Marked changes in right ventricular contractile pattern after cardiothoracic surgery: Implications for post-surgical assessment of right ventricular function

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Background

Longitudinal shortening accounts for the majority of right ventricular (RV) contraction in normal hearts. This finding accounts for the correlation between longitudinal measures of RV contraction such as tricuspid annular plane systolic excursion (TAPSE) and global RV function. We hypothesized that, after cardiac surgery, there are major differences in the RV contractile pattern relative to normal hearts.

Methods

We retrospectively studied 2 cardiac surgical cohorts who underwent cardiopulmonary bypass (CPB) with pericardial incision (OHT, n = 54; CABG, n = 23) and compared them with a lung transplant cohort (n = 25). We compared TAPSE, RV fractional area change (RVFAC) and relative change in RV transverse and longitudinal area in the surgical cohorts with data from normal subjects (n = 84).

Results

RVFAC was lower in the surgical groups compared with the normal group, yet still in the normal range (37% to 42% vs 47%; p < 0.01). TAPSE was markedly lower in OHT (15 ± 3 mm) and CABG (16 ± 4 mm) than in normal (26 ± 4 mm) subjects (p < 0.01), as was the relative contribution of longitudinal area change (OHT group 51 ± 11%, CABG group 54 ± 13%, normal group 78 ± 14%; p < 0.01). The ratio of TAPSE to RVFAC was markedly lower in CABG (40 ± 14 mm/%FAC) and OHT (37 ± 10 mm/%FAC) patients than in normal (56 ± 14 mm/%FAC) subjects (p < 0.001). However, OLT patients had a higher TAPSE (18 ± 3 mm) than OHT (15 ± 3 mm) and CABG (16 ± 4 mm) patients (p < 0.01) and a higher relative contribution of longitudinal area change: OLT 67 ± 10%; OHT 51 ± 11%; and CABG 54 ± 13% (p < 0.01).

Conclusions

After cardiac surgery, the RV contractile pattern changes, with a relative loss of longitudinal shortening and gain in transverse shortening despite normal global RV function. These findings have major implications for quantitative assessment of RV function after cardiac surgery, suggesting that global measures of RV function assessment may be preferred in this setting and that lower normative ranges should be used when measurement of RV function is performed with longitudinal methods.

Section snippets

Methods

We retrospectively evaluated the RV contractile pattern in normal subjects without cardiovascular disease and in subjects who underwent cardiac surgery with CPB plus pericardiotomy. The cohort included patients who had orthotopic heart transplant (OHT) and isolated coronary artery bypass (CABG) surgery. Cardiac transplant patients were included for 2 reasons: (1) by definition, these allografts were normal hearts prior to transplantation; and (2) all patients had invasive hemodynamics at 1

Patient characteristics

A total of 186 patients were included in the study, including 84 normal subjects, 54 OHT patients, 23 CABG patients and 25 OLT patients. Of the OLT patients, 14 had DLT with CPB and 11 had SLT without CPB. Baseline characteristics of the various study cohorts are presented in Table 1. Normal subjects without cardiovascular disease were significantly younger (43 ± 14 years), and the patients undergoing isolated CABG were the oldest (66 ± 11 years). However, there was no significant correlation

Discussion

In this study we found that, after cardiac surgery with CPB and complete pericardiotomy, there was a dramatic reduction in longitudinal contraction and relative increase in transverse shortening despite normal overall RV function. This pattern was similar in post-CABG and -OHT patients compared with normal subjects, resulting in a significantly lower TAPSE relative to global RV function. Patients post-OLT, who underwent CPB and pericardial incision, but did not have cardiac surgery per se,

Disclosure statement

The authors have no conflicts of interest to disclose. There was no off-label use of devices or medications in this investigation. The first 2 authors (A.R. and A.V.) contributed equally to this study.

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