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PubMed1993

Assessment of ejection fraction of the right and left ventricles in patients with acute myocardial infarction by magnetic resonance imaging.

Right and left ventricular function in acute myocardial infarction (AMI) was assessed by ECG-gated magnetic resonance imagine (MRI) in 64 patients and 8 volunteers. Five short axis images for intrinsic cardiac long-axis of the left ventricle were obtained at 9 msec and 309 msec after the R wave as end-diastole and end-systole. Right and left ventricular volumes were measured by Simpson's rule. The intraobserver variabilities in right and left ventricular ejection fraction (RVEF: r = 0.94, LVEF: 0.89) were excellent. The interobserver variabilities in RVEF (r = 0.61) and LVEF (r = 0.77) were fair. LVEF, but not RVEF, was significantly reduced in patients with AMI. Among left ventricular dysfunction (LVEF < or = 40%) patients, 50% exhibited right ventricular dysfunction (RVEF < or = 40%). Among patients without left ventricular dysfunction, only 12% exhibited right ventricular dysfunction. In left ventricular and biventricular dysfunction compared with control, the left ventricular end-diastolic volume index increased (65 +/- 10 ml/m2, 68 +/- 12 ml/m2 vs 54 +/- 8 ml/m2), the end-systolic volume index increased (40 +/- 16 ml/m2, 43 +/- 7 ml/m2 vs 18 +/- 1 ml/m2), and the right ventricular end-diastolic volume index decreased (52 +/- 13 ml/m2, 53 +/- 20 ml/m2 vs 65 +/- 8 ml/m2). MRI can thus be used to assess ventricular systolic function. Since patients with left ventricular dysfunction revealed a high incidence of right ventricular dysfunction, an interaction between the left and right ventricles may occur in ventricular dysfunction.

Adult↗
PubMed1989

Effects of occlusion of the left anterior descending coronary artery during angioplasty on right-sided cardiac pressures and electrocardiographic changes.

Controversy persists regarding the presence and extent of right ventricular involvement with acute anterior injury. Also unclear are the incidence and significance of ST elevations in the right-sided leads in acute left anterior descending artery occlusion. Baseline and coronary occlusion hemodynamics and 15-lead electrocardiograms (addition of RV3 through RV5) were recorded in 42 patients during 32 left anterior descending and 13 right coronary artery angioplasties. The right coronary and left anterior descending artery angioplasties had similar baseline right and left ventricular hemodynamics, as well as identical right atrial to pulmonary wedge pressure ratios (0.51 right coronary vs 0.51 left anterior descending). Whereas the right coronary and left anterior descending occlusions produced similar elevations in right ventricular filling pressures, the left anterior descending occlusions produced greater elevations in left ventricular filling pressures. The right atrial to pulmonary wedge ratio increased with right coronary occlusions, but was unchanged with left anterior descending occlusions (0.79 right vs 0.46 left, p less than or equal to 0.0001). Presence of right-lead ST elevations in 10 left anterior descending occlusions did not con-note increased right ventricular filling pressures, but did suggest increased left ventricular ischemia and dysfunction. In conclusion, right ventricular dysfunction, as manifested by increased filling pressures, is seen with both right coronary and left anterior descending occlusions. Although it is the predominant abnormality in right coronary occlusions, in left anterior descending occlusions it is proportional to left ventricular dysfunction. ST elevations in a right lead with left anterior descending occlusions do not constitute a marker for increased right ventricular dysfunction.

Angioplasty, Balloon↗
PubMed1999

Right ventricular infarction: specific requirements of management.

The principal cause of right ventricular infarction is atherosclerotic proximal occlusion of the right coronary artery. Proximal occlusion of this artery leads to electrocardiographically identifiable right-heart ischemia and an increased risk of death in the presence of acute inferior infarction. Clinical recognition begins with the ventricular electrocardiographic manifestations: inferior left ventricular ischemia (ST segment elevation in leads II, III and aVF), with or without accompanying abnormal Q waves and right ventricular ischemia (ST segment elevation in right chest leads V3R through V6R and ST segment depression in anterior leads V2 through V4). Associated findings may include atrial infarction (PR segment displacement, elevation or depression in leads II, III and aVF), symptomatic sinus bradycardia, atrioventricular node block and atrial fibrillation. Hemodynamic effects of right ventricular dysfunction may include failure of the right ventricle to pump sufficient blood through the pulmonary circuit to the left ventricle, with consequent systemic hypotension. Management is directed toward recognition of right ventricular infarction, reperfusion, volume loading, rate and rhythm control, and inotropic support.

Combined Modality Therapy↗
PubMed2004

High prevalence of right ventricular systolic dysfunction in early systemic sclerosis.

OBJECTIVE: To assess right ventricular (RV) function in patients with early systemic sclerosis (SSc) and the acute effects of calcium channel blockers on RV ejection fraction (RVEF). METHODS: Forty-two consecutive patients with SSc with less than 5 years' disease duration and normal pulmonary arterial pressure (35 women, 7 men; mean age 54.3 +/- 9.7 years; 16 with diffuse and 26 with limited cutaneous forms, systolic pulmonary arterial pressure 30.3 +/- 5.4 mmHg) were prospectively evaluated. All underwent pulmonary function testing, echocardiography, and radionuclide ventriculography at rest and 2 hours after receiving 40 mg oral nicardipine, and were compared at baseline with 20 gender and age matched controls. RESULTS: None of the patients with SSc had clinical evidence of heart failure. At baseline, SSc patients had significantly lower LVEF (68.5% +/- 7.9 vs 72.4% +/- 5.0, p = 0.049) and RVEF (36.5% +/- 7.0 vs 45.8% +/- 5.7, p < 0.0001). Sixteen patients had reduced RVEF (< 35%), 3 had reduced LVEF (< 55%), and 10 had reduced peak filling rate (PFR). RVEF correlated to both LVEF and PFR (r = 0.64, p < 0.0001, and r = 0.36, p = 0.0037, respectively), whereas no correlation was found with pulmonary function impairment or pulmonary arterial pressure. Nicardipine resulted in a significant increase in RVEF (from 36.5% +/- 7.0 to 42.3% +/- 8.4, p < 0.001) whereas afterload indicated by mean arterial pressure did not differ significantly. CONCLUSION: Reduced RVEF appears to be a common feature in early SSc; it may be due to intrinsic myocardial involvement and is acutely improved by nicardipine.

Adult↗
PubMed2003

Major increase in brain natriuretic peptide indicates right ventricular systolic dysfunction in patients with heart failure.

This study sought to investigate whether the presence of right ventricular systolic dysfunction with pre-existing left ventricular systolic dysfunction is associated with higher plasma brain natriuretic peptide (BNP) levels, compared with patients with isolated left ventricular dysfunction. Eighty-five patients referred for evaluation of isotopic ventricular function were prospectively included in the study. Left (LVEF) and right (RVEF) ventricular ejection fractions were evaluated by gated blood pool scintigraphy and compared with plasma BNP levels. BNP correlated negatively with LVEF, except in patients with ischaemic heart disease (P=0.09) and in patients with LVEF<40% (P=0.11). In contrast, BNP levels correlated negatively with RVEF for all subgroups. Among patients with RVEF<40%, no significant BNP difference was found between patients with or without additional left ventricular systolic dysfunction (P=0.51). Among patients with LVEF<40%, plasma BNP levels were significantly higher in patients with RVEF<40% than in patients with RVEF>/=40% (P=0.004) whereas age, renal function, clinical findings, ventricular volumes, LVEF or medication were not significantly different. In conclusion, an important increase in BNP levels in patients with left ventricular systolic dysfunction should be considered by cardiologists as an indication of high risk of right ventricular dysfunction and should justify further investigation.

Adolescent↗
PubMed2002

Patterns of coronary compromise resulting in acute right ventricular ischemic dysfunction.

BACKGROUND: Although proximal right coronary artery (RCA) occlusion is the culprit commonly responsible for acute right ventricular (RV) infarction (RVI), the severity of RV dysfunction ranges broadly. This study was designed to delineate the patterns of coronary compromise that determine the magnitude of RV ischemic dysfunction. METHODS AND RESULTS: In 125 patients with acute inferior myocardial infarction undergoing emergency angiography, the culprit infarct lesion was identified, RV branch flow assessed (TIMI flows and frame counts), and individual patient RV perfusion indices calculated by separately averaging the branch flows and frame counts, which were correlated with RV wall motion by ultrasound. RVI occurred in 53 (42%) patients, with the RCA as the culprit vessel and the lesion sufficiently proximal to compromise flow in at least one RV branch in all cases, thereby resulting in depressed RV perfusion (flow index, 0.7+/-0.2). In patients without RVI, the RCA was the culprit in 89%; the circumflex, in 11%. RCA culprits were proximal in 19% of such cases, with lack of RVI explained by preserved RV perfusion (flow index, 2.7+/-0.3; P=0.001) attributable to at least 1 patent RV branch, spontaneous reperfusion, or prominent collaterals. Overall, there was a strong correlation between RV perfusion and wall motion (Spearman correlation coefficient=0.79). CONCLUSIONS: Proximal RCA occlusion compromising RV branch perfusion commonly results in RV ischemic dysfunction. In some cases with proximal RCA culprits, collaterals or spontaneous reperfusion preserve RV performance.

Acute Disease↗
PubMed2002

Right ventricular diastolic dysfunction in arterial systemic hypertension: analysis by pulsed tissue Doppler.

AIMS: This study analyses right ventricular longitudinal function in arterial systemic hypertension by pulsed tissue Doppler. METHODS AND RESULTS: Thirty normotensives and 30 hypertensives, free of cardiac drugs, underwent standard Doppler echocardiography and pulsed tissue Doppler of right ventricular lateral tricuspid annulus and left ventricular lateral mitral annulus. By tissue Doppler, systolic and diastolic measurements were obtained. Hypertensives had higher left ventricular mass and impaired Doppler diastolic indexes, without changes of global systolic function. Tissue Doppler showed reduction of right ventricular E/A ratio and prolongation of relaxation time in comparison with controls (both P<0.00001). In the overall population, the length of tissue Doppler derived right ventricular relaxation time was positively related to right ventricular anterior wall thickness while right ventricular E/A ratio was positively related to E/A ratio of left ventricular mitral annulus (both P<0.00001). These relations remained significant even after adjusting for clinical and echocardiographic confounders by separate multivariate models. CONCLUSIONS: Arterial systemic hypertension is associated to right ventricular longitudinal diastolic dysfunction. This dysfunction involves the prolongation of active relaxation, which is independently associated with the degree of right ventricular hypertrophy and the impairment of passive wall properties, which is mainly due to ventricular interaction occurring under left ventricular pressure overload conditions.

Adult↗
PubMed2006

Right ventricular dyssynchrony in heart failure: a tissue Doppler imaging study.

BACKGROUND: The development of right ventricular dysfunction is a poor prognostic sign in patients with heart failure (HF). Although left ventricular dyssynchrony has been well described, it is not known whether right ventricular dyssynchrony coexists in HF. We used tissue Doppler imaging to determine whether right ventricular dyssynchrony is also present in HF patients. METHODS AND RESULTS: In 34 HF patients (mean age 56 +/- 13 years), we measured longitudinal strain at the right ventricular free wall, interventricular septum, and left ventricular lateral wall. Right ventricular and left ventricular dyssynchrony were defined as the difference in time to peak strain between the right ventricular free wall and the septum and between the left ventricular lateral wall and septum, respectively. Mean right ventricular dyssynchrony was 59 +/- 45 ms and the mean left ventricular dyssynchrony was 80 +/- 62 ms. We found a strong correlation between right ventricular dyssynchrony and pulmonary artery systolic pressure (r = 0.73; P < .001) and a negative correlation between right ventricular dyssynchrony and right ventricular fractional area change (r = -0.43; P < .02). CONCLUSION: HF patients exhibit right ventricular dyssynchrony by strain imaging which correlates with pulmonary hypertension and right ventricular dysfunction.

Adult↗
PubMed2004

Right ventricular myocardial dysfunction in adult patients late after repair of tetralogy of fallot.

AIM OF THE STUDY: To detect in adult patients late after repair of Tetralogy of Fallot (TOF) possible correlation between myocardial parameters assessed at rest by Tissue Doppler (TD) and cardiac performance during physical effort. METHODS: Doppler echo, treadmill test and pulsed TD of both mitral and tricuspid annulus were performed in 25 healthy subjects and in 40 adult patients who had undergone surgery for TOF at a mean age of 1.4+/-0.5 years. Exclusion criteria were echocardiographic evidence of residual pulmonary, either stenosis or regurgitation. By use of TD, the following parameters were assessed: systolic peak velocities (Sm), pre-contraction time, contraction time, early (E(m)) and late (A(m)) diastolic velocities, E(m)/A(m) ratio, relaxation time. By treadmill test, we measured: maximal heart rate (HR), systolic blood pressure (SBP), rate-pressure product, maximal workload, time duration of the exercise. RESULTS: the two groups were comparable for left ventricular measurements and for all transmitral and transtricuspid Doppler indexes, while tricuspid ring diameter was increased in TOF. TD analysis showed in TOF lower S(m), E(m) and E(m)/A(m) ratio and prolonged PCT(m) and Rt(m) at tricuspid annulus level, despite comparable TD mitral annulus indexes. By treadmill test, TOF showed reduced time of exercise, number of METS reached and rate-pressure product. Multiple linear regression models evidenced in TOF independent positive association between tricuspid Em velocity and time of exercise (p<0.0001), achieved METS at peak effort (p<0.001) and rate-pressure product (p<0.001). An E(m) peak velocity of tricuspid annulus lower than 0.13 m/s showed 90% sensitivity and 93% specificity in identifying TOF patients unable to perform maximal exercise test. CONCLUSIONS: despite normal Doppler parameters, adult patients late after correction of TOF showed impaired right ventricular myocardial function. In these patients pulsed TD may be taken into account as a valuable supporting tool to predict the effort response and possibly to assess long-term follow-up of cardiac functional reserve.

Adult↗
PubMed2005

Cardiac resynchronization therapy in congenital heart disease.

While cardiac resynchronization therapy (CRT) is of proven benefit in selected patients with severe ischemic or dilated cardiomyopathy, refractory symptoms, and conduction delay, extrapolation to congenital heart disease is not straightforward. This rapidly expanding patient population commonly suffers from heart failure, particularly in the presence of a single or systemic right ventricle. Surgical repair may also contribute to ventricular asynchrony. In this systematic review, the current state of knowledge regarding CRT in congenital heart disease is presented. Issues specific to congenital heart disease including right bundle branch block, right (pulmonary) ventricular dysfunction, systemic right ventricular dysfunction, and single ventricle dysfunction are explored. Evidence-based CRT applications for each of these particular conditions are reviewed. Initial experience with CRT in the acute postoperative setting and longer-term, including our own, is elaborated. Unlike standard indications based on multiple randomized clinical trials, supporting evidence for CRT in congenital heart disease is limited to case reports, case series, and small experimental crossover studies in the acute postoperative setting. The heterogeneous patient population, technical limitations from patient size, vascular access issues, and unique forms of ventricular asynchrony further obscure the selection of potential beneficiaries. Despite these limitations, experience thus far has been favorable. Quality of current data precludes definitive evidence-based recommendations, but optimistic initial results suggest that research endeavors in this field should be pursued. Multicenter prospective collaborative efforts are to be encouraged.

Cardiac Pacing, Artificial↗
PubMed1997

In utero management of hydrops fetalis caused by critical aortic stenosis.

Hydrops fetalis is rarely associated with congestive heart failure caused by obstructive left-sided heart lesions. There are rare cases of live born neonates with critical congenital valvar aortic stenosis and hydrops reported in the literature, all with fatal outcomes. This report describes, to the best of our knowledge, the first two newborns who were diagnosed prenatally to have hydrops fetalis caused by critical valvar aortic stenosis, who were treated prenatally with digoxin and who postnatally had successful percutaneous balloon aortic valvuloplasty. Both patients had not only left but right ventricular dysfunction. We speculate that right ventricular dysfunction was a contributing factor in the development of hydrops in these patients and in utero medical therapy with digoxin is associated with resolution of the hydrops before delivery.

Angioplasty, Balloon↗
PubMed2001

The relationship between QT dispersion and left and right ventricular diastolic dysfunction in patients with myocardial infarction.

OBJECTIVE: The purpose of this study was to investigate the relation between electrical dispersion and impairment of ventricular filling in patients with acute myocardial infarction (MI). METHODS: Thirty patients with recent myocardial infarction (17 patients with anterior and 13 patients with inferior MI) were included in the study. QT dispersion (QTd) was defined as maximum minus minimum QT interval durations. Flow propagation velocity measured by color m-mode echocardiography was used to determine diastolic function. RESULTS: There was a positive correlation between isovolumic relaxation time and QTd, as well as negative correlation existed between left ventricular flow propagation velocity (LVFPV) and QTd. The QTd was greater and LVFPV was lower in patients with anterior myocardial infarction as compared with those with inferior MI. CONCLUSION: There is an association between electrical dispersion and left ventricular filling abnormalities in patients with acute myocardial infarction.

Diastole↗
PubMed1996

[Right ventricular failure in terminale cardiac failure: prognostic value and evaluation before transplantation assessment].

Right ventricular failure occurs as a late complication of cardiomyopathy; the observation of biventricular failure usually reduces survival to less than 2 years. Right ventricular dysfunction is related mainly to the important increase of the afterload and also to parietal ischaemia in ischaemic heart disease or direct dysfunction of the contractility in pure myocardial disease, giving rise to the dilated cardiomyopathies. The prognostic value of the right ventricular ejection, fraction has been demonstrated in all forms of cardiomyopathy leading up to cardiac transplantation. Right ventricular function must therefore be taken into account in pretransplantation investigations.

Follow-Up Studies↗
PubMed1991

Right ventricular pump dysfunction with acute experimental septic shock.

Right ventricular (RV) function has been poorly characterized at the onset of acute bacterial septic shock. Using a volumetric thermodilution catheter, previously validated in our laboratory, we serially measured RV function in a porcine model of acute septic shock. Six pigs (21.3 +/- 0.9 kg) were instrumented and Pseudomonas aeruginosa (3.4 x 10(8) cfu/ml, 0.3 ml/20 kg/min) was infused. RV ejection fraction, RV volumes, cardiac output, arterial pressure, central venous pressure, and pulmonary arterial pressure were measured at baseline and at 30, 60, 120, and 240 min after starting the bacterial infusion. RV ejection fraction and stroke volume were decreased at 30 min compared to baseline (21 +/- 5 vs 43 +/- 5% and 14 +/- 3 vs 23 +/- 3 ml, respectively; P less than 0.05) and remained depressed throughout the experiment. Mean arterial pressure was significantly reduced at 60, 120, and 240 min compared to baseline (P less than 0.05). There was a significant increase in pulmonary vascular resistance (1771 +/- 493 vs 301 +/- 99 dyn-sec-cm-5 at 30 min; P less than 0.05) and RV stroke work (5.7 +/- 1.1 vs 2.3 +/- 0.3 gm-m/beat at 30 min; P less than 0.05) while no significant change in RV end-diastolic volume or central venous pressure was observed. Thus, a decrease in RV pump performance was associated with an increase in afterload and no change in preload. These results suggest that severe RV pump dysfunction occurs early in acute septic shock. This was manifested by significant reductions in RV ejection fraction and increased in stroke work.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1991

Right coronary artery disease. Pathophysiology, clinical relevance, and methods for recognition.

Among the clinical manifestations of ischemic heart disease, right coronary artery (RCA) disease offers a wide variety of right and left ventricular ischemic involvement, including prevalent right ventricular dysfunction and severe cardiac failure. Whether the right ventricular impairment is dependent primarily on ischemia of the right ventricle or requires a concomitant left ventricular dysfunction remains debatable. To assess the pathophysiology and clinical relevance of RCA-related ischemia, a systematic study of patients with single RCA disease (either vasospastic angina at rest or typical stable angina) was undertaken by radionuclide ventriculography. A high incidence of ischemia-induced right ventricular dysfunction was observed (93% and 95% in angina at rest and on effort, respectively), either alone or associated with left ventricular impairment. These results were compared with those obtained in a control population with isolated left anterior descending artery disease and either primary or secondary angina pectoris. We infer that the impairment of the right ventricle was related primarily to right ventricular ischemia and that left ventricular dysfunction alone did not cause an important depression of right ventricular systolic function. In conclusion, the clinical manifestations of RCA disease can be protean; the right ventricle can be the target of ischemia, and recognition of its impairment poses diagnostic problems. Radionuclide ventriculography and two-dimensional echocardiography, together with stressors of coronary flow reserve, are reliable techniques for assessing RCA-related ischemia.

Angina Pectoris↗
PubMed2006

Duration of inotropic support after left ventricular assist device implantation: risk factors and impact on outcome.

OBJECTIVES: Because duration of inotropic support after left ventricular assist device implantation has been recognized as a surrogate for right ventricular dysfunction, we sought to (1) identify its preimplantation risk factors, particularly its association with preimplantation right ventricular dysfunction, and (2) assess its impact on clinical outcomes. METHODS: Between 1991 and 2002, left ventricular assist devices were implanted in 207 patients, exclusive of those receiving preoperative mechanical circulatory support, which precluded measuring right ventricular stroke work. Duration of inotropic support was analyzed as a continuous variable, truncated by death or transplantation, and in turn as a risk factor for these 2 events. RESULTS: Inotropic support decreased from 100% on the day of implantation to 57%, 33%, and 22% by days 7, 14, and 21. Its duration was strongly associated with lower preimplantation right ventricular stroke work index, older age, and nonischemic cardiomyopathy and was associated (P < .04) with higher mortality before transplantation but not with transition to transplantation. We identified no preimplantation risk factors for right ventricular assist device use because of its relatively infrequent use in this population (18 patients, only 4 of whom survived to transplantation). CONCLUSION: Duration of inotropic support after left ventricular assist device insertion is strongly correlated with low preimplantation right ventricular stroke work index. In turn, it was associated with reduced survival to transplantation. Thus, right ventricular stroke work measured before implantation might be useful in decision making for biventricular support, destination therapy, or total artificial heart.

Cardiomyopathies↗