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PubMed2002

Right ventricular dysfunction and risk of heart failure and mortality after myocardial infarction.

OBJECTIVES: The aim of this study was to determine the prognostic value of right ventricular (RV) function in patients after a myocardial infarction (MI). BACKGROUND: Right ventricular function has been shown to predict exercise capacity, autonomic imbalance and survival in patients with advanced heart failure (HF). METHODS: Two-dimensional echocardiograms were obtained in 416 patients with left ventricular (LV) dysfunction (ejection fraction [LVEF] < or = 40%) from the Survival And Ventricular Enlargement (SAVE) echocardiographic substudy (mean 11.1 +/- 3.2 days post infarction). Right ventricular function from the apical four-chamber view, assessed as the percent change in the cavity area from end diastole to end systole (fractional area change [FAC]), was related to clinical outcome. RESULTS: Right ventricular function correlated only weakly with the LVEF (r = 0.12, p = 0.013). On univariate analyses, the RV FAC was a predictor of mortality, cardiovascular mortality and HF (p < 0.0001 for all) but not recurrent MI. After adjusting for age, gender, diabetes mellitus, hypertension, previous MI, LVEF, infarct size, cigarette smoking and treatment assignment, RV function remained an independent predictor of total mortality, cardiovascular mortality and HF. Each 5% decrease in the RV FAC was associated with a 16% increased odds of cardiovascular mortality (95% confidence interval 4.3% to 29.2%; p = 0.006). CONCLUSIONS: Right ventricular function is an independent predictor of death and the development of HF in patients with LV dysfunction after MI.

Aged↗
PubMed1993

[Anesthetic management of a patient for giant pulmonary bulla drainage].

Recently it is claimed that the drainage procedure may be a useful method for giant pulmonary bulla in compromised patients. We reported the anesthetic managements of three patients with giant bulla for these procedures. We chose epidural anesthesia in order to prepare for the postoperative analgesia and the expansion of surgical procedure. In selecting circulatory support method, care was taken to choose dobutamine that would cause no suppression of hypoxic ventilatory drive. There is no doubt that right ventricular function is particularly important in patients with chronic obstructive lung disease. We measured right ventricular ejection fraction by thermodilution method and end-tidal CO2 by nasal cannula. These measurements may be useful methods for perioperative monitoring.

Aged↗
PubMed1982

Left and right ventricular adaptation to right ventricular overload before and after surgical repair of tetralogy of Fallot.

On the basis of angiographic projections, left (n = 43) and right (n = 56) ventricular volume data were obtained in patients with tetralogy of Fallot before and after surgical repair. The postoperative patients were divided into 3 groups according to the degree of an additional volume load secondary to a residual ventricular septal defect or pulmonary insufficiency, or both. The decreased left ventricular ejection fraction (p less than 0.01) in preoperative tetralogy of Fallot in the presence of a normal sized left ventricle suggests depressed global myocardial function, which is not improved after surgical repair, even if excellent results are achieved. A certain functional reserve, however, seems to be preserved, since the ejection fraction did not decrease further with increasing additional volume loads. Similar enlargement of the right ventricle secondary to comparable degrees of pulmonary insufficiency and residual ventricular septal defect indicates similar effects of additional diastolic and systolic filling on right ventricular function in patients with tetralogy of Fallot after surgical repair. Even in patients with excellent surgical results, such as those without significant right ventricular outflow tract obstruction and additional volume load, right ventricular pump function is depressed, the ejection fraction being significantly (p less than 0.01) lower than normal. The further decrease of global myocardial function with increasing volume load suggests a loss of functional reserve. Attempts to minimize right ventricular volume load after surgical repair seem advisable.

Adolescent↗
PubMed1994

Three-dimensional echocardiography. In vivo validation for right ventricular volume and function.

BACKGROUND: Current two-dimensional echocardiographic measures of right ventricular volume are limited by the asymmetrical and crescentic shape of the ventricle and by difficulty in obtaining standardized views. Three-dimensional echocardiographic reconstruction, which does not require geometric assumptions or standardized views, may therefore have potential advantages for determining right ventricular volume. Three-dimensional techniques, however, have not been applied to the right ventricle in vivo, where cardiac motion and contraction could affect accuracy. The purpose of this study was to determine the feasibility and accuracy of three-dimensional echocardiographic reconstruction for quantifying right ventricular volume and function in vivo. In particular, it was designed to test the accuracy of a newly developed system that provides rapid, efficient, and automated three-dimensional data collection (minimizing motion effects) and takes advantage of the full three-dimensional data set to obtain volume. METHODS AND RESULTS: The three-dimensional system was applied to reconstruct the right ventricle and measure its volume and function during 20 hemodynamic stages created in five dogs. Actual instantaneous volumes were measured continuously by an intracavitary balloon connected to an external column. Hemodynamics were varied by volume loading and induction of ischemia. Three-dimensional reconstruction successfully reproduced right ventricular volume compared with actual values at end diastole (y = 1.0 chi-3.4, r = .99, SEE = 1.8 mL) and end systole (y = 1.0 chi+ 2.0, 4 = .98, SEE = 2.5 mL). The mean difference between calculated and actual volumes throughout the cycle was 2.1 mL, or 4.9% of the mean. Ejection fraction also correlated well with actual values (y = 0.96 chi-0.3, r = .98, SEE = 3.3%). CONCLUSIONS: Despite the irregular crescentic shape of the right ventricle, this newly developed three-dimensional system and surfacing algorithm can accurately reconstruct its shape and quantitate its volume and function in vivo without geometric assumptions. The increased efficiency of the system should increase applicability to issues of clinical and research interest.

Algorithms↗
PubMedDate not supplied

Inhaled nitric oxide in the evaluation of heart transplant candidates with elevated pulmonary vascular resistance.

The reversibility of elevated pulmonary vascular resistance in heart transplant candidates is currently evaluated with intravenous vasodilators. The aim of this study was to evaluate the effects of increased concentrations of inhaled nitric oxide (20, 40, and 80 ppm) on central hemodynamics and right ventricular function in heart transplant candidates with elevated pulmonary vascular resistance (> 2.5 Wood units). Comparison was made with intravenous vasodilators, sodium nitroprusside, and prostacyclin in doses that lowered the mean arterial pressure by about 15%. Inhalation of nitric oxide did not change systemic or pulmonary arterial pressure, cardiac output, right ventricular function, or systemic vascular resistance. Pulmonary capillary wedge pressure increased and transpulmonary pressure gradient and pulmonary vascular resistance decreased (-34% +/- 4% and -36% +/- 4%, respectively; p < 0.01) during 20 ppm nitric oxide, with no further effects at higher doses. Prostacyclin and sodium nitroprusside decreased pulmonary vascular resistance (-50% +/- 6% and -33% +/- 5%; p < 0.01). Prostacyclin reduced to some extent (p = 0.08) transpulmonary pressure gradient, which was not seen during sodium nitroprusside infusion. Systemic vascular resistance decreased during both sodium nitroprusside (-37% +/- 5%) and prostacyclin (-44% +/- 4%) infusion. The pulmonary vascular resistance/systemic vascular resistance ratio, used as an index of pulmonary selectivity, was decreased by nitric oxide (p < 0.01) but not by the intravenous vasodilators. Metabolic data indicate that inhaled nitric oxide is metabolized in the same way as that formed endogenously. In conclusion, inhaled nitric oxide is a selective pulmonary vasodilator that can be used safely in the hemodynamic evaluation of heart transplant candidates with elevated pulmonary vascular resistance.

Administration, Inhalation↗
PubMed1997

Right ventricular failure--insights provided by a new model of chronic pulmonary hypertension.

This study was designed to examine the effects of both nitric oxide and milrinone on pulmonary hemodynamics and right ventricular function using a newly established model of monocrotaline pyrrole-induced chronic pulmonary hypertension. Sixteen mongrel dogs (23-25 kg) were used. All animals underwent percutanous pulmonary artery catheterization to measure right heart hemodynamics prior to and 8 weeks after a right atrial injection of either monocrotaline pyrrole (MCTP, n=8) or placebo (CTL, n=8). Eight weeks postinjection, all hearts were instrumented with a pulmonary artery flow probe and intracavitary micromanometers. Data were collected at baseline as well as following both nitric oxide and milrinone administration. There was no significant difference in the baseline hemodynamic measurements between the two groups. Eight weeks postinjection, significant increases in the pulmonary artery pressure and pulmonary vascular resistance were observed in MCTP compared with CTL. Both nitric oxide and milrinone resulted in significant improvements in pulmonary vascular resistance, pulmonary blood flow, and right ventricular contractility. In addition, nitric oxide caused a significant improvement in pulmonary artery pressure and transpulmonary efficiency, while milrinone led to a significant increase in right ventricular hydraulic power. This study demonstrates the well-known clinical effects of nitric oxide and milrinone in improving pulmonary hypertension, which were also associated with an increase in pulmonary blood flow, transpulmonary efficiency, and right ventricular hydraulic power in the setting of monocrotaline pyrrole-induced chronic pulmonary hypertension.

Administration, Inhalation↗
PubMed1992

[Doppler echocardiographic assessment of left atrial and left ventricular function during right bundle branch block].

Electrocardiographic, echocardiographic and Doppler echocardiographic studies were performed in 44 patients with coronary heart disease and complete right bundle branch block. The patients were found to have an impaired phase pattern of left ventricular systole and diastole as more prolonged length of its isometric relaxation and contraction, lower economic feasibility and efficiency of its contraction, moderate dilation and hypertrophy. Hemodynamic abnormalities in the left heart in these patients are closely correlate with the changes in the phase pattern of right ventricular systole and they turn out to be so greater as the degree of its hypertrophy is. In complete right bundle branch block, left ventricular pump dysfunction leads to decreased cardiac output and cardiac index, increased total peripheral vascular resistance, thus predisposing to impaired greater circulation.

Adult↗
PubMed2006

What role does the right side of the heart play in circulation?

Right ventricular failure (RVF) is an underestimated problem in intensive care. This review explores the physiology and pathophysiology of right ventricular function and the pulmonary circulation. When RVF is secondary to an acute increase in afterload, the picture is one of acute cor pulmonale, as occurs in the context of acute respiratory distress syndrome, pulmonary embolism and sepsis. RVF can also be caused by right myocardial dysfunction. Pulmonary arterial catheterization and echocardiography are discussed in terms of their roles in diagnosis and treatment. Treatments include options to reduce right ventricular afterload, specific pulmonary vasodilators and inotropes.

Cardiotonic Agents↗
PubMed1984

[Effect of chronic pressure and volume stress on the function of the right ventricle].

Biplane right ventricular angiography was performed in 36 patients with chronic pressure overload of the right ventricle; 12 patients additionally had tricuspid insufficiency (TI). There were 4 subgroups: patients with systolic pulmonary artery pressure less than or equal to 40 mm Hg without (group I, n = 10) and with TI (group II, n = 6), as well as patients with systolic pulmonary artery pressure greater than 40 mm Hg without (group III, n = 14) and with TI (group IV, n = 6). Compared with the normal volumes of groups I and III, a significant increase in end-diastolic right ventricular volumes (p less than 0.01) was found in groups II and IV with 112.2 +/- 22.3 ml/m2 and 116.3 +/- 27.4 ml/m2, respectively. In both groups II and IV end-systolic volumes were also significantly increased, with 51.0 +/- 10.3 ml/m2 in group II and 49.7 +/- 11.3 ml/m2 in group IV. Right ventricular ejection fraction was 53.8 +/- 11.9% in group II, 57.3 +/- 8.5% in group III and 57.8 +/- 7.3% in group IV. There was no significant difference between the ejection fraction of these groups in comparison to the normal ejection fraction of group I with 63.4 +/- 10.9%. The results suggest that the right ventricle can compensate for moderate chronic pressure and volume overload using the Frank-Starling mechanism. Overall right ventricular dysfunction is not determined primarily by the loading conditions alone. Local myocardial and septal involvement is suspected to be an important determinant of right ventricular function.

Aortic Valve Insufficiency↗
PubMed1991

Hypoplastic left heart syndrome: hemodynamic and angiographic assessment after initial reconstructive surgery and relevance to modified Fontan procedure.

After undergoing initial reconstructive surgery for hypoplastic left heart syndrome performed between August 1985 and March 1989, 59 patients (age range 3 to 27 months, mean 13.8 +/- 4.5) underwent elective cardiac catheterization in anticipation of a modified Fontan procedure. Five important hemodynamic and anatomic features considered to be components of successful reconstructive surgery were specifically addressed. 1) Interatrial communication: Only two patients had a measured pressure difference of greater than 4 mm Hg across the atrial septum. 2) Tricuspid valve function: Angiography demonstrated significant tricuspid valve regurgitation in only five patients (moderate in two and severe in three). 3) Aortic arch: Pressure tracings from the right ventricle to the descending aorta revealed a gradient greater than 25 mm Hg in only two patients. 4) Pulmonary vasculature: Ten patients had a calculated pulmonary vascular resistance greater than 4 U.m2; 51 (86%) of the 59 patients had no evidence of distortion (stenosis or hypoplasia) of either the left or the right pulmonary artery. 5) Right ventricular function: Five patients had an end-diastolic pressure in the right ventricle greater than 12 mm Hg and two patients had qualitative assessment of decreased ventricular function. Comparison of catheterization data between survivors and nonsurvivors of the subsequent modified Fontan procedure showed that only significant tricuspid regurgitation is a possible predictor of poor outcome. After first stage reconstructive surgery for hypoplastic left heart syndrome, most survivors have favorable anatomy and hemodynamics at follow-up cardiac catheterization for a subsequent Fontan procedure.

Aorta, Thoracic↗
PubMed1990

Pulmonary vascular impedance in microembolic pulmonary hypertension: effects of synchronous high-frequency jet ventilation.

Increased intrathoracic pressure (ITP) during conventional mechanical ventilation may interfere with the adaptation of right ventricular function to pulmonary hypertension. We studied the effects of synchronous cardiac cycle-specific high frequency jet ventilation (HFJV) in 10 anesthetized dogs before and after embolization of the pulmonary artery with 150-200 microns glass beads. The delivery of the jet was synchronized with early systole, late systole, early diastole and late diastole of the cardiac cycle. Right and left ventricular pressures (Prv and Plv) and pulmonary arterial pressures (Ppa) were measured by transducer-tipped catheters and pulmonary blood flow by an ultrasonic flow probe. Right ventricular end-systolic and end-diastolic volumes (rvESV and rvEDV) were estimated from the thermodilution curve obtained with a Swan-Ganz catheter equipped with a fast response thermistor. Pulmonary hypertension caused significant increases in heart rate (89 +/- 7 to 152 +/- 8 beats/min), rvEDV (80 +/- 7 to 131 +/- 23 ml), diastolic transmural Prv (2 +/- 1 to 5 +/- 1 mm Hg), and rv peak dP/dt (652 +/- 151 to 1035 +/- 160 mm Hg/s). The spectrum of pulmonary vascular input impedance was displaced towards higher frequencies, input resistance was increased and characteristic impedance decreased. The latter change contributed to a relative decrease in the pulsatile component of right ventricular power output. Cardiac output remained unchanged (2.1 +/- 0.2 to 1.9 +/- 0.1 L/min, P NS). Non of these measurements was affected by the timing of the increase in ITP to specific instants in the cardiac cycle compared to apneic periods at any level of pulmonary hypertension. We conclude that in acute microembolic pulmonary hypertension 1 degree a decrease in characteristic impedance contributes to the adaptation of right ventricular function to increased afterload and 2 degrees synchronous cardiac cycle-specific HFJV has no detectable hemodynamic effect.

Animals↗
PubMed1986

The efficacy of blood versus crystalloid coronary sinus cardioplegia during global myocardial ischemia.

The efficacy of blood and crystalloid retrograde cardioplegia in protecting the ischemic myocardium was compared. Seventeen dogs underwent 2 hr of global myocardial ischemia while on cardiopulmonary bypass. Crystalloid (in nine dogs) or blood (in eight dogs) cardioplegic solution was infused continuously into the coronary sinus. Left and right ventricular function were assessed before ischemia and after 30 and 60 min of reperfusion by means of highly sensitive, load-independent index of contractility (the slope of the stroke work vs end-diastolic length relationship). Ventricular biopsies for ATP determination were obtained before ischemia, at the end of ischemia, and after 60 min of reperfusion. Left and right ventricular function returned to normal after 60 min of reperfusion in both groups. Left ventricular ATP remained unchanged, whereas small but significant decreases in right ventricular ATP were observed after 60 min of reperfusion in both groups. Thus continuous crystalloid or blood retrograde coronary sinus cardioplegia in dogs preserved myocardial function and metabolism equally well after 2 hr of global cardiac ischemia.

Adenosine Triphosphate↗
PubMed2000

Right and left ventricular systolic function late after repair of tetralogy of Fallot.

Right ventricular (RV) dysfunction has adverse effects on long-term outcome in patients with repaired tetralogy of Fallot (TOF). We employed serial radionuclide angiography (RNA) to examine RV and left ventricular (LV) systolic function in adults late after TOF repair and its relation to clinical outcome. We reviewed 10-year records of 95 patients (53 men) with TOF followed in our clinic (mean age at repair 12.6 +/- 10.5 years, mean age at last follow-up 37.7 +/- 9.8 years) who underwent at least 2 RNAs between 1987 and 1997. Most patients were well by the end of the study (80% were New York Heart Association class I, 17% were class II, and 3% were in class III). Sixteen patients experienced sustained tachyarrhythmias (8 had atrial; 8 patients had ventricular). One patient died suddenly. Fifteen patients underwent RV outflow reoperations (15 underwent pulmonary valve replacement; 7 had relief of RV outflow obstruction); RV systolic function during exercise in these 15 patients was significantly impaired before and returned to similar levels after surgery, compared with the rest of the patients. Overall, RV and LV function remained stable in the whole group at a mean interval of 5.7 +/- 2.2 years between first and last RNA. This group of closely followed adults with TOF remained well over 10 years with a low incidence of sudden death and stable RV and LV systolic function, despite a relatively large number of RV outflow reoperations. Aggressive intervention for right-sided hemodynamic abnormalities may have contributed to this outcome. Preserved ventricular function may herald a favorable long-term outlook in this group.

Adult↗
PubMed1982

Hemodynamic correlates of right ventricular ejection fraction measured with gated radionuclide angiography.

Right ventricular function was studied in 60 patients with equilibrium gated radionuclide angiography. The mean (+/- standard deviation) right ventricular ejection fraction in 20 normal subjects was 53 +/- 6 percent, a value in agreement with previous data from both radionuclide and contrast angiographic studies. This value was similar (55 +/- 7 percent) in 11 patients with coronary artery disease but normal left ventricular function. Radionuclide measurements of right ventricular ejection fraction were correlated with right heart hemodynamics. There was a significant negative linear correlation between right ventricular ejection fraction and mean pulmonary arterial pressure (r = -0.82) and between right ventricular ejection fraction and right ventricular end-diastolic pressure (4 = -0.67). Furthermore, patients with elevated right ventricular end-diastolic pressure and mean pulmonary arterial pressure had a more severely depressed ejection fraction than did those with an elevated mean pulmonary arterial pressure alone. Thus, an abnormal value for right ventricular ejection fraction by gated radionuclide angiography in the absence of primary right ventricular volume overload suggests abnormal right heart pressures, whereas a normal value excludes severe pulmonary arterial hypertension or an elevated right ventricular end-diastolic pressure.

Adult↗
PubMed1994

Right ventricular dysfunction: an independent predictor of adverse outcome in patients with myocarditis.

To assess the predictive value of right ventricular systolic function in patients with active myocarditis, the echocardiograms of 23 patients with biopsy-confirmed myocarditis were reviewed. Right ventricular systolic function was evaluated qualitatively and quantitatively by descent of the right ventricular base. Patients were divided into those with normal right ventricular function, in whom right ventricular descent was 1.9 +/- 0.1 cm, and those with abnormal right ventricular function, in whom right ventricular descent was 0.8 +/- 0.1 cm (p < 0.001). There were no differences between the two groups in age, duration of symptoms, baseline hemodynamics, or histologic assessment. Initial left ventricular ejection fraction was significantly lower in patients with depressed right ventricular function (27.5 +/- 4.9%) compared with that in patients with normal right ventricular function (47.5 +/- 6.3%) (p = 0.01). The likelihood of an adverse outcome, defined as death or need for cardiac transplantation, was greater in patients with abnormal right ventricular function (right ventricular descent < or = 1.7 cm) than in patients with normal right ventricular function (right ventricular descent > 1.7 cm) (p < 0.03). Multivariate analysis revealed that right ventricular dysfunction as quantified by right ventricular descent was the most powerful predictor of adverse outcome.

Female↗
PubMed2004

Long-term outcome after senning operation for transposition of the great arteries.

BACKGROUND: The Senning operation for transposition of the great arteries (TGA) was first introduced by Senning in 1959 and was revived by Quaegebeur et al. in the late 1970s, thus becoming the intervention of choice for the correction of TGA in many centers. HYPOTHESIS: The purpose of this study was to evaluate the long-term follow-up of a group of patients undergoing surgery with the Senning procedure for TGA. METHODS: From November 1978 to November 1987, 73 consecutive patients underwent the Senning operation. The 70 survivors had an average follow-up of 19 years (16-25 years). RESULTS: (1) Cardiac rhythm: with time there was a progressive decrease in stable sinus rhythm (60% after 20 years) and a progressive increase of supraventricular tachyarrhythmias requiring therapy (10% after 20 years). (2) Right ventricular function: 20% of the patients had reduced ejection fraction. (3) Late mortality: in the last 12 years of follow-up years there were two sudden deaths (2.8%). (4) Functional status: 80% of patients were in NYHA class I, 17% in class II, and 3% in class III. CONCLUSIONS: Our results confirm that the patients who undergo the Senning procedure have a progressive loss of sinus rhythm, an increase in active arrhythmias, and other important adverse outcomes such as late sudden death and a decrease in right ventricular function; however, most patients (93% in our series) are alive and in good functional status.

Adolescent↗
PubMed1994

Traumatic tricuspid valve insufficiency. Experience in thirteen patients.

From 1964 through June 1993, thirteen patients with traumatic tricuspid insufficiency were treated surgically; all were male, and the ages ranged from 17 to 64 years (median 39 years). The condition was associated with blunt chest trauma in all patients: motor vehicle accidents in twelve and an explosion of a tank of compressed air in one. The median duration between trauma and operation was 17 years (range 1 month to 37 years). Preoperatively, six patients were in sinus rhythm and seven were in atrial fibrillation. At operation, the right ventricular function appeared moderately to severely depressed in twelve patients. In twelve patients, the anterior leaflet was flail because of chordal rupture (n = 9), rupture of anterior papillary muscle (n = 3), or tear in the anterior leaflet (n = 1). In one patient, the septal leaflet was missing and in another it was retracted and adherent to the ventricular septum. In five patients the tricuspid valve was repaired and in eight it was replaced. In seven patients in the latter group, the chordae, papillary muscles, and/or tricuspid valve leaflet(s) were found to be in a contracted and atrophic state, precluding repair. No early or late deaths occurred. At follow-up extending to 26 years (median 12 years), 12 patients are in New York Heart Association class I and one patient is in class II. Nine patients were in sinus rhythm and four were in atrial fibrillation. Although our experience indicates that good functional results can still be achieved many years after the onset of traumatic tricuspid valve insufficiency, earlier diagnosis and surgical treatment should increase the feasibility of tricuspid valve insufficiency, earlier diagnosis and surgical treatment should increase the feasibility of tricuspid valve repair, prevent progressive deterioration of right ventricular function, and increase the possibility of maintaining late sinus rhythm in a greater number of patients.

Accidents, Traffic↗