What is the next step in workup for a patient with reduced right ventricular (RV) systolic function?

Diagnostic Workup for Reduced Right Ventricular Systolic Function

The next step in workup for a patient with reduced right ventricular systolic function should be comprehensive echocardiography with assessment of RV size, function, and pulmonary artery systolic pressure, followed by right heart catheterization if pulmonary hypertension is suspected.

Initial Evaluation

• Transthoracic echocardiography (TTE) is the first-line imaging modality to evaluate the severity of right ventricular (RV) dysfunction, determine etiology, measure sizes of right-sided chambers and inferior vena cava, assess RV systolic function, and estimate pulmonary artery systolic pressure 1
• Assessment of RV systolic function is a critical component of evaluation, as impaired RV systolic function negatively impacts early functional, late functional, and survival outcomes 1
• Reduced RV systolic function more closely predicts impaired exercise tolerance and poor survival than does left ventricular systolic function 2

Comprehensive Echocardiographic Assessment

• Standard echocardiographic parameters to assess RV function include:

  • Tricuspid annular plane systolic excursion (TAPSE) - abnormal if <17 mm 1
  • RV fractional area change (FAC) - abnormal if <40% 1
  • RV basal diameter - abnormal if >41 mm 1

• Advanced echocardiographic parameters should also be considered:

  • RV longitudinal strain of lateral RV free wall - abnormal if worse than -23% 1
  • RV mechanical dispersion - abnormal if >25-30 ms 1
  • 3D RV ejection fraction - abnormal if <40% 1

Additional Diagnostic Testing

• If pulmonary hypertension is suspected based on echocardiographic findings:

  • Right heart catheterization is the gold standard for confirming the diagnosis and provides definitive information regarding pulmonary vasoreactivity testing 3
  • Comprehensive evaluation should include pulmonary function tests, six-minute walk test, non-contrast CT scan of the chest or CT angiogram if thromboembolic disease is suspected 1
  • Ventilation/perfusion (V/Q) scan should be performed to evaluate for chronic thromboembolic pulmonary hypertension 3

• For cases with suboptimal echocardiographic images:

  • Cardiac magnetic resonance imaging (CMR) or real-time 3D echocardiography should be considered for more accurate assessment of RV volumes and systolic function 1
  • CMR may be the ideal modality in young asymptomatic patients with severe tricuspid regurgitation to assess initial and serial measurements of RV size and systolic function 1

Evaluation for Underlying Causes

• Search for underlying causes of RV dysfunction, including:

  • Left-sided heart disease (valvular disease, cardiomyopathy) 1
  • Pulmonary hypertension (pulmonary arterial hypertension, chronic thromboembolic pulmonary hypertension) 1
  • Pulmonary disease (COPD, interstitial lung disease) 3
  • Congenital heart disease with systemic-to-pulmonary shunts 3
  • Sleep-disordered breathing 1
  • Autoimmune diseases 1

• Laboratory tests should include:

  • Complete blood count, comprehensive metabolic panel, thyroid function tests 1
  • N-terminal pro B-type natriuretic peptide (NT-proBNP) 1
  • If clinically indicated: hepatitis serologies, HIV testing, hypercoagulable panel 1
  • If screening anti-nuclear antibody is positive, a panel of autoimmune antibodies 1

Functional Assessment

• Exercise testing should be considered for the assessment of exercise capacity in patients with severe tricuspid regurgitation with no or minimal symptoms 1
• Six-minute walk test has been shown to correlate with RV function parameters and can provide a functional baseline 4

Prognostic Considerations

• Patients with TAPSE less than 15 mm have worse prognosis compared to those with TAPSE ≥15 mm 2
• Elevated right ventricular systolic pressure (RVSP) on echocardiography correlates with poor outcomes, with mortality risk increasing by approximately 40% with every 10 mmHg increase in PA systolic pressure 3
• Improvement in RV peak systolic strain after intensive medical treatment is associated with lower adverse events in patients with heart failure 5

Management Implications

• For patients with RV dysfunction due to left-sided heart failure, optimization of left ventricular function with ACE inhibitors and beta-blockers is essential 6
• In patients with RV dysfunction and signs of right-sided heart failure, diuretics can be useful 1
• Medical therapies to reduce elevated pulmonary artery pressures and/or pulmonary vascular resistance might be considered in patients with severe functional tricuspid regurgitation 1
• In severe cases of RV failure, mechanical circulatory support devices may be needed to unload the RV and improve organ perfusion 7