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AimsWe aimed to confirm that three-dimensional echocardiography (3DE)-derived right ventricular (RV) ejection fraction (EF) is a more robust predictor of adverse cardiopulmonary outcomes than the conventional echocardiographic parameters.Methods and ResultsWe performed a meta-analysis of studies reporting the impact of unit change of RVEF, tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and free-wall longitudinal strain (FWLS) on clinical outcomes (all-cause mortality and/or adverse cardiopulmonary outcomes). Hazard ratios (HR) were rescaled by the within-study standard deviations (SD) to represent standardized changes. Within each study, we calculated the ratio of HRs related to 1 SD reduction in RVEF versus TAPSE, or FAC, or FWLS, to quantify the predictive value of RVEF relative to the other metrics. These ratios of HRs were pooled using random-effects models.Ten independent studies were identified as suitable, including data on 1,928 patients with various cardiopulmonary conditions. Overall, 1 SD reduction in RVEF was robustly associated with adverse outcomes (HR: 2.64 [95% CI: 2.18 to 3.20], p2=65%, p=0.002). In studies reporting HRs for RVEF and TAPSE, FAC, or FWLS in the same cohort, RVEF had superior predictive value per SD reduction versus the other three parameters (vs. TAPSE, HR: 1.54 [95% CI: 1.04 to 2.28], p=0.031; vs. FAC, HR: 1.45 [95% CI: 1.15 to 1.81], p=0.001; vs. FWLS, HR: 1.44 [95% CI: 1.07 to 1.95], p=0.018).Conclusion3DE-derived RVEF has superior prognostic value compared with conventional RV indices, therefore, it might further refine the risk stratification of patients with cardiopulmonary diseases.Graphical AbstractAdded predictive value of three-dimensional (3D) echocardiography-derived right ventricular ejection fraction (RVEF) versus conventional metrics of RV systolic function on clinical outcomes: a meta-analysis of 10 studies. FAC: fractional area change, FWLS: free-wall longitudinal strain, HR: hazard ratio, SD: standard deviation, TAPSE: tricuspid annular plane systolic excursion

In various team sports, such as handball, referees work on the court by continuously moving with the players. Therefore, their physical fitness also has an impact on their reaction time, which could affect their professional decisions. The cardiorespiratory fitness status of healthy Hungarian elite handball referees was examined via body composition analysis and vita maxima cardiopulmonary exercise testing with lactate measurements. One hundred referees were examined (age: 29.0 ± 7.9 years; male: 64.0%; training: 4.3 ± 2.0 hours/week; ratio of former elite handball players: 39.0%; 51.0% first and 49.0% second division referees of the Hungarian National Handball Leagues). A resting heart rate (HR) of 79.0 ± 12.6 BPM was measured. On the basis of the body composition analysis the fat-free mass index proved to be 19.9 ± 2.6 kg/m2. The referees achieved a maximal oxygen uptake (V̇O2max) of 44.6 ± 6.1 ml/kg/min, with a maximal HR of 187.2 ± 11.1 BPM (which was 98.1 ± 4.6% of their calculated maximal HR) and a peak lactate of 9.2 ± 3.2 mmol/l at 557.1 ± 168.3 sec on our continuous speed, increasing slope treadmill protocol. Second division referees were younger, on a weekly average they trained more, achieved higher treadmill exercise time (respectively, 463.8 ± 131.9 vs 658.4 ± 143.9 sec, p < 0.001) and anaerobic threshold time (respectively, 265.8 ± 100.9 vs 348.2 ± 117.1 sec, p < 0.001), while the two different divisional referees had similar V̇O2max values. Regarding our physical fitness measurements, huge individual differences were observed between the referees (exercise time range: 259.0–939.0 sec, V̇O2max range: 25.3–62.4 ml/kg/min). Since it can affect their performance as referees, individual training planning, regular physical fitness measurements, and strict selection methods are suggested.