Approach to optimal assessment of right ventricular remodelling in heart transplant recipients: insights from myocardial work index, T1 mapping, and endomyocardial biopsy

Sade, Leyla Elif; Çolak, Ayşe; Düzgün, Selin Ardalı; Hazırolan, Tuncay; Sezgin, Atilla; Donal, Erwan; Butcher, Steele C; Özdemir, Handan; Pirat, Bahar; Eroğlu, Serpil; Müderrisoğlu, Haldun

doi:10.1093/ehjci/jeac108

Cited by 13 publications

(19 citation statements)

References 28 publications

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“…For instance, strictly longitudinal parameters are load dependent, and measurements may be distorted in the case of pronounced TR owing to retrograde unloading into the right atrium. 63 , 84 Severe TR may lead to underestimation of PASP. 34 In highly advanced PH stages, PASP decreases with RV failure, 91 potentially promoting misinterpretation as mild PH.…”

Section: Discussionmentioning

confidence: 99%

“…The importance of non‐longitudinal RV shortening has been repeatedly demonstrated. 75 , 84 , 99 The entire right ventricle is included in 3D echocardiography, but only isolated analysis of shortening components may detect early remodelling. 76 All in all, a combination of several parameters may yield better RV assessment than a single measure.…”

Section: Discussionmentioning

confidence: 99%

“… 82 , 83 Non‐invasive quantification of RVMW from pressure–strain loops [constructed from RV strain, pulmonary pressures (determined invasively or non‐invasively), and valvular events] incorporates contractility, afterload, RV dyssynchrony, and post‐systolic shortening in the RV functional assessment. 83 , 84 It provides indices such as RV constructive work, wasted work, work index, and work efficiency and is consequently able to quantify the portion of MW that actually contributes to RV output and the share that does not, such as post‐systolic shortening. RVMW index was the only parameter found to detect graft failure‐related transition from RV adaptation to failure in heart transplant recipients.…”

Section: Left Ventricular–right Ventricular Asynchrony Timing Of Righ...mentioning

confidence: 99%

“…RVMW index was the only parameter found to detect graft failure‐related transition from RV adaptation to failure in heart transplant recipients. 84 The integration of RV contractility and afterload mean that RVMW may also be regarded as a measure of RV–PA coupling. 83 …”

Section: Left Ventricular–right Ventricular Asynchrony Timing Of Righ...mentioning

confidence: 99%

“…Initially introduced for the left ventricle, 81 myocardial work (MW) was successfully transferred to the right ventricle by Butcher et al ., who also revealed superiority of the method compared with common echocardiographic parameters in estimating invasively assessed RV stroke work index and PVR 82,83 . Non‐invasive quantification of RVMW from pressure–strain loops [constructed from RV strain, pulmonary pressures (determined invasively or non‐invasively), and valvular events] incorporates contractility, afterload, RV dyssynchrony, and post‐systolic shortening in the RV functional assessment 83,84 . It provides indices such as RV constructive work, wasted work, work index, and work efficiency and is consequently able to quantify the portion of MW that actually contributes to RV output and the share that does not, such as post‐systolic shortening.…”

Section: Left Ventricular–right Ventricular Asynchrony Timing Of Righ...mentioning

confidence: 99%

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Adaptive versus maladaptive right ventricular remodelling

et al. 2022

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Right ventricular (RV) function and its adaptation to increased afterload [RV–pulmonary arterial (PA) coupling] are crucial in various types of pulmonary hypertension, determining symptomatology and outcome. In the course of disease progression and increasing afterload, the right ventricle undergoes adaptive remodelling to maintain right‐sided cardiac output by increasing contractility. Exhaustion of compensatory RV remodelling (RV–PA uncoupling) finally leads to maladaptation and increase of cardiac volumes, resulting in heart failure. The gold‐standard measurement of RV–PA coupling is the ratio of contractility [end‐systolic elastance (Ees)] to afterload [arterial elastance (Ea)] derived from RV pressure–volume loops obtained by conductance catheterization. The optimal Ees/Ea ratio is between 1.5 and 2.0. RV–PA coupling in pulmonary hypertension has considerable reserve; the Ees/Ea threshold at which uncoupling occurs is estimated to be ~0.7. As RV conductance catheterization is invasive, complex, and not widely available, multiple non‐invasive echocardiographic surrogates for Ees/Ea have been investigated. One of the first described and best validated surrogates is the ratio of tricuspid annular plane systolic excursion to estimated pulmonary arterial systolic pressure (TAPSE/PASP), which has shown prognostic relevance in left‐sided heart failure and precapillary pulmonary hypertension. Other RV–PA coupling surrogates have been formed by replacing TAPSE with different echocardiographic measures of RV contractility, such as peak systolic tissue velocity of the lateral tricuspid annulus (S′), RV fractional area change, speckle tracking‐based RV free wall longitudinal strain and global longitudinal strain, and three‐dimensional RV ejection fraction. PASP‐independent surrogates have also been studied, including the ratios S′/RV end‐systolic area index, RV area change/RV end‐systolic area, and stroke volume/end‐systolic volume. Limitations of these non‐invasive surrogates include the influence of severe tricuspid regurgitation (which can cause distortion of longitudinal measurements and underestimation of PASP) and the angle dependence of TAPSE and PASP. Detection of early RV remodelling may require isolated analysis of single components of RV shortening along the radial and anteroposterior axes as well as the longitudinal axis. Multiple non‐invasive methods may need to be applied depending on the level of RV dysfunction. This review explains the mechanisms of RV (mal)adaptation to its load, describes the invasive assessment of RV–PA coupling, and provides an overview of studies of non‐invasive surrogate parameters, highlighting recently published works in this field. Further large‐scale prospective studies including gold‐standard validation are needed, as most studies to date had a retrospective, single‐centre design with a small number of participants, and validation against gold‐standard Ees/Ea was rarely performed.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Left Ventricular–right Ventricular Asynchrony Timing Of Righ...mentioning

confidence: 99%

Section: Left Ventricular–right Ventricular Asynchrony Timing Of Righ...mentioning

confidence: 99%

Section: Left Ventricular–right Ventricular Asynchrony Timing Of Righ...mentioning

confidence: 99%

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Adaptive versus maladaptive right ventricular remodelling

et al. 2022

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Echocardiographic pressure–strain loop‐derived stroke work of the right ventricle: validation against the gold standard

et al. 2023

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AimsCommercially available integrated software for echocardiographic measurement of stroke work (SW) is increasingly used for the right ventricle, despite a lack of validation. We sought to assess the validity of this method [echo‐based myocardial work (MW) module] vs. gold‐standard invasive right ventricular (RV) pressure–volume (PV) loops.Methods and resultsFrom the prospectively recruiting EXERTION study (NCT04663217), we included 42 patients [34 patients with pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH) and 8 patients with absence of cardiopulmonary disease] with RV echocardiography and invasive PV catheterization. Echocardiographic SW was assessed as RV global work index (RVGWI) generated via the integrated pressure–strain MW software. Invasive SW was calculated as the area bounded by the PV loop. An additional parameter derived from the MW module, RV global wasted work (RVGWW), was correlated with PV loop measures. RVGWI significantly correlated with invasive PV loop‐derived RV SW in the overall cohort [rho = 0.546 (P < 0.001)] and the PAH/CTEPH subgroup [rho = 0.568 (P < 0.001)]. Overall, RVGWW correlated with invasive measures of arterial elastance (Ea), the ratio of end‐systolic elastance (Ees)/Ea, and end‐diastolic elastance (Eed) significantly.ConclusionsIntegrated echo measurement of pressure–strain loop‐derived SW correlates with PV loop‐based assessment of RV SW. Wasted work correlates with invasive measures of load‐independent RV function. Given the methodological and anatomical challenges of RV work assessment, evolution of this approach by incorporating more elaborated echo analysis data and an RV reference curve might improve its reliability to mirror invasively assessed RV SW.

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