Right ventricular function and its coupling to pulmonary circulation predicts exercise tolerance in systolic heart failure

Abstract

Aims Right ventricular (RV) dysfunction, pulmonary hypertension, and exercise intolerance have prognostic values, but their interrelation is not fully understood. We investigated how RV function alone and its coupling with pulmonary circulation (RV‐PA) predict cardio‐respiratory fitness in patients with heart failure and reduced ejection fraction (HFrEF). Methods and results The Evaluation of Resynchronization Therapy for Heart Failure (EARTH) study included 205 HFrEF patients with narrow (n = 85) and prolonged (n = 120) QRS duration undergoing implantable cardioverter defibrillator implantation. All patients underwent a comprehensive evaluation with exercise tolerance tests and echocardiography. We investigated the correlations at baseline between RV parameters {size, function [tricuspid annular plane systolic excursion (TAPSE), RV fractional area change (RV‐FAC), and RV myocardial performance index (RV‐MPI)], pulmonary artery systolic pressure (PASP), and tricuspid regurgitation}; left ventricular ejection fraction (LVEF), left ventricular end‐diastolic volume index (LVEDVi), and left atrial volume index (LAVi); and cardiopulmonary exercise test (CPET) [peak VO2, minute ventilation/carbon dioxide production (VE/VCO2), 6 min walk distance (6MWD), and submaximal exercise duration (SED)]. We also studied the relationship between RV‐PA coupling (TAPSE/PASP ratio) and echocardiographic parameters in patients with both data available. Univariate and multivariate linear regression models were used. Patients enrolled in EARTH (overall population) were mostly male (73.2%), mean age 61.0 ± 9.8 years, New York Heart Association class II–III (87.8%), mean LVEF of 26.6 ± 7.7%, and reduced peak VO2 (15.1 ± 4.6 mL/kg/min). Of these, 100 had both TAPSE and PASP available (TAPSE/PASP population): they exhibited higher BNP, wider QRS duration, larger LVEDVi, with more having tricuspid regurgitation compared with the 105 patients for whom these values were not available (all P < 0.05). RV‐FAC (β = 7.5), LAVi (β = −0.1), and sex (female, β = −1.9) predicted peak VO2 in the overall population (all P = 0.01). When available, TAPSE/PASP ratio was the only echocardiographic parameter associated with peak VO2 (β = 6.8; P < 0.01), a threshold ≤0.45 predicting a peak VO2 ≤ 14 mL/kg/min (0.39 for VO2 ≤ 12). RV‐MPI was the only echocardiographic parameter associated with ventilatory inefficiency (VE/VCO2) and 6MWD (β = 21.9 and β = −69.3, respectively, both P ≤ 0.01) in the overall population. In presence of TAPSE/PASP, it became an important predictor for those two CPET (β = −18.0 and β = 72.4, respectively, both P < 0.01), together with RV‐MPI (β = 18.5, P < 0.01) for VE/VCO2. Tricuspid regurgitation predicted SED (β = −3.2, P = 0.03). Conclusions Right ventricular function assessed by echocardiography (RV‐MPI and RV‐FAC) is closely associated with exercise tolerance in patients with HFrEF. When the TAPSE/PASP ratio is available, this marker of RV‐PA coupling becomes the stronger echocardiographic predictor of exercise capacity ...

Echo‐Doppler measures of right ventricular systolic function are affected by reduced left ventricular systolic function

“…Although some reports have previously shown that TAPSE 16–19 and TAPSE/PASP 20 could be affected by the presence low LVEF; to the best of our knowledge, direct comparison of different echo‐Doppler variables used for RV systolic function assessment with regards to LVEF, has never been done.…”

“…Even though, this newly validated noninvasive echocardiographic ratio measurement has been indisputably useful to assess RV-PA coupling noninvasively [12][13][14][15] ;data has continued to emerge showing its potential utility in heart failure patients, regardless the LVEF. 18,38,39 In fact, TAPSE/PASP ratio has also been found to be a much better prognostic predictor than either measure of TAPSE or PASP taken separately, particularly when assessing patients with severe mitral regurgitation referred for transcatheter mitral valve repair. 40 Even though TAPSE/PASP ratios were significantly different between normal and reduced LVEF patients in our studied population; this variable lack significance when examined in the stepwise multiple regression analysis model.…”

“…[12][13][14][15] These objective echocardiographic measurements have been invaluable in the overall assessment of RV systolic function, particularly when the identification of subtle abnormalities in RV function identifies patients at risk of worse clinical outcomes. [1][2][3] However, aside from isolated instances in which TAPSE [16][17][18][19] and TAPSE/PASP 20 values have been found abnormal in the presence of reduced LV ejection fraction (LVEF); no study to the best of our knowledge has been purposely conducted to assess the utility of any of these right-sided echo-Doppler measures in the assessment of LV systolic function.…”

Association between Right Ventricular Function and Exercise Capacity in Patients with Chronic Heart Failure

“…Impaired systolic failure of the right ventricle, indicated by low TAPSE, cannot propel the blood against the elevated afterload and supply appropriate deoxygenized blood to the lungs [4,6]. Low levels of TAPSE and systolic pulmonary artery pressure, both of which indicate impaired right ventricular systolic function, were associated with poor exercise ability [12], a phenomenon of right ventricle-pulmonary artery uncoupling [3].…”

“…Very recently, the association between right ventricular function/reserve and exercise capacity has been investigated among various types of cohorts, including hospitalized 2 of 9 heart failure patients, systolic heart failure patients, and diastolic heart failure patients [3][4][5][6]. The association among candidates for cardiac rehabilitation remains uncertain.…”