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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 -
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 -
Current Heart Failure Reports Dec 2022Heart failure (HF) after right ventricular myocardial infarction (RVMI) is common and complicates its clinical course. This review aims to provide a current overview on... (Review)
Review
PURPOSE OF REVIEW
Heart failure (HF) after right ventricular myocardial infarction (RVMI) is common and complicates its clinical course. This review aims to provide a current overview on the characteristic features of RV failure with focus on acute management.
RECENT FINDINGS
While HF after RVMI is classically seen after acute proximal right coronary artery occlusion, RV dysfunction may also occur after larger infarctions in the left coronary artery. Because of its different anatomy and physiology, the RV appears to be more resistant to permanent infarction compared to the LV with greater potential for recovery of ischemic myocardium. Hypotension and elevated jugular pressure in the presence of clear lung fields are hallmark signs of RV failure and should prompt confirmation by echocardiography. Management decisions are still mainly based on small studies and extrapolation of findings from LV failure. Early revascularization improves short- and long-term outcomes. Acute management should further focus on optimization of preload and afterload, maintenance of sufficient perfusion pressures, and prompt management of arrhythmias and concomitant LV failure, if present. In case of cardiogenic shock, use of vasopressors and/or inotropes should be considered along with timely use of mechanical circulatory support (MCS) in eligible patients. HF after RVMI is still a marker of worse outcome in acute coronary syndrome. Prompt revascularization, careful medical therapy with attention to the special physiology of the RV, and selected use of MCS provide the RV the time it needs to recover from the ischemic insult.
Topics: Humans; Heart Failure; Ventricular Dysfunction, Right; Myocardial Infarction; Heart Ventricles; Myocardium
PubMed: 36197627
DOI: 10.1007/s11897-022-00577-8 -
European Journal of Heart Failure Jan 2018There is an unmet need for effective treatment strategies to reduce morbidity and mortality in patients with heart failure with preserved ejection fraction (HFpEF).... (Review)
Review
Right heart dysfunction and failure in heart failure with preserved ejection fraction: mechanisms and management. Position statement on behalf of the Heart Failure Association of the European Society of Cardiology.
There is an unmet need for effective treatment strategies to reduce morbidity and mortality in patients with heart failure with preserved ejection fraction (HFpEF). Until recently, attention in patients with HFpEF was almost exclusively focused on the left side. However, it is now increasingly recognized that right heart dysfunction is common and contributes importantly to poor prognosis in HFpEF. More insights into the development of right heart dysfunction in HFpEF may aid to our knowledge about this complex disease and may eventually lead to better treatments to improve outcomes in these patients. In this position paper from the Heart Failure Association of the European Society of Cardiology, the Committee on Heart Failure with Preserved Ejection Fraction reviews the prevalence, diagnosis, and pathophysiology of right heart dysfunction and failure in patients with HFpEF. Finally, potential treatment strategies, important knowledge gaps and future directions regarding the right side in HFpEF are discussed.
Topics: Cardiology; Europe; Heart Failure; Humans; Practice Guidelines as Topic; Societies, Medical; Stroke Volume; Ventricular Dysfunction, Right
PubMed: 29044932
DOI: 10.1002/ejhf.1029 -
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 -
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 -
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 -
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 -
JACC. Cardiovascular Imaging May 2018The impact of one ventricle on the adjacent ventricle plays a key role in cardiac function. Ventricular-ventricular interactions are based on the arrangement in-series... (Review)
Review
The impact of one ventricle on the adjacent ventricle plays a key role in cardiac function. Ventricular-ventricular interactions are based on the arrangement in-series of the circulation and common pericardium, interventricular septum, and myocardial tracts. Imaging, in particular echocardiography, plays a central role in characterizing these interactions through geometric indices, septal configuration and motion, Doppler flow, timing of events in the ventricles and alterations in strain, remodeling, and diastolic filling with altered loading of the contralateral ventricle. Although standard echocardiography techniques are usually adequate to image ventricular-ventricular interactions, recent developments in automation, post-processing, and advanced techniques (e.g., 3-dimensional) could improve detection and understanding of interventricular interactions. Imaging findings must be analyzed in the context of the pathophysiology to correctly assess and understand ventricular-ventricular interactions. This paper reviews the imaging of ventricular-ventricular interactions in acquired and congenital heart disease, demonstrating their importance in a wide array of conditions.
Topics: Diffusion Magnetic Resonance Imaging; Echocardiography, Doppler; Heart Defects, Congenital; Humans; Predictive Value of Tests; Prognosis; Ventricular Dysfunction, Left; Ventricular Dysfunction, Right; Ventricular Function, Left; Ventricular Function, Right
PubMed: 29747850
DOI: 10.1016/j.jcmg.2018.01.028 -
American Journal of Physiology. Heart... Jan 2019The increasing prevalence of diabetic cardiomyopathy (DCM) is an important threat to health worldwide. While left ventricular (LV) dysfunction in DCM is well recognized,... (Review)
Review
The increasing prevalence of diabetic cardiomyopathy (DCM) is an important threat to health worldwide. While left ventricular (LV) dysfunction in DCM is well recognized, the accurate detection, diagnosis, and treatment of changes in right ventricular (RV) structure and function have not been well characterized. The pathophysiology of RV dysfunction in DCM may share features with LV diastolic and systolic dysfunction, including pathways related to insulin resistance and oxidant injury, although the RV has a unique cellular origin and composition and unique biomechanical properties and is coupled to the lower-impedance pulmonary vascular bed. In this review, we discuss potential mechanisms responsible for RV dysfunction in DCM and review the imaging approaches useful for early detection, protection, and intervention strategies. Additional data are required from animal models and clinical trials to better identify the onset and features of altered RV and pulmonary vascular structure and function during the onset and progression of DCM and to determine the efficacy of early detection and treatment of RV dysfunction on clinical symptoms and outcomes.
Topics: Animals; Diabetic Cardiomyopathies; Humans; Ventricular Dysfunction, Right; Ventricular Remodeling
PubMed: 30412438
DOI: 10.1152/ajpheart.00440.2018