Speckle tracking evaluation of right ventricular function post left-sided valve replacement

Abstract

Background: The right ventricle dilates due to increased pulmonary wedge pressure caused by mitral and/or aortic valve disease, which lowers the right ventricular (RV) ejection fraction. This dilation can lead to tricuspid regurgitation (TR) with secondary right ventricular volume overload. Surgically correcting the left heart valves is thought to result in more favourable RV reverse remodelling, however, a growing number of patients have been observed in the cardiac unit at Port Elizabeth Provincial Hospital (PEPH) with worsening symptoms after left valvular correction. Due to the idea that tricuspid regurgitation (TR) would disappear after the original left-sided valve disease was corrected, surgical correction of the tricuspid valve (TV) has, up to now, been avoided in patients with secondary STR at the time of left valvular surgical correction. Much too little is known about how critical right ventricular (RV) function is and how it affects the cardiovascular patient’s prognosis. When selecting surgical procedures for the mitral valve (MV) and/or aortic valve (AO), RV performance is not the key determining factor. Aims: To determine changes in the right heart after mitral and/or aortic valve surgery, as well as to determine predictors of early signs of tricuspid regurgitation progression post-left valve surgery using two-dimensional Doppler and speckle tracking echocardiography. Study population and design: This study included 30 patients, 12 males and 18 females between the ages of 18 and 65. This was a prospective clinical study on the preoperative and postoperative echocardiographic parameters and their interaction in patients with severe mitral and/or aortic valve disease who were candidates for valve surgical correction. All echocardiographic examinations were conducted in the cardiac clinic of Port Elizabeth (Gqeberha) Hospital in the years 2020 to 2022. Subjects and methods: Participants were subjected to complete clinical examination and transthoracic echocardiography using the Ultra-Premium Aloka Prosound F75 Hitachi system, equipped with S3 transducer under very strict COVID-19 protocols. Standard 2D, M-mode, right ventricular global longitudinal strain, right ventricular free wall longitudinal strain, and Doppler echocardiography in the parasternal and apical views were recorded. Results: The population comprised 30 patients undergoing cardiac surgery for severe mitral and or aortic valve surgery. The study’s results revealed that the mean age of patients was 45.83 years with the majority being females (60%) and males at 40%. The predominant aetiology of valve diseases was degenerative valve disease (43.3%), and the most common valve disease was mitral regurgitation and aortic regurgitation, respectively at 23.3%. Tricuspid valve replacement reduced tricuspid regurgitation significantly, however, due to the small number of patients (n = 1) who progressed to significant tricuspid regurgitation further analysis was not undertaken. All correlations between tricuspid valve annulus, right ventricular systolic pressures and right ventricular diameter 6 months post-op were significant with a p-value of < 0.001. There were significant differences in left ventricular end-diastolic diameter (LVEDD) [5.46 ±.867vs 5.11 ±.850, (p=0.027)] as well as ejection fraction (EF) [65.33 ± 11.902 vs 61.50 ± 15.543, (p=0.037)] 6 months post op. There was no significant global longitudinal strain (GLS) change demonstrated in right ventricular function using speckle tracking imaging [-5.02 ± 7.400 vs -6.07 ± 9.373, p>0.005). The study demonstrated a significant decline in regional basal inferior septum (BIS) segments at 6 months follow-up [-9.67 ± 19.626 vs -4.86 ± 23.126 (p 0.034)]. The study also demonstrated a significant decrease in right ventricular function measured with TAPSE [23.20 ± 6.483 vs 19.182 ± 5.7738 (p<0.001) and FAC [60.63 ± 17.76 vs 41.33 ± 19.62 (p=0.18) 6 months post-op, with an immediate decline in mean measurements directly (72 hours) after surgery, a slight gradual mean increase was noted at 6 months follow up after surgery. A significant negative correlation was seen between RV dimensions and TAPSE 6 months post-op. There was no correlation seen between EF and GLS and TAPSE, LVEDD and GLS 72 hours post-op and again 6 months post-op (p >0.05). Conclusion: The global and/or regional systolic RV function was appropriately estimated using the 2D Doppler measurements and speckle tracking imaging. Together, these echocardiographic parameters measurements allowed for an accurate RV evaluation, improving disease diagnosis and management. Immediately following surgery, a thorough examination that includes TAPSE, S', and RVFAC assessment should be conducted. This examination should be repeated in three and six months to verify whether RV longitudinal function may have fully recovered and to enhance early management of RV failure.