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PubMed1999

Right ventricular dysfunction after cardiac transplantation: primarily related to status of donor heart.

BACKGROUND: It is unclear whether right ventricular dysfunction after transplantation is due to donor brain death-related myocardial injury or recipient pulmonary hypertension. METHODS: A canine donor model of brain death and a monocrotaline pyrrole-induced chronic pulmonary hypertension recipient model were established, and used for 30 orthotopic bicaval cardiac transplantations divided into three groups: Controls (group A, normal donor/recipient), group B (brain-dead donors/normal recipient), and group C (normal donor/recipients with pulmonary hypertension). Right ventricular function was measured before transplant and brain death, 4 hours after brain death, and after transplant (1 hour off bypass) by load-independent means plotting stroke work versus end-diastolic volume during caval occlusion. Right ventricular total power and pulmonary vascular impedance were determined by Fourier analysis. RESULTS: In comparison to the control group right ventricular preload-recruitable stroke work and total power decreased significantly after brain death and transplant in group B (from 22.7 x 10(3) erg (+/-1.2) at baseline to 15.6 x 10(3) (+/-0.9) after brain death and to 11.3 x 10(3) (+/-0.9) after transplant). In group C there was a significant increase in pulmonary artery pressure, impedance, right ventricular preload-recruitable stroke work, total power after transplant. CONCLUSIONS: Normal donor hearts adapt acutely to the recipient's elevated pulmonary vascular resistance by increasing right ventricular power output and contractility. Brain death caused significant right ventricular dysfunction and power loss, which further deteriorated after graft preservation and transplantation. The effects of donor brain death on myocardial function contribute to right ventricular dysfunction after cardiac transplantation.

Animals↗
PubMed1999

Right ventricular dysfunction in congenitally corrected transposition of the great arteries.

Although right ventricular (RV) dysfunction is an important complication in subjects with congenitally corrected transposition of the great arteries, its pathogenesis is poorly understood. We assessed the role of RV myocardial perfusion and found perfusion defects at rest in all 20 patients, involving 4.6 +/- 2.3 of a total of 12 segments; the extent of the resting perfusion defects correlated inversely with the RV ejection fraction.

Adolescent↗
PubMedDate not supplied

Severe right ventricular dysfunction in a neonate with aortic origin of the RPA.

Anomalous origin of the right pulmonary artery from the ascending aorta (AORPA) with severe right ventricular dysfunction in a neonate was completely diagnosed by echocardiography. Cardiac catheterization was performed to explore further right ventricular dysfunction, which is extremely rare at this age. Following cardiac catheterization, the patient died. We suggest that in critically ill infants with the aforementioned condition surgical repair guided by modern echocardiography must be the chosen management.

Aorta↗
PubMed1996

Right ventricular dysfunction in obstructive sleep apnoea: reversal with nasal continuous positive airway pressure.

The incidence and pathogenesis of right ventricular dysfunction in obstructive sleep apnoea (OSA) remains controversial. Using nuclear ventriculography, the prevalence of right ventricular dysfunction (RVD) was therefore determined in obese patients with OSA, as well as their clinical characteristics, arterial blood gas values, spirometry and sleep parameters. The reversibility of RVD was evaluated after long-term use of nasal continuous positive airway pressure (nCPAP). We studied 112 obese patients with OSA by nuclear ventriculography, 35 with RVD (Group 1), 77 without RVD (Group 2), and 14 patients without OSA as controls (Group 3). Repeat nuclear ventriculography was performed in seven patients who used nCPAP nightly for 6-24 months. The mean right ventricular ejection fractions (RVEF) were 31%, 47% and 44% in Groups 1, 2 and 3, respectively. Group 1 also had a lower left ventricular ejection fraction (LVEF) of 55 vs 63% in Group 2. The OSA groups did not differ in mean spirometric or arterial blood gas values. Group 1 had a lower mean nocturnal arterial oxygen saturation (Sa,O2) of 82 vs 87% in Group 2, and a longer apnoea duration of 22.3 vs 19.2 s. All but two patients in Group 1 had either awake alveolar hypoventilation or an apnoea + hypopnoea index > 40 disordered breathing events.h-1. Repeat nuclear ventriculography after nCPAP revealed an increase in RVEF from 30 to 39%. In conclusion, right ventricular dysfunction is common in obstructive sleep apnoea, but it is reversible with nasal continuous positive airway pressure treatment and appears to be related to nocturnal oxygen desaturation.

Adult↗
PubMed2001

Increased brain and atrial natriuretic peptides in patients with chronic right ventricular pressure overload: correlation between plasma neurohormones and right ventricular dysfunction.

OBJECTIVE: To evaluate the role of plasma neurohormones in the diagnosis of asymptomatic or minimally symptomatic right ventricular dysfunction. SETTING: Tertiary cardiovascular referral centre. METHODS: Plasma brain natriuretic peptide (BNP) and atrial natriuretic peptide (ANP) concentrations were measured in 21 asymptomatic or minimally symptomatic patients with chronic right ventricular pressure overload caused by congenital heart disease, and in seven healthy volunteers. Right ventricular ejection fraction was determined using magnetic resonance imaging. RESULTS: Right ventricular ejection fraction in the volunteers was higher than in the patients (69.0 (8.2)% v 58.0(12.0)%, respectively; p < 0.006). Left ventricular ejection fraction was 72.3(7.8)% in volunteers and 68.1(11.0)% in patients (NS). There was a significant difference between patients and volunteers in the plasma concentrations of BNP (5.3 (3.5) v 2.3 (1.7) pmol/l, respectively; p < 0.009) and ANP (7.3 (4.5) v 3.6 (1.4) pmol/l; p < 0.05). In both patients and volunteers, mean plasma ANP was higher than mean plasma BNP. Right ventricular ejection fraction was inversely correlated with BNP and ANP (respectively, r = 0.65; p < 0.0002 and r = 0.61; p < 0.002). There was no correlation between left ventricular ejection fraction and BNP (r = 0.2; NS) or ANP (r = 0.52; NS). Similarly, no correlation was shown between the level of right ventricular systolic pressure and either plasma BNP (r = 0.20) or plasma ANP (r = 0.07). CONCLUSIONS: There was a significant inverse correlation between right ventricular ejection fraction and the plasma neurohormones BNP and ANP in asymptomatic or minimally symptomatic patients with right ventricular pressure overload and congenital heart disease. Monitoring changes in BNP and ANP may provide quantitative follow up of right ventricular dysfunction in these patients.

Adult↗
PubMed2006

Right ventricular function predicts transplant-free survival in idiopathic dilated cardiomyopathy.

BACKGROUND: Right ventricular function may be reduced in patients with idiopathic dilated cardiomyopathy (IDC). The prognostic implications of right ventricular dysfunction have not been investigated in this group of patients. METHODS: In a series of 120 consecutive patients with IDC [defined as a left ventricular ejection fraction (LVEF) < 55%, normal coronary arteries and no other causes for left ventricular dysfunction], right ventricular function was prospectively evaluated by means of angiocardiography at the time of catheterization. A head-to-head comparison of ventricular volumes, ejection fraction, end-diastolic pressure, stroke work index and end-systolic pressure/volume ratio of the left and right ventricle was performed according to the Cox's proportional hazard method for the pre-defined end-point of transplant-free survival. RESULTS: In the study population, LVEF was 31 +/- 11% and right ventricular ejection fraction (RVEF) was 34 +/- 10%. After a mean follow-up of 30 months (range 12-120 months), 26 patients died (22%) and 14 (12%) underwent heart transplantation. At univariate analysis, all the above mentioned parameters were significantly (P < 0.0001) associated with outcome except left and right ventricular end-systolic pressure/volume ratio. At multivariate analysis, independent predictors of transplant-free survival were RVEF (P = 0.001), right ventricular stroke work index (P = 0.015), right ventricular end-diastolic volume (P = 0.034) and left ventricular end-diastolic volume (P = 0.048), but not LVEF. The same relation holds true considering the end point of total mortality. CONCLUSIONS: Parameters of right ventricular function are strong predictors of survival in IDC, even in patients enrolled over a wide range of LVEFs. The present study suggests that right ventricular function should be evaluated in patients with IDC. A large non-invasive based study on right ventricular function in IDC appears to be warranted.

Adult↗
PubMed2006

Inhaled nitric oxide for acute right-ventricular dysfunction after extrapleural pneumonectomy.

Increased pulmonary vascular pressure and decreased right-ventricular performance may occur following pneumonectomy. Inhaled nitric oxide decreases right-ventricular afterload and improves cardiac index by selectively decreasing pulmonary vascular resistance without causing systemic hypotension. We report the use of inhaled nitric oxide in a patient with acute right-ventricular dysfunction after extrapleural pneumonectomy.

Adult↗
PubMed2006

[Right-ventricular dysfunction and the pulmonary vascular obstruction index: predictable variables of the clinical course over 3 months in patients with acute lung emboli].

OBJECTIVE: To quantify right-ventricular dysfunction and the pulmonary artery obstruction index, in patients with acute pulmonary embolism, using helical CT, and to assess the prognostic value of these parameters. DESIGN: Prospective. METHOD: In 120 consecutive patients with proven acute pulmonary embolism, the extent of right-ventricular dysfunction was assessed by quantifying the ratios of the right to left-ventricular short-axis diameters (RV/LV ratio) and the extent ofobstruction ofthe pulmonary-artery circulation by using helical CT images. Regression analysis was used to correlate these parameters with patient outcome. RESULTS: Right-ventricular dysfunction (RV/LV ratio > 1.0) was seen in 69 patients (57.5%). Seven patients died as a direct result of pulmonary embolism. Both the RV/LV ratio and the obstruction index were significant risk factors for mortality within three months (p = 0.04 and 0.01 respectively). The positive predictive value for pulmonary embolism-related mortality of an RV/LV ratio > 1.0 was 10.1% (95% CI: 2.9-17.4). The negative predictive value for an uneventful outcome of an RV/LV ratio < or = 1.0 was 100% (95% CI: 94.3-100). There was a 11.2-fold risk of dying of pulmonary embolism in patients with an obstruction index > or = 40% (95% CI: 1.3-93.6). CONCLUSION: Markers of right-ventricular dysfunction and pulmonary vascular obstruction, assessed by helical CT-examination at baseline, help to predict mortality during follow-up of patients with acute pulmonary embolism.

Acute Disease↗
PubMed1989

Right ventricular dysfunction in septic shock: assessment by measurements of right ventricular ejection fraction using the thermodilution technique.

Right ventricular ejection fraction (RVEF) was measured by the thermodilution technique in a series of 127 consecutive critically ill patients monitored with a modified pulmonary artery (PA) catheter equipped with a fast response thermistor. Thermodilution RVEF was significantly lower in septic shock (23.8 +/- 8.2%, 93 measurements) than in sepsis without shock (30.3 +/- 10.1%, 118 measurements) or in the absence of sepsis or cardiopulmonary impairment (32.5 +/- 7.1%, 62 measurements). Both myocardial depression and pulmonary hypertension could account for this impairment of RV function. RVEF decreased from 35.1 +/- 9.8 to 24.2 +/- 10.4% (P less than 0.01) during development of septic shock and increased from 25.0 +/- 7.6 to 29.8 +/- 8.5% (P less than 0.05) during recovery (14 patients). Initial RVEF in septic shock was 27.8 +/- 8.6% in 11 patients who survived but only 20.9 +/- 6.7% (P less than 0.02) in the 23 patients who eventually died. Thus, RV dysfunction is common during septic shock, is directly related to its severity, and can easily be recognized in patients monitored with a PA catheter.

Adult↗
PubMed2006

Myocardial ischemia and right ventricular dysfunction in adult patients with sickle cell disease.

BACKGROUND AND OBJECTIVES: Patients with sickle cell disease (SCD) have multi-organ manifestations of microvascular disease, though cardiac manifestations have been poorly characterized in vivo. This study sought to characterize myocardial characteristics in adult patients with SCD. DESIGN AND METHODS: Twenty-two consecutive outpatients and 11 age-matched controls underwent magnetic resonance imaging to assess myocardial perfusion reserve as well as left and right ventricular size and function and myocardial iron. Computed tomography of the coronary arteries was performed to assess epicardial coronary stenosis. RESULTS: Three of 22 outpatients with clinically stable SCD and no controls had abnormal myocardial perfusion reserve limited to the subendocardium, consistent with microvascular disease. Coronary arteries were free of disease as detectable by computed tomography angiography. Myocardial T2* was normal in all subjects (29 +/- 5 ms, median 29 ms), consistent with absence of cardiac iron deposition despite a high prevalence of hepatic iron overload (liver T2* 14 +/- 9 ms, median 12.0 ms). SCD patients had right ventricular enlargement and dysfunction (right ventricular ejection fraction 45 +/- 15 in SCD patients vs. 58 +/- 5% in controls, p=0.001) even in the absence of overt pulmonary hypertension. INTERPRETATION AND CONCLUSIONS: A subset of adult SCD patients may have myocardial ischemia in the absence of infarcted myocardium, myocardial iron overload, or coronary artery disease. Right ventricular dysfunction is present in stable SCD patients, despite normal resting pulmonary artery pressures. These findings could represent under-recognized mechanisms for chest pain and mortality in this population, and warrant further investigation in SCD crises.

Adult↗
PubMed1998

Right ventricular dysfunction after tetralogy repair in a pediatric patient with successful ECMO support--a case report.

Right ventricular dysfunction after surgical repair of tetralogy is a serious life threatening complication. Although pulmonary vasodilators and inotropes can be used for cardiac support in tetralogy repair, these drugs may be ineffective in some patients. To date extracorporeal membrane oxygenation (ECMO) support may be used effectively in these patients when medical therapy fails. We report a case with successful ECMO support in right ventricular dysfunction and pulmonary hypertension after total surgical correction of Fallot's tetralogy. ECMO circuit was instituted in the operating room due to difficulty in weaning from cardiopulmonary bypass in spite of aggressive medical therapy. We reviewed and discussed the indications, contraindications of application of ECMO and patient survival with treatment of ECMO. At the same time we wish to share our limited experience we gained in our first attempt of ECMO support.

Extracorporeal Membrane Oxygenation↗
PubMed2006

Right ventricular dysfunction and adverse outcome in patients with advanced heart failure.

BACKGROUND: In patients with heart failure (HF) from left ventricular systolic dysfunction, the presence of coexistent right ventricular (RV) dysfunction is associated with poor exercise capacity and reduced survival. We sought to determine whether a simple measure of RV function, the RV myocardial performance index (RV MPI), is associated with adverse outcome in a population of advanced heart failure patients selected to receive cardiac resynchronization therapy (CRT). METHODS AND RESULTS: The RV MPI was measured on 77 consecutive preimplantation echocardiograms. The relationship between RV MPI and the end point of all-cause mortality, transplantation, or ventricular assist device placement was evaluated. The end point occurred in 28 patients (36%) during a median follow-up of 21 months. The median RV MPI was 0.73 (interquartile range 0.51-0.89). Worse RV function, as demonstrated by a higher RV MPI, was seen in those patients who reached the end point compared with those who did not (0.83 vs. 0.69, P = .004). The highest tercile of RV MPI was associated with a 3.3-fold increased risk of poor outcome (95% CI 1.3-8.5). Each 0.1 unit increase in RV MPI was associated with a 16% increased risk (95% CI 8-26). After adjusting for other echocardiographic variables, RV MPI remained significantly associated with the outcome. CONCLUSION: In a population of advanced HF patients selected to receive CRT, RV dysfunction, as assessed by the RV MPI, is associated with adverse outcome. Wider use of this simple nongeometric parameter may help to identify patients for whom options for further intervention should be carefully evaluated.

Aged↗
PubMed1986

High-frequency ventilation versus conventional ventilation in dogs with right ventricular dysfunction.

A randomized crossover protocol was used to compare conventional mechanical ventilation (CMV) and high-frequency ventilation (HFV) in mongrel dogs experiencing right ventricular dysfunction after right ventriculotomy. When inspired oxygen, pH, PCO2, core temperature, and preload were held constant, cardiac output increased significantly (p less than .05) from 1.16 +/- 0.24 to 1.38 +/- 0.25 L/min and pulmonary vascular resistance decreased significantly (p less than .05) from 734 +/- 257 to 554 +/- 169 dyne X sec/cm5 during HFV relative to CMV. We also noted a significant (p less than .05) increase in mean arterial pressure from 116 +/- 27 to 124 +/- 23 mm Hg and a significant (p less than .05) increase in left ventricular stroke work from 10.2 +/- 3.5 to 12.3 +/- 2.6 g X m during HFV. During the inspiratory phase of CMV there were increases in CVP, pulmonary artery pressure, and systemic arterial pressure, and decreases in pulmonary artery flow which did not occur during HFV. HFV may be preferable to CMV in the presence of right ventricular dysfunction.

Animals↗
PubMed1997

[Clinical, echocardiographic and Doppler outcome in ischemic right ventricular dysfunction associated with inferior wall infarction].

Right ventricular involvement during inferior wall myocardial infarction does not seem to alter long-term clinical prognosis but its specific outcome has not been clearly studied. We have previously demonstrated that pulmonary regurgitant (PR) flow tracings doppler analysis allows the accurate diagnosis of RV involvement, especially when the pressure half-time of PR was < or = 150 ms and the ratio of the minimal velocity to the maximal velocity was < or = 0.5. We studied 40 patients with acute inferior wall myocardial infarction and with PR flow. Doppler echocardiography was obtained during the first day, before discharge (early control) and between 12 and 24 months follow-up (late control). Among 22 patients with RV involvement defined with PR-derived doppler parameters (RVIPR). 8 had right ventricular enlargement and/or wall motion abnormalities, observed in 6 cases at early control and in 4 at late control. Doppler analysis showed remnant RVIPR parameters in 9 patients at early control and 8 among these at late contorl, with no relation with pulmonary artery pressure or other echocardiographic parameters. No clinical, angiographic or therapeutic data predicted these distinct echocardiographic and doppler patterns and the long-term prognosis was not different. At late control, among 12 RVIPR patients which PR-derived doppler parameters were normal at early control, two patients had still RVIPR pattern at late control and described ischemic recurrence. PR flow doppler analysis is a useful tool for diagnosis and outcome evaluation of RV involvement and shows a remnant diastolic dysfunction in half of the patients with acute RV involvement.

Aged↗
PubMed2000

Role of ischemia and infarction in late right ventricular dysfunction after atrial repair of transposition of the great arteries.

OBJECTIVES: This study was conducted to assess whether myocardial ischemia and/or infarction are involved in the pathogenesis of late right ventricular dysfunction in adult survivors of atrial baffle repair for transposition of the great arteries in infancy. BACKGROUND: The medium-term success of intraatrial baffle repair for transposition of the great arteries is good, with many patients surviving into adult life, but prognosis can be limited by progressive right ventricular dysfunction. We hypothesized that ongoing myocardial ischemia and/or infarction are important factors in the pathogenesis of this complication. Radionuclide techniques offer an opportunity to study both myocardial perfusion and concomitant ventricular wall motion. METHODS: Dipyridamole sestamibi single-photon emission computed tomography followed by rest sestamibi single-photon emission computed tomography was used to assess right ventricular myocardial perfusion, wall motion, wall thickening and ejection fraction in 22 adolescents/young adults who had undergone atrial baffle repair for simple transposition of the great arteries at median 6.7 (range 0.5 to 54) months of age. The patients were aged 10 to 25 (median 15.5) years; 19 in New York Heart Association class I, 2 in class II and 1 in class III. All were in a regular cardiac rhythm during the studies. The right ventricular tomographic images were examined in three parallel and two orthogonal planes, analyzed in 12 segments. RESULTS: Perfusion defects were evident in all patients in at least one segment, in either the rest or stress images. Twelve patients (55%) demonstrated fixed defects only, nine (41%) had fixed and reversible defects and one (4.5%) had reversible defects only. Concomitant wall-thickening abnormalities occurred in 83% of segments with fixed perfusion defects, mirrored by a reduction in wall motion in 91% of segments analyzed. Right ventricular ejection fraction was correlated with age (R = 0.62; p = 0.002), and with wall-thickening abnormalities (R = 0.60; p < 0.005). CONCLUSIONS: Reversible and fixed perfusion defects with concordant regional wall motion abnormalities occur in the right (systemic) ventricle 10 to 20 years after Mustard repair for transposition of the great arteries; this may be important in the pathogenesis of late right ventricular dysfunction in this group.

Adolescent↗
PubMed2002

Predictors of right ventricular dysfunction in patients with coronary artery disease and reduced left ventricular ejection fraction.

BACKGROUND: The frequency and determinants of right ventricular (RV) dysfunction in patients with coronary artery disease (CAD) and reduced left ventricular (LV) function have not been thoroughly investigated. METHODS: The study population consists of 80 consecutive patients, invasively evaluated at our centre. Entry criteria were: LV ejection fraction < 45%; angiographic evidence of obstructive CAD; disease history of more than 3 months' duration. Exclusion criteria were: recent myocardial infarction and unstable angina. All patients underwent cardiac catheterization with coronary, LV and RV angiography. RV dysfunction was defined as a RV ejection fraction < 35%, which corresponds to the mean-three standard deviations of controls. RESULTS: Sixty-five patients (81%) had multi-vessel disease and 57 (71%) had a previous myocardial infarction. Mean LV ejection fraction was 31 +/- 8%. Mean RV ejection fraction was 46 +/- 11%. Right ventricular dysfunction was present in 14 patients (18%). An occluded proximal right coronary artery was associated with significantly lower RV ejection fraction (38 +/- 12% versus 47 +/- 10%; P = 0.009) but not LV ejection fraction (30 +/- 8% versus 32 +/- 9%; P = 0.444). However, at multivariate analysis, only pulmonary hypertension was an independent significant predictor of RV dysfunction (P < 0.001; OR: 1.13; CI: 1.06 -1.22). CONCLUSION: Right ventricular dysfunction in patients with chronic ischaemic LV dysfunction is detected in less than 20% of cases. Proximal right coronary artery occlusion is associated with a reduced RV ejection fraction. However, the role of right coronary artery disease is overwhelmed by the haemodynamic burden of pulmonary hypertension, which represents the only independent predictor of RV dysfunction in our population.

Aged↗
PubMed1990

[Right ventricular dysfunction of mitral valve stenosis].

Right ventricular function was studied in 9 patients with mitral valve stenosis who underwent mitral valve replacement (St. Jude Medical valve 29-31 mm) (MVR). The right ventricular systolic pressure/end-systolic volume index (RVSP/ESVI) correlated well with right ventricular ejection fraction (RVEF) in the normal control group thus it considered to be a index of right ventricular contractility. At rest, RVEF in the MVR group was significantly lower than that in the control group. However there was no difference in the RVSP/ESVI between both groups. In the MVR group, the total pulmonary resistance index (TPRI) and mean pulmonary arterial pressure (mPAP) were higher than those in the control group. During exercise, the RVSP/ESVI became higher in both groups, but RVEF did not increase in the MVR group. In the control group, RVEF became higher during exercise. In addition, TPRI and mPAP increased in the MVR group but the control group did not show significant changes during exercise. In conclusion, low RVEF after MVR, which reflects pump function of the right ventricle, was not caused by contractile dysfunction of the right ventricle but mainly by excess afterload due to irreversible pulmonary vascular resistance persisting after operation as a result of chronic pulmonary vascular hypertension.

Adult↗