rv function prognostic implications in heart failure efthimios anagnostou m.d
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RV functionPrognostic implications in heart failure
Efthimios Anagnostou M.D.
No disclosures
After AMI
Congestive HF
Valvular HD
Congenital HD
After HT
Pulmonary Embolism
Pulmonary HTN
HFpEF
The prognostic value of RV function in cardiovascular disease.
Courtesy C.Celton-Saty
reduced RVEF is an independent prognostic factor in moderate to severe CHF.
RVEF predicts prognosis in CHF
Larose
147Pts, late after MI , RVEF<40%
CMR RVEF and survival @ 17 months
Larose JACC 2007
RVEF: Prognostic impact late after AMI
RVEF<40%
RVEF≥40%
Better survival & Better exercise capacity
RV function + PH predict survival in CHF
Ghio, JACC 2001
379 CHF pts, LVEF<35% ,DCM & IHD, optimized Rx RHC with thermodilution RVEF
Normal PAP +Normal RVEF
High PAP +Low RVEF
RV dilatation predicts survival in CHF380 CHF pts, LVEF<45% VS controls
DILATED RV IN 25% of ptsRVESVi: independent predictor of mortality
Bourantas EJHF 2011
RV dysfunction portends an
inferior survival.
• variations in study populations,
• severity and substrates of disease,
• methodologies of assessment.
Despite…
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RV dysfunction
Bibliography
30 years ago …
Insidiously ignored until the BEST trial…
distribution of RVEF in CHF
2008 pts, from the BEST study, LVEF<35%,NYHA III/IVRadionuclide RVEF and mortality @ 24 months
Meyer et al, Circulation 2012
Mortality 47% Mortality 27%
=63% =37%
What is RV failure ?
Inability of the RV to maintain cardiac output through the pulmonary vascular bed at normal central venous pressures.
an Increased Preload (RA pressure) is
required to maintain adequate CO
The commonest cause of RV Dysfunction is Left Heart Disease
LV Systolic DysfunctionCADValve Disease
LV Diastolic Dysfunction Hypertension
Restrictive CardiomyopathyHCM
HFrEF
HFpEF
HTN
HFpEFHFrEF
MV disease
AoV disease
LA pressure
CHF causes Pulmonary Hypertension leading to Right Ventricular Failure
PCWP
Group 2 PH
mPA>25mmHg PCWP >15mmHg CO normal or low
PAP
1000 CHF pts undergoing transplant evaluation
Correlation nice and straight and fairly tight indicating therefore that PAP is driven passively by PCWP
Mechanism of PH in CHF
Drazner J Heart Lung Transplant 1999
PAP
PCWP
intimal Fibrosis
This may or may not result in rise in the PAP with a consequent rise in the TPG or PVR
Mechanism of PH in CHF
Different Hemodynamic Stages in GROUP 2 PH
Drazner J Heart Lung Transplant 1999
1000 CHF pts undergoing transplant evaluation
Mechanism of PH in CHF
because of vascular changes in the arterial side of pulmonary circulation
Out o
f pro
porti
on P
H
CHF, PH-CHF, PH+
Marked medial hypertrophy of a muscular pulmonary artery in a patient with CHF, compared to another of similar size with minimal medial thickening in a patient with
CHF but not pulmonary hypertension
This is NOT, however, idiopathic PAH (a vascular proliferative disease) but rather a secondary medial hypertrophy of the pulmonary arteries
A RESPONSE TO PREVENT ALVEOLAR EDEMA FROM HAPPENING
PAP
PCWP
As a consequence of rise in PAP, PVR and PVH, the RV runs into trouble
Mechanism of PH in CHF
PH and impaired Exercise capacity in CHF
Di Salvo JACC 1995
320 pts
a consequence of rise in PVR is the dramatic decrease in CO both at rest and during exercise
ADULT HEART TRANSPLANTATIONKaplan Meyer estimates of mortality 1999-2007
stratified by PVR
< 2 WU2- 4 WU
> 4 WU
Ventricular Interdependence
Wolferen, EHJ 2007
RV stroke volume predicts prognosis in PAH 64 pts, CMR, RHC, 6MWT
RV failure
RV dilatation
RVH
D-shaped LV
RA dilatation
TricuspidRegurgitation
This is the end, my friendThis is the beginning
The shrinking LV…
HFpEF
PASP estimates are a risk factor for death.
Markers of RV Dysfunction associated with clinical status and prognosis
Systolic Performance RVEFRVFACTAPSERV MPIHemodynamicsRA pressureCIMaximal dP/dTPressure–volume MeasurementsVentricular elastancePreload recruitable stroke work
Diastolic FillingTissue Doppler indicesIsovolumic accelerationSyst/Diast myocardial velocitiesRight-sided DilationRV dilation absolute/ relative to LVRA sizeTR
Which?
We would be poorly served by buying
into the concept that an RVEF is the
only ‘‘reference standard,’’ without
recognition of its shortcomings.
Sugeng, J A C C i m g 2 0 1 0
Multimodality Comparison of Quantitative Volumetric Analysis of the Right Ventricle
However, our results also showed that RV volume measurements are not interchangeable between modalities and, therefore, serial evaluations should be performed using the same modality.
When grappling with what measure
should be adopted to evaluate RV
systolic function, we are left with the
classic answer:
it depends!
RV dysfunction is a strong parameter of functional capacity
RV dysfunction is prognostically superior to LV parameters of systolic/diastolic function
RV dysfunction is present in about two-thirds of patients with CCF and doubles mortality
RV dilatation has the worst prognosis
RV assessment is a must of the diagnostic work-up in CCF patients
Conclusions
Thank you
The myocardium of the entire heart is now known to be a
single sheet of muscle rolled into different chambers
http://www.youtube.com/watch?v=Mih37LLv6IQ&feature=plcp
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