Use of intraoperative right ventricular strain as a predictor of outcomes in adult heart transplant patients

Abstract

Right ventricle (RV) evaluation in the perioperative period is challenging for anesthesiologists, given the limited objective assessment methods available for transesophageal echocardiography (TEE). Speckle-tracking strain imaging may offer a more objective evaluation of RV function. This study evaluated the predictive value of intraoperative RV free wall strain (RVFWS) for early outcomes following orthotopic heart transplantation (OHT). This was a single-center retrospective cohort study of 147 adults who underwent isolated OHT between January 2025 and December 2025. Patients with multiorgan transplant, congenital cases, and those without measurable intraoperative RVFWS were excluded. Post-bypass RVFWS was measured using TEE at a single time point with speckle-tracking analysis. The primary outcome was 90-day mortality. Secondary outcomes included severe primary graft dysfunction, 30-day mortality, need for postoperative venoarterial extracorporeal membrane oxygenation and continuous renal replacement therapy (CRRT), vasoactive-inotropic score, and cardiac index at 24 and 72 h, and intensive care unit length of stay. Multivariable Firth-penalized logistic and median quantile regressions were used, adjusted for a priori pre-transplant weighted risk score. The median post-bypass RVFWS was −13.9% IQR (interquartile range) −19.3 to −9.6. Fourteen recipients (9.5%) died within 90 days of transplantation. After adjusting for the pre-transplant risk score, RVFWS was independently associated with higher 90-day mortality [odds ratio (OR) 2.84 per 5% decrease in magnitude, 95% confidence interval 1.65–5.58; p  < 0.001]. Among the secondary outcomes, the associations with severe primary graft dysfunction (OR 2.70; raw p  = 0.001), CRRT (OR 1.58; raw p  = 0.001), and 30-day mortality (OR 2.94; raw p  = 0.002) remained statistically significant after Bonferroni adjustment for eleven secondary comparisons (adjusted p  = 0.011, 0.011, and 0.022, respectively). RVFWS demonstrated higher discrimination for 90-day mortality [area under the curve (AUC) 0.83] than qualitative intraoperative RV grading (AUC 0.68), although this difference in AUC did not reach statistical significance. RVFWS retained independent prognostic value in a combined model. Intraoperative post-bypass RVFWS is a feasible and objective intraoperative measure that is independently associated with early adverse outcomes after adult OHT. RVFWS shows promise as a signal of early allograft dysfunction that is not fully explained by pre-transplant risk factors.