Decongestion improving right heart function ameliorates prognosis after an acute heart failure episode

Abstract

BackgroundThe prognostic role of decongestion-related change of cardiac morphology and in particular right heart function has not been investigated comprehensively in AHF patients. Methods and resultsThis prospective observational single-centre study included consecutive patients hospitalized for treatment of AHF with reduced, mildly-reduced or preserved left ventricular ejection fraction (LVEF). Comprehensive transthoracic echocardiography at admission and discharge assessed decongestion-related change of cardiac function and morphology. The combined endpoint of 1 year all-cause mortality and cardiovascular rehospitalization explored the prognostic importance of decongestion-related change. The 176 study participants were 83 years old [74-87] and 54% were men. Fifty one (29%) had rLVEF, 65 (37%) mrLVEF, and 60 (34%) pLVEF. The proportion of de novo or worsening chronic HF was not different between LVEF groups. HF aetiology and cardiovascular risk factors were equally distributed across all groups except for a higher BMI in the pLVEF group. Decongestion equally reduced body weight, heart rate, systolic and diastolic blood pressure, tricuspid regurgitation gradient, and inferior vena cava diameter across all groups (P < 0.004 for all). Decongestion-related increase in TAPSE independent of the LVEF was associated with improvement of right-ventricular-pulmonary artery coupling and a lower incidence of the combined outcome in the Cox proportional hazard risk analysis (unadjusted HR 0.50 95% CI 0.33-0.78, P = 0.002; adjusted HR 0.46 95% CI: 0.33-0.78, P = 0.001). Conclusions Decongestion-related increase in TAPSE and recovery of RV/pulmonary artery coupling was observed across all LVEF groups and associated with a risk reduction for the combined endpoint highlighting the important prognostic role of right heart recovery after an AHF episode.

Clinical Value of Novel Echocardiographic Biomarkers Assessing Myocardial Work in Acute Heart Failure—Rationale and Design of the “Beyond Myo-HF Study”

“…Only a few studies have described the echocardiographic changes of acute HF patients from admission to discharge [ 3 , 4 , 6 ]. Hullin et al studied 176 AHF patients and demonstrated a significant decongestion-related improvement for mitral E wave velocity, E/e’ ratio, RV basal diameter, tricuspid regurgitation gradient, PASP, TAPSE/PASP, and inferior vena cava diameter across all LVEF groups [ 4 ]. In regard to parameters of LV systolic function, LVEF remained unchanged with decongestion while LV GLS improved, depicting an LV endomyocardial functional recovery at discharge [ 4 ].…”

“…Hullin et al studied 176 AHF patients and demonstrated a significant decongestion-related improvement for mitral E wave velocity, E/e’ ratio, RV basal diameter, tricuspid regurgitation gradient, PASP, TAPSE/PASP, and inferior vena cava diameter across all LVEF groups [ 4 ]. In regard to parameters of LV systolic function, LVEF remained unchanged with decongestion while LV GLS improved, depicting an LV endomyocardial functional recovery at discharge [ 4 ]. Concerning RV function, subjects who demonstrated an increase of TAPSE and/or TAPSE/PASP with treatment had a significantly lower risk for death or cardiovascular readmission [ 4 ].…”

“…In regard to parameters of LV systolic function, LVEF remained unchanged with decongestion while LV GLS improved, depicting an LV endomyocardial functional recovery at discharge [ 4 ]. Concerning RV function, subjects who demonstrated an increase of TAPSE and/or TAPSE/PASP with treatment had a significantly lower risk for death or cardiovascular readmission [ 4 ]. Akiyama et al studied 77 patients with acute HF and described an improvement of E-wave deceleration time and inferior vena cava diameter for heart failure with reduced ejection fraction patients and an improvement of E/e’ for heart failure with preserved ejection fraction patients [ 3 ].…”

“…In acute decompensated HF, intensive therapy aims to lessen intracardiac pressure and central venous congestion [ 3 ], which is expressed as an improvement of the circulatory volume-dependent echocardiographic parameters, mainly evidenced through reverse remodeling of the thin-walled right ventricle (RV). It has been suggested that improvement of RV function surrogates such as tricuspid annular plane systolic excursion (TAPSE) and right ventricular–pulmonary artery (RV–PA) coupling is of prognostic relevance [ 4 ]. However, TAPSE has obvious limitations as it poorly reflects overall contractility of the RV [ 5 ], and it has been surpassed by speckle tracking echocardiography with longitudinal strain, which is sensitive in detecting dynamic improvement in RV mechanics [ 6 ].…”

The Dysfunctional Right Ventricle in Dilated Cardiomyopathies: Looking from the Right Point of View

“…Furthermore, Ishiwata et al found TAPSE to be independently associated with the primary composite outcome consisting of left ventricular assist device (LVAD) implantation or all-cause death in patients with non-ischemic DCM [ 47 ]. The prognostic role of the RV has also been assessed in acute HF patients with different EF ranges by Roger Hullin et al, who demonstrated that an increase in TAPSE secondary to decongestive HF treatment was associated with a lower incidence of the combined outcome, irrespective of the LVEF [ 48 ]. The prognostic significance of RV systolic dysfunction defined as TAPSE < 17 mm was also confirmed by Dziewiecka et al in a large study on 545 DCM patients, however not irrespective of LVEF [ 49 ].…”