Outcome Prediction by Quantitative Right Ventricular Function Assessment in 575 Subjects Evaluated for Pulmonary Hypertension

Abstract

Background-Although right ventricular (RV) dysfunction is a major determinant of outcome in patients with pulmonary hypertension (PH), the optimal measure of RV function is poorly defined. We hypothesized that RV strain measured by speckle-tracking echocardiography predicts outcome in PH over a broad range of pulmonary pressures. Methods and Results-Prospective peak RV longitudinal systolic strain measurement was performed on 575 patients (mean age, 56±18 years; 63% women) referred for echocardiography for known or suspected PH. Survival status was assessed over a median of 16.5 (interquartile range, 7.6-20.0) months. There were 406 patients with PH (71%) (74% group 1, 14% group 3, and 12% group 4) and 169 patients without evidence of PH (29%). Among patients with PH, 46% were World Health Organization functional class III-IV. The mean RV strain was −21.2±6.7% for all patients. RV strain declined with worse functional class, shorter 6-minute walk distances, higher N-terminal pro-B-type natriuretic peptide levels, and the presence of right heart failure. RV strain predicted outcome across pulmonary pressures and groups of PH. Eighteenmonth survival was 92%, 88%, 85%, and 71% according to RV strain quartile (P<0.001), with a 1.46 higher risk of death (95% confidence interval, 1.05-2.12) per 6.7% decline in RV strain. RV strain predicted survival when adjusted for pulmonary pressure, pulmonary vascular resistance, and right atrial pressure and provided incremental prognostic value over conventional clinical and echocardiographic variables. Conclusions-Quantitative

Right ventricular reserve in a piglet model of chronic pulmonary hypertension

“…They showed that RVFAC better reflects RV systolic function than TAPSE when the pericardium is kept open. Practically, however, there may be more variability in the measure of RVFAC and recent outcome studies carried out by FINE et al [21] suggest that RV longitudinal strain, which was not measured in the current study, is a stronger correlate of survival than RVFAC in prevalent cases of PH.…”

2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension

“…An increase in PAPs does not necessarily reflect disease progression and a decrease in PAPs does not necessarily signal improvement. A comprehensive echocardiographic assessment includes a description of chamber sizes, particularly of the RA and RV area, the magnitude of tricuspid regurgitation, the LV eccentricity index and RV contractility, which can be determined by several variables, including RV longitudinal systolic strain/strain rate and RV fractional area change, Tei index and tricuspid annular plane systolic excursion (TAPSE) [101][102][103][104][105][106][107][108].…”

Intrapulmonary vascular dilatations are common in portopulmonary hypertension and may be associated with decreased survival

“…47,48 Importantly, RV function as estimated by echocardiography and pulmonary hemodynamics as measured by RHC (MPAP, CO, PVR) may independently characterize survival in PAH. 46,49 Our data suggest that the IPVD patients had better RV function (lower median RIMP) than non-IPVD patients at the time of diagnosis of POPH, despite similar hemodynamics. However, survival was worse in the setting of IPVD.…”

“…Finally, RIMP is one transthoracic echocardiography measure of RV function; others are evolving. 46 The RIMP calculation is composed of RV isovolumetric contraction time, relaxation time, and ejection time, and the higher the value, the worse the RV function. 47,48 Importantly, RV function as estimated by echocardiography and pulmonary hemodynamics as measured by RHC (MPAP, CO, PVR) may independently characterize survival in PAH.…”