Right ventricular contractile reserve in mitral stenosis: Implications on hemodynamic burden and clinical outcome
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/Pmax 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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Cited by (22)
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 EchocardiographyExercise speckle-tracking strain imaging demonstrates impaired right ventricular contractile reserve in hypertrophic cardiomyopathy
2017, International Journal of CardiologyCitation 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.
Immediate impact of successful percutaneous mitral valve commissurotomy on echocardiographic measures of right ventricular contractility
2012, Journal of the American Society of EchocardiographyCitation 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.
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 EchocardiographyCitation 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 EchocardiographyCitation 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.