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Canadian Journal of Cardiology

Myocardial Deformation in the Systemic Right Ventricle: Strain Imaging Improves Prediction of the Failing Heart

Published:December 17, 2019DOI:https://doi.org/10.1016/j.cjca.2019.12.014

      Abstract

      Background

      Predicting heart failure events in patients with a systemic right ventricle (sRV) due to transposition of the great arteries (TGA) is important for timely intensification of follow-up. This study assessed the value of strain compared with currently used parameters as predictor for heart failure–free survival in patients with sRV.

      Methods

      In participants of a multicentre trial, speckle-tracking echocardiography (STE) was performed to assess global longitudinal strain (GLS), mechanical dispersion (MD), and postsystolic shortening (PSS). Cox regression was used to determine the association of STE parameters with the combined end point of progression of heart failure and death, compared with cardiovascular magnetic resonance (CMR) and computed tomography (CT) derived parameters.

      Results

      Echocardiograms of 60 patients were analyzed (mean age 34 ± 11 years, 65% male, 35% congenitally corrected TGA). Mean GLS was −13.5 ± 2.9%, median MD was 49 (interquartile range [IQR] 30-76) ms, and 14 patients (23%) had PSS. During a median 8 (IQR 7-9) years, 15 patients (25%) met the end point. GLS, MD, and PSS were all associated with heart failure–free survival in univariable analysis. After correction for age, only GLS (optimal cutoff > −10.5%) and CMR/CT-derived sRV ejection fraction (optimal cutoff < 30%) remained associated with heart failure–free survival: hazard ratio (HR) 8.27, 95% confidence interval (CI) 2.50-27.41 (P < 0.001), and HR 4.34, 95% CI 1.48-12.74 (P = 0.007), respectively). Combining GLS and ejection fraction improved prediction, with patients with both GLS > −10.5% and sRV ejection fraction < 30% at highest risk (HR 19.69, 95% CI 4.90-79.13; P < 0.001).

      Conclusions

      The predictive value of GLS was similar to that of CMR/CT-derived ejection fraction. The combination of GLS and ejection fraction identified patients at highest risk of heart failure and death. Easily available STE parameters can be used to guide follow-up intensity and can be integrated into future risk prediction scores.

      Résumé

      Contexte

      La prévision des manifestations d’insuffisance cardiaque chez les patients présentant un ventricule droit systémique (VDs) en raison d’une transposition des gros vaisseaux (TGV) s’avère importante pour l’intensification du suivi en temps opportun. Cette étude a permis d’évaluer la valeur de la déformation myocardique comme facteur prévisionnel de survie sans insuffisance cardiaque par rapport aux paramètres actuellement utilisés chez les patients présentant un VDs.

      Méthodologie

      Chez les participants d’un essai multicentrique, une échocardiographie de suivi des marqueurs acoustiques (ESMA) a été réalisée afin d’évaluer la déformation longitudinale globale (DLG), la dispersion mécanique (DM) et le raccourcissement postsystolique (RPS). Le modèle de régression de Cox a servi à déterminer l’association des paramètres d’ESMA et du paramètre d’évaluation regroupant la progression de l’insuffisance cardiaque et le décès, comparativement à des paramètres d’imagerie par résonance magnétique cardiovasculaire (IRMC) et de tomodensitométrie (TDM).

      Résultats

      Les échocardiogrammes de 60 patients (âge moyen de 34 ± 11 ans, 65 % de sexe masculin, 35 % présentant une transposition congénitalement corrigée des gros vaisseaux) ont été analysés. La DLG moyenne était de -13,5 ± 2,9 % et la DM médiane, de 49 ms (intervalle interquartile de 30-76 ms), et un RPS a été noté chez 14 patients (23 %). Sur une période médiane de 8 ans (7-9 ans), le paramètre d’évaluation a été atteint chez 15 patients (25 %). La DLG, la DM et le RPS étaient tous associés à la survie sans insuffisance cardiaque dans une analyse unidimensionnelle. Après correction pour tenir compte de l’âge, seules la DLG (valeur seuil optimale > -10,5 %) et la fraction d’éjection du VDs en IRMC/TDM (valeur seuil optimale < 30 %) sont demeurées associées à la survie sans insuffisance cardiaque : rapport des risques instantanés (RRI) de 8,27 et de 4,34, intervalle de confiance (IC) à 95 % de 2,50-27,41 et de 1,48-12,74, p < 0,001 et p = 0,007, respectivement. La combinaison de la DLG et de la fraction d’éjection a amélioré la valeur prévisionnelle; les patients les plus à risque présentaient une DLG > -10,5 % et une fraction d’éjection du VDs < 30 % (RRI de 19,69, IC à 95 % de 4,90-79,13; p < 0,001).

      Conclusions

      La valeur prévisionnelle de la DLG a été similaire à celle de la fraction d’éjection en IRMC/TDM. La combinaison de la DLG et de la fraction d’éjection a permis de cibler les patients présentant le risque le plus élevé d’insuffisance cardiaque et de décès. Des paramètres d’ESMA faciles à mesurer peuvent servir à déterminer le degré de suivi nécessaire. Leur intégration aux scores de prévision du risque est envisageable à l’avenir.
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      Linked Article

      • Echocardiographic Strain Imaging in the Systemic Right Ventricle: Early Clue for Late Decompensation
        Canadian Journal of CardiologyVol. 36Issue 9
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          Right ventricular (RV) systolic function is increasingly appreciated as a powerful determinant of patient outcome in a variety of conditions, including myocardial infarction, heart failure, valvular heart disease, pulmonary hypertension, and congenital heart disease.1,2 Perhaps no other situation highlights the importance of RV systolic function more evidently than systemic RV (SRV), where the morphologic RV must support the systemic circulation. SRV occurs in mainly 3 congenital heart conditions: transposition of the great arteries corrected by a Mustard or Senning operation (TGA-MS), congenitally corrected TGA (CCTGA), and some Fontan patients.
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