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JACC. Cardiovascular Imaging Jan 2020Left ventricular diastolic function plays an important role in determining left ventricular filling and stroke volume. Abnormal diastolic function has been recognized in... (Review)
Review
Left ventricular diastolic function plays an important role in determining left ventricular filling and stroke volume. Abnormal diastolic function has been recognized in many cardiovascular diseases and is associated with worse outcomes, including total mortality and hospitalizations due to heart failure. Using echocardiography, it is possible to diagnose the presence of diastolic dysfunction and the pathophysiologic mechanisms involved as they affect left ventricular and left atrial structure and function. This review addresses the role of echocardiography in understanding the pathophysiology of diastolic dysfunction, its diagnosis, and utility in predicting outcomes.
Topics: Diastole; Disease Progression; Echocardiography, Doppler; Heart Failure; Humans; Predictive Value of Tests; Prognosis; Risk Factors; Ventricular Dysfunction, Left; Ventricular Function, Left
PubMed: 30982669
DOI: 10.1016/j.jcmg.2018.10.038 -
European Journal of Heart Failure Mar 2016Acute right ventricular (RV) failure is a complex clinical syndrome that results from many causes. Research efforts have disproportionately focused on the failing left... (Review)
Review
Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and Right Ventricular Function of the European Society of Cardiology.
Acute right ventricular (RV) failure is a complex clinical syndrome that results from many causes. Research efforts have disproportionately focused on the failing left ventricle, but recently the need has been recognized to achieve a more comprehensive understanding of RV anatomy, physiology, and pathophysiology, and of management approaches. Right ventricular mechanics and function are altered in the setting of either pressure overload or volume overload. Failure may also result from a primary reduction of myocardial contractility owing to ischaemia, cardiomyopathy, or arrhythmia. Dysfunction leads to impaired RV filling and increased right atrial pressures. As dysfunction progresses to overt RV failure, the RV chamber becomes more spherical and tricuspid regurgitation is aggravated, a cascade leading to increasing venous congestion. Ventricular interdependence results in impaired left ventricular filling, a decrease in left ventricular stroke volume, and ultimately low cardiac output and cardiogenic shock. Identification and treatment of the underlying cause of RV failure, such as acute pulmonary embolism, acute respiratory distress syndrome, acute decompensation of chronic pulmonary hypertension, RV infarction, or arrhythmia, is the primary management strategy. Judicious fluid management, use of inotropes and vasopressors, assist devices, and a strategy focusing on RV protection for mechanical ventilation if required all play a role in the clinical care of these patients. Future research should aim to address the remaining areas of uncertainty which result from the complexity of RV haemodynamics and lack of conclusive evidence regarding RV-specific treatment approaches.
Topics: Echocardiography; Heart Failure; Humans; Pulmonary Circulation; Ventricular Dysfunction, Right
PubMed: 26995592
DOI: 10.1002/ejhf.478 -
The New England Journal of Medicine Mar 2023
Review
Topics: Humans; Heart Failure; Heart-Assist Devices; Ventricular Dysfunction, Right
PubMed: 36947468
DOI: 10.1056/NEJMra2207410 -
JACC. Cardiovascular Imaging Jan 2020Research in the last decade has substantially advanced our understanding of the pathophysiology of heart failure with preserved ejection fraction (HFpEF). However,... (Review)
Review
Research in the last decade has substantially advanced our understanding of the pathophysiology of heart failure with preserved ejection fraction (HFpEF). However, treatment options remain limited as clinical trials have largely failed to identify effective therapies. Part of this failure may be related to mechanistic heterogeneity. It is speculated that categorizing HFpEF patients based upon underlying pathophysiological phenotypes may represent the key next step in delivering the right therapies to the right patients. Echocardiography may provide valuable insight into both the pathophysiology and underlying phenotypes in HFpEF. Echocardiography also plays a key role in the evaluation of patients with unexplained dyspnea, where HFpEF is suspected but the diagnosis remains unknown. The combination of the E/e' ratio and right ventricular systolic pressure has recently been shown to add independent value to the diagnostic evaluation of patients suspected of having HFpEF. Finally, echocardiography enables identification of the different causes that mimic HFpEF but are treated differently, such as valvular heart disease, pericardial constriction, and high-output heart failure or infiltrative myopathies such as cardiac amyloid. This review summarizes the current understanding of the pathophysiology and phenotyping of HFpEF with particular attention to the role of echocardiography in this context.
Topics: Comorbidity; Diastole; Echocardiography; Heart Failure; Humans; Phenotype; Predictive Value of Tests; Prognosis; Risk Factors; Stroke Volume; Ventricular Dysfunction, Left; Ventricular Function, Left
PubMed: 31202759
DOI: 10.1016/j.jcmg.2018.12.034 -
The American Journal of Emergency... Aug 2022Right heart failure (RHF) is a clinical syndrome with impaired right ventricular cardiac output due to a variety of etiologies including ischemia, elevated pulmonary... (Review)
Review
INTRODUCTION
Right heart failure (RHF) is a clinical syndrome with impaired right ventricular cardiac output due to a variety of etiologies including ischemia, elevated pulmonary arterial pressure, or volume overload. Emergency department (ED) patients with an acute RHF exacerbation can be diagnostically and therapeutically challenging to manage.
OBJECTIVE
This narrative review describes the pathophysiology of right ventricular dysfunction and pulmonary hypertension, the methods to diagnose RHF in the ED, and management strategies.
DISCUSSION
Right ventricular contraction normally occurs against a low pressure, highly compliant pulmonary vascular system. This physiology makes the right ventricle susceptible to acute changes in afterload, which can lead to RHF. Patients with acute RHF may present with an acute illness and have underlying chronic pulmonary hypertension due to left ventricular failure, pulmonary arterial hypertension, chronic lung conditions, thromboemboli, or idiopathic conditions. Patients can present with a variety of symptoms resulting from systemic edema and hemodynamic compromise. Evaluation with electrocardiogram, laboratory analysis, and imaging is necessary to evaluate cardiac function and end organ injury. Management focuses on treating the underlying condition, optimizing oxygenation and ventilation, treating arrhythmias, and understanding the patient's hemodynamics with bedside ultrasound. As RHF patients are preload dependent they may require fluid resuscitation or diuresis. Hypotension should be rapidly addressed with vasopressors. Cardiac contractility can be augmented with inotropes. Efforts should be made to support oxygenation while trying to avoid intubation if possible.
CONCLUSIONS
Emergency clinician understanding of this condition is important to diagnose and treat this life-threatening cardiopulmonary disorder.
Topics: Heart Failure; Heart Ventricles; Humans; Hypertension, Pulmonary; Ventricular Dysfunction, Right; Ventricular Function, Right
PubMed: 35660367
DOI: 10.1016/j.ajem.2022.05.030 -
JACC. Cardiovascular Imaging Feb 2018Left ventricular (LV) ejection fraction (LVEF) is a simple measure of global systolic function that pervades the risk evaluation and management of many cardiovascular... (Review)
Review
Left ventricular (LV) ejection fraction (LVEF) is a simple measure of global systolic function that pervades the risk evaluation and management of many cardiovascular diseases. However, this parameter is limited not only by technical challenges, but also by pathophysiological entities where the ratio of stroke volume to LV cavity size is preserved. The assessment of global longitudinal strain (GLS) from speckle-tracking analysis of 2-dimensional echocardiography has become a clinically feasible alternative to LVEF for the measurement of myocardial function. Evidence gathered over the last decade has shown GLS to be more sensitive to left ventricular dysfunction (LVD) than LVEF and to provide additional prognostic information. The technology is validated, reproducible within an acceptable range, and widely available. GLS has been proposed as the test of choice in guidelines for monitoring of asymptomatic cardiotoxicity related to chemotherapy. It also has the potential to improve risk stratification, redefine criteria for disease classification, and determine treatment in asymptomatic LVD resulting from a variety of etiologies. GLS provides utility across the spectrum of heart failure (and LVEF) as well as in the evaluation of valvular heart disease. There is a strong case for incorporation of GLS into clinical decision making. This review appraises the evidence addressing the utility of GLS as a complementary metric to LVEF for incorporation into mainstream clinical practice.
Topics: Animals; Biomechanical Phenomena; Echocardiography; Heart Ventricles; Humans; Myocardial Contraction; Predictive Value of Tests; Prognosis; Risk Factors; Stroke Volume; Ventricular Dysfunction, Left; Ventricular Function, Left
PubMed: 29413646
DOI: 10.1016/j.jcmg.2017.11.017 -
Journal of Veterinary Cardiology : the... Dec 2015Left ventricular (LV) diastolic dysfunction is highly prevalent in cats and is a functional hallmark of feline cardiomyopathy. The majority of cats with hypertrophic,... (Review)
Review
Left ventricular (LV) diastolic dysfunction is highly prevalent in cats and is a functional hallmark of feline cardiomyopathy. The majority of cats with hypertrophic, restrictive, and dilated cardiomyopathy have echocardiographic evidence of abnormal LV filling, even during the occult (preclinical) phase. Moderate and severe diastolic dysfunction is an indicator of advanced myocardial disease, is associated with clinical signs including exercise intolerance and congestive heart failure, affects outcome, and influences therapeutic decisions. Therefore, identification and quantification of LV diastolic dysfunction are clinically important. Surrogate measures of diastolic function determined by transthoracic two-dimensional, M-mode, and Doppler echocardiographic (DE) methods have been used widely for such purpose. Major functional characteristics of LV diastole, including global function, relaxation and untwist, chamber compliance, filling volume, and the resultant filling pressures can be semi-quantified by echocardiographic methods, and variables retrieved from transmitral flow, pulmonary vein flow, and tissue Doppler recordings are most frequently used. Although there is still a critical lack of well-designed studies in the field, knowledge has steadily accumulated over the past 20 years, reference ranges of diastolic echocardiographic variables have been determined, epidemiological studies have been conducted, and new treatments of diastolic dysfunction in cats have been evaluated. This report will give the reader a summary of the current status in the field of feline diastology with focus on the noninvasive diagnostic methods and interpretation of echocardiographic surrogate measures of LV diastolic function. Lastly, a grading system using a composite of left atrial size and various DE variables potentially useful in the functional classification of LV diastole in cats is introduced.
Topics: Animals; Cat Diseases; Cats; Echocardiography, Doppler; Ventricular Dysfunction, Left; Ventricular Function, Left
PubMed: 26776572
DOI: 10.1016/j.jvc.2015.02.002 -
The European Respiratory Journal Jan 2019Pulmonary hypertension (PH) is frequent in left heart disease (LHD), as a consequence of the underlying condition. Significant advances have occurred over the past... (Review)
Review
Pulmonary hypertension (PH) is frequent in left heart disease (LHD), as a consequence of the underlying condition. Significant advances have occurred over the past 5 years since the 5th World Symposium on Pulmonary Hypertension in 2013, leading to a better understanding of PH-LHD, challenges and gaps in evidence. PH in heart failure with preserved ejection fraction represents the most complex situation, as it may be misdiagnosed with group 1 PH. Based on the latest evidence, we propose a new haemodynamic definition for PH due to LHD and a three-step pragmatic approach to differential diagnosis. This includes the identification of a specific "left heart" phenotype and a non-invasive probability of PH-LHD. Invasive confirmation of PH-LHD is based on the accurate measurement of pulmonary arterial wedge pressure and, in patients with high probability, provocative testing to clarify the diagnosis. Finally, recent clinical trials did not demonstrate a benefit in treating PH due to LHD with pulmonary arterial hypertension-approved therapies.
Topics: Humans; Hypertension, Pulmonary; Pulmonary Wedge Pressure; Randomized Controlled Trials as Topic; Vascular Resistance; Ventricular Dysfunction, Left
PubMed: 30545974
DOI: 10.1183/13993003.01897-2018 -
Circulation. Arrhythmia and... Dec 2019AF-mediated cardiomyopathy (AMC) is an important reversible cause of heart failure that is likely underdiagnosed in today's clinical practice. AMC describes AF either as... (Review)
Review
AF-mediated cardiomyopathy (AMC) is an important reversible cause of heart failure that is likely underdiagnosed in today's clinical practice. AMC describes AF either as the sole cause for ventricular dysfunction or exacerbating ventricular dysfunction in patients with existing cardiomyopathy or heart failure. Studies suggest that irreversible ventricular and atrial remodeling can occur in AMC, making timely diagnosis and intervention critical to optimize clinical outcome. Clinical correlation between AF onset/burden and progression of cardiomyopathy/heart failure symptoms provides strong evidence for the diagnosis of AMC. Cardiac MRI, continuous cardiac monitoring, and biomarkers are important diagnostic tools. From the therapeutic standpoint, early data suggest that AF ablation may improve long-term outcomes in AMC patients compared with medical rate and rhythm control. Patients with more AF burden and less severe underlying structural heart disease are more likely to experience left ventricle function recovery with successful AF ablation. Despite recent advances, significant knowledge gaps exist in our understanding of the epidemiology, mechanisms, diagnosis, management strategies, and prognosis of AMC.
Topics: Atrial Fibrillation; Atrial Remodeling; Cardiomyopathies; Clinical Decision-Making; Death, Sudden, Cardiac; Humans; Prevalence; Prognosis; Risk Factors; Ventricular Dysfunction; Ventricular Remodeling
PubMed: 31826649
DOI: 10.1161/CIRCEP.119.007809 -
JACC. Clinical Electrophysiology Feb 2023Frequent premature ventricular complexes (PVCs) can result in a reversible form of cardiomyopathy that usually affects the left ventricle (LV).
BACKGROUND
Frequent premature ventricular complexes (PVCs) can result in a reversible form of cardiomyopathy that usually affects the left ventricle (LV).
OBJECTIVES
The objective of this study was to assess whether frequent PVCs have an impact on right ventricular (RV) function.
METHODS
Serial cardiac magnetic resonance (CMR) studies were performed in a series of 47 patients before and after ablation of frequent PVCs.
RESULTS
Patients with RV cardiomyopathy (ejection fraction [EF] <0.45) had more frequent PVCs than did patients without decreased RV function (23% ± 11% vs 15% ± 11%, P = 0.03). Likewise, patients with LV cardiomyopathy (EF <0.50) had more frequent PVCs than did patients without decreased LV function (23% ± 10% vs 14% ± 12%, P = 0.003). LV dysfunction was present in 21 patients (45%). In patients with LV dysfunction, 15 patients (32%) had biventricular dysfunction, and 6 patients (13%) had isolated LV dysfunction. A total of 19 patients (40%) had RV dysfunction, and 4 of the patients with RV dysfunction (9%) had isolated RV dysfunction. Cardiac magnetic resonance was repeated 1.9 ± 1.3 years after ablation. In patients with successful ablation, RV function improved, and in patients without successful ablation, RV function did not significantly change (before and after ablation RVEF 0.45 ± 0.09 and 0.52 ± 0.09; P < 0.001 vs. 0.46 ± 0.07 and 0.48 ± 0.04; P = 0.14, respectively).
CONCLUSIONS
Frequent PVCs can cause RV cardiomyopathy that parallels LV cardiomyopathy and is reversible with successful ablation.
Topics: Humans; Heart; Heart Ventricles; Ventricular Premature Complexes; Ventricular Dysfunction, Right; Ventricular Dysfunction, Left
PubMed: 36858685
DOI: 10.1016/j.jacep.2022.09.016