Right Ventricular Longitudinal Strain In Left Ventricular Assist Device Surgery–A Retrospective Cohort Study

Abstract

Objectives Right ventricular (RV) failure is common after left ventricular assist device (LVAD) surgery and is associated with higher mortality. Measurement of longitudinal RV strain using speckle-tracking technology is a novel approach to quantify RV function. We hypothesized that depressed peak longitudinal RV strain measured by intraoperative transesophageal echocardiography (TEE) examinations would be associated with adverse outcomes after LVAD surgery. Design Retrospective Cohort Study. Setting Tertiary academic medical center. Participants Following IRB approval, we retrospectively identified adult patients that underwent implantation of non-pulsatile LVAD. Exclusion criteria included: inadequate TEE images and device explantation within six months for heart transplantation. Interventions None. Measurements and Main Results The postoperative adverse event outcome was defined as a composite of one or more of death within six months, ≥14 days of inotropes, mechanical RV support, or device thrombosis. Intraoperative TEE images were analyzed for peak RV free wall longitudinal strain by two blinded investigators. Simple logistic regression was used to assess the relationship between adverse outcome and the mean of the strain measurements of the two raters. Agreement between the raters was assessed by intra-class correlation (0.62) and Pearson correlation coefficient (0.63). Of the 57 subjects, 21 (37%) had an adverse outcome. The logistic regression indicated no significant association between RV peak longitudinal strain and adverse events. Conclusions In this retrospective study of patients undergoing non-pulsatile LVAD implantation, peak longitudinal strain of the RV free wall was not associated with adverse outcomes within six months after surgery. Additional quantitative echocardiographic measures for intraoperative RV assessment should be explored.

Transesophageal Speckle Tracking Echocardiography Assessment of Right Ventricular Longitudinal Strain: A Tool in Search of Validation

“…6 Beck et al used a similar GLS cutoff value; their study failed to focus on RVF, focusing instead on composite outcomes, and reported no prognostic utility with TEE-derived RV GLS. 3 However, patients with poor outcomes had lower RV GLS, and a larger sample size may have reached statistical significance. Upon analyzing the outcomes of Beck et al by further focusing on RVF ( 4 14 days of inotropic support, need for mechanical RV support), 16 of 57 patients (28%) developed RVF and had a GLS r -9.2%, a finding akin to the report by Grant et al, showing the potential prognostic value of intraoperative transesophageal STE-derived RV GLS.…”

“…1,2 CF-LVAD therapy has accelerated globally as both a bridge-to-transplantation and destination therapy and has demonstrated superiority over pharmacotherapy and cardiac resynchronization therapy in heart failure patients. [1][2][3][4][5] Despite the survival benefits of CF-LVAD therapy, a significant proportion of patients develop perioperative complications, mainly due to right ventricular dysfunction (RVD) or right ventricular failure (RVF) after CF-LVAD placement. [1][2][3][4][5][6] RVD/RVF occurrence may be secondary to changes in the geometry and function of the right ventricle induced in part by the LVAD (increased circulatory volume and excessive left ventricular decompression) and fluid management and may result in low CF-LVAD output, right heart failure, and multisystem organ failure.…”

“…[1][2][3][4][5] Despite the survival benefits of CF-LVAD therapy, a significant proportion of patients develop perioperative complications, mainly due to right ventricular dysfunction (RVD) or right ventricular failure (RVF) after CF-LVAD placement. [1][2][3][4][5][6] RVD/RVF occurrence may be secondary to changes in the geometry and function of the right ventricle induced in part by the LVAD (increased circulatory volume and excessive left ventricular decompression) and fluid management and may result in low CF-LVAD output, right heart failure, and multisystem organ failure. 2,4 Unfortunately, when RVF develops, treatment using mechanical circulatory support, pulmonary vasodilators, fluid restriction, and inotropes may not restore right ventricular (RV) function, and poor short-and long-term outcomes may ensue.…”

“…In this issue of the journal, Beck et al report on the use of transesophageal STE-derived peak RV free wall GLS as a simple and efficient measure of RV performance to predict adverse outcomes after CF-LVAD implantation in a singlecenter, retrospective analysis of prospectively collected data. 3 Three-segment GLS analysis of the RV free wall was performed in 57 patients using 2D images acquired before the initiation of cardiopulmonary bypass, and the mean peak RV GLS was measured. RV free wall GLS measurements were performed based on current American Society of Echocardiography and European Association of Cardiovascular Imaging recommendations.…”

“…Comprehensive intraoperative TEE assessment of the right ventricle requires the use of multiple echocardiographic parameters to enable precise analysis of regional and global RV function. 3,[8][9][10][11][12][13][14] These TEE indices include FAC, S', TAPSE, 3D ejection fraction, and RV MPI but may not provide accurate regional/global analysis of RV performance. [8][9][10][11][12][13][14] TEE myocardial longitudinal strain measurement using STE is a relatively novel technique that may furnish better quantitative analysis of RV systolic function by way of myocardial deformation (degree of myocardial systolic shortening), although limited evidence exists regarding its usefulness.…”