Right ventricular mechanical pattern in patients undergoing mitral valve surgery: a predictor of post-operative dysfunction?

Márton Tokodi, Endre Németh, Bálint K Lakatos, Erika Kispál, Zoltán Tősér, Levente Staub, Kristóf Rácz, Ádám Soltész, Szabolcs Szigeti, Tamás Varga, János Gál, Béla Merkely, Attila Kovács, Márton Tokodi, Endre Németh, Bálint K Lakatos, Erika Kispál, Zoltán Tősér, Levente Staub, Kristóf Rácz, Ádám Soltész, Szabolcs Szigeti, Tamás Varga, János Gál, Béla Merkely, Attila Kovács

Abstract

Aims: The PREPARE-MVR study (PRediction of Early PostoperAtive Right vEntricular failure in Mitral Valve Replacement/Repair patients) sought to investigate the alterations of right ventricular (RV) contraction pattern in patients undergoing mitral valve replacement/repair (MVR) and to explore the associations between pre-operative RV mechanics and early post-operative RV dysfunction (RVD).

Methods and results: We prospectively enrolled 42 patients (63 ± 11 years, 69% men) undergoing open-heart MVR. Transthoracic three-dimensional (3D) echocardiography was performed pre-operatively, at intensive care unit discharge, and 6 months after surgery. The 3D model of the RV was reconstructed, and RV ejection fraction (RVEF) was calculated. We decomposed the motion of the ventricle to compute longitudinal ejection fraction (LEF) and radial ejection fraction (REF). Pulmonary artery catheterization was performed to monitor RV stroke work index (RVSWi). RVEF was slightly decreased after MVR [52 (50-55) vs. 51 (46-54)%; P = 0.001], whereas RV contraction pattern changed notably. Before MVR, the longitudinal shortening was the main contributor to global systolic RV function [LEF/RVEF vs. REF/RVEF; 0.53 (0.47-0.58) vs. 0.33 (0.22-0.42); P < 0.001]. Post-operatively, the radial motion became dominant [0.33 (0.28-0.43) vs. 0.46 (0.37-0.51); P = 0.004]. However, this shift was temporary as 6 months later the two components contributed equally to global RV function [0.44 (0.38-0.50) vs. 0.41 (0.36-0.49); P = 0.775]. Pre-operative LEF was an independent predictor of post-operative RVD defined as RVSWi < 300 mmHg⋅mL/m2 [OR = 1.33 (95% CI: 1.08-1.77), P < 0.05].

Conclusions: MVR induces a significant shift in the RV mechanical pattern. Advanced indices of RV mechanics are associated with invasively measured parameters of RV contractility and may predict post-operative RVD.

Trial registration: ClinicalTrials.gov NCT03438825.

Keywords: 3D echocardiography; Mitral valve regurgitation; Mitral valve surgery; Right ventricle; Right ventricular dysfunction.

Conflict of interest statement

None declared.

© 2020 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology.

Figures

Figure 1
Figure 1
Outline of the study protocol. FU, follow‐up; ICU, intensive care unit; LVEF, left ventricular ejection fraction; MR, mitral regurgitation; MVR, mitral valve replacement/repair; PAC, pulmonary artery catheterization; RVEF, right ventricular ejection fraction.
Figure 2
Figure 2
Contribution of longitudinal and radial contractions to global systolic RV function in healthy controls and patients undergoing MVR. Before surgery, the longitudinal shortening was the major contributor to global RV function, whereas after MVR, the radial contraction became the dominant component. However, this shift was temporary as 6 months later the contribution of the two components equalized, and the contraction pattern became similar to healthy controls'. *P < 0.05, paired Student's t‐test or paired Wilcoxon test. FU, follow‐up; LEFi, longitudinal ejection fraction index; MVR, mitral valve replacement/repair; REFi, radial ejection fraction index; RV, right ventricle.
Figure 3
Figure 3
RV mechanics in healthy controls and patients undergoing surgical treatment of severe primary MR: representative cases. By decomposing the motion of the 3D RV model, the different wall motion components can be quantified separately. The green mesh represents the end‐diastolic volume, and the blue surface is the end‐systolic volume of the RV. In the healthy subject, the longitudinal and radial motion contributed equally to global RV function (LEFi vs. REFi: 0.48 vs. 0.44). In the patient with severe MR, the pre‐operatively observed longitudinal dominance (LEFi vs. REFi: 0.54 vs. 0.29) shifted to radial dominance (LEFi vs. REFi: 0.39 vs. 0.51). However, this shift was temporary as 6 months later the contribution of the two components equalized, and the contraction pattern became similar to healthy control's (LEFi vs. REFi: 0.46 vs. 0.43). FU, follow‐up; LEFi, longitudinal ejection fraction index; MR, mitral regurgitation; REFi, radial ejection fraction index; RV, right ventricle.

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