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Holmgren;citation_author=Y. Zhao;citation_title=Effect of pericardial repair after aortic valve replacement on septal and right ventricular function.;citation_pages=388-393;citation_volume=155;citation_year=2012;citation_issue=3;citation_pmid=21112100;citation_doi=10.1016/j.ijcard.2010.10.049"/><meta name="citation_reference" content="citation_journal_title=Curr Cardiol Rep;citation_author=SG. Portnoy;citation_author=LG. Rudski;citation_title=Echocardiographic evaluation of the right ventricle: a 2014 perspective;citation_pages=21;citation_volume=17;citation_year=2015;citation_pmid=25725606;citation_doi=10.1007/s11886-015-0578-8"/><meta name="citation_reference" content="citation_journal_title=Echocardiography;citation_author=DR. Okada;citation_author=HW. Rahmouni;citation_author=HC. Herrmann;citation_title=Assessment of right ventricular function by transthoracic echocardiography following aortic valve replacement;citation_pages=552-7;citation_volume=31;citation_year=2014;citation_pmid=24304365;citation_doi=10.1111/echo.12421"/><title>Right ventricular mechanics and contractility after aortic valve replacement surgery: a randomised study comparing minimally invasive versus conventional approach | Open Heart</title><meta name="description" content="Objective Minimally invasive aortic valve replacementsurgery (MIAVR) is an alternative surgical technique to conventional aortic valve replacement surgery (AVR) in selected patients. The randomised study Cardiac Function after Minimally Invasive Aortic Valve Implantation (CMILE) showed that right ventricular (RV) longitudinal function was reduced after both MIAVR and AVR, but the reduction was more pronounced following AVR. However, postoperative global RV function was equally impaired in both groups. The purpose of this study was to explore alterations in RV mechanics and contractility following MIAVR as compared with AVR.Methods A predefined post hoc analysis of CMILE consisting of 40 patients with severe aortic valve stenosis who were eligible for isolated surgical aortic valve replacement were randomised to MIAVR or AVR. RV function was assessed by echocardiography prior to surgery and 40 days post-surgery.Results Comparing preoperative to postoperative values, RV longitudinal strain rate was preserved following MIAVR (−1.5±0.5 vs −1.5±0.4 1/s, p=0.84) but declined following AVR (−1.7±0.3 vs −1.4±0.3 1/s, p<0.01). RV longitudinal strain reduced following AVR (−27.4±2.9% vs −18.8%±4.7%, p<0.001) and MIAVR (−26.5±5.3% vs −20.7%±4.5%, p<0.01). Peak systolic velocity of the lateral tricuspid annulus reduced by 36.6% in the AVR group (9.3±2.1 vs 5.9±1.5 cm/s, p<0.01) and 18.8% in the MIAVR group (10.1±2.9 vs 8.2±1.4 cm/s, p<0.01) when comparing preoperative values with postoperative values.Conclusions RV contractility was preserved following MIAVR but was deteriorated following AVR. RV longitudinal function reduced substantially following AVR. A decline in RV longitudinal function was also observed following MIAVR, however, to a much lesser extent."/><meta name="DC.Contributor" content="Nashmil Hashemi"/><meta name="DC.Contributor" content="Jonas Johnson"/><meta name="DC.Contributor" content="Lars-Åke Brodin"/><meta name="DC.Contributor" content="Andreia Gomes-Bernardes"/><meta name="DC.Contributor" content="Ulrik Sartipy"/><meta name="DC.Contributor" content="Peter Svenarud"/><meta name="DC.Contributor" content="Magnus Dalén"/><meta name="DC.Contributor" content="Magnus Bäck"/><meta name="DC.Contributor" content="Mahbubul Alam"/><meta name="DC.Contributor" content="Reidar Winter"/><meta name="DC.Format" content="text/html"/><meta name="DC.Identifier" content="10.1136/openhrt-2018-000842"/><meta name="DC.Language" content="en"/><meta name="DC.Publisher" content="British Cardiovascular Society"/><meta name="DC.AccessRights" content="open-access"/><meta name="DC.Title" content="Right ventricular mechanics and contractility after aortic valve replacement surgery: a randomised study comparing minimally invasive versus conventional approach"/><meta name="DC.Description" content="Objective Minimally invasive aortic valve replacementsurgery (MIAVR) is an alternative surgical technique to conventional aortic valve replacement surgery (AVR) in selected patients. The randomised study Cardiac Function after Minimally Invasive Aortic Valve Implantation (CMILE) showed that right ventricular (RV) longitudinal function was reduced after both MIAVR and AVR, but the reduction was more pronounced following AVR. However, postoperative global RV function was equally impaired in both groups. The purpose of this study was to explore alterations in RV mechanics and contractility following MIAVR as compared with AVR.Methods A predefined post hoc analysis of CMILE consisting of 40 patients with severe aortic valve stenosis who were eligible for isolated surgical aortic valve replacement were randomised to MIAVR or AVR. RV function was assessed by echocardiography prior to surgery and 40 days post-surgery.Results Comparing preoperative to postoperative values, RV longitudinal strain rate was preserved following MIAVR (−1.5±0.5 vs −1.5±0.4 1/s, p=0.84) but declined following AVR (−1.7±0.3 vs −1.4±0.3 1/s, p<0.01). RV longitudinal strain reduced following AVR (−27.4±2.9% vs −18.8%±4.7%, p<0.001) and MIAVR (−26.5±5.3% vs −20.7%±4.5%, p<0.01). Peak systolic velocity of the lateral tricuspid annulus reduced by 36.6% in the AVR group (9.3±2.1 vs 5.9±1.5 cm/s, p<0.01) and 18.8% in the MIAVR group (10.1±2.9 vs 8.2±1.4 cm/s, p<0.01) when comparing preoperative values with postoperative values.Conclusions RV contractility was preserved following MIAVR but was deteriorated following AVR. RV longitudinal function reduced substantially following AVR. A decline in RV longitudinal function was also observed following MIAVR, however, to a much lesser extent."/><meta name="DC.Date" content="2018-07-23"/><meta name="DC.Type" content="journal-article"/><meta name="DC.Rights" content="This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license"/><meta name="citation_title" content="Right ventricular mechanics and contractility after aortic valve replacement surgery: a randomised study comparing minimally invasive versus conventional approach"/><meta name="citation_abstract" content="Objective Minimally invasive aortic valve replacementsurgery (MIAVR) is an alternative surgical technique to conventional aortic valve replacement surgery (AVR) in selected patients. The randomised study Cardiac Function after Minimally Invasive Aortic Valve Implantation (CMILE) showed that right ventricular (RV) longitudinal function was reduced after both MIAVR and AVR, but the reduction was more pronounced following AVR. However, postoperative global RV function was equally impaired in both groups. The purpose of this study was to explore alterations in RV mechanics and contractility following MIAVR as compared with AVR.Methods A predefined post hoc analysis of CMILE consisting of 40 patients with severe aortic valve stenosis who were eligible for isolated surgical aortic valve replacement were randomised to MIAVR or AVR. RV function was assessed by echocardiography prior to surgery and 40 days post-surgery.Results Comparing preoperative to postoperative values, RV longitudinal strain rate was preserved following MIAVR (−1.5±0.5 vs −1.5±0.4 1/s, p=0.84) but declined following AVR (−1.7±0.3 vs −1.4±0.3 1/s, p<0.01). RV longitudinal strain reduced following AVR (−27.4±2.9% vs −18.8%±4.7%, p<0.001) and MIAVR (−26.5±5.3% vs −20.7%±4.5%, p<0.01). Peak systolic velocity of the lateral tricuspid annulus reduced by 36.6% in the AVR group (9.3±2.1 vs 5.9±1.5 cm/s, p<0.01) and 18.8% in the MIAVR group (10.1±2.9 vs 8.2±1.4 cm/s, p<0.01) when comparing preoperative values with postoperative values.Conclusions RV contractility was preserved following MIAVR but was deteriorated following AVR. RV longitudinal function reduced substantially following AVR. A decline in RV longitudinal function was also observed following MIAVR, however, to a much lesser extent."/><meta name="citation_journal_title" content="Open Heart"/><meta name="citation_publisher" content="British Cardiovascular Society"/><meta name="citation_publication_date" content="2018-07-23"/><meta name="citation_volume" content="5"/><meta name="citation_issue" content="2"/><meta name="citation_doi" content="10.1136/openhrt-2018-000842"/><meta name="citation_mjid" content="openhrt;5/2/e000842"/><meta name="citation_id" content="5/2/e000842"/><meta name="citation_public_url" content="https://openheart.bmj.com/content/5/2/e000842"/><meta name="citation_full_html_url" content="https://openheart.bmj.com/content/5/2/e000842"/><meta name="citation_pdf_url" content="https://openheart.bmj.com/content/5/2/e000842.full.pdf"/><meta name="citation_issn" content="2053-3624"/><meta name="citation_journal_abbrev" content="Open Heart"/><meta name="citation_pmid" content="10.1136/openhrt-2018-000842"/><meta name="citation_article_type" content="other"/><meta name="citation_section" content="Valvular heart disease"/><meta name="citation_access" content="open-access"/><link rel="canonical" href="/content/5/2/e000842" /><link rel="alternate" type="application/pdf" href="/content/5/2/e000842.full.pdf" /><meta property="og:title" content="Right ventricular mechanics and contractility after aortic valve replacement surgery: a randomised study comparing minimally invasive versus conventional approach"/><meta property="og:description" content="Objective Minimally invasive aortic valve replacementsurgery (MIAVR) is an alternative surgical technique to conventional aortic valve replacement surgery (AVR) in selected patients. The randomised study Cardiac Function after Minimally Invasive Aortic Valve Implantation (CMILE) showed that right ventricular (RV) longitudinal function was reduced after both MIAVR and AVR, but the reduction was more pronounced following AVR. However, postoperative global RV function was equally impaired in both groups. The purpose of this study was to explore alterations in RV mechanics and contractility following MIAVR as compared with AVR.Methods A predefined post hoc analysis of CMILE consisting of 40 patients with severe aortic valve stenosis who were eligible for isolated surgical aortic valve replacement were randomised to MIAVR or AVR. RV function was assessed by echocardiography prior to surgery and 40 days post-surgery.Results Comparing preoperative to postoperative values, RV longitudinal strain rate was preserved following MIAVR (−1.5±0.5 vs −1.5±0.4 1/s, p=0.84) but declined following AVR (−1.7±0.3 vs −1.4±0.3 1/s, p<0.01). RV longitudinal strain reduced following AVR (−27.4±2.9% vs −18.8%±4.7%, p<0.001) and MIAVR (−26.5±5.3% vs −20.7%±4.5%, p<0.01). Peak systolic velocity of the lateral tricuspid annulus reduced by 36.6% in the AVR group (9.3±2.1 vs 5.9±1.5 cm/s, p<0.01) and 18.8% in the MIAVR group (10.1±2.9 vs 8.2±1.4 cm/s, p<0.01) when comparing preoperative values with postoperative values.Conclusions RV contractility was preserved following MIAVR but was deteriorated following AVR. RV longitudinal function reduced substantially following AVR. A decline in RV longitudinal function was also observed following MIAVR, however, to a much lesser extent."/><meta property="og:url" content="https://openheart.bmj.com/content/5/2/e000842"/><meta property="og:site_name" content="Open Heart"/><meta property="og:locale" content="en_GB"/><meta property="og:image" content="https://openheart.bmj.com/content/openhrt/5/2/e000842/F1.medium.gif"/><meta property="og:image:width" content="800"/><meta property="og:image:height" content="600"/><meta property="og:image:alt" content="Right ventricular mechanics and contractility after aortic valve replacement surgery: a randomised study comparing minimally invasive versus conventional approach"/><meta property="og:image" content="https://openheart.bmj.com/content/openhrt/5/2/e000842/F1.large.jpg"/><meta property="og:image:width" content="1800"/><meta property="og:image:height" content="1600"/><meta property="og:image:alt" content="Right ventricular mechanics and contractility after aortic valve replacement surgery: a randomised study comparing minimally invasive versus conventional approach"/><meta property="og:type" content="website"/><meta name="twitter:card" content="summary_large_image"/><meta name="twitter:site" content="@bmj_latest"/><meta name="twitter:title" content="Right ventricular mechanics and contractility after aortic valve replacement surgery: a randomised study comparing minimally invasive versus conventional approach"/><meta name="twitter:description" content="Objective Minimally invasive aortic valve replacementsurgery (MIAVR) is an alternative surgical technique to conventional aortic valve replacement surgery (AVR) in selected patients. The randomised study Cardiac Function after Minimally Invasive Aortic Valve Implantation (CMILE) showed that right ventricular (RV) longitudinal function was reduced after both MIAVR and AVR, but the reduction was more pronounced following AVR. However, postoperative global RV function was equally impaired in both groups. The purpose of this study was to explore alterations in RV mechanics and contractility following MIAVR as compared with AVR.Methods A predefined post hoc analysis of CMILE consisting of 40 patients with severe aortic valve stenosis who were eligible for isolated surgical aortic valve replacement were randomised to MIAVR or AVR. RV function was assessed by echocardiography prior to surgery and 40 days post-surgery.Results Comparing preoperative to postoperative values, RV longitudinal strain rate was preserved following MIAVR (−1.5±0.5 vs −1.5±0.4 1/s, p=0.84) but declined following AVR (−1.7±0.3 vs −1.4±0.3 1/s, p<0.01). RV longitudinal strain reduced following AVR (−27.4±2.9% vs −18.8%±4.7%, p<0.001) and MIAVR (−26.5±5.3% vs −20.7%±4.5%, p<0.01). Peak systolic velocity of the lateral tricuspid annulus reduced by 36.6% in the AVR group (9.3±2.1 vs 5.9±1.5 cm/s, p<0.01) and 18.8% in the MIAVR group (10.1±2.9 vs 8.2±1.4 cm/s, p<0.01) when comparing preoperative values with postoperative values.Conclusions RV contractility was preserved following MIAVR but was deteriorated following AVR. RV longitudinal function reduced substantially following AVR. 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class="border-bmj-blue-600 relative inline underline decoration-1 underline-offset-4 group-hover:decoration-2">Jonas Johnson</span><sup class="ml-1 inline">3</sup></span></p></button>,</span><span class="mr-2"><button type="button" aria-haspopup="dialog" aria-expanded="false" aria-controls="radix-:R9pcrpuuuuuj4ja:" data-state="closed" id="" data-testid="" class="text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 [&_span]:focus-visible:text-bmj-silver-800 focus-visible:border-bmj-silver-500 not-prose rounded-md text-[12px] focus-visible:border-[1px] focus-visible:outline-none sm:text-[14px]"><p id="author-list" class="text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 not-prose group mb-2 text-center text-[14px] leading-5"><span class="inline"><span data-testid="author-list-name-2" class="border-bmj-blue-600 relative inline underline decoration-1 underline-offset-4 group-hover:decoration-2">Lars-Åke Brodin</span><sup class="ml-1 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aria-controls="radix-:Rapcrpuuuuuj4ja:" data-state="closed" id="" data-testid="" class="text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 [&_span]:focus-visible:text-bmj-silver-800 focus-visible:border-bmj-silver-500 not-prose rounded-md text-[12px] focus-visible:border-[1px] focus-visible:outline-none sm:text-[14px]"><p id="author-list" class="text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 not-prose group mb-2 text-center text-[14px] leading-5"><span class="inline"><span data-testid="author-list-name-4" class="border-bmj-blue-600 relative inline underline decoration-1 underline-offset-4 group-hover:decoration-2">Ulrik Sartipy</span><sup class="ml-1 inline">5 6</sup></span></p></button>,</span><span class="mr-2"><button type="button" aria-haspopup="dialog" aria-expanded="false" aria-controls="radix-:Rb9crpuuuuuj4ja:" data-state="closed" id="" data-testid="" class="text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 [&_span]:focus-visible:text-bmj-silver-800 focus-visible:border-bmj-silver-500 not-prose rounded-md text-[12px] focus-visible:border-[1px] focus-visible:outline-none sm:text-[14px]"><p id="author-list" class="text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 not-prose group mb-2 text-center text-[14px] leading-5"><span class="inline"><span data-testid="author-list-name-5" class="border-bmj-blue-600 relative inline underline decoration-1 underline-offset-4 group-hover:decoration-2">Peter Svenarud</span><sup class="ml-1 inline">5 6</sup></span></p></button>,</span><span class="mr-2"><button type="button" aria-haspopup="dialog" aria-expanded="false" aria-controls="radix-:Rbpcrpuuuuuj4ja:" data-state="closed" id="" data-testid="" class="text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 [&_span]:focus-visible:text-bmj-silver-800 focus-visible:border-bmj-silver-500 not-prose rounded-md text-[12px] focus-visible:border-[1px] focus-visible:outline-none sm:text-[14px]"><p id="author-list" class="text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 not-prose group mb-2 text-center text-[14px] leading-5"><span class="inline"><span data-testid="author-list-name-6" class="border-bmj-blue-600 relative inline underline decoration-1 underline-offset-4 group-hover:decoration-2">Magnus Dalén</span><sup class="ml-1 inline">5 6</sup></span></p></button>,</span><span class="mr-2"><button type="button" aria-haspopup="dialog" aria-expanded="false" aria-controls="radix-:Rc9crpuuuuuj4ja:" data-state="closed" id="" data-testid="" class="text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 [&_span]:focus-visible:text-bmj-silver-800 focus-visible:border-bmj-silver-500 not-prose rounded-md text-[12px] focus-visible:border-[1px] focus-visible:outline-none sm:text-[14px]"><p id="author-list" class="text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 not-prose group mb-2 text-center text-[14px] leading-5"><span class="inline"><span data-testid="author-list-name-7" class="border-bmj-blue-600 relative inline underline decoration-1 underline-offset-4 group-hover:decoration-2">Magnus Bäck</span><sup class="ml-1 inline">7</sup></span><span class="ml-1 inline-block"><img data-testid="author-list-orcid-icon-7" class="m-0 inline max-h-4" src="https://orcid.org/sites/default/files/images/orcid_16x16.png" alt="orcid logo" width="16" height="16" /></span></p></button>,</span><span class="mr-2"><button type="button" aria-haspopup="dialog" aria-expanded="false" aria-controls="radix-:Rcpcrpuuuuuj4ja:" data-state="closed" id="" data-testid="" class="text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 [&_span]:focus-visible:text-bmj-silver-800 focus-visible:border-bmj-silver-500 not-prose rounded-md text-[12px] focus-visible:border-[1px] focus-visible:outline-none sm:text-[14px]"><p id="author-list" class="text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 not-prose group mb-2 text-center text-[14px] leading-5"><span class="inline"><span data-testid="author-list-name-8" class="border-bmj-blue-600 relative inline underline decoration-1 underline-offset-4 group-hover:decoration-2">Mahbubul Alam</span><sup class="ml-1 inline">1</sup></span></p></button>,</span><span class="mr-2"><button type="button" aria-haspopup="dialog" aria-expanded="false" aria-controls="radix-:Rd9crpuuuuuj4ja:" data-state="closed" id="" data-testid="" class="text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 [&_span]:focus-visible:text-bmj-silver-800 focus-visible:border-bmj-silver-500 not-prose rounded-md text-[12px] focus-visible:border-[1px] focus-visible:outline-none sm:text-[14px]"><p id="author-list" class="text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 not-prose group mb-2 text-center text-[14px] leading-5"><span class="inline"><span data-testid="author-list-name-9" class="border-bmj-blue-600 relative inline underline decoration-1 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type="button" aria-haspopup="dialog" aria-expanded="false" aria-controls="radix-:Rkrpuuuuuj4ja:" data-state="closed" id="three-dot-icon" data-testid="three-dot-icon" class="text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 [&_span]:focus-visible:text-bmj-silver-800 focus-visible:border-bmj-silver-500 not-prose w-full rounded-md text-[12px] focus-visible:border-[1px] focus-visible:outline-none sm:text-[14px]"><span data-testid="share-text" class="bg-bmj-blue-600 hover:bg-bmj-blue-700 active:bg-bmj-blue-800 focus-visible:outline-bmj-silver-500 block h-[44px] w-full rounded-lg md:hidden"><span class="flex h-full items-center justify-center text-sm font-bold leading-6 text-white">Article options</span></span><span class="share-cite-rights-tooltip bg-share-icon-bg hidden h-[44px] w-[44px] rounded-[8px] pb-[12px] pl-[16px] pr-[16px] pt-[12px] md:block lg:block"><img src="/next-resources/tooltip.svg" alt="Tooltip icon" class="m-auto h-full" /></span></button></div></div><div class="grid grid-cols-[3fr_1fr] gap-x-4 gap-y-4 md:grid-cols-[auto_332px]"><div class="col-span-2 mb-2 pt-[40px] md:mb-6 lg:col-span-1"><div><div xmlns="http://www.w3.org/1999/xhtml" class="article fulltext-view flex flex-col -mb-6"><div class="abstract-section" id="abstract-1"><h2>Abstract</h2><div id="sec-1" class="subsection"><p id="p-2"><strong>Objective</strong> Minimally invasive aortic valve replacementsurgery (MIAVR) is an alternative surgical technique to conventional aortic valve replacement surgery (AVR) in selected patients. The randomised study Cardiac Function after Minimally Invasive Aortic Valve Implantation (CMILE) showed that right ventricular (RV) longitudinal function was reduced after both MIAVR and AVR, but the reduction was more pronounced following AVR. However, postoperative global RV function was equally impaired in both groups. The purpose of this study was to explore alterations in RV mechanics and contractility following MIAVR as compared with AVR.</p></div><div id="sec-2" class="subsection"><p id="p-3"><strong>Methods</strong> A predefined post hoc analysis of CMILE consisting of 40 patients with severe aortic valve stenosis who were eligible for isolated surgical aortic valve replacement were randomised to MIAVR or AVR. RV function was assessed by echocardiography prior to surgery and 40 days post-surgery.</p></div><div id="sec-3" class="subsection"><p id="p-4"><strong>Results</strong> Comparing preoperative to postoperative values, RV longitudinal strain rate was preserved following MIAVR (−1.5±0.5 vs −1.5±0.4 1/s, p=0.84) but declined following AVR (−1.7±0.3 vs −1.4±0.3 1/s, p<0.01). RV longitudinal strain reduced following AVR (−27.4±2.9% vs −18.8%±4.7%, p<0.001) and MIAVR (−26.5±5.3% vs −20.7%±4.5%, p<0.01). Peak systolic velocity of the lateral tricuspid annulus reduced by 36.6% in the AVR group (9.3±2.1 vs 5.9±1.5 cm/s, p<0.01) and 18.8% in the MIAVR group (10.1±2.9 vs 8.2±1.4 cm/s, p<0.01) when comparing preoperative values with postoperative values.</p></div><div id="sec-4" class="subsection"><p id="p-5"><strong>Conclusions</strong> RV contractility was preserved following MIAVR but was deteriorated following AVR. RV longitudinal function reduced substantially following AVR. A decline in RV longitudinal function was also observed following MIAVR, however, to a much lesser extent.</p></div><button data-testid="back-to-top-button" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 focus-visible:border-bmj-silver-500 mt-[16px] rounded-md focus-visible:border-[1px] focus-visible:outline-none">Back to top</button></div><div class="section notes text-bmj-silver-800 border-bmj-silver-100 [&_h3]:text-bmj-silver-800 mb-[40px] border-[1px] px-[24px] pt-[8px] pb-[16px] [&_p]:my-[8px] [&_ul]:m-0 [&_ul]:list-none [&_ul]:p-0 [&_li]:m-0 [&_li]:p-0 [&_h3]:mb-0 [&_h3]:mt-[16px] [&_h3]:text-[1.25rem] [&_h3]:font-normal"><div data-testid="article-notes-content" class="article-notes-content"><div class="" id="boxed-text-1"><h3 data-testid="article-notes-subheader">Key questions</h3><div id="sec-5" class="subsection"><h3>What is already known about this subject?</h3><ul class="list-unord " id="list-1"><li id="list-item-1"><p id="p-6">It is well known that right ventricular (RV) longitudinal function as assessed by tricuspid annulus peak systolic excursion (TAPSE) and peak systolic velocity of lateral tricuspid annulus (RVS) decline following aortic valve replacement (AVR) surgery.</p></li><li id="list-item-2"><p id="p-7">In some studies, this phenomenon has been regarded as reduced global RV function, while other studies have reported preserved global RV function despite a reduction in TAPSE and RVS.</p></li><li id="list-item-3"><p id="p-8">The number of studies analysing the impact of minimally invasive aortic valve replacement (MIAVR) surgery on TAPSE and RVS are limited: one study did not show any decline in TAPSE and RVS following MIAVR,<a id="xref-ref-1-1" class="xref-bibr" href="#ref-1">1</a> while the Cardiac Function after Minimally Invasive Aortic Valve Implantation (CMILE) study showed a decline in TAPSE and RVS following MIAVR.</p></li></ul></div><div id="sec-6" class="subsection"><h3>What does this study add?</h3><ul class="list-unord " id="list-2"><li id="list-item-4"><p id="p-9">Most of previous studies have been analysing the impact of AVR or MIAVR on RV function by methods that are load dependent. Few studies have assessed the impact of AVR/MIAVR on RV function by methods that are load independent.</p></li><li id="list-item-5"><p id="p-10">In our randomised study, we aim to analyse and compare the impact of AVR and MIAVR on RV performance with various load-dependent and load-independent modalities.</p></li><li id="list-item-6"><p id="p-11">The main finding of our study is that both AVR and MIAVR modified RV mechanics. However, intrinsic RV contractility quantified by strain rate was preserved following MIAVR, while it was deteriorated following AVR.</p></li></ul></div></div><div class="" id="boxed-text-2"><h3 data-testid="article-notes-subheader">Key questions</h3><div id="sec-7" class="subsection"><h3>How might this impact on clinical practice?</h3><ul class="list-unord " id="list-3"><li id="list-item-7"><p id="p-12">Assessment of RV performance by echocardiography should include both load-dependent and load-independent metrics. Furthermore, evaluation of RV function should be incorporated in decision making and risk stratification of patients undergoing aortic valve surgery.</p></li></ul></div></div></div></div><div class="article-body-sections wrap-urls md:[&_h2]:text-[2.125rem]" data-testid="article-body-section"><section id="sec-8"><h2 class="">Introduction</h2><p id="p-13">Minimally invasive aortic valve replacement (MIAVR) surgery has in selected patients become an alternative approach to conventional full sternotomy aortic valve replacement (AVR) surgery. A number of studies have compared the efficacy, long-term results, clinical outcomes and patient satisfaction between AVR and MIAVR in the treatment of severe aortic valve stenosis.<a id="xref-ref-2-1" class="xref-bibr" href="#ref-2">2–4</a> However, less has been explored regarding the impact of these surgical techniques on right ventricular (RV) function. Evaluation of RV performance is of eminent clinical importance in the management of patients with a variety of cardiac diseases. It has been shown that RV function is one of the major determinants of symptoms and survival in patients with heart failure.<a id="xref-ref-5-1" class="xref-bibr" href="#ref-5">5 6</a> Furthermore, it has been reported that perioperative RV dysfunction is a predictor of morbidity and mortality following AVR.<a id="xref-ref-7-1" class="xref-bibr" href="#ref-7">7–10</a> </p><p id="p-14">Previous studies have consistently reported a reduction in RV longitudinal function assessed by tricuspid annulus peak systolic excursion (TAPSE) and peak systolic velocity of lateral tricuspid annulus (RVS) following AVR.<a id="xref-ref-11-1" class="xref-bibr" href="#ref-11">11–13</a> However, conclusions drawn from these findings regarding global RV function have been divergent. While some have proposed a reduction in global RV function as assessed by TAPSE and RVS,<a id="xref-ref-11-2" class="xref-bibr" href="#ref-11">11 12</a> others have reported a preserved global RV function despite a reduction in TAPSE and RVS.<a id="xref-ref-13-1" class="xref-bibr" href="#ref-13">13</a> These conflicting conclusions are reflecting several aspects of: (i) the complex geometry of the RV, making evaluation of global RV function complicated; (ii) the complex pathophysiology leading to decreased RV longitudinal function following AVR; and (iii) the commonly used measurements in previous studies (eg, TAPSE, RVS and fractional area change (RV-FAC)) are not pure measures of myocardial contractility but rather strongly dependent on the loading conditions and mechanical influences from the loss of pericardial support and adherences. While TAPSE and RVS are measures of RV mechanics, it has been shown that strain rate (RV longitudinal strain rate (RV-LSR)) is the best measure of myocardial contractility.<a id="xref-ref-14-1" class="xref-bibr" href="#ref-14">14 15</a> There are only a few studies addressing impact of MIAVR on RV function. Unsworth <em>et al</em> <a id="xref-ref-1-2" class="xref-bibr" href="#ref-1">1</a> have reported preserved longitudinal function as assessed by TAPSE following MIAVR as compared with AVR. The randomised study Cardiac Function after Minimally Invasive Aortic Valve Implantation (CMILE) showed that TAPSE was reduced following AVR as well as after MIAVR, but the reduction was more pronounced following AVR. However, global RV function as assessed by RV-FAC was equally impaired in both groups postoperatively.<a id="xref-ref-16-1" class="xref-bibr" href="#ref-16">16</a> In the present study, which is a predefined post hoc analysis of CMILE, we aimed to further evaluate alterations in RV function in terms of both RV mechanics and contractility by assessing the velocity of the longitudinal displacement of the RV free wall, RV longitudinal strain (RV-LS) and RV-LSR. We hypothesise that the impact on RV function from MIAVR compares favourably to AVR due to less trauma applied during surgery.</p></section><button data-testid="back-to-top-button" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 focus-visible:border-bmj-silver-500 mt-[16px] rounded-md focus-visible:border-[1px] focus-visible:outline-none">Back to top</button></div><div class="article-body-sections wrap-urls md:[&_h2]:text-[2.125rem]" data-testid="article-body-section"><section id="sec-9"><h2 class="">Materials and methods</h2><div id="sec-10" class="subsection"><h3>Study design</h3><p id="p-15">The CMILE study was designed as a randomised, single-centre, open-label clinical trial. The methods and design of CMILE study has been previously described elsewhere.<a id="xref-ref-16-2" class="xref-bibr" href="#ref-16">16</a> In brief, patients assigned to aortic valve replacement surgery at Karolinska University Hospital in Stockholm, Sweden, were eligible for inclusion into the study. Forty patients were randomised either to AVR or MIAVR in a 1:1 ratio, between October 2013 and July 2015.</p><p id="p-16">All patients provided a written informed consent. The study is "Post-results" of CMILE study, registered at clinical trials.gov (NCT01972555).</p></div><div id="sec-11" class="subsection"><h3>Patient population</h3><p id="p-17">The inclusion criteria were (1) age ≥18 years; (2) severe AS: defined as peak velocity ≥4 m/s, mean gradient ≥40 mm Hg, aortic valve area (AVA) <1.0 cm<sup>2</sup> or indexed AVA <0.6 cm<sup>2</sup> by Doppler echocardiography in combination with two-dimensional echocardiographic morphology of severe valvular stenosis; (3) referred for surgical replacement of severe AS in adherence to current guidelines<a id="xref-ref-17-1" class="xref-bibr" href="#ref-17">17</a>; and (4) sinus rhythm.</p><p id="p-18">Patients were excluded if they had (1) reduced left ventricular ejection fraction (LVEF) <45%); (2) previous cardiac surgery; (3) concomitant other severe valvular heart disease; (4) coronary artery disease (CAD) requiring surgical intervention; and/or (5) urgent or emergent surgery.</p><p id="p-19">Preoperatively, all patients were investigated by coronary angiography for evaluation of coexisting CAD. Echocardiography was performed within 1 week before surgery and 40 days post-surgery.</p><p id="p-20">Patients were analysed as treated (the patients who crossed over from one group to the other group were analysed in the new group).</p></div></section><button data-testid="back-to-top-button" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 focus-visible:border-bmj-silver-500 mt-[16px] rounded-md focus-visible:border-[1px] focus-visible:outline-none">Back to top</button></div><div class="article-body-sections wrap-urls md:[&_h2]:text-[2.125rem]" data-testid="article-body-section"><section id="sec-12"><h2 class="">Surgical techniques</h2><div id="sec-13" class="subsection"><h3>Minimally invasive aortic valve replacement surgery</h3><p id="p-21">MIAVR was performed via upper partial ministernotomy approach. Approximately a 6 cm vertical skin incision over the upper part of the sternum was applied. A partial J-shaped incision was extended into the right third intercostal space. A small vertical pericardial incision was applied anterior to the ascending aorta and subsequently aortic valve was revealed. CE-marked and FDA-approved mechanical and bioprosthetic aortic valves (conventional stented or sutureless bioprosthesis) were implanted. The pericardial incision was closed at the end of the procedure.</p><p id="p-22">Cardiopulmonary bypass was established through a central arterial and peripheral venous cannulation. Antegrade crystalloid cardioplegia solution was used.</p></div><div id="sec-14" class="subsection"><h3>Conventional aortic valve replacement surgery</h3><p id="p-23">AVR was performed via full median sternotomy. A complete pericardial incision was performed. Myocardial protection was performed using antegrade and/or retrograde cold blood cardioplegia. A bioprosthetic or mechanical aortic valve prosthesis was implanted. Pericardium was not closed at the end of operation.</p></div><div id="sec-15" class="subsection"><h3>Echocardiographic assessment</h3><p id="p-24">Comprehensive transthoracic echocardiography examination was performed according to the recent guidelines.<a id="xref-ref-18-1" class="xref-bibr" href="#ref-18">18</a> All examinations were performed on a Vivid E9 (GE, Healthcare, Horten, Norway). The images were stored digitally for subsequent analysis. An experienced echocardiographer, who was blinded to all clinical data, assessed all analysis off-line using commercially available software EchoPAC V.201 (GE Vingmed Ultrasound AS, Horten, Norway).</p></div><div id="sec-16" class="subsection"><h3>Right heart</h3><p id="p-25">RV size and function was quantified in accordance with American Society of Echocardiography Guidelines.<a id="xref-ref-18-2" class="xref-bibr" href="#ref-18">18</a> </p><p id="p-26">RV-LS and RV-LSR were obtained by Speckle Tracking Echocardiography (STE) from RV-focused four-chamber view. The gain setting and the depth of cine loops were optimised in order to achieve a frame rate of at least 50/s. Subsequent analysis was conducted with dedicated, available commercial software for 2D strain analysis on EchoPAC V.201. The region of interest (ROI) was placed over the RV free wall. The width of the ROI was optimised in order to limit it to the myocardium. End systole was predefined by the software used for strain analysis, in which an automatic estimate of aortic valve closure was used. The software automatically calculated segmental and the global RV-LS and RV-LSR. RV stroke volume was calculated according to the existing guidelines.<a id="xref-ref-19-1" class="xref-bibr" href="#ref-19">19</a> </p><p id="p-27">RVS was measured as the maximal systolic velocity of the RV free wall displacement at the level of tricuspid annulus using cardiac state diagram.<a id="xref-ref-20-1" class="xref-bibr" href="#ref-20">20</a> </p><p id="p-28">Right atrial (RA) volume was assessed by tracing the RA endocardial border in a dedicated apical four-chamber view and by using single plane disk summation. Systolic pulmonary artery pressure was calculated by measuring the maximal tricuspid regurgitant velocity and estimation of RA pressure.</p></div><div id="sec-17" class="subsection"><h3>Left heart</h3><p id="p-29">Left ventricular (LV) size and function was assessed in accordance to current guidelines.<a id="xref-ref-18-3" class="xref-bibr" href="#ref-18">18</a> LVEF was assessed using modified Simpson’s biplane. LV longitudinal strain was obtained by STE. LV diastolic function was assessed by measuring peak early diastolic transmitral flow velocity (LVE) and peak late diastolic transmitral flow velocity (LVA). Deceleration time of LVE derived from Doppler recordings of the mitral inflow. The ratio of LVE/LVA was calculated. Left atrial (LA) volume was assessed with the same method as RA volume.</p></div><div id="sec-18" class="subsection"><h3>Automated analysis of the right ventricle</h3><p id="p-30">The myocardial traces from the tissue Doppler imaging (TDI) recordings were imported to a software called GHLab (Gripping Heart AB, Stockholm, Sweden), where the phases of the cardiac cycle and velocities were automatically identified by the software. The cardiac mechanical time events are defined according to the Dynamic Adaptive Piston Pump principle that describes the heart as a mechanical pump controlled by its inflow.<a id="xref-ref-21-1" class="xref-bibr" href="#ref-21">21 22</a> The movement of the atrioventricular plane initiates the mechanical functioning of the heart and, therefore, the atrial contraction is considered as the starting point of the cardiac cycle. The different phases in the cardiac cycle are defined by shifts in myocardial mechanical work rather than by the opening or closure of the valves. The terms pre-ejection and post-ejection are used instead of isovolumic contraction and relaxation. ROI is chosen at the level of tricuspid annulus of RV free wall. The six phases of the cardiac cycle were identified as: atrial contraction, pre-ejection period, ventricular ejection time, post-ejection period, rapid filling/early diastole and slow filling/diastasis.</p><div id="F1" class="flex items-center justify-center"><section class="my-4"><img id="F1" class="mb-2 mt-[20px] max-h-full max-w-full cursor-pointer object-contain" src="/content/openhrt/5/2/e000842/F1.medium.gif" alt="Figure 1" height="400" /></section></div><div class="mb-4"><a id="request-permissions" data-testid="request-permissions" target="_blank" rel="noreferrer" class="focus-visible:border-bmj-silver-500 [&_span]:focus-visible:text-bmj-silver-800 hover:text-bmj-blue-700 inline-flex items-center rounded-md text-sm no-underline focus:outline-none focus-visible:border-[1px]" href="https://s100.copyright.com/AppDispatchServlet?publisherName=BMJ&publication=openhrt&oa=CC-BY-NC-4.0&title=Right%20ventricular%20mechanics%20and%20contractility%20after%20aortic%20valve%20replacement%20surgery:%20a%20randomised%20study%20comparing%20minimally%20invasive%20versus%20conventional%20approach&publicationDate=2018-07-23&author=&contentID=10.1136/openhrt-2018-000842&volumeNum=5&issueNum=2&startPage=&endPage=&numPages=&copyright=Copyright%20%C2%A9%20:YEAR:,%20The%20Author(s).%20Published%20by%20BMJ%20Publishing%20Group%20Ltd.&orderBeanReset=true"><span data-testid="request-permissions-text" class="request-permissions-text text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 text-[14px] font-bold leading-[20px]">Request permission</span><img data-testid="request-permissions-img" src="/next-resources/vector.svg" alt="request permission icon" class="my-0 ml-[5.88px] h-[16.25px] w-[16.25px]" /></a></div><section class="fig-caption"><span>Figure 1</span><p>Automated analysis of cardiac velocities and time intervals: positioning region of interest (A); the curves in GHLab (B).</p></section><p id="p-32">The duration of each phase, peak myocardial velocities during right ventricular ejection (RVS), tricuspid annular early diastolic velocity (RVE′) and tricuspid annular late diastolic velocity (RVA′) were obtained from the software (GHLab) as shown in figure 1. Subsequently right ventricular index of myocardial performance (RIMP) and ratio between E′/A′ were calculated.</p></div><div id="sec-19" class="subsection"><h3>Statistical methods</h3><p id="p-33">The primary endpoints of this study have previously been reported in the CMILE study.<a id="xref-ref-16-3" class="xref-bibr" href="#ref-16">16</a> Statistical analyses were performed using SPSS (V.22) and MATLAB. Continuous data are reported as means±SD. Categorical data are presented as frequencies or percentages. Predata and postdata within each group were compared by paired Student’s t-test or Wilcoxon signed-rank test whenever suitable. Predata and postdata between AVR and MIAVR were compared using independent samples t-test or non-parametric independent sample whenever suitable. Categorical data were compared using χ<sup>2</sup>. All tests were performed as two-sided tests with a significance level of 0.05.</p></div></section><button data-testid="back-to-top-button" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 focus-visible:border-bmj-silver-500 mt-[16px] rounded-md focus-visible:border-[1px] focus-visible:outline-none">Back to top</button></div><div class="article-body-sections wrap-urls md:[&_h2]:text-[2.125rem]" data-testid="article-body-section"><section id="sec-20"><h2 class="">Results</h2><p id="p-34">A total of 40 patients were enrolled in the study, of which 20 patients were randomised to AVR and 20 patients to MIAVR. One patient who was randomised to MIAVR was converted to AVR intraoperatively due to difficulties in cardioplegia. Two patients who were randomised to AVR died after surgery (1) at 2 days post-surgery due to acute pancreatitis and multiorgan disease; and (2) at 4 days postsurgery due to undiagnosed liver cirrhosis and acute hepatic failure. These patients were excluded from the analysis. Finally, 19 patients were analysed in each group.</p><p id="p-35">Baseline characteristics are presented in (<a id="xref-table-wrap-1-1" class="xref-table" href="#T1">table 1</a>). Mean age was slightly but not significantly lower in the patients undergoing MIAVR compared with patients undergoing AVR. The number of patients with diabetes and previous stroke was slightly higher in the AVR arm but without reaching the statistical significance level. However, the proportion of patients suffering from renal impairment, and hyperlipidaemia was higher in the MIAVR group but did not reach statistical significance. There was no significant difference in patients’ medication between AVR and MIAVR groups, neither before surgery nor after surgery (online <a id="xref-supplementary-material-1-1" class="xref-supplementary-material" href="#DC1">supplementary appendix 1</a>).</p><div class="border-bmj-silver-50 my-[40px] w-full border-t border-b" data-testid="table-component" id="T1"><div class="mt-[24px] flex flex-col justify-between md:flex-row md:items-center lg:justify-between" data-testid="table-header"><strong class="text-bmj-silver-800 flex-1 text-[1.25rem] !font-bold" data-testid="table-title">Table 1</strong><div class="my-2 flex content-center items-center md:my-0" data-testid="table-controls"><button type="button" tabindex="0" aria-expanded="false" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 focus:text-bmj-silver-800 focus-visible:border-bmj-silver-500 text-sm outline-none focus:border-[1px] focus-visible:rounded-md">View inline</button><span class="text-bmj-blue-800 mx-2 text-sm">|</span><button class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 focus:text-bmj-silver-800 focus-visible:border-bmj-silver-500 text-sm outline-none focus:border-[1px] focus-visible:rounded-md" data-testid="popup-open-button">View popup</button></div></div><div data-testid="table-description" class="text-bmj-silver-800 !mt-2 !mb-[24px]">Comparison of baseline clinical characteristics between patients undergoing AVR and patients undergoing MIAVR</div></div><p id="p-39">In the AVR arm, 14 patients received bioprostheses: Edwards Perimount (n=10), St Jude Trifecta (n=2) and Medtronic Hancock II (n=2), and five patients received a mechanical prosthesis: St Jude Regent (n=4) and Sorin Slimline (n=1). In the patients undergoing MIAVR, 14 bioprostheses were also implanted, where 50% were sutureless: Sorin Perseval S (n=6) and Edwards Intuity (n=1), and five mechanical prostheses were implanted: Sorin Bicarbon Slimline (n=5). The mean valve size was 23 mm in both AVR and MIAVR groups. The cardiopulmonary bypass time was longer in the MIAVR group compared with AVR group (113.4±36 vs 87.4±28.2 min, p=0.04). Aortic cross clamp time was similar in the MIAVR and AVR groups (80±21.8 vs 82.9±26.9 min, p=0.72). The 30-day mortality was 10% in the AVR group and none in the MIAVR group. The perioperative/postoperative data are presented in <a id="xref-supplementary-material-1-2" class="xref-supplementary-material" href="#DC1">supplementary appendix 2</a>.</p><div id="sec-21" class="subsection"><h3>RV size and function</h3><p id="p-40">The end-diastolic RV transversal inflow diameter and proximal RV outflow diameter was similar in both groups before and after surgery (<a id="xref-table-wrap-2-1" class="xref-table" href="#T2">table 2</a>).</p><div class="border-bmj-silver-50 my-[40px] w-full border-t border-b" data-testid="table-component" id="T2"><div class="mt-[24px] flex flex-col justify-between md:flex-row md:items-center lg:justify-between" data-testid="table-header"><strong class="text-bmj-silver-800 flex-1 text-[1.25rem] !font-bold" data-testid="table-title">Table 2</strong><div class="my-2 flex content-center items-center md:my-0" data-testid="table-controls"><button type="button" tabindex="0" aria-expanded="false" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 focus:text-bmj-silver-800 focus-visible:border-bmj-silver-500 text-sm outline-none focus:border-[1px] focus-visible:rounded-md">View inline</button><span class="text-bmj-blue-800 mx-2 text-sm">|</span><button class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 focus:text-bmj-silver-800 focus-visible:border-bmj-silver-500 text-sm outline-none focus:border-[1px] focus-visible:rounded-md" data-testid="popup-open-button">View popup</button></div></div><div data-testid="table-description" class="text-bmj-silver-800 !mt-2 !mb-[24px]">Preoperative baseline and postoperative echocardiographic RV measurements in the two surgical groups</div></div><p id="p-46">Prior to surgery, there was no difference in RV-LS and RV-LSR between the patients undergoing AVR or MIAVR. Following surgery, RV-LS was deteriorated in both groups, although without any significant difference between them. RV-LSR was deteriorated in patients treated with AVR comparing values from baseline to values post-surgery (−1.7±0.3 vs −1.4±0.3 1/s, p<0.01). However, RV-LSR was preserved in patients treated with MIAVR when comparing preoperative values with postoperative values (−1.5±0.5 vs −1.5±0.4 1/s, p=0.84) (<a id="xref-fig-2-1" class="xref-fig" href="#F2">figure 2</a>).</p><p id="p-47">At baseline, there was no difference in RVS between the patients undergoing AVR and patients undergoing MIAVR. After surgery, RVS declined in both groups, however, to a much lesser extent in the MIAVR group compared with the AVR group (18.8% vs 36.6%, p<0.001).</p><div id="F2" class="flex items-center justify-center"><section class="my-4"><img id="F2" class="mb-2 mt-[20px] max-h-full max-w-full cursor-pointer object-contain" src="/content/openhrt/5/2/e000842/F2.medium.gif" alt="Figure 2" height="400" /></section></div><div class="mb-4"><a id="request-permissions" data-testid="request-permissions" target="_blank" rel="noreferrer" class="focus-visible:border-bmj-silver-500 [&_span]:focus-visible:text-bmj-silver-800 hover:text-bmj-blue-700 inline-flex items-center rounded-md text-sm no-underline focus:outline-none focus-visible:border-[1px]" href="https://s100.copyright.com/AppDispatchServlet?publisherName=BMJ&publication=openhrt&oa=CC-BY-NC-4.0&title=Right%20ventricular%20mechanics%20and%20contractility%20after%20aortic%20valve%20replacement%20surgery:%20a%20randomised%20study%20comparing%20minimally%20invasive%20versus%20conventional%20approach&publicationDate=2018-07-23&author=&contentID=10.1136/openhrt-2018-000842&volumeNum=5&issueNum=2&startPage=&endPage=&numPages=&copyright=Copyright%20%C2%A9%20:YEAR:,%20The%20Author(s).%20Published%20by%20BMJ%20Publishing%20Group%20Ltd.&orderBeanReset=true"><span data-testid="request-permissions-text" class="request-permissions-text text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 text-[14px] font-bold leading-[20px]">Request permission</span><img data-testid="request-permissions-img" src="/next-resources/vector.svg" alt="request permission icon" class="my-0 ml-[5.88px] h-[16.25px] w-[16.25px]" /></a></div><section class="fig-caption"><span>Figure 2</span><p>Changes in the parameters of right ventricular function in patients undergoing aortic valve replacement surgery (AVR) and minimally invasive aortic valve replacement surgery (MIAVR) comparing preoperative to postoperative values. RIMP, right ventricular index of myocardial performance; RV-FAC, right ventricular fractional area change; RV-LS, right ventricular longitudinal strain; RV-LSR, right ventricular longitudinal strain rate.</p></section><p id="p-49">There was no significant difference in RV performance as assessed by RIMP between patients undergoing AVR and MIAVR at baseline. The RIMP was prolonged in both groups following surgery, although without any significant difference between the groups. The postoperative alterations in different phases of one cardiac cycle from baseline in one patient from each group is shown in <a id="xref-fig-3-1" class="xref-fig" href="#F3">figure 3</a>.</p><div id="F3" class="flex items-center justify-center"><section class="my-4"><img id="F3" class="mb-2 mt-[20px] max-h-full max-w-full cursor-pointer object-contain" src="/content/openhrt/5/2/e000842/F3.medium.gif" alt="Figure 3" height="400" /></section></div><div class="mb-4"><a id="request-permissions" data-testid="request-permissions" target="_blank" rel="noreferrer" class="focus-visible:border-bmj-silver-500 [&_span]:focus-visible:text-bmj-silver-800 hover:text-bmj-blue-700 inline-flex items-center rounded-md text-sm no-underline focus:outline-none focus-visible:border-[1px]" href="https://s100.copyright.com/AppDispatchServlet?publisherName=BMJ&publication=openhrt&oa=CC-BY-NC-4.0&title=Right%20ventricular%20mechanics%20and%20contractility%20after%20aortic%20valve%20replacement%20surgery:%20a%20randomised%20study%20comparing%20minimally%20invasive%20versus%20conventional%20approach&publicationDate=2018-07-23&author=&contentID=10.1136/openhrt-2018-000842&volumeNum=5&issueNum=2&startPage=&endPage=&numPages=&copyright=Copyright%20%C2%A9%20:YEAR:,%20The%20Author(s).%20Published%20by%20BMJ%20Publishing%20Group%20Ltd.&orderBeanReset=true"><span data-testid="request-permissions-text" class="request-permissions-text text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 text-[14px] font-bold leading-[20px]">Request permission</span><img data-testid="request-permissions-img" src="/next-resources/vector.svg" alt="request permission icon" class="my-0 ml-[5.88px] h-[16.25px] w-[16.25px]" /></a></div><section class="fig-caption"><span>Figure 3</span><p>Example of right ventricular cardiac state diagram (CSD) displaying postoperative alterations in different phases of one cardiac cycle. AVR, aortic valve replacement surgery; MIAVR, minimally invasive aortic valve replacement surgery.</p></section><p id="p-51">Sixteen patients (84.2%) in the AVR group and 15 patients (78.9%) in the MIAVR-group presented with a mild degree of tricuspid regurgitation before surgery. After surgery, 15 patients (78.9%) in the AVR group and 15 patients (78.9%) in the MIAVR group presented with mild degree of tricuspid regurgitation. No patients had moderate or severe tricuspid regurgitation in none of the groups neither before surgery nor after surgery. Prior to surgery, pulmonary artery systolic pressure (PASP) was mildly elevated in patients undergoing AVR (37.5±9.1 mm Hg). However, there was no statistically significant difference in PASP between the AVR group and MIAVR group at baseline. After surgery, PASP was reduced to normal levels in both AVR group and MIAVR group and without any significant difference between the groups (27.9±6.7 vs 22.8±13.6, p=0.62).</p></div><div id="sec-22" class="subsection"><h3>LV size and function</h3><p id="p-52">LV linear dimensions (LVEDD and LVESD) and LV volumes (LVEDV or LVESV) did not differ between the groups at baseline. LVEF was normal and without any difference when comparing patients undergoing AVR to patients undergoing MIAVR, both prior to surgery and postsurgery.</p><p id="p-53">LV global longitudinal strain was within the normal range in both groups and remained within the normal range when comparing values and from baseline to post-surgery.</p><p id="p-54">There was no difference in diastolic function between the AVR group and MIAVR group at baseline or after surgery (<a id="xref-table-wrap-3-1" class="xref-table" href="#T3">table 3</a>).</p><div class="border-bmj-silver-50 my-[40px] w-full border-t border-b" data-testid="table-component" id="T3"><div class="mt-[24px] flex flex-col justify-between md:flex-row md:items-center lg:justify-between" data-testid="table-header"><strong class="text-bmj-silver-800 flex-1 text-[1.25rem] !font-bold" data-testid="table-title">Table 3</strong><div class="my-2 flex content-center items-center md:my-0" data-testid="table-controls"><button type="button" tabindex="0" aria-expanded="false" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 focus:text-bmj-silver-800 focus-visible:border-bmj-silver-500 text-sm outline-none focus:border-[1px] focus-visible:rounded-md">View inline</button><span class="text-bmj-blue-800 mx-2 text-sm">|</span><button class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 focus:text-bmj-silver-800 focus-visible:border-bmj-silver-500 text-sm outline-none focus:border-[1px] focus-visible:rounded-md" data-testid="popup-open-button">View popup</button></div></div><div data-testid="table-description" class="text-bmj-silver-800 !mt-2 !mb-[24px]">Preoperative baseline and postoperative echocardiographic LV measurements in the two surgical groups</div></div></div></section><button data-testid="back-to-top-button" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 focus-visible:border-bmj-silver-500 mt-[16px] rounded-md focus-visible:border-[1px] focus-visible:outline-none">Back to top</button></div><div class="article-body-sections wrap-urls md:[&_h2]:text-[2.125rem]" data-testid="article-body-section"><section id="sec-23"><h2 class="">Discussion</h2><p id="p-59">The randomised, prospective CMILE study evaluated the impact of MIAVR and AVR on the regional and global RV function. In the present predefined post hoc analysis of the CMILE study, the principal findings were that MIAVR did not significantly affect RV intrinsic myocardial contractility assessed by RV-LSR, while both MIAVR and AVR induced decreased RV function when using methods that are more load dependent and dependent on extrinsic mechanical influence. RV contractile function is of significant clinical importance. It has been shown that RV contractility is one of the most important parameters for prediction of RV failure in patients treated with LV assist device and development of RV failure following transplantation in patients with precapillary pulmonary hypertension.<a id="xref-ref-23-1" class="xref-bibr" href="#ref-23">23</a> Furthermore, previous studies indicate that impaired RV contractile performance implicates poor outcomes in patients with valvular heart disease.<a id="xref-ref-24-1" class="xref-bibr" href="#ref-24">24</a> </p><p id="p-60">Including more novel and conventional quantitative parameters of RV mechanics and contractility, we observed a significant reduction in regional and global RV function following AVR and MIAVR. Following surgery, RVS was reduced in both groups. However, the magnitude of reduction in RVS was significantly higher following AVR as compared with MIAVR, despite longer cardiopulmonary bypass time in the MIAVR group. Global RV function assessed by RV-LS and RIMP declined in both AVR and MIAVR without any significant difference between the groups. However, RV contractility assessed by RV-LSR was preserved following MIAVR while it was deteriorated following AVR. Previously, it has been acknowledged that load-dependent measures of RV function can change without changes in RV myocardial contractility.<a id="xref-ref-23-2" class="xref-bibr" href="#ref-23">23</a> </p><p id="p-61">Our findings could provide an explanation for the discrepancies in earlier studies. The inconsistencies could thus be understood better from alterations in postoperative loading conditions and/or varying degrees of negative mechanical influence from the thoracotomy and pericardial manipulation. Incision of the pericardium due to altered pericardial constraint has been proposed to be the main factor responsible for deterioration of RV function.<a id="xref-ref-25-1" class="xref-bibr" href="#ref-25">25</a> This hypothesis is further strengthened by our results revealing a postsurgical reduction in RVS and RV-LS following both AVR and MIAVR, despite the fact that during MIAVR only limited parts of the pericardium was incised, which was closed at the end of surgery. It can be speculated that RV is dependent on full pericardial support for maintaining its mechanical function, but this would not necessarily be due to the loss of myocardial contractility. Hence, opening even a small part of the pericardium may result in loss of that support. Furthermore, incision of the pericardium may result in geometrical changes of the RV, which is not restored even after closing the pericardium.<a id="xref-ref-26-1" class="xref-bibr" href="#ref-26">26</a> Although RV longitudinal function was more preserved in MIAVR as compared with AVR, no difference in global RV function was observed between the groups. Although RVS correlates well with global RV function in normal hearts, it does not correlate well with global RV function after open heart surgery.<a id="xref-ref-27-1" class="xref-bibr" href="#ref-27">27</a> Increasing PASP has also been proposed to contribute to deterioration of RV function following AVR. In our study, we observed a reduction in PASP following aortic valve surgery regardless of surgical approach.</p><p id="p-62">The effect of AVR on RV longitudinal function in our study is consistent with the results of previous studies.<a id="xref-ref-11-3" class="xref-bibr" href="#ref-11">11 13</a> Currently, few data are available regarding the effect of MIAVR on RV function. In contrast to our study, Unsworth <em>et al</em> <a id="xref-ref-1-3" class="xref-bibr" href="#ref-1">1</a> have reported preserved RV longitudinal function following MIAVR. This discrepancy could be explained by the fact that there were only eight patients included in that study. Furthermore, as the type of surgical approach for MIAVR has not been reported, it is difficult to compare the results of that study to ours, since the location and size of the pericardial incision has been suggested to affect the magnitude of post-surgical modifications in RV longitudinal contraction.<a id="xref-ref-28-1" class="xref-bibr" href="#ref-28">28</a> </p><p id="p-63">To our knowledge, there are only a few studies available that used novel echocardiographic parameters comparing the impact of AVR and MIAVR on RV function in the context of RV mechanics and contractility. Although MIAVR was associated with a better preserved RVS, there was no significant difference between MIAVR and AVR in global RV function as assessed by RV-LS and RIMP. The state of postsurgical RV function can be translated into clinical outcomes. Dalen <em>et al</em> did not show any difference between AVR or MIAVR in 30-day mortality or 2-year survival.<a id="xref-ref-3-1" class="xref-bibr" href="#ref-3">3</a> </p><p id="p-64">Our findings indicate a more complex picture, where myocardial contractility might be more preserved from MIAVR compared with AVR, but both MIAVR as well as AVR seem to negatively impact RV mechanical function despite preserved contractility in the MIAVR group. A composite of echo-derived parameters should be incorporated in assessment of RV function. Future studies are warranted for investigating long-term results of AVR and MIAVR on RV function and its clinical implications.</p><div id="sec-24" class="subsection"><h3>Limitations</h3><p id="p-65">The main limitation of this study is the relatively small number of patients included in the study. Also, the follow-up time of 40 days in our study was relatively short. Future studies with longer follow-up are required to assess long-term impact of MIAVR and AVR on RV function. Since our study is primarily an echocardiographic study, we would not be able to translate the echocardiographic differences between the groups into clinical outcomes, for example, exercise capacity.</p></div></section><button data-testid="back-to-top-button" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 focus-visible:border-bmj-silver-500 mt-[16px] rounded-md focus-visible:border-[1px] focus-visible:outline-none">Back to top</button></div><div class="article-body-sections wrap-urls md:[&_h2]:text-[2.125rem]" data-testid="article-body-section"><section id="sec-25"><h2 class="">Conclusion</h2><p id="p-66">Both MIAVR and AVR influence RV mechanical function, but MIAVR does not result in a decline in RV contractility. A composite of conventional and novel echocardiographic parameters should be incorporated in assessment for RV function since many estimates of RV function are load dependent.</p></section><button data-testid="back-to-top-button" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 focus-visible:border-bmj-silver-500 mt-[16px] rounded-md focus-visible:border-[1px] focus-visible:outline-none">Back to top</button></div><section id="supplementary-materials" class="article-body-sections order-2 mb-0"><div class="wrap-urls accordion-wrapper border-bmj-silver-50 border-t"><button type="button" aria-expanded="false" tabindex="0" class="text-bmj-blue-800 my-[24px] flex w-full items-center justify-between text-left text-[28px] font-normal leading-10 md:text-[34px]" data-testid="accordion-toggle-button"><span data-testid="accordion-title">Supplementary files</span><img class="m-0" src="/next-resources/AccordionArrowDown.svg" alt="Open accordion" /></button></div></section><section class="article-body-sections order-2 mb-0"><section id="fn-group-1" class="!mt-0"><div class="wrap-urls accordion-wrapper border-bmj-silver-50 border-t"><button type="button" aria-expanded="false" tabindex="0" class="text-bmj-blue-800 my-[24px] flex w-full items-center justify-between text-left text-[28px] font-normal leading-10 md:text-[34px]" data-testid="accordion-toggle-button"><span data-testid="accordion-title">Footnotes</span><img class="m-0" src="/next-resources/AccordionArrowDown.svg" alt="Open accordion" /></button></div></section></section><section class="section ref-list order-1" id="ref-list-1"><section data-testid="reference-list" id="ref-list-1"><div class="wrap-urls accordion-wrapper border-bmj-silver-50 border-t"><button type="button" aria-expanded="false" tabindex="0" class="text-bmj-blue-800 my-[24px] flex w-full items-center justify-between text-left text-[28px] font-normal leading-10 md:text-[34px]" data-testid="accordion-toggle-button"><span 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no-underline" data-testid="overview-list-2">Introduction</a></li><li class="mx-0 pl-0 hidden lg:block"><a href="#sec-9" class="text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 leading-6 no-underline" data-testid="overview-list-3">Materials and methods</a></li><li class="mx-0 pl-0 hidden lg:block"><a href="#sec-12" class="text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 leading-6 no-underline" data-testid="overview-list-4">Surgical techniques</a></li><li class="mx-0 pl-0 hidden lg:block"><a href="#sec-20" class="text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 leading-6 no-underline" data-testid="overview-list-5">Results</a></li><li class="mx-0 pl-0 hidden lg:block"><a href="#sec-23" class="text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 leading-6 no-underline" data-testid="overview-list-6">Discussion</a></li><li class="mx-0 pl-0 hidden lg:block"><a href="#sec-25" class="text-bmj-blue-600 hover:text-bmj-blue-700 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All authors have also sufficiently contributed to conception and design of the study, analysis and interpretation of data, drafting of the manuscript or revising it to justify authorship.\u003c/p\u003e\u003c/li\u003e\u003cli class=\"fn-other\" id=\"fn-10\"\u003e\u003cp id=\"p-68\"\u003e\u003cspan class=\"fn-label font-bold\"\u003eFunding:\u003c/span\u003e NH received a grant from Capio Forskningsstiftelsen, grant number 2017-2995.\u003c/p\u003e\u003c/li\u003e\u003cli class=\"fn-conflict\" id=\"fn-11\"\u003e\u003cp id=\"p-69\"\u003e\u003cspan class=\"fn-label font-bold\"\u003eCompeting interests:\u003c/span\u003e None declared.\u003c/p\u003e\u003c/li\u003e\u003cli class=\"fn-other\" id=\"fn-12\"\u003e\u003cp id=\"p-70\"\u003e\u003cspan class=\"fn-label font-bold\"\u003ePatient consent:\u003c/span\u003e Not required.\u003c/p\u003e\u003c/li\u003e\u003cli class=\"fn-other\" id=\"fn-13\"\u003e\u003cp id=\"p-71\"\u003e\u003cspan class=\"fn-label font-bold\"\u003eEthics approval:\u003c/span\u003e The study was approved by regional ethical committee in Stockholm, Sweden.\u003c/p\u003e\u003c/li\u003e\u003cli class=\"fn-other\" id=\"fn-14\"\u003e\u003cp id=\"p-72\"\u003e\u003cspan class=\"fn-label font-bold\"\u003eProvenance and peer review:\u003c/span\u003e Not commissioned; externally peer reviewed.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/div\u003e\u003c/body\u003e\u003c/html\u003e"])</script><script>self.__next_f.push([1,"6:[[[\"$\",\"meta\",\"author-undefined\",{\"name\":\"citation_author\",\"content\":\"$undefined\"}],[\"$\",\"meta\",\"affiliation-undefined\",{\"name\":\"citation_author_institution\",\"content\":\"$undefined\"}]],[[[\"$\",\"meta\",null,{\"name\":\"citation_reference\",\"content\":\"citation_journal_title=Int J Cardiol;citation_author=B. 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No commercial use is permitted unless otherwise expressly granted.\"}],[\"$\",\"div\",null,{\"className\":\"col-span-12 mt-2 bg-white md:mt-0\",\"children\":[\"$\",\"div\",null,{\"children\":[\"$\",\"h1\",null,{\"id\":\"article-title-1\",\"className\":\"text-bmj-silver-800 mb-6 text-center text-[1.75rem] font-normal leading-[2.25rem] md:text-left lg:text-[2.625rem] lg:leading-[3.063rem]\",\"data-testid\":\"title\",\"children\":\"Right ventricular mechanics and contractility after aortic valve replacement surgery: a randomised study comparing minimally invasive versus conventional approach\"}]}]}],[\"$\",\"div\",null,{\"className\":\"bg-white\",\"children\":[[\"$\",\"$L1e\",null,{\"affiliations\":\"$Q1f\",\"authors\":[{\"authorPosition\":\"first\",\"affiliation\":\"Karolinska Institutet, Department of Clinical Sciences, Unit of Cardiology, Danderyd University Hospital, Stockholm, Sweden; Department of Clinical Physiology, Capio S:t Görans Hospital, Stockholm, Sweden\",\"author\":{\"role\":null,\"displayName\":\"Nashmil Hashemi\",\"orcid\":\"http://orcid.org/0000-0002-6106-4281\"},\"correspondingAuthor\":\"false\",\"processedAffilitations\":[{\"text\":\"Karolinska Institutet, Department of Clinical Sciences, Unit of Cardiology, Danderyd University Hospital, Stockholm, Sweden\",\"index\":1},{\"text\":\"Department of Clinical Physiology, Capio S:t Görans Hospital, Stockholm, Sweden\",\"index\":2}]},{\"authorPosition\":\"middle\",\"affiliation\":\"Department of Medical Engineering, School of Technology and Health, KTH Royal Institute of Technology, Stockholm, Sweden\",\"author\":{\"role\":null,\"displayName\":\"Jonas Johnson\",\"orcid\":null},\"correspondingAuthor\":\"false\",\"processedAffilitations\":[{\"text\":\"Department of Medical Engineering, School of Technology and Health, KTH Royal Institute of Technology, Stockholm, Sweden\",\"index\":3}]},{\"authorPosition\":\"middle\",\"affiliation\":\"Department of Medical Engineering, School of Technology and Health, KTH Royal Institute of Technology, Stockholm, Sweden\",\"author\":{\"role\":null,\"displayName\":\"Lars-Åke Brodin\",\"orcid\":null},\"correspondingAuthor\":\"false\",\"processedAffilitations\":[{\"text\":\"Department of Medical Engineering, School of Technology and Health, KTH Royal Institute of Technology, Stockholm, Sweden\",\"index\":3}]},{\"authorPosition\":\"middle\",\"affiliation\":\"Department of Clinical Physiology, Capio S:t Görans Hospital, Stockholm, Sweden\",\"author\":{\"role\":null,\"displayName\":\"Andreia Gomes-Bernardes\",\"orcid\":null},\"correspondingAuthor\":\"false\",\"processedAffilitations\":[{\"text\":\"Department of Clinical Physiology, Capio S:t Görans Hospital, Stockholm, Sweden\",\"index\":4}]},{\"authorPosition\":\"middle\",\"affiliation\":\"Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden; Karolinska Institutet, Department of Molecular Medicine and Surgery, Stockholm, Sweden\",\"author\":{\"role\":null,\"displayName\":\"Ulrik Sartipy\",\"orcid\":null},\"correspondingAuthor\":\"false\",\"processedAffilitations\":[{\"text\":\"Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden\",\"index\":5},{\"text\":\"Karolinska Institutet, Department of Molecular Medicine and Surgery, Stockholm, Sweden\",\"index\":6}]},{\"authorPosition\":\"middle\",\"affiliation\":\"Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden; Karolinska Institutet, Department of Molecular Medicine and Surgery, Stockholm, Sweden\",\"author\":{\"role\":null,\"displayName\":\"Peter Svenarud\",\"orcid\":null},\"correspondingAuthor\":\"false\",\"processedAffilitations\":[{\"text\":\"Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden\",\"index\":5},{\"text\":\"Karolinska Institutet, Department of Molecular Medicine and Surgery, Stockholm, Sweden\",\"index\":6}]},{\"authorPosition\":\"middle\",\"affiliation\":\"Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden; Karolinska Institutet, Department of Molecular Medicine and Surgery, Stockholm, Sweden\",\"author\":{\"role\":null,\"displayName\":\"Magnus Dalén\",\"orcid\":null},\"correspondingAuthor\":\"false\",\"processedAffilitations\":[{\"text\":\"Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden\",\"index\":5},{\"text\":\"Karolinska Institutet, Department of Molecular Medicine and Surgery, Stockholm, Sweden\",\"index\":6}]},{\"authorPosition\":\"middle\",\"affiliation\":\"Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden\",\"author\":{\"role\":null,\"displayName\":\"Magnus Bäck\",\"orcid\":\"http://orcid.org/0000-0003-0853-5141\"},\"correspondingAuthor\":\"false\",\"processedAffilitations\":[{\"text\":\"Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden\",\"index\":7}]},{\"authorPosition\":\"middle\",\"affiliation\":\"Karolinska Institutet, Department of Clinical Sciences, Unit of Cardiology, Danderyd University Hospital, Stockholm, Sweden\",\"author\":{\"role\":null,\"displayName\":\"Mahbubul Alam\",\"orcid\":null},\"correspondingAuthor\":\"false\",\"processedAffilitations\":[{\"text\":\"Karolinska Institutet, Department of Clinical Sciences, Unit of Cardiology, Danderyd University Hospital, Stockholm, Sweden\",\"index\":1}]},{\"authorPosition\":\"last\",\"affiliation\":\"Karolinska Institutet, Department of Clinical Sciences, Unit of Cardiology, Danderyd University Hospital, Stockholm, Sweden\",\"author\":{\"role\":null,\"displayName\":\"Reidar Winter\",\"orcid\":null},\"correspondingAuthor\":\"false\",\"processedAffilitations\":[{\"text\":\"Karolinska Institutet, Department of Clinical Sciences, Unit of Cardiology, Danderyd University Hospital, Stockholm, Sweden\",\"index\":1}]}],\"nonAuthorText\":[]}],[\"$\",\"div\",null,{\"className\":\"mt-6 grid h-12 w-full md:mt-0 md:hidden\",\"data-testid\":\"pdf\",\"children\":[\"$\",\"$L20\",null,{\"doi\":\"10.1136/openhrt-2018-000842\",\"rightsAndPermissionsData\":\"$1b\",\"articlePath\":\"5/2/e000842\",\"shareData\":\"$1d\",\"articleCitationData\":\"$1c\",\"copyrightStatement\":\"© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.\",\"licenceStatement\":\"http://creativecommons.org/licenses/by-nc/4.0/\",\"fullTextPdfPath\":\"/openhrt/5/2/e000842.full.pdf\"}]}]]}],[\"$\",\"div\",null,{\"className\":\"grid grid-cols-[3fr_1fr] gap-x-4 gap-y-4 md:grid-cols-[auto_332px]\",\"children\":[[\"$\",\"div\",null,{\"className\":\"col-span-2 mb-2 pt-[40px] md:mb-6 lg:col-span-1\",\"children\":[\"$\",\"div\",null,{\"children\":[[\"$\",\"div\",\"1\",{\"xmlns\":\"http://www.w3.org/1999/xhtml\",\"className\":\"article fulltext-view flex flex-col -mb-6\",\"children\":[[\"$\",\"$19\",\"0\",{}],[\"$\",\"$19\",\"1\",{}],[\"$\",\"div\",\"2\",{\"className\":\"abstract-section\",\"id\":\"abstract-1\",\"children\":[[[\"$\",\"h2\",\"0\",{\"children\":\"Abstract\"}],[\"$\",\"div\",\"1\",{\"id\":\"sec-1\",\"className\":\"subsection\",\"children\":[\"$\",\"p\",null,{\"id\":\"p-2\",\"children\":[[\"$\",\"strong\",\"0\",{\"children\":\"Objective\"}],\" Minimally invasive aortic valve replacementsurgery (MIAVR) is an alternative surgical technique to conventional aortic valve replacement surgery (AVR) in selected patients. The randomised study Cardiac Function after Minimally Invasive Aortic Valve Implantation (CMILE) showed that right ventricular (RV) longitudinal function was reduced after both MIAVR and AVR, but the reduction was more pronounced following AVR. However, postoperative global RV function was equally impaired in both groups. The purpose of this study was to explore alterations in RV mechanics and contractility following MIAVR as compared with AVR.\"]}]}],[\"$\",\"div\",\"2\",{\"id\":\"sec-2\",\"className\":\"subsection\",\"children\":[\"$\",\"p\",null,{\"id\":\"p-3\",\"children\":[[\"$\",\"strong\",\"0\",{\"children\":\"Methods\"}],\" A predefined post hoc analysis of CMILE consisting of 40 patients with severe aortic valve stenosis who were eligible for isolated surgical aortic valve replacement were randomised to MIAVR or AVR. RV function was assessed by echocardiography prior to surgery and 40 days post-surgery.\"]}]}],[\"$\",\"div\",\"3\",{\"id\":\"sec-3\",\"className\":\"subsection\",\"children\":[\"$\",\"p\",null,{\"id\":\"p-4\",\"children\":[[\"$\",\"strong\",\"0\",{\"children\":\"Results\"}],\" Comparing preoperative to postoperative values, RV longitudinal strain rate was preserved following MIAVR (−1.5±0.5 vs −1.5±0.4 1/s, p=0.84) but declined following AVR (−1.7±0.3 vs −1.4±0.3 1/s, p\u003c0.01). RV longitudinal strain reduced following AVR (−27.4±2.9% vs −18.8%±4.7%, p\u003c0.001) and MIAVR (−26.5±5.3% vs −20.7%±4.5%, p\u003c0.01). Peak systolic velocity of the lateral tricuspid annulus reduced by 36.6% in the AVR group (9.3±2.1 vs 5.9±1.5 cm/s, p\u003c0.01) and 18.8% in the MIAVR group (10.1±2.9 vs 8.2±1.4 cm/s, p\u003c0.01) when comparing preoperative values with postoperative values.\"]}]}],[\"$\",\"div\",\"4\",{\"id\":\"sec-4\",\"className\":\"subsection\",\"children\":[\"$\",\"p\",null,{\"id\":\"p-5\",\"children\":[[\"$\",\"strong\",\"0\",{\"children\":\"Conclusions\"}],\" RV contractility was preserved following MIAVR but was deteriorated following AVR. RV longitudinal function reduced substantially following AVR. A decline in RV longitudinal function was also observed following MIAVR, however, to a much lesser extent.\"]}]}]],[\"$\",\"$L21\",null,{\"targetId\":\"article-title-1\"}]]}],[\"$\",\"$19\",\"3\",{}],[\"$\",\"$19\",\"4\",{}],[\"$\",\"div\",null,{\"className\":\"section notes text-bmj-silver-800 border-bmj-silver-100 [\u0026_h3]:text-bmj-silver-800 mb-[40px] border-[1px] px-[24px] pt-[8px] pb-[16px] [\u0026_p]:my-[8px] [\u0026_ul]:m-0 [\u0026_ul]:list-none [\u0026_ul]:p-0 [\u0026_li]:m-0 [\u0026_li]:p-0 [\u0026_h3]:mb-0 [\u0026_h3]:mt-[16px] [\u0026_h3]:text-[1.25rem] [\u0026_h3]:font-normal\",\"children\":[\"$\",\"div\",null,{\"data-testid\":\"article-notes-content\",\"className\":\"article-notes-content\",\"children\":[[\"$\",\"div\",\"0\",{\"className\":\"\",\"id\":\"boxed-text-1\",\"children\":[[\"$\",\"h3\",\"0\",{\"data-testid\":\"article-notes-subheader\",\"children\":\"Key questions\"}],[\"$\",\"div\",\"1\",{\"id\":\"sec-5\",\"className\":\"subsection\",\"children\":[[\"$\",\"h3\",\"0\",{\"children\":\"What is already known about this subject?\"}],[\"$\",\"ul\",\"1\",{\"className\":\"list-unord \",\"id\":\"list-1\",\"children\":[[\"$\",\"li\",\"0\",{\"id\":\"list-item-1\",\"children\":[\"$\",\"p\",null,{\"id\":\"p-6\",\"children\":\"It is well known that right ventricular (RV) longitudinal function as assessed by tricuspid annulus peak systolic excursion (TAPSE) and peak systolic velocity of lateral tricuspid annulus (RVS) decline following aortic valve replacement (AVR) surgery.\"}]}],[\"$\",\"li\",\"1\",{\"id\":\"list-item-2\",\"children\":[\"$\",\"p\",null,{\"id\":\"p-7\",\"children\":\"In some studies, this phenomenon has been regarded as reduced global RV function, while other studies have reported preserved global RV function despite a reduction in TAPSE and RVS.\"}]}],[\"$\",\"li\",\"2\",{\"id\":\"list-item-3\",\"children\":[\"$\",\"p\",null,{\"id\":\"p-8\",\"children\":[\"The number of studies analysing the impact of minimally invasive aortic valve replacement (MIAVR) surgery on TAPSE and RVS are limited: one study did not show any decline in TAPSE and RVS following MIAVR,\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-1-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-1\",\"children\":\"1\"}],\" while the Cardiac Function after Minimally Invasive Aortic Valve Implantation (CMILE) study showed a decline in TAPSE and RVS following MIAVR.\"]}]}]]}]]}],[\"$\",\"div\",\"2\",{\"id\":\"sec-6\",\"className\":\"subsection\",\"children\":[[\"$\",\"h3\",\"0\",{\"children\":\"What does this study add?\"}],[\"$\",\"ul\",\"1\",{\"className\":\"list-unord \",\"id\":\"list-2\",\"children\":[[\"$\",\"li\",\"0\",{\"id\":\"list-item-4\",\"children\":[\"$\",\"p\",null,{\"id\":\"p-9\",\"children\":\"Most of previous studies have been analysing the impact of AVR or MIAVR on RV function by methods that are load dependent. Few studies have assessed the impact of AVR/MIAVR on RV function by methods that are load independent.\"}]}],[\"$\",\"li\",\"1\",{\"id\":\"list-item-5\",\"children\":[\"$\",\"p\",null,{\"id\":\"p-10\",\"children\":\"In our randomised study, we aim to analyse and compare the impact of AVR and MIAVR on RV performance with various load-dependent and load-independent modalities.\"}]}],[\"$\",\"li\",\"2\",{\"id\":\"list-item-6\",\"children\":[\"$\",\"p\",null,{\"id\":\"p-11\",\"children\":\"The main finding of our study is that both AVR and MIAVR modified RV mechanics. However, intrinsic RV contractility quantified by strain rate was preserved following MIAVR, while it was deteriorated following AVR.\"}]}]]}]]}]]}],[\"$\",\"div\",\"1\",{\"className\":\"\",\"id\":\"boxed-text-2\",\"children\":[[\"$\",\"h3\",\"0\",{\"data-testid\":\"article-notes-subheader\",\"children\":\"Key questions\"}],[\"$\",\"div\",\"1\",{\"id\":\"sec-7\",\"className\":\"subsection\",\"children\":[[\"$\",\"h3\",\"0\",{\"children\":\"How might this impact on clinical practice?\"}],[\"$\",\"ul\",\"1\",{\"className\":\"list-unord \",\"id\":\"list-3\",\"children\":[\"$\",\"li\",null,{\"id\":\"list-item-7\",\"children\":[\"$\",\"p\",null,{\"id\":\"p-12\",\"children\":\"Assessment of RV performance by echocardiography should include both load-dependent and load-independent metrics. Furthermore, evaluation of RV function should be incorporated in decision making and risk stratification of patients undergoing aortic valve surgery.\"}]}]}]]}]]}]]}]}],[\"$\",\"div\",null,{\"className\":\"article-body-sections wrap-urls md:[\u0026_h2]:text-[2.125rem]\",\"data-testid\":\"article-body-section\",\"children\":[[\"$\",\"section\",\"sec-8\",{\"id\":\"sec-8\",\"children\":[[\"$\",\"h2\",\"0\",{\"className\":\"\",\"children\":\"Introduction\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-13\",\"children\":[\"Minimally invasive aortic valve replacement (MIAVR) surgery has in selected patients become an alternative approach to conventional full sternotomy aortic valve replacement (AVR) surgery. A number of studies have compared the efficacy, long-term results, clinical outcomes and patient satisfaction between AVR and MIAVR in the treatment of severe aortic valve stenosis.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-2-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-2\",\"children\":\"2–4\"}],\" However, less has been explored regarding the impact of these surgical techniques on right ventricular (RV) function. Evaluation of RV performance is of eminent clinical importance in the management of patients with a variety of cardiac diseases. It has been shown that RV function is one of the major determinants of symptoms and survival in patients with heart failure.\",[\"$\",\"a\",\"3\",{\"id\":\"xref-ref-5-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-5\",\"children\":\"5 6\"}],\" Furthermore, it has been reported that perioperative RV dysfunction is a predictor of morbidity and mortality following AVR.\",[\"$\",\"a\",\"5\",{\"id\":\"xref-ref-7-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-7\",\"children\":\"7–10\"}],\"\\n\"]}],[\"$\",\"p\",\"2\",{\"id\":\"p-14\",\"children\":[\"Previous studies have consistently reported a reduction in RV longitudinal function assessed by tricuspid annulus peak systolic excursion (TAPSE) and peak systolic velocity of lateral tricuspid annulus (RVS) following AVR.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-11-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-11\",\"children\":\"11–13\"}],\" However, conclusions drawn from these findings regarding global RV function have been divergent. While some have proposed a reduction in global RV function as assessed by TAPSE and RVS,\",[\"$\",\"a\",\"3\",{\"id\":\"xref-ref-11-2\",\"className\":\"xref-bibr\",\"href\":\"#ref-11\",\"children\":\"11 12\"}],\" others have reported a preserved global RV function despite a reduction in TAPSE and RVS.\",[\"$\",\"a\",\"5\",{\"id\":\"xref-ref-13-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-13\",\"children\":\"13\"}],\" These conflicting conclusions are reflecting several aspects of: (i) the complex geometry of the RV, making evaluation of global RV function complicated; (ii) the complex pathophysiology leading to decreased RV longitudinal function following AVR; and (iii) the commonly used measurements in previous studies (eg, TAPSE, RVS and fractional area change (RV-FAC)) are not pure measures of myocardial contractility but rather strongly dependent on the loading conditions and mechanical influences from the loss of pericardial support and adherences. While TAPSE and RVS are measures of RV mechanics, it has been shown that strain rate (RV longitudinal strain rate (RV-LSR)) is the best measure of myocardial contractility.\",[\"$\",\"a\",\"7\",{\"id\":\"xref-ref-14-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-14\",\"children\":\"14 15\"}],\" There are only a few studies addressing impact of MIAVR on RV function. Unsworth \",[\"$\",\"em\",\"9\",{\"children\":\"et al\"}],\"\\n\",[\"$\",\"a\",\"11\",{\"id\":\"xref-ref-1-2\",\"className\":\"xref-bibr\",\"href\":\"#ref-1\",\"children\":\"1\"}],\" have reported preserved longitudinal function as assessed by TAPSE following MIAVR as compared with AVR. The randomised study Cardiac Function after Minimally Invasive Aortic Valve Implantation (CMILE) showed that TAPSE was reduced following AVR as well as after MIAVR, but the reduction was more pronounced following AVR. However, global RV function as assessed by RV-FAC was equally impaired in both groups postoperatively.\",[\"$\",\"a\",\"13\",{\"id\":\"xref-ref-16-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-16\",\"children\":\"16\"}],\" In the present study, which is a predefined post hoc analysis of CMILE, we aimed to further evaluate alterations in RV function in terms of both RV mechanics and contractility by assessing the velocity of the longitudinal displacement of the RV free wall, RV longitudinal strain (RV-LS) and RV-LSR. We hypothesise that the impact on RV function from MIAVR compares favourably to AVR due to less trauma applied during surgery.\"]}]]}],[\"$\",\"$L21\",null,{\"targetId\":\"article-title-1\"}]]}],[\"$\",\"div\",null,{\"className\":\"article-body-sections wrap-urls md:[\u0026_h2]:text-[2.125rem]\",\"data-testid\":\"article-body-section\",\"children\":[[\"$\",\"section\",\"sec-9\",{\"id\":\"sec-9\",\"children\":[[\"$\",\"h2\",\"0\",{\"className\":\"\",\"children\":\"Materials and methods\"}],[\"$\",\"div\",\"1\",{\"id\":\"sec-10\",\"className\":\"subsection\",\"children\":[[\"$\",\"h3\",\"0\",{\"children\":\"Study design\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-15\",\"children\":[\"The CMILE study was designed as a randomised, single-centre, open-label clinical trial. The methods and design of CMILE study has been previously described elsewhere.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-16-2\",\"className\":\"xref-bibr\",\"href\":\"#ref-16\",\"children\":\"16\"}],\" In brief, patients assigned to aortic valve replacement surgery at Karolinska University Hospital in Stockholm, Sweden, were eligible for inclusion into the study. Forty patients were randomised either to AVR or MIAVR in a 1:1 ratio, between October 2013 and July 2015.\"]}],[\"$\",\"p\",\"2\",{\"id\":\"p-16\",\"children\":\"All patients provided a written informed consent. The study is \\\"Post-results\\\" of CMILE study, registered at clinical trials.gov (NCT01972555).\"}]]}],[\"$\",\"div\",\"2\",{\"id\":\"sec-11\",\"className\":\"subsection\",\"children\":[[\"$\",\"h3\",\"0\",{\"children\":\"Patient population\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-17\",\"children\":[\"The inclusion criteria were (1) age ≥18 years; (2) severe AS: defined as peak velocity ≥4 m/s, mean gradient ≥40 mm Hg, aortic valve area (AVA) \u003c1.0 cm\",[\"$\",\"sup\",\"1\",{\"children\":\"2\"}],\" or indexed AVA \u003c0.6 cm\",[\"$\",\"sup\",\"3\",{\"children\":\"2\"}],\" by Doppler echocardiography in combination with two-dimensional echocardiographic morphology of severe valvular stenosis; (3) referred for surgical replacement of severe AS in adherence to current guidelines\",[\"$\",\"a\",\"5\",{\"id\":\"xref-ref-17-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-17\",\"children\":\"17\"}],\"; and (4) sinus rhythm.\"]}],[\"$\",\"p\",\"2\",{\"id\":\"p-18\",\"children\":\"Patients were excluded if they had (1) reduced left ventricular ejection fraction (LVEF) \u003c45%); (2) previous cardiac surgery; (3) concomitant other severe valvular heart disease; (4) coronary artery disease (CAD) requiring surgical intervention; and/or (5) urgent or emergent surgery.\"}],[\"$\",\"p\",\"3\",{\"id\":\"p-19\",\"children\":\"Preoperatively, all patients were investigated by coronary angiography for evaluation of coexisting CAD. Echocardiography was performed within 1 week before surgery and 40 days post-surgery.\"}],[\"$\",\"p\",\"4\",{\"id\":\"p-20\",\"children\":\"Patients were analysed as treated (the patients who crossed over from one group to the other group were analysed in the new group).\"}]]}]]}],[\"$\",\"$L21\",null,{\"targetId\":\"article-title-1\"}]]}],[\"$\",\"div\",null,{\"className\":\"article-body-sections wrap-urls md:[\u0026_h2]:text-[2.125rem]\",\"data-testid\":\"article-body-section\",\"children\":[[\"$\",\"section\",\"sec-12\",{\"id\":\"sec-12\",\"children\":[[\"$\",\"h2\",\"0\",{\"className\":\"\",\"children\":\"Surgical techniques\"}],[\"$\",\"div\",\"1\",{\"id\":\"sec-13\",\"className\":\"subsection\",\"children\":[[\"$\",\"h3\",\"0\",{\"children\":\"Minimally invasive aortic valve replacement surgery\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-21\",\"children\":\"MIAVR was performed via upper partial ministernotomy approach. Approximately a 6 cm vertical skin incision over the upper part of the sternum was applied. A partial J-shaped incision was extended into the right third intercostal space. A small vertical pericardial incision was applied anterior to the ascending aorta and subsequently aortic valve was revealed. CE-marked and FDA-approved mechanical and bioprosthetic aortic valves (conventional stented or sutureless bioprosthesis) were implanted. The pericardial incision was closed at the end of the procedure.\"}],[\"$\",\"p\",\"2\",{\"id\":\"p-22\",\"children\":\"Cardiopulmonary bypass was established through a central arterial and peripheral venous cannulation. Antegrade crystalloid cardioplegia solution was used.\"}]]}],[\"$\",\"div\",\"2\",{\"id\":\"sec-14\",\"className\":\"subsection\",\"children\":[[\"$\",\"h3\",\"0\",{\"children\":\"Conventional aortic valve replacement surgery\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-23\",\"children\":\"AVR was performed via full median sternotomy. A complete pericardial incision was performed. Myocardial protection was performed using antegrade and/or retrograde cold blood cardioplegia. A bioprosthetic or mechanical aortic valve prosthesis was implanted. Pericardium was not closed at the end of operation.\"}]]}],[\"$\",\"div\",\"3\",{\"id\":\"sec-15\",\"className\":\"subsection\",\"children\":[[\"$\",\"h3\",\"0\",{\"children\":\"Echocardiographic assessment\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-24\",\"children\":[\"Comprehensive transthoracic echocardiography examination was performed according to the recent guidelines.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-18-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-18\",\"children\":\"18\"}],\" All examinations were performed on a Vivid E9 (GE, Healthcare, Horten, Norway). The images were stored digitally for subsequent analysis. An experienced echocardiographer, who was blinded to all clinical data, assessed all analysis off-line using commercially available software EchoPAC V.201 (GE Vingmed Ultrasound AS, Horten, Norway).\"]}]]}],[\"$\",\"div\",\"4\",{\"id\":\"sec-16\",\"className\":\"subsection\",\"children\":[[\"$\",\"h3\",\"0\",{\"children\":\"Right heart\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-25\",\"children\":[\"RV size and function was quantified in accordance with American Society of Echocardiography Guidelines.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-18-2\",\"className\":\"xref-bibr\",\"href\":\"#ref-18\",\"children\":\"18\"}],\"\\n\"]}],[\"$\",\"p\",\"2\",{\"id\":\"p-26\",\"children\":[\"RV-LS and RV-LSR were obtained by Speckle Tracking Echocardiography (STE) from RV-focused four-chamber view. The gain setting and the depth of cine loops were optimised in order to achieve a frame rate of at least 50/s. Subsequent analysis was conducted with dedicated, available commercial software for 2D strain analysis on EchoPAC V.201. The region of interest (ROI) was placed over the RV free wall. The width of the ROI was optimised in order to limit it to the myocardium. End systole was predefined by the software used for strain analysis, in which an automatic estimate of aortic valve closure was used. The software automatically calculated segmental and the global RV-LS and RV-LSR. RV stroke volume was calculated according to the existing guidelines.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-19-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-19\",\"children\":\"19\"}],\"\\n\"]}],[\"$\",\"p\",\"3\",{\"id\":\"p-27\",\"children\":[\"RVS was measured as the maximal systolic velocity of the RV free wall displacement at the level of tricuspid annulus using cardiac state diagram.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-20-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-20\",\"children\":\"20\"}],\"\\n\"]}],[\"$\",\"p\",\"4\",{\"id\":\"p-28\",\"children\":\"Right atrial (RA) volume was assessed by tracing the RA endocardial border in a dedicated apical four-chamber view and by using single plane disk summation. Systolic pulmonary artery pressure was calculated by measuring the maximal tricuspid regurgitant velocity and estimation of RA pressure.\"}]]}],[\"$\",\"div\",\"5\",{\"id\":\"sec-17\",\"className\":\"subsection\",\"children\":[[\"$\",\"h3\",\"0\",{\"children\":\"Left heart\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-29\",\"children\":[\"Left ventricular (LV) size and function was assessed in accordance to current guidelines.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-18-3\",\"className\":\"xref-bibr\",\"href\":\"#ref-18\",\"children\":\"18\"}],\" LVEF was assessed using modified Simpson’s biplane. LV longitudinal strain was obtained by STE. LV diastolic function was assessed by measuring peak early diastolic transmitral flow velocity (LVE) and peak late diastolic transmitral flow velocity (LVA). Deceleration time of LVE derived from Doppler recordings of the mitral inflow. The ratio of LVE/LVA was calculated. Left atrial (LA) volume was assessed with the same method as RA volume.\"]}]]}],[\"$\",\"div\",\"6\",{\"id\":\"sec-18\",\"className\":\"subsection\",\"children\":[[\"$\",\"h3\",\"0\",{\"children\":\"Automated analysis of the right ventricle\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-30\",\"children\":[\"The myocardial traces from the tissue Doppler imaging (TDI) recordings were imported to a software called GHLab (Gripping Heart AB, Stockholm, Sweden), where the phases of the cardiac cycle and velocities were automatically identified by the software. The cardiac mechanical time events are defined according to the Dynamic Adaptive Piston Pump principle that describes the heart as a mechanical pump controlled by its inflow.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-21-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-21\",\"children\":\"21 22\"}],\" The movement of the atrioventricular plane initiates the mechanical functioning of the heart and, therefore, the atrial contraction is considered as the starting point of the cardiac cycle. The different phases in the cardiac cycle are defined by shifts in myocardial mechanical work rather than by the opening or closure of the valves. The terms pre-ejection and post-ejection are used instead of isovolumic contraction and relaxation. ROI is chosen at the level of tricuspid annulus of RV free wall. The six phases of the cardiac cycle were identified as: atrial contraction, pre-ejection period, ventricular ejection time, post-ejection period, rapid filling/early diastole and slow filling/diastasis.\"]}],[\"$\",\"$L22\",\"2\",{\"attributes\":{\"id\":\"F1\",\"className\":\"fig pos-float odd\"},\"highQualityImageUrl\":\"/content/openhrt/5/2/e000842/F1.large.jpg\",\"thumbnailImageUrl\":\"/content/openhrt/5/2/e000842/F1.medium.gif\",\"title\":\"Figure 1\",\"description\":\"Automated analysis of cardiac velocities and time intervals: positioning region of interest (A); the curves in GHLab (B).\",\"rightsAndPermissionsData\":{\"id\":\"openhrt\",\"title\":\"Right ventricular mechanics and contractility after aortic valve replacement surgery: a randomised study comparing minimally invasive versus conventional approach\",\"licenseUrl\":\"http://creativecommons.org/licenses/by-nc/4.0/\",\"accessType\":\"open-access\",\"isOpenAccess\":\"true\",\"publicationDateTimestamp\":\"2018-07-23\",\"authorList\":\"Nashmil Hashemi, Jonas Johnson, Lars-Åke Brodin, Andreia Gomes-Bernardes, Ulrik Sartipy, Peter Svenarud, Magnus Dalén, Magnus Bäck, Mahbubul Alam, Reidar Winter\",\"volume\":\"5\",\"issue\":\"2\",\"firstPage\":\"\",\"lastPage\":\"\"},\"doi\":\"10.1136/openhrt-2018-000842\",\"oa\":\"CC-BY-NC-4.0\"}],[\"$\",\"p\",\"3\",{\"id\":\"p-32\",\"children\":\"The duration of each phase, peak myocardial velocities during right ventricular ejection (RVS), tricuspid annular early diastolic velocity (RVE′) and tricuspid annular late diastolic velocity (RVA′) were obtained from the software (GHLab) as shown in figure 1. Subsequently right ventricular index of myocardial performance (RIMP) and ratio between E′/A′ were calculated.\"}]]}],[\"$\",\"div\",\"7\",{\"id\":\"sec-19\",\"className\":\"subsection\",\"children\":[[\"$\",\"h3\",\"0\",{\"children\":\"Statistical methods\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-33\",\"children\":[\"The primary endpoints of this study have previously been reported in the CMILE study.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-16-3\",\"className\":\"xref-bibr\",\"href\":\"#ref-16\",\"children\":\"16\"}],\" Statistical analyses were performed using SPSS (V.22) and MATLAB. Continuous data are reported as means±SD. Categorical data are presented as frequencies or percentages. Predata and postdata within each group were compared by paired Student’s t-test or Wilcoxon signed-rank test whenever suitable. Predata and postdata between AVR and MIAVR were compared using independent samples t-test or non-parametric independent sample whenever suitable. Categorical data were compared using χ\",[\"$\",\"sup\",\"3\",{\"children\":\"2\"}],\". All tests were performed as two-sided tests with a significance level of 0.05.\"]}]]}]]}],[\"$\",\"$L21\",null,{\"targetId\":\"article-title-1\"}]]}],[\"$\",\"div\",null,{\"className\":\"article-body-sections wrap-urls md:[\u0026_h2]:text-[2.125rem]\",\"data-testid\":\"article-body-section\",\"children\":[[\"$\",\"section\",\"sec-20\",{\"id\":\"sec-20\",\"children\":[[\"$\",\"h2\",\"0\",{\"className\":\"\",\"children\":\"Results\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-34\",\"children\":\"A total of 40 patients were enrolled in the study, of which 20 patients were randomised to AVR and 20 patients to MIAVR. One patient who was randomised to MIAVR was converted to AVR intraoperatively due to difficulties in cardioplegia. Two patients who were randomised to AVR died after surgery (1) at 2 days post-surgery due to acute pancreatitis and multiorgan disease; and (2) at 4 days postsurgery due to undiagnosed liver cirrhosis and acute hepatic failure. These patients were excluded from the analysis. Finally, 19 patients were analysed in each group.\"}],[\"$\",\"p\",\"2\",{\"id\":\"p-35\",\"children\":[\"Baseline characteristics are presented in (\",[\"$\",\"a\",\"1\",{\"id\":\"xref-table-wrap-1-1\",\"className\":\"xref-table\",\"href\":\"#T1\",\"children\":\"table 1\"}],\"). Mean age was slightly but not significantly lower in the patients undergoing MIAVR compared with patients undergoing AVR. The number of patients with diabetes and previous stroke was slightly higher in the AVR arm but without reaching the statistical significance level. However, the proportion of patients suffering from renal impairment, and hyperlipidaemia was higher in the MIAVR group but did not reach statistical significance. There was no significant difference in patients’ medication between AVR and MIAVR groups, neither before surgery nor after surgery (online \",[\"$\",\"a\",\"3\",{\"id\":\"xref-supplementary-material-1-1\",\"className\":\"xref-supplementary-material\",\"href\":\"#DC1\",\"children\":\"supplementary appendix 1\"}],\").\"]}],[\"$\",\"$19\",\"3\",{}],[\"$\",\"$L23\",\"4\",{\"title\":\"Table 1\",\"description\":\"Comparison of baseline clinical characteristics between patients undergoing AVR and patients undergoing 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In the patients undergoing MIAVR, 14 bioprostheses were also implanted, where 50% were sutureless: Sorin Perseval S (n=6) and Edwards Intuity (n=1), and five mechanical prostheses were implanted: Sorin Bicarbon Slimline (n=5). The mean valve size was 23 mm in both AVR and MIAVR groups. The cardiopulmonary bypass time was longer in the MIAVR group compared with AVR group (113.4±36 vs 87.4±28.2 min, p=0.04). Aortic cross clamp time was similar in the MIAVR and AVR groups (80±21.8 vs 82.9±26.9 min, p=0.72). The 30-day mortality was 10% in the AVR group and none in the MIAVR group. The perioperative/postoperative data are presented in \",[\"$\",\"a\",\"1\",{\"id\":\"xref-supplementary-material-1-2\",\"className\":\"xref-supplementary-material\",\"href\":\"#DC1\",\"children\":\"supplementary appendix 2\"}],\".\"]}],[\"$\",\"div\",\"6\",{\"id\":\"sec-21\",\"className\":\"subsection\",\"children\":[[\"$\",\"h3\",\"0\",{\"children\":\"RV size and function\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-40\",\"children\":[\"The end-diastolic RV transversal inflow diameter and proximal RV outflow diameter was similar in both groups before and after surgery (\",[\"$\",\"a\",\"1\",{\"id\":\"xref-table-wrap-2-1\",\"className\":\"xref-table\",\"href\":\"#T2\",\"children\":\"table 2\"}],\").\"]}],[\"$\",\"$L23\",\"2\",{\"title\":\"Table 2\",\"description\":\"Preoperative baseline and postoperative echocardiographic RV measurements in the two surgical 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MIAVR.\"}]}],[\"$\",\"li\",\"3\",{\"className\":\"fn\",\"id\":\"fn-5\",\"children\":[\"$\",\"p\",null,{\"id\":\"p-45\",\"children\":\"RV, right ventricular: A′, late diastolic myocardial velocity; AVR, aortic valve replacement surgery; E′, early diastolic myocardial velocity; ET, ejection time; HR, heart rate; MIAVR, minimally invasive aortic valve replacement surgery; PEP, pre-ejection period; POP, post-ejection period; RA, right atrial; RIMP, right ventricular index of myocardial performance; RVD1, RV basal linear dimension; RVOT prox, proximal RV outflow diameter; S, peak systolic myocardial velocity; SPAP, systolic pulmonary artery pressure; TR, tricuspid regurgitation.\"}]}]]}]}]]}],[\"$\",\"p\",\"3\",{\"id\":\"p-46\",\"children\":[\"Prior to surgery, there was no difference in RV-LS and RV-LSR between the patients undergoing AVR or MIAVR. Following surgery, RV-LS was deteriorated in both groups, although without any significant difference between them. RV-LSR was deteriorated in patients treated with AVR comparing values from baseline to values post-surgery (−1.7±0.3 vs −1.4±0.3 1/s, p\u003c0.01). However, RV-LSR was preserved in patients treated with MIAVR when comparing preoperative values with postoperative values (−1.5±0.5 vs −1.5±0.4 1/s, p=0.84) (\",[\"$\",\"a\",\"1\",{\"id\":\"xref-fig-2-1\",\"className\":\"xref-fig\",\"href\":\"#F2\",\"children\":\"figure 2\"}],\").\"]}],[\"$\",\"p\",\"4\",{\"id\":\"p-47\",\"children\":\"At baseline, there was no difference in RVS between the patients undergoing AVR and patients undergoing MIAVR. After surgery, RVS declined in both groups, however, to a much lesser extent in the MIAVR group compared with the AVR group (18.8% vs 36.6%, p\u003c0.001).\"}],[\"$\",\"$L22\",\"5\",{\"attributes\":{\"id\":\"F2\",\"className\":\"fig pos-float odd\"},\"highQualityImageUrl\":\"/content/openhrt/5/2/e000842/F2.large.jpg\",\"thumbnailImageUrl\":\"/content/openhrt/5/2/e000842/F2.medium.gif\",\"title\":\"Figure 2\",\"description\":\"Changes in the parameters of right ventricular function in patients undergoing aortic valve replacement surgery (AVR) and minimally invasive aortic valve replacement surgery (MIAVR) comparing preoperative to postoperative values. RIMP, right ventricular index of myocardial performance; RV-FAC, right ventricular fractional area change; RV-LS, right ventricular longitudinal strain; RV-LSR, right ventricular longitudinal strain rate.\",\"rightsAndPermissionsData\":{\"id\":\"openhrt\",\"title\":\"Right ventricular mechanics and contractility after aortic valve replacement surgery: a randomised study comparing minimally invasive versus conventional approach\",\"licenseUrl\":\"http://creativecommons.org/licenses/by-nc/4.0/\",\"accessType\":\"open-access\",\"isOpenAccess\":\"true\",\"publicationDateTimestamp\":\"2018-07-23\",\"authorList\":\"Nashmil Hashemi, Jonas Johnson, Lars-Åke Brodin, Andreia Gomes-Bernardes, Ulrik Sartipy, Peter Svenarud, Magnus Dalén, Magnus Bäck, Mahbubul Alam, Reidar Winter\",\"volume\":\"5\",\"issue\":\"2\",\"firstPage\":\"\",\"lastPage\":\"\"},\"doi\":\"10.1136/openhrt-2018-000842\",\"oa\":\"CC-BY-NC-4.0\"}],[\"$\",\"p\",\"6\",{\"id\":\"p-49\",\"children\":[\"There was no significant difference in RV performance as assessed by RIMP between patients undergoing AVR and MIAVR at baseline. The RIMP was prolonged in both groups following surgery, although without any significant difference between the groups. The postoperative alterations in different phases of one cardiac cycle from baseline in one patient from each group is shown in \",[\"$\",\"a\",\"1\",{\"id\":\"xref-fig-3-1\",\"className\":\"xref-fig\",\"href\":\"#F3\",\"children\":\"figure 3\"}],\".\"]}],[\"$\",\"$L22\",\"7\",{\"attributes\":{\"id\":\"F3\",\"className\":\"fig pos-float odd\"},\"highQualityImageUrl\":\"/content/openhrt/5/2/e000842/F3.large.jpg\",\"thumbnailImageUrl\":\"/content/openhrt/5/2/e000842/F3.medium.gif\",\"title\":\"Figure 3\",\"description\":\"Example of right ventricular cardiac state diagram (CSD) displaying\u0026nbsp;postoperative alterations in different phases of one cardiac cycle. AVR, aortic valve replacement surgery; MIAVR, minimally invasive aortic valve replacement surgery.\",\"rightsAndPermissionsData\":{\"id\":\"openhrt\",\"title\":\"Right ventricular mechanics and contractility after aortic valve replacement surgery: a randomised study comparing minimally invasive versus conventional approach\",\"licenseUrl\":\"http://creativecommons.org/licenses/by-nc/4.0/\",\"accessType\":\"open-access\",\"isOpenAccess\":\"true\",\"publicationDateTimestamp\":\"2018-07-23\",\"authorList\":\"Nashmil Hashemi, Jonas Johnson, Lars-Åke Brodin, Andreia Gomes-Bernardes, Ulrik Sartipy, Peter Svenarud, Magnus Dalén, Magnus Bäck, Mahbubul Alam, Reidar Winter\",\"volume\":\"5\",\"issue\":\"2\",\"firstPage\":\"\",\"lastPage\":\"\"},\"doi\":\"10.1136/openhrt-2018-000842\",\"oa\":\"CC-BY-NC-4.0\"}],[\"$\",\"p\",\"8\",{\"id\":\"p-51\",\"children\":\"Sixteen patients (84.2%) in the AVR group and 15 patients (78.9%) in the MIAVR-group presented with a mild degree of tricuspid regurgitation before surgery. After surgery, 15 patients (78.9%) in the AVR group and 15 patients (78.9%) in the MIAVR group presented with mild degree of tricuspid regurgitation. No patients had moderate or severe tricuspid regurgitation in none of the groups neither before surgery nor after surgery. Prior to surgery, pulmonary artery systolic pressure (PASP) was mildly elevated in patients undergoing AVR (37.5±9.1 mm Hg). However, there was no statistically significant difference in PASP between the AVR group and MIAVR group at baseline. After surgery, PASP was reduced to normal levels in both AVR group and MIAVR group and without any significant difference between the groups (27.9±6.7 vs 22.8±13.6, p=0.62).\"}]]}],[\"$\",\"div\",\"7\",{\"id\":\"sec-22\",\"className\":\"subsection\",\"children\":[[\"$\",\"h3\",\"0\",{\"children\":\"LV size and function\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-52\",\"children\":\"LV linear dimensions (LVEDD and LVESD) and LV volumes (LVEDV or LVESV) did not differ between the groups at baseline. LVEF was normal and without any difference when comparing patients undergoing AVR to patients undergoing MIAVR, both prior to surgery and postsurgery.\"}],[\"$\",\"p\",\"2\",{\"id\":\"p-53\",\"children\":\"LV global longitudinal strain was within the normal range in both groups and remained within the normal range when comparing values and from baseline to post-surgery.\"}],[\"$\",\"p\",\"3\",{\"id\":\"p-54\",\"children\":[\"There was no difference in diastolic function between the AVR group and MIAVR group at baseline or after surgery (\",[\"$\",\"a\",\"1\",{\"id\":\"xref-table-wrap-3-1\",\"className\":\"xref-table\",\"href\":\"#T3\",\"children\":\"table 3\"}],\").\"]}],[\"$\",\"$L23\",\"4\",{\"title\":\"Table 3\",\"description\":\"Preoperative baseline and postoperative echocardiographic LV measurements in the two surgical 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In the present predefined post hoc analysis of the CMILE study, the principal findings were that MIAVR did not significantly affect RV intrinsic myocardial contractility assessed by RV-LSR, while both MIAVR and AVR induced decreased RV function when using methods that are more load dependent and dependent on extrinsic mechanical influence. RV contractile function is of significant clinical importance. It has been shown that RV contractility is one of the most important parameters for prediction of RV failure in patients treated with LV assist device and development of RV failure following transplantation in patients with precapillary pulmonary hypertension.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-23-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-23\",\"children\":\"23\"}],\" Furthermore, previous studies indicate that impaired RV contractile performance implicates poor outcomes in patients with valvular heart disease.\",[\"$\",\"a\",\"3\",{\"id\":\"xref-ref-24-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-24\",\"children\":\"24\"}],\"\\n\"]}],[\"$\",\"p\",\"2\",{\"id\":\"p-60\",\"children\":[\"Including more novel and conventional quantitative parameters of RV mechanics and contractility, we observed a significant reduction in regional and global RV function following AVR and MIAVR. Following surgery, RVS was reduced in both groups. However, the magnitude of reduction in RVS was significantly higher following AVR as compared with MIAVR, despite longer cardiopulmonary bypass time in the MIAVR group. Global RV function assessed by RV-LS and RIMP declined in both AVR and MIAVR without any significant difference between the groups. However, RV contractility assessed by RV-LSR was preserved following MIAVR while it was deteriorated following AVR. Previously, it has been acknowledged that load-dependent measures of RV function can change without changes in RV myocardial contractility.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-23-2\",\"className\":\"xref-bibr\",\"href\":\"#ref-23\",\"children\":\"23\"}],\"\\n\"]}],[\"$\",\"p\",\"3\",{\"id\":\"p-61\",\"children\":[\"Our findings could provide an explanation for the discrepancies in earlier studies. The inconsistencies could thus be understood better from alterations in postoperative loading conditions and/or varying degrees of negative mechanical influence from the thoracotomy and pericardial manipulation. Incision of the pericardium due to altered pericardial constraint has been proposed to be the main factor responsible for deterioration of RV function.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-25-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-25\",\"children\":\"25\"}],\" This hypothesis is further strengthened by our results revealing a postsurgical reduction in RVS and RV-LS following both AVR and MIAVR, despite the fact that during MIAVR only limited parts of the pericardium was incised, which was closed at the end of surgery. It can be speculated that RV is dependent on full pericardial support for maintaining its mechanical function, but this would not necessarily be due to the loss of myocardial contractility. Hence, opening even a small part of the pericardium may result in loss of that support. Furthermore, incision of the pericardium may result in geometrical changes of the RV, which is not restored even after closing the pericardium.\",[\"$\",\"a\",\"3\",{\"id\":\"xref-ref-26-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-26\",\"children\":\"26\"}],\" Although RV longitudinal function was more preserved in MIAVR as compared with AVR, no difference in global RV function was observed between the groups. Although RVS correlates well with global RV function in normal hearts, it does not correlate well with global RV function after open heart surgery.\",[\"$\",\"a\",\"5\",{\"id\":\"xref-ref-27-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-27\",\"children\":\"27\"}],\" Increasing PASP has also been proposed to contribute to deterioration of RV function following AVR. In our study, we observed a reduction in PASP following aortic valve surgery regardless of surgical approach.\"]}],[\"$\",\"p\",\"4\",{\"id\":\"p-62\",\"children\":[\"The effect of AVR on RV longitudinal function in our study is consistent with the results of previous studies.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-11-3\",\"className\":\"xref-bibr\",\"href\":\"#ref-11\",\"children\":\"11 13\"}],\" Currently, few data are available regarding the effect of MIAVR on RV function. In contrast to our study, Unsworth \",[\"$\",\"em\",\"3\",{\"children\":\"et al\"}],\"\\n\",[\"$\",\"a\",\"5\",{\"id\":\"xref-ref-1-3\",\"className\":\"xref-bibr\",\"href\":\"#ref-1\",\"children\":\"1\"}],\" have reported preserved RV longitudinal function following MIAVR. This discrepancy could be explained by the fact that there were only eight patients included in that study. Furthermore, as the type of surgical approach for MIAVR has not been reported, it is difficult to compare the results of that study to ours, since the location and size of the pericardial incision has been suggested to affect the magnitude of post-surgical modifications in RV longitudinal contraction.\",[\"$\",\"a\",\"7\",{\"id\":\"xref-ref-28-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-28\",\"children\":\"28\"}],\"\\n\"]}],[\"$\",\"p\",\"5\",{\"id\":\"p-63\",\"children\":[\"To our knowledge, there are only a few studies available that used novel echocardiographic parameters comparing the impact of AVR and MIAVR on RV function in the context of RV mechanics and contractility. Although MIAVR was associated with a better preserved RVS, there was no significant difference between MIAVR and AVR in global RV function as assessed by RV-LS and RIMP. The state of postsurgical RV function can be translated into clinical outcomes. Dalen \",[\"$\",\"em\",\"1\",{\"children\":\"et al\"}],\" did not show any difference between AVR or MIAVR in 30-day mortality or 2-year survival.\",[\"$\",\"a\",\"3\",{\"id\":\"xref-ref-3-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-3\",\"children\":\"3\"}],\"\\n\"]}],[\"$\",\"p\",\"6\",{\"id\":\"p-64\",\"children\":\"Our findings indicate a more complex picture, where myocardial contractility might be more preserved from MIAVR compared with AVR, but both MIAVR as well as AVR seem to negatively impact RV mechanical function despite preserved contractility in the MIAVR group. A composite of echo-derived parameters should be incorporated in assessment of RV function. Future studies are warranted for investigating long-term results of AVR and MIAVR on RV function and its clinical implications.\"}],[\"$\",\"div\",\"7\",{\"id\":\"sec-24\",\"className\":\"subsection\",\"children\":[[\"$\",\"h3\",\"0\",{\"children\":\"Limitations\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-65\",\"children\":\"The main limitation of this study is the relatively small number of patients included in the study. Also, the follow-up time of 40 days in our study was relatively short. Future studies with longer follow-up are required to assess long-term impact of MIAVR and AVR on RV function. Since our study is primarily an echocardiographic study, we would not be able to translate the echocardiographic differences between the groups into clinical outcomes, for example, exercise capacity.\"}]]}]]}],[\"$\",\"$L21\",null,{\"targetId\":\"article-title-1\"}]]}],[\"$\",\"div\",null,{\"className\":\"article-body-sections wrap-urls md:[\u0026_h2]:text-[2.125rem]\",\"data-testid\":\"article-body-section\",\"children\":[[\"$\",\"section\",\"sec-25\",{\"id\":\"sec-25\",\"children\":[[\"$\",\"h2\",\"0\",{\"className\":\"\",\"children\":\"Conclusion\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-66\",\"children\":\"Both MIAVR and AVR influence RV mechanical function, but MIAVR does not result in a decline in RV contractility. A composite of conventional and novel echocardiographic parameters should be incorporated in assessment for RV function since many estimates of RV function are load dependent.\"}]]}],[\"$\",\"$L21\",null,{\"targetId\":\"article-title-1\"}]]}],[\"$\",\"$19\",\"12\",{\"children\":[[\"$\",\"section\",null,{\"id\":\"supplementary-materials\",\"className\":\"article-body-sections order-2 mb-0\",\"children\":[\"$\",\"$L24\",null,{\"ids\":[\"DC1\",\"supplementary-materials\"],\"title\":\"Supplementary files\",\"children\":[\"$\",\"section\",null,{\"data-testid\":\"supplementary-materials-section\",\"children\":[[[\"$\",\"div\",\"DC1\",{\"className\":\"mt-3 flex items-center\",\"data-testid\":\"supplementary-link-container\",\"children\":[[\"$\",\"div\",null,{\"className\":\"mr-[9px] mb-[6px]\",\"data-testid\":\"icon-container\",\"children\":[\"$\",\"a\",null,{\"href\":\"/content/openhrt/5/2/e000842/DC1/embed/inline-supplementary-material-1.docx\",\"target\":\"_blank\",\"rel\":\"noopener 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valve replacementsurgery (MIAVR) is an alternative surgical technique to conventional aortic valve replacement surgery (AVR) in selected patients. The randomised study Cardiac Function after Minimally Invasive Aortic Valve Implantation (CMILE) showed that right ventricular (RV) longitudinal function was reduced after both MIAVR and AVR, but the reduction was more pronounced following AVR. However, postoperative global RV function was equally impaired in both groups. The purpose of this study was to explore alterations in RV mechanics and contractility following MIAVR as compared with AVR.Methods A predefined post hoc analysis of CMILE consisting of 40 patients with severe aortic valve stenosis who were eligible for isolated surgical aortic valve replacement were randomised to MIAVR or AVR. RV function was assessed by echocardiography prior to surgery and 40 days post-surgery.Results Comparing preoperative to postoperative values, RV longitudinal strain rate was preserved following MIAVR (−1.5±0.5 vs −1.5±0.4 1/s, p=0.84) but declined following AVR (−1.7±0.3 vs −1.4±0.3 1/s, p\u003c0.01). RV longitudinal strain reduced following AVR (−27.4±2.9% vs −18.8%±4.7%, p\u003c0.001) and MIAVR (−26.5±5.3% vs −20.7%±4.5%, p\u003c0.01). Peak systolic velocity of the lateral tricuspid annulus reduced by 36.6% in the AVR group (9.3±2.1 vs 5.9±1.5 cm/s, p\u003c0.01) and 18.8% in the MIAVR group (10.1±2.9 vs 8.2±1.4 cm/s, p\u003c0.01) when comparing preoperative values with postoperative values.Conclusions RV contractility was preserved following MIAVR but was deteriorated following AVR. RV longitudinal function reduced substantially following AVR. A decline in RV longitudinal function was also observed following MIAVR, however, to a much lesser extent.2a:T715,Objective Minimally invasive aortic valve replacementsurgery (MIAVR) is an alternative surgical technique to conventional aortic valve replacement surgery (AVR) in selected patients. The randomised study Cardiac Functio"])</script><script>self.__next_f.push([1,"n after Minimally Invasive Aortic Valve Implantation (CMILE) showed that right ventricular (RV) longitudinal function was reduced after both MIAVR and AVR, but the reduction was more pronounced following AVR. However, postoperative global RV function was equally impaired in both groups. The purpose of this study was to explore alterations in RV mechanics and contractility following MIAVR as compared with AVR.Methods A predefined post hoc analysis of CMILE consisting of 40 patients with severe aortic valve stenosis who were eligible for isolated surgical aortic valve replacement were randomised to MIAVR or AVR. RV function was assessed by echocardiography prior to surgery and 40 days post-surgery.Results Comparing preoperative to postoperative values, RV longitudinal strain rate was preserved following MIAVR (−1.5±0.5 vs −1.5±0.4 1/s, p=0.84) but declined following AVR (−1.7±0.3 vs −1.4±0.3 1/s, p\u003c0.01). RV longitudinal strain reduced following AVR (−27.4±2.9% vs −18.8%±4.7%, p\u003c0.001) and MIAVR (−26.5±5.3% vs −20.7%±4.5%, p\u003c0.01). Peak systolic velocity of the lateral tricuspid annulus reduced by 36.6% in the AVR group (9.3±2.1 vs 5.9±1.5 cm/s, p\u003c0.01) and 18.8% in the MIAVR group (10.1±2.9 vs 8.2±1.4 cm/s, p\u003c0.01) when comparing preoperative values with postoperative values.Conclusions RV contractility was preserved following MIAVR but was deteriorated following AVR. RV longitudinal function reduced substantially following AVR. A decline in RV longitudinal function was also observed following MIAVR, however, to a much lesser extent.2b:T715,Objective Minimally invasive aortic valve replacementsurgery (MIAVR) is an alternative surgical technique to conventional aortic valve replacement surgery (AVR) in selected patients. The randomised study Cardiac Function after Minimally Invasive Aortic Valve Implantation (CMILE) showed that right ventricular (RV) longitudinal function was reduced after both MIAVR and AVR, but the reduction was more pronounced following AVR. However, postopera"])</script><script>self.__next_f.push([1,"tive global RV function was equally impaired in both groups. The purpose of this study was to explore alterations in RV mechanics and contractility following MIAVR as compared with AVR.Methods A predefined post hoc analysis of CMILE consisting of 40 patients with severe aortic valve stenosis who were eligible for isolated surgical aortic valve replacement were randomised to MIAVR or AVR. RV function was assessed by echocardiography prior to surgery and 40 days post-surgery.Results Comparing preoperative to postoperative values, RV longitudinal strain rate was preserved following MIAVR (−1.5±0.5 vs −1.5±0.4 1/s, p=0.84) but declined following AVR (−1.7±0.3 vs −1.4±0.3 1/s, p\u003c0.01). RV longitudinal strain reduced following AVR (−27.4±2.9% vs −18.8%±4.7%, p\u003c0.001) and MIAVR (−26.5±5.3% vs −20.7%±4.5%, p\u003c0.01). Peak systolic velocity of the lateral tricuspid annulus reduced by 36.6% in the AVR group (9.3±2.1 vs 5.9±1.5 cm/s, p\u003c0.01) and 18.8% in the MIAVR group (10.1±2.9 vs 8.2±1.4 cm/s, p\u003c0.01) when comparing preoperative values with postoperative values.Conclusions RV contractility was preserved following MIAVR but was deteriorated following AVR. RV longitudinal function reduced substantially following AVR. A decline in RV longitudinal function was also observed following MIAVR, however, to a much lesser extent.2c:T715,Objective Minimally invasive aortic valve replacementsurgery (MIAVR) is an alternative surgical technique to conventional aortic valve replacement surgery (AVR) in selected patients. The randomised study Cardiac Function after Minimally Invasive Aortic Valve Implantation (CMILE) showed that right ventricular (RV) longitudinal function was reduced after both MIAVR and AVR, but the reduction was more pronounced following AVR. However, postoperative global RV function was equally impaired in both groups. The purpose of this study was to explore alterations in RV mechanics and contractility following MIAVR as compared with AVR.Methods A predefined post hoc analysis of "])</script><script>self.__next_f.push([1,"CMILE consisting of 40 patients with severe aortic valve stenosis who were eligible for isolated surgical aortic valve replacement were randomised to MIAVR or AVR. RV function was assessed by echocardiography prior to surgery and 40 days post-surgery.Results Comparing preoperative to postoperative values, RV longitudinal strain rate was preserved following MIAVR (−1.5±0.5 vs −1.5±0.4 1/s, p=0.84) but declined following AVR (−1.7±0.3 vs −1.4±0.3 1/s, p\u003c0.01). RV longitudinal strain reduced following AVR (−27.4±2.9% vs −18.8%±4.7%, p\u003c0.001) and MIAVR (−26.5±5.3% vs −20.7%±4.5%, p\u003c0.01). Peak systolic velocity of the lateral tricuspid annulus reduced by 36.6% in the AVR group (9.3±2.1 vs 5.9±1.5 cm/s, p\u003c0.01) and 18.8% in the MIAVR group (10.1±2.9 vs 8.2±1.4 cm/s, p\u003c0.01) when comparing preoperative values with postoperative values.Conclusions RV contractility was preserved following MIAVR but was deteriorated following AVR. RV longitudinal function reduced substantially following AVR. A decline in RV longitudinal function was also observed following MIAVR, however, to a much lesser extent.2d:T715,Objective Minimally invasive aortic valve replacementsurgery (MIAVR) is an alternative surgical technique to conventional aortic valve replacement surgery (AVR) in selected patients. The randomised study Cardiac Function after Minimally Invasive Aortic Valve Implantation (CMILE) showed that right ventricular (RV) longitudinal function was reduced after both MIAVR and AVR, but the reduction was more pronounced following AVR. However, postoperative global RV function was equally impaired in both groups. The purpose of this study was to explore alterations in RV mechanics and contractility following MIAVR as compared with AVR.Methods A predefined post hoc analysis of CMILE consisting of 40 patients with severe aortic valve stenosis who were eligible for isolated surgical aortic valve replacement were randomised to MIAVR or AVR. RV function was assessed by echocardiography prior to surgery a"])</script><script>self.__next_f.push([1,"nd 40 days post-surgery.Results Comparing preoperative to postoperative values, RV longitudinal strain rate was preserved following MIAVR (−1.5±0.5 vs −1.5±0.4 1/s, p=0.84) but declined following AVR (−1.7±0.3 vs −1.4±0.3 1/s, p\u003c0.01). RV longitudinal strain reduced following AVR (−27.4±2.9% vs −18.8%±4.7%, p\u003c0.001) and MIAVR (−26.5±5.3% vs −20.7%±4.5%, p\u003c0.01). Peak systolic velocity of the lateral tricuspid annulus reduced by 36.6% in the AVR group (9.3±2.1 vs 5.9±1.5 cm/s, p\u003c0.01) and 18.8% in the MIAVR group (10.1±2.9 vs 8.2±1.4 cm/s, p\u003c0.01) when comparing preoperative values with postoperative values.Conclusions RV contractility was preserved following MIAVR but was deteriorated following AVR. RV longitudinal function reduced substantially following AVR. 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