Right ventricular dysfunction and impaired right ventricular–pulmonary arterial coupling in paradoxical low‐flow, low‐gradient aortic stenosis

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.

Impact of right ventricular-pulmonary arterial coupling on clinical outcomes in patients undergoing transcatheter aortic valve implantation

Right Ventricular Dysfunction and Adverse Clinical Outcomes in Peripartum Cardiomyopathy: A Meta-Analysis.

AimsThe characteristics and clinical course of hospitalized patients with Coronavirus disease 2019 (COVID-19) have been widely described, while long-term data are still poor. The aim of this study was to evaluate the long-term clinical outcome and its association with right ventricular (RV) dysfunction in hospitalized patients with COVID-19.Methods and resultsThis was a retrospective multicentre study of consecutive COVID-19 patients hospitalized at seven Italian Hospitals from 28 February to 20 April 2020. The study population was divided into two groups according to echocardiographic evidence of RV dysfunction defined by tricuspid annular plane systolic excursion (TAPSE) value <17 mm in accordance with the current guidelines. The primary study outcome was 1-year mortality. The study population consisted of 224 patients (mean age 69 ± 14, male sex 62%); RV dysfunction was diagnosed in 63 cases (28%). Patients with RV dysfunction were older (75 vs. 67 years, P < 0.001) and showed a higher prevalence of coronary artery disease (27% vs. 11%, P = 0.003), heart failure (5% vs. 22%; P < 0.001), chronic obstructive pulmonary disease (13% vs. 38%; P < 0.001), and chronic kidney disease (12% vs. 39%; P < 0.001). Left ventricular ejection fraction (LVEF) was significantly lower in patients with RV dysfunction that in those without (55% vs. 50%; P < 0.001). The rate of mortality at 1-year was significantly higher in patients with RV dysfunction as compared with those without (67% vs. 28%; P ≤ 0.001). After propensity score matching, patients with RV dysfunction showed a significantly lower long-term survival than patients without RV dysfunction (62% vs. 29%, P < 0.001). At multivariable Cox regression analysis, TAPSE, LVEF and acute respiratory distress syndrome during the hospitalization were independently associated with 1-year mortality (Table).ConclusionsRV dysfunction is a relatively common finding in hospitalized patients with COVID-19 and is independently associated with an higher risk of mortality at one-year follow-up.

Background: Transcatheter aortic valve replacement (TAVR) is an alternative to surgical aortic valve replacement in patients at high surgical risk. We investigated the impact of TAVR on left (LV) and right ventricular (RV) function using conventional echocardiography parameters. Methods and results: A total of 202 consecutive patients (age 80.6±8.0 years, aortic valve area 0.80±0.16cm 2 ) who underwent TAVR at Mayo Clinic between 2008 and 2013 were included in the study. LV ejection fraction (EF) and RV systolic function including tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC) and, systolic excursion velocity (S’) were compared before (median 33.5 days) and after TAVR procedure (median 30 days). Patients who underwent pacemaker implantation after TAVR were excluded. LV EF significantly improved following TAVR (55.3±12.6% pre vs 58.5±11.1% post; p&lt;0.05). In contrast, RV systolic function significantly decreased after TAVR (pre vs post; TAPSE: 18.8±6.3 mm vs 17.4±6.3 mm, FAC: 42.6±9.8% vs 37.3±8.2%; S’: 10.7±2.6 cm/s vs 10.2±2.6 cm/s; p&lt;0.05 for all). Stratifying RV functional change by TAVR approach site, patients undergoing trans-femoral TAVR (n=100) showed RV deterioration only by FAC (see Table). In contrast, RV systolic dysfunction was more prominent in trans-apical approach group (n=87) with significant decline in all parameters of RV systolic function (see Table). Conclusion: TAVR is associated with early enhancement in LV systolic function. However, there is evidence of worsening RV function in a significant number of patients. Further studies are necessary to determine whether this deterioration in RV function is related to anatomic access site or to other factors, and to evaluate its prognostic significance.

ObjectiveOur aim was to determine whether right ventricular (RV) dysfunction at 24-hour postnatal age predicts adverse developmental outcome among patients with hypoxic ischaemic encephalopathy (HIE) undergoing therapeutic hypothermia (TH).DesignNeonates≥35 weeks...

BackgroundArterial stiffness is a well-established predictor of cardiovascular events and mortality. However, its relationship with right ventricular (RV) function in patients with coronary artery disease (CAD) remains unclear. We aimed to investigate the association between aortic augmentation index (AIx), a marker of arterial stiffness, and RV dysfunction in CAD patients.MethodsIn this cross-sectional study, 121 patients with stable CAD or acute coronary syndrome who underwent coronary angiography were enrolled. AIx was measured using radial artery applanation tonometry. Comprehensive echocardiography was performed to assess RV function using conventional and speckle-tracking derived parameters. Multivariable linear and logistic regression analyses were used to evaluate the relationship between AIx and RV function, adjusting for potential confounders.ResultsPatients with high AIx (> 80%, n = 53) had significantly worse RV systolic function compared to those with normal AIx (≤ 80%, n = 68), as evidenced by lower tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), RV free wall longitudinal strain (RVLS), and RV systolic velocity (RV S’) (all P < 0.05). AIx correlated negatively with TAPSE (r=-0.421), FAC (r=-0.376), RVLS (r=-0.428), and RV S’ (r=-0.355) (all P < 0.001), and positively with pulmonary artery systolic pressure (r = 0.467, P < 0.001) and pulmonary vascular resistance (r = 0.297, P = 0.001). In multivariable analyses, AIx remained an independent predictor of RV dysfunction (adjusted odds ratio 3.42, 95% confidence interval 1.56–7.51, P = 0.002) after adjusting for age, sex, hypertension, diabetes, dyslipidemia, smoking, left ventricular ejection fraction, and Gensini score.ConclusionsIncreased aortic stiffness assessed by AIx is independently associated with RV dysfunction in patients with CAD. This association is evident across multiple echocardiographic parameters of RV systolic function and is independent of traditional cardiovascular risk factors, left ventricular systolic function, and the extent of coronary artery disease. Our findings suggest that arterial stiffness may play a role in the development of RV dysfunction in CAD patients and highlight the potential importance of assessing and targeting arterial stiffness in this population.

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

Introduction: Left ventricular (LV) dysfunction is observed after right ventricular (RV) pacing from both apical and septal positions. Hypothesis: The primary aim of this study was to assess the impact of RV mid-septal pacing upon RV function using the novel parameter of speckle-tracking derived RV global longitudinal strain (RVGLS), as well as the conventional parameters RV fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE) and tricuspid annular systolic velocity (RV S’). Secondary aims included assessing the impact on LV function and the correlation of pacing burden with echocardiographic parameters. Methods: Thirty-two consecutive patients (mean age 75 ± 10 years) with normal baseline LV and RV function requiring permanent pacemaker insertion were prospectively recruited at a tertiary hospital in Melbourne, Australia. 3 patients were excluded due to poor image quality. Echocardiography was performed prior to implantation, at 1-day, 1-month and 1-year post-implantation, with 29 patients completing follow-up. Results: Compared to 1-day post-implantation, at 1-year a significant decline was noted in mean RV S’ (15.1 to 12.2cm/s), TAPSE (24.2 to 21.9mm), RV GLS (-24.8 to -21.8%), LVEF (66.0 to 57.9%), LV GLS (-19.9 to 17.0), all p &lt;0.01. There was no change in RV FAC (49.1 to 46.9%). Fourteen patients (44%) required a high proportion of ventricular pacing, defined as ≥10% at 1 year. These patients had a greater deterioration in RVGLS (5.0 vs 1.0%) and LVGLS (4.6 vs 0.68%), p &lt;0.05. Changes in RV S’ (3.1 vs 2.7cm/s), TAPSE (1.5 vs 3.1mm), RV FAC (1.9 vs 5.64%) and LVEF (9.5 vs 5.6%) were not significantly different from those in patients with &lt;10% ventricular pacing. Conclusions: RV and LV systolic function declined in all patients after 1 year of RV septal pacing. Further, patients with a high burden of ventricular pacing had a larger deterioration in RVGLS and LVGLS. Myocardial strain may be more useful than conventional echo parameters in detecting RV and LV dysfunction associated with RV septal pacing.

Right ventricular (RV) dysfunction is common in patients with amyloid light-chain (AL) amyloidosis. While cardiac MRI is the reference standard tool for RV assessment, there are a number of measures of RV function that can be evaluated and it is yet unknown which of these results in the highest prognostic performance in AL amyloidosis. To examine the prognostic value of various measures of RV function in a bid to find which best predicts outcome in AL amyloidosis. Single-center, prospective. In all, 129 patients (mean age, 58 ± 11 years; 61.2% men) with biopsy-proven AL amyloidosis. 3.0T / balanced steady-state free-precession cine. RV ejection fraction (EF), RV fractional area change (FAC), RV long axis strain (LAS), RV free wall longitudinal strain (FWS), RV global longitudinal strain (GLS), and tricuspid annular plane systolic excursion (TAPSE). Mann-Whitney U-tests, Student's t-tests, receiver-operating characteristic curves, Kaplan-Meier curves, Cox proportional hazards regression models, and C-statistics. During the median follow-up period of 38.0 months (interquartile range, 18.5-58.0 months), all-cause mortality occurred in 95 patients (73.6%). The RVEF, RVGLS, TAPSE, RVFAC, and RVFWS were significant predictors of outcome in univariate Cox regression (all P < 0.001). After adjusting for New York Heart Association (NYHA) class, Mayo staging 2004, left ventricular (LV) EF, and LV mass index, RVFWS (HR [hazard ratio] =1.074; 95% CI [confidence interval]: 1.041-1.108; P < 0.001) was an independent predictor of all-cause mortality and had a higher C-statistic (0.753) compared to the model including RVEF (C-statistic = 0.724, P = 0.034), the model including RVFAC (C-statistic = 0.723, P = 0.033), and the model including RVGLS (C-statistic =0.733, P = 0.011). RV dysfunction appears to be an independent determinant of outcome in patients with AL amyloidosis. RVFWS is a better predictor of all-cause mortality than RVEF, RVFAC, or RVGLS. 2 TECHNICAL EFFICACY STAGE: 5.

Background: Ischemic heart disease (IHD) remains the leading cause of mortality worldwide, contributing significantly to cardiovascular-related deaths. Right ventricular (RV) dysfunction frequently complicates IHD, especially in the presence of left ventricular (LV) failure or infarction. RV impairment is associated with poorer prognoses, including higher rates of heart failure, arrhythmias, and mortality. Echocardiography, being non-invasive, affordable, and widely available, remains the first-line modality for assessing cardiac function, including RV performance in IHD patients. Objective: To determine the prevalence of right ventricular dysfunction among patients with ischemic heart disease diagnosed on echocardiography in Rahim Yar Khan. Methods: An analytical cross-sectional study was conducted at Sheikh Zaid Medical College and Hospital, Rahim Yar Khan, over a three-month period from February to April 2025. A total of 110 patients, aged 32 to 75 years, with confirmed ischemic heart disease and left ventricular dysfunction were enrolled through non-probability sampling. Patients with congenital cardiac abnormalities, myocarditis, or peripartum cardiomyopathy were excluded. Echocardiographic assessment was performed using a GE Vivid S6 machine with a 3–5 MHz sector probe, evaluating parameters including Tricuspid Annular Plane Systolic Excursion (TAPSE) and RV systolic tissue Doppler imaging (RVSTDI). Data were analyzed using SPSS version 25. Results: Of the 110 patients (62 males, 48 females), RV dysfunction was identified in 48 individuals (43.6%), while 62 (56.4%) had preserved RV function. The mean ejection fraction was 36.3% ± 7.1, with a mean TAPSE of 13.65 mm ± 5.85. TAPSE was significantly lower in patients with RV dysfunction (mean 8.29 mm ± 3.57) compared to those without (mean 17.81 mm ± 3.33), p &lt; 0.001. Conclusion: RV dysfunction was prevalent in patients with ischemic heart disease, particularly among those with more severe LV impairment. Early detection through echocardiography is vital for improving clinical outcomes.

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) is a progressive disease leading to right ventricular (RV) dysfunction and right heart failure. RV adaptation to increased afterload is a key prognostic factor. Traditional echocardiographic parameters offer insight but may not fully capture RV remodeling complexity. Phenotypic classifications combining RV size, contractility, and ventricular-arterial coupling may improve risk stratification. Methods A multicenter prospective cohort study was conducted in patients with de novo diagnosis of PAH as part of the TREPostinil Subcutáneo a LARgo Plazo en Hipertensión Pulmonar registry (TREPAR-HP). Six right ventricular (RV) phenotypes (A–F) were evaluated based on the RV basal diameter, fractional area change (FAC), and the ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP). This classification ranges from a normal and adapted RV (phenotypes A–C) to severe dysfunction and dilation (phenotypes D–F). Results Figure 1 shows the distribution of phenotypes. In a cohort of 93 patients (mean age 46.7 years, 86% women), the most common etiology was idiopathic (57%). Most patients presented with functional class III (62.4%) and received dual therapy (86%). Height (p=0.002), right atrial area (p=0.001), RV basal diameter (p&amp;lt;0.001), and TAPSE (p&amp;lt;0.001) showed significant differences between groups. The median BNP was 290.27 pg/mL, and the average cardiac output was 4.38 L/min (p=0.012). These findings highlight the functional and hemodynamic burden of the cohort. Figure 2 shows the distribution of phenotypes with respect to risk classification according to REVEAL. Conclusion RV phenotypic classification reveals distinct adaptation patterns in PAH. Advanced phenotypes (D–F) showed worse functional class, larger right atrial areas, and greater RV dysfunction. This approach may enhance risk stratification and guide management, underscoring the importance of early detection of RV maladaptation Figure 1. Distribution of phenotypes. Figure 2. distribution of phenotypes with respect to risk classification according to REVEAL.

BackgroundCardiovascular disease (CVD) is a major complication in patients on maintenance hemodialysis (MHD). While the effect of left ventricular dysfunction on patients on MHD is well known, the association between right ventricular (RV) dysfunction and their prognosis remains poorly understood.MethodsWe conducted a retrospective cohort study of 149 patients on MHD (median age, 72 years; male, 67%) between 1 April 2022 and 31 March 2024. All subjects underwent transthoracic two-dimensional and Doppler echocardiographic examination. RV dysfunction was determined when the tricuspid annular plane systolic excursion (TAPSE) was under 16 mm. Kaplan–Meier survival analysis was used to compare survival between patients with and without RV dysfunction. Multivariate Cox regression analyses were used to estimate the effects of RV dysfunction on all-cause mortality, including the effect of confounding factors such as age, sex, previous CVD events, and left ventricular (LV) dysfunction.ResultsIn total, 20 out of 149 patients on MHD (13%) had RV dysfunction. Indexes of their LV function (such as the LV ejection fraction and E/e' ratio) were similar to those of patients without RV dysfunction. During the follow-up period, 23 patients died (7 with RV dysfunction [without LV dysfunction], 3 with LV dysfunction [without RV dysfunction], 2 with biventricular dysfunction, and 11 without any ventricular dysfunction). Kaplan–Meier analyses showed significantly lower survival among patients with RV dysfunction (p < 0.01). The multivariate Cox regression analysis revealed that RV dysfunction (without LV dysfunction) was independently associated with all-cause mortality (hazard ratio: 3.44; 95% confidence interval: 1.28–9.23) after adjusting for confounders.ConclusionsRV dysfunction is a significant risk factor for all-cause mortality among patients on MHD.

Background Right ventricular (RV) dysfunction is a typical complication of acute respiratory distress syndrome (ARDS), which is an independent predictor of poor prognosis in ARDS. Thus, evaluation of RV function is a crucial component of ARDS patient management. The present study aimed to determine the incidence of RV dysfunctionby 2D echocardiography in mechanically ventilated ARDS patients in the ICU and assess the serial changes in tricuspid annular plane systolic excursion (TAPSE) among these patients in the intensive care unit (ICU) of a tertiary care cancer institute of Eastern India. Methods The prospective observational study included 40 patients aged 18-80 years who were admitted to the critical care unit with ARDS and put on mechanical ventilation. Patients meeting eligibility criteria underwent routine investigations on admission to the ICU. Key parameters included recording of the partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) oxygenation index, TAPSEon 2D transthoracic echocardiography, and plasma B-type (or brain) natriuretic peptide (BNP) level estimation conducted on day 0, day 2, and day 5. A TAPSE value <17 mm was considered to indicate RV dysfunction. Weaning outcomes, ventilator days, length of ICU stay, length of hospital stay, and in-ICU mortality were noted. Results Among the 40 study participants, the mean (± SD) age was 52.6 (± 14.3) years, and 52.5% were male patients. The incidence of RV dysfunction in ARDS was 17.5%. These patients were observed to have a progressive worsening of hypoxia along with a significant elevation of plasma BNP levels on day 2 and day 5 as compared to baseline. Weaning outcomes, ventilator days, length of hospital stay, and in-ICU mortality were comparable between the two groups. Conclusion The present study reports a 17.5% incidence of RV dysfunction in ARDS and quantifies a longitudinal deterioration in RV function with the onset of ARDS using TAPSE. The inclusion of objective indices on two-dimensional echocardiography, such as TAPSE, facilitates their regular application at the bedside and equips clinicians with a means to detect and quantify RV dysfunction in its early stages in ARDS.