Conventional echocardiographic parameters or three-dimensional echocardiography to evaluate right ventricular function in percutaneous edge-to-edge mitral valve repair (PMVR)

Abstract

Introduction: In this study, we evaluated right ventricular (RV) function before and after percutaneous mitral valve repair (PMVR) using conventional echocardiographic parameters and novel 3DE data sets acquired prior to and directly after the procedure.

Patients and methods: Observational study on 45 patients undergoing PMVR at an university hospital.

Results: In the overall collective, the 3D RV-EF before and after PMVR showed no significant change (p = 0.16). While there was a significant increase of the fractional area change (FAC, from 23 [19-29] % to 28 [24-33] %, p = 0.001), no significant change of the tricuspid annular plane systolic excursion (TAPSE, from 17 ± 6 mm to 18 ± 5 mm (standard deviation), p = 0.33) was observed. Regarding patients with a reduced RV-EF (< 35%), a significant RV-EF improvement was observed (from 27 [23-34] % to 32.5 [30-39] % (p = 0.001). 71.4% of patients had an improved clinical outcome (improvement in 6-minute walk test and/or improvement in NYHA class of more than one grade), whereas clinical outcome did not improve in 28.6% of patients. Using univariate logistic regression analysis, the post-PMVR RV-EF (OR 1.15: 95% CI 1.02-1.29; p = 0.02) and the change in RV-EF (OR 1.13: 95% CI 1.02-1.25; p = 0.02) were significant predictors for improved clinical outcome at 6 months follow up.

Conclusion: Thus, RV function may be an important non-invasive parameter to add to the predictive parameters indicating a potential clinical benefit from treatment of severe mitral regurgitation using PMVR.

Keywords: 3D-echocardiography; 3DE, 3D-echocardiography; ACE, angiotensin converting enzyme; DMR, degenerative mitral regurgitation; EDV, end-diastolic volume; EF, ejection fraction; ESV, end-systolic volume; Echocardiography; FAC, fractional area change; FMR, functional mitral regurgitation; LA, left atrium; LV, left ventricle; LVOT, left ventricular outflow tract; MR, mitral regurgitation; MRI, magnetic resonance imaging; Mitral regurgitation; NYHA, New York heart association functional classification; Outcome; PAMP, pulmonary artery mean pressure; PASP, pulmonary artery systolic pressure; PCWP, pulmonary capillary wedge pressure; PMVR, percutaneous mitral valve repair; Percutaneous mitral valve repair; RV function; RV, right ventricle; TAPSE, tricuspid annular plane systolic excursion; TAVR, transcatheter aortic valve replacement; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography.

Fig. 1

Effects of percutaneous mitral valve repair (PMVR) on right ventricular pressure parameters in 45 patients with MR not accessible by conventional surgery. (A) Grade of MR pre and post PMVR. (B) PASP and PAMP measured in right heart catheterization before and after PMVR show no significant change before and after PMVR. n.s. = no significant change compared to pre intervention. (C) Echocardiographic PASP before and after PMVR showing no significant change. n.s. = no significant change compared to pre intervention.

Fig. 2

No significant changes of well-established parameters for RV-Function in the total collective of 45 patients after PMVR. (A) Reconstruction of a right ventricular mesh model using the Tomtec 4D RV function 2.0 software using a focused view of the right ventricle. Left side shows enddiastolic frames, right side shows endsystolic frame. Speckle-tracking-based endocardial border detection of the RV endocardium with a basal and middle short axis view of the RV and a 4-chamber view as well as mesh model of these frames is shown. (B) 3D echocardiographic ejection fraction of the right ventricle (RV-EF) before and after PMVR showing no significant change (n = 45, p = 0.16). (C) Right ventricular fractional area change (FAC) showing no significant change (n = 45, p = 0.13). (D) Tricuspid annular plane systolic excursion (TAPSE) showing no significant change (n = 45, p = 0.96). (E) Correlation between the 3D-RVEF and the FAC before the procedure. According to the Pearson correlation test there is a positive correlation (n = 45, p < 0.001).

Fig. 3

In patients with reduced RV-EF < 35%, RV-EF increases after PMVR. (A) In patients with reduced right ventricular ejection fraction (RV-EF < 35%) before PMVR, RV-EF increases significantly after PMVR (n = 24, p = 0.001). (B) Echocardiographic PASP before and after PMVR showing no significant change. (n.s. = no significant difference was observed). (C) FAC before and after PMVR is depicted. We observed a significant increase of FAC after PMVR. (n = 24; p = 0.01). (D) TAPSE before and after PMVR showing no significant change. (n = 24, p = 0.33).

Fig. 4

Predictive value of early RV function change for improvement in clinical outcome 6 months after PMVR. Forrest plot showing the summary measure of the odds ratios (center line) and the 95% confidence intervals (horizontal line) given for improvement in clinical outcome 6 months after PMVR (all patients). The dotted line shows the border of no association. The post-PMVR RV-EF (OR 1.15: 95% CI 1.02–1.29; p = 0.02) and the change in RV-EF (OR 1.15: 95% CI 1.02–1.29; p = 0.02) were significant predictors for improved clinical outcome at 6 months follow up.