ORIGINAL ARTICLE
European Journal of Cardio-Thoracic Surgery 47 (2015) 333–340 doi:10.1093/ejcts/ezu152 Advance Access publication 21 April 2014
Cite this article as: Garatti A, Castelvecchio S, Di Mauro M, Bandera F, Guazzi M, Menicanti L. Impact of right ventricular dysfunction on the outcome of heart failure patients undergoing surgical ventricular reconstruction. Eur J Cardiothorac Surg 2015;47:333–40.
Impact of right ventricular dysfunction on the outcome of heart failure patients undergoing surgical ventricular reconstruction† Andrea Garattia,*, Serenella Castelvecchioa, Michele Di Maurob, Francesco Banderac, Marco Guazzic and Lorenzo Menicantia a b c
Department of Cardiac Surgery, I.R.C.C.S. Policlinico San Donato, Milan, Italy Department of Cardiovascular Disease, L’Aquila University, L’Aquila, Italy Heart Failure Unit, I.R.C.C.S. Policlinico San Donato, Milan, Italy
* Corresponding author. Department of Cardiac Surgery, I.R.C.C.S. Policlinico San Donato, Via Morandi 30, 20097, San Donato Milanese, Milan, Italy. Tel: +39-02-52774511; fax: +39-02-52774327; e-mail: [email protected] (A. Garatti). Received 15 October 2013; received in revised form 13 February 2014; accepted 26 February 2014
Abstract OBJECTIVES: The aim was to assess the impact of right ventricular dysfunction (RVD) on the outcome of heart failure (HF) patients undergoing surgical ventricular reconstruction (SVR).
RESULTS: RV dysfunction was detected in 69 patients (Group A, mean age 64 ± 11 years), while 255 patients (Group B, mean age 65 ± 9 years) had a preserved RV function. Patients in Group A showed a higher New York Heart Association (NYHA) class (P = 0.01), larger left ventricular (LV) end-diastolic and end-systolic volumes (P = 0.01), a lower EF (P = 0.01), a higher percentage of moderate-to-severe mitral regurgitation (P = 0.01) and a higher systolic pulmonary artery pressure (PAPs; P = 0.01). Propensity score matching was applied in order to adjust for baseline differences. In the fully matched population, low-output syndrome (P = 0.01), inotropic support (P = 0.01) and intraaortic balloon pump insertion (P = 0.03) were significantly more frequent in Group A compared with Group B. However, 30-day mortality was not significantly different between the two groups (P = 0.18). Kaplan-Meier 5- and 8-year survival rate (log-rank: P = 0.01) as well as freedom from cardiac events (log-rank: P = 0.02) were significantly lower in patients with RV dysfunction. At Cox regression analysis, preoperative RVD (P = 0.01) and NYHA class at admission >II (P = 0.02) resulted in independent predictor of late mortality. CONCLUSIONS: RV dysfunction correlates with LV dysfunction and it is an important predictor of long-term outcome in HF patients undergoing SVR. Keywords: Heart failure • Surgical ventricular reconstruction • pulmonary hypertension • Right ventricular dysfunction
INTRODUCTION Right ventricular (RV) dysfunction is a well-known predictor for mortality after acute myocardial infarction (MI) or coronary artery bypass grafting (CABG) and in chronic heart failure (HF) [1–3]. In patients with previous MI and left ventricular (LV) dysfunction, RV alterations can occur in a close relationship to the LV alterations that accompany the postischaemic remodelling process [4]. So far, RV systolic function is the result of a complex interaction with the remodelled and enlarged left ventricle, LV septal function, LV myocardial function and pulmonary artery systolic pressures (PAPs) with or without functional mitral regurgitation (MR). The † Presented at the 27th Annual Meeting of the European Association for CardioThoracic Surgery, Vienna, Austria, 5–9 October 2013.
complexity of such interaction suggests in turn a substantial variability in the response of the RV to LV dysfunction. Furthermore, biventricular impairment is a well-recognized pejorative prognostic factor in HF related to ischaemic or non-ischaemic disease [3–5]. Surgical ventricular reconstruction (SVR) is a specific procedure adopted to reverse LV remodelling in patients with ischaemic HF [6, 7]. The aim of SVR is to exclude scar tissue from the LV wall, thereby restoring the physiological volume and shape and improving LV systolic function, clinical status and survival. Furthermore, SVR has been proved to produce a mechanical intraventricular resynchronization that improves LV performance [8]. However, data on the relationship between RV function and SVR are lacking. The purpose of this study was to assess the RV function before and after SVR and its relationship with the clinical outcome in patients with ischaemic LV dysfunction and HF.
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
ADULT CARDIAC
METHODS: A total of 324 patients (65 ± 9 years) with previous myocardial infarction had an echocardiographic assessment of right ventricular (RV) function before and after SVR. RV function was assessed measuring the tricuspid annular plane systolic excursion (TAPSE) and RV dysfunction was defined by a TAPSE < 16 mm.
334
A. Garatti et al. / European Journal of Cardio-Thoracic Surgery
MATERIALS AND METHODS Study design The present study is a retrospective case–control study. Between January 2002 and December 2011, 324 patients with previous MI and LV systolic dysfunction had an echocardiographic assessment of RV function before SVR performed by a single surgeon (Lorenzo Menicanti), eventually associated with CABG and mitral repair/replacement. All patients presented with symptoms of CHF and/or angina or intractable ventricular arrhythmias. Indications to SVR were a previous MI with LV dilatation and scarred tissue. We wanted to test the hypothesis that preoperative RVD was an independent predictor of early and long-term mortality after SVR. RV function was assessed measuring the tricuspid annular plane systolic excursion (TAPSE), and RV dysfunction was defined by a TAPSE of ≤ 16 mm. According to this definition, the study population was divided into two groups (Group A—TAPSE ≤ 16 mm and Group B—TAPSE > 16 mm). The primary end point of the present study was long-term mortality from any cause. Secondary end point was long-term freedom from cardiac events, defined as the sum of death of any cause and HF readmission (each patient included only once). Demographic, clinical, echocardiographic and procedural data were retrospectively collected. The Istituto Policlinico San Donato Ethical Committee approved the study and waived the need for informed consent in consideration of the retrospective nature of the study. All patients admitted to the study gave their informed consent for the scientific analysis of their clinical data in an anonymous form.
All measurements were obtained from the mean of three beats for patients with sinus rhythm and from the mean of five beats for patients in atrial fibrillation. The intraclass correlation coefficient was determined for intraobserver variability. ICC for TAPSE measurement was 0.89, showing an excellent strength of agreement.
Surgical technique Details of the surgical technique have been reported previously [6]. Briefly, the procedure was performed on the arrested heart with antegrade cold blood cardioplegia. Complete coronary revascularization was performed first. After completion of coronary grafting, the LV was opened with an incision parallel to the left anterior descending artery, starting at the middle scarred region and ending at the apex. Surgical ventricular reconstruction was performed using a mannequin (TRISVR, Chase Medical Richardson, TX, USA) filled at 50–60 ml/m2 to optimize the size and shape of the new ventricle. The mannequin shape helps in orienting the plane of the endoventricular circular suture at the transitional zone, obliquely towards the aortic flow tract and mainly in rebuilding the new apex. The device is also useful especially in leaving a residual chamber that is not too small. When needed, the mitral valve was repaired through the ventricular opening with a posterior annuloplasty. The indication to repair the valve was moderate-to-severe regurgitation or mild regurgitation associated with annulus dilatation (>40 mm).
Echocardiography Echocardiography imaging was performed using a GE Vivid 7 (GE Healthcare, Waukesha, WI, USA) echocardiographic instrument. Both preoperative and postoperative echocardiographic exams were performed in our department by the same cardiologist (Serenella Castelvecchio). LV and RV chamber dimensions and function were measured according to the recommendations for chamber quantification from the American Society of Echocardiography/European Association of Echocardiography Guidelines [9].
Left ventricular analysis. LV end-diastolic and end-systolic internal diameters were obtained in parasternal long-axis view (mm) by using M-mode image. LV end-diastolic volume (EDV) and end-systolic volume (ESV) were calculated from the apical four-chamber view using the Simpson method, indexed to BSA (EDVI and ESVI, ml/m2). Ejection fraction (EF) was calculated as (EDV − ESV)/EDV × 100 (%). LA volume was measured at the end of LV systole from the apical four-chamber view (monoplane evaluation using the area-length method) and normalized for body surface area (BSA) (LAVI = LAV/BSA, ml/m2).
Right ventricular analysis. RV function was assessed measuring the TAPSE in the apical four-chamber view with an M-mode cursor placed through the lateral annulus in real time. TAPSE was measured as the total displacement of the tricuspid annulus (mm) from end-diastole to end-systole. PAPs were estimated by Doppler echocardiography recording the tricuspid regurgitant velocity from any view with continuous—wave Doppler (modified Bernoulli equation). MR was assessed using a four-degree scale, based on colour and continuous wave Doppler examination, independently by two different cardiologists.
Surgical risk estimation The estimation of perioperative risk was based on the age, creatinine and ejection fraction (ACEF) score. The ACEF score was recently introduced by Ranucci et al. [10] in 2009. This score is based on three factors only: age, preoperative creatinine value and EF. The LV EF is included as a continuous variable to account for the extremely high risk attributable to patients with EF in the range of 10–30%. In this area, the risk increases exponentially with decreasing EF. The ACEF score does not pool together all patients with an EF 2 Atrial fibrillation Ventricular arrhythmias Preoperative echocardiography EDV (ml) ESV (ml) Indexed EDV (ml/m2) Indexed ESV (ml/m2) EF (%) TAPSE E/A ratio DTE Systolic PAP (mmHg) Mitral regurgitation (>2+)
64 ± 11 55 (80%)
65 ± 9 213 (84%)
0.61 0.55
26 (38%) 39 (57%) 36 (53%) 22 (32%) 5 (7%)
110 (43%) 139 (55%) 151 (59%) 69 (27%) 15 (6%)
0.27 0.40 0.20 0.23 0.43
40 (60%) 48 (70%) 10 (14%) 4 (9%)
155 (64%) 119 (47%) 34 (13%) 28 (16%)
0.51 0.01 0.47 0.19
236 ± 103 176 ± 89 128 ± 53 96 ± 47 27 ± 7 13 ± 1.3 1.8 ± 1.1 163 ± 52 44 ± 17 30 (43%)
209 ± 66 144 ± 58 114 ± 36 79 ± 32 32 ± 8 21 ± 4 1.2 ± 0.8 194 ± 60 38 ± 13 64 (25%)
0.02 0.01 0.02 0.01 0.01 0.01 0.01 0.01 0.01 0.01
Bold values were used to highlight the significant P-value (2 Atrial fibrillation QRS width (mV) Preoperative medication ACE-inhibitor Beta-blockers Amiodarone Aspirin Statins Oral diuretics
65.8 ± 10.8
64.9 ± 9.2
0.60 0.41
55 (80%) 14 (20%) 1.8 ± 0.17
57 (83%) 12 (17%) 1.7 ± 0.21
0.32
26 (38%) 39 (57%) 36 (53%) 17 (24%) 13 (19%) 4 (6%) 5 (7%)
28 (41%) 37 (53%) 39 (57%) 13 (19%) 12 (17%) 5 (7%) 3 (4%)
0.46 0.39 0.40 0.18 0.90 0.63 0.36
45 (67%) 48 (69%) 10 (14%) 120 ± 29
53 (76%) 41 (60%) 12 (17%) 116 ± 28
0.16 0.14 0.41 0.37
62 (91%) 48 (71%) 10 (16%) 53 (78%) 33 (48%) 56 (82%)
58 (84%) 51 (74%) 16 (23%) 54 (78%) 46 (67%) 60 (87%)
0.16 0.40 0.15 0.56 0.02 0.30
ACE: angiotensin-converting enzyme; BSA: body surface area; CAD: coronary artery disease; CVA: cerebrovascular accident; NYHA: New York Heart Association; RV: right ventricular.
Table 3: Preoperative echocardiographic data; fully matched population Variables
RV dysfunction (n = 69 patients)
No RV dysfunction (n = 69 patients)
Parametric P
Non-parametric P
Preoperative echocardiography Diastolic diameter (mm) Systolic diameter (mm) EDV (ml) ESV (ml) Indexed EDV (ml/m2) Indexed ESV (ml/m2) EF (%) SV (ml) Indexed SV (ml/m2) Diastolic IV septum (mm) Systolic IV septum (mm) Dyast. LV posterior wall (mm) Syst. LV posterior wall (mm) Cardiac mass (g) Indexed cardiac mass (g/m2) RWT Left atrium (diameter—mm) DP E/A ratio DTE TAPSE Systolic PAP (mmHg) Mitral annulus (mm) Diastolic Sfericity index Systolic Sfericity index Mitral regurgitation (>2+)
65 ± 9 (64) 53 ± 10 (53) 228 ± 95 (223) 171 ± 83 (167) 125 ± 51 (127) 93 ± 45 (95) 26 ± 8 (24) 59 ± 22 (56) 32 ± 11 (32) 10 ± 2 (10) 12 ± 3 (12) 11 ± 2 (11) 14 ± 3 (14) 310 ± 78 (314) 170 ± 44 (165) 0.33 ± 0.09 (0.33) 46 ± 9 (47) 2.2 ± 1.1 (2) 1.7 ± 1.1 (1.5) 172 ± 59 (157) 14 ± 1.5 (15) 45 ± 18 (46) 34 ± 6 (34) 0.55 ± 0.11 (0.61) 0.48 ± 0.12 (0.55) 23 (33%)
65 ± 10 (65) 53 ± 12 (52) 219 ± 78 (206) 162 ± 71 (149) 121 ± 44 (122) 90 ± 41 (91) 27 ± 7 (25) 56 ± 15 (53) 31 ± 8 (29) 9 ± 3 (10) 11 ± 3 (12) 10 ± 1 (10) 13 ± 2 (14) 307 ± 82 (307) 168 ± 44 (163) 0.32 ± 0.07 (0.30) 45 ± 7 (45) 1.9 ± 0.9 (2) 1.4 ± 0.9 (1.1) 185 ± 54 (182) 20 ± 2.7 (19) 40 ± 12 (40) 34 ± 5 (34) 0.59 ± 0.12 (0.67) 0.51 ± 0.13 (0.59) 20 (29%)
0.92 0.86 0.56 0.53 0.68 0.64 0.57 0.39 0.46 0.37 0.62 0.36 0.83 0.84 0.88 0.87 0.64 0.20 0.11 0.23 0.01 0.11 0.82 0.06 0.19 0.36
0.91 0.75 0.61 0.49 0.75 0.59 0.36 0.63 0.81 0.54 0.75 0.52 0.88 0.71 0.85 0.79 0.48 0.24 0.16 0.10 0.01 0.26 0.85 0.09 0.27 –
Bold values were used to highlight the significant P-value (
European Journal of Cardio-Thoracic Surgery 47 (2015) 333–340 doi:10.1093/ejcts/ezu152 Advance Access publication 21 April 2014
Cite this article as: Garatti A, Castelvecchio S, Di Mauro M, Bandera F, Guazzi M, Menicanti L. Impact of right ventricular dysfunction on the outcome of heart failure patients undergoing surgical ventricular reconstruction. Eur J Cardiothorac Surg 2015;47:333–40.
Impact of right ventricular dysfunction on the outcome of heart failure patients undergoing surgical ventricular reconstruction† Andrea Garattia,*, Serenella Castelvecchioa, Michele Di Maurob, Francesco Banderac, Marco Guazzic and Lorenzo Menicantia a b c
Department of Cardiac Surgery, I.R.C.C.S. Policlinico San Donato, Milan, Italy Department of Cardiovascular Disease, L’Aquila University, L’Aquila, Italy Heart Failure Unit, I.R.C.C.S. Policlinico San Donato, Milan, Italy
* Corresponding author. Department of Cardiac Surgery, I.R.C.C.S. Policlinico San Donato, Via Morandi 30, 20097, San Donato Milanese, Milan, Italy. Tel: +39-02-52774511; fax: +39-02-52774327; e-mail: [email protected] (A. Garatti). Received 15 October 2013; received in revised form 13 February 2014; accepted 26 February 2014
Abstract OBJECTIVES: The aim was to assess the impact of right ventricular dysfunction (RVD) on the outcome of heart failure (HF) patients undergoing surgical ventricular reconstruction (SVR).
RESULTS: RV dysfunction was detected in 69 patients (Group A, mean age 64 ± 11 years), while 255 patients (Group B, mean age 65 ± 9 years) had a preserved RV function. Patients in Group A showed a higher New York Heart Association (NYHA) class (P = 0.01), larger left ventricular (LV) end-diastolic and end-systolic volumes (P = 0.01), a lower EF (P = 0.01), a higher percentage of moderate-to-severe mitral regurgitation (P = 0.01) and a higher systolic pulmonary artery pressure (PAPs; P = 0.01). Propensity score matching was applied in order to adjust for baseline differences. In the fully matched population, low-output syndrome (P = 0.01), inotropic support (P = 0.01) and intraaortic balloon pump insertion (P = 0.03) were significantly more frequent in Group A compared with Group B. However, 30-day mortality was not significantly different between the two groups (P = 0.18). Kaplan-Meier 5- and 8-year survival rate (log-rank: P = 0.01) as well as freedom from cardiac events (log-rank: P = 0.02) were significantly lower in patients with RV dysfunction. At Cox regression analysis, preoperative RVD (P = 0.01) and NYHA class at admission >II (P = 0.02) resulted in independent predictor of late mortality. CONCLUSIONS: RV dysfunction correlates with LV dysfunction and it is an important predictor of long-term outcome in HF patients undergoing SVR. Keywords: Heart failure • Surgical ventricular reconstruction • pulmonary hypertension • Right ventricular dysfunction
INTRODUCTION Right ventricular (RV) dysfunction is a well-known predictor for mortality after acute myocardial infarction (MI) or coronary artery bypass grafting (CABG) and in chronic heart failure (HF) [1–3]. In patients with previous MI and left ventricular (LV) dysfunction, RV alterations can occur in a close relationship to the LV alterations that accompany the postischaemic remodelling process [4]. So far, RV systolic function is the result of a complex interaction with the remodelled and enlarged left ventricle, LV septal function, LV myocardial function and pulmonary artery systolic pressures (PAPs) with or without functional mitral regurgitation (MR). The † Presented at the 27th Annual Meeting of the European Association for CardioThoracic Surgery, Vienna, Austria, 5–9 October 2013.
complexity of such interaction suggests in turn a substantial variability in the response of the RV to LV dysfunction. Furthermore, biventricular impairment is a well-recognized pejorative prognostic factor in HF related to ischaemic or non-ischaemic disease [3–5]. Surgical ventricular reconstruction (SVR) is a specific procedure adopted to reverse LV remodelling in patients with ischaemic HF [6, 7]. The aim of SVR is to exclude scar tissue from the LV wall, thereby restoring the physiological volume and shape and improving LV systolic function, clinical status and survival. Furthermore, SVR has been proved to produce a mechanical intraventricular resynchronization that improves LV performance [8]. However, data on the relationship between RV function and SVR are lacking. The purpose of this study was to assess the RV function before and after SVR and its relationship with the clinical outcome in patients with ischaemic LV dysfunction and HF.
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
ADULT CARDIAC
METHODS: A total of 324 patients (65 ± 9 years) with previous myocardial infarction had an echocardiographic assessment of right ventricular (RV) function before and after SVR. RV function was assessed measuring the tricuspid annular plane systolic excursion (TAPSE) and RV dysfunction was defined by a TAPSE < 16 mm.
334
A. Garatti et al. / European Journal of Cardio-Thoracic Surgery
MATERIALS AND METHODS Study design The present study is a retrospective case–control study. Between January 2002 and December 2011, 324 patients with previous MI and LV systolic dysfunction had an echocardiographic assessment of RV function before SVR performed by a single surgeon (Lorenzo Menicanti), eventually associated with CABG and mitral repair/replacement. All patients presented with symptoms of CHF and/or angina or intractable ventricular arrhythmias. Indications to SVR were a previous MI with LV dilatation and scarred tissue. We wanted to test the hypothesis that preoperative RVD was an independent predictor of early and long-term mortality after SVR. RV function was assessed measuring the tricuspid annular plane systolic excursion (TAPSE), and RV dysfunction was defined by a TAPSE of ≤ 16 mm. According to this definition, the study population was divided into two groups (Group A—TAPSE ≤ 16 mm and Group B—TAPSE > 16 mm). The primary end point of the present study was long-term mortality from any cause. Secondary end point was long-term freedom from cardiac events, defined as the sum of death of any cause and HF readmission (each patient included only once). Demographic, clinical, echocardiographic and procedural data were retrospectively collected. The Istituto Policlinico San Donato Ethical Committee approved the study and waived the need for informed consent in consideration of the retrospective nature of the study. All patients admitted to the study gave their informed consent for the scientific analysis of their clinical data in an anonymous form.
All measurements were obtained from the mean of three beats for patients with sinus rhythm and from the mean of five beats for patients in atrial fibrillation. The intraclass correlation coefficient was determined for intraobserver variability. ICC for TAPSE measurement was 0.89, showing an excellent strength of agreement.
Surgical technique Details of the surgical technique have been reported previously [6]. Briefly, the procedure was performed on the arrested heart with antegrade cold blood cardioplegia. Complete coronary revascularization was performed first. After completion of coronary grafting, the LV was opened with an incision parallel to the left anterior descending artery, starting at the middle scarred region and ending at the apex. Surgical ventricular reconstruction was performed using a mannequin (TRISVR, Chase Medical Richardson, TX, USA) filled at 50–60 ml/m2 to optimize the size and shape of the new ventricle. The mannequin shape helps in orienting the plane of the endoventricular circular suture at the transitional zone, obliquely towards the aortic flow tract and mainly in rebuilding the new apex. The device is also useful especially in leaving a residual chamber that is not too small. When needed, the mitral valve was repaired through the ventricular opening with a posterior annuloplasty. The indication to repair the valve was moderate-to-severe regurgitation or mild regurgitation associated with annulus dilatation (>40 mm).
Echocardiography Echocardiography imaging was performed using a GE Vivid 7 (GE Healthcare, Waukesha, WI, USA) echocardiographic instrument. Both preoperative and postoperative echocardiographic exams were performed in our department by the same cardiologist (Serenella Castelvecchio). LV and RV chamber dimensions and function were measured according to the recommendations for chamber quantification from the American Society of Echocardiography/European Association of Echocardiography Guidelines [9].
Left ventricular analysis. LV end-diastolic and end-systolic internal diameters were obtained in parasternal long-axis view (mm) by using M-mode image. LV end-diastolic volume (EDV) and end-systolic volume (ESV) were calculated from the apical four-chamber view using the Simpson method, indexed to BSA (EDVI and ESVI, ml/m2). Ejection fraction (EF) was calculated as (EDV − ESV)/EDV × 100 (%). LA volume was measured at the end of LV systole from the apical four-chamber view (monoplane evaluation using the area-length method) and normalized for body surface area (BSA) (LAVI = LAV/BSA, ml/m2).
Right ventricular analysis. RV function was assessed measuring the TAPSE in the apical four-chamber view with an M-mode cursor placed through the lateral annulus in real time. TAPSE was measured as the total displacement of the tricuspid annulus (mm) from end-diastole to end-systole. PAPs were estimated by Doppler echocardiography recording the tricuspid regurgitant velocity from any view with continuous—wave Doppler (modified Bernoulli equation). MR was assessed using a four-degree scale, based on colour and continuous wave Doppler examination, independently by two different cardiologists.
Surgical risk estimation The estimation of perioperative risk was based on the age, creatinine and ejection fraction (ACEF) score. The ACEF score was recently introduced by Ranucci et al. [10] in 2009. This score is based on three factors only: age, preoperative creatinine value and EF. The LV EF is included as a continuous variable to account for the extremely high risk attributable to patients with EF in the range of 10–30%. In this area, the risk increases exponentially with decreasing EF. The ACEF score does not pool together all patients with an EF 2 Atrial fibrillation Ventricular arrhythmias Preoperative echocardiography EDV (ml) ESV (ml) Indexed EDV (ml/m2) Indexed ESV (ml/m2) EF (%) TAPSE E/A ratio DTE Systolic PAP (mmHg) Mitral regurgitation (>2+)
64 ± 11 55 (80%)
65 ± 9 213 (84%)
0.61 0.55
26 (38%) 39 (57%) 36 (53%) 22 (32%) 5 (7%)
110 (43%) 139 (55%) 151 (59%) 69 (27%) 15 (6%)
0.27 0.40 0.20 0.23 0.43
40 (60%) 48 (70%) 10 (14%) 4 (9%)
155 (64%) 119 (47%) 34 (13%) 28 (16%)
0.51 0.01 0.47 0.19
236 ± 103 176 ± 89 128 ± 53 96 ± 47 27 ± 7 13 ± 1.3 1.8 ± 1.1 163 ± 52 44 ± 17 30 (43%)
209 ± 66 144 ± 58 114 ± 36 79 ± 32 32 ± 8 21 ± 4 1.2 ± 0.8 194 ± 60 38 ± 13 64 (25%)
0.02 0.01 0.02 0.01 0.01 0.01 0.01 0.01 0.01 0.01
Bold values were used to highlight the significant P-value (2 Atrial fibrillation QRS width (mV) Preoperative medication ACE-inhibitor Beta-blockers Amiodarone Aspirin Statins Oral diuretics
65.8 ± 10.8
64.9 ± 9.2
0.60 0.41
55 (80%) 14 (20%) 1.8 ± 0.17
57 (83%) 12 (17%) 1.7 ± 0.21
0.32
26 (38%) 39 (57%) 36 (53%) 17 (24%) 13 (19%) 4 (6%) 5 (7%)
28 (41%) 37 (53%) 39 (57%) 13 (19%) 12 (17%) 5 (7%) 3 (4%)
0.46 0.39 0.40 0.18 0.90 0.63 0.36
45 (67%) 48 (69%) 10 (14%) 120 ± 29
53 (76%) 41 (60%) 12 (17%) 116 ± 28
0.16 0.14 0.41 0.37
62 (91%) 48 (71%) 10 (16%) 53 (78%) 33 (48%) 56 (82%)
58 (84%) 51 (74%) 16 (23%) 54 (78%) 46 (67%) 60 (87%)
0.16 0.40 0.15 0.56 0.02 0.30
ACE: angiotensin-converting enzyme; BSA: body surface area; CAD: coronary artery disease; CVA: cerebrovascular accident; NYHA: New York Heart Association; RV: right ventricular.
Table 3: Preoperative echocardiographic data; fully matched population Variables
RV dysfunction (n = 69 patients)
No RV dysfunction (n = 69 patients)
Parametric P
Non-parametric P
Preoperative echocardiography Diastolic diameter (mm) Systolic diameter (mm) EDV (ml) ESV (ml) Indexed EDV (ml/m2) Indexed ESV (ml/m2) EF (%) SV (ml) Indexed SV (ml/m2) Diastolic IV septum (mm) Systolic IV septum (mm) Dyast. LV posterior wall (mm) Syst. LV posterior wall (mm) Cardiac mass (g) Indexed cardiac mass (g/m2) RWT Left atrium (diameter—mm) DP E/A ratio DTE TAPSE Systolic PAP (mmHg) Mitral annulus (mm) Diastolic Sfericity index Systolic Sfericity index Mitral regurgitation (>2+)
65 ± 9 (64) 53 ± 10 (53) 228 ± 95 (223) 171 ± 83 (167) 125 ± 51 (127) 93 ± 45 (95) 26 ± 8 (24) 59 ± 22 (56) 32 ± 11 (32) 10 ± 2 (10) 12 ± 3 (12) 11 ± 2 (11) 14 ± 3 (14) 310 ± 78 (314) 170 ± 44 (165) 0.33 ± 0.09 (0.33) 46 ± 9 (47) 2.2 ± 1.1 (2) 1.7 ± 1.1 (1.5) 172 ± 59 (157) 14 ± 1.5 (15) 45 ± 18 (46) 34 ± 6 (34) 0.55 ± 0.11 (0.61) 0.48 ± 0.12 (0.55) 23 (33%)
65 ± 10 (65) 53 ± 12 (52) 219 ± 78 (206) 162 ± 71 (149) 121 ± 44 (122) 90 ± 41 (91) 27 ± 7 (25) 56 ± 15 (53) 31 ± 8 (29) 9 ± 3 (10) 11 ± 3 (12) 10 ± 1 (10) 13 ± 2 (14) 307 ± 82 (307) 168 ± 44 (163) 0.32 ± 0.07 (0.30) 45 ± 7 (45) 1.9 ± 0.9 (2) 1.4 ± 0.9 (1.1) 185 ± 54 (182) 20 ± 2.7 (19) 40 ± 12 (40) 34 ± 5 (34) 0.59 ± 0.12 (0.67) 0.51 ± 0.13 (0.59) 20 (29%)
0.92 0.86 0.56 0.53 0.68 0.64 0.57 0.39 0.46 0.37 0.62 0.36 0.83 0.84 0.88 0.87 0.64 0.20 0.11 0.23 0.01 0.11 0.82 0.06 0.19 0.36
0.91 0.75 0.61 0.49 0.75 0.59 0.36 0.63 0.81 0.54 0.75 0.52 0.88 0.71 0.85 0.79 0.48 0.24 0.16 0.10 0.01 0.26 0.85 0.09 0.27 –
Bold values were used to highlight the significant P-value (
