Right ventricular function in patients with aortic stenosis undergoing aortic valve replacement

doi:10.1016/1053-0770(92)90141-S

Journal of Cardiothoracic and Vascular Anesthesia

Volume 6, Issue 3, June 1992, Pages 287-291

https://doi.org/10.1016/1053-0770(92)90141-S Get rights and content

Abstract

The effects of aortic stenosis (AS) on right ventricular function during cardiac surgery are not fully understood. Forty patients undergoing aortic valve replacement with either a systolic transvalvular gradient of <100 mm Hg (82.1 ± 5.5 mm Hg; group 1, n = 20) or > 120 mm Hg (131.1 ± 6.9 mm Hg, group 2, n = 20) were investigated with regard to right ventricular function in the perioperative period. Right ventricular ejection fraction (RVEF), right ventricular end-systolic volume (RVEDV), and right ventricular end-diastolic volume (RVEDV) were measured by means of the thermodilution technique. Before cardiopulmonary bypass (CPB), RVEF was significantly lower in group 2 patients (34% ± 6%) than in group 1 (45% ± 5%). After CPB, RVEF increased significantly in group 2 (28% ± 4% to 49% ± 5%), and no further differences were noted between the groups. In the patients with a higher systolic transvalvular gradient, RVEDV and RVEDV were lower at the start of surgery, but increased after opening the pericardium. Cardiac index was also lower in these patients. Pericardiotomy resulted in a decrease in right ventricular end-systolic pressure (RVESP) only in the patients of group 2. In these patients more epinephrine was necessary to maintain stable hemodynamics during the postbypass period. It is concluded that patients with AS are at risk of reduced right ventricular function when the systolic transvalvular pressure gradient is more than 120 mmHg. Knowledge of the complex interaction between the two sides of the heart may enable anesthesiologists to optimize management during the perioperative period.

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Cited by (23)

Comparison of Right Ventricular Function Between Three-Dimensional Transesophageal Echocardiography and Pulmonary Artery Catheter
2021, Journal of Cardiothoracic and Vascular Anesthesia
This study aimed to compare measurements of right ventricular function using three-dimensional transesophageal echocardiography (3D TEE), and pulmonary artery catheters (PACs) in patients undergoing cardiac surgery. The authors examined the practicality of using the 3D TEE.
Prospective observational.
Cardiac operating room at a single university hospital.
All adult patients undergoing elective cardiac surgery at a single tertiary care university hospital over two years.
None.
Right ventricular end-diastolic volume (RVEDV), right ventricular end-systolic volume (RVESV), stroke volume (SV), and right ventricular ejection fraction (RVEF) were measured with both 3D TEE and PACs. Assessments were performed using correlation coefficients, paired t tests, and Bland-Altman plots. Thirty-one patients participated in this study. Each measurement showed good agreement. RVEDV and RVESV were slightly lower on 3D TEE than on PAC (205.9 mL v 220.2 mL, p = 0.0018; 143.0 mL v 155.5 mL, p = 0.0143, respectively), whereas no significant differences were observed for SV and RVEF (31.0% v 31.1%, p = 0.0569; 61.6 mL v 66.9 mL, p = 0.92, respectively). Linear regression analysis showed high correlation between 3D TEE and PAC for RVEDV (r = 0.87) and RVESV (r = 0.81), and moderate correlation for SV (r = 0.67) and RVEF (r = 0.67). In the Bland-Altman plot, most patients were within the 95% limits of the agreement throughout all measurements.
A high correlation was found between measurements made with a PAC and with 3D TEE in the assessment of right ventricular function. Three-dimensional TEE would be a potential alternative to PAC for assessment of right ventricular function during intraoperative periods.
Strain Imaging: An Everyday Tool for the Perioperative Echocardiographer
2020, Journal of Cardiothoracic and Vascular Anesthesia
Strain analysis allows for global and regional analysis of myocardial function and has been shown to be an independent predictor of outcomes after cardiac surgery. Strain imaging offers advantages over traditional EF measurements in that it is relatively angle independent, it is less dependent upon loading conditions, it is reproducible, it does not rely on geometric assumptions, and it can detect subclinical systolic dysfunction. Limitations of strain analysis include high temporal resolution requirements, a strong dependence on image quality, and inter-vendor variability. In addition, there is a paucity of data on the intraoperative applications of strain. The ASE has defined a global longitudinal strain of –20% measured by transthoracic echocardiography to be considered normal, with less negative values considered abnormal. Presently, there are no published guidelines on the normal values of strain with transesophageal echocardiography (TEE). However, multiple studies have shown that a reduction in intraoperative strain assessed with TEE has been shown to be an independent predictor of complications during cardiac surgery. Accordingly, further incorporation of intraoperative strain analysis with TEE could aid in prognostication for patients undergoing cardiac surgery. As perioperative strain analysis continues to advance, an understanding of these concepts is imperative for perioperative echocardiographers. It is the authors’ goal to show that strain imaging can provide a reliable and objective measure that can be performed in real time to aid in decision-making and perioperative risk stratification.
Subjective Evaluation of Right Ventricular Function with Transesophageal Echocardiography
2020, Journal of the American Society of Echocardiography
A Comparison of Left- and Right-Sided Strain Software for the Assessment of Intraoperative Right Ventricular Function
2019, Journal of Cardiothoracic and Vascular Anesthesia
To compare intraoperative right ventricular (RV) strain measurements made with left ventricular (LV) strain software commonly found on the echocardiography machine (Philips QLAB chamber motion quantification, version 10.7, Philips, Amsterdam, The Netherlands), with offline analysis using the dedicated RV strain software (EchoInsight, version 2.2.6.2230, Epsilon Imaging, Ann Arbor, MI).
Prospective, nonrandomized, observational study.
Single tertiary level, university-affiliated hospital.
The study comprised 48 patients undergoing transesophageal echocardiography for cardiac or noncardiac surgery.
Two-dimensional (2D) and 3-dimensional (3D) images of the right ventricle were obtained. Intraoperative 2D images were analyzed in real time for RV free wall strain (FWS) and global longitudinal strain (GLS) using QLAB chamber motion quantification (CMQ) LV strain software on the echocardiography machine. Two dimensional images were then analyzed offline to determine the RV FWS and GLS using EchoInsight RV-specific strain software. Three-dimensional images were then analyzed offline to detemine the 3D RV ejection fraction (3D RV EF) using TomTec 4D RV function (Unterschleissheim, Germany). Spearman's correlation and Bland-Altman analyses were used to characterize the relationship between RV strain measurements. Both types of strain measurements were compared to a reference standard of 3D RV EF.
Intraoperative RV strain measurements using LV-specific strain software correlated with offline RV strain measurements using the RV-specific strain software (FWS rho = 0.85; GLS rho = 0.81). The bias and limits of agreement were 0.75% (– 6.66 to 8.17) for FWS and –4.53% (–11.55 to 2.50) for GLS. The sensitivity and specificity for RV dysfunction for the intraoperative LV-specific software were 94% (95% confidence interval [CI] 73-100) and 70% (95% CI 51-85), respectively, for RV FWS and 94% (95% CI 73-100) and 67% (95% CI 47-83), respectively, for RV GLS. The sensitivity and specificity for RV dysfunction for the offline RV-specific software were 89% (95% CI 65-99) and 73% (95% CI 54-88), respectively, for RV FWS and 94% (95% CI 73-100) and 30% (95% CI 15-49), respectively, for RV GLS.
Intraoperative RV strain measurements using LV-specific strain software commonly available on the echocardiography machine (QLAB CMQ) correlate with offline RV strain measurements using RV-specific strain software (EchoInsight). The bias and limits of agreement for these left- and right-sided strain software suggest that these 2 measures of RV function cannot be used interchangeably. Both, however, were sensitive measures of RV dysfunction and therefore are likely clinically relevant.
Right ventricular systolic function in patients undergoing transcatheter aortic valve implantation: A systematic review and meta-analysis
2018, International Journal of Cardiology
Citation Excerpt :
Right ventricular (RV) systolic dysfunction is associated with adverse clinical outcomes in patients undergoing surgical aortic valve replacement (SAVR) [1,2].
Right ventricular (RV) systolic dysfunction is associated with worse survival in patients undergoing surgical aortic valve replacement (SAVR), yet it is not included in traditional risk scores of transcatheter aortic valve implantation (TAVI) candidates. We aimed to evaluate the prognostic value of RV systolic function on clinical outcomes in patients undergoing TAVI at one year follow-up; and, echocardiographic changes of RV systolic function up to 12 months after TAVI and compared with SAVR when possible.
This systematic review and meta-analysis is registered in PROSPERO (CRD42017065761). Studies investigating RV systolic function with echocardiography in TAVI cohorts were identified from Medline, Embase and Cochrane databases. We used random-effects models to assess differences in primary outcomes. Twenty-one studies were identified, where RV systolic function and clinical outcomes were assessed in eight (4016 patients) and RV systolic function changes were evaluated in 14 (1709 patients). For the primary outcome of all-cause death at one year, RV systolic dysfunction was associated with a significant 78% relative risk increase (risk ratio[95% confidence interval (CI)]) = 1.78[1.37, 2.31], P < 0.01), albeit significant heterogeneity (I² = 64%, P < 0.01). RV systolic function was unchanged after TAVI throughout follow-up as shown with tricuspid annular plane systolic excursion (TAPSE)(mean difference[95% CI]pre-discharge = 0.03 [−0.92,0.99]mm,1–3 months = −0.09[−0.89,0.71]mm,6–12 months = 0.52 [−0.29,1.32] mm, all P = NS), while TAPSE was significantly reduced after SAVR (pre-discharge = −10.17[−13.11,−7.24]mm, P < 0.01;1–3 months = −7.3[−8.17,−6.44]mm, P < 0.01;6–12 months = −5.99[−7.95,−4.03]mm, P < 0.01).
RV systolic dysfunction was associated with a significant increase in all-cause mortality at one year after TAVI. RV systolic function was unchanged after TAVI up to 12 months, whereas deteriorated significantly after SAVR.
Impact of right ventricular size and function on survival following transcatheter aortic valve replacement
2016, International Journal of Cardiology
Citation Excerpt :
Despite world-wide adoption of TAVR, mid-term mortality remains as high as 43% at 2 years post implantation in inoperable severe AS [2], and those with a surgical operative mortality risk > 15% have marginal gain, suggesting that number of patients have disease too advanced to derive benefit from TAVR. Right ventricular (RV) dysfunction is a known adverse prognostic factor in a number of conditions including in patients with severe AS undergoing surgical aortic valve replacement [3–9]. However, data on the influence of RV size and function on outcomes after TAVR is limited.
The impact of pre-procedural RV size and function on outcomes following transcatheter aortic valve replacement (TAVR) is not well established.
The aim of this study was to investigate the role of right ventricular size and function on outcomes following TAVR.
Between November 2008 and June 2013, 268 consecutive patients (age 80.5 ± 7.9 years, aortic valve area 0.79 ± 0.16 cm²) with symptomatic severe aortic stenosis (AS) undergoing TAVR at Mayo Clinic were included. Transthoracic echocardiographic quantitative and semiquantitative assessment of RV chamber size and systolic function was performed and included tricuspid annular plane systolic excursion (TAPSE), RV systolic excursion velocity (S′), fractional area change (FAC), RV index of myocardial performance (RIMP). The primary endpoint of all-cause mortality after TAVR was measured and observed in 65 patients (median follow up duration: 412 days). Univariate analysis identified semiquantitative RV dilatation (p < 0.001) and systolic dysfunction (p = 0.013), RV basal dimension (p = 0.003) and RV outflow proximal dimension (p = 0.031) to be of prognostic significance. After multivariate adjustment, patients with semiquantitative RV dilatation (HR 2.61, 95% CI 1.45–4.65, p = 0.002) and larger RV basal dimension (HR 1.07, 95% CI per mm 1.02–1.11, p = 0.007) had significantly worse survival even after adjusting for age, sex, Society of Thoracic Surgeons (STS) risk score, left ventricular ejection fraction, tricuspid regurgitation, pulmonary artery systolic pressure, and atrial fibrillation.
RV dilatation is an important determinant of postoperative outcomes in patients undergoing TAVR.

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Original articleRight ventricular function in patients with aortic stenosis undergoing aortic valve replacement

Abstract

J Surg Res

Prog Cardiovasc Dis

J Cardiothorac Anesth

Am J Cardiol

The role of ventricular interaction in critical illness

The right ventricle: Physiologic and pathophysiologic considerations

Crit Care Med

Right ventricular function in acute disease states: Pathophysiologic consideration

Crit Care Med

Right ventricular contraction

Mechanical support of the failing right ventricle

Selective right ventricular dysfunction after coronary artery bypass grafting

J Thorac Cardiovasc Surg

Perioperative right heart failure: Treatment

Cardiovasc Clin

Acute right ventricular failure is caused by inadequate right ventricular hypothermia

J Thorac Cardiovasc Surg

Right ventricular dysfunction in aortic stenosis

Circulation

Original article
Right ventricular function in patients with aortic stenosis undergoing aortic valve replacement