Right ventricular systolic function in severe tricuspid regurgitation: prognostic relevance of longitudinal strain

Abstract

Aims The aim of this study is to analyse the prognostic implications of right ventricular (RV) dysfunction as detected by strain analysis in patients with severe tricuspid regurgitation (TR). The evaluation of RV systolic function in presence of severe TR is of paramount importance for operative risk stratification; however, it remains challenging, as conventional echocardiographic indexes usually lead to overestimation. Methods and results We enrolled 250 consecutive patients with severe TR referred to our centre. Baseline clinical and echocardiographic data and follow-up outcomes were collected. Patients were predominantly female, with multiple cardiovascular risk factors and comorbidities, history of heart failure, and atrial fibrillation. Most of them had presented with clinical signs of RV heart failure (RVHF) and advanced New York Heart Association class. The RV strain analysis [both RV free wall longitudinal strain (RVFWLS) and RV global longitudinal strain (RVGLS)] reclassified ∼42–56% of patients with normal RV systolic function according to conventional parameters in patients with impaired RV systolic function. RVFWLS ≤17% (absolute values, AUC: 0.66, P = 0.002) predicted the presence of RVHF [odds ratio (OR) 0.93, P = 0.01]. At follow-up, patients with RVFWLS >14% (absolute values, AUC: 0.70, P = 0.001, sensitivity 72%, specificity 54%) showed a better survival (P = 0.01). Conclusion Different ranges of RVFWLS have different implications in patients with severe TR, allowing to identify a preclinical and a clinical window, with correlations to RVHF and survival.

The Predictive Value of Right Ventricular Longitudinal Strain in Pulmonary Hypertension, Heart Failure, and Valvular Diseases

“…The effect of RV function in patients with valvular disease has been investigated in the last several years and it has become evident that effect of RV dysfunction on outcome in these patients is not irrelevant. The majority of studies reported deterioration of RV longitudinal strain in patients with valvular diseases (61, 62), but some recent investigations revealed a significant predictive value of RV strain in patients with aortic stenosis, mitral and tricuspid regurgitation (12,13,40,63). Data are still scarce but warrant a special attention due to constantly increasing number of transcatheter interventions in valvular diseases and importance to develop new scores for better risk stratification in patients who undergo these interventions.…”

“…Investigation that enrolled 250 consecutive patients with severe tricuspid regurgitation investigated RV global and freewall longitudinal strain and reclassified ∼42-56% of patients with normal RV systolic function according to conventional parameters in patients with impaired RV systolic function (13). The authors found that RV free-wall strain >-17% at baseline predicted RV heart failure, whereas patients with RV free-wall strain <-14% at follow-up had significantly better survival (13) (Table 4).…”

“…RV longitudinal strain represents the cornerstone of RV mechanics evaluation with excellent reproducibility and high predictive value in patients with different aforementioned CV diseases (10)(11)(12)(13). It has higher sensitivity and specificity in the detection of subclinical RV damage in patients with cardiomyopathies, cardiac amyloidosis and cancer (14)(15)(16).…”

Functional tricuspid regurgitation, related right heart remodeling, and available treatment options: good news for patients with heart failure?

“…However, reduced free-wall RV longitudinal strain was superior predictor of mortality in comparison with reduced FAC (<35%) and TAPSE in the whole population [36]. Ancona et al involved only patients with severe TR who were mostly presented with symptoms of RV heart failure and advanced NYHA class [6]. The authors used freewall and global RV longitudinal strain for reclassification Fig.…”

“…FTR is associated with significant remodeling of the right ventricle (RV), which includes the impairment of RV mechanical function, dilatation, and ultimately systolic dysfunction [6,7]. FTR has been also related with further changes in tricuspid valve anatomy (annular dilatation, higher level of tethering, and tenting) and right atrial (RA) dilatation, which altogether induce the lack of coaptation and deterioration of FTR grade [3,[8][9][10].…”