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. 2022 Feb 25:9:837584.
doi: 10.3389/fcvm.2022.837584. eCollection 2022.

Prognostic Value of Right Ventricular Strains Using Novel Three-Dimensional Analytical Software in Patients With Cardiac Disease

Tetsuji Kitano  1 , Attila Kovács  2 , Yosuke Nabeshima  3 , Márton Tokodi  2 , Alexandra Fábián  2 , Bálint Károly Lakatos  2 , Masaaki Takeuchi  4
Affiliations

Prognostic Value of Right Ventricular Strains Using Novel Three-Dimensional Analytical Software in Patients With Cardiac Disease

Tetsuji Kitano et al. Front Cardiovasc Med. .

Abstract

Background: Right ventricular (RV) three-dimensional (3D) strains can be measured using novel 3D RV analytical software (ReVISION). Our objective was to investigate the prognostic value of RV 3D strains.

Methods: We retrospectively selected patients who underwent both 3D echocardiography (3DE) and cardiac magnetic resonance from January 2014 to October 2020. 3DE datasets were analyzed with 3D speckle tracking software and the ReVISION software. The primary end point was a composite of cardiac events, including cardiac death, heart failure hospitalization, or ventricular tachyarrhythmia.

Results: 341 patients were included in this analysis. During a median of 20 months of follow-up, 49 patients reached a composite of cardiac events. In univariate analysis, 3D RV ejection fraction (RVEF) and three 3D strain values [RV global circumferential strain (3D RVGCS), RV global longitudinal strain (3D RVGLS), and RV global area strain (3D RVGAS)] were significantly associated with cardiac death, ventricular tachyarrhythmia, or heart failure hospitalization (Hazard ratio: 0.88 to 0.93, p < 0.05). Multivariate analysis revealed that 3D RVEF, three 3D strain values were significantly associated with cardiac events after adjusting for age, chronic kidney disease, and left ventricular systolic/diastolic parameters. Kaplan-Meier survival curves showed that 3D RVEF of 45% and median values of 3D RVGCS, 3D RVGLS, and 3D RVGAS stratified a higher risk for survival rates. Classification and regression tree analysis, including 22 clinical and echocardiographic parameters, selected 3D RVEF (cut-off value: 34.5%) first, followed by diastolic blood pressure (cut-off value: 53 mmHg) and 3D RVGAS (cut-off value: 32.4%) for stratifying two high-risk group, one intermediate-risk group, and one low-risk group.

Conclusions: RV 3D strain had an equivalent prognostic value compared with 3D RVEF. Combining these parameters with 3D RVEF may allow more detailed stratification of patient's prognosis in a wide array of cardiac diseases.

Keywords: ReVISION; cardiac disease; prognosis; right ventricular (RV); right ventricular ejection fraction; three-dimensional strain (3D strain).

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Two representative cases of three-dimensional (3D) right ventricular (RV) analysis using ReVISION software: One case of normal RV function (3D RVEF: 49%, A–C) and another case of severe RV dysfunction (3D RVEF: 28%, D–F). Transparent light-yellow and light-green represents the end-diastolic endocardial boundary, and darker yellow and darker green represents the end-systolic endocardial boundary. Gray lines indicate contours used for 3D RV global circumferential strain (RVGCS) (A,D), and 3D RV global longitudinal strain (RVGLS) (B,E) assessment, respectively. Light-blue segmental areas and their change from end-diastole to end-systole represent the rationale behind area strain calculations [3D RV global area strain (RVGAS) is calculated using entire RV endocardial areas, C,F].
Figure 2
Figure 2
Flow chart of the study population.
Figure 3
Figure 3
Kaplan-Meier survival curves for cardiac death, ventricular tachyarrhythmia, or heart failure hospitalization stratified by predefined cut-off value of 3D RVEF (A) and median values of 3D RVGCS (B), 3D RVGLS (C), and 3D RVGAS (D). CD, cardiac death; HF, heart failure; VA, ventricular tachyarrhythmia.
Figure 4
Figure 4
The nested regression model to evaluate the incremental value of 3D RVEF, 3D RVGCS, 3D RVGLS, and 3D RVGAS for cardiac death, ventricular tachyarrhythmia, or HF hospitalization. χ2 scores show that 3D RVEF, 3D RVGCS, and 3D RVGAS have significant incremental value for prediction of a composite of cardiac events in addition to models, including age, chronic kidney disease, left ventricular ejection fraction, and average mitral E/e' (A–D). χ2 scores show that 3D RVEF, all 3D global strains have significant incremental value for prediction over the models, including age, chronic kidney disease, left ventricular ejection fraction, and maximum 3D left atrial volume index (E–H).
Figure 5
Figure 5
(A) Classification and regression tree (CART) analysis, including twenty-two clinical and echocardiographic parameters. CART selected 3D RVEF (cut-off value: 34.5%) first, followed by DBP (cut-off value: 53 mmHg) and 3D RVGAS (cut-off value: 32.4%), resulting in classification into two high-risk groups (n = 67), one intermediate-risk group (n = 154), and one low-risk group (n = 120). (B) CART analysis, including fifteen echocardiographic parameters. CART selected 3D RVEF (cut-off value: 34.5%) first, followed by average mitral E/e' (cut-off value: 25.6) and 3D LVESVI (cut-off value: 51.5 mL/m2), resulting in classification into two high-risk groups (n = 59), one intermediate-risk group (n = 126), and one low-risk group (n = 156).
Figure 6
Figure 6
Kaplan-Meier survival curves for heart failure hospitalization stratified by predefined cut-off value of 3D RVEF (A) and median values of 3D RVGCS (B), 3D RVGLS (C), and 3D RVGAS (D).
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