Right heart dysfunction and failure in heart failure with preserved ejection fraction: mechanisms and management. Position statement on behalf of the Heart Failure Association of the European Society of Cardiology

Electrocardiographic characteristics in patients with heart failure and normal ejection fraction: A systematic review and meta-analysis

BACKGROUND

Little is known about ECG abnormalities in patients with heart failure and normal ejection fraction (HeFNEF) and how they relate to different etiologies or outcomes.

METHODS AND RESULTS

We searched the literature for peer-reviewed studies describing ECG abnormalities in HeFNEF other than heart rhythm alone. Thirty five studies were identified and 32,006 participants. ECG abnormalities reported in patients with HeFNEF include atrial fibrillation (prevalence 12%-46%), long PR interval (11%-20%), left ventricular hypertrophy (LVH, 10%-30%), pathological Q waves (11%-18%), RBBB (6%-16%), LBBB (0%-8%), and long JTc (3%-4%). Atrial fibrillation is more common in patients with HeFNEF compared to those with heart failure and reduced ejection fraction (HeFREF). In contrast, long PR interval, LVH, Q waves, LBBB, and long JTc are more common in patients with HeFREF. A pooled effect estimate analysis showed that QRS duration ≥120 ms, although uncommon (13%-19%), is associated with worse outcomes in patients with HeFNEF.

CONCLUSIONS

There is high variability in the prevalence of ECG abnormalities in patients with HeFNEF. Atrial fibrillation is more common in patients with HeFNEF compared to those with HeFREF. QRS duration ≥120 ms is associated with worse outcomes in patients with HeFNEF. Further studies are needed to address whether ECG abnormalities correlate with different phenotypes in HeFNEF.

Usefulness of Right Ventricular to Pulmonary Circulation Coupling as an Indicator of Risk for Recurrent Admissions in Heart Failure With Preserved Ejection Fraction

In recent years, the study of right ventricular (RV) to pulmonary circulation (PC) coupling in heart failure with preserved ejection fraction (HFpEF) has been a matter of special interest. Tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) ratio has emerged as a reliable noninvasive index of RV to PC coupling. Thus, we hypothesized that TAPSE/PASP would be a predictor of readmission burden in HFpEF. One thousand one hundred and twenty seven consecutive HFpEF patients discharged for acute HF were included. In 367 patients (32.6%), PASP could not be accurately measured by echocardiography, leaving the final sample size to be 760 patients. Negative binomial regression method was used to evaluate the association between TAPSE/PASP ratio and recurrent admissions. Mean age of the cohort was 75.6 ± 9.7 years and 68.3% were women. At a median (interquartile range) follow-up of 2.0 (2.9) years, 352 (46.3%) patients died and 1,214 readmissions were registered in 482 patients (63.4%), being 506 of them HF-related. There was a stepwise increase in the rates of all-cause and HF readmissions by decreasing TAPSE/PASP ratio. After multivariable adjustment, TAPSE/PASP <0.36 was associated with a higher risk of HF-related recurrent admissions (incidence rate ratio [IRR] 1.51, 95% confidence interval [CI], 1.01 to 2.24; p = 0.040), whereas patients in the lowest quintile (TAPSE/PASP <0.28) exhibited the highest risk of both all-cause and HF-related recurrent admissions (IRR 1.40, 95% CI 1.04 to 1.87, p = 0.025; and IRR 1.85, 95% CI 1.22 to 2.80, p = 0.004, respectively). In conclusion, TAPSE/PASP ratio, as a noninvasive index of RV-PC coupling, emerges as a strong predictor of recurrent hospitalizations in HFpEF.

Galectin-3 as a candidate upstream biomarker for quantifying risks of myocardial ageing

AIMS

Galectin-3 (Gal-3) is implicated in the pathogenesis of heart failure and is also influenced by ageing. This study aims to determine the extent to which Gal-3 levels estimate odds of myocardial dysfunction in ageing cohorts, 'upstream' prior to clinical disease.

METHODS AND RESULTS

Four hundred seventy-five asymptomatic subjects underwent simultaneous assessments of cardiovascular structure and function, with measurements of circulating Gal-3. Myocardial dysfunction was defined as impaired myocardial relaxation (ratio of peak velocity flow in early diastole E (m/s) to peak velocity flow in late diastole by atrial contraction A (m/s) <0.84) (mean E/A ratio 0.84 in the cohort). Of 475 subjects (mean age 68 ± 12 years, 231 women), 222 (47%) had myocardial dysfunction. Subjects with myocardial dysfunction were older (mean age 73 ± 5 vs. 64 ± 14 years, P < 0.0001), and more had hypertension (59 vs. 40%, P < 0.0001), dyslipidaemia (54 vs. 39%, P = 0.001), diabetes mellitus (25 vs. 14%, P = 0.002), higher body mass index (BMI) (24 vs. 23 kg/m² , P = 0.002), and higher heart rate (76 vs. 71 b.p.m., P = 0.0001). Participants with impaired myocardial relaxation had lower peak velocity flow in early diastole E (0.6 ± 0.1 vs. 0.8 ± 0.2 m/s, P < 0.0001), higher peak velocity flow in late diastole by atrial contraction A (0.9 ± 0.1 vs. 0.7 ± 0.2 m/s, P < 0.0001), and higher mitral valve flow deceleration time (224.7 ± 43.2 vs. 204.8 ± 33.1 m/s, P < 0.0001). Participants with impaired myocardial relaxation had higher Gal-3 levels (17.2 ± 6.2 vs. 15.5 ± 4.1, P = 0.0004) but similar B-type natriuretic peptide (37 ± 4 vs. 34 ± 29, P = 0.37) and high-sensitivity troponin I (21 ± 72 vs. 11 ± 41, P = 0.061) levels and urine microalbumin-to-creatinine ratio (4.6 ± 8.1 vs. 4.2 ± 10.8, P = 0.75) compared with those without impaired myocardial relaxation. After multivariable adjustments, Gal-3 [odds ratio (OR) 1.05, 95% confidence interval (CI) 1.00-1.10, P = 0.039], age (OR 2.60, 95% CI 1.64-4.11, P < 0.0001), BMI (OR 2.16, 95% CI 1.44-3.23, P < 0.0001), and heart rate (OR 1.04, 95% CI 1.02-1.06, P < 0.0001) were associated with impaired myocardial relaxation. Adjusted ORs (95% CI) for myocardial dysfunction were 1.0 (ref), 1.62 (0.92-2.85), 1.92 (1.08-3.41), and 2.01 (1.11-3.66) across consecutive quartiles of Gal-3 after adjustment for age, BMI, risk factors, and heart rate.

CONCLUSIONS

Among asymptomatic community-dwelling elderly adults, the highest quartile of Gal-3 was associated with two-fold increased odds of myocardial dysfunction compared with the lowest quartile of Gal-3. Gal-3 may have a role as an 'upstream' biomarker in estimating odds of myocardial ageing prior to clinical disease.

Assessment of right heart functions in the patients with arteriovenous fistula for hemodialysis access: Right ventricular free wall strain and tricuspid regurgitation jet velocity as the predictors of right heart failure

Objectives

Previous studies have mostly focused on the left-sided cardiovascular changes, but right-sided cardiac changes and predictive factors have not been examined in advance following arteriovenous fistula (AVF) creation. We aimed to identify new parameters which contribute to the prediction of right heart failure (RHF) after AVF creation.

Methods

The study cohort comprised 81 patients who underwent AVF creation between January 2014 and April 2019 in our center. The study cohort was divided into the patients with RHF ( n = 15, 18.5%) and without RHF ( n = 66, 72.5%) following AVF creation.

Results

Mean age of cohort was 49.9 ± 14.7 years (range 23–66) and 39 (48.1%) were men. Approximately 74.07% (60 patients) were in New York Heart Association Class II and III profile preoperatively. Independent predictors for RHF following AVF were right ventricle longitudinal strain (RVLS) free wall <-19% [odds ratio (OR) 2.31, 95% CI 1.02–3.22], and tricuspid regurgitation jet velocity (TRJV) >2.5 m/s [odds ratio (OR) 5.68, 95% CI 1.21–4.38]. Receiver operating characteristic analysis was performed with a resulting area under the curve value of 0.86 (95% CI 0.55–0.89, p = 0.004) for RVLS free wall <-14.2% and 0.81 for TRJV >2.61 m/s (95% CI 0.55–0.89, p = 0.005) in predicting RHF following AVF.

Conclusions

RVLS free wall <-14.2% and TRJV >2.61 m/s were independent predictors of RHF following AVF creation. The patients at risk for having RHF following AVF creation or who may benefit from AVF should be identified with predictive parameters and prospective clinical studies.

Right ventricular mechanical pattern in health and disease: beyond longitudinal shortening

Right ventricular (RV) function has proven to be a prognostic factor in heart failure with reduced and preserved ejection fraction and in pulmonary hypertension. RV function is also a cornerstone in the management of novel clinical issues, such as mechanical circulatory support devices or grown-up congenital heart disease patients. Despite the notable amount of circumferentially oriented myofibers in the subepicardial layer of the RV myocardium, the non-longitudinal motion directions are often neglected in the everyday assessment of RV function by echocardiography. However, the complex RV contraction pattern incorporates different motion components along three anatomically relevant axes: longitudinal shortening with traction of the tricuspid annulus towards the apex, radial motion of free wall often referred as the "bellows effect", and anteroposterior shortening of the chamber by stretching the free wall over the septum. Advanced echocardiographic techniques, such as speckle-tracking and 3D echocardiography allow an in-depth characterization of RV mechanical pattern, providing better understanding of RV systolic and diastolic function. In our current review, we summarize the existing knowledge regarding RV mechanical adaptation to pressure- and/or volume-overloaded states and also other physiologic or pathologic conditions.

[A. N. Bakoulev Scientific Center for Cardiovascular Surgery]

OBJECTIVE

to assess dynamics of diastolic function for detection of development of diastolic dysfunction (DD) and it's causes, to evaluate the effect of DD on prognosis in the postoperative period in patients with acquired heart diseases.

MATERIALS AND METHODS

We included in this study 112 patients with aortic and mitral valve diseases (90 men, 22 women, median age 51 [35; 57] years). All patients underwent echocardiography (echo), tissue Doppler, speckle tracking echo prior to surgery, in the early postoperative period (8-14 days) and in 12-36 months after surgery. In 28 patients dynamic contrast-enhanced magnetic resonance imaging was also performed. Patients were divided into groups according to prognosis: group 0 - without complications; group 1 - with postoperative heart failure (HF) and preserved left ventricular ejection fraction (EF); group 2 - with HF and EF &lt;45 %. The following parameters were used for identifying left ventricular (LV) DD: septal velocity es &lt;7 cm / sec, lateral el &lt;10 cm / sec, average E / e ratio &gt;14, left atrial (LA) volume index &gt;34 ml / m2, peak tricuspid regurgitation velocity &gt;2.8 m / sec.

RESULTS

Initially diastolicLV function was normal in 34 of 112 patients (30.4 %), in early postoperative period DD emerged in 9 (26.5 %) of these patients. The appearance of LV DD was associated with decrease of septal es immediately after surgery and its subsequent progressive decline in the long-term postoperative period from 8.5±0.71 to 4.6 ±0.53 cm / sec (p=0.005). Worsening of diastolic function and lowering of septal velocity was detected namely in patients with presence of fibrosis. In the group of other patients in whom fibrosis was not studied and the degree of DD increased there was a transient decrease of lateral el (from 10.2±3.1 to 7.5±2.43 cm / sec, p=0.035) and an increase of the E / el (from 10.53±4.07 to 14.5±5.23, p=0.05) in the early period after the operation. There were no correlations between DD and LV EF,LV volumes, and development of arrhythmias. The prognostic model for DD included average longitudinal deformation of LA (global LA longitudinal strain) and E / e ratio on the tricuspid lateral annular velocity.

CONCLUSIONS

Appearance of DD in postoperative period after correction of acquired heart defects was due to damage of the septal diastolic function which correlated with fibrosis and was indicative of inadequate myocardial protection. The model of development of heart failure with normal EF after operation was designed.

Prominent 'Y' descent is an ominous sign of a poorer prognosis in heart failure with preserved ejection fraction

AIMS

The heterogeneity of heart failure with preserved ejection fraction (HFpEF) represents different pathophysiological paths by which individual patients develop heart failure. The deterioration mechanisms are considered to be mainly left ventricular diastolic dysfunction, right ventricular (RV) systolic function, and RV afterload. It is unclear whether RV distensibility affects the deterioration of HFpEF. Our study aimed to clarify whether impaired RV distensibility is associated with the deterioration of HFpEF.

METHODS AND RESULTS

We retrospectively enrolled 322 patients with HFpEF and examined their echocardiography results, electrocardiograms, phonocardiograms, and jugular venous pulse waves. Using signal-processing techniques, the prominent 'Y' descent of the jugular venous waveform was detected as an established haemodynamic sign of a less-distensible right ventricle. We defined cardiovascular events of HFpEF as follows: sudden death, death from heart failure, or hospitalization for HFpEF. During a mean follow-up period of 33 ± 20 months, 73 patients had cardiovascular events of HFpEF. The prevalence of a less-distensible right ventricle and the variables of RV systolic pressure were independent risk factors for cardiovascular events (hazard ratio, 2.046, P = 0.005, and hazard ratio, 1.032 per 1 mmHg, P = 0.002, respectively). The event-free rate of HFpEF was the lowest for HFpEF with a less-distensible right ventricle and elevated RV systolic pressure (≥35 mmHg) (P for trend <0.001).

CONCLUSIONS

A less-distensible right ventricle and elevated RV systolic pressure were found to be closely associated with the deterioration of HFpEF. Assessment of a less-distensible right ventricle may help to stratify patients and improve therapeutic strategies for HFpEF.

Right atrial-right ventricular coupling in heart failure with preserved ejection fraction

BACKGROUND

Right ventricular (RV) function is prognostically relevant in heart failure with preserved ejection fraction (HFpEF) but data on profound assessment of RV and right atrial (RA) interaction in HFpEF are lacking. The current study characterizes RV and RA interaction using invasive pressure-volume-loop analysis and cardiac magnetic resonance imaging (CMR) data.

METHODS AND RESULTS

We performed CMR and myocardial feature-tracking in 24 HFpEF patients and 12 patients without HFpEF. Invasive pressure-volume-loops were obtained to evaluate systolic and diastolic RV properties. RV early filling was determined from CMR RV volume-time curves. RV systolic function was slightly increased in HFpEF (RV EF 68 ± 8 vs. 60 ± 9%, p = 0.01), while no differences in RV stroke volume were found (45 ± 7 vs 42 ± 9 ml/m², p = 0.32). RV early filling was decreased in HFpEF (21 ± 11 vs. 40 ± 11% of RV filling volume, p < 0.01) and RV early filling was the strongest predictor for VO_2max even after inclusion of invasively derived RV stiffness and relaxation constant (Beta 0.63, p < 0.01). RA conduit-function was lower in HFpEF (RA conduit-strain - 11 ± 5 vs. - 16 ± 4%, p < 0.01) while RA booster-pump-function was increased (RA active-strain - 18 ± 6 vs. - 12 ± 6%, p = 0.01) as a compensation. RV filling was associated with RA conduit-function (r = - 0.55, p < 0.01) but not with invasively derived RV relaxation constant.

CONCLUSION

In compensated HFpEF patients RV early filling was impaired and compensated by increased RA booster pump function, while RV systolic function was preserved. Impaired RV diastology and RA-RV interaction were linked to impaired exercise tolerance and RA-RV-coupling seems to be independent of RV relaxation, suggestive of an independent pathophysiological contribution of RA dysfunction in HFpEF.

CLINICAL-TRIAL-REGISTRATION

NCT02459626 (www.clinicaltrials.gov).

Deterioration in right ventricular structure and function over time in patients with heart failure and preserved ejection fraction

AIMS

Prevalent right ventricular (RV) dysfunction (RVD) is associated with increased mortality in patients with heart failure with preserved ejection fraction (HFpEF), but no study has characterized long-term changes in RV structure and function within the same patient.

METHODS AND RESULTS

Patients with unequivocal HFpEF defined by either invasive haemodynamics or hospitalization for pulmonary oedema (n = 271) underwent serial echocardiographic evaluations >6 months apart. Clinical, structural, functional, and haemodynamic characteristics were examined. Over a median of 4.0 years (interquartile range 2.1-6.1), there was a 10% decline in RV fractional area change and 21% increase in RV diastolic area (both P < 0.0001). These changes greatly exceeded corresponding changes in the left ventricle. The prevalence of tricuspid regurgitation increased by 45%. Of 238 patients with normal RV function at Exam 1, 55 (23%) developed RVD during follow-up. Development of RVD was associated with both prevalent and incident atrial fibrillation (AF), higher body weight, coronary disease, higher pulmonary artery and left ventricular filling pressures, and RV dilation. Patients with HFpEF developing incident RVD had nearly two-fold increased risk of death (adjusted hazard ratio 1.89, 95% confidence interval 1.01-3.44; P = 0.04).

CONCLUSION

While previous attention has centred on the left ventricle in HFpEF, these data show that right ventricular structure and function deteriorate to greater extent over time when compared with changes in the left ventricle. Further study is required to evaluate whether interventions targeting modifiable risk factors identified for incident RVD, including abnormal haemodynamics, AF, coronary disease, and obesity, can prevent RVD and thus improve outcomes.

Novel Insights and Treatment Strategies for Right Heart Failure

PURPOSE OF REVIEW

The function of the right ventricle (RV) is intimately linked to its preload (systemic volume status) and afterload (pulmonary vasculature). In this review, we explore current knowledge in RV physiology, RV function assessment, causes of right heart failure (RHF), and specific treatment strategies for RHF.

RECENT FINDINGS

We examine the evidence behind new pharmacological therapies available, such as macitentan and riociguat in the treatment of specific etiologies of RHF. We will also focus on RHF in the setting of heart failure with preserved ejection fraction (HFpEF) and in the presence of left ventricular assist devices (LVAD), looking at current treatment recommendations, including mechanical circulatory support. Lastly, we will look to the horizon for the latest research on RHF, including the molecular basis of RHF and potential novel treatment methods for this old yet poorly understood syndrome. Disturbances in this complex relationship result in the clinical syndrome of RHF. Despite advances in the management of left heart diseases, much work remains to be done to understand and manage RHF.

Relationship of Liver Stiffness With Congestion in Patients Presenting With Acute Decompensated Heart Failure

OBJECTIVE

The significance of liver stiffness (LS) in the setting of cardiovascular congestion during the course of acute decompensated heart failure (ADHF) is under investigation. The aim of this study was to assess LS with the use of transient elastography (TE) and its associations with volume overload as determined by means of bioimpedance vector analysis (BIVA) in ADHF.

METHODS AND RESULTS

TE (Fibroscan 502; Echosens) and BIVA (ABC-01, Medass) were performed in the first 48 hours of admission and on the day of discharge in 149 ADHF patients without known primary chronic liver disease or acute hepatitis. During hospitalization the median value of LS decreased from 12.2 kPa (interquartile range 6.3-23.6) to 8.7 (5.9-14.4) kPa (P < .001). Changes in LS correlated (P < .001) with changes in weight and BIVA parameters. LS was compared with histologic features of livers of ADHF patients who died (n = 7). Liver fibrosis 2B-4 was observed but was not associated with LS. LS at discharge was associated with increased risk of 12-month all-cause death, HF readmission, and the combined end point.

CONCLUSIONS

There was a moderate association between LS with clinical congestion and volume overload according to BIVA and no correlation with degree of histologic liver fibrosis. LS may be a marker of negative HF outcomes.

Right Ventricular Dysfunction and Its Contribution to Morbidity and Mortality in Left Ventricular Heart Failure

PURPOSE

In patients with left-sided HF, there has been less emphasis on the pathophysiology of the RV in terms of diagnostic evaluation and treatment, versus focus on structural abnormalities of the LV. This review seeks to delineate the importance of RV dysfunction in terms of its contribution to symptomatic limitations and cardiovascular outcomes in patients with left-sided HF.

RECENT FINDINGS

Recent studies have demonstrated that RV dysfunction is common in both HFpEF and HFrEF, but more pronounced in HFrEF. LV dysfunction and atrial fibrillation are most commonly associated with RV dysfunction in left-sided HF. RV dysfunction may develop due to afterload-dependent and afterload-independent pathways. Regardless, RV dysfunction is strongly associated with functional limitations and worsened survival in patients with left-sided HF. In patients with HFpEF, a recent study showed that RV failure was the most common cause of overall mortality. Among LVAD patients and patients post-cardiac transplantation, RV dysfunction is also strongly associated with survival. Despite a number of previous and ongoing clinical trials that target the RV directly or decrease RV afterload in left-sided HF, there are no definitive therapies specifically targeting RV dysfunction in left-sided HF patients CONCLUSIONS: RV dysfunction is an important determinant of symptomatic limitations and cardiovascular outcomes in patients with left-sided HF. Further research is needed to developed pharmacotherapy that may target the RV specifically in left-sided HF patients.

Cardiac contractility modulation: mechanisms of action in heart failure with reduced ejection fraction and beyond

Heart failure (HF) is responsible for substantial morbidity and mortality and is increasing in prevalence. Although there has been remarkable progress in the treatment of HF with reduced ejection fraction (HFrEF), morbidity and mortality are still substantial. Cardiac contractility modulation (CCM) signals, consisting of biphasic high-voltage bipolar signals delivered to the right ventricular septum during the absolute refractory period, have been shown to improve symptoms, exercise tolerance and quality of life and reduce the rate of HF hospitalizations in patients with ejection fractions (EF) between 25% and 45%. CCM therapy is currently approved in the European Union, China, India, Australia and Brazil for use in symptomatic HFrEF patients with normal or slightly prolonged QRS duration. CCM is particularly beneficial in patients with baseline EF between 35% and 45%, which includes half the range of HF patients with mid-range EFs (HFmrEF). At the cellular level, CCM has been shown in HFrEF patients to improve calcium handling, to reverse the foetal myocyte gene programme associated with HF, and to facilitate reverse remodelling. This review highlights the preclinical and clinical literature related to CCM in HFrEF and HFmrEF and outlines the potential of CCM for HF with preserved EF, concluding that CCM may fill an important unmet need in the therapeutic approach to HF across the range of EFs.

Right ventricular dysfunction and remodeling in diabetic cardiomyopathy

The increasing prevalence of diabetic cardiomyopathy (DCM) is an important threat to health worldwide. While left ventricular (LV) dysfunction in DCM is well recognized, the accurate detection, diagnosis, and treatment of changes in right ventricular (RV) structure and function have not been well characterized. The pathophysiology of RV dysfunction in DCM may share features with LV diastolic and systolic dysfunction, including pathways related to insulin resistance and oxidant injury, although the RV has a unique cellular origin and composition and unique biomechanical properties and is coupled to the lower-impedance pulmonary vascular bed. In this review, we discuss potential mechanisms responsible for RV dysfunction in DCM and review the imaging approaches useful for early detection, protection, and intervention strategies. Additional data are required from animal models and clinical trials to better identify the onset and features of altered RV and pulmonary vascular structure and function during the onset and progression of DCM and to determine the efficacy of early detection and treatment of RV dysfunction on clinical symptoms and outcomes.

Right Atrial Phasic Function in Heart Failure With Preserved and Reduced Ejection Fraction

OBJECTIVES

This study researched right atrial (RA) deformation indexes and their association with all-cause mortality among subjects with or without heart failure (HF).

BACKGROUND

Although left atrial dysfunction is well described in HF, patterns of RA dysfunction and their prognostic implications are unclear. Cardiac magnetic resonance (CMR) imaging can provide excellent visualization of the RA. We used CMR to characterize RA phasic function in HF and to assess its prognostic implications.

METHODS

This study prospectively examined 608 adults without HF (n = 407), as well as adults with HF with a reduced ejection fraction (HFrEF) (n = 105) or with HF with a preserved ejection fraction (HFpEF) (n = 96). Phasic RA function was measured via volume measurements and feature-tracking methods to derive longitudinal strain. All-cause death was ascertained over a median follow-up of 38.9 months. Standardized hazard ratios (HRs) were computed via Cox regression.

RESULTS

Measures of RA phasic function were more prominently impaired in subjects with HFrEF than those in subjects with HFpEF. In analyses that adjusted for demographic factors, HF status, left ventricular ejection fraction, right ventricular end-diastolic volume index, and right ventricular ejection fraction, RA reservoir strain (HR: 0.66; 95% confidence interval [CI]: 0.47 to 0.92; p = 0.0154), RA expansion index (HR: 0.53; 95% CI: 0.31 to 0.91; p = 0.0116), RA conduit strain (HR: 0.58; 95% CI: 0.40 to 0.84; p = 0.0039), and RA conduit strain rate (HR: 1.51; 95% CI: 1.02 to 2.220; p = 0.0373) independently predicted all-cause mortality. In contrast, RA booster pump function and RA volume index did not independently predict the risk of death.

CONCLUSIONS

Phasic RA function is predictive of the risk of all-cause death in a diverse group of subjects with and without HF. RA conduit and reservoir function are independent predictors of mortality.

Preexisting Right Ventricular Dysfunction Is Associated With Higher Postoperative Cardiac Complications and Longer Hospital Stay in High-Risk Patients Undergoing Nonemergent Major Vascular Surgery

OBJECTIVES

To evaluate whether the presence of preexisting right ventricular (RV) dysfunction in high-risk patients undergoing nonemergent major vascular surgery is associated independently with higher incidents of postoperative cardiac complications and a longer length of hospital stay.

DESIGN

Retrospective chart review.

SETTING

Single-center university hospital setting.

PARTICIPANTS

The patient population consisted of those identified as American Society of Anesthesiologists classification III and above who had a preoperative echocardiogram within 1 year of undergoing nonemergent major vascular surgery between January 2010 and May 2017.

MEASUREMENTS AND MAIN RESULTS

After multivariate analyses, RV dysfunction (RVD) is associated independently with a higher incidence of postoperative major cardiac complications with an odds ratio = 6.3 (95% confidence interval [CI], 1.0-38.5; p = 0.046). In addition, patients with RVD had a 50% longer length of stay than those without RVD (incident rate ratio [95% CI], 1.5 [1.2-1.8]; p < 0.001).

CONCLUSION

In this retrospective study of high-risk patients undergoing major vascular surgery, RV dysfunction was associated independently with a higher incidence of postoperative major cardiovascular events and longer length of hospital stays. Based on current findings, the prognostic value of RVD extends beyond the cardiac surgical cohort. Knowledge in management of patients with RVD in the perioperative setting should be understood by all anesthesiologists. Of note, a future study with a larger sample size is needed to validate the current findings given the small sample size of this study.