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PubMed1983

Unsuspected right ventricular dysfunction in shock and sepsis.

Monitoring of ventricular function by central venous (CVP) and pulmonary wedge pressures (PCW) was compared with ejection fraction and end-diastolic volume (gated pool scan) in patients resuscitated from hypovolemic and septic shock. Sixteen patients were studied within 24 hours of resuscitation and all showed depressed right ventricular ejection (RVEF) and/or an increased end-diastolic volume (RVEDVI). Group I (eight patients, hypovolemia and sepsis) had low RVEF (mean, 0.30), high RVEDVI (mean 129.2 ml/m2), and nearly normal left ventricular function (LVEF 0.63 and LVEDVI 63.6 ml/m2), compared to angiographic normals (RVEF 0.52, RVEDVI 55.8 ml/m2; nL LVEF 0.59, LVEDVI 52.3 ml/m2). Group II (3 patients, all septic) had better RVEF (mean, 0.54) but high RVEDVI (mean, 121.1 ml/m2) with normal LVEF (mean, 0.67) and high LVEDVI (mean LVEDVI 107.2 ml/m2). Group III consisted of five patients (hypovolemia and sepsis) who had biventricular depression (RVEF 0.25 and LVEF 0.29) and elevated EDVI. The mortality rate for group I (25%) was significantly less than for groups II and III (100% and 80%, respectively), and could be correlated with failure to improve RV function. Follow-up studies in ten patients showed improvement in seven which correlated with increased RVEF and reduced RVEDVI. Comparing survivors to non-survivors showed no predictability on the basis of initial studies but a significantly larger RVEDVI and RV stroke work index in non-survivors' follow-up studies. No correlation could be made with left ventricular performance, and there were no correlations between PCWP and LVEDVI or CVP and RVEDVI. A significant negative correlation was seen between RVEF and pulmonary vascular resistance (r = -0.34, p less than 0.05). Both LVEDVI and RVEDVI were correlated significantly with cardiac index and with each other. RV dysfunction occurs after resuscitation of hypovolemia and sepsis without reliable alteration in filling pressure and is likely related to myocardial ischemia as well as increased pulmonary vascular resistance. Survival seems to depend on improvement in RV performance, which can be measured at the bedside by cardiac scintigraphy.

Adult↗
PubMed1983

Right ventricular dysfunction and surgical outcome in postinfarction ventricular septal defect.

The data of 50 consecutive patients treated for postinfarction ventricular septal defect were reviewed. Cardiac catheterization was carried out in all patients and surgical repair was undertaken in 32 patients. The main factors affecting surgical outcome were the site of infarction and the extent of right ventricular damage. Anterior myocardial infarction carried a better hospital survival rate than inferior infarction (67 and 31%, respectively). Poor right ventricular free wall contraction, present in 44% of anterior infarctions and 71% of inferior infarctions carried a high mortality. Eighty per cent (12/15) of patients with good right ventricular contraction survived operation compared to only 24% (4/17) of patients with poor right ventricular contraction. Surgery within 24 h to 14 days of infarction carried a survival rate of 50% (7/14), similar to that in patients operated on more than two weeks following infarction (9/18). Seventeen out of 18 patients who did not undergo surgery either died suddenly before scheduled operation or were considered too poor a surgical risk. Of these, 12 patients died within one week of infarction and five patients survived between two weeks and three months. Early surgical repair should therefore be considered in all patients with postinfarction ventricular septal defect, the prognosis in patients with good right ventricular contraction being excellent.

Adult↗
PubMed1993

[Successful two-staged Jatene operation for severe right ventricular dysfunction and tricuspid regurgitation after Senning operation--a case report].

We report a seven-year-old boy who underwent a successful Jatene procedure seven years after Senning procedure. The modified Senning operation was performed for the treatment of transposition of the great arteries with intact ventricular septum at three years of age. However, he gradually showed the progressive right ventricular failure with tricuspid regurgitation after operation. When he was referred to our hospital, he was in severe right ventricular failure and showed massive tricuspid regurgitation simultaneously with the moderate degree of left ventricular failure. Staged pulmonary artery banding was applied to prepare the left ventricle for Jatene procedure in spite of the presence of left ventricular failure. The systolic pressure ratio of left ventricle to right ventricle was elevated to 0.91 by this banding although the left ventricular ejection fraction decreased from 43% to 30%. And Jatene procedure was successfully performed after three months of preparation period. Catheterization study after Jatene procedure revealed improved right and left ventricular functions with decrease of tricuspid regurgitation. We conclude that the Jatene procedure should be an ideal alternative in patient with right ventricular failure and/or tricuspid regurgitation after an atrial switch operation; the left ventricle could be prepared by an effective pulmonary banding in most instances.

Child↗
PubMed1991

Right ventricular dysfunction in chronic obstructive pulmonary disease. Evaluation and management.

Cor pulmonale is an important consequence of COPD. Although the incidence is not precisely known, it is seen more frequently in patients with hypoxemia, CO2 retention and severely reduced FEV1. When present, it limits peripheral oxygen delivery, increases shortness of breath, and reduces exercise endurance. It is also associated with higher mortality rates independent of other prognostic variables. Numerous factors may contribute to the development of cor pulmonale in patients with COPD, but its primary cause is chronic alveolar hypoxia resulting in pulmonary vasoconstriction, vascular remodeling and pulmonary hypertension. The physical exam, chest radiograph and ECG may be helpful in detecting the presence of cor pulmonale, but because of anatomic changes that occur in the chest, these tests are often insensitive in patients with COPD. Noninvasive diagnostic techniques utilizing Doppler echocardiography and radionuclide angiography allow for detection of RV dysfunction at an earlier stage and in most cases, preclude the need for right heart catheterization. LTO2 is the only therapy shown to improve survival in patients with COPD. However, statistical proof correlating improvements in pulmonary hemodynamics with increased survival is lacking. Bronchodilators, such as the beta 2 agonists and especially theophylline, may have beneficial effects on pulmonary hemodynamics in addition to their effect on respiratory function and are useful in COPD when RV dysfunction is present. Diuretics and phlebotomy are also useful in improving symptoms in appropriate patients. Vasodilators such as calcium channel blockers and ACE-inhibitors may improve pulmonary hemodynamics acutely, but may lower arterial PO2 by worsening ventilation-perfusion matching or blunt the improvement in pulmonary hemodynamics seen with supplemental oxygen. The long-term benefits of these agents have not been proven and their routine use in patients with cor pulmonale due to COPD cannot be recommended.

Humans↗
PubMed2005

Plasma N-terminal pro-brain natriuretic peptide as a marker of right ventricular dysfunction in patients with tetralogy of Fallot after surgical repair.

OBJECTIVE: Chronic heart failure is associated with neurohormonal activation that is not only related to outcome but is also a therapeutic target. We have attempted to demonstrate whether a similar pattern of neurohormonal activation exists in adult congenital heart disease (ACHD) and, if so, whether it relates to disease severity determined by cardiopulmonary exercise testing. METHODS AND RESULTS: Concentrations of N-terminal pro-atrial natriuretic peptide, N-terminal pro-brain natriuretic peptide (NT-proBNP), endothelin (ET)-1, renin, aldosterone, adrenalin, and noradrenalin were determined in 50 adults (mean age, 27.8 +/- 1.7 years [+/- SEM]; 26 women) with tetralogy of Fallot (TOF) after surgical repair (New York Heart Association functional class 1.1 +/- 0.1). One hundred age- and sex-matched healthy blood donors served as a control group for NT-proBNP determination. Dimensions of ventricles, left ventricular pump function, and estimated right ventricular (RV) systolic pressure were determined by echocardiography. Maximum oxygen uptake (V(O2max) was measured in all patients using spiroergometry. TOF patients had elevated levels of NT-proBNP compared with healthy individuals: NT-proBNP (women: 180 pg/mL vs 43 pg/mL, and men: 147 pg/mL vs 32 pg/mL; p < 0.0001) and ET-1 (2.5 fmol/L vs 0.7 fmol/L). There was a significant correlation of NT-proBNP to dimension and estimated peak systolic pressure of the RV as well as impairment of V(O2max). CONCLUSIONS: RV dysfunction detected by echocardiography and plasma NT-proBNP determination in asymptomatic or minimally symptomatic TOF patients correlates well with their cardiopulmonary exercise capacity. Thus, these simple and noninvasive screening methods can be used additionally to stratify ACHD patients with impaired cardiac function before they become clinically symptomatic.

Adult↗
PubMed1993

["Severe" congestive heart failure at a medical center].

UNLABELLED: Heart failure (HF) is a dynamic clinical syndrome depending on multiple hemodynamic and neurohormonal factors. This syndrome concerns not only left ventricular systolic dysfunction but also left ventricular diastolic dysfunction and right ventricular dysfunction. Clinical features and therapeutic approaches are different for each of them. NYHA class IV is just one of the various prognostic factors of heart failure; consequently, severe heart failure is not synonymous of NYHA class IV. OBJECTIVE: To study hospitalised patients with heart failure in NYHA class IV, in order to characterise the predominant dysfunction, and analyze evolution and mortality. DESIGN: A retrospective analysis of a prospective study. SETTING: Hundred and eight hospitalised patients (1985-89). Patients with chronic obstructive pulmonary disease and acute myocardial infarction were excluded. PATIENTS: Sixty nine patients: 29 female and 40 male, aged 18 to 81 years old (m = 59 +/- 15.5). METHODS: Patients were clinically examined and had chest radiographs, electrocardiogram and M + 2D mode echocardiogram. Three groups were identified: Group I-patients with predominant left ventricular systolic dysfunction; Group II-patients with predominant left ventricular diastolic dysfunction; Group III-patients with predominant right ventricular dysfunction. RESULTS: 41% of the patients had coronary artery disease; 44%, valvular heart disease; 11.8% dilated cardiomyopathy; 8.7% hypertrophic cardiomyopathy; 8.7% hypertensive cardiomyopathy. Fifty five percent of the patients were in group I and the major aetiology were coronary artery disease and valvular heart disease; 25% of the patients were in group II and the major aetiology were coronary artery disease and hypertrophic cardiomyopathy; 20% of the patients were in group III, all had valvular heart disease. The global mortality during the hospitalisation period was 15.9%, mostly group III (29%) and II (17%). CONCLUSIONS: Heart failure patients in NYHA class IV formed an heterogeneous group, requiring individualised therapeutic approaches. Left ventricular systolic dysfunction was the major pathophysiological mechanism, however, diastolic dysfunction and right ventricular dysfunction were frequent. Coronary artery disease presented as a frequent aetiology of heart failure, resulting in diastolic and/or systolic dysfunction. Valvular heart disease can be present as left ventricular systolic or diastolic dysfunction or as a right ventricular dysfunction, depending on the valvulopathy and the time of evolution. Echocardiography, in association with clinical features, has been very useful for each patient approach, allowing HF aetiology and pathophysiological mechanisms characterisation. The low mortality observed in this study was related certainly to the correction of precipitating factors, together with early etiologic diagnosis and pathophysiological characterisation, and adequate individualised treatment.

Adolescent↗
PubMed1989

Nursing implication for pulmonary artery balloon counterpulsation: a treatment for right ventricular dysfunction after cardiac surgery.

PPRVD is a phenomenon frequently observed in the operating room. Its development can be attributed to a single or many factors associated with cardiac operation. Namely, its presence is precipated by injury to the RV myocardium or changes in the normal hemodynamic functions of the RV. While PPRVD occurs in isolation, it is usually seen with concomitant LV dysfunction. When conventional medical management of LV dysfunction does not improve yet unmasks RV dysfunction, some type of ventricular assist device to support RV dysfunction may be needed to wean patients from cardiopulmonary bypass such as PABC. PABC has been demonstrated to be useful in the management of mild to moderate PPRVD and weaning from CPB. Severe PPRVD has not been demonstrated to benefit from PABC. The major concern in managing PPRVD is the lack of quantifiable criteria for determining levels of RV injury. Research is continuing in this area. Likewise, investigations are under way to develop a transvenous PABC catheter. This catheter would allow for increased PABC use as it would not require surgical placement or removal. The present PABC model could potentially be used in any hospital that uses conventional intra-aortic balloon counterpulsation. The patient presented in this case was cared for in a 350-bed community hospital in the Northeast section of the United States. A PABC patient can present a unique nursing challenge. It is hoped that this article will assist nurses in the future management of these patients.

Aged↗