Prognostic significance of right ventricular dysfunction in patients presenting with acute left-sided heart failure

(2024) 76:2 Shaker et al. The Egyptian Heart Journal https://doi.org/10.1186/s43044-023-00432-8 The Egyptian Heart Journal Open Access RESEARCH Prognostic significance of right ventricular dysfunction in patients presenting with acute left‑sided heart failure Mirna M. Shaker1, Hesham S. Taha1*, Hossam I. Kandil1, Heba M. Kamal1, Hossam A. Mahrous1 and Ahmed A. Elamragy1 Abstract Background The prognostic value of right ventricular (RV) function in chronic heart failure (HF) has lately been well established. However, research on its role in acute heart failure (AHF) is sparse. Results This study comprised 195 patients, aged between 18 and 80 years, with acute left-sided heart failure (HF) and a left ventricular ejection fraction (LVEF) < 50%. Patients with LVEF ≥ 50%, mechanical ventilatory or circulatory support, poor echocardiographic windows, prosthetic valves, congenital heart diseases, infective endocarditis, and/or life expectancy < 1 year due to non-cardiac causes were excluded. The study participants’ mean age was 57.7 ± 10.9 years, and 74.9% were males. Coronary artery disease was present in 80.5% of patients. The mean LVEF was 31% ± 8.7. RV dysfunction (RVD), defined as tricuspid annular plane systolic excursion (TAPSE) < 17 mm, RV S’< 9.5 cm/s and/or RV fractional area change (FAC) < 35%, was identified in 48.7% of patients. The RV was dilated in 67.7% of the patients. RVD was significantly associated with a longer HF duration, atrial fibrillation, and idiopathic dilated cardiomyopathy. The primary outcome, a 6-month composite of cardiovascular death or hospitalization for worsening HF (HHF), occurred in 42% of the participants. Cardiovascular mortality and HHF occurred in 30.5% and 23.9% of the patients, respectively. The primary endpoint and longer CCU stays were significantly more common in patients with RVD than in those with normal RV function. RV dilatation was significantly associated with the primary outcome, whether alone or in combination with RVD. Multivariate regression analysis showed that only RV global longitudinal strain (GLS) independently predicted poor outcomes. Conclusions RVD and RV dilatation strongly predict CV death and HHF in patients with AHF and LVEF < 50%. Multivariate analysis showed that RV GLS was the only predictor of a composite of CV death and HHF. Keywords Acute heart failure, Right ventricular dysfunction, Echocardiography, Cardiovascular death, Heart failure hospitalization *Correspondence: Hesham S. Taha 1 Department of Cardiology, Faculty of Medicine, Cairo University, 27 Nafezet Sheem El Shafae St Kasr Al Ainy, Cairo 11562, Egypt Background Despite significant advances in heart failure (HF) management, acute HF (AHF) remains a devastating condition and a cause of frequent hospital admissions [1]. Right ventricular (RV) function is generally accepted as an essential prognostic factor in chronic HF. Nevertheless, few recommendations have emerged based on RV assessment, [2] which may be due to conflicting data on determinants of RV function, a limited understanding of © The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Shaker et al. The Egyptian Heart Journal (2024) 76:2 the mechanisms leading to its impairment, and relatively limited evidence on its relation to outcomes [3]. Bedside focused heart ultrasound is the first-line modality for RV assessment in critically ill patients. In contrast, invasive hemodynamic assessment is indicated in case of resistance to treatment or inconclusive non-invasive tests [4]. The global RV function is usually assessed by quantitative evaluation of one or more of the following parameters: fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), tissue Doppler imaging (TDI)-derived systolic S’ velocity or RV myocardial performance index [5]. Speckle tracking imaging is a relatively new technology for assessing myocardial deformation and offers many advantages over conventional echocardiographic methods. Unlike pulsed wave and TDI, it is less dependent on angle or load, rapid, and more precise. Thus, it is a valid method for assessing RV mechanical changes, with results comparable to cardiac magnetic resonance (CMR) [5, 6]. In view of the peculiar shape of the RV, three-dimensional echocardiography (3DE) may have an advantage over two-dimensional echocardiography (2DE) in RV assessment [7]. CMR has become the gold standard for evaluating the ventricular function with high accuracy and reproducibility [8]. However, CMR use may be limited in vitally unstable patients or those with some cardiac implantable electronic devices [9, 10]. Therefore, echocardiography remains a necessary non-invasive tool to assess the cardiac function in those patients [11]. Given these facts, echocardiography is the first choice for assessing the RV in different cardiovascular diseases. Nevertheless, further research is required to highlight the diagnostic and predictive role of the RV evaluation by echocardiography in patients with AHF, particularly in our population. In this registry, we studied the effect of right ventricular structure and function on acute left-sided heart failure clinical outcomes. Methods Study population This was a prospective cohort study of all consecutive patients presenting with left-sided AHF and left ventricular ejection fraction (LVEF) < 50% in the cardiovascular department of our hospital between September 2019 and September 2021. Left-sided AHF was defined as the rapid onset or worsening of symptoms and/or signs of HF (orthopnea, paroxysmal nocturnal dyspnea, bilateral pulmonary rales, or manifestations of hypoperfusion) [12, 13]. Patients were defined as having heart failure with reduced ejection fraction (HFrEF) if LVEF was < 40% Page 2 of 18 and HF with mildly reduced ejection fraction (HFmrEF) if LVEF was 40–49% [12]. Exclusion criteria included any of the following: LVEF ≥ 50%, age < 18 years or > 80 years, mechanical circulatory support, mechanical ventilation, inadequate image quality to assess RV parameters, life expectancy < 1 year due to non-cardiac factors such as advanced cancer, prosthetic valves, congenital heart disease, (...truncated)