Three-dimensional right ventricular function and dimensions in patients undergoing transcatheter aortic valve replacement

Lukas Stolz (München)1, S. Schmid (München)1, J. Steffen (München)2, L. Weckbach (München)2, T. Stocker (München)2, P. Doldi (München)2, K. Löw (München)2, M. Haum (München)2, H. D. Theiss (München)2, K. Rizas (München)2, K. Stark (München)1, M. Näbauer (München)2, S. Peterß (München)3, S. Sadoni (München)3, C. Hagl (München)3, S. Massberg (München)2, J. Hausleiter (München)2, S. Deseive (München)2

1Ludwig-Maximilians Universität München Medizinische Klinik und Poliklinik I München, Deutschland; 2LMU Klinikum der Universität München Medizinische Klinik und Poliklinik I München, Deutschland; 3LMU Klinikum der Universität München Herzchirurgische Klinik und Poliklinik München, Deutschland


Background: Three-dimensional echocardiography (3DE) has emerged as an important imaging modality for the quantification of right ventricular (RV) function and dimensions. Until today, data on 3DE derived RV assessment in patients undergoing transcatheter aortic valve replacement (TAVR) are scarce. 


Objectives: The aim of this study was to evaluate the prognostic value of RV dilation and dysfunction as assessed by 3DE in patients who underwent TAVR for severe aortic stenosis (AS) regarding three-year survival and changes in New York Heart Association from baseline to latest available follow-up.


Methods: The study included patients with available 3DE of the RV who underwent TAVR from 2018 until 2019 at our institution. 3DE included RV end-diastolic volume (RVEDV3D), RV end-systolic volume (RVESV3D) and RV ejection fraction (RVEF3D). Depending on the patter of RV dilation (RVEDVi > 87 ml/mfor men and > 74 ml/mfor women) and RV dysfunction (LVEF < 45%) (1), three groups of TAVR patients were distinguished: 1) normal RV function and dimensions; 2) either RV dilation or dysfunction and 3) RV dilation and dysfunction. Using a Cox regression model, we evaluated the impact of RV dilation and dysfunction on three-year mortality after TAVR.


Results: The study included a total of 324 patients with available 3D RV echocardiograms at a mean age of 81.8 ± 6.1 years (47.2% females). All patients suffered from severe AS as indicated by mean aortic valve pressure gradients of 37.1 ± 14.2 mmHg, a mean aortic valve opening area of 0.71 ± 0.20 cm2 Left ventricular function was borderline (left ventricular ejection fraction 49.4 ± 8.9%). 3DE assessment of the RV revealed overall preserved RV dimensions (RVEDV3D 121.8 ± 43.3 ml; RVESV3D 49.2 ± 19.0 ml) and mildly reduced RV function (RVEF3D 41.1 ± 10.1%). Overall, 100 patients (30.9%) presented with normal RV function and dimensions, 169 patients (52.1%) with either RV dilation or dysfunction and 55 (17.0%) with RV dilation and dysfunction. Three-year survival rates differed by group assignment (normal RV function and dimensions: 84.3% vs. RV dysfunction or dilation 68.1% vs. RV dysfunction anddilation 46.8%, p<0.001, Figure 1). In a multivariate Cox regression model, RV dysfunction or dilation (HR 1.77; CI 0.98-3.20, p=0.058) and RV dysfunction and dilation (HR 2.36; CI 1.74-6.49; p<0.001) were independently associated with three-year all-cause mortality besides STS score, estimated glomerular filtration rate and NYHA functional class.


Conclusions: 3DE is of prognostic value in patients undergoing TAVR for severe AS. Since especially the presence of RV dilation and dysfunction at the same time is associated with worse survival prognosis, 3DE-derived RV function should be included into preprocedural patient evaluation. 

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