Significant Disagreement Between Conventional Parameters and 3D Echocardiography-Derived Ejection Fraction in the Detection of Right Ventricular Systolic Dysfunction and Its Association With Outcomes

Máté Tolvaj; Attila Kovács; Noela Radu; Andrea Cascella; Denisa Muraru; Bálint Lakatos; Alexandra Fábián; Márton Tokodi; Michele Tomaselli; Mara Gavazzoni; Francesco Perelli; Béla Merkely; Luigi P Badano; Elena Surkova

doi:10.1016/j.echo.2024.04.005

Significant Disagreement Between Conventional Parameters and 3D Echocardiography-Derived Ejection Fraction in the Detection of Right Ventricular Systolic Dysfunction and Its Association With Outcomes

J Am Soc Echocardiogr. 2024 Apr 17:S0894-7317(24)00173-1. doi: 10.1016/j.echo.2024.04.005. Online ahead of print.

Authors

Affiliations

¹ Heart and Vascular Center, Semmelweis University, Budapest, Hungary.
² Heart and Vascular Center, Semmelweis University, Budapest, Hungary; Department of Experimental Cardiology and Surgical Techniques, Semmelweis University, Budapest, Hungary. Electronic address: attila.kovacs@med.semmelweis-univ.hu.
³ Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Carol Davila University of Medicine and Pharmacy, Prof. Dr. C. C. Iliescu Institute, Bucharest, Romania.
⁴ Department of Cardiology, Istituto Auxologico Italiano, IRCCS, San Luca Hospital, Milan, Italy.
⁵ Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Department of Cardiology, Istituto Auxologico Italiano, IRCCS, San Luca Hospital, Milan, Italy.
⁶ Royal Brompton and Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom.

PMID: 38641069
DOI: 10.1016/j.echo.2024.04.005

Abstract

Aims: Conventional echocardiographic parameters such as tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and free-wall longitudinal strain (FWLS) offer limited insights into the complexity of right ventricular (RV) systolic function, while 3D echocardiography-derived RV ejection fraction (RVEF) enables a comprehensive assessment. We investigated the discordance between TAPSE, FAC, FWLS, and RVEF in RV systolic function grading and associated outcomes.

Methods: We analyzed two- and three-dimensional echocardiography data from 2 centers including 750 patients followed up for all-cause mortality. Right ventricular dysfunction was defined as RVEF <45%, with guideline-recommended thresholds (TAPSE <17 mm, FAC <35%, FWLS >-20%) considered.

Results: Among patients with normal RVEF, significant proportions exhibited impaired TAPSE (21%), FAC (33%), or FWLS (8%). Conversely, numerous patients with reduced RVEF had normal TAPSE (46%), FAC (26%), or FWLS (41%). Using receiver-operating characteristic analysis, FWLS exhibited the highest area under the curve of discrimination for RV dysfunction (RVEF <45%) with 59% sensitivity and 92% specificity. Over a median 3.7-year follow-up, 15% of patients died. Univariable Cox regression identified TAPSE, FAC, FWLS, and RVEF as significant mortality predictors. Combining impaired conventional parameters showed that outcomes are the worst if at least 2 parameters are impaired and gradually better if only one or none of them are impaired (log-rank P < .005).

Conclusion: Guideline-recommended cutoff values of conventional echocardiographic parameters of RV systolic function are only modestly associated with RVEF-based assessment. Impaired values of FWLS showed the closest association with the RVEF cutoff. Our results emphasize a multiparametric approach in the assessment of RV function, especially if 3D echocardiography is not available.

Keywords: 2D echocardiography; 3D echocardiography; Fractional area change; Free-wall longitudinal strain; Right ventricular ejection fraction; Tricuspid annular plane systolic excursion.