Discordant Severity Grading in Right Ventricular Dysfunction: Prognostic Implications of Conventional Parameters versus Three-Dimensional Echocardiography–Derived Ejection Fraction

AIMS: The 2025 American Society of Echocardiography guidelines on the right heart introduce severity grading for right ventricular (RV) dysfunction based on individual functional parameters. However, single-parameter assessment may result in inconsistent diagnosis of RV dysfunction and discordant grading of its severity. We aimed to investigate the prognostic value and discordance among RV functional echocardiographic parameters. METHODS: We analyzed two- and three-dimensional echocardiographic data from 3 centers, including 1,146 consecutive patients followed for the composite end point of all-cause mortality and heart failure hospitalization. RV dysfunction severity was graded using the guideline-recommended cutoff values for tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC) and free-wall longitudinal strain (FWLS) and compared with severity assessment based on RV ejection fraction (RVEF). RESULTS: Over a median follow-up of 3.2 years, 261 patients (23%) met the composite end point. Assessed by RVEF, worsening RV dysfunction categories carried a higher risk of the composite end point, which was significant between mild versus normal and moderate versus mild dysfunction (hazard ratio [HR] = 2.385 [95% CI, 1.720-3.307], P < .001; and HR = 1.581 [95% CI, 1.066-2.346], P = .023), but not between severe versus moderate dysfunction. TAPSE and FWLS did not show a significant difference in risk between the dysfunction categories. FAC identified a significant risk difference between adjacent severity categories only for moderate versus mild dysfunction (HR = 1.928 [95% CI, 1.309-2.840], P < .001). Agreement with RVEF in patients with dysfunction was poor for TAPSE (quadratic weighted κ = 0.06, P = .132) and fair for FAC and FWLS (κ = 0.34, P < .001, and κ = 0.30, P < .001, respectively). CONCLUSION: Significant discordance exists between conventional echocardiographic parameters of RV function and RVEF in grading RV systolic dysfunction. None of the individual RV functional parameters provided consistent risk stratification across all severity categories. RVEF showed the most consistent overall risk discrimination, whereas FAC and FWLS provided partial prognostic stratification.