Right ventricular function in adult atrial septal defect. Preoperative and postoperative assessment and clinical implications.
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Adolescent↗
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STUDY OF THE RIGHT ATRIAL PRESSURE PULSE IN FUNCTIONAL TRICUSPID REGURGITATION AND NORMAL SINUS RHYTHM.
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Atrial Pressure↗
Functionally atrialized parchment-like right ventricle with extensive myocardial fibrosis of left ventricle.
A 18-year-old female with unusual type of parchment-like right ventricle died of intractable congestive heart failure was reported. A catheter study revealed the absence of systolic contraction of the right ventricle. The pressure tracing curve in the right ventricle was virtually the same as in the right atrium. At autopsy, there was an extensive myocardial fibrosis of the left ventricle in addition to the almost total absence of the myocardium of the right ventricle. The case was considered to be a unique type of idiopathic cardiomyopathy.
Adolescent↗
[A case of tricuspid pouch associated with ventricular septal defect and functional left ventricular-right atrial communication].
We reported a 60-year-old woman with tricuspid pouch associated with ventricular septal defect and subsequent left ventricular-right atrial communication. Preoperative angiographic findings suggested the presence of membranous septal aneurysm, ventricular and atrial septal defects, and tricuspid insufficiency. However, at operation, besides perimembranous inlet type ventricular septal defect, a pouch, 1.5 cm in diameter was found in the adjacent part to the septal leaflet within the anterior one of the tricuspid valve. The ventricular septal defect was closed with a patch. From these findings, it is speculated that the tricuspid pouch was formed by the effect of jet stream through the ventricular septal defect.
Diagnosis, Differential↗
[Functional importance of the right atrial terminal crest in damage to the sinoatrial node].
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Animals↗
Hemodynamic effect of progressive right atrial dilatation in atriopulmonary connections.
OBJECTIVE: Right atrial dilation occurring late after the modified Fontan procedure is frequently associated with low output states, supraventricular arrhythmias, and atrial thrombus formation. We addressed the hypothesis that progressive right atrial dilatation contributes to inefficient right heart flow dynamics. METHODS: Modified atriopulmonary connections were performed on explanted isolated sheep heart preparations with various degrees of surgically induced right atrial dilatation (right atrial volumes 6 to 55 cm3). Flow models were perfused in an in vitro flow loop with the use of a blood analog fluid. A fluid energy balance was performed for six flow rates (1.0 to 6.0 L/min) at each degree of right atrial dilatation, and the rate of total fluid energy loss was calculated and expressed as a function of right atrial volume and flow rate. Effective pressure drop and fluid resistance across the right atrial chamber were also determined for each flow condition. RESULTS: The rate of fluid energy loss increased with increasing right atrial dilatation and flow rate for all conditions studied (p < 0.001). Over the range of right atrial volumes and flow rates examined, the average increase in the rate of energy loss was 3.8- and 117-fold, respectively. Calculated fluid resistance through the right atrium also increased with increasing right atrial volume and flow rate (p < 0.001), exhibiting an average increase of 3.2- and 3.3-fold respectively. CONCLUSIONS: Right atrial dilatation in atriopulmonary connections causes fluid energy losses and increases the energy required to move blood from the venae cavae to the pulmonary arteries. These observations may help explain the progressive nature of late failures of atriopulmonary connections and provide additional rationale for conversion from atriopulmonary connections to lateral tunnel total cavopulmonary connections in selected patients.
Animals↗
Atrial flutter--update on the mechanism and treatment.
Atrial flutter is a common and usually benign but symptomatic supraventricular tachycardia. There is a striking similarity between patients with atrial flutter suggesting a common substrate despite the presence or absence of underlying heart disease. In man, the mechanism is a single reentrant circuit originating in the right atrium whose center appears to be functional within the anatomical constraints of the right atrium. The reentrant circuit of atrial flutter contains an area of slow conduction in the inferior right atrium but the size and exact location is uncertain. Drug therapy directed at terminating and preventing atrial flutter has been available for many years. The efficacy and safety of this therapy is not as well tested as is the same therapy for atrial fibrillation. The most effective way to terminate atrial flutter is a nonpharmacological approach. Several nonpharmacological methods provide new treatment options in the management of patients with drug resistant or hemodynamically unstable atrial flutter. The use of anticoagulation for this disorder is still evolving. There is a risk of clinically apparent thromboemboli in some patients with atrial flutter although the risk appears less than that for atrial fibrillation. In the future, refinements and improvements in therapy for atrial flutter will likely be derived from a better understanding of its mechanism.
Animals↗
Bicaval versus atrial anastomoses in cardiac transplantation. Right atrial dimension and tricuspid valve function at rest and during exercise up to thirty-six months after transplantation.
Conventional cardiac transplantation with atrial anastomoses alters atrial integrity, geometry, and possibly function. Theoretically, this may also contribute to the development of tricuspid insufficiency that is frequently observed after the operation. Thus more anatomic transplantation techniques using bicaval anastomoses were recently introduced into clinical practice. Knowledge of their efficacy, however, is scarce. Therefore right atrial size and tricuspid valve function were compared in patients with bicaval (group A) and standard atrial (group B) anastomoses in a randomized, prospective study. The results of this echocardiographic study at rest and exercise in 18 patients (bicaval n = 8; atrial n = 10) on the average 28 months after transplantation are presented. The right atrial dimension was comparable between group A patients and control subjects and larger in group B patients (p < 0.05). The incidence of tricuspid regurgitation was not different between the two groups at rest, but it was at exercise (50 watts of workload) (p < 0.05). This study suggests that up to 36 months after cardiac transplantation the technique of bicaval in contrast to atrial anastomoses preserves right atrial size and reduces tricuspid regurgitation during exercise. Whether this leads to improved hemodynamics and increased exercise capacity remains to be evaluated in a larger series of patients.
Cardiac Output, Low↗
Intrinsic cardiac nervous system in tachycardia induced heart failure.
The purpose of this study was to test the hypothesis that early-stage heart failure differentially affects the intrinsic cardiac nervous system's capacity to regulate cardiac function. After 2 wk of rapid ventricular pacing in nine anesthetized canines, cardiac and right atrial neuronal function were evaluated in situ in response to enhanced cardiac sensory inputs, stimulation of extracardiac autonomic efferent neuronal inputs, and close coronary arterial administration of neurochemicals that included nicotine. Right atrial neuronal intracellular electrophysiological properties were then evaluated in vitro in response to synaptic activation and nicotine. Intrinsic cardiac nicotine-sensitive, neuronally induced cardiac responses were also evaluated in eight sham-operated, unpaced animals. Two weeks of rapid ventricular pacing reduced the cardiac index by 54%. Intrinsic cardiac neurons of paced hearts maintained their cardiac mechano- and chemosensory transduction properties in vivo. They also responded normally to sympathetic and parasympathetic preganglionic efferent neuronal inputs, as well as to locally administered alpha-or beta-adrenergic agonists or angiotensin II. The dose of nicotine needed to modify intrinsic cardiac neurons was 50 times greater in failure compared with normal preparations. That dose failed to alter monitored cardiovascular indexes in failing preparations. Phasic and accommodating neurons identified in vitro displayed altered intracellular membrane properties compared with control, including decreased membrane resistance, indicative of reduced excitability. Early-stage heart failure differentially affects the intrinsic cardiac nervous system's capacity to regulate cardiodynamics. While maintaining its capacity to transduce cardiac mechano- and chemosensory inputs, as well as inputs from extracardiac autonomic efferent neurons, intrinsic cardiac nicotine-sensitive, local-circuit neurons differentially remodel such that their capacity to influence cardiodynamics becomes obtunded.
Animals↗
Closure of atrial septal defect in the adult. Cardiac remodeling is an early event.
BACKGROUND: Study aimed to describe the extent and the temporal profile of cardiac remodeling after atrial septal defect closure in the adult. METHODS: Prospective and longitudinal echocardiographic assessment of right and left heart size before and after (1 day-1 week/1/4/12 months) surgical or catheter-based atrial septal closure in 39 adults (age 54+/-15 years). RESULTS: Right ventricular and atrial sizes were markedly reduced, left ventricular size increased and left atrial size remained unchanged after closure. Older age and a history of atrial fibrillation reduced the potential to normalize right and left atrial size after closure. The greater part of the changes occurred very early, in the 1st day/1st week. From then on the speed of change gradually diminished and after 4 months no important changes were observed. The mode of closure did not influence the degree or the pace of the remodeling. CONCLUSION: Cardiac remodeling after atrial septal closure in the adult is a common and early event that seems by and large completed within the first half year after closure. The ventricles seem to have a higher capacity of remodeling than the atria in this setting. The mode of closure does not seem to significantly impact remodeling.
Adult↗
Initial experience with the radial incision approach for atrial fibrillation.
BACKGROUND: Surgery for atrial fibrillation (AF) is performed with the aim of restoring sinus rhythm and atrial transport function, and preventing thromboembolism. The radial incision approach (RIA), in which the atrial incisions radiate from the sinus node toward the atrioventricular annular margins and parallel the coronary arteries, was developed as an outgrowth of and an alternative to the maze procedure in order to preserve a more physiological activation sequence and the atrial transport function. METHODS: To determine whether the RIA is a promising procedure for AF, 23 patients who had undergone the RIA (n = 10) or the maze procedure (n = 13) for chronic AF associated with valvular heart disease were examined in terms of the postoperative cardiac rhythm and atrial transport function. RESULTS: AF was cured in 90% of RIA patients and 92.3% of maze patients (not significant). One patient in each group required pacemaker implantation for an insufficient sinus rate postoperatively. The RIA was technically easier than the maze procedure, because the incisions were more linear and there was no isolation incision or "T-shape" incision in the left atrium. The left atrial transport function, assessed by transthoracic Doppler echocardiography, was greater after the RIA than after the maze procedure, while the right atrial transport function was equally preserved by both procedures. The peak atrial filling/early filling waves of the flow-velocity spectra across the mitral valve was significantly larger after the RIA than after the maze procedure (0.58+/-0.17 vs. 0.25+/-0.07, p<0.005). The left atrial filling fraction was significantly larger after the RIA than after the maze procedure (28.5%+/-5.0% vs. 15.1%+/-4.0%, p<0.001). CONCLUSIONS: RIA provides a greater atrial transport function, and thus may represent a physiological alternative to the maze procedure as a surgical procedure for AF.
Atrial Fibrillation↗
Influence of advancing age on fractionated right atrial endocardial electrograms.
The influence of advancing age on atrial endocardial electrograms recorded during sinus rhythm in humans who do not have atrial fibrillation has not been assessed thus far. The prevalence of atrial arrhythmias has been reported to increase with advancing age. Right atrial endocardial catheter mapping during sinus rhythm was performed in 106 patients who had normal sinus node function and no paroxysmal atrial fibrillation to evaluate the influence of advancing age on atrial endocardial electrograms. The bipolar electrograms were recorded at 12 sites in the right atrium, and an abnormal atrial electrographic result was defined as lasting > or =100 ms and/or showing > or =8 fragmented deflections. A total of 1,272 right atrial endocardial electrograms was assessed and quantitatively measured. The mean number of abnormal atrial electrograms per patient (0.61 vs 0.14, p <0.02) and the incidence of abnormal atrial electrograms (11% vs 30%, p <0.02) were significantly greater in patients who were >60 years of age than in younger patients. The longest duration (r = 0.24, p <0.02) and the maximal number of fragmented deflections (r = 0.28, p <0.005) of atrial electrograms among the 12 right atrial sites showed a slight positive correlation with age. The process of aging modifies the electrophysiologic properties of the atrial muscle. There is a progressive increment in the extension of altered atrial muscle with advancing age in humans who do not have atrial fibrillation. Patients who are >60 years of age have significantly greater abnormalities on atrial endocardial electrograms than do younger patients.
Adolescent↗
Effect of surgical repair of secundum-type atrial septal defect on right atrial, right ventricular, and left ventricular volumes in adults.
Surgical repair of atrial septal defect in adults reduces right ventricular and right atrial diameters and volumes, and improves left ventricular filling.
Adult↗
Electrocardiographic assessment of right heart dysfunction.
The electrocardiogram, when used in light of other clinical data, can be a powerful tool in detecting right heart dysfunction. Right bundle branch block can be identified on the electrocardiogram by the presence of an RSR' configuration in right-sided chest leads. Right atrial enlargement produces tall pointed P waves in lead II and biphasic P waves in V1, whose initial upstroke is larger than the terminal downstroke. Right ventricular enlargement is best seen on the electrocardiogram by a reverse in the pattern of normal R wave progression across the precordium. Occurring most often with an inferior wall myocardial infarction, a right ventricular infarction is depicted by ST segment elevations in right-sided precordial leads. The ability to detect these electrocardiographic changes will enhance the nurse's assessment and management of patients with right heart dysfunctions.
Atrial Function, Right↗
Echocardiography of the right side of the heart.
Echocardiography has not only revealed the morphologic aspects of the right-sided cardiac structure but has, through the use of pulsed and color Doppler imaging, provided a whole new level of certainty in the diagnosis of cardiac disease. The structure and function of the right-sided chambers are now far better appreciated since this technique has become more widely used for early clinical diagnosis of right-sided cardiac disease.
Atrial Function, Right↗
Right-to-left interatrial shunt after pneumonectomy.
BACKGROUND: Platypnea and Orthodeoxia have been described with congenital heart and severe lung diseases. METHODS: We report 4 patients in whom platypnea and orthodeoxia developed after pneumonectomy. In these patients the mean oxygen saturation on room air was 65% (range, 45% to 79%) in the supine position. On O2 therapy it improved to 94% (range, 80% to 99%). When the patients assumed the erect position and were receiving O2 therapy the saturation dropped to a mean of 76% (range, 56% to 82%) and the patients complained of shortness of breath. Cardiac catheterization revealed a mean pulmonary capillary wedge pressure of 11.6 mm Hg (range, 7 to 18 mm Hg). All patients had normal right atrial pressure. A right-to-left interatrial shunt through a patent foramen ovale was documented by transesophageal echocardiography and dynamic ultrafast magnetic resonance imaging. The patients underwent surgical closure of the patent foramen ovale. RESULTS: In the erect position, the room air O2 saturation improved to a mean of 95% (range, 92% to 99%), and the shortness of breath disappeared. CONCLUSIONS: Postpneumonectomy patients complaining of shortness of breath should be assessed for platypnea and orthodeoxia. A right-to-left interatrial shunt through a patent foramen ovale can occur even in the absence of elevated right heart pressures, especially after right pneumonectomy, and is accentuated in the upright posture. Surgical correction of the patent foramen ovale can produce dramatic improvement.
Aged↗
Ventricular function after atrial cardioplegia.
Continuous retrograde coronary sinus cardioplegia (CSCP) has previously been carefully evaluated experimentally and shown to be efficacious during ischemia, even in the presence of coronary lesions and in the hypertrophied state. A new technique of retrograde cardioplegia delivery through the right atrium, using right ventricular distension and pressures of 60 mm Hg, has recently been described with excellent clinical results. This study was designed to specifically examine right ventricular function after atrial cardioplegia and acute passive right ventricular distension. CSCP (n = 10) was compared with cardioplegia delivered through the right atrium both continuously (n = 10) and intermittently (n = 8). When ventricular function was examined with the use of the load-independent relationship of stroke work vs end-diastolic length, there was a profound deterioration of right ventricular function in both atrial cardioplegia groups (44% and 37% of control values, respectively) after 1 hr of reperfusion. In contrast, biventricular function was fully preserved in the CSCP group 1 hr after reperfusion. Left ventricular function measured at the end of reperfusion was preserved in all three groups. Right ventricular ATP levels were slightly but significantly depressed in all groups and in the atrial cardioplegia groups, this metabolic change was also seen in the left ventricle. These metabolic and hemodynamic data may reflect the inability of atrial cardioplegia to cool the myocardium below 16 degrees C. Postoperative right ventricular dysfunction may be more common than has been previously thought when atrial cardioplegia is used, particularly in the absence of topical cooling.
Adenine Nucleotides↗
Cardiovascular effects of increasing airway pressure in the dog.
In paralyzed anesthetized dogs the cardiovascular effects of increasing positive end-expiratory pressure (PEEP) were explored under two conditions: a) end-expiratory lung volume increasing, b) end-expiratory lung volume kept nearly constant by matching pleural pressure rise to end-expiratory airway pressure rise. Two series of experiments were done: I) xenous return was allowed to fall, II) venous return was kept constant by infusion of volume. Right atrial pressure, pulmonary arterial pressure, and left atrial pressure increased under all conditions when measured relative to atmospheric pressure, but increased relative to pleural pressure only under condition a. The rise in left atrial relative to pleural pressure may indicate a degree of left ventricular dysfunction associated with increasing end-expiratory lung volume. Furthermore, when end-expiratory lung volume increased, inequality of the rise in pulmonary artery wedge pressure exceeded the rise in left atrial pressure in series I. From plots of cardiac output as a function of right atrial pressure it was possible to conclude that the decrease in venous return is partially offset by an increase in mean circulatory pressure.
Airway Resistance↗