Presence Of Right Ventricular Dysfunction Research Articles

P3370Prevalence of right ventricular dysfunction according to different parameters: basal and one year after transcatheter aortic valve implantation

Abstract Background Right ventricle (RV) is not often specifically studied in patients with severe aortic stenosis (AS). It's difficult to find the correct tool to assess RV function with echocardiographic parameters, and the percentage of patients with dysfunction may vary depending on the parameter that we use. The aim of the study was to evaluate the prevalence of RV dysfunction basal and one year after transcatheter aortic valve implantation (TAVI), according to different parameters. Methods Consecutive patients with severe AS undergoing TAVI from January 2016 to July 2017 were included. RV anatomical and functional parameters were analyzed according to ESC and ASE guidelines. RV dysfunction was assessed using tricuspid annular plane systolic excursion (TAPSE) <17 mm, fractional area change <35%, systolic movement of the RV lateral wall by tissue Doppler imaging (RV-S'TDI) <9.5 cm/s, global longitudinal (RV-GLS) and free wall strain (RV-FWS) using as cutting point [20]. Pre procedure echo, immediate post procedure and 1 year echo were analyzed. Statistical analysis was performed using SSPS version 22. Results The final study population consisted of 78 patients (115 patients were included, 37 were excluded due to suboptimal acoustic window for RV anatomical and functional evaluation), mean age 83.73±6.31 year-old, 38.2% females. We analyzed the percentages of RV dysfunction according to the different parameters evaluated before and in the control one year after. They are shown in Figure 1. Prevalence of RV dysfunction Conclusions The presence of RV dysfunction in patients with severe AS is higher than expected Our data suggest that RV function improve one year after TAVI, in terms of a reduction in the number of patients with dysfunction. The assessment of RV function is difficult, and there is no agreement on what tools are more accurate and useful. RV strain seems to be the most sensible parameter to assess RV function in patients with AS undergoing TAVI. Impact of these measurements in patients management needs further evaluation.

The Prognostic Impact of Pulmonary Artery Proportional Pulse Pressure in Patients with Right Ventricular Failure - A Single-Center, Retrospective Study

Introduction The pulmonary artery proportional pulse pressure (PAPP), an index of right ventricle to pulmonary artery coupling obtained by dividing the pulmonary artery pulse pressure by the pulmonary artery systolic pressure on invasive hemodynamics, has been shown to predict adverse cardiovascular events in patients with advanced heart failure and pulmonary arterial hypertension. Its prognostic utility in an all-comers cohort of patients with right ventricular failure (RVF) has yet to be studied. Hypothesis We hypothesized that PAPP will be strongly associated with mortality and prolonged hospital stay in patients with RVF Methods We retrospectively analyzed data on patients admitted in our institution from January 2012 to November 2016 with RVF defined as 1. presence of right ventricular dysfunction on transthoracic echocardiogram 2. cardiac index 15 and 4. CVP/PCWP > 0.6. Baseline demographic, clinical, laboratory, echocardiographic and hemodynamic data were obtained. Data on inotrope or vasopressor use, need for right ventricular percutaneous mechanical support and length of hospital stay were likewise obtained. Baseline characteristics of patients were compared based on survival at hospital discharge and 6 months thereafter. Categorical variables were reported as frequency or percentage in its group. Continuous variables were characterized using mean and standard deviation. Results We included 47 patients (mean age 62 years, 66% males) majority were African American men with severe left ventricular dysfunction (mean LVEF 30%). Biventricular failure as a consequence of non-ischemic cardiomyopathy was the predominant etiology for the RVF. The total mortality was 32%. PAPP was not independently associated with death (p = 0.374) or length of hospital stay (p=0.81). The clinical, echocardiographic and hemodynamic variables found to be independently associated with increased mortality included right ventricular fractional area change (RV FAC) (p= 0.016), mean arterial pressure (MAP) (p=0.049), right ventricular systolic pressure (RVSP) (p=0.026), inotrope or vasopressor use (p=0.05) and the need for percutaneous right ventricular mechanical support (p= 0.008). Conclusions In an “all-comers” cohort of patients with RVF, PAPP was not independently associated with mortality or longer hospital stay. Independent predictors of mortality include a high RV FAC, a low MAP, a low RVSP, inotrope or vasopressor use and the need for percutaneous right ventricular support.

Prognostic value of right ventricular dysfunction or elevated cardiac biomarkers in patients with low-risk pulmonary embolism: a systematic review and meta-analysis.

AimsPatients with acute pulmonary embolism (PE) classified as low risk by the Pulmonary Embolism Severity Index (PESI), its simplified version (sPESI), or the Hestia criteria may be considered for early discharge. We investigated whether the presence of right ventricular (RV) dysfunction may aggravate the early prognosis of these patients.Methods and resultsWe did a systematic review and meta-analysis of studies including low-risk patients with acute PE to investigate the prognostic value of RV dysfunction. Diagnosis of RV dysfunction was based on echocardiography or computed tomography pulmonary angiography. In addition, we investigated the prognostic value of elevated troponin or natriuretic peptide levels. The primary outcome was all-cause mortality at 30 days or during hospitalization. We included 22 studies (N = 3295 low-risk patients) in the systematic review: 21 were selected for quantitative analysis. Early all-cause mortality rates in patients with vs. without RV dysfunction on imaging were 1.8% [95% confidence interval (CI) 0.9–3.5%] vs. 0.2% (95% CI 0.03–1.7%), respectively, [odds ratio (OR) 4.19, 95% CI 1.39–12.58]. For troponins, rates were 3.8% (95% CI 2.1–6.8%) vs. 0.5% (95% CI 0.2–1.3%), (OR 6.25, 95% CI 1.95–20.05). For natriuretic peptides, only data on early PE-related mortality were available: rates were 1.7% (95% CI 0.4–6.9%) vs. 0.4% (95% CI 0.1–1.1%), (OR 3.71, 95% CI 0.81–17.02).ConclusionsIn low-risk patients with acute PE, the presence of RV dysfunction on admission was associated with early mortality. Our results may have implications for the management of patients who appear at low risk based on clinical criteria alone, but present with RV dysfunction as indicated by imaging findings or laboratory markers.

Predictors of hospital stay in normotensive acute pulmonary embolism: a retrospective pilot study

ABSTRACTIntroduction: The aim of our study is to determine the clinical, biochemical, and imaging factors that affect the duration of hospital stay in patients admitted with normotensive acute pulmonary embolism.Methods: This was a single-center retrospective study conducted in a community hospital in New York metropolitan area for patients admitted from October 2015 to October 2017.Results: A total of 79 patients were included, the mean age was 55.76 (SD = 17.33), 29 cases were males (37%) and 50 cases were females (63%). Among all patients, 17 cases had short length of stay (LOS) (≤2 days) and 62 cases had long LOS (>2 days). There were statistically significant differences in age (p = .041), presence of lung disease (p = .036), number of comorbidities (p = .043), and pulmonary embolism severity index (PESI) scores (original and simplified; p = .002 and .001, respectively). Logistic regression analysis showed that PESI score significantly predicted long LOS (OR 1.067, 95% CI [1.001, 1.137], p = .048). Similarly, sPESI significantly predicted long LOS (OR 0.223, 95% CI [0.050, 0.999], p = .050). Both regression models were adjusted for age, lung disease, and number of comorbidities.Conclusion: Both original and simplified PESI scores were statistically significant predictors of duration of hospital stay. Patients with multiple comorbidities or with chronic lung disease were also likely to have prolonged hospital stay. None of the cardiac biomarkers affected the duration of hospital stay, neither did the presence of right ventricular dysfunction nor treatment modality.

Impact of syncope and pre-syncope on short-term mortality in patients with acute pulmonary embolism

BackgroundSyncope and pre-syncope are well-known symptoms of acute pulmonary embolism (PE). However, data about their impact on short-term mortality are scant. We assess the short-term mortality (30-day) for all-causes in PE patients admitted with syncope or with pre-syncope, according their hemodynamic status at admission. MethodsPatients from the prospective Italian Pulmonary Embolism Registry (IPER) were included in the study. At admission, subjects were stratified according to 2008 ESC guidelines (as high- and non-high-risk patients). ResultsAmong the 1716 patients with confirmed acute PE, syncope or pre-syncope was the initial manifestation of the disease in 458 (26.6%) patients. Short-term mortality (30-day) for all causes were significantly higher in patients with syncope/presyncope (42.5% vs 6.2%, p < 0.0001) while PE patients with presyncope demonstrated a worst short-term outcome, in terms of mortality for all-causes, when compared to those subjects with syncope at admission (47.2% vs 37.4%, p = 0.03). A statistically significant difference in survival between pre-syncope and syncope was observed only in hemodynamically unstable patients [log rank p = 0.036]. Cox regression analysis confirmed that pre-syncope resulted an independent predictor of 30-day mortality in hemodynamically unstable patients at admission (HR 2.13, 95% CI 1.08–4.22, p = 0.029), independently from right ventricular dysfunction (RVD) (HR 6.23, 95% CI 3.05–12.71, p < 0.0001), age (HR 1.03, 95% CI 1.00–1.06, p = 0.023) and thrombolysis (HR 2.27, 95% CI 1.11–4.66, p = 0.025). ConclusionsPE patients with syncope/presyncope had a higher 30-day mortality for all-causes as well as patients with presyncope had a worst short-term outcome when compared to PE patients with syncope. Moreover, hemodynamically unstable patients with presyncope had a worst prognosis independently from the presence of RVD, age, positive cTn and thrombolytic treatment.

Diagnostic Accuracy of Point-of-Care Ultrasound Performed by Pulmonary Critical Care Physicians for Right Ventricle Assessment in Patients With Acute Pulmonary Embolism.

Risk stratification for acute pulmonary embolism using imaging presence of right ventricular dysfunction is essential for triage; however, comprehensive transthoracic echocardiography has limited availability. We assessed the accuracy and timeliness of Pulmonary Critical Care Medicine Fellow's performance of goal-directed echocardiograms and intensivists' interpretations for evaluating right ventricular dysfunction in acute pulmonary embolism. Prospective observational study and retrospective chart review. Four hundred fifty bed urban teaching hospital. Adult in/outpatients diagnosed with acute pulmonary embolism. Pulmonary critical care fellows performed and documented their goal-directed echocardiogram as normal or abnormal for right ventricular size and function in patients with acute pulmonary embolism. Gold standard transthoracic echocardiography was performed on schedule unless the goal-directed echocardiogram showed critical findings. Attending intensivists blinded to the clinical scenario reviewed these exams at a later date. Two hundred eighty-seven consecutive patients were evaluated for acute PE. Pulmonary Critical Care Medicine Fellows performed 154 goal-directed echocardiograms, 110 with complete cardiology-reviewed transthoracic echocardiography within 48 hours for comparison. Pulmonary Critical Care Medicine Fellow's area under the curve for size and function was 0.83 (95% CI, 0.75-0.90) and 0.83 (95% CI, 0.75-0.90), respectively. Intensivists' 1/2 area under the curve for size and function was (1) 0.87 (95% CI, 0.82-0.94), (1) 0.87 (95% CI, 0.80-0.93) and (2) 0.88 (95% CI, 0.82-0.95), (2) 0.88 (95% CI, 0.82-0.95). Median time difference between goal-directed echocardiogram and transthoracic echocardiography was 21 hours 18 minutes. This is the first study to evaluate pulmonary critical care fellows' and intensivists' use of goal-directed echocardiography in diagnosing right ventricular dysfunction in acute pulmonary embolism. Pulmonary Critical Care Medicine Fellows and intensivists made a timely and accurate assessment. Screening for right ventricular dysfunction using goal-directed echocardiography can and should be performed by pulmonary critical care physicians in patients with acute pulmonary embolism.

Preoperative right ventricular dysfunction is a strong predictor of 3years survival after cardiac surgery.

Prognostic value of right ventricular (RV) systolic function is well established in valvular disease, heart failure but has not been evaluated in patients undergoing cardiac surgery. The aim of the present study was to evaluate the prognostic value of preoperative RV dysfunction extensively evaluated on the basis of a large set of echocardiographic parameters [S', RV fractional area change (RVFAC), right myocardial performance index (RMPI), isovolumic acceleration (IVA), RV dP/dt and basal longitudinal strain (BLS)] in a large population of unselected patient awaiting cardiac surgery. We prospectively studied 400 consecutive patients referred for cardiac surgery, in a single surgical center. Echocardiography was performed 24h before surgery and phone interview assessed the survival status (overall and cardiovascular death) 3-years after surgery. Among 400 patients, 271 were male, mean age was 70.3±10.2. At 3-years the overall and cardiovascular mortality was, respectively, 10.5 and 6.8%. The univariate Cox analysis identified all RV function parameters excepted BLS as predictive factors of overall mortality, with the strongest value for RVFAC<35% (HR 4.8), S'<10cm/s (HR 3.8) and IVA<1.8m/s2 (HR 3.2) (all P<0.001). All parameters were associated to cardiovascular mortality. In multivariate analysis, RVFAC, S', dP/dt and IVA were significantly associated to 3-years overall mortality whatever the EuroSCORE. Abnormal RVFAC, S', IVA and BLS were associated to cardiovascular mortality. The presence of RV dysfunction before cardiac surgery assessed by echo significantly predicts postoperative mortality, and this is true whatever the EuroSCORE level. This result demonstrates the need of adding the assessment of echographic RV function before cardiac surgery.

Evaluation of Right Ventricular Systolic Function in Chagas Disease Using Cardiac Magnetic Resonance Imaging.

Right ventricular (RV) impairment is postulated to be responsible for prominent systemic congestion in Chagas disease. However, occurrence of primary RV dysfunction in Chagas disease remains controversial. We aimed to study RV systolic function in patients with Chagas disease using cardiac magnetic resonance. This cross-sectional study included 158 individuals with chronic Chagas disease who underwent cardiac magnetic resonance. RV systolic dysfunction was defined as reduced RV ejection fraction based on predefined cutoffs accounting for age and sex. Multivariable logistic regression was used to verify the relationship of RV systolic dysfunction with age, sex, functional class, use of medications for heart failure, atrial fibrillation, and left ventricular systolic dysfunction. Mean age was 54±13 years, 51.2% men. RV systolic dysfunction was identified in 58 (37%) individuals. Although usually associated with reduced left ventricular ejection fraction, isolated RV systolic dysfunction was found in 7 (4.4%) patients, 2 of them in early stages of Chagas disease. Presence of RV dysfunction was not significantly different in patients with indeterminate/digestive form of Chagas disease (35.7%) compared with those with Chagas cardiomyopathy (36.8%) (P=1.000). In chronic Chagas disease, RV systolic dysfunction is more commonly associated with left ventricular systolic dysfunction, although isolated and early RV dysfunction can also be identified.

Impact of right ventricular function on outcome of severe aortic stenosis patients undergoing transcatheter aortic valve replacement

Right ventricular (RV) dysfunction was shown to be associated with adverse outcomes in a variety of cardiac patients and is considered a risk factor for adverse outcome according to the updated Valve Academic Research Consortium criteria. Our goal was to assess the impact of RV function at baseline on 1-year mortality among patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). All patients with severe AS treated with TAVR from May 2007 to March 2015 at our center were included in the present study, and baseline and procedural characteristics were recorded for each patient. The patients were categorized according to RV function at baseline as assessed by current guidelines, and a comparison of mortality rates up to 1 year was performed. Among 650 patients, 606 had adequate echocardiogram quality and 146 (24%) had RV dysfunction. There were significant differences between the 2 groups, as patients with RV dysfunction were younger (81±9 vs 84±7 years, P=.01) and were more likely to be male (65% vs 42%, P<.001). In addition, patients with RV dysfunction had higher rates of prior myocardial infarction (26% vs 16%, P=.02) and atrial fibrillation (51% vs 39%, P=.02). Echocardiographic parameters demonstrated higher rates of left ventricular ejection fraction <40% (40% vs 18%, P<.001), tricuspid regurgitation above moderate (16% vs 9%, P=.04), and higher pulmonary artery systolic pressure (50±17 vs 44±16 mm Hg, P<.001) among patients with severe AS and RV dysfunction compared with patients with normal RV function. Despite the unfavorable cardiac function, patients with severe AS undergoing TAVR have similar functional class (P=.22) and mortality rates at 1year (27% vs 23%, log-rank P=.45). Patients with severe AS and RV dysfunction have similar 1-year mortality and functional class after TAVR to patients with normal RV function. The presence of RV dysfunction does not correlate with outcome in patients with severe AS.

Red Blood Cell Distribution Width in Patients With Chronic Obstructive Pulmonary Disease and Healthy Subjects

BackgroundChronic obstructive pulmonary disease (COPD) increases the risk of cardiovascular disease (CVD). Red blood cell distribution width (RDW) is accepted as a powerful predictor of outcomes in patients with CVD. AimsTo study RDW in patients with COPD, and to compare the value of this measurement with clinical, echocardiographic, nutritional and laboratory status. Secondly, we aimed to determine the effect of smoking on RDW values in healthy subjects. MethodsOne hundred and seventy-five patients with stable COPD and 210 healthy controls were enrolled in the study. Demographic, clinical, nutritional status, echocardiographic, and laboratory characteristics, RDW values were recorded and compared. ResultsRDW values were higher in the COPD group than in controls (15±2.3% vs 13.8±2.5%, p<0.001). In COPD patients, RDW levels positively correlated with CRP levels (r=0.27, p<.001), albumin levels (r=0.23, P=.04), right ventricular dysfunction (RVD) (r=0.24, P=.001), pulmonary hypertension (PAH) (r=0.1, P=.02), and presence of CVD (r=0.24, P=.02). In multivariable logistic regression suggested that presence of CVD (4.3; 95% CI: 1.3–11; P=.01), and presence of RVD (3.1; 95% CI: 1.7–8.3; P=.02) were independently related to elevated RDW levels in COPD patients. In the healthy population, correlations analysis showed only a significant correlation between RDW and cigarette smoking years (r=0.57, p<.001). ConclusionRDW is independently associated with CVD and RVD in patients with COPD. In the healthy population, RDW is also associated with smoking status.

Amplitud de distribución eritrocitaria en pacientes con enfermedad pulmonar obstructiva crónica y en sujetos sanos

BackgroundChronic obstructive pulmonary disease (COPD) increases the risk of cardiovascular disease (CVD). Red blood cell distribution width (RDW) is accepted as a powerful predictor of outcomes in patients with CVD. AimsTo study RDW in patients with COPD, and to compare the value of this measurement with clinical, echocardiographic, nutritional and laboratory status. Secondly, we aimed to determine the effect of smoking on RDW values in healthy subjects. MethodsOne hundred and seventy-five patients with stable COPD and 210 healthy controls were enrolled in the study. Demographic, clinical, nutritional status, echocardiographic, and laboratory characteristics, RDW values were recorded and compared. ResultsRDW values were higher in the COPD group than in controls (15±2.3% vs. 13.8±2.5%, p<0.001). In COPD patients, RDW levels positively correlated with CRP levels (r=0.27, P<.001), albumin levels (r=0.23, P=.04), right ventricular dysfunction (RVD) (r=0.24, P=.001), pulmonary hypertension (PAH) (r=0.1, P=.02), and presence of CVD (r=0.24, P=.02). In multivariable logistic regression suggested that presence of CVD (4.3; 95% CI: 1.3 to 11; P=.01), and presence of RVD (3.1; 95% CI: 1.7 to 8.3; P=.02) were independently related to elevated RDW levels in COPD patients. In the healthy population, correlations analysis showed only a significant correlation between RDW and cigarette smoking years (r=0.57, P<.001). ConclusionRDW is independently associated with CVD and RVD in patients with COPD. In the healthy population, RDW is also associated with smoking status.

Shock index for outcome and risk stratification in acute pulmonary embolism

IntroductionRisk stratification of patients with acute pulmonary embolism (PE) is crucial in deciding appropriate therapy management. Shock index (SI) is rapidly available and a reliable parameter. We aimed to investigate SI for short term outcome in acute PE. Materials and methodsData of 182 patients with acute PE were analysed retrospectively. SI was defined as heart rate divided by systolic blood pressure. Logistic regression models were calculated to investigate associations between SI and in-hospital-death, myocardial necrosis and presence of right ventricular dysfunction (RVD) respectively. Moreover ROC curves and cut-off values for SI predicting in-hospital death, myocardial necrosis and RVD were computed. Results182 patients (61.5% female, mean age 68.5 ± 15.3 years) with acute PE event were included in the study. 5 patients (2.7%) died an in-hospital death.Logistic regression models revealed an association between SI and respectively in-hospital death (OR 5.854, 95% CI 1.876–18.274, P = 0.00234), myocardial necrosis (OR 5.043, 95% CI 1.362–18.674, P = 0.0154) and RVD (OR 53.539, 95% CI 6.810–420.914, P = 0.000155).ROC analysis for SI predicting in-hospital death, myocardial necrosis and RVD revealed an AUC of 0.806, 0.636 and 0.713 respectively with respectively SI cut-off values of 0.89, 0.75 and 0.54. ConclusionsSI is a significant predictor of in-hospital death, myocardial necrosis and RVD. The effectiveness of SI to predict in-hospital death is high with an optimal cut-off value of 0.89 for differentiation between PE patients with lower and higher risk to die in hospital after acute PE event.

Diabetes is an independent predictor of right ventricular dysfunction post ST-elevation myocardial infarction.

BackgroundDiabetes mellitus (DM) is estimated to become the 7th leading cause of death by 2030. Right ventricular dysfunction (RVD) complicating ST elevation myocardial infarction (STEMI) is independently associated with a higher mortality; however the relationship between DM and RVD is currently unknown. The purpose of this study was to determine whether DM is an independent predictor for the presence of right ventricular dysfunction (RVD) post STEMI.Methods106 patients post primary PCI for STEMI were enrolled in the study. Cardiac MRI was performed within 48–72 h after admission in order to assess ventricular function. Statistical analysis consisted initially of descriptive statistics including Chi square, Fisher’s exact, or the Wilcoxon rank sum as appropriate. Subsequently, logistic regression analysis was performed to determine independent predictors of RVD.ResultsThe median age in the study was 58 years (IQR 53, 67). 30 % of the patients had diabetes. Of 99 patients for which RV data was available, 40 had RVD and 59 did not. Patients with DM were significantly more likely to have RVD when compared to those without diabetes (45 vs 22 %, p = 0.03). There was no significant difference in age, hypertension, smoking status, dyslipidemia, serum creatinine or peak CK levels between the two groups. After adjusting for other factors, presence of DM remained an independent predictor for the presence of RV dysfunction (OR 2.78, 95 % CI 1.12, 6.87, p = 0.03). Amongst diabetic patients, those with HbA1C ≥ 7 % had greater odds of having RVD vs those with HbA1C < 7 % (OR 5.58 (1.20, 25.78), p = 0.02).ConclusionsThe presence of DM conferred an approximately threefold greater odds of being associated with RVD post STEMI. No other major cardiovascular risk factors were independently associated with the presence of RVD.

Echocardiographic Assessment of Right Ventricular Function by Two-Dimensional Strain In Patients with Left-Sided Valvular Heart Disease: Comparison with Three-Dimensional Echocardiography

Abstract Background: Right ventricular (RV) dysfunction is a well-known predictor of mortality in patients with valvular heart disease (VHD). The assessment of RV function is often difficult due to complex geometry and hemodynamic factors. We aim to analyze RV function in patients with severe mitral and/or aortic valve disease using two-dimensional strain (2DS) imaging and conventional echocardiographic parameters, comparing it with right ventricular ejection fraction (RVEF) measured by three-dimensional echocardiography (3DE). Methods: Fifty-three patients with severe mitral and/or aortic VHD underwent complete transthoracic echocardiogram in the preoperative setting for cardiac surgery, including conventional echocardiographic parameters of RV function and speckle-tracking derived 2DS indices: RV global longitudinal strain (RVGS) and RV free wall longitudinal strain (RVFWS). Conventional echocardiographic and 2DS parameters were compared with real-time 3DE RVEF using Spearman correlation test. For comparison between two groups of patients based on the presence of RV dysfunction (normal RVEF ≥ 44% - A, abnormal RVEF < 44% - B), we used nonparametric Mann-Whitney U test. ROC (receiver operating characteristic) curve analysis was used to assess the clinical utility of all RV function variables in defining RV dysfunction. P values <0,05 were considered statistically significant. Results: We found a significant correlation between all parameters and RVEF (p<0.05), with best results for RV fractional area change (FAC), RVGS, and RVFWS. Dividing the population into two-groups based on RVEF, we found 14 patients with RV dysfunction (27.4%), and significant differences between the groups for all RV function variables. For detection of RV dysfunction defined by 3DE, ROC curve analysis showed the best area under the curve (AUC) for RVGS (0.872), RVFWS (0.851) and FAC (0.932). Conclusions: We observed significant correlation between RVGS, RVFWS and RVEF, with good accuracy in detecting RV dysfunction, comparable to FAC and better than other conventional parameters of RV function assessment. The evaluation of RV myocardial deformation with 2DS may have additional diagnostic and prognostic value in patients with severe left-sided VHD. (Int J Cardiovasc Sci. 2018; [online].ahead print, PP.0-0).

Right Ventricular Function and Prognosis in Patients with Low-Flow, Low-Gradient Severe Aortic Stenosis

Patients with low left ventricular ejection fractions and low-flow, low-gradient aortic stenosis (AS) represent a challenging cohort with high morbidity and mortality. The prevalence and clinical impact of right ventricular dysfunction (RVD) on risk stratification and prognosis in these patients is unknown. A retrospective analysis was performed of 65 patients with low-flow, low-gradient AS who underwent low-dose dobutamine stress echocardiography to determine AS severity and to ascertain flow reserve status (≥20% stroke volume increase). Clinical, demographic, and imaging data were prospectively collected. Per guidelines, RVD was defined as tricuspid annular plane systolic excursion<16mm in the apical four-chamber view and measured at baseline. Cox proportional hazards modeling was used to risk-adjust comparisons for the end point of all-cause mortality. The mean age was 74±9years, the mean left ventricular ejection fraction was 29±10%, the mean indexed aortic valve (AV) area was 0.49±0.1cm(2)/m(2), and the mean AV gradient 22±7mmHg. RVD was present in 37 patients (57% of the study cohort). After a median follow-up period of 13months (interquartile range, 5-30months), there were 29 AV replacements and 30 deaths. The presence of RVD (hazard ratio, 2.86; 95% CI, 1.21-6.75; P=.02) was an independent risk factor associated with all-cause mortality despite many adjustments for potential clinical and echocardiographic confounders such as AV replacement, Society of Thoracic Surgeons Predicted Risk of Mortality score, severity of tricuspid regurgitation, and left ventricular global longitudinal strain. Baseline RVD is prevalent in patients with low-flow, low-gradient AS undergoing dobutamine stress echocardiography. Quantification of right ventricular systolic function in these complex patients provides important prognostic value and risk stratification adjunctive to Society of Thoracic Surgeons Predicted Risk of Mortality score and should be incorporated into the decision-making process.

Heart rate in pulmonary embolism.

Heart rate is a rapidly available risk stratification parameter in acute pulmonary embolism (PE). We aimed to investigate the effectiveness of heart rate in predicting the outcome in acute PE. Data of 182 patients with acute PE were analysed retrospectively. Logistic regression models were calculated to investigate the associations between heart rate and in-hospital death, myocardial necrosis, PE status and presence of right ventricular dysfunction (RVD), respectively. ROC curve and cut-off values for heart rate predicting RVD as well as intermediate risk PE status in normotensive PE patients and for heart rate predicting in-hospital death and myocardial necrosis in all PE patients were calculated. ROC analysis for heart rate predicting RVD and intermediate risk PE were 0.706 and 0.718, respectively, with cut-off value of 86 beats/min. Regression models showed associations between heart rate >85 beats/min and both RVD (OR 4.871, 95 % CI 2.256-10.515, P = 0.000055) and intermediate risk PE (OR 5.244, 95 % CI 2.418-11.377, P = 0.000027). In hemodynamically stable and unstable PE patients, logistic regression models showed a borderline significant association between tachycardia and in-hospital death (OR 7.066, 95 % CI 0.764-65.292, P = 0.0849) and a significant association between heart rate and myocardial necrosis (OR 0.975, 95 % CI 0.959-0.991, P = 0.00203). ROC analysis for heart rate predicting in-hospital death and myocardial necrosis revealed AUC of 0.655 and 0.703 with heart rate cut-off values of 99.5 beats/min and 92.5 beats/min, respectively. An elevated heart rate in acute PE is connected with a worse outcome. Effectiveness in the prediction of RVD, intermediate PE status, cardiac injury and in-hospital death is acceptable. The cut-off value for the prediction of RVD and intermediate risk PE status in normotensive PE is 86 beats/min, while tachycardia predicts in-hospital death.

Assessing right ventricular function in patients with hypertrophic cardiomyopathy with cardiac MRI: correlation with the New York Heart Function Assessment (NYHA) classification.

PurposeTo determine whether 3.0-T magnetic resonance imaging (MRI) could assess right ventricular (RV) function in patients with hypertrophic cardiomyopathy (HCM), and if this assessment is correlated with the New York Heart Function Assessment (NYHA) classification.Materials and MethodsForty-six patients with HCM and 23 normal individuals were recruited. Left and right ventricular function parameters including end-diastolic and end-systolic volumes (EDV, ESV), stroke volume (SV) and ejection fraction (EF) and dimensions were measured and compared using 3.0-T MRI. RV function parameters between HCM patients and controls were compared using independent sample t tests. A one way ANOVA test with Bonferroni correction was used to determine significant differences among different NYHA groups. Receiver operating characteristic analyses calculated the sensitivity and specificity of RV dysfunction on MRI for the prediction of HCM severity.ResultsStatistical analysis revealed significant differences of left ventricular (LV) and RV volumetric values and masses between the HCM patients and controls (all p<0.05). Within the HCM group, the simultaneously decreased maximum RVEDD correlated well with the LVEDD (r = 0.53; p<0.001). The function and dimension parameters among Class I to III were not determined to be significantly different (all p>0.05). However, significant differences between the Class IV and I-III groups (all P<0.0167) indicated that the diastolic and systolic function in both the RV and LV were impaired in Class IV patients. ROC analyses identified the EDV, ESV and EDD of both the LV and RV with a high sensitivity cutoff value to predict the HCM patients with severe heart failure (Class IV) with high sensitivity and specificity.ConclusionsRV involvements were comparable to those of LV global function impairments in patients with HCM. The presence of RV dysfunction and decreased dimension on the MRI helped to predict the severe symptomatic HCM with high sensitivity and specificity.

The prognostic role of right ventricular function in left ventricular disease in the setting of cardiac resynchronization therapy

Cardiac resynchronization therapy (CRT) offers a new therapeutic approach for treating patients with ventricular dyssynchrony and moderate-to-severe heart failure (HF). The impact of right ventricular dysfunction on global cardiac function remains imperfectly understood despite increasing research on right ventricular function as it pertains to long-term outcomes in HF. In this article, we aim to review the prognostic role of right ventricular function in the setting of CRT. Right ventricular dysfunction has emerged as a strong prognostic predictor of poor clinical outcomes in HF patients with CRT. The presence of right ventricular dysfunction at baseline is associated with poor prognosis and CRT response. Preliminary data indicate that CRT may have a positive influence on right ventricular remodeling and function. CRT guidelines continue to be optimized on the basis of emerging data. The prognostic role of right ventricular dyssynchrony and right ventricular response to CRT will further contribute to the understanding of this topic and the identification of HF populations that will benefit from this therapy. As the impact of right ventricular function on global cardiopulmonary function remains imperfectly understood, ongoing research on right ventricular function in HF patients with CRT and its implication for long-term outcome is required. It is, however, clear that right ventricular function is a prognostic marker of response to CRT and adverse long-term outcome. Conversely, recent data indicate that CRT may in turn influence right ventricular remodeling and function.

Quantification of Pulmonary Thromboembolism in CT Angiography Reports and Predicting Right Ventricular Dysfunction and Patient Mortality

: Recently, attempts have been made to quantify the clot burden on the basis of CT angiographic findings. The development of clot burden index [pulmonary arterial obstruction index (PAOI)] may have important prognostic and therapeutic implications and may provide a reproducible standard for measuring response to thrombolytic therapy. The presence of right ventricular dysfunction (RVD) is a marker for adverse clinical outcome in patients with acute pulmonary embolism (PE). The ratio of the right ventricle to left ventricle short axis diameters (RV/LV) has been proposed as an accurate sign for the presence of RVD. Other studies suggested that the quantification of a clot at pulmonary computed tomography (CT) angiography is an important predictor of right heart failure and patients' outcome in the setting of PE. In this study, we assess the measurement of PAOI and RV/LV ratio in pulmonary CT angiography and discuss the significant correlations between them. Patients and Methods: The study population comprised 42 patients (19 women, 23 men; mean age, 52 + 18 years) with the definite diagnosis of PE based on their pulmonary CT angiography. The CT angiographies of patients were reviewed, and PAOI and RV/LV ratio were measured. PAOI was calculated from the size of embolus and the location of thrombus on CT images in accordance with another study by Qanadli et al. The index was defined as the product of N x D, where N was the value of the proximal clot site, equal to the number of segmental bronchial branches, and D was the degree of obstruction, defined as 1 for partial obstruction and 2 for total obstruction. Furthermore, the scans were evaluated by measuring the minor axes of the right and left ventricles of the heart in the transverse plane at their widest points between the inner surface of the free wall and interventricular septum. By using logistic regression, PAOIs were compared with RV/LV ratio. Correlation between PAOI and RV/LV ratio was evaluated by Spearman correlation test, and receiver operating characteristic (ROC) curve was used to determine an optimal cut-off value for PAOI. : Results: In our study group, mean PAOI was 24.3 + 19.2%. Nine cases (21.4%) had a PAOI of more than 40%. The mean RV/LV ratio was 1.03 + 0.25; eighteen patients (43%) had an RV/LV ratio of more than 1; twenty-four patients (57%) had an RV/LV ratio of less than 1. There was a statistically significant correlation between PAOI and RV/LV ratio (P = 0.007; r = 0.4). The mean PAOI of patients with RV/LV ratio of >1 was significantly higher than that of patients with RV/LV ratio of ? 1 (32.6% vs. 18.1%; P = 0.02). However, based on ROC analysis, an ideal cut-off value for PAOI could not be defined. Also, there was no significant difference in PAOIs between different age (P > 0.05) and sex (P > 0.05) groups. Conclusion: Our findings were in agreement with those of Wu et al. and suggested that the quantification of a clot at CT pulmonary angiography is an important predictor of right heart failure and determines patients' outcome in the setting of PE. There was a significant correlation between PAOI and RV/LV ratio in PE. However, there was no ideal PAOI cut-off value for the diagnosis of right ventricular dysfunction (RV/LV ratio > 1). Further studies with a larger study population may be necessary to generalize our findings and to suggest a sensitive and specific cut-off point for ventricular dysfunction in patients with PE. The prognostic role of RV/LV ratio and obstruction index on spiral CT may also warrant further investigation in patients with PE.

Relationship Between Tricuspid Annular Excursion and Velocity in Cardiac Surgical Patients

The primary objective of this study was to establish the relationship among tricuspid annular velocity (S'), tricuspid annular plane systolic excursion (TAPSE), and stroke volume (SV) in a cardiac surgical population with and without right ventricular (RV) dysfunction. The secondary objective was to assess the effect of ephedrine on these relationships in a population without RV dysfunction. Prospective, nonrandomized, unblinded study. Single tertiary-level, university-affiliated hospital. Twenty-seven patients undergoing elective coronary artery bypass grafting with no evidence of RV dysfunction (Group 1). Sixteen ventilated postcardiac surgical patients with suspected RV dysfunction (Group 2). Ten mg of intravenous ephedrine to Group 1 only. Using transthoracic echocardiography, S' and TAPSE were measured using color tissue Doppler applied at the RV base in a 4-chamber view. SV was calculated using thermodilution. Six patients in Group 1 and 6 patients in Group 2 were excluded because of poor imaging or ineligibility. Modest correlation was found between TAPSE and SV in Group 1 (R = 0.50, p<0.001). There was no correlation between TAPSE and SV in Group 2. There was no correlation between S' and SV in both groups. In Group 1, the relationship between TAPSE and S' was curvilinear (R = 0.74 pre-ephedrine, p<0.001; R = 0.64, p = 0.009 post-ephedrine). There was no relationship between TAPSE and S' in Group 2. Ephedrine increased S' and TAPSE. The TAPSE-S' relationship was not significantly altered. In the presence of RV dysfunction, TAPSE did not correlate with cardiac output. In the absence of RV dysfunction, the relationship between TAPSE and S' described a curvilinear relationship.