IJCS | Volume 31, Nº6, November / December 2018

640 Felix et al. RV function by 2D strain in left-sided valve disease Int J Cardiovasc Sci. 2018;31(6)630-642 Original Article difference in all parameters of RV function between the groups. ROC curve analysis was performed to test the diagnostic performance of these variables to detect RV dysfunction. The best AUC was obtained for FAC (0.932) followed by RVGS (0.872) and RVFWS (0.851), showing the clinical utility of these parameters in detecting RV dysfunction. Among all, FAC had the best performance, and this may be explained by the fact that this is the only parameter directly related to RV ejective function, while all others are closely related to longitudinal systolic function. We performed intraobserver and interobserver analysis for RVGS and RVFWS and found good reproducibility for both parameters, making these measurements more robust and reliable, confirming previous data. 4,32,33 Mittal et al., 34 did not find any correlation between RV systolic parameters andPASP in 22mitral stenosis patients, attributing RV myocardial dysfunction to inflammatory damage caused by the rheumatic disease. Ozdemir et al., 35 demonstrated that patients with mild-to-moderate mitral stenosis had altered values of longitudinal RV 2DS compared to controls, probably unrelated to pulmonary hypertension, since they found only a mild elevation of PASP in these patients (39 ± 14 mmHg). Tanboga et al., 32 studied patients with mild-to-moderate mitral stenosis and also found altered values of longitudinal RV 2DS compared to controls, but did not find any correlation of these values with PASP. Castro et al., 36 studied 46 patients with isolated severe mitral stenosis, showing reduced longitudinal RV 2DS compared to controls, and a weak correlation between 2DS and PASP. Galli et al., 37 studying 200 patients with degenerative aortic valve stenosis, demonstrated RV dysfunction in 24% of these patients, and established concomitant LV and RV dysfunction as the major predictor of mortality in 16 months. Le Tourneau et al., 38 evaluating RV systolic function in 208 patients with severe organic mitral regurgitation found severe RV dysfunction (RVEF ≤ 35% measured by radionuclide angiography) in 63 patients (30%). The authors showed a weak correlation between PASP and RVEF and suggested a direct relation of RV dysfunction with septal function alteration and of LV enlargement with remodeling (ventricular interdependence). Mitral valve disease typically causes greater overload in the right chambers than aortic valve diseases, 39 probably due to an exceptional elevation of capillary pulmonary pressure, either by volume overload in mitral regurgitation or pressure overload in mitral stenosis. Our findings suggest that RVGS and RVFWS may be reliable markers of RV dysfunction in VHD patients, with good accuracy and the potential advantage of early detection of alterations in myocardial function that precede alterations in the RV ejective function. Limitations Our findings must be validated in other studies involving a larger number of subjects. Our small sample size does not allow us to extrapolate these results to other populations. This was a clinical, uncontrolled study, which included consecutive patients with left- sided VHD from different etiologies and mechanisms of valvular dysfunction, reflecting the population of patients currently treated in our clinical practice. Conclusion In left-sidedVHDpatients, RVGS and RVFWS showed good correlation when compared with RVEF 3DE and good accuracy in detecting RV dysfunction. 2DS might be a useful tool for the early detection of changes in RV function in VHD patients. Acknowledgements The author would like to thank Doctor D. Muraru for the invaluable help and precious lessons in the use of 3D techniques, and Doctors M.L. Alcantara, L.M. Alves and C. Weksler, for the constant support along the entire course of this research. Author contributions Conceptionanddesignof the research: FelixAS, Lorenzo AR, Azevedo Filho CF. Acquisition of data: Felix AS. Analysis and interpretation of the data: Felix AS, Siciliano APRV, Xavier SS. Statistical analysis: Felix AS, Xavier SS, Azevedo Filho CF. Obtaining financing: Felix AS. Writing of the manuscript: Felix AS, Lorenzo AR. Critical revision of themanuscript for intellectual content: FelixAS, Siciliano APRV, Belém LHJ, Azevedo FS, Xavier SS, Lorenzo AR, Azevedo FilhoCF. Supervision/ as themajor investigador: Felix AS. Referral of Patients: Azevedo FS. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported.