Prognostic Value of Right Ventricular Two-Dimensional Global Strain in Patients Referred for Cardiac Surgery

Perioperative echocardiographic strain analysis: what anesthesiologists should know

PURPOSE

Echocardiographic strain analysis by speckle tracking allows assessment of myocardial deformation during the cardiac cycle. Its clinical applications have significantly expanded over the last two decades as a sensitive marker of myocardial dysfunction with important diagnostic and prognostic values. Strain analysis has the potential to become a routine part of the perioperative echocardiographic examination for most anesthesiologist-echocardiographers but its exact role in the perioperative setting is still being defined.

CLINICAL FEATURES

This clinical report reviews the principles underlying strain analysis and describes its main clinical uses pertinent to the field of anesthesiology and perioperative medicine. Strain for assessment of left and right ventricular function as well as atrial strain is described. We also discuss the potential role of strain to aid in perioperative risk stratification, surgical patient selection in cardiac surgery, and guidance of anesthetic monitor choice and clinical decision-making in the perioperative period.

CONCLUSION

Echocardiographic strain analysis is a powerful tool that allows seeing what conventional 2D imaging sometimes fails to reveal. It often provides pathophysiologic insight into various cardiac diseases at an early stage. Strain analysis is readily feasible and reproducible thanks to the use of highly automated software platforms. This technique shows promising potential to become a valuable tool in the arsenal of the anesthesiologist-echocardiographer and aid in perioperative risk-stratification and clinical decision-making.

Perioperative Right Ventricular Dysfunction and Abnormalities of the Tricuspid Valve Apparatus in Patients Undergoing Cardiac Surgery

Right ventricular (RV) dysfunction frequently occurs after cardiac surgery and is linked to adverse postoperative outcomes, including mortality, reintubation, stroke, and prolonged ICU stays. While various criteria using echocardiography and hemodynamic parameters have been proposed, a consensus remains elusive. Distinctive RV anatomical features include its thin wall, which presents a triangular shape in a lateral view and a crescent shape in a cross-sectional view. Principal causes of RV dysfunction after cardiac surgery encompass ischemic reperfusion injury, prolonged ischemic time, choice of cardioplegia and its administration, cardiopulmonary bypass weaning characteristics, and preoperative risk factors. Post-left ventricular assist device (LVAD) implantation RV dysfunction is common but often transient, with a favorable prognosis upon resolution. There is an ongoing debate regarding the benefits of concomitant surgical repair of the RV in the presence of regurgitation. According to the literature, the gold standard techniques for assessing RV function are cardiac magnetic resonance imaging and hemodynamic assessment using thermodilution. Echocardiography is widely favored for perioperative RV function evaluation due to its accessibility, reproducibility, non-invasiveness, and cost-effectiveness. Although other techniques exist for RV function assessment, they are less common in clinical practice. Clinical management strategies focus on early detection and include intravenous drugs (inotropes and vasodilators), inhalation drugs (pulmonary vasodilators), ventilator strategies, volume management, and mechanical support. Bridging research gaps in this field is crucial to improving clinical outcomes associated with RV dysfunction in the near future.

Right Ventricular Limitation: A Tale of Two Elastances

Right ventricular (RV) dysfunction is a commonly considered cause of low cardiac output in critically ill patients. Its management can be difficult and requires an understanding of how the RV limits cardiac output. We explain that RV stroke output is caught between the passive elastance of the RV walls during diastolic filling and the active elastance produced by the RV in systole. These two elastances limit RV filling and stroke volume and consequently limit left ventricular stroke volume. We emphasize the use of the term "RV limitation" and argue that limitation of RV filling is the primary pathophysiological process by which the RV causes hemodynamic instability. Importantly, RV limitation can be present even when RV function is normal. We use the term "RV dysfunction" to indicate that RV end-systolic elastance is depressed or diastolic elastance is increased. When RV dysfunction is present, RV limitation occurs at lowerpulmonary valve opening pressures and lower stroke volume, but stroke volume and cardiac output still can be maintained until RV filling is limited. We use the term "RV failure" to indicate the condition in which RV output is insufficient for tissue needs. We discuss the physiological underpinnings of these terms and implications for clinical management.

Echocardiography as a Tool to Assess Cardiac Function in Critical Care-A Review

In critically ill patients, hemodynamic disturbances are common and often lead to a detrimental outcome. Frequently, invasive hemodynamic monitoring is required for patients who are hemodynamically unstable. Although the pulmonary artery catheter enables a comprehensive assessment of the hemodynamic profile, this technique carries a substantial inherent risk of complications. Other less invasive techniques do not offer a full range of results to guide detailed hemodynamic therapies. An alternative with a lower risk profile is transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE). After training, intensivists can obtain similar parameters on the hemodynamic profile using echocardiography, such as stroke volume and ejection fraction of the right and left ventricles, an estimate of the pulmonary artery wedge pressure, and cardiac output. Here, we will review individual echocardiography techniques that will help the intensivist obtain a comprehensive assessment of the hemodynamic profile using echocardiography.

Recommendations for the Use of Echocardiography in the Evaluation of Rheumatic Heart Disease: A Report from the American Society of Echocardiography

Acute rheumatic fever and its chronic sequela, rheumatic heart disease (RHD), pose major health problems globally, and remain the most common cardiovascular disease in children and young people worldwide. Echocardiography is the most important diagnostic tool in recognizing this preventable and treatable disease and plays an invaluable role in detecting the presence of subclinical disease needing prompt therapy or follow-up assessment. This document provides recommendations for the comprehensive use of echocardiography in the diagnosis and therapeutic intervention of RHD. Echocardiographic diagnosis of RHD is made when typical findings of valvular and subvalvular abnormalities are seen, including commissural fusion, leaflet thickening, and restricted leaflet mobility, with varying degrees of calcification. The mitral valve is predominantly affected, most often leading to mitral stenosis. Mixed valve disease and associated cardiopulmonary pathology are common. The severity of valvular lesions and hemodynamic effects on the cardiac chambers and pulmonary artery pressures should be rigorously examined. It is essential to take advantage of all available modalities of echocardiography to obtain accurate anatomic and hemodynamic details of the affected valve lesion(s) for diagnostic and strategic pre-treatment planning. Intraprocedural echocardiographic guidance is critical during catheter-based or surgical treatment of RHD, as is echocardiographic surveillance for post-intervention complications or disease progression. The role of echocardiography is indispensable in the entire spectrum of RHD management.

A one-day focused cardiac ultrasound training has a limited impact on residents' abilities to visually assess right ventricular dimensions and function

BACKGROUND

Focused cardiac ultrasound (FCU) is a helpful tool to rapidly identify right ventricular (RV) causes of hemodynamic instability and facilitate the initiation of therapy. The clinical value of existing course models often remains unclear. This study investigated the effects of a one-day FCU training on the visual estimation skills of RV characteristics.

METHODS

Four residents were included as the study group after completing a standardized one-day FCU training. Four gender-matched controls did not take part in the training. All residents graded image quality, RV systolic function, and RV dimensions in a test comprising 35 ultrasound clips.

RESULTS

The study and control group did not differ in ICU or ultrasound experience. Overall, training participants were able to distinguish between good and insufficient image quality significantly better than the control group (agreement 80.0% vs 61.4%, p = 0.04). The agreement for the estimation of RV function and RV dimensions was not different between the groups (63.2% vs 60.5%, p = 0.66 and 64.3% vs 67.1%, p = 0.18, respectively). Descriptively, only small differences were found between the groups for the estimation of RV function and RV dimensions in subgroups of patients with normal versus reduced systolic RV function or normal versus enlarged RV dimensions, respectively. Both groups struggled in identifying RV enlargement (34.6% vs 46.2%).

DISCUSSION

In this study, a single one-day FCU training had no impact on residents' skills to visually assess systolic RV function or RV dimensions. Improvements of current training modalities or continuous teaching models are needed to optimize residency programs and patient care.

Lateral annular systolic excursion ratio: A novel measurement of right ventricular systolic function by two-dimensional echocardiography

Introduction

Accurate assessment of right ventricular (RV) systolic function has prognostic and therapeutic implications in many disease states. Echocardiography remains the most frequently deployed imaging modality for this purpose, but estimation of RV systolic function remains challenging. The purpose of this study was to evaluate the diagnostic performance of a novel measurement of RV systolic function called lateral annular systolic excursion ratio (LASER), which is the fractional shortening of the lateral tricuspid annulus to apex distance, compared to right ventricular ejection fraction (RVEF) derived by cardiac magnetic resonance imaging (CMR).

Methods

A retrospective cohort of 78 consecutive patients who underwent clinically indicated CMR and transthoracic echocardiography within 30 days were identified from a database. Parameters of RV function measured included: tricuspid annular plane systolic excursion (TAPSE) by M-mode, tissue Doppler S', fractional area change (FAC) and LASER. These measurements were compared to RVEF derived by CMR using Pearson's correlation coefficients and receiver operating characteristic curves.

Results

LASER was measurable in 75 (96%) of patients within the cohort. Right ventricular systolic dysfunction, by CMR measurement, was present in 37% (n = 29) of the population. LASER has moderate positive correlation with RVEF (r = 0.54) which was similar to FAC (r = 0.56), S' (r = 0.49) and TAPSE (r = 0.37). Receiver operating characteristic curves demonstrated that LASER (AUC = 0.865) outperformed fractional area change (AUC = 0.767), tissue Doppler S' (AUC = 0.744) and TAPSE (AUC = 0.645). A cohort derived dichotomous cutoff of 0.2 for LASER was shown to provide optimal diagnostic characteristics (sensitivity of 75%, specificity of 87% and accuracy of 83%) for identifying abnormal RV function. LASER had the highest sensitivity, accuracy, positive and negative predictive values among the parameters studied in the cohort.

Conclusions

Within the study cohort, LASER was shown to have moderate positive correlation with RVEF derived by CMR and more favorable diagnostic performance for detecting RV systolic dysfunction compared to conventional echocardiographic parameters while being simple to obtain and less dependent on image quality than FAC and emerging techniques.

New developments in the understanding of right ventricular function in acute care

PURPOSE OF REVIEW

Right ventricular dysfunction has an important impact on the perioperative course of cardiac surgery patients. Recent advances in the detection and monitoring of perioperative right ventricular dysfunction will be reviewed here.

RECENT FINDINGS

The incidence of right ventricular dysfunction in cardiac surgery has been associated with unfavorable outcomes. New evidence supports the use of a pulmonary artery catheter in cardiogenic shock. The possibility to directly measure right ventricular pressure by transducing the pacing port has expanded its use to track changes in right ventricular function and to detect right ventricular outflow tract obstruction. The potential role of myocardial deformation imaging has been raised to detect patients at risk of postoperative complications.

SUMMARY

Perioperative right ventricular function monitoring is based on echocardiographic and extra-cardiac flow evaluation. In addition to imaging modalities, hemodynamic evaluation using various types of pulmonary artery catheters can be achieved to track changes rapidly and quantitatively in right ventricular function perioperatively. These monitoring techniques can be applied during and after surgery to increase the detection rate of right ventricular dysfunction. All this to improve the treatment of patients presenting early signs of right ventricular dysfunction before systemic organ dysfunction ensue.

[Echocardiographic Assessment of Perioperative Right and Left Ventricular Function]

The perioperative quantification of left and right ventricular function is cornerstone to provide optimal patient care. Echocardiography has emerged as the most important cardiac imaging modality in this setting, mainly due to its rapid availability, non-invasiveness and cost-efficiency. Both the transthoracic and the transesophageal acoustic windows offer manifold modes, e.g., doppler-based measurements or M-mode display, to assess systolic and diastolic ventricular function. An association with patient outcome and corresponding prognostic implications could be demonstrated for the majority of those parameters. Hence, a profound understanding of these measurements is key to delineate sufficient from failing left or right ventricular function and guide treatment decisions. This article gives the reader an overview over the most important measurements, reference values and pitfalls.

Regional Right Ventricular Function Assessed by Intraoperative Three-Dimensional Echocardiography Is Associated With Short-Term Outcomes of Patients Undergoing Cardiac Surgery

Background

The assessment of right ventricular (RV) function in patients undergoing elective cardiac surgery is paramount for providing optimal perioperative care. The role of regional RV function assessment employing sophisticated state-of-the-art cardiac imaging modalities has not been investigated in this cohort. Hence, this study investigated the association of 3D echocardiography-based regional RV volumetry with short-term outcomes.

Materials and Methods

In a retrospective single-center study, patients undergoing elective cardiac surgery were included if they underwent 3D transesophageal echocardiography prior to thoracotomy. A dedicated software quantified regional RV volumes of the inflow tract, apical body and RV outflow tract employing meshes derived from 3D speckle-tracking. Echocardiographic, clinical and laboratory data were entered into univariable and multivariable logistic regression analyses to determine association with the endpoint (in-hospital mortality or the need for extracorporeal circulatory support).

Results

Out of 357 included patients, 25 (7%) reached the endpoint. Inflow RV ejection fraction (RVEF, 32 ± 8% vs. 37 ± 11%, p = 0.01) and relative stroke volume (rel. SV) were significantly lower in patients who reached the endpoint (44 ± 8 vs. 48 ± 9%, p = 0.02), while the rel. SV of the apex was higher (38 ± 10% vs. 33 ± 8%, p = 0.01). Global left and right ventricular function including RVEF and left ventricular global longitudinal strain did not differ. In univariable logistic regression, tricuspid regurgitation grade ≥ 2 [odds ratio (OR) 4.24 (1.66–10.84), p < 0.01], inflow RVEF [OR 0.95 (0.92–0.99), p = 0.01], inflow rel. SV [OR 0.94 (0.90–0.99), p = 0.02], apex rel. SV [OR 1.07 (1.02–1.13), p < 0.01] and apex to inflow rel. SV ratio [OR 5.81 (1.90–17.77), p < 0.01] were significantly associated with the endpoint. In a multivariable model, only the presence of tricuspid regurgitation [OR 4.24 (1.66–10.84), p < 0.01] and apex to inflow rel. SV ratio [OR 6.55 (2.09–20.60), p < 0.001] were independently associated with the endpoint.

Conclusions

Regional RV function is associated with short-term outcomes in patients undergoing elective cardiac surgery and might be helpful for optimizing risk stratification.

Right Ventricular Function Improves Early After Percutaneous Mitral Valve Repair in Patients Suffering From Severe Mitral Regurgitation

Background

Percutaneous mitral valve edge-to-edge procedure (PMVR) using the MitraClip^® system (Abbot Vascular, CA) is an established therapy for severe mitral regurgitation (MR) in patients judged inoperable or at high surgical risk. Besides determining exercise capacity, right ventricular (RV) function has prognostic value in heart failure and after cardiac surgery. We therefore investigated the impact of PMVR on RV function in patients with severe MR.

Methods and Results

Sixty-three patients undergoing PMVR at our department were prospectively enrolled. Transthoracic echocardiography was performed before, early (2–12d) after PMVR and after 3 months, including advanced echocardiographic analyses such as 3D imaging and strain analyses. At baseline, all patients presented with advanced heart failure symptoms. Etiology of MR was more often secondary and, if present, left ventricular (LV) dysfunction was predominantly caused by ischemic cardiomyopathy. PMVR substantially reduced MR to a grade ≤ 2 in most patients. Echocardiographic assessment revealed a largely unchanged LV systolic function early after PMVR, while in contrast RV function substantially improved after PMVR [3D RV EF (%): pre 33.7% [27.4; 39.6], post 40.0% [34.5; 46.0] (p < 0.01 vs. pre), 3 months 42.8% [38.3; 48.1] (p < 0.01 vs. pre); 2D RV GLS (%): pre −12.9% [−14.5; −10.5], post −16.0% [−17.9; −12.6] (p < 0.01 vs. pre), 3 months −17.2% [−21.7; −14.9] (p < 0.01 vs. pre)]. Factors that attenuated RV improvement were larger ventricular volumes, lower LV function, secondary MR, and a higher STS score (all p < 0.05).

Conclusion

By using advanced echocardiographic parameters, we discovered an early improvement of RV function after PMVR that is preserved for months, independent from changes in LV function. Improvement of RV function was less pronounced in patients presenting with an advanced stage of heart failure and a higher burden of comorbidities reflected by the STS score.

A standardized definition for right ventricular failure in cardiac surgery patients

Right ventricular failure (RVF) is a significant cause of mortality and morbidity after cardiac surgery. Despite its prognostic importance, RVF remains under investigated and without a universally accepted definition in the perioperative setting. We foresee that the provision of a standardized perioperative definition for RVF based on practical and objective criteria will help to improve quality of care through early detection and facilitate the generalization of RVF research to advance this field. This article provides an overview of RVF aetiology, pathophysiology, current diagnostic modalities, as well as a summary of existing RVF definitions. This is followed by our proposal for a standardized definition of perioperative RVF, one that captures RV structural and functional abnormalities through a multimodal approach based on anatomical, echocardiographic, and haemodynamic criteria that are readily available in the perioperative setting (Central Image).

Pre-Procedural Right Ventricular Longitudinal Strain and Post-Procedural Tricuspid Regurgitation Predict Mortality in Patients Undergoing Transcatheter Aortic Valve Implantation (TAVI)

Background: Right ventricular (RV) dysfunction has been linked to worse outcomes in patients undergoing TAVI. Assessment of RV function is challenging due to its complex morphology. RV longitudinal strain (LS) assessed by speckle-tracking echocardiography (STE) is a novel measure that may overcome most of the limitations of conventional echocardiographic parameters of RV function. The aim of current study was to assess the prognostic value of RV LS in patients undergoing TAVI and to assess echocardiographic predictors of long-term mortality. Methods and results: A retrospective analysis of all consecutive patients who underwent TAVI at our hospital between 1 January 2015 and 1 June 2016. Indication for TAVI was approved by a local heart-team. Echocardiographic data at baseline and after TAVI were re-analyzed and RV LS was measured in all patients with adequate image quality. A total of 229 patients were included in our study (mean age 83.8 ± 5 years, 62% women, mean EuroSCORE II 5.7 ± 5%). All-cause mortality occurred in 17.3% over a mean follow-up of 929 ± 373 days. In multivariate analysis, only baseline average RV free-wall LS (HR 1.05, 95% CI (1.01 to 1.10), p = 0.049) and more than mild tricuspid valve regurgitation (TR) after TAVI (HR 4.39, 95% CI (2.22 to 8.70), p < 0.001) independently increased the risk of all-cause mortality at long- term follow-up (2.5 years), while conventional echocardiographic parameters of RV function did not predict mortality. Conclusion: Pre-procedural RV LS and post-procedural tricuspid regurgitation significantly predicted long-term all-cause mortality in patients undergoing TAVI while conventional echocardiographic parameters of RV function failed in predicting long-term outcome. RV longitudinal strain by STE should be considered in the routine echocardiographic assessments of patients with severe AS.

Association of Three-Dimensional Mesh-Derived Right Ventricular Strain with Short-Term Outcomes in Patients Undergoing Cardiac Surgery

BACKGROUND

Three-dimensional (3D) right ventricular (RV) strain analysis is not routinely performed perioperatively. Although 3D RV strain adds incrementally to outcome prediction in various cardiac diseases, its role in the perioperative setting is not sufficiently understood. The aim of this study was to investigate the association between 3D RV strain measured on RV meshes created from 3D transesophageal echocardiographic data and short-term outcomes among patients undergoing cardiac surgery.

METHODS

A total of 496 patients undergoing cardiac surgery who underwent intraoperative 3D transesophageal echocardiography (under general anesthesia, before sternotomy) were retrospectively selected, and RV meshes were generated using commercially available speckle-tracking software. Custom-made software automatically quantified longitudinal and circumferential RV strains on the mesh surfaces. Echocardiographic and clinical parameters were entered into logistic regression models to determine their associations with the primary (in-hospital death or need for extracorporeal life support) and secondary (postoperative ventilation > 48 hours) end points.

RESULTS

Mesh-derived RV strain analysis was feasible in 94% of patients and revealed distinct regional patterns with basal-apical gradients for both longitudinal and circumferential strain. Thirty-seven patients (7.6%) reached the primary end point, and 118 patients (23.8%) reached the secondary end point. In a multivariable logistic regression model, serum lactate (P < .01), an emergency indication for surgery (P < .01), tricuspid regurgitation (P < .001), and mesh-derived RV global longitudinal strain (RV-GLS; P < .01) were independently associated with the primary end point, while established measures of RV function (3D RV ejection fraction, fractional area change, tricuspid annular plane systolic excursion) and left ventricular (LV) function (3D-derived LV ejection fraction and LV-GLS) were not independently associated. Hematocrit (P < .01), serum lactate (P < .001), pulmonary hypertension (P = .04), tricuspid regurgitation (P < .01), emergency procedures (P = .02), LV-GLS (P = .02), and RV-GLS (P < .001) were associated with the secondary end point.

CONCLUSIONS

RV-GLS measured on RV meshes derived from 3D transesophageal echocardiography was independently associated with short-term outcomes in patients undergoing cardiac surgery and might be helpful for identifying patients at risk for adverse postoperative events.

The Right Ventricle in the Trans-Catheter Era: A Perspective for Planning Interventions

Dysfunction of the right ventricle (RV) is common in patients with advanced left-sided valve disease and the significant impact of RV dysfunction on both short and long-term outcome is well established. However, considerations of RV function are largely absent in current management guidelines for valve disease and cardiac procedural risk models. As the indications and use of trans-catheter therapies rapidly expand for patients with acquired valvular disease, it is critical for clinicians to understand and consider RV function when making decisions for these patients. This review summarizes contemporary data on the assessment of RV function, the prognostic importance of baseline RV dysfunction on surgical and transcatheter procedures for acquired left-sided valvular disease, and the relative impact of these interventions on RV function. Baseline RV dysfunction is a powerful predictor of poor short- and long-term outcome after any therapeutic intervention for acquired left-sided cardiac valve disease. Surgical intervention for aortic or mitral valve disease is associated with a significant but transient decline in RV function, whereas trans-catheter procedures generally do not appear to have detrimental effects on either longitudinal or global RV function. Guidelines for therapy in patents with acquired left-sided valvular disease should account for RV dysfunction. Whereas surgical intervention in these patients leads to a predictable decline in RV function, trans-catheter therapies largely do not appear to have this effect. Further study is needed to determine the impact of these findings on current practice.

Role of Echocardiography for the Perioperative Assessment of the Right Ventricle

Purpose of Review

This review aims to highlight the perioperative echocardiographic evaluation of right ventricular (RV) function with strengths and limitations of commonly used and evolving techniques. It explains the value of transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) and describes the perioperative changes of RV function echocardiographers should be aware of.

Recent Findings

RV dysfunction is an entity with strong influence on outcome. However, its definition and assessment in the perioperative interval are not well-defined. Moreover, values assessed by TTE and TEE are not interchangeable; while some parameters seem to correlate well, others do not. Myocardial strain analysis and three-dimensional echocardiography may overcome the limitations of conventional echocardiographic measures and provide further insight into perioperative cardiac mechanics.

Summary

Echocardiography has become an essential part of modern anesthesiology in patients with RV dysfunction. It offers the opportunity to evaluate not only global but also regional RV function and distinguish alterations of RV contraction.

Predicting and measuring mortality risk after transcatheter aortic valve replacement

Introduction: Over the last decade, transcatheter aortic valve replacement (TAVR) has emerged as a treatment option for most patients with severe symptomatic aortic stenosis (AS). With growing indications and exponential increase in the number of TAVR procedures, it is important to be able to accurately predict mortality after TAVR.Areas covered: Herein, we review the surgical and TAVR-specific mortality prediction models (MPMs) and their performance in their original derivation and external validation cohorts. We then discuss the role of other important risk assessment tools such as frailty, echocardiographic parameters, and biomarkers in patients, being considered for TAVR.Expert opinion: Conventional surgical MPMs have suboptimal predictive performance and are mis-calibrated when applied to TAVR populations. Although a number of TAVR-specific MPMs have been developed, their utility is also limited by their modest discriminative ability when applied to populations external to their original derivation cohorts. There is an unmet need for robust TAVR MPMs that accurately predict post TAVR mortality. In the interim, heart teams should utilize the currently available TAVR-specific MPMs in conjunction with other prognostic factors, such as frailty, echocardiographic or computed tomography (CT) imaging parameters, and biomarkers for risk assessment of patients, being considered for TAVR.

Could strain echocardiography help to assess systolic function in critically ill COVID-19 patients?

Strain echocardiography enables the automatic quantification of the global longitudinal strain (GLS), which is a direct measure of ventricular shortening during systole. In the current context of overwhelmed ICUs and clinician shortage, GLS has the advantage to be quick and easy to measure by non-experts. However, little is known regarding its value to assess bi-ventricular systolic function in critically ill COVID-19 patients. Therefore, we designed a study to compare right and left ventricular GLS with classic echo-Doppler indices of systolic function, namely the ejection fraction for the left ventricle (LVEF) and the fractional area change (FAC), the tricuspid annular plane systolic excursion (TAPSE), and the tissue Doppler velocity of the basal free lateral wall (S’) for the right ventricle. Eighty transthoracic echocardiographic evaluations done in 30 ICU patients with COVID-19 were analyzed. We observed a fair relationship (r = 0.73, p < 0.01) between LVEF and left ventricular GLS. The GLS cut-off value of − 22% identified a LVEF < 50% with a sensitivity of 63% and a specificity of 80%. All patients with a GLS > − 17% had a LVEF < 50%. Although statistically significant, relationships between FAC (r = 0.41, p < 0.01), TAPSE (r = 0.26, p < 0.05) and right ventricular GLS were weak. S’ was not correlated with right ventricular GLS. In conclusion, left ventricular GLS was useful to assess left ventricular systolic function. However, right ventricular GLS was poorly correlated with FAC, TAPSE and S’. Further studies are needed to clarify what is the best method to assess right ventricular systolic function in ICU patients with COVID-19.

[Classification of stages of severe aortic stenosis based on the prevalence of extravalvular heart damage]

This thematic review focuses on recently proposed classification of stages in pronounced aortic stenosis based on the prevalence of extravalvular cardiac damage and its modified variant designed for asymptomatic patients. The review presents studies, which analyzed the predictive significance of the proposed classification. The use of this classification allows predicting the course of disease in patients with pronounced aortic stenosis in valve replacement. The classification is based on routinely used structural and functional echocardiographic signs with already proven predictive values with respect of adverse events in patients after aortic valve replacement. The review discusses limitations of the classification for pronounced aortic stenosis stages based on the prevalence of extravalvular cardiac damage.

Perioperative Course of Three-Dimensional-Derived Right Ventricular Strain in Coronary Artery Bypass Surgery: A Prospective, Observational, Pilot Trial

OBJECTIVES

Few data exist on perioperative three-dimensional-derived right ventricular strain. The authors aimed to describe the perioperative course of three-dimensional-derived right ventricular strain in coronary artery bypass graft (CABG) surgery patients.

DESIGN

Prospective, observational, pilot trial.

SETTING

Single university hospital.

PARTICIPANTS

The study comprised 40 patients with preserved left ventricular and right ventricular (RV) function undergoing isolated on-pump CABG surgery.

INTERVENTIONS

Three-dimensional strain analysis and standard echocardiographic evaluation of RV function were performed preoperatively (T1) and postoperatively (T4) with transthoracic echocardiography (TTE) and intraoperatively before sternotomy (T2) and after sternotomy (T3) with transesophageal echocardiography (TEE). All echocardiographic measurements were performed under stable hemodynamic conditions and predefined fluid management without any vasoactive support.

MEASUREMENTS AND MAIN RESULTS

The measurements of three-dimensional-derived RV free-wall strain (3D-RV FWS) and RV ejection fraction were performed using TomTec 4D RV-Function 2.0 software. Philips QLAB 10.8 was used to analyze tissue velocity of the tricuspid annulus, tricuspid annular systolic excursion, and RV fractional area change. There were no significant differences (median [interquartile range {IQR}]) between preoperative TTE and intraoperative TEE measurements for 3D-RV FWS (T1 v T2: -22.35 [IQR -17.70 to -27.22] v -24.35 [IQR -20.63 to -29.88]; not significant). 3D-RV FWS remained unchanged after sternotomy (T2 v T3: -24.35 [IQR -20.63 to -29.88] v -23.75 [IQR -20.25 to -29.28]; not significant) but deteriorated significantly after CABG (T1 v T4: -22.35 [IQR -17.70 to -27.22] v -18.5 [IQR -16.90 to -21.65]; p = 0.004).

CONCLUSION

In patients undergoing on-pump CABG, 3D-RV FWS values for awake, spontaneously breathing patients measured with TTE and values assessed in patients under general anesthesia with TEE did not significantly differ. Three-dimensional RV FWS did not change after sternotomy but deteriorated after on-pump CABG.

Global Longitudinal Strain: Is It Time to Change the Preoperative Cardiac Assessment of Oncology Patients?

The introduction of new anticancer treatment modalities has improved survival rates, transforming cancer into a chronic disease in many instances. One of the most devastating complications of cancer treatment is cancer therapy-related cardiac dysfunction. Adequate preoperative assessment of any significant cancer therapy-related cardiac impairment is critical, and may be missed with conventional measures. The assessment of global longitudinal strain by speckle-tracking echocardiography is more sensitive for the early detection of cardiac contractility before a decline in ejection fraction can be discovered. Global longitudinal strain can also predict postoperative cardiac dysfunction, which makes it a good alternative for preoperative cardiac assessment in the oncology population when cancer therapies have been administered that can alter normal performance.

Comparison of echocardiographic parameters with cardiac magnetic resonance imaging in the assessment of right ventricular function

INTRODUCTION

The right ventricle (RV) strain measured by speckle tracking (RVS) is an echocardiographic parameter used to assess RV function. We compared RVS to RV fractional area change (FAC%), tricuspid annular plane systolic excursion (TAPSE) and Doppler tissue imaging-derived peak systolic velocity (S') in the assessment of right ventricular (RV) systolic function measured using cardiac magnetic resonance imaging (MRI).

METHODS

We enrolled consecutive patients who underwent cardiac MRI between Jan 2012 and Dec 2017 and a transthoracic echocardiogram (TTE) within 1 month of the MRI with no interval event. Baseline clinical characteristics and MRI parameters were extracted from chart review. Echocardiographic parameters were measured prospectively. TTE parameters including RVS, TAPSE, S', and FAC% were tested for accuracy to identify impaired RV EF (EF < 45% & <30%) using receiver operator curves.

RESULTS

The study cohort included 500 patients with mean age 55 years ± 18 and peak tricuspid regurgitation velocity 2.7 ± 1.4 m/s. The area under ROC for RVS was 0.69 (95% CI 0.63-0.75) and 0.78 (95% CI 0.70-0.88) to predict RVEF < 45% & RVEF < 30%, respectively. The RV FAC% had second highest accuracy of predicting RVEF among all the TTE parameters tested in study.

CONCLUSION

Right ventricular strain is the most accurate echocardiographic method to detect impaired right ventricular systolic function when using MRI as the gold standard.

Acute changes of global and longitudinal right ventricular function: an exploratory analysis in patients undergoing open-chest mitral valve surgery, percutaneous mitral valve repair and off-pump coronary artery bypass grafting

Background

Right ventricular (RV) function is an important prognostic indicator. The acute effects of cardiac interventions or cardiac surgery on global and longitudinal RV function are not entirely understood. In this study, acute changes of RV function during mitral valve surgery (MVS), percutaneous mitral valve repair (PMVR) and off-pump coronary artery bypass surgery (OPCAB) were investigated employing 3D echocardiography.

Methods

Twenty patients scheduled for MVS, 23 patients scheduled for PMVR and 25 patients scheduled for OPCAB were included retrospectively if patients had received 3D transesophageal echocardiography before and immediately after MVS, PMVR or OPCAB, respectively. RV global and longitudinal function was assessed using a 3D multiparameter set consisting of global right ventricular ejection fraction (RVEF), tricuspid annular plane systolic excursion (TAPSE), longitudinal contribution to RVEF (RVEF_long) and free wall longitudinal strain (FWLS).

Results

Longitudinal RV function was significantly depressed immediately after MVS, as reflected by all parameters (RVEF_long: 20 ± 5% vs. 13 ± 6%, p <  0.001, TAPSE: 13.1 ± 5.1 mm vs. 11.0 ± 3.5 mm, p = 0.04 and FWLS: −20.1 ± 7.1% vs. -15.4 ± 5.1%, p <  0.001, respectively). The global RVEF was slightly impaired, but the difference did not reach significance (37 ± 13% vs. 32 ± 9%, p = 0.15). In the PMVR group, both global and longitudinal RV function parameters were unaltered, whereas the OPCAB group showed a slight reduction of RVEF_long only (18 ± 7% vs. 14 ± 5%, p <  0.01). RVEF_long yielded moderate case-to-case but good overall reproducibility.

Conclusions

TAPSE, FWLS and RVEF_long reflect the depression of longitudinal compared to global RV function initially after MVS. PMVR alone had no impact, while OPCAB had a slight impact on longitudinal RV function. The prognostic implications of these phenomena remain unclear and require further investigation.

Changes in Right Ventricular Function After Off-Pump Coronary Artery Bypass Grafting

OBJECTIVE

Right ventricular (RV) dysfunction is associated with poor outcomes after cardiac surgery. The aim of this study was to assess RV systolic and diastolic function in the perioperative period after off-pump coronary artery bypass grafting (OPCAB).

DESIGN

Prospective observational study.

SETTINGS

Tertiary care hospital.

PARTICIPANTS

Thirty adult patients undergoing OPCAB.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Transthoracic echocardiography was performed twice: first preoperatively and second postoperatively, when patients were moved to wards. The following five parameters of RV systolic function were used: tricuspid annular plane systolic excursion (TAPSE), systolic tissue Doppler imaging of lateral tricuspid annulus (S'), fractional area change (FAC), RV myocardial performance index (RIMP), and isovolumic acceleration (IVA). Grading of RV diastolic function (RVDD) was done as per guidelines. Paired t test was used for comparing means and χ² test was used for categorical and ordinal data. The parameters of RV longitudinal function (TAPSE and S') reduced significantly (preoperative 21.93 ± 2.80 mm and 13.24 ± 2.24 cm/s to postoperative 11.67 ± 1.91 mm and 10.31 ± 1.56 cm/s, respectively, p < 0.001), whereas parameters of RV global function (FAC, RIMP, and IVA) remained preserved (preoperative 46.75 ± 6.80%, 0.34 ± 0.06, and 4.66 ± 0.87 m/s² to postoperative 46.21 ± 6.44%, 0.36 ± 0.06, and 4.37 ± 0.83 m/s²; p values of 0.76, 0.13, and 0.11, respectively). The median grade of RVDD worsened from normal in the preoperative period to pseudo-normal in the postoperative period (p < 0.001). The changes in both RV systolic and diastolic function were similar in patients with normal and reduced left ventricular systolic function.

CONCLUSIONS

RV function can be assessed in perioperative settings with two-dimensional and tissue Doppler imaging. For systolic function assessment, exclusive measurement of longitudinal parameters might be inadequate; use of complementary global parameters like FAC, RIMP, and IVA is essential to complete the RV assessment after OPCAB. RVDD worsened significantly after OPCABG.

Meta-analysis of right ventricular function in patients with aortic stenosis after transfemoral aortic valve replacement or surgical aortic valve replacement

Background:

Right ventricular function (RVF) is an independent predictor of prognosis for patients undergoing aortic valve replacement: transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). The effect of transfemoral aortic valve replacement (TF-TAVR) on RVF is uncertain. We aimed to perform a meta-analysis of the effect of TF-TAVR on RVF in patients with aortic stenosis (AS) and compare the effect of TF-TAVR with SAVR.

Methods:

We searched relevant studies from PubMed, Embase, Cochrane Library databases, and Web of Science. Furthermore, two reviewers (Wang AQ and Cao YS) extracted all relevant data, which were then double checked by another two reviewers (Zhang M and Qi GM). We used the forest plot to present results. Tricuspid annular plane systolic excursion (TAPSE) was the primary outcome.

Results:

This meta-analysis included 11 studies. There were 353 patients who underwent TF-TAVR, and 358 patients who were subjected to SAVR. There was no significant difference in TAPSE at 1 week and 6 months as well as right ventricular ejection fraction (RVEF) at <2 weeks and 6 months after TF-TAVR. For the SAVR group, TAPSE at 1 week and 3 months as well as fractional area change (FAC) at 3 months post procedure were significantly aggravated, while RVEF did not change significantly. Moreover, TAPSE post-TF-TAVR was significantly improved as compared with post-SAVR. The △TAPSE, the difference between TAPSE post-procedure and TAPSE prior to procedure, was also significantly better in the TF-TAVR group than in the SAVR group.

Conclusion:

RVF was maintained post TF-TAVR. For SAVR, discrepancy in the measured parameters exists, as reduced TAPSE indicates compromised longitudinal RVF, while insignificant changes in RVEF implicate maintained RVF post procedure. Collectively, our study suggests that the baseline RV dysfunction and the effect of TF-TAVR versus SAVR on longitudinal RVF may influence the selection of aortic valve intervention.

Association of Right Ventricular Longitudinal Strain with Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement

BACKGROUND

Conventional right ventricular (RV) echocardiographic measurements of systolic function (SF) have demonstrated conflicting results when their association with long-term outcomes after transcatheter aortic valve replacement (TAVR) is evaluated. RV free-wall (FW) longitudinal strain (LS) is a novel, single parameter to measure RV SF and may provide a better evaluation than fractional area change, tricuspid annular plane systolic excursion, and myocardial velocity (S'). The value of RV FW LS in patients undergoing TAVR and its association with 1-year mortality are unknown. The aim of this study was to test the hypothesis that RV FW LS would be associated with 1-year all-cause mortality in patients undergoing TAVR.

METHODS

Consecutive patients who underwent TAVR between 2007 and 2014 in whom RV FW LS was measurable were included; a subgroup that had 1-year follow-up echocardiographic evaluation of RV FW LS was analyzed. FW LS was derived from speckle-tracking analyses. The standard reference was determined as normal or impaired RV SF, the latter defined as the presence of ≥50% of tricuspid annular plane systolic excursion < 1.7 cm, S' < 9.5 cm/sec, and fractional area change < 35%. Cox proportional-hazards regression analysis was used to assess the association of RV FW LS with 1-year all-cause mortality.

RESULTS

Of 612 patients, 334 were included for RV FW LS analysis on pre-TAVR echocardiography (feasibility 55%); exclusion criteria included atrial fibrillation (n = 92 [15%]), pacemaker (n = 73 [12%]), and poor image quality (n = 113 [18%]). Baseline impaired RV SF was present in 19% of cases. RV FW LS did not change significantly at 1-year follow-up, in both the groups with baseline impaired and normal function. Cox regression analysis showed that RV FW LS was associated with all-cause mortality at 1 year (hazard ratio, 1.06; 95% CI, 1.01-1.11). For each unit increase in RV FW LS, there was a 6% higher risk for 1-year mortality.

CONCLUSIONS

In a high-risk TAVR population, RV FW LS should be considered a single echocardiographic parameter for the assessment of RV SF. When measurable, RV FW LS is associated with all-cause mortality at 1 year after TAVR.

Conventional echocardiographic parameters or three-dimensional echocardiography to evaluate right ventricular function in percutaneous edge-to-edge mitral valve repair (PMVR)

Introduction

In this study, we evaluated right ventricular (RV) function before and after percutaneous mitral valve repair (PMVR) using conventional echocardiographic parameters and novel 3DE data sets acquired prior to and directly after the procedure.

Patients and methods

Observational study on 45 patients undergoing PMVR at an university hospital.

Results

In the overall collective, the 3D RV-EF before and after PMVR showed no significant change (p = 0.16). While there was a significant increase of the fractional area change (FAC, from 23 [19–29] % to 28 [24–33] %, p = 0.001), no significant change of the tricuspid annular plane systolic excursion (TAPSE, from 17 ± 6 mm to 18 ± 5 mm (standard deviation), p = 0.33) was observed. Regarding patients with a reduced RV-EF (< 35%), a significant RV-EF improvement was observed (from 27 [23–34] % to 32.5 [30–39] % (p = 0.001). 71.4% of patients had an improved clinical outcome (improvement in 6-minute walk test and/or improvement in NYHA class of more than one grade), whereas clinical outcome did not improve in 28.6% of patients. Using univariate logistic regression analysis, the post-PMVR RV-EF (OR 1.15: 95% CI 1.02–1.29; p = 0.02) and the change in RV-EF (OR 1.13: 95% CI 1.02–1.25; p = 0.02) were significant predictors for improved clinical outcome at 6 months follow up.

Conclusion

Thus, RV function may be an important non-invasive parameter to add to the predictive parameters indicating a potential clinical benefit from treatment of severe mitral regurgitation using PMVR.

Superior Prognostic Value of Right Ventricular Free Wall Compared to Global Longitudinal Strain in Patients With Heart Failure

BACKGROUND

Global right ventricular (RV) longitudinal strain (RVGLS) and free wall RV longitudinal strain (RVFWS) have both been advocated as sensitive tools to evaluate RV function and predict prognosis in patients with heart failure and reduced ejection fraction (HFrEF). However, because the interventricular septum is an integral part of the left ventricle (LV) also, RVGLS might be influenced by LV dysfunction. Thus, we compared the prognostic performance of either RV strain parameter in HFrEF patients, also taking into account the degree of LV systolic dysfunction.

METHODS

In 288 prospectively enrolled outpatients with stable HFrEF, RVGLS and RVFWS were assessed by speckle-tracking and LV systolic function by global longitudinal strain and LV ejection fraction. Patients were followed up for 30.2 ± 23.0 months; the primary endpoint was all-cause death/heart failure-related hospitalization. Prognostic performance was assessed by C-statistic and net reclassification improvement.

RESULTS

There were 95 events during follow-up. By univariable analysis, both RVGLS (hazard ratio × 1 SD, 1.60; 95% CI, 1.29-1.99; P < .0001) and RVFWS (hazard ratio × 1 SD, 1.82; 95% CI, 1.45-2.29; P < .0001) were associated with outcome, and both remained significant after correction for EMPHASIS risk score, New York Heart Association class, natriuretic peptides, and therapy. However, after further correction for LV systolic function parameters, only RVFWS remained significantly associated with outcome (P < .01). A basic prediction model was improved by adding RVFWS (net reclassification improvement 0.390; P < .05), but not RVGLS.

CONCLUSIONS

Although both RVGLS and RVFWS have prognostic value, RVFWS better predicts outcome in HFrEF patients, mainly because it is less influenced by LV longitudinal dysfunction.

Impact of tricuspid regurgitation and right ventricular dysfunction on outcomes after transcatheter aortic valve replacement: A systematic review and meta-analysis

Far less attention has been paid to the prognostic effect of right-side heart disease on outcomes after transcatheter aortic valve replacement (TAVR) when compared with the left side. Therefore, we performed a systematic review and meta-analysis on the impact of tricuspid regurgitation (TR) and right ventricular (RV) dysfunction on outcomes after TAVR. We hypothesized that TR and RV dysfunction may have a deleterious effect on outcomes after TAVR. Article revealing the prognostic effect of TR and RV dysfunction on outcomes after TAVR were being integrated. Random or fixed effect model was adopted in accordance with the heterogeneity. There were nine studies with a total of 6466 patients enrolled after a comprehensive literature search of the MEDLINE/PubMed, EMBASE, ISI Web of Science, and Cochrane databases. The overall analysis revealed that moderate or severe TR at baseline increased all-cause mortality after TAVR (HR = 1.79, CI 95% 1.52-2.11, P < 0.001). Both baseline RV dysfunction (HR = 1.53, CI 95% 1.27-1.83, P < 0.001) and presence of RV dilation (HR = 1.83, CI 95% 1.47-2.27, P < 0.001) were associated with all-cause mortality. Both baseline moderate or severe TR and RV dysfunction worsen prognosis after TAVR and careful assessment of right heart function should be done for clinical decision by the heart team before the TAVR procedure.

A Comparison of Left- and Right-Sided Strain Software for the Assessment of Intraoperative Right Ventricular Function

OBJECTIVE

To compare intraoperative right ventricular (RV) strain measurements made with left ventricular (LV) strain software commonly found on the echocardiography machine (Philips QLAB chamber motion quantification, version 10.7, Philips, Amsterdam, The Netherlands), with offline analysis using the dedicated RV strain software (EchoInsight, version 2.2.6.2230, Epsilon Imaging, Ann Arbor, MI).

DESIGN

Prospective, nonrandomized, observational study.

SETTING

Single tertiary level, university-affiliated hospital.

PARTICIPANTS

The study comprised 48 patients undergoing transesophageal echocardiography for cardiac or noncardiac surgery.

INTERVENTIONS

Two-dimensional (2D) and 3-dimensional (3D) images of the right ventricle were obtained. Intraoperative 2D images were analyzed in real time for RV free wall strain (FWS) and global longitudinal strain (GLS) using QLAB chamber motion quantification (CMQ) LV strain software on the echocardiography machine. Two dimensional images were then analyzed offline to determine the RV FWS and GLS using EchoInsight RV-specific strain software. Three-dimensional images were then analyzed offline to detemine the 3D RV ejection fraction (3D RV EF) using TomTec 4D RV function (Unterschleissheim, Germany). Spearman's correlation and Bland-Altman analyses were used to characterize the relationship between RV strain measurements. Both types of strain measurements were compared to a reference standard of 3D RV EF.

MEASUREMENTS AND MAIN RESULTS

Intraoperative RV strain measurements using LV-specific strain software correlated with offline RV strain measurements using the RV-specific strain software (FWS rho = 0.85; GLS rho = 0.81). The bias and limits of agreement were 0.75% (- 6.66 to 8.17) for FWS and -4.53% (-11.55 to 2.50) for GLS. The sensitivity and specificity for RV dysfunction for the intraoperative LV-specific software were 94% (95% confidence interval [CI] 73-100) and 70% (95% CI 51-85), respectively, for RV FWS and 94% (95% CI 73-100) and 67% (95% CI 47-83), respectively, for RV GLS. The sensitivity and specificity for RV dysfunction for the offline RV-specific software were 89% (95% CI 65-99) and 73% (95% CI 54-88), respectively, for RV FWS and 94% (95% CI 73-100) and 30% (95% CI 15-49), respectively, for RV GLS.

CONCLUSION

Intraoperative RV strain measurements using LV-specific strain software commonly available on the echocardiography machine (QLAB CMQ) correlate with offline RV strain measurements using RV-specific strain software (EchoInsight). The bias and limits of agreement for these left- and right-sided strain software suggest that these 2 measures of RV function cannot be used interchangeably. Both, however, were sensitive measures of RV dysfunction and therefore are likely clinically relevant.

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.

Right Ventricular Function in Left Heart Disease

Right ventricular (RV) function is an independent prognostic factor for short- and long-term outcomes in cardiac surgical patients. Patients with mitral valve (MV) disease are at increased risk of RV dysfunction before and after MV operations. Yet RV function is not part of criteria for decision making or risk stratification in this setting. The role of MV disease in the development of pulmonary hypertension (PHTN) and the ultimate impact of PHTN on RV function have been well described. Nonetheless, there are other mechanisms by which MV disease and MV surgery affect RV performance. Research suggests that PHTN may not be the most important determinant of RV dysfunction. Both RV dysfunction and PHTN have independent prognostic significance. This review explores the unique anatomic and functional features of the RV and the pathophysiologic and prognostic implications of RV dysfunction in patients with MV disease in the perioperative period.

Right Ventricular Systolic Performance Determined by 2D Speckle-Tracking Echocardiography and Acute Kidney Injury After Cardiac Surgery

OBJECTIVE

An association between central venous pressure and acute kidney injury (AKI) has been observed following cardiac surgery, but it is unknown whether this reflects intravascular volume status or impaired right ventricular (RV) myocardial performance. This study was performed to test the hypothesis that decreased RV peak longitudinal strain (PLSS), as measured by 2-dimensional speckle-tracking echocardiography, is associated with AKI following cardiac surgery.

DESIGN

Retrospective observational cohort study.

SETTING

Cardiovascular intensive care unit in a 576-bed referral hospital.

PARTICIPANTS

Adult patients having undergone cardiac surgery in whom a transthoracic echocardiogram (TTE) was performed within 48 hours after chest closure.

INTERVENTIONS

This was a retrospective study. Urine output and serum creatinine values were recorded at baseline and for 48 hours after surgery. Statistical analysis was performed to identify differences in baseline demographic and echo-derived values between patients with and without postoperative AKI criteria.

MEASUREMENTS AND MAIN RESULTS

One hundred ninety-nine subjects had postprocessing of TTE performed. AKI was observed in 87% of patients (173 of 199). Age, body mass index, and preoperative serum creatinine were higher in the AKI group. The mean PLSS was -17.2% ± 4.3% versus -17.1% ± 3.7% in patients with AKI versus those without (p = 0.95). The calculated RV systolic pressure was elevated in the AKI group compared to the non-AKI group (38.9 ± 9.9 v 34.6 ± 7.9 mmHg, p = 0.02).

CONCLUSION

In this cohort of cardiac surgery patients, speckle-tracking analysis of RV myocardial performance was feasible. Elevated RV systolic pressure associated with AKI, while speckle tracking-derived echocardiography measurements did not.

Which echocardiographic parameters improve the risk prediction for peri-operative outcomes in patients undergoing coronary bypass surgery: a prospective study

OBJECTIVE

To assess the performance of transthoracic echocardiographic parameters to predict operative mortality and morbidity in patients undergoing coronary artery bypass grafting, and to assess its incremental prognostic value as compared to the Society of Thoracic Surgeons (STS) score.

MATERIALS AND METHODS

We prospectively collected the clinical and biological data required to calculate the STS score in patients hospitalised for coronary artery bypass grafting. Preoperative transthoracic echocardiography was performed for each patient. The primary endpoint was 30-day mortality or major morbidity (i.e. stroke, renal failure, prolonged ventilation, deep sternal wound infection, reoperation) as defined by the STS. The secondary endpoint was prolonged hospitalisation for over 14 days.

RESULTS

A total of 172 patients was included (mean age 66.1±10.2 years, 12.2% were women). The primary endpoint occurred in 33 patients (19.2%), and 28 patients (16.3%) had a prolonged hospital stay. Independent predictive factors for the primary endpoint were an increased left atrial volume (>31 mL/m²; odds ratio (OR) 3.55, 95% confidence interval (CI) 1.38-9.12; P=0.004) and a decreased tricuspid annular plane systolic excursion (<20 mm; OR 3.45, 95% CI 1.47-8.21; P=0.008). The predictive value of the multivariate model increased when the two echocardiographic parameters were added to the STS score (area under the curve 0.598 vs. 0.695, P=0.001; integrated discrimination improvement 7.44%).

CONCLUSION

In patients undergoing coronary artery bypass grafting, preoperative assessment of left atrial size and tricuspid annular plane systolic excursion should be performed systematically, as it provides additional prognostic information to the STS score.

Role of Two-Dimensional Speckle-Tracking Echocardiography Strain in the Assessment of Right Ventricular Systolic Function and Comparison with Conventional Parameters

Despite the already well-known role the right side of the heart plays in many diseases, right ventricular (RV) function has only recently been carefully considered. Echocardiography is the first-line diagnostic technique for the assessment of the right ventricle and right atrium, whereas cardiac magnetic resonance is considered the gold standard but is limited by cost and availability. According to the current guidelines, systolic RV function should be assessed by several conventional measurements, but the efficacy of these parameters as diagnostic and prognostic tools has been questioned by many authors. The development in recent years of myocardial deformation imaging techniques and their application to the right heart chambers has allowed deeper evaluation of the importance of RV function in the pathophysiology of a large number of cardiovascular conditions, but the real value of this new tool has not been completely clarified. The aim of this review is to provide a wide and careful analysis of findings available in the literature about the assessment of RV systolic function by strain measurements, comparing them with conventional parameters and evaluating their role in several clinical settings.