Normal Right Ventricular Function Research Articles

3D Imaging Reveals Complex Microvascular Remodeling in the Right Ventricle in Pulmonary Hypertension.

Pathogenic concepts of right ventricular (RV) failure in pulmonary arterial hypertension focus on a critical loss of microvasculature. However, the methods underpinning prior studies did not take into account the 3-dimensional (3D) aspects of cardiac tissue, making accurate quantification difficult. We applied deep-tissue imaging to the pressure-overloaded RV to uncover the 3D properties of the microvascular network and determine whether deficient microvascular adaptation contributes to RV failure. Heart sections measuring 250-µm-thick were obtained from mice after pulmonary artery banding (PAB) or debanding PAB surgery and properties of the RV microvascular network were assessed using 3D imaging and quantification. Human heart tissues harvested at the time of transplantation from pulmonary arterial hypertension cases were compared with tissues from control cases with normal RV function. Longitudinal 3D assessment of PAB mouse hearts uncovered complex microvascular remodeling characterized by tortuous, shorter, thicker, highly branched vessels, and overall preserved microvascular density. This remodeling process was reversible in debanding PAB mice in which the RV function recovers over time. The remodeled microvasculature tightly wrapped around the hypertrophied cardiomyocytes to maintain a stable contact surface to cardiomyocytes as an adaptation to RV pressure overload, even in end-stage RV failure. However, microvasculature-cardiomyocyte contact was impaired in areas with interstitial fibrosis where cardiomyocytes displayed signs of hypoxia. Similar to PAB animals, microvascular density in the RV was preserved in patients with end-stage pulmonary arterial hypertension, and microvascular architectural changes appeared to vary by etiology, with patients with pulmonary veno-occlusive disease displaying a lack of microvascular complexity with uniformly short segments. 3D deep tissue imaging of the failing RV in PAB mice, pulmonary hypertension rats, and patients with pulmonary arterial hypertension reveals complex microvascular changes to preserve the microvascular density and maintain a stable microvascular-cardiomyocyte contact. Our studies provide a novel framework to understand microvascular adaptation in the pressure-overloaded RV that focuses on cell-cell interaction and goes beyond the concept of capillary rarefaction.

Outcomes of Transcatheter Tricuspid Edge-to-Edge Repair in Patients With Right Ventricular Dysfunction

BACKGROUND: We assessed the safety profile of tricuspid transcatheter edge-to-edge repair (TEER) in patients with right ventricular (RV) dysfunction. METHODS: We identified patients undergoing TEER to treat tricuspid regurgitation from June 2015 to October 2021 and assessed tricuspid annular plane systolic excursion (TAPSE) and RV fractional area change (RVFAC). RV dysfunction was defined as TAPSE <17 mm and RVFAC <35%. The primary end point was 30-day mortality after TEER. We also investigated the change in the RV function in the early phase and clinical outcomes at 2 years. RESULTS: The study participants (n=262) were at high surgical risk (EuroSCORE II, 6.2% [interquartile range, 4.0%–10.3%]). Among them, 44 patients met the criteria of RV dysfunction. Thirty-day mortality was 3.2% in patients with normal RV function and 2.3% in patients with RV dysfunction ( P =0.99). Tricuspid regurgitation reduction to ≤2+ was consistently achieved irrespective of RV dysfunction (76.5% versus 70.5%; P =0.44). TAPSE and RVFAC declined after TEER in patients with normal RV function (TAPSE, 19.0±4.7 to 17.9±4.5 mm; P =0.001; RVFAC, 46.2%±8.1% to 40.3%±9.7%; P <0.001). In contrast, those parameters were unchanged or tended to increase in patients with RV dysfunction (TAPSE, 13.2±2.3 to 15.3±4.7 mm; P =0.011; RVFAC, 29.6%±4.1% to 31.6%±8.3%; P =0.14). Two years after TEER, compared with patients with normal RV function, patients with RV dysfunction had significantly higher mortality (27.0% versus 56.3%; P <0.001). CONCLUSIONS: TEER was safe and feasible to treat tricuspid regurgitation in patients with RV dysfunction. The decline in the RV function was observed in patients with normal RV function but not in patients with RV dysfunction.

Prognostic significance of right ventricular dysfunction in patients presenting with acute left-sided heart failure.

The prognostic value of right ventricular (RV) function in chronic heart failure (HF) has lately been well established. However, research on its role in acute heart failure (AHF) is sparse. This study comprised 195 patients, aged between 18 and 80years, with acute left-sided heart failure (HF) and a left ventricular ejection fraction (LVEF) < 50%. Patients with LVEF ≥ 50%, mechanical ventilatory or circulatory support, poor echocardiographic windows, prosthetic valves, congenital heart diseases, infective endocarditis, and/or life expectancy < 1year due to non-cardiac causes were excluded. The study participants' mean age was 57.7 ± 10.9years, and 74.9% were males. Coronary artery disease was present in 80.5% of patients. The mean LVEF was 31% ± 8.7. RV dysfunction (RVD), defined as tricuspid annular plane systolic excursion (TAPSE) < 17mm, RV S' < 9.5cm/s and/or RV fractional area change (FAC) < 35%, was identified in 48.7% of patients. The RV was dilated in 67.7% of the patients. RVD was significantly associated with a longer HF duration, atrial fibrillation, and idiopathic dilated cardiomyopathy. The primary outcome, a 6-month composite of cardiovascular death or hospitalization for worsening HF (HHF), occurred in 42% of the participants. Cardiovascular mortality and HHF occurred in 30.5% and 23.9% of the patients, respectively. The primary endpoint and longer CCU stays were significantly more common in patients with RVD than in those with normal RV function. RV dilatation was significantly associated with the primary outcome, whether alone or in combination with RVD. Multivariate regression analysis showed that only RV global longitudinal strain (GLS) independently predicted poor outcomes. RVD and RV dilatation strongly predict CV death and HHF in patients with AHF and LVEF < 50%. Multivariate analysis showed that RV GLS was the only predictor of a composite of CV death and HHF.

Do we always need a pulmonary valve?

Abstract Limited right ventricular (RV) outflow patching with preservation of pulmonary valve function are key therapeutic goals during primary repair of tetralogy of Fallot (TOF). Obligatory severe pulmonary regurgitation (PR) following the repair of tetralogy has variable consequences. This is the story of a 38-year-old young woman (out of several such cases) whom the corresponding author has followed for 37 years after she was operated upon for complete repair of the TOF at 1 year of age. During surgery, her pulmonary valve was completely removed, leaving just a tag of valvar tissue. Despite severe PR, she has enjoyed an unrestricted childhood, got married, had two children, and remains completely symptom-free till date. She has normal RV function and no heart failure. This raises an important philosophical question about the necessity of an intact pulmonary valve for long-term survival.

A Noninvasive Circulating Signature of Combined Right Ventricular Pressure and Volume Overload in Tetralogy of Fallot/Pulmonary Atresia/Major Aortopulmonary Collateral Arteries.

Background: Despite surgical advances, children with tetralogy of Fallot/pulmonary atresia/major aortopulmonary collaterals (TOF/PA/MAPCAs) are subject to chronic right ventricular (RV) pressure and volume overload. Current diagnostic tools do not identify adverse myocardial remodeling and cannot predict progression to RV failure. We sought to identify a noninvasive, circulating signature of the systemic response to right heart stress to follow disease progression. Methods: Longitudinal data were collected from patients with TOF/PA/MAPCAs (N = 5) at the time of (1) early RV pressure overload and (2) late RV pressure and volume overload. Plasma protein and microRNA expression were evaluated using high-throughput data-independent mass spectroscopy and Agilent miR Microarray, respectively. Results: At the time of early RV pressure overload, median patient age was 0.34 years (0.02-9.37), with systemic RV pressures, moderate-severe hypertrophy, and preserved systolic function. Late RV pressure and volume overload occurred at a median age of 4.08 years (1.51-10.83), with moderate RV hypertrophy and dilation, and low normal RV function; 277 proteins were significantly dysregulated (log2FC ≥0.6/≤-0.6, FDR≤0.05), predicting downregulation in lipid transport (apolipoproteins), fibrinolytic system, and extracellular matrix structural proteins (talin 1, profilin 1); and upregulation in the respiratory burst. Increasing RV size and decreasing RV function correlated with decreasing structural protein expression. Similarly, miR expression predicted downregulation of extracellular matrix-receptor interactions and upregulation in collagen synthesis. Conclusion: To our knowledge, we show for the first time a noninvasive protein and miR signature reflecting the systemic response to adverse RV myocardial remodeling in TOF/PA/MAPCAs which could be used to follow disease progression.

Speckle tracking echocardiography for diagnosis of right ventricular failure in children with totally corrected tetralogy of Fallot in Sulaimani, Iraq

ObjectivesThe study was aimed at using speckle tracking echocardiography as a novel technique to diagnose right ventricular failure (RVF) in children with total correction of tetralogy of Fallot (TOF) through surgery. MethodsA quasi-experimental study was performed at the Children's Heart Hospital of Sulaimani for 9 months. A total of 150 children with completely repaired TOF were enrolled to investigate RVF. Conventional echocardiographic data were recorded, including right ventricular (RV) ejection fraction (EF), tricuspid annular plane systolic excursion (TAPSE), myocardial performance index (MPI), and RV end-systolic and diastolic volume (RVESV and RVEDV). Additionally, speckle tracking was performed for the regional and longitudinal strain and strain rate in four-chamber apical view. RVF diagnosis was determined on the basis of electrocardiography measurement of P-wave dispersion, T-wave dispersion, and QRS duration. ResultsChildren with repaired TOF who were diagnosed with RVF through conventional echocardiography exhibited abnormalities with respect to children with normal RV function, including a TAPSE of 1.3 ± 0.11 cm, RVEF of 35.5 ± 6.72, RVESV of 69.8 ± 15.13 ml, RVEDV of 110.1 ± 14.13 ml, MPI of 0.60 ± 0.12, and Pmax of 52.4 ± 14.08. The use of speckle tracking in RVF diagnosis revealed a relatively lower longitudinal strain and strain rate (−12.1 ± 2.3 and −0.9 ± 0.3, respectively) in the children with RVF. Moreover, longitudinal right ventricular strain was positively correlated with TAPSE (r = 0.656) and EF (r = 0.675), and negatively correlated with RVEDV (r = −0.684), RVESV (r = −0.718), MPI (r = −0.735), and Pmax (r = −0.767). ConclusionsThe application of speckle tracking with the longitudinal RV strain and strain rate to estimate RV function in children with repaired TOF is a new advanced method that, compared with conventional echo, significantly improves the diagnosis of regional myocardial deformations and cardiac muscle motion velocity.

Abstract 15082: Novel Imaging/Hemodynamic Based Right Ventricular Phenotypes in Patients With Pulmonary Hypertension

Introduction: Right ventricular function and ventricular dynamics associate with outcomes in pulmonary hypertension (PH). Measures of RV strain describe ventricular mechanics but are not included in RV function assessments. This study aimed to develop novel RV imaging-hemodynamic phenotypes using unsupervised machine learning. Methods: Participants with cardiac magnetic resonance (CMR) and right heart catheterization data were identified from The Ohio State University CMR PH registry (n=81). RV areas were segmented from CMR 4-chamber images and used to determine RV free wall (RVFW) and septal strain. K-medoids clustering was used on imaging features, RV hemodynamics, and RV function (Figure A). Correlation analysis was used to reduce collinearity. Significance was measured with Kruskal Wallis and chi-squared tests. A p-value &lt; 0.05 was considered significant. Results: Participants were assigned to three clusters and top contributors to cluster assignment were RVEF, RVFW strain, and Ea. RV phenotypes progress from mild/no RV dysfunction (Cluster 1) to severe RV dysfunction (Cluster 3) (Figure A). Cluster 1 had normal RV function with high RVEF and PA compliance, preserved LVEF, low RVSP, and low Eed. Compared to cluster 1, cluster 2 demonstrates more RV dysfunction with reduced RVEF, stroke volume, and PA compliance with an increase in RVSP but no change in Eed. In addition to more RV dysfunction (decreased RVEF and stroke volume), cluster 3 had increased RA pressure and Eed. In terms of RV strain, (Figure B), cluster 2 had less negative RVFW and septal strain compared to cluster 1. In cluster 3, RV septal strain is similar to cluster 2 but with decreased RVFW strain. Conclusions: Imaging and hemodynamic RV variables contribute to identification of novel RV-centric phenotypes and should be included in phenotyping efforts to better describe altered ventricular dynamics contributing to RV dysfunction in PH.

Prognostic value of right ventricular function in patients with severe tricuspid regurgitation undergoing tricuspid valve intervention

Abstract Funding Acknowledgements Type of funding sources: None. Background Indications and optimal timing of intervention for severe tricuspid regurgitation (TR) remain controversial due to insufficient evidence. Right ventricular (RV) function assessment, a key factor of preoperative evaluation, remains challenging due to limitations of conventional echocardiographic indexes, particularly with concomitant severe TR. Right ventricular free wall longitudinal strain (RVFWLS) is able to evaluate intrinsic systolic function and to identify RV dysfunction at early stage compared to conventional echocardiographic indices. Purpose to analyze the prognostic implications of pre-operative RV dysfunction, evaluated through conventional and speckle-tracking echocardiography, in patients with severe TR undergoing tricuspid valve intervention. Methods In this single-center retrospective study, we enrolled consecutive patients with severe TR who underwent surgical or transcatheter tricuspid valve intervention (TTVI) between November 2016 and July 2021. The primary endpoint was all-cause mortality. For a secondary exploratory analysis, to compare outcomes of operated versus conservatively treated patients, we enrolled consecutive patients with severe TR who underwent echocardiographic evaluation in the same time period and who undergo conservative management. Results Study population included 100 patients: 78 patients underwent isolated TV surgical intervention and 22 TTVI. ROC curve analysis showed RVFWLS as the best echocardiographic parameter to predict all-cause mortality (AUC: 0.726, IC 0.57–0.88 P = 0.006). Estimated 4-years survival was significantly lower in patients with RV dysfunction (defined as an absolute value of RVFWLS ≤ 21%, cutoff derived from ROC analysis with sensitivity 60% and specificity 87%) compared to patients with normal RV function: 70.0% vs 93.9% p = 0.002 (Figure 1). Independent prognostic role of RVFWLS was confirmed at multivariable analysis adjusted for significative clinical and echocardiographic variables (OR 0.88, 95% CI 0.80–0.98; P = 0.016). At secondary exploratory analysis, patients treated conservatively had a worst estimated 4-year survival compared to operated patients (59.6% vs 84.0%, p = 0.001). Stratifying this population according to the presence of RV dysfunction, in the group with lower RVFWLS values there were no significative differences in overall survival between operated and conservatively-treated patients (Figure 2). Conclusions Preoperative RV dysfunction defined by echocardiographic strain analysis is independently associated with outcomes after TV intervention. RVFWLS could be useful for indication and timing of intervention for severe TR.

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

AimsThe 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). Methods and resultsIn 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 1 year as compared to patients with normal RV-function (HRadjusted 2.06, 95 % CI 0.97–4.37). ConclusionAfter 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.” Clinical trial registrationhttps://www.clinicaltrials.gov: NCT01368250.

Right Ventricular-Pulmonary arterial (RV-PA) coupling is load independent and accurately predicts right ventricular function

RV-PA coupling can be evaluated, using non-invasive surrogates such as Tricuspid annular plane systolic excursion/Systolic pulmonary artery pressure (TAPSE/SPAP) or RV free wall longitudinal strain/SPAP (RVFWLS/SPAP) emerged. The aim of the present study was: 1) Population 1: in Hemodialysis population (HD), to evaluate RV parameters during important load variations, immediately before and after HD. 2) Population 2: in routine cardiologic population, to evaluate the diagnostic value of RV-PA coupling for RV dysfunction Population 1: 85 patients (53 men), 64 ± 16 years old, had an echocardiography with RV analysis (s’, TAPSE, RVFWLS)immediately before starting HD(Pre-HD)and at the end of HD(Post-HD). Population 2: 96 patients (60 men), 64 ± 14 years old with various disease in the Department of cardiology had an echocardiography including RVFWLS,RV fractional area change(RVFAC), TAPSE,S’, Tei index, Isovolumic acceleration(IVA),and 3D RVEF. Patients were split in normal RV function (defined by 6 concordant normal indices) and RV dysfunction (defined by the presence of at least 3 abnormal indices) Population 1: TAPSE, s’, RVFWLS were significantly decreased in post-HD as compared to pre-HD; when indexing these parameters by SPAP (s’/SPAP, TAPSE/SPAP, RVFWLS/SPAP), they remain unchanged. Population 2: RVFWLS/SPAP and TAPSE/SPAP were significantly higher in normal RV function compared to dysfunction (1.02 ± 0.31 vs 0.57 ± 0.34 and 0.83 ± 0.20 vs 0.47 ± 0.21); diagnostic thresholds for RV dysfunction were 0.67 for RVFWLS/SPAP(sensitivity:95%, specificity:78%)and 0.63 for TAPSE/SPAP (sensitivity:86%, specificity:80%) Surrogates of RV-PA coupling, such as TAPSE/SPAP or RVFWLS/SPAP are load independent in a HD population. Moreover, these parameters may contribute to precisely evaluate RV function.

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.

Long term recovery of right ventricular function after treatment of intermediate and high risk pulmonary emboli

IntroductionPulmonary embolism (PE) is a common and significant source of mortality and morbidity worldwide. A subset of patients with PE, particularly those who have intermediate and high risk events, are at increased risk for long-term right ventricular (RV) dysfunction; however, the impact of novel advanced therapies used for acute PE, including catheter-directed intervention, on long-term RV function remains uncertain. We sought to determine whether use of advanced therapies (catheter-directed intervention or systemic thrombolysis) is associated with improved long-term RV function. Materials and methodsRetrospective, single-center cohort study of adult (≥18 year old) patients admitted and discharged alive with a diagnosis of acute PE, who fell under the category of intermediate or high risk, with available follow-up echocardiograms at least 6 months after the index, seen at a single quaternary referral center in Los Angeles, CA between 2012 and 2021. ResultsThere were 113 patients in this study (58 (51.3 %) treated with anticoagulation alone, 12 (10.6 %) treated with systemic thrombolysis, and 43 (38.1 %) treated with catheter-directed intervention), with approximately equal gender and racial distribution. Patients treated with advanced therapies were significantly more likely to have moderate-severe RV dysfunction (100 % for those treated with thrombolysis, 88.3 % for those treated with catheter-directed intervention, vs 55.2 % for those treated with anticoagulation alone; p < 0.001). At a follow-up of about 1.5 years, patients treated with advanced therapy (systemic thrombolysis or catheter-directed intervention) were more likely to have normalization of RV function (93–100 % vs 81 % for anticoagulation alone, p = 0.04). The subgroup of patients with intermediate-risk PE was significantly more likely to have normalization of RV function (95.6 % vs 80.4 % for anticoagulation alone, p = 0.03). Use of advanced therapy was not associated with substantial short-term adverse events among patients who survived to hospital discharge. ConclusionPatients with intermediate and high risk PE were more likely to have recovery in RV function long-term if treated with catheter-directed intervention or systemic thrombolysis, as compared to anticoagulation alone, without substantial safety issues, despite having worse RV function at baseline. Further data is needed to verify this observation.

Biventricular Function is Impaired in Right Ventricular Septal Pacing-A Prospective Study Using Myocardial Strain Imaging.

Left ventricular (LV) dysfunction is known to occur after right ventricular (RV) pacing; the effect on RV function is less well studied. The aim of this study was to assess the impact of RV mid-septal pacing upon RV function using the novel parameters of speckle-tracking derived RV global longitudinal strain (RV GLS) and RV free wall strain (RV FWS), as well as the conventional parameters RV fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), and tricuspid annular systolic velocity (RV S'). Thirty-two (32) consecutive patients with normal baseline LV and RV function requiring permanent pacemaker insertion were prospectively recruited. Echocardiography was performed prior to implantation, at 1 day, 1 month and 1 year after implantation, with 29 patients completing follow-up. After 1 year, three patients (10%) with otherwise normal RV parameters developed abnormal RV strain patterns. Compared to 1 day after implantation, at 1 year significant reductions were observed in mean RV GLS (-24.8 to -21.8%) RV S' (15.1 to 12.2 cm/s), TAPSE (24.2 to 21.9 mm), RV GLS (-24.8 to -21.8%), left ventricular ejection fraction (LVEF) (66.0 to 57.9%), LV GLS (-19.9 to 17.0), all p<0.01. There was a non-significant reduction for RV FWS (-29.0 to -26.7%, p=0.06) and there was no change in RV FAC (49.1 to 46.9%, p=0.24). We report abnormalities of RV strain developing 1 year after pacemaker insertion. Measurement of myocardial strain is emerging as an additional method to detect patients at risk of RV dysfunction in those who have undergone pacemaker implantation.

Right Ventricular Free Wall Strain and Effect of Defibrillator Implantation in Patients With Nonischemic Systolic Heart Failure

BackgroundPatients with nonischemic systolic heart failure have an increased risk of malignant ventricular arrhythmias and sudden cardiovascular death. Because the risk is less pronounced than for patients with ischemic cause of heart failure more discriminating tools are needed to identify patients most likely to benefit from implantable cardioverter-defibrillator (ICD) implantation. Right ventricular (RV) dysfunction is associated with a worse prognosis, but whether RV free wall strain (RV-FWS) measured with echocardiography can identify the patients most likely to benefit from ICD implantation is not known. Methods and ResultsIn this extended follow-up analysis of the Danish Study to Assess the Efficacy of ICDs in Patients with Non-ischemic Systolic Heart Failure on Mortality (DANISH) trial, RV-FWS was measured with echocardiography in 445 patients before randomization. RV dysfunction was defined as an RV-FWS of greater than –20%. The primary end point was all-cause mortality. The median RV-FWS was –18% (quartiles –23% to –14%), and RV dysfunction was measured in 255 patients (57%). During a median follow-up of 5.7 years, 170 patients (38%) died. There was a statistically significant interaction between RV dysfunction and the effect of ICD implantation (P = .003), also after adjusting for known cardiovascular risk factors (P = .01). ICD implantation significantly decreased all-cause mortality in patients with RV dysfunction (hazard ratio 0.54, 95% confidence interval 0.36-0.80, P = .002), but not in patients with normal RV function (hazard ratio 1.34, 95% confidence interval 0.84-2.12, P = .22). ConclusionsIn patients with nonischemic systolic heart failure, RV dysfunction on echocardiography was associated with a greater effect of ICD implantation and could be used to select patients with benefit from ICD treatment.

Preoperative Levosimendan therapy reduces postoperative right ventricular failure in patients undergoing left ventricular assist device implantation

Perioperative mortality and complications still remain high after left ventricular assist device (LVAD) implantation, especially in highly compromised patient cohorts. Here, we evaluate the effects of preoperative Levosimendan therapy on peri- and postoperative outcomes after LVAD implantation. We retrospectively analysed 224 consecutive patients with LVAD implantation for end-stage heart failure between November 2010 and December 2019 in our centre with regard to short- and longer-term mortality as well as incidence of postoperative right ventricular failure (RV-F). Out of these, 117 (52.2%) received preoperative i.v. Levosimendan therapy within 7 days before LVAD implantation (Levo group). In-hospital, 30-day and 5-year mortality was comparable (in-hospital mortality: 18.8% vs 23.4%, P = 0.40; 30-day mortality: 12.0% vs 14.0%, P = 0.65; Levo vs control group). However, in the multivariate analysis, preoperative Levosimendan therapy significantly reduced postoperative RV-F but increased postoperative vasoactive inotropic score ([RV-F: odds ratio 2.153, confidence interval 1.146-4.047, P = 0.017; vasoactive inotropic score 24 h post-surgery: odds ratio 1.023, confidence interval 1.008-1.038, P = 0.002). These results were further confirmed by 1:1 propensity score matching of 74 patients in each group. Especially in the subgroup of patients with normal preoperative RV function, the prevalence of postoperative RV-F was significantly lower in the Levo- group as compared to the control group (17.6% vs 31.1%, P = 0.03; respectively). Preoperative Levosimendan therapy reduces the risk of postoperative RV-F, especially in patients with normal preoperative RV function without effects on mortality up to 5 years after LVAD implantation.

Bosentan Is Associated with a Reduction in Right Ventricular Systolic Pressure N-Terminal Pro-Hormone B-Type Natriuretic Peptide Levels in Young Patients with Pulmonary Hypertension

Pulmonary hypertension is a rare and potentially fatal disease in children if left untreated. Emerging therapies, including Bosentan, a dual endothelin receptor antagonist, have shown significant benefits in the adult pulmonary hypertension population; however, few studies have assessed the efficacy and safety of endothelin receptor antagonists in infants and young children. Our study was a single-center retrospective analysis of patients less than two years of age with a confirmed diagnosis of pulmonary hypertension and initiated on Bosentan therapy between 2017 and 2020. Twelve cases met eligibility criteria. Demographic data, laboratory data, echocardiographic, and cardiac catheterization data were analyzed. With treatment, there was a statistically significant decrease in mean right ventricular systolic pressure estimated by the tricuspid regurgitation jet (79 ± 23 mmHg reduced to 52 ± 25 mmHg; p < 0.001) N-terminal pro-hormone B-type natriuretic peptide levels (21,071 reduced to 2,037; p < 0.001). Additionally, improvement and eventual normalization of right ventricular function and septal geometry was seen within the first four months of therapy. Patients who underwent cardiac catheterization after therapy initiation (n = 4) demonstrated hemodynamic improvements; however, only the decrease in diastolic pulmonary artery pressure was statistically significant (p = 0.018). No significant differences in hemoglobin, platelet count, or liver function tests were observed between groups. In conclusion, these data suggest that Bosentan may be an effective and relatively safe treatment option for children less than two years of age with pulmonary hypertension. Further long-term randomized control studies are necessary to validate the potential clinical benefit of utilizing this drug therapy in young children.

Abstract 11687: Diagnosis and Management of High-Risk Pulmonary Embolism in a Term Neonate

Case Presentation: A 5 day old, term infant born to a 39-year-old G1P0 with a history of diet-controlled gestational diabetes mellitus presented with hypernatremic dehydration in the setting of poor feeding. On hospital day 2, the infant suffered a bradycardic cardiac arrest requiring 2 minutes of CPR prior to return of spontaneous circulation. An echocardiogram (Figure 1A) revealed moderately depressed right ventricular (RV) function, elevated RV pressure and a large mobile mass extending from the main pulmonary artery (PA) into the left PA with obstruction of flow. D-dimer was markedly elevated at 2740 ng/mL. A subsequent CT angiogram revealed acute pulmonary emboli in the distal left and right branch PAs (Figure 1B). Additional imaging was obtained and showed dural venous sinus, left portal vein and right cephalic vein thromboses. The infant was managed with a heparin infusion and supportive therapy for the RV dysfunction and pulmonary hypertension including mechanical ventilation, inhaled nitric oxide as well as epinephrine and milrinone infusions. Over the course of two weeks, the infant improved clinically with normalization of RV function. Discussion: Neonatal pulmonary arterial thrombosis is an exceedingly rare phenomenon. The majority of cases described in the literature are associated with either an inherited thrombophilia or with underlying congenital heart disease, which were not found to be present in this case. However, this patient presented with severe dehydration and a history of maternal diabetes, both of which are risk factors for neonatal thrombosis. Fortunately, this patient responded to treatment with anticoagulation alone and did not require more invasive therapies, such as surgical thrombectomy or systemic and catheter-directed thrombolysis. Although rare, neonatal pulmonary arterial thrombosis can occur and delays in recognition and treatment may lead to significant RV dysfunction, morbidity, and even death.

Abstract 10279: Three-Dimensional Deep-Tissue Imaging of the Right Ventricle Reveals the Complex Remodeling of the Microvascular Network in Right Heart Failure

Introduction: Right ventricular (RV) failure is the leading cause of death in patients with pulmonary arterial hypertension (PAH). Capillary rarefaction has been proposed as the hallmark of RV failure, yet our understanding of the capillary architecture is limited by 2D image analysis. Three-dimensional (3D) confocal deep tissue imaging offers the unparalleled opportunity to characterize the architectural microvascular changes in relationship to cardiomyocytes in pressure-overloaded RV failure. Methods and Results: 250 μm heart tissue slices from mice with RV failure, 7-weeks after Pulmonary Artery Banding (PAB) were harvested and the microvascular network was assessed for density, segment length, diameter, orientation, as well as microvasculature-cardiomyocyte contact area in regions with and without interstitial fibrosis using confocal 3D imaging. Human heart tissue from end-stage PAH patients was compared to controls with normal RV function. In PAB mice, 3D imaging of the RV free wall revealed tortuous, shorter, thicker and higher-branched microvascular segments as well as development of fibrosis compared to Sham animals (Fig A). When corrected for fibrosis, the microvascular density was preserved even in advanced stages of RV failure. Physical contact between the microvasculature and cardiomyocytes was preserved in areas without fibrosis, yet significantly impaired in areas with interstitial fibrosis (Fig B), accompanied by an overexpression of β-myosin heavy chain suggesting local ischemia (Fig C). 3D imaging of human RV tissue of end-stage PAH patients revealed architectural microvascular remodeling that varied depending on etiologies and length of disease yet showed preserved microvascular density. (Fig. D). Conclusions: 3D deep tissue imaging revealed compensatory changes of the microvascular network to maintain a stable cardiomyocyte coverage in pressure-overloaded RV failure, which was impaired in areas of interstitial fibrosis.

Abstract 13878: A Case of Severe Tricuspid Regurgitation, Recurrent Ascites, Worsening Renal Function Leading to Hemodialysis Secondary to RV Lead Impingement, Resolved Completely With Lead Extraction

Introduction: 1. In contemporary practice, implantation of Cardiovascular Implantable Electronic Devices (CIED) is associated with low complication rate peri-procedurally. 2. However, in some patients these complications can have high morbidity and mortality; namely pneumothorax, pericardial tamponade, pacemaker syndrome, and rarely tricuspid regurgitation (TR) secondary to lead impingement. 3. TR secondary to RV lead impingement is not uncommon but infrequently lead to severe TR and worsening heart failure symptoms. 4. We present a case of severe TR secondary to RV lead impingement leading to splanchnic congestion and recurrent ascites, worsening renal failure leading to hemodialysis (HD), all of which resolved with lead extraction. Case: A 77-year-old woman with known CAD with prior PTCA, paroxysmal AF, and prior watchman implantation, evaluated in our clinic for severe TR. She had recurrent admissions for ascites needing paracentesis. Her liver function and ultrasound was normal. Her renal function worsened and HD was initiated. ECHO showed normal LVEF, severe TR with RVSP of 74mmHg, and mild RV dysfunction. Pericardial physiology was normal. The lead was noted to be impinging on the septal leaflet, and adherent. Normal pulmonary valve function. Follow up: We proceeded to perform RV lead extraction and implanted a new leadless pacemaker [MICRA-AV, Medtronic Inc]. Her follow up ECHO in 2 weeks showed mild TR and normal RV function. RVSP had dropped significantly to 34mmHg. Surprisingly, her needs for paracentesis came down and by 3 months follow up she did not need paracentesis anymore. Her renal function improved, and her HD needs stopped. Conclusions: 1. CIED implantations are associated with low complication rate (less than 5% in total) in most patient cohorts but in some patients it can be associated with significant complications increasing their morbidity and sometimes mortality. 2. Severe TR is a well-recognized complication of pacemaker implantation. It led to recurrent ascites needing paracentesis, ESRD requiring HD and multiple hospital admissions and thus increasing the morbidity. 3. It is important to recognize the uncommon complications of such commonly used intracardiac devices for electrophysiologists, cardiologists and PCPs.

Coronavirus disease 2019 and cardiovascular disease: what we have learnt during the last 2 years.

Coronavirus disease 2019 and cardiovascular disease: what we have learnt during the last 2 years.