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PubMed2002

Functional assessment of the right ventricle with gated myocardial perfusion SPECT.

BACKGROUND: The evaluation of right ventricular function can provide valuable information in a variety of cardiac and noncardiac conditions. Functional assessment of the right ventricle is difficult because of its anatomy and geometry. The authors describe a method for assessing right ventricular function using gated myocardial perfusion SPECT. METHODS: In 20 patients, right and left ventricular ejection fractions (RVEF, LVEF) were determined using gated blood-pool scintigraphy (GBPS) and gated myocardial perfusion SPECT (GSPECT). To avoid contamination with right atrial activity, the two-frame method was adopted for gated blood-pool data when RVEF was measured. In nine patients with normal right ventricles, an index of wall thickening for the right ventricle was derived from the peak systolic and diastolic counts in the free wall. RESULTS: Linear correlation between the two methods adopted for calculation of LVEF and RVEF was good. Bland-Altman analysis revealed good agreement between the two methods with no specific bias. The mean LVEF was 47.9 +/- 12% (GBPS) and 47.3 +/- 12.4 (GSPECT). The mean RVEF was 43.2 +/- 9.6% (GBPS) and 44.2 +/- 8.5% (GSPECT). In both cases, the values were not significantly different. The mean wall motion index was 35%. There was no correlation between the wall thickness index and ejection fraction, but the index was greater in patients with a normal right ventricle compared with those with reduced RVEF. CONCLUSIONS: Gated SPECT offers an alternative to GBPS for the functional assessment of the right ventricle. Using GSPECT will allow the simultaneous assessment of both the right and left ventricles.

Gated Blood-Pool Imaging↗
PubMedDate not supplied

Surgical results after total transatrial/transpulmonary correction of tetralogy of Fallot.

INTRODUCTION: Surgical repair of tetralogy of Fallot is associated with low early morbidity and mortality. However, there may be late morbidity and mortality due to right ventricular dysfunction. The transatrial/transpulmonary technique may ameliorate these long-term complications. Here we present the results from our use of this approach. METHODS: A hundred sixty-three consecutive patients (age 6 months to 45 years, median 1.5 years) underwent transatrial/transpulmonary total correction in our department. In 142 patients the main pulmonary artery was augmented by an autologous pericardial patch, in 31 cases the arterioplasty was extended to the pulmonary artery branches, and pulmonary artery valvuloplasty was needed in 129 patients. A monocusp autologous pericardial valve mechanism was inserted in 14 patients. RESULTS: Patient follow up was 100% complete with a median duration of 3.05 years. There were no deaths. One patient required early reoperation to relieve residual right ventricular outflow tract (RVOT) obstruction. Median ICU and hospital stay were 3 and 11 days, respectively. At hospital discharge RVOT gradient was 13.7 +/- 13 (median 10) mmHg, while most patients (94%) had up to moderate pulmonary valve insufficiency (1 + in 63.8%, 2+ in 30.6%), and normal (92.6%) or mildly reduced (6.1%) right ventricular function. In 81% some degree of tricuspid regurgitation was noted. One patient required late reoperation for mitral valve repair. All patients are in NYHA class I or II. The degree of pulmonary valve insufficiency remains stable (69.9% with 0-1 + and 24.5% up to 2+). Likewise, tricuspid valve function remains unchanged (96% of the patients had mild or up to moderate regurgitation). There was no significant RVOT obstruction and in most patients (93.2%) right ventricular function was normal. CONCLUSION: These results compare very favorably to those reported in the literature. The medium-term findings auger well for future adverse event rates, but long-term follow up is still necessary to confirm them.

Adolescent↗
PubMed1995

Isolated right ventricular unloading for postcardiotomy right ventricular failure in a child.

Severe right ventricular (RV) failure after total correction of double outlet RV (DORV) with pulmonary atresia was completely reversed with extracorporeal mechanical RV unloading in a 2.5-year-old child. The patient could be weaned after 168 h of RV assist device (RVAD) support using a centrifugal Bio-Medicus pump and was discharged from the hospital without adverse effects. This experience of isolated RV unloading in a child encourages further application of RVAD in pediatric patients.

Cardiopulmonary Bypass↗
PubMed2000

[Echo-Doppler study of the right ventricle in patients with chronic cardiac failure].

Echocardiography is a well-established and accurate method for the evaluation of cardiac anatomy and function in patients with heart failure. In this review we summarize the role of echocardiography not only in assessing right ventricular anatomy and function, but also in the prediction of prognosis and in the study of ventricular interaction.

Chronic Disease↗
PubMed2001

[Pulmonary hemodynamics and right ventricular function].

Measurement of continuous blood flow by thermodilution catheter takes into account measures that are intermittent, though the estimation of mean pressures is satisfactory. Natural pulsatile pulmonary circulation would remain unknown. To evaluate pulsatile pulmonary hemodynamics and its importance in right ventricular function, the calculation of impedance based on spectral analysis of pressure and flow waves would allow their respective contributions to resistance, elastance and wave reflection upon after right ventricle loading. Computerization allows bedside monitoring of this sophisticated assessment of right ventricle after loading.

Cardiac Catheterization↗
PubMed2006

Tako-Tsubo cardiomyopathy (apical ballooning) with parvovirus B19 genome in endomyocardial biopsy.

The phenomenon of transient apical ballooning is a rare underlying cause of severe left ventricular dysfunction and has been described as Tako-Tsubo-like cardiomyopathy. Acute myocarditis has been reported to masquerade as acute myocardial infarction or vice versa and is considered as differential diagnosis in this phenomenon. We present here a case of an adult female who was admitted to our cardiology department with chest pain, electrocardiographic and echocardiographic features, suggestive of an acute anterior myocardial infarction, preceded by physical and emotional stress. Coronary angiography demonstrated coronary arteries without relevant atherosclerotic lesions; left ventriculography showed a severe anteroapical dysfunction. Right ventricular endomyocardial biopsy showed normal cardiac tissue, but was positive for Parvovirus B19. Follow-up (2 months later) showed complete regression of regional wall motion abnormalities in transthoracic echocardiography.

Aged↗
PubMed2001

Effect of acutely increased left ventricular afterload on work output from the right ventricle in conscious dogs.

OBJECTIVE: To determine the effect of acute increments in left ventricular afterload on the stroke work output of the right ventricle in vivo. METHODS: After pharmacologic attenuation of autonomic reflexes, left and right ventricular pressure-volume data were obtained in 9 conscious dogs during vena caval occlusions performed before and during aortic constriction. RESULTS: The relationship between right ventricular stroke work and end-diastolic volume during vena caval occlusion was highly linear (r = 0.97 +/- 0.02), but the slope decreased by 20% +/- 13% during aortic constriction sufficient to increase left ventricular mean ejection pressure by 25% +/- 14% (P <.05). The volume-axis intercept remained constant. Similarly, the slope of the linear relationship between right ventricular free wall regional segment work and end-diastolic segment length declined by 22% +/- 10% during aortic constriction (P <.05), without significant change in the length-axis intercept. The reduction in both global and regional right ventricular stroke work at any given preload with increased left ventricular afterload was due entirely to decreased right ventricular stroke volume and free wall shortening, because right ventricular mean ejection pressure was unchanged. Additional experiments were performed in 5 open-chest dogs to produce a greater reduction in left ventricular free wall shortening than observed with aortic constriction by transient constriction of the left circumflex coronary artery. However, this intervention had no effect on right ventricular free wall segment work output. CONCLUSION: Increased left ventricular afterload decreases global and regional right ventricular stroke work at any given preload, a direct, negative systolic ventricular interaction.

Acute Disease↗
PubMedDate not supplied

Biventricular long axis function after repair of tetralogy of Fallot.

Right ventricular restrictive physiology is common after repair of tetralogy of Fallot and relates to exercise performance and symptomatic arrhythmias. In this study, we examined biventricular long axis function in an attempt to clarify further the mechanical substrate of this phenomenon. We studied prospectively 95 patients with tetralogy of Fallot (age range 1-44.3 years) at a median of 4.3 years after repair with Doppler and M-mode echocardiography. Pulmonary arterial, tricuspid, and mitral Doppler spectrals and 2-D guided M-mode recordings of ventricular minor and long axes were obtained with simultaneous phonocardiogram and respirometer recordings. Right ventricular restriction was defined by the presence of antegrade pulmonary arterial flow during atrial systole throughout the respiratory cycle. Restrictive right ventricular physiology was demonstrated in 36 (39%) [group 1] of the 92 patients in whom the data were analyzed. Left ventricular function (FS, isovolumic relaxation time and transmitral E wave deceleration time) was not different in the two groups (p < 0.1, p < 0.6, and p < 0.8, respectively). The presence of antegrade diastolic flow shortened the pulmonary regurgitation in the restrictive group (PR duration/square root of RR 10.7 +/- 2.1 vs 12.1 +/- 2.1, p < 0.01). There was delayed onset of shortening (97.4 +/- 24 vs 88.8 +/- 24 ms, p = 0.01), and the amplitude of right atrioventricular ring excursion, corrected for body surface area, was significantly lower during atrial systole in the restrictive group (0.43 +/- 0.15 vs 0.54 +/- 0.2 cm/m2, p < 0.01). There was also a tendency toward a smaller ratio of right to left total atrioventricular ring excursion in the same group (1.14 +/- 0.19 vs 1.22 +/- 0.23, p = 0.1). Impaired long axis function in patients with restrictive right ventricular physiology following repair of tetralogy of Fallot is associated with abnormal diastolic filling and may contribute to the long-term cardioprotective effect of restrictive physiology by limiting the degree of right ventricular dilatation.

Adolescent↗
PubMed2002

Determinants of maximal right ventricular function: role of septal shift.

BACKGROUND: Right heart failure can occur after orthotopic heart transplantation and can complicate implantation of left ventricular assist devices. The functional codeterminants of right ventricular function are not fully understood. We investigated the effects of left ventricular preload and afterload, systemic pressure, and the contribution of the interventricular septum to right ventricular function. METHODS AND RESULTS: In vivo studies were conducted in 12 dogs by using a highly defined, isovolumic right heart preparation. At any given arterial pressure, maximal right ventricular developed pressure was not influenced by left heart output; however, right ventricular volumes at which peak right ventricular developed pressure occurred differed significantly between the volume-loaded versus the unloaded left ventricle (P <.05). A correlation was found between peak right ventricular developed pressure and mean arterial pressure. The shift of the interventricular septum toward the left ventricle is delayed under the influence of left ventricular volume load, but the maximal interventricular septal deformation does not differ at maximal right ventricular developed pressure. There was a substantial and significant decrease in peak right ventricular developed pressure when the interventricular septum was inactivated (P <.05). CONCLUSIONS: Right ventricular function has multiple determinants, including the right ventricular free wall, the left ventricle, and the interventricular septum. Changes in right ventricular performance caused by alterations in left ventricular volume load and mean arterial pressure are mediated partially through the interventricular septum, as well as through perfusion of the right ventricular free wall; inactivation of the interventricular septum leads to a significant decrease in right ventricular function. Maintaining left ventricular developed pressure and hence the contribution of the interventricular septum to right ventricular function may be important in the management of right ventricular failure.

Animals↗
PubMed2003

[The arrhythmogenic right ventricular cardiomyopathy (ARVC)].

The following report illustrates the case of a 40-year old patient, who was transferred to our hospital because of a symptomatic sustained ventricular tachycardia (VT). The documented VT showed typical left bundle branch block morphology with an inferior axis, which was accompanied by repolarization abnormalities in the right precordial leads, as revealed by the surface ECG. While coronary angiography allowed the exclusion of an obstructive coronary heart disease and confirmed an intact left ventricular function, the right ventricular angiography as well as the MRI demonstrated not only reduced right ventricular function but also regional abnormalities of contraction in the inferior and diaphragmal regions and typical "outpouchings" and "bulgings". The MRI also provided evidence for sporadic fatty infiltrations of the right ventricle. In the electrophysiological study, sustained VT could be reproducibly induced, while showing the typical RVOT configuration, which corresponded to the clinically apparent VT. Since these examination results matched with the criteria of McKenna et al., arrhythmogenic right ventricular cardiomyopathy was diagnosed. The patient underwent implantation of a cardioverter-defibrillator (ICD) and medical treatment with metoprolol. This particular case report was selected because it shows a typical presentation of an ARVC. Furthermore, the present example offers the possibility of demonstrating that in the case of an ARVC in the regions of the right ventricle, arrhythmogenic areals can also be found which seem morphologically inconspicuous.

Adult↗
PubMed2003

Ventricular fibrillation resulting from acute right ventricular infarction from isolated occlusion of a right ventricular branch artery.

Malignant ventricular arrhythmias can result from isolated right ventricular infarction, and reports of this phenomenon in the literature are rare. We present a case of a 46-year-old man with acute onset of chest pain angiographically confirmed to be a result of isolated occlusion of a right ventricular branch artery. He developed ventricular fibrillation within 5 hours of symptom onset. This case highlights the point that despite its benign clinical appearance and preserved left ventricular function, necrosis of right ventricular tissue can have life-threatening consequences.

Acute Disease↗
PubMed1995

Hemodynamic and physiologic changes during support with an implantable left ventricular assist device.

To evaluate hemodynamic effectiveness and physiologic changes on the HeartMate 1000 IP left ventricular assist device (Thermo Cardiosystems, Inc., Woburn, Mass.), we studied 25 patients undergoing bridge to heart transplantation (35 to 63 years old, mean 50 years). All were receiving inotropic agents before left ventricular assist device implantation, 21 (84%) were supported with a balloon pump, and 7 (28%) were supported by extracorporeal membrane oxygenation. Six patients died, primarily of right ventricular dysfunction and multiple organ failure. Nineteen (76%) were rehabilitated, received a donor heart, and were discharged (100% survival after transplantation). Pretransplantation duration of support averaged 76 days (22 to 153 days). No thromboembolic events occurred in more than 1500 patient-days of support with only antiplatelet medications. Significant hemodynamic improvement was measured (before implantation to before explantation) in cardiac index (1.7 +/- 0.3 to 3.1 +/- 0.8 L/min per square meter; p < 0.001), left atrial pressure (23.7 +/- 7 to 9 +/- 7.5 mm Hg; p < 0.001), pulmonary artery pressure, pulmonary vascular resistance, and right ventricular volumes and ejection fraction. Both creatinine and blood urea nitrogen levels were significantly higher before implantation in patients who died while receiving support. Renal and liver function returned to normal before transplantation. We conclude that support with the HeartMate device improved hemodynamic and subsystem function before transplantation. Long-term support with the HeartMate device has a low risk of thromboemboli and makes a clinical trial of a portable HeartMate device a realistic alternative to medical therapy.

Adult↗
PubMed2005

The adult with congenital heart disease: born to be bad?

The population of patients with adult congenital heart disease is approximately 800,000 in the U.S. Those with prior cardiac surgery often consider themselves "cured," although the majority faces a lifetime of problems including arrhythmias, ventricular dysfunction, and one or more re-operations. Even patients with repaired "simple" lesions such as an atrial septal defect may not have normal survival if they are repaired in adulthood. Patients with repaired coarctation may have premature cardiovascular complications including sudden cardiac death, myocardial infarction, and stroke. They also have aortic complications such as aneurysm and dissection, which result from a diffuse arteriopathy and continued hypertension that may be caused by underlying endothelial dysfunction. In addition, bicuspid aortic valve occurs in more than one-half of the patients with coarctation, so continued surveillance for significant aortic valvular heart disease is necessary. More complex lesions also pose problems after "total correction." Patients with repaired tetralogy of Fallot often have pulmonary regurgitation, which is frequently overlooked on clinical exam and echocardiography. Pulmonary valve replacement should be performed before the development of irreversible right ventricular dysfunction and an increased risk of ventricular tachycardia or sudden cardiac death. Because they are vulnerable to deterioration of systemic ventricular function, those with congenitally corrected transposition require special vigilance, usually with concomitant atrio-ventricular valve regurgitation. Late referral is common with a deleterious effect on long-term survival. These patients need lifelong follow-up and the residua and sequelae of their complex anomalies must be understood in order to provide optimum care.

Adult↗
PubMed2006

Risk factors for the assessment of patients with pulmonary embolism.

Pulmonary embolism (PE) occurs frequently among cancer patients, with a spectrum ranging from small, clinically insignificant thrombi to life-threatening massive PE. It is fatal in as many as 14% of cancer patients, primarily by producing right ventricular heart failure and cardiogenic shock. PE diagnosis is difficult because the signs and symptoms imitate other commonly occurring diseases. Clinicians must be able to integrate a wide array of diagnostic imaging tools and laboratory tests to ensure rapid assessment and diagnosis. Risk stratification with the use of cardiac biomarkers and imaging tests to evaluate right ventricular function will identify treatment options. Hemodynamically stable patients can be treated effectively with anticoagulation alone, whereas those with right ventricular dysfunction require an aggressive strategy with thrombolysis, surgical embolectomy, or a catheter-based intervention. When anticoagulation is contraindicated, a vena caval filter may be deployed. PE treatment must be customized to the individual and consider the existing thrombus burden, presence of underlying cardiopulmonary disease and right side heart dysfunction, and cancer status of the patient. Clinicians should focus on providing adequate thromboprophylaxis in hospitalized cancer patients to avoid PE treatment.

Humans↗
PubMed2006

Physiopathology of right ventricular failure.

The physiopathology of right ventricular failure after repair of tetralogy of Fallot is complex. While primarily reflecting chronic volume overload resulting from pulmonary regurgitation, its determinants reflect a varied contribution of different boundary conditions. The competence of the outflow tract, right ventricular afterload, and the integrity of right ventricular diastolic performance are all crucial elements to the long-term responses of the right ventricle. When adverse, chronic right ventricular volume overload may lead to exercise intolerance, congestive cardiac failure, and both atrial and ventricular arrhythmia. Indeed, there appears to be a close relationship between the mechanical properties of the right ventricle and its electrical stability. In this chapter the determinants of pulmonary incompetence and its secondary effects on right ventricular function and performance, and mechano-electric interactions will be discussed.

Adult↗