Outcomes With Hybrid Catheter-Directed Therapy Compared With Aspiration Thrombectomy for Patients With Intermediate-High Risk Pulmonary Embolism.

PURPOSE: Intermediate-high-risk pulmonary embolism (IHR PE) is a challenging form of embolism obstruction that causes right ventricular (RV) dysfunction. The optimal management of IHR PE has not been established. This single-center prospective, observational study aimed to evaluate the efficacy and safety of complex catheter-directed therapy (CDT) - catheter-directed mechanical aspiration thrombectomy (CDMT) supplemented with catheter-directed thrombolysis (hybrid CDT) in comparison to CDMT alone for IHR PE. METHODS: A propensity score based on the pulmonary embolism severity index class and Miller obstruction index (MOI) was calculated, and 21 hybrid CDT cases (mean age 54.8 (14.7) years, 9/21 women) were matched with 21 CDMT cases (mean age 58.8 (14.9) years, 13/21 women). The baseline demographics, clinical, and treatment characteristics were analyzed. RESULTS: No significant differences were detected regarding baseline demographics and PE severity parameters. Hybrid CDT demonstrated a higher reduction in mean pulmonary artery pressure (mPAP) (hybrid CDT: median mPAP reduction 8 mmHg (IQR: 6-10 mmHg) vs CDMT: median mPAP reduction 6 mmHg (IQR: 4-7 mmHg); P = 0.019), MOI score (hybrid CDT: median change - 5 points (IQR: 5-6 points) vs CDMT median change - 3 points (IQR: 3-5 points); P = 0.019), and median RV: left ventricular ratio (hybrid CDT: median change 0.4 (IQR: 0.3-0.45) vs CDMT median change 0.26 (IQR: 0.2-0.4); P = 0.007). No major bleeding was observed. Both the hybrid CDT and CDMT alone treatments are safe and effective in managing IHR PE. CONCLUSIONS: Hybrid CDT is a promising technique for the management of IHR PE with insufficient thrombus load reduction by CDMT. TRIAL REGISTRATION: NCT0447356-registration date 16 July 2020.

The impact of unilateral pulmonary artery stenosis on right ventricular to pulmonary arterial coupling in patients with transposition of the great arteries.

BACKGROUND: Unilateral pulmonary artery (PA) stenosis is common in the transposition of the great arteries (TGA) after arterial switch operation (ASO) but the effects on the right ventricle (RV) remain unclear. AIMS: To assess the effects of unilateral PA stenosis on RV afterload and function in pediatric patients with TGA-ASO. METHODS: In this retrospective study, eight TGA patients with unilateral PA stenosis underwent heart catheterization and cardiac magnetic resonance (CMR) imaging. RV pressures, RV afterload (arterial elastance [Ea]), PA compliance, RV contractility (end-systolic elastance [Ees]), RV-to-PA (RV-PA) coupling (Ees/Ea), and RV diastolic stiffness (end-diastolic elastance [Eed]) were analyzed and compared to normal values from the literature. RESULTS: In all TGA patients (mean age 12 ± 3 years), RV afterload (Ea) and RV pressures were increased whereas PA compliance was reduced. RV contractility (Ees) was decreased resulting in RV-PA uncoupling. RV diastolic stiffness (Eed) was increased. CMR-derived RV volumes, mass, and ejection fraction were preserved. CONCLUSION: Unilateral PA stenosis results in an increased RV afterload in TGA patients after ASO. RV remodeling and function remain within normal limits when analyzed by CMR but RV pressure-volume loop analysis shows impaired RV diastolic stiffness and RV contractility leading to RV-PA uncoupling.

Right pulmonary artery compression following acute type A aortic dissection resulting in acute right ventricular heart failure: A case report.

Right ventricular failure is a mechanism of hemodynamic collapse in acute aortic dissection. Mostly RV failure happens as a result of coronary malperfusion secondary to compression of right coronary artery ostium by the false lumen of type A aortic dissection or the dissection flap involving this coronary artery. Another mechanism is compression of pulmonary artery and an acute rise of pulmonary pressure below the level of obstruction, which is rarely reported. Herein, we presented an 82-year-old man who was admitted with type A aortic dissection in whom echocardiographic examination revealed right pulmonary artery compression resulting in acute right ventricular failure.

Outcomes of Transcatheter Tricuspid Edge-to-Edge Repair in Patients With Right Ventricular Dysfunction.

BACKGROUND: We assessed the safety profile of tricuspid transcatheter edge-to-edge repair (TEER) in patients with right ventricular (RV) dysfunction. METHODS: We identified patients undergoing TEER to treat tricuspid regurgitation from June 2015 to October 2021 and assessed tricuspid annular plane systolic excursion (TAPSE) and RV fractional area change (RVFAC). RV dysfunction was defined as TAPSE <17 mm and RVFAC <35%. The primary end point was 30-day mortality after TEER. We also investigated the change in the RV function in the early phase and clinical outcomes at 2 years. RESULTS: The study participants (n=262) were at high surgical risk (EuroSCORE II, 6.2% [interquartile range, 4.0%-10.3%]). Among them, 44 patients met the criteria of RV dysfunction. Thirty-day mortality was 3.2% in patients with normal RV function and 2.3% in patients with RV dysfunction (P=0.99). Tricuspid regurgitation reduction to ≤2+ was consistently achieved irrespective of RV dysfunction (76.5% versus 70.5%; P=0.44). TAPSE and RVFAC declined after TEER in patients with normal RV function (TAPSE, 19.0±4.7 to 17.9±4.5 mm; P=0.001; RVFAC, 46.2%±8.1% to 40.3%±9.7%; P<0.001). In contrast, those parameters were unchanged or tended to increase in patients with RV dysfunction (TAPSE, 13.2±2.3 to 15.3±4.7 mm; P=0.011; RVFAC, 29.6%±4.1% to 31.6%±8.3%; P=0.14). Two years after TEER, compared with patients with normal RV function, patients with RV dysfunction had significantly higher mortality (27.0% versus 56.3%; P<0.001). CONCLUSIONS: TEER was safe and feasible to treat tricuspid regurgitation in patients with RV dysfunction. The decline in the RV function was observed in patients with normal RV function but not in patients with RV dysfunction.

The Evolving Concept of Secondary Mitral Regurgitation Phenotypes: Lessons From the M-TEER Trials.

Conflicting results from 2 randomized clinical trials of transcatheter mitral valve edge-to-edge repair in secondary mitral regurgitation (SMR) have led to the recognition that SMR is a heterogeneous disease entity presenting with different functional and morphological phenotypes. This review summarizes the current knowledge on SMR caused primarily by atrial secondary mitral regurgitation (aSMR) and ventricular SMR pathology. Although aSMR is generally characterized by severe left atrial enlargement in the setting of preserved left ventricular anatomy and function, different patterns of mitral annular distortion cause different phenotypes of aSMR. In ventricular SMR, the relation of SMR severity to left ventricular dilation as well as the degree of pulmonary hypertension and right ventricular dysfunction are important phenotypic characteristics, which are key for a better understanding of prognosis and treatment response.

Atrial Arrhythmias in Patients With Pulmonary Hypertension.

TOPIC IMPORTANCE: Atrial arrhythmia (AA) are common in patients with pulmonary hypertension (PH) and contribute to morbidity and mortality. Given the growing PH population, understanding the pathophysiology, clinical impact, and management of AA in PH is important. REVIEW FINDINGS: AA occurs in PH with a 5-year incidence of 10% to 25%. AA confers a higher morbidity and mortality, and restoration of normal sinus rhythm improves survival and functionality. AA is thought to develop because of structural alterations of the right atrium caused by changes to the right ventricle (RV) due to elevated pulmonary artery pressures. AA can subsequently worsen RV function. Current guidelines do not provide comprehensive recommendations for the management of AA in PH. Robust evidence to favor a specific treatment approach is lacking. Although the role of medical rate or rhythm control, and the use of cardioversion and ablation, can be inferred from other populations, evidence is lacking in the PH population. Much remains to be determined regarding the optimal management strategy. We present here our institutional approach and discuss areas for future research. SUMMARY: This review highlights the epidemiology and pathophysiology of AA in patients with PH, describes the relationship between AA and RV dysfunction, and discusses current management practices. We outline our institutional approach and offer directions for future investigation.

Right Ventricular Dysfunction before and after Cardiac Surgery: Prognostic Implications.

Right ventricular dysfunction is a prognostic factor for morbidity and mortality across a broad spectrum of cardiovascular diseases. While the role of the right ventricle in surgical patients has emerged, the prognostic impact of right ventricular dysfunction remains unclear in a large cardiac surgery population. We reviewed the existing literature about the role of right ventricular dysfunction in adults undergoing different kinds of cardiac surgery either present before or developed after surgery itself. Pre- and post-operative right ventricular dysfunction has demonstrated substantial prognostic implications. However, there remains a lack of consensus regarding its definition and diagnostic criteria. The available literature is limited to small-sized studies, underscoring the need for studies with larger populations.

Prognostic value of right ventricular free wall strain in patients with sepsis.

Background: Right ventricular systolic dysfunction (RVSD) in patients with sepsis is an area of growing interest, but its prognostic significance remains unclear and additional tools are needed to improve our understanding. Right ventricular free wall strain (RV-FWS) is a relatively new parameter to assess RV function. This study aimed to investigate the potential correlation between impaired RV-FWS and prognostic outcomes in patients with sepsis. Methods: We prospectively assessed right ventricular function in patients with sepsis within the initial 24 h of their hospital admission. RV-FWS, right ventricular global strain (RV-GS), fractional area change (FAC), and tricuspid annular plane systolic excursion (TAPSE) were examined. RVSD was defined as impaired RV-FWS. Moreover, the association between RVSD and 30-day mortality rate was assessed. Results: This study included 89 patients. Among them, 27 (30.3%) succumbed to their illness within 30 days. The nonsurviving patients demonstrated significantly lower absolute RV-FWS (-19.7% ± 2.4% vs. -21.1% ± 2.1%, P = 0.008) and RV-GS (-17.7% ± 1.2% vs. -18.4% ± 1.4%, P = 0.032) values than the surviving patients. However, TAPSE and FAC values were not significantly different between the two groups. The optimal cutoff values for RV-FWS, RV-GS, FAC, and TAPSE were -19.0%, -17.9%, 36.5%, and 1.55 cm, respectively. Kaplan-Meier survival curves revealed that patients with impaired RV-FWS and RV-GS demonstrated lower 30-day survival rates, and the predictive performance of RV-FWS (hazard ratio [HR]: 3.97, 95% confidence interval [CI]: 1.85-8.51, P < 0.001) was slightly higher than FAC and TAPSE. However, multivariable Cox regression analysis revealed no association between impaired RV-FWS and mortality outcomes (HR: 1.85, 95% CI: 0.56-6.14, P = 0.316). Conclusions: Impaired RV-FWS is not associated with short-term mortality outcomes, and RV strain imaging is of limited value in assessing the prognosis of sepsis.

Optimal combination of right ventricular functional parameters using echocardiography in pulmonary arterial hypertension.

AIMS: Novel echocardiographic parameters of right ventricular (RV) function, including speckle-tracking-derived, three-dimensional, and RV-pulmonary artery coupling parameters, have emerged for the evaluation of pulmonary arterial hypertension (PAH). The relative role of these parameters in the risk stratification of PAH patients is unclear. We compared the performance of multiple RV parameters and sought to establish an optimal model for identifying the risk profile of patients with PAH. METHODS AND RESULTS: Comprehensive risk assessments were performed for 70 patients with PAH. The risk profile of every patient was determined based on the guideline recommendations. Conventional parameters, including fractional area change (FAC) and tricuspid annular plane systolic excursion (TAPSE), novel speckle-tracking-derived RV longitudinal strain (RVLS), and three-dimensional RV ejection fraction (3D-RVEF), were used to evaluate RV function. Pressure-strain loops were measured for the assessment of RV myocardial work, including RV global wasted work (RVGWW). RV-pulmonary artery coupling was assessed by indexing RV parameters to the estimated pulmonary artery systolic pressure (PASP). The median age was 34 (30-43) years, and 62 (88.6%) patients were female. Forty-five patients were classified into the low-risk group, while 25 patients were classified into the intermediate-high-risk group. Most RV parameters could be used to determine the risk profile and exhibited significantly improved diagnostic performance after indexing to PASP (including FAC/PASP, TAPSE/PASP, and 3D-RVEF/PASP). RVLS/PASP showed the best performance, with an area under the curve of 0.895. In multivariate analysis (Model 1), only RVGWW (>90.5 mmHg%), RVLS (> -16.7%), and TAPSE (<17.5 mm) remained significant (all P < 0.05). Model 1 outperformed every single RV parameter, with a significantly larger area under the curve (all P < 0.05). With PASP indexing in Model 2, RVLS/PASP > -0.275 [odds ratio (OR) 20.63, 95% confidence interval (CI) 4.62-92.11, P < 0.001] and RVGWW > 90.5 mmHg% (OR 6.17, 95% CI 1.37-27.76, P = 0.018) independently identified a higher risk profile. The addition of RVGWW to two models determined incremental value in identification (continuous net reclassification improvement 1.058, 95% CI 0.639-1.477, P < 0.001). CONCLUSIONS: The combination models for RV function outperformed any single parameter in identifying the risk profile of patients with PAH. Comprehensive assessment of RV-pulmonary artery coupling using multiparametric methods is clinically meaningful in patients with PAH.

Right ventricular dysfunction in left ventricular assist device candidates: is it time to change our prospective?

The use of left ventricular assist devices (LVAD) has significantly increased in the last years, trying to offer a therapeutic alternative to heart transplantation, in light also to the significant heart donor shortage compared to the growing advanced heart failure population. Despite technological improvements in the devices, LVAD-related mortality is still fairly high, with right heart failure being one of the predominant predictors. Therefore, many efforts have been made toward a thorough right ventricular (RV) evaluation prior to LVAD implant, considering clinical, laboratory, echocardiographic, and invasive hemodynamic parameters. However, there is high heterogeneity regarding both which predictor is the strongest as well as the relative cut-off values, and a consensus has not been reached yet, increasing the risk of facing patients in which the distinction between good or poor RV function cannot be surely reached. In parallel, due to technological development and availability of mechanical circulatory support of the RV, LVADs are being considered even in patients with suboptimal RV function. The aim of our review is to analyze the current evidence regarding the role of RV function prior to LVAD and its evaluation, pointing out the extreme variability in parameters that are currently assessed and future prospective regarding new diagnostic tools. Finally, we attempt to gather the available information on the therapeutic strategies to use in the peri-operative phase, in order to reduce the incidence of RV failure, especially in patients in which the preoperative evaluation highlighted some conflicting results with regard to ventricular function.

Challenges in clinical identification of right ventricular dysfunction in preterm infants with persistent pulmonary hypertension of the newborn.

BACKGROUND: Right ventricular dysfunction, typically qualitatively diagnosed (Q-RVd) in preterm infants, requires echocardiography which is not always acutely available. We aimed to identify clinical indices of Q-RVd in very preterm infants (gestational age, GA <32 weeks) with persistent pulmonary hypertension of newborn (PPHN) and examine the reliability and validity of Q-RVd. METHODS: Forty-seven infants with mean ± SD GA of 26.8 ± 2.7 weeks who had targeted neonatal echocardiography (TNE) ≤72 h old, during PPHN, were retrospectively studied. Three standard TNE clips were reviewed by two blinded assessors, and infants categorized as Q-RVd if moderate-severe RVd was diagnosed on ≥2 clips. Cardiopulmonary clinical indices at TNE and quantitative RV functional markers were compared between Q-RVd vs. no-RVd groups. Potential quantitative RVd definitions examined by classifying each measurement as "low" or "normal" using published data. Inter-rater agreement for Q-RVd assessed using Kappa statistics. RESULTS: Mean age at TNE was 25.3 ± 20.4 h with Q-RVd diagnosed in 19(40 %) infants. Q-RVd group demonstrated higher peak oxygen requirements (96 ± 9 % vs. 84 ± 16 %, p < 0.01); however, no clinical parameters at TNE differentiated the groups. Quantitative measures were lower in Q-RVd patients, confirming classification validity. Among tested quantitative definitions, low RV stroke volume was associated with lower systolic blood pressure (41±7 vs. 47±9 mmHg, p = 0.02) and higher shock index (4.02±0.80 vs. 3.44±0.72, p = 0.02). Kappa for Q-RVd was 0.55 (95%CI 0.32-0.77). CONCLUSIONS: The non-specific nature of clinical markers of RVd in preterm infants with PPHN necessitates echocardiographic diagnosis of RVd. Studies should examine prognostic relevance of RVd and establish outcome-based quantitative definitions in preterm infants.

Risk Stratification and Management of Intermediate-Risk Acute Pulmonary Embolism.

Pulmonary embolism (PE) is the third most common cause of cardiovascular death and necessitates prompt, accurate risk assessment at initial diagnosis to guide treatment and reduce associated mortality. Intermediate-risk PE, defined as the presence of right ventricular (RV) dysfunction in the absence of hemodynamic compromise, carries a significant risk for adverse clinical outcomes and represents a unique diagnostic challenge. While small clinical trials have evaluated advanced treatment strategies beyond standard anticoagulation, such as thrombolytic or endovascular therapy, there remains continued debate on the optimal care for this patient population. Here, we review the most recent risk stratification models, highlighting differences between prediction scores and their limitations, and discuss the utility of serologic biomarkers and imaging modalities to detect right ventricular dysfunction. Additionally, we examine current treatment recommendations including anticoagulation strategies, use of thrombolytics at full and reduced doses, and utilization of invasive treatment options. Current knowledge gaps and ongoing studies are highlighted.

Prognostic implication of glomerular filtration rates in patients with chronic thromboembolic pulmonary hypertension who have undergone balloon pulmonary angioplasty.

Chronic thromboembolic pulmonary hypertension (CTEPH) plays a key role in the deterioration of lung hemodynamics and contributes to secondary dysfunction of the right heart, which is consistently accompanied by systemic malperfusion and a reduced glomerular filtration rate (GFR). The prognosis of CTEPH is markedly influenced by renal function. The aim of the present study was to evaluate the prognostic value of GFR in patients with CTEPH who have undergone balloon pulmonary angioplasty (BPA). From December 2012 to September 2020, a total of 47 patients diagnosed with CTEPH who received BPA were retrospectively studied. Patients were categorized according to their renal function on admission into two groups: GFR >53 and ≤53. Biological, clinical and demographic data of the patients were collected. Data for the two groups in hospital and during follow-up were systematically analyzed and compared. All-cause mortality, death from right heart failure (RHF) and rehospitalization associated with RHF were considered major adverse events (MAEs). The results revealed that the 6-min walk distance, N-terminal pro-B type natriuretic peptide (NT-proBNP), Troponin I and right ventricle diameter were significantly lower, and tricuspid annular plane systolic excursion was significantly higher in the GFR >53 group compared with the GFR ≤53 group at final follow-up. In addition, GFR levels were significantly correlated with NT-proBNP at baseline and final follow-up. Furthermore, based on a multivariate analysis, it was determined that the decreased GFR was an independent predictor of MAEs during follow-up. Therefore, it may be concluded that in addition to being associated with right ventricular function, decreased GFR is also a prognostic marker in CTEPH treated with BPA.

Prognostic significance of right ventricular dysfunction in patients presenting with acute left-sided heart failure.

BACKGROUND: The prognostic value of right ventricular (RV) function in chronic heart failure (HF) has lately been well established. However, research on its role in acute heart failure (AHF) is sparse. RESULTS: This study comprised 195 patients, aged between 18 and 80 years, with acute left-sided heart failure (HF) and a left ventricular ejection fraction (LVEF) < 50%. Patients with LVEF ≥ 50%, mechanical ventilatory or circulatory support, poor echocardiographic windows, prosthetic valves, congenital heart diseases, infective endocarditis, and/or life expectancy < 1 year due to non-cardiac causes were excluded. The study participants' mean age was 57.7 ± 10.9 years, and 74.9% were males. Coronary artery disease was present in 80.5% of patients. The mean LVEF was 31% ± 8.7. RV dysfunction (RVD), defined as tricuspid annular plane systolic excursion (TAPSE) < 17 mm, RV S' < 9.5 cm/s and/or RV fractional area change (FAC) < 35%, was identified in 48.7% of patients. The RV was dilated in 67.7% of the patients. RVD was significantly associated with a longer HF duration, atrial fibrillation, and idiopathic dilated cardiomyopathy. The primary outcome, a 6-month composite of cardiovascular death or hospitalization for worsening HF (HHF), occurred in 42% of the participants. Cardiovascular mortality and HHF occurred in 30.5% and 23.9% of the patients, respectively. The primary endpoint and longer CCU stays were significantly more common in patients with RVD than in those with normal RV function. RV dilatation was significantly associated with the primary outcome, whether alone or in combination with RVD. Multivariate regression analysis showed that only RV global longitudinal strain (GLS) independently predicted poor outcomes. CONCLUSIONS: RVD and RV dilatation strongly predict CV death and HHF in patients with AHF and LVEF < 50%. Multivariate analysis showed that RV GLS was the only predictor of a composite of CV death and HHF.

The Zurkurnai ECG Pattern: A Novel ECG Pattern of the High-Risk Features of Acute Pulmonary Embolism.

Acute pulmonary embolism is an important differential diagnosis in patients presenting with acute shortness of breath. However, the overlapping clinical presentation between acute coronary syndrome, aortic dissection, pneumonia, and heart failure made the diagnosis of pulmonary embolism very challenging in a limited resources center. We present a case of acute pulmonary embolism with an uncommon ECG pattern that was initially misdiagnosed as acute coronary syndrome. The authors made the appropriate diagnosis using the Zurkurnai ECG pattern in acute pulmonary embolism, which is defined as the presence of right axis deviation, deep symmetrical T wave inversion in V1 to V5, II, III, and AVF with the maximum at V3-V4 and poor R wave progression, which indicates the high-risk features of acute pulmonary embolism.

How to assess and treat right ventricular electromechanical dyssynchrony in post-repair tetralogy of Fallot: insights from imaging, invasive studies, and computational modelling.

BACKGROUND AND AIMS: Right bundle branch block (RBBB) and resulting right ventricular (RV) electromechanical discoordination are thought to play a role in the disease process of subpulmonary RV dysfunction that frequently occur post-repair tetralogy of Fallot (ToF). We sought to describe this disease entity, the role of pulmonary re-valvulation, and the potential added value of RV cardiac resynchronization therapy (RV-CRT). METHODS: Two patients with repaired ToF, complete RBBB, pulmonary regurgitation, and significantly decreased RV function underwent echocardiography, cardiac magnetic resonance, and an invasive study to evaluate the potential for RV-CRT as part of the management strategy. The data were used to personalize the CircAdapt model of the human heart and circulation. Resulting Digital Twins were analysed to quantify the relative effects of RV pressure and volume overload and to predict the effect of RV-CRT. RESULTS: Echocardiography showed components of a classic RV dyssynchrony pattern which could be reversed by RV-CRT during invasive study and resulted in acute improvement in RV systolic function. The Digital Twins confirmed a contribution of electromechanical RV dyssynchrony to RV dysfunction and suggested improvement of RV contraction efficiency after RV-CRT. The one patient who underwent successful permanent RV-CRT as part of the pulmonary re-valvulation procedure carried improvements that were in line with the predictions based on his Digital Twin. CONCLUSION: An integrative diagnostic approach to RV dysfunction, including the construction of Digital Twins may help to identify candidates for RV-CRT as part of the lifetime management of ToF and similar congenital heart lesions.

Right Ventricular Dysfunction on Transthoracic Echocardiography and Long-Term Mortality in the Critically Unwell: A Systematic Review and Meta-Analysis.

OBJECTIVE: Right ventricular dysfunction (RVD) is common in the critically ill. To date studies exploring RVD sequelae have had heterogenous definitions and diagnostic methods, with limited follow-up. Additionally much literature has been pathology specific, limiting applicability to the general critically unwell patient. METHOD AND STUDY DESIGN: We conducted a systematic review and meta-analysis to evaluate the impact of RVD diagnosed with transthoracic echocardiography (TTE) on long-term mortality in unselected critically unwell patients compared to those without RVD. A systematic search of EMBASE, Medline and Cochrane was performed from inception to March 2022. All RVD definitions using TTE were included. Patients were those admitted to a critical or intensive care unit, irrespective of disease processes. Long-term mortality was defined as all-cause mortality occurring at least 30 days after hospital admission. A priori subgroup analyses included disease specific and delayed mortality (death after hospital discharge/after the 30th day from hospital admission) in patients with RVD. A random effects model analysis was performed with the Dersimionian and Laird inverse variance method to generate effect estimates. RESULTS: Of 5985 studies, 123 underwent full text review with 16 included (n = 3196). 1258 patients had RVD. 19 unique RVD criteria were identified. The odds ratio (OR) for long term mortality with RVD was 2.92 (95% CI 1.92-4.54, I2 76.4%) compared to no RVD. The direction and extent was similar for cardiac and COVID19 subgroups. Isolated RVD showed an increased risk of delayed mortality when compared to isolated left/biventricular dysfunction (OR 2.01, 95% CI 1.05-3.86, I2 46.8%). CONCLUSION: RVD, irrespective of cause, is associated with increased long term mortality in the critically ill. Future studies should be aimed at understanding the pathophysiological mechanisms by which this occurs. Commonly used echocardiographic definitions of RVD show significant heterogeneity across studies, which contributes to uncertainty within this dataset.