Right ventricular dysfunction affects survival after surgical left ventricular restoration

Objective

Several clinical and left ventricular parameters have been associated with prognosis after surgical left ventricular restoration in patients with ischemic heart failure. The aim of this study was to determine the prognostic value of right ventricular function.

Right ventricular longitudinal strain and right ventricular stroke work index in patients with severe heart failure: left ventricular assist device suitability for transplant candidates

Background

Right ventricular (RV) systolic function has a critical role in determining the clinical outcome and the success of using left ventricular assist devices in patients with refractory heart failure. RV deformation analysis by speckle tracking echocardiography (STE) has recently allowed the analysis of RV longitudinal function. Using cardiac catheterization as the reference standard, this study aimed to explore the correlation between RV longitudinal function by STE and RV stroke work index (RVSWI) among patients referred for cardiac transplantation.

Methods

Right heart catheterization and transthoracic echo-Doppler were simultaneously performed in 47 patients referred for cardiac transplant assessment due to refractory heart failure (ejection fraction 25.1 ± 4.5%). Thermodilution RV stroke volume and invasive pulmonary pressures were used to obtain RVSWI. RV longitudinal strain (RVLS) by STE was assessed averaging RV free-wall segments (free-wall RVLS). We also calculated. Tricuspid S' and tricuspid annular plane systolic excursion (TAPSE).

Results

No significant correlation was observed for TAPSE on tricuspid S' with RV stroke volume (r = 0.14 and r = 0.06, respectively). A close negative correlation between free-wall RVLS and RVSWI was found (r = −0.82; P < .0001). Furthermore, free-wall RVLS showed the highest diagnostic accuracy (area under the curve of 0.90) with good sensitivity and specificity of 95% and 91%, respectively, to predict depressed RVSWI using a cutoff value less than −11.8%.

Conclusions

Among patients referred for heart transplantation, TAPSE and tricuspid S' did not correlate with invasively obtained RVSWI. RV longitudinal deformation analysis by STE correlated with RVSWI, providing a better estimate of RV systolic performance.     

Prediction of right ventricular failure after left ventricular assist device implantation in patients with heart failure: a meta-analysis comparing echocardiographic parameters

 Open in a separate windowOBJECTIVESBetween 10% and 40% of patients who receive a left ventricular assistance device (LVAD) suffer from right ventricular failure (RVF) shortly after the device is implanted. Patients with post-LVAD RVF tend to have poor outcomes. Only a few predictive factors concerning the right ventricle (RV) have been investigated. Our goal was to search for non-invasive variables that correlate with RV function, focusing on echocardiographic parameters of the RV. METHODSWe selected 3 parameters: tricuspid annular plane systolic excursion, right ventricular fractional area change and right ventricular global longitudinal strain. We searched the literature and pooled relevant studies in a meta-analysis. Finally, we performed a statistical analysis to confirm whether each parameter was a reliable predictor of RVF after LVAD implantation.RESULTSWe retained 19 articles involving a total of 1561 patients. We found a pooled standardized mean deviation of −0.13 cm for the tricuspid annular plane systolic excursion, with the lower and upper tails of −0.21 and −0.04 cm, respectively. Concerning the right ventricular fractional area change, the averaged standardized mean deviation was equal to −2.61%, with the lower and upper extremities of −4.12% and −1.09%, respectively. Finally, regarding the global longitudinal strain, the standardized mean deviation was equal to −2.06% with an uncertainty value between −3.23% and −0.88%.CONCLUSIONSThe tricuspid annular plane systolic excursion could be a reliable parameter in RVF prediction. The right ventricular fractional area change and global longitudinal strain are likely to be stronger predictors of RVF after LVAD implantation. Prospective studies should be carried out to confirm this observation.     

Right Heart Echocardiography Parameters and Other Predictors to Evaluate Mechanical Cardiac Support Necessity During Lung Transplantation

BackgroundLung transplantation (LuTx) is a challenge when right heart function fails. Mechanical circulatory support (MCS) is then necessary.MethodsWe aimed to investigate whether preoperative transthoracic echocardiography (TTE) can predict MCS use and help to exclude the sickest patients. Between 2011 and 2018, 52 patients at our institution received LuTx and qualified for this study: 35 bilateral, 16 single, 1 lobar [1] and 1 retransplantation procedure. Of these, 22 were operated using MCS and 30 without MCS. The patients were aged between 18 and 65 years, and 23 were women. The indications were lung fibrosis for 18 patients, chronic obstructive lung disease for 16, cystic fibrosis for 15, primary pulmonary hypertension for 2 and bronchiectasis for 1. TTE was performed up to 30 days before treatment and 1 to 7 days after.ResultsPatients undergoing MCS versus patients not undergoing MCS: preoperative right ventricular systolic pressure 56.5 (30) vs 37.8 (11.5) mm Hg (P = .03); tricuspid regurgitation pressure gradient 48.7 (27) vs 30.2 (10.8) mm Hg (P = .015); tricuspid annular plane systolic excursion 17.8 (4.3) vs 19.9 (2.8) mm Hg (P = .04); pulmonary artery diameter 27.5 (5.2) vs 23.9 (4.1) mm (P = .004); age 41.9 (14.1) vs 54.3 (11.8) years (P = .001). Patients who were Dead versus patients who were alive pulmonary valve acceleration time of 82.8 (24.1) vs 104.9 (27.2) ms (hazard ratio [HR] = 0.959, 95% confidence interval [CI] = 0.923–0.996 per ms, P = .02) and pulmonary artery diameter of 28.9 (5.8) vs 24.4 (4.1) mm HR = 1.225, 95% CI = 1.028-1.460 per 1 mm, P = .016 were predictors of death.ConclusionsPreoperative TTE parameters: right ventricular systolic pressure, tricuspid regurgitation pressure gradient, tricuspid annular plane systolic excursion, and pulmonary artery diameter predicted MCS use during LuTx. Certain values of valve acceleration time and pulmonary artery diameter could help discern LuTx qualification.     

Efficacy of Retrograde Coronary Sinus Cardioplegia in Patients Undergoing Myocardial Revascularization: A Prospective Randomized Trial

The efficacy of retrograde coronary sinus cardioplegia (RCSC) administered through the right atrium compared with aortic root cardioplegia (ARC) has not been examined critically in patients undergoing coronary artery bypass grafting (CABG). Twenty patients having elective CABG were randomized prospectively to receive cold blood ARC (Group I, 10 patients) or cold blood RCSC (Group II, 10 patients). Patient demographics were similar in both groups. Ventricular function was assessed preoperatively by radionuclide ventriculography and post-operatively by simultaneous hemodynamic and radionuclide ventriculographic studies with volume loading. There was no change in ejection fraction (EF) (preoperative versus postoperative value) in Group I (50 ± 6% versus 53 ± 6%) but in group II, at similar peak systolic pressure and similar left ventricular end-diastolic volume index (LVEDVI), LVEF improved significantly (49 ± 6% versus 60 ± 12%, p < 0.05). Postoperative ventricular function (stroke work index versus EDVI) for the left ventricle and right ventricle were similar in both groups. Evaluation of postoperative LV systolic function (end-systolic blood pressure versus end-systolic volume index) and diastolic function (pulmonary capillary wedge pressure versus EDVI) were also similar in both groups.Retrograde coronary sinus cardioplegia is as effective as ARC for intraoperative myocardial protection, and provides excellent postoperative function in patients undergoing elective CABG.     

The effect of pericardial incision on right ventricular systolic function: a prospective observational study

Background

Echocardiographic longitudinal markers of right ventricular (RV) systolic function are commonly depressed after coronary artery bypass graft surgery (CABG) despite an uncomplicated course and good clinical recovery. The exact timing and cause of these changes is unknown. The aim of this observational study was to monitor echocardiographic markers of RV systolic function intraoperatively during CABG. We used angle-independent speckle tracking to measure the primary endpoints of tricuspid annular plane systolic excursion (TAPSE) and tricuspid annular systolic velocity (S′) before and after pericardiotomy.

Methods

Twenty-four patients undergoing elective on-pump CABG were enrolled in the study. Speckle tracking-derived TAPSE, S’, free wall systolic strain, RV outflow tract strain, colour tissue Doppler-derived isovolumic acceleration (IVA) and two-dimensional RV dimensions and fractional area change (FAC) were measured at three intraoperative time points: 1) after sternotomy immediately prior to pericardiotomy; 2) after pericardiotomy and placement of pericardial retraction sutures; and 3) following cardiopulmonary bypass after chest closure.

Results

Adequate image quality to perform speckle tracking measurements was obtained in twenty-one patients. We found that there were no significant changes to echocardiographic parameters of RV systolic function between pre- and post-pericardiotomy. The mean (SD) of the primary endpoints were: TAPSE [28.1 (5.1) mm vs 27.7 (7.4) mm, respectively; mean difference, ?0.4 mm; 97.5% confidence interval (CI), ?4.0 to 3.1; P = 0.76] and S′ [10.4 (2.1) cm·sec^?1 vs 10.8 (1.9) cm·sec^?1, respectively; mean difference, 0.4 cm·sec^?1; 97.5% CI, ?0.9 to 1.7; P = 0.48]. Significant reductions in the parameters of RV systolic function were found only after cardiopulmonary bypass and chest closure.

Conclusion

Pericardial opening and suspension had no significant effect on the indices of RV systolic function derived from speckle tracking or colour tissue Doppler.

     

Dominance of free wall radial motion in global right ventricular function of heart transplant recipients

Assessment of right ventricular (RV) function using conventional echocardiography might be inadequate as the radial motion of the RV free wall is often neglected. Our aim was to quantify the longitudinal and the radial components of RV function using three‐dimensional (3D) echocardiography in heart transplant (HTX) recipients. Fifty‐one HTX patients in stable cardiovascular condition without history of relevant rejection episode or chronic allograft vasculopathy and 30 healthy volunteers were enrolled. RV end‐diastolic (EDV) volume and total ejection fraction (TEF) were measured by 3D echocardiography. Furthermore, we quantified longitudinal (LEF) and radial ejection fraction (REF) by decomposing the motion of the RV using the ReVISION method. RV EDV did not differ between groups (HTX vs control; 96 ± 27 vs 97 ± 2 mL). In HTX patients, TEF was lower, however, tricuspid annular plane systolic excursion (TAPSE) decreased to a greater extent (TEF: 47 ± 7 vs 54 ± 4% [?13%], TAPSE: 11 ± 5 vs 21 ± 4 mm [?48%], P < .0001). In HTX patients, REF/TEF ratio was significantly higher compared to LEF/TEF (REF/TEF vs LEF/TEF: 0.58 ± 0.10 vs 0.27 ± 0.08, P < .0001), while in controls the REF/TEF and LEF/TEF ratio was similar (0.45 ± 0.07 vs 0.47 ± 0.07). Current results confirm the superiority of radial motion in determining RV function in HTX patients. Parameters incorporating the radial motion are recommended to assess RV function in HTX recipients.     

Effect of variable annular reduction on functional tricuspid regurgitation and right ventricular dynamics in an ovine model of tachycardia-induced cardiomyopathy

ObjectiveTo investigate the effect of variable tricuspid annular reduction (TAR) on functional tricuspid regurgitation (FTR) and right ventricular (RV) dynamics in ovine tachycardia-induced cardiomyopathy.MethodsNine adult sheep underwent implantation of a pacemaker with an epicardial lead and were paced at 200 to 240 bpm until the development of biventricular dysfunction and functional TR was noted. During reoperation on cardiopulmonary bypass, 6 sonomicrometry crystals were placed around the tricuspid annulus (TA) and 14 were placed on the RV epicardium. Annuloplasty suture was placed around the TA and externalized to an epicardial tourniquet. After weaning from cardiopulmonary bypass, echocardiographic, hemodynamic, and sonomicrometry data were acquired at baseline and during 5 progressive TARs achieved with suture cinching. TA area and RV free wall strains and function were calculated from crystal coordinates.ResultsAfter pacing, changes in left ventricular (LV) ejection fraction and RV fractional area decreased significantly. Mean TA diameter increased from 25.1 ± 2.9 mm to 31.5 ± 3.3 mm (P = .005), and median TR (range, 0-3+) increased from 0 (0) to 3 (2) (P = .004). Progressive suture cinching reduced the TA area by 18 ± 6%, 38 ± 11%, 56 ± 10%, 67 ± 9%, and 76 ± 8%. Only aggressive annular reductions (67% and 76%) decreased TR significantly, but these were associated with deterioration of RV function and strain. A moderate annular reduction of 56% led to a substantial reduction of TR with little deleterious effect on regional RV function.ConclusionsA moderate TAR of approximately 50% may be most advantageous for correction of functional TR and simultaneous maintenance of regional RV performance. Additional subvalvular interventions may be needed to achieve complete valvular competence.     

Echocardiographic Changes in the Context of Metal-on-Metal Versus Nonmetal-on-Metal Total Hip Arthroplasty

BackgroundThe purpose of this study is to determine if there is a difference in echocardiographic results between patients with metal-on-metal (MoM) vs non-MoM total hip arthroplasty (THA) and to determine if a correlation exists between serum metal levels and echocardiographic outcomes.MethodsSeventy-five patients with the same modular THA enrolled in this prospective cohort study, and 49 had MoM bearings. All patients had serum cobalt, chromium, and titanium levels drawn at 2 study visits with a transthoracic echocardiogram at the second visit. Serum metal concentrations and echocardiographic parameters were compared with 2-way t-tests. Multiple linear regression analyses identified any significant predictors of echocardiographic outcomes.ResultsMean serum cobalt and chromium levels were significantly greater in the MoM group at both time-points (P < .001 and P < .05, respectively). Titanium levels were similar between groups (P > .05). MoM patients had significantly lower global longitudinal strain compared with the non-MoM group (18.4% vs 20.2%; P = .026). Serum cobalt concentration was found to be an independent predictor of tricuspid annular plane systolic excursion (P = .02).ConclusionMoM THA bearings are associated with increased serum cobalt and chromium levels. Patients with MoM THAs had decreased global longitudinal strain, a measure of left ventricular function, but both groups remained within normal range. The clinical impact of the positive association between serum cobalt concentration and tricuspid annular plane systolic excursion, a marker of right ventricular function, deserves further study. These findings can reassure physicians and patients that metal-induced cardiomyopathy is not typical in the setting of MoM THA.Level of EvidenceLevel II, Prospective Cohort Study.     

Validation of mitral regurgitation reversibility in patients with HeartMate 3 LVAD implantation

The resolution of functional mitral valve regurgitation (MR) in patients awaiting left ventricular assist device (LVAD) implantation is discussed controversially. The present study analyzed MR and echocardiographic parameters of the third-generation LVAD HeartMate 3 (HM3) over 3 years. Of 135 LVAD patients (with severe MR, n = 33; with none, mild, or moderate MR, n = 102), data of transthoracic echocardiography were included preoperatively to LVAD implantation, up to 1 month postoperatively, and at 1, 2, and 3 years after LVAD implantation. Demographic data and clinical characteristics were collected. Severe MR was reduced immediately after LVAD implantation in all patients. The echocardiographic parameters left ventricular end-diastolic diameter (P < .001), right ventricular end-diastolic diameter (P < .001), tricuspid annular plane systolic excursion (P < .001), and estimated pulmonary artery pressure (P < .001) decreased after HM3 implantation independently from the grade of MR prior to implantation and remained low during the 2 years follow-up period. Following LVAD implantation, right heart failure, ventricular arrhythmias, ischemic stroke as well as pump thrombosis and bleeding events were comparable between the groups. The incidences of death and cardiac death did not differ between the patient groups. Furthermore, the Kaplan-Meier analysis showed that survival was comparable between the groups (P = .073). HM3 implantation decreases preoperative severe MR immediately after LVAD implantation. This effect is long-lasting in most patients and reinforces the LVAD implantation without MR surgery. The complication rates and survival were comparable between patients with and without severe MR.     

Quantification of right ventricular extracellular volume in pulmonary hypertension using cardiac magnetic resonance imaging

PurposeThe purpose of this prospective study was to assess the value of biventricular extracellular volume (ECV) in pre-capillary pulmonary hypertension (PH) obtained using cardiac magnetic resonance imaging (CMR) and to correlate ECV with markers of prognosis such as strain echocardiography and blood biomarkers of fibrosis.Materials and methodsTwelve patients with PH (6 men, 6 women; mean age = 50 ± 16 [SD] years; age range: 22–73 years) underwent the same day: (i), transthoracic echocardiography including measurement of right ventricular (RV) fractional shortening (RVfs), tricuspid annular plane systolic excursion (TAPSE), maximal tricuspid annular velocity, RV global and segmental deformation; (ii), right heart catheterization measuring pulmonary arterial pressures (in mmHg) and cardiac output (in L/min); (iii), CMR at 1.5-T measuring RV volumes and ejection fraction; (iv), native and 15 min post-contrast T1 mapping using modified look-locker inversion-recovery sequence; and (v), serum quantification of two biomarkers of collagen turnover and hematocrit. Non-parametric Mann-Whitney tests were used to search for differences between categorical variables. Spearman correlation test was used for search for correlation between quantitative values.ResultsGlobal RV ECV was 34% ± 4.2 (SD) for our entire population. A significant correlation was found between RV ECV and RVfs (r = 0.6; P = 0.026), S wave velocity (r = 0.7; P = 0.009), TAPSE (r = 0.6; P = 0.040) and RV systolic ejection fraction on CMR (r = 0.6; P = 0.04). There were no correlations between the ECV values in the lateral wall of the RV and in the septum (r = 0.4; P = 0.206). A significant correlation was found between septal ECV and 2D septal strain (r = 0.7; P = 0.013).ConclusionECV in PH as obtained using CMR appears to correlate with known echocardiographic prognostic markers and more specifically with the markers, which assess RV systolic function.     

Impact of Residual Mitral Regurgitation on Right Ventricular Systolic Function After Left Ventricular Assist Device Implantation

Significant mitral regurgitation (MR) is thought to decrease after left ventricular assist device (LVAD) implantation, and therefore repair of mitral valve is not indicated in current practice. However, residual moderate and severe MR leads to pulmonary artery pressure increase, thereby resulting in right ventricular (RV) dysfunction during follow‐up. We examined the impact of residual MR on systolic function of the right ventricle by echocardiography after LVAD implantation. This study included 90 patients (mean age: 51.7 ± 10.9 years, 14.4% female) who underwent LVAD implantation (HeartMate II = 21, HeartWare = 69) in a single center between December 2010 and June 2014. Echocardiograms obtained at 3–6 months and over after implantation were analyzed retrospectively. RV systolic function was graded as normal, mild, moderate, and severely depressed. MR (≥moderate) was observed in 43 and 44% of patients at early and late period, respectively. Systolic function of the RV was severely depressed in 16 and 9% of all patients. Initial analysis (mean duration of support 174.3 ± 42.5 days) showed a statistically significant correlation between less MR and improved systolic function of RV (P = 0.01). Secondary echocardiographic analysis (following a mean duration of support of 435.1 ± 203 days) was also statistically significant for MR degree and RV systolic dysfunction (P = 0.008). Residual MR after LVAD implantation may cause deterioration of RV systolic function and cause right‐sided heart failure symptoms. Repair of severe MR, in selected patients such as those with severe pulmonary hypertension and depressed RV, may be considered to improve the patient's clinical course during pump support.     

Echocardiographic assessment of right heart function in heart transplant recipients and the relation to exercise hemodynamics

This study aimed to characterize right heart function in heart transplantation (HTx) patients using advanced echocardiographic assessment and simultaneous right heart catheterization (RHC). Comprehensive two‐dimensional (2D) and three‐dimensional (3D) echocardiographic assessment of right heart function was performed in 105 subjects (64 stable HTx patients and 41 healthy controls). RHC was performed at rest and during semi‐supine maximal exercise test. Compared with controls, in conclusion, HTx patients had impaired right ventricle (RV) systolic function in terms of decreased RV‐free wall (FW) global longitudinal strain (GLS) (?20 ± 5% vs. ?28 ± 5%, P < 0.0001) and 3D‐ejection fraction (EF) (50 ± 8% vs. 60 ± 6%, P < 0.0001). In HTx patients, echocardiographic RV systolic function was significantly correlated with NYHA‐class (3D‐RVEF: r = ?0.62, P < 0.0001; RV‐FW‐GLS: r = ?0.41, P = 0.0009) and cardiac allograft vasculopathy (3D‐RVEF: r = ?0.42, P = 0.0005; RV‐FW‐GLS: r = ?0.25, P = 0.0444). RHC demonstrated a good correlation between invasively assessed resting RV‐stroke volume index and exercise capacity (r = 0.58, P < 0.0001) and NYHA‐class (r = ?0.41, P = 0.0009). RV systolic function is reduced in HTx patients compared with controls. 3D RVEF and 2D longitudinal deformation analyses are associated with clinical performance in stable HTx patients and seem suitable in noninvasive routine right heart function evaluation after HTx. Invasively assessed RV systolic reserve was strongly associated with exercise capacity.     

Effects of respiration on the velocity of tricuspid regurgitation and estimation of systolic pulmonary artery pressure in patients with right ventricle systolic dysfunction

Objective. We investigated the effects of quiet respiration on the peak velocity of tricuspid regurgitation (TR) and estimation of systolic pulmonary artery pressure (SPAP) in patients with right ventricle (RV) systolic dysfunction using Doppler echocardiography. Methods. Continuous-wave Doppler spectra of TR were recorded in 32 patients with and 28 controls without RV systolic dysfunction. Electrocardiography and respiratory tracing were recorded simultaneously. Expiratory and inspiratory peak velocities of TR were acquired and averaged for five consecutive respiratory cycles. The SPAP during expiration and inspiration was calculated. Results. The velocity of TR and SPAP was not significantly different between expiration and inspiration in controls (2.77 ± 0.23 and 2.82 ± 0.26 m/s, P = 0.776; 35.94 ± 4.96 and 36.18 ± 5.12 mmHg, P = 0.747), whereas the velocity of TR and SPAP decreased significantly from expiration to inspiration in patients with RV systolic dysfunction (3.27 ± 0.35 and 2.59 ± 0.22 m/s, P < 0.001; 53.72 ± 7.39, 38.45 ± 5.63 mmHg, P < 0.001). Conclusions. Quiet respiration has significant effects on the velocity of TR in patients with RV systolic dysfunction. This factor should be taken into account when using Doppler echocardiography to estimate these patients’ SPAP, and the measurements should be performed in patients at the end of expiration.     

Identifying the optimal regional predictor of right ventricular global function: a high-resolution three-dimensional cardiac magnetic resonance study

Right ventricular (RV) function has prognostic value in acute, chronic and peri-operative disease, although the complex RV contractile pattern makes rapid assessment difficult. Several two-dimensional (2D) regional measures estimate RV function, however the optimal measure is not known. High-resolution three-dimensional (3D) cardiac magnetic resonance cine imaging was acquired in 300 healthy volunteers and a computational model of RV motion created. Points where regional function was significantly associated with global function were identified and a 2D, optimised single-point marker (SPM-O) of global function developed. This marker was prospectively compared with tricuspid annular plane systolic excursion (TAPSE), septum-freewall displacement (SFD) and their fractional change (TAPSE-F, SFD-F) in a test cohort of 300 patients in the prediction of RV ejection fraction. RV ejection fraction was significantly associated with systolic function in a contiguous 7.3 cm² patch of the basal RV freewall combining transverse (38%), longitudinal (35%) and circumferential (27%) contraction and coinciding with the four-chamber view. In the test cohort, all single-point surrogates correlated with RV ejection fraction (p < 0.010), but correlation (R) was higher for SPM-O (R = 0.44, p < 0.001) than TAPSE (R = 0.24, p < 0.001) and SFD (R = 0.22, p < 0.001), and non-significantly higher than TAPSE-F (R = 0.40, p < 0.001) and SFD-F (R = 0.43, p < 0.001). SPM-O explained more of the observed variance in RV ejection fraction (19%) and predicted it more accurately than any other 2D marker (median error 2.8 ml vs 3.6 ml, p < 0.001). We conclude that systolic motion of the basal RV freewall predicts global function more accurately than other 2D estimators. However, no markers summarise 3D contractile patterns, limiting their predictive accuracy.     

Right Ventricular Systolic Function Is Not Depressed In Morbid Obesity

Background: The increased pulmonary blood volume associated with the increased total blood volume in morbidly obese patients increases pulmonary artery pressure and pulmonary vascular resistance, resulting in increased right ventricular (RV) afterload. Thus, the morbidly obese may develop RV dysfunction owing to the increased RV afterload. We examined this possibility by assessing RV contractile function in morbidly obese patients, using RV end-systolic pressure-volume relationship and RV systolic time intervals. Methods: Included were 25 morbidly obese patients undergoing gastric bypass surgery under general anesthesia. Pulmonary artery pressure and RV end-systolic volume were measured with a thermodilution pulmonary artery catheter. Pulmonary arterial dicrotic notch pressure was used as an estimate of RV end-systolic pressure. Two data points were used to define RV end-systolic pressure-volume relationship. RV systolic time intervals were determined by simultaneous graphic display of the electrocardiograph, phonocardiograph, and pulmonary artery pressure curve, and were expressed as a pre-ejection period/RV ejection time ratio. Results: The mean slope of right ventricular end-systolic pressure-volume relationship line was 0.54 ± 0.13 and mean pulmonary vascular resistance 274 ± 80 dyne·sec·cm⁻⁵·m⁻². The mean pre-ejection period/RV ejection time ratio was 0.4 ± 0.11. There was an inverse correlation between the pre-ejection/RV ejection time ratio and the slope of RV end-systolic pressure-volume relationship line (R²=0.658, P<0.0001). Conclusion: Our data indicate that RV function is not depressed in morbid obesity despite increased RV afterload.     

The Prevalence and Course of Pulmonary Hypertension and Right Ventricular Dysfunction in Patients Undergoing Orthotopic Heart Transplantation

BackgroundPulmonary hypertension (PHT) and right ventricular (RV) dysfunction are among the commonly observed and potentially serious complications following heart transplantation. RV dysfunction is reported to occur in as much as half of these patients. In this study, the authors sought to examine the prevalence and the course of these prognostically important complications.MethodsThe records of 30 patients who had undergone orthotopic heart transplantation at our center were examined. Demographic and clinical variables were noted; RV dysfunction, pulmonary artery pressure on Doppler echocardiographic examination, and catheter findings were recorded.ResultsThe mean age of the study population was 31.3 years. On preoperative assessment, PHT was present in 21 (70%) patients. The average value of systolic pulmonary artery pressure was 44.5 ± 5.9 mm Hg. The mean value of pulmonary vascular resistance was 3.3 ± 1.8 hybrid reference unit (HRU). RV dysfunction was detected on postoperative assessment in 17 (56.7%) patients. The mean ischemia time was 216 ± 77 minutes; in 3 cases it exceeded 5 hours but in none of the cases did it reach 6 hours. Rejection was detected in 14 (46.7%) patients. Most of the patients received inotropic agents in the early postoperative period. When compared with preoperative values, on follow up at the end of the first year, a significant decrease in pulmonary artery pressure was observed (47.4 ± 4.8 vs 38.5 ± 7.5 mm Hg; P = .03), and the ratio of patients experiencing RV dysfunction decreased to 16.6% (n = 5).ConclusionThe findings of this study indicate that RV dysfunction and PHT are common complications following heart transplantation and improve with appropriate management over time with monitoring.     

Determination of right ventricular function by transesophageal echocardiography: impact of proximal right coronary artery stenosis

STUDY OBJECTIVE: To investigate whether transesophageal echocardiography (TEE) can provide accurate information on right ventricular (RV) function in patients with right coronary artery (RCA) stenosis, given that a decrease in blood supply from the RCA may invalidate the use of single 2-D echocardiography imaging plane as a guide to RV function. DESIGN: Prospective, nonblinded study. SETTING: University hospital. PATIENTS: 30 adult patients undergoing elective cardiac or vascular procedures. INTERVENTIONS: Patients were classified into two groups according to the presence or absence of the proximal RCA (segment 1 or 2) stenosis. Group A patients had no obstructive lesions in the proximal RCA (n = 15). Group B patients had 75% or greater obstructive lesions in the proximal RCA (n = 15). MEASUREMENTS AND MAIN RESULTS: After induction of anesthesia, RV function was evaluated by both fast-response thermodilution pulmonary artery catheter and TEE. Transesophageal echocardiography-derived RV fractional area change (FAC) and tricuspid annular plane systolic excursion ratio (TAPSE ratio) were compared with thermodilution-derived RV ejection fraction (EF) using linear regression analysis. Transesophageal echocardiography-derived RV end-diastolic area (EDA) was compared with thermodilution-derived end-diastolic volume (EDV). Both methods showed a good correlation in RV, EDV, and EF in Group A, but no correlations in Group B. CONCLUSIONS: Transesophageal echocardiography does not provide reliable information on RVEF and EDV when proximal RCA stenosis is present.     

Left Ventricular Assist Device Implantation in Patients With Optimal and Borderline Echocardiographic Assessment of Right Ventricle Function

Background

Left ventricular assist devices (LVADs) are used for treatment of end-stage heart failure. Outcomes are dependent on right ventricle (RV) function. Prediction of RV function after LVAD implantation is crucial for device selection and patient outcome.The aim of our study was to compare early LVAD course in patients with optimal and borderline echocardiographic parameters of RV function.

Influence of functional tricuspid regurgitation on right ventricular function

Background. Although right ventricular (RV) function has been extensively studied during the past decade, few reports have described the influence of functional tricuspid regurgitation (TR) on RV function.

Methods. One hundred forty-two patients with left-side valvular heart disease associated with TR were enrolled in the study and divided into three groups according to tricuspid annular diameter: group 1 (n = 66), tricuspid annular diameter less than 40 mm; group 2 (n = 58), tricuspid annular diameter of 40 to 50 mm; and group 3 (n = 18), tricuspid annular diameter greater than or equal to 50 mm. In groups 2 and 3, the right heart parameters had deteriorated to the point that TR repair was necessary. The mean follow-up period was 102 months after the operation.

Results. In each of the three groups, as pulmonary arteriolar resistance index increased, RV forward stroke work index increased in a linear fashion. The slope of the linear regression line was progressively less in group 1, 2, and 3 preoperatively. Postoperatively, this line moved in a parallel manner in group 1 and became steeper in group 2, consequently becoming similar in both groups. However, in group 3, although the slope became steeper in spite of a remarkable decrease of TR, it remained less when compared with groups 1 and 2. In addition, the right heart parameters also improved, but still remained worse in group 3 than group 2; 7 patients undergoing a flexible annuloplasty have shown gradual aggravations in TR and late postoperative clinical manifestations.

Conclusions. Functional TR with severely dilated annulus may produce an irreversible deterioration of RV function. The preoperative relationship between pulmonary arteriolar resistance index and RV forward stroke work index, that is, RV systolic function to pressure afterload, might predict a postoperative fate of the right heart function.