Right Ventricular End-diastolic Area Research Articles

Assessment of right ventricular function in patients with severe secondary tricuspid regurgitation, following to the TVARC recommendations: association with outcome

Abstract Introduction Severe tricuspid regurgitation (TR) is associated with increased mortality if left untreated. Recently, the Tricuspid Valve Academic Research Consortium (TVARC) has published standardized definitions of disease aetiology and severity, as well as endpoints for future clinical trials. Right ventricular (RV) function assessment represents one of the cornerstones for risk stratification in these patients, but current guidelines do not propose specific cut-off values for the echocardiographic measures. Also, the thresholds proposed by the TVARC have been derived from normative value and not yet validated in large cohorts of TR patients. Purpose To test the prognostic value of the TVARC proposed echocardiographic cut-offs for grading RV-dysfunction (figure1) in a large real-world cohort of patients with severe secondary TR (STR). Methods Consecutive patients from a single centre with first diagnosis of severe secondary STR, and without a cardiac implantable electronic device, were included. Tricuspid annulus plane systolic excursion (TAPSE), RV global and free wall strain (RVGLS and RVFWLS) and fractional area change (FAC) were used to measure RV function. The study endpoint was all-cause mortality, censored for tricuspid valve intervention. Results A total of 1043 patients (mean age 69 ± 13 years, 43% male), were included. Approximately half of the population (45%) was in NYHA class III or IV and 52% was treated with loop diuretics. Overall patients showed mild RV-dilatation (RV end-diastolic area indexed 12.2 [10.1-15.2cm2/m2]) and moderate-to-severe right atrial dilatation (right atrial maximal area indexed: 13.9 [11.0-17.5cm2/m2]). Using the proposed cut-off values, strain analysis identified a higher number of patients with impaired RV function as compared to standard echocardiographic parameters (89% based on RVGLS; 80% based on RVFWS, 61% based on TAPSE and 54% based on RVFAC). During a median follow-up of 51 [IQR 6 - 98] months, 445 (43%) patients died. The Kaplan-Meier survival curves for each echocardiographic parameter of RV-function are shown in Figure 1. TAPSE, which is the most widely used RV-function parameter, was able to clearly identify patients at high and intermediate risk when mildly, moderately and severely impaired. However, patients with normal TAPSE were still at intermediate risk when RVFWLS was (even mildly) reduced (figure 2). We therefore propose a stepwise practical approach including the measure of RVFWLS when measuring normal TAPSE, in order to possibly re-stratify patients into a higher risk group (Figure 2). This novel grading approach remained independently associated with all-cause mortality after correcting for relevant clinical and echocardiographic variables on multivariable analysis. Conclusion Novel TAVRC cut-off values for RV function show prognostic value in patients with severe STR; particularly the combination of TAPSE and RVFWLS could be use in clinical practice for risk stratification.Figure 1Figure 2

Effect of Semaglutide on Cardiac Structure and Function in Patients With Obesity-Related Heart Failure

BackgroundObesity is associated with adverse cardiac remodeling and is a key driver for the development and progression of heart failure (HF). Once-weekly semaglutide (2.4 mg) has been shown to improve HF-related symptoms and physical limitations, body weight, and exercise function in patients with obesity-related heart failure with preserved ejection fraction (HFpEF), but the effects of semaglutide on cardiac structure and function in this population remain unknown. ObjectivesIn this echocardiography substudy of the STEP-HFpEF Program, we evaluated treatment effects of once-weekly semaglutide (2.4 mg) vs placebo on cardiac structure and function. MethodsEchocardiography at randomization and 52 weeks was performed in 491 of 1,145 participants (43%) in the STEP-HFpEF Program (pooled STEP-HFpEF [Semaglutide Treatment Effect in People with Obesity and HFpEF] and STEP-HFpEF DM [Semaglutide Treatment Effect in People with Obesity, HFpEF, and Type 2 Diabetes] trials). The prespecified primary outcome was change in left atrial (LA) volume, with changes in other echocardiography parameters evaluated as secondary outcomes. Treatment effects of semaglutide vs placebo were assessed using analysis of covariance stratified by trial and body mass index, with adjustment for baseline parameter values. ResultsOverall, baseline clinical and echocardiographic characteristics were balanced among those receiving semaglutide (n = 253) and placebo (n = 238). Between baseline and 52 weeks, semaglutide attenuated progression of LA remodeling (estimated mean difference [EMD] in LA volume, −6.13 mL; 95% CI: −9.85 to −2.41 mL; P = 0.0013) and right ventricular (RV) enlargement (EMD in RV end-diastolic area: −1.99 cm2; 95% CI: −3.60 to −0.38 cm2; P = 0.016; EMD in RV end-systolic area: −1.41 cm2; 95% CI: −2.42 to −0.40] cm2; P = 0.0064) compared with placebo. Semaglutide additionally improved E-wave velocity (EMD: −5.63 cm/s; 95% CI: −9.42 to −1.84 cm/s; P = 0.0037), E/A (early/late mitral inflow velocity) ratio (EMD: −0.14; 95% CI: −0.24 to −0.04; P = 0.0075), and E/e′ (early mitral inflow velocity/early diastolic mitral annular velocity) average (EMD: −0.79; 95% CI: −1.60 to 0.01; P = 0.05). These associations were not modified by diabetes or atrial fibrillation status. Semaglutide did not significantly affect left ventricular dimensions, mass, or systolic function. Greater weight loss with semaglutide was associated with greater reduction in LA volume (Pinteraction = 0.033) but not with changes in E-wave velocity, E/e′ average, or RV end-diastolic area. ConclusionsIn the STEP-HFpEF Program echocardiography substudy, semaglutide appeared to improve adverse cardiac remodeling compared with placebo, further suggesting that treatment with semaglutide may be disease modifying among patients with obesity-related HFpEF. (Research Study to Investigate How Well Semaglutide Works in People Living With Heart Failure and Obesity [STEP-HFpEF]; NCT04788511; Research Study to Look at How Well Semaglutide Works in People Living With Heart Failure, Obesity and Type 2 Diabetes [STEP-HFpEF DM]; NCT04916470)

Outcomes of Adults With Unrepaired Partial Anomalous Pulmonary Venous Return and Intact Atrial Septum.

The purpose of this study was to describe the correlates and outcomes in adults with unrepaired partial anomalous pulmonary venous return and intact atrial septum (PAPVR-IAS). We identified adults with PAPVR-IAS who received care at the Mayo Clinic, while those with unrepaired PAPVR-IAS comprised the reference group. Clinical indices (New York Heart Association class, peak oxygen consumption, and NT-proBNP [N-terminal pro-B-type natriuretic peptide]) and echo-derived right heart indices (right atrial [RA] volume, RA reservoir strain, right ventricular [RV] free wall strain, RV end-diastolic area, and RV systolic pressure) were assessed at baseline and 3-year and 5-year follow-up. There were 80 patients and 38 patients with unrepaired versus repaired PAPVR-IAS, respectively. The clinical predictors of surgical repair were the number of anomalous veins, RA volume, and RV end-diastolic area. The PAPVR-IAS risk score, derived from these clinical predictors, was associated with surgical repair (adjusted odds ratio, 1.37 [95% CI, 1.24-1.65] per unit increase in risk score; area under the curve, 0.742). Among patients with unrepaired PAPVR-IAS with 3-year (n=73) and 5-year follow-up (n=36), there was no temporal change in clinical indices (New York Heart Association class, predicted peak oxygen consumption, and NT-proBNP) and right heart indices (RA volume index, RA reservoir strain, RV end-diastolic area index, RV free wall strain, and RV systolic pressure). The PAPVR-IAS risk score can be used to assess the odds of requiring surgical repair. Furthermore, there was no temporal deterioration in clinical and right heart indices during follow-up in adults with unrepaired PAPVR-IAS.

Acute effect of ultramarathon on systolic and diastolic cardiac function: Systematic review and meta-analysis

BackgroundUltramarathon running poses physiological challenges, impacting cardiac function. This systematic review and meta-analysis explore the acute effects of single-stage ultramarathon running on cardiac function. MethodsPreferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations were followed. Searches covered Medline, Embase, CINAHL, SPORTDiscus, Web of Science, Central Cochrane, and Scopus. Random effects meta-analyses assessed left ventricular (LV) and right ventricular (RV) variables, expressed as mean differences (MD) with 95% confidence intervals (CI). ResultsAmong 6972 studies, 17 were included. Post-ultramarathon reductions were found in LV end-diastolic diameter (LVEDD) (−1.24; 95% CI = −1.77, −0.71 mm), LV end-diastolic volume (LVEDV) (−9.92; 95% CI = −15.25, −4.60 ml), LV stroke volume (LVSV) (−8.96 ml, 95% CI -13.20, −4.72 ml), LV ejection fraction (LVEF) (−3.71; 95% CI = −5.21, −2.22%), LV global longitudinal strain (LVGLS) (−1.48; 95% CI = −2.21, −0.76%), E/A (−0.30; 95% CI = −0.38, −0.22 cm/s), .E' (−1.35 cm/s, 95% CI -1.91, −0.79 cm/s), RV fractional area change (RVFAC) (−3.34, 95% CI = −5.84, −0.84%), tricuspid annular plane systolic excursion (TAPSE) (−0.12, 95% CI = −0.22, −0.02 cm), RV global longitudinal strain (RVGLS) (−1.73, 95% CI = −2.87, −0.59%), with increases in RV end-diastolic area (RVEDA) (1.89, 95% CI = 0.63, 3.14 cm2), RV Peak A' (1.32 cm/s, 95% CI 0.20, 2.44), and heart rate (18.24, 95% CI = 15.16, 21.32). No significant differences were observed in LV end-systolic diameter (LVESD), LV end-systolic volume (LVESV), RV end-diastolic diameter (RVEDD), RV Peak E', and RV Peak S′. ConclusionsEvidence suggests immediate impairment of systolic and diastolic cardiac function post-ultramarathon running.

Low circulating lysophosphatidylcholine and phosphatidylcholine are linked to pulmonary hypertension severity

Background: Pulmonary hypertension (PH) is a progressive pulmonary vascular disease. Given the mechanistic role of lipids in peripheral vascular diseases, we hypothesized that PH is also associated with pathologic circulating lipid metabolites. To test this, lipid metabolites of patients with PH were evaluated in association with clinical severity, including right ventricle systolic pressure (RVSP), pulmonary vascular resistance (PVR), right ventricular size and function, and plasma endothelin-1. Methods and Results: Participants were recruited as a part of a small site clinical trial (Clinicaltrials.gov, # NCT01586156). Comprehensive lipidomes were determined using unbiased nontargeted lipidomics (Metabolon Inc., Durham, NC) in 30 PH patients and 12 healthy controls. RVSP, right ventricular end diastolic (RVED) and end systolic (RVES) area were measured by echocardiogram and PVR was calculated. Plasma endothelin-1 was measured by Elisa. Nontargeted analysis detected 1099 lipid-related metabolites of which 83 and 60 metabolites were upregulated and downregulated in PH ( p<0.05), respectively. Pathway enrichment analysis identified abnormalities of lipid metabolic pathways including choline-related, acylcarnitine, and sphingolipid metabolism. Targeted measures of lysophosphatidylcholine (lysoPC) and phosphatidylcholine (PC) confirmed these findings. Total circulating lysoPC and PC were downregulated [Healthy vs. PH, mean ± SD, mM; LysoPC, 786±102 vs. 586±139, p<0.01; PC, 1855±389 vs. 1495±282, p<0.01]. Sixteen out of the 25 lysoPC detected, and 25 out of 39 PC detected, were lower in PH, including the most abundant lysoPC-16:0 [226±31 vs. 186±39, p<0.01] and PC-34:2 [436±91 vs. 360±75, p<0.01]. RVSP, PVR, RVED area, RVES area and endothelin-1 were all higher in PH (all, p<0.01). Lipid metabolites were inversely related to clinical measures of PH severity. For example, lysoPC-20:3 was related to RVSP [ r=−0.63, p<0.01], PVR [ r=−0.50, p<0.01], and endothelin-1 [ r=−0.51, p<0.01], and PC-36:5 was inversely related to RVSP [ r=−0.36, p=0.02], PVR [ r=−0.43, p<0.01], and endothelin-1 [ r=−0.50, p<0.01]. Additionally, both lysoPC-20:3 and PC36:5 metabolites were inversely associated with right ventricular size, measured as RVED area [lysoPC-20:3, r=−0.62, p<0.01; PC-36:5, r=−0.69, p<0.01], RVES area [lysoPC-20:3, r=−0.66, p<0.01; PC-36:5, r=−0.71, p<0.01] and related with RV systolic function, measured as RV fractional area change [lysoPC-20:3, r=0.57, p<0.01; PC-36:5, r=0.50, p<0.01). Conclusion: Plasma phosphatidylcholine is low in PH and is associated with disease severity, suggesting disturbances in PC metabolism are important in pulmonary vascular disease. NIH NHLBI R37HL60917, R01HL115008 CTSA UL1TR000439; UL1TR002548. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Effect of reperfusion time on right ventricular remodeling in inferior ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention

Background: Right ventricle (RV) remodeling and dysfunction are frequent in inferior ST-elevation myocardial infarction (STEMI) patients and possibly implicated to poor outcomes. Objective: The purpose of this study is to investigate the influence of reperfusion time on RV remodeling in patients with inferior STEMI who had primary percutaneous coronary intervention (PPCI).Methods: The subjects were patients with inferior STEMI who had undergone PPCI and met the inclusion and exclusion criteria. From September 2021 to April 2022, samples were taken in the order in which they arrived at the Dr. Sardjito Hospital in Yogyakarta, Indonesia. To investigate the occurrence of RV remodeling, 2D-transthoracic echocardiography was performed before PPCI as baseline and 3-months after PPCI. Confounding factors were investigated using bivariate and multivariate analysis.Results: The RV remodeling was observed in 12 (28.6%) of 42 inferior STEMI patients undergoing PPCI. The RV remodeling group had a longer median reperfusion time (798.5 vs 710 minutes, p=0.568). The baseline RV end-systolic area (RVESA) and RV end-diastolic area (RVEDA) had significant correlations with the occurrence of RV remodeling (p=0.046; p=0.008, respectively). The tricuspid annular plane systolic excursion (TAPSE) rose considerably in both groups during the 3-month follow up. There were significant variations in RVEDA and RV basal diameter in the RV remodeling group, but there was a substantial rise in fractional area change (FAC) and RVESA in the non-RV remodeling group.Conclusion: In patients with inferior STEMI undergoing PPCI, reperfusion time showed no significant effect on RV remodeling.

Left main coronary artery compression in precapillary pulmonary hypertension.

Pulmonary hypertension (PH) is a progressive and invalidating condition despite available therapy. Addressing complications such as left main coronary artery compression (LMCo) due to the dilated pulmonary artery (PA) may improve symptoms and survival. Nevertheless, clear recommendations are lacking. The aim of this study is to analyze the prevalence, characteristics, predictive factors and impact of LMCo in a heterogenous precapillary PH population in a single referral center. Two hundred sixty-five adults with various etiologies of precapillary PH at catheterization were reviewed. Coronary angiography (CA) was performed for LMCo suspicion. Revascularization was performed in selected cases. Outcomes were assessed at a mean follow-up of 3.9 years. LMCo was suspected in 125 patients and confirmed in 39 (31.2%), of whom 21 (16.8%) had 50%-90% stenoses. Nine revascularizations were performed, with clinical improvement. The only periprocedural complication was a stent migration. LMCo was associated with PH etiology (p 0.003), occuring more frequently in congenital heart disease-associated PH (61.5% of all LMCo cases, 66.6% of LMCo ≥ 50%). Predictors of LMCo ≥50% were PA ≥ 37.5 mm (Sn 81%, Sp 74%) and PA-to-aorta ≥1.24 (Sn 81%, Sp 69%), with increased discrimination when considering RV end-diastolic area. LMCo ≥ 50% without revascularization presented clinical deterioration and worse survival (p 0.019). This analysis of a heterogeneous pre-capillary PH population provides LMCo prevalence estimation, predictive factors (PA size, PA-to-aorta, RV end-diastolic area and PH etiology) and long-term impact. While LMCo impact on survival is inconclusive, untreated LMCo ≥ 50% has worse prognosis. LMCo revascularization may be performed safely and with good outcomes.

Feasibility Value of Right Ventricular Longitudinal Shortening Fraction and the Prognostic Implications in Patients With Heart Transplantation.

Right ventricular longitudinal shortening fraction (RVLSF) is a 2-dimensional speckle tracking echocardiography parameter based on tricuspid annular displacement analysis that could be used to assess right ventricular (RV) systolic function. The value of RVLSF in the assessment of RV systolic function in recipients of heart transplantation (HT) and whether RVLSF can replace strain parameters remains unknown. A total of 153 adult patients who underwent HT were consecutively enrolled in this prospective longitudinal study. All subjects were examined by conventional transthoracic 2-dimensional echocardiography and 2-dimensional speckle tracking echocardiography to evaluate the RV end-diastolic basal diameter, RV end-diastolic area, fractional area change, peak systolic velocity of tricuspid annulus, tricuspid annular plane systolic excursion, RV free wall strain, and RVLSF. Cox proportional hazards regression was used to test if the parameters of interest had independent prognostic value for adverse outcome prediction in patients who underwent HT. A significant positive correlation was found between the measurements of RVLSF and RV free wall strain (r=0.927, P<0.001). Compared with the event-free group, the adverse outcome group displayed reduced RVLSF and RV free wall strain and higher age (P<0.001, <0.001, =0.016, respectively) in patients who underwent HT. RVLSF and RV free wall strain were independently associated with poor prognosis in multivariable analysis (both P<0.001). RVLSF assessment provides an effective evaluation of RV longitudinal systolic function in the transplanted hearts and has prognostic value for adverse outcomes in patients undergoing HT.

Acute changes in cardiac dimensions, function, and longitudinal mechanics in healthy individuals with and without high-altitude induced pulmonary hypertension at 4559m.

High-altitude pulmonary hypertension (HAPH) has a prevalence of approximately 10%. Changes in cardiac morphology and function at high altitude, compared to a population that does not develop HAPH are scarce. Four hundred twenty-one subjects were screened in a hypoxic chamber inspiring a FiO2 =12% for 2h. In 33 subjects an exaggerated increase in systolic pulmonary artery pressure (sPAP) could be confirmed in two independent measurements. Twenty nine of these, and further 24 matched subjects without sPAP increase were examined at 4559m by Doppler echocardiography including global longitudinal strain (GLS). SPAP increase was higher in HAPH subjects (∆=10.2vs. ∆=32.0mm Hg, p<.001). LV eccentricity index (∆=.15vs. ∆=.31, p=.009) increased more in HAPH. D-shaped LV (0 [0%] vs. 30 [93.8%], p=.00001) could be observed only in the HAPH group, and only in those with a sPAP ≥50mm Hg. LV-EF (∆=4.5vs. ∆=6.7%, p=.24) increased in both groups. LV-GLS (∆=1.2vs. ∆=1.1 -%, p=.60) increased slightly. RV end-diastolic (∆=2.20vs. ∆=2.7cm2 , p=.36) and end-systolic area (∆=2.1vs. ∆=2.7cm2 , p=.39), as well as RA end-systolic area index (∆=-.9vs. ∆=.3cm2 /m2 , p=.01) increased, RV-FAC (∆=-2.9vs. ∆=-4.7%, p=.43) decreased, this was more pronounced in HAPH, RV-GLS (∆=1.6vs. ∆=-.7 -%, p=.17) showed marginal changes. LV and LA dimensions decrease and left ventricular function increases at high-altitude in subjects with and without HAPH. RV and RA dimensions increase, and RV longitudinal strain increases or remains unchanged in subjects with HAPH. Changes are negligible in those without HAPH.

Can Glypican-6 Levels Be Used to Determine Right Ventricular Remodeling After Non-ST Segment Elevation Myocardial Infarction?

Myocardial infarction is associated with right ventricular (RV) remodeling. Glypican-6 (GPC6), a member of the membrane proteoglycan family, plays a significant role in cardiac remodeling. This study aims to determine if GPC6 can predict RV remodeling after percutaneous coronary intervention (PCI) in patients with non-ST segment elevation myocardial infarction (NSTEMI). The study enrolled 164 consecutive patients with NSTEMI and controls. It compared baseline plasma GPC6 levels, echocardiography, and laboratory parameters between the RV remodeling and non-RV remodeling groups with NSTEMI. Echocardiographic data were measured at baseline and at six months. GPC6 levels were higher in the NSTEMI group 11.06 ng/mL (4.61-18.17) vs. 5.98 ng/mL (3.81-9.83) compared to the control group in the initial phase. RV remodeling, defined as a ≥ 20% increase in RV end-diastolic area (RV EDA), was observed in 23 patients (30%). After six months, RV EDA increased significantly from baseline 18.68 ± 1.20 cm2 vs. 24.91 ± 1.08 cm2, P < 0.001. GPC6 was a significant independent predictor of RV remodeling (hazard ratio [HR]: 1.546, 95% confidence interval [CI]: 1.056-2.245, P < 0.001). Receiver operating characteristic curve (ROC) analyses showed that GPC6 values > 15.5 ng/mL (area under the curve [AUC] = 0.828, sensitivity: 70%, specificity: 74%, P < 0.001) were strong predictors of RV remodeling. NSTEMI patients should be closely monitored for RV remodeling. GPC6 appears useful in detecting RV remodeling following NSTEMI in patients undergoing PCI.

Acute right ventricular geometric change predicts outcomes in HeartMate 3 patients

BackgroundThe physiological response of the right ventricle (RV) following left ventricular assist device (LVAD) implantation is difficult to predict. We aimed to investigate RV geometric and functional changes after LVAD insertion and their effects on clinical outcomes. MethodsWe retrospectively reviewed 188 patients who underwent HeartMate 3 implantation at our center between November 2014 and September 2021. The RV end-diastolic diameter (RVEDD) and area (RVEDA) were measured on preoperative and pre-discharge transthoracic echocardiography. The non-adapted group included patients with increased RVEDD and RVEDA at discharge. The composite outcome was defined as death or readmission due to worsening right heart failure. ResultsThere were 82 patients (44%) who had a non-adapted and 106 (56%) who had an adapted RV. Preoperatively, the non-adapted group had smaller RVEDD (46 vs. 49 mm, p < 0.001) and RVEDA (27 vs. 31 cm2, p < 0.001). At discharge, the non-adapted group had larger RVEDD (51 vs. 43 mm, p < 0.001) and RVEDA (33 vs. 27 cm2, p < 0.001). Kaplan-Meier analysis demonstrated worse 3-year survival (77% vs. 91%, p = 0.006) and freedom from composite outcome (58% vs. 85%, p < 0.001) in the non-adapted group. A multivariable Cox proportional hazards model showed that non-adaption (HR 3.09, 95% CI 1.29–7.40 p = 0.01) and age (HR 3.73, 95% CI 1.42–9.77, p = 0.007) were independent predictors of composite outcome. ConclusionsAcute RV dimensional changes after LVAD insertion may represent intrinsic RV function and may be a useful prognostic marker.

Clinical utility and prognostic value of right atrial function in severe tricuspid regurgitation. One more piece of the puzzle

Abstract Background Optimal management of severe tricuspid regurgitation (TR) remains controversial. While right ventricular systolic function is an established prognostic marker of outcomes, the potential role of right atrial (RA) function is unknown. Purpose This study aimed to describe RA function by 2D speckle tracking echocardiography (STE) in at least severe TR and to evaluate its potential association with cardiovascular outcomes. Methods Consecutive patients with at least (≥) severe TR (severe, massive or torrential TR) evaluated in the Heart Valve Clinic following a comprehensive clinical protocol were included. Consecutive control subjects and patients with permanent isolated AF were included for comparison (control and AF group respectively). RA function was measured with 2D-STE and RA reservoir strain (RASr) was calculated in all subjects (figure 1, AutoStrain, Philips Medical Systems the EPIQ system). The interobserver variability of RA strain was assessed in 30 randomly selected subjects (20 TR+5 AF+5 controls). A combined endpoint of hospital admission due to heart failure (HF) or all cause mortality was defined. Results A total of 227 patients with severe TR, 20 AF patients and 20 controls subjects were included in this study. Patients with at least severe TR showed lower RASr compared to controls and to AF patients (p&amp;lt;0,05). After a median follow-up of 26 months (IQR: 15-48 months), n=83 patients with severe TR (37%) reached the combined endpoint. Patients with events showed lower values of RASr (p&amp;lt;0,01 for both). RASr was an independent predictor of heart failure and all cause mortality adjusted by additional imaging prognostic parameters in a multivariable analysis (biplane vena contracta, RV end-diastolic area, and RV- free wall longitudinal strain [LR Chi2 : 49,7, p&amp;lt;0,001]). RA area or volume was not associated with outcomes. A cut-off value of RASr of &amp;lt;10% held the best accuracy to predict outcomes (adjusted HR 3,8 (2,4-6,1), p&amp;lt;0,001, figure 2). Inter-observer agreements for RA strain values across the whole cohort were high (intraclass correlation coefficient for RASr, RAScd and RASct, r= 0,95, r=0,86, r=0,92 respectively). Conclusions Evaluation of RA function by 2D-STE is feasible, reproducible and is an independent predictor of heart failure and all-cause mortality in patients with at least severe TR.LA STRAINKaplan Meier Curves

Abstract 13652: Machine Learning Prediction of RV End-Diastolic Volume in Patients With Pulmonary Regurgitation

Introduction: RV end-diastolic volume (RVEDV) by cardiac MRI (cMRI) guides intervention in congenital heart disease. Guideline directed linear and area measurements from two-dimensional echocardiography (2DE) have poor univariable linear correlation with RVEDV. We hypothesized that non-linear modeling of 2DE RV measurements may predict cMRI volume. Aims: We sought to develop a prediction algorithm for RVEDV from guideline-directed RV 2DE measurements. Methods: Patients from 2009 to 2022 with &gt; mild pulmonary regurgitation and cMRI +/- 3 months were included. 2DE measurements were: RV end-diastolic (RVED) apical 4-chamber area, basal RVED diameter (d), mid RVED d, tricuspid annulus d, RVED length; PSLAX proximal RVOT d; PSSAX proximal RVOT d, distal RVOT d. A gradient-boosting decision trees algorithm (XGBoost) regressed cMRI RVEDV (mL) using 2DE inputs (including missing data) with leave-one-out crossvalidation. Predicted RVEDV was BSA-indexed to examine performance at clinical threshold 150 mL/m 2 . Intraclass correlation coefficient (ICC) in 30 samples was measured. Results: Of 243 subjects (median age 21 [IQR 16-31] y, 58% tetralogy of Fallot, 22% congenital pulmonary stenosis s/p intervention), 19% had cMRI RVEDV &gt; 150 mL/m 2 . Missing ranged from 5% (basal RVED d) to 17% (PSSA proximal RVOT), and ICC ranged from 0.46 (basal RVED d) to 0.78 (tricuspid annulus). Mean absolute error was 40 mL (27 mL/m 2 ). At the predicted threshold 150 mL/m 2 had 39% sensitivity, 87% specificity, 40% positive predictive value, and 86% negative predictive value for true RV dilation. Conclusion: Prediction of RVEDV from guideline recommended 2DE RV measurements is possible. Detection of clinically significant RV dilation has low sensitivity but may be helpful in ruling out cases. Sources of error include interrater variability and missing data due to poor visualization of the RV on 2DE. Future work to develop a consistent and informative feature set for modeling is required.

Does lateral approach preserve the right ventricular function after HeartMate 3 insertion?

Lateral thoracotomy (LT) approach may preserve the right ventricular (RV) function after left ventricular assist device (LVAD) implantation. This study evaluated the short- and long-term RV function using echocardiography after LVAD implantation via LT or median sternotomy (sternotomy). The patients who underwent HeartMate 3 implantation were retrospectively reviewed. The RV function was assessed before and 1 month and 1 year after LVAD implantation. The primary and secondary outcomes were all-cause mortality and a composite of death or readmission due to RV failure, respectively. Of the 195 patients, 55 (28%) underwent LT and 140 (72%) underwent sternotomy. There were no significant differences in the preoperative RV geometry or function. One month after the LVAD implantation, the LT group had a smaller RV end-diastolic dimension [42 (29-48) vs 47 (42-52) mm; P = 0.003] and RV end-diastolic area [25 (21-28) vs 29 (24-36) cm2; P < 0.001] and a greater RV fractional area change [30 (25-34)% vs 28 (23-31)%; P = 0.04] and peak systolic tissue velocity [8 (7-9) vs 7 (6-8) cm/s; P = 0.01]. Twenty-four patients died and 46 met the composite end point. Kaplan-Meier curve analysis did not reveal significant differences between LT and sternotomy in the 2-year survival (93% vs 83%; log-rank test, P = 0.28) and adverse event rate (76% vs 71%; log-rank test, P = 0.65). LT approach yielded a better-preserved RV function at 1 month; however, there were no significant differences in the 2-year survival and adverse event rates.

Right Ventricular Dysfunction Patterns among Patients with COVID-19 in the Intensive Care Unit: A Retrospective Cohort Analysis.

Rationale: Right ventricular (RV) dysfunction is common among patients hospitalized with coronavirus disease (COVID-19); however, its epidemiology may depend on the echocardiographic parameters used to define it. Objectives: To evaluate the prevalence of abnormalities in three common echocardiographic parameters of RV function among patients with COVID-19 admitted to the intensive care unit (ICU), as well as the effect of RV dilatation on differential parameter abnormality and the association of RV dysfunction with 60-day mortality. Methods: We conducted a retrospective cohort study of ICU patients with COVID-19 between March 4, 2020, and March 4, 2021, who received a transthoracic echocardiogram within 48 hours before to at most 7 days after ICU admission. RV dysfunction and dilatation, respectively, were defined by guideline thresholds for tricuspid annular plane systolic excursion (TAPSE), RV fractional area change, RV free wall longitudinal strain (RVFWS), and RV basal dimension or RV end-diastolic area. Association of RV dysfunction with 60-day mortality was assessed through logistic regression adjusting for age, prior history of congestive heart failure, invasive ventilation at the time of transthoracic echocardiogram, and Acute Physiology and Chronic Health Evaluation II score. Results: A total of 116 patients were included, of whom 69% had RV dysfunction by one or more parameters, and 36.3% of these had RV dilatation. The three most common patterns of RV dysfunction were the presence of three abnormalities, the combination of abnormal RVFWS and TAPSE, and isolated TAPSE abnormality. Patients with RV dilatation had worse RV fractional area change (24% vs. 36%; P = 0.001), worse RVFWS (16.3% vs. 19.1%; P = 0.005), higher RV systolic pressure (45 mm Hg vs. 31 mm Hg; P = 0.001) but similar TAPSE (13 mm vs. 13 mm; P = 0.30) compared with those with normal RV size. After multivariable adjustment, 60-day mortality was significantly associated with RV dysfunction (odds ratio, 2.91; 95% confidence interval, 1.01-9.44), as was the presence of at least two parameter abnormalities. Conclusions: ICU patients with COVID-19 had significant heterogeneity in RV function abnormalities present with different patterns associated with RV dilatation. RV dysfunction by any parameter was associated with increased mortality. Therefore, a multiparameter evaluation may be critical in recognizing RV dysfunction in COVID-19.

Morphological and functional types of tricuspid regurgitation: prognostic value in patients undergoing tricuspid annuloplasty during left-sided valvular surgery.

The nonuniform benefit of tricuspid annuloplasty may be explained by the proportionality of tricuspid regurgitation (TR) severity to right ventricular (RV) area. The purpose of this study was to delineate distinct morphological phenotypes of functional TR and investigate their prognostic implications in patients undergoing tricuspid annuloplasty during left-sided valvular surgery. The ratios of pre-procedural effective regurgitant orifice area (EROA) with right ventricular end-diastolic area (RVDA) were retrospectively assessed in 290 patients undergoing tricuspid annuloplasty. Based on optimal thresholds derived from penalized splines and maximally selected rank statistics, patients were stratified into proportionate (EROA/RVDA ratio ≤ 1.74) and disproportionate TR (EROA/RVDA ratio > 1.74). Overall, 59 (20%) and 231 (80%) patients had proportionate and disproportionate TR, respectively. Compared to those with proportionate TR, patients with disproportionate TR were older, had a higher prevalence of atrial fibrillation, lower pulmonary pressures, more impaired RV function, and larger tricuspid leaflet tenting area. Over a median follow-up of 4.1years, 79 adverse events (47 heart failure hospitalizations and 32 deaths) occurred. Patients with disproportionate TR had higher rates of adverse events than those with proportionate TR (32% vs 10%; P = 0.001) and were independently associated with poor outcomes on multivariate analysis. TR proportionality outperformed guideline-based classification of TR severity in outcome prediction and provided incremental prognostic value to both the EuroSCORE II and STS score (incremental χ2 = 6.757 and 9.094 respectively; both P < 0.05). Disproportionate TR is strongly associated with adverse prognosis and may aid patient selection and risk stratification for tricuspid annuloplasty with left-sided valvular surgery.

Echocardiographic Parameters for Risk Prediction in Borderline Right Ventricle: Review with Special Emphasis on Pulmonary Atresia with Intact Ventricular Septum and Critical Pulmonary Stenosis.

The aim of the present review is to highlight the strengths and limitations of echocardiographic parameters and scores employed to predict favorable outcome in complex congenital heart diseases (CHDs) with borderline right ventricle (RV), with a focus on pulmonary atresia with intact ventricular septum and critical pulmonary stenosis (PAIVS/CPS). A systematic search in the National Library of Medicine using Medical Subject Headings and free-text terms including echocardiography, CHD, and scores, was performed. The search was refined by adding keywords "PAIVS/CPS", Ebstein's anomaly, and unbalanced atrioventricular septal defect with left dominance. A total of 22 studies were selected for final analysis; 12 of them were focused on parameters to predict biventricular repair (BVR)/pulmonary blood flow augmentation in PAIVS/CPS. All of these studies presented numerical (the limited sample size) and methodological limitations (retrospective design, poor definition of inclusion/exclusion criteria, variability in the definition of outcomes, differences in adopted surgical and interventional strategies). There was heterogeneity in the echocardiographic parameters employed and cut-off values proposed, with difficultly in establishing which one should be recommended. Easy scores such as TV/MV (tricuspid/mitral valve) and RV/LV (right/left ventricle) ratios were proven to have a good prognostic accuracy; however, the data were very limited (only two studies with <40 subjects). In larger studies, RV end-diastolic area and a higher degree of tricuspid regurgitation were also proven as accurate predictors of successful BVR. These measures, however, may be either operator and/or load/pressure dependent. TV Z-scores have been proposed by several authors, but old and heterogenous nomograms sources have been employed, thus producing discordant results. In summary, we provide a review of the currently available echocardiographic parameters for risk prediction in CHDs with a diminutive RV that may serve as a guide for use in clinical practice.

Characterization of right-sided strain parameters in atrial and ventricular functional tricuspid regurgitation

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial functional tricuspid regurgitation (A-FTR), defined as TR due to prominent right atrial (RA) dilatation without significant right ventricular (RV) remodelling, has recently emerged as a distinct subtype of FTR, and can be distinguished from ventricular FTR (V-FTR), defined by significant RV remodelling leading to annular dilatation and leaflet tethering. However, so far no data has been reported on the values of RV and RA strain in these patients. Purpose To evaluate potential differences in right-sided strain parameters in patients diagnosed with severe atrial and ventricular FTR. Methods Patients with severe FTR, without a cardiac implantable electronic device, were categorized as V-FTR when in sinus rhythm and either having left-sided cardiac disease, pulmonary hypertension, or moderate/severe RV dysfunction. Patients, in sinus rhythm or atrial fibrillation, with no other cause of annular dilatation and impaired leaflet coaptation than RA dilatation were classified as A-FTR. Extensive echocardiographic assessment was performed, including 2D-speckle-tracking strain analysis. Results A total of 525 patients with severe FTR (mean age 66 ± 15 years, 42% male) were included, of which 401 patients (76%) were classified as V-FTR and 124 patients (24%) as A-FTR. Baseline clinical and echocardiographic characteristics are shown in Figure 1. Patients presented with mild RV dilatation (RV end-diastolic area 12.9 ± 4.0cm2/m2) and RV dysfunction (RV free wall longitudinal strain [FWLS] 18.3 ± 6.8%), and with moderate-to-severe RA dilatation (RA max volume 36.8 [26.9 – 52.2] ml/m2) and moderate-to-severe RA dysfunction (RA reservoir strain 17.0 [11.0 – 27.0] %). Corresponding to the phenotype, patients with A-FTR presented with significantly smaller RV size and better RV function (Figure 1). However, despite overall normal values of RV function by RV fractional area change, tricuspid annular plane systolic excursion (TAPSE) and RV FWLS, 27% of A-FTR patients showed reduced RV FWLS based on cut-off value of −20%. In addition, patients with A-FTR showed more dilated RA, as compared to patients with V-FTR, but with better RA function assessed by 2D-strain values (Figure 1). Notwithstanding, still 73% of the A-FTR-patients showed reduced RA strain values, when using the cut-off reported for normality of 34%. Conclusion Approximately 25% of patients diagnosed with severe FTR presented with A-FTR. These patients presented with significantly better right-sided strain parameters as compared to patients with V-FTR, despite more pronounced RA dilatation.

Automated measurements based on artificial intelligence software in pediatric echocardiography: a feasibility study

Abstract Funding Acknowledgements Type of funding sources: None. Background Transthoracic echocardiography is the first-line non-invasive investigation for assessing pediatric patients' cardiac anatomy, physiology, and hemodynamics, based on its accessibility and portability, but complete anatomic and hemodynamic assessment is time-consuming. The study aimed to determine the accuracy and reliability of a new automated artificial intelligence software initially developed for adults for analyzing the main echocardiographic parameters in pediatric patients. Materials and Methods The study was performed at the University Hospital of Bordeaux between August and September 2022 and included 45 patients who underwent a 2D transthoracic echocardiographic examination, mainly for murmur (n=8), post ASD closure evaluation(N=5), chest pain, or arrhythmia as we aimed to have a homogeneous group of patients with normal or near normal heart architecture. We compared AI automatic measurements with manual measurements performed by a senior and junior pediatric cardiologist. Pearson correlation and Bland and Altman analysis were used. As the AI software has been developed for adults, we decided to subclassify our patients into two subgroups: the first group (patients aged between 0–8 years) and the second group (patients over 8 years). The decision was made because pediatric anatomy differs from adults and to see if the dedicated artificial intelligence soft for adults has better reproducibility for pediatric patients older than 8 years. Results The median age was 8.9 years. Comparison between senior and junior pediatric cardiologists for all subgroups was significant (Pearson correlation &amp;gt;0,7 for most measurements performed). For younger patients (&amp;lt;8 years old), we found excellent correlations (Pearson correlation &amp;gt;0.8) for heart chambers measurements measured from A4CH and A2CH views (LV end-diastolic volume, LV end-systolic volume, RV end-diastolic area, and RV area) between AI software and both junior and senior pediatric cardiologist, but poor correlation for the measurements performed from parasternal long axis view (r=0.06 for STJ measurement). We achieved stronger correlations for the measurements evaluation of patients over 8 years old ( r&amp;gt;0.8 for aortic annulus, STJ, E, A, S waves, LV end-diastolic volume in A4CH, LV end-systolic volume in A4CH) for both junior and senior cardiologist in relation to AI measurements. Conclusion In this preliminary study, we found that automated artificial intelligence software provided promising results for measuring mainly volumes (LV end-diastolic volume, LV end-systolic volume) in A4CH and A2CH. The software requires improvements for automated measurements within the parasternal long-axis section to achieve better accuracy. Results obtained with the AI software for patients over 8 years old were significantly improved compared to those obtained for those under 8 years of age.

Abnormal left atrial compliance is associated with history of life-threatening arrhythmia in corrected tetralogy of Fallot

This study examined the left atrial (LA) function and compliance using two-dimensional (2D) strain analysis in adult patients with corrected tetralogy of Fallot (c-ToF), as well as relationships between LA function and patient characteristics, especially history of life-threatening arrhythmia (h-LTA). Fifty-one patients (34 males, age: 39 ± 15 years; h-LTA: n = 13) with c-ToF were included in this retrospective monocenter study. Besides a 2D standard echocardiography examination, 2D strain imaging was performed to assess left ventricular (LV) and LA functions including peak-positive LA strain (LAS – reservoir function) and LA compliance [defined as the ratio LAS/(E/Ea)]. Patients with h-LTA were older and exhibited a longer QRS duration. LV ejection fraction, LAS and LA compliance were significantly lower in the group of patients with h-LTA. Indexed LA and RA volumes, RV end-diastolic area and RV fractional area change were significantly higher in the h-LTA group. LA compliance was the best echocardiographic predictor for h-LTA (AUC: 0.839; P < 0.001). Moderate inverted correlations were found between LA compliance and age and either QRS duration. Among the echocardiographic parameters, LA compliance was moderately inversely correlated with RV end-diastolic area (r = −0.40, P = 0.01). We documented abnormal LAS and LA compliance values in adults after c-ToF. Further study is needed to determine how best to incorporate LA strain, particularly LA compliance into multi-parametric predictive models for LTA in c-ToF.