Over recent decades, several studies have clearly demonstrated the important role of the right ventricle (RV) in the pathophysiology of different cardiac and pulmonary diseases. Heart failure is a severe chronic disease and risk stratification of patients is an important step in their management. Right ventricular (RV) systolic function is a key determinant of prognosis in patients with left ventricular systolic dysfunction . The RV has a complex geometry, making it hard to analyse its contractility. Since the mid 1990s, several studies have analysed different methods – from right heart catheterization to magnetic resonance imaging (MRI) – to accurately determine RV ejection fraction (RVEF). However, in 2016, we are still looking for the most practical parameter of RV systolic function.

In this issue of the Archives , Venner et al. have retrospectively evaluated the prognostic effect of RV systolic function in 136 patients with idiopathic dilated cardiomyopathy (DCM) . Their mean age was 59.0 ± 13.2 years and their mean left ventricular ejection fraction was 27.5 ± 8.7%. The population was treated according to current guidelines: 88% received angiotensin-converting enzyme inhibitors, 90% beta-blockers and 37% mineralocorticoid receptor antagonists. Moreover, 43% of the patients had an internal cardiac defibrillator and 31% had undergone resynchronization therapy. During a mean follow-up of 2.7 years, there were 49 major cardiac events (36% of patients), including 20 cardiac-related deaths. They used the tricuspid annular plane systolic excursion (TAPSE) for the estimation of RV systolic function with a cut-off value of 15.4 mm. They demonstrated – in both a multivariable Cox analysis and a propensity score analysis – the independent prognostic information derived from TAPSE in patients with DCM (hazard ratio: 2.35, 95% confidence interval 1.27–4.34) .

Various methods are available for the determination of RV systolic function. Selected studies that demonstrate the prognostic role of the RV parameters are detailed in the Table 1 . The gold standard is considered to be MRI, but there are three major limitations of this technique: its limited availability, its expense and, currently, its contraindication in patients with devices, which applies to the majority of our patients. Radionuclide angiography is an alternative to MRI, and we have demonstrated that radionuclide RVEF is more powerful than echocardiographic parameters for the risk stratification of outpatients with stable left ventricular systolic dysfunction . However, radionuclide angiography is not always available, is expensive and induces irradiation to patients, albeit less than a computed tomography scan, which is not a technique used in daily practice for the analysis of the RV. These different techniques need a sinus rhythm or a quite regular cardiac rhythm, which is also a limitation. The thermodilution technique is, of course, an invasive method and is not performed routinely in stable patients. Finally, the easiest way to analyse the RV is, of course, echocardiography.

Table 1

Selection of some studies related to RVEF and prognosis in systolic heart failure.

Study	Publication year	n	Aetiology	Methods	Parameters	Cut-off values
Polak et al.	1983	34	Ischaemic	Radionuclide	RVEF	35%
Di Salvo et al.	1995	67	All	Radionuclide	RVEF exercise	35%
Juillière et al.	1997	62	DCM	Thermodilution	RVEF	50%
Sun et al.	1997	100	DCM	Echo	RV/LV ratio	0.5
Karatasakis et al.	1988	48	All	Echo	RV shortening	12.5 mm
de Groote et al.	1998	205	All	Radionuclide	RVEF	39%
Ghio et al.	2001	377	All	Thermodilution	RVEF	35%
Zornoff et al.	2002	416	Post-MI	Echo	RV FAC	32.2%
Gavazzi et al.	2003	76	All	RHC	RVEF and NTG	30%
Meluzin et al.	2005	177	All	Echo	TAPSV/TAPEDV	10.8/8.9 cm/s
Field et al.	2006	77	Post-CRT	Echo	RV MPI	Continuous
Dokainish et al.	2007	100	All	Echo	TAPSV	9 cm/s
Larose et al.	2007	147	Post-MI	MRI	RVEF	40%
Kjaergaard et al.	2007	817	All	Echo	TAPSE	14 mm
Bistola et al.	2010	102	All	Echo	TAPSV	7.3 cm/s
Damy et al.	2012	722	All	Echo	TAPSE	15.9 mm
de Groote et al.	2012	527	All	Radionuclide/Echo	RVEF/TAPSE, TAPSV	37%/18.5 mm, 9.7 cm/s
Melenovsky et al.	2013	408	All	Echo	TAPSE/TAPSV (combined)	10 mm/6 cm/s
Gulati et al.	2013	250	DCM	MRI	RVEF	45%
Iacoviello et al.	2016	332	All	Echo	RV strain	Global: –14% RV free wall: –20.6%

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