Echocardiographic Assessment Of Right Ventricular Function And Implications Of Prognosis In Heart Transplantation Patients

Part 1 Serial Changes of Right Ventricular Function Assessed by Three-dimensional Speckle-Tracking Echocardiography in Heart Transplantation Patients[Objective] The present study aimed to evaluate serial changes of right ventricular(RV)function in clinically well adult heart transplantation(HT)patients using three-dimensional speckle-tracking echocardiography(3D-STE).[Methods] We included 58 adult HT patients,who were free from severe valvular insufficiency,severe coronary artery disease,acute rejection,or multiple organ transplantation,and 58 healthy controls.The healthy controls were matched by the distribution of age and sex with HT group.Conventional and three-dimensional(3D)echocardiography were performed in all HT patients at 1-,3-,6-,9-and 12-months post HT.Meanwhile,all the healthy controls underwent conventional and 3D echocardiography when recruited.Tricuspid annular plane systolic excursion(TAPSE),s’ and RV fractional area change(RV FAC)were measured.Two-dimensional RV free wall longitudinal strain(2D-RV FWLS)was derived from two-dimensional speckle-tracking echocardiography(2D-STE).3D RV free wall longitudinal strain(3D-RV FWLS)and RV ejection fraction(RVEF)were assessed by 3D-STE.[Results] 1)TAPSE,s’,RV FAC,2D-RV FWLS,3D-RV FWLS,and RVEF increased significantly from 1 to 6 months post-HT: TAPSE(11.3±2.1mm vs.14.6±2.1mm,P < 0.001);s’(8.9±2.0cm/s vs.9.8±1.9cm/s,P = 0.034);RV FAC(37.1±3.2% vs.45.1±2.4%,P < 0.001);2D-RV FWLS(15.7±3.2% vs.19.5±2.4%,P < 0.001);3D-RV FWLS(13.2±1.9% vs.17.9±1.0%,P < 0.001);RVEF(38.2±2.2% vs.45.9±2.2%,P < 0.001).TAPSE,s’,RV FAC and 2D-RV FWLS showed no significant changes from 6 to 12 months post-HT(P > 0.05),while 3D-RV FWLS and RVEF were still significantly increased: 3D-RV FWLS(17.9±1.0% vs.18.7±1.4%,P < 0.001);RVEF(45.9±2.2% vs.46.8±2.0%,P = 0.025)2)By 12 months post HT,TAPSE,s’,RV FAC,2D-RV FWLS,3D-RV FWLS and RVEF were significantly lower than the healthy controls: TAPSE(15.1 ± 2.1mm vs.23.5 ± 3.0mm,P < 0.001),s’(10.3 ± 1.9cm/s vs.12.9 ± 2.0cm/s,P < 0.001),RV FAC(45.3 ± 1.8% vs.49.2 ± 3.8%,P < 0.001),2D-RV FWLS(19.9 ± 2.3% vs.23.5 ± 3.8%,P < 0.001),3D-RV FWLS(18.7 ± 1.4% vs.22.4 ± 2.3%,P < 0.001)and RVEF(46.8 ± 2.0% vs.49.9 ± 5.7%,P < 0.001).[Conclusions] RV systolic function improved significantly over time in clinically well adult HT patients.By 12 months post-HT,the patient’s RV systolic function still improved significantly,but remained lower than the control.Part 2 Prognostic Value of Three-dimensional Right Ventricular Echocardiographic Parameters for Prediction of Adverse Events in Heart Transplantation Patients[Objective] We aimed to assess the prognostic value of three-dimensional(3D)right ventricular(RV)echocardiographic parameters for prediction of adverse events in adult heart transplantation(HT)patients.[Methods] The study enrolled 155 adult HT patients who were under their routine reexamination at our center between January 1,2018 and December 31,2018.Conventional and 3D echocardiography were performed in all patients.Tricuspid annular plane systolic excursion(TAPSE),s’,RV fractional area change(RV FAC),two-dimensional RV free wall longitudinal strain(2D-RV FWLS),3D-RV free wall longitudinal strain(3D-RV FWLS)and RV ejection fraction(RVEF)were measured.Patients were prospectively followed up,until death or major cardiovascular adverse events(MACE)or censuring date on December 31,2020.During follow-up,death or MACE were recorded.MACE included: 1)acute rejection;2)severe coronary artery disease;3)heart failure requiring hospitalization;4)malignant arrhythmia;5)re-heart transplantation.[Results] 1)During follow-up,16 patients experienced MACE and 4 patients died.Median follow-up was 33.7 months(29.5,35.5).2)The risk of adverse events in 2D-RV FWLS ≤ 17.7%,3D-RV FWLS ≤ 17.6% and RVEF ≤ 44.2% were significantly higher than those in 2D-RV FWLS > 17.7%,3D-RV FWLS > 17.6% and RVEF > 44.2%(P < 0.05).3)Multivariate Cox analysis revealed that previous rejection,hemoglobin,TAPSE(hazard ratio [HR]: 0.78,95% confidence interval [CI]: 0.63 ~ 0.97;P = 0.028),2D-RV FWLS(HR: 0.84,95% CI: 0.71 ~ 0.99;P < 0.001),3D-RV FWLS(HR: 0.24,95% CI: 0.13 ~ 0.44;P < 0.001)and RVEF(HR: 0.82,95% CI: 0.68 ~ 0.99;P = 0.037)were independent predictors of adverse events in HT patients.4)The prediction ability of the model including 3D-RV FWLS(C-index = 0.83,AIC = 147)was better than TAPSE(C-index = 0.76,AIC = 164),2D-RV FWLS(C-index = 0.79,AIC = 63)or RVEF(C-index = 0.75,AIC = 164).[Conclusions] 3D-RV FWLS was a strong independent predictor of adverse events in adult HT patients.3D-RV FWLS was recommended to be assessed in the routine follow-up of HT patients and used for risk stratification combined with previous rejection and hemoglobin.