Significant Disagreement Between Conventional Parameters and 3D Echocardiography-Derived Ejection Fraction in the Detection of Right Ventricular Systolic Dysfunction and Its Association With Outcomes

Assessing Right Ventricular Function in the Perioperative Setting, Part I: Echo-Based Measurements

This article explores the growing significance of right ventricular (RV) function, particularly in perioperative settings. The right ventricle plays a crucial role in predicting morbidity and mortality, especially in cardiac surgeries. Right ventricular failure is associated with high in-hospital mortality, making accurate assessment vital. The article discusses echocardiographic evaluation, emphasizing both qualitative and quantitative measures, including tricuspid annular plane systolic excursion, fractional area change, and myocardial strain imaging. Understanding RV pathophysiology is essential for effective diagnosis and management, particularly in dynamic perioperative conditions influenced by ventilation, anesthesia, and extracorporeal circulation.

Incremental Prognostic Value of Echocardiography Measures of Right Ventricular Systolic Function in Patients With Chronic Heart Failure

BACKGROUND

Tricuspid annular plane systolic excursion (TAPSE), Doppler tissue imaging-derived tricuspid lateral annular systolic wave velocity (S'), and right ventricular fractional area change (RV-FAC) are the most widely used echocardiographic measures of right ventricular systolic function. This study aimed to compare the prognostic value of TAPSE, S', and RV-FAC in a large cohort of patients with chronic heart failure.

METHODS

Consecutive outpatients with heart failure and left ventricular ejection fraction <50% on guideline-recommended therapies undergoing echocardiography were followed up for the end point of cardiac and all-cause death.

RESULTS

Among 1590 patients (71±12 years, 77% men, left ventricular ejection fraction 34%±9%), 202 (13%) died from cardiac causes during a median follow-up of 28 (interquartile range, 14-40) months. According to the recommended cut points for TAPSE (<17 mm), S' (<9.5 cm/s), or RV-FAC (<35%), right ventricular systolic dysfunction was found in 37%, 40%, and 35% of patients, respectively, with 21%, 31%, and 33% of discordant cases comparing TAPSE versus S', TAPSE versus RV-FAC, and S' versus RV-FAC. Both TAPSE <17 mm and RV-FAC <35% were more accurate than S' <9.5 cm/s in predicting the risk of cardiac death (P<0.001), and their combination showed incremental prognostic power (P<0.001). Adding S' to the combination of TAPSE and RV-FAC did not provide further incremental value (P=0.145). Similar findings were obtained when all-cause death was considered as the end point.

CONCLUSIONS

In patients with chronic heart failure and left ventricular ejection fraction <50%, TAPSE, and RV-FAC are more accurate than S' in predicting the risk of cardiac and all-cause death. Considering both RV-FAC and TAPSE provides incremental prognostic value.

Arrhythmogenic Right Ventricular Cardiomyopathy: A Comprehensive Review

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is characterized by structural abnormalities, arrhythmias, and a spectrum of genetic and clinical manifestations. Clinically, ARVC is structurally distinguished by right ventricular dilation due to increased adiposity and fibrosis in the ventricular walls, and it manifests as cardiac arrhythmias ranging from non-sustained ventricular tachycardia to sudden cardiac death. Its prevalence has been estimated to range from 1 in every 1000 to 5000 people, with its large range being attributed to the variability in genetic penetrance from asymptomatic to significant burden. It is even suggested that the prevalence is underestimated, as the presence of genotypic mutations does not always lead to clinical manifestations that would facilitate diagnosis. Additionally, while set criteria have been in place since the 1990s, newer understanding of this condition and advancements in cardiac technology have prompted multiple revisions in the diagnostic criteria for ARVC. Novel discoveries of gene variants predisposing patients to ARVC have led to established screening techniques while providing insight into genetic counseling and management. This review aims to provide an overview of the genetics, pathophysiology, and clinical approach to ARVC. It will also focus on clinical presentation, ARVC diagnostic criteria, electrophysiological findings, including electrocardiogram characteristics, and imaging findings from cardiac MRI, 2D, and 3D echocardiogram. Current management options-including anti-arrhythmic medications, device indications, and ablation techniques-and the effectiveness of treatment will also be reviewed.

Deep Learning-Enabled Assessment of Right Ventricular Function Improves Prognostication After Transcatheter Edge-to-Edge Repair for Mitral Regurgitation

BACKGROUND

Right ventricular (RV) function has a well-established prognostic role in patients with severe mitral regurgitation (MR) undergoing transcatheter edge-to-edge repair (TEER) and is typically assessed using echocardiography-measured tricuspid annular plane systolic excursion. Recently, a deep learning model has been proposed that accurately predicts RV ejection fraction (RVEF) from 2-dimensional echocardiographic videos, with similar diagnostic accuracy as 3-dimensional imaging. This study aimed to evaluate the prognostic value of the deep learning-predicted RVEF values in patients with severe MR undergoing TEER.

METHODS

This multicenter registry study analyzed the associations between the predicted RVEF values and 1-year mortality in patients with severe MR undergoing TEER. To predict RVEF, 2-dimensional apical 4-chamber view videos from preprocedural transthoracic echocardiographic studies were exported and processed by a rigorously validated deep learning model.

RESULTS

Good-quality 2-dimensional apical 4-chamber view videos could be retrieved for 1154 patients undergoing TEER between 2017 and 2023. Survival at 1 year after TEER was 84.7%. The predicted RVEF values ranged from 26.6% to 64.0% and correlated only modestly with tricuspid annular plane systolic excursion (Pearson R=0.33; P<0.001). Importantly, predicted RVEF was superior to tricuspid annular plane systolic excursion levels in predicting 1-year mortality after TEER (area under the curve, 0.687 versus 0.625; P=0.029). Furthermore, Kaplan-Meier survival analysis revealed that patients with reduced RV function (n=723; defined as a predicted RVEF of <45%) had significantly worse 1-year survival rates than patients with preserved RV function (n=431; defined as a predicted RVEF of ≥45%; 80.3% [95% CI, 77.4%-83.3%] versus 92.1% [95% CI, 89.5%-94.7%]; hazard ratio for 1-year mortality, 2.67 [95% CI, 1.82-3.90]; P<0.001).

CONCLUSIONS

Deep learning-enabled assessment of RV function using standard 2-dimensional echocardiographic videos can refine the prognostication of patients with severe MR undergoing TEER. Thus, it can be used to screen for patients with RV dysfunction who might benefit from intensified follow-up care.