European Journal of Echocardiography

European Journal of Echocardiography 2003 4(4):262-271; doi:10.1016/S1525-2167(02)00171-3
© 2003 by European Society of Cardiology

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Copyright © 2003, The European Society of Cardiology

Prognostic Importance of the Right Ventricular Function Assessed by Doppler Tissue Imaging

J Meluzín^1,*, L pinarová¹, L Duek², J Toman¹, P Hude¹ and J Krejí¹

¹1st Department of Internal Medicine, St. Anna Hospital, Masaryk University, Brno, Czech Republic
²Centre of Biostatistics and Analyses, Masaryk University, Brno, Czech Republic

Received 7 August 2002; received in revised form 19 November 2002; accepted after revision 22 November 2002.

^* Address correspondence to: Jaroslav Meluzín, 1st Department of Internal Medicine, St. Anna Hospital, Pekaská 53, Brno 65691, Czech Republic. Tel: +420-5-4318-2224; Fax: +420-5-4318-2205. jaroslav.meluzin{at}fnusa.cz

	Abstract

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Aims: We sought to assess whether the peak systolic and diastolic tricuspid annular velocities as indicators of the right ventricular systolic and diastolic function are of prognostic importance in patients with symptomatic heart failure.

Methods and Results: The study included 139 consecutive patients with symptomatic heart failure. Their mean left ventricular ejection fraction was 24% (range, 10–39%); 107 patients (77%) were in functional class III according to the New York Heart Association. All patients underwent clinical and laboratory examination, standard echocardiography completed by the Doppler tissue imaging of the tricuspid annular motion, and the right-sided heart catheterization. They were followed up for cardiac-related death and non-fatal cardiac events including the need for implantation of a cardioverter-defibrillator and hospitalization for heart failure. The median follow-up was 11 months (range, 1–48 months). There were 17 cardiac-related deaths and 23 non-fatal cardiac events. The multivariate stepwise Cox regression modelling revealed three effective predictors for both survival and event-free survival: aetiology of heart failure, left ventricular end-diastolic diameter, and the peak systolic tricuspid annular velocity (Sa). Patients with Sa < 10.8 cm s^–1 exhibited worse survival (P=0.048) and event-free survival (P<0.001) compared with those having Sa 10.8 cm s^–1. Risk values of Sa (<10.8 cm s^–1) and the left ventricular end-diastolic diameter (>70 mm) were found to be of additive simultaneous influence leading to a very poor prognosis, mainly if aetiology of heart failure was idiopathic dilated cardiomyopathy (P<0.001).

Conclusion: The Sa represents a significant independent predictor of survival and event-free survival in patients with symptomatic heart failure. Its combination with the left ventricular end-diastolic diameter provides a very powerful tool for patient risk stratification.

Keywords: prognosis; heart failure; right ventricular dysfunction; Doppler tissue imaging

	Introduction

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Despite significant advances in medical and surgical treatment, the prognosis of patients with chronic heart failure remains poor and 1-year survival of selected patient groups may even fall below 50%^[1–3]. One of the ways to improve their prognosis is the identification of patients at high risk of cardiac events. Such patients may be submitted to more intensive medical management or may be rapidly referred for bypass surgery or heart transplantation. Despite the knowledge of a high number of factors accounting for increased mortality^[1–17], the therapeutic results are not satisfactory, and there is no agreement on which factors or their combination are the best to predict the high risk of cardiac death or non-fatal cardiac events. Many of the prognostic parameters are not routinely investigated because of their invasive nature, high cost or low availability. Variables describing the right ventricular function obtained mostly by radionuclide ventriculography^[14,17–19] or by the thermodilution technique during the right heart catheterization^[15,16,20] belong to such parameters. The consequence is that the right ventricular function is not routinely examined to stratify the risk of patients with heart failure, even if the reports published thus far have suggested a high potential of right ventricular systolic function parameters for the prediction of cardiac events^[14–18,20]. In 2001, we demonstrated that the peak systolic velocity of tricuspid annular motion assessed non-invasively with pulsed Doppler tissue imaging represents an accurate and reproducible parameter of right ventricular systolic function^[21]. It is easy to obtain and its investigation does not represent any discomfort for the patient. In addition, Doppler tissue imaging of the tricuspid annular motion also enables evaluation of the right ventricular diastolic function on whose clinical and prognostic importance minimum information is available^[22]. Thus, the aim of this study was to find out whether the peak systolic and diastolic tricuspid annular velocities are of prognostic importance in patients with symptomatic heart failure.

	Methods

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Study Population
The study included 139 consecutive patients with symptomatic heart failure (classes II–IV according to the New York Heart Association), who were admitted to our department as potential candidates for orthotopic heart transplantation for pre-transplant investigation. The inclusion criteria were: (a) good quality of echocardiographic imaging of the tricuspid annular motion, (b) sinus rhythm on electrocardiography, (c) absence of acute coronary event within the last 3 months, (d) absence of any non-cardiac disease adversely affecting prognosis (malignancy, advanced liver, renal, or lung disease), and (e) no need for myocardial revascularization. Patients not stabilized on hospital admission (resting dyspnoea, need for catecholamine support or parenteral diuretics, ankle oedema, rales on lung auscultation) were investigated and included in the study after cardiac compensation. Three patients requiring permanent parenteral diuretic therapy and catecholamine support were not included in our study and were referred for urgent heart transplantation. We also excluded three patients with bad quality of echocardiographic imaging of the tricuspid annular motion and four patients with congenital or acquired valve diseases. The aetiology for heart failure was ischaemic cardiomyopathy (70% angiographically verified luminal diameter narrowing in at least one major coronary artery or documented myocardial infarction—74 patients) or idiopathic dilated cardiomyopathy (65 patients). Of patients with ischaemic cardiomyopathy, 68 (92%) suffered from a large Q wave myocardial infarction. The diagnosis of dilated cardiomyopathy was made on the basis of echocardiography, electrocardiography (no Q waves), and clinical criteria; in patients above 40 years of age with risk factors for coronary artery disease, the absence of coronary artery disease was confirmed by coronary angiography. The coronary angiography was performed in 78 patients with unknown aetiology of heart failure having risk factors for coronary artery disease or in patients with known coronary artery disease and the presence of viability in dysfunctional myocardium. Fifty-four patients were found to have significant coronary artery disease; 24 patients with no evidence of previous myocardial infarction had smooth coronary vessels or only insignificant stenoses and were assigned to a dilated cardiomyopathy group. The clinical characteristics of the patient population are listed in Table 1. There were 113 (81%) men and 26 (19%) women, aged 52 years on average (range, 17–63 years). The mean left ventricular ejection fraction was 24% (range, 10–39%). Forty-nine (35%) patients suffered from hypertension, 79 (57%) from hypercholesterolaemia, and 30 (22%) were treated for diabetes mellitus. Medical therapy was optimized before entering the study, and it comprised angiotensin-converting enzyme inhibitors in 130 patients (94%), digitalis in 103 (74%), furosemide in 138 (99%), spironolactone in 97 (70%), and beta blockers in 97 (70%) of the patients. In spite of this therapy, the majority of patients (107, 77%) were in the New York Heart Association functional class III; 28 (20%) were in class II and 4 (3%) in class IV. In 40 patients (29%), elective orthotopic heart transplantation was indicated following the initial investigations. On entering the study, the patients underwent physical examination, routine blood chemistry and haematological measurements, 12-lead electrocardiography, chest radiography, standard and Doppler tissue echocardiography, and the right-sided heart catheterization. All patients gave their written consent to the investigations. The study complies with the Declaration of Helsinki and was approved by the institutional ethics committee.

View this table: [in this window] [in a new window]   Table 1 Baseline patient characteristics.

 
Echocardiography
Standard echocardiography and pulsed Doppler tissue imaging of the tricuspid annular motion were obtained in all the patients. We used SONOS 5500 (Hewlett Packard, Andover, Mass, USA) equipment with a phased array transducer of 2.5 MHz, and with a system equipped with Doppler tissue imaging technology. A detailed concept and technical aspects of Doppler tissue imaging have been published previously^[23,24]. Doppler tissue measurements were performed with patients in the left lateral decubitus position during shallow respiration or end-expiratory apnoea. Guided by the two-dimensional four-chamber view, a sample volume was placed on the tricuspid annulus at the place of attachment of the anterior leaflet of the tricuspid valve. Care was taken to obtain an ultrasound beam parallel to the direction of the tricuspid annular motion. Peak systolic (Sa), peak early (Ea) and late (Aa) diastolic tricuspid annular velocities, along with simultaneous electrocardiography, were recorded on videotape at a speed of 50 mm s^–1 for subsequent analysis. When evaluating peak systolic velocity, the initial peak that occurs during isometric contraction was ignored. All pulsed Doppler tissue imaging parameters were measured on 4–6 consecutive heart cycles and mean value was calculated. The same methodology was applied in our previous study demonstrating a good accuracy and reproducibility of pulsed Doppler tissue imaging of tricuspid annular motion for the non-invasive detection of right ventricular systolic function^[21]. In addition to pulsed Doppler tissue imaging, conventional echocardiography was performed, including M-mode, two-dimensional, pulsed and colour Doppler echocardiography. Left ventricular ejection fraction was calculated according to the modified Simpson's rule^[25].

Right Heart Catheterization
One hundred and thirty-four patients underwent right heart catheterization within 24 h of echocardiography. In five patients, catheterization was not performed for technical reasons. The investigations were performed via the right subclavian vein or the right jugular vein. A 7F thermodilution catheter (model 131HF7, Baxter Healthcare Corporation, Irvine, CA, USA) was inserted through the right heart cavities and the pulmonary artery into the pulmonary capillary wedge position. Measurements of mean right atrial pressure, mean pulmonary artery pressure, and mean pulmonary capillary wedge pressure were obtained with patients in supine position using a mechanoelectrical transducer (model P23XL, Ohmeda Medical Devices Division, Oxnard, CA, USA). Cardiac output was measured by the thermodilution technique. The thermodilution curve was recorded and calculated using a thermodilution module of the aforementioned monitor. The cardiac index was calculated as follows: cardiac index (1 min^–1 m²)=cardiac output (1 min^–1)/body surface area (m²).

Follow-up
The patients were followed up for cardiac mortality and non-fatal cardiac events relating to heart failure such as hospitalization for heart failure and the need for implantation of a cardioverter-defibrillator due to malignant ventricular arrhythmias. Cardiac death was defined as death due to congestive heart failure, myocardial infarction, malignant arrhythmias or cardiac arrest. In patients who died out of hospital and in whom autopsy was not performed, a sudden unexpected death (within 1 h of the onset of symptoms) was attributed to a cardiac cause. Heart failure requiring hospitalization was identified by dyspnoea, need for parenteral diuretic therapy, and by symptoms associated with left (rales on lung auscultation, S3 gallop) and/or right (neck vein distension, ankle oedema, hepatomegaly) heart failure. In the case of patient death or admission to hospital, the admitting departments or referring physicians were contacted to elucidate the exact reason for hospitalization or cause of death. Only one event was considered in each patient in the following hierarchy: death < need for cardioverter-defibrillator < hospitalization for heart failure. Survival was defined as freedom from cardiac-related death, event-free survival was defined as freedom from combined end-point (cardiac-related death, need for implantation of a cardioverter-defibrillator, hospitalization for heart failure). Since all patients were referred to our department as potential candidates for heart transplantation and echocardiographic results influenced the indication for heart transplantation, this procedure was not considered a cardiac event, and the follow-up of 33 patients who underwent heart transplantation ended with the date of this procedure. The follow-up data were available from all patients and the median follow-up was 11 months (range, 1–48 months).

Statistical Analysis
All cases already recruited in the study were correctly analysed and no values of any parameter were excluded prior to statistical analysis. A P value <0.05 was taken as a universal indicative limit for statistical significance in all univariate and multivariate analyses. Standard descriptive statistics were used to express differences among subgroups of cases (mean supplied with 95% confidence limits or relative frequencies). Standard univariate statistical techniques were used to test the differences between the chosen subgroups of patients: Fisher's exact test in binary outcomes, chi-square test for ordinal categorical variables, unpaired Student's t-test for normally distributed continuous variables, and Mann–Whitney test for non-normally distributed continuous variables. Both univariate and multivariate analytic strategy was applied to quantify the predictive power of examined variables to the predefined study end-points: (1) cardiac-related death, (2) combined end-point. The entire sample was subjected to life table analysis in order to quantify the time profile of survival and event-free survival (in percentiles of survival time). Freedom from death (survival) and freedom from combined event (event-free survival) were analysed quantitatively in survival analysis with potential predictors as stratifying factors. The stratified Kaplan–Meier product-limit method was applied to discriminate survival rates between two or more subgroups given by potential predictors. The standard Peto–Prentice generalized log-rank test was used as comparative statistical test. Time-related probability of combined events obtained as standard output was then used in stratifying of the patients at different levels of risk. The best maximum likelihood estimates of cut-off values were obtained by receiver-operating characteristic curve analysis. A stepwise multivariate Cox proportional hazard analysis was used as a final model identifying significant predictors of survival or event-free survival. The hazard ratio was estimated within its 95% confidence limits and supported by the significance level. The final set of independent prognostic factors was identified by a backward stepwise selection algorithm. A potential contribution of independent predictors to the most significant model was examined for each variable in a successively built set of independent variables and the models reached were compared by the maximum likelihood ratio test. Apart from multivariate modelling, all the predictors associated probabilistically with patients at risk were examined separately by univariate Cox regression models.

	Results

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Clinical, Echocardiographic and Right Heart Catheterization Variables
Table 1 demonstrates the clinical, echocardiographic and right heart catheterization variables in the whole patient population and in patients divided according to the aetiology of heart failure into those with ischaemic heart disease and with idiopathic dilated cardiomyopathy. Comprehensive statistics summarized over all the examined variables revealed statistically negligible differences between the compared primary diagnoses, except for the occurrence of diabetes mellitus and logically distributed medication. The ischaemic heart disease group appeared to be partially associated with a cumulative load of some risk factors for coronary atherosclerosis (systemic hypertension, diabetes mellitus, hypercholesterolaemia). This trend, however, was not proved as dominant for the group and did not correlate with most of the quantitative variables.

Follow-up Data
Of 139 patients studied, 40 (29%) suffered a cardiac event. There were 17 cardiac-related deaths; 10 patients died from progressive heart failure, seven died suddenly. Twenty-three patients suffered a non-fatal cardiac event; 21 were hospitalized for heart failure decompensation, two because of need for implantation of a cardioverter-defibrillator. No patient underwent myocardial revascularization during the follow-up.

Predictors of Cardiac Events
All the investigated variables (listed in Table 1) were examined as potential predictors of survival study end-points in univariate Cox regression models. Table 2 shows only those reaching at least indicative statistical significance (P<0.3). Although many of the variables were potentially bioindicative, only aetiology of heart failure, left ventricular end-diastolic diameter, right atrial and pulmonary artery pressures, and the peak systolic tricuspid annular velocity (Sa) provided unambiguous statistical significance for both survival and event-free survival. To define the contribution of single parameters to the final predictions in simultaneous application, the multivariate stepwise Cox regression models were performed. The stepwise procedure selected the same parameters as effective predictors for both cardiac overall and event-free survival: aetiology of heart failure, left ventricular end-diastolic diameter, and the Sa (Table 3). The final model equations were then proved to be independent of the order of variables entering the model and the variables included were recognized as mutually independent predictors. The Sa was shown to be the more important contributor to the prediction of event-free survival than to the separated survival.

View this table: [in this window] [in a new window]   Table 2 Predictive potential of examined variables in univariate Cox regression modelsa.

 

View this table: [in this window] [in a new window]   Table 3 Results of the multivariate stepwise Cox regression modellinga.

 
Survival and Event-free Survival Analyses Stratified According to Significant Predictors
The receiver-operating characteristic curves were used in order to define the best cut-off values of predictors included in the multivariate models. The curves for binary coded combined events and cardiac death led to statistically negligible differences in cut-off values for both the left ventricular end-diastolic diameter (73 mm and 67 mm, respectively) and the Sa (10.9 cm s^–1 and 10.7 cm s^–1, respectively). Based on this fact, common values discriminating patients at risk were proposed for both survival and event-free survival: <70 mm for the left ventricular end-diastolic diameter and <10.8 cm s^–1 for the Sa. The aetiology of heart failure, the left ventricular end-diastolic diameter with a cut-off value of 70 mm, and the Sa with a cut-off value of 10.8 cm s^–1 were all able to stratify patients according to the risk of occurrence of combined events on a P level of less than 0.001. Figs. 1 and 2 show the Kaplan–Meier analysis of event-free survival and survival stratified according to the Sa. Model estimates of risk categories based on multivariate Cox modelling approach were identified in a cumulative way in Figs. 3 and 4. Fig. 3 represents a comparison of event-free survival of the unselected patient population with that of patients having, (1) Sa < 10.8 cm s^–1, (2) the left ventricular end-diastolic diameter <70 mm, or (3) a combination of Sa < 10.8 cm s^–1 and the left ventricular end-diastolic diameter <70 mm. These model analyses were performed for the whole study population, patients with idiopathic dilated cardiomyopathy and those with ischaemic heart disease. In all patients with heart failure, irrespective of its aetiology, the combined risk values of the Sa and the left ventricular end-diastolic diameter were associated with a very poor prognosis, significantly worse than when applying only a single risk factor (P<0.01). Fig. 4 represents analogical analyses concerning the survival, again at a significance level P<0.01.

View larger version (12K): [in this window] [in a new window] [Download PowerPoint slide]   Figure 1 Kaplan–Meier analysis of event-free survival stratified according to the Sa (+: censored points). Sa = peak systolic tricuspid annular velocity.

 

View larger version (11K): [in this window] [in a new window] [Download PowerPoint slide]   Figure 2 Kaplan–Meier analysis of survival stratified according to the Sa (+: censored points). Sa = peak systolic tricuspid annular velocity.

 

View larger version (16K): [in this window] [in a new window] [Download PowerPoint slide]   Figure 3 Event-free survival in risk categories of patients given by multivariate Cox regression models. The combined risk values of the Sa and the left ventricular end-diastolic diameter (LVEDD) were associated with poor prognosis, significantly worse than when applying only a single risk factor. P value: statistical significance of the effect as related to the baseline. EPS = event-free survival.

 

View larger version (12K): [in this window] [in a new window] [Download PowerPoint slide]   Figure 4 Survival in risk categories of patients given by multivariate Cox regression models. Again, the combined risk values of the Sa and the left ventricular end-diastolic diameter (LVEDD) were associated with poor prognosis, significantly worse than when applying only a single risk factor. P value: statistical significance of the effect as related to the baseline.

 

	Discussion

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There are very many reports on the clinical and prognostic impact of various left ventricular functional parameters in patients with heart failure. However, data on the importance of the right ventricular systolic and diastolic function are rare. Thus, the purpose of our study was to assess the prognostic significance of quickly, readily, and non-invasively obtained parameters of the right ventricular systolic and diastolic function derived from Doppler tissue imaging of the tricuspid annular motion.

There are several methods of assessing the right ventricular function: thermodilution technique during the right heart catheterization, ventriculography with contrast agents, radioisotope ventriculography, nuclear magnetic resonance imaging, and echocardiography. Catheterization, nuclear magnetic resonance imaging, and radioisotope ventriculography most often determine the right ventricular ejection fraction. The main limitations of these methods are a relatively high cost, demand for time and, in the case of catheterization, its invasive nature. Echocardiography is less accurate in the evaluation of right ventricular ejection fraction because of the complex right ventricular shape, but it enables us to assess the right ventricular function by determining the tricuspid annular excursions and velocities reflecting the function of longitudinally oriented myocardial fibres^[21,26–29]. It is known that these fibres contribute to the right ventricular ejection more than circularly oriented fibres. Several authors have proved a good correlation of the right ventricular ejection fraction assessed by radionuclide ventriculography with the magnitude of systolic tricuspid annular excursions^[27]. Recently, we demonstrated a more rapid and easily performable way of evaluating the right ventricular function—the measurement of tricuspid annular velocities using pulsed Doppler tissue imaging^[21]. The Sa <11.5 cm s^–1 predicted the right ventricular systolic dysfunction with a sensitivity of 90% and a specificity of 85%. The method is very fast, sufficiently accurate, and allows on-line evaluation of not only systolic, but also diastolic right ventricular function. Thus it appears to be a hopeful method for the assessment of the right ventricular function and its prognostic importance, with a potential for the application in everyday clinical practice.

Reports on prognosis of patients with heart failure published thus far concordantly proved the increase in mortality and frequency of non-fatal cardiac events in patients with right ventricular systolic dysfunction^{[14–17,19,20,28,29]}. In most studies, the right ventricular ejection fraction obtained by radioisotope ventriculography^[14,17–19] or thermodilution technique^[15,16,20] was used. A minority of authors measured the tricuspid annular systolic excursions using M-mode or two-dimensional echocardiography^[28,29]. When Cox analysis was applied, the parameters of the right ventricular systolic function were found to possess independent prognostic significance^{[14–18,20,28,29]}. Their power for the prediction of cardiac events was even greater than that of peak oxygen consumption during exercise^[14,28] or that of the left ventricular systolic function^[15,16]. Gavazzi et al.^[16], who included in Cox analysis clinical, laboratory, and right-sided heart catheterization parameters, identified the right ventricular ejection fraction to be the single most important predictor of short-term prognosis in a large cohort of patients with severe heart failure. Despite these facts, the right ventricular functional parameters are not routinely evaluated to assess the risk of cardiac events in patients with heart failure. The measurement of tricuspid annular velocities using pulsed Doppler tissue imaging represents a new approach to quantify the systolic and diastolic right ventricular function^[21], which is very easy to perform. However, the prognostic impact of annular velocities has not yet been assessed.

The results of this study demonstrated the independent prognostic power of the Sa for the prediction of both survival and event-free survival. The patients with Sa < 10.8 cm s^–1 exhibited a significantly higher mortality and rate of combined events than the remaining patients. Taking into account the fact that the Sa value of 11.5 cm s^–1 divides patients into those with normal or abnormal right ventricular systolic function^[21], the cohort of patients with Sa < 10.8 cm s^–1 represents those with a moderate or severe right ventricular dysfunction. The Sa value of 10.8 cm s^–1 relatively closely corresponds to the right ventricular ejection fraction of 35%^[21], which has already been demonstrated to divide patients into those with low or high risk of death^[14,19]. Thus, analogically to the left ventricle, the presence of moderate and severe right ventricular systolic dysfunction significantly and independently worsens the prognosis. In both our study and that of Yu et al.^[22], the echocardiographic parameters of the right ventricular diastolic function were not found to affect cardiac mortality significantly. However, the exact relation of the diastolic tricuspid annular velocities to the severity of the right ventricular diastolic dysfunction has not yet been assessed and should be clarified in the future studies. Applying the multivariate Cox regression model, the combination of three variables (aetiology of heart failure, left ventricular end-diastolic diameter, and the Sa) predicted a poor prognosis with a maximum and independent power (Table 3). The significant additive prognostic effect of the left ventricular end-diastolic diameter to the right ventricular dysfunction is not surprising, as the increase in left ventricular end-diastolic diameter has been shown to worsen survival of patients with heart failure^[6,9], and the combination of low Sa and high left ventricular end-diastolic diameter defines in our study the cohort of patients with moderate or severe right ventricular systolic dysfunction accompanied by the left ventricular dilation and dysfunction. The reason for a worse prognosis of patients with idiopathic dilated cardiomyopathy as compared with those having ischaemic heart disease is not clear. These patients tended to have larger left ventricular dimensions and a lower Sa, but the only significant differences were in the frequency of diabetes and in the application of statins and aspirin in their therapy. As shown in Figs. 3 and 4, the combination of left ventricular end-diastolic diameter <70 mm and Sa <10.8 cm s^–1 defines the high risk group of patients irrespective of the aetiology of heart failure. However, mainly in patients with dilated cardiomyopathy this combination may be regarded as ominous. As both Sa and the left ventricular end-diastolic diameter are easy to obtain, their combination may provide a very powerful and fast tool for risk stratification of patients with heart failure and a low left ventricular ejection fraction.

There are several limitations of this study. The patient population included in this study does not represent the average cohort of patients with advanced heart failure encountered in the clinical practice. Since the patients were referred to our hospital as potential candidates for orthotopic heart transplantation, a significant proportion of patients above 60 years of age and those with significant co-morbidities were not included. Another excluded group of patients were those with atrial fibrillation or permanent right ventricular pacing, because the accuracy of tricuspid annular velocities for the evaluation of right ventricular function has not yet been tested in such patients. These facts may explain a relatively low mortality during the follow-up despite the predominant symptomatic heart failure of functional class III. In addition, not all of the parameters known to affect the prognosis of patients with heart failure (such as peak oxygen consumption, deceleration time of early transmitral filling, restrictive left ventricular filling etc.) were systematically followed up and included into survival analysis. Spiroergometry was performed in only 60–70% of patients. In spite of these facts, the study offers a new, easily and quickly obtainable and non-invasive parameter of the right ventricular systolic function possessing a significant potential to predict cardiac events in patients with symptomatic heart failure.

	Acknowledgements

 
This work was supported in part by grant of the Ministry of Education of the Czech Republic (MSM, No. 141100004) and by grant of the Ministry of Health of the Czech Republic (IGA, No. N A/7619-3).

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