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PubMed2003

The effects of right ventricular apical pacing on left ventricular function. Stimulation of the right ventricular apex: should it still be the gold standard?

Current pacing practice is undergoing continuous and substantial changes. Initially pacing had an exclusively palliative role, since it was reserved for patients developing complete heart block or severe symptomatic bradycardia. With the appearance of novel pacing indications such as pacing for heart failure and atrial fibrillation, the effect of pacing site on cardiac function has become a critically important issue and a subject for consideration. It seems that the classical pacing site in the right ventricular apex is no longer the gold standard because of possible disadvantageous effects on cardiac function. The aim of this review article is to discuss the effect of right ventricular apical pacing on cardiac function including cellular and hemodynamic changes. We also aim to discuss the role of alternative pacing sites in the light of cardiac function.

Journal Article↗
PubMed1997

Assessment of right ventricular contractile function in patients with left ventricular dysfunction by a simplified echocardiographic subtraction method.

A simplified version of the modified echocardiographic subtraction method for measuring right ventricular (RV) volume was used to assess the indices of RV contractile function, the end-systolic pressure-volume (RV Emax) ratio and the +dP/dt(max)-end-diastolic volume (EDV) relationship. RV volumes determined by the simplified subtraction method and the modified subtraction method were compared in 18 patients. Subsequently, RV contractile function was assessed in 13 patients with normal left ventricular (LV) function (control group: ejection fraction > 56%, as determined by left ventriculography), and 10 patients (group F; five with myocardial infarction, three with dilated cardiomyopathy, two with ischemic cardiomyopathy) with depressed LV function (ejection fraction < or = 55% by left ventriculography). During the application of lower body negative pressure of -20 mmHg, B-mode echocardiograms (apical four-chamber view) and RV or pulmonary artery pressure were recorded simultaneously. The regression equation between RV volumes obtained by the simplified subtraction method and the modified subtraction method was y = 0.99x + 4.5, and the correlation coefficient (r) was 0.985 (p < 0.001). The RV Emax of group F was not significantly less than that of the control group (0.40 +/- 0.16 vs 0.44 +/- 0.17 mmHg/ml, not significant). The correlation coefficients of RV Emax in each group were large (control group 0.92 +/- 0.09, group F 0.90 +/- 0.07). The +dP/dtmax-EDV ratio of group F was significantly less than that of the control group (2.05 +/- 0.74 vs 3.40 +/- 1.85 mmHg/ml.sec, p < 0.05). The correlation coefficient of the +dP/dtmax-EDV ratio was 0.91 +/- 0.06 in the control group and 0.85 +/- 0.15 in group F. The indices of RV contractile function could be assessed using the simplified subtraction method. RV function in patients with LV dysfunction appeared to be depressed.

Adult↗
PubMed1995

[The diastolic function of the right and left heart ventricles in patients with primary pulmonary hypertension].

To evaluate the condition of left and right ventricular functions in patients with primary pulmonary hypertension (PPH) 21 patients (13 females and 8 males, mean age 35.4 +/- 10.0) were examined. The patients were ill for 5.7 +/- 3.5 years. Ventricular filling was characterized basing on computer data of transmitral and transtricuspid diastolic flow obtained at doppler echocardiography. Right ventricular function proved impaired in all the examinees: early in the disease the speed of early filling (Ve) was inhibited, while late filling was enhanced (Va). At terminal stages of the disease Ve increased, but Va reduced. Left ventricular function was also involved in all the patients: low Ve with the disease progression became more and more evident.

Adolescent↗
PubMedDate not supplied

Can indices of left ventricular function be applied to the right ventricle?

This article compares conventional indices of contractile function in the right and left ventricles. The low operating pressures and left ventricles. The low operating pressures and complex geometry complicate evaluation of right ventricular function. However, when the characteristics of its vascular load are taken into account, the complex right ventricular chamber has pump properties that are similar to the high pressure left ventricular chamber.

Animals↗
PubMed2002

Right ventricular diastolic function in canine models of pressure overload, volume overload, and ischemia.

By limiting filling, abnormalities of right ventricular (RV) diastolic function may impair systolic function and affect adaptation to disease. To quantify diastolic RV pressure-volume relations and myocardial compliance (MC), a new sigmoidal model was developed. RV micromanometric and sonomicrometric data in alert dogs at control (n = 16) and under surgically induced subacute (2-5 wk) RV pressure overload (n = 6), volume overload (n = 7), and ischemia (n = 6) were analyzed. The conventional exponential model detected no changes from control in the passive filling pressure-volume (P(pf)-V) relations. The new sigmoidal model revealed significant quantifiable changes in P(pf)-V relations. Maximum RV MC (MC(max)), attained during early filling, is reduced from control in pressure overload (P = 0.0016), whereas filling pressure at maximum MC (P(MCmax)) is increased (P = 0.0001). End-diastolic RV MC increases significantly in volume overload (P = 0.0131), whereas end-diastolic pressure is unchanged. In ischemia, MC(max) is decreased (P = 0.0102), with no change in P(MCmax). We conclude that the sigmoidal model quantifies important changes in RV diastolic function in alert dog models of pressure overload, volume overload, and ischemia.

Animals↗
PubMed2006

Echocardiographic evaluation of the evolutionary changes after heart transplantation.

AIM: To undertake an evolutionary analysis of echocardiographic examinations carried out during follow-up of cardiac transplant patients. MATERIALS AND METHODS: The study included 193 consecutive patients transplanted between August 1998 and December 2004. We excluded pediatric, cardiopulmonary, and repeat transplants. Four echocardiographic examinations were analyzed per patient (first, second, third quarter and the last study carried out; average time from transplant: 1115 +/- 681 days). The total number of examinations was 772. The evaluated variables were thickness of walls and diameters of the cavities, systolic and diastolic functions, pericardial effusion, and number of rejections. RESULTS: The isovolumetric relaxation time showed reduced values during early echocardiography with subsequent increases during evolution (first echocardiogram: 92 +/- 16 vs final echocardiogram 101 +/- 16 ms; P < .0001). Right ventricular function showed initial deterioration with subsequent recovery (first echocardiogram: 16% vs final echocardiogram: 8%; P < .05); moreover, the existence of delayed malfunction of the right ventricle was correlated with a higher incidence of transplant rejection (P < .01). Pericardial effusion was initially present with a tendency to reduce over time (first echocardiogram: 58% vs final echocardiogram: 12%; P < .0001). There was no difference in the other variables. CONCLUSIONS: Cardiac transplant patients undergo evolutionary echocardiogram alterations that were mainly early and normalized as of the first quarter. The most usual changes in this period were restrictive isovolumetric behavior accompanied by some degree of depressed right ventricular function. Right ventricular malfunction during late evolution was correlated with a higher incidence of transplant rejection during follow-up.

Electrocardiography↗
PubMed1998

Right ventricular regional function using MR tagging: normals versus chronic pulmonary hypertension.

Right ventricular (RV) regional function, in both normal and diseased states, is not well characterized. Using 1D MR myocardial tagging, RV and septal intramyocardial segmental shortening was noninvasively measured in ten healthy subjects and in seven patients with chronic pulmonary hypertension. The normal RV free wall regional shortening was not uniform. A pattern of increasing RV free wall short-axis shortening was found from the RV outflow tract to the RV apex, and a more complex pattern of RV free wall long-axis shortening was observed. Both regional short- and long-axis shortening were globally reduced in pulmonary hypertension patients, with the greatest decreases in the RV outflow tract and in the basal septal wall region. Regional RV function can be quantitatively evaluated using MR tagging to determine the impact of chronic pulmonary hypertension on RV performance.

Adolescent↗
PubMed1985

Right ventricular dysfunction following cold potassium cardioplegia.

Right coronary artery stenoses limit cardioplegic delivery to the right ventricle and may contribute to postoperative right ventricular dysfunction. Right ventricular function was evaluated in 39 patients with right coronary artery stenoses following elective coronary bypass operations. Hemodynamic and nuclear ventriculographic measurements, made between 3 and 6 hours postoperatively, revealed a progressive increase in pulmonary arterial pressure, pulse rate, and right ventricular ejection fraction (p less than 0.05). Right ventricular end-diastolic volume index (calculated from the thermodilution stroke index divided by the nuclear ejection fraction) decreased, but right atrial pressure increased (suggesting a decrease in compliance). The response to the infusion of 2 units of plasma (volume loading) was evaluated 3 hours postoperatively (EARLY) and again 5 hours postoperatively (LATE) in 21 patients. Right ventricular performance (the relation between cardiac index or right ventricular stroke work index and right ventricular end-diastolic volume index) and right ventricular systolic function (the relation between systolic pulmonary arterial pressure and right ventricular end-systolic volume index) were depressed EARLY and improved LATE (p less than 0.01 in analysis of covariance). Left ventricular performance (the relation between cardiac index or left ventricular stroke work index and left ventricular end-diastolic volume index) and left ventricular systolic function (the relation between systolic blood pressure and left ventricular end-systolic volume index) were similar EARLY and LATE. Right ventricular diastolic function (the relation between right atrial pressure and right ventricular end-diastolic volume index) and left ventricular diastolic function (the relation between left atrial pressure and left ventricular end-diastolic volume index) were significantly greater LATE than EARLY. Right, but not left, ventricular performance and systolic function were transiently depressed, and right and left ventricular diastolic stiffness were transiently decreased in the EARLY postoperative period. In patients with right coronary artery stenoses, current methods of cardioplegia may inadequately protect the right ventricle, but further studies are required to establish the relation between intraoperative protection and postoperative function.

Blood Pressure↗
PubMed2004

Left ventricular function during and after right ventricular pacing.

OBJECTIVES: The aim of this research was to evaluate right ventricular pacing effects on left ventricular function. BACKGROUND: Right ventricular pacing alters the ventricular activation sequence and reduces left ventricular ejection fraction (EF). It is unclear whether the observed reduction in EF can be completely attributed to the alteration in activation sequence. METHODS: Twelve subjects (eight women), mean age 68 +/- 12 years, with transvenous dual-chamber pacemakers, normal left ventricular function, and intact atrioventricular (AV) conduction were studied with serial-gated blood pool studies. Left ventricular EF was measured at a fixed rate after at least 1 week of atrial pacing only (baseline), during short-term (2 h) and mid-term (1 week) AV sequential pacing with a short AV delay, and after short- and mid-term AV pacing. RESULTS: Baseline EF was 66.5 +/- 4.5%. Short-term AV pacing resulted in a decrease in EF to 60.3 +/- 5.2% (p < 0.0002). After one week of AV pacing, there was a further decline in EF to 52.9 +/- 8.3% (p < 0.0001). After cessation of mid-term pacing, EF was 57.3 +/- 5.9% (p < 0.0001 vs. baseline). A total of 2, 5, 8, and 24 h later, EF remained depressed (59% to 60%, p < 0.007). At 32 h, EF was 62.9 +/- 7.6% (p < 0.11 compared with baseline). CONCLUSIONS: The abnormal activation sequence resulting from right ventricular pacing accounts for only part of the reduction in EF as mid-term pacing is associated with a lower EF than short-term pacing, and EF remains depressed after cessation of AV pacing. Changes in ventricular function induced by right ventricular pacing may account for some of its associated adverse effects.

Aged↗
PubMed1988

Right ventricular dysfunction in multiple trauma victims.

We studied 17 victims of multiple trauma and found that right ventricular function can be reliably monitored at the bedside using the thermodilution method. In addition, we noted that right ventricular dysfunction occurred early in victims of major trauma without affecting the left ventricular function. If right ventricular function does not improve, the patient is likely to die. Further studies are needed to determine if early intervention aimed at improving right ventricular function can improve survival.

Adolescent↗
PubMed1987

Surgical repair of acquired ventricular septal defect. Determinants of early and late outcome.

Between January 1970 and June 1985, 60 patients underwent surgical repair of postinfarction ventricular septal defect. The preoperative cineangiograms of all patients were reviewed to measure left ventricular ejection fraction and to quantitatively assess right ventricular function by measuring the percentage reduction in right ventricular midcavity diameter. There were 23 early deaths (within 30 days) and 14 late deaths occurring between 1 and 92 months after operation. Of the 23 long-term survivors, 87% are in New York Heart Association Class I or II. The early mortality was significantly higher for inferior infarction (58%) than for anterior infarction (25%). Early mortality was also influenced by the time interval between infarction and operation (under 1 week 41%, over 4 weeks 22%). Early survival was favored by good preoperative right ventricular function; the percentage reduction in right ventricular midcavity diameter was 16.5% +/- 9.5% (mean +/- standard deviation) for the early death group and 26.7% +/- 10.6% for the early survival group. However, the early outcome was not influenced by left ventricular function before operation. Conversely, long-term survival was favored by preserved preoperative left ventricular function; left ventricular ejection fraction was 26.2% +/- 9.3% for the late death group and 35% +/- 8.5% for the late survival group. Long-term survival was not, however, affected by right ventricular function before operation. The results of surgical closure of postinfarction ventricular septal defect have improved between two successive time frames in this series, which is the largest to date.

Aged↗
PubMed2003

Varieties of right ventricular diastolic function in patients with non-obstructive hypertrophic cardiomyopathy.

We examined whether differences in the location of myocardial hypertrophy influence the right ventricular diastolic function in patients with non-obstructive hypertrophic cardiomyopathy using cineangiography. Biplane right ventriculography was performed in 34 subjects (normal = 14, asymmetric septal hypertrophy = 9, apical hypertrophy = 11) during cardiac catheterization. In patients with asymmetric septal hypertrophy, compared with apical hypertrophy and normal groups, the indices of the right ventricular diastolic function including right ventricular peak filling rate and filling fraction of rapid filling phase were lower and the time to peak filling rate was prolonged. But in patients with apical hypertrophy, these indices were not significantly different compared with normal. There were no differences in right ventricular ejection fraction and cardiac index among the three groups. These data suggest that the location of the myocardial hypertrophy of the left ventricle is a significant factor affecting the right ventricular diastolic filling in non-obstructive hypertrophic cardiomyopathy.

Adult↗
PubMed2000

Age- and gender-specific differences in left and right ventricular cardiac function and mass determined by cine magnetic resonance imaging.

We examined possible age- and gender-specific differences in the function and mass of left (LV) and right (RV) ventricles in 36 healthy volunteers using cine gradient-recalled echo magnetic resonance imaging. Subjects were divided into four groups (nine men and nine women in each): men aged under 45 years (32 +/- 7), women aged under 45 (27 +/- 6), men aged over 45 (59 +/- 8), and women aged over 45 (57 +/- 9). Functional analysis of cardiac volume and mass and of LV wall motion was performed by manual segmentation of the endocardial and epicardial borders of the end-diastolic and end-systolic frame; both absolute and normalized (per square meter body surface area) values were evaluated. With age there was a significant decrease in both absolute and normalized LV and RV chamber volumes (EDV, ESV), while LV and RV masses remained unchanged. Gender-specific differences were found in cardiac mass and volume (for men and women, respectively: LV mass, 155 +/- 18 and 110 +/- 16 g; LV EDV, 118 +/- 27 and 96 +/- 21 ml; LV ESV, 40 +/- 13 and 29 +/- 9 ml; RV mass, 52 +/- 10 and 39 +/- 5 g; RV EDV, 131 +/- 28 and 100 +/- 23 ml; RV ESV, 53 +/- 17 and 33 +/- 15 ml). Normalization to body surface area eliminated differences in LV volumes but not those in LV mass, RV mass, or RV function. Functional parameters such as cardiac output and LV ejection fraction showed nonsignificant or only slight differences and were thus largely independent of age and gender. Intra- and interobserver variability ranged between 1.4% and 5.9% for all parameters. Cine magnetic resonance imaging thus shows age- and gender-specific differences in cardiac function, and therefore the evaluation of cardiac function in patients should consider age- and gender-matched normative values.

Adult↗
PubMed2005

Use of tissue Doppler to assess right ventricle function in hemodialysis patients.

AIMS: Although there are plenty of data about the differences in left ventricular tissue Doppler (TD) velocities by preload reduction, only a few studies regarding right ventricular function are found in the literature. We investigated the effect of intravascular volume reduction on right ventricular function by ultrafiltration in dialysis patients. METHODS: 27 end-stage renal failure patients who were hypervolemic and undergoing hemodialysis were included in the study. TD studies of the right ventricle were performed before and 1 h after dialysis. These data were compared. RESULTS: The mean age of the patients was 41 +/- 15 years and mean volume of ultrafiltration was 3.8 +/- 1.8 liters. Systolic, early and late diastolic lateral annular TD velocities before dialysis were 0.109 +/- 0.029, 0.088 +/- 0.039, 0.111 +/- 0.039 m/s, and after dialysis were 0.099 +/- 0.028, 0.078 +/- 0.036, 0.106 +/- 0.037 m/s, respectively (p = 0.216, p = 0.112, p = 0.350). Myocardial early diastolic velocity decreased significantly (p = 0.049) but systolic and late diastolic velocities did not change significantly (p = 0.579, p = 0.146). CONCLUSION: Right ventricular systolic and diastolic velocities detected by TD were not or only minimally affected by preload reduction in hemodialysis patients and the TD early/late ratio is the most valuable variable that can predict right ventricular diastolic function. The right ventricular systolic and early diastolic TD velocities were positively correlated with left ventricle ejection fraction.

Adult↗
PubMed1990

Right ventricular diastolic function in systemic hypertension.

Right (RV) and left ventricular (LV) diastolic function was evaluated in 50 patients with mild, uncomplicated essential hypertension using pulsed-wave Doppler echocardiography. Patients with pulmonary, valvular or coronary artery disease were excluded and antihypertensive drugs were discontinued for the 2 weeks preceding the study. Ten normotensive patients without heart disease acted as control subjects. In the hypertensive patients, RV peak velocity of atrial filling was higher (42 +/- 10 vs 31 +/- 7 cm/s, p less than 0.01) and deceleration half-time was prolonged (96 +/- 20 vs 83 +/- 10 ms, difference not significant); ratio of early/atrial filling velocity (1.1 +/- 0.3 vs 1.7 +/- 0.4, p less than 0.001) and peak filling rate corrected to stroke volume (3.6 +/- 0.7 vs 5.3 +/- 0.9 SV/s, p less than 0.001) were lower. LV filling parameters showed similar changes. RV filling parameters did not correlate with age, LV mass or septal thickness but correlated weakly with LV radius/thickness ratio. There was good correlation between RV and the following corresponding LV filling parameters: peak filling rate, r = 0.68, p less than 0.001; ratio of early/atrial filling, r = 0.88, p less than 0.0001; and deceleration half-time, r = 0.62, p less than 0.001. Data indicate that RV diastolic function is abnormal in essential hypertension and these abnormalities are closely related to those of LV diastolic function.

Adult↗
PubMed2006

Tricuspid annular systolic velocity: a useful measurement in determining right ventricular systolic function regardless of pulmonary artery pressures.

Assessment of right ventricular (RV) systolic function can be somewhat difficult, particularly in pulmonary hypertension (PH). RV fractional area change (FAC) and tricuspid valve annular motion (TAPSE) although useful in the assessment of RV performance, their use can be sometimes limited and tedious. Thus, a quicker but yet reliable alternative is needed. Accordingly, we compared peak tricuspid annulus systolic (TA Sa) velocities derived from Doppler tissue imaging (DTI) with both RVFAC and TAPSE to estimate RV function in 52 patients (53 +/- 16 years) with varying degrees of PH. In this group, mean was RVFAC 49 +/- 20, TAPSE was 2.3 +/- 0.7 cm, peak TA Sa velocity by DTI was 10.4 +/- 3.8 cm/s, left ventricular systolic function was 57 +/- 18%, and pulmonary artery systolic pressure was 47 +/- 28 mmHg. An excellent correlation was noted between TAPSE and RVFAC (r = 0.91, P < 0.001). Similar correlations were noted between peak TA Sa velocity and RVFAC (r = 0.84, P < 0.001) and between peak TA Sa velocity and TAPSE (r = 0.90, P < 0.001). A TA Sa >10.5 cm/s identified individuals with both a normal RV function and without significant PH. Therefore, we conclude that TA Sa velocity, an easily obtainable DTI measure, that has an excellent correlation with more time-consuming methods to assess RV systolic function regardless of the degree of PH should be routinely assessed during the initial evaluation and eventual follow-up of patients either at risk or with documented PH.

Adult↗
PubMed1999

A comparison of ventricular function during high right ventricular septal and apical pacing after his-bundle ablation for refractory atrial fibrillation.

This study compares LV performance during high right ventricular septal (RVS) and apical (RVA) pacing in patients with LV dysfunction who underwent His-bundle ablation for chronic AF. We inserted a passive fixation pacing electrode into the RVA and an active fixation electrode in the RVS. A dual chamber, rate responsive pulse generator stimulated the RVA through the ventricular port and the RVS via the atrial port. Patients were randomized to initial RVA (VVIR) or RVS (AAIR) pacing for 2 months. The pacing site was reversed during the next 2 months. At the 2 and 4 month follow-up visit, each patient underwent a transthoracic echocardiographical study and a rest/exercise first pass radionuclide ventriculogram. We studied nine men and three women (mean age of 68 +/- 7 years) with congestive heart failure functional Class (NYHA Classification): I (3 patients), II (7 patients), and III (2 patients). The QRS duration was shorter during RVS stimulation (158 +/- 10 vs 170 +/- 11 ms, P < 0.001). Chronic capture threshold and lead impedance did not significantly differ. LV fractional shortening improved during RVS pacing (0.31 +/- 0.05 vs 0.26 +/- 0.07, P < 0.01). RVS activation increased the resting first pass LV ejection fraction (0.51 +/- 0.14 vs 0.43 +/- 0.10, P < 0.01). No significant difference was observed during RVS and RVA pacing in the exercise time (5.6 +/- 3.2 vs 5.4 +/- 3.1, P = 0.6) or the exercise first pass LV ejection fraction (0.58 +/- 0.15 vs 0.55 +/- 0.16, P = 0.2). The relative changes in QRS duration and LV ejection fraction at both pacing sites showed a significant correlation (P < 0.01). We conclude that RVS pacing produces shorter QRS duration and better chronic LV function than RVA pacing in patients with mild to moderate LV dysfunction and chronic AF after His-bundle ablation.

Aged↗