). Ees/Ea also correlated with tricuspid annular plane systolic excursion/eSPAP, RV diameter, and RV end‐systolic area, with |ρ | >0.65. In addition, RVFW‐LS/eSPAP yielded high sensitivity (0.84) and specificity (0.75) for detecting reduced Ees/Ea. The present study indicated a limited accuracy of echocardiographic parameters in assessing RV systolic and diastolic function. In contrast to RV function, they showed high accuracy for assessing RV–PA coupling, with RVFW‐LS/eSPAP exhibiting the highest accuracy.

Myocardial work across different etiologies of right ventricular dysfunction and healthy controls.

Evaluating right ventricular (RV) function remains a challenge. Recently, novel echocardiographic assessment of RV myocardial work (RVMW) by non-invasive pressure-strain loops was proposed. This enables evaluation of right ventriculoarterial coupling and quantifies RV dyssynchrony and post-systolic shortening. We aimed to assess RVMW in patients with different etiologies of RV dysfunction and healthy controls. We investigated healthy controls (n=17), patients with severe functional tricuspid regurgitation (FTR; n=22), and patients with precapillary pulmonary hypertension (PCPH; n=20). Echocardiography and right heart catheterization were performed to assess 1) RV global constructive work (RVGCW; work needed for systolic myocardial shortening and isovolumic relaxation), 2) RV global wasted work (RVGWW; myocardial shortening following pulmonic valve closure), and 3) RV global work efficiency (RVGWE; describes the relation between RV constructive and wasted work). RVGCW correlated with invasive RV stroke work index (r=0.66, P<0.001) and increased in tandem with higher afterload, i.e., was low in healthy controls (454±73 mmHg%), moderate in patients with FTR (687±203 mmHg%), and highest among patients with PCPH (881±255 mmHg%). RVGWE was lower and RVGWW was higher in patients with FTR (86±8% and 91 mmHg% [53-140]) or PCPH (86±10% and 110 mmHg% [66-159]) as compared with healthy controls (96±3% and 10 mmHg%). RVMW by echocardiography provides a promising index of RV function to discriminate between patients with RV volume or pressure overload. The prognostic value of this measure needs to be settled in future studies.

The value of right ventricular to pulmonary arterial coupling in the critically ill: a National Echocardiography Database of Australia (NEDA) substudy.

Right ventricular (RV) function is tightly coupled to afterload, yet echocardiographic indices of RV function are frequently assessed in isolation. Normalizing RV function for afterload (RV-PA coupling) using a simplified ratio of tricuspid annular plane systolic excursion (TAPSE)/ tricuspid regurgitant velocity (TRV) could help to identify RV decompensation and improve risk stratification in critically ill patients. This is the first study to explore the distribution of TAPSE/TRV ratio and its prognostic relevance in a large general critical care cohort. We undertook retrospective analysis of echocardiographic, clinical, and mortality data of intensive care unit (ICU) patients between January 2012 and May 2017. A total of 1077 patients were included and stratified into tertile groups based on TAPSE/TRV ratio: low (< 5.9mm.(m/s)-1), middle (≥ 5.9-8.02mm.(m/s)-1), and high (≥ 8.03mm.(m/s)-1). The distribution of the TAPSE/TRV ratio across ventricular function subtypes of normal, isolated left ventricular (LV), isolated RV, and biventricular dysfunction was explored. The overall prognostic relevance of the TAPSE/TRV ratio was tested, including distribution across septic, cardiovascular, respiratory, and neurological subgroups. Higher proportions of ventricular dysfunctions were seen in low TAPSE/TRV tertiles. TAPSE/TRV ratio is impacted by LV systolic function but to a lesser extent than RV dysfunction or biventricular dysfunction. There was a strong inverse relationship between TAPSE/TRV ratio and survival. After multivariate analysis, higher TAPSE/TRV ratios (indicating better RV-PA coupling) were independently associated with lower risk of death in ICU (HR 0.927 [0.872-0.985], p < 0.05). Kaplan-Meier analysis demonstrated higher overall survival in middle and high tertiles compared to low tertiles (log rank p < 0.0001). The prognostic relevance of TAPSE/TRV ratio was strongest in respiratory and sepsis subgroups. Patients with TAPSE/TRV < 5.9mm(m/s)-1 had a significantly worse prognosis than those with higher TAPSE/TRV ratios. The TAPSE/TRV ratio has prognostic relevance in critically ill patients. The prognostic power may be stronger in respiratory and septic subgroups. Larger prospective studies are needed to investigate the role of TAPSE/TRV in pre-specified subgroups including its role in clinical decision-making.

Younger age at initiation of subcutaneous treprostinil is associated with better response in pediatric Group 1 pulmonary arterial hypertension.

Children with severe Group 1 pulmonary arterial hypertension (PAH) have an unpredictable response to subcutaneous treprostinil (TRE) therapy, which may be influenced by age, disease severity, or other unknown variables at time of initiation. In this retrospective single-center cohort study, we hypothesized that younger age at TRE initiation, early hemodynamic response (a decrease in pulmonary vascular resistance by ≥30% at follow-up catheterization), and less severe baseline hemodynamics (Rp:Rs < 1.1) would each be associated with better clinical outcomes. In 40 pediatric patients with Group I PAH aged 17 days-18 years treated with subcutaneous TRE, younger age (cut-off of 6-years of age, AUC 0.824) at TRE initiation was associated with superior 5-year freedom from adverse events (94% vs. 39%, p = 0.002), better WHO functional class (I or II: 88% vs. 39% p = 0.003), and better echocardiographic indices of right ventricular function at most recent follow-up. Neither early hemodynamic response nor less severe baseline hemodynamics were associated with better outcomes. Patients who did not have a significant early hemodynamic response to TRE by first follow-up catheterization were unlikely to show subsequent improvement in PVRi (1/8, 13%). These findings may help clinicians counsel families and guide clinical decision making regarding the timing of advanced therapies.

Right ventricular myocardial work by echocardiography: non-invasive assessment of right ventricle function in patients with pulmonary hypertension

Abstract Background Right ventricular myocardial work (RVMW) assessed by transthoracic echocardiography allows to study and analyze the right ventricular (RV) function non-invasively, using RV pressure-strain loops. The association between these novel indexes of RVMW and invasive hemodynamic parameters has not yet been extensively studied, namely in precapillary pulmonary hypertension (PH) population. In right heart catheterization, stroke volume directly reflects right ventricular function in response to its load, and has prognostic implication in PH. Objectives To evaluate the relationship between RVMW and stroke volume index (SVi) measured invasively by right heart catheterization (RHC), in a cohort of patients with group I and group IV PH. Methods A prospective registry of pre-capillary PH patients evaluated in a single tertiary center was used. Echocardiography and RHC were performed in the same day. Dedicated software for left ventricle myocardial work was used for the RV. RV global myocardial work index (RVGWI) was calculated as the area of the RV pressure-strain loops. From RVGWI, RV global constructive work (RVGCW; work contributing to myocardial shortening during systole and lengthening during isovolumic relaxation), RV global wasted work (RVGWW; work contributing to myocardial lengthening during systole and shortening during isovolumic relaxation), and RV global work efficiency (RVGWE; relation between RVGCW and RVGWW) were estimated. Pearson’s correlation was applied to assess correlations between continuous variables. Results 17 pts (80% women, mean age 67 ± 10 years) were included. The average of mean pulmonary arterial pressure (mPAP) was 33 mmHg (± 9,5), of pulmonary vascular resistance (PVR) was 5,7 WU (± 5,1) and of SVi was 40,7 ml/m2 (± 10,8). Conventional echocardiographic parameters for the evaluation of RV systolic function, such as TAPSE, annular tricuspid s’ velocity and fractional area change (FAC), did not correlate with SVi. Moreover, right ventricle-pulmonary artery (RV-PA) coupling and RV GLS also did not correlate with this invasive parameter of right ventricle function. Of the RVMW indexes, RVGWW and RVGWE strongly correlated with SVi: as this invasive parameter decreases, RVGWW (r = -0,560, p = 0,019) increases significantly, whereas RVGWE (r= 0,539, p = 0,026) declines (Fig 1). In our population, RVGWI and RVGCW didn’t correlate significantly with SVi. Conclusions Finding non-invasive methods to evaluate RV function is essential in patients with RV hemodynamic overload, since conventional echocardiographic parameters do not perform well, and RV function is central in prognosis assessment in this population. Novel echocardiographic assessment of RVMW seems to provide a promising index of RV function in PH patients, as demonstrated with its correlation with SVi.Figure 1:Correlation of RVMW with SVi.

Right heart function in isolated severe tricuspid regurgitation. a new stratification approach by Speckle tracking echocardiography

Abstract Background Optimal management of severe tricuspid regurgitation (TR) remains controversial. While right ventricular (RV) systolic function is an established prognostic marker of outcomes, the potential role of right atrial (RA) function is unknown. Purpose to evaluate the clinical utility of combining RV and RA strain by Speckle-tracking echocardiography to assess RV and RA function for prediction of cardiovascular outcomes. Methods Consecutive patients with at least severe TR (severe, massive or torrential TR) evaluated in the Heart Valve Clinic were prospectively included following a comprehensive clinical protocol. Consecutive control subjects and patients with permanent atrial fibrillation were included for comparison. An independent cohort of patients was included for external validation. RA and RV mechanics analysis was performed using a novel, automated 2D strain analytical software. A combined endpoint of hospital admission due to heart failure (HF) or all-cause mortality was defined. Results 176 patients with at least severe TR, 20 AF patients and 20 control subjects were included in this study. Patients with TR showed lower RA reservoir strain (RASr) and RV-free wall longitudinal strain (RV-FWLS) compared to controls and to AF patients (p&amp;lt;0,001). After a median follow-up of 2,2 years (IQR: 12-41 months), 38% reached the combined endpoint. Reservoir RA strain (RASr) and RV-FWLS were predictors of outcomes independently of TR severity and RV dimensions in a multivariate Cox analysis (table, model 1). RA strain showed incremental value to RV strain. Conventional parameters of RV function were not predictive of events. RV-FWLS&amp;gt;-20% and RASr &amp;lt;10% identified patients with a higher event rate (p&amp;lt;0,001). The combination of abnormal values of RA and RV strain (STREI stratification) stratified 4 different groups of risk independently of TR severity, RV dimensions and clinical status (adj HR per stratum 1,89 (1,4-2,34), p&amp;lt;0,001) (table-model 2 and figure). Pre-defined cut-off values achieved similar prognostic performance in the validation cohort (n=50). Conclusion Clinical outcomes demonstrate that strain parameters are superior to conventional indices of RV function in patients with at least severe TR. The combination of RA and RV strain stratify better patients’ risk, reflecting a broader effect of TR on right heart chambers.STREI STRATIFICATION.Cox regression analysis

The Fragmented QRS Complex in Lead V1: Time for an Update of the Athlete’s ECG?

Differentiating between ECG patterns related to athletes' heart remodeling and pathological findings is a challenge in sports cardiology. As the significance of fragmented complex in athletes remains uncertain, this study aimed to assess the presence of fragmented QRS in lead V1 (fQRSV1) among young athletes and its association with heart adaptations and arrhythmias. Young athletes referred for annual pre-participation screening receiving a maximal exercise testing and transthoracic echocardiography from January 2015 to March 2021 were included. The study included 684 young athletes. The prevalence of fQRSV1 was 33%. Subjects with fQRSV1 had higher exercise capacity and indexes of right ventricular function and remodeling. Among highly trained athletes, the fQRSV1 group demonstrated also increased left ventricular wall thickness. No significant association existed between fQRSV1 and exercise-induced arrhythmias, even in highly trained athletes. The high prevalence of fQRSV1 in young athletes is associated with training-induced heart adaptations but not exercise-induced ventricular arrhythmias.Graphical The fragmented QRS complex in lead V1 in young athletes. PPS = preparticipation screening; EST = exercise stress test; fQRSV1 = fragmented QRS in lead V1; PSBs = premature supraventricular beats; PVBs = premature ventricular beats.

Obesity Modifies Clinical Outcomes of Right Ventricular Dysfunction.

Right ventricular (RV) dysfunction is associated with increased mortality across a spectrum of cardiovascular diseases. The role of obesity in RV dysfunction and adverse outcomes is unclear. We examined patients undergoing right heart catheterization between 2005 and 2016 in a hospital-based cohort. Linear regression was used to examine the association of obesity with hemodynamic indices of RV dysfunction (pulmonary artery pulsatility index, right atrial pressure:pulmonary capillary wedge pressure ratio, RV stroke work index). Cox models were used to examine the association of RV function measures with clinical outcomes. Among 8285 patients (mean age, 63 years; 40% women), higher body mass index was associated with worse indices of RV dysfunction, including lower pulmonary artery pulsatility index (β, -0.23; SE, 0.01; P<0.001), higher right atrium:pulmonary capillary wedge pressure ratio (β, 0.25; SE, 0.01; P<0.001), and lower RV stroke work index (β, -0.05; SE, 0.01; P<0.001). Over median of 7.3 years of follow-up, we observed 3006 mortality and 2004 heart failure hospitalization events. RV dysfunction was associated with a greater risk of mortality (eg, pulmonary artery pulsatility index:hazard ratio, 1.11 per 1-SD increase [95% CI, 1.04-1.18]), with similar associations with risk of heart failure hospitalization. Body mass index modified the effect of RV dysfunction on all-cause mortality (Pinteraction≤0.005 for PAPi and RA:PCWP ratio), such that the effect of RV dysfunction was more pronounced at higher body mass index. Patients with obesity had worse hemodynamic measured indices of RV function across a broad hospital-based sample. While RV dysfunction was associated with worse clinical outcomes including mortality and heart failure hospitalization, this association was especially pronounced among individuals with higher body mass index.

Unmet Needs in the Assessment of Right Ventricular Function for Severe Tricuspid Regurgitation.

Tricuspid regurgitation (TR) is a highly prevalent valvular heart disease that has been long overlooked, but lately its independent association with adverse cardiovascular outcomes was recognized. The time point to intervene and repair the tricuspid valve is defined by the right ventricular (RV) dilation and dysfunction that comes up at a later stage. While guidelines favor tricuspid valve repair before severe RV dysfunction ensues, the definition of RV dysfunction in a universal manner remains vague. As a result, the candidates for transcatheter or surgical TR procedures are often referred late, when advanced RV dysfunction is established, and any derived procedural survival benefit is attenuated. Thus, it is of paramount importance to establish a universal means of RV function assessment in patients with TR. Conventional echocardiographic indices of RV function routinely applied have fundamental flaws that limit the precise characterization of RV performance. More recently, novel echocardiographic indices such as strain via speckle-tracking have emerged, demonstrating promising results in the identification of early RV damage. Additionally, evidence of the role of alternative imaging modalities such as cardiac computed tomography and cardiac magnetic resonance, for RV functional assessment in TR, has recently arisen. This review provides a systematic appraisal of traditional and novel multimodality indices of RV function in severe TR and aims to refine RV function assessment, designate future directions, and ultimately, to improve the outcome of patients suffering from severe TR.

Echocardiographic indices of right ventricular function differentiate pre- and post-capillary pulmonary hypertension

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Heart and Lung foundation Background The importance of assessing right ventricular (RV) function in heart failure is well established. Methods evaluating intrinsic RV function using Doppler echocardiography estimating RV -pulmonary coupling assessment might improve the understanding of RV response due to increase in RV afterload in different conditions. Aim To investigate RV function and RV-pulmonary coupling in patients with pre- and postcapillary pulmonary hypertension. Material and Methods We investigated 85 patients with pulmonary hypertension (PH) defined as mPAP &amp;gt;20mmHg from right heart catheterization (RHC). Those having PH with PCWP≤15mmHg and PVR ≥ 3WU were categorized as pre-capillary PH (preCPH, n=60) and those with PCWP&amp;gt;15mmHg and PVR &amp;lt;3WU as post-capillary PH (postCPH, n=25). Of those 25 having postCPH, 16 had HFrEF (LVEF&amp;lt;50%) and 9 HFpEF )LVEF≥50%). Doppler echocardiography and RHC were done simultaneously. Results Pulmonary artery acceleration time (&amp;lt;0.01), sPAP (&amp;lt;0.01) and regional RV strain ( p&amp;lt;0.05) differed between pre- and postCPH, whereas RV -pulmonary coupling did not, table 1. The indirect echocardiographic measure demonstrating strongest association with Ees/Ea (volume method= SVrhc/ESVecho) in patients with preCPH was mPAP/CO (r=0.61, fig 1A), RV s’/sPAP and RVGLS/sPAP (r=0.62, fig 1B, and 0.57 respectively). RV e’, RV segmental and global strain were lower in HFrEF compared with HFpEF but RV-pulmonary coupling did not differ between groups. Conclusion Right ventricular-pulmonary coupling and RV free wall strain had low accuracy to differentiate pre- from post CPH which was not the case for PAAt, sPAP and RV regional strain. mPAP/CO and RVs’/sPAP suggests promise as markers for right ventricular- pulmonary coupling, especially in pre CPH.

TAPSE/systolic pulmonary artery pressure in patients with repaired TOF: Does it correlate with cardiac magnetic resonance indices?

Abstract Funding Acknowledgements Type of funding sources: None. Background and Purpose Potential benefits and optimal timing of pulmonary valve replacement (PVR) in patients with repaired tetralogy of Fallot (rTOF) are still questionable because of high morbidity due to the need for reinterventions. Cardiac magnetic resonance (CMR) is a valuable tool for the detection of irreversible right ventricular (RV) remodelling. We sought to evaluate the relation between CMR derived volumes and peak tricuspid annular systolic excursion (TAPSE)/invasively measured systolic pulmonary artery pressure (sPAP) ratio in patients who underwent right heart catheterization. Methods One hundred and forty-eight patients with rTOF were evaluated; 26 of the patients either had right ventricular outflow tract obstruction or had corrective surgery with a pulmonary conduit. Patients with severe pulmonary regurgitation underwent CMR to quantify RV volumes and EF either before PVR or as part of the follow-up protocol including those who had previous PVR and recurrent pulmonary regurgitation. Echocardiographic indices of RV function were measured according to the EACVI 2015 recommendations for chamber quantification. In a subset of patients who underwent right heart catheterization, systolic RV pressure, sPAP were recorded and TAPSE/invasively measured sPAP ratio was calculated. CMR derived volumes and EF were compared with TAPSE/sPAP. Results Forty-six patients with matching studies for echo, CMR and right heart catheterization were analyzed. Mean age of the patients were 28.0 ± 7.3 years. Mean tricuspid systolic annular velocity (S’), TAPSE, and fractional area change were 11.4 ± 2.9 cm/sec, 16.8 ± 2.9 cm, and 31.7 ± 4.2 %, respectively. CMR derived end-diastolic volume index, end-systolic volume index and EF were 154.6 ± 38.5 ml/m2, 97.4 ± 26.5 ml/m2and 40.0 ± 7.6 %, respectively. There was a negative correlation between TAPSE/sPAP and CMR derived end-diastolic volume index (r= −0.44, p = 0.049) and end-systolic volume index (r= −0.50, p = 0.024) but not with RV EF. Conclusion In patient with rTOF and significant pulmonary regurgitation, TAPSE/invasively measured sPAP is more strongly correlated to CMR derived end-systolic volume index as opposed to end-diastolic volume index. Our findings support the use of CMR derived end-systolic volume index preferentially in the decision making for PVR.

Impact of right ventricular-pulmonary arterial coupling on clinical outcomes in patients undergoing transcatheter aortic valve implantation

The interplay between pulmonary hypertension (PH) and right ventricular (RV) function is reflected in an index of RV function to pulmonary artery (PA) systolic pressure (PASP). The present study aimed to assess the importance of RV-PA coupling on clinical outcomes after transcatheter aortic valve implantation (TAVI). In a prospective TAVI registry, clinical outcomes of TAVI patients with RV dysfunction or PH were stratified according to coupling or uncoupling of tricuspid annular plane systolic excursion (TAPSE) to PASP, and compared to those of patients with normal RV function and absence of PH. The median TAPSE/PASP ratio was used to differentiate uncoupling (>0.39) from coupling (<0.39). Among 404 TAVI patients, 201 patients (49.8%) had RVD or PH at baseline: 174 patients had RV-PA uncoupling, and 27 had coupling at baseline. RV-PA hemodynamics normalized in 55.6% of patients with RV-PA coupling and in 28.2% of patients with RV-PA uncoupling, and deteriorated in 33.3% of patients with RV-PA coupling and in 17.8% of patients with no RVD, respectively, at discharge. Patients with RV-PA uncoupling after TAVI showed a trend towards an increased risk of cardiovascular death at 1year as compared to patients with normal RV-function (HRadjusted 2.06, 95% CI 0.97-4.37). After TAVI, RV-PA coupling changed in a significant proportion of patients and is a potentially important metric for risk stratification of TAVI patients with RVD or PH. TWEET: "Patients with right ventricular dysfunction and pulmonary hypertension are at increased risk of death after TAVI. Integrated right ventricular to pulmonary artery hemodynamics change after TAVI in a significant proportion of patients and is instrumental to refine risk stratification." https://www. gov: NCT01368250.

Right Ventricular Function Indices at Rest and During Exercise in Hyperthyroid Patients: A Cross-sectional Study.

Since hyperthyroidism could be associated with right ventricular dysfunction, this study intended to investigate right ventricular (RV) function using strain echocardiography in hyperthyroid patients both at rest and in maximum-stress conditions. This cross-sectional study was conducted at Rajaie Cardiovascular Medical and Research Center, Tehran, Iran, from January 2019 to January 2020. All study participants completed a maximum treadmill exercise test, as well as a complete two-dimensional echocardiogram at rest and the peak of stress test. The data were analyzed using SPSS statistical software. The independent samples t test and Mann-Whitney U test were used for numerical, and the Chi square test was used for nominal variables. P<0.05 was considered statistically significant. The final analysis included 52 participants (26 subjects in each group). In a maximal stress situation, we found that among the RV function indices, RV global longitudinal strain (P=0.0001), systolic strain rate (P=0.0001), diastolic strain rate (P=0.0002), and tricuspid annular plane systolic excursion (P=0.019) werereduced significantly in the hyperthyroid patients compared to the control group. There was also a linear correlation between RV size and thyroid stimulating hormone (TSH) level (P=0.009, r=0.36). Moreover, we found a negative linear correlation between TSH level with maximum stress RV strain and diastolic strain rate (P<0.001). The findings of the present study revealed a significant change in RV function indices among hyperthyroid patients. Therefore, it highlights the necessity of early diagnosis and treatment of hyperthyroidism, as well as RV function evaluation in these patients.