Right ventricular mechanical pattern in patients undergoing mitral valve surgery: a predictor of post‐operative dysfunction?

Abstract

Aims The PREPARE-MVR study (PRediction of Early PostoperAtive Right vEntricular failure in Mitral Valve Replacement/Repair patients) sought to investigate the alterations of right ventricular (RV) contraction pattern in patients undergoing mitral valve replacement/repair (MVR) and to explore the associations between pre-operative RV mechanics and early post-operative RV dysfunction (RVD). Methods and resultsWe prospectively enrolled 42 patients (63 ± 11 years, 69% men) undergoing open-heart MVR. Transthoracic three-dimensional (3D) echocardiography was performed pre-operatively, at intensive care unit discharge, and 6 months after surgery. The 3D model of the RV was reconstructed, and RV ejection fraction (RVEF) was calculated. We decomposed the motion of the ventricle to compute longitudinal ejection fraction (LEF) and radial ejection fraction (REF). Pulmonary artery catheterization was performed to monitor RV stroke work index (RVSWi). RVEF was slightly decreased after vs. 51 (46-54)%; P = 0.001], whereas RV contraction pattern changed notably. Before MVR, the longitudinal shortening was the main contributor to global systolic RV function [LEF/RVEF vs. REF/RVEF; 0.53 (0.47-0.58) vs. 0.33 (0.22-0.42); P < 0.001]. Post-operatively, the radial motion became dominant [0.33 (0.28-0.43) vs. 0.46 (0.37-0.51); P = 0.004].However, this shift was temporary as 6 months later the two components contributed equally to global RV function [0.44 (0.38-0.50) vs. 0.41 (0.36-0.49); P = 0.775]. Pre-operative LEF was an independent predictor of post-operative RVD defined as RVSWi < 300 mmHgÁmL/m 2 [OR = 1.33 (95% CI: 1.08-1.77), P < 0.05]. Conclusions MVR induces a significant shift in the RV mechanical pattern. Advanced indices of RV mechanics are associated with invasively measured parameters of RV contractility and may predict post-operative RVD.

Partitioning the Right Ventricle Into 15 Segments and Decomposing Its Motion Using 3D Echocardiography-Based Models: The Updated ReVISION Method

“…The results of the intra- and interobserver variability and reliability analyses are summarized in Tables 1 , 2 . Reproducibility of global EDV, ESV, and decomposed ESVs were high, which is consistent with our previous reports using the earlier versions of the ReVISION software ( 10 , 11 , 13 ). Regarding the 15 segments, a smooth base-to-apex gradient could be observed ( Table 2 , Figures 6 , 7 ), with the inflow tract and basal segments having the lowest variability and the highest reliability and free wall apical segments exhibiting the highest variability and the lowest reliability.…”

“…For this purpose, we developed the Right VentrIcular Separate wall motIon quantificatiON (ReVISION) method a few years ago, which is a 3D echocardiography (3DE)-based solution for the quantification of the relative contribution of longitudinal, radial, and anteroposterior shortening to global RV EF (9). Since then, our technology has been applied in several clinical scenarios (10)(11)(12), and the strengths of the ReVISION method have been demonstrated in the in-depth characterization of RV mechanical pattern and the prognostication of patients even in the face of maintained RV EF (13). The ReVISION method and the associated online platform (demo version available at https://www.revisionmethod.com) are improved continuously, and recently, various new features, such as the assessment of longitudinal, circumferential, and area strains have been implemented to enable the convenient, standardized, and more comprehensive analysis of RV function using 3DE datasets.…”

Importance of Nonlongitudinal Motion Components in Right Ventricular Function: Three-Dimensional Echocardiographic Study in Healthy Volunteers

“…23 However, several studies have contradicted these observations, highlighting the potential importance of the ''bellows'' action (radial shortening) and anteroposterior shortening in healthy individuals and in patients with cardiovascular diseases as well. 7,16,24,25 Although the longitudinal motion of the tricuspid annulus appears to be quite prominent, it is important to emphasize that because of its large surface, even subtle inward motion of the RV free wall can result in a considerable amount of volume change. 26 Nevertheless, current clinical practice lacks any RV functional parameter, which selectively represents the nonlongitudinal motions of the chamber.…”

Comprehensive Echocardiographic Assessment of the Right Ventricular Performance: beyond TAPSE and Fractional Area Change

“…There is an instantaneous shift in the RV contraction at the opening of the pericardial sac: as normal pericardial constraint vanishes the longitudinal shortening will significantly decrease; however, global EF remains maintained due to effective compensation by the radial motion. A recent follow-up study in patients underwent mitral valve replacement or repair confirmed the temporary nature of this phenomenon as 6-months later the normal relative contribution of the aforementioned wall motion directions was restored [26]. Heart transplanted patients represent quite a different patient subpopulation, as the dominance of radial motion seems long-lasting and parameters referring only to longitudinal shortening will report dysfunction for quite a long time after the operation ( Fig.…”