Mean Right Ventricular Ejection Fraction Research Articles

Prognosis and predictors of right ventricular dysfunction by quantitative cardiac magnetic resonance in non-ischaemic cardiomyopathy.

Pathophysiology and prognostic implications of right ventricle (RV) dysfunction in heart failure are complex and incompletely elucidated. Cardiac magnetic resonance imaging (CMR) is the reference standard for RV quantification, but its clinical implications in non-ischaemic cardiomyopathy (NICM), in the context of myocardial fibrosis and functional mitral regurgitation are not well defined. We evaluated predictors, prognostic impact, and thresholds for defining significant RV dysfunction in NICM. NICM patients (n = 624) undergoing CMR assessment during 2002-2017 were retrospectively studied. CMR's quantification of right ventricular ejection fraction (RVEF) was evaluated against the primary outcome of all-cause mortality, heart transplant, and/or left ventricular assist device implantation in threshold and multivariable analyses. Mean RVEF was 43 ± 13%, and factors associated with reduced RVEF were male sex, New York Heart Association (NYHA) class III-IV, right bundle branch block, lower left ventricular ejection fraction, higher mitral regurgitant fraction (MR-RF) and right ventricle size in NICM. RVEF per 5% increase was independently associated with the primary endpoint hazards ratio (95% confidence interval) 0.80 (0.73-0.88), P < 0.001. RVEF ≤40% was the optimal threshold associated with worse prognosis, regardless of late gadolinium enhancement (LGE) or MR-RF quantification. On the other hand, higher LGE was associated with primary endpoint in patients with RVEF ≤40% only, while risk associated with MR-RF was significant dampened after adjusting for RVEF. RVEF provides powerful risk stratification, with RVEF ≤40% defining significant RV dysfunction associated with adverse outcomes in NICM. The integration of quantitative CMR measurements for RVEF, LGE, and MR-RF provides comprehensive NICM risk prognostication.

An attention-based deep learning method for right ventricular quantification using 2D echocardiography: Feasibility and accuracy.

To test the feasibility and accuracy of a new attention-based deep learning (DL) method for right ventricular (RV) quantification using 2D echocardiography (2DE) with cardiac magnetic resonance imaging (CMR) as reference. We retrospectively analyzed images from 50 adult patients (median age 51, interquartile range 32-62 42% women) who had undergone CMR within 1 month of 2DE. RV planimetry of the myocardial border was performed in end-diastole (ED) and end-systole (ES) for eight standardized 2DE RV views with calculation of areas. The DL model comprised a Feature Tokenizer module and a stack of Transformer layers. Age, gender and calculated areas were used as inputs, and the output was RV volume in ED/ES. The dataset was randomly split into training, validation and testing subsets (35, 5 and 10 patients respectively). Mean RVEDV, RVESV and RV ejection fraction (EF) were 163±70mL, 82±42mL and 51%±8% respectively without differences among the subsets. The proposed method achieved good prediction of RV volumes (R2 =.953, absolute percentage error [APE]=9.75%±6.23%) and RVEF (APE=7.24%±4.55%). Per CMR, there was one patient with RV dilatation and three with RV dysfunction in the testing dataset. The DL model detected RV dilatation in 1/1 case and RV dysfunction in 4/3 cases. An attention-based DL method for 2DE RV quantification showed feasibility and promising accuracy. The method requires validation in larger cohorts with wider range of RV size and function. Further research will focus on the reduction of the number of required 2DE to make the method clinically applicable.

Abstract 15106: Echocardiography versus Cardiac Magnetic Resonance-Quantification of Right Ventricular Function to Stratify the Risk of Appropriate Defibrillator Therapy

Background: Right ventricular dysfunction is recently referred as an independent predictor of sudden cardiac death. The purpose of this study was to evaluate the efficiency of risk stratification methods for appropriate implantable cardiac defibrillator (ICD) therapy using two different modalities to quantify the right ventricular function. Methods: Consecutive patients undergoing ICD implantations who completed both preprocedural echocardiography and cardiac magnetic resonance (CMR) were retrospectively enrolled. Any channelopathy or arrhythmogenic right ventricular disease were excluded. The right ventricular fractional area change (RVFAC) and estimated pulmonary artery pressure (EPAP) were calculated from echocardiography. The contraction-pressure index (CPI) was defined as the quotient of the RVFAC divided by EPAP. The right ventricular ejection fraction (RVEF) was automatically provided by CMR. Both were evaluated to predict the initial appropriate ICD therapy. Results: In total, 111 patients (59.5±14.9 years, 79 males) including 20 with ischemic cardiomyopathy were retrospectively enrolled. Fifty-six patients received an ICD as secondary prophylaxis. The mean RVFAC, CPI, and RVEF were 36.7±8.9%, 1.4±0.7%, and 39.9±13.8%, respectively. Regarding appropriate ICD therapy events, the best cut-off value of the RVFAC was 34.8 (specificity 0.63, sensitivity 0.65, ROC-AUC 0.64), CPI 1.59 (specificity 0.42, sensitivity 0.94, ROC-AUC 0.61) and RVEF 43.0 (specificity 0.48, sensitivity 0.87, ROC-AUC 0.64). The hazard ratio of a low RVFAC was 3.13 (95%CI: 1.32-7.44, P&lt;0.01, concordance=0.62), that of low CPI was 9.60 (95%CI: 1.27-72.4, P=0.03, c=0.65), and that of reduced RVEF was 5.55 (95%CI: 1.64-18.7, P&lt;0.01, c=0.67). Conclusion: CPI and RVEF were similarly associated with an increased appropriate ICD therapy. The CPI seemed to provide an equivalent stratification for the risk of appropriate ICD therapy as compared to a CMR indicator.

Safety and feasibility of adjunct autologous cord blood stem cell therapy during the Norwood heart operation

BackgroundWe conducted this phase I, open-label safety and feasibility trial of autologous cord blood (CB) stem cell (CBSC) therapy via a novel blood cardioplegia-based intracoronary infusion technique during the Norwood procedure in neonates with an antenatal diagnosis of hypoplastic left heart syndrome (HLHS). CBSC therapy may support early cardiac remodeling with enhancement of right ventricle (RV) function during the critical interstage period. MethodsClinical grade CB mononucleated cells (CBMNCs) were processed to NetCord-FACT International Standards. To maximize yield, CBSCs were not isolated from CBMNCs. CBMNCs were stored at 4 °C (no cryopreservation) for use within 3 days and delivered after each cardioplegia dose (4 × 15 mL). ResultsOf 16 patients with antenatal diagnosis, 13 were recruited; of these 13 patients, 3 were not treated due to placental abruption (n = 1) or conditions delaying the Norwood for >4 days (n = 2) and 10 received 644.9 ± 134 × 106 CBMNCs, representing 1.5 ± 1.1 × 106 (CD34+) CBSCs. Interstage mortality was 30% (n = 3; on days 7, 25, and 62). None of the 36 serious adverse events (53% linked to 3 deaths) were related to CBMNC therapy. Cardiac magnetic resonance imaging before stage 2 (n = 5) found an RV mass index comparable to that in an exact-matched historical cohort (n = 22), with a mean RV ejection fraction of 66.2 ± 4.5% and mean indexed stroke volume of 47.4 ± 6.2 mL/m2 versus 53.5 ± 11.6% and 37.2 ± 10.3 mL/m2, respectively. All 7 survivors completed stage 2 and are alive with normal RV function (6 with ≤mild and 1 with moderate tricuspid regurgitation). ConclusionsThis trial demonstrated that autologous CBMNCs delivered in large numbers without prior cryopreservation via a novel intracoronary infusion technique at cardioplegic arrest during Norwood palliation on days 2 to 3 of life is feasible and safe.

PO-05-061 RIGHT VENTRICULAR SYSTOLIC FUNCTION ON MRI IS RELATED TO APPROPRIATE ICD THERAPY

Right ventricular function is recently referred as an independent predictor of sudden cardiac death (SCD). The purpose of this study was to evaluate the association of right ventricular ejection fraction (RVEF) on magnetic resonance imaging (MRI) and appropriate ICD therapy. Consecutive patients who underwent initial ICD implantation for any diseases except for non-dilated phase hypertrophic cardiomyopathy and channelopathy were retrospectively enrolled from 2012 to 2018 and were followed up on appropriate ICD therapy and death. We enrolled patients who underwent MRI before ICD implantation. RVEF, RV radial strain, RV circumferential strain (RVCS), RV 4 chamber transmural strain and RV 4 chamber longitudinal stain were evaluated to investigate the association with appropriate ICD therapy. RVEF was analyzed on the software (MR Multi-Chamber Wall Motion Tracking, Canon). In total, 97 patients (58.5±14.5 years, 69 males) including 20 ischemic cardiomyopathy were enrolled. Fifty-one patients received an ICD as a secondary prophylaxis. Mean LVEF and RVEF were 37.4±14.5% and 36.2±12.6%, respectively. There was no correlation between RVEF and LVEF (correlation coefficient =0.36). Regarding appropriate ICD therapy events, the best cut-off value of RVEF was 43.0%. The hazard ratio (HR) of low RVEF was 9.601 (95%CI: 1.287-71.6, P=0.027). Secondary prophylactic cohort with low RVEF showed highest incidence of appropriate ICD therapy as shown in the figure. In multivariate analysis about RVEF and RV strain, low RVEF and RVCS were independent predictors of appropriate ICD therapy (RVEF:HR 12.4, 95%CI:1.51-101, P=0.019 and circumferential strain: HR 0.8, 95%CI:0.76-0.98, P=0.021). RVCS in appropriate ICD group (-11.1±4.6%) was lower than RVCS in non-therapy group (-7.0±11.7%). Low RVCS predicted higher incidence of appropriate ICD therapy. Low RVEF was associated with increased appropriate ICD therapy.

Abstract 13542: Associations of Pulmonary Artery Stiffness With Mortality in Pulmonary Arterial Hypertension

Introduction: Pulsatility, the relative area change of the pulmonary artery (PA) during the cardiac cycle has been associated with impaired prognosis in pulmonary arterial hypertension (PAH), but other measurements of stiffness are not well explored. Hypothesis: Multiple indices of PA stiffness derived from cardiac magnetic resonance (CMR) and right heart catheterization (RHC) predict outcome in PAH Methods: Retrospective chart review on 108 patients with PAH who had a clinically indicated CMR and RHC within 90 days, and for the primary endpoint of all-cause mortality. From CMR and RHC data, PA areas and indexes of stiffness (pulsatility, compliance, capacitance, distensibility, elastic modulus, and the pressure-independent stiffness index beta) were measured. Data was analyzed using Cox-proportional hazards models. Results: We included 108 patients with average age of 51 (+/- 13) years, 79% female with a mean PA pressure of 46 +/-12 mmHg, and a mean right ventricular ejection fraction (RVEF) of 38 +/-14%. After a median follow-up of 6 years, 58 (54%) patients had died. Most indices of increased stiffness were associated with higher mortality after adjusting for age, sex, diuretic use, mean PA pressure and RVEF ( Table ). Conclusions: Among patients with PAH, most measurements of PA stiffness strongly correlated with mortality.

Right ventricular ejection fraction with cardiac magnetic resonance using a wall motion score

The volumetric method in cardiac magnetic resonance (CMR), the reference standard for right ventricular ejection fraction (RVEF), requires expertise because of the complex right ventricular geometry and anatomical landmarks. The aim of our retrospective study was to describe a new method to evaluate RVEF based on wall motion score index (WMSI) in CMR. Visual assessment of wall motion was performed using an eight-segment model (normokinesia=1, hypokinesia=2, akinesia=3). Correlation between WMSI (WMS/8) and the reference volumetric RVEF was analysed. A regression equation was derived to convert the WMSI into RVEF. The accuracy of CMR WMSI-derived RVEF compared with CMR volumetric RVEF was evaluated using Bland-Altman analysis. In the 112 patients using the volumetric method, the mean RVEF was 48±14%. Fifty-nine patients had normal RV kinetics (WMSI=1), which corresponded to a volumetric RVEF of 56% (standard deviation 7%; range 43-76%). CMR WMSI showed a strong correlation with CMR volumetric RVEF (Spearman's Rho=-0.69). A regression equation was created: RVEF=80-22×WMSI. Overall, the WMSI-derived RVEF resulted in good agreement with the CMR volumetric RVEF (mean bias-3%, standard deviation±7.5%). In addition, using a WMSI cut-off of≥1.5 was highly accurate (92%) to predict a reference RVEF of˂45%, an important prognostic indicator in CMR. Our results suggest that using the WMS in CMR (eight-segment) to estimate RVEF is accurate, and correlates well with the volumetric method. A WMSI≥1.5 is optimal to categorize patients in the higher-risk subset of CMR RVEF˂45%.

Right Ventricular Ejection Fraction for the Prediction of Major Adverse Cardiovascular and Heart Failure-Related Events: A Cardiac MRI Based Study of 7131 Patients With Known or Suspected Cardiovascular Disease.

There is increasing evidence that right ventricular ejection fraction (RVEF) may provide incremental value to left ventricular (LV) ejection fraction for the prediction of major adverse cardiovascular events. To date, generalizable utility for RVEF quantification in patients with cardiovascular disease has not been established. Using a large prospective clinical outcomes registry, we investigated the prognostic value of RVEF for the prediction of major adverse cardiovascular events- and heart failure-related outcomes. Seven thousand one hundred thirty-one consecutive patients with known or suspected cardiovascular disease undergoing cardiovascular magnetic resonance imaging were prospectively enrolled. Multichamber volumetric quantification was performed by standardized operational procedures. Patients were followed for the primary composite outcome of all-cause death, survived cardiac arrest, admission for heart failure, need for transplantation or LV assist device, acute coronary syndrome, need for revascularization, stroke, or transient ischemic attack. A secondary, heart failure focused outcome of heart failure admission, need for transplantation/LV assist device or death was also studied. Mean age was 54±15 years. The mean LV ejection fraction was 55±14% (range 6%-90%) with a mean RVEF of 54±10% (range 9%-87%). At a median follow-up of 908 days, 870 (12%) patients experienced the primary composite outcome and 524 (7%) the secondary outcome. Each 10% drop in RVEF was associated with a 1.3-fold increased risk of the primary outcome (P<0.001) and 1.5-fold increased risk of the secondary outcome (P<0.001). RVEF was an independent predictor following comprehensive covariate adjustment, inclusive of LV ejection fraction. Patients with an RVEF<40% experienced a 3.1-fold risk of the primary outcome (P<0.001) with a 1-year cumulative event rate of 22% versus 7% above this cutoff. RVEF is a powerful and independent predictor of major adverse cardiac events with broad generalizability across patients with known or suspected cardiovascular disease. These findings support migration towards biventricular phenotyping for the classification of risk in clinical practice. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04367220.

P6093D echocardiography versus cardiovascular magnetic resonance in the evaluation of the right ventricle in patients with congenital heart disease after pulmonary valve replacement

Abstract Background Cardiac MR (CMR) is the gold standard for right ventricular (RV) quantification. Three-dimensional echo (3DE) is a relatively new technique which may offer a rapid alternative for the examination of the right heart. The purpose of this study was to investigate the clinical significance and interchangeability of these modalities to evaluate patients with congenital heart disease (CHD) who underwent percutaneous pulmonary valve implantation (PPVI) for RV outflow tract dysfunction. Methods 36 patients who underwent PPVI were evaluated with 3DE and CMR to quantify the RV. RV volumes and ejection fraction (EF) were measured for both imaging techniques with commercially available softwares (Tomtec-Germany for 3DE and Medimatic-Netherlands for CMR data). Paired t-test, Bland-Altman analysis, and Pearson's correlation analysis were used as most appropriate to compare both measured techniques with CMR regarded as the reference standard. Results 86% of the patients (31 patients) had adequate image quality on 3DE and was included in the study. Patients underwent both 3D echo and CMR within a mean of 9 days of each other and at a mean time of 3 years after PPVI. Compared to CMR, 3D echo significantly underestimated volumes in all patients and overestimate RV ejection fraction (EF). Mean RV End-diastolic Volumes (EDV) and End-Systolic Volumes (ESV) were significantly greater when measured by CMR compared to 3D echo (EDV: 99 ml/m2 vs. 85 ml/m2; p&lt;0.01, ESV: 52 ml/m2 vs. 41 ml/m2; p&lt;0.01). Mean RV EF was lower when measured by CMR compared to 3D echo (48% vs 52%; p&lt;0.05). Linear regression analysis showed high correlation coefficients between 3DE and CMR (r=0,68 for EDV, r=0,62 for ESV, and r=0,57 for EF; p&lt;0.001). Bland-Altman analysis demonstrated that for both RV EDV and RV ESV there was a significant and systematic under-estimation of volume by 3D echo compared to CMR. Both 3DE and CMR measurements were found to be highly reproducible in terms of intra-observer variability. Conclusions Statistically significant and clinically meaningful differences in volumetric measurements were observed between 3DE and CMR in the evaluation of RV volumes and function in patients with CHD after PPVI. Despite linear regression and Bland-Altman analysis showed that the two techniques are related and present some degree of agreement, 3D Echocardiography systematically underestimates volumes and overestimates EF and this would have to be considered in the clinical practice.

A closer look at right ventricular 3D volume quantification by transthoracic echocardiography and cardiac MRI

To compare right ventricular (RV) volumetry using state-of-the-art three-dimensional (3D) transthoracic echocardiography (3DE) and cardiac magnetic resonance imaging (CMR) near-simultaneously in a clinical setting. Forty-seven consecutive patients received comprehensive echocardiography including 3DE within 30 minutes of CMR. RV volumetry was performed offline with semi-automated 3D endocardial border tracing as well as manual delineation of the compacted myocardium in short-axis views by CMR. Forty-two examinations (89%) could be analysed offline by 3D RV reconstruction. Mean RV volumes assessed by CMR and 3DE were 215±63 and 127±42 ml for end-diastole (RV-EDV), as well as 110±43 and 62±27 ml for end-systole (RV-ESV). RV-EDV, RV-ESV, and RV stroke volume measured by 3DE were significantly lower than RV volumetry by CMR. Mean bias were -88, -48, and -41 ml, respectively. Mean RV ejection fraction (-EF) showed a non-significant deviation of +2% between 3DE and CMR and the correlation coefficient was r=0.58 for RV-EF. RV-EF can be assessed reliably using transthoracic 3DE in patients with good image quality; however, absolute RV volumes measured by 3DE show a systematic deviation to CMR volumetry that has been previously neglected and requires careful interpretation regarding anatomical cardiac imaging.

Myocardial dysfunction as a predictor of the severity and mortality of hypoxic ischaemic encephalopathy in severe perinatal asphyxia: a case–control study

ABSTRACTBackground: In perinatal asphyxia, hypoxia often leads to myocardial ischaemia. Few studies have assessed the degree of myocardial dysfunction in severely asphyxiated term neonates.Aim: To assess the extent of myocardial damage in newborns with severe perinatal asphyxia.Methods: A case–control study was conducted in asphyxiated newborns with hypoxic ischaemic encephalopathy (HIE) and in controls who were term non-asphyxiated newborns. Total (T) creatinine kinase (CK), CK-MB, troponin-T and 12-lead electrocardiography (ECG) and echocardiography were performed in both groups within 24–48 h after birth. The proportions of asphyxiated neonates with myocardial dysfunction and its relationship between severity of HIE and immediate outcome was compared.Results: Five of 23 asphyxiated neonates developed stage I, 10 stage II and eight stage III HIE. Serum levels of CK-T and CK-MB were raised in all 23 cases and troponin-T was raised in 13 (56.5%) HIE cases. ECG was abnormal in all cases and echocardiography in three (13%). Left ventricular ejection fraction (LVEF) and right ventricular ejection fraction (RVEF) were significantly decreased in all asphyxiated neonates. Eight (35%) patients died. Enzyme levels were higher and ECG and echocardiography abnormalities were common in infants with more severe HIE (p <0.05). Mean serum levels of CK-T and MB (p <0.001) and troponin-T (p =0.002) were higher in non-survivors. Mean LVEF and RVEF values were higher in survivors (p <0.001). All the controls had normal enzyme levels and echocardiography. ECG was abnormal in one control.Conclusion: Cardiac enzymes, ECG and echocardiography changes were associated with increasing severity of HIE and mortality.

Right Ventricular Function, Right Ventricular–Pulmonary Artery Coupling, and Heart Failure Risk in 4 US Communities

Limited data exist on the prevalence and prognostic importance of right ventricular (RV) dysfunction for heart failure (HF) in the general population. To assess the prevalence of RV dysfunction and its association with HF and mortality in a community-based elderly cohort. Cross-sectional and time-to-event analysis of participants in the Atherosclerosis Risks in the Community (ARIC), a multicenter, population-based cohort study at the fifth study visit from 2011 to 2013, with a median follow-up of 4.1 years. This study included 1004 elderly participants in the ARIC study attending the fifth study visit who underwent both 3-dimensional and 2-dimensional RV echocardiography. Three-dimensional echocardiography data were analyzed between September 15, 2015, and July 24, 2016. Right ventricular ejection fraction (RVEF), RV-pulmonary artery (PA) coupling defined by the RVEF/PA systolic pressure (PASP) ratio, and RV longitudinal strain by 3-dimensional echocardiography. For cross-sectional analysis, the prevalence of RV dysfunction across ACCF/AHA HF stages (0; A, at elevated risk for HF but without structural heart disease or clinical HF; B, structural heart disease but without clinical HF; and C, prevalent HF). For time-to-event analysis, a composite of incident HF hospitalization or all-cause death among participants free of HF at visit 5. Of the 1004 participants, mean (SD) age was 76 (5) years, 385 were men (38%), and 121 were black (12%). Mean (SD) RVEF was 53% (8%). Right ventricular EF, RVEF/PASP, and RV longitudinal strain were each progressively lower across advancing HF stages. Using reference limits from stage 0 participants, RVEF was abnormal in 103 asymptomatic persons with stage A HF (15%) and 27 with stage B HF (24%). Among participants free of HF at baseline, lower RVEF and worse RV-PA coupling (ie, lower RVEF/PASP ratio) both were associated with incident HF or death independent of LVEF and N-terminal pro b-type natriuretic peptide (hazard ratio, 1.20; 95% CI, 1.02-1.42 per 5% decrease in RVEF; P = .03; hazard ratio, 1.65, 95% CI, 1.15-2.37 per 0.5 unit decrease in RVEF/PASP ratio; P = .007). Right ventricular function and RV-PA coupling declined progressively across American College of Cardiology Foundation/American Heart Association HF stages. Among persons free of HF, lower RVEF was associated with incident HF or death independent of LVEF or N-terminal pro b-type natriuretic peptide.

Myocardial fibrosis as an early feature in phospholamban p.Arg14del mutation carriers: phenotypic insights from cardiovascular magnetic resonance imaging.

The p.Arg14del founder mutation in the gene encoding phospholamban (PLN) is associated with an increased risk of malignant ventricular arrhythmia (VA) and heart failure. It has been shown to lead to calcium overload, cardiomyocyte damage, and eventually to myocardial fibrosis. This study sought to investigate ventricular function, the extent and localization of myocardial fibrosis and the associations with ECG features and VA in PLN p.Arg14del mutation carriers. Cardiovascular magnetic resonance (CMR) data of 150 mutation carriers were analysed retrospectively. Left ventricular (LV) and right ventricular (RV) volumes, mass, and ejection fraction were measured. The extent of late gadolinium enhancement (LGE) was expressed as a percentage of myocardial mass. All standard ECG parameters were measured. Occurrence of VA was analysed on ambulatory 24-h and/or exercise electrocardiography, if available. Mean age was 40 ± 15 years, 42% males, and 7% were index patients while 93% were pre-symptomatic carriers identified after family cascade screening. Mean LV ejection fraction (LVEF) and RV ejection fraction were 58 ± 9% and 55 ± 9%, respectively. LV-LGE was present in 91% of mutation carriers with reduced LVEF (<45%) and in 30% of carriers with preserved LVEF. In carriers with positive LV-LGE, its median extent was 5.9% (interquartile range 3.2-12.7). LGE was mainly observed in the inferolateral wall. Carriers with inverted T-waves in the lateral ECG leads more often had LV-LGE (P < 0.01) than carriers without. Finally, the presence of LV-LGE, but not attenuated R-waves and inverted lateral T-waves, was independently associated with VA. LV myocardial fibrosis is present in many PLN p.Arg14del mutation carriers, and who still have a preserved LVEF. It is seen predominantly in the LV inferolateral wall and corresponds with electrocardiographic repolarization abnormalities. Although preliminary, myocardial fibrosis was found to be independently associated with VA. Our findings support the use of CMR with LGE early in the diagnostic work-up.

Impact of left ventricular assist device implantation on right and left ventricular volumes and functions

Because the right ventricle is not assisted, its function is a critical determinant of the hemodynamic inpatients with left ventricular (LV) assist devices (LVADs) and contributes significantly to postoperative morbidity and mortality. Right ventricular (RV) failure remains a challenge in the area of continuous-flow LVADs. The aim of this study was to evaluate the evolution of RV volumes and function before and after LVAD implantation. Ten patients underwent tomographic equilibrium radionuclide ventriculography for the assessment of LV and RV volumes and functions before and after LVAD implantation. Mean LV and RV ejection fractions before implantation were 20 ± 8 and 46 ± 14%, respectively. LVAD implantation had no impact on RV ejection fraction (46 ± 11% after implantation, P = 0.961) but tended to increase LV ejection fraction (31 ± 21% after implantation, P = 0.09). LVAD led to a decrease of LV end-diastolic volume (Δ = −136 ± 96 after implantation, P = 0.001) and RV end-diastolic volume (Δ = −59 ± 49 after implantation, P = 0.004) ( Fig. 1 ). Inpatients with preserved RV ejection fraction, LVAD implantation leads to a decrease of RV volumes without impact on RV ejection fraction. The increase of cardiac output induced by the LVAD does not increase RV volumes, which could be explained by the decrease of RV after load. These results highlight the importance of after load on the right ventricle inpatients with heart failure.

Right ventricular functional analysis utilizing first pass radionuclide angiography for pre-operative ventricular assist device planning: a multi-modality comparison

BackgroundAdvanced heart failure treated with a left ventricular assist device is associated with a higher risk of right heart failure. Many advanced heart failures patients are treated with an ICD, a relative contraindication to MRI, prior to assist device placement. Given this limitation, left and right ventricular function for patients with an ICD is calculated using radionuclide angiography utilizing planar multigated acquisition (MUGA) and first pass radionuclide angiography (FPRNA), respectively. Given the availability of MRI protocols that can accommodate patients with ICDs, we have correlated the findings of ventricular functional analysis using radionuclide angiography to cardiac MRI, the reference standard for ventricle function calculation, to directly correlate calculated ejection fractions between these modalities, and to also assess agreement between available echocardiographic and hemodynamic parameters of right ventricular function.MethodsA retrospective review from January 2012 through May 2014 was performed to identify advanced heart failure patients who underwent both cardiac MRI and radionuclide angiography for ventricular functional analysis. Nine heart failure patients (8 men, 1 woman; mean age of 57.0 years) were identified. The average time between the cardiac MRI and radionuclide angiography exams was 38.9 days (range: 1 - 119 days). All patients undergoing cardiac MRI were scanned using an institutionally approved protocol for ICD with no device-related complications identified. A retrospective chart review of each patient for cardiomyopathy diagnosis, clinical follow-up, and echocardiogram and right heart catheterization performed during evaluation was also performed.ResultsThe 9 patients demonstrated a mean left ventricular ejection fraction (LVEF) using cardiac MRI of 20.7% (12 – 40%). Mean LVEF using MUGA was 22.6% (12 – 49%). The mean right ventricular ejection fraction (RVEF) utilizing cardiac MRI was 28.3% (16 – 43%), and the mean RVEF calculated by FPRNA was 32.6% (9 – 56%). The mean discrepancy for LVEF between cardiac MRI and MUGA was 4.1% (0 – 9%), and correlation of calculated LVEF using cardiac MRI and MUGA demonstrated an R of 0.9. The mean discrepancy for RVEF between cardiac MRI and FPRNA was 12.0% (range: 2 – 24%) with a moderate correlation (R = 0.5). The increased discrepancies for RV analysis were statistically significant using an unpaired t-test (t = 3.19, p = 0.0061). Echocardiogram parameters of RV function, including TAPSE and FAC, were for available for all 9 patients and agreement with cardiac MRI demonstrated a kappa statistic for TAPSE of 0.39 (95% CI of 0.06 – 0.72) and for FAC of 0.64 (95% of 0.21 – 1.00).ConclusionHeart failure patients are increasingly requiring left ventricular assist device placement; however, definitive evaluation of biventricular function is required due to the increased mortality rate associated with right heart failure after assist device placement. Our results suggest that FPRNA only has a moderate correlation with reference standard RVEFs calculated using cardiac MRI, which was similar to calculated agreements between cardiac MRI and echocardiographic parameters of right ventricular function. Given the need for identification of patients at risk for right heart failure, further studies are warranted to determine a more accurate estimate of RVEF for heart failure patients during pre-operative ventricular assist device planning.

Right Ventricular Function After Acute Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention (from the Glycometabolic Intervention as Adjunct to Primary Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction III Trial)

Right ventricular (RV) dysfunction is a powerful risk marker after acute myocardial infarction (MI). Primary percutaneous coronary intervention (PCI) has markedly reduced myocardial damage of the left ventricle, but reliable data on RV damage using cardiac magnetic resonance imaging (MRI) are scarce. In a recent trial of patients with acute MI treated with primary PCI, in which the primary end point was left ventricular (LV) ejection fraction after 4months measured with MRI, we conducted a prospectively defined substudy in which we examined RV function. RV ejection fraction (RVEF) and RV scar size were measured with MRI at 4months. Tricuspid annular plane systolic excursion (TAPSE) and RV free wall longitudinal strain (FWLS) were assessed using echocardiography before discharge and at 4months. We studied 258 patients without diabetes mellitus; their mean age was 58 ± 11years, 79% men and mean LV ejection fraction was 54 ± 8%. Before discharge, 5.2% of patients had TAPSE <17mm, 32% had FWLS >-20% and 11% had FWLS >-15%. During 4months, TAPSE increased from 22.8 ± 3.6 to 25.1 ± 3.9mm (p <0.001) and FWLS increased from-22.6 ± 5.8 to-25.9 ± 4.7% (p <0.001). After 4months, mean RVEF on MRI was 64.1 ± 5.2% and RV scar was detected in 5 patients (2%). There was no correlation between LV scar size and RVEF (p= 0.9), TAPSE (p= 0.1), or RV FWLS (p=0.9). In conclusion, RV dysfunction is reversible in most patients and permanent RVischemic injury is very uncommon 4months after acute MI treated with primary PCI.

Evaluation of right ventricular function after cardiac surgery: The importance of tricuspid annular plane systolic excursion and right ventricular ejection fraction

ObjectiveThe evaluation of right ventricular systolic function is essential to the hemodynamic management of critically ill cardiac patients. Nevertheless, assessment of right ventricular function remains problematic. We sought to analyze the correlation between tricuspid annular plane systolic excursion (TAPSE) and right ventricular ejection fraction (RVEF) in the assessment of global and regional right ventricular function, respectively. MethodsThis was a prospective study of 61 cardiac surgical patients. TAPSE was measured with transthoracic echocardiography and RVEF was obtained by a thermodilution pulmonary artery catheter. Both measurements were estimated simultaneously during the early postoperative period. Patients with previously identified severe tricuspid insufficiency were excluded from the study to avoid confounding results. ResultsThe etiologies for cardiac surgery were surgical pulmonary thromboendarterectomy in 19 patients, valve replacement in 17 patients, heart transplant in 13 patients, and coronary artery bypass graft in 9 patients. Mean RVEF and TAPSE were 26.2% ± 9.7% and 11.4 ± 4 mm, respectively. RVEF and TAPSE showed a significant correlation (r = 0.73, P < .001). Weak reverse relationships between TAPSE or RVEF with afterload hemodynamic parameters, mean pulmonary artery pressure, or pulmonary vascular resistance were elucidated. ConclusionsTAPSE is a robust measure of right ventricular function that correlates with RVEF assessed by pulmonary artery catheter. A noninvasive method such as echocardiography can guide and support invasive monitoring of right ventricular function in cardiac surgical patients.

Relationship of Right Ventricular Size and Function with Respiratory Status in Duchenne Muscular Dystrophy.

The relationship between pulmonary function and right ventricle (RV) in Duchenne muscular dystrophy (DMD) has not been evaluated. Using cardiac magnetic resonance (CMR), we describe the relationship of RV size and function with spirometry in a DMD cohort. Fifty-seven boys undergoing CMR and pulmonary function testing within 1month at a single center (2013-2015) were enrolled. Comparisons of RV ejection fraction (RVEF) and end-diastolic volume index (RVEDVI) were made across categories of percent forced vital capacity (FVC%), and relationships were assessed. Mean age was 15.5±3.5years. Spirometry and CMR were performed within 3.9±4.1days. Median FVC% was 92.0% (67.5-116.5%). Twenty-three (40%) patients had abnormal FVC% (<80%) of which 13 (57%) had mild (FVC% 60-79%), 6 (26%) had moderate (FVC% 40-59%), and 4 (17%) had severe (FVC <40%) reductions. Mean RVEF was 58.3±3.7%. Patients with abnormal FVC% were older and had lower RVEF and RVEDVI. Both RVEF and RVEDVI were significantly associated with FVC% (r=0.31, p=0.02 and r=0.39, p=0.003, respectively). In a large DMD cohort, RVEF and RVEDVI were related to FVC%. Worsening respiratory status may guide monitoring of cardiac function in these patients.

Gender differences in right ventricular function in patients with non-ischaemic cardiomyopathy.

AimTo evaluate sex-related differences in right ventricular (RV) function, assessed with cardiac magnetic resonance imaging, in patients with stable non-ischaemic dilated cardiomyopathy.MethodsProspective multicentre study. We included 71 patients (38 men) and 14 healthy volunteers.ResultsMean age was 60.9 ± 12.2 years. Men presented higher levels of haemoglobin and white blood cell counts than women, and performed better in cardiopulmonary stress testing. A total of 24 patients (12 women) presented severe left ventricular (LV) systolic dysfunction, 32 (13 female) moderate and 15 (8 women) mild LV systolic dysfunction. In the group with severe LV systolic dysfunction, average right ventricular ejection fraction (RVEF) was normal in women (52 ± 4 %), whereas it was reduced in men (39 ± 3 %) p = 0.035. Only one woman (8 %) had severe RV systolic dysfunction (RVEF < 35 %) compared with 6 men (50 %) p < 0.001. In patients with moderate and mild LV dysfunction , the mean RVEF was normal in both men and women. In the 14 healthy volunteers, the lowest value of RVEF was 48 % and mean RVEF was normal in women (56 ± 2 %) and in men (51 ± 1 %), p = 0.08.ConclusionsIn patients with dilated cardiomyopathy, RV systolic dysfunction is found mainly in male patients with severe LV systolic dysfunction.

Reply to the editorial comment from Van der Wall concerning 'The right ventricle: always normal in normal subjects?'.

To the Editor, We read the comment referring to the challenges in imaging the right ventricle with great interest [1]. The difficulties in distinguishing wall motion abnormalities in healthy subjects from those in diseased patients are very well summarised. The author cites the article by Doesch et al. [2] presenting 20 healthy subjects with CMR-derived measurement of the tricuspid annular plane systolic excursion (TAPSE) with a reference point outside the ventricle (TAPSEout), which might be used for screening right ventricular motion. We could demonstrate TAPSE in cardiac magnetic resonance (CMR), being a fast and easily obtainable parameter correlating well to volumetric quantification of right ventricular ejection fraction (RVEF), with low interobserver and intraobserver variables. Therefore, we investigated 76 patients (age: 58 ± 17 years) with mean RVEF of 42 ± 14 %, assessed by the standardised slice-summation method. CMR-TAPSE was determined to be 19 ± 6 mm and correlated well in linear regression analysis with volumetric RVEF (r = 0.72, p < 0.001). However, we could also show that CMR-TAPSE is not only a fast tool in healthy subjects, but it also discriminates well between patients with impaired and normal RVEF. Multiplying CMR-TAPSE measurements by 2.5 leads to values close to the RVEF by volumetry. Furthermore, CMR-TAPSE correlates well with TAPSE determined using transthoracic echocardiography [3].