CHRONIC HEART FAILURE WITH PRESERVED LEFT VENTRICLE EJECTION FRACTION (HFPEF) AND RIGHT VENTRICLE INVOLVEMENT IN PATIENTS WITH NORMAL SINUS RHYTHM AND ATRIAL FIBRILLATION; A SMALL OBSERVATIONAL STUDY: RELEVANCE OF THE PROBLEM, DIAGNOSTIC APPROACH, ECHOCARDIOGRAPHIC EVALUATION OF RIGHT VENTRICLE.

Abstract

Chronic Heart Failure (CHF) is a complex syndrome that affects at least 6.5 million adults in the USA. The preserved left ventricle ejection fraction was met in at least 50% of patients. The data were published by the Center of Heart and Stroke Statistics in 2020. Right ventricle (RV) involvement in the pathological process of patients with chronic heart failure with preserved left ventricle ejection fraction is a common problem. The pathogenesis, mechanisms, and prognosis of RV dysfunction in patients with HFpEF have not yet been fully evaluated. Several questions have been raised regarding these aspects.

Methods: We investigated 26 patients with documented and confirmed HFpEF diagnoses. Patients were divided into two separate groups: patients with normal sinus rhythm and those with atrial fibrillation. For all subjects, the right ventricle (RV) systolic and diastolic functions were assessed using transthoracic ultrasound. We studied the RV measurements and volume, Tricuspid Annular Plane Systolic Excursion (TAPSE), Fractional Area Change (FAC), Right Ventricular Index of Myocardial Performance (RIMP), pulse Doppler S-wave, and Eccentricity Index (EI). Additionally, we evaluated the secondary echocardiographic parameters for RV dysfunction such as pulmonary hypertension using the following markers: systolic pulmonary artery pressure (sPAP), s pulmonary artery pressure (mPAP), tricuspid regurgitation (TR) velocity, pulmonary velocity acceleration time (PVAT) and SPAP/TAPSE ratio. We searched for selected echocardiographic parameters that might better indicate both RV systolic and diastolic deterioration in patients with HFpEF.

Results: None of the parameters evaluated during transthoracic echocardiography that were proposed to assess RV function revealed specificity for patients with HFpEF, except for the Right Ventricular Index of Myocardial Performance (RIMP). We did not observe the significant statistical correlation between FAC, TAPSE and S` and the severity of RV deterioration or patients` subjective symptoms. Only the RIMP plays an important role in the assessment of RV contractility and diastolic dysfunction. Meanwhile, RIMP values were not correlated with pro-BNP levels, severity of pulmonary hypertension, or heart failure NYHA class.

Conclusions: 1. HFpEF is widespread, especially among elderly women with concomitant arterial hypertension, overweight status, and acquired valvular disease. 2. In patients with HFpEF, the RV is mainly involved in the pathological process, regardless of the cardiac rhythm. In our trial, RV involvement was observed in all 26 patients. Its involvement might have occurred based on subjective, objective, and echocardiographic findings. 3. In patients with HFpEF, the minimal essential echo parameters that should be examined for better evaluation of the RV functions are the following: RV and RVOT linear and volumetric measurements, TAPSE, FAC, Tissue Doppler S`, RIMP. 4. RIMP itself was found to be a sensitive marker for the description of RV dysfunction, including both systolic and diastolic function, in patients with HFpEF despite age, sex, and cardiac rhythm. 5. The value of RIMP was not linked to either the severity of HF, level of pro-BNP or degree of pulmonary hypertension.