Right ventricular function before and after an uncomplicated coronary artery bypass graft as assessed by pulsed wave Doppler tissue imaging of the tricuspid annulus

doi:10.1016/S0002-8703(03)00313-2

American Heart Journal

Volume 146, Issue 3, September 2003, Pages 520-526

https://doi.org/10.1016/S0002-8703(03)00313-2 Get rights and content

Abstract

Background

Right ventricular (RV) function using myocardial velocities before and after a coronary artery bypass graft (CABG) is not known.

Methods

Using pulsed wave Doppler tissue imaging, RV function was studied in 35 patients before and after CABG. Patients were followed-up for 1 year after the CABG. Myocardial velocities at the tricuspid annulus at the RV free wall were recorded from the apical 4-chamber views.

Results

Both the systolic and early diastolic tricuspid annular velocities (TAV) were significantly reduced 1 month after CABG (P < .001 for both). During the follow-up period, there was no improvement in the diastolic TAV. The systolic TAV showed no improvement 3 months after CABG but recovered partially 1 year after the CABG (systolic velocities were 11.8, 8.7, 8.7 and 9.7 cm/s, the early diastolic velocities were 11.0, 8.1, 8.1 and 8.2 cm/s before and 1 month, 3 months and 1 year after the CABG, respectively). The systolic and early diastolic velocities of the interventricular septum were unchanged during the follow-up period. Unlike the right ventricle, the mitral annular systolic velocity was unchanged shortly after CABG and showed signs of improvement after 1 year (6.4, 6.9, 6.8 and 7.3 cm/s respectively before and after CABG). Patients underwent dobutamine stress echocardiography (DSE) before and 3 months after the CABG. The systolic TAV increased significantly during the DSE before CABG (11.8 vs 15.8 cm/s, P < .001). However, the increase in systolic TAV was limited during DSE 3 months after CABG (8.7 vs 9.9 cm/s, P < .05).

Conclusion

RV function, as assessed by TAV, decreased significantly after CABG and the changes were still evident after 1 year. The response of systolic TAV during DSE was more pronounced before CABG than after CABG.

Section snippets

Subjects

Thirty-five patients (30 men and 5 women) with a history of coronary artery disease (CAD) were studied prospectively. All patients had significant CAD and were accepted for CABG within 2 months after the diagnostic coronary angiography. Sixteen patients had a history of myocardial infarction. Nine patients had medically treated diabetes mellitus and 14 had hypertension. None had atrial fibrillation, previous CABG, significant valvular heart disease, significant pulmonary disease or left bundle

Results

The basic clinical and echocardiographic parameters for the patients, compared with healthy subjects, are shown in Table I. The patients had a significantly decreased systolic left ventricular function as assessed by the M-mode mitral annular motion. The tricuspid annular velocities in healthy subjects were the following: systolic velocity 13.9 ± 1.8 mm, early diastolic velocity 14.1 ± 3.6 mm, and late diastolic velocity 15.3 ± 2.8 mm. The RV function assessed by the amplitude of the M-mode

Assessment of RV function by conventional echocardiography

There is no gold standard for assessing RV function by echocardiography. This is partly due to the complex anatomy of the right ventricle. Using contrast material, the first echocardiographic assessment of RV function was described by Kaul et al.10 Later, the method of recording the tricuspid annular motion by either conventional 2-D or 2-D guided M-mode echocardiography was presented.9, 17 Right ventricular systole comprises a complex pattern of contractions of the RV myocardium along its long

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Cited by (109)

Preoperative and mid-term right ventricular systolic function assessment, at rest and during exercise, with speckle-tracking echocardiography after left ventricular assist device implantation
2024, Hellenic Journal of Cardiology
The study aimed to compare pre- and postoperative resting as well as postprocedural resting and exertional right ventricular speckle-tracking echocardiographic parameters at a mid-term follow-up after left ventricular assist device (LVAD) implantation.
Patients with implanted third-generation LVADs with hydrodynamic bearings were prospectively enrolled (NCT05063006). Myocardial deformation was evaluated before pump implantation and at least three months after the procedure, both at rest and during exercise.
We included 22 patients, 7.3 months (IQR, 4.7-10.2) after the surgery. The mean age was 58.4 ± 7 years, 95.5% were men, and 45.5% had dilated cardiomyopathy. The RV strain analysis was feasible in all subjects both at rest and during exercise. The RV free wall strain (RVFWS) worsened from −13% (IQR, −17.3 to −10.9) to −11.3% (IQR, −12.9 to −6; p = 0.033) after LVAD implantation with a particular decline in the apical RV segment [-11.3% (IQR, −16.4 to −6.2) vs −7.8% (IQR, −11.7 to −3.9; p = 0.012)]. The RV four-chamber longitudinal strain (RV4CSL) remained unchanged [-8.5% (IQR, −10.8 to −6.9) vs −7.3% (IQR, −9.8 to −4.7; p = 0.184)]. Neither RVFWS (−11.3% (IQR, −12.9 to −6) vs −9.9% (IQR, −13.5 to −7.5; p = 0.077) nor RV4CSL [−7.3% (IQR, −9.8 to −4.7) vs −7.9% (IQR, −9.8 to −6.3; p = 0.548)] changed during the exercise test.
In patients who are pump-supported, the right ventricular free wall strain tends to worsen after LVAD implantation and remains unchanged during a cycle ergometer stress test.
Incidence, Predictive Factors, and Prognostic Impact of Right Ventricular Dysfunction Before Transcatheter Aortic Valve Implantation
2021, American Journal of Cardiology
Right ventricular dysfunction (RVD) is considered to be a late marker of aortic stenosis. However, there is a lack of consensus regarding the incidence, prognostic impact, and evolution of RVD in patients treated with transcatheter aortic valve implantation (TAVI). All patients treated with TAVI for severe aortic stenosis were included in a prospective single-center database. Patients who had a quantitative assessment of right ventricular (RV) function including tricuspid annular plane systolic excursion (TAPSE) and/or Doppler tissue imaging–derived tricuspid lateral annular systolic velocity (S′ wave) measurements were eligible for this study. RVD was defined as TAPSE <17 mm or S’ <9.5 cm/s if TAPSE was not available. Between 2014 and 2019, 503 patients with RV function assessment were included. The incidence of RVD before TAVI was 18.7%. Predictors of RVD were diabetes (p = 0.03), atrial fibrillation (p = 0.001), impaired left ventricular ejection fraction (p <0.0001), left ventricular dilatation (p = 0.007), and previous cardiac surgery (p = 0.002). Long-term survival was worse in patients with RVD before TAVI compared with those without RVD (hazard ratio 1.97, 95% confidence interval 1.1 to 3.4, p = 0.01). One year after TAVI, 58.7% of patients with baseline RVD had normal RV function and had similar outcomes as compared with those without RVD at baseline. In contrast, patients with persistent RVD had the worst prognosis. In conclusion, RVD is not rare and has a deleterious prognostic impact in patients treated with TAVI. Recovery of normal RV function is frequent after TAVI, whereas persistence of RVD is associated with poor outcomes.
Changes in Right Ventricular Function After Off-Pump Coronary Artery Bypass Grafting
2021, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
RV contraction pattern incorporates different motion components along 3 axes: longitudinal shortening with traction of the tricuspid annulus toward the apex, radial motion of the free wall often referred as the "bellows effect", and antero-posterior shortening of the chamber by stretching the free wall over the septum.30 Many studies have demonstrated reductions in longitudinal parameters of RV function.11-15 This reduction appeared to be independent of procedural characteristics like CABG or valve surgery, full sternotomy or mini sternotomy, and primary or reoperative surgery.24
Objective: Right ventricular (RV) dysfunction is associated with poor outcomes after cardiac surgery. The aim of this study was to assess RV systolic and diastolic function in the perioperative period after off-pump coronary artery bypass grafting (OPCAB).
Design: Prospective observational study.
Settings: Tertiary care hospital.
Participants: Thirty adult patients undergoing OPCAB.
Interventions: None.
Measurements and Main Results: Transthoracic echocardiography was performed twice: first preoperatively and second postoperatively, when patients were moved to wards. The following five parameters of RV systolic function were used: tricuspid annular plane systolic excursion (TAPSE), systolic tissue Doppler imaging of lateral tricuspid annulus (S’), fractional area change (FAC), RV myocardial performance index (RIMP), and isovolumic acceleration (IVA). Grading of RV diastolic function (RVDD) was done as per guidelines. Paired t test was used for comparing means and χ² test was used for categorical and ordinal data.
The parameters of RV longitudinal function (TAPSE and S’) reduced significantly (preoperative 21.93 ± 2.80 mm and 13.24 ± 2.24 cm/s to postoperative 11.67 ± 1.91 mm and 10.31 ± 1.56 cm/s, respectively, p < 0.001), whereas parameters of RV global function (FAC, RIMP, and IVA) remained preserved (preoperative 46.75 ± 6.80%, 0.34 ± 0.06, and 4.66 ± 0.87 m/s² to postoperative 46.21 ± 6.44%, 0.36 ± 0.06, and 4.37 ± 0.83 m/s²; p values of 0.76, 0.13, and 0.11, respectively). The median grade of RVDD worsened from normal in the preoperative period to pseudo-normal in the postoperative period (p < 0.001). The changes in both RV systolic and diastolic function were similar in patients with normal and reduced left ventricular systolic function.
Conclusions: RV function can be assessed in perioperative settings with two-dimensional and tissue Doppler imaging. For systolic function assessment, exclusive measurement of longitudinal parameters might be inadequate; use of complementary global parameters like FAC, RIMP, and IVA is essential to complete the RV assessment after OPCAB. RVDD worsened significantly after OPCABG.
The Reduction in Right Ventricular Longitudinal Contraction Parameters Is Not Accompanied by a Reduction in General Right Ventricular Performance During Aortic Valve Replacement: An Explorative Study
2020, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
Whether that includes a combination of ultrasound-derived longitudinal parameters and PAC or a more complex echocardiographic evaluation seems to be setting- and operator-dependent. Several studies have reported a significant reduction in TAPSE or S’ after cardiothoracic surgery.8,17,18,25,26 In general, opening of the pericardium and weaning from CPB have been identified as pivotal time points for this reduction.14,17,19,27,28
The aim of the present study was to identify whether the decrease of longitudinal parameters after cardiothoracic surgery (ie, tricuspid annular systolic plane excursion [TAPSE] and systolic excursion velocity [S’]) is accompanied by a reduction in global right ventricular (RV) performance.
Prospective, observational study.
Single-center explorative study in a tertiary teaching hospital.
The study comprised 20 patients who underwent aortic valve replacement with or without coronary artery bypass grafting.
During cardiac surgery, simultaneous measurements of RV function were performed with a pulmonary artery catheter and transesophageal echocardiography.
TAPSE and S’ were reduced significantly directly after surgery compared with the time before surgery (TAPSE from 20.8 [16.6-23.4] mm to 9.1 [5.6-15.5] mm; p < 0.001 and S’ from 8.7 [7.9-10.7] cm/s to 7.2 [5.7-8.6] cm/s; p = 0.041). However, the reduction in TAPSE and S’ was not accompanied by a reduction in RV performance, as assessed with the TEE-derived myocardial performance index (MPI) and pulmonary artery catheter–derived RV ejection fraction (RVEF). Both remained statistically unaltered before and after the procedure (MPI from 0.52 [0.43-0.58] to 0.50 [0.42-0.88]; p = 0.278 and RVEF from 27% [22%-32%] to 26% [22%-28%]; p = 0.294).
In the direct postoperative phase, the reduction of echocardiographic parameters of longitudinal RV contractility (TAPSE and S’) were not accompanied by a reduction in global RV performance, expressed as MPI and RVEF. Solely relying on a single RV parameter as a marker for global RV performance may not be adequate to assess the complex adaptation of the right ventricle to aortic valve replacement.
Changes in Right Ventricle Function After Mitral Valve Repair Surgery
2020, Heart Lung and Circulation
Citation Excerpt :
Preoperative RV contractile functional reserve may play a role [14]. Several methods have been used to assess RV systolic function perioperatively in cardiac surgery including: direct placement of conductance catheters [15], pulmonary artery catheters [3,10] and using echocardiography, both transthoracic [2,9] and transoesophageal [11], assessing RV fractional area change (FAC) [16], Tricuspid annular plane systolic excursion (TAPSE) [4], Tissue Doppler Imaging (TDI) [11,12], RV index of myocardial performance (RIMP) or Tei index [9,16], hepatic vein flow patterns and speckle tracking echocardiography (STE) to analyse both the left [17] and right ventricle [18]. Speckle tracking echocardiography has emerged as a technique for quantifying myocardial systolic deformation (known as Strain [S] and Strain Rate [SR]) in a sensitive manner elucidating cardiac dysfunction not recognised by conventional methods [19].
Right ventricular (RV) dysfunction can occur after cardiac surgery and persist for years. We assessed perioperative RV systolic function in patients undergoing mitral valve (MV) repair and further compared minimally invasive robotic-assisted mitral valve repair (MIMVr) vs standard ‘open’ MV repair (MVr). Speckle tracking (RV free wall strain [RVS]) was used as a sensitive echocardiography method to assess RV function.
Retrospective analysis, over 3 years, of consecutive patients (n = 158) referred to Mayo Clinic (Rochester, MN, USA). Preoperative, pre-discharge and 1 year transthoracic echocardiograms were reviewed. A prospective pilot study was performed for sample size estimation. Primary outcome was RV free wall strain (RVS).
Right ventricular free wall strain declined after MV repair surgery (-22.6 ± 7% vs -15 ± 6%, p < 0.001). There were smaller reductions in RVS in MIMVr vs MVr group (-6.0 ± 9% vs -10.3 ± 8%, p < 0.01), which persisted after adjusting for baseline values (RVS treatment effect 1.5%, p = 0.007). There was greater recovery in MIMVr vs MVr group at 1 year follow-up vs pre-surgery values (-3.4 ± 9% vs -8.1 ± 8% respectively, p < 0.001, RVS treatment effect 1.7%, p = 0.001). Bypass time was higher in the MIMVr group (80 min ± 22 vs 40 min ± 20, p < 0.0001). The echo findings remained significant correcting for age, pulmonary pressures and change in ejection fraction.
Right ventricular systolic dysfunction is common after MV repair surgery. Deterioration in RV contraction is less pronounced following MIMVr vs MVr and is associated with enhanced RV functional recovery at 1 year, albeit not to preoperative levels. This may potentially be associated with clinical functional improvement but further studies are warranted to investigate this.
Association of Right Ventricular Longitudinal Strain with Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement
2020, Journal of the American Society of Echocardiography
Conventional right ventricular (RV) echocardiographic measurements of systolic function (SF) have demonstrated conflicting results when their association with long-term outcomes after transcatheter aortic valve replacement (TAVR) is evaluated. RV free-wall (FW) longitudinal strain (LS) is a novel, single parameter to measure RV SF and may provide a better evaluation than fractional area change, tricuspid annular plane systolic excursion, and myocardial velocity (S′). The value of RV FW LS in patients undergoing TAVR and its association with 1-year mortality are unknown. The aim of this study was to test the hypothesis that RV FW LS would be associated with 1-year all-cause mortality in patients undergoing TAVR.
Consecutive patients who underwent TAVR between 2007 and 2014 in whom RV FW LS was measurable were included; a subgroup that had 1-year follow-up echocardiographic evaluation of RV FW LS was analyzed. FW LS was derived from speckle-tracking analyses. The standard reference was determined as normal or impaired RV SF, the latter defined as the presence of ≥50% of tricuspid annular plane systolic excursion < 1.7 cm, S′ < 9.5 cm/sec, and fractional area change < 35%. Cox proportional-hazards regression analysis was used to assess the association of RV FW LS with 1-year all-cause mortality.
Of 612 patients, 334 were included for RV FW LS analysis on pre-TAVR echocardiography (feasibility 55%); exclusion criteria included atrial fibrillation (n = 92 [15%]), pacemaker (n = 73 [12%]), and poor image quality (n = 113 [18%]). Baseline impaired RV SF was present in 19% of cases. RV FW LS did not change significantly at 1-year follow-up, in both the groups with baseline impaired and normal function. Cox regression analysis showed that RV FW LS was associated with all-cause mortality at 1 year (hazard ratio, 1.06; 95% CI, 1.01–1.11). For each unit increase in RV FW LS, there was a 6% higher risk for 1-year mortality.
In a high-risk TAVR population, RV FW LS should be considered a single echocardiographic parameter for the assessment of RV SF. When measurable, RV FW LS is associated with all-cause mortality at 1 year after TAVR.

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Imaging and diagnostic testingRight ventricular function before and after an uncomplicated coronary artery bypass graft as assessed by pulsed wave Doppler tissue imaging of the tricuspid annulus

Abstract

Background

Methods

Results

Conclusion

Section snippets

Subjects

Results

Assessment of RV function by conventional echocardiography

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Am Soc Echocardiogr

Am Heart J

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Am Heart J

J Am Soc Echocardiogr

J Am Soc Echocardiogr

Prog Cardiovasc Dis

Am J Cardiol

Imaging and diagnostic testing
Right ventricular function before and after an uncomplicated coronary artery bypass graft as assessed by pulsed wave Doppler tissue imaging of the tricuspid annulus