Right Ventricular Ejection Fraction and Left Ventricular Dyssynchrony by 3D Echo Correlate With Functional Impairment in Patients With Dilated Cardiomyopathy ANTONELLO D’ANDREA, MD, FESC, 1 RITA GRAVINO, MD, 1 LUCIA RIEGLER, MD, 1 GEMMA SALERNO, MD, 1 RAFFAELLA SCARAFILE, MD, 1 MASSIMO ROMANO, MD, 2 SERGIO CUOMO, MD, FESC, 1 LUCA DEL VISCOVO, MD, 3 ILARIA FERRARA, MD, 1 MARIA LUISA DE RIMINI, MD, 4 PIETRO MUTO, MD, 4 GIUSEPPE LIMONGELLI, MD, FESC, 1 GIUSEPPE PACILEO, MD, 1 EDUARDO BOSSONE, MD-FACC, 5 MARIA GIOVANNA RUSSO, MD, 1 AND RAFFAELE CALABR  O, MD 1 Naples and Milan, Italy ABSTRACT Background: The aim of the study was to detect if right ventricular (RV) ejection fraction assessed by real-time 3-dimensional echocardiography (RT3DE) could predict patients with dilated cardiomyopathy (DCM) with greater functional impairment in response to cardiopulmonary exercise. Methods and Results: Seventy chronic heart failure patients with DCM (55.5 6 9.1 years; 48 males; 30 is- chemic; New York Heart Association Class III: 48) underwent both left ventricular (LV) and RVanalysis by RT3DE. Postprocessing software provided data of RT3DE systolic dyssynchrony index of 16 LV segments (systolic dyssynchrony index [SDI]) and of both LV and RV ejection fraction. Cardiac magnetic resonance was performed in a subgroup of 40 DCM patients to confirm RT3DE measurements. All the patients under- went also bicycle cardiopulmonary exercise test with evaluation of oxygen consumption (VO2) peak% (per- centage of the predicted value), VE/VCO2 slope, and circulatory power (CP). Mean LVejection fraction was 29.8 6 4.6%. RT3DE LV SDI index was 8.4.4 6 4.2, and RVejection fraction was 51.3 6 4.6%. By cardio- pulmonary test, mean VO2 peak was 15.2 6 4.4 mL$kg$min, and mean CP was 2.1 6 0.8. By univariable analyses, significant correlations were detectable between SDI index and VO2 peak% (r 5 0.56; P ! .0001) and peak CP (r 5 0.48; P ! .0005). Also RVejection fraction directly correlated with VO2 peak %(r 5 0.58; P ! .0001) and inversely with VE/VCO2 slope (r 5 0.44; P ! .001). By multivariable anal- ysis, SDI index (b coefficient 5 0.46; P ! .001) and 3D RV ejection fraction (b coefficient 5 0.42; P ! .001) emerged as the only independent determinants of VO2 peak% during cardiopulmonary test. Conclusions: Increased LVelectromechanical dyssynchrony and impaired RV function in DCM patients are independently associated with worse ability to perform aerobic exercise. (J Cardiac Fail 2011;17:309e317) Key Words: Heart failure, cardiopulmonary test, three-dimensional echocardiography, cardiac magnetic resonance, cardiac resynchronization, right ventricle, dyssynchrony. A hallmark symptom of chronic heart failure (HF) is exercise intolerance, typically evidenced by excessive shortness of breath, and/or fatigue with exertion. In recent years, the physiologic response to progressive exercise using direct measures of ventilation and gas exchange, commonly termed ‘‘cardiopulmonary exercise test’’ (CPT), has evolved into an important clinical tool in the management of patients with severe HF. 1,2 In patients with dilated cardiomyopathy (DCM), left ven- tricular (LV) systolic dyssynchrony has an important role in the physiopathology of the disease, and represents an independent prognostic marker. 3 Also the right ventricle, From the 1 Department of Cardiology, Second University of Naples, Naples, Italy; 2 Department of Internal Medicine, Federico II University, Naples, Italy; 3 Department of Internistica Clinica e Sperimentale, Sezione Scientifica di Diagnostica per Immagini, Second University of Naples, Naples, Italy; 4 Department of Nuclear Medicine, Monaldi Hospital, Naples, Italy and 5 Department of Cardiac Surgery, Istituto di Ricovero e Cura a Car- attere Scientifico, Policlinico San Donato, San Donato Milanese, Milan, Italy. Manuscript received June 10, 2010; revised manuscript received Octo- ber 16, 2010; revised manuscript accepted November 10, 2010. Reprint requests: Antonello D’Andrea, MD, Via G. Martucci 35, 80121 - Naples Italy. Tel: þ390817618525; Fax: þ390817145205. E-mail: antonellodandrea@libero.it See page 316 for disclosure information 1071-9164/$ - see front matter Ó 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.cardfail.2010.11.005 309 Journal of Cardiac Failure Vol. 17 No. 4 2011