Assessment of the Predictive Value of Right Ventricular Longitudinal Strain and Functional Trends in Right Ventricular Function of Patients after LVAD Implantation

Assessment of the Predictive Value of Right Ventricular Longitudinal Strain and Functional Trends in Right Ventricular Function of Patients after LVAD Implantation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessment of the Predictive Value of Right Ventricular Longitudinal Strain and Functional Trends in Right Ventricular Function of Patients after LVAD Implantation Carl-Thaddäus Braun, Rene Schramm, Michiel Morshuis, Sabina PW Guenther, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9129803/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Right heart failure (RHF) remains a major determinant of morbidity and mortality following left ventricular assist device (LVAD) implantation. Right ventricular free wall strain (RVFWS) and global longitudinal strain (RVGLS) have emerged as promising echocardiographic markers, yet their long-term prognostic utility and suitability to assess changes in RV function remain poorly defined. Methods In this single-center retrospective study, 57 of 95 consecutive HeartMate 3 LVAD recipients (mean age 57 ± 11 years; 79% male) with adequate echocardiographic quality were analyzed. Patients were stratified by RHF phenotype according to the 2020 MCS-ARC definition: no RHF (n = 28), early acute RHF (eaRHF, n = 18), and early postoperative RHF (epRHF, n = 11). RVFWS and RVGLS were measured preoperatively and at 2 weeks, 6 months, 12 months, and 36 months post-implantation using speckle-tracking echocardiography. Linear mixed-effects modelling and ROC analysis evaluated temporal changes and predictive value. Results Preoperative RVFWS predicted eaRHF with 51.7% sensitivity and 82.1% specificity (AUC = 0.671, p = 0.022). In patients without RHF, RVFWS declined from − 9.8 ± 4.6% preoperatively to − 6.3 ± 4.8% postoperative (Δ=−3.5, p = 0.01) and − 6.5 ± 4.9% at 6 months (Δ=−3.0, p = 0.04), stabilizing thereafter. RVGLS improved significantly from − 5.6 ± 3.7% early postoperatively to − 8.3 ± 4.1% at 12 months (Δ=+3.1, p = 0.02). In eaRHF patients, RVGLS improved from − 5.7 ± 4.1% to − 11.3 ± 5.1% (Δ=+5.1, p < 0.01) by 12 months, suggesting RV recovery after temporary support. No significant longitudinal change was observed in the epRHF group. One-year survival was 84.5%, 81.8%, and 50.0% in the no RHF, epRHF, and eaRHF groups, respectively. The differences did not reach statistical significance. Conclusions RVFWS offers modest predictive accuracy for early acute RHF, while RVGLS more sensitively reflects dynamic right ventricular remodelling and recovery after LVAD implantation. Distinct strain trajectories highlight differential pathophysiologic mechanisms across RHF phenotypes. This study highlights the possibility of using RVGLS and RVFWS to assess functional changes in RV function after LVAD implantation over time. right heart failure LVAD mechanical circulatory support end-stage heart failure Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction The treatment of patients with end-stage heart failure using a left ventricular assist device (LVAD) is continuously advancing. Currently, except for heart transplantation, the HeartMate 3 centrifugal continuous-flow pump is the only treatment option for long-term mechanical circulatory support (MCS) in patients with a failing left ventricle (LV) ( 1 , 2 ). Despite the technological advancements in LVAD therapy, right heart failure (RHF) remains a significant complication post-implantation, adversely affecting patient outcomes and survival ( 3 ). RHF during and after LVAD implantation underlies a complex, incompletely understood pathophysiology, with numerous factors contributing to intra- and postoperative right ventricular (RV) dysfunction and failure. Several risk factors were identified and linked to early acute and postoperative RHF. These risk factors range from laboratory parameters, like creatinine, to advanced hemodynamic parameters ( 4 ). Several echocardiographic parameters have been evaluated to predict postoperative RV function, such as fractional area change (FAC), tissue doppler imaging-derived tricuspid lateral annular systolic velocity (TASV), RV index of myocardial performance (RIMP), as well as tricuspid annular plane systolic excursion (TAPSE) ( 5 , 6 ). However, these measures may not fully reflect the complex and dynamic changes in RV performance following LVAD implantation ( 7 ). Global longitudinal strain (GLS) is a promising marker in evaluating myocardial function in patients with heart failure ( 8 , 9 ). Recent studies have shown that right ventricular free wall strain (RVFWS) and right ventricular global longitudinal strain (RVGLS) are particularly promising for predicting RHF post-LVAD implantation; however, changes in right ventricular strain during long-term follow-up after LVAD implantation have not been reported ( 10 – 12 ). This study aims to assess whether preoperative RVFWS and RVGLS predict early acute and early postoperative RHF. Secondly, this study aimed to characterize longitudinal changes in RVFWS and RVGLS over 36 months following LVAD implantation across different RHF phenotypes. Materials and Methods Study Population We retrospectively analyzed clinical and echocardiographic data from 95 consecutive patients who underwent LVAD (HeartMate 3) implantation at the Heart and Diabetes Center North Rhine-Westphalia between January 2021 and March 2022. Patients with inadequate echocardiographic image quality were excluded. Clinical and laboratory data were obtained using the patient’s electronic medical records. The institutional ethics committee approved the study. Right heart failure definition According to the 2020 Mechanical Circulatory Support – Academic Research Consortium (MCS-ARC) definition, early acute RHF (eaRHF) was defined as patients requiring an RVAD implantation during the operation. Early postoperative RHF (epRHF) was defined as failure to wean from inotropic support within 14 days of the operation or within 30 days following the operation, and at least 2 clinical findings or manifestations listed in the MCS-ARC compendium ( 13 ). Echocardiographic Image Acquisition and Analysis All images were recorded using the Philips Epiq CVx diagnostic ultrasound system (Koninklijke Philips N.V., Amsterdam, The Netherlands) during routine examinations before and after LVAD implantation. The study included the following echocardiographic measurements: left ventricular end-diastolic diameter (LVEDD), left ventricular ejection fraction (LVEF), TAPSE, right ventricular end-diastolic diameter basal (RVEDD), the ratio of RVEDD to LVEDD, tricuspid valve insufficiency, as well as RVFWS and RVGLS. Echocardiographic examination was performed routinely during follow-up visits. Patients who underwent heart transplantation during follow-up were excluded from subsequent examinations. Echocardiographic examinations were planned to be assessed at five discrete time intervals: ( 1 ) pre-LVAD (within 1 week before the operation), ( 2 ) early, post-LVAD (within 2 weeks post-LVAD implantation), ( 3 ) 6 months post-LVAD implantation, ( 4 ) 12 months post-LVAD implantation, ( 5 ) 36 months post-LVAD implantation. Subsequently, patients were categorized into three groups for further strain analysis: no RHF, eaRHF, and epRHF. Strain analysis was performed offline using the Philips Ultrasound Workspace System (Koninklijke Philips N.V., Amsterdam, The Netherlands) (Fig. 1 ). Statistical Analysis Continuous variables were reported as means±standard deviation (SD) for normally distributed data or medians with interquartile ranges (IQRs) for non-normally distributed data. Normality was assessed using the Shapiro-Wilk test. Where appropriate, categorical variables and group-level differences were compared using the chi-squared test or Fisher’s exact test. Statistical significance was defined as a two-sided p-value < 0.05. To compare baseline differences between the three groups, one-way ANOVA or Kruskal-Wallis tests were used, depending on data distribution. Changes in strain values over time and across RHF groups were assessed using linear mixed-effects models (LMM) implemented in R (version 4.4.2, Foundation for Statistical Computing, Vienna, Austria) with the lme4 and emmeans packages. Estimated marginal means and Tukey-adjusted pairwise contrasts were used to evaluate within-group strain changes and between-group differences at each examination. The reported Δ values represent the estimated marginal mean differences in strain between examinations, as derived from the LMM, along with their adjusted p-values. Survival analysis was performed using the Kaplan-Meier method with the survival and survminer packages in R. The survival time was defined as the interval between LVAD implantation and death, with censoring at the time of heart transplantation or the last clinical follow-up. Group comparisons were evaluated using the log-rank test. A Cox proportional hazards model was used to estimate hazard ratios between RHF subgroups. Receiver Operating Characteristic (ROC) curve analysis assessed the predictive ability of preoperative echocardiographic parameters for RHF. Area under the curve (AUC), sensitivity, and specificity were calculated. Statistical analyses were conducted using MedCalc® software (version 23.1.5; MedCalc Software, Ostend, Belgium), while longitudinal modelling and survival analyses were performed in R. Results A total of 95 patients were screened. Of these, 57 patients, with a mean age of 57.3±11.2 years (45 male (79%)), had echocardiographic images of sufficient quality for offline strain analysis. There were 28 (49%) patients in the no RHF group, and 29 patients in the RHF group. Baseline clinical characteristics are summarized in Table 1. Preoperative MCS (Impella and or Extracorporeal Membrane Oxygenation) support was more frequent in the RHF group (13 vs. 2 patients, p=0.002), as was a lower baseline hemoglobin level (10.4 ± 1.5 g/dl vs. 11.8 ± 1.8 g/dl, p=0.002). Patients with RHF were more often classified as INTERMACS 1 profile, while patients without RHF were more often classified as INTERMACS 4. More RHF patients had undergone cardiac procedures before LVAD implantation; however, the differences were not statistically significant. Postoperatively, the RHF group had a significantly longer duration of catecholamine support (25.5 (20–39) days vs. 6 (4–9) days, p<0.001). The number of additional surgical procedures during LVAD implantation was similar between groups (10 vs. 16 patients, p = 0.367). Still, there was a trend toward more re-thoracotomies for bleeding in the RHF group (19 vs. 7 patients; p = 0.059). Eighteen patients in the RHF group (eaRHF group) received RVAD support directly after LVAD implantation. The mean duration of a support was 10.1±2.9 days. Postoperative parameters are shown in Table 2. Echocardiographic Analysis To analyse echocardiographic parameters, patients were divided into 3 groups: no RHF, eaRHF, and epRHF. Preoperative echocardiographic parameters did not differ significantly between groups. Strain values were reduced in all patients across all three groups before the operation compared with normal values (Table 3) (14). RVFWS values during follow-up are shown in Figure 2, as well as in Table 4. RVFWS values declined in all study groups after implantation, as assessed at examination 2. In patients without RHF, a postoperative decline of RVFWS was observed at examination 2 and 3 (-9.8±4.6% preoperatively to -6.3±4.8%, Δ= –3.5, p =0.01, and to –6.5 ± 4.9%, Δ = –3.0 p = 0.04 respectively). Thereafter, no significant difference was observed as compared to baseline. Figure 3 highlights the changes in delta values across the different groups. In the eaRHF group, no statistically significant change in RVFWS value was detected during observation. An improvement of RVFWS was observed at later time points, at examinations 3 and 4. These changes, however, were not statistically significant. The epRHF group exhibited no significant changes in RVFWS across follow-up examinations. The complete results of the RVFWS LMM analysis are shown in Supplementary Table 1. The RVGLS values across follow-ups are shown in Figure 4 and Table 5. Figure 5 shows a heatmap highlighting the changes in delta values between the different examinations. The LMM analysis showed a significant improvement of RVGLS in patients without RHF between Examination 2 and 4, with values increasing from –5.6 ± 3.7% to –8.3 ± 4.1% (Δ = +3.1, p = 0.02). In the eaRHF group, RVGLS improved statistically significant during observation between examinations 1 and 4 (–6.5 ± 5.6% to –11.3 ± 5.1%; Δ = +5.1, p < 0.01), 2 and 3 (-5.7±4.1 to -9±4, Δ =3.3, p=0.04) and 2 and 4 (-5.7±4.1 to -11.3±5.1, Δ =5.14, p<0.001). A significant decrease in RVGLS was found between Examinations 4 and 5 (-11.3±5.1% to -7.1±4.8%, Δ =-4.2, p=0.06). No statistically significant changes in RVGLS were detected in the epRHF group. The complete results are shown in Supplementary Table 2. Consistently, intergroup comparisons at each examination showed no statistically significant differences in RVFWS or RVGLS between the no RHF, eaRHF, and epRHF groups (Supplementary Tables 3 and 4). Receiver Operating Characteristic (ROC) Analysis Preoperative RVFWS predicted eaRHF with 51.7% sensitivity and 82.1% specificity (AUC = 0.671, p = 0.022), using a threshold of –5.3% (Figure 6). Other RV parameters, including RVGLS (AUC = 0.610, p = 0.610), TAPSE (AUC = 0.587, p = 0.587), and RVEDD (AUC = 0.586, p = 0.268), did not show predictive value for eaRHF. No analysed parameter could predict epRHF. Survival Analysis At one year post-implantation, survival in the eaRHF group was markedly lower (50.0%) compared to the no RHF (84.5%) and epRHF (81.8%) groups (Figure 7). A similar pattern was seen at 2 years (50.0% vs. 69.8% vs. 72.7%, respectively). A trend toward reduced mortality risk in the no RHF (HR 0.49, 95% CI 0.21–1.15, p = 0.10) and epRHF groups (HR 0.43, 95% CI 0.15–1.28, p = 0.13). However, these differences were not statistically significant. Discussion This study evaluates RVFWS and RVGLS in patients before and during 36 months after LVAD implantation. To the best of our knowledge, this is the first study to evaluate serial RV strain parameters after implantation of the HeartMate 3 over a long-term follow-up period. The RHF after LVAD implantation is a very serious clinical problem and concerns 5–40% of patients, depending on the reporting center ( 15 ). One reason for the variable RV failure rate is the different definitions of RHF used in clinical studies. The last updated 2020 MCS-ARC definition of RHF was used in our study; however, it is essential to note that many of the studies cited in this paper used the older 2012 MCS-ARC definition of RHF or centre-specific definitions. The timing of RVAD implantation (intraoperative or postoperative) also varied between the studies ( 11 , 12 , 16 ). Therefore, our findings align directly with current standards and more accurately reflect the prognostic utility of RV strain across distinct RHF phenotypes. Compared with previously published LVAD cohorts, our patients presented with more advanced heart failure. In this study, 45% of patients in the RHF group were on preoperative MCS (61% in the eaRHF group). Furthermore, a higher proportion of patients were in INTERMACS 1–2, with 48% in INTERMACS 1 in the RHF group. This contrasts with Liang et al. ( 10 ), in which fewer than 30% of patients required pre-implant MCS, and only 28% were classed as INTERMACS 1 in the RHF group. These baseline differences suggest a more advanced hemodynamic compromise in our population, which could have influenced the predictive performance of strain-based models. The preoperative RVFWS and RVGLS in our study group were lower than those reported by other authors. Furthermore, in contrast to previous studies on this topic, RVFWS and RVGLS were not significantly lower preoperatively in patients with RHF than in those without RHF in our study group. Previous studies evaluating the ability of RVFWS to predict postoperative RHF showed RV strain cut-offs ranging from − 9 to -15%( 7 , 17 ). In contrast, our mean baseline values were approximately − 8% and − 6%, respectively, even among patients who did not develop RHF. This indicates a global and advanced RV impairment inherent to the entire cohort, irrespective of postoperative outcome. Again, indicating that our patient population was sicker. Such uniformly depressed preoperative strain values likely reflect the inclusion of patients with severe biventricular dysfunction and pre-implant hemodynamic instability typical of lower INTERMACS profiles. Across all groups, a decline in RVFWS was observed early after implantation, although this did not reach statistical significance. In the no RHF group, a statistically significant decrease in RVFWS was observed postoperatively during examinations 2 and 3. It is known that cardiac surgery affects RV function, leading to a shift in the contraction pattern from longitudinal to transverse shortening, which may result in decreased postoperative free wall strain values ( 18 – 20 ). This result? to the RV could be due to several factors, like intraoperative ischemia and cardiopulmonary bypass use ( 21 ). Liang et al. showed that RVFWS is a good predictor of eaRHF, with a cut-off value of -9.7%, a sensitivity of 88.9%, and a specificity of 77.8% ( 10 ). In our study group, RVFWS could predict eaRHF (AUC 0.65), with a cut-off value of -5%. The downward shift likely reflects the depressed preoperative RV function in our sicker population, in which the RV's functional reserve was already limited. In such advanced patients, preoperative RV function is uniformly depressed, which may limit the discriminatory capacity of strain parameters to distinguish those who subsequently develop RHF. Furthermore, RVFWS was the only marker to predict eaRHF in the study group. The AUC in this study group was similar to that reported by Dufendach et al., who evaluated the predictive ability of RVFWS in 137 patients ( 22 ). However, the RV failure definition differed from that used in this study. The low cut-off value of -5% is likely attributed to many patients in the INTERMACS 1 or 2 groups, underscoring the severity of the patient’s clinical status and indicating advanced hemodynamic compromise. This finding may indicate that RV strain parameters are inherently less sensitive in distinguishing patients who are already severely compromised preoperatively, as RV dysfunction is prevalent in advanced heart failure patients irrespective of clinical RHF ( 23 ). Consistent with prior registry data, patients with eaRHF experienced reduced one- and two-year survival compared with both the no-RHF and epRHF groups ( 3 ). Although this difference did not reach statistical significance, the trend underscores the prognostic impact of severe early postoperative RV dysfunction. In contrast, epRHF did not confer excess mortality, supporting recent evidence that transient postoperative RHF frequently can resolve with medical management or temporary RVAD support and may not translate into poorer long-term outcomes ( 3 ). The eaRHF is hypothesized to result from abrupt hemodynamic changes, with the RV unable to cope with the new hemodynamic environment, necessitating the implantation of a temporary RVAD ( 24 ). 14 out of 18 patients in the eaRHF group were still on RVAD support during examination 2. The temporary RVAD directly affects RV function, decompressing the ventricle and mitigating the disruption in the normal RV contraction pattern that occurs after cardiac surgery ( 25 , 26 ). This hypothesis is supported by the trend towards improved RV strain observed in subsequent examinations, suggesting that early, aggressive RV support can facilitate recovery of RV function despite initially severe clinical presentations. Subsequent examination revealed no decrease in RVFWS, and patients tended to have higher postoperative RVFWS, indicating an effective reversal of intraoperative RHF. In different studies RVFWS measurements have yielded mixed results over longer-term follow-up. In some cohorts, RVFWS showed no significant improvement (and even a slight worsening) after LVAD implantation, despite an overall improvement in cardiac output ( 27 ). It must be pointed out that a decline in free wall performance can be compensated by the intraventricular septum when measuring RVGLS and, therefore, be masked. Importantly, absolute strain values did not differ significantly between RHF phenotypes at any single examination timepoint, suggesting that serial within-patient trends may be more informative than isolated measurements Conversely, in patients with epRHF, we did not see a decline in either RVFWS or RVGLS over the entire study period. Postoperative right heart failure exists on a continuum, with different hemodynamic factors, such as septal shift from ventricular unloading or inflammatory insults, like elevated cytokines, associated with decreased RV function ( 28 , 29 ). This patient cohort also did not show a reduction in survival compared to no RHF patients. In an extensive recent analysis of more than 5,500 LVAD patients, 24% had RHF by one month post-implant, but in many cases, it was transient. Furthermore, the survival was comparable ( 3 ). It could be hypothesized that RVFWS failed to capture the temporary decrease in RV function observed in this patient cohort, as seen in other studies. ( 10 ) Several limitations must be acknowledged. This single-centre, retrospective design introduces inherent biases, particularly concerning patient selection and potential exclusion of patients due to poor image quality, which is critical for accurate strain analysis. Strain measurements, particularly RV strain, are sensitive to echocardiographic image quality, potentially limiting the generalizability of the findings. Furthermore, the small sample size undoubtedly affected the ability to demonstrate statistically significant differences. Conclusion In this retrospective single-center cohort, preoperative RVFWS demonstrated modest ability to discriminate patients who developed eaRHF requiring intraoperative RVAD support, while no echocardiographic parameter predicted epRHF. Longitudinal modelling showed an early postoperative decline in RVFWS and a delayed improvement in RVGLS, particularly in patients without RHF and in those with eaRHF. These findings suggest that serial RV strain assessment may capture dynamic changes in RV longitudinal mechanics after LVAD implantation, although larger prospective studies with standardized follow-up and clinical correlates are required to define prognostic thresholds and clinical utility. Declarations Ethics consent and approval to participate The study was approved by the ethics committee of the Ruhr-University-Bochum on 02.06.2025 (2025 – 1394). Due to the retrospective nature of the study the need for collecting written consent was waived. Consent for publication Not applicable Availability of data and materials All data used to create this manuscript will be made available upon request. Competing interest The authors declare that they have no competing interests. Funding We acknowledge support by the Open Access Publication Funds of the Ruhr-University Bochum. Author Contribution C.T.B. and L.P. conceived and designed the study,as well as creating the figures and tables. C.T.B. collected and analyzed the data and wrote the original draft. L.P. supervised the study and contributed to writing. R.S., M.M., S.P.W.G., N.H., H.K., H.F., S.V.R., and J.F.G. contributed to data acquisition, interpretation, and critical revision of the manuscript. All authors reviewed and approved the final version. References Mehra MR, Goldstein DJ, Cleveland JC, Cowger JA, Hall S, Salerno CT, et al. Five-Year Outcomes in Patients With Fully Magnetically Levitated vs Axial-Flow Left Ventricular Assist Devices. JAMA. 2022/09/27;328(12). doi: 10.1001/jama.2022.16197 Mehra MR, Uriel N, Naka Y, Joseph C. Cleveland J, Yuzefpolskaya M, Salerno CT, et al. A Fully Magnetically Levitated Left Ventricular Assist Device — Final Report. 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CHEST. 2011/07/01;140(1). doi: 10.1378/chest.10-1136 Joshi SB, Salah AK, Mendoza DD, Goldstein SA, Fuisz AR, Lindsay J. Mechanism of Paradoxical Ventricular Septal Motion After Coronary Artery Bypass Grafting. The American Journal of Cardiology. 2009/01/15;103(2). doi: 10.1016/j.amjcard.2008.08.067 Dufendach KA, Zhu T, Castrillon CD, Hong Y, Countouris ME, Hickey G, et al. Pre‐implant right ventricular free wall strain predicts post‐LVAD right heart failure. Journal of Cardiac Surgery. 2021/06/01;36(6). doi: 10.1111/jocs.15479 Aymami M, Amsallem M, Adams J, Sallam K, Moneghetti K, Wheeler M, et al. The Incremental Value of Right Ventricular Size and Strain in the Risk Assessment of Right Heart Failure Post - Left Ventricular Assist Device Implantation. Journal of Cardiac Failure. 2018/12/01;24(12). doi: 10.1016/j.cardfail.2018.10.012 Bravo CA, Navarro AG, Dhaliwal KK, Khorsandi M, Keenan JE, Mudigonda P, et al. Frontiers | Right heart failure after left ventricular assist device: From mechanisms to treatments. Frontiers in Cardiovascular Medicine. 2022/10/19;9. doi: 10.3389/fcvm.2022.1023549 Sciaccaluga C, Procopio MC, Potena L, Masetti M, Bernazzali S, Maccherini M, et al. Right ventricular dysfunction in left ventricular assist device candidates: is it time to change our prospective? Heart Failure Reviews 2024 29:2. 2024-02-08;29(2). doi: 10.1007/s10741-024-10387-w Fyfe DA, Mahle WT, Kanter KR, Wu G, Vincent RN, Ketchum DL. Reduction of tricuspid annular doppler tissue velocities in pediatric heart transplant patients. The Journal of Heart and Lung Transplantation. 2003/05/01;22(5). doi: 10.1016/S1053-2498(02)00653-8 Stąpór M, Piłat A, Misiuda A, Górkiewicz-Kot I, Kaleta M, Kleczyński P, et al. Preoperative and mid-term right ventricular systolic function assessment, at rest and during exercise, with speckle-tracking echocardiography after left ventricular assist device implantation. Hellenic Journal of Cardiology. 2024/03/01;76. doi: 10.1016/j.hjc.2023.05.011 J. Eduardo Rame M, Francis D. Pagani M, PhD, Michael S. Kiernan M, MS, Guilherme H. Oliveira M, Edo Y. Birati M, Pavan Atluri M, et al. Evolution of Late Right Heart Failure With Left Ventricular Assist Devices and Association With Outcomes. Journal of the American College of Cardiology. 2021-12-7;78(23). doi: 10.1016/j.jacc.2021.09.1362 Houston BA, Kalathiya RJ, Hsu S, Loungani R, Davis ME, Coffin ST, et al. Right ventricular afterload sensitivity dramatically increases after left ventricular assist device implantation: a multi-center hemodynamic analysis. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation. 2016 Feb 9;35(7). doi: 10.1016/j.healun.2016.01.1225 Tables Table 1 Baseline clinical characteristics by right heart failure (RHF) status. Parameter No RHF RHF* p-Value N=28 (49%) 1 N=29 (51%) 1 1.000 Age at implantation (years) 2 56.8±13.2 57.8±9.1 0.740 Male patients 1 24 (86) 21 (72) 0.674 Height (cm) 2 177±8 180±8 0.162 Weight (kg) 2 84.4±16.7 79.3±17.3 0.263 BSA (m 2 ) 2 2.01±0.19 1.98±0.22 0.584 Etiology of HF DCM 1 19 (68) 21 (72) 0.777 ICM 1 9 (32) 8 (28) 0.777 Previous cardiac surgery 1 4 (14) 11 (40) 0.112 INTERMACS - score 1 1 5 (18) 14 (48) 0.084 2 1 7 (25) 9 (31) 0.706 3 1 6 (21) 4 (14) 0.529 4 1 10 (36) 2 (7) 0.032 Destination therapy 1 8 (29) 9 (31) 0.882 Pre-operative MCS 1 2 (7) 13 (45) 0.002 Creatinine (mg/dl) 2 1.7±0.9 1.7±0.8 1.000 Bilirubin (mg/dl) 2 1.3±0.8 2±1.7 0.053 GPT (U/l) 3 26 (12 – 87) 36 (21 – 82) 0.314 GOT (U/l) 3 30 (26 – 79) 47 (29 – 122) 0.216 Hb (g/dl) 2 11.8±1.8 10.4±1.5 0.002 1 number and percentage. 2 mean and standard deviations, 3 median and 25 th and 75 th percentile. Abbreviations: BSA – body surface area, RHF – right heart failure, LVAD – left ventricular assist device, HF – heart failure, DCM – dilated cardiomyopathy, ICM – ischemic cardiomyopathy, INTERMACS – Interagency Registry For Mechanically Assisted Circulatory Support, MCS – mechanical circulatory support, GFR – glomerular filtration rate, GPT- glutamine pyruvate transaminase, GOT – glutamic oxaloacetic transaminase, Hb- haemoglobin, RVAD – right ventricular assist device *RHF: refers to the patients with both acute right heart failure and early post-implant right heart failure Table 2 Postoperative parameters by right heart failure status. Parameter No RHF RHF* p-Value N=28 (49%) 1 N=29 (51%) 1 1.000 Catecholamine support (days) 2 6 (4-9) 25.5(20-39) <0.001 RVAD support (days) 3 0 10.1±2.9 0.001 Additional surgical procedures 1 10 (36%) 16 (55%) 0.367 TVR 1 4(14) 7 (24) 0.504 MVR 1 1(4) 1 (3) 1.000 AVR 1 1 (4) 4 (14) 0.352 ASD closure 1 4(14) 4 (14) 1.000 Re-Thoracotomy 1 7 19 0.059 1 number and percentage. 2 median and 25 th and 75 th percentile. 3 mean and standard deviations. Table 3 Echocardiographic parameters obtained pre-operatively in the study group. No RHF (N=28) Early, acute RHF (N=18) Early, post-implant RHF (N=11) p – value TAPSE (mm) 17±4.4 14.3±3.8 16.7±3.5 p=0.111 LVEF (%) 22.2±7.6 19.9±11.8 20.6±5.1 p=0.277 RVEDD (mm) 46±9 41±11 47±10 p=0.114 LVEDD (mm) 67±10 63±19 70±14 p=0.479 RVEDD/LVEDD 0.7±0.1 0.7±0.1 0.7±0.1 p=0.821 Moderate and Severe TI 16 11 5 p=0.704 RVFWS (%) -9.8±4.7 -8.2±7.6 -7±4.3 p=0.347 RVGLS (%) -7.2±3.6 -6.5±5.6 -5.7±4 p=0.141 TAPSE – tricuspid annular plane systolic excursion, LVEF – left ventricular ejection fraction, RVEDD – right ventricular end diastolic diameter, LVEDD – left ventricular end diastolic diameter, RVEDD/LVEDD – ratio of right ventricular to left ventricular end-diastolic diameter, RVFWS - right ventricular free wall strain, RVGLS – right ventricular global longitudinal strain, TI – tricuspid valve insufficiency Table 4 Right ventricular free-wall strain (RVFWS) during each subsequent examination in patients without right heart failure (no RHF), early, acute RHF (eaRHF), and early, postoperative RHF (epRHF). Examination No RHF (n) RVFWS eaRHF (n) RVFWS epRHF(n) RVFWS 1 28 -9.8±4.6 18 -8.2±7.6 11 -7.0±4.4 2 28 -6.3±4.8 18 -6.3±4.9 11 -6.1±2.3 3 22 -6.5±4.9 13 -9.5±4.9 11 -8.3±3.2 4 17 -8.2±3.9 9 -10.6±3.7 5 -7.7±1.5 5 12 -7.7±3.0 7 -8.5±4.0 3 -9.7±6.1 Table 5 Right ventricular global longitudinal strain (RVGLS) during each subsequent examination in patients without right heart failure (no RHF), early, acute RHF (eaRHF), and early, postoperative RHF (epRHF). Examination No RHF (n) RVGLS eaRHF (n) RVGLS epRHF(n) RVGLS 1 28 -7.2±3.6 18 -6.5±5.6 11 -5.7±4.0 2 28 -5.6±3.7 18 -5.7±4.1 11 -5.8±2.6 3 22 -6.1±4.2 13 -9.0±4.0 11 -7.3±3.1 4 17 -8.3±4.1 9 -11.3±5.1 5 -7.2±2.0 5 12 -7.2±3.9 7 -7.1±4.8 3 -9.7±4.1 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9129803","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":621040160,"identity":"877fddd0-4b85-4751-98b3-5db641798026","order_by":0,"name":"Carl-Thaddäus Braun","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuklEQVRIiWNgGAWjYDACCTBpk8BwAMJnbCBSSxrpWg6ToIV/du/Dz7w7zufxnT/A9riyjUG2n6Ald44bS/OeuV0seeAAu+HZNgbjmYSsMZBIY5DmbbuduOFg/zfJxm0MiRsOENbC/Ju37VzihsMMbGAt+4nQwga05UDihmNQLRsI++UYm+XctuTEmWdAWv5JGM8gZAv/7DbmG2/b7BL7gCEm2XDGRra/gZA16LaSqH4UjIJRMApGAVYAAAnpQUCb01HCAAAAAElFTkSuQmCC","orcid":"","institution":"Ruhr University Bochum, Heart and Diabetes Center NRW","correspondingAuthor":true,"prefix":"","firstName":"Carl-Thaddäus","middleName":"","lastName":"Braun","suffix":""},{"id":621040161,"identity":"7fc42875-104e-405c-9bc2-b1e455b49322","order_by":1,"name":"Rene Schramm","email":"","orcid":"","institution":"Ruhr University Bochum, Heart and Diabetes Center NRW","correspondingAuthor":false,"prefix":"","firstName":"Rene","middleName":"","lastName":"Schramm","suffix":""},{"id":621040162,"identity":"91bf591c-1912-49fb-83d5-e839d11acea5","order_by":2,"name":"Michiel Morshuis","email":"","orcid":"","institution":"Ruhr University Bochum, Heart and Diabetes Center NRW","correspondingAuthor":false,"prefix":"","firstName":"Michiel","middleName":"","lastName":"Morshuis","suffix":""},{"id":621040163,"identity":"df337e0c-4183-450c-a19f-e0578bdd633d","order_by":3,"name":"Sabina PW Guenther","email":"","orcid":"","institution":"Ruhr University Bochum, Heart and Diabetes Center NRW","correspondingAuthor":false,"prefix":"","firstName":"Sabina","middleName":"PW","lastName":"Guenther","suffix":""},{"id":621040166,"identity":"33baf9c3-aa6c-4b6a-acdb-53ee16cff2df","order_by":4,"name":"Nikolai Hulde","email":"","orcid":"","institution":"Ruhr University Bochum","correspondingAuthor":false,"prefix":"","firstName":"Nikolai","middleName":"","lastName":"Hulde","suffix":""},{"id":621040167,"identity":"985569d1-6f64-485c-a857-bfd7a32184b4","order_by":5,"name":"Hermann Körperich","email":"","orcid":"","institution":"Ruhr University Bochum, Heart and Diabetes Center NRW","correspondingAuthor":false,"prefix":"","firstName":"Hermann","middleName":"","lastName":"Körperich","suffix":""},{"id":621040170,"identity":"3d2d0f19-af92-4a99-b3b0-166776625fa5","order_by":6,"name":"Henrik Fox","email":"","orcid":"","institution":"Ruhr University Bochum, Heart and Diabetes Center NRW","correspondingAuthor":false,"prefix":"","firstName":"Henrik","middleName":"","lastName":"Fox","suffix":""},{"id":621040171,"identity":"61a03cc4-033d-48b3-ac28-7e47a3bfeb23","order_by":7,"name":"Sebastian V. Rojas","email":"","orcid":"","institution":"Ruhr University Bochum, Heart and Diabetes Center NRW","correspondingAuthor":false,"prefix":"","firstName":"Sebastian","middleName":"V.","lastName":"Rojas","suffix":""},{"id":621040176,"identity":"311dc525-6b36-454f-90d6-06304d94d0a4","order_by":8,"name":"Jan Fritz Gummert","email":"","orcid":"","institution":"Ruhr University Bochum, Heart and Diabetes Center NRW","correspondingAuthor":false,"prefix":"","firstName":"Jan","middleName":"Fritz","lastName":"Gummert","suffix":""},{"id":621040179,"identity":"7177407c-2f0a-40f3-ba53-8c149e68f6de","order_by":9,"name":"Lech Paluszkiewcz","email":"","orcid":"","institution":"Ruhr University Bochum, Heart and Diabetes Center NRW","correspondingAuthor":false,"prefix":"","firstName":"Lech","middleName":"","lastName":"Paluszkiewcz","suffix":""}],"badges":[],"createdAt":"2026-03-15 15:39:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9129803/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9129803/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106946611,"identity":"14b5cc7e-a6b1-4ac9-bdbd-c509519202db","added_by":"auto","created_at":"2026-04-15 06:45:23","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":46753,"visible":true,"origin":"","legend":"\u003cp\u003eRight Ventricular Longitudinal Strain Analysis in a 64-year-old male patient before LVAD implantation. (A) A 4-chamber view was used to analyse RV strain (B). RV strain curves indicate reduced global RV function, with a peak strain of -7%. The blue, green and purple curves show the regional strain in different areas of the RV.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9129803/v1/a8b350f3e098a8046f234294.jpg"},{"id":106961794,"identity":"2b690d69-3f57-41da-809e-2e7bb918d05c","added_by":"auto","created_at":"2026-04-15 09:27:04","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":36776,"visible":true,"origin":"","legend":"\u003cp\u003eRight-Ventricular Free Wall Strain (RVFWS) at consecutive examination stratified by right heart failure (RHF) status, with error bars presenting standard deviation. No significant difference in RVFWS was noted between the groups.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9129803/v1/ffe7ce911673cbd90f9b94e4.jpg"},{"id":106961482,"identity":"cbc59b45-b202-40f4-8750-ccd814571dc8","added_by":"auto","created_at":"2026-04-15 09:25:43","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":29348,"visible":true,"origin":"","legend":"\u003cp\u003eThe Heatmap shows statistically significant decreases in right ventricular free wall strain (RVFWS) in patients without right heart failure when examination 2 and examination 3 were compared with examination 1. Only boxes with statistically significant differences are labelled.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9129803/v1/04679806da25adc68d430b8c.jpg"},{"id":106946615,"identity":"01cbe809-5c4e-4e34-adce-31c3d1a6a5d5","added_by":"auto","created_at":"2026-04-15 06:45:23","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":35251,"visible":true,"origin":"","legend":"\u003cp\u003eRight-Ventricular Global Strain (RVGLS) at consecutive examination stratified by right heart failure (RHF) status, with error bars presenting standard deviation. No significant difference in RVGLS was noted between the groups.\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9129803/v1/8d75a0c220c3c97b827aeed9.jpg"},{"id":106946616,"identity":"82b0065e-d935-422f-81d6-f040d12ee6dc","added_by":"auto","created_at":"2026-04-15 06:45:23","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":33892,"visible":true,"origin":"","legend":"\u003cp\u003eThe Heatmap shows statistically significant decreases in right ventricular global longitudinal strain (RVGLS) patients without right heart failure (RHF) and early, acute RHF when results of different examinations were compared. Only boxes with statistically significant differences are labelled.\u003c/p\u003e","description":"","filename":"Figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9129803/v1/c3019cfbd12cc7150b5515d0.jpg"},{"id":106946618,"identity":"18fcd576-5f31-4339-8bb5-ba8658aac105","added_by":"auto","created_at":"2026-04-15 06:45:23","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":19338,"visible":true,"origin":"","legend":"\u003cp\u003eReceiver operating curve analysis of preoperative right ventricular free wall strain (RVFWS) in predicting postoperative early, acute right heart failure in the study group.\u003c/p\u003e","description":"","filename":"Figure6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9129803/v1/40bb18228b98c0719b6d1004.jpg"},{"id":106962271,"identity":"9ae19d74-3f3b-4fa3-a7c8-d62268406567","added_by":"auto","created_at":"2026-04-15 09:35:50","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":52136,"visible":true,"origin":"","legend":"\u003cp\u003eSurvival curve analysis of each subgroup after LVAD implantation. The numbers at risk are shown below the curves.\u003c/p\u003e","description":"","filename":"Figure7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9129803/v1/08c24cb2dddf0415437a89b2.jpg"},{"id":108511291,"identity":"cc3ce9b0-a26b-484b-87dd-ead17ea1e770","added_by":"auto","created_at":"2026-05-05 12:42:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":635155,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9129803/v1/25a7907c-e00f-454b-8df3-6e1b3ae4c6c1.pdf"},{"id":106961900,"identity":"be57255c-0203-48c6-857e-bceffe98fb4e","added_by":"auto","created_at":"2026-04-15 09:27:39","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":38540,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTables23.02.26CB.docx","url":"https://assets-eu.researchsquare.com/files/rs-9129803/v1/a26ebb477ad2b3e61cb0dbe8.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessment of the Predictive Value of Right Ventricular Longitudinal Strain and Functional Trends in Right Ventricular Function of Patients after LVAD Implantation","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe treatment of patients with end-stage heart failure using a left ventricular assist device (LVAD) is continuously advancing. Currently, except for heart transplantation, the HeartMate 3 centrifugal continuous-flow pump is the only treatment option for long-term mechanical circulatory support (MCS) in patients with a failing left ventricle (LV) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Despite the technological advancements in LVAD therapy, right heart failure (RHF) remains a significant complication post-implantation, adversely affecting patient outcomes and survival (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRHF during and after LVAD implantation underlies a complex, incompletely understood pathophysiology, with numerous factors contributing to intra- and postoperative right ventricular (RV) dysfunction and failure. Several risk factors were identified and linked to early acute and postoperative RHF. These risk factors range from laboratory parameters, like creatinine, to advanced hemodynamic parameters (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSeveral echocardiographic parameters have been evaluated to predict postoperative RV function, such as fractional area change (FAC), tissue doppler imaging-derived tricuspid lateral annular systolic velocity (TASV), RV index of myocardial performance (RIMP), as well as tricuspid annular plane systolic excursion (TAPSE) (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). However, these measures may not fully reflect the complex and dynamic changes in RV performance following LVAD implantation (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGlobal longitudinal strain (GLS) is a promising marker in evaluating myocardial function in patients with heart failure (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Recent studies have shown that right ventricular free wall strain (RVFWS) and right ventricular global longitudinal strain (RVGLS) are particularly promising for predicting RHF post-LVAD implantation; however, changes in right ventricular strain during long-term follow-up after LVAD implantation have not been reported (\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study aims to assess whether preoperative RVFWS and RVGLS predict early acute and early postoperative RHF. Secondly, this study aimed to characterize longitudinal changes in RVFWS and RVGLS over 36 months following LVAD implantation across different RHF phenotypes.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Population\u003c/h2\u003e \u003cp\u003eWe retrospectively analyzed clinical and echocardiographic data from 95 consecutive patients who underwent LVAD (HeartMate 3) implantation at the Heart and Diabetes Center North Rhine-Westphalia between January 2021 and March 2022. Patients with inadequate echocardiographic image quality were excluded. Clinical and laboratory data were obtained using the patient\u0026rsquo;s electronic medical records. The institutional ethics committee approved the study.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRight heart failure definition\u003c/h3\u003e\n\u003cp\u003eAccording to the 2020 Mechanical Circulatory Support \u0026ndash; Academic Research Consortium (MCS-ARC) definition, early acute RHF (eaRHF) was defined as patients requiring an RVAD implantation during the operation. Early postoperative RHF (epRHF) was defined as failure to wean from inotropic support within 14 days of the operation or within 30 days following the operation, and at least 2 clinical findings or manifestations listed in the MCS-ARC compendium (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eEchocardiographic Image Acquisition and Analysis\u003c/h3\u003e\n\u003cp\u003eAll images were recorded using the Philips Epiq CVx diagnostic ultrasound system (Koninklijke Philips N.V., Amsterdam, The Netherlands) during routine examinations before and after LVAD implantation. The study included the following echocardiographic measurements: left ventricular end-diastolic diameter (LVEDD), left ventricular ejection fraction (LVEF), TAPSE, right ventricular end-diastolic diameter basal (RVEDD), the ratio of RVEDD to LVEDD, tricuspid valve insufficiency, as well as RVFWS and RVGLS. Echocardiographic examination was performed routinely during follow-up visits. Patients who underwent heart transplantation during follow-up were excluded from subsequent examinations. Echocardiographic examinations were planned to be assessed at five discrete time intervals: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) pre-LVAD (within 1 week before the operation), (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) early, post-LVAD (within 2 weeks post-LVAD implantation), (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) 6 months post-LVAD implantation, (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) 12 months post-LVAD implantation, (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) 36 months post-LVAD implantation. Subsequently, patients were categorized into three groups for further strain analysis: no RHF, eaRHF, and epRHF. Strain analysis was performed offline using the Philips Ultrasound Workspace System (Koninklijke Philips N.V., Amsterdam, The Netherlands) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eContinuous variables were reported as means\u0026plusmn;standard deviation (SD) for normally distributed data or medians with interquartile ranges (IQRs) for non-normally distributed data. Normality was assessed using the Shapiro-Wilk test. Where appropriate, categorical variables and group-level differences were compared using the chi-squared test or Fisher\u0026rsquo;s exact test. Statistical significance was defined as a two-sided p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eTo compare baseline differences between the three groups, one-way ANOVA or Kruskal-Wallis tests were used, depending on data distribution. Changes in strain values over time and across RHF groups were assessed using linear mixed-effects models (LMM) implemented in R (version 4.4.2, Foundation for Statistical Computing, Vienna, Austria) with the lme4 and emmeans packages. Estimated marginal means and Tukey-adjusted pairwise contrasts were used to evaluate within-group strain changes and between-group differences at each examination. The reported Δ values represent the estimated marginal mean differences in strain between examinations, as derived from the LMM, along with their adjusted p-values.\u003c/p\u003e \u003cp\u003eSurvival analysis was performed using the Kaplan-Meier method with the survival and survminer packages in R. The survival time was defined as the interval between LVAD implantation and death, with censoring at the time of heart transplantation or the last clinical follow-up. Group comparisons were evaluated using the log-rank test. A Cox proportional hazards model was used to estimate hazard ratios between RHF subgroups.\u003c/p\u003e \u003cp\u003eReceiver Operating Characteristic (ROC) curve analysis assessed the predictive ability of preoperative echocardiographic parameters for RHF. Area under the curve (AUC), sensitivity, and specificity were calculated.\u003c/p\u003e \u003cp\u003eStatistical analyses were conducted using MedCalc\u0026reg; software (version 23.1.5; MedCalc Software, Ostend, Belgium), while longitudinal modelling and survival analyses were performed in R.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 95 patients were screened. Of these, 57 patients, with a mean age of 57.3\u0026plusmn;11.2 years (45 male (79%)), had echocardiographic images of sufficient quality for offline strain analysis. There were 28 (49%) patients in the no RHF group, and 29 patients in the RHF group. Baseline clinical characteristics are summarized in Table 1. Preoperative MCS (Impella and or Extracorporeal Membrane Oxygenation) support was more frequent in the RHF group (13 vs. 2 patients, p=0.002), as was a lower baseline hemoglobin level (10.4 \u0026plusmn; 1.5 g/dl vs. 11.8 \u0026plusmn; 1.8 g/dl, p=0.002). Patients with RHF were more often classified as INTERMACS 1 profile, while patients without RHF were more often classified as INTERMACS 4. More RHF patients had undergone cardiac procedures before LVAD implantation; however, the differences were not statistically significant.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePostoperatively, the RHF group had a significantly longer duration of catecholamine support (25.5 (20\u0026ndash;39) days vs. 6 (4\u0026ndash;9) days, p\u0026lt;0.001). The number of additional surgical procedures during LVAD implantation was similar between groups (10 vs. 16 patients, p = 0.367). Still, there was a trend toward more re-thoracotomies for bleeding in the RHF group (19 vs. 7 patients; p = 0.059). Eighteen patients in the RHF group (eaRHF group) received RVAD support directly after LVAD implantation. The mean duration of a support was 10.1\u0026plusmn;2.9 days. Postoperative parameters are shown in Table 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEchocardiographic Analysis\u003c/p\u003e\n\u003cp\u003eTo analyse echocardiographic parameters, patients were divided into 3 groups: no RHF, eaRHF, and epRHF. Preoperative echocardiographic parameters did not differ significantly between groups. Strain values were reduced in all patients across all three groups before the operation compared with normal values (Table 3) (14).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRVFWS values during follow-up are shown in Figure 2, as well as in Table 4.\u0026nbsp;RVFWS values declined in all study groups after implantation, as assessed at examination 2. In patients without RHF, a postoperative decline of RVFWS was observed at examination 2 and 3 (-9.8\u0026plusmn;4.6% preoperatively to -6.3\u0026plusmn;4.8%, \u0026Delta;= \u0026ndash;3.5, \u003cem\u003ep\u003c/em\u003e=0.01, and to \u0026ndash;6.5 \u0026plusmn; 4.9%,\u0026nbsp;\u0026Delta;\u0026nbsp;= \u0026ndash;3.0 \u003cem\u003ep\u003c/em\u003e= 0.04 respectively). Thereafter, no significant difference was observed as compared to baseline. \u0026nbsp;Figure 3 highlights the changes in delta values across the different groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the eaRHF group, no statistically significant change in RVFWS value was detected during observation. An improvement of RVFWS was observed at later time points, at examinations 3 and 4. These changes, however, were not statistically significant. The epRHF group exhibited no significant changes in RVFWS across follow-up examinations. The complete results of the RVFWS LMM analysis are shown in Supplementary Table 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe RVGLS values across follow-ups are shown in Figure 4 and Table 5. Figure 5 shows a heatmap highlighting the changes in delta values between the different examinations. The LMM analysis showed a significant improvement of RVGLS in patients without RHF between Examination 2 and 4, with values increasing from \u0026ndash;5.6 \u0026plusmn; 3.7% to \u0026ndash;8.3 \u0026plusmn; 4.1% (\u0026Delta; = +3.1,\u0026nbsp;\u003cem\u003ep\u003c/em\u003e = 0.02).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the eaRHF group, RVGLS improved statistically significant during observation between examinations 1 and 4 (\u0026ndash;6.5 \u0026plusmn; 5.6% to \u0026ndash;11.3 \u0026plusmn; 5.1%; \u0026Delta; = +5.1,\u0026nbsp;\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.01), 2 and 3 (-5.7\u0026plusmn;4.1 to -9\u0026plusmn;4,\u0026nbsp;\u0026Delta; =3.3, p=0.04) and 2 and 4 (-5.7\u0026plusmn;4.1 to -11.3\u0026plusmn;5.1,\u0026nbsp;\u0026Delta; =5.14, p\u0026lt;0.001). A significant decrease in RVGLS was found between Examinations 4 and 5 (-11.3\u0026plusmn;5.1% to -7.1\u0026plusmn;4.8%,\u0026nbsp;\u0026Delta; =-4.2, p=0.06).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNo statistically significant changes in RVGLS were detected in the epRHF group. The complete results are shown in Supplementary Table 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsistently, intergroup comparisons at each examination showed no statistically significant differences in RVFWS or RVGLS between the no RHF, eaRHF, and epRHF groups (Supplementary Tables 3 and 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eReceiver Operating Characteristic (ROC) Analysis\u003c/p\u003e\n\u003cp\u003ePreoperative RVFWS predicted eaRHF with 51.7% sensitivity and 82.1% specificity (AUC = 0.671, p = 0.022), using a threshold of \u0026ndash;5.3% (Figure 6). Other RV parameters, including RVGLS (AUC = 0.610, p = 0.610), TAPSE (AUC = 0.587, p = 0.587), and RVEDD (AUC = 0.586, p = 0.268), did not show predictive value for eaRHF. No analysed parameter could predict epRHF.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSurvival Analysis\u003c/p\u003e\n\u003cp\u003eAt one year post-implantation, survival in the eaRHF group was markedly lower (50.0%) compared to the no RHF (84.5%) and epRHF (81.8%) groups (Figure 7). A similar pattern was seen at 2 years (50.0% vs. 69.8% vs. 72.7%, respectively). A trend toward reduced mortality risk in the no RHF (HR 0.49, 95% CI 0.21\u0026ndash;1.15, p = 0.10) and epRHF groups (HR 0.43, 95% CI 0.15\u0026ndash;1.28, p = 0.13). However, these differences were not statistically significant. \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study evaluates RVFWS and RVGLS in patients before and during 36 months after LVAD implantation. To the best of our knowledge, this is the first study to evaluate serial RV strain parameters after implantation of the HeartMate 3 over a long-term follow-up period.\u003c/p\u003e \u003cp\u003eThe RHF after LVAD implantation is a very serious clinical problem and concerns 5\u0026ndash;40% of patients, depending on the reporting center (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). One reason for the variable RV failure rate is the different definitions of RHF used in clinical studies. The last updated 2020 MCS-ARC definition of RHF was used in our study; however, it is essential to note that many of the studies cited in this paper used the older 2012 MCS-ARC definition of RHF or centre-specific definitions. The timing of RVAD implantation (intraoperative or postoperative) also varied between the studies (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Therefore, our findings align directly with current standards and more accurately reflect the prognostic utility of RV strain across distinct RHF phenotypes.\u003c/p\u003e \u003cp\u003eCompared with previously published LVAD cohorts, our patients presented with more advanced heart failure. In this study, 45% of patients in the RHF group were on preoperative MCS (61% in the eaRHF group). Furthermore, a higher proportion of patients were in INTERMACS 1\u0026ndash;2, with 48% in INTERMACS 1 in the RHF group. This contrasts with Liang et al. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), in which fewer than 30% of patients required pre-implant MCS, and only 28% were classed as INTERMACS 1 in the RHF group. These baseline differences suggest a more advanced hemodynamic compromise in our population, which could have influenced the predictive performance of strain-based models.\u003c/p\u003e \u003cp\u003eThe preoperative RVFWS and RVGLS in our study group were lower than those reported by other authors. Furthermore, in contrast to previous studies on this topic, RVFWS and RVGLS were not significantly lower preoperatively in patients with RHF than in those without RHF in our study group. Previous studies evaluating the ability of RVFWS to predict postoperative RHF showed RV strain cut-offs ranging from \u0026minus;\u0026thinsp;9 to -15%(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In contrast, our mean baseline values were approximately\u0026thinsp;\u0026minus;\u0026thinsp;8% and \u0026minus;\u0026thinsp;6%, respectively, even among patients who did not develop RHF. This indicates a global and advanced RV impairment inherent to the entire cohort, irrespective of postoperative outcome. Again, indicating that our patient population was sicker. Such uniformly depressed preoperative strain values likely reflect the inclusion of patients with severe biventricular dysfunction and pre-implant hemodynamic instability typical of lower INTERMACS profiles.\u003c/p\u003e \u003cp\u003eAcross all groups, a decline in RVFWS was observed early after implantation, although this did not reach statistical significance. In the no RHF group, a statistically significant decrease in RVFWS was observed postoperatively during examinations 2 and 3. It is known that cardiac surgery affects RV function, leading to a shift in the contraction pattern from longitudinal to transverse shortening, which may result in decreased postoperative free wall strain values (\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). This result? to the RV could be due to several factors, like intraoperative ischemia and cardiopulmonary bypass use (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eLiang et al. showed that RVFWS is a good predictor of eaRHF, with a cut-off value of -9.7%, a sensitivity of 88.9%, and a specificity of 77.8% (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In our study group, RVFWS could predict eaRHF (AUC 0.65), with a cut-off value of -5%. The downward shift likely reflects the depressed preoperative RV function in our sicker population, in which the RV's functional reserve was already limited. In such advanced patients, preoperative RV function is uniformly depressed, which may limit the discriminatory capacity of strain parameters to distinguish those who subsequently develop RHF. Furthermore, RVFWS was the only marker to predict eaRHF in the study group. The AUC in this study group was similar to that reported by Dufendach et al., who evaluated the predictive ability of RVFWS in 137 patients (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). However, the RV failure definition differed from that used in this study. The low cut-off value of -5% is likely attributed to many patients in the INTERMACS 1 or 2 groups, underscoring the severity of the patient\u0026rsquo;s clinical status and indicating advanced hemodynamic compromise. This finding may indicate that RV strain parameters are inherently less sensitive in distinguishing patients who are already severely compromised preoperatively, as RV dysfunction is prevalent in advanced heart failure patients irrespective of clinical RHF (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConsistent with prior registry data, patients with eaRHF experienced reduced one- and two-year survival compared with both the no-RHF and epRHF groups (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Although this difference did not reach statistical significance, the trend underscores the prognostic impact of severe early postoperative RV dysfunction. In contrast, epRHF did not confer excess mortality, supporting recent evidence that transient postoperative RHF frequently can resolve with medical management or temporary RVAD support and may not translate into poorer long-term outcomes (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe eaRHF is hypothesized to result from abrupt hemodynamic changes, with the RV unable to cope with the new hemodynamic environment, necessitating the implantation of a temporary RVAD (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). 14 out of 18 patients in the eaRHF group were still on RVAD support during examination 2. The temporary RVAD directly affects RV function, decompressing the ventricle and mitigating the disruption in the normal RV contraction pattern that occurs after cardiac surgery (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). This hypothesis is supported by the trend towards improved RV strain observed in subsequent examinations, suggesting that early, aggressive RV support can facilitate recovery of RV function despite initially severe clinical presentations. Subsequent examination revealed no decrease in RVFWS, and patients tended to have higher postoperative RVFWS, indicating an effective reversal of intraoperative RHF.\u003c/p\u003e \u003cp\u003eIn different studies RVFWS measurements have yielded mixed results over longer-term follow-up. In some cohorts, RVFWS showed no significant improvement (and even a slight worsening) after LVAD implantation, despite an overall improvement in cardiac output (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). It must be pointed out that a decline in free wall performance can be compensated by the intraventricular septum when measuring RVGLS and, therefore, be masked. Importantly, absolute strain values did not differ significantly between RHF phenotypes at any single examination timepoint, suggesting that serial within-patient trends may be more informative than isolated measurements\u003c/p\u003e \u003cp\u003eConversely, in patients with epRHF, we did not see a decline in either RVFWS or RVGLS over the entire study period. Postoperative right heart failure exists on a continuum, with different hemodynamic factors, such as septal shift from ventricular unloading or inflammatory insults, like elevated cytokines, associated with decreased RV function (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). This patient cohort also did not show a reduction in survival compared to no RHF patients. In an extensive recent analysis of more than 5,500 LVAD patients, 24% had RHF by one month post-implant, but in many cases, it was transient. Furthermore, the survival was comparable (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). It could be hypothesized that RVFWS failed to capture the temporary decrease in RV function observed in this patient cohort, as seen in other studies. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eSeveral limitations must be acknowledged. This single-centre, retrospective design introduces inherent biases, particularly concerning patient selection and potential exclusion of patients due to poor image quality, which is critical for accurate strain analysis. Strain measurements, particularly RV strain, are sensitive to echocardiographic image quality, potentially limiting the generalizability of the findings. Furthermore, the small sample size undoubtedly affected the ability to demonstrate statistically significant differences.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this retrospective single-center cohort, preoperative RVFWS demonstrated modest ability to discriminate patients who developed eaRHF requiring intraoperative RVAD support, while no echocardiographic parameter predicted epRHF. Longitudinal modelling showed an early postoperative decline in RVFWS and a delayed improvement in RVGLS, particularly in patients without RHF and in those with eaRHF. These findings suggest that serial RV strain assessment may capture dynamic changes in RV longitudinal mechanics after LVAD implantation, although larger prospective studies with standardized follow-up and clinical correlates are required to define prognostic thresholds and clinical utility.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003eEthics consent and approval to participate\u003c/p\u003e\n\u003cp\u003eThe study was approved by the ethics committee of the Ruhr-University-Bochum on 02.06.2025 (2025 \u0026ndash; 1394). Due to the retrospective nature of the study the need for collecting written consent was waived.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eAll data used to create this manuscript will be made available upon request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interest\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eWe acknowledge support by the Open Access Publication Funds of the Ruhr-University Bochum.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eC.T.B. and L.P. conceived and designed the study,as well as creating the figures and tables. C.T.B. collected and analyzed the data and wrote the original draft. L.P. supervised the study and contributed to writing. R.S., M.M., S.P.W.G., N.H., H.K., H.F., S.V.R., and J.F.G. contributed to data acquisition, interpretation, and critical revision of the manuscript. All authors reviewed and approved the final version.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMehra MR, Goldstein DJ, Cleveland JC, Cowger JA, Hall S, Salerno CT, et al. Five-Year Outcomes in Patients With Fully Magnetically Levitated vs Axial-Flow Left Ventricular Assist Devices. JAMA. 2022/09/27;328(12). doi: 10.1001/jama.2022.16197\u003c/li\u003e\n\u003cli\u003eMehra MR, Uriel N, Naka Y, Joseph C. Cleveland J, Yuzefpolskaya M, Salerno CT, et al. A Fully Magnetically Levitated Left Ventricular Assist Device \u0026mdash; Final Report. New England Journal of Medicine. 2019-04-25;380(17). doi: 10.1056/NEJMoa1900486\u003c/li\u003e\n\u003cli\u003eKapelios CJ, Lund LH, Wever-Pinzon O, Selzman CH, Myers SL, Cantor RS, et al. 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Independent and Incremental Role of Quantitative Right Ventricular Evaluation for the Prediction of Right Ventricular Failure After Left Ventricular Assist Device Implantation. Journal of the American College of Cardiology. 2012/08/07;60(6). doi: 10.1016/j.jacc.2012.02.073\u003c/li\u003e\n\u003cli\u003eAlam M, Hedman A, Nordlander R, Samad B. Right ventricular function before and after an uncomplicated coronary artery bypass graft as assessed by pulsed wave Doppler tissue imaging of the tricuspid annulus. American Heart Journal. 2003/09/01;146(3). doi: 10.1016/S0002-8703(03)00313-2\u003c/li\u003e\n\u003cli\u003eRaina A, Vaidya A, Gertz ZM, Chambers S, Forfia PR. Marked changes in right ventricular contractile pattern after cardiothoracic surgery: Implications for post-surgical assessment of right ventricular function. The Journal of Heart and Lung Transplantation. 2013/08/01;32(8). doi: 10.1016/j.healun.2013.05.004\u003c/li\u003e\n\u003cli\u003eBrown SB, Raina A, Katz D, Szerlip M, Wiegers SE, Forfia PR. Longitudinal Shortening Accounts for the Majority of Right Ventricular Contraction and Improves After Pulmonary Vasodilator Therapy in Normal Subjects and Patients With Pulmonary Arterial Hypertension. CHEST. 2011/07/01;140(1). doi: 10.1378/chest.10-1136\u003c/li\u003e\n\u003cli\u003eJoshi SB, Salah AK, Mendoza DD, Goldstein SA, Fuisz AR, Lindsay J. Mechanism of Paradoxical Ventricular Septal Motion After Coronary Artery Bypass Grafting. The American Journal of Cardiology. 2009/01/15;103(2). doi: 10.1016/j.amjcard.2008.08.067\u003c/li\u003e\n\u003cli\u003eDufendach KA, Zhu T, Castrillon CD, Hong Y, Countouris ME, Hickey G, et al. Pre‐implant right ventricular free wall strain predicts post‐LVAD right heart failure. Journal of Cardiac Surgery. 2021/06/01;36(6). doi: 10.1111/jocs.15479\u003c/li\u003e\n\u003cli\u003eAymami M, Amsallem M, Adams J, Sallam K, Moneghetti K, Wheeler M, et al. The Incremental Value of Right Ventricular Size and Strain in the Risk Assessment of Right Heart Failure Post - Left Ventricular Assist Device Implantation. Journal of Cardiac Failure. 2018/12/01;24(12). doi: 10.1016/j.cardfail.2018.10.012\u003c/li\u003e\n\u003cli\u003eBravo CA, Navarro AG, Dhaliwal KK, Khorsandi M, Keenan JE, Mudigonda P, et al. Frontiers | Right heart failure after left ventricular assist device: From mechanisms to treatments. Frontiers in Cardiovascular Medicine. 2022/10/19;9. doi: 10.3389/fcvm.2022.1023549\u003c/li\u003e\n\u003cli\u003eSciaccaluga C, Procopio MC, Potena L, Masetti M, Bernazzali S, Maccherini M, et al. Right ventricular dysfunction in left ventricular assist device candidates: is it time to change our prospective? Heart Failure Reviews 2024 29:2. 2024-02-08;29(2). doi: 10.1007/s10741-024-10387-w\u003c/li\u003e\n\u003cli\u003eFyfe DA, Mahle WT, Kanter KR, Wu G, Vincent RN, Ketchum DL. Reduction of tricuspid annular doppler tissue velocities in pediatric heart transplant patients. The Journal of Heart and Lung Transplantation. 2003/05/01;22(5). doi: 10.1016/S1053-2498(02)00653-8\u003c/li\u003e\n\u003cli\u003eStąp\u0026oacute;r M, Piłat A, Misiuda A, G\u0026oacute;rkiewicz-Kot I, Kaleta M, Kleczyński P, et al. Preoperative and mid-term right ventricular systolic function assessment, at rest and during exercise, with speckle-tracking echocardiography after left ventricular assist device implantation. Hellenic Journal of Cardiology. 2024/03/01;76. doi: 10.1016/j.hjc.2023.05.011\u003c/li\u003e\n\u003cli\u003eJ. Eduardo Rame M, Francis D. Pagani M, PhD, Michael S. Kiernan M, MS, Guilherme H. Oliveira M, Edo Y. Birati M, Pavan Atluri M, et al. Evolution of Late Right Heart Failure With Left Ventricular Assist Devices and Association With Outcomes. Journal of the American College of Cardiology. 2021-12-7;78(23). doi: 10.1016/j.jacc.2021.09.1362\u003c/li\u003e\n\u003cli\u003eHouston BA, Kalathiya RJ, Hsu S, Loungani R, Davis ME, Coffin ST, et al. Right ventricular afterload sensitivity dramatically increases after left ventricular assist device implantation: a multi-center hemodynamic analysis. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation. 2016 Feb 9;35(7). doi: 10.1016/j.healun.2016.01.1225\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cu\u003eTable 1 \u0026nbsp;\u003c/u\u003eBaseline clinical characteristics by right heart failure (RHF) status. \u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"586\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eParameter\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003eNo RHF\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eRHF*\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003ep-Value\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003eN=28 (49%)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eN=29 (51%)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eAge at implantation (years)\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e56.8\u0026plusmn;13.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e57.8\u0026plusmn;9.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e0.740\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eMale patients\u003csup\u003e1\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e24 (86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e21 (72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e0.674\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eHeight (cm)\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e177\u0026plusmn;8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e180\u0026plusmn;8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e0.162\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eWeight (kg)\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e84.4\u0026plusmn;16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e79.3\u0026plusmn;17.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e0.263\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eBSA (m\u003csup\u003e2\u003c/sup\u003e)\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e2.01\u0026plusmn;0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e1.98\u0026plusmn;0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e0.584\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eEtiology of HF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eDCM\u003csup\u003e1\u003c/sup\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e19 (68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e21 (72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e0.777\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eICM\u003csup\u003e1\u003c/sup\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e9 (32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e8 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e0.777\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003ePrevious cardiac surgery\u003csup\u003e1\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e4 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e11 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e0.112\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eINTERMACS \u0026nbsp; \u0026nbsp; - score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e5 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e14 (48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e0.084\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e2\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e7 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e9 (31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e0.706\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e3\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e6 (21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e4 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e0.529\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e4\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e10 (36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e2 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e0.032\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eDestination therapy\u003csup\u003e1\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e8 (29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e9 (31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e0.882\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003ePre-operative MCS\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e2 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e13 (45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eCreatinine (mg/dl)\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e1.7\u0026plusmn;0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e1.7\u0026plusmn;0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eBilirubin (mg/dl)\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e1.3\u0026plusmn;0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e2\u0026plusmn;1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e0.053\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eGPT (U/l)\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e26 (12 \u0026ndash; 87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e36 (21 \u0026ndash; 82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e0.314\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eGOT (U/l)\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e30 (26 \u0026ndash; 79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e47 (29 \u0026ndash; 122)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e0.216\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eHb (g/dl)\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e11.8\u0026plusmn;1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e10.4\u0026plusmn;1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003enumber and percentage. \u003csup\u003e2\u003c/sup\u003emean and standard deviations, \u003csup\u003e3\u003c/sup\u003emedian and 25\u003csup\u003eth\u003c/sup\u003e and 75\u003csup\u003eth\u003c/sup\u003e percentile.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAbbreviations: BSA \u0026ndash; body surface area, RHF \u0026ndash; right heart failure, LVAD \u0026ndash; left ventricular assist device, HF \u0026ndash; heart failure, DCM \u0026ndash; dilated cardiomyopathy, ICM \u0026ndash; ischemic cardiomyopathy, INTERMACS \u0026ndash; Interagency Registry For Mechanically Assisted Circulatory Support, MCS \u0026ndash; mechanical circulatory support, GFR \u0026ndash; glomerular filtration rate, GPT- glutamine pyruvate transaminase, GOT \u0026ndash; glutamic oxaloacetic transaminase, Hb- haemoglobin, RVAD \u0026ndash; right ventricular assist device\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e*RHF: refers to the patients with both acute right heart failure and early post-implant right heart failure\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eTable 2 \u0026nbsp;\u003c/u\u003ePostoperative parameters by right heart failure status.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eParameter\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eNo RHF\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eRHF*\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003ep-Value\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eN=28 (49%)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eN=29 (51%)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eCatecholamine support (days)\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e6 (4-9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e25.5(20-39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eRVAD support (days)\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e10.1\u0026plusmn;2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eAdditional surgical procedures\u003csup\u003e1\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e10 (36%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e16 (55%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.367\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eTVR\u003csup\u003e1\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e4(14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e7 (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.504\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eMVR\u003csup\u003e1\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e1(4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e1 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eAVR\u003csup\u003e1\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e1 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e4 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.352\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eASD closure\u003csup\u003e1\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e4(14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e4 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eRe-Thoracotomy\u003csup\u003e1\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.059\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003enumber and percentage. \u003csup\u003e2\u003c/sup\u003emedian and 25\u003csup\u003eth\u003c/sup\u003e and 75\u003csup\u003eth\u003c/sup\u003e percentile. \u003csup\u003e3\u003c/sup\u003emean and standard deviations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eTable 3\u0026nbsp;\u003c/u\u003eEchocardiographic parameters obtained pre-operatively in the study group.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"633\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eNo RHF (N=28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eEarly, acute RHF (N=18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eEarly, post-implant RHF (N=11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003ep \u0026ndash; value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eTAPSE (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e17\u0026plusmn;4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e14.3\u0026plusmn;3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e16.7\u0026plusmn;3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003ep=0.111\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eLVEF (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e22.2\u0026plusmn;7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e19.9\u0026plusmn;11.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e20.6\u0026plusmn;5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003ep=0.277\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eRVEDD (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e46\u0026plusmn;9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e41\u0026plusmn;11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e47\u0026plusmn;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003ep=0.114\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eLVEDD\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e67\u0026plusmn;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e63\u0026plusmn;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e70\u0026plusmn;14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003ep=0.479\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eRVEDD/LVEDD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e0.7\u0026plusmn;0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.7\u0026plusmn;0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e0.7\u0026plusmn;0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003ep=0.821\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eModerate and Severe TI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003ep=0.704\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eRVFWS (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e-9.8\u0026plusmn;4.7\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e-8.2\u0026plusmn;7.6\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e-7\u0026plusmn;4.3\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003ep=0.347\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eRVGLS (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e-7.2\u0026plusmn;3.6\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e-6.5\u0026plusmn;5.6\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e-5.7\u0026plusmn;4\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003ep=0.141\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTAPSE \u0026ndash; tricuspid annular plane systolic excursion, LVEF \u0026ndash; left ventricular ejection fraction, RVEDD \u0026ndash; right ventricular end diastolic diameter, LVEDD \u0026ndash; left ventricular end diastolic diameter, RVEDD/LVEDD \u0026ndash; ratio of right ventricular to left ventricular end-diastolic diameter, RVFWS \u0026nbsp;- right ventricular free wall strain, RVGLS \u0026ndash; right ventricular global longitudinal strain, TI \u0026ndash; tricuspid valve insufficiency\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eTable 4 \u0026nbsp;\u003c/u\u003eRight ventricular free-wall strain (RVFWS) during each subsequent examination in patients without right heart failure (no RHF), early, acute RHF (eaRHF), and early, postoperative RHF (epRHF).\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eExamination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003eNo RHF (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003eRVFWS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eeaRHF (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003eRVFWS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eepRHF(n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eRVFWS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-9.8\u0026plusmn;4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-8.2\u0026plusmn;7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e-7.0\u0026plusmn;4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-6.3\u0026plusmn;4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-6.3\u0026plusmn;4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e-6.1\u0026plusmn;2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-6.5\u0026plusmn;4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-9.5\u0026plusmn;4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e-8.3\u0026plusmn;3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-8.2\u0026plusmn;3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-10.6\u0026plusmn;3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e-7.7\u0026plusmn;1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-7.7\u0026plusmn;3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-8.5\u0026plusmn;4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e-9.7\u0026plusmn;6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eTable 5 \u0026nbsp;\u003c/u\u003eRight ventricular global longitudinal strain (RVGLS) during each subsequent examination in patients without right heart failure (no RHF), early, acute RHF (eaRHF), and early, postoperative RHF (epRHF).\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eExamination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003eNo RHF (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003eRVGLS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eeaRHF (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003eRVGLS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eepRHF(n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eRVGLS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-7.2\u0026plusmn;3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-6.5\u0026plusmn;5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e-5.7\u0026plusmn;4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-5.6\u0026plusmn;3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-5.7\u0026plusmn;4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e-5.8\u0026plusmn;2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-6.1\u0026plusmn;4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-9.0\u0026plusmn;4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e-7.3\u0026plusmn;3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-8.3\u0026plusmn;4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-11.3\u0026plusmn;5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e-7.2\u0026plusmn;2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-7.2\u0026plusmn;3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-7.1\u0026plusmn;4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e-9.7\u0026plusmn;4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"right heart failure, LVAD, mechanical circulatory support, end-stage heart failure","lastPublishedDoi":"10.21203/rs.3.rs-9129803/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9129803/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eRight heart failure (RHF) remains a major determinant of morbidity and mortality following left ventricular assist device (LVAD) implantation. Right ventricular free wall strain (RVFWS) and global longitudinal strain (RVGLS) have emerged as promising echocardiographic markers, yet their long-term prognostic utility and suitability to assess changes in RV function remain poorly defined.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn this single-center retrospective study, 57 of 95 consecutive HeartMate 3 LVAD recipients (mean age 57\u0026thinsp;\u0026plusmn;\u0026thinsp;11 years; 79% male) with adequate echocardiographic quality were analyzed. Patients were stratified by RHF phenotype according to the 2020 MCS-ARC definition: no RHF (n\u0026thinsp;=\u0026thinsp;28), early acute RHF (eaRHF, n\u0026thinsp;=\u0026thinsp;18), and early postoperative RHF (epRHF, n\u0026thinsp;=\u0026thinsp;11). RVFWS and RVGLS were measured preoperatively and at 2 weeks, 6 months, 12 months, and 36 months post-implantation using speckle-tracking echocardiography. Linear mixed-effects modelling and ROC analysis evaluated temporal changes and predictive value.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePreoperative RVFWS predicted eaRHF with 51.7% sensitivity and 82.1% specificity (AUC\u0026thinsp;=\u0026thinsp;0.671, p\u0026thinsp;=\u0026thinsp;0.022). In patients without RHF, RVFWS declined from \u0026minus;\u0026thinsp;9.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6% preoperatively to \u0026minus;\u0026thinsp;6.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8% postoperative (Δ=\u0026minus;3.5, p\u0026thinsp;=\u0026thinsp;0.01) and \u0026minus;\u0026thinsp;6.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9% at 6 months (Δ=\u0026minus;3.0, p\u0026thinsp;=\u0026thinsp;0.04), stabilizing thereafter. RVGLS improved significantly from \u0026minus;\u0026thinsp;5.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7% early postoperatively to \u0026minus;\u0026thinsp;8.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1% at 12 months (Δ=+3.1, p\u0026thinsp;=\u0026thinsp;0.02). In eaRHF patients, RVGLS improved from \u0026minus;\u0026thinsp;5.7\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1% to \u0026minus;\u0026thinsp;11.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1% (Δ=+5.1, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) by 12 months, suggesting RV recovery after temporary support. No significant longitudinal change was observed in the epRHF group. One-year survival was 84.5%, 81.8%, and 50.0% in the no RHF, epRHF, and eaRHF groups, respectively. The differences did not reach statistical significance.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eRVFWS offers modest predictive accuracy for early acute RHF, while RVGLS more sensitively reflects dynamic right ventricular remodelling and recovery after LVAD implantation. Distinct strain trajectories highlight differential pathophysiologic mechanisms across RHF phenotypes. This study highlights the possibility of using RVGLS and RVFWS to assess functional changes in RV function after LVAD implantation over time.\u003c/p\u003e","manuscriptTitle":"Assessment of the Predictive Value of Right Ventricular Longitudinal Strain and Functional Trends in Right Ventricular Function of Patients after LVAD Implantation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-15 06:45:18","doi":"10.21203/rs.3.rs-9129803/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"25112b7c-fbd8-4d1b-a54c-b369f3195a41","owner":[],"postedDate":"April 15th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-05T12:32:46+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-13T14:29:51+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-15 06:45:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9129803","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9129803","identity":"rs-9129803","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}