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Right ventricle (RV) anatomy and functions

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Right ventricle (RV) anatomy and functions

  1. 1. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE 21/06/2013
  2. 2. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE • In 1616, Sir William Harvey was the first to describe the importance of right ventricular (RV) function in his seminal treatise, De Motu Cordis: “Thus the right ventricle may be said to be made for the sake of transmitting blood through the lungs, not for nourishing them.”
  3. 3. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE DEVELOPMENT OF RV
  4. 4. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  5. 5. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE ANATOMY • Crescent shaped chamber • As suggested by “Goor and Lillehi”, • Inlet • Trabecular • Outflow/Conus/ Infundibulum
  6. 6. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  7. 7. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE • Within the right ventricle, a nearly circular ring of muscle known as the crista supraventricularis (supraventricular crest) forms an unobstructed opening into the outlet region. It consists of – • Parietal band • Outlet septum • Septal band, and • Moderator band
  8. 8. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  9. 9. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  10. 10. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE PHYSIOLOGY OF RV • The primary function of the RV is to receive systemic venous return and to pump it into the pulmonary arteries • PRE LOAD • AFTERLOAD • CONTRACTILE FUNCTION • Also by heart rhythm, synchrony of ventricular contraction and ventricular interdependence
  11. 11. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE STRUCTURE OF RV • Morphologically,ultrastructurally, and biochemically, the RV differs dramatically from the LV. • Normal RV seldom exceeds 2–3 mm wall thickness at end diastole, compared with 8–11 mm for the LV. • 1/6th LV mass • Biochemically,RV has a higher proportion of the alpha- myosin heavy chain isoform that results in more rapid but less energy efficient contraction.
  12. 12. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE PRELOAD • Filling of RV – – RV filling normally starts before and finishes after LV – RV isovolumic relaxation time is shorter – RV filling velocities (E and A) and the E/A ratio are lower. • RV can accommodate varying degrees of preload while maintaining a stable cardiac output and normal filling pressures. • Two characteristics of RV: 1. Distensibility of its free wall 2. Compliance-the ability to increase volume without significant changes in the wall surface area.
  13. 13. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE PRELOAD/FILLING OF RV •Dilation of the RV caused by volume overload is usually well tolerated. •However, two consequences lead to symptoms – 1. Functional tricuspid regurgitation. 2. Compression of LV by mechanism of ventricular interdependence – decreased cardiac output
  14. 14. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE AFTER LOAD • Normally afterload minimal - Low impedance, highly distensible pulmonary vascular system • PVR is the most commonly used index of afterload,but may not reflect the complex nature of ventricular afterload. • Several factors modulate PVR, including hypoxia(Euler- Liljestrand reflex), hypercarbia, cardiac output, pulmonary volume and pressure, and specific molecular pathways,the nitric oxide pathway (vasodilation), the prostaglandin pathway (vasodilation), and the endothelin pathway (vasoconstriction).
  15. 15. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE U-shaped relationship between lung volume and PVR.
  16. 16. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE • Compared with the LV, the RV demonstrates a heightened sensitivity to afterload change
  17. 17. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE RV CONTRACTION • RV consists of – 1.The superficial oblique myocardial fibers , in continuity with the LV fibers – 2.Deeper layer of longitudinally arranged • LV has additional middle transverse fibres • RV contraction begins at the inflow region and progresses toward the outflow tract (likened to a bellows). • In distinction, the LV contracts in a squeezing motion (likened to wringing a towel) from the LV apex to the outflow tract.
  18. 18. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  19. 19. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE Higher ratio of RV volume change to RV free wall surface area change and allows the RV to eject a large volume of blood with little alteration in RV wall stretch. Poorly adapted to generating high pressure.
  20. 20. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE RV PRESSURE VOLUME LOOP • External mechanical work is substantially lower in the right ventricle • Trapezoidal shape • Most notably, RV pressure begins to decline before closure of the pulmonic valve- RV continues to eject blood because of high compliance and low resistance of the pulmonary vasculature • External mechanical work is substantially lower in the right ventricle • Trapezoidal shape • Most notably, RV pressure begins to decline before closure of the pulmonic valve- RV continues to eject blood because of high compliance and low resistance of the pulmonary vasculature LV RV
  21. 21. • Maximal RV elastance better reflects RV contractility than does the end-systolic elastance. • The normal maximal RV elastance is 1.3 +/-0.84 mm Hg/mL(study by Dell’Italia and Walsh) [LV -5.48 +/-1.23]
  22. 22. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  23. 23. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE RV PRESSURE TRACING • Right-sided pressures are – • Significantly lower than comparable left-sided • Show an early peaking and a rapidly decline in contrast to the rounded contour of LV pressure tracing • RV isovolumic contraction time is shorter because RV systolic pressure rapidly exceeds the low pulmonary artery diastolic pressure. • A careful study of hemodynamic tracings and flow dynamics also reveals that end-systolic flow may continue in the presence of a negative ventricular-arterial pressure gradient. This interval, which is referred to as the hangout interval.
  24. 24. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE HANGOUT INTERVAL • Measure of impedence in arterial system. • It is the time interval from the crossover of pressures to actual closure of semi lunar valves. • Longer on pulmonary side due to greater distensibility and less impedence • Accounts for the normal split S2 • In cases of PAH narrows down.
  25. 25. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE AV SYNCHRONY • Maintenance of sinus rhythm and AV synchrony is especially important in the presence of RV dysfunction. • For example, atrial fibrillation or complete AV block are poorly tolerated in acute RV myocardial infarction, acute pulmonary emboli, or chronic RV failure
  26. 26. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE VENTRICULAR INTERDEPENDENCE • The size, shape, and compliance of 1 ventricle may affect the size, shape, and pressure-volume relationship of the other ventricle through direct mechanical interactions. • Systolic – Mainly through the interventricular septum & continuity of muscle fibres • Diastolic – Mainly through the pericardium
  27. 27. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  28. 28. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  29. 29. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE SUMMARY • Thin walled,more complaint,higher ED volumes(RV -49-101 ; LV-44-89 ml/m2 ) • Equal cardiac output at less energy expenditure • Ejects equal amount of blood at lower RVEF (40% - 45%)than LV( 50%–55%) • Tolerates volume overload better • More efficient work output • Preload and afterload sensitive • Hang out interval • Ventricular interdependence
  30. 30. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE EVALUATION OF RIGHT VENTRICLE • Chest X ray • 2d ECHO • Cardiac MRI • Nuclear Studies • Right heart catheterisation • Other studies
  31. 31. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE CHEST X RAY • The lateral view is best suited for the detection of RV enlargement, which can be noted when the cardiac silhouette occupies more than 40% of the lower retrosternal space. • Has reasonable sensitivity but poor specificity
  32. 32. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE 2D ECHO • Inexpensive,portable,non invasive • Limitations –retrosternal location, anatomy, and contractile mechanism of the RV, markedly load dependent indices of RV function. – Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from the American Society of Echocardiography J Am Soc Echocardiogr 2010
  33. 33. The basal diameter is the maximal short-axis dimension in the basal one third of the RV . The upper reference limit for the RV basal dimension is 4.2 cm The midcavity diameter is measured in the middle third of the right ventricle at the level of the RV papillary muscles. Normal <3.2cm The longitudinal dimension is drawn from the plane of the tricuspid annulus to the RV apex Normal<8.6cm
  34. 34. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE RV FRACTIONAL AREA CHANGE • The percentage RV FAC, defined as end-diastolic area end-systolic area)/end-diastolic area x100 • Shown to correlate with RV EF by magnetic resonance imaging (MRI) • RV FAC was found to be an independent predictor of heart failure, sudden death, stroke, and/or mortality in studies of patients after PTE & MI • Lower reference value for normal RV fractional area change- 35%.
  35. 35. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE RV EF • Calculating RV volume can be divided into area- length methods, disk summation methods, and other methods • It is inferior in comparison with 3D echocardiographic methods of RV volume estimation • Normal reference range by 2D-38 – 50% • By 3D echocardiography lower reference limit of 44%
  36. 36. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE INTERVENTRICULAR SEPTAL POSITION • In the PSAX, the left ventricle assumes a progressively more D-shaped cavity as the ventricular septum flattens and progressively loses its convexity with respect to the center of the RV cavity • In Isolated RV volume overload have the most marked shift of the ventricular septum away from the center of the right ventricle at end-diastole • With relatively isolated RV pressure overload have leftward septal shift away from the center of the right ventricle at both end-systole and end-diastole, with the most marked deformation at endsystole
  37. 37. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE The ratio between the LV anteroposterior dimension and the the septolateral dimension. This ‘‘eccentricity index’’ is abnormal and suggests RV overload when this ratio is >1.0
  38. 38. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE TAPSE • TAPSE or TAM(Tricuspid Annular motion) is a method to measure the distance of systolic excursion of the RV annular segment along its longitudinal plane, from a standard apical 4-chamber window. • TAPSE is usually acquired by placing an M-mode cursor through the tricuspid annulus and measuring the amount of longitudinal motion of the annulus at peak systole • Normal lower reference value for impaired RV systolic function of 16 mm. • More specific,less sensitive
  39. 39. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE TAPSE 5mm =20% RVEF 10mm =30% 15mm =40% 20mm =50%
  40. 40. HEMODYNAMIC ASSESSMENT OF THE RV • RVSP • RVSP can be reliably determined from peak TR jet velocity • By the simplified Bernoulli equation and combining this value with an estimate of the RA pressure: RVSP = 4(V)2 + RA pressure • In the absence of a gradient of across the pulmonic valve or RVOT, SPAP is equal to RVSP
  41. 41. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE RA PRESSURE
  42. 42. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE PVR • Pressure gradient = flow x resistance. • PVR = peak TR velocity (in meters per second) /RVOT velocity-time integral (in centimeters) x10 +0.16 • This relationship is not reliable in patients with very high PVR, with measured PVR > 8 Wood units • Peak TR velocity/RVOT TVI = normally 0.15
  43. 43. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE RV dP/dT • Time required for the TR jet to increase in velocity from 1 to 2 m/s • The dP/dt is therefore calculated as 12 mm Hg divided by this time (in seconds), yielding a value in mm of Hg per second. • RV dP/dt < 400 mm Hg/s is likely abnormal
  44. 44. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE RIMP • The MPI, also known as the RIMP or Tei index, is a global estimate of both systolic and diastolic function of the right ventricle • The MPI is defined as the ratio of isovolumic time divided by ET, or [(IVRT + IVCT)/ET] • Normal right-sided MPI = 0.28+/-0.04 • Yoshifuku and colleaguesdescribed pseudonormalized values in acute and severe RV myocardial infarction, which can probably be explained by a decrease in isovolumic contraction time associated with an acute increase in RV diastolic pressure
  45. 45. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  46. 46. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE PULSED TISSUE DOPPLER Peak systolic velocity < 11.5 cm/s identifies the presence of RV dysfunction with a sensitivity and specificity of 90% and 85%, respectively
  47. 47. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE STRAIN IMAGING
  48. 48. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE COLOUR TISSUE DOPPLER
  49. 49. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE SPECKLE TRACKING-STRAIN IMAGING
  50. 50. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE IVA Isovolumic Myocardial acceleration(IVA) is defined as the peak isovolumic myocardial velocity divided by time to peak velocity at the lateral tricuspid annulus The lower reference limit by pulsed-wave Doppler tissue imaging is 2.2 m/s2(1.4 to 3.0)
  51. 51. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE Measurement of RV Diastolic Function • From the apical 4-chamber view, the Doppler beam should be aligned parallel to the RV inflow. Grading of RV diastolic dysfunction • Tricuspid E/A ratio < 0.8 suggests impaired relaxation, • Tricuspid E/A ratio of 0.8 to 2.1 with an E/e’ ratio > 6 or diastolic flow predominance in the hepatic veins suggests pseudonormal filling • Tricuspid E/A ratio > 2.1 with a deceleration Time < 120 ms and late diastolic antegrade flow in the pulmonary artery suggests restrictive filling
  52. 52. RV DYSFUNCTION (RVEF)- MILD -35-44 MOD -26-34 SEVERE -<25
  53. 53. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  54. 54. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE REGIONAL FUNCTION • RCA – Inferior & lateral • PDA – Inferior
  55. 55. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE Mc Connell’s Sign • Severe hypokinesia of the RV mid free wall, with normal contraction of the apical segment. • Sensitivity of 77% and specificity of 94% for acute pulmonary embolism. • Recently, casazza and colleaguesalso recognized this pattern in patients with acute RV myocardial infarction.
  56. 56. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE “Reverse McConnell’s Sign”: A Unique Right Ventricular Feature of Takotsubo Cardiomyopathy • Motion of the basilar and middle segments of the RV free wall is often .However, the motion of the apical segment of the RV free wall is usually hypokinetic
  57. 57. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE ARVD • Regional wall-motion abnormalities occur in 79% of probands • Most common sites of these abnormalities- –Apex (72%) –Anterior wall (70%)
  58. 58. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE TEE
  59. 59. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  60. 60. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  61. 61. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE NUCLEAR IMAGING • First-pass radionuclide ventriculography • Detects transit of a 99mTc labeled tracer through the RV. • Normal values have been reported as 52%+/- 6%(lower limit of normal of 40%). • Considered the nuclear method of choice for RV assessment because of reasonably good correlations with CMR.
  62. 62. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE • Gated equilibrium blood pool imaging • Requires longer acquisition periods, but is technically less demanding. • Nuclear techniques restricted by limited spatial resolution, relatively prolonged imaging times, and need for radioisotopes
  63. 63. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE CARDIAC MRI
  64. 64. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  65. 65. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  66. 66. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE • PET SCAN – • FDG accumulation in RV free wall correlates - – Negatively with RV EF – Positvely with PVR and mean PAP in patients with PAH. • MAGNETIC RESONANCE SPECTROSCOPY- • Quantifies intracellular TG content-correlates to RV systolic and diastolic function in diabetics.
  67. 67. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  68. 68. Right Heart Pressures Tracings
  69. 69. Normal RV waveform artifact • Note the notch on the top of RV pressure waveform – This represents “ringing” of a fluid-filled catheter – Ringing can also be noted on the diastolic portion of the waveform
  70. 70. In advanced RV failure is a reduction in the PAP coincident with a decrease in cardiac index
  71. 71. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE RV DYSFUNCTION • RV dysfunction refers to abnormalities of filling or contraction without reference to signs or symptoms of HF • RV failure is a complex clinical syndrome that can result from any structural or functional cardiovascular disorder that impairs the ability of the RV to fill or to eject blood • The most common cause of RV dysfunction is chronic left- sided HF. • PAH is the second important cause of RV dysfunction The survival rate associated with severe RV failure may be as low as 25%–30%
  72. 72. The cardinal clinical manifestations of RV failure are •(1) fluid retention, which may lead to peripheral edema, ascites, and anasarca •(2) decreased systolic reserve or low cardiac output, exercise intolerance and fatigue •(3) atrial or ventricular arrhythmias
  73. 73. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  74. 74. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
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  77. 77. VOLUME OVERLOAD • RV can handle large volumes easily. • The highly compliant RV & low-resistance pulmonary vasculature is able to accommodate the increased flow without an increase in pressure. • However,chronic right ventricular volume overload eventually leads to high- output RV failure PRESSURE OVERLOAD • In the early stages, RVH is mostly an adaptive response (compensated state). • As the disease progresses, the RV dilates and RV failure eventually occurs (maladaptive right ventricular remodeling). • The compensatory phase during the progressive increasing afterload is shorter in the RV compared with the LV. • The same is true with acute increases in the afterload • Probably due to due inability to switch back to the fetal gene program
  78. 78. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE • RV adaptation to disease is complex and depends on many factors. 1. The type and severity of myocardial injury or stress, 2. The time course of the disease (acute or chronic), 3. The time of onset of the disease process (newborn, pediatric, or adult years) 4. Neurohormonal activation, 5. Altered gene expression, 6. Pattern of ventricular remodelling The role of RV dysfunction in various clinical settings..
  79. 79. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE IMPORTANT CONDITIONS INVOLVING RV DYSFUCTION • Left Heart Failure with RV involvement • Cor pulmonale • Ischemia – RVMI • Congenital conditions • Arrhythmic conditions
  80. 80. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE RV DYSFUNCTION IN LEFT HEART FAILURE • Mechanisms- 1. Pulmonary venous hypertension 2. Intrinsic myocardial involvement 3. Ventricular interdependence 4. Neurohormonal interactions 5. Myocardial ischemia • RV dysfunction appears to be more common in nonischemic cardiomyopathy than in ischemic cardiomyopathy and more closely parallels LV dysfunction
  81. 81. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE INCIDENCE • RV failure is estimated to account for 3% of all acute heart failure admissions and confers worse mortality rates than acutely decompensated left heart failure Nieminen MS,et al,EuroHeart Failure Survey II (EHFS II),Heart J 2006; 27:2725– 2736 • Reeves and Groves reported that 44% of patients with coronary artery disease at the time of coronary arteriography and right heart catheterization have pulmonary hypertension. Approach to the patient with pulmonary hypertension. In: Weir EK, Reeves JT, eds. Pulmonary Hypertension. Mt Kisco, New York: Futura Publishing Company Inc; 1984:1– 44
  82. 82. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  83. 83. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE PROGNOSIS
  84. 84. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
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  86. 86. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE RVEF & PAP -normal Low RVEF High PAP Low RVEF & High PAP
  87. 87. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE OTHER INDICES • RVEF represents a strong and independent predictor of mortality in left HF • Additive effect has been found with presence of PAH • Other indexes of RV function like RV myocardial performance index and systolic and diastolic tricuspid annular velocities also are important.
  88. 88. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  89. 89. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  90. 90. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE Volume 15, Issue 4,Pg- 408-414
  91. 91. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  92. 92. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE • Only a few studies have addressed the prognostic importance of RV diastolic function. • In patients with left HF, Yu and colleagues showed that RV diastolic dysfunction defined by abnormal filling profiles is associated with an increased risk of nonfatal hospital admissions for HF or unstable angina. • Exercise capacity, a strong predictor of mortality in HF, appears to be more closely related to RV function than LV function. • Baker and colleagues and Di Salvo and colleagues observed a significant correlation between RVEF and exercise capacity in HF
  93. 93. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE COR PULMONALE • Definition of cor pulmonale is RV enlargement or hypertrophy secondary to pulmonary disease in the absence of LV failure/congenital heart disease. • May present with RV hypertrophy,asymptomatic RV dysfunction, or RV failure • Chronic obstructive pulmonary disease (COPD) is the most common cause of cor pulmonale in North America (20 to 30% develop cor pulmonale) • Diseases complicated by cor pulmonale have worse survival than the same disease without cor pulmonale. As an example, four-year survival is roughly 75 percent among patients with COPD of varying severity , but <50 percent among patients whose COPD is complicated by cor pulmonale – Cor pulmonale: an overview.Budev MM, Arroliga AC, Wiedemann HP, Matthay RA,Semin Respir Crit Care Med. 2003;24(3):233.
  94. 94. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE • In a study for outcomes by Campo et al In-hospital mortality of PAH patients with cor pulmonale was 14 %, but this increased to 45 to 50 % among patients who required inotropic medications or were admitted to the intensive care unit. • Mortality following discharge was 13, 26, and 35 % at 3, 6, and 12 months, respectively. – Outcomes of hospitalisation for right heart failure in pulmonary arterial hypertension,Eur Respir J. 2011;38(2):359 • In a recent study, Burgess and colleagues showed that RV end-diastolic diameter index and the velocity of late diastolic filling were independent predictors of survival
  95. 95. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE IDIOPATHIC PAH • Increased afterload is the primary cause of right ventricular adaptation and, ultimately, RV failure. • Severity of symptoms and survival are strongly associated with right ventricular function, and right heart failure is the main cause of death in patients with PAH. • Survival rates at 1 year, 68% ; at 3 years, 48% ;and at 5 years, 34%. Measures of right ventricular pump function, such as right atrial pressure, cardiac index and PAP as important prognostic measures – D’Alonzo GE, Barst RJ, Ayres SM, et al. Survival in patients with primary pulmonary hypertension. Results from a national prospective registry. Ann Intern Med 1991; 115: 343–349
  96. 96. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE EMF • Disease of tropical countries • Isolated RV involvement -10%;BV involvement -50% • Fibrous lesions affect the inflow of the right ventricle,may also involve the atrioventricular valves, thereby producing regurgitant lesions. • Presents as Right heart failure • Obliteration of apex and normotensive TR occur. • Biospy-rarely diagnostic • TV repair/replacement & endocardiectomy may be needed.
  97. 97. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE The fibrotic retraction of the right ventricular apex produces the typical apical dimple.
  98. 98. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE PTE • PE is the most common cause of acute cor pulmonale in the adult. • The mortality of PE is closely related to the degree of RV failure and hemodynamic instability. • Thus, patients may be divided into 3 groups: Expected mortality Hemodynamically stable <4 % RV dysfunction +,no shock 5 – 15 % Cardiogenic shock 20 – 50 %
  99. 99. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE RV dysfunction means the presence of at least 1 of the following: — RV dilation (apical 4-chamber RV diameter divided by LV diameter >0.9) or RV systolic dysfunction on echocardiography — RV dilation (4-chamber RV diameter divided by LV diameter >0.9) on CT — Elevation of BNP (>90 pg/mL) — Elevation of N-terminal pro-BNP (>500 pg/mL); --- Electrocardiographic changes (new complete or incomplete right bundle-branch block, anteroseptal ST elevation or depression, or anteroseptal T-wave inversion) RV dysfunction means the presence of at least 1 of the following: — RV dilation (apical 4-chamber RV diameter divided by LV diameter >0.9) or RV systolic dysfunction on echocardiography — RV dilation (4-chamber RV diameter divided by LV diameter >0.9) on CT — Elevation of BNP (>90 pg/mL) — Elevation of N-terminal pro-BNP (>500 pg/mL); --- Electrocardiographic changes (new complete or incomplete right bundle-branch block, anteroseptal ST elevation or depression, or anteroseptal T-wave inversion)
  100. 100. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  101. 101. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE • RV dysfunction may also predict recurrent PE or DVT – Association of persistent right ventricular dysfunction at hospital discharge after acute pulmonary embolism with recurrent thromboembolic events.Grifoni S et al, Arch Intern Med. 2006 • Although the presence of RV dysfunction and co- morbidities are associated with an increased risk of death in the long-term, quantifiable tools that accurately predict outcome are lacking • Evidence of RV dysfunction is an indication for TLT in sub massive PTE(class IIb)
  102. 102. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE RV MI • 30 - 50 % cases of IWMI,upto 13-15 % cases of AWMI • RCA is usually the culprit,typically a proximal occlusion • 25 % -Cardiogenic shock with raised JVP(prominent x) is a common presentation
  103. 103. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  104. 104. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE DIAGNOSIS • The clinical syndrome of RVMI was first recognized by Saunders in 1930 when he described the triad of 1. Hypotension, 2. Elevated jugular veins, and 3. Clear lung fields • Hemodynamic consequences of RVMI depend on the extent of RV free wall dysfunction, presence of concomitant right atrial ischemia & extent of simultaneous left ventricular impairment. • Clinically evident hemodynamic manifestations are seen in less than 50 percent of affected patients
  105. 105. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE • Pattern of equalized diastolic pressures and RV “dip and plateau”press ure tracing
  106. 106. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE MANAGEMENT •The initial therapy for hypotension in patients with right ventricular infarction should almost always be volume expansion. The reported efficacy of this approach is variable, a probable reflection of differences in initial volume status •Opioids, nitrates,vasodilators,CCB and beta blockers should be used with caution •Ventricular pacing may fail to increase cardiac output and atrioventricular sequential pacing may be required
  107. 107. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE OUTCOMES • Many patients spontaneously improve within 3 to 10 days regardless of the patency status of the infarct- related artery. • Furthermore, global RV performance typically recovers, with normalization within 3 to 12 months. • Although RV function may recover despite persistentAlthough RV function may recover despite persistent RCA occlusion, acute RV ischemia contributes to earlyRCA occlusion, acute RV ischemia contributes to early morbidity and mortalitymorbidity and mortality.
  108. 108. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE EARLY PROGNOSIS • Prior to the use of primary percutaneous coronary intervention, meta-analyses found that right ventricular involvement in patients with an acute inferior MI was associated with a worse in-hospital outcome due primarily to persistent hypotension and arrhythmias • Among patients who are diagnosed with RVMI and cardiogenic shock, in-hospital and 30-day mortality have been reported to be 53 and 23 percent, respectively.
  109. 109. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  110. 110. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE LONG TERM PROGNOSIS • In those who survive RVMI, the long-term prognosis is primarily determined by the extent of left ventricular involvement. • Nearly complete recovery of RV function has been shown to occur in 62 to 82 percent of patients within the first few months – Frequency and significance of right ventricular dysfunction during inferior wall left ventricular myocardial infarction treated with thrombolytic therapy (results from the thrombolysis in myocardial infarction [TIMI]II trial). The TIMI Research Group,Am J Cardiol. 1993;71(13):1148 – Prognostic significance of persistent right ventricular dysfunction as assessed by radionuclide angiocardiography in patients with inferior wall acute myocardial infarction,Am J Cardiol. 2000;85(8):939 • Chronic right heart failure attributable only to right ventricular infarction is rare,even in those without successful reperfusion • Over the long term, a persistent reduction in right ventricular function appears to be associated with a worse long-term prognosis • During a mean follow-up of 17 months, patients with an RVEF <40 percent had a significantly higher mortality compared to those with an RVEF >40 percent (adjusted hazard ratio 2.9).
  111. 111. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE RV IN CHD
  112. 112. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE SHUNT PHYSIOLOGY • ASD causes volume overload of RV,while VSD & PDA cause pressure overload of RV. • In those patients with non-restrictive defects, right ventricular wall thickness does not regress. • With aging and growth, right ventricular wall thickness increases at a rate equal to that of the left ventricle and the thickness of the right and left ventricular free walls remains equal resembling fetal heart. • Normal right ventricular function is thus the rule rather than the exception • Even with development of eisenmengerisation, RV dysfunction is rare
  113. 113. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE EISENMENGER’S SYNDROME • Eisenmenger’s has good long-term prognosis among other causes of PAH • Long-term survival of 80% at 10 years, 77% at 15 years, and 42% at 25 years -Kidd L, Driscoll DJ, Gersony WM, et al. Second natural history study of congenital heart defects. Results of treatment of patients with ventricular septal defects. Circulation. 1993;87(2 Suppl):I38–51. -Saha A, Balakrishnan KG, Jaiswal PK, et al. Prognosis for patients with Eisenmenger syndrome of various aetiology. Int J Cardiol. 1994;45(3):199–207
  114. 114. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE “Comparison of the hemodynamics and survival of adults with severe primary pulmonary hypertension or Eisenmenger syndrome” Journal of Heart & Lung Transplant, Volume 15, 1996, Hopkins et al,
  115. 115. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE WHY??
  116. 116. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE It is all about timing! • The better prognosis of Eisenmenger patients is believed to be to the fact that the subpulmonary ventricle has been exposed to high pressures and has been primed since birth; it is betterbetter adaptedadapted because of the long-standing volume and pressure overload
  117. 117. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE POST OP TOF • With Surgical repair-RV remodels with regression of wall thickness. • Significant post-op PR (regurgitant fractions of >50%) Leads to volume overload of the right ventricle and chamber dilatation • It can lead to exertional dyspnea, right ventricular failure & increased incidence of atrial and ventricular arrhythmias and SCD • Severe RV dilatation, especially when progressive, may be an early sign of a failing RV and should prompt consideration of pulmonary valve replacement. • QRS width may reflect the degree of right ventricular dilation and, when extreme (>180 milliseconds) or rapidly progressive, may be a risk factor for sustained ventricular tachycardia and sudden death
  118. 118. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE “RESTRICTIVE RV PHYSIOLOGY” • Defined by the presence of forward and laminar late diastolic pulmonary flow throughout respiration due to stiff RV with RA systole required to maintain forward flow. • EarlyEarly after TOF repair, restrictive RV physiology is associated with a low cardiac output and longer intensive care stay. • LateLate after TOF repair, however, restrictive RV physiology counteracts the effects of chronic pulmonary regurgitation. • It is associated with a smaller RV, shorter QRS duration, and increased exercise tolerance.
  119. 119. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE RVOT OBSTRUCTION • Isolated PS is found in 80%-90% of all patients with RVOT obstruction. • A hypertrophied RV can maintain its function for years, even when RV pressures are near systemic.May cause RV failure on long term. • After pulmonary valve commissurotomy,open valvotomy or a transannular patch placement invariably result in various degrees of PR & RV volume overload. • Eventually RV dysfunction ensues and patients develop symptoms, such as dyspnea, fatigue and substantial arrhythmia.
  120. 120. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE SUICIDAL RV • A dynamic right ventricular outflow obstruction has been referred to as “suicide” RV. • It has been reported in both children and adults following either surgical or catheter relief of valvular obstruction, particularly in patients who have an initial supra-systemic right ventricular pressure. • In some cases, the obstruction may become severe enough to produce low cardiac output. • This is frequently related to infundibular hypertrophy and may gradually resolve spontaneously. • Immediate treatment-hydration & beta blocker therapy
  121. 121. EBSTEIN’S ANOMALY • Rare CHD • Results from failure or incomplete delamination of the inner layers of the inlet zone of the ventricles. • 1)Apical displacement of septal & posterior leaflets • 2)Dilation of the “atrialized” portion of the right ventricle, with various degrees of hypertrophy and thinning of the wall • (3)Redundancy, fenestrations, and tethering of the anterior leaflet
  122. 122. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE • RV failure in Ebstein’s anomaly results primarily from volume overload of the RV and from a hypoplastic RV chamber incapable of adequately handling the systemic venous return • Size of functional ventricle(as measured by GOSE score)is a marker of early mortality. • As noted in the 2008 ACC/AHA adult congenital heart disease guidelines, indications for surgical repair of Ebstein’s anomaly beyond infancy include: 1. Symptoms or deteriorating exercise capacity 2. Cyanosis (oxygen saturation less than 90 percent) 3. Paradoxical embolism 4. Progressive cardiomegaly on chest x-ray 5. Progressive right ventricular (RV) dilation or reduction of RV systolic function
  123. 123. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE Uhl’s Anomaly • Parchment heart • Aplasia/hypoplasia of most if not all of the myocardium of trabecular portion of RV,with normally functioning tricuspid valve. • RV acts as a passive conduit that channels blood from RA to pulmonary trunk. • Survival into adulthood possible • The clinical picture of Uhl’s anomaly is dominated by congestive HF,which may result in death in infancy
  124. 124. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  125. 125. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE ARVD • Genetic disorder involving desmosomal protein • Unusual myopathy that involves predominantly the RV and results in fibrofatty replacement of the myocardium. • The most frequently involved areas of the RV are the posterior base, apex, and the infundibulum. These areas are collectively called the triangle of dysplasia. • Sudden cardiac death frequently is the first manifestation of the disease. • Risk factors for sudden death include RV dilatation, precordial repolarization abnormalities, LV involvement, documented or suspected ventricular tachycardia or fibrillation, and 1 affected family member.
  126. 126. • Classified into four clinico- pathologic stages 1. Concealed phase or silent phase 2. Overt arrhythmic phase 3. Global right ventricular dysfunctional phase - isolated right heart failure(6%). 4. Bi-ventricular pump failure with LV involvement EPSILON WAVES AND T WAVE INVERSION
  127. 127. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE Pattern of RV involvment • RV dilatation can be observed in 80% of patients • RV free wall motion abnormalities(akinesia/dyskinesia) can be found in 33% patients • RV saccular aneursyms • Upto 66.7% show systolic dysfunction • Right ventricular outflow tract (RVOT) dilation (diameter 30 mm) has been reported to have the highest sensitivity and specificity (89% and 86%, respectively) of echocardiographic parameters
  128. 128. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  129. 129. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE MR imaging is the imaging modality of choice in evaluating
  130. 130. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE DEVICE THERAPY-PPI • RV apical pacing • RVOT pacing • Dual site RV pacing
  131. 131. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE RV APICAL PACING • Asynchronous electrical activation –ventricular dyssynchrony • Redistribution of mechanical load within the ventricular wall and may lead to reduction of the blood flow and myocardial wall thickness over the site of early activation,esp inferoposterior and apical areas –ADVERSE REMODELLING • This leads to RWMA and impaired LV function on long term in 9-26 % cases - Ozcan C, Jahangir A,et al; N Engl J Med 2001;344:1043e51 - MOST TRIAL :Adverse effect of ventricular pacing on heart failure and atrial fibrillation among patients with normal baseline QRS duration in a clinical trial of pacemaker therapy for sinus node dysfunction.Sweeney Mo et al,Circulation 2003
  132. 132. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE In the Dual Chamber and VVI Implantable Defibrillator (DAVID) trial,RV pacing was associated with heart failure disease progression, including an increased incidence of worsening heart failure
  133. 133. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  134. 134. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE ALTERNATIVES • Managed ventricular pacing — Devices with this capability allow native conduction to occur, even in the setting of substantial PR prolongation or second degree atrioventricular (AV) block. • Prolonged programmed AV intervals • Eliminating rate responsive AV delay • DDI or DDIR pacing • RVOT pacing,septal pacing, and direct His bundle pacing
  135. 135. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE RVOT PACING
  136. 136. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  137. 137. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE DUAL SITE RV PACING • Recently, the beneficial effects of dual site RV pacing (RVOT + RV apex) in a small group of patients, in whom CS lead implantation failed because of the technical difficulties during CRT, has been reported. – Pachon JC, Pachon EI, Albornoz RN, et al. Pacing Clin Electrophysiol 2001;24:1369e76. – O Sai Satish ,Europace et al (2005) 7, 380e384,The European Society of Cardiology.
  138. 138. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE CRT • Patients with marked RV dysfunction (RVEF < 30%/TAPSE <1.5mm) have a particularly low response rate to CRT. • It is possible that significant RV dysfunction marks extensive and irreversible adverse remodelling, preventing reverse remodelling and functional recovery after CRT implantation. • Right ventricular function is also an important predictor of major adverse events & mortality following CRT – Ghio S,et al: Long-term left ventricular reverse remodelling with cardiac resynchronization therapy: results from the CARE-HF trial. Eur J,Heart Fail 2009, 11:480- 488. – Burri H,et al: Right ventricular systolic function and cardiac resynchronization therapy. Europace 2010, 12:389-394.
  139. 139. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE Heart 2013;99:722–728. doi:10.1136/heartjnl-2012-303076
  140. 140. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE OTHERS • In patients with ARDSARDS,Significant RV dysfunction occurs in 15% of patients(usually is related to microvasculature dysfunction and/or the effects of mechanical ventilation).It is an independent predictor of mortality. • In Sepsis, RV dysfunction is related to myocardial depression or PAH. Persistence of RV dysfunction in sepsis appears to be associated with an increased risk of mortality. • In severe MSsevere MS RV dysfunction may be the cause of mortality in 60% to 70% of untreated patients • In unoperated chronic MRchronic MR patients, subnormal RVEF at rest is associated with decreased exercise tolerance, complex arrhythmias, and mortality.
  141. 141. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE • Preoperative RV systolic dysfunction has been shown to predict late survival after coronary artery bypass surgery and mitral valve surgery. • Severe RV failure after Cardiac surgeryCardiac surgery occurs in 0.1% of patients and is associated with high mortality rates. • Examples • Coronary artery bypass surgery • Valve replacement • LV assist device placement-20-30% • Heart transplantation-2-3%,20% in some reports • Factors involved in the pathophysiology of RV failure in cardiac surgery include RV ischemia, PAH, reperfusion lung injury, pulmonary emboli, sepsis. • After insertion of LV assist deviceLV assist device the underlying reasons-- higher cardiac output after LVAD implantation, decrease in the septal contribution to ventricular interdependence or septal suck down effect).
  142. 142. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE • Many factors contribute to the development of acute RV failure after heart transplantation-after heart transplantation- 1)Preexisting or acquired pah(preoperative PVR >6 wood units & transpulmonary gradient >15 mm hg) 2) Marginal organ preservation and long ischemic time, 3) Mechanical obstruction at the level of the pulmonary artery anastomosis 4) Significant donor-recipient mismatch with a much smaller donor heart (more than 20% mismatch in size) 5) Acute allograft rejection. • RV failure in this setting is associated with increased perioperative mortality • PregnancyPregnancy in patients with severe RV failure is associated with high maternal and fetal mortality rate. The periods of greater risk are the second trimester and the period of active labour and delivery.
  143. 143. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE MANAGEMENT
  144. 144. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  145. 145. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE PAH SPECIFIC THERAPIES • Management of patients with acute and chronic RV failure is more empiric than the management of patients with left heart failure • CCB- RV function return to normal in patients with PAH who are vasoreactive. • ERA- Not found to cause significant fall in PAP or reversal of RV remodeling • PDE5I –Additional inotropic, dose-related increases in cardiac output • PGI2 -Increase in contractility and cardiac output. Maintain relatively normal RV function in the face of severe pulmonary vascular disease
  146. 146. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE IPBP • Earlier standard intraaortic balloon pump was been inserted into a synthetic vascular graft & anastomosed in an end-to-side fashion to the pulmonary artery. • Per cutaneous insertion of 8 ml balloon into pulmonary artery has been shown to be possible in an experiment in dogs. • Have been found to be useful in cases of acute PTE,PAH,Post CABG with RV failure.
  147. 147. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE RV ASSIST DEVICES • When biventricular failure is refractory, mechanical circulatory support may be considered as part of a bridge-to-transplant strategy. • Other indications for RVAD implantation are as follows: – RV MI – Acute myocarditis – Postcardiotomy cardiogenic shock (including valve surgery, coronary artery bypass, heart transplantation, LVAD insertion, and pulmonary thromboendarterectomy) – Acute rejection after orthotopic heart transplantation – Refractory arrhythmias – Bridge to decision following cardiac arrest • Cardiac transplantation is the definitive treatment of patients with advanced RV failure.
  148. 148. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE • 3 broad categories – • Surgically implanted centrifugal pump devices-Centrimag • Percutaneous systems (also mostly centrifugal pump devices) – Tandem heart • Extracorporeal membrane oxygenation (ECMO) system
  149. 149. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE CENTRIMAG
  150. 150. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE
  151. 151. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE HEART TRANSPLANTATION • Indicated for selected patients with advanced refractory RV failure,with arrhythmogenic RV dysplasia and refractory tachyarrhythmias . • Advanced RV failure secondary to PAH (PVR > 6 WU)-heart-lung or isolated lung transplantation been useful. • Complex CHD with PH should be considered candidates for heart-lung transplantation.
  152. 152. RIGHT VENTRICLE ANATOMY,PHYSIOLOGY, ASSESSMENT & CLINICAL SIGNIFICANCE Thank you

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