Prognostic Value of the Three-Dimensional Right Ventricular Ejection Fraction in Patients With Asymptomatic Aortic Stenosis

Abstract

Background: The right ventricular (RV) function is an important prognostic marker of asymptomatic aortic stenosis (AS). However, previous publications have not addressed the additive value of conventional RV parameters over left heart parameters. Whether three-dimensional echocardiography (3DE)-derived RV ejection fraction (RVEF) has prognostic utility independent of 3DE derived left heart parameters is also unknown. We investigated the prognostic utility of 3DE RVEF in patients with asymptomatic AS.Methods: We retrospectively selected 392 asymptomatic AS patients. RVEF, left ventricular ejection fraction (LVEF) and left atrial volumes (LAVs) were measured using 3DE datasets. We determined the association of those parameters, as well as of aortic valve replacement (AVR), and Charlson's comorbidity index with cardiac events. We also analyzed whether RVEF has incremental value over two-dimensional echocardiography (2DE) RV parameters.Results: During a median follow-up of 27 months, 57 patients developed cardiac events, and 68 patients received AVR. Univariate Cox proportional hazard analysis revealed that RVEF was associated with cardiac events (p < 0.001). Multivariate analysis revealed that RVEF was significantly associated with cardiac events (p < 0.001) even after adjusting for AVR, Charlson's comorbidity index, LVEF, LAV, E/e', and indexed aortic valve area (iAVA). An incremental value of RVEF over left heart parameters was also demonstrated using a nested regression model. Classification and regression-tree analysis selected RVEF first with a cut-off value of 41%. RVEF had incremental value over iAVA, LVEF, and 2DE conventional RV parameters for its association with future outcomes.Conclusions: 3DE RVEF had significant prognostic value even after adjusting for comorbidities, left heart parameters, and conventional 2DE RV parameters in asymptomatic aortic stenosis.

Prognostic Value of Right Ventricular Strains Using Novel Three-Dimensional Analytical Software in Patients With Cardiac Disease

“…When we included 15 echocardiography parameters, CART selected 3D RVEF first, followed by LV diastolic function parameter (mitral E/e') and LV systolic function parameter (3D LVESVI). The results suggest that among echocardiographic parameters, 3D RVEF is more important than LV diastolic and systolic parameters to predict future outcome, which agreed with the previous study in patients with asymptomatic aortic stenosis (24).…”

Association of Right Ventricular Functional Parameters With Adverse Cardiopulmonary Outcomes: A Meta-analysis

“…RVEF might be a universal biomarker that refines risk stratification. 10 12,14,16-23 independent studies were included in the final quantitative analysis (Figure 1), which reported the impact of unit change of RVEF and TAPSE (n = 8), 12,15,17,[19][20][21][22][23] or FAC (n = 7), 12,[18][19][20][21][22][23] or FWLS (n = 7) 16,[18][19][20][21][22][23] on clinical outcomes (allcause mortality and/or cardiopulmonary adverse events) as HRs. Four studies were prospective, while 6 were retrospective.…”

“…The mean (6SD) age of the patient population was 63 6 15 years, 46% were female, and the follow-up duration ranged from 3 to 44 months. Three studies included patients with pulmonary hypertension exclusively, 14,16,20 1 included patients with COVID-19 only, 23 1 included patients with dilated cardiomyopathy only, 22 1 included patients with aortic stenosis only, 18 1 included heart failure patients with preserved left ventricular (LV) ejection fraction (HFpEF) only, 19 and the remaining 3 studies included populations with a mixture of cardiovascular diseases. 12,17,21 Outcomes Table 1 contains the definitions of end points assessed in each included study.…”

Superior prognostic value of three-dimensional echocardiography-derived right ventricular ejection fraction: a meta-analysis

“…In three instances (including 3-3 studies), there was an apparent overlap between the patient cohorts; 9,13-17 therefore, studies with a higher number of participants were included. 13,15,17 Overall, ten 13,15,[17][18][19][20][21][22][23][24] independent studies were included in the final quantitative analysis (Figure 1), which reported the impact of unit change of RVEF and TAPSE (n=8), 13,16,18,[20][21][22][23][24] or FAC (n=7), 13,[19][20][21][22][23][24] or FWLS (n=7), 17,[19][20][21][22][23][24] on clinical outcomes (all-cause mortality and/or cardiopulmonary adverse events) as HRs. Four studies were prospective, while six were retrospective.…”

“…The mean (±SD) age of the patient population was 63±15 years, 46% were females, and the follow-up duration ranged from 3 to 44 months. Three studies included patients with pulmonary hypertension exclusively, 15,17,21 one included patients with COVID-19 only, 24 one included patients with dilated cardiomyopathy only, 23 one included patients with aortic stenosis only, 19 one included heart failure patients with preserved left ventricular (LV) EF (HFpEF) only, 20 and the remaining three studies included populations with a mixture of cardiovascular diseases. 13,18,22 Outcomes Table 1 contains the definitions of endpoints assessed in each included study.…”