Right Ventricular Dilatation Research Articles

Differences in clinical and echocardiographic variables and mortality predictors among older patients with pulmonary embolism.

An increase in short-term mortality can be found among older patients with hemodynamically stable acute pulmonary embolism (APE) who have signs of right ventricular (RV) dysfunction. This study was designed to assess whether any difference exists among clinical, laboratory, electrocardiography and echocardiography parameters between older and younger patients diagnosed with APE. The study sample included a total of 635 patients with confirmed APE who were divided into two groups of older (65years and older) and younger (younger than 65years) individuals. Comparisons were performed between these groups in terms of clinical, predisposing factors and laboratory, electrocardiographic and echocardiographic parameters. Analyses of 295 (46.4%) older and 340 (53.6%) younger patients diagnosed with APE were performed. Female sex, Pulmonary Embolism Severity Index score and baseline creatinine levels were higher in the older group. Also, the frequency of atrial fibrillation, RV outflow tract parasternal long-axis proximal diameter, RV end-diastolic diameter (RV-EDD) basal (apical four-chamber) and RV systolic pressure were significantly greater in older patients with APE. A total of 30 (4.7%) deaths were observed during the in-hospital period [21 (7.1%) older vs 9 (2.6%) younger patients; p < 0.01]. In the multivariate logistic regression analysis, age, white blood cell count (WBC), left ventricular ejection fraction (LVEF), RV-EDD basal and tricuspid annular plane systolic excursion (TAPSE) of less than 16mm were found to be independently associated with in-hospital mortality. Older patients might experience greater rates of RV dilatation, RV dysfunction and atrial fibrillation during APE. In addition to age; elevated WBC, low LVEF, increased RV-EDD basal and TAPSE of less than 16mm were independent predictors of mortality among study population.

Right-ventricular dysfunction in HFpEF is linked to altered cardiomyocyte Ca2+ homeostasis and myofilament sensitivity.

AimsHeart failure with preserved ejection fraction (HFpEF) is frequently (30%) associated with right ventricular (RV) dysfunction, which increases morbidity and mortality in these patients. Yet cellular mechanisms of RV remodelling and RV dysfunction in HFpEF are not well understood. Here, we evaluated RV cardiomyocyte function in a rat model of metabolically induced HFpEF.Methods and resultsHeart failure with preserved ejection fraction‐prone animals (ZSF‐1 obese) and control rats (Wistar Kyoto) were fed a high‐caloric diet for 13 weeks. Haemodynamic characterization by echocardiography and invasive catheterization was performed at 22 and 23 weeks of age, respectively. After sacrifice, organ morphometry, RV histology, isolated RV cardiomyocyte function, and calcium (Ca2+) transients were assessed. ZSF‐1 obese rats showed a HFpEF phenotype with left ventricular (LV) hypertrophy, LV diastolic dysfunction (including increased LV end‐diastolic pressures and E/e′ ratio), and preserved LV ejection fraction. ZSF‐1 obese animals developed RV dilatation (50% increased end‐diastolic area) and mildly impaired RV ejection fraction (42%) with evidence of RV hypertrophy. In isolated RV cardiomyocytes from ZSF‐1 obese rats, cell shortening amplitude was preserved, but cytosolic Ca2+ transient amplitude was reduced. In addition, augmentation of cytosolic Ca2+ release with increased stimulation frequency was lost in ZSF‐1 obese rats. Myofilament sensitivity was increased, while contractile kinetics were largely unaffected in intact isolated RV cardiomyocytes from ZSF‐1 obese rats. Western blot analysis revealed significantly increased phosphorylation of cardiac myosin‐binding protein C (Ser282 cMyBP‐C) but no change in phosphorylation of troponin I (Ser23, 24 TnI) in RV myocardium from ZSF‐1 obese rats.ConclusionsRight ventricular dysfunction in obese ZSF‐1 rats with HFpEF is associated with intrinsic RV cardiomyocyte remodelling including reduced cytosolic Ca2+ amplitudes, loss of frequency‐dependent augmentation of Ca2+ release, and increased myofilament Ca2+ sensitivity.

Finding the Optimal Timing for Repair of Standard Tetralogy of Fallot: Analysis of Cardiac Magnetic Resonance and Echocardiography Parameters Related to Intermediate Term Outcomes in a Pediatric Population.

Right ventricular (RV) dilatation is the determining prognostic factor in the long-term follow up of patients with repaired Tetralogy of Fallot (TOF). The objective of this study is to analyze whether the results vary depending on the timing of the complete repair and on the surgical technique applied. This is a retrospective longitudinal study in which patients with standard TOF were divided into 3 groups depending on their age at surgical repair: group 1 = Early repair (n = 12,1-8months), group 2 = Late repair (n = 26, > 8months), and group 3 = Late repair with previous palliative surgery (n = 17, > 8months). Clinical, echocardiographic and cardiac magnetic resonance (CMR) data from patients that had received complete reparative surgery in our institution from January 2000 to March 2014 were analyzed and compared. 55 patients with echocardiogram and CMR studies (13.39 ± 3.59years) were reviewed. All patients had at least moderate pulmonary regurgitation (PR). We observed a positive correlation between PR and right ventricular end-diastolic volume (r2 = 0.418; p = 0,004). Group 3 had more severe right ventricular dilatation than patients in groups 1 and 2 (p = 0.001). No differences in right ventricular end-diastolic volume, PR, and pulmonary trunk dimensions were observed between groups 1 and 2. Patients in group 3 had a longer hospital stay. Although all patients from our cohort had significant PR, age at surgery was not related to RV or pulmonary trunk dilatation. Previous palliative surgery was associated with more severe right ventricular dilatation and longer hospital stays. No differences were observed between early and late repair groups. Our study suggests that postponing TOF repair to a late stage does not improve the degree of PR or long-term morbidity from RV dilatation. Palliative surgery should be avoided if possible.

Echocardiographic Evaluation of Right Ventricular (RV) Performance over Time in COVID-19-Associated ARDS-A Prospective Observational Study.

(1) Background: To evaluate time-dependent right ventricular (RV) performance in patients with COVID-19-associated acute respiratory distress syndrome (ARDS) undergoing intensive care (ICU) treatment. (2) Methods: This prospective observational study included 21 ICU patients with COVID-19-associated ARDS in a university hospital in 2020 (first wave). Patients were evaluated by transthoracic echocardiography at an early (EE) and late (LE) stage of disease. Echocardiographic parameters describing RV size and function as well as RV size in correlation to PaO2/FiO2 ratio were assessed in survivors and nonsurvivors. (3) Results: Echocardiographic RV parameters were within normal range and not significantly different between EE and LE. Comparing survivors and nonsurvivors revealed no differences in RV performance at EE. Linear regression analysis did not show a correlation between RV size and PaO2/FiO2 ratio over all measurements. Analysing EE and LE separately showed a significant increase in RV size correlated to a lower PaO2/FiO2 ratio at a later stage of COVID-19 ARDS. (4) Conclusion: The present study reveals neither a severe RV dilatation nor an impairment of systolic RV function during the initial course of COVID-19-associated ARDS. A trend towards an increase in RV size in correlation with ARDS severity in the second week after ICU admission was observed.

Chronic Inhaled Nicotine‐Induced Pulmonary Hypertension and Right Ventricular Remodeling are Mediated by Angiotensin‐II Type 1 Receptor

Introduction Use of electronic cigarettes is rapidly increasing among youth and young adults, but little is known regarding the long-term cardiopulmonary impacts of these nicotine-containing devices. Our group previously demonstrated that chronic inhaled nicotine induces pulmonary hypertension and right ventricular (RV) remodeling in mice, characterized by increased RV systolic pressure (RVSP) and RV free wall thickness during diastole (RVFWT;d). These changes were associated with upregulated RV angiotensin converting enzyme (ACE), leading us to hypothesize that these nicotine-induced effects are mediated by the renin-angiotensin system. ACE inhibitor and angiotensin-II receptor blocker use in a large retrospective pulmonary hypertension patient cohort was associated with improved survival. Here, we utilized losartan, a specific antagonist of the angiotensin-II type 1 receptor (AT1R), to further explore nicotine's cardiopulmonary effects. Methods: Male C57BL/6 mice received either nicotine vapor or room air for 12 hours per day, and exposure was measured by serum cotinine (559±57 ng/mL; comparable to human cigarette smokers or electronic cigarette users). A subset of mice was treated with losartan via osmotic mini-pump for 8 weeks. Losartan dosage was approximately 5.0 to 6.5 mg/kg/day due to body weight differences throughout the experiment. Cardiac structure and function were assessed using echocardiography and RV catheterization. Results: Chronic inhaled nicotine significantly increased RVSP (40.7±3.5 mmHg, n=11) versus air exposure (25.6±1.0 mmHg, n=11, p<0.005). Mice receiving both losartan and nicotine had significantly reduced RVSP (24.0±1.3 mmHg, n=12, p<0.005) versus nicotine alone. There was no difference in RVSP between air mice and either losartan-infused group (air-losartan: 23.7±1.2 mmHg, n=14). RVFWT;d was increased in nicotine mice (0.44±0.01 mm, n=12) versus air mice (0.31±0.01 mm, n=10, p<0.0001). Losartan infusion of nicotine mice resulted in significantly decreased RVFWT;d (0.34±0.01 mm, n=8, p<0.0001) versus nicotine alone. There was no difference in RVFWT;d between air mice and either losartan-infused group (air-losartan: 0.32±0.01 mm, n=7). Chronic inhaled nicotine increased RV internal diameter during diastole (RVID;d; 1.56±0.04 mm, n=12) versus air mice (1.24±0.07 mm, n=10, p<0.0001), suggesting RV dilation. RVID;d between air-exposed mice receiving losartan (1.23±0.04, n=7) and nicotine-exposed mice receiving losartan (1.44±0.03, n=8) was not significantly different. Neither nicotine nor losartan exposure resulted in changes to left ventricular structure and function. Conclusion: These findings provide the first preclinical evidence that AT1R antagonism can ameliorate chronic inhaled nicotine-induced pulmonary hypertension and RV remodeling.

Tricuspid annular dilation in patients undergoing early mitral valve surgery: is it an old story?

Patients with mitral valve prolapse (MVP), undergoing early surgery for severe regurgitation, are usually characterized by a low degree of right chambers' remodeling. In this selected population, the mechanisms leading to tricuspid annular (TA) dilatation (TAD) are not well understood. In this setting, we aimed to evaluate, using three-dimensional echocardiography (3DE), how right chambers affect TA size and might contribute to functional tricuspid regurgitation (FTR) progression. We studied 159 patients treated with early isolated surgery for MVP, characterized by: sinus rhythm; normal biventricular function; normal or elevated pulmonary artery pressure; tricuspid regurgitation (TR) ≤ mild; no concomitant cardiac disease. All patients reached a 3-year echocardiographic follow-up. Based on two-dimensional echocardiography, patients were divided in Group 1 (N = 68, 43%, TAD, TA ≥ 21mm/m2) and Group 2 (N = 91, 57%, no TAD, TA < 21mm/m2). By 3DE, Group 1 showed larger TA size, right atrial (RA) volume and right ventricular (RV) conical remodeling compared to Group 2 (p < 0.05). The multivariate analysis revealed that RA volume, RV basal diameter and function were independently correlated to TA size (p < 0.05). At the 3-year follow-up there was a low incidence of FTR, with a trend towards FTR progression in Group 1 (p = 0.07). In patients undergoing early surgery for MVP, TAD seems to result from distinctive early-onset geometrical changes of the right chambers, preceding TR, RV dilatation and pulmonary hypertension at rest. An integrated approach, including right chambers' assessment by 3DE, might help to better recognized patients at higher risk for TAD and, potentially for FTR.

Assessment of right ventricular reserve utilizing exercise provocation in systemic sclerosis.

Right ventricular (RV) capacity to adapt to increased afterload is the main determinant of outcome in pulmonary hypertension, a common morbidity seen in systemic sclerosis (SSc). We hypothesized that supine bicycle echocardiography (SBE), coupled with RV longitudinal systolic strain (RVLSS), improves detection of limitations in RV reserve in SSc. 56 SSc patients were prospectively studied during SBE with RV functional parameters compared at rest and peak stress. We further dichotomized patients based on resting RV systolic pressure (RVSP) to determine the effects of load on contractile response. Our pooled cohort analysis revealed reduced global RVLSS at rest (-16.2 ± 3.9%) with normal basal contractility (-25.6 ± 7.7%) and relative hypokinesis of the midventricular (-14.1 ± 6.0%) and apical (-8.9 ± 5.1%) segments. With exercise, global RVLSS increased significantly (p = 0.0005), however despite normal basal contractility at rest, there was no further augmentation with exercise. Mid and apical RVLSS increased with exercise suggestive of RV contractile reserve. In patients with resting RVSP < 35mmHg, global and segmental RVLSS increased with exercise. In patients with resting RVSP ≥ 35mmHg, global and segmental RVLSS did not increase with exercise and there was evidence of exertional RV dilation. Exercise provocation in conjunction with RVLSS identified differential regional contractile response to exercise in SSc patients. We further demonstrate the effect of increased loading conditions on RV contractile response exercise. These findings suggest subclinical impairments in RV reserve in SSc that may be missed by resting noninvasive 2DE-based assessments alone.

Prognostic Value of Feature-Tracking Right Ventricular Longitudinal Strain in Severe Functional Tricuspid Regurgitation: A Multicenter Study

ObjectivesThis study sought to evaluate the prognostic value of cardiac magnetic resonance (CMR) feature-tracking–derived right ventricular (RV) free wall longitudinal strain (RVFWLS) in a large multicenter population of patients with severe functional tricuspid regurgitation. BackgroundTricuspid regurgitation imposes a volume overload on the RV that can lead to progressive RV dilation and dysfunction. Overt RV dysfunction is associated with poor prognosis and increased operative risk. Abnormalities of myocardial strain may provide the earliest evidence of ventricular dysfunction. CMR feature-tracking techniques now allow assessment of strain from routine cine images, without specialized pulse sequences. Whether abnormalities of RV strain measured using CMR feature tracking have prognostic value in patients with tricuspid regurgitation is unknown. MethodsConsecutive patients with severe functional tricuspid regurgitation undergoing CMR at 4 U.S. medical centers were included in this study. Feature-tracking RVFWLS was calculated from 4-chamber cine views. The primary endpoint was all-cause death. Cox proportional hazards regression modeling was used to examine the independent association between RVFWLS and death. The incremental prognostic value of RVFWLS was assessed in nested models. ResultsOf the 544 patients in this study, 128 died during a median follow-up of 6 years. By Kaplan-Meier analysis, patients with RVFWLS ≥median (−16%) had significantly reduced event-free survival compared with those with RVFWLS <median (log-rank p < 0.001). By Cox multivariable regression modeling, RVFWLS was associated with increased risk-of-death after adjustment for clinical and imaging risk factors, including RV size and ejection fraction (hazard ratio: 1.14 per %; p < 0.001). Addition of RVFWLS in this model resulted in significant improvement in the global chi-square (31 to 78; p < 0.001). ConclusionsCMR feature-tracking–derived RVFWLS is an independent predictor of mortality in patients with severe functional tricuspid regurgitation, incremental to common clinical and imaging risk factors.

Does Prosthetic Replacement Impact Right Ventricular Reverse Remodeling in Patients Undergoing Isolated Tricuspid Valve Surgery?

Objective: Tricuspid valve repair (TVrep) is associated with sustained improvement in right ventricular (RV) function, but TV replacement (TVR) may lead to progressive RV dysfunction induced by the rigid prosthesis.To better understand the impact of isolated TVrep and TVR on RV reverse remodeling, we analyzed RV function and dilatation longitudinally following the correction of isolated TR. Methods: Patients who underwent isolated TV procedures (July 2003-November, 2017) with echocardiographic evaluation preoperatively, prior to dismissal, between 3-18 months, and between 18-36 months postoperatively formed the study cohort (n=63). Proportions of patients with moderate/severe RV dysfunction and dilatation were compared between TVrep and TVR groups. Between-group and within-group comparisons were done using Fisher’s exact test and Cochran’s Q test respectively. Results: Mean age of the study cohort was 65.7±14.8 years, and 47.6% were female. All patients had moderately-severe or greater degree of TR and less than moderate aortic/mitral valve dysfunction. Etiology of TV disease was functional (59%), pacemaker-induced (22%), and primary leaflet abnormalities (19%). TVrep was performed in 30% and TVR in 70% of patients. Preoperatively, the proportion of patients with moderate/severe RV dysfunction and dilatation was comparable in both TVrep and TVR groups. Early postoperatively, TVR group had a higher proportion of patients with moderate/severe residual RV dilatation (65% vs 41%) and moderate/severe RV systolic dysfunction (52% vs 32%) compared to TVrep group. By 36 months, RV systolic function had recovered in approximately 70% of patients in both groups. Similarly, RV size recovered to normal or mild dilatation by 36 months after operation in 72% of patients having TVrep and 81% of TVR (both p<0.01). Conclusions: Surgical correction of isolated severe TR initiates RV reverse remodeling with resulting improvement in RV function and RV size. Changes appeared to be of similar magnitude by 36 months in patients having TV repair or replacement.

Clinical implications of late-onset right ventricular failure after implantation of a continuous-flow left ventricular assist device as bridge to transplantation.

The development of late-onset right ventricular failure (LoRVF) that occurs months after a continuous-flow left ventricular assist device (LVAD) is implanted is a clinical problem that warrants investigation. Our goal was to study the incidence, clinical manifestations and prognosis of LoRVF in a population of patients who received an LVAD as bridge to transplantation. Data were analysed from 97 consecutive patients who received an LVAD as bridge to transplantation and underwent a right heart catheterization at least 3 months after receiving an LVAD implantation. LoRVF was defined if both haemodynamic criteria of a central venous pressure >16 mmHg and a cardiac index <2.3 l/min/m2 were present. Clinical and echocardiographic variables, hospitalizations for heart failure and survival were compared between patients with and without LoRVF. LoRVF was diagnosed in 13% of patients after a median time of 11 months. Patients with LoRVF presented preoperative worse right ventricular (RV) dilatation and severe tricuspid regurgitation. LORVF was also associated with postoperative RV dilatation, moderate to severe tricuspid regurgitation and lower tricuspid annular plane systolic excursion. LoRVF resulted in increased brain natriuretic peptide levels and the need for diuretics, lower haemoglobin levels and a higher rate of atrial fibrillation and gastrointestinal bleeding. The rate of hospitalizations for heart failure in patients with LoRVF was 46%, and 15% required an urgent transplantation due to refractory RV failure. LoRVF decreased global survival and survival free from hospitalizations for heart failure (P < 0.0001). LoRVF after the implantation of an LVAD as bridge to transplantation is associated with higher morbidity and lower survival. The results suggest that the routine use of a right heart catheterization and transthoracic echocardiography may contribute to an early diagnosis before further severe complications due to refractory RV failure might occur. AZ-2019-521 on 10 July 2019.

Right ventricular echocardiographic parameters associated with prothrombotic abnormalities in normotensive patients with acute pulmonary embolism

BackgroundIn acute pulmonary embolism (PE) right ventricular (RV) pressure overload negatively affects prognosis. Recently we have shown that RV dilatation is associated with a prothrombotic state in PE. We investigated which RV echocardiographic parameters best indicate prothrombotic alterations in acute PE. MethodsIn 121 normotensive, noncancer PE patients, markers of RV dilatation and dysfunction were evaluated on admission using transthoracic echocardiography, along with prothrombotic state markers, i.e. increased endogenous thrombin generation (ETP), low fibrin clot permeability (Ks, a measure of clot density), and prolonged clot lysis time (CLT). ResultsRV parasternal long axis (RVOT PLAX) >30 mm was associated with ETP (OR 3.86; 95% CI 1.55–9.62; p = 0.004) and CLT (OR 4.08; 95% CI 1.58–10.54; p = 0.004) in the top quartiles, but not with Ks. RV short parasternal axis (RVOT PSAX) >27 mm showed similar associations with higher ETP (OR 3.54; 95% CI 1.50–8.37; p = 0.004) and prolonged CLT (OR 2.78; 95% CI 1.17–6.62; p = 0.021). RV basal diameter >41 mm solely predicted prolonged CLT (OR 2.93; 95% CI 1.23–6.99; p = 0.016). The right atrium area, pulmonary trunk diameter, and tricuspid regurgitation maximum velocity were not related to prothrombotic markers, except for tricuspid annular plane systolic excursion weakly associated with ETP. Multivariable analysis showed that RVOT PSAX is independently associated with prolonged CLT (OR 1.16; 95% CI 1.04–1.30; p = 0.007), low Ks (OR 1.21; 95% CI 1.02–1.44; p = 0.029), and higher ETP (OR 1.14; 95% CI 1.03–1.26; p = 0.009). ConclusionsAmong RV echocardiographic parameters, the RVOT dilatation measured in PSAX best predicts prothrombotic alterations in PE patients.

Impact of concomitant tricuspid annuloplasty on right ventricular remodeling in patients with rheumatic mitral valve disease

BackgroundStudies on the management of functional tricuspid regurgitation (TR) during mitral valve operations have drawn inconsistent conclusions. This study was designed to compare the treatment strategy of concomitant tricuspid annuloplasty (TAP) against isolated mitral valve replacement (MVR) in rheumatic mitral valve disease patients, and to assess the effect of concomitant TAP on postoperative right ventricular (RV) remodeling and function.MethodsOne hundred-seventy patients with rheumatic mitral valve disease receiving MVR were categorized into TAP group (n = 124) and non-TAP group (n = 46). Clinical and echocardiographic data were collected preoperatively and at 1-year follow-up. Three-dimensional echocardiographic indices of RV geometry and function were analyzed.ResultsAt baseline, concomitant TAP group had larger RV end-diastolic volume, more decreased RV ejection fraction and RV longitudinal strain than non-TAP group (all P < 0.001). At 1-year follow-up, TAP group had improved RV geometry and function. While adverse changes were observed in non-TAP group. In analysis of variance, the above indices demonstrated significant interaction with different treatment group (all P < 0.001). In multivariate regression analysis, independent of age and Maze procedure, concomitant TAP was associated with postoperative RV volume reduction (P < 0.001), improvement of RV ejection fraction (P < 0.001), and relieved postoperative functional TR severity (P = 0.025).ConclusionsOur results suggest that concomitant TAP could improve RV remodeling and function for rheumatic mitral valve disease patients, while those with mild preoperative functional TR who had isolated MVR might experience RV dilation and deterioration of RV function at follow-up. Concomitant surgery for functional TR could be considered for patients undergoing MVR with rheumatic mitral valve disease.

Moving beyond size: vorticity and energy loss are correlated with right ventricular dysfunction and exercise intolerance in repaired Tetralogy of Fallot

BackgroundThe global effect of chronic pulmonary regurgitation (PR) on right ventricular (RV) dilation and dysfunction in repaired Tetralogy of Fallot (rTOF) patients is well studied by cardiovascular magnetic resonance (CMR). However, the links between PR in the RV outflow tract (RVOT), RV dysfunction and exercise intolerance are not clarified by conventional measurements. Not all patients with RV dilation share the same intracardiac flow characteristics, now measurable by time resolved three-dimensional phase contrast imaging (4D flow). In our study, we quantified regional vorticity and energy loss in rTOF patients and correlated these parameters with RV dysfunction and exercise capacity.MethodsrTOF patients with 4D flow datasets were retrospectively analyzed, including those with transannular/infundibular repair and conduit repair. Normal controls and RV dilation patients with atrial-level shunts (Qp:Qs > 1.2:1) were included for comparison. 4D flow was post-processed using IT Flow (Cardioflow, Japan). Systolic/diastolic vorticity (ω, 1/s) and viscous energy loss (VEL, mW) in the RVOT and RV inflow were measured. To characterize the relative influence of diastolic vorticity in the two regions, an RV Diastolic Vorticity Quotient (ωRVOT-Diastole/ωRV Inflow-Diastole, RV-DVQ) was calculated. Additionally, RVOT Vorticity Quotient (ωRVOT-Diastole/ωRVOT-Systole, RVOT-VQ) and RVOT Energy Quotient (VELRVOT-Diastole/VELRVOT-Systole, RVOT-EQ) was calculated. In rTOF, measurements were correlated against conventional CMR and exercise stress test results.Results58 rTOF patients, 28 RV dilation patients and 12 controls were included. RV-DVQ, RVOT-VQ, and RVOT-EQ were highest in rTOF patients with severe PR compared to rTOF patients with non-severe PR, RV dilation and controls (p < 0.001). RV-DVQ positively correlated with RV end-diastolic volume (0.683, p < 0.001), PR fraction (0.774, p < 0.001) and negatively with RV ejection fraction (− 0.521, p = 0.003). Both RVOT-VQ, RVOT-EQ negatively correlated with VO2-max (− 0.587, p = 0.008 and − 0.617, p = 0.005) and % predicted VO2-max (− 0.678, p = 0.016 and − 0.690, p = 0.001).ConclusionsIn rTOF patients, vorticity and energy loss dominate the RVOT compared to tricuspid inflow, correlating with RV dysfunction and exercise intolerance. These 4D flow-based measurements may be sensitive biomarkers to guide surgical management of rTOF patients.

Right-left ventricular shape variations in tetralogy of Fallot: associations with pulmonary regurgitation

BackgroundRelationships between right ventricular (RV) and left ventricular (LV) shape and function may be useful in determining optimal timing for pulmonary valve replacement in patients with repaired tetralogy of Fallot (rTOF). However, these are multivariate and difficult to quantify. We aimed to quantify variations in biventricular shape associated with pulmonary regurgitant volume (PRV) in rTOF using a biventricular atlas.MethodsIn this cross-sectional retrospective study, a biventricular shape model was customized to cardiovascular magnetic resonance (CMR) images from 88 rTOF patients (median age 16, inter-quartile range 11.8–24.3 years). Morphometric scores quantifying biventricular shape at end-diastole and end-systole were computed using principal component analysis. Multivariate linear regression was used to quantify biventricular shape associations with PRV, corrected for age, sex, height, and weight. Regional associations were confirmed by univariate correlations with distances and angles computed from the models, as well as global systolic strains computed from changes in arc length from end-diastole to end-systole.ResultsPRV was significantly associated with 5 biventricular morphometric scores, independent of covariates, and accounted for 12.3% of total shape variation (p < 0.05). Increasing PRV was associated with RV dilation and basal bulging, in conjunction with decreased LV septal-lateral dimension (LV flattening) and systolic septal motion towards the RV (all p < 0.05). Increased global RV radial, longitudinal, circumferential and LV radial systolic strains were significantly associated with increased PRV (all p < 0.05).ConclusionA biventricular atlas of rTOF patients quantified multivariate relationships between left–right ventricular morphometry and wall motion with pulmonary regurgitation. Regional RV dilation, LV reduction, LV septal-lateral flattening and increased RV strain were all associated with increased pulmonary regurgitant volume. Morphometric scores provide simple metrics linking mechanisms for structural and functional alteration with important clinical indices.

Exercise right ventricular ejection fraction predicts right ventricular contractile reserve

Right ventricular (RV) contractile reserve shows promise as an indicator of occult RV dysfunction in pulmonary vascular disease. We investigated which measure of RV contractile reserve during exercise best predicts occult RV dysfunction and clinical outcomes. We prospectively studied RV contractile reserve in 35 human subjects referred for right heart catheterization for known or suspected pulmonary hypertension. All underwent cardiac magnetic resonance imaging, echocardiography, and supine invasive cardiopulmonary exercise testing with concomitant RV pressure-volume catheterization. Event-free survival was prospectively adjudicated from time of right heart catheterization for a 4-year follow-up period. RV contractile reserve during exercise, as measured by a positive change in end-systolic elastance (Ees) during exertion, was associated with elevation in pulmonary pressures but preservation of RV volumes. Lack of RV reserve, on the other hand, was tightly coupled with acute RV dilation during exertion (R2 = 0.76, p< 0.001). RV Ees and dilation changes each predicted resting RV-PA dysfunction. RV ejection fraction during exercise, which captured exertional changes in both RV Ees and RV dilation, proved to be a robust surrogate for RV contractile reserve. Reduced exercise RV ejection fraction best predicted occult RV dysfunction among a variety of resting and exercise RV measures, and was also associated with clinical worsening. RV ejection fraction during exercise, as an index of RV contractile reserve, allows for excellent identification of occult RV dysfunction, more so than resting measures of RV function, and may predict clinical outcomes as well.

Right Ventricular Damage in COVID-19: Association Between Myocardial Injury and COVID-19.

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, is a global pandemic. It has resulted in considerable morbidity and mortality around the world. The respiratory system is the main system invaded by the virus involved in COVID-19. In addition to typical respiratory manifestations, a certain proportion of severe COVID-19 cases present with evidence of myocardial injury, which is associated with excessive mortality. With availability of an increasing amount of imaging data, right ventricular (RV) damage is prevalent in patients with COVID-19 and myocardial injury, while left ventricular damage is relatively rare and lacks specificity. The mechanisms of RV damage may be due to increased RV afterload and decreased RV contractility caused by various factors, such as acute respiratory distress syndrome, pulmonary thrombosis, direct viral injury, hypoxia, inflammatory response and autoimmune injury. RV dysfunction usually indicates a poor clinical outcome in patients with COVID-19. Timely and effective treatment is of vital importance to save patients' lives as well as improve prognosis. By use of echocardiography or cardiovascular magnetic resonance, doctors can find RV dilatation and dysfunction early. By illustrating the phenomenon of RV damage and its potential pathophysiological mechanisms, we will guide doctors to give timely medical treatments (e.g., anticoagulants, diuretics, cardiotonic), and device-assisted therapy (e.g., mechanical ventilation, extracorporeal membrane oxygenation) when necessary for these patients. In the paper, we examined the latest relevant studies to investigate the imaging features, potential mechanisms, and treatments of myocardial damage caused by COVID-19. RV damage may be an association between myocardial damage and lung injury in COVID-19. Early assessment of RV geometry and function will be helpful in aetiological determination and adjustment of treatment options.

An exploratory assessment of stretch-induced transmural myocardial fiber kinematics in right ventricular pressure overload

Right ventricular (RV) remodeling and longitudinal fiber reorientation in the setting of pulmonary hypertension (PH) affects ventricular structure and function, eventually leading to RV failure. Characterizing the kinematics of myocardial fibers helps better understanding the underlying mechanisms of fiber realignment in PH. In the current work, high-frequency ultrasound imaging and structurally-informed finite element (FE) models were employed for an exploratory evaluation of the stretch-induced kinematics of RV fibers. Image-based experimental evaluation of fiber kinematics in porcine myocardium revealed the capability of affine assumptions to effectively approximate myofiber realignment in the RV free wall. The developed imaging framework provides a noninvasive modality to quantify transmural RV myofiber kinematics in large animal models. FE modeling results demonstrated that chronic pressure overload, but not solely an acute rise in pressures, results in kinematic shift of RV fibers towards the longitudinal direction. Additionally, FE simulations suggest a potential protective role for concentric hypertrophy (increased wall thickness) against fiber reorientation, while eccentric hypertrophy (RV dilation) resulted in longitudinal fiber realignment. Our study improves the current understanding of the role of different remodeling events involved in transmural myofiber reorientation in PH. Future experimentations are warranted to test the model-generated hypotheses.

Pacemaker lead-associated tricuspid regurgitation in patients with or without pre-existing right ventricular dilatation

BackgroundTranscatheter tricuspid valve intervention became an option for pacemaker lead-associated tricuspid regurgitation. This study investigated the progression of tricuspid regurgitation (TR) in patients with or without pre-existing right ventricular dilatation (RVD) undergoing pacemaker implantation.MethodsPatients were included if they had implantation of transtricuspid pacemaker lead and completed echocardiography before and after implantation. The cohort was divided in patients with and without RVD (cut-off basal RV diameter ≥ 42 mm). TR was graded in none/mild, moderate, and severe. Worsening of one grade was defined as progression. Survival analyses were plotted for 10 years.ResultsIn total, 990 patients were analyzed (24.5% with RVD). Progression of TR occurred in 46.1% of patients with RVD and in 25.6% of patients without RVD (P < 0.001). Predictors for TR progression were RV dilatation (OR 2.04; 95% CI 1.27–3.29; P = 0.003), pre-existing TR (OR 4.30; 95% CI 2.51–7.38; P < 0.001), female sex (OR 1.68; 95% CI 1.16–2.43; P = 0.006), single RV lead (OR 1.67; 95% CI 1.09–2.56; P = 0.018), mitral regurgitation (OR 2.08; 95% CI 1.42–3.05; P < 0.001), and enlarged left atrium (OR 1.98; 95% CI 1.07–3.67; P = 0.03). Survival-predictors were pacemaker lead-associated TR (HR 1.38; 95% CI 1.04–1.84; P = 0.028), mitral regurgitation (HR 1.34; 95% CI 1.02–1.77; P = 0.034), heart failure (HR 1.75; 95% CI 1.31–2.33; P < 0.001), kidney disease (HR 1.62; 95% CI 1.25–2.11; P < 0.001), and age ≥ 80 years (HR 2.84; 95% CI 2.17–3.71; P < 0.001).ConclusionsPatients with RVD receiving pacemaker suffered from increased TR progression, leading to decreased survival.Graphic abstract

Post-acute pre-discharge echocardiography in the long-term prognostic assessment of pulmonary thrombembolism

The aim of our study was to asses the long-term prognostic impact of post-acute, pre-discharge echocardiographic assessment of right ventricular (RV) dysfunction in patients with low- and intermediate-risk pulmonary embolism (PE). Consecutive patients with acute PE underwent post-acute, pre-discharge echocardiographic assessment of RV dysfunction (defined by: RV dilation, tricuspid anulus peak systolic excursion, or tricuspid regurgitation systolic velocity). A Cox multivariate survival mode was constructed to determine the prognostic impact of post-acute, pred-discharge RV dysfunction on all-cause mortality. 615 patients were included: 330 (54%) women, mean age 64 ± 18 years, 265 (43.1%) with post-acute, predischarge RV dysfunction. During follow-up (median 1068 days), 88 (14.3%) patients died. On Cox multivariate analyis, pre-discharge post-acute tricuspid regurgitation systolic velocity emerged as the only independent echocardiographic predictor of mortality (HR 1.73 for every 1 m/s increase; 95% confidence interval 1.033–2.897; p = 0.037). RV dysfunction persists in almost one half of PE patients in the post-acute phase on pre-discharge echocardiography; however, only tricuspid regurgitation systolic velocity independently predicts long-term prognosis.

Right Ventricular Dysfunction and Adverse Outcomes after Renal Transplantation

Introduction: Pulmonary hypertension is common among patients with end-stage renal disease, although data regarding the impact of right ventricular (RV) failure on postoperative outcomes remain limited. We hypothesized that echocardiographic findings of RV dilation and dysfunction are associated with adverse clinical outcomes after renal transplant. Methods: A retrospective review of adult renal transplant recipients at a single institution from January 2008 to June 2010 was conducted. Patients with transthoracic echocardiograms (TTEs) within 1 year leading up to transplant were included. The primary end point was a composite of delayed graft function, graft failure, and all-cause mortality. Results: Eighty patients were included. Mean follow-up time was 9.4 ± 0.8 years. Eight patients (100%) with qualitative RV dysfunction met the primary end point, while 39/65 patients (60.0%) without RV dysfunction met the end point (p = 0.026). Qualitative RV dilation was associated with a significantly shorter time to all-cause graft failure (p = 0.03) and death (p = 0.048). RV systolic pressure was not measurable in 45/80 patients (56%) and was not associated with outcomes in the remaining patients. Conclusion: RV dilation and dysfunction are associated with adverse outcomes after renal transplant. TTE assessment of RV size and function should be a standard part of the pre-kidney transplant cardiovascular risk assessment.