Elsevier

International Journal of Cardiology

Volume 339, 15 September 2021, Pages 120-127
International Journal of Cardiology

Impact of right ventricular systolic function in patients with significant tricuspid regurgitation. A cardiac magnetic resonance study

https://doi.org/10.1016/j.ijcard.2021.07.023Get rights and content

Highlights

  • Accurate assessment of RV size and systolic function is determinant in patients with severe tricuspid regurgitation (TR).

  • For the moment RV thresholds of poor outcomes to support intervention are lacking. · While RVEF by CMR remain the gold standard, it can overestimate RV function in severe TR.

  • RV shortening and effective RVEF can be easily calculated in conventional studies without additional sequences or dedicated software’s.

  • Both parameters detect higher rates of RV dysfunction. Among all, eRVEF has the strongest association with outcomes, incremental to RVEF.

Abstract

Background

Right ventricle (RV) dilatation and dysfunction are established criteria for intervention in severe tricuspid regurgitation (TR); however thresholds to support intervention are lacking. New measures of RV function such as RV shortening (RVS) and effective RV ejection fraction (eRVEF) may be earlier markers of RV dysfunction.

Purpose

to compare the prognostic impact of different parameters of RV function and to describe cut-off values of RV size/function and TR severity of poor prognosis.

Methods

Consecutive patients evaluated in the Heart Valve Clinic with significant TR (severe, massive or torrential TR) undergoing a CMR study were included. In addition to parameters of biventricular volume and function, RVS and eRVEF were assessed. A combined endpoint of hospital admission due to right heart failure and cardiovascular mortality was defined.

Results

75 patients were included (age 75 ± 8 years, female 75%). During a median follow-up of 3 years (IQR: 1.4–3.9 years), 39% experienced the endpoint. Cut-off values of worse prognosis were: RVS ≥ −14%, eRVEF ≤34%, RVEF ≤58%, RV-EDV ≥100 ml/m2, TR regurgitant fraction (TRF) ≥40% and TR volume ≥ 42 ml. RVS and eRVEF identified higher rates of RV dysfunction than RVEF. After adjustment for age and LVEF, both eRVEF ≤34% (HR: 5.29 [2.25–12.4]) and RVS ≥ −14% (HR: 3.46 [1.13–9.17]) were significantly associated with outcomes. Among all parameters of RV function, eRVEF was the strongest predictor of outcomes, incremental to RVEF (ΔC-statistic 0.139 [0.040–0.237], p = 0.005). Patients with eRVEF ≤34% and RV-EDV ≥100 ml/m2 or eRVEF ≤34% and TRF ≥40% had the worst prognosis (p < 0.01 for both).

Conclusion

RVS and eRVEF identify higher rates of RV dysfunction beyond RVEF. Among all measures, eRVEF held the strongest association with outcomes, incremental to RVEF.

Introduction

Tricuspid regurgitation (TR) is a prevalent disease progressively leading to right heart failure and eventually to death, even in the absence of left ventricular (LV) dysfunction or pulmonary hypertension [[1], [2], [3], [4]]. While medical therapy can alleviate symptoms, tricuspid valve (TV) intervention may change the natural course of the disease [5,6]. Optimal timing is crucial to avoid poor results, however it is commonly indicated late in the course of the disease, when surgical risk is sometimes unacceptable [[7], [8], [9], [10], [11], [12], [13], [14]].

Severe TR causes chronic volume overload of the right ventricle (RV), which leads to progressive RV dilation, dysfunction, and finally RV failure. Current ESC guidelines recommend TV surgery in symptomatic patients or in asymptomatic patients with progressive RV dysfunction or dilation [14]. Optimal timing for intervention is particularly important in this condition in which operative mortality and morbidity remain high (10–14%, and 42% respectively) [11]. If surgery is performed late, once RV contractile function is too impaired or the pulmonary pressure is too high, surgery may not provide any kind of clinical or survival benefit [7]. Despite the relevance of RV evaluation, defined cut-off values of significant RV dilation or dysfunction to support intervention are lacking.

Transthoracic echocardiography (TTE) is the first-line imaging modality to evaluate patients with significant TR. While TTE is the preferred method to assess TR severity, cardiac magnetic resonance (CMR) is the gold standard for assessing RV volumes and function [12]. TTE evaluation is challenged by the complex RV geometry, crescentic and highly trabeculated. RV position (retro-sternally and anterior to the LV) difficults RV assessment since it may result in a different size and functional appearance depending on the axis in which it is viewed [13]. As a result, RV evaluation by TTE has limited accuracy and significantly lower reproducibility compared to CMR [15].

Although RV function by CMR is conventionally assessed by RV ejection fraction (RVEF), this parameter may not be optimal in patients with significant TR. The subsequent RV volume overload may overestimate RV systolic function when evaluated by RVEF since it is influenced by changes of preload conditions, remaining unaffected until late stages of the disease. Novel RV parameters such as RV shortening (RVS) and effective RVEF (eRVEF) by CMR are less dependent on load conditions [16,17] and may have an incremental prognostic value compared to RVEF, being able to detect early RV dysfunction in patients with significant TR.

The aim of this study is to compare the prognostic impact of different parameters of systolic function and to describe predictive cut-off values of poor prognosis in patients with significant tricuspid regurgitation.

Section snippets

Study population

Consecutive patients in stable clinical condition with echocardiographically significant TR (severe, massive or torrential TR) evaluated in the Heart Valve Clinic and referred for a CMR study between 2016 and 2019 were included in this observational study. Fig.1 shows the flow chart for patients' selection. The severity of TR was evaluated by echocardiography according to current guidelines combining different semi quantitative and quantitative parameters [18]. Significant TR was defined as a

Results

A total of 155 patients were evaluated in the Heart Valve Clinic for significant TR between 2016 and 2019. After exclusion of those patients that fulfil exclusion criteria or those with incomplete clinical or imaging data, 75 patients were included in this study (Fig. 1). 60 control subjects were also included for comparison. Demographic data and baseline characteristics of patients and controls are presented in Table 1. Most of the patients were females and the mean age was 75 ± 8 years. 93%

Discussion

Our results confirm the prognostic relevance of morphological and functional RV parameters in patients with significant TR. For the first time, cut-off values of RV volume/function and TR severity are defined in a cohort of consecutive patients based on outcome data. RV systolic function is determinant in the prognosis of patients with severe TR. Our data support the incremental benefit of effective RVEF over conventional RVEF to predict mortality and heart failure events.

Untreated severe TR is

Author statement

  • Rocio Hinojar (corresponding autor): Conceptualization; Methodology; Data acquisition; Formal analysis; Supervision; Writing - original draft; editing.

  • Ariana Gonzalez: patients selection; Data acquisition; Manuscript review & Editing

  • Ana García Martin: patients selection; Data acquisition; Manuscript Review & Editing

  • Juan Manuel Monteagudo: Methodology; Formal analysis; Manuscript review & Editing

  • Mª Angeles Fernández-Méndez: Data acquisition; Manuscript review & Editing

  • Ana Garcia de Vicente: Data

Funding

Dr. Hinojar was supported by an intramural grant from IRYCIS with no financial interest.

Declaration of Competing Interest

None.

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