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Right Atrial Volume Index in Chronic Systolic Heart Failure and Prognosis

John A. Sallach, MD^_*, W.H. Wilson Tang, MD, Allen G. Borowski, RDCS, Wilson Tong, MS, Tama Porter, MD, Maureen G. Martin, RDCS, Susan E. Jasper, RN, Kevin Shrestha, AB, Richard W. Troughton, MB, ChB, Allan L. Klein, MD^,_*

^_* University of Michigan, Ann Arbor, Michigan
Cleveland Clinic, Cleveland, Ohio
Christchurch School of Medicine and Health Sciences, Christchurch, New Zealand

^_* Reprint requests and correspondence: Dr. Allan L. Klein, Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Desk J1-5, Cleveland, Ohio 44195 (Email: kleina{at}ccf.org).

Objectives: The aim of this study was to determine the relationship between right atrial volume index (RAVI) and right ventricular (RV) systolic and diastolic function, as well as long-term prognosis in patients with chronic systolic heart failure (HF).

Background: RV dysfunction is associated with poor prognosis in patients with HF, although echocardiographic assessment of RV systolic and diastolic dysfunction is challenging. The ability to visualize the RA allows a quantitative, highly reproducible assessment of the RA volume that can be indexed to body surface area.

Methods: The ADEPT (Assessment of Doppler Echocardiography for Prognosis and Therapy) trial enrolled 192 subjects with chronic systolic HF (left ventricular ejection fraction [LVEF] 35%). The RA volume was calculated by Simpson's method using single-plane RA area and indexed to body surface area (RAVI). RV systolic function was graded as normal, mild, mild-moderate, moderate, moderately severe, or severe dysfunction.

Results: In our study cohort, the mean RAVI was 28 ± 15 ml/m², and increased with worsening RV systolic dysfunction, LVEF, and LV diastolic dysfunction (Spearman's r = 0.61, r = 0.26, and r = 0.51, respectively; p < 0.001 for all). RAVI correlated modestly with echocardiographic estimates of RV diastolic dysfunction, including tricuspid early/late velocities ratio (Spearman's r = 0.34, p < 0.0001), hepatic vein systolic/diastolic ratio (Spearman's r = –0.26, p < 0.001) but not tricuspid early/tricuspid annular early velocities ratio (E/Ea) (Spearman's r = 0.12, p = 0.11). Increasing tertiles of RAVI were predictive of death, transplant, and/or HF hospitalization (log-rank p = 0.0002) and remained an independent predictor of adverse clinical events after adjusting for age, B-type natriuretic peptide, LV ejection fraction, RV systolic dysfunction, and tricuspid E/Ea ratio (hazard ratio: 2.00, 95% confidence interval: 1.15 to 3.58, p = 0.013).

Conclusions: In patients with chronic systolic HF, RAVI is a determinant of right-sided systolic dysfunction. This quantitative and reproducible echocardiographic marker provides independent risk prediction of long-term adverse clinical events.

Key Words: right atrial volume • right ventricular systolic function • echocardiography • Doppler

Abbreviations and Acronyms   BNP = B-type natriuretic peptide   E/A ratio = tricuspid early/late velocities ratio   E/Ea ratio = tricuspid early/tricuspid annular early velocities ratio   HF = heart failure   HR = hazard ratio   LV = left ventricular   LVEF = left ventricular ejection fraction   RA = right atrium   RAVI = right atrial volume index   ROC = receiver-operator characteristic   RV = right ventricle/ventricular   S/D = hepatic vein systolic/diastolic ratio   TDI = tissue Doppler imaging