Mild Right Ventricular Dysfunction Research Articles

Characterization of right-sided strain parameters in atrial and ventricular functional tricuspid regurgitation

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial functional tricuspid regurgitation (A-FTR), defined as TR due to prominent right atrial (RA) dilatation without significant right ventricular (RV) remodelling, has recently emerged as a distinct subtype of FTR, and can be distinguished from ventricular FTR (V-FTR), defined by significant RV remodelling leading to annular dilatation and leaflet tethering. However, so far no data has been reported on the values of RV and RA strain in these patients. Purpose To evaluate potential differences in right-sided strain parameters in patients diagnosed with severe atrial and ventricular FTR. Methods Patients with severe FTR, without a cardiac implantable electronic device, were categorized as V-FTR when in sinus rhythm and either having left-sided cardiac disease, pulmonary hypertension, or moderate/severe RV dysfunction. Patients, in sinus rhythm or atrial fibrillation, with no other cause of annular dilatation and impaired leaflet coaptation than RA dilatation were classified as A-FTR. Extensive echocardiographic assessment was performed, including 2D-speckle-tracking strain analysis. Results A total of 525 patients with severe FTR (mean age 66 ± 15 years, 42% male) were included, of which 401 patients (76%) were classified as V-FTR and 124 patients (24%) as A-FTR. Baseline clinical and echocardiographic characteristics are shown in Figure 1. Patients presented with mild RV dilatation (RV end-diastolic area 12.9 ± 4.0cm2/m2) and RV dysfunction (RV free wall longitudinal strain [FWLS] 18.3 ± 6.8%), and with moderate-to-severe RA dilatation (RA max volume 36.8 [26.9 – 52.2] ml/m2) and moderate-to-severe RA dysfunction (RA reservoir strain 17.0 [11.0 – 27.0] %). Corresponding to the phenotype, patients with A-FTR presented with significantly smaller RV size and better RV function (Figure 1). However, despite overall normal values of RV function by RV fractional area change, tricuspid annular plane systolic excursion (TAPSE) and RV FWLS, 27% of A-FTR patients showed reduced RV FWLS based on cut-off value of −20%. In addition, patients with A-FTR showed more dilated RA, as compared to patients with V-FTR, but with better RA function assessed by 2D-strain values (Figure 1). Notwithstanding, still 73% of the A-FTR-patients showed reduced RA strain values, when using the cut-off reported for normality of 34%. Conclusion Approximately 25% of patients diagnosed with severe FTR presented with A-FTR. These patients presented with significantly better right-sided strain parameters as compared to patients with V-FTR, despite more pronounced RA dilatation.

P219 EXTRINSIC COMPRESSION OF THE RIGHT VENTRICLE CAUSING ISOLATED RIGHT HEART FAILURE

Abstract Isolated right heart failure (RHF) can be caused by right ventricular (RV) compression, mainly described in severe cases of pectus excavatum. Mediastinal masses can determine an extrinsic compression of the RV. A 62–year–old retired agricultural inspector from Sicily presented in our clinic with worsening signs of RHF. His medical history consisted of echinococcosis familiarity, surgically treated congenital subvalvular aortic stenosis, resulted in a residual moderate aortic insufficiency and permanent atrial fibrillation. Around January 2021 he developed isolated leg swelling. Aortic valvular dysfunction, heart failure and other cardiogenic explanations were excluded. A year later dyspnea (NYHA class II) appeared. High resolution CT demonstrated fluid collection with peripheric calcifications inside the anterior mediastinum. PET showed uptake in a limited zone of the anterior mediastinum. The patient slowly started developing ascites, hardly manageable with diuretics because of kidney failure. Transthoracic echocardiography (TTE) highlighted mild RV dysfunction (FAC 35%) and right ventricular free wall hypokinesia due to the mediastinal mass extrinsic compression. Transesophageal echocardiography showed a heterogeneous cystic aspect of the mediastinal mass, an oscillating intraventricular mass of the right aortic cuspid (6x4 mm) and a severe mitral annular calcification. In consideration of medical history, endocarditis was considered. Cardiac magnetic resonance recognized a mediastinal mass with echinococcosis features. Echinococcous serology and antibodies were negative but the Quantiferon tested positive. Laboratory tests showed an absolute eosinophilia and a high CD4/CD8 ratio. Because of the patient severely compromised hemodynamic balance the mass was surgically removed and identified as pseudocystic tuberculoma. After the excision, hemodynamic balance was improved and the TTE showed a restored RV function with persistent hypokinesia of the RV free wall and increased right atrium pressure. In this clinical case RHF was determined by an extracardiac mass which interfered with the hemodynamic balance and the function of the right heart in the absence of any signs of left heart failure. Because of the mass mechanical action on the reduction of RV ejected volumes, a surgical option was the only possible strategy to avoid a following worsening of the heart failure.

Evolution, coronary artery bypass surgery and outcomes of right ventricular dysfunction in ischaemic cardiomyopathy.

Whether the presence or evolution of right ventricular dysfunction (RVD) affects the prognosis and the therapeutic choice between coronary artery bypass grafting (CABG) or medical therapy alone in patients with ischaemic cardiomyopathy (ICM) remains unclear. We investigate the prognostic and therapeutic implications of RVD in patients with ICM. Patients with baseline echocardiographic right ventricular (RV) assessment were included from the Surgical Treatment of Ischaemic Heart Failure trial. The primary outcome was all-cause mortality. Of 1212 patients enrolled in the Surgical Treatment of Ischaemic Heart Failure trial, 1042 patients were included, with 143 (13.7%) mild RVD and 142 (13.6%) moderate-to-severe RVD. After a median follow-up of 9.8 years, compared with patients with normal RV function, patients with RVD had a higher risk of mortality [mild RVD: adjusted hazard ratio (aHR) 1.32; 95% confidence interval (CI) 1.06-1.65; moderate-to-severe RVD: aHR, 1.75; 95% CI 1.40-2.19]. Among patients with moderate-to-severe RVD, CABG provided no additional survival benefits compared to medical therapy alone (aHR: 0.98; 95% CI: 0.67-1.43). Among 746 patients with pre- and post-therapeutic RV assessment, a gradient risk for death increased from patients with consistent normal RV function, to patients with recovery from RVD, new-onset RVD and persistent RVD. RVD was associated with a worse prognosis in patients with ICM, and CABG provided no additional survival benefits to patients with moderate-to-severe RVD. The evolution of RV function had important prognostic implications, which emphasized the importance of both pre- and post-therapeutic RV assessment.

661 TWO CARDIOMYOPATHIES IN ONE HEART: LESSONS FROM CLINICAL CASE

Abstract Case description In November 2020, a 55-years-old female with no significant past medical history, was admitted to our Emergency Department for chest pain after acute stressful event. She had a significant family history of ischemic heart disease, and unclear comatose status of her sister. At admission, she was asymptomatic, blood pressure was 115/80 mmHg, and oxygen saturation was 96%. An electrocardiogram (ECG) showed biphasic T wave in anterolateral leads. Elevated levels of troponin I (hs-TnI of 900 ng/L) and B-type natriuretic peptide (BNP) of 864 pg/mL were detected. Transthoracic echocardiogram (TTE) revealed an ejection fraction (EF) of 30% with apical ballooning of mid and apical segments of the left ventricle (LV) along with a sizable apical thrombus. Aspirin, iv diuretics, iv nitrates and unfractioned heparin were started. After 13 hours, she suffered a sudden transient neurological sign of decreased level of consciousness. Cranial MRI revealed an ischemic lesion in the territory of the apex of basilar artery (thalamic region). After 7 days from stroke, the patients underwent coronary angiography demonstrating unobstructed coronaries. Thus, the diagnosis of takotsubo syndrome was confirmed. During hospitalization, ECG evolution showed T wave inversion in precordial and lateral leads. Hs-TnI declining within normal values. Of note, ventricular arrhythmias burden with polymorphic ventricular contraction (PVC) emerged on continuous ECG-monitoring. Despite resolution of apical balloning and apical thrombosis, there were persistent wall-motion abnormalities in infero-lateral walls and mild LV dysfunction. This was also confirmed by cardiac magnetic resonance (CMR). Further, CMR also showed an intense myocardial edema with elevated LV mass. The patients was discharged on Warfarin, Bisoprolol 2.5 mg/die, Ramipril 5 mg/die, Eplerenone 25 mg/die. A clinical documentation was required to further investigate history of her sister, and neurological sequelae after cardiac arrest at 28s related to ventricular fibrillation emerged. However, no deeply evaluation of underlining heart disease was available. Despite an early favorable follow-up of patient, after six months, she suffered from palpitations and heart failure requiring diuretic therapy. Persistent repolarization abnormalities in infero-lateral leads, and low-voltage in precordial leads were noted. An extensive wall-motion abnormalities and moderate LV dysfunction were detected. Importantly, significant arrhythmic burden with PVC (13%) at 24-hr ECG monitoring was recorded. CMR was requested to further investigate the possibility of underlining coexisting cardiomyopathy. Mild LV dilation, moderate dysfunction (LVEF 39%), wall motion abnormalities and thinning of the inferior wall middle segments were reported. Surprisingly, fibro-fatty replacement in infero-lateral of LV wall was detected, and unexpectedly, right ventricular (RV) fibro-fatty replacement and mild RV dysfunction were also described. Hence, diagnosis of arrhythmogenic cardiomyopathy was made. Since persistent arrhythmic burden despite optimized medical treatment, biventricular involvement, family history of SCD, an implantable cardioverter defibrillator in primary prevention was placed. Furthermore, genetic testing was required and extensive clinical family screening was suggested. Conclusion According to the clinical data collected, takotsubo and arrhytmogenic cardiomyopathy can coexist. A potential link between two myocardial heart disease may be identified in the future, especially among patients presenting takotsubo and long-term unfavorable outcome.

Evolution and clinical implications of right ventricular dysfunction in ischemic cardiomyopathy with or without coronary artery bypass surgery

Abstract Background The Surgical Treatment of Ischemic Heart Failure (STICH) trial demonstrated that coronary artery bypass grafting (CABG) provides additional survival benefits to patients with ischemic cardiomyopathy. However, it remains unclear whether this benefit is affected by preoperative right ventricular (RV) function and how post-therapeutic evolution of RV function influences long-term outcomes. Purpose We sought to investigate the implications of baseline RV function on therapeutic decision-making in patients with ischemic cardiomyopathy, and to evaluate the prognostic implications of post-therapeutic evolution of RV function. Methods Patients with available baseline echocardiographic RV function assessed by experienced Echocardiography Core Laboratory physicians were included from the hypothesis 1 of the STICH trial. The primary outcome was long-term all-cause mortality. Results A total of 1042 patients were included, among them 757 (72.7%) had normal RV function, 143 (13.7%) mild right ventricular dysfunction (RVD), and 142 (13.6%) moderate to severe RVD. After a median follow-up of 9.8 years, patients with RVD had a higher risk of all-cause mortality compared with patients with normal RV function [mild RVD: adjusted hazard ratio (aHR) 1.32; 95% confidence interval (CI) 1.06–1.64; moderate to severe RVD: aHR, 1.74; 95% CI 1.39–2.18]. Although no significant interaction was detected between RVD degree and treatment allocation (P for interaction = 0.399), a gradually decreasing survival benefit associated with CABG was observed among patients with normal RV function (aHR: 0.79; 95% CI: 0.65–0.96), mild RVD (aHR: 0.85; 95% CI: 0.56–1.29), and moderate to severe RVD (aHR: 0.97; 95% CI: 0.67–1.43). Among 746 patients with available RV function assessed at baseline and post-therapeutic 4-month follow-up, there was a gradient of increasing risk for all-cause mortality across patients with consistent normal RV function, recovery of RVD (aHR: 1.20; 95% CI: 0.88–1.64), newly developed RVD (aHR: 1.59; 95% CI: 1.18–2.14), and consistent RVD (aHR: 2.06; 95% CI: 1.60–2.67). Independent predictors of RVD recovery included baseline left ventricular ejection fraction (per 1-percent increment, adjusted odds ratio: 1.04; 95% CI: 1.00–1.09) and mitral regurgitation ≥ grade 2 (adjusted odds ratio: 0.42; 95% CI: 0.21–0.84). Conclusions Baseline RVD was associated with an increased risk of long-term mortality in patients with ischemic cardiomyopathy, and adding CABG to medical therapy might provide limited survival benefits in patients with moderate to severe RVD. A gradient of increasing risk for mortality was observed across different categories of RV function evolution, which emphasizes the necessity of pre- and post-therapeutic RV assessment for prognostic evaluation. Funding Acknowledgement Type of funding sources: None.

Cardiac MRI predictors of good long-term outcomes in patients with repaired TOF

Risk stratification in patients with repaired tetralogy of Fallot (rTOF) have focused on poor clinical outcomes while predictors of a benign clinical course have not been characterized. The goal of this study was to Identify cardiac magnetic resonance (CMR) markers of a good clinical course late after TOF repair. Clinical and CMR data from the International Multicenter TOF Registry (INDICATOR) were analyzed. The primary outcome was time to the earliest occurrence of a composite of death, aborted sudden death, and sustained ventricular tachycardia (VT). The secondary outcome was time to the earliest occurrence of atrial arrhythmia, nonsustained VT, and NYHA class >II. Multinomial regression was used to identify predictors of the 3-category outcome: (a) good outcome, defined as freedom from the primary AND secondary outcomes at age 50 years; (b) poor outcome, defined as presence of the primary outcome before age 50 years; and (c) intermediate outcome, defined as not fulfilling criteria for good or poor outcomes. Among 1088 eligible patients, 96 had good outcome, 60 experienced poor outcome, and 932 had intermediate outcome. Patients were age 25.8±10.8 years at the time of the index CMR. Median follow-up was 5.8 years (IQR 3.0, 9.9) after CMR in event-free patients. By univariate analysis, smaller right ventricular (RV) end-systolic and end-diastolic volume index, smaller left ventricular end-systolic volume index, higher right and left ventricular ejection fraction, lower right and left ventricular mass index, and lower left ventricular mass/volume ratio were associated with good outcome. Multivariable modeling identified higher RV ejection fraction (OR 2.38 per 10% increase, P=.002) and lower RV mass index (OR 1.72, per 10 g/m2 decrease, P=.002) as independently associated with good outcome after adjusting for age at CMR. Classification and regression tree analysis identified important thresholds associated with good outcome that were specific to patients age ≥37 years at the time of CMR; these were RV ejection fraction ≥42% and RV mass index <39 g/m2. Adults with rTOF and no more than mild RV dysfunction combined with no significant RV hypertrophy are likely to be free from serious adverse clinical events into their sixth decade of life and may require less frequent cardiac testing.

Abstract 13977: Identification of Intermediate Right Ventricular Phenotypes Using Consensus Clustering in Patients With Pulmonary Hypertension

Introduction: Current right ventricular (RV) function phenotypes in pulmonary hypertension (PH) rely on few hemodynamic parameters to quantify RV dysfunction disease severity. The aim of the study was to identify novel RV phenotypes using RV hemodynamics and unsupervised machine learning in patients with PH. Methods: Participants were identified from the UArizona PH Registry (n=190). Correlation analyses identified 9 RV variables to include in clustering analysis. Consensus clustering was used to identify an unsupervised clustering method with a large inter-cluster, and small intra-cluster distance (Fig 1A). Significance was tested with Dunn and chi-square tests. Results: K-Medoids with a Pearson distance matrix over &gt;1000 resampling iterations identified 5 clusters (consensus range: 0.8-0.9). World Symposium PH groups were distributed across clusters (Fig 1B). Clusters 1, 2 and 5 exhibit mild RV dysfunction with low diastolic stiffness (Eed) and afterload (Ea, Fig 1C). However, RV-PA coupling (Ees/Ea) was decreased in clusters 1 and 5. Clusters 3 and 4 have moderate to severe RV dysfunction with increased Eed and Ea but cluster 4 had decreased Ees/Ea. For pulmonary hemodynamics, clusters 3 and 4 have increased mean PA pressure (mPAP), increased pulmonary vascular resistance (PVR) and decreased PA compliance (Ca) compared to clusters 1 and 2. Cluster 5 has increased mPAP and high cardiac output resulting in moderately elevated PVR and decreased Ca. Conclusions: Unsupervised clustering identified 5 unique RV phenotypes ranging from mild to severe dysfunction. Further investigations are needed to identify factors modulating intermediate phenotypes to provide insight into RV dysfunction and disease progression.

Intermediate-Term Outcomes for Patients with Submassive Pulmonary Embolism Treated With Catheter-Directed Thrombolysis.

We aimed to assess the intermediate-term outcomes for patients receiving catheter-directed thrombolysis (CDT) for submassive pulmonary embolism (PE). Previous research has shown improvements in right ventricular (RV) function and dilation at 24 hours when CDT was used to treat submassive PE. Consecutive patients presenting with submassive PE treated with directed t-PA infusion at a single center were identified and included in this study. Outcomes included cardiovascular mortality, RV function by echocardiogram, 30-day readmission, and major bleeding. The study population was 79 patients with submassive PE; 46% were men, with an average age of 58 years and an average pulmonary embolism severity index (PESI) score of 108. One patient died of cardiovascular causes during the index hospitalization. There were no additional deaths within 30 days of admission. The observed 30-day mortality rate was low compared with that predicted by PESI (1.3% vs 4.0%-11.4%). Fifty-two patients had follow-up echocardiography available for evaluation after CDT. Of these, 62% showed return to normal RV function and size, and 19% demonstrated mild residual RV dysfunction or dilation. Eight patients (10%) had a hospital readmission within 30 days of discharge, including 6 admissions due to cardiopulmonary complications or minor bleeding and 2 for non-cardiopulmonary or bleeding-related reasons. The observed readmission rate of 10% was similar to historic rates of 12.8%. Intermediate-term follow-up for CDT demonstrates high success rates with low adverse event rates. Further randomized data are needed to study the long-term benefits of CDT.

COVID-19 Complicating Perioperative Management of Left Ventricular Assist Device Implantation

IntroductionThe coronavirus 2019 disease (COVID-19) affected almost 40 million people worldwide and caused more than one million deaths. Some conditions are associated with worse prognosis such as heart failure and left ventricular assist device (LVAD) recipients.Case ReportA 31-year-old male patient without comorbidities was admitted due to cardiogenic shock and pneumonia. He required IABP and ECMO. The patient recovered from organ dysfunctions and ECMO was weaned off. He persisted dependent on dobutamine and IABP. Echocardiogram showed severe left ventricular dysfunction and moderate right ventricular dysfunction (RVD), but right heart catheterization revealed no pulmonary hypertension. SARS-CoV-2 RT-PCR was negative and myocardiopathy investigation was inconclusive after endomyocardial biopsy. LVAD implantation was planned as a bridge to transplant. A Heart Mate 3 was successfully implanted. The patient presented fever in the operating room and persisted febrile for 3 days. COVID-19 was suspected and SARS-CoV-2 RT-PCR was positive. He was extubated on 3rd postoperative day (POD) and echocardiogram showed only mild RVD. On 5th POD, he became hypoxemic requiring high flow nasal cannula, and chest X-ray revealed multiple pulmonary bilateral opacities. Antibiotics and corticosteroids were prescribed. Echocardiogram showed severe RVD and hemodynamic instability led to milrinone and dobutamine requirement in maximal doses. On 10th POD endotracheal intubation was required. The patient experienced severe acute respiratory distress syndrome (ARDS) and multiple complications: shock, bacterial pneumonia, hemothorax, pneumothorax due to barotrauma and bloodstream infection. He had no thromboembolic events. After 48 days he was free from mechanical ventilation and from inotropes. Echocardiogram showed moderate RVD and pulmonary artery systolic pressure 35mmHg. After 51 days he was discharged from the intensive care unit and is now in rehabilitation program.SummarySevere cases of COVID-19 are associated with a cytokine storm and a prothrombotic state. LVAD recipients are at particular risk of unfavorable outcomes. Besides the higher risk of thromboembolic events, LVAD recipients are more vulnerable to RVD in the setting of ARDS. This could be particularly critical during the perioperative management of RV failure as presented in this case.

Degree of right ventricular dysfunction dictates outcomes after tricuspid valve repair concomitant with left-side valve surgery.

The effect of different degrees of right ventricular (RV) dysfunction on long-term outcomes after tricuspid valve repair is the subject of ongoing research. We sought to evaluate the effect of preoperative RV dysfunction on mortality and recurrence of tricuspid regurgitation (TR) after tricuspid valve repair for secondary TR concomitant with left-side valve surgery. This is a retrospective study, including 548 patients who underwent repair of secondary TR (2009-2017) at a single institution. Patients were grouped according to preoperative right ventricular (RV) systolic function into three groups; normal RV function (group 1, n = 451), mild RV dysfunction (group 2, n = 60) and moderate/severe RV dysfunction (group 3, n = 37). Study endpoints were mortality and recurrence of TR. Group 3 was associated with the highest hospital mortality (10.2%, p = .06). Predictors of moderate or higher grade TR were NYHA class (HR 2.1, p = 0.03); preoperative TR grade (HR 1.9, p < 0.01), mild RV dysfunction (HR 2.4, p < 0.01), isolated RV dilatation (HR 2.0, p < 0.01), and flexible TV repair prostheses (HR 2.4, p = 0.01). Predictors of mortality were renal impairment (HR 3.0, p < 0.01), ejection fraction (HR 0.97, p = 0.02), pulmonary artery systolic pressure (HR 1.02, p = 0.02), preoperative TR grade (HR 1.7, p < 0.01), and moderate/severe RV dysfunction (HR 3.1, p = 0.01). Compared to normal and mild degree of RV dysfunction, moderate and severe RV dysfunction were independent predictors of poor long-term survival. Isolated RV dilatation increased the recurrence of TR. RV dysfunction and dilatation could be indications of tricuspid valve repair.

The Da Silva cone operation after the Starnes procedure for Ebstein's anomaly: New surgical strategy and initial results.

The Da Silva cone operation after the Starnes procedure for Ebstein's anomaly: New surgical strategy and initial results.

P1326 Recurrent isolated pulmonary valve endocarditis complicated by heart failure, septic pulmonary embolism and multiple lung abscesses in an intravenous drug abuser

Abstract Background Right-sided infective endocarditis (IE) ( 5-10% of all IE cases)is the most frequently observed in intravenous drug abusers (IVDA) with tricuspid valve as the most predominant site. Isolated pulmonary valve IE is an extremely rare entity in adults. Case report 27-year-old women, IVDA for 15 years, was admitted to the hospital due to fever and severe shortness of breath. Her past history was significant for isolated pulmonary valve IE of methicillin-susceptible Staphylococcus aureus 9 months before with mild pulmonary regurgitation and normal right ventricular (RV) function at discharge after medical treatment. At admission on physical examination, the patient showed tachycardia 140/’, tachypnoea, hypotension and crackles. Initial chest X-ray documented massive bilateral infiltrates. Laboratory tests showed highly elevated inflammatory markers and anaemia. Transthoracic echocardiography (TTE) revealed large (36 x 20 mm) very mobile vegetations on the pulmonary valve (Fig A), pulmonary trunk dilatation, mild pulmonary regurgitation and moderate pericardial effusion. No sign of IE was found on the tricuspid valve (Fig C), which presented anterior leaflet prolapse with mild regurgitation. Computed tomography (CT) revealed numerous cavitary infiltrates in both lungs surrounded by ground-glass opacification. Blood cultures were positive for methicillin-resistant Staphylococcus aureus. The patient was started on vancomycin. On day seven the patient status worsened with symptoms of heart failure and elevated pro-BNP up to 2833pg/ml. TTE revealed severe pulmonary regurgitation (Fig B) with pulmonary hypertension and RV dysfunction (Fig D). Repeated CT showed pulmonary embolism (PE), RV enlargement and multiple abscesses in both lungs. The patient was consulted with cardio surgeon but the intervention was denied and medical treatment was continued with vancomycin, gentamicin, rifampin, glicocorticoids, enoxaparin, betablockers, digoxin and diuretics. Under serial TTE and CT control antibiotics were continued up to 10 weeks. Ultimately patient was discharged in relatively good condition without any symptoms of heart or respiratory failure with smaller vegetation (15-16mm) on the pulmonary valve but with severe pulmonary regurgitation and mild RV enlargement and dysfunction in TTE and significant regression of pulmonary lesions and PE in CT. Discussion With respect to the high recurrence rate of right-sided IE in IVADs surgery should generally be avoided. A prolonged course of parental antibiotics is recommended in cases with lung abscesses. Conclusions We report a case of recurrent isolated pulmonary valve IE and extensive complications but with a positive outcome. Pulmonary valve IE is very rare in IVADs but requires early as well as serial multimodality imaging in the diagnostic workup. Abstract P1326 Figure. TTE of complicated pulmonary valve IE

Baseline Right Ventricular Dysfunction Predicts Worse Outcomes in Patients Undergoing Cardiac Resynchronization Therapy Implantation

Cardiac resynchronization therapy (CRT) has been shown to improve survival in patients with systolic heart failure, wide QRS duration, and left-bundle-branch-block. However, CRT outcomes stratified by right ventricular (RV) function at implant have not been well studied. We retrospectively reviewed patients at Cleveland Clinic who underwent CRT implantation (n = 777) from 2003 to 2011 with a diagnosis of heart failure, echocardiography with both pre-CRT left ventricular ejection fraction (LVEF) ≤35% and available post-CRT echocardiography at 6 months post-implant. CRT response was defined as LVEF improvement ≥5%. Patients were separated into 2 groups: normal or mild RV dysfunction (n = 570) labeled Normal RV; moderate to severe dysfunction (n = 207) labeled RV DYSFXN based on qualitative echocardiography assessment. Survival was calculated as time from CRT implant to death, left ventricular assist device implant, or heart transplant. CRT response was significantly higher in patients with Normal RV (67%) compared with patients with RV DYSFXN (56%; P = .006). Kaplan-Meier analysis showed that CRT patients with Normal RV had significantly greater survival compared with patients with RV DYSFXN (P < .001). In multivariable Cox regression accounting for a priori covariates, RV DYSFXN was associated with worse survival (HR 1.41 [95% CI: 1.14-1.75], P = .002) and lower CRT response (HR 0.66 [95% CI: 0.44-0.97], P = .03). Baseline RV dysfunction at CRT implant is an important predictor of worsened left ventricular remodeling and survival in CRT patients.

P5568Disease stages of structural and functional cardiac changes associate with outcomes in patients with mitral regurgitation receiving mitral valve intervention

Abstract Background/Introduction Severe mitral regurgitation (MR) produces volume overload resulting in progressive cardiac dysfunction that can extend beyond the left-sided chambers. It is unknown whether a specific MR staging system, that would quantify the extent of structural and functional cardiac changes, would be associated with outcomes in severe MR patients receiving mitral valve (MV) intervention. Purpose To examine the clinical utility of a novel MR staging system, based on the extent of cardiac damage, for prediction of clinical outcomes for patients with severe MR who underwent surgical or transcatheter therapy. Methods Patients were categorized into five stages using pre-procedural echocardiography; Stage 0: no other cardiac damage detected; Stage 1: Left atrium (LA) abnormality, as defined by the presence of atrial fibrillation or LA chamber enlargement; Stage 2: LV dysfunction, as defined by LV ejection fraction &lt;60%; Stage 3: Pulmonary artery vasculature or tricuspid valve abnormality, as defined by the presence of systolic pulmonary arterial pressure ≥60 mmHg) or ≥grade 2 tricuspid regurgitation; and Stage 4: Right ventricular (RV) disease as defined by the presence of &gt;mild RV dysfunction. The primary outcomes were all-cause mortality, and the combined endpoint of death or heart failure rehospitalization at one-year follow-up. Results A total of 696 patients with MR (age 70±14 years; 60% men) who underwent MV surgery (69%) or transcatheter MV repair with MitraClip device (31%) were examined. Prevalences of stage 0, 1, 2, 3, and 4 were 6.6%, 34.6%, 20.0%, 26.6%, and 12.2%, respectively. The median follow-up time was 15 months (IQR, 6.4, 24.4 months). At one-year, there was graded increase in all-cause death and in the combined endpoint of death or heart failure rehospitalization with each MR stage (Figure). In multivariate models, these associations remained independently associated with both one-year endpoints for patients receiving either surgical or transcatheter interventions. Figure 1 Conclusion This novel MR staging system is practical and may improve clinical risk stratification of patients with severe MR being considered for MV interventions.

Severe Right Ventricular Dysfunction Predicts Failure of Intra-Aortic Balloon Pump Hemodynamic Support in Cardiogenic Shock

Introduction We previously showed that ischemic history and low left ventricular cardiac power index (LVCPI) predict failure of intra-aortic balloon pump (IABP) hemodynamic support in cases of acute decompensated heart failure complicated by cardiogenic shock. We hypothesized that right ventricular (RV) systolic dysfunction would further impact the adequacy and outcomes of IABP hemodynamic support. Methods We retrospectively studied 74 patients who underwent IABP insertion for treatment of cardiogenic shock not related to acute myocardial infarction. Severity of RV systolic dysfunction, based on echocardiographic assessment, ranged from none to severe. Poor outcomes from IABP support included death or need for unplanned upgrade of mechanical circulatory support. Successful outcomes included bridge to recovery, transplant, or left ventricular assist device. Multivariable regression and Cox proportional hazard ratios were also used to study outcomes. Results Severe RV systolic dysfunction on echocardiogram was found in 10 patients (13.5%). Severe RV dysfunction, when compared to patients with no or mild RV dysfunction, was associated with increased right atrial pressure (RAP) (20.6±6 vs. 16.2±5.9 mmHg, p=0.04) and lower RV stroke work index (3.2±2.0 vs. 5.5±3.4 g/m, p=0.046) at time of IABP placement. After 48 hours of IABP support, patients with severe RV dysfunction continued to have higher RAP (18.9±8.5 vs. 12.2±4.7 mmHg, p=0.03), as well as worsened pulmonary artery pulsatility index (1.3±0.7 vs. 2.6±2.4, p=0.048) and RAP/pulmonary capillary wedge ratio (1.1±0.7 vs. 0.7±0.3, p=0.01). Severe RV systolic dysfunction independently predicted poor outcomes (OR 8.5, p=0.01), even when adjusted for LVCPI and ischemic history. An IABP failure risk score using all 3 variables (severe RV dysfunction, LVCPI, and ischemic history) predicted 28-day outcomes with excellent discrimination (Figure 1). Conclusions Severe RV systolic dysfunction corresponds with poor right-sided hemodynamics at baseline and following IABP support, and may predict failure of IABP hemodynamic support. Severe RV systolic dysfunction complicating cardiogenic shock likely warrants up-front consideration of biventricular support instead of IABP alone.

Right Ventricular Dysfunction in Right Coronary Artery Infarction: A Primary PCI Registry Analysis

A total of 298 patients with a RCA related MI undergone pPCI between January 2011 and June 2015 were included. RV dysfunction was defined by a RV-FAC <35% at echocardiographic examination and further divided into mild (RV-FAC between 35 and 25%) and moderate-severe (RV-FAC <25%). RV function before discharge was reassessed in 95% of the study cohort. The primary endpoint was overall mortality. Median follow-up was 29 months. In RCA related MI, moderate-severe (HR 5.882, p = 0.002, 95% CI 1.882-18.385) but not mild RV dysfunction independently predicted lower survival at follow-up along with age (HR 1.104, p <0.001, CI 1.045-1.167). Importantly, patients recovering RV function at discharge showed a lower mortality (p = 0.001) vs patients with persistent moderate-severe RV dysfunction) that approached the risk of patients without RV dysfunction at presentation. In RCA related MI treated with pPCI, RV dysfunction was one of the strongest independent predictor of lower overall survival. However, patients with only transient RV dysfunction showed a better prognosis compared to patients who had persistent RV dysfunction. The focus on intensive support management of the RV in the first hours after pPCI may be important to overcome the acute phase and to promote RV recovery.

Right ventricular function and residual mitral regurgitation after left ventricular assist device implantation determines the incidence of right heart failure

BackgroundThe effect of significant mitral regurgitation (MR) on outcomes after continuous flow left ventricular assist device (cfLVAD) implantation remains unclear. MethodsWe performed a retrospective review of prospectively collected data from 159 patients with preoperative severe MR who underwent cfLVAD implantation (2003-2017). Two-step cluster analysis using the log-likelihood distance for post-cfLVAD implantation parameters, which included right ventricular (RV) dysfunction, MR severity, and tricuspid regurgitation (TR) severity. Post-cfLVAD implantation echocardiographic parameters were obtained within the first month. ResultsCluster analysis resulted in 3 groups. Group 1 (n = 67) had mild or less MR with moderate-severe RV dysfunction (RVD). Group 2 (n = 43) had moderate-severe MR with moderate-severe RVD. Group 3 (n = 49) had moderate MR with mild RVD. Group 2 had the largest proportion with Interagency Registry for Mechanically Assisted Circulatory Support score of 1 (30.2%) and 2 (41.9%). They were more likely to undergo temporary mechanical circulatory support (18.6%) and tricuspid valve procedure (62.8%). Group 2 had the highest rate of stroke (30.2%; P = .02), hemolysis (39.5%; P = .01), device thrombosis (30%; P = .01), and worst survival (46.5%; P = .01). Survival at 5 years for groups 1, 2, and 3 were 56.0%, 17.6%, and 55.8%. Regression analysis of the entire population showed that greater MR severity after cfLVAD was associated with RV failure (P < .05; odds ratio, 1.6) and RV assist device use (P = .09; odds ratio, 1.6). After excluding tricuspid valve repairs, MR severity had a positive correlation with TR severity (R = 0.33; P < .01). ConclusionsAfter cfLVAD implantation, moderate-severe MR and RVD predicted RV failure. Patients with preoperative moderate-severe MR and TR coupled with moderate-severe RVD might benefit the most from mitral and tricuspid valve intervention.

Multiscale Computational Analysis of Right Ventricular Mechanoenergetics.

Right ventricular (RV) failure, which occurs in the setting of pressure overload, is characterized by abnormalities in mechanical and energetic function. The effects of these cell- and tissue-level changes on organ-level RV function are unknown. The primary aim of this study was to investigate the effects of myofiber mechanics and mitochondrial energetics on organ-level RV function in the context of pressure overload using a multiscale model of the cardiovascular system. The model integrates the mitochondria-generated metabolite concentrations that drive intracellular actin-myosin cross-bridging and extracellular myocardial tissue mechanics in a biventricular heart model coupled with simple lumped parameter circulations. Three types of pressure overload were simulated and compared to experimental results. The computational model was able to capture a wide range of cardiovascular physiology and pathophysiology from mild RV dysfunction to RV failure. Our results confirm that, in response to pressure overload alone, the RV is able to maintain cardiac output (CO) and predict that alterations in either RV active myofiber mechanics or RV metabolite concentrations are necessary to decrease CO.

Early detection of right ventricular dysfunction using transthoracic echocardiography in ARDS: a more objective approach.

Right ventricular (RV) dysfunction is an independent predictor of morbidity and mortality in acute respiratory distress syndrome (ARDS). Our goal was to describe morphologic changes in the RV using objective measures on transthoracic echocardiography (TTE) that occur following ARDS. We retrospectively measured changes in the following RV parameters from a pre-ARDS TTE to an ARDS TTE: tricuspid annular plane systolic excursion (TAPSE), myocardial performance index (MPI), fractional area change (FAC), systolic pulmonary artery pressure (SPAP), peak tricuspid regurgitant (TR) velocity, and septal shift. Over 24months, 14 patients met inclusion/exclusion criteria. Mean TAPSE decreased from 22.4mm pre-ARDS to 16.3mm during ARDS, P<.001. Mean MPI increased from 0.19 to 0.38, P=.001. Mean FAC decreased from 60.8% to 41.2%, P=.003. Peak TR velocity increased from 2.67m/s pre-ARDS to 3.31m/s during ARDS, P=.02. SPAP and septal shift demonstrated trends but not statistically different between pre-ARDS and ARDS states. TAPSE correlated with ARDS severity (PaO2 /FiO2 ratios), P=.004, and was lower among 30-day nonsurvivors compared with survivors, P=.002. Mild RV dysfunction is common after ARDS onset. RV morphologic changes coupled with dysfunction can be detected noninvasively through TTE changes with TAPSE, MPI, and FAC. Mild RV dysfunction by TAPSE is associated with ARDS severity and mortality.

Right ventricular global longitudinal strain in repaired tetralogy of Fallot.

Echocardiogram has limitations in effectively assessing right ventricular (RV) function in children post tetralogy of Fallot (TOF) repair. We evaluated the utility of speckle tracking echocardiography (STE)-based RV global longitudinal strain (GLS) for the assessment of RV systolic function. All patients with repaired TOF who had both echocardiograms and cardiac MRI (CMR) within a 6-month interval were included. RV volumes and ejection fraction (EF) were obtained by CMRs. Traditional echocardiographic function parameters and RV GLS were compared to CMR-derived RV EF. Subjects were divided into two groups based on CMR RV EF (group I: RV EF ≥45%; and group II: RV EF <45%). A total of 57 subjects were included. Mean age was 13.0±3.6years and 58% were males. Group I had 39 subjects and group II had 18. Only six of the 18 patients (33%) in group II were identified as having at least mild RV dysfunction by echocardiogram. The mean RV GLS was significantly abnormal in group II (-15.3±3.8%) compared to group I (-20.9±3.3%; P<.001). By ROC analysis, an RV GLS cutoff value of -18% had 78% sensitivity and 77% specificity in identifying RV EF <45% (area under curve .87, P<.001). Intra- and inter-observer reproducibility of RV GLS were good. RV GLS is a simple and effective tool for the assessment of RV systolic function in patients post TOF repair. This technique would help further refine patient selection for timing of CMR and management.