Right Ventricular Assessment Research Articles

Right ventricular function in pregnant women with or without preeclampsia

Background Preeclamsia (PE) is a multisystem disorder that affects maternal and fetal outcomes. We aimed to assess right heart function in PE by echocardiography using conventional, tissue Doppler techniques, and 2D and 4D strain. Patients and methods This study comprised 100 pregnant women aged between 32 and 41 weeks divided into two groups: group 1 included 50 pregnant women with PE, who were compared with 50 age-matched normotensive pregnant women as a control group (group 2). They were subjected to proteinuria detection, pelviabdominal ultrasound, conventional echo, tissue Doppler imaging, and 2D and 4D speckle tracking echocardiography for measurement of right ventricular (RV) dimensions and RV systolic and diastolic function indices. Results The higher percentages of cesarean delivery, low birth weight, and need for NICU were present in group 1 compared with group 2. There were significantly increased RV dimensions in group 1 compared with group 2. TAPSE (2D and 4D), RV FAC (2D and 4D), average RV Sa, 4D-RV EF, 2D-RV strain, 4D septal strain, and 4D-RV free wall strain were significantly lower in group 1. RV MPI (PW and TDI) was higher in group 1 patients. Both tricuspid E/A and RV E/Ea were significantly higher in group 1. There was a positive correlation between proteinuria and mean arterial pressure, 2D-TAPSE, RV PW-MPI, and RV TD-MPI, whereas there was a negative correlation with 2D and 4D-RV strain, 4D RVEF, 4D-FAC, and T E/A. Conclusion Women with PE had significant RV structural and functional changes. Assessment of RV by newer echocardiographic modalities such as speckle tracking echocardiography and 4D-echocardiography can detect subtle cardiac changes that may help in early diagnosis of maternal and fetal complications.

P5553Right ventricular involvement in hypertrophic cardiomyopathy: insights from a tertiary centre

Abstract Introduction Hypertrophic cardiomyopathy (HCM) is the main cause of sudden cardiac death in the young and a cause of heart failure (HF) and death at any age. Nevertheless, adverse long-term outcomes are not easy to predict. Objectives To assess the prevalence and prognostic value of right ventricular (RV) involvement in patients (pts) with HCM. Methods Retrospective single-centre study of consecutive pts with HCM evaluated in a specialized consultation. Selected those submitted to cardiac magnetic resonance imaging (CMR) as the gold-standard for RV assessment. The primary endpoint (PE) was a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, ventricular arrhythmias with hemodynamic instability and unplanned HF admission. Results Of a total of 181 pts, 104 fulfilled the inclusion criteria (mean age at first consultation 62.1±9.7 years, 63.5% male). Septal asymmetric phenotype was the most frequent (73.1%) and 24 pts (23.1%) had rest LV outflow tract obstruction. Mean value of maximum wall thickness was 18.8±4.6 mm. Regarding CMR parameters (Fig A), 5.8% had RV dysfunction and 2.9% RV free wall hypertrophy; no patient presented RV dilation. Late gadolinium enhancement (LGE) of joint points was observed in 47.1%. During follow-up (FU, mean 56.6±29.5 months), survival free of RV dysfunction was 94.3%. Only 5 pts developed RV compromise assessed by echocardiographic parameters: TAPSE 12.0±3.4 mm and pulsed tissue Doppler systolic annular velocity (tricuspid S') wave 7.3±0.9 cm/s. These pts were significantly older (p<0.01) and had higher values of average tissue doppler E/E' ratio at diagnosis (p<0.01). Global RV involvement (at diagnosis or during FU) were associated with increased values of indexed left atrial area (p<0.01), LV dysfunction (p=0.01), LGE of joint points (p=0.01) and higher values of NT-proBNP (p=0.01). In multivariate logistic regression, left atrial enlargement was the only independent predictor of global RV dysfunction (OR 1.9, 95% CI 1.1–3.2, p=0.01) and average E/E' ratio an independent predictor of RV dysfunction during FU (OR 1.3, 95% CI 1.1–1.5, p<0.01). PE rate was 10.6%. It was significantly higher in pts with global RV involvement and there was a significant difference in survival analysis (Fig B). Average E/E' ratio (OR 1.5, 95% CI 1.1–1.9, p=0.01) and RV ejection fraction (OR 0.8, 95% CI 0.7–0.9, p=0.01) were independent predictors of the outcome. Conclusions Although not common, RV dysfunction was associated with a higher rate of cardiovascular events. Average E/E' ratio, as a measure of left ventricular filling pressure, was a risk factor for both RV dysfunction and PE. Higher values of RV ejection fraction were protective of adverse events occurrence. Together, these results support a potential role of RV function in the risk stratification of HCM pts.

ST-Segment Elevation Myocardial Infarction in Patients With Chronic Obstructive Pulmonary Disease: Prognostic Implications of Right Ventricular Systolic Dysfunction as Assessed with Two-Dimensional Speckle-Tracking Echocardiography

Right ventricular (RV) systolic function in patients admitted with ST-segment elevation myocardial infarction (STEMI) with chronic obstructive pulmonary disease (COPD) and its impact on prognosis have not been characterized. The present study aims to compare the prevalence of RV systolic dysfunction in COPD versus non-COPD patients with STEMI and evaluate the prognostic implications. One hundred seventeen STEMI patients with COPD with transthoracic echocardiography performed within 48hours of admission were retrospectively selected. Matched on age, gender, and infarct size (determined by cardiac biomarkers and left ventricular ejection fraction [LVEF]), 207 non-COPD patients were selected. RV dysfunction was defined based on tricuspid annular plane systolic excursion <17mm (TAPSE), tricuspid annular systolic velocity <6cm/s (S'), RV fractional area change <35% (FAC), and RV longitudinal free wall strain (FWSL) measured with speckle-tracking echocardiography >-20%. Patients were followed for the occurrence of all-cause mortality. RV assessment was feasible in 112 COPD and 199 non-COPD patients (mean age, 69±10; 74% male; mean, LVEF 47%±8%). Patients with COPD had significantly lower RV FAC (38%±11% vs 40%±9%; P=.04), equal TAPSE and S' (17.9±3.7 vs 18.1±3.8mm, P=.72; and 8.4±2.2 vs 8.5±2.2cm/sec, P=.605, respectively) and more impaired RV FWSL (-21.1%±6.6% vs -23.4%±6.5%, P=.005), compared with patients without COPD. RV dysfunction was more prevalent in patients with COPD, particularly when assessed with RV FWSL (46% vs 32%; P=.021). During a median follow-up of 30 (interquartile range 1.5-44) months, 49 patients died (16%). Multivariate models stratified for COPD status showed that RV FWS >-20% was independently associated with 5-year all-cause mortality (hazard ratio, 2.05; 95% CI, 1.12-3.76; P=.020), after adjusting for age, diabetes, peak troponin level, and LVEF. Interestingly, RV FAC < 35%, S'< 6cm/sec, and TAPSE < 17mm were not independently associated with survival. In a STEMI population with relatively preserved LVEF, COPD patients had significantly worse RV FWSL compared with patients without COPD. Moreover, RV FWSL>-20% was independently associated with worse survival. In contrast, conventional parameters were not associated with survival.

RIGHT VENTRICULAR INVOLVEMENT IN PATIENTS WITH SYSTEMIC ARTERIAL HYPERTENSION AND PRESERVED LEFT VENTRICULAR SYSTOLIC FUNCTION

Objective: To analyze the impact of increasing systemic blood pressure (BP) on right ventricular (RV) diastolic, systolic and global function in patients with preserved left ventricular (LV) systolic function. Design and method: The study included 78 subjects, who were divided in 2 groups: the first group involved 39 subjects with grade I-II arterial hypertension (22 women, 17 men; mean age 55.28 ± 7.28 years), the second group included 39 subjects with optimal, normal or high normal BP (20 women, 19 men; mean age 48.08 ± 9.59 years). All subjects underwent careful clinical history and physical examination to reveal risk factors, cardiovascular history and treatments. All participants underwent conventional and pulsed tissue Doppler echocardiography for the assessment of RV and LV functions. We determined tricuspid inflow peak velocity during early (Et) and late (At) filling, their ratio Et/At, early diastolic tissue Doppler velocity of the tricuspid annulus (e′t), the ratio Et/e′t, Et wave deceleration time (DTt), tricuspid annular plane systolic excursion (TAPSE), RV fractional area change (FAC), RV myocardial performance index (RIMP) by pulsed and pulsed tissue Doppler. Results: Mean BP values were significantly higher in the first group vs. controls (systolic BP 157 ± 11 mmHg vs. 123 ± 13 mmHg, p < 0.001; diastolic BP 98 ± 5 mmHg vs. 77 ± 7 mmHg, p < 0.001). Mean values of RV diastolic function parameters, as well as mean values of RIMP were significantly changed in the first group vs. controls: Et 47.88 ± 8.21 cm/s vs. 56.76 ± 9.55 cm/s, p = 0.0009; At 63.72 ± 11.87 cm/s vs. 48.6 ± 11.49 cm/s, p < 0.0001; Et/At 0.72 ± 0.04 vs. 1.14 ± 0.44, p < 0.0001; e′t 10.25 ± 2.36 cm/s vs. 13.92 ± 3.87 cm/s, p = 0.0002; Et/e′t 4.84 ± 1.01 vs. 4.34 ± 0.74, p = 0.0251; DTt 232.36 ± 8.76 ms vs. 206.28 ± 15.71 ms, p < 0.0001; RIMP by pulsed (0.47 ± 0.04 vs. 0.38 ± 0.06, p < 0.0001) and pulsed tissue Doppler (0.56 ± 0.04 vs. 0.46 ± 0.06, p < 0.0001). Mean values of TAPSE (20.0 ± 1.29 mm vs. 21.2 ± 1.34 mm, p = 0.200) and mean values of RV FAC (51 ± 11% vs. 52 ± 9 %, p = 0.425) did not differ significantly between the groups. Conclusions: The systematic assessment of RV function plays an important role in patients with arterial hypertension. Diastolic and global function of RV are influenced by the presence of hypertension in patients with preserved LV systolic function.

Right atrial-right ventricular coupling in heart failure with preserved ejection fraction.

Right ventricular (RV) function is prognostically relevant in heart failure with preserved ejection fraction (HFpEF) but data on profound assessment of RV and right atrial (RA) interaction in HFpEF are lacking. The current study characterizes RV and RA interaction using invasive pressure-volume-loop analysis and cardiac magnetic resonance imaging (CMR) data. We performed CMR and myocardial feature-tracking in 24 HFpEF patients and 12 patients without HFpEF. Invasive pressure-volume-loops were obtained to evaluate systolic and diastolic RV properties. RV early filling was determined from CMR RV volume-time curves. RV systolic function was slightly increased in HFpEF (RV EF 68 ± 8 vs. 60 ± 9%, p = 0.01), while no differences in RV stroke volume were found (45 ± 7 vs 42 ± 9ml/m2, p = 0.32). RV early filling was decreased in HFpEF (21 ± 11 vs. 40 ± 11% of RV filling volume, p < 0.01) and RV early filling was the strongest predictor for VO2max even after inclusion of invasively derived RV stiffness and relaxation constant (Beta 0.63, p < 0.01). RA conduit-function was lower in HFpEF (RA conduit-strain - 11 ± 5 vs. - 16 ± 4%, p < 0.01) while RA booster-pump-function was increased (RA active-strain - 18 ± 6 vs. - 12 ± 6%, p = 0.01) as a compensation. RV filling was associated with RA conduit-function (r = - 0.55, p < 0.01) but not with invasively derived RV relaxation constant. In compensated HFpEF patients RV early filling was impaired and compensated by increased RA booster pump function, while RV systolic function was preserved. Impaired RV diastology and RA-RV interaction were linked to impaired exercise tolerance and RA-RV-coupling seems to be independent of RV relaxation, suggestive of an independent pathophysiological contribution of RA dysfunction in HFpEF. NCT02459626 (www.clinicaltrials.gov).

Biomarkers in the Diagnosis, Management, and Prognostication of Perioperative Right Ventricular Failure in Cardiac Surgery-Are We There Yet?

Right ventricular failure (RVF) is a major risk factor for end organ morbidity and mortality following cardiac surgery. Perioperative RVF is difficult to predict and detect, and to date, no convenient, accurate, or reproducible measure of right ventricular (RV) function is available. Few studies have examined the use of biomarkers in RVF, and even fewer have examined their utility in the perioperative setting of patients undergoing cardiac surgery. Of the available classes of biomarkers, this review focuses on biomarkers of (1) inflammation and (2) myocyte injury/stress, due to their superior potential in perioperative RV assessment, including Galectin 3, ST2/sST2, CRP, cTN/hs-cTn, and BNP/NT-proBNP. This review was performed to help highlight the importance of perioperative RV function in patients undergoing cardiac surgery, to review the current modalities of RV assessment, and to provide a review of RV specific biomarkers and their potential utilization in the clinical and perioperative setting in cardiac surgery. Based on current evidence, we suggest the potential utility of ST2, sST2, Gal-3, CRP, hs-cTn, and NT-proBNP in predicting and detecting RVF in cardiac surgery patients, as they encompass the multifaceted nature of perioperative RVF and warrant further investigation to establish their clinical utility.

Multi-parametric evaluation of right ventricular function in peri-operative surgery for aortic valve replacement

Quantitative assessment of right ventricular (RV) function is difficult with 2D-echocardiography (2D-TTE) and changes in RV longitudinal parameters are surprisingly not predictive of cardiovascular events after surgical Aortic Valve Replacement (SAVR). We aimed at investigating peri-operative evolution of both RV longitudinal parameters and RV global function (assessed by 3D echocardiography (3D-TTE)) and their correlations with cardiac MRI (cMRI) RV function parameters in patients undergoing SAVR. In total, 52 patients with severe aortic stenosis referred to our Heart Valve Clinic for SAVR were explored with a pre-operative (Day-1) and post-operative (Day7) comprehensive 2D- and 3D-TTE assessing RV longitudinal (TAPSE, SDTI, 2D-RV free wall Longitudinal Strain) and global (FAC, 3DE-RVEF and RV-pulmonary arterial coupling) function. Eighteen patients underwent cMRI. In peri-operative period, RV 3D-TTE was feasible in 94% of patients. Correlation between measurements of RV telediastolic volume by 3D-TTE and cMRI was good but not perfect ( R 2 = 0.65, P < 0.0001) with very good intra- and inter-observater reproductibility of RV 3D-TTE measurments (CV = 7.4 ± 7.9% and 7.9% ± 8.1%, respectively). Conversely the correlation between RV telesystolic volume was significant but weak ( R 2 = 0.32, P = 0.0017) and with less robust reproducibility. Although significant decreases of all RV longitudinal parameters were observed, RV global function parameters were stable after SAVR. No relevant correlation ( R 2 < 0.3) was found between post-operative TAPSE and other RV function parameters. 3D-TTE RV assessment is feasible in most of patients in the peri-operative of valvular surgery. The decrease in RV longitudinal function parameters after SAVR does not go with a decrease in RV global function. Prognostic evaluation of global function parameters such as 3DE-RVEF and ventriculo-arterial coupling in the peri-operative require further investigations.

DEVELOPMENT OF A NOVEL DEEP LEARNING MODEL FOR RIGHT VENTRICULAR QUANTIFICATION ON ECHOCARDIOGRAPHY: A MULTIMODALITY VALIDATION STUDY

Echocardiography is widely used to assess right ventricular (RV) function; current techniques are limited by need for dedicated imaging and manual analysis. Deep learning holds potential to improve RV assessment but has yet to be well validated. A deep learning model was developed to track

The Utility of Eccentricity Index as a Measure of the Right Ventricular Function in a Lung Resection Cohort.

Context:Right ventricular (RV) dysfunction occurs after lung resection and is associated with postoperative morbidity. Noninvasive evaluation of the RV is challenging, particularly in the postoperative period. A reliable measure of RV function would have value in this population.Aims:This study compares eccentricity index (EI) obtained by transthoracic echocardiography (TTE) with cardiovascular magnetic resonance (CMR) determined measures of RV function in a lung resection cohort. CMR is the reference method for noninvasive assessment of RV function.Design and Setting:Prospective observational cohort study at a single tertiary hospital.Materials and Methods:Twenty-eight patients scheduled for elective lung resection underwent contemporaneous TTE and CMR imaging preoperatively, on postoperative day (POD) 2 and at 2-month. Systolic and diastolic EI was measured offline from anonymized and randomized TTE and CMR images.Statistical Analysis:Bland–Altman analysis was performed to determine agreement between EITTE and EICMR. Changes over time and comparison with CMR determined RV ejection fraction (RVEFCMR) was assessed.Results:Bland–Altman analysis showed a negligible mean difference between EITTE and EICMR, but limits of agreement were wide (SD 0.24 and 0.28). There were no significant changes in EITTE and EICMR over time (P > 0.35). We found no association between EITTE with RVEFCMR at all-time points (P > 0.22). Systolic and diastolic EICMR on POD 2 demonstrated moderate association with RVEFCMR (r = −0.54 and r = −0.59, P ≤ 0.01). At 2-month, only diastolic EICMR correlated with RVEFCMR (r = −0.43, P = 0.03). There were no meaningful associations between EITTE and EICMR with TTE-derived RV systolic pressure (P > 0.31).Conclusions:TTE determined EI is not useful as a noninvasive method of assessing RV function following lung resection.

Prognostic relevance of the right ventricular myo-mechanical index (RV-MMI) in patients with precapillary pulmonary hypertension

ObjectiveThe aim of the prospective New-RV study was to evaluate a parameter for non-invasive quantification of right ventricular (RV) dysfunction in patients with precapillary pulmonary hypertension (PH) that yields prognostic...

BOP01-9 - Echocardiographic assessment of right ventricular systolic function following lung resection

Using cardiovascular magnetic resonance (CMR), our group has demonstrated right ventricular (RV) dysfunction following lung resection. Despite being a reference method for RV assessment, CMR is not universally available and is inappropriate in the acutely unwell patient, meaning it´s suitability in the post-op period is limited. Although technically challenging, trans-thoracic echocardiography (TTE) is the most common method for assessment of RV function. Tricuspid annular plane systolic excursion (TAPSE), S´Wave velocity at the tricuspid annulus (S´) and fractional area change (FAC) are established methods for assessing RV systolic function. Speckled tracked peak longitudinal strain (PLS) is a novel method of assessing RV function overcoming some of the difficulties associated with conventional methods. None of these parameters have been validated in this population. The aim of this study is to compare these methods to a reference method; RV ejection fraction by CMR imaging (RVEFCMR).

The use of echocardiographic indices in defining and assessing right ventricular systolic function in critical care research.

Many echocardiographic indices (ormethods) for assessing right ventricular (RV) function are available, but each has its strengths and limitations. In some cases, there might be discordance between the indices. We conducted a systematic review to audit the echocardiographic RV assessments in critical care research to see if a consistent pattern existed. We specifically looked into the kind and number of RV indices used, and how RV dysfunction was defined in each study. Studies conducted in critical care settings and reported echocardiographic RV function indices from 1997 to 2017 were searched systematically from three databases. Non-adult studies, case reports, reviews and secondary studies were excluded. These studies' characteristics and RV indices reported were summarized. Out of 495 non-duplicated publications found, 81 studies were included in our systematic review. There has been an increasing trend of studying RV function by echocardiography since 2001, and most were conducted in ICU. Thirty-one studies use a single index, mostly TAPSE, to define RV dysfunction; 33 used composite indices and the combinations varied between studies. Seventeen studies did not define RV dysfunction. For those using composite indices, many did not explain their choices. TAPSE seemed to be the most popular index in the last 2-3years. Many studies used combinations of indices but, apart from cor pulmonale, we could not find a consistent pattern of RV assessment and definition of RV dysfunction amongst these studies.

Temporary assist device support for the right ventricle: pre-implant and post-implant challenges.

Severe right ventricular (RV) failure is more likely reversible than similar magnitudes of left ventricular (LV) failure and, because reversal of both adaptive remodeling and impaired contractility require most often only short periods of support, the use of temporary RV assist devices (t-RVADs) can be a life-saving therapy option for many patients. Although increased experience with t-RVADs and progresses made in the development of safer devices with lower risk for complications has improved both recovery rate of RV function and patient survival, the mortality of t-RVAD recipients can still be high but it depends mainly on the primary cause of RV failure (RVF), the severity of end-organ dysfunction, and the timing of RVAD implantation, and much less on adverse events and complications related to RVAD implantation, support, or removal. Reduced survival of RVAD recipients should therefore not discourage appropriate application of RVADs because their underuse further reduces the chances for RV recovery and patient survival. The article reviews and discusses the challenges related to the pre-implant and post-implant decision-making processes aiming to get best possible therapeutic results. Special attention is focused on pre-implant RV assessment and prediction of RV improvement during mechanical unloading, patient selection for t-RVAD therapy, assessment of unloading-promoted RV recovery, and prediction of its stability after RVAD removal. Particular consideration is also given to prediction of RVF after LVAD implantation which is usually hampered by the complex interactions between the different risk factors related indirectly or directly to the RV potential for reverse remodeling and functional recovery.

Impact of Major Pulmonary Resections on Right Ventricular Function: Early Postoperative Changes.

Right ventricular (RV) dysfunction after pulmonary resection in the early postoperative period is documented by reduced RV ejection fraction and increased RV end-diastolic volume index. Supraventricular arrhythmia, particularly atrial fibrillation, is common after pulmonary resection. RV assessment can be done by non-invasive methods and/or invasive approaches such as right cardiac catheterization. Incorporation of a rapid response thermistor to pulmonary artery catheter permits continuous measurements of cardiac output, right ventricular ejection fraction, and right ventricular end-diastolic volume. It can also be used for right atrial and right ventricular pacing, and for measuring right-sided pressures, including pulmonary capillary wedge pressure. This study included 178 patients who underwent major pulmonary resections, 36 who underwent pneumonectomy assigned as group (I) and 142 who underwent lobectomy assigned as group (II). The study was conducted at the cardiothoracic surgery department of Benha University hospital in Egypt; patients enrolled were operated on from February 2012 to February 2016. A rapid response thermistor pulmonary artery catheter was inserted via the right internal jugular vein. Preoperatively the following was recorded: central venous pressure, mean pulmonary artery pressure, pulmonary capillary wedge pressure, cardiac output, right ventricular ejection fraction and volumes. The same parameters were collected in fixed time intervals after 3 hours, 6 hours, 12 hours, 24 hours, and 48 hours postoperatively. For group (I): There were no statistically significant changes between the preoperative and postoperative records in the central venous pressure and mean arterial pressure; there were no statistically significant changes in the preoperative and 12, 24, and 48 hour postoperative records for cardiac index; 3 and 6 hours postoperative showed significant changes. There were statistically significant changes between the preoperative and postoperative records for heart rate, mean pulmonary artery pressure, pulmonary capillary wedge pressure, pulmonary vascular resistance, right ventricular ejection fraction and right ventricular end diastolic volume index, in all postoperative records. For group (II): There were no statistically significant changes between the preoperative and all postoperative records for the central venous pressure, mean arterial pressure and cardiac index. There were statistically significant changes between the preoperative and postoperative records for heart rate, mean pulmonary artery pressure, pulmonary capillary wedge pressure, pulmonary vascular resistance, right ventricular ejection fraction and right ventricular end diastolic volume index in all postoperative records. There were statistically significant changes between the two groups in all postoperative records for heart rate, mean pulmonary artery pressure, pulmonary capillary wedge pressure, pulmonary vascular resistance, right ventricular ejection fraction and right ventricular end diastolic volume index. There is right ventricular dysfunction early after major pulmonary resection caused by increased right ventricular afterload. This dysfunction is more present in pneumonectomy than in lobectomy. Heart rate, mean pulmonary artery pressure, pulmonary capillary wedge pressure, pulmonary vascular resistance, right ventricular ejection fraction, and right ventricular end diastolic volume index are significantly affected by pulmonary resection.

The Prevalence, Correlates, and Impact on Cardiac Mortality of Right Ventricular Dysfunction in Nonischemic Cardiomyopathy

ObjectivesThis study sought to determine the prevalence, correlates, and impact on cardiac mortality of right ventricular (RV) dysfunction in nonischemic cardiomyopathy. BackgroundCurrent heart failure guidelines place little emphasis on RV assessment due to limited available data on determinants of RV function, mechanisms leading to its failure, and relation to outcomes. MethodsWe prospectively studied 423 patients with cardiac magnetic resonance (CMR). The pre-specified study endpoint was cardiac mortality. In 100 patients, right heart catheterization was performed as clinically indicated. ResultsDuring a median follow-up time of 6.2 years (interquartile range: 2.9 to 7.6 years), 101 patients (24%) died of cardiac causes. CMR right ventricular ejection fraction (RVEF) was a strong independent predictor of cardiac mortality after adjustment for age, heart failure–functional class, blood pressure, heart rate, serum sodium, serum creatinine, myocardial scar, and left ventricular ejection fraction (LVEF). Patients with the lowest quintile of RVEF had a nearly 5-fold higher cardiac mortality risk than did patients with the highest quintile (hazard ratio: 4.68; 95% confidence interval [CI]: 2.43 to 9.02; p < 0.0001). RVEF was positively correlated with LVEF (r = 0.60; p < 0.0001), and inversely correlated with right atrial pressure (r = −0.32; p = 0.001), pulmonary artery pressure (r = −0.34; p = 0.0005), transpulmonary gradient (r = −0.28; p = 0.006) but not with pulmonary wedge pressure (r = −0.15; p = 0.13). In multivariable logistic regression analysis of CMR, clinical, and hemodynamic data the strongest predictors of right ventricular dysfunction were LVEF (odds ratio [OR]: 0.85; 95% CI: 0.78 to 0.92; p < 0.0001), transpulmonary gradient (OR: 1.20; 95% CI: 1.09 to 1.32; p = 0.0003), and systolic blood pressure (OR: 0.97; 95% CI: 0.94 to 0.99; p = 0.02). ConclusionsCMR assessment of RVEF provides important prognostic information independent of established risk factors and LVEF in heart failure patients with nonischemic cardiomyopathy. Right ventricular dysfunction is strongly associated with both indices of intrinsic myocardial contractility and increased afterload from pulmonary vascular dysfunction.

Multimodality Imaging of the Right Ventricle.

Right ventricular (RV) structure and function is clinically important in a wide range of conditions. While conventional echocardiography (echo) methods are widely used, its limitations in RV assessment due its complex geometry are well recognized. New applications of traditional echo methods as well as emerging echo techniques including 3-dimensional (3D) echo and speckle tracking strain have the potential to overcome limitations of conventional echo, though widespread clinical use remains to be seen. Volumetric methods using cardiac magnetic resonance (CMR) and computed tomography (CT) provide accurate assessment of RV function without geometric assumptions. In addition, tissue characterization imaging for myocardial scar and fat using CMR and CT provides important information regarding the RV beyond structure and function alone and has clinical applications for diagnosis and prognosis in a broad range of pathologies. Limitations also exist for these two advanced modalities including availability and patient suitability for CMR and need for contrast and radiation exposure for CT. The complementary role of each modality for the RV as well as emerging evidence for the use of each imaging method in diagnosis and management of RV pathologies is outlined in this study.

Right ventricular involvement evaluated by cardiac magnetic resonance imaging predicts mortality in patients with light chain amyloidosis

Few studies have focused on right ventricular (RV) involvement in cardiac amyloidosis (CA). We investigated the prognostic value of RV assessment by cardiovascular magnetic resonance (CMR) in CA. In 2011–2014, consecutive patients with suspected CA referred for CMR were retrospectively evaluated. Demographic and baseline clinical characteristics were collected. Healthy volunteers were matched for sex and age and served as controls. All subjects underwent a contrast-enhanced CMR examination. RV size, function, and late gadolinium enhancement (LGE) were analyzed. All deaths during follow-up were recorded. Sixty-one patients [37 males (60.7%), age 60 ± 11 years] were included; CA was diagnosed in 47 (77.0%) patients. CA patients displayed decreased biventricular ejection fraction, elevated left ventricular mass index, and increased biventricular end-systolic volume index (ESVi) compared with controls. A total of 27 deaths (57.4%) occurred in the CA group at 21-month median follow-up. Multivariable analysis demonstrated that RVESVi (HR 1.033, 95% CI 1.004–1.063, P = 0.026) and RV-LGE (HR 2.814, 95% CI 1.063–7.450, P = 0.037) were independent predictors of mortality in CA. For all amyloid patients, log NT-proBNP (HR 3.412; 95% CI 1.484–7.845; P = 0.004) and RV-LGE (HR 4.149; 95% CI 1.623–10.607; P = 0.003) were identified as independent predictors. RVESVi and RV-LGE are independent predictors of survival and evaluation of RV by CMR enables risk stratification in patients with CA.

Right Ventricular Longitudinal Strain In Left Ventricular Assist Device Surgery–A Retrospective Cohort Study

Right ventricular (RV) failure is common after left ventricular assist device (LVAD) surgery and is associated with higher mortality. Measurement of longitudinal RV strain using speckle-tracking technology is a novel approach to quantify RV function. The authors hypothesized that depressed peak longitudinal RV strain measured by intraoperative transesophageal echocardiography (TEE) examinations would be associated with adverse outcomes after LVAD surgery. Retrospective cohort study. Tertiary academic medical center. Following Institutional Review Board approval, the authors retrospectively identified adult patients who underwent implantation of non-pulsatile LVAD. Exclusion criteria included inadequate TEE images and device explantation within 6 months for heart transplantation. None. The postoperative adverse event outcome was defined as a composite of one or more of death within 6 months, ≥14 days of inotropes, mechanical RV support, or device thrombosis. Intraoperative TEE images were analyzed for peak RV free wall longitudinal strain by two blinded investigators. Simple logistic regression was used to assess the relationship between adverse outcome and the mean of the strain measurements of the two raters. Agreement between the raters was assessed by intra-class correlation (0.62) and Pearson correlation coefficient (0.63). Of the 57 subjects, 21 (37%) had an adverse outcome. The logistic regression indicated no significant association between RV peak longitudinal strain and adverse events. In this retrospective study of patients undergoing non-pulsatile LVAD implantation, peak longitudinal strain of the RV free wall was not associated with adverse outcomes within 6 months after surgery. Additional quantitative echocardiographic measures for intraoperative RV assessment should be explored.

Afterload Dependence of Right Ventricular Myocardial Strain

Right ventricular (RV) free wall strain (RVFWS) is a feasible method for quantitation and follow-up of RV function and may have benefits over traditional markers such as fractional area change. However, like all ejection phase parameters, RVFWS is difficult to assess in the presence of changing afterload. The aim of this study was to compare RVFWS and traditional RV function parameters for tracking progress of RV function in patients with pulmonary arterial hypertension (PAH) over a range of pulmonary artery systolic pressure (PASPs). Sequential echocardiograms were collected retrospectively at two time points between 2005 and 2015 in 187 patients (71% women; mean age, 63±14years) undergoing pulmonary vasodilator therapy for group 1 PAH. Patients were either studied during PAH therapy (n=111) or before and after treatment initiation (n=76). Standard measurements of RV and left ventricular function and PASP were performed, and speckle-tracking strain was used to calculate RVFWS. The linear response of RVFWS to afterload (PASP) was assessed using a standard regression equation. Because it is unclear if the response might be nonlinear, a quadratic association (PASP squared) was also used in the regression model. At visit 1, patients with PAH showed impaired functional capacity (mean 6-min walk distance, 371±131m), increased PASP (mean, 54±26mmHg), and borderline RVFWS (mean, 18±6%). Patients before PAH therapy showed more pronounced reduction in 6-min walk distance (mean, 302±136m) and RVFWS (mean, 16±5%). RVFWS at baseline was associated with PASP (R2=0.25, P=.001), RV end-diastolic area (R2=0.36, P<.001), and fractional area change (R2=0.21, P<.001). Change in RVFWS was more strongly associated with ΔPASP (std β=-0.20, P=.02) than ΔPASP squared (std β=0.11, P=.20). RVFWS showed strength over fractional area change for sequential RV assessment over a range of PASP changes. Afterload changes should be taken into account in the evaluation of RVFWS during PAH follow-up, with the relationship to PASP likely to be linear.

Contribution of Speckle Tracking to Estimation of Pulmonary Hypertension by Standard Doppler Echocardiography in Patients with Systemic Sclerosis and MCTD

Objectives: Development of pulmonary arterial hypertension (PAH) in systemic sclerosis (SSc) represents one of the most serious complications. The study aimed at assessing right ventricular (RV) global longitudinal strain and its relation to pulmonary artery pressure. Methods: Echocardiography was performed in 74 patients of whom 60 had SSc and 14 had mixed connective tissue disease (MCTD). Besides routine left and right ventricle assessment and pulmonary pressure estimation by Doppler echocardiography, RV fractional area change (FAC) and 2D strain of the RV free wall were evaluated. At the same time, levels of N-terminal pro-brain natriuretic peptide (NT-proBNP), troponin T and auto-antibodies were measured and all patients had diffusing capacity of the lung for carbon monoxide (DLCO) determined. All patients with probable PAH underwent right heart catheterization. Results: Pulmonary hypertension was found to be unlikely in 59 patients (79.7%), possible in 10 patients (13.5%) and probable in 5 patients (6.7%). Significant associations were found between pulmonary artery systolic pressure (PASP) and RV free wall global longitudinal strain (r=0.292; p=0.023), between PASP and NT-proBNP (r=0.436; p=0.001) and between PASP and FAC (r=0.320; p=0.005). Pulmonary artery systolic pressure did not correlate with left ventricular systolic or diastolic function parameters in this cohort. Conclusion: Speckle tracking of the RV represents a useful additional tool in RV assessment in relation to PH in SSc and MCTD patients; right heart catheterization remains an essential method for PAH confirmation.