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PubMed1995

Inhaled nitric oxide for hemodynamic support after postpneumonectomy ARDS.

Inhaled nitric oxide (NO) has been reported to promote selective pulmonary vasodilation and better arterial oxygenation in cases of adult respiratory distress syndrome (ARDS) with pulmonary hypertension (PHT). However, the clinical relevance of these changes and their effects on outcome remain to be proven, since long-term inhalation carries a potential risk of toxicity. We used NO to treat a patient who developed postpneumonectomy ARDS with severe PHT and right ventricular failure. NO resulted in better oxygenation and markedly improved hemodynamic status. As the underlying disease progressively worsened the patient became fully dependent on NO for hemodynamic support, and he died after 24 days of effective supportive therapy with inhaled NO.

Administration, Inhalation↗
PubMed1997

[Reversibility of changes in left and right ventricular geometry and hemodynamics in pulmonary hypertension. Echocardiographic characteristics before and after pulmonary thromboendarterectomy].

Pulmonary thromboendarterectomy (PTE) leads to an acute decrease of right ventricular (RV) afterload in patients with chronic thromboembolic pulmonary hypertension. We investigated the changes in right and left ventricular (LV) geometry and hemodynamics by means of transthoracic echocardiography. The prospective study was performed in 14 patients (8 female, 6 male; age 55 +/- 20 years) before and 18 +/- 12 days after PTE. Total pulmonary vascular resistance and systolic pulmonary artery pressure were significantly decreased (PVR: preoperative 986 +/- 318, postoperative 323 +/- 280 dyn x s/cm5, p < 0.05; PAP preoperative 71 +/- 40, postoperative 41 +/- 40 mm Hg + right atrial pressure, p < 0.05). End diastolic and end systolic RV area decreased from 33 +/- 12 to 23 +/- 8 cm2, respectively, from 26 +/- 10 to 16 +/- 6 cm2, p < 0.05. There was an increase in systolic RV fractional area change from 20 +/- 12 to 30 +/- 16%, p < 0.05. RV systolic pressure rise remained unchanged (516 +/- 166 vs. 556 +/- 128 mm Hg/sec). LV ejection fraction remained within normal ranges (64 +/- 16 vs. 62 +/- 12%). Echocardiographically determined cardiac index increased from 2.8 +/- 0.74 to 4.1 +/- 1.74 l/min/m2. A decrease in LV excentricity indices (end diastolic: 1.9 +/- 1 vs. 1.1 +/- 0.3, end systolic: 1.7 +/- 0.6 vs. 1.1 +/- 0.4, p < 0.05) proved a normalization of preoperatively altered septum motion. LV diastolic filling returned to normal limits: (E/A ratio: 0.62 +/- 0.34 vs. 1.3 +/- 0.8; p < 0.05); Peak E velocity: 0.51 +/- 0.34 vs. 0.88 +/- 0.28 m/sec, p < 0.05; Peak A velocity: 0.81 +/- 0.36 vs. 0.72 +/- 0.42 m/sec, ns; E deceleration velocity: 299 +/- 328 vs. 582 +/- 294 cm/sec2, p < 0.05; Isovolumic relaxation time: 134 +/- 40 vs. 83 +/- 38 m/sec, p < 0.05). We could show a marked decrease in RV afterload shortly after PTE with a profound recovery of right ventricular systolic function--even in case of severe pulmonary hypertension. A decrease in paradoxic motion of the interventricular septum and normalization of LV diastolic filling pattern resulted in a significant increase of cardiac index.

Aged↗
PubMed2005

Right ventricular failure following cardiac surgery.

The management of right ventricular failure remains a significant challenge in cardiac surgery. To date, no single clinical study has encompassed all of the principles that can be called upon to manage this problem. This review deals with the physiological management components that may be of value to cardiac medical and surgical clinicians.

Animals↗
PubMed1998

Efficacy of ventricular rate stabilization by right ventricular pacing during atrial fibrillation.

To assess the effect of right ventricular pacing on rate regularity during exercise and daily life activities, 16 patients with sinoatrial disease and chronic atrial fibrillation (AF) were studied. Incremental ventricular pacing was commenced at 40 beats/min until > 95% of ventricular pacing were achieved during supine, sitting, and standing. Thirteen patients also underwent randomized paired submaximal exercise tests in either a fixed rate mode. (VVI) or a ventricular rate stabilization (VRS) mode in which the pacing rate was set manually at 10 beats/min above the average AF rate during the last minute of each exercise stage. The pacing interval for rate regularization was shortest during standing (692 +/- 26 ms) compared with either supine or sitting (757 +/- 30 and 705 +/- 26 ms, respectively, P < 0.05). During exercise VRS pacing significantly increased the maximum rate (119 +/- 5.2 vs 106 +/- 4.2 ms, P < 0.05), percent of ventricular pacing (85% +/- 5% vs 23% +/- 7%, P < 0.05), rate regularity index (5.8% +/- 1.6% vs 13.4% +/- 1.9%, P < 0.05), and maximum level of oxygen consumption (12.4 +/- 0.5 vs 11.3 +/- 0.5 mL/kg, P < 0.05) compared with VVI pacing. There was no change in oxygen pulse or difference in symptom scores in this acute study between the two pacing modes. It is concluded that right ventricular pacing may significantly improve rate regularity and cardiopulmonary performance in patients with chronic AF. This may be incorporated in a pacing device for rate regularization of AF using an algorithm that is rate adaptive to postural and exercise stresses.

Adult↗
PubMed1997

Right ventricular disarticulation procedures: the role of late potentials in the genesis of postoperative ventricular arrhythmias.

Arrhythmogenic right ventricular disease may be associated with life-threatening and drug refractory ventricular arrhythmias. Right ventricular disarticulation procedures are effective antiarrhythmic surgical approaches in selected patients. This study examined the role of late potentials in the postoperative development of new ventricular arrhythmias, and showed that right ventricular isolation is effective, probably because it destroys the tissue giving rise to late potentials. Total disarticulation is associated with fewer postoperative arrhythmias than partial isolation procedures. Total disarticulation may be the surgical approach of choice in such patients.

Adult↗
PubMed2006

Resuscitation and recovery from acute right ventricular failure using a percutaneous right ventricular assist device.

A number of techniques have been proposed for circulatory support in patients with severe right heart failure. We report on a patient with right ventricular (RV) infarction complicated by cardiogenic shock, who was resuscitated by the novel use of a percutaneous right ventricular assist device. The moribund patient had striking hemodynamic and clinical improvement after placement of a right atrial to pulmonary artery assist circuit. RV decompression for 3 days was accompanied by recovery of contractile function, and the patient was successfully weaned from the device. Future trials are needed to assess the effectiveness of the percutaneous ventricular assist device in patients with RV failure.

Acute Disease↗
PubMed2003

A 38-year-old man with pulmonary hypertension, who had undergone atrial septal closure 26 years previously.

The patient was a 38-year-old man. He underwent atrial septal closure at the age of 12 years at Yokohama City University Hospital, when he already had pulmonary vascular change and reduced left-to-right shunt with Qp/Qs of 1.55 and pulmonary artery pressure (PA) of 56/22 mmHg. Thereafter, he enjoyed running and skiing without any symptoms up until 32 years of age, when he developed syncope due to severe pulmonary hypertension and atrial flutter. PA was 116/57 mmHg and mRA was 13 mmHg on cardiac catheterization. He developed right heart failure and was referred to Keio University Hospital on May 12th, 2001. Home intravenous prostacyclin infusion therapy was introduced in addition to treatment for right heart failure. Echocardiography revealed a residual interatrial shunt (from right to left). He recovered and was discharged. His condition worsened again and he was readmitted to our hospital with chief complaint of visual disturbance due to digoxin intoxication, in addition to right heart failure. Despite aggressive treatment, he died of severe pulmonary hypertension, right heart failure and congestive hepatic failure on December 10th, 2001. The differential diagnosis, pathophysiology and necessary treatment of pulmonary hypertension are discussed in this paper. The clinical diagnosis was Eisenmenger syndrome due to atrial septal defect, and the pathological findings were compatible with this.

Adult↗
PubMed2000

Implantation of the Biomedicus centrifugal pump in post-transplant right heart failure.

BACKGROUND: Right heart failure after heart transplantation represents a life-threatening complication. When conventional therapy including NO-inhalation fails the only choice to reach sufficient haemodynamic conditions may be the implantation of a right ventricular support system. METHODS: In all cases the Biomedicus centrifugal pump was implanted by cannulation of the right atrium and pulmonary artery. RESULTS: Since March 1989 950 heart transplant procedures were performed at our center. In nine cases (7 male, 2 female, mean age 52 years) implantation of a right ventricular support system was necessary because of deterioration of right ventricular function. The implantation was carried out in 7 cases immediately after transplantation, in 2 cases after 2 days. The support time ranged from 4-348 hours. Six patients could be weaned, 2 patients underwent retransplantation and died and 1 patient died on the support system. Three of the six weaned patients died in the further course because of multiorgan failure. CONCLUSIONS: Mechanical right ventricular support is often the only therapeutical tool to reach adequate haemodynamic conditions in post-transplant right heart failure. The Biomedicus centrifugal pump provides good conditions in these cases. Weaning is often possible after short-term support. The mortality rate is determined by multiorgan failure in immuno-suppressed patients. Retransplantation seems not to be successful despite maximal treatment.

Extracorporeal Circulation↗
PubMed2000

Biventricular pacing decreases sympathetic activity compared with right ventricular pacing in patients with depressed ejection fraction.

BACKGROUND: Although there have been few studies in which the hemodynamic effects of right ventricular (RV) and left ventricular (LV) pacing were compared with those of biventricular (BV) pacing, the autonomic changes during these different pacing modes remain unknown. We hypothesized that BV pacing results in improved hemodynamics and a decrease in sympathetic nerve activity (SNA) compared with single-site pacing. METHODS AND RESULTS: Thirteen men with a mean ejection fraction of 0.28+/-0.7 were enrolled in the study. Arterial blood pressure (BP), central venous pressure (CVP), and SNA were recorded during 3 minutes of right atrial (RA)-RV, RA-LV, and RA-BV pacing at a rate 10 beats faster than sinus rhythm. BP was greater during LV (151+/-7/85+/-3 mm Hg) and BV (151+/-6/85+/-3 mm Hg) pacing than during RV pacing (146+/-7/82+/-3 mm Hg) (P:<0.05). There were no differences in CVP among all pacing modes (P:=0.27). SNA was significantly less (P:<0.02) during both LV (606+/-35 U) and BV (582+/-41 U) pacing compared with RV pacing (685+/-32 U) (P:<0.02). Although not statistically significant (P:=0. 08 to 0.14), there was a trend for patients with a narrow QRS to have a lower mean BP and higher SNA during LV pacing than during BV pacing (r=0.42 to 0.49). CONCLUSIONS: LV-based pacing results in improved hemodynamics and a decrease in SNA compared with RV pacing in patients with LV dysfunction regardless of the QRS duration.

Aged↗
PubMed2003

Abnormal response to sodium channel blockers in patients with Brugada syndrome: augmented localised wall motion abnormalities in the right ventricular outflow tract region detected by electron beam computed tomography.

OBJECTIVE: To investigate the relation between the wall motion abnormalities and sodium channel abnormalities in cases of the Brugada syndrome. DESIGN: Consecutive prospective case-control study in a single hospital. SETTING: Tertiary referral centre. PATIENTS: 13 consecutive patients with Brugada syndrome and 13 age and sex matched control subjects. INTERVENTIONS: Each subject underwent electron beam computed tomography (EBT) and a 12 lead ECG before and after disopyramide injection. MAIN OUTCOME MEASURES: QRS width and the magnitude of ST segment elevation in the 12 lead ECG; wall motion by EBT. RESULTS: After disopyramide, EBT revealed deterioration of focal wall motion abnormalities in the right ventricular outflow tract region in eight of the 13 patients (62%). Prolongation of the QRS width after disopyramide injection in lead V2, which usually reflects the electrical activity in right ventricular outflow tract region, was greater in these eight patients (p < 0.01) than in the other five patients, in whom wall motion did not change after disopyramide. The degree of augmentation of ST segment elevation did not differ significantly between the two groups CONCLUSIONS: The deterioration of wall motion abnormalities in the right ventricular outflow tract region after disopyramide suggests the presence of functional abnormalities of the sodium channel. Some patients with Brugada syndrome may have arrhythmogenic substrates with abnormal responses to sodium channel blockers.

Adult↗
PubMed2004

[Pulmonary hypertension and cardiac transplantation].

Evaluation of pulmonary hypertension in chronic cardiac failure before cardiac transplantation is one of the major objectives of the pre-transplantation investigations. The risk of right ventricular failure, a poor short-term prognostic factor, is correlated with the level of pulmonary arteriolar resistance. Based on recent physiopathological data concerning the pulmonary circulation, advances on postoperative care and cardiopulmonary bypass techniques, this article aims to present the modern conception of evaluation of pulmonary hypertension, its reversibility in patients who are candidates for cardiac transplantation, and its treatment after the transplantation.

Cardiopulmonary Bypass↗
PubMed1999

Successful resection of cecal hepatic metastasis extending into the right side of the heart under cardiopulmonary bypass.

Resection is the best hope for the cure of colorectal metastasis to the liver. However, surgery is indicated for only a few patients, especially those who have major vascular involvement. We report a 55-year-old woman with a liver metastasis from the cecum that showed a tumor thrombus in the right side of the heart. She had undergone laparoscopic right hemicolectomy for cecal cancer 6 months before, and presented with a palpable mass in the epigastrium. Abdominal ultrasonography, computed tomography, hepatic angiogram, and echocardiography showed a huge mass on the left lobe of the liver, with a tumor thrombus which extended to the right ventricle through the left hepatic vein and inferior vena cava. Tumor thrombectomy, through a right atriotomy, was success-fully performed under cardiopulmonary bypass, followed by left hepatic lobectomy. The patient's postoperative course was uneventful.

Adenocarcinoma↗
PubMed2004

Aerosolized prostacyclins.

Two prostacyclins (prostaglandin E(1) and prostaglandin I(2)) are potent vasodilators. Aerosolized prostacyclins reduce pulmonary artery pressure, improve right heart function, and increase arterial oxygenation by improving ventilation/perfusion matching. This report describes aerosolized prostacyclins and compares them to inhaled nitric oxide. I review the types of inhalable prostacyclins and their indications, evidence of efficacy, delivery, and adverse effects.

Administration, Inhalation↗
PubMed1996

Right ventricular pathology in chronic pulmonary hypertension.

Right ventricular free wall biopsy specimens in 40 patients undergoing surgery for relief of chronic thromboembolic pulmonary hypertension were normal in 5%, disclosed only myocyte hypertrophy in 80%, mild focal fibrosis in 12.5%, and myocarditis in 2.5%. There was no relation between postsurgical functional or hemodynamic outcomes and the presence of focal fibrosis.

Aged↗
PubMed2001

Appearance of right bundle branch block in electrocardiograms of patients with pulmonary embolism as a marker for obstruction of the main pulmonary trunk.

A number of changes occur in the electrocardiogram (ECG) of pulmonary embolism. This article deals with the diagnostic value of the newly emerged right bundle branch block (RBBB) as a manifestation of acute right ventricular overload. A certain correlation between the extent of obstruction of the pulmonary artery and the appearance of RBBB is established through dynamic monitoring of the ECG. Fifty cases of dissectionally proven pulmonary embolism are observed, in 20 of which massive trunk obstruction had taken place, and in the remaining 30 peripheral embolism in the pulmonary artery was established. With 80% of the trunk embolism patients (16 cases), a newly emerged RBBB was detected in their ECG, and with the remaining 20% (4 cases), ST-segment depression and T-wave inversion in leads V(1)-V(4) were observed as well as right axis deviation. S(1)Q(3)T(3) syndrome was detected among 60% (12 cases) of trunk embolism patients. In none of the peripheral embolism cases was RBBB in the ECG registered. Thus, its appearance on dynamic monitoring of the ECG of pulmonary embolism patients is a significant sign of the probability of massive obstruction of the main pulmonary trunk.

Bundle-Branch Block↗
PubMed1995

Signal-averaged electrocardiography in familial form of arrhythmogenic right ventricular cardiomyopathy.

This study was performed to establish whether signal-averaged electrocardiography can aid in the diagnosis of the familial form of arrhythmogenic right ventricular cardiomyopathy in order to determine the severity of the disease and to predict ventricular arrhythmias. In arrhythmogenic right ventricular cardiomyopathy there is a fatty fibrous substitution of myocardium, which is the substrate for delayed myocardial activation; this is responsible for the abnormalities seen on the signal-averaged electrocardiogram (SAECG). Seventy-five members of 11 families, both healthy and with various forms of the disease, were studied using a signal-averaged electrocardiographic technique. Forty-seven members, 16 with a severe and 31 with a minor form of the disease, were found to be affected. Forty-three subjects had abnormal results on the SAECG; of these, 39 had the disease (100% in patients with widespread disease and 74.1% in patients with a minor form), whereas the other 4 had no sign of the disease. Only 44.1% of the subjects with an abnormal SAECG had ventricular arrhythmias, whereas 76% of the subjects with ventricular arrhythmias had an abnormal SAECG. In contrast, 90.6% of patients with an abnormal SAECG had the disease, and only subjects with arrhythmogenic right ventricular cardiomyopathy had ventricular arrhythmias. The abnormality on the SAECG appears to be correlated with the severity of the disease. Signal-averaged electrocardiography does not seem useful in diagnosing the minor forms of the disease and it does not give precise information about electrical instability in these patients.

Adolescent↗
PubMed2002

The limitations of preload-adjusted maximal power as an index of right ventricular contractility.

UNLABELLED: Right ventricular (RV) dysfunction is an important cause of perioperative morbidity and mortality, particularly in cardiac surgery. However, assessment of RV contractility remains difficult in clinical practice. Our goal in this study was to examine the value of preload-adjusted maximal power (PWR(max)/end-diastolic volume [EDV](2); PAMP) as an alternative to the load-independent pressure-volume-derived indices of contractility in the RV. In anesthetized dogs, RV end-systolic elastance and preload-recruitable stroke work were studied as "gold standards" by using the conductance technique. PAMP was calculated with pulmonary artery flow and RV pressure measurements. Changes in these indices were compared after modulation of the inotropic state (dobutamine infusion; n = 12) and loading conditions (pulmonary artery and inferior caval vein occlusion; n = 14). All indices increased dose-dependently with dobutamine. PAMP was slightly influenced by preload reduction (the slope of the relation between PAMP and EDV was 0.00397 +/- 0.01026 W. mL(-3). 0.10(-4); mean +/- SD). PAMP decreased significantly during pulmonary artery banding (from 1.1 +/- 0.7 to 0.7 +/- 0.5 W. mL(-2). 0.10(-4); mean +/- SD), whereas end-systolic elastance and preload-recruitable stroke work did not change. We conclude that the value of PAMP as an index of RV contractility is limited in the open-chest/open-pericardium setting, primarily by its sensitivity to alterations in afterload. IMPLICATIONS: Preload-adjusted maximal power (PAMP), a load-independent contractile index in the left ventricle, could offer a solution to the problem of measuring right ventricular (RV) contractility in clinical practice. However, this study in open-chest dogs suggests that PAMP is unreliable for assessment of RV contractility because of its sensitivity to afterload changes.

Algorithms↗