Postoperative Right Ventricular Function Research Articles

Long-term effects of pulmonary endarterectomy on pulmonary hemodynamics, cardiac function, and exercise capacity in chronic thromboembolic pulmonary hypertension

Long-term changes in exercise capacity and cardiopulmonary hemodynamics after pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) have been poorly described. We analyzed the data from 2 prospective surgical CTEPH cohorts in Hammersmith Hospital, London, and Amsterdam UMC. A structured multimodal follow-up was adopted, consisting of right heart catheterization, cardiac magnetic resonance imaging, and cardiopulmonary exercise testing before and after PEA. Preoperative predictors of residual pulmonary hypertension (PH; mean pulmonary artery pressure >20mm Hg and pulmonary vascular resistance ≥2WU) and long-term exercise intolerance (VO2max <80%) at 18months were analyzed. A total of 118 patients (61 from London and 57 from Amsterdam) were included in the analysis. Both cohorts displayed a significant improvement of pulmonary hemodynamics, right ventricular (RV) function, and exercise capacity 6months after PEA. Between 6 and 18months after PEA, there were no further improvements in hemodynamics and RV function, but the proportion of patients with impaired exercise capacity was high and slightly increased over time (52%-59% from 6 to 18months). Long-term exercise intolerance was common and associated with preoperative diffusion capacity for carbon monoxide (DLCO), preoperative mixed venous oxygen saturation, and postoperative PH and right ventricular ejection fraction (RVEF). Clinically significant RV deterioration (RVEF decline >3%; 5 [9%] of 57 patients) and recurrent PH (5 [14%] of 36 patients) rarely occurred beyond 6months after PEA. Age and preoperative DLCO were predictors of residual PH post-PEA. Restoration in exercise tolerance, cardiopulmonary hemodynamics, and RV function occurs within 6months. No substantial changes occurred between 6 and 18months after PEA in the Amsterdam cohort. Nevertheless, long-term exercise intolerance is common and associated with postoperative RV function.

Right ventricular dysfunction after coronary artery bypass grafting

Abstract Background Impaired right ventricular (RV) function is a frequent echocardiographic finding following coronary artery bypass grafting (CABG). It is subject of debate whether this finding reflects actual RV dysfunction with clinical impact, or rather limitations of the applied echocardiographic measurements. Purpose We aimed to investigate prevalence of RV dysfunction using currently available echocardiographic measurements, and self-reported physical capacity more than two years after CABG. Materials and methods This pre-specified cross-sectional substudy of the SWEDEGRAFT trial included patients scheduled for follow-up more than two years after elective CABG at our institution. The SWEDEGRAFT trial is an ongoing multicenter, randomized clinical trial comparing patency of saphenous vein grafts harvested with "no-touch" and open skeletonized technique. We prospectively assessed RV function with multivariable transthoracic echocardiography. Self-reported physical capacity was assessed using the three items for physical limitation of the Seattle Angina Questionnaire (SAQ-7) (3 denotes the worst and 15 the best possible physical capacity), as well as NYHA-class. Baseline and procedural data were retrieved from the SWEDEGRAFT trial. Preoperative echocardiographies were systematically reexamined. Results We enrolled 207 patients into our substudy at a median follow-up after CABG of 31.0 (range 24.2-39.9) months. RV function assessed by tricuspid annular plane systolic excursion (TAPSE) was significantly reduced compared to the preoperative assessment. In contrast, postoperative RV function as assessed by RV fractional area change (FAC) was preserved. Similarly, assessment of three-dimensional RV ejection fraction (3D-RVEF) indicated preserved RV function (mean 49.4 ± 6.3 %). Mean RV global longitudinal strain was -19.7 (±3.6), and mean RV free wall strain was -22.7 (±4.9). At follow-up, assessments of 3D-RVEF and strain modalities were obtainable in 51.7% and 72.4% of patients, respectively. Patient-reported functional capacity was excellent (median score 15, interquartile range 1.5). NYHA-class improved significantly (NYHA-class I preoperative 49.4% vs. postoperative 61.4%, p=0.032). Postoperative median pro-Brain Natiuretic Peptide levels were 163 (interquartile range 195) ng/L. Conclusion RV systolic function was preserved more than two years after CABG when assessed by RV FAC and 3D-RVEF despite significant reduction in TAPSE. These findings likely reflect the increased sphericity of the RV following opening the pericardium during surgery. Our study supports that measurements of longitudinal systolic parameters likely underestimate RV systolic function after CABG.

Right atrial function early after tetralogy of Fallot repair.

Diastolic dysfunction after repair for Tetralogy of Fallot (TOF) is associated with adverse long-term outcomes. Right atrial (RA) mechanics as a proxy of right ventricular (RV) diastolic function in the early post-operative period after surgical repair for TOF has not been reported. We sought to evaluate RA and RV strain prior to hospital discharge after TOF repair and to identify important patient factors associated with strain using a machine learning method. Single center retrospective cohort study of TOF patients undergoing surgical repair, with analysis of RA and RV strain from pre-and post-operative echocardiograms. RA function was assessed by the peak RA strain, systolic RA strain rate, early diastolic RA strain rate and RA emptying fraction. RV systolic function was measured by global longitudinal strain. Pre- and post-operative values were compared using Wilcoxon rank sum test. Gradient boosted machine (GBM) models were used to identify the most important predictors of post-operative strain. In total, 153 patients were enrolled, median age at TOF repair 3.5months (25th-75th percentile: 2.2- 5.2), mostly male (67%), and White (64.1%). From pre-to post-operative period, there was significant worsening in all RA parameters and in RV strain. GBM models identified patient, anatomic, and surgical factors that were strong predictors of post-operative RA and RV strain. These factors included pulmonary valve and branch pulmonary artery Z scores, birth weight, gestational age and age at surgery, pre-operative RV fractional area change and oxygen saturation, type of outflow tract repair, duration of cardiopulmonary bypass, and early post-operative partial arterial pressure of oxygen. There is significant worsening in RA and RV strain early after TOF repair, indicating early alteration in diastolic and systolic function after surgery. Several patient and operative factors influence post-operative RV function. Most of the factors described are not readily modifiable, however they may inform pre-operative risk-stratification. The clinical application of RA strain and the prognostic implication of these early changes merit further study.

COMPARISON OF TRANS-RIGHT ATRIAL VERSUS COMBINED (TRANS-RIGHT ATRIAL, TRANS-RIGHT VENTRICULAR) APPROACH FOR INTRA-CARDIAC REPAIR OF TETRALOGY OF FALLOT: SINGLE-CENTER EXPERIENCE

Background and Objective: We compared trans-right atrial (t-RA) versus combined (trans-right-atrial and trans-ventricular (t-RA/RV) approaches for intra-cardiac repair of Tetralogy of Fallot (TOF) for the pre-operative and post-operative right ventricular (RV) function. The RV function was calculated using a tricuspid annular plane systolic excursion (TAPSE) using two-dimensional (2-D) echocardiography.&#x0D; Materials and Methods: This was a retrospective study. Fifty-three patients operated for the intra-cardiac repair of TOF between August 2019 and March 2021 were included in the study and divided into two groups based on the approach for repair as follows: t-RA or combined (t-RA/RV) approach. The first group (t-RA) had twenty-one patients, and the second group (combined t-RA/RV approach) had thirty-two patients. The assessment of pre-operative and post-operative RV function was done using TAPSE. Records of follow-up at 1 month and 3 months were evaluated.&#x0D; Results: Age, body surface area (BSA), preoperative saturation, cardiopulmonary bypass time, aortic cross?clamp time, postoperative intensive care unit (ICU) stay, and hospital stay&#x0D; were similar in both groups. However, t?RA/RV group had more pleural effusions (9 vs. 1 patients, P &lt; 0.05), but had more improvements in Right Ventricular outflow tract (RVOT) gradients. There were no differences in arrhythmias in either group. Pre-operative TAPSE for both groups was similar (1.46 ± 0.27 vs. 1.61 ± 0.31, P &gt; 0.05) and so was the post?operative TAPSE at discharge (1.54 ± 0.31 vs. 1.49 ± 0.33, P &gt; 0.05), at 1 months (1.64 ± 0.25 vs. 1.48 ± 0.32, P &gt; 0.05) and 3months (1.75 ± 0.19 vs. 1.7 ± 0.15, P &gt; 0.05).&#x0D; Conclusion: Both approaches provide adequate palliation with effective improvements in RVOT gradients for patients with TOF. A limited right ventriculotomy does not adversely affect early RV function or increase the incidence of arrhythmias at the immediate post-operative period and early follow-up. More extensive studies with prospective randomized design and longer follow-ups are needed to address these issues further.&#x0D; Keywords: Tetralogy of Fallot, transatrial approach, intracardiac repair.

Right Ventricular Function After Minimally Invasive Mitral Valve Surgery

Right ventricular (RV) dysfunction is a significant cause of morbidity and mortality after cardiac surgery. Minimally invasive mitral valve surgery (MIMVS) increasingly is being performed. The authors aim was to evaluate postoperative RV function in patients who underwent MIMVS versus traditional mitral valve surgery. Six hundred seventy-five patients who underwent elective isolated mitral valve surgery at Centro Cardiologico Monzino from January 2016 to December 2019 were analyzed. After 1:1 propensity score matching, 60 patients were identified in the MIMVS (study group A) and 58 patients in the median sternotomy (control group B) and compared. A university-affiliated scientific institute, monocentric. Patients. Mitral valve surgery. No in-hospital deaths occurred. Aortic cross-clamp time (102 [87.5-119] v 83 [61-109] minutes, p=0.0001), cardiopulmonary bypass duration (161.5 [142.5-181] v 105.5 [74-134] minutes, p < 0.0001) and intensive care unit stay (47 [44-72] v 45 [40-47] hours, p=0.0015) were significantly longer in group A. The tricuspid annular plane systolic excursion was not different between group A and group B neither postoperatively (15 ± 3 v 14 ± 4 mm, p=0.1) nor at three-month follow-up (18 ± 4 v 15 ± 3 mm, p=0.3). No differences in peak postoperative lactates, inotropic score, central venous pressure, and pulmonary artery pulsatility index were observed. The length of hospital stay was significantly shorter in the minimally invasive group (ten [eight-13] v 12 [ten-17], p=0.006). The authors study showed that the surgical strategy had no significant impact on postoperative RV function after mitral valve surgery.

Journey of the Right Heart Following Left Ventricular Assist Device Implantation

Introduction Right heart function impacts outcomes in left ventricular assist devices (LVADs) but a comprehensive exploration of changes in right heart function over time and its effects on outcomes has not been fully elucidated. We sought to characterize changes in right heart function according to hemodynamic, imaging, and laboratory data at multiple time points and evaluate how pre-implant function compares to postoperative function in predicting heart failure (HF) outcomes. We hypothesized that postoperative (pre-discharge) right ventricular (RV) systolic function would be more predictive of HF readmissions compared to preoperative RV function. Methods In this single-center study, we included consecutive patients (n=298) who received primary LVADs between May 2008 and December 2018. Invasive hemodynamics, echocardiography (ECHO), and laboratory data were collected preoperatively, postoperatively, and at 3, 6, and 12 months following LVAD implantation. Post-implant readmission data were also collected up to 12 months post hospital discharge. Results Compared to pre-implant values, significant and persistent improvements in right atrial pressure (RAP), pulmonary artery (PA) pressures, pulmonary capillary wedge pressure (PCWP), pulmonary vascular resistance (PVR), and RAP/PCWP occurred at 3, 6, and 12 months post-implant respectively (figure 1a). On the other hand, PA pulsatility index (PAPi) fluctuated over time and RV stroke work index (RVSWI) decreased over time (figure 1a). In addition, the proportion of patients with moderate-severe/severe RV dilation, tricuspid regurgitation (TR), and RV systolic function reduction eventually decreased on average by 12 months post-implant (figure 1b). Significant improvements in BNP and bilirubin levels occurred (figure 1c). Finally, we found that postoperative (pre-discharge) RV systolic function by ECHO was significantly predictive of readmissions due to HF (p=.03) whereas preoperative RV systolic function was not (p=0.81). Conclusions Right heart function metrics generally improve and persist at various time points post-implant compared to preoperative values. However, normalization of right heart function is rarely achieved, highlighting the need to redefine “normal” in LVAD patients. Additionally, the superior predictive value of postoperative RV function on HF readmissions underscores the importance of re-assessing right heart function post-implant for improved risk stratification.

Strain and Strain Rate To Evaluate Right Heart Function of Ebstein Anomaly (EA) Patients Before and After Operation.

This study was aimed to elucidate the feasibility of using right ventricular (RV) strain and strain rate to evaluate right heart function of Ebstein anomaly (EA) patients before and after operation. Sixty EA patients and 30 healthy controls underwent echocardiography (UCG) for evaluation of right heart function. Preoperative UCG and 1-week and 3-month postoperative UCG were performed in EA patients. RV strain and strain rate were measured on the four-chamber section of tissue Doppler imaging (TDI). The strain and strain rate representative of right ventricle systolic function were reduced prior to operation. RV strain and strain rate improved after the operation (P < .001), most significantly in the basal segment and middle segment of the free wall of the right ventricle as well as the basal segment of the interventricular septum (P < .001). The measurement of RV strain and strain rate on tissue Doppler imaging can be employed to assess the preoperative and postoperative RV function, proves the positive effect of tricuspid valve repair on right heart function, and offers more insight on right heart function evaluation.

Levosimendan or milrinone for right ventricular inotropic treatment?-A secondary analysis of a randomized trial.

The aim of the present study was to compare the effects of milrinone and levosimendan on right ventricular (RV) inotropy and lusitropy in patients after aortic valve replacement (AVR) for aortic stenosis, a procedure in which an abnormal postoperative RV function may be seen. In a prospective, blinded trial, 31 patients were randomized to receive either milrinone (0.4 and 0.8µg/kg/min, n=16) or levosimendan (0.1 and 0.2µg/kg/min, n=15) after AVR for aortic stenosis. RV performance, afterload (pulmonary arterial elastance), RV strain, systolic (SR-S) and early diastolic (SR-E) strain rate were measured by pulmonary artery thermodilution catheterization and transoesophageal two-dimensional speckle tracking echocardiography. To circumvent the indirect effects of inodilator-induced hemodynamic changes on RV systolic and diastolic deformation, pulmonary arterial elastance, central venous pressure and heart rate were maintained constant by atrial pacing, plasma volume expansion with colloids and phenylephrine-induced vasoconstriction during treatment with the inotropes. A dose-dependent increase in stroke volume index and cardiac index by approximately 20% were seen with both agents at the highest doses, with no difference between groups (P=.792 and 0.744, respectively). In both groups, RV strain and SR-S dose-dependently increased by 20% and 15%-19%, respectively, at the highest doses (P=.742 and 0.259, respectively) with no difference between groups. SR-E improved by both agents 20%-24% at the highest dose with no difference between groups (P=.714). The direct RV inotropic and lusitropic effects of levosimendan and milrinone were comparable at clinically relevant infusion rates.

Echocardiographic Predictors of Tricuspid Ring Annuloplasty Repair Failure for Functional Tricuspid Regurgitation

Significant tricuspid regurgitation (TR) recurs after tricuspid valve repair of functional TR in 15% to 20% within the first year, and 30% to 70% within 5 years. Prior investigations report leaflet tethering, and not tricuspid valve annular diameter (TVAD), as predictive of recurrent TR. The authors hypothesize that pre-repair TVAD is predictive of repair failure for functional TR. Fifty-four patients with functional TR scheduled for left heart surgery and tricuspid valve repair with ring annuloplasty. Retrospective study design. Pre- and post-repair transthoracic and intraoperative transesophageal echocardiographic data included left and right ventricular functions, tricuspid leaflet tethering height, TVAD, and TR severity. Successful repair was defined as ≤2+ TR. Tertiary care medical center. None. Forty-five patients had a successful repair and 9 did not. Preoperative and intraoperative TVAD in diastole (TVADdiast) ≥4.2 cm, and preoperative systole (TVADsyst) ≥3.7 cm, but not leaflet tethering, were predictive of repair failure. Right ventricular (RV) width >4.88 cm was associated with repair failure. Neither pre- nor post-repair pulmonary artery systolic pressures (PASP) were predictors of repair failure. However, PASP did not change nor did RV function improve in the nonsuccessful repair group. For patients with functional TR undergoing primary left heart surgery, preoperative TVAD (systole and diastole), RV width, and postoperative RV function were predictors of repair outcome. Earlier TV repair and optimizing right heart function may improve repair outcome.

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

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

What Happens to Right Ventricular Strain and Function Following Tricuspid Valve Repair in Patients Undergoing Implantation of a Left Ventricular Assist Device?

Purpose Pre- and post-operative RV function were analyzed by echocardiography, including RV longitudinal strain in 80 patients with moderate or higher pre-implant TR to evaluate the impact of concomitant tricuspid valve repair during LVAD implantation on post-operative RV function. Methods Between 2008 and 2017, 100 patients with moderate (Mod), moderate-severe (M/S), or severe (Sev) TR underwent LVAD implantation at our institution. Forty-four (44) patients had concomitant TV repair (TVR) and 56 did not have TV repair (No-TVR). Preoperative and postoperative clinical, echocardiographic and hemodynamic parameters were recorded in 80 of the patients and included right ventricular (RV) freewall longitudinal strain (FLS) and RV Fractional Area Change (FAC) calculated retrospectively using speckle-tracking echocardiography. Results Preoperatively, 41% of patients in the TVR group and 77% in the No-TVR group had Mod TR (p Conclusion RV strain analysis tracks hemodynamic and echocardiographic parameters and does not add to the assessment of RV function in patients undergoing LVAD implantation with or without TVR. Repairing moderate TV regurgitation at the time of LVAD implantation is not associated with improved outcomes and emphasizes the need for a definitive prospective trial.

Late right ventricular performance after mitral valve repair assessed by exercise echocardiography

ObjectivesThe aim of the study was to evaluate the right ventricular (RV) performance during exercise in patients who underwent mitral valve repair for chronic mitral valve insufficiency relative to healthy individuals and to assess exercise capacity using a semisupine ergometer.MethodsWe studied 56 patients who underwent mitral valve repair for degenerative posterior mitral leaflet prolapse between 2005 and 2014 and a control group of 13 healthy individuals. Clinical data were collected prospectively, and echocardiographic measurements of RV function were obtained at rest and at peak exercise.ResultsOne-third of the study patients had RV systolic dysfunction as indicated by tricuspid annular plane excursion (TAPSE) at rest. Resting TAPSE was lower in the study group (16.7 ± 3.3 mm) than in the control group (24.4 ± 4.3 mm), p < 0.001. TAPSE increased in both groups during exercise and exercise was shown to have a significant main effect on TAPSE F(1, 52) = 80, p < 0.001. TAPSE increased more in the control group and an interaction was detected between the participant groups (study group vs. control group) and exercise, F(1, 52) = 24, p < 0.001. In the study group, Poor postoperative RV function was associated with preoperative left ventricular dilatation but was not correlated with impaired maximum exercise capacity.ConclusionsDespite the excellent clinical outcome during rest and exercise after mitral valve repair, our results suggest patients that have undergone mitral valve repair due to posterior leaflet prolapse have significantly reduced RV function at rest and during exercise compared to healthy controls at long-term follow-up, as measured by TAPSE.

Perioperative echocardiography-derived right ventricle function parameters and early outcomes after tetralogy of Fallot repair in mid-childhood: a single-center, prospective observational study.

Right ventricular (RV) function alterations are invariably present in all patients after tetralogy of Fallot (TOF) repair. Unlike the developed world where most of the patients with TOF are corrected in infancy, average age of presentation and thus surgery for these patients in the developing world may be higher. We aimed to study the correlation between RV function parameters such as tricuspid annular peak systolic excursion (TAPSE), fractional area change (FAC), and tricuspid annular peak systolic velocity (S') with early outcome variables after intracardiac repair for TOF. Fifty patients with a preoperative diagnosis of tetralogy of Fallot scheduled for corrective surgery were included in this single-center, prospective observational study. A preoperative transthoracic echocardiogram was performed to measure RV function parameters (FAC0, TAPSE0, S'0). Transthoracic echocardiography was repeated postoperatively to measure FAC1, TAPSE1, S'1 (day 1) and FAC2, TAPSE2, and S'2 (day 3). The relationship between preoperative and postoperative RV function parameters with in-hospital mortality, duration of mechanical ventilation, and intensive care unit stay was studied. The median age of patients was 6years (range 1-14years). Multiple stepwise logistic regression analysis showed RV FAC as best predictor of clinical outcome. Area under the receiver operating characteristic curve for postoperative RV function parameters, that is, FAC, TAPSE, and S' to predict early or delayed recovery was 0.944, 0.875, and 0.655, respectively. Among the RV function parameters studied, RV FAC best predicted the early outcome variables after TOF repair, followed by TAPSE while lateral tricuspid annular velocity S' being the least predictive.

The effect of right ventricular myocardial remodeling on ventricular function as assessed by two-dimensional speckle tracking echocardiography in patients with tetralogy of Fallot: A single center experience from China

BackgroundPublished correlations between histological abnormalities and right ventricular (RV) function, as evaluated by speckle tracking echocardiography (STE), are scarce in patients with tetralogy of Fallot (TOF). The purpose of the study is to assess age-associated differences in the effect of RV myocardial remodeling on ventricular function in patients with TOF. MethodsOperatively resected crista supraventricularis muscle from 30 patients (median age 12months) undergoing intracardiac repair of TOF were studied by light microscopy. The patients were divided into younger (age at surgery ≤12months) and older (age at surgery >12months) subgroups. The RV global longitudinal peak systolic strain (GLS), strain rate (GLSRs) and early diastolic strain rate (GLSRe) were measured by two-dimensional STE before and 6months after repair. ResultsThe histopathological data revealed hypertrophy of the cardiomyocytes, a thickened endocardium, and increased interstitial and perivascular collagen in RV, which were associated with older age at the time of repair. The RV global systolic and diastolic functions in patients with repaired TOF were increased compared with the preoperative values. The RV cardiomyocyte diameter and collagen volume fraction (CVF) correlated with the preoperative GLS, GLSRs and GLSRe, respectively, in the younger patients (r1=−0.566, P1=0.018; r2=−0.493, P2=0.004; r3=−0.504, P3=0.039). The RV cardiomyocyte diameter and CVF correlated with preoperative GLS, GLSRs and GLSRe, respectively, in the older patients (r1=−737, P1=0.004; r2=−0.588, P2=0.035; r3=−0.812, P3=0.001). The correlation of the RV cardiomyocyte diameter with the postoperative GLS and GLSRe (r1=−665, P1=0.036; r2=−0.787, P2=0.007) and the CVF with the postoperative GLSRs and GLSRe (r1=−762, P1=0.002; r2=−0.713, P2=0.004) were identified only in the older patients. Multivariate analysis indicated that the age at repair was an independent predictor of postoperative GLSRs and GLSRe in all of the patients (β=−0.449, P=0.041; β=−0.607, P=0.004). ConclusionsThe effect of RV myocardial remodeling on preoperative RV function was more pronounced in the older patients with TOF than in the younger ones. Preoperative myocardial remodeling affected the postoperative RV function in the older but not in the younger patients. The age at the time of surgical repair was the independent determinant of the postoperative RV myocardial function.

Randomized trial of HTK versus warm blood cardioplegia for right ventricular protection in mitral surgery

Objectives. To clarify the reliability of the one-shot histidine–tryptophane–ketoglutarate (HTK) cardioplegia for right ventricular (RV) myocardial protection during mitral surgery, in patients with or without pre-operative RV dysfunction. Design. Sixty patients undergoing isolated mitral surgery were randomized to myocardial protection with either one-shot HTK or intermittent warm blood cardioplegia (WBC). The RV function was assessed by echocardiography and hemodynamic assessment. Pre-operative tricuspid annular plane systolic excursion (TAPSE), an index of RV systolic function was used to dichotomize groups into patients having impaired (TAPSE < 15) or preserved (TAPSE ≥ 15) RV function. Results. There were no significant intergroup differences in the post-operative indexes of RV function in cases with TAPSE ≥ 15. In patients having TAPSE < 15 we observed statistically worse RV ejection fraction (RVEF, 15% ± 2% vs. 24% ± 3%), end-diastolic volume (RVEDV, 188 mL ± 20 vs. 179 mL ± 14) and fractional area change (RVFAC, 21% ± 6% vs. 30% ± 3%) after use of the HTK solution versus patients who received the WBC. These differences were associated with longer mechanical ventilation and ICU times in patients with impaired RV function and receiving HTK cardioplegia. In a substudy ten patients with TAPSE < 15 received intra-operative topical myocardial cooling in addition to HTK. The addition of topical cooling to HTK cardioplegia yielded statistically significant amelioration in post-operative RV function compared with patients who received the HTK solution without topical cooling (RVEF: 23% ± 3% vs. 15% ± 2%; RVEDV: 180 mL ± 9 vs. 188 mL ± 18; RVFAC: 8.5% ± 1% vs. 6% ± 2%). Conclusions. The one shot HTK solution offers inferior RV protection compared with WBC, mainly in patients with depressed pre-operative RV function. When adopting HTK cardioplegia the addition of topical cooling is strongly advised.

Load Dependency of Right Ventricular Performance Is a Major Factor to be Considered in Decision Making Before Ventricular Assist Device Implantation

Left ventricular assist devices (LVADs) provide better outcome than biventricular devices, but it is a challenge to predict the impact of LV mechanical unloading on postoperative right ventricular (RV) function preoperatively. We assessed the load dependency in RV performance before and after LVAD implantation aiming to improve preoperative decision making. Laboratory, echocardiography, and right heart catheterization data collected from 205 patients before LVAD implantation were tested for relationship with postoperative RV function. Comparing patients with different time-course of RV function after LVAD implantation, we found significant differences (P<0.01) in preoperative RV end-diastolic short-/long-axis and long-axis/length-area ratios, tricuspid annulus peak systolic velocity, RV peak longitudinal global systolic strain rate, systolic pressure gradient between RV and right atrium (ΔPRV-RA), tricuspid regurgitation velocity-time integral, and pulmonary arterial pressure between patients with and without postoperative RV failure. High predictive values for postoperative RV failure were found for end-diastolic short-/long-axis ratio ≥ 0.6, tricuspid annulus peak systolic velocity <8 cm/s, and peak systolic longitudinal strain rate <0.6/s in patients with maximum ΔPRV-RA <35 mm Hg. These parameters also seemed predictive for RV failure in patients with tricuspid regurgitation grade >2 and pulmonary arterial pressure <50 mm Hg. End-diastolic short-/long-axis ratio <0.6, tricuspid annulus peak systolic velocity ≥ 8 cm/s, and peak systolic longitudinal strain rate ≥ 0.6 in patients with maximum ΔPRV-RA ≥ 35 mm Hg showed high predictive values for postoperative freedom from RV failure. The RV load adaptation index seemed particularly predictive for RV function after LVAD implantation. RV geometry and velocity of contraction before LVAD implantation become more predictive for postoperative RV function and can improve decision making before VAD implantation if preoperative RV pressure load and tricuspid regurgitation are also considered.

Determinants of Clinical Right Ventricular Failure After Congenital Heart Surgery in Adults

Right ventricular (RV) failure after cardiac surgery is a clinical entity with high morbidity and mortality. Patients with congenital heart disease (CHD) often undergo right-sided cardiac surgery. The authors aimed to identify determinants of RV failure after cardiac surgery to differentiate patients with increased risk. A retrospective chart review. University hospital. Adults with CHD operated on between January 2001 and January 2011. Clinical characteristics, laboratory tests, surgical data, and intensive care unit outcome were obtained from medical records. The diagnosis of clinical RV failure was made by careful review of the medical records by 2 independent physicians. Patients only were identified as having RV failure if (1) they had elevated jugular venous pressure, (2) they had impaired postoperative RV function on transthoracic echocardiography, and (3) a diagnosis of RV failure was documented clearly in the medical charts by the treating physician. Data of 412 consecutive patients (median age 36 [range 18-74] years, 56% male) were studied. Eighteen patients had clinical RV failure (4.4%) postoperatively, of whom 6 patients died. Patients undergoing left- and both-sided surgery had an equal risk of developing clinical RV failure as compared with patients undergoing right-sided surgery. In multivariate logistic regression analysis, preoperative impaired RV function, supraventricular tachycardia, and cardiopulmonary bypass time >150 minutes were the strongest determinants of clinical RV failure (p<0.05, for all). RV failure after cardiac surgery is a serious complication, and occurs regardless of the side of surgery. A tailored approach in patients with CHD at highest risk of RV failure should be considered.

Abstract 9794: Load Dependency of Right Ventricular Performance is a Major Factor to be Considered in Decision Making Prior to Ventricular Assist Device Implantation

Background Left ventricular assist devices (LVADs) provide better quality of life than biventricular devices (BVADs), but it is a challenge to evaluate right ventricular (RV) function and to predict its time-course after LV support. Severe RV failure after LVAD implantation appeared related to pre-operative RV geometry and tricuspid regurgitation (TR) which are highly load sensitive parameters. We assessed the impact of load dependency on RV performance before and after LVAD implantation aiming to improve pre-operative decision making. Methods We evaluated our patients who received a LVAD after 1/2006. RV anatomic and functional parameters collected prospectively before LVAD implantation and invasively collected data on pulmonary hemodynamics were tested for relationship with post-implant RV function and patient outcome. Echocardiography including tissue Doppler and 2D strain imaging was used to evaluate RV size, geometry and function. Results After LVAD implantation 45 (9.5%) of 475 evaluated patients showed worsening of RV function which necessitated a mechanical support also for the RV. Whereas RVEF was similar in patients with and without stable post-operative RV function there were significant differences in pre-operative long/short axis (L/S) ratio, tricuspid annulus peak systolic velocity (TAPSm) peak global strain rate (RVSSr),RV/right atrial pressure gradient (ΔP-RV/RA) and pulmonary arterial pressure (PAP) between the two patient groups (p &lt; 0.05). The highest predictive values (up to 93.5%) for RV failure after LVAD insertion were found for pre-operative L/S ≥ 0.6, TAPSm &lt; 8cm/s, and peak RVSSr &lt; 0.7/s in patients with maximum ΔP-RV/RA &lt; 35mmHg. L/S, TAPSm and RVSSr also showed high predictive values for RV failure in patients with preoperative TR &gt; grade II and PAP &lt; 50mmHg. L/S &lt; 0.6, TAPSm ≥ 8cm/s, and peak RVSSr ≥ 0.7/s in patients with maximum ΔP-RV/RA ≥ 35mmHg showed high predictive values (≥ 92%) for postoperative freedom from RV failure. Conclusion RV geometry and velocity of contraction before LVAD implantation are highly predictive for postoperative RV function if preoperative PAP and TR are also considered. RV L/S ratio, TAPSm and RVSSr, in connection with maximum ΔP-RV/RA, can improve decision making before VAD implantation.

EFFECT OF SURGICAL CORRECTION OF TETRALOGY OF FALLOT ON SHORT-TERM RIGHT VENTRICULAR FUNCTION AS DETERMINED BY ULTRASOUND TWO-DIMENSIONAL SPECKLE TRACKING IMAGING

ObjectivesThe impact of surgical repair on short-term right ventricular (RV) function in patients with tetralogy of Fallot (TOF) is scarce. The purpose of our study is to assess RV regional...

Changes of Right Ventricular Function and Longitudinal Deformation in Children with Hypoplastic Left Heart Syndrome before and after the Norwood Operation

The purpose of this study was to investigate changes in right ventricular (RV) function and deformation parameters before and at steady state after the Norwood operation in neonates with hypoplastic left heart syndrome. A further aim was to delineate factors that affected these changes. On echocardiograms before and 21 days (range, 10-35 days) after the Norwood operation, the two-dimensional speckle-tracking parameters global and regional peak systolic longitudinal strain and strain rate were retrospectively compared in 33 patients with hypoplastic left heart syndrome. In addition, RV functional assessment included RV fractional area change and tricuspid annular plane systolic excursion. The associations between postoperative echocardiographic findings and preoperative or postoperative complications, prenatal diagnosis, postoperative heart rate, oxygen saturation, and medication use as well as cardiopulmonary bypass and aortic cross-clamp times were tested. Global strain (-18.3 ± 3.6% vs -16.8 ± 3.8%, P= .02) and global strain rate (-1.6 ± 0.3 vs -1.2 ± 0.3 sec(-1), P < .0001) decreased significantly. Regional strain decreased significantly in the apical and mid lateral segments, while regional strain rate decreased significantly in all but the basal septal segments. Tricuspid annular plane systolic excursion of the lateral annulus decreased significantly, while RV fractional area change remained the same. No significant associations were found between postoperative RV function and potential impact factors. Two-dimensional global and regional longitudinal strain and strain rate as well as tricuspid annular plane systolic excursion were reduced in patients with hypoplastic left heart syndrome after the Norwood operation. None of the examined preoperative and postoperative patient or surgical factors was found to explain this decrease.