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PubMed1995

[Pulmonary embolism and thrombi of the right heart].

In general, there are two types of right heart thrombi diagnosed by echocardiography: mobile and non-mobile thrombi, more often located in the atrium than in the ventricle and a potential source of pulmonary embolism. However, they differ in several points: clinical context, clinical and echocardiographic presentations, embolic potential, prognosis and treatment. The result of peripheral venous thrombosis, mobile thrombus it is usually diagnosed during echocardiographic investigation of pulmonary embolism. The appearances are often that of serpentine thrombus floating in the right heart chambers associated with signs of acute cor pulmonale. It is a marker of imminent and often fatal embolism as it completes a previous and usually severe pulmonary embolism; the mortality is over 40%. It is a contra-indication for pulmonary angiography because of the risk of embolism and a therapeutic emergency. Some groups advocate surgical embolectomy and others thrombolysis. Its precise frequency in the acute stage of pulmonary embolism and its treatment remain to be determined by a prospective, multicentre clinical trial. The adherent non-mobile thrombus is usually implanted on the free wall of the right atrium or the interatrial septum. Its formation, in situ, is due to stasis secondary to decompensated congenital or acquired cardiac disease or to the presence of an intracardiac foreign body such as a pacing wire. It is less likely to cause pulmonary embolism. It decreases or disappears with anticoagulant therapy and the outcome is usually good. The differential diagnosis between a mobile thrombus and a Chiari network, or between an adherent thrombus and a vegetation on a intracardiac pacing wire may be difficult and requires transoesophageal echocardiography. The investigation of pulmonary embolism requires systematic echocardiography, one of the objectives of which is to search for right sided thrombi.

Anticoagulants↗
PubMed2001

Relationships between venous return and blood pressure in caval veins and right atrium during pressor stimulation.

The dynamics of changes in blood flow and pressure in the superior and inferior vena cava, total venous return, and right atrial pressure in response to pressor stimuli were studied in acute experiments on cats. It was shown that blood flow and pressure in caval veins changed synchronously and unidirectionally, while shifts in the right atrial pressure did not depend on direction and magnitude of changes in caval flow and pressure and total venous return. Our results suggest that right atrial pressure does not play a role in the regulation of venous return.

Animals↗
PubMed1993

Two-dimensional echocardiographic assessment of right cardiac pressure overload in patients with chronic obstructive airway disease.

Two-dimensional echocardiography was used to estimate right cardiac pressure overload in patients with chronic obstructive airway disease. Area measurements of the four heart chambers were carried out from the apical four-chamber view. Additionally, the respiratory behaviour of the inferior vena cava was examined from the subcostal view. A good apical imaging of the four-chamber view for area measurement was obtained in 44 out of 48 patients with chronic obstructive airway disease. The respiratory behaviour of the inferior vena cava was investigated from the subcostal view in 38 patients. Within 8 days after echocardiography, right cardiac catheterization was carried out in order to measure pulmonary artery and right atrial mean pressures and to determine pulmonary vascular resistance. A good correlation was found between pulmonary artery mean pressure and the following echocardiographic parameters: area index (area/body surface) of the two right heart cavities (r = 0.83), right-to-left ventricular area ratio (r = 0.82) and right-to-left cardiac area ratio (ratio between the added areas of both right heart cavities on the one side and the added areas of both left heart cavities on the other; r = 0.82). Correlation between these parameters and pulmonary vascular resistance (r = 0.71, 0.66 and 0.71, respectively) and between the right atrial mean pressure and the right atrial area index was less close (r = 0.64). On the other hand, the respiratory behaviour of the inferior vena cava proved to be highly specific but not very sensitive in predicting a pathological right atrial pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

Atrial Function, Right↗
PubMed2003

[Right atrial and right ventricular thrombus in a patient with hepatic carcinoma - a case report].

A case of a 62-year-old male with suspected aortic dissection is presented. Echocardiography did not confirm the initial diagnosis and revealed the presence of thrombus in the inferior vena cava, right atrium and right ventricle. Computerised tomography, followed by histological examination of liver biopsy, revealed hepatic carcinoma. The patient received anticoagulation and unfortunately died 14 days later. Symptomatology of the right-heart thrombus and thrombo-embolic complications in patients with neoplastic disorders are discussed.

Atrial Function, Right↗
PubMed1996

Mechanism of spontaneous termination of functional reentry in isolated canine right atrium. Evidence for the presence of an excitable but nonexcited core.

BACKGROUND: According to the spiral wave hypothesis of reentry, the core of functional reentry remains excitable but not excited. We sought to determine whether the core remains excitable and whether excitation of the core by an outside wave front leads to termination of the reentry in the atrium. METHODS AND RESULTS: In nine isolated canine right endocardial atrial tissues (3.8 by 3.2 cm wide), reentry was induced by a premature point stimulus (S2). The isochronal activation maps and dynamics of the activation patterns were visualized with the use of 509 bipolar electrodes (1.6-mm resolution). The S2 applied after 8 regular beats induced reentry with a mean cycle length of 162 +/- 20 ms (15 episodes). Reentry had a large excitable gap (93 +/- 26 ms) as determined by early capture with twice the level of threshold stimuli. The central area (core) around which the wave fronts rotated had a mean surface area of 12 +/- 3 mm2. The electrograms located in the core of the reentry registered no or very low amplitude potentials. In 13 of 15 episodes, reentry terminated when an outside new wave front merged with the original wave front and excited the core. Core excitation caused disruption of the original wave front, and the newly formed wave front(s) vanished at the tissue border within 77 +/- 18 ms. In 2 episodes, reentry terminated abruptly when an outside new wave front propagating in a direction opposite to the reentrant wave front collided with the leading edge of the reentrant wave front. CONCLUSIONS: Functional reentry in the atrium is compatible with a spiral wave of excitation with an excitable but nonexcited core and a large excitable gap. Reentry may be terminated either by direct excitation of the core that displaces the wave front to the tissue border or by collision with an outside new wave front.

Animals↗
PubMed2003

Investigation of cardiac function in children with suspected obstructive sleep apnea.

OBJECTIVE: To assess the prevalence of cardiac failure in a group of children with suspected obstructive sleep apnea (OSA) and to assess the need for preoperative electrocardiograms (ECGs) and chest radiographs (CXRs) in children with OSA. DESIGN: Case record review of 271 children having (adeno)tonsillectomy for symptoms of OSA. METHOD: Preoperative ECGs and CXRs were assessed for signs of right atrial or ventricular hypertrophy or failure. Case records were assessed for evidence of cardiac failure during anaesthesia. RESULTS: One child with congenital heart disease had signs of cardiac failure preoperatively. No other cases of atrial or ventricular hypertrophy or failure were found. CONCLUSIONS: Cardiac failure appears to be uncommon in children with symptoms of OSA. Preoperative ECG and CXR are essential in only selected cases.

Adolescent↗
PubMed1994

Intrinsic cardiac rate regulation in the anaesthetized rabbit.

Intrinsic cardiac regulation, the direct effect of changes in right atrial pressure on heart rate, was examined in rabbits under chloralose/urethane anaesthesia. Autonomic influences on the cardiac pacemaker were eliminated by cervical vagotomy and intravenous propranolol. Right atrial transmural pressure was monitored as the difference between right atrial and pleural pressures. Blood volume expansion (5-15%) increased right atrial transmural pressure and heart rate and produced a sinus arrhythmia associated with respiration-linked fluctuations in right atrial transmural pressure. The gain of intrinsic cardiac rate regulation was calculated as 0.96 +/- 0.24 beats min-1 mmHg-1 at a heart rate of 218 +/- 6 beats min-1 (values as the mean +/- SEM, n = 12). When heart rate was reduced by electrical stimulation of the peripheral end of the right vagus nerve, gain increased to 2.25 +/- 0.57 and 4.61 +/- 1.6 beats min-1 mmHg-1 at heart rates of 180 +/- 4 and 130 +/- 4 beats min-1, respectively (n = 6 and n = 10; P < 0.05 compared with pre-stimulation values). During vagally-induced bradycardia, rapid infusion of blood into the left superior vena cava produced a brief marked cardiac acceleration. We conclude that right atrial pressure has a small direct influence on heart rate, and this is enhanced by background cardiac parasympathetic stimulation.

Anesthesia↗
PubMed1999

Assessment of right artrial mapping and P wave-triggered signal-average in patients with paroxysmal atrial fibrillation.

To assess right atrial mapping and P wave-triggered signal-averaged electrocardiogram (ECG) in patients with paroxysmal atrial fibrillation (PAF), this study examined right atrial electrograms using atrial mapping and parameters by P wave-triggered signal-averaged ECG in 39 patients without sick sinus syndrome. Subjects were divided into those with PAF (n = 13; 60+/-13 years old) and a control group (n = 26; 49+/-19 years old). The total number of abnormal right atrial electrograms per patient was significantly greater in the PAF group (3.2+/-1.9) than in the control group (1.1+/-0.9; P < .001). The longest duration of right atrial electrogram in the PAF group tended to be greater than that in the control group (P = .06). The filtered P wave duration was significantly longer in the PAF group than in the control group (144+/-21 vs 125+/-14 ms [P < .002]). The values of the root mean square of P wave-triggered signal-averaged ECG 15 ms from the onset (RMSi 15) and 20 ms from the offset (RMSe 20) were significantly lower in the PAF group (1.1+/-0.4 microV, 1.4+/-0.5 microV) than in the control group (1.9+/-1.1 microV [P < .02], 2.1+/-0.9 microV [P < .01]). The total number of right atrial electrograms in patients with RMSi 15 of < or =1.5 microV was significantly greater than in patients with RMSi 15 of >1.5 microV (2.2+/-1.8 vs 1.3+/-1.3 [P < .05]). Thus, the total number of abnormal right atrial electrograms per patient, the total filtered P wave duration, RMSi 15, and RMSe 20 may be good indices of PAF in patients without sick sinus syndrome. RMSi 15 may reflect the total number of the abnormal right atrial electrograms per patient.

Atrial Fibrillation↗
PubMedDate not supplied

Right heart ischemia: pathophysiology, natural history, and clinical management.

Right ventricular (RV) ischemia occurs in 50% of patients with acute inferior myocardial infarction, and may result in severe hemodynamic compromise associated with poor clinical outcome. Acute right coronary artery (RCA) occlusion proximal to the RV branches results in right ventricular free wall (RVFW) dysfunction. The ischemic, dyskinetic RVFW exerts mechanically disadvantageous effects on biventricular performance. Depressed RV systolic function leads to a decrease in transpulmonary delivery of left ventricular (LV) preload, resulting in diminished cardiac output. The ischemic right ventricle is stiff, dilated, and volume dependent, resulting in pandiastolic RV dysfunction and septally-mediated alterations in LV compliance, which are exacerbated by elevated intrapericardial pressure. Under these conditions, RV pressure generation and output are dependent on LV-septal contractile contributions, governed by both primary septal contraction and paradoxical septal motion. When the culprit coronary lesion is distal to the right atrial (RA) branches, augmented RA contractility enhances RV performance and optimizes cardiac output. Conversely, more proximal occlusions result in ischemic depression of RA contractility, which impairs RV filling, thereby resulting in further depression of RV performance and more severe hemodynamic compromise. Bradyarrhythmias limit the output generated by the rate-dependent noncompliant ventricles. Patients with right ventricular infarction and hemodynamic compromise often respond to volume resuscitation and restoration of a physiological rhythm. Vasodilators and diuretics should generally be avoided. In some, parenteral inotropic stimulation may be required. The right ventricle appears to be relatively resistant to infarction and has a remarkable ability to recover even after prolonged occlusion. Therefore, the term RV infarction appears to be somewhat of a misnomer, for in most patients a substantial proportion of acute RV dysfunction represents ischemic but viable myocardium. Although RV performance improves spontaneously even in the absence of reperfusion, recovery of function may be slow and associated with high in-hospital mortality. Reperfusion enhances the recovery of RV performance and improves the clinical course and survival of patients with ischemic RV dysfunction.

Animals↗
PubMed1993

Valvular regurgitation and right-sided cardiac pressures in heart transplant recipients by complete Doppler and color flow evaluation.

OBJECTIVE: To define normal profiles of cardiac structure, function, and hemodynamics postcardiac transplantation using Doppler echocardiography. DESIGN: Retrospective clinical case series with mean follow-up of 5.1 months. SETTING: Institutional tertiary care center, ambulatory setting. PATIENTS: A consecutive sample of 48 orthotopic cardiac transplant recipients. RESULTS: Aortic regurgitation was present in two patients, and was trivial in both cases. Mitral regurgitation was present in 29 of 48 patients, was trivial in 19 of 29 patients, and was mild in 10 of 29 patients. Tricuspid regurgitation was present in 41 of 48 patients and was graded as follows: trivial, 23 of 41; mild, 12 of 41; and moderate, 6 of 41. Septal hypokinesis was present in 33 of 49 patients, and no patient had evidence of other wall motion abnormalities. A pericardial effusion was present in 13 of 48 patients. Hemodynamic values were comparable to those of a nontransplant, normal population with pulmonary artery systolic pressures having a mean value of 31 +/- 6 mm Hg (range, 15 to 45 mm Hg) and estimates of right atrial pressure being 0 to 5 mm Hg in 12 of 48, 5 to 10 mm Hg in 32 of 48, and 10 to 15 mm Hg in 1 patient. There was no correlation between the degree of mitral or tricuspid regurgitation and sex, transplant interval, hemodynamic indices, or endomyocardial biopsy specimen grade. Right ventricular enlargement was associated with the presence of moderate tricuspid regurgitation. CONCLUSIONS: Cardiac transplantation recipients commonly display the following: (1) trivial or mild degrees of mitral regurgitation; (2) as much as moderate tricuspid regurgitation; (3) septal hypokinesis; and (4) small pericardial effusions. There is an association between the presence of right ventricular enlargement and moderate tricuspid regurgitation.

Adult↗
PubMed2000

Doppler-derived acceleration rate of right ventricular early filling reliably predicts mean right atrial pressure at baseline and after loading manipulations in patients with chronic heart failure.

BACKGROUND: We investigated whether Doppler-derived variables of tricuspid flow could estimate mean right atrial pressure and monitor its changes after loading manipulations in patients with chronic heart failure. METHODS: Simultaneous mean right atrial pressure (Swan-Ganz catheterization) and tricuspid Doppler recordings were initially evaluated in 136 patients (23 with atrial fibrillation) with chronic heart failure and severe left ventricular systolic dysfunction, and then were repeated in 18 patients after unloading (sodium nitroprusside infusion) and in 13 patients after overloading (active leg elevation) manipulations. RESULTS: A significant correlation was observed between mean right atrial pressure and peak E velocity (r = 0.70), early deceleration time (r = -0.72) and acceleration time (r = -0.75). However, the best correlation found was between the acceleration rate of early flow and mean right atrial pressure, and it was identical in patients in sinus rhythm or with atrial fibrillation (r = 0.98). Moreover, after acute effective unloading or overloading manipulations, although all Doppler tricuspid variables changed significantly, the acceleration rate of early flow still emerged as the strongest independent predictor of mean right atrial pressure (r = 0.95 and 0.99, respectively). CONCLUSIONS: Doppler-derived acceleration rate of early diastolic tricuspid flow is a powerful tool to predict mean right atrial pressure and to monitor its changes after loading manipulations.

Adult↗
PubMed2003

[Haemodynamic mechanism of the variety of changes in the right atrial pressure following catecholamines administration].

Changes of the right atrial pressure and systemic haemodynamics following action of catecholamines (epinephrine and norepinephrine) were studied in acute experiments on anaesthetised mongrel cats with artificial lung ventilation and opened chest. Maximal changes of the right atrial pressure took place on the 12th-16th second following catecholamine administration. In that case, the atrial pressure could be decreased or increased. At the moment of maximal changes of the right atrial pressure, the venous return and the right ventricular myocardial contractility (the first derivative of the right atrial pressure, dP/dt max) increased more if the right atrial pressure decreased, as compared with the animals whose right atrial pressure augmented. The findings suggest that at the time of the maximal changes of the right atrial pressure following action of catecholamines, there may be a direct connection of the right atrial pressure with interrelation of venous return and the right ventricular contractility. The right atrial pressure, however, is a dependent parameter but it does not determine the venous return.

Animals↗
PubMedDate not supplied

Right heart haemodynamic values and respiratory function test parameters in chronic smokers.

During coronary angiography in 24 chronic smokers with coronary heart disease, cardiac function measurements were taken and correlated with respiratory function tests. Fourteen patients had evidence of chronic obstructive pulmonary disease. Cardiac output had a direct correlation with vital capacity, forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), and velocity at 25% of FVC (V(max)25). Pulmonary artery resistance was inversely correlated with FEV1/FVC, while pulmonary artery oxygen saturation weakly correlated with FEV1 and V(max)25. The pulmonary artery pressure had a weak correlation with the pulmonary artery resistance and an intermediate correlation with the right atrium and the right ventricular pressures. Early diagnosis and therapy of chronic obstructive pulmonary disease in smokers may be possible without using invasive methods.

Aged↗