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The Role of Right Ventricular Function
in Chronic Heart Failure

Stefano Ghio, MD

Department of Cardiology, IRCCS Policlinico San Matteo, Pavia, Italy

   For many years, the interest in the study of right ventricular function has been scarce and the role that this cardiac chamber plays in heart failure and in other disease states has been underestimated.

   In fact, to early investigators studying normal physiologic conditions, the right ventricle appeared to act merely as a conduit for blood flow (1). Moreover, in the eighties, several pathophysiological studies showed that the systolic function of right ventricle was strictly and inversely dependent on the afterload that this chamber had to confront, so that the interest in the direct evaluation of its function was considered minor with respect to the measurement of the pulmonary artery pressure (2-5). In addition, one must consider that many technical difficulties arise when trying to assess right ventricular size and function (6). The complex geometry of the right ventricle makes most tomographic imaging techniques unsuitable for an accurate estimate of the volumes and of the ejection fraction of this chamber; its position, immediately below the sternum, makes echocardiographic imaging even more difficult. Finally, the physiology of right ventricular contraction is different and more difficult to be described than that of left ventricle.

   In recent years things have changed. A consensus has grown on the critical role of right ventricular performance in determining the clinical outcome of patients with chronic heart failure (7-12).

   Furthermore, although rapid response thermodilution and radionuclide angiography were initially considered the techniques of choice to study the right ventricle, it turned out that M-mode and 2-D echocardiography allow obtaining simple parameters, which are good indicators of right ventricular function and result of great clinical usefulness (11-12). Non-invasiveness, low-cost and easy repeatability are the obvious advantages of the echocardiographic approach. The right ventricle can be visualized in a modified apical 4-chamber view (it is sufficient a slight tilt of the probe upwards and towards the sternum); the systolic area shrinkage correlates to the right ventricular ejection fraction measured with radionuclides or with thermodilution (12-13). In the same view it is possible to measure the excursions of the tricuspid annular plane (TAPSE) by positioning the M-mode cursor on the lateral portion of the tricuspid annulus; this movement reflects the base to apex shortening of the right ventricle in systole (Figures 1 and 2). Data obtained in our laboratory demonstrate that this index adds significant prognostic information to the NYHA clinical classification, to the conventional echocardiographic evaluation of left ventricular function, and to the consolidated prognostic indicators derived from the analysis of the mitral Doppler curve (Figure 3). In addition, TAPSE can be easily measured in all patients irrespective of heart rate and rhythm; its usefulness can therefore be extended to those patients in whom tachycardia or atrial fibrillation limits the findings from the mitral Doppler flow velocity curve. There is a large consensus that Doppler-derived left ventricular filling parameters are strong predictors of cardiac mortality in patients with chronic heart failure, because these parameters reflect high levels of pulmonary artery wedge pressure. Our results do not contradict this evidence but indicate that TAPSE improves the prognostic stratification of patients with chronic heart failure, identifying those in whom an elevated pulmonary artery pressure has caused a severe dysfunction of the right ventricle.

Figure 1: M-mode recording of TAPSE in a patient with preserved right ventricular function

Figure 2:M-mode recording of TAPSE in a patient with reduced right ventricular function

   Figure 3: Event-free survival according to TAPSE

   These observations on the independent prognostic role of the right ventricular function seem to be contrasting with the long-standing view maintaining that the systolic function of the right ventricle is almost exclusively dependent on the afterload that this cardiac chamber must confront. Pulmonary hypertension frequently complicates heart failure and is generally considered "per se" an indicator of poor prognosis. The coupling between pulmonary artery pressure and right ventricular ejection fraction (measured with rapid response thermodilution) has been studied in a population of 379 patients with dilated or post-ischemic cardiomyopathy (14). While confirming the inverse relationship between right ventricular ejection fraction and pulmonary artery pressure, this study showed that exceptions to this physiologic relation may be observed in clinical practice. First, in some patients with pulmonary hypertension the right ventricular function can be fairly preserved; the reason why this happens is not clear, though it is possible that it has to do with a more recently arisen pulmonary hypertension. Second, right ventricular dysfunction may be observed even in patients with normal pulmonary artery pressure. There are several possible explanations for this finding (a low cardiac output, a primary reduction in right ventricular contractility, overtreatment with diuretic drugs) none of which is, per se, completely satisfactory. There is still much to learn on how and when right ventricular dysfunction develops in the clinical syndrome of heart failure; nonetheless, the prognostic stratification of patients with heart failure improves when taking into account the coupling between the right ventricular function and its afterload. Patients with pulmonary hypertension and preserved right ventricular function have a significantly better prognosis than patients with pulmonary hypertension and right ventricular dysfunction. In fact, in the former group of patients the prognosis is not very different from that of patients with a normal hemodynamic profile or of those with normal pulmonary artery pressure and right ventricular dysfunction (Figure 4). The message emerging from the study is that it is necessary to integrate the right heart hemodynamic variables with a functional evaluation of the right ventricle if we want to improve the prognostic stratification of heart failure patients.

Figure 4:Survival rates without urgent heart transplantation in patients grouped according to the coupling mean pulmonary artery pressure (PAP) and right ventricular ejection fraction (RVEF). Group1 = normal PAP/preserved RVEF (n=73); group 2 = normal PAP/low RVEF (n=68); group 3 = high PAP/ preserved RVEF (n=21); and group 4 = high PAP/low RVEF (n= 215).

   A different but still fruitful approach to the evaluation of right heart performance derives from the analysis of the systemic venous return. Central venous flow velocities curves recorded with pulsed Doppler echocardiography into the hepatic veins or into the superior vena cava are known to provide functional data on the right heart and are commonly used to estimate the degree of tricuspid regurgitation, to differentiate cardiac tamponade from pericardial effusion and constrictive pericarditis from restrictive cardiomyopathy (15-18). However, until recently no information was available on the relationship between right heart filling dynamics and right ventricular function, even though there is a clear demonstration that in the left side of the heart the filling of the atrial cavity through the pulmonary veins is strongly influenced by the function of the left ventricle (19).

   Since these data could be of great clinical relevance in patients with chronic heart failure, we designed a study to test the hypothesis that different flow velocity patterns in systemic vein discriminate between different degrees of right heart hemodynamic impairment in patients with chronic heart failure (20). The superior vena cava flow velocity curve was recorded from the right supraclavear approach. Peak velocities of the systolic and of the diastolic centripetal waves were measured and their ratio calculated. The flow pattern was considered normal when the systolic/diastolic ratio was > 1 and <2 (Figure 5); the flow pattern was categorized as "predominant systolic wave" when the ratio was > 2 (Figure 6), and as "predominant diastolic wave" when the ratio was <1 (Figure 7). A normal flow pattern identified patients with normal right-heart hemodynamics; a "predominant systolic wave" pattern identified patients with a reduced thermodilution-derived right ventricular ejection fraction (<30%) associated with normal or slightly elevated right atrial pressure (< 8mmHg); a "predominant diastolic wave" pattern identified patients with a reduced right ventricular ejection fraction (<30%) and elevated right atrial pressure (>8 mmHg). The usefulness of Doppler interrogation of flow velocities into the superior vena cava is therefore not limited to the differentiation between patients with a normal hemodynamic profile and patients with high right atrial pressure but it extends to the possibility of distinguishing patients with normal right heart hemodynamics from those in whom a normal right atrial pressure is associated with an impaired right ventricular function.

Figure 5: Normal flow velocity pattern into the superior vena cava:

Figure 6: "Predominant systolic wave " flow velocity    pattern into the superior vena cava:

Figure 7: "Predominant diastolic wave "flow velocity pattern into the superior vena cava:

   In conclusion, the data of the literature nowadays justify a close evaluation of the right ventricular performance in all patients with chronic heart failure. We know in fact that right ventricular dilatation and dysfunction may occur in patients with advanced left ventricular dysfunction, mainly as a consequence of the increased pulmonary artery pressure. When this happens, the prognosis of the patient is very poor. Despite the technical difficulties in the assessment of right ventricular size and function, rapid response thermodilution and radionuclide angiography are no more the only techniques which can be used to this aim. In fact the ultrasound examination allows obtaining simple parameters which are of great clinical and prognostic value at the advantage of non-invasiveness, low-cost and easy repeatability.

REFERENCES

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2. Brent BN, Berger HJ, Matthay RA, Mahler D, Pytlik L, Zaret BL. Physiologic correlates of right ventricular ejection fraction in chronic obstructive pulmonary disease: a combined radionuclide and hemodynamic study. Am J Cardiol 1982; 50: 255.

3. Sibbald WJ, Driedger AA, Myers ML, Short AI, Well GA. Biventricular function in the adult respiratory distress syndrome. Hemodynamic and radionuclide assessment with special emphasis on right ventricular function. Chest 1983; 84: 126-134.

4. Morrison D, Goldman S, Wright AL, Henry L, Sorenson S, Caldwell J, Ritchie J. The effect of pulmonary hypertension on systolic function of the right ventricle. Chest 1983; 84: 250-257.

5. Konstam MA, Salem DN, Isner JM, Zile MR, Kahn PC, Bonin JD, Cohen SR, Levine HJ. Vasodilator effect on right ventricular function in congestive heart failure and pulmonary hypertension: end-systolic pressure-volume relation. Am J Cardiol 1984; 54: 132-136.

6. Oldershaw P. Assessment of right ventricular function and its role in clinical practice. Br Heart J 1992: 68: 12-15.

7. Polak JF, Holman L, Wynne J, Colucci WS. Right ventricular ejection fraction: an indicator of increased mortality in patients with congestive heart failure associated with coronary artery disease. J Am Coll Cardiol 1983; 2: 217-224.

8. Di Salvo TG, Mathier M, Semigran MJ, William Dec G. Preserved right ventricular ejection fraction predicts exercise capacity and survival in advanced heart failure. J Am Coll Cardiol 1995; 25: 1143-1153.

9. Gavazzi A, Berzuini C, Campana C, Inserra C, Ponzetta M, Sebastiani R, Ghio S, Recusani F. Value of right ventricular ejection fraction in predicting short-term prognosis of patients with severe chronic heart failure. J Heart and Lung Transplant 1997; 16: 774-785.

10. De Groote P, Millaire A, Foucher-Hossein C, Nugue O, Marchandise X, Ducloux G, Lablanche J-M. Right ventricular ejection fraction is an independent predictor of survival in patients with moderate heart failure. J Am Coll Cardiol 1998; 32: 948-954.

11. Karasatakis GT, Karagounis LA, Kalyvas PA, Manginas A, Athanassopoulos GD, Aggelakas SA, Cokkinos DV. Prognostic significance of echocardiographically estimated right ventricular shortening in advanced heart failure. Am J Cardiol 1998; 82: 329-34.

12. Ghio S, Recusani F, Klersy C, Sebastiani R, Laudisa ML, Campana C, Gavazzi A, Tavazzi L. Prognostic usefulness of the tricuspid annular plane systolic excursion in patients with congestive heart failure secondary to idiopathic or ischemic dilated cardiomyopathy. Am J Cardiol 2000; 85:837-842.

13. Forni G, Pozzoli M, Canizzaro G, Traversi F, Calsamiglia G, Rossi D, Cobelli F, Tavazzi L. Assessment of right ventricular function in patients with congestive heart failure by echocardiographic automated boundary detection. Am J Cardiol 1996; 78: 1317-1321.

14. Ghio S, Gavazzi A, Campana C, Inserra C, Klersy C, Sebastiani R, Arbustini E, Recusani F, Tavazzi L.
Independent and additive prognostic value of right ventricular systolic function and pulmonary artery pressure in patients with chronic heart failure. J Am Coll Cardiol 2001;37:183-8.

15. Pennestrì F, Loperfido F, Salvatori MP, et al. Assessment of tricuspid regurgitation by pulsed Doppler ultrasonography of the hepatic veins. Am J Cardiol 1984;54:363-8.

16. Appleton CP, Hatle LK, Popp RL. Cardiac tamponade and pericardial effusion: respiratory variation in transvalvular flow velocities studied by Doppler echocardiography. J Am Coll Cardiol 1988;11:1020-30.

17. Hatle LK, Appleton CP, Popp RL. Differentiation of constrictive pericarditis and restrictive cardiomyopathy by Doppler echocardiography. Circulation 1989;79:357-70.

18. Klein al, Hatle LK, Burstow DJ, et al. Comprehensive Doppler assessment of right ventricular diastolic function in cardiac amiloidosis. J Am Coll Cardiol 1990;15:99-108.

19. Prioli AM, Marino P, Lanzoni L, et al. Increasing degrees of left ventricular filling impairment modulate left atrial function in humans. Am J Cardiol 1998;82:756-61.

20. Ghio S, Recusani F, Sebastiani R, Klersy C, Raineri C, Campana C, Lanzarini L, Gavazzi A, Gavazzi L. Doppler velocimetry in superior vena cava provides useful information on the right circulatory function in patients with congestive heart failure. Echocardiography 2001, in press.

 

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2nd Virtual Congress of Cardiology

Dr. Florencio Garófalo
Steering Committee
President
Dr. Raúl Bretal
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President
Dr. Armando Pacher
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