Right ventricular contractile reserve in mitral stenosis: Implications on hemodynamic burden and clinical outcome

doi:10.1016/j.ijcard.2008.03.050

International Journal of Cardiology

Volume 135, Issue 2, 26 June 2009, Pages 193-201

https://doi.org/10.1016/j.ijcard.2008.03.050 Get rights and content

Abstract

Background

We investigated whether isovolumic acceleration (IVA) under inotropic stimulation as a means of right ventricular (RV) contractile reserve, is a surrogate for hemodynamic burden and has prognostic value in patients with mitral stenosis (MS).

Methods

Thirty-one pure MS patients and 20 controls underwent cardiac catheterization, exercise test, and dobutamine stress echocardiography. RV fractional area change (FAC), + dP/dt/P_max, RV tissue Doppler indices (isovolumic contraction [IVC] and systolic [S] velocity, and IVA) were measured. Patients were followed-up for the occurrence of cardiac adverse events.

Results

Inotropic modulation unmasked statistically significant differences regarding magnitude of changes in IVA, IVC, S, and + dP/dt/P_max, but not RV FAC. Inability to increase IVA more than 6.5 m/s² was the only independent determinant of pulmonary capillary wedge pressure ≥ 18 mm Hg (P = .004). Although MS severity did not predict the RV contractile reserve and pulmonary artery pressure (PAP) behavior during inotropic stimulation, the RV contractile reserve was related to the degree of systolic PAP. IVA increases of < 3.4 m/s² had 86% sensitivity and 75% specificity to predict unfavorable outcomes during long-term follow-up (20 ± 8 months).

Conclusion

RV contractile reserve provides complementary data to the hemodynamic significance of MS severity, may contribute to clinical decision making, and be of prognostic value in these patients.

Section snippets

Study population

We studied 33 consecutive patients with MS referred for cardiac catheterization and 20 age- and sex-matched controls with normal 2-D and Doppler echocardiographic findings, undergoing electrophysiological study for supraventricular tachycardia with normal coronary arteries. Patients were excluded if they had left bundle branch block, a pacemaker, more than mild mitral regurgitation, or any other concomitant valvular or coronary artery disease. All subjects underwent treadmill exercise testing,

Statistical analyses

Continuous variables are expressed as means ± SD. The paired sample t and unpaired t tests were used to assess differences within the group and between the groups, respectively, or Wilcoxon and Mann–Whitney U tests were used instead, if continuous variables did not have normal distribution. Comparisons between groups were made with Pearson χ² or Fisher's exact test. Correlations between invasive measurements and echocardiographic indices were studied with the Pearson correlation test. A P value

Results

In all, 31 patients with pure MS and 20 controls were studied after excluding 2 patients: 1 had atrial fibrillation with rapid ventricular rate, 1 had a vagal reaction during dobutamine infusion. Two patients could not exercise. Five patients had poor images at peak dobutamine with insufficient endocardial definition to calculate RV FAC despite adequate tissue Doppler data. RV + dP/dt/P_max from the tricuspid regurgitant jet could be determined in 94% of patients at rest and in 87% of patients

Discussion

This study points out that RV contractile performance and contractile reserve are impaired in patients with MS. This impairment is more a reflection of the hemodynamic burden than the MVA itself. Furthermore, impaired RV contractile reserve implicates high risk for a poor outcome.

Limitations

Invasive hemodynamic measurements were obtained at rest, and we did not perform the catheterization simultaneously with dobutamine administration because reliable Doppler quantification requires optimal ultrasound alignment, which is technically challenging during femoral catheterization. But this does not detract from the value of dobutamine stress echocardiography for assessing RV contractile reserve, which was the main objective of the present study. Although exercise stress echocardiography

Conclusions

RV contractile reserve provides complementary data to the hemodynamic significance of the severity of MS. It also confers clinical and prognostic insights in patients with MS. Our data therefore may potentially contribute to clinical decision making and predict the long-term outcome in patients with MS.

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Role of the right ventricular contractile reserve during low-load exercise in predicting heart failure readmission
2023, Journal of Cardiology
Exercise intolerance in patients with heart failure (HF) increases HF-associated readmission, and right ventricular (RV) contractile reserve assessed by low-load exercise stress echocardiography (ESE) is associated with exercise intolerance. This study investigated the impact of RV contractile reserve evaluated by low-load ESE on HF readmission.
We prospectively examined 81 consecutive patients hospitalized for HF who underwent low-load ESE under a stabilized HF condition between May 2018 and September 2020. We performed a 25-W low-load ESE and defined RV contractile reserve as the increment in RV systolic velocity (RV s′). The primary outcome was hospital readmission. Incremental values of the change in RV s′ over a readmission risk (RR) score were analyzed using the receiver operating characteristic (ROC) area under the curve; internal validation using bootstrapping was performed. The association between RV contractile reserve and HF readmission was illustrated with the Kaplan-Meier curve.
Eighteen (22 %) patients were readmitted due to worsening HF during the observation period (median 15.6 months). The cut-off value of 0.68 cm/s for the change in RV s′ to predict HF readmission with the ROC curve analysis indicated good sensitivity (100 %) and specificity (76.2 %). The discriminatory ability for HF readmission was significantly improved by adding the change in RV s′ to the RR score (p = 0.006), and the c-statistic using the bootstrap method was 0.92. The cumulative survival rate free of HF readmission was significantly lower in patients with reduced-RV contractile reserve (log-rank test, p < 0.001).
The change in RV s′ during low-load exercise had an incremental prognostic value for predicting HF readmission. The results demonstrated the loss of RV contractile reserve assessed by low-load ESE was associated with HF readmission.
Right Ventricular Contractile Reserve Is Impaired in Children and Adolescents With Repaired Tetralogy of Fallot: An Exercise Strain Imaging Study
2019, Journal of the American Society of Echocardiography
Pulmonary insufficiency (PI) and right ventricular (RV) dysfunction are long-term complications in patients with repaired tetralogy of Fallot (rTOF). The aim of this study was to investigate RV contractile reserve and changes in PI that occur during exercise in patients with rTOF and the associations of these changes with exercise performance using stress echocardiography.
Subjects with rTOF (n = 32) and healthy control subjects (n = 10) were prospectively enrolled and underwent rest and peak exercise echocardiography during standard cardiopulmonary exercise test protocol on a cycle ergometer or treadmill. RV contractile reserve was defined as the change in RV global longitudinal strain from rest to peak exercise. PI was assessed with the diastolic-to-systolic time-velocity integral ratio and diastolic/systolic velocity ratio from pulmonary artery Doppler interrogation. Exercise measures included heart rate reserve, percentage predicted maximum oxygen consumption, percentage predicted maximum work, and oxygen pulse.
RV contractile reserve was impaired in patients with rTOF compared with control subjects, with a significant drop in the absolute value of RV global longitudinal strain from 17% (range, 8%–27%) at rest to 13% (range, 5%–28%) at peak exercise. Similarly, PI decreased at peak exercise, with decreases in diastolic-to-systolic time-velocity integral and diastolic/systolic velocity ratios. Reduction in PI was directly associated with percentage predicted maximum oxygen consumption, percentage predicted maximum work, and greater oxygen pulse. Heart rate reserve was directly associated with percentage predicted maximum oxygen consumption and percentage predicted maximum work. RV contractile reserve was not associated with any exercise parameters.
Patients with rTOF have an abnormal myocardial response to exercise with impaired RV contractile reserve compared with control subjects. Heart rate reserve and reduction in PI at peak exercise are associated with better exercise performance and appear to be significant contributors to exercise performance in rTOF. Measures to improve chronotropic health in rTOF should be explored.
Exercise speckle-tracking strain imaging demonstrates impaired right ventricular contractile reserve in hypertrophic cardiomyopathy
2017, International Journal of Cardiology
Citation Excerpt :
LV contractile reserve has been estimated by invasively [42,43] or non-invasively measured changes in LV-ejection fraction [44], radionuclide stroke volume [45], or by LV echocardiographic parameter [46,47]. Such LV index has been shown to be a strong prognostic predictor in patients with left heart failure due to idiopathic dilated cardiomyopathy, [45–49] valvular heart disease [50,51] and coronary artery disease. [42,52] Conversely, there are only few data on RV contractile reserve and no standardized methods how to measure it.
To analyse right ventricular (RV) systolic function in patients with hypertrophic cardiomyopathy (HCM) at rest and during exercise, and its possible correlation with left ventricular(LV) morphology and function.
Standard echo, exercise stress echo, and RV 2D speckle-tracking strain (2DSE) were performed in 45 patients with HCM and in 45 age- and sex-comparable healthy controls. RV global longitudinal strain (GLS) was calculated by averaging local strains along the entire right ventricle. LV mass index and IVS wall thickness were significantly increased in HCM, while LV ejection fraction, RV diameters, RV tissue Doppler systolic peak and the RV end-systolic pressure-area relationship at rest were comparable between the two groups. Conversely, all transmitral Doppler indexes were significantly impaired in HCM. In addition, RV GLS and regional peak myocardial RV strains were significantly reduced in patients with HCM (all P < 0.001). During physical effort, LV ejection fraction was comparable between the two groups. Conversely, LV E/E_m ratio was significantly increased in HCM. Increase in TAPSE and RV tissue Doppler Sm peak velocity during effort were similar between the two groups. Conversely, increases of RV end-systolic pressure-area, regional and global RV strain were significantly lower in HCM patients (RV lateral strain: 10.3 ± 3.5% of increase in HCM vs 20.5 ± 4.5% in controls; p < 0.0001). Multivariable analysis detected independent associations of RV lateral strain at peak stress with LV IVS thickness, maximal workload during exercise, and LV E/E_m ratio during effort (all p < 0.0001). An RV lateral 2DSE cut-off point of − 14% differentiated controls and HCM with an 86%sensitivity and a 92% specificity.
RV contractile reserve for HCM is impaired and this suggests that the lower resting values of RV in HCM may represent early subclinical myocardial damage, closely associated with exercise capacity.
Immediate impact of successful percutaneous mitral valve commissurotomy on echocardiographic measures of right ventricular contractility
2012, Journal of the American Society of Echocardiography
Citation Excerpt :
However, in patients with depressed RV contractility, the improvement in preload and afterload conditions after surgery does not always improve the prognosis. In effect, Sade et al.17 showed that impaired RV contractile reserve portends high risk for a poor outcome. Hence, the use of load-independent measures of RV function is crucial for preoperative RV assessment and determining eventual prognosis.
Functional analysis of the right ventricle cannot be reliably evaluated by conventional echocardiography, because of its complex geometry and load dependence of ejection phase indices. The Tei index, dP/dt, and myocardial acceleration during isovolumic contraction are parameters of right ventricular (RV) contractility unaffected by RV geometry. However, the effect of loading conditions on these parameters is controversial. The aim of this study was to examine how afterload reduction observed after percutaneous transverse mitral commissurotomy (PTMC) in patients with mitral stenosis affects these measures of RV contractility.
Fifty-eight patients (mean age, 30.0 ± 8.3 years seven men, 52 women) with isolated rheumatic mitral stenosis, eight of whom had atrial fibrillation, were studied prospectively before and 24 to 48 hours after PTMC.
Immediately after PTMC, mitral valve area increased from 1.0 ± 0.2 to 1.8 ± 0.3 cm² (P = .0001). There was a significant decrease in systolic pulmonary artery pressure from 50.2 ± 26.9 to 33.2 ± 12.3 mm Hg (P = .0001), a decrease in the RV Tei index from 0.5 ± 0.2 to 0.3 ± 0.2 (P = .0001), and an increase in RV dP/dt from 321.0 ± 59.9 to 494.6 ± 139.5 mm Hg/sec (P = .0001). RV myocardial acceleration during isovolumic contraction and systolic velocity at the lateral tricuspid annulus assessed by Doppler tissue imaging did not change. There were weak positive correlations among the Tei index, dP/dt, and systolic pulmonary artery pressure before PTMC (respectively, r = 0.39, r = 0.28, and P = .02, P = .05) but not afterward (respectively, r = 0.17, r = 0.02, and P = .20, P = .90).
This study suggests that RV dP/dt and Tei index are weakly load dependent, whereas myocardial acceleration during isovolumic contraction is unaffected by acute change in RV afterload.
Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from the American Society of Echocardiography. Endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography
2010, Journal of the American Society of Echocardiography
Citation Excerpt :
In a series of cardiac patients under anesthesia, RV IVA appeared to be the most consistent tissue Doppler variable for the evaluation of RV function measured by either transthoracic echocardiography (lateral wall) or transesophageal echocardiography (inferior wall).122 RV IVA has been demonstrated to correlate with the severity of illness in conditions affecting right heart function, including obstructive sleep apnea,123 mitral stenosis,124,125 repaired tetralogy of Fallot with pulmonary regurgitation,126 and transposition of the great arteries following an atrial switch procedure.127 Normal RV IVA values have been obtained from studies that have included a control group of normal adults and/or children.
Longitudinal Right Ventricular Function as a Predictor of Functional Capacity in Patients with Mitral Stenosis: An Exercise Echocardiographic Study
2010, Journal of the American Society of Echocardiography
Citation Excerpt :
In MS, scarce data linked functional capacity to RV function at rest.23 RV systolic performance assessed by isovolumic acceleration during dobutamine infusion lately emerged as an independent predictor of outcome in MS.24 The present study demonstrates that RV systolic function assessed easily at rest by Tric-S is an independent determinant of functional capacity in MS. The predictive value of Tric-S is conveyed, at least in part, by the relation of Tric-S to baseline and exercise cardiac output. This relationship emphasizes the value of Tric-S in assessing RV function.
The influence of right ventricular (RV) function on exercise capacity has been poorly explored in mitral stenosis (MS). The objective of this study was to assess the determinants of functional status with exercise echocardiography in MS.
Thirty-nine patients (55 ± 12 years, 29 female) with MS (1.3 ± 0.5 cm²) underwent an exercise echocardiography (14 patients had previous balloon valvuloplasty). RV function was assessed by tricuspid annulus S-wave velocity (Tric-S) and tricuspid annular plane systolic excursion (TAPSE).
Tric-S correlated with TAPSE (P = .03), cardiac output (P = .006), and mitral valve area (P = .009). With exercise, Tric-S and TAPSE increased significantly (11.3 ± 3.1 cm/s to 15.5 ± 3.4 cm/s and 21.2 ± 5.2 mm to 24.0 ± 5.8 mm, respectively, both P < .05). TAPSE was lower in patients in New York Heart Association class 3 or 4. In multivariate analysis, Tric-S at rest (β = 0.34, P = .006) and mitral Δ mean diastolic gradient (β = 0.34, P = .006) were the independent determinants of maximum workload.
Resting RV longitudinal function assessed through Tric-S is an important determinant of functional capacity in MS.

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Right ventricular contractile reserve in mitral stenosis: Implications on hemodynamic burden and clinical outcome

Abstract

Background

Methods

Results

Conclusion

Section snippets

Study population

Statistical analyses

Results

Discussion

Limitations

Conclusions

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