Impact of hypoplastic left heart syndrome anatomic subtype on mortality, ventricular function, and atrioventricular valve function in the current era.

Two-dimensional echocardiographic assessment of right ventricular function as a predictor of outcome in hypoplastic left heart syndrome

Counterpoint: Should Systemic Lytic Therapy Be Used for Submassive Pulmonary Embolism? No

Right ventricular (RV) function is difficult to be measured but plays a role in morbility and mortality of patients with cardiopulmonary diseases, so many echocardiographic parameters have been developed from M-mode, B-mode and Doppler tissue imaging (DTI) evaluation. Right ventricular presystolic peak velocity (RVPrP) measured with DTI of the tricuspidal annulus and its changes in RV dysfunction have never been assessed in a patient's cohort of stable patients with cardiovascular risk factors. RVPrP velocity could have a role in RV function evaluation; this study addresses such issue. Four hundred thirty-six consecutive patients were submitted to a complete echocardiographic examination with the contemporary evaluation of the following RV function indexes: Tricuspid Annulus Plane Systolic Excurtion (TAPSE), RV Systolic Peak (RVSyP) and RVPrP. Pulmonary artery systolic pressure (PASP), left ventricular and RV diastolic function were also evaluated. According to TAPSE and RVSyP taken alone or in combination, 113 patients had RV dysfunction, while 323 patients had normal RV function. RVPrP was reduced in patient's group with RV dysfunction with respect to patient's group with preserved RV function (16.48±7.3 cm/s vs. 23.98±8.4 cm/s, respectively, P<0.001). RVPrP was related with RVSyP (P<0.001) and with TAPSE (P=0.002). TAPSE and RVSyP revealed a poor concordance to define RV dysfunction. PASP was higher in patient's group with reduced RV function (P=0.033). The study showed RVPrP able to detect stable patients with RV dysfunction.

(1) Background: In propionic acidemia (PA), myocardial involvement often leads to progressive cardiac dysfunction of the left ventricle (LV). Cardiomyopathy (CM) is an important contributor to mortality. Although known to be of prognostic value in CM, there are no published data on right ventricular (RV) function in PA patients. (2) Methods: In this cross-sectional single-center study, systolic and diastolic RV function of PA patients was assessed by echocardiography, including frequency, onset, and combinations of echocardiographic parameters, as well as correlations to LV size and function. (3) Results: N = 18 patients were enrolled. Tricuspid annulus S’ was abnormal in 16.7%, RV-longitudinal strain in 11.1%, tricuspid annular plane systolic excursion (TAPSE) in 11.1%, Tricuspid valve (TV) E/e’ in 33.3%, and TV E/A in 16.7%. The most prevalent combinations of pathological parameters were TV E/A + TV E/e’ and TAPSE + TV S’. With age, the probability of developing abnormal RV function increases according to age-dependent normative data. There is a significant correlation between TAPSE and mitral annular plane systolic excursion (MAPSE), and RV/LV-longitudinal strain (p ≤ 0.05). N = 5 individuals died 1.94 years (mean) after cardiac evaluation for this study, and all had abnormal RV functional parameters. (4) Conclusions: Signs of diastolic RV dysfunction can be found in up to one third of individuals, and systolic RV dysfunction in 16.7% of individuals in our cohort. RV function is impaired in PA patients with a poor outcome. RV functional parameters should be used to complement clinical and left ventricular echocardiographic findings.

ObjectiveTo investigate the relationship between central venous pressure (CVP) and acute right ventricular (RV) dysfunction in critically ill patients on mechanical ventilation.MethodsThis retrospective study enrolled mechanically ventilated critically ill who underwent transthoracic echocardiographic examination and CVP monitoring. Echocardiographic indices including tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and tricuspid lateral annular systolic velocity wave (S’) were collected to assess RV function. Patients were then classified into three groups based on their RV function and presence of systemic venous congestion as assessed by inferior vena cava diameter (IVCD) and hepatic vein (HV) Doppler: normal RV function (TAPSE ≥ 17 mm, FAC ≥ 35% and S’ ≥9.5 cm/sec), isolated RV dysfunction (TAPSE < 17 mm or FAC < 35% or S’ <9.5 cm/sec with IVCD ≤ 20 mm or HV S ≥ D), and RV dysfunction with congestion (TAPSE < 17 mm or FAC < 35% or S’ <9.5 cm/sec with IVCD > 20 mm and HV S < D).ResultsA total of 518 patients were enrolled in the study, of whom 301 were categorized in normal RV function group, 164 in isolated RV dysfunction group and 53 in RV dysfunction with congestion group. Receiver operating characteristic analysis revealed a good discriminative ability of CVP for identifying patients with RV dysfunction and congestion(AUC 0.839; 95% CI: 0.795–0.883; p < 0.001). The optimal CVP cutoff was 10 mm Hg, with sensitivity of 79.2%, specificity of 69.4%, negative predictive value of 96.7%, and positive predictive value of 22.8%. A large gray zone existed between 9 mm Hg and 12 mm Hg, encompassing 95 patients (18.3%). For identifying all patients with RV dysfunction, CVP demonstrated a lower discriminative ability (AUC 0.616; 95% CI: 0.567–0.665; p < 0.001). Additionally, the gray zone was even larger, ranging from 5 mm Hg to 12 mm Hg, and included 349 patients (67.4%).ConclusionsCVP may be a helpful indicator of acute RV dysfunction patients with systemic venous congestion in mechanically ventilated critically ill, but its accuracy is limited. A CVP less than10 mm Hg can almost rule out RV dysfunction with congestion. In contrast, CVP should not be used to identify general RV dysfunction.

Tricuspid regurgitation (TR) is a highly prevalent valvular heart disease that has been long overlooked, but lately its independent association with adverse cardiovascular outcomes was recognized. The time point to intervene and repair the tricuspid valve is defined by the right ventricular (RV) dilation and dysfunction that comes up at a later stage. While guidelines favor tricuspid valve repair before severe RV dysfunction ensues, the definition of RV dysfunction in a universal manner remains vague. As a result, the candidates for transcatheter or surgical TR procedures are often referred late, when advanced RV dysfunction is established, and any derived procedural survival benefit is attenuated. Thus, it is of paramount importance to establish a universal means of RV function assessment in patients with TR. Conventional echocardiographic indices of RV function routinely applied have fundamental flaws that limit the precise characterization of RV performance. More recently, novel echocardiographic indices such as strain via speckle-tracking have emerged, demonstrating promising results in the identification of early RV damage. Additionally, evidence of the role of alternative imaging modalities such as cardiac computed tomography and cardiac magnetic resonance, for RV functional assessment in TR, has recently arisen. This review provides a systematic appraisal of traditional and novel multimodality indices of RV function in severe TR and aims to refine RV function assessment, designate future directions, and ultimately, to improve the outcome of patients suffering from severe TR.

Background: Assessment of the right chamber function has not given much importance; this could be due to complex structure, asymmetric shape, and difficulty in visualization, and resulted in poor understanding of the impact of the right ventricular (RV) function on prognosis. Echocardiography commonly used and most readily available investigation modality for the assessment of the right ventricular function. AIMS AND OBJECTIVES: The aim of this study was to evaluate the relation between RV function and left ventricle (LV) dysfunction and Killip class in acute myocardial infarction (AMI) exclusive of RV infarction. MATERIAL AND METHODS: A total of 21 consecutive patients admitted to the coronary care unit with AMI were included and echocardiography was performed within 24 h of admission to assess RV and LV functions. RV function was quantified with a tricuspid annular plane systolic excursion (TAPSE), RV fractional area change (RVFAC), RV longitudinal strain, RV myocardial performance index (RVMPI), and compared with the LV ejection fraction and Killip class. Results: Statistical analysis revealed that the majority of patients were male (90.5%) and only 9.5% of patients were female with a mean age of 50.9 years. Anterior wall MI was more common (58%) than inferior wall MI (42%). The study findings revealed that the RV longitudinal strain had a significant negative correlation (r2 = 0.803, P = 0.001) with Killip class and LV ejection fraction, whereas TAPSE, RVMPI, and RVFAC were poorly correlated with RV dysfunction. Conclusion: From the study findings, we concluded that echocardiographic assessment of RV functions demonstrated that larger infarcts correlated with RV dysfunction. RV involvement was more pronounced in anterior MI than inferior MI. Hence, the earliest recognition of RV dysfunction is warranted. Keywords: Acute myocardial infarction, echocardiograph, right ventricular function.

Decreased right ventricular function after coronary artery bypass grafting and its relation to exercise capacity: A tricuspid annular motion–based study

Right Ventricular Dysfunction in Right Coronary Artery Infarction: A Primary PCI Registry Analysis

AimsParadoxical low‐flow, low‐gradient aortic stenosis (pLFLG AS) may represent a diagnostic challenge, and its pathophysiology is complex. While left ventricular (LV) systolic function is preserved, right ventricular dysfunction (RVD) and consecutive LV underfilling may contribute to low‐flow and reduced stroke volume index, and to adverse outcomes following transcatheter aortic valve implantation (TAVI). The aim of this study was to evaluate the potential role of RVD in pLFLG AS, and to assess the impact of pre‐procedural RVD on clinical outcomes after TAVI in patients with pLFLG AS.Methods and resultsOut of 2739 native AS patients, who received TAVI at the University of Cologne Heart Center between March 2013 and June 2021, 114 patients displayed pLFLG AS and were included in this study. Right ventricular (RV) function was assessed by transthoracic echocardiography, and a fractional area change (FAC) ≤35% and/or a tricuspid annular plane systolic excursion (TAPSE) <18 mm determined RVD. In addition, the TAPSE/systolic pulmonary artery pressure ratio (TAPSE/sPAP) was monitored as a measure of RV–pulmonary arterial (PA) coupling. An impaired FAC and TAPSE was present in 21.9% and 45.6% of patients, respectively, identifying RVD in 50.0%. RVD (p = 0.016), reduced FAC (p = 0.049), reduced TAPSE (p = 0.035) and impaired RV–PA coupling (TAPSE/sPAP ratio <0.31 mm/mmHg; p = 0.009) were associated with significantly higher all‐cause mortality compared to patients with normal RV function. After adjustment for sex, age, body mass index, EuroSCORE II, previous myocardial infarction and mitral regurgitation, independent predictors for all‐cause mortality were FAC, sPAP, TAPSE/sPAP ratio, right atrial area, RV diameter and tricuspid regurgitation.ConclusionsAdverse RV remodelling, RVD and impaired RV–PA coupling provide an explanation for low‐flow and reduced stroke volume index in a subset of patients with pLFLG AS, and are associated with excess mortality after TAVI.

Background In patients with secondary tricuspid regurgitation (STR) right ventricular (RV) function has a well-known prognostic significance. Assessing the conventional and advanced echocardiographic RV function parameters in patients with STR might be particularly challenging given the sensitivity of the RV to loading conditions. Several cutoffs for tricuspid annular plane systolic excursion (TAPSE), right ventricular free-wall strain (RVFWS), RV fractional area change (FAC), and RV ejection fraction (RVEF) have been proposed in an attempt to stratify RV systolic dysfunction [1-2]. Nonetheless, there is ongoing debate regarding the applicability of established cutoff values for RV systolic function in patients with STR. Purpose We therefore sought to: i. to identify prognostically significant partition values of RV function parameters to stratify RV systolic dysfunction in mildly, moderately, or severely reduced; ii. to assess the association of the identified partition values with clinical outcomes in patients with STR in comparison with previously proposed cutoff values. Methods We included 495 consecutive patients (76±13 years, 54% women) with at least moderate STR (50% moderate, 29% severe, 11% massive, 10% torrential) who underwent comprehensive two-, three-dimensional, and speckle-tracking echocardiography. The primary endpoint was a composite of heart failure hospitalization and all-cause mortality. We used K-Adaptive partitioning for survival data algorithm to identify four groups of patients with significantly different rate of composite endpoint according to each one of the RV function parameters (TAPSE, FAC, RVFWS, and RVEF) (Table). Results Over a median follow-up of 43 months, we recorded 107 deaths and 123 hospitalizations for heart failure. Using a multiway partitioning algorithm to divide the STR cohort into four subgroups based on composite endpoint incidence, we found the following partition values: 57%, 45%, and 31% for RVEF; - 25%, 18%, and 9% for RVFWS; 41%, 32%, and 22% for FAC; and 22 mm, 18 mm, and 13 mm for TAPSE. When previously proposed cutoffs for RV dysfunction were applied to our cohort, Kaplan-Meier survival analysis demonstrated that the use of the newly identified partition thresholds provided superior risk stratification for the composite endpoint, particularly in distinguishing significantly between patients with mild and moderate RV dysfunction (Figure). Conclusions Our findings underscore the need to use dedicated, outcome-based threshold values to grade the extent of RV dysfunction in patients with STR. They better capture the variations in clinical risk compared to currently recommended stratification and may facilitate more individualized therapeutic decision-making or closer follow-up.Table Figure

Introduction: Pulmonary arterial hypertension (PAH) has poor prognosis related to right ventricular (RV) dysfunction and failure. Yet, the underlying mechanisms of RV dysfunction remain unclear. Mitochondrial (mito) dysfunction and energy deficiency in RV have been implicated in RV dysfunction in PAH. A better understanding of RV mito function in PAH is critical in identifying novel therapies to improve RV function. Hypothesis: We hypothesized that impaired RV mito bioenergetics is associated with progression of RV dysfunction in PAH. Methods: PAH was induced in adult Sprague-Dawley (SD) or Fischer (CDF) rats by injecting 20 mg/kg SU5416, followed by exposure to 3 wks of hypoxia (10% FiO 2 ) and then 1-4 wks of normoxia. Control rats injected with vehicle were kept in normoxia. Echocardiography and hemodynamics were performed. RV tissues were collected for mito respiration assessments by high resolution O2K-FluoRespirometer (Oroboros), mito morphology assessments by electron microscopy, and biochemical assays. Results: PAH rats have increased RV systolic pressure, and RV systolic and diastolic dysfunction that ranged in severity from early PAH (1 wk SD), advanced PAH-mild to moderate RV dysfunction (7wks SD), to severe RV dysfunction (4 wks CDF - die of RV failure starting wk 5). Oroboros data show that mito complex I-coupled oxidative phosphorylation and maximal electron transfer capacity are significantly reduced in 7 wks SD rats (O 2 flux per mass: 216±21 vs. 90±19 and 209±22 vs. 91±22 pmol·s -1 ·mg -1 , respectively, control vs. PAH, P &lt;0.01, N=6 each), which are further reduced in 4 wks CDF rats. In parallel, RV ATP amount is significantly lower in PAH rats and is associated with increased apoptosis. There are no changes in mito membrane integrity by cytochrome c assays or in mito content by PCR. Mito size analysis show a significant increase in smaller mito in 4 wks CDF rats but not in 7 wks SD rats, suggesting increased mito fission in severe RV dysfunction. Conclusions: RV mito bioenergetics is impaired in PAH, progressively worsens with progression of RV dysfunction, and occurs prior to increased mito fission. Targeting bioenergetics may aid in developing new therapies to improve mito function and delay RV failure in PAH.

THE PRONOSTIC VALUE OF RIGHT VENTRICULAR SYSTOLIC FUNCTION IN ASYMPTOMATIC PATIENTS WITH ORGANIC MITRAL REGURGITATION

Sodium-glucose cotransporter-2 (SGLT2) inhibitors, a novel class of hypoglycemic drugs, show excellent cardiovascular benefits, and have further improved heart failure outcomes, significantly reducing cardiovascular and all-cause mortality irrespective of diabetes status. However, the efficacy of SGLT2 inhibitors in pulmonary arterial hypertension (PAH) and right ventricular (RV) dysfunction remains unknown. This study aimed to evaluate the effects of dapagliflozin in rats with PAH and RV dysfunction. PAH was induced in rats by monocrotaline (MCT) subcutaneous injection (60 mg/kg). Isolated RV dysfunction was induced in another group of rats by pulmonary trunk banding (PTB). Dapagliflozin (1.5 mg/kg) was administered daily via oral gavage one day (prevention groups) or two weeks (reversal groups) after modeling. Echocardiography and hemodynamic assessments were used to observe pulmonary vascular resistance and RV function. Histological staining was used to observe pulmonary vascular and RV remodeling. As compared with MCT group, dapagliflozin treatment did not significantly improve the survival of rats. Pulmonary arterial media wall thickness in MCT group was significantly increased, but dapagliflozin did not significantly improved vascular remodeling both in the prevention group and reversal group. In MCT group, RV hypertrophy index, RV area, the fibrosis of RV increased significantly, and RV function decreased significantly. Consistently, dapagliflozin did not show protective effect on the RV remodeling and function. In the PTB model, we also did not find the direct effect of dapagliflozin on the RV. This is a negative therapeutic experiment, suggesting human trials with dapagliflozin for PAH or RV failure should be cautious.

Background: In anterior ST-segment elevation myocardial infarction (STEMI), attention paid mainly to the left ventricle. The predictive significance of right ventricular (RV) dysfunction in patients with anterior STEMI has been frequently neglected. In this study, we evaluated the prognostic effect of RV dysfunction on in-hospital outcomes in patients with first anterior STEMI. Methods: Present study is based on the analysis of 77 patients admitted to Coronary care unit of the Sir Salimullah Medical College &amp; Mitford Hospital, Dhaka during April, 2019 to March, 2020, with acute anterior wall myocardial infarction. 12 lead ECG with thorough physical examination was done along with echocardiographic assessment of RV and LV function within index hospitalization, preferably within 24 hours of admission. Patients were divided into two groups depending on right ventricular function assessment. Group I included anterior MI with right ventricular dysfunction and group II included anterior MI without right ventricular dysfunction. In hospital outcomes were observed and compared between two groups. Results: Patients with RV dysfunction had statistically significant higher incidence of cardiogenic shock (22.2 % vs. 2.4%, p &lt; 0.05), acute heart failure (69.4% vs. 24.4%, p &lt; 0.05), arrhythmia (11.1% vs. 0.0%, p &lt; 0.05), increase length of hospital stay in patients of RV dysfunction group. In-hospital mortality was non significantly higher in RV dysfunction group (8.3% vs. 2.4%, p &gt; 0.305). Conclusion: In this study, we observed that in-hospital outcomes were worse in patients with anterior STEMI with RV dysfunction and demands more intense invasive management. Thus, special care should be given for the assessment function of right ventricle in anterior STEMI. Cardiovasc j 2022; 14(2): 128-134