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Comparison of the Usefulness of Strain Imaging by Echocardiography Versus Computed Tomography to Detect Right Ventricular Systolic Dysfunction in Patients With Significant Secondary Tricuspid Regurgitation

Open AccessPublished:August 14, 2020DOI:https://doi.org/10.1016/j.amjcard.2020.07.063
      Assessment of right ventricular (RV) systolic function in patients with significant secondary tricuspid regurgitation (STR) remains challenging. In patients with severe aortic stenosis treated with transcatheter aortic valve implantation (TAVI), STR and RV enlargement have been associated with poor outcomes. In these patients, speckle tracking echocardiography (STE) may detect RV systolic dysfunction better than 3-dimensional (3D) RV ejection fraction (EF). The purpose of this study was to investigate the prevalence of RV dysfunction when assessed with STE in patients with significant STR (≥3+) compared with patients without significant STR (<3+) matched for 3D RV dimensions and RVEF on dynamic computed tomography (CT). Patients with dynamic CT data before TAVI were evaluated retrospectively. To assess the performance of RV-free wall strain (RVFWS) for identifying patients with impaired RV systolic function, patients were subsequently matched 1:1 based on age, gender, indexed RV end-diastolic volume (RVEDVi), indexed RV end-systolic volume (RVESVi), RVEF, and left ventricular ejection fraction (LVEF). In a total 267 patients (80 ± 8 years, 48% male), significant STR (≥3+) was observed in 67 patients. Patients with STR≥3+ had larger RVEDVi, larger RVESVi, lower LVEF, and more impaired RVFWS compared with patients with STR<3+ (n = 200). After propensity score matching, patients with STR≥3+ (n = 53) had significantly more impaired RVFWS compared with patients with STR<3+ (n = 53): −18.2 ± 5.0% versus −21.1 ± 3.7%, p = 0.001. In conclusion, patients with significant STR have more pronounced RV systolic dysfunction as assessed with STE than the patients without significant STR despite having similar 3D RV dimensions and RVEF on dynamic CT.
      The interest in secondary tricuspid regurgitation (STR) has grown since it is an independent predictor of poor prognosis in various cardiovascular diseases.
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      • Foster E
      • Heidenreich PA
      Impact of tricuspid regurgitation on long-term survival.
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      • Michelena H
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      • Mahoney DW
      • Enriquez-Sarano M
      Burden of tricuspid regurgitation in patients diagnosed in the community setting.
      Significant STR is not rare in the patients with aortic stenosis (AS) who are referred for transcatheter aortic valve implantation (TAVI) and has been associated with impaired prognosis.
      • Lindman BR
      • Maniar HS
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      • Zajarias A
      Effect of tricuspid regurgitation and the right heart on survival after transcatheter aortic valve replacement: insights from the placement of aortic transcatheter valves II inoperable cohort.
      In addition, right ventricular (RV) systolic function is a determinant of prognosis in this population.
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      • Asch FM
      Impact of right ventricular function on outcome of severe aortic stenosis patients undergoing transcatheter aortic valve replacement.
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      • Sharbaugh MS
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      • Gleason TG
      • Cavalcante JL
      Association of structural and functional cardiac changes with transcatheter aortic valve replacement outcomes in patients with aortic stenosis.
      • Vollema EM
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      • Prihadi EA
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      • Leon MB
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      • Ewe SH
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      • Bax JJ
      Staging cardiac damage in patients with symptomatic aortic valve stenosis.
      However, due to the shape, assessment of RV volumes is challenging with 2-dimensional (2D) imaging techniques. Therefore, 3-dimensional (3D) analyses are recommended for quantification of RV volumes and ejection fraction (EF).
      • Surkova E
      • Muraru D
      • Iliceto S
      • Badano LP
      The use of multimodality cardiovascular imaging to assess right ventricular size and function.
      • Valsangiacomo Buechel ER
      • Mertens LL
      Imaging the right heart: the use of integrated multimodality imaging.
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      • Muhlenbruch G
      • Rapaee A
      • Sim KH
      • Seyfarth T
      • Gunther RW
      • Mahnken AH
      Assessment of global right ventricular function on 64-MDCT compared with MRI.
      Nonetheless, in the presence of significant TR, RVEF may not accurately reflect the active myocardial shortening as it represents the volume change between diastole and systole and does not take into account the STR and the reduced RV forward flow. Conversely, RV-free wall strain (RVFWS) may better reflect RV systolic function.
      • Prihadi EA
      • van der Bijl P
      • Dietz M
      • Abou R
      • Vollema EM
      • Marsan NA
      • Delgado V
      • Bax JJ
      Prognostic implications of right ventricular free wall longitudinal strain in patients with significant functional tricuspid regurgitation.
      This study aimed to investigate the RV systolic function by speckle tracking echocardiography (STE) in patients with severe AS treated with TAVI.

      Methods

      A total of 418 patients who underwent dynamic CT before TAVI at the Leiden University Medical Center were included. In all patients, echocardiography was performed within 30 days of CT and before TAVI. Patients with an intracardiac device (n = 64), organic TR (n = 1), history of tricuspid valve surgery (n = 1), and insufficient quality of the echocardiography or CT images (n = 85) were excluded. The remaining 267 patients were classified into 2 groups based on the STR severity (≥3+ vs STR <3+).
      To assess the performance of RVFWS for identifying patients with impaired RV systolic function, patients were subsequently matched 1:1 according to the following variables: age, gender, indexed RV end-diastolic volume (RVEDVi), indexed RV end-systolic volume (RVESVi), RVEF, and LV ejection fraction (LVEF) (Figure 1). The Institutional Ethics Committee approved this retrospective evaluation and waived the need for patient written informed consent.
      Figure 1
      Figure 1Patient population. CT = computed tomography; LVEF = left ventricular ejection fraction; RVEDVi = indexed right ventricular end-diastolic volume; RVEF = right ventricular ejection fraction; RVESVi = indexed right ventricular end-systolic volume; TAVI = transcatheter aortic valve implantation; TR = tricuspid regurgitation; TV = tricuspid valve.
      Comprehensive transthoracic echocardiography data, including 2D images and color, pulsed, and continuous-wave Doppler data were acquired using commercially available ultrasound systems equipped with 3.5 MHz transducers (E9 or E95, GE-Vingmed, Horten, Norway). Data were stored in cine-loop format digitally for offline analysis (EchoPAC Version 203.0.1, GE Medical Systems, Horten, Norway). Standard data acquisition was performed according to the current recommendations.
      • Lang RM
      • Badano LP
      • Mor-Avi V
      • Afilalo J
      • Armstrong A
      • Ernande L
      • Flachskampf FA
      • Foster E
      • Goldstein SA
      • Kuznetsova T
      • Lancellotti P
      • Muraru D
      • Picard MH
      • Rietzschel ER
      • Rudski L
      • Spencer KT
      • Tsang W
      • Voigt JU
      Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.
      ,
      • Lancellotti P
      • Moura L
      • Pierard LA
      • Agricola E
      • Popescu BA
      • Tribouilloy C
      • Hagendorff A
      • Monin JL
      • Badano L
      • Zamorano JL
      European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 2: mitral and tricuspid regurgitation (native valve disease).
      With the patients in the left lateral decubitus position, parasternal, apical, and subcostal views were acquired. Left ventricular end-diastolic volume (LVEDV) and left ventricular end-systolic volume (LVESV) were measured using Simpson's biplane method from the apical 4- and 2-chamber views and indexed to the body surface area. LVEF was calculated using the following formula: [(LVEDV − LVESV) / LVEDV] × 100.
      • Lang RM
      • Badano LP
      • Mor-Avi V
      • Afilalo J
      • Armstrong A
      • Ernande L
      • Flachskampf FA
      • Foster E
      • Goldstein SA
      • Kuznetsova T
      • Lancellotti P
      • Muraru D
      • Picard MH
      • Rietzschel ER
      • Rudski L
      • Spencer KT
      • Tsang W
      • Voigt JU
      Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.
      The severity of STR was assessed using an integrated approach as recommended in current guidelines and included an analysis of the vena contracta width:
      • Topilsky Y
      • Maltais S
      • Medina Inojosa J
      • Oguz D
      • Michelena H
      • Maalouf J
      • Mahoney DW
      • Enriquez-Sarano M
      Burden of tricuspid regurgitation in patients diagnosed in the community setting.
      none or trivial STR (0–1+) if the vena contracta width was <2.0 mm, mild STR (2+) if the vena contracta width ranged from 2.0 to 4.9 mm, moderate STR (3+) if the vena contracta width ranged from 5.0 to 7.0 mm and severe STR (4+) if the vena contracta width was >7.0 mm. The vena contracta width of the STR jet was measured in the apical 4-chamber view. The RV systolic pressure gradient was quantified with the maximum STR jet velocity according to the modified Bernoulli equation and subsequently the estimated right atrial pressure was added to determine systolic pulmonary artery pressure (SPAP). Right atrial pressure was estimated by measuring the diameter and respiratory change of the inferior vena cava, as recommended.
      • Lancellotti P
      • Moura L
      • Pierard LA
      • Agricola E
      • Popescu BA
      • Tribouilloy C
      • Hagendorff A
      • Monin JL
      • Badano L
      • Zamorano JL
      European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 2: mitral and tricuspid regurgitation (native valve disease).
      ,
      • Rudski LG
      • Lai WW
      • Afilalo J
      • Hua L
      • Handschumacher MD
      • Chandrasekaran K
      • Solomon SD
      • Louie EK
      • Schiller NB
      Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography.
      For the accurate assessment of RV myocardial deformation, the RV-focused apical 4-chamber view (>60 frames/s) was obtained. Using 2D STE (EchoPAC Version 203.0.1, GE Medical Systems, Horten, Norway), RVFWS measurements were performed according to current recommendations.
      • Ayach B
      • Fine NM
      • Rudski LG
      Right ventricular strain: measurement and clinical application.
      ,
      • Badano LP
      • Kolias TJ
      • Muraru D
      • Abraham TP
      • Aurigemma G
      • Edvardsen T
      • D'Hooge J
      • Donal E
      • Fraser AG
      • Marwick T
      • Mertens L
      • Popescu BA
      • Sengupta PP
      • Lancellotti P
      • Thomas JD
      • Voigt JU
      Standardization of left atrial, right ventricular, and right atrial deformation imaging using two-dimensional speckle tracking echocardiography: a consensus document of the EACVI/ASE/Industry Task Force to standardize deformation imaging.
      RVFWS was calculated as an average of the 3 RV-free wall segments strain (basal, mid, and apical) (Figure 2).
      Figure 2
      Figure 2Assessment of RV systolic function with speckle tracking echocardiography and dynamic computed tomography. (A) Measurement of right ventricular free wall longitudinal strain (RVFWS) using speckle tracking echocardiography. According to the recommendation, 6 right ventricular segments were traced and RVFWS was calculated as an average of the longitudinal strain of the 3 free wall segments. (B) Assessment of right ventricular volumes according to computed tomography (CT). The endocardial border of the right ventricle was traced every 4-mm slice on CT and the end-diastolic volume, end-systolic volume, and ejection fraction were measured.
      CT data were acquired with a 64-detector (Aquilion64, Toshiba Medical Systems, Otawara, Japan) or 320-detector row CT scanner (AquilionOne, Toshiba Medical Systems, Tochigi-ken, Japan) according to a dedicated cardiac CT protocol, as previously described.
      • Delgado V
      • Ng AC
      • van de Veire NR
      • van der Kley F
      • Schuijf JD
      • Tops LF
      • de Weger A
      • Tavilla G
      • de Roos A
      • Kroft LJ
      • Schalij MJ
      • Bax JJ
      Transcatheter aortic valve implantation: role of multi-detector row computed tomography to evaluate prosthesis positioning and deployment in relation to valve function.
      ,
      • Podlesnikar T
      • Prihadi EA
      • van Rosendael PJ
      • Vollema EM
      • van der Kley F
      • de Weger A
      • Ajmone Marsan N
      • Naji F
      • Fras Z
      • Bax JJ
      • Delgado V
      Influence of the quantity of aortic valve calcium on the agreement between automated 3-dimensional transesophageal echocardiography and multidetector row computed tomography for aortic annulus sizing.
      With prospective electrocardiogram-triggered dose modulation, an entire cardiac cycle image was acquired at each 10% of RR interval.
      For the assessment of RV volumes, the end-systolic and end-diastolic phases were defined by visual inspection of the cardiac cycle and were frequently the 30% to 45% and 80% to 100% phase of the cardiac cycle, respectively. Using the 3mensio software, release 10.0 (Pie Medical Imaging, Bilthoven, the Netherlands), the whole RV was traced every 4-mm slices in the transverse plane, and semiautomatically both the RV end-diastolic (RVEDV) and RV end-systolic (RVESV) were measured and indexed for body surface area (Figure 2). RVEF was calculated using the following formula: RVEF = [(RVEDV − RVESV) / RVEDV] × 100%.
      Continuous variables as mean ± standard deviation or as median with interquartile range depending on the presence or absence of a normal distribution. For the comparison of the variables between patients with STR≥3+ or STR<3 the Student's t test or the Mann-Whitney U test were used as appropriate. Categorical variables were expressed as frequency (percentage) and compared with the chi-square or Fisher’s exact test as appropriate. P values <0.05 were considered statistically significant. Comparisons between patients with STR ≥3+ and patients with STR <3+ were performed using a propensity score calculated for the variables age, gender, RVEDVi, RVESVi, RVEF, and LVEF. Matching was then performed using the 1:1 nearest neighbor method with a small tolerance (0.2 standard deviations of the logit of the propensity score). All statistical analyses were performed using SPSS version 25 (SPSS, Inc., Chicago, IL).

      Results

      Among 267 patients (mean age 80 ± 8 years old, 128 (48%) male), STR ≥3+ was observed in 67 (25%) patients (Table 1). The demographic and clinical characteristics of the patients are shown in Table 1. Age, gender, body surface area, the prevalence of hypertension, diabetes, and history of previous myocardial infarction were comparable in both groups. Patients with STR ≥3+ had a higher prevalence of atrial fibrillation and were more frequently using diuretics than their counterparts. Patients with STR ≥3+ had more frequently New York Heart Association functional class III-IV heart failure symptoms, although this did not reach statistical significance.
      Table 1Demographic and clinical characteristics of the overall population
      VariableAll (n = 267)STR ≥3+ (n = 67)STR <3+ (n = 200)p value
      p value between STR ≥3+ versus STR <3+.
      Age (years)80.1 ± 7.980.1 ± 7.980.2 ± 8.00.964
      Men128 (48%)35 (52%)93 (47%)0.416
      BSA (m2)1.82 ± 0.201.83 ± 0.201.81 ± 0.200.600
      Atrial fibrillation36 (14%)24 (36%)12 (6%)<0.001
      Hypertension206 (77%)46 (69%)160 (80%)0.065
      Diabetes mellitus69 (26%)13 (19%)56 (28%)0.198
      Previous myocardial infarction55 (21%)18 (27%)37 (19%)0.163
      Medication
      β-blockers163 (61%)36 (54%)127 (64%)0.193
      ACEi/ARBs128 (48%)32 (48%)96 (48%)1.000
      Diuretics162 (61%)54 (81%)108 (54%)<0.001
      NYHA class
      I21 (8%)1 (1%)20 (10%)0.076
      II99 (37%)23 (34%)76 (38%)
      III122 (46%)34 (51%)88 (44%)
      IV25 (9%)9 (13%)16 (8%)
      ACEi/ARBs = angiotensin converting enzyme inhibitor/angiotensin receptor blockers; BSA = body surface area; NYHA = New York Heart Association; TR = tricuspid regurgitation.
      Values are mean ± SD or n (%).
      low asterisk p value between STR ≥3+ versus STR <3+.
      Table 2 shows the echocardiographic and CT characteristics. Patients with STR ≥3+ had a larger indexed LVESV and a lower LVEF compared with patients with STR <3+. In addition, patients with STR ≥3+ had a more impaired RVFWS and a higher SPAP compared with their counterparts. On the CT data, patients with STR ≥3+ showed significant larger RV volumes. In patients with STR ≥3+, RVEF was significantly lower compared with patients with STR <3+ (Table 2).
      Table 2.Echocardiographic and CT parameters in the overall population
      VariableAll (n = 267)STR ≥3+ (n = 67)STR <3+ (n = 200)p value
      p value between STR ≥3+ versus STR <3+.
      Echocardiographic measurements
       Indexed LVEDV (mL/m2)51.4 ± 21.054.5 ± 24.450.3 ± 19.60.157
       Indexed LVESV (mL/m2)24.3 ± 17.728.7 ± 21.022.9 ± 16.30.020
       LVEF (%)56.9 ± 14.451.6 ± 16.058.6 ± 13.4<0.001
       TR vena contracta width (mm)3.0 [1.0 – 6.0]8.0 [7.0 – 9.0]2.0 [0.0 – 3.0]<0.001
       RVFWS (%)-24.2 ± 6.6-17.1 ± 5.0-26.6 ± 5.2<0.001
      SPAP (mm Hg)34.8 ± 13.944.5 ± 14.031.2 ± 12.0<0.001
      CT measurements
       Indexed RVEDV (mL/m2)81.8 ± 21.295.3 ± 27.377.3 ± 16.4<0.001
       Indexed RVESV (mL/m2)43.1 ± 16.755.3 ± 22.539.0 ± 11.7<0.001
       RVEF (%)47.9 ± 11.242.7 ± 12.549.6 ± 10.3<0.001
      CT = computed tomography; LVEDV = left ventricular end-diastolic volume; LVEF = left ventricular ejection fraction; LVESV = left ventricular end-systolic volume; RVEDV = right ventricular end-diastolic volume; RVEF = right ventricular ejection fraction; RVESV = right ventricular end-systolic volume; RVFWS = right ventricular free wall strain; SPAP = systolic pulmonary artery pressure; TR = tricuspid regurgitation.
      Values are mean ± SD, median (interquartile range), or n (%).
      low asterisk p value between STR ≥3+ versus STR <3+.
      According to the propensity score, 106 patients were matched 1:1 in groups of STR ≥3+ and STR <3+. Similarly to the nonmatched population analysis, the prevalence of atrial fibrillation was higher and the use of diuretics was also more frequent in patients with STR ≥3+ compared with patients with STR <3+ (Table 3).
      Table 3.Comparison between STR ≥3+ group and STR <3+ group after propensity score matching
      VariableAll (n = 106)STR ≥3+ (n = 53)STR <3+ (n = 53)p value
      p value between STR ≥3+ versus STR <3+.
      Age (years)80.9 ± 6.380.2 ± 6.081.6 ± 6.60.244
      Men46 (43%)27 (51%)19 (36%)0.117
      BSA (m2)1.79 ± 0.191.82 ± 0.191.77 ± 0.190.133
      Atrial fibrillation26 (25%)22 (42%)4 (8%)<0.001
      Hypertension75 (71%)34 (64%)41 (77%)0.135
      Diabetes mellitus22 (21%)10 (19%)12 (23%)0.632
      Previous myocardial infarction26 (25%)15 (28%)11 (21%)0.367
      Medication
      β-blockers62 (59%)30 (57%)32 (60%)0.693
      ACEi/ARBs,53 (50%)28 (53%)25 (47%)0.560
      Diuretics72 (68%)41 (77%)31 (59%)0.037
      NYHA class
      I8 (8%)1 (2%)7 (13%)0.115
      II40 (38%)19 (36%)21 (40%)
      III48 (45%)28 (53%)20 (38%)
      IV10 (9%)5 (9%)5 (9%)
      ACEi/ARBs = angiotensin converting enzyme inhibitor/angiotensin receptor blockers; BSA = body surface area; NYHA = New York Heart Association; TR = tricuspid regurgitation.
      Values are mean ± SD or n (%).
      low asterisk p value between STR ≥3+ versus STR <3+.
      Table 4 shows the echocardiographic and CT characteristics in the propensity-matched cohort divided according to the STR severity. RVFWS was significantly more impaired and the SPAP was significantly higher in the patients with STR ≥3+ compared with patients with STR <3+ (Figure 3).
      Table 4Echocardiographic and CT parameters after propensity score matching
      VariableAll (n = 106)STR ≥3+ (n = 53)STR <3+ (n = 53)P value
      p value between STR ≥3+ versus STR <3+.
      Echocardiographic measurements
       Indexed LVEDV (mL/m2)49.7 ± 21.349.4 ± 21.650.0 ± 21.20.886
       Indexed LVESV (mL/m2)22.9 ± 16.323.3 ± 16.222.6 ± 16.40.835
        LVEF (%)57.2 ±14.555.2 ± 14.459.3 ± 14.50.150
       TR vena contracta width (mm)6.0 [3.0 – 7.3]7.0 [7.0-9.0]3.0 [0.0 – 4.0]<0.001
        RVFWS (%)-21.7 ± 5.6-18.1 ± 4.6-25.2 ± 4.2<0.001
        SPAP (mm Hg)38.5 ± 14.041.9 ± 13.834.9 ± 13.40.011
      CT measurements
       Indexed RVEDV (mL/m2)86.0 ± 19.887.5 ± 21.184.4 ± 18.50.418
       Indexed RVESV (mL/m2)46.6 ± 14.547.2 ± 14.646.1 ± 14.50.698
        RVEF (%)45.8 ± 11.546.0 ± 11.345.5 ± 11.70.828
      CT = computed tomography; LVEDV = left ventricular end-diastolic volume; LVEF = left ventricular ejection fraction; LVESV = left ventricular end-systolic volume; RVEDV = right ventricular end-diastolic volume; RVEF = right ventricular ejection fraction; RVESV = right ventricular end-systolic volume; RVFWS = right ventricular free wall strain; SPAP = systolic pulmonary artery pressure; TR = tricuspid regurgitation.
      Values are mean ± SD, median (interquartile range), or n (%).
      low asterisk p value between STR ≥3+ versus STR <3+.
      Figure 3
      Figure 3Representative examples of right ventricular systolic function assessment in a patient with severe tricuspid regurgitation (A) and a patient with trivial tricuspid regurgitation (B). Although these patients had comparable right ventricular volumes and ejection fraction on multidetector row computed tomography, the patient with severe tricuspid regurgitation had more impaired right ventricular-free wall longitudinal strain than the patient with trivial tricuspid regurgitation. RVEDV = right ventricular end-diastolic volume; RVEF = right ventricular ejection fraction; RVESV = right ventricular end-systolic volume; RVFWS = right ventricular free wall longitudinal strain; TR = tricuspid regurgitation.

      Discussion

      This study demonstrates that RV function in patients with significant STR is more frequently impaired when measured with RVFWS than by assessment of 3D RVEF. In the nonmatched cohort, significant STR was associated with RV and LV remodeling, but after matching for LVEF, RV volumes and RVEF, the RVFWS remained significantly more impaired in patients with significant STR compared with patients without significant STR.
      The pathophysiology of STR and RV failure is intertwined: the presence of STR may lead to further RV dilation and failure, which in turn may cause more severe STR. Assessment of RV dimensions and systolic function with conventional echocardiography is limited since the RV has a characteristic 3D shape that cannot be fully evaluated with 2D echocardiography. Therefore, 3D imaging techniques such as echocardiography, cardiac magnetic resonance, CT, or nuclear imaging are needed. Furthermore, the presence of TR facilitates the unloading of the RV into the right atrium through the regurgitant jet which may lead to a falsely preserved RVEF.
      The RV systolic function depends on the loading conditions, myocardial contractility, pericardial constraint and the interventricular dependence represented by the interventricular septum. Normal forward RV flow is the result of an intrinsic inward motion of the RV-free wall, longitudinal shortening of the fibers from the tricuspid annulus in the direction of the RV apex and traction on the free wall secondary to LV contraction.
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      This interplay is complicated if severe tricuspid regurgitation is present, since tricuspid regurgitation leads to increased RV volume overload, and increased wall stress on the myocardial fibers that may impair the intrinsic myocardial performance of the thin-walled RV. Recently, Prihadi et al showed in 896 patients that RV dysfunction as assessed by RVFWS (using a cutoff value > −23%) was present in 84.9% of patients with significant STR.
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      Prognostic implications of right ventricular free wall longitudinal strain in patients with significant functional tricuspid regurgitation.
      Moreover, Prihadi et al demonstrated that RVWFS was a more sensitive parameter for detection of RV dysfunction compared with conventional parameters including tricuspid annular plane systolic excursion and fractional area change which identified RV dysfunction in 71.7% and 49.4% of the 896 patients with STR.
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      Prognostic implications of right ventricular free wall longitudinal strain in patients with significant functional tricuspid regurgitation.
      RVFWS using STE has been considered to be less dependent of volume load compared with conventional RV functional parameters. However, it is important to realize that RVFWS is not completely load independent.
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      • Meurling C
      Right ventricular speckle tracking assessment for differentiation of pressure- versus volume-overloaded right ventricle.
      The relationship between the preload and tension development underscores the importance of taking the RVEDV (as a marker of preload) into consideration for comprehensive assessment of RV contractility. Therefore, to investigate the association between significant STR and the intrinsic RV myocardial performance adjusted for preload, the present study performed a propensity score-matched analysis including RV volumes and RVEF. In the presence of similar RV volumes and RVEF, RVFWS was more impaired in patients with STR ≥3+ compared with those without STR ≥3+. Accordingly, for a comprehensive assessment of RV function in patients with significant STR, the information of 3D RV volumes may be combined with assessment of RVFWS, as this parameter may reflect in more detail the inotropic status of the RV.
      Furthermore it is important to note that after performing the matched analysis, there remained differences in SPAP. Patients with STR ≥3+ had significantly higher SPAP than their counterparts and this may have impact on the value of RVFWS.
      The clinical implications of these findings are important, since RV systolic function has demonstrated to be an important prognostic marker in various cardiac conditions.
      • Harjola VP
      • Mebazaa A
      • Celutkiene J
      • Bettex D
      • Bueno H
      • Chioncel O
      • Crespo-Leiro MG
      • Falk V
      • Filippatos G
      • Gibbs S
      • Leite-Moreira A
      • Lassus J
      • Masip J
      • Mueller C
      • Mullens W
      • Naeije R
      • Nordegraaf AV
      • Parissis J
      • Riley JP
      • Ristic A
      • Rosano G
      • Rudiger A
      • Ruschitzka F
      • Seferovic P
      • Sztrymf B
      • Vieillard-Baron A
      • Yilmaz MB
      • Konstantinides S
      Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and Right Ventricular Function of the European Society of Cardiology.
      When considering the current clinical scenario of TAVI patients, several studies showed the association between RV dysfunction and the outcomes after TAVI.
      • Poliacikova P
      • Cockburn J
      • Pareek N
      • James R
      • Lee L
      • Trivedi U
      • de Belder A
      • Hildick-Smith D
      Prognostic impact of pre-existing right ventricular dysfunction on the outcome of transcatheter aortic valve implantation.
      • Asami M
      • Stortecky S
      • Praz F
      • Lanz J
      • Raber L
      • Franzone A
      • Piccolo R
      • Siontis GCM
      • Heg D
      • Valgimigli M
      • Wenaweser P
      • Roost E
      • Windecker S
      • Pilgrim T
      Prognostic value of right ventricular dysfunction on clinical outcomes after transcatheter aortic valve replacement.
      • Schwartz LA
      • Rozenbaum Z
      • Ghantous E
      • Kramarz J
      • Biner S
      • Ghermezi M
      • Shimiaie J
      • Finkelstein A
      • Banai S
      • Aviram G
      • Ingbir M
      • Keren G
      • Topilsky Y
      Impact of right ventricular dysfunction and tricuspid regurgitation on outcomes in patients undergoing transcatheter aortic valve replacement.
      Data from the Swiss TAVI registry showed in 1,116 patients that RV dysfunction was present in 29.1% of the patients, defined by a tricuspid annulus plane systolic excursion <17 mm, a systolic velocity of the RV lateral wall <9.5 cm/s on tissue Doppler imaging, or a fractional area change <35%.
      • Asami M
      • Stortecky S
      • Praz F
      • Lanz J
      • Raber L
      • Franzone A
      • Piccolo R
      • Siontis GCM
      • Heg D
      • Valgimigli M
      • Wenaweser P
      • Roost E
      • Windecker S
      • Pilgrim T
      Prognostic value of right ventricular dysfunction on clinical outcomes after transcatheter aortic valve replacement.
      In addition, the presence of RV dysfunction was associated with a 2-fold increase in cardiovascular mortality after 1-year follow-up (20% vs 7%, adjusted hazard ratio = 2.94, 95% confidence interval: 2.02 to 4.27).
      • Asami M
      • Stortecky S
      • Praz F
      • Lanz J
      • Raber L
      • Franzone A
      • Piccolo R
      • Siontis GCM
      • Heg D
      • Valgimigli M
      • Wenaweser P
      • Roost E
      • Windecker S
      • Pilgrim T
      Prognostic value of right ventricular dysfunction on clinical outcomes after transcatheter aortic valve replacement.
      Of interest, recovery of RV function can be observed after TAVI in 57% of patients. However, the presence of persistent RV dysfunction was associated with increased 1-year cardiovascular mortality (adjusted hazard ratio = 2.16, 95% confidence interval: 1.16 to 4.02).
      • Asami M
      • Stortecky S
      • Praz F
      • Lanz J
      • Raber L
      • Franzone A
      • Piccolo R
      • Siontis GCM
      • Heg D
      • Valgimigli M
      • Wenaweser P
      • Roost E
      • Windecker S
      • Pilgrim T
      Prognostic value of right ventricular dysfunction on clinical outcomes after transcatheter aortic valve replacement.
      However, since these conventional parameters are more influenced by volume overload compared with RVFWS by STE,
      • Werther Evaldsson A
      • Ingvarsson A
      • Waktare J
      • Smith GJ
      • Thilen U
      • Stagmo M
      • Roijer A
      • Radegran G
      • Meurling C
      Right ventricular speckle tracking assessment for differentiation of pressure- versus volume-overloaded right ventricle.
      the assessment of RVFWS may potentially have incremental prognostic value in patients with significant STR.
      The present study had several limitations. First, this is a single-center retrospective observational study having limitation inherent to the study design. Second, the current analysis included only patients who had undergone TAVI, since those patients had ECG-gated CT data acquired throughout the entire cardiac cycle allowing the measurement of RVEF without geometrical assumptions.
      In conclusion, patients with significant STR have more RV systolic dysfunction assessed with STE than the patients without significant STR despite having similar 3D RV dimensions and RVEF measured on dynamic CT.

      Author Contribution

      Kensuke Hirasawa: Conception and design of the study; collection, analysis and interpretation of data; statistical analysis; drafting of the manuscript; final approval of the manuscript; Philippe J. van Rosendael: Conception and design of the study; collection, analysis and interpretation of data; statistical analysis; drafting of the manuscript; final approval of the manuscript; Marlieke F. Dietz: Conception and design of the study; collection, analysis and interpretation of data; statistical analysis; drafting of the manuscript; final approval of the manuscript; Nina Ajmone Marsan: Conception and design of the study; collection, analysis and interpretation of data; statistical analysis; drafting of the manuscript; final approval of the manuscript; Victoria Delgado; Conception and design of the study; collection, analysis and interpretation of data; statistical analysis; drafting of the manuscript; final approval of the manuscript; Jeroen J Bax: Conception and design of the study; collection, analysis and interpretation of data; statistical analysis; drafting of the manuscript; final approval of the manuscript.

      Disclosures

      The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:
      The Department of Cardiology of the Leiden University Medical Center received research grants from Abbott Vascular, Bayer, Bioventrix, Medtronic, Biotronik, Boston Scientific, GE Healthcare and Edwards Lifesciences. Kensuke Hirasawa is financially supported by an ESC research grant (R-2018-18122). This work was funded by an unrestricted research grant from Edwards Lifesciences (IISUSTHV2018017). Jeroen Bax and Nina Ajmone Marsan received speaking fees from Abbott Vascular. Victoria Delgado received speaker fees from Abbott Vascular, Medtronic, MSD, Edwards Lifesciences and GE Healthcare. The remaining authors have nothing to disclose.

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