Response to Letter Regarding Article, “Right Ventricular Function in Heart Failure With Preserved Ejection Fraction: A Community-Based Study”

Abstract

CorrespondenceWe thank Dr Guazzi for his interest in and insightful comments about our study of right ventricular (RV) dysfunction in heart failure (HF) with preserved ejection fraction. 1 We agree that tricuspid annular plane systolic excursion (TAPSE), like any method of cardiac shortening (LV ejection fraction, RV ejection fraction, etc), is load dependent and influenced by RV afterload, a parameter related to but inadequately reflected by pulmonary artery systolic pressure (PASP). To address these limitations, we adjusted all analyses of the prognostic implications of RV dysfunction (by TAPSE or semiquantitative assessment) for PASP.1 The TAPSE/PASP ratio is another method to assess the interaction of RV function and afterload and had prognostic value in HF of both types.2 Indeed, in our study, TAPSE and PASP were each associated with poor prognosis, with the combination of the worst tertiles of each conferring the worst prognosis.1 Similarly, when we analyzed data by the TAPSE/PASP ratio, the lowest TAPSE/ PASP tertile (ratio ≤0.3) had the worst survival (79% mortality at 8 years). Of note, our findings are consistent with those of a smaller study that assessed the relationship between RV fractional area change and invasively measured PASP in HF with preserved ejection fraction.3 These findings are also in agreement with the outcomes of the lowest TAPSE/PASP ratio group observed by Guazzi et al. 2As we have emphasized in our article, because of challenges with RV function assessment, no single parameter of RV function will likely adequately quantify the complexity of RV contractility. Therefore, we have also incorporated semiquantitative assessment of RV function into our analysis.1 In terms of superiority of semiquantitative RV function assessment compared with TAPSE, we also find this intriguing. We speculate that integrative assessment of RV contractility in different vectors captures more information on RV function than a single measure of longitudinal excursion and, when abnormal, likely reflects more significant RV dysfunction. TAPSE may be an earlier but less specific measure of RV dysfunction in HF with preserved ejection fraction.We clarify that we have only used 2-dimensional TAPSE (ie, we have not combined 2-dimensional and M-mode measurements). We acknowledge that echocardiography is operator and subject dependent and that technical challenges may limit the accuracy and prognostic value of echocardiographic variables. Nonetheless, adjusted for PASP and clinical factors, the presence of RV dysfunction was potently associated with adverse events, including mortality, cardiovascular mortality, and first or total HF hospitalizations in HF with preserved ejection fraction. DisclosuresNone. Selma F. Mohammed, MBBS, PhDDivision