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Decreased Right Ventricular Free Wall Strain Predicts Increased Mortality Even In The Setting Of Normal Fractional Area Change, Tricuspid Annular Plane Excursion, And Normal Right Ventricular Size In Patients With Greater Than Moderate Tricuspid Regurgitation
Vibha Murthy1, Uswa Khan1, Elizabeth Wright1, Shizhen Liu2, Pradeep Yadav2, Vivek Rajagopal2, Amy E. Simone2, Vibhav S. Rangarajan3, Peter Flueckiger3, Vinod H. Thourani2, Mani A. Vannan2.
1Georgia Institute of Technology and Marcus Heart Valve Center, Piedmont Heart Institute, Atlanta, GA, USA, 2Marcus Heart Valve Center, Piedmont Heart Institute, Atlanta, GA, USA, 3Piedmont Heart Institute, Atlanta, GA, USA.

OBJECTIVE: Right Ventricular (RV) function is a key determinant of clinical outcomes in chronic tricuspid regurgitation (TR). 2D RV free wall strain (RVFWS) has been shown to unmask RV dysfunction and may be predictive of symptoms and heart failure (HF) in chronic TR. We examined whether abnormal RVFWS in the setting of normal conventional measures of RV function and size predicted outcomes.
METHODS: In 816 patients with moderate-severe and severe chronic TR, we measured 2D RVFWS, FAC, and TAPSE. Patients were grouped as NNN (all three parameters were normal), LNN (decreased RVFWS but normal FAC and TAPSE), LLN (decreased RVFWS and FAC but normal TAPSE), and LLL (all three parameters were decreased). 2D RV and RA areas in the RV-focused apical view and the view optimized for RA were also measured.
RESULTS: During follow-up (median 1273 days, range 0-2523 days), 354 (43%) patients died. The LLL and the LNN group were more likely to die than the NNN group (HR 2.0 and 1.5 respectively, p = 0.0001). The mortality in the LLN group was comparable to the LNN group (Figure. 1A). The RV size in the NNN and LNN was normal whereas it was increased in the LLN and LLL groups; RA size was increased in all groups but markedly so in the LLN and LLL groups (Figure 1B). Thus, decreased RVFWS in the setting of normal FAC, TAPSE, and RV size but enlarged RA is associated with increased mortality. Decreased FAC and RVFWS but normal TAPSE in the same setting is also associated with increased mortality.
CONCLUSIONS: In greater than moderate chronic TR, in the setting of normal conventional parameters of RV function and size, decreased RVFWS and increased RA size were associated with increased mortality.


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